Based on record review and staff interviews, the facility failed to display accurate Posted Nurse Staffing Information for 4 out of 30 days reviewed. The findings included: A review of the Staff Schedule/Assignment Sheet for 07/19/24 revealed 10 Nursing Assistants (NA)s worked from 7:00 AM until 7:00 PM. A review of the Posted Nurse Staffing for the 7:00 AM-7:00 PM shift on 7/19/24 revealed 11 NAs worked. On 07/21/24 during the 7:00 AM until 7:00 PM shift, the Staff Schedule/Assignment Sheet revealed 8 NAs worked and the Posted Nurse Staffing revealed 10 NAs worked. Additionally, the Staff Schedule/Assignment Sheet revealed 3 Licensed Practical Nurses (LPN)s worked and the Posted Nurse Staffing revealed 4 LPNs worked. The Staff Schedule/Assignment Sheet revealed 1 Registered Nurse (RN) worked and the Posted Nurse Staffing revealed 2 RNs worked. During the 7:00 PM until 7:00 AM shift, the Staff Schedule/Assignment Sheet revealed 5 NAs worked and the Posted Nurse Staffing revealed 7 NAs worked. The Staff Schedule/Assignment Sheet revealed 4 LPNs worked and the Posted Nurse Staffing revealed 2 LPNs worked. The Staff Schedule/Assignment Sheet revealed no RN worked and the Posted Nurse Staffing revealed 1 RN worked. On 07/22/24 during the 7:00 AM until 7:00 PM shift, the Staff Schedule/Assignment Sheet revealed 10 NAs worked and the Posted Nurse Staffing revealed 8 NAs worked. Additionally, the Staff Schedule/Assignment Sheet revealed 2 RNs worked and the Posted Nurse Staffing revealed 1 RN worked. During the 7:00 PM until 7:00 AM shift, the Staff Schedule/Assignment Sheet revealed 7 NAs worked and Posted Nurse Staffing revealed 6 NAs worked, and the Staff Schedule/Assignment Sheet revealed 1 RN worked and Posted Nurse Staffing revealed 2 RNs worked. On 07/23/24 during the 7:00 AM until 7:00 PM shift, the Staff Schedule/Assignment Sheet revealed 8 NAs worked and the Posted Nurse Staffing revealed 11 NAs worked. The Staff Schedule/Assignment Sheet revealed 4 LPNs worked and the Posted Nurse Staffing revealed 3 LPNs worked. The Staff Schedule/Assignment Sheet revealed 1 RN worked and the Posted Nurse. Staffing revealed 2 RNs worked. During the 7:00 PM until 7:00 AM shift, the Staff Schedule/Assignment Sheet revealed 6 NAs worked and the Posted Nurse Staffing revealed 5 NAs worked. The assignment sheet revealed 3 LPNs worked and the Posted Nurse Staffing revealed 2 LPNs worked. The Staff Schedule/Assignment Sheet revealed no RN worked and the Posted Nurse Staffing revealed 2 RNs worked. An interview on 08/21/24 at 8:59 AM was conducted with the Human Resource Coordinator. She stated she was responsible for completing the daily staff posting sheet based on the actual working assignment sheet for the day and posting them in a viewable area. She verified that the number of licensed and unlicensed staff and the total hours worked for licensed and unlicensed staff were incorrect for 4 out of 30 days. She verified staffing sheets for 7/19/24, 7/21/24, 7/22/24 and 7/23/24 did not match the staff posting sheets. She then stated for the staffing sheet on 07/19/24 an unlicensed staff was counted twice which made the count incorrect. She explained it appeared on 07/21/24 and 07/22/24 she got the dates mixed up which resulted in the number of licensed and unlicensed staff and the total hours worked to be incorrect. She verified the staff posting sheets compared to the assignment sheets for 07/23/24 did not match and stated she was not sure what happened and why the count was incorrect. An interview was conducted on 08/21/24 at 8:39 AM with the Administrator. He stated he expected the daily nurse staff sheets, and the assignment sheets should accurately reflect the correct number of staff working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #17 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 had moderately impaired cognition. Resident #17's medical record revealed she was transferred to the hospital on 7/20/23 and was readmitted back to the facility on 7/26/23. There was no documentation that a written notice of transfer was provided to the resident and/or responsible party (RP). The Administrator was interviewed on 11/28/23 at 2:20 PM and stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. He indicated he was unaware that written notifications regarding the reason for the hospital transfer was required. 5. Resident #87 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #87 had severe cognitive impairment. Resident #87's medical record revealed she was transferred to the hospital on [DATE] and did not return to the facility. There was no documentation that a written notice of transfer was provided to the resident and/or responsible party (RP). The Administrator was interviewed on 11/28/23 at 2:20 PM and stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. He indicated he was unaware that written notifications regarding the reason for the hospital transfer was required. Based on record review, Responsible Party (RP) and staff interviews, the facility failed to notify the resident and/or RP in writing for a transfer to the hospital for 5 (Resident #90, #49, #39, #17, #87) of 6 residents reviewed for hospitalization. The findings included: 1. Resident #90 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set, dated [DATE] indicated Resident #90 was coded for moderate cognitive impairment. Resident #90's medical record revealed she was transferred to the hospital on 9/30/22 and readmitted back to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the resident and/or RP. Resident #90's medical record revealed she was transferred to the hospital on 3/22/23 and she did not return to the facility. There was no documentation that a written notice of transfer was provided to the resident and/or RP. A telephone interview was completed on 11/27/23 at 2:46 PM with Resident #90's RP. She stated she did not recall receiving anything in writing from the facility about the reason Resident #90 was transferred to the hospital on 9/30/22 and 3/22/23 but was notified in person. An interview on 11/28/23 at 2:20 PM was completed with the Administrator. He stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. The Administrator stated he was unaware that written notifications regarding the reason for the hospital transfer were required. 2. Resident #49 was admitted to the facility 7/21/22. Review of the quarterly Minimum Data Set, dated [DATE] indicated Resident #49 was coded for severe cognitive impairment. Resident #49's medical record revealed she was transferred to the hospital on 9/4/22 and readmitted back to the facility on 9/8/23. There was no documentation that a written notice of transfer was provided to the resident and/or RP. A telephone interview was completed on 11/29/23 at 9:50 AM with Resident #49's Responsible Party (RP). She stated she did not recall receiving anything in writing from the facility about the reason Resident #49 was transferred to the hospital on 9/4/23 but the facility did call her. An interview on 11/28/23 at 2:20 PM was completed with the Administrator. He stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. The Administrator stated he was unaware that written notifications regarding the reason for the hospital transfer were required. 3. Resident #39 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set, dated [DATE] indicated Resident #39 was coded for severe cognitive impairment. Resident #39's medical record revealed she was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the resident and/or RP. A telephone interview was completed on 11/29/23 at 11:55 AM with Resident #39's Responsible Party (RP). He stated he did not recall receiving anything in writing from the facility about the reason Resident #39 was transferred to the hospital on [DATE] but the facility did call him. An interview on 11/28/23 at 2:20 PM was completed with the Administrator. He stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. The Administrator stated he was unaware that written notifications regarding the reason for the hospital transfer were required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 2 of 5 residents reviewed for unnecessary medications (Residents #22 and #73). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. The admission MDS assessment dated [DATE] indicated Resident #22 had received 5 days of an insulin injection, however the assessment was not coded for hypoglycemic (medications to treat diabetes) medications or an indication present for its use. On 11/29/23 at 1:30 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed she should have marked Resident #22 as receiving a hypoglycemic medication and that there was an indication for its use in his medical record. She felt it was an oversight. During an interview with the Administrator on 11/29/23 at 3:30 PM, he indicated he expected the MDS assessment to be coded accurately. 2. Resident #73 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A quarterly MDS assessment dated [DATE] indicated Resident #73 had received 7 days of an insulin injection, however the assessment was not coded for hypoglycemic (medications to treat diabetes) medications or an indication present for its use. On 11/29/23 at 1:30 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed she should have marked Resident #22 as receiving a hypoglycemic medication and that there was an indication for its use in his medical record. She felt it was an oversight. During an interview with the Administrator on 11/29/23 at 3:30 PM, he indicated he expected the MDS assessment to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to revise the care plan in the area of planned disposition for 1 of 18 resident's (Resident #16) reviewed. The findings included: Resident # 16 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rate) and history of intracerebral hemorrhage (stroke) with hemiparesis (paralysis of one side). The resident's medical record indicated the resident was transitioned to comfort care 11/2/2023. The resident's active physician orders included atropine for terminal secretions, Ativan for terminal agitation, and morphine for pain. Resident #16's care plan was last revised 11/27/2023. The care plan included a focus for comfort measures dated 10/11/2023. The care plan also included a focus for discharge planning dated 10/4/2023 which included the resident was to be discharged from the facility. Interventions included arrange for home modifications, follow up appointment with primary care provider, and make referrals for home care as needed. On 11/29/2023 at 12:45PM an interview was conducted with the Minimum Data Set (MDS) Nurse. She reviewed Resident #16's care plan and stated she should have revised the care plan. The resident was on comfort measures and there was no intention to discharge him home at that time. She stated it was an oversight and she would update the care plan immediately. During an interview with the Administrator on 11/30/2023 at 8:45AM he stated he believed the failure to revise the care plan was and error and had been updated as of that date.

Based on observations, record review, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification survey dated 4/8/21 for two deficiencies in the area of accurate Minimum Data Set (MDS) coding at F641 and in the supervision to prevent accidents at F689. Also, the recertification survey dated 9/22/22 for one deficiency in the area of care plan revision F657. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F641- Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 2 of 5 residents reviewed for unnecessary medications (Residents #22 and #73). During a recertification survey dated 4/8/21, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the activities of daily living (ADLs), bowel and bladder and medications. F657-Based on record review and staff interviews, the facility failed to revise the care plan in the area of planned disposition for 1 of 18 resident's reviewed. During a recertification survey dated 9/22/22, the facility failed to individualize the care plan for a resident reviewed for accidents. F689 - Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner during incontinence care that resulted in a fall with a right hip fracture (Resident #17). This was for 1 of 6 residents reviewed for accidents. During a recertification survey dated 4/8/21, the facility failed to prevent a resident who had cognitive impairment and known wandering behaviors from exiting the facility unsupervised at night. The resident exited the facility unsupervised and self-propelled himself by wheelchair approximately 0.16 miles away from the facility on a roadway that had no sidewalks. An interview was completed on 11/29/23 at 3:20 PM with the Administrator. He was unable to offer any reason for the repeat citation for accurate MDS coding and care plan revision. He also stated the facility completed a complete plan of correction at the time of the incident involving unsafe incontinence care resulting in a fall with injury.

Based on record review and staff interview, the facility failed to ensure the nurse staffing data that were posted daily were accurate for 7 of 30 days reviewed. Findings included: The daily nurse staffing data, and the daily nursing assignments were reviewed from 8/20/22 through 9/20/22 with the Human Resources (HR) staff. The daily staffing data, and the daily nursing schedule did not match on 7 (8/27/22, 8/28/22, 9/3/22, 9/4/22, 9/6/22, 9/17/22 and 9/18/22) of 30 days reviewed. 8/27/22 -2 Registered Nurses (RNs) on nurse staffing data - 1 RN on schedule 8/28/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/3/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/4/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/6/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/17/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/18/22 - 2 RNs on nurse staffing data - 1 RN on schedule The HR staff member was interviewed on 9/22/22 at 8:40 AM. She stated that she was responsible for completing and posting the nurse staffing data daily except on Saturday and Sunday. She indicated that she completes the nurse staffing form for the weekend and the RN Supervisor was supposed to check for accuracy before posting. She verified that the nurse staffing data on 8/27/22, 8/28/22, 9/3/22, 9/4/22, 9/6/22, 9/17/22 and 9/18/22 were not accurate on the number of RNs in the building. The Administrator was interviewed on 9/22/22 at 10:23 AM. He reported that currently, he did not have a weekend RN Supervisor. He will ensure that the RN working on the weekend will be responsible for checking the nurse staffing data for accuracy before posting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #236 was admitted on [DATE] with diagnoses that included stage 3 pressure injury to the sacrum, deep tissue injury (DTI) to the right great toe, and non-pressure related injury to the left great toe. The resident's Minimum Data Set (MDS) was not available. Resident #236's baseline care plan dated 9/12/2022 had a focus for pressure injury, stage 3, to the sacrum, deep tissue injury to the right great toe, and non-pressure related injury to the left great toe. The resident's active physician's orders revealed an order dated 9/8/2022 to cleanse wound to left heel, cover with calcium alginate, and cover with dry dressing daily. He also had an active order dated 9/8/2022 to apply absorbase ointment (skin protectant and barrier cream) to the resident's sacrum twice daily. Resident #236's September 2022 Medication Administration Record (MAR) was reviewed and revealed the wound care to the resident's right heel and sacrum had not been documented as completed or refused for 9/10/2022 day shift. Review of nursing progress notes did not indicate Resident #236 refused wound care treatment on 9/10/2022. On 9/22/2022 at 9:08 AM an interview was conducted with the Director of Nursing. She stated she was assigned to Resident #236, day shift on 9/10/2022. She stated she completed the wound treatments but did not document them on the resident's MAR. It was an oversight. She further stated she expected wound care treatments to be completed or documented as completed. Based on record review, observations, and staff interviews, the facility failed to have accurate medical records for 3 of 10 residents reviewed for wound care (Resident #286, #236 and #68). The findings included: 1. Resident #286 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and osteomyelitis (infection of the bone). The baseline care plan dated 9/9/22 included surgical wound to right groin. Resident #286's active physician orders revealed an order dated 9/9/22, to cleanse the right groin surgical wound with normal saline. Pack the wound with Dakin's (a solution with anti-infective properties) 0.5% soaked gauze and cover with a dry dressing twice a day. The September 2022 Medication Administration Record (MAR) was reviewed and revealed the right groin wound care had not been documented as completed or refused by the resident on the following days: - Day shift (7:00 AM to 7:00 PM) on 9/13/22, 9/15/22 and 9/16/22. - Evening shift (7:00 PM to 7:00 AM) on 9/9/22 and 9/11/22. Review of the nursing progress notes from 9/8/22 until 9/21/22 revealed Resident #286 did not refuse surgical wound care. A phone interview was completed with Nurse #5 on 9/21/22 at 11:25 AM, who scheduled for the day shift on 9/16/22. She explained wound care had been completed after the medication pass and Resident #286 had accepted. Nurse #5 stated she had forgotten to document the wound care as completed on the MAR. On 9/21/22 at 1:00 PM, an interview occurred with Nurse #6, who was scheduled for the day shift on 9/13/22 and 9/15/22. She reviewed the missing documentation for surgical care to Resident #286 and stated she recalled completing the wound care but had forgotten to document as completed on the MAR. On 9/21/22 at 1:23 PM, a phone interview was conducted with Nurse #9 who had been scheduled for the evening shift on 9/9/22. She was able to recall the surgical wound to Resident #286's groin area and could not remember the resident refusing wound care. She verified the date in question and stated she forgot to sign the wound care as completed on the MAR. A phone interview took place on 9/22/22 at 7:45 AM, with Nurse #7 who had been scheduled for the evening shift on 9/11/22. She was able to recall completing Resident #286's wound care after the medication pass, but must have forgotten to document the surgical wound care as completed on the MAR. The Director of Nursing was interviewed on 9/22/22 at 10:33 AM, and indicated she expected the nursing staff to complete wound care as ordered ensuring it was documented as completed or refused by the resident. 3. Resident #68 was admitted to the facility on [DATE] with multiple diagnosis including dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had severe cognitive impairment. Resident #68 had doctor's order dated 8/12/22 to paint deep tissue injury (DTI) to right 5th toe with betadine daily, on 8/19/22 to clean left dorsal foot with normal saline, apply xeroform and cover with transparent dressing daily, on 9/1/22 to paint left 1st toe with betadine daily and on 9/8/22 to clean right posterior heel wound with normal saline, apply calcium alginate (used to treat wounds with moderate to heavy exudates), cover with silicone foam dressing daily. Review of the September 2022 Treatment Administration Records (TARs) revealed that there was no nurse's initial to indicate that treatment was provided to Resident #68's pressure wounds on 9/9/22, 9/10/22, 9/12/22 and 9/16/22. The TARs revealed that Nurse #5 was assigned to Resident #68 on 9/9/22, 9/10/22 and 9/12/22 and the Treatment Nurse was assigned to the resident on 9/16/22. Nurse #5 was interviewed on 9/21/22 at 11:26 AM. She indicated that she was aware that nurses were responsible to provide the treatment when the Treatment Nurse was not available to provide the treatment. She verified that she was assigned to Resident #68 on 9/9/22, 9/10/22 and 9/12/22. She reported that she provided the treatment but missed to initial the TARs. The Treatment Nurse was interviewed on 9/21/22 at 11:30 AM. She reported that she was assigned to work on the floor on 9/16/22 and was assigned to the resident. She reported that she provided the treatments but forgot to the sign the TARs. The Director of Nursing (DON) was interviewed on 9/22/22 at 10:23 AM. The DON stated that she expected nursing to put their initials on the TARs to indicate that treatments were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #36 was admitted on [DATE] with diagnoses that included chronic kidney disease. Resident #36's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. The facility's grievance log for February 2022 through August 2022 revealed Resident #36 filed the following grievances: On 2/24/2022 Resident #36 filed a grievance regarding food. She stated the food was bland and did not have any seasoning. She also stated dietary had failed to provide snacks for residents. On 3/28/2022 Resident #36 filed a grievance regarding food. She stated the meat served to her was tough and dry. On 5/25/2022 Resident #36 filed a grievance regarding condiments with meals. She stated the kitchen did not put condiments on the meal trays for residents. Meals were served without any condiments. An interview was conducted with Resident #36 on 9/19/2022 at 11:14 AM. She stated she did not get a written resolution for the grievances she filed regarding food and the food had not changed nor had the facility provided snacks as requested. On 9/21/2022 at 9:41 AM an interview was conducted with the Social Worker (SW). She stated she maintains the grievance log and all the grievance forms. The grievance form was given to the appropriate department head to investigate and resolve. After the investigation, the department head contacted the person filling the grievance. If the person filing the grievance wanted a copy of the investigation and findings, action/resolution, a copy of the grievance form was given to them. She did not recall anyone requesting a copy of the grievance form. On 9/21/2022 at 9:58 AM an interview was conducted with the Director of Nursing (DON). She stated the SW gave her grievance forms. She investigated the grievance. After the investigation, she would call the person who filed the grievance and discuss the result of her investigation and what actions were taken. The DON did not provide a written copy of the grievance to the complainant and did not know regulations stipulated a written copy should have been provided. Based on record reviews and resident, family and staff interviews, the facility failed to provide a written grievance response summary for 5 of 8 residents reviewed for grievances (Residents #33, #62, #23, #36 and #68). The findings included: A review of the facility grievance policy, dated 11/28/16, included, in part, the resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee. The resident will be offered a copy of the written grievance decision. 1. Resident #33 was originally admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #33 had severe cognitive impairment. Review of the facility grievance logs from November 2021 until September 2022 indicated one grievance was initiated on 7/18/22 for Resident #33, by the responsible party (RP), regarding dissatisfaction with the room. The form indicated the Social Worker (SW) spoke with the family member with a resolution on 7/19/22 and was signed by the Administrator on 7/19/22. The form indicated a verbal resolution was provided. There was no indication a written summary was provided, offered, or requested by/to the RP. On 9/21/22 at 9:41 AM, an interview was conducted with the SW, who stated she logged all the grievance forms, and concerns were investigated by the appropriate department head. She went on to explain after the department head completed the investigation they would call/or speak with the person filing the grievance and provided the resolution verbally. A written copy was only provided to the ones that requested it, but she couldn't remember anyone that had requested a copy recently. A phone interview occurred with Resident #33's RP on 9/21/22 at 3:22 PM, who stated she had received verbal resolution of the past grievance concern but had not been offered or provided a summary in writing. The Administrator was interviewed on 9/22/22 at 10:33 AM and stated he was unaware a written summary of the grievance was not being provided at all times. The Administrator added, it was his expectation for the facility to adhere to the regulatory guidance regarding written grievance response summaries. 2. Resident #62 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #62 was cognitively intact. Review of the facility grievance logs from November 2021 until September 2022 indicated three grievance forms were initiated by the RP for Resident #62 on 3/17/22 regarding missing items, facility communication and room changes. The forms indicated the appropriate department heads spoke with the RP on 3/21/22 regarding the resolutions and were signed by the Administrator on 3/21/22. The forms indicated only a verbal resolution was provided. There were no indications written summaries were provided, offered, or requested by/to the RP/resident. On 9/21/22 at 9:41 AM, an interview was conducted with the SW, who stated she logged all the grievance forms, and it was investigated by the appropriate department head. She went on to explain after the department head completed the investigation they would call/or speak with the person filing the grievance and provided the resolution verbally. A written copy was only provided to the ones that requested it, but she couldn't remember anyone that had requested one recently. On 9/21/22 at 2:00 PM, an interview occurred with Resident #62 who stated he had not received anything in writing regarding the concerns his RP had voiced. A phone interview occurred with Resident #62's RP on 9/21/22 at 3:19 PM, who stated she could only recall getting verbal notification of the grievance resolutions. The Administrator was interviewed on 9/22/22 at 10:33 AM and stated he was unaware a written summary of the grievance was not being provided at all times. The Administrator added, it was his expectation for the facility to adhere to the regulatory guidance regarding written grievance response summaries. 3. Resident #23 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Her quarterly Minimum Data Set, dated [DATE] indicated she was cognitively intact and exhibited no behaviors. Review of the facility grievance list included written intakes on behalf of Resident #23 on 7/26/22, 8/2/22 and 9/11/22. The grievance form indicated Resident #23 was provided verbal investigation findings and actions but nothing was provided in writing. An interview was completed on 9/20/22 at 4:30 PM with Resident #23. She confirmed the Social Worker (SW) completed grievances on her behalf for the dates listed above. Resident #23 stated she did not receive anything in writing about her grievance, but the SW did follow up with her verbally. An interview was completed on 9/21/22 at 9:41 AM with the SW. She stated she was responsible for keeping up with and assigning the grievances to the appropriate department head to investigate and intervene. After the investigation, the department head would follow up with the person filling the grievance and if the person filing the grievance wanted a copy of the investigation findings, action/resolution, a copy the grievance form was given to him/her. The SW stated she did not provide a copy of the grievance investigations with resolutions to Resident #23. An interview was completed on 9/22/22 at 10:30 AM with the Administrator. He stated he thought the SW was providing a written response to each grievance, but he recently found out she only provided the written resolution if it was requested. 5. Resident #68 was admitted to the facility on [DATE] with multiple diagnosis including dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had severe cognitive impairment. Review of the facility's grievance log revealed that Resident #68's family member had reported 5 grievances in the last 4 months. The grievance reporting forms revealed that on 5/23/22, a family member had reported a grievance regarding lack of activities of daily living (ADL) care, on 7/1/22 regarding food/dietary concerns, on 8/30/22 regarding lack of ADL care, 9/2/22 regarding lack of ADL care and on 9/15/22 regarding lack of ADL care. The grievance reporting forms dated 5/23/22, 8/30/22 and 9/2/22 revealed that investigation findings, action/resolution and the grievance decision were reported/given to the person filing the grievance verbally on 5/25/22, and 9/4/22. The grievance reporting forms dated 7/1/22 and 9/15/22 revealed that investigation findings, action/resolution and the grievance decision were reported to the person filing the grievance on 5/25/22, and 9/4/22. The report did not indicate whether the forms were reported/given verbally or in writing. A family member of Resident #68 was interviewed on 9/21/22 at 9:36 AM. The family member stated that she had reported grievances to the facility staff on 5/23/22, 7/1/22, 8/30/22, 9/2/22 and 9/15/22. She indicated that a staff member had called and told her what actions were taken to correct her grievances. She stated that she had never received any responses in writing regarding her grievances and she would prefer to have a copy of the grievance report with the resolution. The Social Worker (SW) was interviewed on 9/21/22 at 9:41 AM. The SW stated that she was responsible for the grievance and keeps all the grievance forms. She reported that the grievance form was given to the department head (depends on the type of grievance) to investigate and to resolve the grievance. The department head would call the person filing the grievance and discuss the resolution. After the investigation, the completed form was returned to the SW for filing. If the person filing the grievance wants a copy of the grievance form, a copy is provided. The Director of Nursing (DON) was interviewed on 9/21/22 at 9:58 AM. The DON stated that the SW was responsible for the grievance. The SW gives her the grievance form if the grievance was related to nursing. She then investigates and takes action to resolve the grievance. She calls the person filing the grievance. She submitted back the completed grievance form to the SW. The Administrator was interviewed on 9/22/22 at 10:23 AM. The Administrator stated that he expected the SW to provide a copy of the completed grievance form to the person filing the grievance. He indicated that he was not aware that the SW was not providing a written copy of the grievance form with the resolution to the person filing the grievance.