**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 1 (Resident #57) out of 2 (#22, #57) residents investigated for hospitalization. The deficient practice has the potential to affect a census of 81. Findings: A request was made for the facility's policy for Ombudsman notifications of hospital transfers to S1ADM (Administrator). No policy was provided by the time of exit. Review of Resident #57's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part, Spastic Hemiplegia Affecting Left Nondominant Side, Lobar Pneumonia, Unspecified Organism, Sepsis, Unspecified and Other Seizures. Review of Resident #57's nurses' notes revealed on 08/14/2024 at 12:21 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 08/15/2024 at 12:35 p.m., the resident returned from the hospital back to the facility. Review of the Emergency Transfer Log for August 2024 revealed Resident #57's transfer to the hospital on [DATE] was not identified on the list. On 12/04/2024 at 1:19 p.m., an interview and record review was conducted with S3BOM (Business Office Manager). She confirmed she was responsible for the Emergency Transfer Log and to send it to the State Long Term Care Ombudsman. S3BOM reviewed Resident #57's EMR (Electronic Medical Record) and confirmed the resident was transferred to the hospital on [DATE]. She then reviewed the Emergency Transfer Log for August 2024 and confirmed the resident was not listed as having been transferred on that date. S3BOM confirmed that Resident #57 should have been listed on the Emergency Transfer Log sent to the State Long Term Care Ombudsman and was not. S1ADM was present during the interview and also confirmed that Resident #57 was not included on the Emergency Transfer Log sent to the State Long Term Care Ombudsman and should have been.

Based on observation and interview, the facility failed to ensure: 1. the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors, and 2. the daily nurse staffing information include the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. Findings: On 12/03/2024 at 3:30 p.m., an observation was made of the daily nursing staffing information posted next to the staff time clock near the dining room and nurse's station which are in the central area of the building. The posting did not include the total number and actual hours worked by the staff responsible for resident care. On 12/03/2024 at 3:45 p.m., an observation and interview was conducted with S1ADM (Administrator) and S2RN (Registered Nurse). An observation of the nursing staffing information posted near the staff time clock was conducted with S1ADM and S2RN. They both confirmed that the posting did not include the total number and actual hours worked by the staff responsible for resident care. When asked if the posting was readily accessible for residents and visitors, S2RN did agree not all residents or visitors went to the dining room and may not see the posting. S1ADM voiced that she had always posted the nursing staffing information this way and posted it by the staff time clock. She stated that she was unaware that the nursing staffing information needed to include the total number and actual hours worked by the staff.

Based on observations and interview, the facility failed to maintain a safe, sanitary environment as evidenced by failing to ensure cookware was stored in a sanitary manner. This deficient practice had the potential to affect a total of 80 residents who consumed meals from the kitchen. On 12/02/2024 at 8:45 a.m., an observation was made of one sheet pan on the floor, in-between the fryer and the standing oven. On 12/02/2024 at 09:55 a.m., a second observation was made of a sheet pan on the floor, in-between the fryer and the standing oven. An immediate interview was conducted with S4RD (Registered Dietician), she confirmed the sheet pan was on the floor and it should not have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a discharge MDS (Minimum Data Set) assessment was completed timely for 1 (Resident #56 ) out of 39 sampled residents. The deficient practice had a potential to affect a total census of 77. Findings: A review of Resident #56's electronic medical record revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 07/31/2023. Further review of Resident #56's electronic medical record revealed that no discharge assessment had been initiated. On 11/15/2023 at 9:37 a.m., an interview and record review was conducted with S1MDS. After review of Resident #56's electronic medical record, she confirmed that the discharge MDS assessment for the resident's discharge on [DATE] was never completed and was overdue.