Based on staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) after a significant change occurred for one of 50 sampled residents (R) (R44). The facility census was 107 residents. Findings include: Review of Minimum Data Set (MDS) revealed that there was no significant change MDS for R44 completed in the electronic health record (EHR) after a significant change occurred. Record review of SBAR Communication Form and Progress Notes dated 10/19/2023 revealed: The Change in Condition/s reported on this CIC (change in condition) evaluation are/were Pain (uncontrolled) as a change in R44's condition did occur. Interview on 3/14/2024 at 12:43 pm with MDS Coordinator CC revealed that a Significant Change MDS assessment should have been completed, but it was not. MDS Coordinator CC confirmed that a Significant Change MDS assessment was not in the EHR. Interview on 3/14/2024 at 12:50 pm with the Director of Nursing (DON) confirmed that there should have been a significant change MDS completed on R44. Interview on 3/14/2024 at 1:09 pm with MDS Coordinator CC confirmed that the Significant Change was missed. MDS Coordinator CC stated that all preventative care was being implemented, however the Significant Change was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plans - Baseline, the facility failed to add anticoagulant (blood clotting medication) use to the baseline care plan for one of 50 sampled residents (R) (R267). The deficient practice had the potential for lack of interventions to monitor anticoagulant treatment that could lead to blood clotting issues. Findings include: Review of the facility policy titled Care Plans - Baseline updated December of 2022 revealed the Policy Statement was A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Under the section titled Policy Interpretation and Implementation number two revealed the interdisciplinary team will review the health care practitioner's orders to implement a baseline care plan to meet the residents immediate care needs. Review of the electronic health record (EHR) revealed R267 was who was admitted to the facility with diagnoses listed but not limited to encounter for other orthopedic aftercare. Review of R267's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/2024 revealed admission date was 3/6/2024 from a short-term general hospital. Review of R267's baseline care plan initiated on 3/6/2024 revealed there was no focus, goal, or interventions related to anticoagulant use. Review of the comprehensive nursing admission assessment dated [DATE] revealed under section R subtitle Physician Orders/Medication Review number two - current medications, the nurse marked, number one - insulin, number six - anticoagulant, and number eight - narcotics/opioids. Review of the EHR revealed physician's orders for R267 included but was not limited to Lovenox injection solution prefilled syringe 40 milligrams (mg)/0.4 milliliters (ml), inject 40 mg subcutaneously one time a day for deep vein thrombosis (DVT) prophylaxis until 3/28/2024. Start date 3/8/2024. The medication monitoring order - Anticoagulant medication monitoring. Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle, joint pain, lethargy, bruising, sudden changes in metal status and or vital signs, shortness of breath, nose bleeds - document Y if monitored and not of the above observed, N if monitored and any of the above was observed. Select chart code other/see nurses notes and progress note findings. Review of the EHR revealed medication orders for R 267 included but was not limited to: Lovenox 40 mg/0.4 mg, inject 40 mg subcutaneously one time a day for DVT (deep vein thrombosis-blood clots) prophylaxis until 3/28/2024 and the nursing staff documented R267 received the Lovenox every day starting on 3/8/2024. Review of education / In-Service Attendance Records revealed on 6/23/2023 an in-service was presented by the Director of Nursing (DON) to staff related to Baseline Care Plan. The discussion covered how to access the baseline care plan in the EHR and the use of four focuses on all residents admitted (falls, pain, skin, and diagnoses). 22 Nursing staff signed the attendance in attestation of attendance. On 7/13/2023 an in-service was presented by the DON related to Baseline Care Plans and Alert Charting with two nursing staff signatures in attestation of attendance. Interview on 3/13/2024 at 10:14 am with LPN HH revealed residents who receive anticoagulants are monitored for increased bruising, prolonged bleeding, s/s of GI bleed. She stated any symptoms of suspected abnormal bleeding/ increased bruising is reported to the physician. She reported the care plan interventions flow into the E-MAR (electronic medication administration record) but she stated the care plan should include interventions for each high risk medication class. She stated all nurses can update the care plan. She revealed that on admission the nurse will create a basic care plan (baseline care plan) based upon the admission assessment which becomes part of the comprehensive care plan. She stated the MDS Coordinator builds the care plan based upon the MDS assessment. Interview on 3/13/2024 at 11:38 am with LPN MDS Coordinator CC revealed that the comprehensive care plan is due 45 days after admission. She stated R267 was admitted on [DATE]. She verified and confirmed the care plan for R267 did not address the use of anticoagulants for prophylaxis. She stated the use of anticoagulant or special care needs should be addressed on the baseline care plan. She stated the baseline care plan does become part of the comprehensive care plan. She stated nursing is responsible for completing the baseline care plan. Interview on 3/13/2024 at 11:41 am with the DON, she confirmed and verified the care plan for R267 did not include anticoagulant use. She stated it should have been captured on the baseline care plan by the admission nurse. She stated her expectation was for the anticoagulant to be captured on admission or during the managers 24 to 48-hour chart review. She stated the managers complete a chart review for all new admissions within 24 to 48 hours of the admission. Interview on 3/13/2024 at 3:10 pm with the Assistant Director of Nursing (ADON), she revealed regarding in-service training that one of the items covered in June 2023 was baseline care plans and assessments, she revealed that baseline care plans had been identified by the QAPI (quality assurance performance improvement) group as a potential area of improvement. She stated it was a result of the QAPI recommendation that she chose to educate on this topic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to maintain respiratory equipment consistent with professional standards for three of 50 sampled residents (R) (R91, R74, and R271). Specifically, the facility failed to bag a CPAP (continuous positive airway pressure) mask when not in use, clean/change/install filters on oxygen (O2) concentrators (machine that administers O2). The deficient practice had the potential to cause infection. Findings include: Review of the facility policy titled Oxygen Administration revised date December 2022 revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the resident goals and preferences. Under Policy Explanation and Compliance Guidelines: 5. Staff shall perform hand hygiene, and don gloves when administrating oxygen or when in contact with oxygen equipment, other infection control measures include: e. Keep delivery devices covered in plastic bags when not in use. 7. Cleaning and care of equipment should be in accordance with facility policies for such equipment. 8. Storage of oxygen should be in accordance with the facility's oxygen safety policy. 1. Review of R91's quarterly Minimum Data Set (MDS) dated [DATE] in the electronic health record (EHR) revealed in Section C - Cognitive Patterns- a Brief Interview for Mental Status (BIMS) score of 13, indicating little or no cognitive impairment, in Section GG - Functional Abilities and Goals-Independent, and in Section O - Special Treatments, Procedures, and Programs- CPAP. Review of Physician's orders for R91 dated 12/30/2023 CPAP: Monitor placement of mask-at bedtime for Sleep Apnea and as needed for sleep. Clean CPAP/BiPAP (bilevel positive airway pressure) Reservoir (clean CPAP/BiPAP Reservoir in the morning) Review of the Care plan dated 12/30/2023 for R91 included Focus Area-The resident has altered respiratory status/difficulty breathing r/t [related to] Sleep Apnea. Goal-The resident will have no complications related to SOB [shortness of breath] though the review date. Intervention-BIPAP/CPAP/VPAP [variable positive airway pressure] SETTINGS: as per medical director / nurse practitioner orders. Observation on 3/12/2024 at 10:12 am revealed that R91's CPAP mask was not bagged. Observation on 3/14/2024 at 8:52 am revealed that R91's CPAP mask was not bagged. Interview on 3/14/2024 at 8:52 am revealed R91 sitting in the bed eating breakfast. R91 stated that he had minor surgery on his toe yesterday. R91's CPAP mask was not bagged. R91 stated that he was not able to bag his CPAP mask due to the bag being out of his reach. R91 stated that it takes him about 15 minutes to reach the plastic bag as staff was always busy around mealtime. Interview on 3/14/2024 at 9:09 am with LPN DD revealed that R91's CPAP mask should be cleaned and bagged after every use. Staff are supposed to assist with bagging. LPN DD confirmed that R91's CPAP mask was not bagged. Interview on 3/14/2024 12:50 pm with the DON confirmed that when CPAP mask/machines are stored they should be clean and bagged. 2. Review of the EHR revealed R74 was admitted to the facility with diagnoses listed but not limited to chronic obstructive pulmonary disease (COPD). Review of R74's significant change MDS assessment with an ARD of 12/14/2023 revealed in Section C-Cognitive Patterns-a BIMS score of 12, which indicated moderate cognitive impairment. Section O-Special Treatments, Procedures, and Programs revealed R74 received oxygen therapy while a resident. Review of R74's care plan indicated a focus of respiratory impairment related to COPD/pulmonary embolus (PE)/diagnosis of acute respiratory failure (date initiated 4/12/2022). Goals included but not limited to: will have no acute respiratory distress (date initiated 4/12/2022). Interventions included but not limited to: administer O2 two liters via nasal cannula (NC) (date initiated 4/12/2022). Review of the EHR revealed physician's orders for R74 included but not limited to oxygen at two liters per minute via nasal cannula (12/8/2022), monitor oxygen saturation, notify physician if saturation drops below 90 percent (12/8/2022), and oxygen tubing change weekly, label each component with date and initials every Sunday morning (12/24/2023). Observation on 3/12/2023 at 3:54 pm of R74 in bed wearing O2 via NC, the O2 concentrator was set of two liters per minute (LPM), the dark gray/black filter located on the back of the O2 concentrator appeared to have a light gray, fuzzy substance covering it. Observation on 3/13/2024 at 9:30 am of R74 in bed wearing O2 via NC, the concentrator was set at two LPM, the dark gray/black filter located on the back of the concentrator was noted to have a light gray, fuzzy substance around the edges and across the filter. Observation and interview on 3/13/2024 at 2:18 pm with the ADON, she confirmed and verified the O2 concentrator used by R74 had a filter on the back of the concentrator and was covered with a light gray, fuzzy substance. She stated the Central Supply Clerk is responsible for changing the filters on the O2 concentrators, but she did not know how often. 3. Review of the EHR revealed R271 was admitted to the with diagnoses listed but not limited to acute and chronic respiratory failure with hypoxia. Review of R271's admission MDS assessment with an ARD of 3/8/2024 revealed the assessment was in progress and not completed. Review of R271's care plan indicated a focus of care on shortness of breath (SOB) (date initiated 3/12/2024). Goals included but not limited to R271 will have no complications related to SOB through the next review date (date initiated 3/12/2024). Interventions included but not limited to administer oxygen as ordered by the physician/nurse practitioner (dated initiated 3/12/2024). Review of R271 baseline care plan dated 3/9/2024 revealed under section three titled Health Conditions/Special Treatments 1a was marked oxygen therapy. No staff signature as on the document. Review of the EHR revealed physician's orders for R271 included but not limited to oxygen saturation every shift, notify physician if saturation less than 90%, Oxygen at four liters per minute via nasal cannula, oxygen tubing: change weekly, label each component with date and initials. Observations on 3/12/2023 at 2:54 pm of R271 sitting up in a wheelchair, wearing O2 via NC set at 3.5 liters per minute. The O2 concentrator was clean, but the filter was missing from the compartment on the back of the O2 concentrator. Observations on 3/13/2024 at 10:30 am of R271 sitting up in a wheelchair wearing her O2 via NC. The O2 concentrator was set at 3.5 liters per minute and the back of the O2 concentrator had an area for a filter, but there was no filter placed on the O2 concentrator. Observation and interview on 3/13/2024 at 2:18 pm with the ADON of R271's O2 concentrator revealed it had an area on the back of the machine intended for the filter but there was no filter located on the O2 concentrator. The ADON verified and confirmed the filter was missing from the O2 concentrator. She stated the Central Supply Clerk was responsible for changing the filters on the O2 concentrators, but she did not know how often. Review of Oxygen Audit forms dated 2/28/2024 revealed R74 was listed as part of the audit, the tubing was dated 2/28/2024, the filter and concentrator clean was marked yes. R271 was not listed as part of the audit. Interview on 3/13/2024 at 2:20 pm with the DON revealed that the O2 concentrator filters are checked weekly on Thursday night (11:00 pm to 7:00 am shift) and the Central Supply Clerk performs a weekly audit every Friday. She stated her expectation was that staff follow up after checking the filters on the O2 concentrators and clean/replace them as needed and weekly. She stated she expected the Central Supply Clerk to replace filters found to be dirty during her audit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and review of the facility's policy titled Medication Storage, the facility failed to discard expired biologicals prior to the expiration date printed on the medication in one of two medication storage rooms and one of seven medication carts. Findings include: Review of the facility policy titled Medication Storage revealed under Policy Explanation and Guidelines: 8. Unused Medications: The Pharmacy and all medication rooms are routinely inspected by the consultant Pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, ineligible or missing labels. Observation and interview on [DATE] at 3:00 pm of the Long-Term Care (LTC) Magnolia Station (nurses' station) revealed one vial of Tuberculin Purified Protein Derivative with an open seal that was not labeled with an open date. Information on the box indicated to discard 30 days after opening. Interview with Licensed Practical Nurse (LPN) AA verified the vial, or the box was not labeled with an open date and should be discarded after 30 days according to the box directions. Observation on [DATE] at 3:36 pm of the 300 Magnolia Hall medication cart revealed a vial of Lantus insulin with an open seal that had an open date of [DATE]. Information on the box indicated to discard 28 days after opening. Interview with LPN BB verified the vial should be discarded 28 days after opening according to the box directions. Interview on [DATE] at 10:45 with the Director of Nursing (DON) revealed the medication room and the medication carts are checked two times a week and as needed. Each Unit Manager (UM) and the nurses on each shift are responsible for checking the dates and labeling during each medication administered. The DON revealed when a medicine is expired it is supposed to be removed from the medication cart or medication room immediately and sent to be destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow the comprehensive, person-centered care plan for one resident (R) (R#58) related to activities. Sample size was 34. Finding include: The facility did not provide a care plan policy upon request. Review of the medical record for R#58 revealed that she was admitted to the facility with diagnoses that included but not limited to: paraplegia, peripheral vascular disease, and spinal stenosis, lumbar region without neurogenic claudication. The quarterly Minimum Data Set (MDS) dated [DATE] for Section C: Cognitive Patterns revealed that R#58 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact and able to make her own decisions. Section F - Preferences for Customary Routine and Activities- How important is it to you to have books, newspapers, and magazines to read? Very important How important is it to you to do things with groups of people? Very important How important is it to you to do your favorite activities? Very important How important is it to you to go outside to get fresh air when the weather is good? Important, but can't do or no choice. Section G - Functional Status revealed R#58 required extensive assistance Two+ person physical assistance with Activities of Daily Living (ADL). Care plan reviewed and revealed that R#58: Enjoys/Enjoyed activities such as reading, watching TV/movies, socializing, and religious activities. Interventions: Find, offer, and make use of newspapers, magazines, or books about the patient's culture. Offer activities consistent with patient's known interest, physical and intellectual capabilities. Offer activity program directed toward specific interests/needs. Provide adaptations of activities/environment specify what adaptations used) to accommodate participation in activities of choice. Provide supplies/materials for leisure activities as needed/requested. Desires to participate in outdoor hot/cold weather activities. Interventions: Avoid extended amount of time outdoors. Observe for and report signs and symptoms of over exposure to heat such as reddening of skin, faintness, blurred vision, dry mucous membranes, muscle cramps, flushed or pale clammy skin, nausea, heavy sweating, headache, elevated pulse, or respiratory rate, etc. Bring patient inside and hydrate. Observe for and report signs and symptoms of over exposure to cold such as shivering, slurred speech, sleepiness, change in consciousness, cool, pale skin, burning sensation, numbness, etc. Offer & assist to put on protective garb such as gloves, hat, coat, etc. as needed. Offer and assist to apply sunscreen prior to exposure. Offer warm or cold beverages. Provide with lightweight loose-fitting garments. Interview on 1/25/2023 at 1:45 p.m. with the Activities Director (AD) revealed R#58 does independent activities, reads newspapers daily, participates in bingo weekly, and makes cards for people. The AD stated with COVID-19 they wanted to do a bridge group with R#58 but as of right now R#58 does not receive any one-on-one activities. The AD could not provide documentation to prove that one-on-one room visits were provided to R#58. The AD further stated that she does not have any written documentation of one-on-one room visits with R#58. When asked, what assistance does she provide in the activities that are part of R#58's care plan, AD stated that she offers several independent activities such as books, games, trivia packets, coloring, arts, and crafts. The AD stated that R#58 reads every day, but she refuses individual packets most of the time. When asked, how do you make sure that R#58 is informed and transported to group activities of choice, the AD stated that R#58 does not come out of her room. The AD stated that R#58 gets socialization when the CNAs comes in to care for her. Interview on 1/25/2023 at 2:24 p.m. with the MDS coordinator revealed she updates the care plans quarterly, annually, and at each completed assessment. She stated that recreations (the AD) created the care plan about the outside activities. She stated that episodically care plans should reflect the residents' current needs and concerns. She further stated that she has never seen R#58 outside for activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to provide an individualized, person-centered activities program to meet the needs for one resident (R)(R#58) of 34 sampled residents who needed extensive assistance by staff for provision of all care. Specifically, R#58 was not provided with person-centered activities that would meet their individual needs. Findings include: The facility did not have a current activity policy in place at the time of the survey. Review of the medical record for R#58 revealed that he was admitted to the facility with diagnoses that included but not limited to: paraplegia, peripheral vascular disease, and spinal stenosis, lumbar region without neurogenic claudication. The quarterly Minimum Data Set (MDS) dated [DATE] for Section C: Cognitive Patterns revealed that R#58 has a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and able to make her own decisions. Section F - Preferences for Customary Routine and Activities- How important is it to you to have books, newspapers, and magazines to read? Very important How important is it to you to do things with groups of people? Very important How important is it to you to do your favorite activities? Very important How important is it to you to go outside to get fresh air when the weather is good? Important, but can't do or no choice. Section G - Functional Status-Bed mobility- Extensive assistance Two+ person physical assist. Transfer- Extensive assistance Two+ person physical assist. Toilet use- Extensive assistance Two+ person physical assist. Review of the care plan revealed: Enjoys/Enjoyed activities such as reading, watching TV/movies, socializing, and religious activities. Interventions: Find, offer, and make use of newspapers, magazines, or books about the patient's culture. Offer activities consistent with patient's known interest, physical and intellectual capabilities. Offer activity program directed toward specific interests/needs. Provide adaptations of activities/environment (specify what adaptations used) to accommodate participation in activities of choice. Provide supplies/materials for leisure activities as needed/requested. Desires to participate in outdoor hot/cold weather activities. Interventions: Avoid extended amount of time outdoors. Observe for and report signs & symptoms of over exposure to heat such as reddening of skin, faintness, blurred vision, dry mucous membranes, muscle cramps, flushed or pale clammy skin, nausea, heavy sweating, headache, elevated pulse, or respiratory rate, etc. Bring patient inside and hydrate. Observe for and report signs and symptoms of over exposure to cold such as shivering, slurred speech, sleepiness, change in consciousness, cool, pale skin, burning sensation, numbness, etc. Offer and assist to put on protective garb such as gloves, hat, coat, etc. as needed. Offer and assist to apply sunscreen prior to exposure. Offer warm or cold beverages. Provide with lightweight loose-fitting garments. Further review of the medical record did not reveal any documentation of one-one on activities offered or provided to R#58. Observation and interview on 1/24/2023 at 9:53 a.m. revealed R#58 was observed lying in bed with eyes open. R#58 stated that she is paralyzed from the waist down. She stated that she cannot sit up in a wheelchair. R#58 stated that she is transported to appointments via stretcher. She stated that she participates in bingo from her bed. R#58 stated that bingo is called on Mondays by the Activity Director (AD) over the intercom. R#58 stated that the AD does not offer her any one-on-one room activities. She stated that she would like to have activities offered to her in her room because she cannot sit up in a wheelchair to participate in activities outside of her room. R#58 stated that she watches as her roommate leaves their room to attend activities. Observation on 1/25/2023 at 2:40 p.m. revealed R#58 lying in bed with a visitor noted sitting at bed side. Observation on 1/26/2023 at 9:31 a.m. revealed R#58 lying in bed with eyes open. During an interview with R#58 at this time she stated that she had a visit from the psychologist yesterday. R#58 stated that she does not receive any activities other than bingo on Mondays. She stated that she would love to have someone come in and play games with her. R#58 stated that she has a personal iPad that she uses. She also reads and watches television. She stated that all of that is great, but she would like some socialization with people. R#58 stated that the only socialization that she receives is from anyone that comes into her room. She stated that no one has offered to provide her with one-on-one activities. R#58 stated that she, along with her roommate and two other residents, formed a group together where they meet in her room occasionally and have discussions. Interview on 1/25/2023 at 1:45 p.m. with the AD revealed R#58 does independent activities, reads newspapers daily, participates in bingo weekly, and makes cards for people. The AD stated with COVID, they wanted to do a bridge group with R#58, but as of right now R#58 does not receive any one-on-one activities. The AD could not provide documentation to prove that one-on-one room visits was provided to R#58. The AD further stated that she does not have any written documentation of one-on-one room visits with R#58. When the AD was asked what assistance does she provide in the activities that are part of R#58's care plan, the AD stated that she offers several independent activities such as books, games, trivia packets, coloring, arts, and crafts. The AD stated that R#58 reads every day, but she refuses individual packets most of the time. When asked, how do you make sure that R#58 is informed and transported to group activities of choice, the AD stated that R#58 does not come out of her room. The AD stated that R#58 gets socialization when the CNAs comes in to care for her. Interview on 1/25/2023 at 2:24 p.m. with the MDS Coordinator revealed she updates the care plans quarterly, annually, and at each completed assessment. She stated that recreations (AD) created the care plan about the outside activities. She stated that episodically care plans should reflect the residents' current needs and concerns. She further stated that she has never seen R#58 outside for activities. Interview on 1/26/2023 at 11:00 a.m. with Charge Nurse Licensed Practical Nurse (LPN) AA revealed she is familiar with R#58 and her care. LPN AA stated that R#58 does not get out of bed. She stated that when R#58 goes out on appointments she is transported by stretcher. LPN AA stated that she has not witnessed R#58 participate in any other activities other than bingo. LPN AA also stated that she has not witnessed the AD conducting one-on-one activities with R#58. Interview on 1/26/2023 at 11:56 a.m. with the Rehab Manager (RM) revealed R#58 is currently not receiving therapy. The RM stated that when R#58 was on the therapy case load in May of 2020, she was capable of sitting up in a wheelchair. She stated that R#58 did not like to sit up in the wheelchair. Interview on 1/26/2023 at 12:35 p.m. with the Director of Nursing (DON) revealed that R#58's name comes up a lot in their interdisciplinary team (IDT) meetings. She stated that the current AD is new, and she has only been at the facility for a month. The DON stated that the former AD offered R#58 one-on-one activities and that R#58 refused, however the DON nor the AD could provide documentation that R#58 refused one-on-one activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, family, and staff interviews, the facility failed to ensure R#54 choice to eat in the residents room was honored. The sample size was 26. Findings: During an interview with R#54 on 8/27/19 at 2:49 p.m. States that she did not receive a lunch tray today. License Practical Nurse ( LPN) AA came around to give meds and she told her that she had not received her lunch yet. LPN AA came back after some time to see if she received a tray, but she had not. Stated that LPN AA offered her a sandwich, but she turned it down due to it being close to dinner time. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] Section C Brief Interview for Mental Status is coded 15/15 which indicates no cognitive impairment. During an interview on 8/27/19 at 3:40 p.m. with LPN AA regarding R#54 lunch she stated that she was going to deliver 1:30 p.m. meds when the resident informed her that she had not received her tray. Stated that she then went to the two aids who were responsible for delivering trays on the hall. One aid stated that she did not deliver trays on R#54's hall today and the other believes that her tray was accidentally picked up under the assumption that she was done eating. LPN AA states that resident usually eats in the dining room but today chose to eat in her room. States that there is no real process for communicating if a person eats in their room or the dining room. States that staff would find out if a person eats in their room by going through and checking to see if they received a tray or if a resident vocalizes that they have not ate. States that there are two aids on the hall responsible for delivering trays to the hall based off the trays that are on the cart. During an interview on 8/28/19 at 10:00 a.m. with Unit Manager (UM) BB stated that everybody that shows up to the dining room has a ticket. Once all tickets are served in the dining room the left-over tickets are assumed to be for the hall. Trays are then delivered to the hall based on the left-over tickets. States that there are two hall Certified Nursing Assistants (CNA's) are assigned to deliver trays. States that it was brought to her attention on yesterday by LPN AA that R#54 did not receive her tray. States that she is unsure as to what happened. States that she was not in hall when trays were delivered, because she is assigned to be in the dining room. States that she is unaware if a tray was created in the kitchen and delivered to the hall for the R#54. Once she was made aware that resident did not receive her tray she went to the resident to ask if she would like a sandwich and the resident stated that she was fine. States that the only way to know if a resident did not receive their tray is by them vocalizing or staff checking. States that the resident usually eats in the dining room and so it threw them off by her staying in her room to eat. During an interview on 8/28/19 at 10:40 a.m. with the Dietary Manager (DM) he explained the tray service delivery process. States that he prints meal tickets in dietary for the day. States that the tickets are separated by hall and then organized in alphabetical order. The CNAs who are assigned to dining come get the tickets. States the dining room opens at 12:00 p.m. and closes at 12:30 p.m. As residents enter the dining room and choose a seat a CNA goes over to take their order. The order is taken on the meal ticket and the ticket is given back to the kitchen to prepare the tray. Once the tray is prepared it is placed on a serving plate with the meal ticket, so the CNA knows who to deliver the tray to. After the dining room closes at 12:30 p.m. the left-over tickets are assumed to be for residents who eat on the hall, because they were not present in the dining room. States that CNAs go to the halls to ask the resident what they would like to eat. Dietary delivers trays to the halls and CNAs serve them. Stated he was not aware of R#54 not receiving her tray on Tuesday because he was absent. The Dietician in room at the time of the interview with the DM states that it was brought to her attention later in the day well after meal service. Both the DM and the Dietician confirmed that the kitchen was not made aware that R#54 did not receive her tray at the time it was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and Resident interview the facility failed to promptly resolve a grievance for one Resident (R) (R#36). The sample size was 27 Residents. Findings include: Review of the Minimum Data Set Quarterly assessment dated [DATE] for R#36 revealed a (C) Basic Interview for Mental Status (BIMS) score of 14 indicating intact cognition. (E) No Behaviors noted. (G) Extensive one person physical assistance with Activities of Daily Living (ADL). (I) Active Diagnosis include but is not limited to anemia, hypertension, diabetes, hyperlipidemia, and depression. (N) Receives an antidepressant 7/7 days a week. Review of the Care Plan for R#36 revealed no care plan in place that would indicate memory loss, dementia, or confusion. During an interview on 8/26/19 at 12:22 p.m. with R#36 she stated a couple of months ago she had 5- twenty dollar bills in her possession. She stated she was keeping the money in her personal folder that she has her social security and debit card in. R#36 stated someone took four of the twenty dollar bills then a couple of days later they took the other twenty. She stated she reported this to the social worker to file a complaint but she hasn't heard anything about it since. R#36 stated it most likely happened during the night and it couldn't have been her roommate because she doesn't have her mind enough to do something like that. She stated that it happened either at night or while she was gone to an activity but she believes it was an employee. Review of the Concern Form dated 7/23/19 revealed at 4:56 p.m. R#36 told Licensed Practical Nurse (LPN) AA that she was missing $80.00. She stated she had 5 $20.00 bills and only has 1 remaining. She voiced that the incident would have to occurred between 3:00 p.m. to 7:00 a.m. 7/22/19 to 7/23/19. There was nothing written under Documentation of Facility Follow-Up. Under Resolution of Concern yes or no was not checked to confirm if the concern was resolved but on the lines provided it stated, Social Worker to get back with family and discuss money as to missing/safe keeping but there is no signature or date. During an interview on 8/27/19 at 12:06 p.m. with the Social Worker, she stated she wrote a grievance last week in regard to a complaint from R#36 that she had money missing. Social Worker stated that she called R#36's son to verify that the resident had the money here in the facility but stated he has not returned her call. She stated she took the grievance to the Administrator. During an interview on 8/27/19 at 12:33 p.m. with the Administrator/Grievance Coordinator, she stated that she recalls the Social Worker meeting with her last week and discussing R#36 concern about money she had in her room that was missing and that the Social Worker called the son but he had not returned the call. Administrator stated when she receives a grievance she reviews the grievance and based on the area of concern she will pass the grievance on for investigation. She stated, for example, if there was a dining concern she would send it to dietary and they would investigate and report their findings to the Resident then inform her of the outcome. Administrator stated in regard to the concern with R#36 she would have gotten information from the resident as to how much money she had. She stated she would recommend to R#36 that she don't keep money on hand. She stated that she hopes an investigation related to a grievance would be completed within 24 hours. Administrator stated that the grievance outcome is usually given to the resident verbally. During an interview on 8/27/19 at 1:29 p.m. with LPN AA, she stated that around the end of July R#36 informed her that she had money missing and stated she wrote the concern on a Concern Form and went to the Social Worker with it. She stated the social worker told her to give it to the Administrator. LPN stated that the Administrator was on vacation so she placed the grievance in her (the Administrators) box. She stated that there has been no follow up with R#36 that she is aware of. She stated that Misappropriation of Property should be reported to the State within 24 hours. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that R#36 grievance regarding missing money was not reported to the State Agency. She stated the resident is confused at times and the amount of money she had changed and the son was called to validate the amount of money she had. She stated that Misappropriation of Property should be reported within 24 to 48 hours to the State Agency. Administrator stated she spoke with R#36 today and apologized for the delay in getting back with her regarding the grievance she filed in July 2019 about her missing money. She stated during her conversation with R#36 she (R#36) told her the amount missing was one hundred and fifty dollars and that she had a debit card, credit card, and a social security card. Administrator stated she discussed a trust account with the facility and allowing the facility to keep her things locked up for her. She stated that the Business Office Assistant went in and R#36 signed the paper for the trust account with the one hundred dollars to replace what was missing. She stated when the Business Office Assistant ask her about putting the debit card, credit card, and social security card in the safe R#36 told her she didn't have any of those. Administrator stated that R#36 initially filed the grievance with her nurse and the nurse went to the Director of Nursing (DON) and then Social Worker gave the grievance to her (Administrator). She stated that the grievance by R#36 dated 7/23/19 was not investigated thoroughly and it was an oversight. During an interview with R#36 she stated that the Administrator came in and spoke with her about the grievance she filed in July. She stated she told the Administrator when she first reported it she said it was $80.00 dollars missing but then the $20.00 that was left was taken a couple of days later so she told the Administrator that she had a total of $100.00 taken from her. R#36 stated that she now has a personal funds account with the facility so she doesn't have to keep money with her but can ask for it when she needs something. During this time the R#36 pulled out her wallet and with her check book in it along with her social security card and insurance cards. She stated that her debit card is not in there and she believes her son must have it. R#36 stated that she will speak to the Business Office Assistant about putting her wallet in the safe until she needs it. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy dated 11/2016 revealed, on page 8, that Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Procedures for Reporting, on page 9, revealed the Concern process is the company's grievance process. The administrator is the designated grievance officer for the center. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that the facility Grievance policy, Misappropriation of Property policy, and the Reporting policy is all covered under their Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy. Employee files related to the 7/22/19 staffing sheet for 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts were requested and reviewed. All staff files were found to have clear criminal background checks and were vetted appropriately prior to hire. There was no employee warning notices written that would cause concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to thoroughly investigate a Grievance related to Misappropriation of Property for one Resident (R) (R#36). The sample size was 30 Residents. Findings include: Review of the Minimum Data Set Quarterly assessment dated [DATE] for R#36 revealed a (C) Basic Interview for Mental Status (BIMS) score of 14 indicating intact cognition. (E) No Behaviors noted. (G) Extensive one-person physical assistance with Activities of Daily Living (ADL). (I) Active Diagnosis include but is not limited to anemia, hypertension, diabetes, hyperlipidemia, and depression. (N) Receives an antidepressant 7/7 days a week. Review of the Care Plan for R#36 revealed no care plan in place that would indicate memory loss, dementia, or confusion. Review of the Concern Form dated 7/23/19 revealed at 4:56 p.m. R#36 told Licensed Practical Nurse (LPN) AA that she was missing $80.00. She stated she had 5 $20.00 bills and only has 1 remaining. She voiced that the incident would have to occurred between 3:00 p.m. to 7:00 a.m. 7/22/19 to 7/23/19. There was nothing written under Documentation of Facility Follow-Up. Under Resolution of Concern yes or no was not checked to confirm if the concern was resolved but, on the lines provided it stated, Social Worker to get back with family and discuss money as to missing/safe keeping but there is no signature or date on that portion of the form. During an interview on 8/27/19 at 12:33 p.m. with the Administrator/Grievance Coordinator, she stated that she recalls the Social Worker meeting with her last week and discussing R#36 concern about money she had in her room that was missing and that the Social Worker called the son of R#36 but he had not returned the call. Administrator stated when she receives a grievance, she reviews the grievance and based on the area of concern she will pass the grievance on for investigation. She stated, for example, if there was a dining concern, she would send the grievance to dietary and they would investigate and report their findings to the Resident then inform her of the outcome. Administrator stated regarding the concern with R#36 she would have gotten information from the resident as to how much money she had. She stated she would recommend to R#36 that she don't keep money on hand. She stated that she hopes an investigation related to a grievance would be completed within 24 hours. Administrator stated that the grievance outcome is usually given to the resident verbally. During an interview on 8/27/19 at 1:29 p.m. with LPN AA, she stated around the end of July R#36 informed her that she had money missing and stated she wrote the concern on a Concern Form and went to the Social Worker with it. She stated the social worker told her to give it to the Administrator. LPN stated that the Administrator was on vacation, so she placed the grievance in her (the Administrators) box. She stated that there has been no follow up that she is aware of. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that R#36 initially filed the grievance regarding missing money with LPN AA, who was her nurse, and she went to the Director of Nursing (DON). She stated last week she and the Social Worker discussed it. She stated that the grievance filed by R#36 dated 7/23/19 was not investigated thoroughly and it was an oversight. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy dated 11/2016 revealed the Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern.