**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide complete incontinent care to prevent urinary tract infections (UTI) for 1 of 3 residents (R68) reviewed for incontinent care in a sample of 66. Findings include: R68's Face Sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, hemiplegia, dementia, and schizophrenia. R68's Physician's Order, with start date of 6/1/25 and end date of 6/6/25, documented Amoxicillin-Pot Clavulanate Tablet 875-125 mg (milligrams), give 1 tablet by mouth every 12 hours for UTI for 5 days. R68's Minimum Data Set (MDS) dated [DATE] documented she was severely cognitively impaired. R68's Care Plan dated 4/24/25 documented she has an ADL (activities of daily living) self-care performance deficit, needs and participation may vary r/t (related to) Dementia. R68's Care Plan also documented on 12/20/2023 R68 has urinary incontinence and included an intervention of providing incontinent/peri-care PRN (as needed). On 6/11/25 at 12:45 PM, V23, Certified Nursing Assistant, CNA, wheeled R68 to her room and assisted her to the toilet. R68's incontinent brief was soiled, and she continued to have a bowel movement on the toilet. When R68 was done using the toilet, V23 wiped R68's rectum region but did not wipe her front peri region before putting a new brief on and pulling her pants up. 6/11/25 at 1:50 PM V29, CNA, stated during peri care for a resident that is incontinent and uses the toilet, she always wipes their front region and back never just the back if they have a bowel movement. 6/12/25 at 9:19 AM, V31, CNA stated whenever a female resident has soiled their brief and needs a new one or uses the toilet, she would wipe entire perineal vaginal region and the rectum completely, not just the rectum. 6/12/25 at 9:20 AM, V36, CNA, stated she would completely clean and wipe a female resident's front vaginal region and rectum after being incontinent, at the toilet or in the bed. On 6/12/25 at 11:43 AM, V1, Administrator, stated she expects peri-care to be performed completely. The facility's Incontinent Care Policy dated 2/2018 documented for a female resident wash perineal area, wiping from front to back; wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to change an indwelling urinary catheter per Physician order and failed to perform urinary catheter care per Physician order for 2 of 3 (R1, R3) residents reviewed for quality of care. Findings include: 1.R1's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R1's EMR dated 12/31/24 documents a diagnosis of unspecified injury at unspecified level of cervical spinal cord, subsequent encounter and pressure ulcer of sacral region, stage 4. R1's Care Plan dated 2/05/25 documents The resident has Indwelling Catheter r/t (related to) Urinary Retention related to neurogenic bladder secondary to Cervical spine injury and Pressure Injury. R1's MDS (Minimum Data Set) dated 3/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident requires partial/moderate assistance for roll left and right. The MDS documents that the resident requires substantial/maximal assistance for sit to lying and lying to sitting on side of bed. The MDS documents that the resident is dependent for sit to stand, chair/bed to chair transfer, and tub/shower transfer. The MDS documents that the resident has an indwelling catheter. R1's Physician Order dated 2/22/25 documents (Urinary) Catheter care and securement device q (every) shift and PRN (as needed) Please change (urinary) catheter monthly starting 2/22/25; every 1 month(s) starting on the 22nd for 28 day(s) for Prophylaxis. On 4/30/25 at 11:09 AM, R1 stated that he has not had his catheter changed since he was admitted . He stated that it should be changed every month. On 4/30/25 at 1:14 PM, V3, Wound Nurse/Licensed Practical Nurse (LPN) stated that she missed the order to change (R1's) catheter because it was combined with another order. She stated that she would change his catheter now and separate the order, so it does not happen again. 2.R3's EMR undated documents that the resident was admitted to the facility on [DATE]. R3's EMR dated 8/3/24 documents a diagnosis of acute kidney failure, unspecified. R3's EMR dated 3/18/24 documents a diagnosis of neuromuscular dysfunction of bladder, unspecified. R3's EMR dated 4/11/25 documents a diagnosis of retention of urine, unspecified. R3's Care Plan dated 4/11/25 documents The resident has an Indwelling (urinary) Catheter r/t diagnosis of Neurogenic bladder and urinary retention. R3's MDS dated [DATE] documents a BIMS score of 15 out of 15. The MDS documents that the resident has an indwelling catheter. The MDS documents that the resident requires supervision or touching assistance for roll left and right. The MDS documents that the resident requires partial/moderate assistance for sit to lying. The MDS documents that the resident requires substantial/maximal assistance for lying to sitting on side of bed and sit to stand. The MDS documents that the resident is dependent for chair/bed to chair transfer and toilet transfer. R3's Physician Order dated 3/9/25 documents (Urinary) Catheter Care; every shift AND as needed for soiling or leakage. On 4/30/25 at 11:20 AM, R3 stated . the (facility) staff do not clean it every shift. On 4/30/25 at 1:35 PM, V8, CNA (Certified Nursing Assistant) stated that urinary catheter care should be done every shift. She stated that she has not completed catheter care for (R3) yet today. On 4/30/25 at 1:41 PM, V9, CNA stated that she does catheter care every time she changes a resident. She stated that she has not done catheter care on (R3). On 4/30/25 at 2:09 PM, V8 was questioned about urinary catheter care for (R3). She stated that the midnight shift switched (R3's) leg bag to the regular bag. She stated that she did not complete catheter care for (R3). Facility's Policy Catheter Care, Urinary dated August 2022 documents The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 2 of 2 residents (R2, R3) reviewed for abuse in the sample of 6. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, end stage renal disease, dependence on renal dialysis, schizoaffective disorder, and bipolar disorder. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact, had no behaviors, and was able to transfer self with supervision. R2's Undated Care Plan documents R2 has a behavioral problem. The goal is for R2 to have fewer episodes of vulgar language toward others. R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including history of mental and behavioral disorders and substance abuse. R3's MDS dated [DATE] documents R3 as moderately cognitively impaired, had behavioral symptoms not directed toward others, ambulated via wheelchair, and was able to transfer with supervision. R3's Undated Care Plan documents R3 has a behavioral problem with goal of having fewer episodes of being verbally abusive. On 2/7/25 at 2:15 PM, R2 stated R3 calls him bad names and has been doing so for the past two or three weeks. He said sometimes R3 curses at him, and staff are aware, but it has continued. On 2/7/25 at 9:02 AM, R3 stated R2 used to be his roommate. R3 stated, (R2) would bend over in the bathroom and let those ladies clean his butt. I would say, (R2) why don't you clean your own self? It's not that hard. On 2/7/25 at 8:58 AM, V6, Licensed Practical Nurse (LPN), stated R3 antagonizes R2 and calls him S***ty (R2). V6 stated he has spoken to R3 about it multiple times, but R3 likes to get in front of people in common areas like the dining room and call him that name. V6 stated it has really bothered R2. On 2/7/25 at 9:25 AM, V8, Dietary Aid, stated R3 and R2 are always picking on each other. R3 calls R2 S***man, S***tyman, or P***yman. They will shout out to each other from opposite sides of the dining room. On 2/7/25 at 9:30 AM, V4, LPN, stated R2 and R3 are always picking on each other. R2 calls R3 Stupid and Bonehead. R3 makes jokes about R2's incontinence. On 2/7/25 at 9:35 AM, R5 stated R2 and R3 have it out at each other and are like little kids. R3 picks on R2, but R2 also picks on R3. R3 came into the dining room about two weeks ago and started picking on R2. I think R3 needs to be placed somewhere else. On 2/7/25 at 9:40 AM, V9, Social Services Director, stated R3 is just an obnoxious little guy. On 2/7/25 at 10:42 AM, V11, Certified Nursing Assistant (CNA), stated R2 and R3 used to yell at each other when they were roommates. On 2/7/25 at 11:13 AM, R6 stated R3 is really loud and likes to call people names. R2's 2/4/25 Progress Note by V13, Social Services Director, documents V13 spoke with R3 regarding issues he is having with R2. V2 stated R3 has been calling him vulgar names, and R3 continuously tries to get a reaction out of R2. On 2/7/25 at 1:18 PM, V13 stated she used to work at the front desk and remembers overhearing R2 say R3 called him names. She recently spoke with both R2 and R3 because R3 called R2 S***typants. On 2/7/25 at 3:20 PM, V1 stated she expects the facility to follow its abuse policy. The Facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program reviewed 11/24 documents, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's hospital discharge order and apply a wound vac and coordinate care for an abdominal wound for 1 (R2) of 4 residents reviewed for quality of care/treatment in the sample of 4. Findings include: R2's Face Sheet documents he was initially admitted to the facility on [DATE] post recent abdominal surgery, multiple ostomies and lower bowel ishchemia. R2's Hospital Discharge Paperwork, dated 12/4/2024 documents R2 is to have a wound vac to abdominal wound to be restarted on 12/4/2024. R2's Health Status Note, dated 12/5/2024 at 12:11 AM, documents wound vac ordered. R2's Nurtritional Progress Note, dated 12/5/2024 at 2:21 PM, documents open surgical abdominal wound has order for wound vac. R2's Physician's Order Sheet (POS) dated 12/2024 documents a physician's order for 12/5/2024 External Debridement Ointment apply to abdomen topically two times a day for dressing change cleanse wound with wound cleanser apply santyl to base of wound gently pack with Dakins moistened kerlex cover with ABD (abdomen) pad and midipore tape change BID (twice a day) and PRN (as needed) use this order if wound vac is off. R2's Medication Administration Record (MAR) dated 12/5/2024 through 12/12/2024 staff documented the above physician's treatment order was administered to R2's abdominal wound. R2's POS, dated 12/11/2024 documents a physician's order cut white foam to fill wound bed cut black foam to fit over white foam and apply - abdomen, check wound vac for proper functioning. Setting maintain at 125 mmHg, change wound vac dressing 3 times per week and PRN (when necessary) or malfunction and change wound vac canister weekly and PRN filling. R2's Treatement Adminstration Record dated 12/12/2024 staff documented the wound vac was applied and started per physicians orders dated 12/11/2024. On 1/14/2025 at 1:45 PM, V16 Wound Nurse, LPN stated when R2 was initially admitted to the facility she read on his hospital discharge paperwork that he was to have a wound vac on his abdominal wound but she spoke with V15, Wound Care Specialist and he said to discontinue the wound vac order and to apply a specific dressing to the wound. She started the specific dressing the day after R2 was admitted to the facility and V15 assessed the wound on 12/10/2024 and the wound was smaller and was showing improvement so V15 stated to keep the wound vac order discontinued. R2 told her that he was supposed to wear a wound vac and she again discussed it with V15 but he stated since the wound was healing and getting smaller he confirmed R2 didn't need a wound vac. On 1/14/2025 at 10:45 AM, V2 Director of Nurses (DON) stated R2 was an emergency admission from the emergency room (ER) and he wasn't admitted with abdominal wound physician's orders so the facility wound specialist gave orders for a treatment and that was administered until there was clarification on the wound vac and then it was administered. V2 stated she didn't know how many days it was that R2 didn't have a wound vac on at the facility and wasn't sure why the hospital discharge paperwork that she reviewed didn't document that R2 was to have a wound vac but that she expected staff to read the hospital discharge paperwork and to communicate with nursing what the physician's discharge orders were to ensure they are followed. V2 stated she always expects staff to follow physician's orders no matter if the orders came from the hospital or a physician at the facility. V2 stated all treatment orders should be documented on the TAR but sometimes they accidentally go on the MAR. On 1/14/2025 at 3:37 PM V15 stated when R2 was admitted to the facility V16 communicated to him that there was an physician's order from the hospital discharge paperwork that he should have a wound vac on this abdominal wound. It was V15's understanding that R2 wasn't being followed by a wound care specialist for the abdominal wound so he discontinued the wound vac order because he ordered a different treatment and when he initially assessed the wound the second week of December 2024 the abdominal wound was getting smaller and showed improvement so he again stated not to start a wound vac. Then R2 went to an outside physician's appointment he returned to the facility with a wound vac order and the wound vac was placed on 12/12/2024. No harm was done and the abdominal wound was healing and getting smaller so in his professional opinion a wound vac wasn't needed for this abdominal wound. The Facility's Medication and Treatment Orders Policy, revised July 2016, documents orders for medications and treatments will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to uphold resident rights for 1 of 3 residents (R2) reviewed for resident rights in a sample of 3. Findings include: R2's Undated Face Sheet, documents she was admitted on [DATE] with diagnosis includes need for assistance with personal care. R2's Care Plan undated documents R2 has an activities of daily living (ADL) self-care performance deficit related to limited mobility with interventions documenting to use a mechanical lift for transfers. R2 currently requires assistance with ADL's such as personal hygiene and bathing with extensive help from one staff member. R2 is on a restorative grooming program as R2 is unable to bathe/groom self independently related to weakness with interventions to encourage R2 to participate in dressing and grooming with substantial/max assistance as tolerated. R2's care plan undated documents R2 has expressed personal and lifestyle preferences, including R2's bathing routine preference is day shift and preferred bathing type is a shower. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has no cognitive deficits and needs substantial/maximal assistance with showering/bathing. R2's Bath and Skin Report Sheet, dated November 2024 documents R2 is to receive a shower Tuesday and Friday evening. On 11/26/2024 at 8:51 AM R2 stated about a week ago her shower schedule was changed from days to evenings, and she does not want to take showers in the evenings due to having to use a mechanical lift. R2 stated the medications she takes in the evening make her tired and she does not feel safe using the mechanical lift after taking them, so she doesn't want to shower in the evening for this reason. On 11/26/2024 at 2:21 PM V2, Director of Nurses (DON) stated she was informed by V6, Certified Nursing Assistant (CNA) that (R2) told her she is an evening shift shower, and she wants to be a day shift shower. V2 stated residents have the right to chose if they are a day or evening shower and she has updated staff to report these issues to her or the Administrator when resident report issues regarding resident rights. On 11/26/2024 at 3:35 PM V13, Regional Clinical of Operations stated (R2's) shower went from day shift to evening shift on 3/5/2024 and she wasn't aware (R2) didn't want to be an evening shower. The Resident Rights Policy revised 2/2021 documents employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be supported by the facility in exercising his or her rights, be informed of, and participate in his or her care planning or treatment and participate in decision-making regarding his or her care. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received a shower. The facility also failed to document residents who received a shower for 4 of 4 residents (R2, R4, R1, R3) reviewed for Activities of Daily Living care for dependent residents in a sample of 4. Finding include: 1. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a diagnosis of need for assistance with personal care. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has no cognitive deficits and needs substantial/maximal assistance with showering/bathing. R2's Undated Care Plan documents R2 has an activities of daily living (ADL) self-care performance deficit related to limited mobility, with interventions documenting to use a mechanical lift for transfers. R2 currently requires assistance with ADL's such as personal hygiene and bathing with extensive help from one staff member. R2 is on a restorative grooming program as R2 is unable to bathe/groom self independently related to weakness with interventions to encourage R2 to participate in dressing and grooming with substantial/max assistance as tolerated. R2's care plan undated documents R2 has expressed personal and lifestyle preferences, including R2's bathing routine preference is day shift and preferred bathing type is a shower. R2's Bath and Skin Report Sheet, dated November 2024 documents R2 is to receive a shower on Tuesdays and Fridays evenings. Shower sheet documents shower were to be given on 11/1/2024, 11/5/2024, 11/08/2024, 11/12/2024, 11/15/2024, 11/19/2024, 11/22/2024 with no documentation of a shower given or refused. R2's Documentation Survey Report v2, dated November 2024 documents R2 was showered on 11/6/2024, 11/16/2024 and 11/20/2024. No other showers documented for the month of November 2024. R2's progress notes dated November 2024 showed no documentation R2 was showered or that R2 refused a shower. On 11/26/2024 at 8:51 AM R2 sitting up in bed with dryness noted to her face and hair is matted and oily. R2 stated she has not had a shower in about 4 weeks or had her hair washed. R2 stated she has an appointment to go to today and feels like she is not ready to go due to smelling from not having a shower. R2 stated about a week ago her shower schedule was changed from days to evenings, and she does not want to take showers in the evenings due to having to use a mechanical lift. R2 stated the medications she takes in the evening make her tired and she does not feel safe using the mechanical lift after taking them. 2. R4's Undated Face Sheet, documents he was admitted to the facility on [DATE] with no diagnosis regarding need for assistance with personal care. R4's Quarterly MDS, dated [DATE], documents Brief Interview of Mental Status (BIMS) 10/15: moderately cognitively impaired. Shower and personal hygiene: substantial/maximal assistance. Lower extremities impairment on both sides. R4's Undated Care Plan, documents resident is an ADL self-care performance deficit r/t (related to) limited mobility, left BKA (below the knee amputation.) and right BKA. Goal: none documented. Interventions/tasks: bathing: extensive - total x1. Review of R4's Bath and Skin Report Sheet, dated November 2024 documents he is to be showered on Mondays and Thursdays in the PM. According to the shower sheet, the dates R4 should have been showered are 11/4/2024, 11/7/2024, 11/11/2024, 11/14/2024, 11/18/2024, 11/21/2024 and 11/25/2024. The form showed no documentation R4 was showered on these days. R4's Documentation Survey Report v2, dated November 2024 showed on 11/15/2024 staff documented codes 98 which means resident refused and 97 not applicable. R4's Progress Notes, dated November 2024 showed no documentation R4 was showered or that he refused a showered. On 11/26/2024 at 11:55 AM R4 stated they don't shower me here and I don't know why. R4 stated they also don't shave him and he prefers to be shaved but he can't shave himself because he has a scab on his upper right cheek and he doesn't want to accidentally rip it off, he would allow staff to shave him but no one has offered that service. During the interview observation made of resident, he had long facial hair and oily/greasy hair and there was white flakes on his t shirt from dry skin on his arms. Observation during the interview showed R4 is a bilateral amputee and uses a wheelchair for mobility device. 3. R1's Undated Face Sheet, documents admission date 7/31/2023 with diagnosis of need for assistance with personal care. R1's quarterly MDS, dated [DATE] documents BIMS 11/15 moderately cognitively impaired. Shower: substantial/maximal assistance and personal hygiene: dependent. R1's Care Plan initiated on 7/31/2023 documents resident has an ADL self-care performance deficit need and participation may vary r/t (related to) needing assistance with personal care. Goals: resident will maintain current level of ADL function, resident free from complications related to ADL deficit and resident will be kept clean and comfortable. Interventions: ADL care: resident may need assistance x1 or x2 for ADL care. Bathing specifically was not addressed on the care plan. Review of R1's Bath and Skin Report Sheet, dated November 2024 documents he is to be showered on Wednesdays and Saturdays in the PM. According to the shower sheet, the dates R1 should have been showered are 11/2/2024, 11/6/2024, 11/9/2024, 11/13/2024, 11/16/2024, 11/20/2024 and 11/23/2024. The form showed no documentation R1 was showered on these days. Review of R1's Documentation Survey Report v2, dated November 2024, documents he was showered on 11/14/2024 and 11/17/2024. R1's Progress Notes, dated November 2024 showed no documentation R1 was showered or that he refused a shower. On 11/26/2024 at 11:15 AM V11, CNA observed giving R1 a bed bath and stated she will shave him as well. Observation of R1 at that time showed his fingernails had dark substance under them. On 11/26/2024 at 11:45 AM R1 stated, I don't get showered or cleaned up very often, this is the most clean I have been since I was admitted to the facility this year. No staff offer to give me a shower or shave me, it has to have been weeks since I've received a shower or been shaved. I can't shower and shave myself anymore. 4. R3's Undated Face Sheet documents R3 was admitted to the facility on [DATE] and has a diagnosis of Heart failure, Chronic Kidney Disease, Dementia, Aphasia, Hypertension, and Hypothyroidism. R3's MDS dated [DATE], documents R3 is cognitively impaired and needs substantial/maximal assistance with showering/bathing. R3's Undated Care Plan documents R3 has an ADL self-care performance deficit and needs and participation may vary. Interventions include R3 may need assistance with one or two staff members for ADL care. R3 participates in restorative nursing programs including dressing and grooming. R3 has expressed personal and lifestyle preferences including bathing type preference as showering. R3's Bath and Skin Report Sheet, documents R3 is to receive a shower on Monday and Thursday evenings. Shower sheet documents shower were to be given on 11/04/2024, 11/07/2024, 11/11/2024, 11/14/2024, 11/18/2024, 11/21/2024, and 11/25/2024, with no documentation of a shower given or refused. R3's Documentation Survey Report v2, dated November 2024 documents a shower was given on 11/14/2024. No other showers were documented as given or refused. R3's Progress Notes, dated November 2024 showed no documentation R3 was showered or that R2 refused a shower. On 11/26/2024 at 9:28 AM V5, CNA stated no residents are complaining of not being showered. V5 stated when she showers a resident, she documents it in the shower book located at the nurse's station. On 11/26/2024 at 9:45 AM V6, CNA stated when she showers a resident, she documents it in the shower book located at the nurse's station. On 11/26/2024 at 9:52 AM V7, CNA stated residents are showered every day, most residents are showered twice a week and resident specific shower days are documented in the hall shower book that is located at the nurse's station. V7 stated she documents when she gives a resident a shower on the resident's shower sheet in the hall shower book. On 11/26/2024 at 9:53 AM V9, Licensed Practical Nurse (LPN) stated certain residents refuse showers and when they do, she expects the CNA to report the refusal so she can go talk to the resident about the shower as well. CNAs are expected to document when they give a resident a shower in the hall shower books that are located at the nurse's station. Hospice CNAs document in the hospice book when they shower a resident. V9 stated (R2) refuses showers unless staff offer them to her as the exact time she wants to take them. (R2) is a night shower due staffing. (R1), (R3) and (R4) do not refuse showers to her knowledge. The Facility's Activities of Daily Living (ADLs), Supporting, revised March 2018, documents residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support with assistance with hygiene (bathing, dressing, grooming and oral care.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to respond to call lights in a timely manner for 3 (R1, R3, and R7) of 7 residents reviewed for adequate and timely care in the sample of 8. Findings include: 1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, congestive heart failure, and aphasia, hemiplegia, and hemiparesis following cerebral infarction. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired, required partial/moderate assistance with toileting and transfer, required substantial/maximal assistance with rolling from side to side, had colostomy, and was occasionally incontinent of urine. R1's Care Plan initiated 1/26/23 documents R1 has a self-performance deficit with activities of daily living and is frequently incontinent of urine. On 10/3/24 at 8:50 AM, R1 was lying in bed in her room. She was unable to articulately express responses, but was able to nod her head yes and no with continued attempts at verbalization. R1 nodded yes and no when asked about specific time frames for call lights and indicated staff usually take around 20 minutes to answer the call light which she feels is too long. She pointed at her incontinent brief which was saturated and indicated she needed to be changed. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, severe protein calorie malnutrition, and need for assistance with personal care. R3's MDS dated [DATE] documented R3 was cognitively intact and always incontinent of bowel and bladder. R3's mobility was not assessed. R3's Care Plan initiated 4/28/23 documents R3 has a self-performance deficit with activities of daily living and requires extensive assistance with activities of daily living and transfer. On 10/3/24 at 8:52 AM, R3 was lying in bed in her room. She stated call lights take a long time to get answered, especially on the midnight shift. On 10/3/24 at 1:25 PM, R3 stated, It makes me feel like I want to get out of here. It is hard, and I have a muscle disease where I'm supposed to be turned every 2 hours and I always have to push my call light and remind them. 3-R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, right above the knee amputation, and left below the knee amputation. R7's MDS dated [DATE] documented R7 was moderately cognitively impaired. The Facility's Grievance/Complaint Report dated 8/2/24 by R7 documents, Call light responses take too long. On 10/3/24 at 2:40 PM, R7 was sitting in his wheelchair in his room. He stated, They (call lights) have gotten worse than before. They take so long I just go ahead and clean myself up. The Facility's Grievance/Complaint Report dated 7/19/24 by Resident Council Group documents, CNA's (Certified Nursing Assistants) are doing the best they can however it is still taking them a bit longer to answer call lights in a timely manner. The Facility's Anonymous Grievance/Complaint Report dated 9/23/24 documents, Res (Resident) reports waiting 4 hrs (hours) for help getting out of bed over the weekend. 9/22 waited 40-50 minutes for call light responses. The Facility's Grievance/Complaint Report dated 9/30/24 by V7, R2's Family, documents, Concerned about call light times. On 10/3/24 at 8:40 AM, V4, CNA, stated she usually has no trouble answering call lights timely unless they are really short staffed, but today someone called off and another person went home sick. On 10/4/24 at 12:06 PM, V2, Director of Nursing (DON), stated she expects call lights to be answered timely, and if staff are busy at that time, she would expect them to pop their head in the door and tell them they will assist them as soon as possible. On 10/4/24 at 12:08 AM, V1, Administrator stated he does not have policies on call lights or resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's responsible party prior to a transfer to an acute care facility for evaluation and treatment of a change in condition for 2 of 3 residents (R3, R4)) reviewed for hospitalization in the sample of 12. The Findings Include: 1. R3's Face Sheet, undated, documents R3 was originally admitted to the facility on [DATE] and was discharged to the hospital on 8/16/24 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Panlobular Emphysema, Type 2 Diabetes Mellitus (DM), Malnutrition, Schizophrenia, Hypertension (HTN), Dependence on Supplemental Oxygen, COVID-19, and Deep Vein Thrombosis (DVT). R3's Care Plan, dated 7/25/24, documents R3 has a behavior problem related to threatening and cursing staff. R3 refuses labs, and wearing oxygen, R3 is a smoker/tobacco user and refuses to give cigarettes to staff for safe keeping. It continues 8/16/24: R3 is at Risk for rehospitalization and or unsuccessful discharge related to health determinant needs, resident refuses care such as keeping oxygen on and lab draws. It continues 8/16/24: R3 has actual/potential altered respiratory status related to: COPD, Emphysema, Respiratory Failure, history of COVID. R3 refuses oxygen at times. Interventions: Administer medications / inhalers / nebulizers as ordered, monitor for effectiveness, elevate head of bed as needed to facilitate ease of breathing, maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions, monitor for changes in/development of signs and symptoms of breathing difficulty and report to nurse if noted: Shortness of breath, cough (productive or non-productive), fever, chills, difficulty speaking, bluish skin color, changes in cognition, monitor lab/diagnostics as ordered and report results to physician, monitor skin integrity of ears, nasal area, or facial areas for pressure or friction issues related to nasal cannula or Oxygen (O2) mask, report any noted skin irritation or breakdown, notify nurse for any observed or reported breathing difficulty, excess secretions, or persistent coughing, report changes in respiratory status to physician, administer continuous oxygen as ordered via: O2 at 3 liters per mask (LPM) or nasal cannula, administer as needed (PRN) oxygen as ordered via O2 concentrator and or etank: via: nasal cannula, provide resident/responsible party education PRN to include: coughing/deep breathing, fluid needs, pursed-lip breathing, need for rest, compensatory strategies, and encourage compliance with O2 therapy. It continues R3 has an Activities of Daily Living (ADL) self-care performance deficit. Interventions: The resident is independent/set up and able to move and reposition in the bed but check with the resident every few hours to remind and assist if needed, Bed Mobility: Supervision-Independent, Transfer: Supervision-Independent, Walking: Supervision-Independent, Eating: Independent, Bathing: Supervision. R3's Minimum Data Set (MDS), dated [DATE], documents R3 had a moderate cognitive impairment and required setup or clean up assistance for most ADLs. On 8/19/24 at 12:19 PM, V5, Registered Nurse (RN) stated I was the emergency room (ER) Nurse who took care of (R3) when he went to the ER on [DATE]. (R3) was very hypoxic upon arrival to the hospital with the Fire Department getting an oxygen saturation of 65%. The Emergency Medical Service (EMS) guys told us that the Nurse at the facility who was taking care of (R3) knew nothing about him and stated she was just a temp there working. No one at the facility was able to tell EMS when (R3) was last seen well, or how long he was like that. The facility gave EMS paperwork that indicated (R3) was a Full Code, so we intubated (R3) in attempts to resuscitate him. The facility did not call (R3's) brother, who was also his Power of Attorney (POA/V6), to let him know they were sending (R3) to the ER, and when (V6) showed up at the facility to see (R3), he was told that (R3) was taken to the hospital. Then (V6) showed up at the ER and saw (R3) intubated, he told us that (R3) was a Do Not Resuscitate (DNR) and that he did not want to be intubated. He told us they signed the appropriate paperwork back in June 2024 for that, and he provided that paperwork to the facility, and they should have sent that. The ER Physician had to withdraw care and let R3 pass away. On 8/19/24 at 12:40 PM, V6, R3's Brother/POA, stated I went to the facility to check on (R3) on 8/16/24. When I got to the facility, I went to (R3's) room, and he was not there and his roommate stated that they took (R3) to the hospital. When I asked, it took three different staff members just to tell me which hospital he went to. When I got to the ER, I found out that the hospital had intubated (R3) and they should not have done so because (R3) was a DNR/Do Not Intubate (DNI). The ER Nurse showed me the paperwork from the facility that was sent with (R3) and it did show that (R3) was a Full Code. I signed paperwork in June 2024 with (R3) indicating that (R3) was a DNR and the facility should have had that in his record, but they sent the wrong one. I was not happy because my sister and I had to make the decision to terminate (R3's) care, so they extubated (R3) and let him pass away. R3's Nursing Note, dated 8/16/24 at 9:53 AM, documents Upon walking past room Therapy stopped me and informed me that the resident didnt look good. Upon assessment resident noted to be in respiratory distress and slow to respond. PA (Physician Assistant) notified and Nurse informed to call 911 and have resident sent to ED (Emergency Department) for eval and treatment. This was documented by the Assistant Director of Nursing (ADON) at that time and is no longer at the facility. There was nothing documented about notifying R3's POA. R3's Hospital Record - page 2, dated 8/16/24, documents [AGE] year-old male with a history of COPD, acute respiratory failure with hypoxia, panlobular emphysema, moderate protein calorie malnutrition, type 2 diabetes, hyperlipidemia, hyponatremia, hypoosmolality, electrolyte imbalance, schizophrenia, dysphagia, hypertension, oxygen dependence that was brought in by EMS secondary to altered mental status and hypoxia. Upon arrival, EMS noted, patient last known well was last night approximately 9:00 PM, however has not been seen until 10:00 AM this morning, all of the nurses at the facility where traveler's and did not know this patient. They did note that he is normally up and smoking however. Upon arrival, EMS noted patient was altered, not following commands, satting in the mid 60s, unsure of how long this has been going on, improved to the 90s with a non-rebreather. No family is at the bedside. R3's Hospital Record - page 13, dated 8/16/24, documents Spoke with the brother (V6) at the bedside, he notes the patient was a DNR and has a very poor quality of life over the last number of days to weeks. He states the signed paperwork is at the facility however the paperwork we initially received has him as a full code. He is going to call his sisters, although he is the POA, to confer and decide the next steps at this time. Brother has opted for extubation and removal of care, comfort measures only. Time of death called, ultrasound confirmed cardiac standstill, brother at the bedside, will page his primary care. R3's Hospital Record - Page 17, documents Patient's brother to bedside. Patient's brother states what facility told EMS was not true and patient has been weaker/not normal since Sunday. Patient's brother also states patient is DNR/DNI, brother is POA. ERP (ER Physician) to bedside to discuss POC (plan of care) due to paperwork from facility showing full code. 2. R4's Face Sheet, undated, documents R4 was originally admitted to the facility on [DATE] and was discharged on 5/3/24 with diagnosis of Metabolic Encephalopathy, Fracture Tibia, Mitral Valve Insufficiency, Adult Failure to Thrive, Malnutrition, Pulmonary Hypertension, Anemia, Hypothyroidism, Cardiomyopathy, Gangrene, HTN, Cellulitis Left Lower Extremity (LLE), Rhabdomyolysis, Peripheral Vascular Disease, Congestive Heart Failure, and Acquired Absence of Right Above Knee Amputation (AKA). R4's Care Plan, dated 5/6/24, documents R4 has need/wants for an enabling device. Interventions: Bed in lowest position, call light in reach, Increased frequency of monitoring, mat next to bed, visual and or verbal reminders to use call light. R4 is also noted to be non-compliant at times with transfers. Interventions: Transfers: Mechanical Lift x 2 assist, non-weight bearing to left lower extremity (Fracture) - in knee brace. Right lower extremity has gangrene to foot. Encourage the resident to use bell to call for assistance. It continues R4 is at risk for falls related to her generalized weakness and impaired cognition. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, fall risk evaluation, monitor/encourage appropriate footwear PRN, keep bed in lowest position acceptable by the resident when the resident is in bed, remind to request assistance when getting up if needed. R4's MDS, dated [DATE], documents R4 had a moderate cognitive impairment and was dependent on staff for all ADLs. On 8/19/24 at 1:45 PM, V7, R4's family member/friend, stated that R4 was her grandfather's significant other for a long time and R4 became like her own grandmother. V7 stated that her grandfather is POA over R4. V7 stated that in December 2023, or January 2024, R4 was treated for cellulitis in that same leg and finally had a physician figure out that she was having a vascular issue. V7 stated they did an Ultrasound and a CT scan and found that R4 had a femoral artery clot. V7 stated that the physician decided they needed to amputate her right leg and did an AKA. V7 stated that a month or so later, her grandfather got a phone call from the hospital asking for consent for R4 to have surgery. V7 stated that her grandfather visited R4 on a Thursday evening, and no one said anything about R4 having a surgery. V7 stated that next day is when the hospital called wanting consent for surgery to do another AKA of her left leg. V7 stated the facility did not notify her grandfather that R4 was even going to the hospital. R4's Nursing Note, dated 5/1/24 at 10:47 AM, documents (Nurse) at (Local Hospital) notifed nurse that resident surgery for amputation on Friday May 3, 2024 at 10 AM and to be at hospital at 7:30 AM, resident ready for transport at 6:30 AM. R4's Nursing Note, dated 5/3/24 at 9:52 AM, documents Resident LOA (leave of absence) from facility for surgery at (Local Hospital). There is no documentation of the facility notifying R4's POA prior to transport to the hospital. On 8/20/24 at 9:05 AM, V1, Administrator, stated I was aware that (R3) went to the hospital due to respiratory distress and had passed away in the hospital, but I was not aware of any issues. On 8/20/24 at 12:00 PM, V12, Registered Nurse (RN), stated If I am sending a resident to the ER, I would first make sure I called the physician and got an order, I would print out all of the resident's orders, Physicians Orders for Life Sustaining Treatment (POLST), the transfer sheet, and the facesheet, and will give it all to the EMS. I would call the residents family/POA and let them know what is going on. After the resident leaves the facility with EMS, I will call the ER and give them a report on why the resident is being sent. On 8/21/24 at 10:30 AM, V18, Licensed Practical Nurse (LPN), If I am sending a resident to the hospital and calling 911, I would make sure I call the POA and the Physician, then I would prepare the transfer paperwork including the facesheet, POLST, order summary, and any other pertinent information. If there is a POLST and POA paperwork in the record, I would send both of them. On 8/21/24 at 10:40 AM, V19, LPN, If I was sending a resident to ER via 911, I would call the Physician, check the resident's code status, send all of the orders, and the POLST. I would send the most up-to-date paperwork we have on that resident. I would give report to the EMS, including the resident's age, name, date of birth , any physical changes, how the resident was acting, any allergies, and basically everything I would know about the resident. The Facility's Transfer or Discharge, Facility Initiated Policy, dated 10/2022, documents Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of Transfer or Discharge (Emergent or Therapeutic Leave): 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). 7. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Orientation for Transfer or Discharge (Emergent or Therapeutic Leave): 2. For an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: a. Call 911 if the resident meets clinical/behavioral criteria per facility policy, or assist in obtaining transportation; b. Notify the resident's attending physician; c. Orient/prepare the resident for transfer; and d. Prepare for medical record transfer. Information Conveyed to Receiving Provider: 1. Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: a. The basis for the transfer or discharge; b. Contact information of the practitioner responsible for the care of the resident; c. Resident representative information including contact information; d. Advance directive information; e. All special instructions or precautions for ongoing care, as appropriate such as: (1) treatments and devices (oxygen, implants, IVs, tubes/catheters); (2) transmission-based precautions such as contact, droplet, or airborne; (3) special risks such as risk for falls, elopement, bleeding, or pressure injury; and/or (4) aspiration precautions; f. Comprehensive care plan goals; and g. All other information necessary to meet the resident's needs, including but not limited to: (1) resident status, including baseline and current mental, behavioral, and functional status, (2) recent vital signs; (3) diagnoses and allergies; (4)medications (including when last received); (5) most recent relevant labs, other diagnostic tests, and recent immunizations; (6) a copy of the residents discharge summary; and (7) any other documentation, as applicable, to ensure a safe and effective transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications as ordered for one of 5 residents (R8) reviewed for medication administration in the sample of 12. Finding include: On 8/21/24 at 8:15 AM R8 stated there is one certain agency nurse who does not come in and give her the 3 little thyroid pills she is supposed to have at 4:30 AM . She stated she did not know who the nurse was and she did not report it to anyone because she couldn't remember when it happened. R8's Minimum Data Set (MDS) dated [DATE] documents R8 is alert and oriented. R8's active Physician Order dated 11/30/23 documents she is to receive Levothyroxine 25 micrograms (mcg) Give 75 mcg by mouth one time a day for hypothyroidism. R8's Medication Administration Record (MAR) dated 8/1/24 to 8/31/24 does not document R8 received her scheduled dose of Levothryroxine on 8/12/24. On 8/22/24 at 10:25 AM V2, Director of Nursing (DON) , stated R8 was in the facility on the morning of 8/12/24 and should have received her Levothyroxine as ordered. V2 stated she would expect all residents to receive their medications as ordered by the physician. The facility's policy, Administering Medications, revised April 2019, documents, Medications are administered in a safe and timely manner, and as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure communication and continuity of care between the facility and dialysis center for 1 of 3 residents (R2) reviewed for dialysis in the sample of 6. Findings include: R2's Physician Order Sheet (POS) for [DATE] documents diagnoses of end stage renal disease, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellites with hyperglycemia, cardiomyopathy, peripheral vascular disease, chronic systolic (congestive) heart failure, unspecified essential (primary) hypertension, need for assistance with personal care, difficulty in walking, gout, primary pulmonary hypertension, paroxysmal atrial fibrillation, systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction. R2's POS also documents she is to receive dialysis one time a day every Monday, Wednesday, and Friday for kidney disease. R2's Care Plan dated [DATE] documents problems: ESRD (end stage renal disease), Short term goal remain free from complications of dialysis. Dialysis three times a week. CHF (congestive heart failure) remain free from complications of cardiac, monitor for /ss (signs and symptoms) of CHF (example SOB [shortness of breath]). R2's Minimum Data Set, dated [DATE] documents she is cognitively intact for decision making for activities of daily living. R2's Health Status Note dated [DATE] at 7:38 AM, Note Text: resident was brushing hair and talking with staff when she went unresponsive. Resident slumped towards right side in wheelchair and would not respond to verbal or physical stimuli. 911 called. Resident became alert and responsive after a few minutes. Notified 911 of current status. EMS (emergency medical services) arrived at 7:25 AM, times two attendants. Resident evaluated by EMS, resident refused transport to ER (emergency room). VS (vital signs) 96/62 64 20 97.5 92% on 3 lpm. BS (blood sugar) 144. NP (Nurse Practitioner) notified of episode. No new orders at this time. Will continue to monitor for change in condition. R2's Progress Notes dated [DATE] at 12:12 PM, Note Text: Message from resident's Dialysis center that resident coded while at Dialysis. Resident currently being taken to (Hospital) for treatment. On [DATE] at 1:11 PM V5, Licensed Practical Nurse (LPN) stated she remembered (R2) because she was the one that I called 911 after (R2) became unresponsive and then when the EMT (Emergency Medical Technician) got here she started doing her hair, laughing, and joking. When the EMT got here she refuses to go, and she even signed a paper refusing to go out. I am not sure of the name of the ambulance but learned later she passed away when she was out on dialysis. On [DATE] at 12:42 PM, V17, Certified Nursing Assistant (CNA) stated, I was the CNA that morning when (R2) was not acting herself. She was just off a little. I went and told the nurse and as I was getting her ready, she then went unconscious. We immediately called the ambulance but by the time they got there she was awake, and she told them she felt better and did not want to go out. Later, I found out she coded when she went out to dialysis. One can never forget that. On [DATE] at 1:11 PM, V18, Registered Nurse (RN) Clinical Manager of Dialysis stated, The fact that (R2) was unconscious earlier in the day, this should have been communicated to us 1 million percent. Dialysis is a four-hour long procedure and the resident coded while she was with us. If we would have known (R2) may have had a better outcome. I did not know she even had anything going on with her until the EMS arrived and told me they had been to the facility earlier that day because (R2) had been unconscious. While the EMT were giving CPR to (R2) I found out she had been acting unusual earlier in the day. It's essential that the facility communicate with us any changes or decline in conditions that may or may not be related to dialysis so that we can implement the appropriate interventions. We did not have any communication and the facility never told us anything about (R2) not feeling ill, acting strange and/or being unconscious. If we would have known she was unconscious earlier, we would not have had her come to dialysis and would have rescheduled the appointment. If we would have known she may have had a better outcome. On [DATE] at 9:02 AM, V2, Director of Nursing (DON) stated, I was not the DON in April. We have a form that staff are supposed to fill out it is a communication form. The form is filled out by staff and then given to the dialysis center. Our copy is in the computer and then the form goes to the dialysis center. It lists all medications and if there are any changes with the patients. I would expect this form to be completed on all dialysis residents before their appointments and given to the staff at the dialysis center. I cannot confirm or deny if there was a form given to the dialysis center indicating (R2) had a been unresponsive before the treatment. If the form was completed it should be available. Let me go back and look. On [DATE] at 10:24 AM, V19, Dialysis Medical Director, stated, I would have expected the facility to notify us especially since she was found at the facility unconscious earlier in the day. If we would have known that detail, we would have advised (R2) to be evaluated at the hospital before we even started treatment. We would ensure all was well before we started the dialysis treatment. This was (R2's) first dialysis treatment and there was no continuity of care from the facility. We should have been given this information and it absolutely would have affected our treatment for (R2). It is my understanding she expired in the emergency room. I cannot not say one way or the other whether the outcome would have been different it's impossible to know that absolute. I only know if we had been given that information, we would have sent her out. On [DATE] at 11:32 PM, V1, Administrator stated We have no documentation for (R2) that we provided on [DATE] to the dialysis center. The Facility Dialysis contract dated [DATE] documents, Long Term Care Facility shall ensure that each Resident is prepared to spend an extended length of time at Dialysis Facility, as necessary for the administration of Resident's prescribed treatment, and has received proper nourishment and any necessary medications before arriving.

Based on interview, observation, and record review, the facility failed to provide the physician prescribed medication. There were 25 opportunities with 2 errors resulting in a 8% medication error rate. The errors involved R13 in the sample of 22. Findings include: On 7/23/24 at 5:21 AM V12, Licensed Practical Nurse (LPN), went to her medication cart to prepare R13's 5:00 AM medications. V12 was unable to locate the Levoxyl or the Omeprozole that was prescribed for R13. V12 stated that these medications have been ordered but have not came in yet. R13's July 2024 Physician Orders, documents, Levoxyl Tablet 88 MCG (micrograms) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for low thyroid hormone. This medication is scheduled for 5:00 AM. R13's July 2024 Physician Orders documents Omeprazole Oral Tablet Delayed Release 20 MG (milligrams) (Omeprazole). Give 1 tablet by mouth one time a day for GI (gastrointestinal). This medication is scheduled for 5:00 AM. R13's July 2024 Medication Administration Record documents that the Levoxyl and the Omeprozole were not available to give. On 7/23/24 at 2:30 PM, V13, LPN, stated, (R13's) Levoxyl was found in the medication room and the Omeprazole is over the counter. V13 was questioned if she gave the 2 medications on her shift, V13 stated, No. The policy Administering Medication, dated 4/2019, documents, Medications are administered in accordance with prescriber orders, including required time frame. This policy fails to document what the procedure is if the medication is not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to operationalize their policy and procedures for testing and tracking COVID-19; wear appropriate PPE (Personal Protective Equipment), clean multi-use equipment, and perform hand hygiene after resident encounter of a COVID-19 resident, and post signage indicating the Facility is in COVID-19 outbreak. This failure has the potential to affect all 126 residents living in the Facility. Findings include: 1-The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents the Facility's COVID-19 Outbreak began on 7/1/24. R6's Progress Notes document R6 was sent to the hospital for cough on 7/5/24 and returned on 7/10/24. R6's COVID Monitoring Assessment documents COVID-19 testing was not completed following hospitalization until four days later on 7/14/24. R6's Medical Records fail to document R6 was tested for COVID-19 upon 7/10/24 return to the Facility. 2-The Facility's Census Lists from 7/10/24 through 7/13/24 document R6 and R15 both resided in same room. R15's Progress Note dated 7/14/24 documents R15 tested positive for COVID-19 on 7/13/24 and was moved to a new room for isolation. R6's COVID Monitoring assessment dated [DATE] documents R6 was exposed to someone with signs and symptoms of COVID-19 and tested positive for COVID-19 on 7/14/24. R6's Medical Records fail to document R6 was tested for COVID-19 immediately after roommate R15 tested positive on 7/13/24, despite having been roommates for the three preceding days. 3-The Facility's Census List from 7/8/24 documents R21 and R22 both resided in same room. R22's Progress Note dated 7/9/24 documents R22 tested positive for COVID and was moved to another room. R21's Progress Notes document R21 was tested for COVID-19 on 7/7/24 and was not retested until 7/18/24. R21's Medical Record fails to document R21 was tested for COVID-19 between 7/7/24 and 7/18/24 which was 9 days after roommate R22 tested positive for COVID-19. 4-The Facility's Census List from 7/7/24 documents R3 and R5 both resided in room. R3's Progress Note dated 7/8/24 documents R3 tested positive for COVID-19 and was moved to another room for isolation. R5's Progress Notes document R5 was tested for COVID-19 on 7/5/24 and was not tested again until 7/14/24. R5's COVID Monitoring Assessment was completed on 7/5/24 and was not completed again until 7/14/24. R5's Medical Record fails to document R5 was tested for COVID-19 between 7/8/24 and 7/14/24 which is 6 days after roommate R3 tested positive. On 7/23/24 at 10:05 AM, V3, Assistant Director of Nursing/Infection Preventionist (ADON/IP), stated COVID-19 testing is documented in the Electronic Medical Record (EMR) and is sometimes sporadic because they cannot always test everyone in a single day. She stated she does not keep specific testing logs and enters all tests and results in the resident EMR, either in the Progress Notes or in the COVID Monitoring Assessment. She stated they aim to test the residents every 3 days, but at the very least it is done every 7 days, per policy. On 7/25/24 at 8:55 AM, V1, Administrator, stated she expects the Facility to follow policies regarding infection control. The Facility's Coronavirus Disease (COVID-19) - Testing Staff Policy revised June 2023 documents, When utilizing broad-based testing, all residents and staff identified as close contacts or on the affected unit(s) are tested, regardless of vaccination status. Testing is done immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. admission testing is done at the discretion of the facility based on recommendations from the public health authorities in the facility. If admission testing is conducted, residents are tested upon admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. A resident who leaves the facility for 24 hours or longer is managed as an admission. For facility outbreak testing, the following is documented: a. The date the case was identified; b. The dates that all other residents were tested; c. The dates that residents who tested negative were retested; and d. The results of all tests. The resident record includes that testing was offered, testing was completed (as appropriate to the resident's testing status), the results of the test and specific actions taken with the resident. If the resident refused the test, the stated reason and how this was addressed is documented. 5. On 4/23/24 at 5:35 AM, R7's door had signage that R7 is on droplet precautions and to see the nurse before entering. V12, Licensed Practical Nurse, prepared AM medications for R7 which included Hydralazine 50 mg. V12 obtained a multi-use blood pressure cuff and stethoscope and entered R7's room with a N95 mask on. V12 obtained R7's blood pressure in the right arm, gave R7 the medication cup, and a cup of water. R7 swallowed the pill and drank sips of water. V12 took the medication and water cup from R7 and threw it away. V12 exited the room. V12 was questioned why R7 was on droplet precautions, V12 stated, COVID. V12 placed the blood pressure cuff and stethoscope on top of her medication cart. V12 returned to the nurses station with her medication cart, V12 then took the stethoscope and the blood pressure cuff and placed it on the 400 hall cart. V12 failed to clean the equipment or the top of the medication cart. V12 was questioned why she did not perform hand hygiene, wear the required PPE (personal protective equipment), or disinfect the multi-use equipment, V12 stated, I just forgot. On 7/24/24 at 10:52 AM, V1 stated, (V12) knows better than that. I send people home immediately if I see them enter a covid room with out the PPE on. They should be using disposable equipment on isolation residents. The policy Coronavirus Disease - Using Personal Protective Equipment, dated 5/23, documents, When caring for a resident with suspected or confirmed SARS-COV-2 infection, personnel who enter the room of the resident will adhere to standard precautions and use a NIOSH - approved N95 or equivalent or higher - level respirator, gown gloves, and eye protection. The policy Coronavirus Disease - Cleaning and Disinfecting, dated 5/23, documents, 4. Dedicated medical equipment is used when caring for a resident with suspected or confirmed SARS-CoV-2 infection. 5. All non-dedicated, non - disposable medical equipment used for that resident is cleaned and disinfected according to manufacturer's instructions and facility policies before us on another resident. The policy Hand Washing / Hand Hygiene, dated 8/2029, documents, 8. hand hygiene is the final step after removing and disposing of personal protective equipment. 6. On 7/22/24 at 8:45 AM, upon entrance, there was no sign or posting indicating that the facility is in Covid outbreak status. On 7/22/24 at 8:50 AM, V2, Director of Nurses, stated that the facility does have a Covid outbreak. The policy Coronavirus Disease - Visitor and Communal Activities, dated 6/23, documents, visual alerts at the entrance and throughout the facility with instructions regarding current infection prevention and control recommendations. The Facility's Census List dated 7/19/24 documents there are 126 residents living in the Facility.

Based on interview and record review, the Facility failed to employ a qualified Infection Preventionist (IP) with specialized training needed to track Facility infections and prevent the spread of infectious diseases, including COVID-19. This has the potential to affect all 126 residents living in the Facility. Findings include: The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents the Facility has been in COVID-19 Outbreak Status since 7/1/24. On 7/23/24 at 12:15 PM, V3, Assistant Director of Nursing/Infection Preventionist (ADON/IP), stated she does not have the IP certification, but is currently working on the training. On 7/25/24 at 8:30 AM, V1, Administrator, stated V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator, oversee infection control since V3, ADON/IP is not yet certified. She stated V2 and V7 both have full time roles, in addition to overseeing infection control. On 7/25/24 at 8:55 AM, V1, Administrator, stated she expects the Facility to follow policies regarding infection control. The Facility's Infection Preventionist Policy revised 8/2022 documents, The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. The infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role. The Policy documents, The infection preventionist has obtained specialized IPC training beyond initial professional training or education prior to assuming the role and Evidence of training is provided through a certificate(s) of completion or equivalent documentation. The Facility's Census Report dated 7/19/24 documents there are 126 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review the facility failed to accommodate and inform 1 of 5 residents (R5) of change in shower schedule. Findings include: R5's Face sheet documents an admission date of 10/10/2022. Diagnosis include Congestive Heart Failure, Atherosclerotic Heart Disease, Protein Calorie Malnutrition, Gastrointestinal Hemorrhage. R5's Minimum Data Set, MDS, dated [DATE] documents R5 has no cognitive deficits and requires partial/moderate assist with showering. R5's Care Plan with a revision date of 10/24/2022 documents R5 has an activity of daily living, ADL's, self-care performance deficit related to ADL needs and participation vary, Fatigue, Impaired balance, Limited Mobility, Weakness. Resident is currently receiving skilled therapy services with goal of returning home upon completion of rehab. Interventions include Bathing: Physical Limited - assist/1 staff. R5's progress notes dated 7/6/2024 at 11:04AM documents R5 very upset about many things going on. R5 is upset about the shower change schedule and states she wasn't given an option. R5 filed a grievance with the Social Services Director, SSD, last week, and is wanting to talk to the Director of Nursing, DON, to get things cleared up. SSD will email the DON about talking to the R5. Grievance dated 7/1/2024 documents R5 stating Director of Nursing, DON, changed shower schedule causing resident to miss therapy this morning. R5 states lots of schedules have been changed without telling residents. Findings of Investigation: R5 stated that evening showers are better for her. R5 would like showers on Wednesday evening and Saturday evening. R5's shower sheets dated 7/4/2024 documents R5 refused shower and stated She's not changing shower days. R5's shower sheet dated 7/8/2024 documents Refused very upset. On 7/9/2024 at 9:45AM, V5, Certified Nursing Assistant, CNA, stated the shower schedule has been changed and is still being worked out. The residents have set shower days. We have had some residents complain about not liking their shower days and as far as I know the shower days have not been changed to what they want. R5 was really upset about it. On 7/9/2024 at 10:55AM stated V6, R2's Power of Attorney, POA, stated R2 was scheduled showers in the evening, and she struggles with evenings. She has Sundowners. I try not to even visit her of an evening, because she gets so upset and cries. I don't know if the shower situation has been fixed. They didn't even ask her family if evening showers would work for her. I haven't been able to talk to anyone in management about it yet. I talked to the staff, and they said they were told schedules were not to be changed back. On 7/9/2024 at 2:00PM R5 stated - They changed the shower schedule, and no one knew it was going to change. They didn't tell anybody even the Certified Nursing Assistants, CNA's. I was so mad I refused showers for a while. I did my own protest. On 7/9/2024 at 2:30PM V2, Director of Nursing, DON, stated she was not aware of grievance filed by R5. V2 stated the schedule can be tweaked to accommodate residents preferences. Facility's undated ADL policy states Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide showers for 4 of 4 residents (R2, R5, R6 and R17) in the sample of 21 reviewed for showers. Findings include: 1.R2's face sheet, dated 6/27/24, documented that R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, dated 6/27/24, documented that R2 has the following diagnoses: cerebral ischemia, hypertension, history of cerebral infarction, depression, anxiety, muscle weakness, schizoaffective disorder, and need for assistance with personal care. R2's MDS (Minimum Data Set), dated 3/15/24, documented R2 is cognitively intact, R2 requires partial moderate assistance with hygiene and is dependent on staff for all mobility. On 6/25/24 R2's bath and skin report sheet, dated June 2024, documented that R2 had 2 showers in June on 6/8/24 and 6/15/24. On 6/25/24 at 9:20 am R2 was lying in bed with dried food stuck to her left arm and chest. R2's hair appeared greasy, and she appeared unkempt. R2 stated that she had not had a shower in about two weeks. R2 stated that she asked for one last Saturday but that no one gave her a shower. 2.R5's face sheet, dated 6/27/24, documented that R5 was admitted to the facility on [DATE]. R5's medical diagnosis sheet, dated 6/27/24, documented that R5 has the following medical diagnoses: cerebral infarction, Alzheimer's disease, chronic kidney disease, congestive heart failure, type 2 diabetes mellitus, hypertension, intervertebral disc degeneration, and need for assistance with personal care. R5's MDS, dated [DATE], documented that R5 is moderately cognitively impaired, requires partial/moderate assistance with showers and partial/moderate assistance with transfers into the shower. On 6/25/24 R5's bath and skin report sheet, dated June 2024, documented that R5 had a shower on 6/3/24, 6/17/24, and 6/24/24. On 6/25/24 at 9:40 am R5 was observed lying in bed and appeared disheveled, unshaven and hair greasy. R5 stated that he received a shower last night but that he usually only gets a shower every 2-3 weeks. R5 stated he would like to receive at least two showers per week. 3.R6's face sheet, dated 6/27/24, documented that R6 was admitted to the facility on [DATE]. R6's medical diagnosis sheet, dated 6/27/24, documented that R6 has the following medical diagnoses: Parkinson's disease with dyskinesia, spinal stenosis, vascular dementia, congestive heart failure, cognitive communication deficit, depressions, and need for assistance with personal care. R6's MDS, dated [DATE], documented that R6 is moderately cognitively impaired and is dependent on staff for showers/bathing. On 6/25/24 R6's bath and skin report sheet, dated June 2024, documented that R6 only received one shower in June on 6/20/24. On 6/25/24 at 9:48 am R6 stated that he hasn't had a shower in about a month and he usually gets one every other week. R6 appeared disheveled with food stuck to his shirt and dried food on his beard. 4.R17's face sheet, dated 6/27/24, documented that R17 was admitted to the facility on [DATE]. R17's medical diagnosis sheet, dated 6/27/24, documented that R17 has the following diagnoses: chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, chronic kidney disease (end stage and on dialysis), hypertensive heart failure, hypertension, and need for assistance with personal care. R17's MDS, dated [DATE], documented that R17 is cognitively intact and requires substantial/maximum assistance with showers/bathing and mobility. On 6/25/24 R17's bath and skin report sheet, dated June 2024, did not document that R17 received any showers for the month of June. On 6/25/24 at 10:55 am R17 stated that she has not had a shower since she moved to her new room about 3 weeks ago. R17 stated that her name was not on the shower list, and she still has not had a shower even though she lets the Certified Nurse Assistants (CNA) know several days ago. On 6/25/24 at 12:45 pm V10 LPN (Licensed Practical Nurse) stated that the showers are supposed to be documented in the shower book after they are completed by the CNAS. On 6/25/24 at 12:50 pm V11 CNA stated that many of the shower sheets are blank so either the CNAS are not getting the showers completed or they are forgetting to document the showers. On 6/26/24 at 11:50 am V15 CNA stated that they document the residents' ability to complete a shower or bath in the EMR (Electronic Medical Record) every day and that they chart when the actual showers are given on the monthly bath and skin report sheet. On 6/26/24 at 11:58 am V16 CNA Supervisor stated that the CNAS are supposed to be using the paper bath and skin report sheets to document when the showers are given. The facility's Activities of Daily Living (ADLs) Policy dated March 2018, documented residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. It continues, appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were seen by a physician for 4 of 7 residents (R2, R5, R18 and R21) reviewed for physician visits in the sample of 21. 1.R2's face sheet, dated 6/27/24, documented that R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, dated 6/27/24, documented that R2 has the following diagnoses: cerebral ischemia, hypertension, history of cerebral infarction, depression, anxiety, muscle weakness, schizoaffective disorder, and need for assistance with personal care. R2's MDS (Minimum Data Set), dated 3/15/24, documented R2 is cognitively intact. On 6/26/24 at 9:15 am R2 stated that she has only seen her Medical Doctor (V18) one time and that was when she was admitted about two years ago. R2 stated that the Physician Assistant comes to see her but that her doctor never does. R2's EMR (Electronic Medical Record) does not document any Medical Doctor progress notes for 2024. 2.R5's face sheet, dated 6/27/24, documented that R5 was admitted to the facility on [DATE]. R5's medical diagnosis sheet, dated 6/27/24, documented that R5 has the following medical diagnoses: cerebral infarction, Alzheimer's disease, chronic kidney disease, congestive heart failure, type 2 diabetes mellitus, hypertension, intervertebral disc degeneration, and need for assistance with personal care. R5's MDS, dated [DATE], documented that R5 is moderately cognitively impaired. R5's EMR does not document any physician visits by his primary Medical Doctor V18 nor any doctor for this year, 2024. 3.R18's face sheet, dated 6/27/24, documented that R18 was admitted to the facility on [DATE]. R18's medical diagnosis sheet, dated 6/27/24, documented that R18 has the following diagnoses: chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, congestive heart failure, peripheral vascular disease, dementia, atherosclerotic heart disease, and hypertension. R18's MDS, dated [DATE], documented that R18 is moderately cognitively impaired. R18's EMR does not document any physician progress notes by V18, Medical Doctor for 2024. 4.R21's face sheet, dated 6/27/24, documented that R21 was admitted to the facility on [DATE]. R21's medical diagnosis sheet, dated 6/27/24, documented that R21 has the following medical diagnoses: COPD, type 2 diabetes mellitus, hypertension, schizophrenia, adult failure to thrive, and sensorineural hearing loss. R21's MDS, dated [DATE], documented that R21 is cognitively intact. R21's EMR does not document any Medical Doctor progress notes by his primary physician, V18 for this year 2024. On 6/26/24 at 10:45 am V1 Administrator stated that she cannot find any physician progress notes for R2, R5, nor R18 for this year. V1 stated that V18's Physician Assistant is at the facility almost every day seeing residents and that V18 must not be seeing his residents every 60 days. V1 stated she will be doing a QA (Quality Assurance) on this. On 6/27/24 at 9:37 am V1 stated that she spoke to her Medical Director (V18) and that he stated he has not visited any of his residents this year unless they were receiving skilled services or newly admitted and that he will conduct an audit and start seeing his residents at least every 60 days. V1 stated that R5 has not seen a medical doctor since August of 2023. The facility's Physician Services Policy, dated February 2021, documented the medical care of each resident is supervised by a licensed physician. It continues, 7. Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to sufficiently staff the facility to care for the resident needs, including Activities of Daily Living (ADLs), and answering call lights for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for sufficient staffing in the sample of 7. This deficiency has the potential to affect all 131 residents living in the facility. Findings include: 1. R1's Face Sheet, undated, documents, R1 was admitted to the facility on [DATE]. R1's Minimum Data Set, (MDS), dated [DATE], documents, R1 is cognitively intact. On 5/6/24 at 11:35 AM, R1 stated, They could use more help on the evenings and nights because, they always seem to be busier. I had an incontinent episode one night, and I put my call light on, and it took three hours to get someone to come clean me up. 2. R2's Face Sheet, undated, documents, R2 was admitted to the facility on [DATE] and was discharged on 4/24/25. R2's MDS, dated [DATE], documents, R2 had a moderate cognitive impairment. On 5/6/24 at 10:10 AM, V5, R2's Daughter, stated, (R2) was in the facility for about a week and half for rehab after a car accident where she broke her leg. I visited (R2) the evening of 4/24/24 and decided that I was taking (R2) out of the facility, and when I showed up the next morning to take (R2) out, I had to wait because there was only one nurse and one CNA, (Certified Nursing Assistant), on the 200-hall, and I feel like there should be more help than that. 3. R3's Face Sheet, undated, documents, R3 was admitted to the facility on [DATE]. R3's MDS, dated [DATE], documents, R3 is cognitively intact. On 5/6/24 at 11:55 AM, R3 stated, I have been here around three weeks. I came from the hospital after the amputation of my foot. They have a problem here with staffing. I feel the staffing is good for days and sometimes evenings but could use more help at night because the call light takes quite a while to get answered. I will sit in the hallway, or at the nurse's desk almost every evening, and I will see the call lights on, and it takes a while to get the lights answered because they only have one CNA working, and she can't be everywhere at once. 4. R4's Face Sheet, undated, documents, R4 was originally admitted to the facility on [DATE], but most recently on 4/10/24. R4's MDS, dated [DATE], documents, R4 is cognitively intact. On 5/6/24 at 11:07 AM, R4 stated, I feel that the staffing is good for days, but they are thin on nights. On days, there is always a nurse on duty, and if I push my call light, someone is there within a few minutes, but for nights, you must have patience, and someone will eventually come and help me. 5. R5's Face Sheet, undated, documents R5 was admitted to the facility on [DATE]. R5's MDS, dated [DATE], documents, R5 is cognitively intact. On 5/6/24 at 10:53 AM, R5 stated, There is always a nurse and CNA available to help me with my AM and PM procedures, like getting cleaned up, changing clothes, and things like that (ADLs). I use my call light and the staff will answer it, but it may take a while. They need more help here, sometimes you have to wait a long time to get help, on all the shifts. On 5/6/24 at 9:45 AM, V4, Staffing Coordinator, stated, I use the State's Staffing Calculator to determine how many staff the facility needs each day. I may add one or two to the staffing if I feel there is a need for extra help. The Day shift for Nurses and CNAs is 6:00 AM to 6:00 PM, the Evening shift for Nurses is 2:00 PM to 10:30 PM and the CNAs is from 2:30 PM to 11:00 PM, and the Night shift for Nurses is from 10:00 PM to 6:30 AM and the CNAs is from 11:00 PM to 7:30 AM. I input the resident census, the number of Medicare and Medicaid residents, and the calculator formulates how many Registered Nurses, (RNs), Licensed Practical Nurses, (LPNs), and CNAs that are needed for each shift, and that is what I staff for. On 5/6/24 at 8:00 AM, there was only one Nurse and one CNA on duty for each resident hall (100, 200, 300, 400, 600, 700, and 900-halls). Each CNA had to use the CNA from another hall when assistance was needed, leaving that hall without a CNA. While observing, managers were seen coming out of their offices to assist with call lights going off due to CNA not available. On 5/6/24 at 10:50 AM, V7, Licensed Practical Nurse, (LPN), stated, There is always a nurse and one to two CNAs on each hall. This facility could use more staff. There are usually three CNAs who share the 100-200 halls, but we had a call off today (5/6/24), so we only have one CNA for each hall. On 5/6/24 at 11:15 AM, V8, CNA, stated, I usually work on the 400-hall, but they moved me to the 200-hall today (5/6/24) due to call offs, so we can have one on each hall. On 5/6/24 at 11:30 AM, V11, LPN, stated, This place is just like all the other places, they could always use more help. Because of the call offs, we have to work together to take care of the residents and get things done. On 5/6/24 at 11:45 AM, V9, LPN, stated, I think the staffing is adequate and the facility staffs plenty, but sometimes they just don't show up. We will have to work short until they can get someone to come in to help. On 5/6/24 at 11:50 AM, V12, LPN, stated, There are usually two to three CNAs to work with me, but they had call offs today, so we are down to one on each hall, which can make it difficult. On 5/6/24 at 3:55 PM, V2, Assistant Director of Nursing, (ADON), stated, I was made aware of the complaints of low staffing for nights, and I agree that we could use more help for evenings and nights. Most of our admissions come in the evening when the staff are already very busy. The daily staffing sheets do not have times on them indicating when a staff member came into work, so when you look at them, it looks like there is sufficient staff. On 5/7/24 at 8:10 AM, V15, RN, stated, I have worked some evenings on the 900-hall where I had 27 residents to pass meds on, with some requiring vital sign checks. Then only having one CNA on the floor assisting residents, I was not able to assist her if needed. I had a code early one morning around 8:00 AM, and it was all hands-on deck and felt like there just wasn't enough staff available to help with the code, and then continue to take care of the other resident needs. The residents are the ones who suffer. On 5/7/24 at 8:17 AM, V16, CNA, stated, I usually work days, and this facility could use more help. For some reason, on Mondays and Fridays, we are always short staffed. I work by myself at times due to call offs, and if a resident is a two-person assist, myself and the resident have to wait until someone else is available. On 5/7/24 at 2:15 PM, V17, Facility Owner, stated, I told (V4, Staffing Coordinator) not to go below the State Minimum Staffing Level, not to staff by it. I agree, staffing should be based on the resident needs. The Facility's Daily Staffing Sheets were reviewed. The Illinois Calculation of Minimum Staffing Levels sheet calculations documents, the Day shift required 19.4 staff members, the Evening shift required 15.1 staff members, and the Night shift required 8.6 staff members. There are seven resident halls in the facility and the night shift is frequently working with three nurses and five CNAs. The Facility's Resident Council Meeting Minutes, dated 12/28/23, documents, New Business: Nursing - waiting a half hour or more for call lights to be answered. We need more evening and midnight staff. The Facility's Resident Council Meeting Minutes, dated 1/19/24, documents, New Business: Nursing - 300/400 need more staff. Staff that are on the hall are very busy attending to the ones who need extra help. Residents feel like there should be more staff on the hall to assist with showers. The Facility's Resident Council Meeting Minutes, dated 2/16/24, documents, New Business: Nursing - CNAs are responding to call lights and telling the residents they will be right back and then forgetting to come back. Can we have more CNAs assigned to the dining room during mealtimes to help pass trays? The Facility's Resident Council Meeting Minutes, dated 4/1/24, documents, New Business: Nursing - Can we hire more CNAs? Can midnight CNAs be given extra things to do when they are not providing care? The Facility's Staffing, Sufficient and Competent Nursing Policy, dated 8/2023, documents, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1. Licenses nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: d. responding to resident needs. 6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment. 7. Factors considered in determining appropriate staffing rations and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. 8. Minimal staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing. The Facility's Call System, Resident Policy, dated 9/2022, documents, 6. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. The Facility Resident Census dated 5/6/24, documents, that the facility has 131 residents residing in the facility.

Based on interview and record review, the facility failed to follow through on a recommendation for a medication change for 1 of 11 residents (R2) reviewed for medications in the sample of 11. Findings include: On 4/23/24 at 2:00PM, V15, R2's Guardian, stated, in January, after R2 was seen by the surgeon, the surgeon called her and told her R2 is cancer free and he will be starting back on his Levothyroxine 137 micrograms, (mcg). V15 stated, that never happened and then some Doctor with the facility, started him on a different dose and his Endocrinologist is upset. V15 stated, she doesn't want anyone changing any of R2's medications without consulting V17, his Endocrinologist. R2's Face Sheet, printed on 4/18/24, documents, his diagnoses to include Vascular Dementia, Unspecified Cirrhosis of Liver, Cerebral Infarction, Hypertension and Postprocedural Hypothyroidism. R2's Order Audit Report dated 4/18/24 documents, an order dated 2/01/24 by V7, Physician Assistant, for R2 to start taking Levothyroxine 112 mcg one time a day for hypothyroidism. Per the Order Audit Summary this order was discontinued on 4/11/24 and R2 was ordered Levothyroxine 137 mcg one time a day for hypothyroidism by the facility's Medical Director. R2's Progress Note from his appointment with Radiation Oncology dated 1/02/24 by V16, Registered Nurse, (RN) at the Oncology clinic documents, he spoke to V20, Licensed Practical Nurse, (LPN), from the facility, regarding setting up an appointment for R2 to receive a radioactive iodine treatment on 1/12/24. Per this progress note, V16 informed V20 that R2 will need to have labs drawn at the facility on 1/09/24 before the treatment. The progress note, also documented, R2 will have a consultation appointment on 1/12/24 on the same day as the treatment and R2 will start on Levothyroxine on 1/13/24. At the end of the progress note, it documented, that V20, on behalf of the patient (R2) verbalized understanding of above instructions and instructions were faxed to the facility's fax number. R2's Progress note dated 1/12/24 at 3:27PM, from V16 at the Radiation Oncology clinic documents, Called post radioiodine treatment report to (V20) at facility. (V20) verbalized understanding of post treatment instructions and was faxed a copy of the same to (facility's fax #). R2's Encounter Information dated 1/12/24 at 3:18PM, and signed by V16, RN documents, Patient here for consult and radioactive iodine, (RAI), treatment. Accompanied by niece (V15). Patient educated and provided printed education materials on 48-hour isolation precautions and possible side effects of RAI treatment. Patient will start daily oral levothyroxine 137 mcg tomorrow and was educated and provided with printed educational materials on levothyroxine. Patient verbalized understanding to have post treatment labs drawn in 6-weeks and was given a paper lab requisition. Patient will return for post therapy scan on 1/16/24 and given instructions on location and time. Patient stated, their Endocrinologist is (V17). Patient verbalized understanding of all info and questions answered. R2's Progress Note dated, 4/09/24 from the Endocrinology Clinic, co-signed by V17, R2's Endocrinologist documents, Thyroid Clinic Lab Follow UP: Spoke to patient's niece, (V15), at (her phone number). TSH, (Thyroid Stimulating Hormone), not suppressed. Recommend increasing dose from Levothyroxine 112 mcg daily, to 137 mcg daily which is what he had been discharged on. R2's Medication Administration Record, dated, 2/01/24 - 2/29/24 documents, his first dose of Levothyroxine 112 mcg daily was administered on 2/02/24. This MAR and the MARs dated 3/01/24-3/31/24 and 4/01/24 to 4/30/24 document, R2 continued to receive Levothyroxine 112 mcg, until 4/11/24 when the order was changed to Levothyroxine 137 mcg daily. R2's MAR dated 1/01/24-1/31/24 did not document any Levothyroxine was given as ordered on 1/12/24. On 4/23/24 at 3:44PM, V18, RN identified herself as V17's, R2's Endocrinologist's, Nurse. She stated, R2 was seen in clinic by V17 on 4/09/24 and was given an order for Levothyroxine to be increased to 137 mcg as he had been only receiving 112 mcg. She stated, V17 had given the prescription for R2 to receive Levothyroxine 137 mcg on 1/12/24, but she did not know who had changed the order to 112 mcg. She stated, R2 received the order for Levothyroxine 137 mcg on 1/12/24, when he was seen in the Radiation Oncology Clinic. She stated, the prescription had been sent to (facility's pharmacy) at that time to be filled as this was his designated Pharmacy. V18 stated, R2 not receiving 137 mcg, starting on January 12, 2024, as ordered, and not having received any thyroid replacement therapy, until 2/02/24 would have had the side effects of R2 feeling more tired and not having much energy. She stated, when V17 had R2's labs drawn on 4/09/24, his thyroid levels were improved, but V17 likes to keep them a little lower, because of R2's history of thyroid cancer. V18 stated, R2's increased dose of Levothyroxine, should lower his levels even more, which is the desired outcome V18 wants to achieve. On 4/24/24 at 9:30AM, V20, LPN stated, she does remember having a conversation with R2's Radiation Oncology staff when they were making plans for his iodine treatment, because they had to make plans for him to be on isolation for a couple of days after his treatment. She stated, this meant he would be moved to another hall for a short time. V20 stated, she was not R2's nurse on the day he got his treatment, but stated, if he came back without orders, the nurse taking care of him should have called the Radiation Oncology Office and requested paperwork for after-treatment orders. V20 stated, she works on different halls day to day, but she recalls R2's Doctors were usually good about sending paperwork back with R2 after his appointments. On 4/24/24 at 9:45AM, V8, LPN stated, she was R2's nurse when he was sent out for his iodine radiation treatment on 1/12/24, but he would have come back to a room on a different hall, due to needing to be isolated. She stated, most times R2's niece, now guardian, would go to appointments with him and she would keep the paperwork and the facility staff, would have to call her and ask about any changes or new orders. V8 stated, if the nurse who was taking care of R2, after he returned from his treatment on 1/12/24, did not receive any orders when he returned, that nurse should have reached out to the Oncology Office and requested his discharge orders, because this was R2's first time receiving that treatment and he had just had his thyroid removed, so they really should have made sure they knew just what was going on with him and if there were any changes in his orders. V8 stated, he returned to her hall after his few days of isolation were completed, but she did not see any order for him to be started on Levothyroxine and could not find anything in his chart regarding his 1/12/24, visit to the Radiation Oncology Clinic or what treatment he received that day. On 4/24/24 at 9:06 AM V1, Administrator, stated, when a resident goes to a medical appointment outside the facility, she would expect the nurse taking care of that resident to follow up with that resident, (if they are alert and oriented) or their family and ask if there were any changes or new orders as an outcome of the appointment. V1 stated, if there is no documentation provided after the outside appointment, she would expect that resident's nurse to call the medical office where the resident was seen and request documentation of any new orders or changes, or follow-up appointments, if needed. V1 stated, she had to get on Epic, a computer program with resident's MD, (Medical Doctor) and hospital reports to pull info on R2's visits on 1/02/24 and 1/12/24, but could not find any documentation, of these visit reports in R2's EMR at time of those appointments. V1 stated, she could not find progress notes or orders from his outpatient visits on 1/02 or 1/12 in R2's electronic medical record, (EMR). On 4/24/24 at 2:12 PM V1, Administrator, stated, the facility does not have a policy specific to following up and obtaining information after a residents outside medical appointments.

Based on observation, interview and record review, the facility failed to Administer Medications as ordered by the Physician for 1 of 11 residents (R11) reviewed for medications in the sample of 11. Findings include: On 4/24/24 at 8:25AM, a medication pass was observed with V19, Licensed Practical Nurse, (LPN), when she administered medications to R11. R11's Order Summary Report dated 4/24/24, documents, the order: 1/02/24: Folic Acid Oral Tablet 1 milligram, (mg), Give 3 tablets by mouth one time a day for supplement. During the observed medication pass, V19 only administered one Folic Acid 1 mg tablet, instead of the 3 tablets that were ordered. R11's Order Summary Report, also documented, the order: 3/28/24: Lamotrigine Oral Tablet 25 mg Give 2 tablets by mouth in the morning for seizures. During the observed medication pass, V19 only administered one tablet of Lamotrigine 25 mg, instead of the two tablets ordered by the Physician. R11's Order Summary Report, also documented, the order dated 1/05/24: Sertraline HCI Tablet 100 mg, Give 2 tablets by mouth one time a day for depression, related to Major Depressive Disorder, Recurrent, in Partial Remission. During the observed medication pass, V19 only administered 1 tablet of Sertraline HCI 100 mg to R11, instead of 2 tablets, as ordered by the Physician. R11's Order Summary Report, documents, the order dated 1/02/24: Symbicort Inhalation Aerosol 80-4.5 mcg, (micrograms),/ACT, (Asthma Control Test), (Budesonide-Formoterol Fumarate Dihydrate), 2 puffs, inhale orally, two times a day for SOB, (Shortness of Breath). V19 did not administer or offer, R11's a Symbicort inhaler to her during the observed medication pass. After dispensing R11's medications into a medication cup, V19 counted, the pills in the cup and stated, There are 11 pills in the cup. If all medications were pulled up as ordered, omitting R11's Oxybutynin, which V19 had to get out of the convenience dispenser, there should have been 15 pills, in the cup. After administering the medications, she had placed in R11's medication cup to R11, V19 stated, to R11, I'll see you around lunch time. and exited the room. On 4/24/24 at 11:00AM, V2, Director of Nursing, (DON), provided progress notes dated, 4/24/24 at 9:47AM and 10:06AM documenting, 2 Folic Acid, Symbicort and one Sertraline were administered late per staff Physician approval. There was no documentation, that V11 administered another Lamotrigine 25 mg tablet to make up the correct dose of that medication. V2 stated, (R11) has now gotten all the medication she had ordered this morning. I think (V19) just got nervous because she was being watched during her medication pass, but that's not an excuse to give that many wrong doses during one med pass. On 4/24/24 at 4:00 PM V1, Administrator, stated, V19 was very stressed and anxious during the medication pass and feels bad, that she missed some of (R11's) medications. V1 stated, she and V2, educated V19 regarding double checking her medications before administering them. The facility's policy, Administering Medications, revised April 2019, documents, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one, (1), hour of their prescribed time, unless otherwise specified, (for example, before and after meal orders). 10. The individual administering the medication checks the label three, (3), times to verify the right resident, right medication, right dosage, right time and right method, (route), of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide Therapeutic Diets as ordered by the Physician for two of three residents (R2 and R4) reviewed for Therapeutic Diets in a sample of 11. Findings Include: 1. On 4/23/2024 at 12:00PM, R4 received his lunch tray in his room. Observed his lunch to be a single serving of pasta and meat, (protein), and double portion of salad. R4's meal ticket documented, no specific diet order. On 4/18/2024 at 2:55PM, R4 face sheet revealed a diagnosis of sepsis, malignant neoplasm of rectum, history of antineoplastic chemotherapy; severe, protein calorie malnutrition, colostomy, human immunodeficiency virus disease, gastroesophageal reflux disease without esophagitis, iron deficiency anemia, hypokalemia, osteomyelitis of vertebrae, sacral and sacrococcygeal region, encounter for surgical aftercare following surgery on the digestive system. R4's Physician Order, dated, 4/16/24, documents, the order: Regular diet, Regular texture, Regular liquids consistency, double protein at lunch, diet order active 4/16/2024. R4's Physician Order dated, 4/23/2024, documents: House Nutritional Supplement one time a day, 120 milliliters, (ml), active 4/23/2024. On 4/23/2024 at12:30PM V4, Dietary Manager stated, she did not know what R4's Diet order is and went to the kitchen to check. She returned and stated, R4 is on a Regular Diet. V4 stated, she was not aware of R4's, Physician Order, on 4/16/24 and will start his double portions on 4/24/24, 8 days after R4 received the order for Double Portions at lunch. 2. R2's Face Sheet printed 4/18/24, documents, his diagnoses to include Rhabdomyolysis, Vascular Dementia, and Cognitive Communication Deficit. It documents, at the time he was admitted to the facility, his diagnoses included Morbid, (Severe), Obesity due to Excess Calories. R2's Minimum Data Set, (MDS), dated [DATE], (Annual): documents, he is severely cognitively impaired. R2's Physician Order dated, 9/18/23 documents, his diet order as: Regular Diet, Regular Texture, Regular Liquids consistency; super cereal at breakfast; ice cream at lunch and dinner, double portions at all meals for diet. R2's Care Plan, undated, documents, the Focus: Resident has specific nutritional needs. Goal: Resident will not experience an unplanned weight loss of 5% or more in a month or a loss of 10% in 180 days. Resident will maintain adequate nutrition levels. Interventions for this care plan include: Provide diet and serve as ordered; Provide supplements as ordered, RD, (Registered Dietician), to evaluate as needed; Report unplanned/unexpected weight loss to physician and/or RD; Able to feed self after set up. At times, behaviors/lethargy may interfere with PO, (oral), intake-reapproach as able. R2's Registered Dietician, Note dated 1/11/24 documents, R2 was readmitted on [DATE] after acute hospitalization for Thyroid Nodules s/p, (status post), Thyroidectomy, (pathology reports indicates thyroid cancer). Appetite good, (75-100%), of all meals. Despite PO, (oral), intake, weight trended down significantly x 6 months likely related to undiagnosed thyroid cancer. On 4/18/24 at 12:00PM V10, Certified Nursing Assistant, (CNA), delivered R2's lunch tray to him in his room and set it on his over-bed table. There was a double portion of the main course, (pasta dish), on R2's plate along with mixed vegetables and a bread stick. R2 had a soda on his table and there was water and lemonade served with his meal. There was no ice cream on his tray. V10 showed writer R2's meal ticket which documented, double portions and ice cream. V10 stated, ice cream may just be one of his likes. She did not go and get R2 any ice cream but continued to pass trays on the hall. On 4/24/24 at 8:40 AM V9, CNA was picking up breakfast trays from residents' rooms on the 300-Hall. R2's tray was observed. V9 stated, he ate all of his scrambled eggs with cheese and toast. A bowl of plain cream of wheat cereal was observed on R2's finished tray. V9 stated, they did not send him any super cereal today, only regular cream of wheat, and he did not eat it. The cream of wheat was white and did not appear to have any additives of butter or brown sugar added. On 4/23/24 at 11:45 AM V4, Dietary Manager, stated, each resident's diet is individualized whether it is due to a resident's preference or a Physician's Order. She stated, if there is a Physician Order specific to that resident, it will be listed on their diet card as other order and diet should be provided as ordered. She stated, sometimes it depended on availability of some items such as ice cream, whether they received it from the vendor or not. V4 stated, she did not recall any notifications of ice cream not being available from vendor on 4/18/24 and R2 should have received ice cream on his lunch and dinner tray if it was ordered by the Physician. She stated, if ice cream was listed on his meal ticket, but was not on his tray, the staff should have come back and asked for it. On 4/24/24 at 8:56AM, V4 stated, super cereal is either cream of wheat or oatmeal with brown sugar, butter and mild added to it. She stated, the cream of wheat would not have appeared white if brown sugar and butter had been added to make it super cereal, and it would have been runnier, due to milk being added. When informed R2 did not receive super cereal as ordered for breakfast this morning, V4 stated, OK, I'll have to look into it. The facility's undated policy, Therapeutic Diets documents, Therapeutic Diets are prescribed by the attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a Therapeutic Diet. 1. A Therapeutic Diet must be prescribed by the resident's attending Physician (or non-physician provider). The attending Physician may delegate this task to a registered or Licensed Dietitian as permitted by state law. 2. A 'Therapeutic Diet is considered a diet ordered by a Physician, Practitioner or Dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: 1. diabetic/calorie-controlled diet. 2. low sodium diet. 3. cardiac diet; and 4. altered consistency diet. R4's Physician Order dated 4/16/24 documents, the order: Regular diet, Regular texture, Regular liquids consistency, double protein at lunch, diet order active 4/16/2024. R4's Physician Order dated 4/23/2024 documents: House Nutritional Supplement one time a day 120 milliliters, (ml), active 4/23/2024. On 4/23/2024 at12:30PM V4, Dietary Manager stated, she did not know what R4's diet order is and went to the kitchen to check. She returned and stated, R4 is on a Regular Diet. V4 stated, she was not aware of R4's Physician Order on 4/16/24 and will start his Double Portions on 4/24/24, 8 days after R4 received the order for Double Portions at lunch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R85's most recent completed MDS was dated 11/28/23. On 3/18/24 at 3:15 PM R85's quarterly MDS, dated [DATE], was documented, in progress, and was not completed. The MDS was 110 days after the last quarterly assessment and was not completed as of 3/18/24. On 3/21/24 R85's MDS with a due date of 2/16/24 was completed on 3/19/24. The Facility's Resident Assessments Policy, dated March 2022, documents A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: 1) admission assessment; 2) quarterly assessment; 3) annual assessment; 4) significant change in status assessment. Based on interview and record review, the facility failed to timely complete the quarterly Minimum Data Sets (MDSs) for 3 of 3 residents (R85, R87) reviewed for timely completion of MDS quarterly assessments in the sample of 59. Findings include: 1.R87's Quarterly Minimum Data Set, (MDS), was dated 11/18/23. R87's Quarterly MDS, dated [DATE], was not completed (no information was entered into the assessment) within the 90 days of the last Quarterly MDS which was conducted on 11/18/23. On 03/19/24 at 2:42 PM, V24, MDS Coordinator, stated, there are two MDS Coordinators. V24 stated V25, MDS Coordinator, went on medical leave the first of February 2024. V24 stated, she thought the residents MDS's assessments, quarterly and annuals were up to date, but the computer system revealed a past due closing date greater that 90 days which included R87's quarterly MDS. V24 stated currently she is completing the residents MDS that is triggered in the system that is overdue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R85's admission Record, undated, documented R85 was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis, osteoarthritis, stage 4 pressure ulcer of sacral region, neuromuscular dysfunction of bladder deafness, anxiety disorder, depression, thrombocytosis and obstructive uropathy. R85's MDS, dated [DATE], documented R85 has moderately impaired cognition and requires substantial/maximal assistance with rolling left to right in bed. R85's Care Plan, undated, documented R85 is at risk for skin impairment/pressure injury due to fragile thin skin, impaired/limited mobility and medication use. This Care Plan goal documented resident will maintain intact skin or current condition of skin integrity through next review date. R85's Care Plan documented interventions to minimize pressure over boney prominences, monitor lab results as ordered and report abnormal results to physician, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration, edema noted during bathing or daily care, nutritional approaches to maintain optimal skin integrity as ordered by physician, preventative skin care per house protocols, lotion to dry skin, barrier creams to areas affected by moisture prn, provide incontinence care after incontinence episodes, apply barrier cream PRN, report changes in skin status to Physician, assist with turning and positioning if resident is unable, it continues provide specialty mattress: low air loss mattress. R85's Nurse Weekly Skin Integrity Review, dated 3/12/24, does not document any skin issues on R85. On 3/19/24 at 11:15 AM V19, Certified Nurse's Aide, CNA entered R85's room, donned gloves without the benefit of hand hygiene and V19 performed indwelling urinary catheter care for R85. V19 then rolled R85 onto her left side and cleansed R85's buttock. R85 had an approximate quarter sized pressure ulcer to her sacral region and two approximate nickel sized pressure ulcer on her inner buttock area. On 3/19/24 at 11:35 V6 Wound Care Nurse stated the floor nurses do the weekly skin checks and she was not aware R85 had open areas. V6 stated R85's last skin assessment, dated 3/12/24, did not document any open areas and that no one has informed her that R85 has open areas again. V6 stated R85 originally had a stage four pressure ulcer but that had been resolved. V6 stated she would have the wound doctor see R85 today. R85's Nurse Weekly Skin Integrity Review, dated 3/20/24, documented R85 has a stage four pressure ulcer on her right buttock measuring 0.5 cm by 1.5 cm by 0.1 cm and a skin tear on her left buttock measuring 2 cm by 0.5 cm by 0.1 cm. On 3/20/24 based on fifteen minutes observations from 8:15 AM to 11:15 AM, R107 remained sitting upright in her bed in the same position. On 3/19/24 at 1:35 PM V6 Wound Care Nurse stated all residents with low air loss mattress should be repositioned at least every two hours. 3. R107's admission Record, undated, documented R107 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia, dysarthria, dysphagia, essential hypertension, hyperlipidemia and type two diabetes. R107's MDS, dated [DATE], documented R107 is cognitively intact. R107's Care Plan, undated, documented R107 is at risk for skin impairment/pressure injury with interventions of avoid prolonged periods of skin-to-skin contact, consult/make referral for screen PRN (as needed), minimize pressure over bony prominences, it continues assist with turning and positioning if resident is unable. R107's Nurse Weekly Skin Integrity Review, dated 5/25/23, documented R107 was admitted with no areas of concern at this time. R107's Weekly Skin Integrity Review, dated 3/12/24, documented R107 had a skin tear measuring 0.9 cm by 1.2 cm x 0.3 cm to R107's sacrum which was 100% necrotic. R107's Wound Progress Note, dated 3/15/24, documented R107 had new facility acquired skin tear to R107's sacrum measuring 0.9 cm by 1.2 cm by 0.3 cm with eschar. On 3/19/24 at 1:35 PM V6, Wound Care Nurse, and V35, Wound Care Doctor, removed R107's dressing from his sacral region. R107 had an open pressure ulcer underneath the dressing. ½ of the wound base had yellow slough. V35 stated that it was caused by sheering but that he must document it as a skin tear because his EMR (Electronic Medical Record) does not recognize sheering of the skin. V6 stated she considers the wound to be a stage three pressure ulcer and she expects the CNAs to reposition R107 at least every two hours even though he is on a pressure reducing mattress. On 3/20/24 based on fifteen-minute observations, from 8:15 AM to 11:15 AM, R107 remained on his back in the same position. On 3/20/24 at 11:20 AM R107 stated that he is not able to reposition himself nor has anyone offered to reposition him. The facility's Repositioning Policy, dated 5/2013, documented the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. It continues, interventions 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 2. Frequency of repositioning a bed or chair bound resident should be determined by: a. The type of support surfaced used; b. The condition of the skin; c. The overall condition of the resident; d. The response to the current repositioning schedule; and e. Overall treatment objectives. 3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. 4. For residents with a stage 1 or above pressure ulcer, an every two hour (q2 hour) repositioning schedule is inadequate. Based on observation, interview and record review, the facility failed to provide timely turning and repositioning to prevent pressure ulcers for 3 of 6 residents (R85, R107, R279) reviewed for pressure ulcers in the sample of 59. Findings include: 1. R279's Face Sheet, undated, documents R279 was admitted to the facility on [DATE] with diagnoses of Sepsis, Urinary Tract Infections (UTI), Malnutrition, COVID-19, Atherosclerotic Heart Disease (ASHD), Congested Heart Failure (CHF), Dementia, Dysphagia, Hypertension (HTN). R279's Care Plan, dated 2/10/24, documents R279 is at risk for skin impairment/pressure injury. R279's Care Plan Interventions document the following: avoid prolonged periods of skin to skin contact, minimize pressure over boney prominences, assist with turning and positioning if resident is unable, provide pressure relieving mattress. It continues R279 has area(s) of skin impairment. Left upper back P4 resolved 3/5/24, Left lower back P4, Right heel Deep Tissue Injury (DTI). Interventions: assist with turning and positioning if resident is unable, administer/apply medications, ointments, creams as ordered- see Medication Administration Record (MAR)/physician orders, consult/make referral for wound specialist as needed, encourage good nutrition and hydration in order to promote healthy skin, report changes in skin status (i.e., s/s infection, non-healing, new areas) to nurse/physician. R279's Minimum Data Set (MDS), dated [DATE], documents R279 has severe cognitive impairment and is dependent on staff for toileting, requires substantial/maximum assistance from staff for dressing, requires partial/moderate assistance from staff for hygiene and bed transfers. R279's Wound Progress Note, effective date 2/16/24, documented R279 was admitted with a Stage III pressure ulcer to his coccyx, measuring 1.5 centimeters (cm) length by 1.3 cm width by 0.1 cm depth. The Wound Progress Note documented R279 was admitted with a Stage IV pressure ulcer to his back, measuring 5.3 cm length by 3.2 cm width by 0.3 depth. The Note documented the Stage IV had slough and eschar (dead tissue) with moderate amount of drainage. The Wound Progress Note documented R279 was admitted with a Stage III pressure ulcer to his proximal left back measuring 2.3 cm in length by 1.6 cm width by 0.3 cm depth with a moderate amount serous drainage. R279's Wound Progress Note, effective date of 3/6/24, documented R279's Stage IV pressure ulcer to left distal back measured 4.5 cm by 3 cm by 0.3 cm. The Note documented R279's Stage III pressure ulcer measured 1.8 cm (length) by 1.0 cm (width) 0.3 cm (depth) with granulating tissue. R279's Wound Progress Note, effective date of 3/15/24, documented R279's Stage IV pressure ulcer to left distal back measured 4.5 cm by 2.8 cm by 0.3 cm. On 3/18/24 at 9:43 AM, R279 was lying in low bed, lying on his back in bed. On 3/18/24 at 10:30 AM, V9, R279's Brother-In-Law, stated R279 has a pressure sore to his back and his heel from lying too much on his back. R279 was on his back at this time. On 3/18/24 at 11:45 AM, R279 remained on his back. No staff has been seen in his room to reposition him. On 3/19/24 at 8:44 AM, R279 was lying on his back in his bed. On 3/19/24 at 2:08 PM, V26 Wound Physician, doing rounds on residents with V6, Wound Nurse. Both went in to see R279's wounds. Upon measurement, V26 measured R279's wound on his mid-back as 5 cm (centimeters) X 3 cm as a Stage-4 Pressure Ulcer. V26 stated This is from (R279) lying on his back all the time. Treatment of Santyl with Calcium Alginate applied to wound. V26 stated the strong odor is from the wound, and he will start Flagyl to be crushed and applied to the wound to get rid of the smell. When questioning the wound on R279's heel, V26 stated he knew nothing about a wound on his heel. V6 stated R279 has had this wound and she has it in her documents, she just treated it and did not tell V26. V26 stated that the wound on R279's heel is 1.5 CM X 1 CM and is deep tissue injury (DTI) Unstageable Necrosis. V26 stated to use Betadine wipe to heel. R279's Wound Progress Note, effective date of 3/20/24, documented R270's Stage IV pressure ulcer to left distal back measured 5 cm by 3 cm by 0.3 cm. The Note documented there was no odor although V26 did note odor during the observation on 3/19/24. The Note documented R279 had a new facility acquired unstageable deep tissue injury to his right lateral heel measuring 1.5 cm by 1 cm with no depth. On 3/20/24 at 12:55 PM, R279 lying in bed on his back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R281's Face Sheet, undated, documents R281 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Atherosclerotic Heart Disease (ASHD), Chronic Obstructive Pulmonary Disease (COPD), Respiratory failure, Type 2 Diabetes Mellitus (DM), Generalized Anxiety disorder, Peripheral Vascular Disease (PVD), Chronic Kidney Disease (CKD), Hypertension (HTN), Personal history of mental and behavioral disorders, personal history of suicidal behavior, Dependence on supplemental oxygen. R281's Care Plan, dated 3/15/24, documents 281 is at risk for falls. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, fall risk evaluation, monitor/encourage appropriate footwear PRN (as needed), keep bed in lowest position acceptable by the resident when the resident is in bed, remind to request assistance when getting up if needed. It continues R281 has actual/potential altered respiratory status. Interventions: Elevate head of bed as needed to facilitate ease of breathing, administer continuous oxygen as ordered via O2 at 2 LPM (liters per minute) via: nasal cannula. R281's Care Plan does not mention R281 smoking. R281's Minimum Data Set, MDS, has not been completed. R281's Basic Interview for Mental Status Score (BIMS), dated 3/15/24, documents R281 is cognitively intact. R281's admission Nursing Note, dated 3/15/24, documents R281 is a Past Smoker. On 3/18/24 at 10:08 AM, R281 stated she is a smoker and can go out and smoke whenever she wants to and always keeps her cigarettes and lighter with her in her walker. On 3/20/24 at 1:00 PM, R281 was walking around pushing her seated walker. Had just finished lunch and was seen outside smoking with other residents and no staff seen. Upon getting back to her room, R281 showed surveyor her pack of cigarettes and a lighter that she always keeps in her walker. R281 stated she has tried to quit but just not there yet. R281 stated that she remembers staff talking about smoking when she first got here but does not remember what exactly it was about. The facility policy smoking policy-residents dated [DATE] documents This facility has established and maintains safe resident smoking practices. 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a smoker or a non-smoker. 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at designated smoking times. 14. Residents may not store any smoking items in their room or on their person, including cigarettes, e-cigarettes, tobacco, etc. Based on observation, interview and record review the facility failed to secure cigarettes and lighters for 2 of 2 residents (R21, and R281) reviewed for supervision to prevent accidents in the sample of 59. Findings include: 1. On 3/19/2024 at 9:15 AM R21 was sitting outside her room on 4 wheeled scooter. R21 stated she can smoke whenever she wants to smoke. R21 stated she smokes without staff supervision. R21 stated she keeps cigarettes and lighter in her personal possession. R21 opened pocket of hoodie and showed surveyor cigarettes and lighter. R21's Care Plan, dated 6/2/2023, documents R21's cigarettes and lighter are to be stored in a secure place. On 3/21/2024 at 1:50 PM, V1, Administrator, stated if R21's Care Plan documents that R2's cigarettes and lighter are to be kept in a secure place, she would expect the Care Plan to be followed.

Based on observation, interview and record review the facility failed to ensure that all medications were administered with an error rate less than 5%. There were 30 opportunities with 2 errors observed which calculated to a medication error rate of 6.67%. This deficient practice was identified for 1 of 3 nurses administering medications to one of 3 residents (R58) reviewed for medication administration in the sample of 59. Findings include: 1. On 03/18/24 at 7:56 AM during medication administration, V4, Licensed Practical Nurse (LPN) did not administer Empagliflozin 10 milligrams (mg) as ordered to R58. V4 stated it was not available in the medication cart to give. During medication administration V4 obtained R58's inhaler out of the mediation cart and laid on top of cart, V4 then had to leave cart to go get stock medication that was not in the cart. At that time V4 locked R58's inhaler up in the cart and upon return did not administer the inhaler to R58. R58's Physician Order (PO) dated 3/6/2024 documents Empagliflozin 10 mg oral tablet give one daily one time a day for Diabetes Mellitus. R58's PO dated 3/6/2024 documents Budesonide-Formoterol Fumarate Aerosol 80-4.5 MCG (micrograms)/ACT (actuation) 2 inhale orally two times a day for Chronic Obstructive Pulmonary Disease (COPD). On 3/21/2024 at 1:50PM V1, Administrator stated she would expect meds to be given as ordered. V1 stated she would expect the pharmacy to be notified. The facility's Administering Medications Policy, dated April 2019, documents Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide complete incontinent care and proper catheter care to prevent urinary tract infections (UTIs) for 4 of 4 residents (R76, R85, R107, R108) reviewed for incontinence care in the sample of 59. Findings include: 1. R107's admission Record, undated, documented R107 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia, dysarthria, dysphagia, essential hypertension, hyperlipidemia and type two diabetes mellitus (DM). R107's Minimum Data Set, MDS, dated [DATE], documented R107 is cognitively intact. R107's Care Plan, undated, documented R107 is incontinent of bladder and bowel and requires facility staff to provide perineal care after each incontinent episode. On 3/19/24 at 9:50 AM V18, Certified Nurse Assistant, CNA, and V19 CNA entered R107's room, donned gloves without the benefit of hand hygiene and removed R107's disposable brief. R107 was incontinent of urine and stool. V18 cleansed R107's inner thighs with a disposable wipe and then cleansed R107's penis with the same wipe. V18 did not fold the wipe over prior to cleansing R107's penis. V18 and V19 then rolled R107 onto his right side and V19 cleansed the feces from R107's buttock. V18 and V19 did not cleanse R107's outer buttock nor hips. V19 then reached into R107's dresser drawer with the same gloves on and obtained R107's barrier cream. V19 then applied the barrier cream to R107's buttock with the same gloves on. V18 and V19 then placed a new disposable brief on R107. On 3/20/24 at 11:20 AM V34 CNA stated the CNAs are expected to use a new disposable wipe or fold the disposable wipe when they cleanse different areas during incontinence care. V34 also stated she would cleanse an incontinent resident's outer buttock and hips when providing incontinence care. 2. R76's admission Record, undated, documented R76 was admitted to the facility on [DATE] with diagnoses of inflammatory polyneuropathy, chronic obstructive pulmonary disease, essential hypertension, hyperlipidemia, chronic pain syndrome, dementia, atherosclerotic heart disease and polyosteoarthritis. R76's MDS, dated [DATE], documented R76 is cognitively intact. R76's Care Plan, undated, documented R76 has occasional urinary incontinence and staff are to provide incontinence care as needed. On 3/19/24 at 10:30 AM V19 entered R76's room and donned gloves without the benefit of hand hygiene. V19 removed R76's urine saturated disposable brief. V19 then rolled R76 onto her left side and V19 cleansed R76's buttock. V19 then assisted R76 onto her back and applied a new disposable brief. V19 did not cleanse R76's inner thighs, hips, inner labia, nor vaginal area. On 3/19/24 at 10:30 AM V19 entered R76's room and donned gloves without the benefit of hand hygiene. V19 provided partial incontinence care to R76. V19 did not change gloves nor perform hand hygiene throughout the incontinence care. 3. R85's admission Record, undated, documented R85 was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis, osteoarthritis, stage 4 pressure ulcer of sacral region, neuromuscular dysfunction of bladder deafness, anxiety disorder, depression, thrombocytosis and obstructive uropathy. R85's MDS, dated [DATE], documented R85 has moderately impaired cognition. R85's Care Plan, undated, documented R85 has an indwelling urinary catheter. R85's Physician Order Sheet, POS, dated 9/6/23, documented catheter care every shift. On 3/19/24 at 11:15 AM, V19 entered R85's room, donned gloves without the benefit of hand hygiene and then emptied R85's urinary catheter bag. V19 changed gloves without the benefit of hand hygiene between glove changes. V19 cleansed R85's inner thighs with a disposable wipe. V19 then cleansed R85's vulva and vaginal area with a new disposable wipe. V19 then cleansed R85's catheter tubing with the same wipe without folding the wipe over. V19 then rolled R85 onto her left side and cleansed V19's buttock with a disposable wipe and then applied barrier cream to V19's buttock with the same gloves that was used to wipe R85's front and back side. R85 had an approximate quarter sized open area to her sacral region and two approximate nickel sized open areas on her inner buttock area. V19 placed a clean disposable brief on R85's bed. The brief fell onto the floor. V19 picked the brief up off the floor and placed it onto R85. On 3/21/24 at 12:15 PM, V13 Registered Nurse, RN Supervisor stated she would expect the CNAs to use a new wipe when cleaning a resident's indwelling urinary catheter tubing. V13 also stated she would expect the CNAs to discard a clean brief that fell onto the floor. 4. R108's Face Sheet, undated, documents R108 was originally admitted to the facility on [DATE] with diagnoses of Respiratory Failure, quadriplegic, Urinary Tract Infections (UTIs), Type 2 DM, gastrostomy, and a tracheostomy. R108's Care Plan, dated 2/22/24, documents R108 has an Activities of Daily Living (ADL) self-care performance deficit Needs and participation may vary related to quadriplegia, tracheostomy status, gastrostomy status, requires total assist of 1-2 staff for all ADL's. Interventions: ADL Care: the resident may need assistance x 1 or x 2 for ADL care, Bed Mobility: the resident is Dependent, assist x 2 and is unable to reposition or move themselves in the bed. Changing the resident's position may require 2 people. Move and reposition the resident about every 2 hours or more often (unless other instructions are given) to prevent discomfort or skin concerns, Transfer: the resident is limited to extensive and may need assistance x 1 or x 2 for transfers in and out of chair or bed. It continues R108 is comatose. Interventions: Check every 2-3 hours and/or as required for incontinence. Provide incontinent care as needed. It continues R108 has a potential for recurrent urinary tract infections r/t (related to): catheter use, history of UTIs. R108's MDS, dated [DATE], documents R108 has a severe cognitive impairment and unable to communicate. R108's MDS documents R108 is dependent on staff for all ADLs and. R108 has a urinary catheter in place. On 3/21/24 at 9:45 AM, V32, CNA, and V41, CNA, entered R108's room to complete incontinent care on R108. V32 wiped once to R108's left groin and disposed of wipe, then wiped once to R108's right groin and disposed of wipe, got a clean wipe and wiped off the urinary catheter from tip of penis down the tube. V32 did not change gloves prior to wiping the catheter. V32 then wiped R108's penis, then scrotum once. R108 was turned to his left side and his anal area was wiped once only with that wipe appearing brownish in color after wiping and no second wipe was done. A clean pad was tucked under R108, V32 changed her gloves with no hand hygiene in between. R108 was rolled to his back and the clean incontinence brief was secured. V41 changed gloves with no hand hygiene in between. V32 kept the same soiled gloves on, moved a chair over to door to keep it open, then took bags out of room to soiled utility room, then was seen exiting within seconds with no gloves on and no apparent hand hygiene done before going to answer another resident's call light. The facility's Perineal Care Policy, dated 2018, documents The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the procedure: For Male Resident: b) Wash perineal area starting with urethra and working outward. c) If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. f) Continue to wash the perineal area including the penis, scrotum and inner thighs. g) Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. i) Gently dry perineum following same sequence. m) Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n) Dry area thoroughly. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 16. Wash and dry your hands thoroughly. For Female Resident: a) Wet washcloth and apply soap or skin cleansing agent. b) Wash perineal area, wiping from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (4) Gently dry perineum. The facility's Urinary Catheter Care Policy, dated 2022, documents The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. 1. Follow aseptic technique when inserting a urinary catheter. Routine Perineal Hygiene: 13. For a female resident: a) Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse the labia. Use one area of the washcloth (or wipe) for each downward, cleansing stroke. b) Change the position of the washcloth (or wipe) and cleanse around the urethral meatus. Do not allow the washcloth/wipe to drag on the resident's skin or bed linen. c) With a clean washcloth (or wipe), rinse using the above technique. 14. For a male resident: a) Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus. c) Change the position of the washcloth (or wipe) with each cleansing stroke. d) With a clean washcloth (or wipe), rinse using the above technique. 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview and record review the facility failed to document a date accessed/opened for multi-dose insulin injection pens for 4 of 4 residents (R12, R27, R122, R229) reviewed for medication labeling in the sample of 59. Findings include: 1. On 3/18/24, at 7: 31AM, V7, Licensed Practical Nurse, (LPN), stated that R27's, NovoLog FlexPen solution (pen-insulin) has been used. On 3/18/24 at 7:34AM, R27's insulin pen, not enclosed in a bag, was located inside the medication cart and did not have a date marked for when it was first accessed/opened. R27's Physician Order Sheet (POS), dated 3/2024, documented R27's is to receive Humulin 70/30, Kwik pen suspension subcutaneous injection of 100units/milliliters, give 20 units subcutaneous at 5:00AM and 30 units at 7:00PM. 2. On 3/18/24, at 7:40 AM, V7 stated R229's Humulin 70/30, Kwik Pen has been used. On 3/18/24 at 7:40 AM, R229's Humulin insulin pen, out of a sealed bag with a label on the injection pen, was not dated when it was accessed/opened. R229's POS documented R229 is to receive Humulin 70/30 to be started on 3/1/24, to administer 100units/milliliters, give 20 units subcutaneous at 5:00AM and 30 units at 7:00PM for diagnosis of Diabetes Mellites Type 2. 3. On 3/18/24 at 7:47 AM, V7 stated that R122's Humalog injection solution 100 units/milliliters, (Insulin Lispro), give 2 units subcutaneous before each meal for a medical diagnosis of Diabetes Mellitus Type 2, has been previously used. R122's, POS documented a start date on 3/9/24 at 6:30AM to administer Humalog injection solution 100 units/milliliters, (Insulin Lispro), give 2 units subcutaneous before each meal for a medical diagnosis of Diabetes Mellitus Type 2. On 3/18/24 at 7:47 AM, R122's Lispro insulin pen, not enclosed in a bag, was in the medication cart and the insulin pen was not documented with a date when it was opened. 4. On 3/18/24, at 7:51 AM, V7 stated that R12's Novolog Flex pen solution injection, 100 units/milliliter, (insulin Aspart) has been previously used. R12's, Physician's Order, dated 2/28/24, documented R12 was to receive 100 units/milliliter, (insulin Aspart), give 10 units before meals related to Diabetes Mellitus. R12's Novolog, flex pen, (Aspart) was not within a bag in the mediation cart and the insulin pen was not dated as when it was opened. On 3/19/24 at 9:20 AM, V12, Assistant Director of Nursing, ADON stated that the insulin pens should be marked when opened with the resident's name or initials, and if insulin pen is in a bag place a date on the bag and put a name and date on insulin pen when opened. The facility's Medication Labeling and Storage Policy, dated February 2023, documents Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform hand hygiene to prevent the spread of infection for 4 of 5 residents (R76, R85, R107, R108) reviewed for infection control in the sample of 59. Findings include: 1. R76's admission Record, undated, documented R76 was admitted to the facility on [DATE] with diagnoses of inflammatory polyneuropathy, chronic obstructive pulmonary disease, essential hypertension, hyperlipidemia, chronic pain syndrome, dementia, atherosclerotic heart disease and polyosteoarthritis. R76's Minimum Data Set, MDS, dated [DATE], documented R76 is cognitively intact. R76's Care Plan, undated, documented R76 has occasional urinary incontinence and staff are to provide incontinence care as needed. On 3/19/24 at 10:30 AM V19, Certified Nurse's Aide, CNA, entered R76's room and donned gloves without the benefit of hand hygiene. V19 CNA removed R76's urine saturated disposable brief. V19 then rolled R76 onto her left side and V19 cleansed R76's buttock. V19 then assisted R76 onto her back and applied a new disposable brief. 2. R85's admission Record, undated, documented R85 was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis, osteoarthritis, stage 4 pressure ulcer of sacral region, neuromuscular dysfunction of bladder deafness, anxiety disorder, depression, thrombocytosis and obstructive uropathy. R85's MDS, dated [DATE], documented R85 has moderately impaired cognition. R85's Care Plan, undated, documented R85 has an indwelling urinary catheter. R85's Physician Order Sheet (POS), dated 9/6/23, documented catheter care every shift. On 3/19/24 at 11:15 AM V19 entered R85's room, donned gloves without the benefit of hand hygiene and then emptied R85's urinary catheter bag. V19 changed gloves without the benefit of hand hygiene between glove changes. V19 cleansed R85's inner thighs with a disposable wipe. V19 then cleansed R85's vulva and vaginal area with a new disposable wipe. V19 then cleansed R85's catheter tubing with the same wipe without folding the wipe over. V19 then rolled R85 onto her left side and cleansed V19's buttock with a disposable wipe and then applied barrier cream to V19's buttock with the same gloves that was used to wipe R85's front and back side. V19 placed a clean disposable brief on R85's bed. The brief fell onto the floor. V19 picked the brief up off the floor and placed it onto R85. On 3/21/24 at 12:15 PM V13, Registered Nurse, RN Supervisor stated she would expect the CNAs to use a new wipe when cleaning a resident's indwelling urinary catheter tubing. V13 also stated she would expect the CNAs to discard a clean brief that fell onto the floor. 3. R107's admission Record, undated, documented R107 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia, dysarthria, dysphagia, essential hypertension, hyperlipidemia and type two diabetes. R107's MDS dated [DATE], documented R107 is cognitively intact. R107's Care Plan, undated, documented R107 is incontinent of bladder and bowel and requires facility staff to provide perineal care after each incontinent episode. On 3/19/24 at 9:50 AM V18, CNA, and V19 entered R107's room, donned gloves without the benefit of hand hygiene. R107 was incontinent of urine and stool. V18 and V19 provided incontinence care to R107 without changing gloves or performing hand hygiene throughout the procedure. V19 then reached into R107's dresser drawer with the same gloves on and obtained R107's barrier cream. V19 then applied the barrier cream with the same gloves on. V18 then changed gloves without performing hand hygiene and proceeded to provide care to R107's roommate. 4. R108's Face Sheet, undated, documents R108 was originally admitted to the facility on [DATE]. R108's Care Plan, dated 2/22/24, documents R108 has an Activity of Daily Living (ADL) self-care performance deficit needs and participation may vary related to quadriplegia, tracheostomy status, gastrostomy status, requires total assist of 1-2 staff for all ADL's. R108's Care Plan Interventions documents check every 2-3 hours and/or as required for incontinence, and provide incontinent care as needed. It continues R108 has a potential for recurrent urinary tract infections r/t (related to): catheter use, history of UTIs (Urinary Tract Infections). R108's MDS, dated [DATE], documents R108 has a severe cognitive impairment and unable to communicate. R108's MDS documents R108 is dependent on staff for all ADLs. R108 has a urinary catheter in place. On 3/21/24 at 9:45 AM, V32, CNA, and V41, CNA, in to do incontinent care on R108. V32 wiped once to R108's left groin and disposed of wipe, then once to R108's right groin and disposed of wipe, got a clean wipe and wiped off the urinary catheter from tip of penis down the tube. V32 did not change gloves prior to wiping the catheter. V32 then wiped R108's penis, then scrotum once. R108 was turned to his left side and his anal area was wiped once only with that wipe appearing soiled. V32 changed her gloves with no hand hygiene in between. R108 was rolled to his back and the clean incontinence brief was secured. V41 changed gloves with no hand hygiene in between. V32 still had her soiled gloves on, moved a chair over to door to keep it open, then took bags out of room to soiled utility room, then was seen exiting within seconds with no gloves on and no apparent hand hygiene done before going to answer another resident's call light. The facility's Perineal Care Policy, dated 2018, documents The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the procedure: For Male Resident: b) Wash perineal area starting with urethra and working outward. c) If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. f) Continue to wash the perineal area including the penis, scrotum and inner thighs. g) Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. i) Gently dry perineum following same sequence. m) Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n) Dry area thoroughly. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 16. Wash and dry your hands thoroughly. For Female Resident: a) Wet washcloth and apply soap or skin cleansing agent. b) Wash perineal area, wiping from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (4) Gently dry perineum. The facility's Urinary Catheter Care Policy, dated 2022, documents The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. 1. Follow aseptic technique when inserting a urinary catheter. Routine Perineal Hygiene: 13. For a female resident: a) Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse the labia. Use one area of the washcloth (or wipe) for each downward, cleansing stroke. b) Change the position of the washcloth (or wipe) and cleanse around the urethral meatus. Do not allow the washcloth/wipe to drag on the resident's skin or bed linen. c) With a clean washcloth (or wipe), rinse using the above technique. 14. For a male resident: a) Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus. c) Change the position of the washcloth (or wipe) with each cleansing stroke. d) With a clean washcloth (or wipe), rinse using the above technique. 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on interview, observation and record review, the facility failed to store food at appropriate temperatures and failed to perform hand hygiene and change gloves while plating food to prevent potential food-borne illnesses. This has the potential to affect all 126 residents in the facility. Findings include: 1. On 3/18/24 at 7:30 AM, the kitchen was entered and toured. V15 Dietary Manager was present for the tour. The walk-in refrigerator thermometer read 44 degrees Fahrenheit (F) during the initial tour. On 3/18/24 at 12:15 PM the walk-in refrigerator thermometer was observed to be at 43 degrees F. On 3/18/24 at 12:40 PM the walk-in refrigerator thermometer was observed to be at 45 degrees F. On 3/19/24 at 12:15 PM the walk-in refrigerator temperature thermometer was observed, and it read 48 degrees F. On 3/18/24 at 7:30 AM there was a Daily Cooler Temperature Log, dated March 2024, posted on the wall by the walk-in refrigerator. V15 stated it was the temperature log for the walk-in refrigerator. The Daily Cooler Temperature Log documented AM and PM temperatures. This document included multiple dates with documented temperatures over 41 degrees. These dates and temperatures documented were 3/1/24 at 43 degrees F , 3/3/24 at 45 degrees F in the AM and 42 degrees F in the PM, 3/4/24 at 43 degrees F, 3/5/24 at 43 degrees F, 3/6/24 at 46 degrees F, 3/7/24 at 46 degrees F, 3/8/24 at 48 degrees F, 3/9/24 at 46 degrees F, 3/10/24 at 47 degrees F, 3/11/24 at 46 degrees F, 3/13/24 at 45 degrees F, 3/14/24 at 46 degrees F, 3/15/24 at 44 degrees F, and 3/18/24 at 46 degrees. On 3/19/24 at 12:25 PM V15 Dietary Manager stated she would expect the walk-in refrigerator to be at 41 degrees F or below. V15 stated she would inform maintenance and get someone out to work on the refrigerator. On 3/18/24 at 12:05 PM V16, Dietary Aide, was wearing disposable gloves and transporting the food service tray carts to the steam table area. V16 then began serving food off the steam table onto plates. V16 did not wash her hands nor change gloves after transporting the food service tray carts or before serving food off the steam table. 2. On 3/18/24 at 12:30 PM V17, Dietary Aide, was wearing disposable gloves and serving food off the tray line. V17 left the tray line with the disposable gloves and went to the freezer. V17 obtained a small container of ice cream and then came back to the tray line and began serving food again. V17 did not perform hand hygiene nor change gloves after returning to the tray line. V17 was then observed going to the bread storage area and then retrieved a hot dog bun from the bag with her gloved hands. V17 did not use tongs to retrieve the hot dog bun. On 3/19/24 at 12:15 PM V17 was wearing disposable gloves while serving food off the steam table. V17 left the food line, walked over to the food warmer, opened it and obtained a grilled cheese sandwich while wearing disposable gloves. V17 then returned to the steam table and began serving food again with the same gloves on. On 3/19/24 at 12:25 PM V15 stated she would expect her staff to perform hand hygiene and put new disposable gloves on anytime they leave the food serving line. The facility's Refrigerators and Freezers Policy, dated 11/2022, documented the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees F and freezer keep frozen foods frozen solid. 2. Monthly tracking sheets for all refrigerators and freezer are posted to record temperatures. 3. Monthly tracking sheets include time, refrigerator temperature, temperature of food, initials, and action taken, it continues 5. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. The facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy, undated, documented food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these prior to working with food or serving food to residents. It continues, Hand Washing/Hand Hygiene 6. Employees must wash their hands; a. after personal body functions, b. after using tobacco, eating or drinking; c. whenever entering or re-entering the kitchen; d. before coming in contact with any food surfaces; it continues g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate hands. It continues, Gloves and Direct Food Contact 8. Contact between food and bare (ungloved) hands is prohibited. 9. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed, and gloves are replaced. The Facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 3/18/24, documents that the facility has 126 residents living in the facility.

Based on interview and record review, the facility failed to provide Dementia, Abuse, and other training to ensure competency of nurse's aides. This failure had the potential to affect all 126 residents residing in the facility. Findings include: 1.On 3/21/24 at 11:50 AM, V42, Human Resource (HR) Director stated All staff are hired with their license or certification prior to starting. They spend time with me to do all the HR paperwork and things like that. I don't know anything about other staff training. I do know when they start, they are on the floor doing hands-on training for at least three days. On 3/21/24 at 11:56 AM, V2, Director of Nursing (DON), stated CNAs (Certified Nursing Assistants) start with on-the -floor training for three to five days, usually one day per unit, and more if they need it. There is no other training done for new hires. I did have a company who was supposed to come in and train for Dementia, but they cancelled last week. (V1, Administrator) has told me that we will be getting (Online Education) training started again, but for now, and since the company change over, there is nothing else done for training new employees. On 3/21/24 at 12:03 PM, V5, Assistant Director of Nursing (ADON), stated (V43, CNA Coordinator) does all of the hands-on competencies for new CNAs on the floor. We were using (Online Education) for computer training for the mandatories, but once the company changed, we don't use it anymore. We do not have an Educator here, so we have to take care of it all. On 3/21/24 at 12:30 PM, V1, Administrator, stated I looked everywhere for training of the employees and was able to find a couple of binders with competencies. I'm not going to lie. We don't have anything in the employee files for any of their training. I started doing employee annual reviews in December 2023, on those who were due, but before then, I don't have anything. I just confirmed, the employee files don't have training or anything in them. On 3/21/24 at 3:30 PM, V42, provided a list of new hires since 12/1/23. This documents that there were 54 new employees that started at the facility since 12/1/23. Of these 54 employees, 37 were CNAs. The Facility's Staffing, Sufficient and Competent Nursing Policy, dated August 2022, documents Our facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competency Staff: Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: a) Resident Rights; b) Behavioral Health; c) Psychosocial care; d) Dementia Care. 5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a) programming for staff training results in nursing competency; c) education topics and skills need are determined based on resident population. The Facility's Long Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 3/18/24, documents that the facility has 126 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to obtain resident blood glucose levels, failed to administer medications, and failed to contact the Physician as ordered for 4 of 6 residents (R1, R8, R12, R13) reviewed for medication administration, in the sample of 13. The findings include: 1. R1's Face Sheet, undated, documented that R1 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure (CHF), Falls, Atrial-Fibrillation (A-Fib), Type 2 Diabetes Mellitus (DM), Occlusion/Stenosis of bilateral carotid arteries, Chronic Kidney Disease (CKD), Atherosclerotic Heart Disease (ASHD), Malignant neoplasm of colon, Depression, COVID, Seizures, and Obstructive/Reflux uropathy. R1's Care Plan, dated 12/27/23, documented, (R1) has an ADL (Activities of Daily Living) self-care performance deficit. Interventions: ADL Care: the resident may need assistance x one or x two staff members for ADL care, Transfer: the resident is limited to extensive assist and may need assistance x one or x two staff members for transfers in and out of chair or bed, encourage the resident to use bell to call for assistance. It continued, (R1) is at risk for falls. Interventions: Anticipate and meet Resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, fall risk evaluation, monitor/encourage appropriate footwear PRN (as needed), keep bed in lowest position acceptable by the resident when the resident is in bed, place Dycem or other non-skid material to wheelchair seat, remind to request assistance when getting up if needed, Other intervention: Call Don't Fall Sign, Other intervention: Lower w/c (wheelchair) seat. R1's Minimum Data Set (MDS), dated [DATE], documented that R1 was cognitively intact and requires supervision of staff for bathing, and transfers, and set-up assistance for toileting, and dressing, and was independent for all other ADLs. R1 was always continent of urine and occasionally incontinent of bowel. R1's Physician Order (PO), dated 12/27/23, documented, Novolog 100 Unit/ML (milliliter) Solution - Inject 6 units subcutaneously with meals related to Type 2 Diabetes Mellitus with other Diabetic Neurological complication. R1's Medication Administration Record (MAR), dated 1/22/24, documented that his medication was scheduled to be given at 5:00 PM, and was documented by V2, Director of Nursing (DON), at 8:55 AM. R1's PO, dated 12/29/23, documents Tamsulosin (Flomax) 0.4 MG (milligram). Give one capsule one time a day for Benign Prostatic Hyperplasia. R1's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM, and was documented as given by V6, Registered Nurse (RN), at 11:36 PM. R1's PO, dated 12/27/23, documents Hydralazine HCl (Hydrochloride) Tablet 100 MG. Give 1 tablet by mouth three times a day for Hypertension (HTN). Hold for systolic < 120. R1's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM, and was documented as given by V6, RN, at 11:36 PM. R1's PO, dated 1/3/24, documents Insulin Glargine Solution Pen-injector 100 Unit/ML. Inject 20 units subcutaneously one time a day for diabetes. R1's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM. and was documented as given by V6, RN at 11:40 PM. R1's PO, dated 12/27/23, documents Metoprolol Succinate ER (Extended Release) Tablet 100 MG. Give 1 tablet by mouth two times a day for hypertension. R1's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM, and was documented as given by V6, RN at 11:40 PM. R1's PO, dated 12/27/23, documents Atorvastatin Calcium Tablet 40 MG. Give 1 tablet by mouth at bedtime for hyperlipidemia. R1's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM, and was documented as given by V6, RN at 11:40 PM. R1's Electronic Medical Record, Weights, and Vitals Summary, dated 1/22/24 to 1/23/24, documents no blood sugars were completed on R1 on 1/22/24. The report documented a blood sugar on 1/21/24 at 7:28 PM as 275, then one on 1/23/24 at 11:28 AM as 134. On 1/31/24 at 2:15 PM, V17, RN, stated We do accu-checks on (R1) every day. 2. R8's Face Sheet, undated, documented that R8 was admitted to the facility on [DATE], with diagnosis of Respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), CHF, Type 2 DM, Morbid obesity, CKD, A-Fib, HTN, Anemia, Malignant neoplasm of Uterus, Diverticulosis, Gastroesophageal Reflux Disease (GERD), and long-term use of insulin. R8's Care Plan, dated 1/10/24, documented, (R8) has potential for hyper/hypoglycemia. Interventions: Diabetes medication and accu-checks as ordered by doctor- see MAR/physician's orders. It continues, (R8) has an ADL self-care performance deficit. Interventions: ADL Care: the resident may need assistance x 1 or x 2 staff members for ADL care, Transfer: the resident is limited to extensive and may need assistance x 1 or x 2 staff members for transfers in and out of chair or bed, sit-to-stand for transfers, encourage the resident to use bell to call for assistance. R8's MDS, dated [DATE], documented that R8 was cognitively intact and was dependent on staff for toileting, footwear, and transfers. R8 also, required partial/moderate assistance from staff for bathing and dressing. R8 was occasionally incontinent of both bowel and bladder. R8's PO, dated 1/12/24, documented, Lyrica Capsule 50 MG (Pregabalin). Give 1 capsule by mouth two times a day for Neuropathy. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2, DON at 12:56 PM. R8's PO, dated 1/12/24, documented, Lyrica Capsule 50 MG (Pregabalin). Give 1 capsule by mouth two times a day for Neuropathy. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM (1/22/24), and was documented as given by V2, DON at 08:46 AM on 1/23/24. R8's PO, dated 1/18/24, documented, Acetaminophen Tablet 500 MG. Give 2 tablet by mouth one time a day for pain AND Give 2 tablet by mouth at bedtime for pain. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:04 PM. R8's PO, dated 1/18/24, documented Acetaminophen Tablet 500 MG. Give 2 tablet by mouth one time a day for pain AND Give 2 tablet by mouth at bedtime for pain. R8's MAR,dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM (1/22/24), and was documented as given by V6, RN, at 00:37 AM on 1/23/24. R8's PO, dated 1/10/24, documented, Furosemide Tablet 80 MG. Give 1 tablet by mouth two times a day for diuretic. R8's MAR,dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:03 PM. R8's PO, dated 1/10/24, documented, Metoprolol Succinate ER Tablet Extended Release 24 Hour 100 MG. Give 1 tablet by mouth one time a day for hypertension. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 12:56 PM. R8's PO, dated 1/10/24, documented, Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG (microgram)/ACT (actuation mist). 2 puffs inhaled orally one time a day for COPD. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:03 PM. R8's PO, dated 1/10/24, documented, Cardizem CD Capsule Extended Release 24 Hour 120 MG. Give 1 capsule by mouth one time a day for hypertension. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:03 PM. R8's PO, dated 1/10/24, documented, Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day for heart health. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:04 PM. R8's PO, dated 1/10/24, documented, Duloxetine HCl Capsule Delayed Release Particles 30 MG. Give 1 capsule by mouth one time a day for depression. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:03 PM. R8's PO, dated 1/20/24, documented, Semaglutide (1 MG/Dose) Subcutaneous Solution Pen-injector 4 MG/3 ML Inject 4 MG subcutaneously one time a day every Mon, Sat for diabetes. Order was D/C on 1/22/24 at 4:21 PM. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 1:10 PM. R8's PO, dated 1/22/24, documented, Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalent). Give 1 tablet by mouth one time a day for supplement. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 11:00 AM (1/22/24), and was documented as given by V2 at 10:00 AM on 1/23/24. R8's PO, dated 1/10/24, documented, Humalog Kwik Pen 100 Unit/ML Solution pen-injector. Inject as per sliding scale: if blood sugar 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Glucose Greater Than 400 Give 12 Units AND Notify MD for further instructions, subcutaneously with meals for DM2. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 12:00 PM (1/22/24), and was documented as given by V2 at 10:01 AM. R8's PO, dated 1/10/24, documented, Humalog Kwik Pen 100 Unit/ML Solution pen-injector. Inject as per sliding scale: if blood sugar 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Glucose Greater Than 400 Give 12 Units AND Notify MD for further instructions, subcutaneously with meals for DM2. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V6, RN at 00:35 AM on 1/23/24. R8's PO, dated 1/10/24, documented, Furosemide Tablet 80 MG. Give 1 tablet by mouth two times a day for diuretic. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 4:00 PM (1/22/24), and was documented as given by V2 at 8:53 AM on 1/23/24. R8's PO, dated 1/10/24, documented, Xarelto Oral Tablet 15 MG (Rivaroxaban). Give 1 tablet by mouth one time a day for anticoagulation. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V2 at 8:53 AM on 1/23/24. R8's PO, dated 1/18/24, documented, Insulin Glargine Solution Pen-injector 100 Unit/ML. Inject 18 units subcutaneously one time a day for diabetes. R8's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM (1/22/24), and was documented as given by V6 at 00:35 AM on 1/23/24. R8's Electronic Medical Record, Weights, and Vitals Summary, dated 1/22/24 to 1/23/24, documents no blood sugars were completed on R8 on 1/22/24. The report documents a blood sugar on 1/23/24 at 00:35 AM, completed by V6, RN, with a result of 248. There are no other blood sugars done on 1/22/24. 3. R12's Face Sheet, undated, documented that R12 was admitted to the facility on [DATE] with diagnosis of COVID-19, Cystitis, Peripheral Vascular Disease (PVD), Type 2 DM, ASHD, Dementia, Extended-Spectrum Beta-Lactamases (ESBL), Depression, Adjustment disorder with mixed anxiety and depressed mood, Hyperlipidemia, HTN, GERD, and Hypothyroidism. R12's Care Plan, dated 1/23/24, documented, (R12) has potential for hyper/hypoglycemia related to Diabetes Mellitus. Interventions: Diabetes medication and accu-checks as ordered by doctor- see MAR/physician's orders, monitor/document/report PRN any s/s (signs/symptoms) of hyper/hypoglycemia. It continued, (R12) has an ADL self-care performance deficit. Interventions: ADL Care: the resident needs assistance x 1 staff member for ADL care; Bathing: The resident needs assist of x 1 staff member based on fatigue, weightbearing, weakness; Bed Mobility: the resident needs limited help to move and reposition the bed. will need one or two-person assistance to change position or scoot up in the bed. This may involve some lifting of the legs or boosts; Eating: the resident needs help setting up their meal; opening packages, cutting meat, etc. and once the meal is set up, they can feed themselves, check in on the resident throughout the meal to be sure they are doing okay and don't need any help; Transfer: the resident is limited assist and needs assistance of x 1 staff member for transfers in and out of chair or bed, this may fluctuate with weakness, fatigue, and weight bearing status, encourage the resident to use bell to call for assistance. R12's MDS, dated [DATE], documented that R12 was cognitively intact and requires substantial/maximal assistance from staff for toileting, and partial/moderate assistance from staff for all other ADLs. R12 was always incontinent of both bowel and bladder. R12's PO, dated 1/21/24, documented, Accucheck ACHS (before meals/bedtime). Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that the accu-check was scheduled to be done at 8:00 AM (1/22/24), and was documented as done by V2 at 9:58 AM on 1/23/24. R12's PO, dated 1/21/24, documented, Accucheck ACHS (before meals/bedtime). Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that the accu-check was scheduled to be done at 11:30 AM (1/22/24), and was documented as done by V2 at 9:59 AM on 1/23/24. R12's PO, dated 1/21/24, documented, Accucheck ACHS (before meals/bedtime). Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that the accu-check was scheduled to be done at 5:00 PM (1/22/24), and was documented as done by V6 at 10:43 PM. R12's eMar-General Note, dated 1/22/24 at 10:43 PM, documented, Accucheck ACHS, before meals and at bedtime for DM. Not given previous shift. R12's PO, dated 1/21/24, documents Accucheck ACHS (before meals/bedtime). Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that the accu-check was scheduled to be done at 9:00 PM (1/22/24), and was documented as done by V6 at 11:10 PM. R12's PO, dated 1/20/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 Unit/ML. Inject 8 units subcutaneously three times a day for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 AM (1/22/24), and was documented as given by V2 at 9:58 AM. R12's PO, dated 1/20/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 Unit/ML. Inject 8 units subcutaneously three times a day for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 12:00 PM (1/22/24), and was documented as given by V2 at 9:59 AM on 1/23/24. R12's PO, dated 1/20/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 Unit/ML. Inject 8 units subcutaneously three times a day for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 4:00 PM (1/22/24), and was documented as given by V6 at 10:42 PM. R12's eMar-General Note, dated 1/22/24 at 10:42 PM, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 8 units subcutaneously three times a day for DM. Not given previous shift. R12's PO, dated 1/20/24, documented, Insulin Lispro Sliding scale glucose 149 or less 0 units, 150 to 199 1 unit, 200 to 249 2 units, 250 to 299 3 units, 300 to 350 4 units, call MD, 350 or greater 5 units and call MD. Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 6:30 AM (1/22/24), and was documented as given by V2 at 9:58 AM on 1/23/24. R12's PO, dated 1/20/24, documented, Insulin Lispro Sliding scale glucose 149 or less 0 units, 150 to 199 1 unit, 200 to 249 2 units, 250 to 299 3 units, 300 to 350 4 units, call MD, 350 or greater 5 units and call MD. Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 11:30 AM (1/22/24), and was documented as given by V2 at 9:59 AM on 1/23/24. R12's eMar-General Note, dated 1/22/24 at 10:43 PM, documented, Inulin Lispro Sliding scale 149 or less 0 units, 150 to 199 1 unit, 200 to 249 2 units, 250 to 299 3 units, 300 to 350 4 units call MD, 350 or greater 5 units and call MD, before meals and at bedtime for DM. Not given previous shift. R12's PO, dated 1/20/24, documented, Insulin Lispro Sliding scale glucose 149 or less 0 units, 150 to 199 1 unit, 200 to 249 2 units, 250 to 299 3 units, 300 to 350 4 units, call MD, 350 or greater 5 units and call MD. Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 4:30 PM (1/22/24), and was documented as given by V6 at 10:43 PM. R12's PO, dated 1/20/24, documented, Insulin Lispro Sliding scale glucose 149 or less 0 units, 150 to 199 1 unit, 200 to 249 2 units, 250 to 299 3 units, 300 to 350 4 units, call MD, 350 or greater 5 units and call MD. Before meals and at bedtime for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM (1/22/24), and was documented as given by V6 at 11:10 PM. R12's eMar-General Note, dated 1/22/24 at 10:44 PM, documented, Cilostazol Tablet 50 MG. Give 1 tablet by mouth two times a day for symptoms of intermittent claudication. Not given previous shift. R12's PO, dated 1/20/24, documented, Cilostazol Tablet 50 MG. Give 1 tablet by mouth two times a day for symptoms of intermittent claudication. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V6 at 10:44 PM. R12's PO, dated 1/20/24, documented, Metformin HCl Oral Tablet 1000 MG. Give 1 tablet by mouth two times a day for DM. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V6 at 11:12 PM. R12's PO, dated 1/20/24, documented, Mirtazapine Oral Tablet 7.5 MG - Give 1 tablet by mouth at bedtime for mixed anxiety, and depression disorder. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM (1/22/24), and was documented as given by V6 at 11:13 PM. R12's PO, dated 1/20/24, documented, Olanzapine Oral Tablet Disintegrating 5 MG. Give 1 tablet by mouth at bedtime for mild anxiety, and depression disorder. R12's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM (1/22/24), and was documented as given by V6 at 11:14 PM. R12's Electronic Medical Record, Weights, and Vitals Summary, dated 1/22/24 to 1/23/24, documents one blood sugar was completed on 1/22/24 at 11:10 PM by V6, RN, with a result of 401. There are no other blood sugars completed on 1/22/24. 4. R13's Face Sheet, undated, documented that R13 was admitted to the facility on [DATE] with diagnosis of Respiratory failure, Pneumonia, Urinary Tract Infection (UTI), Quadriplegia, Type 2 DM, Gastrostomy, Neuromuscular dysfunction of bladder, Dysphagia, Tracheostomy, Cerebrovascular disease, A-Fib, and HTN. R13's Care Plan, dated 10/18/23, documented, (R13) has potential for hyper/hypoglycemia related to diagnosis of Diabetes Mellitus type 2. Interventions: Diabetes medication and accu-checks as ordered by doctor - see MAR/physician's orders, Monitor/document/report PRN any s/s of hyper/hypoglycemia. It continues, (R13) has an ADL self-care performance deficit, needs and participation may vary related to quadriplegia, tracheostomy status, gastrostomy status, (R13) requires total assist of 1-2 staff members for all ADL's. Interventions: Mechanical Lift for transfers, ADL Care: the resident may need assistance x 1 or x 2 staff members for ADL care. Bed Mobility: R13 is Dependent, assist x 2 staff members and is unable to reposition or move themselves in the bed, changing the resident's position may require 2 people, move and reposition the resident about every 2 hours or more often (unless other instructions are given) to prevent discomfort or skin concerns, Transfer: the resident is limited to extensive and may need assistance x 1 or x 2 staff members for transfers in and out of chair or bed, encourage the resident to use bell to call for assistance. R13's MDS, dated [DATE], documented that R13 was comatose and was dependent on staff members for all ADLs. R13 had a G-Tube and indwelling Urinary catheter. R13's PO, dated 1/18/24, documented, Levemir Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject 25 unit subcutaneously two times a day for IDDM. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 AM (1/22/24), and was documented as given by V2 at 1:39 PM. R13's PO, dated 1/18/24, documented Levemir Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject 25 unit subcutaneously two times a day for IDDM. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 8:00 PM (1/22/24), and was documented as given by V6 at 10:59 PM. R13's PO, dated 1/9/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject 8 units subcutaneously before meals and at bedtime for IDDM, Hold for BS (blood sugar) less than 150. Give in addition to sliding scale. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 11:30 AM (1/22/24), and was documented as given by V2 at 1:41 PM. R13's PO, dated 1/9/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject 8 units subcutaneously before meals and at bedtime for IDDM, Hold for BS (blood sugar) less than 150. Give in addition to sliding scale. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 4:30 PM (1/22/24), and was documented as given by V2 at 8:33 AM on 1/23/24. R13's PO, dated 1/9/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject 8 units subcutaneously before meals and at bedtime for IDDM, Hold for BS (blood sugar) less than 150. Give in addition to sliding scale. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM (1/22/24), and was documented as given by V6 at 10:59 PM. R13's Physician Order, dated 1/9/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject as per sliding scale: if glucose 151 - 200 = 2 units, Notify MD for glucose less than 60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units greater than 400 give 12 units and notify MD for further instructions, subcutaneously before meals and at bedtime for IDDM related to Type 2 DM with other specified complication. AND Inject 8 unit subcutaneously before meals and at bedtime for IDDM. HOLD for BS less than 150. Give in addition to sliding scale. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 11:30 AM (1/22/24), and was documented as given by V2 at 1:41 PM. R13's Physician Order, dated 1/9/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject as per sliding scale: if glucose 151 - 200 = 2 units, Notify MD for glucose less than 60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units greater than 400 give 12 units and notify MD for further instructions, subcutaneously before meals and at bedtime for IDDM related to Type 2 DM with other specified complication. AND Inject 8 unit subcutaneously before meals and at bedtime for IDDM. HOLD for BS less than 150. Give in addition to sliding scale. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 4:30 PM (1/22/24), and was documented as given by V2 at 8:32 AM on 1/23/24. R13's Physician Order, dated 1/9/24, documented, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject as per sliding scale: if glucose 151 - 200 = 2 units, Notify MD for glucose less than 60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units greater than 400 give 12 units and notify MD for further instructions, subcutaneously before meals and at bedtime for IDDM related to Type 2 DM with other specified complication. AND Inject 8 unit subcutaneously before meals and at bedtime for IDDM. HOLD for BS less than 150. Give in addition to sliding scale. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 9:00 PM (1/22/24), and was documented as given by V6 at 10:59 PM. R13's PO, dated 12/29/23, documented, Enteral Feed. Every shift Continuous TF (tube feeding). Glucerna 1.2 at 68 ML/HR (hour) with Q (every) 4 HR 120 ML water flush. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 2:00 PM (1/22/24), and was documented as given by V2 at 8:33 AM on 1/23/24. R13's PO, dated 12/19/23, documented, Carvedilol Tablet 3.125 MG. Give 1 tablet via G-Tube two times a day for Hypertension. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V2 at 8:33 AM on 1/23/24. R13's Physician Order, dated 12/21/23, documented, levetiracetam Oral Solution 100 MG/ML - Give 15 ml via G-Tube two times a day for seizures give 1500mg 2x daily. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V2 at 8:33 AM on 1/23/24. R13's Physician Order, dated 1/21/24, documented, Metformin HCl 500 MG. Give 1 tablet enterally two times a day related to Type 2 DM. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V2 at 8:33 AM on 1/23/24. R13's Physician Order, dated 12/15/23, documented, Apixaban Oral Tablet 5 MG. Give 1 tablet via G-Tube two times a day for anticoagulation. R13's MAR, dated 1/22/24, documented that this medication was scheduled to be given at 5:00 PM (1/22/24), and was documented as given by V2 at 8:33 AM on 1/23/24. R13's Electronic Medical Record, Weights and Vitals Summary, dated 1/22/24 to 1/23/24, documented that one blood sugar was completed on R12 on 1/22/24 at 6:49 AM with result of 141. Another blood sugar completed on 1/22/24 at 1:41 PM by V2, with result of 141. A third blood sugar completed on 1/22/24 at 10:59 PM by V6, RN, with a result of 327. On 1/29/24 at 9:42 AM, V3, Registered Nurse (RN), stated I had a Nurse (V6, RN) call me after she took over a shift from (V2, Director of Nursing /DON). That nurse told me that (V2) worked a 16-hour shift that day and that he did not give medications to the residents, check their blood sugars, or give Insulin as needed. She stated that the residents were complaining that they did not get their glucose checks or their insulin, and (V6) was chasing blood sugars all night because of it. On 1/29/24 at 3:30 PM, V2, DON, stated, I covered the days and evening shifts during the ice storm last Monday (1/22/24). I was here from 8:30 AM until 11:00 PM that day. I had two admissions on the 100-hall that I was covering. On the morning of 1/22/24, I got report from the night nurse using both verbal report and the report sheet. The wound nurse (V15, Licensed Practical Nurse/LPN) was also here that day doing her rounds. At the end of the day, I gave a verbal and paper report to (V6, RN). I gave all medications on the 100-200-halls during the day shift, then around 6:00 PM, I got two admissions. I ended up only passing the 4:00 PM medications, and another nurse passed the later meds because I was doing the admission. I had (V12, LPN) from the 300-hall assist with medications, and (V15) also came over and assisted with the evening medications. On 1/29/24 at 4:50 PM, V12, LPN, stated, I was working on the 300-hall and noticed that no medications were being passed on the 100-hall or 200-hall. (V2) was talking all day to (V1) and told me he had to do paperwork. Around 4:00 PM, I got the keys from (V2) and started passing medications on the 200-hall. I know (V15) was doing wounds on the floors and I did not see her passing medications. They called in (V14, LPN) early to help out and she got here between 8:00 to 9:00 PM. Then the other night shift nurse (V6, RN) came in at her normal time around 10:00 PM. (V6) said when she got report from (V2) that he didn't mention anything about resident medications not given. When (V6) opened the residents MARs, they were all red, indicating that they were not given. There were two admissions on the 100-hall that evening and (V6) stated that (V2) didn't do any of the admission stuff that needed to be done. On 1/30/24 at 9:25 AM, V15, LPN/Wound Nurse, stated, On 1/22/24, I didn't make it in due to the ice storm until the afternoon around 2:00 to 2:30 PM. I started with my rounds doing wound care and later in the evening, (V2) asked me to come and help him because he was drowning with admissions. I ended up doing one admission around 8:00 PM. That resident arrived around 6:00 PM but I didn't get to her until later because I finished my wound care first. I only did the admission and did not do any medication pass. (V2) never mentioned to me about medications. I heard the next day that the 100-hall residents didn't get their medications that day. On 1/30/24 at 10:35 AM, V2, DON, stated, I did not do any of the medications, accu-checks, or insulins after about 4 PM on 1/22/24. On 1/30/24 at 10:38 AM, V16, PA, stated, No one notified me of residents not getting accu-checks, and/or insulin, or high blood sugars on Monday 1/22/24. The Physician was not notified either. We definitely would have expected them to call the Physician, or myself, for high blood sugars and/or situations where the residents are not getting their accu-checks or medications. On 1/30/24 at 11:48 AM, V17, RN, stated, I was the nurse who took over for (V6) on Tuesday morning (1/23/24), and (V6) was visibly upset, and shaking, trying to explain what had happened when she got to work last night (1/22/24). (V6) told me that when she took over for (V2), that there was nothing done on the residents on the 100-hall, including accu-checks and resident medications. I'm not sure what exactly (V2) did all day and evening yesterday. On 1/30/24 at 2:13 PM, V6, RN, stated, When I first got to work on Monday (1/22/24), I initially didn't go to a floor because I was just written on top of assignment sheet. I went to the 100-200 hall desk because that is where they typically need help. When I went there, (V14, LPN) was already there and talking to (V2) at the nurse's desk. That is when I found out that (V2) was the nurse covering the 100-hall. (V2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote resident's dignity by answering call lights in a timely manner to address resident's needs for 1 of 9 residents (R13) reviewed for call lights in the sample of 14. Findings include: On 5/26/23 at 1:30 PM R13 stated that sometimes she must wait for an hour before they answer the call light. It makes me pee myself and I don't like that. It happens about every day that I must wait over an hour. I take a diuretic and have to pee a lot. They tell me not use the call light so much but when my bladder is full, I got to go. R13's Minimum Data Set (MDS) dated [DATE] documents R13 is alert and oriented, and she requires limited assistance of one person for bed mobility, transfer, walk in corridor, locomotion on unit, dressing, toilet use, and personal hygiene. It documents R13 is occasionally incontinent of urine and always incontinent of bowel. R13's Care Plan dated 05/16/23 documents The resident has an ADL self-care performance deficit Needs and participation may vary. R13's Care Plans, dated 05/24/23, documents Resident requires use of diuretics and has urinary incontinence. R13's Progress Note dated 05/23/23 at 2:38 PM documents Resident utilizing call light multiple times today and states that she needs to urinate frequently. Resident's Oxycodone should be delivered from pharmacy this afternoon and then if resident is still anxious after administration, nursing staff will re-assess for other issues. Will continue to monitor. On 5/31/23 at 1:36 PM V3, Assistant Director of Nursing (ADON) stated he would expect call lights to be answered right away in a timely manner. V3 stated he always tells the residents to let the staff know if they need something so the staff can do something about it, so it is important to provide good customer service to the residents and answering call lights and providing timely care is part of that. V3 stated answering call lights timely is important for safety and for customer experience. The facility's policy, Standards and Guideline: Call Lights revised 9/15/22 documents, Standard: It will be the standard of this facility to respond to the resident's requests and needs via notification with the call light system. Guidelines: 7. Answer the resident's call light as soon as possible. 8. Be courteous when answering the resident's call. Assist the resident if permitted and able. If there is any uncertainty or if the staff member answering the call light is unable to fulfill the resident's request, seek assistance from the supervisor or another staff member who is qualified and/or able to properly and safely fulfill the resident's request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to prevent a resident from leaving the facility without staff knowledge or supervision for 1 of 3 residents (R3) in the sample of 10. Findings include: R3's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses of Other Cirrhosis of the Liver, Urinary Tract Infection, Polyneuropathy, Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Anxiety Disorder, Gastro-Esophageal Reflux Disease without Esophagitis, Alcohol Abuse and Tobacco Abuse. R3's Care Plan, with date initiated as 04/11/23, documents, Baseline Care Plan: Resident has a history of or may be at risk for exit seeking behaviors, (Elopement Risk). R3's admission Minimum Data Set, (MDS), dated [DATE] documents, a BIMS, (Brief Interview for Mental Status), score of 12, indicating he had moderately impaired cognitive function at that time, and he required limited assist from staff for his Activities of Daily Living, (ADLs), at that time. This was on admission. On 04/25/23 Progress Notes by, V11 PA documents, Discharge Condition: significantly improved. When he (R3) initially arrived at facility he was confused, frail and chronically ill-appearing. However, with time his mentation and overall clinical status improved. He was re-hospitalized for hepatic encephalopathy from 4/8/23 through 4/11/23. His BIMS now is 15 in March and remains that today 04/25/23 per V11, PA. Patient frequently requesting to go home. He is independent with his ADLs and had normal cognition, he was kept in the facility primarily, because of a social dynamic with his wife. R3's Discharge, MDS dated [DATE] documents, R3 was alert and oriented and required limited assist with transfers, walking in corridors, and locomotion off the unit. R3's Progress Note dated 04/20/23 at 6:30 PM documents, Patient insistent he wants to go home, stated, he is calling the police. Staff on phone, notifying wife of patient continued request to leave facility. Wife states, she is unable to take patient home. On 05/03/23 at 10:25 AM V2, DON, provided an untitled document, dated 04/25/23, written by V2, which documented, contacted by V13, Licensed Practical Nurse, LPN, who stated, patient R3, was walking on [NAME] Road. V14, CNA, was driving down [NAME] Road and saw R3 at the intersection by (fast food restaurant), she V14, pulled over and called R3, name, he stated, to V14 his name was R14, (a fake name). V2 informed the staff, they should stay with R3, and V2, DON, called V10, R3's spouse. V10, stated, she had spoken with R3 about 1:30AM, and she blocked his phone calls. Stated, that R3 was on her about going home and she was not going to listen to him, so she blocked his incoming calls. V2, DON, then called V13, LPN, she stated, they did get R3 into her car. V2, then called 911 to meet staff/patient at facility. She then called V1, Administrator, and notified her about resident elopement. Upon V2's, DON, arrival to facility, 2 police officers were at facility talking to R3. R3 continued to state, he wanted to go home, and he owned his home and there was no reason for the facility to keep him. R3 was dressed in t-shirt, hoodie (hooded sweatshirt), socks, underwear, jeans, tennis shoes, and hat. The temperature outside was 48 degrees. Stated his phone screen was broken, he had been using it to navigate home. The wife, V10, arrives about 30 minutes later, R3 and wife went out to patio to smoke. 1 on 1 in place with patient. Officers explained to R3 that he was free to leave the facility. They requested he stay the night and plan a safe dc, (discharge), in am. R3 went to his room and packed all belongings. The Police explained to V10, wife, that we could not keep him here against his will. The facility needed to have a meeting with Hospice and her in the AM and make a plan for DC. V10 stated, she cannot have him at home. V10 left the facility. Staff interviews revealed that R3 had gone out on patio earlier in the shift and smoked and returned to room. Surveillance revealed that R3 had been walking in the hallway approximately 11 PM wearing shorts, sandals, shirt/hoodie. Then at approximately 1:50AM he had changed into tennis shoes, long pants and a hat. This document had V2's name at the bottom. On 05/03/23 the distance from the facility to the intersection by the fast-food restaurant was measured with odometer to be 0.7 miles. On 05/03/23 at 8:15AM V2, DON stated, she did not consider R3's leaving as an elopement, because he had planned it. V2 stated, R3 was an alcoholic and was hospitalized , then came to the facility to recuperate. She stated, he was alert and oriented and was very sick at first, but then he started, doing better and wanted to go home. V2 stated, R3's wife, did not want him to come home, but there was nothing legally stopping him from going home. On 5/9/23 V13, LPN stated she was R3's nurse on the night he eloped from the facility. She stated R3 was a smoker and would come and go off the patio to smoke and that's how he got out without staff realizing he had left was through the gait on the patio. V13 stated, the patio door alarm was not on. V13 stated, she thinks it is supposed to be alarmed, but they leave the alarm off for those residents who are independent smokers, who come and go as they please. V13 stated, R3 had his cigarettes and lighter on him. V13, LPN, stated, V14, CNA had left the faciity on break and saw R3 walking down by the intersection. V14 called facility to inform V13 LPN, that R3 was refusing to stop and come back to the facility. V13 stated, she then drove down and R3 had continued to walk a little further with V14 trailing him and V13 convinced him to get into her car and come back to the facility. R3's IDT Discharge Home Summary dated 04/25/23 documents: The resident/resident representative initiated the discharge verbally. It documented, he is discharging home and personal belongings and medications were sent with him. Discharge Note documented: Resident discharged from facility this shift. All discharge paperwork discussed with resident who verbalized understanding. Resident also signed, for remaining narcotic medication and took out of facility. All medications sent with resident. Resident, (R3) packed personal belongings and removed all from facility. Hospice nurses in building and given a copy of resident's orders and will follow resident in home from this point forward. Resident's wife arrived at facility and staff assisted with placing resident belongings in vehicle. Resident entered private vehicle w/o, (without), incident and left facility showing no s/s, (signs/symptoms), of distress upon departure. This discharge report was signed by R3. The facility's policy, Standards and Guidelines: Resident Elopement revised 3/27/21, documents, For the purpose of this Standard and Guidelines, the definition of resident elopement will be as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (for example, an order for discharge or leave of absence) and/or any necessary supervision to do so. Resident/patient(s) who are not cognitively impaired and are legally able to make their own choices and have been informed of facility guidelines regarding leaving facility grounds, who choose not to follow these guidelines will not be considered in this definition as an elopement. 1. Nursing Administration/ Risk Manager/designee will determine if the resident meets the definition of elopement as defined above. 8. The facility Risk Manager will determine if the event qualifies (according to state guidelines) as an adverse incident then appropriate reporting will be carried out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to don required Personal Protective Equipment (PPE) for residents on Transmission Based Precaution (TBP) and failed to perform hand hygiene during resident care for 1 of 4 residents (R5) reviewed for infection control in the sample of 16. Findings include: 1. R5's Face sheet, undated, documents that R5 was admitted to the facility on [DATE]. R5's Electronic Medical Record, documents that R5's diagnoses include Sepsis, enterocolitis due to C-diff (Clostridium difficile). R5's Care Plan, dated 2/28/23, documents 3/27/23: (R5) requires Isolation Precautions because of an infectious disease. It continues (R5) has infectious bowel process; C-Diff. Interventions: Isolation as ordered by Physician, monitor for symptoms of weakness, fluid volume deficit, fever, nausea and vomiting and blood in stool, provide incontinence care after incontinence episodes PRN (as needed), report changes in bowel status to resident's physician. R5's Minimum Data Set (MDS), dated [DATE], documents that R5 has a moderate cognitive impairment, BIMS (Basic Interview for Mental Status) of 8. The MDS documents R5 requires staff assistance for Activities of Daily Living (ADL) The MDS documents R5 is always incontinent of urine and frequently incontinent of bowels. On 3/29/23 at 10:00 AM, R5 was lying in her bed, on isolation for C-Diff. There was a sign posted on the entry door STOP - See Nurse Before Entering. A PPE cart was sitting in front of the entrance to the room. V6, Certified Nursing Assistant, CNA, was seen inside the room with only a surgical mask on which was pulled down below her nose, V6 had no gloves or other PPE on. V6 was seen caring for R5 while in her bed, throwing items in the trash, and then exited the room without any hand hygiene done. V6 was seen walking down the hall and into the nurse's station, then went into the clean utility room, in the same hallway, and exited that room with a jacket on and then walked down the hall to another nurse's desk on the 300-400-halls, then disappeared for a break. On 3/29/23 at 10:05 AM, V6, CNA, stated I think they (R4 and R5) should be off isolation. I will have to ask the nurse. Yes, the sign and PPE cart are to tell us that the residents are on isolation, and I should have put PPE on before entering. On 3/29/23 at 11:45 AM, V4, Registered Nurse/RN, stated (V6) is our float CNA for the 100 and 200-halls. She helps the residents on both of those halls. On 3/29/23 at 2:08 PM, V2, Director of Nursing (DON), stated I would expect the staff to wear appropriate PPE upon entering a resident's room who is on isolation. I would also expect all staff to wear gloves and perform hand hygiene when caring for a resident. On 3/29/23 at 3:25 PM, R4, R5's roommate, stated I don't think I have seen anyone wear a gown. I have seen the staff come in with the mask like you have on (surgical mask). The Facility's PPE Protocol, dated 3/30/21, documents It will be the standard of this facility that staff appropriately utilize personal protective equipment (PPE) for the prevention of transmission of potentially infectious organisms. 3. Staff, visitors, and family will wear a clean non-sterile gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. Select a gown that is appropriate for the activity and amount of fluid that is likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other residents or environments. Centers for Disease Control and Prevention's, CDC's, website FAQs for Clinicians about C. diff, documents Use contact precautions for patients with now or suspected CDI (C diff infection): Place these patients in private rooms. If private rooms are note available, they can be placed in rooms (cohorted) with other CDI patients. Wear gloves and a gown when entering CDI patient rooms and during their care. As no single method of hand hygiene will eliminate all C. diff spores, using gloves to prevent hand contamination remains the cornerstone for preventing C. diff transmission via the hand of healthcare personnel. Always perform hand hygiene after removing gloves. The Facility's Hand Hygiene Protocol, dated 10/16/22, documents This facility considers hand hygiene a primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on interview and record review, the facility failed to ensure COVID tests results were documented in the residents' medical for 5 of 5 residents (R1, R3, R14, R15, and R16) reviewed for COVID 19 testing in the sample of 16. Findings Include: The Facility provided a Room Rosters in which they document their COVID-19 testing results by drawing a line through which hallways they tested. On the Room Roster, if they had a positive test a positive sign (+) was placed next to the resident's name. The test date was listed on the bottom of the room roster which was a different date from the Room Roster with V9's, Licensed Practical Nurse (LPN) signature. On 3/7/23, 3/8/23, 3/9/23, 3/10/23, 3/14/23, 3/16/23 the Room Roster documents R1 and R3 were tested for COVID 19. R1 and R3's medical records do not document any negative tests results including dates and negative results for any negative test results for the month of March 2023. On 3/7/23 and 3/8/23 the Resident Room Roster documents R15 was tested for COVID 19, and his negative test results were not documented in R15's Clinical Record for these dates. On 3/7/23, 3/8/23, 3/10/23, R14 and R16 were tested for COVID 19, and their negative test results were not documented in their Clinical Record. On 3/31/23 at 10:00 AM, V2, Director of Nursing (DON) stated, the date written at the bottom of the room roster is the date the actual COVID testing was completed. The date on the room roster is the previous date when the testing was performed. V2 stated We do not have a log that is our testing log. We are just using the Room Roster. At one time, we documented all tests for all residents both negative and positive for all COVID tests but now we are only testing by exception. We use the Room Roster and if a resident is positive, we document in the chart but if a resident is negative, we are not documenting in their medical records. On 3/31/23 at 11:00 AM, V9, Licensed Practical Nurse, stated, I am in charge of the COVID testing. I am only documenting certain halls not the entire building. When we have a positive case I document it in the chart. We used to chart the positive and the negative residents, but now we just chart the positive in the chart. I haven't seen the COVID testing policy. I just do what they tell me to do. I am not documenting any resident's chart negative results. The facility policy Standards and Guidelines: SG COVID-19 Resident and Staff Testing dated 10/28/22 documents It is the standard of this facility to follow CMS (Center for Medicaid and Medicare Services) guidelines related to Federal and State regulations for COVID-19 testing of staff and residents. The CMS August 26, 2020 with a revision date of 9/23/2022 documents, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements Center for Clinical Standards and Quality/Survey & Certification Group; (3) For each instance of testing: (i) Document that testing was completed and the results of each staff test; and (ii) Document in the resident records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test.

Based on record review and interview the facility failed to maintain accountability of narcotic medication for 1 resident (R116) of 1 resident reviewed for misappropriation of property in the sample of 57. Findings include: 1. The facility reported dated 12/21/2022 at 4:00PM documents unable to locate 30 hydrocodone 7.5-325mg (card) of medication. The report document immediate action taken; facility obtained replacement card of medication to ensure patient did not miss any needed medication, nurses who have worked since medication delivery were interviewed. all medication carts have bed checked for misplacement of medication, Illinois State Police (ISP) Medicaid fraud control bureau notified. On 1/4/2023 at 3:10PM V2, Director of nursing stated it was not discovered there was medication missing until the nurse called to get a new card and pharmacy informed the facility, they had already sent out a card of 30 pills. V2 stated that she had interviewed all nurses with the exception of a nurse who worked for agency, and she did not return her call. V2 also stated that she had notified the agency supervisor and they had reached out and the nurse had not returned their call. V2 then stated that she marked the staff as Do not return to facility. 1/10/2023 3:05PM R116 stated that pain medication is available 1/10/2023 3:07PM V1 administrator stated she would expect the facility to protect medication from misappropriation. On 1/10/2023 at 3:30PM V2 DON stated she was not able to narrow down the meds to one shift as the nursing staff had not been documenting when receiving a new card so unable to find the missing medication. The facility policy Control Drug Count, undated document control drugs will be counted during each shift change by 2 licensed nurses. The nursing supervisor on duty/on call and the director of nursing service will be immediately notified of any discrepancies in the control drug count. Guideline's document 1. the nurse coming on shift must verify count of all controlled substances with nurse going off shift or any time the med cart keys are exchanged. 2. One nurse will read the Controlled drug record for each controlled medication statin the resident's name, the name and strength of drug, the amount remaining. 3. The second nurse will listen and visually verify: the resident's name, the name and strength of the drug, the amount remain in. 4. nurses must count total #of cards/containers and total # of count sheets both for individual residents and applicable contingency supplies with controlled drugs. 5. Cards and sheets added or removed are to be noted in the middle of the count sheet with resident name, med strength, # of cards/containers added/removed, and initials of 2nd nurse that verifies empty card/containers must be forwarded to DNS with completed sheets. When inventory count sheet is complete the ending balance cards/containers from previous sheet and ending balance of count sheet from previous sheet verified by 2 nurses. 6. During the count both nurses will visually verify the card, bottles and bags are intact and do not appear to have been damaged or altered in any way. 7. Both nurses will date and sign the narcotic control count sheet signifying the count is correct. 8 Any discrepancy in the control drug count will be immediately reported to the nursing supervisor on duty and the Director of Nursing or designee. The off-going nurse will not leave facility until shift supervisor and DON approve. The facility policy standards and guidelines ANE and Investigations dated revised 3/27/2021 documents it is the standard of the facility to honor resident's rights and to address with employee the components regarding misappropriation of resident property in accordance with federal law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers or bathing assist for 2 of 2 (R233 and R236) residents reviewed for Activities of Daily Living in a sample of 57. Findings include: 1. On 01/03/2023 at 08:30 AM, R233 stated that she was admitted last Friday and has not received a shower or bath yet. She continued to state that she doesn't know when her shower days are. R233's hair appeared greasy ad unkept. On 01/09/2023 at 01:50 PM R233 stated that she still has not had a bath or shower since she has been admitted , she would like a shower. She continued to state that there was 1 time that they offered, and she refused it because she wasn't feeling well but they haven't offered since or even on a different day, R233's hair appears greasy. R233's Baseline Care Plan, dated 12/5/2022, documented, BASELINE CARE PLAN: Resident needs assist with ADLs. Resident will have ADL needs met. Assist/provide ADL care and support as needed. The Facilities Shower list, dated 01/09/2023, documents that R233 showers are scheduled for Monday and Thursday on the day shift. On 01/09/2023 at 2:35 PM, V10, Certified Nurse Assistant (CNA) stated that residents get showers 2 times a week and it is on the shower schedule. On 01/10/2023 at 09:00 AM, V2 Director of Nurses (DON) stated that the CNA's document on the task section of the electronic medical record system and shower sheets. On 01/10/2023 at 1:15 PM, V17, CNA stated that if a resident refuses a shower, she tries and clean them up the best she can or she offers a bed bath. R233's Outside Hospice Contact Record, dated 01/05/2023, documented, (Home Health Aide) gave (R233) a bath. (Home Health Aide) then changed linen. (Home Health Aide) had no concerns. R233's face sheet, dated 01/10/2023, documented an admission date of 12/29/2022. The Facility's Shower Schedule, dated 01/09/2023, documented that R233 receives showers on Mondays and Thursdays on the day shift. 2. On 01/03/2023 at 9:15 AM, R236 stated that she was admitted [DATE] and has not had a shower yet. R236's hair appears unkept and greasy. R236's Baseline care plan, dated 12/31/2022, documents, BASELINE CARE PLAN: Resident needs assist with ADLs, Resident will have ADL needs met. Assist/provide ADL care and support as needed. The facility Shower list, dated 01/09/2023, document that R236 receives a shower on Tuesday and Friday on the evening shift. R236's Task flowsheet, dated 01/2023, documented that R236 has only received one shower on 01/06/2023 since her admission. R236's Face sheet dated 01/10/2023, documents an admission date of 12/31/2022. On 01/10/2023 at 12:21 PM, V2 DON stated she would expect the CNAs to re-approach the resident later for a shower or offer a bed bath. The facility policy, Showers/Bathing, dated 03/27/2021, documented, Standard: It will be the standard of this facility to assure that showers/bathing are offered to residents at least 2 times weekly or per resident/resident representative preference unless specifically ordered otherwise by the physician or care planned otherwise.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R18's diagnoses include hypertensive urgency, HTN, malnutrition, difficulty walking, dysphagia and muscle weakness. R18's Minimum Data Set, dated [DATE] documents brief interview for mental status at a 00. MDS documents R18 as needing extensive assist with bed mobility, transfers, dressings, eating and dependent for toilet use and personal hygiene. R18's care plan documents fall interventions of place resident in visible area while up in wheelchair, staff to lay resident down in bed after meals, be sure the resident's call light is within reach, remind resident to ask for assist when getting up. On 1/3/2023 at 10:00 am observed R18 in chair in her room without call light. On 1/5/23 at 10:00am R18 was observed up in chair in room without call light. R18 had dropped her cards and was leaning forward to try and pick up the cards. On 1/9/23 at 10:00am R18 was observed up in chair in room without call light. On 1/10/2023 at 12:15pm V2 stated she expected her staff to provide residents with call lights within reach and to follow the residents care plan. Facility policy titled falls dated 3/27/2021 documents; after a fall, the interdisciplinary team should review the circumstances surrounding the fall and develop appropriate interventions and plan of care. if the cause of the fall is unclear the IDT will attempt to establish reasonable interventions related to the current condition of the resident to attempt to prevent recurrence. Based on observations interview and record review the facility failed to implement interventions and transfer appropriately for 2 of 6 (R18, R283) residents reviewed for accidents and incidents in a sample of 57. This failure caused R283 to experience pain during transfer. 1. R283's Care Plan, dated 12/29/22, documents that Resident needs help transferring in and out of the bed or chair: It continues Transfer: the resident is not able to help with a transfer at all and will need the assistance of 2 staff and a (full body mechanical) lift to move from bed to chair and back. R283's MDS, dated [DATE], documents that R283 requires extensive assist of 2 people for transfers. On 1/3/2022 at 10:40 AM observed V17 transfer R283 into his wheelchair using the sit to stand mechanical lift. Once in chair V17 attempted to reposition R283. R283's right foot and lower leg was turned outward. R283's left leg was stretched out in front of him. V17 lifted R283 up and R283 yelled out how V17 instructed R283 to stand. V17 then pushed R283 back in wheelchair. V17 removed the sling and lift. R283 started rubbing his leg. On 1/3/2023 at R283 stated that his legs hurt a lot when he stands on them. R283 stated that he has not been able to stand on his legs for some time. R283 stated that its painful when he stands on his legs. R283 stated that he has not been getting out of bed and is not sure how he is supposed to transfer out of the bed. On 1/9/2023 at 2:50 PM when asked how do the staff know how to transfer a resident? V2 stated that the nurse knows and tell the aides in report and that the staff have report sheets, and this information is on them. V2 stated that this information is also in electronic record, and she would expect the staff prior to transfer to look in the computer and check. On 1/9/2023 at 3:00 PM requested documentation of resident transfers from V2. As of 1/11/2023 at 2:30 PM the facility had not provided the documentation of resident transfers. On 1/9/2023 at 3:20 PM V25, CNA, stated that she was from agency and did not know how anyone transferred. V25 stated that she was told a few things and given a paper, but it didn't have how the resident transferred. V25 stated that she did not know how R283 transferred and where to get this information. On 1/10/2023 at 12:15PM V2, Director of Nursing, stated that R283 has chronic knee pain bone on bone.

Based on observation, interview and record review, the facility failed to provide appropriate water flushes and give medication as the physician had ordered for 1 of 1 (R107) resident reviewed for enteral feedings in a sample of 57. Findings include: 01/05/23 09:28 AM V16, License Practical Nurse (LPN) prepared R107's Polyethylene powder in 60 ml of water. performed hand hygiene donned gloves. V16 then auscultated gastrostomy tube (g-tube) with air bolus, listened to bowel sounds but did not check for residual. V16 then administered Polyethylene powder mixture as bolus then used plunger to administer rest of the medication. She then flushed the g-tube with 180 ml of water via bolus. R107's Physician Order, dated 10/27/2022, documented, Flush G-tube with 150ml water every 4 hours. R107's Physician Order, dated 11/04/2022, documented, Polyethylene Glycol Powder, Give 17 gram by mouth one time a day for Constipation. R107's Care plan, dated 11/18/2022, documents, Administer tube feeding formula and flushes as ordered (see current physician orders & MAR). Check residual per physician orders. Check tube placement as needed. On 01/10/2023 at 12:00 PM, V2 Director Of Nurses, stated that she would expect the nurses to flush the gastrostomy tube prior to administering medications and that she would expect the nurses to follow physician orders. The facility policy, Medication Administration Via an Enteral Feeding tube, dated 03/27/2021, documented, Purpose: to ensure enteral resident receive medication ordered by the physician with appropriate administration to promote optimal absorption of drug. It continues, 13. For any additional information that might need to be recorded, document in resident's clinical chart, (ie. meds held d/t residual greater than 100 cc, MD notified). It continues, 2. Do not administer drugs without flushing the tube before and after delivery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R284's Care Plan, dated 12/21/22, documents that R284 has urinary incontinence. It continues Resident has, or is at risk for, URINE INCONTINENCE. Check every 2-3 hours and/or as required for incontinence. Provide incontinence care as needed. If the resident has some control, check with resident every 2-3 hours for need to toilet. Encourage to ask for assistance in advance of need and not wait until need to urinate is urgent. R284's MDS, dated [DATE] documents that R284 is cognitively intact, occasionally incontinent of urine, always incontinent of bowel and requires extensive physical assist of 1 for toileting. On 1/9/2023 at 11:23 AM V17 assisted R284 with toileting. V17 assisted R284 on to the toilet and removed R284's brief. R284 was incontinent of bowel. R284 voided and continued to have bowel movement. Upon completion V17 using toilet paper wiped R284 rectal area and applied R284's brief. On 1/10/2023 at 11:26 AM V17 stated that if a resident is incontinent and goes to the bathroom that the staff are to perform incontinent care. On 1/10/2023 at 12:15 PM V2 stated that if a resident is incontinent the staff are to perform incontinent care even if the use the toilet as well. 4. R285's Care Plan, dated 10/24/22, documents The resident has an ADL self-care performance deficit r/t ADL needs and participation vary, Fatigue, Impaired balance, Limited Mobility, Weakness. Resident is currently receiving skilled therapy services with goal of returning home upon completion of rehab. It continues Toilet Use: Extensive assist/1-2 staff It also documents The resident has bowel incontinence It continues Provide peri care after each incontinent episode. It also the resident has urinary incontinence It continues Provide incontinent/peri-care PRN R285's MDS, dated [DATE], documents R285 is cognitively intact, always incontinent of urine and bowel, and requires extensive physical assist of 2 people for toileting. On 1/9/2023, V17, CNA and V18, CNA, assisted R285 with incontinent care. R285 was incontinent of urine. V18 opened R285 brief. Using premoistened wipes V18 wiped R285's right groin, left groin and inner labia. V18 and V19 then assisted R285 onto her right side. V18 using premoistened wipes cleansed R285's left buttock and partial right buttock. V18 then removed the soiled brief. V18 and V19 then applied new brief. V18 and V17 did not cleanse R285 entire right buttocks, inner thighs, and pubic area. On 1/10/2022 11:26 AM V17 stated that when performing incontinent care, you gather your supplies. V17 stated that using the wipes you clean the groin, pubic area, inner thighs. V17 stated that you then turn the resident over and cleanse the buttock and turn them over on the other side and cleanse the other buttock. V17 stated that she was aware that V18 didn't turn R285 over and cleanse the other buttock. On 1/10/2022 at 12:15 PM V2, Director of Nursing, stated that she expects the staff to cleanse all areas of incontinence including the labia, groin, pubic area, inner thighs, both buttocks. The facility's Perineal/Incontinence Care Standards and Guidelines Standard: It will be the standard of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition and provide appropriate care and services required to maintain functional levels while providing perineal/incontinence care. 4. Provide perineal/incontinence care in accordance with physician orders or resident's plan of care, while ensuring to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 6. For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Based on observation, interview and record review the facility failed to provide complete incontinent care for 4 residents (R36, R56, R284, and R285) of 7 residents reviewed for incontinent care in the sample of 57. Findings include: 1. On 1/05/23 at 10:10AM during incontinent care V9, Certified Nursing Assistant (CNA) and V10 transferred R36 from chair with mechanical lift to the bed. R36 had strong odor of urine. V9, CNA with gloves on rolled R36 to left side and removed R36's adult diaper which was saturated with urine. V9, CNA handed V10 CNA cleansing wipes. V10 with cleansing wipe cleansed right groin and then left groin. V10 CNA swiped down front of R36's peri area and did not separate the labia. R36 started urinating V10 CNA doffed gloves sanitized hands and donned gloves. V10 cleansed left and right groin. V10 then swiped down R36's peri area with cleansing wipe. V10 did not separate the labia. V10 doffed gloves and sanitized hands. R36 turned to right side, R36 incontinent of stool. V10, cleaning R36 with cleansing wipes and kept wiping from front to back as stool visible on wipe, at no time did V10, CNA cleanse peri area. V10, CNA Did not cleanse inner thighs or buttocks. R36's care plan dated 1/11/2022, documents R36 has bowel and urinary incontinence Cognitive status, Disease process: Stroke. R36's care plan documents the following interventions: provide incontinent care as needed. 2. On 1/4/2023 at 1:15PM R56 transferred from wheelchair with sit to stand mechanical lift. R56 pants visibly wet and cushion in wheelchair wet. R56 transferred to the toilet by lift and on pad in wheelchair. Placed on toilet by V5 and V6 CNA. V5 sanitizes hand donned gloves removes R56's crocs and then her pants. R56's adult diaper saturated with urine removed by V5, CNA and placed in plastic bag, with same gloves Puts R56's crocs on, places clean pants on and pulls up to her thigh, then places adult diaper between legs and secures sides loosely at thigh level. V5, CNA assists R56 to standing position in sit to stand mechanical lift. With R56 in standing position V6, CNA using wipes sprayed with peri wash and swipe from front to back visible stool on wipe, then repeated the process. V5 CNA applied barrier cream then pulled adult diaper and pants up and wheeled out of toilet to wheelchair and transferred back to wheelchair. CNAs did not provide cleanse perineal area, inner thighs or buttocks or dry R56. R56's Care Plan dated 01/29/2022 documents that R56 has urinary incontinence. R56's care plan documents the following interventions: check every 2-3 hours and/or as required for incontinence. Provide incontinent care as needed.

Based on interview, observation and record review, the facility failed to provide flavorful and palatable food. This failure has the ability to affect all 139 residents residing at the facility. Findings include: 1. On 01/03/2023 at 9:15 am, R236 stated that she can't have eggs because they make her sick nor does she eat sausage, but she has been given it regardless and the food does not taste good. 2. On 01/03/2023 at 9:20 AM, R49 stated that the food was not good. 3. On 01/03/2023 at 09:26 AM, R1 stated food was always cold, does not taste good and they always run out. On 01/04/2023 at 12:00 PM, A test tray was given, the meatloaf had a mushy texture to it and was greasy. The mixed vegetables were mushy and the color of the green beans were faded to clear. The dinner roll was on top of the mixed vegetables and was soggy. The facility's menu, Week at a Glance Week 2 documented for Wednesday, Tomato Glazed Meatloaf, Mushroom Gravy, Whipped Potatoes, Capri Mixed Veg., Dinner roll and Peach Cobbler. What was being served for lunch during the observation period. Resident Council Meeting Minutes, dated 01/21/2022, documented, Food is always cold. Too much pork and chicken breast are dry. We need more sauces and gravies. Residents are tired of the same stuff. Resident Council Meeting Minutes, dated 03/18/2022, documented, Can we please do something about the chicken being so dry. Food is always cold when the resident's get it. Resident Council Meeting Minutes, dated 04/18/2022, documented, The chef salads are horrible all of a sudden, the lettuce is wilted. They are serving burnt grilled cheese and cookies. Resident Council Meeting Minutes, dated 07/19/2022, documented, Something is not the same since the menus have changed the cook is not preparing the food the same as when the new menu first started. Resident Council Meeting Minutes, dated 08/19/2022, documented, Trays for meals are sitting on the halls waiting to be passed and getting cold. Resident Council Meeting Minutes, dated 09/16/2022, documented, Tired of chicken, pork and rice. Resident Council Meeting Minutes, dated 10/21/2022, documented, Dietary: Dietary is always running out of things (condiments, straws, ect .). It continues, Residents were wondering if they could get Splenda sweetener back? Resident Council Meeting Minutes, dated 11/18/2022, documented, Breakfast is cold, the waffles this morning was not warmed up prior to being put on the steam table. They were put on the steam table cold and did not get warmed up in time for breakfast and they were served cold. Resident Council Meeting Minutes, dated 12/19/2022, documented, Just wish they could get the supply thing straightened out. On 01/10/2023 at 03:00 PM V1, Administrator, stated that she would expect the residents to have palatable and to enjoy their meals. The facility policy, Diet Meets Needs of Each Resident, dated 02/19/2021, documented, 1. To provide food that is prepared by methods that conserve nutritive value, flavor and appearance. 2. To provide food and drink that is nutritious, palatable, attractive, and at a safe and appetizing temperature to meet individual needs. The Facility's Resident Census and Conditions Form (CMS 672) dated 01/03/2023, documents there are 139 residents living in the Facility.

Based on observation, interview and record review, the facility failed to perform hand hygiene and cleanse soiled resident equipment 5 of 5 residents (R56, R63, R95, R127 and R235) reviewed for infection control in the sample of 57. Findings include: 1. On 01/04/2023 at 1200 PM V4, Certified Nurse Assistant (CNA) took hall trays down to residents who were in their room for lunch. V4, CNA, without benefit of hand hygiene entered R95's room with his meal tray, came out and retrieved dessert and drink off the hall cart and went back into R95's room. When she exited his room, she did not perform hand hygiene. She then donned gloves, without benefit of hand hygiene and entered R127's room, who is on isolation. V4 CNA stated he was on isolation for a foot wound. She then took his meal tray in set it down, came back out with the same gloves and took a dessert and drink off the cart and took it into R127's room. V4, CNA doffed gloves in room did not perform hand hygiene exited room. Then she took R235's meal tray off cart and entered his room. Set his tray down, came out of his room, took a dessert and drink off cart and re-entered R235's room with it. V4, CNA exited R235's room, without benefit of hand hygiene pushed hall cart down hallway to R63's room, took meal tray into him, and came out and took a dessert off the cart and returned to R63's room. When V4 exited R63's room, she did not perform hand hygiene. R127's Physician order, dated 11/30/2022, documented, Contact isolation R/T VRE/MRSA of wound. On 01/10/2023 at 11:30 AM, V17, CNA, stated that she tries to wash her hands in between passing meal trays and for sure after being in an isolation room when passing meal trays. On 01/10/2023 at 12:24 PM, V2, Director of Nurses (DON) stated that she would expect the staff to perform hand hygiene in between passing meal trays, before putting gloves on and after taking off their gloves. The Facility policy, Hand Hygiene, dated 10/16/2022, documented, 5. Use an alcohol-based hand rub containing at least 60% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. It continues, L. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident: M. After removing gloves. N. Before and after entering isolation precaution settings. It continues, P. Before and after handling food. Q. Before and after assisting a resident with meals; and 6. Hand Hygiene is the final step after removing and disposing of personal protective equipment.2. On 1/4/2023 at 1:15PM R56 transferred from wheelchair with sit to stand lift. R56 pants visibly wet and cushion in wheelchair wet. R56 transferred to the toilet by V5 and V6 CNAs using the sit to stand lift. Placed on toilet by V5 and V6 CNA. V5 sanitizes hand donned gloves removes R56's crocs and then her pants. R56's adult diaper saturated with urine removed by V5, CNA and placed in plastic bag, with same gloves Puts R56's crocs on, places clean pants on and pulls up level with thigh, then places adult diaper between legs and secures sides loosely at thigh level. R56 transferred back to wheelchair. Pad in wheelchair was not cleansed prior to R56 sitting back in the wheelchair. On 1/10/2023 at 3:15PMjV2, DON stated she would expect staff to cleanse soiled areas and sanitize hands between changing gloves. The facility policy standard guideline Infection Prevention and control Program dated revised 9/23/2022 documents equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with written notification prior to room transfers within the facility for 5 of 5 residents (R1, R2, R3, R4. R5) reviewed for room change notification in the sample of 5. Findings include: 1. R2's Minimum Data Set (MDS), dated [DATE], documented R2 has severely impaired mental cognition and an admission date of 3/31/20 with prior residency on 900-hall. The facility's Census Report dated 11/28/22, documented R2 had the following room changes: On 11/21/22 documented move to 600-hall and 11/23/22 documented move to 900-hall. R2's Social Service Department Room change/Roommate Notification was not completed and there was no written notification documented that R2 and/or R2's representative was provided written notification. R2's Health Status Note, dated 11/21/22, documented, (V5, R2's Family) and patient notified of room move to 600-hall, documented by V2, Director of Nursing (DON). R2's Health Status Notes reviewed from 9/12/22 through 11/28/22 do not document any other room changes. On 11/28/22 at 6:45 PM, V5, (R2's Power of Attorney/POA), stated she received a voicemail to her mobile telephone that R2 was being re-located to 600-hall. V5 continued to state she did not receive a written room change notification from the facility, especially on the days of 11/21/22, 11/22/22 and 11/23/22 when visiting R2 in the facility. 2. R1's MDS, dated [DATE], documented an admission date of 8/26/22 and moderately impaired mental cognition. The Census Report dated 11/28/22, documented R1 had the following room changes: 11/11/22 room change from a room on the 200-hall to and room on the 900-hall; on 11/14/22, a room change from the 900-hall to a room on the 400-hall and on 11/21/22 a room change from the 400-hall to a room on the 900-hall. R1's Nurse Note dated 11/14/22, documents, resident moving from (room on 900 hall) to (room on 400 hall) left message with family. There are no other nurse notes that documents R1's room move on 11/11/22 and 11/21/22. R1's Social Service Department Room change/Roommate Notification dated 11/14/22, documented, a room change from 900 to 400 hall. No documentation of the reason for the room change, checked as yes, for resident representative notified by telephone, no documentation of whom received the telephone notification and no written notification documented of a resident and/or residents' representative that includes date and time of written notification. On 11/29/22 at 9:50 AM, R1 stated he has been moved from other room locations and does not recall signing any papers of this room change. 3. R3's MDS dated [DATE], documented no impaired cognition and admission date of 11/4/22. Census Report dated 11/28/22, documented R3 had the following room move changes: On 11/13/22, a room change to 400 hall and on 11/21/22, room change from 400 to 100 hall. R3's Health Status Note, dated 11/13/22, documented, (R3) moved to 400 hall and isolation is complete. Daughter aware of room change. R3's Social Service Department Room change/Roommate Notification was not completed, and no documentation of written bed change notification presented to resident and/or resident representative. On 11/29/22 at 9:15AM, R3 stated she was okay with the room change, and was not presented written notification, the daughter handles this information and was only told she was being moved to another room and did not aware of having a roommate. 4. R4's MDS dated [DATE], documented mild impaired mental cognition and admission date of 10/10/22 to 100-hall. Census Report, dated 11/28/22, documented R4 had the following room move changes: 10/17/22, room change from 100 to 400 hall and on 11/21/22, a room change from 400 to 100 hall. R4's Health status note, dated 11/21/22, documented a telephone message was left to inform family of R4's room change to 100-hall. R4's, Social Service Department Room change/Roommate Notification was not completed for room change dated 11/21/22. A room change notification was completed for room move dated 10/17/22 that documented, family notified checked yes, no name of the family notified, notified by telephone and no signature and/or date from the resident and/or family representative documented and no documentation that written notification was present for the room change. On 11/29/22 at 9:30AM, R4 stated she did not sign anything for this room change, daughter handles her medical decisions. 5. R5's MDS, dated [DATE], documented no impaired mental cognition and admission date of 10/10/22 to room [ROOM NUMBER] hall. Census Report, dated 11/28/22, documented R5 had the following room move changes: 10/25/22, room change from 200-hall to 600-hall; On 11/18/22, room change from 600-hall to 400-hall; On 11/21/22, room change from 400-hall to 200-hall. R5's Health Status Note, documented room change dated 10/25/22. There is no other room change documented. R5's Social Service Department Room change/Roommate notification was not completed for room change of 11/18/22 and 11/21/22 and no written documentation of room changes signed by resident and/or family representative. On 11/29/22 at 9:40AM, R5 stated he has been moved a lot, but does not recall signing any papers. On 11/28/22 at 8:50 AM, V2, stated she contacted family by telephone of the room changes on the date of 11/21/22 and was not aware a room notification form had to be completed and/or written notification was to be presented to family and/or resident when there is a room change and/or roommate change. On 11/29/22 at 9:25AM, V1, Administrator, stated she was not aware that written notification of a room change is to be given to the resident and/or representative prior to move. On 11/28/22 at 3:00PM, V3, Social Services, stated she was not aware that a written notice of a resident room change needed to be completed. The Facility's policy, entitled, Standards and Guidelines, Room Changes, dated 1/3/2022, documented 6. When a resident is being moved at the request of the facility staff, the resident, family, and/or resident representative, must receive an explanation in writing of why the move is required. 7. The designated staff member will complete the FGS Notification of Room or Roommate Change form or other form of notification and documentation in the clinical record. This form can be accessed from the Evaluations Tab of the residents clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to maintain safe and palatable food temperatures for 4 of 9 residents (R3, R7, R8, R9) reviewed for food palatability in the sample of 9. Findings include: On 11/22/22 at 8:32 AM, test tray temperatures were obtained using a metal calibrated thermometer after the last resident tray was served. The temperatures were taken directly after the food was transferred from the steam table to the plate. The scrambled eggs measured 114.6 degrees Fahrenheit (F), and the sausage patty measured 113.0 degrees F. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact. On 11/22/22 at 9:30 AM, R3 stated she usually eats in the dining room, and the food is never hot. She stated sometimes the juice is a little watery. R7's MDS dated [DATE] documents R7 is cognitively intact. R7 stated the food is usually not hot at dinner time, and sometimes the juice is watered down. She stated the facility has been having trouble with its juice machine which she feels may be the reason for this. R8's MDS dated [DATE] documents R8 is cognitively intact. R8's grievance dated 10/4/22 documents, Dinner time. Fries are half frozen, half burned. R9's MDS dated [DATE] documents R9 is cognitively intact. R9 grievance received 10/5/22 documents, Dinner time. 10/4/22 Meals cold. Resident Council Meeting Minutes dated 11/18/22 document, Breakfast is cold. The waffles this morning was not warmed up prior to being put on the steam table. They were put on the steam table cold and did not get warmed up in time for breakfast and they were served cold. On 11/22/22 at 8:33 AM, V3, Cook, stated, We don't have too many complaints about food temps (temperatures) in the dining room, but sometimes people who get hall trays complain. Food should be 135 degrees F when served. On 11/22/22 at 8:52 AM, V2, Director of Nursing (DON), stated, We do have issues with food temps on the hall sometimes, because so many residents are eating in their rooms. We try to encourage them to eat in the dining room, but after COVID, they just haven't wanted to come out. We have the nursing staff offer to heat it up if it's cold. On 11/22/22 at 10:15 AM, V3 stated, We have a work order out for our juice machine. It is not mixing, so we have to mix it ourselves. It comes out as a syrup which we fill to the line in the container, then we fill the rest with water. Most of the residents ask for ice in their juice, so that could be a reason it might seem watered down. On 11/22/22 at 2:21 PM, V1, Administrator, stated, I would expect the Facility to follow its policy regarding food temperatures. The Facility's Holding Temperatures Policy revised 3/2/2021 documents, Standard: Foods will be held at appropriate temperatures during meal service according to the FDA (Food and Drug Administration) 2013 Food Code guidelines, in order to maintain safety and promote optimal palatability. Hot foods that are prepared for residents will be held during meal service at a minimum of 135 degrees F (Fahrenheit), and preferably higher than this to allow for cooling during transport.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure call lights were within resident's reach for one of one residents (R25) reviewed for accommodation of need in the sample of 46. Finding includes: R25's Care Plan, dated 11/14/21 documents R25 is at risk for falls. R25's Care Plan Intervention documents be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. R25's quarterly Minimum Data Set (MDS), dated [DATE], documents she is cognitively intact. On 12/15/21 at 9:15 AM, R25 was in bed and did not have her call light within reach, it was on the floor. R25 stated she did not have her call light within reach from the evening on 12/14/21 into the morning of 12/15/21. R25 stated she needed staff assistance, but she did not have her call light to call for help. Review of the facility's standards and guidance call light policy, revised 3/27/21, documents It will be the standard of this facility to respond to the resident's requests and needs via notification with the call light system. The Policy documents Guidelines: when the resident is in bed or confined to a chair, the call light should be within easy reach of the resident. Some residents may not be able to use their call light or may have visitors that may move belongings, including the call light. Staff should check these residents regularly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer pressure ulcer treatments as ordered for 1 of 8 residents (R81) reviewed for pressure ulcers in the sample of 46. Findings include: R81's Face Sheet documents his diagnoses to include Paraplegia, Unspecified Severe Protein-Calorie Malnutrition, Systemic Inflammation Response Syndrome of Non-Infectious Origin Without Acute Organ Dysfunction, and Pressure Ulcer of Sacrum. On 12/14/21 at 9:33 AM R81 stated sometimes they don't change his dressing to his pressure ulcer on his bottom after he has a BM (bowel movement). He stated the doctor does not want his wound to be soiled with BM and get infected. On 12/15/21 at 11:15 AM V13, Wound Nurse, performed dressing change to R81's coccyx pressure ulcer. V13 removed the old dressing, dated 12/14/21 from R81's coccyx pressure ulcer. The old dressing had brown drainage/fecal material on edges but not on the wound bed. While wound care being done, R81's skin was observed. R81's coccyx pressure ulcer was clean with pink base and scar tissue filling in around the edges. R81's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented, and he has one stage 4 pressure ulcer. R81's Care Plan dated 12/10/21 documents The resident has pressure ulcers which were present on admission. Treatment as ordered. Under interventions, the care plan documents: Wound care as ordered by physician / see current TAR (Treatment Administration Record) Coccyx Wound. R81's Physician Order Review dated 12/16/21 documents his treatment order to his coccyx pressure ulcer as : Silvadene Cream 1 % (Silver sulfanilamide) Apply to coccyx topically every evening shift for wound cleanse area with w/c (wound cleanser) apply ssd (Silvadene Cream), mupirocin, collagen powder, and calcium alginate cover with silicone foam dressing and change daily and as needed. R81's Treatment Administration Record (TAR) dated 11/1/21 to 11/30/21 documents his treatment to his pressure ulcer on his coccyx was not done as ordered on 11/10/21, 11/20/21, 11/22/21, 11/23/21 or 11/29/21. R81's TAR dated 12/1/21 -12/31/21 documents his treatment to his pressure ulcer on his coccyx was not done as ordered on 12/3/21, 12/4/21, 12/5/21, or 12/6/21. On 12/16/21 at 2:36 PM V2, Director of Nursing (DON) stated she would expect the nurse taking care of R81 to change his dressing as ordered when the wound nurse is not available. V2 stated she would expect his dressing to be changed every day as ordered. The facility's policy, Standards and Guidelines: SG Wound Care revised 3/27/21, documents: Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. The Policy documents 6. Wound care procedures and treatments should be performed according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to administer tube feeding as ordered for 1 of 2 residents (R77) reviewed for enteral feedings in a sample of 46. Finding includes: R77's quarterly Minimum Data Set (MDS), dated [DATE], documents R77 is moderately cognitively impaired and 51% or more proportion of total calories the resident received through parenteral or tube feeding. The MDS documents R77 was 65 inches tall and weighed 104 pounds. R77's Health Status Note, dated 12/1/21 at 9:55 PM documents Late entry for 4:00 PM, writer spoke to (proper name of nurse) nurse for the dialysis center that patient attends for tx (treatment.) She asked for a med (medication) list to be faxed specifically inquiring about enteral (tube) feeding schedule and the nutrition that is being administered. Fax was sent, awaiting further correspondence. R77's Nutritional Progress Note, dated 12/3/2021 at 12:01 PM documents Registered dietitian consult regarding dialysis labs and tube feed formula type. Registered dietitian from dialysis clinic recommends to change resident to Nepro secondary to altered labs values of: Albumin 3.5 L (low), K (potassium)+ 5.5 H (high). and Hgb (hemoglobin) L 8.5. Currently receiving Jevity 1.5 at 60 ml (milliliters)/hr (hour). Wt (weight): 105.2# BMI (body mass index): 187.5 and dry weight 50 kg (kilogram) per dialysis registered dietitian. Remains NPO (nothing by mouth), recommend to d/c (discontinue) order for 1 nectar thick packet with current NPO status. Recommend change TF (tube feeding) to nepro carb steady goal rate of 50ml/hr x 24hr to provide: 2160 kcal (43kcal/kg dry weight), 1200ml total volume, 97gm prot (1.9gm/kg dry wt), 872ml free water, flush order: 100ml H2O (water) q (every) 6 hr and 30 ml before/after meds to provide 1452ml free water (29ml/kg dry wt). TF to provide 127% (recommended dietary allowance) RDA and meets 123% kcal needs. Monitor TF (tube feeding) for tolerance and weights per order. registered dietitian to follow as needed. R77's Physician Order Sheet (POS), dated 12/6/21 documents R77 every shift for nutritional needs Nepro carb steady 50 ml/hr via tube 2:00 PM through 10:00 PM. R77's Care Plan, dated 12/7/21 documents focus: the resident requires tube feeding and flushes as ordered r/t (related to) Dysphagia (difficulty swallowing) 8/11/21-New order for puree diet with Nectar thick liquids per speech therapist. Tube Feeding to continue at this time. 11/3/21-Returned from Hospital with NPO order, tube feeding with flushes only. Goal: resident will remain free of complications R/T (related to) use of a feeding tube AEB (as evidence by) no s/s aspiration, no nausea/vomiting / diarrhea, and no abdominal distention through next review. Interventions: administer tube feeding formula and flushes as ordered (see current physician orders & MAR (medication administration record.) R77's Health Status Note, dated 12/14/21 at 3:55 PM, documents Resident feeding is set at 100ml/hr but res order states 50ml/hr. I have communicated to the regular hall nurse concerning this matter. Will inform DON (Director of Nursing.) On 12/15/21 at 8:00 AM, R77 was not in his room. The tube feeding formula bottle which hung from his tube feeding machine was Jevity 1.2 calorie (cal). On 12/15/21 at 8:05 AM, V20, Certified Nurse Assistant (CNA) stated R77 left for dialysis at 6:00 AM and will be back after 11:00 AM. On 12/15/21 at 12:00 PM, R77 lay in bed. He stated he was hungry. R77 was not connected to the tube feeding at that time. At 2:15 PM, R77's tube feeding remained disconnected. At 2:40 PM, R77's tube feeding was not connected. At 3:20 PM, R77's tube feeding was not connected. During these times, tube feeding bottle which was hung but not infusing was Jevity 1.2 cal. On 12/15/21 at 3:30 PM V18, Licensed Practical Nurse (LPN) stated R77's tube feed formula was Nepro and she starts it at 5:00 PM and it was ordered to run until 5:00 AM. V18 stated she was not aware of a time change for the tube feed. V18 stated R77's tube feeding would not work running from 2:00 PM through 10:00 PM because he goes to dialysis on Mondays, Wednesdays and Fridays and he does not get back from dialysis until after 4:30 PM. On 12/15/21 at 3:50 PM R77's tube feeding was not connected. The tube feeding that was hung but not infusing continued to be the Jevity 1.2 cal. On 12/15/21 at 4:05 PM V2, Director of Nurse, DON, stated the dietitian entered the tube feeding order incorrectly in the computer and it needs to be updated. V2 stated the tube feeding order was run at night from 5:00 PM through 5:00 AM in the past and she was not aware the order had changed. V2 stated running the tube feeding 24 hours would not work for R77 because he goes out to dialysis three days a week and they do not have tube feeding administered during dialysis. V2 stated the physician's order and registered dietitian order should match. On 12/15/21 at 4:20 PM R77's remained in his room and his tube feeding was not connected. The tube feeding that was hung continued to be a bottle of Jevity 1.2 cal. On 12/16/21 at 9:30 AM, V2 stated The resident's tube feeding orders were a cluster. The physician's order did not match the registered dietitian's recommendation. V2 stated facility was not aware of the issue until 12/15/21, when the IDPH surveyor asked for the tube feeding order clarification. The facility's standards and guidelines enteral tube feeding policy, revised 3/27/21, documents It will be the standard of this facility to provide nourishment to the resident who is unable to obtain adequate nourishment orally via use of enteral tube feeding. The Policy Guidelines document Verify/obtain physician's order for enteral feeding. Be certain that the order for the enteral feeding tube specifies such as rate, amount, times of administration and any specific orders related to stopping tube feeding. Consult with registered dietitian as needed/ordered related to tube feeding/flush requirements.

Based on observation, interview and record review the facility failed to ensure staff documented the narcotic medication counts correctly on the resident's narcotic medication count sheet for 3 of 3 residents (R21, R41, R46) reviewed for Pharmacy Procedures/Records in a sample of 46. Findings include: 1. R21's December 2021 Physician's Order Sheet (POS), documents R21 is to receive Oxycodone (narcotic) 5 milligram (mg) tablet give 1 tablet by mouth every 4 hours as needed (PRN) for pain. On 12/15/21 at 1:00 PM R21's medication card for Oxycodone 5 mg had 13 tablets. Review of R21's Oxycodone narcotic count sheet documents 14 tablets. 2. R41's December 2021 POS, documents R41 is to receive Tramadol (narcotic) 50 mg 1 tablet three times a day for pain. On 12/15/21 at 1:05 PM observation of 41's narcotic medication card for Tramadol 50 mg showed he had 6 tablets. Review of R41's Tramadol narcotic count sheet documents 7 tablets. 3. R46's POS, dated 12/2021, documents R46 is to receive Diazepam (scheduled 4 controlled substance) tablet 5 mg 1 tablet by mouth three times a day for anxiety and Morphine Sulfate (narcotic) extended release (ER) 15 mg give 1 tablet by mouth every 8 hours for pain. On 12/15/21 at 1:03 PM observation of R46's narcotic medication card for Diazepam 5 mg showed had 15 tablets. Review of R46's Diazepam narcotic count sheet documents 16 tablets. R46's narcotic medication card for Morphine Sulfate Tablet ER 15 mg showed he had 19 tablets. On 12/15/21 at 1:00 PM, V25, Licensed Practical Nurse, LPN, stated the facility's internet was not working that day and she was far behind in her nurse duties. V25 stated she administered the narcotic medication but did not update the resident's narcotic count sheets. V25 stated she knew to do so before she administered the medication, but she was swamped. On 12/15/21 at 2:10 PM, V2, Director of Nurses (DON) stated she expected staff to update the resident's narcotic count sheet before the narcotic was administered. V2 stated it was important to do ensure the narcotic count is always correct to ensure the residents are receiving the narcotic medication as ordered by the physician and to ensure there is not misappropriation and/or diversion. The facility's standards and guidelines control drug count policy, revised 3/27/21, documents no guidance regarding when to sign out narcotic medication on the resident's narcotic count sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify residents on isolation precautions, by failing to place signage outside resident's doors for 2 of 2 residents (R236, R237), reviewed for infections control precautions in the sample of 46. Findings include: 1.R236's Face Sheet documents she was admitted on [DATE] with diagnoses of kidney failure, COPD, and hypoxia. R236 is unvaccinated. R236's Care Plan dated 12/13/2021 documents R236 has the potential for contact or exposure to the novel Coronavirus (COVID-19). The Care Plan document to minimize the risk of resident exposure to the novel Coronavirus (COVID-19). The Care Plan documents Staff will wear required PPE (Personal Care Equipment) while providing care and in contact with resident and resident areas, as is appropriate, to include, but not limited to: Gloves, Masks, Goggles/Face Shields, Gowns. On 12/14/2021 at 9:30 AM R236 was in her room. There was no signage on door to advise visitors and staff that R236 is on contact droplet isolation precautions and what PPE is required when entering R236's room. 2. R237's face sheet documents she was admitted on [DATE] with diagnoses of atrial fibrillation, COPD, diabetes, respiratory failure. R237 medical record documents R237 was administered 1 dose of Pfizer SARS-CoV-2 Vaccination on 12/7/2021. R237's Care Plan dated 12/13/2021 documents R236 has the potential for contact or exposure to the novel Coronavirus (COVID-19). The Care Plan document to minimize the risk of resident exposure to the novel Coronavirus (COVID-19). The Care Plan documents Staff will wear required PPE (Personal Care Equipment) while providing care and in contact with resident and resident areas, as is appropriate, to include, but not limited to: Gloves, Masks, Goggles/Face Shields, Gowns. 12/14/2021 at 9:30 AM R237 was in her room. R237's room door was opened. There was no signage on the door advising staff and visitors that R237 was on contact droplet precautions and what PPE was required when entering R237's room. On 12/16/2021 at 2:17 PM, V9, Assistant Director of Nurses (ADON) stated, When new admissions come into the facility, we have the residents stay in room for 14 days, so we can watch for signs and symptoms. We also put signs on the doors and PPE (Personal Protective Equipment) by the door. We try to keep their doors shut or semi shut if they're a fall risk. The Facility's Infection Control Policy Transmission Based Precautions, revision date 3/27/2021, documents Direct contact with skin, or indirect contact with contaminated surfaces, and physical transfer of organisms (usually on the hands of healthcare workers) from an infected or colonized person to a susceptible host. Utilize Yellow Stop and see Nurse signage outside resident room or on door. Examples of pictures of signage included in policy. The Centers for Disease Control and Prevention (CDC) guidance, updated 9/10/21, documents that all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Instructional signage throughout the facility and proper visitor education on COVID- 19 signs and symptoms should be placed.

Based on observation, interview and record review, the facility failed to maintain confidentiality/privacy of medical records for 4 of 4 residents (R20, R25, R53, and R183) reviewed for privacy in the sample of 46. Findings include: 1. On 12/15/21 at 7:35 AM, V11, Licensed Practical Nurse (LPN), was observed during medication administration. V11 obtained R25's medication, walked away from the computer leaving it open in the hallway and displaying R25's medical information. 2. On 12/15/21 at 8:00 AM, V11 was observed during medication administration. V11 obtained R53's medication, walked away from the computer leaving it open in the hallway and displaying R53's medical information. 3. On 12/15/21 at 8:05 AM, V11 was observed during medication administration. V11 obtained R20's medication, walked away from the computer leaving it open in the hallway and displaying R20's medical information. 4. On 12/15/21 at 8:20 AM, V11was observed during medication administration. V11 obtained R183's medication, walked away from the computer leaving it open in the hallway and displaying R183's medical information. On 12/15/21, V2, Director of Nurses (DON), stated she would expect the computer screen to be closed/locked to protect the resident's confidential information. The Resident Rights, Dignity, and Visitation Rights policy, dated 3/27/21, documents The unauthorized release, access or disclosure or resident information is prohibited. The resident's right to privacy and privacy of the medical record should be maintained.

5. R16's December 2021 POS, documents Lantus Solostar insulin pen inject 15 units subcutaneously at bedtime. On 12/15/21 at 1:30 PM R16's Lantus Solostar insulin pen was opened and in the top drawer of the 300 medication cart, it was not dated. 5. R54's December 2021 POS, documents Humalog Kwik pen inject as per sliding scale. On 12/15/21 at 1:33 PM R54's Humalog Kwik pen was open and in the top drawer of the 300 medication cart, it was not dated. On 12/15/21 at 1:33 PM V12, LPN, stated she put put the new Humalog quick pen for R54 on the 300 hall medication cart on 12/14/21 so she knew when it was open, she must have forgot to date it. She did not know when R16's insulins were open or why they were not dated. On 12/15/21 at 2:00 PM V2 stated she expected staff to date residents insulin after opening it and placing it in the medication carts so all staff know when the insulin will expire. Based on observation, interview and record review, the facility failed to store medications in a locked area to prevent access to resident medications and ensure insulin is labeled upon opening for for 6 of 6 residents (R16, R20, R25, R53, R54 and R183), reviewed for labeling/storage of medications in the sample of 46. Findings include: 1. On 12/15/21 at 7:35 AM, V11, Licensed Practical Nurse (LPN), was observed during medication administration. V11 obtained R25's medication and walked away from the medication cart into R25's room leaving the medication cart unlocked in the hallway, out of sight. 2. On 12/15/21 at 8:00 AM, V11 was observed during medication administration. V11 obtained R53's medication and walked away from the medication cart into R53's room leaving the medication cart unlocked in the hallway, out of sight. 3. On 12/15/21 at 8:05 AM, V11 was observed during medication administration. V11 obtained R20's medication and walked away from the medication cart into R20's room leaving the medication cart unlocked in the hallway, out of sight. 4. On 12/15/21 at 8:20 AM, V11 was observed during medication administration. V11 obtained R183's medication and walked away from the medication cart into R183's room leaving the medication cart unlocked in the hallway, out of sight. On 12/15/21 at 11:46 AM, V2, Director of Nurses (DON), stated she would expect the medication carts to be locked with the cart is not in use. The Medication Storage policy, dated 3/27/21, documents Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view.

Based on interview and record review the facility failed to provide adequate tracking for antibiotic stewardship surveillance to monitor for patterns and trends in infections and antibiotic use for 4 of 4 residents (R40, R47, R79 and R80) reviewed for antibiotic stewardship in the sample of 46. Findings include: 1. The facility infection control log documents R40 has a Urinary Tract Infection (UTI) with an onset date of 10/2/21. The log has no documentation that a urine culture identified an organism. R40's Physician Order Sheet (POS) documents an order, dated 10/2/21, for Nitrofurantoin 100 milligrams (mg) every 12 hours for a UTI. R40's Urinalysis/Urine Culture, dated 9/30/21, documents the urine culture was unable to be performed due to the specimen being too old and it was recommended to collect a new specimen. The urine culture, dated 10/22/21, documents no growth. 2. The facility infection control log documents R47 has a UTI with an onset date of 10/25/21. The log has no documentation that a urinalysis/urine culture was obtained or that an organism was identified. R47's POS documents an order, dated 10/25/21, for Nitrofurantoin 100mg twice daily (BID) for a UTI. R47's Laboratory reports were reviewed, and no urinalysis or urine culture was obtained for this UTI. R47's progress notes were reviewed and have no documentation as to why the antibiotic for the UTI was started. 3. The facility infection control log documents R79 has a UTI with an onset date of 10/4/21. The log has no documentation that a urinalysis or urine culture was obtained or that an organism was identified. R79's POS documents an order, dated 10/5/21, for Cephalexin 500mg four times daily (QID) for UTI. R79's Laboratory reports were reviewed, and no urinalysis or urine culture was obtained for this UTI. R79's progress note, dated 10/4/21 at 2:51pm, documents a new order for Keflex (Cephalexin) was obtained. The progress note does not document a reason for the antibiotic. 4. R80's POS documents an order, dated 12/9/21, for Ciprofloxacin HCL 500mg BID for a UTI. R80's Laboratory reports were reviewed, and no urinalysis or urine culture was obtained for this UTI. R80's progress note, dated 12/9/21 at 3:36 PM, documents R80's urine is dark in color with a strong smell and an order for an antibiotic for a UTI was obtained. On 12/16/21 at 12:15 PM, V2, Director of Nurses (DON) states R80 did not have a urine culture completed, hospice ordered the antibiotic. V2 stated she would expect a urine culture be collected so they know what they are treating. The Antibiotic Stewardship policy, dated 3/29/21, documents Antibiotic usage and outcome data will be collected, monitored and tracked using a facility approved antibiotic use program. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. Therapy is not justified if the organism is not susceptible to the antibiotic chosen. After 72 hours, interventions that may justify therapy: obtain cultures.