**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the resident's representative or Ombudsman was notified in writing, in a language and manner they understand, of the resident transfer for 1 of 1 resident (R) investigated. (R10) Findings include: R10 was admitted to the facility on [DATE] and diagnoses included metabolic encephalopathy, end stage renal disease, and dependence on renal dialysis. On 01/28/25, record review indicated R10 had a hospitalization on 11/29/24 for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. R10's records indicated R10 was dialyzed and improved. R10 returned to facility on 11/30/24. Hospital discharge notes from 11/29/24 indicated in part, R10 was admitted for urgent dialysis needs. On 01/28/25, Surveyor requested R10's written notice of transfer from the facility on 11/29/24, from Director of Nursing (DON) B. No notice of transfer was received. On 01/29/25 at approximately 8:30 AM, Surveyor interviewed DON B, who reported the facility did not send written notice of the transfer to the representative or a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman because written transfer notice was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the resident's representative was provided notice of the resident's bed hold upon transfer for 1 of 1 resident (R) investigated. (R10) Findings include: R10 was admitted to the facility on [DATE] and diagnoses included metabolic encephalopathy, end stage renal disease, and dependence on renal dialysis. On 01/28/25, record review indicated R10 had a hospitalization on 11/29/24 for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. R10's records indicated R10 was dialyzed and improved. R10 returned to facility on 11/30/24. Hospital discharge notes from 11/29/24 indicated in part, R10 was admitted for urgent dialysis needs. On 01/29/25 at 8:45 AM, Surveyor requested documentation of any notification of the facility's bed hold provided to R10's representative upon R10's hospitalization. Surveyor was provided a copy of the Client Handbook, which is given to residents upon admission with information pertaining to the facility's bed hold policy. Surveyor informed DON B, facilities must provide written information about bed hold policies to all residents and/or residents' representatives prior to and upon transfer, regardless of their payment source and requested documentation the representative was provided this upon R10's transfer to the hospital on [DATE]. No documentation notifying R10's representative of the bed hold policy upon R10's transfer or within 24 hours of the transfer, was received from the facility.

Based on observation, record review and interview, the facility did not ensure all drugs and biologicals were securely stored for 2 of 2 residents (R) (R2 and R246) and did not ensure controlled drugs were stored in separately locked, permanently affixed compartments. Findings include: On 01/27/25, Surveyor reviewed Medication Storage Review sheets completed by monthly audits from the contracted pharmacy for 08/24-11/24. -On 09/30/24, Medication storage sheet stated in part: Recommendation Lorazepam concentrate should be double-locked. -On 10/26/24, Medication storage sheet stated in part: Recommendation Lorazepam concentrate should be double-locked. -On 11/23/24, Medication storage sheet stated in part: Recommendation Lorazepam concentrate should be double-locked. On 01/27/25 at 10:26 AM, Surveyor toured medication storage room with Assistant Director of Nursing (ADON) C. Surveyor observed two Lorazepam 2mg/ml bottles opened, one labeled R2 opened 12/16/24, and second bottle labeled R246 opened 01/01/25 in refrigerator in medication storage room. Surveyor observed that Lorazepam was not double locked in refrigerator. On 01/27/25 at 10:28 AM, Surveyor interviewed ADON C and asked about the two Lorazepam 2mg/ml bottles opened and if they are supposed to be stored in refrigerator unlocked. ADON C indicated that R2 has been discharged for a while and that the Lorazepam bottle should be discarded. ADON C indicated that ADON C would complete the destruction now. On 01/28/25 at 8:52 AM, Surveyor interviewed Director of Nursing (DON) B and asked if Lorazepam is supposed to be stored freely in the refrigerator in medication storage room. DON B indicated that all controlled medications are to be double locked, and the facility has now fixed the issue from yesterday 01/27/25. Surveyor indicated to DON B that Surveyor reviewed the pharmacy medication storage recommendations given to facility monthly after monthly audits are complete and pharmacy recommended that Lorazepam concentrate should be double-locked. Surveyor asked DON B who oversees auditing the monthly pharmacy recommendations and implementing the recommendations. DON B indicated that DON B oversees the monthly audits and DON B will be monitoring the monthly recommendations better.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This affected 5 out of 5 residents (R). (R29, R10, R24, R37, and R7) Laundry aide (LA) D did not sanitize hands in between delivering clean linens to R29, R10, R24, R37, and R7. Findings include: The facility policy, titled Laundry and Bedding, Soiled, revised September 2022, states: .Transport: #6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness . On 01/27/25 at 10:17 AM, Surveyor observed LA D carry residents' clothes up the stairs to the 1st floor to clean linen cart. Surveyor observed clean linen cart to be uncovered and exposed to potential debris and dust. LA D took R29's clothes and entered R29's room. LA D opened closet door and cabinet drawers, touching surfaces with bare hands, and placed R29's clothes in dresser. LA D exited R29's room and continued to push the uncovered clean linen cart down hallway without sanitizing hands. LA D took R10's clothes and entered R10's room. LA D opened dresser drawers, touching surfaces with bare hands, and placed R10's clothes in dresser. LA D exited R10's room and continued to push uncovered clean linen cart down hallway without sanitizing hands. LA D took R24's clothes and entered R24's room. LA D opened closet door, touching surfaces with bare hands, and placed R24's clothes in closet. LA D exited R24's room and continued to push uncovered clean linen cart down hallway without sanitizing hands. LA D took R37's clothes and entered R37's room. R37 is on Enhanced Barrier Precautions (EBP). LA D opened R37's closet door and cabinet drawers, touching surfaces with bare hands, and placed R37's clothes in dresser and closet. LA D exited R37's room with used clothes hangers, placed used clothes hangers in the clean linen cart with clean linens. LA D continued to push uncovered clean linen cart down hallway without sanitizing hands. LA D then took R7's clothes and entered R7's room. LA D opened cabinet drawers, touching surfaces with bare hands, and placed R7's clothes in dresser. LA D exited R7's room without sanitizing hands and continued down hallway with uncovered clean linen cart. On 01/28/25 at 10:27 AM, Surveyor interviewed LA D and asked what LA D's process is for covering clean linen cart. LA D stated, Oh yea you guys told us this last year that cart should be covered, I forgot. LA D indicated that clean linen cart should be covered. Surveyor asked LA D what LA D's process is for sanitizing hands between resident rooms when taking clean linens in, especially R37's EBP room. LA D indicated that hands should be sanitized in between rooms when touching closet doors and dressers. On 01/28/25 at 11:30 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectations for hand hygiene and clean cart covered when delivering clean linens. DON B indicated that DON B's expectation is that clean cart is always covered when delivering clean linens to prevent contamination of clean linens. DON B expects that all staff sanitize hands in and out of all resident rooms regardless of cares or delivery of clean linens.

Based on interview and record review, the facility failed to assess resident (R) 28 using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 12 residents reviewed. The facility did not complete a quarterly Minimum Data Set (MDS) assessment for R28 with a frequency of not less than three months. Findings include: The facility policy, entitled Nursing Department Policy and Procedures, dated 10/01/23, states: The ARD [Assessment Reference Date] of the OBRA [Omnibus Budget Reconciliation Act] Quarterly assessments must be within 92 days of the ARD of any previous OBRA assessment. The assessment must be completed by ARD + 14 calendar days. On 11/07/23, record review of R28's past MDS assessments, it was revealed that the most recent MDS assessment was completed on 05/17/23. There was a gap of 174 days without an MDS assessment completion. On 11/07/23 at 11:57 AM, Surveyor interviewed Registered Nurse (RN) C, the facility's MDS coordinator, and the Assistant Director of Nursing. Surveyor asked RN C about the missing MDS assessment for R28. RN C stated it must have been missed. RN C's paper chart did say they had completed it on 08/08/23, but RN C further inspected the document and computer files and did not find a completed MDS assessment. RN C said they crossed it off, and it must not have gotten done, and they plan to do it immediately. On 11/07/23 at 3:22 PM, Surveyor interviewed Director of Nursing (DON) B regarding expectations around MDS completion and submission. DON B said they are starting the MDS assessment for R28 immediately. DON B would expect MDS assessments to be done quarterly and within the time frame they have set; this was just missed.