**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure that two Residents(R)93, and R107) of two residents sampled for restraints, were free from restraints. Specifically, R93 and R107 were observed seated in Broda chairs with chair alarms on, and with bed alarms situated on both of these beds. Additionally, there was no documentation that less restrictive methods were attempted. Continued use of the position alarms has the potential to cause a decline in physical functioning, including an increased dependance in activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, and risk for development of contractures. Findings include: Review of the facility's policy titled Restraint Policy dated 04/21, revealed, Policy Statement .restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Physical restraints are defined as any manual method, or physical, or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily .When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for need for restraints will be documented .Restrained individuals shall be reviewed regularly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 1. Review of R93's undated admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia, muscle weakness, unsteadiness on feet, difficulty walking, and history of falling. Review of R93's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/24, located in the EMR under the MDS tab with a Brief Interview of Mental Status (BIMS) score two out of 15, indicating the resident is severely cognitively impaired. Further review indicates resident was assessed as having chair and bed alarms. Review of R93's Physician Orders dated 02/14/24, located in the EMR under the Orders tab documented, Bed and chair alarms, check placement and function every shift and prn [as needed]. Review of R93's Care Plan dated 11/25/23 located in the EMR under the Care Plan tab documented, Falls: Resident is at risk for falls with or without injury related to antihypertensive medication, and history of falls. Interventions: .bed/chair alarms for poor safety awareness, check placement and function every shift and PRN. Observations on 10/29/24 at 2:30 PM and 10/31/24 at 12:30 PM, R93 was seated in a Broda wheelchair with a chair position alarm attached to the chair. During an interview on 10/31/24 at 1:39 PM, Registered Nurse (RN)2 was questioned concerning why R93 had position alarms located on his chair and bed. RN2 stated the resident is very impulsive and has had multiple falls. The alarms were put into place to prevent his falling. RN2 confirmed that there was no documentation in the EMR of the monitoring and assessment of the alarms. During an interview on 10/31/24 at 2:06 PM, the Nurse Practitioner (NP) was questioned why R93 had chair and bed alarms ordered. The NP responded that the resident has poor safety awareness, and has tried assorted sizes and shapes of wheelchairs, unsuccessfully. 2. Review of R107's undated admission Record located in the EMR under the profile tab, indicated R107 was admitted to the facility on [DATE], with diagnoses including fracture of right humorous, muscle weakness, Parkinson's disease with dyskinesia with fluctuations, and dementia. Review of R107's admission MDS with an ARD of 10/10/24, located in the EMR under the MDS tab with BIMS score of seven out of 15, indicating the resident was severely cognitively impaired. The resident required substantial/maximal assistance for all mobility activities. Review of R107's Physician Orders dated 10/11/24, located in the EMR under the Orders tab revealed an order for bed/chair alarm to bed/chair at all times, every shift. Review of R107's Care Plan dated 10/07/24, located in the EMR under the Care Plan tab documented, Falls: Resident is at risk for falls with or without injury related to weakness, medications. Interventions: initiated 10/11/24 Bed/chair alarm every shift. Check positioning and functioning every shift. Observation's on 10/29/24 at 1:17 PM, and 10/31/24 at 1:32 PM, R107 was seated in a Broda wheelchair with a chair position alarm attached to chair. During an interview on 10/31/24 at 1:32 PM, RN2 was questioned why did R107 have a chair and bed position alarms in place. RN2 responded that R107 has Parkinsons and dementia, he gets very impulsive and tries to stand and falls. When asked if the resident has the ability to stand, RN2 stated, No. RN2 added the alarms are to help keep him from falling. RN2 confirmed that there was no documentation in the EMR of the monitoring and assessment of the alarms. During an interview on 10/31/24 at 2:02 PM, the NP was questioned on why R107 has the chair/bed alarms. The NP stated the resident has Parkinsons and dementia, he is very impulsive and has a complete lack of safety awareness. The resident is a fall risk and is not a candidate for removal of alarms. During an interview on 10/31/24 at 2:26 PM, the Director of Nursing (DON) was questioned concerning the use of the chair and bed alarms for R93 and R107. The DON responded that she expected the alarms to be care planned, the interventions and monitoring to be conducted and documented. The DON confirmed that there were no assessments, monitoring, or other interventions attempted related to the alarms. The DON stated that fall prevention was not a valid use for the alarms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to revise the Preadmission Screening and Resident Review (PASARR) Level I for one of three residents (Resident (R) 34) reviewed for PASARR out of a sample of 29 residents when there was a new diagnosis of mental illness. This had the potential for a failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate. Findings include: Review of R34's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, single episode, and generalized anxiety disorder. A new diagnosis of schizoaffective disorder was added on 09/01/23. Review of R34's PASARR Level 1 Screening Form, with review date of 03/25/24 and located in the Misc tab of the EMR, revealed mental illness diagnoses of anxiety and depression. Psychotropic medications listed included quetiapine 25 milligrams (mg) and Zoloft 50mg. Review of R34's Progress Notes tab of the EMR revealed a Nurse Practitioner (NP) Encounter note dated 06/16/23 where the NP ordered Abilify (aripiprazole- an antipsychotic medication) 2mg daily for delusions and paranoia. Review of NP Encounter note dated 09/01/23 stated to give aripiprazole 2mg daily for schizoaffective disorder. Review of the Orders tab of R34's EMR revealed an order for aripiprazole 2mg daily for schizoaffective disorder dated 09/01/23. Review of R34's Care Plan in the EMR under the Care Plan tab revealed a focus area initiated on 12/05/23 for antipsychotics. Review of R34's quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 10/01/24, located in the MDS tab of the EMR, revealed Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. R34 had a diagnosis of schizophrenia (e.g., schizoaffective, and schizophreniform disorders) and received antipsychotic medication. Review of R34's EMR revealed there was no evidence of a new PASARR I screening after the facility added the schizoaffective disorder diagnosis. During an interview on 10/30/24 at 3:55 PM, the MDS Coordinator (MDSC) stated she entered the schizoaffective disorder diagnosis into the MDS when the NP documented it in a Progress Note. The MDSC reported she failed to inform the Social Services Director (SSD) who did the PASARRs of the new diagnosis and did not know if a new PASSAR screening was completed. During an interview on 10/30/24 at 4:34 PM, the SSD stated the facility was expected to complete a new PASARR Level I with a new diagnosis of schizoaffective disorder. The SSD was unable to locate a PASSAR completed by the facility which included the schizoaffective diagnosis. During an interview on 10/31/24 at 1:45 PM, the Director of Nursing (DON) stated she expected a new PASARR Level I to be completed when a resident had a new diagnosis of schizoaffective disorder. Review of the facility provided PASRR Training for Providers, dated 06/20/23, revealed, Referral to Level II for mental illness is not required for all applicants exhibiting behavior or adaptation problems. Only applicants who have or are suspected of having a serious mental illness must be referred to Level II. The checklist for mental illness indicators included diagnoses (confirmed or suspected): schizophrenia, . , and other mental disorder that may lead to a chronic disability ln cases where the individual is admitted to the nursing facility without the appropriate screening, the nursing facility will be responsible for completing the required screening and for arranging any specialized services or specialized rehabilitative services deemed necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review the facility failed to ensure for one Resident(R)295) of six residents sampled for accidents, maintained a safe, hazard free environment. Specifically, staff left a wooden chair next to the resident's bed and R295 supposedly hit her head on the arm of the chair, resulting in a laceration to her forehead that required sutures. Failure to ensure that residents have a safe and hazardous free environment could result in further accidents with injuries. Findings include: Review of R295's undated admission Record located in the electronic medical record (EMR), under the Profile tab indicated the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, difficulty in walking, and muscle weakness. Review of R295's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24 and the Brief Interview of Mental Status (BIMS) score was three out of 15, indicating the resident was severely cognitively impaired and was assessed as not exhibiting behaviors. The resident was wheelchair bound and dependent on staff for all activities of daily living (ADLs), including mobility in and out of bed. Further review of the MDS indicated the resident had sustained a fall with fracture within six months of admission to facility. Review of R295's Fall Risk Assessment dated 07/21/24, located in the EMR under the Evaluation tab, indicated the resident's fall score was 32, indicating the resident was a high fall risk. The assessment indicated a score of 16-42 indicated high fall risk. Review of R295's Care Plan dated 05/16/24 and revised on 06/20/24 indicated, resident is at risk for falls with or without injury related to altered mental status, antihypertensive medication, antipsychotic medication, history of falls, and unsteady gait. Interventions included: keep bed in low position with brakes locked, keep call light within reach, keep personal items frequently used within reach, keep within supervised view as much as possible, safety devices as ordered: fall mat beside low bed when resident is in bed. Review of the Initial Report, dated 09/05/24 at 1:35 PM, revealed, Resident observed with a small left eyebrow laceration and hematoma. Resident was sent to the emergency room (ER) for evaluation and treatment. Resident returned to facility with six sutures to her left eyebrow. The 5-day investigation report, submitted by the Director of Nursing (DON) indicated, On the morning of September 5, 2024, Administrator, Assistant DON (ADON), and DON went into R295's room to evaluate her and her room. The resident was in bed. She was noted to have sutures intact to her left eyebrow. Her bed was in a low position with a fall mat beside her bed. There was a wooden chair at her bedside with the arm of the chair at the level of the blood, there was noted to be a small amount of blood on the right chair arm. CNA (Certified Nurse Aide) stated she used the chair to feed the resident if she is still in bed, and never thought it would be a potential problem. The wooden chair was removed from the room and a recliner was placed. During an interview on 10/31/24 at 11:33 AM, CNA2 stated that the night shift CNA (CNA1's name) noticed the bruise on R295. CNA2 was questioned concerning R295's mobility, and behaviors. CNA2 stated R295 could be combative at times and was a total assist. The resident spoke incoherently, and sometimes CNA2 fed R295 her meal in her room. During an interview on 10/31/24 at 11:57 AM, Registered Nurse (RN)1 was questioned about the incident with R295. RN1 stated that she was in another cottage, and just left there, approximately 9-9:30 AM. CNA1 stopped her and told her (R295's name) had blood all over her head and that she (CNA1) had called the supervisor and left a voice mail. RN1 stated that she entered F295's room and the resident was lying in bed with her head tilted a little bit. RN1 stated that she assessed her wound, called emergency medical services (EMS), and that a wooden chair was sitting in front of resident, facing the resident. RN1 stated R295 was not alert and oriented, was incomprehensible, and that she has never seen her get up. During an interview on 10/31/24 at 12:30 PM, CNA1 stated that she was making rounds, and when she entered the resident's room, she saw that R295 had blood all over her face, clothing, and sheet. She immediately called the supervisor, there was no answer, she left a voicemail and went to get the nurse. Stated she did not recall if there was a chair in the room or not. During an interview conducted on 10/31/24 at 3:21 PM, the DON stated she went to see the resident who was lying in bed and unable to tell her what had happened. There was a wooden chair right at the level of the bed. The DON stated that she started an investigation, interviewed staff and other residents. CNA1 told her she found the resident like that and that she had notified the supervisor. When asked why the chair was at the bedside, CNA1 told her it was used to feed the resident. The DON noticed a small amount of blood on the chair's arm. CNA1 told her she doesn't remember leaving the chair there. The DON reached the conclusion that the resident pulled the chair onto her causing the laceration to the eyebrow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy reviews the facility failed to ensure that one Resident(R)93 of five residents sampled for unnecessary medications was monitored for behaviors, side effects and efficacy of an antipsychotic medication. The failure to monitor for adverse effects and efficacy does not ensure the safe administration and dosing of the resident's antipsychotic medications. Findings include: Review of the facility's policy titled Antipsychotic Medication Use dated 07/22 indicated, staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: general/anticholinergic: constipation, blurred vision, dry mouth urinary retention, sedation. Cardiovascular: orthostatic hypotension, arrhythmias. Metabolic: increase in total cholesterol triglycerides, unstable or poorly controlled blood sugar, weight gain; or Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke, or TIA [Transient Ischemic Attack]. Review of R93's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including anxiety disorder, Parkinson's disease with dyskinesia, and dementia. Review of R93's Physician Orders dated 10/19/24, located in the EMR under the Orders tab, revealed an order for Quetiapine Fumarate (an antipsychotic medication) 25 milligram (mg) at bedtime for Parkinson's psychosis. Review of R93's October Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no monitoring of behaviors, efficacy, or side effects related to the antipsychotic medication administered. During an interview on 10/31/24 at 1:37PM, Registered Nurse (RN)2 confirmed there was no documentation of the monitoring of behaviors, efficacy, or side effects for R93's use of antipsychotic medication, and that there should have been. During an interview on 10/31/24 at 2:20 PM, the Director of Nursing (DON) was questioned concerning what the expectation of staff was monitoring for behaviors, efficacy, and adverse reactions to antipsychotic usage. The DON responded that the orders for antipsychotic medications are to be flagged for behavioral monitoring and side effects. The DON stated it was missing during chart audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, interview, and observation, the facility failed to report, to the state agency, an allegation of sexual abuse involving Resident (R)1's and R2's, for 2 of 2 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Report and Investigation last revised in August 2022, revealed, All reports of resident abuse . are reported to local, state, and federal agencies . Findings of all investigations are documented and reported. 1. c. Resident to resident altercations-Sexual Contact- Required to report immediately but no later than 2 hours- . Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy, hypertension, Type 2 Diabetes Mellitus, GERD, anxiety disorder, suicidal ideation, depression, and Dementia with behavior disturbances. Review of R1's Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 04/30/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 was severely cognitively impaired. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: atrial fibrillation, Type 2 Diabetes Mellitus, COPD, Chronic Kidney Disease, duodenitis without bleeding, and hypoglycemia. Review of R2's Quarterly MDS with an ARD of 03/19/24, revealed R2 had a BIMS score of 13 out of 15, indicating R2 was cognitively intact. During an interview on 05/30/24 at 11:16 AM, Certified Nursing Assistant (CNA)1 revealed on the night of the allegation, she knocked on R1's door to provide care but the door was blocked. CNA1 states she went to get the nurse because she could not get into the room. When the door was opened, both residents were disrobed and standing beside the bed. CNA1 further stated that R1 was upset, yelling, and crying, stating she did not mean to do it. During an interview on 05/30/24 at 11:40 AM, Registered Nurse (RN)1 revealed that when the door was open, she found both residents disrobed from the waist down. R2 was asked to leave the room and he became very upset and said he was not going anywhere, because R1 asked him to come into her room. RN1 states that she spoke to R1 after R2 left the room and R1 stated that R2 did not do anything wrong, and R1 asked him to come into the room. RN1 further stated that R1 was upset because she was embarrassed about the incident. RN1 states R2 was sent out to the ER because he became upset and non-compliant after being told he could not go back into the room. RN1 states that R2 did not have a history of inappropriateness towards any other resident. During an interview on 05/30/24 at 3:50 PM, the Nurse Practitioner (NP) revealed that he spoke with R1 the day after the incident. The NP states at first, R1 denied the allegation, but eventually stated, she initiated it, and she did not want that man to get into trouble because he did not do anything wrong. The NP stated that R1 asked R2 into her room because she wanted to be with someone and R2 was the only man that was ambulatory on the unit, so that's why she chose to invite him into her room. During an interview on 05/30/24 at 3:55 PM, the Assistant Director of Nursing (ADON) revealed R2 was more abrasive when trying to talk to about the allegation. R2 kept saying she invited me in. the ADON states the police were called to make a report, but did not file a report because R1 expressed it was consensual. During an interview on 05/30/24 at 4:50 PM, the Director of Nursing (DON) revealed that she did not report the incident to the state agency because the incident was consensual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, interview, and observation, the facility failed to report, to the state agency, an allegation of sexual abuse involving Resident (R)1's and R2's, for 2 of 2 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Report and Investigation last revised in August 2022, revealed, Findings of all investigations are documented and reported. 1. c. Resident to resident altercations-Sexual Contact- Required to report immediately but no later than 2 hours- . Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations . 7. The individual conducting the investigation as a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. l. Documents the investigation completely and thoroughly. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy, hypertension, Type 2 Diabetes Mellitus, GERD, anxiety disorder, suicidal ideation, depression, and Dementia with behavior disturbances. Review of R1's Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 04/30/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 was severely cognitively impaired. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: atrial fibrillation, Type 2 Diabetes Mellitus, COPD, Chronic Kidney Disease, duodenitis without bleeding, and hypoglycemia. Review of R2's Quarterly MDS with an ARD of 03/19/24, revealed R2 had a BIMS score of 13 out of 15, indicating R2 was cognitively intact. During an interview on 05/30/24 at 11:40 AM, Registered Nurse (RN)1 revealed, she found both residents disrobed from the waist down. R2 was asked to leave the room and he became very upset and said he was not going anywhere, because R1 asked him to come into her room. RN1 states that she spoke to R1 after R2 left the room and R1 stated that R2 did not do anything wrong, and R1 asked him to come into the room. RN1 further stated that R1 was upset because she was embarrassed about the incident. RN1 states R2 was sent out to the ER because he became upset and non-compliant after being told he could not go back into the room. RN1 states that R2 did not have a history of inappropriateness towards any other resident. During an interview on 05/30/24 at 3:55 PM, the Assistant Director of Nursing (ADON) revealed R2 was more abrasive when trying to talk to about the allegation. R2 kept saying she invited me in. The ADON states the police were called to make a report, but did not file a report because R1 expressed it was consensual. During an interview on 05/30/24 at 4:50 PM, the Director of Nursing (DON) revealed that she did not report the incident to the state agency because the incident was consensual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, interview and record review, the facility failed to ensure 1 of 1 resident reviewed for medications was free of significant medication errors. Resident (R)2 was not administered medications as ordered that were prescribed by a physician. Findings include: Review of the facility's policy titled Documentation of Medication Administration with a revised date of April 2018 revealed The facility shall maintain a medication administration record to document all medications administered. Review of a Face Sheet revealed R2 had diagnoses including but not limited to heart Failure, type 2 diabetes, muscle weakness, anxiety disorder, major depressive disorder. Review of a quarterly MDS dated [DATE] revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Review of R2's Medication Orders revealed R2 was prescribed Amoxicillin Capsule 500 mg on 05/06/23 with the directions to Give 4 capsule by mouth one time a day for dental procedure for 1 day with a start date of 05/09/23. Review of R2s Progress Note titled Infection Note dated 05/06/23 at 12:00 PM revealed resident continues on abt tx, no s/sx of any adverse reactions noted, resident is able to make needs known, resident also started on a amoxicillin today for 4 days r/t dentist appointment on may 9th, as a preventative. Review of R2's Progress Note dated 05/08/23 revealed Amoxicillin Oral Tablet 500 MG Give 4 tablet by mouth one time only for 4 TABLETS for prophylaxis before dental appt tuesday for 1 Day resident needs to take tomorrow Review of R2's Medication Administration Record revealed that on 05/06/23 at 1300 R2 was given 4 capsules of Amoxicillin 500 mg. Further review of R2's MAR revealed that on 05/09/23 R2 was not administered Amoxicillin 500 mg as ordered. During an interview on 06/15/23 at 3:15 PM, R2 reported not receiving his Amoxicillin correctly on multiple occasions. R2 reported that a nurse gave him 1 tablet of Amoxicillin on a Saturday and told him that is it what the doctor ordered. R2 stated he is ordered to receive 4 tablets, 1 hour before his dentist appt, and that over the course of 4 to 5 days he received 8 tablets and from that he had diarrhea for multiple days after. R2 also reported that he voiced his concerns of receiving the wrong medication from a nurse on night shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a comfortable and homelike environment was provided for 3 (Resident (R)1, R2 and R3) of 3 sampled residents whose rooms and common areas were reviewed. Specifically, the facility failed to properly clean resident rooms and common areas and failed to follow their Homelike Environment policy. Findings include: Review of facility policy titled, Homelike Environment revised in 02/21 stated, Resident are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment;. Review of a Face Sheet revealed R1 had diagnoses including but not limited to displaced Trimalleolar fracture of right lower leg, low back pain , generalized anxiety, sprain of unspecified ligament of left ankle. Review of admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/23 revealed there was no MDS data available. Review of a Face Sheet revealed R2 had diagnoses including but not limited to heart Failure, type 2 diabetes, muscle weakness, anxiety disorder, major depressive disorder. Review of a quarterly MDS dated [DATE] revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), indication the resident was cognitively intact. Review of a Face Sheet revealed R3 had diagnoses including but not limited to difficulty in walking, Pneumonia, Polyosteoarthritis, dysphagia, anxiety, unsteadiness on feet. Review of a quarterly MDS with an ARD of 05/24/23 revealed the resident scored 13 on a BIMS, indicating that the resident was cognitively intact. Observation on 06/15/23 at 9:55 AM of Crepe [NAME] cottage revealed dust and debris in the common area on various items. Observation on 06/15/23 at 9:59 AM, [NAME] Cottage revealed a dirty linen cart and trash cans with no bags in rooms [ROOM NUMBERS]. Copious amounts of dust and dirty was also observed in the common area on the counter and on other various items. Observation on 06/15/23 at 10:04 AM of Camelia Cottage revealed dirty line cart dusty counters and black around the corners of the floors in resident bathrooms and rooms. Observation on 06/15/23 at 10:08 AM of Dogwood Cottage revealed a dirty linen cart. Observation on 06/15/23 at 10:13 AM of the [NAME] Cottage revealed wet tissue in the shower drain in room [ROOM NUMBER]. Observation on 06/15/23 at 10:18 AM of Forsythia Cottage revealed no trash bags in the trash cans in multiple resident rooms. A empty and unused resident bed was observed sitting in the hall and dust was observed on the counter. Observation on 06/15/23 at 10:22 AM of the [NAME] Cottage revealed dirty linen carts and dust in the common area on several items, and trash bags missing from the cans. Observation on 06/15/23 at 10:26 AM of the Tea Olive Cottage revealed dirt crumbs and dust on the counter in the common area. Observation cottage on 06/15/23 at 10:30 AM of the Rhododendron Cottage revealed a dirty line cart with black stains on it and a dusty counter in the common area. Observation on 06/15/23 at 10:30 AM of the Lilac Cottage revealed resident rooms [ROOM NUMBERS] with no trash bag in the cans. Observation on 06/15/23 at 10:34 AM of the Magnolia Cottage revealed artificial flowers in the common area covered in dust and the counter covered with dust and debris. Observation on 06/15/23 at 10:39 AM the [NAME] Cottage revealed dust and debris in the common area on several items and equipment. Observation on 06/15/23 at 1:25 PM of room [ROOM NUMBER] located in the [NAME] Cottage revealed a loose sink faucet in the bathroom and a black substance on the floors, there was not a phone located in the room and there was damage to one wall exposing the white interior. There was a wet tissue paper roll sitting on the handrail. During an interview on 06/15/23 at 11:25 AM, R1 stated her room was not clean upon her arrival on the morning of 06/09/23, it did not have phone and the outlet located behind the bed was covered in soot from what appeared to be an previous electrical shortage. R1 stated that there was dust on her lamp shade and that the bathroom floors looked as if they had not been clean in a while. During an interview on 06/15/23 at 1:32 PM, the Environmental Supervisor (EVS) stated that she provide housekeepers with a daily and weekly task list. The EVS states her expectations are to sweep, mop, wipe all surfaces, and clean common areas daily. The EVS also stated that on Fridays they dust the cottages. EVS revealed that they only wash the cloth coverings on the linen carts if they have blood or other bodily fluids on them. During an interview on 06/15/23 at 3:15 PM, R2 stated that he reported the mold on his ceiling to CNAs and has reported it during resident council meetings. R2 reported that housekeeping does not always clean his room and sometimes the just dump the trash and that's all. During an interview on 06/15/23 at 5:15 PM, Certified Nursing Assistant (CNA) stated that housekeeping services at the facility could be better, she also noted that all staff members are responsible for taking out the trash in resident room and not just housekeeping. CNA stated that she was working the night that R1 was at the facility and don't remember if she saw housekeeping clean the resident's room. An attempt was made to interview Licensed Practical Nurse (LPN)1 with no success.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled, admission Assessment and Follow Up: Role of the Nurse, record reviews and interviews, the facility failed to accurately assess, upon admission Resident (R)1, in order to initiate a baseline care plan that included all the needs to give accurate, quality care for R1. Specifically the baseline care plan for R1 did not include isolation for Flu and the need for oxygen. The facility further failed to complete an accurate admission assessment to include Flu and the need for oxygen. Findings include: Review of the facility policy titled, admission Assessment and Follow Up: Role of the Nurse, states, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set) assessment. Review on 04/11/2023 at 10:28 AM of the Baseline Care Plan for R1 included oxygen therapy, however it did not indicate the route of administration.The admission assessment dated [DATE] revealed no indication of R1 requiring oxygen, no amount per nasal cannula and his need for oxygen. The admission Assessment states under section F. Respiratory 1a. states no shortness of breath and 1b. no equipment. Review on 04/11/2023 at 11:45 AM of the hospital discharge orders dated 12/09/2022 revealed diagnoses of chronic obstructive disease, shortness of breath, and a pulmonary nodule. Further review of the discharge summary for R1, indicated a diagnosis of Flu. The orders also indicated that R1 had had surgery for a femoral fracture and during repair surgery he required oxygen at 4 liters per minute. He usually requires 2 liters per nasal cannula at night. Additional review of R1's baseline care plan did not indicate his active diagnosis of Flu or the need for isolation. During an interview on 04/11/23 at 12:08 PM with Licensed Practical Nurse (LPN)1, the nurse who received the R1 at time of admission, could not remember R1, the assessment nor the baseline care plan. However, LPN1 confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled, Medication Orders,resident discharge summary, medical record reviews, and interviews, the facility failed to ensure Resident (R)1 received ordered medication timely. Findings include: Based on review of the facility policy titled, Medication Orders, revealed, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Under recording orders, #3 states, When recording orders for oxygen, specify the rate of the flow, route and rational. The facility failed to ensure physician ordered medications were administered for R1, a new admission in a timely manner. Review of the discharge summary from the hospital, R1 was to receive oxygen therapy for diagnoses including, but not limited to chronic obstructive pulmonary disease, shortness of breath and a pulmonary nodule. R1 had a diagnosis of Flu 2 (two) days prior to admission into the facility. Review of the Medication Administration Record (MAR) on 04/11/23 at 10:20 AM revealed R1 was admitted to the facility on [DATE] in the afternoon. The exact time of admission is not recorded. The MAR indicated that R1 did not receive his 5:00 PM, 9:00 PM, and 10:00 PM medications. He also had missed the 5:00 PM dose on 12/09/2022 and the 9:00 AM dose of Tamiflu on 12/10/2022 ordered to be given 2 times daily. The medications missed were Atorvastatin Calcium 40 milligrams (mgs) at bedtime on 12/09/22 and Melatonin 3 mgs at 9:00 PM on 12/09/2022. R1 had also missed Sinemet CR extended release 50-200 mg for Parkinson's Disease to be given at 9:00 PM and Trazodone HCI 50mg for Insomnia. He had missed Aspirin chewables 81 mg at 5:00 PM. Additional medications not received on 12/09/2022 included Acetaminophen 1000 mgs at 10:00 PM for mild pain and another dose of Carbidopa-Levodopa 25-100 mgs at 10:00 PM. During an interview on 04/11/2023 at 11:45 AM, the Director of Nursing stated that when residents come in the afternoon, the facility has no way of getting medications until the next day. She denied having a back up pharmacy. An interview on 04/11/2023 at 12:15 PM with the Nurse Consultant (NC) confirmed that the facility does have a backup pharmacy. The NC could not verify why the medications were not retrieved from the backup pharmacy.

Based on review of the facility policy titled, Isolation - Initiating Transmission - Based Precautions, the facility failed to ensure Resident (R)1, who was admitted with a diagnosis of Flu was placed on isolation at admission for 1 of 2 residents admitted with the Flu virus. Findings include: Based on the facility policy titled, Isolation - Initiating Transmission - Based Precautions, states as the policy statement, Transmission- Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission -Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. The facility makes every effort to use the least restrictive approach to managing individuals, with potentially communicable infections. Transmission-Based Precautions are used only when the spread of infection cannot be reasonable prevented by less restrictive measures. Number 3 states under the Policy Interpretation and Implementation, : When Transmission-Based Precautions are implemented, the Infection Preventions (or designee): a. Clearly identified the type of precautions, the anticipated duration, the personal protective equipment (PPE) that must be used. d. states, Determines the appropriate notification on the room entrance door and on the front of the resident's chart. The signage informs the staff of the type of CDC precaution (s), instructions for use of PPE, and/or instructions to see a nurse before entering a room. R1 was not put on Transmission - Based Precautions for a diagnoses of the Flu upon admission. Review on 04/11/2023 at 10:50 AM of the admission Assessment for R1 is checked for Standard Precautions, and no indications that R1 was placed on Transmission - Based Precautions upon admission. During an interview on 04/11/2023 at 12:15 PM, the Director of Nursing did agree and state that if a resident is admitted and has a diagnosis of Flu that should be placed on Transmission - Based Precautions at time of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual used as facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessment for one of 30 sampled residents (Resident (R) 113) was accurate. R113's MDS was not accurately coded to indicate the resident was receiving dialysis services related to end stage renal disease. The failure to accurately code/assess the resident's condition has the potential to affect the care planning for the resident to receive all required services. Findings include: Review of R113's admission Record from the electronic medical record (EMR) revealed the resident was admitted on [DATE] with medical diagnoses that included end stage renal disease. Review of R113's EMR Orders tab showed a physician order for Dialysis Center: . Days of treatment: MWF [Monday, Wednesday, Friday] . Chair time: 6am . The order was revised on 08/29/22 with a start date of 08/31/22. Review of dialysis communication forms and progress notes in the EMR confirmed that the resident received dialysis as ordered. Review of R113's admission Minimum Data Set [MDS], with an assessment reference date (ARD) of 09/02/22 revealed that the resident's diagnosis of Renal Insufficiency, Renal Failure, or End Stage Renal Disease was accurately coded. However, the data set items for dialysis treatment were not checked, and the MDS failed to indicate that the resident received dialysis during the assessment period used for this MDS. During an interview on 09/14/22 at 4:15 PM, the MDS Director (MDSD) reviewed R113's 09/02/22 MDS assessment. Interview with the MDSD confirmed that the MDS was not accurate, with the MDSD stating the resident's receipt of dialysis, Should be coded in Section O [of the MDS]. No, it's not coded for dialysis. The MDSD stated an expectation that assessments would be coded correctly. Further interview on 09/14/22 at 4:29 PM with the MDSD revealed the facility uses the RAI (Resident Assessment Instrument) manual as their assessment policies. Review of the October 2019 Resident Assessment Instrument [RAI] Manual showed on pages O-2 and O-4: Steps for Assessment: Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days . Coding Instructions for Column 1 Check all treatments, procedures, and programs received or performed by the resident prior to admission/entry or reentry to the facility and within the 14-day look-back period. Leave Column 1 blank if the resident was admitted /entered or reentered the facility more than 14 days ago. If no items apply in the last 14 days, check Z, none of the above. Coding Instructions for Column 2 Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. Coding Tips .Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record treatments of hemofiltration, Slow Continuous Ultrafiltration (SCUF), Continuous Arteriovenous Hemofiltration (CAVH), and Continuous Ambulatory Peritoneal Dialysis (CAPD) in this item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to ensure 4 of 4 residents and/or their representatives (Resident (R) 13, R32, R114, and R134) reviewed for an emergent discharge to the hospital out of a total sample of 30 were provided with a written notice transfer notice that included all required information. The facility's transfer notice forms did not include information on how to appeal, if desired. In addition, although transfer forms prepared by the facility were provided to Emergency Medical Services (EMS) and the hospital where the resident was being transferred, the facility failed to assure that both the resident and their representative also received the forms. This failure has the potential to affect the resident and/or their Resident Representative (RR) in not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency, revised 08/2018, revealed, Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) . 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures . d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member. On 09/14/22 at 12:50 PM, the Administrator also provided a page from the admission packet that stated, (8) Termination of Agreement, Discharge and Transfer .The notice will set forth the reason for the transfer or discharge and the effective date of the transfer or discharge. The notice will also set forth Resident's rights to a hearing to appeal the Facility's decision to discharge or transfer Resident. 1. Review of R13's admission Record from the electronic medical record (EMR) showed a facility admission date of 03/29/21 with medical diagnoses that included Alzheimer's disease. Interview with R13's RR (RR13) on 09/13/22 at 12:14 PM revealed that R13 was sent to the hospital in June for a hip fracture after a fall in the facility. Review of the EMR Progress Notes tab revealed that, Effective Date: 06/06/22 07:06 [7:06 AM] Type: Health Status Note: Resident was walking in living room area when she lost balance and fell near the book shelf. Notified [management] and will notify [RR13]. Review of the EMR Census tab confirmed R13 was on Hospital Leave effective 06/08/22. Further review of the EMR revealed a Late Entry: Effective Date: 06/15/22 14:52 [2:52 PM] Type: Skin/Wound Note which showed the resident was readmitted to the facility after repair of a hip fracture Review of the resident's record revealed no evidence that a written notice, with all required information, was provided to both the resident and their representative at the time of the transfer to the hospital. In response to a request for evidence that a written notice was provided to all required parties at the time of transfer, the Director of Nursing (DON) provided a SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 06/07/22. Review of this form revealed that it was a communication form between the facility and receiving hospital, which included the location to which R13 was being sent, the reason and date of transfer, and other information, including the resident's functional status, vital signs, skin/wound issues, medications, devices, immunizations, risk alerts, and property sent to the hospital with the resident. Review of this form revealed that it did not include any information on how to appeal the transfer. During a follow-up conversation on 09/14/22 at 9:10 AM, RR13 confirmed that the facility did not provide a written transfer notice to them at the time the resident was sent to the hospital, stating, No, I didn't get anything in writing. They [facility] called me, told me she had a fall and had swelling in the leg. The mobile x-ray found a fracture, facility called and asked which hospital I preferred to send her to. Interview on 09/14/22 at 12:15 PM with Licensed Practical Nurse (LPN) 1 revealed that, in addition to the hospital transfer form provided by the DON, the facility also utilized another form, titled, Transfer/Discharge Notice. Review of a blank copy of this form referenced by LPN1 revealed that it also failed to include information on how to appeal a transfer or discharge. LPN1 stated that two copies of each form (the 'SNF/NF To Hospital Transfer Form' and the 'Transfer/Discharge Notice were made and placed in two packets - one for the hospital, and one for EMS. When asked about the provision of a written transfer notice to the resident and their RR, LPN1 stated One [packet with the form] may be given to the resident but it's for the hospital. When asked if the transfer form she filled out was copied for the resident and RR, LPN1 stated, No, one goes to the EMS packet and one to the hospital packet. The family may sign it if they are at the bedside, but one goes to EMS and one to the hospital. They [the resident and RR] don't get a copy. Although the forms referenced above may have been sent to the hospital with the resident, the DON was unable to provide evidence that a written transfer notice, with all required information, was also provided to the RR at the time the resident was transferred to the hospital. 2. Review of R32's EMR admission Record showed a facility admission date of 01/31/20 and a readmission date of 03/17/20. Per a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/22, the resident had moderate cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 11/15. During an interview on 09/12/22 at 12:46 PM, R32 stated he had been sent to the hospital when the facility ran out of his seizure medicine about two months ago. When asked if he had received a written notice of transfer, R32 responded, No, nothing in writing. Review of R32's EMR Progress Notes revealed, 7/11/2022 07:53 [7:53 AM] Nurses Note Note Text: Pt. is out to [name] hospital via stretcher by EMS [emergency medical services] r/t [related to] ongoing seizure activity. [RR] has been notified and requested him to be sent to [name] ER. Further review of the EMR progress notes did not reveal any documentation of the provision of a written transfer notice to either the resident or RR. In response to a request for evidence that the resident and their representative were both provided a written transfer notice which contained all required information, the DON provided a SNF/NF to Hospital Transfer Form, dated 07/11/22. The form noted where R32 was being sent, the reason, and date, as well as the resident's functional status, belongings sent, vital signs, skin/wound issues, medications, devices, immunizations, and risk alerts. This form failed to include the resident's appeal rights. Further review of the form which the facility provided to the hospital revealed no evidence that the form which was to be sent to the hospital was also provided to the resident, and their representative, as required by the regulation. Review of the documentation provided by the DON revealed that it did not include the Transfer/Discharge Notice form referenced above. During an interview on 09/14/22 at 10:53 AM, the DON stated, There are two packets, one has 'SNF/NF to Hospital' transfer form, med list and face sheet and is given to EMS for the hospital. The second has a handwritten form [transfer notice] and that should be copied put into first envelope so both packets have the same things. When asked when/if the RR is provided a written transfer notice and how it is provided, the DON stated, the RR is not sent a copy of the notice. The Regional Director of Clinical Services (RDCS), who was also present during the interview, added, Medical records was saying they notify [the RR], but it is only by telephone. In an interview on 09/14/22 at 12:06 PM, Unit Manager (UM) 1 stated, I called the wife. The transfer discharge notice goes with him [the resident]. When asked how/if the RR received a written copy of the transfer notice, UM1 replied She [the RR] can get a copy when she comes in or she can get a copy when she goes to see him in the hospital. UM1 stated the SNF/NF Transfer to Hospital form goes to the hospital but confirmed no one at the facility was sending the RR anything in writing. The DON, who was also present during this interview, stated that, When social services does discharges, they educate about appeal process, but it's not on this form. 3. Review of R114's closed record review for hospitalization revealed an 09/10/22 Health Status Note in the EMR Progress Notes tab indicating the Nurse Practitioner ordered the resident sent to the hospital for evaluation and treatment due to elevated creatinine levels. In response to a request for evidence that the resident and the RR were provided a written transfer notice with all required information, the DON provided a SNF/NF to Hospital Transfer Form, dated 09/10/22, that stated where R114 was being sent, the reason and date, as well as functional status, belongings sent, vital signs, skin/wound issues, medications, devices, immunizations, and risk alerts. The form failed to include any information about the resident's right to appeal the transfer. Review of the documentation provided by the DON revealed that it did not include the Transfer/Discharge Notice form referenced above. During an interview on 09/14/22 at 12:15 PM regarding the transfer, LPN1 stated, I was looking thru the [resident's] labs and the creatinine was 7.3 acute renal failure. I called the NP [name] and received an order to send out immediately. The wife was at the bedside. When asked about transfer paperwork provided, LPN1 responded, There are two copies of each, the face sheet, the MAR [medication administration record], the transfer form and the form with the bed hold information that I sign. There are two packets, one for the hospital. When asked if the other packet was for the resident, LPN1 continued Well, I gave it to the wife to give to the hospital. The two packets, one is for EMS and one is for the hospital. Asked to clarify if any paperwork was given to the resident or RR, LPN1 clarified, One may be given to the resident but it's for the hospital. When asked if the transfer form she filled out was copied for the resident and RR, LPN1 stated, No, one goes to the EMS packet and one to the hospital packet. The family may sign it if they are at the bedside, but one goes to EMS and one to the hospital. They [the resident and RR] don't get a copy. Interview with R114's RR on 09/14/22 12:24 PM confirmed she was not provided a written transfer notice with all required information. RR114 stated the facility gave her an envelope when the resident was sent out to the hospital; however, she was told to give the envelope to the hospital, adding I didn't get anything to keep. RR114 then double checked, looking in her bag and confirmed there was nothing. 4. Review of R134's Transfer/Discharge Report in the EMR Profile tab, showed an admission date of 04/12/22 with medical diagnoses that included iron deficiency anemia secondary to blood loss. Review of R134's EMR Prog Note [Progress Notes] tab revealed that on 04/16/22 at 10:36 AM, a note that the resident called for help. enter room pt [patient] was leaning on right side unable to stand. Pt had increased confusion unable to make needs known. all sx [symptoms] noted are a change from her baseline. notified supervisor, family and MD [doctor]. Review of a SNF to Hospital Transfer Form revealed that in response to the change in condition, the resident was transferred to the hospital. Further review of R134's EMR Prog Note and Misc [Miscellaneous] tabs revealed no evidence that either the resident and/or their RR were provided a written notice of transfer, with all required information including appeal rights, at the time the resident was sent to the hospital on [DATE]. A phone interview was conducted on 09/13/22 at 8:25 PM with R134's family member (FM134), who stated that they received a call between 10:00 AM or 11:00 AM on 04/16/22 from the RR (another family member), stating that a hospital had called about R134 needing a blood transfusion. Per FM134, the RR was not sure who had called him, or where R134 was currently located. When asked if R134's RR had received a written transfer notice, which included where R314 was transferred to and why, FM134 responded No, only the one call [RR] received asking for permission for the blood transfusion. Interview on 09/14/22 at 6:17 PM with the DON revealed there is a form signed at the time the resident is sent out it which talks about the transfer notice, bed hold rights, and other information which is sent with the resident to the hospital. In the situation with R134, the DON stated that verbal notice was given to the husband (RR) and then a copy of the transfer form was sent with the patient to be given to the hospital, and EMS also received a copy of the paperwork. The DON stated, It's like a two for one form. When asked about the written transfer notice required by regulation to be provided to the resident and the resident representative, the DON stated, I am aware there must be ink on the paper and we make every effort to do. The types of efforts include if they are here and the patient is cognitively enough, if not the verbal [notification] show more of a good faith effort, or nursing notes types up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure 4 of 4residents (Resident (R) 13, R32, R114, and R134) reviewed for hospitalization and/or their Resident Representative (RR) received a written bed hold notice upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital. Findings include: 1. Review of R13's admission Record from the electronic medical record (EMR) revealed a facility admission date of 03/29/21. Review of a SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 06/07/22, revealed R13 was being sent to the hospital. Review of the EMR Census Tab revealed R13 was on Hospital Leave effective 06/08/22. Further review of the EMR revealed no evidence of the provision of a written bed hold notice to either the resident or RR at the time of this transfer. In response to a request for evidence that a written bed hold policy was provided to R13 or her RR, the facility provided a signed copy of an 03/29/21 Brushycreek [sic] Post Acute Nursing Home Agreement. Review of this form revealed that Page 10 included the Facility Bed Hold Policy. However, although the Director of Nursing (DON) provided evidence that the resident and RR received a copy of the bed hold policy at the time of admission in 2021, no evidence was provided that a copy of the bed hold notice was also provided at the time of the resident's transfer to the hospital in 06/2022. During an interview on 09/14/22 at 9:10 AM regarding receipt of a written bed hold policy at the time of the 06/2022 transfer, RR13 stated, I didn't have any idea they had the option of holding a bed after the 10 days. RR13 confirmed they did not receive written documentation of the facility's bed hold policy at the time that R13 was transferred to the hospital in 06/2022. 2. Review of R32's EMR admission Record showed a facility admission date of 01/31/20 and a readmission date of 03/17/20. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/22, revealed the resident had moderate cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 11/15. During an interview on 09/12/22 at 12:46 PM, R32 stated he had been sent to the hospital about two months ago when the facility ran out of his seizure medicine. When asked if he had received a written bed hold policy at that time, R32 stated he did not remember receiving anything in writing about a bed hold. Review of R32's EMR Progress Notes revealed, 7/11/2022 07:53 [7:53 AM] Nurses Note Note Text: Pt. is out to [name] hospital via stretcher by EMS [emergency medical services] r/t [related to] ongoing seizure activity. [RR] has been notified and requested him to be sent to [name] ER. In response to a request for evidence that a written bed hold policy was provided to R32 and his RR, the facility provided an 01/31/20 signed copy of a Brushycreek [sic] Post Acute Nursing Home Agreement which included bed hold information on page 10. Although the DON provided evidence that a copy of the bed hold notice was provided at the time of admission in 2020, the DON was unable to provide evidence that a written copy of the bed hold notice was also provided, per the regulation, to both the resident and their RR at the time of the 07/11/22 transfer to the hospital. During an interview on 09/14/22 at 10:53 AM regarding written bed hold policy provision, the Regional Director of Clinical Services (RDCS) stated, Just reading the regulation for [bed hold policies] where the admission bed hold notice is not enough. 3. During a closed record review for hospitalization, review of R114's EMR admission Record showed an admission date of 08/30/22. Further review of the EMR Progress Notes tab revealed an 09/10/22 Health Status Note that the resident was being sent out to the hospital for evaluation and treatment due to elevated creatinine levels. In response to a request for documentation a written bed hold policy was provided to R13 or her RR, the facility provided a signed copy of an 08/30/22 Brushycreek [sic] Post Acute Nursing Home Agreement which included the bed hold policy. Although the DON provided evidence that a copy of the bed hold notice was provided at the time of admission in 2022, the DON was unable to provide evidence that a written copy of the bed hold notice was also provided, per the regulation, to both the resident and their RR at the time of the 09/10/22 transfer to the hospital. During an interview on 09/14/22 at 12:15 PM, Licensed Practical Nurse (LPN) 1 stated there were two copies of various forms completed at the time of transfer, including, the form with the bed hold information that I sign. There are two packets, one for the hospital. When asked if the other packet was for the resident, LPN1 continued Well I gave it to the wife to give to the hospital. The two packets, one is for EMS, and one is for the hospital. Asked to clarify if any paperwork was given to the resident or RR, LPN1 clarified, One may be given to the resident but it's for the hospital. When asked if the form she filled out was copied for the resident and RR, LPN1 stated, No, one goes to the EMS packet and one to the hospital packet. The family may sign it if they are at the bedside, but one goes to EMS and one to the hospital, they [resident and RR] don't get a copy. Interview with R114's RR on 09/14/22 12:24 PM, confirmed she was given an envelope at the time of the transfer, but was told to give it to the hospital. RR114 denied being given written information about the facility's bed hold notice at the time of the resident's transfer, stating, I didn't get anything to keep. RR114 then double checked, looking in her bag and confirmed there was nothing. In an interview on 09/14/22 at 10:08 AM regarding written bed hold notices upon emergent discharge, Unit Manager (UM) 2 stated, No, they get that in the packet they sign on admission. UM2 verified that a bed hold notice is not provided at the time a resident is transferred emergently. 4. Review of R134's Transfer/Discharge Report (a report with demographic and limited medical information) from the EMR Profile tab, showed an admission date of 04/12/22 with medical diagnoses that included iron deficiency anemia secondary to blood loss. Review of R134's EMR Prog Note [Progress Notes] tab showed a note on 04/16/22 at 10:36 AM that the resident had a change from her baseline, and staff notified the supervisor, family, and physician. Per a SNF /NF to Hospital Transfer Form, the resident was transferred to the hospital on [DATE] in response to this change in condition. Further review of R134's EMR in the Documents tab under the section, Admissions Packet, revealed a copy of a Bed Hold Notification form that was completed upon admission on [DATE]. No other documentation was found in the EMR regarding written information about the facility's bed hold policies also being provided to R134 or his representative upon his transfer to the hospital on [DATE]. During a phone interview on 09/13/22 at 8:25 PM with a family member (FM134), she stated that she received a call between 10:00 AM or 11:00 AM on 04/16/22, from the RR (a different family member) stating a hospital had called about R134 needing a blood transfusion. When asked if R134's RR had received written information about the facility's bed hold policy at the time the resident was transferred to the hospital, FM134 No, only the one call [RR] received asking for permission for the blood transfusion. Interview on 09/14/22 06:17 PM with the DON revealed that at admission, the Social Worker and whoever does the admission talks about bed hold and what the possible outcomes will be, such as if you are sent home and what might happen and if they need home health etc . Also, during admission discussion are held about the bed holds. In the situation with R134, the DON stated that verbal information (not a written notice) was provided to the husband (RR) at the time of the transfer to the hospital. The DON stated, I am aware there must be ink on the paper and we make every effort to do. The types of efforts include if they are here and the patient is cognitively enough, if not the verbal show more of a good faith effort, or nursing notes types up. The DON confirmed that a written bed hold notice was not sent to the RR at the time of the resident's transfer to the hospital stating that, Forms are not mailed, the original forms are sent with the resident, to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, family interview and staff interview, the facility failed to consult with the resident's physician and provide notification when the resident missed multiple doses of a controlled medication for seizures for one (1) of one (1) sampled residents (Resident #269). Findings include: Review of the policy titled Change in a Resident's Condition or Status (revised May 2017) revealed the policy statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Review of the policy titled Documentation of Medication Administration (revised April 2007) revealed the policy statement: The facility shall maintain a medication administration record to document all medications administered. Review of Resident #269's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Encephalopathy, Aphasia following Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Communicating Hydrocephalus, Malignant Melanoma of Nose, Malignant Neoplasm of Frontal Lobe and Muscle Weakness. Review of Resident #269's most recent admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had a Brief Interview for Mental Status (BIMS) score of six (6) of 15, indicating the resident had a severe cognitive impairment. The resident was not coded for any maladaptive behaviors including physical, verbal, rejection of care or wandering. The resident was coded for extensive assistance and one-person assist for the following: bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the Physician's Orders revealed Resident #269 was prescribed the anticonvulsant antiepileptic medications (Vimpat) Lacosamide Tablet 200 milligrams (mg), give one (1) tablet by mouth two (2) times a day for seizures and levetiracetam Tablet 750mg, give two (2) tablets by mouth two (2) times a day for seizures. Review of the Warnings and Precautions for Vimpat revealed the warnings: In patients with seizure disorders, VIMPAT should be gradually withdrawn to minimize the potential of increased seizure frequency and Do not stop taking VIMPAT without first talking to your healthcare provider. Stopping VIMPAT suddenly can cause serious problems. Review of Resident #269's Care Plan, dated 5/2/2021, revealed that the resident was care planned for a diagnosis of seizure disorder. Interventions included: Labs per order, notify MD of results; Medication per order; Monitor for side effects of medication and Notify MD of any seizure like activity. Review of the Nurse's Notes for Resident #269 revealed that refusals for the 2nd dose of Vimpat on 4/24/21 and two (2) doses of Vimpat on 4/25/21 were not recorded. There was no documentation indicating the NP or attending physician was notified of the medications not being administered on 4/24/21 and 4/25/21. Further review revealed that there was no documentation indicating the NP or attending physician was notified of the medications not being administered on 5/4/21. There were late entries on 5/13/21 and 5/19/21 but they did not indicate that the attending physician was notified. The notes didn't include documentation that the resident was combative, agitated or the reason for the refusal. The notes included the following: - 4/24/21, 8:00 a.m. - electronic Medication Administration Record (eMar) - Medication Administration Note. Note Text: Lacosamide Tablet 200 mg, Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Pt refused to take medicine even nurse explained importance of it. Daughter was at window this time visiting her. - 4/24/21, 9:33 a.m. - eMar - Medication Administration Note. Requested by External System - Note Text: Lacosamide Tablet 200 mg, Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations - 4/25/21, 10:54 p.m. - Social Service (SS) Note: Note Text: 5 Day Assessment: SS met with Resident to conduct her five (5)-day assessment. The Residents needs are met by the staff. The Resident scored a zero-six) 06 for cognition indicating severe impairment. Resident scored a zero-four (04) for mood indicating minimal depression. The Resident is actively participating in therapy. No discharge (DC) dates at this time. SS will observe for changes. - 5/6/21, 12:00 p.m. - Nurse's Note: Note Text: at approx. 11am this nurse called to res room. res sitting on the toilet having active seizure activity. res is lethargic and diaphoretic. res assisted to bed with staff assistance. Blood Pressure (b/p) elevated at 199/97, heart rate (hr) 98. Oxygen (02) saturations 99%. blood sugar taken and is 300. NP #1 notified and came to building to evaluate pt. new orders on chart. res daughter made aware of seizure activity and new orders. Resident is resting calmly in bed at present. b/p is 119/72 and insulin coverage provided for elevated blood sugar. - 5/7/21, 11:27 a.m. - Nurse's Note: Note Text: called to res room by NP #1 Np r/t res having active seizure. np states res had been seizing for seven (7) minutes at that point and needed to go to the ER. 911 called for emergency transport to Greenville Memorial. res daughter made aware of res condition and pending transfer to the hospital. res daughter asked to speak with NP and did converse with her. EMS arrived in facility and transported res to ER via stretcher. - 5/7/21, 1:32 p.m. - eMar - Medication Administration Note: Note Text: leave of absence (loa) to emergency room (ER). - 5/7/21, 7:25 p.m. - eMar - Medication Administration Note: Note Text: hospital. A review of the Controlled Medication Utilization Record for Vimpat revealed that there was no indication that the medication had been signed out and administered on 4/24/21 and 4/25/21 to Resident #269. Further review of the record revealed that the medication was only signed out for one (1) dose on 5/4/21. The record indicated that a total of five (5) doses (1000 mg) were not recorded as signed out, administered, or wasted between 4/22/21 and 5/4/21. Review of the Medication Administration Record (MAR) revealed that the record was marked to indicate that Resident #269 refused the medication Vimpat on 4/24/21, 4/25/21 and 5/4/21 for a total of six (6) doses which does not match the information on the Controlled Medication Utilization Record or the nurse's notes for 5/4/21. Interview with Licensed Practical Nurse (LPN) #1 on 5/19/21 at 9:45 a.m. on Unit 109. LPN #1 confirmed that s/he recalled Resident #269. The nurse stated that the Resident #269 would be combative at times and knocked over his/her medications in late April during medication pass. The nurse stated that s/he documented on the Medication Administration Record (MAR) that the medication was refused by the resident. The LPN stated that Resident #269's family was present and felt that their presence contributed to the resident's combative behavior and agitation. The nurse added that the resident wanted to leave and would be upset when family was visiting. The nurse noted that on one occasion in May when the resident refused the medication, s/he went back to the resident to give a dose of Vimpat. The nurse recalled having conversations with the family, who urged him/her to give the medication. An inquiry was made regarding the process for documentation of the resident's refusals. The nurse indicated that s/he documented the MAR to note the refusals. LPN #1 stated that s/he should have also documented the refusals and combativeness in the nurse's notes. The nurse noted, that since it was a controlled medication, s/he also should have notified the physician of the refusals, incidents and documented it in the nurse's notes. A telephone interview was conducted with the resident's daughter on 5/20/21 at 10:02 a.m. The resident's daughter confirmed the information contained in the complaint narrative. The resident's daughter denied claims that her mother was being combative and stated that her mother didn't have the capacity to refuse any medications. The resident's daughter added that due to Resident #269's medical condition, s/he wouldn't be physically able to knock over medications. The resident's daughter confirmed that s/he had spoken to the Nurse Practitioner (NP) #1 but had not gotten any consistent information from the facility. The resident's daughter expressed that she was very upset with the care given to Resident #269 during their time at the facility and believed that the missed medications were potentially the cause of the resident's seizures. An interview was conducted with the Nurse Practitioner (NP) #1, on 5/20/21 at 11:18 a.m. on the grounds of the facility outside of the Community Center. NP #1 confirmed that s/he felt that the missed dose could have contributed to the resident's seizure condition. NP #1 stated that Resident #269 had a sweet disposition and s/he had never witnessed the resident being combative. The NP stated that, due to her diagnoses and physical condition, the resident would not likely be able to knock over medications if refusing. The NP stated that she had spoken with Resident #269's daughter and informed her of the incident. The NP stated that s/he would have expected to be contacted regarding any resident refusing a controlled medication such as Vimpat and would have sent the resident out to the hospital for evaluation upon first notice of refusal. An interview was conducted with the Director of Nursing (DON) and Administrator on 5/20/21 at approximately 1:35 p.m. in the Administrator's office. An inquiry was regarding the circumstances surrounding Resident #269 and the Zimpat use. The Administrator stated that a complaint was investigated by the State Licensure surveyor and there was no deficiency cited. The DON and Administrator noted that resident had been reported as refusing the medication and that the resident's family may have contributed to the difficulty with the medications. An inquiry was made regarding the failure to notify the physician of the refusal of the controlled medication. The Administrator stated that the NP was notified. The Administrator confirmed that the notification occurred in May after Resident #269 had seizures and not when the refusals happened. An inquiry was made whether the physician should have been notified at the first refusal of the medication. The Administrator and DON stated that a collaboration with the medical team could occur. The DON noted that the expectation was that the physician should have been notified upon the refusal of Vimpat. An inquiry was made regarding incidents where medication was knocked over. The DON stated the medication should be listed as wasted on the controlled medication sheet. This surveyor requested a copy of the controlled medication sheet for Zimpat. An inquiry was made regarding the documentation of refusals in the nurse's notes. The DON stated that the refusals and behaviors could have been placed in the notes and confirmed that the entries were made later. The DON confirmed that Resident #269 didn't get the medication for two (2) days in a row (4/24/21 and 4/25/21) and there were no adverse effects. The Administrator added that cause of the seizures could not be confirmed since Resident #269 was dealing with frontal lobe problems and other issues. The staff recalled what LPN #1 noted about Resident #269 and the nature of the refusals. An inquiry was made regarding the claims NP #1 and the resident's daughter made about Resident #269's calm nature, inability to refuse meds and inability to be combative and knock over medications. The Administrator stated that NP #1 and the resident's daughter did not provide the care in the facility. An interview was conducted with the Administrator and DON on 5/21/21 at approximately 9:34 a.m. in the Administrator's office. An inquiry was made regarding the process for administering medications. The inquiry was to determine if the medications were pulled prior to approaching the resident. The DON confirmed that medications were generally placed in a pill cup/container and brought to the resident. The DON stated that nurses could check with a resident prior to pulling medications but did not confirm whether LPN #1 did. An inquiry was made regarding the lack of documentation on Vimpat Controlled Medication Utilization Record. The Vimpat record did not show that the medication was signed out and pulled for medication administration on 4/24/21, 4/25/21 and for one (1) dose on 5/4/21 and an inquiry was made to whether the medication was actually pulled and refused. The staff did not confirm or deny with a direct response to the inquiry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review and interview, the facility failed to follow the care plan for one (1) of one (1) residents (Resident #269) reviewed for seizures. Findings include: Review of the policy titled Documentation of Medication Administration (revised April 2007) revealed the policy statement: The facility shall maintain a medication administration record to document all medications administered. Review of the policy titled Goals and Objectives, Care Plans (revised April 2009) revealed the policy statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Under the Policy Interpretation and Implementation section of the policy, it noted: The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. Review of Resident #269's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Encephalopathy, Aphasia following Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Communicating Hydrocephalus, Malignant Melanoma of Nose, Malignant Neoplasm of Frontal Lobe and Muscle Weakness. Review of Resident #269's most recent admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had a Brief Interview for Mental Status (BIMS) score of six (6) of 15, indicating the resident had a severe cognitive impairment. The resident was not coded for any maladaptive behaviors including physical, verbal, rejection of care or wandering. The resident was coded for extensive assistance and one-person assist for the following: bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the Physician's Order dated 4/22/21 revealed Resident #269 was prescribed the anticonvulsant antiepileptic medications (Vimpat) Lacosamide Tablet 200 milligrams (mg), give one (1) tablet by mouth two (2) times a day for seizures and levetiracetam Tablet 750mg, give two (2) tablets by mouth two (2) times a day for seizures. Review of the Warnings and Precautions for Vimpat revealed the warnings: In patients with seizure disorders, VIMPAT should be gradually withdrawn to minimize the potential of increased seizure frequency and Do not stop taking VIMPAT without first talking to your healthcare provider. Stopping VIMPAT suddenly can cause serious problems. Review of Resident #269's Care Plan, dated 5/2/21, revealed that the resident was care planned for a diagnosis of seizure disorder. Interventions included: Labs per order, notify MD of results; Medication per order; Monitor for side effects of medication and notify MD of any seizure like activity. Review of the Nurse's Notes for Resident #269 revealed that refusals for the 2nd dose of Vimpat on 4/24/21 and 2 doses of Vimpat on 4/25/21 were not recorded. There was no documentation indicating the NP or attending physician was notified of the medications not being administered on 4/24/21 and 4/25/21. Further review revealed that there was no documentation indicating the NP or attending physician was notified of the medications not being administered on 5/4/2021. Late entries on 5/13/2021 and 5/19/2021 but did not indicate that the attending physician was notified. The notes don't include documentation that the resident was combative, agitated or the reason for the refusal. The notes included the following: - 4/24/21, 8:00 a.m. - electronic Medication Administration Record (eMar) - Medication Administration Note. Note Text: Lacosamide Tablet 200 mg, Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Pt refused to take medicine even nurse explained importance of it. Daughter was at window this time visiting her. A review of the Controlled Medication Utilization Record for Vimpat revealed that there was no indication that the medication had been signed out and administered on 4/24/21 and 4/25/21. Further review of the record revealed that the medication was only signed out for one (1) dose on 5/4/21. The record indicated that a total of five (5) doses (1000 mg) were not recorded as signed out, administered, or wasted between the dates 4/22/21 through 5/4/21. Review of the Medication Administration Record (MAR) revealed that the record was marked to indicate that Resident #269 refused the medication Vimpat on 4/24/21, 4/25/21 and 5/4/21 for a total of six (6) doses which did not match the information on the Controlled Medication Utilization Record or the nurse's notes for 5/4/21. Interview with Licensed Practical Nurse (LPN) #1 on 5/19/21 at 9:45 a.m. on Unit 109. LPN #1 confirmed that s/he recalled Resident #269. The nurse stated that the Resident #269 would be combative at times and knocked over his/her medications in late April during medication pass. The nurse stated that s/he documented on the Medication Administration Record (MAR) that the medication was refused by the resident. The LPN stated that Resident #269's family was present and felt that their presence contributed to the resident's combative behavior and agitation. The nurse added that the resident wanted to leave and was upset when family was visiting. The nurse noted that on one occasion in May when the resident refused the medication, s/he went back to the resident to give a dose of Vimpat. The nurse recalled having conversations with the family, who urged him/her to give the medication. An inquiry was made regarding the process for documentation of the resident's refusals. The nurse indicated that s/he documented the MAR to note the refusals. LPN #1 stated that s/he should have also documented the refusals and combativeness in the nurse's notes. The nurse noted, that since it was a controlled medication, s/he also should have notified the physician of the refusals, incidents and documented it in the nurse's notes. An interview was conducted with the Nurse Practitioner (NP) #1, on 5/20/21 at 11:18 a.m. on the grounds of the facility outside of the Community Center. NP #1 confirmed that s/he felt that the missed dose could have contributed to the resident's seizure condition. NP #1 stated that Resident #269 had a sweet disposition and s/he had never witnessed the resident being combative. The NP stated that, due to his/her diagnoses and physical condition, the resident would not likely be able to knock over medications if refusing. The NP stated that s/he had spoken with Resident #269's daughter and informed him/her of the incident. The NP stated that s/he would have expected to be contacted regarding any resident refusing a controlled medication such as Vimpat and would have sent the resident out to the hospital for evaluation upon first notice of refusal. An interview was conducted with the Director of Nursing (DON) and Administrator on 5/20/21 at approximately 1:35 p.m. in the Administrator's office. An inquiry was regarding the circumstances surrounding Resident #269 and the Zimpat use. The Administrator stated that a complaint was investigated by the State Licensure surveyor and there was no deficiency cited. The DON and Administrator noted that resident had been reported as refusing the medication and that the resident's family may have contributed to the difficulty with the medications. An inquiry was made regarding the failure to notify the physician of the refusal of the controlled medication. The Administrator stated that the NP was notified. The Administrator confirmed that the notification occurred in May after Resident #269 had seizures and not when the refusals happened. An inquiry was made whether the physician should have been notified at the first refusal of the medication. The Administrator and DON stated that a collaboration with the medical team could occur. The DON noted that the expectation is that the physician should have been notified upon the refusal of Vimpat. An inquiry was made regarding incidents where medication was knocked over. The DON stated the medication should be listed as wasted on the controlled medication sheet. This surveyor requested a copy of the controlled medication sheet for Zimpat. An inquiry was made regarding the documentation of refusals in the nurse's notes. The DON stated that the refusals and behaviors could have been placed in the notes and confirmed that the entries were made later. The DON confirmed that Resident #269 didn't get the medication for two (2) days in a row (4/24/21 and 4/25/21) and there were no adverse effects. The Administrator added that cause of the seizures could not be confirmed since Resident #269 was dealing with frontal lobe problems and other issues. The staff recalled what LPN #1 noted about Resident #269 and the nature of the refusals. An inquiry was made regarding the claims NP #1 and the resident's daughter made about Resident #269's calm nature, inability to refuse medications and inability to be combative and knock over medications. The Administrator stated that NP #1 and the resident's daughter did not provide the care in the facility. An interview was conducted with the Administrator and DON on 5/21/21 at approximately 9:34 a.m. in the Administrator's office. An inquiry was made regarding the process for administering medications. The inquiry was to determine if the medications were pulled prior to approaching the resident. The DON confirmed that medications were generally placed in a pill cup/container and brought to the resident. The DON stated that nurses could check with a resident prior to pulling medications but did not confirm whether LPN #1 did. An inquiry was made regarding the lack of documentation on the Vimpat Controlled Medication Utilization Record. The Vimpat record did not show that the medication was signed out and pulled for medication administration on 4/24/21, 4/25/21 and for one (1) dose on 5/4/21 and an inquiry was made to whether the medication was actually pulled and refused. The staff did not confirm or deny with a direct response to the inquiry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview and family interview, the facility failed to ensure that a resident diagnosed with seizures received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of one (1) sampled residents (Resident #269). Findings include: Review of the policy titled Change in a Resident's Condition or Status (revised May 2017) revealed the policy statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Review of the policy titled Documentation of Medication Administration (revised April 2007) revealed the policy statement: The facility shall maintain a medication administration record to document all medications administered. Review of the policy titled Goals and Objectives, Care Plans (revised April 2009) revealed the policy statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Under the Policy Interpretation and Implementation section of the policy, it noted: The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. Review of Resident #269's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Encephalopathy, Aphasia following Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Communicating Hydrocephalus, Malignant Melanoma of Nose, Malignant Neoplasm of Frontal Lobe and Muscle Weakness. Review of Resident #269's most recent admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had a Brief Interview for Mental Status (BIMS) score of six (6) of 15, indicating the resident had a severe cognitive impairment. The resident was not coded for any maladaptive behaviors including physical, verbal, rejection of care or wandering. The resident was coded for extensive assistance and one-person assist for the following: bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the Physician's Orders dated 4/22/21 revealed Resident #269 was prescribed the anticonvulsant antiepileptic medications (Vimpat) Lacosamide Tablet 200 milligrams (mg), give one (1) tablet by mouth two (2) times a day for seizures and levetiracetam Tablet 750 mg, give two (2) tablets by mouth two (2) times a day for seizures. Review of the Warnings and Precautions for Vimpat revealed the warnings: In patients with seizure disorders, VIMPAT should be gradually withdrawn to minimize the potential of increased seizure frequency and Do not stop taking VIMPAT without first talking to your healthcare provider. Stopping VIMPAT suddenly can cause serious problems. Review of Resident #269's Care Plan, dated 5/2/21, revealed that the resident was care planned for a diagnosis of seizure disorder. Interventions included: Labs per order, notify MD of results; Medication per order; Monitor for side effects of medication and notify MD of any seizure like activity. Review of Resident #269's Nurse's Notes revealed that refusals for the 2nd dose of Vimpat on 4/24/21 and 2 doses of Vimpat on 4/25/21 were not recorded. There was no documentation indicating the NP or attending physician was notified of the medications not being administered on 4/24/21 and 4/25/21. Further review revealed that there was no documentation indicating the NP or attending physician was notified of the medications not being administered on 5/4/21. Late entries were entered on 5/13/21 and 5/19/21 but they did not indicate that the attending physician was notified. The notes didn't include documentation that the resident was combative, agitated or the reason for the refusal. The notes included the following: - 4/24/21, 8:00 a.m. - electronic Medication Administration Record (eMar) - Medication Administration Note. Note Text: Lacosamide Tablet 200 mg, Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Pt [patient] refused to take medicine even nurse explained importance of it. Daughter was at window this time visiting her. - 4/24/21, 9:33 a.m. - eMar - Medication Administration Note. Requested by External System - Note Text: Lacosamide Tablet 200 mg, Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. - 4/25/21, 10:54 p.m. - Social Service (SS) Note: Note Text: 5 Day Assessment: SS met with Resident to conduct her 5-day assessment. The Residents needs are met by the staff. The Resident scored a 06 for cognition indicating severe impairment. Resident scored a 04 for mood indicating minimal depression. The Resident is actively participating in therapy. No discharge (DC) dates at this time. SS will observe for changes. - 5/6/21, 12:00 p.m. - Nurse's Note: Note Text: at approx. 11 am this nurse called to res room. res sitting on the toilet having active seizure activity. res is lethargic and diaphoretic. res assisted to bed with staff assistance. Blood Pressure (b/p) elevated at 199/97, heart rate (hr) 98. Oxygen (02) saturations 99%. blood sugar taken and is 300. NP #1 notified and came to building to evaluate pt. new orders on chart. res daughter made aware of seizure activity and new orders. Resident is resting calmly in bed at present. b/p is 119/72 and insulin coverage provided for elevated blood sugar. - 5/7/21, 11:27 a.m. - Nurse's Note: Note Text: called to res room by NP #1 Np r/t [related to] res having active seizure. np states res had been seizing for 7 minutes at that point and needed to go to the ER. 911 called for emergency transport to Greenville Memorial. res daughter made aware of res condition and pending transfer to the hospital. res daughter asked to speak with NP and did converse with her. EMS arrived in facility and transported res to ER via stretcher. - 5/7/21, 1:32 p.m. - eMar - Medication Administration Note: Note Text: leave of absence (loa) to emergency room (ER). - 5/7/21, 7:25 p.m. - eMar - Medication Administration Note: Note Text: hospital. - 5/13/21, 1:31 p.m. - eMar - Medication Administration Note: Note Text: Lacosamide Tablet 200 mg. Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Still acting confused and not willing to take meds. - 5/13/21, 1:34 p.m. - eMar - Medication Administration Note: Note Text: Lacosamide Tablet 200 mg. Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. - 5/13/21, 1:35 p.m. - eMar - Medication Administration Note: Note Text: Lacosamide Tablet 200 mg. Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Resident choose not to take medicine. - 5/13/21, 1:36 p.m. - eMar - Medication Administration Note: Note Text: Lacosamide Tablet 200 mg. Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Patient (Pt) preference. - 5/13/21, 1:38 p.m. - eMar - Medication Administration Note: Note Text: Lacosamide Tablet 200 mg. Give one (1) tablet by mouth two (2) times a day for seizures for 50 Administrations. Resident refused this meds. - 5/19/21, 6:11 a.m. - eMar - Shift Level Administration Note: Note Text: Late entry: Pt refused to take Vimpat 200 mg at 4 pm initially, later Pt changed her mind and took this medicine. Nurse administered this medicine at 4 pm. Review of the Physician Progress Notes written by the Nurse Practitioner (NP #1) revealed the following regarding history of present illness and care plan recommendations: History of Present Illness: Patient is a [AGE] year-old female with a past medical history significant of malignant melanoma of the nasal cavity with metastasis to frontal lobe, seizures, cerebrovascular accident (CVA) with right-sided deficits who presented on March 11th, 2021 with seizures. She was initially admitted to an outlying hospital for altered mental status and was subsequently transferred to [hospital]. Subsequent noted to have gamma knife radiation adjustment of her antiepileptic drugs (AED's) including Vimpat and Keppra, she does have expressive aphasia and right sided weakness, persistent encephalopathy communicating hydrocephalus status post ventriculoperitoneal (VP) shunt placed on April 12, 2021. Overall being admitted for additional physical therapy, speech therapy, occupational therapy, and strength. April 23, 2021: Patient is awake alert lying in bed. She is overall cheerful and responsive to commands. She does have some expressive aphasia but is able to state her name and date of birth . Review of chart indicates this is her norm and not unusual for her. When asked about her CODE STATUS patient indicated that she would like to be a full code. Review of her chart also indicates that she was a full code while in hospital. We will monitor this solution continue her current status as a full code. Medication review performed today, labs will be ordered. Care Plan Recommendations: - Have advised patient of the rehabilitation process which includes therapy as well as medication management. Patient advised that refusal of therapy can result in cancellation and early discharge. Part of the whole rehabilitation process is engaging in therapy. Patient verbalized an understanding and to the best of her ability. - Advance care directives and CODE STATUS was discussed with the patient at this time. The patient has cognitive capacity. Today she reports that she would like to be a full CODE STATUS. Greater than 15 minutes was spent in the counseling coordination of advance care directives. - The current medication list and treatment regimens have been reviewed extensively. Continue all medications as currently ordered. Other: This patient is at very high risk of complications secondary to the acute issues as described above as well as multiple underlying comorbidities that at any given time could become exacerbated and in combination with the acute issues could significantly decompensate the patient even to the point of death. Additional concerns that have also been considered in the treatment of this patient today is a risk of side effects of the treatment regimens, risks and benefits, concerns for polypharmacy, advanced age, and underlying cognitive and physical impairment. This patient will require close monitoring and frequent follow-up for a successful recovery and avoidance of further complications. We will continue to follow the patient very closely and monitor for any signs or symptoms of adverse reactions or other complications that may arise and adjust the plan of care as appropriate. See the above plan of care for continued care coordination. Other: This patient requires to be medically evaluated and treated in their location secondary to the severity of their underlying conditions making it extremely difficult and burdensome for a safe and appropriate timely transport and service to be provided in an outpatient office setting. This patient is also at significant increased risk due to acute/subacute issues on top of their underlying chronic conditions which are also severe. This patient will require close monitoring and frequent follow-up for successful recovery and avoidance of further complications if even possible. Complications also include the higher than average probability of permanent loss of function and even the possibility of death. We will continue to follow patient very closely and monitor for any signs or symptoms of adverse reactions or other complications that may arise in adjust the plan of care as appropriate. A review of the Controlled Medication Utilization Record for Vimpat revealed that there was no indication that the medication was not signed out and administered on 4/24/21 and 4/25/21. Further review of the record revealed that the medication was only signed out for one dose on 5/4/21. The record indicated that a total of five (5) doses (1000 mg) were not recorded as signed out, administered, or wasted between the dates 4/22/21 through 5/4/21. Review of the Medication Administration Record (MAR) revealed that the record was marked to indicate that Resident #269 refused the medication Vimpat on 4/24/21, 4/25/21 and 5/4/21 for a total of six (6) doses which did not match the information on the Controlled Medication Utilization Record or the nurse's notes on 5/4/21. Review of the Treatment Administration Record (TAR) revealed that Resident #269 was not noted to have any agitation, anxiousness, or combativeness on 4/24/21, 4/25/21 and 5/4/21. Resident #269 was noted to have crying behavior on 4/24/21. Review of Licensed Practical Nurse (LPN) #1's employee record revealed that the employee's license was active and there were no indications of disciplinary infractions. Interview with LPN #1 on 5/19/21 at 9:45 a.m. on the Unit 109 revealed LPN #1 confirmed that s/he recalled Resident #269. The nurse stated that Resident #269 would be combative at times and knocked over his/her medications in late April during medication pass. The nurse stated that s/he documented on the Medication Administration Record (MAR) that the medication was refused by the resident. The LPN stated that Resident #269's family was present and felt that their presence contributed to the resident's combative behavior and agitation. The nurse added that the resident wanted to leave and would be upset when family was visiting. The nurse noted that on one occasion in May when the resident refused the medication, s/he went back to the resident to give a dose of Vimpat. The nurse recalled having conversations with the family, who urged him/her to give the medication. An inquiry was made regarding the process for documentation of the resident's refusals. The nurse indicated that s/he documented the refusals on the MAR. LPN #1 stated that s/he should have documented the refusals and combativeness in the nurse's notes as well. The nurse noted, that since it was a controlled medication, s/he also should have notified the physician of the refusals, incidents and documented it in the nurse's notes. A telephone interview was conducted with the complainant on 5/20/21 at 10:02 a.m. the complainant confirmed the information stated in the complaint narrative. The complainant denied claims that his/her mother was being combative and stated that his/her mother didn't have the capacity to refuse any medications. The complainant added that due to Resident #269's medical condition, s/he wouldn't be physically able to knock over medications. The complainant confirmed that s/he had spoken to the Nurse Practitioner (NP) #1 but had not gotten any consistent information from the facility. The complainant expressed that s/he was very upset with the care given to Resident #269 during their time at the facility and believed that missed medications were potentially the cause of the resident's seizures. An interview was conducted with the Nurse Practitioner (NP) #1, on 5/20/21 at 11:18 a.m. NP #1 confirmed that s/he felt that the missed dose could have contributed to the resident's seizure condition. NP #1 stated that Resident #269 had a sweet disposition and s/he had never witnessed the resident being combative. The NP stated that, due to his/her diagnoses and physical condition, the resident would not likely be able to knock over medications if refusing. The NP stated that s/he had spoken with Resident #269's daughter and informed him/her of the incident. The NP stated that s/he would have expected to be contacted regarding any resident refusing a controlled medication such as Vimpat and would have sent the resident out to the hospital for evaluation upon the first notice of refusal. An interview was conducted with the Director of Nursing (DON) and Administrator on 5/20/21 at approximately 1:35 p.m. An inquiry was made regarding the circumstances surrounding Resident #269 and the Zimpat use. The Administrator stated that a complaint was investigated by the State Licensure surveyor and there was no deficiency cited. The DON and Administrator noted that resident had been reported as refusing the medication and that the resident's family may have contributed to the difficulty with the medications. An inquiry was made regarding the failure to notify the physician of the refusal of the controlled medication. The Administrator stated that the NP was notified. The Administrator confirmed that the notification occurred in May after Resident #269 had seizures and not when the refusals happened. An inquiry was made whether the physician should have been notified at the first refusal of the medication. The Administrator and DON stated that a collaboration with the medical team could occur. The DON noted that the expectation was that the physician should have been notified upon the refusal of Vimpat. An inquiry was made regarding incidents where medications were knocked over by the resident. The DON stated the medication should be listed as wasted on the controlled medication sheet. This surveyor requested a copy of the controlled medication sheet for Zimpat. An inquiry was made regarding the documentation of refusals in the nurse's notes. The DON stated that the refusals and behaviors could have been placed in the notes and confirmed that the entries were made later. The DON confirmed that Resident #269 didn't get the medication for two (2) days in a row (4/24/21 and 4/25/21) and there were no adverse effects. The Administrator added that cause of the seizures could not be confirmed since Resident #269 was dealing with frontal lobe problems and other issues. The staff recalled what LPN #1 noted about Resident #269 and the nature of the refusals. An inquiry was made regarding the claims the NP #1 and the resident's daughter made about Resident #269's calm nature, inability to refuse meds and inability to be combative and knock over medications. The Administrator stated that NP #1 and the resident's daughter did not provide the care in the facility. An interview was conducted with the Administrator and DON on 5/21/21 at approximately 9:34 a.m. in the Administrator's office. An inquiry was made regarding the process for administering medications. The inquiry was made to determine if the medications were pulled prior to approaching the resident. The DON confirmed that medications are generally placed in a pill cup/container and brought to the resident. The DON stated that nurses could check with a resident prior to pulling medications but did not confirm whether LPN #1 did. An inquiry was made regarding the lack of documentation on Vimpat in the Controlled Medication Utilization Record. The Vimpat record did not show that the medication was signed out and pulled for medication administration on 4/24/21, 4/25/21 and for one (1) dose on 5/4/21 and an inquiry was made as to whether the medication was actually pulled and refused. The staff did not confirm or deny with a direct response to the inquiry. An interview was conducted with the DON and Administrator on 5/21/21 at 11:28 a.m. in the conference room with the survey team present. The staff were informed of the concerns regarding the Vimpat and subsequent seizures for Resident #269. The staff nodded when presented with the concerns. An inquiry was made regarding any in-service training completed by the facility in regard to medication refusals for controlled medication. The DON stated that s/he would be conducting trainings with staff. An interview was conducted with the DON on 5/21/21 at 12:07 p.m. in the conference room. The DON stated that the Medical Director and Pharmacist wanted to weigh in on the situation and didn't feel the one (1) missed dose contributed to the resident's seizures. The DON offered to bring a phone into the conference room to conduct the interview. The Administrator added that the Medical Director was familiar with the resident. An interview was conducted with the Pharmacist via telephone in the conference room with the survey team members, the DON and Administrator on 5/21/21 at approximately 12:33 p.m. The Pharmacist explained that missing the total of five (5) doses of the Vimpat would not likely have caused the seizures since the half-life of Vimpat is 13 hours. The Pharmacist added that the typical protocol for when the medication was missed was to take immediately or at least at the next cycle and since there was no seizure within the 36 hour window where a seizure did occur, it was unlikely that the missed doses contributed to Resident #269's seizures. The Pharmacist added that Zimpat would take at least a week to leave the body.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure that staff implemented standard and transmission-based precautions (donning and doffing appropriate personal protective equipment (PPE) for one (1) of one (1) transmission-based precaution residents (Resident #65), and for eight (8) of nine (9) quarantine residents (Resident #100, #170, #217, #218, #219, #221, #222, and #223) on three (3) of the 11 cottages. The facility failed to ensure that staff implemented proper hand hygiene between residents for five (5) of 12 residents (Resident #65, #218, #219, #221, and #222). Also, the facility failed to ensure that one (1) of four (4) residents (Resident #3) received medication in a manner that prevented cross-contamination. Total sample size was 46. Findings include: Review of the facility policy titled Administering Oral Medications with revised date of October 2010 revealed that the nurse was not to touch medication with hands. Review of the policy titled Handwashing/Hand Hygiene with revised date of August 2019 revealed that staff are to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves, before and after entering isolation precaution settings, before and after eating or handling food, and before and after assisting a resident with meals. Review of policy titled Isolation-Categories of Transmission Based Precautions with revised date of October 2018 revealed contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Further review revealed that staff and visitors would wear gloves (clean, non-sterile) when entering the room. While caring for a resident staff would change gloves after having contact with infective material (for example fecal material and wound drainage); gloves would be removed and hand hygiene performed before leaving the room; and staff would avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Also, staff and visitors would wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown was removed. Review of the undated Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities revealed that upon admission, new and readmitted residents with unknown COVID-19 status are placed in a separate observation unit in the building. Options may include placing a resident in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 where possible. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission) to the facility. Testing at the end of this period may be considered in coordination with South Carolina Department of Health and Environmental Control (SCDHEC) to increase certainty that the resident is not infected. All recommended PPE should be worn during care of residents on observation. During medication pass on the [NAME] cottage with Registered Nurse (RN) #2 on 5/18/21 at 12:18 p.m. for Resident #3, revealed RN #2 was preparing one (1) by mouth (PO) medication (Norvasc) at the medication cart. Continued observation revealed that RN #2 popped the pill into his/her ungloved left hand from the blister package and placed it into a clear medication cup. RN #2 then transferred the medication from the cup to a baggie which s/he crushed using the silent knight. S/he then placed applesauce in the cup and gave the medication to the resident. Interview with RN #2 on 5/20/21 at 9:57 a.m., s/he confirmed that at no time should medications be put in the staff's bare hands, and that during medication pass s/he pushed the pills through the blister package with his/her thumbs into a medication cup. During lunch observation on the Lilac cottage on 5/18/21 between 12:30 p.m. and 12:40 p.m. revealed the following concerns: At 12:30 p.m., Licensed Practical Nurse (LPN) #5 was observed entering quarantine for Resident #170 with a gown and mask on and gave the resident their lunch tray. A yellow was observed hanging outside the resident's room on the right side of the door; a sign was posted on the door stating the resident was in quarantine from 5/17/21 through 6/3/21 due to COVID precautions. Continued observation revealed LPN #5 left Resident #170's room without doffing the gown, then walked to the steam table, got a lunch tray for Resident #100. The LPN walked into the room and delivered the tray with the same gown on. Resident #100 was not on isolation precautions. In an interview with LPN #5 on 5/18/21 at 12:40 p.m., s/he stated s/he wasn't sure if s/he should take the gown off when going to the different rooms. Continued interview revealed s/he was aware the gown over the door meant s/he should wear the gown, but s/he wasn't sure when to doff the gown. During lunch observation on the Rhododendron cottage on 5/18/21 between 12:40 p.m. and 1:11 p.m. revealed the following concerns: 1. At 12:43 p.m., Physical Therapist (PT) #1 was observed entering the quarantine room for Resident #221 with gloves and a mask on and gave the resident that was sitting in the bed ankle weights. Continued observation revealed that PT #1 spoke with the resident for two (2) minutes. A yellow plastic gown was observed hanging outside resident's room on the right side of the door; however, PT #1 did not don this gown before entering the room. 2. At 12:52 p.m., Certified Nursing Assistant (CNA) #3 entered the quarantine room for Resident #65 to deliver a lunch tray. CNA #3 was observed touching the overbed table, putting down the lunch tray, and speaking with the resident. Continued observation revealed that s/he grabbed the lunch tray and returned to the kitchen area and proceeded to make another lunch tray for another resident without changing his/her gloves and/or washing his/her hands. CNA #3 was not observed donning any PPE prior to entering the room. The note on Resident #65's door was for contact precautions which included an over the door hanger for PPE and a yellow gown that hung on the right side of the bedroom door. However, the only thing in the first pocket on the first row of the over the door hanger was half of a box of gloves, and the second pocket on the first row was empty. Additionally, the second and third row pockets were empty. 3. At 12:57 p.m., CNA #3 entered the quarantine room for Resident #221 without donning a gown. Continued observation revealed that CNA #3 placed the lunch tray down on the resident's overbed table and returned to the kitchen and proceed to make another tray without changing his/her blue gloves and/or washing his/her hands. 4. At 1:01 p.m., CNA #3 entered the quarantine room for Resident #217. S/he adjusted Resident #217's overbed table and threw away a used clear cup from his/her overbed table. However, s/he did not don a gown prior to entering the bedroom. A plastic yellow gown was observed hanging on the right side of the outside of the door. After exiting, CNA #3 removed his/her blue gloves and washed his/her hands. 5. At 1:08 p.m., CNA #3 entered Resident #218's quarantine room where s/he delivered the lunch tray and placed it on the over bed table. CNA #3 was not observed to wear a gown upon entering the room; however, s/he changed his/her gloves after leaving the room but did not wash his/her hands. 6. At 1:10 p.m., PT #1 was observed entering Resident #219's quarantine bedroom without donning a gown. Continued observation revealed that PT #1 adjusted the resident's bed with his/her gloved hands. Observation revealed that there was a yellow plastic gown hanging on the outside, right side of Resident #219's bedroom door. PT #1 changed his/her gloves before exiting the room; however, PT #1 did not wash his/her hands afterwards. 7. At 1:11 p.m., CNA #3 entered Resident #222's quarantine room to deliver a lunch tray without donning a gown, which a plastic yellow gown was observed hanging on the right side of the outside of the door. After exiting the room, CNA #3 did not change gloves, returned to the kitchen, proceeded to make another tray, and got ice from the ice machine. Interview with PT #1 on 5/20/21 at 9:36 a.m., confirmed that the yellow gowns outside hanging on the doors were to be worn in those particular rooms because the residents were on precautions due to being new admissions. Continued interview revealed that the facility cottage had disposable gowns for use as well. During a random breakfast observation on the Rhododendron cottage on 5/19/21 at 8:18 a.m., CNA #4 was observed entering Resident #217's quarantine room to deliver his/her breakfast tray; however, CNA #4 was observed without wearing a gown and/or gloves. While in Resident #217's room, CNA #4 adjusted the resident's bed, and moved his/her pink drinking mug. CNA #4 upon exiting the room, did not sanitize his/her hands. Interview with CNA #4 on 5/19/21 at 1:26 p.m., confirmed that s/he used the disposable gowns when entering resident rooms that have signs on the doors; however, s/he stated that other staff use the yellow gowns hanging up on the door, and s/he was unsure if the gowns hanging were re-usable. During lunch observation on the Rhododendron cottage on 5/20/21 between 12:10 p.m. and 12:30 p.m., revealed the following concerns: 1. At 12:10 p.m., CNA #2 entered Resident #221's quarantine room to deliver a lunch tray without a gown on. 2. At 12:15 p.m., the Nurse Practitioner (NP) entered Resident #217's quarantine room without a gown on. 3. At 12:18 p.m., the NP entered Resident #223's quarantine room without a gown on, and after exiting went into a room that was not on quarantine. 4. At 12:25 p.m., Licensed Practical Nurse (LPN) #4 entered Resident #217's quarantine room without a gown on. 5. At 12:26 p.m., the NP looked into Resident #218's quarantine room; however, the resident was not in the bed, so the NP walked into the room, turned around and came out, all without donning a gown. 6. At 12:27 p.m., the NP, without donning a gown, entered Resident #222's quarantine room where the resident was sitting in his/her wheelchair at the edge of the bedroom door where NP was observed knelt down speaking with Resident #222. At 12:28 p.m., LPN #4, entered the room without a gown on, and closed the bedroom door. During a random observation on the Rhododendron cottage on 5/20/21 at 1:04 p.m. revealed that LPN #4 was observed walking into Resident #221's quarantine room without a gown on. Also, during this time, CNA #2 was observed in Resident #222's quarantine room without a gown on finishing up weighing the resident. Interview with the CNA #2 on 5/20/21 at 12:34 p.m., revealed that the yellow gowns are hung on each door to be used by staff because the residents are on 14-day quarantine due to being a new admit. Interview with LPN #4 on 5/20/21 at 12:32 p.m., revealed that the gowns hanging on the resident doors were reusable and should be laundered at night by the night shift staff using regular detergent; however, the facility did have disposable ones to use. Interview with LPN #1 on 5/19/21 at 1:30 p.m., s/he stated that the signs on the doors meant that a resident was a new admission, and they would be on precautions for the next 14 days. Continued interview revealed that the reusable yellow gowns hanging outside the door of these rooms were to be worn by staff when entering rooms. S/he confirmed these yellow gowns were changed out at the end of the shift and new ones were placed there. LPN #1 confirmed that the facility also had disposable gowns to use. Interview with the Infection Control Nurse on 5/20/21 at 12:51 p.m., revealed that there was no residents with COVID currently in the building; however, there were rooms that were under a 14-day quarantine due to residents being a new admission according to Centers for Disease Prevention and Control (CDC) guidelines. Continued interview revealed that there should be two (2) gowns on each door (one for the CNA and one for the nurse), but extra ones for other staff are available. The Infection Control Nurse confirmed that the gowns being used in Rhododendron were disposable and that the facility got rid of the reusable gowns last week. S/he confirmed that staff should not be wearing the gowns behind each other and said there should be one (1) gown for one (1) staff member. S/he confirmed that all staff, including PT and NP, were to wear a gown in the quarantine rooms. Interview with the Director of Nursing (DON) on 5/20/21 at 1:12 p.m., confirmed that the minimum handling of medication was needed. Continued interview revealed that the yellow gowns on the doors outside the quarantine rooms were reusable and there should be at least one (1) gown but there could be two (2) gowns. The DON said that the gowns could be used by anybody, but that the disposable ones were available for use. S/he stated that his/her expectations were for staff to wear the appropriate PPE for the situation, and change gloves if items were touched. The DON stated when staff go in and out of rooms some sort of infection control practice should be taken. Interview with the Administrator on 5/20/21 at 2:14 p.m., revealed that his/her expectations would be for staff to wear gowns if they go into any 14-day quarantine rooms and/or wear appropriate PPE for any isolation rooms. Continued interview revealed that during medication pass the nurse should have minimal touching of the medication with bare hands. The Administrator said that if staff are going from room to room, whether touching anything or not, that they were expected to wash their hands and/or change their gloves. S/he stated that the yellow gowns hanging on the hooks outside the resident quarantine rooms were reusable and were laundered by the facility's off-site laundry company. Review of the 14-day Mandate Requirement sign located on the quarantine bedroom doors revealed the following: Start Date: __________ End Date: ___________ Gown to be worn at all times Patient to wear a mask during all patient care One gown per patient/shift Gowns to be placed in red biohazard bags in soiled utility room at end of shift Gowns to be laundered on night shift Patient to remain in room for entire duration Thank you for your patience, diligence, and continued efforts to maintain best infection prevention practices at BCPA (Brushy Creek Post-Acute). Review of the Multiple Precautions (Contact Precautions) located on the bedroom door revealed that the door can remain open, staff are to wear gloves and gowns, and staff are to clean hands before entering and leaving the room. Review of the In-Service Training (Administering Oral Medications) dated 2/2/21 and 2/4/21, revealed training about not touching the medications with hands. However, there was no evidence that RN #2 attended this training. Review of the In-Service Infection Prevention and Control Program including Personal Protective Equipment (PPE) and Patient Under Investigation Status dated 2/11/21 revealed that PUI are residents under quarantine for possible COVID-19 infection meaning that the facility was taking extra precautions to prevent more or further spread of COVID-19. For a resident under PUI for a new admission, staff must wear the following personal protective equipment (PPE) when entering their room: Isolation gown, gloves, face mask, and a face shield or goggles. Further review revealed the following staff attended the in-service: LPN #4, PT #1, CNA #2, and RN #2. Review of the Education Attestation Form revealed that by signing this document staff confirmed they had received and read education materials (infection prevention and control program policy, and isolation-categories of transmission based precautions policy), confirmed that staff watched the video titled Keep COVID-19 Out, confirmed staff received a grade of 80% or higher on the infection control quiz, and confirmed they had been given the opportunity to ask questions about the materials. Further review revealed signed and dated 2/11/21 attestation sheets were found for the following staff: RN #2, CNA #2, PT #1, and LPN #4. Review of Resident #65's medical record revealed that s/he was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, and Diabetes. Resident #65 was on isolation precautions per review of the Physician's Order dated 5/4/21 due to Clostridioides difficile (C-Diff). Review of the sign on the resident's door revealed that s/he was on contact precautions. Review of Resident #100 medical record revealed that s/he was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure, Emphysema, and Chronic Obstructive Pulmonary Disease (COPD). Resident #100 was not on quarantine during the survey. Review of Resident #170's medical record that s/he was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anemia, and Chronic Kidney Disease-Stage II. S/he was on quarantine from 5/17/21 through 6/3/21. Review of Resident #217's medical record revealed that s/he was admitted to the facility on [DATE] with diagnoses that included Bipolar, Chronic Hepatitis, and Diabetes. S/he was on quarantine from 5/13/21 through 5/27/21. Review of Resident #218's medical record revealed that s/he was admitted to the facility on [DATE] with diagnoses that included Vascular dementia, Major Depressive Disorder, and Chronic Kidney Disease-Stage III. S/he was on quarantine from 5/5/21 through 5/20/21. Review of Resident #219's medical record revealed that s/he was admitted to the facility on [DATE] with diagnosis that included Anxiety, Bipolar, and Hypertension. S/he was on quarantine from 5/14/21 through 5/28/21. Review of Resident #220's medical record revealed that s/he was admitted to the facility on [DATE] with a diagnosis of Muscle Weakness. S/he was on quarantine from 5/18/21 through 6/1/21. Review of Resident #221's medical record revealed s/he was admitted to the facility on [DATE] with diagnoses of Spinal Stenosis, Crohn's Disease, and Anxiety. S/he was on quarantine from 5/7/21 through 5/21/21. Review of Resident #222's medical record revealed that s/he was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Chronic Hepatitis, and Alcoholic Gastritis. S/he was on quarantine from 5/8/21 through 5/22/21. Review of Resident #223's medical record revealed that s/he was admitted to the facility on [DATE] with a diagnosis of Muscle Weakness. S/he was on quarantine from 5/19/21 through 6/2/21.