**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R3) of 3 sampled residents. R3 had a court-ordered Guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R3's stay exceeded 60 days. Findings include: Wisconsin State Statute 55.055(1)(b) indicates: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days. In order to be admitted under this paragraph, the individual must be in need of recuperative care or be unable to provide for his or her own care or safety so as to create a serious risk of substantial harm to himself, herself, or others. Prior to providing that consent, the Guardian shall review the ward's right to the least restrictive residential environment and consent only to admission to a nursing home or other facility that implements that right. Following the 60 day period, the admission may be extended for an additional 60 days if a petition for protective placement under s. 55.075 has been brought, or, if no petition for protective placement under s. 55.075 has been brought, for an additional 30 days for the purpose of allowing the initiation of discharge planning for the individual. On 3/4/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia without behavioral disturbance, stage 4 pressure injury, adult failure to thrive, dysphagia (difficulty swallowing), and osteomyelitis of vertebra (bone infection). R3's Minimum Data Set (MDS) assessment, dated 1/2/25, had a Brief Interview for Mental Status (BIMS) score of 99 which indicated R3 was not able to complete the assessment. R3 had a court-appointed Guardian since 6/10/19. R3's medical record did not contain an order for protective placement in the facility. On 3/4/25 at 11:24 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated when R3's Guardian decided to have R3 remain in the facility, SSD-C did not know there was anything more that needed to be done. SSD-C indicated SSD-C would check if protective paperwork was initiated for R3. On 3/5/25 at 10:55 AM, Surveyor interviewed SSD-C who indicated Director of Nursing (DON)-B was looking for protective placement paperwork for R3. On 3/5/25 at 10:57 AM, Surveyor interviewed DON-B who indicated DON-B contacted R3's case manager who indicated R3 did not have protective placement prior to being admitted to the facility. DON-B indicated R3's case manager stated they would request a legal consult to obtain a protective placement order for R3 to remain in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not notify the Ombudsman of hospital transfers for 3 residents (R) (R15, R39, and R4) of 3 residents reviewed for hospitalization. R15 was transferred to the hospital on 9/11/24. The facility did not notify the Ombudsmen of R15's hospital transfer. R39 was transferred to the hospital on [DATE], 12/23/24 and 1/16/25. The facility did not notify the Ombudsmen of R39's hospital transfers. R4 was transferred to the hospital on [DATE]. The facility did not notify the Ombudsmen of R4's hospital transfer. Findings include: The facility's Transfer and Discharge policy, revised 10/2024, indicates: .5. The facility will maintain evidence that the notice was sent to the Ombudsmen .10. Emergency Transfers to Acute Care: .h. The Social Services Director, or Designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents monthly if the list meets all requirements for content of such notices. 1. On 3/3/25, Surveyor reviewed R15's medical record and noted R15 was transferred to the hospital on 9/11/24 due to a fall with injury that resulted in a broken left hip. R15's medical record did not indicate the Ombudsman was notified of R15's hospital transfer. 2. On 3/3/25, Surveyor reviewed R39's medical record and noted R39 was transferred to the hospital on [DATE] due to aspiration pneumonia. R39 was also transferred to the hospital on [DATE] due to vomiting, atrial fibrillation, ulcerative esophagitis and weakness, and on 1/16/25 due to hematemesis and hypernatremia. R39's medical record did not indicate the Ombudsman was notified of R39's hospital transfers. 3. On 3/3/25, Surveyor reviewed R4's medical record. R4's medical record indicated R4 was transferred to the hospital on [DATE] due to suprapubic catheter insertion obstruction. R4's medical record did not indicate the Ombudsman was notified of R4's hospital transfer. On 3/3/25, Surveyor requested Ombudsman notification of transfer and discharges from Nursing Home Administrator (NHA)-A. On 3/4/25 at 1:00 PM, Surveyor reviewed monthly transfer and discharge reports sent to the Ombudsman and noted R15, R39 and R4 were not listed on the reports. On 3/5/25 at 8:20 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated residents on Medicaid Part A who are transferred to the hospital do not show up on the monthly reports that are sent to the Ombudsmen. SSD-C confirmed the Ombudsmen does not receive notification of those transfers or discharges. Business Office Manager (BOM)-D (who was in SSD-C's office at the time of the interview) showed SSD-C how to run a report that included Medicaid Part A residents. Surveyor noted R15, R39, and R4 were on the report. SSD-C was unsure why the residents did not show up on the initial report run by SSD-C.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R46) of 2 sampled residents was screened through the Pre-admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required. The facility did not ensure completion of a Level II PASRR Screen for R46 or follow a Qualified Mental Health Professional's (QMHP) request to refile a Level II PASRR Screen if R46 remained in the facility. Findings include: On 3/4/25, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, bipolar disorder, sleep terrors, panic disorder, post-traumatic stress disorder, and adjustment disorder with anxiety. R46's Minimum Data Set (MDS) assessment, dated 1/10/25, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R46 had intact cognition. On 3/4/25 at 10:37 AM, Surveyor reviewed a PASRR Level II determination document for R46 signed by a QMHP representative on 10/22/24. The document indicated the QMHP contacted the facility on 10/8/24, 10/11/24, and 10/16/24 to obtain additional information regarding the date of onset, symptoms, and previous treatment with no response from the facility. The QMHP canceled the PASRR Level II Screen due to an inability to reach the facility and not enough information to make a PASRR determination. The QMHP indicated if R46 still resided in the facility, the facility should re-submit another PASRR Level II for evaluation of R46's needs. On 3/4/25 at 11:32 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated the PASRR for R46 was not re-submitted because SSD-C was out of the office at the time and there was no coverage. SSD-C confirmed the PASRR should have been re-submitted.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 53 residents residing in the facility. The facility did not cool food with an approved food cooling method. Findings include: On 3/3/25, Dietary Manager (DM)-E indicated the facility follows their own food safety policies and procedures. The facility's undated Cooling Procedures document indicates: Foods must be cooled as quickly as possible to prevent the growth of bacteria as the food drops through the danger zone. For hot food: Cool from 135 degrees Fahrenheit (F) to 70 degrees F in 2 hours or less and then from 70 degrees F to 41 degrees F in 4 hours or less. For food prepared at room temperature or using room temperature ingredients, cool from 70 degrees F to 41 degrees F in 4 hours or less. Cooling Methods: Refrigeration: Divide into smaller portions, use shallow 2 to 4 inch pans, do not cover until food reaches 41 degrees F, use containers that transfer heat (metal pans) .Ice Bath: Fill ice and water up to the level of food in the container, stir regularly .use ice paddle along with the refrigeration method or ice bath method . During an initial kitchen tour that began at 9:21 AM on 3/3/25, Surveyor and DM-E observed the following foods in the cooler: ~ Cooked ground beef dated 3/3 ~ Cooked turkey dated 3/1 ~ A bowl of spaghetti sauce, noodles, and ground beef labeled Tuesday and dated 3/3 ~ Ground sausage dated 2/28 ~ Beef casserole dated 3/2 ~ Shredded pork dated 3/1 DM-E indicated every Monday DM-E throws away food in the cooler that has been saved. DM-E indicated leftovers should not be saved for future meals. During a continuous kitchen observation that began at 10:00 AM on 3/4/25, Surveyor observed spaghetti being reheated in the oven for lunch. Surveyor requested the facility's food cooling log from DM-E who indicated the spaghetti was pre-cooked. On 3/4/25 at 11:44 AM, DM-E approached Surveyor and indicated DM-E could not find the cooling log. DM-E stated the foods observed in the cooler were thrown away. DM-E confirmed the spaghetti was not thrown away and was served to residents for lunch. DM-E thought the spaghetti was properly cooled after it was initially made but verified the cooling process was not documented. DM-E provided Surveyor with a copy of training provided to cooks on 3/4/25 that covered the cooling process and cooling logs and indicated the following: Food Cooling and Storage: Leftovers should be disposed of after each meal. Any pre-cooked food should be documented on the cooling log located on the clipboard in the cooking area. The clipboard and forms should not be removed or replaced. Any leftovers or foods not documented will be thrown out. On 3/4/25 at 12:15 PM, Surveyor observed residents in the main dining room eating spaghetti for lunch.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of drugs and biologicals for 5 residents (R) (R5, R20, R4, R7, and R9) of 20 sampled residents. On 1/30/25, medications were observed at R5, R20, R4, R7, and R9's bedsides. The residents did not have self-administration of medication assessments, physician orders to self-administer medication, or care plans that indicated they could safely and accurately self-administer medication. Findings include: The facility's Resident Self-Administration of Medication policy, revised 10/2024, indicates: 1. Eash resident is offered the opportunity to self-administer medication during the routine assessment by the facility's interdisciplinary team .14. The care plan must reflect resident self-administration and storage arrangements for such medications . On 1/30/25 at 10:37 AM, Surveyor interviewed R5 and observed dorzolamide ophthalmic eye drops, brimonidine ophthalmic eye drops, Biofreeze (topical pain reliever), Fast Freeze (topical pain reliever), and anti-fungal powder at R5's bedside. R5 indicated a nurse brings the eye drops at approximately 8:00 AM and comes back for them after 12:00 PM. R5 indicated R5 self-administers the eye drops in the morning at 12:00 PM. On 1/30/25 at 10:46 AM, Surveyor observed fluticasone propionate nasal spray and nystatin powder (anti-fungal) on R20's nightstand. On 1/30/25 at 10:50 AM, Surveyor observed anti-fungal powder and a bottle of acetic acid on R4's nightstand. On 1/30/25 at 11:07 AM, Surveyor was interviewing R7 when Licensed Practical Nurse (LPN)-C entered the room and gave R7 Orajel tooth care cream that had just arrived from pharmacy. On 1/30/25 at 11:30 AM, Surveyor interviewed R9 and observed a paper towel on R9's bed that contained a blue pill. Surveyor also observed a medication cup on R9's table. When Surveyor asked about the pill, R9 was unsure what the pill was. R9 indicated the blue pill dropped on the floor when R9 was taking pills the nurse dropped off that morning. R9 put the pill on the paper towel so the nurse could see it. R9 confirmed nurses drop off R9's medication and leave. R9 indicated R9 takes the medications when R9 is ready. On 1/30/25 at 1:35 PM, Surveyor interviewed LPN-C who indicated LPN-C was unsure if R7 was able to self-administer medication. When Surveyor asked about the pill in R9's room, LPN-C indicated LPN-C was unsure what the pill was. LPN-C indicated LPN-C thought the pill was finasteride (often used to treat an enlarged prostrate), but when LPN-C went back to the room, R9 had already taken the pill. On 1/30/25 at 2:42 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed a resident should have a self-administration of medication assessment completed prior to self-administering medication. NHA-A also indicated the resident's physician should be contacted for approval, the resident's care plan should be updated, and reassessment should be completed at certain intervals to ensure the resident is still able to safely and accurately self-administer medication. NHA-A confirmed R5, R20, R4, R7, and R9 did not have self-administration of medication assessments, physician orders to self-administer medication, or care plans that indicated they could self-administer medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/17/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including biliary acute pancreatitis without necrosis, diabetes, and hypothyroidism. R9's MDS assessment, dated 7/13/24, had a BIMS score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record indicated R9 was responsible for R9's healthcare decisions. On 7/17/24 at 12:40 PM, Surveyor interviewed R9 who stated approximately six to seven months ago a wallet that contained R9's debit card and $16.00 went missing and wasn't found. R9 reported the missing wallet. Four staff searched R9's room but were unable to find the wallet. On 7/17/24 at 1:40 PM, Surveyor interviewed NHA-A who stated NHA-A was not aware of R9's missing wallet and was unable to find a grievance or investigation for the missing wallet. On 7/17/24 at 2:25 PM, Surveyor interviewed CNA-D who confirmed R9 mentioned the missing wallet several months ago but CNA-D was not aware of any details. On 7/17/24 at 2:40 PM, Surveyor interviewed Social Services Assistant (SSA)-E who was not aware of R9's missing wallet. SSA-E reviewed grievance logs from September of 2023 to the present but was unable to find documentation regarding the missing wallet. On 7/17/24 at 2:55 PM, Surveyor interviewed Regional Director (RD)-F who stated RD-F recalled R9's missing wallet and was told there would be an investigation and report by the former NHA. RD-F verified reports to the SA and local law enforcement were not completed for the suspected misappropriation of resident property. Based on staff and resident interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure allegations of abuse and misappropriation were reported to the State Agency (SA) or local law enforcement for 3 residents (R) (R3, R4, and R9) of 11 sampled residents. Director of Nursing (DON)-B was informed of a resident-to-resident altercation between R3 and R4 on 6/17/24 in which R3 sustained a physical injury. The facility did not report the allegation of abuse to the SA or local law enforcement. The facility did not report an allegation of misappropriation of property for R9 to the SA or local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated January 2023, states it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .IV. Identification of Abuse, Neglect and Exploitation: A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services .B. Possible indicators of abuse include, but are not limited to: .3. Physical injury of a resident of unknown source .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. On 7/17/24, Surveyor reviewed an incident report, dated 6/17/24 and completed by DON-B, that indicated R3 swung a call light in R4's room and sustained a laceration on the left forehead and left eyebrow. R4 was not affected by the incident and R3 was removed from the room. R3's injuries were assessed and treated. An interview with Certified Nursing Assistant (CNA)-C indicated CNA-C heard yelling, entered R4's room, and saw R3 swing the call light next to R4's bed. CNA-C removed R3 from the room. An Interdisciplinary Team (IDT) review indicated R3 sustained two small lacerations on the face. During the struggle for the call light, R3 was hit. CNA-C was the only eyewitness to the event. Additional staff statements were not obtained because CNA-C was the only employee directly involved. On 7/17/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] for a Hospice respite stay and had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder, and major depressive disorder. R3's Minimum Data Set (MDS) assessment, dated 6/22/24, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R3 had severely impaired cognition. R3's medical record indicated R3 had an activated Power of Attorney for Healthcare (POAHC). On 7/17/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity with mood disturbance, major depressive disorder, and generalized anxiety disorder. R4's MDS assessment, dated 5/22/24, had a BIMS score of 11 out of 15 which indicated R4 had moderately impaired cognition. R4's medical record indicated R4 had an activated POAHC. On 7/17/24 at 1:45 PM, Surveyor interviewed CNA-C who confirmed CNA-C worked with R3 on 6/17/24. CNA-C stated CNA-C answered R4's call light and observed R3 in R4's room. CNA-C removed R3 from R4's room and closed the door. CNA-C went to do something else and noticed R4's call light was on again. CNA-C answered the call light and again observed R3 in R4's room. R3 was holding the smaller end of the call light which had been pulled from the wall and R4 was holding the longer end of the call light and swinging it around (which was contradictory to what the incident report stated). CNA-C stated R3 was bleeding from the head. CNA-C stated R4 asked if R4 clocked R3 good and asked CNA-C to keep R3 out of R4's room. CNA-C removed R3 from the room. CNA-C stated CNA-C was not asked to provide a statement. CNA-C confirmed CNA-C did not witness how the injury occurred because R3 was already bleeding when CNA-C entered the room. On 7/17/24 at 2:59 PM, Surveyor reviewed the above information with Nursing Home Administrator (NHA)-A who indicated DON-B was unavailable for interview. NHA-A did not deny the findings or that the facility did not report the resident-to-resident altercation as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/17/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including biliary acute pancreatitis without necrosis, diabetes, and hypothyroidism. R9's MDS assessment, dated 7/13/24, had a BIMS score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record indicated R9 was responsible for R9's healthcare decisions. On 7/17/24 at 12:40 PM, Surveyor interviewed R9 who stated approximately six to seven months ago a wallet that contained R9's debit card and $16.00 went missing and was not found. R9 reported the missing wallet. Four staff searched R9's room but were unable to find the wallet. On 7/17/24 at 1:40 PM, Surveyor interviewed NHA-A who stated NHA-A was not aware of R9's wallet missing and could not find a related grievance or investigation. On 7/17/24 at 2:25 PM, Surveyor interviewed CNA-D who stated R9 mentioned the missing wallet several months ago but CNA-D was not aware of any details. On 7/17/24 at 2:40 PM, Surveyor interviewed Social Services Assistant (SSA)-E who was not aware of R9's missing wallet. SSA-E reviewed grievance logs from September of 2023 to the present but could not find any documentation on the missing wallet. On 7/17/24 at 2:55 PM, Surveyor interviewed Regional Director (RD)-F who stated RD-F was informed about R9's missing wallet and was told there would be an investigation by the former NHA. RD-F verified a suspected misappropriation of resident property investigation was not completed. Based on staff and resident interview and record review, the facility did not ensure allegations of abuse and misappropriation were thoroughly investigated for 3 residents (R) (R3, R4, and R9) of 11 sampled residents. Director of Nursing (DON)-B was informed of a resident-to-resident altercation between R3 and R4 on 6/17/24 in which R3 sustained a physical injury. The facility did not thoroughly investigate the allegation of abuse. R9 reported R9's wallet, debit card, and cash were missing. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated January 2023, indicates an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for the investigation include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering with or destroying evidence; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 1. On 7/17/24, Surveyor reviewed an incident report, dated 6/17/24 and completed by DON-B, that indicated R3 swung a call light in R4's room and sustained lacerations on the left forehead and left eyebrow. R4 was not affected by the incident and R3 was removed from the room. R3's injuries were assessed and treated. An interview with Certified Nursing Assistant (CNA)-C indicated CNA-C heard yelling, entered R4's room, and saw R3 swing the call light next to R4's bed. CNA-C removed R3 from the room. The incident report did not include additional resident and staff interviews or a determination on possible resident-to-resident abuse. On 7/17/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] for a Hospice respite stay and had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder, and major depressive disorder. R3's Minimum Data Set (MDS) assessment, dated 6/22/24, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R3 had severely impaired cognition. R3's medical record indicated R3 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 6/17/24, indicated R3 was in R4's room and sustained lacerations on the left forehead and left eyebrow. The areas were cleaned with no signs or symptoms of pain. A message was left for the Nurse Practitioner at 3:30 PM. R3's emergency contact and DON-B were also notified. R3's medical record did not contain any additional documentation related to the incident. On 7/17/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity with mood disturbance, major depressive disorder, and generalized anxiety disorder. R4's MDS assessment, dated 5/22/24, had a BIMS score of 11 out of 15 which indicated R4 had moderately impaired cognition. R4's medical record indicated R4 had an activated POAHC. R4's medical record did not contain any documentation related to the incident. On 7/17/24 at 1:45 PM, Surveyor interviewed CNA-C who confirmed CNA-C worked with R3 on 6/17/24. CNA-C stated CNA-C answered R4's call light and observed R3 in R4's room. CNA-C removed R3 from R4's room and closed the door. CNA-C went to do something else and noticed R4's call light was on again. CNA-C answered the call light and again observed R3 in R4's room. R3 was holding the smaller end of the call light which had been pulled from the wall and R4 was holding the longer end of the call light and swinging it around (which was contradictory to what the incident report stated). CNA-C stated R3 was bleeding from the head. CNA-C stated R4 asked if R4 clocked R3 good and asked CNA-C to keep R3 out of R4's room. CNA-C removed R3 from the room. CNA-C stated CNA-C was not asked to provide a statement. CNA-C confirmed CNA-C did not witness how the injury occurred because R3 was already bleeding when CNA-C entered the room. On 7/17/24 at 2:59 PM, Surveyor reviewed the above information with Nursing Home Administrator (NHA)-A who confirmed DON-B was unavailable for interview. NHA-A did not deny the findings or that the facility did not complete a thorough investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure an injury of unknown origin and allegation of sexual abuse were reported to the Nursing Home Administrator (NHA), the State Agency (SA) and/or local law enforcement in a timely manner for 2 residents (R) (R1 and R2) of 7 sampled residents. On 4/10/24, the facility discovered R1 had a fracture of unknown origin. Staff did not immediately report the injury of unknown origin to NHA-A which delayed the facility's report to the SA. On 4/8/24, R2 alleged R2 was raped by a male nurse. Staff did not immediately report the allegation of sexual abuse to NHA-A which delayed the facility's report to the SA and local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 11/22, indicates: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .IV. Identification of Abuse, Neglect and Exploitation: A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services . B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse .3. Physical injury of a resident of unknown source .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 1. On 5/8/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and polyosteoarthritis (the repetitive use of joints that causes damage to joint tissue and results in pain and swelling). R1's Minimum Data Set (MDS) assessment, dated 4/12/24, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R1 had moderately impaired cognition. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. On 5/8/24, Surveyor reviewed a facility investigation that indicated: On 4/11/24 (date should be 4/10/24), R1 complained of knee pain. R1 was sent to the hospital and diagnosed with a nondisplaced medial condyle fracture of the left femur. Upon investigation, it was discovered that a Certified Nursing Assistant (CNA) who cared for R1 transferred R1 via pivot transfer. After the transfer, R1 complained of pain. The CNA was suspended pending the investigation and was terminated from employment. The police department was contacted and spoke with R1. Conclusion: The improper transfer likely caused the fracture due to R1's inability to properly assist with the pivot transfer and R1's underlying medical conditions. The investigation indicated an initial report was submitted to the SA on 4/11/24 at 9:39 AM. R1's care plan (effective 4/7/23) indicated R1 required the assistance of two staff and a full mechanical lift for transfers. A progress note, dated 4/10/24 at 2:58 PM, indicated: Messages were left for R1's [NAME] of Attorney (POAs) regarding R1's request to go to the hospital due to left knee pain. One of R1's POAs called the facility at 2:41 PM and stated if R1 wanted to go to hospital, the facility should send R1. A progress note, dated 4/10/24 at 4:09 PM, indicated: Writer was called in for a skin check by CNA after R1's weekly shower. Writer noted skin tear on R1's left foot and R1 complained of left knee pain. R1 requested to be transferred to the hospital. R1's family was notified and in agreement. R1 was transferred to the hospital via ambulance. A progress note, dated 4/10/24 at 10:30 PM, indicated: R1 returned from the hospital on a stretcher and was placed in bed. R1 was diagnosed with a closed nondisplaced condyle fracture of the left femur and had an immobilizer on the left knee. R1 denied pain at that time. On 5/8/24 at 12:17 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B reviewed R1's paperwork on 4/11/24 and noticed the fracture diagnosis. DON-B indicated DON-B immediately notified NHA-A and started interviewing staff. DON-B indicated when CNA-C was initially interviewed, CNA-C stated CNA-C and a nurse transferred R1 with a full mechanical lift. DON-B stated CNA-C then admitted CNA-C transferred R1 into a wheelchair with the pivot technique without a second staff present because R1 wanted to go to Bingo. DON-B indicated R1 complained of pain following the incorrect transfer. DON-B stated DON-B found out R1 was transferred incorrectly at approximately 9:00 AM on 4/11/24 and immediately suspended CNA-C from resident care. DON-B stated CNA-C was terminated from employment the same day for being untruthful and not following R1's care plan. On 5/8/24 at 12:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D via phone. LPN-D verified LPN-D was on duty when R1 returned from the hospital on 4/10/24. LPN-D stated LPN-D learned R1 had a fracture when LPN-D read R1's hospital paperwork. LPN-D indicated R1 wore a knee immobilizer and denied pain. LPN-D stated LPN-D was educated to let administration know immediately of any fractures. On 5/8/24, Surveyor reviewed CNA-C's time card which indicated CNA-C worked on 4/10/24 from 5:59 AM to 2:02 PM and on 4/11/24 from 6:01 AM to 9:11 AM. On 5/8/24, Surveyor reviewed the facility's undated education regarding when to call the NHA/DON. The education instructed staff to call for injuries of unknown origin, including bruises, fractures, and suspected abuse. On 5/8/24 at 1:43 PM, Surveyor interviewed DON-B who indicated the facility provided staff education regarding when to call the NHA/DON related to a previous unrelated incident. DON-B indicated the staff education started on 4/9/24 and verified LPN-D's name was on the list of staff educated. DON-B verified the education indicated staff should call immediately for fractures. DON-B verified staff were aware of R1's fracture on 4/10/24, however, administration did not know about R1's fracture until 4/11/24. When Surveyor asked when LPN-D should have called NHA-A regarding R1's fracture, DON-B stated, Once (LPN-D) read the paperwork (from the hospital). 2. R2 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R2's MDS assessment, dated 4/26/24, stated R2's BIMS score was 6 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated POAHC at the time of admission. On 5/8/24, Surveyor reviewed a facility report submitted to the SA on 4/9/24 that stated R2 alleged that a male nurse tried to touch R2's private parts. A progress note, dated 4/8/24 at 6:07 PM, indicated R2's daughter called the facility and said R2 stated a male nurse tried to rape R2. On 5/8/24 at 1:14 PM, Surveyor interviewed DON-B who stated DON-B was made aware of the allegation of abuse on the morning of 4/9/24. DON-B verified Licensed Practical Nurse (LPN)-F should have told administration about R2's allegation on the evening of 4/8/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not prevent further potential abuse during an investigation of sexual assault for 1 resident (R) (R2) of 7 sampled residents. R2 accused Licensed Practical Nurse (LPN)-F of sexual abuse on 4/8/24. The facility did not remove LPN-F from resident care pending the results of the investigation. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 11/22, indicates facility staff should respond immediately to protect residents, including but not limited to, staffing changes and increased supervision. On 5/8/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 4/26/24, stated R2's Brief Interview for Mental Status (BIMS) score was 6 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC) at the time of admission. On 5/8/24, Surveyor reviewed a facility report that was submitted to the State Agency (SA) on 4/9/24 and indicated R2 alleged that a male nurse tried to touch R2's private parts. The investigation included interviews from staff including LPN-F, Registered Nurse (RN)-G, and Certified Nursing Assistant (CNA)-H. A progress note, dated 4/8/24 at 6:07 PM and written by LPN-F, indicated R2's daughter called the facility and said R2 stated a male nurse tried to rape R2. A statement by LPN-F, dated 4/9/24, indicated LPN-F spoke with R2 after the phone call and R2 denied all allegations of sexual abuse. A statement by RN-G, dated 4/9/24, indicated on 4/8/24, RN-G observed LPN-F attempt to assist R2 from the dining room after dinner when R2 began to yell and accuse LPN-F of rape. A statement by CNA-H, dated 4/10/24, indicated on 4/8/24, CNA-H assisted R2 down the hallway in R2's wheelchair. R2 pointed to LPN-F and told CNA-H that a man down the hall touched and hurt R2. On 5/8/24, Surveyor reviewed nursing schedules that indicated LPN-F worked on 4/10/24 4/12/24, 4/13/24, 4/14/24, and 4/15/24. On 5/8/24 at 1:14 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B was made aware of R2's allegation on the morning of 4/9/24. DON-B stated LPN-F was not removed from resident care pending the outcome of the investigation because LPN-F did not match R2's description of the alleged perpetrator provided to DON-B on 4/9/24. DON-B verified the five-day investigation was submitted to the SA on 4/16/24 and stated the allegation of abuse was not substantiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R20 was admitted to the facility on [DATE]. R20's Minimum Data Set (MDS) assessment, dated 1/4/24, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R20 had severe cognitive impairment. R20 had an activated POA. On 1/24/24, Surveyor requested any grievances filed by or on behalf of R20. Social Worker (SW)-F provided a grievance, dated 10/24/24, that indicated R20's family had concerns related to missing clothing. The follow up section of the grievance indicated: will request list of missing items or pictures. On 1/24/24 at 11:20 AM, Surveyor interviewed SW-F who stated SW-F filled out the grievance form the last time the State Agency was in the building due to R20's family's concerns. SW-F indicated SW-F did not follow up yet or request a list or pictures of the missing items. 3. R212 was admitted to the facility on [DATE]. R212's MDS assessment, dated 10/30/23, contained a BIMS score of 14 out of 15 which indicated R212 had intact cognition. On 1/22/24 at 11:47 AM, Surveyor interviewed R212 who indicated Certified Nursing Assistant (CNA)-D and CNA-D's partner were rude to R212 related to R212 self-propelling to the dining room. R212 indicated the facility knew about the incident, but R212 didn't think anything was done. On 1/23/24 at 9:06 AM, Surveyor reviewed a grievance, dated 12/16/23, that indicated R212's family indicated R212 was not cleansed or changed in a week, had to wait over 3 hours for staff to answer R212's call light following a bowel movement, and was left in the cafeteria for hours after eating. R212's family also had concerns that a few unnamed CNAs were rude. The grievance indicated: Spoke with (R212) and confirmed concerns. Then spoke with staff and told them they need to answer calls quickly and not leave residents alone. Starting hourly rounds by the CNAs as well as management to ensure residents are getting their needs addressed. The grievance contained staff statements and an undated education sheet with staff signatures. Surveyor noted CNA-D's signature was not on the education page. On 1/23/24 at 8:57 AM, Surveyor interviewed NHA-A who indicated CNA-D's partner was CNA-E. Surveyor indicated the grievance follow up stated CNAs and management would complete hourly rounds, but the documentation was not included. Surveyor also indicated the grievance did not address the concern regarding rude staff. NHA-A indicated NHA-A thought the previous DON had a conversation with CNA-D and CNA-E and would check with Human Resources. NHA-A stated NHA-A would also look for documentation of hourly rounds. NHA-A did not provide confirmation that hourly rounds were completed. On 1/23/24 at 9:24 AM, NHA-A provided an education sheet with staff signatures and indicated customer service and call light education was completed on 12/14/23 (which was 2 days before the grievance was filed). NHA-A confirmed grievances should be properly addressed and follow up should be completed. Based on resident and staff interview, and record review, the facility did not make a prompt effort to resolve grievances for 3 Residents (R) (R32, R20, and R212) of 5 sampled residents. R32 and R32's Power of Attorney (POA) reported R32's wallet and phone were missing. There was no follow up by the facility. R20's POA filed a grievance related to missing clothing. There was no follow up by the facility. R212 and a family member filed a grievance related to call light wait times and customer service. The grievance was not fully addressed and there was no follow up by the facility. Findings include: The facility's Resident and Family Grievance Policy, dated 10/22, indicates: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination or reprisal .Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. 1. On 1/22/24 at 10:52 AM, Surveyor interviewed R32 who indicated R32 was missing a wallet with all of R32's identification and driver's license. R32 stated R32 told staff, but did not receive any follow up. On 1/24/24 at 10:46 AM, Surveyor interviewed R32's POA who indicated during the week of Christmas (12/25/23), R32 stated R32's wallet and phone were missing. R32's POA informed the facility and then went to the facility and asked staff if R32's wallet and phone were found. A staff member stated they told R32's nurse. R32's POA and the Director of Nursing (DON) were present and someone checked R32's room. R32's POA also stated they told Nursing Home Administrator (NHA)-A that R32's wallet and phone were missing, but there was no follow up. R32's POA stated they received a call from NHA-A that morning (1/24/24) because Surveyors were in the building. When Surveyor informed R32's POA that Surveyor spoke with R32 that morning and R32 showed Surveyor a phone, R32's POA indicated the phone was R32's second phone and the other phone was not found. On 1/24/24 at 11:37 AM, Surveyor interviewed NHA-A who verified NHA-A was informed of the missing wallet and phone by R32's POA around Christmas time, but NHA-A thought the wallet and phone were found. NHA-A verified a grievance should have been filed for the missing items and follow up should have been completed. NHA-A also verified the facility's policy instructs staff to file a grievance for missing items and follow up with an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R31) of 1 resident was assessed for the use of bed rails. R31 had bilateral half rails on R31's bed. Staff did not assess R31 for the use of bed rails, and did not obtain informed consent or a physician's order when the bilateral half rails were implemented. Findings include: The facility's Proper Use of Bed Rails policy, implemented on 3/6/23, indicates: As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. Size and weight; c. Sleep habits; d. Medication(s); e. Acute medical or surgical interventions; f. Underlying medical conditions; g. Existence of delirium; h. Ability to toilet safely; i. Cognition; j. Communication; k. Mobility (in and out of bed); l. Risk of falling. 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails. 4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. 5. The facility will assess to determine if the bed rail meets the definition of a restraint 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails .8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnoses, condition, symptom, or functional reason for the use of the bed rail. R31 was admitted to the facility on [DATE] and had diagnoses including pain in the left shoulder. R31's Minimum Data Set (MDS) assessment, dated 10/23/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R31 had moderate cognitive impairment. On 1/22/24 at 10:20 AM, Surveyor interviewed R31 and noted R31 had bilateral half rails installed on R31's bed. R31 indicated the bed rails were used to assist R31 with mobility. R31 indicated R31 had difficulty raising R31's arms due to shoulder pain. Between 1/22/24 and 1/24/24, Surveyor reviewed R31's medical record and noted the following: ~ A side rail order, initiated on 1/3/24, indicated: Device: Enabler bars: two 1/4 rails both to assist with independent mobility in bed. There were no directions specified. ~A care plan, initiated on 1/3/24, indicated: Risk for injury related to physical restraint due to: side rails. Approaches included: Complete appropriate restraint and/or side rail assessment per living center policy. ~R31 used an air mattress as a pressure relieving device. On 1/23/24, Surveyor requested an assessment for R31's bilateral half rail use. On 1/23/24 at 2:29 PM, the facility provided an assessment titled Quarterly/Annual/Significant Change Assessment, dated 1/23/24, that documented R31's side rail use and indicated R31 was appropriate for half side rails which were not a restraint. The assessment reviewed R31's entrapment risk and noted there were no gaps between R31's air mattress and the rails. The assessment indicated R31 was provided education regarding the use of half rails. Nursing Home Administrator (NHA)-A indicated the assessment was R31's quarterly evaluation. Surveyor requested to see prior evaluations for R31's half rail use. On 1/24/24 at 8:57 AM, NHA-A provided R31's Admit/Readmit assessment, dated 10/16/23. The assessment indicated R31 did not require any type of bed rail. On 1/24/24 at 8:57 AM, NHA-A confirmed an initial assessment should have been completed per the facility's policy when R31's bilateral half rails were implemented on 1/3/24. NHA-A also provided a Performance Improvement Project (PIP) that began on 12/20/23 to be completed on 1/26/24 related to side rail use for residents without proper assessments, orders, or consents. On 1/24/24 at 9:24 AM, Surveyor informed NHA-A that an order in R31's medical record indicated R31 should have quarter rails. NHA-A indicated the original completion date for the PIP was 1/12/24, but the facility chose to extend the date to 1/26/24 after they realized it wouldn't be completed. NHA-A confirmed physician orders for side rails should match what the resident has.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure scheduled showers were provided for 5 Residents (R) (R212, R22, R30, R38, R47) of 22 sampled residents. R212, R22, R30, R38, and R47 did not consistently receive scheduled showers. Findings include: 1. R212 was admitted to the facility on [DATE] and had diagnoses including difficulty in walking, and macular degeneration. R212's Minimum Data Set (MDS) assessment, dated 10/30/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R212 had intact cognition. The MDS indicated R212 required substantial or maximal assistance for showering and bathing. On 1/22/24 at 11:47 AM, Surveyor interviewed R212 who indicated R212 did not receive a weekly shower and received only a few showers since admission. R212 indicated R212 was fine with receiving a bed bath every other day, but indicated that did not always happen. On 1/23/24, Surveyor requested R212's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R212's medical record and noted R212's weekly shower was scheduled on Sunday. R212's medical record, including Point of Care (POC) documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R212 received 6 of 13 scheduled showers with one refusal. 2. R22 was admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies, and macular degeneration. R22's MDS assessment, dated 11/23/23, contained a BIMS score of 15 out of 15 which indicated R22 had intact cognition. The MDS indicated R22 required supervision or touching assistance for showering and bathing. On 1/22/24 at 11:57 AM, Surveyor interviewed R22 who indicated R22 did not receive a weekly shower. R22 indicated R22 did not get nearly enough showers and preferred a shower every other day. On 1/23/24, Surveyor requested R22's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R22's medical record and noted R22's weekly shower was scheduled on Thursday. R22's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R22 received 2 of 13 scheduled showers. 3. R30 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) following cerebral infarction, mild cognitive impairment, and type 2 diabetes mellitus. R30's MDS assessment, dated 8/29/23, contained a BIMS score of 13 out of 15 which indicated R30 had intact cognition. The MDS indicated R30 required partial or moderate assistance for showering and bathing. On 1/22/24 at 1:51 PM, Surveyor interviewed R30 who indicated R30 did not receive a weekly shower. R30 estimated R30 received a shower every two weeks, but preferred to shower every day or at least twice weekly. On 1/23/24, Surveyor requested R30's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R30's medical record and noted R30's weekly shower was scheduled on Thursday. R30's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R30 received 4 of 13 scheduled showers. 4. R38 was admitted to the facility on [DATE] and had diagnoses including macular degeneration, morbid obesity, and type 2 diabetes mellitus. R38's MDS assessment, dated 5/30/23, contained a BIMS score of 15 out of 15 which indicated R38 had intact cognition. The MDS indicated R38 required substantial or maximal assistance for showering and bathing. On 1/22/24 at 2:18 PM, Surveyor interviewed R38 who indicated R38 did not receive twice weekly showers and went months without a shower after admission. On 1/23/24, Surveyor requested R38's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R38's medical record and noted R38's weekly showers were scheduled on Wednesday and Sunday. R38's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R38 received 4 of 27 scheduled showers and one bed bath. 5. R47 was admitted to the facility on [DATE] and had diagnoses including hemiplegia following cerebral infarction, and type 2 diabetes mellitus. R47's MDS assessment, dated 9/21/23, contained a BIMS score of 15 out of 15 which indicated R47 had intact cognition. The MDS indicated R47 required substantial or maximal assistance for showering and bathing. On 1/22/24 at 11:08 AM, Surveyor interviewed R47 who indicated R47 did not receive a weekly shower and went as long as a month without a shower during a COVID outbreak. R47 also stated R47 often went 10 to 14 days between showers. On 1/23/24, Surveyor requested R47's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R47's medical record and noted R47's weekly shower was scheduled on Monday. R47's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R47 received 7 of 13 scheduled showers. On 1/23/24 at 9:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated shower sheets are completed for all residents after showers and placed in Director of Nursing (DON)-B's mailbox. On 1/24/24 at 9:50 AM, Nursing Home Administrator (NHA)-A provided Surveyor with shower sheets and indicated the shower sheets provided were all staff could find because some were thrown away. On 1/24/24 at 12:39 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C and DON-B. ADON-C stated CNAs document showers/bathing in residents' medical records. DON-B indicated residents should receive at least one shower per week if they choose.

Based on staff interview and record review, the facility did not record, thoroughly investigate, and provide follow up or resolution of a grievance for 1 Resident (R) (R2) of 3 residents reviewed. A grievance, dated 10/24/23, was filed on behalf of R2 related to hygiene. The facility did not thoroughly investigate or provide follow-up and resolution for the grievance. Findings include: The facility's Resident and Family Grievances policy, dated 1/2023, indicated: Prompt efforts to resolve include acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. On 11/7/23, Surveyor reviewed R2's medical record. R2 had diagnoses including kidney failure, heart failure, and diabetes. R2's Minimum Data Set (MDS) assessment, dated 8/11/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. The MDS also indicated R2 required staff assistance with activities of daily living (ADLs). R2 had an activated Power of Attorney for Healthcare (APOAHC). A grievance form, dated 10/24/23, indicated a concern related to hygiene was forwarded to Social Worker (SW)-D via email on 10/20/23. SW-D saw the email when SW-D returned to work on 10/23/23, filled out a grievance form on 10/24/23, and gave the form to Assistant Director of Nursing (ADON)-C for review. The grievance form, dated 10/24/23, contained a grievance official follow-up statement that indicated bath sheets were reviewed and R2 was receiving baths. The investigation did not contain resident or staff interviews, including an interview with R2, or follow up with the complainant. On 11/7/23, Surveyor interviewed SW-D who indicated SW-D gave the grievance to ADON-C who completed the investigation. On 11/7/23 at 1:34 PM, Surveyor interviewed ADON-C who indicated ADON-C reviewed the bath sheets and documentation indicated R2 was receiving baths. ADON-C did not recall a conversation with R2 regarding bathing and verified there was no follow up with the complainant. ADON-C verified grievances should be thoroughly investigated and follow up with the complainant should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not review and revise the care plan for 1 Resident (R) (R1) of 5 sampled residents. R1's plan of care indicated R1 had a passive range of motion (PROM) program; however, R1's care plan was not updated to include an intervention for active assistive range of motion (AAROM) on the right side. Findings include: On 11/7/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia and left femur fracture (5/2023). A care plan, dated 2/4/22, indicated R1 had PROM to the right leg and the left ankle due to a fracture in the left femur. The care plan contained a goal that indicated R1 would not have a decline in range of motion or any new contracture development through the three-month review period (revised on 9/18/23). Surveyor reviewed physical therapy notes, dated 9/22/23, that included an intervention for active assist side lying range of motion to R1's lower extremities except the left hip. Surveyor noted the intervention was not added to R1's care plan. On 11/7/23 at 10:00 AM, Surveyor interviewed Registered Nurse Manager (RNM)-E who verified R1 received PROM, but stated R1 often refused and education was provided. RNM-E verified the AAROM side lying intervention was not added to R1's care plan. On 11/7/23 at 10:36 AM, Surveyor interviewed Physical Therapist (PT)-F who verified R1's care plan should have included a new intervention for AAROM on 9/22/23. On 11/7/23 at 12:28 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified R1's care plan should have been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and provider interview, and record review, the facility did not notify the provider of an elevated blood sugar level for 1 Resident (R9) of 28 residents reviewed. R9 had a documented blood sugar level of 495 mg (milligrams)/dL (deciliter) on 2/25/23. R9's provider was not notified. Findings include: According to the American Diabetes Association, hyperglycemia is the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can't use insulin properly .Hyperglycemia can be a serious problem if you don't treat it, so it's important to treat as soon as you detect it. If you fail to treat hyperglycemia, a condition called ketoacidosis (diabetic coma) could occur .Ketoacidosis is life-threatening and needs immediate treatment. The American Diabetes Association suggests the following targets for most non-pregnant adults with diabetes: 1. Before a meal: 80-130 mg/dL 2. 1-2 hours after beginning of the meal: Less than 180 mg/dL R9 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, and acute osteomyelitis (bone inflammation caused by infection). On 10/25/23 at 9:49 AM, Surveyor interviewed Registered Nurse (RN)-D who indicated RN-D thought the facility followed the standard blood sugar notification to providers of under 70 mg/dL and above 350 mg/dL. Between 10/23/23 and 10/25/23, Surveyor reviewed R9's medical record. Surveyor noted on 2/25/23 at 4:00 PM, R1 had a documented blood sugar of 495 mg/dL. R1's medical record did not indicate R1's provider was notified. The facility provided a physician order (contained in R9's admission orders) to notify the physician in 1 week regarding R9's blood sugars. The facility also provided a provider note from Advanced Practice Nurse Prescriber (APNP)-E, dated 2/27/23, that indicated: Type 2 diabetes mellitus without complications. Home regimen included glipizide, metformin, and Lantus daily (medications used to control blood sugar). Currently only on glipizide. Blood glucose ranges in 200-400s. Continues on prednisone (a steroid medication). Restart metformin 2/27/23. If continues to be hyperglycemic, restart Lantus later this week. Monitor. On 10/25/23 at 10:34 AM, Surveyor interviewed APNP-E who indicated APNP-E's parameters for notification of blood sugar levels were over 400 mg/dL and less than 70 mg/dL. APNP-E confirmed the facility did not notify APNP-E or the physician of R9's blood sugar level of 495 mg/dL on 2/25/23. APNP-E indicated if APNP-E was notified, APNP-E likely would not have added or changed anything at that time because R9 was on prednisone and had osteomyelitis, both of which can temporarily cause high blood sugar levels. APNP-E indicated APNP-E would have instructed staff to continue to monitor R9's blood sugar levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not record, thoroughly investigate, or provide resolution of a grievance for 1 Resident (R) (R10) of 28 residents reviewed. R10's dentures were reported missing on either 5/12/23 or 5/13/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. R10 expressed care concerns to R10's physician on 5/22/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. R10's family expressed concerns about a transfer with injury that occurred on 5/27/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. Findings include: The facility's Resident and Family Grievances policy, with an implementation date of 10/2022, indicated the following: 1. Director of Social Services has been designated as the Grievance Official. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility .issuing written grievance decisions to the resident .4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (long-term care) facility stay. 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. R10 was admitted to the facility on [DATE] with diagnoses that included heart failure, peripheral vascular disease (PVD), need of assistance with personal cares, dysphagia (difficulty swallowing), and reduced mobility. On 5/12/23, R10's Minimum Data Set (MDS) assessment, dated 5/12/23, contained a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. R10 had an Activated Power of Attorney for Healthcare (APOAHC). 1. Between 10/23/23 and 10/25/23, Surveyor reviewed R10's medical record and noted a care plan, dated 5/19/23, that indicated: At risk for dental problems related to dentures, full - resident states is missing bottom dentures. On 10/24/23 at 1:30 PM, Surveyor interviewed Social Worker (SW)-C who stated R10's dentures went missing on R10's first or second night at the facility. SW-C stated SW-C was notified in the morning that R10's dentures were missing a day or two after R10 was admitted , but could not recall the exact date. SW-C indicated staff believed R10 put the dentures on R10's dinner tray and the dentures were accidentally thrown away. The dentures were reported missing the next morning when staff couldn't find them prior to breakfast. SW-C recalled a discussion about someone searching the dumpster for the dentures, but was unsure if that occurred. SW-C indicated SW-C did not fill out a grievance form and could not provide Surveyor with documentation of an investigation or follow up. SW-C also indicated SW-C did not make an appointment for R10 because SW-C was not sure if R10 or R10's family wanted the dentures replaced. SW-C indicated the facility would make an appointment if R10 or R10's family requested one. On 10/24/23 at 3:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed a grievance form should have been completed. 2. Between 10/23/23 and 10/25/23, Surveyor reviewed R10's medical record and noted a physician progress note, written by R10's Advanced Practice Nurse Prescriber (APNP) on 5/22/23, that indicated: (R10) seen today resting in wheelchair. (R10) is tearful, feels was not helped by nursing staff yesterday. On 10/25/23, Surveyor reviewed a Witness Statement form signed by Registered Nurse (RN)-D. The statement did not contain an incident date, interview date, or a date next to RN-D's signature. The statement was not attached to a grievance form and did not contain an investigation. The statement indicated: Spoke with (R10) after being told by Nurse Practitioner that (R10) had nursing concerns. (R10) was requesting (RN-D) have a Certified Nursing Assistant (CNA) assigned only to (R10's) room so (R10) doesn't have to wait for staff to answer call light. (RN-D) explained to (R10) that we can not assign an aide to do one-to-one. On 10/25/23 at 9:56 AM, Surveyor interviewed NHA-A who confirmed a grievance form should have been filled out with further investigation into R10's concerns. 3. Between 10/23/23 and 10/25/23, Surveyor reviewed R10's medical record and noted a change of condition note, dated 5/27/23 at 4:35 PM, that indicated: (R10) has laceration to left calf, caused during transfer into wheelchair, pressure was held to control bleeding, Steri-Strips applied followed by Xeroform, gauze, 4 x 4 Kerlix. A call was placed for transfer to ER for evaluation. (R10) sent via (ambulance company). On 10/24/23 at 1:30 PM, Surveyor interviewed SW-C who recalled the above incident and recalled hearing that R10's family had concerns that the staff who completed the transfer were incompetent. SW-C indicated SW-C did not look into the concern because the concern was more of a nursing issue. The facility was not able to provide a grievance form and investigation related to the above care concern. The facility provided Surveyor with a skin injury incident report that contained a statement of what occurred from the CNA who completed the transfer and the nurse who responded. The information also included a note that indicated R10's wheelchair was reassessed for size and fit, and skin and pain assessments were completed. The information did not include a grievance form or investigation into the concern expressed by R10's family. On 10/24/23 at 1:30 PM, SW-C indicated the grievances process is as follows: If there is a grievance and SW-C is aware, the grievance is given to NHA-A who distributes the grievance to the appropriate department. On 10/25/23 at 9:56 AM, Surveyor interviewed NHA-A who indicated grievance forms are available for anyone (family, residents, or staff) to fill out. NHA-A stated grievance forms are given to SW-C who distributes them to the departments that are required to follow up. NHA-A also indicated grievances are discussed at morning meetings, and stated if staff are made aware of a concern, a grievance form should be completed.

Based on staff interview and record review, the facility did not implement their abuse prevention policy and procedure for 2 (Certified Nursing Assistant (CNA)-F and CNA-G) of 8 staff reviewed during the caregiver program compliance check. The facility did not complete a current Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, or Integrated Background Information System (IBIS) letter for CNA-F. The facility did not complete an out-of-state background check for CNA-G. Findings include: The facility's Abuse, Neglect and Exploitation policy and procedure, with an implementation date of 6/1/22, indicates the facility's abuse prevention plan includes a screening process in which potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that the facility will maintain documentation of proof that the screenings occurred. On 10/24/23, Surveyor completed a caregiver program compliance check for eight sampled staff employed by the facility. 1. CNA-F was hired by the facility's corporate company on 7/29/21. Surveyor noted CNA-F's BID form was completed on 11/19/19, and CNA-F's DOJ and IBIS letters contained dates of 12/3/19. On 10/25/23 at 4:05 PM, Surveyor interviewed Human Resource Director (HRD)-H who confirmed CNA-F was hired on 7/29/21, but stated CNA-F was originally hired in 2017. HRD-H could not provide documentation to verify that CNA-F was continuously employed at the facility from the time CNA-F's background checks were completed in 2019 to CNA-F's documented hire date on 7/29/21. 2. CNA-G was hired on 9/26/23. CNA-G's BID form was completed on 9/21/23, and CNA-G's DOJ and IBIS letters were completed on 9/26/23. On the BID form, CNA-G answered Yes to living out of state, and indicated CNA-G lived in Alabama in 2022. On 10/25/23 at 11:19 AM, Surveyor interviewed HRD-H who confirmed the facility did not complete an out-of-state background check for CNA-G.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not thoroughly investigate a fall to ensure the environment was as free of accident hazards as possible for 1 Resident (R) (R4) of 2 residents reviewed for falls. R4 had a fall with injury on 8/18/23. The facility did not complete a thorough investigation to determine a root cause analysis or complete staff education to minimize the likelihood of future falls. Findings include: The facility's Falls Prevention Program Policy dated 10/2023, indicates: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. On 10/24/23, Surveyor reviewed R4's medical record. R4 was readmitted to the facility on [DATE] with diagnoses including encephalopathy, acute kidney injury, and acute renal failure, and received Hospice services. R4's Minimum Data Set (MDS) assessment, dated 5/25/23, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R4 had severely impaired cognition. The MDS also indicated R4 had one fall without injury since admission/prior assessment, and required staff assistance for dressing and other activities of daily living (ADLs). R4's fall care plan, dated 8/14/23, contained the following fall interventions: call light in reach, anticipate needs, appropriate footwear, environment safe and free of clutter, side rails and encourage activities. R4's medical record indicated R4 fell on 8/18/23. The investigation indicated R4 was in the activity room in a wheelchair with R4's head in hand and resting on R4's wheelchair arm. Activity Assistant (AA)-I was moving residents back to their rooms and moved the table in front of R4 to allow other residents through. AA-I's back was to R4 when R4 fell forward out of the wheelchair and onto the floor. R4 incurred a forehead laceration and an eye injury. AA-I's witness statement indicated AA-I was finishing with a birthday party, getting residents back to their rooms, doing nails, and providing water to those in the room. AA-I indicated R4 was asleep on R4's hand when AA-I moved R4 to get another resident to their room. AA-I indicated in the middle of that, R4 fell forward. A witness statement from Certified Nursing Assistant (CNA)-N, dated 8/18/23, indicated CNA-N witnessed R4's head on the table prior to the incident. Surveyor noted the witness statements were vague and did not provide a clear picture of the events prior to the fall. Following the fall, R4 was sent to the ER (Emergency Room) and did not return to the facility. The facility reviewed and investigated R4's fall, did a head-to-toe assessment of R4, and obtained witness statements; however, the facility did not follow-up with a root cause analysis of the fall, obtain a clear indication of what occurred prior to the fall, or provide staff education to prevent future falls. Surveyor was unable to interview AA-I (who no longer worked at the facility) during the course of the investigation. On 10/25/23 at 12:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A did not educate staff on R4's fall. NHA-A indicated there should have been education completed following R4's fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility did not ensure on-going communication and collaboration with the dialysis center for 1 Resident (R) (R1) of 1 resident reviewed for dialysis services. R1's received dialysis three times weekly. R1's dialysis binder and communication forms contained incomplete information from the facility despite multiple requests from the dialysis center for the necessary information. Findings include: From 1/17/23 through 1/18/23, Surveyor reviewed R1's medical record which indicated R1 admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) requiring hemodialysis three times weekly, diabetes mellitus, acute on chronic anemia and dementia. R1's most recent Minimum Data Set contained a Brief Interview for Mental Status (BIMS) score of 6 which indicated R1 was severely cognitively impaired. The facility's Hemodialysis policy, dated 10/20/22, stated, The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b. Physician/treatment orders, laboratory values, and vital signs; c. Advance Directives and code status; specific directives about treatment choices, and any changes or need for further discussion with the resident representative, and practitioners . On 1/17/23 at 11:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated residents who received dialysis took a communication binder with a new communication form to each dialysis session. Facility staff completed the top portion of the form with resident specific information and the dialysis center completed the bottom portion of the form prior to the resident leaving the dialysis center to return to the facility. On 1/17/23, Surveyor reviewed R1's dialysis communication binder. The binder contained seventeen communication record forms, dated 10/28/22 through 12/21/22; however, the binder should have contained twenty-four communication forms for the same time period. Surveyor reviewed the communication forms and noted the top and middle portions were not completed. Four of the documents did not include R1's name or any information from the facility. None of the documents included resident specific pre-dialysis information. On 1/17/23 at 12:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated staff were expected to complete the middle portion of the communication form for a resident who was going to dialysis. The middle portion of the form contained resident specific pre-dialysis information to be completed by facility staff prior to the resident's dialysis appointment. ADON-C stated the top portion of the form was repetitive information, including the resident's name, etc. On 1/17/23 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should complete the top half of the form and send the communication binder with the resident to all dialysis appointments. On 1/17/23 at 2:35 PM, Surveyor received seven dialysis communication forms for R1 for January 2023. All seven forms were incomplete and were missing resident specific pre-dialysis information. On 1/18/23 at 11:57 AM, Surveyor interviewed dialysis Registered Nurse (RN)-G. RN-G indicated the dialysis center was not getting communication sheets from the nursing facility and stated R1 at times brought the wrong type of binder or another resident's binder. RN-G stated when R1's communication binder came with R1, the communication forms were incomplete or blank. RN-G stated a representative from the dialysis center called and talked to an unidentified staff at the facility about the incomplete forms. RN-G stated RN-G wrote notes on some of the communication forms and requested R1's information be filled out prior to R1's dialysis sessions. R1's dialysis communication sheet, dated 12/19/22, stated, Please fill out pre-dialysis form before sending patient to dialysis. R1's dialysis communication sheet, dated 12/21/22, stated, Must fill out top portion. RN-G stated the facility continued to not complete the pre-dialysis information for R1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure the medical record accurately reflected the condition as well as care and services provided for 1 Resident (R) (R1) of 1 resident reviewed for dialysis services. R1's medical record contained dialysis communication forms that were filled out after R1's dialysis appointments and contained signatures of the nurse who completed R1's dialysis (Registered Nurse (RN)-G); however, the forms were not completed or signed by RN-G. Findings include: From 1/17/23 through 1/18/23, Surveyor reviewed R1's medical record. R1 admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) requiring hemodialysis three times weekly, diabetes mellitus, acute on chronic anemia, and dementia. R1's most recent Minimum Data Set (MDS) contained a Brief Interview for Mental Status (BIMS) score of 6 which indicated R1 was severely cognitively impaired. The facility's Hemodialysis policy, dated 10/20/22, stated, The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b. Physician/treatment orders, laboratory values, and vital signs; c. Advance Directives and code status; specific directives about treatment choices, and any changes or need for further discussion with the resident representative, and practitioners . On 1/17/23 at 11:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated residents who received dialysis took a communication binder with a new communication form to each dialysis session. LPN-D stated facility nursing staff completed the top portion of the form with resident specific information and the dialysis center completed the bottom portion of the form prior to the resident leaving the dialysis center and returning to the facility. On 1/17/23, Surveyor reviewed R1's dialysis communication binder. R1's dialysis communication binder contained seventeen communication forms, dated 10/28/22 through 12/21/21, but should have contained twenty-four communication forms for the same time period. Surveyor reviewed the communication forms and noted the top and middle portions were not completed. Four of the documents did not include R1's name or any information from the facility. None of the documents included resident specific pre-dialysis information. On 1/17/23 at 12:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated staff were expected to fill out the middle portion of the communication form for residents going to dialysis. The middle portion of the form contained resident specific pre-dialysis information to be completed by facility staff prior to the resident leaving for dialysis. ADON-C stated the top portion of the form was repetitive information, including the resident's name, etc. On 1/17/23 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should complete the top half of the form and the communication binder should be sent with the resident to all dialysis appointments. On 1/17/23 at 2:35 PM, Surveyor received seven dialysis communication forms for R1 for January 2023. All seven communication forms were missing portions of the resident specific pre-dialysis information, but contained more information than the December 2022 communication forms. On 1/18/23 at 11:57 AM, Surveyor interviewed dialysis RN-G who stated the dialysis center was not getting communication sheets from the nursing facility and R1 at times brought the wrong type of binder or another resident's binder. RN-G stated when R1's communication binder came with R1, the communication forms were incomplete or blank. RN-G stated a representative from the dialysis center called and talked to an unidentified staff at the facility regarding the incomplete forms. RN-G wrote notes on some of the communication forms and requested staff fill in the needed information. R1's dialysis communication sheet, dated 12/19/22, stated, Please fill out pre-dialysis form before sending patient to dialysis. R1's dialysis communication sheet, dated 12/21/22, stated, Must fill out top portion. RN-G indicated the facility continued to not complete the pre-dialysis information for R1. On 1/18/23 following the interview with RN-G, Surveyor received a message from Nursing Home Administrator (NHA)-A that the dialysis center asked to speak with Surveyor. Surveyor returned the call and was told by a dialysis center representative that RN-G reviewed R1's dialysis communication forms for January 2023 and stated the signature of RN-G was not made by RN-G. RN-G then got on the phone and stated RN-G's signature was forged on the communication forms for 1/2/23, 1/4/23, 1/6/23, 1/9/23, 1/11/23, 1/13/23 and 1/16/23 and also stated the dialysis portion of the communication form was not completed by the dialysis center. The dialysis center indicated a facility representative called the dialysis center on 1/17/23 and requested pre and post dialysis weights, labs and the name of the RN who completed R1's dialysis. The dialysis representative could not recall the facility representative's name or other identifying information. On 1/18/23 at 12:15 PM, Surveyor interviewed DON-B who stated DON-B did not call the dialysis center on 1/17/23 and did not sign RN-G's name on R1's January 2023 dialysis communication forms. On 1/18/23 at 12:21 PM, Surveyor interviewed ADON-C and LPN-D who stated they did not call the dialysis center on 1/17/23 and did not sign RN-G's name on R1's dialysis communication forms. On 1/18/23 at 12:50 PM, Surveyor interviewed NHA-A who stated NHA-A did not call the dialysis center on 1/17/23 and did not sign RN-G's name on the dialysis communication forms. NHA-A and Surveyor were joined by Director of Clinical Services (DCS)-H who stated DCS-H called the dialysis center on 1/17/23 to obtain resident specific information including pre and post dialysis weights and completed a record review to obtain R1's vital signs. DCS-H stated DCS-H wrote the information on the dialysis communication forms, including the name of the dialysis nurse and the date in the signature section. DCS-H stated DCS-H printed, but did not sign RN-G's name in the signature section. NHA-A verified R1's dialysis information was not on the communication forms at the time of the appointments and the information on the form and in the signature section was added before the forms were provided to Surveyor.

Based on observation and resident and staff interview the facility did not provide the necessary services to ensure a clean and sanitary environment for 8 Residents (R) (R2, R3, R4, R9, R14, R16, R17, R18) of 8 residents. A garbage can in R2 and R9's shared bathroom contained dried feces. The toilet, floor and wall in R3's room contained dried urine and feces. The toilet, floor and wall in R14's room contained dried urine and feces. The wall in R4 and R16's shared bathroom contained dried feces. The wall and garbage can in R17 and R18's shared bathroom contained dried feces. Findings include: On 1/18/23 at 9:28 AM, Surveyor interviewed R2 and R9 who were roommates and shared a bathroom. Surveyor observed a garbage can next to the bathroom door that did not contain a garbage bag and had streaks of dried feces inside of the can. On 1/18/23 at 9:47 AM, Surveyor observed perineal care for R3 who stood in front of the toilet in R3's bathroom. Certified Nursing Assistant (CNA)-J used a washcloth to clean feces off R3's backside and threw the washcloth toward a garbage can next to the door of the bathroom. R3 was assisted out of the bathroom and Surveyor observed dried feces on the outside of the toilet bowl along the rim and urine streaks from the rim down to the floor. On the wall above the garbage can, Surveyor noted a half dollar-size amount of dried feces and a larger amount of smeared dried feces underneath that appeared to have run down the wall. Surveyor also noted the floor was sticky and the bathroom had an odor of urine. Surveyor asked to speak with CNA-J after CNA-J returned from assisting R3 to the lobby. In the meantime, Surveyor entered R14's room and bathroom. Surveyor noted a large puddle of dried urine that spread across the bathroom to the wall and noted the wall near the garbage was splattered with dried feces. R14's bathroom contained a strong odor and the floor was also sticky. When CNA-J returned, Surveyor confirmed with CNA-J the substances on the floors and walls were urine and feces. On 1/18/23 at 10:12 AM, Surveyor interviewed Housekeeping Supervisor (HSK)-I who stated resident rooms and bathrooms were cleaned daily. HSK-I and Surveyor observed R3 and R14's bathroom. HSK-I verified the walls, toilet, and floors in the bathrooms contained urine and dried feces. HSK-I and Surveyor went to another wing to observe additional resident rooms and bathrooms since staff were done cleaning that wing for the day. HSK-I and Surveyor observed dried feces on the back of R4 and R16's bathroom wall. HSK-I and Surveyor also observed dried feces on the wall above the garbage can and inside the garbage can in R17 and R18's shared bathroom. HSK-I confirmed the rooms were cleaned that morning. Surveyor also reported to HSK-I the observation of dried feces in R2 and R9's garbage can. On 1/18/23 at 11:18 AM, Surveyor and Nursing Home Administrator (NHA)-A observed the above mentioned rooms which were cleaned by housekeeping staff; however, still contained urine and dried feces. NHA-A stated the current contracted housekeeping service was provided a termination notice because they were not meeting the expectations of their contract. NHA-A verified the observations and concerns with urine and feces on the floors, walls, and in the garbage cans.

Based on interview and record review the facility did not ensure 2 (R311, R312) of 2 resident's reviewed, signed and received copies of the Notice of Medicare Non Coverage (NOMNC) form and/or Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) form. The SNF-ABN and NOMNC forms inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility) and standard claim appeal rights and instructions. On 8/23/22, Social Service Assistant (SSA)-X informed R311's Activated Health Care Power of Attorney (HCPOA) of the facility's decision to end R311's Medicare Part A coverage at the facility. SSA-X documented the notification on R311's NOMNC form. However, R311's HCPOA did not sign the form indicating she received and understood the notice nor did she receive a copy of the form with the phone number and instructions on the process to appeal the facility's decision to end Medicare Part A coverage for R311. On 7/11/22, Social Service Assistant (SSA)-X informed R312's Activated Health Care Power of Attorney (HCPOA) of the facility's decision to end R312's Medicare Part A coverage at the facility. SSA-X documented the notification on R312's NOMNC form and Skilled Nursing Facility-Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form. However, R312's HCPOA did not sign the forms indicating he received and understood the notice nor did he receive a copy of the forms with the phone number and instructions on the process to appeal the facility's decision to end Medicare Part A coverage and did not receive information on R311's financial liability to the facility for continued stay. Findings include: On 11/09/22, at 1:58 PM, Surveyor interviewed Social Service Assistant (SSA)- X, who stated she is responsible for proving the resident and/or their responsible party the notices of non coverage or the end of coverage for Medicare Part A and Medicare Replacement plans. SSA-X stated she will call the resident's responsible party with a day or 2 notice informing them of the end of Medicare coverage. SSA-X stated she will speak to responsible parties over the phone or leave a message and has not ever provided them with copies of the notices of non coverage nor has she mailed the notices out to obtain signatures. SSA-X stated when someone has a Medicare Replacement plan and coverage ends she does provide them with a notice of non coverage form and will provide copies of the notices but has not thought about doing the same for ending of Medicare Part A coverage. SSA-X stated she does not mail out the notice of non coverage forms to a resident's responsible party to obtain signatures. SSA-X stated she typically will leave voicemail messages informing responsible parties of the date Medicare Part A coverage will end and the right to appeal the decision. SSA-X states she will also provide the phone number and instructions to appeal the facility's decision to end coverage to a resident's responsible party but does not document this part of the conversation. On 11/9/22, at 3:15 PM, Surveyor informed Nursing Home Administrator (NHA)-A, and Director of Nursing (DON)-B of the concern SSA-X does not provide residents and families with copies of the NOMNC or SNF-ABN forms. SSA-X will leave a voicemail message for families informing them of the end of Medicare Part-A coverage and SSA-X does not follow up with obtaining signatures on the forms to confirm residents and responsible parties were informed and understand the notices, patient liability and appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not develop and implement an effective discharge plan including identification of resident needs, addressing the resident's cognitive status or changes in cognitive status, capacity and capability of caregiver (who is the resident's representative) to perform required care, and discussion with the resident's representative to ensure a safe discharge for 1 (R53) of 2 residents reviewed for discharge planning. The facility did not include or update R53's representative with discharge plans nor did the facility address conflicting assessments of R53's cognitive status that may impact the process of providing a safe discharge from the facility. Findings include: R53 was admitted to the facility on [DATE] with diagnosis that includes, Acute UTI (Urinary Tract infection), failure to thrive, repeated falls, muscle weakness, unspecified dementia, unspecified severity without behavioral disturbances and neurocognitive disorders with Lewy bodies. R53's MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 10/18/2022, documents a BIMS (Brief Interview for Mental Status) score of 15 which indicates R53 is cognitively intact. R53's care plan, dated 10/14/2022, with a target date of 01/25/2022, documents: [Name of R53] wishes to return to the community .discharge goals are to return to the home [name of R53] shares with [representative] after a short rehabilitative stay. Interventions include, Establish a pre-discharge plan with resident/family/caregivers and evaluate progress and revise plan weekly; Make arrangements with required community resources to support independence post-discharge; Prepare [name of R53] and [representative] [name of wife] contact numbers for all community referrals. R53 did not have a care plan addressing the diagnoses of Lewy body dementia. R53 had active physician's orders which included, Quetiapine Fumerate 25mg (milligrams) at bedtime for dementia; Rivastigmine Tartrate Capsule 6 mg two times a day for dementia; and Memantine HCI (hydrochloride) tablet 10mg one time a day for dementia. On 11/07/22, at 9:32 AM, Surveyor observed R53 dressed and sitting upright in a wheelchair in his room. R53 informed Surveyor he fell three times over the weekend but did not have any injuries from the falls. On 11/07/22, at 2:04 PM, Surveyor observed R53 sitting upright in a wheelchair in his room accompanied by representative. R53's representative explained R53's history to Surveyor including the multiple falls at home, diagnosis of dementia with Lewy bodies and Parkinson's disease. R53's representative informed Surveyor that R53 had fallen twice over the weekend, but R53 stated no it was three times, twice in one day. R53's representative was uncertain and informed Surveyor she was only made aware of two falls; one each day over the weekend and that R53 can be confused at times. Surveyor received documentation supporting R53 had two falls over the weekend, not three. Surveyor reviewed R53's progress notes with the following documented related to R53's cognition: Documentation on 10/17, 10/21, and 10/25 states R53 refused the Ketoconazole cream to groin area. On 10/26/2022, at 5:24 AM, a nurses note documents R53 refused the cream for his/her groin area stating it was healed and did not hurt anymore. R53 allowed the nurse to assess the area and the nurse documents that R53's brief was soaked and R53's groin area appeared red and irritated. The nurse provided education to R53 about not refusing the cream as the area was still irritated. On 11/01/22, a skilled nursing note documents R53 is alert, oriented to person, place and situation but has short term memory impairment, noted to be forgetful at times, also very impulsive and forgets to call for assistance. On 11/04/22, a skilled nursing note documents R53 has short term memory impairment and is alert but has periods of confusion. On 11/05/22, a skilled nursing note documents R53 is alert and oriented to person and place but has short term memory impairment, R53's orientation changes throughout the day and still remains very impulsive and forgetful. On 11/08/22, a skilled nursing note documents R53 is working with therapy but quickly forgets what was instructed; R53 is alert and oriented to person and place but has short term memory impairment, impaired decision making ability, impulsive, forgetful and R53's orientation varies throughout the day. On 11/09/22, a skilled nursing note documents R53 is alert and oriented to person with short term memory impairment. This note also documents R53 as being very confused this shift, thinking that family live downstairs, refusing to believe staff that self and linens were soiled, and needing 2-3 staff members to assist with cares and to assist with reorienting. On 11/10/22, a skilled nursing note documents R53 continues to be impulsive, has been educated over and over on safety, but forgets. Staff ensures the call light is within his reach but R53 forgets to use it. R53 continues to need constant reminders, plus supervision to avoid getting hurt. This note also documents R53 is oriented to person, has short term memory impairment with impaired decision making ability that comes and goes, has impulsive behavior, forgets safety factors with transfers and can become very confused at times. On 11/08/22, at 1:10 PM, Surveyor observed R53 sitting upright in his wheelchair, wheeling self into the bathroom. R53's representative was observed sitting in a chair next to R53's bed and stated to Surveyor [name of R53] is using the bathroom again with no assistance. Surveyor asked if the call light was on and R53's representative stated R53 did not put the call light on. Surveyor suggested putting the call light on so staff would be aware R53 needed assistance and at this time R53's representative pushed the call light and staff came to assist. On 11/09/22, at 7:33 AM, Surveyor observed R53 sitting upright in his wheelchair with shoes and shorts on, but shorts were not pulled up. R53 began wheeling self into bathroom. Surveyor suggested to R53 that he push the call light so staff know assistance is needed. R53 pushed the call light upon entering the bathroom and R53 informed Surveyor he fell again last night. Surveyor interviewed staff and reviewed R53's electronic medical record and could not find evidence that R53 had fallen the night before. On 11/8/2022, at 7:25 PM, Social Services documented in a progress note, R53 was given a notice of a last covered day of 11/10/22. Social Services explained appeal rights to R53 and R53 would not be appealing and would discharge home on 11.11.22. Social Services will assist with discharge planning as able. On 11/09/22, at 11:25 AM, Surveyor interviewed SW (Social Worker)-X. SW-X informed Surveyor R53 has a high BIMS score and his cognition is pretty good. Surveyor asked SW-X if R53's representative is involved in care planning/discharge planning to which SW-X stated define involved because R53's representative has some Dementia. Surveyor asked SW-X to elaborate, and SW-X explained R53's representative is forgetful and R53 has expressed concerns relating to representative being at home by self. SW-X explained she had given R53 the NOMNC (Notice of Medicare Non-Coverage) last night and R53 will discharge home on Friday with outpatient therapy because per R53, their house is being remodeled and R53 does not want anyone coming to the house. Surveyor confirmed R53's representative was not informed R53 would be discharging home on Friday. On 11/09/22, at 12:25 PM, Surveyor interviewed R53. R53 informed Surveyor he/she was going home on Friday and that two types of therapy would be provided: someone was coming to R53's house and R53 thought he/she might have to go somewhere as well. On 11/09/22, at 3:35 PM, Surveyor interviewed R53's representative who was in R53's room. R53's representative informed Surveyor she was unaware R53 was discharging home on Friday to which R53 pointed to Surveyor, and stated yes she told me yesterday. Surveyor informed R53 that Surveyor does not work at the facility and Surveyor would not have any involvement in the discharge process. Surveyor offered to ask SW-X to come to R53's room to discuss the discharge and R53's representative stated yes please. On 11/09/22, at 3:45 PM, Surveyor asked SW-X to please speak with R53's representative regarding R53's discharge as R53's representative was currently in the facility and unaware R53 was being discharged . On 11/10/22, Surveyor reviewed R53's speech therapy notes from 10/17/22 to 10/28/22. The Speech Therapy Evaluation and Plan of Treatment, dated 10/17/22, documented R53 had a SLUMS (St. Louis University Mental Status Exam) score of 16/30 indicating R53 has Dementia, R53's executive function, problem solving and memory were impaired. The following was documented in a Discharge Summary from Speech Therapy on 10/28/22: SLUMS score of 20/30 (which although improved from admission still indicates Dementia), problem solving impaired, memory impaired and executive function impaired, demonstrated adequate cognition/communication skills to complete age-appropriate complex living tasks 50-75% of the time and is safe to return to previous living situation with support from others with a morning and afternoon caregiver available. On 11/10/22, at 9:00 AM, Surveyor interviewed R53's physical therapist, PTA (Physical Therapy Assistant)-Y. PTA-Y informed Surveyor although R53 has good range of motion and strength R53 has no safety awareness. PTA-Y explained strategies therapy was using to assist R53 with safety and informed Surveyor she had worked with R53's family in regard to walking and safety issues. PTA-Y informed Surveyor per R53 they are getting a ramp installed outside of their house for the entrance stairs and remodeling to address the sunken living room that has stairs. PTA-Y stated she would prefer to do a house visit/assessment for R53 but informed Surveyor they (therapy staff) are not allowed to do house visits yet. PTA-Y stated R53 needs at home therapy to address certain safety issues and will need Occupational therapy for assistance with activities of daily living such as showering. On 11/10/22, at 10:14 AM, Surveyor interviewed RN (Registered Nurse) MDS (Minimum Data Set)-G in regards to R53's cognition and lack of Dementia care plan. MDS-G explained to Surveyor since R53 had a BIMS of 15, the Dementia care plan or care area would not trigger and the MDS nurses would not initiate a Dementia care plan, even though R53 has a diagnosis of Dementia. MDS-G stated to Surveyor that at the time of the MDS assessment no concerns (with cognition) were identified and if concerns were identified at a later time then nursing would update the care plan. On 11/10/22, at 12:05 PM, Surveyor interviewed R53. R53 told Surveyor I was supposed to go home tomorrow, but now it changed until Tuesday. I am going home today or tomorrow to drop some stuff off. At least I can get out of this building once. Surveyor asked R53 who had informed them of the discharge date change and why was it changed. R53 stated [name of representative] spoke with [name of Surveyor]. R53 then paused, looked at Surveyor's name badge and stated, Wait, no that's you. [Name of representative] spoke with someone else. R53 could not remember which staff member informed them of the discharge date change or why the date had been changed. On 11/10/22, at 12:34 PM, Surveyor interviewed SW-X. SW-X informed Surveyor R53 was still discharging tomorrow, Friday. Surveyor explained to SW-X that R53 thinks the discharge date has been changed to Tuesday. SW-X informed Surveyor she was unaware of any changes or extensions. SW-X stated she discussed R53's discharge with R53's representative that morning and SW-X did not update R53's representative sooner because R53 said he/she would update the representative. Surveyor asked SW-X about R53's cognition and lack of Dementia care plan. SW-X informed Surveyor R53 scored a 15 on the BIMS and she would care plan a cognition issue solely off the score of the BIMS. Surveyor explained the Speech Therapist notes which documented a SLUMS of 16/30 and 20/30. SW-X explained to Surveyor she is not medical personnel and can only go off of certain assessments and when she did R53's BIMS the answers given were appropriate and the questions R53 asked were appropriate. SW-X informed Surveyor if there was a change in cognition then nursing would update/initiate the care plan. On 11/10/22, at 12:50 PM, Surveyor interviewed unit manager, LPN (Licensed Practical Nurse)-L. LPN-L informed Surveyor care plans are generally done by the admitting nurses who do the initial data collection. Surveyor explained R53's SLUMS scores and asked about a lack of a Dementia care plan. LPN-L informed Surveyor she was not sure how nursing would be updated regarding a therapy evaluation or if the SLUMS score would trigger something for MDS. LPN-L informed Surveyor that normally social services would initiate a Dementia care plan, but a different discipline could do it as well. Surveyor expressed concerns with documentation indicating R53 has cognitive deficits which were not addressed by the facility. LPN-L explained to Surveyor residents have the right to make unsafe decisions such as R53 choosing not to wear shoes. The staff can provide education but R53 can still refuse and that is his/her choice. LPN-L stated R53 may talk to himself but R53 can still tell me who the president is and what day he is discharging from the facility. Surveyor informed LPN-L per R53, he believes he is discharging on Tuesday and not Friday. LPN-L replied R53 has been told both days and the facility was going back and forth to ensure safety. Surveyor asked if individuals with Dementia may require different approaches from staff than someone who is cognitively intact. LPN-L replied, it would depend on the severity, maybe yes maybe no. On 11/10/22, at 1:36 PM, Surveyor informed NHA (Nursing Home Administrator)-A of the concerns regarding R53's cognition, lack of care plan regarding R53's cognition and concerns about R53's representative not being made aware, by the facility, that R53 was being discharged . R53's representative was contacted by the facility only after Surveyor had spoken with SW-X about concerns with the lack of discharge planning and coordination. Surveyor asked for any additional information regarding this issue. After exiting the facility, on 11/14/22, Surveyor received an email from NHA-A that contained a signed statement from SW-X documenting R53 was notified of the NOMNC and appeal rights, R53 did not want to appeal and since R53 is own person, R53 signed the notice. SW-X offered to contact R53's representative but R53 declined and told staff he would update the representative. This documentation also states R53's representative confirmed R53 told her R53 was supposed to call (representative) but did not. This documentation was signed by SW-X and R53. No further information was provided as to why R53's representative was not involved in the development of R53's discharge plan nor informed of the final discharge plan until this Surveyor brought the concern to the facility's attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review 2 (R8, R27) of 3 residents reviewed did not receive required assistance with Activities of Daily Living. *R8 did not receive assistance with dressing in accordance with their care plan. *R27 did not receive assistance with nail care. Findings include: 1.) R8 was admitted to the facility on [DATE] with diagnoses that include malnutrition and osteoarthritis. R8's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R8 requires extensive assistance of 2 staff with dressing. On 11/07/22, at 12:40 PM, Surveyor observed R8 in a hospital gown in bed. Surveyor attempted to interview R8 at this time. R8 was incoherent at the time of the attempted interview and was unable to respond to Surveyor's questions. On 11/08/22, at 1:59 PM, Surveyor observed R8 in a hospital gown in bed. R8 was resting at the time of this observation and was unable to be interviewed. On 11/9/22, at 1:02 PM, Surveyor observed R8 in a hospital gown in bed. Surveyor attempted to interview R8 at this time. R8 was incoherent at the time of the attempted interview and was unable to respond to Surveyor's questions. On 11/10/22, at 9:08 AM, Surveyor observed R8 dressed in their bed in a long sleeved shirt and sweatpants. Surveyor conducted interview with Certified Nursing Assistant (CNA)-Z. Surveyor asked CNA-Z if R8 should be getting dressed on a daily basis. CNA-Z told Surveyor that she had just returned to work from a recent leave of absence and that they had previously always helped R8 to dress in the mornings. Surveyor asked CNA-Z if there would be a reason R8 should not be getting dressed. CNA-Z told Surveyor she could not think of a reason why R8 wouldn't get dressed on a daily basis. Surveyor reviewed R8's comprehensive care plan. R8 does not have a care plan in place related to refusal of care, including activities of daily living such as dressing. Surveyor observed R8's closet which had a sufficient amount of clothing available for staff to assist R8 with dressing. On 11/10/22, at 2:00 PM, Surveyor shared concerns with NHA (Nursing Home Administrator)-A related to R8 not receiving assistance with dressing on 11/7/22, 11/8/22 and 11/9/22. No additional information was supplied by the facility at this time. 2. On 11/8/22, at 11:31 am, Surveyor observed R27 in bed. R27 informed Surveyor of her name. During Surveyor's conversation with R27, Surveyor observed both of R27's hands/fingers to be contracted. R27 lifted up both hands showing Surveyor how her fingers were contracted into the palms of each of her hands. R27 referenced what's left of them .being able to hold a pencil sometimes but is a whole lot slower. R27 stated, I have to get my nails cut showing surveyor her finger nails on both hands. Surveyor noted R27's right and left hands consisted of fingers contracting into the palms of her hand forming a fist with very long finger nails. Surveyor informed R27 that Surveyor would let someone know that her nails need to be cut with R27 responding with as long as they can cut them without cutting into my skin. On 11/8/22, at 12:15 pm, Surveyor informed Administrator A of R27's long finger nails and that they needed to be cut. Surveyor reviewed R27's medical record which included a review of the Significant Change Minimum Data Set (MDS) dated [DATE], which indicates R27 is understood and understands others, has adequate vision, no rejection of care, has a Brief Interview for Mental Status (BIMs) score of 3 indicating severe cognitive impairment for daily decision making skills, requires extensive assistance of one staff member for personal hygiene and has functional limitations in range of motion for both upper and lower extremities both sides. R27's care plan initiated 2/27/2018 and revised on 3/6/2018 documents a Focus area of: I have trouble with everyday tasks to take care of myself, including bathing, brushing my hair, brushing my teeth, eating, getting dressed, getting in and out of bed, getting on and off the toilet, using a wheelchair to get about, washing my face related to recent fall down the steps with C7 fracture and spinal cord injury. The goal is: I will do as much of my everyday tasks as I can, and let my caregivers help me with the parts that are difficult for me. (initiated 2/27/18, revision on 10/25/2022, target date 12/29/2022. Interventions consist of in part: Encourage active participation in tasks, gather and provided needed supplies, extensive assist of 2 (bathing/showering) . Surveyor noted R27's care plan does not address the provision of nail care. On 11/9/22, at 2:15 pm, Surveyor observed R27 in bed. Surveyor asked R27 if her nails had been cut with R27 saying not yet and again holding up both hands to show surveyor her long nails. On 11/9/22, at 2:23 pm, Surveyor interviewed Certified Nursing Assistant (CNA )-C who was assigned to care for R27 for second shift. CNA-C responded with the nurses are supposed to. On 11/9/22, at 2:23 pm, Surveyor informed Director of Nursing (DON)-B of R27's long fingernails. DON-B stated our light duty is supposed to be cutting nails and there is a happy nails activity where the Activity Director does the residents nails .anyone in the nursing department can cut nails unless she's diabetic .she's not diabetic we could implement a plan to cut nails on bath day, just had podiatrist here on Monday. On 11/9/22, at 2:55 pm, DON-B informed Surveyor, I personally cut her (R27's) nails myself and did some teaching.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R53 was admitted to the facility on [DATE] with diagnosis that includes, Acute UTI (Urinary Tract infection), failure to thrive, repeated falls, muscle weakness, unspecified dementia, unspecified severity without behavioral disturbances and neurocognitive disorders with Lewy bodies. R53's MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 10/18/2022 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicated R53 is cognitively intact; requires one person staff assist with transfers; R53 did not have a fall in the month prior to admission (this is inaccurate per Surveyor interview with R53's representative, R53 fell which led to hospitalization/admission to the facility) and R53 had fallen in the 2-6 months prior to admission. R53's At Risk for Falls care plan, dated 10/14/2022, has interventions that include: -bladder wheel and assess incontinence; -medication review and orthostatic blood pressures; -anticipate my needs, and potential fall times, make sure my call light/personal belongings are in reach and provided education on wearing proper footwear, transferring without assist, using call light to call for assist; -R53 prefers to be barefoot and will call when R53 needs assistance but also chooses to continue to transfer independently. Resident aware of fall risk by not following safety measures. R53's admission fall risk assessment identified R53 at a moderate risk for falls. R53 was evaluated and treated by Speech Therapy. R53's Speech Therapy Discharge Summary documented R53 had a SLUMS (St. Louis University Mental Status) of 20/30 indicating Dementia and R53 has impaired memory, impaired executive function, impaired problem solving. On 11/07/22, at 9:32 AM, Surveyor observed R53 dressed and sitting upright in his wheelchair in room. R53's room was located at the end of the hall, farthest away from the nursing station. R53 informed Surveyor he fell three times over the weekend but did not have any injuries from the falls. On 11/07/22, at 2:04 PM, Surveyor observed R53 sitting upright in wheelchair in room accompanied by representative. R53's representative explained R53's history to Surveyor including the multiple falls at home, diagnosis of dementia with Lewy bodies and the Parkinson's disease. R53's representative informed Surveyor R53 had fallen twice over the weekend, but R53 stated no it was three times, twice in one day. R53's representative was uncertain and informed Surveyor she was only made aware of two falls; one each day over the weekend and R53 can be confused at times. Surveyor received documentation supporting R53 had fallen two times over the weekend and four times total while at the facility. Surveyor noted a nurses progress note dated 10/26/22, addressing R53's post-fall bowel and bladder assessment which documents, Resident's bladder wheel was completed s/p (status post) fall for possible patterning to assist with toileting. Resident for the most part is denying any incontinence .Declines any new prompted toileting and says he will call if he needs anything. Resident does not want to be awoken at night to use the bathroom. Wishes will be honored. On 11/08/22, at 1:10 PM, Surveyor observed R53 sitting upright in his wheelchair, wheeling self into his bathroom. R53's representative was observed sitting in a chair next to R53's bed and stated to Surveyor [name of R53] is using the bathroom again with no assistance. Surveyor asked if the call light was on and R53's representative stated R53 did not put the call light on. Surveyor suggested putting the call light on so staff would be aware R53's need for assistance and at this time R53's representative pushed the call light and staff came to assist. On 11/09/22, at 7:33 AM, Surveyor observed R53 sitting upright in his wheelchair with shoes and shorts on, but shorts were not pulled up. R53 began wheeling self into bathroom. Surveyor suggested to R53 that he push the call light so staff know assistance is needed. R53 pushed the call light upon entering the bathroom. Surveyor stayed with R53 until staff arrived. On 11/10/22, at 12:46 PM, Surveyor interviewed LPN (Licensed Practical Nurse)-M. LPN-M informed Surveyor R53 is alert but confused, can follow simple directions but is forgetful especially about standing without assistance. On 11/09/22, at 1:55 PM, Surveyor interviewed LPN-L. Surveyor asked LPN-L when the facility identified R53 was at risk for falls and what interventions were in place when R53 first admitted to the facility. LPN-L informed Surveyor the facility was aware R53 was a fall risk upon admission related to a history of falls and the admission fall risk assessment. Per LPN-L, R53's initial care plan fall interventions were: anticipate needs and fall times, and call light and personal items within reach. LPN-L explained there were no rooms closer to the nurse station when R53 was first admitted to the facility which is why R53 remained in the room farthest away from the nurses station. Surveyor asked about R53's second fall on 10/26/22. Per fall documentation R53 was found on the floor attempting to go to bed and the floor nurse documented an intervention of gripper strips to be placed on floor next to R53's bed and toilet. Surveyor noted this information in R53's fall investigation packet from 10/26/2022. Surveyor explained there were no observed gripper strips in R53's room and this fall prevention intervention was not added to R53's care plan. LPN-L explained to Surveyor the gripper strip intervention was made immediately after the fall by the floor nurse, but the IDT (Interdisciplinary Team) discussed the fall and thought the gripper strips would do more harm since R53 refuses to wear footwear at times. LPN-L did not address the statement that R53 was trying to go to bed. On 11/5/22, it is documented R53 was found crawling on the floor in his room and per the facility fall packet documentation R53 had low blood pressure at the time and medications were to be reviewed by the Nurse Practitioner on Monday. Surveyor asked LPN-L if R53's medications had been reviewed per IDT recommended intervention for R53's third fall. Per LPN-L, NP (Nurse Practitioner)-N was supposed to be in the facility on Monday to review R53's medications but was not and R53's medications were reviewed today, Wednesday. LPN-L informed Surveyor she and NP-N briefly discussed R53's medications today and since R53's blood pressure had been stable, there were no medication changes recommended. LPN-L stated she was unaware if NP-N had addressed any other medications besides blood pressure medications. At the time of the fall R53 told staff he had needed to use the bathroom so R53 was provided with an extra urinal to be kept at bedside. Surveyor asked LPN-L about R53's fourth fall on 11/06/22 and what interventions were put into place and if the root cause was determined. LPN-L informed Surveyor there was no intervention for R53's fourth fall which occurred on 11/06/22. Per LPN-L, R53 was trying to pick up a button off the floor but LPN-L was not sure if the fall had been reviewed by the IDT (Interdisciplinary Team) yet. On 11/09/22, at 3:05 PM during the end of the day meeting with NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, Corporate RN (Registered Nurse)-I and Corporate Consultant-Q, Surveyor expressed concerns regarding a lack of an IDT assessment for a root cause of the fall and fall prevention interventions being implemented for R53's fall on 11/06/2022. DON-B informed Surveyor, I explained to you it was not done because you, the State, are in the facility. At this point, Corporate Nurse Consultant-I informed Surveyor LPN-L was working on it. Surveyor noted it had been three days since R53 had fallen and the facility had not reviewed the fall to determine a root cause or identify if new fall prevention interventions were necessary. On 11/10/22, Surveyor reviewed R53's medical record and noted the following progress note dated 11/9/2022 at 16:05 (4:05 PM) documenting, IDT Met: Resident was trying to pick up button off of the floor. Reacher was provided to assist with picking up items. Surveyor noted R53's fall care plan was updated to include a fall intervention of reacher provided with an initiated date of 11/06/2022. Based on interview and record review the facility did not ensure 2 (R15, R53) of 3 Residents reviewed for falls had an environment that was free from accident hazards and received adequate supervision and assistance devices to prevent accidents. R15 was assessed to require extensive assist of 2 plus staff for toilet use, including transfers on and off the toilet. R15's care plan documented R15 required extensive assist of 1 staff with a pivot disc for toilet use and transfers. On 6/9/22 R15 had a fall in the bathroom while being assisted by 1 staff. The facility documented R15 fell due to her knees buckling during transfer. Following the fall R15 was not reassessed to determine if transfers with assist of 1 staff remained appropriate. R15 had a second fall on 10/2/22 in her room. The facility did not identify the root cause of the fall or implement fall interventions to prevent future falls related to the root cause of the fall. R53 had a fall on 11/6/22. The facility did not investigate the fall to determine the root cause and did not implement interventions to prevent future falls. Findings include: R15 was admitted to the facility on [DATE] with diagnoses that include: stroke, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, overactive bladder, anxiety disorder, aphasia following cerebral infarction, chronic obstructive pulmonary disease, and major depressive disorder. R15's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/3/22, documents a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment for daily decision making; Patient Health Questionnaire (PHQ-9) score of 10, indicating moderate depressive symptoms; no behavior concerns; requires extensive assist of of 2 plus staff for transfers and toilet use including transferring on and off the toilet; not steady and only able to stabilize with human assistance when moving from seated to standing position, moving on and off the toilet, and for surface to surface transfers; functional range of motion limitation of the upper and lower extremities on one side; always incontinent of bladder and bowel and does not have a urinary or bowel toileting program. R15's Care Plan, dated 11/15/2018 with revisions on 11/21/2018 documents: I have trouble with everyday tasks to take care of myself, including bathing, getting dressed, getting in and out of bed, getting on and off the toilet, using a wheelchair to get about, washing my face related to weakness with past CVA (Cerebrovascular Accident) with hemiplegia and COPD (Chronic Obstructive Pulmonary Disease) exacerbation. Interventions include: -Bed against the wall due to resident preference to make more room, dated initiated: 3/25/2021, revision on: 6/3/2022; -Encourage to participate in tasks . TOILET USE: extensive assist of 1 to toilet with pivot disc, TRANSFER: Extensive assist of 1 staff for bed/w/c (wheelchair) transfers with pivot disc . date initiated 11/15/2018, revision on 11/01/2022; . -TOILET USE: extensive assist of 1 to toilet with pivot disc, TRANSFER: Extensive assist of 1 staff for bed/w/c (wheelchair) transfers with pivot disc . date initiated 11/15/2018, revision on 06/03/2022; . -TOILET USE: extensive assist of 1 to toilet with pivot disc, TRANSFER: Extensive assist of 1 staff for bed/w/c (wheelchair) transfers with pivot disc . date initiated 11/15/2018, revision on 01/27/2020; . -TOILET USE: extensive assist of 1 to toilet with pivot disc, TRANSFER: Extensive assist of 1 staff for bed/w/c (wheelchair) transfers with pivot disc . date initiated 11/15/2018, revision on 06/04/2019; . R15's Care Plan, dated 11/15/2018, with revisions on 08/09/2022 documents: [Resident's name] is high risk for falls r/t (related to) mobility impairments with hemiplegia, current medications. Interventions include: -10/2/22 fall- med (medication review), date initiated: 10/4/2022; -11/14/21 fall isolated event; 2/28/22 fall from bed, bed in low position during sleeping hours; 6/9/22 fall-refer to therapy as indicated, dated initiated: 11/15/21; revisions on: 10/04/2022; Anticipate and meet [Resident's name]'s needs, date initiated: 11/15/2018, revision on: 07/26/2022; -Be sure [Resident's name]'s call light is within reach and encourage [Resident's name] to use it for assistance as needed. [Resident's name] needs prompt response to all requests for assistance, date initiated: 11/15/2018, revision date: 07/26/2022; -Do not leave [Resident's name] alone in bathroom, dated initiated: 11/15/2018, revision date: 06/03/2022; -Encourage [Resident's name] to participate in activities that promote exercise, physical activity for strengthening and improved mobility, dated initiated: 11/15/2018, revisions on : 07/26/2022; -Ensure [Resident's name] is wearing appropriate footwear gripper or socks/shoes when ambulating or mobilizing in w/c, date imitated: 11/15/2018, revision on: 07/26/2022; -Follow facility fall protocol, date initiated: 11/15/2018; -PT (Physical Therapy) and treat as ordered or PRN (as needed). Evaluate [Resident's name] need/want for communication interventions (headphones), dated imitated: 11/15/2018, revision on: 07/26/2011 . On 6/9/22, R15's Medical Record documents: eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, Situation: the change in condition/s reported are/were: Falls . Nursing observations, evaluation, and recommendations are: Resident had a witnessed fall. Staff present with resident when her leg buckled and she fell. Staff was providing cares after toileting. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: monitor B. New Testing Orders: -neuro (neurological) checks per policy following falls C. New Intervention Orders: (this area is left blank). R15's Fall Packet form documents: [Resident's name] fell on 6/9/22, at 10:30 AM, Medications: antihypertensive, antidepressants, antiseizure, laxatives-PRN (As Needed), Anticoagulants, Muscle Relaxer, and no medication changes in the last 72 hours. Behavior and cognition: Resident is alert and oriented x 2 (person and place), no recent changes in behavior. Fall: The fall occurred in the resident bathroom, CNA (Certified Nursing Assistant) present stood res (resident) up to pull up pants legs buckled and she fell. The call light was within reach. The resident transfers with on person assist and a gait belt. The resident was using the assistive device of a w/c. Prior to the fall the resident was using the toilet. When the resident was last toileted: was just using the toilet. The resident reported the need to be toileted. Resident injuries: bump on head, significantly reduced. Number of falls in last 30 days: ? The fall was witnessed with neurocheck initiated. Surveyor notes R15's Falls Packet form does not indicate if R15 was transferred using a pivot disc as documented in R15's care plan or why R15 was transferred with 1 staff when R15's MDS assessed R15 to need 2 staff to assist for toilet transfers. R15's Staff Fall Investigations form, dated 6/9/22, completed by Agency Licensed Practical Nurse (LPN)- F, who was assigned to care for R15 on this day, documents: R15 fell on 6/9/22 at 1330 (1:30 PM). LPN-F documents she did not observe R15 during her shift. LPN-F also documents: R15 was not displaying any behaviors, LPN-F was performing a treatment on another resident at the time of R15's fall. LPN- F documents R15's toileting plan is to toilet before and after meals and as needed; resident was last checked at 1200 (12:00 noon) estimated time. Interventions taken at the time of the fall: provide cares and assistance as needed, call light within reach. The resident last ate or drank: lunch 1200. The position the resident was found in: N/A (not applicable). What associative devices were used at the time of the fall: N/A. Analysis: Reaction of the fall: N/A unwitnessed. Clinical Considerations: No recent change in medical condition. Pertinent diagnoses: Spastic hemiplegia, cerebral infarction. Contributing clinical factors: Hemeplegia, weakness. Environmental: No rugs or carpet on floor, floor surface was not wet, no concerns with bedspread or blanket, furniture, clothing, shoes, cords, lights. Interventions in place at the time of the fall: (this area is left blank) Root Cause of the Fall: (this area is left blank) Recommendations/Immediate Interventions: (this area is left blank) Witness Statements: See attached witness statements. Surveyor notes R15's Falls Investigation form does not indicate if R15's was transferred using a pivot disc as documented in R15's care plan or why R15 was transferred with 1 staff when R15's MDS assessed R15 to need 2 staff to assist for toilet transfers. R15's Staff Fall Investigation form dated 6/9/22, completed by Certified Nursing Assistant (CNA)-E, who was assigned to care for R15 on the day of the fall, documents: CNA-E did observe R15 on the day of the fall. CNA-E observed the resident while she was cleaning her in the bathroom after toileting her. The resident did not display any behaviors. The resident was continent of urine and BM (Bowel Movement) at the time of the fall. The resident was last toileted 1 minute before the fall. The resident had shoes on and was not agitated at the time of the fall. Interventions taken at the time of the fall: made sure that the resident was stable and comfortable on the floor and then went to retrieve help from another aid and the nurse. Assistive devices used at the time of the fall: gait belt. What the resident was trying to do at the time of the fall: toileting. Reaction at the time of the fall: CNA-E was cleaning the resident and pulling up her pants to get her seated in the wheelchair when her legs went weak and she fell down to her backside and ended on her side. CNA-E did not hear her hit her head but resident hit her head on the floor. CNA-E immediately went to help her to her back and went to grab help. Another CNA assisted and the nurse checked the resident for any injuries-only place that was injured was her bump on her head. The bump has since gone down. Surveyor notes LPN-F and CNA-E document different times the fall occurred. Surveyor notes LPN-F and CNA-E do not document if a pivot disc was used during this transfer as documented in R15's care plan or why only 1 CNA was transferring R15 when R15's MDS assessed R15 to require 2 staff to assist with toilet transfers. R15's Fall report, dated 6/9/22 documents under the Incident Description: Resident was in the bathroom being toileted by RCS (Resident Care Staff). RCS stood her up to clean her bottom and pull up her pants and the resident's legs buckled and she fell to the floor landing on her buttocks. Due to her right sided hemiplegia the resident fell side ways to the right hitting her head on the floor. Skin check was negative except for a bump on the right side of her head approximately 5.0 x (by) 4.0 which has now resolved. Ice was offered but declined. Declines Tylenol at this time. Neuro checks as per policy following a fall. She is being transferred as per the care plan. MD (Medical Doctor) notified. Resident Description: due to aphasia, resident is unable to state what happened but did shake her head yes or no when asking questions about the fall. Immediate Action Taken: First aide was offered and declined by the resident. Resident has no apparent injury other than the bump to her head, which has now resolved. Able to move unaffected side without pain or difficulty. Reports no pain to unaffected side and passive ROM (Range Of Motion) is WNL (Within Normal Limits) for resident. No shortening or rotation of lower extremities noted at the time of the fall. New intervention will be to refer to therapy for Eval (evaluation) and treat if indicated. Alert and oriented to person, place and time. Bump noted to right forehead. Ice and Tylenol offered and declined. Bump now resolved. Predisposing Environmental Factors: the box none is checked. Predisposing Physiological Factors: the box gait imbalance is checked. Predisposing Situation Factors: the box during transfer is checked. No witnesses found. Surveyor notes R15's Fall Report does not document if a pivot disc was used during this transfer as documented in R15's care plan or why only 1 CNA was transferring R15 when R15's MDS assessed R15 to require 2 staff to assist with toilet transfers. R15's eINTERACT Change in Condition Evaluation, dated 6/9/22, at 11:35 AM, documents: The change in condition, symptoms or signs I am calling about is/are: Falls, that started on 6/9/22 in the morning. Any medication changes in the last week: no med changes made; . Required evaluations: Ensure an evaluation of the resident/patient's mental and functional status is completed to reflect current status; Mental Staus Evaluation: no changes observed; Functional Status Evaluation: Describe the functional status changes: fall; associated with no or minor injury; . Summarize your observations, evaluation and recommendations: Resident had a witnessed fall. Staff present with resident when her leg buckled and she fell. Staff was providing cares after toileting. Recommendations of Primary Clinician: monitor; Testing: other box is checked, Specify other: neuro checks per policy following fall. Surveyor notes R15's eINTERECT Form does not document if a pivot disc was used during this transfer as documented in R15's care plan or why only 1 CNA was transferring R15 when R15's MDS assessed R15 to require 2 staff to assist with toilet transfers. R15's Fall Risk assessment, dated 6/9/22, documents a score of 12, indicating R15 is at a high risk for falls. R15's Interdisciplinary Post Fall Review, dated 6/9/22, documents: The fall occurred on 6/9/22 at 10:00 AM, the fall was witnessed; first aid was provided with a bump to the right forehead. Ice was offered but declined. Bump has since resolved and is no longer present at this time; Resident was being toileted. CNA stood resident up using gait belt to clean her and pull up her pants. Resident's leg bucked and she fell to the floor landing on her bottom. Due to her right sided hemiplegia, she then fell over to the right side and hit her head on the floor; fall happened in the bathroom; the resident was being assisted with a transfer at the time of the fall; Predisposing Diseases: CVA; Conditions That May Contribute: History of Falls, Hemiplegia; Footwear/Assistive Devices at The Time of The Fall: shoes; Environmental Factors present at the time of the fall: none; Medications That May Contribute: Cardiovasculars, Laxatives, Others: HTN (hypertension), Antidepressants, seizure meds, muscle relaxers; Summary of Interdisciplinary Team: Refer to therapy for eval (evaluation) and treatment if indicated; Indicate all intervention recommendations: Physical Therapy and Occupational Therapy. Surveyor notes R15's Interdisciplinary Post Fall Review form does not document if a pivot disc was used during this transfer as documented in R15's care plan or why only 1 CNA was transferring R15 when R15's MDS assessed R15 to require 2 staff to assist with toilet transfers. R15's Physical Therapy Screening Form, dated 6/10/22, documents: Medical Dx. (diagnoses) Cerebral Infarction; Discipline PT (Physical Therapy); Physical Therapy evaluation is not recommenced, pt (patient) declines therapy, isolated incident. On 11/9/22, at 1:36 PM, Surveyor interviewed Nurse Manager Licensed Practical Nurse (NM LPN)-D, who stated R15 fell (6/9/22) when she transferred herself to the toilet, then put the call light on for help. Staff then assisted R15 who is able to stand and pivot transfer at times, and sometimes can not, but at the time she could transfer better in the morning and is weaker in the evening. Surveyor asked MN-D who is responsible for competing the MDS identifying the assessed level of assistance R15 would need with toilet transfers. NM-D stated MDS Nurse-G. On 11/10/22, at 9:57 AM, Surveyor interviewed MDS Nurse-G who stated she will complete the MDS and will use daily CNA (Certified Nursing Assistant) charting of ADLs (Activities of Daily Living) in PCC (Point Click Care- Electronic Medical Record) to look up the level of assisted staff provided during the look back period for the MDS to answer the questions about a resident's level of staff assistance required. MDS Nurse-G stated during the look back period for R15's MDS dated [DATE], one CNA documented R15 required Extensive Assist of 2 staff for toileting needs. MDS Nurse-G stated she is required to code the MDS using the highest level of assistance a resident required 1 or more times during the 7 day look back period. MDS Nurse-G stated during the look back period 1 CNA documented R15 required extensive assist of 2 plus staff for toilet transfers 2 times during the 7 days. MDS Nurse-G stated she would need to code R15's MDS as requiring Extensive assist of 2 staff for toilet transfers. Surveyor asked then how could R15's care plan document a need for extensive assist of 1 staff for toilet transfers? MDS Nurse-G stated she spoke with 2 CNAs on the unit R15 lives on and who are familiar with R15 who informed MDS Nurse-G R15 could easily transfer with 1 staff assist and the transfer disc and the care plan is created from that. Surveyor asked MDS Nurse-G how staff who are not familiar with R15 would know she transfers with assist of 1 and the transfer disc but sometime requires assist of 2 staff? MDS Nurse-G stated staff can always get more help if they feel they need more help with a transfer. MDS Nurse-G stated she does not document a as resident as 1 assist, 2 if needed because the CNA's can not make that decision, they are not able to assess, a nurse has to do that. MDS Nurse-G stated R15's care plan documents R15 needs assist of 1 staff and the transfer disc because the resident is capable of transferring with assist of 1 and staff know they can always get more assistance if needed. MDS Nurse-G stated if their is truly a question or a concern with a residents' transfer ability when completing the MDS then a therapy eval would be requested. On 11/10/22, at 11:14 AM, Surveyor interviewed NM-D who stated the root cause of R15's fall on 6/9/22 was R15's knee buckled. NM-G then asked Wound Nurse-H to assist with locating information as to the root cause of R15's fall on 6/9/22. Wound Nurse-H informed Surveyor the root cause of R15's fall is weakness and her knee buckled. Corporate Nurse Consultant (CNC)-I came by the office where the Surveyor is interviewing NM-G and Wound Nurse-H and asked if she could help. Wound Nurse-H stated he was assisting NM-G with identifying the root cause of R15's fall on 6/9/22. CNC-I and Wound Nurse-H both stated R15's knees buckled and she fell, that's the root cause. Surveyor explained the concern for R15's MDS documenting R15 was assessed to require extensive 2 plus staff assistance for toilet transfers but R15's care plan documents R15 requires extensive assist of 1 staff and a pivot disc for toilet transfers and R15 fell when receiving 1 staff assist with a toilet transfer. Surveyor expressed concern there is no documentation R15's transfer status was reevaluated following the fall and if the pivot disc was in use at the time of the fall. NM-D stated R15 was referred to therapy but R15 declined services. Wound Nurse-H stated the MDS is coded due to what assistance the resident needs during the time and it might be only 1 time the resident needed more care so it is coded that way, at the higher level. Wound Nurse-H stated the charting (for the level of assistance for transfers) is from the CNAs and the CNAs can't assess so the MDS isn't an assessment of the resident's ability since it's charting from the CNAs. Surveyor asked NM-G, Wound Nurse-H and CNC-I were the assessment comes from that generates the care plan related to a resident's transfer status. CNC-I informed Surveyor there are many factors that go into determining the transfer status, there is no easy way to give a clear answer as to why it was determined it was okay to transfer R15 with one staff. R15 had a second fall on 10/2/22 R15's Fall documentation, dated 10/2/22 at 19:42 (8:42 PM), documents: Nursing Description: Called to room by CNA, resident was yelling and CNA found resident sitting on the floor in front of her w/c. Resident Description: Resident unable to give description. Immediate Action Taken: Neuo checks initiated, skin checks completed, ROM WNL for resident. No injuries observed at the time of the incident. Alert and oriented to person, place and time. Predisposing Environmental Factors: none. Predisposing Physiological Factors: none. Predisposing Situations Factors: Using Wheelchair. Witnesses: no witnesses found. R15's eINTERACT Change in Condition Evaluation form dated 10/2/22, documents: The change in condition, symptoms or signs is/are: Falls on 10/2/22 in the afternoon. No medication changes made in the last week. Required Evaluations: Ensure an evaluation of the resident/patient's mental and functional status is completed to reflect current status. Mental Status Evaluation: no changes observed. Functional Status Evaluation: fall associated with no or minor injury. Behavioral Status Evaluation: a behavioral assessment is relevant to the change in condition that was reported. The behavioral changes were: was angry. Threw self on floor. Provider Notification and Feedback: The primary care clinician was notified and NNO (No New Orders). Staff statement documented by Registered Nurse (RN)-J, dated 10/2/22, at 19:45 (8:45 PM), documents: Res pedaling self about the unit per norm. RCS approached nurse informing res is on the floor. Resident noted lying on buttock and back in room in front of w/c. Head off floor. No c/o (complaints of) pain noted at this time. Staff statement documented by RN-K, dated 10/2/22, at 19:45 (8:45 PM), which documents, called to rm (room) by RCS [name of staff] stated res was hollering out and when she entered room found res lying on her back on the floor in front of her w/c. When writer entered room resident was lying on her back with head off the floor and she started to sit herself up. Assessed no injury noted. VSS (Vital Signs Stable) Neuro checks WNL. On 11/9/22, at 1:05 PM, Surveyor interviewed NM-D who stated the Interdisciplinary Team (IDT) reviewed the fall and determined a medication review was an appropriate intervention to prevent future falls. Surveyor reviewed the facility's fall investigation and could not locate documentation of an IDT review and a determination that a medication review was an appropriate fall prevention intervention to address the root cause of the fall. On 11/9/22, at 1:06 PM, Director of Nursing (DON)-B informed Surveyor the IDT determined a medication review was the appropriate fall prevention intervention for R15's second fall and that she wrote that on the Accident/Incident Report Checklist and pointed to the area on R15's Accident/Incident Report Checklist where she had hand written this information following this Surveyor's question. Surveyor noted DON-B documented, IDT Intervention-med review on R15's Accident/Incident Report Checklist form. This added information was undated and unsigned by DON-B. On 11/9/22, at 2:50 PM, Surveyor informed NM-D of the concern there is no documentation in R15's fall investigation of the root cause of the fall and how the IDT determined a medication review was an appropriate fall prevention intervention. NM-D stated she will have RN-K write an addendum to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R53 was admitted to the facility on [DATE] with diagnosis that include, Parkinson's disease, Lewy Body Dementia, severe generalized weakness and failure to thrive with noted weight loss. R53's MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 10/18/2022, indicates R53 had weight loss while not on a physician prescribed weight loss regime, documented current weight as 248 lb (pounds), documented no swallowing disorders and needs set up assist with meals. R53's care plan, dated 10/14/2022, with a target date of 01/25/2022, states: Diet general CBW (Current Body Weight) 248# (Pounds) BMI (Body Mass Index) 35.6, Resident is at nutrition risk related to 23 lb weight loss prior to hospital admit, poor intakes, reduced appetite. Interventions include: -monitor meal intake (percentage) of food and fluids; -offer food preferences, and offer snacks between meals. Review of R53's current and active physician's orders documented the following: General diet, Regular texture, Thin consistency, and weight weekly x (times) 4 weeks every day shift on Wednesday until 11/09/2022. After 11/09/2022 the weight order changes from weekly to monthly. Surveyor reviewed R53's medical record and noted the following weights documented: On 11/1/2022, at 9:34 PM, weight was 227.0 lbs. On 10/26/2022, at 12:58 PM, weight was 226.6 lbs. On 10/24/2022, at 1:05 PM, weight was 243.2 lbs. On 10/19/2022, at 12:36 PM, weight was 244.1 lbs. On 10/14/2022, at 9:39 PM, weight was 248.0 lbs. Surveyor noted a twenty-one pound, or 8.4%, weight loss from 10/14/22 to 11/1/22. On 11/07/22, at 2:23 PM, Surveyor interviewed R53 who was accompanied by representative. R53 told Surveyor, I am not hungry. R53's representative informed Surveyor R53 has not been eating and this has been ongoing prior to hospital admission and admission to the facility. Surveyor reviewed R53's medical record and noted the following nutrition documentation from 10/19/2022: Initial Nutrition Assessment on [age and gender specified] admitted for STR (Short Term Rehabilitation) following hospital stay for severe deconditioning .DX (Diagnosis): Parkinson's disease, mild cognitive impairment . dementia - Lewy body type. .CBW (Current Body Weight) 248 lbs BMI 35.6, Overweight/Obese . On Regular diet with average intakes 51-100% (Percent) Res (resident) reports only eating 1 sandwich daily prior to hosp. (hospital). Son reports wt (weight) loss of 23 lbs d/t (due to) res not eating well at home . Res is at nutrition risk due to prior wt loss and poor intakes. No nutrition interventions needed at this time. RD (Registered Dietician) to follow PRN (As Needed). Surveyor also noted a different nutritional assessment, documented by the same dietician, dated 10/19/2022 which documents nutritional interventions: diet as ordered, document intakes, weights as ordered, obtain preferences and take resident to DR (Dining Room) for meals. During review of R53's medical record, Surveyor could not locate any documentation of R53's physician or the registered dietician being made aware of R53's twenty-one pound weight loss at the facility that was documented on 11/1/22. On 11/08/22, at 1:42 PM, Surveyor asked LPN (Licensed Practical Nurse)-M to explain the facility weight procedure. LPN-M informed Surveyor CNAs (Certified Nursing Assistants) usually get the weights, once a month depending on the physician's order. LPN-M stated the dietician, and the physician is notified of any weight discrepancy and the nurse manager, LPN-L, follows the resident's weights as well. LPN-M thought the parameters for updating the RD and physician was either a 3 lb change or a 5 lb change. LPN-M informed Surveyor she would normally update the RD and physician if there was a 3 lb weight change. On 11/08/22, at 1:48 PM Surveyor interviewed nurse manager, LPN-L. LPN-L informed Surveyor she monitors weight loss/gain either by entering the resident's weight herself or nursing staff or dietician informing her of a weight change. LPN-L informed Surveyor at times she weighs the residents herself which makes her aware of any changes. Surveyor asked LPN-L if she was aware of R53's weight loss and if any interventions were put in place. LPN-L stated, Yes, I am aware of R53's weight loss. At this time LPN-L reviewed R53's medical record. LPN-L informed Surveyor she had spoken with R53's representative and R53 multiple times about the weight loss and had updated the NP (Nurse Practitioner). LPN-L continued to review R53's medical record and was unable to locate documentation confirming the NP was updated on R53's weight loss nor any subsequent interventions. LPN-L informed Surveyor R53 was seen by the NP regularly and was not sure why the NP/Physician notes were not uploaded into R53's medical chart. At this time, LPN-L called NP-N and informed NP-N R53 did not have any physician progress notes uploaded. LPN-L informed Surveyor NP-N was going to send the facility all of R53's progress notes and LPN-L would give the notes to Surveyor to review. Prior to exiting the facility on 11/08/2022, LPN-L provided Surveyor with R53's NP notes from 10/17/22, 10/20/22, 10/25/200 and 10/31/2022. Surveyor reviewed the SNF (Skilled Nursing Facility) Initial Visit note dated 10/17/2022 by NP-N which documents the following: .past medical history significant for . dysphagia . depression . Lewy Body dementia, Parkinson's .failure to thrive .Recent history of poor intake for the last 5-6 weeks per [representative] with recent weight loss of 20 pounds since September 2022 .Vitals-reviewed, wt (weight) 248 lbs on 10/18 .Dysphagia, unspecified: Recent weight loss of 20 pounds, poor appetite. ST (speech therapy) treat and eval (evaluate) . This progress note was electronically signed by NP-N on 10/21/2022 at 6:57 AM. Surveyor reviewed SNF (Skilled Nursing Facility) Progress Note dated 10/20/2022 by NP-N which documents: Chief Complaint .failure to thrive .Vitals-reviewed, stable. Wt 248 lbs on 10/18 .Dysphagia, unspecified: Recent weight loss of 20 pounds, poor appetite. ST treat and eval . This note was electronically signed by NP-N on 10/23/2022. Surveyor reviewed the SNF Progress Note dated 10/25/2022 by provider NP-N which documents: Chief Complaint .failure to thrive with noted weight loss .isn't interested in boost or protein supplementation for weight loss . Vitals-reviewed WT (weight) 248 lbs on 10/18, 226.6 lbs on 10/26 . Dysphagia, unspecified: Recent weight loss of 20 pounds, poor appetite. ST (Speech Therapy) treat and eval (evaluate). RD consult reviewed for protein weight loss. PT (patient) has refused boost/protein drink supplementation. Will consider mirtazapine for appetite stimulation on next visit if poor appetite and weight loss continues. Monitor. This progress note was signed by NP-N on 11/08/2022 at 2:37 PM. Surveyor reviewed the SNF Progress Note dated 10/31/2022 by provider NP-N which documents: Chief Complaint .failure to thrive .Participating in therapy, eating and sleeping well .Vitals-reviewed, stable. WT (Weight) 248 lbs on 10/18 .Dysphagia, unspecified: Recent weight loss of 20 pounds, poor appetite. ST treat and eval. This note was electronically signed by NP-N on 11/01/22 at 10:59 PM. Surveyor noted the NP progress note from 10/31/22 did not mention any follow up of issues specified in the NP progress note from 10/26/2022 such as R53's weight loss, weight loss intervention attempts or R53's refusals of said interventions. Surveyor reviewed R53's medical record and noted the above NP progress notes had been scanned into R53's electronic chart. Surveyor opened the NP progress note dated 10/25/2022 and noted the following discrepancies from the 10/25/22 progress note Surveyor had been given by LPN-L: the progress note Surveyor physically had mentioned failure to thrive with noted weight loss .isn't interested in boost or protein supplementation for weight loss . Vitals-reviewed WT (weight) 248 lbs on 10/18, 226.6 lbs on 10/26 . Dysphagia, unspecified: Recent weight loss of 20 pounds, poor appetite. ST (Speech Therapy) treat and eval (evaluate). RD consult reviewed for protein weight loss. PT (patient) has refused boost/protein drink supplementation. Will consider mirtazapine for appetite stimulation on next visit if poor appetite and weight loss continues. Monitor. The progress note that was scanned into the computer did not contain the words with noted weight loss, did not contain isn't interested in boost or protein supplementation for weight loss, did not contain weight from 10/26/22 and did not contain the following RD consult reviewed for protein weight loss. PT (patient) has refused boost/protein drink supplementation. Will consider mirtazapine for appetite stimulation on next visit if poor appetite and weight loss continues. Monitor. The NP progress note dated 10/25/22 that was scanned into the computer was electronically signed by NP-N on 10/29/2022; the NP progress note dated 10/25/2022 that Surveyor physically had a copy of was electronically signed by NP-N on 11/08/2022. On 11/09/22, at 10:43 AM, Surveyor interviewed NP-N. NP-N informed Surveyor she had spoken to R53 regarding the weight loss but had not spoken with R53's representative. NP-N stated R53 refused the Boost (supplement) then, but today when she spoke with R53 he was agreeable to trying the Boost twice a day. NP-N stated she spoke with R53, today, about the Mirtazapine, which R53 refused. On 11/09/22, at 12:25 PM, Surveyor observed R53 lying in bed on his back. Surveyor asked R53 if anyone at the facility had spoken with him regarding weight loss, trying Boost supplement or the medication Mirtazapine. R53 informed Surveyor someone spoke with him about weight loss at a previous facility in Hartford, but no one discussed his weight loss or mentioned a Boost supplement at this facility. R53 stated he had heard of the drug Mirtazapine but was unaware of any specifics regarding the medications and could not remember if anyone at the facility had mentioned it. On 11/10/22, at 08:02 AM, Surveyor interviewed NP-N regarding the discrepancies found in NP-N's progress notes. NP-N informed Surveyor the progress note LPN-L physically gave Surveyor is the right note. Per NP-N, LPN-L had mentioned the weight loss to her (NP-N) the week of 10/25/2022, but NP-N did not update her notes timely. NP-N explained to Surveyor she sees about 100 patients a week and sometimes needs to update her notes. NP-N also stated the progress note that is scanned into the computer should be removed. Surveyor asked NP-N if an addendum to a progress note was written would that be identified anywhere in said progress note? NP-N stated it would not be identified due to the way the progress note was updated. NP-N explained the progress note was changed instead of addendum and NP-N stated maybe the note should have been addendum instead of changed but at the time she thought changing the note would be more comprehensive. NP-N informed Surveyor she spoke with R53 about the weight loss, previously and R53 did not want Boost or the Mirtazapine, but yesterday R53 was agreeable to trying the Boost because, per NP-N, the food and spices were not to R53's liking. Surveyor asked if NP-N had informed any staff at the facility about R53's comments relating to the food. NP-N stated no. Surveyor informed NP-N of Surveyor's conversation with R53 the day before, in which R53 had no recollection of anyone discussing weight loss or interventions with him/her. NP-N stated, R53 is confused at times sometimes not remembering what day it is. Surveyor asked if NP-N had spoken with R53's representative regarding the weight loss or possible interventions. NP-N stated no and informed Surveyor it is her and the facility's responsibility to address concerns with family members. NP-N informed Surveyor if she wanted an RD consult, she (NP-N) would put an order in the computer. NP-N stated she did not put an order in the computer for R53 to have an RD consult related to the documented weight loss. NP-N relayed to Surveyor R53's MD (Medical Doctor) had also addressed R53's weight loss and the MD progress note would reflect that information and the progress note should be uploaded today. Surveyor reviewed R53's medical record and noted an MD History and Physical note uploaded with a date of 10/21/2022 and electronically signed by the MD on 10/23/2022. There is no mention of weight loss while at the facility and no mention of attempted interventions in this MD note. On 11/09/22, at 9:16 AM, Surveyor interviewed RD-O. RD-O informed Surveyor she was aware of R53's weight loss prior to admission but no interventions, such as nutritional supplements were put in place at that time. Surveyor asked RD-O if she was aware of R53's recent 8% weight loss, to which RD-O replied no, she was not aware. Surveyor asked RD-O about the intervention mentioned in the nutritional assessment on 10/19 stating, take resident to dining room for meals. RD-O informed Surveyor R53 should be eating in the dining room, but facility staff try to encourage everyone to eat in the dining room. Surveyor explained this intervention was not care planned, and RD-O was uncertain of how it should be documented. On 11/10/2022, at 1:36 PM, Surveyor met with NHA (Nursing Home Administrator)-A and relayed concerns regarding weight loss with no RD updates and the conflicting progress notes from NP-N. Surveyor asked for any additional information. No additional information was provided. Based on observation, interview and record review the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrates that this is not possible for 2 (R14 and R53) of 4 residents reviewed for weight loss. R14 sustained a 22 pound weight loss in 1 month with no Dietician notification or interventions implemented to prevent further weight loss. R53 sustained a 21 pound weight loss in 1 month with no Dietician notification or interventions implemented to prevent further weight loss. Findings include: 1.) R14 admitted to the facility on [DATE] and has diagnosis that include Streptococcal Arthritis right knee, Metabolic Encephalopathy, Sepsis, Acute Kidney Failure, Chronic Kidney Disease stage 3, ileus, morbid (severe) obesity, Type 2 Diabetes Mellitus, Schizophreniform Disorder. R14's Care plan Focus area, revised 11/7/22 documents: The resident has nutritional problem or potential nutritional problem r/t (related to) Obesity (300# (pounds) BMI (Body Mass Index 48 Adj (adjusted) IBW (Ideal Body Weight) 172.5#). Goal: The resident will have gradual weight loss (1-2 lbs (pounds) per week) through review date 3/10/2023. Intervention: Provide, serve diet as ordered. Monitor intake and record q (every) meal. R14's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 9/16/22, documents a weight of 320 pounds (lbs). No swallowing disorder. On 11/7/22, at 10:12 AM, during initial interview, R14 reported the food was disgusting. When asked why the food was disgusting, R14 stated: What they make and how they make it, it's disgusting, everything they make is disgusting. R14 would not elaborate on how or why the food is disgusting. R14 reported she eats in her room and the food is usually cold. Surveyor review of R14's medical record which documents R14's weights recorded as follows: 9/9/22: 320.1 lbs. (admission weight) 9/24/22: 321.0 lbs. 10/7/22: 298.6 lbs. 10/15/22: 301.2 lbs. 11/5/22: 300.0 lbs. Surveyor noted an initial weight loss of 22.4 lbs. on 10/7/22, in less than 1 month and a total weight loss of 20.1 lbs. or 6.25% in less than 2 months. Surveyor located no evidence the Dietician was notified of the initial weight loss of 22.4 pounds documented on 10/7/22 or anytime thereafter. Facility progress note dated 10/7/22 ,at 3:15 PM, documented (in part) . .Skilled Charting W (weight) 298.6 lb 10/7/2022 1:18 PM, Scale: Mechanical Lift. Surveyor review of facility progress notes (after survey team entered the facility) documented: 11/7/22, at 9:32 AM, Nutrition Note Text: RD (Registered Dietician) consult received for evaluation of nutrition risk. Resident is at nutrition risk r/t (related to) Morbid obesity with comorbidities of HTN (Hypertension), T2DM (Diabetes Mellitus Type 2), CKD3 (Chronic Kidney Disease Stage 3). Resident was admitted for STR (short term rehabilitation) with acute R (right) knee infection on antibiotics. Antibiotics are now completed. Resident reports a good appetite and intakes. Resident triggers for significant weight loss X (for) 30D (days). CBW (current body weight) 300 lbs BMI 48.4, Obese for age. Weight History: 11/5 300, 10/15 301.2, 10/7 298.6, 9/24 321, 9/9 320.1. Weight loss is desirable for resident. On Regular diet with mostly 76-100% intakes over the last 2 weeks. Meals 4-0-25%, 5-51-75%, 17-76-100%. Meds (medications): probiotic, folic acid, Allopurinol, Risperidone (may affect weight), Clozapine (may affect weight), Oxcarbazepine (may affect wt (weight) changes). 10/24 labs: Hgb (Hemoglobin) 8.5, Hct (Hematocrit) 28, CRP (C-Reactive Protein) 2.98 (trending down), Albumin 2.9, ALT (Alanine Transaminase low at 5, Alkanine Phosphase elevated 106. No nutrition interventions needed at this time. RD (Registered Dietician) to follow PRN (as needed). Surveyor asked the facility for R14's meal intake record since admission and was provided records from 10/10/22 forward. Surveyor was advised by Wound Nurse-H the facility is unable to look back further than 30 days and maybe the Dietician will know how to look back further. Surveyor review of R14's meal intake from 10/10/22 - 11/7/22. Surveyor noted there was no meal intake recorded for 10/20/22 and 10/23/22. Further review noted of the 27 days R14's meal intake was recorded, there was 2 days with only 1 meal intake recorded and 18 days with only 2 meal intakes recorded. Surveyor review of Nurse Practitioner notes documented: 10/10/22: Abnormal weight loss: Noted weight loss-wt (weight) 298.7 lbs. on 10/7, 321 lbs. on 9/24, 320.2 lbs. on 9/9. RD consult. Monitor. 10/31/22: Abnormal weight loss: Noted weight loss-wt 298.7 lbs. on 10/7, 321 lbs. on 9/24, 320.2 lbs. on 9/9. RD consult, awaiting recommendations. Monitor. On 11/9/22, at 8:57 AM, Surveyor spoke with Registered Dietician (RD)-O and asked how she is notified of residents' weight loss. RD-O stated: When I come in I check the triggers. I look in PCC (Point Click Care-Electronic Medical Record) under vitals/weights for triggers. RD-O reported she comes to the facility twice a week, not on specific days. Surveyor asked RD-O if she was notified of R14's significant weight loss of 22 pounds on 10/7/22. RD-O stated: I don't think so. I was probably not aware right away, but probably when I checked PCC. Surveyor asked RD-O since she comes to the facility twice weekly, did she see that R14 triggered for a 22# weight loss on 10/7/22, to which she replied: I don't remember. Surveyor asked RD-O how and when she was made aware of R14's significant weight loss. RD-O stated: The first time I noticed her weight loss was on 11/7/22. I saw it in PCC and her orders.Surveyor advised RD-O the survey team entered the facility on 11/7/22 and asked if she was called or notified to review R14's weight loss. RD-O stated: No, I was in the building, that's when I saw it. Surveyor confirmed RD-O was not notified of R14's significant weight loss on 10/7/22 and that she just happened to see it in the NP (Nurse Practitioner) orders and PCC on 11/7/22. Surveyor asked RD-O what she would have done if she had been notified of the 22# weight loss on 10/7/22 when the weight was taken. RD-O reported she would have talked to (R14), find out how she was eating, if she wanted anything different. RD-O reported R14's albumin is low, but felt like it's more related to inflammation. Surveyor asked RD-O if she was notified of the NP order for an RD consult written on 10/10/22, to which she stated: No. Surveyor asked RD-O if she was notified of the NP order on 10/31/22 which again documented RD consult, awaiting recommendations. RD-O stated: No, no-one mentioned it to me. Surveyor asked RD-O if she has consulted with R14's Physician or NP regarding the nutritional assessment or followed up on the NP note that documented the NP was awaiting recommendations following the RD consult. RD-O stated: No. Surveyor asked how R14's Physician is made aware of the RD's assessment and recommendations. RD-O stated: I don't know. RD-O advised Surveyor she is unable to look back at meal consumption documentation beyond 30 days. Surveyor confirmed RD-O's look back and assessment on 11/7/22 was for the previous 2 weeks of R14's meal consumption, and RD-O was not aware of how R14 was eating during the month of September leading up to the documented significant weight loss on 10/7/22. RD-O confirmed that was accurate. On 11/9/22, at 12:31 PM, Nursing Home Administrator (NHA)-A was advised of the concern regarding R14's weight loss and the NP's order on 10/10/22 and 10/31/22 for a RD consult and the RD was not made aware of the NP orders. Surveyor also advised NHA-A, R14's meal intake record over the last 30 days was not accurate and was missing documentation for multiple meals. NHA-A reported she would try to see if there was a way to print R14's meal intake record prior to 10/10/22. No additional information was provided. On 11/9/22, at 1:53 PM, Surveyor met with Lead RD-P and NHA-A. Lead RD-P reported R14's usual body weight was 320 pounds. Lead-RD-P reported R14 had an ileus in the hospital and some fluid shift which could contribute to her weight loss and stated: I've spoke with the resident and she is happy with her weight loss. Surveyor advised Lead RD-P of the understanding regarding R14's obesity and desired weight loss, however there was concern of significant weight loss of 22# in 1 month with the Dietician having not been notified and not addressing the significant weight loss until 2 months later on 11/7/22. Surveyor advised Lead RD-P of the NP orders x2 for RD consult which was not followed. Surveyor further advised Lead RD-P that R14's Care Plan documents a goal of gradual weight loss of 1-2 pounds per week, which would be a loss of no more than 8 pounds in 1 month and not the 22 pound weigh loss R14 sustained. NHA-A reported RD-O did complete a nutritional assessment on 10/9/22 and provided a copy. While reviewing the nutrition assessment provided by the facility, Surveyor noted the assessment documented: Effective date 10/9/22 at 6:00 PM. Type: Admission Nutrition goals: No significant weight changes 30-180 days. Weight loss desirable 1-2 lbs/week. Surveyor noted the nutrition assessment indicated no significant weight change although R14 already had a documented significant weight loss of 22# on 10/7/22. Surveyor asked NHA-A why the 22# weight loss was not addressed on this assessment. NHA-A stated: I don't know why she (RD-O) didn't write it on there. Surveyor noted the assessment signed date was 11/7/22. Surveyor asked why the form was signed 11/7/22, if the assessment was completed on 10/9/22. NHA-A stated: Maybe she (RD-O) went back in to look at it again, but the date of the assessment is 10/9/22. Surveyor advised NHA-A of the interview with RD-O to which she stated she was not aware of R14's weight loss until 11/7/22. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure 1 of 1 (R53) Residents reviewed for respiratory care received such services consistent with professional standards of practice, comprehensive person-centered care plan and the resident's goals and preferences. R53 did not have physician's orders documenting instructions for use or cleaning of a CPAP (continuous positive airway pressure) machine. This is evidenced by: Facility Policy, entitled CPAP/BiPAP (bilevel positive airway pressure) Support, dated 04/26/2022, states: .Preparation: . .3) Review the physician's order to determine the oxygen concentration and flow, and the PEEP (positive end-expiratory pressure) pressure (CPAP .) for the machine. Steps in the Procedure: .8)Set mode, CPAP . settings on the machine, as prescribed. General Guidelines for Cleaning .4) Wipe machine with warm, soapy water and rinse at least once a week and as needed. R53 was admitted to the facility on [DATE] with a diagnosis that includes Obstructive Sleep Apnea. R53's MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 10/18/2022, does not indicate R53 uses a CPAP machine, or has used a CPAP machine prior to admission, and documents R53 has a BIMS (Brief Interview for Mental Status) of 15, indicating R53 is cognitively intact. R53's care plan dated, 10/14/2022, with a target date of 01/25/2022 documents, [Name of resident] has altered respiratory status/difficulty breathing r/t (related to) OBSTRUCTIVE SLEEP APNEA. Interventions include, BIPAP/CPAP/VPAP (Variable Positive Airway Pressure) SETTINGS: as ordered. Surveyor notes no CPAP settings are documented in R53's care plan. On 11/07/22, at 2:04 PM, Surveyor observed R53 in his room sitting upright in his wheelchair. R53 was accompanied by his representative. Surveyor noted a CPAP machine on the bedside dresser. At this time, R53's representative informed Surveyor R53 uses the machine at home because of a diagnosis of sleep apnea and did not think staff was assisting R53 with the machine at the facility. R53's representative pointed to a gallon sized bottle of distilled water on a table in R53's room and stated to Surveyor the staff brought in distilled water, but was uncertain if it had been used. Surveyor noted the bottle was close to full, but Surveyor was unable to determine if the bottle had been opened or used. R53 told Surveyor staff has not hooked up the machine since he was admitted to the facility and normally at home he operates the machine by himself but it was difficult at the facility due to the machine placement and lack of mobility. On 11/07/2022, after interviewing R53 and representative, Surveyor reviewed R53's medical record and noted there were no active physician's orders for the operation or care of R53's CPAP machine. Surveyor reviewed progress notes with the following documented on 10/15/2022, at 5:48 AM, slept well with cpap on . Surveyor could not locate any other progress notes documenting the use of the CPAP machine. On 11/08/2022, at 11:50 AM, Surveyor observed R53 dressed and sitting upright in a wheelchair in his room. Surveyor observed the CPAP machine on the bedside table and asked R53 if he had used the CPAP machine last night. R53 could not remember if he had used the CPAP machine last night. At this time Surveyor asked R53 if the facility staff offered to assist with setting up the CPAP machine last night. R53 was uncertain if staff had offered to assist with the CPAP machine. On 11/08/22, at 1:40 PM, Surveyor interviewed R53's nurse, LPN (Licensed Practical Nurse)-M, who informed Surveyor R53 was wearing his CPAP machine this morning. LPN-M informed Surveyor there is a bottle of water in the room for the CPAP machine and either the second shift or third shift nurses assist R53 with the operation of the CPAP machine. On 11/08/22, at 1:57 PM, Surveyor interviewed nurse manager LPN-L. LPN-L informed Surveyor R53 has orders for the operation and the cleaning of his CPAP machine. At this time LPN-L reviewed R53's physician's orders and stated, I don't' think R53 has a CPAP machine. Surveyor informed LPN-L of the observation of a CPAP machine in R53's room. LPN-L could not locate physician's orders relating to the CPAP machine and confirmed with Surveyor there should be orders for the use and cleaning of the machine. LPN-L stated R53 didn't admit with CPAP settings, the settings were from home. On 11/08/22, at 3:24 PM, during the end of the day meeting with DON (Director of Nursing)-B, NHA (Nursing Home Administrator)-A, wound nurse RN (Registered Nurse)-H, Corporate Consultant Nurse-I and Corporate Consultant-Q, Surveyor relayed concerns regarding R53 having a CPAP in his room with no documented physician's orders on operation or care of the machine. Surveyor asked for additional information. No additional information was provided. After Surveyor expressed concerns regarding lack of physician's orders for R53's CPAP machine, the following was documented in R53's medical record: On 11/8/2022, at 19:00 PM (7:00 PM), a nurses' note documents, [Name of Nurse Practitioner] NP (Nurse Practitioner) updated on not having orders for C-PAP in residents' room that [R53] has been using since admit. Able to get home settings per machine and [R53] [representative] validating the settings. States, those are the settings that were programmed in by the Dr (Doctor). They change them remotely when changes are made. New orders received and noted. Physician's orders were added to R53's medical record as follows: Cleanse C-PAP face mask with warm lightly soapy rinse and hang on rail to dry. Weekly on day shift . every Wed for infection prevention. Active date of 11/9/2022. C-PAP at HS (Hour of Sleep) with settings from home, AVS (Adaptive Sero-Ventilation) 15 and PS (Pressure Support) 18.0. Check water level every night during application at bedtime for sleep apnea. Active date and time of 11/8/2022, 7:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not collaborate with hospice with the development of R6's care plan. The facility did not have R6's hospice care plan and did not have a copy of the Hospice contract for 1 of 2 (R6) residents reviewed for hospice services. R6 was admitted into the facility on 8/19/22 with hospice services. On 11/9/22, Surveyor was unable to locate R6's hospice admission contract along with the hospice care plan. On 11/9/22, Administrator A contacted R6's hospice services and was able to have the hospice contract and R6's hospice care plan provided to the facility. The facility did not have a copy of the contract with R6's hospice provider and did not have the hospice's care plan for R6 until Surveyor inquired. Findings include: Surveyor reviewed R6's medical record. Surveyor noted on 8/19/22, R6 was admitted to the facility with hospice care/private pay. Prior to admission, R6 was hospitalized from [DATE] and discharged on 8/19/22 after a fall (which occurred prior to R6's placement into the facility). The hospital discharge summary indicated R6 was being discharged to the facility under hospice care. On 11/8/22, at 10:23 am, Surveyor interviewed R6. During the conversation, R6 expressed worry as to where she could live for the rest of her life. Surveyor informed R6 that Surveyor would bring her concern forward to the facility social services staff. On 11/8/22 and 11/9/22, Surveyor reviewed R6's paper chart medical record and R6's electronic medical record. Surveyor reviewed R6's Baseline Care Plan Summary dated 8/19/22. The Baseline Care Plan Summary indicates R6's initial admission goals is Hospice care and R6's initial discharge goals is to receive hospice care/coordination is checked. The Baseline Care Plan Summary indicates R6 is alert, cognitively impaired, oriented to self only, cognition varies at times. The Baseline Care Plan Summary documents Does the resident need end of life care? and yes is checked. The Baseline Care Plan Summary is not checked for End of Life Care planning on this form. Surveyor reviewed R6's facility care plan which includes inpart: The resident is grieving related to diagnosis of a terminal illness and loss of independence/change in lifestyle: placement in skilled nursing facility initiated 8/19/22. The goal: The resident will share their grief with caregivers/family buy review date. Interventions dated 8/19/22 include: Allow the opportunity to identify own self care needs as needed. Assist resident to identify, access and use support systems of friends, family and caregivers. Encourage the resident to express feelings of anger and concerns to friends, family and caregivers as needed. Another care plan initiated on 8/19/22 contains a focus area of: R6 is on Hospice care related to end of life. R6 is followed by [name] Hospice. DNR (Do Not Resuscitate), Goal: Resident will be comfortable with needs met through next review. Interventions dated 8/19/22 include: Allow resident to verbalize fears and concerns about dying process. Bathing, personal care, ADL's (Activities of Daily Living), transfers, assist with meals as needed. Evaluate effectiveness of medications/interventions to address comfort. Keep family informed of change in condition or medication changes. Offer private room if available. Provide emotional support to resident and family during decline in the dying process. Respect resident and family wishes. Surveyor noted these interventions are provided by the facility's interdisciplinary team. Surveyor noted R6's care plan does not incorporate what services will be provided by Hospice services. Surveyor inquired as to where Surveyor could find R6's hospice contract, care plan and notes. Surveyor was informed there were hospice binders located behind the nurses station however Surveyor was not able to locate a hospice binder for R6. On 11/9/22, Surveyor informed Administrator A that Surveyor could not locate R6's hospice information, such as the hospice contract and care plan. On 11/09/22, at 7:54 am, Administrator A stated she could not find R6's hospice book/care plan and that she was going to call the specific hospice agency right away. On 11/9/22, Administrator A provided Surveyor with R6's hospice meeting review form (care plan) and Hospice contract which had been faxed to the facility on [DATE]. Surveyor noted the meeting review form date was 8/19/2022 and the certification period is from 8/19/2022 through 10/17/22. Under Frequencies active is listed as: CNA (Certified Nursing Assistant): 3 times a week for 9 weeks starting 8/22/22 end date: 10/17/22. RN/LVN (Registered Nurse/Licensed Vocational Nurse): 2 times a week for 9 weeks starting 8/21/22 end date: 10/17/22 SCC (Chaplain) : 2 times a month starting 9/1/22 end date: 9/30/22 SW (Social Worker) : 2 X month for 1 month starting 9/1/22 end date: 9/30/22. The Hospice contract was signed by facility Administrator and the Hospice agency on 8/19/22. The Hospice contract includes in part: 4.2 Design Plan of Care (POC): The Hospice Plan of Care shall include . * Details concerning the scope and frequency of such Hospice Services * Delineation between Hospice and Facility clinical duties and task. 4.4 POC Development for Nursing Facility Patients At the time of admission to the Hospice of eligible Facility Residents, in accordance with Federal and State laws and regulations, Hospice shall (in conjunction with nursing facility personnel) develop a Hospice plan of care for the management and palliation for the resident's terminal illness. The Facility shall be provided with a copy of the Hospice Plan of Care and if the Facility has any concerns in regards to the Hospice care plan, the Facility shall promptly advise Hospice of its concerns. On 11/9/22, at 11:19 am, Surveyor asked Social Service (SS) Assistant X if the facility had a care conference with R6's Hospice provider team. SS Assistant X informed Surveyor the facility has not had an official care conference yet, one is coming up with everyone on 11/15/22. Hospice, family, county worker and facility staff will be part of the care conference. R6 came in on 8/19/22 with this Hospice. Normally we have a binder, we don't have one for [name of Hospice].

Based on observation, interview, and record review the facility did not ensure there was a medication error rate below 5 percent. There were 5 medication errors for 4 Residents (R16, R13, R42, & R10) which resulted in a medication error rate of 16.67%. * R16 received Tetrahydrozoline-Zn Sulfate Solution 0.05-0.25 % eye drops which expired 8/22/22. * R13's humalog kwik pen was not primed prior to dialing 5 units. * R42 received the incorrect dose of Fluexotine and did not receive Loratadine Tablet 10 mg (milligrams). * R10 received 1 tablet multivitamin with multimineral. R10's physician orders document multivitamins. Findings include: The Insulin Pen policy and procedure not dated under Policy Explanation and Compliance Guidelines documents for Procedure . h. Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. 1.) On 11/7/22, at 8:39 a.m., Surveyor observed RN (Registered Nurse)-S prepare R16's medication which consisted of one tablet Clopidogrel 75 mg (milligrams), two tablets of Co Q 10 50 mg, one tablet Eliquis 5 mg, one tablet Furosemide 40 mg, two capsules Gabapentin 300 mg, one tablet Hydralazine 50 mg, One table Metoprolol Tartrate 25 mg, one tablet multivitamin with minerals and one tablet Potassium Chloride ER (extended release) 10 meq (milliequivalent). At 8:47 a.m., RN-S informed Surveyor she needs to find R16's eye drops. At 8:49 a.m., Surveyor verified with RN-S there are 11 pills in the medication cup. At 8:51 a.m., RN-S administered R16's medication which R16 took whole with water. RN-S informed R16 she has to get her eye drops. At 8:55 a.m., RN-S informed LPN (Licensed Practical Nurse) Manager-L she needs artificial tears for R16 as she can't find them in the medication cart. LPN Manager-L stated to RN-S let me look they are usually in here. LPN Manager-L looked in the medication cart, was unable to locate the eye drops and stated I'll go get you one. At 9:23 a.m., LPN Manager-L informed RN-S she received an order for a new eye drop and the original eye drop is on hold. LPN Manager-L provided RN-S with a bottle of Tetrahydrozoline HL 0.05% and Zinc Sulfate 0.25% eye drops. At 9:25 a.m., RN-S informed R16 has her eye drops and asked R16 if she wants her to put them in to see if it helps. RN-S placed gloves on, gave R16 a tissue and at 9:27 a.m. RN-S administered one drop into R16's left eye and then one drop into R16's right eye. At 9:27 a.m., RN-S wiped off the tip of the eye drop bottle with a bleach wipe, removed her gloves and cleansed her hands. At 9:28 a.m., Surveyor asked to see R16's eye drop box which contained Tetrahydrozoline HL 0.05% & zinc sulfate 0.25 %. Surveyor observed the eye drops are expired with an expiration date of 8/22. Surveyor showed RN-S the eye drops she administered expired on 8/22. RN-S stated I should of checked but I didn't expect them to be expired. On 11/9/22, at 9:18 a.m., Surveyor asked LPN Manager-L if a nurse should check the expiration date before administering medication. LPN Manager-L replied yes. Surveyor informed LPN Manager-L the bottle of Tetrahydrozoline HL 0.05% & zinc sulfate 0.25 % eye drops she gave RN-S was expired. LPN Manager-L informed Surveyor that was her error as she didn't check the expiration date. LPN Manager-L informed Surveyor she did a medication report and notified the NP (Nurse Practitioner) R16 was given expired drugs. This observation resulted in one medication error for R16. 2.) On 11/07/22, at 9:03 a.m., Surveyor observed RN (Registered Nurse)-S check R13's blood sugar which was 193. At 9:10 a.m., Surveyor observed RN-S placed a needle on the end of the Humalog Kwik insulin pen and dial the pen to 5 units. RN-S did not prime the insulin pen prior to dialing 5 units. At 9:11 a.m., RN-S then prepared R13's oral medication which consisted of one tablet of Eliquis 5 mg (milligrams), one tablet of Levitiracetam 500 mg, one tablet Multivitamin with multimineral, and 17 grams Clear Lax. At 9:13 a.m., Surveyor verified the number of pills in the medication cup with RN-S. At 9:16 a.m., RN-S informed R13 she needs to give him 5 units of insulin and asked where R13 would like it. RN-S placed gloves on, cleansed R13's left lower abdomen and injected 5 units of Humalog. At 9:17 a.m., RN-S administered R13 the by mouth medications which R13 took whole with water. At 9:18 a.m., RN-S disposed the insulin needle, wiped the insulin pen with a bleach wipe, removed her gloves and cleansed her hands. On 11/7/22, at 12:15 p.m., Surveyor asked LPN-W if an insulin pen should be primed prior to dialing the number of units the physician ordered. LPN-W replied yes. Not priming R13's Humalog Kwik insulin pen prior to dialing 5 units resulted in one medication error for R13. 3.) On 11/7/22, at 9:34 a.m., Surveyor observed LPN (Licensed Practical Nurse)-R prepare R42's medication which included one tablet Amlodipine Besylate 5 mg (milligrams), one capsule Fluexotine HCL 40 mg, one capsule Fluoxetine HCL 20 mg, one tablet Metoprolol Succ ER 50 mg, one tablet Pravastatin Sodium 40 mg, one tablet Vitamin D3, one tablet Aspirin 81 mg, and one bottle Sodium Polystyrene Sulfonate. At 9:41 a.m., Surveyor verified the 7 tablets/capsules in the medication cup with LPN-R. LPN-R crushed the tablets, opened the Fluoxetine HCL capsules and mix with applesauce. LPN-R placed on PPE (personal protective equipment). At 9:46 a.m., LPN-R administered R42's medication. At 9:49 a.m., LPN-R removed her PPE and cleansed her hands. On 11/7/22, at 10:46 a.m., Surveyor reviewed R42's physician's orders and noted the following: Fluoxetine HCL Capsule 10 mg with directions to give 1 capsule by mouth one time a day related to major depressive disorder, give with 40 mg to equal 50 mg daily dated 10/26/22. Loratadine Tablet 10 mg with directions to give 1 tablet by mouth one time a day for allergies dated 6/27/22. On 11/7/22, at 11:16 a.m., Surveyor spoke with LPN-R regarding R42's medication. Surveyor showed LPN-R the physician order for R42 to receive Fluoxetine HCL 10 mg and she administered 20 mg. Surveyor also informed LPN-R Surveyor noted she initialed Loratadine 10 mg being administered on the MAR (medication administration record). LPN-R informed Surveyor she thought she gave R42 her Loratadine. Surveyor informed LPN-R Surveyor had verified the number of pills/capsules with her prior to her administering R42's medication and the Loratadine 10 mg was not administered. On 11/9/22, at 9:04 a.m., Surveyor spoke with LPN Manager-D regarding the observation of R42's medication administration with LPN-R. Surveyor informed LPN Manager-D Surveyor observed LPN-R administer Fluoxetine 20 mg instead of Fluoxetine 10 mg. LPN Manager-D informed Surveyor the pharmacy was called on Monday (11/7/22) to have Fluoxetine 10 mg stat out. LPN Manager-D informed Surveyor she notified DON (Director of Nursing)-B & LPN-R left a message for the physician. Surveyor informed LPN Manager-D LPN-R did not administer Loratadine 10 mg to R42 although she initialed the medication as being administered on the MAR. This observation resulted in 2 medication errors for R42. 4.) On 11/9/22, at 7:19 a.m. Surveyor observed LPN (Licensed Practical Nurse)-R cleanse her hands and go into the medication room. LPN-R poured 10 ml (milliliters) Omeprazole 2mg/ml (milligrams/milliliter) into a medication cup for R10. At 7:23 a.m., LPN-R prepared R10's medication. LPN-R poured Pro Stat 60 ml into a medication cup and then into a glass. One tablet Amlodipine Besylate 5 mg and one tablet Low dose Aspirin 81 mg into a medication cup. Opened a banana flakes packet and poured the flakes into a cup. LPN-R poured 5 ml Ferrous Sulfate into a medication cup. LPN-R stated there is an order they can cocktail the medications together and poured the Ferrous Sulfate into the cup with Pro Stat. LPN-R opened a Probiotic capsule into the Pro Stat. One tablet Lamotrigine 100 mg and one tablet Multivitamin with Multiminerals was placed in the medication cup. LPN-R poured 17 grams Clear Lax with banana flakes. At 7:31 a.m., Surveyor verified with LPN-R the medications she poured and the number of tablets in the medication cup. LPN-R crushed the medication tablets and poured the crushed medication into the banana flakes. At 7:38 a.m., Surveyor observed LPN-R administer R10's medication via gastrostomy tube. LPN-R flushed R10's feeding tube with water prior to administering, between and after administering R10's medication. On 11/9/22, at 8:04 a.m., Surveyor reviewed R10's physician orders and noted a physician order dated 11/8/22 which documents May Cocktail medications and give all together and 9/23/22 Multivitamin Tablet (Multiple Vitamin) with directions to give 1 tablet via PEG-Tube one time a day for supplement. On 11/9/22, at 8:38 a.m., Surveyor asked LPN-R to show Surveyor the multivitamin bottles in the medication cart. LPN-R showed Surveyor 2 bottles, a blue labeled Multi Vitamin and red label Multi Vitamin/Multi Minerals. Surveyor informed LPN-R during R10's medication observation she administered R10 Multi Vitamins with Multi Minerals and the physicians order is for Multi Vitamin. This observation resulted in one medication error for R10. On 11/9/22, at 3:05 p.m., Administrator-A & DON (Director of Nursing)-B were informed of the medication errors for R16, R13, R42, & R10.

Based on observation and interview the Facility did not ensure eye drops were dated when opened and medications were not expired. This has the potential to affect R2, R9, R32 and the 27 other Residents residing on the long term 2 unit. Findings include: 1.) On 11/7/22, at 10:03 a.m., Surveyor observed in the third drawer of the split medication cart on long term 2 a stock bottle of Milk of Magnesia with the expiration date of 11/21. At 10:05 a.m. Surveyor asked LPN (Licensed Practical Nurse)-R who checks for expired medications. LPN-R replied we all do. Surveyor showed LPN-R the expired bottle of Milk of Magnesia. 2.) On 11/7/22, at 10:11 a.m,. Surveyor observed in the top drawer of the long hall medication cart on long term 2 a bottle of Artificial tears with an open date of 9/2 for R2. R2's eye drop medication should have been removed after 28 days. 3.) On 11/7/22, at 10:14 a.m., Surveyor observed in the top drawer of the long hall medication cart on long term 2 two open & used bottles of Timolol Maleate 0.25% eye drops for R9 which are not dated when opened and an open & used bottle of Moxifloxacine 0.5% eye drops for R32 which was not dated when opened. 4.) On 11/7/22, at 10:17 a.m., Surveyor observed in the third drawer of the long hall medication cart on long term 2 a bottle of Milk of Magnesia with the expiration date of 8/22. On 11/7/22, at 10:19 a.m., Surveyor asked LPN-R if eye drops should be dated when they are opened. LPN-R replied yes. Surveyor showed LPN-R the expired eye drops for R2 and the eye drop bottles not dated when opened for R9 & R32. 5.) On 11/7/22, at 1:34 p.m., Surveyor observed the Facility's medication room with LPN Manager-L. At 1:37 p.m. on the top shelf in a cabinet a bottle of Magnesium Citrate with the expiration date of 12/21. Surveyor asked LPN Manager-L who checks medication for expiration dates. LPN Manager-L informed Surveyor it's suppose to be everyone. On 11/7/22, at 2:11 p.m., Surveyor asked LPN Manager-L if eye drops should be dated when they are opened. LPN Manager-L replied yes. Surveyor informed LPN Manager-L of the eye drops not being dated when opened and the expired medication when Surveyor checked the two medication carts on the long term 2 unit. On 11/9/22, at 3:05 p.m., Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, interview and record review, the Facility did utilize proper infection control techniques to prevent and control the spread of infections such as COVID-19. * Facility staff were observed not wearing Personal Protective Equipment (PPE). Dietary Assistant-AA was observed not wearing an N-95 mask as per facility's policy for employees who are exempt and not fully vaccinated from COVID-19. Dietary Assistant- AA was observed wearing a surgical mask which was not covering her nose or mouth and was not wearing any eye protection on 11/8/22 and 11/9/22 while preparing food and testing food temperatures. Findings include: On 11/8/22, at 10:30 AM, Surveyor observed Dietary Assistant-AA in the facility's main kitchen preparing lunch for residents receiving a puree diet. Surveyor observed Dietary Assistant-AA had a surgical mask under her chin, not covering her nose or mouth, during preparation of the pureed lunch meal. Dietary Assistant-AA was also observed not wearing eye protection at this time. On 11/9/22, at 11:45 AM, Surveyor observed Dietary Assistant-AA in the facility's main kitchen preparing to check food temperatures for the lunch meal. Surveyor observed Dietary Assistant-AA had a surgical mask on under her chin, not covering her nose or mouth, while checking temperatures for the lunch meal. Dietary Assistant-AA was also observed not wearing eye protection at this time. Surveyor reviewed the facility's list of staff that have received a vaccination exemption and are not fully vaccinated against COVID-19. Surveyor noted Dietary Assistant-AA is currently identified as not being fully vaccinated against COVID-19 and receiving a vaccination exemption. On 11/9/22, at 3:00 PM, Surveyors conducted daily meeting with facility staff. Surveyor asked what type of PPE unvaccinated staff should wear when working at the facility. Corporate Nurse Consultant-I informed Surveyor unvaccinated staff should be wearing N-95 masks and eye protection at all times when in the facility. On 11/10/22, at 2:30 PM, Surveyor shared concerns with NHA (Nursing Home Administrator)-A that Dietary Assistant-AA was observed on 11/8/22 and 11/9/22 not wearing appropriate PPE due to their unvaccinated status. No additional information was provided by the facility at this time.

Based upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order for 2 of 3 clothes dryers observed. This has the potential to impact 57 of 57 Residents residing in the Facility. Surveyor observed the top flat surface and wires above the dry screen on the right dryer had a thick accumulation of lint and the lint screen on the left dryer had a thick accumulation of lint which is a potential fire hazard. Findings include: The Dryer Cleaning Policy, not dated, for lint screens documents a lint screen is installed in the bottom compartment of all commercial dryers. Lint that falls from the linen as it dries is caught by the lint screen, preventing lint from moving directly through the vent and blowing all over the outside of the building. These lint screens must be brushed and cleaned after every load or every hour. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation; i.e. where one spark on lint can cause a fire. Lint may also: a.) Build-up between the drum and the sides of the dryer is the root cause of many dryer fires. This may cause a problem because in many dryers there is a heat sensor there. This sensor reads the heat of the basket and is programmed to shut the dryer down if the temperature gets too hot. If this sensor is covered with lint, the lint acts as insulation and fools the sensor into thinking the basket is not as hot as it really may be. So, instead of shutting the dryer down, it allows heat to continue to pour in. It is extremely important that you remove the entire front of the dryer and vacuum the entire interior. b.) Build-up on the top compartment of the dryer. This is dangerous because the heat source is here. The top panel must be opened and the area must be cleaned daily. Findings include: On 11/9/22, at 9:25 a.m., Surveyor toured the Facility's laundry area with Housekeeping/Laundry Account Manager-U and Laundry Worker-T. Surveyor observed there are three working commercial dryers in the laundry area. At 9:29 a.m., Surveyor asked Laundry Worker-T how often the lint is cleaned from the dryers. Laundry Worker-T informed Surveyor after each load. Surveyor inquired if the laundry staff log the times the lint is removed. Laundry Worker-T replied yes and pointed to a log on the counter which Surveyor reviewed. At 9:32 a.m., Laundry Worker-T turned off the middle dryer and opened the bottom door to show Surveyor the lint screen. Surveyor did not observe an accumulation of lint on the screen or any where in this area. Laundry Worker-T then opened the bottom door of the right dryer. Surveyor observed above the screen there are wires hanging down which has a thick coating of lint as well as the area above the screen. Surveyor asked who removes the lint from this area. Laundry Worker-T informed Surveyor Maintenance Supervisor-V gets in there two to three times a week but Maintenance Supervisor-V has been backed up. Surveyor showed Laundry Worker-T and Housekeeping/Laundry Account Manager-U the accumulation of lint. Housekeeping/Laundry Account Manager-U then started to remove the accumulation of lint. Surveyor observed when Housekeeping/Laundry Account Manger-U was finished removing the lint, the pile of lint was approximately 1 foot in length and approximately 6 to 8 inches in height. Housekeeping/Laundry Account Manager-U stated definitely needs to be clean, thought [name of Maintenance Supervisor-V] was in here. At 9:36 a.m., Surveyor asked to see the left dryer. Surveyor observed the left screen has a thick coating of lint which was coming away from the screen along with large clumps of lint on the floor of the screen area on each side of the screen. Laundry Worker-T informed Surveyor the weekend worker uses this dryer but she doesn't. Housekeeping/Laundry Account Manager-U informed Surveyor the weekend laundry worker is on restrictions and can't bend down. Housekeeping/Laundry Account Manager-U then removed the lint from the left dryer and informed Surveyor she will have to pay more attention. On 11/9/22, at 10:29 a.m., Surveyor asked Maintenance Supervisor-V if he cleans lint from the dryers. Maintenance Supervisor-V informed Surveyor he vacuums behind the dryers and laundry cleans the lint traps. Surveyor inquired who would clean the lint from above the lint screens were the wires are. Maintenance Supervisor-V he doesn't really get in there and laundry has a dust broom to clean the wire. Maintenance Supervisor-V informed Surveyor the wires is connected to a sensor. Surveyor informed Maintenance Supervisor-V of the large accumulation of lint Surveyor observed. Maintenance Supervisor-V informed Surveyor it shouldn't be like that. On 11/9/22, at 3:05 p.m., Administrator-A and DON (Director of Nursing)-B were informed of the above.