**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure 1 (R10) of 1 Resident reviewed for communication with the use of hearing aides, received proper treatment and assistive device to maintain R10's hearing abilities. Findings Include: R10 was admitted to the facility on [DATE] with diagnoses of Chronic Systolic Congestive Heart Failure, Chronic Kidney Disease, Stage 3, Anemia, , Nocturia, Dysphagia, and Unspecified Dementia. Surveyor reviewed R10's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R10's Brief Interview for Mental Status (BIMS) score to be a 13 which indicates R10 is cognitively intact for daily decision making. R10's MDS also documents that R10 requires limited assistance of 1 for bed mobility, transfers, dressing, toileting, and hygiene. R10's MDS documents that R10 has hearing aides and hears with minimal difficulty. R10's comprehensive care plan includes the following: Impaired communication-receptive related to hard of hearing as evidenced by use of bilateral hearing aides with the following interventions: -Allow adequate time and do not rush or supply words when conversing with R10-1/17/20 Start -R10 to wear hearing aides to bilateral ear. Keep hearing aides clean, provide assistance and instruction as needed. Adjust sound level of hearing aides after insertion as needed. Report hearing aide malfunction as needed for repair. Replace battery in hearing aides as needed. Provide assistance as necessary. Schedule appointments with hearing aide clinic as needed. Consults as ordered. Hearing aide is kept at medication cart. 1/17/20 Start -Speak slowly and enunciate clearly 1/17/20 Start -Speak in normal tone of voice 1/17/20 Start -Verify that R10 has heard correctly 1/17/20 Start -Bilateral hearing aides-Nurse to manage hearing aides and keep in med cart when not in use (R10 at times removes and puts on med carts, education to give to nurse) 4/13/20 Start -Able to make needs know 3/5/21 Start -Has new bilateral hearing aides 9/28/23 Start Surveyor notes that R10's current physician orders document that R10 has bilateral hearing aides with instructions to put in AM, and remove at HS (keep in med room), twice a day. On 9/28/23 there is a progress note in R10's electronic medical record (EMR) that R10 has new hearing aides. On 10/18/23 there is a progress note in R10's EMR that R10 is hard of hearing with bilateral hearing aides. R10 will lay hearing aides in random places at times. Able to make needs known. Surveyor notes there is no documentation that R10 refuses to wear R10's hearing aides. On 10/23/23 at 12:59 PM, Surveyor observed R10 laying in bed awake. Surveyor attempted to speak with R10 and realized R10 is hard of hearing. Surveyor had to speak in extremely very loud voice to interview R10. R10 informed Surveyor that R10 does not have R10's bilateral hearing aides in. R10 appeared frustrated and agitated that R10 could not communicate with Surveyor. Surveyor notes it was difficult to communicate with R10 due to the hearing impairment. On 10/24/23 at 7:55 AM, Surveyor observed R10 up and in the dining room waiting for breakfast. R10 informed Surveyor that they have not given R10 her hearing aides yet. Surveyor was unable to finish the conversation because R10 could not hear Surveyor and R10 appeared frustrated. On 10/24/23 at 9:57 AM, Surveyor observed R10 laying on R10's bed watching television. Surveyor notes the television is extremely loud. R10 states they have R10's hearing aides and the hearing aides are not in. R10 appeared with a flat affect. On 10/24/23 at 11:08 AM, R10 attended the Resident Group Meeting and informed Surveyor two times that R10 could not hear Surveyor because they hadn't given R10 her hearing aides. R10 appeared frustrated that R10 could not hear Surveyor during the meeting. On 10/24/23 at 1:10 PM, Surveyor observed R10 laying on top of the bed, watching television, and the television is extremely loud. R10 confirmed that R10 is still not wearing R10's hearing aides and informed Surveyor that it is frustrating to not be able to hear Surveyor despite Surveyor being right in front of R10. On 10/24/23 at 1:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN-D) in regards to R10. LPN-D informed Surveyor that LPN-D only gives R10 her hearing aides if R10 asks for them. Surveyor asked LPN-D if LPN-D offers the hearing aides on a daily basis? LPN-D stated that the hearing aides should be given to R10 on a daily basis, but LPN-D confirmed that LPN-D did not offer the hearing aides to R10 today. LPN-D stated, We keep them on the med cart because R10 lost the previous pair. On 10/24/23 at 1:19 PM, Surveyor observed R10 come to the nurse's station and asked LPN-D for R10's hearing aides. On 10/24/23 at 3:09 PM, Surveyor shared the concern with Administrator(NHA-A) and Director of Nursing(DON-B) the concern that R10 has been observed with no bilateral hearing aides in for two days during the survey process. No further information was provided by the facility at this time. On 10/25/23 at 10:40 AM, Surveyor approached R10 on the left side and said Good Morning and R10 was able to hear Surveyor right away and answered appropriately even though Surveyor was not directly facing R10 yet. R10 then showed Surveyor that R10's hearing aides were in. R10 informed Surveyor that R10 has to wait awhile to have the hearing aides put in because they keep them overnight. R10 stated that the nurse working today is good about giving the hearing aides to R10 right away in the morning, I have to wait awhile for the others. Surveyor notes that R10 heard Surveyor right away and was smiling while engaged in the conversation and displayed no frustration or agitation. On 10/25/23 at 10:43 AM, LPN-E stated that LPN-E has worked with R10 for several years. I probably drive R10 crazy making sure R10 has R10's hearing aides when I work. On 10/25/23 at 11:09 AM, NHA-A informed Surveyor the facility does not have a policy and procedure for assistive devices like hearing aides and will be developing one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility did not ensure 1 (R28) of 5 Resident's drug regime reviewed was free from unnecessary medications. R28 receives an anticoagulant (Eliquis) in which the facility is not adequately monitoring and there is no care plan in place to address the use of the anticoagulant. Findings Include: Surveyor reviewed the Anticoagulant Monitoring policy and procedure last revised 9/2023 and notes the following applicable: .D. Monitoring for Signs and Symptoms of Bleeding 1. Residents on Warfarin/Eliquis/Pradaxa/Lovenox/Heparin/Xarelto/ASA or alike drug class, should be monitored for bruising, bleeding from gums during teeth brushing, blood in the stool, sudden onset of confusion that may indicate bleeding in the brain, or recent changes in breathing patterns or sounds that may indicate bleeding in the lungs. 2. Signs/symptoms of bleeding will be documented in the IDN by the nurse and reported as a change in condition. MD will be notified. 3. Report any signs and symptoms of bleeding in a timely manner to the physician. R28 was admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure with Hypoxia, Hypertensive Heart Disease with Heart Failure, Chronic Atrial Fibrillation, Chronic Pulmonary Embolism,Long Term Use of Anticoagulants, Type 2 Diabetes Mellitus, Vascular Dementia, and Anxiety Disorder. Surveyor reviewed R28's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R28's Brief Interview for Mental Status (BIMS) score to be 7, indicating R28 is severely impaired for daily decision making. R28's MDS also documents that R28 requires extensive assistance of 2 for bed mobility, transfers, and toileting. R28's MDS documents that R28 receives an anticoagulant and has had 1 fall with no injury since the last assessment. On 10/24/23 at 1:37 PM, Surveyor completed a record review of R28's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R28 is on Eliquis 5mg two times a day for blood clots last ordered 1/23/23. Surveyor reviewed R28's MARS and TARS and noted there is no monitoring of R28's Eliquis for signs and symptoms of an adverse effect from this medication, such as bruising, bleeding, etc. Surveyor notes that R28 has had 2 recent falls on 5/19/23 and 10/20/23 with no injuries. There is no indication the facility monitored R28 for any signs/symptoms of bleeding, bruising, or change of condition due to being on an anticoagulant. On 10/24/23 at 1:37 PM, Surveyor completed a record review of R28's comprehensive care plan and notes that there is no person-centered specific care plan for R28's anticoagulant. On 10/24/23 at 3:14 PM, Surveyor shared the concern with Administrator (NHA-A) and Director of Nursing(DON-B) there is no care plan for R28's anticoagulant and that there has been no monitoring for signs and symptoms of bleeding. NHA-A and DON-B understand the concern. No further information was provided by the facility at this time. On 10/25/23 at 7:55 AM, DON-B believes the anticoagulant is incorporated in another care plan and will follow-up. On 10/25/23 at 8:23 AM, DON-B provided a care plan for R28's cardiac status with an intervention of a administer medication as ordered. DON-B agreed that the intervention is not specific to R28's anticoagulant and what signs/symptoms to monitor for. DON-B agreed there should be a detailed specific care plan just for R28's anticoagulant, and informed Surveyor that a new care plan was initiated and back dated for the date of when the anticoagulant started. On 10/25/23 at 8:44 AM, DON-B provided a detailed anticoagulant comprehensive care plan for R28 which includes the following: Alteration in Circulatory Status related to potential for blood clots/chronic pulmonary embolism as evidenced by anticoagulant use, increased risk for bruising. Increased risk of bleeding secondary to anticoagulant use-neurochecks as indicated post falls. Start date of 1/23/23, Created 10/25/23 Interventions: Start date of 1/23/23, Created 10/25/23 -No signs/symptoms blood clot x90 days -Elevate legs as tolerated to prevent dependent edema -Monitor extremities for increased edema, pulses, warmth, color, pain -Provide careful skin care to lower extremities to prevent skin breakdown due to stasis -If abnormal signs/symptoms noted, or complaints numbness or tingling, update MD -R28 will not have adverse effect from anticoagulant x 90 days -R28 receives an anticoagulant. Monitor for side-effects and report to MD if present: hemorrhage, bruising, hematuria, black tarry stools,guiac positive stools, coffee ground emesis, bleeding of the gums during teeth brushing, sudden onset of confusion that may indicate bleeding in the brain, recent changes in breathing pattern that may indicate bleeding in the lungs; unexplained shortness of breath; chest pain, coughing, hemoptysis; feelings of anxiety or dread -Administer anticoagulant as ordered -Observe for signs/symptoms of thromboembolism: pain or tenderness and swelling of upper or lower extremity: increased warmth, edema and/or erythema of affected extremity

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not always ensure that 1 (R342) of 5 residents reviewed were given psychotropic medications with adequate monitoring. * R342 was administered scheduled Sertraline (Zoloft- antidepressant) with no identified targeted behaviors for staff to be monitoring in order to determine the effectiveness of the medication. Findings include: The facility policy entitled, Psychotropic Drug Use, revised on 11/2017 states: Residents will receive care that optimizes or maintains their highest level of well-being which may incorporate use of psychotropic drug regimen as a part of the therapeutic plan of care. Psychotropic medications will: - Be used only when non- pharmacological approaches have been unsuccessful at maintain or improving resident quality of life. - Be administered and evaluated through avenues such as, but not limited to behavior/intervention monthly monitoring on the resident's Medication Administration record (MAR) in the electronic medical record (EMR), Interdisciplinary Behavior Management Team Review, and psychology and/or psychiatry consultation. 4. If not already initiated, the nurse will create and/or update as needed, the resident's EMR MAR with the specific targeted behavior and interventions for daily monitoring every shift. R342 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus, muscle weakness, and prostate cancer. On 10/24/2023 surveyor reviewed R342's physician orders. Current physician's orders for Sertraline 50mg every day for depression started on 10/21/2023. On 10/24/2023 R342's MAR for October 2023 was reviewed and indicated R342 received Sertraline as ordered and signed off by each nurse who administered it. No targeted behaviors for the medication use were identified. On 10/24/2023 at 1:00 PM Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of surveyors concern that R342 behaviors were not being monitored. NHA-A stated that behavior monitoring should be located on the MAR and would investigate it. No other information was provided at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure coordination of care and the hospice communication process was followed for 1 Resident (R25) of 2 Residents reviewed for hospice services. R25's hospice care plan was not integrated in the facility care plan or easily identifiable by facility staff in R25's hospice binder. R25's hospice binder did not include the agreed upon hospice documentation of interdisciplinary progress notes (IDT), updated plan of care, schedule of visits. Further, R25's recertification for hospice benefits ended as of 3/25/23 and R25's hospice documentation did not reflect the recertification had been renewed. Findings Include: Surveyor reviewed the facility's Hospice Coordination of Services policy and procedure last reviewed on 9/11/23 and notes the following applicable: .Policy: For those Residents who have willingly entered into a hospice contract, the facility will work collaboratively with the hospice organization of the Resident's choice to ensure an integrated coordination of services and holistic approach to managing end-of-life care issues. II. Coordination of Services: 3. All information relevant to the Residents care must be shared and contained in the medical records compiled by both the hospice and nursing home. The health center will maintain all original documents initiated by the health care center staff and hospice. Both entities will retain copies of all pertinent/necessary records. 6. The hospice and nursing home will jointly coordinate the development, implementation and evaluation of the comprehensive plan of care and will clearly delineate each provider's responsibility for the Resident specific care and services. 7. Residents on hospice will be assessed by the health center IDT on a quarterly basis and as changes of condition occur. The social worker will be responsible for making sure the Residents, families, and hospice members are aware of the meeting date and time. V. Medical Record Management 1. Copies of physician orders and coordinated plan of care will be maintained on both organizations medical records. 2. Copies of physician certification and informed consent for hospice services will be maintained in the Resident's medical record at the facility. Original documents will be maintained with the hospice agency. 6. The records of the Resident residing in the facility must include all clinical information that is relevant to the care of the Resident(Orders, Assessment, etc) whether obtained by the hospice or the facility. 7. The clinical information must be included in the records maintained by each provider. Surveyor also reviewed the hospice nursing facility agreement between the facility and hospice provider signed on 9/20/21 and notes the following applicable: .3. Joint Responsibilities 3.2 Communication and Access. Both parties will allow each other to: 3.2.1 Access all records of hospice services rendered to the hospice Residents 3.2.2 Attend and participate in the other party's IDT group meetings held for the purpose of developing and evaluating the plans of care for hospice Residents. 4.2 Designation of a facility IDT group member 4.2.4 Obtaining the following information from the hospice a. The most recent hospice plan of care b. Hospice election form c. Physician certification of the terminal illness d. Names and contact information for the hospice personnel involved in the care 4.3 Availability of Records. With respect to management of a hospice Resident's terminal illness, facility will make records of care and services to the hospice. 4.8 Plan of Care. Hospice will collaborate with Facility on a coordinated plan of care developed jointly between hospice and facility. Each hospice Resident's written plan of care must include both the most recent hospice plan of care and a description of the services furnished by facility to attain or maintain the hospice Resident's highest practicable physical, mental, and psychosocial well being. 4.9 Medical Chart. Facility and hospice will prepare and maintain complete medical records for hospice Residents receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by hospice will be filed and maintained in the facility chart. Originals of all documents of services provided by hospice will be filed and maintained by hospice at the hospice office. Facility and hospice will each have access to the hospice Resident's records maintained by the other party. 5.5 Plan of Care. Hospice is responsible for determining the appropriate course of hospice care, including making the determination to change the level of services provided. A written plan of care will be established and maintained for each Resident admitted to hospice. These plans of care and reviews will be documented. Hospice will attend facility's care conferences and Resident/caregiver meetings as deemed necessary. 5.11 Medical Record. Hospice will maintain a completed and timely medical record on each hospice Resident relating to all services rendered. All records of services and treatment are part of the hospice record. Hospice will maintain possession of all original paperwork generated by hospice under this agreement. Surveyor notes in R25's hospice binder there is a form that states the following: .Required items for F309 compliance-do not thin from chart -Aide care plan -Updated hospice comprehensive assessment and plan of care update summaries -Hospice coordinated task plan -Copies of all provider orders obtained by hospice team -Recertification orders These items are required to show ongoing collaboration between hospice and skilled facility for the care of this Resident. R25 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Dementia. Prior to admission to the facility, R25 had been on hospice and hospice service transferred when admitted to the facility. R25's Quarterly Minimum Data Set(MDS) dated [DATE] documents R25's Brief Interview for Mental Status(BIMS) score to a be a 2 which indicates R25 demonstrates severely impaired skills for daily decision making. R25's MDS documents that R25 requires partial to moderate assistance for eating, oral hygiene, upper body cares and dressing. R25 requires substantial to maximal assistance for toileting, hygiene, shower bath, lower body, and personal hygiene and R25 requires substantial/max to partial/moderate assist for mobility. R25's MDS documents R25 is receiving hospice benefits. Surveyor notes that R25's current physician orders do not document an order for hospice services. R25's facility comprehensive care plan for hospice services was initiated on 4/5/23 with the following interventions: -Review advance directives as indicated with R25/family -Provide in room leisure supplies as desired -Provide 1:1 supportive visits through end stage of life -Offer appropriate sacraments to the dying person -Keep family updated/involved -Acknowledge R25/family grief/feelings of loss -Facility team will collaborate with hospice team regarding needs, pain, potential crisis care at end of life, and chaplain services per R25 request Surveyor notes this comprehensive plan of care does not reflect a coordinated plan of care between hospice and the facility. On 10/23/23 at 9:43 AM, Surveyor reviewed R25's hospice binder located at the nurse's station. Surveyor notes R25's hospice binder did not contain any IDT progress notes. The last documented hospice certification was for the period of 1/25/23-3/25/23, which was before R25 was admitted to the facility. The last updated hospice care plan is dated 6/7/23. R25's hospice binder did not contain documentation of a schedule of hospice IDT visits. On 10/24/23 at 11:56 AM, Surveyor shared the concern with Director of Nursing(DON-B) that there is no progress notes, no schedule of visits, the care plan has not been updated since 6/7/23, and the recertification for hospice benefits for R25 has not been renewed since 3/25/23. DON-B stated DON-B will look for the documentation. DON-B informed Surveyor that the social worker is the designee. On 10/24/23 at 1:16 PM, R25's hospice binder still does not contain the agreed upon documentation between hospice and the facility. On 10/24/23 at 3:10 PM, Surveyor shared the concern with Administrator(NHA-A) and DON-B that R25's hospice binder does not contain IDT progress notes, schedule of visits, and the care plan has not been updated since 6/7/23, and the recertification for hospice benefits for R25 has not been renewed since 3/25/23. Surveyor expressed the medical records were not readily accessible. No further information was provided by the facility at this time. On 10/24/23 at 3:29 PM, Surveyor interviewed Social Worker(SW-C) in regards to R25 and hospice. SW-C informed Surveyor that the hospice IDT should be bringing updated information and documentation when they visit. SW-C stated that the facility should have access to hospice visits and plan of care on a daily basis. SW-C stated the hospice IDT members do not communicate with SW-C when they are in the facility. SW-C informed Surveyor that no one monitors R25's hospice binders to make sure the necessary information and documentation is in the binder and readily accessible. On 10/25/23 at 7:26 AM, NHA-A provided documented hospice visit notes going back to 3/30/23. Surveyor asked why the documented notes were not available during the survey process. Surveyor was provided at this time a plan of care update report as of 9/13/23 for R25. NHA-A stated that about a month ago, NHA-A had contacted the hospice provider and was told at the time that all documentation was in the binder. NHA-A is waiting for hospice to call and possibly provide more information on the availability of information. NHA-A confirmed and understands the concern that R25's hospice documentation/medical records has not been available in the facility during the survey process. On 10/25/23 at 10:16 AM, Surveyor spoke with SW-C who informed Surveyor that members of the hospice IDT have not attended a facility care conference for R25. SW-C stated hospice has not been attending care conferences since R25's admission. SW-C provided 4 documented dates of care conference, 4/13, 4/20, 7/13, and 10/12/23 and no member of the hospice IDT signed in for attendance.