. Based on record review and staff interview the facility failed to properly investigate and make prompt efforts to resovle a grievance from Resident #19. This was true for 1 (one) of 1 (one) resident's reviewed for the Long Term Care Survey Process. Resident identifier: #19. Facility census: 93. Findings included: a) Resident #19 On 08/05/24 at 1:04 PM, an interview was conducted with Resident #19. During this interview, Resident #19 stated, Employee #86 is hateful to her when Resident #19 uses her call bell. Resident #19 further stated that when Employee #86 answers her call bell, Employee #86 states, What do you want now? This Surveyor then notified the facility Administrator of what Resident #19 stated. The Administrator stated she will have the facility Social Worker (SW) speak with Resident #19. On 08/06/24 at 1:19 PM, an interview was conducted with the facility Administrator and SW. At this time, Resident #19's complaint was discussed along with how the facility resolved it. The Administrator and SW stated a facility form entitled, Grievance/Complaint Report had been completed. When reviewing the form it was noted no statement had been obtained from Employee #86. On 08/06/24 at 3:46 PM a review of the policy and procedure entitled, Resident Grievance was conducted. This policy and procedure stated the facility shall complete a timely investigation of the resident's grievance which will include a review of facility processes, programs and policies, as well as interviews with staff, residents, others involved in resident care. On 08/07/24 at 2:05 PM, an additional interview was conducted with the facility Administrator who acknowledged an interview should have been conducted with Employee #86 as stated in the policy and procedure, Resident Grievance.

. Based on medical record review and staff interview, the facility failed to update the care plan for a new diagnosis. This was true for three (3) out of 30 residents reviewed during the long-term care process. Resident identifiers: #17, # 26 and #29. Facility census: 93. Findings included: a) Resident #17 During a medical record review on 08/06/24 at approximately 9:46 AM the medical record for Resident #17 identified a diagnosis of Major Depression Disorder. A further review of the care plan identified Resident #17 was being monitored for the use of an anti-depressant only and not the diagnosed condition of Major Depression Disorder. During an interview with the Clinical Manager Registered Nurse (CM RN) #51 on 08/06/24 at approximately 10:00 AM, The CM RN #51 agreed the Major Depression disorder was not care- planned. b) Resident #26 During a medical record review on 08/06/24 at approximately 9:50 AM the medical record for Resident #26 identified a diagnosis of schizoaffective disorder, bipolar type. A further review of the care plan identified Resident #26 is being monitored for the use of an anti-psychotic medication only and not the diagnosed condition of schizoaffective disorder, bipolar type. During an interview with the Clinical Manager Registered Nurse (CM RN) #51 on 08/06/24 at approximately 10:03 AM, The CM RN #51 agreed the schizoaffective disorder, bipolar type was not care - planned. c) Resident #29 During a medical record review on 08/06/24 at approximately 9:54 AM the medical record for Resident #29 identified a diagnosis of hallucinations dated 08/01/23. A further review of the care plan identified that Resident #26 was not care - planned for hallucinations. During an interview with the Clinical Manager Registered Nurse (CM RN) #51 on 08/06/24 at approximately 10:03 AM, The CM RN #51 agreed hallucinations was not care - planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and resident and staff interview, the facility failed to ensure resident environment, over which it had control, was as free of accident hazards as possible, by failing to complete a smoking assessment, upon admission, for smokeless tobacco use for Resident #25. This was true for one (1) of eight (8) residents reviewed for accident hazards during the survey process. Resident identifier: #25. Facility census: 93. Findings included: A) Resident #25 At approximately 2:07 PM on 08/05/24, an interview was conducted with Resident #25. During the interview, the resident was observed using smokeless tobacco in his room. When asked if he had used smokeless tobacco since he had been at the facility, Resident #25 replied, yes. At approximately 3:00 PM on 08/05/24, a record review was conducted for Resident #25. During the review, it was determined there was no smoking assessment completed for Resident #25, despite being admitted to the facility on [DATE]. At approximately 10:30 AM on 08/06/24, an interview was conducted with the Interim Director of Nursing (IDON) regarding smokeless tobacco use in the facility. When asked if the facility performed smoking assessments on all smokeless tobacco users, the IDON responded, yes. IDON was asked to produce the assessment for Resident #25's tobacco usage. At approximately 4:00 PM on 08/06/24, IDON presented a smoking assessment for Resident #25's smokeless tobacco usage, with the effective date of 08/06/24. Review of the facility's smokeless tobacco use policy revealed Smokeless tobacco assessments for those residents requesting to use smokeless tobacco will be completed or re-evaluated: i. On admission ii. Quarterly iii. Significant change in condition At approximately 10:05 AM on 08/07/24, the IDON confirmed the smoking assessment was not completed on Resident #25 on admission as required, and confirmed the only smoking assessment that had been completed was the one on 08/06/24, after surveyor intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review and staff interview, the facility failed to monitor Resident #30, #29, and #82 for side effects of antidepressant, antianxiety, and antipsychotic medications as ordered. This was true for three (3) out of five (5) residents monitored for unnecessary medications during the survey process. Resident identifiers: #30, #29, #82. Facility census: 93. Findings include: A) Resident #30 On 08/06/2024 at approximately 11:30 AM during a record review for Resident #49, it was discovered side effects were not monitored for antidepressant, antianxiety, and antipsychotic medications, according to the Medication Administration Record (MAR) for the following days: -Day and night shift on 06/01/2024 -Day and night shift on 06/02/2024 -Day Shift on 06/03/2024 -Day shift on 07/20/2024 -Day shift on 07/21/2024 -Day shift on 07/24/2024 -Day shift on 07/25/2024 -Day shift on 07/30/2024 -Day and night shift on 08/01/2024 At approximately 10:05 AM on 08/07/2024, an interview was conducted with the Interim Director of Nursing (IDON). During the interview, the IDON confirmed the above dates where no side effect monitoring was documented to have occurred for antidepressant, antianxiety, and antipsychotic medications. IDON was unable to provide any additional documentation to support side effect monitoring had taken place. b) Resident #29 During a medical record review of Resident #29's behavior monitoring on 08/06/24 at approximately 12:09 PM the following monitoring orders were identified for medication behavior side effects with the noted discrepancies of the orders being completed as observed on the behavior monitoring documentation per each date identified. * Antianxiety side effect monitoring [typed as written] but not limited to : Dystonia; torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy. Weakness, hangover effect. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of antianxiety side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed the antianxiety side effect behavior monitoring was not completed as ordered. *Antidepressant side effect monitoring not limited to: Dystonia, torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, weakness, tremors, appetite change/weight change, insomnia, confusion, tardive dyskinesia, suicidal ideations. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of Antidepressant side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed Antidepressant side effect behavior monitoring was not completed as ordered. *Antipsychotic side effect monitoring list #1: Dystonia: torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, pseudo parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of Antipsychotic side effect list #1 behavior monitoring for the following: 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that Antipsychotic side effect list #1 behavior monitoring was not completed as ordered. **Antipsychotic side effect monitoring list #2 not limited to: Insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity. Every shift. Order and Start date 06/29/23 with no end date identified. - Missing documentation of Antipsychotic side effect list #2 behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that the Antipsychotic side effect monitoring list #2 was completed as ordered. *Mood Stabilizer side effect monitoring: Hives, a rash, fever, or swollen glands. Signs of [NAME] Johnson's syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids. Confusion, Slurred speech. Nausea, vomiting, and diarrhea. Trembling. Increased thirst and increased need to urinate Weight gain in the first few months of use. Drowsiness. Every shift. Order and Start date 05/21/23 with no end date identified. - Missing documentation of Mood Stabilizer side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing day shift (7:00 AM - 7:00 PM) 07/06/24 - missing day shift (7:00 AM - 7:00 PM) 07/07/24 - missing day shift (7:00 AM - 7:00 PM) 07/18/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 08/05/24 - missing night shift (7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that the Mood Stabilizer side effect behavior monitoring was not completed as ordered. b) Resident #82 During a medical record review of Resident #82's behavior monitoring on 08/06/24 at approximately 12:11 PM the following monitoring orders were identified for medication behavior side effects with the noted discrepancies of the orders being completed as observed on the behavior monitoring documentation per each date identified. * Antianxiety side effect monitoring [typed as written] but not limited to : Dystonia; torticollis (stiffness of neck), anticholinegic symptom: Dry mouth, burred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy. Weakness, hangover effect. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of antianxiety side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed the antianxiety side effect behavior monitoring was not completed as ordered. *Antidepressant side effect monitoring not limited to: Dystonia, torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, weakness, tremors, appetite change/weight change, insomnia, confusion, tardive dyskinesia, suicidal ideations. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of Antidepressant side effect behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed Antidepressant side effect behavior monitoring was not completed as ordered. *Antipsychotic side effect monitoring list #1: Dystonia: torticollis (stiffness of neck), anticholinergic symptom: Dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities (tachycardia, bradycardia, irregular HR (heart rate) NMS (Neuroleptic malignant syndrome). Anxiety/agitation, blurred vision, sweating/rashes, headaches, urinary retention/hesitancy, pseudo parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of Antipsychotic side effect list #1 behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that Antipsychotic side effect list #1 behavior monitoring was not completed as ordered. **Antipsychotic side effect monitoring list #2 not limited to: Insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity. Every shift. Order and Start date 02/15/24 with no end date identified. - Missing documentation of Antipsychotic side effect list #2 behavior monitoring for the following; 07/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/02/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/03/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/04/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/05/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/06/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/07/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) 07/08/24 - missing day shift (7:00 AM - 7:00 PM) 07/20/24 - missing day shift (7:00 AM - 7:00 PM) 07/21/24 - missing day shift (7:00 AM - 7:00 PM) 07/24/24 - missing day shift (7:00 AM - 7:00 PM) 07/25/24 - missing day shift (7:00 AM - 7:00 PM) 07/30/24 - missing day shift (7:00 AM - 7:00 PM) 08/01/24 - missing both day and night shift (7:00 AM - 7:00 PM/ 7:00 PM - 7:00 AM) On 08/07/24 at 12:30 PM during an interview with the DON, the DON agreed that the Antipsychotic side effect monitoring list #2 was completed as ordered.

. Based on record review and staff interview, the facility failed to ensure medical records for each resident were accurately documented for two (2) of five (5) records reviewed. The facility failed to obtain correct signatures on Physician orders for scope of treatment (POST) form. Resident identifiers: #36 and #17. Facility census: 93 Findings included: a) Resident #36 On 08/05/24 at 03:06 PM a review of POST, revealed that a verbal consent was obtained and no signature was ever obtained on POST form on file dated 09/08/23. Stated signature obtained via telephone with one witness signature. On 08/07/24 at 09:45 AM a review of [NAME] Virginia POST Form Guidance for Health Care Professionals 2021 Edition which revealed that Medical Power of Attorney (MPOA) signature must obtained for POST to be valid. If MPOA is not available, verbal consent can be obtained with 2 witness signatures until the original signature can be obtained. On 08/07/24 at 10:16 AM, during an interview with the administrator and social worker, they acknowledged this resident's POST form was only singed by one witness and had not yet be signed by the Medical Power of Attorney. Social Worker stated she was currently working on correcting this. b) Resident #17 During a medical record review of Resident #17's POST form 08/07/24 at 9:25 AM it was identified that the post form did not have a signature for the Patient/Patient MPOA representative/surrogate signature. The medical record revealed a hand written note that read [typed as written] via email [West Virginia Department of Health Services (WVDOHS) name of case worker] and dated 07/19/24 with a certified mail receipt dated 08/02/24 to [WVDOHS name of case worker]. On 08/07/24 at 9:45 AM Review of WV POST, using the POST Form Guidance for Health Care Professionals 2021 Edition which reveals that MPOA signature must obtained for POST to be valid. If MPOA is not available, verbal consent can be obtained with two (2) witness signatures until the original signature can be obtained. During an interview with Director of Social Services (DSS) on 08/07/24 at approximately 9:50 AM with the Director of Social Services (DSS) #78 , she acknowledge that this resident's POST form was not signed and that an email is not an acceptable signature as identified in the Health Care Professionals 2021 Edition. The DSS #78 states she is working on getting this signed by the [WVDOHS name of case worker].

. Based on facility records review and staff interview the facility failed to ensure to have all the required signatures and attendees and signatures for their Quality Assurance Performance Improvement (QAPI) meetings. This was discovered during the long term care survey process and had the ability to affect more than a limited number of residents. Identifiers: Meetings dated- 02/23/23, 06/30/23, 08/10/23, 08/02/24. Facility Census: 93. a) 02/23/23 During a record review on 08/07/24 at approximately 2:00 PM of the QAPI meeting attendance it was identified that the Director of Nursing (DON) who was also the Person In Charge (PIC) for the facility. The DON/PIC at this time did not sign in attendance for this meeting. It is further identified, the QAPI information was reviewed with the Medical Director verbally. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated it did not make sense that the DON/PIC did not attend this meeting. She felt the DON/PIC may have forgotten to sign. The Administrator stated the Medical Director did not attend the meeting and the DON/PIC later spoke with him. She stated that the Medical Director and his Family Nurse Practitioner later signed the form. b) 06/30/23 Record review on 08/07/24 of the QAPI meeting attendance identified the Director of Nursing (DON) who was also the Person In Charge (PIC) for the facility at this time did not sign in attendance for this meeting. It was further identified that QAPI information was reviewed with the Medical Director verbally. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated it did not make sense that the DON/PIC did not attend this meeting. She felt the DON/PIC may have forgotten to sign. The Administrator then confirmed the Medical Director did not attend the meeting and the DON/PIC later spoke with him. She stated the Medical Director and his Family Nurse Practitioner later signed the form. c) 08/10/23 Record review on 08/07/24 at approximately 2:00 PM of the QAPI meeting attendance identified that the Director of Nursing (DON) who was also the Person In Charge (PIC) for the facility did not sign in attendance for this meeting. It was further identified that the QAPI information was reviewed with the Medical Director verbally. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated it did not make sense that the DON/PIC did not attend this meeting. She felt the DON/PIC may have forgotten to sign. The Administrator further explained the note [typed as written] Spoke with and reviewed with [Medical Directors name] that was written on the signature sheet. The Administrator stated the Medical Director did not attend the meeting and the DON/PIC later spoke with him. She stated that the Medical Director and his Family Nurse Practitioner later signed the form. d) 08/02/24 During a record review on 08/07/24 at approximately 2:00 PM of the QAPI meeting attendance is was identified that the Director of Nursing (DON) did not sign in attendance for this meeting. During an interview with the Administrator on 08/07/24 at approximately 2:10 PM she stated that the DON at this time was an Interim and she felt that the DON may had already left for the week. She was not certain why the Interim DON did not attend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to update the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening and Resident Review (PASRR) with new qualifying diagnoses for five (5) out of 30 residents reviewed during the long term survey process. Residents identifiers: #26, #49, #14, #17, #45. Facility Census: 93. Findings include: a) Resident #17 During a medical record review on 08/06/24 at 9:30 AM, Resident #17's PASRR was reviewed. The PASRR was dated 08/19/16 with no level two required. A further review of the medical diagnosis of Resident #17 found a new diagnosis of unspecified dementia, moderate with psychotic disturbances, dated 05/13/24, unspecified dementia unspecified severity with other behavioral disturbance dated 10/01/22, unspecified psychosis not due to a substance or known physiological condition dated 09/16/24. During an interview with Director of Social Services (DSS) #78 on 08/06/24 at approximately 10:00 AM, DSS #78 stated she was aware that numerous PASSARS needed updated but she had not completed them yet. She further stated, she discussed this with the leadership team but they had not covered it in their Quality Assurance meeting. She further acknowledged, the recent diagnosis referenced had not been resubmitted on a new PASRR. b) Resident #26 During a medical record review on 08/06/24 at 9:30 AM, Resident #26's PASSAR was reviewed. The PASRR was dated 06/12/23 with no level two required. A further review of the medical diagnosis of Resident #26 found a new diagnosis of schizoaffective disorder dated 04/24/24, was not identified on the PASRR submitted on 06/12/23. During an interview with the Director of Social Services (DSS) #78 on 08/06/24 at approximately 11:45 AM, DSS #78 stated she was aware numerous PASRRs needed updated and she had completed this one on the morning of 08/06/24 and it was submitted with the new diagnosis. She further stated, she has discussed this with the leadership team but they have not covered it in their Quality Assurance meeting. c) Resident #49 Resident #49 was admitted to the facility on [DATE]. During a record review for Resident #49, it was discovered the resident was diagnosed with major depressive disorder on 01/08/20, during her stay at the facility. Upon further review, it was discovered the facility had not completed a new PASRR for Resident #49 after the diagnosis was made. At approximately 10:00 AM on 08/07/24, an interview was conducted with the Social Worker (SW) at the facility. The SW stated there was a backlog of PASRRs that needed to be resubmitted and Resident #49 was on that list. The SW stated she was submitting new PASRRs for residents in alphabetical order and would get to Resident #49, but it would take a while. d) Resident #14 On 08/05/24 at 3:05 PM, a review of the resident's medical records, found Resident #14's medical diagnoses include the following: Atherosclerotic Heart Disease, Morbid Obesity, Hereditary Idiopathic Neuropathy, Angina Pectoris, Paroxysmal Atrial Fibrillation, Vitamin B12 Deficiency Anemia, Unspecified Combined Systolic and Diastolic Congestive Heart Failure, Unspecified Psychosis Not Due to a substance or known physiological condition, Generalized Anxiety Disorder, Major Depressive Disorder Recurrent, Conversion Disorder with Seizures, Paraphilia, Hallucinations, Opioid Abuse in remission. On 08/05/24 at 3:10 PM, a review of Resident #14's current [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (WVPASRR) dated 01/28/22, revealed section III, Question 30. MI/MR Assessment, Current Diagnosis was marked a) None. Section V. Question 40. Major Mental Illness Suspected was marked none. On 08/06/24 at 4:25 PM, an interview with the social worker revealed she was aware of the WVPASRR needing updated. She said she was currently working on renewing the WVPASRRs, for the entire building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the correct diagnoses on the Pre-admission Screening and Resident Review (PASRR) and, if necessary, submit a new one, at the time of admission. This was true for five (5) of thirty (30) residents reviewed for PASRRs during the survey process. Resident identifiers: #53, #33, #7, #17, #29. Facility census: 93. Findings include: A) Resident #53 At approximately 2:00 PM on 08/05/2024, a record review was conducted for Resident #53. During the review, it was determined Resident #53 was admitted to the facility on [DATE] and was diagnosed with major depressive disorder upon admission, on 08/16/22. The original PASRR was missing a diagnosis of major depressive disorder, and the facility did not submit a new PASRR upon the diagnosis of major depressive disorder. At approximately 10:00 AM on 08/07/2024, an interview was conducted with the Social Worker (SW) at the facility. The SW stated there was a backlog of PASRRs that needed resubmitted, and Resident #53 was on that list. The SW stated she was submitting new PASRRs for residents in alphabetical order and would get to Resident #53, but it would take a while. b) Resident #33 On 08/06/24 at 10:07 AM a review of Resident # 33's medical record noted a diagnosis of Bipolar Disorder, Major Depressive Disorder, Seizure Disorder and Post Traumatic Stress Disorder was present at Resident #33's time of admission to the facility. Resident # 33's Preadmission Screening and Resident Review form (PASRR) dated 01/09/19 did not reflect these diagnoses. The facility failed to complete a new PASARR that reflected the diagnoses that were present at the time of Resident # 33's admission which were Bipolar Disorder, Major Depressive Disorder, Seizure Disorder and Post Traumatic Stress Disorder. On 08/06/24 at 10:15 AM an interview with the Administrator and Social Worker (SW) was completed. At this time, the Administrator and SW acknowledged a new PASRR was not completed to reflect the diagnoses Bipolar Disorder, Major Depressive Disorder, Seizure Disorder and Post Traumatic Stress Disorder which were present at time of admission. c) Resident #7 On 08/06/24 at 11:00 AM a review of Resident #7's medical record noted a diagnosis of Major Depressive Disorder and Psychosis, and convulsions was present at Resident #7's time of admission to the facility. Resident #7's Preadmission Screening and Resident Review form (PASRR) dated 01/09/19 did not reflect these diagnoses. The facility failed to complete a new PASRR that reflected the diagnoses that were present at the time of Resident #7's admission which were Major Depressive Disorder and Psychosis and convulsions. On 08/06/24 at 10:15 AM an interview with the Administrator and Social Worker (SW) was completed. At this time, the Administrator and SW acknowledged a new PASRR was not completed to reflect the diagnoses, Major Depressive Disorder and Psychosis and convulsions, which were present at time of admission. d) Resident #17 During a medical record review on 08/06/24 at 9:30 AM, Resident #17 [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PASSAR) was identified dated 08/19/16 with no level two required. A further review of the medical diagnosis of Resident #17, identified a diagnosis of major depressive disorder dated 08/09/16. During an interview with the Director of Social Services (DSS) #78 on 08/06/24 at approximately 10:00 AM, DSS #78 stated she was aware that numerous PASRRs needed updated, but she had not completed them yet. She further stated that she had discussed this with the leadership team, but they had not covered it in their Quality Assurance meeting. She further acknowledged the diagnosis should have been submitted on the admitting PASRR and should have been resubmitted upon admission with it not included on the PASRR. e) Resident #29 During a medical record review on 08/06/24 at 9:30 AM, Resident #26 PASRR was reviewed. The PASRR was submitted on 05/22/24 with no level two required. A review of the medical diagnosis for Resident #26 identified, a diagnosis of hallucinations dated 08/01/23 and a diagnosis of psychotic disorder with delusions due to known physiological condition dated 08/01/23 which were not identified on the PASRR submitted on 05/22/24. During an interview with the Director of Social Services (DSS) #78 on 08/06/24 at approximately 10:00 AM, DSS #78 stated she was aware that numerous PASSARS needed updated, but she had not completed them yet. She further stated had discussed this with the leadership team, but they have not covered it in their Quality Assurance meeting. She acknowledged the diagnoses were missing from the PASRR when it was submitted and should have been resubmitted upon admission with it not being included on the PASRR.

. This will be cited as past noncompliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not recur. All components of the plan of correction were completed prior to this survey beginning. On 08/07/24 at 9:05 AM record review shows the facility reported incident concerning wound dressings that were not changed according to the Physicians order. Resident #45 has an order to change the dressing to the coccyx daily. On 07/21/24 when Registered Nurse (RN) #73 went to change Resident #45's wound dressing she found the old dressing to be dated 07/18/24 and the initials of Licensed Practical Nurse (LPN) #180. The documentation in Point Click Care reflected the dressing was changed on 07/20/24 when in fact it had not been changed since 07/18/24 reflecting it had not been changed for three (3) days. This allegation was reported to the appropriate offices and investigated. It was substantiated by the investigating staff. There were audits performed of all residents in house that have dressings ordered. There was a mandatory in service performed with all nursing staff attending. LPN #180 was released from their employment. The plan in place is to continue to audit all dressings weekly times ten (10) weeks and randomly thereafter. On 08/07/24 the surveyor and LPN #84 observed dressings for Resident #30, #45, #77, #35, #95 and #152. All dressings were appropriately dated for 08/06/24. The above findings were discussed and confirmed with the Administrator on 08/07/24 at 1:10 PM. d) Resident #77 This will be cited as past noncompliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not recur. All components of the plan of correction were completed prior to this survey beginning. On 08/07/24 at 9:05 AM record review shows the facility reported incident concerning wound dressings that were not changed according to the Physicians order. Resident #77 has an order to change the dressing to the the right heel daily. On 07/21/24 when Registered Nurse (RN) #73 went to change Resident #77's wound dressing she found the old dressing to be dated 07/18/24 and the initials of Licensed Practical Nurse (LPN) #180. The documentation in Point Click Care reflected the dressing was changed on 07/20/24 when in fact it had not been changed since 07/18/24 reflecting it had not been changed for three (3) days. This allegation was reported to the appropriate offices and investigated. It was substantiated by the investigating staff. There were audits performed of all residents in house that have dressings ordered. There was a mandatory in service performed with all nursing staff attending. LPN #180 was released from their employment. The plan in place is to continue to audit all dressings weekly times ten (10) weeks and randomly thereafter. On 08/07/24 the surveyor and LPN #84 observed dressings for Resident #30, #45, #77, #35, #95 and #152. All dressings were appropriately dated for 08/06/24. The above findings were discussed and confirmed with the Administrator on 08/07/24 at 1:10 PM. e) Resident #84 On 08/05/24 at 3:44 PM an interview was conducted with Resident # 84 who reported in the early morning of Wednesday 07/31/24, she had fallen. She stated a nurse assisted her and told her they would send her for an x-ray. The resident stated that she hurt the left stump of her amputated leg and is in the process of getting a prosthetic leg. She fears if it was injured it would delay that process. Resident stated, x-ray comes in on Tuesday and Thursday, but left before seeing her this week. She stated, nursing told her they would send her out over the weekend for an x-ray but did not. An interview was conducted on 08/05/24 at 3:53 pm with Registered Nurse (RN) #107 who was the resident's assigned nurse for 08/05/24. Says she seen notes for a fall and for residents to be x-rayed. RN #106 assisted resident in reviewing the computer order and reported the facility had been having issues with the company who provides X-rays for them but was unsure as to why the resident had not yet been x-rayed. She reported she was on schedule now for 08/06/24. On 08/05/24 at 7:14 PM, a review of the resident's physician orders revealed the following: X-ray of the left stump every shift for pain post fall Diagnostic, Active dated 7/31/24 at 7:00 pm. On 08/06/24 the fall log was reviewed and revealed the resident had fallen but was caught on 07/30/24 at 12:35 AM. f) Resident #29 A medical record review on 08/07/24 at approximately 12:00 PM , found Resident #29 had an order for accu-check BID (twice a day) and to notify MD if less than 60 or greater than 350 two (2) times a day related to Type 2 (two) Diabetes Mellitus without complications. The start date for this order was identified to be 08/29/22. During a further review of the Medication Administration Record (MAR) it was identified on 07/22/24 the morning accu-check was not marked as completed. During an interview with the DON 08/07/24 at approximately 12:00 PM, the DON confirmed the accu-check had not been completed for 07/22/24 morning shift.

Based on observation and staff interview the facility failed to ensure a dignified dining experience. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside in the facility. Resident identifier: #57. Facility census 90. Findings included: a) Resident #57 While monitoring staff serving lunch on 09/12/23 at 12:00 PM it was noted that the roommate of Resident #57 was eating her lunch, while Resident #57 did not have a lunch tray. The Nurse Aide (NA) #44 was asked why Resident #57 did not have a tray at the same her roommate did? NA #44 said she does have her tray. After looking in the room herself she said she must have forgotten to give Resident #57 her tray. The above was reported to the Administrator on 09/12/23 at 1:00 PM.

b) Observation of the kitchen Observation on 09/12/23 at 8:15 A.M., found a box of spoiled lettuce and spoiled cabbage in separate boxes in the refrigerator walk in. An interview was conducted on 09/12/23 at approximately 8:20 A.M. with Employee 12. Employee #12 stated I will take these boxes out. I did not know the lettuce and cabbage were spoiled. I will make sure we get rid of them today. I will clean this area now. Based on observation and staff interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 90. Findings included: a) Ice Machine in the nourishment room On 09/12/23 at 8:45 AM an observation of the ice machine found the ice machine was covered along the top and around the door with a thick buildup of a white, gray, and rusty substance. On 09/12/23 at 11:00 AM a tour with Director of Plant Maintenance (DPM) #67 said if they stop the use of the ice machine then staff would have to go upstairs to get it. DPM #67 agreed the ice machine was rusty and leaks. On 09/12/23 at 1:07 PM, the Administrator informed of the above findings and stated it will be replaced as soon as possible.

Based on staff interviews and observation the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents who recurrently reside at the facility. Facility census 90. Findings included: a) A and B Hallways On 09/12/23 at 8:10 AM while touring the facility it was discovered the wallpaper was peeling off of the walls in hall A and B. The baseboards were pulled away from the walls bearing broken pieces of sheet rock. On the walls behind the handrails were multiple holes in the wall. On 09/12/23 at 11:00 AM, a tour with Director of Plant Maintenance (DPM) #67 found DPM #67 agreed the walls on A and B hallways were in need of repair.

. Based on record review, family interview, resident interview, and staff interview, the facility failed to send a notice of discharge to a hospital resident who was not permitted to return to the facility. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of discharge. Resident identifier: #89. Facility census: 82. Findings included: a) Resident #89 The facility's policy titled Discharge of a Resident issued 03/01/14 and revised 09/28/22 did not specifically address discharge of a resident who had been transferred to the hospital. Review of Resident #89's medical records showed the resident had been admitted for therapy following a right above knee amputation. She was receiving dialysis treatments and receiving Vancomycin for cellulitis of the left foot. She had capacity to make her own medical decisions per the physician's determination of capacity performed on 02/10/23. On 03/08/23, the resident's left foot wound worsened. The resident was transferred to the hospital that day. A discharge, return anticipated Minimum Data Set (MDS) Assessment was performed on 03/08/23. The following nursing note was written on 3/9/2023 at 6:39 AM, This nurse called [hospital's name] ER [emergency room] regarding admission status. This patient admitted to [hospital's name] for DX [diagnosis]: gangrene left great toe. This was the last note entered into the resident's medical chart. Review of reportables showed on 03/20/23, Resident #89's daughter alleged the resident had been mistreated. The allegation was unsubstantiated after investigation. The investigation concluded, It is probable and plausible that the allegation stemmed from [daughter's name]'s frustration with the denial of placement back to this facility. During an interview at 04/17/23 at 2:20 PM, the Director of Nursing (DON) stated the hospital had contacted the facility for the resident to return to the facility. The facility declined to reaccept the resident. The DON confirmed no written discharge notification had been sent to the resident. On 04/17/23 at 5:00 PM, the complainant was interviewed by telephone. The complainant said she was told by the resident's caseworker at the hospital that the resident was not permitted to return to the nursing home. The complainant said she never saw a discharge notice. On 04/17/23 at 7:05 PM, Resident #89 was interviewed. She stated she had wanted to transfer back to the facility when her hospitalization was completed. She confirmed she had not received a discharge notice. She stated she heard from her daughter that she was not permitted to return to the facility. .

. Based on medical record review and staff interview, the facility failed to provide written information regarding the facility's bed hold policy. This was true for 12 of 20 residents reviewed for discharge from the facility. Resident identifiers: #93, #16, #94, #18, #70, #95, #30, #36, #12, #60, #42, and #98. Facility census: 92. Findings include: a) Residents #93, #16, #94, #18, #70, #95, #30, #36, #12, #60, #42, and #98. The facility had the following transfers to an acute care facility after 04/28/23 through current (06/20/23): -- Resident #93- on 05/09/23. --Resident #16- on 05/10/23. --Resident # 94- on 05/11/23. --Resident #18-on 05/17/23. -- Resident #70- on 05/18/23. -- Resident #95- on 05/22/23. -- Resident #30- on 05/24/23. --Resident #36 - on 05/24/23. --Resident #12-on 05/31/23. --Resident #60-on 06/02/23. -- Resident #42- on 06/03/23. -- Resident #98- on 05/04/23. Review of the above-mentioned residents' medical records found no indication a bed hold policy was provided to the resident and/or the resident's representatives. On 06/20/23 at 11:30 AM, an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), confirmed a written copy of the facility's bed hold policy was never provided to the residents/responsible parties.

. Based on observation and staff interview the facility failed to ensure all residents were provided a dignified existence. The failed to provide a privacy cover on the Foley catheter collection bag. This was a random opportunity for discovery and was true for Resident #64. Resident identifiers: Resident # 64. Facility census 91. Findings included: a) Resident # 64 During a brief observation of Resident # 64 on 08/22/22 at 12:26 PM, it was discovered there was not a privacy cover on the indwelling Foley urine collection bag. Licensed Practical Nurse (LPN) #7 was present during this observation and verified there was not a privacy bag covering Resident #64's urine collection bag. LPN #7 stated she would replace the privacy cover immediately. .

. Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment by not providing a clean, and safe ventilation wall unit for Resident #23. This was a random opportunity for discovery. Resident identifier #23 Facility Census: 91 Findings Included: a) Resident #23 On 8/22/22 at 11:44 AM during the initial interview process of the survey it was observed that the ventilation wall unit under the window was rusty and the front of the unit was loose and hanging off on the right hand corner. The Director of Nursing observed this ventilation wall unit on 08/23/22 at 10:12 am and agreed the unit was rusted and in poor repair. .

. Based on medical record review and staff interviews the facility failed to timely submit a correct discharge tracking Minimum Data Sets (MDS) for : Resident # 89. The MDS was inaccurate in the area of discharge status. This was true for one (1) of one (1) sampled residents reviewed during the Long Term Care Survey Process. Resident identifiers: #89. Facility census: 91. Findings included: a) Resident #89 A medical record review for Resident #89 revealed a discharge MDS had been coded as an acute care hospital discharge for Resident #89, who was discharged to community on 06/07/22. In an interview with the Director of Nursing on 08/23/22 at 11:38 AM, she verified the discharge MDS tracking completed when Resident #89 was inaccurate in the area of discharge status. She verified the resident was discharge to the community (home) not to a acute care facility. .

. Based on record review and staff interview the facility failed to develop a care plan that included non-pharmacological interventions for a resident who was receiving a PRN (as needed) medication for pain. This was true for one (1) out of 19 sampled residents reviewed. Resident identifiers: Resident #77. Facility census 91. Findings included: a) Resident #77 While reviewing the medical record for Resident #77 in regards to receiving an as needed (PRN) pain medication. It was revealed the facility failed to use non-pharmacological interventions prior to administrating the pain medication (Norco). The care plan contained the following information: Focus: *Chronic pain related to Neuropathy Dated initiated: 02/07/22 Created by: Former employee #139 Goal: *Will not have an interruption normal activities due to pain through the review date. Interventions: * Monitor/document pain characteristics PRN: Quality (e.g., Sharp, burning). Severity (faces scale). Anatomical location, onset, duration (e.g., continuous, intermittent). Aggravating factors, Relieving factors. *Provide Lyrica, Norco as ordered. *Monitor/document for side effects and effectiveness. On 08/23/22 at 11:13 AM, the Director of Nursing (DON) reviewed the care plan and agreed there was not any non-pharmacological interventions and there should be. The DON stated she would look for more information. At the close of the survey no additional information was provided. .

. Based on record review and staff interview the facility failed to revise the care plan for Resident #84's dialysis information. In addition the facility failed to revise Resident #66's care plan when an antifungal medication was discontinued. This was true for two (2) of 19 sampled residents. Resident identifier: #84 and #66. Facility Census: 91 Findings included: a) Resident #84 During the initial interview of the annual survey process on 8/22/22 at 11:17 AM it was found Resident #84 was a dialysis patient. She had a right upper extremity dialysis fistula and goes to a local dialysis center on Monday, Wednesday and Fridays for dialysis. The Care Plan states: Assist patient with transportation to dialysis appointments. Dialysis Schedule: [At name of dialysis center and phone number) on Monday, Wednesday, Friday at 6:30 PM. Transport to Dialysis: STAT ambulance. Pick up time: 5:30 PM. Transport from Dialysis: STAT ambulance. Certificate of Medical Necessity for ambulance transport on file. Send cushion, blanket, and with resident. Resident states She goes early in the morning on Monday, Wednesday and Friday. She is served breakfast before she leaves. An interview on on 08/23/22 at 10:07 am, with the Director of Nursing confirmed the Resident goes to dialysis Monday, Wednesday and Fridays for a chair time of 6:30 AM, not PM as the care plan states the pick up time incorrectly. b) Resident #66 On 08/22/22 at 1:15 PM, a record review was completed for Resident #66. An acute care discharge summary was found dated 05/27/22. The discharge instructions listed the following: --Consider polypharmacy as likely cause of lethargy, candida (yeast infection) in inguinal area (lower abdomen) & (and) under right breast, Rx: (prescription) nystatin cream, UTI Rx: (prescription) Keflex 250mg po (by mouth) q (every) 6 (six) hours x (times) 5 (five) more days. (Typed as written.) A discontinued physician's order was found dated 05/27/22 to start on 05/28/22 was written as follows: --Nystatin Cream 100000 unit/GM (gram) apply to under right breast and inguinal areas (lower abdomen) topically every day and night shift for candida (yeast infection) for 5 (five) days. (Typed as written.) The discontinue date of the Nystatin cream was 06/02/22. On 08/23/22 at 3:00 PM, the current care plan was reviewed. The care plan listed a focus area of fungal infection to the lower abdomen skin fold and right breast. The focus area was initiated on 05/31/22. On 08/23/22 at 3:58 PM, the Director of Nursing (DON) confirmed the care plan had not been revised when the Nystatin cream was discontinued. No further information was obtained during the survey process. .

. Based on observation and staff interview the facility failed to provide urinary catheter care in accordance with the current professional standards of care. This was a random opportunity for discovery. Resident identifiers: #64. Facility census 91. Findings included: a) Resident # 64 During a brief observation of Resident # 64 on 08/22/22 at 12:26 PM, it was discovered the indwelling Foley collection bag was hanging in the center of the bed. The bed was at it's closest position, with the head and foot of the bed raised. The collection bag should have been placed at the foot of the bed to prevent the collection bag from touching the floor. On 08/22/22 at 12:30 PM, Licensed Practical Nurse (LPN) #7 arrived in the room and agreed the collection bag was laying on the floor. LPN #7 placed the collection bag inside of a gray basin pan. .

. Based on record review and staff interview the facility failed to ensure the attending physician provided a rationale for a pharmacy recommendation they declined. This failed practice was true for one (1) out of five (5) sampled residents for unnecessary medications. Resident identifiers: Resident #77. Facility census 91. Findings included: a) Resident #77 While reviewing the medical records for Resident #77 it was discovered on 07/21/22 the facility pharmacist completed a MRR (monthly regimen review). This form was titled, Note to Attending Physician/Prescriber, and read as follows: Resident has a PRN (as needed) order for Norco (Hydrocodone/APAP) 7.5/325 mg Q6hr (every six hours) PRN, with needed administrations four (4) times everyday of July except for 07/07/22 three (3) administrations, please evaluate if resident would benefit from scheduling QID (four times a day). On the section Physician/Prescriber Response, there are three boxes to choose from to check. Agree, Disagree, and other. None of the boxes were checked. In addition there are lines for the Physician/Prescriber to provide a rationale, these lines were blank. It was noted the word NO was wrote above the line of this section on the form. This was signed by the facility attending physician and dated on 08/01/22. During an interview on 08/23/22 at 10:33 AM, Director of Nursing (DON) was asked if there was any information about why the physician only responded with one word, NO. The DON stated she would try to find out. On 08/23/22 at 10:43 AM, the DON stated the physician increased the medication Lyrica on 07/12/22, so that is why he did not want to make the Norco a scheduled medication. The DON was asked if the attending physician provided a rationale by writing, No. The DON said she did not think so. .

. Based on observation and staff interview the facility failed to store food in a safe manner. There was opened foods stored in the kitchen walk in freezer that were not labeled as to when the foods were opened and when they expired. The failed practice had the potential to affect a limited number of residents currently receiving nutrition from the facility's kitchen. Facility Census: 91 Findings Included: a) Kitchen During the initial walk through tour of the kitchen on 8/22/22 at 11:50 AM with the Dietary Services Supervisor #20 it was found that there was a bag of opened breaded fish sticks and a bag of breaded chicken that was not dated with an open date, nor a use by date. This was confirmed with the Dietary Services Supervisor #20 on 8/22/22 at 11:50 AM. According to the Food Service Procedural Manual titled Sanitation/Food Handling, Section B.1 Labeling Food ( Foods must be labeled when opened with name of food and date opened and the use by date .). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to ensure the dialysis order for Resident #84 was correct and failed to properly complete a smoking assessment for Resident #13. Resident identifiers: #84 and #13. Facility Census: 91 Findings included: a) Resident #84 During the initial interview of the annual survey process on 8/22/22 11:17 AM it was found Resident #84 was a dialysis patient. She had a right upper extremity dialysis fistula and goes to a local dialysis center on Monday, Wednesday and Fridays for dialysis. The current order states: (dialysis facility name, address and phone number). Dialysis days are Monday, Wednesday & Friday at 6:30 PM. Pick up is at 5:30. Transportation provided by STAT Emergency Medical Services. Send Cushion, Blanket with resident. The Care Plan states: Assist patient with transportation to dialysis appointments. Dialysis Schedule: [At name of dialysis center and phone number) on Monday, Wednesday, Friday at 6:30 PM. Transport to Dialysis: STAT ambulance. Pick up time: 5:30 PM. Transport from Dialysis: STAT ambulance. Certificate of Medical Necessity for ambulance transport on file. Send cushion, blanket, and with resident. Resident states She goes early in the morning on Monday, Wednesday and Friday. She is served breakfast before she leaves. An interview with the Director of Nursing on 08/23/22 at 10:07 am confirmed the Resident goes to dialysis Monday, Wednesday and Friday for a chair time of 6:30 AM, not PM. b) Resident #13 On 8/23/22 at 10:42 AM the Administrator provided a list of current smokers of which Resident #13 was listed. The smoking evaluation is included in the Nursing Assessment Version 3-V8. According to the latest Nursing assessment dated [DATE], page 17, Resident #13 does not report current use of tobacco. On 8/23/22 at 10:45 AM verification with the Resident and the Director of Nursing confirmed the Resident does currently smoke. Operations Policy for Use of Tobacco Products by Residents dated 3/01/18 states: assess each resident desiring to use tobacco products for the amount of supervision required to use the products safely, including but not limited to smoking ). .

Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders for two (2) of 18 residents reviewed during the long-term care survey process. Resident identifiers: #46, and #59. Facility census: 84. Findings included: a) Resident #46 Review of Resident #46's physician's orders revealed the following order written on 02/15/21: Three times a day Give 240 ml of Isosource 1.5 after meal if he consumes less than 50%. Resident #46's Medication Administration Record (MAR) and meal intake percentages recorded by nursing assistants on the documentation survey report were reviewed for the preceding two (2) weeks. The MAR had sections to record the percentage of meal intake and whether tube feeding was administered. On 04/21/21 at 8:00 AM, Resident #46's MAR did not record the percentage of meal intake. For administration, an 11 was noted. According to the chart code, 11 means not administered. The documentation survey report recorded 20% of breakfast was consumed, indicating the resident should have received tube feeding. On 04/21/21 at 6:00 PM, Resident #46's MAR did not record the percentage of meal intake. For administration, an 11 was noted, indicating tube feeding was not administered. The documentation survey report recorded 20% of dinner was consumed, indicating the resident should have received tube feeding. On 04/26/21 at 8:00 AM, Resident #46's MAR recorded 90% of breakfast was consumed, indicating tube feeding was not to be administered. However, a check mark was documented on the MAR, indicating the tube feeding had been administered. The meal intake percentage on the documentation survey report agreed with the intake percentage recorded on the MAR. On 04/26/21 at 1:00 PM, Resident #46's MAR did not record the percentage of meal intake. For administration, an 11 was noted, indicating tube feeding was not administered. The documentation survey report recorded 25% of lunch was consumed, indicating the resident should have received tube feeding. On 04/27/21 at 8:00 AM, Resident #46's MAR documented 90% of breakfast was consumed, indicating tube feeding was not to be administered. However, a check mark was documented on the MAR, indicating the tube feeding had been administered. The documentation survey report recorded 35% of breakfast had been consumed, which did not match the percentage recorded on the MAR. On 04/27/21 at 1:00 PM, Resident #46's MAR documented 90% of lunch was consumed, indicating tube feeding was not to be administered. However, a check mark was documented on the MAR, indicating the tube feeding had been administered. The meal intake percentage on the documentation survey report agreed with the intake percentage documented on the MAR. On 04/27/21 at 6:00 PM, Resident #46's MAR documented 90% of dinner was consumed, indicating tube feeding was not to be administered. However, a check mark was documented on the MAR, indicating the tube feeding had been administered. The documentation survey report reported 25% of dinner had been consumed, which did not match the amount reported on the MAR. On 04/30/21 at 8:00 AM, Resident #46's MAR documented the resident consumed 0% of breakfast. A check mark was documented on the MAR, indicating tube feeding had been administered. However, the documentation survey report documented the resident had consumed 85% of breakfast, indicating tube feeding should not have been administered. On 04/30/21 at 6:00 PM, Resident #46's MAR documented the resident consumed 0% of dinner. A check mark was documented on the MAR, indicating tube feeding had been administered. However, the documentation survey report documented the resident had consumed 80% of dinner, indicating tube feeding should not have been administered. On 05/01/21 at 8:00 AM, Resident #46's MAR documented the resident consumed 0% of breakfast. A check mark was documented on the MAR, indicating tube feeding had been administered. However, the documentation survey report documented the resident had consumed 100% of breakfast, indicating tube feeding should not have been administered. On 05/02/21 at 8:00 AM, Resident #46's MAR did not document the percentage of meal intake. For administration, an 11 was noted, indicating tube feeding was not administered. The documentation survey report reported 25% of breakfast was consumed, indicating the resident should have received tube feeding. On 05/02/21 at 1:00 PM, Resident #46's MAR documented the resident consumed 0% of lunch. A check mark was documented on the MAR, indicating tube feeding had been administered. However, the documentation survey report documented the resident had consumed 70% of lunch, indicating tube feeding should not have been administered. On 05/02/21 at 6:00 PM, Resident #46's MAR did not document the percentage of meal intake. For administration, an 11 was noted, indicating tube feeding was not administered. The documentation survey report reported 25% of dinner was consumed, indicating the resident should have received tube feeding. During an interview on 05/04/21 at 3:06 PM, the Director of Nursing (DON) was informed that on the following dates and times, Resident #46's MAR indicated the resident had received tube feeding when the recorded meal percentages did not indicate tube feeding should have been given: 04/26/21 at 8:00 AM and 04/27/21 at 1:00 PM. The DON was also notified that on the following dates and times Resident #46's MAR indicated the resident had not received tube feeding when the recorded meal percentages indicated tube feeding should have been given: 04/21/21 at 8:00 AM, 04/21/21 at 6:00 PM, 04/26/21 at 1:00 PM, 05/02/21 at 8:00 AM, and 05/02/21 at 6:00 PM. The DON was also notified that on the following dates and times, the meal percentages recorded on Resident #46's MAR did not match the meal percentages recorded on the documentation survey report: 04/27/21 at 8:00 AM, 04/27/21 at 6:00 PM, 04/30/21 at 8:00 AM, 04/30/21 at 6:00 PM, 05/01/21 at 8:00 AM, and 05/02/21 at 1:00 PM. Due to the conflicting information for these dates and times times, it could not be determined whether the resident should have received tube feeding or whether it should have been held. The DON had no further clarification regarding the matter through the completion of the survey. b) Resident #59 A medical record review for Resident #59 on 05/04/21, had an order (as written) Novalog FlexPen Solution Pen-injector 100 unit/ML. Inject 16 units subcutaneously three times a day related to Diabetes Mellitus. Contact physician if BS is less than 60 or greater than 401. HOLD if BS below 120. A review of the Medication Administration Record (MAR) for 04/01/21 to 04/30/21 indicated on two (2) occasions the parameters for insulin was not followed. On 04/02/21 the blood sugars (BS) completed at 7:30 AM was 94 and 16 units of insulin was given instead of being held, on 04/12/21 the BS completed at 11:30 AM was 124 and the insulin was held, instead of being given. In an interview with the Director of Nursing on 05/04/21 at 12:50 PM, verified the the insulin on 04/02/21 should have been held and the insulin on 04/12/21 should have been given for Resident #59.