**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure a thorough investigation was completed for allegations of abuse/neglect for 1 (R7) of 2 Residents reviewed for alleged abuse. *The Facility did not ensure a thorough investigation was completed related to the allegation of neglect of R7 which was reported by Adult Protective Services on 6/24/25. Findings include: The Facility policy, titled, Abuse Investigation and Reporting, with a last revised date of 11/2023, documents: .Role of the Administrator or designee:A If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown sources reported, the Administrator or designee will assign the investigation to an appropriate individual. B. The administrator or designee will provide any supporting documents relative to the alleged incident to the person in charge of the investigation.C. The administrator or designee will keep the resident, and his/her representative informed of the progress of the investigation. Role of the Investigator:A. The individual conducting the investigation will, at a minimum:1. Review the completed documentation forms2. Review the Resident's medical record to determine events leading up to the incident3. Interview the person(s) reporting the incident4. Interview any witnesses to the incident5. Interview the Resident7. Interview associates members (on all shifts) who have had contact with the Resident during the period of the alleged incident9. Interview other Residents to who the accused employee provides care or services10. Review other Residents to whom the accused employee provides care or services B. The following guidelines will be used when conducting interviews: .3. Witness reports will be obtained in writing. Either the witness will 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. G. 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 or designee. ReportingA. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies:1. The state licensing/certification agency responsible for surveying/licensing the community.2. Other officials in accordance with State Law, including adult Protective Services where state law provides for jurisdiction in long term care facilities;3. The Resident's Representative (Sponsor) of Record; .B. Alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported:1. Abuse or Serious Bodily Harm-Immediately but not later than two hours. R7 was admitted to the facility on [DATE] with diagnoses of Pulmonary Hypertension (high blood pressure that affects arteries in the lungs and in the heart), Unspecified Protein-Calorie Malnutrition (deficiency of both protein and energy), Hypertensive Heart Disease (long term conditions developed from chronic high blood pressure), Hyperlipidemia (high levels of fat particles in the blood), Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). The facility does not have an activated Health Care Power of Attorney on file for R7. R7's admission Minimum Data Set (MDS) completed 4/4/25 documents R7's Brief Interview for Mental Status (BIMS) score to be 10, indicating R7 demonstrates moderately impaired skills for daily decision making. R7's MDS documents R7's Patient Health Questionnaire (PHQ-9) score to be 7 indicating R7 demonstrates mild depressive symptoms. R7 has no behavior concerns. R7 has range of motion impairment to both upper extremities. R7 required supervision for eating; required substantial/maximum assistance for showers, lower body dressing, mobility, and transfers; and requires partial/moderate assistance for upper body dressing. On 6/24/25, the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report which documents Adult Protective Services (APS) arrived at the facility and reported a family member had reported an allegation of neglect on 6/22/25.On 7/2/25, at 2:33 PM, Surveyor requested and reviewed the facility's internal investigation of the allegation of neglect involving R7. Surveyor notes the file does not contain a Misconduct Incident Report. The file contained brief documentation with random notes in regard to R7's admission, 2 falls, and also contained an audit of call light wait times. The investigation contained in the facility documentation did have a summary of events, staff and resident interviews or a summary of findings. On 7/2/25, at 3:11 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R7's facility reported incident (FRI) of the allegation of neglect. NHA-A confirmed NHA-A is responsible for submitting the facility incident reports. NHA-A stated the expectation is to report neglect concerns to the State Agency and the process is to interview the Resident, get details from family, interview staff to find evidence of what was alleged, look at a sample of Residents to interview to determine any other allegations. Surveyor shared with NHA-A that the facility investigation did not include interviews with staff and other residents. NHA-A informed Surveyor that NHA-A didn't anticipate Surveyors to come into the facility. NHA-A stated NHA-A took documentation of the investigation, placed in NHA-A's bag, and removed the documentation from the facility. NHA-A stated NHA-A didn't have time to assemble the paperwork yet. Surveyor shared the concern the facility did not complete a thorough investigation as there are no staff or resident statements to assist in determining if neglect occurred or not. NHA-A expressed understanding of the concern that a thorough investigation was not completed for R7's allegation of neglect. On 7/2/25, at 3:54 PM, NHA-A informed Surveyor that NHA-A would be providing additional information on the investigation. At the time of the survey exit no additional information had been provided. On 7/3/25, at 11:04 AM, Surveyor was provided staff statements and Resident interviews dated 6/24/25. However, the staff interview questions are not specific in addressing R7's allegation of neglect which included multiple issues. There are 2 questions:1. Have you seen/heard/witnessed any employee or staff ignoring or neglecting facility Residents when they needed care in this facility?2. Have you ignored or neglected a Resident who needed care in this facility.The staff member was to circle yes or no.Surveyor noted there is no signature of the staff member who completed each questionnaire.The Resident interview questionnaires are dated 6/24/25 but were not available as part of the investigation of R7's allegations of neglect during the survey process. Surveyor notes there is no signature of whom interviewed the resident.Surveyor has concerns that a thorough investigation was not completed. Surveyor was unable to obtain schedules of employees working during the time of R7's allegation of neglect to identify if the staff interviewed worked during the time in questions and would have knowledge of the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not ensure residents received adequate fluid intake for 1 (R1) of 1 Residents reviewed for nutrition. R1was transferred from the facility to the hospital on [DATE] due to weakness, encephalopathy (a disturbance of brain function causing confusion, and abnormal lab values). The facility did not ensure R1 received adequate fluid intake to maintain acceptable parameters of hydration as evidenced by failing to total and assess daily fluid intake, accurately assess and complete on-going assessments for signs and symptoms of dehydration when R1 was assessed to be at risk for dehydration and had a history of poor oral intakes. Findings include:R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Dementia, Delirium and Acute Kidney failure. R1's admission MDS (Minimum Data Set) with an ARD (Assessment Reference) of 11/11/24 documents R1 has a BIMS (Brief Interview for Mental Status) score of 07, indicating R1 was severely cognitively impaired at the time of assessment and has both short- and long-term memory impairments. R1 required assistance of 1 staff for transfers and personal cares at the time of assessment. Surveyor reviewed R1's hospital referral information dated 11/4/24, which documents a speech therapy evaluation was recommended and completed. A video swallow study was declined by the patient. The patient needs assist for feeding and can feed self. Volitional swallow (The act of swallowing that is initiated intentionally by the individual, as opposed to a reflexive swallow which occurs automatically. It's the conscious decision to swallow, often associated with eating or drinking.) present and weak. multiple swallows noted. Slightly slow mastication, however functional to consume, complete mastication with complete oral clearance. Occasional double swallow.Recommendations: Diet: Regular, thin. Feeding guidelines: feeds self a tolerated, slow rate of intake, sit up straight in bed/chair, stay upright after meals, small bites, small single sips, limit talking while eating, limit distractions when eating, stop feeding if coughing and periodic liquid wash.Surveyor notes the hospital identified eating guidelines were not included in R1's care plan. Eating guidelines would be important for staff to be aware of due to R1's diagnosis of Parkinson's Disease, Dementia and history of and risk for dehydration. R1 was discharged from the facility on 11/21/24 due to a change of condition and abnormal lab values. Surveyor reviewed R1's hospitalization records from 11/21/24, which documented the following, .Patient presents with abnormal labs .Today labs were done which showed that he had a Potassium of 6.8, Blood Urea Nitrogen (BUN) of 127 and Creatinine of 14.27 .Patient presents here with gradual decline in mental status over the past couple weeks, abnormal labs at nursing home, mucous membranes are dry .dry and encephalopathic .profoundly high creatinine of 15.6, BUN elevated to 133, Potassium of 6.7 .gave him an IV (intravenous) fluid bolus .nephrologist recommends bicarbonate drip (an intravenous medication for treatment of acute and chronic kidney disease). Surveyor notes the reference ranges for Potassium to be 3.5-5.1 millimoles per Liter (mmol/L), BUN 7-26 milligrams per deciliter (mg/dL) and Creatinine 0.60-1.30 mg/dL.On 7/2/25, at 11:08 AM, Surveyor conducted an interview with Certified Nursing Assistant (CNA)-C. CNA-C told Surveyor they remembered taking care of R1 frequently as they would often work double shifts and were assigned to R1 often. CNA-C recalled R1 was at the facility for not very long but midway through their stay they started acting different. Surveyor asked CNA-C to elaborate on what different meant CNA-C responded R1 had good days and bad days and that a couple of weeks before R1's discharge from the facility, she remembered R1 becoming more confused and that they didn't want to eat or drink with help and would become agitated. Surveyor asked CNA-C if they had reported their concerns about R1's medical condition to a nurse or a unit manager. CNA-C responded I know I told more than 1 nurse for sure . [R1] wasn't doing well, and I remember filling out a note about it to the nurses so [R1] could get looked at closer .I'm not sure why [R1] didn't go out to the hospital sooner .R1 was more and more confused, and I wondered if [R1] had an infection or was dehydrated or something [R1] wasn't acting right. Surveyor asked CNA-C what made them question if R1 was dehydrated. CNA-C responded that R1's lips and mouth were often dry and sticky and they could only get R1 to drink soda. Surveyor asked CNA-C if they recalled ever documenting R1's fluid intake. CNA-C told Surveyor they remember recording meal intakes but not specifically R1's fluid intake amounts. On 7/2/25, at 1:01 PM, Surveyor conducted interview with Registered Nurse (RN)-F. Surveyor notes RN-F is a unit manager at the facility on the unit where R1 resided. RN-F told Surveyor they recalled R1 had Dementia and Parkinson's Disease. RN-F also remembered R1 was a fall risk and very impulsive at times and suffered from generalized weakness. Surveyor asked RN-F if they recalled R1 experiencing a change of condition at any time throughout their stay at the facility. RN-F told Surveyor they remembered hearing R1 went to the hospital but R1 never came back to the facility after that. RN-F could not recall any details of why R1 went to the hospital. Surveyor asked RN-F if a resident is assessed to be at risk for dehydration what the facility protocol would be for monitoring a resident's risk. RN-F responded they would expect a resident who is at risk for dehydration to be monitored by checking for signs and symptoms of dehydration such as dry mucous membranes and tenting of the skin. Surveyor asked if a resident at risk for dehydration should have their intake and output monitored. RN-F responded, I would think for sure they should be on I&O (Intake and Output) to make sure they don't become dehydrated. Surveyor asked RN-F who would be responsible for monitoring a resident's I&O. RN-F responded it would be a collaboration between CNAs and Nurses to monitor for resident I&O. RN-F added if a resident is at risk for dehydration, it should definitely be care planned for the resident in the medical record. Surveyor reviewed R1's comprehensive care plan. R1's Nutrition care plan with an initiation date of 11/5/24 documents the following: R1 is at nutritional risk due to poor appetite and triggering for malnutrition. Documented interventions dated 11/8/24 include: .R1's meal intake is monitored daily .R1 is offered a minimum of 480 milliliters (mL) at each meal. R1's Dehydration risk care plan with an initiation date of 11/13/24 documents the following: R1 has a potential for fluid volume deficit related to inadequate oral intakes. R1 will be free from signs and symptoms of dehydration and will be well hydrated as evidenced by physical condition. Documented interventions dated 11/13/24 include: .Assess for signs/symptoms of dehydration (dizziness, confusion, decreased urine output, poor skin turgor, fever, constipation), assess skin turgor and mucus membranes for signs of dehydration every shift. Surveyor reviewed R1's Electronic Health Records. Surveyor was unable to identify any documentation of R1's fluid intake at meals, intake and output records or assessments of R1's hydration status. On 7/2/2025, at 4:00 PM, Surveyor conducted an interview with Director of Nursing (DON)-B. Surveyor asked DON-B if they could show Surveyor documentation of R1's fluid intake and hydration status monitoring. DON-B told Surveyor they would need to follow up on R1's record and would let Surveyor know if they could find additional information. On 7/2/25, at 5:05 PM, DON-B made Surveyor aware they could not find any additional information pertaining to monitoring of R1's hydration status. Surveyor shared concerns with DON-B and Director of Quality-E there is no documentation the facility was monitoring R1's fluid intake or hydration status when R1 was assessed to be at risk for dehydration. Surveyor shared concern R1's hospital records indicate R1 was exhibiting signs of dehydration upon arrival at the emergency room on [DATE] and had to receive intravenous fluids due to clinical signs of dehydration. No additional information was provided by the facility at this time.

Based on interview, document review, and review of facility policy, the facility failed to ensure that there was evidence that an initial report of an abuse allegation was submitted to the State Survey Agency (SA) within two hours for one of two residents (Resident (R) 5) reviewed for abuse from a total sample of 13 residents. This failure had the potential to delay corrective measures and appropriate response to abuse allegations ensuring the safety of the residents. Findings include: Review of the facility policy titled Abuse Investigation and Reporting, last approved 12/2024, revealed: Reporting A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: . B. Alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or Serious Bodily Harm - immediately but not later than 2 hours.*[sic] If the alleged violation involves abuse or results in serious bodily injury. 2. No Serious Bodily Injury - As soon as practical, but not later than 24 hours*. [sic] If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury. C. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. Review of the facility reported incident (FRI) file regarding an allegation R5 made that a Certified Nurse Aide (CNA) refused to assist her to bed sometime in April and was mean showed a printed Wisconsin Department of Health Services Misconduct Incident Report that had the entity information completed, the date discovered (04/29/25), the incident summary stated, See attached summary. R5 was identified as the person affected, and Unknown was typed in the section for Accused Person Information. The section for Person Preparing This Report was not filled out. The form had large print DRAFT on each page. Nothing showed a submission date or time. In the lower left corner of each page was Incident ID:1197928, Status: Draft and in the right lower corner was Printed on: 5/8/2025 3:12:09 PM. During an interview on 05/29/25 at 1:30 PM, the Administrator pointed out the Incident ID in the right lower corner of the Misconduct Incident Report and stated that number was evidence the initial report was submitted. However, the Misconduct Incident Report sections for Report Submitted BY and Report Submitted Date were blank. There was no way to tell the actual date and time it was first submitted to show the allegation of abuse was initially reported within two hours. During a follow up interview on 05/30/25 at 3:45 PM the Administrator stated, If we suspect abuse, we report within two hours and the investigation would be in within five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R2) of 3 residents reviewed had a complete and accurate medical record. R2 had a diabetic wound ulcer and was being followed by Wound MD-C for four weeks. The facility changed their contract with Wound MD-C and obtained a new contract with Wound MD-D. The facility did not obtain Wound MD-C documentation of R2 wounds assessments. Surveyor asked to review R2's wound assessments from Wound MD-C and Nursing Home Administrator (NHA)-A stated the facility has no access to those records because they ended the contract with Wound MD-C. Findings include: R2 was admitted to the facility on [DATE] with diagnoses of right hip pining, type 2 diabetes, right diabetic foot ulcer. R2 was discharged home on [DATE]. The admission MDS (minimum data set) dated 10/29/24 indicates R2 is cognitively intact. The facility's documentation indicates Wound MD-C was assessing and ordering treatments to R2's diabetic foot wound. The medical record indicates the facility was assessing R2's wounds along with Wound MD-C. Surveyor requested all wound assessments completed by the facility staff and Wound MDs. Surveyor received the facility staff skin/wound weekly assessments and Wound MD-D assessments dated 12/9/24 and 12/16/24. On 2/11/25, at 8:30 a.m., Surveyor asked Nursing Home Administrator (NHA)-A for Wound MD-C's wound assessments. NHA-A stated the facility doesn't have access to those assessments because when the facility switched contracted wound providers, Wound MD-C closed the facility's access to the medical record. Surveyor explained Wound MD-C's assessments are part of R12's medical record and the facility needs to be able to access that information. NHA-A stated he understood but had no additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R2 was admitted to the facility on [DATE] with a diagnosis that includes dementia, Alzheimer's Disease, age-related physical debility, unsteadiness on feet, and need for assistance with personal cares. R2's Annual Minimum Data Set (MDS), dated [DATE] documents that R2 has short and long-term memory problem and is severely impaired for cognitive skills for daily decision making. R2 is dependent on staff for transfers. Surveyor reviewed facility documents regarding R2. R2 was not at the Facility during time of Survey. Surveyor reviewed a complaint indicating R2 was struck by a Hoyer lift during a transfer, resulting in R2 sustaining a bloody upper lip. The complaint indicates CNA-F, CNA-E and LPN-G were involved in the incident. On 12/26/2024, at 11:56 AM, Surveyor interviewed CNA-F, via phone, who was mentioned in a complaint filed with the State Survey Agency. Surveyor asked CNA-F if she recalled an incident involving R2 during a transfer using a Hoyer lift. CNA-F indicated to Surveyor that CNA-F and CNA-E were using a Hoyer lift to transfer R2. CNA-F stated the Hoyer accidentally nipped R2 in the lip. CNA-F indicated to Surveyor that R2 cried and said, you hit me. CNA-F informed Surveyor that R2 was agitated and uncomfortable prior to the incident, which is why the CNAs were in the process of transferring R2 into a different position. CNA-F informed Surveyor that CNA-F did not observe any marks on R2 after the incident. CNA-F indicated CNA-F informed a Nurse after the incident but could not recall the nurse's name. CNA-F informed Surveyor that at the time of the incident, R2's family member was in the room as well. On 12/26/2024, at 12:04 PM, Surveyor interviewed CNA-E, via phone, who was also mentioned in the complaint. CNA-E indicated to Surveyor that CNA-E and CNA-F were transferring R2, and the Hoyer came close to R2's face and scared R2. CNA-E indicated that R2's family member, asked CNA-E if the Hoyer hit R2, and CNA-E indicated it did not. Surveyor reviewed the Facility's staff schedule and noted LPN-G was the nurse working with CNA-E and CNA-F on the alleged date of the incident. On 12/26/2024, at 01:39 PM, Surveyor interviewed LPN-G via phone, LPN-G indicated to Surveyor that LPN-G did not have any knowledge of an incident involving R2 during a Hoyer transfer. On 12/26/2024, at 03:01 PM, Surveyor interviewed NHA-A and Director of Quality Assurance (DQA)-C. NHA-A and DQA-C denied having knowledge of the incident involving R2 during a Hoyer transfer. On 12/30/2024, at 08:12 AM, Surveyor interviewed DON-B. DON-B indicated to Surveyor that DON-B was not aware of an incident involving R2 during a Hoyer transfer. DON-B informed Surveyor that DON-B spoke to LPN-G, who informed DON-B that the Hoyer barely touched R2 in the lip, and that rounding was completed the day following the incident and nothing was noted for R2. DON-B informed Surveyor that LPN-G is writing a note on the incident now. DON-B informed Surveyor that R2's family member was in the room and usually would report things like that but states the family had not reported anything to the Facility. DON-B indicated to Surveyor the facility is investigating the incident. Surveyor reviewed the Facility provided document regarding R2, titled SBAR Communication Form, documents in part . SITUATION. This started on 11/25/24. Other relevant information CNA reported hoyer sling grazed resident upper lip. The SBAR documents that R2's physician was notified on 12/30/2024. On 12/30/2024, at the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the concern that staff not reporting the above incident to the facility. Surveyor also informed NHA-A and DON-B of the concern that staff did not implement any interventions after the above incident to prevent future accidents for R2. No additional information was provided. Based on interview and record review, the facility did not ensure that 2 (R1, R2) of 3 residents reviewed were kept safe from accidents or hazards. *R1 sustained 3 falls while residing at the facility. The facility did not ensure that fall risk assessments were completed for each fall. The facility did not implement appropriate fall interventions for R1. *R2 was hit in the lip during a hoyer lift transfer on 11/25/24. The facility did not ensure staff reported the incident so that the facility was able to evaluate the circumstances on how the accident occurred and how to prevent future similar accidents from occurring. Findings include: On 12/30/24 at 9:30 AM, Surveyor reviewed the facility's Fall Policy with an initiation date of 12/2017 and a revision date of 07/2023 which documented: Policy Detail: The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process should be completed quarterly and after every fall. 1.) R1 was admitted to the facility on [DATE] with a diagnoses that included Parkinson's Disease,Dementia, Delirium, Acute Kidney Failure and unsteadiness on feet. R1's admission MDS (Minimum Data Set) with an ARD (Assessment Reference) of 11/11/24 documents that R1 has a BIMS (Brief Interview for Mental Status) score of 07, indicating that R1 was severely cognitively impaired at the time of assessment and has short and long term memory impairments. R1 required assistance of 1 staff for transfers and personal cares at the time of assessment. R1 was discharged from the facility on 11/22/24 Surveyor reviewed R1's closed medical record including nurse progress notes, therapy documentation, nurse practitioner progress notes, medication administration records, treatment administration records and comprehensive care plans. On 12/26/24, Surveyor reviewed a grievance regarding R1 dated 11/20/24. R1's comprehensive fall care plan with an initiation date of 11/5/24 documents: R1 has the potential for falls related to recent admission to community, immobility, impaired cognition, incontinence. R1's comprehensive fall care plan dated 11/5/24 documented the following initial interventions: R1 has anti-slip dycem device in place between W/C (wheelchair) and cushion .keep pathways clear and provide adequate lighting .orient to room and call light R1 had sustained falls while residing at the facility on 11/7/24, 11/9/24 and 11/12/24. On 12/30/24, Surveyor requested R1's fall investigations for 11/7/24, 11/9/24 and 11/12/24. Surveyor reviewed R1's fall investigation for 11/7/24. Surveyor noted a care plan revision initiated on 11/8/12 which documents: When restless or agitated, encourage and assist to area of high visibility. Surveyor reviewed R1's fall investigation for 11/9/24. Surveyor noted a care plan revision initiated on 11/10/12 which documents: Resident to have non slip footwear on at all times. Surveyor reviewed R1's fall investigation for 11/12/24. R1's nursing note dated 11/12/24 documents, At 02:20 am patient found on the floor from w/c (wheelchair)laying on left side by nursing station. No injury noted, ROM (range of motion) wnl (within normal limits). No s/s (signs and symptoms) of pain. Patient unable to explain what he was doing at the time of fall. Neurochecks wnl. Call placed and Informed NP (nurse practitioner) at 02:59 am on call nurse at 03:00 am and DON (Director of Nursing) at 03:10 am. Will continue to monitor. R1 was noted by staff to be on the floor laying next to their wheelchair near the nurses station. It was determined by the facility's interdisciplinary team that R1 had been attempting to self transfer, lost their balance and fell to the floor near the nurses station. Surveyor did not note a revision to R1's fall care plan regarding their fall on 11/12/24. Surveyor reviewed the investigation document titled Nurse Post Fall Assessment and Follow Up. Surveyor noted that on 11/12/24, the facility documented the following intervention on the form titled Nurse Post Fall Assessment and Follow Up: Frequent reminders to ask for staff assist prior to ambulation/transfers. Upon Surveyor review of R1's falls on 11/7/24, 11/9/24 and 11/12/24, Surveyor noted that the facility did not complete [NAME] Fall Risk Assessment forms to document R1's fall risk factors on 11/7/24, 11/9/24 or 11/12/24. Surveyor reviewed R1's fall interventions. On 11/12/24, the facility documented the following intervention on the form titled Nurse Post Fall Assessment and Follow Up: Frequent reminders to ask for staff assist prior to ambulation/transfers. On 12/30/24 at 9:20 AM, Surveyor conducted interview with Director of Quality Assurance-C. Surveyor asked Director of Quality Assurance-C if [NAME] Fall Risk Assessments should be completed for residents after each fall that they sustain. Director of Quality Assurance-C responded Yes, that should be the expectation .I think it's in the policy how often we should do those . Surveyor asked Director of Quality Assurance-C if it would be an appropriate expectation for a resident with severe cognitive impairment including diagnosis of Dementia and a BIMS score of 07 to be expected to call for staff assistance to prevent falls. Director of Quality Assurance-C responded that it may not be the best intervention for someone with a cognitive impairment. Surveyor shared concern with Director of Quality Assurance-C related to R1's BIMS score of 07 and their cognitive ability related to the fall intervention implemented on 11/12/24. Surveyor also shared concerns related to the lack of [NAME] Fall Risk Assessments related to R1's fall on 11/7/24, 11/9/24 and 11/12/24. Director of Quality Assurance-C responded that they would go and look into R1's medical record to see if they could find additional information. On 12/30/24 at 10:40 AM, Director of Quality Assurance-C told Surveyor that they could not find any [NAME] Fall Risk Assessments completed for R1's falls on 11/7/24, 11/9/24 or 11/12/24 On 12/30/2024 at 11:33 AM, Surveyor conducted meeting with NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B. Surveyor shared concern with NHA-A and DON-B related to R1's BIMS score of 07 and their cognitive ability related to the fall intervention implemented on 11/12/24. Surveyor also shared concerns related to the lack of [NAME] Fall Risk Assessments related to R1's fall on 11/7/24, 11/9/24 and 11/12/24. On 12/30/24 at 12:30 PM, at the Survey exit meeting, the facility was unable to provide any additional information regarding R1's missing [NAME] Fall Risk Assessments or fall interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure medication administration records were complete and accurate for 1 (R2) of 4 residents reviewed for medication administration. * R2's Medication Administration Record (MAR) indicated R2 was given R2's prescribed narcotic pain medication twice in the month of November 2024. The Facility's controlled drug log indicated R2's prescribed narcotic medication was signed out six times in the month of November 2024. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnosis that include Alzheimer's Disease, chronic pain, and dementia. The facility policy, titled Administering Medications dated 12/2024, documents: . Policy Interpretation and Implementation. The individual administering the medication to document on the MAR or eMAR after giving each medication and before administering the next ones. S. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: 1. The date and time the medication was administered; . Surveyor reviewed the facility's provided document for R2, titled, MEDICATION RECORD for 11/2024 with a print date of 12/26/2024 at 11:56 AM, which documents R2 received R2's as needed narcotic pain medication (Morphine) on 11/7/2024 and 11/16/2024. On 12/26/2024, at 01:58 PM, Surveyor interviewed LPN-D. LPN-D indicated to Surveyor that two nurses will go through the narcotic medications in the medication cart lock box and count them before and after every shift. LPN-D informed Surveyor that if a resident is discharged from Hospice services, the residents-controlled medications are discarded as soon as possible, but there is no specific time frame. LPN-D showed Surveyor the process of discarding discontinued controlled medications. LPN-D showed Surveyor the controlled medication logbook on top of a large, blue, locked bin. Surveyor noted R2's discontinued controlled medications are listed on the log, but the log does not have dates of when the controlled medication was put into the lock bin. On 12/30/2024, at 08:12 AM, Surveyor interviewed DON-B. DON-B informed Surveyor that nurses will discard any discontinued controlled medications in the unit medication room. DON-B indicated 2 nurses will validate the controlled medication, fill out a paper, put the paper with the controlled medication, and put it into a locked bin in the medication room. Once per month, DQA-C and a unit manager will go through the locked bin and destroy the controlled medications. DON-B provided Surveyor with a document titled, MEDICATION RECORD FOR 11/2024 for R2. DON-B pointed out to Surveyor that there were actually 7 documented administrations of R2's morphine, and informed Surveyor that if multiple doses are given on the same day, it may not show on the regular Medication Record. Surveyor noted the document titled MEDICATION RECORD FOR 11/2024 provided by DON-B, documents R2 received R2's Morphine on 11/07/24, twice on 11/09/24, 11/16/24, 11/19/24 and twice on 11/23/24. Surveyor reviewed the Facility provided document titled, CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM documents R2 received doses of R2's Morphine on 11/7/24, 11/09/24 x2, 11/16/24, 11/19/24 and 11/23/24. On 12/30/2024, at 10:35 AM, Surveyor interviewed DON-B. Surveyor asked DON-B why the medication records provided do not match the narcotic medication logs. Surveyor also noted that the most recent Medication Record for R2 has more administration times documented for R2's Morphine than what is documented in R2's MAR. DON-B informed Surveyor that the nurse went back into the record and entered R2's Morphine administrations late. Surveyor noted that the facility did not ensure R2's-controlled medication was documented in R2's record at time of administration and that the facility did not ensure medication records were accurately documented. On 12/30/2024, at 11:33 AM, Surveyor informed NHA-A and DON-B of above concerns. No additional information was provided at time of write up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility did not ensure the right of a Resident to receive visitors and at the time of their choosing for 1 (R36) of 1 Resident reviewed for visitation rights. The facility restricted a family member immediate access to R36 without developing any strategies to continue safe and enjoyable visits for R36. Findings include: R36 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anxiety Disorder, and Alzheimer's Disease. R36's medical record indicates R36 has an Activated Power of Attorney for Health Care (HCPOC). R36's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/5/24 documents R36's Brief Interview for Mental Status (BIMS) not able to be completed due to severe cognitive deficits. On 9/17/24, a Facility Reported Incident dated 8/16/24 was reviewed and indicated on 8/15/24 it was reported that R36's family member was observed to say shut up to R36 in a loud voice. During the investigation a statement from 8/17/24 indicated R36's family member also pushed R36's head into the bed. The Facility Administration determined at that time to institute supervised visitation between R36 and their family member. On 9/17/24, at 10:30 AM, Nursing Home Administrator (NHA)-A was interviewed and indicated R36's family member must make an appointment for visitation to be supervised and currently they don't have anyone to supervise the visitation on weekends. Administrator-A indicated he was working on getting supervision for weekend visits but the Facility investigation substantiated the abuse did occur. So, the facility did not have any plan to change R36's visits with her family member and they would remain by appointment and supervised. Nursing Home Administrator-A could not provide any documentation to indicate he meet with R36's family to discuss the Facility imposed visitation arrangements after 8/16/24 when it was put in place. On 9/17/24, at 10:45 AM, Social Worker (SW)-C was interviewed and indicated she had previously talked to R36 about R36's family member being restricted to supervised visitation. SW-C indicted R36 did not respond and looked out the window during the conversation. SW-C indicated she did not document this interaction or complete an assessment as to the potential impact the restricted visitation would have on R36. SW-C indicated R36's family member would visit her several hours a day and provide some of the care R36 received. SW-C indicated she did not meet with R36's family regarding the restricted visitation. On 9/19/24, an email sent by R36's family member was reviewed and indicated, the Facility never told her what was required for the supervised visitation to occur with R36. R36's family member stated when she showed up to visit with R36 on 9/5/24 she was turned away with the Facility saying she needed to make an appointment for supervised visitation even though she was allowed to visit on 7/3/24 and 7/4/24 with just staff monitoring the visit and not sitting with her the whole time. R36's family member denied the allegations made against her. On 9/18/24, the Facility's policy titled Visitation dated 11/22 was reviewed and documented: The community provided 24 hour access to individuals visiting. The above findings were shared with Nursing Home Administrator-A and Director of Nurses (DON)-B on 9/19/24 at the daily exit meeting. Additional information was requested if available, none was provided as to why R36's family member was not allowed visitation without an appointment or on weekends as the facility put a restriction in place that it could not provide for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure advanced directives were in the resident's medical record for 2 (R6, R19) of 13 residents reviewed. R6 did not have a Do Not Resuscitate consent form placed in R6's medical record. The facility was unable to locate the signed form. R19 did not have a Do Not Resuscitate consent form place in R19's medical record. The facility was able to locate the signed form. Findings include: The facility policy entitled Do Not Resuscitate Order last approved on 6/2022 documents: . Policy Interpretation and Implementation- A. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. B. A Do Not Resuscitate (DNR) order form must be obtained from the Attending Physician and resident (or resident's legal surrogate, as permitted by State Law) and placed in the resident's medical record. 1. Use State-required DNR forms as applicable. 1) R6 was admitted to the facility on [DATE] and has diagnoses that include systolic/diastolic heart failure, atrial fibrillation, vascular dementia, major depressive disorder, osteoarthritis, and muscle weakness. R6's annual minimum data set (MDS) dated [DATE] indicated R6 has moderately impaired cognition with a brief interview for mental status (BIMS) score of 11. R6 has an activated power of attorney (POA) that makes medical decisions for R6. On 9/16/2024, R6's medical record was reviewed, and Surveyor was unable to locate R6's DNR form. Surveyor requested a copy of R6's DNR form. On 9/18/2024, at 10:12 AM, Nursing Home Administrator (NHA)-A stated R6's DNR form was not able to be located and they are in the process of getting a form signed. Surveyor asked what the process was for obtaining a DNR form. Director of Nursing (DON)-B stated on admission if the resident comes electing a DNR status the admitting nurse will get the form signed or the form is obtained on admission. NHA-A and DON-B were unsure why R6 did not have a signed DNR form in their medical record. Surveyor shared concern with NHA-A and DON-B that R6 did not have a signed DNR form in their medical record per Facility policy. 2) R19 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction resulting in left side hemiplegia, dysphagia, and dysarthria, type 2 diabetes mellitus, neurologic neglect syndrome, anxiety disorder, and depression. R19's quarterly Minimum Data Set (MDS) dated [DATE] indicates R19 is cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. R19 has an activated Power of Attorney (POA) that makes medical decisions for R19. On 9/16/2024, R19's medical was reviewed, and Surveyor was unable to locate R19's DNR form. Surveyor requested a copy of R19's DNR form. On 9/18/2024, at 10:12 AM, Nursing Home Administrator (NHA)-A stated R19's DNR form was not able to be located and they are in the process of getting a form signed. Surveyor asked what the process was for obtaining a DNR form. Director of Nursing (DON)-B stated on admission if the resident comes in electing a DNR status the admitting nurse will get the form signed or the form is obtained on admission. NHA-A and DON-B were unsure why R6 did not have a signed DNR form in their medical record . Surveyor shared concern with NHA-A and DON-B that R19 did not have a signed DNR form in their medical record per Facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents were free from abuse/neglect for 1 (R19) of 4 residents reviewed for abuse/neglect. R19 was transferred using a Hoyer lift and assist of 1 staff member instead of 2 staff members per R19's care plan resulting in a bruise to R19's right forearm. Findings include: The facility policy entitled Abuse Prevention last approved on 6/2022 documents: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. PREVENTION- A. The community will develop and implement policies and procedures to aid our community in preventing and prohibiting all types of abuse, neglect, or mistreatment of our residents. C. Implement preventative measures to address factors that may lead to abusive situations. 9. Identification, ongoing assessment, care planning, and appropriate interventions and monitoring of residents with needs and behaviors that may lead to conflict and neglect. The facility policy entitled Mechanical Lifts last revised 1/2024 documents: It is the policy of [Facility name] to use mechanical lift(s) according to current standards of practice and keeping with manufacturers guidelines. G. Education shall be provided on the proper use of the assistive mechanical lifting equipment prior to use. R19 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction resulting in left side hemiplegia, dysphagia, and dysarthria, type 2 diabetes mellitus, neurologic neglect syndrome, anxiety disorder, unsteadiness on feet, and depression. R19's quarterly minimum data set (MDS) dated [DATE] indicates R19 is cognitively intact with a brief interview for mental status (BIMS) score of 15 and the facility asses R19 needing total assistance of 1 staff member with 1 staff member for toileting hygiene, personal hygiene, dressing, repositing, and requires a Hoyer lift transfer with 2 staff. R19's care plan documents assistance with daily activities of daily living (ADL) related to (R/T) immobility, left side weakness, and neglect, initiated 9/15/2023 has the following intervention: -TRANSFER: I need total assistance with 2 person staff support. I use total assist device. On 7/9/2024, at 10:53 AM, in the progress notes nursing documented observed 6.7 X 8.3 centimeter (cm) bruise to resident's right outer forearm. There is a 1 cm in diameter knot located in the center of the bruise. Bruise is black and blue in color. R19 denies pain, R19 stated hit arm on the windowsill. nurse practitioner made aware and new orders to apply ice every shift until resolved. On 7/29/2024, at 22:28 (10:28 PM), in the progress notes nursing documented monitoring bruise/mass to right forearm, PRN (as needed) ice pack used for pain and was effective. Director of Quality Management (DQM)-[K] notified about increase in size and mass. Nurse practitioner (NP) will assess resident tomorrow. Surveyor reviewed R19's medication list and noted R19 was ordered the following medications that would increase risk of bleeding: - Aspirin 81 mg (milligrams)- 1 tab daily - Clopidogrel 75mg- 1 tab every day The facility submitted a self-report to the State Agency regarding R19's injury of unknown origin/current bruise increasing in size. Surveyor reviewed the facility self-report and noted the facility concluded R19's right forearm bruise increased in size as a result of a certified nursing assistant (CNA)-S transferring R19 into bed using a Hoyer lift by themselves. On 9/18/2024, at 7:39 AM, Surveyor noted R19 was wearing tubigrips on R19's right and left arms. Surveyor asked R19 why R19 was wearing tubigrips. R19 stated R19 bruises easily and the tubigrips were supposed to protect her arms due to R19 bumping them a lot. Surveyor asked R19 if R19 has any current bruising. R19 stated had a bruise when she hit her arm on her windowsill, but the bruise was now gone. Surveyor asked R19 if R19 ever got a bruise when transferring into R19's bed with a Hoyer lift. R19 could not recall if R19 got a bruise when being transferred. Surveyor asked R19 if R19 was ever transferred using the Hoyer lift and only 1 staff member being present. R19 could not recall if only 1 staff member transferred R19 using the Hoyer lift. On 9/18/2024, at 9:58 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B). NHA-A stated during the investigation into why R19's right forearm bruise increased in size Registered Nurse (RN)-T stated R19 was transferred into bed with the assist of 1 staff. At the time there was RN-T and CNA-S on the unit and when RN-T last checked on R19, R19 was in the broda wheelchair and did not have the bruise to R19's right forearm. When RN-T went in later, R19 was in bed and that is when the bruise to R19's right forearm was noted. DON-B stated through interviews CNA-S never stated that CNA-S transferred R19 by themselves using the Hoyer lift, but R19 stated R19 was transferred with only CNA-S. DON-B stated R19 could not recall bumping R19's arm during the transfer but stated could have bumped it. DON-B stated that R19 bruises very easily, and the physician ordered for tubigrips for protection. CNA-S is no longer employed with the facility and was unavailable for interview. RN-T was not available for interview. On 9/18/2024, at 10:30 AM, Surveyor shared concern with NHA-A and DON-B that R19 was transferred using a Hoyer lift and only one staff member when R19's care plan is documented as needing 2 staff members. CNA-S neglecting to follow R19's care plan resulting in R19's right forearm bruising. No additional information provided at this time.

Based on interview and record review the facility did not report 3 allegations of abuse/neglect for 1 Resident (R36) of 4 residents reviewed for allegations of abuse, neglect, misappropriation, or injury of unknown origin allegations, immediately to the Nursing Home Administrator or to the State Agency within the required timeframe. *An allegation of verbal abuse was observed between R36's family and R36 which was alleged to have occurred on 08/11/2024. This incident was not reported to Nursing Home Administrator (NHA)-A until 08/15/2024. NHA-A reported the allegation of verbal abuse on 08/16/2024 at 03:06 PM to the State Agency. *An allegation of physical abuse was alleged to have occurred between R36's family and R36 on 08/10/2024 and 08/11/2024. It was not reported to NHA-A until 08/17/2024. The allegation of physical abuse was not reported to the State agency, law enforcement, or APS until 09/18/2024 during survey. *On 6/2/24, an allegation of neglect was reported to Registered Nurse (RN)-G related to R36. The allegation was not reported to NHA-A or the State Agency within specified time frame and was not investigated. Findings include: Surveyor reviewed the Facility policy, titled, Abuse Prevention, with a last reviewed date of 08/2024, and documents in part: The objective of this abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. DEFINITIONS Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish including abuse facilitated or enabled through the use of technology. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Immediately means as soon as possible, but are not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement. * immediately for the purposes of reporting a crime resulting in serious bodily injury means covered individual shall report immediately but not more than two hours after forming the suspicion. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Neglect means the failure of the community, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. IDENTIFICATION . B. Associates or person affiliated with this community who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report suspected abuse or incidents of abuse to the administrator or designee 1. If such incidents occur or are discovered after hours, the administrator or designee shall be notified and informed of such incident. a. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. INVESTIGATION A. The community will investigate and report any allegations of abuse within timeframe as required by federal, state, and local requirements; B See Abuse Investigation Reporting policy for reporting guidelines and roles and responsibilities. REPORTING/RESPONSE A. The community will immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse of result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the Administrator and/or designee, State agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames. Surveyor reviewed the Facility Reported Incident (FRI) submitted to the State Agency, titled, Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report. Surveyor noted the following information, Date discovered 08/15/2024. Surveyor noted, the summary of incident documents, Allegation of verbal abuse by resident's daughter [initials of R36's daughter] of yelling shut up to resident (R36). Investigation has been initiated. Report submitted to the State Agency on 08/16/2024, at 03:06 PM, by NHA-A. The Facility provided document, entitled Investigation Summary, documents in part, Type of Incident: Abuse Date: August 11, 2024 Time: 6:00 PM. Investigation Steps Included: Thursday, 8/15/24- Approximately 2:45 PM, the Executive Director was notified. Surveyor notes NHA-A was not informed of the allegation of abuse immediately when the staff was aware of the allegation on 8/11/24 and NHA-A was informed on 8/15/24. Surveyor reviewed the Facility provided document, with no date, signed by Registered Nurse (RN)-U; and documents in part on 08/11/2024, RN-U heard R36's family member telling R36 to shut up repeatedly and was in an aggressive sounding voice. RN-U asked two other CNA's that were working if they ever heard R36's family member telling R36 to shut up. RN-U was then made aware of alleged physical contact observed between R36's family member and R36 by the CNA's. The Facility provided document, entitled, Witness Statement, signed on 08/17/2024, documents in part, Certified Nursing Assistant (CNA)-J witnessed, on 08/11/2024, R36's family member whisper shut up into R36's ear and then the family member placed a hand on R36's forehead, shook R36's head and told R36 to stay lying down. CNA-J documented, I witnessed this while charting in plain view. CNA-J documented witnessing R36's family member pushing R36's head down, telling R36 to lay down and be quiet on 08/10/2024. Surveyor notes CNA-J did not inform Facility administration of her observations on 8/10/24 and 8/11/24 of alleged abuse until 8/17/24 when the Facility was conducting and investigation of alleged verbal abuse. The Facility provided document, entitled, Witness Statement, signed on 08/17/2024, documents CNA-V witnessed R36's family member tell R36 to shut up, family member put a finger on R36's nose and R36's head went back a little bit. On 09/16/2024, at 02:12 PM Surveyor interviewed CNA-J. CNA-J informed Surveyor she could not remember the exact date but recalls during night shift, R36's family member kept telling R36 to shut up and lay down and put a hand on R36's head. CNA-J informed Surveyor the nurse asked her the same night if CNA-J heard R36's family member tell R36 to shut up, which is when she told the nurse what she witnessed. CNA-J informed Surveyor that any signs of abuse are to be reported to NHA-A right away. On 09/17/2024, at 02:38 PM, Surveyor interviewed NHA-A who indicated only the Ombudsman was notified of the verbal abuse allegation on 08/16/2024. On 09/17/2024, 03:28 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B. NHA-A informed Surveyor RN-S called NHA-A on 08/15/2024 and reported the 08/11/2024 abuse allegation regarding R36. NHA-A informed Surveyor NHA-A will submit a facility self-report (to the State Agency) today (09/17/2024), regarding the physical abuse allegation involving R36 that occurred on 08/10/2024, 08/11/2024 and reported on 08/17/2024. An allegation of verbal and physical abuse was not reported to NHA-A immediately and not reported to the State Agency until days and weeks after the incidents. The Facility did not report the physical abuse allegation to the State Agency until the Survey Team informed the Facility of their concerns. No further information was provided during time of Survey. On 9/18/24, R36's progress notes dated 6/2/24, at 9:30 PM, written by Registered Nurse (RN)-G were reviewed and documented: Daughter believes that R36 was up in her wheelchair for 40 hours continuous according to a staff member Writer states that I didn't think that occurred. On 9/18/24, at 1:30 PM, Nursing Home Administrator-A was interviewed and indicated he was not aware of the allegation that R36 was up 40 hours continuous and should have been made aware. On 9/18/24, at 1:45 PM, Director of Nurses (DON)-B was interviewed and indicated she was not aware of the allegation R36 was up 40 hours continuous and should have been made aware. No other notes were made regarding R36's behavior or staying up in a wheelchair with the last progress note before 6/2/24 being 5/29/24. On 9/18/24, at 10:00 AM, RN-G was interviewed and indicated she did not report the allegation R36 was up 40 hours continuous because she thought it was ridiculous and could not have happened. RN- indicated R36's daughter is always making up stories and did not feel a need to notify Nursing Home Administrator-A or DON-B. On 9/19/24, the Facility's policy entitled Abuse prevention dated 8/24 was reviewed and documented: Neglect means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The community will immediately, but not longer than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse, and do not involve serious bodily injury, report alleged violations involving neglect to the Administrator or designee, State agency, adult protective services and all other required agencies. The above findings were shared with Nursing Home Administrator-A and DON-B on 9/19/24 at 3:00 PM at the daily exit meeting. Additional information was requested if available, none was provided as to why RN-G did not report neglect allegations to Nursing Home Administrator-A and/or DON-B.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure a thorough investigation was completed for 3 allegations of abuse/neglect for 1 (R36) of 4 residents reviewed for alleged abuse investigations. *The Facility did not ensure a thorough investigation was completed related to the allegation of verbal abuse of R36 by R36's daughter which was to have occurred on August 11, 2024. *The Facility did not ensure a thorough investigation was completed related to the allegation of physical abuse of R36 by R36's daughter which were identified during the investigation of the August 11, 2024, alleged verbal abuse. *On 6/2/24, Registered Nurse-G documented R36's daughter expressed a concern R36 was left up for 40 hours continuously and the Facility did not investigate the allegation of neglect. Findings include: The Facility policy, titled, Abuse Investigation and Reporting, with a last revised date of 11/2023, documents in part, . Role of the Administrator or designee: A If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown sources reported, the Administrator or designee will assign the investigation to an appropriate individual. C. The administrator or designee will keep the resident and his/her representative informed of the progress of the investigation. Reporting A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: 1. The state licensing/certification agency responsible for surveying/licensing the community; 2. Other officials in accordance with State Law, including adult Protective Services where state law provides for jurisdiction in long term care facilities; 3. The Resident's Representative (Sponsor) of Record; . B. Alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or Serious Bodily Harm-Immediately but not later than two hours. R36 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, metabolic encephalopathy, and insomnia. R36's Quarterly Minimum Data Set (MDS), dated [DATE], documents R36 has adequate hearing, does not use hearing aids, has severely impaired cognitive skills, short- and long-term memory problems. The Facility provided document, entitled Investigation Summary, prepared by Nursing Home Administrator (NHA)-A, documents in part, Type of Incident: Abuse Date: August 11,2024 Time: 6:00 pm. Description of Incident: Staff reported they overheard the (R36's) daughter in the room yelling at Resident [R36's name] to shut up. Investigation Steps Included: -Thursday, 8-15-24, Approximately 2:45 pm, the Executive Director was notified. -Thursday, 8-15-24- Executive Director spoke with [R36's family members name] about the allegation. She said she would type up a statement and bring in the following day, she stated she talks loud because her mom is hard of hearing. -Friday, 8-16-24, Executive Director and interim Director of Nursing (DON) again spoke with [daughter's name] about a witness statement. Daughter declined to fill out a witness statement as earlier agreed, but stated she was on the phone with either her husband or her sister when saying shut up but did not confirm who she was talking with. -Friday, 8-16-24- Executive Director and interim DON called [name of Ombudsman], to inform her of the situation. The Ombudsman stated to allow visitation of the daughter in public areas but not in the room. Executive Director and interim DON attempted to contact daughter to inform her of the allowed visitation. There has been no response to the calls. -Reasonable conclusion as follows: upon investigation, other staff had concerns that they had brought to the nurse around the same time. CNA-J Reported seeing [daughter's name] in what seemed like placing a hand on her forehead and shake her head and tell her to stay laying back down. Certified Nursing Assistant (CNA)-V heard [daughter's name] state shut up ma and noted what seemed like placing a finger on her (R36's) nose hard enough for resident's head to move back a little. Upon conclusion of the investigation, the center will substantiate the act of abuse related to the investigation findings, but we reserve the right to amend if [name of R36's daughter] provides her statement. On 09/17/2024, at 01:43 PM, NHA-A informed Surveyor NHA-A was informed on 08/15/2024 of the verbal abuse allegations against R36's daughter. NHA-A informed Surveyor he spoke to R36's accused family member regarding the allegation and asked for a statement about what transpired. NHA-A stated R36's family member wanted to type it and was going to send via email. NHA-A informed Surveyor R36's family member came in to the Facility the next day with their husband and no longer wanted to write a statement, and stated to NHA-A, she talks loudly to her sister and husband on phone. NHA-A informed Surveyor he reached out to the Ombudsman, who informed him to implement supervised visitation between R36's family member and R36. NHA-A informed Surveyor he attempted to reach back out to R36's family member regarding the need for supervised visits, but no phone calls were returned. NHA-A informed Surveyor the police were notified of the verbal abuse allegation. NHA-A stated he spoke to R36's family member on the phone and informed the family member they would be able to have supervised visitation. NHA-A stated R36's family member would need to arrange visits ahead of time to ensure proper staff for supervised visits. (Cross Reference F563) Surveyor notes the Facility did not complete a thorough investigation of the alleged verbal abuse between R36's daughter and R36 that occurred on 8/11/24 as the Facility did not meet with R36's family to discuss why staff alleged R36's daughter verbally abused R36, discuss with R36's daughter and Activated Health Care Power of Attorney the reason the Facility was implementing supervised visits and how long they would occur, or meet with the family of R36 to identify the history of family dynamics or the families understanding of long and short term memory loss in the elderly and appropriate interventions to be implemented during interactions. Surveyor also notes the Facility did not investigate the allegations of physical abuse between R36's daughter and R36 when Facility administration was made aware of the allegations on 8/17/24, during the investigation of the 8/11/24 allegation of verbal abuse. On 09/17/2024, at 03:28 PM, NHA-A informed Surveyor he will submit a Facility self-report to the State Agency today (09/17/2024), regarding the physical abuse allegation reported on 08/17/2024 and start an investigation at this time. On 09/17/2024, at 04:08 PM, Surveyor spoke with Caledonia Police Department Officer-P regarding reported allegation. Caledonia PD Officer-P informed Surveyor an officer responded to a call for an assault at the Facility, on 08/16/2024, case # [12970]. Caledonia PD Officer-P informed Surveyor, there was no report of physical abuse, no bruising, or marks, and it was reported that the nurse reported daughter yelling shut up to R36. Surveyor informed NHA-A of the above concerns. No further information was provided. 3) On 9/18/24 Surveyor reviewed R36's progress notes which documented, on 6/2/24, at 9:30 PM, written by Registered Nurse (RN)-G, Daughter believes that R36 was up in her wheelchair for 40 hours continuous according to a staff member. Writer documents, I didn't think that occurred. No other notes were made regarding R36's behavior or staying up in her wheelchair with the last progress note before this 6/2/24 progress note being 5/29/24. On 9/18/24, at 1:30 PM, Surveyor interviewed Nursing Home Administrator-A who indicated he was not aware of the allegation that R36 was up 40 hours continuous and should have been made aware so he could investigate. On 9/18/24, at 1:45 PM, Director of Nurses (DON)-B was interviewed and indicated she was not aware of the allegation that R36 was up 40 hours continuous and should have been made aware. On 9/18/24, at 10:00 AM, RN-G was interviewed and indicated she did not report the allegation that R36 was up 40 hours continuous because she thought it was ridiculous and could not have happened. RN- indicated R36's daughter is always making up stories and did not feel a need to notify Nursing Home Administrator-A or DON-B to do an investigation. RN-G indicated she talked to a couple staff on the shift but does not know who they were and did not document the conversations. The above findings were shared with Nursing Home Administrator-A and DON-B on 9/19/24, at 3:00 PM, at the daily exit meeting. Additional information was requested if available, none was provided as to why RN-G did not report neglect allegations to Administrator-A and/or DON-B so an investigation could be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 1 (R36) of 13 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. * R36's family member was denied regular visitation and the facility implemented appointment only supervised visitation with R36's family member. An assessment and monitoring of how the decision was affecting R36 was not completed. No meetings with R36's Family member and Power of Attorney for Healthcare (HCPOA) were conducted to establish how visits with R36's family would continue in the future. Findings include: R36 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anxiety Disorder, and Alzheimer's Disease. R36's medical record indicates R36 has an Activated Power of Attorney for Health care (HCPOC). R36's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/5/24 documents R36's Brief Interview for Mental Status (BIMS) not able to be completed due to severe cognitive deficits. On 9/17/24, a Facility Reported Incident from 8/16/24 was reviewed and indicated on 8/15/24 it was reported R36's family member was observed to say shut up to R36 in a loud voice. During the investigation a statement from 8/17/24 indicated R36's family member also pushed R36's head into the bed. It was determined by the Facility to institute supervised visitation with R36's family member at this time. On 9/17/24, at 10:30 AM, Nursing Home Administrator-A was interviewed and indicated R36's family member must make an appointment for visitation to be supervised and currently they don't have anyone to supervise the visitation on weekends. Nursing Home Administrator-A indicated he was working on getting supervision for weekend visits but the investigation substantiated the abuse did occur and the Facility did not have any plan to change R36's visits with her family member and they would remain with an appointment and supervised. Nursing Home Administrator-A could not provide any documentation that he meet with R36's family to discuss the visitation arrangements after 8/16/24 when it was put in place. On 9/17/24, at 10:45 AM, Social Worker (SW)-C was interviewed and indicated she had previously talked to R36 about R36's family member being restricted to supervised visitation. SW-C indicted R36 did not respond and looked out the window during the conversation. SW-C indicated she did not document this interaction or complete an assessment as to the potential impact on R36 having restricted visitation. SW-C indicated R36's family member would visit her several hours a day and provide some of the care R36 received. SW-C indicated she did not meet with R36's family regarding the restricted visitation. On 9/17/24, R36's care plan was reviewed and did not contain any revisions based on the visitation restrictions put in place on 8/16/24. On 9/19/24, an email sent by R36's family member was reviewed and indicated. The facility never told her what was required for the supervised visitation with R36. R36's family member documented when she showed up to visit with R36 on 9/5/24 she was turned away with the facility saying she needed to make an appointment for supervised visitation even though she was allowed to visit on 7/3/24 and 7/4/24 with just staff monitoring the visit and not sitting with her the whole time. R36's family member denied the allegations of abuse made against her. On 9/23/24, the Facility policy titled Social Services dated 12/17 was reviewed and documented: the social service department is responsible for: maintaining contact with residents family members, involving them in residents total plan of care. Identifying individual social and emotional needs. Factors that have a potential negative effect on psychosocial functioning include: the lack of family/social support system. The above findings were shared with Nursing Home Administrator-A and Director of Nurses (DON)-B on 9/19/24 at the daily exit meeting. Additional information was requested if available, none was provided as to why R36's was not assessed and ongoing monitoring conducted into R36's mental well being after visitation was restricted with a family member who visited multiple hours daily.

Based upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order for 2 of 3 dishwashing machines located in the on unit kitchens. The machines were leaking water onto the floor. 1 of 3 dishwashers did not display temperatures. This deficient practice has the potential to affect 24 of 24 residents total on the 2 units. *Surveyor observed 2 of 3 dishwashing machines in the on the unit kitchens, to be leaking water onto the floor, causing a potential hazard. *Surveyor observed 1 of 3 dishwashing machines in the on unit kitchen, did not have a temperature display to properly identify the dishwasher is reaching required water temperature. Findings include: On 09/16/2024, at 11:39 PM, Surveyor observed the dishwasher on the Fairview Unit, on the floor next to the dishwasher were soaked towels and water. Dietary Manager-N informed Surveyor this started happening this morning, a maintenance request has already been submitted and maintenance will be looking at it this afternoon. On 09/16/2024, at 11:47 PM, Surveyor observed the dishwasher on the church view unit spraying out water onto the floor and observed the display for water temperature was not working. Dietary Manager-N informed Surveyor that the dishwasher is supposed to spit water out like that when building up pressure. Dietary Manager-N informed Surveyor that the dishwasher display screen went out last week. Surveyor asked Dietary Manager-N how they know the dishwasher is getting up to the proper temperature without the display functioning properly. Dietary Manager-N informed Surveyor that they use a disk simulator that goes inside the washing machine. Surveyor asked Dietary Manager-N to show Surveyor how the disk simulator works inside the washing machine, Dietary Manager-N informed Surveyor she would need to go get the device. Dietary Manager-N then left the unit kitchen area and shortly returned with a disk simulator. Dietary Manager-N then placed the disk simulator into the washer. On 09/17/2024, at 07:47 AM, Surveyor observed water on the floor around the dishwasher on the unit Church View. On 09/17/2024, at 07:56 AM, Surveyor observed the dishwasher on the Fairview unit had water on the floor around the dishwasher. On 09/17/2024, at 08:17 AM, Surveyor interviewed Director of Facilities-E. Director of Facilities-E informed Surveyor that he was given a verbal request last night or this morning regarding the dishwasher leaking on the unit Fairview. Director of Facilities-E informed Surveyor that the dishwashing machines are worked on through a contract company. Director of Facilities-E informed Surveyor he still needs to put in a request for the company to come out for the dishwasher on unit Fairview. On 09/17/2024, at 08:24 AM, Director of Facilities-E informed Surveyor that they are waiting on a part to come in before the company can come fix the dishwasher. Director of Facilities-E provided Surveyor with an e-mail, dated 09/17/2024, providing confirmation of service request for the company to come out for the dishwashers on 09/19/2024. Surveyor informed Nursing Home Administrator (NHA)-A of above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not make a prompt effort to resolve grievances for 4 (R4, R5, R6, & R7) of 4 residents reviewed for grievances. *On 11/13/23, R4 voiced concerns to the facility that R4 was not dressed or gotten out of bed until 2nd shift and did not receive a shower. The facility did not follow up with R4 to ensure that after speaking with staff there were any further concerns regarding not getting dressed, getting out of bed, or being showered. R4's grievance does not include the date the written decison was issued. * On 11/13/23, R5 voiced a concern to the facility that R5 was not dressed until 2nd shift. R5's grievance does not include a summary of findings or a conclusion. After interviewing staff, the facility did not follow up with R5 to see if there were any further concerns regarding not getting dressed. R5's grievance does not include the date a written decision was issued. * On 1/24/24, R7's representative filed a grievance about R7 not receiving a shower, that R7 was soaked, and requested a new pad for R7. The grievance does not include a summary of findings or conclusions, whether the grievance was confirmed as received or not, and does not include follow up with R7's representatives on the concerns voiced on 1/24/24 and date the written decision was issued. * On 1/31/24, R6's friend filed a grievance that R6 did not receive a shower on 1/30/24. The grievance does not include a date a written decision was issued. Findings include: The facility's policy titled, Complaints and Grievances, last revised on 5/2021, documents the Grievance Official or designee, will be responsible for the complaint and grievance process through their conclusion to include: . 3. Documentation of complaints and grievances must be captured and include: a. Date the grievance or complaint was received orally or in writing. b. A summary statement of the resident's or resident representative's grievance. c. The steps actions taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the resident's/resident representative's concerns(s). e. A statement as to whether the grievance was confirmed or not. f. Any corrective action taken or to be taken by the community as a result of the grievance. g. Date the written decision was issued to complainant in response to their grievance. 4. Acknowledging the grievance within 7 working days from receipt. 5. Issuing a final written grievance decision to the resident and/or family members within a reasonable time frame but not to exceed 30 days. On 4/17/24 at 10:09 a.m., Surveyor asked NHA (Nursing Home Administrator)-A for the facility's grievance log for the last 6 months. On 4/17/24 at 12:23 p.m., Surveyor received & reviewed the facility's grievance log from 11/7/23 to 4/17/24. Surveyor requested grievances for R4 dated 11/13/23, R7 dated 1/24/24 and for R6 dated 1/31/24. 1.) On 4/17/24 at 9:45 a.m., Surveyor spoke with R4 regarding concerns Surveyor was investigating. Surveyor asked R4 if she receives showers in the bathroom located in R4's room. R4 replied yes and explained to Surveyor her shower days are Thursday & Sunday. R4 informed Surveyor she has not received showers because at times because there is not enough staff. R4 informed Surveyor they need more staff. R4's quarterly MDS (minimum data set) with an assessment reference date of 1/19/24, has a BIMS (brief interview mental status) score of 13 which documents that R4 is cognitively intact. R4 is assessed as requiring substantial/maximum assistance for showering and bathing herself. Surveyor reviewed R4's grievance dated 11/13/23 and noted this grievance also included another resident R5. Under the section titled describe the compliment, suggestion, or concerns it documents that R4 stated she was not dressed or out of bed until 2nd shift. R4 was asked at 6AM if she wanted to get up but she said not that was too early but that didn't mean she wanted to stay in bed all day. R4 stated she also didn't receive shower. For R5, the grievance documents Resident [name of R5] [room number] stated concerns to nurse [name] about not getting dressed on the same day until 2nd shift. Sunday was the worst day I've had since I've been here. Under the Summary of Findings or Conclusions section it documents Resident refused to get up in the morning but should have been offered later in the morning since she stated it was too early. Surveyor noted that this statement is about R4. Surveyor was unable to locate a summary of findings or conclusions for R5's grievance. Under corrective action taken by the community section it documents Discussed with staff resident's rights and their wants to get up later on a day. If they are late to get up, offer bed bath or shower after getting up. Surveyor noted this grievance which includes R4 & R5 does not include follow up with R4 or R5 to determine if their concerns continued after staff were spoken to and does not include the date a written decision regarding their grievance was issued to R4 & R5. 2.) Surveyor reviewed R7's grievance that was filed by R7's representative on 1/24/24. Under describe the compliment, suggestion or concerns section, it documents On 1/23 daughter came in to visit resident. Requested a shower since she has not gotten one since being here. No one did her shower, so she asked for a shower chair, no urgency to help family member. Notice her mother was soaked all the way to the pad on her chair. Ask for new pad and no one brought one in. Daughter was here till 7:30 pm and no one checked on her mom since she had been here since 330 pm. In the For the question would you like someone to contact you regarding this section, it documents, Yes is checked. Under actions taken to investigate section it documents CNA (Certified Nursing Assistant) DNR'd (do not return) from Facility. Agency staff member filling in at the facility. Surveyor noted that the summary of findings or conclusions section has not been completed and is blank. The grievance was able to be confirmed/not confirmed section had also not been completed. Under the any corrective action taken by the community section it documents Discussed with staff about the importance of showers as well as the need to provide timely service. To offer bed bath if shower is refused. Surveyor also noted that the date written decision issued had not been completed and is blank. Surveyor noted that R7's representative grievance does not include a summary of findings or conclusions, whether the grievance was confirmed or not, and does not include follow up with R7's representatives regarding the concerns voiced on 1/24/24 and the date the written decision was issued. 3.) Surveyor reviewed R6's grievance filed by R6's friend on 1/31/24. Under the describe the compliment, suggestions, or concerns section it documents Lack of shower on 1-30-24. Surveyor noted that For the question would you like someone to contact you regarding this section it was not completed. The signature of person completing this grievance section had not been completed. The summary of findings or conclusions section documents Concerns valid, Outcome of care conference was effective per her (A) POAHC (activated power of attorney healthcare) and Director of Health Care Service-[NAME] Center. Under the corrective action taken by the community section it documents Changed shower days to better meet the needs of the resident. Staff showered resident the next day (1/31/24). Ordered hoyer more shower slings. Surveyor noted the date written decision issued section had not been completed for R6's grievance. On 4/17/24 at 3:13 p.m., Surveyor asked NHA-A who is the grievance officer for the facility. NHA-A informed Surveyor that SSD (Social Service Director)-C was the grievance officer for the facility. On 4/17/24 at 3:19 p.m., Surveyor asked SSD-C about the Facility's grievance process. SSD-C informed Surveyor that grievances get filtered to her or sometimes they are given directly to her. SSD-C informed Surveyor she shares the grievance form at the 9:00 a.m. morning meeting with the team and, depending on what the grievance is, some departments will take the form & resolve the issue and sometimes she keeps the form while the grievance is being resolved. SSD-C informed Surveyor after the grievance is resolved NHA-A signs off on it and the form is placed in a binder. Surveyor asked if there is a process for getting back to the person who filed the grievance. SSD-C informed Surveyor sometimes at care conference or nursing will talk directly to the person. Surveyor asked who follows up to make sure the issues have been resolved. SSD-C stated I would say it happens informally. Surveyor informed SSD-C Surveyor had reviewed R4, R5, R6, & R7's grievances. Surveyor informed SSD-C their grievances do not consistently include the summary of findings or conclusions, whether the grievance was confirmed or not, any follow up to ensure the concerns have not continued and the date written decisions were issued. On 4/17/24 at 3:54 p.m. NHA-A and DON (Director of Nursing)-B were informed of the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility did not ensure that 1 (R1) of 2 Residents reviewed received required assistance with their ADL's (activities daily living). R1 did not receive their weekly showers/baths consistently per their plan of care. Findings include: R1 was admitted to the facility on [DATE] & discharged on 2/3/24. R1's diagnoses includes Parkinson Disease, status post Left Hip Fracture, CKD (Chronic Kidney Disease) and CLL (Chronic Lymphocytic Leukemia). The admission MDS (minimum data set) with an assessment reference date of 1/10/24 has a BIMS (brief interview mental status score of 15) which indicates that R1 is cognitively intact. R1 is assessed as requiring substantial/maximal assistance for showering/bathing self. The ADL (activities daily living)/rehabilitation potential care plan with a start date of 1/5/24, includes an intervention dated 1/5/24 that documents BATHING: I need extensive assistance with 2 person staff support. I prefer a shower. R1's progress notes from 1/5/24 to 2/3/24 document only one nursing note regarding R1's shower dated 1/23/24 which documents Resident refused a shower. CNA (Certified Nursing Assistant) attempted multiple times to give resident bed bath. Resident refused. Resident stated he was warm & comfortable. CNA offered warm blankets & resident still refused bed bath. Review of the daily charting by CNAs (Certified Nursing Assistants) for January 2024 for the question Did the resident receive a shower or bath? Documents the following for the 6:00 a.m. to 2:00 p.m. shift documents the following: 1/6/24 0, 0 indicates no. 1/7/24 & 1/8/24 are blank, 1/8/24 to 1/13/24 documents 0 for no, 1/14/24 is blank, 1/15/25 documents 0 for no, 1/16/24 is blank, 1/17/24 documents 0 for no, 1/18/24 is blank, 1/19/24 to 1/23/24 documents 0 for no, 1/24/24 is blank, 1/25/24 is 0 for no, 1/26/24 to 1/28/24 documents 0 for no, 1/29/24 is blank, 1/30/24 documents 0 for no, and 1/31/24 is blank. For January 2024, for the question Did the resident receive a shower or bath? Documents the following for the 2:00 p.m. to 10:00 p.m. shift: 1/6/24 to 1/12/24 are blank, 1/13/24 documents 1. 1 indicates yes. 1/14/24 to 1/18/24 are blank, 1/19/24, 1/20/24 & 1/21/24 documents 1 for yes, 1/22/24 to 1/25/24 are blank, 1/26/24 to 1/28/24 documents 0 0 indicates no. 1/29/24 is blank, 1/30/24 documents 0 for no, and 1/31/24 is blank. Daily charting by CNAs for February 2024 for the question Did the resident receive a shower or bath? Documents for the 6:00 a.m. to 2:00 p.m. shift the following: 2/1/24 0 for no, 2/2/24 & 2/3/24 are blank. For February 2024, for the question Did the resident receive a shower or bath? Documents for the 2:00 p.m. to 10:00 p.m. shift the following: 2/1/24 & 2/2/24 are blank and 2/3/24 has an X. R1 was discharged on 2/3/24. Surveyor noted residents are scheduled for showers two times a week. R1 only received one shower for the week of 1/7/24 to 1/13/24, and one shower for the week of 1/21/24 to 1/27/24. Surveyor noted that R1 did not receive a shower for the week of 1/28/24 to 2/3/24. On 4/17/24 at 12:11 p.m., Surveyor asked LPN (Licensed Practical Nurse)-E who was working on the unit where R1 resided and if LPN-E remembered R1. LPN-E replied no to remembering R1. On 4/17/24 at 12:14 p.m., Surveyor asked CNA (Certified Nursing Assistant)-D if when they provide a resident with a shower if they document this. CNA-D replied yes and explained they chart that a shower was provided in the resident's plan of care. On 4/17/24 at 1:40 p.m., Surveyor asked DON (Director of Nursing)-B if she knew R1. DON-B replied no. Surveyor informed DON-B that Surveyor had spoken to LPN-E who was working R1's unit when R1 was admitted but that LPN-E didn't know R1. Surveyor asked DON-B if there was anyone at the facility who would be able to speak to Surveyor about R1. On 4/17/24 at 2:29 p.m., Surveyor met with OTA (Occupational Therapy Assistant)-F and RN (Registered Nurse) Unit Manager-G regarding R1. OTA-F informed Surveyor R1 was very weak, and that therapy staff had to approach R1 several times for R1 to participate in therapy where they were working on strengthening for transfers. RN Unit Manager-G informed Surveyor he remembers that R1 wanted to go home, didn't want to get out of bed, refused to eat, complained of a metal taste in his mouth and that at one time had an IV (intravenous therapy). Surveyor asked OTA-F and RN Unit Manager-G if there were any concerns with R1's showers. RN Unit Manager-G informed Surveyor he didn't recall anything about showers and just remembered the concern of trying to get R1 to eat. On 4/17/24 at 2:45 p.m., Surveyor asked RN-H how long she has worked at the facility. RN-H informed Surveyor she left the facility December 2nd and just came back yesterday. Surveyor informed RN-H that Surveyor was going to ask her about R1, but that RN-H wasn't at the facility when R1 resided here. On 4/17/24 at 3:50 p.m., DON-B informed Surveyor she does not have any additional information to provide regarding R1's showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents received needed care and services based on professional standards of practice for 1 (R2) of 2 residents reviewed. R2 was determined to be at risk for weight loss and had a physician's order for weekly weights. The facility failed to obtain weekly weights per R2's physician's order for eleven weeks. As evidenced by: The facility's weight monitoring policy dated as last reviewed on January 2023 and titled, Weight Monitoring documents under the Policy Interpretation and implementation section A. Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter. R2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia following Cerebral Infarct (stroke) affecting Left side, Diabetes Mellitus Type II, Dysphagia, and Obesity. R2's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 8, indicating R2 is moderately cognitively impaired. Section GG0130 (Self-Care) documents R2 requires setup or clean-up assistance with eating. Section K0100 (Swallowing Disorder) documents R2 suffers from loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications and complaints of difficulty or pain with swallowing. Section K0200 (Height & Weight) documents R2's weight at time of admission is 186lbs (pounds). R2's Activities of Daily Living (ADL) Functional/Rehabilitation Potential care plan, dated 09/15/2023, indicates R2 requires extensive assistance and support from one person for eating. R2's Nutritional Status care plan dated, 02/18/2024, documents R2 is to be monitored for appetite and weight loss. R2's Nutritional Status care plan also documents R2 requires a mechanical soft diet and nectar thick liquids. R2's physician's order, with a start date of 08/13/2023, documents weekly weights to be obtained. On 04/17/2024 at 9:18 AM, Surveyor interviewed R2 who stated she had lost some weight, greater then 10lbs. R2 informed Surveyor R2 wishes to weigh 159lbs. On 04/17/2024 at 10:42 AM, Surveyor reviewed R2's electronic medical record which documents the following weights: 09/19/2023 at 1126- 145.7lb, 10/11/2023 at 0853- 145.6lb, 11/17/2023 at 1340- 138.5lb, 12/21/2023 at 2205- 141.4lb, 12/31/2023 at 1017- 142.4lb, 01/08/2024 at 1017- 142.4lb, 02/04/2024 at 1030- 140.2lb, 02/18/2024 at 1903- 130.8lb, 03/11/2024 at 1630-132.1lb, 03/24/2024 at 1656- 133.6lb, and 04/08/2024 at 1306- 131.6lb. Surveyor noted R2's admission weight on 08/15/2023 was186lbs. and on 04/08/2024 R2's current weight is documented as 131.6lbs. Surveyor was unable to locate weights for the following weeks: 08/20/2023, 09/24/2023, 01/14/2024, 01/21/2024, 01/28/2024, 02/11/2024, 02/28/2024, 03/03/2024, 03/17/2024, 03/31/2024 and 04/14/2024. On 04/17/2024 at 2:55 PM, Surveyor interviewed Certified Dietician Manager (CDM)-C regarding the facility's practices for weight monitoring. CDM-C informed surveyor that she monitors resident's weight every 1-2 weeks and that she notified nursing and the dietician if changes or recommendations are needed. CMD-C informed Surveyor that if weights are missing, she will notify nursing via email. 04/17/2024 at 3:20 PM, Surveyor interviewed DON (Director of Nursing)-B who stated if there is a physician order it should be followed. On 04/18/2024 at 4:05 PM, the facility provided Surveyor with R2's MAR (Medication Administration Record)/TAR (treatment Administration Record) from 8/9/23 to 4/17/24. Surveyor reviewed R2's MAR/TAR records and noted that R2 did not have weekly weights for the following dates: 08/20/2023, 09/24/2023, 01/14/2024, 01/21/2024, 01/28/2024, 02/11/2024, 02/28/2024, 03/03/2024, 03/17/2024, 03/31/2024 and 04/14/2024. Surveyor noted that from 08/9/2023 through 04/17/2024, the facility did not obtain weekly weights, per R2's physician order, 11 times on the dates as listed above. No additional information was provided by the facility as to why R2 did not receive weekly weights per physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure that necessary treatment and services were provided, consistent with professional standards of practice, to prevent and promote healing of pressure injuries for 1 (R3) of 3 residents reviewed for pressure injuries. R3 was admitted to the facility on [DATE], the facility did not thoroughly assess R3's wounds until 1/4/2024. Assessments included measurements but did not include a thorough assessment of the wound. R3 did not have clarification orders for R3's right buttock and left gluteal wounds on admission. Findings include: The facility policy entitled Skin Identification, Evaluation and Monitoring revised 11/2022 states: The purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion of findings. Procedure: Licensed nursing associate will evaluate the skin integrity through a physical skin evaluation and use of the Braden Skin at Risk tool. Upon admission, weekly for three weeks, quarterly and when a significant change is identified. The nursing assistant will observe the resident's skin when assessing with activities of daily living (ADL) and report changes to the nurse. Upon admission: The licensed nursing associate: A. Complete physical skin evaluation, document findings. If a skin condition is present on admission: 1. Initiate protective dressing 2. Notify health care provider of findings and for further treatment orders 3. Notification/Education of resident and resident representative of findings and physician orders. 4. Document evaluation in the medical record. B. Initiate preventative and/or treatment intervention, as indicated. D. Document findings, notifications, and interventions. R3 was admitted to the facility on [DATE] and has the following diagnoses surgical amputation of all the toes on the left foot- gangrene, cellulitis of left lower limb, type 2 diabetes mellitus with diabetic neuropathy, foot ulcer, dermatitis and kidney complication, peripheral vascular disease, edema, gastrointestinal hemorrhage, and chronic duodenal ulcer with hemorrhage. R3's admission minimum data set (MDS) dated [DATE] indicates R3 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13 and the facility assessed R3 needing total assistance with 1 person staff support with lower body dressing, putting on and taking off footwear, and toileting hygiene. R3 was non weight bearing on left lower extremity due to recently having left toes amputated and used a Hoyer lift with assist of two support staff for transfers. R3 uses a wheelchair mobility, had a Foley catheter in place and is continent of bowel. R3 was admitted to the facility with pressure injuries that R3 obtained at home while not being able to get off of R3's toilet for three days before being found by family on the fourth day. The facility assesses R3 on 1/3/2024 to be at mild risk for the development of pressure injuries with a Braden score of 16. [R3's name] Pressure ulcers/Skin prevention Care Plan was initiated on 1/3/2024 with the following interventions: [R3] is at risk for pressure ulcers and other skin related injuries related to immobility, diabetes, peripheral vascular disease, recent surgical amputation left foot- [R3] will maintain skin integrity without new skin related injuries over the next review period. - Braden Scale to be completed. - Keep bed linens wrinkle free and do not use excess pads. - Observe skin for redness and breakdown during routine care. - Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated. - Follow community skin care protocol. - Treatments, as indicated, see physician order sheet. - Pressure reducing mattress on bed. [R3] has impaired skin integrity related to right great toe, pressure wound to scrotum, pressure wound to right buttock and pressure wound to left gluteal fold- R3 will be free from signs and symptoms of infection and will demonstrate optimal healing (initiated on 1/9/2024). - Provide treatment as ordered. - Educate resident and/or family to the importance of frequent turning/ shifting and repositioning. - Minimize force and friction applied to skin. - Registered dietician consult. - Assess and evaluate wound size, depth, color, and drainage present every week. - Assist/teach to reposition self to reduce pressure (shifting own weight or turning) - Provide Supplements to promote healing as ordered by physician. - Specialized mattress on bed. Type low air loss and setting #7. R3's physician orders on admission included: 1. Utilize barrier cream to macerated are of right and left lower buttocks area, keep area clean and dry as needed on day shift, evening shift, and night shift. Surveyor reviewed R3's skin evaluation forms dated 1/4/2024: 1. Left foot dorsal- - Surgical amputation dorsal region, dressing clean/dry/and intact- follow-up with surgeon. 2. Right great toe- - Full thickness diabetic foot ulcer, clean intact dressing applied- evaluation by wound care 3. Right lower buttock, partial thickness, moisture associated skin damage (MASD)- - 6.0cm (centimeters) X 2.0cm X 0.1cm, keep area clean and dry, utilize barrier cream, wound care to evaluate. 4. Scrotum- full thickness trauma - 1.3cm X 2.0cm X 0.2cm, serous drainage with slough, macerated- keep area clean and dry, wound care to evaluate. Surveyor noted there were no measurements documented for R3's right great toe wound, no orders were in place for R3's right great toe or scrotum wounds, there is no description of the wounds including tissue type observed or staging of the right lower buttock or scrotum areas. Surveyor reviewed R3's wound care assessments dated 1/9/2023: 1. Right buttock- stage 2 pressure ulcer - 6.14cm X 3.8cm X 0.1cm, wound bed: non-granulating, attached edges - new order to cleanse with normal saline, apply hydrocolloid to wound bed and protect peri wound (around the wound) with skin prep. Change Tuesday, Thursday, Saturday and as needed. 2. Scrotum- full thickness, unstageable -1.3cm X 2.5cm X 0.2cm, wound bed: 26-50% granulation, 26-50% Slough, attached edges. - New order to clean with ½ strength Dakin's solution, apply Santyl to wound bed, cover area with a abdominal (ABD) pad, change daily and as needed. 3. Right great toe, Trauma -1.8cm X 2.7cm X 0.1cm, wound bed: eschar, attached edges. - new order to clean wound with normal saline, apply skin prep two times a day. 4. Left gluteal fold, unstageable - 5.9cm X 8.1cm X 0.1cm, wound bed: 26%-50% granulation, 26%-50% slough, attached edges. - new order to clean area with normal saline, apply hydrocolloid to wound bed and protect peri wound with skin prep. Change Tuesday, Thursday, Saturday, and as needed. Surveyor reviewed R3's wound care assessments dated 1/16/2023: 1.Scrotum- unstageable -1.2cm X 2.7cm X 0.1cm, wound bed: slough 76-100%, attached edges. - No new orders 2. Right great toe- trauma -1.6X 2.7 X 0.1cm, wound bed: eschar, attached edges. - No new order 3. Right buttock- stage 2 -0.6cm X 0.8cm X 0.1cm, wound bed: fully granulated, attached edges. - new orders: clean wound with normal saline, protect peri-wound with skin prep, cover wound with foam dressing. Change on Tuesday, Thursday, Saturday and as needed. 4. Left gluteal fold, Stage 3 -6.5cm X 5.0cm X 0.1cm, wound bed: 51-75% granulation, 1-25% slough, attached edges. - new orders: clean wound with normal saline, protect peri-wound with skin prep, cover wound with foam dressing. Change daily and as needed. On 1/22/2024, at 2:10 PM, Surveyor observed R3 in bed lying on their back. R3 had heel boots on R3's right and left feet. Surveyor asked R3 how R3 was feeling and if there were any concerns R3 had. R3 stated R3 was feeling better and was cleared to bare some weight on R3's left foot today at R3's doctor appointment and that the doctor said R3's left foot was healing well from having the toe amputations. Surveyor asked R3 about R3's wounds on R3 buttocks and scrotum. R3 stated facility staff are doing treatments and that the wound doctor said the areas are improving and will see the doctor tomorrow (1/23/2024) for another follow- up. R3 stated R3 had no concerns and was happy and feeling like R3 was getting better and stronger. On 1/23/2024, at 10:30 AM, Surveyor observed Wound Medical Doctor (Wound MD)-I and Wound Registered Nurse (Wound RN)-H assess R3's wounds, documented was: 1. Right great toe-improved and scab will peel off, continue with same treatment. Surveyor observed eschar on tip of right great toe. 2. Scrotum- -continue with same treatment, almost closed. Small area that is still open. 3. Left gluteal fold- -looks better, almost all healed and intact, continue with same treatment 4. Right buttock- -healed, continue with foam dressing for two weeks for protection On 1/23/2024, at 10:40 AM, Surveyor interviewed Wound MD-I and asked Wound MD-I to clarify the staging of R3's wounds as upon admission the facility staged R3's right buttock wound as MASD and currently staged as Stage II per Wound MD-I. Wound MD-I stated R3's right buttock wound was originally mislabeled as MASD but because R3 was on the toilet so long at R3's home before entering the facility it would be considered pressure and R3's scrotum was originally labeled as trauma but staged it due to it being pressure from trauma of the toilet seat at R3's house. Wound MD-I stated R3's right great toe wound is not vascular or diabetic ulcer. Wound MD-I stated it may be from trauma or when R3 was left on R3's toilet at home because it is a blood blister that is drying up and will eventually peel off. Surveyor asked Wound MD-I regarding R3's left gluteal fold of being unstageable and now a stage 3. Wound MD-I stated that it was unstageable because of not being able to see the wound bed, but the wound is improving and can see the wound bed and staged at a stage 3 that is almost healed. Wound MD-I stated all cites are healing nicely and has no concerns. On 1/23/2024, at 11:00 AM, Surveyor interviewed Wound RN-H who stated Wound RN-H is only in the facility on Tuesdays during wound rounds so the first time Wound RN-H saw R3's wounds were on 1/9/2024. Wound RN-H stated expectations would be staff to do measurements when a wound or area of concern is noticed on a resident and a call to the resident's primary physician or appropriate doctor to get orders. Wound RN-H stated the facility will email or notify directly if there are concerns or new areas to view on residents. On 1/23/2024, at 11:14 AM, Surveyor interviewed Director of Nursing (DON)-B who stated expectations of staff are to get measurements and descriptions of areas of concerns upon admission of residents into the facility and weekly skin checks. Nursing is to obtain an order from a physician for treatment to the area of concern if warranted. Surveyor shared concerns with DON-B regarding R3 not having measurements of R3's right big toe wound and not having orders/treatment in place for R3's scrotum and right big toes wounds. DON-B stated the admission nurse had separate pieces of paper regarding R3's wounds upon R3's admission on [DATE] and would have to find the paperwork. On 1/23/2024, at 12:10 PM, Surveyor interviewed Clinical Nurse Manager (CNM)-G who stated the nurse on duty is supposed to measure R3's wounds upon admission into the facility. CNM-G stated staff are to measure and describe the wound upon admission or discovery of it and chart it on a skin assessment form in the resident's medical record, staff are to then call the appropriate physician for orders. CNM-G stated CNM-G recalls hearing about R3's wounds on admission but was not the one to observe R3's wounds. CNM-G stated CNM-G entered the information into R3's medical record from the nurse who observed R3's wounds. On 1/23/2024, at 12:23 PM, Surveyor interviewed RN-F who stated RN-F recalls R3 being admitted at the end of RN-F's shift. RN-F stated RN-F measured and documented all of R3's wounds the following day on 1/4/2024 by direction of CNM-G who stated R3's wounds were not documented. RN-F stated she filled out a sheet with all the measurements on it but does not recall if there were treatments ordered or not. RN-F sated RN-F just assessed and wrote down the wounds and measurements for R3's wounds and gave them to CNM-G to document in the medical record. On 1/23/2023, at 1:30 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and DON-B regarding the concerns that a thorough assessment of R3's wounds did not occur upon admission and treatment orders were not obtained until 1/9/24 for R3's right great toe and scrotum pressure injuries. On 1/24/2023, at 2:55 PM, Surveyor received wound documentation and hospital paperwork from DON-B via email. Surveyor reviewed paperwork and noted the following concerns: 1. Surveyor reviewed the skin check sheet from the facility for R3's admission skin check done on 1/4/2023. Surveyor noted the skin check sheet does not have a date or staff initials on it to indicate who or when it was completed. - scrotum area circled with 1.3 X 2, barrier cream documented on the form. - right foot circled, big toe eschar, 1.6 X 2.6 - left foot circled, amputated toes. - left buttock area with 13 X 2 documented. - right buttock area with 6 X 2 documented. - note underneath measurements that document wound on bottom, hydrocolloid drsg (dressing) 3XW (three times a week). -note on bottom right corner of page states: to leave dressing on left amputation surgical until follow- up on 1/8/2024. 2. Hospital paperwork documented the following wounds (date unknown of hospital assessment): - Right buttock with more partial thickness appearance, pink tissue with epidermal layer peeling. - Left buttock evolving deep tissue pressure injury now unstageable with 1.3 X 3.0 are of adherent slough. - Scrotum evolving deep tissue pressure not unstageable - Left foot transmetatarsal amputation (TMA), sutures in place. Incision approximated with no drainage or dehiscence, left lower extremity edema. - Right foot intact stable eschar to tip/planter aspect of right great toe. 3. Hospital paperwork documented the following treatment plans: Wound care to scrotum: -clean wound with disposable bathing cloth, pat dry, apply triad cream (barrier cream) once daily, do not need a secondary dressing. Complete wound care daily. Wound care to right buttock: -clean with Sea cleanse wound cleanser, pat dry, apply oil emulsion dressing cut to fit wound, cover with bordered foam dressing, complete wound care and change every three days. Wound care to left buttock: -Cleanse with Sea cleanse wound cleanser, pat dry, apply thin layer of Medi honey gel to dark tissue, apply oil emulsion dressing cut to fit wound, cover with bordered foam dressing, complete wound care and change dressing every three days. Wound care to right second toe: -cleans with normal saline and pat dry, paint wound with betadine, leave open to air, or cover with gauze, complete wound care daily, offload heels with heel boots. 4. Hospital paperwork documented recommendations for preventative measures for R3: - Reposition every 2 hours while in bed and every hour while in chair, mostly side to side - Float heels off of bed with pillows, and or heel lift boots. - Keep head of bed greater than 30 degrees unless contraindicated. - Utilize incontinence management as needed: cleanse with sage barrier wipes. - Avoid use of adult briefs while in bed, briefs should only be used when patient is up in chair or off unit for testing. - Utilize only two layers of linen while in bed, flat sheet and disposable underpad, or fitted sheet and disposable underpad. On 1/26/2024, at 2:50 PM, Surveyor called DON-B and left message with call back number so Surveyor could ask clarification questions from information that was sent via email on 1/24/2024. On 1/29/2024, at 4:00 PM, DON-B returned phone call to Surveyor. Surveyor asked DON-B to clarify if R3 had a wound to R3's second right toe as stated in the wound orders from the hospital. DON-B stated R3 has never had an area of concern on R3's second toe. Surveyor expressed concern with DON-B that the right second toe was documented to have stable eschar by the hosptial however the facility never followed-up on or clarified with the hospital to determine what the hospital identified on R3's right second toe. Surveyor asked DON-B if the preventative measures suggested from the hospital for R3, to be repositioned every 2 hours while in bed, or for R3 not to wear an adult briefs were implemented on R3's current care plan. DON-B stated that repositioning is not on R3's care plan or CNA [NAME] and was not sure about R3 not wearing adult briefs while in bed. Surveyor shared concerns that R3 requires assist of one with bed mobility so is unable to reposition alone. Surveyor asked DON-B to clarify if R3's right buttock and left gluteal wound treatment admission orders were confirmed with the physician when reviewing the admission orders and medications. DON-B stated she will have to confirm with the nurse who admitted R3. DON-B stated that the barrier cream was an order from the physician, and she could only assume the orders were reviewed and the physician ordered the barrier cream, but would confirm with the admitting nurse and get back to Surveyor. Surveyor did not receive a return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R2 was admitted to the facility on [DATE] and has diagnoses that include dementia with anxiety, aneurysm of the descending thoracic aorta, anxiety disorder, anemia, and depression. R2's Minimum Date Set (MDS) dated [DATE] indicated R2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 9, the facility assessed R2 required supervision with toileting hygiene, was modified independent needing a device for upper body and lower body dressing, and independent with walking with a walker, cane. R2 was occasionally incontinent of urine and continent of bowel and wore an adult brief for protection. R2 was assessed on 6/26/2023 as being at low risk for falls with a [NAME] Fall Risk Assessment score of 5 and was receiving Hospice care. R2's activities of daily living (ADL) functional/rehab potential care plan was initiated on 12/22/2022 which documented: [NAME] needs assistance with daily ADL care related to impaired cognition . - TRANSFER: R2 needs supervision assistance with one person staff support. R2 uses no assistive device. - MOBILIYTY: R2 needs supervision assistance with one person staff support. R2 uses a walker and cane. - TOILETING: R2 needs supervision assistance with one person staff support. - R2 is occasionally incontinent of bladder and continent of bowel, R2 wears briefs. (Initiated 9/7/2023) - Some days R2 needs more assistance with cares. R2's Incontinence Care Plan was initiated on 11/7/2023 which documented: R2 has altered elimination due to occasional incontinence of bladder . - Offer to assist to the bathroom whenever observed to be awake at night. Reposition once returning to bed. R2's Falls Care Plan was initiated on 12/22/2022 which documented: R2 has potential for falls related to recent admission to community, and impaired cognition. R2 wants to remain free from injury related to falls over the next review period) - Keep pathways clear and provide adequate lighting. - Keep bed at the appropriate height. - Keep personal items within reach. - Orient to room and call light. R2's certified nursing aide (CNA) Care [NAME] had the following interventions in place: -TRANSFER: R2 needs supervision assistance with one person staff support. - MOBILITY: R2 needs supervision assistance with one person staff support. R2 uses a walker or cane. - Some days R2 needs more assistance with cares. - TOILETING: R2 needs supervision assistance with one person staff support. On 12/29/2023, at 3:45 AM, in the progress notes nursing charted at approximately 2:00 AM nursing heard screaming from R2's room. R2 was observed lying on R2's back in R2's bathroom. R2 did not have shoes on and R2's walker was by R2's bed. R2 was screaming about R2's hip and back multiple times. Nursing observed a hematoma (bruising) on R2's left temple. Nursing attempted to assess R2's left hip but R2 was unable to move bilateral lower extremities. Nursing and CNA lifted R2 off the ground using a Hoyer lift and transferred R2 back to R2's bed. Nursing charted R2 continued to scream while lying in bed. R2 was transferred to the hospital via ambulance. On 12/29/2023, at 10:20 AM, nursing charted bed hold in place for R2. R2 admitted to hospital with left hip fracture. On 12/31/2023 R2 had a left hip arthroplasty. On 1/22/2024, Surveyor reviewed the Facility's Fall investigation for R2's fall that occurred on 12/29/2023. Surveyor noted R2's fall was not thoroughly investigated to determine the root cause. The fall investigation does not include when the resident was last toileted or observed by staff and investigation forms were missing names and dates. The fall investigation also does not include if the facility identify causative factors and/or identified preventative interventions. Surveyor also noted the new intervention identified was to have R2 wear non-skid socks but the facility did not identity if the non-skid socks would address the root cause of R2's fall. Surveyor noted no education was provided to staff regarding assessments or transfers of residents with injuries. On 1/22/2023 Surveyor requested any other information regarding R2's fall on 12/29/2023 from Nursing Home Administrator (NHA)-A. NHA-A provided Surveyor with signed and dated investigation notes but had no further information regarding the fall investigation for R2 other than what was previously provided. On 1/23/2024, at 8:02 AM, Surveyor interviewed CNA-J who stated CNA-J was called into the room by nursing because R2 was on the floor. CNA-J stated R2 was crying out in pain and R2 did not want to move their legs. Surveyor asked CNA-J if R2's legs looked different or out of place. CNA-J stated R2's left hip did not look right, and they knew something was wrong. CNA-J stated nursing asked for help to lift R2 off the ground with a Hoyer lift and transferred R2 back to bed. CNA-J stated R2 was screaming the whole time and in pain. Surveyor asked CNA-J what R2's behavior was at nighttime and when the last time R2 was toileted or observed. CNA-J stated R2 usually slept through the night once R2 fell asleep. CNA-J stated CNA-J was in the middle of doing toileting rounds when CNA-J was called to R2's bedroom and that CNA-J last observed R2 sleeping in R2's bed about an hour prior to R2's fall. CNA-J could not remember the last time they assisted R2 with toileting needs. CNA-J stated R2 would use the bathroom independently and would put on shoes or non-skid slippers. CNA-J stated CNA-J would check frequently on R2 and if found in the bathroom would assist R2 in getting back to R2's bed. CNA-J stated R2 did not like staff watching or standing close by R2 so staff would stay a little away from R2 so R2 did not feel like staff were watching R2. CNA-J stated R2 did not have any prior falls that CNA-J was aware of and that R2 was pretty steady with walking with R2's walker. Surveyor asked CNA-J if education was provided regarding falls etc. CNA-J stated CNA-J thinks upon hiring and could not remember the last education or training CNA-J received. On 1/23/2032, at 10:00 AM, Surveyor interviewed Registered Nurse (RN)- K who stated RN-K heard yelling coming from R2's room and when RN-K walked into the bedroom RN-K observed R2 lying on the bathroom floor on R2's back. RN-K stated when RN-K assessed R2 on the ground, R2's hip looked displaced, not right, and R2 was having a lot of pain and could not move R2's leg. Surveyor asked RN-K why RN-K decided to lift R2 off the ground with a Hoyer lift and put back in bed. RN-K replied that RN-K wanted to get R2 off the ground and more comfortable in R2's bed and R2 was asking to get off the ground. RN-K stated after R2 was off the ground and in bed, RN-K called R2's physician, Hospice, and the Director of Nursing (DON). RN-K stated the DON directed RN-K to send R2 to the hospital. Surveyor asked RN-K if there were any concerns during the shift with R2 of feeling anxious or if R2 was forgetful when it came to using their walker. RN-K stated RN-K did not have any concerns with R2 during the shift. RN-K stated R2's room was close to the nursing station so staff could look in and see R2. RN-K stated R2 did not like the feeling of staff watching or helping R2 so staff would check frequently on R2 to make sure R2 was being safe and was ok. RN-K was not sure when R2 was last toileted during the night. RN-K stated RN-K does room checks every 1-2 hours during RN-K's shift and did not have concerns prior to R2's fall on 12/29/2023. RN-K stated RN-K does not recall getting education or the last time education was provided regarding falls at the facility. On 1/23/2023 at 11:04 AM Surveyor interviewed DON-B who stated DON-B did not provide education to staff about moving residents that have an injury after a fall. DON-B stated DON-B did not investigate or ask RN-K or CNA-J about R2's fall or gather information about what happened, including when the last time R2 was observed or toileted. DON-B stated staff would do frequent checks on R2 because R2 would get anxious and upset if R2 felt staff were watching or following R2. DON-B stated staff should probably not have moved R2 off the floor after seeing R2 had an injury to R2's hip, but an investigation was not done to determine a cause for moving R2 and education should have been provided to staff regarding moving a resident with possible injury after a fall. DON-B stated they are planning on provided education every other month for staff on top of the annual required trainings. DON-B stated falls is one of the topics DON-B wants to present education on. Surveyor shared concerns with DON-B regarding R2's fall investigation on 12/29/2023 not being thorough and did not identify the root cause of the fall or identify if the interventions put into place address the root cause of the fall. No other information was provided at this time. Based on observation, interview and record review the facility did not ensure 2 (R2 and R4) of 3 residents received the necessary services to prevent falls/accidents. The Facility did not thoroughly investigate R2's and R4's falls to identify a root cause and implement preventative interventions to prevent falls/accidents in the future. Findings include: On 1/23/24 the facility policy titled Accidents and Incidents-Investigating and Reporting dated 01/24 was reviewed and read: The following information shall be included in the investigation, as applicable. The circumstances surrounding the accident or incident. The names of the witnesses and their accounts of the accident or incident. Follow up information. Other pertinent data as necessary. 1.) R4 was admitted to the facility on [DATE] with diagnosis that included osteoporosis and dementia. R4's initial Minimum Data Set (MDS) dated [DATE] indicated R4 was totally dependent on 2 or more staff with transfers. R4's MDS also indicated a score of 6 (severe cognitive impairment) on the Brief Interview for Mental Status assessment. On 1/22/24 R4's progress note written by Licensed Practical Nurse (LPN)-L on 1/10/24, at 5:34 PM, was reviewed and indicated: At 4:50 PM writer heard a loud scream from R4's room, Writer saw R4's daughter and granddaughter transferring R4 to bed. R4 said it's broken, you broke it. R4's daughter replied it's not broken it's the bed you heard. Writer assessed left leg and there was a slit with bone exposed and blood spurting out. Writer phoned R4's physician who insisted R4 be sent to the Emergency Room. R4 sent to [name of the hospital]. On 1/23/24 R4's hospital record dated 1/10/24 was reviewed and indicated R4 suffered a break of the left tibia and fibula that required surgical repair. R4 was discharged back to the facility on 1/17/24. On 1/22/24, at 1:30 PM, Nursing Home Administrator (NHA)-A was interviewed and indicated he was in charge of R4's investigation for the 1/10/24 incident. Nursing Home Administrator-A indicated there was no documentation of R4's family transferring her other than the initial incident on 12/7/23 when therapy reported R4's family had transferred her to bed. NHA-A indicated he did not ask R4's family or staff if R4's family had been transferring her between 12/7/23 and 1/10/24. NHA-A indicated R4's family indicated the staff are busy, so they just did it. NHA-A indicated when R4 came back to the facility R4's family had to sign an agreement that they would not provide care to R4, or she would be discharged . On 1/22/24 R4's medical record was reviewed and indicated no directions or concerns with R4's family transferring her. On 1/23/24 R4's care plan for Activities of Daily Living dated 12/5/23 was reviewed and indicated R4 needed extensive assistance of 2 staff for transfers. On 1/22/23 at 2:00 PM, R4 was interviewed and indicated she did not remember how her left leg got injured. On 1/22/24 the Facility's investigation into how R4's leg was fractured was reviewed and only included statements from CNA's and the LPN working the shift the incident took place. No questions were asked to determine if R4's family had been observed transferring R4 and no statement was taken from R4 or R4's family regarding the incident. On 1/23/24, at 9:30 AM, Physical Therapist (PT)-C was interviewed and indicated on 12/7/23 herself and another therapist went to transfer R4 out of bed and once R4 got in her wheelchair they both left to help another resident and told R4's family they would be back to transfer R4 back to bed. PT-C indicated when they came back R4 was already in bed. R4's family indicated they transferred R4 to bed. PT-C indicated she told R4's family the facility staff should be the only ones transferring R4. PT-C indicated R4 has severe osteoporosis and she did not even want facility staff to transfer R4 until they made sure it was safe to do so. PT-C indicated she told the nurse on duty of her observation of R4's family transferring R4 to bed. On 1/23/24, at 9:00 AM, Power of Attorney for Healthcare (POA)-D was interviewed and indicated she had transferred R4 several times from 12/7/23 to 1/10/24 sometimes with the help of facility staff. POA-D indicated she was a Certified Nursing Assistant (CNA) 40 years ago and felt competent to do so. POA-D indicated she never asked for help on 1/10/24 or any other time she transferred R4. POA-D indicated there was a gait belt in R4's room but herself and the other family member just transferred R4 under her arms. POA-D indicated R4's injury was all her fault, and the facility did not do anything wrong. POA-D indicated no one asked her what happened immediately after R4's injury and she was never asked if she had been transferring R4 from 12/7/23 to 1/10/24. On 1/23/24,at 10:30 AM, CNA-E was interviewed and indicated she worked with R4 several times between 12/7/23 to 1/10/24 and that R4's family transferred her all the time and did what they wanted when they wanted. CNA-E indicated she was never told R4's family couldn't transfer R4 but even if they had they would have done what they wanted anyway. CNA-E indicated she was never asked about the frequency R4's family was transferring her prior to R4's injury on 1/10/24. Schedules were reviewed and indicated CNA-E was responsible for R4's care on day shift at least 20 times from 12/7/23 to 1/10/23. The above finding was shared with Nursing Home Administrator-A and DON-B on 1/23/24 at 10:30 AM. Additional information was requested if available. None was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were available for administration for two (Residents (R)1 and R2) upon readmission to the facility following a hospitalization out of a sample of nine residents. This had the potential to have adverse health issues for both residents. Findings include: 1. Review of R1's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an original admission date of 09/17/21 and a readmission date of 09/30/23. Review of R1's Physician's Orders located in the EMR under the Orders tab, revealed a physician's order to admit resident to skilled level of care, dated 09/30/23. Review of R1's 10/2023 Medication Administration Record (MAR) provided by the facility revealed the following medications were not administered to R1 on 10/01/23: 0600 [6:00 AM] Diclofenac 1% topical gel every 6 hours bilateral knees, for pain 0800 [8:00 AM] Metamucil Fiber Gummy Chew, 3 gummies, for constipation 0800 [8:00 AM] Sodium chloride 1000 mg soluble tablet, 1 tablet, for supplement 0800 [8:00 AM] Pantoprazole 40 mg, delayed release, 1 tab, for GERD [Gastroesophageal reflux disease] 0800 [8:00 AM] Lisinopril 40 mg, 1 tablet, for Hypertension 0800 [8:00 AM] Olanzapine 5 mg tablet, 1 tablet, for dementia 0800 [8:00 AM] Amlodipine 5 mg tablet, 1 tablet, for Hypertension 0800 [8:00 AM] Hiprex 1 gram tablet, 1 tablet, for prophylaxis 0800 [8:00 AM] Ascorbic Acid 500 mg, 1 tablet for supplement 0800 [8:00 AM] Florastor 250 mg capsule, 1 capsule, for supplement 0800 [8:00 AM] FeroSul 325 mg tablet, 1 tablet for supplement 1200 [12:00 PM] Diclofenac 1% topical gel, every 6 hours bilateral knees, for pain 1600 [4:00 PM] Sodium chloride 1000 mg soluble tablet, 1 tablet, for supplement 1600 [4:00 PM] Ascorbic Acid 500 mg tablet, 1 tablet, for supplement 1700 [5:00 PM] Hiprex 1 gram tablet, 1 tablet, for prophylaxis 1800 [6:00 PM] Diclofenac 1% topical gel every six hours bilateral knees, for pain 2000 [8:00 PM] Cranberry extract 500 mg capsule, 1 capsule, for supplement HS [Hour of Sleep] Mirtazapine 15 mg disintegrating tablet, 1 tablet, for insomnia HS [Hour of Sleep] Melatonin 10 mg capsule, 1 capsule, for insomnia 2000 [8:00 PM] Florastor 250 mg capsule, 1 capsule, for supplement The following medications were not administered to R1 on 10/02/23: 0600 [6:00 AM] Diclofenac 1% topical gel every 6 hours bilateral knees, for pain 0800 [8:00 AM] Sodium chloride 1000 mg soluble tablet, 1 tablet, for supplement 0800 [8:00 AM] Olanzapine 5 mg tablet, 1 tablet, for dementia 0800 [8:00 AM] Hiprex 1 gram tablet, 1 tablet, for prophylaxis 0800 [8:00 AM] Ascorbic acid 500 mg tablet, 1 tablet, for supplement 0800 [8:00 AM] Florastor 250 mg capsule, 1 capsule, for supplement 1200 [12:00 PM] Diclofenac 1% topical gel every 6 hours bilateral knees, for pain The medications that were not administered on 10/02/23 were noted, on the MAR as not available. Review of the Interdisciplinary Note located in the EMR under the Clinical tab revealed on 10/02/23, the Registered Nurse (RN)1 documented, call placed to pharmacy, meds have not been delivered - writer informed that resident is inactive-writer has notified HUC [Health Unit Coordinator] for assistance. 2. Review of R2's Face Sheet located in the EMR under the Profile tab, revealed an original admission date of 09/25/23 and a readmission date of 09/30/23. Review of R2's Physician's Orders located in the EMR under the Orders tab, revealed a physician's order to admit resident to skilled level of care, dated 09/30/23. Review of the Interdisciplinary Notes located in the EMR under the Clinical tab, dated 09/27/23, revealed R2 was sent to the ER [emergency room] for evaluation and admitted to the hospital. On 09/30/23, R2 returned to the facility at 8:20 PM. The note further revealed, admission orders reviewed and obtained from . MD [Medical Doctor] and sent to . Pharmacy. Review of R2's 10/2023 MARs revealed the following medications were not administered on 10/01/23: AC Brkft [Before Breakfast] Blood glucose test once daily, for type 2 Diabetes Mellitus 0800 [8:00 AM] Pantoprazole 40 mg tablet delayed release, 1 tablet by mouth twice a day, for duodenal ulcer 0800 [8:00 AM] Hydralazine 50 mg tablet, 1 tablet twice a day, for essential hypertension 0800 [8:00 AM] Metamucil 0.4 gram capsule, 2 capsules every morning, for constipation 0800 [8:00 AM] [NAME] Thyroid 30 mg tablet, 1 tablet every day, for hypertension 0800 [8:00 AM] Senna 8.6 mg tablet, 1 tablet twice a day, for constipation 0800 [8:00 AM] Metformin ER 500 mg tablet extended release 24 hour, 2 tablets twice a day, for type 2 diabetes mellitus 0800 [8:00 AM] Losartan 100 mg tablet, 1 tablet every day, for hypertension 1600 [4:00 PM] Cholestyramin Light 4 gram oral powder, 4 grams every day, for hyperlipidemia 1600 [4:00 PM] Hydralazine 50 mg tablet, 1 tablet twice a day, for hypertension 1600 [4:00 PM] Senna 8.6 mg tablet, 1 tablet twice a day, for constipation 1600 [4:00 PM] Metformin ER 500 mg extended release 24 hour, 2 tablets twice a day, for type 2 diabetes mellitus The following medications were not administered on 10/02/23: 0800 [8:00 AM] Pantoprazole 40 mg tablet delayed release, 1 tablet by mouth twice a day, for duodenal ulcer 0800 [8:00 AM] Hydralazine 50 mg tablet, 1 tablet twice a day, for essential hypertension 0800 [8:00 AM] Senna 8.6 mg tablet, 1 tablet twice a day, for constipation 0800 [8:00 AM] Metformin ER 500 mg tablet extended release 24 hour, 2 tablets twice a day, for type 2 diabetes mellitus 0800 [8:00 AM] Losartan 100 mg tablet, 1 tablet every day, for hypertension 1600 [4:00 PM] Senna 8.6 mg tablet, 1 tablet twice a day, for constipation 1600 [4:00 PM] Metformin ER 500 mg extended release 24 hour, 2 tablets twice a day, for type 2 diabetes mellitus Review of the Interdisciplinary Notes located in the EMR under the Clinical tab revealed on 10/02/23, RN1 documented, call placed to pharmacy to inquire about meds (medications) that have not been delivered - writer informed that they do not have record of (R2) being readmitted . Writer to re-enter all medications. Review of the EMR revealed R2 was readmitted on [DATE]. R2's medication orders were noted to start 10/02/23. There was no documentation as to why R2's medications were not ordered for 10/01/23 to be administered on 10/01/23. During an interview with RN1 on 10/04/23 at 12:45 PM, revealed she was the nurse who called the pharmacy, on 10/02/23, to inquire why R1 and R2 did not have their medications at admission, on 09/30/23. The Interdisciplinary Note read pharmacy had the residents as inactive, did not know they had been readmitted . In an interview with the Clinical Nurse Manager (CNM) on 10/05/23 at 2:15 PM, revealed he was not aware that the medications had not been delivered on 10/02/23. The CNM revealed the admitting nurse should have informed the pharmacy. When asked if there was a policy in place for admission orders, the CNM said he would have to look into that. The CNM confirmed, after reviewing the staffing sheet dated 09/30/23, that the nurse on duty at the time of R1 and R2's readmission on [DATE] was an agency staff member. No policy was provided related to resident admission/readmission orders, prior to exit on 10/05/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R51 was admitted to the facility on [DATE] and has diagnoses that include acute chronic diastolic congestive heart failure, type 2 diabetes, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and weakness. R51 was discharged from the facility on 5/9/23. R51's admission Minimum Data Set (MDS) dated , 4/6/23, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R51 is cognitively intact for daily decision making. R51 is their own person. Section Q 0300A (Participation in Assessment and Goal Setting) assesses that R51 is expecting to be discharged to the community. 0400 documents that there is an active discharge plan in place for the resident to return to the community. R51's care plan dated 4/13/23, documents R51 does not plan to make the community a long-term home. Interventions include assisting with the plan to stay in the community until discharge is practicable and support R51's plan to stay short term and assist with referrals as needed to meet goals for discharge, Active date 3/31/23. R51's Universal Transfer Form dated 5/9/23 which documents a recapitulation of R51's stay at the facility has sections A, B, C, H, I, L and M completed, however section D, E, F, G, J, K, N, O, P incomplete. The Setting Discharge From and Setting discharged To is left blank on the top of the form. Surveyor reviewed interdisciplinary notes for R51. On 5/8/23 it documents, Resident continues on ABT (antibiotic) for pneumonia. Persistent cough persists. Resident refuses Mucinex. States it makes it hard for (R51) to sleep. Denies any pain or discomfort. Was up in wheelchair for a good portion of the day. No adverse reactions noted to ABT. Will continue to monitor. Surveyor notes that there is no documentation of a discharge for R51. On 06/21/23, at 11:05 AM, Surveyor interviewed Social Worker-D who explained that discharge planning begins right when a resident is admitted . When a resident is ready for discharge Social Worker-D creates a yellow folder that contains printed physician orders and discharge order form. This folder is placed at the front desk for MD to review. One the day of discharge Social Worker-D will do a home health referral and referral for any equipment if necessary. Surveyor asked if a recapitulation of services provided is completed for discharges and Social Worker-D stated, Consistently, no. There is just too much to do and too little time. Surveyor asked Social Worker-D if a progress note is created documenting that a resident is being discharged . Social Worker stated that nurses often do put in a note upon resident discharge, or she does herself, but she does not go back in and check that these are being done. Surveyor and Social Worker reviewed the electronic health record for R51, and Social Worker-D confirmed that there are no progress notes documenting R51's discharge from facility. On 06/22/23, at 08:40 AM, Surveyor interviewed Director of Quality-C who explained that when a resident is ready to discharge the Social Worker will send out an email to the team and she will put out orders in a yellow folder and place it at the front desk. The discharge forms in Matrix should be completed by night shift nurses. If an agency nurse is working, then RN Manager-F or Director of Quality-C will complete them. Director of Quality-C stated that there are three forms completed for a resident discharge. They include a covid discharge instruction, universal transfer form and discharge instruction for care. Director of Quality-C confirmed that these forms should be completed in entirety. She explained that the diagnoses and immunization sections self-populate from Matrix on the Universal Transfer Form as well as a couple of other sections. The nurse is responsible to complete the other sections. Normally the nurse would go over discharge instructions with the resident as well as medications. When the resident is discharged the nurse should be documenting that the resident was discharged and who picked up the resident, medications sent with resident and where the resident was discharged to. Director of Quality-C stated that there is currently no quality measures in place to audit the discharge process. On 06/22/23, at 08:46 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed that the Social Worker is responsible to start the discharge process and that discharge forms should be filled out completely. NHA-A confirmed that they do not have anyone conducting audit of their discharge process and that he was unaware that discharge forms were incomplete. Surveyor informed NHA-A of concerns regarding discharge paperwork for R51 and that the Universal Transfer Form was incomplete and that there is no documentation in progress notes that R51 was discharged from the facility. No additional information was provided as to why the facility did not ensure that R51 received a complete discharge summary to communicate necessary information to the resident and continuing care provider. Based on record review and staff interviews, the facility did not always ensure that 2 out of 2 residents ( (R302, R51) who were discharged from the facility had a discharge summary that included all the pertinent information, a final summary of the resident; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. * R302 was discharged back into the community and the facility did not make the necessary referrals for home health so that services could be started after discharge and to assist with the transition of moving back into the community. * R51 was discharged from the facility on 5/9/23. The facility's Universal Transfer form which documents a recapulation of R51's stay was incomplete. R51's medical record did not include a recapitulation of R51's stay, nor did R51's medical record include information pertaining to R51's discharge. This is evidenced by: Surveyor reviewed the facility's policy: Transfer or Discharge, Preparing a Resident for, last revised 11/2022 Policy statement- Residents will be prepared in advance for discharge. Policy interpretation and implementation (includes): A.) When a resident is scheduled for transfer or discharge, the social worker, or designee, will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. B.) A post discharge plan is developed (in writing) for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four hours before the resident's discharge or transfer from the facility. C.) Nursing services are responsible for: (includes) 1.) Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment. 2.) Preparing the discharge summary and post discharge plan Policy review; Discharge Summary and plan- last revised on 01/2022 Policy statement: When residents discharge is anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy interpretation and Implementation: A. When the community anticipates a resident's discharge to a private residence, another nursing care community, a discharge summary, and post- discharge plan will be developed which will assist the resident to adjust to his or her new living environment. B. The discharge summary will include a recapitulation of the resident's stay at this community and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 1. R302 was originally admitted on [DATE] and discharged on 3/6/2023. R302 had diagnosis that included surgical aftercare, chronic obstructive pulmonary disease, obesity, weakness, asthma, depression, hypertension, GERD. R302 was admitted for rehabilitation therapies with a goal to return to her home. R302's plan of care indicated that R302 does not plan to make the community a long-term home. The goal will be assist with the plan to stay in the community until discharge is practical, through the next review period. Interventions include to support R302's plan to stay short term and assist with referrals, as needed, to meet goals for discharge. Social Service note dated 2/28/23: writer met with R302, brother and daughter in law this afternoon. R302's discharge plan was to return to her home however this is no longer a feasible plan. R302 would like to look into an ALF (Assisted Living Facility) that accepts Medicaid and a dog. Writer provided her with a brochure for Assisted Living Locators, Care Patrol and the Senior Resource guide for [NAME], Kenosha, and [NAME] counties. R302 lives in Kenosha County. Family has been in touch with the Kenosha ADRC (Aging and Disability Resource Center) . Family has the Medicaid application. R302 will also be the POAHC while here. R302 does not want to move to Ohio with brother and sister-in-law. R 302 has a group of friends in the area. Discharge plan is to move to an ALF once one is found. Social Service note dated 3/2/23: Discharge plan is to discharge to a friend's home on 3/6/23. R302's brother sister-in-law will transport. They will stay in WI until resident transfers to her friend's home. Nursing note dated 3/2/23; R302 maintaining 96% on room air. No complaints of pain or fatigue. R302 became tearful in the morning due to life changes and having a lot to deal with. Writer sat with R302 to calm her down. No other concerns at this time. R302 participated in physical and occupational therapy while at the facility. R302 was discharged from therapy services on 3/2/2023. A review of the PT Patient Discharge Instructions stated that R302 was given a home exercise program that she will continue to perform. Discharge plans and instructions: R302 will continue with in home PT (physical therapy) and OT (occupational therapy) to ease her transition to a new living environment. Nursing note dated 3/5/23; R302 stated she will be discharging from facility on 3/6/23 between 10:00 - 11:00 am. R302 O2 levels remained above 96% without O2. No complaints of pain or discomfort. The above nursing note is the last entry into the medical record concerning the discharge of R302. The medical record does not have evidence that physician order for discharge was obtained. Additional there was no documentation about request for needed services after discharge for home health services. Surveyor requested a copy of the discharge summary and discharge instructions for R302. Facility provided Discharge Instructions for Care for R302, dated 3/6/22. The form is blank and does not include any instructions. The instructions don't indicate where R302 is being discharged too, need for equipment and home health is blank. The discharge summary does not include information about R302's stay at the facility. On 6/21/23 at 11: 35 a.m., Surveyor interviewed Social Worker (SW)-D in regard to R302's discharge. SW- D stated that R302 originally wanted to return to her home but after further evaluation R302 could no longer live there. R302 did not want to move out of state with family. R302 found placement with a friend. Surveyor asked SW- D if she had assisted in setting up home health services for R302 to continue with therapy. SW- D stated that she thought she did but could not remember. SW- D did look into the electronic record and could not find any further documentation about assisting R302 with discharge. SW- D did state that R302's family called after she was discharged to say home health had not been setup. SW- D stated that the nurse that the family talked with then called and made arrangements. SW- D stated that it was the nursing departments responsibility to provide discharge instructions. SW- D stated that she has been spread pretty thin with a large workload and does not have anyone to cover for her when she is not at the facility. On 6/22/23, the facility stated they were able to locate some additional discharge documentation for R302 that had been in medical records. The facility provided a cover page for a fax to Horizon Home Care and Hospice. The fax cover sheet indicated that there was a request for Nursing, PT and OT services and that R302 had discharged from the facility this morning. A discharge instruction for care was also provided that had some information about R302's physical status, equipment and need for physical therapy and a home health aide. The instructions did not include information about a referral being made ahead of time for services to start for R302 on the day she would arrive to her friend's home. There was not a summary of R302's stay or if there were any additional follow-up appointments for R302. There was no information that pharmacy had been contacted regarding medications and did not contain documentation that the physician had written an order for R302's discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not always ensure that they provided care and treatment, based on a comprehensive assessment, for 1 out of 4 residents (R17) reviewed who had a pressure ulcer. * R17 was readmitted to the facility, after being at the hospital for 6 days, and staff stated that R17 had a stage #3 pressure injury to the coccyx. The facility staff did not comprehensively assess the wound upon readmission and did not verify treatment orders with the physician. This wound was discovered on 4/11/23 and the facility did not provide a comprehensive assessment of the wound until 4/18/23. This is evidenced by: Policy Review; Skin Identification, Evaluation and Monitoring revised 11/2022 Purpose: The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion. Procedure: ( includes) Upon admission: The licensed nursing associate: a.) Complete physical skin evaluation, document findings. If skin condition is present on admission: 1.) Initiate protective dressing 2.) Notify health care provider of findings and for further treatment orders 3.) Notification/ Education of resident and resident representative of findings and physician orders 4.) Document evaluation in the medical record R17 was admitted to the facility on [DATE] and went out for surgical repair of femur on 4/5/23. R17 was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated [DATE], indicates that R17 is at risk for developing pressure ulcers/ injuries and does not have any unhealed areas at the time of assessment. R17 does have a surgical wound. R17 has a pressure reducing device for chair and bed. No other treatments or interventions listed. Surveyor conducted a review of R17's plan of care, which indicated that R17 tightly crosses legs and rubs legs together causing bruising and is at risk for pressure ulcers and other skin related injuries due to immobility, hx (history) of pressure wound to coccyx. Updates to interventions on 4/11/23 included pressure reducing mattress on bed, device for wheelchair, treatments as indicated. Skin wound note dated 4/2/23 (prior to hospitalization); R17 being monitored and observed for skin condition of pressure ulcer to coccyx area. R17 is alert. Wound site coccyx had granulated tissue/ redness upon assessment. Stage #2 observed 1.5 cm x 1.5 cm. Writer cleansed with wound cleanser, dried and applied allevyn dressing for protection. 0/10 pain noted to site. To be changed daily or when soiled. Wound care nurse to assess for further evaluation. Wound site has redness and small amount of blood during dressing change. Nursing note from 4/3/23 indicates new pressure ulcer discovered on coccyx. Physician communication note dated 4/4/23- R17 seen by wound NP (Nurse Practitioner) for pressure wound to coccyx- new treatment orders received. The wound physician evaluated R17's wound on 4/4/23 noting it was a suspected deep tissue injury to the coccyx measuring 0.77 centimeters in length by 0.86 centimeters width with 76-100 % eschar and 1-25 % granulation. The new treatment order was to skin prep to peri wound then anasept gel and foam, change daily. R17 was out of facility from 4/5 to 4/11/23 for surgical repair of fx (fracture) femur. Surveyor conducted a review of the facility's skin/ wound tracking report which contained charting from 3/20/23- 6/20/23. The tracking report, dated 4/11/23, indicates that R17 has a stage #3 pressure ulcer to the coccyx. There was no additional information provided about the condition of the wound. It was noted that this entry was for the day R17 was re-admitted to the facility. The Skin Evaluation Form , dated 4/11/23 at 10:39 p.m. states that R17 has a stage #3 pressure injury to the coccyx, measures 3.0 centimeters in length and 3.0 centimeters width. No depth entered. There was no information about tissue type, wound edge, or if there was drainage and it was noted that this entry was written by a LPN and not a registered nurse. Further review of the medical record did not indicate if the physician had been notified of the pressure ulcer and if the wound had been comprehensively assessed by a Registered Nurse. R17's plan of care was updated to state that R17 has impaired skin integrity related to pressure wound to coccyx. There was a start date of 4/11/23 and interventions included cushion for chair, float heels in bed, specialized mattress on bed- low air- loss and setting #2. Nursing note dated 4/14/23 indicates that treatment to coccyx in place. 4/18/23 Physician Communication: R17 seen by wound MD for pressure wound to coccyx- new tx orders received including lab work and Prostat supplement. Surveyor conducted a review of the wound MD progress note, dated 4/18/23. The progress note states that R17 has an unstageable pressure ulcer to the coccyx that measures 0.50 centimeters by 0.46 centimeters and 1-25 % granulation and 51-75 % slough. The new treatment was to cleanse the area with ½ strength Dakins solution, protect periwound with skin prep, cover with foam and change daily. Wound MD progress note dated 4/25/23 states that R17's unstageable pressure ulcer to the coccyx measures 0.51 cm by 0.52 cm with 0.10 depth. Granulation 1-25% and slough 51-75%. periwound is clean, dry and intact. Treatment remained the same. Wound MD progress note dated 5/2/23 indicates that R17's wound to the coccyx is now healed. Treatment is for zinc barrier cream three times daily/ as needed. On 6/22/23 at 11:25 a.m., Surveyor interviewed Administrator- A in regards to R17's pressure ulcer to the coccyx that was noted upon readmission to the facility on 4/11/23. Administrator- A stated that the process for wounds is that if a resident is admitted / readmitted with a pressure ulcer the nurse should do an initial evaluation, initial measurement but should not stage the wound, this should be done by a Registered Nurse. The registered nurse should be alerted and will provide a re-assessment of the area and notify the physician and obtain a treatment. Administrator- A stated that it was an LPN who conducted the admission skin assessment on R17 on 4/11/23. The LPN figured that R17 had an area to the coccyx prior to going out to the hospital and there was a treatment in place at the time so she figured they would just continue the previous treatment orders. R17 was on a bed hold so all the orders were put on hold. The LPN was able to unhold the orders and resume the treatment. Administrator- A stated that the staff must have been confused on what to do and went ahead and staged the pressure ulcer to the coccyx as a Stage 3. Administrator- A stated that the staff should have followed protocol and had an RN assess the area as soon as possible upon readmission to the facility and followed up with the physician to confirm what treatment should have been in place. Administrator- A reviewed the progress of R17's would that was stage 3 on 4/11/23 and then determined to be unstageable on 4/18/23. R17's wound was healed on 5/2/23 and has remained healed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident received needed supervision and assistance to prevent accidents for 2 (R303 and R15) 6 residents reviewed for accidents. *R303 sustained a fall and the facility did not provide an individualized fall intervention. *R15 sustained multiple falls and the facility did not thoroughly investigate the falls to determine a root cause and to establish and provide individualized person centered interventions to prevent potential further falls from occurring. Findings include: The facility policy entitled, Fall Policy with a last approved date of 01/2022 documented, The purposes of this procedure is to provide guidelines for the evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall .The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates .The falls should be reviewed at the Daily Stand-up meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. 1. R303 was admitted to the facility on [DATE] and had diagnoses including Cerebral Infarction due to embolism of right post cerebral artery; Muscle Weakness and Alzheimer's Disease with late onset. R303's Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 06/09/23 documented R303 had a Brief Interview for Mental Status (BIMS) of 4 indicating R303 had severe cognitive impairments and R303 required one-person physical assist with transfers. R303's [NAME] Fall Risk Assessment score dated 06/05/23 was a 24 indicating R303 was at a moderate risk for falls. The facility re-assessed R303 on 06/12/23 and the [NAME] Fall Risk score at that time was 36 indicating R303 was at a high risk for falls. R303's Fall care plan, initiated 06/03/23, documented R303 has potential for falls related to recent admission to community, repeated falls, impaired cognition, poor safety awareness and had interventions including, Keep pathways clear and provide adequate lighting; Keep bed at the appropriate height. Keep personal items within reach. Transfer per intake information .Orient to room and call light. Those interventions have a start date of 06/03/23. An additional intervention was added on 06/15/23 which documented, Offer toileting assistance with rounding. R303's Certified Nursing Assistant care guide documented, Offer toileting assistance with rounding, not dated; and Care Plan: Toileting: I need extensive assistance with 1 person staff .I am incontinent of bladder and bowel, dated 06/03/23. Surveyor noted there was no individualized toileting care plan for R303 in their care plan nor could Surveyor locate a bowel and bladder assessment for R303. Surveyor reviewed R303's Electronic Medical Record (EMR) and noted R303 sustained a fall with no injuries on 06/07/23 at 7:34 AM. Surveyor reviewed R303's fall investigation provided by the facility which documented, Resident found laying between dresser and wheelchair. [sic] States (sex of resident) was trying to find their bike. No new bruises, open cuts or new bruising noted. Vitals WNL (Within normal limits) NP (Nurse Practitioner) [name of NP] notified and daughter [name of daughter] notified. No new orders at this time. This investigation also documented, Appears resident toileted self and fell attempting to sit back in wheelchair. On 06/19/23 at 9:10 AM, Surveyor observed R303 sitting upright in their recliner in room. Surveyor attempted to interview R303, however R303 was difficult to understand and did respond appropriately to questions. On 06/21/23 at 1:42 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who was working on R303's unit. Surveyor asked CNA-I what she does when she rounds. CNA-I informed Surveyor she would lay eyes on the resident and ensure they are safe and ask the residents if their needs are met such as needing water or needing to use the bathroom. Surveyor asked CNA-I if asking residents to use the bathroom was always included in rounding. CNA-I confirmed she would always ask a resident if they needed to use the bathroom while rounding. Surveyor asked CNA-I if there were any residents on the unit she rounds on more frequently than others. CNA-I stated I don't think so. CNA-I stated if a resident used their call light more often she would maybe check on them more frequently. On 06/22/23 at 8:59 AM Surveyor interviewed CNA-J. Surveyor asked CNA-J how often does she round on her residents and what she does when she rounds. Per CNA-J, she tries to round on her residents every two hours. CNA-J stated during her rounds she is checking on the residents and offering toileting/changing briefs if needed and ensuring their needs are met. Surveyor asked CNA-J if toileting needs were considered a normal part of rounding. CNA-J replied yes I offer toileting needs during my regular rounds. On 06/21/23 at 2:02 PM, Surveyor interviewed Register Nurse Unit Manager (RN)-F. Surveyor asked about the fall intervention for R303 of offer toileting during rounds. Per RN-F initially the facility thought R303 could express their toileting needs more often than maybe they were capable of, so the intervention just made staff members more aware. Surveyor asked RN-F if CNA's should offer toileting during their normal rounds. RN-F replied yes. Surveyor asked if there was a bowel and bladder assessment completed on R303 to determine an individualized toileting plan. RN-F was unsure of what Surveyor meant. Surveyor showed RN-F the Bowel and Bladder Assessment option under Assessments in the facility's charting system. RN-F stated he did not think they did that but they will now. Surveyor relayed the concern of not having an individualized fall intervention for R303. Per RN-F the facility staff could do a better job of having more personalized fall interventions. On 06/22/23 at 10:16 AM, Surveyor interviewed RN Director of Quality (RN)-C. RN-C also assist with managing residents. Per RN-C the root cause of R303's fall was going to the bathroom by themselves. RN-C stated at the time R303 had a UTI (Urinary Tract Infection) and was having urgency and frequency and the intervention for the fall was to offer toileting during rounds. Surveyor asked if the CNAs should offer toileting during their normal rounds. RN-C replied yes. Surveyor relayed the concern that offer toileting during rounds did not seem to be a personalized fall intervention, nor an individualized toileting plan. RN-C stated she felt R303 was confused due to the UTI. Surveyor asked if a Bowel and Bladder assessment was completed on R303. RN-C stated there should be one done on admission. At this time, RN-C reviewed R303's EMR. RN-C stated it is in the CNA charting they chart like every two hours for 72 hours after an admission. RN-C was unable to locate the charting. Surveyor asked if the CNAs chart on the resident's toileting/incontinence for 72 hours who assesses that information? RN-C asked if she could get back to Surveyor. As of surveyor exit, RN-C did not provide Surveyor with any additional information. On 06/22/23 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor explained the concern of a lack of an individualized fall intervention and a lack of appropriate assessments related to the fall. Surveyor asked for any additional information. 2. R15 was currently admitted to the facility on [DATE] with diagnoses including, major joint replacement, infection following a procedure, weakness, unsteadiness on feet and Alzheimer's disease. R15's admission Minimum Data Set Assessment (MDS) dated [DATE] documented R15 had Brief Interview for Mental Status (BIMs) of 15, indicating R15 was cognitively intact; R15 had falls prior to facility admission and R15 required extensive assist of 1 staff for toileting and transfers. R15's fall care plan with a start date of 2/20/23 documented, R15 is at high risk for falls related to recent admission to community, immobility, debility, dementia and falls on 2/27/23 and 03/01/23 and 04/29/23, interventions included, Keep pathways clear and provide adequate lighting. Keep bed in the lowest position when resident is laying down. Keep personal items within reach. Transfer intake per therapy .Orient to room and call light; those interventions had start dates of 02/20/23. Scoop Mattress intervention had a start date of 03/01/23; Ask resident to use the toilet during every interaction on NOC (night) shift had a start date of 04/29/23; Education provided to resident on using call light for safe transfers and staff to offer toileting during rounds when awake had a start date of 4/23/23 (Surveyor noted this intervention was not on R15's care plan when surveyor first reviewed the care plan on 06/19/23. This intervention had a created date of 06/21/23) and Anti-rollback bar applied to w/c (wheelchair) had a start date of 06/01/23. (Surveyor noted this intervention was not on R15's care plan when Surveyor first reviewed the care plan on 06/19/23. This intervention had a created date of 06/21/23.) R15's discontinued physician's orders included, Tylenol PM Extra Strength 25 mg (miligrams)-500 mg tablet [Diphenhydramine-acetaminophen]; Pain. This order had a start date of 02/26/23 and a stop date of 06/13/23. R15's Certified Nursing Assistant care guide documented, I am incontinent of bladder and bowel. Surveyor could not locate above mentioned fall interventions on the CNA care guide. Surveyor noted there was no individualized toileting care plan nor could Surveyor locate a bowel and bladder assessment. R15's [NAME] fall risk assessment completed on 02/20/23 documented a score of 9, indicating R15 was at a high risk for falls. Surveyor noted R15 sustained the following falls: On 02/27/23 at 1700 (5:00 PM), R15 had an unwitnessed fall with head injury noted. R15 was sent to the hospital. Surveyor reviewed the fall investigation provided by the facility which documented R15 was attempting to self-transfer into bed. There was no intervention mentioned on the investigation. R15 had a bump on their head and returned from the hospital that same day. On 03/01/23 at 2:45 AM, R15 had an unwitnessed fall. Surveyor reviewed the fall investigation provided by the facility which documented R15 was found on the floor and just pointed to the wall stating, I don't know, look over there. The root cause for this fall was documented as Alzheimer's/confusion. On 04/23/23 at 2:50 PM, R15 had an unwitnessed fall. Surveyor reviewed the fall investigation provided by the facility which documented R15 was self-transferring to the toilet. New intervention was education on using call light for safe transfers and staff to offer toileting. On 04/29/23 at 5:10 AM, R15 had unwitnessed fall. Surveyor reviewed the fall investigation provided by the facility which documented R15 was self-transferring to the toilet to have a bowel movement. The new intervention was resident will be asked to use toilet during every round on NOC (night) shift. On 06/01/23 R15 had a witnessed fall in lounge area while doing a puzzle. Surveyor reviewed the fall investigation provided by the facility which documented R15 slid out of the chair while attempting to sit back down. The intervention was to apply anti-roll back bar to wheelchair. Surveyor did not identify concerns with this fall. Although the anti-roll back intervention was not care planned timely, Surveyor's investigation showed the anti-roll backs were applied to the wheelchair timely. On 06/19/23 at 9:38 AM, Surveyor observed R15 in their room sitting in their wheelchair doing a word search. Surveyor attempted to interview R15 who is hard of hearing. Even with Surveyor speaking loudly, R15 was not answering questions appropriately. On 06/21/23 at 1:42 PM, Surveyor interviewed CNA-I who was working on R15's unit. Surveyor asked CNA-I what she does when she rounds. CNA-I informed Surveyor she would lay eyes on the resident and ensure they are safe and ask the residents if their needs are met such as needing water or needing to use the bathroom. Surveyor asked CNA-I if asking residents to use the bathroom was always included in rounding. CNA-I confirmed she would always ask a resident if they needed to use the bathroom while rounding. Surveyor asked CNA-I if there were any residents on the unit she rounds on more frequently than others. CNA-I stated I don't think so. CNA-I stated if a resident used their call light more often she would maybe check on them more frequently. On 06/22/23 at 8:59 AM Surveyor interviewed CNA-J. Surveyor asked CNA-J how often does she round on her residents and what she does when she rounds. Per CNA-J, she tries to round on her residents every two hours. CNA-J stated during her rounds she is checking on the residents and offering toileting/changing briefs if needed and ensuring their needs are met. Surveyor asked CNA-J if toileting needs were considered a normal part of rounding. CNA-J replied yes I offer toileting needs during my regular rounds. On 06/21/23 at 2:02 PM, Surveyor interviewed Register Nurse Unit Manager (RN)-F. Surveyor asked RN-F if CNA's should offer toileting during their normal rounds. RN-F replied yes. Surveyor asked about R15's falls and the two interventions that mention to offer toileting with rounding. Surveyor relayed the concern of not having an individualized fall intervention for R303. Per RN-F the facility staff could do a better job of having more personalized fall interventions. RN-F did not have any additional information related to R15's falls. On 06/22/23 at 10:28 AM, Surveyor interviewed Director of Quality, Registered Nurse (RN)-C. RN-C also assists with managing resident care. Surveyor asked RN-C about R15's fall on 2/27/23 and what the root cause was and what the intervention was. Per RN-C, the previous DON (Director of Nursing) was doing the fall interventions at that time. RN-C reviewed R15's fall investigation and informed Surveyor after dinner R15 wheeled herself back to her room and self-transferred to bed. Per RN-C nobody has care planned the intervention of having R15 do puzzles after dinner which is what we have been doing, but nobody care planned it. Surveyor noted there were no new care planned interventions after this fall (such as having R15 do puzzles after dinner) and no documentation the root cause was assessed besides self-transferring to bed. Surveyor asked RN-C about R15's fall on 03/01/23. Surveyor asked what the root cause was and what the intervention was. Per RN-C, R15 fell at 2:45 AM and R15 said they were confused. RN-C stated R15 didn't know what they were doing and pointed towards the wall. Surveyor asked if anyone assessed the reason for the confusion. Per RN-C said they thought it had to do with the surgical infection and/or pain. RN-C stated we ended up scheduling the (regular) Tylenol after that fall. Surveyor asked if anyone did a medication review to look for possible medications that could contribute to a fall. Surveyor brought up the concern of R15 taking scheduled Tylenol PM and asked if anyone thought maybe the Tylenol PM could have contributed to the confusion. RN-C informed Surveyor she could not say, because the previous DON was doing the fall investigations at that time. RN-C thought the Nurse Practitioner (NP) was aware of the Tylenol PM and wanted to keep that medication in addition to scheduling regular Tylenol throughout the day. Per RN-C a scoop mattress was placed on R15's bed. Surveyor asked if anyone assessed toileting needs related to this fall. RN-C stated she was not sure because the previous DON was managing the falls at that time. Surveyor asked RN-C about R15's fall on 04/23/23. Surveyor asked what the root cause was and what the intervention was. Per RN-C, R15 fell at 14:50 (2:50 PM), attempting to self-transfer to the toilet. RN-C stated the intervention was to offer toileting during rounds and encourage to use the call light. Surveyor asked if a bowel and bladder assessment had been done to assess individual toileting needs. RN-C stated she would have to check. Surveyor asked if CNAs are supposed to offer toileting with rounding routinely? RN-C stated yes the staff should offer toileting with rounding. Surveyor asked if staff are already offering toileting with rounding how is an intervention of offer toileting with rounding new and/or individualized person centered? Per RN-C, fall interventions were not supposed to be too detailed or personalized because it is too hard to have staff follow through. Surveyor asked about the conflicting start date of this intervention on R15's care plan, which was documented as 04/23/23, and the created date which was documented as 06/21/23. RN-C stated you can change the start date on the care plan. Per RN-C she was certain the intervention was documented in R15's care plan previously, but she did not know where it went to. RN-C stated she did add the intervention into R15's care plan the day before, on 06/21/23, but reiterated she thought someone had entered the intervention into R15's care plan at the time of the fall investigation and thought maybe somehow it got erased. Surveyor informed RN-C the intervention was not on R15's care plan upon Surveyor's initial review. Surveyor asked RN-C about R15's fall on 04/29/23. Surveyor asked what the root cause was and what the intervention was. Per RN-C, R15 fell at 5:10 AM while self-transferring to have a bowel movement. RN-C stated the intervention was to ask for toileting during each round during night shift. Surveyor asked if the medications were looked at as being a fall risk? Surveyor explained R15 was still taking the Tylenol PM and asked if that medication had been addressed as a possible fall risk. Per RN-C she was not certain, and she would have to look at the NP's notes to see if the medication was addressed. Surveyor expressed the concern that R15 had fallen twice during night shift while taking Tylenol PM and the facility had not addressed that as a possible contributor to R15's falls. Surveyor asked for any additional information on R15's falls and what the facility may have done/assessed to create a safe environment for R15. RN-C did not provide Surveyor with any additional information. On 06/22/23 at 11:35 AM, Surveyor interviewed NP-G. Surveyor asked about R15 taking the Tylenol PM. NP-G stated she discontinued the medication when she received the pharmacy recommendation to discontinue it. NP-G was not certain when that was. Surveyor stated the medication was discontinued in June 2023. Per NP-G she thought she had discontinued it sooner but she was uncertain. Surveyor asked NP-G if Tylenol PM could contribute to confusion and falls in the elderly. NP-G stated yes, it can cause drowsiness which is why people take it but that can lead to confusion. Surveyor asked if the facility had ever asked her, NP-G, to address the Tylenol PM in relation to R15's falls. NP-G stated no, the facility never mentioned the medication in relation to R15's falls. On 06/22/23 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor explained the concern of a lack of investigation into the root causes of R15's falls including a lack of assessments such as bowel and bladder and a medication assessment, and a lack of individualized fall interventions. Surveyor asked for any additional information. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility did not always ensure that 2 out of 2 residents ( R17, R34) who were at nutritional risk had a nutrition risk assessment received the proper assessment and care planning to help maintain acceptable parameters of nutritional status. * The facility conducted a nutritional risk assessment for R17 upon re-admission on [DATE]. The assessment indicated R17 weighed 94.2 pounds and weights were stable. The assessment indicated R17 was at risk for unintended weight loss and should be weighed weekly. R17 was noted to have a 7.7 % weight loss in 1 month (May 11- June 13, 2023). The facility did not update R17's plan of care to reflect the significant weight loss and provide additional interventions to avoid further weight loss from occurring. * The facility conducted a nutritional risk assessment for R34 upon her admission dated 3/23/23. The assessment indicated R34 weighed 141.2 pounds and was at risk for unintended weight loss, there were no interventions listed. R34 was noted to have lost 7.8 % of her weight in the last month and 14.73 % in the last 3 months. The facility did not update R34's plan of care to reflect the significant weight loss and provide additional interventions to avoid further weight loss from occurring. This is evidenced by: Review of facility policy Weight Monitoring, last revised on 01/2023. Policy statement: It is the policy of Ascension Living that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5 % in 90 days, or 10% in 180 days. Policy interpretation and implementation (includes): B). Residents with a weight change of 5 pounds or greater should be reweighed to determine an accurate weight. The accurate weight should be entered into the resident's medical record. E.) The RD (Registered Dietician) should make recommendations for nutritional interventions based on the information obtained from the weekly Resident at Risk Review huddle meetings. RD recommendations should be reviewed and initiated by nursing associates. 1. R17 was admitted to the facility 3/2/23 and went out for surgical repair of the femur on 4/5/23. R17 was readmitted to the facility on [DATE] with diagnosis that included major joint replacement, chronic obstructive pulmonary disease, hyperlipidemia, panic disorder, unsteadiness on feet and need for assistance with personal cares. A review of the admission MDS (Minimum Data Set), dated 3/8/23 indicates that R17 weighed 94 pounds and has not had any weight loss or weight gain. R17 is also noted to not have a swallowing disorder. Surveyor conducted a review of R17's plan of care with a start date of 4/11/23. R17 is at nutritional risk due to being underweight and being at risk for malnutrition. Interventions include to monitor weight monthly, meal intake is monitored daily and offered supplements as prescribed by physician. The facility conducted a re-admission Nutrition Risk Assessment, dated 4/13/23. The assessment indicates that R17 has a current weight of 94.2 pounds and weight trend for the last 6 months is stable. R17 is being observed and monitored for the orthopedic condition of fracture left femur status post nailing. R17 was visited on 3/9/23 and reports good appetite. R17 thinks weight has been stable but states has not been weighed. Usual body weight 120-122 pounds. R17 does not take nutritional supplement. 8-ounce chocolate Ensure Enlive twice daily ordered. Intake fair 50-75%, no current weight available. weight on 3/10/23 94.2 # (pounds), BMI 16.2 below normal. Stage 3 coccyx wound. Registered Dietician previously added nutritional supplement since has very low body weight and fracture diagnosis. Continues to be beneficial for wound healing. Continue supplement as ordered. Surveyor conducted a review of R17's weights that are documented within the electronic medical record. The following was noted: 4/17/23 97.8 # 5/11/23 88.20 # 5/25/23 97.4 # 6/8/23 64.20 # variance 1 month -27.21% 6/13/23 81.40 # variance is 7.7% 1 month ago (5/11 to 6/13/23) Nutrition Note dated 4/26/23: Nutrition Follow-up. Weight gain. R17 admitted after hip fx and L hip ORIF. Has coccyx unstageable wound .5 x .5 cm. Height 64 inches weight 97.8 # BMI 16.8 underweight. UBW 120-122 pounds previously reported. Continue 8oz. ensure Enlive BID (2 times a day) for healing of fracture and underweight status. Nutrition follow-up note dated 5/5/23: Notified of coccyx wound, unstageable resolved. HX of leg surgical wound. R17 is provided with Ensure Enlive BID. Has history of weight loss and low BMI. Recommended d/c prostat supplement. Continue ensure Enlive. Nursing note dated 5/9/23; New order from dietary recommendation signed by NP (Nurse Practitioner), discontinue prostat 30 ml daily. Nutrition follow-up note dated 6/15/23; Weight on 6/13/23 81.4 # compared to 97.4 on 5/25/23 and 92.4 on 3/18/23. Significant loss in last month down 16.5 %. Recent UTI. Increased confusion noted. HX low BMI. Skin tears. has been receiving 8oz chocolate ensure Enlive TID. accepting nutritional supplement based on MAR. Continue supplement as ordered. On 06/21/23 at 01:15 p.m., Surveyor observed that R17 was asleep in the wheelchair in room. Supplement is opened, on table with straw. On 6/21/23 at 2:55 p.m., Surveyor interviewed Registered Dietician (RD)- L via telephone regarding R17's weight loss. RD-L stated that she is physically in the building one day a week but has almost daily communication with staff via email or phone calls. RD- L stated that she will run weight loss reports as well as communicates with the certified dietary manager. RD- L stated that she will document weekly for those residents who have wounds as well as significant weight concerns. Surveyor asked RD- L about R17's weight loss. RD- L stated that she had previously reviewed [R17's] chart in anticipation of being interviewed by the surveyor and questioned if [R17's ] weights were documented correctly. RD- L stated she also wondered if [R17] was dehydrated. RD- L stated she will request a re-weight on a resident if the weight seems to be inaccurate. Surveyor asked RD- L if she had requested a re-weight on R17. RD- L stated she could not recall requesting another weight. RD- L stated [R17's] wound did heal so they discontinued the pro-stat. Surveyor asked RD- L if there was any further assessment of R17 and any additional interventions put into place to help R17 maintain nutritional parameters. RD- L stated no additional interventions were put in place. Surveyor asked if RD- L reviews any additional information besides the documented weights. RD-L stated she used to review the daily intakes (food and supplement) when the staffing situation was better. RD- L reported when the facility was not short on staffing the aides would be better at documenting on the intakes. RD- L stated this no longer happens consistently so she will just talk with staff instead. On 06/22/23 at 09:40 AM, Surveyor interviewed LPN -N who stated [R17] gets tired a lot, just like most of the residents do .when she (R17) is tired, she really doesn't want anything to do with the food .when she is feeling better, she will eat. [R17] will drink her supplements at times .is not aware of any food complaints from [R17]. On 06/22/23 at 10:11 AM Surveyor interviewed Administrator- A regarding R17's weight loss. Administrator- A stated that they don't believe [R17] has lost weight and that the weights had been taken inaccurately. [R17] was using different chair types (broda, high back) over the last month and it's possible the staff did not properly deduct the chair weight. On 6/22/23 at 3:00 p.m., Surveyor asked Administrator- A, for the 3rd time, to provide Surveyor a copy of R17's meal and supplement intakes. As of the time of exit, Administrator A did not provide any evidenced that the staff was monitoring R17's meal intake per the plan of care. Surveyor reviewed a Dietary Follow up note, dated 6/22/23 at 10:26 a.m.; Weight recheck of 86.4# 6/22/23 showing a weight change of 11% loss in the last month. Down from 97.4#. Recent urinary tract infection, BP noted. Have discussed this weight change with certified dietary manager who will update care plan to encourage fluid intake. R17's representative has also asked for cranberry tablet to be added. As of the time of exit, the facility did not provide additional information as to why they did not address R17's (potential) significant weight loss by re-assessing R17 and making sure the documented weights were accurate. The facility did not include additional interventions to assist in R17 maintaining her nutritional parameters. 2. R34 was originally admitted to the facility on [DATE] with diagnosis that included Aphasia, weakness, anxiety disorder, Hyperlipidemia, legal blindness and major depressive disorder. Surveyor reviewed R34's medical record and noted the following: The admission MDS (Minimum Data Set), dated 3/23/23 indicates that R34 weighed 141 # (pounds) and did not have any weight loss or gain during the assessment reference period. R34 is also documented to not have any swallowing disorders. The facility conducted a Nutrition Risk Assessment- new admission, dated 3/23/23. Diet order- unknown, no fluid restrictions, food preferences obtained. R34 is independent with eating and the current weight 141.20 pounds. BMI 26- overweight. R34 admitted for rehab. R34 denies having difficulties with chewing or swallowing or malnutrition. R34 denies having any allergies to food. R34 avoids sausage and oatmeal at breakfast. Likes decaf coffee and cranberry juice with meals. Appetite has improved, R34 reports that she lost 30 pounds while in hospital. MNA score is 6, triggers for malnutrition. Comments/ recommendations: Diet no specific order, on regular diet. No record of intake. Height 62 weight 141.2 #. BMI 26 overweight. No chewing or swallowing problems identified. Reported a 30# weight loss during hospital stay is on diuretics', may have been fluid related. Fair intake per certified dietary manager report. No labs. Will monitor intake, weight. The Facility conducted a re-admission nutrition risk assessment on 4/13/23. R34 on regular diet. No chewing or swallowing problems identified. Appetite reported as good. 8oz. chocolate ensure enlive ordered BID (2 times a day). Intake fair 50- 75%. height 64 inches, no current weight available, R34 thinks weight might be stable. RD (Registered Dietician) previously added nutritional supplement since has very low body weight and fx. diagnosis. Continues to be beneficial for wound healing. Continue supplement as ordered. Surveyor conducted a review of the weights documented for R34 in the electronic medical record: The following was noted: 6/14/23 120.4 -7.8 % variance 1 month 14.73 % in 3 months 6/7/23 126.6 5/31/23 130.2 5/17/23 129.2 5/10/23 130.6 5/3/23 129.62 4/19/23 no data 4/12/23 135.2 4/8/23 133 4/7/23 138 3/29/23 135.6 3/22/23 141.2- conformed 3/20/23 141.2 Nutrition follow-up note dated 4/17/23; gangrene of right and 2nd toes. Tolerating regular diet. Mild weight loss of 4% in last month. Not significant. No new recommendations related to wounds/ gangrene of toes. Nutrition follow-up note dated 4/26/23; Weight down 6 # since admission from 141.2# on 3/20/23 to 135.2# on 4/1/23. Diet regular. Limited record of intake but intake looked to be poor on 4/7/23. Fair intake at time of initial assessment. Does have medical diagnosis of protein calorie malnutrition. Is on lasix diuretic. Will provide order for 8 oz. Ensure Enlive twice daily. Nursing note dated 5/1/23- New order from dietary recommendation signed by NP. 8 oz ensure Enlive am, pm. Nutrition follow up note dated 5/5/23; Hx Atherosclerosis and PVD. Notified of gangrene right great toe and right 2nd toe. Also had a 5.8% weight loss in last month (significant loss in last month) . Weight 129.6# 5/3/23 compared to 138# on 4/7/23 and 141.2# on 3/20/23. Usual weight unknown to resident. Ensure Enlive BID started 5/1/23. Spoke to R34 and nurse. R34 was eating poorly when first got here. Doing better with eating now that getting up more but does not always finish meals or take supplement per nurse report. C/O upset stomach. Prefers the Strawberry Ensure supplement now. Had liked the chocolate supplement at first but that upset her stomach. Is also on diuretic Lasix. Weight loss may be related to poor to fair intake. Continue supplement ordered. Nutrition follow-up note, dated 5/10/23; Gradual weight loss. Current weight 129.6# on 5/3/23 down 5.8% from 138# on 4/7/23. Gangrene of right toes. This RD recently visited R34. History of upset stomach. Did not always finish meal trays or take the regular Ensure Enlive supplement. MD initiated Ensure clear BID on 5/8/23. No new recommendations. Nutrition follow-up note dated 5/31/23; Notified of gradual weight loss. Weight 129.2# on 5/17/23. Takes Ensure clear twice daily. Signed on medication record takes supplement most of the time. Refused on 5/22/23. Continue supplement as ordered. Nutrition follow-up note dated 6/2/23; Weight loss and has right great toe and 2nd toe with gangrene. 7.8 % weight loss in 3 months. Weight 130.2# compared to 141.2 # on 3/20/23. R34 eating lunch at time of visit. Also spoke with nurse on duty. Afraid to eat. Does not like items if too sweet. Disliked the cranberry juice too sweet. Afraid to eat the grille sandwich. States would take strawberry Ensure. Is currently getting Ensure clear BID since May 8. Will double check with MD as previously recommended the strawberry Ensure. Nursing note dated 6/8/23; New order signed by NP due to dietary recommendation. Discontinue ensure clear. Please send strawberry ensure Enlive bid. Follow-up nutrition note dated 6/12/23; notified of gangrene right first and second toes no changes. Now on 8 oz. strawberry ensure Enlive twice daily. History weight loss and afraid to eat, dislikes if too sweet. No longer on Ensure clear or chocolate Ensure Enlive. Continue supplement as ordered. Surveyor conducted review of the plan of care for R34. The plan indicates that R34 has at nutritional risk due to triggering for malnutrition. R34 will receive adequate nutrition, and hydration through next review. POC developed on 3/17/23 and last updated on 3/23/23. R34's weight to be monitored monthly, meal intake monitored daily. The plan of care states that R34 needs no assistance with eating, staff support with set-up. Further review of the plan of care did not indicate that R34 was now experiencing significant weight loss, fear of eating, a change in dietary preferences and receiving a supplement twice daily. On 6/21/23 at 2:55 p.m., Surveyor interviewed Registered Dietician (RD)- L via telephone regarding R34's weight loss. RD-L stated that she is physically in the building one day a week but has almost daily communication with staff via email or phone calls. RD- L stated that she will run weight loss reports as well as communicates with the certified dietary manager. Surveyor asked RD- L about R34's weight loss and if RD- L had re-assessed R34. RD- L stated that R34 had complained that some of supplements were too sweet so they did change the flavor of supplement being offered. RD- L stated that R34 preferred the strawberry flavor and that is what she is currently receiving. Surveyor asked RD- L if she had followed up on the statement that R34 made about being afraid to eat. RD- L stated she did not but would not want to restrict R34's diet. RD- L stated she is not sure what the cause would be for R34 to state she was afraid to eat. RD-L stated that she has not put additional interventions in place for R34 besides the changes in flavor of the supplement. On 6/21/23 at 3:30 p.m., Surveyor asked Administrator- A, for the 3rd time, to provide Surveyor a copy of R34's meal and supplement intakes. As of the time of exit, Administrator A did not provide any evidenced that the staff was monitoring R34's meal intake per the plan of care. On 06/22/23 at 09:35 AM, Surveyor interviewed LPN- N regarding R34 food and supplement intake. LPN- N stated that it depends on the day, someday's she will take supplements. R34's family has had some health issues, and this is upsetting to R34. R34's mood will go down and she just wants to be left alone. Staff must keep encouraging R34 and if she is in the mood she will eat. She has been on a soup phase. R34 also gets ensure and will drink most of this. As of the time of exit, the facility did not provide additional information as to why they did not address R34's significant weight loss by re-assessing R34 . The facility did not include additional interventions to assist in R34 maintaining her nutritional parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure the physician reviewed the pharmacy recommendation timely for 1 (R15) of 5 residents reviewed for pharmacy recommendations. * R15's pharmacy recommendation from 02/11/23 recommended discontinuing R15's Tylenol PM. The same recommendation was made on 2/25/23, 3/6/23, 4/3/23, 5/1/23 and 6/5/23. R15's medical record did not contain documentation the physician was made aware of this recommendation. Findings include: Facility policy entitled, Procedure: Medication Regimine [sic] Review for Nursing, last approved on 09/2022, documented, .The pharmacist reports any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing, and these reports are acted upon in a manner that meets the needs of the residents .C. For non-urgent recommendations, the facility and the Attending Physician must address the recommendations in a timely manner that meets the needs of the resident-but no later than their next routine visit to assess the resident-and the Attending Physician should document in the medical record: 1. What irregularity has been reviewed 2. What action has been taken to address the issue 3. The pharmacy recommendation itself can be used as a tool to document . R15 was originally admitted to the facility on [DATE] and then returned to the hospital on [DATE]. R15 was re-admitted to the facility on [DATE] with diagnoses including, Major Joint replacement, infection following a procedure, weakness, unsteadiness on feet and Alzheimer's disease. R15's discontinued physician's orders included, Tylenol PM Extra Strength 25 mg (milligrams)-500 mg tablet [Diphenhydramine-acetaminophen]; Pain. This order had a start date of 02/26/23 and a stop date of 06/13/23. Surveyor reviewed R15's Electronic Medical Record (EMR) for pharmacy recommendations. Surveyor noted every month since R15's admission in February 2023 there was a progress note from the pharmacist documenting a possible irregularity. Surveyor could not find documentation in R15's medical record as to what the irregularity was and if a physician had addressed it. On 06/20/23, Surveyor received the monthly pharmacy recommendations for R15's stay at the facility from Nursing Home Administrator (NHA)-A. Surveyor reviewed the recommendations and noted the following: On 02/11/23 the pharmacist documents, Resident receives a Beers Criteria Antihistamine, diphenhydramine (as Tylenol PM). Due to the anticholinergic and sedative effects of this medication, it is typically not recommended in the elderly when alternatives are available. Please consider conversion of this agent to Trazadone 50mg QHSPRN (At hour of sleep as needed) OR Please consider discontinuation of this agent if possible. There was no physician documentation on the pharmacy recommendation document or elsewhere. On 2/25/23 the pharmacist documents, Resident receives a Beers Criteria Antihistamine, diphenhydramine (as Tylenol PM). Due to the anticholinergic and sedative effects of this medication, it is typically not recommended in the elderly when alternatives are available. Please consider conversion of this agent to Trazadone 50mg QHSPRN (At hour of sleep as needed) OR Please consider discontinuation of this agent if possible. There was no physician documentation on the pharmacy recommendation document or elsewhere. On 3/6/23 the pharmacist documents, Resident receives a Beers Criteria Antihistamine, diphenhydramine (as Tylenol PM). Due to the anticholinergic and sedative effects of this medication, it is typically not recommended in the elderly when alternatives are available. Please consider conversion of this agent to Trazadone 50mg QHSPRN (At hour of sleep as needed) OR Please consider discontinuation of this agent if possible. There was no physician documentation on the pharmacy recommendation document or elsewhere. On 04/03/23 the pharmacist documents, Resident receives a Beers Criteria Antihistamine, diphenhydramine (as Tylenol PM). Due to the anticholinergic and sedative effects of this medication, it is typically not recommended in the elderly when alternatives are available. Please consider conversion of this agent to Trazadone 50mg QHSPRN (At hour of sleep as needed) OR Please consider discontinuation of this agent if possible. There was no physician documentation on the pharmacy recommendation document or elsewhere. On 05/01/23 the pharmacist documents, Resident receives a Beers Criteria Antihistamine, diphenhydramine (as Tylenol PM). Due to the anticholinergic and sedative effects of this medication, it is typically not recommended in the elderly when alternatives are available. Please consider conversion of this agent to Trazadone 50mg QHSPRN (At hour of sleep as needed) OR Please consider discontinuation of this agent if possible. There was no physician documentation on the pharmacy recommendation document or elsewhere. On 06/05/23 the pharmacist documents, Resident receives a Beers Criteria Antihistamine, diphenhydramine (as Tylenol PM). Due to the anticholinergic and sedative effects of this medication, it is typically not recommended in the elderly when alternatives are available. Please consider conversion of this agent to Trazadone 50mg QHSPRN (At hour of sleep as needed) OR Please consider discontinuation of this agent if possible. There was no physician documentation on the pharmacy recommendation document or elsewhere. On 06/20/23 at 3:05 PM, Surveyor interviewed NHA-A and asked how the facility processes the medication reviews? Per NHA-A, the pharmacists email the recommendations to the managers, DON (Director of Nursing) and me. NHA-A stated the DON is responsible for notifying the physician but with the interim DON, RN-C is responsible. Per NHA-A the pharmacy gets a summary back once the physician has reviewed it. Surveyor relayed the concern of the same recommendation for R15 for five months and asked if there was any additional information. On 06/21/23 at 10:55 AM, Surveyor interviewed RN-C. RN-C informed Surveyor normally the pharmacy will send the recommendations via email to herself, the DON, and the other clinical manager. Per RN-C, the previous DON would print the recommendations out and put them in the physician's folders. RN-C stated after the physician reviews them, the recommendations go to the other unit manager or herself to follow through. RN-C stated she had spoken with the interim DON, DON-B, who is still following that process. RN-C did not have information on R15's pharmacy recommendations and directed Surveyor to speak with DON-B. On 06/21/23 at 3:01 PM, Surveyor interviewed DON-B. DON-B confirmed she is responsible for the pharmacy recommendations. Per DON-B she prints them out and places them in Nurse Practitioner (NP)-G's or the physician's folder. DON-B stated she does not receive the recommendations back; they go to the unit manager and then are scanned into the resident's medical records. Per DON-B the recommendations should be addressed within 30 days unless it is an urgent recommendation. Surveyor asked about R15's pharmacy recommendations from 02/23-06/23 documenting the same recommendation. DON-B stated she would not know since she started in late April. DON-B informed Surveyor she was aware of the recommendation to discontinue the Tylenol and had taken care of that recommendation in either May or June. Per DON-B NP-G discontinued that order. DON-B stated she could not answer to what happened prior to her being employed at the facility. On 06/22/23, NHA-A provided Surveyor with a copy of R15's pharmacy recommendation from 03/06/23. On this copy there was a handwritten note on the bottom stating, PT (patient) says still effective for sleep/continue for now. Surveyor cannot make out the signature and it was not dated. NHA-A informed Surveyor, the physician did address the recommendation and wanted to keep the medication. Per NHA-A, the physician had emailed this back to the previous DON but was not sure where it went after it was emailed to the DON. NHA-A stated the previous DON left and it just remained in her emails. No information was provided as why the recommendation was not addressed in April or May. On 06/22/23 at 11:35 AM, Surveyor interviewed NP-G. NP-G stated she has been working at the facility for over a year and just last month started receiving the pharmacy recommendations. Per NP-G she could see the pharmacist notes in the resident's EMRs but was unable to see the recommendations. Surveyor asked about R15's recommendation to discontinue the Tylenol PM. Per NP-G when she was made aware of the pharmacy recommendation, she discontinued that medication right away. NP-G was unaware if the medication had been addressed previously. On 06/22/23 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor explained the concern of the physician not addressing the same pharmacy recommendation for five months. Surveyor explained the pharmacy never received the recommendation from March 2023 which had the physician documenting the rationale for keeping the medication, which is part of the medication review process. No additional information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R15) of 5 residents on psychotropic medications received the necessary behavior monitoring. * R15 received two anti-depressants without monitoring for effectiveness. Findings include: Facility policy entitled, Behavioral Assessments, Intervention and Monitoring, last approved on 01/2022 documented, .Residents with behavioral expressions and those on a psychotropic medication will have their behaviors monitored routinely. R15 was originally admitted to the facility on [DATE] and then returned to the hospital on [DATE]. R15 was re-admitted to the facility on [DATE] with diagnoses including, Major Joint replacement, infection following a procedure, Alzheimer's disease and depression. R15's admission Minimum Data Set Assessment (MDS) dated [DATE] documented R15 had Brief Interview for Mental Status (BIMs) of 15, indicating R15 was cognitively intact; R15's mood was not assessed and R15 received an antidepressant seven out of the last seven days. R15's Psychotropic Drug use care plan, dated 02/20/23, documented, R15 has potential for drug related complications associated with use of psychotropic medications related to Antidepressant use, and had interventions including, .Monitor for target behaviors/symptoms and document per facility protocol .Monitor for increase in depressive/behavior symptoms and document PRN interventions as appropriate. R15 had the following active physician orders: Bupropion (Wellbutrin) HCL 150 mg (Miligrams) tablet 12hr (hour) sustained release for depression. Sertraline (Zoloft) 100mg tablet every day for depression. Surveyor could not locate behavior monitoring nor documentation of specific behaviors/interventions in R15's Electronic Medical Record (EMR). On 06/21/23 at 8:37 AM, Surveyor interviewed Social Worker (SW)-D. SW-D informed Surveyor if a resident comes into the facility on a psychotropic medication she would care plan it and then nursing is supposed to monitor for mood/behaviors and if there are any concerns nursing would reach out to the physician/Nurse Practitioner. On 06/21/23 at 8:57 AM, Surveyor asked SW-D if R15 had any behavior monitoring in place. SW-D reviewed R15's EMR and stated, R15 is on Zoloft and Wellbutrin, [R15] is on two antidepressants. Per SW-D she did not see the behavior monitoring and stated she would add that to her list of things to do. On 06/21/23 at 2:11 PM Surveyor interviewed Unit Manager, Registered Nurse (RN)-F. RN-F informed Surveyor there should be behavior monitoring in progress notes and there should be an order on the Electronic Medication Administration Record (EMAR). Surveyor questioned why R15 did have orders for behavior monitoring. RN-F did not have an answer. On 06/22/23 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor relayed the concern of the lack of behavior/mood monitoring for R15's antidepressant medication. No additional information was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. R15 was admitted to the facility on [DATE] with diagnoses including, major joint replacement, infection following a procedure, weakness, unsteadiness on feet, depression and Alzheimer's disease. R15's admission Minimum Data Set Assessment (MDS) dated [DATE] documented R15 had Brief Interview for Mental Status (BIMs) of 15, indicating R15 was cognitively intact; R15 required extensive assist of 1 staff for toileting and transfers. Section D which assesses Mood documented R15 should have a mood interview conducted however the assessment is blank besides a 0 documented for trouble sleeping. Section G which assesses function status documented an 8, meaning activity did not occur during the lookback period for dressing, eating and personal hygiene and documented a 7, meaning occurred once during the look back period, for toileting. A review of progress notes during that time did not indicate these activities did not occur. R15's Quarterly MDS, dated [DATE], documented a BIMS should be conducted for R15 however the assessment is blank. Section D which assesses Mood documented R15 should have a mood interview conducted however the assessment is blank. On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding the missing BIMS, Mood and inaccuracies in Functional Status. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS and that they should have been completed. MDS Supervisor-E identified that the BIMS and Mood sections are typically completed by Social Worker-D and she did not complete the sections on time. Surveyor asked MDS Supervisor-E if she was aware of any other sections not being completed accurately and MDS Supervisor-E stated that she has noticed that other resident MDS's have not been completed as well. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. Surveyor asked where the information is being pulled from to be used in Section G: Functional Status. MDS Supervisor-E stated that she is pulling the information from CNA (Certified Nursing Assistant) charting and therapy notes however, if the CNA does not document daily there is no information to pull from and she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents and she stated, Correct. If there is no documentation, then I just code an 8. Surveyor asked MDS Supervisor-E how care plans are developed if the MDS has inaccurate assessments. MDS-Supervisor explained that care plans are developed by the interdisciplinary team, and they base care plans off the MDS information. MDS Supervisor will fill in any gaps in care plans and so will the nursing managers. On 06/20/23, at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that he was just made aware of the BIMS not being completed a few weeks ago. NHA-A stated that he was made aware after he was contacted by the State Agency Regional Field Operations Director. NHA-A stated that MDS supervisor-E was closing out the MDS so that they would be timely. NHA-A informed Surveyor that he was not aware that Section G: Functional Status was not being completed as well. NHA-A was aware of general noncompliance with documentation as regular staff were charting, however agency staff lacks provisions to complete charting, and it is not getting done. On 06/21/23, at 01:59 PM, Surveyor interviewed Social Worker-D who confirmed that she was responsible to complete Sections C, D, and E. Social Worker-D confirmed that there is missing information in resident MDS assessments and stated that she cannot get everything done herself and that there is no reason why other people cannot enter in that data also. Social Worker-D stated that the NHA-A was aware that the MDS assessments are not fully completed before being sent and that it is an ongoing problem. Surveyor asked Social Worker-D if any plan was in place to help correct this and ensure that MDS assessments are completed and accurate before submitted and she stated that she was not aware of any. On 06/22/23, at 12:50 PM, Surveyor informed NHA-A of concerns regarding the completion and accuracy of two MDS assessments for R15. No additional information was provided at the time. 11. R303 was admitted to the facility on [DATE] and had diagnoses including Cerebral Infarction due to embolism of right post cerebral artery; Muscle Weakness and Alzheimer's Disease with late onset. R303's Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 06/09/23 documented R303 had a Brief Interview for Mental Status (BIMS) of 4 indicating R303 had severe cognitive impairments. Section G which assesses functional status was documented as follows: a 7, meaning occurred only once during the look back period, was coded for bed mobility, transfers, eating and toilet use; an 8, did not occur during the look back period, was coded for dressing and personal hygiene. A review of progress notes during this time does not indicate these activities did not occur or occurred on a limited basis. Section D which assesses Mood documents that R303 should have a mood interview conducted however the assessment is blank. On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding the missing Mood assessment and inaccuracies in Functional Status sections. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS and that they should have been completed. MDS Supervisor-E identified the Mood section is typically completed by Social Worker-D and she did not complete the section on time. Surveyor asked MDS Supervisor-E if she was aware of any other sections not being completed accurately and MDS Supervisor-E stated that she has noticed that other resident MDS's have not been completed as well. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. Surveyor asked where the information is being pulled from to be used in Section G: Functional Status. MDS Supervisor-E stated that she is pulling the information from CNA (Certified Nursing Assistant) charting and therapy notes however if the CNA does not document daily then there is no information to pull from then she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents and she stated, Correct. If there is no documentation, then I just code an 8. Surveyor asked MDS Supervisor-E how care plans are developed if the MDS has inaccurate assessments. MDS-Supervisor explained that care plans are developed by the interdisciplinary team, and they base care plans off the MDS information. MDS Supervisor will fill in any gaps in care plans and so will the nursing managers. On 06/20/23, at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that he was just made aware of the BIMS not being completed a few weeks ago. NHA-A stated that he was made aware after he was contacted by the State Agency Regional Field Operations Director. NHA-A stated that MDS supervisor-E was closing out the MDS so that they would be timely. NHA-A informed Surveyor that he was not aware that Section G: Functional Status was not being completed as well. NHA-A was aware of general noncompliance with documentation as regular staff were charting, however agency staff lacks provisions to complete charting, and it is not getting done. On 06/21/23, at 01:59 PM, Surveyor interviewed Social Worker-D who confirmed that she was responsible to complete Sections C, D, and E. Social Worker-D confirmed that there is missing information in resident MDS assessments and stated that she cannot get everything done herself and that there is no reason why other people cannot enter in that data also. Social Worker-D stated that the NHA-A was aware that the MDS assessments are not fully completed before being sent and that it is an ongoing problem. Surveyor asked Social Worker-D if any plan was in place to help correct this and ensure that MDS assessments are completed and accurate before submitted and she stated that she was not aware of any. On 06/22/23, at 12:50 PM, Surveyor informed NHA-A of concerns regarding the completion and accuracy of the admission MDS for R303. No additional information was provided at the time. 8. R13 was admitted to the facility on [DATE] with diagnoses that include hemiplegia following cerebral infarction affecting left nondominant side, type 2 diabetes with diabetes peripheral angiopathy, idiopathic aseptic necrosis of left femur, and anxiety disorder. R13's Interim Payment Assessment Minimum Data Set (MDS), dated [DATE], documents that a brief interview for mental status (BIMS) should be conducted for R13 however the assessment is blank. Section D which assesses Mood documents that R13 should have a mood interview conducted however the assessment is blank. Section Z documents signatures of persons completing the assessment. Sections C and D are signed by MDS Supervisor-E. R13's Quarterly MDS, dated [DATE], documents that a BIMS should be conducted for R13 however the assessment is blank. Section D which assesses Mood documents that R13 should have a mood interview conducted however the assessment is blank. Section G which assesses functional status documents an 8 which means activity did not occur for bed mobility, transfer, eating, toilet use and personal hygiene. A review of progress notes during that time did not indicate that these activities did not occur. Section H assess for bladder and bowel. It does not document that R13 has an indwelling catheter. Section Z documents signatures of persons completing the assessment. Sections C, D, G and H are signed by MDS Supervisor-E. R13's CNA (Certified Nursing Assistant) Worksheet dated, 6/22/23, documents R13 needs extensive assistance with 2 person staff support for transfers, needs extensive assistance with 1 person staff support for bed mobility, needs no assistance with eating and set up staff support for eating and extensive assistance with 1 person staff support for personal hygiene. It also documents that extensive assistance with 2 person staff support for toileting and that R13 uses an indwelling catheter. On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding the two MDS assessments for R13 and the missing BIMS, Mood and inaccuracies in Functional Status and Bowel and Bladder sections. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS and that they should have been completed. MDS Supervisor-E identified that the BIMS and Mood sections are typically completed by Social Worker-D and she did not complete the sections on time. Surveyor asked MDS Supervisor-E if she was aware of any other sections not being completed accurately and MDS Supervisor-E stated that she has noticed that other resident MDS's have not been completed as well. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. Surveyor asked where the information is being pulled from to be used in Section G: Functional Status. MDS Supervisor-E stated that she is pulling the information from CNA (Certified Nursing Assistant) charting and therapy notes however if the CNA does not document daily then there is no information to pull from then she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents and she stated, Correct. If there is no documentation, then I just code an 8. Surveyor asked MDS Supervisor-E how care plans are developed if the MDS has inaccurate assessments. MDS-Supervisor explained that care plans are developed by the interdisciplinary team, and they base care plans off the MDS information. MDS Supervisor will fill in any gaps in care plans and so will the nursing managers. On 06/20/23, at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that he was just made aware of the BIMS not being completed a few weeks ago. NHA-A stated that he was made aware after he was contacted by the State Agency Regional Field Operations Director. NHA-A stated that MDS supervisor-E was closing out the MDS so that they would be timely. NHA-A informed Surveyor that he was not aware that Section G: Functional Status was not being completed as well. NHA-A was aware of general noncompliance with documentation as regular staff were charting, however agency staff lacks provisions to complete charting, and it is not getting done. On 06/21/23, at 01:59 PM, Surveyor interviewed Social Worker-D who confirmed that she was responsible to complete Sections C, D, and E. Social Worker-D confirmed that there is missing information in resident MDS assessments and stated that she cannot get everything done herself and that there is no reason why other people cannot enter in that data also. Social Worker-D stated that the NHA-A was aware that the MDS assessments are not fully completed before being sent and that it is an ongoing problem. Surveyor asked Social Worker-D if any plan was in place to help correct this and ensure that MDS assessments are completed and accurate before submitted and she stated that she was not aware of any. On 06/21/23, at 03:34 PM, at the end of the day meeting, Surveyor informed NHA-A of concerns regarding the completion and accuracy of two MDS assessments for R13. No additional information was provided at the time. 9. R2 was admitted to the facility on [DATE] with diagnoses that include heart disease, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes, and chronic diastolic congestive heart failure. R2's Quarterly Minimum Data Set (MDS), dated [DATE], documents that a brief interview for mental status (BIMS) should be conducted for R2 however the assessment is blank. Section D which assesses Mood documents that R2 should have a mood interview conducted however the assessment is blank. Section G which assesses functional status documents an 8 which means activity did not occur for bed mobility, transfer, eating, toilet use and personal hygiene. A review of progress notes during that time did not indicate that these activities did not occur. Section Z documents signatures of persons completing the assessment. Sections C, D, and G are signed by MDS Supervisor-E. R2's Quarterly MDS, dated [DATE], documents that a BIMS should be conducted for R2 however the assessment is blank. Section D which assesses Mood documents that R2 should have a mood interview conducted however the assessment is blank. Section Z documents signatures of persons completing the assessment. Sections C and D are signed by Social Worker-D. R2's CNA (Certified Nursing Assistant) Worksheet dated, 6/21/23, documents R2 needs limited assistance with 1 person staff support for transfers, needs limited assistance with 1 person staff support for bed mobility, needs no assistance with eating and set up staff support for eating and extensive assistance with 1 person staff support for personal hygiene and dressing. On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding the two MDS assessments for R2 and the missing BIMS, Mood and inaccuracies in Functional Status sections. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS and that they should have been completed. MDS Supervisor-E identified that the BIMS and Mood sections are typically completed by Social Worker-D and she did not complete the sections on time. Surveyor asked MDS Supervisor-E if she was aware of any other sections not being completed accurately and MDS Supervisor-E stated that she has noticed that other resident MDS's have not been completed as well. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. Surveyor asked where the information is being pulled from to be used in Section G: Functional Status. MDS Supervisor-E stated that she is pulling the information from CNA (Certified Nursing Assistant) charting and therapy notes however if the CNA does not document daily then there is no information to pull from then she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents and she stated, Correct. If there is no documentation, then I just code an 8. Surveyor asked MDS Supervisor-E how care plans are developed if the MDS has inaccurate assessments. MDS-Supervisor explained that care plans are developed by the interdisciplinary team, and they base care plans off the MDS information. MDS Supervisor will fill in any gaps in care plans and so will the nursing managers. On 06/20/23, at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that he was just made aware of the BIMS not being completed a few weeks ago. NHA-A stated that he was made aware after he was contacted by the State Agency Regional Field Operations Director. NHA-A stated that MDS supervisor-E was closing out the MDS so that they would be timely. NHA-A informed Surveyor that he was not aware that Section G: Functional Status was not being completed as well. NHA-A was aware of general noncompliance with documentation as regular staff were charting, however agency staff lacks provisions to complete charting, and it is not getting done. On 06/21/23, at 01:59 PM, Surveyor interviewed Social Worker-D who confirmed that she was responsible to complete Sections C, D, and E. Social Worker-D confirmed that there is missing information in resident MDS assessments and stated that she cannot get everything done herself and that there is no reason why other people cannot enter in that data also. Social Worker-D stated that the NHA-A was aware that the MDS assessments are not fully completed before being sent and that it is an ongoing problem. Surveyor asked Social Worker-D if any plan was in place to help correct this and ensure that MDS assessments are completed and accurate before submitted and she stated that she was not aware of any. On 06/21/23, at 03:34 PM, at the end of the day meeting, Surveyor informed NHA-A of concerns regarding the completion and accuracy of two MDS assessments for R2. No additional information was provided at the time. Based on interview and record review the facility did not ensure 11 (R10, R16, R29, R31, R17, R20, R34, R13, R2, R15, R303) of 14 residents had complete and accurate MDS (Minimum Data Set) assessments. * R10, R16, R29, R31, R17, R20, R34, R13, R2, R15, and R303 had MDS assessments that were not complete and accurate. Findings include: Surveyor reviewed the facility policy which indicated; MDS ( Minimum Data Set) , last revised on 12/2017 Policy Statement: Residents of our skilled nursing communities will have a MDS assessment completed in accordance with CMS guidelines as outlined in the RAI (Resident Assessment Instrument) Manual. Policy Interpretation and Implementation: (includes) To follow Federal regulatory requirements at 42 CFR 483.20(B)(1) and 483.20(c) that requires facilities to use an RAI process that has been specified by the State and approved by CMS. B. MDS Assessments are based on information from resident, family, physician, caregivers, and/or clinical assessment that includes description of the resident's capability to perform daily life functions and significant impairments in functional capacity, which include, but are not limited to, all sections located in the MDS Assessment. G. ADL self-performance coding will follow the Rule of 3 as defined in section G of the RAI Manual. Supportive documentation sources include, but are not limited to, nurse's notes, nursing aid documentation, therapy documentation, and assessors documented observations. H. Signatures attesting to the accuracy of the MDS will be in section Z of the MDS in accordance with the RAI Manual. 1. R10 was originally admitted to the facility on [DATE]. Surveyor conducted a review of the annual MDS (Minimum Data Set) dated 1/11/23 and noted the following concerns; Section G which assesses functional status documents 8 which means activity did not occur for walk in room and in corridor, locomotion on and off unit, dressing and hygiene. Entries for bed mobility, transfer, eating and toilet use indicate 7 which means activity only occurred once or twice. A review of progress notes during that time did not indicate that these activities did not occur. Section Z documents signatures for persons completing the assessment. Section G is signed by MDS Supervisor E as being completed on 1/25/23. Surveyor reviewed the significant change MDS dated [DATE] and noted the following concerns; The MDS section C documents that a BIMS (brief interview for mental status) should be conducted for R10, however the assessment is blank. Section D which assesses mood documents R10 should have a mood interview conducted however the assessment is blank. Section G which assesses functional status documents an 8 which means activity did not occur for locomotion on and off unit, dressing, eating and personal hygiene. A review of progress notes during that time did not indicate that these activities did not occur. Section Z documents signatures of persons completing the assessment. Section C, D and G are signed by MDS Supervisor E as being completed on 4/27/23. On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding the MDS assessments for R10 and the missing BIMS, Mood and inaccuracies in Functional Status and Bowel and Bladder sections. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS and that they should have been completed. MDS Supervisor-E identified that the BIMS and Mood sections are typically completed by Social Worker-D and she did not complete the sections on time. Surveyor asked MDS Supervisor-E if she was aware of any other sections not being completed accurately and MDS Supervisor-E stated that she has noticed that other resident MDS's have not been completed as well. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. Surveyor asked where the information is being pulled from to be used in Section G: Functional Status. MDS Supervisor-E stated that she is pulling the information from CNA (Certified Nursing Assistant) charting and therapy notes however if the CNA does not document daily then there is no information to pull from then she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents and she stated, Correct. If there is no documentation, then I just code an 8. Surveyor asked MDS Supervisor-E how care plans are developed if the MDS has inaccurate assessments. MDS-Supervisor explained that care plans are developed by the interdisciplinary team, and they base care plans off the MDS information. MDS Supervisor will fill in any gaps in care plans and so will the nursing managers. On 06/20/23, at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that he was just made aware of the BIMS not being completed a few weeks ago. NHA-A stated that he was made aware after he was contacted by the State Agency Regional Field Operations Director. NHA-A stated that MDS Supervisor-E was closing out the MDS so that they would be timely. NHA-A informed Surveyor that he was not aware that Section G: Functional Status was not being completed as well. NHA-A was aware of general noncompliance with documentation as regular staff were charting, however agency staff lacks provisions to complete charting, and it is not getting done. On 06/21/23, at 01:59 PM, Surveyor interviewed Social Worker-D who confirmed that she was responsible to complete Sections C, D, and E. Social Worker-D confirmed that there is missing information in resident MDS assessments and stated that she cannot get everything done herself and there is no reason why other people cannot enter in that data also. Social Worker-D stated that the NHA-A was aware the MDS assessments are not fully completed before being sent and that it is an ongoing problem. Surveyor asked Social Worker-D if any plan was in place to help correct this and ensure that MDS assessments are completed and accurate before submitted and she stated that she was not aware of any. On 06/22/23, at 12:45 PM, Surveyor informed NHA-A of concerns regarding the completion and accuracy of two MDS assessments for R10. No additional information was provided at the time. 2. R16 was originally admitted to the facility on [DATE]. Surveyor conducted a review of the quarterly MDS dated [DATE] and noted the following concerns; Section D which assesses mood documents R16 should have had staff assessment for mood however the assessment is blank. Section G which assesses functional status documents an 8 which means activity did not occur for transfers, walk in room and corridor, locomotion on and off unit, dressing and personal hygiene. Section H which assesses urine and bowel continence, indicates bowel continence was document as 9 which means R16 did not have a bowel movement for 7 days or has an ostomy. There is no documentation R16 has an ostomy. A review of progress notes during that time did not indicate that these activities did not occur. Section Z documents signatures of persons completing the assessment. Section D, G and H are signed by MDS Supervisor E as being completed on 2/3/23. Surveyor reviewed the quarterly MDS dated [DATE] and noted the following concerns; The MDS section C documents that a BIMS (brief interview for mental status) should be conducted for R16, however the assessment is blank. Section D which assesses mood documents R10 should have a mood interview conducted however the assessment is blank. Section G which assesses functional status documents an 8 which means activity did not occur for bedmobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. Section H which assesses urine and bowel continence, indicates bowel continence was document as 9 which means R16 did not have a bowel movement for 7 days or has an ostomy. There is no documentation R16 has an ostomy. A review of progress notes during that time did not indicate that these activities did not occur. Section Z documents signatures of persons completing the assessment. Section C, D, G and H are signed by MDS Supervisor E as being completed on 5/4/23. On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding the MDS assessments for R16 and the missing BIMS, Mood and inaccuracies in Functional Status and Bowel and Bladder sections. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS and that they should have been completed. MDS Supervisor-E identified that the BIMS and Mood sections are typically completed by Social Worker-D and she did not complete the sections on time. Surveyor asked MDS Supervisor-E if she was aware of any other sections not being completed accurately and MDS Supervisor-E stated that she has noticed that other resident MDS's have not been completed as well. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. Surveyor asked where the information is being pulled from to be used in Section G: Functional Status. MDS Supervisor-E stated that she is pulling the information from CNA (Certified Nursing Assistant) charting and therapy notes however if the CNA does not document daily then there is no information to pull from then she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents and she stated, Correct. If there is no documentation, then I just code an 8. Surveyor asked MDS Supervisor-E how care plans are developed if the MDS has inaccurate assessments. MDS-Supervisor explained that care plans are developed by the interdisciplinary team, and they base care plans off the MDS information. MDS Supervisor will fill in any gaps in care plans and so will the nursing managers. On 06/20/23, at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that he was just made aware of the BIMS not being completed a few weeks ago. NHA-A stated that he was made aware after he was contacted by the State Agency Regional Field Operations Director. NHA-A stated that MDS Supervisor-E was closing out the MDS so that they would be timely. NHA-A informed Surveyor that he was not aware that Section G: Functional Status was not being completed as well. NHA-A was aware of general noncompliance with documentation as regular staff were charting, however agency staff lacks provisions to complete charting, and it is not getting done. On 06/21/23, at 01:59 PM, Surveyor interviewed Social Worker-D who confirmed that she was responsible to complete Sections C, D, and E. Social Worker-D confirmed that there is missing information in resident MDS assessments and stated that she cannot get everything done herself and that there is no reason why other people cannot enter in that data also. Social Worker-D stated that the NHA-A was aware that the MDS assessments are not fully completed before being sent and that it is an ongoing problem. Surveyor asked Social Worker-D if any plan was in place to help correct this and ensure that MDS assessments are completed and accurate before submitted and she stated that she was not aware of any. On 06/22/23, at 12:45 PM, Surveyor informed NHA-A of concerns regarding the completion and accuracy of two MDS assessments for R16. No additional information was provided at the time. 3. R29 was originally admitted to the facility on [DATE]. Surveyor conducted a review of the quarterly MDS dated [DATE] and noticed the following concerns; The MDS section C documents that a BIMS (brief interview for mental status) should be conducted for R29 however the assessment is blank. Section D which assesses mood documents R29 should have a mood interview conducted however the assessment is blank. Section G which assesses funtional status documents an 8 which means activity did not occur for transfer, walk in room and in corridor, locomotion on and off unit, dressing and hygiene. Bed mobility, eating and toilet use are assessed as 7 which indicates activity only occurred once or twice in a 7 day period. A review of progress notes during that time did not indicate that these activities did not occur. Section Z documents signatures of persons completing the assessment. Section C, D and G are signed by MDS Supervisor E as being completed on 4/14/23. Surveyor reviewed the significant change MDS dated [DATE] and noticed the following concerns; The MDS section C documents that a BIMS (brief interview for mental status) should be conducted for R29 however the assessment is blank. Section D which assesses mood documents R29 should have a mood interview conducted however the assessment is blank. Section G which assesses functional status documents an 8 which means activity did not occur for bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. Section H which assesses bowel and bladder continence documents 9 which means not rated for urinary and bowel continence. A review of progress notes during [TRUNCATED]

Based on observation, interview and record review the facility did not ensure 2 of 3 medication rooms were free from expired medications. Surveyor observed the 2nd floor medication room and 1st floor rehab unit medication room. Expired medications were observed in both medication rooms. This had the ability to affect total of 38 residents. Findings include: On 6/22/23 at 9:15 a.m. Surveyor observed 2nd floor medication room with Director of Quality C. Surveyor noticed a bottle of chewable antacid 500 mg that expired June 2022 and a bottle of polyethylene glycol that expired 2/2023. Director of Quality C stated she would dispose of it. On 6/22/23 at 9:26 a.m. Surveyor observed the rehab medication room with Director of Quality C. Surveyor noticed 3 bottles of 60 tables of melatonin 3 mg that expired 1/2023. Director of Quality C stated she would dispose of it. Director of Quality C stated the nursing staff is responsible for disposing of expired medications.

Based on interview and record review the facility's Quality Assurance Committee did not ensure a system was in place to measure the success of implemented performance improvements, and track performance to ensure that improvements are realized and sustained for the accurate completion of 11 of 14 Minimum Data Set Assessments reviewed for R10, R16, R29, R31, R17, R20, R34, R13, R2, R15, and R303. * During the recertification survey from 06/19/23 - 06/22/23, the Survey team identified concerns with inaccurate and incomplete Minimum Data Set (MDS) Assessments which were partly a result of a lack of Certified Nursing Assistant (CNA) charting. The facility had identified an issue with the lack of CNA charting and implemented improvements, but did not have a plan to measure the success of the improvements nor a plan to track the performance. (Cross Reference F641) Findings include: Facility policy entitled, Quality Assurance and Performance Improvement Program (QAPI), last approved date of 09/2022 documented, The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, community-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents .6. Goals, targets and benchmarks are established and measured based on available evidence . On 06/20/23, at 11:15 AM, Surveyor interviewed MDS Supervisor-E regarding missing and inaccurate MDS Assessments. MDS Supervisor-E informed Surveyor that she was aware that there are missing sections in the MDS including section G which assesses functional status. Per MDS Supervisor-E, she pulls the information from CNA (Certified Nursing Assistant) charting and therapy notes to complete section G, however if the CNA does not document daily and there is no information to pull from she will document 8 which indicates the activity did not occur in the look back period. Surveyor clarified with MDS Supervisor-E that the information assessed in Section G may not be accurate for some residents due to a lack of CNA charting and she stated, Correct. If there is no documentation, then I just code an 8. MDS Supervisor-E stated that the Nursing Home Administrator (NHA) and corporate are aware of this. On 06/22/23 at 11:09 AM, Surveyor interviewed Director of Quality, Registered Nurse (RN)-C about the facility's QAPI program. Surveyor asked about the identified concerns regarding the inaccurate and incomplete MDS assessments. Per RN-C they had been talking a lot about the MDS and the issues surrounding the lack of charting due to having large amounts of agency staff. RN-C stated the facility was trying to hire contract Certified Nursing Assistants (CNA) for a three-month period so it was easier to get them provisioned to chart. Per RN-C, MDS Supervisor-E had brought up concerns in QAPI regarding a lack of CNA charting which was leading to inaccurate/incomplete MDS assessments. Surveyor asked how long the facility was having this issue with agency CNAs and a lack of charting. Per RN-C it had been going on since they increased their agency use, maybe January or February. RN-C showed Surveyor QAPI minutes from February which mentioned trying to get CNAs provision quicker so they would be able to chart. Surveyor asked if there was a documented plan, or a performance improvement project related to the lack of documentation. RN-C stated we had the CNAs document on paper and then it was supposed to be scanned in. RN-C stated the facility had begun contracting CNAs last month which should help with the documentation. Surveyor asked who was following up to ensure the CNA charting was being completed? Per RN-C the DON (Director of Nursing) would run that report weekly. RN-C stated when the facility had their own staff nurses, the unit nurse would run the CNA charting report prior to the end of their shift. RN-C stated it would be the DON's responsibility to run that report, but RN-C was unsure if DON-B was running that report. Per RN-C she was going to discuss the issue at the next QAPI. On 06/22/23 at 12:30 PM, Surveyor interviewed scheduler (SC)-K. SC-K informed Surveyor 80% of the staff are through agency because agency pays better. Per SC-K the facility does staff contract nurses who work for 8 to 12 weeks. SC-K stated the facility is always advertising positions, but people don't always show up for their interviews. SC-K informed Surveyor all the nurses who work through agency are provisioned to use the charting system prior to coming to the facility for their shifts which can take 4-48 hours. Per SC-K, she cannot get the CNAs provisioned in time for their shifts, so they do not have access to the electronic record to complete their daily charting. SC-K informed Surveyor, the agency CNAs are supposed to be documenting on paper and then the nurse would enter the information. SC-K stated she was uncertain if anyone was following up to ensure the daily CNA charting was completed. Surveyor asked SC-K if anyone else was aware of the issues with agency staff and lack of documentation? Per SC-K MDS Supervisor-E is aware of the issue with staff not documenting as MDS-Supervisor-E keeps contacting SC-K to tell her no one is documenting. Per SC-K it is frustrating. On 06/22/23 at 12:32 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A informed Surveyor MDS Supervisor-E never brought forward concerns with inaccurate/incomplete MDS assessments. Per NHA-A, he was only made aware of an issue with the MDS assessment because the State Agency Regional Field Operations Director contacted him to inquire about the facility census not appearing accurate. NHA-A stated he was made aware of MDS assessments that were not closed properly or entered late which then gave the appearance the facility's census was higher than the number of the beds the facility was licensed to care for. Per NHA-A this happened in the beginning of May. NHA-A informed Surveyor he spoke with MDS Supervisor-E who told him the Brief Interview for Mental Status (BIMS) section was not being completed timely which was why the MDS assessments were submitted late. Per NHA-A, he was only aware of the BIMs not being completed, he was unaware of any issues with section G addressing the residents' functional status, until the survey team brought it to his attention. NHA-A informed Surveyor, it is a consensus that CNA charting has been an issue. NHA-A stated the facility uses a lot of agency CNAs due to a lack of staff. Per NHA-A he tried to get general computer logins for the agency CNAs, but the corporate IT would not allow that due to security issues. NHA-A informed Surveyor the issue with agency CNAs charting is a delay in getting them provisioned to use the charting system, which can take 4-48 hours, depending on who is working. NHA-A stated not all facility employees/managers have access to get agency staff provisioned so that poses an issue as well. NHA-A stated if an agency cancels one CNA and sends a different CNA at the last minute there might not be a staff member at the facility who has access to provision the new CNA. NHA-A stated the facility started hiring contract nurses and have moved to contract CNAs to have continuity in staff and terminate the per diem staff. NHA-A explained he could not keep up with provisioning the per diem staff, due to the issues mentioned above. Per NHA-A, the goal is to have the same people coming back so those staff can get computer logins and complete their charting. Surveyor asked if there was a documented plan or performance improvement project with measurable goals and defined outcomes. NHA-A stated we started using contract CNAs about a month ago, so they have logins to chart and we were going to discuss the MDS assessment issue at the next QAPI. Surveyor asked who is responsible for ensuring the contracted CNAs are documenting? NHA-A stated the previous DON used to run the CNA charting report, but now the managers should be doing it. Surveyor asked if anyone was currently running the CNA charting report? NHA-A was uncertain. Surveyor expressed the concern that an issue was identified at QAPI with a lack of CNA charting; the facility's plan was to use contract CNAs which had begun a month prior but no one at the facility was following up to ensure these CNAs were documenting. Surveyor questioned how would the facility know if the contract CNAs were solving the charting problem if no one was following up? NHA-A stated the plan moving forward will be to have the unit managers run the CNA charting reports at the end of the day. No additional information was given.

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 32 opportunities which resulted in a 6.25% medication error rate affecting 1 Resident (R) (R22) of 2 residents observed during medication pass. During medication administration LPN-C administered TUMS chewable tablet (used to treat heartburn, upset stomach, or indigestion) to R22. R22 did not have an order for TUMS. R22 received Pantoprazole (used to treat heartburn) after ate meal, instead of before meal as ordered. Findings Include: The facility policy, titled Administering Medications, revised 12/2021, states: Medications shall be administered in accordance with the orders. On 3/23/2022 at 8:40 AM, Surveyor observed LPN-C administer medications to R22. LPN-C administered R22's pantoprazole after R22 had already eaten breakfast. The physician's order for R22's pantoprazole stated For GERD before meals. LPN-C administered TUMS, which R22 has no physican order for. On 3/23/21 at 9:40 AM, Surveyor interviewed LPN-C who verified administered pantoprazole after R22 already ate breakfast. LPN-C verified R22 had no physician order for TUMS. On 3/23/21 at 10:05 AM, Surveyor interviewed CM (Clinical Manager)-D regarding expectations when a physicans order states, give before meal, CM-D verified medication should be given before meal. Surveyor interviewed CM-D regarding LPN-C giving TUMS without a physician order. CM-D verified administering TUMS without a physician order is considered a medication error.