**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 3 residents (R17) reviewed for change in condition. R17 had a significant weight loss that was not reported to R17's provider timely. R17 had a change in condition on 11/24/24 that was not reported to R17's provider timely. This is evidenced by: The facility's Notification of Change policy, dated 1/2025, states, in part: The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: .acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The facility's Weights of Residents policy, dated 1/2019, states, in part: .3. Resident should be reweighed if there is a weight variance of over 3 pounds or more. (important to note: the policy does not indicate when the physician should be notified of weight variance.) The facility's Nurse/CNA (certified nursing assistant) / RA (resident assistant) Meeting Agenda, dated [DATE] and 31, 2024, states, in part: .11. Weights .d. Once you look at the weight on the clipboard, if you notice a change in weight of 3 pound either way, please reweigh resident to verify weight. e. If there is a change, notify nurse immediately. Nurse will update provider of weight change and enter a nurse progress note in the chart. R17 was admitted to the facility on [DATE], and has diagnoses that include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain; depression; and dysphagia (difficulty swallowing). R17's Minimum Data Set (MDS) dated [DATE] shows R17 has a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Example 1 R17's physician's orders state, in part: Weight Management: Weights-daily x3 (3 times), and then weekly. Start date 11/20/24. R17's care plan states, in part: Focus: Nutrition/Hydration: Potential for Complications with Nutritions/Hydration d/t (due to) appetite, meal intake, medication side effects, past medical history. Date initiated: 11/25/24. R17's Weights and Vitals Summary indicates the following weights: *11/19/24 222 Lbs (pounds) *11/20/24 222.2 Lbs *11/21/24 221.6 Lbs *11/25/24 224.2 Lbs *11/27/24 222.4 Lbs *12/18/24 196.8 Lbs *12/25/24 198.8 Lbs *12/25/24 198.8 Lbs *1/1/25 196.9 Lbs *1/1/25 196.4 Lbs *1/8/25 194.4 Lbs *1/15/25 189 Lbs *1/22/25 187 Lbs On 1/29/25 at 9:36 AM, Surveyor interviewed RN C (Registered Nurse) and asked how often residents are weighted. RN C stated that residents are weighed at least weekly, some as often as daily. Surveyor asked if weights are monitored. RN C stated that the standard is for physician to be notified of a 3 pound change in 1 day or a 5 pound change in 1 week. Surveyor asked where physician notification is documented. RN C stated in the resident's chart under progress notes. Surveyor asked if R17 has had any change in her weight. RN C reviewed the chart and stated R17 has had weight loss. RN C stated she could see a 10 pound weight loss in an alert screen. RN C stated that weight loss would be significant and would need physician notification. On 1/29/25 at 1:45 PM, Surveyor interviewed DON B (Director of Nursing) and asked if resident weights are monitored. DON B stated weights are reviewed by the nurses and the dietician. Surveyor asked when physicians are updated on changed in weight. DON B stated physician is updated with weight change of 3-5 pounds and that notification is documented in the progress notes. Surveyor asked about R17's weights. DON B stated that R17 was on isolation in December and was not weighed during that time. DON B stated following isolation R17's weight was down. Surveyor asked if DON B would expect the facility to notify the physician of a change from 222.4 pounds to 196.8 pounds (a 25.6 pound / 11.5% loss between 11/27/24 and 12/18/24). DON B stated yes. Surveyor asked for documentation of physician notification. No documentation was provided. On 1/30/25 at 1:18 PM, Surveyor interviewed NP D (Nurse Practitioner) and asked if NP D would expect to be notified of a resident's weight loss. NP D stated yes. Surveyor asked if facility had notified of R17's weight loss from 11/19/24 to 12/18/24. NP D stated no, not that I am aware of. Surveyor asked if NP D would expect to be notified of this weight loss. NP D stated yes. Example 2: R17's Progress Note, dated 11/24/24 at 3:20 PM, states: Res (resident) has one large incontinent BM (bowel movement) this morning with moderate to large amount of blood noted. Denies any rectal pain and no hemorrhoids noted. B/P (blood pressure) 108/54. On 1/29/25 at 9:47am, Surveyor interviewed RN C (Registered Nurse) and asked what would be done if bleeding were noted from a resident. RN C stated the resident would be assessed and the physician would be notified. On 1/29/25 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing) and asked if a physician should be updated of a resident having moderate to large amount of blood following a bowel incontinence. DON B stated yes. DON B stated that the resident was sent to the hospital for evaluation at approximately 5:30 PM and returned to the facility at approximately 9:00 PM. Surveyor asked if the facility notified the physician in the morning when the bleeding was noted. DON B stated no. Surveyor asked if facility would be expected to notify the physician at the time of the bleeding. DON B stated yes. On 1/30/25 at 1:18 PM, Surveyor interviewed NP D (Nurse Practitioner) and asked if NP D would expect the facility to notify the provider of a resident having an episode of bowel incontinence with moderate to large amount of blood noted. NP D stated yes. Surveyor asked when NP D would expect notification of a bleeding episode noted in the morning. NP D stated right away in the morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for 1 of 5 residents (R23) reviewed for unnecessary medications. R23 receives an antidepressant for sleep without an appropriate diagnosis. R23 did not have a sleep assessment conducted prior to medication administration. This is evidenced by: The facility policy entitled, Psychotropic Medication dated 5/2020, states, in part: .1. The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. The medical record must show documentation of adequate indication and diagnosed condition . 2. A Psychotropic Drug Assessment will be completed on admission, quarterly, a new medication or renewal order, an irregularly identified in the pharmacist's medication regimen review and with changes of condition . The assessment will be reviewed by the IDT (Interdisciplinary Team) helps to identify resident's needs, goals, comorbid conditions, and prognosis to determine factors (including medications and new or worsening medical conditions) that are affecting signs, symptoms, and test results. This evaluation process is important when selecting initial medications and/or non-pharmacological approaches and when deciding whether to modify or discontinue a current medication. Attempt to identify underly cause for behavioral symptom(s) .4. Based upon individualized assessment, determine non-pharmacological approaches that can be implemented prior to the use of psychotropic medications . R23 was admitted to the facility on [DATE] with diagnoses that include, in part: fatty liver, pulmonary embolism (blood clot in the lungs), dementia, Wernicke's encephalopathy (memory disorder most often caused by alcohol), alcohol dependence, and panlobular emphysema (disorder causing damage to all lobes of the lung making it difficult to breathe). R23's Physician Orders, dated 1/17/25, include, in part: Trazadone (antidepressant medication often used for sleep) 50 MG, Give by mouth one time daily for sleep. Take 50 MG daily at bedtime. Start date: 10/7/24. Order status: Active. (Of note: Patient does not have a diagnosis of insomnia and there is no diagnosis associated with this medication) Surveyor requested the sleep assessment for R23 that was conducted prior to ordering and administering the Trazadone. Surveyor was provided a document titled, SNF-ADMIT/READMIT TOOL, dated 10/1/24 at 7:04 AM. In the section titled, Sleep, questions were asked regarding R23's sleep patterns are marked trouble staying asleep, wakes in night. The usual bedtime is indicated to be between 8:00 PM and 8:30 PM. The usual hours of sleep states, depends 4 to 5. The usual waking time is indicated to be between 5:00 AM and 6:00 AM. The preference for AM and PM naps are both marked, not really. (Of note: The facility reports this is the only sleep assessment conducted for R23) A Physician Notification, dated, 10/1/24, states, Resident having difficulty sleeping, and pain in BLE (bilateral lower extremities). No PRNs (as needed medications) available if there is anything we can get? Thanks! A reply was made to this notification that was signed on 10/3/24, which provided the order for 50 MG of Trazadone by mouth at bedtime. A progress note, indicated to be effective on 10/5/24 at 5:00 AM, indicates R23 was restless and had difficulty sleeping. R23 had to be assisted back to her room and settled into her recliner. (Of note: In the SNF-ADMIT/READMIT TOOL, conducted on 10/1/24, R23 indicated she usually wakes up between 5:00 AM and 6:00 AM) On 10/7/24 at 1:13 PM, a progress note is written that states, Resident received new orders for trazadone at bedtime. (Of note, no other progress notes are written describing the patient's sleep patterns or habits during this time period.) On the Behavior Monitoring and Interventions Report from admission on [DATE] through 10/8/24, Insomnia is marked as a behavior only once on 10/7/24 at 5:25 AM. On 1/30/25 at 2:20 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how the facility assesses a resident's sleep upon admission. DON B indicates, they initiated behavior monitoring if they are on psychotropics, but states, I really don't have a process. DON B indicates if a resident is having trouble sleeping, staff should be notifying the doctor. DON B also indicates melatonin, or other medications should be attempted prior to starting hypnotics. DON B also states R23 did have an assessment upon admission and did not sleep well prior to admission. Surveyor asked DON B how the facility monitors residents' sleep. DON B indicates they track sleep on the Behavior Monitoring and Interventions section of the EMR (electronic medical record), and staff are expected to document insomnia, but there is no actual sleep hours tracking. Surveyor asked DON B if the facility uses sleep diaries. DON B states, no. Surveyor asked DON B how R23's sleep was on admission. DON B indicates her sleep was not good, she was very restless and had a couple falls. Surveyor asked DON B if the facility was tracking R23's sleep. DON B indicates staff were tracking her sleep by marking insomnia in the Behavior Monitoring and Interventions section of the EMR. Surveyor asked DON B if there should be documentation if a resident is experiencing insomnia. DON B states, there should be a progress note or physician notification. DON B also indicates the facility was aware the hospital was using Seroquel (antipsychotic medication) for sleep and did not think melatonin would be effective. Surveyor asked DON B if a sleep assessment should be conducted prior to starting trazadone for sleep. DON B states, probably, and indicates she would leave that up to the provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure a grievance was documented, thoroughly investigated, and resolved for 1 Resident (R) (R11) of 15 sampled residents. The facility did not document, investigate and resolve R11's grievance regarding a pair of missing pants. Findings include: The facility's Grievance Policy and Procedure, with a revised date of January 2020, indicated: Residents have a right to voice grievances to the facility .Such grievances include those regarding care and treatment which has been furnished, as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay .A grievance form will be completed either by the person filing the grievance or the staff member of the facility that received the complaint .The grievance officer and additional support staff will investigate the formal grievance, write a summary statement of the grievance, include the steps taken to investigate the grievance, a summary of the findings or conclusions regarding the grievance, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued .The grievance should be resolved, on average, within 7 days or less .Following the conclusion of the grievance, a summary will be provided to the resident of any findings by the grievance officer or designee. The facility will respond in writing, by phone, or one on one with the results of the investigation. R11 was admitted to the facility on [DATE] with diagnoses including diabetes, major depressive disorder, and displaced simple supracondylar fracture without intercondylar fracture of the left humerus (an injury to the upper arm bone, at its narrowest point, just above the elbow). R11's Minimum Data Set (MDS) assessment, dated 10/25/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 had intact cognition. On 11/20/23 at 9:17 AM, Surveyor interviewed R11 and asked R11 if R11 had any missing personal items. R11 indicated R11 was missing a pair of burgundy pants that matched one of R11's tops. R11 indicated laundry staff was aware of the missing pants. On 11/22/23 at 12:21, Surveyor again interviewed R11 who indicated R11's pants were missing since the second week of September. R11 expressed concern the facility would not resolve the issue without Surveyor inquiring about R11's pants. R11 indicated R11 would like the pants back since they were new and part of a matching outfit. R11 indicated R11 informed Laundry Lead (LL)-C and Laundry Aide (LA)-D about the missing pants. Per R11, LL-C informed R11 a grievance would be filed if the pants were not found after 6 weeks. On 11/20/23, Surveyor reviewed the facility's grievance log which did not contain a grievance regarding R11's missing pants. On 11/21/23 at 12:10 PM, Surveyor interviewed LL-C who confirmed LL-C was aware of R11's missing pants for approximately 4-6 weeks. LL-C indicated LL-C did not file a grievance because LL-C waited to see if R11's pants were returned from the facility's outside laundry service. On 11/22/23 at 10:04 AM, Surveyor interviewed LA-D who confirmed LA-D was aware of R11's missing pants. LA-D could not recall the date R11 informed LA-D that R11's pants were missing, but confirmed if a grievance form was filled out, LA-D would know the exact date R11 reported the missing pants. On 10/22/23 at 11:00 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was not aware R11's pants were missing for approximately 4-6 weeks and stated NHA-A thought R11's pants were only missing for a few weeks. NHA-A indicated a grievance should have been filed and investigated when R11 first reported R11's pants were missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interview, the facility did not make a prompt effort to resolve a grievance for 1 Resident (R) (R3) of 5 sampled residents. In addition, the grievance was not contained in the facility's grievance file. R3 reported to staff that R3 was missing a large tube of toothpaste. The facility did not follow up with R3 or resolve the grievance in a timely manner. Findings include: The facility's Grievance Policy and Procedure, last revised in January 20202, contained the following information: Policy Statement: Residents have a right to voice grievances to the facility or other agency or entity that hears grievances without fear of discrimination or reprisal. Such grievances include those regarding care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents and other concerns regarding their stay. Procedure: 1. If a resident or family member has a concern, complaint or suspects resident neglect, abuse, exploitation or misappropriation of property and would like to file a formal grievance, it is to be reported to the charge nurse on duty or the department supervisor. 3. A grievance form will be completed either by the person filing the grievance or the staff member of the facility that received the complaint. Note: Any sort of misconduct will be reported to the Division of Quality Assurance in accordance with the facility's current abuse policies and the current regulatory requirements regarding the specified time frames. 6. The grievance should be resolved on average, within 7 days or less, unless the grievance is complex in nature and/or requires additional time for further investigation and response . On 2/28/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses to include heart failure and diabetes. R3's Minimum Data Set assessment, dated 2/27/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R3 had intact cognition. On 2/28/23 at 11:59 AM, Surveyor interviewed R3 who stated R3 was missing a large tube of toothpaste R3 won playing Bingo at the facility. R3 stated, I let the nurses and aides know about 2 weeks ago about my large toothpaste in the drawer was gone. R3 also stated, Sometimes you feel like somebody doesn't believe you. R3 stated no one followed up with R3 regarding the toothpaste. R3 stated the toothpaste is not worth a lot; however, the thought of missing items doesn't feel right. On 2/28/23 at 12:38 PM, Surveyor interviewed Certified Nursing Aide (CNA)-D who confirmed R3 informed CNA-D about the missing toothpaste 2 weeks ago. CNA-D stated CNA-D told R3 to check in the closet. CNA-D stated, I looked for (the toothpaste) and passed the information to the nurse. When Surveyor asked CNA-D which nurse CNA-D informed, CNA-D stated, I don't remember who it was. CNA-D verified CNA-D did not know where the facility's grievances forms were located. CNA-D also confirmed CNA-D did not follow up with R3 regarding the missing toothpaste. On 2/28/23 at 12:55 PM, Surveyor interviewed Social Worker (SW)-C who had no knowledge of R3's missing toothpaste. SW-C stated SW-C's expectation is for staff to report resident grievances promptly to SW-C. On 2/28/23 at 2:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who also had no knowledge of R3's missing toothpaste. NHA-A stated if a resident reported a missing item to staff, staff should inform NHA-A promptly.

Based on staff interview and record review, the facility did not implement their written policies and procedures that prohibit abuse of residents (including misappropriation of property), provide abuse training to employees at orientation and provide on-going education for 1 (Social Worker (SW)-C) of 2 staff interviewed regarding abuse training. SW-C was not trained on abuse to include misappropriation of property. Findings include: The facility's undated Resident Abuse-Employee Training policy contained the following information: It is the policy of the facility to train employees, through orientation and on-going education, on issues related to abuse to include misappropriation of property. Annual mandatory education will be provided to train staff on the prevention of abuse. This information will also be included in the orientation of new employees. On 2/28/23 at 12:40 PM, Surveyor interviewed SW-C regarding R1's allegation of abuse/misappropriation of property. SW-C stated R1 did not make an allegation of abuse as misappropriation of property was not abuse. Additionally, SW-C stated SW-C was not provided abuse training during orientation and was not provided on-going education related to abuse to include misappropriation of property. On 2/28/23 at 3:36 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding abuse training for employees. NHA-A verified all staff need abuse training (including misappropriation of property) at orientation, through ongoing annual education, and as needed. NHA-A verified SW-C was not trained on abuse related to nursing home regulations at orientation and was not provided ongoing education related to abuse, including misappropriation of property. The only abuse training SW-C received at hire was geared toward hospital fraud.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/28/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include terminal dementia, recent pneumonia, generalized weakness, disorientation and confusion, poor balance and gait difficulty. R2 was discharged to the hospital on 1/1/23. A progress note, dated 1/1/23 at 5:00 AM, contained the following information: (R2) slept well through the night. During repositioning, appeared (R2) had pain and with assessment noted left lower extremity to be rotated out and shorter than right. (R2) did grab left hip and grimace with movement of left lower extremity. (R2) had a fall on 12/28/22 and has been non-ambulatory since the fall. (R2) appears to favor leaning to the right in bed. (R2) remains confused and difficult to assess. Will contact (Director of Nursing) regarding findings. On 1/1/23, R2 was sent to the emergency room for evaluation of the left hip for a possible hip fracture. On 2/28/23 at 9:45 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R2's fall. DON-B stated R2 was discharged from the facility's assisted living unit and was used to walking independently. Per DON-B, R2 was at the facility for approximately 10 minutes when R2 was wheeled into R2's assigned room. DON-B stated R2 must have then wheeled R2's self into another resident's room; however, there were no witnesses. Per DON-B, R2 was able to independently wheel R2's self in the wheelchair; however, there were foot pedals on the wheelchair which R2 was not used to. DON-B spoke with R2 after the unwitnessed fall while R2 was still on the floor. R2 denied pain and displayed no signs or symptoms of pain. On 2/28/23, Surveyor reviewed the facility-reported incident (FRI). Surveyor noted the facility's initial report was not submitted on SA identified initial reporting document (F-62617), instead the initial report was sent on SA identified document Misconduct Incident Report (F-62447) which is used to report the results of the facility's investigation. The facility reported the result of R2's injury of unknown origin on a word document titled Final Reportable, instead of the appropriate SA identified document (F-62447). Based on record review, and resident and staff interview, the facility did not ensure all allegations of misappropriation of property and injuries of unknown origin were reported timely to the State Agency (SA) and law enforcement for 2 Residents (R) (R1 and R2) of 5 sampled residents. R1 reported an allegation of misappropriation of property to staff who reported the allegation to administration. Administration did not report the allegation of misappropriation to the SA within 24 hours on a form identified by the SA and did not report the results of the investigation to the SA within 5 working days. In addition, the facility did not report the allegation of misappropriation to law enforcement. R2 had an injury of unknown origin which resulted in a left hip fracture. Administration did not report the injury of unknown origin to the SA within 24 hours on a form identified by the SA and did not report the results of the investigation to the SA within 5 working days on a form identified by the SA. Findings include: The facility's Resident Abuse-Investigation policy, updated on 6/2/21, contained the following information: It is the policy of the facility to send an initial report (F-62617) of an allegation of abuse to include misappropriation of property to the Division of Quality Assurance (DQA) immediately. The local police department will be contacted for assistance if it appears that a crime has been committed. The results of the investigation must be documented on the appropriate state Caregiver Misconduct Incident Report DQA form F-62447 and provided to DQA within 5 working days. 1. On 2/28/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility with diagnoses to include chronic obstructive pulmonary disease and diabetes mellitus. R1's annual Minimum Data Set (MDS) assessment dated [DATE], documented R1's cognition was 15 out of 15 (the higher the score, the more cognizant). On 2/28/23, Surveyor reviewed a complaint form with an occurrence date of 11/3/22 and a reported date of 11/4/22 at 3:30 PM completed by Caring Partner (CP)-E. On 2/28/23 at 11:53 AM, Surveyor interviewed R1. R1 stated R1 reported two missing rings to CP-E. R1 did not know if the rings were misplaced or stolen. R1 paid $189 for one ring and $50 for the other ring. R1 was not asked if R1 wanted the police contacted and was not interviewed by a police officer. On 2/28/23 at 12:09 PM, Surveyor interviewed CP-E regarding R1's allegation of misappropriation of property. CP-E stated the allegation of misappropriation was reported to the prior Nursing Home Administrator (NHA) the same date (11/4/22) R1 reported the allegation to CP-E. CP-E verified CP-E did not call the police. On 2/28/23 at 12:25 PM, Surveyor interviewed NHA-A regarding R1's allegation of misappropriation. NHA-A verified the initial 24 hour report indicated it was submitted to the SA on a Microsoft Word document rather than on form F-62627 on 11/7/22, and the 5 day report was submitted to the SA late on 11/22/22. Additionally, NHA-A verified the police should have been contacted regarding the allegation of misappropriation. On 2/28/23 at 12:40 PM, Surveyor interviewed Social Worker (SW)-C regarding R1's allegation of misappropriation. SW-C stated SW-C did not call the police when R1 alleged misappropriation of property and was not aware the police needed to be notified by the facility when an allegation of abuse, including misappropriation of property, was reported to the facility. The facility did not submit the initial allegation of misappropriation of property on the form identified by the SA, the results of the investigation of the allegation of missing property were not reported to the SA within 5 working days as required, and the facility did not contact the police when R1 reported the allegation of missing or stolen rings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure all injuries of unknown origin and allegations of misappropriation of property were thoroughly investigated for 2 Residents (R) (R2 and R1) of 5 residents. R2 was admitted to a local hospital following left leg pain on 1/1/23 and diagnosed with a left hip fracture. The facility did not conduct a thorough investigation to determine the cause of the injury and/or rule out potential abuse/neglect. R1 reported to staff that R1 was missing two rings. The facility did not conduct a thorough investigation to rule out misappropriation of property. Findings include: The facility's undated Resident Abuse-Investigation Including Unexplained Injury policy contained the following information: Policy Statement: It is the policy of this facility to thoroughly investigate reports of abuse, neglect, injury of unknown origin . Procedure: 14. Injury of Unknown Source: a. CMS requires that nursing homes report all injuries to a resident of unknown source. The federal interpretative guidelines for 42. C.R.R. 484.13 (c) (2) and (4) define injuries of unknown source to mean an injury that: 2. Is suspicious because of the extent of the injury or the location of the injury, or the number of injuries observed at one particular point in time or the incidence of injuries over time. b. An injury of unknown origin or suspicious injury must be immediately investigated to rule out abuse .An injury is suspicious based on the extent of the injury, for example, the size or severity of the injury, such as a large bruise, a skin tear or a broken bone. 15. Interviewing/investigation: As appropriate, the investigation should consist of: b. Who was present at the time of the incident? (Victim, perpetrator, witnesses). f. Interview other residents to determine if they have had a similar experience or if they have been abused or mistreated. 23. Additional items are included/considered based on the type of misconduct and is helpful to send these investigative documents .to (Division) of Quality Assurance (DQA). f. Injury of Unknown Source: 5. Interviews with staff, residents, visitors, and family members who visit/live/work in the affected resident's unit as appropriate. The facility is responsible to prohibit and prevent abuse including misappropriation of resident property. Interview other residents to determine if they have had a similar experience. 1. On 2/28/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include terminal dementia, recent pneumonia, generalized weakness, disorientation and confusion, poor balance and gait difficulty. R2 was discharged to the hospital on 1/1/23 due to left hip pain and was diagnosed with a left hip fracture. Surveyor reviewed R2's fall investigation which was not thorough and did not contain resident interviews or staff education post incident. A progress note, dated 1/1/23 at 5:00 AM, contained the following information: (R2) slept well through the night. During repositioning, appeared (R2) had pain and with assessment noted left lower extremity to be rotated out and shorter than right. (R2) did grab left hip and grimace with movement of left lower extremity. (R2) had a fall on 12/28/22 and has been non-ambulatory since the fall. (R2) appears to favor leaning to the right in bed. (R2) remains confused and difficult to assess. Will contact (Director of Nursing) regarding findings. On 1/1/23, R2 was sent to the emergency room for evaluation of the left hip for a possible hip fracture. On 2/28/23 at 9:45 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R2's fall. DON-B stated R2 was discharged from the facility's assisted living unit and was used to walking independently. Per DON-B, R2 was at the facility for approximately 10 minutes when R2 was wheeled into R2's assigned room. DON-B stated R2 must have then wheeled R2's self into another resident's room; however, there were no witnesses. Per DON-B, R2 was able to independently wheel R2's self in the wheelchair; however, there were foot pedals on the wheelchair which R2 was not used to. DON-B spoke with R2 after the unwitnessed fall while R2 was still on the floor. R2 denied pain and displayed no signs or symptoms of pain. On 2/28/23 at 11:59 AM, Surveyor interviewed R3 regarding R2's fall. R3 stated R3 witnessed R2 enter R3's room and fall against the wall by the room entrance. R3 confirmed R3 was not interviewed by the facility regarding R2's fall. On 2/28/23 at 1:52 PM, Surveyor interviewed DON-B regarding R2's fall investigation. DON-B stated R2 tripped on the foot pedals of the wheelchair. DON-B confirmed residents were not interviewed, including R3 (who resides in the room where the fall occurred). Surveyor questioned DON-B if R3 and other residents should have been interviewed to rule out abuse/neglect. DON-B confirmed R3 should have been interviewed and stated, I would not have thought to ask the residents. If the injury is unknown, then yes, interview residents. Per DON-B staff education was not completed, only a questionnaire in regard to R2's pain. 2. On 2/28/23, Surveyor reviewed a facility-reported incident (FRI). The FRI indicated R1 reported an allegation of misappropriation of property that was discovered on 11/7/22. The FRI stated R1 reported two missing rings. One ring was valued at $189 and the other ring was valued at $50. The FRI indicated no other residents on R1's unit stated they were missing valuable items. The FRI did not include documentation that the allegation of misappropriation was thoroughly investigated as the facility did not document interviews with other residents regarding misappropriation of property to determine if other residents were missing jewelry or other items. On 2/28/23 at 12:25 PM, Surveyor interviewed NHA-A who verified other residents should have been interviewed to determine if other residents were missing jewelry or other items. NHA-A also verified the interviews should have been documented and included in the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R13 was admitted to the facility on [DATE] and had a BIMS score of 1/15 which indicated that R13 had severe cognitive impairment. R13 had diagnoses that included: trsoke with right side of body paralysis, anxiety disorder, panic disorder, chronic kidney disease, dognitive deficits and weakness. R13 had a Falls care plan in place with multiple falls interventions. Between 10/17/22 and 10/19/22, Surveyor reviewed R13's Medical Record for falls. Surveyor reviewed 4 unwitnessed falls R13 had between 6/1/22 and 10/19/22. Surveyor noted that 4/4 of R13's falls reviewed did not have neuro checks completed according to facility policy / protocol. ~On 10/11//22, R13 had an unwitnessed fall. Surveyor noted 6 out of 17 Neuro checks were completed. ~On 9/20/22, R13 had an unwitnessed fall. Surveyor noted 5 out of 17 neuro checks were completed. ~On 8/4/22, R13 had an unwitnessed fall. Surveyor noted 8 out of 17 neuro checks were completed. ~On 6/15/22, R13 had an unwitnessed fall. Surveyor noted 8 out of 17 neuro checks were completed. ~On 6/6/22, R13 had an unwitnessed fall, Surveyor noted 14 out of 17 neuro checks were completed. On 10/18/22 at 12:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated neuro checks for unwitnessed falls were as follow: Every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for two hours and lastly every shift for 72 hours. This is in accordance with facility neuro check policy. On 10/19/22 at 10:15 AM, Surveyor interviewed Minimum Data Set Registered Nurse (MDSRN)-D who confirmed there were no documented neuro checks in resident's medical record and that all neuro checks should be in resident's electronic health records. MDSRN-D confirmed if neuro checks were not there then they weren't completed. MDSRN-D reviewed R13's neuro checks for the above unwitnessed falls with surveyor and verified missing neuro checks. See staff interview following example #1. Based on interview and record review, the facility did not ensure post-fall neurological observations (neuro checks) were completed consistently and/or timely for 3 Residents (R) (R17, R13, R18) of 4 residents reviewed for falls. R17 did not have neuro checks completed consistently and/or timely for 5 out of 6 unwitnessed falls reviewed. R18 did not have neuro checks completed consistently and/or timely for 1 unwitnessed fall reviewed. R13 did not have neuro checks completed consistently and/or timely for 4 unwitnessed falls reviewed. Findings include: Facility policy titled, Neurological Observations, with a revision date of May 2020, indicated: Checks are to be performed at 15-minute intervals for a minimum of 1 hour. Thereafter, they are to be done every 30 minutes for one hour, then every hour for two hours; then once a shift for 72 hours or as ordered by the attending physician or per facility standard. This totals 17 neurological checks to be completed after each unwitnessed fall. 1. R17 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 4/15, which indicated that R17 had severe cognitive impairment. R17 had diagnoses that included: vascular dementia with behavioral disturbance (a disorder characterized by changes in the brain that cause changes to memory, thinking, behavior, impulsivity); generalized anxiety disorder; and psychotic disorder with delusions. R17 had a Falls care plan in place with multiple falls interventions. Between 10/17/22 and 10/19/22, Surveyor reviewed R17's medical record for falls. Surveyor reviewed 6 unwitnessed falls R17 had between 5/1/22 and 10/19/22. Surveyor noted that 5/6 of R17's falls reviewed did not have neuro checks completed according to facility policy/protocol. ~On 9/29/22, R17 had an unwitnessed fall. Surveyor noted 5 out of 17 Neuro checks were completed. ~On 8/2/22, R17 had an unwitnessed fall. Surveyor noted 7 out of 17 neuro checks were completed. ~On 7/29/22, R17 had an unwitnessed fall. Surveyor noted 0 out of 17 neuro checks were completed. ~On 7/26/22, R17 had an unwitnessed fall. Surveyor noted 10 out of 17 neuro checks were completed. ~On 6/28/22, R17 had an unwitnessed fall. Surveyor noted 12 out of 17 neuro checks were completed. On 10/19/22 at 10:37 AM, Surveyor interviewed Director of Nursing (DON-B) who confirmed the expectation that neuro checks should be completed per the new management companies policy (listed above) for unwitnessed falls. DON-B indicated the facility has been in transition with changing policies due to a new management company taking over as well as a new electronic health records system being implemented on 8/1/22. At this same time, Consultant Nurse (CN-C) also confirmed this expectation. 2. R18 was admitted to the facility with diagnoses to include Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and a history of falling. R18 had a BIMS score of 3 out of 15 indicating a severe cognitive deficit. The Surveyor reviewed R18's medical record and noted R18 sustained a fall on 10/1/22 at 12:15 pm. Nursing progress notes stated: ~resident heard yelling help and writer entered room and resident was laying on [her] left side in front of wheelchair .called and spoke with the on call MD (Medical Doctor) .she stated to follow protocol. The Surveyor noted neurological checks were initiated for the unwitnessed fall with 8 of 17 neurological checks being completed. See staff interview following example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R13 was admitted to the facility on [DATE] with related diagnoses that included: anxiety disorder and panic disorder. Additionally R13's physician prescribed psychotropic medication, Ativan (an antianxiety,) as needed to treat anxiety disorder and panic disorder. Between 10/17/22 and 10/19/22, Surveyor reviewed R13's medical record which showed R13 had a PASRR Level 2 completed on 4/5/22 due to a diagnoses of serious mental illness and use of antianxiety medication. Between 10/17/22 and 10/19/22, Surveyor reviewed R13's MDS assessment dated [DATE]. In Section A1500 (Preadmission Screening and Resident Review (PASRR)), the question asks: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was answered: No. On 10/19/22 at 10:14 AM, Surveyor and Minimum Data Set Registered Nurse (MDSRN)-D reviewed R13's MDS assessment dated on 8/31/22 together. MDSRN-D confirmed incorrect coding of Section A1500. MDSRN-D verbalized the error will be corrected. 3. R23 was admitted to the facility on [DATE] and had related diagnoses that included: major depressive disorder. Additionally R23's physician prescribed psychotropic medication Duloxetine (an antidepressant) used to treat depression. Between 10/17/22 and 10/19/22, Surveyor reviewed R23's medical record which showed R23 had a PASRR Level 1 completed on 9/19/22: Under the question: Check one of the boxes below based on the responses to the questions in Section A of this form. Resident is not suspected of having a serious mental illness or a developmental disability was checked. Between 10/17/22 and 10/19/22, Surveyor reviewed R23's admission MDS assessment dated [DATE]. In Section A1500 (Preadmission Screening and Resident Review (PASRR)), the question asks: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was answered: No. On 10/18/22 at 3:03 PM, Surveyor interviewed Social Worker (SW)-F who confirmed R23's PASRR Level 1 dated 9/19/22 and the MDS dated [DATE] were coded incorrectly. SW-F verbalized her expectation is to code MDS correctly and would correct R23's PASRR Level 1. On 10/19/22 at 10:14 AM, Surveyor interviewed MDSRN-D who confirmed PASRR Level 1 and MDS assessment dated on 9/21/22 was incorrectly coded. MDSRN-D verbalized the error will be corrected. 4. R30 was admitted to the facility on [DATE] and discharged to an assisted living facility on 8/23/22. Between 10/17/22 and 10/19/22, Surveyor reviewed R30's discharge MDS assessment dated [DATE]. In Section A2100 (Discharge Status), this section was coded 03 which indicated R30 was discharged to an acute hospital. On 10/19/22 at 10:00 AM, Surveyor interviewed MDSRN-D who confirmed an error was made on R30's discharge MDS assessment dated [DATE] in section A2100 (Discharge Status). MDSRN-D confirmed resident discharged to assisted living and will correct error. MDSRN-D verbalized expectation is to code MDS assessment correctly. Based on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments accurately reflected the residents status for 4 Residents (R) (R19, R13, R23, R30) of 13 residents reviewed. R19 had a diagnoses of mental illness and also had a Preadmission Screening and Resident Review (PASRR) Level 1 and Level 2 completed. R19's MDS did not accurately reflect this. R13 had a diagnoses of mental illness and also had a PASRR Level 1 and Level 2 completed. R13's MDS did not accurately reflect this. R23 had a diagnoses of mental illness and also had a PASRR Level 1 completed. R23's MDS and PASRR Level 1 did not accurately reflect this. R30 was discharged to the community. R30's MDS did not accurately reflect this. Findings Include: 1. R19 was admitted to the facility on [DATE] and had related diagnoses that included: disorganized schizophrenia, vascular dementia with behavioral disturbance, Post Traumatic Stress Disorder (PTSD), generalized anxiety disorder and other specified depressive episodes. Additionally, R19 has physician prescribed psychotropic medications; Escitalopram (an antidepressant,) related to PTSD and other specified depressive episodes and antipsychotic medication Quetiapine, related to disorganized schizophrenia. Between 10/17/22 and 10/19/22, Surveyor reviewed R19's medical record which showed R19 had a PASRR Level 2 completed on 2/7/18 due to a diagnoses of serious mental illness and use of antipsychotics and psychotropic medications. Between 10/17/22 and 10/19/22, Surveyor reviewed R19's last full MDS assessment dated [DATE], which was related to a Significant Change of Condition. In Section A1500 (Preadmission Screening and Resident Review (PASRR)), the question asks: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was answered: No.