**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed provide and document appropriate nonpharmacological interventions prior to administering as needed (PRN) psychotropic medication consumption for 3 of 5 residents (R16, R17, R1) reviewed for unnecessary medication use. Findings include: R16’s annual Minimum Data Set (MDS) dated [DATE], identified R16 with experiencing hallucinations (false perceptions that seem real but are not) and delusions (misconceptions or beliefs that are opposite of reality), and had psychiatric diagnoses of anxiety, depression, psychotic disorder, schizophrenia and post-traumatic stress disorder (PTSD). R16’s Pharmacist Consultant Report dated July 11, 2025-July 13, 2025, identified “[R16] receives frequent doses of diazepam prn (as needed psychotropic medication). Ensure staff document dangerous or distressful behavior, nonpharmacological interventions attempted before psychotropic administration, and effectiveness of the psychotropic and any adverse effects.” R16’s physician order dated 7/16/25, “diazePAM Oral Tablet 5 MG (Diazepam, also known as Valium) Give 1 tablet by mouth as needed for give 1 tab BID PRN related to ANXIETY DISORDER, UNSPECIFIED (F41.9) Document non pharmaceutical intervention before administering med. -Start Date07/16/2025 1700”. R16’s Medication Administration Report dated July, August, and September identified R16 was administered prn diazepam the following dates: July 17-31, 2025: Received one dose on 5 of the 15 days. Received two doses on 10 of the 15 days. August 1-31, 2025: Received one dose on 15 days. Received two doses on 16 days. September 1-10, 2025: Received one dose on 5 days. Received two doses on 4 days. R16's medical record lacked identification or documentation of non-pharmacological approaches prior to administration of diazepam. During interview with licensed practical nurse (LPN)-A on 9/10/25 at 9:57 a.m., LPN-A stated expectation of nursing staff to document behaviors in a progress note including, “what worked and what happened” with psychotropic medication administration. LPN-A stated purpose of nonpharmacological interventions was “to reduce the need of taking [prn] psychotropics”. LPN-A reviewed R16’s electronic medical record (EMR) and stated she had documented administering the prn Valium but there was nothing in the EMR that identified what nonpharmacological interventions were used prior to administering the medication. During interview with assistant director of nursing (RN)-A on 9/10/25 at 10:14 a.m., RN-A identified purpose of assessing nonpharmacological medications prior to administering it was, to reduce anxiety meds”. RN-A reviewed R16’s EMR and verified the Pharmacist Consultant Report dated July 11, 2025-July 13, 2025, had instructed nursing staff to document nonpharmacological interventions attempted before administering prn Valium and that it was not done. R1 R1’s quarterly Minimum Data Set (MDS) assessment, dated 6/13/25, indicated R1 had intact cognition with hallucination, delusions with fluctuating disorganized thinking and was independent with all activities of daily living (ADLs). MDS-Section N indicated R1 was taking antipsychotic, antianxiety, antianxiety and antidepressant medications. R1’s diagnosis report, printed 9/11/25, included the following diagnosis: bipolar disorder with psychotic features (a severe form of bipolar disorder characterized by psychotic symptoms such as hallucinations and delusions during manic and depressive episodes), anxiety disorder, and schizoaffective disorder (a mental health disorder that combines symptoms of schizophrenia and a mood disorder). R1’s September 2025 Medication Administration Record (MAR), printed 9/11/25, included the following: -hydroxyzine (an antihistamine that helps with anxiety) 50 milligrams (mg) tablet – give one tablet by mouth as needed for anxiety/sleep for 30 days with a start date of 8/15/25 and end date of 9/9/25 which was administered eight (8) times from 9/1/25 to 9/9/25. Administrations were documented with an “e” indicating effective. There was no documentation on the MAR of nonpharmacological interventions prior to administration. -hydroxyzine 50 mg tablet – give one tablet by mouth as needed for anxiety/sleep starting 9/9/25 until 9/14/25 – nonpharmacological intervention attempted before psychotropic administration effectiveness / any adverse effects with a start date of 9/9/25 which was administered once on 9/10/25. Administrations were documented with an “e” indicating effective. There was no documentation on the MAR of nonpharmacological interventions prior to administration. The MAR lacked evidence of offering any nonpharmacological interventions prior to administration of administering PRN psychotropic medication. R1’s care plan, printed 9/8/25, indicated R1 received psychotropic medications. Care plan listed the following nonpharmacological interventions: -encourage (R1) to decrease TV watching late at night -encourage R1 to be up more during the day -attempt to re-direct and cue -offer psychotherapy bi-weekly -give her alone space/time to process emotions R1’s progress notes, dated 9/1/25 to 9/11/25, reviewed and lacked evidence of documentation of any nonpharmacological interventions offered prior to administration of psychotropic medication. During an interview on 9/10/25 at 11:23 a.m., assistant director of nursing (ADON) stated any nonpharmacological interventions offered prior to administration of PRN medications would be documented in the progress notes. ADON reviewed R1’s progress notes and electronic medical record (EMR) and verified there was no documentation of nonpharmacological interventions offered to R1 prior to administration of PRN psychotropic for the month of September. ADON stated nonpharmacological interventions should be offered and documented prior to administration of PRN medications. Surveyor attempted to reach consulting pharmacist. A voicemail was left for pharmacist on 9/11/25 at 8:08 a.m. without a return call. A facility titled Policy and Procedure for Administering PRN Psychotropic Medication, updated 5/5/25, indicated that the nurse attempts an intervention prior to administering a PRN psychotropic medication.

Based on interview and document review, the facility failed to ensure a comprehensive care plan was maintained to ensure appropriate care was provided for 1 of 2 residents (R1) reviewed for discharge planning. Findings include: R1's quarterly Minimum Data Set (MDS) assessment, dated 6/13/25, indicated R1 had intact cognition with hallucination, delusions with fluctuating disorganized thinking and was independent with all activities of daily living (ADLs). Section Q indicated there was no active discharge plan for resident to return to the community. During an interview on 9/8/25 at 2:44 p.m., R1 stated she was looking forward to moving to an assisted living. R1 stated she had an assessment and was told it might take 6 months to find a place which R1 was frustrated by. R1 stated again that she wants to move out of the facility.R1's care plan, printed 9/8/25, indicated the following: -Discharge plan: discharge plans reviewed with resident on 3/10/25 and R1 wants to remain in the facility and does not have any plans to discharge. Resident only want to be asked about discharge plans yearly which was last revised on 3/21/25. R1's progress notes, dated 5/6/25 to 9/8/25, were reviewed and identified the following:-5/6/25: R1 expressed her intention to give notice to move out of the facility. -5/12/25: R1 canceled meeting with care coordinator for assessment on 5/22/25.-5/27/25: R1 expressed a desire to move out of facility, obtain a part-time job and rent a hotel room. Social worker told her it was not an appropriate discharge and her worker would only assist her if she decided to move into an Assisted Living.-7/23/25: R1 had an assessment to assess what resident would qualify for housing services for an assisted living. R1 ended the assessment as R1 was told staff would enter her room to clean.-6/24/25: care conference note: DISCHARGE PLAN: Resident is appropriate for this facility; no discharge is planned. Resident has stated she would like to discharge to the community without services, but this goal may be unrealistic. Declined to be assessed for CADI Waiver.-6/9/25: Discharge Plans: Resident believes she can discharge to independent living. Resident declined to work with her Health Plan Coordinator to discharge to an ALF or Group Home. Resident only wants to be asked about her discharge plans yearly.re not.-9/3/25: R1 completed assessment with care coordinator and will be referred for further assistance for discharge planning for an Assisted Living Facility. -9/4/25: reviewed issues with resident regarding delusions related to wanting to discharge and doing a MN-Choice Assessment. This was completed with staff assistance yesterday. No further follow up needed. R1's care plan lacked evidence of being updated after R1 expressed desire to move out of the facility. During an interview on 9/10/25 at 10:57 a.m., nursing assistant (NA)-A stated they were not aware of any discharge plans for R1. NA-A stated R1 talked about a lot of things but were not sure if they could recall if R1 had talked about wanting to move out. During an interview on 9/10/25 at 11:15 a.m., assistant director of nursing (ADON) stated she was aware of R1 wanting to discharge as R1 mentioned it this week. R1 stated the social worker was assisting her with this. ADON stated a comprehensive care plan should be up to date and include residents' goals and preferences. ADON reviewed R1's care plan and verified it did not reflect R1's desire to move out of the facility. ADON verified discharge plans should be updated and on the care plan. During an interview on 9/11/25 at 10:35 a.m., social worker (SW)-A verified that R1 had expressed desire to move out of the facility. SW-A stated social services had assisted with setting up assessments for relocation services for R1. SW-A stated when a resident's discharge plans changed then the care plan needed to be updated. SW-A verified R1's care plan had not been updated to reflect her desire to move and should have been updated. A facility policy titled Comprehensive Care Plan Policy, updated 5/2025, indicated residents shall have a comprehensive care plan which include the following: reflects their assessed care needs, preferences, goals and values; identify risks to their safety, well-being, and quality of life; details planned interventions and strategies to meet their care needs; promote coordination across multidisciplinary teams; it will be regularly reviewed and updated to reflect changes in condition or preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to collaborate with a resident's external mental health provider to ensure adequate behavioral services were provided if needed for 1 of 2 residents (R4) reviewed for behavioral Health Services. Findings include: R4's quarterly minimum data set (MDS), dated [DATE], indicated R4 was admitted to the facility on [DATE] and was cognitively intact. R4's diagnoses list, printed 9/18/25, indicated R4 had several medical diagnoses including major depressive disorder, attention deficit hyperactivity disorder, generalized anxiety disorder, panic disorder, and post-traumatic stress disorder (PTSD). R4's care plan, revised 12/19/24, indicated R4 had a history of trauma and was classified high risk and in need for psychotherapy for PTSD. Interventions included ACP [Associated Clinic of Psychology] therapy with her provider. R4's electronic medical record (EMR) lacked evidence the facility was in collaboration with R4's outside therapy provider. During an interview on 9/9/25 at 11:46 a.m., the director of social services (DSS) confirmed the facility did not have a process for ensuring therapy notes for R4 were obtained and did not have a process for collaboration between the facility and outside provider. The DSS stated the facility rarely received notes from outside therapists, although if there was an issue she would try to collaborate. During an interview on 9/10/25 at 8:12 a.m., the director of nursing and the administrator stated it would be expected that the facility collaborate with outside therapy providers, stating social services would be expected to review the notes for any new information and upload them into the resident's EMR. During an interview on 9/10/25 at 12:58 p.m., R4 stated the facility had assessed if she had PTSD but did not assess specific triggers for her. R4 confirmed she went to therapy outside the facility. A facility policy on behavioral health was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure pharmacist recommendations were acted upon timely for 2 of 5 residents (R3, R1) reviewed for unnecessary medication use.Findings include: Findings include: R3’s quarterly Minimum Data Set (MDS) dated [DATE] identified R3 with diagnoses of hallucinations (false perceptions that seem real but are not) and delusions (misconceptions or beliefs that are opposite of reality), anxiety, schizophrenia, and was taking antipsychotics and antidepressants. R3’s physician orders dated 2/22/25 identified the following: Quetiapine Fumarate Oral Tablet 400mg, give 400mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE (F25.0) with Medication Class: ANTIPSYCHOTICS/ANTIMANIC AGENTS, Quetiapine Fumarate Oral Tablet 100mg, give 100mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE (F25.0) with Medication Class: ANTIPSYCHOTICS/ANTIMANIC AGENTS, and ARIPiprazole ER Intramuscular Prefilled Syringe 400MG, inject 1 syringe intramuscularly one time a day every 4 weeks on Friday for Schizophrenia related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE (F25.0). Review of R3’s electronic medical record (EMR) for medication review recommendations (MRR’s) from April to September of 2025, identified missing MRR for June 2025. During an interview on 9/11/25 at 10:40 a.m., administrator stated the facility did not have any more pharmacy reviews than what had been provided and verified the facility did not have the June pharmacy review for R3. R1’s quarterly Minimum Data Set (MDS) assessment, dated 6/13/25, indicated R1 had intact cognition with hallucination, delusions with fluctuating disorganized thinking and was independent with all activities of daily living (ADLs). R1’s Order Summary Report, printed 9/11/25, identified R1 had current physician orders for several psychotropic medications including: -hydroxyzine 50 milligram (mg) tablet - give one tablet by mouth as needed for anxiety twice a day as needed for anxiety/sleep for 30 days - nonpharmacological intervention attempt before psychotropic administration effectiveness/any adverse effects with a start date of 9/9/25 and end date of 9/14/25 -lurasidone 60 mg tablet – give one tablet by mouth in the evening for bipolar – give with dinner with a start date of 2/15/25. -melatonin 3 mg tablet – give one tablet by mouth at bedtime for insomnia with a start date of 12/26/23. -trazodone 100 mg tablet – give 150 mg by mouth at bedtime for insomnia with a start date of 11/21/24. R1’s progress notes, dated 5/8/25 to 9/10/25, were reviewed for pharmacy recommendations and identified the following: -5/8/25: Medication regimen review: Based upon information available at time of review and assuming accuracy and completeness of such information, it is my professional judgment that the medication regimen contained no new irregularities. -6/10/25: Medication regimen review: see comments for recommendations. -7/13/25: Medication review: Based upon information available at time of review and assuming accuracy and completeness of such information, it is my professional judgment that the medication regimen contained no new irregularities. -8/8/25: Medication review: see recommendation -9/4/25: Medication review: see recommendation R1’s Consultant Pharmacist’s Medication Review, dated 6/10/25, identified the consulting pharmacist (CP) a recommendation: “Please attempt a gradual dose reduction (GDR) of Trazodone to 100mg QD. If contraindicated, please provide a detailed rationale.,” along with a section titled Rationale for Recommendation which outlined requirements for GDR. A Physician’s response section directed the physician to check if they accepted or rejected the recommendation. Furthermore, if the recommendation for a GDR was clinically contraindicated to mark either box 1 or 2 along with providing a patient-specific rationale. However, neither of the boxes were marked nor did the report have any signature from the physician to demonstrate it had been reviewed and/or addressed. A cover letter, dated 7/16/25, was provided. The cover letter was a “Fax Transmittal Sheet” with a note “please see attached pharmacy recommendation and address” with R1’s name and date of birth . However, the cover letter lacked confirmation of fax transmission. Surveyor attempted to reach consulting pharmacist. A voicemail was left for pharmacist on 9/11/25 at 8:08 a.m. without a return call. During an interview on 9/11/25 at 10:43 a.m., assistant director of nursing (ADON) stated the June pharmacy recommendation review was not signed by the provider. ADON stated the provider was sent the recommendation and the facility did not receive a response. ADON stated she was unsure if the facility attempted to follow up with provider and was going to investigate this as it should have been. No additional information was provided. A facility policy on pharmacy recommendations was requested; however, none was received.

Based on interview and document review, the facility failed to ensure recommended influenza, pneumococcal, and Covid-19 vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R3) reviewed for immunizations.Findings include: R3's immunization tab and progress notes in electronic medical record (EMR) lacked evidence R3 was educated about, offered, and received or declined the influenza, pneumococcal and Covid-19 vaccine.During interview with infection control preventionist (ICP) on 9/10/25 at 11:36 a.m., ICP stated expectation of facility to offer and document vaccine status for all residents. ICP stated expectation of staff to document in a progress note of any vaccine education, what was offered, what was received or declined. ICP reviewed R3's EMR and stated R3 EMR lacked documentation of refusals and follow up for influenza, pneumococcal, and Covid vaccine status.Facility policy titled Influenza and Pneumococcal Immunizations and Covid, updated 05/14/2025 identified, all residents and their legal representative will be offered the opportunity to receive the Influenza [and Covid-19] Vaccine on a yearly basis and that the Pneumovax and Prevnar Vaccine will also be made available to each resident. In addition, the EMR will be documented with the following:Education provided, whether they received it and did not receive it including refusals.

Based on observation and interview, the facility failed to ensure soiled linen was covered when transporting it through facility. This had the potential to impact all 19 residents of the facility. Findings include: During observation on 9/8/25 at 11:50 a.m., a staff member was observed walking through first floor living room and dining room with uncovered linen basket that also had no liner or bag. There were 4 residents sitting in the living room and 3 residents sitting in the dining room as he walked past. Staff transported uncovered linen outside of the building and around the corner to the back of the facility and then entered the facility to walk down the stairs to the laundry room.During interview with on 9/8/25 at 2:06 p.m., with trained medication aide (TMA)-A admitted he was the one that transported the uncovered soiled linen from upstairs of the facility (second floor) and walked it down the stairs, through the living room and dining room to outside the facility and around the back to the basement laundry area. TMA-A verified the dirty linen basket he transported had no liner and was not closed or cinched. TMA-A stated, I should have it all covered for infection control.During interview with infection control preventionist (ICP) on 9/10/25 at 10:38 a.m., ICP stated expectation of staff to ensure all linen is covered, in a plastic bag to prevent infection. ICP stated expectation of staff to should wrap the clothes in the liner or plastic bag and then cover it with the lid [of the laundry basket]. It should always be covered when transporting linen, whether it is clean or dirty.During interview with nursing assistant (NA)-A on 9/10/25 at 1:58 p.m., NA-A stated expectation of staff to cover all linen when transporting it through the facility. NA-A stated each laundry basket should have a plastic bag as a liner which will have to be cinched prior to transporting it. NA-A stated importance of covering dirty laundry during transport is important for infection control contamination.Facility policy titled Linen and Laundry, updated 5/2025 identified soiled linen is transported in covered containers only.

Based on observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair which had the potential to affect all 19 residents, staff, and visitors of the facility.Findings include:Walls:During observation on 9/8/25 at 12:18 p.m., wallboard under the hand railing leading to second floor had several areas of missing wallboard and peeling paint showing underlayment. The dining room had curling vinyl tile on the floor along wall the with the window and old-style radiator. A window air conditioner unit was attached to the upper sash of window that had curled up blue masking tape surrounding it while it was wedged into the window on a board. Air space was observed on the bottom of the unit. On second floor, the shower room had broken vinyl wall board at the top of wall above the toilet. The second-floor lounge room had an alcove with exposed mechanical venting material, and the three walls were peeling and missing paint and part of baseboard. In addition, dark red carpet on the floor of second floor lounge area had area of 24 inches by 24 inches of bright white stains.During observation and interview on 9/8/25 at 1:46 p.m., R7 was lying in bed of their shared room with two other residents. The window ledge along the wall where R7's bed was aligned had peeling and flaking paint, the window was unable to close completely showing a small area of opening, and there was crumpled up clear plastic wrap hanging from the top half of the window attached by two-sided tape. R7 pointed to the window and said the condition of the window ledge and hanging plastic wrap has been on there since I have been here and did not like the look of the window and stated [I] just have to take what they give me.During observation and interview with infection control preventionist (ICP) on 9/10/25 at 10:38 a.m., ICP stated expectation of maintenance to visit facility daily and do their rounds to look at building including walls, floors [sic] and talk to staff about any concerns. ICP stated there was no formal process to request and perform repairs. ICP observed the holes in the wall below the hand railing leading up to the second floor and said, I do not know how long that has been there. It should be fixed because it is peeling and not attractive. Is should be repaired and painted to match the wall.During interview with R16 on 9/10/25 at 12:40 p.m., R16 pointed to wall below the hand railing leading to the second floor and stated she did not like the holes in the wall, looks awful like no one cares. R16 also stated the window air conditioner unit in the dining room should look better. It is barely in there and Looks like it is gonna fall out. The floor [pointing to the dining room floor] has old peeling tiles and it looks awful.During interview with R7 on 9/10/25 at 12:46 p.m., R7 pointed to the wall below the hand railing leading to the second floor and said, 'I don't like the hole in that wall there. Should be fixed.During interview with nursing assistant (NA)-A on 9/10/25 at 1:58 p.m., NA-A stated staff do not have to fill out any form or anything [for work orders]. NA-A stated the maintenance director (M-D) arrived every day and fixes what needs to be fixed.During observation on 9/11/25 at 8:01 a.m., first floor lounge with door to unit bathroom had white plumbing tubing extending out from the wall in an area taking up 18 inches long by 10 inches wide and extended beyond the wall by 6 inches. The patched area was never finished to match the wall.During observation on 9/11/25 at 8:18 a.m., an outside post railing at the bottom of the stairs had metal bracket that was attached to the front of the stairs and then formed around a loose and rotting post with no attachments noted. The area where the metal bracket could attach to outside of railing had no concrete to attach to due to cracked and missing concrete corner. The post was loose and was not secured causing anyone who held onto the railing to sway.During interview with R2 on 9/11/25 at 8:21 a.m., R2 stated, the stains [on second floor carpet] are nasty!! I don't like the looks of it. Should be replaced. Been there a long time. The wall there [second floor alcove] needs to get fixed. Should be covered.During interview with R1 on 9/11/25 at 8:26 a.m., R1 was walking up the stairs from first floor past the holes in the wall and stated, I hate the holes in the wall there. The carpet [on second floor lounge] should be fixed and replaced. Too many stains. It looks awful.During interview with M-D on 9/11/25 at 8:37 a.m., M-D stated the facility did not have a formal request system for work orders. M-D stated he had no evidence of what he worked on and what was repaired. M-D stated the staining on the second-floor lounge carpet, broken wallboard, cracked and peeling vinyl wall in the upstairs bathroom and the downstairs dining room, exposed plumbing into the first floor lounge, the air conditioner unit that was taped to a wallboard with blue masking tape with visible areas outside, and the unsecured post at the bottom of the stairs all posted a sanitary issue. M-D stated they were all in need of repair and finishing. M-D stated R7's bedroom window ledge which was covered with large bits of peeling paint and the crumpled-up plastic wrap hanging on her window needed attention. That [crumpled up plastic wrap] is winter window covering for insulation. It should be removed after winter. Looks bad. Should be thrown away. M-D agreed the outside stair post was used by all the residents and staff and that it should be repaired and, That is wobbly.Facility policy titled Maintenance, updated 5/5/25 identified objective is to maintain a safe and sanitary environment for residents and staff. The scope of the policy applies to the physical plan of the nursing home, including :Resident rooms and bathroomsCommon areas (lounges, dining rooms, hallways, therapy rooms)Mechanical and utility systemsExterior grounds and structures.

Based on interview and record review, the facility failed to prepare resident care plans with an interdisciplinary team (IDT) to include a nursing aide (NA), the attending physician, or a resident/resident representative. This deficiency had the ability to affect all 19 residents. Findings include: During an interview on 1/21/25 at 9:11 a.m., the director of nursing (DON) stated the IDT consists of an RN, the administrator, herself, the social worker, a member from medical records, the infection preventionist (IP) nurse, the minimum data set (MDS) nurse, and a compliance nurse. During an interview on 1/21/25 at 9:39 a.m., the administrator stated the facility's IDT consists of a RN, the DON, a member of the activities department, herself, the social services director, the social services assistant, and a member of the kitchen. During an interview on 1/21/25 at 11:35 a.m., the DON stated they do not take IDT notes. The DON stated during the IDT meetings they will look at the risk management and then they will update the care plan. The DON stated they do not take notes as to what they talk about or who attends the meetings. The facility's IDT policy revised on 12/24 stated the IDT will consist of the DON, one other nurse designated by the DON, social services director and/or the social services assistant, the activity director and/or designee, and other staff members as established by the Administrator.

Based on interview and record review the facility failed to ensure their director of nursing (DON) was a registered nurse (RN) when the facility had a licensed practical nurse (LPN) in the DON role since 7/30/24. This deficiency had the ability the affect all 19 residents. Findings include: During an interview on 1/16/25 at 11:39 a.m., the administrator stated the DON is a LPN. The administrator she knew the facility has to hire an RN to be in the DON role. There is not a signed DON job description for the current DON. During an email correspondence on 1/16/25 at 2:21 p.m., the administrator stated the DON has been in her role since 7/30/24. During an interview on 1/21/25 at 9:11 a.m., the DON stated she is a LPN who worked a the facility full time. On 1/16/25, the facility provided the DON's LPN license which is valid. The facility provided the DON's education which did not contain any training for the DON role. The facility provided an undated Director of Nursing job description. The description stated an RN must be hired in the DON role.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to notify and consult with the resident's physician after a resident (R1) was tested for Coronavirus disease 2019 (COVID-19). Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated 2/28/24, identified she had a respiratory disease that could affect her appetite or nutritional status. An initial nursing assessment, careplan, and progress notes document dated 2/21/24, indicated R1's lung sounds were clear with no labored breathing noted. The assessment further indicated R1 did not have a cough. R1's care plan lacked documentation on R1's respiratory status. An after-visit summary (AVS) dated 4/15/24, indicated R1 was seen at an urgent care center for cough, bronchitis (swelling or inflammation of the airways leading to your lungs), and a history of emphysema (lung condition that causes shortness of breath). The AVS instructed R1 to call a doctor or seek immediate attention if she experienced the following symptoms: - new or worse trouble breathing. - coughing up dark brown or bloody mucus (sputum). - new or higher fever. - new rash. R1's electronic health record (EHR) was reviewed daily during the survey week (8/24/24 - 8/28/24) and lacked documentation of reported symptoms by R1. Furthermore, R1's EHR lacked documentation of a COVID test or result. During observation and interview on 8/25/24 at 2:00 p.m., R1 sat in the 2nd floor TV lounge and coughed harshly. She stated the cough was not productive and she had it for approximately one week. R1 denied telling staff about her symptoms but stated she planned to tell them and request a coronavirus (COVID) test. During observation and interview 8/26/24 at 8:52 a.m., R1 sat in the 2nd floor TV lounge and stated I don't feel good this morning. My head feels bizarre, my stomach hurts and I'm shaky. R1 stated she asked for a COVID test and staff reported they would give her one, but they weren't sure when. R1 reported staff had not taken her temperature or assessed her vital signs. During interview on 8/27/24 at 8:15 a.m., R1 reported increased difficulty breathing and said, I can't breathe. She stated staff administered a COVID test the day before but had not given her the results. During observation on 8/27/24 between 2:05 p.m. and 3:17 p.m., R1 reported to social services (SS) she wanted help filing a report. SS questioned R1 for further information and R1 told her she was not feeling and wanted to go to urgent care. SS discussed the options for filing the report and it was agreed they would file the report first. SS and R1 walked to the nursing office to file the report. At 3:17 p.m., R1 walked into the 2nd floor TV lounge with her coat on. She appeared short of breath and stated staff refused to call 911 for her. R1 stated the director of nursing (DON) told me I needed to take a nebulizer treatment. She stated no one had listened to her lungs but checked her oxygen saturation levels (a measure of how much oxygen is in your blood) which was 100%. R1 stated she was going to call 911 herself. She walked away and into the telephone room and closed the door. During interview on 8/28/24 at 8:42 a.m., licensed practical nurse (LPN)-A stated R1 first reported difficulty breathing around the end of my shift at approximately 3:00 p.m. on 8/27/24. LPN-A stated the DON requested an oxygen saturation level check, but LPN-A did not listen to R1's lung sounds. During interview on 8/28/24 at 8:53 a.m., the DON reported being first notified of R1's respiratory symptoms of cough and difficulty breathing on 8/27/24 when R1 came into the nursing office and wanted staff to call 911. The DON stated R1 would not allow staff to fully assess her and said she wanted to go to the hospital. The DON reported R1 walked out of the nursing office and called an ambulance for herself. The DON stated she offered R1 a nebulizer treatment but R1 declined. The DON verified being aware that R1 requested a COVID test. The DON stated, I don't know why she wanted the COVID test. It was negative, I saw the results. The DON expected staff to document the results and notify the provider. The DON verified R1's EHR lacked such documentation. The DON expected staff to follow up if they were made aware of a resident not feeling. A request for a notification of change policy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure personal privacy could be maintained in resident room for 1 of 3 residents (R8) reviewed for privacy. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and was independent with her activities of daily living (ADLs). R8's MDS also indicated she had diagnoses of anxiety, bipolar disorder, and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). Furthermore, the MDS indicated R8 experienced hallucinations and delusions and exhibited verbal and other behavioral symptoms for 1-3 days during the lookback period. R8's annual MDS dated [DATE], indicated she felt it was very important to take care of her personal belongings and things. A progress note dated 3/25/24 indicated staff knocked on R8's door and when they did not hear a response, opened the door, and invited her to an activity. The progress note indicated later, R8 came downstairs and reported discomfort when staff walked into her room while she was changing and requested that staff wait on a response before entering her room. The progress note indicated staff did not challenge R8's assertion so that the situation would not be escalate., The note indicated when staff approached R8 earlier to invite her to the activity, she was sitting on her bed fully clothed. R8's care plan lacked documentation of privacy preferences or assessment. During observation on 8/25/24 at 6:16 p.m., there were no privacy curtains or privacy screen in R8's bedroom that she shared with two other residents. During interview on 8/26/24 at 12:48 p.m., R8 stated she would like to have privacy curtains, especially when you're changing clothes. It would be nice to have privacy. During interview on 8/28/24 at 8:42 a.m., licensed practical nurse (LPN)-A stated there was not really any privacy in resident rooms. LPN-A stated if a resident needed privacy, they would have to come to the nursing office or go to the bathroom. During interview on 8/28/24 at 9:13 a.m., the director of nursing (DON), verified there were no privacy curtains in the resident rooms and stated the facility was in the process of looking into privacy curtains. A facility policy titled Resident Privacy updated 9/14/23, indicated the facility wanted to provide privacy to residents and endorsed some challenges they faced. The policy indicated if a resident wanted more privacy in a shared bedroom, they could request a privacy screen. The policy recognized there are some beds where privacy screens would not be able to be used as they would create an accident hazard. The policy provided alternative options to meet the privacy needs of each resident, including moving the resident to a different bed or room, or discharge may be an appropriate option for some residents.

Based on record review and interview the facility failed to ensure a potential incident of neglect was recognized and reported to the State Agency (SA) after the administration had knowledge of the incident. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During interview on 8/27/24 at 11:17 a.m. interim Director of Nursing (DON) stated she was aware of a fire that had taken place a few weeks before she started working at the facility. DON stated she did not see any investigation report regarding the fire. DON stated she did not know if the fire had been reported to the SA. During interview on 08/27/24 at 11:28 a.m. Administrator acknowledged there had been a fire in the smoking room on the second floor of the facility sometime in May 2024 and the incident should have been investigated by the social worker (SW). Administrator went on to say she expected staff to file an incident report, update the management staff and complete all appropriate reporting to SA. Administrator stated the SW was enroute to the facility and would be available to interview later that day. During interview on 8/27/24 at 2:32 p.m. R-13 stated another resident had altered her of a fire in a plastic garbage can in the smoking room. R-13 stated she went to the smoking room and attempted to put out the fire with a fire extinguisher but was unable to pull the pin on the extinguisher. R-13 stated the cook came to the smoking room and took the fire extinguisher from her and was able to extinguish the fire. During interview on 8/27/24 at 2:41 p.m. cook-A stated he was working on the day of the fire. Cook-A stated he had been in the kitchen when a resident came into the kitchen yelling there was a fire in the smoking room. Cook-A told the resident to call 911 and he went up the stairs to the smoking room. Cook-A stated R-13 was present in the smoking room and was attempting to pull the pin on the fire extinguisher. Cook-A took the fire extinguisher from R-13, pulled the pin out and was able to extinguish the fire. Cook-A stated the nurse who had been working at the time of the fire had removed all the residents from the facility and the fire was completely out by the time the fire department showed up approximately five minutes later. Cook-A stated the fire department brought fans into the facility to clear out the smoke. On 8/27/24 at 2:54 p.m. an attempt was made to contact the nursing staff who had been working the day of the fire but was unable to reach or leave a message requesting return call. During a second interview on 8/28/24 at 9:09 a.m. Administrator stated she had discussed the incident with the SW and was informed there was no investigation completed, and the incident had not been reported to the SA. During interview on 8/28/24 at 1:03 p.m. infection preventionist (IP) who was overseeing the DON acknowledged he was aware of the incident and his expectation of all staff was to complete an incident report and report any like incidents to the SA. IP went on to say if staff were unaware of how to report to SA the expectation of staff was to at minimum report all incident to management for further investigation and instructions. IP stated this was important so all incidents could be investigated thoroughly and promote resident safety. The facility's document titled, Abuse, Neglect, and Exploitation Prevention Policy, dated 4/26/22, recognizes the right of residents to be free from abuse and neglect. The policy provides the following definitions: a) Abuse - non-therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress and is not accidental; b) Neglect - failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; c) Financial exploitation - engaging in unauthorized expenditure of vulnerable adult's funds which is likely to result in detriment, failure to use financial resources for vulnerable adult's needs which results or is likely to result in detriment, and in the absence of legal authority, using or withholding vulnerable adult's funds or property; d) Immediately - immediately after an incident occurs for alleged violations of maltreatment, abuse, neglect, and financial exploitation. The policy identifies procedures for abuse prevention including employee training about reportable incidents to assist them in identifying these incidents; providing instructions and encouragement to staff, families, residents to immediately report incidents of suspected maltreatment including how and to whom incidents should be reported; reporting by staff of suspected maltreatment are mandatory, the administrator is to be notified immediately of any events of suspected or reported vulnerable adult abuse events. The policy directs staff to report any situation where there is reason to believe that a vulnerable adult is being or has been abused and/or neglected. The policy also directs the administrator, director of nursing, and the social service director, or designee to conduct all vulnerable adult investigations, review results, and respond appropriately to the results of the internal investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to have a process in place to ensure resident medications were re-ordered in a timely manner for 1 of 1 residents (R1). Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated [DATE], identified she had a respiratory disease that could affect her appetite or nutritional status. R1's Care Area Assessment (CAA) for psychotropic drug use dated [DATE], indicated she mental illnesses and was being treated long-term with psychotropic medications for her personal best in mental health stability. The CAA indicated all disciplines were working with R1 to minimize the risks related to psychotropic medication use. R1's medication administration record (MAR) dated 8/2024, indicated a morning medication pass included the following medications: - acetaminophen oral tablet 500 milligrams (mg), Give 1,000mg by mouth three times a day (for pain), dated [DATE]. - albuterol sulfate inhalation aerosol powder breath activated 108 (90 base) micrograms (mcg)/actuation (for shortness of breath or difficulty breathing), Administer 2 inhaled puffs one time per day, dated [DATE]. - Albuterol sulfate inhalation nebulization solution (2.5mg/3 milliliters (mL)) 0.083% (for shortness of breath), Administer 1 vial inhaled every 6 hours as needed, dated [DATE]. - aspirin oral capsule 81mg, Give 81mg by mouth one time a day (for heart health), dated [DATE]. - baclofen tablet 10mg, Give 1 tablet by mouth two times a day (for chronic pain), dated [DATE]. - cariprazine HCl (for schizoaffective disorder, depression) oral capsule 4.5mg, Give 4.5mg by mouth in the morning, dated [DATE]. - diazepam (for anxiety) oral tablet 2mg, Give 2mg by mouth three times per day as needed, dated [DATE]. - fluticasone propionate nasal suspension, Give 2 spray in each nostril one time a day (for nasal congestion), dated [DATE]. - lactulose oral solution 10 gram (GM)/15mL, Give 15mL by mouth two times a day (for constipation), dated [DATE]. - Lasix oral tablet, Give 20mg by mouth time a day (for swelling), dated [DATE]. - Metamucil Fiber Packet, Give 1 packet by mouth two times a day (for constipation), dated [DATE]. - omeprazole oral capsule delayed release 20mg, Give 1 capsule by mouth one time per day (for acid reflux or heartburn), dated [DATE]. - Serevent Diskus Inhalation Aerosol Powder Breath Activated 50mcg/actuation (for shortness of breath), Administer 1 inhaled puff two times a day, dated [DATE]. - sertraline hydrochloride (HCl) (for depression) oral tablet 50 milligrams (mg), Give 1 tablet by mouth in the morning every day, dated [DATE]. R1's care plan revised [DATE], indicated R1 used sertraline for depression. The care plan guided nursing staff to give medication as ordered by the doctor to meet R1's goal of managing symptoms with medication management. The care plan also indicated R1 was unable to self-administer medications due to her cognitive deficit and identified a goal of receiving all prescribed medications and treatments per physician orders. The care plan directed nursing staff to dispense all medications when R1 was in the facility and to medicate and do treatments per physician orders. A review of Refill Reorder Forms dated [DATE] lacked documentation that R1's sertraline re-ordered. A review Refill Reorder Forms dated [DATE] lacked documentation that R1's sertraline re-ordered. A review of an undated and untitled refill and reorder form lacked documentation that R1's sertraline was re-ordered. No further refill and reorder forms were provided for review although they were requested. During medication administration observation on [DATE] at 7:41 a.m., surveyor50762 observed licensed practical nurse (LPN)-A administering morning medications for R1. LPN-A stated being unable to find sertraline HCl 50 mg medication card and the Serevent Diskus was expired. R1 did not receive her ordered and scheduled sertraline and Serevent Diskus. During interview on [DATE] at 8:15 a.m., R1 stated, I quit smoking and I don't what know to do with myself. I can't sit still. I'm finding it real difficult. R1 stated the facility did not have her sertraline during morning medication pass. She stated, I can't figure out why they don't order them when they start running out. It's been going on for a long time. She endorsed feelings of nervousness and stated she wanted to run away as far as she could. At 8:40 a.m., R1 stated she had two cigarettes left and she was going to have one to see if that'll help calm me down. At 8:47 a.m., R1 stated she smoked part of a cigarette, which helped her restlessness a little. During follow up interview on [DATE] at 9:52 a.m., LPN-A stated it was the responsibility of the nurses to input new orders, send them to the pharmacy, and to request medication refills. During interview on [DATE] at 9:17 a.m., the director of nursing (DON) stated medications should be re-ordered when there was a week's worth of medication left. During subsequent interview at 12:23 p.m., the DON stated the facility had implemented a new process recently. The DON explained when the medication card gets to the last row, staff were expected to peel the re-order sticker off and use it to re-order medications. A facility policy titled Ordering Medication from Pharmacy reviewed 10/2023, indicated each nurse or trained medication aide (TMA) was responsible for re-ordering any medications that were not on automatic renewal when it had less than a five day supply. The policy guided staff to write NEED TODAY PLEASE if the medication was needed for the same day or next morning. The policy directed staff to fax the pharmacy order sheet to the pharmacy and then initial and date the original pharmacy order sheet. Next, the policy instructed staff to put the order sheet in the weekly medication order book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to recognize a change in respiratory status for 1 of 1 residents (R1) reviewed for change of condition. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated 2/28/24, identified she had a respiratory disease that could affect her appetite or nutritional status. An initial nursing assessment, careplan, and progress notes document dated 2/21/24, indicated R1's lung sounds were clear with no labored breathing noted. The assessment further indicated R1 did not have a cough. R1's medication administration record (MAR) dated 8/2024, indicated the following medication orders: - albuterol sulfate inhalation aerosol powder breath activated 108 (90 base) micrograms (mcg)/actuation (for shortness of breath or difficulty breathing), Administer 2 inhaled puffs one time per day, dated 7/31/24. - Albuterol sulfate inhalation nebulization solution (2.5 milligrams (mg)/3 milliliters (mL)) 0.083% (for shortness of breath), Administer 1 vial inhaled every 6 hours as needed, dated 2/20/24. - Serevent Diskus Inhalation Aerosol Powder Breath Activated 50mcg/actuation (for shortness of breath), Administer 1 inhaled puff two times a day, dated 3/12/24. A progress note dated 4/15/24 at 10:47 a.m., indicated R1 was sent to urgent care for possible pneumonia and general unwell and cough. A progress note dated 4/15/24 at 5:55 p.m., indicated R1 returned with a diagnosis of bronchitis. An after-visit summary (AVS) dated 4/15/24, indicated R1 was seen at an urgent care center for cough, bronchitis (swelling or inflammation of the airways leading to your lungs), and a history of emphysema (lung condition that causes shortness of breath). The AVS instructed R1 to call a doctor or seek immediate attention if she experienced the following symptoms: - new or worse trouble breathing. - coughing up dark brown or bloody mucus (sputum). - new or higher fever. - new rash. A progress note dated 5/3/24, indicated R1 reported shortness of breath (SOB) while walking but it was not reported to staff. Additionally, the progress note indicated R1 had scheduled inhalers and had not requested any additional as-needed breathing treatments. The progress note indicated R1 denied SOB with sitting or lying down and was a smoker. Furthermore, the note indicated, there has been no known complaints of SOB or indication of respiratory distress. She has the ability to report and SOB or discomfort for nursing assessment and treatment if indicated. A progress note dated 5/18/24, indicated R1 reported to staff she was not feeling well due to cough, congestion, and tiredness. A progress note dated 6/13/24, indicated R1 received an appointment reminder to schedule with pulmonology (a physician who specializes in the respiratory system). The note indicated staff scheduled an appointment with pulmonology per R1's request. A provider progress note dated 7/31/24, listed chronic obstructive pulmonary disease (COPD), under the current diagnoses header. COPD is an ongoing lung condition caused by damage to the lungs resulting in blocked airflow and difficulty breathing. The provider addressed R1's COPD and indicated it was stable in nature and R1 was SOB at times with exertion or activity. The provider reviewed R1's current medications for her SOB and did not provide new orders during the encounter. A care conference note date 8/14/24, indicated R1's upcoming pulmonology appointment was reviewed with the interdisciplinary team (IDT) in attendance and R1. R1's care plan lacked documentation on R1's respiratory status. During observation and interview on 8/25/24 at 2:00 p.m., R1 sat in the 2nd floor TV lounge and coughed harshly. She stated the cough was not productive and she had it for approximately one week. R1 denied telling staff about her symptoms but stated she planned to tell them and request a coronavirus (COVID) test. During observation and interview 8/26/24 at 8:52 a.m., R1 sat in the 2nd floor TV lounge and stated I don't feel good this morning. My head feels bizarre, my stomach hurts and I'm shaky. R1 stated she asked for a COVID test and staff reported they would give her one, but they weren't sure when. R1 reported staff had not taken her temperature or assessed her vital signs. During interview on 8/27/24 at 8:15 a.m., R1 reported increased difficulty breathing and said, I can't breathe. She stated staff administered a COVID test the day before but had not given her the results. During observation on 8/27/24 between 2:05 p.m. and 3:17 p.m., R1 reported to social services (SS) she wanted help filing a report. SS questioned R1 for further information and R1 told her she was not feeling and wanted to go to urgent care. SS discussed the options for filing the report and it was agreed they would file the report first. SS and R1 walked to the nursing office to file the report. At 3:17 p.m., R1 walked into the 2nd floor TV lounge with her coat on. She appeared short of breath and stated staff refused to call 911 for her. R1 stated the director of nursing (DON) told me I needed to take a nebulizer treatment. She stated no one had listened to her lungs but checked her oxygen saturation levels (a measure of how much oxygen is in your blood) which was 100%. R1 stated she was going to call 911 herself. She walked away and into the telephone room and closed the door. During interview on 8/28/24 at 8:42 a.m., licensed practical nurse (LPN)-A stated R1 first reported difficulty breathing around the end of my shift at approximately 3:00 p.m. on 8/27/24. LPN-A stated the DON requested an oxygen saturation level check, but LPN-A did not listen to R1's lung sounds. During interview on 8/28/24 at 8:53 a.m., the DON reported being first notified of R1's respiratory symptoms of cough and difficulty breathing on 8/27/24 when R1 came into the nursing office and wanted staff to call 911. The DON stated R1 would not allow staff to fully assess her and said she wanted to go to the hospital. The DON reported R1 walked out of the nursing office and called an ambulance for herself. The DON stated she offered R1 a nebulizer treatment but R1 declined. The DON verified being aware that R1 requested a COVID test. The DON stated, I don't know why she wanted the COVID test. It was negative, I saw the results. The DON expected staff to follow up if they were made aware of a resident not feeling well. The DON stated staff should follow up with residents if they are requesting COVID testing which I am not sure they did. The DON verified there was no documentation of R1's COVID test or results in her EHR. A change of condition policy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure smoking interventions were implemented to reduce the risk for avoidable injuries for 1 of 1 (R7) reviewed for smoking. Findings include: R7's annual Minimum Data Set (MDS) dated [DATE] indicated R7 had diagnoses to include depression, schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors), and asthma. R7's smoking assessments dated 9/27/22, 12/27/22, 6/23/23, and 8/14/24 indicated R7 had a history of injuries secondary to smoking, and staff should store all smoking supplies in the nursing office. R7's care plan with an initiated date of 10/13/22 and revision date of 8/14/24, indicated R7 was on a smoking plan, could receive 10 cigarettes per day, and facility staff was to store her smoking supplies. The care plan also indicated R7 would be assessed for safe smoking practices at time of admission, significant change, and annually for determination of ability to smoke safely. During observation and interview on 8/25/24 at 14:45 p.m., R7 was in her room lying on her bed. A blue lighter was located on the bedside table to the immediate right of R7's bed. R7 stated she smoked throughout the day and into the evening. During observation on 8/26/24 at 12:40 p.m., resident exited her room with a blue lighter in her right hand and went into the smoking room. R7 was observed through an observation window to light her cigarette independently. Approximately ten minutes later R7 exited the smoking room and walked directly back to her room with a blue lighter in her right hand. During observation on 8/27/24 at 8:42 a.m., R7 was observed exiting her room with a blue lighter in her right hand and entered the smoking room. R7 was observed to light a cigarette independently and when finished smoking, exited the smoking room, and returned immediately to her room. A blue lighter was noted to be in her left hand. During interview on 8/27/24 at 10:57 a.m., certified nursing assistant (CNA)-A stated R7 smoked daily, and she had not been informed of any resident who was not allowed to keep smoking materials with them. CNA-A stated she did not know where to find any information on which residents could keep their smoking materials or which residents would require more supervision. CNA-A went on to say it would be nice to have that information available to the staff. During interview on 8/27/24 at 11:17 a.m., director of nursing (DON) stated residents are assessed for safe smoking at time of admission and as needed by the social worker. DON stated she considered smoking supplies to include cigarettes, lighters, and anything else a resident would use to smoke. DON stated she was unaware of any residents who were not allowed to keep their lighters with them. After reviewing R7's safe smoking assessments and care plan, DON acknowledged R7 should not be allowed to keep her lighter and expected the facility staff to make sure the lighter is returned after R7 was done smoking. DON stated this would be important for the safety of all residents in the building. A policy regarding safe smoking practice was requested by not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8% with 2 errors out of 25 opportunities for errors involving 1 of 5 residents (R1) who were observed during the medication pass. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and independent with most activities of daily living. The MDS indicated R1 had anxiety disorder, depression, and shortness of breath with exertion (activity). R1's annual MDS dated [DATE], identified R1 had chronic obstructive pulmonary disease (lung disease that limits airflow which may cause breathing problems). R1's care plan focus initiated on [DATE], indicated Resident uses Anti-Depressant (Zoloft) related to Diagnosis of Major Depressive Disorder: Resident displays: Depression, Feeling depressed, bad about self, sleep problems. Staff were tasked with providing medications per order. R1's [DATE] medication administration record (MAR), indicated R1 was to start Sertraline HCl 50 milligrams (mg) on [DATE] and had received Serevent Diskus twice a day. R1's provider order dated [DATE] indicated, Sertraline HCl (antidepressant) Oral Tablet 50 MG (Sertraline HCl) Give 50 mg by mouth in the morning for MMD (sic). R1's provider order dated [DATE] indicated, Serevent Diskus (long-acting bronchodilator to improve breathing) Inhalation Aerosol Powder Breath Activated 50 MCG/ACT (Salmeterol Xinafoate) 1 puff inhale orally two times a day for SOB Rinse mouth with water, spit out. Do NOT swallow. During observation and interview on [DATE] at 7:41 a.m., licensed practical nurse (LPN)-A prepared medications for R1. LPN-A stated being unable to find Sertraline HCl 50 mg medication card and that the Serevent Diskus was expired. This resulted in R1 not receiving either medication. During follow up interview on [DATE] at 9:52 a.m., LPN-A stated it was the responsibility of the nurses to input new orders, send them to the pharmacy, and to request medication refills. During interview on [DATE] at 9:17 a.m., interim director of nursing (DON) stated medications should be reordered when there was a week's worth of medication left. Requested a policy regarding medication reordered, none provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had diagnoses of seizure disorder, anxiety disorder, depression, and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). The MDS also indicated R5 was prescribed antipsychotic, antianxiety, and antidepressant medications. R5's treatment administration records dated May 2024, and June 2024 lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R5's care plan dated 12/30/23, indicated R5 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to demonstrate steady gait/balance and to have minimal/no side effects related to medication usage. The care plan indicated the interdisciplinary team (IDT) would evaluate effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and confer with M.D. quarterly and as needed. During interview on 8/28/24 at 10:00a.m., director of nursing (DON) stated the facility hadn't been completing any orthostatic blood pressures for any residents An undated facility policy titled Psychotropic Medication Side Effect Monitoring, indicated it was the policy of the facility to assess residents taking psychotropic medications for side effects on an ongoing basis and document the results of these assessments monthly. Additionally, the policy indicated its purpose was to assure the prompt recognition of psychotropic medications side effects. Based on interview and document review, the facility failed to ensure orthostatic blood pressure monitoring was in place for 4 of 5 residents (R1, R8, R5, R13) reviewed for psychotropic medications. Findings include: R1 R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R1's Care Area Assessment (CAA) for psychotropic drug use dated 2/28/24, indicated she mental illnesses and was being treated long-term with psychotropic medications for her personal best in mental health stability. The CAA indicated all disciplines were working with R1 to minimize the risks related to psychotropic medication use. R1's order summary report, printed 8/27/24, included the following orders: - Orthostatic blood pressure monthly, three times a day every 28 day(s) for psychotropic medication monitoring, dated 5/8/22. - sertraline hydrochloride (HCl) (for depression) oral tablet 50 milligrams (mg), Give 1 tablet by mouth in the morning every day, dated 8/27/24. - cariprazine HCl (for schizoaffective disorder, depression) oral capsule 4.5mg, Give 4.5mg by mouth in the morning, dated 8/8/24. - diazepam (for anxiety) oral tablet 2mg, Give 2mg by mouth three times per day as needed, dated 5/2/24. R1's treatment administration record (TAR) dated May 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R1's TAR dated June 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R1's TAR dated July 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R1's TAR dated August 2024, indicated R1 refused to have orthostatic blood pressures taken. R1's care plan dated 5/10/22, indicated R1 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to show minimal or no side effects of mediations taken. The care plan indicated the interdisciplinary team (IDT) would evaluate the effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and discuss with provider for instruction quarterly and as needed. R1's electronic health record (EHR) lacked further documentation of orthostatic blood pressure readings. R8 R8's quarterly MDS, dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited verbal and other behavioral symptoms 1 -3 days of the lookback period, and had diagnoses of high blood pressure, high cholesterol, bipolar disorder (a mental disorder that causes extreme mood swings), anxiety, schizophrenia, and a traumatic brain injury or TBI (an injury to the brain that occurs when the head is suddenly struck, or when an object pierces the skull and enters the brain). R8's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R8's CAA for psychotropic drug use dated 3/15/24, indicated staff would continue to follow the plan of care to maintain her current level of functioning to minimize risks. R8's order summary report, printed 8/27/24, included the following active orders: - Orthostatic blood pressure monitoring monthly, three times a day every 28 day(s) for psychotropic medication monitoring, dated 8/23/24. - lurasidone HCl (for bipolar disorder) oral tablet 80mg, Give 80mg by mouth in the evening, dated 12/12/23. - trazodone HCl (for insomnia) oral tablet 50mg, Give 50mg by mouth after bedtime dose after one hour if not asleep as needed, dated 8/23/24. - trazodone HCl (for insomnia) oral tablet 50mg, Give 50mg by mouth at bedtime, dated 8/23/24. R8's TAR dated May 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R8's TAR dated June 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R8's TAR dated July 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R8's TAR dated August 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. A progress note dated 11/9/23, indicated R8's blood pressure while laying down was 125/74 millimeters of mercury (mmHg), while sitting was 122/76 mmHg, and standing was 109/75 mmHg. A progress note dated 12/21/23, indicated R8's blood pressure while laying down was 113/69 mmHg, while sitting was 105/77 mmHg, and standing was 107/81 mm Hg. A progress note dated 1/18/24, indicated R8's blood pressure while laying down was 119/62 mmHg while sitting was 118/77 mmHg, and standing was 98/76 mmHg. R8's care plan dated 3/21/24, indicated R1 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to show minimal or no side effects of mediations taken. The care plan indicated the interdisciplinary team (IDT) would evaluate the effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and discuss with provider for instruction quarterly and as needed. R8's electronic health record (EHR) lacked further documentation of orthostatic blood pressure readings. R13 R13's annual MDS dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of anxiety, depression, psychotic disorder (disorder characterized by a disconnection from reality), schizophrenia, and post-traumatic stress disorder or PTSD (mental health condition that can develop after a person experiences or witnesses a traumatic event). R13's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R13's CAA for psychotropic drug use dated 7/12/24, indicated she was at risk for adverse reactions to the medications and staff would proceed to the care plan related to risks. R13's order summary report, printed 8/26/24, included the following orders: - Orthostatic blood pressure monitoring monthly, three times a day every 28 day(s) for psychotropic medication monitoring, dated 8/27/24. - prazosin HCl (for schizoaffective disorder, bipolar type) oral capsule 2mg, Give 2mg by mouth at bedtime, dated 8/22/24. - Rozerem (for PTSD) oral tablet 8mg, Give 8mg by mouth in the evening, dated 2/19/24. - trazodone HCl (for insomnia) oral tablet 150mg, Give 150mg by mouth at bedtime, dated 12/26/23. - venlafaxine HCl extended release (ER) (for anxiety) oral capsule 24-hour 150mg, Give 1 capsule by mouth one time per day, take with food, dated 2/7/24. - venlafaxine HCl extended release (ER) (for anxiety) oral capsule 24-hour 75mg, Give 1 capsule by mouth one time per day, take with food, dated 2/7/24. - ziprasidone HCl (for schizoaffective disorder, bipolar type) oral capsule 20mg, Give 2 capsules by mouth in the evening, take with food, dated 2/6/24. - ziprasidone HCl (for schizoaffective disorder, bipolar type) oral capsule 80mg, Give 2 capsules by mouth in the evening, take with food, dated 2/6/24. R13's TAR dated May 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R13's TAR dated June 2024, lacked documentation of ordered orthostatic blood pressure monitoring for 6/27/24. R13's TAR dated July 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. PointClickCare (PCC)'s weights and vitals summary, printed 8/29/24, indicated R13's sitting blood pressure on 8/27/24 was 123/94 mmHg, and standing blood pressure was 124/89 mmHg. No laying blood pressure was documented for 8/27/24. Furthermore, on 2/2/24, the weights and vitals summary indicated R13's lying blood pressure was 143/96 mmHG, sitting was 143/101 mmHg, and standing was 134/92 mmHg. R13's electronic health record (EHR) lacked further documentation of orthostatic blood pressure readings. R13's care plan dated 11/15/22, indicated R13 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to shave no injury related to medication usage or side effects. The care plan indicated the interdisciplinary team (IDT) would evaluate the effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and discuss with provider for instruction quarterly and as needed. During interview on 8/27/24 at 1:22 p.m., the interim director of nursing (DON) stated they realized there were no active orders for orthostatic blood pressure monitoring for residents on psychotropic medications. The DON stated orders to assess orthostatic blood pressures for psychotropic medication monitoring were entered a month prior. The DON was unable to locate documentation of orthostatic blood pressures for R1, R8, and R13. The DON stated it was important to monitor residents on psychotropic medications to know if the medication is effective and to monitor for side effects.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 18 residents at the facility. Findings include: Review of the facility staff schedules and staffing hours from 1/1/24 to 3/31/24 revealed there was no RN scheduled for 1/14/24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/16/24, 2/17/24, 2/18/24, 2/24/24, 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/30/24, and 3/31/24. During interview on 8/26/24 at 9:17 a.m., the interim director on nursing (DON) confirmed the dates identified that there was no RN coverage. During a follow up interview on 8/28/24 at 9:39 a.m., the interim DON stated they were to have an RN in the building at least 8 hours a day. Requested a policy regarding staffing, none provided.

Based on observation, interview and record review, the facility failed to identify quality deficiencies and to develop and implement appropriate actions to correct these deficiencies. Furthermore, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 18 residents. Findings include: A review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report (a quality measure report for nursing facilities) last updated 8/18/24, indicated the facility had the following deficiencies with a survey exit date of 9/01/23: - F727 RN Coverage for 8 hours per day for 7 days per week. - F758 Free from Unnecessary psychotropic medications. - F880 Infection prevention and control. - F881 Antibiotic Stewardship program - Emergency Preparedness (EP)0009 Local, State, Tribal Collaboration Process - EP0029 Development of Communication Plan - EP0039 EP Testing Requirements The CASPER report also revealed the facility had the following repeat deficiencies with a survey exit date of 9/2022: - F880 Infection prevention and control. - EP0009 See F727 See F757 See F880 See F881 See EP009 See EP0039 A review of the facility's QAPI meeting minutes for quarter 2 dated 6/19/24, lacked documentation of improvement activities. The minutes lacked documentation of tracking adverse events and/or medical errors and any analysis of causes. Furthermore, the meeting minutes lacked documentation of preventive actions and mechanisms implemented to improve performance. A review of the facility's QAPI reports for quarter 2 included infection control tracking, skin and wounds, and medication errors. The report lacked documentation on analysis of their causes or preventive actions implemented. A review of the facility's Quality Assurance/Assessment and Performance Improvement Plan last updated 8/24/23, indicated its purpose was to utilize an on-going, proactive approach to advance the quality of life and quality of care for all residents. The plan indicated the principles would drive the facility's decision making to promote excellence in all resident and staff related areas. Furthermore, the plan indicated the facility would review data and identify areas where gaps in performance could negatively affect resident or staff outcomes and prioritize focus areas for PIP development. The plan guided staff to consider activities that were high-risk to resident and/or staff, high-volume or problem-prone areas, health outcomes, resident safety, resident autonomy, resident choice, cost, feasibility, relevance, responsiveness, and areas not outside of benchmarks but still important to the resident population served. The plan advised staff within the PIP to develop an action plan with an identified problem statement, causes, goals, and interventions, staff responsible, and due dates. During interview on 8/28/24 at 1:43 p.m. social services (SS) stated the facility's QAPI team met every three months and reviewed corrections from survey results, trends for falls and medications, and changes in staffing. The SS stated the medical director also provided educational information to review during QAPI meetings. Additionally, the SS stated if a grievance was brought forward, the QAPI team would address the grievance. The SS stated the QAPI team utilized root cause analysis to remedy grievances and identify and overcome trends. The SS stated after last year's survey results, the QAPI team focused extensively on infection prevention and control and sanitary environment issues. The SS stated the QAPI team ensured corrective actions were implemented and effective by performing general monitoring and spot checking. The SS was unaware of any ongoing PIPs in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based off interview, observation, and document review the facility failed to utilize proper handling of linen to prevent contamination, failed to have a functioning infection surveillance program, and failed to have a functioning water management program. This had the potential to affect all residents who resided in the facility. Linen During an observation on 8/26/24 at 2:53 p.m., nursing assistance (NA)-A walked through the kitchen carrying a mesh-designed hamper and within it, dirty resident clothing. During an interview on 8/26/24 at 2:55 p.m., cook aide (CA)-B stated other staff will walk through the kitchen with laundry or go out and around the back. During an observation and interview on 8/27/24 at 2:04 p.m., NA-A carried an uncovered basket of clean linen through the kitchen. NA-[NAME] stated this was their process to bring clothing through the kitchen, clean and dirty. During an interview on 8/28/24 at 9:33 a.m., the interim director of nursing (DON) stated staff should be using the back door to the basement not going through the kitchen when dealing with laundry. DON stated it was an infection control concern regarding the clean linen and for sanitary conditions for the kitchen. During an interview on 8/28/24 at 8/28/24 at 10:09 a.m., infection preventionist (IP) stated that linen should be not carried through the kitchen and that it posed an infection control concern. Policy requested regarding linen and/or transportation of linen requested, none provided. Infection Surveillance During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning infection surveillance program in place. IP stated it was their intention to rebuild the program. Water Management During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning water management program in place. IP stated it was their intention to rebuild the program.

Based on interview and document review, the facility failed to have a functioning antibiotic stewardship program. This had the potential to affect any resident who had infections requiring antibiotic use. Findings include: During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning antibiotic stewardship program in place. IP stated it was their intention to rebuild the program. The one-page Grand Avenue Rest Home Antibiotic Stewardship Program policy undated, indicated the IP will track and assess all antibiotic use to review patterns of use and assure appropriate antibiotic use . The IP will review any antibiotic order and reassess the ongoing need for and choice of an antibiotic as more information becomes available. The policy lacked protocols and criteria for determining what was appropriate use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a once monthly injection was administered per physician orders, resulting in the monthly injection being administered twice over two days for 1 of 4 residents (R1) reviewed for medication errors. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact and independent with activities of daily living. R1's Face Sheet dated 7/18/24 indicated R1 had diagnoses of schizoaffective disorder, bipolar disorder,and extrapyramidal movement disorder (brain abnormalities that can lead to motor deficits). R1's Physician Order started 7/4/24 directed Invega Sustenna (Antipsychotic) Intramuscular Suspension Prefilled Syringe 234 milligrams/1.5 milliliters (Paliperidone Palmitate). Inject 1 dose intramuscularly one time a day every 28 days related to schizoaffective disorder. R1's care plan dated 7/10/24 indicated on 7/3/24, due to increased behaviors, nursing reviewed medication records and discovered that Invega injection was not given as ordered on 6/12/24. A dose was given on 7/3/24. On 7/4/24 resident received a second dose of Invega due to nurse not recording first dose on the medication administration record (MAR). Nursing staff will monitor blood pressure every shift, monitor resident for any unusual neck movement/muscle twitching for next 24 hours. R1's Physician Order dated 7/4/24 through 7/6/24, to Check blood pressure each shift for 48 hours, document on any abnormal neck movement or muscle twitching and make appointment for psych as soon as possible. R1's June MAR indicated an order for Invega Sustenna Suspension Prefilled Syringe 234 milligrams/1.5 milliliters. Inject 1.5 ml intramuscularly one time a day every 28 days for schizoaffective disorder. The start date was 11/02/22 and was discontinued on 7/4/24. The medication was scheduled for 6/12/24. The MAR indicated the medication was held on 6/13/24 and was not given during the month of June. R1's July MAR indicated the Invega injection was given only on 7/4/24. The MAR lacked indication the injection was administered on 7/3/24. On 7/3/24 at 4:20 p.m., a progress note indicated a return call was received from nurse practitioner (NP)-A to administer the Invega injection 234 milligrams intramuscular one time now. The staff nurse was updated with the new order. On 7/3/24 at 4:35 p.m., a progress note indicated a review of R1's electronic medical record was completed. R1 had last received the Invega injection in May 2024. A call was placed to R1's psychiatry clinic which was closed. A message was left for R1's primary care provider to request a new order for Invega. On 7/3/24 at 6:30 p.m., a progress note indicated licensed practical nurse (LPN)-A received a phone order from the director of nursing (DON)-A to administer the Invega suspension. LPN-A administered the medication as instructed from the phone call from the DON. On 7/4/24 at 10:50 a.m., a verbal phone order was given by nurse practitioner (NP)-A. The order was Invega Sustenna Suspension Prefilled Syringe 234 milligrams/1.5 milliliters. Inject 1.5 milliliters Intramuscularly one time a day every 28 days for schizoaffective disorder. The discontinue/reason was schedule updated. On 7/4/24 at 4:00 p.m., a physician note signed by medical doctor (MD)-A indicated MD-A was notified R1 had received the Invega injection back-to-back within two days in error. MD-A spoke to poison control. The nursing staff were directed to be vigilant to prevent falls, dystonic reactions, or autonomic instability. If any of those signs were to develop, R1 was to be brought to the hospital. It was recommended nursing staff reach out to R1's psychiatrist and schedule the earliest available appointment. On 7/4/24 at 9:48 a.m., a progress note indicated a call was made to R1's psychiatric clinic to report that R1 had missed the June dose of Invega, but there was no psychiatry staff available. Another call was made to NP-A. NP-A directed to give the Invega and resume the 28-day schedule. On 7/4/24 at 11:18 a.m., a progress note indicated the resident received the Invega injection. On 7/4/24 at 11:47 a.m.,a progress note indicated LPN-B received a verbal order from DON-B to give the Invega injection. After LPN-B gave the injection, she received a call from DON-A. DON-A told LPN-B that the injection was already given the day before. LPN-B had checked progress notes and R1's medication administration record and did not see documentation that the injection was given on 7/3/24. LPN-B called R1's psychiatrist and left a message for the on-call physician. On 7/5/24 at 1:04 p.m., a progress note indicated R1 was alert and able to respond to the questions. She went on a chaperoned trip to the store. On 7/19/24 at 10:49 a.m., LPN-A stated she was working on 7/3/24. DON-A had been working on the follow up for R1's missing injection. DON-A left and later called LPN-A directing her to give the injection since DON-A had heard back from NP-A. LPN-A was waiting for the order to be put in R1's electronic medical record so she could document that it was given but LPN-A never saw the order come through. LPN-A stated she felt she had to do what DON-A said since she was the director. The next day, LPN-A received a phone call from DON-A asking if LPN-A gave the injection, which she did. LPN-A then found out someone else gave the injection again. LPN-A stated the day she gave the injection she did not enter a progress note, but she did the following morning. Instead, she wrote a handwritten note stating she gave the injection and left it on DON-A's desk. LPN-A stated she was able to enter orders into PCC herself but since she did not receive the order from the NP, she thought DON-A would do that. LPN-A stated she had received education about administering medications without a physician's order, but at the time of the incident she was confused since DON-A gave her an okay to give it. On 7/19/24 at 11:32 a.m., the administrator stated he was not directly involved with the incident because DON-B said he would take over the investigation after the missing dose was discovered. DON-B called the provider to see if it was okay to administer it and checked R1's progress notes and electronic medical record and did not find any indication that the injection had already been given. DON-B then directed LPN-B to give the injection after the MD stated it was okay to administer it. Once staff realized R1 was given the injection twice they immediately started monitoring and updating the providers. The director stated LPN-A and LPN-B had received education on medication administration. DON-A and DON-B had not yet received education on how to direct nursing staff to give medication following verbal or written orders from the provider. The administrator stated this was related to the facility's previous administrator leaving the week prior to the medication error and the administrator is now in charge of three facilities but the education was still in progress. On 7/19/24 at 11:53 a.m., DON-A stated there was care conference for R1 on 7/3/24 because R1 had been declining. While going through her medication administration records, she noted an omission for the injection on 6/12/24. She immediately began the investigation and had calls out to the provider. The medication was initially missed was because R1 was discharged from the hospital late on 6/12/24. The day nurse marked it as held, but the next nurse did not administer it once R1 returned to the facility on 6/12/24. A social worker was present at the 7/3/24 care conference and alerted the administrator and DON-B from the sister facility of the medication error. After DON-A had left work for the day, NP-A called back and stated it was okay to give the injection following the missed dose. She called LPN-A to give the injection. LPN-A didn't know where to document the administration, so she just left a note for DON-A to read. The next day, DON-B directed LPN-B to give the medication, but DON-A had never received a call from DON-B asking about the status of the medication error. DON-A was not working on 7/4/24 but still called to check in on the facility. DON-A called LPN-B who asked why DON-B was asking her to give the injection. DON-A immediately called the administrator, and it was discovered the medication had been given twice in error. She had taken time off, and when she received the call late in the day on 7/3/24 from NP-A, she did not have the ability to enter the order in the electronic health record. It was an unusual situation trying to put it together. The correct way to document the medication was given was for the nurse who received the order to enter it in the system, but LPN-A did not make that concern known to her. Everyone was well intended, but there were too many people working on the issue. R1 was monitored and did not experience any adverse side effects related to the medication errors. Phone calls requesting interviews were made to NP-A, the pharmacist and LPN-B, but were not returned. A policy pertaining to verbal and written orders was requested but not received. The facility policy Administering Medications last revised 2/26/24 directed medications are administered in accordance with prescriber orders. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to maintain a system that assured full and complete accounting of resident personal funds entrusted to the facility which had the potential to affect 14 of 14 residents who had trust fund accounts. In addition, the facility failed to provide quarterly statements for individual resident trust fund accounts for 5 of 14 residents (R6, R9, R1, R10, R14) reviewed who had resident trust accounts accounts. Findings include: On 4/11/24 at 10:09 a.m., the director of nursing (DON) stated the facility kept petty cash withdrawn from the resident trust funds in two locations, a cash box for use during business hours and a cash box in the nursing cart for use after hours. The DON counted the cash in the business hours box which totaled $293.59 and the cash in the after hours box which totaled $99.05. The DON confirmed the combined total cash was $392.64. The business hours box also contained receipts for two resident withdrawals from 4/10/24 totaling $57. The DON stated these withdrawals had not yet been entered into the accounting system in the EHR and had not been subtracted from the total it reflected of $485.84. Including these withdrawals, the total accounted for resident trust fund petty cash totaled $449.64. The DON confirmed this total and confirmed that it was $36.20 less than the total cash reflected in the EHR accounting system. The business hours cash box total of $293.59 plus the $57 in withdrawals totaled $350.59. The DON confirmed this matched the total listed on the last cash box reconciliation sheet dated 4/8/24. The DON confirmed the after hours box total of $99.05 was $0.95 short of the total listed on the after hours cash box ledger. The DON confirmed a total of $36.20 in cash noted in the EHR's resident trust fund cash balance was unaccounted for. The facility's electronic health record system (EHR) included tracking of resident trust fund accounts. The trust current account balance report dated 4/11/24, indicated the facility's on-hand balance of petty cash from the resident trust funds totaled $485.84. The balance of resident trust funds in the bank totaled $17,394.12. The combined total balance of all resident trust funds was $17,822.96. In an interview on 4/11/24 at 4:07 p.m., the administrator confirmed the current balance of resident trust funds reflected in the EHR accounting system was $485.84 in cash and $17,394.12 in the bank. The administrator stated the cash in the business hours cash box and after hours cash box together would equal the cash balance listed in the EHR. A transaction history from 4/1/24 to 4/11/24 for the resident trust fund savings account (Grand Avenue Savings account), listed a current balance of $21,783.88. A transaction history from 4/1/24 to 4/11/24 for the resident trust fund checking account (Grand Avenue Trust account), listed a current balance of $2,636. The combined total resident trust fund balance dated 4/11/24, was $24,419.88. In an interview on 4/15/24 at 10:22 a.m., the administrator confirmed the resident trust fund savings and checking accounts totaled $24,419.88 on 4/11/24. In an interview on 4/15/24 at 10:36 a.m., the chief financial officer (CFO) stated that per the tracking of resident trust funds in the EHR the total resident trust fund on 4/11/24 was $17,822.96 with $17,394.12 in the bank. The CFO noted the total resident trust funds held by the facility should be the exactly what the EHR stated. The CFO confirmed that the total resident trust funds in the resident trust fund savings and checking bank account transaction records reflected a total balance of $24,419.88 on 4/11/24. The CFO stated this was a difference of $7,025.76 over from the balance of resident trust funds in the bank on 4/11/24 recorded in the EHR. The CFO stated there was a mess in the account and she was trying to find where it was, it was not correctly reconciled. The CFO noted the resident trust fund checking account transaction record included a deposit of $1,536 on 4/10/24 for the rent of two residents that was made in error and should have been deposited in the facility's operations account. The CFO noted the resident trust fund savings account balance of $21,783.88 on 4/11 included $5,248.01 in uncleared checks. The CFO stated the total of the deposit in error and two uncleared checks, $6,784.01, still left a difference of $241.75 in funds that she was trying to find. The CFO stated transactions had been entered in the EHR incorrectly and she was going through past transactions to try to locate the difference in funds, she did not know what had happened. The CFO stated she was not aware of the missing $36.20 in resident trust fund petty cash at the facility. The $7,025.76 discrepancy between the resident trust fund total balances in the EHR and the bank account transaction statements in addition to the $36.20 in petty cash totaled $7,061.96 in resident trust funds not fully and completely accounted for. Facility policy titled Resident Trust Fund and Authorization Policy dated 10/6/22, included Grand Avenue Rest Home shall maintain resident funds in a collective, interest-bearing bank account under an established system of generally accepted accounting principles. A written record of all financial transactions involving a resident's personal funds will be maintained. QUARTERLY STATEMENTS The facility electronic health record (EHR's) trust current account balance report dated 4/11/24, indicated 14 residents had resident trust fund accounts with the facility. Residents included R1 through R14. R6's Minimum Data Set (MDS) dated [DATE], indicated R6 admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder and had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. R6's facesheet dated 4/15/24, noted R6's family member (FM)-A was her billing contact. In an interview on 4/11/24 at 11:45 a.m., R6 stated she had a resident trust fund account and did not get quarterly statements for the account. R6 stated she had never gotten statements about her account. R6 identified that FM-A was responsible for her banking. In an interview on 4/11/24 at 2:35 p.m., FM-A stated she was R6's family member and payee and R6 had a trust fund account with the facility. FM-A stated she received billing statements in the mail with information about amounts owed and bills, but this did not include information about R6's trust fund account. FM-A stated she had never received an account statement with information such as transactions and balances. R9's MDS dated [DATE], indicated R9 admitted to the facility on [DATE] with a diagnosis of bipolar affective disorder and had a BIMS score of 15 indicating intact cognition. R9's facesheet dated 4/15/24, noted R9 was her own billing contact and responsible party. In an interview on 4/11/24 at 11:53 a.m., R9 stated she kept funds with the facility and hadn't gotten a quarterly statement in a long time. R9 stated she believed the last statement she received was last fall in October. R10's MDS dated [DATE], indicated R10 admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder and had a BIMS score of 15 indicating intact cognition. R10's facesheet dated 4/15/24, noted R10 was her own billing contact and responsible party. In an interview on 4/11/24 at 1:05 p.m., R10 stated she had a trust account with the facility, did not get statements, and did not remember ever getting an account statement. R1's MDS dated [DATE], indicated R1 admitted to the facility on [DATE] with a diagnosis of schizophrenia and had a BIMS score of 15 indicating intact cognition. R1's facesheet dated 4/15/24, noted services agency (SA)-A was her billing contact and representative payee (entity responsible for managing a person's Social Security or Supplemental Security Income payments). In an interview on 4/11/24 at 1:17 p.m., R1 stated she had an account with the facility and didn't ever get statements about her money. She noted if she wanted to know how much money she had in the account, she would ask the administrator. In an interview on 4/15/24 at 11:12 a.m., payee manager (PM)-A for SA-A confirmed SA-A was the representative payee for R1. PM-A stated the last resident trust fund account statement from the facility received by SA-A was from October of 2023. PM-A identified a document from February 2024 but noted it only regarded R1's rent payment. R14's MDS dated [DATE], indicated R14 admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia and had a BIMS score of 15 indicting intact cognition. R14's facesheet dated 4/15/24, noted R14 was her own billing contact and responsible party. In an interview on 4/11/24 at 1:23 p.m., R14 stated she had a trust fund account with the facility. R14 stated she did not get account statements from the facility, she did not remember ever getting an account statement from the facility, and that she would be the person to get a statement as she managed her own finances. In an interview on 4/11/24 at 4:07 p.m., the administrator noted facility policy is statements for resident trust funds should be sent out quarterly. The administrator stated quarterly statements were sent to representative payees or guardians if the resident was not responsible for their own funds or were hand delivered to the resident if they were responsible; statements were printed and mailed or handed to the appropriate person. The administrator noted statements were last provided for the facility's residents a few days ago and he or the DON were responsible for their dissemination and identified himself as the person ultimately responsible for the quarterly statements. In an interview on 4/15/24 at 10:00 a.m., the administrator noted the most recent quarterly resident trust fund account statements were sent to residents last week, were sent by accounting specialist (AS)-A, and were handed to residents or mailed to representative payees. The administrator did not know if there was documentation of this and identified himself as responsible for tracking and confirming it was done. The administrator noted the EHR showed when the statement reports were last run but identified that was not necessarily proof that the statements were sent; he relied on when the EHR showed the statements were run and word from AS-A that statements were given out. The administrator stated he had something in his email indicating the day the statements were sent out but did not provide this information. In an interview with the CFO and administrator on 4/15/24 at 10:36 a.m., the CFO stated she or AS-A generated the quarterly resident trust fund statements and she did not do anything else with them. The CFO noted she was aware there was an issue with handing them out due to staffing changes and didn't know if the most recent statements were ever distributed. The CFO noted the statements were last generated on 3/31/24 as reflected in the EHR but could not guarantee that the statements were sent out. The CFO stated she notified AS-A after the reports were generated. The administrator stated AS-A sent the statements to the DON to hand out, statements were mailed to guardians or responsible parties if a resident had one and the DON delivered the statements to residents who were their own person. In an interview on 4/15/24 at 11:01 a.m., the DON stated she did not hand out the quarterly statements, she was given certificates of rent paid to distribute. She did not recall handing out anything other than certificates of rent paid and handing out resident trust fund quarterly statements was not part of her routine duties. In an interview on 4/15/24 at 11:05 a.m., the administrator stated he communicated with AS-A who said the most recent statements were mailed out to responsible parties or mailed to the facility for distribution to residents. In an email communication from AS-A to the administrator dated 4/15/24 at 11:59 a.m., AS-A indicated, Yes, all in house [statements] were mailed to resident. Reminder, I do not control when the USPS delivers to the facility or once they are received I have no idea who handles out the mail . If the resident has a guardian or rep payee then the statement is mailed to the guardian/rep payee. Facility policy titled Resident Trust Fund and Authorization Policy dated 10/6/22, included A written record of all financial transactions involving a resident's personal funds will be maintained. The resident and/or resident's representative will receive a written quarterly statement, which will include all deposits and withdrawals.

Based on interview and document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the total balance of the resident trust fund, which had the potential to affect 14 of 14 residents (R1 to R14) who had a personal trust account managed by the facility. Findings include: The transaction history for the facility's resident trust fund savings account from 4/1/24 to 4/11/24, identified the account balance on 4/11/24 was $21,783.88. The transaction history for the facility's resident trust fund checking account from 4/1/24 to 4/11/24, identified the account balance on 4/11/24 was $2,636. The combined total balance on 4/11/24 of the two resident trust fund accounts was $24,419.88. The facility's surety bond (legally binding contract protecting the resident trust funds) with effective date of 9/9/23, was for a sum of $20,000. The sum was inadequate to cover the balance of the resident trust fund on 4/11/24. During an interview on 4/15/24 at 10:36 a.m., the chief financial officer (CFO) stated the surety bond did not cover the balance of $24,419.88 in the resident trust fund accounts on 4/11/24 and she realized the surety bond was not sufficient. Facility policy titled Resident Trust Fund and Authorization Policy dated 10/6/22, included Grand Avenue Rest Home maintains a surety bond to ensure the security of all personal funds deposited with the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to update a care plan to include a resident history of leaving the facility against the leave of absence policy for 1 of 3 patients reviewed when R1, who was her own person, left the facility overnight and did not inform staff when she would return. R1 admitted to the facility on [DATE] at 10:10 a.m. from an outside facility. R1's diagnoses included paranoid schizophrenia, post-traumatic stress disorder, schizoaffective disorder, delusional disorders, and major depressive disorder. On 3/27/24, a progress note indicated R1 left the facility at approximately 10:30 a.m. On 3/28/24 at 8:52 a.m., a progress note indicated R1 had returned at an undetermined point and planned to leave the facility again on 3/28/24. On 3/29/24 at 6:26 a.m., a progress note indicated R1 did not return to the facility during the overnight shift. On 3/29/24 at 10:10 a.m., a progress note indicated R1 refuse to disclose her whereabout to the facility but would contact the facility to discuss when she planned to return. On 3/29/24 at 12:52 p.m., a progress note indicated R1 remained away from the facility despite claiming she was on her way back. On 3/29/24 at 2:29 a.m., a progress note indicated facility staff informed the police and filed a report with the state agency for a missing person report. There was no progress note indicating when R1 returned to the facility. R1's medication administration record indicated on 3/29/24, R1 received her scheduled medications at 8:00 p.m. R1's care plan did not indicate R1 had a history of leaving the facility without following the leave of absence policy. On 4/1/24 at 11:05 a.m., R1 stated she understands the leave of absence policy and knows she needs to inform the nursing staff if she wants to leave overnight. R1 stated she was informed of this policy when she returned from her extended absence on the evening of 3/29/24. R1 stated she did not remember when she returned on 3/29/24. On 4/1/24 at 11:40 a.m., license practical nurse (LPN) -A stated she knows about residents needs by referencing their care plans. LPN-A stated a resident's needs and risks should be noted in the care plan. LPN-A stated she can change make changes to the care plan by asking for clarification from the on-call supervisor, physician, or the director of nursing (DON). LPN-A stated any member of the care team can update a care plan. On 4/1/24 at 11:57 a.m., LPN-B stated any changes to a resident's care should be noted in their care plan with the permission of the physician or DON. LPN-B stated if any changes are made to the care plan, a progress note should be completed afterwards to explain why the alterations were made. LPN-B stated any member of the care team can update a care plan. On 4/1/24 at 12:13 a.m., the DON stated the staff were instructed to educate R1 on 3/29/24 when she returned, and a newly updated policy would have been provided to her. The DON stated there is an initial care plan that fulfills a resident's needs until they can be completely assessed by staff. The DON stated the care plan is then updated to include that information. On 4/1/24 at 1:36 p.m., the director of social services stated R1 was reeducated again on the morning of 4/1/24. The director of social services stated the care plan would need to be updated to include R1's absence and address any like instances in the future. On 4/1/24 at 2:20 p.m., the social services assistant stated she reeducated R1 at approximately 11:00 a.m. The social services assistant stated she did not update the care plan. The social services assistant stated the weekend nursing staff could have updated R1's care plan to include her noncompliance with the facility leave of absence policy. The social services assistant stated this likely did not occur because the nurses who worked over the weekend were agency nurses and may not have had appropriate administrative privileges in their electronic medical record system. A facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicated resident care plans should be updated as information and resident condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to grant a resident request to access their personal funds within three business days for one of one resident (R1) reviewed for personal funds when the facility was notified on 1/8/24 the resident would like to access her money and the facility denied her access. Findings include: R1's admission Record printed on 2/16/24 indicated R1 was admitted to the facility on [DATE] with primary diagnoses of a traumatic brain injury and depression. R1's Trust Account Authorization dated 8/25/23, indicated R1 authorized the facility to handle any or all her personal funds and to assist her with business mail as needed. R1's care plan initiated 8/1/22 and revised 11/8/22 and 5/23/23 indicated R1 was her own person, and she managed her own finances responsibly. R1's care plan indicated R1 continued to manage her finances independently and staff would assist with money management if requested. R1's care plan indicated R1 brief interview for mental status (BIMS) score was 15 which meant R1 was cognitively intact. On 12/20/23, the facility received a check from Social Security Administration written out to R1 for $24,094.00. The letter addressed to R1 from Social Security Administration dated 12/24/23 indicated R1 did not get her social security benefits from 10/2021 to 6/2023 and the check for $24,094.00 was back pay for those missed benefits. R1's trust transaction history showed the facility credited R1's resident trust account on 1/2/24 for $24,094.00. R1's trust transaction history shows the facility charged R1's spenddown/rent on 1/5/24 of $22,475.89. R1's trust transaction history shows the facility credited R1's resident trust account for $17,919.01. R1's full trust transaction history indicated R1's spenddown on 11/21/23 was $1,382.80. R1's spenddown on 1/2/24 was $2,879.20. There are no additional ledger statements of spend down's prior to 11/21/23. R1's trust transaction history indicated R1's closing balance in her resident trust account was $17,919.01. R1's progress note dated 1/8/24 at 2:09 p.m., indicated R1 reported she received a $20,000 check and was informed days later about it and had been informed she cannot have access to the money due to staff not knowing the purpose of the check. The note indicated R1 stated she had a separate account through a social services account. R1 was unhappy she was not properly informed about the facility receiving the check. R1's progress note dated 1/9/24 at 11:54 a.m., indicated R1 requested to change her mail preferences and signed a form stating she wanted to get all of her mail unopened. R1's progress note dated 1/9/24 at 10:49 a.m., indicated the administrator explained what he had found out and the owner would like to speak with the lawyer and wanted a copy of the court order R1 spoke about. If everything checked out R1 would be getting a check written out to her. R1 indicated she would contact her lawyer and/or Lutheran Social Services Special Needs who managed her trust to get a copy and would email the copy to the administrator. R1's progress note dated 1/9/24 at 11:42 a.m., indicated staff met with R1 on 1/7/24 and gave her county notice of the amount she owed to the facility. R1 was concerned because her account showed a $0 balance and she had known she had received a back paycheck. During email correspondence between the ombudsman and the owner on 2/6/24 at 12:37 p.m., the ombudsman indicated he had a discussion with the county and indicated it was clear to him the owner owed R1 a refund. The ombudsman indicated to the owner the county confirmed the spenddown amount can only be for the cost of care in any given month. During email correspondence between the owner and administrator-B on 2/9/24 at 9:49 a.m., the owner indicated R1 did not have social security benefits for approximately two years between October 2021 and November 2023. The owner indicated R1 would receive a check in the amount of $24,094. The owner indicated the facility did not receive any spenddown payments from R1 between October 2021 and November 2023 but did get paid by the State of Minnesota for the full amount. The owner indicated the facility received correspondence dated 12/30/23 from Hennepin County in the amount of $25,105 and in the letter indicated R1 is responsible for the full cost of care for December 2023 up to the spenddown amount of $23,973. The owner indicated he thought this meant that he should withhold the spenddown amount that R1 should have paid to the facility over that period dating back to October 2021 because the State of Minnesota would charge back $23,973 spenddown amount for the social security payment that R1 received. The owner indicated R1 was upset because she wanted the money transferred to a special needs trust account to avoid the $3,000 Medicaid limit. The owner indicated he was not comfortable transferring the money to R1's special needs trust account because he viewed this as fraudulent. The owner indicated the ombudsman told him he was obligated to transfer the money to R1. The owner indicated he needed direction on where to send the money. The owner indicated he was concerned the State of Minnesota had already paid the $23,973 for R1's spenddown and was worried the State of Minnesota would be notified R1 received the $23,973 check from her social security benefits and would require a charge-back of $23,973. The owner indicated he would reimburse R1 $23,973 and transfer the money to her special needs trust if he were certain the State of Minnesota would not charge back against the facility. During email correspondence between the owner and the ombudsman on 2/9/24 at 9:55 a.m., the owner indicated to the ombudsman he had reached out to administrator-B and indicated once he was given direction from the State of Minnesota as to who should get the money, he would deliver the money to that person. During email correspondence between administrator-B and the county case worker on 2/9/24 at 12:40 p.m., administrator-B indicated he was not sure why R1 would be charged a spenddown of $23,973.00 when the total charges for December 2023 were $6,000. Administrator-B asked the county case worker if the facility should refund the difference to R1 or if there should be a spend down until that money is used up. During an email correspondence between the county case worker and administrator-B on 2/9/24 at 12:56 p.m., the county case worker indicated the facility should have refunded the difference to R1. During an email correspondence between administrator-B and the county case worked on 2/9/24 at 12:57 p.m., administrator-B questioned if refunding the difference back to R1 would have put her over her assets and questioned whether she would lose her medical assistance. During an email correspondence between the county case worker and administrator-B on 2/9/24 at 1:17 p.m., the county case worked indicated the county is not enforcing the asset limits until the second renewal of the unwind. The county case worked indicated R1 would have until the next review to properly reduce assets. During an email correspondence between the social worker and administrator-B on 2/9/24 at 1:41 p.m., the social worker indicated the lump sum from Retirement, Survivors, and Disability Insurance (RSDI) is counted as income in the month received and an asset thereafter. The social worker indicated R1 would be responsible for the full cost of care and the facility should have reimbursed the remainder. During an email correspondence between administrator-B and the owner on 2/9/24 at 1:50 p.m., administrator-B indicated the full amount of the check in the amount of $23,973 was applied to her spenddown for the month of December 2023 and the remaining amount of $17,919.01 should be refunded back to R1. During an email correspondence between the owner and administrator-B on 2/9/24 at 2:21 p.m., the owner indicated the facility would not be subject to any charge-back regarding the $17,919.01 and the facility can refund that amount to R1. The owner indicated he needed administrator-B to confirm this is correct. During an email correspondence between administrator-B and the owner on 2/9/24 at 4:19 p.m., administrator-B confirmed the facility would not be subject to any charge-back. During an email correspondence between the owner and the ombudsman on 2/12/24 at 12:23 p.m., the owner indicated he spoke to administrator-B and confirmed the facility needed to refund $17,919.01 back to R1. The owner indicated this refund amount had been determined by the county and the State of Minnesota. The owner indicated he needed the ombudsman to confirm with R1 she would agree with the refund amount and after she agreed, the owner would transfer the money to R1. The owner indicated he needed the ombudsman and R1 to agree the refund amount of $17,919.01 so neither the ombudsman nor R1 could dispute the remainder of the additional funds. The owner indicated if the ombudsman or R1 disagreed with the refund amount then he would inform the county and the State of Minnesota of the amount the ombudsman and R1 demanded to be refunded. The owner indicated he would return whatever amount the ombudsman, R1, the State of Minnesota, and the county agreed to be refunded to R1. During an email correspondence between the county social worker and the ombudsman on 2/12/24 at 4:25 p.m., the county social worker indicated R1 was happy to receive her $17,000 back. The county social worker indicated this was R1's money and had not consented to it being taken. The county social worker indicated R1 was concerned about the cost of care in December 2023 being $6,000. The county social worked indicated R1 had repeatedly asked for her accounting of what her cost of care is each month and she had been told it does not exist. The county social worker indicated once R1 verified the cost of care for December 2023 of $6,000 was accurate, then R1 would agree to a refund amount of $17,000. During an email correspondence between surveyor and chief financial officer (CFO) on 2/16/24 at 11:26 a.m., the CFO indicated the previous owners of the facility recorded ledgers by paper and the new owners started using electronic ledgers on 3/1/22. The CFO indicated they are unable to find ledger records prior to 3/1/22. During an email correspondence between the surveyor and the manager at the social services account on 2/20/24 at 9:08 a.m., the manager indicated there had not been a deposit made into R1's Special Needs Pooled Trust account. During an email correspondence between the surveyor and the owner on 2/20/24 at 10:32 a.m., the owner indicated he received an email from R1 on 1/10/24 for the first time relating to her social security benefits issue and he had spoken with R1's attorney and the attorney told the owner he had applied the funds correctly. The correspondence indicated the owner had spoken to the county case worker on 2/6/24 and the county case worker had indicated the facility owed R1 a refund but did not state the amount to refund R1. The correspondence indicated the owner had sent an email to the ombudsman on 2/12/24 and requested the ombudsman confirm with R1 the refund amount should be $17,919.01. The owner indicated he did not hear back from the ombudsman. During an interview with administrator-A on 2/16/24 at 9:01 a.m., administrator-A stated he had no administrative authority. During an interview with R1 on 2/16/24 at 9:15 a.m., R1 stated she requested to withdraw $50 from her facility account on 1/3/24 and when the aide turned around the computer, R1 had noticed there was a $24,000 check that was deposited into her account. R1 stated she had requested her account statements at which point the administrator stated they do not have account statements. R1 stated on 1/4/24, she had a previous employee state $24,000 was withdrawn from her account which left her with a zero balance. R1 stated she had requested to withdraw the $24,000 several times and the facility would not give it to her. During an interview with the ombudsman on 2/16/24 at 9:18 a.m., the ombudsman stated the State of Minnesota, and the county assured the owner he could refund R1's money. During an interview with the owner on 2/16/24 at 11:25 a.m., the owner stated R1's money was transferred to her account on 2/14/24. The owner stated he told administrator-B to give him direction on what to do with the money. The owner stated administrator-B spoke with the county and confirmed the amount of money the facility should keep and the amount that should be refunded. The owner stated he spoke to the ombudsman and requested the ombudsman speak with R1 about the refund amount. The owner stated he needed the ombudsman or R1 to tell him R1 required the full amount refunded. The owner stated the money is in her resident trust account through the facility and once he received confirmation from the ombudsman and R1 he would write a check and put it in her name. During an interview with administrator-A on 2/16/24 at 12:00 p.m., administrator-A stated he was not aware where the facility got the communication to withhold the $6,000 from R1. During an interview with administrator-B on 2/16/24 at 1:15 p.m., administrator-B stated R1's spenddown was $23,000 but her actual charges were a little over $6,000. Administrator-B stated the $17,000 was what the facility would refund R1 after the charges. Administrator-B stated the owner did not do anything with the check for a month because he was afraid the State of Minnesota would reprocess the claims and take the money. During an interview with administrator-A on 2/16/24 at 1:58 p.m., administrator-A stated $17,000 was in R1's trust account through the facility. Administrator-A stated there was a check written out to R1 from the Social Security Administration. Administrator-A stated R1 had agreed for the facility to manage her money. During an interview with R1 on 2/16/24 at 2:21 p.m., R1 stated the amount of the refund should be $24,000 and stated the facility stole $6,000 from her. R1 stated the facility had managed her bills but stated this was a different situation. R1 stated she did not know she received the money from Social Security Administration. R1 stated the facility had not refunded any of the money or told her about any information regarding her refund. During an interview with the manager at Lutheran Social Services of Minnesota on 2/20/24 at 8:13 a.m., the manager stated R1 can make a deposit into her account. The manager stated R1 does have access to her special needs pooled trust account. During an interview with administrator-A on 2/20/24 at 2:52 p.m., administrator-A stated the facility did not notify R1 the $17,000 was put in her resident trust account through the facility because the owner was waiting on confirmation from the ombudsman that R1 agreed with the refund of $17,000. Surveyor attempted to reach the CFO on 2/20/24 at 9:55 a.m. for an interview with no response. Surveyor attempted to reach the CFO on 2/20/24 at 3:00 p.m. for an interview with no response. Resident Fund Policy dated 10/27/21 and signed by R1 indicated funds were available seven days per week. The policy indicated the facility would accept resident personal funds for safeguarding if requested in writing by the resident or their guardian. The policy indicated funds held up to $50 would be locally available. The policy indicated any funds held above $50 would be placed into an interest-bearing account and interest would be paid quarterly. The policy indicated available balances and statements were available to the resident. The policy indicated each resident envelop would have a financial record of the beginning balance, deposits, and withdrawals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a resident with quarterly statements and upon request for two of two residents (R1, R2) reviewed for personal funds when R1 and R2 stated they have not received quarterly statements from the facility. Findings include: R1's admission Record printed on 2/16/24 indicated R1 was admitted to the facility on [DATE] with primary diagnoses of a traumatic brain injury and depression. R1's Resident Funds Policy dated 10/27/21 signed by R1 indicated each resident would have a financial record of beginning balances, deposits, and withdraws. R1's Trust Account Authorization dated 8/25/23 signed by R1 indicated quarterly statements would be issued to the resident or guardian at the end of each calendar quarter. The policy indicated review and/or additional statements would be available upon request during regular business hours. R2's admission Record printed on 2/21/24 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of schizophrenia. R2's Resident Funds Policy dated 8/22/18 signed by R2 indicated each resident would have a financial record of beginning balances, deposits, and withdraws. R2's Trust Account Authorization dated 9/14/22 signed by R2 indicated quarterly statements would be issued to the resident or guardian at the end of each calendar quarter. The policy indicated review and/or additional statements would be available upon request during regular business hours. During an email correspondence between the county social worker and the ombudsman on 2/12/24 at 4:25 p.m., the county social worker indicated R1 had repeatedly asked for her accounting statements from the facility and R1 had been told the statements do not exist. During an interview with R1 on 2/16/24 at 9:15 a.m., R1 stated she had requested her account statements from the facility and the owner stated they did not have any account statements for her. During an interview with R2 on 2/16/24 at 10:03 a.m., R2 stated she had never received quarterly statements since living at the facility. During an interview with administrator-A on 2/20/24 at 2:52 p.m., administrator-A stated that he does not know the last time quarterly statements were sent out to residents or their guardian's and stated he will refer the surveyor to the business office. Surveyor attempted to reach the CFO on 2/20/24 at 9:55 a.m. for an interview with no response. Surveyor attempted to reach the CFO on 2/20/24 at 3:00 p.m. for an interview with no response. Policies and Procedures requested from the administrator-A on 2/20/24 at 3:00 p.m. and none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report staff to resident abuse timely for 1 of 1 resident (R1) who alleged verbal abuse by staff. Findings include: R1's quarterly Minimum data set (MDS) dated [DATE], identified intact cognition. During an interview on 10/25/23 at 3:30 p.m., licensed social worker (LSW) indicated on 10/22/23, she had gone into the facility electronic records from home to review progress notes and read a progress note the director of nursing (DON) had wrote on 10/20/23 at 12:31 p.m. regarding a staff to resident verbal altercation which should have been reported. LSW stated she spoke with the DON on 10/22/23, around 3:30 p.m. and informed her the incident should have been filed with the state and the immediately investigated. LSW stated she then notified the administrator (out on funeral leave) on 10/22/23. LSW verified they filed the complaint with state agency (SA) on 10/22/23, between 5:00 p.m. and 6:00 p.m. (more than 48 hours later). During an interview on 10/26/23 at 2:47 p.m. DON confirmed last on 10/20/23, R1 had informed her a staff identified as NA-A had yelled at her regarding her husband. DON stated R1 indicated she was tired of being yelled at and had felt really upset about the incident. DON stated she was unsure if this incident was reportable. Facility policy titled Vulnerable Adult/Resident Protection Plan last revised 7/14/23, identified all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property immediately but not later than two hours if alleged violation involves abuse or serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to prevent potential further abuse during an investigation and ensure allegations of potential abuse were thoroughly investigated for 1 of 1 resident (R1) who reported allegations of staff to resident abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). R1's medical diagnoses included: anxiety disorder, depression, and schizophrenia (mental disorder in which people interpret reality abnormally). R1's progress noted on 10/20/23 at 12:39 p.m., director of nursing (DON) indicated R1 reported she had been yelled at by a staff in the morning, felt suicidal, and did not want to get out of bed. DON wrote R1 was out of bed and appeared anxious. DON spoke with R1 and she denied suicidal ideation's, endorsed being yelled at by staff, and was upset about the carpet cleaning today. R1's progress notes on 10/25/23 at 4:50 p.m., LSW attempted to talk with resident in her room regarding the concerns voiced this weekend related to her report made. R1 stated she was too anxious right now and wanted writer to call 911. Notified nursing. During an interview on 10/25/23 at 9:00 a.m., R1 stated a staff yelled at her, unsure of staff's name, but it was early in the morning about one week ago. R1 stated the staff had woke her up screaming that R's husband had called the facility and yelled the staff and the staff did not appreciate him calling her a spic and whore. R1 stated this staff yelled at her frequently, she do not like her, she lacked respect for the residents. R1 indicated the staff made her feel helpless and told to call her husband and tell him to quit calling her names, and never do it again. R1 stated she reported the staff to the director of nursing (DON) and was informed the facility had worked on the concern and she had not worked with the staff again. During an interview on 10/25/23 at 3:30 p.m., licensed social worker (LSW) indicated on 10/22/23, she had gone into the facility electronic records from home to review progress notes and read a progress note the director of nursing (DON) had wrote on 10/20/23 at 12:31 p.m. regarding a staff to resident verbal altercation which should have been reported. LSW stated she spoke with the DON on 10/22/23, around 3:30 p.m. and informed her the incident should have been filed with the state and the immediately investigated. LSW indicated was unaware of which staff had yelled at R1 and had forgot to ask the DON. LSW stated the investigation was usually shared with the DON and administrator and should have started right away on Monday. LSW stated administrator was gone on Monday, DON was new and had not filed a complaint. LSW indicated they had planned on visiting with R1 on Monday but was at another facility, got sidetracked, and was unable to be at this facility on Monday and Tuesday. LSW stated DON indicated on 10/22/23 from her assessment completed on 10/20/23, felt R1 was safe. LSW stated should have found out which staff was involved, placed on leave until investigation was completed to keep R1 safe, and that was not done. LSW stated just found out today 10/25/23, which staff was involved and they had worked a day shift today and had already left. During a follow up interview on 10/26/23 at 12:30 p.m. LSW approached surveyor and stated had forgotten she was at the facility on 10/23/23 at 3:30 p.m. stopped in to see R1. LSW stated R1 refused to interview and rolled cigarettes. During an interview on 10/26/23 at 2:47 p.m. DON stated last Friday 10/20/23, R1 had informed her a staff identified as NA-A had yelled at her regarding her husband. DON stated R1 indicated was tired of being yelled at, felt really upset about the incident, and documented in progress notes she had met with R1. DON indicated to be unsure if this incident was reportable but felt R1 was ok for the weekend. DON indicted NA-A was not scheduled for the weekend, was scheduled to work Monday and Tuesday but had called in sick. DON also stated NA-A had worked the entire day shift today but had already left for the day. DON stated NA-A had taken a resident to an appointment at 8:10 a.m. and returned to facility prior to lunch. DON stated NA-A assisted other residents with cares but R1 was pretty much independent. DON stated she should have interviewed NA-A and residents but had not done that yet. DON indicated R1 had a history/pattern for complaining about a lot of things, accusing staff of taking things, and required a lot of attention. DON also stated R1 struggled with changes and had noticed more behaviors lately. During a telephone conversation on 10/26/23 at 12:00 p.m. administrator stated the investigation process for this incident was slower than he wanted it to be but the facility had five days for it to be completed. (today was day six) Facility policy titled Vulnerable Adult/Resident Protection Plan last revised 7/14/23, identified investigation of suspected incident of abuse was reported the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation was to assure the resident is fully protected. The designated facility personnel will begin the investigation immediately to promptly and thoroughly investigate the incident. The investigation would include resident statements, resident's roommate statements, involved staff and witness statements, a description of the resident's behavior and environment at the time of the incident and observation of the resident and staff's behaviors during the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review, the facility failed to ensure medications were administered as prescribed by the physician for 1 of 3 residents (R1) who reported symptoms of constipation. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). R1's medical diagnoses included: anxiety disorder, depression, and schizophrenia (mental disorder in which people interpret reality abnormally). R1 was independent with personal hygiene, toileting, and continent of bowel. R1's face sheet dated 10/26/23, identified diagnoses constipation and intestinal obstruction. R1's physician orders identified: - 4/20/22, Metamucil Fiber Packet (Psyllium) give 1 packet by mouth two times a day related to constipation. Take in 8 ounce (oz) liquid. -12/24/22, Bowel monitoring 1 unspecified miscellaneous every day shift related to constipation normal bowel movement (BM) pattern daily; if no BM after two days initiate bowel protocol. House standing orders for bowel protocol for constipation dated 5/31/18, identified: -Maintain hydration. Encourage 2000 milliliters (ml) daily fluid intake unless contraindicated. -Milk of Magnesia (laxative) 1 oz eight days as needed (PRN) for constipation. -Prune juice 120 cubic centimeters (cc) PRN for constipation. -Initiate interventions if no bowel movement (BM) longer than normal resident bowel pattern. -If no BM for two days after initiation of interventions, notify physician. R1's Electronic Medication Administration Record (EMAR) October 2023, from 10/1/23 through 10/26/23, indicated: -Metamucil was documented as administered 34 times. -Metamucil was documented as code 5 (refused) five times. -Metamucil was documented as code 9 (see progress notes) 13 times. R1's EMAR progress notes 9/2/23, through 10/26/23, identified: -10/16/23 Metamucil not available. -10/17/23 Metamucil refused today. -10/22/23 Metamucil no supply. -10/24/23 Metamucil is not available. R1's EMAR progress notes lacked documentation of dates Metamucil was coded 9. R1's progress notes (PN) from 9/2/23, through 10/26/23, identified: -10/12/23, Call placed to nurse practitioner (NP) requested new script to be sent to pharmacy for Metamucil. Writer spoke with pharmacy staff who will forward the message. Fax number to pharmacy was provided. R1's progress notes lacked documentation and follow up with pharmacy, NP, and nursing assessments. Review of R1's Treatment administration record (TAR) September 2023, related to bowel monitoring everyday related to constipation normal BM pattern was daily, if no BM after two days initiate bowel protocol. Start date 12/24/22 indicated: - No BM was documented on 9/1/23, 9/4/23, 9/9/23, 9/16/23, 9/21/23, 9/24/23, 9/25/23, 9/26/23, 9/27/23, and 9/28/23. R1's TAR October 2023 related to bowel monitoring indicated: - No BM was documented 10/3/23, 10/8/23, 10/10/23, 10/24/23, 10/26/23, 10/27/23, 10/27/23, 10/28/23, 10/29/23, and 10/30/23. R1's Medical Record lacked documentation monitoring everyday related to constipation. Additionally, no BM was noted for five consecutive days during the months of September and October 2023. Normal BM pattern was daily, if no BM after two days initiate bowel protocol. During an interview on 10/25/23 at 9:00 a.m., R1 stated she had not received her Metamucil for about three weeks now and should have been given two times a day. R1 indicated she had trouble having a BM and had purchase her own laxative (over the counter) at the local grocery store about one month ago. R1 stated had a very small BM this morning but felt bloated, nauseated, and unable to eat. R1 had not told staff she had taken her own laxative because she feared they would have taken it away from her. R1 indicated when unable to have a BM she got worried about being constipated, having a bowel obstruction, and had been hospitalized for that in the past. R1 stated they told staff she needed to take the Metamucil and was told the facility did not have Metamucil, and was unable to get it. During a follow up interview on 10/26/23 at 9:02 a.m., R1 approached surveyor and stated she felt really uncomfortable. R1 stated she took the last of the generic laxative she had purchased, had a small BM again this morning but was still feeling bloated/full, was unable to eat breakfast this morning and needed to have a BM. R1 stated she had told the staff nurse almost every day she needed her Metamucil twice a day at 8:00 a.m. and 8:00 p.m. R1 revealed she felt like crying and stated, they just do not want to help me. During an observation and interview on 10/26/23 at 9:24 a.m., R1 entered the nurse's office and requested her morning medications. R1 asked LPN-B, did they get the Metamucil in yet? LPN-B indicated she would check. R1 informed LPN-B she had been taking a chocolate stool softener on her own but was unable to have a BM and needed her Metamucil. During this observation the DON stopped in the nurse's office. R1 informed DON she had not received her Metamucil and was worried about a bowel obstruction. LPN-B confirmed there was no Metamucil to administer to R1. LPN-B also indicated the pharmacy consultant was here today and she planned on asking him about it. LPN-B confirmed she had signed into R1's EMAR yesterday, did not administer R1's Metamucil, may have not signed out of computer and now see it had been documented as refused (which was not correct). LPN-B stated we are expected to enter the number 9 when medication was not administered. LPN-B indicated she had worked with another nurse yesterday and most likely the medication had been charted by the other nurse under her name. LPN-B verified in the past two weeks no documentation was in R1's progress notes for those dates the Metamucil was not given. LPN-B also indicated she was new to the facility (1 1/2 weeks) and had administered another resident's generic laxative to R1. LPN-B stated she was unaware R1 had taken her own laxatives. LPN-B stated she was not familiar with what the bowel protocol was or where to find it, but noted R1 had an order for it if needed. LPN-B also stated R1's BM's were to be monitored daily and if no BM after two days the physician's order for the bowel protocol should have been followed and documented in the progress notes. LPN-B indicated R1 had a history of constipation and could potentially end up with a bowel obstruction if not monitored as ordered. LPN-B confirmed this did not appear to have been followed. During an interview on 10/25/23 at 1:34 p.m., licensed practical nurse (LPN)-A stated pharmacy did not deliver medications on the day shift only the evening shift. LPN-A stated during medication administration medications can not be borrowed from one resident to administer to another resident. LPN-A verified staff are to code the EMAR when a medication had not been given and should have used the number 9 or not available, or documented a two when it had been refused. LPN-A stated nursing staff were expected to contact pharmacy if a mediation was not available to let them know. LPN-A stated she had called pharmacy on 10/12/23, about R1's Metamucil and was told there was not an order for it. LPN-A indicated she had looked for a Metamucil order and was unable to find it. LPN-A placed a call to the NP and also spoke to pharmacy. LPN-A had not seen an order come through on the fax machine yet. LPN-A verified the facility did not have Metamucil on hand. LPN-A reviewed R1's medical record and verified R1 had not had a BM for five days straight. LPN-A was unaware of what the bowel protocol was or whether it was initiated, no documentation was found. During an interview on 10/26/12 at 10:37 a.m., pharmacy consultant stated the last medication review was completed on 10/11/23, remotely. PC stated all medications for each resident were reviewed at that time. PC indicated R1's Metamucil was not delivered and therefore not administered at times and essentially was missed during the medication review. PC also indicated when staff entered a number 9 onto the EMAR a progress note should have followed that entry and would have identified why the medication was not administered. PC confirmed last time a medication order was sent via fax was 9/22/23, Metamucil had not been delivered to this facility for the past two months and unsure how that happened. During an interview on 10/26/23 at 10:45 a.m., medical records manager (MRM) confirmed there was an order for R1's Metamucil and no order for R1's medication had been faxed to the pharmacy since 9/22/23. During an interview on 10/26/23 at 11:21 a.m., DON stated we currently do not have Metamucil at this facility and was not sure why. DON indicated she aware of this concern and thought LPN-A had taken care of it. DON verified R1 had an order for Metamucil since 4/2022. DON stated she would expect the facility nurse to call the pharmacy and see where the medication was. DON also stated we have no process set up for this as of yet but would have expected within a day or two (two days was stretching it) the staff nurse would follow up and contacted the pharmacy as to why the Metamucil was not received. DON reviewed R1's EMAR and stated staff had documented the last week the Metamucil was given, not sure how that could be when we do not have any. DON stated she intended to follow up with the staff nurses. DON stated the staff may have taken Metamucil from another resident. DON also verified only one or two staff nurses documented in the progress notes and were expected to document anytime the number 9 was entered into the EMAR to identify why it had not been given. DON indicated the bowel protocol would be located in the standing orders and should have been followed per physician's order. DON stated she expected staff to monitor R1's BM's along with abdominal assessments completed and documented in the progress notes. DON also indicated it was obviously important for R1's Metamucil to be administered, orders followed when unable to have a BM and documentation in the progress notes so that she had regular BMs and did not get a bowel obstruction. Requested facility policy and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure written notice was sent to the resident and/or the resident's representatives after emergent transfer from the facility to the hospital for two residents (R5, R8) who were reviewed for hospitalization. Further, the facility failed to send a copy to a representative of the Office of the State Long-Term Care Ombudsman. The failure to provide the required written notices containing all required information places the residents at risk of involuntary transfer and/or not being informed of their rights, including how to appeal their transfer. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact. R5's progress note dated 8/22/2023 at 11:44 a.m., indicated she was transferred to the hospital for evaluation and treatment due to a change in medical condition. R5's medical record revealed no evidence a hospital transfer notice was provided to the resident. During interview on 8/28/23 at 6:44 p.m., R5 stated she recently went to the hospital via ambulance and indicated she did not receive any paperwork including a transfer notice. R8's quarterly MDS dated [DATE], indicated she was moderately cognitively impaired, and lacked documentation regarding her ability to make her own decisions. R8's progress note dated 6/30/23 at 11:00 a.m., indicated she was transferred to the hospital for evaluation and treatment due to a change in medical condition. R8's medical record revealed no evidence a hospital transfer notice was provided to the resident. During interview on 8/31/23 at 1:42 p.m., R8 stated she did not receive any paperwork, including transfer notice when she went to the hospital. In an email dated 8/30/23 at 8:24 a.m., ombudsman identified he received no notifications of transfer in the previous year. During interview on 8/30/23 at 8:48 a.m., director of nursing stated the nurses did not provide a transfer notice to residents when they went to the hospital or notify the ombudsman. She stated the medical records specialist (MR), and the social worker completed any required paperwork, and the social worker (SW) notified the ombudsman. During interview on 8/30/23 at 11:02 a.m., MR stated he did not know anything about transfer notices and the SW was responsible for notifying the ombudsman of resident transfers. During interview on 8/31/23 at 12:07 p.m., SW stated it was her responsibility to notify the ombudsman of resident transfers, but it had not been getting done. She stated it was important to ensure residents did not get unlawfully discharged . During interview on 9/1/23 at 10:23 a.m., administrator stated it was important to provide transfer notices per regulation to ensure no resident was improperly discharged . A policy was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure each resident and/or responsible party was provided a written bed hold policy/notice at the time of each discharge for 2 of 2 resident (R5, R8) reviewed for hospitalization. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact. R5's progress note dated 8/22/2023 at 11:44 a.m., indicated she was transferred to the hospital for evaluation and treatment due to a change in medical condition. R5's progress note dated 8/24/23 at 12:09 p.m. indicated medical record specialist (MR) sent a copy of the bed hold policy directly to the hospital, one for the hospital chart and one for R5. R5's medical record revealed no evidence a bed hold policy/notice was provided to the resident. During interview on 8/28/23 at 6:44 p.m., R5 stated she recently went to the hospital via ambulance and indicated she did not receive any paperwork including a bed hold notice. R8's quarterly MDS dated [DATE], indicated she was moderately cognitively impaired, and lacked documentation regarding her ability to make her own decisions. R8's progress note dated 6/30/23 at 11:00 a.m., indicated she was transferred to the hospital for evaluation and treatment due to a change in medical condition. R8's medical record revealed no evidence a bed hold policy/notice was provided to the resident. During interview on 8/31/23 at 1:42 p.m., R8 stated she did not receive any paperwork, including a bed hold notice when she went to the hospital most recently. During interview on 8/30/23 at 8:48 a.m., director of nursing stated the nurses did not send a bed hold notice with the resident when they went to the hospital, and the medical records specialist (MR) completed that sometime in the future since it could be done later. During interview on 8/30/23 at 11:02 a.m., MR stated he was responsible for providing bed hold notices when a resident went to the hospital, and if a resident left on an evening or weekend, he completed them the next day he worked. MR reviewed R5's medical record and confirmed he sent the bed hold notice to the hospital via fax on 8/24/23 for R5's hospital admission of 8/22/23, and not to the resident or a representative, and he had no way to confirm R5 received it. Upon review of R8's medical record, MR confirmed he did not provide a bed hold notice for her most recent hospitalization and stated some bed hold notices may have been missed. During interview on 8/31/23 at 12:07 p.m., SW stated MR sent bed hold notices to the hospital. During interview on 9/1/23 at 10:23 a.m., administrator stated it was important to ensure a resident's bed was held per regulation to ensure no resident was improperly discharged and could return when able. The facility Bed Hold Policy dated 2019, indicated if a resident is transferred to the hospital, a copy of the bed hold is provided for resident, mailed/emailed/faxed to responsible party and faxed to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to make a followup appointment for 1of 1 resident (R7) reviewed for vision received services to obtain assistive devices needed to maintain vision abilities. Findings include: R7's admission Record accessed 8/31/23 indicated R7 had a diagnosis of diabetes and bilateral myopia (difficulty seeing things at a distance). R7's Minimum Data Set (MDS) Annual assessment dated [DATE] indicated R7 was in need of corrective lenses. During an interview on 8/28/23 at 6:35 p.m., R7 stated they had been to an eye specialist several months ago and received a new lens prescription. R7 further stated they had been waiting to receive new glasses since at least May but had not received any new lenses or a notification from the facility about an appointment to pick up new glasses. A document in R7's medical record indicated R7 went to an optometrist on 4/17/23. During this visit, it was determined R7 needed a lens prescription change and received a recommendation for new eyeglasses. During an interview on 8/30/23 at 1:07 p.m., the director of nursing (DON) stated that the medical records specialist (MRS)-A was expected to coordinate the receipt of assistive devices such as eyeglasses when they are recommended from an appointment. During an interview on 8/31/23 at 10:43 a.m., MRS-A stated he was the staff member that coordinated appointments but has operated under the assumption that the nursing department were the ones responsible for follow up with assistive devices recommended at appointments. A facility policy regarding assistive devices and vision maintenance was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 2 of 5 residents (R6, R15) were offered or received the pneumococcal vaccine (PCV20) in accordance with the Centers for Disease Control (CDC) recommendations. Findings include: R6's Medical Diagnosis list printed 8/31/23, indicated she was [AGE] years old and had diagnoses of Type 2 diabetes mellitus and nicotine dependence, and no allergies to vaccines or contraindications to the pneumococcal vaccine. R6's immunization documentation indicated she had one dose of PPSV 23 on 12/19/09, and another dose of PPSV 23 on 12/19/17. The CDC's PneumoRecs VaxAdvisor indicated for patients aged 19-64 who have not received PCV15 or PCV20, with a risk factor of Type 2 diabetes mellitus and nicotine dependence and had a PPSV23, Give one dose of PCV15 or PCV 20 at least one year after their last dose of PPSV23. If PCV 20 is used their vaccinations are complete. R15's Medical Diagnosis list printed 8/31/23, indicated she was [AGE] years old and had a diagnosis of alcohol abuse and no allergies to vaccines or contraindications to the pneumococcal vaccine. R15's immunization documentation indicated she had not received any pneumococcal vaccinations. The CDC's PneumoRecs VaxAdvisor indicated for patients aged 19-64 who have not received PCV15 or PCV20, with a risk factor of alcoholism and did not receive the PPSV23 or the PCV13, Give one dose of PCV15 or PCV 20. If PCV20 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. R6's and R15's medical records lacked evidence the recommended PCV15 or PCV20 vaccination was offered or received. During interview on 9/1/23 at 9:33 a.m., director of nursing (DON) stated she was the facility infection preventionist, but admissions staff interviewed residents upon admission and added any immunization information into the medical record. DON reviewed the medical records for R6 and R15 and stated she was not able to find complete pneumococcal immunization information for either resident. She stated she had not followed up to make sure admissions did the right thing or to ensure residents received their immunizations, and it was important to keep up to date to prevent illness. The facility Infection Prevention and Control policy dated 8/2023, indicated all resident or their legal representatives will be offered the opportunity to receive vaccines as they are recommended by their provider or the medical director. This includes but is not limited to: influenza, pneumococcal or COVID-19 vaccinations. Resident and resident representatives have the right to refuse any vaccine, but education will be provided. Resident medical record will be updated with residents choice on the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure appropriate side-effect monitoring (i.e. blood pressures [BP], involuntary movements) was completed for 3 of 5 residents (R1, R15, R17), failed to identify a duplicate as needed (PRN) psychotropic medication (drugs that affect a person's mental state) for 1 of 5 residents (R1), failed to ensure residents were reassessed for continued use of PRN antipsychotic medications (used for a variety of mental health disorders), beyond the 14 days for 3 of 5 residents (R1, R9, R15), failed to identify a possible drug allergy for 1 of 5 residents (R1), and failed to appropriately schedule administration of medication to treat orthostatic hypotension (a rapid drop in BP with change in position) for 1 of 5 residents (R15) reviewed for unnecessary medications. Findings include: R1 - Monitoring of Orthostatic BP and Side Effects, Duplicate Antipsychotic Order, 14-day PRN, Allergy R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact, and had diagnoses of high BP, anxiety, depression, and schizophrenia, and took antipsychotic, antianxiety, and antidepressant medications seven of the previous seven days. R1's care plan dated 8/15/22, included nursing will review complete a mini mental exam yearly or as needed, and evaluate effectiveness and side effects of psychotropic drugs with physician for possible decrease in dosage/elimination. R1's Order Summary Report dated 8/29/23, included: - Citalopram Hydrobromide 30 milligrams (mg) daily for depression starting 11/29/22. - Risperidone 2 mg twice per day for psychosis starting 6/6/23. - Orthostatic BP monthly starting 3/29/22. - Benztropine Myselate 0.5 mg daily for extrapyramidal side effects (EPSE - drug-induced movement disorders often caused by psychotropic medications) starting 11/18/22. - Trihexyphenidyl HCL 2 mg PRN twice daily for EPSE starting 2/7/23. - Olanzapine 5 mg (an antipsychotic), one tablet every 24 hours PRN for anxiety starting 8/25/23. - Olanzapine 5 mg, one tablet every 24 hours PRN for voices starting 8/28/23. - Valium 2 mg, one tablet daily PRN for anxiety starting 2/2/23. - Allergy to Zyprexa (olanzapine) R1's Blood Pressure Summary printed 8/31/23, lacked evidence of orthostatic BPs since 1/9/23. R1's medical record lacked indication orthostatic BPs were taken since 1/9/23. R1's Dyskinesia Identification System: Condensed User Scale, (DISCUS - used to measure abnormal involuntary movements related to psychotropic medications) completed 2/4/22, indicated she had no involuntary movements. R1's medical record lacked evidence of an EPSE evaluation since. R1's medical record lacked indication the PRN Valium order was reviewed or renewed by a provider since the medication was last ordered on 2/2/23. R1's allergy list displayed on the resident header in the electronic medical record indicated she was allergic to olanzapine. R1's progress note dated 8/25/23, indicated The system has identified a possible drug allergy for the following order: OLANZapine Oral Tablet Disintegrating 5 MG (Olanzapine) Give 1 tablet by mouth every 24 hours as needed for Anxiety. R1's progress note dated 8/28/23, indicated The system has identified a possible drug allergy for the following order: OLANZapine Oral Tablet Disintegrating 5 MG (Olanzapine) Give 1 tablet by mouth every 24 hours as needed for Anxiety. R1's medical record lacked documentation of staff identification and/or communication with the provider regarding the duplicate olanzapine orders, which could result in R1 receiving two doses in 24 hours and lacked evidence of acknowledgment and/or communication with the ordering provider regarding the possible allergy. R15 - Midodrine timing, Orthostatic BP, 14-day PRN R15's quarterly MDS dated [DATE], indicated she was cognitively intact, had diagnoses of orthostatic hypotension, anxiety, and manic depression, and took antipsychotic, antianxiety, and antidepressant medications seven of the previous seven days. R15's care plan dated 5/8/23, included interdisciplinary team (IDT) will evaluate effectiveness and side effects of medications for possible need of increase, decrease, or elimination of psychotropic drugs quarterly and as needed, and medications per doctor order starting 7/28/22. R15's Order Summary Report dated 8/29/23, included: - Hydroxyzine HCl 25 mg at bedtime for anxiety (with side effect of orthostatic hypotension), and 50 mg by mouth every four hours as needed for anxiety starting 7/30/23. - Midodrine HCl 2.5 mg twice per day for orthostatic hypotension starting 5/17/23. - Monitor orthostatic BP monthly starting 3/29/22. R15's Treatment Administration Record (TAR) dated 8/31/23 for July 2023, included monitor orthostatic BPs and call clinic if readings are low starting 5/18/23 and discontinued 7/28/23. R15's medical record lacked evidence of orthostatic BPs from 7/29/23, through 8/31/23, and a documented rationale for use of Hydroxyzine HCl beyond the 14-day PRN limit. R15's Medication Administration Record (MAR) dated 8/31/23 for August 2023, identified R15's midodrine doses were scheduled for 8:00 a.m. and 8:00 p.m. During observation and interview on 8/30/23 at 11:37 a.m. R15 was lying supine in her bed. She stated she took Midodrine in the morning and at night, and staff used to take orthostatic BPs to make sure it didn't go too low. She stated they stopped and changed to BP checks about every two weeks and no longer completed orthostatic BPs. She stated she had taken a dose of midodrine that morning and had a headache. R9 - 14-day PRN R9's quarterly MDS assessment dated [DATE] indicated R9 exhibited delusions and refusals of care in the 7-day look-back period. The assessment further indicated R9 had received an antianxiety agent seven of seven days during the lookback period. R9's admission Record, accessed 8/31/23, revealed R9 had diagnoses including bipolar disorder, anxiety disorder, schizoaffective disorder (a mental condition which can affect your thoughts, mood and behavior), and a history of traumatic brain injury. R9's physician orders included an order for Alprazolam (Xanax) 0.25mg as needed (PRN) since 4/28/23. R9's medical record lacked indication the PRN Alprazolam order had been reviewed and renewed by a physician since the medication was ordered. According to the Mayo Clinic website updated 8/1/23, the last daily dose of midodrine should not be taken after the evening meal (not later than 6:00 p.m.) or less than 3 to 4 hours before bedtime because high blood pressure upon lying down (supine hypertension [increased in BP]) can occur, which can cause blurred vision, headaches, and pounding in the ears while lying down after taking this medicine. Also, midodrine should not be taken if you will be lying down for any length of time. (https://www.mayoclinic.org/drugs-supplements/midodrine-oral-route/proper-use/drg-20064821) R17 - Orthostatic BP R17's admission MDS dated [DATE], indicated she was cognitively intact, independent with activities of daily living, had diagnoses of orthostatic hypotension, anxiety disorder, and post-traumatic stress disorder. R17 received antidepressant, antipsychotic, and antianxiety medication seven of the previous seven days. R17's care plan dated 6/20/23, included R17 took antipsychotic medication, the consulting pharmacist will monitor for compliance during monthly visits, and nursing and resident services will review and make changes to target symptoms quarterly and/or as needed. R17's Order Summary Report dated 9/1/23, included: - Clozapine (an antipsychotic), 325 mg by mouth at bedtime - Prazosin HCl 2 mg for high blood pressure (which can cause orthostatic hypotension) - Orthostatic BP monthly three times a day on the first day of every month both starting 6/7/23. R17's Blood Pressure Summary report included five blood pressure readings since 6/7/23, and no evidence of orthostatic blood pressures. R17's medical record lacked indication orthostatic blood pressures were taken since ordered on 6/7/23. During interview on 8/31/23 at 9:53 a.m. pharmacist (Pharm)-A stated orthostatic BPs should be done at least monthly for R1, R15, and R17 because a large drop in blood pressure could cause them, or any resident taking certain medications to fall and become injured. He stated R15's BP ran low, and he thought there was an order to change R15's orthostatic BP monitoring from monthly to weekly because it needed to be monitored more often. In addition, R15's should not be given midodrine at 8:00 p.m. due to the potential for supine hypertension. Pharm-A stated PRN antianxiety medications needed a 14-day end date or rationale for continued use, and confirmed they were missing for the medications for R1, R9, and R15. He stated those recommendations usually went to the psychiatrist, but it was difficult to get a response because they didn't come to the facility. Pharm-A stated R1 needed to evaluate EPSE for residents taking psychotropics, and they should have ensured it was completed for R1. He stated R1's duplicate olanzapine orders were not there when he completed his last review, and it was a big concern. He stated she was already on a lot of medications with potential for sedation which could lead to balance concerns and then falls and was concerned about compounding side effects. During interview on 8/31/23 at 10:50 a.m., director of nursing (DON) stated DISCUS evaluations were completed yearly by registered nurse (RN)-A. During interview on 8/31/23 at 11:34 a.m., RN-A stated they used to complete DISCUS evaluations every three months, but then nobody could find a policy, so she started to complete them every six months. She stated she was behind and confirmed R1's DISCUS was not done. During interview on 9/1/23 at 9:33 a.m., DON stated the nurse completed orthostatic BPs to make sure residents did not get hypotensive and was not sure why they were not being completed. She was unaware of R1's duplicate orders for olanzapine and her allergy, and stated some of the nurses' entered medications into the record and she did not know which ones unless she worked on the medication cart. DON stated she did not know why there were orders for PRN psychotropic medications longer than 14 days, but some of the doctors wanted to keep it longer than 14 days, and they were getting some education from the pharmacy. In addition, she also stated it was important to complete the DISCUS to see if they had side effects and if their medication needed to be changed. Regarding R15, she stated she did not know what midodrine was or what it did. She stated there was a resident on it because her blood pressure was very low, but when her blood pressure increased the house doctor came in and discontinued the orthostatic BP order. DON stated she did not know midodrine should not be given past 6:00 p.m. She stated it was hard to monitor every little thing because they had so many residents, but a few things were missed, and it was her responsibility. Policies pertaining to psychotropic medications, vital sign monitoring, and related topics were requested but not provided.

Based on interview and document review, the facility failed to ensure the purchased surety bond (a contract or promise by a surety or guarantor to pay if a second party fails to meet the obligation) had sufficient coverage to protect the total account balance of the resident trust fund. This had the potential to affect 15 of 15 residents who had a trust account while residing at the facility. Findings include: A facility provided Trust Transaction History report dated 8/31/23, identified 15 current resident trust accounts were managed by the facility. The sum of all 15 resident trust accounts on 8/31/23 totaled $16,659.88. During an interview on 8/31/23 at 2:06 p.m., the medical records specialist (MRS)-A, who was responsible for the day-to-day accounting for resident trust accounts, indicated he was unaware of a surety bond. During interview on 9/1/23 at 8:02 a.m., the administrator stated he would have to request the surety bond as he did not have it on hand. A Nationwide Mutual Insurance Company Verification Certificate dated 2/1/23 and effective until 1/31/23 was provided on 9/6/23 and indicated the facility was covered for a $10,000 patient trust fund. A policy for resident trust funds was requested but not received. The facility's request for a continuing waiver of the following health deficiency has been forwarded to the CMS Region V Office. Approval of the waiver request has been recommended.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 17 residents at the facility. Findings include: Review of the facility staff schedules and staffing hours from 6/1/23 to 8/28/23 revealed there was no RN scheduled for 6/24/23, 7/8/23, 7/9/23, 7/31/23, 8/12/23, 8/26/23 and 8/27/23. During an interview on 8/30/23 at 8:46 a.m., the director of nursing (DON) stated the facility tried to keep an RN on staff 8 hours per day 7 days a week, but sometimes did not happen. The DON stated she was the RN coverage during the weekdays, but there were occasional RN call-ins that took place on the weekend that could only be replaced by licensed practical nurses (LPNs) from a staffing agency. During an interview on 8/31/23 at 10:31 a.m., the administrator reviewed staff schedules and staffing hours from 6/1/23 to 8/28/23. The administrator verified no RN was onsite 6/24/23, 7/8/23, 7/9/23. 7/31/23, 8/12/23, 8/26/23 or 8/27/23. The administrator stated the facility tried to ensure an RN was on staff 8 hours each day, but this had not always been possible. A policy on staffing was requested but not provided. The Facility Assessment Tool, updated 8/23, did not outline a facility plan for RN staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure cooking utensils were properly sanitized (i.e., high temperature) in 1 of 1 commercial dishwashers observed in the main production kitchen. This had potential to affect all 17 residents, visitors, and staff who consumed food from the kitchen. Finding include: During interview on 8/30/23 at 10:49 a.m., dietary manager (DM) stated she usually worked at another facility but was spending more time at this facility due to staffing shortages and was training a new full-time dietary supervisor (DS). DM identified the dishwasher was [NAME], used heat to sanitize, was installed in 1998, held one rack, and required a wash temperature of 150 degrees Fahrenheit (°F) and a rinse temperature of 180°F to ensure dishes were sanitized. Staff tracked temperatures at each meal on a form located on the counter. During observation and interview on 8/30/23 at 1:15 p.m., the dishwasher wash temperature was observes at 134°F, and the rinse temperature reached 179°F and held for one second. DM started the load of 10 plates, six plastic drinking cups and five coffee cups again at 1:16 p.m. The wash temperature during this cycle was 146°F, and the rinse cycle reached 175°F which held for one second. DM stated the dishwasher might have needed to be serviced and was unsure when it was serviced last, and sometimes it took a few cycles for it to get up to temperature. She opened the dishwasher, removed the tray of dishes, removed some food remnants from the bottom of the dishwasher, reloaded it, and started it again. The temperature was 158°F during the wash cycle and 181°F during the rinse cycle, with the rinse cycle lasting one second. During observation and interview on 8/31/23 at 8:56 a.m., DS placed a tray containing eight plastic cups, one plate, one sheet pan, and one plastic container into the dishwasher and started the unit. The wash temperature reached 131°F and the rinse reached 180°F and dropped back down to 131°F one second later. DS stated it should reach 150°F and then stay at the rinse temperature of 180°F for about a minute. He stated the machine needed to be at a 'certain temperature' to prevent bacteria from forming on the dishes. DS started the dishwasher again with the same load of dishes at 9:01 a.m. where it reached a wash temperature of 137°F and a rinse temperature of 186°F. The unit shut off after approximately five seconds. DS stated the dishes were clean and he took them out of the unit and set them aside to air dry. He stated he didn't know much about the dishwasher, and usually documented the temperature on the log during the last load of dishes. He stated staff were supposed to do it early in the morning before starting to wash dishes, but if he missed it, he could always do it later. DS continued to use the dishwasher and stated if it was not working properly, he notified DM, administrator, or maintenance. During observation and interview on 8/31/23 at 11:20 a.m., DS ran a load of dishes through the dishwater. The wash temperature was 128°F and the rinse temperature was 180°F for one second and the unit turned off. DS stated the dishwasher was still working the same as it was previously and was unsure what the temperature was supposed to be and the lower wash temperatures 'might be the standard for this one [dishwasher]. During interview on 9/1/23 at 8:24 a.m. DS stated he had not had a chance to let anyone know about the dishwasher yet. During interview on 9/1/23 at 8:38 a.m. administrator stated nobody told him about the dishwasher not working properly, but they were working on the kitchen hot water heater to figure out how to ensure the water was hot enough for the dishwasher, but not so hot staff would burn themselves with the water in the kitchen sink. He stated the temperature needed to be as outlined by the manufacturer to ensure the dishes were sanitized to prevent anyone from getting sick. During observation with the administrator on 9/1/23 at 8:48 a.m., DS pre-rinsed approximately 30 pieces of silverware in the sink, added them to the dishwashing tray, placed the tray in the dishwasher, and started it. The wash temperature reached 107°F and the rinse temperature rose to 176°F for one second, then dropped back down to 107°F. The load was started again. The wash temperature reached 124°F and the rinse temperature rose to 179°F for one second, then dropped back down to 125°F. The administrator stated the rinse cycle should last for 10 seconds, not one, and the facility would use the three compartment sink for dish sanitization until the dishwasher could be fixed. During interview on 9/1/23 at 8:57 a.m. DM stated she did not inform the administrator of the dishwasher temperatures because it was working fine the rest of the day when she was there last. The Dishwasher Log (undated) identified wash temperatures at or greater than 150°F and rinse temperatures at or greater than 180°F for all morning readings from 8/1 - 8/30, and all midday readings from 8/1 - 8/29. The log lacked temperature readings for the evening shift from 8/1 - 8/21, and all readings from 8/22 - 8/29 were documented as within acceptable temperature ranges. Temp machine 3 times daily was written on the top of the form, along with the minimum wash and rinse temperatures of 150°F and 180°F respectively. The tag affixed to the side of the dishwasher indicated it was a [NAME] model LX30H. The [NAME] LX Series Dishwashers Instructions dated 7/2000, indicated the LX30H wash temperature should be above 150°F, the rinse water was heated to at least 180°F, and the rinse cycle time was 10 seconds. A dish sanitation policy was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to transport and store linens to prevent contamination, remove and replace soiled furniture to prevent the spread of bacteria, and failed to implement a surveillance plan, for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. This had the potential to affect all residents, visitors, and staff in the facility. Findings include: Furniture During interview on 8/28/23 at 7:17 p.m., anonymous resident (AR)-A stated staff said the facility would replace the communal living room leather furniture because it was all stained with urine. She stated the residents needed to sit on a towel or their clothes smelled like urine, and both the furniture and the room lighting were so dark it was hard to see what one could be sitting in. R10's quarterly Minimum Data Set, dated [DATE], indicated she was severely cognitively impaired, required extensive assistance of one staff for toilet use, and was frequently incontinent of bladder and occasionally incontinent of bowel. During observation on 8/29/23 at 8:54 a.m., R10 was seated on a white towel in a brown leather-looking chair closest to the television the facility communal living area. There was a large, overstuffed leather-looking couch and loveseat also in the room. During observation on 8/30/23 at 10:21 a.m., a white towel was present on the seat of the chair and another on the left half of the love seat in the living area. At 10:55 a.m., R10 was sitting in the chair on top of the towel. At 12:05 p.m., R10 was no longer in the chair, and the white towel had yellowish discolored areas where R10 previously sat. During observation on 8/31/23 at 9:17 a.m., R10 was seated in the chair on top of a white towel, while AR-A was seated on a white towel on the loveseat. At 10:34 a.m. the chair was unoccupied and covered with a white towel which was slightly yellowed and discolored. At 12:33 p.m. R10 was again seated in the chair on the white towel. During interview on 8/31/23 at 1:07 p.m., nursing assistant (NA)-A stated the towels on the furniture were there because sometimes R10 or other residents had incontinence accidents on the furniture. She stated she had never seen anyone wipe the furniture down and would never lay down on it herself but thought it should somehow be disinfected. During interview on 8/31/23 at 1:25 p.m., director of nursing (DON) stated the residents didn't like to sit on the furniture without a towel because some residents were incontinent and soiled the furniture. She stated she thought housekeeping cleaned them but did not know how they would clean dark leather furniture. She stated she would not sit in the chair by the television herself because you never know what you could sit in and bacteria could be present. During interview won 9/1/23 at 10:23 a.m., administrator stated there were some residents with continence issues or leg sweat from sitting on leather, and the towels were for peace of mind. He stated some residents have had accidents on the couches, and he had seen towels but had not personally seen where someone sat in something they didn't want to. He was unsure how staff would sanitize leather furniture, indicated it was not appropriate for the facility, and confirmed the furniture should be replaced. Laundry/Linen Storage During interview and tour of the basement laundry facilities with the housekeeper (HK) on 8/30/23 at 11:44 a.m., one fan was running and oscillating on a shelf to the left of the washer and dryer and another much large fan was on the floor to the right, also blowing air and small dust particles throughout the laundry room. Several exposed pipes were covered with dust, while others were covered with a white thick gauzy insulation-like substance which was ripped apart in numerous areas exposing the pipes underneath. Two large, uncovered plastic linen carts were against the far wall next to the floor fan. The top shelf contained approximately 60 bath towels which were stacked to the ceiling against the pipes with the insulation-like covering. The shelving unit also contained a stack of washcloths, several large bundles of pillowcases, approximately 50 fitted sheets, and three large stacks of flat sheets, all of which were not covered. HK stated soiled linens were sent out to a contracted company for washing and she placed them on the shelf when they received clean ones back. She brought resident clothing down in baskets to the laundry room, washed and folded them, and laid the clean clothes on top of the baskets or hung them on a clothing rack uncovered until she could bring them back up and put them away. She stated the clothing and linens were always out in the open, and confirmed they were likely covered in the dust being blown around by the fans in the room. During interview on 9/1/23 at 9:33 a.m., DON stated HK was new to the role of housekeeping and had not gotten training, but thought the laundry should be covered when stored to prevent spread of germs. Handling of Soiled Linen On 8/30/23 at 11:03 p.m., NA-A was observed walking from the upstairs level, through the living room, dining room, and kitchen to the basement with her arms full of soiled linen held next to her body touching her clothing. During interview on 8/31/23 at 1:07 p.m., NA-A stated she was instructed to change resident sheets after each resident had a shower but thought it would be easier to do it all at once, so she removed and replaced resident sheets once per week on the first floor every Monday and the second floor every Wednesday, or more often if they were visibly soiled. She described she removed the disposable pads from the beds and put them in the garbage, removed the sheets, replaced them, and replaced the disposable pads with new ones. Once she collected all the soiled sheets, she stated she wrapped them up tightly in her arms close to her body so they were not hanging out and brought them to the basement laundry area by walking through the resident living area, dining room, and kitchen. Once she arrived at the laundry area, she placed them in a red bag which was then placed in a large laundry bin to be picked up by a contracted company. She stated if the kitchen was too busy, she went outside with the laundry and in the back door, but this was not normal practice, and not realistic in bad weather. She stated nobody asked her not to go through the kitchen with the dirty linen, or to bag it before bringing it through, and identified she did not get any training at the facility. She indicated the red bags in the laundry area were too big and heavy to bring up with her, and there were not enough to bring a new one up each time linens needed to be collected for washing. During interview on 9/1/23 at 9:33 a.m., DON stated the facility had new staff and some did not have initial training, and indicated soiled laundry should be bagged before taking it down to the laundry and not be held against the body to prevent the spread of infection. During interview on 9/1/23 at 10:23 a.m., administrator stated the process for handling soiled linen could and would be improved and holding laundry against one's clothing had the potential to spread bacteria. The Soiled Linen Handling policy (undated) indicated soiled linen is transported in a covered container. Infection surveillance During interview on 8/31/23 at 7:23 a.m., DON presented the facility infection control binder. She stated she thought the administrator created a new one which was stored at another site, but the only one she had at the facility was the one she provided. Review of the binder revealed it was last updated 3/13/20. DON stated she was unsure when it was updated last, as the previous administrator who no longer worked at the facility did that. During interview on 8/31/23 at 8:36 a.m., administrator stated the facility infection control binder was the one DON presented and he was unsure of the date. During interview on 8/28/23 at 7:17 p.m., AR-A stated there was a breakout of bronchitis over the past two or three weeks and there were several residents who had prolonged and persistent coughing. She stated the staff just ignored it, and nobody was asked to wear a mask or stay away from other people. During interview on 9/1/23 at 9:33 a.m., DON stated the facility used to record COVID-19 symptoms on a COVID testing log but stopped on January 28th, and they no longer kept a tracking list of residents with specific symptoms or tests. DON stated the facility used to report COVID-19 cases, but was unsure which diseases were reportable since the previous administrator did that if needed. When asked about tracking other potential infectious diseases she stated there were several residents who recently had respiratory symptoms, but they didn't track them because some were smokers, some had bronchitis, some had COPD, some had pneumonia, and some went to the doctor and got allergy medication. She identified it as important to track symptoms of infection because if they didn't, they could spread infection. The Infection Precention and Control policy dated 8/2023, indicated a system is in place for surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom to report incidents of communicable disease or infection. The Infection Preventionist will track and record resident and staff infections, treatments and resolutions of infections for the purposes of containing a potential epidemic or outbreak within our facility.

Based on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, and trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Findings include: The Grand Avenue Residence Antibiotic Stewardship Monthly Log listed four occurrences where antibiotics were dispensed to residents from 1/1/23 through 8/31/23. The form included resident name, date, infection, antibiotic, completion date and outcome, but lacked evidence of review for appropriate antibiotic use and appropriate action taken. The 'Details Rxs and supplies categorized by therapeutic class and/or products' pharmacy report for the period 1/1/23 through 8/31/23, included 16 dispensed prescriptions for antibiotic/antibacterial medications. During interview on 9/1/23 at 9:33 a.m., director of nursing (DON) stated she was the infection preventionist for the building for the past year. She identified she did not have a report or log of all residents who had orders for antibiotics, and it was the provider's responsibility to review a resident's symptoms, make a diagnosis, and determine which, if any, antibiotic should be prescribed, and how long to take it. She stated since the nurses did not diagnose, they did not question an antibiotic selection or length of treatment and the facility did not use any criteria to determine whether any antibiotic was appropriate. DON stated she did not review antibiotic use and there was no method to provide feedback to providers unless an antibiotic did not seem to be working, and the providers were responsible for any follow-up with the resident. DON stated the facility did not have an antibiotic stewardship program, did not get education to know how to address antibiotic stewardship, and confirmed she did not know she was supposed to track or monitor antibiotic usage. During interview on 8/31/23 at 9:53 a.m., pharmacist (Pharm)-A stated the facility used to track antibiotic usage in a book which was broken down by resident name, but the facility changed to an electronic medical record, and he was not sure how they tracked it anymore. He stated the facility ownership changed hands, and since then they had one quality and performance improvement (QAPI) meeting, but antibiotic stewardship was not discussed. The one-page Birchwood Care Home and Grand Rest Home Antibiotic Stewardship Policy revised 8/24/23, indicated the infection preventionist will track and assess all antibiotic use to review patterns of use and assure appropriate antibiotic use. The infection preventionist will review any antibiotic order and reassess the ongoing need for and choice of antibiotic when the clinical picture is clearer, and more information is available. The policy lacked protocols and criteria for determining what is appropriate use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to ensure a consent was obtained prior to opening a trust account, and the facility did not honor choice to receive un-opened mail for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated intact cognition. R1's care plan indicated ability to manage own finances as noted, Resident is her own person and manages her own finances responsibly. There is no withdrawal limit. The care plan also indicated a goal for R1 to continue manage finances independently. The care plan directed staff to assist with money management if requested by resident. The care plan indicated that R1 is able to communicate her needs to others and is understood during the conversation. The document titled, Information and Authorizations, dated 6/8/22, indicated R1's preference to receive all her mail intact or unopened. The document titled, Trust Statement, indicated R1's trust account started on 11/15/22. R1's trust account statement also showed $150.00 deposited on 5/4/23. During interview on 7/6/23 at 12:45 p.m., the social services director (SSD) stated that R1 desired to receive all her mail unopened, however, sometime in 4/23, the social services office received and opened R1's incoming mail, which contained a check amounting to $150.00. The SSD stated that the social services assistant (SSA), who opened R1's mail with out her knowledge or consent, deposited the $150.00 check into an onsite trust account, also without R1's consent. The SSD verified that R1 had a trust account that the facility managed, contrary to R1's preference reflected in the care plan. The SSD also verified there was lack of evidence to show R1 consented to opening a trust account nor for the facility to manage such trust account. The SSD stated that she talked to R1 on 7/5/23 at about 4:00 p.m. (after R1 talked with surveyor) and asked for R1's consent for the facility to manage her trust account. The SSD further stated R1 was still thinking about it and that R1 was given 24 hours to decide and to let the SSD know of her decision. During interview on 7/7/23 at 9:01 a.m., the director of nursing (DON) stated that R1's trust account was opened around the last quarter [November] of last year. The DON also verified there was lack of proof to show R1 consented to opening the trust account including its management by the facility. The policy titled, Resident Assessment and Care Planning, dated 9/30/17, provides that care planning is person-centered and an ongoing process. The policy also provides that the resident has the right to participate in care planning, goal setting, and be informed of changes to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to initiate a grievance process to address resident concerns pertaining to finances, missing personal clothing and curtains for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated intact cognition, with diagnoses including anxiety disorder, depression, and paranoid schizophrenia. The MDS also indicated behavioral hallucinations, delusions, other behaviors not directed towards others. R1's care plan indicated ability to manage own finances as noted, Resident is her own person and manages her own finances responsibly. There is no withdrawal limit. The care plan also indicated a goal for R1 to continue manage finances independently. The care plan directed staff to assist with money management if requested by resident. The care plan indicated that R1 is able to communicate her needs to others and is understood during the conversation. On 7/5/23 at 1:40 p.m., R1 stated the facility took her clothes and curtains out when they cleaned her room and never gave back the said items. R1 also indicated financial concerns, saying she did not understand how she had overdrawn trust account and now had to pay back money. The progress notes showed on 5/15/23, R1 ranted about people stealing her checks, and indicated SS [social services] cashed her check without her permission and cannot trust anyone here to give her a straight answer on how much rent she owes. The progress notes also showed on 6/27/23, R1 voiced that her curtains were stolen. The facility's grievance log from 9/11/22 through 7/5/23 was requested for review, but the log did not reflect R1's concerns regarding stolen financial checks, and the missing clothes and curtains. During interview on 7/6/23 at 12:45 p.m., the social services director (SSD) stated she talked to R1 on 7/5/23 at approximately 4:00 p.m. (after R1's interview with surveyor) and made an inventory of R1's missing clothes that would be replaced. The SSD also acknowledged they could not find R1's curtains. In addition, the SSD acknowledged R1's concern that sometime in 4/23, R1 had a check amounting to $150 that was deposited into trust account without R1's consent. The SSD verified that the grievance log did not reflect R1's concerns. During interview on 7/7/23 at 10:09 a.m., the administrator verified that staff were aware of R1's concerns about her financial checks being stolen since 5/15/23, and concerns related to missing clothes and curtains on 6/27/23. The administrator stated expectations that residents' concerns be documented and addressed possibly on the same day. The administrator also verified that R1's concerns were not in the grievance log. The facility's document titled, Resident Grievance Policy, indicates that the facility allows residents to express any concerns or grievances they have, orally or written, and to ensure all concerns are addressed. The policy directs social services to review all concerns, and reply to resident's concern within 2 weeks, and a copy of the grievance form will be filed in the grievance book. The policy also directs social services to lead and coordinate all investigations. The policy indicates that all concerns will be investigated, documented in a file, logged, and maintained for 3 years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to safeguard personal funds and property for 1 of 3 residents (R1) reviewed, when the facility did not identify the beneficiary for multiple trust account cash withdrawal transactions. In addition, the facility did not account for personal clothes and curtains taken from resident's room. Findings include: On 7/5/23 at 1:40 p.m., at the 2nd floor living room, R1 approached surveyor and stated the facility cleaned her room and took her clothes and curtains out. R1 stated the facility explained that the curtains posed a fire hazard concern, however, R1 said, they should have just given them to me, and I will give them to my friend. R1 stated being nervous because the facility does not address issues. R1 also stated concerns about her finances when the facility informed her that she had overdrawn and now owed money. R1 said, I am so confused. R1's quarterly minimum data set (MDS) dated [DATE], indicated intact cognition, with diagnoses including anxiety disorder, depression, and paranoid schizophrenia. The MDS also indicated behavioral hallucinations, delusions, other behaviors not directed towards others. R1's care plan indicated ability to manage own finances as noted, Resident is her own person and manages her own finances responsibly. There is no withdrawal limit. The care plan also indicated a goal for R1 to continue manage finances independently. The care plan directed staff to assist with money management if requested by resident. The care plan indicated that R1 is able to communicate her needs to others and is understood during the conversation. The document titled, Trust Statement, indicated R1's trust account quarterly statement dated 5/31/23, which showed the following: - On 4/3/23, an opening balance of $388.02, with interests amounting to $0.03, and leaving a balance of $388.05, - On 5/1/23, a cash withdrawal in the amount of $100.00, leaving a balance of $288.05, - On 5/2/23, a cash withdrawal in the amount of $100.00, leaving a balance of $188.05, - On 5/3/23, a deposit in the amount of $150.00, leaving a balance of $338.05, - On 5/4/23, a cash withdrawal in the amount of $150.00, leaving a balance of $188.05, - On 5/5/23, a cash withdrawal in the amount of $100.00, leaving a balance of $88.05, - On 5/6/23, a cash withdrawal in the amount of $50.00, leaving a balance of $38.05 - On 5/10/23, a rent was paid in the amount of $360.00, leaving a negative balance of ($321.95), - On 5/16/23, another cash withdrawal in the amount of $8.00, increasing the negative balance to ($329.95). The progress notes showed on 5/15/23, R1 ranted about people stealing her checks, and indicated SS [social services] cashed her check without her permission and cannot trust anyone here to give her a straight answer on how much rent she owes. The progress notes also showed on 6/27/23, R1 voiced that her curtains were stolen. The facility's grievance log from 9/11/22 through 7/5/23 was requested for review, however, the log did not reflect R1's concerns regarding stolen financial checks and the missing curtains. During interview on 7/6/23 at 12:45 p.m., the social services director (SSD) stated she talked to R1 on 7/5/23 at approximately 4:00 p.m. (after R1 talked with surveyor) and made an inventory of R1's missing clothes that facility would replace. The SSD also acknowledged they could not find R1's curtains. In addition, the SSD stated that sometime in 4/23, R1 had a check amounting to $150 that was deposited into trust account without R1's consent. The SSD also stated that R1's account is now on the negative because the previous social services assistant (SSA) kept giving money to R1 without first checking the availability of funds in the account. The SSD verified that the records show R1 owes money back because of the overdrawn account. During interview on 7/7/23 at 10:09 a.m., the administrator stated that when he started his position on 5/15/23, he identified the problem regarding lack of records for accounting residents' funds and immediately took action to correct it. The administrator stated his lack of knowledge about the facility's system for accounting of residents' funds prior to his term. The administrator also stated he talked to R1 on 5/23/23, but R1 did not indicate a problem regarding stolen checks. However, the administrator acknowledged there was no evidence to show who made the transactions and who received the cash withdrawn from R1's trust account. The administrator verified the entries in progress notes (dated 5/15/23) indicating R1's concerns that her checks were being stolen. The administrator also acknowledged that without any documentation, R1's money could not be traced, and the administrator further said, I do not have an answer. The facility's document titled, Abuse, Neglect, and Exploitation Prevention Policy, dated 4/26/22, recognizes the right of residents to be free from abuse and neglect. The policy defines abuse to include the deprivation by an individual of goods or services that are necessary to maintain physical, mental, and psychosocial well-being. The policy provides that instances of abuse cause physical harm, pain, or mental anguish. The policy indicates that abuse includes non-therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress and is not accidental. The policy also defines vulnerable adult as any resident of the facility. The policy further defines financial exploitation as engaging in unauthorized expenditure of vulnerable adult's funds which is likely to result in detriment, and in the absence of legal authority, using or withholding vulnerable adult's funds or property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to report allegations of misappropriation of funds and personal property for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated intact cognition, with diagnoses including anxiety disorder, depression, and paranoid schizophrenia. The MDS also indicated behavioral hallucinations, delusions, other behaviors not directed towards others. R1's care plan indicated ability to manage own finances as noted, Resident is her own person and manages her own finances responsibly. There is no withdrawal limit. The care plan indicated a goal for R1 to continue manage finances independently. The care plan directed staff to assist with money management if requested. The care plan also indicated that R1 is able to communicate her needs to others and is understood during the conversation. R1's trust account quarterly statement dated 5/31/23, showed a beginning balance of $388.00 on 4/3/23. Thereafter, there had been transactions for a single deposit, single rent payment, and multiple cash withdrawals on the following dates: on 5/1/23, withdrawal for $100.00; on 5/2/23, withdrawal for $100.00; on 5/3/23, deposit for $150.00; on 5/4/23, withdrawal for $150.00; on 5/5/23, withdrawal for $100.00; on 5/6/23, withdrawal for $100.00; on 5/10/23, rent for $360.00, and on 5/16/23, withdrawal for $8.00. R1's trust account showed an ending balance of ($329.95), indicating an overdrawn account. The progress notes dated 5/15/23, showed that R1 voiced concerns about her checks being stolen, and being cashed without her consent. During interview on 7/7/23 at 10:09 a.m., the administrator stated that the facility did not follow the protocol to report R1's concern. The administrator acknowledged the importance of reporting, investigating, and then developing and implementing action plans to appropriately address or resolve identified concerns. The facility's document titled, Abuse, Neglect, and Exploitation Prevention Policy, dated 4/26/22, recognizes the right of residents to be free from abuse and neglect. The policy provides the following definitions: a) Abuse - non-therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress and is not accidental; b) Neglect - failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; c) Financial exploitation - engaging in unauthorized expenditure of vulnerable adult's funds which is likely to result in detriment, failure to use financial resources for vulnerable adult's needs which results or is likely to result in detriment, and in the absence of legal authority, using or withholding vulnerable adult's funds or property; d) Immediately - immediately after an incident occurs for alleged violations of maltreatment, abuse, neglect, and financial exploitation. The policy identifies procedures for abuse prevention including employee training about reportable incidents to assist them in identifying these incidents; providing instructions and encouragement to staff, families, residents to immediately report incidents of suspected maltreatment including how and to whom incidents should be reported; reporting by staff of suspected maltreatment are mandatory, the administrator is to be notified immediately of any events of suspected or reported vulnerable adult abuse events. The policy directs staff to report any situation where there is reason to believe that a vulnerable adult is being or has been abused and/or neglected. The policy also directs the administrator, director of nursing, and the social service director, or designee to conduct all vulnerable adult investigations, review results, and respond appropriately to the results of the internal investigation.