Based on observation and staff interview, the facility staff failed to ensure adherance to the expiration dates for over-the counter (OTC) medications in bulk containers. The findings included: On 10/23/24 at 3:30 PM, medication checks of one medication cart was conducted on the Colonial Unit. Based on observation and staff interviews, the facility staff failed to ensure adherence to the expiration dates for over-the-counter (OTC) medications in bulk containers. The findings included: On 10/23/24 at 3:30 PM, medication cart checks were conducted on the Colonial Unit. One bottle of Thiamine Vitamin B-1 had an expiration date of 7/2024 and a marked open date of 10/17/24. Registered Nurse (RN) #1 said the medication should have been removed from the medication cart, and could not explain why the expired drug was marked as open on 10/17/24, well after the expiration date. RN#1 stated it was a facility policy to dispose of expired medications at least within 30 days of the expiration date with another nurse. The Unit Manager was present, and the Director of Nursing (DON) was made aware of the abovementioned observation. The DON stated she checked the other facility unit's medication carts for expired drugs. No further information was provided before the survey exited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication and treatment administration in nursing practice for one Resident (Residents #63) in a survey sample of 27 Residents. For Resident #63, the facility staff failed to administer treatments and pain medications for a dependent Resident with wounds and pain. The findings included: Resident #63's diagnoses included; Osteomyelitis right ankle and foot with amputation, acute and chronic respiratory failure with continuous oxygen use, chronic pain syndrome, anxiety and PTSD, foot drop, and hypothyroidism. Resident #63's most recent MDS (minimum data set) was coded as a quarterly assessment. Resident #63 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #63 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The resident was coded as incontinent of bowel and bladder. On 4-16-24 at 12:00 noon, Resident #63 was observed in bed, with the head of the bed slightly elevated, during the initial tour of the facility, th resident was interviewed during this time. The resident stated that her legs and arms itching all the time, and that she would like to have some medicated cream to help that. She was observed to be scratching her thighs while speaking to the surveyor. The resident continued to state that she was in pain most of the time, and needed more pain medication daily. The resident's physician orders were reviewed and reveal orders for wound treatments, and pain medication administration for chronic pain treatment. Those orders were for the following; Treatments; 1. Ordered 1-11-24 foam border gauze to sacrum wound every day at 9:00 a.m. 2. Ordered 1-11-24 xeroform dressing to right foot every day at 9:00 a.m. 3. Ordered 1-15-24 Collagen sheet to sacrum every day at 9:00 a.m. 4. Ordered 1-20-24 Betadine left posterior knee every day at 9:00 a.m. Medications; 1. Ordered 1-24-24 Fentanyl patch 72 hour 25 mcg (micrograms) per hour change every 3 days for pain. 2. Ordered 1-26-24, discontinued 2-7-24, Hydromorphone 4 mg (milligrams) give 1/2 tablet every 6 hours as needed for pain. 3. Ordered 2-8-24 Hydromorphone 2 mg (milligrams) give 1/2 tablet every 8 hours as needed for pain. 4. Ordered 3-22-24 Hydromorphone 2 mg give 1/2 tablet 2 times per day at 6:00 a.m., and 6:00 p.m. for chronic pain syndrome. 5. Ordered 3-22-24 Methocarbamol 500 mg two times per day at 10:00 a.m., and 10:00 p.m. for chronic pain syndrome. 6. Ordered 4-9-24 Percocet 10-325 mg 1 tablet per day at 1:00 p.m. for chronic pain, one hour prior to physical or occupational therapy. The Medication and Treatment Administration Records (MAR/TAR) were reviewed for February and April 2024, and revealed the absence of nursing signatures indicating that the treatments and medications were omitted on multiple occasions. Those follow; Treatments; (13 opportunities) Foam border - 2-8-24, 2-19-24. Xeroform - 2-6-24, 2-8-24, 2-10-24, 2-13-24, 2-15-24, 2-16-24. Collagen - 2-8-24, 2-19-24, 2-24-24. Betadine - 2-8-24, 2-19-24. Medications; (8 opportunities) 1. Fentanyl patch - 4-3-24, 4-9-24. 2. Hydromorphone 2 mg (milligrams) give 1/2 tablet at 6:00 a.m., and 6:00 p.m. - 4-7-24 both doses, 4-8-24 both doses. 3. Methacarbamol - 4-7-24 at 10:00 p.m. 4. Percocet - 4-11-24 Nursing medication administration notes do not indicate why the treatments and medications were not administered. Nurses on the nursing unit were asked if treatments and medications were administered on the dates in question and the responses were if it's not documented, it's not done. Guidance for the administration of medications is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov Insulin must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses as ordered to decide proper dosing needed. Do not discontinue medication without seeking a doctor's help. Stopping narcotic pain medications may increase the risk of precipitous withdrawal which can be life threatening. The nursing facility stated [NAME] as their nursing standard. [NAME] stated all medications must be administered per the physician's order. Resident #63's care plan was reviewed and revealed a care plan for chronic pain and wound treatments that instructed to administer medications and treatments as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the treatments and medications had been omitted, nor that the doctor was made aware of the omissions. On 4-18-24 at 5:30 p.m., the DON and Administrator were interviewed and stated that they had been unaware that treatments and medications had not been given, nor that the doctor and family were not notified of them being omitted by staff. On 4-19-24 at approximately 10:00 a.m., at the end of day debrief, the Corporate Director of Operations and DON were again made aware of the failure of staff to administer treatments and medications as ordered. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to store medication in a secure location for 1 resident, Resident #61, out of a survey sample of 27 residents. The findings included: For Resident #61, facility staff failed to store prescribed antifungal powder in a secure location to ensure only authorized persons had access to the medication. On 4/16/24 at approximately 2:45 PM, Surveyor B observed a 3 ounce bottle which read, Antifungal Powder with Miconazole Nitrate 2%, expiration date 01/2025, with a prescription label from an outside provider attached to the bottle with Resident #61's name, date of birth , and prescriber/pharmacy information. The bottle was located on top of Resident #61's bedside table next to the head of his bed. On 4/16/24 at 2:50 PM, an interview was conducted with Resident #61 who stated, My wife brought that [referencing the bottle of antifungal powder] in the other day, it has been there [referencing his bedside table] a couple of days, I don't know if it is being used or not, the nurses put some kind of powder on me each day but that's all I know. On 4/16/24 at 3:00 PM, an interview was conducted with RN B, who also identified himself as the Unit Manager. RN B observed the medication at Resident #61's bedside, picked it up to remove it, and stated, I am not sure how this [medication] got there [bedside table] but I am going to look into it. RN B stated, Staff have been in here several times today, someone should have seen it, removed it, and locked it up, that is both my expectation and facility policy. A facility policy was requested and received. Review of the facility policy, Medication Storage, read, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. On 4/17/24 at approximately 10:15 AM, the Facility Administrator was updated on the findings. No further information was provided.

Based on observation, staff interview, and facility policy review, the facility staff failed to properly store, label and date food items, and clean the floors in 2 out of 4 refrigerators/freezers located within the facility's main kitchen. The findings included: 1. Facility staff failed to label and date food items located within the vegetable and meat freezers. On 4/17/24 at approximately 2:00 PM, an interview and kitchen tour was conducted with the Dietary Manager (DM). A partial bag of crinkle-cut french fries, which had been previously opened, was observed in the vegetable freezer, however the bag was not labeled or dated. A partial bag of round meat patties, which had been previously opened, was observed in the meat freezer, however the bag was not labeled or dated. The DM stated, These bags should be labeled and dated, I will dispose of these things right now. The DM also stated, Labels are needed to identify food items so that potential food allergans can be identified before serving it to people and dating food lets us know when it may no longer be safe to serve. 2. Facility staff failed to ensure the floors in the beverage refrigerator and the walk-in refrigerator, located within the facility kitchen, was free from dirt and debris. On 4/16/24 at approximately 1:00 PM, an interview and kitchen tour was conducted with the DM. Observations of the beverage refrigerator and the walk-in refrigerator revealed dirt and debris, including food/beverage spillage, located on the bottom/floor of the refrigerators. The DM stated, It is dirty and not acceptable, I will be sure that it gets cleaned up. On 4/17/24 at approximately 2:15 PM, the Facility Administrator was informed of the findings. A facility policy was requested and received. The facility policy titled, Receiving and Storage of Food, dated 10/1/21, Policy: Foods shall be received and stored in a manner that complies with safe food handling practices, Item 1, read, Food Services, or other designated staff, will maintain clean food storage areas at all times and Item 8 read, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). The facility policy titled, Refrigerators and Freezers, dated 10/1/21, Policy: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines, Item 10, read, Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, facility documentation review, and clinical record review, the facility staff failed to assess and determine if a resident was safe to self-administer medications, for one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, who had medications stored in their room, the facility staff failed to assess if Resident #14 was safe to self-administer medications. On 10/17/2023 at approximately 12:40 p.m., observations were conducted of Resident #14's room. Resident #14 was not present in the room. It was noted that Resident #14 had a basket on the bed that contained two blister packets of medications. There was also a 3-drawer plastic storage unit against the wall that had clear drawers and it was observed there was a bottle of Tylenol and 2 cans of jock itch spray present. On 10/17/2023 at 1:33 p.m., Resident #14 was visited in her room. When asked about medications, Resident #14 said, the facility staff give her medications. On 10/18/2023, during mid-morning, observations were made in Resident #14's room. Resident #14 was present but asleep and unable to be aroused with verbal stimuli, which included knocking and calling out her name. Surveyor C noticed on the bed, in a basket were 2 blister packs of medications which were labeled as Mucinex and Nauzene. The clear 3-drawer storage unit contained Tylenol, Pepto Bismol, and jock itch spray. On 10/19/2023, during the early afternoon, Resident #14 was visited in her room again. All of the above noted medications were still present and in addition, Preparation H cream was noted sitting on top of the 3-drawer storage bin. Resident #14 was asked about the items, and she said she puts the Preparation H on herself. When asked where she obtained the items from, the resident was unsure. A review of Resident #14's entire clinical record, to include but not limited to, physician's orders, care plan, nursing notes, assessments, and interdisciplinary team meeting notes, there was no indication that Resident #14 had been assessed for his ability to self-administer medications. Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE] following a hospitalization. On 10/19/2023 at 11:21 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated they do not have any residents who self-administer medications. When asked about the protocol for this, the DON said, If a Resident wanted to self-administer, I would speak to the doctor and do an assessment. When asked if there was a specific assessment that is used, the DON said, Yes, there is an assessment and we would have them do a successful return demonstration, we would give them a supply [of medication being self-administered], we would check to make sure they have supply, and that they have given it properly. When asked where the medication that is being self-administered would be stored, the DON said, In a lock box. When asked why a lock box is used to store the medications, the DON said, Because I wouldn't want anyone else to have access to it, and confirmed they do have residents that wander and go into other residents' rooms. During the above interview with the DON, she was asked to provide a copy of the facility policy regarding self-administration of medications and the assessment tool used to assess residents for this ability. On the afternoon of 10/19/2023, the facility policy and self-administration of medication assessment was received. On the afternoon of 10/19/2023, the facility Administrator, Director of Nursing, and Corporate staff were made aware that Resident #14 was not assessed for the ability to self-administer medications and medications were noted at the bedside. The Corporate Nursing Consultant advised Surveyor C that the Administrator had found 2 bottles of vodka in Resident #14's room and had to remove them. They felt Resident #14's daughter was providing/putting the items in Resident #14's room to sabotage the survey. Of note, Resident #14's daughter is also a resident of the facility. A review was conducted of the facility policy titled, Self-Administration of Medications and Treatments. Excerpts from the policy read, Policy: Residents have the right to self-administer medications/treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Specific Procedures/Guidance: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treats is clinically appropriate for the resident .3. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment .8. Self-administered medications and/or treatments will be stored in a safe and secure place, which is not accessible by other residents . On 10/20/2023, prior to conclusion of the survey, the facility staff provided the survey team with a listing of items removed from Resident #14's room, which included the following: Mucinex, Pepto Bismol, acne treatment, Preparation H gel, Tylenol, Diclofenac Gel, Preparation H cream, jock itch spray, Nauzene, Salonpas patches, which are all over the counter medications. No further information was provided.

2. For Resident #70, the call bell was located beyond his reach, making it unavailable for him to call for assistance. On 10/17/2023 at approximately 1:35 p.m. during initial tour, Resident #70 was observed lying awake in his bed with his call bell located on the floor at the foot of his bed. When asked if he knew where his call bell was, he felt around his bed and shook his head, No. Resident #70 was unable to speak due to previous history of a stroke. LPN B, assigned to Resident #70's unit, was asked to come into Resident #70's room. LPN B was asked if she thought Resident #70 could reach his call bell to call for assistance, and she stated, No, he cannot get to that [the call bell], it should be kept within his reach at all times so he can use it. He cannot speak but he does know how to use his call bell. LPN B picked the call bell up off the floor and secured it to Resident #70's bedspread within his reach. On 10/17/2023, a facility policy regarding call bells was requested and received. The facility policy entitled, Answering the Call Light, item 5 read, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. On 10/17/2023, the Facility Administrator and Director of Nursing were updated on the findings. No further information was provided. Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to accommodate the needs of 2 residents (Residents #274 and #70) in a survey sample of 39 residents. The findings included: 1. For Resident #274, who was unable to get out of bed without assistance, the call bell was not in reach; therefore, leaving the resident with no way to call facility staff for assistance. On 10/17/2023 at 1:45 p.m., Resident #274 was visited in his room. The resident was noted to be alert, oriented x4 and a good historian upon interview. The resident was observed lying in bed, was noted to be a bilateral amputee of lower extremities. Resident #274 said, his call bell is the only way he can call for assistance and frequently it is out of reach or has fallen behind the bed. He said he frequently has to get his roommate to use his call bell to get assistance to the room. Resident #274 reports he does not get out of bed. On 10/17/2023 at 1:49 p.m., an interview was conducted with CNA B. CNA B was asked about the call bells, to explain their purpose, and where they are located. CNA B said, The call bell is how the residents let us know if they need something. If they can't get out of bed, that is the only way they can call for assistance other than staff checking on them regularly. CNA B accompanied Surveyor C to the room of Resident #274 and confirmed the call bell was laying on the bed frame at the foot of the bed and out of reach of the resident. CNA B further confirmed the resident had no way of calling staff for assistance if he had needed it. A clinical record review of Resident #274's chart was conducted on 10/17/2023. This review revealed that he was dependent on facility staff for activities of daily living (ADL). There was a care plan initiated on 10/08/2023, that indicated Resident #274 Is at risk for falls r/t [related to] bilateral BKA's [below knee amputations]. One intervention listed read, Be sure The [sic] resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the facility policy titled, Answering the Call Light was conducted. An excerpt from the policy read, .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the Resident . On 10/17/2023 during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the physician and family of a resident's change in medications and change in condition for one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, who had a medication change which was not communicated to the family, there was a noted increase in sleeping and she was difficult to arouse following the start of an antipsychotic medication. The facility staff failed to notify the doctor and family member of the change until prompted by survey team. On 10/17/2023, Resident #14 was visited in her room by Surveyor C. Resident #14 was awake, able to engage in conversation with no difficulty, and appeared to have some memory loss. There was no obvious significant hearing deficit noted. On 10/18/2023, Surveyor C visited Resident #14's room on 3 occasions, once mid-morning, once early afternoon, and lastly around 3:30 p.m. Each time, Surveyor C knocked on the resident's room door, entered the room, and called the resident's name. The resident was observed laying on her bed asleep. Surveyor C got closer to the resident and called her name again, Resident #14 did not arouse. On 10/18/2023 at approximately 3:30 p.m., Surveyor C interviewed CNA D. CNA D was in the hallway outside of Resident #14's room, and was filling a water pitcher with ice. CNA D was asked about Resident #14 and asked if she normally sleeps a lot. Surveyor C explained that she had attempted to visit the resident on several occasions, but Resident #14 would not arouse. CNA D said he was in the hall filling the water pitcher to not awaken the resident. He said that normally she is awake. On 10/19/2023 at approximately 8:30 a.m., Surveyor C went to visit Resident #14 in her room again. Surveyor C knocked on the door, entered the room, and called the resident's name. Resident #14 did not respond. Surveyor C approached the bedside and observed Resident #14 asleep on top of the covers, with her dentures protruding from her mouth. Surveyor C again called Resident #14's name, with no response. On 10/19/2023 at approximately 9:00 a.m., Surveyor C interviewed CNA B and CNA E. They were asked if Resident #14 usually sleeps a lot and is hard to arouse. They said she does sleep at times but is easily aroused. They were informed that Surveyor C had made multiple attempts to visit the resident yesterday and again this morning, but Resident #14 was asleep and not responding to her name being called. They stated this was not the resident's normal behavior, but she had awakened for breakfast. On 10/19/2023, an interview was conducted with CNA F. CNA F was asked about Resident #14. CNA F said he was not too familiar with the resident's pattern, but knew she stayed in her room a lot and would doze on and off at times. On 10/18/2023 - 10/19/2023, a clinical record review was conducted. A progress note dated 10/16/2023, read, Resident was seen by her outside PCP today. New order for Sulfamethoxazole 400 mg- Trimethoprim 80 mg, 1 tab every 8 hours x 7 days. Also an increase in Quetiapine/Seroquel to 50 mg once a day at bedtime. There was no indication Resident #14's family member had been notified of the start of an antipsychotic medication. Review of the Medication Administration Record (MAR) for October 2023 revealed that Resident #14 was not receiving Seroquel prior to 10/16/2023. Resident #14 did receive a dose on 10/17/2023 and 10/18/2023. Physician's orders and the MAR revealed that that Resident #14 was started on Sertraline HCl oral tablet, (also known as Zoloft, which is an antidepressant) 50 mg, once daily for depression symptoms starting 08/12/2023. At the time of survey, this medication continued. Review of the progress notes revealed no evidence of any behaviors in the past 30 days that would have precipitated the medication change. On the afternoon of 10/19/2023 during an end of day meeting, the facility Administrator, Director of Nursing, and corporate staff were made aware of the above concern that Resident #14 was displaying significant somnolence and had a recent medication change that may be a contributing factor as well as the over-the-counter medications that were noted in the room, since they are unaware of what and how much the resident may be self-administering. A copy of the physician's progress notes from 10/16/2023 was requested. On 10/20/2023 during the morning, Resident #14 was visited in her room and was sitting at the bedside and awaiting her breakfast. She was talkative and able to engage in conversation. On the morning of 10/20/2023, Surveyor C requested the physician's progress note from 10/16/2023. A clinical record review was conducted again and revealed that following the end of day meeting held on 10/19/2023, the facility staff had completed an SBAR Communication Form, which indicated Resident #14 had a change in Altered level of consciousness, which was reported to the physician. In response to this, an order was received to change the dosage of the Seroquel to decrease it to 25 mg daily at bedtime. On 10/20/2023 in the afternoon, the facility staff provided Surveyor C with the physician's progress note from 10/16/2023. It was reviewed and there was no indication for the medication, Quetiapine, other than diagnosis listed on a Report of Consultation that included, compulsive behavior, and generalized anxiety. There were no other details given as to why the Quetiapine/Seroquel was being ordered. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a proper Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to 2 residents (Residents #43 and #70) in a survey sample of 3 residents reviewed for such notices. The findings included: For Residents #43 and #70, the facility staff failed to utilize a CMS approved SNF ABN form, which provided the option for the resident to select/choose to continue services and pay for the care without Medicare being billed. On 10/17/2023, the facility Administrator was asked to provide a listing of residents who were discharged from Medicare Part A services, prior to exhausting their benefit days. From this listing, a sample of 3 residents was selected, which included Residents #43 and #70. The notices issued to these residents was requested and received. Review of the SNF ABN forms revealed the following: 1. For Resident #43, the facility staff provided a SNF ABN notice on 09/11/2023, which indicated therapy services were ending. The form provided Resident #43 with 2 options to select from. The Centers for Medicare & Medicaid Services (CMS) approved form provides 3 options. 2. For Resident #70, the facility staff provided a SNF ABN notice on 09/11/2023, which indicated therapy services were ending. The form provided Resident #70 with 2 options to select from. The Centers for Medicare & Medicaid Services (CMS) approved form provides 3 options. The form provided to Residents #43 and #70, as indicated above, only offered them 2 options to choose from. The options given read as follows: Option 1. YES. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes its decision. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare's decision. Option 2. NO. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your option that Medicare won't pay. I understand that, in the case of any physician-ordered items or services, should notify my doctor who ordered them that I did not receive them. On 10/18/2023 at 4:13 p.m., an interview was conducted with Employee F, the Social Services Director, and Employee J, the social worker. Both employees stated they are responsible for issuing Advance Beneficiary Notices (ABN). When asked to explain the purpose of the form, Employee F said, With a part A you also do a SNF ABN to go with the NOMNC (Notice of Medicare Non-Coverage). Employee F went on to say, The NOMNC is 2 pages and the ABN, which is 1 page, says after this date you will incur a fee between $150-$300 for therapy if you decided to stay and do therapy, after this day you either go home or decide I'm going to be here long-term care. Both Employees F and J indicated the notices are issued 48 hours before the last covered day. Both employees further confirmed the SNF ABN form has 3 options for the resident to choose from. During the above meeting, Employees F and J were shown the notices provided to Residents #43 and #70, which only indicated 2 options. Both employees stated they were not aware of and had not noticed the change and confirmed it was not the CMS approved form issued. The facility policy titled, Medicare Liability Notice was reviewed. It read, .4) The Social Worker, Business Office representative, or designee will; fully complete the required liability notice and provide it to the beneficiary/beneficiary representative prior to stopping the Medicare coverage. 5. The facility will utilize and follow the Medicare approved notices and instructions . The approved CMS form CMS-10055 titled, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) was reviewed. The facility's Social Services Director, Employee F, provided Surveyor C with a blank form. The CMS approved form had 3 options for the beneficiary to choose from. The options read as follows: OPTIONS (Check only one box. We can't choose a box for you).: Option 1: I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the directions on the MSN. Option 2: I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Option 3: I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. The Centers for Medicare & Medicaid Services (CMS) provides facilities with the following guidance document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. An excerpt from this document read, .Completing the SNF ABN: The SNFABN is available for download by selecting the FFS SNFABN link from the menu on the webpage http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html. The SNFABN is a CMS-approved model notice and should be replicated as closely as possible when used as a mandatory notice. Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question . Accessed online at: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn On 10/18/2023, the facility Administrator was made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure freedom from abuse and neglect for 1 resident (Resident #54) in a sample of 39 residents. The findings included: For Resident #54, the facility staff failed to ensure the resident was not verbally abused by a CNA who threatened to, and did in fact, neglect the resident's needs. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023, Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit mgr. dated 7/20/23]. A review of the clinical record revealed there were no progress notes for 07/20/2023 addressing this situation. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with Resident #54 who stated that on the day of the incident he was wanting the air conditioner turned up and the CNA told him if he rings the call bell, they will not answer it. When asked how that makes him feel, he stated, I hear stuff like that all the time around here. Resident #54 stated he was also in need of incontinence care, but the staff failed to answer the call bell. He stated he ended up having to get a shower to get cleaned up because they waited so long to change him. The resident stated he complained to the Social Worker about it. Resident #54 was not able to recall who the staff member was that threatened to not answer the call bell. Resident #54 went on to state he had the Social Worker purchase prune juice to keep in his room because the staff would not give it to him when he asked for it. He stated they would sit at the nurses station and ignore the call bell to the point he would have to wheel himself to the nurses' station, which has a high wall, and Resident #54 could not see over it while in his wheelchair, so he would have to go around the side to see if anyone was at the nurses' station. He stated many times they would be quiet and not answer until he went around the side and could see they were there. On 10/19/2023, an interview with the Social Worker was conducted, and he stated he did not identify this incident as abuse or neglect; therefore, did not escalate it up to an abuse allegation. On 10/19/2023 at 6:28 p.m., an interview was conducted with the Administrator and Employee C (Corporate Clinical Nurse Consultant). They were asked if the Social Worker/Grievance Officer should be able to identify and report abuse and neglect. The Administrator stated that all the staff should be able to identify and report abuse and neglect. The Administrator and Employee C were shown the grievance report from 07/20/2023 involving Resident #54 and agreed it was a threat to neglect the resident. When asked if this incident was investigated, the Administrator stated it had not been. When asked if this was reported to the appropriate offices, the Administrator stated it had not been. On 10/19/2023, a review of the facility's abuse policy read as follows: Page 1 Paragraph 1 Definitions: ABUSE is also the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. On 10/19/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to protect one resident (Resident #14) from misappropriation of property in a survey sample of 39 residents. The findings included: For Resident #14, the facility staff failed to protect the resident from a known perpetrator, who had been identified by the facility as a verbal abuser and who had previously financially exploited the resident. The facility staff continued to permit unsupervised and unrestricted access to Resident #14 and her personal possessions by the known perpetrator, which allowed the perpetrator to gain access to Resident #14's bank cards when she had no legal right to possess the items. On [DATE] in the afternoon, Resident #14 was visited in her room. During the interview/conversation, cognitive impairment and difficulty with memory recall was noted. The resident did acknowledge she had been to visit her daughter earlier in the day. Resident #14's daughter is also a resident of this facility. Resident #14 reported they are able visit each other anytime they want. Review of the facility's investigation documents revealed that on [DATE], there was an incident between Resident #14 and her daughter, Resident #55. The incident was witnessed by 2 staff members and involved Resident #55 being verbally abusive to Resident #14. The facility's investigation findings concluded, The investigation showed that [Resident #55's name redacted] did verbally abuse her mother and upset her .APS [Adult Protective Services], the physician and local police were notified. In conclusion, the facility stated, The facility substantiated this verbal abuse due to the relationship of these two individuals it is tough to hold tight on interventions because of resident rights and the mother daughter relationship. On [DATE], the Social Worker wrote a progress note that read, [Resident #14's name redacted] met with the city of [City name redacted] Adult Protective Services social worker, [APS worker's name redacted], the Director of Nursing, Social Services, and the Business Office Manager to review bank statements. [APS worker's name redacted] reviewed transactions on the bank statements that displayed funds that were being utilized for means not pertaining to [Resident #14's name redacted]'s stay in the facility. [Resident #14's name redacted] expressed that she did not want to get her daughter into any trouble or arrested. The Director of Nursing comforted [Resident #14's name redacted] by stating that the purpose of the meeting was for to ensure that the facility was being a good steward of the Medicare and Medicaid process in an effort to protect the best interest of [Resident #14's name redacted]. [Resident #14's name redacted] verbalized that she does not want her daughter to control her money anymore. She also stated that she wants to revoke her power of attorney on file. [APS worker's name redacted] stated that she would attempt to collaborate with an outside organization to revoke the power of attorney and enter into a fiduciary agreement with [Resident #14's name redacted] to make sure her funds are used for her stay in the facility. [Resident #14's name redacted] was in complete agreement as she stated, I have never dealt with money in my life. She also authorized for her Social Security checks to be direct deposited into her Resident Fund Management Services account. [APS worker's name redacted] praised the staff for providing excellent care. Social Services will continue to monitor. Another entry by the Social Worker was made into Resident #14's chart on [DATE]. This entry read, Social services was given the paperwork with the new POA [power of attorney] information that was orchestrated with the assistance of APS [Adult Protective Services]. The son of the resident is now the current POA which was awarded to him by his mom [Resident #14's name redacted], and the paperwork has been uploaded into [name of electronic health record system redacted]. Social services will continue to monitor the resident at this time. According to facility investigation documents, on [DATE], Resident #55 Alerted staff that she called the police because a bag with clothes and purse were taken from her mother's room and given to her and she believed that items may have been stolen out of the purse, but she holds her mother's debit, medical and identification cards . Also in the investigation documents was a typed timeline dated [DATE]. This document read, At 9:30 this writer [writer did not sign document, so unaware of who the writer was] was called to the front lobby to meet [Resident #55's name redacted] .[Resident #55's name redacted] called police to say [Resident #14's name redacted] purse was taken out of her room and taken to laundry and then brought to her [Resident #55] room. The purse was in a clear bag with [Resident #14's name redacted] soiled clothes from the hospital Writer spoke with [Resident #55's name redacted] and asked her to identify the housekeeper that brought her the purse. [Resident #55's name redacted] identified the housekeeper. This writer asked the housekeeper how she got the clear bag and the items in it, and she stated that the evening CNA brought it down to be laundered [sic] . Also in the document titled, timeline, was the following statement, The police officers and APS worker and this writer interview [sic] [Resident #14's name redacted] if she gave [Resident #55's name redacted] her debt [sic] cards before she went to her doctor's appointment on [DATE] or she had them taken from her by [Resident #55's name redacted]. [Resident #14's name redacted] stated she gave them to [Resident #55's name redacted] to hold. [APS worker's name redacted] reeducated [Resident #14's name redacted] that [Resident #55's name redacted] is not the power of attorney, and she is not authorized to hold her debit cards. The investigation summary stated, After investigation was completed by Local Police Department and Local Adult Protective Services were on site to obtain the debit cards from [Resident #55's name redacted] as this resident is not the Power of Attorney for [Resident #14's name redacted] because of prior financial exploitation .In work with the Local Police Department and Local Adult Protective Services they will be reopening the case on [Resident #55's name redacted] of financial exploitation of [Resident #14's name redacted] and will subpoena financial records for both [Resident #14 and #55's names redacted] . In Resident #14's clinical record there was a progress note dated [DATE], written by the Director of Nursing. It read, Medical Director notified by this RN that Residents purse was misplaced for a short period of time. Resident stated that nothing was missing from purse. It was later identified that Residents daughter had obtained cards from Residents purse. APS [adult protective services] notified [City name redacted] Police and both entities as well as Residents RP [responsible party/son] came to the Facility. APS and [police department name redacted] initiated an investigation. Medical Director verbalized understanding of all information provided, no questions or concerns voiced. Therefore, it is unclear how Resident #55's obtained Resident #14's bank cards, but the facility staff allowed unrestricted and unsupervised access between the two residents which permitted Resident #55 to have access to Resident's #14's personal possessions. Review of Resident #14's care plan revealed no mention of the prior abuse between Residents #14 and #55, the relationship of the two, or any other problems. Within Resident #14's clinical record was a document titled, Psychological Assessment, with an evaluation date of [DATE]. This document read, .Reason for Referral: [Resident #14's name redacted] was referred for assessment by [City name redacted] Department of Social Services to help determine her need for guardianship assistance. Specific concern was expressed that a seeming inability to monitor her finances was leaving her open to financial exploitation . The document went on to read, .Conclusions and Recommendations: [Resident #14's name redacted] is demonstrating a range of cognitive declines/deficits consistent with early-stage and progressing dementia. She currently appears incapacitated to the point that she will need another person to make decisions for her regarding her personal affairs to include residential planning, medical care, and all aspects of her finances. [Resident #14's name redacted] is capable of offering limited input regarding her preference of where she might live but cannot make sound living arrangement/residential placement decisions (and is easily misguided in that area). Her cognitive deficits are ones for which she will be unable to make improvements. That is, there is no known treatment by which they can be remedied to any meaningful extent, and instead, her deficits can be expected only to worsen over time. [Resident #14's name redacted] appears in need of legal guardian to manage her personal and financial affairs. She appears to possess the capacity to grasp that nature of a guardianship and conservatorship but lacks the ability to intelligently consent to the appointment of a guardian or conservator. The above is true and correct to the best of my information and belief . [signed by a Licensed Clinical Psychologist, whose name is redacted]. Throughout the course of the survey, it was noted that Resident #14 had multiple over-the-counter medications in her room. On the afternoon of [DATE], the facility Administrator, Director of Nursing, and Corporate staff were made aware that Resident #14 had multiple over-the-counter medications at the bedside. The Corporate Nursing Consultant advised Surveyor C that the Administrator had removed 2 bottles of vodka from Resident #14's room earlier that day. The administrative staff reported to the survey team that Resident #14's daughter, Resident #55, was the one giving Resident #14 items. On [DATE] during the end of day meeting, an interview was conducted with the facility Administrator, Director of Nursing and Corporate Nursing Consultant. During the interview, the survey team shared concerns regarding Resident #55 and Resident #14. The administration was asked what steps they were taking to protect Resident #14's safety. In response to the survey team's shared concerns, on the morning of [DATE], the facility Administrator and Corporate Nursing Consultant reported to the survey team that on the evening of [DATE], following the end of day meeting with the survey team, Resident #14's room assignment had been moved directly across from the nursing station for closer monitoring. Additionally, a staff member had been assigned to Resident #14 as one-to-one, to supervise any visits between Resident #14 and Resident #55 to ensure there was no exchange of items or items being brought into Resident #14's room that were not permitted. On [DATE], interviews were conducted with CNA B, LPN D and LPN C, the unit manager. All three stated that prior to [DATE], Residents #14 and #55 have been permitted to have unrestricted and unsupervised visits with each other ad lib [as they choose]. The facility policy titled, Abuse, was reviewed. Excerpts from the policy read, .6. Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. b. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident . No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #14, the facility staff failed to implement their abuse policy as evidenced by failure to protect the resident from a known perpetrator by allowing unrestricted/unsupervised visits between the resident and her known perpetrator. On 10/17/2023 in the afternoon, Resident #14 was visited in her room. During the interview/conversation, cognitive impairment and difficulty with memory recall was noted. The resident did acknowledge she had been to visit her daughter earlier in the day. Resident #14's daughter is also a resident of this facility. Resident #14 reported they can go and visit each other anytime they want. During the interview, observations were made of the resident's room, and revealed that Resident #14 had 2 blister packs of medication sitting on her bed and in a 3-drawer clear storage container there was a bottle of Tylenol and 2 cans of jock itch spray. Review of the facility's investigation documents revealed that on 2/3/23, there was an incident between Resident #14 and her daughter, Resident #55. The incident was witnessed by 2 staff members and involved Resident #55 being verbally abusive to Resident #14. The facility's investigation findings concluded, The investigation showed that [Resident #55's name redacted] did verbally abuse her mother and upset her .APS [adult protective services], the physician and local police were notified. In conclusion, the facility stated, The facility substantiated this verbal abuse due to the relationship of these two individuals it is tough to hold tight on interventions because of resident rights and the mother daughter relationship. In Resident #14's chart, there was a nursing progress note dated 06/23/2023, that read, I was called to the residents' room. Upon entering the residents' room, the resident expressed concerns about her daughter, she said she had not seen her for a couple days and was worried about her and asked if I could go check on her daughter for her. I received permission from the ADON [Assistant Director of Nursing] that the mother and daughter could have a supervised dinner in the dining area. The mother and daughter were supervised throughout the whole dinner. The daughter asked if she could help the mother find her Medicare card, permission was given, only the Medicare card was taken out of the wallet and given to the mother. The mother placed all her cards in her wallet and placed them in her purse. There was no personal contact noted during the dinner. The daughter left the dining room first then the mother was taken back to her room after the dinner. This progress note established that at some point the facility staff identified the necessity to supervise and restrict visits between Residents #14 and #55. On the afternoon of 10/19/2023, the Corporate Nursing Consultant advised Surveyor C that the Administrator had found 2 bottles of vodka in Resident #14's room and had to remove them. They felt Resident #14's daughter was providing/putting the items in Resident #14's room, to sabotage the survey. Throughout the survey, an abundance of over-the-counter medications were noted in Resident #14's room, which the facility staff also reported she was getting from her daughter, Resident #55. On 10/19/2023 during the end of day meeting, an interview was conducted with the facility Administrator, Director of Nursing, and Corporate Nursing Consultant. During the interview, the survey team shared concerns with regards to Resident #55 providing Resident #14 with items that could be potentially harmful, to include the over-the-counter medication and vodka. The administration was asked what steps they were taking to protect Resident #14's safety. On the morning of 10/20/2023, the facility Administrator and Corporate Nursing Consultant reported to the survey team that Resident #14's room assignment had been moved directly across from the nursing station for closer monitoring and a staff member had been assigned to Resident as 1-on-1 to supervise any visits with Resident #55 and ensure that no items were given to Resident #14. On 10/20/2023, interviews were conducted with CNA B, LPN D, and LPN C, the unit manager. All three stated that prior to 10/20/2023, Residents #14 and #55 have been permitted to have unrestricted and unsupervised visits with each other ad lib [as they choose]. The facility policy titled, Abuse, was reviewed. Excerpts from the policy read, .6. Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. b. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident . No further information was provided. Based on resident interview, facility staff interview, clinical record review, and facility documentation, the facility staff failed to implement the abuse, neglect, and exploitation policy for 2 residents (Residents #54 and #14) in a survey sample of 39 residents. The findings included: 1. For Resident #54, the facility staff failed to implement the abuse/neglect policy when Resident #54 reported to the Social Worker an allegation of abuse/neglect. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023 Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit manager & Social Worker dated 7/20/23] A review of the clinical record revealed there were no progress notes for 07/20/2023 addressing this situation. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with Resident #54 who stated that on the day of the incident he was wanting the air conditioner turned up and the CNA told him if he rings the call bell, they will not answer it. When asked how that makes him feel he stated, I hear stuff like that all the time around here. Resident #54 stated he was also in need of incontinence care, but the staff had failed to answer the call bell. He stated he ended up having to get a shower to get cleaned up because they waited so long to change him. He stated he complained to the Social Worker about it. Resident #54 was not able to recall who the staff member was that threatened to not answer the call bell. On 10/19/2023, an interview with the Social Worker was conducted, and he was not able to identify this issue as abuse or neglect; therefore, did not escalate it up to an abuse allegation. On 10/19/2023 at 6:28 p.m., an interview was conducted with the Administrator and Employee C (the Corporate Clinical Nurse Consultant). They were asked if the Social Worker/Grievance Officer should be able to identify and report abuse and neglect. The Administrator stated all the staff should be able to identify and report abuse and neglect. The Administrator and Employee C were shown the grievance report from 07/20/2023 involving Resident #54, and agreed it was a threat to neglect the resident. When asked if this incident was investigated, the Administrator stated it had not been. When asked if this was reported to the appropriate offices, the Administrator stated it had not been. On 10/19/2023, a review of the facility's abuse policy revealed the following excerpts: Page 1 Paragraph 1: Definitions: ABUSE is also the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Page 3 Paragraph 4: Identification: B. Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. On 10/19/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and facility documentation, the facility staff failed to report an allegation of abuse/neglect within 24 hours, if the events do not result in serious bodily injury, for 1 resident (Resident #54) in a survey sample of 39 residents. The findings included: For Resident #54, the facility staff failed to identify, investigate, and report allegations of abuse to the Administrator. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, and muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023 Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit manager & Social Worker dated 7/20/23]. A review of the clinical record revealed there were no progress notes for 07/20/2023 addressing this situation. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with Resident #54 who stated that on the day of the incident he was wanting the air conditioner turned up, and the CNA told him if he rings the call bell, they will not answer it. When asked how that makes him feel, he stated, I hear stuff like that all the time around here. Resident #54 stated he was also in need of incontinence care, but the staff had failed to answer the call bell. He stated he ended up having to get a shower to get cleaned up because they waited so long to change him. He stated he complained to the Social Worker about it. Resident #54 was not able to recall who the staff member was that threatened to not answer the call bell. On 10/19/2023, an interview with the Social Worker was conducted and he was not able to identify this issue as abuse or neglect; therefore, did not escalate it up to an abuse allegation. On 10/19/2023 at 6:28 p.m., an interview was conducted with the Administrator and Employee C (the Corporate Clinical Nurse Consultant). They were asked if the Social Worker/Grievance Officer should be able to identify and report abuse and neglect. The Administrator stated all the staff should be able to identify and report abuse and neglect. The Administrator and Employee C were shown the grievance report from 07/20/2023 involving Resident #54, and agreed it was a threat to neglect the resident. When asked if this incident was investigated, the Administrator stated it had not been. When asked if this was reported to the appropriate offices, the Administrator stated it had not been. On 10/20/2023, the Administrator submitted a copy of the Facility Reported Incident (FRI) that was submitted to the OLC and other reporting agencies. A review of the facility Policy for abuse read as follows: Page 3 Paragraph 4 Identification B. Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. On 10/20/23 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and facility documentation, the facility staff failed to investigate an allegation of abuse for 1 resident (Resident #54) in a survey sample of 39 residents. The findings included: For Resident #54, the facility staff failed to identify, report, and investigate an allegation of abuse made to the Social Worker on 07/20/2023. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023, Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit manager & Social Worker dated 7/20/23]. A review of the clinical record revealed there were no progress notes for 07/20/2023 addressing this situation. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with Resident #54 who stated that on the day of the incident he was wanting the air conditioner turned up, and the CNA told him if he rings the call bell, they will not answer it. When asked how that makes him feel, he stated, I hear stuff like that all the time around here. Resident #54 stated he was also in need of incontinence care, but the staff had failed to answer the call bell. He stated he ended up having to get a shower to get cleaned up because they waited so long to change him. He stated he complained to the Social Worker about it. Resident #54 was not able to recall who the staff member was that threatened to not answer the call bell. On 10/19/2023, an interview with the Social Worker was conducted and he was not able to identify this issue as abuse or neglect; therefore, did not escalate it up to an abuse allegation. On 10/19/2023 at 6:28 p.m., an interview was conducted with the Administrator and Employee C (the Corporate Clinical Nurse Consultant). They were asked if the Social Worker/Grievance Officer should be able to identify and report abuse and neglect. The Administrator stated all the staff should be able to identify and report abuse and neglect. The Administrator and Employee C were shown the grievance report from 07/20/2023 involving Resident #54, and agreed it was a threat to neglect the resident. When asked if this incident was investigated, the Administrator stated it had not been. When asked if this was reported to the appropriate offices, the Administrator stated it had not been. On 10/20/2023, the Administrator submitted a copy of the Facility Reported Incident (FRI) that was submitted to the OLC and other reporting agencies. A review of the facility abuse policy revealed the following excerpts: Page 3 Paragraph 4 Identification B. Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. Page 3 Paragraph 5 Investigation: Designated staff will immediately review and investigate all allegations or observations of abuse. a. The results of all investigations are to be communicated to the Administrator or his or her designated representative and to other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. On 10/19/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete resident assessments/Minimum Data Set (MDS) in a timely manner for 6 Residents (Residents #1, #33, #36, #39, #68 and #274) in a survey sample of 39 residents. The findings included: 1. For Residents #1, #33, #36, #39, #68 and #274, the facility staff failed to ensure the timely completion of MDS assessments. On 10/19/2023 at 8:50 a.m. during the completion of the survey process, clinical record reviews were conducted of Residents #1, #33, #36, #39, #68 and #274's MDS assessments with particular attention to the date(s) the assessments were completed. The following was noted: a. Resident #1 had a quarterly MDS with an Assessment Reference Date (ARD) of 08/27/2023. The assessment was completed on 09/11/2023. b. Resident #33 had a quarterly MDS with an ARD date of 09/08/2023. The assessment was completed on 09/30/2023. c. Resident #36 had a quarterly MDS with an ARD of 09/01/2023. The assessment was completed on 09/17/2023. d. Resident #39 had a quarterly MDS with an ARD of 08/22/2023. The assessment was completed on 09/06/2023. e. Resident #68 had a quarterly MDS with an ARD of 09/01/2023. The assessment was completed on 9/30/23. f. Resident #274, was admitted to the facility on [DATE]. He had an admission assessment with an ARD of 10/07/2023. The assessment was due to be completed by 10/10/2023, as of the date of survey, 10/19/2023, it had not been completed. On 10/19/2023 at 10:34 a.m., an interview was conducted with the facility's MDS nurse/LPN H. LPN H was asked to explain the frequency and timing of MDS. LPN H said, They all have dates and times they need to be done. When asked to explain the time frames and how she knows when they have to be completed and transmitted, LPN H stated, The computer tells me. LPN H then showed Surveyor C in the electronic health record where dates are noted when assessments must be completed and transmitted. It was noted that some of the dates were in black text, some in red text, and some in green text. When asked what the different colors meant, LPN H was unsure. LPN H was asked about the transmission of MDS to CMS. LPN H said, Transmitting to the state is actually done by my regional, I am an LPN so my RN has to sign for me, and normally the RN that signs for me is my regional. She signs and then will transmit. She will give me the ok to transmit. LPN H also stated, We started the new things in Oct. [referring to the MDS changes that went into effect October 1, 2023] she is looking and paying attention to see what I am doing is correct. There are some things that haven't been transmitted because of that. I usually transmit on Fridays unless she tells me not to and she wants to check something. Prior to October, I transmit every Friday. During the above interview, the MDS Coordinator/LPN H was asked if she has a policy or document she follows that gives her direction and timeframes. LPN H said, The RAI manual, it is like the bible of MDS. Also during the above conversation/interview with LPN H, the Corporate Nurse Consultant, Employee C, joined Surveyor C and LPN H. Employee C confirmed the facility follows the RAI manual. Employee C was shown Resident #274's assessment, which was incomplete, and awaiting RN signature. Employee C confirmed the findings. The facility policy titled, Electronic Transmission of the MDS, was reviewed. This policy read, Specific Procedures/Guidance: 1. Staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual, before being permitted to use the MDS information system. An electronic copy of the MDS RAI Instruction Manual is maintained by the MDS coordinator . The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, October 2023 was reviewed. On page 2-10 of the RAI Manual, it read, .Assessment Timing refers to when and how often assessments must be conducted, based upon the resident's length of stay and the length of time between ARDs. The table in Section 2.6 describes the assessment timing schedule for OBRA-required assessments, while information on the PPS assessment timing schedule is provided in Section 2.8. o For OBRA-required assessments, regulatory requirements for each assessment type dictate assessment timing, the schedule for which is established with the admission (comprehensive) assessment when the ARD is set by the RN assessment coordinator and the Interdisciplinary Team (IDT). In the RAI manual, the table in Section 2.6 was referenced, and gave the following time frames for completion of the MDS. Quarterly assessments have an MDS Completion date No Later than: ARD + 14 calendar days . admission assessments MDS completion Date is no later than 14th calendar day of the resident's admission (admission date +13 calendar days). The previous version of the RAI manual, prior to the October 2023 revision, had the same requirements/dates for transmission of MDS. Therefore, there were no changes to the timing of MDS transmission to CMS with the revisions in October 2023. On 10/19/2023 during the end of day meeting, the facility Administrator, Director of Nursing, and corporate staff were made aware of the concerns regarding the facility not completing MDS timely. No further information was provided.

2. For Resident #70, facility staff failed to develop and implement a plan of care for limited range of motion of the right upper extremity. On 10/17/2023 at approximately 1:35 p.m., Resident #70 was observed lying quietly in bed. During the course of an initial interview with Resident #70, he demonstrated a limited range of motion with his right arm, in particular, his right shoulder. His right wrist appeared to be contracted as he was unable to move or rotate his wrist joint. Resident #70 was unable to speak due to a history of stroke but was able to nod Yes or No appropriately. On 10/18/2023 at approximately 2:00 p.m., Resident #70's clinical record was reviewed and included the following: *A progress note dated 05/25/2023, date of admission to the facility, which read in part, .Patient does have right side weakness with verbal aphasia [inability to speak] due to a stroke .Pt [Patient] right arm is contracted and pt splint is to be worn when resting at night . *A baseline nursing care plan dated 05/25/2023, page 7, Item I, Neurological, Item 16, LOC, Item 4, Right Upper Extremity Movement/Grasps, had a check mark placed next to Item f, Unable to Do. *The current comprehensive care plan for Resident #70 did not address the limited range of motion to his right upper extremity. On 10/19/2023 at approximately 3:00 p.m., an interview was conducted with Employee E who stated she was responsible for the resident care plans. Employee E confirmed Resident #70's limited range of motion to his right arm. Employee E reviewed Resident #70's clinical record and current comprehensive care plan and stated, There is nothing on the care plan about his right arm weakness and contractures, I have assessed him myself and I know he has impairments with his right arm at minimum. I'm not sure how we missed this, but his range of motion deficits should absolutely be part of his care plan, we need to make sure that we are doing all that we can, so it doesn't get any worse if possible. A facility policy was requested and received. Review of the facility policy entitled, Care Planning--Comprehensive Person-Centered, page 3, item 13 read, The comprehensive care plan will: (a) Incorporate identified problem areas .(g) Aid in preventing or reducing declines in the resident's functional status and/or functional levels .(i) Enhance the optimal functioning of the resident by focusing on a rehabilitative program . On 10/19/2023 at the end of day meeting, the facility Administrator and Director of Nursing were updated on the findings. No further information was provided. For Resident #21, the facility staff failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the needs of the resident. On 10/20/2023, a review of the clinical record was conducted, and the following are excerpts from the care plan: FOCUS: The resident has limited physical mobility AEB [As Evidenced By] Date Initiated: 05/03/202. INTERVENTION: AMBULATION: The resident requires assistance) by (X) staff to walk (SPECIFY FREQ) and as necessary. Date Initiated: 05/03/2023 Revision on 05/05/202. FOCUS: The resident has (SPECIFY: URGE, STRESS, FUNCTIONAL, MIXED) bladder incontinence r/t [related to] Date Initiated: 05/03/2023. FOCUS: o The resident has (SPECIFY) pressure ulcer (SPECIFY LOCATION) or potential for pressure ulcer development r/t. Date Initiated: 05/03/2023. FOCUS: The resident has (SPECIFY acute/chronic) pain r/t Date Initiated: 05/03/2023. FOCUS: The resident has diabetic ulcer of the (SPECIFY location) r/t Date Initiated: 05/03/2023. On 10/20/2023 at 11:45 a.m., an interview was conducted with the DON, who was asked the purpose of a care plan, and she stated that care plans tell staff what the care needs of the resident are. When asked if they should be tailored to the needs of each resident, and she stated they should. When asked if a care plan should be specific to that individual resident, she stated it should. The DON was shown the care plan, and asked if the care plan should have been filled in where it says (Specify), and she stated it should have been. When asked if this was a comprehensive care plan, she stated it was supposed to be. When asked if the resident was on an anti-coagulant, she stated she was. When asked if that should be care planned, she stated it should have been. On 10/20/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided. Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive care plan for three residents (Residents #125, #70, and #21) in a survey sample of 39 Residents. The findings included: 1. For Resident #125, facility staff failed to implement and/or monitor for changes in behavior related to the use of psychotropic medications and/or dementia. On 10/17/2023 at 12:30 p.m., Resident #125 was observed in bed lying flat on his back. The resident was picking at the bed linens and pulling on his hospital gown repeatedly. The surveyor asked him if he needed help, and he replied in a stream of disjointed words in a rambling response.The surveyor asked Resident #125 his name, and other questions, the resident did not look up or respond to the surveyor. He simply kept picking at the gown, pulling it up, and attempting to disrobe. Review of the physician's orders in the clinical record revealed Resident #125 was currently receiving the following 3 psychotropic medications: 1. Buspar ER 100 mg (milligrams) ordered 09/28/2023, give every 12 hours at 9:00 a.m., and 9:00 p.m. for depression. 2. Seroquel 50 mg ordered 09/28/2023, give at 9:00 p.m. for anxiety. 3. Lexapro 20 mg ordered 10/12/2023, give at 9:00 a.m. for depression. On 10/18/23 after surveyor concerns were made known to the facility, the diagnosis for Seroquel was changed from Anxiety to Dementia. Review of the Registered Pharmacist (RPH) medication regimen review (MRR) was conducted. The review revealed a recommendation document from the RPH on 10/11/2023 indicating that Resident #125 had no defined target behaviors and no behavior monitoring nor side effect monitoring forms for the Seroquel medication. It further stated that informed consent for psychotropic medication administration had not been obtained, which would be received from the resident's Power of Attorney (POA), as the resident was not able to be his own decision maker, and no behavior modification record or form had been started regarding non-pharmacologic interventions. Review of the current care plan dated 09/28/2023, revised 10/05/2023 upon discharge to the hospital, but not revised on 10/12/2023 upon return to the facility, revealed only 3 care planned problem areas that could be related to dementia. In the first two focuses there are options given beside a direction for staff to SPECIFY which is to be observed for the individual resident. None were highlighted as individualized for Resident #125. The 3 care plan entries read: 1. FOCUS. The (name) resident uses psychotropic medications r/t (related to) depression. GOAL. The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment thru review date. Target date 12-27-23. INTERVENTIONS. Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (every shift). Consult with pharmacy, MD to consider dosage reductions when clinically appropriate at least quarterly. Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression toward staff/others. Etc.) and document per facility protocol. 2. FOCUS. The resident has impaired cognitive function/dementia or impaired thought processes. GOAL. The resident will remain oriented to (SPECIFY: person, place, situation, time) through the review date. Target date 12-27-23. INTERVENTIONS. Cue, reorient and supervise as needed. Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall, and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. 3. FOCUS. The resident has potential for psychosocial well-being problem. GOAL. The resident will have no indications of psychosocial well-being problem by/through review date. Target date 12-27-23. INTERVENTIONS. Monitor/document resident feelings relative to isolation, unhappiness, anger, loss). On 10/17/2023 and 10/18/2023, Resident #125 was experiencing cognitive/behavioral impairment, was attempting to disrobe, and had inappropriate or absent responses to verbal communication. These behaviors were not monitored nor documented anywhere in the clinical record. There were no non-pharmacologic interventions care planned for this Resident, and the interventions were not individualized for this resident. On 10/12/2023 at 8:00 p.m., nursing notes indicated the resident was Very confused . unscrewed bed remote .friend was going to come & pick him up shortly .Resident unplugged IV machine .had female visitor who stated he was very confused, and she couldn't understand what he was talking about. Nursing indicated they were placing him on 1:1 for safety precautions. This was not care planned. On 10/18/2023 in an interview with the Social Worker, when asked what should be in a care plan for patients with dementia, he stated there should be non-pharmacological interventions for specific behaviors and activities specific to residents with dementia. On 10/17/2023 and 10/18/2023 during the end of day debriefing, the Corporate RN, Administrator, and Director of Nursing (DON) were made aware of the findings. At the time of exit, they stated there was no further information available to submit to surveyors.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow standards of practice affecting one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, the facility staff failed to monitor for changes in condition, and for medication interactions, following the implementation of an antipsychotic medication. On 10/17/2023, Resident #14 was visited in her room by Surveyor C. Resident #14 was awake, able to engage in conversation with no difficulty, and appeared to have some memory loss. There was no obvious significant hearing deficit noted. During the interaction and observations of the room, it was noted by the Surveyor that Resident #14 had multiple over-the-counter medications in the room. They included 2 foil blister packets on the bed, a bottle of Tylenol, and 2 cans of jock itch spray. On 10/18/2023, Surveyor C visited Resident #14's room on 3 occasions, once mid-morning, once early afternoon, and again around 3:30 p.m. Each time, Surveyor C knocked on the resident's room door, entered the room, and called the resident's name. Resident #14 was observed laying on her bed asleep. Surveyor C got closer to the resident and called her name again, Resident #14 did not arouse. The over-the-counter medications remained at the bedside. The blister packs of medication were observed to be Mucinex and Nauzene. The Tylenol and jock itch spray remained in the room, and it was also noted that now there was Pepto Bismol present. On 10/18/2023 at approximately 3:30 p.m., Surveyor C interviewed CNA D. CNA D was in the hallway, outside of Resident #14's room and was filling a water pitcher with ice. CNA D was asked about Resident #14 and asked if she normally sleeps a lot. Surveyor C explained that she had attempted to visit the resident on several occasions, but the resident would not arouse. CNA D said he was in the hall filling the water pitcher to not awaken Resident #14. He said that normally she is awake. On 10/19/2023 at approximately 8:30 a.m., Surveyor C went to visit Resident #14 in her room again. Surveyor C knocked on the door, entered the room, and called the resident's name. Resident #14 did not respond. Surveyor C approached the bedside and observed Resident #14 asleep on top of the covers, with her dentures protruding from her mouth. Surveyor C called Resident #14's name again, with no response. The over-the-counter medications previously identified in the room remained present and in addition a container of Preparation H hemorrhoid cream was noted as well. On 10/19/2023 at approximately 9:00 a.m., Surveyor C interviewed CNA B and CNA E. They were asked if Resident #14 usually sleeps a lot and is hard to arouse. They said she does sleep at times, but is easily aroused. They were informed that Surveyor C had made multiple attempts to visit the resident yesterday and again this morning, but Resident #14 was asleep and not responding to her name being called. They stated this was not the resident's normal behavior, but she had awakened for breakfast. On 10/19/2023, an interview was conducted with CNA F. CNA F was asked about Resident #14. CNA F said he was not too familiar with the resident's pattern, but knew she stayed in her room a lot and would doze on and off at times. On 10/18/2023 - 10/19/2023, a clinical record review was conducted. A progress note dated 10/16/2023, was noted that read, Resident was seen by her outside PCP today. New order for Sulfamethoxazole 400 mg- Trimethoprim 80 mg, 1 tab every 8 hours x 7 days. Also an increase in Quetiapine/Seroquel to 50 mg once a day at bedtime. There was no indication that Resident #14's family member had been notified of the start of an antipsychotic medication. Review of the Medication Administration Record (MAR) for October 2023 revealed that Resident #14 was not receiving Seroquel prior to 10/16/2023. Resident #14 did receive a dose on 10/17/2023 and 10/18/2023. Physician's orders and the MAR revealed that that Resident #14 was started on Sertraline HCl oral tablet, (also known as Zoloft, which is an antidepressant) 50 mg, once daily for depression symptoms starting 08/12/2023. At the time of survey, this medication continued. It was also noted that the only order for over-the-counter medications that had been observed in the resident's room was for Preparation H, the other medications had no physician's order. Review of the progress notes revealed no evidence of any behaviors in the past 30 days that would have precipitated the medication change. On 10/18/2023 at 3:04 p.m., the Corporate Nurse Consultant identified the facility follows the Lippincott Nursing standards of practice for nursing care. On the afternoon of 10/19/2023, the facility Administrator, Director of Nursing, and Corporate staff were made aware that Resident #14 had multiple over-the-counter medications at the bedside and was displaying significant somnolence. The Corporate Nursing Consultant advised Surveyor C that the Administrator had removed 2 bottles of vodka from Resident #14's room earlier that day. Review of the facility policy titled, Administration Procedures for all Medications, was reviewed. This policy read, .IV. Administration: .8. Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift .13. Notify the attending physician and/or prescriber of: .c. Suspected adverse drug reactions. Review of the Nursing Drug Handbook revealed on pages 478-479 the following information regarding Quetiapine/Seroquel: Indications & Dosage: Management of signs and symptoms of psychotic disorders .Elderly: lower dosages, slower adjustment, and careful monitoring in initial dosing period . Adverse Reactions: CNS [central nervous system] dizziness, headache, somnolence, hypertonia, dysarthria, asthenia . Interactions: . Drug-lifestyle: Alcohol use: increased CNS effects. Use cautiously . Nursing Considerations: Use with caution in patients with WV or cerebrovascular disease or conditions that predispose to hypotension, in those with a history of seizure threshold, and in patients who will be experiencing conditions in which the core body temperature may be elevated . Patient teaching: .advise patient to avoid alcohol while taking drug. The Lippincott Manual of Nursing Practice, eighth edition, was reviewed. On page 18, in box 2-3, Common Legal Claims for Departure from Standards of Care, were noted to include, but not limited to: Failure to monitor or observe a change in a patient's clinical status, failure to communicate or document a significant change in a patient's condition to appropriate professional .Failure to observe a medication's action or adverse side effect . On the afternoon of 10/19/2023 during an end of day meeting, the facility Administrator, DON, and corporate staff were again made aware of the above concerns that Resident #14 was displaying significant somnolence and had a recent medication change that may be a contributing factor as well as the over-the-counter medications and alcohol that was noted in the room may be a contributing factor since they are unaware of what and how much the resident may be self-administering. There was no evidence of nursing monitoring for side effects. No further information was provided.

Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to provide assistance to one resident (Resident #274), who was dependent upon staff for activities of daily living, in a survey sample of 39 residents. The findings included: For Resident #274, the facility staff failed to provide baths to include hair care, which resulted in the resident's hair becoming matted and having to be cut. On 10/17/2023 at 1:58 p.m., Resident #274 was visited in his room. Observations revealed that Resident #274's hair appeared uncombed, and it being matted in the back of his hair was noted. Resident #274 was asked about baths and showers, and he stated he had not been out of bed since his admission, which was 09/27/2023. On 10/18/2023 at 11:14 a.m., Resident #274 was visited in his room again. It was noted that his hair still appeared uncombed, and the resident said he had asked to be shaved and said, They said if they can't get to it today, they will do it tomorrow. Later in the afternoon, Surveyor C visited Resident #274 and noted he had been shaven. When asked if he was bathed, he said, Just a wash up, and his hair was still uncombed. On 10/19/2023 at 11:56 a.m., Resident #274 was visited in the dining room. Resident #274 commented that it felt good to be up and out of the bed. When asked if he had a shower, he said, No. Surveyor C commented that he looked nice sitting up, and the resident went on to say, They cut my hair because it had knots in it. On 10/19/2023 at 1:45 p.m., an interview was conducted with CNA B. CNA B was asked about showers and said they are given twice weekly and have a schedule at the nursing station. CNA B was asked about Resident #274's report that his hair had been cut. CNA B acknowledged she had cut the resident's hair and said, He wanted me to, you couldn't get a comb through the knots. She then asked if this was a problem. On 10/19/2023, a clinical record review was conducted. Review of the bathing records for Resident #274 revealed that from 10/06/2023 - 10/19/2023, the Resident was only provided partial baths or a bed bath. There was no evidence that Resident #274 had been offered a shower or tub bath. Review of the nursing notes revealed no documentation that the resident had refused. Review of Resident 274's care plan revealed the resident Has an ADL self-care performance deficit AEB [as evidenced by] bilateral amputees and kidney cancer. The intervention for this care plan read, Physical assist as needed with all ADL's . Review of the facility's bathing schedule indicated the assigned room for Resident #274 was scheduled for a bath on Mondays and Thursdays during the 3:00 p.m. - 11:00 p.m. shift. On 10/19/2023 at 4:28 p.m., the Director of Nursing (DON) and corporate clinical consultant were made aware of the above findings. They were asked to provide any information they had regarding baths/showers being provided for Resident #274, as the surveyor was not able to find any documentation. A review was conducted of the facility policy titled, Activities of Daily Living (ADLs). The policy read, .4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law . On 10/19/2023 at 5:25 p , the Administrator was made aware of the above findings. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide proper foot care to 1 resident (Resident #67) in a survey sample of 39 residents. The findings included: For Resident #67, the facility staff failed to have her seen by podiatry for cutting her toenails as she is diabetic and on an anti-coagulant medication for history of Transient Ischemic Attack (TIA). On 10/17/2023 at approximately 2:00 p.m., Resident #67 was observed in the hall sitting in her wheelchair wearing open toe sandals. Her toenails were clearly visible, and they were jagged and at least 1/4 inch long. Resident #67 has a Brief Interview of Mental Status (BIMS) score of 0/15 and could not follow the line of questions. On 10/18/2023 at approximately 11:00 a.m., an observation was made of Resident #67 sitting in her wheelchair in her room and she was not wearing shoes or socks. Her toenails were clearly visible and had not been trimmed. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with CNA C who was asked if residents get their nails cut by staff. CNA C stated the CNA assigned to the resident will clean and trim fingernails if they are not a diabetic or if they do not take blood thinners. She stated if they are diabetic or they are on blood thinners, the nurse must do it. On 10/19/2023 at approximately 2:30 p.m., an interview was conducted with LPN E who stated that she personally does not cut the nails or toenails of any residents that are diabetic or on anti-coagulants. She stated she makes the unit manager or the DON aware, so they can be put on the podiatry list for feet, or the RN/DON can do the fingernails. When asked if she had looked at Resident #67's nails, she stated they needed to be trimmed, and she would notify the DON. On 10/20/2023, a review of the clinical record was conducted. Resident #67 had not seen the podiatrist since her arrival at the facility in June. On 10/20/2023, the podiatry list was reviewed and found that Resident #67 had not been on the list for July, August, September, or October. A fax was sent by the DON to add Resident #67 to the list for November. On 10/20/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on observation, staff interviews, and facility documentation review, the facility staff failed to ensure 1 of 2 nursing units was safe and free of accident hazards. The findings included: The facility staff failed to ensure that one resident unit was free of accident hazards/over-the-counter medications, which were accessible to residents who are confused and wander. On 10/17/2023 at approximately 12:30 p.m., Surveyor C made observations on one of the nursing units. It was noted in Resident #14's room, multiple items were observed that could pose as a safety hazard to confused residents. The items included over-the-counter medications, Mucinex, Nauzene, Tylenol, and jock itch spray. During the above observation, it was noted there were residents who wander ambulating independently within the hall. During residents' interviews, Resident #38 verbalized there is a resident who wanders into her room and takes her items. On 10/18/2023 during mid-morning, observations were made in Resident #14's room. During this observation, the Mucinex, Nauzene, Tylenol, and jock itch spray were all still present and accessible. In addition, Pepto Bismol was noted. On 10/19/2023 during the early afternoon, Resident #14 was visited in her room again. All the above noted medications were still present, and in addition, Preparation H cream was noted sitting on top of the 3-drawer storage bin. Resident #14 was asked about the items, and she said she puts the Preparation H on herself. When asked where she obtained the items from, the resident was unsure. On 10/19/2023 at 11:21 a.m., an interview was conducted with the Director of Nursing (DON). The DON said they do not have any residents who self-administer medications. When asked how would the medications that would be self-administered be stored, the DON said, In a lock box. When asked why a lock box is used to store the medications, the DON said, Because I wouldn't want anyone else to have access to it, and confirmed they do have residents that wander and go into other residents' rooms, and it would pose as a safety hazard. On the afternoon of 10/19/2023, the facility Administrator, Director of Nursing and Corporate staff were made aware that Resident #14 had multiple over-the-counter medications at the bedside. The Corporate Nursing Consultant advised Surveyor C, that the Administrator had removed 2 bottles of vodka from Resident #14's room earlier that day. On 10/20/2023 prior to conclusion of the survey, the facility staff provided the survey team with a listing of items removed from Resident #14's room. The list included, Mucinex, Pepto Bismol, acne treatment, Preparation H gel, Tylenol, Diclofenac Gel, Preparation H cream, jock itch spray, Nauzene, Salonpas patches, which are all over-the-counter medications. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and facility documentation, the facility staff failed to provide medications as ordered by the physician to 1 resident (Resident #53) in a survey sample of 39 residents. The findings included: For Resident #53, the facility staff failed to administer Gabapentin as ordered by the physician. On 10/29/2023 during clinical record review, it was found that the facility staff failed to acquire the medication, Gabapentin, for administration to Resident #53. Resident #54 had an order for Gabapentin as follows: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth at bedtime related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY (G90.09) -Start Date 10/05/2023. The following excerpts are from the progress notes for Resident #53 regarding the Gabapentin: 10/13/2023 9:35 PM Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth at bedtime related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY Medication on order from the pharmacy, signed prescription received. 10/15/2023 9:13 PM Medication on order from the pharmacy, signed prescription received. MD is aware. 10/17/2023 9:12 PM- Note Text: Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth at bedtime related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY (G90.09) Resident medication is awaiting signed prescription be sent to the pharmacy. MD aware. 10/18/23 at 9:29 PM-Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth at bedtime related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY (G90.09) - Medication has not been received from the pharmacy yet. Nurse called the pharmacy at [phone number redacted] to check the status of the medication order and was informed that the signed prescription was never received. Prescription re-printed and a message was sent to [MD name redacted] at [phone number redacted] to please fax the prescription to [phone number redacted]. Resident #53 had the following order for Apixaban (also known as Eliquis, an anti-coagulant): Apixaban (an anti-coagulant) Tablet 5 MG Give 1 tablet by mouth two times a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA -Start Date_12/21/2022. The following excerpts are from the progress notes for Resident #53 regarding the order for Apixaban: Effective Date: 09/02/2023 09:13 AM Type: Orders - Administration Note Text: Resident refused Apixaban related to surgery on the 7th. of Sept. On 10/20/2023, an interview was conducted with the DON who stated, Medications that are not signed off or not given should have documentation of physician notification and Resident Representative notification, and any medications marked as hold, should have a valid physician's order to hold. On 10/20/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on observation, interview, and facility documentation, the facility staff failed to appropriately label medication with accepted professional principals in 1 of 2 medication refrigerators. The findings included: For the medication refrigerator located on the skilled unit, the staff failed to date when opened a multi-use vial of Tubersol solution used for Tuberculin testing. On 10/19/2023 at approximately 4:00 p.m., an inspection of the medication room and refrigerator was conducted. LPN F was asked what was missing on the multi-use vial of Tubersol found in the refrigerator. LPN F looked at the bottle and stated the date should have been placed on the label when the vial was opened. When asked why that should happen, LPN F stated, The vial is only good for 30 days. If you do not label it, you do not know when it was opened and therefore you will not know when the expiration date is. According to the manufacturer instructions on the product: Sanofi Pasteur - TUBERSOL® Package Insert. A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. On 10/20/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on observation, resident interview, facility staff interview, and facility documentation review, the facility staff failed to ensure a functioning call bell was present for one resident (Resident #59) in a survey sample of 39 residents. The findings included: For Resident #59, the facility staff failed to ensure a call bell was present and functioning in the bathroom. On 10/17/2023 at 1:49 p.m., an interview was conducted with CNA B. CNA B was asked about the call bells, to explain their purpose, where they are located, etc. CNA B stated, The call bell is how the residents let us know if they need something. On 10/18/2023 at 8:30 a.m., an interview was conducted with Resident #59. During this interview, Resident #59 said that her call bell in the bathroom does not work. She did acknowledge she has had falls previously in the bathroom. Surveyor C went to the bathroom and pulled the string/pull cord, which did not engage the call bell/light and auditory alarm for staff. Resident #59 reported the call bell had not worked for about a month, which was the length of time she had been in that room. On 10/18/2023, a clinical record review was conducted of Resident #59's chart. This review included a care plan revision dated 10/12/2023, which read, The resident has an ADL [activities of daily living] self-care performance deficit AEB [as evidenced by] need for limited assist with ADL completion. One of the associated interventions read, Encourage the resident to use bell to call for assistance. There was an additional care plan focus area with a revision date of 01/30/2023, that read, The resident has had an actual fall with minor injury 12/2022. Additional risk related to sleep aid, incontinence with diuretic use, and polyneuropathy. The interventions for this focus area read, Call bell within reach. Additional clinical record review was conducted, which included the review of progress notes and assessments. There was no indication that Resident #59 had sustained any recent falls in the bathroom related to the inability to call for assistance. Resident #59 was interviewed, and she said there was one time she needed to call for help to get off the toilet, but was unable to since the call bell would not work but had not fallen or had any injury as a result. On 10/19/2023 at approximately 2:00 p.m., Surveyors C and E, interviewed LPN G. LPN G said the call bell is used for the resident to alert facility staff if they need assistance. LPN G was asked to pull the cord of the call bell in Resident #59's bathroom and see if it would work. LPN G did and confirmed the call bell would not engage by pulling the string, which is how the resident would use the bell if sitting on the toilet and needed assistance. On 10/19/2023 at 2:15 p.m., the facility Administrator was made aware of the call bell not working in Resident #59's room, she went to the room with Surveyors C and E, and confirmed the findings. The Administrator stated that monthly call bells audits are conducted. On 10/19/2023 at 3:11 p.m., the Administrator provided call system monthly audit forms, which indicated the room's call lights were functioning properly. The form had the month and year and no date as to when the audit was completed. On the afternoon of 10/19/2023, the facility Administrator was observed working on the call bell in Resident #59's bathroom. The facility policy titled, Answering the Call Light, was provided and reviewed. The policy read, The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely responses to the resident's requests and needs .7. Report all defective call lights to the licensed nurse and the maintenance promptly. No further information was received.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to transmit resident assessments/Minimum Data Set (MDS) in a timely manner to Centers for Medicare & Medicaid Services (CMS) for 8 residents (Residents #1, #2, #33, #36, #39, #61, #63, and #68) in a survey sample of 39 residents. The findings included: 1. For Residents #1, #2, #33, #36, #39, #61, #63, and #68, the facility staff failed to transmit the MDS to the CMS system within the required timeframe of 14 days. On 10/19/2023 at 8:50 a.m. during the completion of the survey process, clinical record reviews were conducted of Residents #1, #2, #33, #36, #39, #61, #63, and #68's MDS assessments with particular attention to the date(s) they were transmitted to CMS. The following was noted: a. Resident #1 had a quarterly MDS with an Assessment Reference Date (ARD) of 08/27/2023, completed on 09/11/2023. This assessment was not transmitted to CMS until 10/16/2023. Review of the transmission batch report revealed this assessment had been rejected by the CMS system; therefore, it was still not accepted as being transmitted. b. Resident #2 had a quarterly MDS with an ARD of 09/13/2023, completed on 09/22/2023. This assessment was not transmitted to CMS until 10/16/2023, which exceeded the required 14 days from completion. c. Resident #33 had a quarterly MDS with an ARD date of 08/23/2023 completed on 09/06/2023. This assessment was not transmitted to CMS until 10/13/2023. The following assessments were transmitted to CMS late: quarterly assessment with an ARD of 09/08/2023 was completed on 09/30/2023. This assessment was not transmitted to CMS until 10/16/2023. Another quarterly MDS with an ARD date of 09/22/2023 was completed on 9/30/23. This assessment was not transmitted to CMS until 10/16/2023. d. Resident #36 had a quarterly MDS with an ARD of 09/01/2023. This assessment was completed on 09/17/2023, and was not transmitted to CMS until 10/16/2023. e. Resident #39 had a Quarterly MDS with an ARD of 08/22/2023 and was completed on 09/06/2023. This assessment was not transmitted to CMS until 10/13/2023. The resident also had an annual MDS with an ARD of 09/08/2023. The assessment and care plan were completed on 09/17/2023. This assessment was not transmitted to CMS until 10/16/2023. f. Resident #61 had a Discharge, Return Not Anticipated assessment with an ARD of 09/08/2023. The assessment was completed on 09/08/2023 and was not transmitted to CMS until 10/13/2023. g. Resident #63 had a quarterly MDS with an ARD of 08/24/2023 completed on 09/06/2023. This assessment was not transmitted to CMS until 10/13/2023. h. Resident #68 had a quarterly MDS with an ARD of 09/01/2023. The assessment was completed on 09/30/2023 and was not transmitted to CMS until 10/16/2023. On 10/19/2023 at 10:34 a.m., an interview was conducted with the facility's MDS nurse/LPN H. LPN H was asked to explain the frequency and timing of MDS. LPN H said, They all have dates and times they need to be done. When asked to explain the time frames and how she knows when they have to be completed and transmitted, LPN H stated, The computer tells me. LPN H then showed Surveyor C in the electronic health record where dates are noted when assessments must be completed and transmitted. It was noted that some of the dates were in black text, some in red text, and some in green text. When asked what the different colors meant, LPN H was unsure. LPN H was asked about the transmission of MDS to CMS. LPN H said, Transmitting to the state is actually done by my regional, I am an LPN so my RN has to sign for me, and normally the RN that signs for me is my regional. She signs and then will transmit. She will give me the ok to transmit. LPN H also stated, We started the new things in Oct. [referring to the MDS changes that went into effect October 1, 2023] she is looking and paying attention to see what I am doing is correct. There are some things that haven't been transmitted because of that. I usually transmit on Fridays unless she tells me not to and she wants to check something. Prior to October, I transmit every Friday. During the above interview the MDS Coordinator, LPN H, was asked if she has a policy or document she follows that gives her direction and timeframes. LPN H said, The RAI manual, it is like the bible of MDS. LPN H was then asked to pull up several of the above residents, which included Resident #1, #33, and #36. LPN H was shown that the text in red meant that the MDS was completed or transmitted late. LPN H confirmed the findings. Also during the above conversation/interview with LPN H, the Corporate Nurse Consultant, Employee C, joined Surveyor C and LPN H. Employee C confirmed that MDS are to be transmitted within 14 days of completion. Employee C later in the morning approached Surveyor C and said he had spoken to the corporate MDS person, and found out they had some difficulty with the third-party vendor/system they use to transmit MDS around the beginning of October. Employee C was asked to provide any evidence and/or documentation of where they had communicated with the third-party vendor or CMS about the issues they were having. Nothing further was submitted. The facility policy titled, Electronic Transmission of the MDS, was reviewed. This policy read, Specific Procedures/Guidance: 1. Staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual, before being permitted to use the MDS information system. An electronic copy of the MDS RAI Instruction Manual is maintained by the MDS coordinator . The facility policy titled, MDS Completion and Submission Timeframes, was reviewed. This policy read, The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Specific Procedures/Guidance: 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, October 2023 was reviewed. On page 5-3 of the RAI Manual, it read, .Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . The prior version of the RAI manual was reviewed and it noted the same requirements/dates for transmission of MDS. Therefore, there were no changes to the timing of MDS transmission to CMS with the revisions made in October 2023. On 10/19/2023 during the end of day meeting, the facility Administrator, Director of Nursing, and corporate staff were made aware of the concerns regarding the facility not transmitting MDS timely to CMS. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide influenza and pneumococcal vaccines for 5 residents (Residents #124, #125, #274, #275, and #276), in a survey sample of 5 residents reviewed for immunizations. The findings included: 1. The facility staff failed to provide education of the risks/benefits about influenza immunization, and offer flu vaccines for Residents #125, #274, #275, and #276. On 10/18/2023, clinical record reviews were performed and revealed the following: Residents #125, #274, #275, and #276, had no immunization information under the immunization tab of their clinical record. The miscellaneous tab and progress notes were reviewed, and revealed no evidence of the residents' immunization status regarding the flu and had no evidence that education had been provided or the vaccine offered. On 10/19/2023 at 4:28 p.m., Surveyor C met with the Director of Nursing (DON), who was also the facility's Infection Preventionist. During the above interview, the DON was asked to access each of the residents' clinical records and identify their vaccine status regarding the flu. The findings were as follows: a. Resident #125 was admitted to the facility on [DATE]. The DON confirmed he had not been educated or offered the flu vaccine and his current immunization status was unknown. b. For Resident #274, who was admitted to the facility on [DATE], there was no information regarding the flu vaccine noted. c. For Resident #275, the DON confirmed the resident was admitted to the facility on [DATE]. The DON also confirmed the resident's immunization status for flu was unknown, and they had not been educated nor offered the vaccine. d. For Resident #276, who was admitted to the facility on [DATE], the facility had no information regarding the flu vaccine status, being educated, or offered the vaccine. 2. The facility staff failed to provide education of the risks/benefits about pneuococcal immunization, and offer pneumococcal vaccines for Residents #124, #125, #274, #275, and #276. On 10/18/2023, clinical record reviews were performed and revealed the following: Residents #124, #125, #274, #275, and #276, had no immunization information under the immunization tab of their clinical record. The miscellaneous tab and progress notes were reviewed and revealed no evidence of the residents' immunization status regarding pneumonia vaccines, and had no evidence that education had been provided or the vaccine offered. On 10/19/2023 at 4:28 p.m., Surveyor C met with the Director of Nursing (DON), who was also the facility's Infection Preventionist. The DON accessed each of the residents' clinical records (Residents #124, #125, #274, #275, and #276), and confirmed they did not know the residents' pneumonia immunization status and had no evidence of the residents being educated and/or offered the vaccine. On 10/19/2023 at 4:28 p.m., the DON was asked, Why is it important to know someone's immunization status? The DON stated, You want to know if they are protected from whatever, you don't want to administer a vaccine if they are allergic to it or have already had it, and because we live in a community lifestyle, we want to keep people as protected as possible. The DON stated on admission the facility should identify the resident's immunization status, educate them on vaccines, and offer any vaccines the resident is eligible for. The DON was asked to explain the process about immunizations. The DON stated, I am the only one with access to the VIIS [Virginia Immunization Information System] system, so I do it in the first couple of days. I look to see their immunization status for COVID, pneumonia and flu. We are doing the flu vaccines right now. The DON also stated she has the flu vaccine in-house and on hand and can administer it when a resident requests and/or consents to it. The facility policy titled, Influenza Vaccination, was received and reviewed. Excerpts from this policy read as follows: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility will provide pertinent information about the significant risks and benefits of vaccine to staff and residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy .1. Residents and employees of the long-term care facility will be offered the influenza vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control and/or ACIP [Advisory Committee on Immunization Practices]. The Advisory Committee on Immunization Practices gives guidance in their document titled, Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, 2023-24. The recommendations read, .Summary of Recommendations .Groups recommended for vaccination: Routine annual influenza vaccination is recommended for all persons aged = 6 months who do not have contraindications . Adults Aged = 65 Years: ACIP recommends that adults aged = 65 years preferentially receive any one of the following higher dose or adjuvanted influenza vaccines: quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If none of these three vaccines is available at an opportunity for vaccine administration, then any other age-appropriate influenza vaccine should be used. Accessed online at: https://www.cdc.gov/flu/pdf/professionals/acip/acip-2023-24-Summary-Flu-Vaccine-Recommendations.pdf The facility policy titled, Pneumococcal Vaccine, was reviewed. The policy read, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Residents of the long-term care facility will be offered the pneumococcal vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control and/or ACIP. 3. Before offering pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization. On 10/19/2023 during an end of day meeting, the facility Administrator, Director of Nursing, and Corporate staff were made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer COVID-19 vaccines for 4 residents (Residents #125, #274, #275, and #276) in a survey sample of 5 residents reviewed for immunizations and 5 staff (Staff #1, #2, #3, #4 and #5). The findings included: 1. For Residents #125, #274, #275 and #276, the facility staff failed to provide COVID-19 immunization, to include education of risks/benefits about COVID-19 immunization. On 10/18/2023, a clinical record review was conducted of each of the residents' clinical charts. There was no information noted that indicated the residents' current COVID-19 immunization status, no evidence they had been educated on the risk/benefits of immunization, and no evidence they had been offered the COVID-19 immunization. On 10/19/2023 at 4:28 p.m., an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Residents #125, #274, #275, and #276 and verified the findings. The DON confirmed there was no information regarding the residents' COVID-19 immunization status, nor any evidence of any education or offer to receive the COVID-19 immunization following admission to the facility. During a survey entrance conference, the facility's policy regarding COVID-19 immunizations was requested and received. A review of the facility policy entitled, COVID-19 Vaccinations for Residents, was conducted. It stated under the subtitle, Specific Procedures/Guidance, item 1, Prior to admission, the facility will validate COVID-19 vaccination status. 2. Resident/resident representatives will be educated on: a. risks/benefits of COVID-19 vaccination .b. current CDC guidelines for vaccination of residents for COVID-19 and; c. Symptoms, risks and benefits associated with the COVID-19 virus. 3. Residents will be encouraged to accept COVID-19 vaccinations in accordance with CDC guidance. The Centers for Disease Control and Prevention (CDC) document titled, CDC COVID-19 Vaccination Program Provider Requirements and Support, dated 10/06/2023, gives guidance to providers. The document read, On Monday, Sept. 11, 2023, the FDA took action authorizing and approving the updated 2023-2024 monovalent XBB.1.5 variant mRNA COVID-19 vaccines by Moderna and Pfizer-BioNTech. On September 12, 2023, CDC recommended use of these updated 2023-2024 COVID-19 vaccines in all individuals ages 6 months and older. And, on October 3, 2023, FDA authorized the updated 2023-2024 monovalent XBB.1.5 variant Novavax COVID-19 Vaccine, Adjuvanted, which is recommended by CDC for use in individuals 12 years and older. Accessed online at: https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html#print The U.S. Food and Drug Administration (FDA) document titled, Novavax COVID-19 Vaccine, Adjuvanted Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) Authorized for Individuals [AGE] years of age and Older, was accessed. It read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart. Immunocompromised individuals: an additional dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at least 2 months following the last dose of a COVID-19 vaccine (2023-2024 Formula). Additional doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at the discretion of the healthcare provider, taking into consideration the individual's clinical circumstances. The timing of the additional doses may be based on the individual's clinical circumstances. Accessed online at: https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted On 10/19/2023 during the end of day meeting, the facility Administrator, Director of Nursing and corporate staff were made aware of the findings. No further information was provided. 2. For facility Staff #1, #2, #3, #4, and #5, the facility staff failed to maintain documentation that staff were provided education on the risks/benefits of the COVID-19 vaccine and were offered the vaccine, or information on obtaining the vaccine. On 10/19/2023 at 4:28 p.m., an interview was conducted with the Director of Nursing (DON). The DON was given the names of the staff sample being reviewed for immunizations and asked to provide any evidence she had regarding their immunization status and education of immunization benefits and risks. On the morning of 10/20/2023, the DON provided Surveyor C with the staff immunization information she had on file. It included the following: a. For Staff #1, a copy of the staff's COVID-19 vaccination record card was provided that was emailed to the human resources director that morning. It indicated that Staff #1 had received 2 doses of a COVID-19 vaccine in 2021. There was no evidence of any education, offer, or information to obtaining COVID-19 booster vaccines. b. For Staff #2, a copy of the staff member's COVID-19 vaccine record card was submitted that indicated she had received 2 doses of the COVID-19 vaccine in 2021. There was no evidence submitted regarding education, offer, or information on how to obtain COVID-19 booster vaccines. c. For Staff #3, a copy of the staff member's COVID-19 vaccine record card was submitted that indicated she had received 2 doses of the COVID-19 vaccine in 2021. There was no evidence submitted regarding education, offer, or information on how to obtain COVID-19 booster vaccines. d. For Staff #4, a copy of the staff member's COVID-19 vaccine record card was submitted that indicated she had received 3 doses of the COVID-19 vaccine, with the last dose being administered 03/18/2022. There was no evidence submitted regarding education, offer, or information on how to obtain COVID-19 booster vaccines. e. For staff #5, no information was submitted. In the early afternoon of 10/20/2023, the DON was asked to clarify if she had any additional information to show the employees had been educated on, offered, or given information on how to obtain the 2023-2024 Formula COVID-19 vaccine. The DON stated she had nothing further to submit. No facility policy regarding COVID-19 immunizations for facility staff was provided to the survey team. The Centers for Disease Control and Prevention (CDC) document titled, CDC COVID-19 Vaccination Program Provider Requirements and Support, dated 10/6/23, gives guidance to providers. The document read, On Monday, Sept. 11, 2023, the FDA took action authorizing and approving the updated 2023-2024 monovalent XBB.1.5 variant mRNA COVID-19 vaccines by Moderna and Pfizer-BioNTech. On September 12, 2023, CDC recommended use of these updated 2023-2024 COVID-19 vaccines in all individuals ages 6 months and older. And, on October 3, 2023, FDA authorized the updated 2023-2024 monovalent XBB.1.5 variant Novavax COVID-19 Vaccine, Adjuvanted, which is recommended by CDC for use in individuals 12 years and older. Accessed online at: https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html#print The U.S. Food and Drug Administration (FDA) document titled, Novavax COVID-19 Vaccine, Adjuvanted Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) Authorized for Individuals [AGE] years of age and Older was accessed. It read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart. Immunocompromised individuals: an additional dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at least 2 months following the last dose of a COVID-19 vaccine (2023-2024 Formula). Additional doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at the discretion of the healthcare provider, taking into consideration the individual's clinical circumstances. The timing of the additional doses may be based on the individual's clinical circumstances. Accessed online at: https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted On 10/20/2023 during the end of day meeting, the facility Administrator, Director of Nursing and corporate staff were made aware of the findings. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, having the potential to affect all 72 residents residing in the facility. The findings included: The facility staff failed to maintain an effective QAPI program that was sustained during transitions in leadership and staffing, regarding call bells, abuse protocol, and resident and staff immunizations. Throughout the survey conducted 10/17/2023 - 10/20/2023, the survey team inspected and investigated the facility's systems and processes regarding correcting previously cited deficiencies and resident care concerns. It was noted the facility had several systemic failures and remained out of compliance in several areas that had previously been cited as deficient during a standard survey conducted 04/11/2023 - 04/13/2023. 1. The facility staff failed to maintain an effective QAPI program regarding their resident call bell system and staff response to call bells. On 10/17/2023, the survey team noted that two residents (Residents #70 and #274), who had no other means to call facility staff for assistance, did not have a call bell in reach. Another resident (Resident #59) was noted to have a call bell that was not functioning. Review of the facility grievances revealed concerns expressed by Resident #54 of his call bell not being answered timely and being told if he put his call bell on staff would not answer it. Review of the facility's policy titled, Answering the call light, it was noted, .QAPI. 1. Resident/resident representatives concerns regarding timeliness of answering call bells will be referred to the Director of Nursing, Grievance officer and/or administrator for investigation and follow up. 2. Grievances regarding call bell response time will be monitored through the facility Quality Assurance Performance Improvement Committee. 2. The facility staff failed to maintain an effective QAPI program regarding their abuse protocol and policy. It was noted that during a standard survey conducted at the facility 04/11/2023 - 04/13/2023, the facility failed to report an allegation of neglect. As part of their plan of correction they stated the following, .3. The leadership of the facility have been provided education on the [corporate ownership name redacted] Abuse and neglect policy by the regional nurse consultant. The Director of Nursing will provide campus wide education on [corporate ownership name redacted] Abuse and Neglect policy. 4. The facility Interdisciplinary Team (IDT) will complete an audit of all FRI for 8 weeks. Results of the audits will be reported monthly by the NHA [nursing home administrator] to the QAPI Committee x 3 months. The facility QAPI Committee is responsible for the on-going monitoring of Compliance. On 10/17/2023, a review of the facility grievance log revealed on 07/20/2023, Resident #54 was threatened by a CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit mgr. dated 7/20/23]. The facility staff had failed to identify the allegation of abuse and neglect as such and responded to it as a service concern. The facility staff failed to conduct an investigation, report the incident, and take measures to protect the resident from any alleged perpetrators while an investigation was conducted. There was also evidence that Resident #14 had been the victim of financial exploitation while a resident of the facility. The facility staff had conducted an investigation and involved outside agencies to include the Ombudsman and Adult Protective Services. Resident #14 was found to have been exploited by a family member, who was also a resident of the facility. Despite having knowledge of Resident #14 being a victim of financial exploitation, they continued to allow Resident #14's perpetrator to have unrestricted access to her, as evidenced by, the facility Administration indicated that Resident #14 was found to have vodka in her room during the survey and it was removed by the facility Administrator. The facility administration stated they felt the family member, who was previously found guilty of financial exploitation, had provided it to Resident #14. Review of the facility's policy titled, Abuse Prevention Program, was conducted. An excerpt from this policy read, .9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. 3. The facility staff failed to maintain oversight from the QAPI committee to ensure ongoing infection control systems and procedures were sustained during changes in staffing. It was noted during a standard survey conducted at the facility 04/11/2023 - 04/13/2023, the facility failed to maintain an effective infection control program based on nationally approved standards for immunization(s) for residents and facility staff. As part of their plan of correction they indicated, 2 .The facility completed a facility wide audit of resident immunizations. The DON or designee will complete an audit of all residents to ensure education was provided on the benefits and potential side effects of the influenza immunization and the pneumococcal vaccines. In addition to the education the facility will offer the immunization and vaccines to the residents. 3. The Interdisciplinary team of the facility will be educated by the Director of Nursing or designee on the company policy and CDC guidance for Immunizations and vaccines. 4. The Facility will audit the status of 3 residents weekly for 8 weeks, and all new admissions. New Admissions will also be provided the education on benefits and potential side effects of the immunization and vaccines. Results of the audit will be reported monthly to the facility QAPI Committee x 3 months. The QAPI Committee is responsible for the on-going monitoring of compliance. During this survey, a sample of 5 recently admitted residents was selected for immunization review. All 5 were noted to be deficient regarding being provided education and being offered immunization for flu or pneumonia. On 10/20/2023 at 1:58 p.m., an interview was conducted with the facility Administrator and Corporate Nurse Consultant, Employee C. During this interview, the QAPI program/plan was reviewed. The Administrator and Employee C stated the purpose of the QAPI program is to identify anything from the previous month and implement system changes to bring the facility into compliance. They indicated, The organization has a standardized system to identify issues. When asked if previously survey results are reviewed, Employee C stated, It does include survey results from past surveys and if we wrote a plan of correction, we designate that action to our QA, and they monitor ongoing compliance. If we feel we meet substantial compliance, we take it off [meaning the QAPI committee stops the monitoring of that item]. The facility Administrator was asked to reference their previously submitted and approved plan of correction for the survey ending 04/13/2023 regarding resident immunizations. The Administrator read the plan of correction and was asked if the QAPI committee provided oversight? Employee C said, The reality is the plan we developed incorporated the Infection Preventionist Nurse, when that position turned over, it appears we did not adjust our plan. When the position turned over, we didn't go back and identify that. Employee C was asked, Is it fair to say, you made some changes, and the results would have been talked about for 3 months? He said, I'm thinking we resolved both of them in July. We felt the process was hard wired and the process was effective. We would have fixed it if we had known it. It could have been something that was missed. When that role [Infection Preventionist] transitioned, it fell through the cracks. Review of the facility policy titled, Quality Assurance Performance Improvement (QAPI) Committee, was conducted. Excerpts from this policy read as follows, The facility will maintain systems and processes to ensure that the quality assurance/performance improvement program identifies and addresses issues and/or risks and that implements corrective action plans as necessary. All appropriate and reasonable efforts will be made, and resources provided to maintain compliance with applicable regulations for nursing facilities and needs of residents .2. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to resident based on performance indicator data, and resident, resident representative, provider and staff input, and other information . 3. iii. Action plans, corrective and preventative, will be developed and monitored for quality improvement based on identified opportunity. After implementing those actions, the facility will monitor and measure the success, and track performance to ensure that improvements are realized and sustained . 13. The QAPI program is sustained during transitions in leadership and staffing. No further information was provided.

Based on interview clinical record review and facility documentation the facility staff failed to ensure medications were available for 1 resident (Resident #4) in a survey sample of 6 residents. The findings included. For Resident #4, the facility staff failed to ensure the provision of routine medications for diabetes type II. On 6/13/23 during a review of the clinical record it was discovered that Resident #4 had the following orders: Alpha-Lipoic Acid Oral Tablet 300 MG [milligrams] (Alpha-Lipoic Acid (Thioctic Acid) Give 1 tablet by mouth two times a day. for type 2 DM [Diabetes Mellitus] -Start Date-06/01/2023 1700 Benfotiamine Oral Capsule 150 MG (Benfotiamine) Give 2 capsule by mouth two times a day for DM neuropathy related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9); UNSTEADINESS ON FEET (R26.81)-Start Date-06/02/2023 0900 The Medication Administration Record from 06/01/2023 (for the Alpha-Lipoic Acid) and 06/02/2023 (for the Benfotiamine) through 06/13/2023 were signed off with a 9 indicating to see the nurses' notes. A review of the progress notes read either, Med Unavailable or Awaiting arrival from pharmacy all parties aware or awaiting arrival. On 6/14/23 at approximately 3:30 PM, an interview was conducted with the Director of Nursing and the Administrator who both stated that if medications are not available from the pharmacy, the nurses should check the stat box, notify the supervisor, call the physician to see if an alternate is available, and notify the Responsible Party of the medication unavailability. On 6/14/23 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive hydration care plan for 1 Resident (Resident #125) in the survey sample of 34 residents. The findings included: For Resident #125, the facility staff failed to develop and implement a hydration care plan for a Resident with known congestive heart failure and dehydration. Resident #125 was first admitted to the facility on [DATE] and discharged [DATE]. Resident #125 had an admission minimum data set assessment which coded the Resident with a Brief Interview of Mental Status score indicating cognitive impairment. The Resident was totally dependent on staff for activities of daily living. Resident #125 was discharged to the hospital on 7-20-22 with a diagnosis of dehydration. The Resident's closed record was reviewed on 11-1-22. The Resident was seen by Speech therapy upon admission for documented pocketing of food, coughing, choking, and taking only drops of fluids. No care plan was developed nor implemented for dehydration during the Resident's stay. On 11-3-22 an interview was conducted by the survey team with the Resident's physician. The physician stated that the goal was to limit fluid intake to manage the Resident's congestive heart failure, while trying to relieve dehydration. The physician stated it was a balancing act between the two problems and that the Resident was still exhibiting edema in the lower extremities. Intravenous hydration was out of the question, and diuretic medications would further dehydrate the Resident. Fluids by mouth was the only intervention which could be implemented with some control. The Administrator and Director of Nursing were notified of the missing hydration care plan at the end of day meeting on 11-2-22. On 11-3-22 at 10:30 a.m. the Administrator stated that they could not locate a hydration care plan in the clinical record for Resident #125. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to complete a discharge summary to include recapitulation of stay for 1 resident (Resident #125) in the survey sample of 34 residents. The findings included: For Resident #125, the facility staff failed to complete a recapitulation (discharge summary) of care, upon discharge from the facility. Resident #125 was first admitted to the facility on [DATE] and discharged [DATE]. Resident #125 had an admission minimum data set assessment which coded the Resident with a Brief Interview of Mental Status score indicating cognitive impairment. The Resident was totally dependent on staff for activities of daily living. Resident #125 was discharged to the hospital on 7-20-22. The Resident's closed record was reviewed on 11-1-22. No discharge summary or recapitulation of stay was included in the closed record. The Administrator and Director of Nursing were notified of the missing discharge summary at the end of day meeting on 11-2-22. On 11-3-22 at 10:30 a.m. the Administrator stated that they could not locate a discharge summary in the clinical record for Resident #125. No further information was provided by the facility.