**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Responsible Party (RP), and staff interviews the facility failed to notify the RP and the Ombudsman in writing when 1 of 1 sampled residents was discharged to the hospital (Resident #6). Resident #6 had originally been admitted to the facility in 2009. She had been discharged to the hospital on 1/27/2023 and readmitted on [DATE]. Resident #6's most recent Minimum Data Set assessment dated [DATE] indicated she had severe cognitive impairment. An interview with Resident #6's Responsible Party (RP) was conducted on 11/07/23 at 1:29 PM. She stated she had been present when Resident #6 had been transferred to the hospital in January, but she had not received any a written explanation of the reason for discharge to the hospital. On 11/07/23 at 3:45 PM an interview with the Resident Care Coordinator was conducted. She explained she was new to the position and was unaware that anything had to be sent to the family in writing or to the Ombudsman regarding discharges. An interview on 11/08/23 at 3:36 PM was conducted with the Director of Nursing (DON). She stated she thought contacting the RP during an emergency was adequate for notification and was unaware of needing to send a written notice for discharge to the RP or the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, responsible party, and staff interviews the facility failed to provide written notice of bed hold policy upon transfer to the hospital for 1 of 1 resident reviewed for hospitalization (Resident #6). Resident #6 had originally been admitted to the facility in 2009. She had been discharged to the hospital on 1/27/2023 and readmitted on [DATE]. Resident #6's most recent Minimum Data Set assessment dated [DATE] indicated she had severe cognitive impairment. An interview with Resident #6's Responsible Party (RP) was conducted on 11/07/23 at 1:29 PM. She stated she had been present when Resident #6 had been transferred to the hospital in January, but she had not received any information regarding bed hold. On 11/07/23 at 3:45 PM an interview with the Resident Care Coordinator was conducted. She explained she was new to the position and recently learned the bed hold information needed to be given to the family when residents were discharged to the hospital. An interview on 11/08/23 at 3:36 PM was conducted with the Director of Nursing (DON). She stated she had recently become aware of the bed hold policy needing to be sent with the resident or to the RP upon transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to accurately code nutrition and Pre-admission Screening and Resident Review (PASRR) on the Minimum Data Set (MDS) assessments for 2 of 16 residents (Residents #63, and #53) reviewed for MDS accuracy. Findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was assessed as severely cognitively impaired and needed substantial /maximal assistance to partial / moderate assistance for Activities of Daily living. Assessment indicated for eating the resident needed setup or clean up assistance only. The assessment indicated the resident had significant weight loss. Assessment indicated the resident was on tube feeding and on mechanically altered diet. On 11/6/23 at 1:16 PM during an observation and interview, Resident #63 was observed during lunch. Resident #63 was eating her lunch in her room and was able to self-feed. The resident was monitored during meals and encouraged to consume her food. The resident was on a low sodium, pureed meat diet. The resident consumed 25% of her meals at the time of observation. Nurse Aide (NA) #1 was observed sitting with the resident during lunch and encouraging the resident to consume her food. NA #1 stated the resident could feed self but needed a lot of encouragement and cues to eat. NA #1 further stated, during meals a staff member would sit with the resident to encourage meal intake. NA #1 indicated the resident was assisted with feeding as needed. During an interview on 11/7/23 at 3:17 PM, the Registered Dietitian (RD) stated the resident was on a low sodium, mechanical soft, pureed meats, thin liquids diet. The resident could self-feed, however needed some encouragement and cues at mealtime. The RD indicated the resident did not receive any tube feeding and consumed 25-75% of her meals. During an interview on 11/8/23 at 11:50 AM the MDS Coordinator indicated it was an error that Resident #63 was marked for tube feeding. She indicated Resident #63 was not on tube feeding. The resident should be marked for therapeutic diet and mechanically altered diet in the MDS. During an interview on 11/8/23 at 2:45 PM, the Administrator stated it was a MDS error and would be corrected immediately. The Administrator further stated resident's MDS assessments should reflect current status of the resident. 2. Resident #53 had been admitted on [DATE] with diagnoses including moderate intellectual disabilities and major depressive disorder. An undated care plan noted Resident #53 had a Level 2 Preadmission Screen and Annual Record Review (PASRR determination) related to moderate intellect disability. Resident #53's most recent annual MDS assessment dated [DATE] did not indicate she was considered by the state Level II PASRR process to have intellectual disability. An interview with the MDS Coordinator was conducted on 11/08/23 at 11:18 AM. She explained Resident #53 was technically considered as Level II PASRR, but she did not mark it on the MDS because there were no restrictions noted on the PASRR determination letter. An interview with the Director of Nursing (DON) was conducted on 11/08/23 at 3:36 PM. The DON stated the PASRR information should be correct on the MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation on 8/31/22 at 1:20 PM of room [ROOM NUMBER] revealed the wall behind both beds (Bed A and Bed B) had holes and damaged dry wall. The wall behind Bed A and Bed B had overlapping rectangular marks of exposed dry wall measuring approximately 1-2 inches in width by 4-10 inches in length. Observation also revealed an additional hole behind Bed B measuring approximately 8 inches by 12 inches and was rectangular in shape. An interview was conducted with Nurse Aide #1 on 8/31/22 at 1:20 PM. She stated she had not known the walls in room [ROOM NUMBER] were damaged. She indicated she typically reported damaged walls to the Administrator or to the Resident Care Coordinator (RCC). An interview was conducted with the RCC on 8/31/22 at 1:20 PM. She stated protective wall covers were on back order and that was why room [ROOM NUMBER] did not have one behind the beds. During an interview on 08/31/22 12:00 PM, The Director of Facility Services stated when any work order was received from the facility, the jobs were completed accordingly. The Director of Facility Services further stated all resident's rooms were inspected quarterly by the maintenance staff. Quarterly inspections were done to ensure that the resident's rooms were maintained in good condition. The Director of Facility Services indicated the staff moved the resident's beds too close to the wall resulting in the wall plaster getting peeled and walls damaged. The Director of Facility Services further indicated most the resident's room walls behind the bed were mounted with a protector sheet to prevent wall damage. This was an antimicrobial plastic sheet protector that protected the walls. The Director of Facility Services stated she would be ordering more of these sheets to ensure all resident's rooms had these sheets on the wall. The Director of Facility Services further stated the screws of the call bell box were tightened so that it was properly mounted on the wall. The Administrator was unable to be interviewed during the survey. During an interview on 09/01/22 03:05 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer further stated if any staff saw anything that needed to be repaired, it should be reported immediately so that appropriate action could be taken. She indicated the Director of Facility Services had ordered a few more wall protectors and these were on backorder. Based on observations and staff interviews, the facility failed to maintain walls in resident rooms in good repair (room [ROOM NUMBER] and room [ROOM NUMBER]) and failed to secure the call bell box to the wall (room [ROOM NUMBER]). This was for 2 of 14 resident rooms reviewed for homelike environment. The findings included: 1. An observation on 8/30/22 at 9:39 AM of room [ROOM NUMBER] revealed the wall behind the bed had a hole approximately measuring 11''X 3 long. Observation also revealed the call bell box near Bed A was not properly mounted to the wall. The cover of the call bell box was not attached to the wall. The call bell was tested and was working. During an interview on 8/31/22 at 10:51 AM, Nurse Aide #1 stated the call bell was working and she had not noticed the call bell box not mounted correctly on the wall. Nurse Aide further stated she had not noticed the hole on the wall behind the resident's bed. Nurse Aide #1 indicated when any repair were needed to be done in resident's rooms the Nurse was notified. Nurse Aide confirmed she had not notified the nurse as she had not observed it. During an interview on 8/31/22 at 11:08 AM, Nurse #2 stated the management was notified when any repairs were needed in resident's rooms. Nurse #2 further stated she was unaware of these repairs and the Nurse Aide had not notified her. Nurse #2 indicated the Administrator or Director of Nursing (DON) would place a work order for these repairs. During an interview on 8/31/22 at 11:15 PM, Interim DON stated the nurses would notify the Administrator or any management team when any repairs were needed in resident's rooms. The interim DON stated she was not notified of these repairs and there was no work order placed for these repairs. During an interview on 08/31/22 12:00 PM, The Director of Facility Services stated when any work order was received from the facility, the jobs were completed accordingly. The Director of Facility Services further stated all resident's rooms were inspected quarterly by the maintenance staff. Quarterly inspections were done to ensure that the resident's rooms were maintained in good condition. The Director of Facility Services indicated the staff moved the resident's beds too close to the wall resulting in the wall plaster getting peeled and walls damaged. The Director of Facility Services further indicated most the resident's room walls behind the bed were mounted with a protector sheet to prevent wall damage. This was an antimicrobial plastic sheet protector that protected the walls. The Director of Facility Services stated she would be ordering more of these sheets to ensure all resident's rooms had these sheets on the wall. The Director of Facility Services further stated the screws of the call bell box were tightened so that it was properly mounted on the wall. The Administrator was unable to be interviewed during the survey. During an interview on 09/01/22 03:05 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer further stated if any staff saw anything that needed to be repaired, it should be reported immediately so that appropriate action could be taken. She indicated the Director of Facility Services had ordered a few more wall protectors and these were on backorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment and failed to transmit Quarterly MDS assessments within the required time frame for 3 of 3 residents (Resident # 1, Resident # 7, and Resident # 8) selected to be reviewed for Resident Assessments. Findings included: 1. Resident #1 was admitted on [DATE]. The last MDS assessment completed and transmitted was Medicare - 5-day admission MDS dated [DATE]. Record review dated 4/12/22 revealed the resident was discharged home with home health. discharged note from physician dated 4/12/22 revealed the resident was discharged home with home health services. There was no discharge MDS completed for this resident. During an interview on 9/1/22 at 1:51 PM, the MDS coordinator indicated the resident was discharged on 4/12/22 and the discharge MDS was not completed. MDS coordinator further indicated it was during the transition period when the old MDS staff resigned. The MDS coordinator stated the assessment must have slipped through the cracks. Administrator was unavailable for interview. During an interview on 9/1/22 at 3:02 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer stated all assessment should be completed and transmitted on time. 2. Resident #7 was admitted on [DATE]. A review of resident's most recent MDS assessment revealed an Assessment Reference Date (ARD) of 7/25/22 and was coded as a quarterly assessment. The MDS was signed as completed by the MDS Coordinator on 8/7/22 and indicated as ready to export. The MDS assessment was not transmitted to the national database. During an interview on 9/1/22 at 1:51 PM, the MDS coordinator stated the assessment was completed and signed on 8/7/22. The MDS coordinator further stated the assessment should have been transmitted within 14 days of completion. The submit by date was 8/21/22. MDS coordinator indicated she was unsure why the assessment was not transmitted. She further indicated all completed MDS assessments were transmitted every other week. Administrator was unavailable for interview. During an interview on 9/1/22 at 3:02 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer stated all assessment should be completed and transmitted on time. 3. Resident #8 was readmitted on [DATE]. A review of resident's most recent MDS assessment revealed an ARD of 7/26/22 and was coded as a quarterly assessment. The MDS was signed as completed by the MDS Coordinator on 8/7/22 and indicated as ready to export. The MDS assessment was not transmitted to the national database. During an interview on 9/1/22 at 1:51 PM, the MDS coordinator stated the assessment was completed and signed on 8/7/22. The MDS coordinator further stated the assessment should have been transmitted within 14 days of completion. The submit by date was 8/21/22. MDS coordinator indicated she was unsure why the assessment was not transmitted. She further indicated all completed MDS assessments were transmitted every other week. Administrator was unavailable for interview. During an interview on 9/1/22 at 3:02 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer stated all assessment should be completed and transmitted on time.