**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) Form (CMS-10123) was given to all Medicare beneficiaries who were discharged home with benefit days remaining, at least two days before the end of a Medicare covered Part A stay, for 3 (Resident #201, Resident #202, Resident #203) of 3 (Resident #201, Resident #202, Resident #203) sampled residents reviewed for beneficiary notification. Findings: Resident #201 Review of Resident #201's medical record revealed, in part, Resident #201 was admitted for Medicare Part A services on 09/03/2024, and was discharged home on [DATE]. Review of Resident #201's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #201's last covered day of Medicare Part A services was on 09/20/2024. Further review revealed there was no notification date documented on the NOMNC form. Resident #202 Review of Resident #202's medical record revealed, in part, Resident #202 was admitted for Medicare Part A services on 12/13/2024, and was discharged home on [DATE]. Review of Resident #202's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #202's last covered day of Medicare Part A services was on 12/27/2024. Further review revealed Resident #202's representative was notified via telephone on 12/27/2024 that Resident #202's last covered day of Medicare Part A services was 12/27/2024. Resident #203 Review of Resident #203's medical record revealed, in part, Resident #203 was admitted for Medicare Part A services on 11/04/2024, and was discharged home on [DATE]. Review of Resident #203's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #203's last covered day of Medicare Part A services was on 11/15/2024. Further review revealed Resident #203 was notified on 11/14/2024 of Resident #203's last covered day of Medicare Part A services was 11/15/2024. In an interview on 02/05/2025 at 8:59AM S2Minimum Data Set Coordinator confirmed Resident #201, Resident #202, and Resident #203 was not notified via NOMNC (CMS-10123) Form at least two days before the last covered day of the Medicare Part A services and it should have been.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) registry verification was completed prior to hire for 1 (S6Nursing Assistant [NA]) of 5 (S3CNA, S4CNA, S5NA, S6CNA, S7CNA) personnel records reviewed for registry verification. Findings: Review of S6NA's personnel record revealed a hire date of 05/20/2024. Further review revealed no documented evidence, and the facility did not present any documented evidence, a CNA registry check was obtained prior to hire for S6NA. In an interview on 02/05/2025 at 12:10PM S1Director indicated a CNA registry check was not obtained prior to hire for S6NA, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a staff member received dementia trainings for 1 (S3Certified Nursing Assistant [CNA]) of 5 (S3CNA, S4CNA, S5Nursing Assistant [NA], S6CNA, S7CNA) personnel records reviewed for required trainings. Findings: Review of the facility's Skilled Nursing Facility assessment dated [DATE] revealed, in part, the facility had 31 residents with behavioral health needs, and serviced a population that was typically over [AGE] years old. Further review revealed CNAs were to receive trainings on Bathing and Dementia Care and Communicating with Residents with Dementia during orientation and/or annual competencies. Review of S3CNA's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S3CNA received trainings on Bathing and Dementia Care and Communicating with Residents with Dementia during orientation and/or annual competencies. In an interview on 02/04/2025 at 4:25PM, S1Director indicated S3CNA had not received the above mentioned dementia trainings as determined to be required in the facility's Skilled Nursing Facility Assessment.

Based on record review and interviews, the facility failed to ensure their policy and procedure included: 1. A process of screening employees to prevent abuse, neglect, and exploitation of residents; and, 2. A process for training employees on abuse, neglect, and exploitation of residents. Findings: Review of the facility's Identifying and Reporting Allegations of Abuse/Neglect policy dated 08/28/2023 revealed no documented evidence and the facility did not present any documented evidence the policy included how the facility would perform screening of employees to prevent abuse, neglect, and exploitation of residents and how employees would be trained on abuse, neglect, and exploitation of residents. In an interview on 02/15/2024 at 3:00 p.m., S1Assistant [NAME] President of Nursing Services acknowledged the facility's policies did not identify how the facility would perform screening of employees to prevent abuse, neglect, and exploitation of residents and how employees would be trained on abuse, neglect, and exploitation of residents and it should have.

Based on record reviews, observations, and interviews, the facility failed to ensure medications were locked and not available for use at a resident's bedside for 1 (Resident #56) of 4 (Resident #56, Resident #57, Resident #58, and Resident #59) sampled residents observed for medications left at the bedside. Findings: Review of the facility's Storage of Medications after Dispensing to Provider policy revealed, in part, medications should be stored in a safe and secure manner, and storage locations should provide a locking mechanism for safety and security of medications. Further review revealed all locking mechanisms should be utilized to assure medications were secure at all times, and medications should not be left unattended or at a patient's bedside. Review of Resident #56's January and February 2024 physician's orders revealed, in part, no documented evidence of an order for Resident #56 to have medications available for self-administration at the bedside. Review of Resident #56's record revealed no documented evidence and the facility did not present any documented evidence Resident #56 requested to self-administer medications, and/or was assessed and careplanned to have medications at the bedside for Resident #46's use. Observation of Resident #56's room on 02/12/2024 at 10:45 a.m. revealed an unsecured and unattended Trelegy Ellipta 200-62.5-25 microgram (mcg) inhaler (a medication used to treat chronic obstructive pulmonary disease) on the right side of the sink and an unsecured and unattended bottle of Desenex (Miconazole Nitrate) 2% powder (a medication used to treat yeast) on the window sill. In an interview on 02/12/2024 at 10:44 a.m., Resident #56 confirmed she had a Trelegy Ellipta inhaler and a bottle of Desenex 2% powder available in her room. Resident #56 further stated she had not requested to self-administer the medications. Observation on 02/14/2024 at 12:30 p.m. revealed a Trelegy Ellipta 200-62.5-25mcg inhaler noted on the right side of Resident #56's sink in her room. Further observation revealed, Desenex (Miconazole Nitrate) 2% powder) noted on the window seal of Resident #56's room. Observation on 02/14/2024 at 1:42 p.m. revealed a Trelegy Ellipta 200-62.5-25mcg inhaler noted on the right side of Resident #56's sink in her room. Further observation revealed, Desenex (Miconazole Nitrate) 2% powder noted on the window seal of Resident #56's room. In an interview on 02/15/2023 at 11:33 a.m., S2Nurse Manager stated Resident #56 was not care planned or assessed to self-administer medications; therefore, Resident #56 should not have medications present at the bedside. Observation on 02/15/2023 at 12:00 p.m., with S2Nurse Manager present, revealed a Trelegy Ellipta 200-62.5-25mcg inhaler and a bottle of Desenex (Miconazole Nitrate) 2% powder were present in Resident #56's. In an interview on 02/15/2023 at 12:00 p.m., S2Nurse Manager confirmed the Trelegy Ellipta 200-62.5-25 mcg inhaler and the Desenex (Miconazole Nitrate) 2% powder should not have been unattended and unsecured in Resident #56's room. In an interview on 02/15/2024 at 12:00 p.m., S1Assistant [NAME] President of Nursing Services stated Resident #56 should not have had medications at the bedside.

Based on observations, record reviews, and interviews the facility failed to: 1. Ensure the registered nurse (RN) performed hand hygiene and applied gloves after contact with equipment and prior to touching and administering medication for 4 (Resident #56, Resident #57, Resident #58, and Resident #59) of 4 (Resident #56, Resident #57, Resident #58, and Resident #59) sampled residents observed during medication administration; 2. Ensure the RN and certified nursing assistant (CNA) performed hand hygiene and changed gloves appropriately as required during wound care for 1 (Resident #58) of 1 (Resident #58) sampled residents observed during wound care; and, 3.Ensure the licensed practical nurse (LPN) performed hand hygiene and applied gloves after contact with her uniform and equipment prior to performing blood glucose monitoring for 1 (Resident #56) of 1 (Resident #56) sampled residents observed during blood glucose monitoring. Findings: Review of the facility's Hand Hygiene policy and procedure revealed, in part: -wash hands with soap and water when hands are visibly dirty or contaminated; -perform hand hygiene before having direct contact with patients; -perform hand hygiene after contact with a patient's intact skin; -perform hand hygiene after contact with body fluids or excretions, non-intact skin, or wound dressings; -perform hand hygiene if moving from a contaminated body site to a clean body site during resident care; and, -perform hand hygiene after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 1. Observation on 02/14/2024 at 9:43 a.m. revealed S4RN performed hand hygiene, applied gloves in the hallway, pushed the medication cart to the door, and then opened the door with his gloved hand. Further observation revealed S4RN opened the package containing Resident #59's medication, used his gloved hand to obtain the medication from the blister pack with his gloved hand, and then administered the medication to Resident #59. S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #59's medication. Observation on 02/14/2024 at 10:53 a.m. revealed S4RN performed hand hygiene and applied gloves in the hallway, then pushed the medication cart to the door and opened the door with his gloved hand. Observation further revealed S4RN proceeded to scan Resident #59's bracelet with the hand scanner and utilized the computer's mouse. S4RN opened Resident #59's medication packet, pulled the pill from the blister pack with his gloved hand, and handed the pill to Resident #59. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #59's medication. Observation on 02/14/2024 at 1:42 p.m. revealed S4RN performed hand hygiene and applied gloves, a gown, and a mask in the hallway and then opened the door with his gloved hand. Observation further revealed S4RN touched Resident #56's recliner handle to sit Resident #56 up, scanned Resident #56's bracelet with the hand scanner, and then opened Resident #56's medication packaging. S4RN used his gloved hand to pull the pill from the medication packaging and handed the pill to Resident #56. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #56's medication. Observation on 02/14/2024 at 2:18 p.m. revealed S4RN notified the surveyor of the medication administration with his gloves already present on his hands. Further observation revealed S4RN pushed the medication cart into Resident #58's room, and scanned Resident #58's bracelet with the hand scanner. S4RN then used the computer's mouse, opened Resident #58's medication packaging, used his gloved hand to remove Resident #58's pill from the medication package, and administered Resident #58 his medication. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #56's medication. Observation on 02/14/2024 at 4:19 p.m. revealed S4RN entered Resident #59's room, performed hand hygiene, and applied gloves. Further observation revealed S4RN scanned Resident #59's bracelet, used the computer's mouse, opened Resident #58's medication packaging, used his gloved hand to remove Resident #58's pill from the medication package, and administered Resident #58 his medication. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #56's medication. Observation on 02/14/2024 at 4:23 p.m. revealed S4RN performed hand hygiene and applied gloves. S4RN then used the vital sign machine to obtain Resident #58's blood pressure, scanned Resident #58's bracelet with the hand scanner, and used the computer's mouse. Observation revealed S4RN removed Resident #58's pill from the medication package with his gloved hand and administered the pill to Resident #58. In an interview on 02/15/2024 at 9:19 a.m., S4RN confirmed the above observations and stated he should have performed hand hygiene and changed gloves after touching items in the residents' environment and prior to administering residents' medications. In an interview on 02/15/2024 at 9:36 a.m., S2Nurse Manager stated nurses should change gloves and perform hand hygiene between touch items in the environment and administering medications. In an interview on 02/15/2024 at 9:40 a.m., S1Assistant [NAME] President of Nursing Services confirmed glove changes and hand hygiene should have been completed between touching objects in the environment and administering residents' medications. 2. Observation on 02/15/2024 at 10:50 a.m. revealed S6CNA grabbed a brown paper towel and blotted blood to Resident #58's left buttock wound. Observation revealed S4RN performed hand hygiene, applied gloves, and cleaned Resident #58's buttock with normal saline. Without performing hand hygiene or changing gloves, S4RN applied stoma paste, powder, and Calmoseptine (a topical ointment used to protect and/or treat skin irritations) to Resident #58's buttock wound rubbing the Calmoseptine in with S4RN's gloved finger. S4RN then applied calmoseptine to Resident #58's buttock wound using his, S4RN, finger without having changed gloves or having performed hand hygiene. Observation revealed S4RN then applied skin prep (solution used to prepare skin for adhesives) to Resident #58's periwound area and dressed Resident #58's buttock wound with a foam dressing without having changed gloves or performed hand hygiene. Observation revealed S6CNA used her gloved hands to hold open Resident #58's garbage can lid while S4RN disposed of the soiled wound care supplies. Without changing their soiled gloves or performing hand hygiene, S6CNA and S4RN turned Resident #58, removed soiled bed linens, and applied new bed linens to Resident #58's bed. S6CNA then placed Resident #58's soiled linen on the floor. In an interview on 02/15/2024 at 11:01 a.m., S4RN stated he should have changed gloves and performed hand hygiene after cleaning Resident #58's wound and prior to applying Resident #58's buttock wound medication and dressing. S4RN further stated he should have also completed hand hygiene and changed gloves after wound care and prior to touching Resident #58 and Resident #58's new, clean linens. In an interview on 02/15/2024 at 11:02 a.m., S6CNA stated she should have completed hand hygiene and changed gloves after assisting with Resident #58's wound care, after touching Resident #58's garbage can, and prior to touching Resident #58 and Resident #58's clean linens. S6CNA further stated she should not have placed the soiled linen directly onto the floor. In an interview on 02/15/2024 at 11:27 a.m., S2Nurse Manager stated S4RN and S6CNA should have changed their gloves and performed hand hygiene between cleaning Resident #58's wound and applying Resident #58's the medication and dressing. S2Nurse Manager further stated the staff should have also performed hand hygiene and changed gloves after wound care and prior to applying new linen. S2Nurse Manager stated S6CNA should not have blotted the blood from Resident #58's buttock with brown paper towels, and should have changed her gloves and performed hand hygiene after touching the garbage can and prior to contact with Resident #58. In an interview on 02/15/2024 at 11:30 a.m., S1Assistant [NAME] President of Nursing Services confirmed S4RN and S6CNA failed to follow infection control standards as noted during Resident #58's wound care. In an interview on 02/15/2024 at 11:53 a.m., S3Infection Control Nurse stated staff were to perform hand hygiene and change gloves between any dirty to clean tasks, and between wound care and other tasks. 3. Observation on 02/12/2024 at 10:45 a.m. revealed S5Licensed Practical Nurse (LPN) performed hand hygiene and applied gloves, a gown, and a mask in the hallway and opened the door with her gloved hand. Observation further revealed S5LPN reached into her uniform pockets with gloved hands, and pressed the call bell. Without removing her gloves or completing hand hygiene, S5LPN then utilized a lancet to puncture Resident #56's skin and obtained a blood glucose sample. In an interview on 02/15/2024 at 11:15 a.m., S5LPN stated she should have changed gloves and performed hand hygiene after reaching into her pockets, and touching Resident #56's call light and prior to obtaining Resident #56's blood glucose. In an interview on 02/15/2024 at 9:36 a.m., S2Nurse Manager further stated S5LPN should have changed gloves and performed hand hygiene between touching the inside of her pockets and pressing Resident #56's call light and performing Resident #56's blood glucose monitoring. In an interview on 02/15/2024 at 11:30 a.m., S1Assistant [NAME] President of Nursing Services confirmed S5LPN failed to follow infection control standards while obtaining Resident #56's blood glucose level.

Based on record reviews and interviews, the facility: 1. Failed to ensure staff were provided abuse and neglect training (S8Agency Registered Nurse (RN), S9Agency RN, and S10Agency RN); and 2. Failed to ensure staff were provided dementia management training (S6Certfied Nursing Assistant (CNA) and S11CNA). This deficient practice was identified for 5 (S6CNA, S8Agency RN, S9Agency RN, S10Agency RN, and S11CNA) of 8 (S6CNA, S8Agency RN, S9Agency RN, and S10Agency RN, S11CNA, S12Licensed Practical Nurse (LPN), S13CNA, and S14CNA) personnel records reviewed. Findings: 1. Review of the facility's Skilled Nursing Facility (SNF) schedule from 10/29/2023 through 12/09/2023 revealed, in part, S8Agency RN, S9Agency RN, and S10Agency RN worked at the facility as a Registered Nurse. Review of S8Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/18/2023. Review of S9Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/16/2023. Review of S10Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/29/2023. In an interview on 02/15/2024 at 3:02 p.m., S2Unit Manager confirmed the above mentioned agency employees were not provided abuse and neglect training since hire by the facility and/or the contracted nursing agency. 2. Review of the facility's Skilled Nursing Facility (SNF) schedule dated 10/29/2023 through 02/17/2024 revealed, in part, S8Agency RN, S9Agency RN, S10Agency RN, and S11CNA worked at the facility providing care to residents. Further review revealed S11CNA worked on the SNF unit as a CNA. Observation on 02/15/2024 at 10:50 a.m. revealed S6CNA was observed providing care to residents in the facility. Review of S6CNA's personnel file revealed a hire date of 10/23/2023. Further review revealed no documented evidence and the provider did not present any documented evidence dementia training and/or behavior management was completed since hire. Review of S9Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence dementia training was completed since hire. Review of S10Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence dementia training was completed upon hire. Review of S11CNA's personnel file revealed a hire date of 09/18/2023. Further review revealed no documented evidence and the provider did not present any documented evidence dementia training and/or behavior management was completed since hire. In an interview on 02/15/2024 at 3:02 p.m., S2Unit Manager confirmed the above mentioned CNAs were not provided dementia training since hire. S2Unit Manager further confirmed the above mentioned agency employees were not provided dementia training since hire by the facility and/or the contracted nursing agency.