**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice-Centers for Medicare and Medicaid-10055 (SNFABN-CMS-10055) was provided for 1 of 3 residents (R126) reviewed for beneficiary notices. Findings include: R126's Part A discharge Minimum Data Set (MDS) dated [DATE], indicated R126 was admitted [DATE]. R126's was cognitively intact. R126's Notice of Medicare non-coverage form CMS-10123 (NOMNC-CMS-10123), signed and dated 7/29/24, indicated R126's services would end 7/31/24 although Medicare coverage days remaining. R126 remained in the facility. R126's discharge MDS dated [DATE], included R126 was discharged from the facility on 11/17/24. R126's medical record lacked evidence the SNFABN-CMS-10055 was provided to R126. During interview on 1/8/24 at 3:36 p.m., Medicare case manager (CM)-A confirmed R126 did not receive a SNFABN-CMS-10055 prior to his Medicare coverage ending. CM-A confirmed R126 should have received this form since he was staying in the facility with coverage days remaining. CM-A stated the form was not completed because there was confusion on who was responsible for completing this form. Facility policy titled Advance Beneficiary Notice of Non-Coverage dated 2/14/23, included the SNFABN-CMS-10055 was to be issued prior to providing a service that is usually paid for by Medicare but may not be because it was not considered medially necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to use proper personal protective equipment (PPE) for 1 of 1 residents (R17) reviewed for droplet precautions. Findings include: R17's annual Minimum Data Set (MDS) dated [DATE], included R17 was severely cognitively impaired and required substantial assistance for toilet hygiene, dressing, and transfers. R17's electronic medical record (EMR) included a facility form titled Good Samaritan Society - Ambassador COVID - 19 Test dated 12/30/24, indicated a positive test result for COVID-19. R17's EMR entry dated 12/30/24, included R17 tested positive for COVID-19 and droplet precautions were initiated. On 1/7/25 at 8:43 a.m., nursing assistant (NA)-A was observed entering R17's room with a food tray. NA-A donned a gown, glove and a N95 mask prior to entering room. Eye protection was not donned. R17's room had a sign posted with the title droplet precautions and included instructions to make sure eyes, nose and mouth are fully covered before room entry. On 1/7/25 at 9:09 a.m., NA-A was observed exiting R17's room and utilizing alcohol-based hand sanitizer. During interview on 1/7/25 at 9:12 a.m., NA-A stated she was aware R17 was on precautions for a COVID-19 infection, and she was supposed to wear eye protection when entering the room. NA-A stated she had not worn eye protection because there was not any in the precautions cart outside of R17's room. During interview on 1/7/25 at 9:56 a.m., registered nurse (RN)-A confirmed R17 was on precautions for a COVID-19 infection and all staff should have been trained on what PPE was necessary when caring for a resident with an infection. RN-A stated the nurses usually stock the precautions carts on the units, but all PPE supplies were available to any staff. On 1/7/25 at 12:46 p.m., trained medical assistant (TMA)-A was observed entering R17's room. TMA-A was wearing gown, gloves, and mask without eye protection. During interview on 1/7/25 at 2:09 p.m., TMA-A confirmed he gave R17 medication earlier in the day. TMA-A stated he wore a gown, gloves and N95 mask. TMA-A stated he did not wear a face shield because none were available in the precautions cart. TMA-A stated they have received training and was aware he was supposed to wear a face shield. During interview on 1/9/25 at 10:25 a.m., infection preventionist (IP) confirmed staff were trained to wear a gown, N95 mask, face shield and gloves when working with a resident who is positive for COVID-19. IP stated everyone was able to stock the precautions cart and did have access to PPE. The IP stated she would have expected the staff to get a face shield if none were available in the precautions cart prior to entering the room to care for a resident who was on precautions. This was important to prevent spread to vulnerable residents. During interview on 1/9/25 at 10:25 a.m., director of nursing (DON) stated all staff were educated on proper use of PPE. Facility policy for infection prevention dated 12/2/24, included the facility would utilize transmission based precautions in addition to standard precautions, to prevent and control known and suspected infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R32's significant change MDS dated [DATE], identified R32 was cognitively intact, was able to express needs and required limited assistance with activities of daily living (ADL's). The MDS identified the following diagnoses: hypertension, asthma/chronic obstructive pulmonary disease or chronic lung disease and respiratory failure. R32's orders directed staff to administer ipratropium 0.5 milligrams (mg)/3 milliliters 1 vial (medication to open airways, and treat air flow blockage) via nebulizer every 6 hours with albuterol sulfate 1.25mg/3ml 1 applicator via nebulizer every 6 hours. During observation on 3/13/23, at 7:10 p.m. RN-B placed both medications into medication chamber and placed nebulizer chamber into holder of machine, administered R32's oral medications, then left room reminding R32 to complete nebulizer treatment. On 3/16/23, at 8:48 a.m. RN-C stated an assessment to self-administer medications with education provided to resident and return demonstration was needed to self-administer in addition to an order from the provider. RN-C stated R32 was able to self-administer nebulizer medications after set up by nursing. RN-C reviewed R32's orders, stated no order was in medical record for OK to self-administer nebulizer's, R32 had a resident self-administer of medications dated 3/7/23, which indicated R32 was able to self-administer albuterol inhaler. On 3/16/23, at 9:00 a.m. RN-D stated R32 had a quarterly self-administration of medications assessment completed on 3/7/23. Prior self-administration assessment was completed on 8/30/22, which indicated R32 was able to self-administer albuterol inhaler, assessment had been completed during prior admission to facility, R32 had discharged from facility on 11/9/22. R32 admitted back facility on 11/15/22 however no self-administration of medication was completed during admission. RN-D stated R32 was cognitively intact and was able to recall information so R32 was safe to self-administer nebulizer. R32's medical record lacked any assessment indicating she was safe to self administer nebulizer medications after nurse set up, record lacked any order from provider that indicated R32 was ok to self-administer nebulizer medications. The Resident Self-Administration of Medication policy, last reviewed 10/21/22, indicted the purpose of the policy was the following: - To determine if the resident can safely self-administer medications - To identify which medications may be safely self-administered - To assist the resident who is self-administering medications to manage his or her prescribed medications in a safe manner - To provide residents who can do so safely with the opportunity to self-administer medications Based on observation, interview and document review, the facility failed to assess the ability of 2 of 2 residents (R38 and R32) to self-administer medications observed to be left at bedside, or without a nurse present during administration. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 was cognitively intact, and able to express needs. R38 was identified as receiving limited assistance to complete activities of daily living (ADLs). R38's diagnoses included, dementia, anxiety, depression, chronic obstructive pulmonary disease (COPD) and coronary artery disease. During interview on 3/13/23, at 2:28 p.m. it was noted R38 had the following medications on her bedside stand: 1. a 30 milliliter bottle of artificial tears 2. a 180 count bottle of vitamin C Gummies - approximately 1/2 full 3. a bottle of TUMS 160 count - approximately 1/2 full R38 stated she had been arguing with a nurse who took her artificial tears from her, stating she could not keep them bedside. R38 would not state where she obtained the vitamin C and TUMS. R38's physicians orders, identified on 2/17/23, OK to self administer eye drops every shift. There was another order, dated 3/14/23, OK to keep at bedside and self administer eye drops every shift. R38's medical record had a Self-Administration of Medications assessment, dated 2/15/23, which found R38 was able to self administer her artificial tears, keeping them at bedside. There was no assessment for TUMS or Vitamin C. During interview on 3/15/23, 1:30 p.m. registered nurse (RN)-A verified R38 was assessed to have the capability to self administer and keep at bedside her eye drops, however she was unaware of the vitamin C and TUMS in R38's room. RN-A stated staff should report any medications noted in resident rooms, while R38 did not have orders for either of the other two medications in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review the facility failed to ensure 1 of 1 resident (R327) who had a significant weight loss received assistance with eating. Findings include: R327's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and required extensive physical assistance of one person for eating. R327's care plan dated 2/21/23, indicated resident required supervision and eating assistance as needed. R327's Mini-Nutritional assessment dated [DATE], indicated no weight loss or decrease in food intake in the prior 3 months, but scored at risk of malnutrition. R327's Food and Nutrition Data Collection dated 2/20/23, indicated R327's hospital admission weight was 180#. R327's Dietician assessment dated [DATE], indicated weight was not stable, and resident had greater than 5% weight loss in 30 days. Additionally, R327 required feeding assistance, food intake varied 0-100% at meals, and was at risk of malnutrition. Interventions included weekly weights and feeding assistance. R327's occupational therapy (OT) assessment dated [DATE], indicated R327 required cueing to eat. R327's progress notes and weight documentation indicated the following: On 2/17/23, admitted to the facility. No weight was recorded this date. On 2/18/23, was fed at breakfast and had 25% intake, a poor appetite, and required cues with eating. 173.1#. On 2/20/23, had a poor appetite and required moderate assistance with eating. 169.6 #. On 2/21/23, had a poor appetite and ate 25% of his meal. 167#. On 2/22/23, fed himself with cueing and some hands-on assistance. On 2/24/23, ate about 40% of meals with cues. On 2/24/23, the care conference progress note lacked information in the nutritional section of the note. On 2/25/23, had low appetite and required encouragement to eat, with a diagnosis of gastrointestinal (GI) cancer, which was not previously mentioned in progress notes, nor on the diagnosis list or nutritional assessment. On 2/27/23, lacked mention of appetite, intake, or level of assistance required for eating. 164#. On 2/28/23, required cues for eating, and had poor appetite. 163.4#. On 3/2/23, the nutritional status note indicated a significant weight loss of 6.4%/-11 pounds, Likely due to disease progression and sub-optimal intake. R327 required supervision and prompting to improve intake. 162#. On 3/4/23, had eaten less than 50% of meals. Level of assistance required to eat was not documented. On 3/6/23, had eaten less than 50% of meals, and had fed self after set-up. On 3/8/23, fed self and needed, Lots of help with eating and drinking. On 3/93/23, the care conference note indicated intake greater than 50% of meals, required feeding supervision, food intake varied 0-100% at meals, weight 162# with a significant weight loss of 6.1%, and was at risk of malnutrition. On 3/9/23, the skilled care progress note indicated staff was monitoring needs related to GI cancer. 159.6#. On 3/10/23, appetite remained poor to fair. Level of assistance required to eat was not documented. Required cues for drinking fluids. On 3/11/23, appetite fair to poor. 159#. On 3/12/23, was able to feed self after set-up, but required prompts to participate. On 3/14/23, had good appetite for breakfast, but not the rest of the days. On 3/14/23, had red flags for significant weight loss based on weight recorded 3/11/23, 159#, which was a 8/1% loss or -14 # since admission, Likely due to progression of dementia, advanced age, and sub-optimal intake. R327 required supervision and prompting to improve intake. No additional weights were recorded prior to discharge on [DATE]. R327's Discharge summary dated [DATE], lacked mention of weight loss or level of assistance required for eating. When interviewed on 3/13/23 at 6:04 p.m., family member (FM)-C stated, He's lost his appetite, and he eats better when we feed him. He was worse after surgery. They set him up and pretty much expect him to eat on his own. During observation on 3/14/23 at 8:54 a.m., staff provided meal set-up, but did not provide additional physical help or cueing for the meal. R327 ate his cold cereal but mostly poked at the scrambled eggs, sliced banana, and French Toast with the fork. By the end of the meal, R327 had eaten a couple of bites of eggs and the sliced banana. Staff removed him from the dining room without encouraging or assisting the resident to eat. During observation on 3/14/23 at 1:12 p.m., staff provided meal set-up, but did not provide additional physical assistance or cueing for the meal. R327 was served beef tips, green beans, mashed potatoes, and a chocolate magic cup (nutritional supplement for extra calories). R327 ate a few bites of his beef tips and his magic cup. Occupational therapist (OT)-D was also observing the meal. When interviewed on 3/14/23 at 1:40 p.m., OT-D stated R327 ate about 50% of the meal and the purpose of that OT observation and assessment was about the functionality of eating with the adaptive utensil, not intake. When interviewed on 3/14/23 at 1:50 p.m., the registered dietician (RD) stated it was part of R327's dementia diagnosis to push food around on the plate. Additionally, the RD stated staff should provide feeding assistance if the MDS assessment and care plan indicated feeding assistance was required and was unsure if staff was providing feeding assistance. The RD stated the medical record indicated R327 was eating greater than 50% of his meals, but the medical record progress notes lacked documentation to support R327 was eating greater than 50% of his meals. When interviewed on 3/15/23 at 7:58 a.m., speech therapist (ST)-E stated the RD the role of ST is to ensure food and liquid textures for the resident ensure low risk for aspiration, and the RD oversaw oral intake and monitoring weights. When interviewed on 3/16/23 at 9:43 a.m. the director of nursing (DON) stated if staff is offering to assist a resident to eat, but the resident refuses the assistance, the refusals should have been documented. The DON stated she did not know if staff was offering to feed R327. The Activities of Daily Living Policy Dated 11/29/22, indicated any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition.