Every finding on record at Ossian Health Care and Rehabilitation Center

Based on interview and record review, the facility failed to ensure behavioral health services were provided for 1 of 1 resident reviewed (Resident 11).Findings Include:Resident 11's record was reviewed on 4/20/2026 at 12:21 PM. Diagnoses included bipolar disorder unspecified, anxiety disorder unspecified, post-traumatic stress disorder (PTSD) chronic, and major depressive disorder (MDD) recurrent.A review of Resident 11's current annual MDS indicated their Basic Interview for Mental Status (BIMS) score was 15, cognitively intact.A review of Resident 11's current care plan titled I have a PASRR Level II without specialized services related to mental illness indicated the resident had a problem of receive services as indicated in the PASRR Level II outcome with a goal date of 6/18/2026. Interventions included providing supportive counseling. A plan titled I have had a recent loss of mother in 2026 indicated the resident had a problem of needing assistance through the grieving process with a goal date of 6/18/2026. Interventions included offering mental health services as needed.A review of a psychotherapy diagnostic assessment, dated 9/22/2025, indicated psychotherapy may be beneficial in decreasing symptoms, improving overall functioning and maintaining the resident's improvements regarding the diagnosis of major depressive disorder and generalized anxiety disorder. The assessment indicated Resident 11 was agreeable to psychotherapy 1-4 times a month over the next 12 months with the psychotherapist. The assessment also indicated the initial treatment frequency would be 1-4 times monthly.A review of psychotherapy progress notes, dated 10/21/2025, indicated Resident 11 was welcoming toward the therapist. The progress note indicated Resident 11 continued to participate in and benefit from psychotherapy services.A review of psychiatry progress notes, dated 2/17/2026, indicated Resident 11 indicated her mood was terrible and her heart was in a million pieces. The note indicated Resident 11 shared her mother had recently passed away and she was suffering from the loss. The note indicated Resident 11 was encouraged to speak with the psychotherapist related to her grief. The progress note did not indicate Resident 11 declined psychotherapy services or the therapist was notified.A review of psychiatry progress notes, dated 3/3/2026, indicated Resident 11 reported she was still struggling with the recent loss of her mother. The notes indicated Resident 11 was not interested in medication adjustments or psychotherapy services at that time.A review of psychiatry progress notes, dated 4/6/2026, indicated Resident 11 reported her mood was okay, but she was still struggling with the passing of her mother. Resident 11 indicated she was looking forward to talking with the psychotherapist, as she continued to struggle with her grief.A review of progress notes, dated 4/3/2026 at 6:51 AM, indicated Resident 11 requested to see a priest to be blessed. Resident 11 reported losing faith when her mother passed away.No additional psychotherapy notes were available for review. No progress notes indicated Resident 11 declined to meet with the therapist.In an interview, on 04/22/2026 at 1:01 PM, the Director of Nursing (DON) indicated the therapist had not seen the resident since October 2025. The DON indicated the therapist attempted to meet with the resident in November 2025 however, the resident refused. The DON indicated the therapist did not document a note after Resident 11 refused in November 2025.In an interview, on 04/22/2026 at 1:58 PM, Resident 11 indicated she had met with the therapist however, they did not meet with her often and had only met a few times months prior. Resident 11 indicated she was not sure why the therapist stopped coming to meet with her. Resident 11 indicated no one from the facility or other grief service providers came to speak with her after her mother's passing. Resident 11 indicated she had asked to talk to someone and had also requested to have a priest come. Resident 11 indicated it had been very hard and she would have liked someone to talk to.In an interview, on 04/22/2026 at 2:22 PM, the Director of Social Services (DSS) indicated she called on 4/22/2026 for Resident 11 to be seen by a priest. The DSS indicated she called and requested for a priest to see the resident on 4/9/2026, however the priest was unable to see the resident when they came. The DSS indicated she did not have any documentation she requested Resident 11 be seen by a priest prior to 4/22/2026. The DSS indicated she should have documented when she made the call on 4/9/2026 and when she was made aware the priest did not see Resident 11.In an interview, on 04/24/2026 at 9:59 AM, the DSS indicated she spoke with the psychotherapist. The psychotherapist indicated she saw Resident 11 after her mother's death but did not document the visit. The DSS indicated the last documented note of the therapist meeting with Resident 11 the facility had was from October 2025. The DSS indicated she could not find any notes of Resident 11 being seen for counseling services after her mother's death. The DSS indicated she met with Resident 11 after her mother's death however, she was unable to locate any progress notes of her meeting with Resident 11 specific to the resident's mother.A current policy dated 3/5/2024 provided by the Administrator indicated, Ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.410 IAC (Indiana Administrative Code) 16.2-3.1-31(a)(1)

Based on interview and record review, the facility failed to ensure accident risks were identified and interventions put into place to prevent accidents for 1 of 1 resident reviewed (Resident 388). Findings include: In an interview, on 5/5/25 at 1:24 PM, Resident 78 indicated Resident 388 had entered their room multiple times asking for their family. Resident 78 indicated Resident 388 had entered their bathroom on 2 different occasions and rummaged through Resident 78's personal belongings. Resident 78 indicated they had activated their call light for staff to assist Resident 388 back to their own room. A Quarterly Risk Evaluation, dated 4/23/25, indicated Resident 388 had the ability to walk around the facility independently. The evaluation indicated Resident 388 did not have a history of wandering or searching for their family. Resident 388's Kardex (care summary for direct care staff) indicated the resident's vision was adequate. The Kardex indicated Resident 388 required limited assistance or supervision from staff for activities of daily living. The Kardex did not indicate Resident 388 had a cognitive loss. The evaluation did not indicate Resident 388 had wandered in the facility. Resident 388's Care Plan, dated 4/23/25 and revised on 4/29/25, indicated the resident had a fall risk due to memory loss as specified by their BIMS score. The target goal was to minimize fall risk through 7/22/25. Interventions included following the care plan when the resident was in pain and placing the resident's call light in reach. Resident 388's Care Plan did not indicate the resident wandered or attempted to enter other residents' rooms. Resident 388's record was reviewed on 5/6/25 at 1:03 PM. Diagnoses included unspecified disorientation, macular degeneration (central vision loss) and open angle glaucoma (vision loss). Resident 388's Admission Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 4 (severe cognitive loss). A progress note, dated 4/25/25 at 3:16 AM, indicated Resident 388 had been confused and had trouble sleeping. Resident 388 indicated they wanted to go home. A progress note, dated 4/26/25 at 5:52 AM, indicated Resident 388 had been disoriented a few times. The note indicated Resident 388 was legally blind and was checked periodically to ensure safety. A progress note, dated 4/28/25 at 11:29 PM, indicated Resident 388 had been confused and wandering on the unit. A progress note, dated 4/30/25 at 5:30 AM, indicated Resident 388 was very confused and had been walking down the hallway asking to go to the hospital. Resident 388 indicated they wanted to call the police because they didn't belong there. A progress note, dated 5/1/25 at 3:53 AM, indicated Resident 388 had been very confused and was knocking on other residents' doors. A progress note, dated 5/3/25 at 4:05 AM, indicated Resident 388 had been wandering in the hall attempting to enter other residents' rooms. A progress note, dated 5/5/25 at 6:54 AM, indicated Resident 388 had been confused, wandering in the hall and indicated they were looking for a way to call the police. A progress note, dated 5/5/25 at 11:54 PM, indicated Resident 388 had been wandering on the unit looking for their daughter. A progress note, dated 5/6/25 at 5:18 PM, indicated Resident 388 had been confused at times. The resident had walked out of their room looking for the bathroom. A progress note, dated 5/7/25 at 12:47 AM, indicated Resident 388 had continued to be confused and often needed redirection. A progress note, dated 5/8/25 at 6:54 AM, indicated Resident 388 had indicated they needed to go somewhere and die and not be a bother to anyone. In an interview, on 5/8/25 at 9:07 AM, the Administrator indicated Resident 388 did not have a history of wandering when they were admitted . In an interview, on 5/8/25 at 10:29 AM, Licensed Practical Nurse (LPN) 35 indicated elopement assessments were completed upon admission, quarterly and as needed. In an interview, on 5/9/25 at 9:53 AM, the Director of Nursing (DON) indicated Resident 388 wandered when looking for the bathroom due to blindness. The DON indicated Resident 388 had not scored as an elopement risk upon admission. The DON indicated the resident had never attempted to leave the facility. The DON indicated direct care staff were made aware of possible behavior risks on each resident's individual Kardex. The DON indicated on 5/8/25, Resident 388 had been ordered to have a sleep aid due to wandering at night. The DON indicated Resident 388's Care Plan had been updated after the resident had made statements of wanting to die. The DON indicated they were not aware of the resident's Care Plan having been updated to include wandering. The DON indicated a new risk evaluation should have been completed when the resident had been observed wandering and looking for their family. A current facility policy, titled Elopements and Wandering Residents, dated 11/1/23, provided by the DON on 5/8/25 at 10:34 AM, indicated the facility would identify and assess elopement risk. The policy indicated the risks would be added to the resident's care plan. The policy indicated the risk would be communicated to the appropriate staff. 3.1-45(a)

Based on record review and interview the facility failed to ensure trauma informed care was implemented for 1 of 2 residents reviewed. (Resident 53) Findings include: Resident 53's record review began on 05/05/25 at 10:46 AM. The record indicated diagnosis included major depressive disorder, past traumatic stress disorder (PTSD), and anxiety disorder. Resident 53's care plan had a problem related to past trauma as evidenced by angry outbursts, anxiety, changes in sleeping patterns, depression, emotional swings, history of past traumatic events and refusing care. The goal of Resident 53's care plan was I will not display angry outburst or sadness through the next review. The interventions listed were as follows: o Encourage Resident 53 to participate in activities of my choice. o Provide Resident 53 time to express my feelings. o Provide Resident 53 time to talk to social services. o Consult with Psych Services and LCSW as needed. o When talking to Resident 53, allow her enough time to process the information. There were no triggers listed. There was no mention of Resident 53's original trauma to avoid re-traumatization. In an interview, on 05/07/25 at 11:20AM, Certified Nursing Assistant (CNA) 2 indicated to her knowledge no one had p PTSD on her hallway (200 hall). CNA 2 was only aware Resident 45 required a calm approach. In an interview, on 05/07/25 at 11:34 AM, Licensed Practical Nurse (LPN) 3, was not able to indicate anyone on the 200 hall with PTSD or any triggers to be aware of with any of her residents. She was able to determine after looking in the record; Resident 53 had a diagnosis of PTSD. She was unable to indicate any triggers, approaches, or actions to avoid doing or saying. LPN 3 was unaware of what Resident 53's trauma was in nature or what needed to be avoided implemented to ensure no re-traumatization occurred. In an interview, on 5/7/25 at 2:17PM, the Social Services Director indicated she changed Resident 53's care plan on 5/7/25 after doing an audit. The Social Services Director was unable to indicate any specific triggers for Resident 53 at the time of interview. The Social Service Director indicated Resident 53 became anxioux, restless, and at times had outbursts. She was unable to determine exact triggers or what occurred prior to behaviors or symptoms of Resident 53's PTSD. On 5/7/25 at 12:10PM, a current policy and procedure titled Trauma Informed Care dated 3/5/24 with a revision date of 3/4/25, was provided by the Administrator. The policy indicated; It is the policy of this facility to provide care and services which .address the needs of trauma survivors by minimalizing triggers and re-traumatization .Policy Explanation and Compliance Guidelines: 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan . No state rule applies.

Based on interview, observation, and record review the facility failed to ensure an intrathecal pump (ITP) (surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord) had orders and directions for use for 1 of 7 residents reviewed (Resident 337). Findings include: In an interview on 6/25/24 at 12:06 PM, Resident 337 indicated she had a morphine pain pump in her abdomen for back and foot pain. She indicated the pump had been in place for about one year. Resident 337's record was reviewed on 06/26/24 at 11:27 AM. Diagnoses included rheumatoid arthritis, diabetic neuropathy, non-pressure chronic ulcer of part of right foot, hypotension, urine retention and back pain. Resident 337's quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident was on scheduled and as needed pain medication. The MDS did not indicate the resident was on opioid medication. Resident 337's current Care Plan, dated 2/15/24, indicated the resident had chronic pain related to rheumatoid arthritis with a goal date of 5/10/24. The plan indicated her pain would be managed at her current level of control. Interventions included Resident 337 had a pain pump she managed and was refilled at her Pain Management Clinic, she would be referred to the pain clinic for unmanageable pain, and she would be monitored for increased sedation, constipation, and respiratory depression. The care plan did not indicate the pain medication used in the ITP, monitoring for morphine side effects, and monitoring for signs/symptoms of infection that could occur with use of an ITP. Resident 337's medical record, dated 1/23/24 (faxed to the facility on [DATE]), from the Pain Medicine clinic indicated the resident had an intrathecal pump for pain management of her lower back pain. The ITP which was filled in their office every other month. The record indicated on 1/23/24 Resident 337's ITP was refilled with Morphine Sulfate 4 milligram (mg) per milliliter (ml) for a total of 40 ml. A Special Instruction statement in Resident 337's medical record indicated the resident saw the Pain Medicine clinic for her pain pump management. In an interview on 6/26/24 at 11:36 AM, LPN , Resident 337's nurse, indicated the resident was on ibuprofen 400mg every 8 hours as needed and added she also received gabapentin 600mg 4 times a day and this was the only pain medication the resident received. In an interview on 6/27/27 at 11:21 PM, LPN 2 indicated she provided nursing staff with a 2-page handout at morning huddle on Resident 337's pain pump. The handout provided the pump's brand name, helpful information, and a third page indicated nurses should follow manufacturer guidelines. signed by the employees in attendance. The ITP User Guide (2019) indicated side effects related to intrathecal morphine use included nausea (vomiting), constipation, urinary retention, daytime drowsiness, itching, rash, excessive sleepiness, sleep difficulty, confusion, euphoria, withdrawal, excessive sweating, swelling caused by fluid retention, flushing of face or anxiety, diarrhea, dizziness, dry mouth, allergic reaction, dysphoria (profound state of dissatisfaction), hallucinations, leg weakness, fall, headache, flu-like symptoms, numbness after activating a dose, shortness of breath, taste distortion, and weight gain. The User manual indicated symptoms of overdose may include shallow or slow breathing, excessive sleepiness, swelling due to fluid retention, low blood pressure (blood pressure less than 90/60 mm Hg), and reduced heart rate. The User Guide indicated symptoms of withdrawal due to ITP failure may include restlessness, body aches, chills, sweating, and pupil dilation. A Delhaas and Huygen ([DATE]) article titled Complications associated with intrathecal drug delivery systems indicated health professionals often fail to recognize potential infection complications from an ITP following refilling the ITP reservoir. The article indicated possible resident signs and symptoms of infections included fever, headache, stiff neck, vomiting, and change in consciousness. Resident 337's current physician orders did not include an order for the resident's ITP management. No orders were located for the ITP, the medication, dosage, bolus, lockout rate for the ITP, monitoring of ITP pain medication side effect, or monitoring of signs/symptoms of infection from the ITP usage. Resident 337's Medication Administration record (MAR) dated 6/1/24 to 6/27/24 at 12:00 PM indicated the nursing staff observed for side effects of antipsychotic, antidepressant, anti-anxiety, and hypnotic use. Resident 337's MAR did not indicate to observe for and/or document side effects of morphine/opioid use. Resident 337's MAR did not indicate for nursing staff to document signs and/or symptoms of infection due to ITP usage. Resident 337's progress note dated 6/22/24 at 5:57 PM indicated the resident indicated her urine output had slowed, a bladder scan was conducted, and 523 milliliters of urine was in the bladder. Resident 337's progress notes, dated 6/22/24 through 6/27/24 did not indicate the resident's Pain Medicine Clinic was notified of her possible intrathecal morphine side effects of urinary retention with placement of a Foley catheter on 6/22/24. In an interview on 6/26/24 at 1:51 PM, the Director of Nursing (DON) indicated there was no current order for Resident 337's morphine pain ITP since the resident returned from the hospital on 6/17/24. The Assistant Director of Nursing (ADON) entered the following order: Implanted pain pump with Morphine 4.0 mg/mL. Continuous Morphine 0.0542 mg/hr with total of 1.3003 mg/day. Bolus Morphine 0.4504mg with duration 7 minutes, maximum activations 4/day, lockout interval 3 hours (hrs), dose restriction interval 1/(3 hrs). Managed by Doctor at Pain Medicine. No directions specified for order. In an interview on 6/28/24 at 9:30 AM, the Executive Director and DON indicated there was no current order for Resident 337's morphine pain ITP on her returned from the hospital 6/17/24 and should had been. They indicated the facility had not been monitoring for ITP morphine side effects and potential infection risk due to the ITP, but should had been. A current policy titled Following Physician Orders, provided by the ADON on 6/27/24 at 12:00 PM, indicated licensed healthcare providers would manage resident care in a safe and effective manner. The policy indicated the licensed healthcare provider would assess the resident for appropriate response to orders and it would be documented in the medical record. A current policy titled Readmission to Facility, provided by the ADON on 6/27/24 at 12:00 PM, provided no information concerning the medication orders at readmission. No additional policies were provided by survey exit. 3.1-37

Based on observation, interview and record review, the facility failed to properly contain the transmission of COVID-19 for 5 of 11 residents reviewed for infection control (Resident E, Resident G, Resident N, Resident O, and Resident Q). Findings include: A list of COVID-19 positive residents was provided by the Administrator on 9/20/23 at 12:54 PM. The list indicated Resident E, Resident G, Resident N, Resident O and Resident Q tested positive for COVID-19. During an observation on 9/20/23 at 10:22 AM, Resident E, Resident G, Resident N, Resident O and Resident Q's rooms had signage to indicate the residents were on red zone precautions (COVID positive). The signage indicated upon entrance the staff donned personal protective equipment (PPE), a gown, gloves, N95 mask and face shield prior to entering the resident's room. During a continuous observation on 9/20/23 at 10:22 AM, Restorative Aide 2 donned PPE outside of Resident E and Resident G's room. Restortative Aide 2 donned a gown, gloves and face shield and kept on her surgical mask. Restorative Aide 2 entered Resident E and Resident G's room without an N95 mask on. During a continuous observation on 9/20/23 at 10:51 AM, Activity Assistant 3 entered Resident N's room with only a surgical mask on. Activity Assistant 3 handed Resident N a newspaper and patted his back. Activity Assistant 3 then exited the room. Activity Assistant 3 then donned a gown, gloves and an additional surgical mask. Activity Assistant 3 entered Resident O and Resident Q's room. Activity Assistant 3 did not put on a face shield prior to entering Resident O and Resident Q's room. Activity Assitant 3 exited the room at 10:54 AM with a gown, gloves and surgical masks on. Activity Assistant 3 did not dispose of her PPE, but walked around in the hallway with her PPE on until reminded to doff the PPE. In an interview on 9/20/23 at 10:54 AM, Activity Assistant 3 indicated she had worked at the facility for 5 months. Activity Assistant 3 indicated she had not been educated on what to wear into or when to take off PPE from a red zone room. In an interview on 9/20/23 at 10:28 AM, the Director of Nursing (DON) indicated staff should wear a gown, gloves, N95 mask and a face shield into a red zone room and take them off prior to exit from the room. In an interview on 9/20/23 at 2:09 PM Certified Nurse Aide 5 (CNA) and the Activity Director indicated prior to entering a red zone room staff donned PPE. CNA 5 and the Activity Director indicated staff donned a gown, gloves, face shield and N95 prior to entering a red zone room and doffed the PPE right before they exited the room. A policy, dated 5/8/2023, titled Core Principles of COVID IPC & NH Visitation, was provided by the Administrator on 9/20/23 at 12:54 PM. The policy indicated staff should use appropriate PPE in accordance with the Center for Disease Control and Prevention (CDC) when staff assisted those who tested positive for COVID-19, experienced symptoms or had close contact with someone with COVID-19. The CDC COVID Data Tracker,accessed on 9/20/23, indicated the county transmission level was low. This Federal citation is related to Complaint IN00417226. 3.1-18(a)

Based on interview and record review the facility failed to ensure families/representatives were notifed of COVID-19 exposure for 3 of 10 residents reviewed (Resident B, Resident C, Resident J). Findings include: A list of COVID-19 positive residents was provided by the Administrator on 9/20/23 at 12:54 PM. The list indicated the roommates of Resident B, Resident C and Resident J were COVID-19 positive. The document indicated Resident B's roommate tested positive on 9/18/23, Resident C's roommate tested positive on 9/10/23 and Resident J's roommate tested positive on 9/10/23. A record review was completed for Resident B on 9/20/23 at 2:15 PM. There was no documentation indicating Resident B's representative/family was notified of the positive roommate exposure. A record review was completed for Resident C on 9/20/23 at 2:16 PM. A COVID Resident testing/screening assessment indicated Resident C's family was notified on 9/12/23 of the positive roommate exposure three days after the exposure. A record review was completed for Resident J on 9/20/23 at 2:17 PM. A progress note, dated 9/13/23, indicated Resident J's family was notified of positive roommate exposure three days after the exposure. A policy, dated 5/8/2023, titled Core Principles of COVID IPC & NH Visitation, was provided by the Administrator on 9/20/23 at 12:54 PM. The policy did not indicate notification procedures of positive exposures. This Federal citation relates to Complaint IN00417327, and IN00417226.

Based on interview and record review the facility failed to ensure 1 of 5 residents were free from mental abuse by staff. (Resident B) Findings include: A record review was completed on 1/5/23 at 11:14 AM for Resident B. Diagnoses included Alzheimers, unspecified dementia and depression. A quarterly Minimum Data Set (MDS) assessment, dated 11/29/22, indicated Resident B had a Brief Mental Interview Status (BIMS) score of 5/15 (severely impaired). An investigation file was provided by the Director of Nursing (DON) on 1/5/23 at 12:24 PM. The file included a facility reported incident, dated 12/28/22. The report indicated on 12/28/22 a staff member alerted the DON there was a brief video put on snapchat (social media) of Resident B, dressed in pajamas and two nurse aides, Certified Nursing Assistant (CNA) 2 and CNA 3, were dancing with Resident B. Resident B was smiling and laughing with the staff members. A statement, dated 12/29/22, indicated Scheduler 7 received a video from a previous employee showing CNA 2 and CNA 3 dancing on snapchat with Resident B . A statement, dated 12/29/22, indicated the DON spoke with CNA 3 via phone. CNA 3 indicated she had posted a video of Resident B on snapchat and sent the video to 7 people. CNA 3 indicated she had not received any notifications that the video was recorded. CNA 3 also indicated she then deleted the video. A statement, dated 12/29/22, indicated CNA 2 was in the video with Resident B. CNA 2 indicated she did not think CNA 3 would post the video on social media. CNA 2 also indicated she had viewed the video on snapchat but did not send the video to anyone. In an interview on 1/5/23 at 12:16 PM, the DON indicated on 12/28/22 Scheduler 7 notified the DON that a former employee had sent a video of 2 CNAs with a resident to her. The DON indicated the video had been sent to a private group message of 7 people. The DON indicated through the investigation it was found that CNA 3 had taken a video of CNA 2 and Resident B dancing and posted the video on social media. In an interview on 1/5/23 at 11:44 AM, CNA 4 indicated videos and/or photographs should not be taken by anyone, including staff. A policy, dated 10/17/22, titled Freedom from Abuse, Neglect, Exploitation and Misappropriation of Property, was provided by the Executive Director on 1/5/23 at 12:13 PM. The policy indicated each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. The policy also indicated mental abuse includes abuse that is facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeaned or humiliated a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive states, the surveyor must consider the noncompliance related to abuse at this tag. This Federal Finding relates to Complaint IN00398123 3.1-27(b)

Based on interview and record review the facility failed to ensure security of medications from misuse for 1 of 1 residents reviewed. (LPN 2, QMA 6, CNA 5) Findings Include: An incident report, dated 10/13/22, was provided by the Healthcare Facility Administrator (HFA) on 10/27/22 at 1:40 PM. The incident report indicated on 10/13/22 a police officer entered the facility, spoke with the HFA and Assistant Director of Nursing (ADON) about Certified Nursing Assistant (CNA) 5. The officer indicated CNA 5 was found to be in possession of a medication packet with a resident's name on it from the facility. The report indicated a completed investigation indicated Licensed Practical Nurse (LPN) 2 and Qualified Medication Assistant (QMA) 6 had given CNA 5 (2) two antibiotic pills. Statements were reviewed on 10/27/22 at 1:40 PM. A statement, dated 10/19/22 by QMA 6 indicated CNA 5 approached the medication cart, indicated she had a boil under her arm. QMA 6 indicated there were antibiotics in the cart that had to be deposed of. QMA 5 indicated she was unsure who handed CNA 5 the pills. A statement, dated 10/19/22 by LPN 2 indicated CNA 5 showed LPN 2 and QMA 6 a boil on her arm. LPN 2 and QMA 6 told CNA 5 to apply warm compress. CNA 5 indicated she needed an antibiotic. LPN 2 indicated there were discontinued antibiotics they needed to destroy. LPN 2 indicated they gave her 2 [MEDICATION(S)] and destroyed 17 using the prescription destroyer. A statement dated 10/13/22 by CNA 5 indicated on or around 9/30/22 CNA 5 had a boil on her arm and was in pain. CNA 5 indicated she had shown LPN 2 and QMA 6 the boil and they had recommended an antibiotic. CNA 5 indicated one of them opened the cart and gave her 2 [MEDICATION(S)] pills. In an interview on 10/27/22 at 1:19 PM, LPN 3 indicated once a medication is discontinued the medication is removed from the medication cart immediately. If the medication is opened a medication destruction form is completed and the medication should be destroyed. If a medication is sealed a medication return form should be completed and placed with the medication in the pharmacy return tote located in the medication room. LPN 3 also indicated medication should never be given to anyone but the person who was prescribed the medication. In an interview on 10/27/22 at 2:14 PM, LPN 4 indicated when medications arrive from the facility they are contained in a roll of individual packets for each scheduled medication time. The packets indicated the resident's name, dates of medication order , medication, ordered and dose of the medication included in the packet. When an antibiotic is added to the resident's medications, a separate roll for the antibiotic is supplied with the same information visible on the packets. LPN 4 indicated medications should never be given to a staff member. LPN 4 indicated if a medication is discontinued and opened the medication should be removed from the medication cart immediately and destroyed with 2 staff present. In an interview on 10/27/22 at 1:47 PM, QMA 4 indicated only nurses could destroy medications. QMA 4 indicated if a medication is discontinued and opened, the medication must be destroyed immediately by the nurse. QMA 4 also indicated medication should never be given to anyone who does not have the specific order for the medication. A policy, revised 7/2021, titled Accidents and Incident Investigating and Reporting, was provided by the HFA on 10/27/22 at 1:40 PM. The policy indicated residents' property includes all residents' possessions includes any medication dispensed in the name of the resident. This Federal Finding relates to Complaint IN 398. 3.1-28(a)

Based on interview and record review the facility failed to ensure medication was destroyed in a timely manner for 1 of 1 residents reviewed. (Resident B) Findings include: A record review was completed for Resident B on 10/27/22 at 1:45 PM. An order, dated 9/18/22, indicated Resident B received [MEDICATION(S)] (antibiotic) 500 mg TID (three times a day) for 7 days. A nursing note, dated 9/19/22, indicated to discontinue the [MEDICATION(S)] and start [MEDICATION(S)] (antibiotic) 100 mg daily. A medication destruction form was provided by the Healthcare Facility Administrator (HFA) on 10/27/22 at 1:40 PM. The form indicated on 9/30/22 Licensed Practical Nurse (LPN) 2 destructed 17 pills of [MEDICATION(S)] 500 mg because the medication was discontinued. In an interview on 10/27/22 at 1:19 PM, LPN 3 indicated once a medication is discontinued the medication is removed from the medication cart immediately. If the medication is opened a medication destruction form is completed and the medication should be destroyed. In an interview on 10/27/22 at 1:47 PM, Qualified Medication Assistant (QMA) 4 indicated only nurses can destroy medications. QMA 4 indicated if a medication is discontinued and open the medication must be destroyed. A policy, approve dated 5/20/22, titled: Pharmacy Products and Services, was provided by the HFA on 10/27/22 at 1:40 PM. The policy indicated Disposal of medication(s) should be completed for medication(s) that are without secure closure, outdate, contaminated and/or deteriorated: disposal needs to be timely and remove medication(s) immediately from stock. This Federal Finding relates to Complaint IN 398.

Based on record review and interview, the facility failed to ensure the MDS ( minimum data set) for hospice care was completed for 1 of 5 residents reviewed (Resident 56). Findings included: A review of Resident 56's record on 8/18/2022 at 1:45 PM, indicated Dx (Diagnoses) included cerebral atherosclerosis, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] An MDS dated [DATE], was reviewed. Under section O special treatments, procedures, and programs; under other, hospice care was not selected for resident. The MDS did not show anything to indicate Resident 56 had hospice care. In an interview on 8/18/22 at 3:13 PM, the Director of Nursing and Administrator indicated they should have done an MDS with hospice. The significant change was done because of hospice, and it should have been there. A current facility policy, Care planing, dated 3/20, was provided by the Administrator on 8/19/22 at 9:47 AM. The policy indicated . The comprehensive care plan will be completed within 7 days after completion of the comprehensive MDS

Based on record review and interview, the facility failed to ensure a care plan for hospice care was completed for 1 of 5 residents reviewed (Resident 56). Findings included: A review of Resident 56's record on 8/18/2022 at 1:45 PM, indicated Dx (Diagnoses) included, cerebral atherosclerosis, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan dated 8/11/22, was reviewed. There was not a care plan for hospice care that would include a focus, goal and personalized interventions or coordinate with Hospice services. In an interview on 8/18/22 at 3:13 PM the Director of Nursing and Administrator indicated there should have been a care plan for hospice. A current facility policy, Care planning, dated 3/20 was provided by the Administrator on 8/19/22 at 9:47 AM. The policy indicated . It is the policy of this facility to develop a comprehensive plan of care that is individualized, and reflective of the resident's goals, preferences, and services, that are to be provided to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being 3.1-35(a)

Based on interview and record review, the facility failed to ensure assessment and care plan development for urinary incontinence for 1 of 3 residents reviewed (Resident J). Findings include: On 7/27/22 at 11:00 A.M., Resident J's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated 5/25/22, indicated the resident had a BIMS (Brief Interview Mental Status) score of 14. This indicated the resident had no cognitive impairment. She had no moods, behaviors, or rejection of care. She required supervision of 1 staff member for bed mobility, transfers, walking in the hallway, locomotion on and off the unit, and eating. She required limited assistance from 1 staff member for walking in her room, dressing, toileting, and personal hygiene and needed physical help of 1 for bathing. She was occasionally incontinent of bladder and a trial toileting program had been completed which resulted in decreased wetness. An ADL Care Area Assessment (CAA), dated 6/1/22, indicated Resident J had recently admitted from assisted living due to incontinence and weakness. Her goal was to return to her home in assisted living. She was at risk for further decline, including but not limited to, ADL's (activities of daily living), falls, and incontinence. She was referred to and was working with PT (physical therapy) and OT (occupational therapy) to return to her prior level of functioning. A Urinary incontinence CAA, dated 6/1/22, indicated the resident was occasionally incontinent and required limited assistance with toileting. Modifiable factors contributed to her incontinence was psychological/psychiatric problems, urinary urgency, depression, restricted mobility, and medications. She was at risk for skin rashes, skin breakdown, falls, isolation, and urinary infection. Care plans indicated the following: -5/18/22: Resident needed assistance with ADL's related to impaired cognition. The goal was that her ability to perform ADL's would improve using her care planned interventions which included, but were not limited to, staff to provide assistance with am and pm care; assistance of 1 with toileting and bathing; and supervision with walking, transfers, and eating. -5/18/22 and revised on 5/24/22: Resident was occasionally incontinent related to functional incontinence (decreased mental awareness, mobility or personal unwillingness) due to overactive bladder. The goal was her transient incontinence would be managed through her care planned interventions which were: assist with clothing adjustment, cleansing, and transfers during toileting; encourage/remind resident to wear incontinence products to manage incontinence; follow individualized toileting program which was to assist the resident to toilet upon rising, before and after meals, at bedtime, and as needed; refer to therapy for urinary incontinence interventions; and assist with incontinence care. -5/18/22: Resident was at risk for developing pressure ulcers related to incontinence. Interventions included, but were not limited to, the resident would report redness, tenderness, or changes in her skin; provide incontinence care; and observe skin weekly and as needed. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had confusion not new for her. Her past medical history indicated she had urinary urgency. Resident J had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A Bowel and Bladder Evaluation, dated 5/24/22 at 2:31 p.m., indicated the resident was frequently incontinent of bladder with modifiable factors of psychiatric problems, caffeine use, and excess fluid intake. Medications prescribed to the resident that could contribute to her incontinence were sedative/hypnotics, anti-depressants, and calcium channel blockers. Environmental contributing factors were restricted mobility, use of pads/briefs and urgency. The MDS nor CAA's indicated the resident had impaired cognition, dementia, decreased mental awareness, or personal unwillingness/behaviors related to her incontinence. The care plans did not indicate the resident had behaviors or refusals to shower or change her incontinence briefs. The care plans did not indicate the resident was at risk for urinary tract infections nor were there interventions to prevent their occurrence. On 7/27/22 at 11:23 A.M., Resident J's family member was interviewed. The family member had several concerns related to the resident's care. She indicated the facility notified family the resident required more assistance than could be provided in assisted living and recommended she be moved over to the nursing home for a probation period where therapies and nursing staff would work with the resident's incontinence and mobility with the goal of returning to assisted living. She indicated the resident had a leaky bladder, wasn't aware when she was wet and was in the early stages of dementia. The family member indicated they were told shortly after she came over to the nursing home that she would have to stay and could no longer live safely in assisted living. Since being in the nursing home, the resident had continued with incontinence, had several refusals of incontinence care and showers which the family were not always notified of. The resident developed a urinary tract infection and a severe yeast infection. The family member indicated she had contacted the facility on 4 different occasions and had spoken with a male nurse about her concerns of a urinary tract infection due to her mother having symptoms of past infections. She indicated nothing was done about her concerns until a week after she had called. Family members took the resident to a walk in clinic on because of the severe red rash she had across her pelvis and between her legs. The resident needed to have her showers completed 2 times per week and incontinence care completed timely so the resident wasn't sitting in wet briefs to prevent infections. She and her other family members were willing to be present during showers and had been coming to the facility on Mondays and Thursday (her scheduled shower days). The family member believed the resident received more thorough care in assisted living and expressed concern with the residents hygiene/incontinence care. Progress notes indicated the following: -6/3/22 at 11:11 p.m., resident was refusing to get up to use the bathroom and would rather be changed in bed. Encouraged to get up but refused so was changed in bed. -6/16/22 at 1:36 p.m., resident medications were reviewed and new order given to discontinue sleeping medication. Daughter was notified of change and reported the resident had some confusion during a visit on 6/11/22 and on 6/13/22, the resident had blood on the toilet paper when being assisted to toilet. The resident was noted to have a foul urine odor due to incontinence. 3:11 p.m., resident's family requested that a urinalysis be done due to symptoms of urinary tract infection. The Nurse Practitioner (NP) was notified and new order given for urine sample. -6/19/22 at 2:50 p.m., resident had been continent on this day but went to the bathroom frequently and changed her underwear if she dribbled or had an accident. -6/20/22 at 2:17 p.m., resident's urinalysis sample was sent for culture. -6/22/22 at 8:35 a.m., urine culture returned with large growth of bacteria. A new order was given for an antibiotic 2 times per day for 7 days. 3:58 p.m., urine was clear yellow but with odor. -6/23/22 at 4:06 a.m., resident refused to allow brief to be changed earlier in the shift and currently. Her brief was clearly soaked. She had also refused her early morning shower. -6/24/22 at at 7:18 a.m., urine in commode and in brief had strong odor and was dark amber in color. Resident had been resistant to getting up to void on commode but finally agreed. -6/28/22 at 4:32 p.m., resident voiding yellow urine without odor; is occasionally incontinent of bladder. -7/14/22 at 5:51 p.m., the resident was observed with redness to both sides of her groin area. The NP was notified and new orders received for antifungal powder. -7/15/22 at 4:57 a.m., the resident refused care from the nurse aid when attempted 3 times. The resident had told the aid to get out of her room. The nurse was notified and approached the resident who at first ignored the nurse but then agreed to be assisted with care. 3:44 p.m., the resident arrived back to the facility with her family. Her family brought in 2 tubes of antifungal cream from a local pharmacy and gave it to the nurse for the resident's yeast infection for 7 days. Family requested that the resident be showered daily and if refused, continue to encourage her and family would follow up to ensure the task was completed. -7/21/22 at 2:39 p.m., the resident refused her shower on 1st shift. She had been re-approached several times but still refused. Her family was notified of the refusals. -7/23/22 at 6:06 a.m., resident refused assistance with her ADL's and told staff to leave her alone and let her sleep. 2:04 p.m., resident was observed to fall in her room and landed on her buttocks. -7/24/22 at 1:55 a.m., staff attempted to change the resident's brief as it was moderately saturated. The resident yelled at staff and told them to get out of her room. Staff re-approached but resident refused assistance. 5:25 a.m., different staff members tried to change the resident but she continued to yell for staff to get away from her. -7/25/22 at 2:02 a.m., the nurse aid went into resident's room to change her brief. The resident told the aid don't even start with me. She refused care. -7/27/22 at 5:33 a.m., staff attempted to assist resident with her ADL's but she refused and attempted to hit staff to get them away from her as she yelled for them to get out. She was agitated and yelled at the nurse stating you are always waking me up and then I can't get back to sleep. Resident was told that she needed to let staff help her because her family request it. She yelled at the nurse and refused assistance. A review of the resident's OT evaluation and discharge plan indicated on 5/19/22, Resident B was referred for therapy. She'd been a resident in assisted living, had declined in her abilities with self care and was unable to manage her incontinence. She received 4 days of therapy and was discharged on [DATE] with recommendation to continue to complete toileting on a regular basis to assist with decreasing episodes of incontinence. She had progressed well with treatment and met her goals. She was managing her incontinence and had decreased her episodes of incontinence by increasing her frequency of going to the toilet. In interviews on 7/27/22, the following was indicated -At 1:42 P.M., CNA 5 (Certified Nurse Assistant) indicated she had worked with Resident J for the past 2 months. The resident was resistant at times to being assisted with incontinence care and showers according to her mood. At times she was open to assistance. At other times would refuse and could not be talked into it. -1:48 P.M., the Social Services Director (SSD) indicated Resident J had been brought over to the nursing home to work with therapy to try and do incontinence training, establish a routine the resident could follow to decrease her incontinence and allow for her to stay in assisted living. She indicated the resident could be resistant to care but was not on a behavior plan nor were there specific behavioral interventions care planned. -2:03 P.M., the Director of Nurses (DON) indicated the facility was trying to assist the resident to go back to assisted living and were trying to determine if her urinary incontinence was a functional issue. The resident had an overactive bladder but hadn't had any further follow up to determine if there were other interventions to be done. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the resident had some cognition issues and behaviors of refusing to be assisted with incontinence care and hygiene. -2:20 P.M., Certified Occupational Therapy Assistant (COTA) 6 indicated she had worked with the resident previously while in assisted living and while in the nursing home. She indicated the resident had contributing issues to her inability to care for her incontinence. These were cognition/confusion, her schedule, and her lack of recognition for hygiene needs. The resident liked to attend activities and didn't want to be bothered for toileting. -2:39 P.M., the Administrator and MDS nurse were interviewed. The MDS nurse indicated some time during the resident's stay at assisted living, her family had taken her to appointments with the urologist who had administered [MEDICATION(S)] injections for the incontinence although she was not aware if the family still did this. The resident had a recent [CONDITION(S)] but it was not care planned. The Administrator indicated the resident was resistant to care due to interruption of her activities. Her toileting plan was to toilet in the morning, before bed, before and after meals and as needed. The plan did not address the resident's activities and coordination with planned toileting. This Federal tag relates to Complaint IN 715. 3.1-41(a)(2)

Based on observation and interview the facility failed to properly prevent COVID-19 related to Personal Protective Equipment use for 2 of 5 residents reviewed. (Resident V and Resident W) Findings include: A continuous observation, on 1/7/22 from 11:10 AM to 11:56 AM, at 11:20 AM, observed 5 rooms with yellow zone signs on doors had a hanger on outside with the proper PPE (personal protective equipment). On two of the 5 rooms, over the outer most part of the door, gowns were hung with half being inside the room and half outside the room. During continued observation CNA 3 was going into a room without donning gloves. CNA 3 came out of the room with a pitcher for ice water. She sat the pitcher on the handrail outside of the room, then picked it up and sat it down next to the ice chest on cart. The CNA touched the ice scoop with ungloved hand, then proceeded to fill pitcher. CNA 3 took the pitcher back into room. The CNA was interviewed. She indicated she was in a hurry due to the resident being demanding. She indicated should have worn gloves and performed hand hygiene. Resident V and Resident W resided in the room. An interview, with Director of Nursing and Infection Prevention (IP) Nurse on 1/7/22 at 12:03 PM, indicated hand hygiene shoudl be performed when donning and doffing gloves. Obtained , from IP nurse, and reviewed Policy and Procedure for Personal Protective Equpment, last revision 7/21. The policy indicated staff, residents and visitors would be supplied with appropriate PPE, hand hygiene was to be performed when donning and doffing gloves. 3.1-18(a)

Based on observations, interviews and record reviews, the facility failed to properly ensure staff used Personal Protective Equipment (PPE) during an outbreak of COVID-19 for 5 of 5 residents observed for infection control (Resident 2, Resident 7, Resident 8, Resident 9, and Resident 10). Findings include: During observation on 8-16-21 at 9:35 A.M., it was noted that all rooms on 200 hall and 300 hall were on Transmission Based Precautions (TBP) with signs on the doors to indicate proper PPE necessary to enter the rooms. The TBP signs indicated Single gown- with each encounter During observation on 8-16-21 at 9:44 A.M., Employee 3 entered room [ROOM NUMBER] and turned off the call light for Residents 8 and 9. Employee 3 failed to don a gown prior to entering the room. During an interview on 8-16-21 at 9:45 A.M., Employee 3 indicated there was not a reason why she did not put gown on to enter room and she guessed she was supposed to put one on. During observation on 8-16-21 at 9:52 A.M., Employee 5 and Employee 7 were observed in room [ROOM NUMBER] asking Resident 5 what he needed. Employee 5 and Employee 7 both failed to don gowns or gloves upon entering the room. During observation on 8-16-21 Employee 5 was observed to enter room [ROOM NUMBER] to ask Resident 2 if she was finished with her breakfast tray. Employee 5 failed to don gown and gloves prior to entering the room. During an interview on 8-16-21 at 9:54 A.M., Employee 5 indicated she did not know they were to put gowns on, and the facility did not tell her. During observation at 10:04 A.M., Agency staff 6 was observed to enter room [ROOM NUMBER] to answer the call light for Resident 10. Agency staff 6 failed to don a gown and gloves prior to entering the room. During an interview on 8-16-21 at 10:05 A.M., Agency staff 6 indicated she should have had a gown on and there was no reason she didn't. During observation on 8-16-21 at 10:09 A.M., Agency staff 7 was observed to enter room [ROOM NUMBER] and then exited the room with the same gown on and with the hoyer lift. Agency staff 7 failed to remove the gown prior to exiting the room. During an interview on 8-16-21 at 10:10 AM, Agency staff 7 indicated she had entered room [ROOM NUMBER] to look for a gown earlier; and indicated she just went into the bathroom in 316 to get the hoyer lift to take to room [ROOM NUMBER], and that she did not touch anything. She asked if she should change the gown. During an interview on 8-16-21 at 12:57 P.M., the Director of Nursing indicated all staff have PPE training and in-services, and agency staff get orientation packets and were always welcome to come to the in-services. She also indicated staff should not be going into TBP rooms without gowns, even if it's something minor. The facility policy titled Personal Protective Equipment (PPE), revised 10/26/20, indicated It is the policy of this facility to ensure PPE is available to staff . and they understand when and how to use the PPE. 9. Staff will follow the policy for isolation precautions and the use of PPE The facility policy titled Covid-19 Policy, revised 4/21, indicted It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to Federal and State/Local recommendations . Note: All healthcare personnel will be correctly trained and capable of implementing infection control procedures and adhere to requirements. The Yellow Zone Transmission Based Precautions signs on the doors indicated Single gown- with each encounter . Gloves 3.1-18(b)(1)

Based on, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) in a timely manner, related to assistance with bowel elimination for 1 of 5 residents reviewed for ADL. This failure resulted in a resident using a wastebasket to defecate, causing emotional embarrassment and humiliation (Resident B). Findings include: During an interview on 4/26/21 at 12:05 p.m., Resident B indicated she could no longer hold her bowel movement. She had put on her call light and waited about 30 minutes until she could no longer hold it. She scooted to the edge of the bed and used her waste basket to have a bowel movement in. The aides then came in and were cleaning her up and one aide said she thought she told the other aide to answer the call light. LPN 1 came into her room and said what are you doing because the staff had her lying across her bed. LPN 1 then laughed and left. Resident B indicated she was bawling out of embarrassment because she had to use her wastebasket. During a second interview on 4/26/21 at 1:58 p.m., Resident B indicated she needed extra assistance because she had hurt her back. She indicated CNA 2 was one of the aides, but she had not seen the other aide before. The aides apologized for what happened, but the nurse just laughed. She did not want to get anyone in trouble, but what happened was unacceptable. The clinical record for Resident B was reviewed on 4/26/21 at 10:33 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/22/21, indicated the resident was cognitively intact. The resident required one-person physical assist for toileting. She was unsteady, but able to stabilize with staff assistance. A second health care plan, dated 3/2/21, indicated the resident needed assistance with ADL's related to pain. Interventions included, but were not limited to, provide limited assistance with 1 staff for toileting. On 4/26/21 at 2:14 p.m., the facility Administrator was informed of the allegation of abuse and an investigation was initiated. On 4/26/21 at 3:00 p.m., the Administrator interviewed Resident B who indicated she needed some extra assistance that day and was unable to get her shoe and/or brace from under the bed to go to the restroom. Two CNA's came in, one was CNA 2 and she did not know the other aide and cleaned her up. LPN 1 came in and the resident stated well I had a BM [bowel movement] today, mark me off the list and that was when LPN 1 laughed. The resident stated she was upset LPN 1 did not ask how she was doing. A written statement was obtained from LPN 1 on 4/26/21. LPN 1 indicated she was alerted by staff the resident had used the trash can by her bed to have a bowel movement. Staff entered Resident B's room and she was holding onto the bed rail and her back was on the bed and her feet were on the floor. LPN 1 spoke to the resident when she was back in bed and asked the resident what happened. The resident stated she needed to go to the bathroom and could not reach her shoes and braces. She had turned on the call light, but no one came fast. A written statement from CNA 2 indicated Resident B's light was on, but was not sure how long it had been on. She walked into her room and she was half off and half on the bed. She asked her what happened and the resident indicated she had to use the restroom and no one answered her call light. She stated how embarrassed she was that she had to have a bowel movement but couldn't make it to the bathroom. The resident stated her shoe and or her brace were under the bed and she could not get them. CNA 2 apologized and asked if there was anything else she could do and Resident B just kept saying how embarrassed she was. A Social Service interview with Resident B, dated 4/26/21, indicated approximately 2-3 weeks ago, she felt the need to have a bowel movement. She was unable to say if she placed her call light on at that time or if she told the staff who had been in assisting her roommate. She waited approximately 30 minutes, looked to see if the red light was on and recalled pressing the call light two more times. She scooted herself to the edge and attempted to put on her shoes, but found one was located under the bed. She then scooted across the bed and was unable to contain her bowels and placed herself on top of her trash an while holding onto the bed rail. She then began yelling for help and the aides then came in and assisted her off the trash can. She felt embarrassed and humiliated. Resident B then stated after the aides came in her room, LPN 1 came in her room. She stated to LPN 1 well, you can mark me down for a BM because I just pooped in the trash can. LPN 1 then chuckled or snickered and left. The resident was upset LPN 1 did not ask how she was doing and it hurt her feelings. During an interview on 4/26/21 at 2:57 p.m., the Administrator indicated CNA 2 denied any laughing, but comments were made about being embarrassed. On 4/27/21 at 10:03 a.m., the Administrator, Director of Nursing (DON) and Corporate Nurse were present. The DON indicated they needed to assign sensitivity training and professionalism to the nurses. The resident did say she was humiliated with having to void in the trash can and no response by the nurse. The nurse did not report the incident because they felt it was related to urgency and not a long wait time. On 4/27/21 at 1:02 p.m., CNA 2 indicated it was not her sections for call lights that night, but could not recall who the other CNA was. She apologized many time to the resident and just felt terrible for her. She denied hearing any laughing related to the incident. LPN 1 was currently suspended pending the investigation. A current facility policy, dated 2/2012 and revised 4/2021, titled, Abuse, Neglect and Misappropriation of Resident Property, which was provided by the Administrator on 4/26/21 at 10:40 a.m., indicated the following: Policy: This facility's policy is the resident has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal .Mental Abuse: This includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .Neglect: This occurs on an individual basis when a resident is not care for in one or more areas. Neglect is also lack of attentiveness, carelessness or the failure to provide timely, consistent, safe, adequate and appropriate services This Federal tag relates to complaint IN 440. 3.1-37(a)

Based on record review and interview, the facility failed to complete bowel monitoring and ensure the treatment for constipation for 1 of 5 residents reviewed (Resident B). Findings include: The clinical record for Resident B was reviewed on 4/26/21 at 10:33 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/22/21, indicated the resident was cognitively intact. The resident required one-person physical assist for toileting. She was unsteady, but able to stabilize with staff assistance. A health care plan, dated 6/13/18, indicated the resident had constipation related to decreased mobility. Interventions included, but were not limited to, resident to report and you will observe for any changes in my normal bowel pattern. A second health care plan, dated 3/2/21, indicated the resident needed assistance with Activities of Daily Living (ADL) related to pain. Interventions included, but were not limited to, provide limited assistance with 1 staff for toileting. Review of the bowel monitoring documents for April 2021, the resident last had a documented large bowel movement on 4/19/21 at 11:19 a.m. The next bowl movement was noted to be small on 4/23/21 at 8:51 p.m. A change of condition, dated 4/24/21 at 5:07 p.m., indicated the resident complained of abdominal pain that started in the morning on 4/24/21. The summary indicated the resident had complained of a lump to the right lower quadrant and tender to tough. All bowl sound were active. The resident complained of this pain beginning a few days now. Denies any difficulty with bowels. A progress note, dated 4/25/2021 at 10:47 a.m., indicated the Nurse Practitioner (NP) was notified of the abdominal pain and order a Kidneys, Ureters, and Bladder (KUB) x-ray to be done. An abnormal KUB result, dated 4/25/21 at 4:29 p.m., indicated there was slight amount of rectal stool present. A progress note, dated 4/26/2021 at 5:40 a.m., indicated the resident denied any complaints of pain or discomfort, but a lump was observed to the right lower quadrant with bowel sounds. A progress note, dated 4/26/2021 at 12:43 p.m., indicated the resident complained of pain in the right lower quadrant with tenderness. During an interview with the Director of Nursing (DON) on 4/27/21 at 10:03 a.m., she indicated the NP has seen the resident, a Computerized Tomography (CT) of the abdomen was ordered and waiting to be scheduled. They discussed bowel alerts in morning meeting and followed up on any that may have flagged. She was unsure, but would check to see if the resident flagged on a bowel alert. On 4/27/21 at 11:19 a.m., the DON indicated the resident did show up on a bowel alert, but she no longer had the form. Once the situation was resolved, the form is then shredded. The Medical Record nurse confirmed with the resident that she did not go a day without a bowel movement, but did not document the information at that time. A current facility policy, dated 6/2014 and revised 9/2019, titled, BOWEL ELIMINATION POLICY, which was provided by the Administrator on 4/26/21 at 2:53 p.m., indicated the following: Policy: It is the policy of this facility to ensure residents receive proper treatment for constipation. .General Protocol: 1. Follow specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. All nursing staff will record resident bowel movements every shift in the electronic medical record. 3. Each nurse will compile a daily [MEDICATION(S)] list on all residents who have not had a bowel movement for two days (six shifts) at the beginning of each shift. 4. The nurse that is notified of no bowel movement in 48 hours will give the first line of intervention for those who have not had a bowel movement for two day .as ordered by the physician. a. If no order, give four (4) ounces of prune juice b. Give [MEDICATION(S)] as ordered 7. Alert charting will begin with the initiation of the first intervention .not limited to; a) Vital Signs b) Bowel sounds c) Abdomen palpation d) Complaints of abdominal discomfort. This Federal tag relates to complaint IN 440. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were kept at a safe temperature for 45 of 81 residents residing in 2 halls (Touchstone Memory unit and 300 hall). This had the potential to affect 21 of 45 residents who were independently mobile and cognitively impaired. This deficiency had the potential to cause hot [MEDICAL CONDITION] the residents residing in these 2 halls. The Immediate Jeopardy began on 2-11-2019 when a staff member observed hot water temperatures were greater than 120 degrees F and did not notify the Administrator of the elevated hot water temperatures. The Administrator, Director of Nursing, and the Regional Director of Quality Assurance were notified of the Immediate Jeopardy at 1:40 p.m. on 2-15-2019. The Immediate Jeopardy was removed on 2-17-2019, but noncompliance remained at a lower scope and severity of pattern, no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy. Findings include: During an observation on 2-15-2019 of resident rooms in the 300 hall, the following hot water temperatures were observed: The hot water temperatures were obtained in the 300 hall rooms with steam observed to rise from the hot water as it was flowing. The room numbers and hot water temperatures on 2-15-2019 were: At 10:10 a.m., in room [ROOM NUMBER], the hot water temperature was 151.2 degrees F and 2 residents were in this room. At 10:13 a.m., in room [ROOM NUMBER], the hot water temperature was 152.2 degrees F and 2 residents were in this room. At 10:15 a.m., in room [ROOM NUMBER], the hot water temperature was 154.8 degrees F. An interview with an alert and oriented resident with a BIMS of 10 in this room, indicated if the water was too hot, he would turn on the cold water. There were 2 residents in this room. At 10:25 a.m., in room [ROOM NUMBER], the hot water temperature was 147.6 degrees F. There were 2 residents in this room. At 10:28 a.m., in room [ROOM NUMBER], the hot water temperature was 150.4 degrees F. There were 2 residents in this room. During an observation on 2-15-2019 of resident rooms in the Touchstone Memory unit, the following hot water temperatures were observed: At 10:26 a.m., in room [ROOM NUMBER], the hot water temperature measured 134.4 degrees F. There was 1 resident in this room. At 10:32 a.m., in room [ROOM NUMBER], the hot water temperature was 133.7 degrees F. There were 2 residents in this room. At 10:35 a.m., in room [ROOM NUMBER], the hot water temperature was 133.5 degrees F. There were 2 residents in this room. At 10:38 a.m., in room [ROOM NUMBER], the hot water temperature was 128.7 degrees F. There were 2 residents in this room. At 10:40 a.m., in room [ROOM NUMBER], the hot water temperature was 128.8 degrees F. There were 2 residents in this room. At 10:45 a.m., in room [ROOM NUMBER], the hot water temperature was 128.9 degrees F. There were 2 residents in this room. At 10:48 a.m., in room [ROOM NUMBER], the hot water temperature was 129 degrees F. An interview with an alert and oriented resident with a BIMS of 15, indicated I know the water gets hot. This was the only resident in this room. At 10:52 a.m., in room [ROOM NUMBER], the hot water temperature was 128.5 degrees F. There was 1 resident in this room. At 10:55 a.m., in room [ROOM NUMBER], the hot water temperature was 128.5 degrees F. There was 1 resident in this room. On 2-15-19 at 10:22 a.m., the community accessible bathroom in the common area outside the nurses' station had the hot water checked. The temperature was 139 F. On 2-15-19 at 11:00 a.m., the hot water temperature in the sink in the kitchenette area of the locked, Touchstone Memory unit was checked and was 122.2 F. This area was accessible to all staff and residents. At the time this water temperature was checked, a resident in his wheelchair and was observed to propel himself by the counter by the sink. The resident was drinking a glass of juice, reached up to the counter and picked up the pitcher of juice and poured himself another glass of juice. On 2-15-19 at 11:18 a.m., the DON (Director of Nursing) was interviewed. She indicated in the locked Touchstone Memory unit, there was a total of 14 residents. Of those, there were 12 residents with a BIMS (Brief Interview of Mental Status) less than 10 which meant they were cognitively impaired. Of those 12, there were 10 residents who were cognitively impaired and independently mobile. An interview with CNA 1 who was assigned to the 300 hall, on 2-15-2019 at 10:41 a.m., indicated she usually turned on both the hot and cold water in the residents' bathrooms. She indicated she usually did not run just the hot water. An interview with the Maintenance Supervisor on 2-15-2019 at 10:45 a.m., indicated he had been fighting the hot water temperatures in the 300 hall since Monday, (MONTH) 11, 2019. He indicated the water mixer valve was not working and if he tried to turn it down to lower the temperature, the hot water would shut off. At this time, both the Administrator and the Maintenance Supervisor indicated the valve replacement had been an urgent request with their corporation and had not been repaired as yet. An observation in room [ROOM NUMBER] with the Administrator and the Maintenance Supervisor on 2-15-2019 at 10:45 a.m., indicated the hot water temperature with the Maintenance Supervisor's thermometer was 148 degrees F. An interview with the DON (Director of Nursing) on 2-15-2019 at 10:53 a.m., indicated there were 11 cognitively impaired, (BIMS less than 10), independently mobile residents in the 300 hall and no residents in the building with burns. An interview with the Administrator and the Maintenance Supervisor on 2-15-2019 at 11:01 a.m., indicated the Maintenance Supervisor discovered the hot water temperatures were too high in the 300 hall and both indicated they had been trying to get it resolved. An observation in room [ROOM NUMBER] in the Touchstone Memory unit with the Administrator and the Maintenance Supervisor on 2-15-2019 at 11:07 a.m., indicated the hot water temperature was obtained with the Maintenance Supervisor's thermometer and was 127.9 degrees F. The Maintenance Supervisor indicated this room was next to the hot water heater. He also indicated he checked hot water temperatures yesterday (2-14-2019) in the memory unit and they were 117 degrees F and 119 degrees F. The Maintenance Supervisor was observed to adjust the water mixer valve and turned it 1/4 turn to the left to lower the temperature. An observation of the temperature on the hot water heater itself was 140 degrees F. and the thermometer reading after the mixing valve was at 120 degrees F. An interview with the Administrator on 2-15-2018 at 11:08 a.m., indicated all the mixing valves had been replaced in the building except for the one in the 300 hall. He indicated the Maintenance Supervisor was new and did not report to him the high hot water temperatures in the 300 hall on Monday (February 11, 2019). He indicated the Corporate Maintenance was contacted today and was trying to locate a mixing valve and was going to arrange for a local plumber to install the new mixing valve today. An interview with the Maintenance Supervisor on 2-15-2019 at 11:15 a.m., indicated he rechecked the hot water temperatures in the 300 hall daily since Monday (February 11, 2019), but did not record the temperatures. He indicated the hot water temperatures from his memory were about 130 degrees F. At this time, the Administrator was observed to inform the Maintenance Supervisor, he needed to be informed of any hot water temperatures over 120 degrees F. A copy of the weekly water temperatures for the facility was provided by the Administrator at this time for 1-30-2019 and 2-8-2019. The hot water temperatures ranged from 116 degrees F. to 119 degrees F. for 8 random rooms in the 3 halls and 1 memory care kitchen on 1-30-2019 and for 9 random resident rooms in the 3 halls. An interview with the Regional Director of Quality Assurance on 2-15-2019 at 12:15 p.m., indicated the staff and residents with BIMS 10 or above were educated about the high hot water temperatures and instructed the residents to turn on the cold water with the hot water. An interview with the Administrator, DON and the Director of Quality Assurance on 2-15-2019 at 12:17 p.m., indicated the Maintenance Supervisor had physically turned down the temperature on the water heater. The Administrator indicated the hot water was too cool now and not up to temperature. Observations of the facility hot water temperatures were made on 2-16-2019 from 10:31 a.m. to 11:06 a.m., with the Maintenance Supervisor, the DON and Administrator. In the Touchstone Memory Care unit, the hot water temperatures in all resident bathrooms and the kitchenette sink ranged from 104 degrees F to 119 degrees F. The hot water temperatures in rooms 301, 302, 304, 316 and 317 ranged from 105 degrees F to 116 degrees F. The hot water was turned off in the bathroom near the main nurse station. An observation in the shower room utility closet in the 300 hall with the Maintenance Supervisor on 2-16-2019 at 10:55 a.m., indicated there was a new mixing valve installed and the thermometer after the hot water went through the mixing valve read 112.0 degrees F. While observing the hot water temperatures as above, there were paper signs taped above the sink in each of the areas when using the hot water and recommended turning on the cold water first. Observations of the facility hot water temperatures were made on 2-17-2019 from 1:32 p.m. to 1:53 p.m., with the Maintenance Supervisor, the DON and Administrator. In the Touchstone Memory Care unit, the hot water temperatures in all resident bathrooms and the kitchenette sink ranged from 106 degrees F to 118 degrees F. The hot water temperatures in rooms 301, 302, 304, 316 and 317 ranged from 110 degrees F to 118 degrees F. The hot water was turned off in the bathroom near the main nurse station. An interview with RNA 2 (Restorative Nurse Aide) on 2-17-2019 at 1:30 p.m., indicated if she would find the hot water in a resident's bathroom too hot to keep her hands in the water, she would report this to the Maintenance Supervisor and the Administrator. An interview with CNA 3, who was working in the Touchstone Memory Care unit on 2-17-2019 at 1:42 p.m., indicated she would report to the Maintenance Supervisor and the Administrator if she was not able to keep her hand under the running hot water at the kitchenette sink or in a resident's bathroom sink. An interview with the Housekeeping Supervisor on 2-17-2019 at 1:50 p.m., indicated if she was unable to hold her hand under running hot water at a resident's bathroom sink, she would report this to the Maintenance Supervisor and the Administrator. An interview with CNA 4 who was assigned to the 300 hall on 2-17-2019 at 1:52 p.m., indicated if she was unable to hold her hand under running hot water at a resident's bathroom sink, she would report this to the Maintenance Supervisor and the Administrator. A Current Policy, Legionnaire's Disease Policy dated 6-2017 was provided by the Administrator on 12-15-2019 at 4:04 p.m. The policy indicated .each (name of corporation) facility heats their hot water with water heaters or boilers that reach a minimum temperature of 140 degrees F. The water is then sent through a mixing valve to control the temperature back down to a non-scolding (sic) temperature of approximately 105 degrees F - 119 degrees F. At this point the hot water circulates throughout the facility on a reoccurring loop powered by circulating pumps The Immediate Jeopardy that began on 2-11-2019 was removed on 2-17-2019 when the hot water temperatures were observed at a safe level in resident bathrooms and staff education was started on whom to report noticing the hot water was too hot. The Immediate Jeopardy was removed on 2-17-2019, but noncompliance remained at the lower scope and severity of pattern, no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated on whom to report noticing the hot water was too hot and the need for continued monitoring of the hot water temperatures. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure trash was transported in a sanitary manner. This had the potential to affect 81 of 81 residents residing in the facility. Findings included: On 2/15/2019 at 9:05 a.m., HK (Housekeeper) 5 was observed carrying trash bags, slung over their shoulder to the outside dumpster. The bags were touching HK 5's uniform and jacket. On 2/19/2019 at 12:16 p.m., HK 5 was observed a carrying a large bag of trash to the outside dumpster. The bag was slung over their shoulder and touching HK 5's uniform and jacket. On 2/20/2019 at 10:52 a.m., HK 5 was observed carrying three bags of trash outside. The bags were slung over their shoulder and touching HK 5's uniform and jacket. During an interview on 2/20/2019 at 10:54 a.m., the Housekeeping Supervisor indicated the trash bags were to be carried off the floor, away from the body and not to touch the uniform. Also, the bags are not to be slung over shoulders. The housekeeping Supervisor indicated HK 5 worked in all areas of the facility. A current undated facility directions form, Remove Trash Carefully ! , indicated .Don't swing filled trash bags on your back! . and .Avoid bumping your body against a filled trash bag during removal and disposal . 3.1-18(b)(4)

Based on interview and record review, the facility failed to ensure a written Bed Hold policy was provided on transfer for 4 of 5 residents reviewed with transfers. (Resident 14, Resident 72, Resident 73, Resident 7) Findings include: 1. The record review for Resident 14 began on 2/18/19 at 11:05 a.m. [DIAGNOSES REDACTED]. Review of Resident 14's MDS (Minimal Data Set) Assessments indicated a Discharge-Return Anticipated Assessment was completed on 10/29/18. An Admission MDS Assessment, dated 11/12/18, indicated a BIMS (Brief Interview for Mental Status) Score of 12 which indicated the resident had moderately impaired cognition. Review of the facility's Bed Hold Authorization and Bed Hold Policy, indicted the facility currently Does Not meet the 90% occupancy requirement and therefore payment Will Not be required to hold the bed. The Resident/Resident Representative's signature was lacking and the form was signed and dated by a staff member on 10/29/18. The form indicated a copy was sent with Resident 14 at the time of discharge. The document did not indicate a copy was mailed to the resident representative. The document was also lacking if the resident representative was notified by phone. 2. The record review for Resident 72 began on 2/19/19 at 1:24 p.m. [DIAGNOSES REDACTED]. Review of Resident 72's MDS (Minimal Data Set) Assessments indicated a Discharge-Return Anticipated Assessment was completed on the following date, 10/29/18. A Quarterly MDS dated [DATE] indicated a BIMS Score of 02 which indicated Resident 72 had severe cognitive impairment. Review of the nurse's progress notes dated 10/29/18 indicated documentation was lacking for Resident 72's transfer to an in-patient psychiatric hospital. Review of a Social Service progress note dated 10/30/18 indicated the resident had aggressive behaviors of hitting and biting. The progress note indicated the Psychiatric Nurse Practitioner was notified and an order was received to send Resident 72 for inpatient psychiatric hospital stay. Review of the Resident 72's record lacked documentation whether the resident representative had received a copy of the facility's Bed Hold Policy. In an interview with the Regional Director of Quality Assurance on 2/19/19 at 3:55 p.m., they indicated the hospital was faxing the transfer papers that were sent to the hospital with Resident 72. She also indicated they had spoken to the facility nurse who transferred the resident and they indicated the transfer paperwork had been completed, but copies must not have been made for the resident's record. In an interview with Unit Manager 7 on 2/19/19 at 4:53 p.m.,they indicated the hospital had only faxed the (MONTH) (YEAR) MAR (Medication Administration Record) and TAR (Treatment Administration Record) to the facility. Unit Manager 7 indicated more of the paperwork should be coming from the hospital. The facility did not provide documentation if Resident 72's Representative was provided the Facility Bed Hold Policy. 3. A review of Resident 73's record on 2/20/2019 indicated the resident had a BIMS score of 4 out of 15, meaning severe cognitive impairment. [DIAGNOSES REDACTED]. An SNF/NF(Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form, dated 1/8/2019, indicated Resident 73 was transferred to an acute care facility. A Bed Hold Authorization, dated 8/1/2014, provided by the DON on 2/20/2019 at 2:10 p.m., had no signature or date of the resident/resident representative had been provided the notification. The DON signed and dated the form and checked the box marked .Copy sent with resident at time of discharge . However, Resident 73 had a BIMS score of 4, meaning severe cognitive impairment. The other box .Copy mailed to resident representative on _________ by ___________ . was not marked. A Bed Hold Policy, dated 8/1/2014, provided by the DON on 2/20/2019 at 2:10 p.m., indicated a phone consent dated 1/8/2019 at 11:51 a.m., but did not document the name of the person who was called. The DON was the facility representative making the call. 4. On 2/18/19 at 10:30 a.m., the record of Resident 7 was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set Assessment (MDS) Assessment, dated 2/5/19, indicated the resident had been discharged with a return anticipated. A progress note dated 2/5/19 at 10:21 p.m., indicated the resident had a change of condition which included, but was not limited to the following: very lethargic, severe shortness of breath with exertion, labored breathing, hypoxic (with oxygen saturations dropping to 85%), resident was unable to lay down, very uncomfortable. An order was obtained to send the resident to the emergency room for evaluation and treatment. The daughter was notified of the resident's condition and was going to meet her mother at the hospital. Resident was transferred to the hospital via ambulance. On 2/19/19 at 4:52 p.m., Unit Manager 7 provided a copy of facility SNF (skilled nursing facility)/NF (nursing facility) Hospital Transfer/Interact form, dated 2/5/19. This form was completed electronically. Documentation was lacking on the form regarding the resident and/or resident representative having been provided a copy of the bed hold policy. On 2/20/19 at 11:12 a.m., the RN 6 was interviewed. She indicated when a resident was discharged , as the nurse, she would have called the family and notified them of bed hold options. She indicated the bed hold options were dependent on the facility census. RN 6 indicated if the family was not at the facility at the time of transfer, she would have read the bed hold information to the family over the phone. She further indicated she would have had a second nurse witness the phone conversation and cosign a form which indicated the family had been notified of the bedhold policy information. She indicated if the family came into the facility, they would be provided a paper copy of the bed hold policy. On 2/20/19 at 11:17 a.m., the Director of Nursing (DON) was interviewed. She indicated the resident representative could be notified of the the bed hold policy verbally over the phone. She indicated two nurses would cosign the information which would have indicated the bed hold policy had been provided to resident representative verbally on the phone. She indicated information regarding the bed hold policy was documented on the electronic Interact Transfer Form. The DON indicated the nurses sent a copy of the bed hold policy with the resident to the hospital. On 2/20/19 at 11:44 a.m., a Bed Hold Authorization, with a revision date of 8/1/14, was provided by Medical Records staff 8. Medical Records staff 8 indicated this Bed Hold Authorization was for Resident 7. The form included, but was not limited to, the following: a vacant bed may be held for you while you are in the hospital or on therapeutic leave. Residents must pay one-half the per diem rate to hold the bed during their departure if the facility's occupancy rate is over 90% of operational beds. If the occupancy is below 90% on the day of leave, the bed will be held for 5 days at no charge. The form was signed and dated by an employee on 2/5/19. An area was available on the form for the resident/family signature. Documentation was lacking of a resident/family signature. An area was available on the form to indicate a copy had been mailed to the resident representative on (date) by (staff). Documentation was lacking on the form a copy had been mailed to the resident representative and by whom. A Bed Hold Policy form, which was on the back side of the Bed Hold Authorization form, had the following areas available to complete: I wish to hold a bed, I do not wish to hold a bed, undecided, resident/legal representative signature; phone consent with date/time of call in addition to facility representative making call. Documentation was lacking on the Bed Hold Policy form of the following: resident and/or resident representative decision regarding bed hold status, resident/representative signature, phone consent with date/time of call and the facility representative making the call. On 2/20/19 at 1:10 p.m., the DON was interviewed. She indicated for an emergency transfer of a resident to the hospital, a copy of the bed hold policy would be sent with the resident to the hospital. She indicated the Business Office Manager (BOM) or herself, would send the resident representative a copy of the bed hold policy in the mail after the 5 day courtesy bed hold. She said if they were over 90% occupancy, they would call the family and mail the information about bed hold immediately to the resident representative. She indicated she did not document when she mailed the resident representative a copy of the bed hold policy. On 2/20/19 at 11:23 a.m. the Regional Director of Quality Assurance (RDQA) provided a current copy of the facility policy and procedure for Bed-Hold/Readmission Policy, with a revised date of 11/2017. The policy and procedure included, but was not limited to, the following: To ensure communication between the facility and the resident and resident representative. The notice of facility bed hold policy will comply with State and Federal laws and rules. In cases of emergency transfer, notice at the time of transfer means that the resident and resident representative is provided with written notification within 24 hours of the transfer. 3.1-12(a)(25)(26)

Based on interview and record review, the facility failed to ensure the appropriate Medicare liability notification forms were provided for 2 of 3 residents reviewed for Beneficiary Protection Notifications (Resident 46 and Resident 60) Findings include: On 2/14/19 at 1:00 p.m., the facility provided the Medicare SNF Beneficiary Protection Notifications for review. On 2/18/19 at 11:55 a.m., the Regional Director of Quality Assurance provided Resident 46 and Resident 60's Medicare Beneficiary Notices. Resident 46's Beneficiary Notification documents were reviewed on 2/18/19 at 1:36 p.m. Resident 46 was identified by the facility to have remained in the facility after being discharged from Medicare Skilled Services. The SNF Beneficiary Protection Notification Review document, which was completed by the facility, indicated Resident 46's Medicare Part A Skilled Services episode start date was 11/12/18 and the last covered day of Part A Services was on 1/24/19. The document also indicated the facility initiated the discharge from Medicare Part A Services when the benefit days were not exhausted. The Notification Review document indicated the facility had not provided Resident 46 a SNF ABN (Skilled Nurse Facility Advance Beneficiary Notice of Non-Coverage) form, and indicated niether the resident nor family wanted to appeal decision. The NOMNC (Notice of Medicare Non-Coverage) was provided to Resident 46. Review of the NOMNC form indicated Resident 46's representative was notified by telephone on 1/21/19 of skilled services which would end on 1/24/19. Documentation was lacking whether the Beneficiary Notices were mailed to the resident representative. Resident 60's Beneficiary Notification documents were reviewed on 2/18/19 at 1:50 p.m. Resident 60 was identified by the facility to have remained in the facility after being discharged from Medicare Skilled Services. The SNF Beneficiary Protection Notification Review document, completed by the facility, indicated Resident 60's Medicare Part A Skilled Services Episode start date was 8/15/18 and the last covered day of Part A Services was on 10/20/18. The document also indicated the facility initiated the discharge from Medicare Part A Services when the benefit days were not exhausted. The Notification Review document indicated the facility had provided Resident 60 a SNF ABN (Skilled Nurse Facility Advance Beneficiary Notice of Non-Coverage) form CMS- (Center for Medicare and Medicaid Services), and indicated a NOMNC was provided to the resident. Resident 60's ABN (Advance Beneficiary Notice of Non-coverage) form CS-R-131 was provided. The document lacked information to whom the ABN was given. The ABN form was not signed or dated. Review of Resident 60's NOMNC indicated the resident representative was notified by telephone on 10/17/18 of skilled services which would end on 10/19/18. Resident 60's record lacked documentation whether the Beneficiary Notices were mailed to the resident representative. An interview with the MDS (Minimum Data Set) Coordinator on 02/20/19 at 12:28 PM, indicated she provided the Beneficiary Notices to the residents and their representatives. She indicated when the representative was contacted by phone, the representative's name and phone number was listed on the NOMNC. She indicated she did not send a copy of the written Beneficiary Notices to the resident's representative. She indicated she only would send the notices by certified mail if the representative could not be reached by phone. She also indicated the ABN form she used was CMS-R-131. She indicated she was instructed by the facility on which forms were to be used. She indicated she had not used the CMS- form. She indicated she had access to the form, but was instructed to use the R-131 form. She also indicated she was instructed about 1-2 months ago, to only give the ABN if they wanted to appeal the decision. She indicated she only followed the instructions given to her. An interview with the Regional Director of Quality Assurance on 2-20-2019 at 4:54 p.m., indicated the facility followed the CMS form instructions for the NOMNC and the facility did not have a policy for the NOMNC. An undated, current Guidelines for Administration of Beneficiary Notices was provided by Nurse 10 on 2-20-2019 at 4:43 p.m. The Guidelines indicated .At the completion of all skilled services the appropriate beneficiary notices will be completed and given to the resident/responsible party by the Case Manager/MDS Nurse or designee. MDS/Case Manager will notify resident or responsible party of: Medicare/Insurance non-coverage and obtain signature on appropriate forms. MDS/ Case Manager must explain the right to appeal the facility decision to end skilled services. If resident unable to understand the content or purpose, the representative of resident will be notified. MDS must attempt to contact the representative to advise him or her when the resident's services are no longer covered. Must also explain the appeal rights and then give them the phone number of the QIO (Quality Improvement Organization). Document in the .Case Management Notes notice telephone contact to include: name of person initiating contact, name of the representative of resident contacted, date and time of the contact and the telephone number called. Date of conversation is also to be listed on the notice. Confirm the telephone contact by written notice mailed on the same date .Business Office Manager will ensure: Signed form will be filed in business office file Notice confirmed by telephone conversation will be mailed by regular mail to the representative 3.1-12(f)(1)(2)