Resident #26 On 01/29/2024 at approximately 1:54 PM, an interview was conducted with Resident #26, who reported that he had bought a jogging suit, a big sweater, a light and heavy weight zip up jacket, and hoodie that had all gone missing about two weeks before Christmas. He stated that he had reported it to the Social Worker, but did not hear anything back. On 01/31/24 at approximately 10:27 AM. a record review was conducted of the facility's grievance logs, which revealed no grievances related to Resident #26. A review of progress notes showed no documentation for missing personal property. On 01/31/2024 at approximately 10:34 AM, an interview was conducted with the Social Worker, where she indicated that Resident #26 did report these items missing to her, but that Resident #26 couldn't tell her if the items had been labeled or not. The Social Worker indicated that she did not complete a grievance log but does have a log for lost items that she keeps up with on her computer. She stated that she has debated on whether to file a grievance for missing items or not but decided to just keep a log on her computer instead. When asked to review the log for lost items, the Social Worker indicated she was not able to locate it right now. She stated she spoke with the son of Resident #26 about the missing items and advised him to notify staff when new items come in so that they can be labeled with the resident's name. On 01/31/2024 at approximately 11:00 AM, the policy titled Resident Grievances (dated 08/24/2009 and last revised date of 10/18/2017) revealed the Social Worker acts as the Grievance Officer. Under Procedures on section 2 of the policy number 3, the policy states, All alleged abuse, mistreatment, neglect, injuries of unknown source, and/or misappropriation of property by anyone furnishing services on behalf of the provider will be reported to the Administrator immediately, and will be referred to the Risk Manager, and/or designee, for investigation and reporting of abuse, neglect and misappropriation of property, as per federal and state law. On 01/31/24 at approximately 11:20 AM, an interview was conducted with the Administrator and the Social Worker. The Administrator indicated that the Delta side of the building has a book for grievance logs and presented the book with grievances for missing items. When asked if Resident #26's grievance would be in this book, she indicated that it would not. She indicated that Alpha side has it's own system of keeping up with missing items and Resident #26 is on the Alpha side. When asked how missing items are followed up, results documented, and/or resident notified of results, the Social Worker indicated that she would go look for her log on her computer and return with it. On 01/31/24 at approximately 11:55 AM, the Social Worker returned with a notebook of printed papers inside that included the name of Resident #26 with missing items noted. There was no follow up, investigation, or tracking record noted on the form. The Social Worker indicated that she mostly keeps up with the missing items and status of the search for them in her head. On 01/31/24 at approximately 01:44 PM, an interview was conducted with the Administrator. When asked what the expectation of the facility is when residents report missing personal property, the Administrator indicated that, when residents first bring it up to them and if it's something small such as a missing shoe, eyeglasses, or a remote, then they should look for it and wait to see if the items can be located. If they can find the personal property, then the issue is resolved and nothing else is done, but if it becomes a pattern then she would expect it to go on grievance form. Based on observations, interviews, and record review the facility failed to ensure that all grievances were resolved for 2 of 2 residents sampled for personal property. (Resident #11 and #26) The findings include: Resident #11 On 01/29/24 at approximately 1:00 PM, an interview was conducted with Resident #11 concerning personal property. Resident #11 indicated that he had a cell phone go missing a few months ago. He also stated when clothing goes to the laundry, it often goes missing and does not come back. When asked if he had notified the facility, Resident #11 stated that he had. A review was conducted of the facility's grievance logs which revealed no grievance form concerning Resident #11's missing cell phone. On 2/1/24 at approximately 9:57 AM, an interview was conducted with the facility's Social Worker. The Social Worker stated that she was notified of Resident #11's missing cell phone, but that she did not fill out a grievance form because she kept missing items on a log in her computer. A review of the missing item log revealed an entry stating, 12/4/23- [Resident #11] has been missing his phone. There was no resolution or follow up documentation concerning the missing cell phone. When asked about the resolution for the missing cell phone, the Social Worker stated, I did not complete the documentation of the conversation with the family, or that we looked for the phone in laundry and other places, and it could not be found. Social Worker A went on to state that she notified the family, and they were not pleased but the family would buy Resident #11 another phone. On 2/1/24 at approximately 10:42 AM, an interview was conducted with the Administrator concerning missing items. The Administrator indicated that her expectation would be to follow the policy for grievances.

Based on observations and interviews, the facility failed to maintain a safe environment for staff in the laundry room. The findings include: On 2/1/24 at approximately 12:40 PM, a tour was conducted of the laundry's dirty linen room, which revealed standing water on the floor in front and behind the three industrial washing machines that the facility uses to launder the resident's linens and personal clothing. (Photographic evidence obtained) On 2/1/24 at approximately 12:57 PM, an interview was conducted with the Supervisor of Laundry and Housekeeping concerning the leaking washing machines. The Laundry Supervisor indicated that the washing machines have been leaking for about 2 months now and that she has been reporting the issue to maintanence. The supervisor went on to state that a plumber did come out to look at the washing machines on 1/29/24, but they are still leaking. The Laundry Supervisor stated that they have been notifing the Administrator as well. She stated she tries to keep it mopped up as much as possible and have been putting blankets down to keep the water out of the walk area. On 2/1/24 at approximately 1:00 PM, an interview was conducted with Staff B, a maintenance worker, concerning the leaking washing machines. Maintenance Worker B stated that he had informed his supervisor a couple of weeks ago, and the issue had been looked at by an outside repairman a few days prior, but they could not find a leak. Maintenance Worker B stated that his helper checked the drains and found and removed a knife which helped some. He stated he was going to take a look at the machines again today to see if he could find the leak. On 2/1/24 at approximately 1:30 PM, an interview was conducted with the Administrator, who indicated that they have been working on the issue to try and get it fixed. The Administrator stated that another outside repairman was supposed to look at the machines again soon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to refer a resident with a diagnosis of a serious mental disorder for a PASARR (pre-admission screening and resident review) level II for 1 of 1 sampled residents reviewed for PASARR. (Resident #40) The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] and had a level I PASARR completed on 7/1/2021. Further review revealed the resident was prescribed Seroquel (an antipsychotic medication) on 8/26/2021 with a diagnosis of mood disorder. Review of a psychiatric physician progress note dated 10/20/2021 revealed the physician added a diagnosis of brief psychotic disorder and the resident had additional diagnoses of unspecified dementia without behavioral disturbance, depressive episodes, and anxiety disorder effective 8/11/2021. The record failed to contain evidence of a level II PASARR resident review. An interview was conducted with the facility Licensed Clinical Social Worker on 9/13/2022 at 3:31 PM. She reviewed Resident #40's record and confirmed a level II PASARR had not been completed. She stated she was not aware of the requirement to request a level II if a diagnosis of serious mental disorder was added after admission. Review of the facility policy for Social Services Practice Guidelines revealed the facility shall Assist in coordination with the Department of Children and Families to submit initial review or additional documentation for PASRR Level II screening.