**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation when a staff member obtained the resident's phone, gained account access, and transferred money. The findings include: Resident #1's diagnoses included acute respiratory failure with hypercapnia (when the body can't remove excess carbon dioxide from the bloodstream causing it to build up) and cognitive communication deficit. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented with good memory recall and required a two (2) person assist for transfers and ambulation and was independent with bed mobility and positioning. The baseline Resident Care Plan (RCP) dated 2/14/25 identified Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included utilizing a walker when ambulating. Review of the Resident Personal Possessions form dated 2/14/25 identified Resident #1 brought an iPhone and an iPad to the facility on admission. A nurse's note dated 2/16/25 at 4:08 AM identified Resident #1 was complaining of shortness of breath with noted oxygen levels between 71-72 percent (low oxygen level/body is not getting enough oxygen). The note identified that Emergency Medical Services (EMS) was called, and Resident #1 was transferred to the hospital Emergency Department (ED) for evaluation. Review of the facility Accident and Incident (A & I) report dated 3/19/25 identified the facility was notified by Resident #1's family member (Person #1) of unauthorized financial transactions made from Resident #1's personal cell phone to a PayPal account associated with a facility staff member's (NA #1) address and telephone number. Review of the facility Summary Report dated 3/21/25 identified that on 2/16/25, Resident #1 was transferred to the hospital for an acute change in condition and his/her belongings, including his/her cell phone remained at the facility following the transfer. The report identified that the resident did not return to the facility, subsequently passing away in the hospital, and on 3/14/25, Person #1 came to the facility to retrieve Resident #1's belongings and reported Resident #1's cell phone to be missing. On 3/19/25, Person #1 contacted the facility and reported that he/she identified multiple unauthorized financial transactions originating from Resident #1's PayPal account. Person #1 identified there was a bank login alert on 3/17/25 which prompted him/her to access Resident #1's email where a series of PayPal withdrawals were discovered, dating from 2/19/25 through 3/17/25, totaling approximately $1735.00. Person #1 identified that the PayPal account in question was linked to an email and phone number which the facility verified matched a facility staff member (NA #1). The report identified that upon notification, the facility immediately initiated an internal investigation, the police were notified and the employee in question was suspended pending the outcome of the investigation. Interview with the DNS on 4/11/25 at 10:48 AM identified that following Person #1's report on 3/19/25 of unauthorized transactions on Resident #1's account associated/linked with NA #1's account, NA #1 was suspended pending an investigation. She identified that the facility had since been unable to contact NA #1, and reported he will no longer be employed by the facility. Review of NA #1's timecard identified that he worked the 11:00 PM to 7:00 AM shift on 2/14/25, 2/21/25, 2/22/25, 2/23/25, 2/27/25, 2/28/25, 3/4/25, 3/5/25, 3/7/25, 3/13/25 and 3/15/25. The timecard identified that he worked 7:09 AM to 11:04 PM on 2/17/25, 3:04 PM to 11:05 PM on 2/18/25, 7:08 AM to 3:20 PM on 2/19/25, 7:14 AM to 11:03 PM on 3/3/25, 3:02 PM to 11:00 PM on 3/17/25 and 3:10 PM to 10:59 PM on 3/18/25. Interview with Person #1 on 4/11/25 at 10:55 AM identified that he/she was Resident #1's financial Power of Attorney (POA) and reported Resident #1's personal bank account security reset was linked to his/her (Person #1's) phone. Person #1 indicated that on 3/17/25, he/she received a text with a code to sign into Resident #1's bank account. Person #1 identified when he/she (Person #1) signed into the account there was only about $500 left in the account, and the balance was usually between $2,000 and $6,000 depending on the time of the month. Person #1 identified he/she noticed numerous withdrawals from Resident #1's personal PayPal account. Person #1 identified that he/she was unable to gain access to Resident #1's PayPal account, so accessed Resident #1's email where he/she observed numerous emails associated with PayPal transactions that were made. She identified that fraudulent charges included: $108 on 2/19/25, $100 on 2/24/25, $377 on 3/6/25, $550 on 3/12/25, $550 on 3/17/25 and $50 on 3/17/25. Person #1 then withdrew all remaining funds from the bank account after filing a police report on 3/18/25. Person #1 reported that although not all the transfers were identified in Resident #1's email, he/she was able to locate an email showing a transfer of $200 was sent to NA #1 from Resident #1 on 3/15/25 and another email with a transfer of $200 was sent to Person #2 with NA #1's phone number on 3/17/25. Person #1 identified that he/she was unsure who Person #2 was but that there was a NA with Person #2's last name who worked at the facility. Person #1 indicated he/she never reported Person #2 to the facility. Additionally, Person #1 identified that a letter was received and identified a PayPal credit card was requested in Resident #1's name but was denied because Resident #1's identity was not confirmed. Further, an email was received on 3/17/25 stating that the PayPal account billing address for Resident #1 was changed to NA #1's address. Review of the facility schedule dated 2/15/25 identified NA #3 was scheduled to work the 11:00 PM to 7:00 AM shift on 2/15/25 at the facility. Interview with the DNS on 4/11/25 at 11:25 AM identified that NA #3 was terminated prior to the misappropriation allegation on 3/19/25 for attendance issues. She indicated there were no reports made to her of a connection between NA #3 and the allegation. Review of NA #3's personnel file identified his address matched that of NA #1. Review of NA #3's timecard identified he worked the 3:00 PM to 11:00 PM shift on 2/17/25, 2/19/25, 2/20/25, 2/22/25, 2/23/25, 2/24/25, 2/26/25, 2/27/25, 3/3/25, 3/5/25, 3/6/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25 and 3/17/25. He worked the 11:00 PM to 7:00 AM shift on 3/15/25. Interview with NA #3 on 4/11/25 at 12:15 PM identified that he did not have recent contact with NA #1 and reported that he never stole from a resident or been involved with misappropriation of resident property or money. He identified that the phone number associated with Person #2's name was NA #1's phone number. Interview with Administrator #2 (previous Administrator) on 4/11/25 at 1:44 PM identified she was unaware NA #3 was involved in the allegation. Administrator #2 indicated that other staff, residents and their representatives were not interviewed to ensure other residents were not affected but stated those interviews should have been conducted. Administrator #2 identified that the misappropriation of Resident #1's money should not have occurred. Although attempted, an interview with NA #1 was not obtained. Review of the Abuse policy (undated) directed, in part, that abuse or mistreatment of any kind towards a resident is strictly prohibited. Any allegation of abuse by a staff member, visitor, family member, or resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated, and appropriate action will be taken. Misappropriation of resident property is defined as the deliberate misuse, exploitation, or theft of a resident's belongings or money without consent. Any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the Director of Nursing (DNS) and the Administrator. An A & I report will be completed for each resident involved. Nursing staff will document a description of the incident in the resident's record. The DNS or designee will notify the resident's family, physician, Department of Public Health and local police as needed. The Administrator/DNS or designee will initiate an investigation and submit an online report to the Facility Licensing and Investigation Section (FLIS) within two (2) hours of notification. The accused individual will be immediately suspended pending the outcome of the investigation. The investigation will include: Interviews with all witnesses, including the accused, interviews with any individuals with relevant information, signed and dated statements from all involved parties and review of the accused staff member's employment record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to fully investigate an allegation of misappropriation of money to include obtaining statements from the accused, other staff, other residents and/or resident representatives to ensure all residents were free from misappropriation in accordance with facility policy. The findings include: Resident #1's diagnoses included acute respiratory failure with hypercapnia (when the body can't remove excess carbon dioxide from the bloodstream causing it to build up) and cognitive communication deficit. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented with good memory recall and required a two (2) person assist for transfers and ambulation and was independent with bed mobility and positioning. The baseline Resident Care Plan (RCP) dated 2/14/25 identified Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included utilizing a walker when ambulating. Review of the Resident Personal Possessions form dated 2/14/25 identified Resident #1 brought an iPhone and an iPad to the facility on admission. A nurse's note dated 2/16/25 at 4:08 AM identified Resident #1 was complaining of shortness of breath with noted oxygen levels between 71-72 percent (low oxygen level/body is not getting enough oxygen). The note identified that Emergency Medical Services (EMS) was called, and Resident #1 was transferred to the hospital Emergency Department (ED) for evaluation. Review of the facility Accident and Incident (A & I) report dated 3/19/25 identified the facility was notified by Resident #1's family member (Person #1) of unauthorized financial transactions made from Resident #1's personal cell phone to a PayPal account associated with a facility staff member's (NA #1) address and telephone number. Review of the facility Summary Report dated 3/21/25 identified that on 2/16/25, Resident #1 was transferred to the hospital for an acute change in condition and his/her belongings, including his/her cell phone remained at the facility following the transfer. The report identified that the resident did not return to the facility, subsequently passing away in the hospital, and on 3/14/25, Person #1 came to the facility to retrieve Resident #1 ' s belongings and reported Resident #1's cell phone to be missing. On 3/19/25, Person #1 contacted the facility and reported that he/she identified multiple unauthorized financial transactions originating from Resident #1 ' s PayPal account. Person #1 identified there was a bank login alert on 3/17/25 which prompted him/her to access Resident #1's email where a series of PayPal withdrawals were discovered, dating from 2/19/25 through 3/17/25, totaling approximately $1735.00. Person #1 identified that the PayPal account in question was linked to an email and phone number which the facility verified matched a facility staff member (NA #1). The report identified that upon notification, the facility immediately initiated an internal investigation, the police were notified and the employee in question was suspended pending the outcome of the investigation. Interview with the DNS on 4/11/25 at 10:48 AM identified that following Person #1's report on 3/19/25 of unauthorized transactions on Resident #1's account associated/linked with NA #1 ' s account, NA #1 was suspended pending an investigation. She identified that the facility had since been unable to contact NA #1 and reported he will no longer be employed by the facility. Review of NA #1's timecard identified that he worked the 11:00 PM to 7:00 AM shift on 2/14/25, 2/21/25, 2/22/25, 2/23/25, 2/27/25, 2/28/25, 3/4/25, 3/5/25, 3/7/25, 3/13/25 and 3/15/25. The timecard identified that he worked 7:09 AM to 11:04 PM on 2/17/25, 3:04 PM to 11:05 PM on 2/18/25, 7:08 AM to 3:20 PM on 2/19/25, 7:14 AM to 11:03 PM on 3/3/25, 3:02 PM to 11:00 PM on 3/17/25 and 3:10 PM to 10:59 PM on 3/18/25. Interview with Social Worker #1 (Director of Social Services) and Social Worker #2 on 4/11/25 at 10:34 AM identified they were not involved in the investigation regarding NA #1 and that Resident #1 was no longer in the facility when the allegations were made. They indicated they were made aware of the allegations but were not provided a timeline or instructed to assist in the investigation or conduct interviews. They identified they had no reports of expensive missing items between February and March 2025, only reports of missing clothing. Interview with Person #1 on 4/11/25 at 10:55 AM identified that he/she was Resident #1's financial Power of Attorney (POA) and reported Resident #1's personal bank account security reset was linked to his/her (Person #1's) phone. Person #1 indicated that on 3/17/25, he/she received a text with a code to sign into Resident #1's bank account. Person #1 identified when he/she (Person #1) signed into the account there was only about $500 left in the account, and the balance was usually between $2,000 and $6,000 depending on the time of the month. Person #1 identified he/she noticed numerous withdrawals from Resident #1 ' s personal PayPal account. Person #1 identified that he/she was unable to gain access to Resident #1's PayPal account, so accessed Resident #1 ' s email where he/she observed numerous emails associated with PayPal transactions that were made. She identified that fraudulent charges included: $108 on 2/19/25, $100 on 2/24/25, $377 on 3/6/25, $550 on 3/12/25, $550 on 3/17/25 and $50 on 3/17/25. Person #1 then withdrew all remaining funds from the bank account after filing a police report on 3/18/25. Person #1 reported that although not all the transfers were identified in Resident #1's email, he/she was able to locate an email showing a transfer of $200 was sent to NA #1 from Resident #1 on 3/15/25 and another email with a transfer of $200 was sent to Person #2 with NA #1's phone number on 3/17/25. Person #1 identified that he/she was unsure who Person #2 was but that there was a NA with Person #2's last name who worked at the facility. Person #1 indicated he/she never reported Person #2 to the facility. Additionally, Person #1 identified that a letter was received and identified a PayPal credit card was requested in Resident #1's name but was denied because Resident #1's identity was not confirmed. Further, an email was received on 3/17/25 stating that the PayPal account billing address for Resident #1 was changed to NA #1's address. Review of the facility schedule dated 2/15/25 identified NA #3 was scheduled to work the 11:00 PM to 7:00 AM shift on 2/15/25. Interview with the DNS on 4/11/25 at 11:25 AM identified that NA #3 was terminated prior to the misappropriation allegation on 3/19/25 for attendance issues. She indicated there were no reports made to her of a connection between NA #3 and the allegation. Review of NA #3's personnel file identified his address matched that of NA #1. Review of NA #3's timecard identified he worked the 3:00 PM to 11:00 PM shift on 2/17/25, 2/19/25, 2/20/25, 2/22/25, 2/23/25, 2/24/25, 2/26/25, 2/27/25, 3/3/25, 3/5/25, 3/6/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25 and 3/17/25. He worked the 11:00 PM to 7:00 AM shift on 3/15/25. Interview with NA #3 on 4/11/25 at 12:15 PM identified that he did not have recent contact with NA #1 and reported that he never stole from a resident or been involved with misappropriation of resident property or money. He identified that the phone number associated with Person #2's name was NA #1's phone number. Interview with Administrator #2 (previous Administrator) on 4/11/25 at 1:44 PM identified she was unaware NA #3 was involved in the allegation. Administrator #2 indicated that other staff, residents and their representatives were not interviewed to ensure other residents were not affected but stated those interviews should have been conducted. Administrator #2 identified that the misappropriation of Resident #1's money should not have occurred. Interview with the DNS on 4/11/25 at 2:51 PM identified that a full investigation regarding the 3/19/25 allegation of misappropriation should have been completed to include interviews with other staff, residents and their representatives. The DNS indicated interviews were not conducted because the allegation was made a month after the alleged misappropriation and the residents and their families on Resident #1's unit were involved and vocal, and she assumed they would report anything missing. Although attempted, an interview with NA #1 was not obtained. Review of the Abuse policy (undated) directed, in part, that abuse or mistreatment of any kind towards a resident is strictly prohibited. Any allegation of abuse by a staff member, visitor, family member, or resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated, and appropriate action will be taken. Misappropriation of resident property is defined as the deliberate misuse, exploitation, or theft of a resident's belongings or money without consent. Any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the Director of Nursing (DNS) and the Administrator. An A & I report will be completed for each resident involved. Nursing staff will document a description of the incident in the resident's record. The DNS or designee will notify the resident's family, physician, Department of Public Health and local police as needed. The Administrator/DNS or designee will initiate an investigation and submit an online report to the Facility Licensing and Investigation Section (FLIS) within two (2) hours of notification. The accused individual will be immediately suspended pending the outcome of the investigation. The investigation will include: Interviews with all witnesses, including the accused, interviews with any individuals with relevant information, signed and dated statements from all involved parties and review of the accused staff member's employment record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for personal care and assistance, the facility failed to ensure documentation was complete in the clinical record. The findings include: Resident #2's diagnoses included type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels), congestive heart failure (when the heart cannot pump blood efficiently enough to give your body a normal supply), obesity and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition and required setup assistance with eating, substantial assistance with toileting hygiene, showering/bathing self, personal hygiene, bed mobility and transfers. Additionally, it identified that Resident #1 had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and was occasionally incontinent of bowel. The Resident Care Plan (RCP) dated 3/25/25 identified Resident #2 required assistance with Activities of Daily Living (ADLs) due to a history of falls, Acute Kidney Injury (AKI) and chronic first thoracic (T1) fracture (topmost vertebrae in the thoracic spine). Interventions included to offer assistance as needed with washing, bathing, dressing, toileting and oral hygiene, offer comfort bath/bed bath if the resident refuses a bath/shower, offer the resident assistance with tasks that they are unable to complete and provide assistance as ordered with transfers, ambulation and toileting. Review of the March 2025 Documentation Survey Report (Nurse Aide Documentation) for Resident #2 failed to identify documentation every shift on: a. Bladder elimination on 3/3/25, 3/4/25, 3/8/25 through 3/14/25, 3/17/25, 3/19/25 and 3/23/25 through 3/26/25. b. Bowel elimination on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/17/25, 3/19/25 and 3/23/25 through 3/26/25; c. Eating on 3/4/25, 3/5/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25; d. Personal hygiene on 3/4/25, 3/5/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25. e. Showering/bathing self on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25. f. Toileting hygiene on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25 g. Amount eaten on 3/3/25, 3/4/25, 3/8/25 through 3/10/25, 3/12/25 through 3/14/25, 3/19/25 and 3/24/25 through 3/26/25. h. Bowel and Bladder diary on 3/4/25 through 3/6/25, 3/8/25 through 3/10/25 and 3/12/25 through 3/14/25. i. Fluid intake on 3/19/25 and 3/23/25 through 3/26/25. j. Output on 3/19/25 and 3/23/25 through 3/26/25. A nurse's note dated 3/29/25 at 4:01 PM identified that Resident #2 was unable to hold the phone per his/her baseline. The note reported that a blood pressure was obtained and was high, blood sugar was normal, skin was pale and cool to touch and the resident was unable to respond verbally to staff regarding how he/she felt. The APRN was notified, and an order was obtained to transfer the resident to the Emergency Department for evaluation. Review of facility census identified that Resident #2 did not return to the facility. Interview with the DNS on 4/11/25 at 1:25 PM identified that it is expected that the Nurse Aides (NA's) are documenting on every resident, every shift, or as directed in the electronic medical record. She identified that NA compliance with consistent documentation was a work in progress and she is continuing to educate staff as she identifies missing documentation. Review of the CNA Flow Sheets (Resident Care Record) policy dated 05/2023 directed, in part, that the resident flow sheet will be completed nearest to the end of the shift as possible by the Certified Nursing Assistant (CNA) assigned to the resident. The following guide must be followed: Each resident in the facility will have a new flow sheet initiated by the CNA in Point Click Care (electronic health record), the flow sheet will have the resident's name, month, year and date, the CNA will document the care provided to the resident for that shift by completing the entire flow sheet, all the approved coding and abbreviations shall be used and upon completion each CNA must initial in the appropriate box. The flow sheet is a part of the resident's medical record in Point Click Care. The CNA flow sheet will be used to assist in developing an individualized plan of care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure Resident #1 was not verbally abused by staff. The findings include: Resident #1's diagnoses included schizoaffective disorder, cognitive communication deficit, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, had not exhibited behavioral symptoms, and was dependent on staff for toileting. The Resident Care Plan dated 2/20/25 identified Resident #1 required assistance with incontinent care. Interventions directed to assist the resident with incontinent care timely and assist the resident in and out of bed during the day. The Facility Reported Incident form dated 3/2/25 identified at 3:40 PM Resident #1 reported having an interaction with an 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/2/25 that upset him/her. Resident #1 requested that NA #1 no longer provides care for him/her. The nurse's note dated 3/3/25 at 2:02 PM identified the Social Worker and the Assistant Director of Nursing provided support to Resident #1 following a concern of staff to resident interaction. The note identified Resident #1 expressed concern regarding a nurse aide being argumentative on the prior overnight shift. Resident #1 reported staff had been supportive, he/she feels comfortable and safe at the time. The summary report dated 3/4/25 indicated on the 11PM- 7AM shift, 3/1/25 into 3/2/25, Resident #1 reported he/she had an interaction with NA #1 that he/she found upsetting and Resident #1 expressed concern about the way the situation was handled by NA #1. The report indicated the interaction did not reflect a level of professionalism and resident care that the facility expected from the team. NA #1 was suspended pending the investigation and then terminated. Interview with the Assistant Director of Nursing (ADON) on 3/26/25 at 11:25 AM identified on 3/2/25 the 3PM-11PM Nursing Supervisor called her at approximately 3:00 PM to report that the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, told her she was made aware by a 3PM-11PM nurse aide, NA #2, that Resident #1 had an audio recording of an interaction that occurred between Resident #1 and NA #1 on 3/2/25 at approximately 2:00 AM. The ADON indicated she met with Resident #1 and listened to the recording which was very disturbing. The ADON explained when NA #1 entered Resident #1's room to provide care, Resident #1 inquired why it took so long for NA #1 to come back into his/her room to change him/her at which time the two (2) began to argue and NA #1 became extremely argumentative, and her voice escalated. The ADON identified the recording revealed Resident #1 had asked NA #1 to leave the room several times and NA #1 was heard refusing to leave the room, Resident #1 requested to see a supervisor several times and at one (1) point NA #1 said no, and Resident #1 was heard telling NA #1 to stop touching him/her several times. The ADON identified NA #1 should have left the room when Resident #1 requested she leave the room. The ADON explained Resident #1's roommate told her NA #1 was very rude, and he/she was scared the nurse aide was going to hit Resident #1, so she turned his/her light on. Interview with Resident #1 on 3/26/25 at 12:45 PM identified although he/she could not recall the exact date of the altercation with NA #1, he/she was able to recall the details as written in his/her original statement. Resident #1 stated he/she recalled pressing the call bell at approximately 1:00 AM requesting assistance to be changed and NA #1 came into his/her room and said she would be back as soon as she could, however an hour passed, so Resident #1 explained he/she called again. Resident #1 indicated when NA #1 entered the room, he/she began to question her about the delay and NA #1 became belligerent and argumentative. Resident #1 stated he/she played the audio recording and the contents of the conversation match what was reported to the ADON. Resident #1 identified NA #1 could be heard yelling at, arguing with, and refusing to stop care and get the supervisor as he/she requested. Resident #1 identified he/she and his/her roommate were fearful of NA #1. In a written statement obtained by the facility of an interview on 3/3/25 with NA #1, NA #1 identified when she went into Resident #1's room the second time she told the resident that he/she was not the only resident there. NA #1 explained Resident #1 started going off on her and she said if you're going to go off, were going to go off together. In the statement NA #1 acknowledged it was not okay to raise her voice, and she should have excused herself and gotten a nurse to intervene. The facility Abuse Policy identified abuse or mistreatment of any kind toward a resident is strictly prohibited. Review of facility documentation identified that a Plan of Correction was initiated immediately: Staff training on Abuse and Neglect including Timely Reporting. Random audits on abuse and neglect, customer service, resident to staff interactions, care, and customer service will be conducted and will continue for a period of thirty (30) days or until substantial compliance is met. Audits to be reviewed at the monthly QAPI meetings. The Administrator or designee are responsible for the plan. Compliance as of 3/7/25. The plan of correction was reviewed on 3/26/25 and the facility met all components for past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to report the allegation of verbal abuse to the Administrator and/or designee within two (2) hours after the event was reported by the resident to facility staff. The findings include: Resident #1's diagnoses included schizoaffective disorder, cognitive communication deficit, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, had not exhibited behavioral symptoms, and was dependent on staff for toileting. The Facility Reported Incident form dated 3/2/25 identified at 3:40 PM Resident #1 reported having an interaction with an 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/2/25 that upset him/her. Resident #1 requested that NA #1 no longer provides care for him/her. The nurse's note dated 3/3/25 at 2:02 PM identified the Social Worker and the Assistant Director of Nursing provided support to Resident #1 following a concern of staff to resident interaction. The note identified Resident #1 expressed concern regarding a nurse aide being argumentative on the prior overnight shift. Resident #1 reported staff had been supportive, he/she feels comfortable and safe at the time. The summary report dated 3/4/25 indicated on the 11PM- 7AM shift, 3/1/25 into 3/2/25, Resident #1 reported he/she had an interaction with NA #1 that he/she found upsetting and Resident #1 expressed concern about the way the situation was handled by NA #1. The report indicated the interaction did not reflect a level of professionalism and resident care that the facility expected from the team. NA #1 was suspended pending the investigation and then terminated. In a written statement dated 3/4/25 the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #2, identified on 3/2/25 sometime after 1:00 AM, NA #1 informed her that she was upset with Resident #1 because Resident #1 was rude and disrespectful, and Resident #1 requested to speak with the Nursing Supervisor. LPN #2 indicated she spoke with Resident #1 who appeared very upset and Resident #1 informed her of the altercation with NA #1. LPN #2 explained Resident #1 played the recorded audio for her. LPN #2 identified she provided care to Resident #1 the remainder of the shift and although she told NA #1 she was no longer to provide care to Resident #1, LPN #2 allowed NA #1 to provide care for others on her assignment. LPN #2 indicated she did not report the allegation to the Nursing Supervisor. Interview with the Assistant Director of Nursing (ADON) on 3/26/25 at 11:25 AM identified on 3/2/25 the 3PM-11PM Nursing Supervisor called her at approximately 3:00 PM to report that the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, told her she was made aware by a 3PM-11PM nurse aide, NA #2, that Resident #1 had an audio recording of an interaction that occurred between Resident #1 and NA #1 on 3/2/25 at approximately 2:00 AM. The ADON indicated she met with Resident #1 and listened to the recording which was very disturbing. The ADON indicated Resident #1 identified the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #2 had come into her room, listened to the recording of the incident that occurred and provided care to him/her. The ADON identified she spoke with LPN #2 and LPN #2 confirmed she was aware of the altercation, and she did not allow NA #1 to provide further services to Resident #1 that night. The ADON identified LPN #2 stated she did not report the incident to anyone because Resident #1 did not want it reported and LPN #2 allowed NA #1 to continue working the shift with other residents. The ADON identified LPN #2 should have informed the Nursing Supervisor and NA #1 should have been sent home immediately pending an investigation. The facility Abuse Policy identified abuse or mistreatment of any kind toward a resident must be reported to a supervisor immediately and the accused individual will be immediately suspended pending the outcome of the investigation. Review of facility documentation identified that a Plan of Correction was initiated immediately: Staff training on Abuse and Neglect including Timely Reporting. Random audits on abuse and neglect, customer service, resident to staff interactions, care, and customer service will be conducted and will continue for a period of thirty (30) days or until substantial compliance is met. Audits to be reviewed at the monthly QAPI meetings. The Administrator or designee are responsible for the plan. Compliance as of 3/7/25. The plan of correction was reviewed on 3/26/25 and the facility met all components for past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for Leave of Absence (LOA), the facility failed to ensure a resident who is dependent on staff for transfers, Activities of Daily Living (ADLs) and severely impaired cognition was accompanied to a medical appointment out in the community, resulting in the resident being dropped off at the wrong location, then dropped off by an unknown person to the emergency department. The findings include: Resident #1 had diagnoses that included mild cognitive impairment, seizures, diabetes mellitus, peripheral vascular disease, and bipolar disorder. The clinical record failed to identify an LOA order. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) indicative of severely impaired cognition, has impaired vision, dependent with ADLs and transfers. The care plan dated 10/8/24 identified Resident #1 needs assistance with ADLs due to cognitive deficit with interventions that direct to assure Resident #1 is accompanied to medical appointments as deemed necessary per facility policy. The nurse's note dated 11/12/24 at 2:32 P.M. written by LPN #3 identified Resident #1's daughter called, and she scheduled a vascular appointment for Resident #1, the family member will meet Resident #1 at the appointment. A nurse's note dated 11/20/24 (Late entry) at 9:42 A.M. written by the Assistant Director of Nursing (ADNS) identified that Resident #1 was scheduled for a vascular appointment. The appointment was changed to another location and the facility was not made aware. The ADNS indicated she called the transportation company who agreed to go back to transport Resident #1 to the other address. The ADNS indicated she spoke with Resident #1's family member who was on her way to meet Resident #1 at the original location and Resident #1's daughter acknowledged she was not made that the location of Resident #1's appointment had been changed. The ADNS identified she provided Resident #1's family member with the address of the new location of the appointment and she would to go meet Resident #1 at the appointment. A nurse's note dated 11/20/24 (Late entry) at 3:37 P.M. written by the ADNS identified she was alerted by RN #2 (supervisor) that Resident #1's family member called the facility looking to see if Resident #1 made it back because Resident #1 never came to the appointment. The ADNS identified another family member called the facility and stated that Resident #1 was dropped off at the wrong location and Resident #1 was transported to the emergency room by an unknown person. The ADNS identified Resident #1 returned to the facility via car Resident #1 was transported by a family member. Review of the emergency department observation note dated 11/20/24 at 2:00 P.M. identified Resident #1 was dropped off at the door in a wheelchair with no family or staff. Resident #1 is unable to provide history due to cognitive impairment. Resident #1 does have paperwork that has h/her medical history, medication, and name of the facility h/she is from. Collateral information obtained from the facility Resident #1 was supposed to go to a vascular appointment today with an aide, instead, Resident #1 reportedly was dropped at the wrong address and then from there dropped off at the emergency department. Resident #1 discharged from the emergency department back to the facility accompanied by a family member. Interview with the ADNS on 12/13/24 at 11:40 A.M. identified on 11/20/24 Resident #1 was picked up at the facility by the transportation company, and sent out unaccompanied for h/her appointment, and dropped off at the appointment. The ADNS indicated she received a call from the MD office reporting that Resident #1 had not arrived for h/her appointment. The ADNS identified that the MD office informed her the location of Resident #1's appointment had changed. The ADNS indicated prior to 11/20/24 that the MD office had not communicated that the location of Resident #1's appointment had been changed. The ADNS indicated she contacted the transportation company who agreed they would have the driver return to the original MD address and transport Resident #1 to the appointment at the new location of the MD appointment. The ADNS indicated she contacted Resident #1's family would meet Resident #1 at the new location. Interview with RN #2 on 12/13/24 at 3:25 P.M. identified on 11/20/24 she tried to contact Resident #1's family prior to the resident leaving, but was unable to reach her. RN #2 identified a nurse aide was not assigned to accompany Resident #1 to h/her appointment. RN #2 indicated she spoke with Resident #1 and Resident #1 indicated h/her daughter would be meeting Resident #1 at the appointment. RN #2 identified when a resident is going out to a medical appointment if is is noted that the resident's family will accompany the resident the family needs to be present in the facility prior to the resident leaving the facility. RN #2 indicated it was a miscommunication and Resident #1 should not have been sent out to h/her appointment unaccompanied. Interview with the DNS on 12/13/24 at 1:00 P.M. identified when a resident is going out to a medical appointment with family the family must be physically present in the facility prior to the resident leaving the building or a nurse aide must accompany the resident. The DNS identified on 11/20/24 when Resident #1's daughter was not present in the facility to accompany The DNS identified on 11/20/24 Resident #1 should not have left the facility with the transportation company alone to go to h/her medical appointment. The DNS identified on 11/20/24 RN #2 was provided with employee coaching because RN #2 sent Resident #1 who requires assistance, is cognitively impaired, and wheelchair bound out to h/her appointment unaccompanied. The DNS identified supervisors are responsible for assuring the resident's family is present at the time of pick up or a nurse aide is assigned to accompany the resident to the appointment. The DNS stated that it is unclear how the resident ended up at the emergency department. Interview with the MD #1 (Medical Director) on 12/13/24 at 2:25 P.M. identified his expectation is when a resident is going out for an appointment a family member, or a staff member must accompany the resident. MD #1 identified on 11/20/24 Resident #1 should not have been sent out alone to h/her appointment and Resident #1 should have been accompanied by a staff member. Review of the undated facility MD appointment/Offsite/Transportation policy identified the purpose of the policy is to ensure the safety of residents going to offsite M.D. appointments and assist with transportation to and from any appointments. In instances where the resident requires supervision on medical appointments, the resident's family/responsible party may be contacted to attend the appointment. If the family is unable to attend and the facility is unable to provide a staff member to accompany the resident, the appointment may have to be rescheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: Resident #1 was admitted with diagnoses that included stroke with resultant left sided hemiplegia (inability to move the left side of the body), anxiety and depression. An admission MDS assessment dated [DATE] identified that Resident #1 was alert and oriented, and was independent for transfers and mobility with a wheelchair. The RCP dated 6/11/2024 identified Resident #1 was in the facility for short term rehabilitation and needed orientation to facility and new surroundings. The RCP directed to check in to see if there was anything to assist adjustment to new environment and to be aware of mood and behaviors. A facility incident report dated 8/19/2024 accident and investigation report dated 8/19/2024 at 11:00 AM identified an allegation of staff-to-resident abuse without injury; NA #1 was involved in an interaction with Resident #1 in which inappropriate language was used. NA #1 was suspended pending investigation. Psych and social services saw Resident #1 immediately after the incident for emotional support. A facility summary dated 8/24/2024 identified Resident #1 stated that he/she and NA #1 were involved in an interaction where inappropriate language was used by the NA, and that NA #1 hit him/her on the right shoulder. The investigation confirmed yelling and cursing, but failed to confirm any foul language was directed towards Resident #1 by NA #1. The summary indicated a review of video footage failed to show any direct verbal or physical abuse to the resident and the allegation of abuse was unsubstantiated. Interview and facility documentation review with RN #1 identified she was the day shift supervisor 8/19/2024, and she was asked to speak with NA #1 because NA #1 was late to work and after NA #1 had punched in, she went on a break in the room behind the nursing station. RN #1 entered the back room and told NA #1 that she needed to start her assignment and that NA #1 should not take a break after punching in about an hour and half late. NA #1 immediately got upset and responded to her by yelling you can't tell me what to f--- to do. RN #1 replied to NA #1 that she was the supervisor, and it was within her role to tell NA #1 that she needed to start her assignment. RN #1 stated that NA #1 then stood up and got close to RN #1's face and was saying in a loud voice that she didn't care about this f---ing job and that RN #1 could not tell her what the f---- to do and RN #1 should not be talking to NA #1 that way. RN #1 walked to her office (located on the same unit) and NA#1 followed her while speaking to her in a loud voice. RN #1 told NA #1 that her behavior was unprofessional and unacceptable, and to punch out and go home. At this time, RN #1 identified Resident #1 had wheeled him/herself outside of her office and began to tell NA #1 to calm down. NA #1 appeared to be headed to the punch clock and leaned close to Resident #1's face and told Resident #1 to get the f---- out of her way, leave her the f--- alone and to mind his/her own f---ing business. Resident #1 responded that NA #1 was scaring the other residents. RN #1 again directed NA #1 again to clock out and go home, and NA #1 left the unit. RN #1 then reported the incident and observed NA #1 leave the facility. Interview with NA #2 on 9/4/2024 at 11:30PM identified that on 8/19/2024 she observed Resident #1 in the hallway in his/her wheelchair. Resident #1 was wheeling him/herself down the hall towards NA #1 who was standing in the hallway near the supervisor's office. NA #2 stated she heard NA #1 say to Resident #1 back the f---k away from me. She indicated she then observed NA #1 lean slightly forward so NA #1 was closer to Resident #1's face and she heard NA #1 repeat the same comment again directly to Resident #1 and heard NA #1 say Don't you f---ng touch me and NA #1 pushed Resident #1's hand away from her. Interview with NA #4 on 9/4/2024 at 11:45 AM identified on 8/19/2024 she heard yelling when she was in a resident room and when she stepped into the hallway, she observed NA #1 follow RN #1 to her office, cursing at her and yelling at RN #1. NA #4 then observed Resident #1 had stopped his/her wheelchair and put the brakes on to stand and talk to NA #1. LPN #1 was behind Resident #1 and was telling him/her to sit down and NA #4 observed NA#1 say in a loud voice to Resident #1 not to f---ing touch her. Interview with NA #3 on 9/4/2024 at 11:52 AM identified she witnessed RN #1 talk to NA #1 in the room behind the nursing station when she heard loud voices and observed RN #1 walk toward her office. NA #1 followed RN #1 to her office saying loudly that she didn't care if she came in at noon, the supervisor could not tell her what to f---ing do. She observed Resident #1 in the hallway near NA #1 tell NA #1 to calm down and heard NA #1 began to curse and speak in a loud voice at Resident #1 using the f word. Interview with the DON on 9/4/2024 at 1:30 PM identified that if a staff member swears at a resident, it could be abuse depending upon the context of the conversation the foul language was used in. The DON stated although staff are educated not to use foul language within hearing distance of the residents, use of foul language would be considered disrespectful and not abuse as long as the resident was not upset Interview failed to identify why the interaction witnessed by several staff was not substantiated. Interview with the Administrator on 9/4/2024 at 1:35 PM identified the facility investigation conclude the foul language used in front of residents was not directed at Resident #1, and therefore was not abuse. The Administrator further identified the video reviewed during the investigation did not have any recorded audio. The Administrator stated NA #1's employment was terminated due to attendance issues and did not return to work at the facility after the incident. Interview failed to identify why the interaction witnessed by several staff was not substantiated. The facility Abuse/Residents Policy directed in part, purpose was to ensure each resident is treated with kindness, compassion and in a dignified manner. Abuse or mistreatment of any kind towards a resident is strictly prohibited. Verbal abuse is defined as the use of oral, written or gestured language that will fully included disparaging and derogatory terms to residents or families or within their hearing distance, regardless of their age, ability to comprehend, or disability. The facility Resident's [NAME] of Rights Policy dated 11/18 identified that residents have the righty to be treated with consideration, respect and full recognition of their dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for three (3) of four (4) residents (Resident #1, Resident #3, and Resident #4) reviewed for elopement risk, the facility failed to complete the elopement risk assessment in a timely manner in accordance with facility policy. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, adjustment disorder and delusional disorders. An elopement risk evaluation dated 8/24/23 identified Resident #1 was at risk for elopement (8 months since the last assessment was completed). A physician's order dated 1/20/24 directed wander guard to left ankle and under seat of rolling walker, check placement every shift and check function every night shift. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition and was independent with ambulation with a device. The care plan dated 2/27/24 identified Resident #1 was at risk for elopement from the building due to an attempt to go out the front door in August 2023 with interventions that included to discuss with Resident #1's family the risk of wandering and elopement and ensure they are aware of all steps to maintain safety, offer to escort Resident #1 to another area of the building if seen heading towards or lingering near an exit door, offer to engage Resident #1 in an activity he/she enjoys and wander guard per physician's orders. 2. Resident #3 was admitted to the facility with diagnoses that included dementia, generalized anxiety disorder and insomnia. A physician's order dated 1/29/24 directed wander guard to left underside of wheelchair, check placement every shift and check function every night shift. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition and required assistance with activities of daily living. The care plan dated 5/7/24 identified that Resident #3 was at risk for elopement from the building with interventions that included to apply wander guard, discuss with Resident #3's family the risks of wandering and elopement and ensure that they are aware of the steps taken to maintain safety, if you see Resident #3 heading towards or lingering near an exit door offer to escort to another area of the building and offer to engage Resident #3 in an activity he/she would enjoy. An elopement risk evaluation dated 5/20/24 identified Resident #3 was at risk for elopement from the building. Resident #3's medical record failed to identify an elopement risk assessment(s) was completed between 8/30/23 - 5/20/24 (8 months). 3. Resident #4 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease, and generalized anxiety disorder. A physician's order dated 1/29/24 directed wander guard to left ankle, check placement every shift and check function every night shift. Expiration dated 6/2026. The annual MDS dated [DATE] identified Resident #4 had severely impaired cognition. The care plan dated 3/22/24 identified Resident #4 wandered and could be confused and forgetful. Resident #4 was at risk for elopement from the building with interventions that included to apply wander guard, discuss with Resident #3's family the risks of wandering and elopement and ensure that they are aware of the steps taken to maintain safety, if you see Resident #4 heading towards or lingering near an exit door offer to escort to another area of the building and offer to engage Resident #3 in an activity, he/she would enjoy. An elopement risk evaluation dated 5/20/24 identified Resident #4 was at risk for elopement. Resident #3's medical record failed to identify an elopement risk assessment(s) was completed between 9/12/23 - 5/20/24 (8 months). Interview with the Administrator on 5/31/24 at 2:00 PM identified she was under the impression that elopement risk assessments were completely annually. She could not speak to why the policy directed elopement risk assessments to be completed quarterly. Review of the elopement risk policy directed the purpose of the policy is to identify all residents at risk of elopement and to institute interventions for those residents identified to be at risk. The policy further directed all residents are evaluated for risk of elopement of admission, readmission, quarterly, and with a change in condition, utilizing the elopement risk evaluation.

Based on review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure the facility exit doors equipped with a wander guard system were checked daily. The findings include: Review of the accident and incident form (A&I) dated 5/19/24 identified on 5/19/24 at 6:15 PM Resident #1 was found outside walking towards the police station. Resident #1 was wearing his/her wander guard on his/her right ankle. The wander guard was tested, and the front door alarmed but did not lock. Review of the audit forms for facility doors for the month of May 2024 identified on the weekends; 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/18/24 and 5/19/24 (day of event) there were no door checks completed and documented. Interview with RN #1 on 5/22/24 at 12:43 PM identified when Resident #1 was brought back into the facility she tested the front doors with three (3) wander guards and the door alarmed but did not lock. RN #1 identified she did not call maintenance because she was informed the team would take care of it in the morning. Interview with Maintenance on 5/22/24 at 10:40 AM identified he was not notified of any issues with the front lobby doors until Monday, 5/20/24. He identified he would have expected to be called on 5/19/24 if there was an issue identified with the facility doors and he would have come in and checked the doors. He identified he tested the lobby doors on 5/20/24 at 9:20 AM and identified the front door lock was engaging and the alarm sounded when approached with a wander guard. He stated there could have been a piece of debris between the door and frame causing the lock not to engage. He further identified the doors are to be checked daily for function, however, no one was checking the doors on the weekends. Interview with the Administrator on 5/22/24 at 12:00 PM identified that there has been a lapse in personnel checking the doors for function on the weekends, subsequent to the event, the nursing supervisor will be checking the doors on the weekends. Review of the door checks policy directed that facility doors are checked for proper functioning on a routine basis, ensuring the safety of residents and staff. The policy directed the maintenance supervisor or designee is responsible for checking and documenting the proper functioning of the exterior doors, stairwell doors, and doors equipped with wander guard devices on a routine basis and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 26 residents (Resident #43 and Resident #315) reviewed for advance directives, the facility failed to accurately document the resident's life support choices and/or failed to ensure advanced directives were reviewed with a newly admitted resident. The findings include: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses which included enterocolitis due to clostridium difficile, hemiplegia and hemiparesis following cerebrovascular disease, and heart failure. The signed advance directive consent form dated [DATE] identified the conservator of Resident #43's choice regarding life support systems elected for Resident #43 to receive cardiopulmonary resuscitation (CPR). The admission MDS assessment dated [DATE] identified Resident #43 had severely impaired cognition. The hospital Discharge summary dated [DATE] identified Resident #43 was admitted to the hospital on [DATE]; on [DATE] a meeting was held with representatives from the hospital's medical and palliative care services and Resident #43's conservator, via telephone. Resident #43's conservator had come to a consensus with the family to change Resident #43's code status to do not resuscitate (DNR). Resident #43 was amenable to this plan (communication and understanding were somewhat limited by the patient's history of cerebrovascular accident (CVA) but he/she was able to nod emphatically when the details of the care plan were discussed). Resident #43's conservator indicated that he/she would review the applicable documentation and get back to the representative with a time to return and complete it in person. Resident #43 was readmitted to the facility on [DATE]. A physician's order dated [DATE] directed Resident #43's code status was a DNR. The signed advance directive consent form dated [DATE] identified the conservator of Resident #43's choice regarding life support systems elected Resident #43's code status be changed to DNR/DNI. Interview and clinical record review with SW #1 on [DATE] at 4:37 PM identified that during Resident #43's January admission to the hospital a meeting with the palliative care team took place with his/her conservator. SW #1 indicated that according to the hospital's documentation Resident #43's family had become more interested in changing Resident #43's code status to DNR/DNI and that the hospital staff offered to assist the conservator with filling out the appropriate documentation to assure Resident #43 and the family's wishes regarding advance directives were followed. SW #1 further indicated, if she remembered correctly, Resident #43's conservator did not change Resident #43's code status from CPR to DNR prior to his/her readmission to the facility, as the conservator was still discussing the advance directive options with the family. Interview and clinical record review with the DNS on [DATE] at 8:17 AM identified that when Resident #43 returned from the hospital on [DATE] a physician's order was put into the resident's electronic health record for a DNR code status, by the admitting nurse, but the advance directive consent form was not signed by the conservator until [DATE]. The DNS indicated that there should not be a time gap from the advance directive consent form being signed and physician's advance directive orders being entered into the resident's clinical record. The DNS identified that while the hospital discharge instructions indicated that the palliative team recommended that Resident #43's code status be changed to a DNR, the code status in Resident #43's electronic health record should not have been changed until the facility was able to contact Resident #43's conservator and confirm that he/she consented to the DNR/DNI. The DNS indicated that a telephone consent could have been obtained from Resident #43's conservator with 2 nurses as a witness if they were not able to obtain a timely in-person consent. Although attempted, an interview with the admitting nurse (RN #5) was not obtained. The Advance Directives policy directs the health care provider and/or resident's attending physician will review advance directives with the capable resident or the appropriate substitute decision maker(s). The plan of care related to advance directives and withholding/withdrawing life sustaining treatment will be documented on resident's advance directive consent form and physician's orders. The form will be signed and dated by the person who reviewed the advance directive with the resident or decision maker(s), and the person who consented to the advance directives. A physician's order will be obtained related to the resident's advance directives and refusal of treatment. It the resident or substitute decision maker(s) does not execute an advance directive; the resident will be a full code until a decision is made by the resident or substitute decision maker. 2. Resident # 315 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, history of falls, and hypertension. Review of the clinical record identified an admission checklist dated [DATE] for Resident #315. The checklist identified that the facility had not reviewed code status and consent with Resident #315 with and that follow up items were needed including that advance directives and consents required signatures. The checklist also identified that code status review and consent were a must complete admission item. The care plan dated [DATE] identified Resident #315 needed assistance with ADLs due to weakness following a recent hospitalization. Interventions included advance directives per resident. The admission MDS assessment dated [DATE] identified Resident # 315 had intact cognition, was always incontinent of bladder and required the assistance of two staff members with transfers, toileting, and was independent with eating. Review of the clinical record on [DATE] identified multiple blank admission documents in Resident #315's paper chart, which included release and consent for treatment at the facility, consent and authorization for treatment with facility contracted mental health provider, and informed consent for wound care consultation and treatment. Interview with Resident #315 on [DATE] at 11:55AM identified he/she had not reviewed any information with facility staff related to advance directives and had not signed any documents since admission to the facility. Review of the clinical record and interview with LPN #1 on [DATE] at 12:30 PM identified she was aware that Resident #315 did not have any documentation related to signed advance directives in the clinical record. LPN #1 identified that it was the responsibility of the nurse admitting the resident to the facility to ensure all the admission documentation was completed, including advance directives. When asked what the staff did in the event the advance directive paperwork or any other admission documentation was not completed, LPN #1 reiterated it was the responsibility of the admitting nurse for the resident to complete outstanding admission documentation. Interview with RN # 1 on [DATE] at 12:34 PM identified that all admission paperwork should be completed when the resident is admitted by the admitting nurse, but that it was the responsibility of the nursing staff to ensure it was completed. Subsequent to surveyor inquiry, the facility reviewed and obtained signatures on all admission documents, including advance directives and all consents for treatment, from Resident #315 on [DATE]. Review of the clinical record and interview with the DNS on [DATE] at 1:54 PM identified that all residents of the facility should have an admission packet and checklist reviewed and completed by the admitting nurse. The DNS identified that the admitting nurse was usually the RN supervisor, and if the RN supervisor was not able to complete the admission paperwork, it would be delegated to any nurse available to complete the paperwork or handed off the to the oncoming RN supervisor. The DNS identified that while it was the responsibility of the admitting nurse to complete the admission documentation, including review and consents related to advance directives, any nurse caring for Resident #315 could and should have reviewed advance directives to ensure his/her choices. The facility policy on advance directives directed that the resident would be provided the policy and education on advance directives upon admission to the facility including the resident's rights regarding refusal of treatment. The policy further directed that the advance directives form would be signed and dated by the resident and the person who reviewed the advance directives with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for pressure ulcers, the facility failed ensure the APRN/physician and resident representative were notified, of a newly identified skin blister, in a timely manner.The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses which included dementia, severe protein-calorie malnutrition, and adult failure to thrive. The annual MDS assessment dated [DATE] identified Resident #66 had severely impaired cognition, was at risk for developing pressure ulcers/injuries, was always incontinent of bowel and bladder, and was dependent on staff for chair/bed-to-chair transfers and rolling left to right. The care plan dated 1/26/24 identified Resident #66 was at risk for alterations in skin integrity related to incontinence of bowel and bladder, severe malnourishment, and failure to thrive. Interventions included to inspect skin for signs and symptoms of breakdown including bruising, rashes and infection when providing care and report any issues, keep skin clean and dry, apply lotions and barrier creams as ordered, and provide wound care and adjust wound care treatments as ordered. The nurse's note dated 2/9/24 at 11:11 PM identified a superficial dime sized area was observed on Resident #66's left hip, the nursing supervisor was notified, and a note was placed in the APRN's book. The nurse's notes dated 2/9/24 through 2/29/24 failed to identify Resident #66's responsible party was notified of the change in skin condition. The nurse's note dated 2/15/24 at 3:40 PM identified Resident #66 was seen by the wound MD; an open blister was noted to the left hip and new orders for bordered hydrogel every 3 days were obtained. The wound specialist progress note dated 2/15/24 identified Resident #66 had a full thickness blister with a status of not healed, wound measurements were 1.0cm x 1.0 cm x 0 cm, a scant amount of sanguineous drainage was noted, and the peri-wound skin texture, moisture and color were normal. Physician's orders directed to apply bordered hydrogel every 3 days and to change as needed for soiling, saturation, or accidental removal. The wound specialist progress note dated 2/29/24 identified the blister to Resident #66's left hip had been resolved. Interview and clinical record review with the DNS on 3/14/24 at 8:50 AM, indicated that non-emergent matters could be communicated to the medical providers through the APRN communication book and concerns would be addressed on rounds the next day. The DNS further indicated that while the identification of the left hip blister was communicated in the APRN communication binder, it may not have been seen by a medical provider until Monday because the blister was identified on a Friday evening. The DNS identified that because the blister was identified on a Friday, she would have expected a phone call to the on-call provider notifying him/her of the new skin alteration; he/she may want to provide new orders. The DNS further identified that she would expect to see documentation that the resident's representative was notified, as well. Interview with APRN #1 on 3/14/24 at 9:06 AM identified that the APRN communication book can be used for non-emergencies, however she would have expected the facility to notify the on-call physician, in this case. The Change in Resident Condition/Family/MD Notification policy directs when there is a significant change in the condition of a resident's physical, mental, or emotional status the resident's attending physician and responsible party shall be notified, and an RN assessment will be conducted. The Pressure Ulcer Prevention policy directs the notification of the attending physician and family/guardian if a new skin alteration is noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one resident (Resident #20) reviewed for misappropriation of resident property, the facility failed to ensure the resident was free from misappropriation of an ordered (Scheduled II Controlled Drug) medication. The findings include: Resident #20 was admitted to the facility in December 2022 with diagnoses which included Alzheimer's disease, vascular dementia with behavioral disturbance, and vascular dementia with agitation. Review of the Controlled Substance Disposition Record (CSDR) dated 5/19/23 for Morphine Sulfate 100 mg/5 ml Solution take 0.25 ml (5 mg total) by mouth every 3 hours as needed for moderate pain or severe pain and shortness of breath. Maximum daily amount of 40 mg. Review of the Controlled Substance Disposition Record (CSDR) dated 5/19/23 for Morphine Sulfate 100 mg/5 ml Solution for Resident #20. Identified on 12/3/23 at 9:15 AM 0.25 ml was borrowed for another resident with 2 licensed staff signatures on the CSDR. On 12/3/23 at 9:30 AM 0.50 ml was borrowed for another resident with 2 licensed staff signatures on the CSDR. On 12/3/23 at 10:00 AM 0.5 ml was borrowed for another resident with 2 licensed staff signatures on the CSDR. The quarterly MDS assessment dated [DATE] identified Resident #20 was severely cognitively impaired and required total dependence with personal hygiene. Resident #20 was identified receiving scheduled pain medication regimen. Physician's order dated 12/1/23 directed to administer Morphine Sulfate Oral Solution 20 mg/ml (Schedule II Controlled Drug) give 0.25 ml sublingually every 3 hours as needed for pain or shortness of breath. The care plan dated 3/8/24 identified Resident #20 may take opioid medications to help manage moderate to severe pain and was receiving Hospice services. Interventions included to administer medications as ordered by the physician. Determine level of pain using scale (verbal or nonverbal) before administering as needed medications. Interview with the Administrator on 3/11/24 at 3:28 PM identified she was not aware of controlled substances medication was borrowed from Resident #20 for other another resident. The Administrator indicated the licensed nurses are aware that they are not supposed to borrow controlled substance medications. The Administrator indicated the licensed nurses are to notify the supervisor when controlled substance medications are unavailable and to notify the pharmacy. Interview with RN #1 on 3/12/24 at 10:32 AM identified she has been employed by the facility since October 2023. RN #1 indicated she was not aware that she cannot borrow narcotics or controlled substance medications from Resident #20 to administer to another resident. RN #1 indicated this is her first long term care position in the nursing home. RN #1 indicated in the beginning of 2024 was when she found out that she was not supposed to borrow controlled substance medication from Resident #20 to give to another resident. RN #1 indicated she does not remember which residents the controlled substance was borrowed for. Interview with the DNS on 3/12/24 at 10:46 AM identified she was not aware of the issue until yesterday (3/11/24). The DNS indicated there is no borrowing of narcotics and controlled substances. The DNS indicated RN #1 should have checked the Omnicell and/or called the pharmacy. The DNS indicated RN #1 should have called the physician/APRN for another controlled substance for the resident that the controlled substance was borrowed for. Interview with MD #1 (Medical Director) on 3/13/24 at 11:10 AM identified he was not aware of the issue. MD #1 indicated the license nurses should not have borrowed controlled substance medications from one resident for another resident. MD #1 indicated the license nurse should have called the physician/APRN for another controlled substance medication. Review of the facility abuse/resident policy identified to ensure each resident is treated with kindness, compassion and in a dignified manner. To ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws. Abuse or mistreatment of any kind toward a resident is strictly prohibited. Allegations of abuse by any individual (staff, family, visitor, resident) toward a resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated and acted upon according to the steps of this policy. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent. Review of the Verification: Access to and administration of controlled substances form identified to document nursing confirmation that she/he will adhere to all required processes in place to assure that controlled substances are handled safely. It is mandatory for all Registered Nurse's (RN'S) and Licensed Practical Nurses (LPN'S) to sign who have access to and administer any controlled substances while employed at facility. I will not borrow any controlled substance from one resident and administer it to another resident. If ordered controlled substance for a resident has not been received from the pharmacy I will attempt to obtain it from the Omnicell. If it is not available in the Omnicell I will notify the provider for further orders. I will never sign out a controlled substance and give it to another nurse to administer to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #31) reviewed for abuse, the facility failed to ensure the local law enforcement was notified of a staff to resident abuse per facility policy. The finding include: Resident #31 was admitted to the facility with diagnoses which included dementia, tramatic brain injury, and dysphasia. A physician's order dated 12/16/22 directed when out of bed Resident #31 was to sit in an adaptive tilt in space wheelchair with specialty cushion with bilateral elevating leg rests and a head support via standing mechanical lift with assist of 2. Reposition every 2 hours and sit upright for meals. The annual MDS assessment dated [DATE] identified Resident #31had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with toileting and eating and required total assistance with personal hygiene, dressing, bed mobility and transfers. Additionally, Resident #31 had no behaviors of physical or verbal directed towards others. The care plan dated 1/31/23 identified an alleged staff to resident altercation. Interventions included to report incident to family and physician, watch for any signs of distress, and investigate per facility policy. The reportable event dated 1/31/23 at 12:45 PM alleged LPN #8 forced crushed medications into Resident #31's mouth while holding resident left wrist down which resulted in the resident sustaining a cut on the lip . Additionally, LPN #8 allegedly spoke to the resident in Spanish using profanity. The APRN was notified on 1/31/23 at 1:00 PM however the police were not notified. The timeclock punch detail for LPN #8 identified that he clocked in on 1/31/23 at 7:17 AM until 3:15 PM (2.5 hours after incident). A written statement by RN #4 on 1/31/23 identified an incident occurred at 12:45 PM where she was notified by the DNS that the charge nurse (LPN #8) was holding residents' arm down and forcefully spooning medication into resident's mouth and he/she was bleeding. This writer assessed resident for injuries in the mouth area and gums. No injury or bleeding observed. Resident #31 was sitting in wheelchair and sleeping. A written statement by the prior DNS #2 on 1/31/23 at 1:15 PM indicated NA #1 and NA #3 went to her office and reported they witnessed LPN #8 hold down Resident #31's arm and shove medication on a spoon into the resident's mouth. Additionally, they reported the residents' lip was bleeding. NA #1 and #3 reported that LPN #8 whispered to Resident #31 in Spanish using profanity. The nurse's note written by RN #4 on 1/31/23 at 3:00 PM indicated this writer was informed by staff members an incident occurred at 12:45 PM they allegedly witnessed charge nurse treating a resident poorly. This writer updated DNS, and investigation was initiated. RN#4 performed a head-to-toe assessment on resident, no injuries observed. Call made to update APRN with no new orders at this time. Attempted to update resident representative left a message. Reportable event to FLIS written by prior DNS #2 on 1/31/23 at 3:42 PM indicated she was reporting alleged staff to resident abuse and she was first aware of incident on 1/31/23 at 1:00 PM. DNS #2 indicated that it was reported that an LPN held a combative resident's left wrist and aggressively administered medications and whispered to Resident #31 in Spanish using profanity. Reported that resident could have sustained a cut on his/her lip from the encounter. Incident occurred in the common area. Resident #31 does not recall the incident. APRN aware and LPN sent home until further investigation. Resident #31 was a hoyer (mechanical lift) with the assistance of 2 and required total assistance with activities of daily living. NA #3 was a witness. Law Enforcement agency was not notified. Interview with LPN #7 on 3/13/24 at 9:30 AM indicated that she remembers that she was sitting at the nurses station and heard Resident #31 talking loud which is Resident #31's baseline and when she stood up and she witnessed LPN #8 talking mean to Resident #31 and being very aggressive trying to place spoon with medications in Resident #31's mouth. LPN #7 indicated she went over to Resident #31 right away, but LPN #8 was done and had started walking away. LPN #7 indicated that LPN #8 held Resident #31's left arm down forcefully with LPN #8's right hand. LPN #7 indicated that LPN #8 was forcing the medications with his left hand on a spoon. LPN #7 indicated that Resident #31 never cries but on this day Resident #31 was crying during and after the incident. LPN #7 indicated she saw a crack/broken skin on Resident #31's bottom lip, but it was not bleeding. LPN #7 indicated she then reported it to RN #4. LPN #8 was very aggressive. LPN #7 indicated that Resident #31 always talks loud but never cries and on this day was crying. LPN #7 indicated that RN #4 did not take the alllegation seriously and LPN #8 worked until the end of the shift. Interview with NA#2 on 3/13/24 at 10:37 AM identified she was standing by nurses' station in the community room, and she could see Resident #31 sitting in his/her wheelchair at table in community room. NA #2 indicated she saw LPN #8 forcefully slam Resident #31's left arm down onto the armrest of the wheelchair and shovel the medicine in Resident #31's mouth while Resident #31 was resisting the medication by turning his/her head side to side. NA #2 indicated that Resident #31 was saying no, no, no and shaking his/her head side to side. NA #2 indicated at no time did Resident #31 raise his/her arms. LPN #8 was very aggressive with Resident #31 by shoving the spoon with medicine in his/her mouth. NA #2 indicated NA #3 was present and spoke Spanish and understood what LPN #8 had said to Resident #31. NA #2 indicated whatever LPN #8 said to Resident #31 at the end really agitated Resident #31. NA #2 indicated that NA #1 was present. NA #2 indicated she saw blood on Resident #31's had blood in his/her mouth from the cut on his/her lower lip from the spoon. NA #2 indicated she became upset when she saw the blood in the residents mouth.NA #2 indicated that Resident #31's hands were shaking on the wheelchair arm rest at the table after incident and Resident #31 was crying like a child in trouble and was asking for his/her mother. NA #2 stated she never had seen Resident cry like that before. NA #2 indicated she reported it immediately to RN #4, but RN #4 really wasn't listening and brushing NA #2 off. NA #2 indicated that when the staff reported it to RN #4, she wasn't taking the staff seriously. NA #2 indicated so she later went to the prior Administrator #2 and reported the incident because nothing was getting done. NA #2 indicated that Administrator #2 had her write a statement and she informed the Administrator #2 that there were other people standing there that witnessed the incident. NA #2 indicated that LPN #8 did not get sent home after the incident it wasn't until after she had reported it to Administrator #2 that a short time after that LPN #8 was sent home but it was at the end of the shift. Although attempted, an interview with prior Administrator #2, prior DNS #2, RN #4, LPN #8 were not obtained. Review of the clinical record, interviews and time clock punch detail identified LPN #8 continued to work and placed residents at risk for 2.5 hours after the alleged allegation of abuse. Although attempted, an interview with prior Administrator #2, prior DNS #2, RN #4, LPN #8 were not obtained. Review of the facility Abuse Policy identified to ensure each resident is treated with kindness, compassion, and in a dignified manner. Additionally, to ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws. Abuse or mistreatment of any kind towards a resident is strictly prohibited. Allegations of abuse, by any individual towards a resident must be reported immediately to a facility supervisor. The DNS or designee shall notify the resident representative, physician, DPH, and local police.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #10, #16 and #31) reviewed for care planning, the facility failed to have a comprehensive social worker assessment admission, quarterly, and annual completed timely. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, anxiety, major depression, and paranoid schizophrenia. Review of the clinical record dated 3/17/22 - 3/14/24 identified 1 social services assessment completed on 1/29/24. The admission assessment dated [DATE] at 1:48 PM identified Resident #10 was transferred from another facility on 3/17/22 at 2:30 PM for long term care. admission assessment did not reflect a social services assessment was completed. The care plan dated 4/3/22 identified Resident #10 was admitted for long term care. Interventions included to provide social services to provide opportunities to express concerns as needed. Review of the Social Services Assessments were not completed for the admission dated 3/17/22, Quarterly dated 6/2/22, 9/2/22, 11/15/22, 1/20/23, 6/3/23, Annual dated 3/3/23 and Significant Change in Condition assessment dated [DATE]. Interview and clinical record review with SW #1 on 3/14/24 at 9:30 AM identified the Social Worker was responsible to do an admission assessment within one week of admission, a quarterly every 3 months, an annual, and if there is a change in condition MDS. SW #1 indicated there were 2 full time social workers and they just communicate with each other what must get done it is not divided by units or any other system. SW #1 indicated that SW #2 had been there longer and there were families that preferred her. SW #1 indicated additionally the social worker was responsible to complete the MDS sections C, D, E, and Q and just review section B. SW #1 indicated that herself and SW #2 were behind in the assessments, and they open them when a resident has a care plan meeting scheduled but do not have time to complete them until later. SW #1 indicated the quarterly and annual social worker assessments were not completed from 3/17/22 admission until 4/3/23 because there was only 1 social worker at that time out on maternity leave for an extended period. SW #1 indicated that for Resident #10 she had opened the social worker progress note on 9/12/22 and on 4/3/23 but did not complete it until 7/11/23 and that it was not an assessment just a progress note. SW #1 indicated she maybe had paper notes and just had imputed into the computer late. SW#1 indicated that she just did not have time to input notes into her computer due to the workload, that's why the notes were late. SW #1 indicated there were no social worker assessments on admission, quarterly, or annual completed from 3/17/22 - 4/3/23, a quarterly on 6/5/23 or a significant change on 10/30/23. 2. Resident #16 was admitted to the facility on [DATE] with diagnoses which included Alzheimer s disease and dementia. The care plan dated 10/3/22 identified Resident #16 was admitted for long term care. Intervention included to continue to keep family involved and updated regarding health and well being. The Social Services admission assessment dated [DATE] was completed. Review of the clinical record from 10/5/22- 3/14/24 did not reflect quarterly or annual assessments by the social worker in December 2022, March 2023, June 2023, September 2023, December 2023, and March 2024. The clinical record identified progress notes for 3/8/23 and 7/25/23, but no assessments. The significant change of condition MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and required extensive assistance with bed mobility, toileting, and personal hygiene. Additionally, needed limited assistance with transfers, dressing, and locomotion on and off the unit. The Social Services Quarterly assessment dated [DATE] identified as of 3/14/24 was blank. Interview and clinical record review with SW #2 on 3/12/24 at 11:33 AM indicated she or SW #1 must do the admission, quarterly, annual and change of condition assessments and progress notes for the residents. After clinical record review for Resident #16, SW #2 indicated she had not done the assessments July and October 2023 and January 2024. SW #2 indicated that either SW 32 or herself should have don them but did not have time to get them done. SW #2 indicated that she was on maternity leave was November of 2021 through May of 2022 and SW #1 was out from September of 2023 through January/February of 2024. SW #2 indicated that there was only 1 person here so 1 person cannot do this facility. SW #2 indicated she was responsible to do the quarterly assessments and did not do the social worker assessments in July 2023, October 2023, or January/February 2024. SW #2 indicated the other social worker was out and she informed the Administrator she needed assistance and was given a trainee. SW #2 indicated the facility started a new assessment for the social workers to do for the quarterly assessments in the electronic medical records which started in October 2023, but she had not utilized it. Interview and clinical record review with SW #1 on 3/14/24 at 9:45 AM identified that Resident #16 the admission assessment was completed on 10/5/22. SW #1 indicated the admission assessment was the only assessment completed for Resident #16. SW #1 indicated that on 1/31/23 she opened to write a progress note but did not complete it and lock it until 3/8/23. SW #1 indicated she had opened another progress note on 4/13/23 and did not complete it until 7/25/23. SW #1 indicated the quarterly assessments not done were 1/31/23 (a progress note), 4/13/23 (a progress note), 11/10/23, 2/10/24 were not completed. SW #1 indicated the progress notes are not equivalent to what she should be doing for an assessment. 3. Resident #31 was admitted to the facility on [DATE] with diagnoses that included stroke and dementia. The admission assessment dated [DATE] did reflect a social services assessment was completed. The care plan dated 2/17/21 identified Resident #31 was admitted for long term placement. Interventions included to have 1:1 social service visits to see how resident is doing and to see if there is anything that the resident may need to help the resident with adjusting to this new environment. Review of the clinical record for Resident #31 from 1/27/21-3/14/24 only reflected 1 social worker assessment completed on 1/27/21. The clinical record did not reflect any additional quarterly or annual assessments completed by a social worker. Interview and clinical record review with SW #1 on 3/14/24 at 9:55 AM identified that Resident #31 admission assessment was completed on 2/3/21. SW #1 indicated that the 2/15/21 quarterly progress note was completed late on 3/12/21. SW #1 indicated that the social worker assessments were not completed for an annual in January 2022, January 2023, and January 2024. SW #1 indicated the quarterly assessments not completed were April 2022, July 2022, October 2022, July 2023, and October 2023. SW #1 indicated they were not completed because she had been out on leave for an extended period and prior to her the other social worker had been out for an extended amount of time. SW #1 indicated it is hard to keep up with 2 social workers with all the admissions and discharges every week and impossible with only 1 at the facility. SW #1 indicated it is also confusing when MDS has a quarterly last month for a resident and then again, this month has another quarterly. SW #1 indicated that the MDS office is putting in more quarterly's than needed and more frequently, so we are not getting them all done. Additionally, SW #1 indicated MDS is putting in more MDS's than needed and now she is required to do 2 MDS's every quarter for every resident for reimbursement reasons. Interview with the Administrator on 3/14/24 at 10:49 AM indicated that she was aware that the social worker assessments were not being done timely and that she was looking to hire a new social worker to assist getting the assessments completed. Social Worker Job Description identified the social worker was responsible to be knowledgeable of admissions and discharges procedures and be familiar with resident rights and documentation requirements in accordance with OBRA regulations and guidelines. The social worker must meet requirements as stated in the public health code. The social worker was responsible for documenting initial and biopsychosocial assessments of residents, interim notes regarding changes, and MDS sections and quarterly, annual, significant changes, and documents the discharge plan. Although requested, a facility policy for social worker assessments and documentation policy it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and interviews for 1 of 5 residents (Resident #5) reviewed for PASARR, the facility failed to ensure the PASARR was updated when there was a change in condition. The findings include: Resident #5 PASARR dated 3/23/17 identified a diagnosis of schizoaffective disorder and major depression. PASARR indicated Resident #5 does not have a diagnosis of dementia or Alzheimer's disease. Resident #5 was admitted to the facility on [DATE] with diagnoses which included dementia, major depression, and schizoaffective disorder. The hospital Discharge summary dated [DATE] identified Resident #5 had a diagnosis of schizoaffective disorder, diabetes, and dementia. A physician's order dated 6/24/21 directed Divalproex (used for schizoaffective disorder) 750 mg extended release in the morning and Divalproex 1000 mg delayed release at bedtime, Perphenazine (used for schizoaffective disorder) 4 mg tablet twice a day, Duloxetine (depression) 90 mg daily. The physician admission note dated 6/25/21 identified Resident #5 had a diagnosis of dementia, schizoaffective disorder, diabetes, and hypertension. The admission MDS assessment dated [DATE] identified Resident #5 had moderately impaired cognition and required extensive assistance for bed mobility, dressing, toileting, and personal hygiene. Resident #5 was totally dependent on staff for transfers. Additionally, Resident #5 had a diagnosis of dementia. The care plan dated 10/3/22 identified a positive level of care due to psychiatric diagnosis. Interventions included mental health counseling, recreation activities, and ongoing evaluation of effectiveness of psychotropic medications. The psychiatric provider dated 10/26/22 indicated Resident #5 was seen for follow up for schizoaffective and dementia with behaviors. Interview with SW #2 on 3/12/24 at 9:01 AM indicated she was responsible to check the PASARR on admission and if a resident needed a Level 2 . SW #2 indicated she was also responsible to update PASARR if a resident received a new psychiatric diagnosis or a new diagnosis of dementia. SW #2 indicated that Resident #5 had PASARR completed on 3/23/17 at another facility with a diagnosis of schizoaffective disorder and major depression. SW #2 indicated Resident #5 was referred for a level 2 on 3/17/17 and had long term care approval. Interview with SW #2 on 3/12/24 at 9:30 AM indicated Resident #5 did not have a diagnosis of dementia on the admission PASARR dated 3/17/21 and when there was a change in condition with a new diagnosis of dementia, she should have updated Ascend with a new PASARR level 2. After clinical record review, SW #1 indicated that when Resident #5 was admitted to the facility she should have submitted a new PASARR with the new diagnosis of dementia so Resident #5 would have received an exclusion from PASARR, but she missed it. SW #2 indicated that she was responsible for reviewing the hospital paperwork, but she had missed the diagnosis of dementia on it. SW #2 indicated Resident #5 was seen by the psychiatric provider on 10/26/22 who gave Resident #5 the diagnosis of dementia and she could have updated Ascend then of the diagnosis, but she missed it, and the psychiatric provider did not tell her. SW #2 indicated that she had missed the diagnosis of dementia on admission and on 10/26/22 so she will update Ascend today. SW #2 indicated that they did not have a policy regarding Ascends. Interview with the Administrator on 3/12/24 at 10:26 AM indicated the Social Worker was responsible to update Ascend of any changes such as the diagnosis of dementia on admission or when there is a new diagnosis. The Administrator indicated that the diagnosis on admission 6/24/21 did not have dementia listed. The Administrator indicated that when the psychiatric APRN added the diagnosis of dementia it was not communicated to the Social Worker. Although requested, a facility policy for PASARR was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #10 and #48) reviewed for accidents, the facility failed to ensure the neurological assessments were completed after multiple falls and for 1 resident (Resident #16) reviewed for hospice, the facility failed to ensure there was a physician order for hospice services and 1 of 2 residents (Resident #66) reviewed for pressure ulcers, the facility failed ensure an RN assessment was completed for a newly identified skin blister and for 1 of 7 residents (Resident #104) reviewed for nutrition, the facility failed to follow the physician's orders to obtain repeated labs for a resident with an abnormal blood count and for 2 of 7 ( Resident #2 and Resident#315) reviewed for nutrition, the facility failed to obtain weights according to facility policy. The findings include: 1. Resident #10 was admitted to the facility with diagnoses which included paranoid schizophrenia, schizoaffective disorder, and atrial fibrillation. The significant change in condition MDS dated [DATE] identified Resident #10 had moderately impaired cognition and required extensive assistance with dressing and personal hygiene and requires total assistance with toileting. Additionally, has had 2 falls since admission. A physician's order dated 10/26/23 directed to administer Coumadin 3.5 mg in the evening. The care plan dated 10/30/23 identified fall risk. Interventions included to ensure frequently used items are within resident's reach, encourage resident to call for assistance, and encourage resident to ask and wait for staff assistance for transfers and toileting. The Reportable event form dated 11/7/23 at 12:45 PM identified Resident #10 had an unwitnessed fall while throwing away a cup and slid from the bed to the floor. Resident #10 had socks on but was not wearing grippy socks. The nurse fed resident lunch from 12:15 -12:35 M. Resident #10 had no injury. The neurological assessment form did not reflect that the neurological assessments were conducted. The Reportable event form dated 12/18/23 at 7:15 PM identified Resident #10 had an unwitnessed fall. Resident #10 was observed sitting on the floor in residents' room next to the bed stated he/she was reaching to turn off the light and slipped out of bed. Resident #10 had no injury. The neurological assessment form did not reflect that the neurological assessments were conducted. Reportable event form dated 12/22/23 at 3:20 PM identified Resident #10 had an unwitnessed fall. Resident #10 was last seen in bed and found on the floor. Resident #10 had no injury. The neurological assessment form identified did not reflect that the neurological assessments were completed. Reportable event form dated 1/17/24 at 10:30 AM PM identified Resident #10 had an unwitnessed fall. Resident #10 stated he/she fell on his/her knees trying to reach for a cup on his side table. Bruise to right side of shoulder blade, abrasions noted to both knees, and an open area noted to right buttocks. Interview with DNS on 3/13/24 at 1:15 PM identified any unwitnessed fall the neurological assessment must be done. The DNS indicated that Resident #10 has moderate impairment cognition, and she would expect the neurological assessments to be done and completed per the facility policy. After clinical record review, the DNS indicated that the 11/17/23, 12/18/23, 12/22/23 and 1/17/24 were not done per the facility policy. The DNS indicated that the charge nurses were responsible for completing the neurological assessments and when the assessments were completed, they were to hand the forms in to her. The DNS indicated the neurological assessments are done on paper and not in the electronic medical record. The DNS indicated she would prefer it if the nurses would have to document the neurological assessments in the electronic medical record, so papers don't get lost. The DNS indicated the neurological assessments were very important so the nurses could pick up on any slight changes as soon as possible and notify the supervisor to do an evaluation and then update the provider to send the resident to the hospital. Review of the facility Falls Minimizing Risk of Injury Policy identified a resident that experiences an un-witnessed fall and is unable to accurately verbalize if he/she hit head due to cognition status will have neurological checks instituted. Each time a resident falls an accident and incident report will be completed and neurological monitoring will be documented for 72 hours. Review of the facility Neurological Policy identified a resident that experiences an unwitnessed fall will have neurological checks instituted. The nurse will explain to the resident to report any symptoms such as blurred vision, headache, drowsiness, vomiting, slurred speech, weakness, or paralysis and numbness or tingling. A neurological flow sheet will be instituted by the nurse. The checks will be completed as follows: every 15 minutes for 1 hour, every hour for 4 hours, every 4 hours for 24 hours, and every shift for 48 hours. The neurological flow sheet shall include the following documentation: date, time, level of consciousness, pupillary response, strength and sensation of all extremities, and vital signs. The nurse will observe and listen to speech for appropriate clarity, expressiveness, and receptive components. The nurse will assess orientation to person, place, and time. 2. Resident # 48 was admitted to the facility on [DATE] with diagnoses which included dementia, repeated falls, and psychophysical visual disturbances. Review of a facility Accident and Incident(A&I) report dated 9/2/23 at 3:15 PM identified Resident #48 had an unwitnessed fall, and Resident #48 was unable to provide a clear description of what happened. The Accident and Incident report included documentation that neurological checks were initiated at 3:30 PM. Review of a facility A&I report dated 9/2/23 at 7:30PM identified Resident #48 had 2nd unwitnessed fall and was observed sitting on the floor against the wall of his/her room. The report identified Resident #48 had 2 abrasions to the mid back and hit his/her head. The A&I report identified that Resident #48 was sent to the hospital for evaluation at 8:30 PM. A nursing note dated 9/2/23 at 9:11 PM completed by RN #10 identified that Resident #48 had no change in condition. The note further identified that Resident #48 was admitted to the facility on [DATE] at 2:55 PM and fell at 3:15PM onto his /her buttocks his/her buttocks but did not hit his/her head, was confused at baseline, and was unable to follow simple commands, and was oriented to his/her room prior to the fall. A nursing note dated 9/2/23 at 9:51 PM completed by RN #10 identified that Resident #48 was admitted to the facility on [DATE] at 2:55 PM and fell earlier 3:15PM. The note further identified that Resident #48 fell on his/her buttocks and hit his/her head, was confused at baseline, and was unable to follow simple commands. The note identified Resident #48 was sent to the hospital for evaluation. Review of the clinical record failed to identify any additional documentation related to Resident #48's fall on 9/2/23 at 7:30 PM. The care plan dated 9/4/23 identified Resident # 48 had a history of falls due to multiple risk factors. Interventions included offering toileting and incontinent care during first rounds on the 3PM- 11PM shift. The admission MDS dated [DATE] identified Resident # 48 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of one to two staff members with transfers, toileting, and dressing. The MDS also identified Resident #48 had 2 or more falls with injury since admission to the facility. Review of a facility A&I report dated 9/8/23 at 2:30 PM identified Resident #48 had an unwitnessed fall that resulted in a 1 cm x 2 cm laceration to the left side of the forehead. The report included neurological checks completed at 2:30 PM and again at 2:45 PM. The report identified Resident #48 was sent to the hospital for evaluation at 3:00PM. The 9/8/23 neurological check documentation identified Resident #48 was at the hospital beginning at 3:00 PM. A nursing note dated 9/8/23 at 8:50 PM by RN #10 identified Resident #48 returned to the facility at 8:35 PM following hospital evaluation for a fall. The note further identified Resident #48 was observed to have small hematoma where he/she hit her head. Review of the clinical record for Resident #48 failed to identify any documentation that neurological checks were completed following his/her return to the facility on 9/8/23 at 8:35 PM. Review of a facility A&I report dated 9/8/23 at 10:00 PM identified Resident #48 had an unwitnessed fall and was found on the floor of his/her room bleeding from the head. The report identified that Resident #48 was sent to the hospital for evaluation at 10:10 PM. Review of the clinical record failed to identify any documentation related to vital signs following Resident #48's readmission to the facility on 9/8/23 or subsequent unwitnessed fall at 10:00 PM. Review of the clinical record identified Resident #48 returned to the facility from the hospital on 9/9/23 at 5:30 AM and neurological checks were initiated at 7 AM. Review of a facility A&I report dated 9/11/23 at 3:30 PM identified Resident #48 had an unwitnessed fall and was found lying next to his/her wheelchair. The report identified Resident #48 was unable to describe what happened and complained of right ankle pain and was sent to the hospital for evaluation. Review of the clinical record failed to identify any documentation related to initiation of neurological checks or the time Resident #48 was sent to the hospital for evaluation of the unwitnessed fall on 9/11/23. Review of the clinical record identified Resident #48 was hospitalized from 9/11-9/15/23 for urinary tract infection. Review of a facility A&I report dated 9/22/23 at 6:30 PM identified Resident #48 had an unwitnessed fall and was found lying on the ground next to his/her roommate's bed. The report identified Resident #48 was unable to describe what happened, complained of head pain, and was sent to the hospital for evaluation. Review of the clinical record identified that Resident #48 returned to the facility from the hospital on 9/23/23 at 5:55 AM. Review of the clinical record failed to identify any neurological checks were conducted following Resident #48's unwitnessed fall on 9/22/23 at 6:30 PM until 9/23/23 at 5:00 PM. Review of the neurological check documentation identified Resident #48 out to the hospital from [DATE] at 6:15 PM until 9/23/23 at 5:55 AM. Review of the clinical record and interview on 3/13/23 at 2:15 PM with the DNS identified the facility policy for a resident with an unwitnessed fall included a nursing assessment and initiation of neurological checks for a total of 72 hours. A review of Resident #48's clinical record and A&Is were completed with the DNS, who identified that there had been issues related to RN #10's clinical documentation and she was aware of the issue. The DNS also identified that the documentation in the clinical record related to the nursing assessments and falls on 9/2/23 appeared to be duplicate documentation of the fall that occurred at 3:15 PM. The DNS identifed that 2 comprehensive RN assessment should have been completed following Resident #48's falls 9/2/23 with clear documentation related to the time of each fall. The DNS also identified that updated vital signs should be obtained with a nursing assessment, and that neurological checks should be completed per facility policy, regardless of whether a resident is sent to the hospital for evaluation. The DNS identified that neurological checks should have been completed every 15 minutes for the first hour, then every hour for 4 hours, every 4 hours for 24 hours and every shift until the 72 hours was reached. The DNS identified that the nursing staff may have been confused on when Resident #48 needed to have neurological checks done, since there were multiple falls within the same day at times, but the policy would be to restart neurological checks with each new unwitnessed fall or fall with head injury. Although attempted, an interview with RN #10 was not obtained. The facility policy on falls directed that residents who experience an unwitnessed fall and were unable to accurately verbalize if he/she hit their head due to cognitive status, or if there was any type of head injury, would have neurological checks instituted. The policy also directed that after a resident fall a RN assessment would be completed. The facility policy on neurological checks directed that any resident who experienced an unwitnessed fall and was unable to accurately verbalize if he/she hit their head due to cognitive status or had any type of head injury would have neurological checks instituted. The policy further directed neurological sheets would be instituted by the nurse and checks would be completed as follows: every 15 minutes for the first hour; every hour for 4 hours; every 4 hours for the next 24 hours, and then every shift for 48 hours after that. The policy also directed that neurological checks should include vital signs, and that the resident's blood pressure, pulse, and respirations would be check for any significant changes. The facility policy on nursing documentation directed the purpose of the policy was to capture any changes in condition that required a licensed staff assessment of a resident and should provide an account of any changes in condition, current assessments, and any concerns that could alter the resident's current plan of care. The policy further directed that nursing documentation should be clear, concise, and specific. 3. Resident #16 was admitted to the facility with diagnoses which included Alzheimer's disease and dementia. The quarterly MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition and required extensive assistance with dressing, toileting, and personal hygiene. Additionally, did not have hospice services currently. The social worker progress note dated 7/18/2023 at 1:19 PM indicated she had meet with resident's representative on 7/17/23. Discussed possibility of hospice eligibility for resident per the physician's assistant recommendation. Discussed goals of care, resident representative was agreeable to referral. At resident representatives request referral made to Hospice Agency today on 7/18/23. Hospice evaluation is pending. The social worker progress note dated 7/21/2023 at 12:18 PM indicates that Resident #16 was evaluated by hospice and admitted on their services effective on 7/20/23. Review of the physician orders dated 7/1/23-3/13/24 did not reflect a physician's order for a consult with hospice or a hospice evaluation and treatment order was in place. Interview with the DNS on 03/14/24 11:18 AM indicated there should be an initial physician's order for hospice to evaluate and treat and then another physician's order for when Resident #16 was picked up by hospice services. The DNS indicated that nursing was responsible to put in the orders for hospice. The DNS indicated that Resident #16 was picked up by hospice as of 7/20/23 per the social worker note. The DNS indicated it was managed by social workers and resident is on hospice services. After clinical record review, the DNS indicated that she did not see a physician order from July 2023 until today 3/14/24 and nursing was responsible to put order in. After surveyor inquiry, a physician's order dated 3/14/24 at 11:39 AM as a late entry for 7/20/23 directed for a hospice evaluation completed on 7/20/23 and accepted. Interview with the DNS on 3/14/24 at 11:55 AM indicated she had spoken via phone with the physician assistant and obtained an order for hospice services for Resident #16. Review of the facility Hospice Services Policy identified the social worker will assist the resident and/or resident representative per facility policy regarding hospice resources. The social worker will be the liaison for the resident and/or resident representative, facility, and the hospice service. If the resident/resident representative chooses in house hospice services, the attending physician will be notified and a physician's order will be obtained by nursing for a hospice evaluation. 4. Resident #66 was admitted to the facility on [DATE] with diagnoses which included dementia, severe protein-calorie malnutrition, and adult failure to thrive. The annual MDS assessment dated [DATE] identified Resident #66 had severely impaired cognition, was at risk for developing pressure ulcers/injuries, was always incontinent of bowel and bladder, and was dependent on staff for chair/bed-to-chair transfers and rolling left to right. The care plan dated 1/26/24 identified Resident #66 was at risk for alterations in skin integrity related to incontinence of bowel and bladder, severe malnourishment, and failure to thrive. Interventions included to inspect skin for signs and symptoms of breakdown including bruising, rashes and infection when providing care and report any issues, keep skin clean and dry, apply lotions and barrier creams as ordered, and provide wound care and adjust wound care treatments as ordered. The nurse's note dated 2/9/24 at 11:11 PM identified that a superficial dime sized area was observed on Resident #66's left hip, the nursing supervisor was notified and a note was placed in the APRN's communication book. The nurse's notes dated 2/9/24 through 2/14/24 failed to identify an RN assessment of Resident #66 left hip area was documented in the clinical record. The nurse's note dated 2/15/24 at 3:40 PM identified Resident #66 was seen by the wound MD; an open blister was noted to the left hip and new orders for bordered Hydrogel every 3 days was obtained. The wound specialist progress note dated 2/15/24 identified Resident #66 had a full thickness blister with a status of not healed, wound measurements were 1cm x 1 cm x 0 cm, a scant amount of sanguineous drainage was noted, and the peri-wound skin texture, moisture and color were normal. Physician's orders directed to apply bordered Hydrogel every 3 days and to change as needed for soiling, saturation, or accidental removal. The wound specialist progress note dated 2/29/24 identified the blister to Resident #66's left hip had received an outcome of resolved. Interview and clinical record review with the DNS on 3/14/24 at 8:50 AM, failed to provide documentation that an RN assessment was completed following the identification of a new skin blister. The DNS indicated that she would expect an RN assessment to be completed by the nursing supervisor following the recognition of a new wound and for the RN to initiate a wound tracking sheet. The DNS identified that documentation of the wound assessment should be in the resident's clinical record and should include if the wound was pressure or non-pressure related, size, shape, drainage, and measurements. The DNS further identified that while the wound nurse had assessed the wound on 2/13/24 and started tracking the wound; she would have expected to see an assessment documented in the clinical record from the nursing supervisor when the wound was first recognized. Although attempted, an interview with the 3-11 PM nursing supervisor (RN #5) was not obtained. The Wound Prevention Interventions for Residents policy directs that interventions are directed toward minimizing and/or eliminating any negative effects of the causal/contributing factors such as pressure, moisture, friction/shear, and poor nutrition for all residents admitted to the facility, and when an abnormal skin area is observed, it will immediately be reported to a licensed nurse who will assess and follow through as indicated per protocol. The Pressure Ulcer Prevention policy directs that a comprehensive skin assessment be conducted with every risk assessment and if a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in the skin. The Change in Resident Condition/Family/MD Notification policy directs when there is a significant change in the condition of a resident's physical, mental, or emotional status the resident's attending physician and responsible party shall be notified, and an RN assessment will be conducted. 5. Resident #104 was admitted to the facility on [DATE] with diagnoses which included diabetes type 2, neutropenia, chronic lymphocytic leukemia and was readmitted [DATE]. The annual MDS assessment dated [DATE] identified Resident # 104 had intact cognition, required substantial assistance with showering or bathing, and was independent with eating, oral hygiene, toileting, dressing, and personal hygiene. The annual MDS also identified Resident #104 had neutropenia (a blood disorder impacting immunity). The care plan dated 1/12/24 identified a focus on chronic kidney disease with interventions that included monitoring labs and to report abnormal labs to physician or APRN. A consultation report from oncology on 1/18/24 directed to continue Filgrastim (a bone marrow stimulant) and schedule a complete blood count (CBC) once per week. The consultation was reviewed by APRN #1 on 1/23/24. The nurse's note written by LPN #10 dated 1/18/24 at 5:56 PM identified that Resident #104 should continue with Filgrastim and have a CBC drawn once per week. The labs for a CBC drawn on 1/23/24 identified the WBC (white blood count) was 2.2 therapeutic range is 3.8-10.8, and the absolute neutrophil count was 946 the therapeutic range is 1500-7800. An interview with APRN #1 on 3/12/24 at 1:45PM noted the Filgrastim was ordered by oncology. APRN #1 indicated that she would expect that the facility monitors for infection, bleeding, loose stools, and monitor labs. She further identified, Resident #104 sees the oncologist frequently, and the facility sends labs. APRN #1 also identified a resident on Filgrastim should have lab monitoring minimally on a monthly basis. Interview and clinical record review with the DNS on 3/13/23 at 3:45 PM identified it is her expectation that physicians' orders are followed . Clinical record and lab review with the Medical Director on 03/13/24 at 04:09 PM identified if oncology requested a weekly CBC, the CBC should have been continued weekly until the absolute neutrophil's exceeded 1000. When disclosed the labs on 1/23/24, identified an absolute neutrophil count of 946 (the therapeutic range is 1500-7800), the Medical Director indicated the labs should have been done weekly. Although requested, a facility policy on neutropenic monitoring was not provided. 6. Resident #2 was admitted to the facility on [DATE] with diagnoses which included surgical aftercare following a right shoulder joint replacement, hypothyroidism and hyperlipidemia. A physician's order dated 2/25/24 directed to obtain an admission height and weight for Resident #2. The care plan dated 2/29/24 identified Resident #2 had a potential for nutritional decline due to recent hospitalization. Interventions included monitoring weights as ordered. The admission MDS assessment dated [DATE] identified Resident # 2 had intact cognition, was continent of bowel and bladder and required partial assistance with toileting, dressing, and was independent with eating. A physician order dated 3/4/24 directed that Resident #2 required weekly weights for 4 weeks. A review of the clinical record failed to identify any documentation related to weights for Resident #2. 7. Resident # 315 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, history of falls, and hypertension. The care plan dated 2/26/24 identified Resident #315 had potential for nutritional decline due to a history of morbid obesity and celiac disease. Interventions included obtaining weights as ordered. A physician's order dated 2/29/24 directed that Resident #315 required weekly weights every evening shift on Thursday for 4 weeks. Review of the clinical record identified that Resident #315 had a weight of 220.6 lbs on 2/29/24, 4 days after admission. Further review of the clinical record failed to identify any additional weights documented for Resident #315. The admission MDS assessment dated [DATE] identified Resident # 315 had intact cognition, was always incontinent of bladder and required the assistance of two staff members with transfers, toileting, and was independent with eating. Interview with MD #1 (Medical Director) on 3/13/24 at 11:10 AM identified that it was the policy of the facility to obtain weights on all residents upon admission with the initial nursing assessment. MD #1 identified that from admission, the weights would then depend on the orders for the resident, with some residents only requiring monthly weights. MD #1 further identified that some residents have orders for more frequent monitoring, including weight loss, and that his expectation would be weights would be obtained on admission and per the physician's orders. Interview with the Dietician on 3/13/24 at 1:41 PM identified that the nursing staff was responsible to ensure weights were obtained on admission for all residents of the facility. The Dietician identified that she completed nutritional assessments on newly admitted residents, and that if she did not see an admission weight on the resident at the time of assessment, she would add an order for weekly weights for 4 weeks for the physician or APRN to sign off on to ensure weights would be done. The Dietician identified that she would not follow up on the orders to ensure they were done but would follow up on any documented weights if there were issues, and that she was not aware that no weights had been obtained for Resident #2, and only one weight was obtained for Resident #314. The Dietician identified that the facility did not use weight books and only documented weights within the electronic clinical record. Interview with the DNS on 3/13/24 at 1:54 PM identified that the facility policy was for weights to be obtained upon admission as part of the initial assessment of the residents. The DNS identified that while it would be ideal to obtain the weight when the resident comes into the facility, there are times when it is not done right away due to the time of evening the resident arrives, or if the resident does not feel up to it and needs to rest. The DNS identified that in this case, the weight should be done the following day within 24 hours. The DNS identified she was unsure why the weights were not done per the physician orders, but that they should have been completed within 24 hours of admission and then weekly for Resident #2 and Resident #315. The facility policy on weight monitoring directed that residents would be weighed upon admission and then every week for 4 weeks and then monthly, unless otherwise indicated by the physician's order or recommendation of the dietician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #94) reviewed for nutrition, the facility failed to ensure that weights were monitored per physician's order for a resident with a significant weight loss. The findings include: Resident # 94 was admitted to the facility on [DATE] with diagnoses which included stroke, hypertension, and diabetes. The APRN note dated 3/6/23 identified Resident #94 did not require medication or blood glucose monitoring for diabetes. A physician's order dated 3/9/23 directed for weekly weights and vital signs to be obtained every Friday day shift. The quarterly MDS assessement dated 3/16/23 identified Resident # 94 had moderately impaired cognition, and required supervision with eating. The care plan dated 3/16/23 directed that Resident #94 had a potential for nutritional decline related to medical history. Interventions included obtaining weights as ordered. The nutritional assessment dated [DATE] identified that Resident #94 had a current weight of 149.6 lbs., had weighed 156 lbs. 30 days prior, and was at low nutritional risk. Review of the clinical record identified the following weights documented in Resident #94's clinical record beginning 3/2023: 03/04/2023 14:25 149.6 lbs. 03/15/2023 14:39 149.6 lbs. 03/24/2023 14:52 149.8 lbs. 04/12/2023 11:39 149.5 lbs. 05/04/2023 10:05 148.4 lbs. 06/09/2023 09:12 145 lbs. 07/10/2023 10:53 142.8 lbs. 08/04/2023 14:58 138.6 lbs. 08/25/2023 13:20 137 lbs. A physician's order dated 8/9/23 directed Resident #94 required an 8 oz diabetic supplement every day shift due to weight loss. A nutritional assessment dated [DATE] identified that Resident #94 had a weight of 137 lbs on 8/25/23, and had a 7.4% total loss since 3/4/23, 6 months prior. The assessment identified that Resident #94 had a weight loss trend over 6 months and had an order for weekly weight monitoring. The assessment further identified that Resident #94 was at increased nutritional risk for inadequate oral intake and required nutritional supplements. Review of the clinical record identified the following weights for Resident #94 following the 9/6/23 nutritional assessment: 09/10/2023 13:46 139.6 lbs. 11/12/2023 10:53 128.8 lbs. 12/01/2023 15:49 126.6 lbs. A physician's order dated 12/6/23 directed Resident #94 required 8 oz house supplements twice daily after lunch and dinner for weight loss. A nutritional assessment dated [DATE] identified that Resident #94 had a weight of 127.7 lbs on 1/6/24, and had a 10.6% total loss since 7/10/23, 6 months prior. The assessment identified that Resident #94 had a weight loss trend over 6 months and had an order for weekly weight monitoring. The assessment further identified that Resident #94 had a significant unintentional weight loss over the prior 6 months and that weight had been stable x 3 months. Review of the clinical record identified Resident #94 had a weight of 128 lbs. on 2/8/24, with no additional weights documented or recorded after this date. Interview with MD #1 (Medical Director) on 3/13/24 at 11:10 AM identified it was the policy of the facility to obtain weights on all residents upon admission with the initial nursing assessment. MD #1 identified that from admission, the weights would then depend on the orders for the resident, with some residents only requiring monthly weights. MD #1 further identified that some residents have orders for more frequent monitoring, including weight loss, and that his expectation would be weights would be obtained on admission and per the physician's orders. Review of the clinical record and interview with the DNS on 3/13/24 at 2:07 PM identified that the facility policy was for weights to be obtained upon admission as part of the initial assessment of the resident, weekly for 4 weeks and then monthly unless the physician's order directed otherwise. The DNS identified that she was aware Resident #94 had a history of weight loss and she had discussed this with the Dietician, but was not aware Resident #94 had weekly weight orders in place and was unsure why the weights were not done per the physician orders. Subsequent to surveyor inquiry, review of the clinical record identified Resident #94 had a weight of 124.1 lbs documented on 3/13/24 at 10:46 PM, a 3.9 lb or 3% loss from 5 weeks prior on 2/8/24, and a 15.5 lb or 11.1% weight loss from 6 months prior on 9/10/23. A physician's order dated 3/14/24 directed Resident #94 required 8 oz house supplements twice daily after breakfast and lunch, and to offer evening snacks. The facility policy on weight monitoring directed that residents would be weighed upon admission and then every week for 4 weeks and then monthly, unless otherwise indicated by the physician's order or recommendation of the dietician. The policy further directed that if there was a 5 lb weight discrepancy (plus or minus) a reweight should be obtained and compared to the previous weights to determine if the resident had a 5% weight change over 30 days or 10 % weight change over 180 days

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #49 and #268) reviewed for respiratory care, the facility failed to ensure (Resident #49)respiratory equipment was labeled, dated, and stored per policy when not in use and (Resident # 268) failed to maintain BiPaP tubing in a sanitary manner. The findings include: 1. Resident #49 was admitted to the facility with diagnoses which included dementia, hypertension, and Covid-19. The quarterly MDS assessment dated [DATE] identified Resident #49 had severely impaired cognition and requires total assistance with oral hygiene, bathing, and personal hygiene. The care plan dated 2/13/24 identified Resident #49 has pneumonia. Interventions included to use oxygen and oxygen saturation levels as ordered. Additionally, respiratory modalities per physician orders. A physician's order dated 2/13/24 directed to apply oxygen between 1-5 liters per minute to maintain oxygen level greater than 90% as needed and Albuterol Sulfate nebulizer solution 2.5mg per 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Observation on 3/7/24 at 11:35 AM Resident #49 was lying in bed with a concentrator on left side of bed with oxygen tubing draped over the concentrator not labeled, dated, or bagged. The nebulizer machine with tubing and face mask was sitting on the nightstand on the right side of bed not labeled, dated, or bagged. Observation and interview with LPN #1 on 3/7/24 at 11:50 AM indicated the oxygen tubing and nebulizer tubing and mask were not labeled and dated and were not bagged. LPN #1 indicated that there should be a physician order for when the oxygen tubing and nebulizer tubing and mask were to be changed weekly. Review of the clinical record, LPN #1 indicated there was not an order for the changing of the oxygen tubing or for the nebulizer tubing and mask. Interview with RN #1 on 3/7/24 at 11:55 AM indicated the oxygen tubing and nebulizer tubing and mask were to be labeled and dated and to be changed every Sunday on 3:00 PM - 11:00 PM shift. After review of the clinical record, RN #1 indicated that there should be a physician order for the changing of the tubing's and mask, but it was not in the physician orders. Interview with the DNS on 03/13/24 at 1:30 PM indicated it was the responsibility of the night nurse to label, date, and change the oxygen tubing with nasal cannula and the nebulizer tubing and mask every Sunday 11:00 PM - 7:00 AM shift and placing the tape with the date on the tubing. After clinical record review, the DNS indicated there was not a physician's order to change the oxygen and nebulizer tubing and mask weekly. The DNS indicated that when any of the respiratory equipment such as the oxygen tubing or the nebulizer mask and tubing are not in use, they must be bagged to stay clean. 2. Resident # 268 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), and dementia. The nursing admission assessment dated [DATE] identified Resident # 268 had impaired cognition, frequently required guidance for transfers, relies on support to propel manual wheelchair, and was admitted with a BiPaP machine to assist with breathing while asleep. The care plan dated 2/20/24 identified a focus on COPD with interventions which included providing CPAP as ordered and maintain equipment per protocol. A physician's order dated 2/16/24 directed to provide continuous oxygen at 3 L (liters per minute), and BiPaP settings 12/4 apply at sleep/remove in the morning related to COPD. A physician's order dated 2/18/24 directed to change and label oxygen tubing every week and as needed, for Sunday on the 11:00PM-6:00AM shift. Observation on 3/7/23 at 10:50AM identified the tubing associated with Resident #268's BiPaP was not dated nor contained in a bag. Interview with LPN #6 on 3/7/23 at 10:50AM identified the night shift should have updated the tubing and provided a bag. LPN #6 proceeded to discard the existing tubing, and stated she would secure new tubing when she leaves the room. Interview with the DNS on 3/13/24 at 3:20 PM identified the tubing is changed on the Sunday 11:00 PM-7:00AM shift and should have been labeled with the date assigned and bagged when not in use. The policy of BiPaP/CPAP care dated 6/19/2024, instructs the disposable tubing associated with the nebulizer should be changed every 2 weeks. Review of the facility Oxygen and Nebulizer Tubing Changes Policy identified to help prevent nosocomial respiratory infections while receiving oxygen therapy and/or nebulizer treatments. All oxygen tubing and nebulizer tubing including masks are for single resident use only. Oxygen and nebulizer tubing will be changed weekly, when visibly soiled, and as needed. Oxygen tubing, mask and nebulizer devices will be bagged and labeled with date and initials. The changing of the tubing and bagging is to prevent the spread of infection. Documentation of changes of tubing will be in the residents MAR or TAR. Licensed nursing staff will obtain physician order for any resident receiving oxygen therapy and/or nebulizer treatments to change the tubing once a week and as needed. Tubing will be changed by licensed staff on the designated day of the week and shift per the physician's order. The tubing will be dated at the time of the change. Any tubing that is not in use at the time of the tubing change will be placed in a bag for storage in the resident's room. Nasal cannulas, masks, and nebulizer mouth pieces will not be left uncovered when not in use.

Based on review of facility documentation, facility policy, and interviews for 1 of 2 certified nurse aide personnel files reviewed, the facility failed to complete annual employee performance reviews. The findings include: Review of NA #2's personnel file identified she was hired on 9/1/21, and no performance review was completed for the year of 2023. Interview with the DNS on 3/14/24 at 8:28 AM identified that certified nurse aide performance reviews are expected to be completed annually. The DNS further identified that she had begun her employment at the facility in July of 2023 and had identified that there were employee performance reviews that had not been completed in years. The DNS indicated that she has developed a plan to complete all the outstanding 2023 certified nurse aide performance reviews, with the assistance of a nursing supervisor. The DNS further indicated that once she has completed all the 2023 reviews, she will devise a calendar that will aid her in scheduling and completing annual performance reviews based on the employee's date of hire, for the year ahead. The Performance and Review policy directs the facility to provide a formal and documented performance review at the end of an employee's introductory period and will endeavor to give reviews at least annually thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, review of policy, and interviews for two of five residents reviewed for unnecessary medications (Resident #10, and Resident #74), the facility failed to document and monitor specific behaviors with the use of antipsychotic medication. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, anxiety disorder, and sleep disorder. The quarterly MDS assessment dated [DATE] identified Resident #10 had moderately impaired cognition, identified no behaviors, and required total dependent with personal hygiene. The care plan dated 1/29/24 identified Resident #10 was at risk for an alteration in mood and behaviors, I have multiple psych diagnoses. Interventions included provide medication as prescribed by physician. Be aware of changes in my mood/behavior and notify the physician. Psych evaluation and follow up as ordered and needed. The care plan dated 1/29/24 identified Resident #10 was at risk for changes in mood state due to diagnoses of anxiety, depression, and schizoaffective disorder. Interventions include follow up with psych as needed. Be aware of and report any changes in my mental status. The care plan dated 1/29/24 identified Resident #10 was at risk for potential adverse effects of psychotropic drug use. Diagnoses mental disorder, anxiety, depression, schizoaffective disorder, and paranoid schizophrenia. Interventions included being aware of my mood state and behavior. Be aware of my interaction with residents or others for appropriateness. The physician's order dated 2/1/24 directed to administer Zyprexa (antipsychotic medication) 10 mg in the evening for anxiety as part of 25 mg dose. Zyprexa 15 mg in the evening for anxiety as part of 25 mg dose. Review of the Medication Administration Record (MAR) dated 2/1/24 - 2/29/24 failed to reflect documentation for specific behavior monitoring for the use of an antipsychotic medication Zyprexa. Review of the clinical record and the MAR dated 2/1/24 through 2/29/24 failed to reflect documentation for specific behavior monitoring for Resident #10, who was receiving Zyprexa (antipsychotic medication). The physician's order dated 3/1/24 directed to administer Zyprexa (antipsychotic medication) 10 mg in the evening for anxiety as part of 25 mg dose. Zyprexa 15 mg in the evening for anxiety as part of 25 mg dose. Review of the Medication Administration Record (MAR) dated 3/1/24 - 3/14/24 failed to reflect documentation for specific behavior monitoring for the use of an antipsychotic medication Zyprexa. Review of the clinical record and the MAR dated 3/1/24 through 3/14/24 failed to reflect documentation for specific behavior monitoring for Resident #10, who was receiving Zyprexa (antipsychotic medication). Interview and review of the clinical record with the DNS on 3/14/24 at 10:35 AM identified she has been employed by the facility since July 2023. The DNS indicated she was not aware of Resident #10's behavior was not being monitored daily. The DNS indicated the facility expectation was that specific behavior monitor flow sheets should have been initiated whenever a resident is receiving an antipsychotic medication. The DNS indicated the resident behavior should have been monitored and documented on every shift. Review of the facility behavior monitoring/antipsychotic medications policy identified to ensure antipsychotic medications are administered and monitored per OBRA guidelines. Residents receiving antipsychotic medications will have specific target behaviors identified and monitored every shift. Any time a resident is started on an antipsychotic medication. A behavior flow sheet will be initiated. The target behavior(s) will be recorded were indicated on the flow sheet. Each shift will record, where indicated, the number of episodes for each behavior, interventions, outcomes, and side effects. 2. Resident #74 was admitted to the facility on [DATE] with diagnoses which included vascular dementia with behavioral disturbance, vascular dementia with mood disturbance, psychotic disturbance, and anxiety. The care plan dated 10/23/23 identified Resident #74 tends to wander around the unit looking for his/her sister, granddaughter, daughter, and keys at times. Interventions included to offer emotional support as needed. Wander guard continues. The care plan dated 12/29/23 identified Resident #74 was at risk for an altercation in my mood and behaviors as evidence by wandering in and out of rooms at times. Interventions included being aware of changes in my mood and behaviors and notify the physician. Remove me to a quiet area as possible. Adjust medication as ordered. Redirect when entering another resident's room. Wander guard continues. The care plan dated 1/10/24 identified Resident #74 has a history of aggressive behavior with other residents (last occurrence 1/10/24). Interventions included psych consults as ordered. Body audit/skin check as ordered. The physician's order dated 1/11/24 directed to administer Seroquel (antipsychotic medication) 5 mg every day at lunch for dementia, delusions, and combativeness. Seroquel 10 mg every day at hours of sleep for dementia, delusions, and combativeness. Review of the MAR dated 1/1/24 - 1/31/24 identified an order with a start date on 1/14/24 to monitor, observe, and document resident behaviors every 1 hour times 48 hours. Every hour observation for 2 days. The MAR failed to reflect documentation of Resident #74 behaviors every one hour on 1/15/24 - 1/16/24 at 4:00 AM. Who utilizes an antipsychotic medication. The nurse's note dated 1/2/24 - 1/27/24 failed to reflect documentation of Resident #74 behaviors on 1/15/24 on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. And on 1/16/24 on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift (3:00 AM). Review of the clinical record and the MAR for the month of January 2024 failed to reflect documentation of resident behaviors every hour on 1/14/24 on the 7:00 AM - 3:00 PM shift and the 3:00 PM - 11:00 PM shift. 1/15/24 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. And on 1/16/24 on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift (3:00 AM). Who utilizes an antipsychotic medication. The psych APRN note dated 1/10/24 identified she was asked to see Resident #74 after an incident with a peer. Behavior of concern resistant, wandering, intrusive, and compulsive. Resident #74 is not currently a danger to self or others. Current risk factors physical aggression. Per staff report Resident #74 was confused, wandering, and entered peer's room. Met with Resident #74 via telehealth, Resident #74 was guarded but cooperative with interview process. Denies mood concerns, and anxiety. Appears to be stable, no sign and symptoms of agitation. Denies wanting to harm self or others. Staff report that Resident #74 is redirectable and benefits from as needed (PRN) medication. Does not feel that medication changes are necessary at this time. Continue to provide support and reassurance. Discontinue 1:1. Psych will continue to follow. The significant change MDS assessment dated [DATE] identified Resident #74 had severely impaired cognition, exhibited wandering behavior, and was independent with bed mobility and transfer. Review of the summary report dated 1/14/24 at 1:26 PM identified on 1/10/24 Resident #74 wandered and startled Resident #76 who was sleeping in his/her room. On this occasion Resident #74 was having delusions that he/she was looking for his/her keys and believed that Resident #76 had them despite Resident #76 stating a number of times that he/she did not have the keys. Resident #74 then struck Resident #76. Resident #74 is experiencing delusions that are new and required psych evaluation of these behaviors and review of current medications. Upon completion of this investigation medications were adjusted and a new medication for delusions and agitation was added. On 1/11/24 Resident #74 medications were adjusted Trazodone dosing was changed, and Seroquel was added to address the delusions and agitation. Resident #74 behaviors were currently being observed every hour for the next 48-hours to assure the medications started are working to address the behaviors. The physician's order dated 2/1/24 directed to administer Seroquel (antipsychotic medication) 25 mg at bedtime for dementia. Review of the clinical record identified Resident #74 was hospitalized on [DATE] for complaining of chest pain and was readmitted to the facility on [DATE] with diagnoses of coronary artery disease (CAD). The physician's order dated 2/8/24 - 2/29/24 directed to administer Seroquel (antipsychotic medication) 25 mg at bedtime for dementia. Review of the MAR dated 2/1/24 - 2/29/24 failed to reflect documentation of Resident #74 behaviors every shift who utilizes an antipsychotic medication. Review of the clinical record dated 2/8/24 - 2/29/24 failed to reflect consistent documentation of Resident #74 behaviors who has a diagnoses of vascular dementia with behavioral disturbance, vascular dementia with mood disturbance, psychotic disturbance, and anxiety who utilize an antipsychotic medication. The psych APRN note dated 2/16/24 identified asked to see Resident #74 for concerns of increased yelling out, restlessness. Resident #74 has behaviors of concerns of physically assaultive, resistant, pacing, intrusive, combative, suspicious, wandering, compulsive, and delusions. Resident #74 is not currently a danger to self or others. Resident #74 appears calm at baseline, though Resident #74 does have increasing anxiety in the afternoon and evening. Discussed with medical APRN, per report Seroquel had been inadvertently stopped in the hospital and was recently restarted. Would recommend continue use of Trazodone for anxiety and irritability as well as redirection and reassurance. Continue to provide least stimulating environment. If symptoms persist would recommend increase in Seroquel with agreement from resident representative. No new orders with this visit. The physician's order dated 3/1/24 directed to administer Seroquel (antipsychotic medication) 25 mg at bedtime for dementia. Review of the MAR dated 3/1/24 - 3/8/24 failed to reflect documentation of Resident #74 behaviors every shift who utilizes an antipsychotic medication. On 3/8/24 on the 7:00 AM - 3:00 PM shift and the 3:00 PM - 11:00 PM shift failed to reflect documentation of Resident #74 behavior. The physician's order dated 3/8/24 directed for psychotropic medication: Behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document N if monitored and none of the above observed. Document Y if monitored and any of the above was observed, select chart code. See nurse's notes and progress note findings every shift. Interview with MD #1 on 3/13/24 at 11:10 AM identified he was not aware of the issues. MD #1 indicated the facility staff should have been following the facility policy on behavior monitoring and the facility policy on behavior monitoring with antipsychotic medications. Interview and review of the clinical record with the DNS on 3/14/24 at 10:35 AM identified she has been employed by the facility since July 2023. The DNS indicated she was not aware of Resident #74's behavior was not being monitored daily. The DNS indicated the facility expectation was that specific behavior monitor flow sheets should have been initiated whenever a resident is receiving an antipsychotic medication. The DNS indicated the resident behavior should have been monitored and documented on every shift. The DNS indicated all license nurses will be in-service. Review of the facility behavior monitoring/antipsychotic medications policy identified to ensure antipsychotic medications are administered and monitored per OBRA guidelines. Residents receiving antipsychotic medications will have specific target behaviors identified and monitored every shift. Any time a resident is started on an antipsychotic medication. A behavior flow sheet will be initiated. The target behavior(s) will be recorded were indicated on the flow sheet. Each shift will record, where indicated, the number of episodes for each behavior, interventions, outcomes, and side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #48) reviewed for accidents, the facility failed to ensure clinical record reflected complete and accurate documentation related to neurological checks and RN assessments following unwitnessed falls. The findings include: Resident # 48 was admitted to the facility on [DATE] with diagnoses included dementia, repeated falls, and psychophysical visual disturbances. A nursing note dated 9/2/23 at 9:11 PM completed by RN #10 identified Resident #48 had no change in condition. The note further identified that Resident #48 was admitted to the facility on [DATE] at 2:55 PM and fell at 3:15PM onto his /her buttocks his/her buttocks but did not hit his/her head, was confused at baseline, and was unable to follow simple commands, and was oriented to his/her room prior to the fall. A nursing note dated 9/2/23 at 9:51 PM completed by RN #10 identified that Resident #48 was admitted to the facility on [DATE] at 2:55 PM and fell earlier 3:15PM. The note further identified that Resident #48 fell on his/her buttocks and hit his/her head, was confused at baseline, and was unable to follow simple commands. The note identified Resident #48 was sent to the hospital for evaluation. Review of the clinical record failed to identify additional documentation related to Resident #48 and the fall documentation on 9/2/23 related to initiation of neurological checks or vital sign monitoring. The care plan dated 9/4/23 identified Resident # 48 had a history of falls due to multiple risk factors. Interventions included offering toileting and incontinent care during first rounds on the 3PM- 11PM shift. Review of the clinical record identified Resident #48 had 2 unwitnessed falls on 9/8/23. The clinical record failed to identify any documentation on 9/8/23 related to initiation of neurological checks or vital sign monitoring following these falls. The admission MDS assessment dated [DATE] identified Resident # 48 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of one to two staff members with transfers, toileting, and dressing. The MDS also identified Resident #48 had 2 or more falls with injury since admission to the facility. Review of the clinical record identified Resident #48 had an unwitnessed fall on 9/11/23 and required transport to the hospital for evaluation. The clinical record failed to identify any documentation related to initiation of neurological checks or the time Resident #48 was sent to the hospital for evaluation. The clinical record also identified Resident #48 was hospitalized from 9/11-9/15/23. Review of the clinical record identified that Resident #48 had an unwitnessed fall on 9/22/23. Further review failed to identify any documentation related to initiation of neurological checks or the time Resident #48 was sent to the hospital for evaluation of the unwitnessed fall on 9/22/23. Following a request on 3/12/24 for accident/incident(A&I) reports for Resident #48 related to falls, the facility a total of 6 reports for the following dates and times: 9/2/23 3:15 PM 9/2/23 7:30 PM 9/8/23 2:30 PM 9/8/23 10:00 PM 9/11/23 3:30 PM 9/22/23 6:30 PM Review of the A&I reports also identified Resident #48 had 2 falls on 9/2/23, the first occurred at 3:15 PM and a second fall at 7:30 PM that required transport to the hospital for evaluation. The A& I reports also identified documentation related to vital sign monitoring and neurological checks initiated following each fall were attached to each A&I report and not identified within Resident #48's electronic or paper clinical records. Review of the clinical record and interview on 3/13/23 at 2:15 PM with the DNS identified there had been concerns related to RN #10's clinical documentation and she was aware of the issue. The DNS also identified that the documentation in the clinical record related to the nursing assessments and falls on 9/2/23 appeared to be duplicate documentation of the fall that occurred at 3:15 PM. The DNS identified that 2 comprehensive RN assessments should have been completed following Resident #48's falls 9/2/23 with clear documentation related to the time of each fall. The DNS also identified that updated vital signs should be obtained with a nursing assessment, and that neurological checks should be completed per facility policy, regardless of whether a resident is sent to the hospital for evaluation. The DNS identified that neurological checks should have been completed every 15 minutes for the first hour, then every hour for 4 hours, every 4 hours for 24 hours and every shift until the 72 hours was reached. The DNS identified that the nursing staff may have been confused on when Resident #48 needed to have neurological checks done, since there were multiple falls within the same day at times, but the policy would be to restart neurological checks with each new unwitnessed fall or fall with head injury. The DNS also identified the facility utilized neurological check flowsheets on paper, but these should be scanned into the resident's electronic medical record, and that vital signs for should be documented in the electronic record. Although attempted, an interview with RN #10 was not obtained. The facility policy on falls directed that residents who experience an unwitnessed fall and were unable to accurately verbalize if he/she hit their head due to cognitive status, or if there was any type of head injury, would have neurological checks instituted. The policy also directed that after a resident fall, a RN assessment would be completed. The facility policy on nursing documentation directed the purpose of the policy was to capture any changes in condition that required a licensed staff assessment of a resident and should provide an account of any changes in condition, current assessments, and any concerns that could alter the resident's current plan of care. The policy further directed that nursing documentation may be in the form of a handwritten note or entered electronically and would be stored in the resident's medical record and nursing documentation should be clear, concise, and specific.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #16) reviewed for Hospice, the facility failed to have compete medical record with the hospice election form and the physician certification of terminal illness specific to Resident #16. The findings include: Resident #16 was admitted to the facility with diagnoses which included Alzheimer's disease and dementia. The care plan dated 7/24/23 identified Resident #16 was receiving hospice care. Interventions included to provide emotional support to the resident and family. The significant change of condition MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and required extensive assistance with bed mobility, toileting, and personal hygiene. Additionally, needed limited assistance with transfers, dressing, and locomotion on and off the unit and was receiving Hospice services. Interview with the DNS on 03/14/24 11:18 AM indicated nursing was responsible to obtain the physicians order but Social Services is responsible for the contracts and signing a resident up for a Hospice service. Interview with Business Office staff #1 on 3/14/24 at 11:20 AM indicated she had emailed the hospice agency requesting the hospice election form and the physician certification of terminal illness form. Business Office #1 indicated she was waiting for a response. Business Office #1 did provide the hospice list of contacts, a consult form stating Resident #16 was evaluated and accepted by hospice agency, a billing notification form, and an interim plan of care. Interview with the Business Office staff #1 on 3/14/24 at 11:35 AM indicated she only receives a change in billing notification form from Hospice. Business Office staff #1 indicated she does not have anything on file regarding Hospice services contract or hospice certification for Resident #16. After review of Resident #16's file in the business office, Business Office staff #1 indicated she did not have a copy of the Hospice contract signed by the resident representative or the physician terminal illness certification for Hospice. Business office #1 indicated she would contact Resident #16's hospice agency for a copy of the documents. Interview with the SW #2 on 3/14/24 at 11:40 AM indicated that Hospice does not give her any copies of the Hospice contract signed by the resident or resident representative nor does she get any copies of the Hospice physician terminal illness certification forms. SW #2 indicated she had asked the hospice company in the past but never received any documents. Interview with Business Office #1 on 3/14/24 at 1:20 PM indicated she had received the consent and election of Hospice benefit form signed by the resident representative. Business Office #1 provided a copy of the forms date and time of 3/14/24 at 12:18 PM. The Hospice Contract with the facility not dated identified each clinical record shall be completely, promptly, and accurately document all services provided to, and events concerning, each hospice resident, including evaluations, treatments, progress notes, authorizations to admissions to Hospice, physician orders entered pursuant authorizations to this Agreement and discharge summaries. Each record shall document that the specified services are furnished in accordance with this agreement and shall be readily accessible and systemically organized to facilitate retrieval by either party. Although requested, a facility policy for required documentation from hospice services was not provided.

Based on review of facility documentation, facility policy, and interviews for 6 of 7 personnel files reviewed, the facility failed to conduct required background checks for newly hired licensed nurses and certified nurse aides prior to hire. The findings include: Review of NA #2's personnel file identified that she was hired on 9/1/21 and failed to contain documentation that the required background checks were completed. Review of NA #4's personnel file identified that she was hired on 9/2/22 and failed to contain documentation that the required background checks were completed. Review of RN #7's personnel file identified that she was hired on 7/18/20 and failed to contain documentation that the required background checks were completed. Review of LPN #10's personnel file identified that she was hired on 3/29/23 and failed to contain documentation that the required background checks were completed, including fingerprinting.1. Employee File for LPN #8 identified he started working for the facility on 12/27/22 and was terminated on 2/20/23 with the last day worked on 2/15/23. Termination report indicated LPN #8 was not eligible for rehire and was not eligible to be paid his PTO time. On LPN #8's Job Application indicated he currently was not employed. Last place of employment at a nursing facility, RN #4 was his supervisor. Additionally, it asked Have you ever been convicted of a crime of any of the following: a felony, cruelty to persons under CGS 53-20, assault of a victim 60 years or older under CGS 53a-61 or has been subject to any decision imposing disciplinary action by the licensing agency in any state or foreign jurisdiction? LPN #8 did not answer yes or no. The verification of the nursing license was on 3/7/23 (There were no disciplinary/council forms in the file after 2 allegations of abuse one on 1/31/23 and one dated 2/15/23. File did not reflect reference checks, license verification at hire, nor the background checks. Employee File for RN #4 identified on the Job Application that she was referred to facility by a personal reference LPN #8. LPN #8 and RN #4 had the same address. RN #4 indicated she had not been convicted of a crime. RN #4 started working for the facility on 1/8/23 and she resigned effective immediately on 7/17/23. RN #4 file did not reflect verification of a nursing license, no references, and no background check (ABCMS). RN #4 had disciplinary action dated 5/9/23 due to RN#4 refused to come into facility for shift while on call RN #4 was given a written warning and if occurs again will be suspension and placed on 90-day probation. RN #4 had disciplinary action dated 5/26/23 for tardiness and call outs given a 90-day probation and if behavior continues will be suspension/termination. Interview with Human Resources Coordinator (HR) on 3/13/24 at 11:20 AM indicated he had started at the facility about 3 months ago. HR indicated he had reviewed the employee files for RN #4 and LPN #8, and he did not find the background checks (ABCMS), research services background check, or the 2 references needed identifying that RN #4 and LPN #8 were eligible for hire. HR indicated that an employee cannot start orientation until the ABCMS comes back and states the employee was eligible for hire. HR indicated that if a potential employee already had already their fingerprints on file with ABCMS (good for 3 years) the facility would accept it and print it and place in the employees file but would additionally do another background check from research services prior to the potential employee starting. HR #1 indicated that there were not 2 reference checks, ABCMS, or research services background checks in RN #4 or LPN #8's employee files. HR indicated neither should have started working without those items being completed first. Interview with the HR Coordinator on 3/14/24 at 11:35 AM identified that he began his employment at the facility on 12/28/23 and that the employee personnel files reviewed during survey had their pre-hire screenings completed prior to his employment with the facility. The HR Coordinator indicated that he was not able to identify documentation for NA #2, NA #4, RN #7, and LPN #10's background checks in their personnel file or in the facility's shared drive that houses new hire's application documents. The HR Coordinator further indicated that he was also unable to identify that LPN #10's fingerprinting was completed through ABCMS or in the facility's shared drive. The HR Coordinator identified that in accordance with the facility's pre-hire checklist the following documentation should be on file prior to a new employee beginning employment: copy of license/certification, CT and National sex offender registry, exclusion screening verification, ABCMS background check, third party background check, and reference checks. The HR Coordinator indicated that he has already started the process of auditing employee files to ensure the pre-hire background checks were completed and the employee's personnel file reflects the appropriate documentation; moving forward he will continue to work with the Administrator to ensure best practice and that audits of all employee personnel will be completed for the required pre-hire screenings and documentation. Interview with the Administrator on 3/14/24 at 11:47 AM identified that she began her employment at the facility on 10/16/23 and that her expectation would be that all pre-hiring screening, including the required background checks, would be completed in accordance with the facility's pre-hire checklist. The Facility Pre-hire Checklist Form identified the facility needed the following: copy of license or certification, Connecticut and National sex offender registry, exclusion screening verification, ABCMS background check and date sent, research services background check and date sent, copy of covid vaccination card, check 2 references, and offer letter. The Employee Handbook identified there was a pre-employment post offer the final acceptance to the position will be contingent upon the outcome of the criminal background checks and drug screen. Conflict of interest all employees have an obligation to conduct business within guidelines that prohibit actual or potential conflicts of interest. In order to avoid any favoritism or to prevent an employee from having an improper advantage or gain, an employee should inform the facility if he/she has a personal relationship, or any member of employee's family or household or a person whom the employee has a personal relationship, or provides services.

Based on observation, facility documentation, facility policy, and interviews reviewed for Dietary Services , the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings include: A tour of the Kitchen on 3/7/24 at 9:10 AM with [NAME] #1 identified in the walk in refrigerator; 4 pancakes in a zip lock bag not labeled or dated, 2 large rectangle deep metal pans on 3/4 full of salad mix and one almost empty salad mix neither was not labeled or dated, a large rectangle deep metal pan a third full with scoop marks out of the puree pancake mix not labeled but dated 2/29, a large rectangle deep metal pan with puree eggs not labeled but dated 3/3, a square deep metal pan half full with a brown liquid appeared jelly thickness not labeled or dated, 3 large plastic containers with green lids with dices fruit were not labeled or dated, 15 chocolate chip cookies in a plastic bag were not labeled or dated, and a pie with tin foil over the top with some missing was not labeled or dated. Interview with the [NAME] #1 on 3/7/24 at 9:25 AM indicated that all foods that had been prepared must be labeled and dated and were good for 3 days. [NAME] #1 indicated it was all dietary staff responsibility to discard outdated foods after 3 days in the refrigerator. [NAME] #1 indicated she would discard all food that was not labeled, dated, and discard the outdated items. Although requested a policy for prepared foods in the kitchen it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents reviewed for abuse, (Resident #2), the facility failed to ensure that the resident was free from neglect. The findings include: Resident # 2's diagnoses included multiple sclerosis, COPD, hypertension, dementia with psychotic and mood disturbance, and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10 out of fifteen, indicative of moderate cognitive impairment, and was totally dependent for assistance with eating, was totally dependent with other Activities of Daily Living (ADL) and was always incontinent with bowel and bladder. A Resident Care Plan (RCP) dated 8/26/22 identified Resident #2 had the potential for a nutritional decline related to multiple sclerosis and dementia the care plan dated 8/30/22 also identified that Resident #2 required assistance with ADL's due to multiple sclerosis, dementia, and right lower extremity weakness. Care plan interventions directed to provide diet as ordered, set up and fully assist Resident #2 with meals, ensure resident was seated upright when eating in wheelchair, assist with toileting, keep the resident's skin clean and dry, and to provide incontinent care in accordance with facility policy. Review of Resident #2's NAs care card (which directs NAs how to care for resident), directed that Resident #2 was alert, oriented, forgetful, prefers breakfast in bed and should be assisted for feed with meals as needed and should be positioned fully upright during mealtime and that Resident #2 was incontinent and should be offered incontinent care after lunch and required incontinent care to prevent skin breakdown. A physician's order dated 10/1/22 directed for Resident #2 to have a regular consistency diet with thin liquids and was assist of one (1) for feeding. A Reportable Event report dated 10/16/22 on 7:00 AM to 3:00 PM shift identified that Resident #2's spouse reported that Resident #2 was found with feces in his/her undergarment and that Resident #2's perineal area was red and swollen. The report further identified that Resident #2 was alert and needed assistance with ADLs, eating, transfers, bathing, and toileting. The report identified that facility substantiated allegations of abuse following an investigation and identified that NA #2 did not feed Resident #2 because she had assumed that Resident #2's spouse had fed Resident #2 (spouse usually come in to help feed Resident #2 daily but was unable to go in on 10/16/22 for feeding time). The report also identified that NA #2 did not provide incontinent care timely and the NAs on the 3:00 PM to 11:00 PM shift assisted Resident #2 back to bed at approximately 4:00 PM and provided incontinent care (at that time Resident #2 was incontinent of Bowel and bladder). A body check performed identified no impaired skin integrity. NA #2 was suspended then terminated. A statement from administrator attached to reportable event report dated 10/18/22 indicated that NA #2 identified that after she transferred Resident #2 out of bed at around noon she did not move or give incontinent care subsequently. NA #2 also stated that she did not feed Resident #2 his/her breakfast or lunch and did not know if anyone did, other staff interviewed identified they did not assist Resident #2 with meals. The statement further identified NA #2 was suspended that day and later terminated. A statement attached to report from NA #2 identified that she changed Resident #2 in bed at about 9:00 AM and then at 12:00 PM she changed and transferred Resident #2 in his/ her wheelchair for lunch. Interview with Resident #2 on 11/09/22 at 10:55 AM identified Resident was alert but could not recall any details of the incident. Interview with NA #1 on 11/09/22 at 1:00 PM identified that when she came in at 3:00 PM NA #2 had already left for the day. She identified that approximately 4:00 PM Resident #2's spouse came in to visit and called for assistance to place Resident #2 back in bed. She identified that when she entered the room, Resident #2 was slumping to his/her right side in the wheelchair and had no call bell or phone next to h/her. She further identified that Resident #1 was saturated in urine and had also had a bowel movement, and his/her perineal area was red. Interview attempt with NA #2 on 11/09/22 at 2:40 PM was unsuccessful, the surveyor was told by NA#2 to refer to her written statement taken by the facility. Interview with DNS and Administrator on 11/09/22 at 3:00 PM identified that NA #2's behavior of failing to help Resident #2 to eat his meals, not checking in on the resident and not providing incontinent care timely, did not represent the expectations of the facility. They further identified that an audit of the other Residents assigned to NA #2 that day (10/16/22) did not identify any issues with their care. They also identified that an in-service was started with staff at facility to provide reeducation on Resident abuse. Review of facility ' s Abuse Policy directed in part, that abuse or mistreatment of any kind toward a Resident is strictly prohibited. The policy defined neglect as the deprivation by an individual including a caregiver of goods or services that are necessary to maintain physical, mental, and psychosocial wellbeing. (Resident #2 was not given his/her breakfast or lunch meal and was not assisted with repositioning or incontinent care for four (4) hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, and interviews for one (1) of three (3) residents who were reviewed for medication administration, (Resident #1), the facility failed to ensure the resident was free from a medication omission. The findings include: A review of clinical record identified that Resident #1's diagnoses included multiple sclerosis, seizures, convulsions, dementia, and major depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment with no behavioral issues and was totally dependent or extensive assistance with ADLs. A care plan dated 12/21/22 identified that the resident had a seizure disorder with interventions that included to administer medications as ordered. A physician's order dated 10/07/22 directed that if Resident #1 had a seizure, to administer sublingual Ativan 0.5 mg one time, if the seizure lasts for more than five (5) minutes, send to the hospital. A nurse's note dated 10/21/22 at 5:17 PM identified Resident #1 was not responding as usual; the Nurse Aide (NA) called the nurse and APRN to assess Resident #1, Vital signs were completed, and Resident #1 was assessed by the APRN who determined Resident #1 was having seizure activity. An APRN note dated 10/21/22 at 6:00 PM identified Resident #1 had a multifactorial cognitive decline and was hospitalized for new onset focal seizure in left hemisphere. The resident is now on Keppra and had been stable after he/she was discharged back to facility, until today. Supportive staff had reported that Resident #1 is not eating and had appeared lethargic, upon arrival to the dining room, the resident was sitting in wheelchair with h/her eyes close. Resident #1 was not responding to voice or tactile stimuli. He/she started moving and opening her eyes after 5 minutes. However, it was unknown how long he/she had been in this state prior to the assessment. Blood pressure was elevated but other vitals were stable. Although he/she woke up, he/she was not at his/her baseline, such as smiling, talking (with some degree dysarthria but understandable) and following commands. Her pupils were sluggish. Given his/her new diagnosis of new onset of seizure, Resident #1 should be sent to ED for further evaluation and management as per responsible party ' s request. A review of facility's grievance log identified a grievance filed by Resident #1's responsible party dated 10/24/22 that identified a medication for seizure was not administered when Resident #1 had a seizure. A Nurse's note dated 10/31/22 at 10:22 PM identified that Resident #1 returned to facility from hospital. An interview with APRN on 11/04/22 at 11:10 AM identified she performed an assessment on Resident #1 on 10/21/22 when he/she was having a seizure. She identified that she was not the regular primary care practitioner for Resident #1 and happened to be on the unit at the time of incident. She further identified that she was not aware of physician's order for Resident #1 to administer sublingual Ativan 0.5 mg with seizure activity. An interview with DNS on 11/4/22 at 1:35 PM, who was the nurse assigned to care for Resident #1 on the 10/21/22 identified that although there was a physician's order to give Resident #1 sublingual Ativan 0.5 mg once, with seizure, she did not administer the medication because she thought the medication was only to be administered if Resident had convulsions (jerky-like movements). Interview with Physician's assistant on 11/09/22 at 10:35 AM who wrote order for Resident #1 sublingual Ativan identified based on prior consult with neurologist Resident #1 required the sublingual Ativan to help with relaxation after a seizure episode. Review of the facility's Seizure Precaution (not dated) directed that during a seizure provide privacy and safe environment, loosen clothing, assign a staff member to stay with Resident, observe time of onset, and cessation of seizure. Assess Resident ' s movements and level of consciousness. If airway obstructs, tilt head back and pull chin forward. Take blood pressure, pulse, respiration, and pulse oximetry. Notify the physician and responsible party, administer medications as prescribed and document in clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, review of facility policy, and interviews for one of two residents (Resident #45), reviewed for pain management the facility failed to notify Physician that a medication was not administered for three consecutive doses. The findings include: Resident #45 had diagnoses which included Malignant Neoplasm of Prostate, Colostomy, Hemiplegia & Hemiparesis, affecting right dominant side, hydronephrosis, and anxiety. The Quarterly Minimum Data Sheet (MDS) dated [DATE] identified Resident #45 as alert and cognitively intact, requiring one person assist for Activities of Daily Living (ADL's) and transfers to a manual wheelchair. Resident #45 required set up for meals and was able to self propel in a manual wheelchair. The Quarterly Resident Care Plan (RCP) dated 10/25/2019 identified Resident #45, as at risk for pain, with complaints of abdominal pain, left hip abscess, and pain around stomas. The RCP identified that Resident #45 will report any pain and identified interventions including administer scheduled pain medication as ordered by physician; staff to be aware if Resident #45 was having an increased need for as needed medications for break-thru type of pain; evaluate effectiveness; and offer to make adjustments to promote optimal comfort The Physician's order dated 10/29/2019 directed to administer Oxycontin 10 mg tab ER 1 tab by mouth every 12 hours. On 01/07/20 at 9:40 AM, Resident #45 identified that he/she was told at one point, the facility did not have any of his/her prescribed pain medication, the nurse forgot to re-order it, therefore he/she did not receive his/her prescribed medication for two days. Review of the Medication Administration Record (MAR) for November 2019 and December 2019, identified, on 11/30/2019 there was no documentation for the 8:30 AM dose of Oxycontin 10mg tab ER, every 12 hours. For the 11/30/2019 8:30 PM dose of Oxycontin 10 mg, ER every 12 hours documentation reflected N/A (not available). For the 12/1/2019 8:30 PM dose of Oxycontin 10 mg tab. ER, N/A is documented. Review of the Controlled Substance Disposition Record (CSDR) for Oxycontin 10 mg tab ER Every 12 hours for Resident #45, the documentation identified on 11/30/2019 one tab was removed at 8:00AM. Review of the next CSDR for Oxycontin 10 mg tab ER for Resident #45 identified, on 12/2/2019 at 8:00 AM one tab was removed. There is no documentation on the CSDR that any oxycontin was provided for Resident #45 at scheduled medication times for 11/30/2019 at 8:30 PM, 12/1/2019 at 8:30AM or 12/1/2019 at 8:30PM. Review of the clinical record failed to reflect that the Physician and/or Advanced Practice Registered Nurse were notified of the missed doses. On 1/9/2020 at 12:45PM an interview with Advanced Practice Registered Nurse (APRN) #1 identified that the physician or APRN should have been notified if Resident #45 did not receive the prescribed medciations for three doses. APRN #1 identified if the medication was not available in the medication dispensing machine, the nurse should have obtained the medication from the Emergency supply and provided it for the Resident. APRN #1 further identifed that if the medication was not available in the Emergency supply, he/she would have ordered what was readily available. Review of the Medication Shortage/Unavailable Medication policy for the facility identified if a medication shortage is discovered after normal Pharmacy hours a licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. The Policy further identifed when a dose is unavailable, the facility nurse should document the missed dose and the explanation for such missed dose on the MAR and in the nurse's note. Additionally, if an emergency delivery of the medication is unavailable, the facility nurse should contact the attending physician for additional orders or directions. The facility lacked documentaiton that this had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and review of facility policy, for one of two residents (Resident #150) reviewed for abuse, the facility failed to protect a resident's right to be free from misappropriation of resident property. The findings include: Resident #150 was admitted to the facility on [DATE] with diagnoses including dementia, subdural hemorrhage, major depressive disorder, dysphagia, and monoplegia of upper limb affecting right dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #150 had moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance with dressing and personal hygiene. The care plan dated 5/14/19 identified Resident #150 was confused and forgetful due to advancing age and recent hospitalization. Resident #150 was also more lethargic since return from the hospital. Interventions included to allow time for responses when speaking to the resident, offer gentle reminders, and restate sentences using simpler terms. Physician's order dated 8/3/19 directed to place Resident #150 on comfort measures. A social services note dated 8/5/19 identified Person #1 stated that Resident #150's ring was missing. Person #1 reported that Resident #150's ring was last seen on Friday, August 2nd in the afternoon at 4:00PM. A nurse searched Resident #150's room and the med cart, but the ring was not found. Administrator and Director of Nurses (DNS) were made aware. Department of Public Health and Police department contacted. A written witness statement by NA #1 identified himself/herself to have given care for Resident #150 on the dates August 2nd, 3rd and 4th. NA #1 identified he/she was not aware of the missing ring until the situation was presented to him/her. An accident and incidence report submitted to the Department of Public Health (DPH) on 8/5/2019 by the DNS identified an investigation was initiated regarding Resident #150's missing ring. The police were notified at 3:02 PM and a case was opened. A police report dated 10/11/2019 identified on 8/5/2019, Person #3 responded to the facility, to take a complaint of lost property. Upon arrival, Person #3 spoke with the DNS who stated Person #1 wanted to report Resident #150's ring missing. Person #1 stated after cleaning Resident #150's belongings, the ring was not located. Person #1 stated Resident #150's ring was always on his/her left ring finger until Person #1 noticed it missing on August 5th, 2019 when he/she immediately reported it to the facility staff. The report further identified that upon investigation, NA #1 was identified as allegedly having the ring and the facility was notified. Review of the prevention and reporting of fraud, waste and abuse policy for the facility identified for all employees to vigorously combat fraud, waste and abuse in federal and state healthcare programs. The facility failed to ensure that Resident #150 was free from misappropriation of personal items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of two Residents (Resident #45) reviewed for pain management, the facility failed to administer pain medication per physician's orders. The finding include: Resident #45 had diagnoses including Malignant Neoplasm of Prostate, Colostomy, Hemiplegia & Hemiparesis, affecting right dominant side, hydronephrosis, and anxiety. The Quarterly Minimum Data Sheet (MDS) dated [DATE] identified Resident #45 as alert and cognitively intact, requiring one person assist for Activities of Daily Living (ADL's) and transfers to a manual wheelchair, required set up for meals, and was able to self propel in a manual wheelchair. The Quarterly Resident Care Plan (RCP) dated 10/25/2019 identified Resident #45 as at risk for pain, with complaints of abdominal pain, left hip abscess, and pain around stomas. The RCP identified that Resident #45 will report any pain. Interventions included administer scheduled pain medication as ordered by physician; staff be aware if Resident #45 is having an increased need for as needed medications for break-thru type of pain; Evaluate effectiveness; and offer to make adjustments to promote optimal comfort. The Physician's order dated 10/29/2019 directed to administer Oxycontin 10 mg tab ER 1 tab by mouth every 12 hours. On 01/07/20 9:40 AM Resident #45 identified that he/she was told at one point the facility did not have any of his/her prescribed pain medication, the nurse forgot to re-order it, therefore he/she did not receive his/her prescribed medication for two days. Resident #45 was not certain of the dates, but believed it was about a month ago. Review of the Medication Administration Record (MAR) for November 2019 and December 2019, identified, on 11/30/2019 there was no documentation for the 8:30 AM dose of Oxycontin 10mg tab ER, every 12 hours. For the 11/30/2019 8:30 PM dose of Oxycontin 10 mg, ER every 12 hours documentation reflected N/A (not available). For the 12/1/2019 8:30 PM dose of Oxycontin 10 mg tab. ER, N/A is documented. Review of the Controlled Substance Disposition Record (CSDR) for Oxycontin 10 mg tab ER Every 12 hours for Resident #45, the documentation identified on 11/30/2019 one tab was removed at 8:00AM. Review of the next CSDR for Oxycontin 10 mg tab ER for Resident #45 identified, on 12/2/2019 at 8:00 AM one tab was removed. There was no documentation on the CSDR that any oxycontin was provided for Resident # 45 at scheduled medication times for 11/30/2019 at 8:30 PM, 12/1/2019 at 8:30AM, or 12/1/2019 at 8:30PM. Interview on 1/7/2020 at 12:30 PM with Licensed Practical Nurse (LPN) #1 identified that it was true that Resident #45, did not get his/her prescribed medication for a time over one weekend but he/she was not working that weekend and it appeared some nurse did to re-order the medications for the resident. LPN #1 further identified that the medication needs to be re-ordered by the nurse on a Thursday or Friday before a weekend if the medication is running low. LPN #1 identified that he/she had no knowledge of exactly what happened and heard from the Resident #45 that he/she did not receive his/her scheduled medication on the weekend. In an interview with the Director of Nurses (DNS) on 1/8/2020 at 1:30 PM, identified that the medication dispensing machine did not reflect that it was entered on 11/30/2019 or on 12/1/2019 to obtain any Oxycontin 10 mg tab for Resident #45. The DNS further identified that the nurse could have had the nursing supervisor go into the the Emergency supply to obtain the Oxycontin 10 mg for Resident #45, as there is Oxycontin 10 mg tabs in the Emergency box. Review of the Pharmacy Prescription Blank dated 12/1/2019 identified an order for Resident #45, for Oxycontin ER 10 mg, one tab by mouth every 12 hours, signed by Medical Director and transmitted to the pharmacy. On 1/8/2020, interview and record review with Registered Nurse (RN) #2 identified the procedure for ordering or re-ordering scheduled medications and failed to identify why the medciation was not re-ordered for Resident #45 nor why the medication was not obtained from the Emergency stock. Interview on 1/9/2020 at 12:30 PM with LPN #2 identified that he/she knew Resident #45 and did not recall or remember not giving Resident #45 any of his/her medications. LPN #2 identified that if N/A was dodumented on the MAR that meant the Resident did not receive the medications. On 1/9/2020 at 12:30 PM an interview with the Director of Nurses (DNS), identified that the nurse with the supervisor could have obtained the Oxycontin 10 mg from the Emergency supply. There was no documentation of any access to the medication Emergency supply, on 11/30/2019 or on 12/1//2019. Review of the Medication Shortage/Unavailable Medication policy for the facility identified if a medication shortage is discovered after normal Pharmacy hours a licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. The facility failed to ensure that this had occurred to ensure that Resident #45 received his/her pain medications as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of five sampled residents (Resident #94) reviewed for unnecessary medications, the facility failed to ensure a pharmacy recommendation was acted upon in a timely manner. The findings include: Resident #94's diagnoses included diabetes mellitus and end stage renal disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #94 was severely cognitively impaired and required extensive assistance with Activities of Daily living (ADL's). The Resident Care Plan (RCP) dated 9/17/19 identified Resident #94 was at risk for cardiac issues related to hypertension. Interventions directed to check Resident #94's blood pressure as ordered, notify the physician/Advanced Practice Registered Nurse (APRN) if not within established parameters. A physician's order dated 9/28/19 directed to administer doxazosin mesylate 1 mg by mouth at bedtime. The pharmacy consultant report dated 10/22/19 identified a pharmacy recommendation to reassess a medication, Doxazosin Mesylate. The consultant identified that Resident #94 was also receiving Losartan and Norvasc. The rationale for the recommendation identified the medication was a peripheral alpha-1 antagonist and that use in the elderly should be avoided due to an increased risk for orthostatic hypotension. The recommendation was signed by APRN #1 on 10/24/19 with instructions to defer the recommendation to nephrology. Interview and review of facility documentation with the Assistant Director of Nurses (ADNS) and Licensed Practical Nurse (LPN) #1 on 1/9/20 at 10:18 AM identified that LPN #1 thought that he/she had sent the pharmacy recommendation to the dialysis provider for review per the APRN response. LPN #1 identified that he/she may have copied the Consultation Report from the pharmacy and placed it in the dialysis communication book. LPN #1 identified that facility communication sheets are used to communicate issues to and from the dialysis center and that he/she should have written the request on the Dialysis Communication Form. LPN #1 identified that if a response was not received from the dialysis center, the facility should have called the dialysis provider to address the recommendation. Interview and review of facility documentation with APRN #1 on 1/9/20 at 12:30 PM identified that he/she had no notes regarding Resident #94's discontinuation of the Doxazosin except the original request he/she made, to defer to nephrology. APRN #1 would have expected the facility to follow up with the dialysis center if they did not get a response to the review. Interview with the dialysis center, Person #1 on 1/9/20 at 2:16 PM identified that they had not received any information from the facility to review the pharmacy recommendation for the continued need for Doxazosin until the request was received on 1/8/19. At that time a recommendation to discontinue the medication was provided to the facility. Interview with the Director of Nurses (DNS) on 1/9/20 at 1:00 PM identified that the facility discontinued the medication. Review of facility Medication Regimen Review Policy identified that the facility should encourage the Physician/Prescriber or other Responsible Parties receiving the Medication Regimen Review (MRR) and the Director of Nursing to act upon the recommendations contained in the MRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, review of facility policy, and interviews, the facility failed to monitor refrigerator temperatures in 3 of 3 medication rooms according to facility policy and/or store medications under proper temperature controls for Residents #2, 4, 11, 14, 25, 36, 46, 53, 61, 69, 72, 73, 76, 78, 94, and 200. The findings include: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, peripheral vascular disease (PVD), and Congestive Heart Failure (CHF). A physician's order for Resident #2 dated 01/07/2020, directed administration of Performist 20 mcg/2ml via nebulizer every 12 hours. b. Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus without complications, morbid obesity, and CHF. A physician's order dated 12/16/19, directed 1.5 mg Trulicity be administered subcutaneously to the resident every Sunday. Additionally, a physician order dated 12/20/19 directed 33 units of Toujeo be administered to Resident #4 subcutaneously twice a day. c. Resident #11 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, acute kidney failure, and vascular dementia. A physician's order dated 12/26/19 directed 0.5 ML of Trulicity 0.75 mg/ 0.5 mL pen be administered to the resident subcutaneously every week on Wednesday. d. Resident #14 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with hyperglycemia, PVD, and hypertension (HTN). A physician's order dated 12/20/19 directed 45 units of Lantus be administered to the resident subcutaneously every morning. e. Resident #25 was admitted to the facility on [DATE] with diagnoses that included long term use of insulin, type 2 diabetes, Chronic Obstructive Pulmonary Disease (COPD), and HTN. A physician's order dated 12/19/19 directed 55 units of Basaglar KwikPen 100 unit/ mL insulin pen be administered to the resident at bedtime. f. Resident #36 was admitted to the facility on [DATE] with diagnoses that included anemia, chronic kidney disease, morbid obesity, type 2 diabetes, and PVD. A physician's order dated 12/10/19 directed administration of 0.5 mL of Trulicity 1.5 mg/mL subcutaneously every week. Additionally, a physician's order dated 12/10/19, directed that Procrit 20,000 units be administered three times a week subcutaneously to Resident #36. g. Resident #46 was admitted to the facility on [DATE] with diagnoses that included long term use of insulin, type 2 diabetes mellitus, and HTN. A physician's order dated 1/7/2020, directed Resident #46 be administered 0.5 mL of Trulicity 1.5 mg/0.5 mL subcutaneously every week. h. Resident #53 was admitted to the facility on [DATE] with diagnoses that included benign neoplasm of meninges, dementia, glaucoma, and HTN. A physician's order dated 11/30/19, directed 1 drop of Latanoprost 0.005% be instilled into both of the resident's eyes at bedtime. i. Resident #61 was admitted to the facility on [DATE] with diagnoses that included unspecified asthma, long term use of insulin, and adjustment disorder. A physician's order for Resident #61 dated 12/12/19, directed administration of Performist 20 mcg/2 mL via nebulizer every 12 hours. A physician's order dated 12/ 12/19, directed administration of Humulin R 500 KwikPen 500 Units/1 mL 100 units subcutaneously once daily before breakfast and 85 units before dinner. j. Resident #69 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with diabetic polyneuropathy, charcot's arthropathy, and HTN. A physician's order dated 12/10/19, directed Levemir 100 Unit/mL 42 units be administered to the resident subcutaneously 2 times daily. A physician's order dated 12/10/19, directed administration of Novolog insulin 21 units subcutaneously every morning at 6:30 AM. k. Resident #72 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with other circulatory complications, hypothyroidism, PVD and HTN. A physician's order dated 12/28/19, directed administration of 12 units of Lantus Solostar 100 unit/1 mL insulin subcutaneously at bedtime to Resident #72. l. Resident #73 was admitted to the facility on [DATE] with diagnoses that included long term use of insulin, type 2 diabetes mellitus with proliferative diabetic retinopathy, chronic kidney disease, and morbid obesity. A physician's order dated 12/23/19 directed 28 units of Lantus 100 unit/1 mL be administered to the resident 2 times daily subcutaneously. m. Resident #76 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, muscle weakness, dementia, and gastroesophageal reflux disease (GERD). A physician's order for Resident #76 dated 12/12/16 directed 20 mg of Glatopa be injected subcutaneously once daily. n. Resident #78 was admitted to the facility on [DATE] with diagnoses that included long term use of insulin, diabetes type 2 with hyperglycemia, and vascular dementia with behavioral disturbance. A physician's order dated 12/18/19, directed administration of Bydureon 2mg/0.65 mLpen injector (2 mg) subcutaneously every week on Sunday, to Resident # 78 and administration of 7 Units of Basaglar insulin subcutaneously at bed time. o. Resident #94 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with foot ulcer, HTN, end stage renal disease, and glaucoma. A physician's order dated 12/3/19 directed Humalog insulin be administered subcutaneously to the resident 4 times a day using a sliding scale in accordance with the resident's blood sugars. The orders directed 1 drop of Latanoprost 0.005% be instilled into the resident's right eye at bedtime. A physician's order of 12 /3/19, directed 5 units of Lantus 100 U/ 1 mL be administered to the resident subcutaneously at bedtime. p. Resident #200 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, COPD, and obesity. A physician's order dated 12/19/19 directed Resident #200 be administered Lantus solution insulin 45 units subcutaneously every AM, and Humalog 100 unit/ml insulin administered subcutaneously three times a day before meals and at hour of sleep, according to results of his/her blood sugar using a sliding scale. Observations and interview with Licensed Practical Nurse (LPN) #1 on 1/7/20 at 1:21 PM identified that upon opening the medication refrigerator on [NAME] Terrace the thermometer inside read 34 degrees Fahrenheit and the corresponding log posted on the outside of the refrigerator documented the night shift logged the refrigerator temperature as 32 degrees Fahrenheit. LPN #1 identified that the night shift nursing staff was responsible for checking and logging the medication refrigerator temperature. LPN #1 identified the refrigerator log fastened on the front of the refrigerator documented the refrigerator temperature on 1/7/20 was 32 degrees Fahrenheit. Although LPN #1 identified that he/she thought the medication refrigerator temperature was colder than it should have been, he/she was not able to find the facility policy directing what the temperature of the refrigerator should be. Additionally, LPN #1 identified that on the day shifts he/she worked, he/she did not adjust the refrigerator temperature as the refrigerator temperature was monitored by the night shift. Observation and interview with Registered Nurse (RN) #1, infection control, wound care and staff development nurse on 1/7/20 at 1:33 PM of the medication refrigerator on the Rosewood unit noted that upon opening the refrigerator, the thermometer inside the refrigerator read 30 degrees Fahrenheit and the corresponding temperature log pasted on the front of the refrigerator door identified the temperature was 30 degrees Fahrenheit. RN #1 identified that the night shift was responsible for monitoring and logging the medication refrigerator temperatures in all the medication rooms. RN #1 identified he/she did not know what the medication refrigerator temperature should be, but believed that 30 degrees Fahrenheit was too low and identified he/she would use the pharmacist as a resource. RN #1 identified all nurses were responsible for ensuring the refrigerator temperature was within an acceptable range so as to store resident medications at the appropriate temperature. RN #1 identified the supervisors and the Director of Nurses (DNS) were ultimately in charge of making certain the medication refrigerator temperatures were maintained at the correct temperature so the integrity of the medications were not compromised. Review of the contents of the Rosewood medication refrigerator with RN #1 identified the following medications within the refrigerator: For Resident #2: 2 vials of Performist 20 mcg/2 mL neb. For Resident #46: Trulicity 1.5 mg/0.5 mL injection Pen. For Resident #61: 6 vials of Performist 20 mcg/ 2 mL and 1 unopened KwikPen containing Humulin R U-500 Units/ mL. For Resident #72: Lantus Solstar 100 unit/1 mL pen. For Resident #76: 12 syringes of Glatopa 20 mg/ 1 mL syringe. Resident #78 4 injector pens of Bydureon pen 2 mg/0.65 mL pen and 1 Basaglar KwikPen 100 u/ mL House stock: 1 syringe Prevnar Vaccine. House stock: 2 opened 5 mL multi-dose vials of AFLURIA® QUADRIVALENT (Influenza Vaccine) Observation and interview with RN #1 of Ashwood Unit medication room refrigerator on 1/7/20 at 1:58 PM identified that upon opening the medication refrigerator the inside thermometer read 32 degrees Fahrenheit and the corresponding log posted on the outside of the refrigerator door documented the night shift logged the temperature as 30 degrees Fahrenheit. Review of the contents of the Ashwood Unit medication refrigerator with RN #1 identified the following medications within the refrigerator: For Resident #4: 1 bottle of Toujeo Solstar 300 unit/ 1 mL and 2 Pens containing Trulicity 1.5 mg/ 0.5 mL. For Resident #11: 2 Pens of Trulicity 0.75 mg/ 0.5 mL. For Resident #14: 3 insulin pens of Lantus Solostar 100 unit/ mL. For Resident #25: 5 insulin pens of Basaglar KwickPen 100 u/ 3 mL. For Resident #33: 1 0.5 mL vial of Pneumovax 23. For Resident #36: 6 bottles of Procrit 20,000 units/1 mL vial and 2 Pens containing Trulicity 1.5/.5 mL. For Resident #69: 1 vial of Levemir 100 U/1 mL. For Resident #200: 1 vial of Humalog 100 U/mL 3 ml vial. House stock; 1 vial of Tubersol (Tuberculin Purified Protein Derivative) NDC 49281-752-21. House Stock: 1 5 mL multi-dose bottle of AFLURIA® QUADRIVALENT (Influenza Vaccine) ndc 33332-419-10. House stock: 8 Acetaminophen 650 mg suppositories. Observation and interview of the [NAME] Terrace Unit medication room refrigerator on 1/07/20 at 2:11 PM with RN #1 identified that upon opening the medication refrigerator the thermometer read 32 degrees Fahrenheit and the corresponding log posted on the outside of the refrigerator door documented the night shift logged the temperature as 30 degrees Fahrenheit. Review of the contents of the [NAME] Terrace Unit medication refrigerator with RN #1 identified the following medications within the refrigerator: For Resident #53: 1 bottle 2.5 mL of Latanoprost 0.005 %. For Resident #73: 1 10 mL bottle of Lantus 100 u/mL. For Resident #94: 1 bottle 2.5 mL of Latanoprost 0.005%, 1 10 mL bottle of Lantus 100 u/1 mL, 2 bottles 3 mL of Humalog 100 u/ mL. House stock: 1 syringe of Prevnar 13. House stock:1 vial of Pneumovax 23. House stock: 1 vial Tubersol (Tuberculin Purified Protein Derivative) NDC 49281-752-21. House stock: 1 5 mL multi-dose bottle of AFLURIA® QUADRIVALENT (Influenza Vaccine) ndc 33332-419-10. House stock: 14 acetaminophen 650 mg suppositories. House stock: 2 3 mL vials of Humalog 100 u/ 1 mL. Interview with the DNS on 1/7/20 at 2:26 PM identified that the medication refrigerator temperatures were monitored and logged by the night shift. The DNS identified that nursing was to monitor the temperature to ensure the integrity of the resident medications within the refrigerator. The DNS could not recall the recommended range for the medication refrigerator. He/She identified that the policy for monitoring the medication refrigerator temperatures was part of the facility pharmacy procedure book. The DNS identified the acceptable temperature range was not listed on the temperature log. Also, night staff was to check the refrigerator temperatures and adjust the temperatures to ensure medications were stored at the recommended temperature as directed. In addition, he/she would expect the staff to adjust the refrigerator temperatures and to document follow up temperatures on the refrigeration logs to demonstrate the temperatures were accurate. Also, that nursing was to notify the maintenance department and the supervisor of issues with the refrigerator temperature. The DNS identified all shifts would be responsible for ensuring the temperature of the refrigerators continued to be within acceptable parameters. The DNS also identified subsequent to observations of the medication room refrigerator temperatures below 36 degrees with RN #1 and surveyor, the resident's medications contained within the medication refrigerators would require replacement to ensure their integrity. Interview with Person #5, Pharmacist on 1/7/20 at 2:52 PM identified that medication refrigerators are to be kept at 36 to 46 degrees Fahrenheit so as to ensure the integrity of medications. He/She identified that the following medications are to be stored at a temperature between 36 to 46 degrees Fahrenheit to maintain integrity of the medication: Glatopa, Flu vaccines, insulins, pneumovax, pneumococcal vaccine, tubersol, Trulicity, Procrit, Latanoprost, Toujeo. Person #5 identified that storing Performist at 30 degrees Fahrenheit had the potential to alter the integrity of the drug. Interview and review of maintenance log with Director of Maintenance on 1/8/20 at 9:01 AM identified that he/she could not recall when he/she last had been contacted by nursing to service a medication refrigerator. The Director of Maintenance identified that the DNS had contacted him/her earlier on 1/8/20 to adjust the temperature controls of the medication refrigerators. He/She identified that in order to make the temperature go up in the refrigerators the dial had to be turned down which seemed contra intuitive. The Director of Maintenance identified he/she shared this with the nursing staff. Interview with the Director of Nursing on 1/8/20 at 9:30 AM identified that the documentation log for recording of the medication refrigerator temperatures had been updated subsequent to surveyor inquiry to reflect the expected refrigerator temperatures of 36 to 46 degrees Fahrenheit. The DNS identified staff development was in the process of providing education to the nursing staff related to temperature logs in the medication rooms. Review of the September 2019 through January 7, 2020 refrigerator logs for the medication rooms failed to identify documentation of refrigerator temperature adjustment or rechecks of the temperatures when temperatures were documented outside of the acceptable temperature range of 36 to 46 degrees Fahrenheit. Furthermore, review of the logs failed to identify that the refrigerators containing vaccines had temperature monitoring twice a day per the facility's pharmacy services and procedure manual for storage and dating of medications and biologicals. Review of facility pharmacy and procedure manual for storage and expiration dating of medications, Biologicals, Syringes, and needles identified the facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility Staff should monitor the temperatures of vaccines twice a day. Refrigerated medications should be kept at 36 to 46 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and review of facility document for four sampled residents ( Resident # 51, Resident # 58 Resident # 64 and Resident #81) reviewed for hospitalization, the facility failed to provide documentation to ensure the Ombudsman was notified in writing of the resident's hospital admission. The Findings included: 1. Resident # 51 was admitted [DATE] with diagnoses included Dementia, heart failure and Chronic Obstructive Pulmonary Disease (COPD). The discharge MDS assessment dated [DATE] identified Resident # 51 had short term memory problem and was independent with personal care. The nursing progress note dated 9/17/18 identified Resident # 51 presented with altered mental status changes and was transferred to an acute care hospital and admitted . The care plan dated 9/24/18 identified Resident # 51 had a concern related to cognition and ADL care with interventions that included to offer gentle reminders and provide assistance as needed with ADL care. An interview with Social Worker (SW #1) on 11/8/18 at 2:20 P.M. identified she/he was unaware the Ombudsman should have been notified of an admission to the hospital and indicated he/she had not been sending notifications to the facility representative and going forward will implement a plan. 2. Resident # 58 diagnosis included major depressive disorder, Peripheral Vascular Disease (PVD), anxiety, Chronic Kidney Disease (CKD) stage 3. A 5 day MDS assessment dated [DATE] identified intact cognition, extensive assistance with most ADL with the exception of supervision for eating and extensive assistance with personal hygiene. The care plan dated 7/14/18 identified risk for respiratory complications with hospitalizations on 6/29/18 for complaints of SOB/respiratory distress, a hospital transfer on 6/29/18 and a transfer on 7/10/18 for abnormal laboratory values. Interventions included to notify the Medical Doctor (MD) with any SOB (Shortness of Breath). Interview with SW #1 on 11/8/18 at 2:20 P.M. identified the Ombudsman was not notified of Resident #58's discharges to the hospital. SW # 1 also indicated she/he was unaware the Ombudsman was supposed to be notified but will notify the Ombudsman starting now. 3. Resident #64 was re-admitted on [DATE] with diagnoses that included sepsis, aspiration pneumonia, neurogenic bladder, multiple sclerosis and Urinary Tract Infection (UTI). A discharge MDS assessment dated [DATE] identified the resident was discharged to an acute care facility for treatment with an anticipated return. A re-entry MDS assessment dated [DATE] identified the resident was re-admitted to the facility. On 11/8/18 at 2:45 P.M. an interview and review of the clinical record with the DNS indicated, although the resident and/or responsible party were provided written notification of a bed hold and/or verbal notification of Resident#64 hospitalization prior to transfer, the facility was unable to provide documentation and/or evidence to reflect the Regional Ombudsman was provided written notification of Resident #64's transfer and/or hospitalization. The DNS further indicated he/she was unaware the Regional Ombudsman should have received a written notification of the resident's hospitalization as well. 4. Resident # 81 was readmitted [DATE] to the facility. The resident's diagnosis include bilateral lower extremity cellulitis. The care plan dated 9/5/18 identified Resident # 81 had an alteration in skin integrity related to bilateral lower extremity cellulitis. Interventions included to elevate legs and monitor for signs of active infection including wound drainage, increased discomfort. The Medicare 5 day MDS assessment dated [DATE] identified Resident # 81 had intact cognition and was independent with ADL with the exception of supervision for bed mobility and personal hygiene. Nursing progress note dated 9/14/18 identified Resident # 81 presented with increased BLE pain and requested to go to the hospital. APRN and conservator notified and resident transported to the hospital. Interview with SW #1 on 11/8/18 at 2:20 P.M. identified the residents conservator was not notified in writing and the Ombudsman was not notified that Resident #81 was sent to the hospital. SW #1 also indicated the Ombudsman should have been notified and have implement a plan going forward to notify the Ombudsman.