Every finding on record at Good Samaritan - West Union

Based on electronic health record (EHR), clinical records, facility records, facility policy review, and staff interview the facility failed to timely report an allegation of abuse for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 35 residents. Findings Include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS documented Resident #2 had no hallucinations or delusions. The MDS identified Resident #2 had been occasionally incontinent of urine. The MDS listed diagnoses of renal insufficiency, over-active bladder, non-Alzheimer's dementia, and post-traumatic stress disorder (PTSD).The Care Plan Report revised on 4/20/26 identified Resident #2 had a psychosocial well-being deficit related to Post Traumatic Stress Disorder (PTSD). The Care Plan Intervention dated 4/20/26 directed staff to explain all care procedures prior to completing, and the Care Plan intervention revised on 4/20/26 directed to allow resident time to answer questions, verbalize feelings perceptions, and fears.A Suggestion or Concern facility form dated 4/10/26 completed by Staff A, Lead Social Services Coordinator documented Resident #2 reported a certified nursing assistant (CNA) came in to do a brief check for incontinence and stated she felt like the CNA squeezed her vaginal lips. The Director of Nursing (DON) investigated Resident #2's concern and determined the incident occurred on 3/23/26. The investigation documented Staff B, Licensed Practical Nurse had witnessed an agency staff member check Resident #2's brief for incontinence with no inappropriate contact occurring.The Progress Notes lacked documentation of Resident #2 reporting an incident. An Outpatient Behavior Health Progress note dated 4/23/26 at 11:45 AM, documented the following:Resident #2 stated she could not remember the date, just stated a couple of nights ago that a CNA (Certified Nursing Assistant) had came into her room to check if she was dry. Resident #2 stated the CNA that checked her stuck her hands down her pants to check her and the CNA squeezed her vagina lips. Resident #2 stated that she yelled at the CNA and the lady stopped. Resident #2 stated that she did tell staff member DON (Director of Nursing) and the Administrator. Resident #2 stated that she had asked staff that this particular CNA not be her worker at night. Resident #2 stated that the worker did come in her room again several nights ago and Resident #2 stated she screamed for the CNA to get out of her room. Resident #2 was visibly upset and crying and this triggered some feeling regarding things from her past. Review of the Self Reports provided by the facility documented an incident date of 3/23/26 filed on 4/24/26 for an allegation of abuse.On 5/19/26 at 3:47 PM, the DON recalled Resident #2 reported a concern to the Social Worker on 4/10/26. The DON reported Resident #2 had kept voicing concerns and complained to a new provider. The DON decided to report the allegation to the appropriate state agency due to Resident #2's continued complaints. The DON acknowledged the report had been filed nearly a month after the incident occurred. The DON reported she is responsible for submitting reportable incidents to the appropriate state agency. The DON acknowledged the allegation was not reported timely.Review of the Abuse and Neglect - Rehab/Skilled, Adult Day Services, Therapy & Rehab with a revision date of 4/7/25 revealed the following:Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident/client property or witnesses suspected abuse, neglect or misappropriation of resident/client property, the employee will take measures to protect the resident/client, provided the safety of the employee is not jeopardized. The employee will then report the allegation to a supervisor.

Based on electronic health record (EHR) review, clinical records, facility records, facility policy review, and staff interviews the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) before the PASRR short term approval end date for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 35 residents.Findings Include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 2/25/26. The MDS identified Resident #2 was currently considered by the state level II PASRR process to have a serious mental illness. The MDS included a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. The MDS documented Resident #2 had no hallucinations or delusions. The MDS listed diagnoses of depression, bipolar disorder, and post-traumatic stress disorder.The Notice of PASRR Level II Outcome dated 2/16/26 documented a short-term approval end date of 4/17/26. The PASRR Outcome Explanation Notice of Short-Term Nursing Facility Approval revealed the following: .You need the level of services provided in a nursing facility for a time-limited period only. The number of approved days is listed on the first page of the notice. If you or the nursing facility things you need to stay in the nursing facility longer than the time period listed on the first page of this notice, the facility must contact [Redacted] to seek authorization for an additional period of time .Specialized services for your behavioral health and/or developmental conditions are required The nursing facility will be required to Care Plan in a PASRR Compliant fashion for all identified service including Specialized Services and Rehabilitative Services. Community Placement Supports must be included in the Care Plan in a PASRR compliant fashion if the individual has received a Short Term PASRR approval, the individual at any time states they wish to return to a lower level of care, and/or the MDS Section Q-500 indicates that the individual wishes to discharge to a lower level of care. Specialized services: You will need to be provide the following specialized services:Service or SupportInitial Psychiatric Evaluation to determine diagnosis and develop plan of careOngoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP) (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services.)Neuropsychological evaluation that begins with the psychological evaluation, by a psychologist, and leads to further neurological evaluation if indicated (to identify the functionality of the brain).On 5/19/26 at 2:48 PM, Staff C, MDS Coordinator/Registered Nurse (RN), acknowledged the current PASRR was completed on 2/16/26 with a time limited Level II ending on 4/17/26. Staff C verbalized she had been trying to submit an update and ensure services were in place and on the Care Plan Report. Staff C acknowledged she received a notification of non-compliance with Resident #2's PASRR on 4/24/26. Staff C revealed at that time psych appointment dates or medication management hadn't been in place for Resident #2. Staff C reported when she next went to work on submitting the update information to PASRR, Resident #2 had discharged against medical advice. Review of the resident's clinical record revealed they left the facility against medical advice on 5/2/26. On 5/20/26 at 12:30 PM, the Director of Nursing (DON) verbalized the MDS Coordinator was responsible for submitting updated PASRR information. The DON expected an update for a time limited Level II would be submitted prior to the end of the time limited date. Review of the Pre-admission Screening and Resident Review (PASARR)-Rehab/Skilled facility policy revised on 12/29/25 revealed the following:The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders (MD), intellectual disabilities (ID) and related conditions. This initial screening is referred to as a Level I and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identity individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility.PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings PASARR recommendations will be incorporated into the care plan (i.e., a PASARR recommendation for counseling to address a resident's social withdrawal could be care planned under mood state).The policy lacked direction for time limited Level II requirements.

Based on observation, clinical record review, policy review and staff interview the facility failed to provide education and obtain informed consent prior to starting psychotropic medication that have black box warnings (the most serious safety warning used by the Food and Drug Administration (FDA) and requires the healthcare provider to have a comprehensive discussion with the resident about the risks, benefits and alternatives for use) for 1 of 5 resident sampled (Resident #7). The facility identified a census of 38 residents.Findings include: Resident #7's 2/19/26 Minimum Data Set (MDS) Assessment documented the resident utilized a hearing aid and was able to hear with minimal difficulty. Resident #7 had unclear speech but was usually able to understand others. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. The MDS documented Resident #7 had little interest/pleasure in doing things 2-6 days; felt down, depressed or hopeless 7-11 days; had little energy 2-6 days; felt bad, or a failure of letting herself or family down 7-11 days; and moved/spoke slowly 12-14 days. The MDS documented diagnoses of cancer, heart failure, end stage renal disease, diabetes mellitus, Parkinson's Disease and depression. The MDS identified Resident #7 received antidepressant medication.A 9/05/25 Note to Attending Physician/Prescriber documented to start Mirtazapine (antidepressant medication) 15 Milligrams (MG) at bedtime.A 9/06/25 11:29 PM Health Status Progress Note documented Resident #7 was not making sense. Stated, have to get the stuff to keep them away. Nurse had to perform a sternal rub to get the resident's attention.A 9/06/25 11:44 PM Mood/Behavior Progress Note documented Resident #7 had been started on Mirtazapine 15 MG and is drowsy and talking in her sleep. A 9/07/25 1:22 PM Summary of Skilled Services Daily Skilled Note documented Resident #7 appeared drowsy and confused. A 9/07/25 4:08 PM Mood/Behavior Progress Note documented Resident#7 was drowsy in the afternoon. A 9/07/25 9:36 PM Other Progress Note documented Resident #7 was confused and thought it was morning. A 9/08/25 Urgent, Response Required facsimile (fax) sent to the provider detailed Resident #7 started mirtazapine 15 MG and had been extremely drowsy, talking in her sleep and was believed to be sensitive to the dose of antidepressant medication. The fax requested to reduce the dose of antidepressant medication to 7.5 MG for 14 days, then take the dose back up to 15 MG. The Provider responded 9/08/25 to reduce the antidepressant medication.The September 2025 Electronic Medication Administration Record (EMAR) documented Resident #7 received 15 MG of Mirtazapine 9/6/25 - 9/8/25 and Mirtazapine 7.5 MG from 9/9/25 -9/30/25.The October, November, December 2025 and January, February, March 2026 EMARs showed Resident #7 continued to receive the antidepressant medication each day at bedtime. An Order Review History Report electronically signed by the Provider on 12/19/25 documented a continued current order for Mirtazapine 7.5 MG, one tablet daily related to major depressive disorder. Interview completed on 3/10/26 at 3:00 PM Staff A, Licensed Practical Nurse (LPN) reported to her knowledge the psychotropic education and consent is completed by the Director of Nursing (DON). Interview on 3/10/26 at 3:03 PM the DON explained the physician is responsible for providing psychotropic medication education and getting consent when they order the medication. She completes the psychotropic medication education and consent for residents that newly admit to the facility on psychotropic medications. During an interview on 3/11/26 at 3:44 PM the MDS Coordinator explained there is a psychotropic medication assessment the nurses have to do before they start a psychotropic medication. Education is part of the psychotropic medication assessment. The education and consent should be addressed by the nurse that is taking the physician order for the medication before the medication is started. To her knowledge the nurses had received education regarding the psychotropic medication education and consent. The MDS Coordinator further explained the education and consent can be done by the resident if they are alert enough, otherwise it should be done with a family member. They have a three page document they go over with the resident/family and have signed. During an interview on 3/11/26 at 4:30 PM the Director of Nursing (DON) reported they still had not found any documentation that Resident #7 or a legal representative had received education and given informed consent for the use of the antidepressant medication. During an interview on 3/12/26 at 11:50 AM the DON explained she or the charge nurse, if she is not available, meets with the resident if they can understand or a family member to go over the medication, why the medication was ordered, dose, risk factors/side effects and benefits. The resident or family signs a psychotropic medication form to indicate they understand and they are consenting to the nurses administering the medication to the resident. The facility was not able to find documentation Resident #7 or a legal representative had received education or signed informed consent to start the antidepressant medication. The Psychotropic Medications Policy revised 12/09/25, provided by the facility, directed a consent form must be signed for the use of psychotropic medications. The Policy defined a psychotropic medication as any drug that affects the brain activity associated with mental processes and behavior which included anti-depressant medications.

Based on observation, clinical record review, policy review, and staff interview the facility failed to implement a revised Restorative Nursing Program (RNP) and failed to provide active assist range of motion (AAROM) per the RNP for 1 of 1 residents sampled (Resident #2). The facility identified a census of 38 residents. Findings include:Resident #2's 1/1/26 Minimum Data Set (MDS) Assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The Resident exhibited impaired functional mobility on one side of the upper and lower body; utilized a walker and wheelchair. The MDS listed diagnoses of stroke, hip fracture, and multiple sclerosis (a disabling autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves) that causes disruption of communication between the brain and body, leading to symptoms like fatigue, mobility challenges, vision problems, and numbness). The MDS documented Resident #2 participated in 1 day of restorative nursing active range of motion in the last 7 days.A 2/25/26 Therapy and Nursing Communication Form signed by the Physical Therapist specified a goal to maintain the current mobility level. The Form specified a restorative nursing program for the upper extremity, 3 times a week, 3 pound dowel for 15 repetitions, static standing for max time for 2 repetitions, arm bike, level 1 for 1 minute for 3 repetitions and lower extremity RNP laying or seated Therex with AAROM, 15 repetitions, standing at the wheeled walker with assist of one for max time for 2 repetitions. The Restorative Care Plan revised 3/01/26 directed the following:a. Nursing Rehabilitation #1: Active Range of Motion (AROM) laying down or seated Therex with AAROM (means to actively assist a resident with exercise when not able to complete the exercise themself) 15 repetitions, 3 times a week, updated 2/28/26).b. Nursing Rehabilitation #2 AROM standing at the wheeled walker, 1 assist for maximum time, 2 repetitions, 3 times a weekly.c. Nursing Rehabilitation #3 AROM, 3-pound dowel exercises, 15 repetitions, 3 times weekly. d. Nursing Rehabilitation #4 AROM static standing for maximum time for 2 repetitions, 3 times weekly.e. Nursing Rehabilitation #5 AROM, arm bike for 1 minute, 3 repetitions, 3 times a week. Observation on 3/11/26 at 12:47 PM revealed Resident #2 sunk into the seat of a wheelchair on a two inch pressure reducing cushion with her hips situated to the right and her upper torso to the left. Staff C, Restorative Aide (RA)/Certified Nursing Assistant (CNA) instructed Resident #2 to start lower body marches/knee raises while seated in the wheelchair. Resident #2 completed approximately 4 marches and struggled to get her knees lifted on both lower extremities. Staff C continued to count out the steps but did not provide any active assistance to help Resident #2 with the lower body marching. At 12:48 PM Staff C assisted Resident #2 to pull up her socks. Resident #2 stated she was sitting crooked in the wheelchair. Staff C adjusted Resident #2's position in the wheelchair and then continued to instruct her to lift her knees five more times. Resident #2 lifted her right knee approximately two inches up off the ground and stated her left (leg) couldn't do it. Staff C did not provide any AAROM during the marches/knee raises. Staff C instructed the resident to start leg kicks. Resident #2 completed three repetitions of 15 leg kicks on the RLE kicking out 5-8 inches. At 12:54 PM Staff C instructed Resident #2 to start leg kicks on the left leg verbalizing she knew it was harder for Resident #2 but to do what she could. Resident #2 was not able to kick the left foot forward and used her right foot under her left foot to try to kick the leg forward 1-2 inches for two repetitions. On the second set of leg kicks Resident #2 did the leg kicks with her right leg instead of her left leg. Staff C did not correct the resident. Staff C assisted Resident #2 to complete the third set of leg kicks on the left leg. At 12:57 PM Staff C instructed Resident #2 to perform leg pulls using a green resistance band. Resident #2 was only able to pull the left leg back 1/2 inch to 1 inch for six repetitions, then stopped. Resident #2 stated, It moves but not enough to stretch it. Staff C stated that is a hard one to do, then moved on to another resident to perform their exercises. Staff C did provide AAROM to fully complete the exercise. At 1:06 PM Staff C placed a green resistance band around the resident's knees and asked her to pull her knees apart. Resident #2 completed the first exercise repetition but was only able to move her legs out 1/4 to 1/2 inches. On the last set of leg abductions Resident #2 completed 7 repetitions, but had trouble moving her legs. She completed repetitions 8-15 with only the right leg. Staff C did not assist with any AAROM to finish the exercise on the left leg. At 1:14 PM Staff C placed a 10-inch ball between Resident #2 knees and instructed her to squeeze the ball between her knees. The resident started to fall asleep and was hardly squeezing the ball as the RA counted. Resident #2 was not able to tolerate the ball for the second and third sets. Staff C placed her fist at the knees and asked her to squeeze her fist between her knees. She did not provide any AAROM for the exercise. At 1:19 PM Staff C instructed Resident #2 to complete toe raises with both feet. Resident #2 was only able to complete the exercise with the right foot. Staff C instructed Resident #2 they were going to complete sewing machine raises (heel and toe raises). Resident #2 completed 15 repetitions with the right foot and was not able to do more. Staff C performed passive range of motion for one set of 15 to each foot. Staff C reported she had completed Resident #2's RNP. During an interview on 3/11/26 at approximately 1:38 PM Staff C reviewed Resident #2's Electronic Healthcare Record (EHR) Restorative Program and verbalized she only completes the program as it is in the EHR system. Staff C flipped through a Restorative Communication Book and pulled out a Therapy & Nursing Communication Form. Staff C reviewed the Form and reported she had only completed the program as written in the restorative program EHR. The EHR system did not contain the 2/28/26 updates to Resident #2's RNP, so she had not completed those exercises. Interview on 3/11/26 at 1:48 PM Staff C reported she had reported the issue to the Director Of Nursing (DON) and the updates to the RNP had been put under the CNA documentation, not the restorative documentation so she wasn't able to see the updates in Resident #2's program to provide the updated program. Interview on 3/11/26 at 4:08 PM the MDS Coordinator explained sometimes she updates the care plan with the RNP updates, but in Resident #2's case, Staff A, LPN/Restorative Nurse had updated Resident #2's Care Plan with the RNP updates on 3/01/26. A 3/11/26 4:09 PM review of the February 2026 Restorative Record documented the Nursing Restorative #1 AROM supine or seated therex with AAROM 15 repetitions, 3 times a week updated 2/28/26. The February 2026 Restorative Record lacked documentation of the 2/28/26 RNP updates. A 3/11/26 4:12 PM review of the March 2026 Restorative Record documented the Nursing Rehabilitation #1 program completed on March 2, 4, 6, 9, and 11th. The March 2026 Restorative Record lacked documentation of the Nursing Rehabilitation programs #2, #3, #4 and #5 being completed. Observation on 3/12/26 at 9:15 AM Resident #2 in the restorative exercise room performing the arm bike exercises per the RNP. During an interview on 3/12/26 at 10:10 AM Staff A explained she just updated Resident #2's RNP today, so it will not show in the EHR program until 3/13/26. Resident #2 came in today and did the arm bike and standing exercises and did very well. She reported when the DON updated Resident #2's program, it was put under the CNA documentation, not restorative. The program updates have to go into the EHR in the Restorative Only area to communicate over to where they document the RNP programs. If the RNP is not put in the EHR correctly it will not communicate over. Staff A further explained AAROM means once a resident is not able to perform the exercise themselves fully, then the aide should actively assist the resident hands on to complete the exercise. In an interview completed on 3/12/26 at 11:56 AM the DON reported they recently had to move the restorative nurse out to the floor to work as a charge nurse which was supposed to be temporary, but they are needing to get her back in the restorative room along with a restorative aide. She needs the restorative nurse to manage and oversee the RNPs. She plans to provide the restorative staff with more training. As for the documentation, she tried to go in and input Resident #2's program and it went over to the CNA documentation and she made it worse because that was not where the documentation was supposed to go, but they have that figure out now. The Restorative Nursing Care Implementation and Screening Policy, revised 12/08/25, defined a Purpose to provide appropriate restorative nursing care to each resident and assist in the implementation of a RNP. The Policy lacked staff direction on specific communication and implementation of revised RNP programs.

Based on clinical record review, policy review, Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Version 1.20.1, dated October 2025 (RAI) review and staff interview the facility failed to correctly code insulin on the Minimum Data Set (MDS) for 1 of 3 residents (Resident #12) reviewed for insulin use. The facility reported a census of 38 residents.Findings include:The admission Record for resident #12 documented an admission date of 10/10/22.The MDS dated [DATE] documented the resident received insulin 1 time during the assessment period of 12/19/25- 12/25/25.The Order Summary Report dated 12/25/25 lacked an order for insulin.The Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of insulin being given.Facility policy titled MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument)- Rehab/Skilled & Therapy and Rehab last reviewed on 10/27/25 directs staff to determine if there is accurate documentation to support coding for the MDS. The policy documents nursing staff is responsible for entering the medications on the MDS.The RAI instructs staff to code the number of days insulin was received by the resident.During an interview on 3/11/26 at 3:49 PM the MDS coordinator explained the insulin should not have been coded on the MDS as the resident was not taking insulin.During an interview on 3/12/26 at 1:53 PM, the Director of Nursing (DON) explained she expected the MDS to be accurate. She further explained she expected staff to follow the RAI guidelines and directions when completing the MDS.

Based on clinical record review, document review, policy review and staff interview, the facility failed to serve the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) as required; failed to outline the specific Medicare services that would be ending and failed to document the estimated charges to continue skilled services for 2 of 3 residents sampled (Resident #1 and #13). The SNF ABN Form communicates to a resident and/or legal representative when Medicare services will no longer be covered and they may be liable for payment of services. The facility identified a census of 38 residents.Findings include: 1.Resident #1's Electronic Healthcare Record (EHR) Census showed he admitted into Medicare skilled services on 1/22/26. A 1/22/26 10:10 PM Health Status Progress Note documented Resident #1 admitted to the facility and would be receiving physical therapy (PT) and occupational (OT) therapy services. A Center for Medicare and Medicaid (CMS) SNF Beneficiary Protection Notification Review Form documented Resident #1 started Medicare Skilled Services on 1/22/26 and received the last covered day of service on 2/11/26. The Provider initiated the discharge from the Medicare Part A Services when the benefit days were not exhausted. The CMS SNF Beneficiary protection Notification Review Form completed by the facility documented a SNF ABN was not provided to Resident #1 without an explanation as to why the notice was not provided. During an interview on 3/11/26 at 11:33 AM the Interim Administrator reported Resident #1 had not been served a SNF ABN when skilled services were ending and it should have been done. 2. Resident #13's EHR Census showed admission to the facility on [DATE] for Medicare A Skilled services. A 10/20/25 11:39 PM Other Progress Note documented Resident #13 admitted to the facility on skilled level of care and required PT and OT services to increase strength. A 12/4/25 10:55 AM Communication with Family Progress Note documented Staff B, Social Services Designee (SSD) reached out to a family member on the Medicare part A stay ending. Staff B informed the family member they would get back to them regarding pricing to stay at the facility after the skilled stay.A SNF Beneficiary Protection Notification Review completed by the facility documented Resident #13 discharged from Medicare Part A services when benefit days were not exhausted. The SNF ABN signed by Resident #13 on 12/4/25 lacked documentation PT and OT services were ending and the estimated cost for services to continue. The Form documented Resident #13 choose Option 2 indicating she wanted the services listed which included custodial services, room and board charges, but not to bill Medicare. The resident would be billed because they were responsible for the payment of the care and could not appeal because Medicare would not be billed. During an interview on 3/11/26 at 11:35 AM the Interim Administrator verified beneficiary notices did not specifically address the ending of PT and OT services, only the nursing skilled services and Resident #13's estimated cost had not been addressed on the SNF ABN. She stated she would look into who covered the cost of Resident #13's skilled stay. On 3/11/26 at 11:48 the Interim Administrator provided a United [NAME] (UB) Form showing the facility billed Medicare, Part A for Resident #13's skilled stay from 10/20/25 to 12/06/25. Resident #13 did not pay for the skilled stay. During an interview on 3/12/26 at 9:18 AM the Social Service Director reported when a resident goes off of skilled care services, which would be physical therapy (PT), occupational therapy (OT) or speech therapy (ST), she is to serve the Notice of Medicare Non-Coverage (NOMNC). She has to fill out the NOMNC form with the facility name, resident's name, skilled services that are ending, provide information if the resident/family wants to contact the Quality Improvement Organization (QIO) and then the resident or family member signs the form. The SSD voiced she had been informed yesterday that she could not use acronyms such as PT/OT/ST when referring to therapy services on the NOMNC. She was not aware she needed to serve the SNF ABN or the components that had to be addressed on the SNF ABN. The Beneficiary Notice of Non-Coverage (SNF ABN) Policy revised 2/13/23 directed the SNF ABN should be issued prior to extended care items or services that are furnished, reduced or terminated when the skilled nursing facility believes Medicare may not pay for the extended care services due to the services not being reasonable and necessary or a a custodial care level (level of care not covered by Medicare). The Facility must allow enough time for the beneficiary to make an informed decision on whether or not to receive the item/services in question and accept potential financial responsibility. The Center for Medicare and Medicaid Form Instructions for completing the SNF ABN directed the following:Care Section - the SNF chooses the appropriate check boxes to indicate the care that it believes may not or won't be covered by Medicare. These include Physical Therapy, Occupational Therapy, Daily Skilled Nursing Care and Other. If Other is checked, the SNF must enter the exact nature of the service that had previously been provided. The description must be written in plain language that the patient can understand. Estimated Cost Section - the SNF should enter the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or perservice cost estimate. SNFs must make a good faith effort to insert a reasonable cost estimate for the care. Option Boxes - there are 3 options listed on the SNF ABN with corresponding check boxes. The patient must check only one option box. If the patient is physically unable to make a selection, the SNF mayenter the patient's selection at his/her request and indicate on the notice that this was done for the patient. Otherwise, SNFs are not permitted to select or pre-select an option for the patient as thisinvalidates the notice. When the patient selects Option 2, the care is provided, and the patient pays for it out-of-pocket. The SNF does not submit a claim to Medicare. Since there is no Medicare claim, the patient has no appeal rights. Medicare requires a SNF ABN to be provided to the resident when discharging from skilled care services when the resident will continue to reside in the nursing facility.

Based on an electronic health record (EHR) review, policy review, and staff interview, the facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for 1 of 1 resident reviewed (Resident #14). The facility reported a census of 42 residents. Findings include: Resident #14 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS included diagnoses of Alzheimer's disease, Schizophrenia, and Depression. Resident #14 current PASRR Level 1 Screening Outcome dated 3/2/2022 reflected a PASRR Level 1 outcome referral for a Level II onsite visit. The Notice of PASRR Level II outcome dated 3/8/22 revealed a PASRR determination of Level II -Excluded from PASRR - No PASRR diagnosis. On 3/11/25 a review of the EHR medical diagnoses list documented on 11/8/24 an active diagnosis of paranoid schizophrenia. The Resident #14 Order Summary Report included a listing of all active diagnoses, including the diagnosis of paranoid schizophrenia. The primary physician reviewed and electronically signed the Order Summary Report on 12/13/2024 and 2/14/25. A review of the primary physician Progress Note visit summary dated 2/14/25 at 10:00 AM revealed the assessment included paranoid schizophrenia, recurrent major depression, severe stage Alzheimer's disease, developmental delay history, dilated cardiomyopathy, and aortic stenosis. The Progress Note had been electronically signed by the primary physician on 3/3/25 at 3:29 PM. During an interview on 3/12/24 at 9:13 AM, the Director of Nursing (DON) revealed she had been submitting the PASRR updates for review. The DON acknowledged she was aware of the new diagnosis of paranoid schizophrenia and failed to submit the required PASRR update for Resident #14. A review of the Pre-Admission Screening and Resident Review (PASRR) - Rehab/Skilled facility policy dated 12/30/24 revealed the following: 1. If the resident is diagnosed with a mental disorder while in the location, social services, or the designated individual, will contact the designated state agency for a Level II screening. 2. PASRR recommendations will be incorporated into the care plan (i.e., a PASRR recommendation for counseling to address a resident's social withdrawal could be care planned under mood state). 3. The location will notify the state-designated mental health or intellectual disability authority promptly when a resident with MD or ID experiences a significant change in mental or physical status. Examples of such changes include, but are not limited to: * A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms. * A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment. * A resident who experiences an improved medical condition, such that the resident's plan of care or placement recommendations may require modifications. * A resident whose significant change is physical, but has behavioral, psychiatric, or mood-related symptoms, or cognitive abilities that may influence adjustment to an altered pattern of daily living. * A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASRR Level II evaluation and determination. The Maximus PASRR manual dated 2/8/23 directs PASRR evaluations are referred to as Level II evaluations to distinguish them from their counterpart Level I screens; the Level I screen is a brief screen used to identify persons applying to or residing in Medicaid certified nursing homes that are subject to the Level II process. Once a person with a suspected or known diagnosis is identified through that screen, a Level II evaluation must be performed to determine whether the individual has special treatment needs associated with the MI and/ or ID/RC.

Based on clinical record review, staff and resident interviews, and observations the facility failed to provide a sufficient number of staff to ensure each resident's call light is answered timely for 5 of 6 residents reviewed (Resident #2, #3, #4, #5, #6). The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set, dated dated dated [DATE], Resident #2 had diagnoses which included diabetes and dementia. The resident had a brief interview for mental status score (BIMS) of 9 which indicated moderate cognitive ability. The MDS revealed the resident required substantial assistance from staff for toileting and activities of daily living. The resident utilized a walker with one staff to ambulate to the rest room. During an interview with Resident #2 on 10/29/24 at 11:10 am, the resident indicated when he presses his call light it takes a while for the staff to assist him to the restroom. He admitted that he sometimes has to go to the bathroom and does not wait for the staff to assist him, he reported he has had several falls while waiting for staff. 2. According to the Minimum Data Set, dated dated dated [DATE], Resident #3 had diagnoses which included thoracic spinal bifida with paraplegia. The resident had a brief interview for mental status score of 15 which indicated he was alert and oriented. The MDS revealed the resident had total dependence on staff for all activities of daily living. Staff utilize a mechanical lift for all transfers. During an interview with Resident #3 on 10/28/24 at 11:40 am, the resident revealed the call light response times really depends on the day, he stated when the facility only has 3 aides working in the building, he has to wait 15-30 minutes for his call light to be answered. The resident has timed his call lights. 3. According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had diagnoses which include post polio syndrome. The resident had a BIMS score of 15 which indicated he was alert and oriented. The MDS revealed the resident had total dependence on staff for all activities of daily living. The staff utilize a mechanical lift for all transfers. During an interview on 10/29/24 at 8:15 am with Resident #4, the resident stated the staff use a Hoyer lift to place him on the commode which he will sit on for an extended period of time per his choice. The resident stated when he needs to get off the commode he has to wait for extended periods of time for the staff to answer his call light to assist him off the commode. 4. According to the MDS dated [DATE], Resident #5 had a BIMS score of 11 which indicated moderate cognitive ability. The MDS revealed the resident had diagnoses which included morbid obesity. The resident utilized a wheelchair to move about the facility and required assistance of 1 staff for transfers. During an interview with Resident #5 on 10/29/24 at 11:13 am revealed she stated she will wait sometimes up to 1 hour for the staff to answer her call light but mostly it is answered within 20-30 minutes. The resident also reported if a staff will answer her light, they will often come into her room, turn off the call light and leave saying they will return but they do not return. She reported she sometimes has to put her call light on again. 5. According to the MDS dated [DATE], Resident #6 had a BIMS score of 15 which indicated they were alert and oriented. The resident had diagnoses which included chronic kidney disease, degenerative disc disease, and history of falls. The resident required extensive assistance of 1 staff for transfers using a non-mechanical lift. The resident moved about the facility in a motorized wheelchair. During an interview with Resident #6 on 10/29/24 at 9:20 am, the resident stated the call lights usually take a long time for the staff to answer, a lot of times over 15 minutes. The longest he has waited is up to 40 minutes. During an interview with Staff A-Certified Nurses Aide on 10/28/24 at 11:15 am, the C.N.A. stated she was working on the 100, 200 and 300 hall alone today, and reported having 18 residents she was responsible to get up for the day and dress, responsible for the baths that day on her wing, answer the call lights, and assist the residents during the day as they need help. The 3 wings have a total of 18 residents with 5 residents who required the use of a Hoyer lift with 2 staff for transfers. Staff A stated she got her last resident up at 10:00 am. this morning and provided the resident a room tray as the dining room was closed. Staff A stated the resident call lights ring longer than they should, and stated I do the best I can. Staff A stated the staffing in the facility for day and evening shift should be 4 certified nurses aides but reported they work short about 1-2 days a week. During an interview with Staff B-Certified Nurses Aide on 10/28/24 at 1:30 pm, Staff B stated the staffing levels are terrible, we work short a lot of the time. She described short as being only 3 aides for all the residents, the facility has 5 wings and is spread out. Staff B stated today they only have 3 aides working which is 1 aide short than it should be. They could not find an agency aide to work today so they are working without the 4th aide, this happened frequently. Staff B admitted the call lights are not always answered within 15 minutes but stated we try. During an interview with Staff C-LPN on 10/28/24 at 2:40 pm, Staff C stated she was now responsible for the schedule as of last week. She stated the day shift and evening shift should have 4 aides if the census is over 44. She stated they are short today, she attempted to reach out to a staffing agency but they did not respond back to her. Staff C admitted it was very hard for 1 aide to provide resident care for the 100, 200, and 300 hall that had a census of 18 residents. During an interview with Staff D-Register Nurse on 10/28/24 at 2:50 pm, Staff D reported they only have 3 aides working today and the staffing was frequently like this. She stated they cannot get the residents down to the dining room in the morning due to low staff. She indicated the dining room closes at 9:30 am so this required the residents to get a room tray instead of going to the dining room. Staff D stated she frequently gets resident complaints of delayed call light response times, and had witnessed call lights go off for 45 minutes. Staff D stated she was frequently the only RN working her shift and must decide which resident needs her most. She stated it is impossible for 3 aides to provide resident cares and answer call lights timely for the entire building. An interview with Staff E-Certified Nurses Aide on 10/29/24 at 10:33 am revealed the aides work with only 3 staff about 2-3 times a week. She stated when she works the 100-200 and 300 Hall she cannot get the residents down on time for breakfast so the residents receive a room tray. She stated a lot of her residents want to go the dining room but are not able to get to the dining room on time. In an interview with Staff G-Food Service Supervisor on 10/28/24 at 1:15 pm, Staff G stated almost daily she will use her walkie talkie and alert the CNA staff which residents have not shown up in the dining room for meals. She stated she will then fix those residents a room tray for the staff to pick up. Staff G stated the dining times are as follows; breakfast 7-9 am, lunch 11:30-12:30 and evening meal from 5-6 pm. In an interview with Staff F-RN/Interim Director of Nurses on 10/29/24 at 2:15 pm, Staff F stated she had only been in the facility a short time and didn't know about the staffing shortage, the aide and resident complaints due to low staff level and delayed call lights. Review of a meal time posting displayed in the resident dining room identified the dining hours; breakfast from 7-9 am, lunch 11:30-12:30 pm and evening meal from 5-6 pm.

Based on clinical record review, staff and resident interviews, and observations the facility failed to provide tuberculosis screening for 2 of 3 new employees reviewed (Staff H and Staff I). The facility reported a census of 45 residents. Findings include: Review of employee file documents revealed Staff H-Certified Nurses Aide had a hire date of 6/25/24 and worked full time. During an interview with Staff H-CNA on 10/29/24 at 11:10 am, Staff H stated when she began her employment at the facility the former Director of Nurses only did 1 tuberculosis screening test and failed to give her the second step as required. Staff H began her Step 2 Tuberculosis screening on this day. Review of employee file documents revealed former Staff I-Certified Nurses Aide had a hire date of 12/19/23. The facility received her archived employee file from the Corporate office but failed to find the aide ever had any tuberculosis screening completed as per facility policy. Review of the Tuberculosis Control Plan and Screening for Employees policy dated 12/7/2023 indicated new employees will have a baseline TB screening and post-exposure screening according to current CDC recommendations and guidelines prior to employment. During an interview with Staff F-Interim Director of Nurses on 10/29/24 at 4:45 pm, Staff F stated she cannot find any TB testing for either Staff H or Staff I in their employee files and assumed it was not done. Staff H began her screening on this day. Staff F stated all staff are required to have 2 Step TB testing prior to working with the residents in the facility.

Based on record review, staff interview, and policy review the facility failed to ensure 4 of 5 residents were educated about immunizations and offered the Influenza and Pneumococcal vaccination annually (Resident #20, #39, #15, and #34). The facility reported a census of 38 residents. Findings include: 1. Record review of Resident #20 Electronic Health Record (EHR) Immunizations on 5/9/24 revealed she had not received the following: a. Pneumococcal Polysaccharide (PPSV23) b. Pneumococcal Conjugated (PCV20) Record review of Resident #20 Progress Notes 2/28/2020 to 5/9/24 lacked documentation that education was provided or that she was given or refused PPSV23 and PCV20 vaccinations (for Pneumonia). 2. Record review of Resident #39 EHR Immunizations on 5/9/24 revealed he was not up to date with Pneumococcal vaccinations. Record review of Resident #39 Progress Notes 11/30/2023 to 5/9/24 lacked documentation that education was provided or that he was given or refused Pneumococcal vaccines. 3. Record review of Resident #15 EHR Immunizations on 5/9/24 revealed he was not up to date with Influenza and Pneumococcal vaccinations. Record review of Resident #15 Progress Notes 10/26/2021 to 5/9/24 lacked documentation that education was provided or that he was given or refused Influenza and Pneumococcal vaccines. 4. Record review of Resident #34 EHR Immunizations on 5/9/24 revealed he was not up to date with Influenza and Pneumococcal vaccinations. Record review of Resident #34 Progress Notes 10/26/2021 to 5/9/24 lacked documentation that education was provided or that he was given or refused Influenza and Pneumococcal vaccines. During an interview on 5/8/24 at 3:15 PM with the facilities Infection Preventionist revealed she had been working at the facility for one (1) month but would expect to have documentation to the show the facility asked and educated residents annually regarding the Influenza or Pneumococcal vaccinations. Record review of the facilities policy titled Immunizations/Vaccinations for Residents Pneumococcal, Influenza dated 9/21/2023 revealed the following: Residents will be reviewed for vaccine eligibility on an ongoing basis as the immunization recommendations change.

Based on record review, staff interview, and policy review the facility failed to provide documentation of what interventions were attempted prior to giving as needed (PRN) anti-anxiety medications for 1 of 3 residents reviewed for anti-anxiety medications (Resident #22). The facility reported a census of 38 residents. Findings include: Record review of Resident #22's March 2024 Medication Administration Record (MAR) documented he received his once a day PRN anti-anxiety medication on the following dates: a. 3/2/24 b. 3/3/24 c. 3/4/24 d. 3/5/24 e. 3/7/24 f. 3/8/24 g. 3/9/24 h. 3/10/24 i. 3/11/24 j. 3/12/24 k. 3/13/24 l. 3/16/24 m. 3/18/24 Record review of Resident #22's Progress Notes from 3/4/24 to 3/18/24 lacked documentation of non-pharmacological interventions attempted prior to giving his PRN anti-anxiety medication. Record review of Resident #22's Progress Notes by the Pharmacy Consultant from 2/4/24 to 5/3/24 lacked direction to staff that they needed to document interventions attempted prior to giving PRN anti-anxiety medications. During an interview on 5/9/24 at 10:42 AM the Director of Nursing revealed she would expect documentation of what they tried prior to giving PRN anti-anxiety medications. She then stated their Electronic Health Record system has a spot you can put a Progress Note right in and she would expect some type of behavior documentation prior to giving a PRN anti-anxiety medication. Record review of the facilities policy, Psychotropic Medications Rehab/Skilled last revised on 12/06/2023 instructed the following: Non-pharmacological interventions are recommended before medication interventions. Attempts should be documented in the resident care record.

Based on record review, staff and pharmacist interview, the facility inaccurately coded 2 of 2 residents Minimum Data Set (MDS) by documenting the residents received insulin during the look back period when they did not (Resident #4 and #10). The facility reported a census of 38 residents. Findings include: 1. The MDS for Resident #4 dated 2/15/24 documented she received one insulin injection between 2/9/24 to 2/15/24. Record review of Resident #4 Treatment Administration Record (TAR) for February 2024 revealed she did not receive insulin medications. 2. The MDS for Resident #10 dated 2/22/24 documented she received one insulin injection between 2/16/24 to 2/22/24. Record review of Resident #10 TAR for February 2024 revealed she did not receive insulin medications. During an interview on 5/8/24 at 11:16 AM with the facilities Nurse Consultant revealed Trulicity is an insulin and provided TAR for Resident #4 and #10 showing they received the Trulicity injection during their MDS look back period. During an interview on 5/8/24 at 11:18 AM with one of the facilities Pharmacists revealed the medication Trulicity is not an insulin it is in the drug class Incretin Mimetics and it is not considered an insulin. During an interview on 5/8/24 at 11:20 AM with Staff A, Registered Nurse who coded Resident #4 and #10 MDS revealed she coded the residents Trulicity orders as insulin. She stated her form instructs her that Trulicity is a hypoglycemic drug class and is an insulin. She also stated she does not use the Resident Assessment Instrument (RAI) medication websites, instead used a form provided from her corporation.

Based on record review, staff interview, and policy review the facility failed to send appropriate records for a transfer to the local emergency room (ER) for 1 of 1 residents reviewed (Resident #42). The facility reported a census of 38 residents. Findings include: Record review of Resident #42 Minimum Data Set (MDS) dated [DATE] documented he was discharged on [DATE] to the local hospital. The MDS informed his cognitive skill for daily decision making was severely impaired. Record review of Resident #42 Assessments in his Electronic Health Record (EHR) lacked documentation a discharge Assessment was completed on 4/5/24. Record review of Resident #42 Progress Notes on 4/5/24 lacked documentation of what paperwork was sent with the resident to the local hospital. During an interview on 5/9/24 at 10:40 AM the facilities Administrator revealed when Resident #42 went to the hospital on 4/5/24 they did not update the hospital or send documents regarding ADL's, his Care Plan, or what personal belongings were being sent with him. The facilities Policy titled, Interact Transfer Form User Defined Assessment (UDA) and Acute Care Transfer checklist - Rehab/Skilled, last reviewed/revised on 4/1/2024 instructed the following: a. Complete a Transfer Form in the facilities EHR under the assessments tab b. Print the Transfer Form and place it in the Acute Care Transfer envelope. c. Send the envelope with the resident to the hospital.

Based on observation, policy review and staff interview the facility failed to distribute and serve food in accordance with professional standards for food service safety by touching the drinking surface of beverage glasses for 12 residents observed during meal service. The facility reported a census of 48 residents. Findings include: During an observation of the meal on 1/23/23 at 11:41 AM Staff F, Food Service Assistant, was observed serving 10 residents their meal beverages by gripping the top of the cup, fingers on the drinking surface, palm over the top of the cup. Staff F was observed filling a spouted drinking cup at the beverage dispenser. The spouted lid held in her bare hand with the spout in direct contact with her palm. During an observation on 1/24/23 at 12:20 p.m. Staff H, Food Service Assistant, was observed serving 1 resident his meal beverages, touching the drinking surface of the cup. Facility Policy titled Dining Service Standards- Food and Nutrition Services, dated 8/11/22 directed staff to never touch the eating surface of utensils and dishware. During an interview on 1/25/23 at 10:20 AM, the Food Service Supervisor stated he would expect staff to hold beverage cups by the bottom and to never touch the drinking surface that would come in contact with the mouth.

Based on clinical record review, observation, staff interview and policy review the facility failed to promote dignity for Residents requiring meal assistance (Resident #3, #7, #14, #20, #21 and #39) by leaving meals on a plastic serving tray. All resident not requiring meal assistance did not have meals left on plastic serving trays. The facility identified a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a short/long term memory problem, severely impaired decision making and listed diagnoses of Alzheimer's Disease and Non-Alzheimer's Disease. The Resident required extensive assistance of one staff member for eating. The Care Plan revised 5/28/22 directed the staff to assist with meals as needed. 2. The MDS dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive loss with a diagnosis of Alzheimer's Disease and Non-Alzheimer's Disease. The Resident required extensive assistance of one staff member for eating. The Care Plan revised 5/29/22 identified Resident #7 as independent to supervision with eating. Requires an assist of one when she needs increased assistance. 3. The MDS dated [DATE] for Resident #14 documented a short/long term memory problem, severely impaired decision making and listed a diagnosis of Alzheimer's Disease with late onset. The Resident required extensive assistance of one staff member for eating. The Care Plan revised 5/25/22 directed Resident #14 needed staff assistance to eat. 4. The MDS dated [DATE] for Resident #20 showed a BIMS score of 3 indicating severe cognitive loss with a diagnosis of Alzheimer's Disease and Non-Alzheimer's Disease. The Resident required extensive assistance of one staff member for eating. The Care Plan revised 6/30/22 directed Resident #20 as dependent/requiring total assistance of staff member with eating meals. 5. The MDS dated [DATE] for Resident #21 showed a BIMS score of 4 indicating severe cognitive loss with a diagnosis of Non-Alzheimer's Disease. The Resident required supervision and set up help with eating meals. The Care Plan revised 11/02/22 directed the staff to provide supervision and assist with meals at times. 6. The MDS dated [DATE] for Resident #39 documented a short/long term memory problem, severely impaired decision making and listed a diagnosis of Alzheimer's Disease with late onset. The Resident required supervision and set up assistance with eating. The Care Plan 11/29/22 documented Resident #39 as independent with eating. Dining observations completed during the survey revealed the following: a. During an observation on 1/23/23 at 12:14 p.m. Staff A, Certified Nursing Assistant (C.N.A.), set up Resident #14's drinks along with a plate of food on a blue serving tray and placed the tray down on the table. She continued to assist Resident #14 with her meal from the plastic blue serving tray. b. During an observation on 1/23/23 at 12:24 p.m. Staff B, C.N.A., set up Resident #3's drinks on a blue serving tray with the resident's meal plate and placed the tray down on the table in front of Resident #3. Staff B sat down beside Resident #3 and assisted Resident #3 with the meal from the blue plastic serving tray. c. Observation on 1/23/23 at 12:35 p.m. revealed none of the residents independently dining were eating meals from blue plastic serving trays. d. During an observation on 1/24/23 at 9:46 a.m. Resident #3 sat in her wheelchair at the dining room table drinking a glass of chocolate milk from a blue plastic serving tray which contained her plate of half eaten food. Staff A sat at the table assisting another resident. e. During an observation on 1/24/23 at 12:18 p.m. Staff B walked from the kitchenette area to the table carrying Resident #14's lunch meal on a blue plastic serving tray. Staff B laid the blue serving tray of food down on the dining room table and walked back to the kitchenette area. Staff C, Senior Nursing Assistant (SNA) started to assist Resident #14 with her meal from the blue plastic serving tray. f. During an observation on 1/24/23 at 12:22 p.m. Staff B brought Resident #39's meal to the table on a blue plastic serving tray with a plate containing pureed chicken alfredo, broccoli, peach crisp, one glass of orange juice and one glass of chocolate milk. Staff B laid the blue plastic serving tray of food on the table without removing the plated meal or drink glasses from the tray. Resident #39 consumed her meal from the blue plastic serving tray. g. Observation on 1/24/23 at 12:35 p.m. revealed approximately 22 residents independently dining in the main dining room. None of the residents were eating meals from blue plastic serving trays. h. During an observation on 1/24/23 at 12:44 p.m. Staff D, C.N.A., brought Resident #20's meal to the table on a blue plastic serving tray with a plate containing pureed chicken alfredo, broccoli, peach crisp and two nosey cups of water. Staff D laid the blue plastic serving tray of food on the table without removing the plated food or drinks from the serving tray. She sat down by Resident #20 and Resident #14 to assist with the meals from the blue plastic serving trays. i. During an observation on 1/25/23 at 9:10 a.m. Staff E, Licensed Practical Nurse, Clinical Learning and Developmental Specialist, assisted Resident #14 and Resident #7 with their breakfast meals. Both Resident #7 and #14 had their plated breakfast food and drinks sitting on green plastic serving trays on the table. h. Further observation on 1/25/23 at 9:10 a.m. revealed seven other residents eating independently. None of the seven resident were eating from plastic food trays. During an interview on 1/25/23 at 9:11 a.m. Staff E reported she had also noticed residents not requiring meal assistance did not have the trays left on the table, but those resident requiring meals assistance had their meals left on serving trays. She stated she did not know why or what the difference was, but Staff F, Food Service Assistant, had served both residents trays this morning so she would know why. During an interview on 1/25/23 at 9:12 a.m. Staff F, Food Service Assistant, when asked what the difference is between serving residents requiring meal assistance and those residents that eat independently, Staff F stated they serve the residents that require meals assistance on serving trays. They leave their meal items on the tray as it is easier for the kitchen staff and the C.N.A.'s to pick up the dishes when the residents are finished with their meals. During an interview on 1/25/23 at 9:50 a.m. Staff G, Registered Nurse (RN), reported she did not know why resident requiring meal assistance would be served meals on a (food) tray. She inquired to the Surveyor, is there a regulation regarding that? She stated she didn't have an answer and to check with the Dietary Supervisor. During an interview on 1/25/23 at 9:52 a.m. the Supervisor of Nutrition and Food Services, stated staff should not be leaving resident meals on the plastic meal trays for the meal. He expected the staff to remove plated food and drink items off the meal trays after serving the resident's their meals. During an interview on 1/25/23 Staff E reported the facility did not have any policies regarding food trays, but the facility did have a policy for dignity in dining. The Dignity in Dining, Food and Nutritional Services Policy, revised 1/19/23, provided by the facility, documented a purpose to provide dining in a manner that enhances resident dignity. The Policy defined to promote services for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality, cultural, ethnic and religious beliefs. The Procedure directed to treat each resident like an individual and focus on making the dining experience as individualized as possible. The Dining Service Standards, Food and Nutrition Services Policy, revised 8/11/22, provided by the facility defined residents have the right to receive assistance from employees in a dignified manner.

Based on clinical record review, policy review and staff interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility identified a census of 37 resident. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #13 with a Brief Interview for Mental Status score of 15 indicating no cognitive loss. The resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and full staff assist with transfer. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident used a diuretic medication 7 days per week. The Care Plan identified Resident #13 with congestive heart failure and directed the staff to weigh daily, dated 11/20/20. An Order Review History Report electronically signed by the physician on 06/14/21 at 9:47 a.m. documented the following order: a. Daily weight: contact physician with weight gain of 2 pounds in 24 hours or 5 pounds in one week one time a day related to heart failure, unspecified. Start date 11/20/20. The Weights and Vitals Summary Record from 5/1/21 - 7/14/21 documented the following weight changes: - 07/10/21 weight 241.2 - 07/09/21 weight 237.0 - 06/29/21 weight 239.3 - 06/28/21 weight 235.3 - 05/30/21 weight 238.4 - 05/29/21 weight 232.7 A review of the Nursing Progress Notes from 5/1/21 - 7/14/21 lacked documentation of timely physician notification of the weight changes between 07/09/21 - 07/10/21, 06/28/21 - 06/29/21, 5/29/21 - 05/30/21. A review on 7/14/21 of the Treatment Administration Record (TAR) for 5/1/21 - 5/31/21, 6/1/21 - 6/30 21 and 7/1/21 - 7/13/21 showed the staff nurse had signed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/21, the Administrator provided a physician visit note dated 6/14/21. The physician documented with use of a compression (hose) the resident's [CONDITION(S)] (swelling) is in good control. The Administrator submitted a copy of a communication/visit with physician note dated 6/14/21 that documented the physician in the facility for a routine visit. The physician reviewed the resident's medications, vital signs and all systems. Discussed resident working with occupational therapy on [CONDITION(S)]. New orders for lab work (given). The documents submitted lacked documentation of notification to the physician or the actual weight changes. On 7/14/21, the Administrator provided a copy of a new order from the physician to change Resident #13 to a weekly weight and contact the physician with weight gains greater than 5 pounds in 1 week. The Administrator submitted a document dated 7/14/21 that documented in-person or phone education provided to every nurse on 07/14/21 regarding communication with physicians on weight gain specified orders. During an interview on 07/14/21 at 12:38 p.m. Staff A Registered Nurse, (R.N.), reported when a resident is on physician ordered daily weights and there are parameters for physician notification for a 2 pound in 1 day or 5 pound in a week the nurses would call the physician to report the weight gain and to see if the physician wants to change medication orders or monitor the resident. The nurses would document the physician notification in the progress notes. On 07/14/21 at 12:45 p.m. the Administrator reported she would expect that the nurses to follow the physician orders. During an interview on 7/15/21 at 7:05 a.m., the Director of Nursing, (DON), reported if she would have seen a parameter of 2 pounds she would have contacted the physician to clarify and obtain a better parameter for Resident #13's weights. She reported her expectation is if there is a weight gain that meets the physician ordered parameter; she would expect the CNA to report the weight to the nurse. The nurse should assess the resident for fluid overload and call the physician. The nurses should document the resident weight, assessment and physician notification in the progress notes in the medical record. The Physician/Practitioner Order, Rehab/Skilled Policy, revised 11/20/20 documented the following purpose: a. To provide individualized care to each resident by obtaining appropriate, accurate, and timely physician/practitioner orders. b. To provide a procedure that facilitates the timely and accurate processing of physician/practitioner orders.

Based on record review and staff interview the facility failed to complete assessments before and after [MEDICAL TREATMENT] for 1 of 1 sampled (Resident #12) on [MEDICAL TREATMENT]. The facility reported a census of 40. Findings include: Review of the Electronic Health Record (EHR) revealed Resident #12 had a [DIAGNOSES REDACTED]. Resident #12 had documented weekly vital sign assessments that included blood pressure, temperature, pulse, and respiration rate. However, the record failed to contain vital sign assessments before and after [MEDICAL TREATMENT] as expected in standard practice of care for patients on [MEDICAL TREATMENT]. During an interview 8/13/19 the Director of Nurses (DON) verified that they have not been doing routine before and after [MEDICAL TREATMENT] assessments on Resident #12, they believe the [MEDICAL TREATMENT] clinic does this but have no documentation from the [MEDICAL TREATMENT] clinic that they are doing this or what the residents vital signs assessments are before and after [MEDICAL TREATMENT]. During a follow-up interview 8/14/19 the facility DON stated that as of today facility staff have begun doing pre and post [MEDICAL TREATMENT] vital signs assessments and documenting them in the EHR.

Based on record review and staff interview the facility failed to transfer a resident as ordered leading to a fall that resulted in a leg fracture (Resident # 18). The facility census was 46 residents. Findings include: Review of the MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #18 had a BIMS (Brief Interview for Mental Status) score of 04 indicating severe cognitive impairment, she could not ambulate, needed extensive assistance of 2 staff members for bed mobility, and extensive assistance of 2 staff members to transfers. Review of the current care plan for Resident #18 at the time of the fall on 4/13/18 revealed interventions which directed staff to utilize a slide board with 2 staff assist for transfers or to use a total mechanical lift if the resident had weakness and unable to use the slide board. During an interview 5/8/18 at 12:05 p.m., Staff A (CNA) stated on the morning of 4/13/18 at about 6:00 a.m. she was getting ready to give Resident #18 a shower. Staff A called for assistance to transfer the resident to the shower chair. Staff B (CNA) arrived and they attempted to pivot Resident #18 from her bed onto the shower chair. The shower chair brakes were not locked and it slid back and they had to lower Resident #18 to the floor. Staff A stated they lowered Resident #18 to the floor very gently and did not feel the resident could have been injured so they called for another CNA to come and assist getting the resident off the floor and into the shower chair without notifying a nurse to assess the resident. Staff A indicated Staff C (CNA) arrived and they transferred Resident #18 into the shower chair and there were no visible signs of any injury. During an interview 5/8/18 at 12:50 p.m. Staff C verified that on the morning of 4/13/18 she was called to come and assist to transfer Resident #18. When Staff C arrived the resident was sitting on the floor with her legs extended out in front of them and there was no apparent signs of any injury. Staff C assisted Staff A and B in lifting Resident #18 off the floor and into the shower chair. Staff C was unaware Staff A and B had not notified the nurse and there was no nursing assessment prior to moving the resident. During an interview 5/8/18 at 1:25 p.m. Staff B (CNA) verified that on the morning of 4/13/18 around 6:00 a.m. she heard Staff A call for assistance to transfer Resident #18. Staff B responded and assisted Staff A in pivoting Resident #18 from the bed to the shower chair, Staff B was aware Resident #18 required a slide board to transfer. Staff B indicated they did not have time to get the slide board as Resident #18 was already starting to slide on the edge of the bed. The shower chair brakes were not locked and the chair slid away so they gently lowered Resident #18 to the floor. Staff B verified the resident did not hit anything on the way to the floor and her legs remained out in front of her. Staff B felt Resident #18 could not have been injured. Staff C was called to assist in getting Resident #18 off the floor and into the shower chair without notifying a nurse to assess the resident first. During an interview 5/9/18 at 9:35 a.m. Staff D (CNA) stated that prior to her leg fracture Resident #18 required 2 staff assistance with a slide board to transfer. However, the slide board did not work for showers because her skin did not slide well on the board. The mechanical lift was used for transfers in and out of the shower chair. The progress notes had no documentation of a fall on 4/13/18 or any incident that required the resident to be lowered to the floor. The notes on the morning of 4/19/18 indicated staff observed the resident's right knee was swollen and discolored. Staff assessed and notified the medical provider who assessed the knee and ordered X-rays which revealed a distal femur (above the knee) fracture on the right leg. The hospital transferred Resident #18 for evaluation/consultation with an Orthopedic Surgeon. The Orthopedic Surgeon consultation dated 4/20/18 found a pathologic distal femur fracture on the right that may have occurred from the fall on 4/13/18. Review of follow up documentation provided by the facility to the surveyor on 5/8/18 found the CNA's involved received education on 4/19/18, 4/20/18, and 4/21/18 prior to working back on the floor. The facility also completed audits the week of 4/22/18 to ensure staff followed residents care plans for proper transfers.

Based on clinical record review and staff interview, the facility failed to provide a referral for the Level II Pre Admission Screening and Resident Review (PASRR) evaluation and determination for 1 of 1 resident reviewed (Resident # 31). The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #31 had a [DIAGNOSES REDACTED]. The MDS listed indicators of [MEDICAL CONDITION] as delusions (misconceptions or beliefs that are firmly held, contrary to reality). The PASRR Level I screen dated 10/31/14, directed no further Level I screen was required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. The PASRR listed no major mental illness. During interview on 5/9/18 at 1:57 p.m., the Social Worker reported there was no additional PASRR documentation after the 10/31/14 PASRR. The Social Worker stated dementia was the primary [DIAGNOSES REDACTED]. During interview on 5/9/18 at 3:30 p.m., the Social Worker reported completing a new PASRR after calling Ascend (state designee for evaluation of Level II PASRR). The Social Worker reported Ascend stated a new [DIAGNOSES REDACTED].

Based on clinical record review and staff interview, the facility failed to provide a copy of the initial care plan to the resident or their representative as required. (Resident #29) The facility census was 46 residents. Findings include: 1. Review of the EMR (Electronic Medical Record) for Resident #29 with an admission date of [DATE] revealed no documentation the resident or their representative was provided a written copy of the initial care plan that was easily understood by the resident or their representative as required. During interview on 5/9/18 at 12:10 p.m., the Director of Nursing and Social Worker state they were not aware of the regulation that required a written copy of the resident care plan be given to the resident or their representative.