Based on review of the facility policy, record review, and interviews, the facility failed to report their five-day follow-up to the State Agency (SA) within five (5) days. Findings include: Review of the facility's policy titled, Investigating Injuries and Reporting Injuries, with a revision date of December 2016 revealed, A facility shall submit a written report of its investigation of every serious accident and incident to the Department within five (5) days of the serious accident or incident. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: · Thoroughly investigate the alleged violation; · Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and · Take appropriate corrective action, as a result of investigation findings. Upon arrival at the facility on 04/10/24, the Assistant Director of Nursing (ADON) presented an investigative file with a report dated 11/30/23, which indicated the date the facility notified the SA. Review of the facility's investigation showed the facility did complete their 24-hour initial report. However, there was no five (5) day report completed. During an interview on 04/10/24 at approximately 3 PM with the ADON and Administrator, it was stated that they only complete a 24-hour report. During their 24-hour report, they convene their Interdisciplinary Team and send all relative information and complete the total investigation then send it under the 24- hour report. If any additional information is found later, they do send that relative information to the SA. However, they did not complete the five (5) day report. The Administrator stated she did not know she needed to complete a five day.

Based on interview, record review, and review of facility policy, the facility failed to ensure the resident, his or her family, and/or the resident representative (RR) was provided information related to the benefits and risks to the residents for prescribed psychotropic medications. The facility further failed to obtain consents for the psychotropic medications by the resident, or family, and/or the RR. This affected 3 of 5 residents (Resident (R) 21, R31, and R32) reviewed for unnecessary medications. Findings include: Review of the facility's policy titled, Lifestyle Support/Behavior Management Policy and Procedure, reviewed 06/21 indicated, If the resident is receiving a psychotropic medication, the community will obtain consent for the medication. 1. Review of R21's Resident Face Sheet located in the Electronic Medical Record (EMR) under the Resident and Face Sheet tab, revealed an admission date of 02/11/21 and included diagnoses of encephalopathy (altered brain function) and major depressive disorder. Review of R21's quarterly Minimum Data Set (MDS), located in the EMR under the MDS 3.0 Assessments tab, with an Assessment Reference Date (ARD) of 05/20/22 revealed a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R21's Orders located in the EMR under the Orders tab, revealed the resident was prescribed Trazodone (antidepressant). Review of R21's EMR revealed no evidence the resident nor the RR had been notified of the potential risks and benefits of receiving the prescribed medication, nor had the RR been given the opportunity to consent or refuse the drugs' use. 2. Review of R31's Resident Face Sheet located in the EMR under the Resident and Face Sheet tab, revealed an admission date of 01/26/22 and included diagnoses of encephalopathy, dementia without behavioral disturbance, and hallucinations. Review of R31's quarterly MDS, located in the EMR under the MDS 3.0 Assessments tab, with an ARD of 06/09/22 revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R31's Orders, located in the EMR under the Orders tab, revealed the resident was prescribed Seroquel (antipsychotic) and Ativan (antianxiety). Review of R31's EMR revealed no evidence the resident nor the RR had been notified of the potential risks and benefits of receiving the prescribed medication, nor had the RR been given the opportunity to consent or refuse the drugs' use. 3. Review of R32's Resident Face Sheet located in the EMR under the Resident and Face Sheet tab, revealed an admission date of 02/11/22 and included diagnoses of encephalopathy, Alzheimer's disease, dementia with behavioral disturbance, and anxiety disorder. Review of R32's quarterly MDS located in the EMR under the MDS 3.0 Assessments tab, with an ARD of 05/28/22 revealed a BIMS score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Review of R32's Orders, located in the EMR under the Orders tab, revealed the resident was prescribed Seroquel (antipsychotic). Review of R32's EMR revealed no evidence the resident nor the RR had been notified of the potential risks and benefits of receiving the prescribed medication, nor had the RR been given the opportunity to consent or refuse the medication's use. In an interview on 07/08/22 at 9:30 AM, the Assistant Director of Nursing (ADON) stated all residents that receive psychotropic medications should have informed consents in the medical record. The ADON stated she could not locate the consents for R21, R31, and R32 but would reach out to the Director of Nursing (DON). In a follow-up interview on 07/08/22 10:40 AM, the ADON stated she spoke with the DON and the DON noticed the consents were not in the medical records during a chart audit. In an interview on 07/08/22 at 10:47 AM, the DON stated she completed a chart audit in April of all residents that receive psychotropic medications. The DON stated the audit uncovered residents did not have informed consents in their medical records. The DON stated she gave the task to the Admissions Coordinator (AC) to complete. In an interview on 07/08/22 at 11:27 AM, the AC stated she was not responsible for adding the informed consents to the chart. The AC stated it was discussed for her to ensure informed consents were completed upon admission. The AC confirmed the facility did not obtain consents notifying R21, R31, and R32 nor their representatives of the risks/benefits of the use of psychotropic medications.

Based on interviews, record review, and review of facility policy, the facility failed to investigate and respond to resident grievances for 2 of 9 grievances reviewed for grievance resolution. The facility further failed to respond to concerns brought up during resident council meetings from January 2022 through July 2022. Specifically, the facility failed to resolve/respond to grievances/concerns related to lengthy call light response times, communication difficulties, wheelchair needs, activities of daily living (ADLs), noise levels, staff communication, staff being on their phones during ADL care, and unprofessional behavior. Findings include: Review of the facility policy titled Grievances/Complaints, Filing revised April 2017 revealed, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is Admissions Coordinator [AC] . Once grievance is obtained, Grievance officer will present to the unit supervisor to be completed for that portion (action taken) .The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years . Review of Resident Council Meeting Minutes for the months of January 2022 through July 2022 revealed multiple nursing department complaints including lengthy call light response times, communication difficulties, wheelchair needs, ADLs, noise levels, staff communication, and staff being on their phones during ADL care. Review of the documentation provided by the facility and sent out by Activities Lead [AL] revealed emails were sent to the Director of Nursing [DON] and Assistant Director of Nursing [ADON] regarding grievances/concerns voiced by multiple residents during monthly resident council meetings. Grievance notifications were sent on 01/28/22, 02/23/22, 03/30/22, 04/27/22, 06/02/22, and 06/28/22. An email sent on 01/28/22 stated Attached you will find the residents' identified concerns for the month of January .does not like it that it sometimes takes over an hour for his call light to be answered .some nursing staff .gets frustrated when trying to communicate with him, due to him being hard of hearing .would like a better wheelchair .in the evening it takes staff longer to answer her call light .some of the staff does not know how to properly make his bed .evening shift can sometimes be a little loud outside of his door. Department response was blank, was not signed off by the department head, not dated, and not returned to AL by 02/22/22 as requested. An email sent on 02/23/22 stated Attached you will find the residents' identified concerns for the month of February .still has issues with certain staff members who cannot put the catheter bag on correctly .feels like most days she is left in the bed too long .it takes 2nd shift a long time to answer call lights .would like for the water to already be warm when he is taken to the shower .would like nursing staff to tell him what activities are going on for the day . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 03/29/22 as requested. An email sent on 03/30/22 revealed Attached you will find the residents' identified concerns for the month of March .it takes the nursing staff a long time to come to her room when she needs help .continues to have issues with CNAs [Certified Nursing Assistants] not being able to properly place his catheter bag on his wheelchair without it dragging the ground .shower rooms tend to be very disheveled . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 04/26/22 as requested. An email sent on 04/27/22 stated Attached you will find the residents' identified concerns for the month of April .says he pushes his call light and ends up yelling for help because no one will answer his light in the evenings . waits a long time for help to come . still commenting that most of the CNAs cannot hang the catheter bag correctly .would prefer for staff to not be on their phone when they are in his room . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 05/31/22 as requested. An email sent on 06/01/22 stated Attached you will find the residents' identified concerns for the month of May .mentioned again that the evening shift does not answer her call light in a timely manner .it takes evening shift awhile to answer his call light .mentioned again that his catheter bag does not get hung correctly on his wheelchair . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 06/28/22 as requested. An email sent on 06/28/22 stated Attached you will find the residents' identified concerns for the month of June .CNAs are sometimes slow at coming to help. When asked what time of day he was referring to, he said, 'it varies'. Department response was blank, was not signed off by department head, not dated, and not returned to AL by 07/26/22 as requested. Review of grievance logs from July 2021 through July 2022 revealed there were nine grievances reported. Grievance dated 01/19/22 regarding unprofessional behavior was not responded to or investigated. Grievance dated 02/23/22 regarding lack of nursing assistance during toileting was not responded to or investigated. In an interview with the Admissions Coordinator (AC) on 07/08/22 at 10:50 AM, revealed she was the grievance officer and was responsible for following up on grievances. Facility protocol included the AL sends out emails to all departments regarding any grievances and complaints made during the resident council meetings or individual complaints made by the resident/responsible party. If the department was able to resolve the complaint/grievance the day of the reported grievance, then the facility did not report as a grievance. AC confirmed that grievance filed 01/19/22 related to quality of care for the nursing department resulted in her speaking with the ADON with no resolution received. AC confirmed that grievance filed on 02/23/22 related to quality of care for the nursing department resulted in her speaking with the ADON with no resolution received. In an interview with the Social Work Assistant (SWA) on 07/08/22 at 11:43 AM, revealed she frequently holds the resident council meetings on the last Tuesday of the month. SWA confirmed that complaints/concerns are then forwarded to the AL who then enters the information into the system and sends out emails to the appropriate department leads who are expected to respond in a timely manner to the grievances/concerns. In an interview with the ADON on 07/08/22 at 12:22 PM, revealed she had spoken with one of the residents regarding generalized concerns, but she had not read or reviewed the emails from the AL regarding resident council grievances/concerns dated January through June 2022. The ADON further stated that the AL brought it to her attention on 07/08/22 that resident council grievances/concerns had not been responded to by the nursing department and returned to the AL. During an interview with the AL on 07/0822 at 1:28 PM stated she was responsible for typing up the resident council minutes and then sending an email to the appropriate departments with specific grievances/concerns. The emails include a summary of concerns voiced during the resident council meeting, a form to fill out including the department's response, signature of department head, date completed, and date to return the form back to her. The AL confirmed that she had not received any resolutions to nursing department complaints/concerns in the past six months reviewed with this surveyor. During an interview with the Director of Nursing (DON) on 07/08/22 at 6:08 PM stated she was aware of one resident that recently complained of call light times. Staff were educated a few weeks ago and she was not aware of a trend regarding complaints/concerns. The DON stated she did not consistently run reports for call light response times, but her expectation was for staff to answer the lights within 10 to 20 minutes. In an interview with the Administrator on 07/08/22 at 6:27 PM, revealed he was aware of extended call light response times for certain residents and the expectation would be to answer the call lights in a timely manner and let the resident know if there would be a delay in assisting them. The Administrator confirmed that the AL sends out emails to the department leads with notification of grievance/concerns, the department is expected to investigate and then notify the grievance officer with resolution. The expectation was also for the department head to return the form back to the AL with resolution. The Administrator was not aware that multiple grievances were not followed up on or investigated.