Based on record review and interview the faciity failed to complete a significant change assessment for one (#57) of two sampled residents reviewed for a significant change. Findings: Resident #57 had diagnoses which included Parkinson's, repeated falls and pain. A Physician Order, dated 01/12/24 documented to admit the resident to hospice services. The clinical health record did not document a significant change assessment had been completed. The last assessment completed was a quarterly assessment on 02/08/24. On 03/18/24 at 4:11 p.m., the DON was asked if a significant change should have been completed when the resident was admitted to hospice. They stated Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident assessments was transmitted within seven days of completion for one (#44) of two sampled residents reviewed for resident assessments. The Administrator identified 51 residents resided in the facility. Resident #44's quarterly assessment, dated 01/21/24, had been completed but still showed In Progress in the clinical health record. On 03/20/24 at 9:02 a.m., the MDS coordinator was asked why does the quarterly MDS, dated [DATE], still say In progress. They stated, I don't know might have missed it.

Based on record review and interview, the facility failed to ensure neurological checks were accurately completed for one (#22) of two sampled residents reviewed for neurological checks. The Administrator identified 51 residents resided in the facility. Findings: A Resident Falls policy, dated 03/19/22, read in part .Assessments of falls with head injury or unwitnessed falls shall include neurological checks as follows: a. Q 15 min x 4, Q 30 min x 2, Q 1 Hr x 2, Q 2 Hrs x 1, Q 8 Hrs x 72 HRS . Resident #22 had diagnoses which included, debility, dementia and arthritis. A nurse progress note, dated 10/29/23 at 7:10 a.m., read in part, .Res observed in floor in sitting position .neuro [checks] initiated . A Neurological Record, dated 10/29/23 at 7:15 a.m., documented neuro checks were started every fifteen minutes for an hour, every 30 minutes times one check, every hour for two checks, every two hours for one check, then every shift for seven shifts. The record did not document neuro check was completed at 30 minutes for a second time, and did not document times eight hour checks had been completed, just shift times. A nurse progress note, dated 11/13/23, read in part, .Staff alerted this nurse to come to residents room STAT. Upon entry res noted on floor laying on [right] side beside bed. Moderate amount of blood noted under head .EMS arrives [and] transports res to .ER . A Neurological Record, dated 11/13/23 documented neuro checks were started when the resident returned from the emergency room at 12:03 a.m., then 3:03 a.m., then documented neuro checks were completed every shift for six shifts. The record did not document times eight hours checks had been completed, just shift times. On 03/19/24 at 3:17 p.m. the MDS coordinator was shown the neurological records for Resident #22 and asked if every 8 hours checks for 72 hours had been completed correctly for the two neurological checks dated 11/13/23 and 10/29/23. They stated No. On 03/20/24 at 08:15 a.m., the DON was asked to review the neurological records dated 11/13/23 and 10/29/23. They stated they do the whole neuro checks for a total of 72, not every 8 hours for 72 hours. They stated the neurological checks had not been completed correctly.

Based on observation and interview the facility failed to ensure staff secured medication carts when unattended. The Administrator identified 51 residents resided in the facility. Findings: On 03/19/24 at 07:32 a.m., CMA #2 was observed to be preparing medications at their cart. They left the cart unlocked and stepped a few feet away with their back to the cart to administer medications. On 03/19/24 at 07:38 a.m., CMA #2 was observed to leave their med cart unlocked to answer the phone. On 03/19/24 at 9:42 a.m., CMA #2 was asked when should the cart be secured. They stated everytime their away from it. CMA #2 was asked if they recalled leaving their cart unlocked. They stated they did not remember. On 03/19/24 10:49 a.m., the DON was asked is there any time when a cart should be left unlocked if the med aide is not present. They stated No.

Based on record review and interview the facility failed to provide timely and complete beneficiary notices to three (#51, #16, #109) of three sampled residents reviewed for beneficiary notices. The Administrator identified 51 residents resided in the facility. Findings: An undated Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 policy, read in part, .The provider must ensure that the beneficiary or representative signs and dated the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . A Notice of Medicare Non-Coverage (NOMNC) policy, dated 03/18/24, read in part, .It is the policy of this facility that [name of facility] must deliver required notice to residents/resident representatives at least 2 calendar days prior to termination of skilled nursing care . 1. Resident #51's Notice of Medicare Non-Coverage documented skilled services would end on 11/11/23. There was no resident or resident representative signature or date on the document. A Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN), was signed and dated by the resident's representative on 02/01/24. On 03/18/24 at 1:18 p.m., the MDS coordinator was asked if the NOMNC had been signed by the resident. They stated, No. They were asked why the ABN had been signed and dated after the resident was discharged from skilled services. They stated, that was as soon as they got it signed. 2. Resident #16's Notice of Medicare Non-Coverage documented skilled services would end on 12/07/23. The document had been signed by the residents representative but had no date when the notification had been signed. There was no documentation an ABN had been provided to Resident #16. On 03/18/24 at 1:21 p.m., the MDS coordinator was asked if Resident #16 had been provided a copy of an ABN. They stated the NOMNC form was all they had. They were asked when the residents skilled services ended. They stated on 12/07/23. They were asked when the residents representative signed the NOMNC. They stated it was not dated. 3. Resident #109's Notice of Medicare Non-Coverage documented skilled services would end on 01/26/24. The NOMNC documented the form was signed by the resident representative on 02/02/24. A Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN), was signed and dated by the resident's representative on 02/02/24. The ABN did not document what option the resident or representative chose. On 03/18/24 at 1:13 p.m., the MDS coordinator was shown Resident #109's forms and asked why was the form signed on 02/02/24. They stated that was the day the residents representative signed the form and discharged on 02/03/24. They were asked to review the ABN and why the options were left blank and if that was a completed form. They stated No.

Based on record review, interview the facility failed to develop a comprehensive care plan related to hospice, antipsychotic, anticoagulant, and opioid medications for two residents (#14 and #46) of 13 sampled residents reviewed for care plans. The Administrator identified 51 residents resided in the facility. Findings: 1. Resident #14 had diagnosis which included Dementia, depression, and pain. Facility had no Care Plan policy until 03/19/24. A care plan, dated 11/30/22, documented no focused area's for antipsychotic, anticoagulant, and opiod medications on the comprehensive care plan. On 03/19/24 at 11:34 a.m., the MDS Coordinator #1 was asked What the policy was for developing a comprehensive care plan. They stated they go by the resident's diagnosis and the cause section from admit MDS. They were then asked to review the comprehensive careplan for resident #14 and determine if the care plan had focus area's addressing the antipsychotic, anticoagulant, and Opioid mediation for Resident #14. They stated No, they are not on the care plan. They were then asked what the process if for updating and revising a care plan. They state, They go by the orders when they get them. 2. Resident #46 had diagnoses which included non-Alzheimer's dementia and non-traumatic brain dysfunction. A physician order, dated 07/03/23, documented Comforting Hands Hospice. A quarterly assessment, dated 12/06/23, documented severly impaired cognition and hospice services. A care plan, revised on 03/18/24, contained no documentation for hospice services. On 03/20/24 at 10:05 a.m., the DON reported hospice should have been on resident #46's care plan.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised after each assessment for two (#31 and #36) of 13 residents whose care plans were reviewed. The administrator identified 51 residents resided in the facility. Findings: 1. Resident #31 was admitted with diagnoses which included non-Alzheimer's dementia, dementia with other behavioral disturbance, and depression A care plan, revised 09/13/23, documented [name removed] has a mood problem r/t depression. The care plan contained no documentation of being reviewed or revised with quarterly assessments since 09/13/23. A physician order, dated 12/29/23, documented Quetiapine 25 mg 1 tablet by mouth one time a day for behavioral and psychological symptoms of dementia. A quarterly assessment, dated 02/21/24, documented cognition was moderately impaired and routine use of antipsychotic medication. 2. Resident #36 had diagnoses which included non-Alzheimer's dementia, depression, and dementia with other behavioral disturbance. A care plan, revised on 05/31/23, documented [name removed] uses psychotropic medications (Seroquel) r/t sleep/bpsd .[name removed] has dx of depression. The care plan contained no documentation of being reviewed or revised with quarterly assessments since 05/31/23. On 03/19/24 at 11:34 a.m., the MDS coordinator reported the facility had no policy related to care plan review or revision. On 03/19/24 at 2:30 p.m., the MDS coordinator reported the care plan meeting notes documented when the care plans were reviewed and what revisions were made. The MDS coordinator reported no care plan meeting notes were available for resident #31 and resident #36.

Based on observation, record review, and interview, the facility failed to ensure staff maintained infection control measures when passing medications. The Administrator identifed 51 residents resided in the facility. Findings: A Policy and Procedure, dated 03/04/21, read in part, .Precautions are utilized to prevent and control transmission of infectious organisms through direct and indirect contact .Hand hygiene means cleaning your hands by using either handwashing .antiseptic hand wash .antiseptic hand rub .medication preparation areas .Proper cleaning/disinfection of resident care care equipment including equipment shared among residents . On 03/19/24 at 7:32 a.m., CMA #2 obtained a blood pressure with a manual cuff and stethoscope on Resident #15. CMA #2 was observed to place their stethoscope around their neck and put the manual BP cuff back on the cart. CMA #2 did not sanitize the cuff or stethoscope or their hands. On 03/19/24 at 7:44 a.m., CMA #2 was observed to obtain a blood pressure on Resident #39 with a manual cuff and stethoscope. CMA #2 placed the stethoscope around their neck and put the cuff back on the top of the cart without sanitizing the cuff or stethoscope and did not sanitize their hands. On 03/19/24 at 7:53 a.m., CMA #1 was observed to administer medications to Resident #26. CMA #1 did not sanitize their hands then began to prepare Resident #41's medications. On 7:57 a.m., CMA #1 administered medications to Resident #41, returned to the cart and was not observed to sanitize their hands. On 03/19/24 at 8:07 a.m., CMA #1 was observed to prepare resident #49's medications and take to their room. CMA #2 obtained a blood pressure and pulse oximetry on Resident #49 using a manual BP cuff, stethoscope, and finger pulse ox. CMA #1 put the stethoscope around their neck rolled up the blood pressure cuff and returned to the cart. They were not observed to sanitize the blood pressure cuff, stethoscope or pulse ox. On 03/19/24 at 9:11 a.m., CMA #1 was asked how they maintain infection control when using their blood pressure cuff, stethoscope and pulse ox. They stated they wipe them off. They were asked if they had cleaned their equipment. They stated I should have cleaned my equipment but I did not. CMA #1 was asked if they had sanitized their hands prior to and after each medication pass. They stated, No. On 03/19/24 at 9:42 a.m., CMA #2 was asked when they should sanitize their hands when passing medications. They stated after every pass. CMA #2 was asked when should they sanitize their blood pressure cuff and stethoscope. They stated after a blood pressure is obtained. CMA #2 was asked if they had sanitized their equipment during medication pass. They stated No. They were asked what do they use to sanitize their equipment. They stated sanitizing wipes but did not have any on their cart. On 03/19/24 at 10:49 a.m., the DON was asked when should equipment be sanitized to include BP cuff, stethoscope and pulse ox. They stated before and after each use. The DON was asked when should staff sanitize their hands when passing medications. They stated before and after medications are passed.

Based on record review and interview, the facility failed to ensure a registered nurse coordinated and signed resident assessments prior to submission to CMS. The DON reported 51 residents resided in the facility. Findings: A Clinical - MDS list, dated 12/02/23 through 03/18/24, documented 112 assessments had been submitted to CMS and accepted. On 03/20/24 at 2:38 p.m., the MDS coordinator reported being a licensed practical nurse not a registered nurse. The MDS coordinator reported she had signed all the assessments that were submitted to CMS between 12/02/23 through 03/18/24. On 03/20/24 2:40 p.m., the DON reported the facility did not have a policy related to completing and submitting MDS assessments. The DON reported being aware that MDS assessments required an RN signature and had failed to sign any of the MDS assessments dated 12/02/23 through 03/18/24.