Every finding on record at Aperion Care Summerfield

Based on observation, interview, and record review, the facility failed to ensure proper handwashing for 1 of 2 dining observations. Findings include: 1. During a dining observation, on 4/30/25 at 11:55 a.m., Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to a table and adjusted a resident in their wheelchair, so she was closer to the table. 2. During a dining observation, on 4/30/25 at 11:56 a.m., Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to wait at the counter for the lunch trays to be ready to be served, pulled on the back of her t-shirt and placed her hands behind her back. 3. During a dining observation, on 4/20/25 at 12:20 p.m., Dietary Aide 4 washed her hands for 5 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to the serving counter and served 3 bowls of cereal to residents. 4. During a dining observation, on 4/30/24 at 12:21, Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to the serving counter and obtained a lunch tray to serve to a female resident. During an interview, on 4/30/25 at 2:58 p.m., the Assistant Director of Nursing (ADON) indicated she had noted there were some concerns identified during meal service today related to handwashing. She indicated the staff was observed to not be washing hands for the appropriate amount of time and not the correct technique. During an interview, on 4/20/25 at 3:05 p.m., the Administrator indicated they had provided a hand hygiene in-servicing to staff today after improper technique was noted during the lunch meal service. During an interview, on 5/5/25 at 10:34 a.m., Housekeeping Aide 7 indicated staff should wash their hands for approximately 1 minute, obtain a paper towel to turn off the faucet and then obtain a second paper towel to dry your hands. She further indicated staff should not touch the water faucet with bare hands. On 4/30/25 at 3:05 p.m., the Administrator provided an undated document, titled, Hand Washing, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Apply soap, using friction rub hands together, cleaning under nails and between fingers thoroughly and up to wrist for 20 seconds. 3. Rinse hands well without touching the inside of sink or faucet. 4. Dry hands well with paper towel. Use clean paper towel to turn off faucet. Discard paper towel in trash receptacle 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure water temperatures in the dining room wash station and common restrooms were within safe parameters for 3 of 3 random observations. Findings include: On 4/30/25 at 11:51 a.m., while observing the staff washing their hands during meal service, noted the water was very hot and staff had to continually adjust the water. The water temperature was 143 degrees in the main dining room kitchen sink. During two observations one at 10:00 a.m. and again at 2:05 p.m., the door to the common restroom on the south hall was unlocked. The water temperature was 135.5 degrees. During observation of the south hall resident room and shower room indicated, the water temperature in the south hall shower and sink was 119 degrees. Resident rooms on both halls observed water temperatures were within acceptable parameters. On 4/30/25 at 2:39 p.m., during interview the Administrator indicated the water in the employee restroom was connected to the main kitchen. She was not aware the door was unlocked and indicated a visitor must have left it unlocked. She indicated the small dining kitchen serving area had a latch on the half door preventing residents from entering into the area. She indicated the water was set to the current temperature so they could prepare hot drinks and did not think it was too hot for the employees. She indicated she was advising the Maintenance Director to turn the temperature down. The Administrator provided water temperature logs indicating water temperatures in the resident rooms was within acceptable parameters. On 5/1/2025 at 12:54 p.m., the provided an undated document, titled, Domestic Water Temperature, and indicated it was the policy currently being used by the facility. The policy indicated, .Temperatures of water coming out of sink faucets and showers should be between 100-120 degrees F to prevent 3.1-45(a)

Based on record review and interview, the facility failed to ensure quarterly care plan meetings, which addressed the specific needs of the Resident were completed for 1 of 16 residents reviewed (Resident 29). Findings include: On 5/1/25 at 9:32 a.m., during an initial interview, Resident 29 did not recall attending care plan meetings which addressed his specific needs. On 5/1/25 at 1:00 p.m., the medical record of Resident 29 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but not limited to Huntington's Disease (a progressive inherited brain disorder that causes uncontrolled movements, cognitive decline, and psychiatric symptoms), and epilepsy (a disorder of the brain characterized by repeated seizures). An annual Minimum Data Set (MDS) assessment, dated 3/15/25, indicated the resident was cognitively impaired. A comprehensive care plan addressing the resident's needs, initiated on 3/27/24, was reviewed and updated accordingly. The medical record lacked documentation of a quarterly care plan meeting or of the resident being notified and offered to attend. On 5/1/25 at 10:00 a.m., during an interview the Social Services Director indicated the facility had regular care plan meetings with the resident and the resident's responsible party were invited to attend. On 5/2/25 at 10:30 a.m., during interview the Administrator indicated the resident had several care plan meetings with the Social Services Director and the resident did attend. She acknowledged the documentation did not reflect a specific care plan meeting addressing all needs. She indicated the meetings they had with the resident had been regarding his desire for more freedom and ability to pursue intimacy. On 5/2/2025 at 10:38 a.m., the Administrator provided a document, titled, Comprehensive Care Plan, dated 11/28/12, and indicated it was the policy currently being used by the facility. The policy indicated, .A comprehensive care plan must be .To the extent practicable, the participation of the resident and the resident's representative (s). An explanation should be included in a resident's medical record .Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments .The resident and or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person , via telephone or video conference (if available) at least quarterly 3.1-35(c)(1)

Based on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 of 11 residents MDS assessments reviewed (Resident 32). Findings include: During an interview, on 4/30/25 at 9:57 a.m., Resident 32 denied that she had a feeding tube for nutritional intake. She indicated that she had never had one. Resident 32's record was reviewed on 5/2/25 at 9:02 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), dysphagia, unspecified (refers to medical term for difficulty swallowing), and nutritional deficiency (lack of sufficient nutrients in the body). A quarterly MDS assessment, dated 4/25/25, indicated the resident had a feeding tube (a medical device used to deliver nutrition and fluids directly into the digestive system, bypassing the mouth and esophagus). A physician order, dated 10/7/24, indicated a regular diet, mechanical soft (foods that have been altered in texture to make them easier to chew and swallow) thick liquids consistency. A care plan, dated 10/11/24, indicated the resident had alteration in nutrition related to Huntington's disease. Interventions included, but were not limited to, honor food preferences, encourage good intake, and notify medical doctor of significant weight changes. During an interview, on 5/5/25 at 9:50 a.m., the MDS Coordinator indicated there was a coding error on Resident 32's quarterly MDS assessment and she would need to go in and modify it. She indicated the resident never had a feeding tube. During an interview, on 5/5/25 at 9:52 a.m., the Administrator indicated it was a possibility the Dietary Manager marked the wrong box on the MDS assessment. The MDS assessment had been coded wrong and needed to be modified. Section K of the CMS (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, indicated.N0520: Nutritional Approaches: Check all of the following nutritional approaches that apply: .3. while a resident .B. Feeding tube .Steps for Assessment: Review the medical record to determine if any of the listed nutritional approaches were performed during the look-back period .check all that apply .K0520B, feeding tube .Coding tip for K0502B: only feeding tubes that are used to deliver nutritive substances and or hydration during the assessment period are coded in K0502B 3.1-31(c)(5)

Based on record review and interview, the facility failed to ensure the code status of a resident was accurate for the physician order, careplan, and POST (physician's order for scope of treatment) form for 1 of 17 records reviewed. (Resident 24) Findings include: On [DATE] at 11:21 a.m., the medical record of Resident 24 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to Huntington's Disease (a progressive inherited brain disorder that causes uncontrolled movements, cognitive decline, and psychiatric symptoms), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress) and dysphagia (difficulty swallowing). A physician order, dated [DATE], indicated that the resident chose to be a full code (to provide full resuscitation in the event of the need for life saving measures). A POST form (Physician Orders for Scope of Treatment form is a standardized document that allows patients with advanced chronic or terminal illnesses to document their specific treatment preferences for end-of-life care), dated [DATE], indicated that the resident chose to be a DNR (Do Not Resuscitate). The form had been updated from full code on the previous POST form to administer CPR. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated that the resident was cognitively impaired. A care plan, dated [DATE], indicated per the Power of Attorney (POA) for healthcare and per resident, the resident signed a valid DNR which indicated Do Not resuscitate should I stop breathing, display no pulse as a result of failure of the heart to contract effectively or at all. On [DATE] at 1:00 p.m., during interview the Administrator indicated the resident was to be a DNR and the POST form currently in the medical record was correct and the physician order was incorrect. On [DATE] at 9:47 a.m., during interview Licensed Practical Nurse (LPN) 6 indicated she would look for the most recent POST form to verify code status. She indicated the resident's status changes often and updates were recorded in the medical record. On [DATE] at 12:54 p.m., the Administrator provided a document, titled, Advanced Directives, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, . 8. If a resident or healthcare representative indicates an Advanced Directive regarding CPR or scope of treatment (POLST or POST) the appropriate forms will be completed. 9. A written physician's order is required in response to the resident's Advanced Directive(s). Physician's orders shall be specific and address each advanced Directive(s) 3XXX,d+[DATE](d)

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage 8 hours per day 7 days per week for 7 of 28 days reviewed for staffing. This had the potential to affect 40 of 40 residents who resided in the facility. Findings include: On 4/30/24 at 11:00 a.m., review of RN staffing schedules for 4/1/24 to 4/27/24 indicated the Director of Nursing was scheduled as the RN Monday through Friday. An RN was not scheduled for the weekends of 4/6/24, 4/7/24, 4/12/24, 4/13/24, 4/19/24, 4/20/24, or 4/28/24. The Administrator indicated the Director of Nursing was available for calls during the weekends. On 4/30/24 at 11:45 a.m., the Administrator provided a document titled, Staffing, dated 2001, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement .Our facility provides adequate staffing to meet needed care and services for our resident population .1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed staff are available to provide and monitor the delivery of resident care services 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure staff wore a hairnet restraint when in the kitchen, hand hygiene was completed appropriately, food items were labeled and dated, expired foods were discarded, dented cans were not stocked for usage for the residents' meals, and food was not stored directly onto the storeroom floor for 1 of 2 kitchen observations. This deficiency had the potential to affect 40 of 40 residents who received food from the kitchen. Findings include: During an initial tour of the kitchen with the Dietary Manager (DM), on [DATE] at 9:50 a.m., the following was observed: a. While in the kitchen, the DM had her hair in a ponytail without a hairnet and failed to wash her hands prior to beginning the kitchen tour and handling food items. b. The kitchen freezers contained an undated bag of biscuits, 2 undated bags of frozen French fries, 3 undated lemon pies, 2 undated bulk sausage tubes, 6 undated packages of waffles, 2 packages of puree peas labeled with a use by date of [DATE], 6 undated bags of tator tots, a large bag of frozen hamburger patties undated, an undated package of fish [NAME], 6 undated apple pies, 3 undated hamburger rolls, undated package of pizza crusts, 8 undated rolls of ground pork shoulder, undated package of chicken and dumplings seasoning, undated package of donuts, undated bag of chicken tenders, 2 undated packages of hashbrown, 2 undated bags of diced chicken, and 2 undated packages of chicken tender. c. The dry storage area contained 3 dented cans of 106-ounce (oz) tomato sauce and a large cardboard box of ice cream cones stored directly on the stockroom floor without a barrier. On [DATE] at 10:30 a.m., the DM wiped her brawl with her bare hand and tucked her hair behind her ear, then touched more food items. She indicated no food items should be stored directly on the floor, all dented cans including the dented cans of tomato sauce should be discarded. All food items should be dated when received and stocked in the kitchen, but it was not getting done. On [DATE] at 10:37 a.m., the DM washed her hands, turned off the water faucet with her bare hand, indicated there were no paper towels in the dispenser, shook out her wet hands onto the floor, wiped her wet hands onto her pants, and then continued the tour of the kitchen and dry storage area. On [DATE] at 11:00 a.m., the Administrator (ADM) indicated staff were required to wear hairnet restraints when in the kitchen. Staff were required to wash their hands and turn off the water faucet with a paper towel when entering the kitchen and before and after touching food items. All food items should be labeled and dated when received, food items should not be stored directly on the floor, and canned goods with a compromised seal (dented) should be returned to the vendor. The ADM provided and identified a document as a current facility policy titled, Hand Washing, dated ,d+[DATE]. The policy indicated, .Policy: It is the policy of the Dietary Department to prevent the spread of infection through proper handwashing .Procedure: .1. Hands are washed: .a When entering and before starting work in the Dietary Department .d. Before and after handling foods .e. After using the bathroom, sneezing, coughing, touching face or hair, scratching and using a handkerchief .2. Handwashing Procedure: .e. Hands must be washed for a minimum of 20 seconds .f. Rinse thoroughly .g. Wipe dry with disposable paper towels .h. Turn off water faucet with paper towels The ADM, on [DATE] at 11:00 a.m., provided and identified a document as a current facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020. The policy indicated, .Procedure: .General storage guidelines to be followed: .a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded .f. Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure The ADM, on [DATE] at 11:00 a.m., provided and identified a document as a current facility policy titled, Storage of Dry Foods, dated ,d+[DATE]. The policy indicated, .7. Food should not be exposed to splash, dust or other contamination and at least six inches above the floor 3XXX,d+[DATE](i)(1) 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure a call light was kept within the resident's reach for 1 of 16 residents reviewed for call lights (Resident 39). Finding includes: On 4/25/24 at 9:22 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/26/24 at 8:55 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/29/24 at 9:02 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/29/24 at 3:15 p.m., the Director of Nursing (DON) observed the call light under the two storage containers and indicated, Resident 39's call light should be within reach and not on the floor under the two storage containers. Resident 39's record was reviewed on 4/30/24 at 9:48 a.m. Resident 39 was admitted to the facility, on 2/26/24, with diagnoses included, but were not limited to, Huntington's disease (A condition that damages nerve cells in the brain causing them to stop working properly. The damage to the brain gets worse over time. It can affect movement, cognition, and mental health), unspecified lack of coordination, unsteadiness of feet, reduced mobility, and repeated falls. An admission Minimum Data Set (MDS) assessment, dated 3/4/24, indicated the resident had a severe cognitive impairment and required supervision or assistance from staff for activities of daily living (ADL) (daily tasks related to resident care and hygiene). A care plan, goal target, dated 5/26/24, indicated the resident was at risk for falls due to Huntington's disease. Interventions included, but were not limited to, keep all light within reach. On 4/30/24 at 8:45 a.m., the Administrator (ADM) indicated the residents' call lights should be within their reach. The ADM provided and identified a document as a current facility policy titled, Call Light, revision dated 2/2/18. The policy indicated, .Purpose: To respond to residents' requests and needs in a timely and courteous manner .1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location 3.1-3(v)(1)

Based on observation, record review and interview, the facility failed to ensure psychotropic medications (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had been documented as administered for 4 of 11 residents medications reviewed (Residents 30, 9, 40, and 35). Findings include: 1. Resident 30's record was reviewed on 2/7/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), mood affective disorder (mental disorders that primarily affect a person's emotional state), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder), generalized anxiety disorder (a condition of excessive worry about everyday issues and situations), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). An annual Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had moderate cognitive deficit and received antipsychotic medications (used to treat symptoms of psychosis), antianxiety medications (used to treat symptoms of anxiety), and antidepressant medications (used to treat symptoms of depression). A care plan, dated 10/13/21, indicated the resident used psychotropic medications. Interventions included, but were not limited to, administer medications as ordered. A review of the resident's December 2022, January 2023, and February 2023, medication administration records (MAR) indicated the following: A physician's order, dated 12/9/22, indicated Depakote sprinkles (medication used to treat mental and mood disorders) 125 milligrams (mg), 2 capsules, by mouth, two times daily, at 7:00 a.m., and 4:00 p.m. The December 2022 MAR lacked documentation that the 4:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 11/22/22, indicated Haloperidol (used to treat certain mental and neurological disorders) tablet, 10 milligrams (mg), by mouth, three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Give with 20 mg to equal 30 mg. The December 2022 MAR lacked documentation that the 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 11/22/22, indicated Haloperidol (used to treat certain mental and neurological disorders) tablet, 20 milligrams (mg), by mouth, three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Give with 10 mg to equal 30 mg. The December 2022 MAR lacked documentation that the 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 9/22/22, indicated lorazepam (used to treat anxiety) tablet, 2 milligrams (mg), by mouth, three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The December 2022 MAR lacked documentation that the 4:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 1/11/22, indicated Seroquel (used to treat depression) tablet 300 milligrams (mg), by mouth, three time daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. 2. Resident 9's record was reviewed on 2/9/23 at 2:20 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). A quarterly Minimum Data Set (MDS) assessment, dated 12/12/22, indicated the resident had moderate cognitive deficit and had a mood severity score of zero. A care plan, dated 1/3/23, indicated the resident uses antidepressant medication related to diagnosis of depression. Intervention included, but were not limited to, administer antidepressant medications as ordered. A review of the resident's January 2023, medication administration record (MAR) indicated the following: A physician's order, dated 12/20/22, indicated sertraline hydrochloride (HCl) (used to treat depression), 25 milligrams (mg), by mouth, one time daily at 5:00 p.m. Give with 50 mg to equal 75 mg. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. A physician's order, dated 12/20/22, indicated sertraline hydrochloride (HCl) (used to treat depression), 50 milligrams (mg), by mouth, one time daily at 5:00 p.m. Give with 25 mg to equal 75 mg. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. 35317 3. Observation made during the tour on 02/06/2023 at 10:15 a.m., noted that Resident 40 was in the North hallway sitting in wheelchair and was tearful and placed her head down towards the floor. On 02/07/2023 at 1:33 p.m., Resident 40 was observed in the common TV room sitting in her wheelchair, tearful and difficult to understand her speech. On 02/08/2023 at 8:45 a.m., Resident 40 was observed in the North hallway propelling self in a wheelchair down the hallway and was noted to be tearful and her head was down towards the floor. During an interview with LPN 12 (licensed practical nurse) on 02/07/2023 at 1:40 p.m., she indicated the psych physician (a medical doctor who specializes in mental health) believed Resident 40's tearfulness was from pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). She further indicated the resident was good one minute and not the next. During an interview with the Administrator on 02/07/2023 at 09:45 a.m., she indicated Resident 40 had been tearful since arriving to the facility and tearfulness was not a new behavior. The facility was working with the psych physician on medication adjustments and psych services for the resident. Resident 40's record was reviewed on 02/7/2023 at 1:19 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (characterized by persistently depressed mood and long-term loss of pleasure or interest in life), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). An admission Minimum Data Set (MDS) assessment, dated 12/6/22, indicated the resident had severe cognitive deficit, exhibited mood symptoms of feeling down, depressed, and hopeless and had been administered medications which included, but were not limited to antipsychotics (a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders), antianxiety medication (medications used to assist in the management of anxiety symptoms), and antidepressants (used to treat major depressive disorder and some anxiety disorders). A care plan, dated 12/08/2022, indicated the resident received antidepressant medication related to her diagnoses of depression. Interventions included, but were not limited to, administer medications as ordered by physician, monitor and document side effects and effectiveness. A care plan, dated 12/08/2022, indicated the resident received psychotropic medication related to her diagnoses of Huntington's disease and dementia. Interventions included, but were not limited to, administer medication as ordered by physician, monitor for signs and symptoms of adverse effects from psychotropic medication usage. an A care plan, dated 12/08/2022, indicated the resident received antianxiety medications related to her diagnoses of anxiety disorder. Interventions included, but were not limited to, administer medication as ordered by physician, monitor for signs and symptoms of adverse effects from psychotropic medication usage. Review of Social Service note, dated 11/30/2022 at 2:03 p.m., indicated Resident 40 was extremely tearful. Review of Social Service note, dated 12/06/2022, indicted Resident 40 was very tearful and would yell out and cry. Review of Social Service note, dated 01/18/2023 at 07:47 a.m., indicated Resident 40 was in the hallway crying and grabbing staff. Resident was not understood when crying. Review of the resident's December 2022, January 2023, and February 2023 medication administration records (MARs) indicated the following: A physician's order, dated 12/13/2022, indicated Risperdal (antipsychotic medication) 1milligram (mg), by mouth two times daily. The December 2022 MAR lacked documentation of the medication having been administered at 5:00 p.m. on 12/21/2022. The record lacked documentation of resident refusal. A physician's order, dated 12/13/2022, indicated Haloperidol (antipsychotic medication) 10mg, by mouth three times daily. The December 2022 MAR lacked documentation of the medication having been administered at 5:00 p.m. on 12/21/2022. The January 2023 MAR lacked documentation of the medication having been administered at 5:00 p.m. on 01/30/2023. The February MAR lacked documentation of the medication having been administered at 5:00 p.m. on 02/01/2023, 02/04/2023, and 02/05/2023. The record lacked documentation of resident refusal. A physician's order, dated 12/16/2022, indicated Lorazepam (antianxiety medication) 1mg, by mouth four times daily. The December 2022 MAR lacked documentation of the medication being administered at 5:00 p.m. on 12/21/2022. The January 2023 MAR lacked documentation of the medication being administered at 5:00 p.m. on 01/02/2023 and 01/03/2023. The record lacked documentation of resident refusal. A physician's order, dated 02/02/2023, indicated Mirtazapine (antidepressant medication) 7.5mg, by mouth one time daily. The February 2023 MAR lacked documentation of the medication being administered at 4:00 p.m. on 02/04/2023 and 02/05/2023. The record lacked documentation of resident refusal. A physician's order, dated 01/10/2023, indicated Sertraline HCl (antidepressant medication) 100mg, by mouth in the evening. The January 2023 MAR lacked documentation of the medication being administered at 5:00 p.m. on 01/30/2023. The February 2023 MAR lacked documentation of the medication being administered at 5:00 p.m. on 02/01/2023, 02/02/2023, and 02/05/2023. The record lacked documentation of resident refusal. A physician's order, dated 01/20/2023, indicated Diazepam (antianxiety medication) 5mg, by mouth three times daily. The January 2023 MAR lacked documentation of the medication being administered at 4:00 p.m. on 01/30/2023. The February 2023 MAR lacked documentation of the medication being administered at 4:00 p.m. on 02/01/2023, 02/04/2023, and 02/05/2023. The record lacked documentation of resident refusal. 34129 4. Resident 35's record was reviewed on 02/07/23 at 1:19 p.m. Diagnoses on the profile included, but were not limited to, Huntington's disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A quarterly Minimum Data Set Assessment, dated 12/10/22, indicated the resident had a severe cognitive impairment and routinely received medications which included, but were not limited to, antipsychotics (medications used to treat symptoms of psychosis, such as delusions), antianxiety medications (medication to treat anxiety symptoms), and antidepressants (used to treat depressive symptoms). A care plan, initiated on 6/2/22 and revised on 9/27/22, indicated the resident received psychotropic medications (used to treat mental health disorders) with interventions included, but were not limited to, administer medications as ordered and monitor/document for side effects and effectiveness. Review of Resident 35's December 2022, January 2023, and February 2023 medication administration records indicated the following: A physician's order, start dated 6/6/22, indicated to administer Zoloft tablet (antidepressant medication) 200 milligrams (mg) by mouth in the evening at 5:00 p.m. for depression. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. A physician's order, start dated 10/4/22, indicated to administer Haloperidol tablet (antipsychotic medication) 5 mg by mouth two times a day, at 8:00 a.m. and 5:00 p.m., for psychosis. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, and 1/5/23. The record lacked documentation the resident refused the medication. A physician's order, start dated 5/25/22, indicated to administer Risperdal tablet (antipsychotic medication) 2 mg by mouth two times a day, at 7:00 a.m. and 5:00 p.m., for psychosis. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. A physician's order, start dated 8/9/22, indicated to administer clonazepam tablet (medication used to prevent and treat seizures, panic disorder, and anxiety disorders) 2 mg by mouth three times a day, at 8:00 a.m., 12:00 p.m., and 5:00 p.m., for anxiety. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. During an interview, on 2/7/23 at 2:45 p.m., the Administrator (ADM) indicated she was pretty sure the medications had been given, but just not signed off on the MAR. It was the nurse's responsibility to document in the MAR when a medication had been administered. On 2/7/23 at 2:49 p.m., the Administrator (ADM) provided an undated document, titled, Medication Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .7. The medication administration record (MAR) is always employed during medication administration .4. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration 3.1-48(b)(1)

Based on observation, interview, and record review, the facility failed to ensure the laminate flooring (a multi-layer synthetic flooring product) in the facility was safe in good repair, for 5 of 5 days the facility environment was observed. Findings include: During a random observation, on 2/6/23 at 2:28 p.m., a mat on top of the laminate flooring at the entrance to the television (TV) lounge next to the nurse's station, appeared to move when stepped on. Upon request, the Administrator (ADM) lifted the rug and exposed a large area where the laminate flooring was broken and no longer stable on the subfloor (a rough floor laid as a base for a finished floor) and was sliding back and forth in place. The entire piece of a single laminate floor plank was loose and broken. Each surrounding plank of the flooring, around the initial broken area, were also beginning to become loose. Areas of exposed subfloor were visible around the broken area of the planks. Along the area of the hallway leading to mat was observed to have gaps between the laminate floor planks. A single large, gapped area appeared to be large enough that a walker (a wheeled device used to assist with ambulation) wheel could get stuck in the gap area. Several smaller gapped areas were also observed. During environment rounds with the Maintenance Director, on 2/7/23 at 9:16 a.m., measurements of the gapped and broken laminate flooring areas were completed by the Maintenance Director. The area at the beginning of the hallway leading to TV lounge measured 3/4 (three-quarters) inches by 5 and 1/2 (one-half) inches (the width of a laminate plank). At the same time, the Maintenance Director indicated the gap was large enough that a walker wheel could get caught up in it or a resident could trip over the gapped area. Further measurements, completed by the Maintenance Director, were as follows: a. The area with the broken laminate plank, covered by the mat, measured 36 inches in length (the entire length of a single laminate floor plank) had become totally loose from the subfloor. An area of exposed subfloor (on the left side of the broken plank, facing south), measured 18 inches in length, with the widest area of exposed subfloor measured 1 and 1/8 (one-eighth) inches and tapered down to 1/2 inch. A second area of exposed subfloor (central of the broken plank, facing south) measured 3/4 inch by 1 and 1/2 inches. A third area of exposed subfloor (right side of the broken plank, north facing), measured 1 inch by 5 and 1/4 (One-quarter) inches (the width of the plank) and tapered down to 1/4 inch. All of the surrounding floor planks were observed beginning to loosen from the subfloor. b. An area of exposed subfloor, approximately 12 inches from the large broken laminate floor plank was observed to have an area of exposed subfloor, which measured 1 and 1/4 inches by 5 and 1/2 inches and tapered to 1/4 inch. c. An area to left (facing north from the above area b) had exposed subfloor which measured 1 and 1/2 inches by 5 and 1/2 inches. d. A plank in front of nurse's station, had an area of exposed subfloor which measured 3/4 inch. The plank was coming loose from the floor at a length of 14 inches. e. Another area of exposed subfloor (south facing from area d) measured 1 inch by 1 inch. f. In the hallway, leading to the south end of the facility, multiple gaps of exposed subfloor were observed. The areas were small and were not measured. During an interview, on 2/7/23 at 9:26 a.m., the Maintenance Director indicated he had been taking bids for the replacement of the laminate flooring throughout the facility. He had yet to receive a final bid. The broken areas and the significant gapped areas were of significant concern to him, due to the increased fall risks potentials for the Huntington's disease (a rare, inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities) resident who reside at the facility. On 2/8/23 at 11:48 a.m., the Maintenance Director provided a document, dated December 2004, titled, Maintenance Service, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .2. The following functions are performed by maintenance, but are not limited to, a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards 3.1-19(a)(4)

Based on observation, interview, and record review, the facility failed to ensure safe food temperatures as evidenced by inadequate external and internal temperatures for 1 of 4 reach in refrigerators and the facility failed to dispose of expired food for 2 of 2 kitchen observations. This had the potential to effect 40 of 40 residents who received food from the kitchen. Findings Include: During an initial tour observation of the kitchen with Dietary Supervisor (DS), on [DATE] at 09:50 a.m., the inside thermometer temperature was reading 48 degrees Fahrenheit (F) on reach in refrigerator # 3. No internal temperature of food was taken at that time. The reach in refrigerator contained 2 containers of heavy whipping cream, bags of shredded cheese, boxes of stick butter, and containers of sour cream. Inside freezer # 2 there were 3 frozen concentrated grape juice containers. They were dated [DATE], [DATE], and [DATE]. During an interview with DS on [DATE] at 09:50 a.m., she indicated the reach in refrigerator had too much food in it and that was the reason it was reading warm. She would have to move stuff around. She also indicated she had a new staff member doing the stocking of the food as well. During a food storage observation with DS on [DATE] at 10:50 a.m., inside freezer # 2 there were 3 frozen concentrated grape juice containers. They were dated [DATE], [DATE], and [DATE]. The reach in refrigerator # 3 had an inside thermometer temperature reading of 45 degrees F. An internal food temperature was obtained by DS using an infrared thermometer. The bottom shelf of food items was reading ,d+[DATE] degrees F. The bottom shelf contained stick butter, sour cream, and bags of shredded cheese. During an interview with DS on [DATE] at 10:50 a.m., she indicated the frozen grape juice containers were expired but they were activities and weren't a part of kitchen's stock. She further indicated she should have noticed the expiration dates and disposed of the frozen juice concentrate but was missed. During an interview with DS on [DATE] at 10:54 a.m., she indicated the thermometer was reading 45 degrees F, she would need to get the infrared thermometer to see what the foods internal temperature was. The internal temperature of the food on the bottom shelf was reading ,d+[DATE] degrees F. She again indicated that the refrigerator was too full, and items needed to be moved around. She indicated she would need to contact maintenance to see if there is an issue with the refrigerator unit. During an interview with Administrator on [DATE] at 1:44 p.m., she indicated when a refrigerator temperature is reading over 41 degrees F than an internal temperature needs to be obtained by dietary staff of the food. She further indicated if the internal temperature is over 41 degrees F then the food needs to be discarded. If the food has an internal temperature lower than 41 degrees F, then they need to be moved to a properly working refrigerator unit. She indicated she was not made aware of recent elevated refrigerator temperatures from the kitchen staff. A document titled, Refrigerator/Freezer temperature log was obtained by Administrator on [DATE] at 1:44 p.m., the log indicated on [DATE] at 7:30 p.m., the inside of refrigerator # 3 thermometer was reading 45 degrees F. The log lacked documentation of an internal temperature being obtained. On [DATE] at 1:30 p.m., the Administrator provided and identified a document as a current facility policy, titled Storage of Frozen Foods, dated ,d+[DATE]. The policy indicated, .Policy: A proper handling procedure for frozen food safety lessens the risks of acquiring foodborne disease .Procedure: .8. Food should be used within one year of receipt On [DATE] at 1:44 p.m., the Administrator provided and identified a document as a current facility policy, titled Cleaning and Maintenance of the Reach-In Refrigerator and Freezer, dated ,d+[DATE]. The policy indicated, .Policy: It is necessary to ensure that reach-in units are kept clean, organized, and operating safely. Procedure: Daily .9. Immediately check the internal temperature of food; should be < or = 41 degrees F in the refrigerator .10. If food items are within the safety zone in the refrigerator, move them to a properly working unit .11. Discard all food items with an internal food temperature > 41 degrees F .13. Notify your supervisor, administrator, and maintenance director that unit is not working 3XXX,d+[DATE](i)(1)(3)

Based on record review and interview, the facility failed to ensure medications had been documented as administered for 3 of 5 residents reviewed for unnecessary medications (Residents 30, 9, and 35). Findings include: 1. Resident 30's record was reviewed on 2/7/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and unspecified leg pain. An annual Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had moderate cognitive deficit and received routine pain medications. A care plan, dated 12/30/22, indicated the resident has alterations in comfort related to leg pain. Interventions included, but were not limited to administer medications as ordered. A review of the resident's December 2022, January 2023, and February 2023, medication administration records (MAR) indicated the following: A physician's order, dated 8/18/22, indicated gabapentin (medication used to treat neuropathic pain) capsule 300 milligrams (mg), by mouth, one time daily at 5:00 p.m. The December 2022 MAR lacked documentation that the medication had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the medication had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the medication had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 9/30/22, indicated meloxicam (medications called nonsteroidal anti-inflammatory drugs [NSAIDs] and works by stopping the body's production of a substance that causes pain, fever, and inflammation) tablet 7.5 mg, by mouth two times daily at 8:00 a.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the 5:00 p.m., dose of the medication had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose of the medication had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose of the medication had been administered on 2/1/23, 2/4/23, and 2/5/23. 2. Resident 9's record was reviewed on 2/9/23 at 2:20 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). An annual Minimum Data Set (MDS) assessment, dated 9/8/22, indicated the resident had no cognitive deficit. A care plan, dated 6/10/21, indicated the resident has impaired cognitive function related to dementia. A care plan, dated 8/25/20, indicated the resident has a potential for alteration in nutrition related to unplanned weight loss due to diagnosis of Huntington's disease and disease process. A review of the resident's December 2022, and January 2023, medication administration records (MAR) indicated the following: A physician's order, dated 8/30/22, indicated Namenda (drug used to treat dementia) 10 milligrams (mg), by mouth two times daily at 8:00 a.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 12/21/22. The January 2023 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. A physician's order dated 12/21/20, indicated Magic Cup (frozen dessert used as a great option for adding calories and protein for those experiencing involuntary weight loss) with meals, three times daily as a supplement at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. 34129 3. Resident 35's record was reviewed on 02/07/23 at 1:19 p.m. Diagnoses on the profile included, but were not limited to, Huntington's disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia) and dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD-when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). A quarterly Minimum Data Set Assessment, dated 12/10/22, indicated the resident had a severe cognitive impairment and required supervision with one person assistance for eating. A care plan, initiated on 6/2/22 and revised on 9/27/22, indicated the resident received psychotropic medications (used to treat mental health disorders) with interventions included, but were not limited to, administer medications as ordered and monitor/document for side effects and effectiveness A care plan, initiated on 5/26/22 and revised on 9/27/22, indicated the resident received a regular, mechanical soft texture, thin liquids diet due to Huntington's disease and progression of such and was at risk for aspiration (choking or breathing in a foreign object [sucking food into the airway]). A physician's order, start dated 7/19/22, indicated to give the resident Magic Cup (nutritional supplement) two times a day with lunch and supper. The December 2022 medication administration record (MAR) lacked documentation the Magic Cup was administered at supper on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the Magic Cup was administered at supper on 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the Magic Cup was administered at supper on 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident had refused the Magic Cup. A Social Services' care conference progress note, dated 1/31/23 at 1:57 p.m., indicated the Administrator (ADM), Social Services Director (SSD), and Director of Nursing (DON) had a care plan meeting with Resident 35's husband, regarding the resident not feeling well. The husband was educated on possible aspiration, a chest x-ray was ordered, and the physician was notified. A physician's order, start dated 1/31/23, indicated to administer Augmentin oral tablet 875-125 milligrams (mg) (antibiotic medication) by mouth two times a day for possible aspiration for 10 days. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. During an interview, on 2/7/23 at 2:45 p.m., the Administrator (ADM) indicated she was pretty sure the medication and Magic Cup supplement had been given, but just not signed off on the MAR. It was the nurse's responsibility to document on the MAR when a medication or the Magic Cup had been administered to the resident. On 2/7/23 at 2:49 p.m., the Administrator (ADM) provided an undated document, titled, Medication Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .7. The medication administration record (MAR) is always employed during medication administration .4. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure potential side effects of [CONDITION(S)] medications (any medication that affects behavior, mood, thoughts, or perception) were monitored for 4 of 5 residents reviewed for unnecessary medications (Residents 11, 6, 17, and 21). Findings include: 1. Resident 11's record was reviewed on 12/8/21 at 9:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, [CONDITION(S)] (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia), [CONDITION(S)] with delusions due to a known physiological condition (refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate motor behavior), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and obsessive-compulsive disorder (a common, chronic, and long-[MEDICATION(S)] disorder in which a person has uncontrollable, reoccurring thoughts and/or behaviors that he or she feels the urge to repeat over and over). An annual Minimum Data Set (MDS) assessment, dated 1/1/21, indicated the resident had severe cognitive deficit, exhibited verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others, and had been administered medications which included, but were not limited to antipsychotics (a class of [CONDITION(S)] medication primarily used to manage [CONDITION(S)], principally in [CONDITION(S)] but also in a range of other psychotic disorders), antianxiety medication (medications used to assist in the management of anxiety symptoms), and antidepressants (used to treat major depressive disorder and some anxiety disorders). A care plan, dated 1/24/16, revised 10/1/21, indicated the resident received antidepressant medication related to her diagnoses of [CONDITION(S)] and depression. Interventions included, but were not limited to, monitor and document side effects and effectiveness. A care plan, dated 10/16/17 and revised on 10/1/21, indicated the resident received antipsychotic medications related to her diagnoses of [CONDITION(S)] and [CONDITION(S)]. Interventions included, but were not limited to, monitor for signs and symptoms of adverse effects from [CONDITION(S)] medication usage. A care plan, dated 10/16/17 and revised on 10/1/21, indicated the resident received antianxiety medications related to her diagnoses of [CONDITION(S)] and [CONDITION(S)]. Interventions included, but were not limited to, monitor for signs and symptoms of adverse effects from [CONDITION(S)] medication usage. A current physician's order, dated 4/30/19, indicated [MEDICATION(S)] (an antidepressant medication), give 60 milligrams (mg) by mouth, one time a day for depression. A current physician's order, dated 9/10/20, indicated [MEDICATION(S)] ([MEDICATION(S)]) tablet (an antipsychotic medication) 5 mg, give 1 tablet by mouth, three times a day for [CONDITION(S)]. A current physician's order dated 1/21/21, indicated monitor for adverse reactions for medications [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], every day and evening shift. If noted notify physician. A current physician's order, dated 9/14/21, indicated [MEDICATION(S)] tablet (an antianxiety medication) 10 mg, give 1 tablet by mouth, three times a day for anxiety. The July 2021 MAR indicated a physician's order for [MEDICATION(S)] differed from the current order above. The order for July 2021 was [MEDICATION(S)] 10 mg, give one-half tablet, by mouth, in the afternoon for anxiety disorder. The orders for the resident's antipsychotic, antidepressant medications and monitoring remained as above. The July 2021, Treatment Administration Record (TAR) lacked documentation that the side effects had been monitored on the day shift on, 7/17/21, 7/22/21, 7/23/21, 7/27/21, 7/28/21, and 7/29/21. The August 2021 MAR indicated a physician's order for [MEDICATION(S)] differed from the current order above. The order for August 2021 was [MEDICATION(S)] 10 mg, give one-half tablet, by mouth, in the afternoon for anxiety disorder. The orders for the resident's antipsychotic, antidepressant medications and monitoring remained as above. The August 2021, TAR lacked documentation that the side effects had been monitored on the day shift on, 8/3/21, 8/7/21, 8/8/21, 8/12/21, 8/13/21, 8/21/21, 8/25/21, 8/27/21, 8/28/21, and 8/29/21. The September 2021 MAR indicated the [MEDICATION(S)] order differed from the current order above, until 9/14/.21 when the current order was written. The order, active until 9/14/21, was [MEDICATION(S)] 10 mg, give one-half tablet, by mouth, in the afternoon for anxiety disorder. On 9/14/21, the current order was written for [MEDICATION(S)] 10 mg, give 1 tablet, by mouth, three times a day for anxiety. The orders for the resident's antipsychotic, antidepressant medications and monitoring remained as above. The September 2021 TAR lacked documentation that the side effects had been monitored on the day shift on, 9/11/21, 9/12/21, 9/16/21, 9/23/21, 9/24/21, 9/25/21, 9/28/21, and on the evening shift of 9/3/21. The October 2021 TAR lacked documentation that the side effects had been monitored on the days shift on, 10/2/21, 10/3/21, 10/6/21, 10/11/21, 10/12/21, 10/18/21, 10/23/21, 10/24/21, 10/27/21, 10/28/21, and on the evening shift on, 10/14/21 and 10/23/21. The November 2021 TAR lacked documentation that the side effects had been monitored on the day shift on, 11/6/21, 11/8/21, 11/11/21, 11/13/21, 11/14/21, 11/17/21, 11/18/21, 11/24/21, 11/27/21, 11/28/21, and on the evening shift on 11/30/21. The December 2021 TAR lacked documentation that the side effects had been monitored on the days shift on, 12/4/21 and 12/5/21. 2. Resident 6's medical record was reviewed on 12/9/21 at 11:01 a.m. Diagnoses included but were not limited to, [CONDITION(S)] (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A quarterly Minimum Data Set (MDS) assessment, dated 9/10/21, indicated Resident 6 was moderately impaired, exhibited inattention behaviors of difficulty focusing attention or difficulty keeping track of what was being said, and had been administered medications which included, but were not limited to antipsychotics (a class of [CONDITION(S)] medication primarily used to manage [CONDITION(S)], principally in [CONDITION(S)] but also in a range of other psychotic disorders), antianxiety medication (medications used to assist in the management of anxiety symptoms), and antidepressants (used to treat depression). A care plan, dated 1/24/16, revised 10/1/21, indicated the resident received antidepressant medication related to her diagnoses of [CONDITION(S)] and depression. Interventions included, but were not limited to, monitor and document side effects and effectiveness of medication. A care plan, initiated on 1/17/18 and revised on 9/15/21, indicated the resident received [CONDITION(S)] medications related to behavior management, [CONDITION(S)] [CONDITION(S)], and [CONDITION(S)] process. Interventions included, but were not limited to, monitor, record, report to medical doctor side effects and adverse reactions of psychoactive medications of unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [CONDITION(S)], social isolation, blurred vision, diarrhea, fatigue, [CONDITION(S)], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. A care plan, initiated on 6/18/18 and revised on 9/15/21, indicated the resident received antianxiety medications related to her diagnosis of anxiety disorder. Interventions included, but were not limited to, monitor and document signs and symptoms of adverse effects from antianxiety medication usage. A current physician's order, dated 11/23/21, indicated [MEDICATION(S)] tablet (an antipsychotic medication) 10 milligram (mg), give 1 tablet by mouth three times a day for agitation. A current physician's order, dated 8/6/19, indicated [MEDICATION(S)] Capsule 250 mg (medication used to treat mental/mood conditions), give three capsules by mouth two times a day for [CONDITION(S)]. A current physician's order, dated 8/9/21, indicated [MEDICATION(S)] tablet (movement disorder drug therapy) give 25 mg in the evening for [CONDITION(S)] chorea. A current physician's order, dated 3/6/20, indicated [MEDICATION(S)] (brand name [MEDICATION(S)]) (an antidepressant medication) tablet 100 mg, give two tablets in the evening for depression. A current physician's order, dated 7/29/20, indicated [MEDICATION(S)] tablet 5 mg, give 1 tablet three times a day for anxiety. A current physician's order dated 6/12/20, indicated monitor for adverse reactions for medications [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], every day and evening shift. If noted notify physician. The July 2021 treatment administration record (TAR) lacked documentation the side effects monitoring for medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] had been completed for the day shift on, 7/12/21, 7/15/21, 7/22/21, 7/23/21, 7/27/21, 7/28/21, 7/29/21 and the evening shift on 7/31/21. The August 2021 TAR lacked documentation the side effects monitoring for medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] had been completed for the day shift on, 8/3/21, 8/7/21, 8/8/21, 8/12/21, 8/13/21, 8/16/21, 8/21/21, 8/25/21, 8/27/21, 8/28/21, and 8/29/21. The September 2021 TAR lacked documentation the side effects monitoring for medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] had been completed for the day shift on, 9/11/21, 9/12/21, 9/16/21, 9/23/21, 9/24/21, 9/25/21, 9/28/21, and on the evening shift on 9/3/21. The October 2021 TAR lacked documentation the side effects monitoring for medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] had been completed for the day shift on, 10/2/21, 10/3/21, 10/6/21, 10/11/21, 10/12/21, 10/18/21, 10/23/21, 10/24/21, 10/27/21, 10/28/21, and the evening shift on, 10/14/21 10/16/21, and 10/23/21. The November 2021 TAR lacked documentation the side effects monitoring for medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] had been completed for the day shift on, 11/6/21, 11/8/21, 11/13/21, 11/14/21, 11/17/21, 11/18/21, 11/24/21, 11/27/21, 11/28/21, and the evening shift on 11/30/21. The December 2021 TAR lacked documentation the side effects monitoring for medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] had been completed for the day shift on 12/4/21 and 12/5/21. 3. Resident 21's record was reviewed on 12/8/21 at 9:40 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 12/2/21, indicated the resident was cognitively intact and received antipsychotic (primarily used to manage [CONDITION(S)], principally in [CONDITION(S)] but also in a range of other psychotic disorders), antianxiety, and antidepressant medication during the assessment period. Diagnoses on the resident's profile included, but were not limited to, [CONDITION(S)] (an inherited condition in which nerve cells in the brain break down over time), anxiety disorder, major depressive disorder recurrent, and unspecified [CONDITION(S)] not due to a substance or known physiological condition. A care plan, initiated 8/1/17, indicated the resident used [CONDITION(S)] medication related to [CONDITION(S)], delusions, anxiety, and depression. Interventions included, but were not limited to, monitor for and document side effects. A care plan, initiated 7/26/18, indicated the resident used antianxiety medications related to anxiety disorder. Interventions included, but were not limited to, monitor for and document side effects. A physician's order, dated 8/15/20 and discontinued 6/22/21, indicated [MEDICATION(S)] (an antianxiety medication) 2.5 milligrams (mg) by mouth in the afternoon related to anxiety. A physician's order, dated 6/22/21 and discontinued 8/24/21, indicated [MEDICATION(S)] 5 mg by mouth three times daily for anxiety. A physician's order, dated 3/23/21 and discontinued 8/10/21, indicated [MEDICATION(S)] (a mood stabilizer) sprinkles capsule 125 mg by mouth twice daily for [CONDITION(S)]. A physician's order, dated 4/27/21, indicated [MEDICATION(S)] (an antidepressant) 50 mg by mouth in the morning for anxiety and depression. A care plan, initiated 4/27/21, indicated the resident used antidepressant medication related to depression. Interventions included, but were not limited to, monitor for and document side effects. A treatment administration record (TAR), dated June 2021, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. A TAR, dated July 2021, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift on 7/12/21, day shift 7/15/21, day shift 7/17/21, day shift 7/22/21, day shift 7/23/21, day shift 7/27/21, day shift 7/28/21, day shift 7/29/21, and evening shift on 7/31/21. A physician's order, dated 8/10/21, indicated [MEDICATION(S)] sprinkles 125 mg by mouth in the morning, and 250 mg by mouth in the evening for [CONDITION(S)]. A physician's order, dated 8/24/21, indicated [MEDICATION(S)] 10 mg by mouth three times daily for anxiety. A TAR, dated August 2021, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 8/3/21, day shift 8/7/21, day shift 8/8/21, day shift 8/12/21, day shift 8/13/21, day shift 8/16/21, day shift 8/21/21, day shift 8/26/21, day shift 8/27/21, day shift 8/28/21, day shift 8/29/21, and day shift 8/30/21. A physician's order, dated 9/7/21 and discontinued 9/14/21, indicated [MEDICATION(S)] (an antipsychotic) 0.25 mg by mouth twice daily for [CONDITION(S)]. A physician's order, dated 9/14/21 and discontinued 9/21/21, indicated [MEDICATION(S)] 0.5 mg by mouth twice daily for [CONDITION(S)]. A physician's order, dated 9/21/21, indicated [MEDICATION(S)] 1 mg by mouth twice daily for [CONDITION(S)]. A TAR, dated September 2021, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)] or [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on evening shift 9/3/21, day shift 9/7/21, day shift 9/11/21, day shift 9/12/21, day shift 9/16/21, day shift 9/17/21, day shift 9/21/21, day shift 9/22/21, day shift 9/23/21, day shift 9/24/21, day shift 9/25/21, day shift 9/27/21, and day shift 9/28/21. A TAR, dated 10/1/21 to day shift of 10/22/21, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)] and [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 10/2/21, day shift 10/3/21, day shift 10/6/21, day shift 10/7/21, day shift 10/8/21, day shift 10/11/21, day shift 10/12/21, day shift 10/13/21, evening shift 10/14/21, evening shift 10/16/21, day shift 10/18/21, day shift 10/20/21, and day shift 10/22/21. A TAR, dated evening shift of 10/22/21 to 10/31/21, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]), [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day and evening shift 10/23/21, day shift 10/24/21, day shift 10/27/21, day shift 10/28/21, and day shift 10/29/21. A TAR, dated November 2021, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]), [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 11/3/21, day shift 11/6/21, day shift 11/9/21, day shift 11/13/21, day shift 11/14/21, day shift 11/17/21, day shift 11/18/21, day shift 11/19/21, day shift 11/22/21, day shift 11/24/21, day and evening shift 11/27/21, day shift 11/28/21, day shift 11/29/21, and day shift 11/30/21. A TAR, dated December 2021, indicated the resident received [MEDICATION(S)] ([MEDICATION(S)]), [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 12/1/21, day shift 12/4/21, and day shift 12/5/21. 4. Resident 21's record was reviewed on 12/8/21 at 9:40 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 10/12/21, indicated the resident had a severe cognitive impairment and received antipsychotic (primarily used to manage [CONDITION(S)], principally in [CONDITION(S)] but also in a range of other psychotic disorders), antianxiety, and antidepressant medication during the assessment period. Diagnoses on the resident's profile included, but were not limited to, [CONDITION(S)] (an inherited condition in which nerve cells in the brain break down over time), anxiety disorder, major depressive disorder recurrent, and [CONDITION(S)] with hallucinations due to known physiological condition. A care plan, initiated 5/18/18, indicated the resident used [CONDITION(S)] medication related [CONDITION(S)] process and anxiety. Interventions included, but were not limited to, monitor and document side effects. A care plan, initiated 6/30/18, indicated the resident used antianxiety medication related to adjustment issues and anxiety disorder. Interventions included, but were not limited to, monitor and document side effects. A care plan, initiated 6/30/18, indicated the resident used antidepressant medication related to depression. Interventions included, but were not limited to, monitor and document side effects. A physician's order, dated 5/27/20, indicated [MEDICATION(S)] (an antipsychotic) 10 milligrams (mg) twice daily for [CONDITION(S)]. A physician's order, dated 11/10/20, indicated [MEDICATION(S)] (an antianxiety) 2 mg by mouth three times daily for anxiety. A physician's order, dated 3/3/21 and discontinued 8/10/21, indicated [MEDICATION(S)] (an antidepressant) 200 mg by mouth daily for anxiety and depression. A physician's order, dated 7/27/21, indicated [MEDICATION(S)] (an antidepressant) 15 mg by mouth at bedtime related to depression. A treatment administration record (TAR), dated July 2021, indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The physician's orders lacked documentation the resident received [MEDICATION(S)] or [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 7/12/21, day shift 7/15/21, day shift 7/17/21, day shift 7/22/21, day shift 7/23/21, day shift 7/27/21, day shift 7/28/21, day shift 7/29/21, and evening shift 7/31/21. A physician's order, dated 8/10/21 and discontinued on 9/14/21, indicated [MEDICATION(S)] 100 mg by mouth daily related to depression. A TAR, dated August 2021, indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The physician's orders lacked documentation the resident received [MEDICATION(S)] or [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 8/3/21, day shift 8/7/21, day shift 8/8/21, day shift 8/12/21, day shift 8/13/21, day shift 8/16/21, day shift 8/21/21, day shift 8/26/21, day shift 8/27/21, day shift 8/28/21, day shift 8/29/21, and day shift 8/30/21. A physician's order, dated 9/14/21 and discontinued on 9/28/21, indicated [MEDICATION(S)] 50 mg by mouth daily related to depression. A physician's order, dated 9/29/21, indicated [MEDICATION(S)] 100 mg by mouth daily related to depression. A TAR, dated September 2021 indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The physician's orders lacked documentation the resident received [MEDICATION(S)] or [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on evening shift 9/3/21, day shift 9/7/21, day shift 9/11/21, day shift 9/12/21, day shift 9/16/21, day shift 9/17/21, day shift 9/21/21, day shift 9/22/21, day shift 9/23/21, day shift 9/24/21, day shift 9/25/21, day shift 9/27/21, and day shift 9/28/21. A TAR, dated 10/1/21 to day shift 10/22/21, indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation the resident needed to be monitored for signs and symptoms of adverse reactions to the [MEDICATION(S)]. The physician's orders lacked documentation the resident received [MEDICATION(S)] or [MEDICATION(S)]. The TAR lacked documentation adverse reactions were monitored on day shift 10/2/21, day shift 10/3/21, day shift 10/6/21, day shift 10/7/21, day shift 10/8/21, day shift 10/11/21, day shift 10/12/21, day shift 10/13/21, evening shift 10/14/21, evening shift 10/16/21, day shift 10/18/21, day shift 10/20/21, and day shift 10/22/21. A TAR, dated evening shift of 10/22/21 to 10/31/21, indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation adverse reactions were monitored on day and evening shift 10/23/21, day shift 10/24/21, day shift 10/27/21, day shift 10/28/21, and day shift 10/29/21. A TAR, dated November 2021, indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation adverse reactions were monitored on day shift 11/3/21, day shift 11/6/21, day shift 11/9/21, day shift 11/13/21, day shift 11/14/21, day shift 11/17/21, day shift 11/18/21, day shift 11/19/21, day shift 11/22/21, day shift 11/24/21, day and evening shift 11/27/21, day shift 11/28/21, day shift 11/29/21, and day shift 11/30/21. A TAR, dated December 2021, indicated the resident received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], to monitor signs and symptoms of adverse reactions twice daily, and to notify the physician if any were noted. The TAR lacked documentation adverse reactions were monitored on day shift 12/1/21, day shift 12/4/21, and day shift 12/5/21. During an interview, on 12/8/21 at 11:43 a.m., Licensed Practical Nurse (LPN) 6 indicated side effects of [CONDITION(S)] medications were monitored based on what was ordered on the TAR. The nursing staff was aware of what to monitor for based on the orders. The TAR should have been signed off each shift to document the monitoring. During an interview, on 12/9/21 at 10:51 a.m., LPN 4 indicated all residents should have an order to monitor for side effects of [CONDITION(S)] medications. The orders should have been updated and accurate when medications were changed. If there was an order in place, it should have been signed off by the nurse on duty each shift. On 12/9/21 at 11:38 a.m., the Administrator provided a document titled, Psychoactive Medications, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: 1. To assure each Resident receives the appropriate assessment and intervention regarding the use of [CONDITION(S)] medications in order to attain and/or maintain his/her highest practicable level of function .Policy Interpretation and Implementation: 1. For purposes of this policy a [CONDITION(S)] medication is defined as: Any antipsychotic, antianxiety, antidepressant, sedative or hypnotic medication prescribed for the treatment of mental illness or behavioral manifestations .14. Each resident receiving [CONDITION(S)] medication will have an interdisciplinary plan of care addressing medication, potential problems, attainable goals and individualized approaches to assure attainment and/or maintenance of highest practicable level of function 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure staff distributed and served food under sanitary conditions for 1 of 2 dining observations (Resident 11). Finding includes: During a dining observation, on 12/6/21 at 11:57 a.m., Certified Nursing Assistant (CNA) 14 picked up a cookie with her bare hand from Resident 11's lunch plate and assisted the resident to take bites of the cookie. CNA 14 sat the remainder portion of the cookie onto the resident's lunch plate. Next, CNA 14 with her bare hand picked up a quartered portion of a hamburger sandwich from Resident 11's lunch plate and assisted the resident to take several bites from the sandwich. CNA 14 held the hamburger sandwich with her bare hand while Resident 14 chewed and swallowed the previous bite of the sandwich, until the entire potion of the sandwich was eaten by Resident 11. On 12/9/21 at 3:26 p.m., the Administrator indicated staff should not be touching the resident's food with their bare hands while assisting the resident to eat. Staff should use silverware of a spoon or fork, wear gloves, or use a barrier such as the food wrapper when they are assisting a resident to eat. An undated facility policy, titled Dining Assistant Policy and Procedure, identified as current by the Administrator, on 12/9/21 at 4:15 p.m., indicated, .Feeding instructions for residents who cannot feed themselves .Feed slowly and in small amount to prevent choking and aspiration .Allow the resident enough time to chew and swallow .Don't feed resident with bare hands even if finger foods need to be a barrier (example gloves) or use silverware 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure staff followed hand hygiene procedures while serving meals for 32 of 32 residents who ate in the dining room during 2 of 2 random meal observations. Findings include: During a random dining observation on 8/28/19, from 12:10 p.m. to 12:28 p.m., Dietary Aide 7 served all food to the residents in the dining room. During this meal service, Dietary Aide 7 touched her mouth with her finger, the back of a dining room chair, her nose, the legs of her pants, the handle of a cart, her hair and mouth, the back of a resident's wheelchair, a gate leading into the kitchenette area, and coughed into her closed fist. Hand hygiene was not completed at any time during the continuous observation. During a random dining observation on 9/3/19, from 12:07 p.m. to 12:26 p.m., Dietary Aide 7 served all food to the residents in the dining room. During the meal service, Dietary Aide 7 touched her ear, the counter, touched the handle of a cart, a resident's wheelchair, another employee's arm, placed a clothing protector on a resident, and placed a dirty bowl in a dirty dish container. Dietary Aide 7 removed a napkin from a table, wiped her hands with it, balled it up in her hand, and served a tray to a resident with the napkin balled up in her hand. She then threw away the napkin. Dietary aide dipped her finger in a cup of water on the counter and began separating meal tickets. Hand hygiene was not completed at any time during the continuous observation. On 9/3/19 at 12:27 p.m., the Dietary Manager indicated the water cup was for Dietary Aide 7 to wet her finger so she was able to separate the meal tickets. The tickets stuck together sometimes. Dietary Aide 7 should not have used the water, and she should have washed her hands. The Dietary Manager instructed Dietary Aide 7 to wash her hands at this time. During an interview, on 9/3/19 at 2:14 p.m., the Administrator indicated Dietary Aide 7 had not followed the facility policy for handwashing in the dining room. She should have washed her hands prior to starting the meal service. Anytime anything, other than the residents' plates, was touched she should have washed her hands or used hand sanitizer. On 9/3/19 at 2:14 p.m., the Administrator provided a document titled, Policy and Procedure Meal Service, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .6. Staff providing direct resident care by passing meals/trays will wash their hands before serving the food. Staff will wash their hands after removing dirty dishes from a resident's table and/or assisting another resident with their meal/tray delivery and set up. Those authorized to deliver/serve trays will refrain from touching their own person such as face/hair or clothes during the serving of trays. This action would require hand hygiene prior to serving the next tray 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for 1 of 12 residents reviewed for care plans (Resident 15). Findings include: Resident 15's record was reviewed on 8/30/19 at 9:33 a.m. [DIAGNOSES REDACTED]. and mental abilities with no cure) and dysphagia (difficulty eating and swallowing). Review of Resident 15's weight on 2/4/19 was 197 pounds, weight on 7/16/19 was 162 pounds, and current weight on 8/6/19 was 151 pounds, which was a 6.79% weight loss since July, 2019 and a 23% weight loss since February, 2019. A quarterly Minimum Data Set (MDS) assessment, dated 7/5/19, indicated Resident 15 was moderately impaired, required supervision with set up for eating, had weight loss, and was on a mechanically altered diet. A care plan, initiated on 5/2/16 and target dated 8/27/19, indicated the resident had difficulty at meal times with food and fluids related to [MEDICAL CONDITION]'s chorea and had the potential for weight loss. A care plan, initiated on 1/17/18 and target dated 8/27/19, indicated the resident had the potential for unplanned weight loss related to the [DIAGNOSES REDACTED]. A care plan, initiated on 1/22/18 and target dated 10/4/19, indicated the resident had a high body mass index (BMI), with a goal of the resident would maintain weight of +/- 5 pounds. During an interview, on 9/3/19 at 2:09 p.m., the Dietary Manager (DM) indicated, Resident 15 had declined with significant weight loss due to the [MEDICAL CONDITION]'s disease process. The Resident's current BMI was 20, which was not considered a high BMI. The nutritional care plans should have been updated with the current information and new target dates. The Administrator, on 9/4/19 at 8:40 a.m., provided and identified as a current facility policy, titled Quarterly Review of Care Plans, dated (MONTH) 2006, which indicated, .Each resident's care plan shall be reviewed at least quarterly .The Care Planning/Interdisciplinary Team is responsible for maintaining care plans on a current status .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans .When there has been a significant change in the resident's condition .When the desired outcome is not met 3.1-35(a) 3.1-35(c)(1)

Based on interview and record review, the facility failed to ensure resident to resident abuse did not occur for 1 of 2 allegations of abuse reviewed. (Residents D and E) Finding includes: On 5/30/19 at 9:35 a.m., the Administrator was interviewed. She indicated Resident [NAME] had gone to another resident's room and choked him (Resident D). No injuries occurred and Resident [NAME] had been placed on one on one supervision for a couple of weeks. She indicated, on 5/20/19, the resident had gone to jail for aggressive behavior with staff. She indicated there had been eight instances of the resident beating staff up. The physician had been called and ordered the Sheriff be called for possibly a 72 hour hold. The Sheriff arrived and indicated the resident would have to be arrested for assault. She indicated the resident resided in the facility since (MONTH) (YEAR), and behaviors had escalated recently. She indicated the only resident altercation had been with Resident D on 3/17/19. On 5/30/19, at 10:00 a.m., a facility reported incident was reviewed. The incident date was 3/17/19 at 2:55 p.m. The report included Resident [NAME] had run down the hallway to Resident D's room. Resident D had been sitting in a wheelchair in the hallway outside of his room. Resident [NAME] made contact with Resident D's neck. No injury had been found. The residents had been immediately separated, and both residents placed on one on one supervision until it was determined to no longer be necessary. The resident's clinical record was reviewed on 5/30/19 at 1:00 p.m. [DIAGNOSES REDACTED]. A progress note, dated 3/11/19, included but was not limited to, the resident approached the nurses' station in the morning laughing and running the halls. He then approached the nurses' station and tried to grab a Certified Nursing Assistant (CNA) by the throat. The resident's arms were grabbed by staff in an effort to avoid him choking the staff member. The resident then attempted to bite the staff and did make contact. He then began spitting on one of the staff members. The resident was restrained until an order was received to administrator [MEDICATION NAME] (antipsychotic). The resident continued to bite, spit, and head butt the nurse. After the resident had received the medication he asked to return to his room, was escorted by the nurse and said I'm sorry. Documentation on 15 Minute Checks X (times) 24 Hours indicated the resident had been placed on one to one supervision through 3/13/19. He had remained in an agitated state. Documentation in the progress notes for 3/14/19 and 3/16/19, indicated the resident continued to run up and down the hallways laughing and talking to self widely. No aggressive behaviors occurred. A progress note, dated 3/17/19 at 2:00 p.m., included after lunch the resident was observed walking to the dining room then to his room then the nurses' station. At the nurses' station the resident had delusions as evidenced by telling staff someone was trying to kill him. Staff reassured the resident of safety. The resident returned to his room. A few minutes later another resident was heard yelling. When staff went to check on the resident, Resident [NAME] had been choking Resident D. Staff immediately intervened, no injuries had been noted. One on one supervision was initiated. The physician, psychological services, and family had been notified. On 5/31/19 at 9:10 a.m., the Administrator provided a written statement regarding the incident between Resident [NAME] and Resident D. She indicated during the formal investigation the term choking utilized in the progress notes was inaccurate, the resident had grabbed the resident's shirt in the neck area consistent with prior investigations involving the resident. The resident remained on one to one supervision until 3/30/19, when every 15 minute checks had been implemented. No further aggressive behaviors had occurred until 4/21/19, when the resident had pushed, punched, and spit on the nurse. After the incident, the resident had been admitted to a behavioral health unit. A discharge Minimum Data Set (MDS) assessment, dated 5/21/19, coded the resident with moderate cognitive impairment. Behavior physical symptoms directed toward others occurred 4 to 6 days but less than daily. A plan of care addressed resident had impulsive physical behaviors as evidenced by aggression towards staff and other residents (choking, taking staff to floor, ripping co-resident shirt, etc.) The initiated date was 9/17/18, and was current until resident's discharge 5/22/19. Resident D's clinical record was reviewed on 5/31/19 at 1:29 p.m. A quarterly MDS dated [DATE], coded the resident with moderate cognitive impairment. Delusions physical behavioral symptoms directed toward others occurred daily. The Administrator was interviewed on 5/31/19 at 2:00 p.m., and indicated the resident rejected care. A facility policy titled Abuse Prevention, revised 7/1/15, provided by the Administrator on 5/30/19 at 1:55 p.m., included, but was not limited to, It is the policy of the facility to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. We have established policies and procedures that will provide facility personnel with the knowledge and training to further ensure each resident is treated with individual respect and dignity This Federal tag relates to Complaint IN 355. 3.1-27(a) 3.1-27(b)

Based on interview and record review, the facility failed to prevent resident funds from being diverted into a staff person's personal account for 1 of 1 resident identified with misappropriation of property. (Resident B) Finding includes: On 10/1/18 at 9:12 a.m., the Administrator was interviewed. She indicated she had been contacted on 9/4/18, by a Detective in another county and notified that Business Office Manager (BOM) 1 had been under investigation for theft from a previous facility. The detective indicated that on 8/27/18, the BOM had deposited a check for $2,800.00 from Resident B into her personal account by a mobile deposit, with the resident's signature. The Administrator indicated an investigation had begun and the staff person suspended. An audit done with the Regional Business Office Manager did not reveal any further misappropriation of funds and the employee was terminated. The local police authorities, state and resident's representative were notified. The money was returned to the resident's account by the facility. Resident B's clinical record was reviewed on 10/1/18 at 10:54 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 9/11/18, coded the resident without cognitive impairment. The resident had a representative, a guardian, who was the account receivable guarantor. BOM 1's employee file was reviewed on 10/1/18 at 12:57 p.m. A hire date of, 8/6/18/ was noted. Documentation of orientation, signed by the employee included but not limited to, Abuse and Neglect of the Elderly - An Overview Training Exam, dated 8/6/18, completed by the staff member, included but was not limited to, .7. Financial abuse can include which of the following? a. Cashing an elderly person's check without permission b. Forcing an elder to sell his/her home, c. Stealing cash d. All of the above (correct answer.) A form titled Customer Service Pledge, signed by the employee and manager on 8/6/18, included but was not limited to, I will respect the possessions of our Residents and not use those private possessions for myself, nor let my co-workers take any of our Residents' possessions. Documentation of the Business Office Manager Training Checklist, (no date) was signed by the employee and Regional Business Office Manager, no date. A facility policy titled HR-408: Abuse & Neglect Policy, dated 9/1/14, included but was not limited to, Application This policy applies to all employees Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent Screening The facility will 1) screen potential employees for a history of abuse, neglect or mistreating residents, 2) attempt to obtain information from previous and/or current employers, and 3) check with the appropriate licensing boards and registries Documentation in the employee handbook, no date, provided upon hire, included but was not limited to, Improper Use of Funds: We may not use (facility corporation name) funds for improper or illegal activities .Billing Practices: (corporate name) Employees are responsible for ensuring that billing is accurate and honest at all times This Federal tag relates to Complaint IN 865. 3.1-28(a)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed for 1 of 5 Residents reviewed for unnecessary medications (Resident 41). Findings include: On 8/22/18 at 1:22 p.m., Resident 41's record was reviewed, [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A pharmacy consultation report, dated 7/5/18, indicated, .(Resident 41's name) receives an anticonvulsant, [MEDICATION NAME] Sodium DR, which has been shown to increase risk for [MEDICAL CONDITION] (bone loss) .Recommendation: Please consider initiating calcium [MEDICATION NAME] 950 mg twice daily with food and [MEDICATION NAME] (vitamin D3) 1,000 international units daily, which can reduce the rate of bone loss .Physician's Response: .I decline the recommendation(s) above due to the reasons below .Rationale: (blank) The report was signed and dated 8/7/18 by the physician and the Director of Nursing (DON), but the rationale for the decline was left blank. The DON indicated, on 8/22/18 at 2:30 p.m. Resident 41 received [MEDICATION NAME] Sprinkle Capsules daily at bedtime. She was unsure why the doctor had declined the pharmacy recommendation. On 8/23/18 at 10:24 a.m., the Administrator (ADM) indicated, the doctor should have documented on the pharmacy consultation report the rationale as to why he had declined the pharmacy recommendation. At that time, the ADM provided and identified as a current facility policy, titled Omnicare LTC FACILITY PHARMACY SERVICES AND PR[NAME]EDURES MANUAL, dated 2013, which indicated .Policy #/Title 9.2 Interim Medication Regimen Review (iMRR) .Facility should encourage Physician/Prescriber or other responsible parties receiving the iMRR and the Director of Nursing to act upon the recommendations contained in the iMRR. For those issues that require Physician/Prescriber intervention, Physician/Prescriber should either (a) accept and act upon the recommendations contained within the iMRR, or (b) reject all or some of the recommendations 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure proper infection control procedures were performed for 1 of 2 residents observed during blood glucose tests (Resident 22). Findings include: On 8/23/18 at 11:47 a.m., Resident 22's blood sugar was tested . Licensed Practical Nurse (LPN) 1 removed the glucometer (blood glucose monitor) from a plastic storage bag, cleaned the glucometer with an alcohol prep pad, and then proceeded to perform the blood glucose test on Resident 22. After the blood test was completed, LPN 1 dropped the glucometer onto the floor, picked it up, cleaned the monitor with an alcohol prep pad, and then placed the soiled monitor back into the storage bag. LPN 1, on 8/23/18 at 11:54 a.m., indicated she routinely cleaned the resident's glucometer with an alcohol swab (prep pad). On 8/23/18 at 11:58 a.m., the Administrator (ADM) indicated LPN 1 was a new nurse and should not have used an alcohol swab to clean the glucometer, but a disinfectant wipe, per the facility policy. The Director of Nursing (DON), on 8/23/18 at 1:20 p.m., indicated the facility policy specified for staff to properly disinfect and clean the glucose monitors with PDI Sanitation Wipes, not alcohol swabs. The nurse was new and did not know she should clean the monitors with these cloths. Resident 22's record was reviewed, on 8/27/18 at 8:59 a.m., [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Accu checks (blood glucose tests) before meals and at bedtime for DM II. Call MD (physician) if BS (blood sugar) is less than 60 or over 450 On 8/23/18 at 1:20 p.m., the DON provided and identified as current, an undated facility policy titled, Summerfield Health Care Center Nursing Policy and Resource Manual, which indicated, .Policy: Glucometer .Purpose: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices (Glucometers) to prevent transmission of blood borne diseases to residents and employees .Procedure: 1. Obtain and gather equipment and supplies: Disinfectant wipe, Glucometer, Gloves as indicated .9. Retrieve disinfectant wipe from container. Recommended Disinfectant Wipe: PDI Sanitation Wipes .10. Cleanse the glucometer with the disinfectant wipe 3.1-18(a)