**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to comprehensively assess or re-assess and, if needed, develop interventions to promote safety and reduce the risk of injury or impairments for 1 of 2 residents (R40) reviewed for assessments. Findings include: Significant change of status minimum data set (MDS) dated [DATE], indicated R40 was admitted to the facility on [DATE], was cognitively intact, displayed no behaviors, and had the following diagnoses: pulmonary embolism (a life-threatening condition that occurs when a blood clot blocks an artery in the lungs), generalized weakness and restless leg syndrome (a neurological disorder that causes uncomfortable feelings in the legs). Additionally, the MDS indicated R40 was dependent on staff for toileting, mobility, transfers, and required substantial assistance for bathing, upper, and lower body dressing. Nursing progress notes indicated R40 had a syncopal episode (a brief loss of consciousness caused by a sudden drop in blood flow to the brain) on 7/5/24, 8/9/24, 9/5/24, and 9/13/24, while being transferred with an e-z stand lift (a device used to assist a person from a sitting to a standing position). R40's medical record lacked evidence of an assessment after each episode, vital signs taken, or re-assessment for transfer status. Further, the care plan lacked interventions to guide staff with safe transfers in the event of a syncopal episode. During interview on 12/11/24 at 10:01 a.m., registered nurse (RN)A stated any resident who had a syncopal episode would immediately be evaluated by staff, have vital signs taken and if the episode happened during a transfer, the resident would be re-assessed for transfer safety. RN-A went on to say it was important to obtain vital signs and assess after a syncopal episode to identify any concerns and determine if a resident needed to be evaluated in an emergency room. RN-A stated if a resident had a history of syncopal episodes, it would be indicated on the care plan and interventions would be in place to ensure staff followed appropriate interventions for the resident. During interview on 12/11/24, at 12:31 p.m. director of nursing (DON) stated she was aware R40 had multiple syncopal episodes. DON stated she expected staff to do an assessment, including vital signs, after any syncopal episode. Furthermore, she expected R40's care plan and the staff pocket care plans to include R40's history of syncopal episodes and include guidelines to direct staff care. DON confirmed R40's medical record lacked evidence of any assessments or vital signs being taken after each syncopal episode. Further, R40's care plan lacked specific staff guidance on syncopal episodes. DON stated it was important to obtain vital signs immediately after a syncopal episode to assist in identifying any significant changes and assess if R40 needed to be transferred to a higher level of care for evaluation. A policy on assessments was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 4 of 5 residents (R20, R25, R29, R34) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 43 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE 65 years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose Review of 4 sampled residents for vaccinations identified: 1) R20 was admitted [DATE]. R20 received the PCV-13 on 08/13/2020 and the PCV-23 on 09/04/2019 (age 82). There was no documentation to support R20 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. 2) R25 was admitted [DATE]. R25 received the PCV-13 on 02/12/2015 and the PCV-23 on 09/03/2002 (age 65). There was no documentation to support R25 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. 3) R29 was admitted [DATE]. R29 received the PCV-13 on 10/16/2018 and the PCV-23 on 04/11/2017 (age 74). There was no documentation to support R29 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. 4) R34 was admitted [DATE]. R34 received the PCV-13 on 11/19/2023 and the PCV-23 on 09/29/2011 (age 88). There was no documentation to support R34 had been offered the PCV-15 or PCV-20 to ensure being updated with current CDC guidance for vaccines. When interviewed on 3/19/24 at 9:42 a.m., registered nurse (RN)-A stated she normally relied on Walmart or Thrifty [NAME] Pharmacies to help determine eligibility for vaccines and had not initiated education, obtaining consent or declination or administered the pneumovax 20 for R20, R25, R29 or R34. The facility policy Pneumonia vaccinations dated 4/2023, identified pneumonia vaccinations will be offered to all residents per Centers for Disease control (CDC) recommendations.

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 10/21/23, 10/22/23, 10/29/23, and 11/11/23 for failure to have licensed nurse coverage 24 hours per day. Review of applicable nursing staff's timecards on the above-mentioned dates identified licensed nursing staff had worked 24 hours each day, therefore the data submitted in the PBJ to CMS was inaccurate. Interview with the Executive Director (ED) on 3/19/24 identified due to nursing schedules of 12 hour shifts with a half hour break automatically removed from the employee shift it appeared the nurse only was working 11.5 hours, therefore data submitted through PBJ specifications established by CMS was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to thoroughly investigate alleged violations for 2 of 2 residents (R17, R139) involved in two separate allegations of neglect. Findings include: R17 R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had moderate cognitive impairment, used a wheelchair independently for mobility, and diagnoses included stroke, hemiplegia (paralysis) affecting right dominant side, and depression. On 11/2/22, an allegation of neglect related to elopement was reported to the state agency (SA), and the subsequent investigation summary was submitted to the SA on 11/7/22. The facility investigation documentation for the 11/2/22 allegation consisted of a copy of the 11/2/22 SA report and the 11/7/22 SA report. However, the facility investigation documentation lacked evidence of a thorough investigation. The investigation lacked evidence the facility: -conducted observation of the alleged victim, including the location where the alleged situation occurred, physical/mental condition of the alleged victim, and interactions between the staff and alleged victim. -conducted observations and interviews to determine a timeline of the alleged situation. -conducted an interview with the alleged victim. -conducted interviews with witnesses. -conducted interviews with facility personnel. -conducted record review for pertinent information related to the alleged victim, as appropriate, such as progress notes, incident reports, plan of care, assessments, lab reports, and video/photographic evidence. R139 R139's quarterly MDS dated [DATE], indicated R139 had severe cognitive impairment, and required extensive staff assist with activities of daily living (ADLs). R139's resident face sheet, undated, indicated diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and long-term (current) use of anticoagulants (prevents blood clots). On 3/12/23, an allegation of neglect related to falls was reported to the state agency (SA), and the subsequent investigation summary was submitted to the SA on 3/15/23. The facility investigation documentation for the 3/12/23 allegation consisted of a copy of the 11/2/22 SA report and the 11/7/22 report, fall incident report, and toileting log. However, the facility investigation documentation lacked evidence of a thorough investigation. The investigation lacked evidence the facility: -conducted observation of the alleged victim, including the location were the alleged situation occurred, physical/mental condition of the alleged victim, and interactions between the staff and alleged victim. -conducted observations and interviews to determine a timeline of the alleged situation. -conducted an interview with the alleged victim. -conducted interviews with witnesses. -conducted interviews with facility personnel. -conducted record review for pertinent information related to the alleged victim, as appropriate, such as progress notes, call light reports, assessments, hospital records, physician orders, plan of care, and video/photographic evidence. On 4/19/23, at 2:37 p.m. the administrator stated there were no additional investigation documents for the allegations related to R17 and R139. On 4/20/23, at 1:46 p.m. the social worker (SW) stated the facility did not document and retain the individual observations, interviews, and record reviews that were completed during an investigation. All of the observations, interviews, and record review information was summarized and documented in the investigation summary submitted to the SA. On 4/20/23, at 4:24 p.m. the administrator stated when she and the SW conducted an investigation, they took notebooks and do not take a lot of notes. They document their investigation in real time in the investigation summary report, and we basically all got in a room and shared 'this is what she said', and do not have notes from the interviews. The administrator acknowledged the facility policy specifically indicated the need for interviews, record review, and retention of all documentation. The administrator stated it was important to conduct a complete investigation of all allegations. The facility Vulnerable Adult Abuse/Neglect Policy and Procedures, last reviewed 12/22/22, indicated the facility investigation would gather, document, and keep evidence related to the allegation, including documented evidence of observations, interviews, and record reviews.

Based on observation, interview and document review, the facility failed to ensure resident' room walls were maintained in a clean, sanitary manner for 2 of 2 residents (R1, R4) who resided on different wings and whose walls were in disrepair. Findings include: On 4/17/23, at 1:12 p.m. R1 was seated in a recliner chair in his room. R1's back of recliner was against the wall which contained numerous scraped areas, dents and blackened marks extending along a large portion of the room' back wall approximately three to four feet in length. R1 stated the wall had been like that since he moved into the facility and staff were aware of the wall. On 4/17/23, at 3:40 p.m. R4 was seated in a recliner chair in her room. The wall behind R4's recliner chair was scraped and tattered causing the wall to have exposed sheetrock which extended several centimeters (cm) into the wall. The area of damage was approximately three feet in length. R4 stated the wall had been like that for several years and that staff were aware of it. On 4/20/23, at 4:41 p.m. the administrator was interviewed and stated she was not aware several resident rooms had walls which needed repair. Administrator stated staff reported maintenance concerns by either leaving a note at the nurse's desk, sliding a post it note under administrator's door or calling maintenance's extension and leaving a message. Administrator stated facility did not have any maintenance logs or tracking forms. Administrator stated if she hears about a maintenance issue/concern more than twice then she knows that it was not completed. A facility policy on building repair was not provided.