**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #21) reviewed for incontinent care, in that: The facility failed to provide appropriate treatment and services to prevent urinary tract infection by having CNA B using a back to front motion to clean Resident #21's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #21's face sheet, dated 09/04/2025, revealed an admission date of 02/25/2022, and, a readmission date of 07/08/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Mood disorder (conditions that affect a person's emotional state), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09 indicating moderate cognitive impairment. Resident #21 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #21's care plan, dated 07/09/2024, revealed a problem of Resident will be clean, dry, odor free, will have regular BM (bowel movement) patterns and will be free from S/S (sign and symptoms) of UTI through next review. Observation on 09/04/2025 at 2:11 p.m. revealed while providing incontinent care for Resident #21, CNA B wiped Resident #21's buttocks in a back to front motion. During an interview on 09/04/2025 at 2:20 p.m. with CNA B, she stated, she wiped Resident #21's buttocks in a back to front motion. She said she did not realize she had used the wrong motion, and it could cause a risk for infection for the resident. She stated she received training on incontinent care from the facility. During an interview with the DON on 09/04/2025 at 4:20 p.m., she stated the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra (tube that lets urine, a waste product, leave your body) and possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. skills were checked yearly. The DON stated she spot checked the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA B revealed CNA B passed competency for incontinent care on 03/26/2025. Review of facility policy and procedure, titled Nurse Aide Incontinence Care Proficiency Assessment , undated, revealed [ .] work from base of labia (part of the female external genitalia) toward back [ .] clean hips working toward back using one swipe technique.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements, in that:The Dietary Supervisor did not have the appropriate certification, education, or qualification to serve as the Director of Food and Nutrition Services.This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.The findings were:During an interview with the Dietary Supervisor on 09/02/2025 at 10:30 a.m., he stated that he was not certified as a Dietary Manager, and that he was enrolled in a course scheduled to begin 09/04/2025. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator confirmed the Dietary Supervisor was not yet certified and stated he had expected to receive a citation. The Administrator further stated that the facility did not have a specific policy regarding the Dietary Supervisor's credentials but provided the Job Description. Record review of the Dietary Supervisor Job Description, undated, revealed, In this role you will.Ensure Safety and Compliance.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Observation of the South Wing shower room on 09/02/2025 at 1:42 p.m. revealed that the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. During an interview with RN E on 09/02/2025 at 1:45 p.m., RN E confirmed the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. RN E confirmed that this could potentially cause residents who utilized the toilet to fall and stated she would alert the Maintenance Department. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator stated that he agreed the loose toilet could potentially cause residents who utilized it to fall and provided documentation of the Maintenance repair request, dated 09/02/2025. The Administrator stated the facility did not have a specific policy pertaining to the circumstance. Observation on 09/05/2025 at 1:00 p.m. revealed the toilet had been repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Residents #4, #7 and #21) reviewed for infection control, in that: 1. The facility failed to maintain correct infection control when, while providing wound care for Resident #4, LVN C failed to use proper protective equipement. 2. The facility failed to maintain correct infection control when, while observing Resident #7's room, a reusable urinal was seen hang uncovered and hanging from the resident's trash can. 3. The facility failed to maintain correct infection control when, while providing incontinent care for Resident #21, NA A did not change her gloves or wash hands after touching the resident's trash can. These deficient practices could place residents at-risk for infection due to improper care practices. The findings were: 1. Record review of Resident #4's face sheet, dated 09/04/2025, revealed an admission date of 09/11/2024, and, a readmission date of 07/16/2025, with diagnoses which included: Brief psychotic disorder ( Psychiatric condition characterized by sudden and temporary periods of psychotic behavior, such as delusions, hallucinations, and confusion), Dementia (decline in cognitive abilities), Myalgia (muscle pain), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), Epilepsy (brain condition that causes recurring seizures.), Hemiplagia (Paralysis of one side of the body), Chronic kidney disease (gradual loss of kidney function). Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 11 indicating moderate cognitive impairment. Resident #4 required total assistance and was always incontinent of bowel and bladder. Resident #4 was coded as having a stage 4 pressure ulcer (deep wounds that may impact muscle, tendons, ligaments, and bone). Review of Resident #4's care plan, dated 07/25/2025, revealed a problem of The resident has a pressure ulcer and a goal of The resident's Pressure ulcer will show signs of healing and remain free from infection by review date. Observation on 09/04/2025 at 1:50 p.m., revealed, while providing wound care for Resident #4, LVN C did not wear a gown. Further observation revealed the resident did not have a sign indicating he was on enhanced barrier precaution. During an interview with LVN C, on 09/04/2025 at 1:59 p.m., she stated Resident #4 should be on enhanced barrier precautions because he had a wound, but he was on standard precautions. During an interview with the DON, on 09;04/2025 at 4:30 p.m., she stated Resident #4 should be on enhanced barrier precaution and LVN C should have worn a gown while providing wound care for the resident to prevent infection. The DON further stated the staff had received training on infection control and enhanced barrier precaution within the current year. Review of facility policy, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs), dated 07/12/2022, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. 2. Record review of Resident #7's face sheet, dated 09/05/2025, revealed an admission date of 07/05/2025, with diagnoses which included: Spinal stenosis (space around the spinal cord becomes too narrow causing pain and tingling), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Pain. Record review of Resident #7's admission MDS, dated [DATE], revealed the resident had a BIMS score of 14 indicating no cognitive impairment. Resident #7 required limited assistance and was always continent of bladder and occasionally incontinent of bowel. Observation on 09/04/2025 at 8:25 a.m., revealed during observation of medication administration in Resident #7's room, provided by MA D,a urinal was seen hanging from the outside of the trashcan and unbagged. The urinal had Resident #7's name written on it. During an Interview with MA D on 09/04/2025 at 8:27 a.m., she stated the urinal bottle belonged to Resident #7 and was unbagged while hanging on the trash can. She stated the trash can was considered dirty and the urinal should not have been in direct contact with the trash can because it was a risk for cross contamination and infection for the resident. She stated she received infection control within the current year. During an Interview with the DON on 09/04/2025 at 4:30 p.m., she stated the urinal should not have been hanging from the trash can to prevent cross contamination for the resident. She stated infection control training was provided to the staff, at least, yearly. Review of annual skills check for MA D revealed MA D passed competency for Perineal care/incontinent care and infection control on 01/08/2025. Review of facility policy, titled Toileting, Bedpan/urinal, undated, revealed Clean and store urinal per facility policy During an interview with the Administrator on 09/05/2025 at 11:12 a.m., he stated the facility had no policy on storage of urinal. 3. Record review of Resident #21's face sheet, dated 09/04/2025, revealed an admission date of 02/25/2022, and, a readmission date of 07/08/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Mood disorder (conditions that affect a person's emotional state), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09 indicating moderate cognitive impairment. Resident #21 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #21's care plan, dated 07/09/2024, revealed a problem of Resident will be clean, dry, odor free, will have regular BM (bowel movement) patterns and will be free from S/S (sign and symptoms) of UTI (urinary tract infection) through next review. Observation on 09/04/2025 at 2:11 p.m. revealed while providing incontinent care for Resident #21, NA A, after washing her hands and putting gloves on, touched the trash can with her gloved right hand. She, then, touched the clean wipe with the same right hand without changing her glove or washing her hands. During an interview on 09/04/2025 at 2:20 p.m. with NA A, she stated, she had touched the trash can with her gloved hand and did not change gloves or wash her hands before touching the clean wipe. She stated the trash can was considered dirty and she should have changed her gloves to prevent infection for the resident. She stated receiving infection control within the current year. During an interview with the DON on 09/04/2025 at 4:20 p.m., she stated the staff should have changed gloves and wash her hands prior to start the care to prevent cross contamination and infection to the resident. She stated infection control training was provided for the staff at least yearly and their skills were checked annually. Review of annual skills check for NA A revealed NA A passed competency for Perineal care/incontinent care and infection control on 07/31/2025. Review of Facility policy, titled Hand Hygiene, undated, revealed you may use alcohol-based hand cleaner or soap/water for the following: [ .] after handling soiled equipment or utensils

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (Resident #23) reviewed for infection control, in that: CNA B failed to wash or sanitize her hands or change her gloves after touching the remote of Resident #23's bed before starting incontinent care. After cleaning Resident #23's genitals, CNA B let the soiled briefs get in contact with the resident's genitals. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #23's face sheet, dated 08/07/2024, revealed an admission date of 11/14/2022 and, a readmission date of 06/15/2023, with diagnoses which included: Dementia (General decline in cognitive abilities), Neutropenia (low concentration of neutrophils (white blood cell) in the blood making it harder to fight infection), Hyperlipidemia (high concentration of lipids(fats) in the blood) and, squamous cell carcinoma (skin cancer). Record review of Resident #23's Annual MDS assessment, dated 06/17/2024, revealed the resident had no BIMS score, he had memory problems and was severely cognitively impaired. Resident #23 was always incontinent of bladder and frequently incontinent of bowel and, required limited to extensive assistance with his ADLs. Record review of Resident #23's care plan, dated 11/14/2022, revealed a problem of The resident has bladder incontinence, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 08/07/24 at 1:36 p.m. revealed while providing incontinent care for Resident #23, CNA B after putting gloves on, touched the bed remote that was on Resident #23's bed and then without changing her gloves or sanitizing her hands, started to provide care to the resident. CNA B rolled Resident #23's soiled brief between his legs. After cleaning the resident's genitals, CNA B let the soiled brief get in contact with the resident's genitals. During an interview on 08/07/2024 at 1:50 p.m. with CNA B, she confirmed the environment around the resident was considered dirty and she should have changed her gloves and sanitized her hands prior to providing care. She confirmed the soiled briefs should not have come in contact the resident's genitals after she cleaned them. She confirmed they received infection control training within the year. During an interview with the DON on 08/07/2024 at 3 p.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed soiled brief should not come in contact with the cleaned genitals to avoid cross contamination. She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed if there were concerns with infection control. The DON revealed herself and the ADON were in charge of the training and checking of the staff's kills. Record review of the annual skills check for CNA B revealed CNA B passed competency for infection control on 06/25/2024. Record review of the facility policy, titled Fundamental of Infection control precaution , dated 2019, revealed The following is a list of some situations that require hand hygiene: [ .] after handling soiled equipment or utensils.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 shower rooms reviewed, in that: 1. The South Hall shower room had a strong foul odor. 2. The temperature in the facility kitchen was 95.1 degrees Fahrenheit. These deficient practices could place residents at risk and result in an environment that is not safe, functional, sanitary, or comfortable for residents, staff, and visitors. The findings were: Observation on 08/05/2024 at 10:42 a.m. revealed a strong foul odor was emanating from the shower room in the South Hall. During an interview with CNA C on 08/05/2024 at 10:42 a.m., CNA C confirmed a strong foul odor was emanating from the shower room in the South Hall. During an interview with LVN D on 08/05/2024 at 10:44 a.m., LVN D confirmed a strong foul odor was emanating from the shower room in the South Hall. Record review of the facility policy, Deep Cleaning Process - Bathroom/Showers, undated, revealed, Follow the cleaning process in the Housekeeping Training Manual for using appropriate products can help you keep the room as sanitary as possible. 2. Observation on 08/08/2024 at 11:42 a.m., while the lunchtime meal was being prepared, revealed the temperature in the facility kitchen near the sink was 95.1 degrees Fahrenheit. During an interview with the Maintenance Director on 08/08/2024 at 11:42 a.m., the Maintenance Director confirmed the temperature in the facility kitchen near the sink was 95.1 degrees Fahrenheit. Observation on 08/08/2024 at 11:43 a.m., while the lunchtime meal was being prepared, revealed the temperature in the facility kitchen near the stove was 90.3 degrees Fahrenheit. During an interview with the Maintenance Director on 08/08/2024 at 11:43 a.m., the Maintenance Director confirmed the temperature in the facility kitchen near the stove was 90.3 degrees Fahrenheit. Observation on 08/08/2024 at 11:46 a.m., while the lunchtime meal was being prepared, revealed the temperature in the facility kitchen near the dishwasher was 83.8 degrees Fahrenheit and cans of food for resident consumption were stored within the dishwashing area. During an interview with the Maintenance Director on 08/08/2024 at 11:46 a.m., the Maintenance Director confirmed the temperature in the facility kitchen near the dishwasher was 83.8 degrees Fahrenheit and cans of food for resident consumption were stored within the dishwashing area. During an interview with the Maintenance Director on 08/08/2024 at 11:48 a.m., the Maintenance Director stated that the air conditioning unit in the facility kitchen had been in disrepair for approximately three months, a replacement unit had been chosen, and the replacement would be installed when the parent company authorized the expenditure. During an interview with the Administrator on 08/08/2024 at 3:32 p.m., the Administrator confirmed the facility strives to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the facility policy, Food Storage and Supplies, dated 2012, revealed, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects .Storerooms are to be well lighted, ventilated, and temperature controlled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 12 residents (Resident #10) reviewed for MDS assessments, in that: The facility failed to complete a Significant Change MDS for Resident #10 within 14 days after the resident was admitted to hospice services. This failure could place residents admitted to hospice services at-risk of not having their individual needs met. The findings were: Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: hypertensive heart disease without heart failure (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle weakness, difficulty in walking and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions). Record review of Resident #10's Care Plan, revised on 06/06/2023, did not reveal a focus for hospice services. Record review of Resident #10's electronic MDS record revealed the resident did not have a Significant Change MDS initiated or completed. Record review of Resident #10's electronic medical record Order Summary Report of Active Orders as of 07/13/2023, revealed an order Admit to Hospice B with a start date of 06/06/2023. During an interview with MDS Coordinator on 07/12/2023 at 2:12 p.m., the MDS Coordinator confirmed the significant change MDS should have been completed withing the 14 days and stated, We had several admissions and discharges and payor changes during that time. I will get it scheduled now. During an interview with the Regional Compliance Nurse on 07/12/2023 at 4:25 p.m., the RCN confirmed the significant change MDS should have been completed and stated the facility follows the RAI manual as policy for completing resident assessments. Record review of CMS's RAI Version 3.0 Manual, dated 10/2019, page 2-23 and 2-24 revealed a Significant Change in Status Assessment is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #10 and #17) for care plan revisions in that: 1. The facility failed to ensure Resident #10's care plan was revised to include hospice services. 2. The facility failed to ensure Resident #17's care plan was revised to include may sleep in another room after an altercation with their roommate (Spouse) on 7/08/23. These failures could place residents at risk of not receiving care according to their needs. These findings were: 1. Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting and atrophy (loss of muscle tissue), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions). Record review of Resident #10's electronic medical record revealed as of 07/14/2023 a significant change MDS had not been completed related to Resident #10's hospice admission. Record review of Resident #10's care plan, last review date 06/06/2023, revealed no focus area for hospice care. Record review of Resident #10's electronic medical record Order Summary Report of Active Orders as of 07/13/2023, revealed an order on 06/06/2022 for: Admit to [Hospice Company]. In an interview with the MDS Coordinator on 07/12/23 at 02:12 p.m., the MDS Coordinator confirmed she was responsible for updating care plans and that Resident #10's care plan had not been updated. The MDS Coordinator stated during the time the revision was due the facility had several admissions and discharges which may have caused her to overlook the revision. 2. Record Review of Resident #17's admission record, dated 7/14/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis to include: [Major Depressive Disorder] persistently low or depressed mood, decreased interest in pleasurable activities. [Cerebral Infarction] occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts. [ Muscle Wasting] A weakening, shrinking, and muscle loss caused by disease or lack of use. Review of the progress note, dated 7/9/23, revealed that Resident #17 had an altercation with their roommate (spouse), resulting in Resident # 17 spending the night in another room per her request. Review of Resident #17's Care Plan, last revised on 01/24/23, did not reveal a focus area for Resident #17 may spend the night in another room after Altercation with a spouse if it were to occur again. Review of the facility investigation dated 7/9/2023 revealed Resident #17 had an altercation with their spouse roommate and that Resident #17 requested to spend the night in another room. Interview and observation on 07/13/2023 at 01:30 PM with Resident #17, noted no visible injuries. Resident # 17 stated she would like a spare bedroom to spend the night when her spouse has alterations as this has been his common behavior, which he has demonstrated over the last 68 + years of marriage. Resident #17 stated in the morning it's like nothing happened. Interview on 07/13/23 at 04:39 PM the MDS Coordinator confirmed she was responsible for updating care plans, and she stated she had not updated Resident #17 's care plan as no further altercations had occurred and stated Resident #17's spouse was her roommate'. The MDS coordinator stated it was a one-time occurrence and Resident #17's spouse was only in the facility for a temporary skilled stay. The MDS coordinator stated the risk of not updating the care plan was possibly risking not all team members being aware. Interview on 7/13/2023 at 515PM the DON stated she was new at her position and that the MDS coordinator would have more information regarding the care plan. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 11. Assessments of residents are on-going and care plans are revised as information about the residents and residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: (a) when there has been a significant change in the resident's condition; (b) when the desired outcome is not met; (c) when the resident has been readmitted to the facility from a hospital stay; and (d) at least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 (Resident # 12) reviewed for hospice services. 1. The facility failed to obtain Resident #12's most recent hospice plan of care, signed hospice election form, and a physician's re-certification of the terminal illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #12's face sheet, dated 07/14/23, revealed a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses: [Ascites] is a buildup of fluid in your abdomen. [Malignant neoplasm]is another term for a cancerous tumor, and [Parkinson's disease] is a progressive disorder that affects the nervous system. Record review of Resident #12''s Quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated Intact cognitive response. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #12''s comprehensive care plan initiated on 02/04/23 revealed a focus area for end-of-life care with the name and number of the hospice agency. Interventions included visits from the following hospice interdisciplinary team members, RN, CNA, SW, and Spiritual support. Record review of Resident #12's electronic medical record active orders as of 07/14/2023 revealed an order on 02/04/2023, Admit to [name of facility] under [Hospice A, MD name] attending. Record review of Resident #12''s hospice binder at the nurse's station, revealed a hospice plan of care dated 04/10/2023, a hospice election form not signed by the resident/responsible party, and a physician's re-certification of the terminal illness not signed by the physician. Documentation by specific interdisciplinary hospice staff was in the hospice binder. Record review of the facility's hospice services agreement with Hospice A, with effective date, April 22, 2011, revealed, in 3.1.16 coordination of Services. Hospice shall: (c) provide facility with the following information specific to each Hospice Patient residing at Facility: (i) the most recent Plan of Care; (ii) the hospice election form and any advanced directives; (iii) the Physician certification and recertification(s) of the terminal illness; and 3.3.1 Development and implementation of Joint Plan of Care. When a facility resident is authorized by Hospice for admission to the Hospice Program, and the Facility admits a Hospice Patient to the Facility, Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care. Hospice and Facility each shall maintain a copy of each Patient's JPOC in the respective clinical records maintained by each party. Hospice and Facility each shall designate a registered nurse responsible for coordinating the implementation of the JPOC for each Patient. Record review of Resident #76's hospice binder at the nurse's station, revealed another hospice election form, dated 02/11/2023, signed by resident's family member when Resident #76 was receiving hospice services at home. Record review of the facility's hospice services agreement with Hospice Company , with effective date, February 7, 2020, revealed, in 2.4 (d) As frequently as required by the Hospice Patient's condition, but no less frequently than every fifteen (15) days, the Hospice Interdisciplinary Committee (in collaboration with the patient's Attending Physician) shall review, revise and document the Hospice Plan of Care to include information from updated patient assessments, and progress toward outcomes and goal specified in the Hospice Plan of Care. All such updates shall be communicated to Nursing Home. Further review revealed in 2.5 Hospice Services (a) Coordination of Services. (ii) Hospice shall provide Nursing Home with the following information: (a) the most recent individualized Hospice Plan of Care for each Hospice patient; (b) the Patient's election form for Hospice Services and any advance directives specific to each patient; (c) each Hospice Patient's physician certification and recertification of terminal illness. In an interview with the DON on 07/13/2023 at 10:45 a.m., the DON revealed MDS nurse was the staff person responsible for coordinating with the hospice agencies and ensuring all hospice documentation was in the resident's electronic record. In an interview with the DON on 07/13/2023 at 11:45 a.m., the DON revealed the facility must receive a hospice election form when a resident was admitted to hospice in order to bill for services. The DON further revealed the form would have to be fully completed and signed because the facility would have to know if the resident or family had chosen to elect or cancel the hospice benefit. DON stated she does not know why the needed information was not in the Hospice binder; she stated she is responsible for Auditing Hospice Binders to ensure that all needed information is included however does not know why it was missed; she stated the resident risked not having the Hospice agency and Nursing staff not communicating effectively by information needed not being in the chart. In an interview with MDS Nurse on 07/13/2023 at 11:12 a.m., MDS Nurse revealed she was assigned to coordinate with hospice agencies to ensure hospice agencies email over their documentation, and she uploads what is sent to the resident's electronic record and places necessary documentation in Hospice binder. MDS Nurse could not provide the documents needed for Resident #12 and stated she would call the agencies and ask them to bring any documentation being requested to the facility. Record review of the facility's policy titled, End of Life Hospice Type Care & Coordination, dated 2/7/2007, revealed, To provide supportive care for residents and their families during the end stages of life by enabling them to participate in interactions of their choice in a supportive environment with the assistance of compassionate caregivers and interdisciplinary teams.

Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 10 of 18 staff (The DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator) reviewed for employment registry screenings, in that: The DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator did not have current employment registry screenings. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Record review of the staff roster provided on 07/11/2023 by the facility revealed a hire date of 07/01/2022 for the DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator. In an interview with the HR Coordinator on 07/13/2023 at 10:07 a.m., the HR Coordinator revealed when the current corporation acquired the facility all staff were given a new hire date as of the date of acquisition. The HR Coordinator further revealed EMRs (employee misconduct registry) were run for all staff the month prior to the acquisition. Record review of the HR background screenings file, with the HR Coordinator present revealed the last annual Employee Misconduct Registry (EMR) check for the DS was completed on 06/01/2022. Record review of the HR background screenings file, with the HR Coordinator present revealed the last annual Employee Misconduct Registry (EMR) check for LVN I was completed on 06/18/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 10:28 a.m., the HR Coordinator revealed she was unable to find an annual EMR check for MA A, CNA D, CNA E, MA F, [NAME] G, AD, RH J, and the MDS Coordinator, however stated they all would have had one completed in June 2022 prior to the acquisition. She further stated all EMRs are currently checked based on each employee's annual competency renewal and the check in June 2022 threw off that schedule. In an interview with the AIT and RCN on 07/13/2023 at 5:26 p.m., the AIT confirmed the HR Coordinator had revealed the EMRs had not been completed due to the HR Coordinator's scheduling process. Record review of the facility's policy titled, Employment Eligibility, revised 09/20/2019, revealed, This facility completes a comprehensive background check prior to offer of employment, annually following your hire and as needed for reported concerns that could impact the resident care or facility liability. Record review of the facility's policy titled, Abuse/Neglect, revised 3/29/18, revealed, Procedure. A. Screening: Criminal History and Background Checks. 7. Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry .

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received training in the QAPI program. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware QAPI was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform and QAPI would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies.

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received the required compliance and ethics training. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware ethics was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform and ethics would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies.

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received the require mandatory effective behavioral health. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware behavior health was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform where it would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies.

Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 facility review for the surety bond, in that: The facility's surety bond was not enough to match the total residents' trust fund account balance. This failure could place residents who deposit personal funds with the facility at-risk of their personal funds not being assured. The findings were: Record review of the facility's surety bond, dated 09/01/2022, revealed the bond amount was $15,000.00. Record review of the resident trust fund as of 07/14/2023, revealed the balance was $15,717.38. During an interview with the BOM on 07/14/2023 at 12:20 p.m., the BOM confirmed the total balance of the residents' trust fund accounts was $15,717.38 which exceeded the facility's $15,000.00 surety bond. The BOM stated she had just recently completed a trust audit and didn't know how it was missed. The ABOD stated the BOM was responsible for this task and confirmed the residents' trust fund account should not have exceeded the surety bond as this could place the resident's funds at risk of not being protected. During an interview with the ABOD on 07/14/2023 at 3:07 p.m., the ABOD stated the facility did not have a policy regarding surety bonds or resident trust accounts. During an interview with the AIT and RCN on 07/14/2023 at 5:15 p.m., the AIT confirmed the residents' trust fund total balance had exceeded the amount of the surety bond and should not have done so.