**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitoring of target symptoms was completed for 1 of 5 sample residents (#2) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had diagnoses which included non-Alzheimer's dementia, anxiety disorder, and depression. Review of the physician orders showed the resident received Sertraline (antidepressant) 100 milligrams (mg) by mouth daily for anxiety with depression. The following concerns were identified: a. Review of the physician orders showed behaviors related to the use of Sertraline were to be monitored every shift; however, there were no medication or resident specific target symptoms identified; b. Review of the care plan, last revised on 10/7/24, showed no medication or resident specific target symptoms were identified related to the use of the Sertraline. c. Review of the medication administration record for October 2024 showed no evidence of medication or resident specific target symptoms were identified related to the use of the Sertraline. d. Review of the Anti-Depressant Informed consent for medication dated 8/23/24 showed the consent was for Sertraline; however, there was no medication or resident specific target symptoms were identified related to the medication use. e. Interview with the DON and regional nurse on 10/9/24 at 3:09 PM revealed target symptoms should be on the care plan, medication administration record, or medication consent. f. Interview with the DON and regional nurse on 10/10/24 at 10:16 AM confirmed the resident did not have resident or medication specific target symptoms identified. 2. Review of the policy titled Psychotropic Medication Use dated July 2022 showed .Resident Evaluations .3. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: b. signs and symptoms are clinically significant to warrant medication therapy .

Based on observation and resident and staff interview, the facility failed to ensure a clean environment for 1 of 3 sample residents (#5) reviewed for bowel and bladder incontinence and activities of daily living. The findings were: 1. Observation of resident #5's room on 10/7/24 at 2:28 PM showed the resident was in his/her room with a visitor and there was a strong urine odor present, which could be smelled in the hallway. 2. Observation of resident #5's room on 10/8/24 at 8:22 AM showed the room had a very strong urine odor and the floor was sticky. 3. Observation of resident #5's room on 10/9/24 at 10:24 AM showed a housekeeper #1 was cleaning the resident's room. Upon completion at 10:32 AM, the housekeeper #1 exited the room; however, the urine odor and sticky floors remained. Interview with the resident at that time revealed s/he could not smell the odors; however, s/he asked housekeeper #1 to mop again due to the floors remaining sticky. 4. Observation of resident #5's room on 10/10/24 at 9 AM showed the room smelled of urine, the bathroom ventilation was not working, and the resident's floor was sticky. 5. Interview with the housekeeping manager on 10/10/24 at 9:13 AM revealed the facility was aware of increased urination on the floor in resident #5's room and revealed they did not perform a heavy mop on the floor while the resident was in the room due to potential fall risk. She revealed nursing staff had a mop bucket available to clean if housekeeping was not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were labeled with an open date or not expired in 2 of 5 medication storage areas (100 hall medication cart, 200 hall medication cart). The findings were: 1. Observation of the 100 hall medication cart on [DATE] at 8:52 AM showed an Insulin Glargine 100 units/milliliter pen for resident #5 was not labeled with an open date and did not indicate when the medication should be discarded. The following concerns were identified: a. Interview with LPN #1 on [DATE] at 8:57 AM revealed the person who opened the insulin should label it with the date it was opened and with a 28-day expiration date. She confirmed she did not know if the insulin, which she administered to the resident, was within the useable timeframe or was expired. b. Interview with the DON on [DATE] at 10:39 AM confirmed insulin pens should be labeled with the open date. She revealed nurses should not administer the medication and should discard the pen if it was not labeled. 2. Observation of the 200 hall medication cart on [DATE] at 8:29 AM showed a multidose bottle of Aspirin 81 milligram (mg) tablets with a manufacturer's expiration date of 7/2024. Interview with RN #2 at that time revealed multidose medication bottles should not be used after the manufacturer's expiration date on the bottle. 3. Interview with the DON on [DATE] at 4:10 PM stated her expectation is that the nurse who dispensed the medication should check the expiration date prior to administration. 4. Review of the policy titled Administering Medications, provided by the DON on [DATE], showed .The expiration/beyond use date on the medication label is checked prior to administering .

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure infection control procedures were implemented for 4 of 4 sample residents (#2, #14, #23, #41) who required enhanced barrier precautions. The findings were: 1. Observation on 10/9/24 at 9:56 AM showed CNA #1 and CNA #2 assisted resident #41 to transfer from the bed to the wheelchair. Prior to the transfer, CNA #1 applied gloves, disconnected the resident's wound vacuum, and placed the tubing over the bed. Following the transfer, the end of the tubing for the wound vacuum dropped on floor and CNA #1 picked it and reconnected the tubing, without disinfecting the open end of the tubing which was on the floor. Further observation showed neither CNA used enhanced barrier precautions during the care. Interview with the DON and regional nurse on 10/9/24 at 11:35 AM revealed open tubing dropped on the floor should not have been reconnected without disinfection of the tubing. 2. Observation on 10/9/24 at 3:51 PM showed CNA #3 and CNA #4 entered resident #2's room with a sit to stand lift, applied gloves, and positioned the lift sling behind the resident. The CNAs assisted the resident to stand and removed his/her pants. The resident had a dressing present on his/her coccyx which was not attached on bottom right side. CNA #4 performed perineal care and without removing her soiled gloves, touched a bottle of silicone cream, the outside of the resident's clean brief, and the resident's pants when she pulled them up. The CNA also touched the lift, the lift sling, a wipe container, and a bedside table without removing the gloves. Further observation showed no enhanced barrier precautions were used. Interview with the DON on 10/10/24 at 9:41 AM revealed gloves should be changed prior to touching clean surfaces. 3. Observation of catheter care performed on resident #14 on 10/9/24 at 9:44 AM showed the CNA #3 performed the catheter care while wearing only gloves. Observation of resident #14's room at that time showed no enhanced barrier precaution signage posted in the room or additional personal protective equipment (PPE), other than gloves, was available. Interview with the CNA on 10/9/24 at 9:52 AM revealed she was not aware of the need for enhanced barrier precautions when performing catheter care. 4. Observation of resident #23 on 10/7/24 at 2:08 PM, 10/8/24 at 9:43 AM, and 10/9/24 at 8:31 AM, showed the resident was in his/her wheelchair, his/her bilateral lower legs were wrapped with a dressing, and the resident's bare feet were on the floor. Observation of the resident's room on 10/8/24 at 8:31 AM showed no PPE, other than gloves, was available. Interview with LPN #1 on 10/9/24 at 10:40 AM revealed she was not aware of any interventions in place to prevent reinfection of the resident's legs, or keep his/her bare feet off of the floor. The LPN revealed there were no residents on enhanced barrier precautions on South or North Birch Halls, which was where the resident's room was located. Interview with the DON on 10/9/24 at 10:55 revealed she was unaware the resident did not have foot pedals on his/her wheelchair or that his/her bare feet were on the floor. 5. Interview with CNA #1 on 10/9/24 at 9:52 AM revealed she was not aware of enhanced barrier precautions until 10/9/24 when education was provided by the DON. 6. Interview with CNA #2 on 10/9/24 at 9:52 AM revealed she was not aware of enhanced barrier precautions until 10/9/24 when education was provided by the DON. 7. Review of policy titled Enhanced Barrier Precautions, provided by the DON on 10/9/24, showed .Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDRO) to residents. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization . 8. Review of the policy titled Briefs/Underpads dated 2001 showed .12. Perform perineal care the resident's back side .14. Remove gloves, sanitize hands and replace with clean gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure ventilation was working in 7 of 10 resident rooms observed. The census was 48. The findings were: 1. Observation of room [ROOM NUMBER] on 10/10/24 at 8:16 AM showed the ventilation in the room was not working. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:58 AM confirmed the ventilation in the room was not working. 2. Observation of room [ROOM NUMBER] on 10/10/24 at 8:20 AM showed the ventilation in the room was not working. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:54 AM confirmed the ventilation in the room was not working. 3. Observation of room [ROOM NUMBER] on 10/10/24 at 8:24 AM showed the ventilation in the room was not working. 4. Observation of room [ROOM NUMBER] on 10/10/24 at 8:26 AM showed the ventilation in the room was not working. 5. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:32 AM showed the ventilation in the room was not working. 6. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:38 AM showed the ventilation in the room was not working. 7. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 9 AM showed the ventilation in the room was not working, the floor was sticky, and the room smelled of urine. Interview with the maintenance director at that time confirmed the ventilation system was not working in some of the resident rooms.

Based on staff interview, the facility failed to ensure the dietary manager met the required qualifications. The facility census was 48. The findings were: Interview with the dietary manager on 10/9/24 at 11:24 AM revealed the manager had one more month to complete the certified dietary manager coursework. Further interview with the dietary manager revealed the facility had two part time dietitians who were not on site. Interview with the administrator on 10/10/24 at 10:57 AM confirmed the facility did not have a qualified dietary manager or a full-time dietitian.

Based on staff interview and policy and procedure review, the facility failed to ensure a qualified individual was designated as the facility infection preventionist. The facility Census was 48. The findings were: Interview with the DON on 10/10/24 at 9:41 AM revealed she had been covering the infection control program since May and she had not completed any specialized training in infection prevention. Review of the facility policy titled Infection Preventionist last revised September 2022 showed .Specialized Training .1. The infection preventionist has obtained specialized IPC beyond initial professional training or education prior to assuming the role .2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation .

Based on medical record review, State Survey Agency incident report log review, policy review, and staff interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of the reasonable suspicion of a crime in accordance with Section 1150B of the Act for 1 of 3 sample residents (#9) reviewed for allegations of abuse. The findings were: 1. Review of the facility's policy Abuse & Neglect Prohibition, last revised July 2018, showed .Reporting and Response 1. STATE REPORTING OBLIGATIONS: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and adult protective services (where state law provides for jurisdiction in long-term care facilities) in accordance with Federal and State law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the facility is notified of the allegation .5. The facility will submit a summary of its investigation to the appropriate State agency within 5 days of its initial report or within whatever time frame required by the State agency. The following concerns were identified: a. Review of a nurse's note dated 4/27/23 and timed 4:40 PM showed the power of attorney for resident #9 and the police department had been notified of an allegation of abuse which involved the resident and CNA #1; however, review of the state survey agency incident report logs showed this allegation was not reported to the agency until 4/28/23 at 5:23 PM. In addition, the summary of the facility's investigation was not reported to the agency until 5/16/23. 2. Interview with the DON, and the regional resource nurse on 7/25/23 at 1:05 PM confirmed the allegation of abuse was not reported within the required timeframe.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure pharmacist recommendations were addressed by the attending physician for 1 of 5 sample residents (#8) reviewed for medications. The findings were: 1. Review of the 1/3/23 pharmacist consultation report showed resident #8 received an antipsychotic, Aripiprazole, for a potentially inappropriate indication: currently listed for DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY The pharmacist's recommendation was to .review and consider updating indication vs. an attempt at a gradual dose reduction, with the end goal of discontinuation. The following concerns were identified: a. Review of the physician's response dated 1/11/23 showed he had declined the pharmacist's recommendation due to Started by another provider. b. Review of the pharmacist's recommendation, dated 3/3/23, showed REPEATED RECOMMENDATION from 1/3/2023: Please respond promptly to assure facility compliance with Federal regulations. Review of the medical record showed no evidence the physician had responded to the recommendation. c. Review of the pharmacist's recommendation, dated 4/5/23, showed REPEATED RECOMMENDATION from 1/3/2023: Please respond promptly to assure facility compliance with Federal regulation. Review of the medical record showed no evidence the physician had responded to the recommendation. d. Review of the July 2023 medication administration record showed the resident received 2 milligrams of aripiprazole by mouth one time a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY with a start date of 12/17/2022. 2. Interview with the regional resource nurse, SSD, DON, and ADON/infection preventionist on 7/26/23 at 5:20 PM confirmed the pharmacist's recommendation had not been addressed. 3. Review of the LTC [long term care] Facility's Pharmacy Services and Procedures Manual, last revised 3/3/20, showed .7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR [medication regimen review] and the Director of Nursing to act upon the recommendations contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. 8. Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure medication-specific target symptoms were identified and appropriate monitoring in place for 2 of 5 sample residents (#8, #9) reviewed for psychotropic medication use. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included dementia, chronic pain, and age-related cognitive decline. Further review showed the resident received an antipsychotic and an antidepressant on 7 out of 7 days during the look-back period. Review of the physician orders showed the resident was prescribed aripiprazole (an antipsychotic) 2 milligrams (mg) by mouth one time a day related to dementia and duloxetine hydrochloride (an antidepressant) 60 mg delayed release capsule one time a day for pain. The following concerns were identified: a. Review of the resident's pain care plan, initiated on 9/27/22, showed the resident was prescribed an antidepressant for pain and the interventions included to monitor for side effects every shift by using the behavior monitoring tool in the TAR [treatment administration record]. Review of the July 2023 TAR showed no evidence the side effects of the psychoactive medication were being monitored. b. Review of the medical record showed no evidence medication-specific target symptoms and side effects for the use of the antipsychotic medication had been identified and were being monitored. c. Interview with the DON on 7/26/23 at 5:17 PM confirmed the medical record lacked documentation of the monitoring for side effects of the antidepressant. In addition, the medical record lacked documentation of the identification of target symptoms and monitoring for the antipsychotic prescribed. 2. Review of the 6/7/23 quarterly MDS assessment showed resident #9 had a BIMS score of 5 out of 15, which indicated the resident had severe cognitive impairment, and had a diagnosis of depression. Review of the physician orders showed the resident was prescribed 150 mg extended release bupropion hydrochloride (antidepressant) one time a day every other day for depression with a start date of 6/25/23 and 10 mg of escitalopram oxalate (antidepressant) one time a day related to depression with a start date of 2/4/23. The following concerns were identified: a. Review of the medical record showed no evidence medication-specific target symptoms and side effects for each antidepressant prescribed had been identified and were being monitored. b. Interview with the DON and the regional resource nurse on 7/26/23 at 3:43 PM confirmed the medical record lacked documentation of the identification of medication-specific target symptoms and monitoring for each antidepressant prescribed.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure infection control techniques were utilized during 1 of 2 dining observations. The census was 53. The findings were: 1. Observation on 7/24/23 beginning at 12:16 PM showed CNA #3 approached resident #27 and touched the resident on his/her shoulder. The resident requested something to drink and the CNA walked across the dining room, obtained a cup of hot water and a packet of cocoa, opened the cocoa packet, and emptied the contents of the packet into the cup. The CNA took the empty packet to the trash receptacle, used his hand to push open the hinged door of the trash receptacle and discarded the empty packet. After placing a plastic spoon in the cup, the CNA began stirring the contents and delivered the cup to the resident. The CNA left the table and obtained a meal tray from the kitchen window and delivered the tray to resident #47. The CNA picked up the resident's utensils and cut the resident's food before handing the utensils to the resident. The CNA returned to the kitchen window, obtained another tray, and delivered it to resident #50. Before placing the tray on the resident's table, the CNA grabbed the resident's drinking glass by placing his fingers around the external rim, and moved it to the side. The CNA used the resident's utensils to cut his/her food before handing the utensils to the resident. Before leaving the table, the CNA placed his hand on the handle of resident #50's wheelchair. The CNA returned to the kitchen window, obtained a meal tray, and delivered it to resident #40. The CNA removed the items from the tray, placed his hand on the back of resident #29, used resident #40's utensils to cut his/her meal, and handed the utensils to the resident. No hand hygiene was performed during the observation. 2. Interview with the infection preventionist/ADON on 7/27/23 at 12:54 PM revealed when serving meal trays, hand hygiene should be performed between trays or when staff contact other individuals or items to prevent cross contamination. 3. Review of the policy titled Handwashing/Hand Hygiene last revised August 2019 showed .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .o. Before or after eating or handling food; p. Before and after assisting a resident with meals .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure vaccinations were administered to 2 of 5 sample residents (#25, #42) reviewed for immunizations. The findings were: 1. Review of a Resident Immunization Consent Form dated 11/10/22 showed resident #25 accepted the pneumococcal vaccine; however, review of the medical record showed no evidence the pneumococcal vaccine was administered. 2. Review of a Resident Immunization Consent Form dated 4/2/22 showed resident #42 accepted the influenza vaccine; however, review of the resident's medical record showed no evidence the resident received the vaccination. 3. Interview with the infection preventionist/ADON, regional resource nurse, and DON on 7/27/23 at 12:51 PM revealed the facility was unable to find evidence the residents received the accepted vaccinations. 4. Review of the policy titled Vaccinations of Residents provided by the administrator on 7/27/23 showed .All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .3. All new residents shall be assessed for current vaccination status upon admission .6. If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration; b. Date of administration; c. Lot number of the vaccine (located on the vial); d. Expiration date (located on the vial; and e. Name of person administering the vaccine. 7. Certain vaccines (e.g., influenza and pneumococcal vaccines) may be administered per the physician-approved facility protocol (standing orders) after the resident has been assessed by the physician for medical contraindications for each vaccine. The resident's attending physician must provide a separate written order for any other vaccination, and such orders shall be recorded in the resident's medical record .

Based on staff interview, the facility failed to ensure the dietary manager met the required qualifications. The facility census was 53. The findings were: Interview with the dietary manager on 7/24/23 at 10:02 AM revealed she had been hired for the dietary manager position approximately a month ago and had enrolled in a certified dietary program in the past; however, she had not completed the course. Interview with the administrator and the dietary manager on 7/27/23 at 10:19 AM confirmed the facility did not have a qualified dietary manager or a full-time dietitian.

Based on observation, temperature log review, manufacturer instruction review, staff interview, and policy and procedure review, the facility failed to ensure the sanitization level of the automatic dishwasher was checked for 10 of 63 meals reviewed. In addition, the facility failed to ensure a sanitary environment during 2 of 2 kitchen observations and safe food temperatures during 1 of 1 meal preparation observations. The census was 53. The findings were: Related to monitoring of the dishwasher's chemical sanitizer concentration: 1. Review of the kitchen's temperature log worksheet showed the temperature of the wash and rinse water and the concentration of the chemical sanitizer was to be checked with each meal. The following concerns were identified: a. Review of the July 2023 temperature log sheets showed a sanitizer concentration of 0 ppm (parts per million) was recorded for the evening meal on 7/9/23 and 7/18/23. In addition a sanitizer concentration of 30 ppm was recorded for the evening meal on 7/16/23. There was no evidence the unacceptable ppm levels had been investigated. b. Review of the July 2023 temperature log sheets showed no documentation of the sanitizer or water temperatures were recorded for the morning and noon meals on 7/16/23; the evening meal on 7/17/23; the morning and noon meals on 7/20/23; and the morning and noon meals on 7/22/23. 2. Interview with the registered dietitian on 7/26/23 at 2:41 PM confirmed the sanitization level of the dishwasher should be monitored. 3. Interview with the dietary manager and the administrator on 7/27/23 at 10:19 AM confirmed the sanitizer concentration level of the dishwasher was not monitored correctly. 4. Review of the Dishwashing Machine Use 2001 MED-PASS, Inc. (Revised March 2010) policy and procedure showed Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation .6. Corrective action will be taken immediately if sanitizer concentrations are too low. 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log .9. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. The policy stated the concentration of the chlorine sanitizer should between 50 and 100 ppm. 5. Review of the 2022 U.S. Public Health Service Code showed 4-703.11 Hot Water and Chemical. (C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under § 4-501.114. Contact times shall be consistent with those on EPA-registered label use instructions by providing: (1) Except as specified under Subparagraph (C)(2) of this section, a contact time of at least 10 seconds for a chlorine solution specified under 4-501.114(A), (2) A contact time of at least 7 seconds for a chlorine solution of 50 MG/L that has a PH of 10 or less and a temperature of at least 38oC (100oF) or a PH of 8 or less and a temperature of at least 24oC (75oF), (3) A contact time of at least 30 seconds for other chemical SANITIZING solutions, or (4) A contact time used in relationship with a combination of temperature, concentration, and PH that, when evaluated for efficacy, yields SANITIZATION as defined in 1-201.10(B). 6. Review of the EcoLab ES-4000 dish machine manufacturer's instructions for use retrieved from http://manuals.jacksonmsc.com/ecolab%20manuals/ES-2000%20&%20ES-4000%20Rev%20O.pdf on 8/1/23 showed at a minimum water temperature of 120 degrees Fahrenheit was required with a recommended temperature of 140 degrees Fahrenheit and the minimum chlorine concentration was 50 ppm. Related to sanitary environment: 1. Observation on 7/26/23 at 9:27 AM showed cook #1 had donned gloves and was placing rolls on a pan with her gloved hands. At 9:35 AM the cook left the pan of rolls and opened the walk-in refrigerator door. The cook doffed her gloves and without performing hand hygiene donned new gloves then removed frozen soup from a container and placed it into a saucepan; turned on the faucet with her gloved hands, added water to the soup; covered the pan with aluminum foil, adjusted the heat on the stove, and placed the saucepan on the stove. With the same gloved hands the cook consulted the recipe book; entered the dry storage area and retrieved a box of scalloped potatoes; obtained a clean pan; sprayed the pan with cooking spray; and returned to the recipe book. The cook used her gloved hands to turn on the faucet to fill up a pitcher with water; entered the walk-in refrigerator and retrieved a cube of butter; obtained a knife and a cutting board; unwrapped the butter and touching the butter with her gloved hands cut off a section; rewrapped the butter and returned it to the walk-in refrigerator. The cook used scissors to open seasoning packets for the scalloped potatoes and added the contents of the packets to a pan on the stove; opened the oven door; adjusted the temperature knob; poured the dried potatoes from the box into the pan; donned oven mitts over the top of her gloved hands; again opened the oven door; removed the oven mitts and covered the saucepan with aluminum foil; donned the oven mitts over her gloved hands; and placed the pan into the oven. The cook removed the oven mitts and adjusted a knob on the oven. At this time the dietary manager donned the same oven mitts with her bare hands. 2. Observation at 11:44 AM showed cook #1 donned a pair of gloves; used a pen; donned oven mitts over her gloved hands and removed a pan of rolls from the oven; removed the oven mitts; obtained the temperature of the rolls; and used her gloved hands to pick up the rolls and place them in a serving pan. The cook placed her gloved hands into the oven mitts and retrieved a second pan of rolls from the oven; doffed the oven mitts; and transferred the rolls using her gloved hands to the serving pan. At this time the cook placed her gloved hands into the oven mitts and retrieved a pan of gravy off of the serving table; doffed the oven mitts; entered the dry storage area and obtained a new packet of gravy and proceeded to make the gravy. At 11:59 AM the cook doffed her gloves and performed hand hygiene. 3. Observation on 7/24/23 at 9:45 AM and again on 7/26/23 at 8:58 AM showed a pedestal fan that was darkened and soiled with debris was blowing air on the dishwashing racks which held clean dishes. Interview with dietary aide #1 on 7/26/23 at 9:01 AM revealed the fan was used to help the dishes dry faster. 4. Interview with the registered dietitian on 7/26/23 at 2:41 PM confirmed a fan soiled with debris should not be blowing on clean dishes and acknowledged the facility needed more training in the area of hand hygiene. 5. Interview with the dietary manager and the administrator on 7/27/23 at 10:19 AM confirmed there was a need for education in regard to hand hygiene, and they had the pedestal fan removed from the kitchen. 6. Review of the Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices 2001 MED-PASS, Inc (Revised November 2022) showed All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .6. Employees must wash their hands: .c. whenever entering or re-entering the kitchen; d. before coming in contact with any food surfaces; e. after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate the hands. 7. Review of the 2022 U.S. Public Health Service Food Code showed 2-301.14 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 8. Review of the 2022 U.S. Public Health Service Food Code 4-601.11 showed Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. and 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. Related to food temperature: 1. Observation on 7/26/23 at 11:44 AM showed cook #1 was checking the temperature of the unmodified foods which included soup, ham and potato casserole, scalloped potatoes, fish, carrots, and rolls which had been placed in the waterless hot food unit prior to the start of food service. However, the temperature of the fortified potatoes, gravy, and pureed carrots were not obtained. 2. Observation on 7/26/23 at 12:12 PM showed cook #1 and the dietary manager became aware the texture of the main dish of ham and potato casserole had not been modified for the residents which required a pureed diet. The dietary manager obtained 7 portions of the ham and potato casserole from the waterless hot food unit and placed it into the Robot Coupe (food processor) with some hot water and thickening powder. After changing the consistency of the food, the dietary manager placed the pureed main course back onto the serving unit without checking the food's temperature. 3. Review of the 7/2/23 to 7/22/23 kitchen temperature log worksheets showed no evidence the temperature of mechanically-altered foods had been taken prior to service on any of the 21 days reviewed. 4. Interview with the registered dietitian on 7/26/23 at 2:41 PM confirmed the temperature of pureed foods should be monitored. 5. Interview with the dietary manager and the administrator on 7/27/23 at 10:19 AM confirmed the temperature of mechanically-altered food was not monitored. 6. Review of the Food Preparation and Service 2001 MED-PASS, Inc policy, last revised November 2022 showed .11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees F (Fahrenheit) during preparation or they are reheated to 165 degrees F for at least 15 seconds if holding for hot service. 7. Review of the 2022 U.S. Public Health Service Food Code showed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5°C (41°F) or less.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, hospital record review, hospital staff interview, and policy and procedure review, the facility failed to ensure a care plan was developed for 1 of 6 residents (#1) identified as being at risk for developing pressure ulcers. The findings were: Review of the 12/6/22 admission MDS assessment showed resident #1 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus II, osteoporosis, and non-Alzheimer's dementia. The review showed the resident was rarely or never understood. Further review showed the resident required the extensive assistance of 1 staff member for bed mobility and personal hygiene. Review of the 12/13/22 Braden Scale For Predicting Pressure Sore Risk assessment showed a score of 8, which indicated the resident was at very high risk of developing pressure ulcers. Review of the resident's care plan showed the facility failed to ensure a plan was in place to address this risk. Review of the activities of daily living plan showed the resident required extensive assistance from staff with bed mobility, locomotion, and transfers. However, the plan failed to address the need for repositioning and off-loading. The following concerns were identified: a. Review of the 1/2/23 hospital wound assessment note by DPT #1 after wound assessment was performed from 9:52 AM to 10:39 AM showed the following: Assessment: Wounds evaluated, photographed, and treated with focus on comfort. Purple foot wounds are consistent with deep tissue injury from prolonged pressure over bony prominence. b. Interview with hospital RN #1 on 3/14/23 at 9:50 AM revealed she was present for the resident's visit to the ED on 1/1/23. She stated the resident's appearance on 1/1/23 indicated s/he had not received ADL care since being seen in the ED on 12/29/22. She also stated it was her professional opinion the resident was not repositioned adequately between 12/29/22 and 1/1/23 at the facility to prevent pressure ulcers. c. Interview with the assistant director of nursing on 3/13/23 at 4:20 PM confirmed the facility failed to develop a plan to address the resident's very high risk of developing pressure ulcers. d. According to the facility policy titled, Care Plans, Comprehensive Person-Centered last revised March 2022, the Policy Statement shows, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation the following was included, . The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, hospital record review, hospital staff interview, and policy and procedure review, the facility failed to ensure residents received received necessary services to maintain good grooming, and personal and oral hygiene for 1 of 6 sample residents (#1) reviewed who required staff assistance with ADLs. The findings were: Review of the 12/6/22 admission MDS assessment showed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus II, osteoporosis, and non-Alzheimer's dementia. The review showed the resident was rarely or never understood. Further review showed the resident required the extensive assistance for one staff member for bed mobility and personal hygiene. Review of the care plan showed a 12/11/22 plan with a focus as follows: I have increased risks for actual/potential limitations in my ability to perform my ADLs. The interventions included an extensive assistance requirement from staff with bed mobility, dressing, eating, locomotion, personal hygiene, toileting, and transfers. Review of the 1/1/23 progress note timed 12:21 PM showed the family requested the resident be transferred to the local hospital, and the resident was sent to the ED by non-emergent transfer at 11:40 AM. The following concerns were identified: a. Review of the hospital record showed the resident was admitted to the local ED on 1/1/23 at 12:07 PM and was then admitted to the hospital on [DATE] at 4:04 PM with a diagnosis of sepsis. Review of a 1/1/23 nursing note timed 12:15 PM by hospital RN #1 showed the following, On arrival .[Resident #1] has dry mucous membranes with severe halitosis, dirty teeth, and dry lips. [Resident #1's] perineal area is malodorous and [s/he] has crusting in [his/her] groin and [genitalia]. There is dried crusted bowel movement between [his/her] buttocks. Further review showed pictures of the resident's right and left hand. The right hand picture showed a dried brownish substance under the resident's thumbnail. The left hand picture showed the same dried brownish substance under the fingernail of the fourth and fifth fingers, and the brownish substance was around the nailbed and down to the first digit of the fourth finger. The middle finger could also be observed in the picture, and the appearance of both pictures showed the resident's fingers were dirty, and the resident's fingernails had not been cared for. The resident's right middle fingernail was jagged on the left hand. b. Review of the Intervention/Task documentation by CNAs for the resident from 12/17/22 through 12/31/22 showed that documentation failed to include an area for oral care or fingernail care. c. Interview with CNA #1 on 3/13/23 at 11:05 AM revealed the resident was resistant to cares, especially from male staff. The CNA had taken care of the resident in the last few days at the facility and was unsure when the resident had any fingernail care from anyone. The CNA further stated that residents sometimes received fingernail care during showers, but there was no specific timeframe or plan for care of fingernails. The CNA could not remember the condition of the resident's fingernails at the time of transfer to the ED on 1/1/23. Interview with CNA #2 on 3/13/23 at 1:20 PM revealed that either nurses or an outside provider that came to the facility normally provided care for fingernails, and added that CNAs sometimes provide fingernail care for non-diabetics when providing showers. The CNA was unsure how often the outside provider completed fingernail care for residents. Interview with CNA #3 on 3/13/23 at 1:27 PM revealed residents routinely received nail care with showers. The CNA stated the resident was resistant to cares, and further stated it took 3 staff members to try and do anything for the resident's fingernails. The CNA could not remember the condition of the resident's fingernails prior to being transferred to the local ED on 1/1/23. d. Interview with hospital RN #1 on 3/14/23 at 9:50 AM revealed she was present for the resident's visits to the ED on both 12/29/22 and 1/1/23. She stated the resident's appearance was unkempt on arrival to the ED on 12/29/22. She stated staff provided a bedbath and care at that time, which included oral care because she was concerned that baths and oral care had not been provided in a timely manner for the resident as shown by the resident's mouth odor, unclean teeth, and unkempt appearance. She stated when the resident was brought back to the ED on 1/1/23, there was an odor about the resident so strong that staff thought the odor came from the resident's entire body due to sepsis. She stated staff realized at some point the odor was coming from the resident's mouth, and a respiratory therapist assisted in oral care which included utilizing normal saline and swabbing. At one point the respiratory therapist removed what appeared to be a nasty mucous plug. She further stated the resident's mouth, lips, and teeth were all dry and dirty. She also stated the resident's fingernails had dry bowel movement on them and under them, and the resident's perineal area had dried bowel movement that was noticeable and appeared to have been there for an extended period of time. She further stated the resident's appearance indicated s/he had not received ADL care since being in the ED on 12/29/23. e. Interview with the director of nursing on 3/9/23 at 12:05 PM revealed her primary concern for the resident on 1/1/23 was starting intravenous fluids and transferring the resident to the local ED per family request. She confirmed that a head to toe skin assessment was not performed at that time. f. According to the facility policy title, Activities of Daily Living (ADLs), Supporting last revised March 2018, the Policy Statement was as follows, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure residents with urinary catheters received appropriate treatment and services to prevent urinary tract infections for 1 of 2 sample residents (#6) with urinary catheters. The findings were: 1. Review of the 11/9/22 annual MDS assessment showed resident #6 had a BIMS score of 8 out of 15 (moderately impaired). The activities of daily living (ADL) section showed the resident needed extensive to total assistance. Diagnoses included indwelling catheter, benign prostatic hyperplasia, neurogenic bladder, and multiple sclerosis. Review of the physician orders showed the resident was given Macrobid capsule (antibiotic) 100 milligrams (mg) daily for urinary tract infection (UTI) prophylaxis from 11/3/22 through 11/16/22, nitrofurantoin macrocrystal capsule (antibiotic) 100 mg daily for UTI prophylaxis was started 11/21/22, and Renacidin solution (irrigating solution) 30 milliliter (ml) irrigation 1 time a day every Tuesday, Friday related to personal history of urinary tract infections start date of 11/23/22. In addition, sulfamethoxazole-trimethoprim tablet (antibiotic) 800-160 mg 1 tablet two times a day for UTI for 2 day with a start date of 11/20/22. The following concerns were identified: a. Observation on 11/30/22 at 12:10 PM showed the resident was up in a Hoyer lift. The resident's urinary catheter bag was attached to the strap on the harness and positioned above the resident's bladder. Dark yellow urine was observed in the Foley tubing returning to the resident's bladder. Further observation showed CNA #2 moved the urinary catheter bag down to the side of the wheelchair at 12:18 PM. b. Interview with the resident on 11/30/22 at 12:15 AM revealed s/he .could have a urinary tract infect right now, I do have a history of them. c. Interview with CNA #1 on 11/30/22 at 12:22 PM revealed it was normal for her to hook the bag to the harness while transferring the residents. Further, she confirmed the urinary catheter bag was above the bladder. In addition CNA #1 and CNA #2 denied in-service education on peri-care and care of a Foley catheter. d. Interview with the ADON on 11/30/22 at 4 PM revealed the CNAs were trained yearly on peri-care and Foley catheters. Further, she revealed it was the expectation for the urinary catheter bag to be kept below the level of the bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review the facility failed to implement measures to effectively ensure resident lifts were clean in 2 of 4 mechanical lifts observed. The findings were: 1. Observation on 11/30/22 at 9:45 AM showed a sit-to-stand lift in the hall by room [ROOM NUMBER]. The foot rest had crumbs and clumps of brown and white substances all over it. 2. Observation on 11/30/22 at 10:37 AM showed a sit-to-stand lift by room [ROOM NUMBER]. The lift had clumps of brown and white substance all over it, with two circular half dollar-sized areas of black substance on it. 3. Interview with CNA #1 on 11/30/22 at 10:42 AM revealed We don't really clean it as a CNA. We do spray the handles between uses. Maintenance cleans the foot rest once a month. The CNA confirmed the lift was dirty-dirty. 4. Interview with maintenance #1 on 11/30/22 at 10:55 AM revealed We do clean the sit-to-stands occasionally; mainly housekeeping does it. He stated he was unsure of when the last time maintenance had cleaned one. 5. Interview with housekeeping #1 on 11/30/22 at 11:05 AM revealed No, we do not clean the sit-to-stand lifts. It is the CNA's job. 6. Interview with the ADON on 11/30/22 at 11:35 AM revealed The CNAs are to clean the lifts between uses and if dirty. The night nursing staff are to clean the sit-to-stands every night. 7. Review of policy Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022 showed .5. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment).

Based on resident representative interview, medical record review, staff interview, and policy and procedure review, the facility failed to notify the resident's representative for 1 of 7 sample residents (#35) reviewed for hospitalization. The findings were: 1. Review of the 1/19/22 quarterly MDS assessment for resident #35 showed the staff assessment for mental status was coded as severely impaired. The following concerns were identified: a. Review of the Situation, Background, Assessment, Recommendation (SBAR) form which was not dated, showed the resident had fallen on 4/2/22 at 10:34 PM. The name, date, and time the resident's representative was notified was blank. b. Interview with the resident's representative on 6/9/22 at 11:41 AM revealed he had not been informed of the resident's fall until the resident had been taken to the hospital on 4/8/22. c. Interview with the DON on 6/9/22 at 2:40 PM confirmed the section documenting the notification of the resident's representative was blank and the facility was unable to provide additional documentation of notification. 2. Review of the Fall Management and Investigation policy with the effective date of 9/1/18 showed .III POLICY GUIDELINES .F. The resident's family members/responsible persons and physician are notified of Falls .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 23 sample residents (#32, #34, #42, #155). The findings were: 1. Review of the 3/18/22 admission MDS assessment showed resident #32 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and cognitive communication deficit. The resident was cognitively intact with a BIMS score of 15/15. Further review showed it was very important to the resident to have books, newspapers, and magazines to read, as well as keeping up with the news and going outside to get fresh air when the weather was good. It was somewhat important to the resident to be around animals such as pets, as well as participating in religious services or practices. The following concerns were identified: a. Interview with the resident on 6/6/22 at 4:54 PM revealed s/he .had nothing to do except watch television and roll around in this chair. b. Review of the current care plan, last revised 6/8/22 showed no documentation of the resident's interests or activities. c. Interview with the NHA, DON, and ADON on 6/9/22 at 11:47 AM confirmed the care plan was not individualized to the resident's needs and preferences. 2. Review of the 5/5/22 annual MDS assessment showed resident #42 was admitted to the facility on [DATE] with diagnoses which included macular degeneration and cognitive communication deficit. The resident was cognitively intact with a BIMS score of 15/15. Further review showed it was very important to the resident to have books, newspapers, and magazines to read, to listen to music s/he liked, to be around animals such as pets, to keep up with the news, to do his/her favorite activities, and to go outside to get fresh air when the weather was good. The following concerns were identified: a. Interview with the resident on 6/6/22 at 3:38 PM revealed the residents .just watch television since there isn't anything else to do. There's no activities for [the residents] in the COVID unit. I like to build my models and puzzles, but don't have any or anywhere to work on [them]. b. Review of the current care plan, last revised 6/6/22, showed a focus area for activities; however, documentation did not reflect the resident's preferences from the MDS or his/her interest in the models or puzzles. c. Interview with the NHA, DON, and ADON on 6/9/22 at 11:47 AM confirmed the care plan was not individualized to the resident's needs and preferences. 3. Review of the 4/20/22 quarterly MDS assessment showed resident #34 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, major depressive disorder, and other specified mental disorder due to known physiological condition. Review of the current physician orders showed the resident was started on aripiprazole (an antipsychotic medication) on 5/26/22 related to bipolar disorder. Review of a 5/29/22 nurse progress note showed .Has been noted to be easier to redirect when behaviors start . The following concerns were identified: a. Review of the current care plan showed no documentation related to the identified behaviors that resulted in the administration of the new medication, or non-pharmacological interventions. b. Interview with the NHA, DON, and ADON on 6/9/22 at 11:47 AM confirmed the care plan was not individualized to the resident's needs and preferences. 4. Review of the 5/19/22 admission MDS showed resident #155 was admitted to the facility on [DATE] with diagnoses which included unspecified mood [affective] disorder, generalized anxiety disorder, and unspecified dementia without behavioral disturbance. Review of the 5/18/22 admission physician orders showed an order for buspirone (antianxiety) 5 milligrams (mg) daily and 10 mg daily, and fluoxetine (antidepressant) 60 mg daily. Review of the treatment administration record for June 2022 showed an area to monitor behavior and document intervention codes for buspirone and fluoxetine. The following concerns were identified: a. Review of the admission care plan showed the resident had a focus area for mood related to generalized anxiety. The interventions included administer medications as ordered and encourage and reassure as needed; however, there were no specific individualized non-pharmacological interventions identified. b. Interview with the DON on 6/9/22 at 9:48 AM revealed the care plan was not individualized to the resident's needs and preferences. 5. Review of the Care Plan Development and Communication Policy, revised 1/4/19, showed 1. Policy Statement .The overall plan of care (POC) is oriented towards: .2. Person-centered interventions that honor the resident's preferences Please note: Both baseline and comprehensive plans of care include a problem statement developed as a result of comprehensive review; measurable resident-centered goals; time frames for meeting those goals; and interventions designed to assist the resident in meeting the goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure the care plan was revised to identify resident specific approaches for 2 of 23 sample residents (#15, #35). The findings were: 1. Review of the 3/16/22 annual MDS assessment for resident #15 showed diagnoses which included unspecified dementia with behavioral disturbance, and anxiety disorder. Review of the medication administration record for June 2022 showed the resident received apiprazole (antipsychotic) 5 mg daily, quetiapine (antipsychotic) 25 mg daily, and Celexa (antidepressant) 30 mg daily. Review of the treatment administration record for June 2022 showed target behaviors to monitor and the interventions included redirection and remove from the environment. Interview on 6/8/22 at 11:36 AM with MA-C #1 revealed some behavioral interventions were on the care plan. He further stated the resident liked to watch the Catholic channel and wanted to hold a rosary for comfort. The following concerns were identified: a. Review of the care plan with a revision date of 3/23/22 showed focus areas for mood and behaviors; however, the care plan failed to identity specific resident centered interventions. b. Interview on 6/9/22 at 9:48 AM with the DON confirmed there were some interventions on the care plan; however, it lacked the interventions regarding television show preference, and holding the rosary. She further stated the interventions were something they needed to work on. 2. Review of the 4/20/22 quarterly MDS assessment showed resident #35 was admitted to the facility on [DATE] and was at risk for pressure ulcers. Observation throughout the survey timeframe showed the resident wore a foam boot on his/her right foot. Review of a nurse progress note dated 4/10/22 showed Boggy area with dark coloration found on medial side of right heel .skin prep applied to the area and is showing signs of improvement. Review of a 4/11/22 Skin/Wound note showed New wound evaluation. Blistered area from pressure between feet. Skin prep applied to area to help toughen skin. Review of a physician order dated 4/10/22 showed WOUND ORDER: skin prep to bilat (bilateral) heels, float heels every shift. Review of the 4/21/22 skin and wound evaluation showed Wound resolved. Will continue wound prevention to bilateral heels. The following concerns were identified: a. Review of the resident's entire care plan, last revised 5/29/22, failed to include the wound prevention intervention. b. Interview with the ADON on 6/8/22 at 4:33 PM confirmed the care plan had not been updated to include the use of the foam boot. An additional interview with the DON on 6/8/22 at 4:51 PM confirmed the wound prevention interventions should be on the care plan. 3. Review of the Care Plan Development and Communication policy with a revision date, 9/1/18, showed I. Policy Statement .The overall plan of care is oriented towards: .2. Person centered interventions that honor the resident's preferences .II. Definitions 1 .Person-centered care includes making an effort to understand what each resident is communicating verbally and non-verbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to the community. It incorporates the resident's personal and cultural preferences in developing the goals of care . 4. Review of the Behavioral Health Management policy, revised on 9/1/18, showed .III. Policy Guidelines . E. Person-centered approaches and their outcomes are recorded on the plan of care. IV. Provision(s) and Procedure(s) .N. Interventions are person-centered and incorporated as part of the overall care environment that supports physical, functional and psychosocial needs. O .5. Non-pharmacological approaches that are person-centered will be optimally utilized at a maximum .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and policy and procedure review, the facility failed to provide an ongoing program of activities for 3 of 3 sample residents (#8, #32, #42) isolated in the COVID-19 unit. The COVID-19 unit census was 20. The findings were: 1. Review of the 3/18/22 admission MDS assessment showed resident #32 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and cognitive communication deficit. The resident was cognitively intact with a BIMS score of 15/15. Further review showed it was very important to the resident to have books, newspapers, and magazines to read, as well as keeping up with the news and going outside to get fresh air when the weather was good. It was somewhat important to the resident to be around animals such as pets, as well as participating in religious services or practices. Review of the line listing of COVID-positive residents showed the resident was admitted to the COVID unit on 5/31/22. The following concerns were identified: a. Observation on 6/6/22 at 4:54 PM showed the resident self-propelling in his/her wheelchair in the hallway. Interview at that time revealed the resident had .nothing to do except watch TV and roll around in this chair. 2. Review of the 5/5/22 annual MDS assessment showed resident #42 was admitted to the facility on [DATE] with diagnoses which included macular degeneration and cognitive communication deficit. The resident was cognitively intact with a BIMS score of 15/15. Further review showed it was very important to the resident to have books, newspapers, and magazines to read, to listen to music s/he liked, to be around animals such as pets, to keep up with the news, to do his/her favorite activities, and to go outside to get fresh air when the weather was good. Review of the line listing of COVID-positive residents showed the resident was admitted to the COVID unit on 5/31/22. The following concerns were identified: a. Observation on 6/6/22 at 3:38 PM showed the resident's room contained completed wooden models. Interview with the resident at that time revealed the residents just watch TV since there isn't anything else to do. There's no activities for [the residents] in the COVID unit. The resident stated s/he liked to build models and do puzzles; however, s/he did not have any or any place to work on them. 3. Review of the 3/9/22 quarterly MDS assessment showed resident #8 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, cognitive communication deficit, and other intellectual disabilities. The resident was cognitively intact with a BIMS score of 15/15. Review of the current care plan, last revised 6/2/22, showed the resident preferred group activities and socializing with other residents. Further review showed s/he liked the news, watching television, listening to music, and going on outings. Interventions included providing the resident with a new activities calendar at the beginning of each month. Review of the line listing of COVID-positive residents showed the resident was admitted to the COVID unit on 5/31/22. The following concerns were identified: a. Observation on 6/8/22 at 3:39 PM showed the resident was seated in a recliner watching television. At that time the resident stated s/he was bored since there is nothing to do besides watch TV. 4. Interview with activities assistant (AA) #1 on 6/9/22 at 11:36 AM revealed the activities director was out of the facility and he was handling the day-to-day activities in the director's absence. AA #1 stated the facility was limited to what activities could be provided for the facility, especially the COVID unit, and had canceled most activities for the month for the whole facility. 5. Review of the posted activities calendar for June 2022 showed from 6/2/22 through 6/10/22, 35 of the 58 offered activities had been canceled for the entire facility. There was not an alternative calendar or activities available for the residents isolated in the COVID unit. 6. Interview with the NHA, DON, and ADON on 6/9/22 at 11:47 AM revealed activities were at a minimum due to the COVID outbreak in the facility and the activities director was out of the facility. In addition, the activity director had prepared activity packets and baskets for the residents prior to his departure; however, they were not aware if the packets and baskets had been provided to residents in the COVID unit. 7. Review of the policy titled Activities Policy, effective 9/1/14, showed The community will provide space, supplies, equipment and the staff support necessary for social, physical, educational and leisurely activities, both within and outside the Community, that are planned according to the preferences, needs and abilities of residents .the Community will encourage participation in independent or self-directed activities, as well as offer group activities at least three times per week .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 1 of 6 sample residents (#34) reviewed for psychotropic medications. The findings were: 1. Review of the 4/20/22 quarterly MDS assessment showed resident #34 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, major depressive disorder, and other specified mental disorder due to known physiological condition. Review of current physician orders showed a 5/25/22 order for 5 milligrams of aripiprazole (an antipsychotic medication) to be administered once daily, related to bipolar disorder, current episode depressed, and other specified mental disorder due to known physiological condition. Review of a nurse progress note dated 5/29/22 showed .Has been noted to be easier to redirect when behaviors start . The following concerns were identified: a. Review of daily progress notes from 5/26/22 through 5/30/22 addressing the resident's new medication showed .no adverse effects . associated with the medication. Further review showed no relevant behaviors were documented. b. Review of the current physician orders showed no orders of documentation related to behavior monitoring or non-pharmacological interventions. c. Review of the current care plan, last revised 4/24/22, showed no documentation related to the identified behaviors which resulted in the administration of the new medication or any non-pharmacological interventions. 2. Interview with the NHA, DON, and ADON on 6/9/22 at 11:47 AM confirmed the resident's medical record lacked documentation of behavior monitoring and interventions. 3. Review of the policy titled Unnecessary Medications, last revised 4/9/07, showed .IV. Provisions(s) and Procedures(s) .D. Monitoring Medications .1. The Community's Monitoring system includes observation, assessment and reporting of the following: a. Symptoms suggesting the need for medication (including initiated or continued use of Antipsychotic Medication) . 4. Review of the policy titled Behavioral Health Management last revised 12/8/08 showed .IV. Provisions(s) and Procedure(s) .K. Nursing staff identify, document and inform the physician immediately about specific details regarding changes in an individual's mental status, behavior or cognition in order to determine the root cause, including: .1. Onset, duration, intensity and frequency of behavioral symptoms; .4. A new onset or alteration in behavior is documented and communicated with the physician immediately . P. When psychoactive medications are prescribed for behavioral symptoms, the following are documented: .2. Potential cause of the behavior .4. Target Behaviors .7. Monitoring for efficacy .

Based on observation, staff interview, policy and procedure review, CMS Guidance review, CDC guideline review, facilty COVID line list review, and county transmission rate review. the facility failed to ensure adequate transmission-based precautions were implemented to prevent the spread of COVID-19 during 2 random observations, and failed to ensure infection control practices were implemented for 2 random observations. The census was 55. The findings were: Related to transmission-based precautions: 1. Observation on 6/6/22 at 11:23 AM showed an unmasked visitor was in the room of resident #105 and resident #107 interacting with both residents at a distance of less than 6 feet. Observation on 6/7/22 at 9:24 AM showed the same unmasked visitor was in the resident's room and interacting with both residents at a distance of less than 6 feet. During this time physical therapist #1 was in the room and then at 9:29 AM RN #1 entered the room. Neither staff member asked the visitor to don a mask. Interview with RN #1 at 9:33 AM revealed the visitor should have had a mask on. The nurse then returned to the room and asked the visitor to don a mask. Interview with the DON on 6/9/22 at 1:31 PM revealed she was aware the visitor was not compliant with wearing a mask and had educated him more than once. 2. Review of the policy titled Coronavirus (COVID-19) last revised 5/12/21 showed .D. Visitors, Vendors, and Third-Party Contractors . 1. Refer to CDC and State for further guidance . 3. Review of the CMS memo QSO-20-39-NH last revised on 3/10/22 showed .Guidance . visitation can be conducted through different means based on a facility's structure and residents' needs, such as in resident rooms, dedicated visitation spaces, and outdoors. Regardless of how visits are conducted, certain core principles and best practices reduce the risk of COVID-19 Infection Prevention . Face covering or mask (covering mouth and nose) and physical distancing at least six feet between people, in accordance with CDC guidance . 4. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Health Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated 2/2/22 showed . Patient Visitation: Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are not present; or in designated visitation areas when others are not present): The safest practice is for patients and visitors to wear source control and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated. If the patient and all their visitor(s) are up to date with all recommended COVID-19 vaccine doses, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP (Healthcare Personnel), regardless of vaccination status. 5. Observation on 6/7/22 at 2:13 PM showed CNA #1 and CNA #2 used a mechanical lift to transfer resident #48 to bed. Further observation showed the CNAs rolled the mechanical lift to the hallway and did not disinfect it. Interview with CNA #1 confirmed the mechanical lift was not disinfected after use. She stated there were disinfecting wipes at the nurses' station; however, she was not sure when the lift should be disinfected. Interview with the DON on 6/8/22 at 2:14 PM revealed her expectation was to disinfect the lifts after each resident use. Review of the Cleaning & Disinfection of Nursing Equipment policy, revised 6/1/18, showed .III Procedures, nursing responsibility include cleaning and disinfecting equipment between patient uses: a. Hand hygiene performed b. Use of approved disinfection products per manufacturers' guidelines in between resident use 6. Review of the facility's line list of active COVID-19 cases provided by the facility on 6/6/22, showed 20 residents were confirmed positive for COVID-19 infection. 7. Review of the CDC's COVID-19 Integrated County View showed the level of community transmission was High at the time of the survey. Related to implementation of infection control practices: 1. Observation on 6/8/22 at 2:47 PM showed resident #42's catheter bag was lying on the ground under his/her wheelchair. The privacy bag was torn down the seam on the right side of the bag. Interview at that time with RN #2 confirmed the bag should not be on the ground due to potential infection control issues. RN #2 stated when the catheter bags get too full the privacy bags tear. Interview with the NHA, DON, and ADON, on 6/9/22 at 11:47 AM confirmed catheter bags should not be on the ground. 2. Observation on 6/7/22 at 2:13 PM showed CNA #2 perform perineal care for resident #48. The CNA removed her gloves and did not perform hand hygiene before donning a clean pair of gloves. The CNA then put clean briefs on the resident. Interview with the CNA confirmed she was supposed to perform hand hygiene after performing perineal care, and before donning clean gloves. Review of the Hand Washing policy, revised 10/1/17, showed .1. Hand washing is performed: 4. If moving from a contaminated-body site to a clean-body site during resident care .