**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility did not provide written notice including the reason for the room change to a resident and offer a choice in a change of room for 1 (R13) of 1 residents reviewed for room change. R13 returned from the hospital on 2/24/2025 and was placed into a different room, the Facility did not take resident preference into account or offer to show possible rooms to the resident/resident representative prior to the change. There is no documentation R13 received prior written notice for the reason for the transfer. Findings include: The Facility's Policy and Procedure titled, Transfer, Room to Room, last revised December 2016 documents, in part: .Preparation 1. Orient the resident to the transfer in a form and manner that the resident can understand. Provide the resident with information about: a. Where the room is located. b. Who the resident's new roommate, if any, will be. c. Who will be providing the resident's care. d. That his or her family and visitors will be informed of the room change. e. Why the transfer is taking place. 2. Reassure the resident that all his or her personal effects will be brought to his or her new room . 5. If possible, take the resident to see his or her new room before the actual move is made . 15. Store the resident's personal effects. Ask the resident how he or she would like them arranged . Documentation The following information should be recorded in the resident's medical record: 1. The date and time the room transfer was made. 2. The name and title of the individual(s) who assisted in the move. 3. All assessment data obtained during the move. 4. How the resident tolerated the move. 5. If the resident refused the move, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data . R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. R13 is coded as making self understood and understands others. Per MDS R13 has a catheter and an ostomy for bladder and bowel function. On 02/24/2025, at 10:54 AM, a progress note was written that reads Resident returning to facility today from AMCB (name of Medical Center [NAME]). He finished his IV (intravenous) antibiotics, and per discharge summary has no new medications. He is moving rooms to (room number) due to MRSA + UTI (urinary tract infection). On 02/26/25, at 11:45 AM, Surveyor interviewed R13 who stated today was hectic. They switched his room and today they moved his belongings to the new room. R13 stated that limited notice had been given. R13 was concerned because R13 had decorated old room with pictures that were not back up in new room. On 03/03/25, at 01:06 PM, Surveyor followed up with R13 who stated that when R13 was brought back from hospital R13 was taken to a new room. It took a day or 2 for staff to bring possessions from old to new room. R13 stated that no notice was given. After R13 asked questions was told the move was because of MRSA, R13 could not share a room so was moved to a private room. R13 asked if could make new room their own and was told would be moved again, however no timeframe was given. R13 was told can't be in a room with someone else. Doesn't understand because can be out of room socializing, this confuses R13. On 03/03/25, at 01:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding R13 and was told Facility will continuously look into this because of MRSA, right now R13 needs to be in a private room. Surveyor asked about setting room up to R13's wishes and was told this needs to be a discussion. ADON-F is trying to find right guidelines and then will discuss options. On 03/04/25, at 09:48 AM, Surveyor interviewed Admissions-U about when the room change was communicated to R13. Admissions-U stated that when R13 came back, R13 was placed in the bed in the new room, then Admissions-U went to room to discuss with R13 the MRSA diagnosis and that R13 can't share a room. Admissions-U was not sure the length of time it will be for. Admissions-U stated that the decision was made that day by management to move R13. Admissions-U was unsure about what the plan was to organize the room to R13's liking at this time. On 03/04/25, at 09:53 AM, Surveyor observed R13's new room and there was only a clock on the walls, no pictures. There was a bookshelf with books on it. R13's clothes were laying across a chair in the room. On 03/04/25, at 10:08 AM, Surveyor interviewed Director of Nursing (DON)-B and asked about communicating to R13 about the room change. DON-B stated that to my understanding social services and admissions were to communicate with each other and they should have alerted him. Surveyor asked about the length of time the room change will be for and was told the Facility will repeat labs continuously to determine if can move back. Surveyor asked about the set up of the room and was told we can set it up. To DON-B's knowledge R13 asked someone about it, R13 can set it up per wishes. Surveyor notes no documentation was found indicating R13 had been aware of the room change, given a preference as to which room R13 would like, and there was no documented follow-up on how R13 was adjusting to the new room. On 03/04/25, at 10:12 AM, Surveyor let DON-B know this is a concern, R13 was transferred to another room and there is no documentation R13 received prior written notice of the reason for the transfer or documentation on how R13 was adjusting to new room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility did not promote or facilitate the resident's choice for a sleep schedule. This was observed with 1 (R13) of 14 residents reviewed. * R13's morning preference of time to get up was not followed by staff. Findings include: R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. R13 is coded as making self understood and understands others. Per MDS R13 has a catheter and an ostomy for bladder and bowel function. R13's care plan reads resident requests to be woke up at 0630 hrs (hours) every day of the week. Please document refusal for following request of resident with wake time and medications. Reassess resident requests PRN (as needed), start date 2/7/25, edited 3/4/25. The Approach and Long Term Goal Target . is resident will be woken up every day at 0630 hours per resident request. Signs will be hung in LTC (long term care) nurses' station and resident's room and closet as reminders for staff. Created: 02/07/2025. R13's care plan reads R13 has history of insomnia. The approach is encourage R13 to go to bed at the same time every day and wake up at the same time every day. Created: 08/14/2024. On 02/26/25, at 10:05 AM, Surveyor observed two staff in R13's room doing ADLs (activities of daily living) with R13. One staff then stepped out of room and went to get the Hoyer to get R13 out of bed for day. On 03/03/25, at 10:00 AM, Surveyor observed R13's door shut, Surveyor knocked on door and was told staff were doing R13's cares to get up for the day. Surveyor notes R13's care plan and sign on R13's door state resident likes to be up at 6:30 AM. On 03/03/25, at 01:06 PM, Surveyor interviewed R13 about what time R13 likes to get up. R13 stated by 6:30 AM and that has not happened since R13 came back from the hospital on 2/24/2025. R13 stated that when R13 can be up in power wheelchair R13 can maintain independence and that is R13's goal. When in wheelchair R13 has ability to get food, water and medications otherwise R13 just lays in bed unable to get needs met. On 03/04/25, at 09:30 AM, Surveyor interviewed R13 again and asked if was up at 6:30 am today. R13 stated yes they were, but not up properly. R13 does not have seat cover on seat and there was no teeth brushing among other things, R13 is working on getting that accomplished. On 03/04/25, at 09:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K and asked what time R13 got up. CNA-K replied it was before they got here so must be before 6:30 AM. CNA-K stated that they finished helping R13 get ready today. On 03/04/25, at 10:10 AM, Surveyor interviewed Director of Nursing (DON)-B about R13's desire to get up by 6:30 AM. DON-B stated that there is a sign on the door and R13's desired time is on the get up list CNA get. Per DON-B R13 refuses sometimes if staff ask and it should be documented but it's not. Surveyor let DON-B know this is a concern as a resident has the right to get up at the time desired. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure that residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms and document ongoing re-evaluation of the need for restraints for 1 (R13) of 1 residents reviewed for restraints. R13 has an abdominal binder in place which cannot be removed easily by R13 and restricts R13's freedom of movement or normal access to body. The Facility did not have a Physician order or signed consent form, did not provide evidence that the use of the abdominal restraint is the least restrictive alternative, did not document scheduled time binder should be on and did not document on-going evaluation of the need for the abdominal binder. Findings include: R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. R13 has no behavior concerns. R13 is assessed as making self understood and understands others. Per MDS R13 has a catheter and an ostomy for bladder and bowel function. The MDS assesses that physical restraints are not used. Surveyor's review of R13's medical record revealed no Physician's order, assessment, care plan, consent or ongoing monitoring of an abdominal binder. R13 does have a care plan for indwelling catheter and one approach listed is Abdominal Binder to maintain placement of tubes. Created: 01/07/2025. Surveyor notes that it is not documented why the abdominal binder was needed to maintain placements of tubes in use, how long the abdominal binder should be used and alternative interventions that had previously been used that may have been less restrictive. Surveyor notes the abdominal binder is not a regularly prescribed intervention with nephrostomy tubes. Surveyor notes there are no instructions given on times binder should be put on or off of R13. Surveyor notes the medical record does not contain a Physician's order, care plan or consent for the binder restraint and there is no evidence of ongoing monitoring of the restraint on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 03/03/25, at 01:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding R13's nephrostomy tubes getting dislocated by staff during cares and was told they started an intervention of using an abdominal binder to hold the tubes in place. They discussed with the Nurse Practitioner today if there are other ideas on how to keep the tubes from not getting pulled out. (Cross-reference F684). On 03/04/25, at 09:30 AM, Surveyor interviewed R13 regarding the abdominal binder, R13 stated they are not using it now because it is so tight that R13 got a rash. R13 decided on own that they did not want the rash so have asked staff not to put the binder on. On 03/04/25, at 09:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who finished helping R13 get ready that morning and asked about R13's abdominal binder to which CNA-K responded ya he wear it. On 03/04/25, at 09:58 AM, Surveyor interviewed Director of Nursing (DON)-B regarding steps taken to prevent pulling of nephrostomy tubes by Facility. Per DON-B the first couple times it happened it was during Hoyer transfers so DON-B got an abdominal binder to hold tubes in place. DON-B admits not being aware R13 is not wearing the binder due to rash, stated will have to talk to R13 about skin protection options. On 03/04/25, at 03:34 PM, Surveyor asked DON-B if the abdominal binder was assessed and was told that it was not assessed or considered a restraint. The Nursing Home Administrator was also in the room. Surveyor reiterated that this is a concern. As of the time of exit, no additional information was provided as to why the Facility did not comprehensively assess the use of the physical restraint (abdominal binder) and then develop a plan of care based on the outcome of the assessment for its continued use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R47 was admitted to the facility on [DATE]. On 10/30/2024, R47 was transferred to the hospital due to x-ray and lab results that had been ordered by R47's physician. R47 was readmitted to the facility on [DATE]. On 12/24/2024, R47 was transferred to the hospital with hypoglycemia, anemia, and COVID-19. R47 was readmitted to the facility on [DATE]. On 1/9/2025, R47 was transferred to the hospital due to proctitis. R47 was readmitted to the facility on [DATE]. On 1/19/2025, R47 was transferred to the hospital due to a gastrointestinal bleed. R47 was readmitted to the facility on [DATE]. No documentation was found in R47's medical record that a bed hold notice was provided to R47 or R47's representative. On 2/27/2025 at 3:01 PM and on 3/3/025 at 8:47 AM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R47's bed hold notices were not found in R47's medical record. Surveyor requested a copy of R47's bed hold notices for 10/30/2024, 12/24/2024, 1/9/2025, and 1/19/2025. Surveyor asked DON-B if the bed hold notices should be in R47's medical record. DON-B stated they should be. Surveyor requested a copy of R47's bed hold notices for 10/30/2024, 12/24/2024, 1/9/2025, and 1/19/2025. On 3/4/2025 at 8:05 AM, DON-B stated R47 did not have any bed hold notices for the dates requested. DON-B stated there were not any bed hold notices scanned into R47's medical record and they were not able to find any that had not been scanned in. Based on Interview and Record Review, the facility did not provide bed hold notices to 3 (R5. R47, R13) of 3 residents reviewed for hospitalization. *R5 was hospitalized on [DATE] and did not receive a bed hold notice. *R47 was hospitalized on [DATE], 12/24/24 and 1/19/25. R47 did not receive bed hold notices for all 3 hospitalizations. *R13 was hospitalized on [DATE] and did not receive a bed hold notice. Findings include: 1.) R5 was admitted to the facility on [DATE]. On 1/24/25, R5 was transferred to the hospital due to a change of condition. R5 was readmitted to the facility on [DATE]. On 2/27/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R5's bed hold notice was not found in R5's medical record. Surveyor requested a copy of R5's bed hold notice for 1/24/25. On 3/4/2025 at 8:00 AM, DON-B told Surveyor that R5 did not have any bed hold notice for the requested date. No additional information was supplied by the facility at this time. 3.) R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. R13 is coded as making self understood and understands others. Surveyor reviewed R13's electronic medical record which indicated R13 was transferred to the hospital emergency room for leaking nephrostomy tubes and urine with foul odor on 2/14/2025. Surveyor requested evidence from the Facility that a bed hold notice was provided to R13 and to R13's responsible party when R13 went to the hospital. Surveyor was given a form Bed Hold Consent Form/Policy dated 11/19/24 that R13 had signed and checked the box indicating Accept Bed Hold. On 02/27/25, at 02:47 PM, Surveyor interviewed Director of Nursing (DON)-B and was told that November 19th was the last admission for R13 and the form given was is all they have. On 03/03/25, at 09:45 AM, Surveyor interviewed Social Worker (SW)-S and was told bed hold notices are done by nursing staff. On 03/04/25, at 07:56 AM, DON-B told Surveyor that they do not have any paperwork provided at the time of transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not complete a Pre-admission Screening & Resident Review (PASARR) assessment for 1 (R37) of 1 residents reviewed. R37 was admitted to the facility on [DATE], and did not have a PASARR Level I completed at time of admission. Findings include: The facility's Policy and Procedure titled admission Criteria, not dated, documents: All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. R37 was admitted to the facility on [DATE] with a diagnosis that includes Bipolar disorder, Depression, Anxiety, and Post Traumatic Stress Disorder (PTSD). R37's hospital documentation dated 12/20/24, documents R37 with a history of chronic bipolar, depression, anxiety, and PTSD. On 2/27/25, at 1:39 PM, Surveyor interviewed Medicaid Pending Manager (MPM)- C who states she is notified by the facility of new admissions and will read through the referral to see if there are any medications or diagnoses to fill out the Level I PASARR. MPM- C indicates a Level I PASARR is required on every resident, and she will download in the Electronic Medical Record (EMR). MPM- C states she will complete a Level 2 PASARR if it is required and will send a notification to the facility's Director of Nursing (DON) if a Level 2 PASARR is required. Surveyor asked MPM- C if a Level I PASARR was completed on R37 and MPM- C states she completed the Level I PASARR today on 2/27/25. Surveyor notes R37 was admitted on [DATE]. Surveyor asked why the Level I PASARR was completed on 2/27/25 and MPM- C states she works in 6 other facilities and sometimes doesn't catch everything. MPM- C indicates R37's Level I PASARR was completed and submitted on 2/27/25 and the Level 2 PASARR is not completed but is requested. On 2/27/25, at 3:02 PM, Surveyor notified Nursing Home Administrator (NHA)- A, Assistant Nursing Home Administrator (ANHA)- D, and DON- B of concerns with R37 not having a Level I PASARR completed on admission. NHA- A, ANHA- D, and DON- B acknowledge concerns.

Based on interview and record review the facility did not ensure 1 (R50) of 1 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to care for the resident. *R50 discharged from the facility on 1/13/25. The facility did not complete a discharge summary or a recapitulation of their stay that was available to R50. Findings include: R50 was admitted to the facility for rehabilitation on 1/7/25 with dehydration, weakness and congestive heart failure. On 1/13/25, R50 had a planned discharge from the facility into the community. Surveyor reviewed R50's physician orders and noted no discharge order documented by a physician. Surveyor reviewed R50's electronic medical record. R50 was discharged from the facility on 1/13/25. Surveyor could not identify a completed recapitulation of R50's stay at the facility or a completed discharge summary. On 3/3/25 at 9:45 AM, Surveyor conducted interview with Social Worker-S. Social worker-S informed Surveyor that they were hired by the facility in July of 2023 in a Social Services role. Surveyor asked Social Worker-S if a resident should be given a discharge summary and recapitulation of their stay at the facility upon discharge. Social Worker-S responded Yes, that would be the expectation upon discharge. On 3/3/25 at 3:15 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A related to R50 discharging from facility on 1/13/25 without evidence of a completed discharge summary or recapitulation of R50's stay at facility being provided to R50. The facility did not provide any additional information at this time

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not always ensure that 1 (R44) out of 3 residents reviewed for accident hazards, received the care and services to prevent a further accident from happening. R44 had a history of swallowing difficulties and experienced a choking episode. The facility did not get a referral for R44, immediately following the incident, to identify the cause of the choking and provide supervision and assistance devices to prevent further choking incidents from happening. Findings include: R44 was originally admitted to the facility on [DATE] with diagnoses that included neuropathy, dementia, muscle weakness, hypothyroidism, gastroesophageal reflux disease (GERD), anxiety disorder and depression, The most recent significant change of condition MDS (Minimum Data Set) dated 1/14/25, indicates that R44 does not have any swallowing disorders or oral concerns. R44 did not participate in the BIMs (brief interview for mental status) assessment but is documented to have long and short-term memory concerns. The MDS indicates R44 is assessed as needing supervision or touching assistance by staff while eating, no signs or symptoms of a swallowing disorder, but is on a mechanically altered diet as a resident. R44's 11/17/24 quarterly MDS indicates R44 requires set up assistance from staff for eating. R44 shows signs and symptoms of coughing and choking while eating or taking medications and is on a mechanically altered diet as a resident. R44's 8/17/24 quarterly MDS indicates R44 requires set up assistance for eating, has no signs or symptoms of swallowing issues, and is on a mechanically altered diet. A nursing note dated 11/12/24 at 10:03 a.m. indicates; (R44) was in main dining room eating breakfast and c/o (complained of) having chest discomfort, (R44) sounded nasally, (R44) has hx (history of) gerd and receives scheduled Famotidine q (every) am which writer administered (R44's) meds this am. (R44) did eat her whole breakfast and drank most fluids. (R44) had a coughing spell in dining room and a copious amount of clear phlegm came up on (sic) (R44) stated she had felt better, and her nose did not feel as stuffed up. Writer performed COVID test on (R44) and it is negative for COVID. (R44) currently sleeping in recliner in back lounge. Writer to update MD and ask for CXR (chest Xray) to rule out URI (upper respiratory infection). Nursing note dated 11/22/2024 at 8:38 a.m. indicates; Staff called for nursing to the dining room. (R44) complaining of feeling full in her throat or like something is stuck. Writer noting mucous production, (R44) making attempts to clear throat. Denies heart burn, however states pain. Tablemate stated that this has been happening every so often, and (R44) confirmed. Updated NP (nurse practitioner) and requested ST (speech therapy) eval/treat. On 11/22/2024 the NP approved ST eval/treat and notified therapy staff. R44 did receive speech therapy from 11/25/24 to 12/2/24. Upon discharge from therapy, the recommendations were for thin liquids and regular texture solids. The recommendation was to also give appropriate redirection with R44 and pre-cut large solids. R44's plan of care was updated at this time. A nutrition note dated 12/05/2024 at 9:41 a.m.; Wt. (weight) has been stable past 3 months. Wt. gain over past 6 months is desirable given that BMI (body mass index)/wt. were low for age. Her (R44) current BMI is now indicative of overweight but remains appropriate for advanced age. She (R44) had recent episode for concern for difficulty w (with)/swallowing and getting food stuck. She was evaluated by SLP (speech language pathologist) with recommendations for continued general diet w/regular texture and thin liquids. Her po (by mouth) intake is typically at 76-100% majority of meals which is appropriate. She does receive house supplements at all meals which is appropriate to keep weight stabilized at approp (appropriate) amount given advanced age. No new recommendations. Surveyor noted the nutrition note did not include ST recommendations to pre-cut large solids. Nursing note date 12/19/2024 at 2:51 p.m.; During breakfast (R44) started to choke on her sausage as she could not swallow it or chew it all the way. (R44) had a small emesis after choking on the sausage, vitals were taken and were stable. At lunch time (R44) was complaining of feeling like her chest way full (sic) resident was given Mylanta to see if that would clear up some of the full feeling in her chest. Writer called the doctor, and the doctor said to call the POA (Power of Attorney) and ask if they would like (R44) to go to the emergency room to get a workup. The resident's (R44) POA said to call him back after a while to see if the Mylanta would settle some of the discomfort. Writer checked back after an hour and (R44) said that her chest did not hurt anymore, and she seems much more relaxed and calmed down. Surveyor conducted further review of R44's medical chart and noted that there was no additional follow-up about the choking incident on the morning of 12/19/24. The facility staff did not notify the physician immediately following the incident. There was no update to the plan of care for further supervision and no referral to the Dietician regarding concerns with meal textures. In addition, there was no follow-up by the facility to ensure that R44's breakfast meal which consisted of larger food items (breakfast sausage) were cut-up before consumption. Nursing note dated 12/21/2024 at 3:56 p.m.; no issues with swallowing noted this shift. On 12/26/2024 at 10:34 a.m., the IDT (interdisciplinary team) spoke with NP and requested video swallow study due to Dysphagia, oropharyngeal phase. Voicemail left for POA to return phone call. Scheduling staff made aware of need for appointment. On 12/27/24 the facility obtained a physician order for R44 to have a Video Swallow Study. On 12/30/24, an order was written to monitor R44 for swallowing complications at every meal followed up with documentation. With Meals 08:00 AM, 12:00 PM, 05:00 PM On 1/8/25, R44 received a speech therapy evaluation for the treatment of swallowing dysfunction and /or oral function for feeding. Patient (R44) goals to reach least restrictive diet needs. The reason for the referral was a change in overall status since a recent fall. R44 was presenting with decreased awareness and ability to self-feed, reason, and swallow itself marked. The assessment noted that R44 was seen by Speech Therapy in the fall of 2024 and able to be discharged on regular thin liquids and self-feeding after set-up for help with cutting of foods. Surveyor noted that there was a Notice of care plan change, dated 1/8/25, from Speech Therapist that R44 is to have a dietary change: downgraded to puree. Advise increased supervision and support at mealtimes. Copies given to nurse on unit, DON (Director of Nursing), CNA (Certified Nursing Assistants), Binder. Nursing note dated 01/14/2025 at 5:21 p.m.; CARE PLAN UPDATE: Dietary change: downgrade to puree, advise increased supervision and support at mealtimes. On 1/17/25, an additional Notice of Care Plan Change from Speech Therapist to upgrade to mech (mechanical) soft and ground meats. Continue thin liquids. Nurse to remind CNA's that R44 needs quiet setting, pre-cut large items to finger food size. Indirect supervision after set-up. Nursing note dated 01/21/2025 at 10:20 a.m.; (R44) continues to be monitored for diet change to mech soft, (R44) ate all her scrambled eggs and toast, and about half of her oatmeal, drank all fluids offered, no coughing or choking present during breakfast. Nursing note dated 01/30/2025 at 03:36 p.m.; (R44) was seen by Speech therapy and new orders to upgrade diet to regular solid texture. Continue swallow guidelines per order. POA called and updated. A physician order was obtained on 1/30/25 ; DIET: Regular solid diet and thin liquids. Instructions: Nurse to remind CNAs that R44 needs quiet setting, pre-cut large items to finger food size. Indirect supervision after set-up. Before Meals 08:00 AM, 12:00 PM, 04:00 PM On 03/04/25 at 08:00 a.m., Surveyor interviewed DON (Director of Nursing)-B regarding R44's choking incident on 12/19/24. DON- B stated that she verified that the nurse on that shift did not notify the physician of the incident. DON- B stated she would have expected the nurse to call the physician immediately and discuss the need for further evaluation and treatment. On 03/04/25 at 11:01 a.m., Surveyor interviewed RD-W (Registered Dietician) regarding R44's choking incident on 12/19/24. RD-W stated the previous RD was at the facility that day and upon her review of the progress notes, there was no documentation that she was alerted of R44's choking incident. RD-W stated that she definitely would want to get the referral to Speech Therapist, make dietary changes if needed and add supervision at meals. RD-W stated that the Dietician or any nurse can downgrade a diet until we can get them a swallow evaluation and diagnosis. RD-W stated that she would expect that facility staff would have notified Dietary just so we can look at weights and if resident has had trouble eating previously and needs diet consistency changes. On 03/04/25 at 01:12 p.m., Surveyor interviewed SP (Speech therapist)-X regarding R44's choking episode on 12/19/24. SP-X stated that she was not made aware of that incident and had previously worked with R44. Surveyor went over the nursing notes and the time it took for R44 to get an order for a swallow study and for Speech Therapy to evaluate and treat her. SP-X stated that it seems like odd intervals in between the incident and the orders, and she cannot say where communication broke down. SP-X stated that she has been treating R44 since January and she has been doing well. SP-X stated that she was the staff that wrote the referral for speech services as she noticed a change in R44's cognition, it was not due to the choking incident in December 2024. R44 was noted to have a history of swallowing concerns and after the choking incident on 12/19/24 nursing staff did not ensure R44 received additional assessments of her swallowing to ensure R44's safety. It was not until SP-X noted a change in R44 that led to the 1/8/25 evaluation of R44's swallowing and changes to R44's diet were initiated until further assessments and therapies could be completed related to R44's swallowing abilities. The facility did not do a thorough review to determine if R44 received the correct sized food when she had swallowing concerns. The lack of assessment immediately following the choking incident caused a potential for R44 to choke again without further assessment of her capabilities to eat safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents received appropriate treatment to restore continence to the extent possible for 1 (R47) of 2 residents reviewed for bladder incontinence. R47 had an indwelling urinary catheter that was removed while at the facility. The facility did not comprehensively assess R47's bladder pattern to develop a toileting program to restore R47's urinary continence. R47's Care Plan was not revised when the catheter was removed. Findings include: The facility policy and procedure titled Behavioral Programs and Toileting Plans for Urinary Incontinence from MED-PASS © 2001 revised 10/2010 documents: The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Conduct a thorough assessment of the resident and his or her environment to determine factors that may have contributed to any recent decline in urinary continence. 3. Provide treatment and services to address factors that are potentially modifiable. For example: a. managing pain; b. providing adaptive equipment for residents with mobility problems; c. removing or improving environmental impediments (lighting, distance to toilet or commode, etc.); and d. reviewing medication regimen and notifying the physician with any concerns. 4. Monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence, including: a. voiding patterns .; b. associated pain or discomfort .; c. type of incontinence (stress, urge, mixed, overflow, functional, etc.); d. level of incontinence .; and e. response to specific interventions. 5. Assess the resident for appropriateness of behavioral programs which promote urinary continence. General Guidelines: 1. Options for managing urinary incontinence include primarily behavioral programs, toileting plans and medication therapy. 3. Toileting Plans that are relatively more dependent on staff involvement and assistance as opposed to resident function include: a. prompted voiding; and b. habit training/scheduled voiding. Toileting Plans: 1. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence and/or behavior modification, the staff will initiate a toileting plan. 2. As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. Documentation: 1. The staff will document the results of behavioral/toileting trial in the resident's medical record. 2. If the resident responds well, behavioral/toileting programs will be continued. 1. R47 was admitted to the facility on [DATE] with diagnoses of left femur fracture, right pubis fracture, diabetes, congestive heart failure, lumbar disc degeneration, and morbid obesity. R47's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R47 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and had an indwelling urinary catheter. R47 did not have an activated Power of Attorney. R47's Indwelling Catheter Care Plan was initiated on 10/29/2024. On 2/15/2025 at 11:22 AM in the progress notes, nursing documented R47 was voiding freely with no difficulty in urination after the indwelling urinary catheter was removed on 2/14/2025. R47's Indwelling Catheter Care Plan was not resolved or revised after the catheter was removed. R47 did not have a care plan in place to address urinary incontinence. On 2/26/2025 at 10:08 AM, Surveyor observed R47 lying in bed. R47 had on a nightgown that was pulled up exposing R47's abdomen and incontinence brief. Surveyor noted an odor of urine. Surveyor asked R47 if R47 had been provided incontinence care recently. R47 stated R47 had urinated in the incontinence brief, and no one had changed her since the previous night. R47 stated R47 had just urinated in the brief and was waiting until Certified Nursing Assistant (CNA)-K was done helping R47's roommate with cares. R47 stated R47 wanted a bedside commode in the room so R47 could get up to use it instead of urinating in the incontinence brief. On 3/3/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R47 did not have a comprehensive bladder assessment completed after the indwelling catheter had been removed and R47's Care Plan still indicated R47 had an indwelling urinary catheter in place. In an interview on 3/4/2025 at 10:49 AM, Surveyor asked Certified Nursing Assistant (CNA)-J how often R47 had incontinence cares completed. CNA-J stated R47 tells staff when R47 is wet and needs to be changed. CNA-J stated staff also check R47 as well to see if R47 had been incontinent. In an interview on 3/4/2025 at 8:07 AM, Surveyor asked Director of Nursing (DON)-B if R47 had a bladder assessment completed after the indwelling urinary catheter was removed on 2/14/2025. DON-B provided CNA documentation that was completed hourly from 2/14/2025 to 3/4/2025 to establish if R47 had voided and had incontinence care provided. Surveyor asked DON-B if a nurse or nurse manager had reviewed the documentation to establish a toileting program such as prompted voiding. DON-B stated nothing was done with the information and no toileting program had been developed. In an interview on 3/4/2025 at 8:16 AM, Surveyor asked R47 if R47 was aware of the need to urinate before voiding. R47 stated R47 knows when R47 has to go but the staff do not offer R47 anything to go to the toilet. R47 stated R47 uses a mechanical lift so it does not fit in the bathroom, but the staff could put a bedside commode next to the bed and R47 could be lifted to the commode. Surveyor asked R47 if the staff offered R47 a bed pan. R47 stated they tried to use a bed pan once, but it caused R47 pain because the bed pan was not straight underneath R47. On 3/4/2025 at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R47 did not have a comprehensive bladder assessment completed after the urinary catheter was removed to determine a toileting program to meet R47's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility did not adequately address Nutrition needs for 1 (R19) of 1 residents reviewed for Nutrition. *R19 sustained a 9.2% weight loss from October 2024 to December 2024. The facility did not monitor R19's weight or implement proper interventions per RD (Registered Dietician) recommendations. Findings include: *R19 was admitted to the facility on [DATE] with diagnoses including left femur fracture, hemiparesis of left side, polyneuropathy and cerebrovascular disease. R19's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/30/24 indicated that R19 has a Brief Interview for Mental Status (BIMS) score of 12, indicating that R19 is moderately cognitively impaired. R19's admission MDS with ARD of 10/30/24 indicated that R19 is dependent upon staff for bed mobility, transfers, bathing, dressing and toileting. R19's admission MDS with an ARD of 10/30/24 indicates that R19 did not have any pressure injuries or an active risk for pressure injuries. R19's Quarterly MDS with ARD of 1/13/25 indicated that R19 is dependent upon staff for bed mobility, transfers, bathing, dressing and toileting. R19's Quarterly MDS with an ARD of 1/13/25 indicates that R19 was assessed with a stage 3 pressure injury and at active risk for pressure injuries. Surveyor reviewed R19's electronic medical record including nursing progress notes, physician orders, Registered Dietician progress notes and comprehensive care plan. On 10/25/2024, R19's weight was documented at 148.7 lb. On 10/27/2024, R19's weight was documented at 147.9 lb. On 11/7/2024, R19's weight was documented at 149.2 lb. On 12/27/2024, R19's weight was documented at 135.0 lb. On 2/24/2025, R19's weight was documented at 140.4 lb. Surveyor did not identify any documented weight for R19 for January 2025. From 10/25/2024 to 12/27/2024, R19 sustained a 9.2 % weight loss. Surveyor reviewed R19's nutrition care plan with an initiation date of 12/20/2024. R19's nutrition care plan documents the following: Problem: I (R19) am on a Regular diet, with thin liquids. No straws. R19's nutritional care plan included the following interventions: House stock supplement beverage daily .Obtain dietary consultation as needed .monitor and record weight, notify the health care provider and family of significant weight change .provide supplements as ordered . Surveyor reviewed R19's dietary progress notes from Reg (Registered) Dietician-Y from 10/30/2024 to present. On 10/30/2024 at 11:23 AM Reg Dietician-Y documented the following: RD new admit assessment. Ht (Height): not recorded, Wt (Weight)147.9 lb, BMI (Body Mass Index) unable to calculate. Resident admits post fall with L (left) hip fx (fracture) . (surgical repair). PMH (Primary Medical History): hemiplegia/hemiparesis, COPD (Chronic Obstructive Pulmonary Disease, PVD (Peripheral Vascular Disease), HTN (Hypertension, HLD (Hyperlipidemia), polyneuropathy, pre diabetes, CHF (Congestive Heart Failure). Receiving regular diet which is appropriate. PO (by mouth) intake appears to be > (greater than) 50% at meals which is adequate. No reports of any recent significant weight changes .Suggest obtaining height. No further recommendations. Resident (R19) is low nutritional risk. RD to follow as consult. On 11/21/2024 at 11:28 AM, Reg Dietician-Y documented the following: RD review. Ht 70, Wt 149.2 lb, BMI 21.41 . DTI (Deep Tissue Injury) to R (Right)-heel, being treated by wound nurse. He (R19) receives a regular diet w/thin liquids. He (R19) has snacks/food items brought in from family at times. Recorded po intake does varying depending on day/meal. Does tend to have at least 1 smaller meal each day. His (R19) weight is stable without any recent changes. Would suggest offering 30ml pro-source daily for additional protein to support healing of DTIs. Resident is high nutritional risk r/t wounds. RD to follow as consult. On 12/19/2024 at 12:46 PM, Reg Dietician-Y documented the following: RD review. Ht 70, Wt 149.2 lb (11/7/24), BMI 21.41. Most recent weight available from November, unable to assess any recent weight changes. He continues with a DTI to R-heel which has a scab intact .He (R19) is on a general diet order with varying po intake. He is receiving a multivitamin to support wound healing. Would suggest offering a house supplement at least 1x day due to varying po intake and low BMI/wt. Also suggest obtaining recent weight to better assess any weight changes. Resident is high nutritional risk r/t wounds. RD to follow as consult. On 1/29/2025 at 10:44 AM, Reg Dietician-Y documented the following: RD review. Ht 70, Wt 135 lb (12/27/24), BMI 19.37. Most recent weight available from December and indicates a -9.2% weight loss since October. Receives regular diet w/thin liquids. Po intake appears adequate around 76-100% majority meals. Skin reviewed: PI (Pressure Injury) to R heel, improving. Would suggest offering a house supplement at least 1x day due to varying po intake and low BMI/wt, increased needs for wound healing. Also suggest obtaining recent weight to better assess any weight changes and weekly weights therefore after given significant weight loss. Resident is high nutritional risk r/t wounds and weight. RD to follow as consult. On 2/27/2025, Surveyor requested to conduct interview with Reg Dietician-Y. Nursing Home Administrator (NHA)-A informed Surveyor that Reg Dietician-Y is no longer employed by the facility. The facility has a newly appointed dietician and offered to ask them to speak to Surveyor. On 3/3/2025 at 2:05 PM, the Survey team conducted a group interview with Reg Dietician-W. Surveyor asked Reg Dietician-W what their expectation would be for how often residents should be weighed upon admission to the facility. Reg Dietician-W told Surveyor that usually each facility has their own procedure for obtaining weights for new admissions and that they are not sure what procedure the facility has been following. Surveyor asked Reg Dietician-W if they are familiar with R19. Reg Dietician-W responded that they are not familiar with that resident and that they are currently covering for another dietician who is on vacation. Surveyor asked Reg Dietician-W what their expectation would be regarding the facility's time frame to carry out dietary recommendations by a dietician, such as supplement orders or recommendations for weekly weights. Reg Dietician-W responded that as a dietician that they would expect no more than a 24 hour turn around time for facility to initiate dietician recommendations and share those with resident's physician and power of attorney if applicable. Reg Dietician-W added that they had been made aware by Reg Dietician-Y that the facility was not timely following up on Reg Dietician-Y's recommendations and sometimes not responding to recommendations at all. On 3/3/2025 at 3:40 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R19 had sustained a documented 9.2 % weight loss from October 2024 to December 2024. Surveyor shared concerns that Reg Dietician-Y had made recommendations including a liquid protein supplement and weekly weights for R19 that were not carried out by the facility. The facility did not provide any additional information at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments for 1 (R46) of 1 residents reviewed for dialysis. R46 has a physician order for dialysis on Tuesday, Thursday and Saturday. Communication between the Facility and the dialysis center was not being shared with each visit. Findings include: The Facility Policy titled Dialysis Policy and Procedure last reviewed 9/17/2024 documents (in part): Procedure .: -Communicate with dialysis facility before and after treatment via the Dialysis Communication form . R46 was admitted to the facility on [DATE], pertinent diagnoses include dementia, pleural effusion, end stage renal disease, and dependence on renal dialysis. R46's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/7/25 indicated R46 had a Brief Interview for Mental Status score of 99, which indicates severe cognitive impairment. R46 uses a wheelchair for mobility. Dialysis was selected in Section O of the MDS. On 02/27/25, at 08:27 AM, Surveyor reviewed the electronic medical record and for January and February only found two dialysis communication forms dated 1/25/25 and 1/28/25. Surveyor requested January and February communication forms regarding dialysis for R46. On 02/27/25, at 09:47 AM, Surveyor interviewed Director of Nursing (DON)-B who stated that the Nursing Home Administrator (NHA)-A had talked to dialysis regarding a hiccup in getting communication forms back from dialysis, NHA-A would be in to discuss. Surveyor reviewed Dialysis Communication forms provided. None were provided for: 1/4/25, 1/7/25, 1/9/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 2/8/25, and 2/22/25. On 02/27/25, at 01:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q regarding the process of sending R46 to dialysis. LPN-Q stated that when transportation gets here, they are given an orange folder. There is a paper inside that has who is doing transport along with vitals etc. about R46. The nurse signs the form and sends it with R46. (Name of dialysis center) will send pertinent information back on that form. LPN-Q states this happens each time R46 goes out. On 02/27/25, at 03:00 PM, Surveyor interviewed NHA-A who stated they talked to (name of dialysis center) before Christmas regarding the missing forms, will get Surveyor an exact date. On 03/03/25, at 08:15 AM, NHA-A followed up with Surveyor that they spoke with (name of dialysis center) originally on [DATE] then followed up with them on January 6, 2025. Surveyor notes eight dialysis communication forms were not on record after the NHA-A followed up with dialysis. No additional information was provided regarding the missing dialysis communication forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 1 (R13) of 1 residents were free from significant medication errors. R13 had a physician order to receive one 100 mg Amantadine HCl capsule (Per Drugs.com Amantadine is used to treat Parkinson's disease and Parkinson-like symptoms such as stiffness or tremors, shaking, and repetitive uncontrolled muscle movements that may be caused by the use of certain drugs) one time a day. It was documented that R13 did not receive three administrations of Amantadine between 2/28/2025 and 3/3/2025. Findings include: The Facility's Policy and Procedure titled, Adverse Consequences and Medication Errors, last revised February 2023 documents, in part: Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services . 2. Examples of medication errors include: a. Omission - a drug is ordered but not administered . R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. R13 is assessed as making self understood and understands others. Per MDS R13 has a catheter bladder function and an ostomy for bowel function. R13 has a care plan with diagnosis of Parkinsonism, start date 6/26/2024. A pertinent intervention is provide medications as ordered by MD (medical doctor) Start date 6/26/2024. R13 has a physician order that started 11/19/2024 for Amantadine HCl 100mg, once a day for Parkinsonism. Surveyor reviewed R13's Medication Administration Record (MAR) and saw that Amantadine HCl was documented as not given three times between 2/28/25 to 3/3/25. Surveyor notes on 3/1/25 the medication was signed out as given, however, the three missed doses are coded as drug/item unavailable so unsure how it was available to be given on 3/1/25. On 03/03/25, at 01:06 PM, Surveyor interviewed R13 and was told that at least three times a week the improper medication or dose is given. R13 must be vigilant and watch each medication given. On 03/03/25, at 01:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding the missed doses of Amantadine HCl. ADON-F stated they will look into this. Surveyor asked if the Facility has a contingency supply of medications and was told they do, ADON-F will see if Amantadine HCl is included in contingency. On 03/03/25, at 02:25 PM, ADON-F followed up with Surveyor and stated that the Amantadine HCl medication was delivered and put into overflow, the nurses did not look there for the medication. ADON-F moved the medication to the medication cart. Also, Amantadine HCl is not available in contingency. ADON-F had contacted the Nurse Practitioner (NP) and was waiting to hear from NP if ok to give Amantadine HCl now. Surveyor notes an order was entered as once-one time for Amantadine HCl on 3/3/2025 to be given between 3:00 PM and 11:00 PM. On 03/04/25, at 10:00 AM, Surveyor interviewed Director of Nursing (DON)-B regarding the missed doses of Amantadine HCl and was told that ADON-F talked to DON-B and it was decided to reach out to doctor to update and get order to give late since it is a once a day medication. On 03/04/25, at 01:29 PM, Surveyor interviewed Agency Licensed Practical Nurse (LPN)-T regarding the Amantadine HCl not being administered on 3/3/24 and that it was coded as drug/item unavailable. Per LPN-T they worked [PHONE NUMBER] AM yesterday, then left. LPN-T does not remember this medication. On 03/04/25, at 01:38 PM, Surveyor interviewed LPN-Q who gave the once-one time dose of Amantadine HCl on 3/3/25. LPN-Q stated they had to call the pharmacy and ask them to resend the order so could be given. No further information was provided as to why the Facility did not ensure that R13 was free from this significant medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. R13 is coded as making self understood and understands others. Surveyor reviewed R13's electronic medical record which indicated R13 was transferred to the hospital emergency room for leaking nephrostomy tubes and urine with foul odor on 2/14/2025. Surveyor requested evidence from the Facility that a transfer notice was provided to R13 and to R13's responsible party when R13 went to the hospital. Surveyor was given a form Bed Hold Consent Form/Policy dated 11/19/24 that R13 had signed and checked the box indicating Accept Bed Hold. On 02/27/25, at 02:47 PM, Surveyor interviewed Director of Nursing (DON)-B and was told that November 19th was the last admission for R13 and the form given to Surveyor was is all they have. On 02/27/25, at 03:08 PM, during the end of day meeting with the DON-B, Assistant Nursing Home Administrator-D and the Nursing Home Administrator-A Surveyor again requested Facility look for paperwork that was given to R13 on 2/16/25 at the time of transfer to hospital. On 03/03/25, at 09:45 AM, Surveyor interviewed Social Worker (SW)-S and was told transfer notices are done by nursing staff. On 03/04/25, at 07:56 AM, DON-B told Surveyor that they do not have any paperwork provided at the time of transfer. 4.) Surveyor requested paperwork to document that discharge information was being sent to the Ombudsman on a monthly basis. On 03/03/25, at 09:05 AM, Nursing Home Administrator (NHA)-A brought the emails sent to the Ombudsman indicating who was discharged . December and January discharged resident information was sent together in an email dated February 20th, 2025. Per NHA-A the Social Worker was out sick a couple weeks so things got delayed. February discharge information was sent in an email on 3/3/25 during the survey. On 03/03/25, at 09:45 AM, Surveyor interviewed Social Worker (SW)-S and asked why December and January discharge information was not sent to the Ombudsman until 2/20/2025. SW-S knows it should be done the 1st of a new month it was their error, it was a busy time. No further information was provided regarding discharge information being sent to the ombudsman in a timely manner monthly. Based Interview and record review, the facility did not provide transfer notices to 3 (R5, R47, R13) of 4 residents reviewed for discharge. The facility did not provide transfer notice information to the Ombudsman on a consistent basis. *R5 was hospitalized on [DATE] and did not receive a transfer notice. *R47 was hospitalized on [DATE], 12/24/24 and 1/19/25. R47 did not receive a transfer notice for all 3 hospitalizations. * R13 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information including appeal rights. * Monthly discharge summaries were not sent to the Ombudsman in a timely manner for the months of December and January. Finding include: 1.) R5 was admitted to the facility on [DATE]. On 1/24/25, R5 was transferred to the hospital due to a change of condition. R5 was readmitted to the facility on [DATE]. On 2/27/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R5's transfer notice was not found in R5's medical record. Surveyor requested a copy of R5's transfer notice for 1/24/25. On 3/4/2025 at 8:00 AM, DON-B told Surveyor that R5 did not have any transfer notices for the requested dates. No additional information was supplied by the facility at this time. 2.) R47 was admitted to the facility on [DATE]. On 10/30/2024, R47 was transferred to the hospital due to x-ray and lab results that had been ordered by R47's physician. R47 was readmitted to the facility on [DATE]. On 12/24/2024, R47 was transferred to the hospital with hypoglycemia, anemia, and COVID-19. R47 was readmitted to the facility on [DATE]. On 1/9/2025, R47 was transferred to the hospital due to proctitis. R47 was readmitted to the facility on [DATE]. On 1/19/2025, R47 was transferred to the hospital due to a gastrointestinal bleed. R47 was readmitted to the facility on [DATE]. No documentation was found in R47's medical record that a transfer notice was provided to R47 or R47's representative. On 2/27/2025 at 3:01 PM and on 3/3/025 at 8:47 AM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R47's transfer notices were not found in R47's medical record. Surveyor requested a copy of R47's transfer notices for 10/30/2024, 12/24/2024, 1/9/2025, and 1/19/2025. Surveyor asked DON-B if the transfer notices should be in R47's medical record. DON-B stated they should be. Surveyor requested a copy of R47's transfer notices for 10/30/2024, 12/24/2024, 1/9/2025, and 1/19/2025. On 3/4/2025 at 8:05 AM, DON-B stated R47 did not have any transfer notices for the dates requested. DON-B stated there were not any transfer notices scanned into R47's medical record and they were not able to find any that had not been scanned in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that 5 out of 5 residents (R44, R26, R16, R34 and R5) drug regimen was free from unnecessary medications. R44, R26, R16, R34 and R5 received recommendations from the Pharmacy Consultant via the monthly review and the facility did not address the recommendations by having the physician review and sign acknowledge of receiving the recommendations and if they accept or want to modify the recommendation for each individual resident. Findings include: Policy review: Medication Regimen Reviews , revised 5/2019 Policy statement: The consultant pharmacist reviews the medications regimen of each resident at least monthly. Policy Interpretation and Implementation: 8.) Within 24 hours of the MRR (medication regimen review), the consultant pharmacist provides a written report to the attending physicians for each resident identified as having non-life-threatening medication irregularity. The report contains the resident's name, the name of the medication, the identified irregularity and the pharmacist's recommendation. 11.) If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12.) The attending physician documents in the medical record that the irregularity has been reviewed an what (if any) action was taken to address it. 14.) The consultant pharmacist provides the director of nursing services and medical director with a written, signed copy of all medication regimen reports. 15.) Copies of the medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 1. ) R44 was originally admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, and depression. Surveyor conducted a review of the monthly pharmacy consultant reviews and noted the following: On 11/27/2024 at 10:54 a.m., med review complete; see report. On 12/28/2024 at 08:56 a.m. med review complete; see report. On 01/24/2025 at 10:33 a.m., med review complete; see report. On 03/03/25 at 08:31 a.m., DON- B stated that she will need to print the pharmacy recommendations but she does not have any of them signed off or notations if they followed up on them. On 03/03/25 09:05 a.m., Surveyor was provided with the pharmacy consultation report/ recommendations for R44, dated 11/27/24, and 12/28/24 These reports had to be downloaded and printed prior to being available for review and were not part of R44's medical record. The 11/27/24 pharmacy consultation report indicated that R44's PRN (as needed) order for Desitin paste has not been used within the previous 60 days. Recommendation is to consider discontinuing due to lack of use. The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response. The 12/28/24 pharmacy consultation report states that R44 receives 2 or more medications known to prolong the QT interval (length of time it takes for the ventricles of the heart to depolarize & repolarize as measured on an electrocardiogram): Ondansetron ODT (Zofran-anti-nausea), Escitalopram Oxalate (Lexapro), quetiapine (Seroquel). Recommendation to reevaluate continued use of these medications and consider decreasing dose of the escitalopram from 20 mg each day to 10 mg each day. The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response. On 03/04/25 at 08:00 AM Surveyor interviewed DON (Director of Nursing)-B who stated that the facility did not respond to the pharmacy recommendations for R44 for those dates. DON- B stated that there was a break in the system and not all of the communication was made to the physician. 2.) R26 was originally admitted to the facility on [DATE] with diagnoses that included adjustment disorder with mixed anxiety and depressed mood. Surveyor conducted a review of the monthly pharmacy consultation reports and noted the following: On 10/26/2024 at 01:20 p.m., med review complete; see report. On 12/28/2024 at 09:23 a.m., med review complete; see report. On 03/03/25 at 08:31 a.m., DON- B stated that she will need to print the pharmacy recommendations but she does not have any of them signed off or notations if they followed up on them. On 03/03/25 09:05 a.m., Surveyor was provided with the pharmacy consultation report/ recommendations for R26, dated 10/26/24 and 12/28/24. These reports had to be downloaded and printed prior to being available for review and were not part of R26's medical record. The 10/26/24 pharmacy consultation report documented that R26 receives a medication containing an inhaled corticosteroid, Wixela Inhub. The recommendation is to reduce the risk of thrush, please update the order to include the directions: Rinse mouth with water after use. Do not swallow. The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response. On 12/28/24, the same recommendation was made as on 10/26/24. R26 receives a medication containing an inhaled corticosteroid, Wixela Inhub. Recommendation to reduce the risk of thrush, please update the order to include the directions: Rinse mouth with water after use. Do not swallow. The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response. On 3/4/25 at 10:30 a.m., Administrator-A confirmed that there is no behavior monitoring for R26. In addition, there has been no follow-up on the pharmacy recommendations. Administrator- A stated that they are going to start having behavior meetings to discuss these types of issues. 3.) R16 was originally admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety. Surveyor conducted a review of the monthly pharmacy consultation reports and noted the following: On 11/29/2024 at 12:28 p.m., med review complete; see report. On 01/26/2025 at 03:35 p.m., med review complete; see report. On 03/03/25 at 08:31 a.m., DON- B stated that she will need to print the pharmacy recommendations but she does not have any of them signed off or notations if they followed up on them. On 03/03/25 09:05 a.m., Surveyor was provided with the pharmacy consultation report/ recommendations for R16, dated 11/29/24 and 1/26/25. These reports had to be downloaded and printed prior to being available for review and were not part of R16's medical record. The 11/29/24 pharmacy consultation/ report documented that R16's PRN (as ordered) orders below have not been used within the previous 60 days- miconazole powder. Recommendation: Please consider discontinuing due to lack of use. The facility was unable to provided evidence that they followed-up on this recommendation by obtaining the Physician's response. The 1/26/25 pharmacy consultation/ report; (R16) receives two antiplatelets, Aspirin low dose and Plavix and does not have a CBC (complete blood count) documented in the medical record within the previous 6 months. Recommendation: Please monitor a CBC on the next convenient lab day and every 6 months thereafter. Consider fecal occult blood tests if clinically indicated. Ongoing surveillance for bleeding is recommended. The facility was unable to provided evidence that they followed-up on this recommendation by obtaining the Physician's response. Further review of R16's electronic record did not show an order for CBC drawn following the 1/26/25 recommendation. On 03/04/25 at 08:00 AM Surveyor interviewed DON (Director of Nursing)- B who stated that the facility did not respond to the pharmacy recommendations for R16 for those dates. DON- B stated that there was a break in the system and not all of the communication was made to the physician. 4.) R34 was admitted to the facility on [DATE]. R34's current diagnoses include Atrial Fibrillation, Cerebral Infarction and Hyperlipidemia. R34's Quarterly MDS (Minimum Data Set) Assessment with ARD (Assessment Reference Date) of 2/17/25 indicates that R34 is receiving a Antidepressant and Anticoagulant medication. Surveyor reviewed R34's electronic medical record including physician orders, and comprehensive care plans. An anticoagulant care plan with an initiation date of 8/6/24 documents: (R34) is at risk for bleeding and bruising d/t (due to) use of Eliquis (an anticoagulant medication). The following interventions are documented: Administer anticoagulants as ordered by MD .Monitor for bruising .monitor lab work as ordered by MD .Observe for signs of active bleeding. A psychosocial care plan with an initiation date of 8/6/24 documents: (R34) receives Fluoxetine (an antidepressant medication) d/t depression. The following interventions are documented: Assess/record effectiveness of drug treatment, Monitor (R34's) mood and response to medication, Pharmacy consultant review. Surveyor could not identify monitoring for R34's anticoagulant or antidepressant medications in R34's medical record. On 2/27/25 at 2:47 PM, Surveyor requested R34's monthly pharmacy reviews from Director of Nursing (DON)-B. DON-B told Surveyor that they do not have resident's pharmacy recommendations available at the facility and have requested additional documentation from the pharmacy. DON-B told Surveyor that they are unable to verify if R34's pharmacy recommendations have been followed up upon. On 3/3/25 at 3:24 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that R34 does not have any documented evidence of monitoring for anticoagulant medication, antidepressant medication and no evidence of monthly pharmacy reviews. No additional information was given by the facility at this time. 5.) R5 was admitted to the facility on [DATE]. R5's diagnoses include aphasia, diabetes mellitus and traumatic brain injury. On 2/27/25 at 2:47 PM, Surveyor requested R5's monthly pharmacy reviews from Director of Nursing (DON)-B. DON-B told Surveyor that they do not have resident's pharmacy recommendations available at the facility and have requested additional documentation from the pharmacy. DON-B told Surveyor that they are unable to verify if R5's pharmacy recommendations have been followed up upon. On 3/3/25 at 3:24 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that R5 does not have any documented evidence of monthly pharmacy reviews. No additional information was given by the facility at this time.

Based on observation and interview, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect a pattern of the facility 53 residents who receive food served in the facility common dining room. * A dietary staff member was observed taking temperatures and serving food in the common dining room for breakfast service on 3/3/25 and not wearing a hair net. * Food temperatures were not obtained prior to providing breakfast service on 3/3/25 and throughout breakfast serving times, in the common dining room. Findings include: The facility Policy and Procedure titled, Food Preparation and Service with no date, documents: Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Food Distribution and Service: 2. The temperature of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. 8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. On 3/3/25, at 8:08 AM, Surveyor entered the common dining room and reviewed the clip board containing food temperature logs, hanging on the wall next to the warming station. Surveyor notes food temperature entries on 3/1/25 and 3/2/25 with no missed entries or concerns with temperatures. Surveyor notes there are not food temperatures noted for breakfast on 3/3/25 and residents currently eating breakfast in the common dining room. Surveyor observed Dietary Aide-H enter the common dining room with her hair loosely pulled back with a hair tie and no hair net on. Surveyor observed Dietary Aide-H serve food from the warming trays to a resident in the common dining room without a hair net on. Dietary Aide-H returned to the warming tray station and Surveyor asked if staff record food temperatures. Dietary Aide-H responded yes and directed Surveyor to the food temperature clip board hanging on the wall. Surveyor noted to Dietary Aide-H there were no temperatures recorded for breakfast today on 3/3/25. Dietary Aide-H then grabbed the thermometer and proceeded to temp the food in the warming trays. Surveyor asked Dietary Aide-H if food temperatures should be tested prior to serving food and Dietary Aide-H responded, yes. On 3/3/25, at 8:43 AM, Surveyor observed Dietary Aide-H with hair loosely pulled back in a hair tie and a hair net on. Dietary Aide-H was observed in the common dining room assisting residents with food and requests. On 3/3/25, at 9:16 AM, Surveyor interviewed Dietary Aide-H who states she is supposed to wear a hair net at all times while serving food and throughout the common dining room while serving food. Surveyor noted to Dietary Aide-H she was not wearing a hair net when temping food and serving residents food from the warming trays earlier at breakfast. Dietary Aide-H states she was returning from using the restroom and was caught off guard which is why she didn't have a hair net on. Surveyor observed Dietary Aide-H wearing a hair net at the time of the interview. On 3/3/25, at 11:09 AM, Surveyor went back into the common dining room to review the clip board containing food temperatures. Surveyor notes there was one temperature log from 3/3/25 breakfast that was obtained earlier with Dietary Aide-H and Surveyor. No further temperatures for 3/3/25 breakfast were noted. Cook- G walked into the common dining area where Surveyor was reviewing the food temperature log. Surveyor asked Cook- G if he serves food in the common dining room and if temperatures of food are obtained. Cook- G states yes, he serves lunch from the warming trays in the common dining room and food temperatures are to be completed and documented on the clip board, prior to serving food and in the middle of passing lunch. Cook- G pointed to the food temperature log on the clip board and states this is where temperatures are recorded. Surveyor asked Cook- G if he would expect additional entries for 3/3/25 breakfast time and Cook- G indicates yes. On 3/3/25, at 3:05 PM, Surveyor notified Nursing Home Administrator (NHA)- A of concerns listed above. NHA- A acknowledged concerns.

Based on interview and record review, the Facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident potentially affecting 53 of 53 residents in the Facility. * The Facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. Findings include: On 02/27/25, at 10:58 AM, Surveyor reviewed 30 days of nursing staff schedules. Surveyor noted that the Facility's nursing staff schedules did not designate who the charge nurse was for each tour of duty. On 02/27/25, at 01:25 PM, Surveyor interviewed Nursing Scheduler-R regarding how to know who the charge nurse is at any given time. Nursing Scheduler-R replied that during the day the Director of Nursing (DON) or Assistant DON are in the building. On PM shift the Nurse Educator is usually in the building otherwise there is an on-call person listed at the bottom of the schedule page who is reachable by phone. Surveyor then asked who is in the building that is labeled as charge nurse during each shift, the answer was staff know to call the on-call person. On 02/27/25, at 03:08 PM, Surveyor informed the Nursing Home Administrator-A, DON-B and Assistant Nursing Home Administrator-D of the concern related to the Facility's schedules not designating who the Facility charge nurse would be for each shift on the Facility's nursing staff schedules. The Facility did not provide any additional information as to why it did not ensure there was a designated charge nurse for each tour of duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not develop an infection prevention and control program that included preventing, identifying, reporting, and controlling infections and communicable diseases potentially affecting all 53 residents, and providing a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 (R47, R34, R17, and R19) of 12 residents in Enhanced Barrier Precautions (EBP). *Facility outbreaks did not have complete surveillance data on the residents and staff affected. *Monthly infection surveillance data did not have infection rates calculated. *The Water Management Plan did not have a detailed description and diagram of the water system in the facility identifying control measures and how the control measures are monitored. *R47 was in EBP. Observations were made of staff not wearing appropriate Personal Protective Equipment (PPE) when performing cares and wound care. *R34 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care. *R17 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care. *R19 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care. Findings include: The facility policy and procedure titled Surveillance for Infections from MED-PASS © 2001 revised 9/2017 documents: Policy Interpretation and Implementation: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. Gathering Surveillance Data: 1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI committee may be involved in interpretation of the data. 5. In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; for example, focused surveillance data may be gathered for residents with a high risk for infection or those with a recent hospital stay. Data Collection and Recording: 1. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: a. Identifying information .; b. Diagnoses; c. admission date, date of onset of infection .; d. Infection site .; e. Pathogens; f. Invasive procedures or risk factors .; g. Pertinent remarks Also, record if the resident is admitted to the hospital, or expires; and h. Treatment measures and precautions . 4. For targeted surveillance sing facility-created tools, follow these guidelines: a. DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form b. MONTHLY: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (e.g., Line Listing of Infections by Resident or similar form). c. MONTHLY: Summarize monthly data for each nursing unit by site and by pathogen d. MONTHLY/QUARTERLY: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends . e. MONTHLY/QUARTERLY: Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period (for example, over the past 12 months) as the baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates. Calculating Infection Rates: 1. Obtain the month's total resident days from the business office. The following data is used as the denominator to calculate the monthly infection rate: a. Total resident days (daily census of each day in the designated time period added together). 2. To determine the incidence of infection per 1000 resident days, divide the number of new healthcare associated infections for the month by the total resident days for the month (obtained from the business office) X 1000. Interpreting Surveillance Data: 1. Analyze the data to identify trends. a. Compare the rates to previous months in the current year and to the same month in previous years, to identify seasonal trends. b. Consider how increases or decreases might relate to recent process changes, events, or activities in the facility 2. Surveillance data will be provided to the infection control committee regularly. 3. The infection control committee will determine how important surveillance data will be communicated to the physicians and other providers, the administrator, nursing units, and the local and state health departments. The facility policy and procedure titled Enhanced Barrier Precautions from MED-PASS © 2001 revised 8/2022 documents: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bating/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 1.) On 2/26/2025 at 8:00 AM, Surveyor entered the facility and observed a sign on the front door stating the facility was in a COVID-19 outbreak and anyone entering the facility needed to wear a mask. Surveyor asked for a list of residents in COVID-19 isolation and was told by facility staff that no residents currently have any positive COVID-19 tests, and the facility staff and visitors are wearing masks for the ten days beyond the last symptom to prevent future spread of COVID-19. On 2/26/2025 at 3:00 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (Don)-B all outbreak summaries and line lists since the last recertification survey. DON-B stated Assistant DON (ADON)-F is the facility infection preventionist and would provide that information to Surveyor. On 2/27/2025, ADON-F provided Surveyor with two COVID-19 outbreak packets consisting of resident and staff line lists and a summary of the outbreak, two respiratory line lists, and two gastrointestinal line lists. Surveyor noted the gastrointestinal line lists each had one resident listed and therefore did not meet the definition of an outbreak. Surveyor noted the respiratory line list that had current dates of infection was an Influenza outbreak and not a COVID-19 outbreak as was documented on the sign at the facility entrance. Surveyor reviewed the outbreak packet for COVID-19 that started on 10/26/2024 when a staff member tested positive. Another staff member and one resident tested positive on 10/28/2024. Per the line lists, 7 staff members tested positive and 17 residents tested positive totaling 24 individuals being affected by COVID-19. The last positive collected sample was on 11/4/2024. The summary of the outbreak documented the outbreak began on 10/29/2024 with a total of 20 residents and 7 staff members testing positive. Surveyor noted the number of residents on the summary did not match the number of affected residents on the line list. Surveyor reviewed the outbreak packet for COVID-19 that started on 12/4/2024 when three staff members tested positive. Two staff members tested positive on 12/5/2024. A resident tested positive on 12/18/204, thirteen days after the last staff member tested positive. The outbreak should have been concluded on 12/15/2024, ten days after the last staff member tested positive. 1/6/2025-1/22/2025 had two staff members and eight residents positive. The Outbreak Summary Report documented 17 individuals were affected in the outbreak with testing of residents and staff from 12/4/2024-1/6/2025 with the outbreak conclusion being 1/6/2025. The conclusion date does not match the last resident testing positive on 1/22/2025. On 3/3/2025 at 11:14 AM, Surveyor met with DON-B and ADON-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor shared with ADON-F the concern the outbreak summaries did not match the information on the line lists. ADON-F agreed. 2.) Surveyor reviewed ADON-F's IP binder for the previous months infection surveillance logs listing the residents and infective processes including the use of antibiotics. The monthly sections included line lists and plot maps of the facility. In an interview on 3/3/2025 at 11:14 AM, Surveyor asked ADON-F if monthly rates of infection were calculated. ADON-F stated no. Surveyor asked ADON-F what information was brought to Quality Assessment and Assurance (QAA) meetings for the infection prevention program. ADON-F stated ADON-F brings the binders with the line lists to QAA. Surveyor shared the concern trends in infection could not be determined if rates of infection were not calculated monthly to compare to previous months/years. ADON-F agreed. On 3/3/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern rates of infection were not calculated per infection monthly. DON-B agreed the rates should be calculated. 3.) On 3/3/2025 at 11:14 AM, Surveyor asked ADON-F if ADON-F is part of the Water Management Plan (WMP). ADON-F stated Maintenance Director (MainDir)-L is in charge of the WMP and would have any information Surveyor needed. Surveyor requested ADON-F contact MainDir-L to provide the WMP to Surveyor for review. The facility policy and procedure titled Legionella Water Management Program from MED-PASS © 2001 revised 7/2017 documents: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program. 5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (1) storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP machines, hydrotherapy equipment; etc. d. The identification of situations that can lead to Legionella growth, such as: (1) Construction; (2) Water main breaks; (3) Changes in municipal water quality; (4) The presence of biofilm, scale or sediment; (5) Water temperature fluctuations; (6) Water pressure changes; (7) Water stagnation and; (8) Inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. 6. The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: a. The control limits are consistently not met; b. There is a major maintenance or water service change; c. There are any disease cases associated with the water system; or d. There are changes in laws, regulations, standards or guidelines. On 3/3/2025 at 11:36 AM, MainDir-L provided to Surveyor the facility Legionella Water Management Program policy and procedure. Surveyor asked MainDir-L for the WMP, which should include diagrams of the water system, control measures, and logs of flushes. MainDir-L stated MainDir-L thought Surveyor just wanted the policy for the WMP. MainDir-L stated MainDir-L would get more information for Surveyor. On 3/3/2025 at 1:34 PM, MainDir-L provided to Surveyor a second copy of the facility Legionella Water Management Program policy and procedure, a checklist for developing a legionella water management program that was not dated, a facility policy and procedure titled Legionella Water Management dated 1/10/2024, and a hand-drawn diagram of the facility with no control measures designated. -The facility policy and procedure titled Legionella Water Management dated 1/10/2024 documented: I. OBJECTIVE: The purpose of this policy is to reduce the risk associated with the control of Legionella to the lowest practical level. II. DEFINITION: Legionella-the bacterium that causes legionnaires' disease, flourishing in air conditioning and central heating systems. III. POLICY: The Legionella Team consisting of the Administrator, Director of Nursing, Maintenance Director, Dietary Manager and Housekeeping Supervisor are to achieve by improving the standard of existing water, implementing safe operational procedures, and ensuring that the design and installation of all new systems conform to the current standards. IV. PROCEDURES: A. NURSING 1. Make sure medical devices such as CPAP and BIPAP machines are cleaned and sanitized on a daily basis. B. HOUSEKEEPING 1. DAILY TASKS: a. Clean and sanitize all showerheads for a minimum of 3 minutes. b. Clean and sanitize all facets [sic] regardless of use. 2. WEEKLY TASKS a. Run water through every showerhead for a minimum of 3 minutes. b. Run water through every facet [sic] for a minimum of 3 minutes. C. DIETARY 1. Clean/drain and sanitize all steam tables daily. 2. Monitor ice machine filters and notify Maintenance when the filter needs to be replaced. 3. Check water temperatures and chemical dispensers on Dishwasher daily. 4. Notify vendor of and repairs. [sic] D. MAINTENANCE 1. Insure [sic] the water heaters are running within the required WI State code guidelines. 2. Flush when required. Surveyor noted the policy did not include the infection preventionist as part of the team and no documentation showed the appropriate time to flush shower heads and faucets to be 3 minutes. Surveyor reviewed with MainDir-L the facility Legionella Water Management Program policy and procedure. Surveyor asked MainDir-L if there was a more detailed drawing or description of the water system showing where control measures were in the building. Surveyor went through each item listed in 5. The water management program includes the following elements: to clarify with MainDir-L what information Surveyor needed to see to assess the facility WMP that was in place. MainDir-L stated the information provided to Surveyor, the policies, the checklist, and the hand-drawn diagram, was the information provided to MainDir-L by the previous maintenance director. MainDir-L stated MainDir-L would get logs that have been completed by kitchen and housekeeping. In an interview on 3/3/2025 at 1:47 PM, Surveyor asked Nursing Home Administrator (NHA)-A who was part of the Water Management team. NHA-A stated the Regional Maintenance Director, MainDir-L, and ADON-F. Surveyor asked NHA-A if NHA-A was part of the team. NHA-A stated no. Surveyor shared the concern with NHA-A that NHA-A should be part of the team per their policy, and the information provided by MainDir-L was not complete or thorough. On 3/3/2025 at 1:52 PM, MainDir-L provided logs that showed six rooms a week were tested for water temperature coming out of the faucets. Surveyor noted the temperatures logged ranged from 94 degrees to 112 degrees. The Centers for Disease Control and Prevention (CDC) guidelines document Legionella grows best between 77-113 degrees; hot water should be stored at temperatures above 140 degrees and hot water in circulation should not fall below 120 degrees. MainDir-L provided logs from the kitchen that documented daily draining and sanitizing steam tables. Surveyor noted not all the boxes had been filled in indicating the task had been completed. In an interview on 3/4/2025 at 8:04 AM, Surveyor asked NHA-A to explain the water temp logs for resident rooms. NHA-A stated temperatures are gotten from six different rooms every week and the rooms are listed on the logs. Surveyor noted it takes about one and a half months to get the temperatures of every room in the facility. Surveyor shared with NHA-A the concern the temperatures taken in resident rooms were below the recommended 120 degrees by the CDC. Surveyor asked NHA-A if they had a policy to show what temperature should be reached and if there was a measure in place to follow if the temperatures were not at the level indicated. NHA-A provided a facility policy and procedure titled Water Temperatures, Safety of dated MED-PASS © 2001 revised 12/2009 that documented: 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 115 degrees F. Surveyor noted 115 degrees was hand-written in the policy where a blank had been left. On 3/4/2025 at 10:57 AM, Surveyor measured the temperature of the water coming out of the faucet in room [ROOM NUMBER]. The temperature measured 124 degrees. On 3/4/2025 at 3:32 PM, Surveyor shared with NHA-A and DON-B the concern staff measuring the temperature of the running water did not keep the thermometer in the water for a long enough period of time to come up with an accurate measurement. Surveyor shared the observation of the temperature of the water coming from the faucet in room [ROOM NUMBER]. Surveyor shared the concern NHA-A was not a member of the WMP team and the WMP did not have a detailed description and diagram of the water system in the facility identifying control measures and how the control measures are monitored. 4.) R47 was admitted to the facility on [DATE] and was in EBP due to wounds to the right heel, right lateral foot, and coccyx. On 2/27/2025 at 11:14 AM, Surveyor was with Registered Nurse (RN)-M who was preparing to provide wound care to R47. A sign was observed outside of R47's room indicating R47 was in EBP. RN-M knocked on R47's door prior to entering and told R47 RN-M was there to do wound care. RN-M did not put on a gown prior to entering R47's room. RN-M brought the treatment cart into R47's room rather than leaving it in the hallway and bringing in only the treatment items needed to provide wound care. R47 informed RN-M that R47 had a bowel movement and needed to be cleaned up. RN-M told R47 RN-M would return after R47 had been cleaned. RN-M pushed the treatment cart back into the hallway. Surveyor observed Certified Nursing Assistant (CNA)-K enter R47's room to provide incontinence care. CNA-K did not put on a gown prior to entering the room. CNA-K came out of R47's room with a bag of garbage which CNA-K deposited into a garbage container in the hallway. Surveyor asked RN-M if gowns should be worn in resident rooms when wound care is performed. RN-M stated yes. Surveyor asked RN-M if RN-M should have put on a gown to provide wound care to R47. RN-M stated yes. In an interview on 2/27/2025 at 11:27 AM, Surveyor asked CNA-K if any special PPE needed to be put on when doing incontinence care for R47. CNA-K stated CNA-K did not think any PPE needed to be worn when caring for R47, but maybe for R47's roommate. CNA-K looked at the sign posted on R47's door and stated R47 was in EBP and next time, CNA-K will wear a gown to do cares with R47. On 2/27/2025 at 11:28 AM, Surveyor observed RN-M put on a gown prior to entering R47's room. RN-M pushed the treatment cart into R47's room. R47 asked RN-M why RN-M was wearing a gown since RN-M had never had a gown on to do wound care before. On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern CNA-K did not wear a gown when performing cares on R47 and RN-M put on a gown after a discussion was had regarding R47 being in EBP. Surveyor shared the concern RN-M brought the treatment cart into the room when providing wound care. 5.) R34 was admitted to the facility on [DATE] and was in EBP due to a wound to the right heel. On 2/27/2025 at 10:39 AM, Surveyor was with RN-M who was preparing to provide wound care to R34. A sign was observed outside of R34's room indicating R34 was in EBP. RN-M knocked on R34's door and entered the room pushing the treatment cart into R34's room. RN-M did not put on a gown prior to providing wound care to R34's right heel. After RN-M completed the wound treatment and pushed the cart into the hallway, Surveyor asked RN-M if RN-M should have worn PPE when doing R34's wound treatment. RN-M stated yes. On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern RN-M did not wear a gown when performing wound care on R34 and the concern RN-M brought the treatment cart into the room when providing wound care. 6.) R17 was admitted to the facility on [DATE] and was in EBP due to wounds to the left and right buttocks. On 2/27/2025 at 10:57 AM, Surveyor was with RN-M who was preparing to provide wound care to R17. A sign was observed outside of R17's room indicating R17 was in EBP. CNA-O accompanied RN-M to help position R17 during wound care. RN-M and CNA-O did not put on a gown prior to entering the room to provide wound care. RN-M pushed the treatment cart into R17's room. When RN-M completed R17's wound treatments, RN-M pushed the cart out of R17's room and CNA-O followed. Surveyor asked CNA-O when a resident is in EBP, what PPE should be worn. CNA-O stated they should wear a gown. CNA-O showed Surveyor the bin outside of R17's room that had PPE in the drawers. Surveyor asked CNA-O what would cause a resident to be in EBP. CNA-O stated if a resident has a wound or a catheter, then they are in EBP. Surveyor asked CNA-O if R17 was in EBP. CNA-O stated CNA-O did not know if R17 was on precautions or not so did not wear a gown. On 2/27/2025 at 11:14 AM, Surveyor asked RN-M if gowns should be worn in resident rooms when wound care is performed. RN-M stated yes. Surveyor asked RN-M if RN-M should have put on a gown to provide wound care to R17. RN-M stated yes. On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern RN-M and CNA-O did not wear a gown when performing wound care on R17 and the concern RN-M brought the treatment cart into the room when providing wound care. 7.) R19 was admitted to the facility on [DATE] and was in EBP due to a heel wound. On 2/27/2025 at 10:29 AM, Surveyor was with RN-M who was preparing to provide wound care to R19. A sign observed outside of R19's room door indicated R19 was in EBP. RN-M knocked on R19's door and entered the room pushing the treatment cart into R19's room. RN-M did not don a gown prior to providing wound care to R19's heel wound. After RN-M completed the wound treatment RN-M pushed the cart back into the hallway, On 2/27/2025 at 3:10 PM, Surveyor shared with NHA-A and DON-B the concern that RN-M did not don a gown prior to performing R19's wound care. Surveyor shared the concern RN-M brought the treatment cart into the room when providing wound care for R19 who is in EBP. No additional information was supplied by the facility at this time.

Based on interview and record review, the facility did not ensure they implemented their antibiotic stewardship program potentially affecting all 53 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics indicated antibiotic use without documentation of appropriate use of the antibiotic. Findings include: The facility policy and procedure titled Surveillance for Infections from MED-PASS © 2001 revised 9/2017 documents: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. On 3/3/2025 at 11:14 AM, Surveyor met with Assistant Director of Nursing (ADON)-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor reviewed ADON-F's IP binder for the previous months infection surveillance logs listing the residents and infective processes including the use of antibiotics. Surveyor asked ADON-F what standard of practice for antibiotic stewardship was used. ADON-F stated they use McGeer, and they are trying to get it in place more frequently. (The McGeer criteria are a set of clinical guidelines used for infection surveillance in long-term care facilities, focusing on identifying potential infections and guiding antibiotic stewardship.) Surveyor asked ADON-F what was meant by that. ADON-F stated they are trying to complete the McGeer form for each resident on an antibiotic and then scanning it into the resident record. Surveyor asked ADON-F if each resident has had a McGeer form completed prior to the use of an antibiotic. ADON-F stated that was their goal, but that had not been done for everyone at that time. Surveyor reviewed the monthly line lists for 1/2025, 2/2025, and 3/2025. 1/2025 had 36 resident entries on the line list, 2/2025 had 29 resident entries on the line list, and 3/2025 had 24 resident entries on the line list. Examples from the line list review: -R1 was diagnosed with a urinary tract infection on 3/1/2025 with a culture taken on 3/1/2025; the antibiotic Macrobid was started on 3/2/2025. No documentation was found of a McGeer criteria review being completed prior to the use of the antibiotic. -R151 was diagnosed with a urinary tract infection on 2/17/2025 with a culture taken on 2/17/2025; the antibiotic ciprofloxacin was started on 2/23/2025. On 2/22/2025 at 9:52 AM in the progress notes, nursing documented a call was received from R151's physician regarding the urine culture results and to stop Keflex immediately and start ciprofloxacin. Surveyor noted R151 had not received Keflex, and no documentation was found of a McGeer criteria review being completed prior to the use of any antibiotic. On 3/4/2025 at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern residents are put on antibiotics without documentation that the use of the antibiotic meets the McGeer criteria. Antibiotic stewardship relies on the use of a standard of practice to prevent unnecessary antibiotic usage. Surveyor shared with NHA-A and DON-B resident records were reviewed and no documentation was found in the medical record of the McGeer criteria checklist being completed prior to the use of antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not allow the resident representative the right to exercise their rights as delegated to the representative for 1 (R7) of 2 residents reviewed with an activated power of attorney. R7's power of attorney was not present for the admission of R7 into the facility and did not sign any admission consents or contracts. R7 had been deemed incapacitated by a physician and a psychologist prior to admission. R7 signed all admission consents and contracts while assessed to be incapacitated. Findings include: The facility policy and procedure titled Resident Representative and revised 2/2021 documents: The facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or to the extent required by the court, in accordance with applicable law. Policy Interpretation and Implementation . 2. If the resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction, the rights of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident's behalf. a. The court-appointed resident representative will exercise the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with state law. b. In the case of a resident representative whose decision-making authority is limited by state law or court appointment, the resident retains the right to make those decisions outside the representative's authority. c. The resident's wishes and preferences are considered in the exercise of rights by the representative. d. To the extent practicable, the resident is provided with opportunities to participate in the care planning process. 3. The term resident representative is defined as: . b. A person authorized by state or federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; . 5. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative. a. The facility will treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or authorized by the resident (in accordance with applicable laws). b. If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility will report such concerns when and in the manner required under state law. c. The facility will not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident (in accordance with applicable laws). 6. Documentation designating that the representative has been delegated the necessary authority to exercise the resident's rights for decision-making issues is obtained by the director of nursing or a designee. a. To the degree permitted by state law, the facility staff respects the delegated resident representative's decisions regarding the resident's wishes and preferences so long as the resident representative is acting within the scope of authority contemplated by the agreement authorizing the person to act as the resident's representative. b. Whether or not the resident has been judged incompetent by a court of law, if it is determined that the resident understands the risks, benefits, and alternatives to a proposed health care decision and expresses a preference, the resident's wishes are considered to the degree practicable. 7. The resident may exercise his or her rights not delegated to a resident representative, including the right to revoke a delegation of rights (accept as limited by state law). 8. The director of nursing (or designee) is responsible for making reasonable efforts to obtain updates or changes that are made by the resident, including the resident's revocation of delegated rights, to ensure that the resident's preferences are being upheld. R7 was admitted to the facility on [DATE] with diagnoses of wedge compression fracture of T11-T12 vertebra, cancer of the lung, malnutrition, Parkinsonism, congestive heart failure, atrial fibrillation, emphysema, and peripheral vascular disease. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had a fall prior to admission. The Cognitive Care Area Assessment documented R7 had a current BIMS of 15, an activated Power of Attorney (POA) in place, and had some forgetfulness noted. R7 had completed a POA for Healthcare document on 3/27/2018 designating Family Member (FM)-Z as the primary POA and FM-AA as secondary POA if R7 should become incapacitated. The document was signed by R7, two witnesses, FM-Z as the healthcare agent, and FM-AA as the alternate healthcare agent. R7 was hospitalized from [DATE] to 6/14/2024 with a T12 compression fracture and on 6/11/2024 was found to be incapacitated by a physician and a psychologist therefore activating the POA, and making FM-Z R7's responsible party. The hospital Social Worker documented on 6/12/2024 in a progress note that the activated POA was contacted to discuss discharge arrangements from the hospital. FM-Z returned the call on 6/13/2024 and the Social Worker documented FM-Z was given a list of subacute rehab referrals; FM-Z approved of referrals to the facilities provided. The hospital Discharge summary dated [DATE] documents the physician had an in-depth conversation with FM-Z regarding R7's medications, a final plan about the several medical issues, and the Do Not Resuscitate wishes R7 had expressed with the admitting physician. The Hospital Face Sheet documented FM-Z was the active substitute decision maker. The hospital documentation was provided to the facility prior to and upon R7's discharge from the hospital to the facility. R7's admission Sheet completed by the facility prior to R7 being admitted documented R7 would be admitted on [DATE] and had an activated POA for healthcare. On 6/14/2024 at 12:25 PM, R7's progress notes written by Admissions-R documented R7's POA was activated at the hospital and documented R7's POA as FM-Z. At 8:02 PM in the progress notes, Admissions-R documented Admissions-R sat with R7 and went over the admission packet and paperwork. Admissions-R documented R7 signed: payor source verification, informed consent for telemedicine, Medicare coverage, consent to treat, transportation policy, authorization for disclosure of contact information, influenza vaccine, pneumonia vaccine, TB risk assessment, and Advanced Directives; discharge planning was started. The following forms were signed on 6/14/2024 by R7 and scanned into R7's medical record: -Skilled Nursing Facility Services Agreement -Advanced Directives (for code status) -Resident Social History -Responsible Person Agreement -Resident Rights -Resident Responsibilities -Resident Grievance/Concern Procedures -HIPAA Notice of Privacy Practices -Privacy Act Statement - Health Care Records -TB Skin Test -Consent to Administer Influenza Vaccine -Pneumococcal and Prevnar Vaccine Administration Assessment and Consent Form -Authorization for Disclosure of Contact Information -Consent to Treat -Informed Consent for Your Telemedicine Visit -Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation -Medicare Coverage -Transportation Policy No documentation was found indicating that FM-Z was contacted or provided admission paperwork. FM-Z's signature was not found on any documentation in R7's medical record. On 6/18/2024 at 10:00 AM, in R7's progress notes, Social Worker (SW)-I documented a Care Conference was held with the IDT, R7, and FM-Z. At 11:38 AM in the progress notes, SW-I documented FM-Z sent an email about concern for R7 wanting to go home and FM-Z wanted to meet with SW-I to discuss Assisted Living Facilities (ALFs). SW-I documented R7 was very against going to an ALF and wanted to return home. SW-I documented SW-I informed FM-Z that SW-I was more than happy to speak with FM-Z about this but also informed FM-Z that regardless of if the POA was active or not, they cannot force R7 to go to an ALF. FM-Z was provided with Ombudsman-T's number in case FM-Z had concerns regarding the rights as Active POA. On 6/18/2024 at 2:04 PM in the progress notes, Director of Rehab (DoR)-U documented a care plan meeting was held that day with the IDT, R7 and FM-Z on the phone. Therapy goals were discussed, and discharge planning was completed with R7 reporting that R7's goal was to return home. Home physical therapy (PT), occupational therapy (OT), and Home Health Aide (HHA) was recommended upon discharge. On 6/22/2024 at 2:07 PM in the progress notes, nursing documented FM-BB arrived to take R7 home and was informed R7 was not able to go home because the physician and insurance had not released R7. FM-BB stated FM-BB was going to take R7 home and they could not keep R7 at the facility like a prisoner. Nursing staff explained to FM-BB that FM-Z did not want R7 to leave the facility. FM-Z was contacted via the phone and FM-Z talked to R7 to explain the situation to R7. FM-BB had removed some of R7's belongings and put them in the car. The police were notified and spoke to FM-BB who then brought back R7's belongings. On 6/23/2024 at 3:21 AM in the progress notes, nursing documented at approximately 10:00 PM on 6/22/2024, R7 came out of the room fully dressed with a walker and a suitcase. R7 stated FM-BB was going to pick R7 up and R7 wanted to wait. Nursing documented nursing explained that FM-Z would not allow that to happen and reminded R7 of the incident that happened earlier that day. R7 went to sit on the couch in front of the TV and then went back to R7's room to watch TV. Frequent checks were made for safety and to decrease the risk of elopement. No other situations occurred throughout the night. Safety measures were in place and the call light was within reach. On 6/24/2024 at 2:57 PM in the progress notes, SW-I documented SW-I had a long conversation with R7 about R7's wants. R7 did not want to go to an ALF while FM-Z was insisting R7 had to. R7 stated R7 barely had any contact with FM-Z and FM-AA until R7's POA was activated. R7 stated FM-Z wants R7 to go into an ALF so FM-Z can live in R7's house rent free. R7 could not recall when FM-Z was picked to be R7's POA and does not want FM-Z to be the POA. SW-I documented SW-I had spoken to Ombudsman-T about this and Ombudsman-T told SW-I that R7 had the right to revoke the POA whether R7 was activated or not. R7 felt FM-Z was abusing their POA power and would like FM-BB to be the POA since FM-BB might start living with R7 as R7's caretaker. On 6/24/2024, R7 signed a Revocation of Power of Attorney for Health Care form removing both FM-Z as the primary POA and FM-AA as alternate POA. R7 no longer had a designated decision maker. On 6/25/2024 at 10:09 AM in the progress notes, SW-I documented SW-I spoke with an APS SW about R7. Per the APS SW, APS had been working with FM-Z for years to have R7's Primary Care Physician (PCP)-X sign to make R7 incapacitated but PCP-X would not sign it and now R7's POA had been activated in the hospital. SW-I documented the APS SW seemed very biased towards FM-Z and made it known that SW-I should have been in full contact with FM-Z regardless of what R7 wanted. R7 wanted to go home and made allegations that FM-Z was wanting to live in R7's house rent free and had been stealing money out of R7's account. SW-I documented the APS SW said that SW-I revoked the POA and R7 is activated so R7 cannot sign a different POA document and the facility must file for guardianship. SW-I documented SW-I needed clarification on this as Ombudsman-T made it sound like R7 could still sign a new POA document if two witnesses were present. SW-I documented R7 was very distraught by this whole process and said R7 needed someone to advocate for R7 and be on R7's side as R7's family was always making decisions about R7 that R7 does not want. SW-I documented the APS SW claimed that the house was in R7's name and that FM-BB stands to gain it after R7 passes. R7 does not want to sell the house and per the APS SW, FM-Z and FM-AA are trying to sell it so R7 can go to an ALF. R7 was very against an ALF and wants to go home where R7 is comfortable. The APS SW said that FM-BB was not living with R7 but R7 and FM-BB said that FM-BB was. On 6/25/2024 at 1:59 PM in the progress notes, SW-I documented PCP-X was going to assess R7 the next day. On 6/25/2024 at 3:58 PM in the progress notes, Business Office Manager (BOM)-V documented BOM-V met with R7 to discuss the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). BOM-V documented BOM-V explained R7 was covered through 6/27/2024 and would discharge on [DATE]. R7 said FM-BB would be taking R7 home around 11:00 AM on Friday (6/28/2024). BOM-V documented a voicemail was left for FM-AA as well to inform FM-AA of the insurance update. The NOMNC and SNFABN paperwork was signed by R7 on 6/25/2024. No other family members witnessed or were a part of the conversation regarding the end of coverage. On 6/26/2024 at 11:47 AM in the progress notes, SW-Y documented SW-Y spoke with R7's POA, FM-AA. Surveyor noted R7 did not have a designated POA at this time due to the revocation and FM-AA was revoked as the alternate POA. SW-Y explained to FM-AA that FM-Z was revoked from being the POA which bumped FM-AA up to R7's primary POA. SW-Y documented R7 was to be discharged on Friday. FM-AA stated that FM-AA was not okay with that and R7 needed to be in an ALF or nursing home. SW-Y informed FM-AA that the facility had suggested an ALF several times to R7 and R7 refused. FM-AA then questioned what the point of being a POA was if FM-AA had no say in what goes on with R7's care. SW-Y informed FM-AA that per Ombudsman-T, the state agency for resident rights, R7 gets to make the call of what R7 wants to do and that we cannot deny R7 that right, with or without a POA. SW-Y told FM-AA that R7 would be discharged with home health to make the transition back home a little easier. FM-AA stated FM-AA understood and requested that SW-Y call FM-Z to explain to FM-Z what is going on. SW-Y told FM-AA SW-Y could not do that as FM-Z was no longer R7's POA. FM-AA did not agree with R7's decision to go back home but stated if FM-AA has no say, then it is what it is and that FM-AA would be there on Friday. On 6/26/2024 at 1:00 PM in the progress notes, SW-Z documented FM-BB called and explained that R7 was calling FM-BB saying that R7 can go home on Friday. Since FM-BB was not the POA, FM-BB stated FM-BB would prefer FM-AA, the Active POA, to pick up R7. Surveyor noted R7 did not have a designated POA at this time due to the status of incapacitation. FM-BB stated that FM-BB does not want to be in the middle of R7 and FM-AA. FM-BB stated once R7 returns home, FM-BB would be there to assist R7, such as going to the store, the doctors, etc., however FM-BB does not want to stay there since FM-BB is not the active POA and does not want to get caught up in the mess. SW-Y informed FM-BB that R7 was being taken care of and that R7 would receive the support R7 needs along with receiving home health upon discharge. On 6/26/2024 at 5:22 PM in the progress notes, SW-I documented APS SW-S visited with R7 and then came to speak with SW-I. R7 had revoked both FM-Z and FM-AA as POAs but from the hospital was still deemed incapacitated and does not currently have a decision maker. APS SW-S felt that since both sides of the family were fighting over R7 and R7's house that the best option at that point would be to file for guardianship so the courts could handle the family dynamic and it can be decided/finalized. APS SW-S said SW-I would need a letter from PCP-X stating incapacity. SW-I spoke with PCP-X's nurse who said that PCP-X would like to look over the documents again before writing the letter but will get it to SW-I by Friday. PCP-X's office also noted how R7's family has been fighting over R7 for a while and the family will call PCP-X's office over it. SW-I went to speak with R7 to update R7 and R7 was upset but also said R7 understood what had to happen now. On 6/26/2024 at 5:37 PM in the progress notes, SW-I documented SW-I spoke to FM-AA and FM-BB as per APS SW-S suggested as they would be the candidates for guardianship. SW-I did not document what the conversation entailed. On 6/28/2024, PCP-X faxed a letter to the facility documenting R7 had undergone a psychological evaluation with a Neuropsychologist where R7 was found to have a neurocognitive disorder. PCP-X agreed that R7 was unable to make rational decisions with regard to R7's healthcare or fully understand R7's medical condition and need for care. PCP-X was the third medical professional to deem R7 incapacitated. On 6/28/2024 at 2:26 PM in the progress notes, SW-I documented SW-I spoke to R7 who said R7 had changed their mind and did not want to revoke FM-Z or FM-AA as POAs anymore. R7 said R7 did not have a problem with FM-Z or FM-AA. R7 said R7 was upset with them before but not anymore. Surveyor noted a revoked POA could not be reversed until authorized individuals deemed R7 to have the capacity to make that decision. On 7/8/2024 at 10:00 AM in the progress notes, SW-I documented Assistant Nursing Home Administrator (ANHA)-D and SW-I spoke with Ombudsman-T and Ombudsman-T told the facility that R7 had the right to go home regardless of whether R7 was activated or not for POA. On 7/8/202 at 11:27 AM in the progress notes, SW-I documented Ombudsman-T was contacted and Ombudsman-T said R7 had the right to go home, no one could stop R7 from going home. Ombudsman-T said R7 should be able to sign a new POA as long as the primary doctor PCP-X would write a statement R7 could. PCP-X's office was called who agreed FM-BB should be the POA but would call back after lunch. No further documentation was found regarding PCP-X calling the facility back. The Transition of Care/Discharge Summary for R7 dated 7/10/2024 documented R7 was not resident responsible. No special instructions were documented. No discharge medications were documented. No signatures were found indicating who received the discharge instructions and information. In an interview on 11/5/2024 at 9:57 AM, Surveyor asked Admissions-P what the process was for a newly admitted resident. Admissions-P stated a referral will come from the hospital via fax prior to a resident being admitted and then if they are accepted by the facility, the hospital will fax a discharge summary before the resident arrives. Admissions-P stated the After Visit Summary is brought to the facility by the resident. Admissions-P stated the referral and discharge summary are printed off and put at the nurses' station so the nurses have the information, and an email is sent out to all the departments and the physician to let everyone know of the new admission. Surveyor asked Admissions-P what admission paperwork is presented to the resident and who reviews that paperwork with the resident or resident representative. Admissions-P stated Admissions-P will sit with the resident or POA if the resident is activated or will call the POA if the POA is not present at the time of admission. Admissions-P stated if the POA is not present at the time of admission, Admissions-P will set up a phone call to review the paperwork with the POA and then either email the paperwork to the POA or have them come to the facility to sign the paperwork. Surveyor asked Admissions-P what happens if the POA does not respond. Admissions-P stated that had never happened to Admissions-P so was not sure. Surveyor asked if Admissions-R, who had completed R7's admission, was available. Admissions-P stated Admissions-R no longer worked at the facility. In an interview on 11/5/2024 at 10:10 AM, Surveyor asked SW-I if FM-Z was involved in R7's admission process. Surveyor shared with SW-I the concern the admission paperwork was signed by R7, and no signatures were found by FM-Z. SW-I stated the admission paperwork is done by the Admissions nurse and social services has nothing to do with that. SW-I stated Admissions-R no longer works at the facility. SW-I stated an activated POA would be expected to be involved with the admission process. Surveyor asked SW-I when was the first time SW-I had contact with FM-Z. SW-I stated SW-I called FM-Z on 6/17/2024 to arrange R7's care conference for the next day. SW-I stated FM-Z was involved in the care conference that was held on 6/18/2024 by phone. Surveyor asked SW-I if SW-I knew the circumstances around FM-BB coming to pick up R7 on 6/22/2024. SW-I stated that was on the weekend and R7 was not set to discharge at that time. SW-I stated SW-I was not informed of the situation until a couple hours after it happened. SW-I stated nursing did not know what to do so they called the police; there were no other instances of FM-BB coming to get R7. Surveyor asked SW-I if SW-I could recall the situation with R7 wanting to revoke the activated POA. SW-I stated therapy informed SW-I that R7 did not like FM-Z and when SW-I talked with R7, R7 claimed FM-Z was stealing money from R7. SW-I stated SW-I contacted APS to investigate that claim. SW-I stated R7 told SW-I that R7 had not seen FM-Z for five years. SW-I stated APS SW-S talked to R7 and in that conversation, R7 told APS SW-S R7 was fine with going to an ALF, but when R7 talked to SW-I, R7 did not want to go to an ALF. SW-I stated SW-I called Ombudsman-T to get clarification of what R7 could and could not do as R7 had an activated POA. SW-I stated Ombudsman-T informed SW-I that R7 could not be kept at the facility against R7's will and R7, even though was deemed incapacitated, still had the right to be discharged . SW-I stated SW-I had multiple conversations with R7 and Ombudsman-T. SW-I stated R7 was against what FM-Z wanted and SW-I explained to R7 what it meant to revoke the POA. SW-I stated R7 felt R7's rights were being taken away. Surveyor asked SW-I what was done for R7 once R7 revoked the POA and had no one as the decision maker. SW-I stated they were going to start getting corporate guardianship, but R7 became very pushy about going home and Ombudsman-T told them R7 had the right to discharge. Surveyor asked SW-I who was involved in obtaining guardianship. SW-I stated Administration and the legal department took over that part of it; SW-I did not know what happened from there with guardianship. In an interview on 11/5/2024 at 10:48 AM, Surveyor asked Ombudsman-T if Ombudsman-T could recall R7 and the conversations with the facility regarding R7's POA being revoked. Ombudsman-T stated Ombudsman-T never knew the resident's name. Ombudsman-T stated the facility called Ombudsman-T with questions about discharge. Ombudsman-T stated Ombudsman-T told the facility that the resident had the right to go home, and they need a discharge meeting. Ombudsman-T stated the resident was not under protective placement so they could not keep the resident against their will. Ombudsman-T stated the resident did not want the POA listed anymore so Ombudsman-T told the facility that if the resident revokes the POA, they have to reach out to their legal team for guardianship or a new POA. Ombudsman-T stated APS got involved. Ombudsman-T stated APS called Ombudsman-T and Ombudsman-T reiterated to APS what Ombudsman-T told the facility. Ombudsman-T stated Ombudsman-T would never tell inaccurate information to the facility and it has to be a safe discharge. Ombudsman-T stated what the facility did was the facility choice, not what Ombudsman-T told them to do. Ombudsman-T stated Ombudsman-T could tell the facility the regulations but cannot tell the facility what to do. Ombudsman-T stated they needed to go through their legal team before the resident was discharged . Ombudsman-T stated Ombudsman-T talked to SW-I and ANHA-D many times about this situation. In an interview on 11/5/2024 at 2:01 PM, BOM-V stated BOM-V provided R7 with the NOMNC and SNFABN paperwork on 6/25/2024. BOM-V stated BOM-V saw R7 had revoked the POA, so BOM-V had R7 sign the NOMNC and SNFABN and then notified FM-AA and FM-BB of the NOMNC and SNFABN because BOM-V did not know what to do with no resident representative or POA in place. BOM-V stated BOM-V wanted to cover all the bases and notify anyone that would need to know. In an interview on 11/6/2024 at 8:09 AM, APS SW-S stated R7 was admitted to the facility with an activated POA and R7 wanted to discharge home. APS SW-S stated the activated POA, FM-Z, did not feel it was safe for R7 to go home. APS SW-S stated FM-Z had a lot of concerns such as R7 had no food or medications at home. APS SW-S stated FM-Z wanted R7 to enroll in Medicaid and R7 was told R7 would lose the house so if there was no POA, R7 could keep the house. APS SW-S stated R7 thought if R7 revoked the healthcare POA, both primary and secondary, R7 would be able to go home. APS SW-S stated with R7 revoking the POA, maybe the facility thought that would be an easy discharge. APS SW-S stated PCP-X determined R7 was still incapacitated so APS SW-S recommended the facility seek guardianship for R7. APS SW-S stated APS SW-S and the APS supervisor talked to their legal counsel about the process needed to have a decision maker for R7 since R7 revoked the POA and APS SW-S told the facility to consult with their attorneys to have the courts involved. APS SW-S stated the facility documented in R7's chart that the family could create a new POA per PCP-X which was not true. APS SW-S stated PCP-X was confused about revoking R7's POA when R7 was incapacitated. APS SW-S stated R7 did not have a decision maker on discharge. In an interview on 11/6/2024 at 9:31 AM, ANHA-D stated Admissions-R no longer is employed at the facility and was aware R7 was incapacitated at the time of admission requiring the POA to sign the admission paperwork. ANHA-D stated ANHA-D was not sure what happened at that time, but ANHA-D would have called the hospital to get the advanced directives. ANHA-D stated SW-I informed ANHA-D and Nursing Home Administrator (NHA)-A that R7 did not want FM-Z or FM-AA as R7's POA anymore because FM-Z and FM-AA were going to sell R7's house and take the money. ANHA-D stated R7 was angry at FM-Z and FM-AA. ANHA-D stated SW-I contacted Ombudsman-T and was told R7 could revoke the POA. ANHA-D stated SW-I ran with that and had R7 revoke the POA. ANHA-D stated now that R7's POA was revoked, ANHA-D did not know what the next step was but knew something needed to be done. Surveyor asked ANHA-D if the facility filed for guardianship. ANHA-D stated they did not do anything to obtain guardianship that ANHA-D was aware of. ANHA-D stated there was a conversation with corporate but could not recall the details of the conversation. In an interview on 11/6/2024 at 10:22 AM, Surveyor asked SW-I once R7 revoked FM-Z as the POA, what was done to get a decision maker for R7. SW-I stated SW-I made Corporate aware and SW-I had nothing more to do with it. Surveyor asked SW-I what Corporate's directive to SW-I was. SW-I stated SW-I kept Ombudsman-T involved and from what SW-I knew, nothing was done legally. SW-I stated APS is responsible for that in the state SW-I was from and was not sure what the protocol is for this state. SW-I stated Corporate and Administration would handle this type of situation, it was too big for SW-I to handle. On 11/6/2024 at 3:00 PM, Surveyor shared with Director of Operations-C, Director of Nursing-B and ANHA-D the concerns R7 had an activated POA, FM-Z, that was not involved in the admission process, and when R7 revoked their POA, Social Services did not assist R7 with completing an advanced directive, such as guardianship to represent R7. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R5) of 2 allegations of abuse or neglect reviewed. * R5 had an injury of unknown origin that was not thoroughly investigated. Findings include: The Facility Policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022, documents (in part) . Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly . d. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement or the investigator may obtain a statement . 1.) R5 was admitted to the facility on [DATE] and has diagnoses which include, in part, encephalopathy, vascular dementia, benign neoplasm colon, muscle weakness and general anxiety disorder. R5's quarterly Medicare Minimum Data Set (MDS) with an assessment reference date of 10/30/2024 indicated R5 had a Brief Interview for Mental Status score of 99 (unable to complete interview). R5 has an activated Power of Attorney (POA). R5's MDS showed that a wheelchair is used for mobility. R5 has an indwelling catheter and is always incontinent of bowel. R5 is coded as being on hospice. Surveyor was reviewing the electronic medical record of R5 and saw a progress note written on 11/3/2024, at 10:09 PM, regarding a bruise to the left wrist from an unknown cause written by Licensed Practical Nurse (LPN)-K. On 11/6/2024, at 10:55 AM, Surveyor interviewed Director of Nursing (DON)-B about the progress note. DON-B stated Assistant DON and a nurse manager would be assigned to investigate the bruise and determine if it is an injury of unknown origin. On 11/6/2024, at 2:59 PM, during the daily exit meeting with the Facility, Surveyor shared the concern regarding lack of investigation of the bruise to R5's wrist. ANHA-D, DON-B and Director of Operations-C were present. On 11/7/2024, at 8:24 AM, DON-B and Assistant Nursing Home Administrator (ANHA)-D shared with Surveyor an investigation into R5's injury of unknown origin had been initiated. Surveyor noted that the facility only investigated R5's injury of unknown origin after it was brought to the facility's attention. No additional information was provided as to why the Facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for R5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person centered care for 2 (R16 and R7) of 2 residents reviewed. * R16 was admitted to the facility on [DATE] and did not have a baseline care plan initiated. * R7's baseline care plan did not include individualized, person-centered interventions. Findings include: The facility policy, entitled Care Plans-Baseline, revised March 2022, documents: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person centered comprehensive care plan The baseline care plan is updated as needed to meet the residents needs until the comprehensive care plan is developed. 1.) R16 was admitted to the facility on [DATE] and has diagnoses that include metabolic encephalopathy, enterocolitis due to clostridium difficile (C-Diff), vascular dementia, memory deficit following cerebral infarction, anxiety disorder without behaviors, adult failure to thrive, severe sepsis, fibromyalgia, chronic cough, and weakness. R16's admission minimum data set (MDS) dated [DATE] documents that R16 had intact cognition with a brief interview for mental status (BIMS) score of 14 and the facility assessed R16 needing total assistance with 1 staff member for toileting hygiene and lower body dressing and required a Hoyer lift transfer with 2 staff members, and moderate assist with 1 staff member for personal hygiene and upper body dressing. R16 was incontinent of bowel and bladder and wore adult briefs and was on contact isolation for the diagnosis of C-Diff. Surveyor reviewed R16's medical record and noted a baseline care plan was not initiated upon R16's admission to the facility. R16's did not have a care plan initiated until 8/6/2024, 4 days after R16's admission. On 11/6/2024, at 10:13 AM, Surveyor interviewed Director of nursing (DON)-B who confirmed with the Surveyor that a care plan was not initiated for R16 until 8/6/2024. DON-B stated a baseline care plan should have been initiated when R16 was admitted to the facility on [DATE]. DON-B was not sure why a care plan was not initiated until 8/6/2024. DON-B stated at that time the facility was having a transition and there was not an admissions nurse at that time and maybe got missed by the floor nurses, DON-B stated but that should not have happened and R16 should have had a baseline care plan in place. On 11/6/2024, at 3:00 PM, Surveyor shared concerns that R16 did not have a baseline care plan once admitted to the facility on [DATE] until 8/6/2024. DON-B and assistant nursing home administrator (ANHA)- D understood the concern. No additional information was provided. 2.) R7 was admitted to the facility on [DATE] with diagnoses of wedge compression fracture of T11-T12 vertebra, cancer of the lung, malnutrition, Parkinsonism, congestive heart failure, atrial fibrillation, emphysema, and peripheral vascular disease. R7's Baseline Care Plan was initiated on 6/15/2024 targeting problems based on the admission assessment. All the interventions documented for each problem area of the Care Plan did not have individualized approaches for the care of R7. A generic baseline care plan was documented without selecting the pertinent interventions for R7. The Activities of Daily Living (ADL) Care Plan within the Baseline Care Plan documents the following interventions: I am (independent) of all activities of daily living. (OR) Overall I require (supervision, limited, extensive, dependent) assistance with oral care; (supervision, limited, extensive, dependent) with bathing; (supervision, limited, extensive, dependent) with grooming; (supervision, limited, extensive, dependent) with eating; (supervision, limited, extensive, dependent) with toileting; (supervision, limited, extensive, dependent) with dressing; (supervision, limited, extensive, dependent) with mobility. I will need (support, assistance) to have my personal care needs met while supporting my strengths and personal goals. All subsequent care plan problems within the Baseline Care Plan have the same documentation of supplying all possible needs without selecting the appropriate care based on R7's needs and assessment. On 6/17/2024, three days after admission, R7's care plan was revised to incorporate individualized approaches for care. In an interview on 11/6/2024 at 12:50 PM, Surveyor asked Assistant Nursing Home Administrator (ANHA)-D if ANHA-D had reviewed R7's Baseline Care Plan when it had been provided to Surveyor. ANHA-D stated ANHA-D had printed the document but had not looked closely at the care plan. Surveyor showed ANHA-D R7's Baseline Care Plan to ANHA-D for ANHA-D to review. Surveyor shared with ANHA-D the concern R7's Baseline Care Plan had no personalization of interventions on how to care for R7 until the care plan was revised on 6/17/2024. ANHA-D agreed the care plan looked like the nurse had initiated the care plan in the computer charting system but did not address any of the problem topics by selecting what care level R7 needed. ANHA-D stated it appeared to ANHA-D that on 6/17/2024, the care plan was reviewed and revised with the information that individualized the interventions. No additional information was provided as to why the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person centered care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a discharge plan was in place to effectively transition the resident to post-discharge care for 1 (R7) of 2 residents reviewed for discharge. R7 was discharged to home while incapacitated with no appointed decision maker. R7 did not receive home health services upon discharge due to no appointed Power of Attorney (POA) to sign contracts for services and no medications were available for R7 upon return to home. Findings include: The facility Policy and Procedure titled Discharge Summary and Plan revised 10/2022 documents: 3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside; b. arrangements that have been made for follow-up care and services; c. a description of the resident's stated discharge goals; d. the degree of caregiver/support person availability, capacity and capability to perform required care; e. how the IDT will support the resident or representative in the transition to post-discharge care; f. what factors may make the resident vulnerable to preventable readmission; and g. how those factors will be addressed. 5. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. 6. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan. 7. Residents are asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. 8. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 9. Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility are assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. 10. The resident or representative (sponsor) is asked to provide the facility with a minimum of seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. 11. A member of the IDT reviews the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 1.) R7 was admitted to the facility on [DATE] with diagnoses of wedge compression fracture of T11-T12 vertebra, cancer of the lung, malnutrition, Parkinsonism, congestive heart failure, atrial fibrillation, emphysema, and peripheral vascular disease. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had a fall prior to admission. The Cognitive Care Area Assessment documented R7 had a current BIMS of 15, an activated Power of Attorney (POA) in place, and had some forgetfulness noted. R7 had completed a POA for Healthcare document on 3/27/2018 designating Family Member (FM)-Z as the primary POA and FM-AA as secondary POA if R7 should become incapacitated. The document was signed by R7, two witnesses, FM-Z as the healthcare agent, and FM-AA as the alternate healthcare agent. R7 was hospitalized from [DATE] to 6/14/2024 with a T12 compression fracture and on 6/11/2024 was found to be incapacitated by a physician and a psychologist therefore activating the POA, FM-Z. The hospital Social Worker documented on 6/12/2024 in a progress note that the activated POA was contacted to discuss discharge arrangements from the hospital. FM-Z returned the call on 6/13/2024 and the Social Worker documented FM-Z was given a list of subacute rehab referrals; FM-Z approved of referrals to the facilities provided. The hospital Discharge summary dated [DATE] documents the physician had an in-depth conversation with FM-Z regarding R7's medications, a final plan about the several medical issues, and the Do Not Resuscitate wishes R7 had expressed with the admitting physician. The Hospital Face Sheet documented FM-Z was the active substitute decision maker. The hospital documentation was provided to the facility prior to and upon R7's discharge from the hospital. R7's admission Sheet completed by the facility prior to R7 being admitted documented R7 would be admitted on [DATE] and had an activated POA for healthcare. No documentation was found indicating that FM-Z was contacted or provided admission paperwork. FM-Z's signature was not found on any documentation in R7's medical record. On 6/17/2024, a Discharge Care Plan was initiated to discharge from the facility. The following interventions were implemented at that time: -Arrange for discharge planning conference with interdisciplinary team (IDT) for discharge planning within 48-72 hours. -Arrange for necessary home modifications per therapy recommendations. -Assist R7 and/or support person in locating and coordinating post discharge services. -Consider R7's and family preference for care. -Define roles and expectations with R7 and support person. -Ensure access to services. -Obtain needed equipment and supplies per therapy and nursing recommendations. -Plan for specific needs/continuing care needs after discharge: e.g., personal care, sterile dressings, physical therapy, etc. -Provide education for medications, treatment, therapy, safety, equipment, etc. prior to discharge. -Provide opportunity for R7/support person to return demonstrate treatment regime/skills prior to discharge. -Provide written instructions for care and resources to use in case of emergency. -Refer to home health services. On 6/18/2024 at 10:00 AM, in R7's progress notes, Social Worker (SW)-I documented a Care Conference was held with the IDT, R7, and FM-Z. At 11:38 AM in the progress notes, SW-I documented FM-Z sent an email about concern for R7 wanting to go home and FM-Z wanted to meet with SW-I to discuss Assisted Living Facilities (ALFs). SW-I documented R7 was very against going to an ALF and wanted to return home. SW-I documented SW-I informed FM-Z that SW-I was more than happy to speak with FM-Z about this but also informed FM-Z that regardless of if the POA was active or not, they cannot force R7 to go to an ALF. FM-Z was provided with Ombudsman-T's number in case FM-Z had concerns regarding the rights as Active POA. On 6/18/2024 at 2:04 PM in the progress notes, Director of Rehab (DoR)-U documented a care plan meeting was held that day with the IDT, R7 and FM-Z on the phone. Therapy goals were discussed, and discharge planning was completed with R7 reporting that R7's goal was to return home. Home physical therapy (PT), occupational therapy (OT), and Home Health Aide (HHA) was recommended upon discharge. On 6/22/2024 at 2:07 PM in the progress notes, nursing documented FM-BB arrived to take R7 home and was informed R7 was not able to go home because the physician and insurance had not released R7. FM-BB stated FM-BB was going to take R7 home and they could not keep R7 at the facility like a prisoner. Nursing staff explained to FM-BB that FM-Z did not want R7 to leave the facility. FM-Z was contacted via the phone and FM-Z talked to R7 to explain the situation to R7. FM-BB had removed some of R7's belongings and put them in the car. The police were notified and spoke to FM-BB who then brought back R7's belongings. On 6/24/2024 at 2:57 PM in the progress notes, SW-I documented SW-I had a long conversation with R7 about R7's wants. R7 did not want to go to an ALF while FM-Z was insisting R7 had to. R7 stated R7 barely had any contact with FM-Z and FM-AA until R7's POA was activated. R7 stated FM-Z wants R7 to go into an ALF so FM-Z can live in R7's house rent free. R7 could not recall when FM-Z was picked to be R7's POA and does not want FM-Z to be the POA. SW-I documented SW-I had spoken to Ombudsman-T about this and Ombudsman-T told SW-I that R7 had the right to revoke the POA whether R7 was activated or not. R7 felt FM-Z was abusing their POA power and would like FM-BB to be the POA since FM-BB might start living with R7 as R7's caretaker. On 6/24/2024, R7 signed a Revocation of Power of Attorney for Health Care form removing both FM-Z as the primary POA and FM-AA as alternate POA. R7 no longer had a designated decision maker. On 6/25/2024 at 3:58 PM in the progress notes, Business Office Manager (BOM)-V documented BOM-V met with R7 to discuss the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). BOM-V documented BOM-V explained R7 was covered through 6/27/2024 and would discharge on [DATE]. R7 said FM-BB would be taking R7 home around 11:00 AM on Friday (6/28/2024). BOM-V documented a voicemail was left for FM-AA as well to inform FM-AA of the insurance update. The NOMNC and SNFABN paperwork was signed by R7 on 6/25/2024. No other family members witnessed or were a part of the conversation regarding the end of coverage or if any conversation was had about applying for Medicaid assistance. On 6/26/2024 at 11:47 AM in the progress notes, SW-Y documented SW-Y spoke with R7's POA, FM-AA. Surveyor noted R7 did not have a designated POA at this time due to the revocation and FM-AA was revoked as the alternate POA. SW-Y explained to FM-AA that FM-Z was revoked from being the POA which bumped FM-AA up to R7's primary POA. SW-Y documented R7 was to be discharged on Friday. FM-AA stated that FM-AA was not okay with that and R7 needed to be in an ALF or nursing home. SW-Y informed FM-AA that the facility had suggested an ALF several times to R7 and R7 refused. FM-AA then questioned what the point of being a POA was if FM-AA had no say in what goes on with R7's care. SW-Y informed FM-AA that per Ombudsman-T, the state agency for resident rights, R7 gets to make the call of what R7 wants to do and that we cannot deny R7 that right, with or without a POA. SW-Y told FM-AA that R7 would be discharged with home health to make the transition back home a little easier. FM-AA stated FM-AA understood and requested that SW-Y call FM-Z to explain to FM-Z what is going on. SW-Y told FM-AA SW-Y could not do that as FM-Z was no longer R7's POA. FM-AA did not agree with R7's decision to go back home but stated if FM-AA has no say, then it is what it is and that FM-AA would be there on Friday. On 6/26/2024 at 12:53 PM in the progress notes, SW-I documented a signed referral for home health services was sent. The Home Health referral paperwork documented R7 was seen by PCP-X on 6/26/2024 and R7 was to receive Physical Therapy (PT) and Occupational Therapy (OT). On 6/26/2024 at 1:00 PM in the progress notes, SW-Z documented FM-BB called and explained that R7 was calling FM-BB saying that R7 can go home on Friday. Since FM-BB was not the POA, FM-BB stated FM-BB would prefer FM-AA, the Active POA, to pick up R7. Surveyor noted R7 did not have a designated POA at this time due to the status of incapacitation. FM-BB stated that FM-BB does not want to be in the middle of R7 and FM-AA. FM-BB stated once R7 returns home, FM-BB would be there to assist R7, such as going to the store, the doctors, etc., however FM-BB does not want to stay there since FM-BB is not the active POA and does not want to get caught up in the mess. FM-BB stated FM-BB felt FM-AA and FM-Z were stealing money from R7 along with belongings from R7's home. SW-Y informed FM-BB that R7 was being taken care of and that R7 would receive the support R7 needs along with receiving home health upon discharge. On 6/26/2024 at 1:20 PM in the progress notes, SW-I documented Meals on Wheels was contacted and the service would be starting for R7 on 7/1/2024. On 6/26/2024 at 5:22 PM in the progress notes, SW-I documented APS SW-S visited with R7 and then came to speak with SW-I. R7 had revoked both FM-Z and FM-AA as POAs but from the hospital was still deemed incapacitated and does not currently have a decision maker. APS SW-S felt that since both sides of the family were fighting over R7 and R7's house that the best option at that point would be to file for guardianship so the courts could handle the family dynamic and it can be decided/finalized. APS SW-S said SW-I would need a letter from PCP-X stating incapacity. SW-I spoke with PCP-X's nurse who said that PCP-X would like to look over the documents again before writing the letter but will get it to SW-I by Friday. SW-I went to speak with R7 to update R7 and R7 was upset but also said R7 understood what had to happen now. On 6/27/2024 on the OT Discharge Summary, the OT therapist documented R7's discharge recommendations: R7 was staying at the long term care facility with 24/7 care at standby assist 4-wheeled walker level; R7 will have assist for AM and PM activities of daily living and putting on and taking off the back brace. On 6/27/2024 on the PT Discharge Summary, the PT therapist documented R7's discharge recommendations: R7 required standby assist for safety of transfers with vocal cues for safety of locking and unlocking the walker and hand placement; R7 needed minimal assist for putting on back brace; R7 was to have assist with bathing and dressing; R7 was to stay with long term care since it was not safe for R7 to discharge home. On 6/28/2024, PCP-X faxed a letter to the facility documenting R7 had undergone a psychological evaluation with a Neuropsychologist where R7 was found to have a neurocognitive disorder. PCP-X agreed that R7 was unable to make rational decisions with regard to R7's healthcare or fully understand R7's medical condition and need for care. PCP-X was the third medical professional to deem R7 incapacitated. On 6/28/2024 at 3:06 PM in the progress notes, SW-I documented spoke to FM-AA and FM-BB and both were aware they needed to pick up R7. At 3:19 PM in the progress notes, SW-I documented a discharge folder was placed in the nurses station and home health had been updated. A medication list had been faxed to the pharmacy. No documentation was found indicating the circumstances of why R7 was not discharged on 6/28/2024. On 7/8/2024 at 10:00 AM in the progress notes, SW-I documented Assistant Nursing Home Administrator (ANHA)-D and SW-I spoke with Ombudsman-T and Ombudsman-T told the facility that R7 had the right to go home regardless of whether R7 was activated or not for POA. On 7/8/202 at 11:27 AM in the progress notes, SW-I documented Ombudsman-T was contacted and Ombudsman-T said R7 had the right to go home, no one could stop R7 from going home. Ombudsman-T said R7 should be able to sign a new POA as long as the primary doctor PCP-X would write a statement R7 could. PCP-X's office was called who agreed FM-BB should be the POA but would call back after lunch. No further documentation was found regarding PCP-X calling the facility back. On 7/9/2024 at 12:28 PM in the progress notes, SW-I documented SW-I spoke with FM-BB about R7's discharge plan. FM-BB stated FM-BB was there to support R7 and so are other family members that live close to R7. FM-BB stated FM-BB would be going grocery shopping for R7 and calling Meals on Wheels to get restarted. SW-I documented per Ombudsman-T, the facility cannot hold R7 there against R7's will and R7 had the right to go home regardless of if R7 was activated or not. R7 currently had a safe discharge plan to go home with family support. At 1:24 PM in the progress notes, SW-I documented SW-I spoke with FM-BB and would fax medications to the pharmacy. On 7/10/2024 at 12:48 PM in the progress notes, SW-I documented home health confirmed that everything was set up for R7 to receive home health. On 7/10/2024 at 5:21 PM in the progress notes, nursing documented R7 was discharged to home at 5:00 PM with family and the discharge folder was sent with R7. The Transition of Care/Discharge Summary for R7 dated 7/10/2024 documented R7 was not resident responsible. No special instructions were documented. No discharge medications were documented. No signatures were found indicating who received the discharge instructions and information. In an interview on 11/5/2024 at 10:10 AM, Surveyor asked SW-I if SW-I knew the circumstances around FM-BB coming to pick up R7 on 6/22/2024. SW-I stated that was on the weekend and R7 was not set to discharge at that time. SW-I stated SW-I was not informed of the situation until a couple hours after it happened. SW-I stated nursing did not know what to do so they called the police; there were no other instances of FM-BB coming to get R7. SW-I stated APS SW-S talked to R7 and in that conversation, R7 told APS SW-S R7 was fine with going to an ALF, but when R7 talked to SW-I, R7 did not want to go to an ALF. SW-I stated SW-I called Ombudsman-T to get clarification of what R7 could and could not do as R7 had an activated POA. SW-I stated Ombudsman-T informed SW-I that R7 could not be kept at the facility against R7's will and R7, even though was deemed incapacitated, still had the right to be discharged . SW-I stated SW-I had multiple conversations with R7 and Ombudsman-T. SW-I stated R7 was against what FM-Z wanted and SW-I explained to R7 what it meant to revoke the POA. SW-I stated R7 felt R7's rights were being taken away. Surveyor asked SW-I what was done for R7 once R7 revoked the POA and had no one as the decision maker. SW-I stated they were going to start getting corporate guardianship, but R7 became very pushy about going home and Ombudsman-T told them R7 had the right to discharge. SW-I stated R7 had safe discharge arrangements. In an interview on 11/5/2024 at 10:48 AM, Surveyor asked Ombudsman-T if Ombudsman-T could recall R7 and the conversations with the facility regarding R7's POA being revoked and R7's discharge from the facility. Ombudsman-T stated Ombudsman-T never knew the resident's name. Ombudsman-T stated the facility called Ombudsman-T with questions about discharge. Ombudsman-T stated Ombudsman-T told the facility that the resident had the right to go home, and they need a discharge meeting. Ombudsman-T stated the resident was not under protective placement so they could not keep the resident against their will. Ombudsman-T stated the resident did not want the POA listed anymore so Ombudsman-T told the facility that if the resident revokes the POA, they have to reach out to their legal team for guardianship or a new POA. Ombudsman-T stated APS got involved. Ombudsman-T stated APS called Ombudsman-T and Ombudsman-T reiterated to APS what Ombudsman-T told the facility. Ombudsman-T stated Ombudsman-T would never tell inaccurate information to the facility and it has to be a safe discharge. Ombudsman-T stated what the facility did was the facility choice, not what Ombudsman-T told them to do. Ombudsman-T stated Ombudsman-T could tell the facility the regulations but cannot tell the facility what to do. Ombudsman-T stated they needed to go through their legal team before the resident was discharged . Ombudsman-T stated Ombudsman-T talked to SW-I and ANHA-D many times about this situation. In an interview on 11/5/2024 at 1:55 PM, Surveyor asked DoR-U how the facility or therapy determines a resident is safe to discharge home. DoR-U stated DoR-U attends the initial care plan meeting to discuss discharge goals, what level the resident should be at in order to go home, and the home environment, such as stairs and home layout. Surveyor asked DoR-U if PT or OT assessed R7 prior to discharge from the facility. DoR-U stated R7 discharged from therapy services on 6/27/2024 and therapy was told R7 was going to stay at the facility long term so R7 was never evaluated after that date. DoR-U stated R7 did not have any Med B visits with therapy after 6/27/2024 and was not aware of R7 discharging from the facility. In an interview on 11/6/2024 at 8:09 AM, APS SW-S stated R7 was admitted to the facility with an activated POA and R7 wanted to discharge home. APS SW-S stated the activated POA, FM-Z, did not feel it was safe for R7 to go home. APS SW-S stated FM-Z had a lot of concerns such as R7 had no food or medications at home. APS SW-S stated FM-Z wanted R7 to enroll in Medicaid and R7 was told R7 would lose the house so if there was no POA, R7 could keep the house. APS SW-S stated R7 thought if R7 revoked the healthcare POA, both primary and secondary, R7 would be able to go home. APS SW-S stated with R7 revoking the POA, maybe the facility thought that would be an easy discharge. APS SW-S stated PCP-X determined R7 was still incapacitated so APS SW-S recommended the facility seek guardianship for R7. APS SW-S stated APS SW-S and the APS supervisor talked to their legal counsel about the process needed to have a decision maker for R7 since R7 revoked the POA and APS SW-S told the facility to consult with their attorneys to have the courts involved. APS SW-S stated Ombudsman-T said the facility cannot hold R7 against their will, but APS SW-S did not think Ombudsman-T knew the whole picture, that R7 lacked capacity and did not have a decision-maker. APS SW-S stated FM-BB told APS SW-S that the facility called FM-BB to come and pick up R7 and when R7 got home, R7 could not be admitted to home health services because there was no one to sign the admission contract. APS SW-S stated the facility documented in R7's chart that the family could create a new POA per PCP-X which was not true. APS SW-S stated PCP-X was confused about revoking R7's POA when R7 was incapacitated. APS SW-S stated R7 did not have a decision maker on discharge and R7 did not have any medications when discharged home; R7 needed refills, and no one picked them up from the pharmacy. APS SW-S stated R7's discharge folder barely had any paperwork in it. APS SW-S stated FM-BB did not stay with R7 longer than two days after discharge. APS SW-S stated FM-Z got temporary guardianship with the assistance of APS after R7 was home. APS SW-S stated APS SW-S talked to Administrator of Home Health (AHH)-W to find out about R7 getting home health services. APS SW-S stated AHH-W said the facility paperwork listed FM-BB as R7's POA with no documentation to support that; there was no evidence of POA paperwork. AHH-W told APS SW-S that R7 could not be admitted for services because there was no responsible party to sign the paperwork. APS SW-S stated FM-BB was not reliable, and FM-BB yelled at R7 on the phone not to call FM-BB. APS SW-S stated the facility never notified APS that R7 was discharged . In an interview on 11/6/2024 at 9:31 AM, ANHA-D stated SW-I informed ANHA-D and Nursing Home Administrator (NHA)-A that R7 did not want FM-Z or FM-AA as R7's POA anymore because FM-Z and FM-AA were going to sell R7's house and take the money. ANHA-D stated R7 was angry at FM-Z and FM-AA. ANHA-D stated SW-I contacted Ombudsman-T and was told R7 could revoke the POA. ANHA-D stated SW-I ran with that and had R7 revoke the POA. Surveyor shared with ANHA-D that no one signed R7's discharge paperwork. ANHA-D stated ANHA-D saw that when ANHA-D was printing the discharge paperwork. Surveyor asked ANHA-D how it was determined R7 had a safe discharge. ANHA-D stated SW-I had services set up. Surveyor shared the concern the services had been set up for discharge on [DATE] and R7 did not discharge until 7/10/2024 with no input from therapy or family. Surveyor shared with ANHA-D R7 did not have home health services once R7 arrived home because there was no decision maker to sign the admission paperwork for home health services and FM-BB did not pick up any of R7's medications from the pharmacy. ANHA-D was not aware of that. In an interview on 11/6/2024 at 9:49 AM, AHH-W stated R7 was rejected for services by the home health company. AHH-W stated R7's POA was revoked while at the facility and was still deemed incapacitated with no legal guardian in place to sign admission paperwork and contract. AHH-W stated AHH-W contacted APS and alerted APS SW-S of the situation. Surveyor asked AHH-W if AHH-W was aware of R7 not having a POA in place at the time of R7's discharge or was it discovered after R7 was home. AHH-W stated the referral from the facility was accepted and the referral showed the POA was activated with FM-BB as the POA. AHH-W stated FM-BB was contacted and FM-BB wanted to wait one week for services to start. AHH-W stated they scheduled the first visit for 7/15/2024 and left a voicemail with FM-BB to have FM-BB send POA paperwork to them. AHH-W stated that was when APS got involved and APS got FM-Z to have temporary guardianship. AHH-W stated multiple messages were left for FM-Z with no return call, so the referral was rejected; R7 did not receive any home health services. In an interview on 11/6/2024 at 10:22 AM, Surveyor asked SW-I how FM-BB was aware that R7 was discharging on 7/10/2024. SW-I stated SW-I called FM-BB to come and get R7. SW-I stated home health was set up and medications had been called to the pharmacy from the physician. SW-I stated FM-BB was going to restart Meals on Wheels. SW-I stated SW-I sends an order sheet signed by the physician and a signed medication sheet to the home health service through email. SW-I provided a copy of the email. The information sent had been signed by PCP-X on 6/24/2024 and 6/26/2024. SW-I stated AHH-W comes in weekly to talk over any questions with upcoming discharges. SW-I stated R7 wanted FM-BB to be the point of contact and PCP-X thought FM-BB was the POA, too. Surveyor asked SW-I if APS was notified at the time of R7's discharge. SW-I thought APS was notified by leaving a message for APS SW-S and PCP-X was called as well when R7 discharged . On 11/6/2024 at 3:00 PM, Surveyor shared with Director of Operations-C, Director of Nursing-B and ANHA-D the concern R7 did not have a safe discharge and no discharge meetings were held with R7's family members prior to discharge. Surveyor shared with ANHA-D R7 did not receive any home health services upon discharge due to no designated decision maker to sign admission contracts and no medications were obtained for R7 after discharge. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure medically related social services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R7) of 2 residents reviewed for discharge. R7 had an activated Power of Attorney (POA) on admission that was not included in the admission process, social services did not assist R7 in obtaining a decision-maker or guardian prior to R7 revoking the POA, R7 was not assisted in applying for Medicaid after changing payor sources from Medicare, and social services did not ensure R7 had a safe discharge. Findings include: The facility policy and procedure titled Social Services from the publication Med-Pass ©2001 revised 9/2021 documents: Policy Interpretation and Implementation: . 3. The facility staff is able to identify and address factors that have a potentially negative effect on psychosocial functioning of a resident, for example: a. situations that impede the resident's dignity and sense of control; b. lack of family/community support; c. distress resulting from depression, chronic diseases, difficulty with personal interactions or social skills, and/or resident to resident altercations; d. abuse of any kind; e. difficulty coping with change or loss; f. financial needs or problems; g. behaviors problems (i.e., confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episodes); h. substance abuse; and i. bereavement or unresolved grief. 4. The social worker/social services staff are responsible for: a. being knowledgeable about the rights of residents in accordance with federal requirements, including . Resident Rights .Freedom from Abuse, Neglect and Exploitation .Transitions of Care . b. advocating for and assisting residents with asserting their rights in the facility; c. assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights and accommodation of needs; . f. assisting with informing and educating residents, families and representatives about health care options and ramifications; g. making referrals and obtaining needed services from outside entities; h. assisting residents with financial and legal matters; i. helping residents with transitions of care services (for example, community placement options, home care services, transfer arrangements, etc.); . m. assisting residents with advance care planning, including but not limited to completion of advance directives (F578, Advance Directives); . o. meeting the needs of residents who are grieving from losses and coping with stressful events. 1.) R7 was admitted to the facility on [DATE] with diagnoses of wedge compression fracture of T11-T12 vertebra, cancer of the lung, malnutrition, Parkinsonism, congestive heart failure, atrial fibrillation, emphysema, and peripheral vascular disease. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had a fall prior to admission. The Cognitive Care Area Assessment documented R7 had a current BIMS of 15, an activated Power of Attorney (POA) in place, and had some forgetfulness noted. R7 had completed a POA for Healthcare document on 3/27/2018 designating Family Member (FM)-Z as the primary POA and FM-AA as secondary POA if R7 should become incapacitated. The document was signed by R7, two witnesses, FM-Z as the healthcare agent, and FM-AA as the alternate healthcare agent. R7 was hospitalized from [DATE] to 6/14/2024 with a T12 compression fracture and on 6/11/2024 was found to be incapacitated by a physician and a psychologist therefore activating the POA, FM-Z. The hospital Social Worker documented on 6/12/2024 in a progress note that the activated POA was contacted to discuss discharge arrangements from the hospital. FM-Z returned the call on 6/13/2024 and the Social Worker documented FM-Z was given a list of subacute rehab referrals; FM-Z approved of referrals to the facilities provided. The hospital Discharge summary dated [DATE] documents the physician had an in-depth conversation with FM-Z regarding R7's medications, a final plan about the several medical issues, and the Do Not Resuscitate wishes R7 had expressed with the admitting physician. The Hospital Face Sheet documented FM-Z was the active substitute decision maker. The hospital documentation was provided to the facility prior to and upon R7's discharge from the hospital. R7's admission Sheet completed by the facility prior to R7 being admitted documented R7 would be admitted on [DATE] and had an activated POA for healthcare. On 6/14/2024 at 12:25 PM in the progress notes, Admissions-R documented R7's POA was activated at the hospital and documented R7's POA as FM-Z. At 8:02 PM in the progress notes, Admissions-R documented Admissions-R sat with R7 and went over the admission packet and paperwork. Admissions-R documented R7 signed: payor source verification, informed consent for telemedicine, Medicare coverage, consent to treat, transportation policy, authorization for disclosure of contact information, influenza vaccine, pneumonia vaccine, TB risk assessment, and Advanced Directives; discharge planning was started. The following forms were signed on 6/14/2024 by R7 and scanned into R7's medical record: -Skilled Nursing Facility Services Agreement -Advanced Directives (for code status) -Resident Social History -Responsible Person Agreement -Resident Rights -Resident Responsibilities -Resident Grievance/Concern Procedures -HIPAA Notice of Privacy Practices -Privacy Act Statement - Health Care Records -TB Skin Test -Consent to Administer Influenza Vaccine -Pneumococcal and Prevnar Vaccine Administration Assessment and Consent Form -Authorization for Disclosure of Contact Information -Consent to Treat -Informed Consent for Your Telemedicine Visit -Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation -Medicare Coverage -Transportation Policy No documentation was found indicating that FM-Z was contacted or provided admission paperwork. FM-Z's signature was not found on any documentation in R7's medical record. On 6/17/2024, a Discharge Care Plan was initiated to discharge from the facility. The following interventions were implemented at that time: -Arrange for discharge planning conference with interdisciplinary team (IDT) for discharge planning within 48-72 hours. -Arrange for necessary home modifications per therapy recommendations. -Assist R7 and/or support person in locating and coordinating post discharge services. -Consider R7's and family preference for care. -Define roles and expectations with R7 and support person. -Ensure access to services. -Obtain needed equipment and supplies per therapy and nursing recommendations. -Plan for specific needs/continuing care needs after discharge: e.g., personal care, sterile dressings, physical therapy, etc. -Provide education for medications, treatment, therapy, safety, equipment, etc. prior to discharge. -Provide opportunity for R7/support person to return demonstrate treatment regime/skills prior to discharge. -Provide written instructions for care and resources to use in case of emergency. -Refer to home health services. On 6/18/2024 at 10:00 AM in the progress notes, Social Worker (SW)-I documented a Care Conference was held with the IDT, R7, and FM-Z. At 11:38 AM in the progress notes, SW-I documented FM-Z sent an email about concern for R7 wanting to go home and FM-Z wanted to meet with SW-I to discuss Assisted Living Facilities (ALFs). SW-I documented R7 was very against going to an ALF and wanted to return home. SW-I documented SW-I informed FM-Z that SW-I was more than happy to speak with FM-Z about this but also informed FM-Z that regardless of if the POA was active or not, they cannot force R7 to go to an ALF. FM-Z was provided with Ombudsman-T's number in case FM-Z had concerns regarding the rights as Active POA. On 6/18/2024 at 2:04 PM in the progress notes, Director of Rehab (DoR)-U documented a care plan meeting was held that day with the IDT, R7 and FM-Z on the phone. Therapy goals were discussed, and discharge planning was completed with R7 reporting that R7's goal was to return home. Home physical therapy (PT), occupational therapy (OT), and Home Health Aide (HHA) were recommended upon discharge. On 6/22/2024 at 2:07 PM in the progress notes, nursing documented FM-BB arrived to take R7 home and was informed R7 was not able to go home because the physician and insurance had not released R7. FM-BB stated FM-BB was going to take R7 home and they could not keep R7 at the facility like a prisoner. Nursing staff explained to FM-BB that FM-Z did not want R7 to leave the facility. FM-Z was contacted via the phone and FM-Z talked to R7 to explain the situation to R7. FM-BB had removed some of R7's belongings and put them in the car. The police were notified and spoke to FM-BB who then brought back R7's belongings. On 6/23/2024 at 3:21 AM in the progress notes, nursing documented at approximately 10:00 PM on 6/22/2024, R7 came out of the room fully dressed with a walker and a suitcase. R7 stated FM-BB was going to pick R7 up and R7 wanted to wait. Nursing documented nursing explained that FM-Z would not allow that to happen and reminded R7 of the incident that happened earlier that day. R7 went to sit on the couch in front of the TV and then went back to R7's room to watch TV. Frequent checks were made for safety and to decrease the risk of elopement. No other situations occurred throughout the night. Safety measures were in place and the call light was within reach. On 6/24/2024 at 2:57 PM in the progress notes, SW-I documented SW-I had a long conversation with R7 about R7's wants. R7 did not want to go to an ALF while FM-Z was insisting R7 had to. R7 stated R7 barely had any contact with FM-Z and FM-AA until R7's POA was activated. R7 stated FM-Z wants R7 to go into an ALF so FM-Z can live in R7's house rent free. R7 could not recall when FM-Z was picked to be R7's POA and does not want FM-Z to be the POA. SW-I documented SW-I had spoken to Ombudsman-T about this and Ombudsman-T told SW-I that R7 had the right to revoke the POA whether R7 was activated or not. R7 felt FM-Z was abusing their POA power and would like FM-BB to be the POA since FM-BB might start living with R7 as R7's caretaker. On 6/24/2024, R7 signed a Revocation of Power of Attorney for Health Care form removing both FM-Z as the primary POA and FM-AA as alternate POA. R7 no longer had a designated decision maker. On 6/24/2024 at 3:04 PM in the progress notes, SW-I documented FM-BB stated FM-Z and FM-AA had not seen R7 in over 2 years but like to remain in control. Per FM-BB, FM-Z and FM-AA were upset that the deceased parents left the house in FM-BB's name and per FM-BB, the dad made FM-BB promise that FM-BB would care for R7 until the end. FM-BB stated FM-Z and FM-AA do not do anything for R7. At 3:16 PM in the progress notes, SW-I documented FM-BB stated FM-Z and FM-AA had been taking money from R7's account causing it to be overdrawn all the time. On 6/24/2024 at 3:27 PM in the progress notes, SW-I documented R7 stated FM-CC would like to talk with SW-I. FM-CC told SW-I that what the facility did was illegal, and no one explained to R7 that now the state was in charge of R7. FM-CC stated FM-CC was contacting an attorney and would becoming after SW-I and the facility. SW-I documented SW-I would file an Adult Protective Services (APS) report. At 3:32 PM in the progress notes, SW-I documented APS was called and a voice mail was left. On 6/25/2024 at 10:09 AM in the progress notes, SW-I documented SW-I spoke with an APS SW about R7. The APS SW during the conversation said that R7 had been an open case in the past but was not at that time. Per the APS SW, APS had been working with FM-Z for years to have R7's Primary Care Physician (PCP)-X sign to make R7 incapacitated but PCP-X would not sign it and now R7's POA had been activated in the hospital. SW-I documented the APS SW seemed very biased towards FM-Z and made it known that SW-I should have been in full contact with FM-Z regardless of what R7 wanted. R7 wanted to go home and made allegations that FM-Z was wanting to live in R7's house rent free and had been stealing money out of R7's account. The APS SW stated the APS SW would make an APS report about this. SW-I documented the APS SW said that SW-I revoked the POA and R7 is activated so R7 cannot sign a different POA document, and the facility must file for guardianship. SW-I documented SW-I needed clarification on this as Ombudsman-T made it sound like R7 could still sign a new POA document if two witnesses were present. SW-I documented R7 was very distraught by this whole process and said R7 needed someone to advocate for R7 and be on R7's side as R7's family was always making decisions about R7 that R7 does not want. SW-I documented the APS SW claimed that the house was in R7's name and that FM-BB stands to gain it after R7 passes. R7 does not want to sell the house and per the APS SW, FM-Z and FM-AA are trying to sell it so R7 can go to an ALF. R7 was very against an ALF and wants to go home where R7 is comfortable. The APS SW said that FM-BB was not living with R7 but R7 and FM-BB said that FM-BB was. On 6/25/2024 at 1:59 PM in the progress notes, SW-I documented PCP-X was going to assess R7 the next day. On 6/25/2024 at 3:58 PM in the progress notes, Business Office Manager (BOM)-V documented BOM-V met with R7 to discuss the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). BOM-V documented BOM-V explained R7 was covered through 6/27/2024 and would discharge on [DATE]. R7 said FM-BB would be taking R7 home around 11:00 AM on Friday (6/28/2024). BOM-V documented a voicemail was left for FM-AA as well to inform FM-AA of the insurance update. The NOMNC and SNFABN paperwork was signed by R7 on 6/25/2024. No other family members witnessed or were a part of the conversation regarding the end of coverage or if any conversation was had about applying for Medicaid assistance. On 6/26/2024 at 11:47 AM in the progress notes, SW-Y documented SW-Y spoke with R7's POA, FM-AA. Surveyor noted R7 did not have a designated POA at this time due to the revocation and FM-AA was revoked as the alternate POA. SW-Y explained to FM-AA that FM-Z was revoked from being the POA which bumped FM-AA up to R7's primary POA. SW-Y documented R7 was to be discharged on Friday. FM-AA stated that FM-AA was not okay with that and R7 needed to be in an ALF or nursing home. SW-Y informed FM-AA that the facility had suggested an ALF several times to R7 and R7 refused. FM-AA then questioned what the point of being a POA was if FM-AA had no say in what goes on with R7's care. SW-Y informed FM-AA that per Ombudsman-T, the state agency for resident rights, R7 gets to make the call of what R7 wants to do and that we cannot deny R7 that right, with or without a POA. SW-Y told FM-AA that R7 would be discharged with home health to make the transition back home a little easier. FM-AA stated FM-AA understood and requested that SW-Y call FM-Z to explain to FM-Z what is going on. SW-Y told FM-AA SW-Y could not do that as FM-Z was no longer R7's POA. FM-AA did not agree with R7's decision to go back home but stated if FM-AA has no say, then it is what it is and that FM-AA would be there on Friday. On 6/26/2024 at 12:53 PM in the progress notes, SW-I documented a signed referral for home health services was sent. The Home Health referral paperwork documented R7 was seen by PCP-X on 6/26/2024 and R7 was to receive Physical Therapy (PT) and Occupational Therapy (OT). On 6/26/2024 at 1:00 PM in the progress notes, SW-Z documented FM-BB called and explained that R7 was calling FM-BB saying that R7 can go home on Friday. Since FM-BB was not the POA, FM-BB stated FM-BB would prefer FM-AA, the Active POA, to pick up R7. Surveyor noted R7 did not have a designated POA at this time due to the status of incapacitation. FM-BB stated that FM-BB does not want to be in the middle of R7 and FM-AA. FM-BB stated once R7 returns home, FM-BB would be there to assist R7, such as going to the store, the doctors, etc., however FM-BB does not want to stay there since FM-BB is not the active POA and does not want to get caught up in the mess. FM-BB stated FM-BB felt FM-AA and FM-Z were stealing money from R7 along with belongings from R7's home. SW-Y informed FM-BB that R7 was being taken care of and that R7 would receive the support R7 needs along with receiving home health upon discharge. On 6/26/2024 at 1:20 PM in the progress notes, SW-I documented Meals on Wheels was contacted and the service would be starting for R7 on 7/1/2024. On 6/26/2024 at 5:22 PM in the progress notes, SW-I documented APS SW-S visited with R7 and then came to speak with SW-I. R7 had revoked both FM-Z and FM-AA as POAs but from the hospital was still deemed incapacitated and does not currently have a decision maker. APS SW-S felt that since both sides of the family were fighting over R7 and R7's house that the best option at that point would be to file for guardianship so the courts could handle the family dynamic and it can be decided/finalized. APS SW-S said SW-I would need a letter from PCP-X stating incapacity. SW-I spoke with PCP-X's nurse who said that PCP-X would like to look over the documents again before writing the letter but will get it to SW-I by Friday. PCP-X's office also noted how R7's family has been fighting over R7 for a while and the family will call PCP-X's office over it. PCP-X's office felt something more was going on. SW-I went to speak with R7 to update R7 and R7 was upset but also said R7 understood what had to happen now. On 6/26/2024 at 5:37 PM in the progress notes, SW-I documented SW-I spoke to FM-AA and FM-BB as per APS SW-S suggested as they would be the candidates for guardianship. SW-I did not document what the conversation entailed. On 6/27/2024 on the OT Discharge Summary, the OT therapist documented R7's discharge recommendations: R7 was staying at the long term care facility with 24/7 care at standby assist 4-wheeled walker level; R7 will have assist for AM and PM activities of daily living and putting on and taking off the back brace. On 6/27/2024 on the PT Discharge Summary, the PT therapist documented R7's discharge recommendations: R7 required standby assist for safety of transfers with vocal cues for safety of locking and unlocking the walker and hand placement; R7 needed minimal assist for putting on back brace; R7 was to have assist with bathing and dressing; R7 was to stay with long term care since it was not safe for R7 to discharge home. On 6/28/2024, PCP-X faxed a letter to the facility documenting R7 had undergone a psychological evaluation with a Neuropsychologist where R7 was found to have a neurocognitive disorder. PCP-X agreed that R7 was unable to make rational decisions with regard to R7's healthcare or fully understand R7's medical condition and need for care. PCP-X was the third medical professional to deem R7 incapacitated. On 6/28/2024 at 2:26 PM in the progress notes, SW-I documented SW-I spoke to R7 who said R7 had changed their mind and did not want to revoke FM-Z or FM-AA as POAs anymore. R7 said R7 did not have a problem with FM-Z or FM-AA. R7 said R7 was upset with them before but not anymore. Surveyor noted a revoked POA could not be reversed until authorized individuals deemed R7 to have the capacity to make that decision. On 6/28/2024 at 3:06 PM in the progress notes, SW-I documented spoke to FM-AA and FM-BB and both were aware they needed to pick up R7. At 3:19 PM in the progress notes, SW-I documented a discharge folder was placed in the nurses station and home health had been updated. A medication list had been faxed to the pharmacy. No documentation was found indicating the circumstances of why R7 was not discharged on 6/28/2024. On 6/29/2024 at 12:33 PM in the progress notes, SW-I documented SW-I went to check on R7 who was upset. R7 was crying about the whole situation. R7 said R7's family was calling R7 and were upset about what R7 did. R7 said R7 should have stayed quiet. R7 stated that for years the family members have fought over R7 and more specifically over R7's house. R7 was beyond frustrated and upset and felt like R7 could not trust anyone. R7 said R7 just wants control of their life again. SW-I explained to R7 the possible next steps. R7 understood R7 would probably have to go on Medicaid and sell the house. SW-I talked with R7 about guardianship and R7 said R7 did not even know who R7 could trust in the family and does not trust anyone to respect R7's rights. SW-I was able to calm R7 down. On 7/8/2024 at 10:00 AM in the progress notes, SW-I documented Assistant Nursing Home Administrator (ANHA)-D and SW-I spoke with Ombudsman-T and Ombudsman-T told the facility that R7 had the right to go home regardless of whether R7 was activated or not for POA. On 7/8/202 at 11:27 AM in the progress notes, SW-I documented Ombudsman-T was contacted and Ombudsman-T said R7 had the right to go home, no one could stop R7 from going home. Ombudsman-T said R7 should be able to sign a new POA as long as the primary doctor PCP-X would write a statement R7 could. PCP-X's office was called who agreed FM-BB should be the POA but would call back after lunch. No further documentation was found regarding PCP-X calling the facility back. On 7/9/2024 at 12:28 PM in the progress notes, SW-I documented SW-I spoke with FM-BB about R7's discharge plan. FM-BB stated FM-BB was there to support R7 and so are other family members that live close to R7. FM-BB stated FM-BB would be going grocery shopping for R7 and calling Meals on Wheels to get restarted. SW-I documented per Ombudsman-T, the facility cannot hold R7 there against R7's will and R7 had the right to go home regardless of if R7 was activated or not. R7 currently had a safe discharge plan to go home with family support. At 1:24 PM in the progress notes, SW-I documented SW-I spoke with FM-BB and would fax medications to the pharmacy. On 7/10/2024 at 12:48 PM in the progress notes, SW-I documented home health confirmed that everything was set up for R7 to receive home health. On 7/10/2024 at 5:21 PM in the progress notes, nursing documented R7 was discharged to home at 5:00 PM with family and the discharge folder was sent with R7. The Transition of Care/Discharge Summary for R7 dated 7/10/2024 documented R7 was not resident responsible. No special instructions were documented. No discharge medications were documented. No signatures were found indicating who received the discharge instructions and information. In an interview on 11/5/2024 at 9:57 AM, Surveyor asked Admissions-P what the process was for a newly admitted resident. Admissions-P stated a referral will come from the hospital via fax prior to a resident being admitted and then if they are accepted by the facility, the hospital will fax a discharge summary before the resident arrives. Admissions-P stated the After Visit Summary is brought to the facility by the resident. Admissions-P stated the referral and discharge summary are printed off and put at the nurses' station so the nurses have the information, and an email is sent out to all the departments and the physician to let everyone know of the new admission. Surveyor asked Admissions-P what admission paperwork is presented to the resident and who reviews that paperwork with the resident or resident representative. Admissions-P stated Admissions-P will sit with the resident or POA if the resident is activated or will call the POA if the POA is not present at the time of admission. Admissions-P stated if the POA is not present at the time of admission, Admissions-P will set up a phone call to review the paperwork with the POA and then either email the paperwork to the POA or have them come to the facility to sign the paperwork. Surveyor asked Admissions-P what happens if the POA does not respond. Admissions-P stated that had never happened to Admissions-P so was not sure. Surveyor asked if Admissions-R, who had completed R7's admission, was available. Admissions-P stated Admissions-R no longer worked at the facility. In an interview on 11/5/2024 at 10:10 AM, Surveyor asked SW-I if FM-Z was involved in R7's admission process. Surveyor shared with SW-I the concern the admission paperwork was signed by R7, and no signatures were found by FM-Z. SW-I stated the admission paperwork is done by the Admissions nurse and social services has nothing to do with that. SW-I stated Admissions-R no longer works at the facility. SW-I stated an activated POA would be expected to be involved with the admission process. Surveyor asked SW-I when was the first time SW-I had contact with FM-Z. SW-I stated SW-I called FM-Z on 6/17/2024 to arrange R7's care conference for the next day. SW-I stated FM-Z was involved in the care conference that was held on 6/18/2024 by phone. Surveyor asked SW-I if SW-I knew the circumstances around FM-BB coming to pick up R7 on 6/22/2024. SW-I stated that was on the weekend and R7 was not set to discharge at that time. SW-I stated SW-I was not informed of the situation until a couple hours after it happened. SW-I stated nursing did not know what to do so they called the police; there were no other instances of FM-BB coming to get R7. Surveyor asked SW-I if SW-I could recall the situation with R7 wanting to revoke the activated POA. SW-I stated therapy informed SW-I that R7 did not like FM-Z and when SW-I talked with R7, R7 claimed FM-Z was stealing money from R7. SW-I stated SW-I contacted APS to investigate that claim. SW-I stated R7 told SW-I that R7 had not seen FM-Z for five years. SW-I stated APS SW-S talked to R7 and in that conversation, R7 told APS SW-S R7 was fine with going to an ALF, but when R7 talked to SW-I, R7 did not want to go to an ALF. SW-I stated SW-I called Ombudsman-T to get clarification of what R7 could and could not do as R7 had an activated POA. SW-I stated Ombudsman-T informed SW-I that R7 could not be kept at the facility against R7's will and R7, even though was deemed incapacitated, still had the right to be discharged . SW-I stated SW-I had multiple conversations with R7 and Ombudsman-T. SW-I stated R7 was against what FM-Z wanted and SW-I explained to R7 what it meant to revoke the POA. SW-I stated R7 felt R7's rights were being taken away. Surveyor asked SW-I what was done for R7 once R7 revoked the POA and had no one as the decision maker. SW-I stated they were going to start getting corporate guardianship, but R7 became very pushy about going home and Ombudsman-T told them R7 had the right to discharge. Surveyor asked SW-I who was involved in obtaining guardianship. SW-I stated Administration and the legal department took over that part of it; SW-I did not know what happened from there with guardianship. SW-I stated R7 had safe discharge arrangements. In an interview on 11/5/2024 at 10:48 AM, Surveyor asked Ombudsman-T if Ombudsman-T could recall R7 and the conversations with the facility regarding R7's POA being revoked and R7's discharge from the facility. Ombudsman-T stated Ombudsman-T never knew the resident's name. Ombudsman-T stated the facility called Ombudsman-T with questions about discharge. Ombudsman-T stated Ombudsman-T told the facility that the resident had the right to go home, and they need a discharge meeting. Ombudsman-T stated the resident was not under protective placement so they could not keep the resident against their will. Ombudsman-T stated the resident did not want the POA listed anymore so Ombudsman-T told the facility that if the resident revokes the POA, they have to reach out to their legal team for guardianship or a new POA. Ombudsman-T stated APS got involved. Ombudsman-T stated APS called Ombudsman-T and Ombudsman-T reiterated to APS what Ombudsman-T told the facility. Ombudsman-T stated Ombudsman-T would never tell inaccurate information to the facility and it has to be a safe discharge. Ombudsman-T stated what the facility did was the facility choice, not what Ombudsman-T told them to do. Ombudsman-T stated Ombudsman-T could tell the facility the regulations but cannot tell the facility what to do. Ombudsman-T stated they needed to go through their legal team before the resident was discharged . Ombudsman-T stated Ombudsman-T talked to SW-I and ANHA-D many times about this situation. In an interview on 11/5/2024 at 1:55 PM, Surveyor asked DoR-U how the facility or therapy determines a resident is safe to discharge home. DoR-U stated DoR-U attends the initial care plan meeting to discuss discharge goals, what level the resident should be at in order to go home, and the home environment, such as stairs and home layout. Surveyor asked DoR-U if PT or OT assessed R7 prior to discharge from the facility. DoR-U stated R7 discharged from therapy services on 6/27/2024 and therapy was told R7 was going to stay at the facility long term so R7 was never evaluated after that date. DoR-U stated R7 did not have any Med B visits with therapy after 6/27/2024 and was not aware of R7 discharging from the facility. In an interview on 11/5/2024 at 2:01 PM, Surveyor asked BOM-V if BOM-V has conversations with residents and resident representatives about Medicaid such as what qualifies them and how they apply. BOM-V stated on admission, if they have the potential of staying long-term, BOM-V will talk about going from Medicare to Medicaid. BOM-V stated if the resident has a POA, then the POA is involved in the conversation as well. BOM-V stated even if the resident is resident responsible, BOM-V likes to have another family member in on the conversation because there is a lot of information to go over. BOM-V stated another conversation is had about Medicaid when the resident is given the NOMNC paperwork. Surveyor asked BOM-V if BOM-V ever had a conversation with R7 or R7's POA about Medicaid. Surveyor shared with BOM-V R7 changed from Medicare to private pay on 6/28/2024 and did not leave the facility until 7/10/2024. BOM-V stated BOM-V thought R7 was going to discharge home on 6/28/2024 so BOM-V did not pursue Medicaid. BOM-V stated BOM-V was not aware R7 did not leave on 6/28/2024, so BOM-V never had another conversation with R7 after BOM-V provided R7 with the NOMNC and SNFABN paperwork on 6/25/2024. BOM-V stated BOM-V saw R7 had revoked the POA, so BOM-V had R7 sign the NOMNC and SNFABN and then notified FM-AA and FM-BB of the NOMNC and SNFABN because BOM-V did not know what to do with no resident representative or POA in place. BOM-V stated BOM-V wanted to cover all the bases and notify anyone that would need to know. Surveyor asked BOM-V if the facility had been paid for the dates R7 was paying privately. BOM-V stated no, they had not been paid. In an interview on 11/6/2024 at 8:09 AM, APS SW-S stated R7 was admitted to the facility with an activated POA and R7 wanted to discharge home. APS SW-S stated the activated POA, FM-Z, did not feel it was safe for R7 to go home. APS SW-S stated FM-Z had a lot of concerns such as R7 had no food or medications at home. APS SW-S stated FM-Z wanted R7 to enroll in Medicaid and R7 was told R7 would lose the house so if there was no POA, R7 could keep the house. APS SW-S stated R7 thought if R7 revoked the healthcare POA, both primary and secondary, R7 would be able to go home. APS SW-S stated with R7 revoking the POA, maybe the facility thought that would be an easy discharge. APS SW-S stated PCP-X determined R7 was still incapacitated so APS SW-S recommended the facility seek guardianship for R7. APS SW-S stated APS SW-S and the APS supervisor talked to their legal counsel about the process needed to have a decision maker for R7 since R7 revoked the POA and APS SW-S told the facility to consult with their attorneys to have the courts involved. APS SW-S stated Ombudsman-T said the facility cannot hold R7 against their will, but APS SW-S did not think Ombudsman-T knew the whole picture, that R7 lacked capacity and did not

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R2 was admitted to the facility on [DATE] and has diagnoses which include type 2 diabetes with foot ulcer, end stage renal disease, dependence on renal dialysis, and dementia. R2's annual Medicare Minimum Data Set (MDS) with an assessment reference date of 5/24/2024 indicated R2 had a Brief Interview for Mental Status score of 11 (moderately impaired cognition). R2 is able to make decision for themselves. R2's MDS showed that no behaviors were noted. R2 is always continent of bladder and bowel. The MDS noted that R2 receives dialysis. Surveyor was at the facility investigating a complaint about R2 receiving medications crushed before dialysis. Surveyor reviewed the electronic medical record in which there was a progress note dated 05/22/2024, at 11:13 AM, which reads spoke to RN from dialysis . she reported pt (patient) received his medication crushed and that's the reason his BP (blood pressure) is high, requested he received it whole for best medication result. writer placed a nursing order for pt to receive medications whole. Surveyor reviewed medication orders and found Ensure patient takes medications whole for best medication effective result. Every Shift. Take medication whole. Effective 05/22/2024 - 06/28/2024. On 11/5/2024, at 9:10 AM, Surveyor interviewed Director of Nursing (DON)-B regarding the medications being crushed on 5/22/2024. DON-B was unaware and stated that DON-B knows the computer says to give the medications whole. On 11/5/2024, at 9:35 AM, Surveyor interviewed Social Worker (SW)-E from DaVita, the dialysis center R2 visited, who informed Surveyor that they contacted the Facility on numerous occasions regarding R2's complaints of not enough staff and medications not given at all or incorrectly. Surveyor asked if R2 was a good historian and SW-E stated that R2 was alert and oriented and knew staff names and good at remembering details. SW-E agreed to fax progress notes to Surveyor to review related to contact with Facility. On 11/5/2024, at 10:06 AM, Surveyor received the fax from DaVita and reviewed the progress notes. On 5/22/2024, at 11:34 AM, a progress note reads BP continues to be elevated, patient stated 'All my medications were given today in powdered form which is very unusual' MD (medical doctor) advised patient to report to RN (registered nurse) in charge if anything is looking different. IDT (interdisciplinary team) called DON (Director of Nursing) at Nursing home and reported this concern. Spoke with RN . who stated 'We are not sure what he took, but night nurse was from agency'. RN advised to educate all other RN's to follow up MAR (Medication Administration Report) and give patient correct medications and on time. Verbalized understanding . On 11/6/2024, at 1:58 PM, Surveyor followed up with DON-B and asked if it is a medication error to give a resident that gets medications whole, crushed medication. DON-B responded that yes it would be an error. Surveyor asked for the investigation into this occurrence. On 11/6/2024, at 2:59 PM, during the daily exit meeting with the Facility, Surveyor shared the concern that a medication error was not investigated regarding crushed medications being given to R2. Assistant Nursing Home Administrator (ANHA)-D, DON-B and Director of Operations-C were present. On 11/7/2024, at 8:35 AM, ANHA-D and DON-B let Surveyor know there was no medication error investigation completed after the 5/22/2024 crushed medication issue. No additional information was provided. Based on record review and interview, the facility did not ensure a medication administration errors were thoroughly investigated to prevent reoccurrence. This was observed with 2 (R6 and R2) of 4 residents reviewed with medication administration errors. * R6 received potassium 40 (milliequivalents) meq that was not prescribed for R6. There is not documentation to how this occurred and preventative action. * R2 did not have a reported medication error investigated by the Facility. Findings include: The facility's policy and procedure Administering Medications, dated April 2019. The policy under 6. Medication errors are documented, reported, and reviewed by the (Quality Assurance and Performance Improvement) QAPI committee to inform process changes and or the need for additional staff training. 1.) R6 was readmitted to the facility on [DATE] and was discharged to the hospital on 5/29/24. R6's progress note on 5/15/24 at 2:46 PM documents: Patient administered 40 meq of potassium this morning by medication error. Order was put in R6 (electronic medication administration record) E-Mar by mistake for another resident. Surveyor noted that there was the appropriate notifications and monitoring documented after R6 was provided with the wrong medication. Surveyor reviewed R6 Medication Error report. The report only identifies the medication and notifications. There is not documentation of the possible cause of the medication error and interventions to prevent reoccurrence. On 11/5/24, at 11:03 AM, Surveyor interviewed the (Director of Nurses) DON-B. The DON-B did not have any involvement with the medication error. On 11/5/24, at 3:03 PM, Surveyor shared the concerns with R6's medication error with DON-B, (Assistant Nursing Home Administrator) ANHA-D and (Director of Operations) DOO-C. There was no additional information provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R17) of 1 resident were free of significant medication errors. R17 did not receive various medications from September 2024 through November 2024 because the medication was not available. The medications that were not administered were Trulicity (diabetic medication), losartan hydroclorothiazide 100/25 mg (milligrams) (blood pressure medication), allopurinol 300 mg (medication to treat gout), latanoprost (eye drops for glaucoma), sertraline 50 mg (depression), toprol xl 100 mg (blood pressure medications), pantoprazole EC 40mg (for GERD-gastro-esophageal reflux disease), and fluticasone (treat asthma). Findings include: R17 was admitted to the facility on [DATE] with diagnoses of cellulitis of abdomen wall, morbid obesity, type 2 diabetes and COPD (Chronic obstructive pulmonary disease). The admission MDS (minimum data set) dated 9/3/24 indicate R17 is cognitively intact and independent with eating, bed mobility and transfers with a walker. On 11/5/24 at 9:30 a.m. Surveyor interviewed R17. R17 stated she frequently doesn't get all her medications. R17 asks the staff why she doesn't have all her meds and they say they don't have it. Surveyor reviewed R17's MAR (medication administration record) from 8/28/24 through 11/4/24. The following medications were not administered due to the medication not being available. August 2024 MAR 8/29/24 Allopurinol 300 mg daily 8/31/24 AM dose Fluticasone propion-salmeterol 250/50 mcg/dose 1 puff inhalation twice a day 8/31/24 latanoprost drops 0.005% 1 drop both eyes at bedtime September 2024 MAR 9/28/24 and 9/29/24 Allopurinol 300mg daily 9/30/24 latanoprost drops 0.005% 1 drop both eyes at bedtime 9/28/24 and 9/29/24 Losartan-hydrochlorothiazide 100-25 mg daily 9/2/24, 9/4/24 and 9/5/24 Pantoprazole EC 40 mg daily 9/28/24 sertraline 50mg daily 9/14/24, 9/18/24 and 9/22/24 Toprol XL 100 mg October 2024 MAR 10/2/24, 10/7/24, 10/27/28 and 10/28/24 Allopurinol 300 daily 10/2/24, 10/4/24 and 10/7/24 Losartan-hydrochlorothiazide 100-25 mg daily 10/7/24 omeprazole EC 20 mg daily 10/20/24 Trulicity pen injector once weekly November 2024 MAR 11/1/14, 11/4/24 Allopurinol 300mg daily Surveyor reviewed R17 blood glucose levels and blood pressure levels and found there were no unusual drops or elevation in those levels due to not receiving the medications as ordered. On 11/5/24 at 2:01 p.m. Surveyor interviewed DON (director of nursing)-B. Surveyor explained to DON-B the many medications that were not administered to R17. Surveyor explained to DON-B, R17 confirmed she has not been getting all her medications on a consistent basis. DON-B stated the facility changed how they refill medications, and the nursing staff were educated on the new way of refilling medications. DON-B stated this is education is on going because of the agency staff they utilize. DON-B stated she understood the concern but had no additonal information. No additional information was provided as to why the facility did not ensure that R17 was free of significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not address and resolve grievances conveyed on behalf of 4 (R2, R5, R10 and R12) of 4 residents reviewed for grievances. * R2's dialysis social worker contacted the Facility on numerous occasions with concerns that were not recorded or investigated. * R5's Power of Attorney (POA) filed a grievance related to medication administration that was not thoroughly investigated. * R10 expressed care concerns. There was not documentation they the concerns were thoroughly investigated, along with appropriate resolution. * A grievance was filed on behalf of R12 by Hospice for neglect when R12 was found in bed soiled and wet. The grievance was not thoroughly investigated. Findings include: The Facility Policy titled Grievance with no implementation or revision date documents (in part): Policy: It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay. The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by the Administrator, Grievance Official, who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with residents and resident representative throughout the process to resolution and coordinate with other staff and with state or federal agencies as may be indicated by specific allegations. The facility will provide a mechanism for filing a grievance/complaint without fear of retaliation and/or barriers of service; will provide residents, resident representatives and others information about the mechanisms and procedure to file a grievance; provide a designated individual to oversee the grievance process; provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by residents and resident representatives and will provide an ongoing system for monitoring and trending grievances and complaints. OBJECTIVE OF GRIEVANCE POLICY The objective of the grievance policy is to ensure the facility makes prompt efforts to resolve grievances a resident may have. The intent of the grievance process is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost articles, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident and resident representative appropriately apprised of its progress toward resolution. The grievance policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement Program (QAPI). 1.) R2 was admitted to the facility on [DATE] and has diagnoses which include, in part, type 2 diabetes with foot ulcer, end stage renal disease, dependence on renal dialysis, and dementia. R2's annual Minimum Data Set (MDS) with an assessment reference date of 5/24/2024 indicated R2 had a Brief Interview for Mental Status score of 11 (moderately impaired cognition). R2 is able to make decision for themselves. R2's MDS showed that no behaviors were noted. R2 is always continent of bladder and bowel. The MDS noted that R2 receives dialysis. On 11/5/2024, at 9:10 AM, Surveyor interviewed DON (Director of Nursing)-B and asked about the phone calls from the dialysis center regarding medications not given to R2 and DON-B stated that they did not know or remember any calls. DON-B stated DON-B would look into these calls. On 11/5/2024, at 9:35 AM, Surveyor interviewed Social Worker (SW)-E from DaVita, the dialysis center R2 visited, who informed Surveyor that they contacted the Facility on numerous occasions regarding R2's complaints of not enough staff and medications not given at all or incorrectly. Surveyor asked if R2 was a good historian and SW-E stated that R2 was alert and oriented and knew staff names and was good at remembering details. SW-E agreed to fax progress notes to Surveyor to review related to contact with Facility. Surveyor reviewed the Facility's Grievance Log but did not locate any grievances for R2. On 11/5/2024, at 10:06 AM, Surveyor received the fax from DaVita and reviewed the progress notes. On 3/27/2024, at 7:43 AM, progress note reads Patient reported today that he had no medications all day yesterday at nursing home. Pt (patient) came with elevated BP's (blood pressures), reported concerns to DON (Director of Nursing) at NH (Nursing Home) . On 5/13/2024, at 10:05 AM, progress note reads Pt (patient) reported dissatisfaction with SNF (Skilled Nursing Facility) at this time d/t (due to) lack of staff and per pt. 'I only got 2 of my 12 pills this morning and my bp was in the 200's when I came here', RN (Registered Nurse) confirmed bp was 209/73. MSW (Master of Social Work) called and spoke to ADON (Assistant Director of Nursing) and relayed concerns. ADON reported she will further look into and address accordingly . On 5/22/2024, at 11:34 AM, progress note reads BP (blood pressure) continues to be elevated, patient stated 'All my medications were given today in powdered form which is very unusual' MD (medical doctor) advised patient to report to RN in charge if anything is looking different. IDT (interdisciplinary team) called DON at Nursing home and reported this concern. Spoke with RN . who stated 'We are not sure what he took, but night nurse was from agency'. RN advised to educate all other RN's to follow up MAR (Medication Administration Report) and give patient correct medications and on time. Verbalized understanding . On 6/10/2024, at 8:21 AM, progress note reads patient with c/o (complaint of) SNF not giving binder at mealtime or miss dose of binder. RD (registered dietician) has faxed phosphorus lab results to SNF with note of importance of giving Sevelamer with meals . On 6/25/2024, at 8:29 AM, progress note reads BP's continue to be issue d/t not given as ordered to NH. This communicated with DON at NH. Surveyor notes 5 documented times the Facility was contacted regarding concerns and that no grievances were filed to show investigation was completed. On 11/6/2024, at 8:35 AM, Assistant Nursing Home Administrator (ANHA)-D and DON-B confirmed with Surveyor that there was nothing completed for grievances after the DaVita calls. On 11/6/2024, at 2:59 PM, during the daily exit meeting with the Facility, Surveyor shared the concern that contact from DaVita regarding medications and staffing were not recorded as grievances and investigated. ANHA-D, DON-B and Director of Operations-C were present. No additional information was provided. 2.) R5 was admitted to the facility on [DATE] and has diagnoses which include, in part, encephalopathy, vascular dementia, benign neoplasm colon, muscle weakness and general anxiety disorder. R5's quarterly Minimum Data Set (MDS) with an assessment reference date of 10/30/2024 indicated R5 had a Brief Interview for Mental Status score of 99 (unable to complete interview). R5 has an activated Power of Attorney (POA). R5's MDS showed that a wheelchair is used for mobility. R5 has an indwelling catheter and is always incontinent of bowel. R5 is coded as being on hospice. On 10/20/2024, R5's POA filed a grievance with Social Worker (SW)-I. SW-I wrote that I received a text about 9 PM from Activated POA that R5's meds (medications) were not passed. The witnesses section was left blank. The investigation section reads I went into unit and spoke with R5's nurse who reassured me that meds were received. I checked on R5 who was sleeping peacefully in bed. The resolution sections reads I scheduled a care conference with R5, MD (medical doctor), Director of Nursing (DON) and SW to speak about med concerns. Some meds (medications) were changed to help R5 sleep. Surveyor notes the only investigation was to interview the nurse. No other witnesses were interviewed. The medication record was not reviewed. On 11/6/2024, at 10:44 AM, Surveyor interviewed SW-I who stated that they spoke with two nurses on the unit that night. The SW-I stated they did nothing further because R5 was not in distress. When asked if the medication administration record was reviewed SW-I stated yes, but that the actual medication cards were not reviewed. SW-I stated that the issue was the POA felt R5 was restless at night and texted because worried and could not come out that night. Since R5 was sleeping SW-I felt there was no issue. On 11/6/2024, at 2:59 PM, during the daily exit meeting with the Facility, Surveyor shared the concern that a grievance was filed but not thoroughly investigated regarding medications being given to R5. ANHA-D, DON-B and Director of Operations-C were present. No additional information was provided. 3.) R12 was admitted to the facility on [DATE] with a diagnosis that includes cellulitis of right and left lower limbs, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, chronic pain, chronic peripheral venous insufficiency, dysphagia, heart failure, syncope/ collapsing, and adult failure to thrive. R12's significant change minimum data set (MDS) dated [DATE] indicated R12 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 and the facility assessed R12 needing total assist with one staff member for toileting hygiene, repositioning, lower body dressing and minimal assist with one staff member for upper body dressing and personal hygiene. R12 was incontinent of bowel and bladder and wore a protective brief. R12 required a Hoyer lift transfer with assist of two staff members for transferring. R12 was enrolled into Hospice services on 8/9/2024 for COPD. A grievance was filed with the facility on 9/6/2024 reporting that R12 was found by hospice staff on 8/28/2024 with urine and feces on R12 and that facility staff would not help hospice staff when R12 experienced a fainting episode that same day. Hospice staff stated they reported the concerns to the nurse on duty and that R12 stated R12 felt neglected to the hospice staff. On 11/5/2024, at 8:10 AM, Surveyor observed R12 lying in bed. R12 appeared to be comfortable and content. Surveyor asked R12 how R12 liked being at the facility and how staff were. R12 replied that R12 enjoyed the facility and staff were great. Surveyor asked if there was a time R12 ever felt neglected or felt like staff were not meeting R12's needs. R12 replied R12 could not remember a time R12 felt neglected and stated staff assist R12 as needed. Surveyor asked if R12 remembered a time when R12 was wet and dirty in the morning and hospice assisted R12 to be cleaned. R12 replied that R12 could not remember that ever happening. Surveyor reviewed in R12's hospice binder and noted hospice nursing and CNA notes dated 8/28/2024 that documents: Hospice Nurse: -Routine visit, vital signs stable. (R12) became unresponsive with syncope (fainting) episodes when in shower. (R12) put back to bed and back to (R12's) baseline. (R12) denied pain, wound care was provided. (Hospice nurse) told floor staff resident felt neglected. Hospice CNA: -Transfer/ shower/ dressing/ hair care/ skin care/ oral care/ incontinence care (provided for R12), Xlg (extra-large) incontinence and medium BM (bowel movement). (R12) provided fluids and socialization period. (completed) light housekeeping, trash emptied, and linens changed. On 11/5/2024, at 1:21 PM, Surveyor interviewed Registered Nurse (RN)-P who stated RN-P recalled being approached by the hospice staff regarding R12 but could not recall specific details. Surveyor asked RN-P if RN-P recalled concerns with R12 being found wet and soiled. RN-P stated she did recall that and when she went to check on R12, R12 had already gotten a shower, dressed, and was back in bed. RN-P stated that RN-P educated with the certified nursing assistants (CNA's) on the unit to remember to check residents often. On 11/8/2024, at 8:41 AM, Surveyor interviewed Assistant Nursing Home Administrator (ANHA)-D who stated ANHA-D was not notified of the grievance until 9/6/2024. The grievance was related to R12 that was reported from Hospice via phone call from the hospice social worker. ANHA-D stated when the concern from hospice came through on 9/6/2024 ANHA-D started an investigation into the concern. Surveyor attempted to interview NHA-A regarding the above concern, however NHA-A was not feeling well during survey and was not available for interviews. Surveyor reviewed the investigation and noted that no other residents were interviewed, and staff education was not included. On 11/6/2024, at 9:00 AM, Surveyor shared with ANHA-D that the investigation did not include resident interviews or staff education. ANHA-D stated that ANHA-D recalled talking with residents and that education was provided at an all staff that same month. On 11/6/2024, at 10:33 AM, Surveyor received education from an all staff meeting that was dated 9/27/2024. ANHA-D stated that the all staff meeting including education on abuse, neglect, etc. and believed the situation with R12 was included with that. Surveyor reviewed the sign in sheet and noted that not all staff was present for the education. ANHA-D stated that the education would have been done at the all staff meeting on 9/27/2024. Surveyor shared concern with ANHA-D that education that was provided, did not include all staff after the concern of neglect was reported to the facility on 9/6/2024 and that it should have included all staff and the specific concern with R12. On 11/6/2024, at 11:17 AM, ANHA-D shared with Surveyor that other residents were not interviewed regarding patient cares on 8/28/2024. ANHA-D stated that audits were done on residents that resided in the same hall as R12 on 9/8/2024, 9/9/2024, and 9/10/2024 and observed if the residents were clean, dry, and cared for. Surveyor asked ANHA-D why residents were not interviewed regarding if there were any concerns with care on 8/28/2024. ANHA-D stated that ANHA-D thought the audits were enough. Surveyor explained that residents should have been interviewed to determine if there were any other care concerns the same day R12 had a concern on 8/28/2024 and that the audits were a good tool to use for the any follow up to concerns and education provided to staff, but residents should have been interviewed. On 11/6/2024, at 3:00 PM, Surveyor shared concerns with ANHA-D, Director of Nursing (DON)-B, and Director of Operations-C that the concern of neglect for R12 reported to RN-P was not reported and investigated on 8/28/2024 until a grievance was filed by the hospice agency on 9/6/2024 and that the investigation was not thoroughly investigated by getting resident interviews or educate staff after the concern was reported. No additional information was provided. 4.) R10 was admitted to the facility on [DATE]. R10 is their own person and obtained a left hip fracture in the community. R10's admission MDS (minimum data set) completed 5/27/24 documents that R10 has no cognitive impairments, assistance with transfers and dressing. R10 was discharged home on 6/10/24. On 5/22/24, R10 expressed a grievance to (Social Worker) SW-I. The concern occurred on 5/20/24 and 5/22/24. R10 expressed long call light response time in the morning, a (Certified Nursing Assistant) CNA would not close their blinds when asked, then reactivated their call light, and it took another 30 minutes. On 5/20/24 R10 soiled themselves due to long wait time. The Investigation states: Social Services spoke with the (Director of Nurses) about the concern. The DON plans on finding out who the CNA's were and attempting to re-educate them. The Resolution states: Followed up with nursing who identified the CNA's involved from agency and marked them unable to come back. On 11/5/24, at 8:45 AM, Surveyor interviewed SW-I. SW-I stated they review concerns with the stand-up meetings. SW-I directs the concern to the appropriate department. They shared this concern with the (Director of Nurses) at that time. That DON no longer works at the facility. SW-I stated they did not attach any interviews or call logs. They were new at the time and have gotten better. SW-I stated they just had the agency staff that worked with R10 on the do not return list. There are not staff statements documented to determine possible causes of delayed response. There are not resident interviews documented to determine others potentially affected. There is not documented resolution that identifies the cause and a plan to prevent reoccurrence. On 11/5/24, at 8:55 AM, Surveyor shared concerns with (Director of Nurses) DON-B and (Director of Operations) DOO-C. The DON-B did not recall the concern. On 11/5/24, at 3:03 PM, Surveyor shared the investigation concerns with DON-B, DOO-C and (Assistant Nursing Home Administrator) ANHA-D. No additional information provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R5 was admitted to the facility on [DATE] and has diagnoses which include, in part, encephalopathy, vascular dementia, benign neoplasm colon, muscle weakness and general anxiety disorder. R5's quarterly Medicare Minimum Data Set (MDS) with an assessment reference date of 10/30/2024 indicated R5 had a Brief Interview for Mental Status score of 99 (unable to complete interview). R5 has an activated Power of Attorney (POA). R5's MDS showed that a wheelchair is used for mobility. R5 has an indwelling catheter and is always incontinent of bowel. R5 is coded as being on hospice. Surveyor was reviewing the electronic medical record of R5 and saw a progress note written on 11/3/2024, at 10:09 PM, Resident has bruise on left wrist. Previous shift was unaware and didn't get report on it. unknown cause. bruise is reddish/purple written by Licensed Practical Nurse (LPN)-K. Surveyor conducted a further review and noted that the Department of Health Services Form, F- 62617, was not submitted to the State Survey Agency. On 11/6/2024, at 10:55 AM, Surveyor interviewed Director of Nursing (DON)-B about the progress note. DON-B states that they round and review progress notes each morning, but since State Agency came to building it threw off schedule and this is new to DON-B's knowledge. On 11/6/2024, at 3:54 PM, Surveyor interviewed LPN-K who stated they overheard a certified nursing assistant telling the medication technician about a bruise on R5's wrist. LPN-K then went over and looked at wrist and wrote the progress note about the bruise. LPN-K stated did not report the bruise to anyone, thought the progress note would count as reporting to the Facility. On 11/6/2024, at 2:59 PM, during the daily exit meeting with the Facility, Surveyor shared the concern regarding lack of investigation and reporting of the bruise to R5's wrist. ANHA-D, DON-B and Director of Operations-C were present. On 11/7/2024, at 8:24 AM, DON-B and Assistant Nursing Home Administrator (ANHA)-D shared with Surveyor the investigation that had been initiated. No additional information was provided. Based on interview and record review the facility did not report 4 (R12, R9, R10, and R5) allegations to the Nursing Home Administrator or the State Agency during the required time frames. * R12 had an allegation of neglect on 8/28/2024 that was not reported to the Nursing Home Administrator (NHA) until 9/6/2024 when a grievance was filed. The allegation/grievance was not reported to the State Agency. * R5's injury of unknown origin was not reported to the Nursing Home Administrator (NHA) or state agency. * R9 had an injury of unknown origin and was not reported to the state agency. * R10 expressed in a Grievance that staff did not answer the call light timely. This resulted in R10 having an incontinent episode. Findings include: The facility policy entitled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022 documents: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The State licensing/ certification agency responsible for surveying/ licensing the facility. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions if any are needed for the protection of residents. 1.) R12 was admitted to the facility on [DATE] and has diagnoses that include cellulitis of right and left lower limbs, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic pain, chronic peripheral venous insufficiency, dysphagia, heart failure, syncope/ collapsing, and adult failure to thrive. R12's significant change minimum data set (MDS) dated [DATE] indicated R12 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 and the facility assessed R12 needing total assist with one staff member for toileting hygiene, repositioning, lower body dressing and minimal assist with one staff member for upper body dressing and personal hygiene. R12 was incontinent of bowel and bladder and wore a protective brief. R12 required a Hoyer lift transfer with assist of two staff members for transferring. R12 was enrolled into Hospice services on 8/9/2024. A grievance was filed with the facility on 9/6/2024 reporting that R12 was found by hospice staff on 8/28/2024 with urine and feces on R12 and that facility staff would not help hospice staff when R12 experienced a fainting episode that same day. Hospice staff stated they reported the concerns to the nurse on duty and that R12 stated R12 felt neglected to the hospice staff. On 11/5/2024, at 1:21 PM, Surveyor interviewed registered nurse (RN)-P who stated RN-P recalled being approached by the hospice staff regarding R12 but not specific details. Surveyor asked RN-P if RN-P recalled concerns with R12 being found wet and soiled. RN-P stated she did recall that and when she went to check on R12, R12 had already gotten a shower, dressed, and was back in bed. RN-P stated that RN-P educated with the certified nursing assistants (CNA's) on the unit to remember to check residents often. Surveyor asked RN-P if RN-P reported the concern from hospice to anyone. RN-P could not remember, RN-P stated that R12 also had a fainting episode, so RN-P was probably more concerned with that so probably did not mention anything. On 11/6/2024, at 9:00 AM, Surveyor interviewed assistant nursing home administrator (ANHA)-D who stated ANHA-D was not notified until the grievance on 9/6/2024 concerning R12. ANHA-D stated when the concern from hospice came through on 9/6/2024 NHA-A and ANHA-D started an investigation into the concern. Surveyor asked why the concern was not submitted to the state agency. ANHA-D stated that it never dawned on ANHA-D to submit a report, as ANHA-D just wanted to see what happened. Surveyor shared concern that the concern should have been reported on 8/28/2024 when facility staff were notified and on 9/6/2024 when ANHA-D was notified. No additional information was provided. 3.) R10 was admitted to the facility on [DATE]. R10 is their own person and obtained a left hip fracture in the community. R10's admission (minimum data set) MDS assessment completed 5/27/24 documents no cognitive impairments, assistance with transfers and dressing. The MDS assessment also documents that R10 required assistance from staff for toileting and transfers. R10 was discharged home on 6/10/24. On 5/22/24, R10 expressed a grievance to (Social Worker) SW-I. The concern occurred on 5/20/24 and 5/22/24. R10 expressed long call light response time in the morning, a (Certified Nursing Assistant) CNA would not close their blinds when asked, then reactivated their call light, and it took another 30 minutes. On 5/20/24 R10 soiled themselves due to long wait time. The Investigation states: Social Services spoke with the (Director of Nurses) about the concern. The DON plans on finding out who the CNA's were and attempting to re-educate them. The Resolution states: Followed up with nursing who identified the CNA's involved from agency and marked them unable to come back. The Resolution does not document this was reported to the State Agency for neglect. On 11/5/24, at 8:45 AM, Surveyor interviewed SW-I. SW-I stated they review concerns with the stand-up meetings. SW-I directs the concern to the appropriate department. They shared this concern with the (Director of Nurses) at that time. That DON no longer works at the facility. SW-I stated they just had the agency staff that worked with R10 on the do not return list. SW-I was not aware of this being reported to the State Agency. There is not a resolution that identifies the cause and a plan to prevent reoccurrence. For an allegation of neglect of care, would meet the reporting criteria, to report it to the State Agency. On 11/5/24, at 8:55 AM, Surveyor shared concerns with (Director of Nurses) DON-B and (Director of Operations) DOO-C. The DON-B did not recall the concern. On 11/5/24, at 3:03 PM, Surveyor shared the investigation concerns with DON-B, DOO-C and (Assistant Nursing Home Administrator) ANHA-D. No additional information was provided. 2.) R9 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, poly neuropathy, hypertension and atrial fibrillation. The significant MDS (minimum data set) dated 8/30/24 indicate R9 is cognitively impaired. Surveyor reviewed the facility self report dated 8/17/24 which indicated on 8/17/24 R9 was observed with bruising to the left side of her face. The investigation indicate on 8/17/24 at 12:30 a.m. CNA (certified nursing assistant) DD observed R9 in bed with facial bruising to the left side of the head. It indicates CNA-DD notified RN (registered nurse) EE regarding the bruising and RN-EE Stated R9 had a fall on 8/13/24. The investigation indicates it wasn't until the first shift staff came on shift that R9 was assessed and was discovered to have bruising to the left side of her face. The nurses note dated 8/17/24 at 6:21 a.m. indicate at 0600 writer went into room to take resident vitals and give Synthroid. Observed patient in bed lying on her side. Patient had a hand sized bruise noted to left forehead with small 3 cm laceration noted to middle of bruise. Patient was in low bed sleeping on side. Writer (RN-EE) and CNA (CNA-DD) walked past room many times from 2330 to 06 and observe patient sleeping in bed. At 0600 patient was in bed with covers pulled up. No blood was noted to sheets. Assessment was done. AM nurse called family, notified family, notified DON, notified MD. 911 was called and patient was transported to (hospital) for treatment and evaluation. The investigation indicate when R9 returned to the facility from the hospital, at 1:20 p.m. the NHA (nursing home administrator)-A was notified of the injury of unknown origin and the significant injury. NHA-A then began the investigation and contacted the state agency and police. On 11/5/24 at 2:00 p.m. Surveyor interviewed DON-B. DON-B stated NHA-A is not feeling well and is not in the facility. Surveyor explained R9 injury of unknown source was significant, and this was not reported to NHA-A, the state agency and the police within 2 hours. DON-B stated she understood the concern and had no additional information.

Based on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 of 5 residents reviewed (R42). * R42 is prescribed Seroquel, an antipsychotic medication for agitation related to Alzheimer's disease and dementia diagnosis. The facility did not have a written, signed consent explaining the risks and benefits of to R42's power of attorney (POA). This is evidenced by: Surveyor reviewed R42's physician orders and noted that R42 is currently prescribed Seroquel 25 mg tablet twice a day with start date of 11/22/23 and ending on R42's date of discharge 01/09/24. R42 has an activated power of attorney (POA) for health care decisions. Surveyor reviewed R42's electronic health record (EHR) and could not locate a written consent for the reason for the antipsychotic medication, alternative modes of treatment, the risks of taking the medication and the benefit of taking the medication. On 01/11/24, at 8:50 AM, Surveyor requested documentation for signed consent of Seroquel from Director of Nursing (DON). At 10:30 AM, DON stated that she cannot find the informed consent for the antipsychotic medication and could not locate it in the EHR.

Based on observation, the facility did not ensure the privacy and confidentiality of protected health information (PHI) for 2 of 2 residents (R2 and R9). This is evidenced by: On 01/09/24, at 10:37 AM, Surveyor observed a medication cart in hallway in front of R2's room. The computer screen was up with R2's medication administration screen viewable. R2's door was closed, and Licensed Practical Nurse Q (LPNQ) was in R2's room. LPNQ was observed coming out of R2's room and started setting up R2's medications. At 10:40 AM, LPNQ completed R2's medication set up. LPNQ locked the medication cart and went back into R2's room. LPNQ left the medication cart computer screen up with R2's PHI visible. At 10:45 AM, Surveyor observed LPNQ pushing the medication cart throughout the hallways with the computer screen up and R9's PHI viewable. On 01/11/24, at 8:50 AM Director of Nursing (DON) B was asked to provide a Policy & Procedure for resident PHI during medication pass. Surveyor did not receive a Policy & Procedure from DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 2 of 2 resident-to-resident incidents of physical abuse involving R36 towards R32 and R7 were reported to the State Agency within 2 hours, when the allegation involves abuse, and did not submit the results of their investigation within 5 working days to the State Agency. * On 12/26/23 at 2:00 pm, R36 struck R32 on the hand, when R32 wheeled past R36's wheelchair. The facility did not report this resident-to-resident physical abuse incident between R36 and R32 to the State Agency within 2 hours. The facility did not provide their investigation results within 5 working days to the State Agency. * On 12/27/23, R36 struck R7 on the shoulder when R36 was being wheeled past R7. The facility did not report this resident-to-resident physical abuse incident to the State Agency. The facility did not report this resident-to-resident physical abuse within 2 hours and did not submit their investigation results within 5 working days to the State Agency. Findings include: The facility policy titled Abuse Investigation and Reporting dated July 2017 states: * All reports of resident abuse, neglect and mistreatment shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse neglect, exploitation, or mistreatment will be reported by the facility Administrator, or his/her designee to the State licensing/certification agency responsible for surveying/licensing the facility. An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 1. R32 is a [AGE] year-old resident who has resided in the facility since admission on [DATE]. R32's diagnoses include dementia, altered mental status, major depressive disorder, hemiplegia, anxiety disorder, muscle weakness generalized, transient ischemic attack (TIA), and dysphagia. R32's most recent Quarterly Minimum Data Set (MDS) was completed on 12/3/23. R32 has unclear speech, usually makes herself understood and sometimes understands others during conversation. R32's Brief Interview for Mental Status (BIMS) was not completed as she is rarely/never understood. R32's cognition is severely impaired and never/rarely able to make decisions regarding tasks of daily living. R32 uses a wheelchair for mobility and is dependent for toileting as well as dressing and requires substantial or maximal assistance with bathing. On 1/9/24 at 10:00 am, Surveyor reviewed the facility self-report submitted to the State Agency on 1/4/24 (Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, form F62617). The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report indicates, on 12/26/23, R36 and R32 were sitting in the front day room with several other residents. R36 slapped R32 on the hand as R32 wheeled past R36. R32 and R36 were separated from each other for the remainder of the day. On 1/10/24 at 9:38 am, Surveyor requested the facility's investigation results (Misconduct Incident Report Form -F6247) from the Nursing Home Administrator (NHA-A). NHA-A stated he submitted the self-report for R32 and R36 to the State Agency on 12/27/23. Surveyor reviewed the date of submission for the initial self-report (Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, form 62617) on R32 and R36, and confirmed it was submitted on 1/4/24 at 9:00 am to the State Agency. The Surveyor requested the five-day investigation results for R32 and R36 incident, and the NHA-A indicated it was put in the facility investigation folder but was unable to provide the date it was submitted to the State Agency. The NHA-A indicated the process to submit reports is different in Wisconsin compared to Iowa where he previously worked and stated he did not know how to properly submit self-reports to the State Agency. The Surveyor notified NHA-A of concerns with the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse report for R32 and R36 resident-to-resident altercation not being submitted to the State Agency timely within the 2 hours and the State Agency not receiving the 5-day investigation results. On 1/11/24 at 12:11 pm, the Surveyor interviewed NHA-A and notified him of concerns with no the initial report (Form F62617) for R36 and R32's resident-to-resident incident being filed with the State Agency on 1/4/24 which is past the 2 hours requirements and no investigation results submitted to the State agency within 5 days (Form F62447). 2. R7 is an [AGE] year-old resident who has resided in the facility since admission on [DATE]. R7's diagnoses include, depression, muscle wasting and atrophy, muscle weakness generalized, difficulty walking, weakness, speech disturbances, need for assistance with personal care, and traumatic ischemia of muscle. R7's most recent Quarterly MDS was completed on 12/19/23. R7's speech is clear, is usually understood verbally and has a BIMS (Brief Interview for Mental Status) score of 7 which indicates severe cognitive impairment. R7 uses a walker or wheelchair for mobility and is dependent for toileting, showering and dressing. On 1/10/24 at 9:38 am, the Surveyor requested the initial self-report (Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report-F62617), and the 5 day investigation results (Misconduct Incident Report - F62447) from Nursing Home Administrator (NHA)-A for the resident-to-resident altercation between R36 and R7. NHA-A provided to the Surveyor, a copy of the initial report (F62617) that was a draft and had no submission date indicating it was submitted to the State Agency. NHA-A stated he did not know how to properly submit reports to the State Agency and thought the form was submitted. NHA-A indicated he needed to educate himself with the process of submitting incident reports to the State Agency and that he was new in the role of Nursing Home Administrator with the facility and was still learning. NHA-A indicated the facility could have done a better job with submitting Incident Reports to the State Agency for the resident-to-resident incidents regarding R7 and R32 that involved R36. On 1/11/24 at 12:11 pm, the Surveyor interviewed NHA-A and notified him of concerns wth no initial report (Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse - F62617) Report and the facility's investigation results (Misconduct Incident Report-F62447) being filed for the resident-to-resident incident involving R7 and R36. NHA-A indicated he forgot to click the submit button on the computer when filling out the reports to the State Agency. Additional information was requested if available. 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 2 resident-to-resident incidents (involving R32 and R7) of 2 incidents of physical abuse by a resident (R36), had a thorough investigation completed. * The facility self-report Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 1/4/24 indicates, on 12/26/23 at 2:00 pm, R36 struck R32 on the hand, when R32 wheeled past R36's wheelchair. The facility did not complete a thorough investigation of this incident. * On 12/27/23, R36 struck R7 on the shoulder when R36 was being wheeled past R7. The facility did not report this resident-to-resident physical abuse incident to the State Agency and did not complete a thorough investigation. Findings include: The facility's Abuse Investigation and Reporting policy dated July 2017, indicate: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The individual conducting the investigation will, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) report the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; j. Review all events leading up to the alleged incident. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location. d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. 1. R32 is a [AGE] year-old resident who has resided in the facility since admission on [DATE]. R32's diagnoses include dementia, altered mental status, major depressive disorder, hemiplegia, anxiety disorder, muscle weakness generalized, transient ischemic attack (TIA), and dysphagia. R32's most recent Quarterly Minimum Data Set (MDS) was completed on 12/3/23. R32 has unclear speech, usually makes herself understood and sometimes understands others during conversation. R32's Brief Interview for Mental Status (BIMS) was not completed as she is rarely/never understood. R32's cognition is severely impaired and never/rarely able to make decisions regarding tasks of daily living. R32 uses a wheelchair for mobility and is dependent for toileting as well as dressing and requires substantial or maximal assistance with bathing. R36 is an [AGE] year-old resident who has resided in the facility since admission on [DATE]. R36's diagnoses include, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness generalized, major depressive disorder, lack of coordination, dysphasia, altered mental status, anxiety disorder, and vascular dementia. R36's most recent Quarterly MDS was completed on 12/21/23. R36 has clear speech, usually makes himself understood, usually understands others, and has a BIMS score of 8 which indicates moderate cognitive impairment. R36 uses a wheelchair for mobility, is dependent or substantial/maximal assistance with toileting, bathing, transferring, and dressing. On 1/9/24 at 10:00 am, Surveyor reviewed the facility self-report that was submitted to the State Agency on 1/4/24. The facility self-report Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report indicates on 12/26/23, R32 and R36 were sitting in the front day room with several other residents. R36 slapped R32 on the hand while R32 wheeled past R36. The facility self-report Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report indicates R32 and R36 were separated from each other for the remainder of the day. On 1/10/24 at 9:38 am, the Surveyor requested a copy of the facility investigation reuslts (Misconduct Incident Report) from Nursing Home Administrator (NHA)-A for the resident-to-resident incident with R36 and R32. Surveyor interviewed Certified Nursing Assistant (CNA)-Y on 1/10/24 at 11:04 am. CNA-Y indicated R36 is known to have new behaviors of agitation recently and is doing better since staff have been redirecting him and keeping a distance between R36 and other residents. CNA-Y indicated she will offer a [NAME] cup or offer R36 to go to the activities room if he is seen hitting himself in the forehead or becoming agitated. CNA-Y indicated R36 has had issues with a few residents including R32. CNA-Y indicated staff will redirect R32 if they see her approach R36. CNA-Y indicates R32 is slow and can usually redirect her. On 1/10/24 at 12:04 pm, Surveyor observed R36 in the activity dining room at a table eating with one other male resident sitting across from R36. R36 was being assisted by female staff members with feeding and cutting up R36's food at times. R36 appeared comfortable in his wheelchair while in the activity dining room. On 1/10/24 at 12:08 pm, Surveyor interviewed Dietary Aide-AA. Dietary Aide-AA indicates she is familiar with R36 and R36 likes to be in the activity room while eating his meals and throughout the day. Dietary Aide-AA indicates the activity room is less busy and has a calmer environment which helps R36 stay calm. Dietary Aide-AA stated staff are aware to keep R32 and R7 away from R36. Dietary Aide-AA stated R36 does not like to receive assistance by male staff members with eating and prefers female staff to assist. 2. R7 is an [AGE] year-old resident who has resided in the facility since admission on [DATE]. R7's diagnoses include, depression, muscle wasting and atrophy, muscle weakness generalized, difficulty walking, weakness, speech disturbances, need for assistance with personal care, and traumatic ischemia of muscle. R7's most recent Quarterly MDS was completed on 12/19/23. R7's speech is clear, is usually understood verbally and has a BIMS score of 7 which indicates severe cognitive impairment. R7 uses a walker or wheelchair for mobility and is dependent for toileting, showering and dressing. On 1/10/24 at 9:38 am, the Surveyor requested a copy of the facility self-report along with the facility investigation from the Nursing Home Administrator (NHA)-A for the resident-to-resident incident with R36 and R7. On 1/10/24 at 10:31 am, Surveyor interviewed R7 who indicates she has friends within the facility however, these friends don't visit her often. R7 reports another resident within the facility is her fiancé and is unable to provide additional details to her engagement and the resident she is engaged to. R7 states she feels safe within the facility. On 1/10/23 at 10:41 am, Surveyor observed R7 in the common area with other residents, talking with nursing staff and showing off her newly painted nails to staff. Surveyor observed R7 self-propelling independently in her wheelchair throughout the common area. On 1/10/24 at 9:38 am, the Surveyor interviewed NHA-A. NHA-A indicated interviews and statements were not completed for both resident to resident incidents (incident between R36 and R32 and incident between R36 and R7) since they were both witnessed events. NHA-A stated staff education (therapy, housekeeping, nursing, and dietary) had been performed on 1/4/24 and 1/8/24. NHA-A stated R36 started having new behaviors of hitting himself on the head that were witnessed by staff prior to both the 12/26/23 and 12/27/23 resident-to-resident incidents. NHA-A reports new interventions were placed for R36 due to these new behaviors and staff are aware of the new interventions. NHA-A indicates these interventions include, placing R36 in the activities lounge that is a calmer environment, keeping R36 separate from other residents, offer R36 a [NAME] cup if seen hitting himself in the forehead, and offer R36 to sit in rehab lounge to watch a movie. On 1/11/24 at 12:11 pm, the Surveyor interviewed NHA-A and notified NHA-A of concerns with not having a thorough investigation for the 2 resident-to-resident incidents between R36, R32 and R7. On 1/11/24 at 2:59 pm, Surveyor notified [NAME] President of Clinical Operations-D, NHA-A, and Director of Nursing (DON)-B of concerns with not having a thorough investigation to include witness statements, resident statements and staff statements for the resident-to-resident incidents involving R36 and R32 on 12/26/23 and R36 and R7 on 12/27/23. Additional information was requested if available. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that the PASARR (Pre-admission Screen and Resident Review) for 1 (R5) of 2 Residents reviewed was completed accurately upon admission to the Facility and was appropriately referred for a Level II screen. R5 has a diagnosis of bipolar disorder and being treated with antidepressants of Trazadone & Effexor. The Facility did not complete Section C Questions pertinent for an abbreviated Level II screen and did not refer R5 for a Level II screen on or before the 30th day of stay at the Facility as required. A required Level II screen which would indicate if R5 needs nursing home placement and if R5 needs specialized service related to developmental disability and/or serious mental illness which is defined by federal PASARR regulations. Findings include: The admission Criteria policy 2001 Med-Pass Inc. (Revised March 2019) under policy interpretation and implementation documents; 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. R5 was originally admitted to the facility on [DATE] with a diagnosis which includes bipolar disorder. The Preadmission screen and resident review (PASARR) Level 1 Screen was completed on 10/26/23. Section A questions regarding mental illness is checked yes for question #1 Current Diagnosis Does the person have a major mental disorder under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM III-R) or DSM 5? Check the Yes box if the person's symptoms and behaviors could support an appropriate diagnosis of a major mental illness under DSM II-R or DSM 5. and #2 Medications Within the past six months, has this person received psychotropic medication(s) to treat symptoms or behaviors of a major mental disorder under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM III-R) or DSM 5 (see the above box for clarification)? Surveyor noted Antidepressants are checked along with Trazadone and Effexor. For Section B Short-Term Exemptions no is checked for the three questions. If no is answered to the questions in Section B, proceed to Section C. Section C Questions pertinent for an abbreviated Level II Screen has not been completed for the two sections Severe Medical Condition and Severe Cognitive Deficits. Section D Referring a person for a Level II screen documents If you have answered Yes to any questions in Section A and No to all of the exemptions listed in Section B, follow these instructions: Contact the PASARR Contractor to notify them that the person is being considered for admission. Forward a copy of the Level 1 Screen to the PASARR Contractor ( a copy must also be maintained by the nursing facility). The PASARR Contractor will perform a Level II Screen to determine if the person has a developmental disability and/or a serious mental illness as defined by the federal PASARR regulations, and if so, then whether or not the person needs nursing facility placement and if the person needs specialized services. The screening agency will notify the nursing facility, the county of responsibility and the resident or his/her legal representative, in writing of the determinations. Surveyor was unable to locate a Level II for R5. On 1/11/24 at 9:54 a.m. Surveyor asked AC (admission Coordinator)-N if she complete PASARR's. AC-N replied I do Surveyor asked AC-N to explain the Facility's process. AC-N explained when they receive a referral of someone who is on psychotropic medications or psych diagnosis she fills out the PASARR and sends it to BCS (Behavioral Care Solutions). They wait for the referral to come back before the Resident is admitted . If the resident does not have any psychotropic medications or diagnosis they let the hospital know the resident is good to come. AC-N informed Surveyor the PASARR goes in the chart. Surveyor showed AC-N R5's Level I screen. AC-N informed Surveyor R5's PASARR was completed by their old social worker and she started doing them after she left which she thinks was in October. Surveyor informed AC-N Section C was not completed and Surveyor was unable to locate a Level II. AC-N stated to Surveyor let me do some digging and will get back to you. On 1/11/24 at 10:14 a.m. AC-N informed Surveyor they do not have a Level 2 for R5, the social worker is no longer with the Facility and they do not know where that process was dropped. On 1/11/24 at 3:10 p.m. NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were informed of the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility did not ensure residents who are dependent on staff for personal hygiene/showering were provided the necessary care. This was observed with 1 (R15) 2 Residents reviewed who were dependent on staff for personal hygiene/showering. * On 1/9/24 at 9:58 AM, R15 informed Surveyor that R15 has not been getting showers on a regular basis and is scheduled for Tuesdays and Fridays. There is no documentation or comprehensive care plan of R15 refusing showers. The facility was not able to provide documentation that R15 has received showers. Findings Include: Surveyor reviewed the facility's Bath, Shower/Tub policy and procedure revised February 2018 and notes the following: .Purpose The purposes of this procedure are to promote cleanliness, provide comfort to the Resident and to observe the condition of the Resident's skin. Documentation 1. The date and time the shower/bath was performed. 2. The name and title of the individual(s) who assisted the Resident with shower/tub bath. 3. All assessment data (reddened areas sores) obtained during the the shower/tub bath. 4. How the the Resident tolerated the shower/tub bath. 5. If the Resident refused the shower/tub bath, the reason(s). Reporting 1. Notify the supervisor if the Resident refuses the shower/tub bath. 2. Notify the physician of any skin areas that may need to be treated. 3. Report other information in accordance with facility policy and professional standards of practice. R15 was admitted to the facility on [DATE] with diagnoses of Cellulitis of Right and Left Lower Limb, Morbid Obesity, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Glaucoma, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. R15 currently has an activated Health Care Power of Attorney (HCPOA). R15's Annual Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview for Mental Status (BIMS) score to be 13, indicating R15 is cognitively intact for daily decision making. R15's MDS also documents for mobility that R15 requires substantial/maximum assistance for rolling left and right and is dependent for sit to lying and sit to stand. R15's MDS documents that R15 is dependent for upper and lower hygiene as well as personal hygiene. Behaviors for R15 are not documented. The MDS indicates R15 is dependent on a helper who does all the effort in getting in and out of a tub/shower. R15's MDS also indicates it is somewhat important for R15 to be able to choose between a tub bath, shower, bed bath or sponge bath. Surveyor reviewed R15's care card which does not document that R15 has a potential for refusal of showers. R15's care card does document that R15 requires assistance of 1 for bathing. On 1/9/24 at 9:58 AM, R15 informed Surveyor that R15 has not been getting showers on a regular basis and is scheduled for Tuesdays and Fridays. On 11/21/23, Surveyor notes there is documentation that R15 refused a shower. On 1/9/24, Surveyor requested R15's last six months of documentation of R15 receiving showers. Surveyor notes there is no comprehensive care plan documenting that R15 refuses showers with individualized interventions. On 1/16/24 at 12:34 PM, Certified Nursing Assistant (CNA-P) informed Surveyor that R15 will refuse showers because R15 does not want agency staff to give the shower, CNA-P stated R15 is more likely to take a shower with regular staff. On 1/11/24 at 12:16 PM, [NAME] President of Clinical Operations(VP-D) informed Surveyor there is no documentation of R15 refusing showers and is aware there is no comprehensive care plan in place for R15's refusal of showers. Understands there have been no interventions put into place for refusal of showers. VP-D stated the facility is unable to provide documentation that R15 has received showers. VP-D confirms R15's refusal of showers should be documented within R15's comprehensive care plan. On 1/11/24 at 3:31 PM, Surveyor shared the concern with Administrator (NHA-A) and Director of Nursing (DON-B) that R15's refusal of showers is not documented within R15's comprehensive care plan along with individualized interventions. Surveyor shared that implemented interventions with R15's preferences, needs, and goals was not developed as well as monitoring R15's response to care plan interventions. Surveyor shared the concern that there is no documentation that R15 has been receiving showers. No further information was provided by the facility at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure the resident's record reflected the accurate resuscitation code status as identified in the resident's advanced directive for 2 of 2 residents (R3 and R40) reviewed for a Do Not Resuscitate (DNR) code status. * R3's Emergency Care Do Not Resuscitate Order (DNR) was signed [DATE]. R3's current physician orders for [DATE]-[DATE] documents that R3 is a full code with a start date of [DATE]. * R40's Emergency Care Do Not Resuscitate Order (DNR) was signed [DATE]. R40's current physician orders for [DATE]-[DATE] documents that R40 is a full code with a start date of [DATE]. Surveyor requested during the survey process the facility's policy and procedure for documenting a Resident's preference for CPR but did not receive a policy and procedure. Findings Include: 1. R3 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Failure and Stage 1 Through Stage 4 Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus and Other Specified Anxiety Disorders. On [DATE], R3's Health Care Power of Attorney (HCPOA) was activated. R3's Quarterly Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score to be a 12, indicating R3 demonstrates moderately impaired skills for daily decision making. On [DATE], R3's activated HCPOA chose for R3 to be DNR status. However, R3's current physician orders at time of survey, document that R3 is a full code as of [DATE]. 2. R40 was admitted to the facility on [DATE] with diagnoses of Complete Traumatic Amputation at Level Between Knee and Ankle, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus and Essential Hypertension. R40 is currently R40's own person. R40's Quarterly MDS dated [DATE] documents R40's Brief Interview for Mental Status(BIMS) score to be 15, indicating R40 is cognitively intact for daily decision making. On [DATE], R40 signed to be a DNR, however, R40's current physician orders document that R40 is a full code effective [DATE]. Surveyor notes documentation from the facility's Quality Assurance Performance Improvement (QAPI) Committee indicates the facility completed an audit on code status in [DATE]. On [DATE] at 1:16 PM, [NAME] President of Clinical Operations(VP-D) informed Surveyor that VP-D is not sure what happened with the incorrect code status on the physician's orders but the facility acquired a DNR status order from the physician for R3 and R40 as of this date. On [DATE] at 3:30 PM, Surveyor shared the concern with Administrator (NHA-A) and Director of Nursing (DON-B) that the physician's order for CPR status did not match the wishes of R3 and R40 whom wanted DNR. No further information was provided at this time by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R300 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, Dysphagia, Dyspnea, and Adjustment Disorder with Depressed Mood. R300 is currently R300's own person. R300's Quarterly MDS dated [DATE] documents R300's Brief Interview for Mental Status (BIMS) score to be 15, indicating R300 is cognitively intact for daily decision making. R300's MDS also documents for mobility that R300 requires partial to moderate assistance for rolling left to right and substantial to maximum assistance for sit to lying and sit to stand. Bed rails are not documented on R300's MDS. R300's MDS also documents that R300 has upper and lower range of motion impairment on one side. R300's MDS also documents that R300 requires substantial to maximum assistance for transfers. R300 had 4 falls. Of the 4 falls, 3 were not witnessed by staff. The facility's Neuro Check Assessment has the following policy documented: Policy: All Residents who experience a head injury or an unwitnessed fall will have neuro checks completed. Procedure: Neuro checks, vitals, and assessments will be completed every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 1 hour for 4 hours, and then every 4 hours for 24 hours and every shift for 48 hours. -9/13/23 R300 was found facing down under R300's recliner stating R300 was trying to put lotion on R300's heel and slid out of chair and landed on R300's bottom. MD notified and ordered to continue to monitor with neuro-check. Surveyor reviewed the neuro checks for the 9/13/23 fall. Surveyor notes there is no documentation for 1, 4 hour neuro check and for, 4 shifts within the 48 hours. -10/4/23 R300 raised electric recliner too far and slid out of chair to sitting position on floor with back and head resting on cushioned recliner. Neuro-check's in place per unwitnessed fall protocol. Surveyor reviewed the neuro checks for the 10/4/23 fall. Surveyor notes there is no documentation for 1, 4 hour neuro check and for 5 shifts within the 48 hours. -11/12/23 Report given that R300 had raised recliner all the way up and slid/fell out of chair. Surveyor requested neuro-checks for this unwitnessed fall, but the facility did not provide any documentation that neuro checks had been completed. On 1/16/24 at 1:30 PM, Surveyor shared the concern with Director of Nursing(DON-B) that R300 had 3 unwitnessed falls from the recliner, 2 of which had incomplete neuro check documentation and 1 fall that the facility had no neuro check documentation. DON-B stated that if a Resident is alert and oriented and can tell us what happened, the facility would not do neurochecks. Surveyor asked DON-B to define or share the measurement of a Resident being alert and oriented at the time of a fall. DON-B stated if the Resident has an activated health care power of attorney or guardian, the facility would complete neuro checks. On 1/16/24 at 2:13 PM, Surveyor went over the facility's policy and procedure for neuro checks with DON-B. DON-B agreed with Surveyor that the policy states that any unwitnessed fall, neuro checks should be completed and DON-B stated that would include R300's 3 unwitnessed falls. No further information was provided by the facility at this time. Based on interview, and record review the Facility did not ensure quality of care was provided for 2 (R5 & R300) of 3 Residents reviewed for neurological checks. * R5's neurological checks were not completed after unwitnessed falls on 12/8/23, 12/20/23, 12/28/23, & 12/30/23. * R300's neurological checks were not completed after unwitnessed falls on 9/13/23 & 10/4/23. Findings include: The Neuro Check Assessment form documents for Policy: All resident who experience a head injury or an unwitnessed fall will have Neuro Checks completed. Under Procedure documents Neuro checks, vitals and assessments will be completed every 15 minutes X (times) (1) hour, every 30 minutes for (1) hour, every 1 hour X 4 hours and then every 4 hours X 24 hours and every shift X 48 hours. This form is dated on the date of a Resident's fall. 1. R5 has diagnoses which include diabetes mellitus, depression, hypertension, generalized anxiety disorder, and bipolar disorder. R5's power of attorney for healthcare was activated on 10/25/23. The quarterly MDS (Minimum Data Set) with an assessment reference date of 1/2/24 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderate cognitive impairment. The nurses note dated 12/4/23 at 7:56 p.m. documents writer called to resident's room, aid, daughter and therapy all in room and resident was sitting on floor in front of recliner, resident stated she was going to sit in recliner and slid off edge, denied pain or hitting head, ROM (range of motion) baseline, neuro check neg (negative), vitals charted, resident helped into recliner. This nurses note was written by RN (Registered Nurse)-M. The nurses note dated 12/8/23 at 2:04 p.m. documents resident found sitting on floor in day room, denied pain, ROM (range of motion) baseline, did state she bumped her head, said she was trying to transfer into other chair, neuro check negative, vitals WNL (within normal limits), resident helped up into wheelchair, NP (Nurse Practitioner) notified, DON (Director of Nursing) notified, daughter/POA (Power of Attorney) updated, will continue to monitor. This nurses note was written by RN (Registered Nurse)-M. Surveyor noted R5's fall on 12/8/23 was unwitnessed. The nurses note dated 12/20/23 at 1:46 p.m. documents Resident's roommate was yelling for help and resident was sitting on the floor facing heater, w/c (wheelchair) behind her unlocked, bathroom door open, call light wasn't on at time of incident, floor was clean dry and free of debris, shoes on feet, pants were wet with urine, resident didn't hit head, maew (moves all extremeties well), no c/o pain, small bruise noted to middle of rt (right) buttock. This nurses note was written by LPN (Licensed Practical Nurse)-U. Surveyor noted R5's fall on 12/20/23 was not witnessed by staff. The nurses note dated 12/28/23 at 8:44 p.m. documents Called to patients room. She was sitting on the floor with her back to the wall. States she just wanted to use the bathroom and fell on the floor. Proper shoes worn. Call light not on, pt (patient) not using walker or gait belt. Denies hitting head. No injury noted. Able to move all extremities. Was assisted with gait belt and walker to stand. She then sat on toilet. Skin checked and no injury. Encouraged to call for help when needed however pt has forgetfulness and will self transfer all the time. VS (vital signs) taken. Family to be updated. This nurses note was written by LPN-Q. The nurses note dated 12/30/23 at 8:10 a.m. documents Resident found on the floor sitting beside her door, unable to tell staff what happen, initial neuro check negative, ROM WNL (range of motion within normal limits), denies any pain/ discomfort, slight redness noted at the upper back, writer updated NP [Name], resident's daughter [Name] and left a message for the DON. The following vital was obtained BP (blood pressure) 168/91, p (pulse) 96, spo2 (saturation of peripheral oxygen) 90%, R (respirations) 18, Temp (temperature) 97.8. This nurses note was written by RN-T. On 1/16/24 at 9:44 a.m. VP (Vice President) of Clinical Operations-D provided Surveyor with neuro checks for R5. Surveyor was provided with neuro checks for only two of R5's five falls. Neuro checks were provided for R5 fall on 12/4/23 & 12/8/23. Surveyor was not provided with neuro checks for R5's fall on 12/20/23, 12/28/23, & 12/30/23. Surveyor reviewed these two neuro checks and noted neuro checks were completed according to the Facility's policy for R5's fall on 12/4/23. Surveyor reviewed R5's neuro checks for the 12/8/23 fall and noted the neuro checks were not completed on 12/8/23 at 12:45 p.m., 1345 (1:45 p.m.), & 1445 (2:45 p.m.). On 12/9/23 neuro checks were not completed on the PM (evening shift). On 12/10/23 neuro checks were not completed on the day and evening shift. On 1/16/24 at 10:34 a.m. DON-B was informed Surveyor was not provided with neuro checks for R5's fall on 12/20/23, 12/28/23, & 12/30/23. On 1/16/24 at 10:37 a.m. Surveyor was informed by a team mate DON-B stated she had given Surveyor everything she has and if a Resident's fall is witnessed & they don't hit their head they do not do neuro checks. Surveyor noted R5's falls on 12/20/23, 12/28/23, & 12/30/23 were not witnessed. On 1/16/24 at 11:35 a.m. Surveyor again asked DON-B if she was able to locate R5's neuro checks for the falls on 12/20/23, 12/28/23, & 12/30/23. DON-B informed Surveyor she doesn't have them. On 1/16/24 at 1:29 p.m. DON-B informed Surveyors if a Resident's fall is unwitnessed and they have an activated power of attorney neuro checks are done as the Resident isn't able to let them know what happened but if a Resident is alert & orientated and able to tell them what happened they wouldn't do neuro checks. Surveyor asked DON-B if R5 has an activated power of attorney. DON-B replied yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure daily diabetic foot inspections was provided in accordance with professional standards of practice for 1 Resident (R) (R20) of 2 Residents reviewed with a diagnosis of Diabetes. * R20 who has Type 2 Diabetes Mellitus with diabetic neuropathy. R20's care plan and care card does not address performing daily foot care and inspection. R20 reported R20 has been taught to do diabetic foot checks but is not able to physically check his own feet. R20 reported staff do not check his feet daily. According to Director of Nursing (DON)-B foot checks are not completed daily but are completed weekly. Findings Include: According to the American Medical Directors Association (AMDA), Diabetes Management in the Post-Acute and Long Term Care Setting Clinical Practice Guideline. [NAME], MD: AMDA 2015 page 32-33 states in part: Train caregivers to perform daily foot care and inspection . The American Medical Directors Association (AMDA) - The Society for Post-Acute and Long-Term Care Medicine. Pressure Ulcers. Clinical Practice Guideline, dated 12/9/14, includes, in part: Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: At-risk foot: . has neuropathy .vascular insufficiency .cannot see, feel, or reach their feet Treatment Plan: Refer for podiatric care at least annually and as needed for specific foot problems. Train caregivers to perform daily foot care and inspection . According to AMDA - The Society for Post-Acute and Long-Term Care Medicine - Pressure Ulcers - Clinical Practice Guideline - http:// www.amda.com/ tools/ guideline.cfm#pressureulcer .to the extent feasible, caregivers should educate patients about daily foot care (e.g., washing, moisturizing), nail care, and about the importance of avoiding walking barefoot, avoiding foot trauma, and promptly telling a caregiver about foot pain or changes in the appearance of the feet . Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: at-risk foot; current mild foot, ankle, or heel infection or ulcer; and limb-threatening foot, ankle, or heel infection or ulcer . Risk Category: At-risk foot (patients who smoke; have vascular insufficiency, neuropathy, retinopathy, nephropathy, history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) Treatment Plan: · Refer for podiatric care at least annually and as needed for specific foot problems · Train caregivers to perform daily foot care and inspection · To the extent feasible, train patients to perform daily foot care and inspection . The American Diabetes Association (ADA) recommends, .Check your feet for sores, cuts, blisters, corns, or redness daily. The facility's Nursing Care of the Older Adult with Diabetes Mellitus revised November 2020 states the following: .Purpose To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further diabetes education and guidelines, refer to the provider orders and instructions as well as the American Diabetes Association, Standards of Medical Care in Diabetes. Complications Associated with Diabetes f. foot complications-neuropathy, dry skin, calluses, poor circulation, ulcers . The Facility does not have a formal diabetic foot care policy. On 1/16/24, Surveyor was provided an email from Medical Director (MD-Z) in regards to diabetic foot checks which states the following: .For diabetics living in long-term care, regular foot checks are crucial for preventing serious complications like ulcers and amputations. Here are the recommendations: Frequency: Daily self checks: Residents should visually inspect their feet daily for any changes, such as redness, swelling, cracks, blisters, or temperature differences. Professional checks: Trained staff should perform comprehensive foot checks at least weekly, and more often if the Resident has a history of foot problems or neuropathy What to check: skin-look for dryness, cracking, calluses, blisters,ulcers,redness, swelling, and any changes in temperature nails-check for ingrown toenails, fungal infections, and thickening bones and joints-look or deformities, swelling, and pain temperature-feel the feet to compare their temperature, cold feet may indicate poor circulation neuropathy-test for sensation using a monofilament or tuning fork . 1. R20 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Type 2 Diabetes Mellitus With Diabetic Neuropathy, Metabolic Encephalopathy, Hemiplegia and Hemiparesis Affecting Left Dominant Side, Morbid Obesity, and Major Depressive Disorder. R20 is currently R20's own person. R20's Quarterly MDS (Minimum Data Set) dated 10/27/23 documents R20's Brief Interview for Mental Status (BIMS) score to be 15, indicating R20 is cognitively intact for daily decision making. R20's MDS also documents for mobility that R20 requires substantial to maximum assistance to roll left to right as well as to go from sit to lying position. R20 requires substantial to maximum assistance for upper body hygiene and R20 is dependent for lower body hygiene. Surveyor reviewed R20's comprehensive care plan which contains the potential for hypo/hyperglycemia related to IDDM (Insulin dependent diabetes mellitus), started on 6/15/17 and edited on 11/2/23. The care plan contains an intervention with start date of 6/15/17, edited 2/18/18 that states monitor skin daily with cares and with showers, bathing for any adverse skin changes and notify nurse/md as needed and individualized teaching according to R20's needs R20's comprehensive care plan also indicates R20 has a potential for impaired skin/tissue integrity related to history of pressure areas, incontinence, edema, obesity a bed mobility problem, impaired physical mobility and diabetes started on 6/15/17, edited on 11/2/23. R20's care card does not contain documentation instructing staff to daily foot checks with cares. Surveyor reviewed R20's current physician orders and notes there is no order to complete daily diabetic foot inspections. Surveyor reviewed R20's Treatment Administration Records and notes that there is no documentation that R20's feet are being checked daily for signs/symptoms related to diabetes. Surveyor requested documentation of daily diabetic foot checks and was provided shower sheets for R20. On 1/11/24 at 10:51 AM, per [NAME] President of Clinical Operations (VP-D), skin checks and shower sheets are completed for each Resident one time weekly. Surveyor reviewed R20's Wound Management Detail Report and notes the following: -On 6/23/23 R20 was identified to have a pressure ulcer to the left big toe which was healed on 7/14/23. -On 6/23/23 R20 was identified to have a pressure ulcer to the left top of foot that was healed on 11/24/23. Surveyor notes that R20 has history of wound issues with R20's lower extremity. On 1/11/24 at 3:24 PM, Surveyor shared the concern with Administrator (NHA-A) and Director of Nursing (DON-B) the concern that with R20's Type 2 Diabetes Mellitus, Neuropathy, and Morbid Obesity diagnoses that R20 is prone to develop diabetic ulcers, has had wound issues in the past with the left foot, and has not received daily diabetic foot inspections. DON-B stated that for diabetics, daily foot checks are not completed, foot checks are only done on a weekly basis. Surveyor asked what standard of practice is the facility following. DON-B was unable to state at this time. No further information was provided by the facility at this time. On 1/16/24 at 9:00 AM, Assistant Director of Nursing (ADON-C) who is responsible for monitoring wounds stated that ADON-C periodically checks R20's feet. ADON-C is not sure if R20 has been instructed on how to do R20's own diabetic foot checks. ADON-C stated R20 most likely can not physically check R20's own feet for any changes, issues, etc. ADON-C stated that some facilities have mirrors so Residents can do this easily, but this facility does not have the mirrors. On 1/16/24 at 9:20 AM, Surveyor asked R20 if the facility has instructed R20 on how to do diabetic foot checks. R20 stated R20 has been taught how to do a diabetic foot check. R20 stated R20 physically could not check R20's own feet. R20 stated the staff is not checking R20's feet daily and are only checking R20's skin with showers. On 1/16/24 at 12:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA-P) in regards to R20, and diabetic foot checks. CNA-P stated CNA-P is a facility employee and takes care of R20 on a regular basis. CNA-P stated that CNA-P has not checked R20's feet for issues every time CNA-P has cared for R20. CNA-P did stated that CNA-P conducts skin checks with every shower. CNA-P stated the CNAs do not do diabetic foot checks on a daily basis. Surveyor asked CNA-P if CNA-P has been taught how to do a diabetic foot check like looking for temperature difference, redness, swelling, blisters, open areas, etc. CNA-P stated CNA-P has not received any training on diabetic foot checks. Surveyor asked if CNA-P has been instructed to document diabetic foot checks on a daily basis and CNA-P stated no. Surveyor reviewed the facility Agency CNA Expectations provided at time of Agency orientation and notes that there is no instructions to monitor Residents' feet who are diabetic. On 1/16/24 at 1:34 PM, DON-B, stated that R20 has the potential to injure a foot. DON-B stated that the CNAs put R20's diabetic shoes on everyday and would be looking at R20's feet because of that. DON-B stated that even though the wound notes document R20 had pressure areas on R20's left foot, DON-B believes it started as a callous.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure ongoing communication with a dialysis facility for 1 (R24) of 1 resident who received dialysis care and services. * R24 received dialysis three times per week. The Facility did not ensure ongoing communication occurred between the nursing facility and the dialysis facility prior to and following R24's dialysis appointments. Findings include: The nursing home dialysis transfer agreement between the nursing home and [Name of] Dialysis Center dated 5/18/22 under Now, Therefore, the Owner and Company agree to the following documents: 3. Designated Resident Information. Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center. This information, shall include, but is not limited to, where appropriate, the following: (a) Designated Resident's name, address, date of birth and Social Security Number; (b) Name, address and telephone number of the Designated Resident's next of kin; (c) Designated Resident's third party payer data and copies of cards or certificates evidencing same; (d) Appropriate medical records, including history of the Designated Resident's illness, including laboratory and x-ray findings; (e) Treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet or fluid intake; (f) Name, address and telephone number of the nephrologists with admitting privileges at Center referring the Designated Resident to Center; (g) Any advance directive executed by the Designated Resident; and (h) Any other information that will facilitate the adequate coordination of care, as reasonably determined by Center. The Dialysis policy and procedure revised 1/2023 under policy documents Geneva Lake Manor will use the Critical Element Pathway from CMS (Centers for Medicare & Medicaid Services) to provide quality dialysis services to our clients. Under procedure includes documentation of Communicate with dialysis facility before and after treatment via the Dialysis Communication Form. Coordinate Care Plan with dialysis facility. R24's diagnosis includes end stage renal disease. The physician orders dated 9/26/22 documents Hemodialysis 3 times weekly for ESRD (end stage renal disease) Special instructions: [Name of] Dialysis [phone number] [fax number]. The quarterly MDS (minimum data set) with an assessment reference date of 12/28/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Dialysis is checked while a Resident. On 1/9/24 at 10:06 a.m. Surveyor spoke with R24. R24 informed Surveyor he goes to dialysis three times a week by van. Surveyor inquired if prior to him leaving the facility for dialysis does staff give him a binder or any paper work. R24 informed Surveyor they don't send any paper work with him and once a month the dialysis center goes over his care plan with him. On 1/11/24 at 10:05 a.m. Surveyor asked CNA (Certified Nursing Assistant)-L if she knew if a dialysis binder or any papers went with R24 to dialysis. CNA-L informed Surveyor she's not sure but there may be a paper for the driver. CNA-L informed Surveyor she knows R24 goes to dialysis Monday, Wednesday, and Friday. On 1/11/24 at 10:08 a.m. Surveyor asked LPN/CM (Licensed Practical Nurse/Clinical Manager)-K if any papers are sent with R24 to dialysis. LPN/CM-K informed Surveyor she doesn't think they send anything with him but R24 is gone by the time she comes in. On 1/11/24 at 10:13 a.m. Surveyor noted under the resident document tab in R24's electronic medical record for dialysis communication there is only an order dated 8/23/23 regarding low hemoglobin and request for an occult blood test. There was no further information after this date. On 1/11/24 at 10:20 a.m. Surveyor asked ADON (Assistant Director of Nursing)-C how the Facility is communicating with the R24's dialysis center for R24. ADON-C replied to be honest I'm new don't know everything they do. ADON-C informed Surveyor [Name] is R24's nephrologists, R24 goes to [Name of] dialysis center, [Name] is RN at dialysis center. ADON-C informed Surveyor she doesn't know if they do vital signs before R24 goes or upon return. On 1/11/24 at 10:25 a.m. Surveyor informed DON (Director of Nursing)-B Surveyor reviewed R24's medical record and wasn't able to locate how the Facility was communicating with the dialysis center. DON-B informed Surveyor she can see where they are keeping the information and let Surveyor know. On 1/11/24 at 10:48 a.m. VP (Vice President) of Clinical Operations-D informed Surveyor they can't find any dialysis communication sheets. VP of Clinical Operations-D informed Surveyor they were sending a binder to dialysis, dialysis staff was not filling out their portion of the communication sheet so they stopped sending the communication sheet to dialysis instead of fixing the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure self-administration assessments were completed prior to leaving medication at the bedside to ensure safe medication delivery for 1 of 1 resident (R403) reviewed for self-administration. * R403 was observed to have medication left at bedside to self-administer and did not have a physician order or an assessment to self-administer medications. This is evidenced by: The facility's Medication Self-Administration of Medications policy states in part . Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. ability to read and understand medication labels; b. comprehension of the purpose and proper dosage and administration time for his or her medications; c. ability to remove medications from a container and ingest and swallow the medication; d. ability to recognize risks and major averse consequences of his or her medications. R403 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, respiratory failure, sepsis, weakness, anxiety, and depression. R403's Minimum Data Set (MDS) assessment on 01/04/24, confirmed R403 scored 8/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. R403 has an activated Power of Attorney to assist with decision-making. R403's physician orders, beginning 12/30/23, did not include an order to self-administer medications. R403's high risk medications include mirtazapine, an anti-depressant. R403's care plan included the following: Cognition: I am confused with dementia/Alzheimer's. I require orientation to my surroundings and reminders and assistance with medication management (01/10/24). Review of R403's record did not include an assessment to self-administer medications. On 01/09/24 at 9:45 AM, Surveyor observed R403 lying in her bed. Surveyor observed R403's breakfast tray and a medication cup containing seven pills on a bedside table, lateral to R403's bed. Surveyor noted R403 had not eaten any of her breakfast. R403 stated she was not hungry. Surveyor asked R403 about the medications on the bedside table, R403 stated, staff leave them there. At this time, R403 tried reaching for the medication cup, but was unable to do so due to the angle of her lying in bed and the position of the bedside table. R403 then tried to sit up in bed, however, was not able to sit up on her own. On 01/09/24 at 10:15 AM, Surveyor observed the medication cup with medications still on R403's bedside table. On 01/09/24 at 11:12 AM, Surveyor observed Certified Nursing Assistant (CNA) L assisting R403 to sit up on edge of bed and transfer to a shower chair. CNA L stated, I see you didn't take your meds yet. CNA L requested nurse come to R403's room. On 01/09/24 at 11:18, Licensed Practical Nurse (LPN) K entered R403's room. CNA L reported to LPN K, R403 had not taken her medications. LPN K took medication cup from bedside table. LPN K stated medications should not have been left in R403's room, and she would talk with the nurse who administered the medications. On 01/09/24 at 11:21 AM, Surveyor interviewed Registered Nurse (RN) J. RN J administered R403's medications in the morning. RN J reported medications administered were aspirin, atorvastatin, calcium carbonate, lisinopril, magnesium, metoprolol, and memantine. All medications were schedule to be taken at 8:00 AM. RN J stated R403 usually takes them with breakfast. RN J stated, I could go in there and see if she will take them. She is not due for other meds until later tonight, I know she is outside the window. On 01/09/24 at 11:34 AM, RN J administered R403's medications. RN J stated she does not know what the facility policy is regarding missed medications. RN J stated most of the medications R403 takes are for only once per day, and the ones that are twice per day, she will not take again until later this evening, like 6:00 PM or 9:00 PM. On 01/09/24 at 12:58 PM, progress note indicated R403's primary care provider was updated that R403's medications were not given until 11:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the Facility did not keep 1 (R5) of 1 Residents reviewed for antibiotic use free from unnecessary drugs. * On 11/3/23 R5 was ordered & received Macrobid 100 mg (milligrams) BID (twice daily) x (times) 5 days for UTI (urinary tract infection) when R5 did not have/ appropriate signs and symptoms for use of the antibiotic. Findings include: The Urinary Tract Infection/Bacteriuria-Clinical Protocol 2001 Med-Pass Inc. (Revised April 2018) under assessment and recognition includes documentation of; 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. a. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTIs varies. b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. c. New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc) is not enough to diagnose a UTI. Urine odor, color and clarity also are not adequate to indicate bacteriuria or a UTI. d. Acute deterioration in previously stable chronic urinary symptoms may indicate an acute infection. Multiple concurrent findings such as fever with hematuria or catheter obstruction are more likely to be due to a urinary source. e. A positive urine culture in someone with chronic genitourinary symptoms is not enough to diagnose a symptomatic UTI. The presence of either pyuria or a positive leukocyte esterase test alone are not enough to prove that the individual has a UTI, but the absence of pyuria, or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. The Revised McGeer Criteria for Infection Surveillance Checklist Table 2 Urinary Tract Infection (UTI) Surveillance Definitions for UTI without indwelling catheter under Criteria documents: Must fulfill both 1 and 2. 1. At least one of the following sign or symptom * Acute dysuria or pain , swelling , or tenderness of testes, epididymis, or prostate. * Fever or leukocytosis and [greater than or equal to sign] 1 of the following: * Acute costovertebral angle pain or tenderness * Suprapubic pain * Gross hematuria * New or marked increase in incontinence * New or marked increase in urgency * New or marked increase in frequency * If no fever or leukocytosis, then [greater than or equal to sign] 2 of the following: * Suprapubic pain * Gross hematuria * New or marked increase in incontinence * New or marked increase in urgency * New or marked increase in frequency 2. At least one of the following microbiologic criteria * [greater than or equal to sign] 10 5 cfu/ml (colony forming units/milliliter) of no more than 2 species of organisms in a voided urine sample. * [greater than or equal to sign] 10 2 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter. R5 was readmitted to the facility on [DATE] with diagnoses which include diabetes mellitus, depression, hypertension, generalized anxiety disorder, chronic kidney disease, and bipolar disorder. The quarterly MDS (Minimum Data Set) with an assessment reference date of 1/2/24 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderate cognitive impairment. R5 is assessed as requiring partial/moderate assistance with toileting hygiene and is frequently incontinent of urine. The nurses note dated 10/30/23 at 12:16 p.m. documents Per [Name of] NP (Nurse Practitioner)-V order noted for UA (urinalysis) and C+S (culture and sensitivity) order placed in computer. This nurses note was written by RN (Registered Nurse)-J. The nurses note dated 11/1/23 at 10:36 a.m. documents Resident admitted with weakness. Resident is alert and oriented to self only, needs anticipated and met by staff. VSS (vital signs stable) no s/s (signs/symptoms) discomfort noted. Resident sings and laughs to herself, semi cooperative with cares was yelling out during adls (activities daily living) but was fine once she was dressed and in her recliner. Lungs cta (clear to auscultation) bil (bilateral) denies cough, sob (shortness of breath) or chest pains. Radial/pedal pulses 2+, 1+ edema noted tubi grips in place. Abd (abdomen) soft, non-tender, bs (bowel sounds) present x4 incontinent of both b&b (bowel and bladder), U/A collected this am results pending. Appetite fair needs encouragement drinks fluids offered. Skin is warm and dry to touch. This nurses note was written by LPN-U. The nurses note dated 11/2/23 at 7:11 a.m. documents admitted weakness/altered mental status post hospitalization polypharmacy. Pleasantly confused. Much more alert and compliant compared to admission day. Lung sounds clear. No shortness of breath. Bilateral lower extremities swollen, non pitting at this time. Skin warm, slightly dry and pink. Incontinent of both bowel and bladder. Abdomen soft, non tender. Bowel sounds active. Upgraded to Lumex for transfers by therapy yesterday. One assist with ADL's (activities daily living). Able to position self in bed. Appetite fair. Adequate fluid intake. U/A pending. Pulse elevated at 100 and all other vital signs stable as charted. Denies any pain at time of assessment and voices no complaints at this time. This nurses note was written by LPN/CM (Licensed Practical Nurse)/Clinical Manager)-K. The nurses note dated 11/3/23 at 12:10 a.m. documents Faxed over pending lab. Awaiting results for culture. No new orders received. This nurses note was written by LVN (Licensed Vocational Nurse)-W. The nurses note dated 11/3/23 at 5:14 p.m. documents Received order from NP (Nurse Practitioner) for Macrobid 100 mg (milligram) BID (twice daily) x (times) 5 days for UTI, entered, message left for POA (Power of Attorney)/daughter to update. This note was written by RN (Registered Nurse)-M. The nurses note dated 11/3/23 at 9:38 p.m. documents ABT/UTI (antibiotic/urinary tract infection), no adverse reactions, afebrile, fluids encouraged, voices no complaints, will continue to monitor. This note was written by RN (Registered Nurse)-M. The nurses note dated 11/6/23 at 9:40 a.m. documents No adverse reaction noted from po (by mouth) ABT. This nurses note was written by RN-J. The nurses note dated 11/9/23 at 2:29 a.m. documents Completed oral ABT for UTI. F/U (follow up), no adverse drug reactions noted. Vital signs stable and charted. Started Trazadone at HS (hour sleep), appears to be resting comfortably tonight. Denies discomfort and refused midnight Tylenol per typical. Call light within reach. This nurses note was written by RN-X. On 1/16/24 at 12:53 p.m. Surveyor asked LPN/CM-K when she started being the Infection Preventionist at the Facility. LPN/CM-K informed Surveyor November. Surveyor asked if the Facility uses McGeers as their standard of practice for treating UTI's. LPN/CM-K replied yes. Surveyor informed LPN/CM-K Surveyor noted NP-V ordered an UA with C & S on 10/30/23 for R5. LPN/CM-K replied she's notorious for that. Surveyor informed LPN/CM-K R5 was placed on an antibiotic for an UTI but Surveyor was unable to locate any urinary symptoms. LPN/CM-K replied I don't think I was doing it then (referring to infection control) but don't think we had anyone just the DON (Director of Nursing). LPN/CM-K stated couldn't tell you, I don't know. On 1/16/24 at 1:11 p.m. Surveyor informed DON-B R5 was placed on an antibiotic on 11/3/23 for an UTI. Surveyor understands the Facility uses McGeers as their standard of practice for treating UTI's. Surveyor informed DON-B Surveyor was unable to locate any urinary symptoms to be placed on an antibiotic. DON-B informed Surveyor she will look into this and get back to Surveyor. On 1/16/24 at 1:59 p.m. DON-B informed Surveyor with their pan program the qualification is for weekly labs. DON-B indicated NP-V was the one that ordered the UA and C & S as R5 had an elevated WBC (white blood count). DON-B informed Surveyor she thinks because of the way hospitals run this is why the UA and C & S was ordered. DON-B informed Surveyor she can have their Medical Director talk to her about what we have to meet here. Surveyor asked DON-B if she was able to locate any urinary symptoms for R5. DON-B replied no urinary symptoms.

Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 33 opportunities which resulted in a medication error rate of 6.06%. Medication errors were identified for R351 & R38. * R351 did not receive PreserVision AREDS-2 on 1/10/24 as this medication was not available. * R38 did not receive Colchicine 0.6mg on 1/11/24 as this medication was not available. Findings include: 1. On 1/10/24 at 9:21 a.m. Surveyor observed LPN (Licensed Practical Nurse)-S prepare R351's medication which consisted of Carvedilol 3.125 mg one tablet, Finasteride 5 mg one tablet, Torsemide 10 mg one tablet and Vitamin D3 25 mcg (micrograms) one tablet. On 1/10/24 at 9:24 a.m. Surveyor verified the number of pills in R351's medication cup with LPN-S. On 1/10/24 at 9:24 a.m. LPN-S administered R351 the medication whole with water. LPN-S cleansed her hands after administering R351's medication. On 1/10/24 at 9:35 a.m. Surveyor reviewed R351's physician order and noted an order dated 1/6/24 which documents PreserVision AREDS-2 (vit c,e-zn-copper-lutein-zeaxan) capsule; 250-90-40-1 mg; amt: 1 capsule; oral Twice A Day 06:30 AM - 10:00 AM, 04:00 PM - 06:30 PM. On 1/10/24 at 9:37 a.m. Surveyor reviewed R351's January 2024 MAR (medication administration record) and noted for PreserVision on 1/10/24 for the time 06:30 a.m. to 10:00 a.m. (DG27) is documented. On 1/10/24 at 9:42 a.m. Surveyor spoke with LPN-S and showed LPN-S R351's January 2024 MAR for PreserVision. Surveyor asked LPN-S what (DG27) meant. LPN-S showed Surveyor Not Administered: Drug/Item Unavailable. LPN-S stated there wasn't a blister pack or bottle. This resulted in a medication error for R351. 2. On 1/11/24 at 7:51 a.m. Surveyor observed LPN/CM (Licensed Practical Nurse/Clinical Manager)-K cleanse her hands and prepare R38's G (gastrostomy) tube medications into separate medication cups which consisted of Amantadine 10 ml (milliliter) and Vitamin C 250 mg (milligrams) one tablet. LPN/CM-K then stated of course missing a pill. Surveyor inquired what LPN/CM-K was referring to. LPN/CM-K informed Surveyor she doesn't see R38's Colchicine 0.6 mg. LPN/CM-K withdrew 2 ml of Furosemide 10mg/ml into a syringe and squirted the medication into a medication cup. LPN/CM-K cleansed her hands. LPN/CM-K continued to prepare R38's medication of Losartan Potassium 50 mg two tablets, Protonix 40 mg packet, Senna plus one tablet, and Simethicone 80 mg one tablet. LPN/CM-K cleansed her hands, shook a bottle of Levetiracetam 100 mg/ml and poured 5 ml. On 1/11/24 at 8:06 a.m. Surveyor verified R38's medication with LPN/CM-K. After verifying R38's medication, LPN/CM-K crushed the tablets into separate medication cups. On 1/11/24 at 8:08 a.m. LPN/CM-K placed R38's medication cups on top of the bedside dresser, shut off the tube feeding which was not running and unhooked the feeding. LPN/CM-K informed R38 she was going to flush his tube and flushed G-tube with 150 cc (cubic centimeter) of water. After flushing R38's G-tube LPN/CM-K administered each medication individually flushing with 30 cc of water in between. On 1/11/24 at 1:31 p.m. Surveyor reviewed R38's January 2024 MAR (medication administration record. Surveyor noted Colchicine tablet; 0.6 mg; frequency once a day, time 6:30 AM - 10:00AM is blank on 1/11/24 which indicates not administered. Not administering Colchicine 0.6 mg tablet resulted in a medication error for R38. On 1/11/24 at 3:10 p.m. during the end of the day meeting, NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were informed of the above. No additional information was provided to Surveyor regarding R351 & R38's medication not available. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R2 was admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure and emphysema. R2 was admitted on hospice care. R2 had been bed ridden for a year prior to admission to facility and is morbidly obese. Due to concerns for R2's skin integrity and to prevent skin breakdown, R2 has an indwelling foley catheter. On 01/09/24 09:57 AM, Surveyor observed R2 with an indwelling foley catheter. On 01/11/24, at 8:44 AM, Surveyor could not locate a comprehensive care plan for R2's indwelling foley catheter. Surveyor requested a copy of R2's care plan for indwelling foley catheter and received an indwelling foley catheter care plan with created date of 01/11/24. Based on observations, record review and interviews, the facility did not ensure Residents had an individualized comprehensive plan of care. This was observed with 5 (R15, R20, R40, R300, and R2) of 21 Residents comprehensive care plan reviews. *R15 has a repositioning bar on R15's bed and has an active history of refusing showers. There was no comprehensive plan of care with individualized interventions to address the repositioning bar or the refusal of showers. *R20 has bilateral half side rails on R20's bed and there was no comprehensive plan of care with individualized interventions to address the half side rails. *R40 is a smoker and there was no comprehensive plan of care with individualized interventions to address smoking safety. *R300 returned from the hospital on 1/7/24 with a new diagnosis of Type 2 Diabetes and there was no comprehensive plan of care with individualized interventions to address R300's new diagnosis of Type 2 Diabetes. *R2 was admitted with an indwelling foley catheter and there was no comprehensive plan of care with individualized interventions to address R2's indwelling foley catheter. Findings Include: Surveyor reviewed the facility's Care Plans, Comprehensive Person Centered policy and procedure revised March 2022 and notes the following: .Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical, psychosocial, and functional needs is developed and implemented for each Resident. Policy Interpretation and Implementation 1. The interdisciplinary(IDT), in conjunction with the Resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each Resident. 2. The comprehensive, person-centered care plan is developed within seven(7) days of completion of the required minimum data set(MDS) assessment and no more that 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes b. describes the services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, and psychosocial well-being 3. which professional services are responsible for each element of care. c. includes the Resident's stated goals upon admission and desired outcomes d. builds on the Resident's strengths e. reflects currently recognized standards of practice for problem areas and conditions 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the Resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of Residents are ongoing and care plans are revised as information about the Residents and the Residents' condition change. 12. The IDT reviews and updates the care plan: a. when there has been a significant change in the Resident's condition b. when the desired outcomes is not met c. when the Resident has be been readmitted to the facility from a hospital stay d. at least quarterly, in conjunction with required quarterly MDS assessment . 1. R15 was admitted to the facility on [DATE] with diagnoses of Cellulitis of Right and Left Lower Limb, Morbid Obesity, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Glaucoma, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. R15 currently has an activated Health Care Power of Attorney(HCPOA). R15's Annual Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview for Mental Status (BIMS) score to be 13, indicating R15 is cognitively intact for daily decision making. R15's MDS also documents for mobility that R15 requires substantial/maximum assistance for rolling left and right and is dependent for sit to lying and sit to stand. Bed rails are not documented as well as any behaviors for R15 are not documented. R15's MDS documents that showers are somewhat important to R15. Surveyor reviewed R15's care card which does not document that R15 uses a repositioning bar for bed mobility or there is potential for refusal of showers. On 1/9/24 at 9:59 AM, Surveyor observed that R15 had a repositioning bar on the right side of the bed. R15 informed Surveyor that R15 uses the repositioning bar to assist with getting in and out of bed. On 1/9/24, Surveyor reviewed R15's comprehensive care plan and notes that R15's repositioning bar is not documented along with individual interventions. On 1/16/24 at 12:49 PM, Certified Nursing Assistant (CNA-P) confirmed that R15 does use the repositioning bar, usually to boost R15's self up and to reposition. On 1/9/24 at 9:58 AM, R15 also informed Surveyor that R15 has not been getting showers on a regular basis and is scheduled for Tuesdays and Fridays. On 11/21/23, Surveyor notes there is documentation that R15 refused a shower. On 1/9/24, Surveyor asked for R15's last six months of documentation of R15 receiving showers. Surveyor notes there is no comprehensive care plan documenting that R15 refuses showers with individualized interventions. On 1/16/24 at 12:34 PM, CNA-P informed Surveyor that R15 will refuse showers because R15 does not want agency staff to give the shower, CNA-P stated R15 is more likely to take a shower with regular staff. On 1/11/24 at 12:16 PM, [NAME] President of Clinical Operations(VP-D) informed Surveyor there is no documentation of R15 refusing showers and is aware there is no comprehensive care plan in place for R15's refusal of showers. Understands there have been no interventions put into place for refusal of showers. VP-D confirms R15's refusal of showers should be documented within R15's comprehensive care plan. On 1/11/24 at 3:31 PM, Surveyor shared the concern with Administrator(NHA-A) and Director of Nursing(DON-B) that R15's repositioning bar and R15's refusal of showers is not documented within R15's comprehensive care plan along with individualized interventions. No further information was provided by the facility at this time. 2. R20 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Type 2 Diabetes Mellitus, Metabolic Encephalopathy, Hemiplegia and Hemiparesis Affecting Left Dominant Side, Morbid Obesity, and Major Depressive Disorder. R20 is currently R20's own person. R20's Quarterly Minimum Data Set (MDS) dated [DATE] documents R20's Brief Interview for Mental Status (BIMS) score to be 15, indicating R20 is cognitively intact for daily decision making. R20's MDS also documents for mobility that R20 requires substantial to maximum assistance to roll left to right as well as to go from sit to lying position. Bed rails are not documented on R20's MDS. Surveyor reviewed R20's care card which does not document that R20 uses a repositioning bar for bed mobility. On 1/9/24 at 9:38 AM, Surveyor observed bilateral half side rails on R20's bed. R20 informed Surveyor that R20 used the side rails to assist R20's self with sitting up and rolling side to side. On 1/9/24, Surveyor reviewed R20's comprehensive care plan and notes that R20's repositioning bar is not documented along with individual interventions. On 1/11/24 at 3:26 PM, Surveyor shared the concern that R20 did not have documentation located within R20's comprehensive care plan addressing the need for side rails and with individualized interventions. No further info was provided at this time by the facility On 1/16/24 at 12:52 PM, CNA-P informed Surveyor that R20 uses the half side rails to roll and grip on to when being assisted in the bed. 3. R40 was admitted to the facility on [DATE] with diagnoses of Complete Traumatic Amputation at Level Between Knee and Ankle, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus and Essential Hypertension. R40 is currently R40's own person. R40's Quarterly MDS dated [DATE] documents R40's Brief Interview for Mental Status(BIMS) score to be 15, indicating R40 is cognitively intact for daily decision making. Surveyor reviewed R40's care card which does not document that R40 is a safe or supervised smoker. On 1/10/24 at 7:13 AM, Surveyor reviewed R40's electronic medical record(EMR) and noted that R40's comprehensive care plan does not contain documentation that R40 is a smoker and if R40 is safe to smoke by R40's self, with individualized interventions. On 1/10/24 at 9:45 AM, Director of Nursing(DON-B) informed Surveyor that the MDS nurse was doing most of all the IDT sections of the Residents' comprehensive care plans but no longer works as of 'last Friday'. Surveyor asked DON-B would the expectation be that R40 should have a smoking care plan, and DON-B stated yes. On 1/11/24 at 3:29 PM, Surveyor shared the concern with NHA-A and DON-B that R40 does not have a smoking care plan in place. No further information was provided by the facility at this time. On 1/15/24, DON-B provided Surveyor with a smoking care plan for R40 created 1/15/24. 4. R300 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, Dysphagia, Dyspnea, and Adjustment Disorder with Depressed Mood. R300 is currently R300's own person. R300's Quarterly Minimum Data Set (MDS) dated [DATE] documents R300's Brief Interview for Mental Status(BIMS) score to be 15, indicating R300 is cognitively intact for daily decision making. R300's MDS also documents for mobility that R300 requires partial to moderate assistance for rolling left to right and substantial to maximum assistance for sit to lying and sit to stand. Bed rails are not documented on R300's MDS. R300's MDS also documents that R300 has upper and lower range of motion impairment on one side. On 12/30/23, R300 was discharged to the hospital and returned to the facility on 1/7/24. R300 returned with a new diagnosis of Diabetes Mellitus. On 1/9/24 at 11:37 AM, Surveyor observed R300 has 1 repositioning bar on the right side of R300's bed. R300 informed Surveyor that R300 uses it to roll from side to side. Surveyor reviewed R300's EMR and notes the following documentation: On 1/7/2024 at 8:15 PM, LPN-R documents R300 is being monitored due to being a readmit. R300 is now a type 2 diabetic. New diet has been tolerated well. No issues this shift or complaints of any. On 1/11/2024 at 2:17 PM, Licensed Practical Nurse (LPN-S) documents that monitoring due to readmitting, new diabetic diet, has snacks in R300's room that R300 eats, accepting of insulin and blood sugar checks this shift. Surveyor notes that R300's care card does not have documentation that R300 uses a repositioning bar for mobility and R300's diet is marked as regular and not diabetic. On 1/11/24 at 9:35 AM, Surveyor reviewed R300's comprehensive care plan. R300's repositioning bar is not addressed on the comprehensive care plan. R300's diabetic status and interventions are not addressed on R300's comprehensive care plan. On 1/16/24 at 12:53 PM, CNA-P confirmed that R300 uses the repositioning bar to reposition self. On 1/16/24 at 2:13 PM, Surveyor interviewed DON-B. DON-B is aware a care plan for R300's diabetes was not initiated and should have been. DON-B stated I saw that [R300] did not have a care plan (referring to diabetic care plan) and did not get to it yet. Surveyor shared that R300 did not have a care plan for R300's repositioning bar. Surveyor also shared the concern that R15, R20, R40 and R300 should have had a care plan for all services provided with measurable objectives and timeframes along with individualized interventions. DON-B understands the concern. No further information was provided by the facility at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not provide adequate supervision and interventions to prevent accidents for 4 (R17, R300, R32 and R5) of 4 sampled Residents identified by the facility to be at risk for falls. *On 1/19/24, R17 was not transferred per plan of care (including the care card), which indicates the use of 2 staff assist when transferring with the hoyer lift. *R300 had 4 falls all from R300's recliner on 9/13/23, 10/4/23, 11/12/23, and 12/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R300's falls. *R32 had 2 falls on 7/29/23 and 11/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R32's falls. *R5 had 5 six falls in December 2023: 12/4/23, 12/8/23, 12/20/23, 12/27/23, 12/28/23, & 12/30/23. The Facility did not thoroughly investigate these falls. There is no evidence staff were interviewed to determine when R5 was last observed, when R5 was provided cares, and were prior interventions in place. Findings Include: The facility's Falls-Clinical Protocol policy and procedure revised March 2018 was reviewed and the following is applicable: .Assessment and Recognition 1. The physician will help identify individuals with a history of falls and risk factors for falling. c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 2. In addition, the nurse shall assess and document/report the following: h. Precipitating factors, details on how fall occurred. 3. The staff and practitioner will review each Resident's risk factors for falling and document in the medical record. 4. The physician will identify medical conditions affecting fall risk. 5. The staff will evaluate and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position b. Those that occur while upright and attempting to ambulate c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor 7. Falls should also be identified as witnessed or unwitnessed events Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. a. Often, multiple factors contribute to a falling problem. 2. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction(ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. Monitoring and Follow-Up 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the Resident is stable and delayed complications. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 3. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed, for example, if the problem that required intervention has resolved by addressing the underlying cause. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the Resident's falling and also reconsider the current interventions. 5. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes. Surveyor also reviewed the facility's Safe Lifting and Movement of Residents policy and procedure revised July 2017 and notes the following: .Policy Statement In order to protect the safety and well-being of staff and Residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move Residents. Policy Interpretation and Implementation 4. Staff responsible for direct Resident care will be trained in the use of manual and mechanical lifting devices. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move Residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Surveyor also reviewed the facility's Agency Certified Nursing Assistant (CNA) Expectations which documents that all mechanical lift transfers require 2 people. It also documents that long term Residents have care cards on the inside of the closet door where you can find Resident information (transfer status, needs, and interventions). 1. R17 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, Osteomyelitis, Parkinsonism, Type 2 Diabetes Mellitus, Colostomy Status, Contracture of Right Hand, Contracture of Left Hip, and Unspecified Abnormalities of Gait and Mobility. R17 is R17's own person. R17's Annual Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R17 is cognitively intact for daily decision making. R17's MDS also documents R17 requires substantial/maximum assistance for upper body dressing and dependent for lower body dressing. R17 is dependent for transfers and rolling in bed. R17 also has range of motion impairment on both sides of upper and lower extremities. R17's care cards document the assistance of 2 for hoyer transfers. R17's comprehensive care plan documents the following in regards to falls: -R17 has impaired physical mobility related to pain, disease process-parkinsons, history of cva, contracture to left side extremities and right wrist, bed/chairfast-start 5/16/19, edited 11/16/23 Intervention-5/16/19-Transfer with hoyer lift with assist of 2 -R17 is at risk for falls related to high fall risk assessment, weakness, impaired physical mobility, sensory impairment and history of falls-start 5/16/19, edited 11/16/23 Intervention-5/16/19-Medi-hoyer lift for all transfers with the assist of 2 R17's most recent Fall assessment dated [DATE] documents R17 is a moderate fall risk. On 1/10/24 at 10:05 AM, R17 informed Surveyor at the Resident Council meeting, that R17 had been transferred from chair to bed in the hoyer by one cna in the evening of 1/9/24. Surveyor asked if R17 had told anyone in the facility of this. R17 stated R17 informed CNA Supervisor (CNA-EE) of the transfer by one CNA. On 1/10/24 at 1:13 PM, CNA-EE informed Surveyor that R17 had informed CNA-EE of the transfer of one with the hoyer lift. CNA-EE stated CNA-EE was instructed by Director of Nursing (DON-B) to call the CNA and get a statement of what occurred on 1/9/24. On 1/10/24 at 2:45 PM, CNA-EE informed Surveyor that the agency CNA stated she did transfer R17 by herself in the hoyer lift, but alleges the nurse was watching from the doorway. CNA-EE confirmed at this time that a hoyer lift always requires assist of 2. CNA-EE stated to Surveyor that a re-education is being completed. On 1/10/24 at 3:33 PM, Surveyor shared the concern about R17 being transferred by 1 with the hoyer lift with Administrator (NHA-A) and DON-B. DON-B stated re-education is being done, and informed Surveyor that an orientation is done for agency CNAs before they start working on the floor. DON-B stated that the care cards are to be followed and located in closets, and that all Residents who utilize a hoyer should be transferred assist of 2 and the CNA knew she should not have transferred R17 by herself. On 1/11/24 at 8:00 AM, Surveyor interviewed R17 about the incident again. R17 stated the only way to transfer R17 from the bed to chair with the hoyer lift, is to close the door because of the way the hoyer lift needs to be positioned. On 1/16/24 at 12:44 PM, CNA-P informed Surveyor that all hoyer lifts must be operated with assistance of 2. 2. R300 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, Dysphagia, Dyspnea, and Adjustment Disorder with Depressed Mood. R300 is currently R300's own person. R300's Quarterly MDS dated [DATE] documents R300's Brief Interview for Mental Status(BIMS) score to be 15, indicating R300 is cognitively intact for daily decision making. R300's MDS also documents for mobility that R300 requires partial to moderate assistance for rolling left to right and substantial to maximum assistance for sit to lying and sit to stand. The MDS also documents that R300 requires substantial to maximum assist for transfers. MDS also documents that R300 has upper and lower range of motion impairment on one side. R300's care card instructs staff that R300 requires the assist of 1 for bed mobility, assist of 1 for transfers using the gait belt, and assist of 2 with ambulation. R300's comprehensive care plan documents the following in regards to falls: -R300 is at risk for falls related to high fall risk assessment, unsteady gait, history of cva left hemiplegia, impaired physical mobility, history of fall-start 8/3/17, edited 1/10/24 Intervention-12/1/23-Place signs near Residents recliner to remind R300 not to elevate recliner due to possibility of sliding out when in upright position. Intervention-9/13/23-Encourage R300 to leave door open after cares have been provided if R300 refuses document refusal in progress note. Intervention-12/31/21-R300 to shut off own call light after staff assist Intervention-11/12/21-R300 instructed to use call-light and wait for staff Intervention-1/1/21-R300 to wear brace on left ankle for more stability Intervention-11/26/19-R300 provided new recliner as prior chair easily tips forward Intervention-8/3/17-Keep call light within reach of R300 at all times while in room and answer promptly -Non-skid footwear on for transfers and ambulation -Keep adjustable bed in proper position for safe transfers -Encourage to use recommended assistive device in transfer/ambulation per therapy recommendation. 1 assist with gait belt for transfers. -Encourage to request assist in transfer and ambulation and not to attempt alone -BP to assess for postural hypotension prn -Grabber provided to reach for items on the floor or out of reach -R300 to work with therapy on balance and ambulation as needed -Education provided to sister and R300 for need of assistance and R300's inability to ambulate independently. Remind R300 of the need for patience and wait for staff to assist R300 with transfers. Grip tape applied to bathroom floor to prevent shoe from slipping. Intervention-2/18/23-Gripper strips in front of recliner Intervention-5/18/21-Prevent falls and reduce impulsiveness by keeping wheelchair in bathroom while R300 sitting in recliner R300's most recent fall assessment dated [DATE] documents a score of 18 indicating R300 is high risk for falling. On 9/27/23 the fall assessment documents a score of 21 indicating a high risk for falling. R300 had 4 falls all from R300's recliner on 9/13/23, 10/4/23, 11/12/23, and 12/30/23. 9/13/23-R300 was found facing down under R300 recliner stating R300 was trying to put lotion on R300's heel and just slide down R300's recliner landing on R300's bottom. MD notified and ordered to continue to monitor with neuro-check. A registered nurse (RN) assessment was completed. The Facility did not thoroughly investigate this fall. There is no evidence staff were interviewed to determine when R300 was last observed, when R300 was provided cares, and were prior interventions in place. 10/4/23 R300 raised electric recliner too far and slid out of chair to sitting position on floor with back and head resting on cushioned recliner. MD notified. The Facility did not thoroughly investigate this fall. There is no evidence staff were interviewed to determine when R300 was last observed, when R300 was provided cares, and were prior interventions in place. 11/12/23 Report given that R300 had raised recliner all the way up and slid/fell out of chair. A registered nurse(RN) assessment was completed. The Facility did not thoroughly investigate this fall. There is no evidence staff were interviewed to determine when R300 was last observed, when R300 was provided cares, and were prior interventions in place. 12/30/23 R300 was observed raising recliner with controller and it went too high. R300 seen slipping out of chair, landed on buttocks onto floor. MD notified. The Facility did not thoroughly investigate this fall. There is no evidence staff were interviewed to determine when R300 was last observed, when R300 was provided cares, and were prior interventions in place. On 1/16/24 at 1:38 PM, DON-B stated that an assessment is completed at time of the fall. The RN might not look at fall or injury, because there is an RN not in the building all the time, usually on pm and noc shifts. There should be a layout of the room completed. CNA fills out the incident report for root/cause analysis, nurse does notification of MD and family. DON-B stated that staff should be writing out statements. Part of the investigation covers last toileted, last meal, last seen, equipment issues. Incident reports was discovered that it was not being done by old Assistant Director of Nursing (ADON). DON-B stated the ADON said it only needed to be discussed in the huddle. Surveyor shared the concern that R300 had 4 falls all from R300's recliner on 9/13/23, 10/4/23, 11/12/23, and 12/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R300's falls. Surveyor also shared with DON-B that there is no evidence staff were interviewed to determine when R300 was last observed, when R300 was provided cares, and were prior interventions in place. On 1/11/24 at 9:39 AM, VP of Clinical Operations (VP-D) informed Surveyor that a performance improvement plan was established for falls and was signed (1/9/24) right before the survey started. 3. R32 is a [AGE] year-old resident who has resided in the facility since admission on [DATE]. R32's diagnoses include dementia, altered mental status, major depressive disorder, hemiplegia, anxiety disorder, muscle weakness generalized, transient ischemic attack (TIA), and dysphagia. R32's most recent Quarterly Minimum Data Set (MDS) was completed on 12/3/23. R32 has unclear speech, usually makes herself understood and sometimes understands others during conversation. R32's Brief Interview for Mental Status (BIMS) was not completed as she is rarely/never understood. R32's cognition is severely impaired and never/rarely able to make decisions regarding tasks of daily living. R32 uses a wheelchair for mobility and is dependent for toileting as well as dressing and requires substantial or maximal assistance with bathing. R32's care card indicates R32 is an assist of 1 for bathing, grooming and transfers. Fall prevention interventions on R32's care card indicates, a fall mat and 1 to 1 during toileting. Surveyor reviewed R32's comprehensive care plan. A focused problem initiated 7/15/2020 and edited on 12/9/23 for R32 is at risk for falls related to moderate fall risk assessment, unsteady gait, weakness, impaired physical mobility, sensory impairment, impaired judgment - the use of psychotropic medication-antidepressant use, poor safety awareness, impulsivity, balance loss, incontinence, limited ability to communicate with staff due to cognitive loss and history of being non-verbal etiology unknown, does not use call light to alert staff of any care needs, meandering in wheelchair in and out of room, other rooms or facility. R32' Comprehensive Care Plan Interventions are as follows: ~ Motion alarm at all times while she is in her room and fall mat on floor next to bed. Alarm on bathroom door to alert staff of attempts to toilet self as she needs help with toileting. Start date on 5/5/23, edited 5/8/23. ~ Every two-hour checks while in bed. Created on 2/9/23. ~ No pads on wheelchair to ensure R32 does not slip out of wheelchair. Created on 9/28/22. ~ Staff to do frequent rounding to maintain safety. Created on 5/9/22. ~ Bed in lowest position. Created on 8/25/20. ~ Follow toileting schedule. Created on 7/15/20. ~ Keep call light within reach of R32 at all times while in room and answer promptly. Created on 7/15/20 ~ Lock bed brakes. Created on 7/15/20. ~ Non-skid footwear on for transfers and ambulation. Created on 7/15/20. On 01/16/24 at 9:00 AM, Surveyor observed R32 in a low bed that was in low position, with a fall mat next to the bed, and a motion sensor alarm on the fall mat. Surveyor also observed a motion sensor alarm on R32's bathroom door. R32's room was observed to be clean and free of items on the floor, along with R32's broda chair in the corner. R32 was laying on her back in bed with her head of bed up approximately 45 degrees, with a hospital gown and sweat pants on with a sheet partially covering her. Surveyor reviewed R32's Progress Notes which documented in part; 07/29/2023 11:46 PM Resident discovered during shift change rounds lying facedown on floor next to bed. Floor mat on floor. Bed alarm not on. Call light within reach, not activated. Large hematoma on left forehead and eye. Guarding left hand/arm. When asked if ULE (upper left extremity) hurt resident responded yes. Baseline confused and forgetful. VSS. Alert and responsive. Orders to send to ED (Emergency Department for eval and tx (treatment) obtained from [Name] medical. Message left for POA (Power of Attorney). DON (Director of Nursing) aware. Ambulance service here to transport resident 2340 (8:40 pm). RN-G 07/30/2023 02:50 AM Resident returned from ED via ambulance at this time. All scans negative. Resident in bed, bed in lowest position, floor mat next to bed and floor alarm on. Wanderguard replaced to RLE (right lower extremity). RN-G 07/30/2023 12:40 PM post fall charting. vitals within limits. up in wheelchair at time of assessment. neuro checks completed on paper form. unable to assess pupil dilation d/t (due to) swelling of L (left) eye. large dark purple hematoma to L eye. mentation per baseline. denies pain. no pain indicating behaviors. DON-B 07/30/2023 04:33 PM f/u (follow up) post unwittness fall: Pt is alert denies pain and no signs of pain at this time, negative neuro check, unable to assess Left eye reaction or pupil size d/t large purple hematoma to left eye. baseline movement to extremities. VSS and written in paper form. RN - MM 07/31/2023 02:35 AM Follow up on unwitnessed fall. Resident in bed with safety measures in place. Vital signs stable and charted. Neuro check negative. Alert and denies any discomfort when asked. Large purple bruising and edema noted to left eye. Unable to assess eye due to large hematoma. No change in mental status. Wander guard in place, floor mat in place, floor alarm on and in place. RN-X Surveyor reviewed the 7/29/23 facility fall report for R32. R32 had an unwitnessed fall on 7/29/23. R32 was found on the floor next to her bed lying face down. R32's floor mat was on the floor, but the bed alarm was not on. The call light was within reach of R32 and was not activated. R32 was found to have a large hematoma on her left forehead and eye. R32 was also guarding her left hand and arm. R32 had complaints of pain in her left upper extremity and was sent to the emergency room (ER) for evaluation. Surveyor reviewed the facility's internal self-report file and notes there is no root cause analysis and no thorough investigation as related to the fall. Surveyor notes, there is not a thorough investigation into possible causes contributing to R32's fall which may include causes such as, confirming proper bed alarm function, when R32 was last seen by staff, chair properly locked, or possible behavior or medical changes prior to R32's fall. Surveyor requested further fall investigation documentation from [NAME] President (VP) of Clinical Operations-D on 1/11/24 at 9:38 am. VP of Clinical Operations-D indicated the facility did not have a full investigation for R32's fall on 7/29/23. Surveyor interviewed Director of Nursing (DON)-B on 1/16/24 at 1:28 pm. DON-B indicated all staff working on the day of a resident fall are to write up statements. DON-B stated the previous Assistant Director of Nursing, who is no longer employed at the facility, did not perform incident reports, which included R32's 7/29/23 fall and performed huddles with staff. DON-B indicated the facility took action regarding the Certified Nursing Assistant (CNA) who was working with R32 at the time of 7/29/23 fall due to not doing a final round on R32 prior to fall and not checking to see if fall alarm was turned on. DON-B indicated this CNA left their shift prior to filling out a fall report. Surveyor notified DON-B of concerns with the facility's internal self-report for not conducting a root cause analysis and the facility not performing a thorough investigation for R32's fall on 7/29/23. Surveyor requested additional information if available. No additional information was provided. Surveyors continued to review R32's progress notes which indicate in part; On 11/30/2023 10:36 PM Resident found on the floor about 1615 (4:15) pm, CNA [name] called nurse into the room, resident was face down on the floor, resident had a big hematoma on forehead, some bleeding not much, v/s taken immediately B/P 170/118, P 57, RR 19, O2 91%, T 97.8, resident sent to the hospital, paramedics arrived about 1630 (4:30) pm, hospital called and stated resident will return back to facility about 2030 (8:30) pm, CT to head, neck and cervical spine negative, resident returned to facility by 2100 (9:00) pm, neuro checks started on resident, family was called and updated, resident's forehead and eye very swollen, resident currently resting in her bed, will continue to monitor. LPN-H 11/30/2023 11:22 PM Resident found on floor in her room face down. Noted bleeding from forehead and mouth. Resident was wearing gripper socks and was seen in wheelchair just 3 mins (minutes) prior to being found. Writer called to room, Vitals taken, 911 called, cool towel and ice pack placed on forehead. Resident taken to hospital via ambulance. Writer called DON, son [name], NP [name] all updated. Fall unwitnessed, charge nurse [name] present and assisted with assessment. LPN-NN 12/01/2023 04:25 AM Resident remains on 24 hour board for neuro checks for 11/30 fall. Resident is very sleepy. RN-OO 12/01/2023 10:46 PM Resident still being monitored d/t fall, neuro checks in place, no signs of pain or discomfort, some bruising and swelling to eye and forehead, resident sleeping peacefully in her bed, will continue to monitor. LPN-H 12/02/2023 01:45 PM Post fall monitoring. Staff feeding pt noted she was more lethargic than yesterday. Left hand contracted and tremors noted. Pt moving extremities weaker and slower than usual. Call out to NP. POA updated and wanted pt. sent to ED for evaluation. Pt. sent to [name] ER. Called then back around noon for update. They state pt. had urinary tract infection (UTI) and will be started on [NAME] (antibiotics) and sent back to facility. LPN-Q Surveyor reviewed the 11/30/23 facility fall report for R32. R32 had an unwitnessed fall on 11/30/23. R32 was found on the floor in her room lying face down. R32 was found to have bleeding from her forehead and mouth. Surveyor reviewed the facility's internal self-report file and notes there was no root cause analysis and no thorough investigation related to the fall. Surveyor noted R32 was sent to the emergency room (ER) on 12/2/23 and was diagnosed with a Urinary Tract Infection (UTI). Surveyor requested further fall investigation documentation from VP of Clinical Operations-D on 1/11/24 at 9:38 am. VP of Clinical Operations-D indicated the facility did not have a full investigation for R32's fall on 11/30/23. Surveyor interviewed Director of Nursing (DON)-B on 1/16/24 at 1:28 pm. Surveyor notified DON-B of concerns with the facility's internal self-report not including a root cause analysis and the facility not performing a thorough investigation for R32's fall on 11/30/23. Surveyor reviewed with the DON-B, that record review indicates R32 was sent to the ER on [DATE] and diagnosed with a UTI which could be a potential cause for falls with the elderly. DON-B acknowledged the 12/2/23 ER admission for R32 and stated the facility did not perform a thorough investigation for R32's 11/30/23 fall. Surveyor requested additional information if available. No additional information was provided. 4. R5 has diagnoses which include diabetes mellitus, depression, hypertension, generalized anxiety disorder, and bipolar disorder. R5's power of attorney for healthcare was activated on 10/25/23. The at risk for falls care plan with a start date of 12/4/23 & edited on 12/21/23 documents the following approaches: *Place signs near resident recliner and bed to ask for assistance for transferring. Start date 12/5/23. *PT (physical therapy) screen for use of walker at all times vs use of w/c (wheelchair). Start date 12/11/23. *Autolock breaks to w/c due to fall on 12/8/23 as intervention to help prevent further falls. Start date 12/15/23. *Patient to ambulate to meals with one assist and walker and toilet before and after meals. Start date 12/21/23. *Lab to draw to determine if patient requires vitamin D supplement due to HX (history) of deficiency which could contribute to falls. Label to patient w/c for proper identification to ensure she is using her w/c vs someone without autolock breaks sic (brakes). Start date 12/28/23. *Patient to have sensor alarm while in w/c and motion alarm when in bed as intervention for further falls. Start date 12/29/23. The quarterly MDS (Minimum Data Set) with an assessment reference date of 1/2/24 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderate cognitive impairment. R5 is assessed as requiring partial/moderate assistance for toileting hygiene, mobility rolling left to right is independent, and transfer is supervision/touching assistance. R5 is continent of bowel and frequently incontinent of urine. R5 has fallen since prior assessment period with 2 or more falls with no injury and one with injury (except major). FALL #1 The nurses note dated 12/4/23 at 7:56 p.m. documents writer called to resident's room, aid, daughter and therapy all in room and resident was sitting on floor in front of recliner, resident stated she was going to sit in recliner and slid off edge, denied pain or hitting head, ROM (range of motion) baseline, neuro check neg (negative), vitals charted, resident helped into recliner. This nurses note was written by RN (Registered Nurse)-M. The nurses note dated 12/5/23 documents IDT (interdisciplinary team) meeting regarding yesterdays fall. Signs placed in room to remind resident to ask for assistance for transfers as intervention. This nurses note was written by LPN/CM-K. The nurses note dated 12/5/23 at 12:44 p.m. documents F/U (follow up) fall no injury noted and patient denies any pain see flow sheet. A/O (alert/orientated) 2-3 forgetful needs cuing likes to sing and hum. Participated with activity today. Appetite good eats in the dining room. Non labored breathing no cough or congestion. No GI (gastrointestional) or cardiac issues. Protective wear for occasional incontinence. 1 assist with ADL's (activities daily living) and 1 assist with gb (gait belt) and walker steady gait noted. Propels self in w/c (wheelchair). Skin warm and dry. Am (morning) labs collected to right AC (antecubital) without difficulty. Sensor alarm on in the room and bathroom door sensor on for safety. This nurses note was written by RN-J. On 1/13/24 at 2:55 p.m. Surveyor reviewed the fall information provided by the Facility for R5's December 2023 falls. Surveyor noted for R5's fall on 12/4/23 Surveyor was provided with a four page event report dated 12/4/23 and an Ad Hoc QAPI (quality assurance performance improvement) meeting/four point plan of correction agenda and summary dated 12/5/23 which has the root cause for R5's 12/4/23 fall. The event report under the fall section for location of fall is checked for resident room. For Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage. If unwitnessed describe how resident was found documents Writer called to resident's room, aid, daughter, and therapy all in room and resident was sitting on floor in front of recliner, resident stated she was going to sit in recliner and slid off edge, denied pain or hitting head. ROM baseline, neuro check neg (negative), vitals charted. resident helped into recliner. Surveyor was not provided with a thorough investigation as there are no staff statements, who last observed R5, what was R5 doing prior to the fall and was the call light in reach. FALL #2 The nurses note dated 12/8/23 at 2:04 p.m. documents resident found sitting on floor in day room, denied pain, ROM (range of motion) baseline, did state she bumped her head, said she was trying to transfer into other chair, neuro check negative, vitals WNL (within normal limits), resident helped up into wheelchair, NP (Nurse Practitioner) notified, DON (Director of Nursing) notified, daughter/POA (Power of Attorney) updated, will continue to monitor. This nurses note was written by RN (Registered Nurse)-M. The nurses note dated 12/9/23 at 10:55 a.m. documents F/U Fall. No apparent injury noted. VSS (vital signs stable) as charted. Denies pain and voices no complaints. Enjoying herself in the day area singing Christmas carols. This nurses note was written by LPN/CM-K. The nurses note dated 12/11/23 at 11:55 a.m. documents IDT meeting regarding fall on 12/8/23. PT (physical therapy) to screen for safety of use of walker at all times vs W/C. Care plan reviewed and updated. This nurses note was written by LPN/CM-K. On 1/13/24 at 2:55 p.m. Surveyor reviewed the fall information provided by the Facility for R5's December 2023 falls. Surveyor noted for R5's fall on 12/8/23 Surveyor was provided with a four page event report dated 12/8/23 and an Ad Hoc QAPI meeting/four point plan of correction agenda and summary dated 12/11/23 which has the root cause for R5's 12/8/23 fall. The event report under the fall section for location of fall is checked for day room. For Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage. If unwitnessed[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, and did not have evidence the risks and benefits of bed rails were discussed with the resident and/or resident representatives and informed consent was obtained prior to installation for 4 (R15, R20, R300 and R38) of 4 Residents reviewed for repositioning bars. *R15 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior to the installation, or a care plan was in place for R15's repositioning bars. *R20 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior to the installation, or a care plan was in place for R20's repositioning bars. *R300 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior to the installation, or a care plan was in place for R300's repositioning bars. *R38 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior to the installation, or a care plan was in place for R38's repositioning bars. Findings Include: Surveyor reviewed the facility's undated Grab Bar Policy and Procedure and notes the following applicable: .Policy: To provide the necessary adaptive equipment to promote independence, while ensuring the safety of our Residents, this policy identifies the risks, benefits, and alternatives to bedrail use, to guide the orientation, assessment and care planning process. Procedure: 1. All Residents who are admitted to the facility will be assessed for bed rail/grab bar using the grab bar assessment. They will subsequently be assessed quarterly by the assigned nurse and as needed by the therapy department and/or nursing. 3. Residents who use bedrails are at risk for entrapment and/or injury, including death. g. Therapy Department i. Screen all new Residents to help determine needs for bedrails/grab bars, consulting with nursing to complete grab bar assessment ii. For all Residents on caseload, work towards independent bed mobility without a rail/bar, especially if this was their prior level iii. Develop restorative programs for Residents with good potential to reach independence without a bedrail/grab bar iv. Screen current Residents quarterly and as needed, consulting with nursing to complete grab bar assessment v. Along with Director of Nursing(DON), request removal or addition of rails/bars from maintenance department vi. Consult with nursing and/or MDS coordinator to complete care plans. 1. R15 was admitted to the facility on [DATE] with diagnoses of Cellulitis of Right and Left Lower Limb, Morbid Obesity, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Glaucoma, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. R15 currently has an activated Health Care Power of Attorney (HCPOA). R15's Annual MDS (Minimum Data Set) dated 11/20/23 documents R15's Brief Interview for Mental Status (BIMS) score to be 13, indicating R15 is cognitively intact for daily decision making. R15's MDS also documents for mobility that R15 requires substantial/maximum assistance for rolling left and right and is dependent for sit to lying and sit to stand. Bed rails are not documented as well as any behaviors for R15 are not documented. R15's MDS documents that showers are somewhat important to R15. Surveyor reviewed R15's care card which does not document that R15 uses a repositioning bar for bed mobility. On 1/9/24 at 9:59 AM, Surveyor observed that R15 had a repositioning bar on the right side of the bed. R15 informed Surveyor that R15 uses the repositioning bar to assist with getting in and out of bed. On 1/9/24, Surveyor reviewed R15's comprehensive care plan and notes that R15's repositioning bar is not documented along with individual interventions. On 1/16/24 at 12:49 PM, Certified Nursing Assistant (CNA-P) confirmed that R15 does use the repositioning bar, usually to boost R15's self up and to reposition. The only grab bar assessment Surveyor located in R15's electronic medical record (EMR) was completed 11/20/23. Discussion held with R15/guardian regarding the dangers and benefits of grab bars was dated 5/26/20 and 'invalid' is written. Surveyor reviewed R15's physician orders which documents that R15 has had the repositioning bar since 5/26/20. Surveyor notes the facility completed a new grab bar assessment dated [DATE]. 2. R20 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Type 2 Diabetes Mellitus, Metabolic Encephalopathy, Hemiplegia and Hemiparesis Affecting Left Dominant Side, Morbid Obesity, and Major Depressive Disorder. R20 is currently R20's own person. R20's Quarterly MDS dated [DATE] documents R20's Brief Interview for Mental Status(BIMS) score to be 15, indicating R20 is cognitively intact for daily decision making. R20's MDS also documents for mobility that R20 requires substantial to maximum assistance to roll left to right as well as to go from sit to lying position. Bed rails are not documented on R20's MDS. Surveyor reviewed R20's care card which does not document that R20 uses a repositioning bar for bed mobility. On 1/9/24 at 9:38 AM, Surveyor observed bilateral half side rails on R20's bed. R20 informed Surveyor that R20 used the side rails to assist R20's self with sitting up and rolling side to side. On 1/9/24, Surveyor reviewed R20's comprehensive care plan and notes that R20's repositioning bar is not documented along with individual interventions. On 1/11/24 at 3:26 PM, Surveyor shared the concern that R20 did not have documentation located within R20's comprehensive care plan addressing the need for side rails and with individualized interventions. On 1/16/24 at 12:52 PM, CNA-P informed Surveyor that R20 uses the half side rails to roll and grip on to when being assisted in the bed. The only grab bar assessment Surveyor located in R20's electronic medical record (EMR) was completed 2/7/23. Discussion held with R20/guardian regarding the dangers and benefits of half side rails was dated 4/17/18 and 'invalid' is written. Surveyor reviewed R20's physician orders which documents that R20 has had bilateral quarter rails since 4/17/18. 3. R300 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, Dysphagia, Dyspnea, and Adjustment Disorder with Depressed Mood. R300 is currently R300's own person. R300's Quarterly MDS dated [DATE] documents R300's Brief Interview for Mental Status(BIMS) score to be 15, indicating R300 is cognitively intact for daily decision making. R300's MDS also documents for mobility that R300 requires partial to moderate assistance for rolling left to right and substantial to maximum assistance for sit to lying and sit to stand. Bed rails are not documented on R300's MDS. R300's MDS also documents that R300 has upper and lower range of motion impairment on one side. Surveyor notes that R300's care card does not have documentation that R300 uses a repositioning bar for mobility and R300's diet is marked as regular not diabetic. On 1/9/24 at 11:37 AM, Surveyor observed R300 has 1 repositioning bar on the right side of R300's bed. R300 informed Surveyor that R300 uses it to roll from side to side. On 1/11/24 at 9:35 AM, Surveyor reviewed R300's comprehensive care plan and notes that R300's repositioning bar is not documented as well as individualized interventions. On 1/16/24 at 12:53 PM, CNA-P confirmed that R300 uses the repositioning bar to reposition self. The only grab bar assessment Surveyor located in R300's electronic medical record (EMR) was completed 8/9/23. Discussion held with R300/guardian regarding the dangers and benefits of repositioning bars is blank. Surveyor reviewed R300's physician orders which documents that R300 has had the repositioning bar since 4/27/18. On 1/11/24 at 3:00 PM, Surveyor shared the concern with Administrator(NHA-A) and Director of Nursing (DON-B) that the facility did not have evidence for R15, R20, and R300 of the facility attempting appropriate alternatives prior to installation of bed rails, did not have evidence they assessed residents at risk of entrapment from bed rails prior to installation, and did not have evidence the risks and benefits of bed rails were discussed with the resident and/or resident representatives with informed consent obtained prior to installation. Surveyor explained that R15, R20, and R300 did not have completed grab bar assessments quarterly. DON-B agreed that the grab bar assessments have not been completed on a quarterly basis for R15, R20, and R300. 4. R38's diagnoses includes hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, aphasia, and diabetes mellitus. R38 had a guardian appointed in December 2022. The grab bar assessment dated [DATE] answers no for the questions Is resident independent in bed mobility without grab bars, Does the use of grab bars allow the resident to assist the care-giver in bed mobility and Is there a diagnosis that would justify the use of grab bars? For the question Is the resident a high risk for injury or entrapment R/T (related to) an altered cognitive status yes is answered with incapacitated. False is answered for Grab bars are NOT needed as resident is independent without them and Grab bars ARE indicated and serve as an enabler to promote increased independence. True is answered for Grab bars are NOT indicated D/T (due to) the increased risk of injury/entrapment outweighs the benefits and Grab bars are NOT needed as resident is physically/cognitively unable to utilize them Surveyor noted there was not another grab bar assessment completed after 6/20/23. The quarterly MDS (Minimum Data Set) with an assessment reference date of 12/2/23 is assessed for severe impairment for cognitive skills for daily decision making. For speech clarity is assessed as no speech. R38 rarely/never makes self under stood and rarely/never understands others. R38 is dependent for mobility rolling left to right & transfers. Bed rails are coded as not being used. On 1/9/24 at 9:22 a.m. Surveyor observed R38 in bed on the back on an air mattress. A urinary collection bag was attached to the left side of the bed frame. Surveyor observed there are two transfers bars up towards the head of the bed. During R38's record review, Surveyor was unable to locate an doctor's order or care plan for R38's transfer bars. On 1/9/24 from 10:48 a.m. to 11:12 a.m. Surveyor observed morning cares for R38 with CNA (Certified Nursing Assistant)-CC and CNA-Y. During this observation Surveyor observed R38's two transfer devices were up. Surveyor observed R38 did not respond to CNA-CC or CNA-Y and was dependent for cares & repositioning. On 1/9/24 at 11:24 a.m. Surveyor observed CNA-CC & CNA-Y transfer R38 from the bed into a broda chair using a hoyer lift. After the transfer was complete, Surveyor asked CNA-Y why R38 has two transfer bars on the bed. CNA-Y informed Surveyor she didn't know. On 1/10/24 at 8:30 a.m. Surveyor observed R38 in bed on his back with the head of the bed elevated. Surveyor observed there are two transfer bars up. On 1/10/24 at 9:51 a.m. Surveyor observed Transportation Drive/Maintenance-DD starting to remove R38's transfer bars from the bed. Surveyor asked Transportation Drive/Maintenance-DD why he was removing the transfer bars. Transportation Drive/Maintenance-DD informed Surveyor there is a work order in Tels to remove them. On 1/10/24 at 3:10 p.m. during the end of the day meeting NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were informed of the observations of R38's transfer bars up in the bed, the last grab bar assessment dated [DATE] doesn't indicate R38 should have transfer bars and Surveyor had spoken to staff and staff was unaware why R38 has transfer bars. DON-B informed Surveyor R38 received a new bed on Friday (1/5/24) which must of had the grab bars and put a work order in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the Facility did not ensure insulin was dated when opened, eye drops were dated when opened & labeled with a Resident's name, medications belonging to residents who no longer resided in the facility were disposed of properly, and pharmacy labels were not removed from medications. This has the potential to affect R6, R8, R349, R21, R14, R39, R249, R28, R250, R251, R403, R252, R253, and a pattern of residents residing on the rehab unit who utilize metamucil. Findings include: The Insulin Administration policy and procedure 2001 Med-Pass Inc (Revised [DATE]) under Steps in the Procedure for #4 documents Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). The Ophthalmic Administration Policy and Procedure not dated under Procedure for Multi-dose Ophthalmic Drops and Ointments Action Rationale for #16 documents Label the medication bottle or tube with the date opened, the initials of the person opening the vial and the expiration date of the vial, not to exceed 28 days unless specified long in the manufacturer guidelines. If the manufacturer expiration date occurs prior or after to the 28th day, the manufacturer's expiration date must be used. Some medications may indicate an expiration date of less or more than 28 days once the vial has been accessed. Refer to the package insert of the medication for additional information. 1.) On [DATE] at 11:47 a.m. Surveyor observed R6's aspart insulin bottle is open, used and not dated when opened. 2.) On [DATE] at 12:50 p.m. Surveyor observed in the top right drawer of the rehab medication cart a plastic bag containing 2 insulin pens for R8. R8's glargine insulin and aspart insulin flexpen were not dated when opened. On [DATE] at 12:52 p.m. Surveyor asked RN (Registered Nurse)-M if insulin should be dated when opened. RN-M replied yes we do. Surveyor showed RN-M R8's two insulin pens which were not dated when opened. 3.) On [DATE] at 1:13 p.m. in the Zone 1 medication cart Surveyor observed an open bottle of Systane eye drops that are not dated when open, is only labeled with a room number and not a Resident's name. 4.) On [DATE] at 12:47 p.m. Surveyor observed the Rehab medication room with RN (Registered Nurse)-J. Upon entering this medication room on the left side there is a table with multiple Resident's medication blister packs. Under the table on the floor is a clear plastic bin which is approximately three feet by 2 feet overflowing with Resident's medication blister packs. Surveyor asked RN-J about the blister packs on top of the table and in the bin. RN-J informed Surveyor these are medications for Residents who have been discharged . Surveyor inquired when pharmacy is suppose to remove the medication. RN-J informed Surveyor the PM (evening) nurse is to scan, put the medication in bags and then pharmacy will picks up the medication. RN-J informed Surveyor she never works the evening shift but that is her understanding. Surveyor informed RN-J Surveyor is not going to write down the blister packs in the plastic bin but will document the blister packs on the table. Surveyor asked RN-J approximately how many blister packs are in the bin under the table. RN-J replied 75 maybe there's a lot. Surveyor with RN-J noted the following medication blister packs on the table: * 8 medication blister packs & 1 box of rivastigmine transdermal 9.5 mg patches for R349. RN-J informed Surveyor R349 was just discharged . * 2 medication blister packs for R21. R21 was not on the current Resident roster when the survey team entered on [DATE]. * 10 medication blister packs for R14. R14 was not on the current Resident roster when the survey team entered on [DATE]. * 6 medication blister packs for R39. R39 was not on the current Resident roster when the survey team entered on [DATE]. * 11 medication blister pack and a bottle of megestrol acetate 40 mg/ml (milligrams per milliliter) for R249. R249 was discharged on [DATE]. * 1 medication blister pack for R28. R28 was not on the current Resident roster when the survey team entered on [DATE]. * 2 medication blister packs for R250. R250 was discharged on [DATE]. * 1 medication blister pack for R251. R251 was discharged on [DATE]. * 4 medication blister packs for R409. RN-J informed Surveyor R409 is still at the Facility. * 7 medication blister packs for R252. RN-J informed Surveyor R252 is still at the Facility. 5.) On [DATE] at 1:00 p.m. Surveyor observed in the left cabinet located in the rehab medication room [ROOM NUMBER] containers of metamucil with the pharmacy labels removed. Surveyor noted there is only a small portion of the yellow area of the pharmacy label left. The metamucil containers have open dates written on the top of [DATE] & [DATE]. Surveyor showed RN-J the metamucil containers with the pharmacy labels removed. 6.) On [DATE] at 1:03 p.m. in the refrigerator located in the rehab medication room R 253's Latanoprost .005% eye drops which are used but not dated when opened. RN-J informed Surveyor R253 is discharged . R253 expired in the Facility on [DATE]. On [DATE] at 1:06 p.m. Surveyor showed DON (Director of Nursing)-B the medication blister packs on top of the table and over flowing in the plastic bin under the table. DON-B informed Surveyor the PM (evening) shift returns the medication and the bin should never be that filled. On [DATE] at 1:19 p.m. Surveyor informed VP (Vice President) of Clinical Operations-D of the observation of the medication which was suppose to be returned to the pharmacy and asked for a returning medication to pharmacy policy. The Medication Returns policy dated [DATE] documents Medication rooms are to be kept free of clutter, personal items, and resident medications are to be returned in a timely manner. Medication returns are to be completed weekly by second shift nurse scheduled to respected Zone. Nurse returning medications log in to [pharmacy name]-view and scanned to pharmacy. Placed in [pharmacy name]white bag, with report and given to pharmacy on next pick up. Copy of Medication return reports are to be printed and placed in the DON's door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. This had the potential to affect all 53 of the 53 residents residing in the facility at the the time of the survey. -The facility did not maintain surveillance data to monitor communicable diseases within the facility. -Registered Nurse (RN) performed wound care for resident (R31) who was on transmission-based precautions (TBP), without wearing appropriate personal protective equipment (PPE). - Dietary staff were observed not wearing their PPE appropriately. Dietary staff were observed wearing their mask below their nose and mouth. - The December 2023 monthly infection control log does not include baseline rates by infection. Surveyor was not provided with monthly infection control surveillance logs for June 2023, July 2023, August 2023, September 2023, October 2023 or November 2023. No surveillance long was provided for January 2024. The facility provided did provide to the survey team Covid-19 Infection control line listing for October and into November 2023. R38, R11, R24, R3, R15, R300, R17 and R36 were identified as having an infection (s) and were not on the correlating infection control log as the facility was not able to evidence of infection control logs. This is evidenced by: 1. The facility's policy, Infection Prevention and Control Program, states in part . The elements of the infection prevention and control program (IPCP) consist of coordination/oversight, policies/procedures, surveillance, data analysis, outbreak management, prevention of infection . Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Data gathered during surveillance is used to oversee infections and spot trends. On 01/09/24 at 3:10 PM, Surveyor requested surveillance data from Director of Nursing (DON) B and Licensed Practical Nurse (LPN) K. Surveyor received surveillance data from 10/16/23-11/29/23, however data only includes COVID-19 infections. On 1/10/24 at 3:11 PM, Surveyor interviewed DON B. DON B reported the facility has surveillance data from October 2023 through current, but does not have data for June, July, August, and September of 2023. DON B reports the facility's previous infection preventionist (IP) left the facility in May 2023. DON B was acting as DON and IP during that time. LPN K is the facility IP as of 11/21/23. Surveyor requested surveillance for December 2023 and January 2024. On 01/11/24 at 9:54 AM, Surveyor requested surveillance data from IP K and DON B. On 01/11/24 at 10:14 AM, the facility did not provide surveillance data for June, July, August, September, December of 2023, or January of 2024. On 01/11/24 at 10:54 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported he was newly hired in December. NHA A reported he attended one Quality Assurance and Performance Improvement (QAPI) meeting in December, and infection control was discussed at that meeting. NHA A reported he would provide Surveyor with infection control performance improvement plans (PIPs) discussed at that meeting. NHA A provided Surveyor with PIP dated 01/11/24. 2. R31 admitted to the facility on [DATE] with diagnoses including pressure ulcers of left and right hip, right buttocks, and right flank. Documentation confirmed R31's pressure ulcers contain bacteria methicillin-resistant staphylococcus aureus (MRSA). R31 also admitted with diagnosis of C. diff (clostridium difficile, bacteria causing diarrhea and inflammation of the colon). According to the Centers for Disease Control (CDC), MRSA and C. diff bacteria can be transferred from person to person, contact precautions should be implemented, such as healthcare providers wearing a gown and gloves when providing care, to prevent the spread of infection to themselves or others. On 01/09/24 at 9:51 AM, Surveyor observed signs outside of R31's room, indicating R31 was in contact precautions. There was no PPE outside or near R31's room. On 01/10/24 at 10:58 AM, Surveyor observed there were no signs outside of R31's room indicating he was on contact precautions. RN F reported R31's precautions were discontinued on 01/08/23. R31 also reported he had not been in precautions, for a while. Surveyor observed RN F complete dressing change to R31's buttocks wound, RN F wore gloves during the treatment, however no other PPE was worn (such as gown). On 01/10/24 at 12:15 PM, Surveyor interviewed LPN K. LPN K reported R31 remains on contact precautions for MRSA infection, however he no longer has C. diff infection. LPN K stated she was not sure why the contact precaution signs were taken off R31's door and stated she would place new signs immediately. 3. The facility's policy, Personal Protective Equipment - Using Face Masks states in part . The purpose: to guide the use of masks. Objectives include: 1. To prevent transmission of infectious agents through the air; 2. To protect the wearer from inhaling droplets; 3. To prevent transmission of some infections that are spread by direct contact with mucous membranes; Miscellaneous include: 2. Be sure that face mask covers the nose and mouth while performing treatment or services for the patient; 4. Do not hang the face mask around the neck; 6. Do not remove the mask while performing treatment or services for the patient; 9. Never touch the mask while it is in use. Surveyor had the following infection control concerns related to wearing the proper personal protective equipment (PPE) based on facility policy. Surveyor notes the facility was in a COVID-19 outbreak status and Respiratory Syncytial Virus (RSV) outbreak status at the time of the survey. ~ On 1/10/24 at 9:00 am, Surveyor observed pureed foods being prepared by Cook-E with Cook-E's mask on his chin below his nose and mouth while preparing pureed foods for residents in the facility. ~ On 1/10/24 at 11:54 am, Surveyor observed Cook-E in the common dining area during lunch time with residents present. Cook-E was observed multiple times pulling his mask on his chin below his mouth and nose while serving lunch trays to residents and while speaking to residents in the dining room. ~ On 1/11/24 at 7:59 am, Surveyor observed Cook-E in the common dining area during breakfast time with residents present. Cook-E was observed with his mask down on his chin below his mouth and nose when speaking with residents and while serving food trays to residents. ~ On 1/16/24 at 12:01 pm, Surveyor interviewed Cook-F who indicated the expectation was to always wear a mask that covers their nose and mouth. Cook-F stated she would kindly ask someone to properly wear a mask covering their nose and mouth if she were to come across someone in the facility who was not wearing or properly wearing a mask. ~ On 1/16/24 at 1:36 pm, Surveyor shared the infection control concerns with Cook-E on 1/10/24 and 1/11/24 with the DON-B. No further information was provided at this time. 4. On 1/16/24 at approximately 11:00 a.m. Surveyor reviewed infection control information provided earlier this day. Surveyor noted there is a December 2023 monthly infection control log which includes type of infection, cultures, antibiotic, whether the infection met the infection definition, community or healthcare associated infections, date resolved and isolation. There is also a December 2023 infection summary Surveyor noted this information summary has the total number of UTI (urinary tract infection) with or without indwelling catheter, total number of respiratory, total number of skin, soft tissue, mucosal and total number of Gastrointestinal tract. Surveyor noted this infection summary does not include baseline rates of infections. Surveyor was not provided with monthly infection control logs for June 2023, July 2023, August 2023, September 2023, October 2023, or November 2023. On 1/16/24 at 2:02 p.m. Surveyor spoke with DON (Director of Nursing)-B. Surveyor asked DON-B if baselines rates of infection should be completed for the Facility's prevalent infections. DON-B informed Surveyor they should be done. Surveyor informed DON-B baseline rates of infections were not completed for December 2023. DON-B informed Surveyor they will be using the infection tracker through [Name of] electronic record and they want to send LPN/CM (Licensed Practical Nurse/Clinical Manager)-K, who is the infection preventionist, to their sister facility for training. Surveyor asked DON-B if there are monthly infection control logs for June, July, August, September, October, and November 2023. DON-B replied no. Surveyors noted the following progress notes and noted the below Residents should have been on a monthly infection control log: 5. R38's nurses note dated 11/27/23 at 3:30 p.m. documents Resident arrived back to facility around 3:30p via [Name of] ambulance. R38's nurses note dated 11/28/23 at 2:39 a.m. documents F/u (follow up) readmission s/p (status post) hospitalization: VSS (vital signs stable). No signs of pain or discomfort. No signs of sob (shortness of breath) or dyspnea. No signs of cardiac/resp (respiratory) distress. BSx4 (bowel sounds times four). Tolerating TF (tube feeding) as ordered. HOB (head of bed) elevated 45 degrees. Continues ABT (antibiotic) therapy for PNA (pneumonia). No adverse reactions noted. Repositioned PPOC (per plan of care). Resting quietly in bed. Frequent checks made by staff. R38's nurses note dated 11/29/23 at 12:49 a.m. documents F/U readmission s/p pneumonia @ (at) hospital. Remains on ABT VIA G-tube. No adverse drug reactions noted. All vital signs are stable and charted. Lung sounds clear in all fields, some tracheal congestion noted. Scoplamine patch intact to posterior left ear. Abdomen round and soft with bowel sounds present Q (every) 4 quads (quadrants). Staff gave resident shower tonight. Small dime size scabbed area on left upper buttock. Zinc cream applied per order. G-tube patent with [NAME] valve attached due to original cap missing. Supra pubic catheter in place and draining properly. No signs of any discomfort or distress. New tube feeding started and HOB elevated at 45 degrees. Tolerating well. R38 would have been included on the November 2023 monthly infection control log for pneumonia had the Facility conducted surveillance. 6. R11's nurses note on 9/27/23 at 9:29 a.m. documents Resident readmitted to facility s/p (status post) hospital for DX (diagnoses): CHF (congestive heart failure), unspecified HF (heart failure) chronicity, unspecified heart failure type, increase in lasix x (times) 3 day, NADR, LSC (lung sounds clear), no s/sx (signs/symptoms) of distress, SpO2 95% on RA (room air), no noted cough or congestion at this time. resident voices no complaints, Has UTI (urinary tract infection) currently on oral ABT (antibiotic) Keflex, NADR (no adverse drug reaction), no c/o (complaint of) frequency, pain, or discomfort, VSS and logged, will continue to monitor. R11's nurses note dated 9/28/23 at 6:02 a.m. documents Resident readmitted to facility s/p (status post) hospital for DX: CHF, and UTI. Alert and orientated and able to make needs known. New order for Lasix to 40mg daily. Currently on oral ABT BID (twice daily). No adverse drug reaction noted. Vial signs stable and charted. Abdomen round with bowel sounds present Q 4 quads. No tenderness during palpation. Lung sounds clear, no SOB (shortness of breath) noted. PRN (as needed) Tramadol requested by resident at 0210 (2:10 a.m.) for c/o general aches, Effective. Lying in bed resting and appears comfortable. Call light within reach for any needs. R11's nurses note dated 10/3/23 at 3:50 a.m. documents Remains on oral ABT until 10/3/23 for UTI. No complaints of urinary frequency or burning. NADR from oral ABT noted. Vital signs stable and charted. Requested PRN Tramadol this shift for general aches. Effective. R11 would have been included on the September 2023 monthly infection control log for an UTI had the Facility conducted surveillance. 7. R24's nurses note dated 7/27/23 at 10:13 a.m. documents resident voiced that he has had the sniffles for a week, sore throat for last 2 days, and been coughing all night. writer gave PRN (as needed) tussin, assessed lungs and vitals, LSC (lung sounds clear) and VSS (vital signs stable). writer updated [Name] from [Name of medical group] and she ordered BMP (basic metabolic panel), CBC (complete blood count), and Resp. (respiratory) panel. co-nurse approached resident and informed him of lab draw and resp. panel. resident said NO that his blood was fine and he doesn't need anything just cough syrup. [Name] assessed when she arrived voiced that resident is crappy, [Name] stated to monitor resident she had placed resident on the call list for tonight and reattempt labs and update her if resident refuses. R24's nurses note dated 7/27/23 at 5:33 p.m. documents Resident continues to be monitored for cold s/s. vss afebrile, states his head feels like a balloon with nasal stuffiness, voice sounds congested, lungs cta (clear to ascultation) bil (bilateral) denies chest pains or sob has cough prn cough syrup and Tylenol given per request, currently eating dinner with his wife. [Medical group] RN called 1735 (5:35 p.m.) for update on resident, and stated continue to monitor and to call if residents condition changes. R24's nurses note dated 7/28/23 at 1:12 a.m. documents Resident being monitored for respiratory symptoms. Resident is afebrile. Resident has nasal stiffness. Resident pain is being monitored and controlled with Tylenol. R24's nurses note dated 7/31/23 documents Respiratory symptoms appear resolved. Per charting, resident has been feeling much better. No cough, SOB, or complaints of feeling ill this shift. Resting in bed comfortably with call light in reach. R24 would have been included on the July 2023 monthly infection control log for respiratory symptoms had the Facility conducted surveillance. 8. R3's nurses note dated 7/26/23 at 11:10 p.m. documents F/u (follow up) on Oral ABT (antibiotic) for pneumonia: [NAME] (no adverse drug reactions), VSS (vital signs stable), Pt (patient) receive nebulizer tx (treatment) spo2 was at 95% on RA (room air), no c/o of pain but received schedule Tramadol, audible nasal congestion noted. crackles on bilateral lobes. R3's nurses note dated 9/22/23 at 11:20 a.m. documents Patient slept in. Denies pain/dysuria. Very confused. Vital signs stable. Tremors quite pronounced. Holding glass of juice and shaking so badly the juice is spilling all over. Appetite poor. Needing much encouragement for fluid intake. Lung sounds clear. No shortness of breath. Blood sugar 312 at this time. Writer observing her drinking/eating and has a delayed swallow. New order for ST/eval (speech therapy/evaluation) and treat and to have lidded cups at all times due to tremors. Copy of ST eval to therapy. Starting Cefadroxil 500 mg (milligram) BID (twice daily) for UTI (urinary tract infection). Started initial dose at this time. No sensitivity from U/A (urinalysis) in hospital but due to increased confusion and unstable blood sugars to start ABT (antibiotic) without sensitivity per NP (Nurse Practitioner). NP [Name] will be contacting son to update on all medications/issues. New orders also noted to D/C (discontinue) Tizanidine, and continue PRN (as needed) order. TSH (thyroid stimulating hormone) this Monday. To stop Lantus 6 units at HS (hour sleep) and to start Humalog SS BID. R3's nurses note dated 9/26/23 at 1:08 p.m. documents new orders to start Azithromycin 500 mg stat, then 250 mg daily x 5 days d/t (due to) left upper lobe PNA (pneumonia) if new acute issues will add a Z-pack Nursing. R3's nurses note dated 11/28/23 at 9:50 a.m. documents [Physician's name] here orders noted and placed in the computer for Keflex 500 mg po TID x 10 days for RLE (right lower leg) cellulitis. R3 would have been included on the July 2023 monthly infection control log for pneumonia, September 2023 for UTI & pneumonia, and November 2023 for cellulities had the Facility conducted surveillance. 9. R15's nurses note dated 6/16/23 at 10:48 p.m. documents Pt. (patient) just arrived back from [Hospital Name] at 10:30 pm. With DX (diagnosis) of cellulitis. New order of Amoxicillin take 1 tab (500 mg (milligram) total) by mouth 3 times daily for 7 days and Doxycycline hyclate (100mg) capsule, take 1 cap by mouth twice daily for 7 days Writer put new orders in. return to ER (emergency room) for fever, chills, worsening swelling, redness, pain, discharge or if symptoms worsen or fro any other concerns. and to schedule an appointment with primary care scheduling as soon as possible . writer placed schedule appt. (appointment) on [Name] bin. R15 would have been included on the June 2023 monthly infection control log for cellulitis had the Facility conducted surveillance. 10. R300's nurses note dated 8/8/23 at 1:28 a.m. documents Follow up: readmission s/p (status post) hospitalization for PNA (pneumonia) and COPD (chronic obstructive pulmonary disease) exacerbation, afebrile. No c/o (complaint of) pain or discomfort this shift. Took scheduled Tylenol for arthritis pain. Pleasant during the encounter. Continues on oral ABT (antibiotic) for PNA, NADR (no adverse drug reactions) noted. Tolerating ABT therapy well. No cough or SOB (shortness of breath) during assessment. Call light within reach. Appears comfortable. R300's nurses note dated 9/25/23 at 1:04 a.m. documents Resident on board due to UTI (urinary tract infection). Continues on oral ABT (antibiotic), no adverse drug reactions noted. Afebrile, all other vital signs stable and charted. On contact precautions with cares. No complaints of any discomfort. On 2 liters of oxygen VIA nasal cannula with SpO2 @ (at) 95%. Call light within reach for needs. R300 would have been included on the August 2023 monthly infection control log for pneumonia & September 2023 monthly infection control log for UTI had the Facility conducted surveillance. 11. R17's nurses note dated 6/6/23 at 10:00 a.m. documents Started antibiotic ear drop left ear. This morning he asks writer what's hanging out of his ear. He did have some thick yellow drainage in canal. After writer inserted drops which come in an individual dropper for each dose, [R17's first name] saw the dropper and loudly states that's what was hanging out of my ear?!. Writer showed him it was just the dropper. When given his morning medications he stares intently into the med cup examining the medications for quite some time. When writer gave him his 9 a.m. meds he noted writer looking down the hall and he asks why do you keep looking down the hall behind me?. Patient appears more paranoid every day to writer. Continues to dig in his left ear. Complains of itching more than pain. R17's nurses note dated 7/5/23 at 3:07 p.m. documents Resident was seen by ENT (ears nose throat) today new orders obtained to start ciprodex ear drops bid (twice daily) for 1 week, ciprofloxacin 500mg (milligrams) po (by mouth) daily for 14 days, and to follow up in 1 week with [Physician's name] ENT. [Medical group] nurses faxed over new orders, copy of f/u (follow up) given to scheduler. R17's nurses note dated 7/21/23 at 3:00 a.m. documents Remains on oral ABT for left ear infection until 7/26/23 per order. NADR (no adverse drug reaction) noted, afebrile, and no complaints of any discomfort. Left ear remains with cotton ball covered with Band-Aid to prevent ear digging. Catheter placed yesterday AM (morning) draining well. R17's nurses note dated 9/27/23 documents n.o (new order) from [Name] to obtain lab culture Left ear drainage, keep left ear covered to prevent pt. (patient) from picking in it. and after culture is obtain start ciprodox 4 drops to left eat BID (twice daily) x 7 days. Lab obtained and sent out, all other orders in MAR (medication administration record) and placed in 24 hr. (hour) board to monitor. R17's nurses note dated 11/10/23 at 2:43 p.m. documents Resident is covid positive, asymptomatic, remains on isolation, no c/o (complaint of) pain or discomfort, v/s stable, afebrile, continues on ABT (antibiotic) for left ear infection, no a/r (adverse reactions), will continue to monitor. R17's nurses note dated 11/28/23 at 3:30 p.m. record as a late entry on 11/29/23 at 10:47 a.m. documents Resident returned from ENT appt. orders received to continue Levaquin 750 mg daily , will continue until infection resolved minimum of 8 weeks. Check ESR (erythrocyte sedimentation rate) once every 14 days, return 4-5 weeks. Per ENT MD. R17 would have been included on the July 2023, September 2023, & November 2023 monthly infection control log for an ear infection had the Facility conducted surveillance. Surveyor noted R17 was included in the Facility's COVID outbreak line list. 12. R36's nurses note on 9/10/23 at 8:54 a.m. documents Resident continues to be monitored for oral cipro for UTI with narn (no adverse reactions), and neuro checks for f/u (follow up) fall without injury, neuro checks wnl (within normal limits), maew, no c/o (complaint of) discomfort. Resident told med tech that she was in church and that she had got confirmed, resident has intermittent confusion and forgetfulness baseline. Resident currently in MDR (main dining room) having coffee and breakfast. R36 would have been included on the September 2023 monthly infection control log for UTI had the Facility conducted surveillance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not notify the resident or resident's representative in writing of the transfer and the reasons for the move including the effective date of transfer, the location to which the resident is transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form as well as the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman for 1 (R22) of 1 residents reviewed for transfer to the hospital. *R22 was transferred and admitted into the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. No documentation was found indicating a transfer notice was provided to R22 or R22's representative. Nursing Home Administrator-A was not aware of the requirement to provide transfer notices to residents and their representative for facility initiated transfers. Findings: The facility policy and procedure entitled Bed-Holds and Returns dated 3/2017 states: 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold period (Medicaid resident); and d. The details of the transfer (per the Notice of Transfer). R22 was admitted to the facility on [DATE] with diagnoses of discitis, toxic liver disease with chronic active hepatitis with ascites, cirrhosis of liver, diabetes, atrial fibrillation, hepatic failure, and inguinal hernia. R22's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R22 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R22 as needing extensive assistance with all activities of daily living except independent with eating. R22's POA was not activated. On 12/31/2021 at 10:56 AM in the progress notes, nursing charted a phone call was received from the hospital laboratory stating fluid from the paracentesis showed probable spontaneous bacterial peritonitis and suggested R22 go straight to the emergency room for evaluation and testing. The hospital notified R22 of the test results as well. R22 was sent and admitted in to the hospital at that time. Surveyor did not see any documentation a transfer notice was provided to R22 or R22's representative. On 2/26/2022 at 11:17 AM in the progress notes, nursing charted R22 was more confused than normal, trying to crawl out of bed onto the floor, and R22 was yelling at nursing staff and did not recognize them. R22 had upper extremity twitching and R22's breathing was more labored. R22 could not hold up arm when blood pressure was attempted to be obtained, flopping down the side of the wheelchair. Nursing staff checked R22's ammonia level which was elevated at 59. The physician was notified of the altered mental status and was ordered to send to the hospital for evaluation and treatment. On 2/26/2022, R22 was admitted to the hospital with hepatic encephalopathy. Surveyor did not see any documentation a transfer notice was provided to R22 or R22's representative. On 5/10/2022 at 10:32 AM in the progress notes, nursing charted R22 had left the facility around 5:30 AM for hernia surgery. (The surgery was scheduled.) Surveyor did not see any documentation a transfer notice was provided to R22 or R22's representative. On 7/9/2022 at 3:13 PM in the progress notes, nursing charted the physician was contacted and updated on the events of the day (fall out of bed and increased confusion). The physician suggested sending R22 to the hospital for evaluation and treatment. Nursing staff noticed R22 appeared more jaundiced looking that day. R22 was transported to the hospital. On 7/9/2022, R22 was admitted to the hospital with hyperammonemia, a urinary tract infection, and ascites. Surveyor did not see any documentation a transfer notice was provided to R22 or R22's representative. In an interview on 9/12/2022 at 10:44 AM, Surveyor asked Nursing Home Administrator (NHA)-A if transfer notices were provided to R22 or R22's representative when R22 was transferred to the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. NHA-A was not aware of the requirement to provide transfer notices to the resident and their representative for facility initiated transfers. NHA-A stated no transfer notices were provided to R22 when transferring to the hospital and education on that aspect of the transfer has been started with staff. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not notify at the time of transfer the resident or resident's representative in writing the state bed-hold policy, the duration of the bed hold, the reserve bed payment policy, and the return to the facility for 1 (R22) of 1 residents reviewed for bed hold notice. *R22 was transferred and admitted into the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. No documentation was found indicating a bed hold notice was provided to R22 or R22's representative. Findings: The facility policy and procedure entitled Bed-Holds and Returns dated 3/2017 states: 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold period (Medicaid resident); and d. The details of the transfer (per the Notice of Transfer). R22 was admitted to the facility on [DATE] with diagnoses of discitis, toxic liver disease with chronic active hepatitis with ascites, cirrhosis of liver, diabetes, atrial fibrillation, hepatic failure, and inguinal hernia. R22's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R22 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R22 as needing extensive assistance with all activities of daily living except independent with eating. R22's POA was not activated. On 12/31/2021 at 10:56 AM in the progress notes, nursing charted a phone call was received from the hospital laboratory stating fluid from the paracentesis showed probable spontaneous bacterial peritonitis and suggested R22 to straight to the emergency room for evaluation and testing. The hospital notified R22 of the test results as well. R22 was sent to the hospital and admitted at that time. Surveyor did not see any documentation a bed hold notice was provided to R22 or R22's representative. On 2/26/2022 at 11:17 AM in the progress notes, nursing charted R22 was more confused than normal, trying to crawl out of bed onto the floor, and R22 was yelling at nursing staff and did not recognize them. R22 had upper extremity twitching and R22's breathing was more labored. R22 could not hold up arm when blood pressure was attempted to be obtained, flopping down the side of the wheelchair. Nursing staff checked R22's ammonia level which was elevated at 59. The physician was notified of the altered mental status and was ordered to send to the hospital for evaluation and treatment. On 2/26/2022, R22 was admitted to the hospital with hepatic encephalopathy. Surveyor did not see any documentation a bed hold notice was provided to R22 or R22's representative. On 5/10/2022 at 10:32 AM in the progress notes, nursing charted R22 had left the facility around 5:30 AM for hernia surgery. (The surgery was scheduled.) Surveyor did not see any documentation a bed hold notice was provided to R22 or R22's representative. On 7/9/2022 at 3:13 PM in the progress notes, nursing charted the physician was contacted and updated on the events of the day (fall out of bed and increased confusion). The physician suggested sending R22 to the hospital for evaluation and treatment. Nursing staff noticed R22 appeared more jaundiced looking that day. R22 was transported to the hospital. On 7/9/2022, R22 was admitted to the hospital with hyperammonemia, a urinary tract infection, and ascites. Surveyor did not see any documentation a bed hold notice was provided to R22 or R22's representative. In an interview on 9/12/2022 at 10:44 AM, Surveyor asked Nursing Home Administrator (NHA)-A if bed hold notices were provided to R22 or R22's representative when R22 was transferred to the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. NHA-A stated no bed hold notices were provided to R22 when transferring to the hospital and education on that aspect of the transfer has been started with staff. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice after an unwitnessed fall for 2 (R22 and R8) of 4 residents reviewed for falls. *R22 had unwitnessed falls on 12/16/2021, 1/29/2022, 2/9/2022, 2/16/2022, 2/21/2022, 2/26/2022, 3/3/2022, and 7/9/2022. Neurological checks were not completed following the fall to assess for a change in mentation. *R8 had unwitnessed falls on 2/23/2022, 4/28/2022, and 6/4/2022. Neurological checks were not completed following the fall to assess for a change in mentation. Findings: The facility policy and procedure entitled Neurological Assessment dated 10/2010 states: General Guidelines: 1. Neurological assessments are indicated: a. Upon physician order; b. Following an unwitnessed fall; c. Following a fall or other accident/injury involving head trauma; or d. When indicated by resident's condition. The facility Neuro Check Assessment form states: Policy: All residents who experience a head injury or an unwitnessed fall will have Neuro Checks completed. Procedure: Neuro checks, vitals and assessments will be completed every 15 minutes x (1) hour, every 1 hour x 4 hours and then every 4 hours x 24 hours and every shift x 48 hours. 1. R22 was admitted to the facility on [DATE] with diagnoses of discitis, toxic liver disease with chronic active hepatitis with ascites, cirrhosis of liver, diabetes, atrial fibrillation, hepatic failure, and inguinal hernia. R22's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R22 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R22 as needing extensive assistance with all activities of daily living except independent with eating. R22's POA was not activated. On 12/16/2021 at 5:54 AM in the progress notes, nursing charted R22 was found on the floor at 1:00 AM, lying in front of bed on the stomach and slightly on the right side with legs straight. R22 had gotten up to use the bathroom and the roommate was using the bathroom so R22 walked back to bed and the right knee buckled causing R22 to fall on the knees. R22 denied hitting the head. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 1/29/2022 at 8:32 PM in the progress notes, nursing charted R22 was yelling help from the doorway. R22 was found crawling in the doorway of the room. When asked what had happened, R22 stated R22 rolled out of bed and fell to the floor. R22 stated R22 crawled to the door to get help because the legs do not work. R22 was assisted back to bed with a mechanical lift. R22 then stated R22 fell out of bed when trying to plug the phone. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 2/9/2022 at 9:28 AM in the progress notes, nursing charted a Certified Nursing Assistant (CNA) was assisting R22 get ready for an appointment and stepped out of the room so the nurse could administer medications. When the CNA returned to the room, R22 was found face-down on the floor. R22 stated R22 had been trying to pull the pants up independently and fell to the left side and when R22 tried to get himself up, rolled onto his belly. The CNA had told R22 to wait for assistance prior to leaving the room, but R22 stated the CNA told R22 to walk on his own. R22 was assisted back to bed with a mechanical lift. R22 denied hitting his head. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 2/16/2022 at 5:20 AM in the progress notes, nursing charted R22 was found on the floor at 4:45 AM lying on his stomach slightly on the left with legs straight out. The CNA had been checking on R22 throughout the night and asking R22 to stay off the edge of the bed. R22 stated R22 rolled over wrong and slid off the bed. R22 denied hitting the head. Staff asked R22 why R22 did not wait for assistance and R22 became angry and belligerent yelling at the staff. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 2/21/2022 at 1:21 PM in the progress notes, nursing charted R22 reported to be reaching for something on the bedside table and slid off of the bed onto the floor. R22 was assisted back to bed with a mechanical lift. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 2/26/2022 at 4:16 AM in the progress notes, nursing charted R22 was found on the floor at 12:10 AM next to the roommate's bedside table by the bathroom door. R22 was lying on the stomach. R22 stated R22 was trying to get something from the other side of the room. R22 stated R22 slid out of bed onto butt and then crawled. R22 was assisted to bed with a mechanical lift. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 3/3/2022 at 10:15 AM in the progress notes, nursing charted R22 had been on the floor after rolling out of bed the night before. R22 was combative and resistive causing staff to care for R22 for over three hours. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 7/9/2022 at 2:29 PM in the progress notes, nursing charted R22 was on the floor lying on the left side next to the wheelchair in the middle of the room. The CNA stated R22 had been sitting in the wheelchair filling out a menu just prior to the fall. R22 had confusion stating the opposite of what had occurred. R22 denied hitting the head. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. On 9/7/2022 at 10:01 AM, Surveyor observed R22 in bed with a floor mat at the bedside and the overbed table next to the bed. R22 stated R22's roommate had been calling out for help and no one came to assist so R22 crawled out of bed to see if R22 could help the roommate. R22 stated the nurse said R22 had fallen out of bed, but R22 denied that had happened. R22 was unable to say when this event had occurred. R22 stated R22 fell to the floor about a month ago when R22's legs turned into jelly. In an interview on 9/12/2022 at 10:56 AM, Surveyor met with Director of Nursing (DON)-B to review R22's falls. Surveyor asked DON-B if neurological checks had been completed for R22's unwitnessed falls. DON-B stated R22 had denied hitting the head so neurological checks had not been completed. In an interview on 9/12/2022 at 1:06 PM, DON-B stated neurological checks after an unwitnessed fall are now being utilized; the facility had started a Performance Improvement Project (PIP) for falls and they discovered neurological checks had not been done for falls until recently when they started the PIP. Surveyor asked when the PIP was initiated. DON-B stated the PIP started 7/4/2022 and was not yet completed. No further information was provided at that time. 2. R8 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, diabetes, anxiety, and Alzheimer's disease. R8's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R8 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 and needed limited to extensive assistance with activities of daily living. On 2/23/2022 at 9:32 PM in the progress notes, nursing charted R8 fell in the dayroom attempting to self-transfer and lost their footing. The fall was unwitnessed; R8 stated R8 wanted to go to the bathroom. R8 was found sitting with the back against the recliner R8 had been sitting in and denied hitting the head. Surveyor did not find any documentation of neurological checks after R8 had the unwitnessed fall. In an interview with Director of Nursing (DON)-B on 9/12/2022 at 10:50 AM, DON-B stated R8 had slid out of the chair and landed on the buttocks so the staff could tell by looking that R8 had not hit the head so no neurological checks were done. On 4/28/2022 at 1:24 PM in the progress notes, nursing charted R8 had been in the activity dining room having lunch when R8 left the dining room to go to the bathroom. Staff was notified R8 was going to the bathroom and staff was on their way when R8's alarm sounded. The CNA entered the bathroom and found R8 on the floor. R8 had the back against the wall with knees up and feet on the floor. R8 denied hitting the head. Surveyor did not find any documentation of neurological checks after R22 had the unwitnessed fall. In an interview on 9/12/2022 at 10:52 AM DON-B stated staff saw R8 go into the bathroom and the alarm sounded when staff was already on their way to get R8 when they found R8 on the floor (4/28/22). DON-B stated there was not enough time for R8 to hit the head so no neurological checks were done after the fall. Surveyor was also presented with 3 staff statements indicating R8 was found on the floor on on 6/4/22.There was no documentation of this fall in R8's medical record. There was no indication neurological checks were completed after this fall. On 9/7/2022 at 10:37 AM, Surveyor observed R8 in the resident lounge on the unit. R8 was seated in a recliner with feet propped up on the wheelchair. R8 had sneakers on. In an interview on 9/12/2022 at 10:56 AM, Surveyor met with DON-B to review R8's falls. Surveyor shared with DON-B the concern neurological checks had not been completed for R8's unwitnessed falls. DON-B stated staff had not been completing neurological checks with falls at that time. In an interview on 9/12/2022 at 1:06 PM, DON-B stated neurological checks after an unwitnessed fall are now being utilized; the facility had been started a Performance Improvement Project (PIP) for falls and they discovered neurological checks had not been done for falls until recently when they started the PIP. Surveyor asked when the PIP was initiated. DON-B stated the PIP started 7/4/2022 and was not yet completed. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility did not ensure Residents with pressure injuries receives appropriate care, treatment, & preventative measures to promote healing for 1 (R99) of 2 Residents with pressure injuries reviewed. R99 was admitted to the facility on [DATE] with a right buttocks Stage 2 pressure injury. There was no assessment of the pressure injury until after Surveyor spoke with ADON (Assistant Director of Nursing)-C on 9/12/22. The physician order dated 8/26/22 documents may apply medseptic cream to areas of concern every shift - PRN (as needed). There is no documentation in R99's Treatment Administration Record (TAR) from 8/26 to 9/11/22 of R99 receiving the medseptic cream, even though the Assistant Director of Nursing (ADON) -C informed Surveyor staff had been applying it. On 9/7, 9/8, and 9/12/22, R99 was observed sitting in a chair without a pressure relieving cushion in the chair. Findings include: The Pressure Ulcers/Skin Breakdown - Clinical Protocol 2001 Med-Pass Inc. (Revised April 2018) under Assessment and Recognition includes In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. R99 was admitted to the facility on [DATE] with diagnoses which include congestive heart failure, severe protein-calorie malnutrition, hypertension, and muscle wasting & atrophy. The body observation dated 8/26/22 under the skin section for pressure sores is marked yes with right buttocks for site. Surveyor noted this body observation does not include an assessment of R99's right buttocks pressure injury. The body observation was completed by a LPN (Licensed Practical Nurse). The nurses note dated 8/26/22 documents, Admit from hospital with Acute Heart Failure with preserved ejection fraction. Hx (history) of HTN (hypertension), Sjogrens disease, Restrictive lung disease, COPD (chronic obstructive pulmonary disease), hypoxia, hyponatremia, Elevated troponin-secondary to ischemia and severe protein-calorie malnutrition. Family states they will bring in Berry ensure due to not able to swallow milk like supplements. Will get order when they provide type. Pt. (patient) also confirms she takes larger pills in applesauce and thin liquids. States some pain from bummpy sic (bumpy) ride to facility to low back but refused intervention, stating she just wanted to get in her pajamas and lay down. 1 assist for adls (activities daily living) and transfers. Pt. slow steady gait with walker. LSC (lung sounds clear), RR (respiratory rate) even and unlabored. ABD (abdomen) soft active x 4. Continent of B&B (bowel and bladder). Skin warm and dry. Noted small mark to upper spine, covered with bordered foam. Also Foam to coccyx for protection. Stage 2 to right buttocks measuring 1x1. Will fax MD (medical doctor) for med septic. Heels firm and blanchable. No bruising noted. VS (vital signs) charted. This note was written by a LPN. The physician order dated 8/26/22 documents may apply medseptic cream to areas of concern every shift - PRN (as needed). Surveyor reviewed R99's TAR (Treatment Administration Record) from 8/26/22 to 9/11/22 and noted there is no documentation R99 received medseptic cream. The nurses note dated 8/27/22 documents Patient A/O (alert/orientated) x (times) 4 able to use call light appropriately, adequate hearing and vision. Currently on 02 (oxygen) 2 L (liters) NC (nasal cannula) non labored breathing no chest pain, cough or congestion. Abdomen soft non tender BS (bowel sounds) active all 4 quadrants. Briefs in place continent of bowel and bladder. Skin warm and dry. Mepilex in place to coccyx area for prevention. Peripheral pulses palpable no edema noted. 1 assist with walker and 1 assist with ADL's. Able to feed self appetite adequate. PT (physical therapy) and OT (occupational therapy) as ordered. Denies any pain at this time. Daughter at bedside plan of care reviewed. The at risk for pressure ulcers care plan created 9/1/22 includes approaches all dated 9/1/22 of: * Avoid shearing resident's skin during positioning, transferring and turning. * Conduct a systematic skin inspection per facility protocol and pay particular attention to the bony prominences. * Keep clean and dry as possible. Minimize skin exposure to moisture. * Keep linens clean, dry, and wrinkle free. * Report any signs of skin breakdown (sore, tender, red or broken areas). * Supplements as indicated related to malnutrition. * Turn and reposition every 2-3 hours and PRN (as needed). * Use moisture barrier product to perineal area. The admission MDS (Minimum Data Set) with an assessment reference date of 9/1/22 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R99 requires limited assistance with one person physical assist for bed mobility, transfers, ambulating in room & toilet use. R99 is occasionally incontinent of urine and continent of bowel. R99 is at risk for pressure injury development and is coded as having one Stage 2 pressure injury which was present upon admission. The pressure injury CAA (care area assessment) dated 9/5/22 under analysis of findings documents; This is an [AGE] year old admitted to the hospital with acute heart failure, HTN (hypertension), Sjogren's disease, restrictive lung disease, COPD, hypotension, hyponatremia, elevated troponin secondary to demand ischemia and severe protein calorie malnutrition-30 pound weight loss in the past 7 months. On a general regular diet, does have difficulty with swallowing, will request larger medications be crushed with applesauce. NG (nasogastric) tube placed in the hospital, did have potassium through NG tube on day of discharge 8/26. Per patient due to Sjogrens disease has difficulty eating/swallowing if food is dry, if she puts too much in her mouth or trys to eat larger pieces of food/medication. Family provides supplements that she is able to tolerate and enjoys. Oxygen worn at all times, has shortness of breath with exertion, at times at rest and with laying down. Head of bed elevated at all times due to shortness of breath, even at home. Takes antidepressant daily for depression. Diuretic 3 times weekly for heart failure. Wears reading glasses to correct her vision. Has her own teeth. Wears hearing aides bilaterally. Occasional episode of urinary incontinence, continent of bowel. [NAME] pain. Triggered for the stage 2 pressure area present on admission, for her weight loss and for requires limited assist with bed mobility. She is at risk for skin breakdown, pain and infections. On 9/7/22 at 11:18 a.m. Surveyor observed R99 sitting in a personal type chair in the room with therapy standing next to R99. On 9/7/22 at 11:27 a.m. Surveyor reviewed the Facility's roster matrix and noted R99 is coded as having a Stage 2 pressure injury. On 9/7/22 at 2:56 p.m. Surveyor observed R99 in bed on her left side with the head of the bed. Surveyor did not observe a cushion in the personal type chair in R99's room. On 9/8/22 at 8:22 a.m. Surveyor observed R99 sitting in the personal type chair wearing a night gown and receiving oxygen via nasal cannula. Surveyor did not observe a cushion in the personal type chair. Surveyor asked R99 if they are sitting on another cushion other than the chair's cushion. R99 replied no. On 9/8/22 at 10:26 a.m. Surveyor observed R99 sitting in a personal type chair dressed for the day. Surveyor did not observe a pressure relieving cushion in the personal type chair. R99 informed Surveyor she was just about to go to the bathroom. On 9/8/22 at 12:29 p.m. Surveyor observed R99 sitting in a personal type chair in her room eating lunch. Surveyor did not observe a pressure relieving cushion in the personal type chair. The nurses note dated 9/12/22 includes documentation of Skin is warm and dry to touch, barrier cream applied for protection. On 9/12/22 at 7:58 a.m. Surveyor observed R99 sitting in a personal type chair in her room. Surveyor did not observe a pressure relieving cushion in the personal type chair. Surveyor asked R99 if she is sitting on a cushion. R99 pointed to the chair cushion and stated just this. On 9/12/22 at 11:10 a.m. Surveyor informed ADON-C, who is the Facility's wound nurse, R99's body observation and nurses note dated 8/26/22 along with the admission MDS documents R99 was admitted with a Stage 2 pressure injury on R99's right buttocks. Surveyor informed ADON-C Surveyor was unable to locate a RN assessment for this pressure injury. ADON-C informed Surveyor she was not aware of the buttocks pressure injury. Surveyor asked ADON-C how she becomes aware of a Resident with a pressure injury. ADON-C informed Surveyor staff leaves her a note and she checks the skin assessment sheet which is completed upon admission. Surveyor asked if the skin assessment sheet she is referring to is the body observation. ADON-C indicated it was. ADON-C stated I guess I did not assess that. Surveyor asked if there should be a pressure relieving cushion in the personal type chair in R99's room. ADON-C replied yes that's the main source of where she sits. Surveyor informed ADON-C Surveyor has not observed a pressure relieving cushion in R99's chair. ADON-C informed Surveyor she is going to assess R99. On 9/12/22 at 11:39 a.m. ADON-C informed Surveyor R99's right buttocks is healed and she put a cushion in R99's chair. ADON-C also informed Surveyor there is a jar of medseptic which staff had been applying. Surveyor asked ADON-C if she had assessed R99 before. ADON-C replied no. On 9/12/22 at 2:20 p.m. Surveyor informed Administrator-A of the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received adequate supervision to prevent falls for 3 (R9, R8, and R22) of 4 residents reviewed for falls. *R9 had a fall on 7/4/2022 due to staff not following interventions per the Falls Care Plan. *R8 had six falls in eight months. R8's Falls Care Plan was not revised timely after falls to prevent future falls, interventions were not implemented as stated per the Fall Care Plan, and no documentation was found in R8's medical record of having a fall yet staff statements of a fall were provided. *R22 had eleven falls in eight months. R22's Falls Care Plan was not revised timely after falls to prevent future falls with resident-centered interventions. Findings: The facility policy and procedure entitled Falls - Clinical Protocol dated 3/2018 states: Assessment and Recognition: . 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. a. Often, multiple factors contribute to a falling problem. 2. If the cause of the fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility policy and procedure entitled Falls and Fall Risk, Managing dated 3/2018 states: Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The facility policy and procedure entitled Assessing Falls and Their Causes dated 3/2018 states: After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate time frame. 8. Complete an incident report for resident falls no later than end of shift after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Defining Details of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. 2. For each individual, distinguish falls in the following categories: a. Rolling, sliding, or dropping from an object (e.g., from bed or chair to floor); b. Falling while attempting to stand up from a sitting or lying position; or c. Falling while already standing and trying to ambulate. Identifying Causes of a Fall or Fall Risk: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to residentspecific [sic] evidence including medical history, known functional impairments, etc. 2. Evaluate the chain of events or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way); and/or h. Whether there is a pattern of falls for this resident. 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. Documentation: When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). 2. Assessment date, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. 1. R9 was admitted to the facility on [DATE] with diagnoses of cerebral infarction with hemiplegia and hemiparesis affecting the left side, aphasia, epilepsy, depression, anxiety, and essential tremor. R9's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R9 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 99 and needed extensive to total assistance with activities of daily living. R9's Falls Care Plan was initiated on 9/24/2019 and the following interventions were in place on 7/4/2022: -Bed against wall. -Bed to lowest position. -Fall mat on floor next to bed as needed. -Moved to room closer to nurses' station and with more staff interaction. -Scoop mattress placed on bed. -Currently use of Broda chair which has provided safest environment. -Signs in room reminding R9 to call for assistance. -Activities to work with R9 at least three times a week. -Recline Broda chair to help for trunk control. -Nursing to ensure motion alarm is placed correctly to face R9; on floor mat at foot of bed facing bedside dresser. -Frequent round. -R9 to be centered in bed so not close to the edge of the bed. On 7/4/2022 at 5:42 AM in the progress notes, nursing charted R9 was found crouched on elbows and knees on the bedroom floor next to the Broda chair. R9 had been placed in the Broda chair by a Certified Nursing Assistant (CNA) 10-15 minutes prior to discovery of R9 on the floor. Dycem was placed in the chair. On 7/5/2022 at 9:23 AM in the progress notes, Director of Nursing (DON)-B charted R9's fall was discussed with the interdisciplinary team. Physical Therapy had re-evaluated R9's wheelchair status and changed R9's from a Broda chair to a high back wheelchair. Over the weekend, nursing staff put R9 back into the Broda chair and on 7/4/2022, after R9 was in the Broda chair, staff left the back of the Broda chair straight and did not do the slight recline to keep R9 from falling forward. Re-education of the nursing staff will be the intervention to prevent future falls. On 7/5/2022, R9's Falls Care Plan was revised with the following intervention: my broda chair needs to be slightly reclined so when I lean forward I don't fall out of my chair. Surveyor noted this intervention was in R9's Falls Care Plan on 11/20/2020. The CNA on 7/5/2022 did not follow R9's Falls Care Plan resulting in R9 falling from the Broda chair. On 9/7/2022 at 10:19 AM, R9 was observed reclined in a Broda chair in R9's room. R9 had a scoop mattress on the bed and a fall mat was folded at the end of the bed. Surveyor attempted to engage R9 in conversation but R9 was non-verbal. On 9/8/2022 at 2:39 PM, Surveyor requested from the facility a copy of R9's fall investigations. On 9/12/2022 at 8:09 AM, DON-B provided the requested fall investigations. DON-B stated DON-B knew she was not doing what should have been done for falls so a PIP (performance improvement plan) was started on 8/15/2022 to reduce the falls in the facility and was still in progress. In an interview on 9/12/2022 at 12:47 PM, CNA-H stated R9 has to have the Broda chair leaned back to prevent falls. In an interview on 9/12/2022 at 1:18 PM, Surveyor reviewed with DON-B R9's fall on 7/4/2022. Surveyor shared the concern R9's Falls Care Plan had the intervention to lean back the Broda chair for trunk control on 11/20/2020. DON-B agreed the CNA did not follow R9's Falls Care Plan. DON-B stated the CNAs in the facility were educated on the need to have R9's Broda chair reclined to prevent falls. DON-B did not know if licensed staff were educated on that intervention. In an interview on 9/12/2022 at 2:01 PM, DON-B stated only the CNA education was completed after R9's fall on 7/4/2022, not any licensed staff. No further information was provided at that time. 2. R8 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, diabetes, anxiety, and Alzheimer's disease. R8's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R8 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 and needed extensive assistance with transferring and limited assistance with walking. R8 had a Health Care Power of Attorney that was not activated. R8's Falls Care Plan was initiated on 4/26/2021 and had the following interventions in place on 2/5/2022: -Blood pressure to assess for postural/orthostatic hypotension as needed. -Encourage to request assist in transfer and ambulation. -Encourage to use recommended assistive device in transfer/ambulation per therapy recommendations. -Follow toileting schedule prompted voiding plan. -Keep adjustable bed in proper position for safe transfers. -Keep call light within reach of R8 at all times while in room and answer promptly may need frequent reminders to use call light. -Lock bed brakes. -Monitor during activities and bring to supervised areas during waking hours as needed. -Monitor for change in gait. -Non-skid footwear on for transfers and ambulation. -Frequent rounding. -Sign in room in Spanish to encourage R8 to call staff for assistance before getting up. -Educate family regarding to inform staff when return from outing with family so staff can make sure motion alarms are in place correctly. -Fall 6/12/2021 non-displaced right hip fracture; family requesting sensor pad at all times; PT evaluation and treatment ordered. -Staff to toilet R8 after lunch. Fall #1: On 2/5/2022 at 9:27 PM in the progress notes, nursing charted R8's alarm was going off. R8 had a witnessed fall onto buttocks. R8 denied pain or injury; R8 was able to move all extremities. R8 was attempting to self-transfer to get into the wheelchair so R8 could have a snack of cereal. R8 was laughing after the fall. R8 was assisted into the wheelchair. On 2/5/2022 an Event Report was initiated regarding R8's witnessed fall. The Evaluation section of the Event Report stated R8 was getting a box of cereal and became unsteady and lost their balance while reaching for it. The intervention to prevent future falls was to keep cereal by R8 in the day room at night. The Event Report was closed on 5/10/2022 by Director of Nursing (DON)-B. R8's Falls Care Plan was not revised with any new interventions at that time. Fall #2: On 2/23/2022 at 9:32 PM in the progress notes, nursing charted R8 fell in the dayroom attempting to self-transfer and lost their footing. The fall was unwitnessed. R8 sustained a small abrasion to the left elbow which was cleansed, and a band aid was applied. R8 stated they wanted to go to the bathroom. R8 was found sitting with the back against the recliner R8 had been sitting in and the chair alarm was sounding. The nurse charted the intervention would be to toilet R8 every two hours. On 2/23/2022 an Event Report was initiated regarding R8's unwitnessed fall. The Evaluation section of the Event Report stated R8 was spontaneous with transfers and unsteady on the feet due to Parkinson's. The intervention to prevent future falls was to toilet R8 every two hours. The Event Report was closed on 5/10/2022 by DON-B. R8's Falls Care Plan was not revised with any new interventions at that time. Fall #3: On 4/28/2022 at 1:24 PM in the progress notes, nursing charted R8 was having lunch in the activity dining room and left to go to the bathroom. Staff was notified R8 was on the way to the bathroom. Staff were on their way to the bathroom when they heard R8's alarm sounding. The Certified Nursing Assistant (CNA) entered the bathroom and found R8 on the floor. The CNA notified nursing staff. R8 was fully clothed with the back against the wall, knees up, and feet on the floor. R8 did not have any injuries and was assisted to the toilet. Nursing documented R8 was to be toileted every two hours. On 4/28/2022 an Event Report was initiated regarding R8's unwitnessed fall. The Evaluation section of the Event Report stated R8's medications were evaluated and adjusted. The intervention to prevent future falls was to toilet R8 every two hours. The Event Report was closed on 5/10/2022 by DON-B. On 4/28/2022, R8's Falls Care Plan was revised with the intervention: staff to toilet R8 every two hours. Surveyor noted the intervention of toileting R8 every two hours was to be implemented after R8's fall on 2/23/2022 per the Event Report but the Falls Care Plan was not revised at that time. R8's fall on 4/28/2022 could have been prevented if the intervention had been implemented after the 2/23/2022 fall. On 5/10/2022, R8's Falls Care Plan was revised with the intervention: keep cereal close to R8 in day room. Surveyor noted this intervention was addressing R8's fall on 2/5/2022, three months after the fall. Fall #4; On 6/4/2022, three staff statements were made on Incident Report forms indicating R8 had a fall on 6/4/2022 at 3:20 PM. The staff, consisting of two CNAs and a Med Tech, reported R8 fell in R8's room between the recliner and the roommate's bed. A cushion was behind R8's head. A nurse was called to the room and assessed R8 and determined R8 did not have any injuries. No documentation was found in R8's medical record of a fall on 6/4/2022. Fall #5: On 7/30/2022 at 5:16 AM in the progress notes, nursing charted R8 attempted to independently transfer from the chair to the wheelchair in the TV room when the alarm sound and alerted staff or R8's movement. As staff approached R8, R8 lost their balance and staff eased R8 to the floor. On 8/1/2022 at 9:25 AM in the progress notes, the interdisciplinary team (IDT) met to discuss R8's fall on 7/30/2022. It was determined R8 needed to be monitored while in the day room. An Event Report was initiated on 8/3/2022 by DON-B regarding R8's witnessed fall on 7/30/2022. The Evaluation section of the Event Report was not provided to Surveyor. The Event Report was closed on 8/3/2022 by DON-B. On 8/3/2022, R8's Falls Care Plan was revised with the intervention: R8 will need to be monitored for standing up spontaneously while in the wheelchair or sitting in the day room or R8's room. Fall #6: On 9/1/2022 at 8:11 PM in the progress notes, DON-B charted R8 was observed sitting with back on recliner and legs extended. The CNA had been assisting R8 with a transfer and R8's legs buckled and R8 was assisted to the floor. On 9/1/2022 an Event Report was initiated regarding R8's unwitnessed fall. The Evaluation section of the Event Report stated: N/A (not applicable): Event still open. The Event Report was closed on 9/1/2022 by DON-B. On 9/1/2022, R8's Falls Care Plan was revised with the intervention: Physical Therapy to evaluate. On 9/6/2022, R8's Falls Care Plan was revised with the intervention: Physical Therapy/Occupational Therapy screening/evaluation and treat as indicated. On 9/7/2022 at 10:37 AM, R8 was observed to be sitting in a recliner in the TV room on the unit. R8 had feet propped up on the seat of the wheelchair and had athletic shoes on. Other residents were in the TV room and staff were passing through the area on a regular basis. On 9/8/2022 at 2:39 PM, Surveyor requested from the facility a copy of R8's fall investigations. On 9/12/2022 at 8:09 AM, DON-B provided the requested fall investigations. DON-B stated DON-B knew she was not doing what should have been done for falls so a PIP (performance improvement plan) was started on 8/15/2022 to reduce the falls in the facility and was still in progress. In an interview on 9/12/2022 at 12:47 PM, CNA-H stated R8 needs assistance of one with a walker and gait belt to ambulate because R8 is unbalanced and needs help. CNA-H stated R8 can sit in any chair and needs to be watched by staff when they are walking by the TV room. In an interview on 9/12/2022 at 1:21 PM, Surveyor reviewed R8's falls with DON-B. Surveyor asked DON-B why the Falls Care Plan was not revised until 5/10/2022 for the fall that occurred on 2/5/2022. DON-B stated DON-B had no idea why R8's Fall Care Plan was not revised until 5/10/2022 for a fall that occurred on 2/5/2022. DON-B stated the Fall Care Plan should have been revised right after the fall occurred. Surveyor reviewed with DON-B R8's fall on 2/23/2022 where it was determined R8 should be toileted every two hours. That intervention was implemented and on 4/28/2022, R8 had another fall that was attributed to toileting. Surveyor shared the concern with DON-B that if the toileting intervention had been implemented, R8 may not have had the fall on 4/28/2022. DON-B agreed the toileting intervention should have been added to the Falls Care Plan after the 2/23/2022 fall. Surveyor asked DON-B about the staff statements that had been provided for the fall on 6/4/2022 and no documentation in R8's medical record of the fall. DON-B did not know why there was no Event Report for the fall on 6/4/2022 and would look into it. Surveyor shared with DON-B the fall on 7/30/2022 did not have a revised Falls Care Plan until 8/3/2022. DON-B stated the policy is to have the nurse on the floor put the intervention in at the time of the fall and the nurse probably did not do that, so DON-B put the intervention in when DON-B saw it was not completed. Surveyor asked DON-B if R8 was assessed by Physical Therapy after the fall on 9/1/2022 since that was the intervention to address that fall. DON-B stated DON-B would find out and get back with the information. In an interview on 9/12/2022 at 2:07 PM, DON-B stated DON-B was not able to find any documentation by nurses in R8's medical record of a fall on 6/4/2022. DON-B stated it is the facility's protocol to call DON-B when a resident has a fall. DON-B stated DON-B did not get a call and nurses did not do an event report, so DON-B had no idea what happened on that date. DON-B stated the PT evaluation after the 9/1/2022 fall was not done. Surveyor shared the concerns with R8's falls with DON-B of the Falls Care Plan not being revised timely after falls to prevent future falls, lack of documentation after a fall, and interventions not followed up. No further information was provided at that time. 3. R22 was admitted to the facility on [DATE] with diagnoses of discitis, toxic liver disease with chronic active hepatitis with ascites, cirrhosis of liver, diabetes, atrial fibrillation, hepatic failure, and inguinal hernia. R22's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R22 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R22 as needing extensive assistance with all activities of daily living except independent with eating. R22's POA was not activated. R22's Falls Care Plan was initiated on 10/21/2021 as the initial safety plan with the following intervention: bed to lowest position. No other interventions were implemented. Fall #1: On 12/16/2021 at 5:54 AM in the progress notes, nursing charted R22 was found on the floor at 1:00 AM in front of the bed on the stomach and slightly on the right side with legs out straight. R22 stated R22 had gotten up to use the bathroom but the roommate was in the bathroom and when R22 walked back to bed, the right knee buckled and R22 went down on the knees. R22 had no injuries and was able to get up on own. The nurse charted an intervention of R22 wearing gripper socks and encouraging to ask for assistance if feeling weak or difficulty with the knees would be added to the Falls Care Plan. On 12/16/2021, a Falls Care Plan was initiated with the following interventions: -Physical Therapy/Occupational Therapy to evaluate as needed and as ordered by physician. -Non-skid footwear on for transfers and ambulation. -Monitor for change in gait. -Monitor during activities and bring to supervised areas during waking hours as needed. -Mattress on the floor next to bed as needed. -Low bed as needed. -Lock bed brakes. -Keep call light within reach of resident at all times while in room and answer promptly. -Keep adjustable bed in proper position for safe transfers. -Follow toileting schedule (prompted void, per resident request or check and change for moderate/severe cognitive deficits). -Ensure gripper socks are worn; encourage R9 to call for assist with transfers if feeling weak or difficulty with knees. -Encourage to use recommended assistive device in transfer/ambulation per therapy recommendations. -Encourage to request assist in transfer and ambulation. -Blood pressure to assess for postural/orthostatic hypotension as needed. Fall #2: On 1/29/2022 at 8:32 PM in the progress notes, nursing charted R22 yelled help from the doorway and was found crawling in the doorway of the room. R22 stated R22 had rolled out of bed and fell on the floor. R22 stated R22 crawled to the door to get help because the legs do not work. R22 was lifted back into bed with a mechanical lift. R22 stated R22 had been rolling around in bed back and forth to plug the phone in and rolled out of bed. On 1/29/2022 an Event Report was initiated regarding R22's unwitnessed fall. The Evaluation section of the Event Report stated R22 was rolling in bed to get the cell phone plugged in. The intervention to prevent future falls was to apply a fall mat to the floor at bedside to help R22 stay safe when R22 rolls out of bed. The Event Report was closed on 2/28/2022 by DON-B. R22's Fall Care Plan was not revised with any new interventions at that time. Fall #3: On 2/9/2022 at 9:28 AM in the progress notes, nursing charted R22 was being assisted by a Certified Nursing Assistant (CNA) getting ready for an appointment. R22 was sitting at the edge of the bed when the CNA went into the hallway while the nurse was administering medications. The nurse left the room and when the CNA came back into the room, R22 was on the floor face down. R22 stated R22 was trying to pull up their pants and fell onto the left side and rolled onto the stomach. R22 was lifted back into the bed with a mechanical lift. On 2/9/2022 an Event Report was initiated regarding R22's unwitnessed fall. The Evaluation section of the Event Report stated staff was not to leave R22 on the side of the bed during ADLs until confusion clears. The Event Report was closed on 5/9/2022 by Director of Nursing (DON)-B. On 2/9/2022, R22's Falls Care Plan was revised with the following intervention: R22 not to be left alone during ADLs/dressing/grooming. Fall #4: On 2/16/2022 at 5:20 AM in the progress notes, nursing charted R22 was found on the floor at 4:45 AM lying on the stomach slightly on the left side with legs straight out. The CNA had been checking on R22 throughout the night and asking R22 to please stay off the edge of the bed. R22 stated R22 had rolled over wrong and slid off the bed. R22 was lifted back into the bed with a mechanical lift. When R22 was questioned as to why R22 did not ask for assistance, R22 became angry and belligerent raising the voice and not following nursing recommendations. The nurse documented a motion alarm may be the best intervention. On 2/16/2022 an Event Report was initiated regarding R22's unwitnessed fall. The Evaluation section of the Event Report stated a motion alarm was added for intervention as R22 was confused at times due to ascites. The Event Report was closed on 5/9/2022 by DON-B. R22's Falls Care Plan was not revised with any new interventions at that time. Fall #5: On 2/21/2022 at 1:21 PM in the progress notes, nursing charted R22 was reaching for something on the bedside table and slid off of the bed onto the floor. R22 was lifted back into bed with a mechanical lift. On 2/21/2022 an Event Report was initiated regarding R22's unwitnessed fall. The Evaluation section of the Event Report stated the intervention was to have a tray table next to R22 while in bed or in the chair; R22 had been confused and awaited labs that were ordered. The Event Report was closed on 5/9/2022 by DON-B. R22's Falls Care Plan was not revised with any new interventions at that time. Fall #6: On 2/26/2022 at 4:16 AM in the progress notes, nursing charted R22 was found on the floor at 12:10 AM next to roommates bedside table just outside of the bathroom door. R22 stated R22 was trying to get something from the roommate's side of the room and then was incontinent of bowel. R22 did not use the call light and the motion alarm did not sound even though it was on. R22 stated R22 slid out of bed onto the buttocks and crawled across the room. The nurse asked R22 why R22 did not use the call light; R22 did not have an answer. R22 was encouraged to ask for help. On 2/26/2022 an Event Report was initiated regarding R22's unwitnessed fall. The Evaluation section of the Event Report stated the intervention was to have a fall mat next to the bed when R22 was in bed; R22 was sent to the hospital for evaluation and was admitted (due to altered mental status and not the fall). Staff statements indicated the fall mat was placed next to the bed after the fall. The Event Report was closed on 5/9/2022 by DON-B. On 2/26/2022, R22's Falls Care Plan was revised with the intervention: fall mat on floor next to bed in low position. (Surveyor noted the fall mat intervention had been suggested after R22's fall on 1/29/2022 but not implemented in the Falls Care Plan.) On 2/28/2022, R22's Falls Care Plan was revised with the following intervention: fall mat on floor next to bed at all times while in bed. Surveyor noted the Approach Start Date was 1/29/2022 after the fall on that date, but not added to the care plan until one month after the fall. Fall #7: On 3/3/2022 at 10:15 AM in the progress notes, nursing charted R22 had rolled out of bed the previous night, was combative and resistive, and CNAs and a nurse was with R22 for over three hours attempting to care for R22. On 3/3/2022, R22's Falls Care Plan was revised with the following intervention: Call physician to review medications; physician discontinued fentanyl patch and tramadol. On 3/31/2022, R22's Falls Care Plan was revised with the following intervention: offer toileting with night rounds. Surveyor noted the Approach Start Date was 2/26/2022 after the fall on that date, but not added to the care plan until one month after the fall. Fall #8: On 4/4/2022 at 6:25 PM in the progress notes, nursing charted R22 had a witnessed fall trying to transfer from the bed to the wheelchair. R22 had leaned forward and lost balance. On 4/4/2022 an Event Report was initiated regarding R22's witnessed fall. The Evaluation section of the Event Report stated the intervention was to remind R22 to call for assistance due to unsteady gait. The Event Report was closed on 5/9/2022 by DON-B. R22's Falls Care Plan was not revised with any new interventions at that time. On 5/9/2022, R22's Falls Care Plan was revised with the following interventions: -bedside table next to bed or R22 while in bed or in room -remind R22 to call for assistance before transferring due to unsteady gait. Surveyor noted the Approach Start Date for the bedside table placement was 2/21/2022 after the fall on that date, but not added to the care plan until two and a half months after the fall. Surveyor noted the Approach Start Date for reminding R22 to call for assistance was 4/4/2022 after the fall on that date, but not added to the care plan until one month after the fall. Fall #9: On 6/4/2022 at 3:40 AM in the progress notes, recorded as a late entry on 6/7/2022, nursing charted R22 independently transferred from the bed, lost balance, and fell to the floor. This was an unwitnessed fall with no injuries. An Event Report for the fall on 6/4/2022 was recorded on 6/8/2022 and the event was still open with no Evaluation section completed. On 6/9/2022, R22's Falls Care Plan was revised with the following intervention: frequent rounding for toileting at night. Fall #10: On 7/2/2022 at 1:09 AM in the progress notes, nursing charted R22 was found lying on the floor next to the bed. R22 had no injuries, the bed was in the lowest position, the call light was not activated, and R22 was continent. R22 was lifted back into bed with a mechanical lift. On 7/6/2022, R22's Falls

Based on observation, interview and record review, the facility did not ensure that 1 (R36) of 1 residents reviewed received dialysis services consistent with professional standards of practice. R36 did not have a physician's order documenting the frequency of dialysis treatments, the location of the dialysis center in the community, the care, monitoring, and location of the dialysis access site. R36's care plan did not document the location of the dialysis access site or the monitoring of the dialysis site for complication such as bleeding. Findings include: The Dialysis policy and procedure revised 1/2017 under policy documents [name of facility] will use the Critical Element Pathway from CMS (Centers for Medicare & Medicaid Services) to provide quality dialysis services to our clients. [name of facility] does not provide in-house dialysis. If any resident needs dialysis, Admissions or Social Worker will set up the appointments and arrange for transportation, either with our van or with an outside vendor. Under procedure documents; Obtain physician order for hemodialysis or peritoneal dialysis as appropriate. Obtain orders for access care, dialysis schedule, any individualized dialysis prescriptions, such as the number of treatments per week, length of treatment (if appropriate), fluid restriction, target weight and blood pressure monitoring. Communicate with dialysis facility before and after treatment via the Dialysis Communication form. Under Coordinate Care Plan with dialysis facility includes Monitor for risk factors such as hemorrhage, access site infection, hypotension and who to report concerns. Assessment and care of the access site and potential special infection control measures. R36's diagnoses includes end stage renal disease, dependence on renal dialysis, and chronic kidney disease with heart failure. The hemo dialysis related to renal failure care plan with a start date of 2/19/21 & edited 7/3/22 documents the following approaches: * Resident to go out patient dialysis 3 days a week Monday, Wednesday, and Friday. With a start date of 2/19/21. * Restrict intake of fluids to 1500 ml's (milliliters)/day. NAS (no added salt) Renal diet with double protein and fortified mashed potatoes daily. Prosource 30 cc (cubic centimeters) on non dialysis days. With a start date of 2/19/21 and edited 6/1/21. The nurses note dated 5/23/22 includes documentation of Attends dialysis M-W-F (Monday-Wednesday-Friday). Port to chest, dressing remains CDI (clean dry intact). The nurses note dated 8/16/22 documents Resident has dialysis three times a week. The nurses note dated 9/7/22 documents Resident refused to go to dialysis today d/t (due to) having intense pain to her left shoulder that radiates to her neck. Writer gave Tylenol and will monitor resident. Dialysis called and rescheduled for 9/8 at 11am. On 9/8/22 at 7:38 a.m. Surveyor observed R36 in bed on her back with the head of the bed elevated. Surveyor asked R36 if she was going to dialysis today. R36 informed Surveyor she was suppose to go yesterday but didn't want to go as her left side was hurting her and they want her to go today. R36 informed Surveyor she would like to get up as she is leaving about 10:30 a.m. for her dialysis appointment. R36 informed Surveyor she doesn't have any problems with her dialysis explaining she has a port in her upper right chest as she didn't want the access in her arm. R36 informed Surveyor she can't have the access on her left side as she had cancer. Surveyor asked R36 where she has her dialysis. R36 informed Surveyor its in Lake Geneva but she doesn't know the name. On 9/8/22 at 9:14 a.m. Surveyor reviewed R36's physician orders. R36's physician orders does not include an order for dialysis nor does the physician orders include monitoring of R36's access site for complications. On 9/8/22 at 10:21 a.m. Surveyor asked LPN (Licensed Practical Nurse)-D where R36 was. LPN-D informed Surveyor R36 left for dialysis. On 9/8/22 at 11:01 a.m. Surveyor noted the last dialysis communication in R36's electronic medical record is from 2021. On 9/8/22 at 12:01 p.m. Surveyor asked LPN-D where Surveyor would be able to find R36's dialysis communications. LPN-D informed Surveyor they are in the folder R36 has with her. On 9/8/22 at 1:55 p.m. Surveyor informed ADON-C Surveyor was unable to locate a physician's order for R36's dialysis. ADON-C looked at R36's electronic medical record and informed Surveyor she doesn't see one either. ADON-C then informed Surveyor she doesn't see an order even in R36's old orders. Surveyor asked ADON-C where Surveyor would be able to locate monitoring for complications such as bleeding of R36's access site. ADON-C informed Surveyor you would think there would be an order and then indicated she doesn't see that order. Surveyor informed ADON-C Surveyor wasn't able to locate staff was monitoring the dialysis access site and R36's care plan doesn't address monitoring. On 9/12/22 at 7:41 a.m. Surveyor informed CNA (Certified Nursing Assistant)/Med Tech-P last week Surveyor had asked for R36's dialysis communication and was told the folder was with R36 at dialysis. Surveyor inquired if Surveyor could look at the folder before R36 leaves for dialysis. CNA/Med Tech-P looked through the folder stating it's a hot mess and doesn't know if they send something every week. Surveyor inquired if the communications have pre weights. CNA/Med Tech-P informed Surveyor the dialysis center took that over a long time ago and typically they want phone calls. CNA/Med Tech-P informed Surveyor if dialysis calls the nurse will put a note in their chart. On 9/12/22 at 7:47 a.m. Surveyor reviewed R36's dialysis communication folder. Surveyor noted the information in this folder is from 2021 with the exception of 7/15/22. On 9/12/22 Surveyor received a copy of the dialysis center's physician orders. Surveyor noted on top of the orders is a fax date of 9/8/22 at 15:15 (3:15 p.m.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure 1 (R35) of 1 residents reviewed for mood and behavior received appropriate treatment and the services to attain the highest practicable mental and psychosocial well-being. The facility did not ensure that R35 received a psychiatric consult as requested by R35's POA (Power of Attorney). Findings include: R35 was admitted for rehabilitation on July 23rd, 2022, and has diagnoses that include: fracture of unspecified part of the neck of the left femur, dementia, and depression. R35's MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/29/22 documented R35 has a BIMS (Brief Interview for Mental Status) of 4, indicating R35 is cognitively impaired; R35 used anti-depressant medication six days during the reference period, and documented a PHQ-9 (Patient Health Questionnaire-9) score of 00, indicating no depression; however, the PHQ-9 assessment contains an area for staff to assess residents' level of depression if the resident is cognitively impaired. The PHQ-9 (Patient Health Questionnaire-9) section was done via interview with R35; the staff assessment section was not completed. R35's documented CAAs (Care Area Assessments) included: 1.) Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED 2.) Verbal behaviors directed toward others (e.g., threatening, screaming at, or cursing at others) 3.) Other behavior symptoms not directed toward others ( hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) 4.) Behavior significantly interferes with the resident's care R35's care plan, dated 07/29/22, with a target date of 11/05/22, states: Resident receives antidepressant medication Zoloft due to depression. Interventions include Assess/record effectiveness of drug treatment, Drug reduction as recommended by pharmacist, monitor resident's mood and response to medication, and pharmacy consultant review per protocol. Surveyor reviewed R35's medical record and noted the following documentation in progress notes: On 07/26/2022 at 08:15 PM, RN (Registered Nurse) documents, .at night has had bouts of crying, none noted thus far this shift On 07/30/2022 at 01:55 PM, RN (Registered Nurse) documents, RN and CNA used [NAME] steady go get weight on patient. During the whole time patient screaming and yelling out. Patient then placed in bed to attempt to remove staples and continues to scream and yell leave me alone. Brief changed small bm noted. Will attempt again. Daughter (name of daughter) at bedside aware of plan of care. On 7/30/2022 at 09:33 PM, RN (Registered Nurse) documents, alert and oriented to self. difficulty articulating needs. needs anticipated. daughter in this evening and concerned about pt (patient) yelling out stating possibly behavioral and would like a psych (psychiatric) consult. MD (medical doctor) faxed for consult . On 07/31/2022 at 08:21 PM, RN (Registered Nurse) documents, Patient heard yelling out prior to dinner, writer and (name of certified nursing assistant) approached patient and attempted to redirect. Patient hard to redirect, however was content once food arrived. Patient began calling out again after dinner, writer and (name of certified nursing assistant) attempted to redirect. Unsuccessful. Writer and (name of certified nursing assistant) assisted patient into bed, patient incontinent of urine at that time. Patient yelled out with repositioning but unable to verbalized if she was in pain. Patient quickly closed eyes once in bed and cares completed. Patient remained calm for a bit and then began yelling out again. Patient found sitting on edge of bed. Writer and (name of registered nurse) assisted patient into bed, not incontinent, requested boots to be removed, which was done, and then patient assisted back into bed. Patient appeared to be comfortable. Patient again found sitting on edge of bed and was noted to have had a bowel movement. Writer and (name of certified nursing assistant) assisted with incontinence cares, patient yelled out, but less frequently and loudly. Patient then tucked in which was around 1845. Patient remains asleep and comfortable at this time. On 08/03/2022 at 10:05 AM, LPN (licensed practical nurse) documents, . Calling out and talking to herself Can be resistive with cares. On 08/15/2022 at 02:21 PM, LPN (Licensed Practical Nurse) documents, Resident admitted s/p (status post) hospitalization for left hip fx (fracture) post-surgical, hx (history) of dementia. NO pain noted this shift during cares however did hear pt. (patient) crying out during therapy. Pleasant and cooperative mood today. Crying after breakfast to go to room. Easily redirected. Coloring at dining table most of day . On 08/15/2022 at 06:09 PM, LPN (Licensed Practical Nurse) documents, POA (Power of Attorney) here asking if pts (patients) sertraline can be increased to improve mood and decrease crying episodes. On 08/16/2022 at 09:32 AM, LPN (Licensed Practical Nurse) documents, Resident alert and oriented x1-2 confused and forgetful at times, makes some needs known, staff anticipate needs as well. VSS (vital signs stable), has no c/o (complaints of) pain at this time but does c/o (complain of) pain to left leg often and will massage her left leg, she cries out/screams during transfers anxiety vs pain, staff talk calmly to resident and able to redirect some of her behaviors. Resident has times of crying out and saying i just don't want to be here anymore. Fax to md (Medical Doctor) out for sertraline increase per family request, awaiting response . On 08/16/2022 at 12:34 PM, LPN (Licensed Practical Nurse) documents, New order received to increase sertraline from 50mg (milligrams) to 100mg (milligrams) po (by mouth) q(daily) pm, writer to call and update family Review of R35's physician's orders document an order for Sertraline 100mg (milligrams), 1 tablet, by mouth in the evening which started on 08/16/22 and does not have an end date. Surveyor did not find a physician's order for a psychiatric consult nor documentation that R35 had a psychiatric consult per family request on 07/30/22. On 09/12/22 at 10:47 AM, surveyor interviewed Admissions-I who is the Facility's Social Worker. Admissions-I told surveyor she is responsible for psychiatric/psychological consults and the nurses would let her know if a resident needed to have a psychiatric/psychological consult. Admissions-I told surveyor that R35 has not had a psychiatric/psychological consult because R35's family had refused. Surveyor informed Admissions-I of the progress note from 07/30/22 documenting R35's family had requested a psychiatric consult; Admissions-I was unaware of this request. On 09/12/22 at 02:21 PM, surveyor interviewed DON (Director of Nursing)-B. DON-B told surveyor the process for obtaining a psychiatric/psychological consultant was to have the nurse notify the MD (Medical Doctor) of the request and receive an physician's order and then the nurse would inform the social worker. DON-B reviewed R35's 07/30/22 progress note with surveyor and told surveyor the nurse who wrote the note is a good nurse and if she said she faxed something she faxed it. DON-B told surveyor she would look for follow up documentation. On 09/12/22 at 02:50 PM, DON-B informed surveyor that she did not have a physician's order for a psychiatric consult and did not have any additional information for surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 2 (R31 & R35) of 6 Residents reviewed. * R31 receives metoprolol tartrate 25 mg (milligrams) with instructions to hold the medication if R31's systolic blood pressure is less than 100. R31's PM (evening) blood pressure was not taken before administering the medication on 8/12/22, 8/18/22, 8/19/22, 8/20/22, 8/21/22 & 9/3/22. * R35 receives a prophylactic antibiotic for UTI (urinary tract infection) without adequate indications for its use. Findings include: R31 was admitted to the facility on [DATE] with diagnoses which includes hypertension. The physician orders dated 7/15/22 include metoprolol tartrate 25 mg (milligrams) with directions to administer twice a day 6:30 a.m. -10:00 a.m. and 7:00 p.m. - 9:30 p.m. Special instructions document HTN (hypertension) Hold Med for SBP (systolic blood pressure less than 100. On 9/8/22 at 12:20 p.m. Surveyor asked RN (Registered Nurse)-U where Surveyor would be able to locate a blood pressure for a medication which requires the blood pressure be taken prior to administration. RN-U informed Surveyor it would be under the vital sign tab for blood pressure. Surveyor reviewed R31's blood pressure under the vital sign tab and noted there was no blood pressure taken for the PM (evening shift) on 8/12/22, 8/18/22, 8/19/22, 8/20/22, 8/21/22 & 9/3/22. On 9/8/22 at 1:51 p.m. Surveyor informed ADON (Assistant Director of Nursing)-C R31 receives amlodipine 5 mg once daily and metoprolol tartrate 25 mg twice daily with instructions for both medications to hold the medication if R31's systolic blood pressure is less than 100. Surveyor informed ADON-C Surveyor noted R31's blood pressure has been obtained during the day shift but there is no blood pressure taken on the evening shift on 8/12/22, 8/18/22, 8/19/22, 8/20/22, 8/21/22 & 9/3/22. Surveyor inquired how would the nurse know the medication requires a blood pressure. ADON-C informed Surveyor most of the time there is a task for blood pressure. ADON-C informed Surveyor Amlodipine has a task for blood pressure but the metoprolol tartrate 25 mg does not have a task. ADON-C informed Surveyor she is going to add the task so the blood pressure will be obtained. On 9/8/22 at 2:44 p.m. during the end of the day meeting with the Facility Administrator-A was informed of the above. 2.) The facility policy, entitled Antibiotic Stewardship revised December 2016 states in part, 1. The purpose of our Antibiotic Stewardship program is to monitor the use of antibiotics in our residents . 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b. Dose c. Frequency of administration d. Duration of treatment (1) Start and stop date, or (2) Number of days of therapy e. Route of administration and f. Indications for use 5. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. 6. Discharge or transfer medical records must include all of the above drug and dosing elements The Antibiotic Stewardship-Orders for Antibiotics section of the policy documents: .3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending) The Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes section of the policy documents: .2. The IP (Infection Preventionist), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics . R35 was admitted for rehabilitation on July 23rd, 2022 and has diagnoses that include: fracture of unspecified part of the neck of the left femur, dementia, and depression. R35's MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/29/22 documented R35 has a BIMS (Brief Interview for Mental Status) of 4, indicating R35 is cognitively impaired; R35 used antibiotics five days during the reference period, and no infections were documented under Section I. R35's care plan, dated 07/29/22, with a target date of 08/27/2022, states: (Name of R35) has a UTI (urinary tract infection) and has potential for complications. Interventions include: Administer medications as ordered and evaluate and document and report effectiveness and any adverse side effects, encourage prompt complete bladder emptying, ensure meticulous personal hygiene ., monitor vital signs and report fever. Surveyor reviewed R35's physician orders and noted an order for an antibiotic: Macrodantin (nitrofurantoin macrocrystal) capsule; 50mg (milligrams); 1 capsule; oral [Diagnosis Urinary Tract Infection, site not specified], At Bedtime; 0730pm-0930pm. This order was documented as open ended, meaning there was no stop date. On 09/08/22 at 12:36 PM, surveyor interviewed ADON (Assistant Director of Nursing)-C, who is also the infection preventionist. ADON-C told surveyor R35 does not have an active UTI (Urinary Tract Infection) and per R35's family the antibiotic is prophylactic, because she has recurrent UTIs (Urinary Tract Infections). ADON-C told surveyor that R35 has been on that antibiotic since her admission. ADON-C told surveyor the facility follows the McGreer's criteria for diagnosing/treating infections and that R35 does not meet the McGreer's criteria to treat an active infection. ADON-C stated she has not spoken with R35's medical doctor or the medical director at the facility regarding the antibiotic order and that R35's medical doctor is the facility's medical director. ADON-C stated infection control is reviewed in QAPI (Quality Assurance and Performance Improvement) and she has talked to the medical director about some residents' antibiotic orders but not about R35. ADON-C did not have any additional information. On 09/08/22, during the daily exit conference, surveyor informed NHA (Nursing Home Administrator)-A of the above concern. On 09/12/22, surveyor reviewed R35's progress notes and noted the following documented from ADON-C on 09/08/2022 at 05:08 PM, writer spoke to (physician's name) in regards to resident had admitted with oral antibiotic for recurrent bladder infections. resident has been without s/sx (signs and symptoms) of infection through admission. resident came from Kenosha hospital so no current records to support the use of the prophylactic use of the antibiotic. writer discussed that resident doesn't meet the McGeer criteria to support use. MD (medical doctor) reports they will look into resident past history and get back to writer. This progress note was entered after surveyor discussed the antibiotic concern with the facility staff, including ADON-C. On 09/12/22, surveyor received communication from the facility documenting the medical doctor would like to continue with the antibiotic order due to recurrent urinary tract infections and a hospitalization related to failed attempts at discontinuing the prophylactic antibiotic. This communication has a date of 09/09/22 which is after surveyor had discussed the antibiotic concerns with the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure that 1 (R31) of 4 Resident's medications reviewed were free from unnecessary drugs. * R31 receives Risperidone (Risperdal) 0.5 mg twice a day. The Facility is not monitoring R31's behavior and an AIMS (Abnormal Involuntary Movement Scale) was not completed. Findings include: R31 was admitted to the facility on [DATE] with diagnoses which includes multiple sclerosis, depression, anxiety disorder, and Alzheimer's disease. The physician orders dated 7/15/22 includes Risperidone 0.5 mg (milligrams) with directions to administer twice a day for Alzheimer's dementia. Risperidone (Risperdal) is an antipsychotic medication. The admission MDS (minimum data set) with an assessment reference date of 7/18/22 is coded as having received an antipsychotic 3 days in the last 7 days. The quarterly MDS with an assessment reference date of 8/31/22 is coded as having received an antipsychotic for 7 days in the last 7 days. On 9/8/22 at 12:02 p.m. Surveyor asked Admissions-I, who is the Facility's Social Worker, where Surveyor would be able to locate a Resident's AIMS. Admissions-I informed Surveyor she doesn't do them. ADON (Assistant Director of Nursing)-C who was also there informed Surveyor LPN/MDS (Licensed Practical Nurse/Minimum Data Set)-T does the AIMS. On 9/8/22 at 12:23 p.m. Surveyor asked LPN/MDS-T where Surveyor would be able to locate a Resident's AIMS. LPN/MDS-T informed Surveyor it would be under observations in the electronic medical record. Surveyor informed LPN/MDS-T Surveyor was unable to locate an AIMS for R31 who is on Re. LPN/MDS-T looked at R31's electronic medical record and informed Surveyor she's not seeing one. Surveyor asked LPN/MDS-T if she is responsible for completing the AIMS. LPN/MDS-T informed Surveyor she does them when they come up for the quarter. LPN/MDS-T explained when a Resident is admitted she trys to put the AIMS in the order so when the nurse does the admitting observation they can do the AIMS also. Surveyor asked if an AIMS was completed for R31. LPN/MDS-T informed Surveyor there was not. During R31's record review Surveyor was unable to locate any behavior monitoring for R31 who receives Risperidone. On 9/12/22 at 10:55 a.m. Surveyor spoke with Admissions-I, who is the Facility's Social Worker, and LPN/MDS-T to inquire about behavior monitoring for R31. Admissions-I informed Surveyor R31 doesn't have any behaviors and there is a note on 7/20/22 which the pharmacist recommended a GDR (gradual dose reduction) and the doctor declined. Surveyor informed Admissions-I the Facility needs to be monitoring R31's behavior such as verbal, physical etc to help determine if the Risperdal is effective. LPN/MDS-T informed Surveyor she will see if there is a report for behaviors. Surveyor informed LPN/MDS-T Surveyor did receive a report where staff are monitoring R31's mood but not behavior. LPN/MDS-T informed Surveyor she is looking in the plan of care, doesn't see it but will keep looking. Surveyor asked LPN/MDS-T if she locates any behavior monitoring for R31 to let Surveyor know. Surveyor was not provided with any behavior monitoring for R31's antipsychotic medication, Risperidone (Risperdal).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure 1 (R16) of 5 residents reviewed for medication administration were free of significant medication errors. R16 was administered an extra 4 units of long-acting insulin before lunch time instead of the prescribed 4 units of short-acting insulin. Findings include: Surveyor reviewed facility's Administering Medications policy with a revision date of April 2019. Documented was: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . R16 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, severe sepsis with septic shock, Type 2 diabetes mellitus (DM) with diabetic nephropathy, and other specified diabetes mellitus with ketoacidosis without coma. Surveyor reviewed the quarterly Minimum Data Set (MDS) with an assessment reference date of 7/8/22 documented R16 had a Brief Interview Mental Status (BIMS) score of 15 which indicated R16 is cognitively intact. On 9/8/22 at 11:57 AM, Surveyor observed Licensed Practical Nurse (LPN)-D administer insulin to R16. LPN-D primed the insulin pen and turned the dial to 4 units. Surveyor observed a Tresiba long-acting insulin pen being used when LPN-D was administering the insulin to R16's abdomen. After administration R16 stated that is the wrong one noting the resident saw LPN-D was administering the wrong insulin pen. LPN-D shouted oh no, that was the long-acting and came out of the room. LPN-D stated to Surveyor that she administered the wrong insulin. LPN-D stated she administered the long-acting Tresiba that he had already received in the AM instead of the short-acting insulin that gets administered prior to meals. Surveyor asked LPN-D what the process was if the wrong insulin is given. LPN-D stated she was going to call the MD and give him an update right away. On 9/8/22 at 11:55 AM, Surveyor told Assistant Director of Nursing (ADON)-C about LPN-D administering the wrong insulin to R16. ADON-C stated she was going to call the doctor right away and they will follow up on what to do. ADON-C stated LPN-D should have checked the medication to make sure it was the correct insulin. Surveyor reviewed R16's MD orders. Documented with a start date of 7/27/22 was Novolog U-100 Insulin aspart (insulin aspart u-100) solution; 100 unit/mL; amt: 4 units; subcutaneous Special Instructions: inject 4 units sq-15min prior to meals for DM; Three Times A Day; 06:30 AM - 10:00 AM, 11:00 AM - 01:00 PM, 04:00 PM - 06:30 PM. Documented with a start date of 1/27/22 was Tresiba FlexTouch U-100 (insulin degludec) insulin pen; 100 unit/mL (3 mL); amt: 27 units; subcutaneous Special Instructions: DM; Once A Day; 06:30 AM - 10:00 AM. Surveyor reviewed Medication Administration Record (MAR) for R16 and noted R16 was administered 27 units of Tresiba insulin prior to breakfast on 9/8/22. Surveyor reviewed Tresiba's Patient Instructions Link. Documented was: Prescribing Tresiba When sending prescribing information, be sure to specify the right formulation of Tresiba for your patients: The U-100 pen has a maximum dose of 80 units per injection and is dosed in 1-unit increments . Efficacy and Safety Ensure that at least 8 hours have elapsed between Tresiba injections . Important Safety Information Warnings and Precautions . Accidental mix-ups between basal insulin products and other insulins, particularly rapid-acting insulins, have been reported. To avoid medication errors, always instruct patients to check the insulin label before each injection . https://www.novomedlink.com/diabetes/products/treatments/tresiba/dosing-administration/starting-adult-patients.html Tresiba is a long-acting insulin that is dosed every 24 hours. Tresiba guidance indicates that doses should not be given closer than 8 hours apart. R16 was administered Tresiba prior to 8:00 AM breakfast and then was mistakenly given a dose of 4 units at 11:57 AM prior to lunch at 12:00 PM, less than 8 hours. Tresiba dose changes would be 1 unit at a time for an increase to the U-100 pen. A 4 unit dose increase would be outside of guidelines for an increase. Surveyor reviewed R16's Progress Notes for follow-up after the medication error. Documented on 9/8/22 at 12:32 PM was Blood sugar prior to lunch 111. Given 4 units of [Tresiba] instead of short acting Novolog by mistake. [MD] updated and ordered to hold short acting for lunch. Patient aware of med error as he noticed while administering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 2 (CNA-V & CNA-H) of 5 unvaccinated Facility staff including individuals providing services under arrangements were tested for COVID 19 according to Facility's outbreak protocol and [NAME] County community transmission rates. This had the potential to affect all 48 Residents residing at the Facility. Findings include: On 9/8/22 at 12:36 p.m. Surveyor conducted the infection control interview with ADON (Assistant Director of Nursing)-C, who is the infection preventionist at the Facility. During this interview Surveyor discussed with ADON-C the Facility's COVID-19 outbreaks. Surveyor inquired how often employees who have been granted an exemption are tested. ADON-C informed Surveyor they have been tested twice a week due to their COVID-19 outbreaks & the county's transmission rates. Surveyor inquired if there was a time since May 2022 these employees were not tested twice weekly. ADON-C informed Surveyor she didn't think there was a time when they weren't testing twice a week. Surveyor informed ADON-C Surveyor would like to review employee testing beginning 5/1/22. ADON-C informed Surveyor she would print the testing and provide to Surveyor. On 9/8/22 at approximately 3:50 p.m. ADON-C provided Surveyor with employee testing log beginning 5/2/22. ADON-C explained employees printed in red are not vaccinated. On 9/11/22 at 10:00 a.m. Surveyor reviewed the Facility's employees COVID-19 testing log. Surveyor noted for the week of 5/29/22 to 6/4/22 CNA (Certified Nursing Assistant)-V was tested for COVID-19 on 5/30/22 but did not have a 2nd test during this week. Surveyor noted CNA-H did not have any COVID-19 testing during the week of 5/8/22 to 5/14/22. During the week of 6/5/22 to 6/11/22 CNA-H was tested for COVID-19 on 6/6/22 but did not have a 2nd test during this week. During the week of 6/12/22 to 6/18/22 CNA-H was tested for COVID-19 on 6/13/2 but did not have a 2nd test during this week. During the week of 6/26/22 to 7/2/22 CNA-H was tested for COVID-19 on 6/29/22 but did not have a 2nd test during this week. On 9/12/22 at 8:48 a.m. Surveyor informed ADON-C Surveyor was unable to locate COVID-19 testing for CNA-H during the week of 5/8/22 to 5/14/22. During the weeks 6/5/22 to 6/11/22, 6/12/22 to 6/18/22, & 6/26/22 to 7/2/22 CNA-H was only tested on ce during these weeks. ADON-C informed Surveyor she will look into this and get back to Surveyor. On 9/12/22 at 9:41 a.m. ADON-C informed Surveyor during the week of 5/8/22 to 5/14/22 CNA-H worked and should of been tested. During the weeks of 6/5/22 to 6/11/22, 6/12/22 to 6/18/22, & 6/26/22 to 7/2/22 CNA-H worked and the 2nd tests were missed. On 9/12/22 at 8:52 a.m. Surveyor informed ADON-C Surveyor noted during the week of 5/29/22 to 6/4/22 CNA-V was tested for COVID-19 on 5/30/22 but Surveyor wasn't able to locate when CNA-V was tested a 2nd time. ADON-C informed Surveyor she will look into this and get back to Surveyor. On 9/12/22 at 10:17 a.m. ADON-C informed Surveyor there is not a 2nd test for CNA-V and CNA-V worked during this time. On 9/12/22 at 9:24 a.m. Surveyor again asked ADON-C if there was a time from May 2022 forward unvaccinated employees were not required to test twice a week. ADON-C informed Surveyor she highly doubt it but would check and get back to Surveyor. ADON-C did not provide Surveyor with any time period unvaccinated employees did not have to be tested twice a week. On 9/12/22 at 9:58 a.m. Surveyor asked ADON-C if there are set days when unvaccinated employees are tested for COVID-19. ADON-C informed Surveyor there aren't set days as an employee may work on Sunday and be off Monday. Surveyor asked ADON-C how she ensures unvaccinated employees are tested twice a week if required. ADON-C explained she has a list of individuals who require testing & will highlight their name when they have tested twice and leaves letters for staff who only work on the weekends regarding testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility did not ensure 4 (R2, R12, R41, & R43) of 5 Residents reviewed for COVID-19 vaccination had documented risk and benefits. Findings include: The COVID-19 Vaccination Education, Offering, and Documentation policy & procedure updated 5/25/21 under COVID-19 Immunizations Requirements includes documentation of The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and b. Each dose of COVID-19 vaccine administered to the resident. c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusals. On 9/8/22 at 1:12 p.m. during the infection control interview with ADON (Assistant Director of Nursing)-C who is the Facility's infection preventionist, Surveyor asked where Surveyor would be able to locate documentation the Resident was educated on the benefits and risks of the COVID-19 vaccine. ADON-C informed Surveyor she doesn't know if she has documented this and would say she doesn't have it in there. ADON-C informed Surveyor if a Resident refuses she reapproaches the resident. ADON-C informed Surveyor if she did document this it would be in the progress notes. On 9/8/22 at 3:30 p.m. Surveyor reviewed the Resident COVID vaccination log and noted there are 7 Residents listed who are not vaccinated. Surveyor selected R2, R12, R41, & R43 who are checked as not vaccinated to review for education provided. 1.) R2 was admitted to the facility on [DATE]. R2 is listed on the resident COVID vaccinations as not being vaccinated. Surveyor reviewed R2's medical record and was unable to locate documentation of R2 being educated on the risks and benefits of the COVID-19 vaccine. On 9/12/22 at 12:30 p.m. Surveyor informed ADON-C Surveyor was unable to locate documentation R2 was educated on the risk & benefits of the COVID-19 vaccine. On 9/12/22 at 12:35 p.m. ADON-C informed Surveyor on 3/26/21 she informed R2 if he changed his mind she would assist R2 with receiving the vaccine but R2 continues to decline. ADON-C informed Surveyor she did not document the risk & benefits for R2. 2.) R12 was admitted to the facility on [DATE]. R12 is listed on the resident COVID vaccinations as not being vaccinated. Surveyor reviewed R12's medical record and was unable to locate documentation of R12 being educated on the risks and benefits of the COVID-19 vaccine. On 9/12/22 at 12:30 p.m. Surveyor informed ADON-C Surveyor was unable to locate documentation R12 was educated on the risk & benefits of the COVID-19 vaccine. On 9/12/22 at 12:35 p.m. ADON-C informed Surveyor she did not find any documentation regarding educating R12. 3.) R41 was admitted to the facility on [DATE]. R41 is listed on the resident COVID vaccinations as not being vaccinated. Surveyor reviewed R41's medical record and was unable to locate documentation of R41 being educated on the risks and benefits of the COVID-19 vaccine. On 9/12/22 at 12:30 p.m. Surveyor informed ADON-C Surveyor was unable to locate documentation R41 was educated on the risk & benefits of the COVID-19 vaccine. On 9/12/22 at 12:45 p.m. ADON-C provided Surveyor with R41's progress note dated 3/26/21 which documents writer updated resident, husband and daughter on negative swab results and facility status. writer did remind resident and daughter if at any time would like to receive the vaccine writer would assist in getting them vaccinated, both continue to decline at this time. Surveyor noted this note does not include R41 on being educated on the risk and benefits of the COVID-19 vaccine. 4.) R43 was admitted to the facility on [DATE]. R43 is listed on the resident COVID vaccinations as not being vaccinated. Surveyor reviewed R43's medical record and was unable to locate documentation of R43 being educated on the risks and benefits of the COVID-19 vaccine. On 9/12/22 at 12:30 p.m. Surveyor informed ADON-C Surveyor was unable to locate documentation R43 was educated on the risk & benefits of the COVID-19 vaccine. ADON-C informed Surveyor R43 won't take any vaccines and she spoke to R43 last Wednesday. ADON-C informed Surveyor she did not document education for R43. On 9/12/22 at 2:20 p.m. Administrator-A was informed of the above.

Based on interview and record review the Facility did not ensure 3 (CNA (Certified Nursing Assistant)-N, CNA-O, & CNA-Q) of 5 randomly selected CNAs had a performance (competency) review at least once every 12 months. This has the potential to affect all 48 Residents residing in the Facility as staff work throughout the facility. A performance (competency) review was not completed for CNA-N, CNA-O, & CNA-Q in 2021. Findings include: On 9/12/22 at 7:30 a.m. Surveyor reviewed the competency reviews for CNA-N, CNA-O, CNA/Med Tech-P, CNA-Q and CNA-R and noted the following. CNA-N was hired on 12/6/06. The competency reviews for CNA-N are dated 3/17/08, 7/29/13, & 4/16/14. CNA-N did not have a performance (competency) review in 2021. CNA-O was hired on 4/3/13. The competency reviews for CNA-O are dated 6/11/15, 8/11/16, and one dated 11/26 with the year not documented. Surveyor noted the competency review is not signed by the current DON (Director of Nursing) who started in 2020 at the Facility as the signature for the first name initial is M and the current DON's first name initial is J. CNA-O did not have a performance (competency) review in 2021. CNA-Q was hired on 9/2/20. The competency review for CNA-Q is dated 10/2/20. CNA-Q did not have a performance (competency) review in 2021. On 9/12/22 at 2:20 p.m. Surveyor informed Administrator-A performance (competency) reviews were not completed in 2021 for CNA-N, CNA-O, & CNA-Q. Surveyor was not provided with any additional information.

Based upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order potentially impacting 48 of 48 Residents residing in the Facility. Surveyor observed the left dryer in the laundry and observed the top flat surface and wires above the dry screen had a large accumulation of lint, which is a potential fire hazard. Findings include: On 9/8/22 at 8:28 a.m. Surveyor toured the laundry with LA (Laundry Aide)-M who has worked in the laundry since February 2022. Surveyor observed there are two working commercial dryers. Surveyor asked LA-M how often she cleans the dryers to remove lint. LA-M informed Surveyor she cleans the lint every other load unless the load would have a lot of lint, like towels, then she cleans the lint after every load. LA-M showed Surveyor a white erase board which she writes the time when she has cleaned the lint from the dryers. At 8:35 a.m. LA-M opened the bottom door of the left dryer where the lint screen is located. Surveyor observed there is a large amount of lint accumulated on flat portion above the lint screen, towards the back of the dryer, and the wires above the screen are coated with a large amount of lint. Surveyor asked LA-M if she cleans the wires and area above the screen to remove the lint. LA-M informed Surveyor she's not going to put a broom up there to clean the lint off as she doesn't want to get electrocuted. Surveyor showed LA-M the accumulation of lint on the flat portion above the lint screen, towards the back of the dryer, and the wires. LA-M informed Surveyor no one told her about cleaning this. At 8:39 a.m. Housekeeping/Laundry Supervisor-L entered the laundry. Surveyor showed Housekeeping/Laundry Supervisor-L the large accumulation of lint on the flat portion above the lint screen, towards the back of the dryer, & on the wires of the left dryer. Surveyor asked who should be cleaning this area. Housekeeping/Laundry Supervisor-L informed Surveyor whoever is working in the laundry should be cleaning this. LA-M informed Housekeeping/Laundry Supervisor-L she didn't want to get electrocuted. Housekeeping/Laundry Supervisor-L informed LA-M she wouldn't get electrocuted. On 9/8/22 at 2:44 p.m. during the end of the day meeting Administrator-A was informed of the above.

Based on interview and record review the Facility did not ensure 4 (CNA (Certified Nursing Assistant)-O, CNA/Med Tech-P, CNA-Q, & CNA-R) of 5 randomly sampled CNA's (Certified Nursing Assistant) who had been employed for over a year received dementia management & resident abuse prevention training. This has the potential to affect all 48 Residents residing at the Facility as staff work throughout the facility. Findings include: On 9/8/22 at 3:38 p.m. Surveyor reviewed in-service education records for CNA-O, CNA/Med Tech-P, CNA-Q, and CNA-N and noted the following: CNA-O was hired on 4/3/13. Surveyor reviewed CNA-O's in-service record for the period of 4/3/21 to 4/3/22. Surveyor noted CNA-O received abuse, neglect & exploitation training but did not receive dementia training. CNA/Med Tech-P was hired on 2/7/07. Surveyor reviewed CNA/Med Tech-P's in-service record for the period of 2/7/21 to 2/7/22. CNA/Med Tech-P did not receive dementia training or abuse, neglect, & exploitation training. CNA-Q was hired on 9/2/20. Surveyor reviewed CNA-Q's in-service record for the period of 9/2/21 to 9/2/22. Surveyor noted CNA-Q received abuse, neglect & exploitation training but did not receive dementia training. On 9/12/22 at approximately 7:45 a.m. Surveyor reviewed CNA-R's in-service record. CNA-R was hired on 6/7/21. Surveyor reviewed CNA-R's in-service record for the period 6/7/21 to 6/7/22. CNA-R did not receive dementia training or abuse, neglect, & exploitation training. On 9/12/22 at 2:20 p.m. Administrator-A was informed of the above. On 9/8/22 Administrator-A informed Surveyor they did a PIP (Performance improvement plan) for employees' education as she realized this was a problem after she started working at the Facility. Administrator-A provided Surveyor with the Facility's PIP which is not dated when initiated and is in progress. Surveyor noted the interventions in progress are 7/12/22 Management follow-up. Staff who are not current on education will be counseled on the need to complete as assigned, 8/13/22 Education audit will be completed, 9/8/22 Receptionist will assume responsibility to work with Administrator to track staff training hours and 10/3/22 $50 gift card drawing monthly.