**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey from 6/13/23 to 6/20/23, the facility did not ensure a resident or their designated representative was provided with a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) at the termination of Medicare Part A benefits. This was evident for 2 (Residents # 12 and # 21) of 2 residents reviewed for Beneficiary Notification of a total sample of 13 residents. Specifically, 1) Resident #12 and their designated representative were not provided with a SNFABN once Resident #12 was terminated from skilled rehabilitation services and remained in the facility, and 2) Resident #21 and their designated representative were not provided with a SNFABN once Resident #21 was terminated from skilled rehabilitation services and remained in the facility. The findings are: The facility policy titled Expedited Appeal Process, Termination of Medicare Services dated August 2022 documented it is the policy of the Nursing and Financial Department to provide timely notification to a Resident or their Responsible Party when Skilled Services are no longer indicated. 1) Resident # 12 had diagnoses of dementia and osteoarthritis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #12 was severely cognitively impaired and only Resident #12 participated in the assessment. The SNF Beneficiary Protection Notification Review form documented skilled nursing services for Resident #12 began 1/19/23 and the last Medicare Part A covered day was 3/17/23. A Notice of Medicare Non-Coverage (NOMNC) form was signed by Resident #12 on 3/15/32. There was no documented evidence Resident #12 or their designated representative was provided with a SNFABN. 2) Resident #21 had diagnoses of cerebral infarction and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #21 was moderately cognitively impaired and only Resident #21 participated in the assessment. The SNF Beneficiary Protection Notification Review form documented skilled services for Resident #21 began 3/10/23 and the last Medicare Part A covered day was 5/5/23. A Notice of Medicare Non-Coverage (NOMNC) was signed by Resident #21 on 5/3/23. There was no documented evidence Resident #21 or their designated representative was provided with a SNFABN. On 06/20/23 at 12:37 PM, the MDS Coordinator (MDSC) was interviewed and stated they were not aware the SNFABN had to be provided to the residents and/or their designated representatives when the residents were discharged from Medicare Part A and remained in the facility. The MDSC also stated they worked at the facility for about 5 to 6 years. On 06/20/23 at 12:42 PM, the Administrator was interviewed and stated the MDSC was responsible for providing forms to residents and/or designated representatives to review and sign before discharging them from Medicare Part A. The Administrator also stated they were not familiar with the forms residents and their designated representatives were required to sign. 415.3(g)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 06/13/23 to 06/20/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident needs. This was evident for 1 (Resident #41) of 2 residents reviewed for Urinary Catheter of 13 total sampled residents. Specifically, a CCP related to Resident #41's Foley catheter (FC) use was not developed. The findings are: The facility's policy titled 'Resident Care Planning' dated 03/20/23 documented the CCP will be developed within 21 days of admission and reviewed and revised on a quarterly basis. Resident #41 had diagnoses of urinary retention and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #41 was moderately cognitively impaired and had an indwelling catheter. The Physician Orders last renewed 05/22/23 documented Resident #41 had a FC for urinary retention and was ordered to receive FC care twice daily and have their FC changed as needed if leaking or blocked. The CCP related to Resident #41's potential for alteration in urinary elimination initiated 7/27/21 documented to assess Resident #41's urine for color, odor, clarity, frequency, and amount as needed. The CCP also documented to monitor for signs/symptoms of dehydration, such as thirst, infrequent urination, dry skin, lightheadedness, or dark urine. There was no documented evidence a CCP related to Resident #41's FC use was developed. On 06/20/23 at 10:58 AM, the MDS Coordinator (MDSC) was interviewed and stated every morning the MDSC reviews the morning report to see if there are any changes with the residents. The MDSC compares the MDS assessments to ensure CCPs address all resident areas. The MDSC stated they manage and review the care plans quarterly and when a change happens with a resident. The MDSC does not know what happened in the case of Resident #41's FC CCP. It is a glitch in the computer system because there was one initially and the CCP had certainly been reviewed prior. Resident #41's CCP has now been updated to reflect FC use. On 06/20/23 at 3:00PM, the Director of Nursing (DNS) was interviewed and stated the MDSC updates the CCPs quarterly and if there is any change in condition with the resident. The DNS stated Resident #41 previously had a CCP related to FC use but somehow the CCP was discontinued and no one realized. The DNS has been working at the facility for less than a month and intends to look at these areas to prevent reoccurrence. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #40 had diagnoses of dementia with other behavioral disturbance and major depressive disorder (MDD), recurrent, severe with psychotic symptoms. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #40 was cognitively intact, had hallucinations, and received antipsychotic medication 7 of 7 days prior to the assessment. The last gradual dose reduction (GDR) was attempted on 1/24/23 and the physician documented GDR was clinically contraindicated on 2/21/23. On 06/13/23 at 11:33 AM, Resident # 40 was interviewed and stated someone was coming to their room and stealing their soda occasionally. On 06/15/23 at 11:47 AM, 06/16/23 at 10:08 AM, and 06/20/23 at 10:24 AM, Resident # 40 was observed sitting in the chair and quietly in their room. A comprehensive care plan (CCP) related to behavioral problems initiated 11/17/21 and last updated 4/3/23 documented Resident # 40 exhibited hallucinations and delusions by talking about other things not existing. A CCP related to the use of antipsychotic medication initiated 3/1/22 and last updated 6/14/23 documented Resident #40 was receiving Seroquel medication related to diagnosis of MDD with psychotic symptoms. Interventions included be aware of adverse reactions related to use of Seroquel and provide Psychiatrist consultation/evaluation as ordered by physician. The Psychiatry Consult dated 1/24/23 documented resident #40 had a diagnosis of senile dementia and major depressive disorder with psychosis. Seroquel was prescribed for psychosis and Remeron was prescribed for depression. Resident #40 had been quiet and the Psychiatrist recommended decreasing the Seroquel from 25mg daily to 12.5mg daily. Nursing Note (NN) dated 2/8/23 documented Resident #40 asked for a corn muffin and coffee and cursed and screamed when the nursing assistant told the resident the items were not in the kitchen. The Medical Doctor (MD) Orders dated 2/9/23 documented Resident #40 was ordered to receive Seroquel 25mg once daily for MDD with severe psychotic symptoms. Nursing Note dated 2/9/23 documented Resident #40 was anxious when demanded food was not available right away and refused to go for a knee MRI. Resident #40 will follow up with the Psychiatrist. The MD increased Resident #40's Seroquel to 25mg once daily. NN dated 2/11/23 documented Resident #40 was very needy and had multiple somatic complaints. The Psychiatry Consult dated 2/21/23 documented negative behavior returned since Resident #40's dose reduction on 1/24/23. Resident #40 was demanding different foods and refused to go for an MRI. Seroquel was increased from 12.5 mg to 25mg once daily on 2/9/23 and was required to treat psychosis. NN dated 2/22/23 documented Resident #40 stated their cousin was coming into their room and punching and hurting them. Resident #40 was reoriented with little effect. NN dated 2/23/23 and Social Work (SW) Note dated 3/6/23 documented Resident #40 had hallucinations of their cousin. SW Note dated 3/23/23 documented Resident #40 continues to report their cousin visits them and does not appear to be in any distress o fear when they speak of the hallucination of their cousin visiting. NN dated 4/11/23 documented Resident #40 reported hallucination of snakes and crocodiles in their room. SW Note dated 4/24/23 documented Resident #40 was upset about soda. The Psychiatry Consult dated 5/2/23 documented Resident #40's obsession with sods a was starting again with some hallucinations. SW Note dated 5/2/23 documented Resident #40 was noted with periods of agitation and visual hallucinations and was seen by the Psychiatrist. NN dated 5/14/23 documented Resident #40 had increased verbal and physical aggression towards staff, constantly ringing the call bell, demanding an ice box to store their soda, and complaining the food tastes like sand. Note sent to medical. The Psychiatry Consult dated 5/16/23 documented Resident #40 had an increase in hallucinations and appeared annoyed by staff presence. The psychiatrist recommended increasing Seroquel to 25mg in the morning and 12.5mg in the afternoon. SW Note dated 5/16/23 documented Resident #40 displayed an increase in behaviors, was demanding, and used verbally abusive negative language. The MD Order documented Resident #40 was ordered to receive an increase in Seroquel to 12.5mg in the afternoon and 25mg in the morning. NN dated 5/20/23 and 5/21/23 documented Resident #40 used derogatory language towards staff and continued on increased dose of Seroquel. SW Note dated 5/31/23 documented Resident #40 reported it was peaceful now that their Health Care Proxy (HCP got rid of the hallucination of their cousin. SW Note dated 6/12/23 documented Resident #40 was very angry because someone stealing their soda. Resident #40 requested an ice box in their room to keep their soda safe and settled for a cabinet that the resident can lock. The Medication Administration Record (MAR) from 5/1/23 through 6/17/23 documented Resident #40 was administered Seroquel daily according to the MD Order. There was no documented evidence non-pharmacological interventions were used to address Resident #40's behavior. On 06/15/23 at 01:51 PM, the Certified Nursing Assistant (CNA) # 1 was interviewed and stated Resident # 40 was alert, had mood swing, and was verbally and physically abusive to staff. CNA # 1 also stated Resident # 40 had visual hallucination once a while, did not interact with anyone, and stayed in their room watching TV all the time. On 06/20/23 at 10:55 AM, the Pharmacy Consultant was interviewed and stated they checked the psychiatrist consult in record, verified the med order with the psychiatrist, reviewed if the tapering of antipsychotic medication was done, and recommended the gradual dose reduction (GDR) to the MD for antipsychotic medication when performing the monthly medication regimen review. The psychiatrist consult documented Resident # 40 had MDD with severe psychotic symptoms and it was an appropriate indication to prescribe Seroquel. The Pharmacy Consultant stated they did not recommend that the MD check if Resident # 40 had diagnoses of schizophrenia and bipolar disorder before the MD prescribes Seroquel because Resident # 40 was diagnosed with psychotic symptoms. On 06/16/23 at 10:48 AM, the Psychiatrist was interviewed and stated they were aware of the black box warning regarding the use of Seroquel which is indicated to treat schizophrenia, bipolar disorder, and depression with psychotic symptoms. Seroquel was prescribed to treat Resident #40's psychotic symptoms related to MDD. On 06/16/23 at 02:23 PM, the Attending Physician/Medical Director (MD) was interviewed and stated they discussed recommended medications with the Psychiatrist after the Psychiatrist visits with residents. The MD is aware of the black box warning related to Seroquel and uses their clinical judgement to see if the resident benefits from the medication. Seroquel was prescribed to treat Resident #40's hallucinations and other abusive behavior. 415.12(1)(2)(i) Based on observation, record review, and interviews conducted during the Recertification survey from 6/13/23 to 6/20/23, the facility did not ensure psychotropic medication was prescribed to treat a diagnosed condition and behavioral interventions were used in an effort to discontinue these drugs. This was evident in 2 (Resident #28 and #40) of 5 residents reviewed for Unnecessary Medication of 13 total sampled residents. Specifically, 1) Resident #28 was prescribed an Seroquel to treat dementia without documented use of non-pharmacological interventions to address behavior, and 2) Resident #40 had a diagnosis of dementia and was prescribed Seroquel for depression with psychotic features without documented non-pharmacological interventions used to address behavior. The findings are: The facility policy titled Psychotropic Drugs dated 11/18/21 documented psychotropic drugs shall be ordered to treat a specific documented condition, and after possible alternative methods for treating the condition or symptoms have been tried and have failed. Psychotropic medications may be used only for the treatment of specific medical and/or psychiatric conditions. 1) Resident #28 had diagnoses of non-Alzheimer's dementia and macular degeneration. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #28 had moderately impaired cognition, had a behavior of hitting or screaming towards others, and did not receive antipsychotic medication. There were multiple observations of Resident #28 alert, calm, and out of bed from 6/14/23 at 11:10 AM to 6/16/23 at 1:35 PM. A Comprehensive Care Plan (CCP) relate to psychotropic medication initiated 4/26/23 documented Resident #28 used antipsychotic medication for a diagnosis of dementia with agitation/psychotic disturbance. Interventions documented increases to Resident #28's Seroquel on 4/26/23, 6/5/23, and 6/13/23. A CCP related to aggressive behavior documented Resident #28 struck their husband on 10/19/22 and held a knife to their husband's throat 5/16/23. Interventions included psychiatric evaluation, transfer resident to the hospital for psychiatric evaluation, approach Resident #28 in a clam manner, encourage the resident to express their feelings, remove the stimulus, and report to the nurse and physician. The CCP related to threatening/abusive behavior towards staff documented to administer medications to Resident #28 as ordered by the physician. A Medical Doctor Order (MDO) dated 5/5/23 documented Resident #28 receive Seroquel 25mg in the morning and 25 mg at bedtime for psychosis. A Psychiatry Consult dated 5/2/23 documented Resident #28 returned from the hospital on 4/26/23 on Seroquel. Current psychotropic medications included Seroquel 25mg at bedtime for dementia/psychotic disorder. Resident #28 experienced an acute deterioration when Seroquel was decreased upon readmission to the facility and was observed restless and pacing in their room. The Psychiatrist recommended increasing Seroquel to 12.5 mg in the morning and 25 mg at bedtime for psychosis. A Nursing Note (NN) dated 5/4/23 documented Resident #28 had increased confusion and was at high risk for fall due to frequent wandering. NN dated 5/11/23 documented Resident #28 has anxiety, agitation, and confusion in the afternoon after supper. Seroquel in progress. NN dated 5/16/23 documented Resident #28 held a knife to their husband's throat and was transferred and admitted to the hospital's dementia unit. MDO dated 5/22/23 documented Resident #28 was readmitted to the facility with an order for Seroquel 12.5 mg daily and Seroquel 50 mg at bedtime for dementia with psychotic disturbance. A Psychiatry Consult dated 5/30/23 documented Resident #28 had a diagnosis of senile dementia with psychotic disturbance and was currently prescribed Seroquel 12.5mg in the morning and 50mg at bedtime for dementia with psychotic disturbance. Resident #28 improved since Seroquel was increased and was smiling. The Psychiatry Consult also documented Resident #28 fell twice since their return from the hospital. Reduction of dosage was not recommended as Seroquel was required for the treatment of dementia. Interim Physician's Order dated 6/5/23 documented Resident #28's Seroquel order was changed to 25 mg three times daily. A Psychiatry Consult dated 6/13/23 documented Resident #28 was currently prescribed Seroquel 25mg three times daily for psychosis. Resident #28 was agitated, yelling/hitting staff has increased, and could not be redirected. The Psychiatrist recommended to increase Resident #28's Seroquel to 100mg once daily for dementia with psychotic features. Will increase Seroquel to 25mg by mouth in the morning, 50 mg at 1:30 PM, and 25 mg at bedtime for the treatment of psychotic symptoms with behavioral disturbances. A Nurse's Progress Note dated 6/13/23 documented the Psychiatrist was informed about Resident #28's behaviors and agitation. The Psychiatrist saw Resident #28 and ordered Seroquel 25mg at 9:30 AM, 50mg at 2 PM, and 25 mg at bedtime. A Interim Physician's Order dated 6/13/23 documented to increase Resident #28's Seroquel order to 25mg in the morning, 50 mg at 1:30 PM, and 25 mg at bedtime. The Medication Administration Record from 5/1/23 through 6/20/23 documented Resident #28 received Seroquel according to MDO. There was no documented evidence non-pharmacological interventions were used to address Resident #28's behavior. On 06/16/23 at 10:14 AM, an interview was conducted with Certified Nursing Assistant (CNA) #2 who stated Resident #28 was confused and always asks for their children and spouse. Resident #28 was aggressive in the past but has not been aggressive lately. At times, Resident #28 will swing their arm and yells at the staff. On 6/16/23 at 2:12 PM, CNA #3 was interviewed and stated Resident #28 has sundown features and usually exhibits behaviors of yelling and being combative in the evening. On 06/20/23 11:52 AM, an interview was conducted with the Registered Nurse (RN) #2 who stated that Resident # 28 is on Seroquel because the resident gets aggressive at times. Seroquel keep the resident calm and quiet. On 06/20/23 at 12:21 PM, an interview was conducted with the Assistant Director of Nursing (ADNS) who stated Resident #28 returned from the hospital on 4/26/23 on Seroquel, the Attending Physician decreased the dose, the Psychiatrist saw the resident on 5/2/23, and the Seroquel dose was increased due to resident's symptoms. Resident #28 was seen by the Attending Physician on 6/5/23 and 6/13/23 and Seroquel was increased. A dose reduction was tried but the symptoms were not improving. Resident #28 receives Seroquel for dementia, anxiety, mood disturbance, and psychotic disturbance. On 06/16/23 at 2:33 PM, an interview was conducted with the Attending Physician/Medical Director (MD) who stated that Resident #28 is on Seroquel for dementia with behavior Disturbances. The resident had an increase in agitation and psychotic behavior. The MD knows the black box warning but Seroquel can be used off-label for psychotic behaviors. As per the Psychiatrist, Seroquel is being used for behaviors with psychotic symptoms. On 06/20/23 12:01 PM an interview was conducted with the Psychiatrist who stated Resident #28 was in the hospital recently and they started the resident on Seroquel and has been threatening towards their spouse, also another resident. Resident #28 is on Seroquel for psychotic features and it is good for the resident. They do not have bipolar disorder or schizophrenia. Resident #28's psychosis is secondary to the dementia diagnosis. The Psychiatrist is left with nothing else to treat Resident #28 except for Seroquel. There is a black box warning alert but there is no other alternative.

Based on record review and staff interview during the Recertification survey, the facility did not ensure infection prevention control practices were maintained to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the facility was missing a Legionella sampling plan based on the facility's risk assessment. Finding is: Record review revealed the Facility Risk Assessment lacked a Legionella sampling plan that identified specific locations where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. On 11/17/2021 at approximately 1:10PM, the Director of Maintenance was interviewed and stated that water samples for Legionella tests were collected from distal, end-sampling points that were facilitated by an outside contracted laboratory. They were unable to provide documentation that identified specific sampling locations within the facility's water management plan based on the facility environmental risk assessment, and further stated that they were unaware of the requirement. On 11/17/2021 at approximately 1:20PM, the Director of Nursing was interviewed and stated that they were the responsible person for maintaining the water management plan, and was unaware of the requirement for sampling plan locations to be based on the facility's completed environmental risk assessment. Documentation of a Legionella sampling plan was not available for review during the survey. The facility provided documentation via email on 11/23/2021, one day after exit. 415.19(a) (1-3)