**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and review of the facility's policy titled Pharmacy Services - Medication Administration: General, the facility failed to follow professional standards of nursing practice for two of 39 sampled Residents (R) (R386 and R17). Specifically, the facility failed to document an explanation for a missed dose of enoxaparin (a blood thinner used to prevent and treat blood clots) for R386 and failed to follow prescribed blood pressure parameters outlined in a physician's order and to ensure that an antihypertensive medication was transcribed accurately for R17 observed during medication administration. Findings include: Review of the undated facility policy Pharmacy Services - Medication Administration: General under the Intent section revealed, To facilitate that medications are administered as prescribed, in accordance with good nursing principles. Under the section titled Guidelines revealed, . The joint responsibility of the center and the pharmacy is to facilitate accurate medication administration . Medications are . administered with a valid prescribed order . If a dose of regularly scheduled medication is withheld, refused, or given at an alternate time . the nurse or CMA should document an explanation of each instance in the permanent medical record. 1. Review of medical records revealed, R386 was admitted with diagnoses that included but not limited to right femoral fracture, status post right hip open reduction internal fixation (ORIF), fall, and compression fracture of the lumbar vertebra. Review of R386's physician orders dated 1/29/2025 revealed, an order for enoxaparin 40 mg (milligram)/0.4 ml (milliliter) subcutaneously, to be administered daily. Review of R386's Electronic Medication Administration Record (eMAR) revealed that the medication was documented as administered daily, except on 2/16/2025. It was signed by Licensed Practical Nurse (LPN) AA with the comment See nurse note; however, no corresponding nurse's note was documented. Interview on 3/27/2025 at 2:45 pm with the Director of Nursing (DON) revealed, she contacted LPN AA, who stated she was unable to locate the enoxaparin at the time and had forgotten to document the reason it was not administered. LPN AA also reported that she had informed the incoming nurse on the next shift that the medication had not been given. The following day, the medication was located, and the resident received the next dose prior to discharge. As a result, one dose was missed during the resident's stay. The DON further stated that she expects staff to document a reason whenever a medication was not administered. In an interview with Pharmacist EE from [Name] Pharmacy on 3/26/2025 at 3:20 pm she stated that, upon reviewing the records, enoxaparin was dispensed three times during the resident's stay, each as a one-week supply-on 1/29/2025, 2/7/2025, and 2/14/2025. She confirmed that the facility could not have been out of stock of that medication. Pharmacist EE also provided the surveyor with a faxed confirmation showing that the medication was sent and delivered to the facility. The surveyor reviewed the delivery sheet, which confirmed that the medication was last delivered on 2/14/2025. In an interview with Pharmacist EE from Eldercare Pharmacy on 3/27/2025 at 4:05 pm, the surveyor asked her about the possible consequences if a resident missed a dose of enoxaparin. Pharmacist EE explained that enoxaparin was typically prescribed to prevent blood clots, and while it was difficult to say with certainty whether a single missed dose would directly result in a clot, the risk cannot be ruled out. She emphasized that the medication must be administered daily to maintain its effectiveness, as inconsistent dosing could compromise the resident's protection against thromboembolic events. 2. Review of the medical records for R17 revealed diagnoses that included, but not limited to, prostate cancer with metastasis, heart failure, Gastro-Esophageal Reflux Disease (GERD) hyperlipidemia, Benign Prostatic Hypertrophy (BPH), vitamin D deficiency and cognitive communication deficit. Review of R17's Physicians Orders revealed an order dated 2/18/2025 for lisinopril (an Angiotensin Converting Enzyme (ACE) inhibitor medication used to treat high blood pressure), one tablet by mouth one time a day. Hold if systolic blood pressure less than (<) 110, diastolic blood pressure greater than (>) 65. Review of the R17's eMAR revealed, on 3/4/2025 Blood Pressure(B/P) was 107/46, on 3/8/2025 B/P was 95/42, on 3/10/2025 B/P was 115/48, and on 3/18/2025 B/P was 90/48 however, lisinopril was documented as administered on these dates. During observation of medication administration on 3/25/2025 at 8:36 am with Certified Medication Assistant (CMA) BB revealed, R17's lisinopril was held by CMA BB because his blood pressure was outside of parameters, as the diastolic blood pressure was greater than 65. R17's blood pressure reading was 137/76. CMA BB was questioned about her decision and if the parameter was appropriate. The CMA BB then administered the medication, stating the appropriate use of the drug and admitting that the parameter was incorrect. She brought it to the attention of her supervisor the Resident Care Coordinator (RCC). The RCC also agreed that the order for the parameters had been entered incorrectly. In an interview on 3/25/2025 at 9:00 am, the RCC stated all nurses were able to transcribe physician orders. She verified that R17's orders related to the parameters for lisinopril was not transcribed accurately and should specify, hold for a diastolic blood pressure less than (<) 65.

Based on observations, staff interviews, and record review, the facility failed to cover clean laundry when transporting to prevent the spread of infection on one of five halls. These failures had the potential to increase the risk of infection transmission. Findings include: Observation on 3/25/2025 at 9:51 am revealed an unattended, uncovered clean clothes rack in the hallway. Further observation revealed two staff members transporting the hanging clothes from the cart to the resident rooms. An interview on 3/25/2025 at 9:52 am with the Environmental Supervisor (ES) revealed, that they have never covered the hanging clean laundry in the hallways, and that they use a sheet to cover the hanging clothes when transporting outside from the laundry room to the main building, as the laundry room was in a separate building from the main building. The ES further stated that their standard practice was not to cover the clean hanging laundry when in the hallways. An interview on 3/26/2025 at 1:20 pm with Laundry Aide (LA) DD revealed she has worked at the facility for four years. LA DD stated they cover the clothes with a sheet on top when transporting the clean hanging laundry from the laundry building to the facility and then remove the sheet when going from room to room. An interview on 3/27/2025 at 11:57 am with the Administrator revealed that the ES oversees the laundry operations. The Administrator stated that she expects clean laundry carts to be covered when transporting from building to building and in the hallways. The Administrator further stated that they have a clean hanging laundry rack which should also be covered when transported from building to building and in the hallways. The Administrator further confirmed that covering clean linen during transportation was the facility's standard of practice.

Based on staff interviews, record reviews, and review of the facility's policy titled, Abuse Prohibition, the facility failed to report an allegation of abuse reported immediately, but no later than two (2) hours after the allegations of abuse for one of five Residents (R) (R 17) reviewed for alleged abuse. This failure had the potential for allegations of abuse to not be identified and reported as required. Findings include: Review of the facility's policy titled Abuse Prohibition dated 12/30/2022, revealed It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property .Mandated Reporters: .Employees of a public or private agency engaged in professional health related services to elder persons or disable adults. The policy failed to include timeframes for the required reporting and failed to include who and what agencies allegations of abuse should be reported to. Review of R17's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/20/2023, located in R17's Electronic Medical Records (EMR) under the MDS tab revealed R17's Staff Assessment of Mental Status indicated R17's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). Review of R17's Patient Transfer Record-Inter Agency Referral revealed she was transferred to the hospital on 2/20/2023 with primary diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Review of the R17's Nurses Notes, dated 2/21/2023 completed by Licensed Practical Nurse (LPN) 2, included in the Facility Reportable Incident (FRI) provided by the facility, documented Family of R17, called the facility stated he had some news to share with the person in charge. He stated he was calling to give us a heads-up that when [R17] went to her wound care appointment, she told them she had been abused. Wound Care sent resident [R17] to the ER [emergency room] for breathing difficulty, where she continued to state she had been abused at the facility. He wanted to make sure we knew the family had nothing to do with the report and they had tried to tell the hospital that this was a behavior for her and that she was delusional or dreaming. During a telephone interview on 11/15/2023 at 9:26 am, the emergency room (ER) Patient Affairs Coordinator (PAC) 2 revealed, R17 complained of being abused at the facility while at the ER. PAC 2 revealed the resident could not recall any dates or names related to the alleged abuse. The PAC 2 stated the allegation was reported to the police and the State Survey Agency. During an interview on 11/15/2023 at 10:05 am, LPN2 stated she informed the Resident Care Coordinator (RCC) and the Director of Nursing (DON) regarding Family of R17's phone call and was told to document the conversation in a nursing note. When questioned if the family said the abuse was related to another resident or staff member, LPN2 stated the son did not say, and she did not ask if it was a resident or a staff member. LNP2 also stated R17 was care planned for embellishing stories. During an interview on 11/15/2023 at 10:30 am, the RCC was asked what she done after LPN2 reported the alleged abuse to her? The RCC stated it was discussed in the management group. When asked who was part of the management group, the RCC stated it was herself. The DON was present during the interview and stated honestly I can't remember. I don't recall if we reported the allegation. Because [we] assumed the hospital reported it [the allegation]. [I] don't remember doing anything. Generally, we report everything, [I] guess since it [the allegation] was reported at the hospital, and they did the investigation we left it at that. During an interview on 11/15/2023 at 10:40 am, the Director of Nursing (DON) stated she remembered R17 going to an appointment and then being sent to the hospital for respiratory issues. The DON also stated she did not recall what the facility did about it (the allegation of abuse). A further interview revealed the DON spoke to the Administrator during the morning meeting about the allegation of abuse. The DON further stated the allegation was not reported to the State Survey Agency and she could not recall if she spoke to resident, about the allegation. The DON also stated she did not talk to the resident's family about the allegation. When questioned if the allegation should have been reported to the State Survey Agency and other required agencies, the DON responded, technically the facility should have reported it. During an interview on 11/15/2023 at 10:50 am, the Administrator stated she did not recall the incident of the alleged abuse. When questioned what her expectation was related to reporting the Family of R17 allegation of abuse, the Administrator stated, once we heard from the family, we should have spoken to the resident who was at the hospital, and we should have reported it [the allegation of abuse].

Based on staff interviews, record reviews, and review of the facility's policy titled, Abuse Prohibition, the facility failed to conduct a thorough investigation following an allegation of abuse for one of five Residents (R) (R17) reviewed for alleged abuse. This failure not to conduct a thorough abuse investigation had the potential to result in other residents not being identified as potential victims of abuse. Findings include: Review of the facility's policy titled, Abuse Prohibition, dated 12/30/2022, revealed, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse .We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse . The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse . Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures . The facility's policy did not include a process for completing an investigation. Review of R17's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/20/2023, located in R17's EMR under the MDS tab revealed R17's Staff Assessment of Mental Status indicated R17's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). Review of R17's Patient Transfer Record-Inter Agency Referral revealed she was transferred to the hospital on 2/20/2023 with primary diagnoses of chronic obstructive pulmonary disease (COPD) exacerbation. Review of the R17's Nurses Notes, dated 2/21/2023 completed by Licensed Practical Nurse (LPN) 2, included in the Facility Reportable Incident (FRI) provided by the facility, documented Family of R17, called the facility stated he had some news to share with the person in charge. He stated he was calling to give us a heads-up that when [R17] went to her wound care appointment, she told them she had been abused. Wound Care sent resident [R17] to the ER [emergency room] for breathing difficulty, where she continued to state she had been abused at the facility. He wanted to make sure we knew the family had nothing to do with the report and they had tried to tell the hospital that this was a behavior for her and that she was delusional or dreaming. During an interview on 11/15/2023 at 10:05 am, LPN2 stated she informed the Resident Care Coordinator (RCC) and the Director of Nursing (DON) regarding Family of R17's phone call and was told to document the conversation in a nursing note. During an interview on 11/15/2023 at 10:40 am, the DON stated the facility should have conducted an abuse investigation. During an interview on 11/15/2023 at 10:50 am, the Administrator stated she did not recall the incident of alleged abuse. The Administrator stated it was her expectation after the facility learned of the allegation of abuse from the Family of R17, the facility should have investigated the allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure meaningful activities were offered for three of five Residents (R) (R3, R65, and R68) reviewed for dependent activities. This failure created the potential for the residents to experience a decreased quality of life. Findings include: 1. Review of R3's undated Face Sheet, provided by the facility, indicated R3 was with diagnoses which included dementia. Review of R3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/27/2023, revealed a Brief Interview of Mental Status (BIMS), score of three out of 15, which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed R3 was assessed for the following activity preferences as very important to her: having books, newspapers, and magazines to read, to listen to music, to be around animals, such as pets, to keep up with the news, to do things with groups of people, to do her favorite activities, to go outside to get fresh air when the weather is good, and to participate in religious services or practices. Review of R3's Care Plan initially dated 6/7/2019 and updated on 11/15/2023 during survey was provided by the facility revealed, Needs assistance to participate in activities due to hearing related to planned activity development as evidence by SNF (skilled nursing facility) residency. Interventions included: If patient needs hearing aids, ensure they are present and working. Hearing aids were not working at one time and had to be fixed. Place patient near the activity leader/speaker or in the line of sight of the activity leader. Place her close to the speaker if we are using the microphone. (Revision added on 11/15/2023): We usually sit right outside her room during hallway activities so she can see what we are doing even if she doesn't come out into the hall for the activity. Repeat instructions as needed to enhance communication and hearing. Check with her to make sure she is understanding what we are asking and watch her to see if she is able to hear what it is we are saying. Review of R3's Attendance Record for one (1) to1 Visits and Specialized Small Groups dated 9/2023, provided by the Activity Director (AD), revealed on 9/14/2023 the resident participated in an activity listed as Family Visit. There was no other documented evidence the resident participated or was offered to participate in any other activities for the month. Review of R3's Attendance Record for 1 to 1 Visits and Specialized Small Groups dated 10/2023, provided by the AD, revealed there was no documented evidence the resident participated or was offered to participate in any activities for the month. Review of R3's Attendance Record for 1 to 1 Visits and Specialized Small Groups, dated 11/2023, AD revealed on 11/2/2023 the resident participated in an activity listed as Family Visit. There was no other documented evidence that the resident participated or was offered to participate in any other activities for the month. During observations conducted throughout the survey on 11/13/2023, 11/14/2023, and 11/16/2023, R3 was observed in bed, and not participating in any meaningful activities that were important to her. 2. Review of R65's undated Face Sheet provided by the facility, indicated R65 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of R65's admission MDS with an ARD of 10/11/2023, revealed the facility assessed the resident to have a BIMS score of seven out of 15 which indicated R65 was severely cognitively impaired. Continued review of the MDS revealed the following activity preferences were very important to the resident: to be around animals, such as pets, to keep up with the news, to do my favorite activities, to go outside to get fresh air when the weather is good, and to participate in religious services or practices. It is somewhat important to listen to music I like, and not very important to have books, newspapers, and magazines to read, and it is important, but can't do or no choice to do things with groups of people. Review of R65's Care Plan dated 10/17/2023, provided by the facility, documented Expresses past and/or present activity interests (strength) related to decreased mobility as evidenced by patient expresses interest in activities. Interventions included: Past and/or resent interest in games including playing some games when he was younger. Past and/or present interest in music including listening to country music. Past and/or present interest outdoor activities including going hunting and fishing. He loved to go hunting and it didn't matter what he went hunting for as long as he got to go. And he loved working out in the yard. Past and/or present interest in pets/animals including having three (3) cats at home. Past and/or present interest in socializing with others including spending time with his family mostly. He says he used to be more social than he is now. Past and/or present interest in spiritual/religious including attending church services often when he lived in Kansas. Past and/or present interest in sports including going hunting and fishing. He is also a football fan who enjoys watching all levels of football both college and pro. UGA (University of Georgia) is his favorite team. Past and/or present interest in (television)TV/Internet including watching ABC, CBS, [NAME], ESPN (channel listings), and the Weather Channel. He likes to watch sports, especially football and UGA football. Provide a schedule of events to post in his/her room. Review of R65's Attendance Record for 1 to 1 visits and Specialized Groups dated 10/2023, documented the resident participated in the following activities: 10/5-admitted , 10/9-family visit, 10/10-family visit, 10/11-family visit, 10/13- family visit, 10/16-family visit, 10/19-barbershop and family visit, 10/20-family visit, 10/23-family visit, 10/26-family visit, and 10/31-family visit. There was no documented evidence the resident participated in or offered to participate in any facility provided activities. Review of R65's Attendance Record for 1 to 1 visits and Specialized Groups dated 11/2023, documented the resident participated in the following activities: 11/02-family visit, 11/9, family visit, and 11/14-family visit. There was no documented evidence the resident participated in or was offered to participate in any facility provided activities. During observations conducted during the survey on 11/13/2023, 11/14/2023, and 11/16/2023, R65 was observed lying in bed, and not participating in any meaningful preferred activities. 3. Review of R68's undated Face Sheet provided by the facility, indicated R68 was admitted with diagnoses which included dementia. Review of R68's significant change in status MDS with an ARD of 9/25/2023, located in the resident's EMR under the MDS tab, revealed the Staff Assessment of Cognitive Skills indicated the resident's cognition was severely impaired-never/rarely made decisions. The resident was not assessed for preferences in activities. Review of R68's Care Plan dated 10/11/2023, documented Expresses past and/or present activity interests (strengths) related to planned activity development as evidenced by SNF (Skilled Nursing Facility) Residency. Interventions included: Past and/or present interest in arts/crafts including cooking for all. She loved cooking for her family, Past and/or present interest in music including listening to gospel music, Past and/or present interest in outdoor activities including gardening and doing yard work, Past and/or present interest in socializing with others including spending time with her family, Past and/or present in spiritual/religious including attending church services and listening to gospel music, her faith is very important to her, Past and/or present interest in TV/Internet including watching the news, lifetime channel and mystery/crime shows, provide a schedule of events to post in his/her room, provide assist to/from activities of interest as needed, assist with transportation to/from activity settings, and place patient near activity leader. Review of R68's Attendance Record for 1 to 1 visits and Specialized Groups dated 9/2023, documented the resident participated in the following activities: 9/4-family visit, 9/7-hospital, 9/18-returned from hospital, and 9/19- family visit. There was no documented evidence that the resident participated in or was offered to participate in any facility provided activities. Review of R68's Attendance Record for 1 to 1 visits and Specialized Groups dated 10/2023, documented the resident participated in the following activities: 10/11-hospital, 10/16-returned from hospital, and 10/18-family visit. There was no other documented evidence the resident participated in or was offered to participate in any facility provided activities. Review of R68's Attendance Record for 1 to 1 visits and Specialized Groups dated 11/2023, documented the resident participated in the following activities: 11/1-family visit. There was no documented evidence the resident participated or was offered to participate in any facility provided activities. During observations conducted during the survey on 11/13/2023, 11/14/2023, 11/15/2023, and 11/16/2023, R68 was observed sitting in the hallway in a Geri-chair, staring at the wall and lying in bed. The resident was not observed participating in any activities. During an interview on 11/13/2023 at 3:42 pm, Family Member (FM)1 stated R68 was supposed to be out of bed. FM1 also stated R68 liked to watch television shows such as westerns and enjoyed listening to music. During an interview on 11/16/2023 at 8:36 am, the Activity Director (AD), was questioned concerning R3, R65, and R68's lack of documented evidence that the residents participated or were offered to participate in facility provided activities? The AD stated she was trying to get R3 back into activities, R65 had not shown any interest in getting out of the room. The AD stated as far as R68 attending group activities, when there was too much going on around her, we had to take her back to the hallway or to her room. The AD was asked what the activity department was doing for residents who needed one-to-one activities? The AD stated it was just her in the activity department, so she tried to keep her eyes and ears open to see if the residents needed anything. The AD further stated she tried to do activities with the residents as needed; however, there was no set schedule for dependent residents. During the interview, the AD confirmed the observations made by the surveyor of the three residents not participating in any activities. During an interview on 11/16/2023 at 9:46 am, the Administrator stated it was her expectation that activities were provided for all residents. The Administrator stated it was also her expectation for the AD to go around with the activities cart and try to do activities that interest the dependent residents.

Based on staff interview and record review, the facility failed to ensure four of four Certified Nurse Aides (CNA) (CNA 1, CNA3, CNA4 and CNA5) and one of one Licensed Practical Nurses (LPN) (LPN 4) reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present. Findings include: Review of the Facility Assessment, reviewed 9/8/2023, revealed under the category I. Resident Profiles showed the facility accepted Psychiatric/Mood Disorders of Psychosis (Hallucinations, Delusions, etc.) Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Anxiety Disorder Unspecified, Schizophrenia, Schizoaffective, Post Traumatic Stress Disorder, Behaviors not listed else where [sic], Pasarr Level II Review of five random direct care employee files with Human Resources (HR) on 11/16/2023 at 4:00 pm revealed four CNAs and one LPN did not have any behavioral health training on the facility provided list of education courses and/or in-service sign in sheet. The staff roster showed CNA1 was hired on 2/16/2015 and the list of courses taken in 2023 did not include anything related to behavioral health training. The staff roster showed CNA3 was hired on 10/1/2014 and the list of courses taken in 2023 did not include anything related to behavioral health training. The staff roster showed CNA4 was hired on 7/26/2023 and the list of courses taken since hire did not include anything related to behavioral health training. The staff roster showed CNA5 was hired on 7/26/2021 and the list of courses taken in 2023 did not include anything related to behavioral health training. The staff roster showed LPN4 was hired on 10/1/2014 and the list of courses taken in 2023 did not include anything related to behavioral health training. During an interview on 11/16/2023 at 4:00 pm, while reviewing the employee files with HR, HR stated They are starting the behavioral health training in December [2023]. When asked to clarify if that was an annual training or the first time it was being completed, HR clarified it was the first time it was being done. During an interview on 11/16/2023 at 5:10 pm, the Administrator stated they [the facility] did not find a policy about behavioral health training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and review of the facility's policy titled, Notice of Transfer or Discharge from Center, the facility failed to ensure five of five Residents (R) (R11, R16, R64, R74 and R79) reviewed for facility initiated emergent hospital transfers were provided with written transfer notice that contained all required information. This failure has the potential to affect the residents and/or the Resident Representatives (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Notice of Transfer or Discharge from Center, reviewed 12/30/2022, showed: Intent It is the intent of this center to provide notification of a transfer or discharge in writing. Guideline A completed Notice of Transfer or Discharge form will be provided to the patient or legal representative. This notice: -Will be completed in a language and manner they can understand .Is required for all discharges except for death in the facility. 1. Review of R11's undated Face Sheet, provided by the facility revealed the R11 was admitted to the facility on [DATE] with diagnoses that included kidney stones. Review of R11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11 out 15 which indicated the resident was cognitively intact. During an interview on 11/13/2023 at 2:28 pm, R11 stated, I've been to the hospital several times, last April I was non-responsive; last time I went [to the hospital] was two months ago for kidney stone surgery. Review of R11's MDS showed discharge to hospital assessments with ARDs of 3/23/2023, 6/21/2203, 7/20/2023, and 9/25/2023. Review of R11's Nurse's Notes, Progress Notes, Data Collection, and Scanned Docs [Documents] tabs located in the resident's Electronic Medical Record (EMR) showed no evidence R11 and/or her RR received a written notice of transfer/discharge. Review of the Notice of Transfer or Discharge dated 3/23/2023, 6/21/2203, 7/20/2023, and 9/25/2023 revealed a section at the bottom of the form: Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy-Resident Representative's Copy- Chart Copy None of the four forms had any of the check boxes marked. During an interview on 11/16/2023 at 3:08 pm, R11 was shown the written transfer notice form and asked if she had received one for each transfer. R11 reviewed the form and stated, No, I've never seen that form before. 2. Review of R64's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R64's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R64 was transferred to the hospital on 1/8/2023 due to an unwitnessed fall. 3. Review of R16's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R16's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R16 was transferred to the hospital on 8/28/2023 due to an unwitnessed fall, and on 8/31/2023 due to becoming unresponsive later in the day after experiencing delusions and hallucinations throughout the day. During an interview on 11/15/2023 at 12:25 pm, the Health Information Manager (HIM) stated residents were not given written information during a resident's transfer to the hospital, the resident's representative was notified via telephone; however, no written information was given to a resident and/or their representative prior to, upon, or post transfer. 4. Review of R74's undated Face Sheet, provided by the facility showed the resident was admitted to the facility on [DATE] with diagnoses that included hydronephrosis with renal and ureteral calculous, urinary tract infection, chronic kidney disease, hypertensive heart failure, and diverticulosis. Review of R74's Nurse's Notes located in the resident's EMR under the Nurse's Notes tab showed: 7/28/2023. 17:46 [5:46] pm at 10 am Residents B/P 88/44, per staff has had weight gain since admission on the 25th, dizzy, . PT [Physical Therapy] states placed resident back into bed because of weakness. Notified NP [Nurse Practitioner] sent to ER [Emergency Room] to evaluate and treat. Family notified.8/15/2023. 12:46 pm Resident nephrostomy tubes were not draining and had blood in the tubing this am [morning]. Flush attempted by RN [Registered Nurse], flush was unsuccessful. Resident sent to [hospital name] via transport. Resident was alert and oriented upon leaving facility vital signs were within normal limits. RP [RR name], and NP [Nurse Practitioner name] both notified. 8/17/2023. 18:01 [6:01 pm] 08:00 [8:00 am] Therapy aide came to unit 3 for nurse to check on resident, stated resident was having respiratory difficulty O2 sat [oxygen saturation] 72-74 with O2 at 2lpm [liters per minute], resident lethargic. SOB [short of breath]. call D.O.N. send to ER report called to [hospital name] .EMS called for transport. resident transported to [hospital name] 09:00 [9:00 am]. resident admitted to hospital DX [diagnosis]: severe UTI [urinary tract infection]. Review of R74's Notice of Transfer or Discharge dated 7/28/2023, 8/15/2023, and 8/17/2023, provided by the facility showed at the bottom of the form Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. For all three forms, nothing had been Checked/Marked to indicate R74 and/or his RR received copies of any of the three forms. During an interview on 11/16/2023 at 2:10 pm, the Director of Nursing (DON) reviewed the forms and stated, Have transfer notices for all and nurses' notes, but none of the boxes are checked [at the bottom] so no, the resident and representative didn't get a copy. 5. Review of R79's undated Face Sheet, provided by the facility showed R79 was admitted to the facility on [DATE] with diagnoses that included femur fracture, urinary tract infection, dementia, shoulder fracture, chronic kidney disease, and hypertensive heart disease. Review of R79's written Notice of Transfer or Discharge, dated 8/4/2023 provided by the facility revealed Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. There were no Checks/Marks to indicate R79 and/or his RR received a copy of the form. Review of R79's Nurse's Notes and Progress Notes tabs revealed no documented evidence why R79 was sent to the hospital on 8/4/2023. During an interview on 11/15/2023 at 9:11 am regarding the provision of the transfer/discharge notice to the resident & RR, the DON stated, .The notice is scanned in the chart, goes to financial, and it goes in the record. We don't give it to the family, and no, the resident doesn't get a copy either.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to ensure the resident and/or the Resident Representative (RR) was provided with the notice of the facility's notice of bed-hold policy for five of five Residents (R) (R11, R16, R64, R74, and R79) reviewed for hospital transfers. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility policy titled Bed Hold During Hospital Stays and Therapeutic Leaves, reviewed 12/30/2022, showed: Intent It is the intent of this nursing center to offer all residents and/or his/her designee the choice of either paying the appropriate amount to hold the bed when the resident goes to the hospital or on therapeutic leave or releasing the bed and being readmitted to their previous room if available or to the first available bed. A letter must be mailed to the resident and/or responsible party within twenty-four (24) hours of the resident's admission to the hospital or the start of the resident's therapeutic leave. The decision regarding holding the bed or releasing the bed must be submitted in writing to the Administrator and/or his/her designee .The Financial Controller, or Administrator's designee, will attempt to telephone the resident and/or the responsible party to explain the process and make arrangements to obtain a signed decision regarding the holding of the bed and payment of bed hold. The date and time of the telephone call will be documented. Upon notification that a resident has been transferred to the hospital or is going on therapeutic leave, the Financial Controller, or the Administrator's designee, will prepare a bed hold letter to be sent to the resident and/or his/her designee. The letter to be used is in the Business Office Forms Manual and is to be retyped on facility letterhead. This letter will specify the rules regarding absence. This letter will indicate the date that private bed hold begins. This letter will specify the amount to be paid per day on private bed hold. This letter will provide a space for signature of the resident and/or his/her designee indicating the desire to pay private bed hold or a space to decline to do so. The letter will advise of the resident's right to return to the facility to their previous room if available or to the first available bed if the resident declines to hold the bed provided that the resident requires the services provided by the Facility and the Facility is able to meet the clinical needs of the resident. The letter must be mailed to the resident and/or responsible party within twenty-four (24) hours of transfer. 1. Review of the R11's undated Face Sheet, provided by the facility showed R11 was admitted to the facility on [DATE]. During an interview on 11/13/2023 at 2:28 pm, R11 stated, I've been to the hospital several times, last April I was non-responsive; last time I went [to the hospital] was two months ago for kidney stone surgery. Review of R11's MDS showed discharge to hospital assessments with ARDs of 3/23/2023, 6/21/2203, 7/20/2023, and 9/25/2023. Review of R11's) Nurse's Notes, Progress Notes, Data Collection, and Scanned Docs [Documents] tabs located in the resident's EMR showed no documented evidence the resident and/or the RR received a written bed-hold policy prior to or upon discharge to the hospital. Review of R11's written Notice of Transfer or Discharge provided by the facility and contained the information regarding the written bed hold notices for the four transfers showed a section at the bottom of the form: Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy Resident Representative's - Copy -Chart Copy None of the four forms had any of the boxes Checked/Marked to indicate the resident was provided with the facility's bed-hold policy prior to or upon transfer to the hospital. 2. Review of R64's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R64's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R64 was transferred to the hospital on 1/8/2023 due to an unwitnessed fall. 3. Review of R16's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R16's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R16 was transferred to the hospital on 8/28/2023 due to an unwitnessed fall, and on 8/31/2023 due to becoming unresponsive later in the day after experiencing delusions and hallucinations throughout the day. During an interview on 11/15/2023 at 12:25 pm, the Health Information Manager (HIM) stated residents and/or their representatives were not given written information regarding the facility's bed hold policy prior to or upon transfer to the hospital. 4. Review of R74's undated Face Sheet, provided by the facility showed the resident was admitted to the facility on [DATE]. Review of R74's Nurse's Notes, located in the resident's EMR under the Nurse's Notes tab showed the resident was transferred to the hospital on 7/28/2023, 8/15/2023, and 8/17/2023. The notes revealed no documented evidence that the resident and/or representative received bed-hold notice information prior to each transfer. Review of R74's three Notice of Transfer or Discharge forms dated 7/28/2023, 8/15/2023, and 8/17/2023 revealed each form contained information regarding the written bed hold notices. Continued review of the forms revealed Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. None of the three forms had any of the check boxes Checked/Marked to indicate the resident was provided with the facility's bed-hold policy prior to or upon transfer to the hospital. 5. Review of R79's undated Face Sheet provided by the facility showed R79 was admitted to the facility on [DATE]. Review of R79's written Notice of Transfer or Discharge, form dated 8/4/2023, provided by the facility revealed the form included information regarding the written bed hold notice policy. Continued review of the form revealed Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. The form did not have any of the boxes Checked/Marked to indicate the resident was provided the facility's bed-hold policy prior to or upon transfer to the hospital. During an interview on 11/15/2023 at 9:11 am, the Director of Nursing (DON) stated, .The notice is scanned in the chart, goes to financial, and it goes in the record. We don't give it to the family, and no, the resident doesn't get a copy either. The DON confirmed the facility's Notice of Transfer or Discharge form contained the bed hold policy; however, residents and/or the RR were not provided the forms prior transferring to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that two residents (R#12 and R#260) were provided showers according to their preferences. The sample size was 20 residents. Findings include: Per the Director of Nursing (DON) the facility did not have a policy related to resident bathing/showering. 1. Review of the clinical record for R#12 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to diabetes, chronic kidney disease, hypertension (HTN), and hyperlipidemia. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section F revealed that making decisions related to bathing was very important to resident. Review of the shower schedule for R#12, who resides in room [ROOM NUMBER]W, revealed she was scheduled to receive showers on Tuesday and Friday during the day shift. Review of the facility shower sheets with Licensed Practical Nurse (LPN) BB on 11/12/22 at 7:45 a.m., revealed there were no shower sheets completed for R#12 to indicate showers were completed for September 2022, October 2022, and November 1 through November 12, 2022. Interview on 11/11/22 at 9:32 a.m. with R#12, stated she was supposed to get a bath twice per week, but only received a bath on Tuesdays. She stated she would like to bathe twice a week. During further interview, she stated she did not know why she did not receive her baths as scheduled. During an interview on 11/12/22 at 7:40 a.m. with R#12, stated staff did not offer her a bed bath, or shower yesterday. Additionally, she said she did not receive a shower this week. 2. Review of the clinical record for R#260 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to traumatic subdural hemorrhage, Alzheimer's disease, anemia, diabetes, hypertension (HTN), chronic kidney disease, anxiety, and atherosclerotic heart disease. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Section F revealed that making decisions related to bathing were very important to resident. Review of the shower schedule for R#260, who resides in room [ROOM NUMBER]D, revealed she was scheduled to receive showers on Tuesday and Friday during the day shift. Review of the shower sheets with LPN BB on 11/12/22 at 7:45 a.m., revealed no shower sheet was completed for R#260 to indicate showers were completed for November 1 through November 12, 2022. Interview on 11/11/22 at 9:32 a.m. with R#260, stated she had been in the facility for three weeks. She stated she had only received one bed bath and had not had her hair washed or showered since her arrival. She stated the facility explained she would receive regular bathing and did not know why she had not received any baths or showers. Interview on 11/12/22 at 7:40 a.m. with R#260, she stated staff did not offer her a bed bath, or shower yesterday. She said she would like to have a shower and wash her hair. She again explained that she had not showered or washed her hair since admission to the facility. Interview on 11/12/22 at 7:45 a.m. with the Licensed Practical Nurse (LPN) BB, stated the Certified Nursing Assistants (CNA) provided the baths and showers for the residents, two times per week. She stated the CNAs completed a bath sheet for each resident when bathed. She added that if a resident refused a bath, the bath sheet still had to be filled out, and the word refused is written on the sheet. She said the nurse was supposed to be informed if a resident refused their bath or shower. During further interview, she stated that the CNAs placed the completed forms in a box outside of her office door, and she filed them. When asked why there are no bath sheets completed for R#12 and R#260, LPN BB explained that she assumed both residents received their showers. She said it was her expectation for the CNAs to offer the residents a bath or shower on their scheduled days, and it was her expectation for the shower sheets to be completed for each resident. Interview on 11/12/22 at 7:56 a.m. with the DON, she stated it was the responsibility of LPN BB to monitor the bathing forms to ensure that residents received a bath or shower. She stated if a resident refused a shower, a bath sheet would still be filled out and documented as refused. She stated she expected the CNAs and nurses to offer a bath or shower to each resident on their scheduled bath/shower days. Interview on 11/13/22 at 10:17 a.m. with CNA CC, she stated that residents receive a bath or shower two days per week. She explained that each resident had a bath form filled out, which indicated whether they received or refused their bath/shower. She stated the CNAs gave the completed forms to LPN BB after completion. LPN BB had a box on the wall outside her office to place the forms if she was not in her office to receive them.

Based on record review, staff interviews, and review of the policy titled Patient's Plan of Care, the facility failed to develop a person-centered care plan for one resident (R) (R#261) for refusal of care and medications. The sample size was 20 residents. Findings include: Review of the policy titled Patient's Plan of Care, reviewed 12/4/21, revealed each patient will have a person-centered comprehensive plan of care developed and implemented to meet patient's medical, physical, mental, and psychosocial needs. A continued review revealed if a patient chooses to decline certain services or treatments that staff believe to be indicated to assist the patient in reaching his or her highest practicable level of well-being or safety, the comprehensive care plan would identify the care or service being declined, the risk the declination poses to the patient, and efforts by the interdisciplinary team to educate the patient and the representative, and attempts to find alternative means to address the identified risk/need. Review of the History and Physical (H&P) for R#261, dated 11/22/21, revealed under Review of Systems: psychiatric refusal of care and medications. Review of updated care plan dated 9/2/22, did not have evidence that R#261 had a care plan problem to include refusal of care and medications. Review of the Nursing Notes dated 3/27/22 at 11:58 a.m. revealed that R#261 refused to take her scheduled medications. Resident stated she would wait for her son to arrive before taking any medications. Staff educated resident on the importance of medication compliance, and resident verbalized understanding. Review of the Nursing Notes dated 8/23/22 at 11:21 p.m. revealed that R#261 was confused, spat out her medications, and refused water. Review of the Medication Administration Record (MAR) dated 11/2021 through 3/2022 revealed R#261 refused the following prescribed medications: Hydralazine 50 milligrams (mg) 11 times; Boost supplement 1 carton four times; Ferrous Sulfate 65 mg seven times; Amlodipine 10 mg three times; Vitamin D3 125 micrograms (mcg) three times; Vitamin B-12 1000 mcg three times; Oxybutynin five mg three times; Folic acid one mg one time. Interview on 11/12/22 at 11:00 a.m. with the Minimum Data Set (MDS) Coordinator, stated she develops the comprehensive care plan for each resident based on information from family interviews, the clinical history and physical (H&P), hospital documentation, resident interviews, and the admission assessment. She stated that the staff did not notify her of R#261's refusal of medications. She stated she reviews the MAR to determine medication and treatment compliance. She confirmed that R#261 was not care planned for medication refusal and should have been. Interview on 11/12/22 at 12:35 p.m. with the Licensed Practical Nurse (LPN) AA, stated if a resident refuses care or medications, she would document the refusal on the MAR. LPN AA stated she would fill out a communication form for the physician and Nurse Practitioner (NP) to ensure they were aware of the resident's refusal. She stated the only person that could create a care plan for a care area was the MDS Coordinator. She stated she was unaware how the MDS Coordinator was made aware of a care area issue for a resident.