ST. FRANCIS NURSING HOME

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 5 (Residents #3 and #49) reviewed for resident rights, in that:<BR/>The facility failed to ensure Resident #3's and Resident #49's call light was within reach. <BR/>This failure could place residents at risk of not achieving independent functioning, dignity, and well-being. <BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet dated 10/16/24 reflected an 86 - year old female who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Depressive Disorder (a mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities), and Dementia (condition characterized by loss of brain functions such as memory loss). <BR/>Record review of Resident #3's Quarterly MDS assessment, dated 8/05/24, reflected a BIMS score of 3 which indicated severe cognition impairment. <BR/>Record review of Resident 3's care plan, dated 2/14/24, reflected Impaired mobility related to Dementia interventions keep call light within reach.<BR/>Observation and interview on 10/16/24 in Resident #3's room at 10:20 AM revealed the call light was found on the night stand out of arms reach. Resident # 3 stated, They will come check on me if call light is out of reach. <BR/>2. Record review of Resident #49's face sheet, dated 10/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: Heart Failure (a condition in which heart doesn't pump as well as it should), Osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the end of bones breaks down over time), and Hyperlipidemia (a condition where there are high levels of lipids in the blood) . <BR/>Record review of Resident #49's Quarterly MDS assessment, dated 7/30/24, reflected a BIMS score of 12 which indicated moderate cognition impairment. <BR/>Record review of Resident #49's care plan, dated 11/8/23, reflected Impaired physical mobility related to decreased strength with interventions keep essential items call light within reach. <BR/>Observation and interview on 10/16/24 in Resident #49's room at 10:45 AM, revealed the call light was on the night stand out of arm's length. Resident #49 stated they work so hard they forgot to move that thing (call light) close to me, I will have to send smoke signals if I need help.<BR/>During an interview on 10/16/24 at 11:00 AM, CNA A stated she was the assigned nursing assistant for Resident #3, and Resident #49 she mentioned she did not know how Resident #3's and Resident # 49's call light ended up on the nightstand, but she always clipped call light to the residents' clothes when they were up out of bed. CNA A also noted if Resident #3 and Resident #49 lacked access to the call light, it could potentially lead to a possible fall if they requested assistance. <BR/>During an interview with the DON on 10/17/24, at 8:35 AM, the DON emphasized the importance of ensuring the call light was accessible to all residents, and stated that the lack of accessibility to a call light for any resident could lead to a potential negative outcome if assistance is needed. The DON also mentioned charge nurses currently monitored this task during their morning rounds daily, and she and her ADON were responsible for overseeing this process.<BR/>Record review of the facility's policy titled, Answering Call Light, undated, revealed, when a resident is in bed or confined to a wheel chair be sure call light is with in reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning was provided such care, consistent with professional standards of practice, for 2 of 3 residents (Residents #6 and #23) reviewed for respiratory care in that:<BR/>The facility failed to ensure Residents #6 and #23's, oxygen tubing was dated. <BR/>This deficient practice could place residents at risk for an increase in respiratory complications.<BR/>The findings were:<BR/>1. Record review of Resident #6's face sheet, dated 10/17/24, reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included: Hypertension (a condition where the pressure in your blood vessels is persistently high), Heart Failure (long term condition that occurs when the heart can not pump enough blood to meet the body's need's), and Hearing loss (Inability to hear sound in one or both ears). <BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 12 which indicated moderate cognitive impairment. <BR/>Record review of Resident #6's care plan, dated 8/13/24, reflected the resident received oxygen therapy with interventions of administer oxygen as ordered. <BR/>Record review of Resident #6 monthly physician orders for The month of October 2024, reflected an order to change oxygen tubing weekly on Sunday. <BR/>Observation and interview on 10/17/24 at 9:45 a.m. revealed Resident #6 in her room reading with the oxygen tubing which was undated. Resident #6 stated she did not recall if the tubing was ever dated. <BR/>2. Record review of Resident #23's face sheet dated 10/17/24, reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included: General Anxiety (feeling of fear, dread and uneasiness that can be a normal reaction to stress), Congestive Heart Failure (serious condition that occurs when the heart cant pump enough blood to meet the needs of body), and Dependent on Oxygen (requirement of supplemental oxygen constantly). <BR/>Record review of Resident #23's Quarterly MDS, dated [DATE], reflected a BIMS score of 13 which indicated moderate cognitive impairment. <BR/>Record review of Resident #23's care plan, dated 4/10/24, reflected the resident was on continuous oxygen related to shortness of breath. <BR/>Record review of Resident #23's monthly physician orders for the month of October 2024, reflected an order to change oxygen tubing weekly on Sunday. <BR/>Observation and interview with Resident #23 on 10/17/24 at 11:25 a.m., in the dining room revealed Resident #23 waiting to be served lunch wearing a portable oxygen tank with oxygen tubing which was undated. Resident #23 stated, I don't recall if oxygen tubing gets changed.<BR/>During an interview with LVN C on 10/17/24 at 12:28 p.m., LVN C stated she was the assigned LVN for Residents #6 and #23 and stated there was no date on the oxygen tubing for both residents. LVN C stated she did not know why the residents' oxygen tubing was undated and revealed night shift nurses usually dated and changed oxygen tubing weekly. LVN C stated, if the oxygen tubing was undated, we would not know when it was last changed which could cause a possible respiratory infection. <BR/>During an interview with the DON on 10/18/24 at 2:27 p.m., the DON confirmed Residents #6 and #23 should have had their oxygen tubing changed and dated by the night shift. The DON stated Residents #6 and #23 risked a possible respiratory infection due to the oxygen tubing being undated as no one would know when it was last changed. The DON stated she was responsible for over seeing this task was completed and would have the ADON start monitoring this weekly moving forward. <BR/>Record review of the facility's policy titled, Oxygen Equipment, undated, revealed, label all equipment such as oxygen tubing with date / time / initials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days , except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #41) reviewed for pharmacy services, in that:<BR/>The facility failed to ensure Resident #41 had a stop date for PRN Xanax 0.25 mg (a medicine used to treat the symptoms of anxiety).<BR/>This failure could place residents at risk of receiving unnecessary psychotropic medications. <BR/>The findings include:<BR/>Record review of Resident #41's face sheet, dated 10/16/24, reflected an 84- year old female who was admitted to the facility on [DATE] with diagnoses which included: Anxiety (a feeling of fear, dread, and uneasiness), Dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), and Hypertension (when the pressure in your blood vessels is too high).<BR/>Record review of Resident #41's most recent comprehensive MDS assessment, dated 10/08/24, revealed the resident was severely cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications.<BR/>Record review of Resident #41's comprehensive care plan dated 10/16/24 reflected the resident had a diagnosis of anxiety and used antianxiety medication as ordered by the physician.<BR/>Record review of Resident #41's Order Summary Report, dated 10/16/24, reflected the following: <BR/>- Xanax Oral Tablet 0.25 MG, give 1 tablet by mouth twice a day as needed for anxiety disorder, with start date 10/11/24 and no stop date.<BR/>Record review of Resident #41's Medication Administration Record for October 2024 revealed Xanax 0.25 mg was not administered PRN all month in October 2024. <BR/>During an observation and interview on 10/16/24 at 12:17 p.m. Resident #41 was observed in wheelchair awake and alert. Resident #41 stated she did not recall if she had been administered any medications. <BR/>During an interview on 10/16/24 at 12:25 p.m., LVN C disclosed she did not recall if she had administered Xanax to Resident #41 to help with anxiety. LVN C stated psychotropic medications like Xanax should be used for a limited time, usually up to 14 days. After 14 days, the nurse was required to contact the physician to reassess the resident's need for the medication. LVN C stated she was unsure why the order for Xanax for Resident #41 was written for an indefinite period, and she expressed concern the resident was at risk of falls by taking the medication for more than 14 days.<BR/>During an interview and record review on 10/17/24 at 2:10 p.m., the DON revealed Resident #41 required the use of Xanax as recommended by the physician due to the resident's diagnosis. The DON stated if the medication was taken all the time, it could result in Resident #41 being overmedicated. After reviewing Resident #41's order summary, the DON confirmed there was no stop date on the order for prn Xanax . The DON revealed she was unaware Xanax should only be ordered for 14 days and then reassessed by a physician for continued use. The DON stated moving forward she would be responsible for overseeing that psychotropic drugs were limited to 14 days, and her Assistant Director of Nursing was to start monitoring this daily moving forward to prevent this from occurring again.<BR/>Record review of the facility's policy and procedure titled, Antipsychotic Medication, undated, revealed, PRN antipsychotics: 14 day limitation on all PRN orders, order may not be extended beyond the 14 day limit.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder or related condition for level II resident review upon a significant change in status assessment for 1 of 1 Resident (Resident #2) reviewed for PASARR eligibility, in that: <BR/>The facility failed to refer Resident #2 for a PASARR level II evaluation after being diagnosed with Major Depressive Disorder (MDD) and Bipolar Disorder. <BR/>This deficient practice could affect residents with new mental illness diagnoses and it could result in residents not receiving services as needed. <BR/>The findings were:<BR/>Review of Resident #2's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including (MDD), Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest). Further review revealed during 2017 Resident #2 was diagnosed with Bipolar Disorder (mental health condition defined by periods (or episodes) of extreme mood disturbances that affect mood, thoughts, and behavior). <BR/>Review of Resident #2's annual MDS assessment, 6/26/23, revealed she had a BIMS of 3 indicative of severe cognitive impairment, and diagnoses of depression and Bipolar. <BR/>Review of Resident #2's Care Plan, dated 6/28/23, revealed Resident #2 had Depression and Bipolar and receiving psychotropic medications for these conditions.<BR/>Review of Resident #2's EHR revealed she had a PASARR pre-screening completed prior to admission but there was no evidence she had a PASARR level II evaluation since being diagnosed with MDD and Bipolar. <BR/>Interview on 09/07/23 at 02:27 PM with the SW revealed she was in charge of the ensuring the PASARR process was completed for the residents. However, stated she was not familiar with it. The SW stated she had an entry level PASARR but had never referred anyone for a Level II evaluation including Resident #2 because she had Dementia. Upon the SW's review of Resident #2's diagnoses she confirmed Resident #2 had MDD upon admission; diagnosed with Bipolar during 2017 and diagnosed with Dementia during 2018. The SW confirmed this information and stated she understood qualifying residents received services through the local authority but again stated she had not referred Resident #2 for a Level II evaluation. The SW stated she had not received training since 2019 and was not familiar with the current requirements or processes in place. <BR/>Interview on 09/08/23 at 01:15 PM with the DON revealed she read the licensing standards for PASARR level II screening and confirmed staff should have submitted a request for a level II screening for Resident #2 related to her diagnosis of MDD and then Bipolar Disorder. She stated she completed PASARR training before COVID but neither she nor staff had received recent training. The DON stated she understood if Resident #2 met the level 11 requirements then she would qualify for services and this was why it was important to request the screening. <BR/>Review of a facility policy title, PASARR Policy., undated, read: Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that Medicaid-certified nursing facilities: 1. Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). 2. Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). 3. Provide all applicants the services they need in those settings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that:<BR/>1. The facility failed and refused to readmit Resident #1 from the hospital where he was transferred for evaluation and treatment.<BR/>2. The facility did not give Resident #1 or the representative a discharge notice when he was transferred to another facility from the hospital.<BR/>3. The facility did not permit Resident #1 to remain in the facility and failed to initiate a 30-day discharge based upon the facility's ability to meet the resident's needs and welfare. <BR/>These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process.<BR/>Findings Include:<BR/>Record review of Resident #1's admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). <BR/>Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. <BR/>During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police.<BR/>During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. <BR/>During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: <BR/>1) <BR/>Resident/Representative verbal or written notice of intent to leave the facility.<BR/>2) <BR/>Comprehensive care plan that includes the resident's goals for admission and discharge<BR/>3) <BR/>Discharge planning process<BR/>4) <BR/>Discharge summary<BR/>5) <BR/>Signed physician order of discharge<BR/>6) <BR/>Notice to Adult Protective Service (APS)<BR/>7) <BR/>Meeting with Interdisciplinary Team (IDT) about discharge<BR/>8) <BR/>Required 30-day notice to Resident #1 <BR/>9) <BR/>No communication with receiving facility<BR/>Record review of Resident #1's progress notes, dated 08/17/23, revealed the following:<BR/>-On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. <BR/>-On 10/05/22 another note states he was forgetful and follows redirection. <BR/>-On 10/06/23 Resident was pleasant to talk with and was looking for his family member. <BR/>-Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. <BR/>-On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. <BR/>-On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. <BR/>- On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. <BR/>-On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. <BR/>-On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. <BR/>-On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors.<BR/>-On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. <BR/>-On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. <BR/>-On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. <BR/>-On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. <BR/>-A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. <BR/>-A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR &lt;10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. <BR/>-On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. <BR/> Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that:<BR/>1. The facility failed and refused to readmit Resident #1 from the hospital where he was transferred for evaluation and treatment.<BR/>2. The facility failed to establish and follow a written policy on permitting the resident to return to the facility after he was hospitalized .<BR/>These deficient practices could affect residents discharged from the facility and their ability to return to the facility.<BR/>Findings Include:<BR/>Record review of Resident #1's admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). <BR/>Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. <BR/>During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police.<BR/>During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. <BR/>During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: <BR/>1) <BR/>Resident/Representative verbal or written notice of intent to leave the facility.<BR/>2) <BR/>Comprehensive care plan that includes the resident's goals for admission and discharge<BR/>3) <BR/>Discharge planning process<BR/>4) <BR/>Discharge summary<BR/>5) <BR/>Signed physician order of discharge<BR/>6) <BR/>Notice to Adult Protective Service (APS)<BR/>7) <BR/>Meeting with Interdisciplinary Team (IDT) about discharge<BR/>8) <BR/>Required 30-day notice to Resident #1 <BR/>9) <BR/>No communication with receiving facility<BR/>Record review of Resident #1's progress notes, dated 08/17/23, revealed the following:<BR/>-On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. <BR/>-On 10/05/22 another note states he was forgetful and follows redirection. <BR/>-On 10/06/23 Resident was pleasant to talk with and was looking for his family member. <BR/>-Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. <BR/>-On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. <BR/>-On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. <BR/>- On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. <BR/>-On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. <BR/>-On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. <BR/>-On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors.<BR/>-On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. <BR/>-On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. <BR/>-On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. <BR/>-On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. <BR/>-A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. <BR/>-A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR &lt;10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. <BR/>-On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. <BR/> Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure when the facility anticipates discharge, a resident must have a discharge summary that includes a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that:<BR/>The facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay which included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.<BR/>This deficient practice could affect resdients discharged from the facility due to improper discharge summary. <BR/>Findings Include:<BR/>Record review of Resident #1's admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). <BR/>Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. <BR/>During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police.<BR/>During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. <BR/>During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: <BR/>1) <BR/>Resident/Representative verbal or written notice of intent to leave the facility.<BR/>2) <BR/>Comprehensive care plan that includes the resident's goals for admission and discharge<BR/>3) <BR/>Discharge planning process<BR/>4) <BR/>Discharge summary<BR/>5) <BR/>Signed physician order of discharge<BR/>6) <BR/>Notice to Adult Protective Service (APS)<BR/>7) <BR/>Meeting with Interdisciplinary Team (IDT) about discharge<BR/>8) <BR/>Required 30-day notice to Resident #1 <BR/>9) <BR/>No communication with receiving facility<BR/>Record review of Resident #1's progress notes, dated 08/17/23, revealed the following:<BR/>-On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. <BR/>-On 10/05/22 another note states he was forgetful and follows redirection. <BR/>-On 10/06/23 Resident was pleasant to talk with and was looking for his family member. <BR/>-Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. <BR/>-On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. <BR/>-On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. <BR/>- On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. <BR/>-On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. <BR/>-On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. <BR/>-On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors.<BR/>-On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. <BR/>-On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. <BR/>-On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. <BR/>-On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. <BR/>-A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. <BR/>-A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR &lt;10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. <BR/>-On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. <BR/> Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with dignity and respect in a manner and environment that enhances his and her quality of life for 3 of 3 residents (Resident #7, #15, and #42) reviewed for , in that:<BR/>CNA B referred to Resident #7 and Resident #42 as feeders. <BR/>MA C shouted, twice in a dining area those are feeders, while pointing to table of residents, which included Resident #15. <BR/>This deficient practice could affect residents at the facility who receive assistance with meals and could place them at-risk for diminished quality of life, loss of dignity and low self-esteem.<BR/>The findings were:<BR/>Record review of Resident #7's admission record, dated 07/22/2022, revealed an initial admission date of 10/22/2020 and a readmission date of 12/23/2020 with diagnoses that included chronic obstructive pulmonary disease, anemia, and dementia. <BR/>Record review of Resident #7's MDS, a Quarterly assessment dated [DATE], revealed under Section C her BIMS (Brief Interview for Mental Status) score was 3 out of 15, which indicated her cognition was severely impaired. Review of Section B revealed the resident vision was impaired. Review of Section G revealed the resident required extensive assistance from staff with eating.<BR/>Record review of Resident #15's admission record, dated 07/22/2022, revealed an admission date of 02/02/2018 with a diagnosis that included anemia, bradycardia (low heart rate), dysphagia (swallowing difficulty), age-related physical debility, muscle weakness, and cognitive communication deficit. <BR/>Record review of Resident #15's MDS, a Quarterly assessment dated [DATE], revealed under Section C her BIMS (Brief Interview for Mental Status) score was 0 out of 15, which indicated her cognition was severely impaired. Review of Section B revealed the resident hearing was minimally difficult, and vision was impaired. Review of Section G revealed the resident required extensive assistance from staff with eating.<BR/>Record review of Resident #42's admission record, dated 07/22/2022, revealed an admission date of 03/15/2017 with a diagnosis that included age related physical debility, muscle weakness, lack of coordination, altered mental status, macular degeneration (vision impairment), and dementia. <BR/>Record review of Resident #42's MDS, a Quarterly assessment dated [DATE], revealed under Section C her BIMS (Brief Interview for Mental Status) score was 0 out of 15, which indicated her cognition was severely impaired. Review of Section B revealed the resident hearing was minimally difficult, and vision was highly impaired. Review of Section G revealed the resident required extensive assistance from staff with eating.<BR/>Interview on 07/19/22 at 1:20 PM with CNA B, this surveyor asked when Resident #7 and Resident #42 would be served lunch. CNA B stated Resident #7 and Resident #42 are feeders, so they serve her prior to the rest of the residents. <BR/>Observation on 07/20/22 at 12:38 PM revealed when MA C was assisting with meal service in the dining area. MA C shouted those are feeders twice while pointing to a table of residents and talking to other staff. <BR/>Interview on 07/20/22 at 12:40 PM with MA C confirmed she had used the term feeders when she referred to a table of residents who were receiving assistance with meals. <BR/>Interview on 07/22/22 at 9:41 AM with the ADON confirmed staff should not refer to residents as feeders, that is would be a dignity issue. <BR/>Interview with Administrator on 07/22/22 at 9:45 AM revealed staff are trained to use other terms than feeder. The Administrator stated the staff member maybe new or staff that have been working at the facility for a long period of time and have a habit of using these types of words. The Administrator stated she tries to promote other terms during in-services, by passing out flyers, and posting signage with more appropriate terms. <BR/>Review of document titled QAPI: DINNING ROOM CULTURE CHANGE (no date) . Old Words/Phrases: Feeders . New words/Phrases: Feeders= People who need assistance with meals. <BR/>Review of the policy titled Quality of Life- Dignity (no date) revealed Policy statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.7. Staff shall speak respectfully to resident at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on observation, interview and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that:<BR/>The facility failed to ensure sanitary practices were maintained in the kitchen as clean spatulas, ladles, pots were hanging on a fixture above a 3-compartment sink that had dirty pots and a plastic container. <BR/>This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illnesses. <BR/>Finding included:<BR/>In an observation of the kitchen on 7/19/22 at 11:15 a.m., accompanied by [NAME] A revealed there were pots, pans, tongs, ladles, spatulas hanging above 3 compartment sink containing soiled pots and a plastic container was observed. <BR/>In an interview on 7/19/22 at 11:15 a.m., [NAME] A stated they washed those dishes in that sink and placed them on the other side of that sink to dry. [NAME] A stated the pots and spatulas hanging above were clean where they manually wash dishes. <BR/>In an interviewed on 07/19/22 11:20 a.m., the Dietary Supervisor stated they washed and rinse dthe soiled dishes in the 3-compartment sink and placed them on the fixtures above the sink to dry. The Dietary Supervisor stated the fixtures were placed there when the sink was installed.<BR/>In an interviewed on 07/21/22 at 10:20 a.m., the Dietary Supervisor stated they trained their kitchen staff once a year on dish washing and storage. <BR/>Record review of Facility's policy on Storing clean dishes in the Kitchen (not dated) revealed:<BR/>-After cleaning and sanitizing it is necessary to let dishes air dry on the drain board or rack. Once dry you should store them in a clean place where they will be protected from contamination.<BR/>-Cleaned and sanitized food equipment and utensils must be stored above the floor in a clean, dry location in a way that protects them from being contaminated by splash, dust and contaminants.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for effective pest control, in that:<BR/>The facility failed to ensure the facility was free from live rodents.<BR/>This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents.<BR/>The findings include: <BR/>Observation on 10/15/2024 at 8:54 AM in the dry storage room of the kitchen revealed a rat running out of the dry storage room into the kitchen.<BR/>During an interview on 10/17/2024 at 11:30 AM, the assistant KS stated she observed the rat as it exited the dry storage room.<BR/>During an interview on 10/18/2024 at 11:05 AM, the KS and assistant KS stated neither of them had ever seen a rat in the kitchen prior to that day. There was no evidence of any food packages that were chewed open by a rat anywhere in the kitchen. Rodents could carry diseases and contaminate food. <BR/>During an interview on 10/18/2024 at 11:20 AM, the Maintenance Director stated Pest Control came to the facility twice per month to treat for rodents and pests. A small opening in the drywall was found in the mechanical room that housed the compressors for the cooler and freezer, but the opening did not lead to the outside and he did not believe the rat entered from this opening. The Maintenance Director did not know how the rat could have possibly entered the facility. There had never been a rat sighting in the facility prior to this one.<BR/>Record review of the contracts provided by the facility revealed the facility had a contract with a pest control company and the facility was serviced for roaches and pests twice per month. The most recent visit was 4 days prior to the sighting of the rodent, on 10/11/2024. The contractor serviced every area of the facility, including exterior areas and the kitchen.<BR/>Record review of the facility policy, Pest Control Policy, undated, revealed: 3. Definitions: Pests: Includes rodents, insects, and other unwanted organisms that may affect the health of the residents. 4. Responsibilities: Management: Oversee pest control measures and ensure compliance with health regulations. Staff: Report pest sightings. Pest Control Contractor: Conduct regular inspections and treatments, adhering to safety measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (Residents #47 and #51) reviewed for infection control, in that: <BR/>The facility failed to ensure MA C did not sanitize the blood pressure cuff between Residents #47's and #51's care. <BR/>This deficient practice could place residents at risk of infections. <BR/>The findings include:<BR/>Record review of Resident #47's face sheet, dated 7/22/22, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which atrial fibrillation (abnormal heart rhythm), Type II diabetes mellitus, hypertension (high blood pressure), and presence of cardiac pacemaker. <BR/>Record review of Resident #51's face sheet, dated 7/22/22, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which heart failure, age related physical debility, hypertension (high blood pressure), pain, and macular degeneration (visual impairment). <BR/>Observation on 07/21/22 at 9:00 a.m. revealed MA C obtained Resident #47's blood pressure prior to giving blood pressure medication. MA C placed the blood pressure cuff back on top of the medication cart without sanitizing it. <BR/>Observation on 07/21/22 at 9:20 a.m. MA C used the same unsanitized blood pressure cuff to obtain Resident #51's blood pressure. <BR/>In an interview on 07/21/22 at 9:27 a.m. MA C stated she would have normally sanitized the blood pressure cuff with a hand sanitizer spray she had on her cart. MA C stated she was not sure if this surveyor would have an issue with her using a spray. MA C showed the bottle to this surveyor which stated 75% alcohol. MA C also stated she had wipes to use on her cart to sanitize medical equipment. MA C pointed to the package of sanitizing wipes on top of her medication cart. <BR/>In an interview on 07/22/22 at 9:38 a.m. the ADON stated staff should be sanitizing equipment with spray or wipes between resident care. The ADON stated not sanitizing could possibly spread infection and there should be no time they are not sanitizing between residents. The ADON stated the facility did trainings and in services for infection control. <BR/>Record review of document titled In Service: Infection Control and updates, dated 06/10/2021, stated . properly disinfect equipment in between patient use. MA C name and signature noted on the document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 2 residents (Resident #1) reviewed for discharge requirement.<BR/>There was no documentation from the physician which indicated the resident had specific needs that could not be met in the facility.<BR/>This deficient practice could affect residents discharged from the facility due to improper discharge. <BR/>Findings Include:<BR/>Record review of Resident #1's admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). <BR/>Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. <BR/>During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police.<BR/>During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. <BR/>During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: <BR/>1) <BR/>Resident/Representative verbal or written notice of intent to leave the facility.<BR/>2) <BR/>Comprehensive care plan that includes the resident's goals for admission and discharge<BR/>3) <BR/>Discharge planning process<BR/>4) <BR/>Discharge summary<BR/>5) <BR/>Signed physician order of discharge<BR/>6) <BR/>Notice to Adult Protective Service (APS)<BR/>7) <BR/>Meeting with Interdisciplinary Team (IDT) about discharge<BR/>8) <BR/>Required 30-day notice to Resident #1 <BR/>9) <BR/>No communication with receiving facility<BR/>Record review of Resident #1's progress notes, dated 08/17/23, revealed the following:<BR/>-On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. <BR/>-On 10/05/22 another note states he was forgetful and follows redirection. <BR/>-On 10/06/23 Resident was pleasant to talk with and was looking for his family member. <BR/>-Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. <BR/>-On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. <BR/>-On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. <BR/>- On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. <BR/>-On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. <BR/>-On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. <BR/>-On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors.<BR/>-On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. <BR/>-On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. <BR/>-On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. <BR/>-On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. <BR/>-A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. <BR/>-A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR &lt;10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. <BR/>-On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. <BR/> Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

Based on observation, interviews, and record reviews, the facility failed to post information on a daily basis regarding the total number of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical nurses or licensed vocational nurses, certified nurses aides and resident census for 1 of 1 facility reviewed for posting.<BR/>The facility failed to include the actual hours worked for the nursing staff on the nursing daily staff posting <BR/>This deficient practice could place residents at risk or missed or inadequate care. <BR/>The findings were:<BR/>Observation on 10/16/24 at 9:30 a.m., revealed the facility had a daily nursing staffing posting for 10/16/24 in a visible area on the wall adjoining the main entrance to the facility. The daily nursing staffing posting included the following: 1- the hours of each of the nursing shifts for the 24 hour period, 2- the staff working on the shift which included registered nurses, licensed vocational nurses, certified nurses aides, restorative aides, and medications aides, 3-the number of the staff by discipline who worked on the shift, 4- the total hours worked for each group of staff during the shift, and 5- the summary of the total hours worked for that nursing discipline during the shift, and 6-the resident census for the day.<BR/>During an interview with the HR Director on 10/18/24 at 12:15 p.m. the HR Director stated the hours worked by licensed and unlicensed nursing staff usually exceeded the number of hours for these disciplines that were posted. The HR Director provided sample documentation for the dates of 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, and 10/16/24 which reflected licensed and unlicensed staff, on those days, had actual hours worked that exceeded the number of hours that were posted for that day. The HR Director stated the licensed and unlicensed staff generally stayed at the facility longer than required in order to ensure a more thorough change of shift.<BR/>During an interview with the Administrator on 10/18/24 at 12:30 p.m., the Administrator stated the facility always posted the daily nurse staffing form in a visible location and the nursing hours posted was usually less than the actual hours worked. The Administrator stated she felt the nursing staff hours that were posted demonstrated staffing levels that met the needs of the residents.<BR/>Record review of the facility's posted daily nursing staffing forms for the time period 9/1/24 through 10/16/24 reflected the daily staffing postings did not include the actual hours worked for the licensed and unlicensed nursing staff<BR/>Record review of the facility's undated policy on Staffing reflected, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Our facility furnishes information from payroll records setting forth the actual recorded time, and types of personnel on each day of each quarter to appropriate state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #3) reviewed for privacy, in that:<BR/>The facility failed to ensure MA D locked the computer, which exposed Resident #3's morning medication list after she walked away and left the computer unattended. <BR/>This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. <BR/>The findings include:<BR/>Record review of Resident #3's face sheet dated 10/16/24 reflected an 86 - year old female who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Depressive Disorder (a mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities), and Dementia (condition characterized by loss of brain functions such as memory loss). <BR/>Record review of Resident #3's Quarterly MDS assessment, dated 8/05/24, reflected a BIMS score of 3 which indicated severe cognition impairment. <BR/>Observation on 10/17/24 at 9:12 AM, revealed MA D prepared Resident's #3's morning medication and ,walked away from the computer, MA D did not lock the computer screen. <BR/>During an interview on 10/17/24 at 9:20 AM, MA D stated she was not aware of the option to lock the computer screen and believed minimizing the screen was sufficient. MA D stated when she stepped away from the computer, Resident #3's private medical information may have been exposed.<BR/>During an interview on 10/17/24 at 11:41 AM, the DON stated she was not aware Resident #3's records were left open and unattended. The DON stated it was her expectation for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members were responsible for ensuring the protection of residents' information. The DON expressed concern that leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated the ADON would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks.<BR/>Record review of the facility's policy titled, Privacy of Computers during medication pass, dated March 2014, reflected: all patient information accessed during the medication pass shall be positioned to minimize visibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (Residents #47 and #51) reviewed for infection control, in that: <BR/>The facility failed to ensure MA C did not sanitize the blood pressure cuff between Residents #47's and #51's care. <BR/>This deficient practice could place residents at risk of infections. <BR/>The findings include:<BR/>Record review of Resident #47's face sheet, dated 7/22/22, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which atrial fibrillation (abnormal heart rhythm), Type II diabetes mellitus, hypertension (high blood pressure), and presence of cardiac pacemaker. <BR/>Record review of Resident #51's face sheet, dated 7/22/22, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which heart failure, age related physical debility, hypertension (high blood pressure), pain, and macular degeneration (visual impairment). <BR/>Observation on 07/21/22 at 9:00 a.m. revealed MA C obtained Resident #47's blood pressure prior to giving blood pressure medication. MA C placed the blood pressure cuff back on top of the medication cart without sanitizing it. <BR/>Observation on 07/21/22 at 9:20 a.m. MA C used the same unsanitized blood pressure cuff to obtain Resident #51's blood pressure. <BR/>In an interview on 07/21/22 at 9:27 a.m. MA C stated she would have normally sanitized the blood pressure cuff with a hand sanitizer spray she had on her cart. MA C stated she was not sure if this surveyor would have an issue with her using a spray. MA C showed the bottle to this surveyor which stated 75% alcohol. MA C also stated she had wipes to use on her cart to sanitize medical equipment. MA C pointed to the package of sanitizing wipes on top of her medication cart. <BR/>In an interview on 07/22/22 at 9:38 a.m. the ADON stated staff should be sanitizing equipment with spray or wipes between resident care. The ADON stated not sanitizing could possibly spread infection and there should be no time they are not sanitizing between residents. The ADON stated the facility did trainings and in services for infection control. <BR/>Record review of document titled In Service: Infection Control and updates, dated 06/10/2021, stated . properly disinfect equipment in between patient use. MA C name and signature noted on the document.

Based on observation, interview and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that:<BR/>The facility failed to ensure sanitary practices were maintained in the kitchen as clean spatulas, ladles, pots were hanging on a fixture above a 3-compartment sink that had dirty pots and a plastic container. <BR/>This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illnesses. <BR/>Finding included:<BR/>In an observation of the kitchen on 7/19/22 at 11:15 a.m., accompanied by [NAME] A revealed there were pots, pans, tongs, ladles, spatulas hanging above 3 compartment sink containing soiled pots and a plastic container was observed. <BR/>In an interview on 7/19/22 at 11:15 a.m., [NAME] A stated they washed those dishes in that sink and placed them on the other side of that sink to dry. [NAME] A stated the pots and spatulas hanging above were clean where they manually wash dishes. <BR/>In an interviewed on 07/19/22 11:20 a.m., the Dietary Supervisor stated they washed and rinse dthe soiled dishes in the 3-compartment sink and placed them on the fixtures above the sink to dry. The Dietary Supervisor stated the fixtures were placed there when the sink was installed.<BR/>In an interviewed on 07/21/22 at 10:20 a.m., the Dietary Supervisor stated they trained their kitchen staff once a year on dish washing and storage. <BR/>Record review of Facility's policy on Storing clean dishes in the Kitchen (not dated) revealed:<BR/>-After cleaning and sanitizing it is necessary to let dishes air dry on the drain board or rack. Once dry you should store them in a clean place where they will be protected from contamination.<BR/>-Cleaned and sanitized food equipment and utensils must be stored above the floor in a clean, dry location in a way that protects them from being contaminated by splash, dust and contaminants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of residents' food items for 4 of 5 resident refrigerators (refrigerators in resident Rooms 115, 208, 213, and 215) reviewed for personal food policy, in that:<BR/>1. The personal refrigerators in three residents' Rooms (115, 208, and 215) contained food items which were unlabeled and undated. <BR/>2. The internal temperature of the refrigerator on resident room [ROOM NUMBER] exceeded 41 degrees Fahrenheit.<BR/>These deficient practices could place residents at risk of foodborne illness due to consuming foods which were spoiled. <BR/>The findings were: <BR/>1. a. Observation on 10/15/24 at 10:28 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained melted ice cream shake in refrigerator which was unlabeled and undated. <BR/>Observation on 10/15/24 at 11:10 a.m., revealed undated and unlabeled melted ice cream shake in resident room [ROOM NUMBER] personal refrigerator was still present. <BR/>During an Interview with CNA A on 10/15/24 at 11:20 a.m., revealed personal refrigerator in resident's room [ROOM NUMBER] contained undated and unlabeled melted ice cream shake.<BR/>b. Observation on 10/15/24 at 11:20 a.m. revealed the personal refrigerator in residents' room [ROOM NUMBER] contained sliced apples that were undated and unlabeled <BR/>Observation on 10/15/24 at 11:30 a.m., revealed unlabeled and undated sliced apples in resident's room [ROOM NUMBER] personal refrigerator was still present. <BR/>c. Observation on 10/15/24 at 11:35 a.m. revealed the personal refrigerator in resident's room [ROOM NUMBER] contained hard boiled eggs that were undated and unlabeled. <BR/>Observation on 10/15/24 at 10:37 a.m. revealed the unlabeled and undated hard-boiled eggs in residents room [ROOM NUMBER] personal refrigerator was still present. <BR/>During an Interview with CNA B on 10/15/24 at 11:45 a.m. revealed the personal refrigerator in rooms [ROOM NUMBERS] contained food that was undated and unlabeled. <BR/>During an interview with the DON and ADON on 10/15/24 at 12:25 p.m., the DON and ADON stated perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated housekeeping were responsible for overseeing this and currently this was not being monitored.<BR/>2. Observation on 10/15/2024 at 11:06 a.m. of the thermometer inside the refrigerator revealed it read 53 degrees Fahrenheit. <BR/>During an interview on 10/15/2024 at 11:15 a.m., LVN E stated the thermometer inside the refrigerator read 55 degrees and was too high. LVN E also stated according to the temperature log, the temperature of the refrigerator had exceeded the acceptable range for several days and nothing had been done about it. The night shift took and recorded the temperatures; however, it was also his responsibility to monitor the temperatures to ensure they were in the proper range and sometimes these things got overlooked.<BR/>Record review of the Refrigerator Temperature Log for October 2024 placed inside a document protector taped to the right side of the refrigerator inside room [ROOM NUMBER] revealed the temperature recorded every day from 10/01/2024 - 10/14/2024 was 50 degrees Fahrenheit.<BR/>Record review of the facility's undated policy, Foods Brought by Family/Visitors, reflected, .Food brought to the facility by visitors and family is permitted. The nursing staff will discard perishable foods on or before the use by date <BR/>Record review of the facility's undated In-Room Refrigerator Policy, reflected, The housekeeping supervisor, or her designee, will also inspect in-room refrigerators monthly and keep a written log of all in-room refrigerators and the dates they are inspected .In room refrigerators must be kept clean and in good working condition .