Based on observation and staff interview, the facility failed to ensure it notified the Ombudsman of discharges/transfers. This was true for three (3) of seven (7) residents.Resident Identifiers: #72, #71,and #68. Facility Census: 65. a) Resident #72 09/10/2025 8:54 AM record review revealed Resident #72 was discharged to another skilled nursing facility on 08/02/24. The review of this discharge revealed no evidence that the Ombudsman was not notified of Resident #72's discharge. This was discussed with Employee #89. b) Resident #71 On 09/09/25 at 9:10 PM Resident #71 a review of the discharge record found no evidence that the Ombudsman had been notified of the discharge. c) Resident #68 A review of the discharge record on 09/04/25 at 11:21 AM found Resident #68 had been transferred to a local hospital and was discharged from the facility on 08/04/25. The family requested the discharge so that Resident #68 could be closer to family. There was no evidence that the Ombudsman had been notified. An interview with the Nursing Home Administrator (NHA) and the Social Worker (SW) on 09/04/25 at 12:12 PM, revealed they were not aware that the Ombudsman was to be notified of discharges/transfers. The Ombudsman had not been notified of any discharges/transfers. The facility was now going to send a monthly list to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to confer with the appointed resident representative regarding the physician recommendation for medical treatment (biopsy of thyroid nodules) and the recommendation of the Registered Dietitian for nutritional support. This was true for one (1) of four (4)residents whose rights were reviewed during the long-term care process. Resident identifier: #29. Census: 64. Findings included: a) Resident #29 ENT referral A medical record review on [DATE] at approximately 10:00 AM identified the resident had a Brief Interview for Mental Status (BIMS) of 06. It was further identified that the physician note completed on [DATE] stated the patient was alert and oriented x1 with no acute distress and that Resident #29 did not have capacity. It was further identified that the Nurse Practitioner (NP) assisted Resident #29 to complete Physician Orders for Scope of Treatment (POST) form on [DATE]. The POST form was for no cardiopulmonary resuscitation (CPR) with comfort-focused treatments and no artificial means of nutrition. Additional orders were handwritten on the Post for no intravenous infusion (IV) fluids, no weights and no labs with exceptions. The authorization was not initialed by the resident to allow changes if decision making capacities were lost. The participants noted to attend the discussion with the NP was marked for the patient with decision making capacity. It was further identified the facility failed to follow up on the hospital attending physician's referral recommendation for a biopsy for Resident #29's thyroid nodules following a hospitalization readmission to the facility on [DATE]. During this medical record review there were no notes observed of the surrogate, who was appointed by the facility physician, being contacted regarding making the medical decision for the biopsy referral recommendation. On [DATE] at 11:43 PM during an interview with the Director of Nursing (DON) and NP, both DON and NP confirmed the health care surrogate had not been contacted about the referral to the (Ear Nose Throat) ENT physician. The NP stated this was because Resident#29 made it clear to her during the discussion on [DATE] that she did not want any treatment. The NP stated during the time of that discussion, the resident had issues with her gall bladder and had declined treatment for the gallbladder. Therefore, the NP did not contact the surrogate because the NP stated she firmly believed the resident would not want this done. The NP further stated the resident had a hard time with the anesthesia from her hip surgery and the NP did not feel Resident #29 would do well with a follow up with the ENT for the nodule. The DON and NP further stated they were not aware that Resident #29's grandson was the resident's appointed surrogate. The NP denied the need to contact the surrogate for follow up on the referral for the nodule biopsy because the resident had already made her wants known on [DATE]. On [DATE] at approximately 11:00 AM during an interview with the NP, she stated she was not aware of the physician note that was completed on [DATE] that identified the patient as alert and oriented x 1 with no acute distress and not having capacity. When the NP was asked why an invalid POST form was completed with Resident #29 after being deemed incapacitated on [DATE] by the facility attending physician, the NP stated that she does her own capacity determination prior to completing the post forms. She acknowledged the physician capacity form deeming the resident to be incapacitated on [DATE] made the POST form she completed on [DATE] invalid. The NP agreed the surrogate should have been contacted for their right to exercise the resident's rights in determining the decision for the recommendation/ referral with an ENT for the thyroid nodules biopsy. b) Resident #29-nutritional support Medical record review on [DATE] at approximately 10:00 AM identified the resident had a Brief Interview for Mental Status (BIMS) of 06. It was further identified that the physician note completed on [DATE] stated that the patient was alert and oriented x 1 with no acute distress and that Resident #29 did not have capacity at this time. It was further identified that the Nurse Practitioner (NP) assisted Resident #29 to complete the Physician Orders for Scope of Treatment (POST) form on [DATE]. The POST form was for no cardiopulmonary resuscitation (CPR) with comfort-focused treatments and no artificial means of nutrition. Additional orders were handwritten on the Postform for no intravenous infusion (IV) fluids, no weights and no labs with exceptions. The authorization was not initiated to allow changes if decision making capacities were lost. The participants noted to attend the discussion with the NP was marked for the patient with decision making capacity. Further review identified the facility Dietitian completed a nutritional assessment on [DATE]. The evaluation/nutritional plan stated: readmission assessment: 80 yr.(year)/old female readmitted following fracture of left femur and UTI (urinary tract infection) with other pmh (past medical history)/dx (diagnosis) including Alzheimer's, dementia, CKD 3A (Stage 3 chronic kidney disease), Type 2 DM(diabetes mellitus) cognitive communication deficit, and history of falling. Resident DNR (Do Not Resuscitate), CMO (comfort measures only), no intravenous infusion (iv)/weights (wts)./Percutaneous Endoscopic Gastronomy (PEG) tube/labs with exception. Working with ST (speech therapy), PT (physical therapy) OT(occupational therapy). Loss of (-24.4%) -20.0 lbs. (pounds) x 14 months. CBW(current body weight) 98.2 pounds. IBW (initial body weight) 125 lbs. Regular diet order with good po (by mouth) intake since admit. Intakes 75-100% of most meals since readmit. Medications reviewed. Registered Dietician recommendation for house shakes bid (2 times daily) for nutrition support. Further review of the medical record identified a nursing note dated [DATE] (typed as written)RD with recommendation for house shakes BID (twice a day), however NP declines this order at this time. Resident refuses them. Resident is comfort care with no weights as well. Appetite and intake sufficient at this time. During medical record review there were no notes identified showing the surrogate appointed by the facility physician was contacted regarding the Registered Dietitians recommendation for house shakes for Resident #29's nutritional support. [DATE] 11:43 Am during an interview with Nurse Practitioner (NP) and Director of Nursing (DON),the NP stated she had declined the dietary recommendations based on the resident's comfort care. The NP stated she had not made any attempt to notify the surrogate about their choice of care for the resident. She stated she did not feel like she needed to contact the surrogate because she felt that she knew what the resident wanted since she had talked with her on [DATE]. The NP stated the resident had refused at that time to do anything with her gall bladder so the NP knew she would refuse them. She stated that because of the resident having issues with her gallbladder she felt the recommended milk product would only irritate her stomach. The NP further stated she did not consider any alternate supplement for the nutritional recommendation made by the Registered Dietician for the resident nutritional support. On [DATE] at approximately 11:00 AM during an interview with the NP, she stated she was not aware of the physician note completed on [DATE] that identified the patient as alert and oriented x 1 with no acute distress and that Resident #29 did not have capacity at this time. When the NP was asked why an invalid POST form was completed with Resident #29 after being deemed incapacitated on [DATE] the NP stated did her own capacity determination prior to completing the post forms. The NP further acknowledged the physician capacity form deeming the resident to be incapacitated on [DATE] and that the POST form she completed on [DATE] was not valid. The NP agreed the surrogate should have been contacted for their right to exercise the resident's rights in determining the decision for the recommendation made by the Registered Dietician for house shakes twice a day for the resident's nutritional support.

Based on record review and staff interview, the facility failed to allow Resident #28 to participate in his care and make treatment decisions, by failing to inform him of his right to participate in hospice care. The facility also failed to notify the responsible party for Resident #61 of the potential side effects of a psychotropic medication before administration. This was true for two (2) of three (3) residents reviewed for the right to make informed decisions during the survey process. Resident identifiers: #28, #61. Facility census: 64. Findings included: a) Resident #28 Resident #28 was admitted to the facility with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma. He had a Brief Interview for Mental Status (BIMS) score of 14, suggesting he was cognitively intact, and was determined to have capacity. Upon review of the resident matrix after arrival to the facility at approximately 11:00 AM on 07/08/2024, it was noted Resident #28 was marked for end of life/palliative care/comfort measures along with 25 other residents in the facility. At approximately 2:15 PM on 07/08/2024, Resident #28 was observed sitting on the side of his bed, bent over at the waist, with his hands almost touching the floor. Staff members then came into the room to help Resident #28 get back into his bed. At this time an interview was attempted with Resident #28, however, he was not interviewable due to him being unable to hold his eyes open, slurred speech, and his head bobbing up and down as he was unable to stay awake. At approximately 2:30 PM on 07/09/2024, a review of Resident #28's medication orders was reviewed. The following orders were found in Resident #28's electronic health record (EHR: Ativan Oral Tablet 1 MG- Give one tablet by mouth two times a day for anxiety r/t (related to) restlessness. Gabapentin - Give 300 mg by mouth two times a day for neuropathy in feet. Morphine Sulfate (Concentrate) Solution 20 MG/ML- Give 1 ml sublingually every 4 hours for pain/sob (shortness of breath). Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulphate) - Give 1 ml by mouth one time only for agitation and S.O.B. (shortness of breath) for 1 day. Oxycodone HCI Oral tablet 30 MG (Oxycodone HCI) - Give 1 tablet by mouth every 4 hours for pain. Morphine Sulphate (Concentrate) Solution 20 MG/ML - Give 0.5 ml sublingually every 2 hours as needed for pain/sob 0.5 ml = 10 mg Morphine Sulphate (Concentrate) Solution 20 MG/ML - Give 0.5 ml sublingually every 2 hours as needed for pain/sob 0.5 ml = 10 mg At approximately 1:00 PM on 07/10/2024, a review of progress notes for Resident #28 revealed he had passed away at the facility that morning. At approximately 2:09 PM on 07/10/2024, an interview was conducted with the Nurse Practitioner (NP) regarding the medication orders for Resident #28 and the fact that he seemed sedated when an interview was attempted with him. During the interview the NP stated Resident #28 was end of life care and the medications were ordered for that purpose. The NP was asked if Resident #28 was referred to hospice to assist with end-of-life care to which the NP replied, No, I don't offer anyone hospice. The NP was asked if they were aware residents had the right to participate in their care and to make informed decisions, meaning hospice should have been discussed with Resident #28 for him to make the most informed decision. The NP replied Yes, but I do not offer hospice to anyone. I don't mention hospice to anyone, I don't discuss it with anyone. I feel like we can do what they do here, without them. The NP was asked why Resident #28 was not given the option of hospice care at the end of his life, and the NP replied, I didn't ' offer him hospice because he did not have any family or representatives. The NP was asked what that had to do with Resident #28 being offered hospice care or not being offered hospice care, to which they replied, I guess nothing. The NP was then asked if the other 25 residents in the facility were offered hospice care, due to them being on end of life/palliative care, to which the NP replied, If they've ever been seen by me then they haven't. b) Resident #61 On 07/08/24 at approximately 09:11 PM, a review of Resident #61's medical record was performed. It revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. (name) and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it was revealed that the change in condition signs and symptoms identified were documented as agitation and restlessness, with the most recent vital signs documented dated and timed for 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the resident representative notified, however, the section for the date and time of that notification was left blank. A reviewof Resident #61's Medication Administration Record (MAR), revealed on 05/19/24 at 11:10 PM, documentation of administration of Zyprexa 10 mg IM, one time only for agitation. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. It revealed that when administering a medication for behavioral symptoms, a consent should be obtained and that the form Psychotropic/Therapeutic Medication Use Evaluation should be completed when a patient is newly prescribed a psychotherapeutic medication. On 07/10/24 at 2:35 PM, a further review of Resident #61's medical record was performed. It revealed that Resident #61 had 2 (two) forms titled, Psychotropic Medication Administration Disclosure. Both forms revealed that Resident #61's representative had the risks and benefits of psychotropic medication verbally explained and provided in writing. It also revealed that Resident #61's representative understood the right to refuse the administration of these medications and the right to withdraw consent of medication administration at any time. Under the signature section of both forms, it revealed that verbal consent had been obtained and both forms were dated as the verbal consent being obtained on 05/07/24. However, when reviewing the forms, it revealed that each form was different. One of the forms listed Aricept and Ativan as the medications verbal consent had been obtained for on 05/07/24. The next form listed Aricept, Ativan and Lexapro as the medication verbal consent had been obtained for 05/07/24. Lexapro had 06/13/24 written beside it. On 07/10/24 at 3:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON acknowledged that no consent was obtained before the administration of Zyprexa and that a new form titled, Psychotropic Medication Administration Disclosure should have been completed for this medication. DON further acknowledged that instead of adding Lexapro and writing the date beside it to the already existing form dated 05/07/24, a new form titled Psychotropic Medication Administration Disclosure should have been completed.

Based on observation, staff interviews and record reviews, the facility failed to implement two (2) of 19 resident's care plans. Resident #7's care plan was not implemented in the area of nutritional assistance. Resident #7 was not monitored or assisted with her meal for over one (1) hour after her meal was delivered. Resident #61 had no nutritional care plan developed despite having experienced weight loss. Resident identifiers: #7, #61. Facility census: 64. Findings include: a) Resident #7 07/08/2024 based on record review the flow chart revealed Resident #7's lunch was delivered to her room at 12:00 PM. Before surveyor entered resident's room at 1:05 PM. 07/08/24 at 1:05 PM the surveyor observed resident's tray was not eaten. Her hands appeared constricted, and she was holding her tea between her knuckles and could not place it back on her tray. The resident's roommate stated Resident #7 needed help and could not feed herself. This surveyor asked Resident #7 if she needed help with her food and drink and she said yes. This surveyor went into the hall and found Registered Nurse (RN) #43 for assistance. She stated the resident had been feeding herself last week but thought this could be due to med issues. She stated staff should have checked on her, but that she would get help. During observation at or around 1:15 PM Certified Nurse Aide (CAN) #38 Certified entered the resident's room and asked Resident #7 if she wanted to eat and if she needed help. Resident #7 stated, yes. CNA #38 picked up the fork and started to feed her from the same food tray that had been sitting there since approximately 12:00 PM. This surveyor asked CNA #38 if the food was warm and she stated, It is kind of cold and said she would reorder the resident another tray. Observation on 07/08/24 at 1:35PM revealed a new tray was brought in by CNA #20 and assisted Resident #7 with eating her meal. A review of the resident's care plan as of 07/09/2024 revealed the following interventions: Monitor for signs/symptoms of aspiration i.e. coughing, watery eyes, choking, moist sounding voice. If coughing occurs, no food/liquids until coughing resolves. Provide assistance as needed. b) Resident #61 On 07/08/24 at 9:33 PM, a review of Resident #61's medical record was performed. It revealed that Resident #61 had a physician's order for weekly weights for four (4) weeks then every month entered on 05/17/24, along with a diet order for Regular/Liberalized diet, Regular Texture entered on 05/17/24 also. Further review of Resident #61's medical record revealed the following weights entered Point Click Care (PCC): 7/8/2024 124.0 Lbs. 5/31/2024 125.8 Lbs. 5/17/2024 129.6 Lbs. At that time, a review of Resident #61's care plan was performed revealing no dietary care plan present. On 07/10/24 at 2:54 PM, an interview was conducted with the Director of Nursing. At that time the DON acknowledged no dietary care plan had been developed for Resident #61.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #61 On [DATE] at 09:33 PM, a review of Resident #61's medical record was performed. It revealed that Resident #61 had a physician's order for weekly weights for 4 weeks then every month entered on [DATE], along with a diet order for Regular/Liberalized diet, Regular Texture entered on [DATE] also. Further review of Resident #61's medical record revealed the following weights entered into Point Click Care (PCC): [DATE] 07:37 124.0 Lbs Standing LLEE44 (Manual) [DATE] 11:59 125.8 Lbs Standing LLEE44 (Manual) [DATE] 16:19 129.6 Lbs Standing ksurface (Manual) On [DATE] at 02:54 PM, an interview was conducted with the Director of Nursing. At that time the DON acknowledged the physician's order for weekly weights had not been followed and that Resident #61 had weights missing. The facility failed to address the needs of residents at risk or already experiencing impaired nutrition and hydration. The facility declined the Registered Dietician dietary recommendations without notifying the surrogate and failed to obtain weights. This was true for two (2) of four (4) residents reviewed for nutritional needs during the long term care survey process. Resident identifiers: Resident #29 and Resident #61. Census. 64. a) Resident #29- nutritional support During a medical record review on [DATE] at approximately 10:00 AM of Resident #29's medical record, it is identified that the resident has a Brief Interview for Mental Status (BIMS) of 06. It is further identified that the physician note completed on [DATE] stated that the patient was alert and oriented x 1 with no acute distress and that Resident #29 does not have capacity at this time. It is further identified that the Nurse Practitioner (NP) assisted Resident #29 to complete the Physician Orders for Scope of Treatment (POST) form on [DATE]. The POST form was for no cardiopulmonary resuscitation (CPR) with comfort-focused treatments and no artificial means of nutrition. Additional orders were hand written on the Post form for no intravenous infusion (IV) fluids, no weights and no labs with exceptions. The authorization was not initialed to allow changes if decision making capacities lost. The participants noted to attend the discussion with the NP was marked for the patient with decision making capacity. With further review it is identified that the facility Dietitian completed a nutritional assessment on [DATE]. The evaluation/nutritional plan is as written: readmission assessment: 80 yr (year)/old female readmitted following fracture of left femur and UTI (urinary tract infection) with other pmh (past medical history)/dx (diagnosis) including Alzheimer's, dementia, CKD 3A (Stage 3 chronic kidney disease), Type 2 DM (diabetes mellitus) cognitive communication deficit, and history of falling. Resident DNR (Do Not Resuscitate), CMO (comfort measures only), no intravenous infusion (iv)/weights (wts)./Percutaneous Endoscopic Gastronomy (PEG) tube/labs with exception. Working with ST (speech therapy), PT (physical therapy) OT (occupational therapy). Loss of (-24.4%) -20.0 lbs (pounds) x 14 months. CBW (current body weight) 98.2 pounds. IBW (initial body weight) 125 lbs. Regular diet order with good po (by mouth) intake since admit. Intakes 75-100% of most meals since readmit. Medications reviewed. Registered Dietician recommendation for house shakes bid (2 times daily) for nutrition support. Further review of the medical record identified a nursing note dated [DATE] identified that the (typed as written) RD with recommendation for house shakes BID, however NP declines this order at thist time. Resident refuses them. Resident is comfort care with no weights as well. Appetite and inake sufficient at this time. During this medical record review there were no notes identified of the surrogate who was appointed by the facility physician to have been contacted in regards to the Registered Dietitians recommendation for house shakes for Resident #29's nutritional support. [DATE] 11:43 AM during an interview with Nurse Practitioner (NP) and Director of Nursing (DON), She further stated that she had declined the dietary recommendations based on the residents comfort care. The NP stated that she had not made any attempt to notify the surrogate for their choice of care for the resident. She stated that she didn't feel like she needed to contact the surrogate because she felt that she knew what the resident wanted since she had talked with her on [DATE]. The NP stated that the resident had refused at that time do do anything with her gall bladder so the NP knew she would refuse them. She stated that because of the resident having issues with her gallbladder the NP felt that the recommended milk product would only irritate her stomach. The NP further stated she did not consider any alternate supplement for the nutritional recommendation made by the Registered Dietician for the resident nutritional support. On [DATE] at approximately 11:00 AM during an interview with the NP, she stated she was not aware of the physician note that was completed on [DATE] that identified the patient as alert and oriented x 1 with no acute distress and that Resident #29 does not have capacity at this time. When the NP was asked why an invalid POST form was completed with Resident #29 after being deemed incapacitated on [DATE] by the facility attending physician, the NP stated that she does her own capacity determination prior to completing the post forms. She further acknowledged that with the physician capacity form deeming the resident to be incapacitated on [DATE] that the POST form she completed on [DATE] was not valid. The NP further agreed that the surrogate should have been contacted for their right to exercise the resident's rights in determining the decision for the recommendation made by the Registered Dietician for house shakes bid for the resident nutrtional support.

Based on record review, staff interview and observation, the facility failed to follow physician's order related to volume of feeding to be administered to Resident #52. This was true for 1 (one) of 1 (one) resident reviewed for the Long-Term Care Survey Process. Facility census: 64. Resident identifier: #52. Findings include: a) Resident #52 On 07/10/24 at approximately 12:30 PM, a review of Resident #52's medical record was completed which revealed that in the physician's orders, the following order was present: Order: five times a day for Nutrition Jevity 1.5 CAL Administer bolus via gravity 320 ML 5 times per day FLUSH tube with 30 ML of water prior to feeding, and a final 30 ML flush of water at the end of each feeding. Total volume of flush = 300 ML/24 hrs (excluding medication flushes). Total volume of nutrient + this flush = 380 ml (1900 ML/24 hrs.) On 07/10/24 at 12:53 PM, a tube feeding administration observation was completed for Resident #52 with LPN #46. When LPN #46 was preparing the feeding at the cart to take into the room, LPN #46 poured feeding from a 1000 milliliter (ml) ready to hang bottle that was stored in the 3rd drawer of LPN #46's medication cart. The bottle was labeled with Resident #52's name and dated as being opened 07/10/24. LPN #46 poured the Jevity 1.5 into 2 (two) 7 (seven) ounce non-graduated plastic cups. At this time, this Surveyor asked LPN #46 how much Jevity 1.5 the order stated to be administered. LPN #46 responded, 320 ml's. This Surveyor then asked how LPN #46 knew how much feeding was in the 2 (two) 7 (seven) ounce cups. LPN #46 responded, Me and my manager measured it yesterday, there is 207 ml's in each 7 (seven) ounce cup, which is 414 ml' This Surveyor then asked LPN #46 how he was able to determine if he had the correct amount because both cups had varying amounts close to the top (lip) of the cup. LPN #46 stated that he would pinch the Percutaneous Endoscopic Tube (PEG) of Resident #52 and measure the amount using the graduated syringe. LPN #46 also stated I have asked for graduated cups/cylinder to measure the feeding, but we haven't gotten any. I can see how you are questioning this. At that time, LPN #46 and this Surveyor went into Resident #52's room to administer the feeding. LPN #46 was observed pouring the feeding into the graduated syringe without pinching the tube to use the graduated syringe as a measuring device. LPN #46 was then noted to completely administer both 7 (seven) ounce cups of feeding. After administrating, LPN #46 acknowledged that he did not use the graduated syringe to measure the feeding and administered both cups of feeding which was more feeding than the physician's order called for.

Based on facility record review and staff interview, the facility failed to complete the Nurse staffing information accurately. Some of the data required was not completed, the direct care staff and the total actual hours worked by the direct care staff was inaccurate. This was true for nine (9) of ten (10) Nurse Staffing forms reviewed during the long term care survey process. Census: 24. Findings included: a) 03/19/23 During a review of the Daily Staffing form on 07/09/24 at approximately 7:30 PM, the total direct care staffing hours identified was 148 hours with a hours per patient day (hppd) for a census of 65 at 2.28. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total direct care staffing hours were 164.65 with an HPPD of 2.53. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care staffing hours identified was not correct for 03/19/23. b) 05/14/23 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total direct care staffing hours identified was 160 with a hours per patient day for a census of 63 at 2.53. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total direct care staffing hours were 167.20 with an HPPD of 2.65. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care staffing hours identified was not correct for 05/14/23. c) 07/02/23 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total direct care staffing hours identified was 159.50 with a hours per patient day for a census of 61 at 2.61. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total direct care staffing hours were 163.80 with an HPPD of 2.68. During a further review of the Daily Staffing form the total hours for the evening shift direct care staffing was not completed. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care staffing hours identified was not correct for 07/02/23 and the evening shift direct care staffing hours total was not completed. d) 11/23/23 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total direct care staffing hours identified was 163 with a hours per patient day for a census of 65 at 2.50. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total direct care staffing hours were 157.92 with an HPPD of 2.43. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care staffing hours identified was not correct for 11/23/23. e) 05/07/24 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total direct care staffing hours identified was 158.5 with a hours per patient day for a census of 63 at 2.501 During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total direct care staffing hours were 140.85 with an HPPD of 2.235. During a review of the CNA's on 07/09/24 at approximately 07:30 PM it is identified that the day shift CNA total hours and the total direct care staffing hours for the day shift staff (RN, LPN, CNA) was not completed. During a review of the direct care staffing on 07/09/24 at approximately 07:30 PM, it is identified that the Registered Nurse (RN) direct care total staff for the day to be 8 RN Staff members, this included but was not limited to the RN Administrative Clinical Reimbursement Staff, RN Administrative Nurse Practice Educator, RN Unit Manager, RN Assistant Director of Nursing and the Director of Nursing. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care hours identified was not correct and the data was not completed for 05/07/24. A further review was completed with the Administrator of The Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee' s primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator agreed that based on the job descriptions being RN with administrative roles and the inability to identify how the RN with nursing administrative roles completed their individual eight (8) hours shifts of direct care for this shift, they should not be identified on the daily staffing form as total direct care staff for 05/07/24. f) 05/08/24 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total hours identified was 168 with a hours per patient day for a census of 64 at 2.62. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total hours were 143.58 with an HPPD of 2.24. During a review of the direct care staffing on 07/09/24 at approximately 07:30 PM, it is identified that the Registered Nurse (RN) direct care total staff for the day to be 9 RN Staff members, this included but was not limited to the RN Administrative Clinical Reimbursement Staff, RN Administrative Nurse Practice Educator, RN Unit Manager, RN Assistant Director of Nursing and the Director of Nursing. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care hours identified was not correct, the data was not completed for 05/08/24. A further review was completed with the Administrator of The Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee' s primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator agreed that based on the job descriptions being RN with administrative roles and the inability to identify how the RN with nursing administrative roles completed their individual eight (8) hours shifts of direct care for this shift, they should not be identified on the daily staffing form as total direct care staff for 05/08/24. g) 05/09/24 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total hours identified was 192.5 with a hours per patient day for a census of 6 at 2.96. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total hours were 183.56 with an HPPD of 2.86. During a review of the direct care staffing on 07/09/24 at approximately 07:30 PM, it is identified that the Registered Nurse (RN) direct care total staff for the day to be 8 RN Staff members, this included but was not limited to the RN Administrative Clinical Reimbursement Staff, RN Administrative Nurse Practice Educator, RN Unit Manager, RN Assistant Director of Nursing and the Director of Nursing. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care hours identified was not correct, the data was not completed for 05/09/24. A further review was completed with the Administrator of The Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee' s primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator agreed that based on the job descriptions being RN with administrative roles and the inability to identify how the RN with nursing administrative roles completed their individual eight (8) hours shifts of direct care for this shift, they should not be identified on the daily staffing form as total direct care staff for 05/09/24. h) 06/08/24 During a review of the Daily Staffing form on 07/09/24 at approximately 07:30 PM, the total direct care staffing hours identified was 162.5 with a hours per patient day for a census of 62 at 2.62. During a review of the Genstar daily staffing sheet and the Genstar daily time detail, the actual total hours were 168.12 with an HPPD of 2.71. 07/10/24 at 08:58 AM during an interview with the Administrator, the Administrator agreed that the total direct care staffing hours identified was not correct for 06/08/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary behavioral health care and psychiatric services to Resident #61. This was true for 1 (one) of 3 (three) residents reviewed for the Long Term Survey Process. Facility census: 64. Resident identifier: Resident #61. Findings include: a) Resident #61 On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical recorder revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with the following conditions *Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. * Altered Mental Status, unspecified, onset 05/17/24. * Generalized Anxiety Disorder, onset 06/25/24. * Major Depressive Disorder, Recurrent, Moderate, onset 06/13/24. At this time, Resident #61's care plan was also reviewed, which revealed that Resident #61 had a care plan entered with a focus of Resident/Patient is at risk for or exhibits symptoms of delirium related to dementia was present. In this care plan each intervention listed had a creation date of 06/05/24 with no revisions noted. In addition, no care plan addressing Resident #61's anxiety or depression diagnosis. Further review did not reveal a care plan related to Resident #61's behaviors such as wandering at night, refusal of care and physical and verbal aggression towards staff and other residents. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan with each occurrence of behaviors, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt.

Based on record review and staff interview, the facility failed to provide necessary appropriate person-centerd care and individualized treatment and services to meet Resident #61's behavioral and psychosocial needs. This was true for 1 (one) of 3 (three) residents reviewed for the Long Term Survey Process. Facility census: 64. Resident identifiers: Resident #61. Findings include: a) Resident #61 On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to physical and verbal aggression towards staff and other residents. During the review, the following documentation was revealed to be entered into Resident #61's medical record: On 07/06/24 at 6:05 PM a progress note read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. On 6/15/2024 at 21:21 PM a Medication Administration Record progess note read as follows: Note Text: Ativan Oral Tablet 1 MG Give 1 tablet by mouth two times a day for anxiety r/t restlessness Resident refused medication. Spit medication into floor. Provider aware. On 06/13/24 at 21:44 PM a nursing skilled evaluation read as follows: Level of cognitive impairment: Severe impairment (affecting all areas of judgement). Resident is incoherent. Speech is clear. Language barrier: No. Resident usually makes self understood. Resident sometimes understands others. Mental Status Note: Poor safety awareness d/t Dementia. Hx: falls. Mood and Behavior: Resident is agitated. Resident is anxious. Anxious - No recent change in mood. Agitated - No recent change in mood. Resident is awake at night. Resident wanders at night. Resident verbalizes expressions of fear / depression. Resident is currently experiencing unwanted behavior(s). Delusions: Chronic. Hallucinations: Chronic. Refuses care: Chronic. Resident is refusing to wear denture(s).Resident is refusing to allow dressing to be changed. Resident is refusing to receive a bath. Wandering: Chronic. Withdrawn: Chronic. Mood & Behavior Note: Increased anxiety, anger, agitation, and depression. When awake at night, does not understand not to go into other resident's rooms. Wanders. Wander guard to right ankle. Nutrition: Change in appetite noted. Decrease in fluid intake noted. Complaints of thirst: No. Nutrition note: Decreased fluid intake. Decreased appetite. Safety Note: Wander guard to right ankle. Poor safety awareness d/t dementia. Functional: Able to move all extremities. Upper extremity ROM: No impairment. Lower extremity ROM: No impairment. Gait is unsteady. Balance is poor. At this time, Resident #61's care plan was also reviewed, no documentation was revealed related to Resident #61's tearfulness over wanting to go home, his refusal of care or verbal or physical aggression. On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with the following conditions *Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. * Altered Mental Status, unspecified, onset 05/17/24. * Generalized Anxiety Disorder, onset 06/25/24. * Major Depressive Disorder, Recurrent, Moderate, onset 06/13/24. At this time, a further review of Resident #61's care plan was performed, which revealed that Resident #61 had a care plan entered with a focus of Resident/Patient is at risk for or exhibits symptoms of delirium related to dementia was present. In this care plan, each intervention listed had a creation date of 06/05/24 with no revisions noted. In addition, no care plan addressing Resident #61's anxiety or depression diagnosis was present. Further review did not reveal a care plan related to Resident #61's behaviors such as tearfulness, hallucinations, delusions, wandering at night, refusal of care and physical and verbal aggression towards staff and other residents. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty would receive appropriate treatment and services to correct the problem or to attain the highest practicable mental and psychosocial well being. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan with each occurrence of behaviors, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an addition interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide an interdisciplinary approach to address Resident #61's needs and to provide the necessary services related to the diagnosis of dementia. This was true for 1 (one) of 3 (three) residents reviewed during the Long Term Care Survey Process. Facility census: 64. Resident identifier: Resident #61. Findings include: a) Resident #61 On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical recorder revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at (name of provider) provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. Also at this time, Resident #61's care plan was reviewed, which revealed a care plan for Psychiatric Disorder Dementia and Parkinson's was noted. The care plan read as follows: Focus: * Resident #61 exhibit or is at risk for distressed/fluctuating mood symptoms related to : Psychiatric Disorder Dementia and Parkinson's. Goal: * Resident #61 will demonstrate improved mood state as evidenced by calmer appearance, happier demeanor by the next review date. Interventions: * Observe for signs of delirium, including delusions/hallucinations; notify physician/advance practice practitioner as needed. * Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. * Observe for worsening signs/symptoms of existing psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Notify physician/advanced Practice Practitioner as needed. * Observe for signs/symptoms of new psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Notify physician/advanced Practice Practitioner as needed. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty that the Center would implement individualized, person centered, non-pharmacological interventions as the initial behavior mitigation strategy and update the care plan accordingly. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor Resident #61 for side effects of psychotropic medication after administration of Zyprexa 10mg Intramuscularly (IM). This was true for 1(one) of 5 (five) residents reviewed for the Long Term Care Survey Process. Facility census: 64. Resident identifier: Resident #61. Findings include: a) Resident #61 On 07/08/24 at approximately 9:11 PM, a review of Resident #61's medical record was performed. It revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa IM. Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vital signs documented dated and timed 05/19/24 at 5:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. A review was performed of Resident #61's Medication Administration Record (MAR), it revealed on 05/19/24 at 11:10 PM, documentation of administration of Zyprexa 10 mg IM, one time only for agitation. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. It revealed that when administering a medication for behavioral symptoms, a consent should be obtained and that the form Psychotropic/Therapeutic Medication Use Evaluation should be completed when a patient is newly prescribed a psychotherapeutic medication. On 07/10/24 at 02:35 PM, a further review of Resident #61's medical record revealed that Resident #61 had 2 (two) forms titled, Psychotropic Medication Administration Disclosure. Both forms revealed that Resident #61's representative had the risks and benefits of psychotropic medication verbally explained and provided in writing. It also revealed that Resident #61's representative understood the right to refuse the administration of these medications and the right to withdraw consent of medication administration at any time. Under the signature section of both forms, it revealed that verbal consent had been obtained and both forms were dated as the verbal consent being obtained on 05/07/24. However, when reviewing the forms, it revealed that each form was different. One of the forms listed Aricept and Ativan as the medications verbal consent had been obtained for on 05/07/24. The next form listed Aricept, Ativan and Lexapro as the medication verbal consent had been obtained for 05/07/24. Lexapro had 06/13/24 written beside it. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON acknowledged that no consent was obtained before the administration of Zyprexa and that a new form titled, Psychotropic Medication Administration Disclosure should have been completed for this medication. DON further acknowledged that instead of adding Lexapro and writing the date beside it to the already existing form dated 05/07/24, a new form titled Psychotropic Medication Administration Disclosure should have been completed. In addition, the DON acknowledged that no monitoring occurred on Resident #61 after the administration of Zyprexa IM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to administer a as needed (PRN) psychotropic for a specifically diagnosed condition for Resident #61. This was true for 1 (one) of 5 (five) residents reviewed for the Long-Term Care Survey Process. Facility census: 64. Resident identifier: #61. Findings include: a) Resident #61 On 07/08/24 at approximately 9:11 PM, a review of Resident #61's medical record was performed. It revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa IM. Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it was revealed that the change in condition signs and symptoms were identified and documented as agitation and restlessness, with the most recent vital signs documented dated and timed 05/19/24 at 5:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. A review was performed of Resident #61's Medication Administration Record (MAR). This MAR review revealed on 05/19/24 at 11:10 PM, documentation of administration of Zyprexa 10 mg IM (intramuscular), one time only for agitation. The order contained no specific condition as diagnosed and documented in the clinical record. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. The Policy and Procedure review revealed that when administering a medication for behavioral symptoms, a consent should be obtained and that the form Psychotropic/Therapeutic Medication Use Evaluation should be completed when a patient is newly prescribed a psychotherapeutic medication. On 07/10/24 at 02:35 PM, a further review of Resident #61's medical record was performed. It revealed that Resident #61 had 2 (two) forms titled, Psychotropic Medication Administration Disclosure. Both forms revealed that Resident #61's representative had the risks and benefits of psychotropic medication verbally explained and provided in writing. It also revealed that Resident #61's representative understood the right to refuse the administration of these medications and the right to withdraw consent of medication administration at any time. Under the signature section of both forms, it revealed that verbal consent had been obtained and both forms were dated as the verbal consent being obtained on 05/07/24. However, when reviewing the forms, it revealed that each form was different. One of the forms listed Aricept and Ativan as the medications verbal consent had been obtained for on 05/07/24. The next form listed Aricept, Ativan and Lexapro as the medication verbal consent had been obtained for 05/07/24. Lexapro had 06/13/24 written beside it. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON acknowledged that no consent was obtained before the administration of Zyprexa and that a new form titled, Psychotropic Medication Administration Disclosure should have been completed for this medication. When the DON as was asked if agitation was a specific condition that was diagnosed and documented in the clinical record, the DON stated, I can't say. I am a nurse and not able to diagnose. DON further acknowledged that instead of adding Lexapro and writing the date beside it to the already existing form dated 05/07/24, a new form titled Psychotropic Medication Administration Disclosure should have been completed. In addition, DON acknowledged that no monitoring occurred on Resident #61 after the administration of Zyprexa IM.

The facility failed to make good faith attempts to identify deficiencies of which they had or should have had knowledge of. The Quality Assurance and Performance Improvement (QAPI) program implemented to correct the [NAME] Virginia Portable Order for Scope of Treatment (POST) form completions was not being modified correctly. This has the potential to affect all the residents residing in the facility that completes a POST form. This was identified during the long term care survey process. Identifier: POST forms. Census: 64 a) Post forms During a POST form document review of on 07/12/24 at approximately 04:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. It is further noted that to void a POST form the following must be completed; If a patient or MPOA representative/surrogate (for patients lacking capacity) wants to void the form: destroy paper form and contact patients health care provider and the WV e-Directive Registry to void orders in patient's medical record and the Registry. For healthcare provider: destroy copy (if possible), note in patient record from is voided and notify the WV 3-Directive Registry If no new form is completed, note that full treatment and resuscitation may be provided. During an interview with the Administrator on 07/11/24 06:05 PM the Administrator identified the POST forms as an ongoing QAPI program that was implemented to correct the WV POST forms. She stated this was an ongoing program that began with an audit because they were getting witnessed verbal signatures but not receiving back the original POST form back from mailing it to the surrogates/medical power of attorneys. The Administrator stated it had been ongoing since April of 2024. The Administrator stated that they had also began auditing the POST forms to make sure the POST forms were completed with no blanks such as missing social security numbers, addresses, physicians information, the question box on the back of the form and etc. The Administrator stated that the corrections were being completed on the original POST form but she stated she was unable provide any data in regards to the QAPI program because the Administrators computer was not operable and the data is on it. During this review of the facilities QAPI process to correct the POST forms and the POST form itself with the referenced Instructions, the Administrator stated that she nor the Quality Assurance Committee (QAC) was aware that the forms could not be modified. She further stated they QAC was not aware of the process in which a post form is to be destroyed if modifications had to be made.

Based on medical records, facility records and staff interview the facility Quality Assurance and Performance Improvement committee failed to develop corrective actions to effectively change systems level to prevent quality of care and or quality of life problems. The POST forms were not being accurately completed and or modified based on the physician's determination of capacity. All residents had the potential to be affected by this practice. This was discovered during the facilities long term care survey process. Census: 64. a) Post forms During a POST form document review of on 07/12/24 at approximately 4:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. It is further noted that to void a POST form the following must be completed; If a patient or MPOA representative/surrogate (for patients lacking capacity) wants to void the form: destroy paper form and contact patients' health care provider and the WV e-Directive Registry to void orders in patient's medical record and the Registry. For healthcare provider: destroy copy (if possible), note in patient record from is voided and notify the WV 3-Directive Registry If no new form is completed, note that full treatment and resuscitation may be provided. During an interview with the Administrator on 07/11/24 6:05 PM the Administrator identified the POST forms as an ongoing QAPI program that was implemented to correct the WV POST forms. She stated this was an ongoing program that began with an audit because they were getting witnessed verbal signatures but not receiving back the original POST form back from mailing it to the surrogates/medical power of attorneys. The Administrator stated it had been ongoing since April of 2024. The Administrator stated they had also began auditing the POST forms to make sure the POST forms were completed with no blanks such as missing social security numbers, addresses, physicians' information, the question box on the back of the form etc. The Administrator stated that the corrections were being completed on the original POST form, but she stated she was unable provide any data in regard to the QAPI program because the Administrators computer was not operable, and the data is on it. During this review with the Administrator a further review was completed of the POST form itself with the above referenced Instructions; If a patient or MPOA representative/surrogate (for patients lacking capacity) wants to void the form: destroy paper form and contact patients health care provider and the WV e-Directive Registry to void orders in patient's medical record and the Registry. For healthcare provider: destroy copy (if possible), note in patient record from is voided and notify the WV 3-Directive Registry If no new form is completed, note that full treatment and resuscitation may be provided. The Administrator stated that she nor the Quality Assurance Committee (QAC) was aware that the forms could not be modified. She further stated the QAC was not aware of the process in which a post form is to be destroyed if modifications had to be made. The Administrator further stated that she nor the QAC was aware the Nurse Practitioner was completing her own capacity process without the guidance of the attending physician capacity determination for the residents. She further acknowledged that she nor the QAC were aware that the NP was completing residents POST forms without the attending physician's determination of capacity. The Administrator stated that she does feel like she has missed pertinent details in the QAPI process and audits of the POST form completions and corrections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to review and revise the care plan for Resident #61's psychotropic medication, dementia, and behaviors. In addition the facility failed to revise the care plan to reflect weights no longer be obtained for Resident #59 and the care plan to reflect the surrogate for Resident #29. This was true for 3 (three) of 19 residents reviewed for the Long Term Care Survey process. Facility census: 64. Resident identifiers: #61,#59 and #29. Findings include: a) Resident #61 Psychotropic Medication On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical record revealed on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. A review was performed of Resident #61's Medication Administration Record (MAR), it revealed on 05/19/24 at 11:10 PM, documentation of administration of Zyprexa 10 mg IM, one time only for agitation. On 07/08/24 at 09:33 PM, Resident #61's physician's orders was reviewed. Resident #61 was noted to be prescribed the following medications: * Ativan oral tablet 0.5 milligrams (mg). Give 1 (one) tablet by mouth two times a day for anxiety related to restlessness. * Lexapro oral tablet 10 mg. Give 1 (one) tablet by mouth one time a day for depression. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. It revealed that when administering a medication for behavioral symptoms, a consent should be obtained and that the form Psychotropic/Therapeutic Medication Use Evaluation should be completed when a patient is newly prescribed a psychotherapeutic medication. In addition, Resident #61's care plan was reviewed. It revealed a care plan with the focus of Resident is at risk for complications related to the use of psychotropic drugs: Ativan. No further care plan related to the use of psychotherapeutic drugs was found at that time. On 07/10/24 at 02:35 PM, a further review of Resident #61's medical record was performed. It revealed that Resident #61 had 2 (two) forms titled, Psychotropic Medication Administration Disclosure. Both of these forms revealed that Resident #61's representative had the risks and benefits of psychotropic medication verbally explained and provided in writing. It also revealed that the Resident #61's representative understood the right to refuse the administration of these medications and the right to withdraw consent of medication administration at any time. Under the signature section of both forms, it revealed that verbal consent had been obtained and both forms were dated as the verbal consent being obtained on 05/07/24. However, when reviewing the forms, it revealed that each form was different. One of the forms listed Aricept and Ativan as the medications verbal consent had been obtained for on 05/07/24. The next form listed Aricept, Ativan and Lexapro as the medication verbal consent had been obtained for 05/07/24. Lexapro had 06/13/24 written beside it. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON acknowledged that Resident #61's psychotherapeutic medication care plan had not been revised to reflect the use of Lexapro and the one time administration of Zyprexa. The DON further acknowledged that Resident #61 had not been monitored for adverse reactions following the one time dose of Zyprexa IM. b) Resident # 61 Dementia Care On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical recorder revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. Also at this time, Resident #61's care plan was reviewed, which revealed a care plan for Psychiatric Disorder Dementia and Parkinson's was noted. The care plan read as follows: Focus: * Resident #61 exhibit or is at risk for distressed/fluctuating mood symptoms related to : Psychiatric Disorder Dementia and Parkinson's. Goal: * Resident #61 will demonstrate improved mood state as evidenced by calmer appearance, happier demeanor by the next review date. Interventions: * Observe for signs of delirium, including delusions/hallucinations; notify physician/advance practice practitioner as needed. * Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. * Observe for worsening signs/symptoms of existing psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Notify physician/advanced Practice Practitioner as needed. * Observe for signs/symptoms of new psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Notify physician/advanced Practice Practitioner as needed. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty that the Center would implement individualized, person centered, non-pharmacological interventions as the initial behavior mitigation strategy and update the care plan accordingly. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt. c) Resident #61 Behavior Care On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical recorder revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. Further review of Resident #61's documentation revealsed the following Medication Administration Record (MAR) Progress Notes (PN): 6/15/2024 21:21 eMAR PN Note Text: Ativan Oral Tablet 1 MG Give 1 tablet by mouth two times a day for anxiety r/t restlessness Resident refused medication. Spit medication into floor. Provider aware. 6/15/2024 06:04 eMAR PN Note Text: Sepsis Vitals three times a day Resident refused to allow vital signs to be obtained this AM. Provider aware On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with the following conditions *Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. * Altered Mental Status, unspecified, onset 05/17/24. * Generalized Anxiety Disorder, onset 06/25/24. * Major Depressive Disorder, Recurrent, Moderate, onset 06/13/24. At this time, Resident #61's care plan was also reviewed, which revealed that Resident #61 had a care plan entered with a focus of Resident/Patient is at risk for or exhibits symptoms of delirium related to dementia was present. In this care plan, that each intervention listed had a creation date of 06/05/24 with no revisions noted. In addition, no care plan addressing Resident #61's anxiety or depression diagnosis. Further review did not reveal a care plan related to Resident #61's behaviors such as wandering at night, tearfulness, refusal of care and physical and verbal aggression towards staff and other residents. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan with each occurrence of behaviors, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt. d) Resident #29 During a medical record review for Resident #29 on 07/08/24 at approximately 07:45 PM it is identified in the residents care plan that the resident has an established advanced directive, Health Care Surrogate appointing her sister. This focus was created and intiated on 04/20/22 and revised on 10/11/22. A further record review identified a State of [NAME] Virginia Checklist for Surrogate Selection completed that states that the sister was the previous Health Care Surrogate (HCS) but is no longer able to be reached or returns calls. This State of [NAME] Virginia Checklist for Surrogate Selection further identifies that the resident was notified on 06/06/24 that the residents grandson was now the appointed surrogate. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care plan had not been revised to reflect the change in the Surrogate. e) Resident #59 During a medical record review on 07/08/24 at approximately 08:22 PM, Resident #59 physician determination of capacity identified resident to be incapciated on 04/47/24. The attending physician completed the surrogate selection appointing Resident #59's sister as the health care surrogate. A further review of the medical record the physicians note dated 04/26/24 stated the Residents sister wantes Resident # 59 to be DNR/Comfort care, No Peg tube or weights. A review of the physicians orders Resident #59 identified a verbal order for no weights ordered on 06/06/24. A further review of the residents care plan identified the resident to be care planned for the risk of oral health and dental care problems as evidenced by dentures. An intervention created on and initiated on 05/10/24 is to monitor for changes in nutritional/hydration status (changes in intake, ability to feed self, unplanned weight loss or gain). No other care plan was identified regarding Resident #59 weight orders. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care had not been revised to reflect the Surrogate request and physicians orders for no weights. d) Resident #29 During a medical record review for Resident #29 on 07/08/24 at approximately 07:45 PM it is identified in the residents care plan that the resident has an established advanced directive, Health Care Surrogate appointing her sister. This focus was created and intiated on 04/20/22 and revised on 10/11/22. A further record review identified a State of [NAME] Virginia Checklist for Surrogate Selection completed that states that the sister was the previous Health Care Surrogate (HCS) but is no longer able to be reached or returns calls. This State of [NAME] Virginia Checklist for Surrogate Selection further identifies that the resident was notified on 06/06/24 that the residents grandson was now the appointed surrogate. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care plan had not been revised to reflect the change in the Surrogate. e) Resident #59 During a medical record review on 07/08/24 at approximately 08:22 PM, Resident #59 physician determination of capacity identified resident to be incapciated on 04/47/24. The attending physician completed the surrogate selection appointing Resident #59's sister as the health care surrogate. A further review of the medical record the physicians note dated 04/26/24 stated the Residents sister wantes Resident # 59 to be DNR/Comfort care, No Peg tube or weights. A review of the physicians orders Resident #59 identified a verbal order for no weights ordered on 06/06/24. A further review of the residents care plan identified the resident to be care planned for the risk of oral health and dental care problems as evidenced by dentures. An intervention created on and initiated on 05/10/24 is to monitor for changes in nutritional/hydration status (changes in intake, ability to feed self, unplanned weight loss or gain). No other care plan was identified regarding Resident #59 weight orders. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care had not been revised to reflect the Surrogate request and physicians orders for no weights.

Based on record review, staff interview and resident interview, the facility failed to provide medically related social services for Resident #61 or residents that suffered abuse from Resident #61. This was true for 1 (one) of 3 (three) residents reviewed during the Long-Term Survey Process. Facility census: 64. Resident identifiers: Resident #61 and Resident #42. Findings include: a) Resident #61 On 07/08/24 at 1:30 PM an interview was conducted with Resident #42. At that time, Resident #42 stated, I don't sleep much at night due to Resident #61 coming into my room at night. I nap during the day so I don't wake up to find him in my room. It scares me. That's why I had the staff put up the stop sign in my door. On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. At this time, Resident #61's care plan was also reviewed, no documentation was revealed related to Resident #61's verbal or physical aggression. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty would receive appropriate treatment and services to correct the problem or to attain the highest practicable mental and psychosocial well-being. In addition, at this time, the Policy and Procedure titled, Abuse Prohibition was reviewed. This policy stated that verbal abuse was the use of oral, written or gestured language that willfully included disparaging and derogatory terms to patients or their families, within their hearing distance, regardless of their age, ability to comprehend or disability. This policy and procedure further stated that examples of abuse include but are not limited to threats of harm and saying things to frighten a patient. The Policy and Procedure titled; Abuse Prohibition also stated that if the suspected abuse if patient to patient the Center will do the following: * The patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. * The Center will provide adequate supervision when the risk of patient to patient altercation is suspected. * The Center will be responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit behaviors that make them more likely to be involved in an altercation. * The patient representative and physician will be notified and any follow up recommended will be completed (e.g., psychiatric evaluation). * The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. * Immediately upon receiving information concerning a report of suspected or alleged abuse the allegation will be entered into the PCC Risk Management Portal. * Allegations involving abuse will be reported not later than 2 (two) hours after the allegation is made. * The Center will protect other patients from further harm. * The Center will provide the patient with a safe environment. * The Center will assign a representative from Social Services or designee to monitor the patients feelings concerning the incident, as well as the patients involvement in the investigation. On 07/09/24 at 2:13 PM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON acknowledged the following: * Knowledge of Resident #61's wandering behaviors. * Knowledge of Resident #61's verbal and aggressive behaviors. * No knowledge of any incident occurring between Resident #42 and Resident #61. * The residents in room Resident #61 had entered on 07/06/24 and verbally and physically threatened had not been identified. * No assessment has been carried out on the unidentified residents. * No follow up related to potential adverse outcomes from Resident #61's verbal and aggressive behavior had been completed for any resident this occurred with. * No follow-up was made by Social Services for any of the incidents. * The incident from 07/06/24 had not been reported and should have been. * Resident #61 should have been placed on one-on-one observation following the incident occurring on 07/06/24 and was not. * Nothing had been done at this time to ensure other residents residing in the facility feel safe. * The IDT had not assessed Resident #61 for underlying causes which could contribute to Resident #61's verbal and aggressive behavior. * Resident #61's verbal and aggressive behavior have not been discussed in the IDT meetings. * Resident #61's verbal and aggressive behavior had not been taken to or reviewed in Quality Assurance and Performance Improvement (QAPI) committee meetings. On 07/09/24 at 3:35 PM, an additional interview was conducted with Resident #42 who stated, I don't remember who I told about the fact that Resident #61 scares me when Resident #61 comes into my room at night, it was a staff member and that staff member placed the stop sign on my door, but it doesn't stop Resident #61, Resident #61 just ducks under it. I hate to close my eyes. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt.

Based on record review and staff interview, the facility failed to accurately document medication administration times on the Medication Administration Record (MAR) and medication sign out and administration times on the narcotic count sheet for Resident #28 ' s Morphine Sulphate. This was a random opportunity for discovery. Facility census: 64. Findings include: A) Resident #28 Resident #28 was admitted to the facility with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma. He had a Brief Interview for Mental Status (BIMS) score of 14, suggesting he was cognitively intact, and was determined to have capacity. Upon review of the resident matrix after arrival to the facility at approximately 11:00 AM on 07/08/2024, it was noted Resident #28 was marked for end of life/palliative care/comfort measures along with 25 other residents in the facility. At approximately 2:15 PM on 07/08/2024, Resident #28 was observed sitting on the side of his bed, bent over at the waist, with his hands almost touching the floor. Staff members then came into the room to help Resident #28 back into his bed. At this time an interview was attempted with Resident #28, however, he was not interviewable due to him being unable to hold his eyes open, slurred speech, and his head bobbing up and down as he was unable to stay awake. At approximately 2:30 PM on 07/09/2024, a review of Resident #28 ' s medication orders were reviewed. The following orders were found in Resident #28 ' s electronic health record (EHR: Ativan Oral Tablet 1 MG- Give one tablet by mouth two times a day for anxiety r/t (related to) restlessness. Gabapentin - Give 300 mg by mouth two times a day for neuropathy in feet. Morphine Sulfate (Concentrate) Solution 20 MG/ML- GIve 1 ml sublingually every 4 hours for pain/sob (shortness of breath). Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulphate) - Give 1 ml by mouth one time only for agitation and S.O.B. (shortness of breath) for 1 day. Oxycodone HCI Oral tablet 30 MG (Oxycodone HCI) - Give 1 tablet by mouth every 4 hours for pain. Morphine Sulphate (Concentrate) Solution 20 MG/ML - Give 0.5 ml sublingually every 2 hours as needed for pain/sob 0.5 ml = 10 mg Morphine Sulphate (Concentrate) Solution 20 MG/ML - Give 0.5 ml sublingually every 2 hours as needed for pain/sob 0.5 ml = 10 mg At approximately 1:00 PM on 07/10/2024, a review of progress notes for Resident #28 revealed he had passed away at the facility that morning. At approximately 2:30 PM on 07/10/2024, a review of the narcotic count sheet and the MAR was completed for Resident #28. During the review of the narcotic sheet for Resident #28 ' s morphine sulphate 100 mg/5 ml concentrate solution, the following eight (8) discrepancies were noted: Registered Nurse (RN) #30 signed out 0.5 ml at 7:30 PM on 07/06/2024 but no documentation was found on the MAR to indicate the medication had been administered. RN #30 signed out 0.5 ml at 9:00 PM on 07/07/2024 but no documentation was found on the MAR to indicate the medication had been administered. The next sign out time on the narcotic medication count sheet was 0.5 ml by RN #30 at 1:00 AM on 07/07/2024. No documentation was found on the MAR to indicate the medication had been administered. The next sign out time on the narcotic medication count sheet was 0.5 ml by RN #30 at 5:00 AM on 07/07/2024. No documentation was found on the MAR to indicate the medication had been administered. RN #30 signed out 0.5 ml at 10:00 PM on 07/08/2024 and there was documentation found on the MAR to indicate the medication was administered RN #30 signed out 0.5 ml at 2:00 AM on 07/09/2024 and there was no documentation found on the MAR to indicate the medication was given. Two one (1) ml doses were signed out on the narcotic medication count sheet at 7:00 PM and 11:00 PM on 07/09/2024, without signatures.No documentation was found on the MAR to indicate the medications were given. RN #30 later confirmed via interview they logged the medications out and forgot to sign the sheet. The narcotic medication count sheet noted there was 7.5 ml of morphine remaining in the bottle. Licensed Practical Nurse (LPN) #46 counted the medication and stated there was between 7.5 and eight (8) ml remaining in the bottle. Two surveyors witnessed the count of the medication and confirmed the amount remaining. At approximately 3:45 PM on 07/10/2024, an interview was conducted with the Director of Nursing (DON) and the Unit Managers at the facility regarding the discrepancies in the narcotic count sheet and the MAR. LPN #6 stated RN #30 was having a lot of trouble with documentation and the facility had provided prior training and was continuing to work with RN #30. LPN #6 then provided documentation from the progress notes for Resident #28, showing RN #30 administered the medications at 10:00 PM on 07/08/2024 and 2:00 AM on 07/09/2024, however, had forgotten to log them in the MAR and entered the administration into the progress notes as a MAR error. Further review of the MAR for Resident #28 indicated RN #30 had documented the logged out medications from 7:00 PM and 11:00 PM on 07/09/2024 were given at 9:00 PM on 07/09/2024 and 1:00 AM on 07/10/2024. At approximately 5:00 PM on 07/10/2024 a phone interview was conducted with RN #30 concerning the discrepancies in the MAR and the narcotic count sheet. RN #30 stated they struggle with military time and the computer system the facility uses to document times for medication. RN #30 states education has been provided on a couple occasions and the staff at the facility are continuing to assist with documentation problems. RN #30 states the two logged medications that had no signature belonged to them. RN #30 stated I logged the medication out and had a resident that got sick and had to go assist with them. I just forgot to go back and sign. I struggle with military time and thought the times I wrote down were the correct times. I gave the medications at 9:00 PM on the 9th and 1:00 AM on the 10th. LPN #6 helped me with the missed times on the MAR from 10:00 PM on the 8th and 2:00 AM on the 9th. The following medication sign out times were still unaccounted for on the MAR: 0.5 ml at 7:30 PM on 07/06/2024 0.5 ml at 9:00 PM on 07/07/2024 0.5 ml at 1:00 AM on 07/07/2024 0.5 ml at 5:00 AM on 07/07/2024 RN #30 confirmed during the phone interview they had forgotten to log the times in the MAR. At approximately 9:30 AM on 07/11/2024, an interview was conducted with the DON. The DON stated RN #30 had been suspended pending investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to practice proper infection control to prevent the spread of communicable diseases during lunch service. This was a random opportunity for discovery. This has the potential to affect all residents residing in the facility. Facility census: 64. Findings included: At approximately 12:12 PM on 07/08/2024, an observation was made during lunch service in the 400 hallway of the facility. Nurse Aide (NA) #10 took a tray off the delivery cart, took it to room [ROOM NUMBER] and brought it back to the cart upon realizing the resident was out of the facility. Upon returning to the delivery cart, NA #10 placed the tray back onto the cart with the clean, undelivered trays. NA #10 acknowledged they should not have placed the tray back onto the cart and stated I ' m not sure why I did.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide a safe, comfortable, homelike environment for residents, staff and the public. Issues were found with dead flowers and items being stored over on top of the over bed light fixture. In addition the facility did not have record of fire drills being completed as required. These were random opportunities for discovery during the long term care survey and has the potential to affect all of the residents. Room identifiers: #304, #307. Census: 64. Findings included: a) Exit door window pane across of dining room On 07/08/24 at approximately 2:30 PM during a tour of the facility, the exit door to the court yard located across the hallway from the dining room was observed. This door has a glass insert that would provide a full view of the court yard outside. The glass appeared to have the seal broken with moisture trapped between the panes. The window glass that covered approximately 75% was extremely cloudy, making it impossible to enjoy the view outside in the courtyard area. On 07/08/24 at approximately 2:44 PM during an interview with the Administrator, the Administrator agreed that the glass did not allow unobstructed visibility for the residents and visitors to enjoy the view outside in the courtyard area. b) Exit door window pane inside the 100 hall lounge On 07/08/24 at approximately 2:35 PM during a tour of the facility, the exit door to the court yard located inside the 100 hall lounge was observed. The door has a glass insert that would provide a full view of the court yard outside. The glass however appeared to have the seal broken with moisture trapped between the panes. The window glass that covered approximately 65% appeared cloudy, making it impossible to enjoy the view outside in the courtyard area. On 07/08/24 at approximately 2:44 PM during an interview with the Administrator, the Administrator agreed that the glass did not allow unobstructed visibility for the residents and visitors to enjoy the view outside in the courtyard area. c) Window pane at the entrance of the front entry door. On 07/08/24 at approximately 2:37 PM during a tour of the facility, the window pane at the entrance of the front facility entry door was observed. This window allows the view of the front entrance area to the facility's main entrance. The glass appeared to have the seal broken with moisture trapped between the panes. This window appeared to be foggy throughout the entire surface preventing a clear visibility when looking outside to the front area of the facility. On 07/08/24 at approximately 2:44 PM during an interview with the Administrator, the Administrator agreed that the glass did not allow unobstructed visibility for the residents and visitors to enjoy the view outside in the courtyard area and the visibility outside the main entrance. d) Over the bed table room [ROOM NUMBER] A On 07/08/24 at approximately 01:25 PM during a tour of the facility 300 hall, the bedside table top for bed 305 A was observed to have large cracks that covered 3/4 of the top laminate surface. The molding around the edge of the table was falling off leaving the sharp edges of the inner board exposed. During an interview with Registered Nurse (RN) #14 on 07/08/24 at approximately 1:27 PM, RN #14 acknowledged the table presented a skin tear hazard for the resident and replaced it with a different bedside table. e) Dead flowers During a tour of the facility on 07/08/24 at approximately 3:25 PM room [ROOM NUMBER] and #307 was identified to have containers of dead flowers in the room. The flowers were wilted and the water was cloudy and had an unpleasant odor. During an interview with Skin Health Team Lead (SHTL) #36 on 07/08/24 at approximately 1:30 PM. SHTL #36 stated the flowers were dead and should have been removed from the room before now. f) Storage on top of over the bed light fixture On 07/12/24 at approximately 03:00 PM during a facility tour, room [ROOM NUMBER]B over the bed wall light was observed to have a small glass oil lamp, a corded telephone, a medium sized clock, a corded [NAME] and a corded walkie-talkie stored on top of it. These items covered approximately 75% of the top surface of the over the bed wall light fixture. The bed was positioned with the left side of the bed against the wall directly underneath the over the bed wall light. On 07/12/24 at 03:15 PM during an interview with the DON she stated the light fixture is not designed to be a shelf and the items being stored there presents a hazard for the resident. g) As referenced during the annual Life Safety / Emergency Preparedness Recertification Survey conducted on 07/08/24 through 07/09/24, record review on 07/08/24 at approximately 4:08 p.m., revealed no documentation during survey was available for review of a fire drill being conducted on the 3rd Shift of the 2nd Quarter of 2024. This deficiency was reiterated to the Administrator during the complaint survey on 07/10/24 at approximately 1:20 p.m. h) As referenced during the annual Life Safety/Emergency Preparedness Recertification Survey conducted on 07/08/234 through 07/09/24, record review on 07/08/24 at approximately 4:21 p.m., revealed no documentation during survey was available for review for review of a fire drill being conducted on the 2nd Shift of the 3rd Quarter of 2023. This deficiency was reiterated to the Administrator during the complaint survey on 07/10/24 at approximately 1:22 p.m. i) Interview on 07/10/24 at approximately 1:23 p.m. with the Administrator verified these findings. These findings were also acknowledged by the Administrator at the exit interview on 07/10/24 at approximately 1:41 p.m.

Based on record review and staff interview, the facility failed to employ qualified dietary staff, due to letting employees work in the dietary department before obtaining food handler permits. This had the potential to affect all residents residing in the facility. Facility census: 64. Findings include: a) At approximately 10:00 AM on 07/09/2024, food handler permits were requested from the Dining Services Account Manager (DSAM). The DSAM made copies of the ones on file in the dietary office and stated, I'll have to find the others. At approximately 1:30 PM the DSAM stated they were still waiting on a couple food handlers cards. On 07/10/2024, the DSAM supplied a copy of a food handler permit for [NAME] #59, with an issue date of 07/10/2024. Upon review of the employee list provided by the facility, [NAME] #59 has been employed at the facility and working without a food handler permit since 10/17/2023. On 07/11/2024, the DSAM supplied copies of food handler permits for Dietary Aide/Cook #64 and Dietary Aide/Cook #58, both with an issued date of 07/11/2024. Upon review of the employee list proved by the facility, it was determined Dietary Aide/Cook #64 had been employed at the facility and working without a food handler permit since 04/30/2024. It was determined Dietary Aide/Cook #58 had been employed at the facility and working with a food handler permit since 05/30/2024 All three instances were acknowledged by the DSAM and Dining Services District Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident refrigerator temperatures The following was identified during a review of the facility Policy and Procedure OPS192 refrigerators:. Patient In-Room that states the PROCESS (documented as written) Maintenance will provide calibrated refrigerator thermometers and placed within each unit for both refrigerator and freezer, if applicable. 4.1 A refrigerator/freezer temperature log will be maintained for every patient refrigerator. .2 Nursing will observe and record temperatures of the refrigerator on a daily basis using the refrigerator/freezer temperature log. 4.3 If temperature falls outside of the acceptable range, notify the Maintenance Department immediately. During a tour of the facility on 07/08/24 at approximately 3:23 PM it was identified that the residents with their personal refrigerators in their rooms did not have a visible temperature log being maintained. During an interview with Registered Nurse Skin Health Team Lead (RN TLSH) #36, she identified Unit Clerk (UC) #08 to be the one who completed the temperature logs for each resident refrigerator daily. A request of the temperatures logs was made at this time. During an interview with the UC #08 on 07/08/24 at approximately 04:00 PM, UC #08 apologized for taking so long to get the documents that she was still completing the form for a newly admitted resident. She further stated if she was not in the facility, someone else would obtain the temperatures for her and she would document them when she returned to the facility. A review of the refrigerator temperatures UC #08 provided identified a distinct pattern for each refrigerator with the same exact times and/or the same exact temperatures noted for each day for the refrigerator and the freezer. During a review with the Administrator of the June 2024 and July 2024 resident refrigerator temperature logs on 07/08/24 at 4:10 PM the Administrator completed a random observation of three (3) of the 19 resident temperature logs provided. The log completed for each resident identifies the acceptable temperature ranges for the refrigerator to be 32-40 degrees Fahrenheit and the freezer to be 0-10 degrees Fahrenheit. The following discrepancies were identified: room [ROOM NUMBER]B The refrigerator temperature logs for the entire month of June was documented to be checked at exactly 9:05 AM every day and each day the refrigerator was documented to be at 35 degrees Fahrenheit and the freezer was documented to be at 10 degrees Fahrenheit. The July temperatures were documented to be checked at exactly 09:05 AM every day from 07/01/24 through 07/04/24 and then exactly at 9:00 AM each day from 07/05/24 through 07/08/24. The July temperatures were also documented to be at 35 degrees Fahrenheit for the refrigerator every day and 10 degrees Fahrenheit for the freezer consistently each day. During the random observation of 108 B refrigerator temperatures the Administrator made at 4:13 PM on 07/08/24 the refrigerator did not have a thermometer inside to obtain a temperature with. The freezer temperature was 10 degrees Fahrenheit. The Administrator agreed with the identified concern of the distinct pattern and the accuracy of the documentation when there was not a thermostat located in the refrigerator to obtain the temperature with. room [ROOM NUMBER] The refrigerator temperature logs for the entire month of June was documented to be checked at exactly 9:10 AM every day and each day the refrigerator was documented to be at 32 degrees Fahrenheit and the freezer was documented to be at 10 degrees Fahrenheit. The July temperatures were checked at exactly 9:10 AM every day from 07/01/24 through 07/04/24 and at exactly 9:05 AM every day from 07/05/24 through 07/08/24. The July temperatures were also documented to be at 32 degrees Fahrenheit every day for the refrigerator and 10 degrees Fahrenheit for the freezer consistently each day. During the random observation of 109 A refrigerator temperatures the Administrator made at 4:15 PM on 07/08/24 the refrigerator temperature was 35 degrees Fahrenheit and the freezer temperature was -5 degrees Fahrenheit. The Administrator agreed that the temperatures were not consistent with the monthly documentation being completed and that the freezer temperature was outside the acceptable temperature range. room [ROOM NUMBER] B The refrigerator temperature logs for the entire month of June was documented to be checked at exactly 9:15 AM every day and each day the refrigerator was documented to be at 35 degrees Fahrenheit and the freezer were documented to be at 10 degrees Fahrenheit. The July temperatures were checked at exactly 9:15 AM every day from 07/01/24 through 07/04/24 and exactly at 09:10 AM from 07/05/24 through 07/08/24. The July temperatures were also documented to be at 35 degrees Fahrenheit every day for the refrigerator and 10 degrees Fahrenheit for the freezer consistently each day. During the random observation of room [ROOM NUMBER] B refrigerator temperatures the Administrator made at 4:15 PM on 07/08/24 the refrigerator temperature was 38/40 degrees Fahrenheit and the freezer temperature was 10 degrees Fahrenheit. The Administrator agreed that the temperatures were not consistent with the monthly documentation being completed. Based on observation and staff interview, the facility failed to store and prepare food in a sanitary manner, due to having items that were out of date and not dated in the refrigerators, items exposed to the elements, having dirty equipment, and failing to monitor refrigerator temperatures of personal refrigerators in resident rooms. This has the potential to affect all residents receiving food from the kitchen and all residents with personal refrigerators in their rooms. Facility census: 64. Findings include: A) Outdated, undated, and exposed items At approximately 11:20 AM on 07/08/2024 a tour of the kitchen in the facility was conducted. During the tour, the following were found in the walk-in refrigerator: Three (3) trays of cake with no date. A plastic container of beef based with no lid on it. A plastic container of strawberries with no date on it. A cardboard box containing squash with a discard date of 07/01/2024. Twenty (20) individual cookies placed in plastic sleeves were in the dry stock room with no date. Dietary Aide/Cook #59 stated Those were made yesterday (Sunday) for today. The following items were found in the walk-in freezer: Chicken breasts with no date. A box containing a bag of frozen corn. The bag was open, exposing the corn to the elements. A box containing a plastic bag of frozen biscuits. The bag was open, exposing the biscuits to the elements. The following items were found in the reach in refrigerator: Barbeque Sauce with manufacturers discard date of 05/28/2024. A pitcher of pink lemonade without a date on it. A large container of tea without a date on it. A box of peeled hard cooked eggs with a discard date of 07/03/2024. Dietary Aide/Cook #59 confirmed the items found during the tour were out of date, not dated, or exposed to the elements in the freezer. Dietary Aide/Cook #59 stated, You will probably find all kinds of stuff in there that doesn't have dates because we have people coming to work here from other centers and they don't care, they will throw stuff in there without dates on it and everything else. B) Oven At approximately 11:30 AM on 07/08/2024, during a tour of the kitchen, [NAME] #66 opened the oven to take the temperature of French fries that were being prepared for lunch. When the oven was opened, burnt food was found lying at the bottom along with four (4) large globs of black debris. What appeared to be pieces of burned shredded cheese were observed scattered throughout the oven. [NAME] #66 was asked how often the oven was cleaned, to which they replied, We should have already cleaned it, it needs cleaned, but we haven't had a chance to clean it because we haven't had staff here to do it. C) Nourishment room microwaves At approximately 3:00 PM on 07/08/2024, a tour of the nourishment rooms was conducted with the Dining Services Account Manager (DSAM). Upon entering the nourishment room for the 100 and 300 units of the facility, the microwave was noted to have rust throughout the inside. The DSAM stated We have been trying to get new ones for a while because we can't get these cleaned. The DSAM was asked if the facility prepared food for residents in the microwave, to which they stated, Yes. Upon entering the nourishment room for the 200 and 400 units of the facility, the microwave was noted to have rust through the inside and was missing the turntable. The DSAM stated We have been trying to get a new one here also. We can't get either of them clean, and this one is missing the turntable on the inside. The DSAM confirmed resident food was prepared and heated in the microwave.

Based on observation and staff interview, the facility failed to dispose of refuse in a manner to prevent attracting vermin. This has the potential to affect all residents residing in the facility. Facility census: 64. Findings include: a) At approximately 2:00 PM on 07/10/2024, a tour was conducted of the rear of the facility where the facility kept their dumpsters. Upon arriving at the dumpsters, an empty potato chip bag, multiple clear gloves, pieces of food, and clear plastic garbage bags were scattered around and underneath the dumpsters. Three (3) of the four (4) dumpsters had the lids opened, with one missing a lead entirely. One dumpster was leaking a white substance out of the bottom, onto the pavement. At approximately 2:09 PM on 07/10/2024, the Dining Services District Manager acknowledged the trash on the ground and the state of the dumpsters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview and staff interviews, the facility failed to accurately complete the Minimal Data Set (MDS) assessment for dialysis services for one (1) of one (1) resident reviewed for the care area of dialysis, and for one (1) of one (1) resident reviewed for the care area of discharge, during the long term care survey. Resident Identifiers: #5 and #62. Census 65. Findings Included: a) Resident #5 On 03/06/23 an electronic record review found the quarterly MDS, with an Assessment Reference Date (ARD) of 02/09/23, section O, letter J, Dialysis was marked No, indicating the resident did not receive dialysis. The electronic record contained a physician's order for dialysis dated March 2021. On 03/06/23 at 1:05 PM, the resident said he has been receiving dialysis for years, including February of 2023. Staff interviews on 03/07/23 at 8:39 AM, with the minimum data set coordinators (#46 and #31), confirmed the MDS with the ARD of 02/09/23 was marked incorrectly on section O, letter J, Dialysis. Both staff stated that she in fact was receiving dialysis at the time and the MDS was accidentally marked incorrectly and they would correct it today. b) Resident #62 While reviewing a closed record for Resident #62 the MDS coded the resident as being discharged to an acute care hospital on [DATE]. Nursing notes revealed the resident had a planned discharge to home and instructions were given. An interview on 03/07/23 at 11:10 AM, with MDS nurse #31 confirmed Resident # 62 was discharged to home, not an acute care hospital. .

. Based on record review and staff interview, the facility failed to complete a new Pre admission Screening And Resident Review (PASARR) for a resident with a newly evident or possible serious mental disorder for one (1) of four (4) residents reviewed for the category of PASARR, during the long term care survey. Resident identifier #5. Census 65. Findings Included: a) Resident #5 On 03/07/23 the Director of Nursing (DON) was asked to provide the most recent PASARR for Resident #5. The DON presented a PASARR for resident #5, dated 09/10/10. The review of this PASARR, section III MI/MR (Mental Illness / Mental Retardation) Assessment, #30 Current Diagnosis, letter n. Other related conditions (Specify:), was answered, Adjustment Disorder. All other choices on this section were not checked. On 03/07/23 at 10:48 AM an electronic medical record review, finds the resident was diagnosed with the following diagnosis on the following dates: Major Depressive Disorder Single Episode on 02/02/11 Anxiety Disorder on 07/11/11 Psychotic Disorder with Hallucinations due to known Psychological Condition on 07/21/15 Schizophrenia Unspecified on 11/23/15 Major Depressive Disorder, recurrent moderate on 03/29/16 Schizoaffective Disorder on 03/29/16 Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety on 06/01/16 On 03/07/23 at 10:58 AM, an interview with the Social Worker confirmed that the most recent PASARR for Resident #5 was dated 09/10/10. A new PASARR had not been completed since the resident received numerous diagnosis that fall under the MI/MR Assessment section of the PASARR. .

. Based on record review and staff interview, the facility failed to provide pressure ulcer care and treatments consistent with the professional standards of care for one (1) of one (1) resident reviewed for the care area of pressure ulcers during the long term care survey process. Resident identifier: #1. Facility census: 65. Findings included: a) Resident #25 Record review found the resident was readmitted to the facility after a hospital stay on 03/04/23. Review of the progress notes found the following: 03/04/2023 00:32 Nursing Documentation Note General: Patient was admitted /readmitted for the following reason(s): Exacerbation of Respiratory Condition Therapy Infection Management of Diabetes Management of Renal Disease Pain Management readmission The pt. had been hospitalized for greater then 5 days Additional details about this note: Integumentary System reviewed Skin Check completed: resident is experiencing foot pain: Left foot pain- heel protector boot in place No skin injury/wound(s) were noted. On 03/06/23, two days after admission, a nurse completed a skin and wound evaluation noting the resident had a deep tissue pressure injury (DTI) on the left heel upon return from the hospital. On 3/6/23 a Registered Nurse wrote a late entry note at 11:13 AM: Left heel DTI present upon admission, SHTL to evaluate. A treatment order for sure-prep to the left heel was written on 03/06/23- two days after admission: Sure-prep to left heel BID (two times a day) for DIT (Typed as written) On 03/07/23 at 1:08 PM, the Director of Nursing said the notes and treatments for the DTI to the left heel were written late. The DON was asked how the facility could say the DTI was present upon admission when the DTI wasn't documented as being present upon admission and treatments and nursing notes were not written until 2 days after admission? The DON said, well it was just late, the nurse just forgot to write a note. .

. Based on observation and staff interview the facility failed to provide catheter care with current professional standards of practice. This was true for one (1) of one (1) resident reviewed for catheter care. Resident identifier: #4. Facility census 65. Findings included: a) Resident #4 Observation on 03/07/23 at 1:25 PM, found nurse aide (NA) #42 providing catheter care for Resident #4. Observation found there was no anchor device on the resident to secure the Foley catheter and prevent accidental remover and/or tissue damage. NA#42 said she was told at the beginning of her shift Resident #4 needed a secure device. NA #42 cleansed the inside of the vagina and the buttock area. NA #42 failed to cleanse the Foley tubing. While performing hand hygiene NA #42 failed to use a paper towel to turn off the sink. The above was also witnessed by Registered Nurse (RN) #58. RN #58 said she will re-educate NA#42. .

. Based on resident interviews, staff interviews, and record review the facility failed to ensure sufficient qualified nursing staff are available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This has the potential to affect more than a minimal number of residents at the facility. Census 65. Findings Included: a) Anonymous Resident Interviews On 03/06/23 at 12:19 PM, an anonymous resident complained about having to wait a long time last night to get cleaned up and being left in urine for hours. On 03/06/23 at 1:57 PM, another anonymous resident stated he/she has to sit in their poo for hours, especially if it is meal time. The staff make residents wait until trays are served and picked back up before they will change the residents. This resident also stated, Nurses only want to pass meds and won't help you get cleaned up either. Sometimes I wait for hours for someone to answer. On 03/06/23 at 12:43 PM, an anonymous resident stated that the staff respond quickly when there is enough staff. Last night they only had one (1) nurse and one (one) Nursing Assistant (NA) so he/she knew they would have to wait longer to get a call light answered. A Resident Council Meeting was held on 03/07/23 at 9:51 AM. Confidential interviews with the resident group voiced the following concerns related to response to call lights: -Call lights not being answered on night shift -There are only two (2) aides for 65 residents -There are call ins on night shift and no one to replace them b) Staff Interviews The surveyor interviewed the nurses that worked the day shift on 03/05/23 questioning if there were call ins for that night shift. Registered Nurse (RN) #48 confirmed she worked day shift on 03/05/23 but no one called in to her because she was not in charge. She believes Licensed Practical Nurse (LPN) #43 was in charge. LPN #43 said someone told her that NA #57 called in the night of 03/04/23, but no one called in to her for the night shift of 03/05/23. LPN #48 said if she would've taken a call off, she would've made sure the night shift was covered. LPN #48 reviewed the schedule and confirmed night shift on 03/05/23 was short a nurse aide. RN #44 nor NA #57 were not available for an interview. Staff interview with DON on 03/07/23 at 1:06 PM, indicated that the nurse who took the call off would've been responsible for making sure the shift was covered. On 03/07/23 at 1:24 PM, the DON provided the call off slip. NA #57 called off at 5:15 PM on 03/05/23 to RN #44. The DON confirmed that RN #44 should have ensured that sufficient staff were in place for the night shift by calling in someone or mandating someone to stay. The DON confirmed that only one (1) RN, one (1) LPN, and two (2) NA's worked night shift on 03/05/23. On 03/07/23 at 11:43 AM a record review of the Time Detail Report from 03/05/23 indicated that there was one (1) RN, one (1) LPN, and two (2) NAs working the nightshift. The Surveyor asked the DON if that was sufficient staff and she responded, Would I like to have more, yes, but can they take care of everyone, yes they can. The DON confirmed that the census was 65 at that time. The Surveyor said that's more than 30 residents per NA and the DON made no further comment. c) Payroll-Based Journal (PBJ) The Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) staffing data report notes that the facility triggered excessively low weekend staffing for the first quarter in 2023. d) Facility assessment Review of the Facility Assessment states that Direct Care Staff working night shift will consist of 5 staff. On the date of 03/05/23 the facility failed to provide five (5) direct care staff on nightshift, only four (4) direct care staff worked. e) CMS 672 Review of the facility's CMS 672, on 03/08/23 indicates: 65 of their residents require assistance of one (1) or two (2) staff members for toileting 27 of the residents at the facility suffer from dementia 28 of their residents are diagnosed with a psychiatric diagnosis excluding dementia and depression 43 of their residents require preventative skin care 0 residents toilet themselves On 03/07/23 at 1:40 PM the surveyor requested a list of residents that require a two (2) person assist. The DON provided lift assessments for 35 residents stating they require two (2) people to toilet. .

. Based on observation, resident interview, resident council meeting and staff interview, the facility failed to serve food which was palatable and appetizing in appearance. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident identifiers: Resident #17, Resident #21, Resident #40, Resident #56 and Resident #5. Facility Census: 65. Findings Included: a) Resident #17 During the initial tour on 03/06/23 at 11:54 AM, Resident # 17 stated the food sucks, I eat the food that my friend brings me. You can not eat the food that is prepared here it is terrible. b) Resident #21 During the initial tour on 03/06/23 at 11:38 AM, Resident # 21 stated the food is bad, I am not offered a substitute if I don't like my meal. I just don't eat it. I have lost weight, because I don't eat. c) Resident #40 During the initial tour 03/06/23 at 11:29 AM, Resident # 40 stated the food is nasty, I am not offered a substitute if I don't like it I just don't eat. d) Resident Identifier #56 Resident interview on 03/06/23 at 12:43 PM, indicates that the food is not good and he can't chew the meat. The Resident stated he has never asked for something different when he doesn't like the food because all of the food is bad. e) Resident Identifier #5 On 03/06/23 at 1:02 PM, during resident interview, resident says that the food here isn't good. She states that she doesn't ask for something else if she doesn't like it but says that they do have several options of food that you can always get. She says that a lot of the time she doesn't feel like eating because she's sick from dialysis. She said she buys her own snacks and food to eat in her room. f) Resident Council meeting A Resident Council Meeting was held on 03/07/23 at 9:51 AM. Confidential interviews with the Resident group found the following concerns related to the meals: -There is a lack of food, and it never tastes good. -We have a lot of chicken and does not taste good anyway they prepare it. -We have a lot of grits and they are running and tasteless. -Sometimes the food is cold but it doesn't taste any better when it's warm. -The food just tastes bad, there is a lack of seasoning. -Its bland and tasteless Numerous anonymous resident interviews during the initial tour stated the food was not palatable. On 03/07/23 at 12:30 PM, five (5) state surveyors observed the noon time meal for appearance. The noodles for the dumplings were rubberish. The broccoli was over cooked and mushy. The meatballs were tough to cut. The meal was not appealing and did not look appetizing. During an interview on 03/07/23 at 1:25 PM, the administrator stated the broccoli is way over cooked and the noodles which is not a dumpling are not cooked and rubbery. The meatballs are the frozen kind and very tough. It does not look appealing to eat. .

. Based on observation, staff interview, resident interview, resident council meeting and previous minutes from resident council, the facility failed to provide Residents with evening snacks. This had the potential to affect more than a limited numbers of residents living in the facility that could receive snacks from the kitchen. Facility Census: 65. Findings Included: a) Nourishment Rooms During the tour of the Nourishment Room on 400 hall with the Account Manager (AM) on 03/07/23 at 8:13 AM the following snacks were reveled: -three (3) bags of chips left over from last night snack pass -eight (8) half sandwiches -pitches of purple drink, red drink and tea During the tour of the Nourishment Room on 200 hall with the AM on 03/07/23 at 8:18 AM the following snacks were revealed: -1 can of tomato soup -6 half sandwiches -a pitcher of grape drink During an interview on 03/07/23 at 8:19 AM the Account Manager (AM) stated I deliver the snacks between breakfast and lunch, that is just what is left over from snack pass last night. During an interview on 03/07/23 at 10:14 AM, the AM stated there is no snack list that is provided and no list of what we have to keep in the pantry. We deliver the snacks between breakfast and lunch. We provide various items and rotate weekly. For example snacks include chips, nabs, lunch cakes, deli meat sandwiches, chopped meats and peanut butter and jelly sandwiches and drinks. b) Resident Council meeting A Resident Council Meeting held on 03/07/23 at 9:51 AM, found the following concerns were presented: Confidential interviews with the Resident group found the following concerns related to evening snacks: -I don't get my Physician order snack at night -I am supposed to have have cereal at night, but they never have it or when they do I have to go to another hall to find it. -We like snacks cakes and they never have them anymore -The last three nights we have had no snacks. The following Resident Council Minutes From 02/22 to present revealed the following documentation related to snacks: --The Resident Council Minutes dated on 02/09/22 revealed the following statement, Snack pass continues to be a problem, the snacks are not being delivered to the patient's room. --The Resident Council Minuets dated on 08/22/22 reveled the following statement, Snacks are not always being served in a timely manner. --The Resident Council Minutes dated on 11/16/22 revealed the following statement, Need more snacks for 400 hall once 200 hall is served there is nothing left for 400 hall. --The Resident Council Minutes dated on 12/08/22 revealed the following statement, Snacks are still not being given or offered to everyone. --The Resident Council Minutes dated on 02/15/23 reveled the following statement, Would like more variety of snacks, especially fudge rounds and peanut butter and jelly sandwiches. A review of a snack list provided by the AM on 03/07/23 revealed there are five (5) residents that have physician ordered snacks at night. .

. Based on observation, policy review and staff interview, the facility failed to ensure foods were stored and prepared in a safe, clean, and sanitary environment. The facility failed to ensure kitchen equipment, kitchen area and ice machine were clean and sanitary in a manner in accordance with professional standards for food service safety. The facility also failed to correctly document temperatures for the dish machine. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 65 Findings Included: a) The improper sanitization of kitchen equipment A review of a facility policy titled Equipment with a revised date 09/17 stated (typed a written): Procedures 1. All equipment will be routinely cleaned and maintained in accordance with manufacture's directions and training materials. 2. All staff members will be properly trained in the cleaning and sanitized after every use. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non food contact equipment will be clean and free of debris A review of the Local Health Department Food Establishment Inspection follow up dated 11/30/22 stated the following (typed as written). -Observation; Kitchen is not as clean as it should be: utensil holders, bulk storage bins, hand sink, dish machine, shelving, all noted to have build up. An initial tour of the kitchen with the Account Manager (AM) #88 beginning on 03/06/23 at 10:31 AM, found the following kitchen equipment was not properly cleaned and sanitized: -A dish cart found in the dish machine room used to transport clean dishes, utensils and pans to the kitchen had built up of food and grime. -Two (2) transport carts, which staff deliver drinks to the resident for meals, had built up of food and grime. -Two (2) coffee carts, which staff deliver coffee to the resident for meals, had built up of food and grime. -Food Serving carts that deliver meal trays to the Residents had a built up of food and grime. -Shelving above the stove had a spoon that was being used to stir the split pea soup, which had dried up food and black small rodent droppings. -Utility shelf with cooking oil and cooking sprays was covered in a sticky, oily residue built up. -Steam table shelving had serving and meal preparation pans stored face down on rusted shelving and dried up food and debris. -The outside lid of the trash can appeared to be cover with unknown substance in close proximity to the steam table. During an interview on 03/06/23 the AM acknowledged the carts, shelving units and trash can needed to be cleaned and sanitized. b) Unclean and Unsanitized areas A review of the Local Health Department Food Establishment Inspection follow up dated 11/30/22 stated the following (typed as written). .Repeat observation the plumbing in dish room is very rusty-rusty wires running behind rusty plumbing. Repeat observation due to the excessive moisture in the kitchen, paint on ceiling is peeling over the food prep areas-poses cross contamination hazard. Observation of the kitchen is not as clean as it should be: utensil holders, bulk storage bins, hand sink, dish machine, shelving all noted to have build up. Observation of build up around the edges and hard to reach areas-grout discolored and shows build up Disclaimer: A re-inspection to assess your correction of these violations will be conducted on, or about 02/28/23. An initial tour of the kitchen with the AM beginning on 03/06/23 at 10:31 AM, found the following kitchen areas was not properly cleaned and sanitized: -Exhaust fan was an accumulation of a thick dark gray dust and debris. During an interview on 03/06/23 The AM stated we never use the exhaust so I guess that's why its not cleaned. -The floor in the kitchen and the dish room was severely soiled with a black built up in the tiles and dirt in the corners. The kitchen floors were sticky to step, and had dried food and dried liquid spills. -Paint was peeling from kitchen ceiling. -The door handles going into the kitchen from the main dining room, had dried up food and were sticky to touch. On 03/06/23 at 11:00 AM, the Administrator took a tour of the kitchen with this surveyor and was shown the above issues. The ED acknowledges the need for cleaning and sanitization of the kitchen equipment, shelving, carts and floors. During the follow up visit to the kitchen on 03/07/23 at 11:16 AM an observation of two ceiling vents had a black substance and a thick gray dust and debris. During an immediate interview with the AM, the AM stated I requested it to be cleaned a month ago on our TEL'S program. During an interview on 03/07/23 at 11:18 AM, the administrator acknowledged the vent needed to be cleaned. During an interview on 03/07/23 at 12:40 PM, the administrator stated I am the person who put the maintenance order for the vents to be cleaned on 01/23/23. b) Ice Machine A review of the facility policy titled Ice with a revised date of 09/2017 read a follows (typed as written). Procedures: .3. The exterior of the ice machine will be cleaned weekly. 4. Ice bins will be cleaned monthly and as needed. An initial tour of the kitchen with the AM beginning on 03/06/23 at 10:43 AM, revealed an Ice Machine in the main dining area had a white substance on the outside of the machine and under the lid. It also had dried food and built up on the sides and front of the machine. The inside of the ice machine contained a black substance. During an interview immediately following on 03/06/23, the AM stated the Maintenance is responsible for cleaning the ice machine monthly. It needs shut down, the ice emptied and sanitized because of the mold. During an interview on 03/06/23 at 11:00 AM the Administrator stated, the white substance on the ice machine is from the water, it is on everything in this town. It's like a calcification that forms. c) Dish Machine Log An initial tour of the kitchen with the AM beginning on 03/06/23 at 10:31 AM, revealed: -A dish machine temperature log that was incomplete. Evidence revealed the temperature log was missing documented temperatures for the following dates: -03/04/23 Dinner -03/05/23 Lunch and Dinner An immediate interview with CDM, on 03/06/23, confirmed the dish machine log was incomplete and should have been completed daily. .

Based on observation, record review, and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to place residents with active Multidrug-resistant organisms (MDRO) in Transmission Based Precautions (TBP) and provide proper hand washing practices during catheter care. Resident identifiers: R#4, #35, #22, #56, #1, and #117. Facility census 65. Findings included: a) Resident #4 While reviewing the line listing provided by the facility Infection Preventionist (IP), it was noted Resident #4 had extended-spectrum beta-lactamases (ESBLs) in urine on 12/11/22 and was being treated with antibiotic. Resident #4 was not placed in any type of TBP. aa) Resident #4 During an observation of catheter care on 03/07/23 at 1:25 PM, NA #42 provided catheter care for Resident # 4. While performing hand hygiene NA #42 failed to use a paper towel to turn off the sink. The above was also witnessed by Registered Nurse #58. This failed practice was also noticed by RN #58. RN #58 gave instructions on hand washing to NA #42 and said she will re-educate NA#42. b) Resident #35 Resident #35 was listed on the line listing for having ESBL in the urine on 01/19/23 and was being treated with an antibiotic. Resident #35 was placed in standard precautions. c) Resident #22 On 03/07/23 at 9:23 AM, the IP was asked why Resident #22 had TBP signage on the door. IP stated Resident #22 has been in modified TBP since 07/22 because he has Carbapenem-resistant Enterobacterales (CRE). A review of the line listing for the past three months, found Resident #22 was not on the line listing. d) Resident #56 A review of the medical record found Resident #56 had Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) in the surgical wounds on the right lower extremity. Resident #22 was in standard precautions per the line listing. e) Resident #1 Resident #1 was found to have ESBL in the urine on 01/16/23. Resident #1 was being treated with an antibiotic but was not placed in TBP. f) Resident #117 Review of medical records found Resident #117 had VRE pneumonia on readmission and was being treated with an antibiotic. A review of the line listing found Resident #117 did not have the VRE on the line listing and also not placed in TBP to prevent spread. During an interview on 03/07/23 at 12:43 PM, the IP was asked about all the above residents and why were they never placed in TBP until after the treatment was completed? The IP stated she was told to not isolate the residents. The IP was asked how the staff were informed when these residents had MDROs? MDRO's can be carried from one person to another via the hands of health care provides (HCP). Hands are easily contaminated during the process of caregiving or from contact with environmental surfaces near the patient. The IP said it would be in the chart. The IP confirmed staff did not wear Personal Protection Equipment (PPE) when providing care because there was no signage on the door to alert staff to use PPE. The IP agreed those residents should have been placed in TBP while actively infectious. In addition, the IP was then asked why Resident #22 was not on the line listing? The IP said he has been here for so long she did not think it was needed. The IP was asked about Resident #117, not being included on the line listing showing the resident had VRE pneumonia. The IP said she must have missed that diagnosis in the hospital discharge record.

. Based on observation and staff interview, the facility failed to maintain an effective pest control program so the facility is free of rodents. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 65. Findings Included: a) Kitchen Tour An initial tour of the kitchen with the Account Manager(AM) #77 beginning on 03/06/23 at 10:31 AM, revealed the following: - A sticky mouse trap with a piece of fudge cake was found in the dry storage area. - A sticky mouse trap with a piece of fudge cake was found beside an upright cooler. The AM stated, we have mice in the building, I just put the new sticky traps out this morning with fresh fudge cakes. - A shelf about the stove had small black rodent pellets. b) Staff Interviews During an interview on 03/06/23 at 11:00 AM, the Administrator stated we did have a mice issue, we have had the exterminator here every two weeks and we use the sticky traps. We have not seen any sign of mice in about a month. During an interview on 03/07/23 at 10:41 AM, [NAME] #79 stated, I saw a mouse three (3) days ago. There was one on a sticky trap and then when I opened the dry storage door a mouse ran into the kitchen. During an interview on 03/07/23 at 10:42 AM, Manager In Training #84 stated, it has been around three (3) days since I have seen any mice. .

. Based on observation and staff interview the facility failed to ensure residents were treated with dignity and respect during their dining experiences. Resident # 18 and Resident #48 did not receive a meal while other residents were served at the same table. Resident # 12 was assisted with a meal from a staff member kneeling on the floor. This was a random opportunity for discovery. Resident Identifiers: Resident # 18, Resident #48, and Resident #12. Facility Census: 61. Findings Included: a) Resident #18 During dining room observation on 11/30/21 at 11:49 AM, Resident #18 was not served the noon meal while others at the same table were eating. This surveyor asked the Account Manager/Chef about Resident #18's meal, he stated we are working on it now. Two other tables were served before Resident #18 received his meal. b) Resident #48 During a dining room observation on 11/30/21 at 11:52 AM, Resident #48 had not received a meal after all the residents in the dining room had been served. This surveyor asked Account Manager/Chef # 14, why Resident #48's had not received a lunch meal. Account Manager/Chef # 14, stated he must have come in late; we sent his ticket back on the floor. On 11/30/21 at 11:53 AM, the Executive Director stated, they don't usually do that, he must have been late. c) Resident #12 Observation on 11/30/21 at 12:29 PM, found Nurse Aide (NA) #44 was assisting Resident #12 with her lunch meal, while kneeling beside her. This surveyor asked NA #44, if that was appropriate to assist the resident with meals while on the floor. NA #44 grabbed a chair and sat down to finish assisting with the meal. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, record review, and staff interview the facility failed to allow a resident to exercise his right to choose to not wear a brief, which is an aspect of life significant to the resident. This was true for one (1) of one (1) resident reviewed for the care area of choices. Resident identifier: #64. Facility census 61. Findings included: a) Resident #64 The resident was admitted to the facility on [DATE] with the diagnosis of: Peripheral vascular disease, Polyneuropathy, Gastro-esophageal reflux disease, Benign Prostatic Hyperplasia without lower urinary tract symptoms, abnormalities of gait and mobility, muscle weakness, history of falling, and difficulty in walking. During an interview on 11/29/21 at 11:44 AM, Resident #64 stated, he would like to have at least one side of his brief not fastened so he can use the urinal faster and not wet on himself. Resident #64 became angry and stated, he was told by the night shift aide that it was a rule he had to keep both sides always fastened or he would get kicked out. He asked if that was true. He explained that if he had to fasten both sides of his brief, he will, but it works out better for him if he could do his toileting the way he wants to. He said he has three urinals because even though he only urinates about 2 inches in the urinal at a time, if the urinal is not empty, he will spill it on himself. He said, so having to try to get this dang brief off in time is so frustrating and causes me to wet myself and my bed. A review of the care plan revealed the following: Focus *Resident requires extensive assistance for Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to, weakness. Interventions *Resident prefers not to wear any clothing items. *Resident prefers use of napkins to soak up incontinent episodes, prefers napkins padded in the groin area. *Resident prefers multiple urinals on backside of bedside commode. On 11/29/2021 at 1:37 PM, Nurse Aide #33 was asked about Resident #64 toileting, NA #33 said the Resident does not want his brief fastened. NA #33 said she encourages him to fasten at least one side. During an interview with Director of Nursing (DON) on 11/30/2021 at 2:00 PM, the DON was asked why Resident #64 was being told he must wear a brief and it must be fastened, when his preference is to not wear anything. The DON stated as far as she knows he does not wear anything but has one blanket and keeps his door closed. .

. Based on Resident Council minutes, Resident interviews during Resident Council, and staff interview, the facility failed to act promptly upon the grievances and demonstrate their response and rationale for such response. This was related to brake issues on the wheelchairs of Resident #17 and #43 and was an ongoing issue. This was a random opportunity for discovery. Facility census 61. Findings included: a) Resident Counsel Minutes A review of Resident Council minutes dated 06/15/2021: - Resident #17 Wheelchair needs repaired A review of Resident Council minutes dated 07/16/2021: -Resident #17 complained about her brakes on her wheelchair not working. She said her brakes were worked on but the stop and go brake still is not working correctly. A note by the former Maintenance Supervisor indicated the brake was fixed on 07/21/2021. During this Resident Council Meeting on 11/30/2021 at 1:27 PM the following was discussed: - Resident #17 said, her brake on her wheelchair is not working correctly and has not been working correctly for six (6) months. She went on to say they (maintenance) fixed one side but not the other side. -Resident #43 stated her brake on her wheelchair has not been working right since the first of November. The Activities Director (AD) was asked if these grievance/concerns were being reported to the Social Worker? The AD stated no, but she will ask the Social Worker to start attending the meeting. During an interview with Social Worker on 11/30/2021 at 2:10 PM, the SW said she was not aware of the ongoing issues with the wheelchair brakes or any other of the complaints, and did not know to fill out a grievance and concern report. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, and staff interview the facility failed to prevent verbal, and mental abuse. This failed practice was true for one (1) of three (3) reviewed for the care area of abuse. Resident identifier: Residents #64. Facility census 61. Findings included: a) Resident #64 Record review found Resident #64 was admitted to the facility on [DATE] with the diagnosis of; Peripheral vascular disease, Polyneuropathy, Gastro-esophageal, Reflux disease, Benign Prostatic Hyperplasia without lower urinary tract symptoms, Abnormalities of gait and Mobility, Muscle weakness, history of falling, difficulty in walking. During an interview on 11/29/21 at 11:44 AM, Resident #64 stated, he would like to have at least one side of his brief not fastened so he can use the urinal faster and not wet on himself. Resident #64 became angry and stated, he was told by the night shift aide that it was a rule he had to keep both sides always fastened. He said the nurse aide (whom he cannot remember her name) got in his face and told him, he would get Kicked out. He asked if that was true. Resident #64 said he does not think some of the staff like him. He said there are some staff that seem to really care about his care and there are a few that do not. He said, he felt mad and worried about being Kicked out. He explained that if he had to wear a brief and have it fastened he will; however, it works out better for him if he could do his toileting the way he wants to. A review of the care plan revealed the following: Focus -Resident requires extensive assistance for Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to, weakness. Interventions *Resident prefers not to wear any clothing items. *Resident prefers use of napkins to soak up incontinent episodes, prefers napkins padded in the groin area. *Resident prefers multiple urinals on backside of bedside commode. On 11/29/2021 at 1:37 PM, Nurse Aide #33 was asked about Resident #64's toileting, and the fact that he does not want his brief fastened. NA #33 said she encourages him to fasten at least one side. She was asked if he needed extensive care today like a bed change due to his bed being soiled. NA#33 stated, no not on her shift. During an interview with Director of Nursing (DON) on 11/30/2021 at 2:00 PM, the DON was asked about why Resident #64 was being told he must wear a brief and it must be fastened, when his preference is to not wear anything? The DON stated as far as she knows he does not wear anything but has one blanket and keeps his door closed. On 11/30/2021 at 2:07 PM, the Social Worker (SW) was informed about Resident #64 voicing a Nurse Aide telling him he would be kicked out of the facility. The SW began an investigation of the allegation. On 11/30/2021 at 4:40 PM, the SW provided additional information regarding her investigation: Resident #17 reported to the social worker that she was told that if she did not do as she was told she would get kicked out. Resident #17 said that was a long time ago and that person no longer works at the facility. The Social Worker completed a reportable allegation to the proper state authorities for Resident #17. Resident #43 also reported to the social worker she was also told a long time ago that she could be kicked out if she did not do as she was told. She stated that nurse aide no longer works here. The Social Worker completed a reportable allegation of abuse to the proper state authorities for Resident #43. Resident #64 reported to the Social Worker that a nurse aide told him he would be kicked out one or two nights ago on night shift; however, it was not one of the two aides that normally work nights. He was unable to say who this. He further stated he did not like wearing the brief due to being unable to get the urinal in place quick enough. The Social Worker informed the resident as to why he was wearing brief and explained that it was his choice to wear or not wear a brief. A statement from Nurse Aide # 71, on 12/01/2021, found she assisted with care for Resident #64 on 11/30/2021 and he did not say anything about being kicked out. He did express to her and Nurse Aide #23 that he could not fasten the brief and they encouraged him to at least fasten one side to help with spilling urine on his bed. He agreed and was pleasant about it. A statement on 12/01/2021, from Nurse Aide #70 found he does not normally work on Resident #64's hallway. He did assist with care on 11/30/2021 to change his bed at 7:30 PM. Resident #64 did not have a brief on, and one was not placed on him. A statement (not dated) from Licensed Practical Nurse (LPN) #32 said she had a 45-minute conversation with Resident #64 about how he was told he had to wear a brief. This nurse explained to resident he could lay naked or wear a brief or not wear one that it was totally up to him. The Resident stated he was rudely told he had to wear the brief. This nurse apologized for whoever told him that and assured him he could wear or did not have to wear a brief . A statement dated 11/30/2021 at 11:00 AM, Nurse Aide # 28 stated Resident #64 keeps his light on all night sometimes by accident, sometimes 10-15 minutes after leaving the room. She states that up until 4 AM, the resident refused to have his bed changed and just wanted a towel put down. The Resident kept unhooking one side of his brief saying he don't like to wear it. Normally has paper towels laid down instead of brief. States he turned on the light many times by accident. Sometimes he is sleeping and needs nothing, other times he is arguing with the nurse about wanting his pain medications. She says at 4 AM she checked on him and resident did not want her to change his bed, but she explained that it had to be done due to a wet bed. She changed his bed, he did not like it, but he agreed. He had the light on several more times after but was complaining to the nurse about his pain pill. On 12/01/2021 at 11:00 AM, the Administrator stated, they (facility) would get to the bottom of this problem and are continuing to investigate who told Resident #64 he had to wear a brief or get kicked out. The social worker reported the allegation to the proper State authorities on 11/30/2021 and the investigation was ongoing at the close of the survey. .

. Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for one (1) of one (1) resident reviewed for respiratory services during the survey process. Resident # 4 was not receiving oxygen therapy at the prescribed flow rate. Resident identifier: #4. Facility census: 61. Findings Included: a) Resident #4 During the facility tour on 11/29/21 at 1:40 PM, observation found Resident #4 laying in bed receiving oxygen via a nasal cannula. The oxygen air flow was set on 4 liters. On 11/29/21 at 1:40 PM,the Registered Nurse (RN) #76 stated oops it's suppose to be on 2 liters as needed. The RN asked Resident #4 if she needed her oxygen on right now. Resident #4 stated, why yes I need my oxygen you just now turned it on A Physicians order dated 12/04/20, found O2 (oxygen) at 3 Lpm (Liters per minute) via NC (Nasal Cannula) as needed. .

. Based on Resident interviews during Resident Council, and staff interview, the facility failed to inform residents on how to file a grievance. This had the potential to affect more than a limited number of residents residing at the facility and was a random opportunity for discovery. Facility census 61. Findings included: a) Resident Council Meeting A Resident Council Meeting was held on 11/30/2021 at 1:27 PM. Residents in attendance were Residents #17, #43, #32, #51, #31, and #61. Also in attendance was the Activities Director, the Assistant Activities Director, the Kitchen Manger, and the Housekeeping Manager. All Residents in attendance were asked if anyone knew how to file a grievance at the facility or who to go to for help to file a grievance. All residents said, no. The Activities Director was asked if she routinely went over the Residents Rights, including the right to file a grievance, during any of the Resident Council Meeting? She stated, she did not. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, and staff interview, the facility failed to properly store food in a sanitary manner in accordance with professional standards for food service safety. This deficient practice has the potential to affect more than a limited number of residents that receive nutrients from the kitchen and all residents receiving nectar thickened liquids. Facility Census:61 Findings Included: a) Kitchen During the initial tour of the kitchen with Employee #14, the Account Manager/Chef at 11:30 AM on 11/29/21, the following food items were found in the reach in refrigerator: two grocery bags containing, 1 bottle of Pepsi, 2 body [NAME] drinks and 1 bottle of water. Account Manager/Chef stated, these are staffs, the County Health Department said I could put them in as long as they are in this bin. This surveyor stated, no employee food or drinks are allowed in the kitchen refrigerator or freezers used to store resident food. Account Manager/Chef stated, but the County Health Department said I could. This issue was discussed with the Executive Director (ED) on 11/29/21 at 11:49 AM, with no further information provided. b) Nutritional Room A tour of the Nutritional Room on 11/29/21, with the ED, found nutritional room [ROOM NUMBER], had an opened bottle of thick and easy hydrolyte thickened water nectar consistency dated 11/23/21, in the refrigerator. The ED, stated it's only good for 2-3 days after opened. The ED disposed of the Thick and easy hydrolyte thickened water at that time. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, policy review, and staff interview the facility failed to establish an infection prevention and control program to prevent the development and transmission of communicable diseases and infections. Staff did not wear Personal Protective Equipment (PPE) appropriately and Resident hand hygiene was not provided before meals. Facility census 61. Findings included: a) Personal Protective Equipment (PPE) Facility policy, titled, Use of Goggles, Face Shields, and N95 respirators on and off, dated 09/24/2021. * Units without outbreaks: a. universal use of a well-fitting standard facemask is still required by all vaccinated and unvaccinated staff and personnel. c. When COVID-19 is not suspected, staff working in facilities located in counties with substantial or high transmission should continue to wear eye protection. (At this time this county is at a high transmission rate.) An observation on arrival on 12/01/21 at 4:00 AM, found a call light was sounding for room [ROOM NUMBER]. At 4:04 AM, Nurse Aide (NA) #74 went into room [ROOM NUMBER] belonging to Resident #63 with her standard mask under her chin. NA #74 was not wearing any type of eye protection. The door was opened, the light was on and NA #74 had her mask under her chin when she entered the room. She was overheard telling Resident #63, I have to close your door because the state is here, and they can't see this. When NA #74 was asked what is it that she does not want the state to see? NA #74 stated he was on the POT and she did not know he was on the POT, until she saw the surveyor approaching. At this time, she was asked if she was wearing her mask appropriately? She stated she was wearing the mask appropriately, earlier. She also said she had contact lenses for eye protection. On 12/01/201 At 4:25 AM, NA #74 was walking down the 200 hall with her mask under her chin and still no eye protection. She was asked to adjust her mask and if she was supposed to wear goggles? She stated she has reading glasses on top of her head and has contacts. On 12/01/2021 at 8:01 AM, the Assistant Director of Nursing and Infection Preventionist was asked if contacts took the place of eye protection? She stated, no. She was informed NA #74 not wearing her mask in the care area and in the hallway along with not wear any type of eye protection. b) Hand Hygiene During observation of lunch meal pass, on 11/30/21 at approximately 12:00 PM, no residents were provided hand hygiene prior to the meal arrival on the 200 hallway. During an interview on 11/30/21 at approximately 12:15 PM, NA #44 stated we use the hand sanitizer up there on top of the cart. The sanitizer was on top of meal cart that came from the kitchen and was not in use. During an interview on 11/30/21 at approximately 12:15 PM, NA #71 stated we use the hand sanitizer in their room, on the wall we squirt it in our hands for them. On 11/30/21 at 4:21 PM, The Director of Nursing was notified about hand hygiene for residents. She stated, who did that, sounds like they need an education. .