**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide clean linens for 1 of 11 residents (R4) reviewed for linens in the sample of 20.Findings include:R4 admission record, print date of 9/17/25, documents R4 was admitted [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy Status.R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact, dependent on staff for activities of daily living, and mobility.On 9/16/25 at 12:00 PM, R4 is lying in bed. R4's pillowcase is soiled with a large brown stain.On 9/17/25 at 1:51 PM, R4's pillowcase remains with the large brown stain that was observed on 9/16/25 at 12:00 PM. On the right quarter side rail there is a white towel with dried green, brown stains on it.On 9/24/25 at 9:01 AM, V2, Director of Nurses, stated linens should be changed when dirty.On 9/29/25 at 11:19 AM, V1, Administrator, stated, I am not sure where the linen policy is, but I expect dirty linens to be changed no matter what.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent Urinary Tract Infections for 2 of 3 residents (R7, R13) reviewed for incontinent care in the sample of 20.Findings include:1. R7's admission record, print date of 9/25/25, documents R7 was admitted on [DATE] and has diagnoses of Chronic Obstructive Pulmonary Disease and Diabetes.R7's Minimum Data Set, dated [DATE], documents that R7 is severely cognitively impaired, dependent on staff for toileting, and is always incontinent of bowel and bladder. On 9/25/25 at 9:11 AM, V19, Certified Nurse Aide (CNA) removed R7's incontinent brief. The brief was soiled with urine and feces. R7 with pre-moistened periwash cloths cleansed, the groins, labia, perivaginal area, rolled R7 over onto her side, cleansed the rectal are with multiple cloths, placed a new incontinent brief, had R7 roll to her back, and then roll to the right to cleanse the right buttock, roll to her back and then fastened the incontinent brief. On 9/25/25 at 9:15 AM, V19 stated she missed the left buttock because she was nervous.2. On 9/17/25 at 2:15 PM, V12, CNA removed R13's incontinent brief. The brief was soiled with urine. With a wet soapy washcloth, V12 wiped R13's groins, labia, meatus, rectal area, and left buttocks. V12 used the same portion of the washcloth, did not cleanse the right buttocks, and did not dry R13 before putting on a new incontinent brief.R13's Face Sheet, print date of 9/25, documents R13 was admitted on [DATE] and has a diagnosis of Congestive Heart Failure.R13's MDS, dated [DATE], documents R13 is cognitively intact, requires supervision touching assistance with toileting, and is always incontinent of bowel and bladder.On 9/24/25 at 9:05 AM, V2, Director of Nurses, stated staff should be doing complete incontinent care. Staff should have multiple towels so when you clean a dirty area you get a new towel and clean again. You need towels for rinsing and drying also. The incontinent care policy, dated 1/25, documents, 2. Perform hand hygiene and don gloves. It continues, 5. Clean peri area with appropriate cleanser and dry. Appropriate cleanser can mean soap and water, periwash, etc. Cleansing should always be from front to back. 6. If resident needs more cleansing than above, a bath or shower may be given,' It continues, 11. Perform hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide complete tracheostomy care and educate the resident on the proper way to provide tracheostomy care for 1 of 2 residents (R4) reviewed for tracheostomies in the sample of 20.Findings include:R4 admission record, print date of 9/17/25, documents, R4 was admitted [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy (trach) Status.R4's Physician Orders, dated 11/7/24, documents, Change inner cannula daily on dayshift and PRN (as needed) every day shift AND as needed as needed.R4's Physician Orders, dated 10/18/24, documents, CHANGE TRACH COLLAR/TIES TWICE WEEKLY AND PRN every day shift every Tue, Fri AND as needed. R4's Physician Orders, dated 10/18/24, documents, TRACH CARE EVERY SHIFT AND PRN every shift.R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact and dependent on staff for activities of daily living.On 9/16/25 at 12:00 PM, R4 is lying in bed. R4 has a tracheostomy. R4's neck ties and trach collar are wet, soiled with yellow, green, and brown drainage. There is no drainage sponge under the trach. When R4 raised his head to expose the trach, a foul odor was detected. R4 has a red spotted rash on his neck and upper chest.On 9/17/25 at 1:51 PM, V4, Licensed Practical Nurse, entered R4's room to provide tracheostomy care. V4 stated R4 does the tracheostomy care himself and needs very little assistance with the care. V4 washed her hands and donned gloves. V4 opened multiple drawers gathering supplies for the care, sterile saline, gauze pads, tracheostomy kit, and placed the supplies on the bedside table. V4 changed her gloves without hand hygiene. R4 removed the left tracheostomy tie and loosened the tracheostomy collar. The left side of the collar has green, brown drainage on it. R4's left neck and under his neck has dried drainage on it. V4 gathered more supplies and changed her gloves without hand hygiene. R4 grabbed a 4 x 4 gauze pad and dipped it in sterile saline multiple times. R4 began to clean the left side of his neck and around the tracheostomy tube of the dried drainage with one 4 x 4 gauze pad dipping it in the sterile saline multiple times. V4 removed her gloves, washed her hands, and donned sterile gloves. V4 attached the new tracheostomy tie and collar to the left side. R4 took another 4 x 4 gauze pad, dipped it in the sterile water, and cleaned the right side of his neck. With a 4 x4 gauze pad V4 dried R4's neck and around the tracheostomy tube. V4 removed the sterile gloves and donned non-sterile gloves without hand hygiene. R4 was attempting to remove the tracheostomy collar from behind his neck. V4 with her gloved hands is touching her long hair and moving it to her back. With the same gloves, V4 assisted R4 with removing the tracheostomy collar. V4 then attached the right tracheostomy tie and the tracheostomy collar. V4 changed her gloves without hand hygiene, obtained a gauze tracheostomy pad and placed it under the tracheostomy tube and collar. R4 is also trying to tuck the pad.On 9/17/25 at 2:00 PM, R4 stated he has been taking care of his tracheostomy for almost 4 years now. He stated that he takes the tracheostomy tube out and cleanses it when it is needed. R4 stated if he asks the staff to do it they will, but he prefers to do it. On 9/24/25 at 8:59 AM, V2, Director of Nurses, stated we just recently did an in service on tracheostomy care for the nurses. I did not know that R4 was doing his trach care. We cannot tell him he can't do it, but we need to educate him and make sure he is doing the care correctly. V4 should have followed the sterile procedure for tracheostomy care. R4 should have been offered hand hygiene and told not reuse gauze pads. The inner cannula should be cleaned daily, the trach ties, and collar should be changed when soiled. The Tracheostomy Care Policy, dated 10/24, documents, Procedure: III. Tracheostomy care. B. Gather equipment and apply sterile gloves; maintain sterility of the dominant hand. C. Suction as needed. D. Assess the need for hyper-oxygenation prior to procedure and provide supplemental oxygen if indicated. It continues, D. Wash hands, open tracheotomy kit, don gloves, and arrange contents on the sterile field. It continues, G. With clean hand, remove the inner cannula. 1. For disposable cannula, insert new inner cannula and lock into place; maintain sterility. 2. For reusable cannula, reapply tracheostomy collar over outer cannula to provide oxygenation during cleaning; cleanse secretions from outside and inside of inner cannula and rinse in sterile saline; gently reinsert cannula and lock into place; maintain sterility. H. Cleanse stoma site. 1 With sterile hand, moisten applicators or gauze with sterile and cleanse around stoma site and flange of outer cannula. 2. Assess for signs of infection, dry with sterile gauze. 3. Place new drain sponge under tracheostomy flange. I. Replace ties as needed. 1. For Velcro ties, with assistance, remove old Velcro tie, replace tie, and fasten Velcro securely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to wear a personal protective gown, wash hands when needed, change soiled gloves, encourage residents to wash hands, and clean multi-use equipment for 1of 5 residents (R4) reviewed for infection control in the sample of 20.Findings include:1. R4's Physician Orders dated 9/19/24, documents, Enhanced Barrier Precautions related to colonization for wounds, colostomy, tracheotomy.R4 admission record, print date of 9/17/25, documents R4 was admitted [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy Status.On 9/17/25 at 1:51 PM, V4, Licensed Practical Nurse, entered R4's room to provide tracheostomy care. V4 stated R4 does the tracheostomy care himself and needs very little assistance with the care. V4 washed her hands and donned gloves. V4 opened multiple drawers gathering supplies for the care and placed them on the bedside table. V4 changed her gloves without hand hygiene. R4 removed the left tracheostomy tie and loosened the tracheostomy collar. The left side of the collar has green, brown drainage on it. R4's left neck and under his neck has dried drainage on it. V4 gathered more supplies and changed her gloves without hand hygiene. R4 grabbed a 4 x 4 gauze pad and dipped it in sterile saline multiple times. R4 began to clean the left side of his neck and around the tracheostomy tube of the dried drainage with one 4 x 4 gauze pad. V4 removed her gloves, washed her hands, and donned sterile gloves. V4 attached the new tracheostomy tie and collar to the left side. R4 took another 4 x 4 gauze pad and cleaned the right side of his neck dipping it into the sterile saline multiple times. With a 4 x4 gauze pad V4 dried R4's neck and around the tracheostomy tube. V4 removed the sterile gloves and donned non-sterile gloves without hand hygiene. R4 was attempting to remove the tracheostomy collar from behind his neck. V4 with her gloved hands is touching her long hair and moving it to her back. With the same gloves, V4 assisted R4 with removing the tracheostomy collar. V4 then attached the right tracheostomy tie and the tracheostomy collar. V4 changed her gloves without hand hygiene, obtained a gauze tracheostomy pad and placed it under the tracheostomy tube and collar. R4 is also trying to tuck the pad. With the same gloves, V4 took a bottle of Nystatin powder and sprinkled and rubbed the powder in on his neck and upper chest. V4 removed her gloves and washed her hands. V4 left the room to get a pulse oximetry. V4 returned and placed it on R4's finger and obtained a reading of 95%. V4 did not wear a Personal Protective Gown, provide a sterile field for supplies, did not cleanse the pulse oximetry after use, and did not encourage or offer to cleanse R4's hands before, during, or after the care.On 9/24/25 at 8:59 AM, V2, Director of Nurses, stated V4 should have washed her hands, wear a gown, change gloves with hand hygiene, and follow the sterile procedure. R4 should have been offered hand hygiene and not reuse gauze pads.The policy Equipment Cleaning, dated 10/24, documents, general: To provide guidance on how to clean equipment between residents. Policy: 1. Obtain bleach wipe. 2 apply gloves. 3. Take a pre-moistened disinfectant wipe and clean the entire surface of monitor. Inspect to ensure all areas are clean. 4. Allow product to remain on equipment according to manufacturer's recommendations. 5. Remove and discard gloves. Sanitize hands.The policy Enhanced Barrier Precautions, dated 10/16/23, documents, Staff utilize gown and gloves for high contact resident care activities when residents require EBP (Enhanced Barrier Precautions); high contact activities may include Device Care or use: central line, urinary catheter, feeding tube, tracheostomy / ventilator.The Policy Hand Hygiene, dated 1/24, documents, hand hygiene is done before and after resident contact, before and after any procedure.The Tracheostomy Care Policy, dated 10/24, documents, Procedure: III. Tracheostomy care. B. Gather equipment and apply sterile gloves; maintain sterility of the dominant hand. It continues, D. Wash hands, open tracheotomy kit, don gloves, and arrange contents on the sterile field.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide Health Shakes for 5 of 5 residents (R14, R15, R16, R17, R20) reviewed for Dietary Supplements in the sample of 20.Findings include:On 9/24/25 at 12:17 PM the dining room was entered. R14, R15, R16, R17, and R20, all did not have their Physician prescribed health shake. On 9/24/25 at 12:20 PM, R16 stated, They forget the shakes a lot.On 9/24/25 at 12:28 PM, V15, Dietary Manager, stated the shakes are poured up and on this cart. The aides just took the tray and didn't look at the ticket to know that resident needed a health shake.1.R14's admission record, print date of 9/24/25, documents that R14 was admitted on [DATE] and has diagnoses of aphasia and Cerebrovascular disease.R14's Minimum Data Set, dated [DATE], documents R14 is severely cognitively impaired and requires supervision / touching assistance with eating.R14's Physician Order, dated 4/15/25, documents Diabetic shakes with meals Sugar Free. 2. R15's admission record, print date of 9/24/25, document R15 was admitted on [DATE], and has diagnoses of Type 2 Diabetes and Dementia.R15's MDS, dated [DATE], documents R15 is severely cognitively impaired and requires touching or supervision with eating.R15's Physician Order, dated 4/15/25, documents MED PASS 2.0 with meals.3.R16's admission Record, print date of 9/24/25, documents R16 was admitted on [DATE] and has diagnosis of schizoaffective disorder.R16's MDS, dated [DATE], documents R16 has modified independence for decision making, requires set up clean up assistance with meals.R16's Physician Order, dated 5/2/25, documents, Health Shakes in the afternoon with lunch.4.R17's admission Record, print date of 9/24/25, documents R17 was admitted on [DATE] and has a diagnosis of hemiplegia and hemiparesis affecting the right dominant side after a stroke.R17's MDS, dated [DATE], documents R17 is severely cognitively impaired and requires partial to moderate assistance with eating.R17's Physician Order, dated 4/10/25, documents, Health Shakes with meals for supplement.5. R20's admission Record, print date of 9/24/25, documents R20 was admitted on [DATE] and has a diagnosis of Alcohol Abuse with other Alcohol Induced Disorder.R20's MDS, dated [DATE], documents R20 is cognitively intact and requires supervision touching assistance with eating.R20's Physician Order, dated 7/24/25, documents, Health Shakes with meals.The policy Meal Service, dated 8/25, documents, 8. When the tray is delivered, the staff ensures that the correct tray is given to the correct resident and the diet on the card matches what is on the tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform wound treatment as ordered for 3 or 3 residents (R4, R6, R9), reviewed for Quality of Care in a sample of 3. Finding Include:1. On 7/18/2025 at 12:06 PM R4 stated while admitted to the facility he did not always receive his dressing change to his left knee as ordered.R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and has a diagnosis of Pain in the Left Knee, Morbid Obesity, Presence of Left Artificial Knee Joint, and Hypertension.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact, needed supervision/touching assistance with showering/bathing, lower body dressing, personal hygiene, rolling left and right, sitting to standing, and chair/bed to chair transfers.R4's Care Plan date initiated 4/7/2025 documents skin complications related to right knee surgery, skin at risk for skin complications related to impaired mobility and obesity.R4's Physician Order dated 5/15/2025 at 10:09 AM documents cleanse wound to left knee with wound cleanser, pat dry, pack with iodoform packing gauze, and cover with bordered gauze. Change daily and as needed (PRN), one time a day for to promote wound healing.R4's May Treatment Administration Record (TAR) dated 5/1/2025 through 5/31/2025 reviewed with no treatment documented on 5/21/2025, 5/26/2025, 5/27/2025, 5/30/25, and 5/31/2025.R4's June TAR dated 6/1/2025 through 6/30/2025 reviewed with no treatment documented on 6/3/2025, 6/4/2025, 6/5/2025, 6/10/2025, 6/12/2025, 6/13/2025, 6/17/2025, and 6/18/2025.2. On 7/22/2025 at 3:46 PM R6 stated the facility changes the dressing to his left middle finger most days, but not every day.On 7/22/2025 at 3:46 PM V10, Licensed Practical Nurse (LPN)/Wound Nurse, completed R6's dressing change to R6's left middle finger.R6's Undated Face Sheet documents R6 was admitted to the facility on [DATE] and has a diagnosis of Type 2 Diabetes and Hypertension.R6's MDS dated [DATE] documents R6 is moderately cognitively intact and needs partial/moderate assistance with showering/bathing.R6's Care Plan date initiated 1/17/2024 documents skin: at risk for skin complications related to Cerebrovascular Accident (CVA) and malnutrition.R6's Physician Order dated 6/20/2025 at 9:59 AM documents cleanse left hand with wound cleanser daily apply xeroform, 4x4 and gauze wrap once daily and PRN.R6's June Treatment Administration Record (TAR) dated 6/1/2025 through 6/30/2025 reviewed with no treatment documented on 6/24/2025, 6/26/2025, and 6/28/2025.R6's July TAR dated 7/1/2025 through 7/31/2025 reviewed with no treatment documented on 7/10/2025, 7/11/2025, 7/19/2025, and 7/20/2025.3. On 7/22/2025 at 3:19 PM R9 stated the facility staff does not change the dressing to his left lower leg daily, and he has gone multiple days without the dressing being changed. On 7/22/2025 at 3:23 PM V10, LPN/Wound Nurse completed R9's dressing change to R9's left lower leg.R9's Undated Face Sheet documents R9 was initially admitted to the facility on [DATE] and has a diagnosis of Cellulitis of the Right and Left Lower Limb, Hypertension, and Congestive Heart Failure.R9's MDS dated [DATE] documents R9 is cognitively intact, needs supervision or touching assistance with lower body dressing, and needs partial/moderate assistance with showering/bathing and personal hygiene.R9' Care Plan with dated initiated 3/5/2024 documents skin: at risk for skin complications related to venous hypertension.R9's Physician Order dated 6/20/2025 at 6:13 PM documents cleanse bi-lateral shin apply xeroform and border gauze, then apply ace bandages to both legs one time a day for swelling and blisters once daily and PRN if needed.R9's June Treatment Administration Record (TAR) dated 6/1/2025 through 6/30/2025 reviewed with no treatment documented on 6/24/2025, 6/26/2025, and 6/28/2025.R9's July TAR dated 7/1/2025 through 7/31/2025 reviewed with no treatment documented on 7/10/2025, 7/11/2025, 7/17/2025, 7/19/2025, and 7/20/2025. On 7/22/2025 at 10:20 AM V2, Director of Nursing (DON), stated when a dressing change is completed it is to be signed off on the resident's TAR. V2, DON, stated dressing changes should be documented as soon as they are done and if a resident's TAR does not have any documentation on a day, it would appear as if the dressing change was not performed. On 7/22/2025 at 3:40 PM V10, LPN/Wound Nurse, stated when a resident's dressing change is completed it is documented on the resident's TAR.The Facility's Skin Management: Monitoring of wounds and documentation policy dated 1/2022 documents It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility.

**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 4 of 5 residents (R4, R6, R7, and R9) in a sample of 5.Finding Include:1. On 7/18/2025 at 12:06 PM R4 stated while admitted to the facility he did not always receive his medications daily.R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and has a diagnosis of Pain in the Left Knee, Chronic Diastolic (Congestive) Heart Failure, Morbid Obesity, Epilepsy, Cortical Age-Related Cataract, Low-Tension Glaucoma, Cardiomegaly, Barrett's Esophagus, Hypothyroidism, and Hypertension.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact, needed supervision/touching assistance with showering/bathing, lower body dressing, personal hygiene, rolling left and right, sitting to standing, and chair/bed to chair transfers.R4's Physician Order dated 4/1/2025 at 4:25 PM documents Bumetanide Oral Tablet 1 MG (Bumetanide) Give 1 tablet by mouth one time a day every other day.R4's Physician Order dated 4/1/2025 at 4:25 PM documents Aspirin Oral Capsule 81 MG (Aspirin) Give 1 capsule by mouth one time a day.R4's Physician Order dated 4/1/2025 at 4:25 PM documents Lansoprazole Oral Capsule Delayed Release 30 MG (Lansoprazole) Give 1 capsule by mouth two times a day. R4's Physician Order dated 4/1/2025 at 4:25 PM documents Apixaban Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day.R4's Physician Order dated 4/1/2025 at 4:56 documents Famotidine Oral Tablet 20 MG (Famotidine) Give 2 tablet by mouth at bedtime. R4's Physician Order dated 4/1/2025 at 4:56 PM documents Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime.R4's Physician Order dated 4/1/2025 at 4:56 PM documents Lansoprazole Oral Capsule Delayed Release 30 MG (Lansoprazole) Give 1 capsule by mouth two times a day.R4's Physician Order dated 4/1/2025 at 5:20 PM documents Levothyroxine Sodium Oral Tablet 200 MCG (Levothyroxine Sodium) Give 1 tablet by mouth in the morning, take with 25 mcg tablet. R4's Physician Order dated 4/1/2025 at 5:20 documents Levothyroxine Sodium Oral Tablet 25 MCG (Levothyroxine Sodium) Give 1 tablet by mouth in the morning, take with 200 mcg tablet.R4's Physician Order dated 4/1/2025 at 5:24 PM documents Loratadine Oral Capsule 10 MG (Loratadine) Give 1 capsule by mouth one time a day. R4's Physician Order dated 4/1/2025 at 5:24 PM documents Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day.R4's Physician Order dated 4/1/2025 at 5:50 PM documents Phenytoin Sodium Extended Capsule 100 MG Give 3 capsule by mouth at bedtime.R4's Physician Order dated 4/1/2025 at 5:56 PM documents Propranolol HCl Oral Tablet 60 MG (Propranolol HCl) Give 1 tablet by mouth one time a day.R4's Physician Order dated 4/1/2025 at 5:58 PM documents Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth two times a day.R4's May Medication Administration Record (MAR) dated 5/1/2025 through 5/31/2025 does not document R4 received Levothyroxine 200 mg, Levothyroxine 25 mg, and Claritin 10 mg as ordered on 5/13/2025 and 5/21/2025 at 6:00 AM. R4's May MAR dated 5/1/2025 through 5/31/2025 does not document R4 received Atorvastatin 10mg, Famotidine 20 mg 2 tablets, Latanoprost Ophthalmic Solution 0.005% 1 drop, Phenytoin Sodium Extended Capsule 100 mg, Apixaban 2.5 mg, Lansoprazole Delayed Release Capsule 30 mg 3 capsules, and Tamsulosin 0.4 mg as ordered on 5/31/2025 at 8:00 PM. R4's May MAR dated 5/1/2025 through 5/31/2025 does not document R4 received Levothyroxine 200 mg, Levothyroxine 25 mg, and Claritin 10 mg as ordered on 5/13/2025 and 5/21/2025 at 6:00 AM. R4's June MAR dated 6/1/2025 through 6/30/2025 does not document R4 received Claritin 10 mg, Levothyroxine 200 mg, and Levothyroxine 25 mg as ordered on 6/1/2025 at 6:00 AM. R4's June MAR dated 6/1/2025 through 6/30/2025 does not document R4 received Bumetanide 1 mg, Lisinopril 10 mg, Propranolol 60 mg, Apixaban 2.5 mg, Lansoprazole 30 mg, Tamsulosin 0.4 mg as ordered on 6/5/2025 at 9:00 AM. R4's June MAR dated 6/1/2025 through 6/30/2025 does not document R4 received Claritin 10 mg, Levothyroxine 200 mg, and Levothyroxine 25 mg as ordered on 6/1/2025 at 6:00 AM. R4's June MAR dated 6/1/2025 through 6/30/2025 does not document R4 received Bumetanide 1 mg, Lisinopril 10 mg, Propranolol 60 mg, Apixaban 2.5 mg, Lansoprazole 30 mg, Tamsulosin 0.4 mg as ordered on 6/5/2025 at 9:00 AM.2. R6's Undated Face Sheet documents R6 was admitted to the facility on [DATE] and has a diagnosis of Type 2 Diabetes, Hyperlipidemia, Bipolar Disease, Seizures, and Hypertension.R6's MDS dated [DATE] documents R6 is moderately cognitively intact and needs partial/moderate assistance with showering/bathing.R6's Physician Order dated 10/14/2024 at 1:03 PM documents Aspirin Oral Capsule 81 MG (Aspirin) Give 1 capsule by mouth one time a day.R6's Physician Order dated 10/14/2024 at 1:04 PM documents Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day.R6's Physician Order dated 10/14/2024 at 1:05 PM documents Caplyta Oral Capsule 42 MG (Lumateperone Tosylate) Give 1 capsule by mouth one time a day.R6's Physician Order dated 10/14/2024 at 1:11 PM documents Atorvastatin Calcium Oral Tablet 80 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day.R6's Physician Order dated 10/14/2024 at 1:13 PM documents Valproate Sodium Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth with meals.R6's Physician Order dated 10/14/2024 at 1:14 PM documents Venlafaxine HCl Oral Tablet 75 MG (Venlafaxine HCl) Give 1 tablet by mouth with meals.R6's Physician Orders dated 1/8/2025 at 11:05 AM documents Lisinopril Oral Tablet 5 MG (Lisinopril) Give 0.5 tablet by mouth one time a day related.R6's Physician Order dated 1/23/2025 at 9:42 AM documents GLUCERNA two times a day.R6's Physician Order dated 3/16/2025 at 4:54 AM documents cloNIDine HCl Oral Tablet 0.2 MG (Clonidine HCl) Give 1 tablet by mouth three times a day.R6's Physician Order dated 3/16/2025 at 4:55 AM documents busPIRone HCl Oral Tablet 15 MG (Buspirone HCl) Give 1 tablet by mouth three times a day.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Valproate Sodium Oral Solution 250mg/5 ml take 10 ml and Venlafaxine HCL 75 mg as ordered on 6/4/2025 at 12:00 PM.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Buspirone 15 mg and Clonidine 0.2 mg as ordered on 6/4/2025 at 2:00 PM.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Valproate Sodium Oral Solution 250mg/5 ml take 10 ml and Venlafaxine HCL 75 mg as ordered on 6/4/2025 at 6:00 PM.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Buspirone 15 mg and Clonidine 0.2 mg as ordered on 6/5/2025 at 8:00 AM.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Aspirin 81mg, Atorvastatin Calcium 80 mg, Caplyta 42 mg, Clopidogrel Bisulfate 75 mg, Lisinopril 5 mg take 1/2 tablet, Glucerna, Valproate Sodium Oral Solution 250mg/5 ml take 10 ml, and Venlafaxine HCL 75 mg as ordered on 6/5/2025 at 9:00 AM.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Valproate Sodium Oral Solution 250mg/5 ml take 10 ml and Venlafaxine HCL 75 mg as ordered on 6/5/2025 at 12:00 PM.R6's June MAR dated 6/1/2025 through 6/30/2025 does not document R6 received Buspirone 15 mg and Clonidine 0.2 mg as ordered on 6/5/2025 at 2:00 PM.3. R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] and has a diagnosis of Hypertension, Gastro-Esophageal Reflux Disease, Chronic Ischemic Heart Disease, Peripheral Vascular Disease, and Hypertension.R7's MDS dated [DATE] documents R7 is mildly cognitively impaired, needs supervision or touching assistance with toileting hygiene, showering/bathing, personal hygiene.R7's Physician Order dated 2/12/2025 at 3:57 PM documents Aspirin 81 Oral Tablet Chewable (Aspirin) Give 81 mg by mouth one time a day.R7's Physician Order dated 2/12/2025 at 4:13 PM documents Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 mg by mouth one time a day.R7's Physician Order dated 2/12/2025 at 4:33 PM documents Keppra Oral Tablet 500 MG (Levetiracetam) Give 500 mg by mouth two times a day.R7's Physician Order dated 2/12/2025 at 4:35 PM documents Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 25 mg by mouth two times a day.R7's Physician Order dated 2/12/2025 at 4:36 PM documents Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth two times a day.R7's Physician Order dated 2/21/2025 at 4:40 PM documents Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) Give 100 mg by mouth one time a day.R7's Physician Order dated 6/12/2025 at 5:10 PM documents Vitamin D3 Oral Capsule 1.25 MG (50000 UT) (Cholecalciferol) Give 1 capsule by mouth one time a day every 7 day(s) for Vitamin D deficiency for 8 Weeks.R7's Physician Order dated 6/19/2025 at 1:32 PM documents Sucralfate Tablet 1 GM Give 1 tablet by mouth three times a day.R7's June MAR dated 6/1/2025 through 6/30/2025 does not document R7 received Sucralfate Oral Suspension 10 ml as ordered on 6/4/2025 at 12:00 PM.R7's June MAR dated 6/1/2025 through 6/30/2025 does not document R7 received Sucralfate Oral Suspension 10 ml as ordered on 6/4/2025 at 6:00 PM.R7's June MAR dated 6/1/2025 through 6/30/2025 does not document R7 received Aspirin 81 mg, Folic Acid 1 mg, Thiamine HCL 100 mg, Keppra 500 mg, Metoprolol Tartrate 25 mg, Protonix Delayed Release 40 mg as ordered on 6/5/2025 at 9:00 AM.R7's June MAR dated 6/1/2025 through 6/30/2025 does not document R7 received Sucralfate Oral Suspension 10 ml as ordered on 6/5/2025 at 12:00 PM.4. On 7/22/2025 at 3:19 PM R9 stated there have been days where he does not receive all his medications but cannot recall a particular date. R9's Undated Face Sheet documents R9 was initially admitted to the facility on [DATE] and has a diagnosis of Cellulitis of the Right and Left Lower Limb, Chronic Obstructive Pulmonary Disease, Gastro-Esophageal Reflux Disease, Hypertension, and Congestive Heart Failure.R9's MDS dated [DATE] documents R9 is cognitively intact, needs supervision or touching assistance with lower body dressing, and needs partial/moderate assistance with showering/bathing and personal hygiene.R9's Physician Order dated 4/8/2025 at 2:24 PM documents Metformin HCL Oral Tablet 500 mg (Metformin HCL) Give 2 tablets by mouth two times a day.R9's Physician Order dated 4/8/2025 at 3:11 PM documents Polyethylene Glycol 3350 Oral Packet 17 gm (Polyethylene Glycol 3350) Give 1 packet by mouth two times a day.R9's Physician Order dated 4/8/2025 at 3:20 PM documents Spironolactone Oral Tablet 25 MG (Spironolactone) Give 0.5 tablet by mouth one time a day.R9's Physician Order dated 4/9/2025 at 12:07 PM documents Protonix Tablet Delayed Release 20 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day.R9's Physician Order dated 4/9/2025 at 12:07 PM documents Eliquis Oral Tablet 5 mg (Apixaban) Give 1 tablet by mouth two times a day.R9's Physician Order dated 4/9/2025 at 12:08 PM documents Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally one time a day.R9's Physician Order dated 4/9/2025 at 12:08 PM documents Vitamin D3 Oral Tablet 50 MCG (2000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day.R9's Physician Order dated 4/9/2025 at 12:09 PM documents Vitamin-B Complex Oral Tablet (B-Complex Vitamins) Give 1 tablet by mouth in the morning.R9's Physician Order dated 4/9/2025 at 12:09 PM documents Aspirin 81 Oral Tablet Chewable (Aspirin) Give 81 mg by mouth one time a day.R9's Physician Order dated 4/9/2025 at 12:13 PM documents Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml 3 ml inhale orally three times a day.R9's Physician Order dated 4/9/2025 at 12:14 PM documents Alprazolam Oral Tablet 0.5 mg (Alprazolam) Give 1 tablet by mouth three times a day.R9's Physician Order dated 4/9/2025 at 12:14 PM documents Buspirone HCL Oral Tablet 10 mg (Buspirone HCL) Give 15 mg by mouth three times a day.R9's Physician Order dated 4/9/2025 at 12:15 PM documents Magnesium Oral Tablet (Magnesium) Give 400 mg by mouth three times a day.R9's Physician Order dated 4/9/2025 at 12:16 PM documents Ferrous Sulfate Tablet 325 (65 Fe) mg Give 1 tablet by mouth two times a day.R9's Physician Order dated 4/9/2025 at 12:16 PM documents Fish Oil Oral Capsule 1000 MG (Omega-3 Fatty Acids) Give 1 capsule by mouth in the morning.R9's Physician Order dated 4/9/2025 at 12:17 PM documents Calcium 600 Oral Tablet (Calcium Carbonate) Give 1 tablet by mouth one time a day.R9's Physician Order dated 4/9/2025 at 12:18 PM documents Tacrolimus Oral Capsule 0.5 mg (Tacrolimus) Give 1 capsule by mouth two times a day.R9's Physician Order dated 4/9/2025 at 12:18 PM documents Potassium Chloride ER Tablet Extended Release 20 meq Give 1 tablet by mouth three times a day.R9's Physician Order dated 4/9/2025 at 12:35 PM documents Pregabalin Oral Capsule 100 mg (Pregabalin) Give 1 capsule by mouth two times a day.R9's Physician Order dated 4/9/2025 at 12:36 PM documents Jardiance Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth one time a day.R9's Physician Order dated 5/13/2025 at 2:48 PM documents Lasix Oral Tablet 40 mg (Furosemide) Give 1 tablet by mouth 2 times a day.R9's June MAR dated 6/1/2025 through 6/30/2025 does not document R9 received Metformin HCL 500 mg 2 tablets, Tacrolimus 0.5 mg, Alprazolam 0.5 mg, Buspirone HCL 10 mg take 15 mg, Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml, Magnesium 400 mg, and Potassium Chloride Extended Release 20meq as ordered on 6/1/2025 at 6:00 AM.R9's June MAR dated 6/1/2025 through 6/30/2025 does not document R9 received Metformin HCL 500 mg 2 tablets and Tacrolimus 0.5 mg as ordered on 6/4/2025 at 6:00 PM.R9's June MAR dated 6/1/2025 through 6/30/2025 does not document R9 received Alprazolam 0.5 mg, Buspirone HCL 10 mg take 15 mg, Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml, Magnesium 400 mg, and Potassium Chloride Extended Release 20meq as ordered on 6/4/2025 at 12:00 PM.R9's June MAR dated 6/1/2025 through 6/30/2025 does not document R9 received Lasix 40 mg as ordered on 6/4/2025 at 4:00 PM.R9's June MAR dated 6/1/2025 through 6/30/2025 does not document R9 received Aspirin 81 mg, Calcium 600 mg, Fish Oil 1000 mg, Jardiance 10 mg, Protonix Delated Release 20 mg, Spironolactone 25 mg take 1/2 tablet, Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT 1 puff, Vitamin D3 50 mcg, Vitamin-B Complex 1 tablet, Eliquis 5 mg, Ferrous Sulfate 325 mg, Lasix 40 mg, Polyethylene Glycol 3350 Oral [NAME] 17 gm, Pregabalin 100 mg, as ordered on 6/5/2025 at 9:00 AM.R9's June MAR dated 6/1/2025 through 6/30/2025 does not document R9 received Alprazolam 0.5 mg, Buspirone HCL 10 mg take 15 mg, Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml, Magnesium 400 mg, and Potassium Chloride Extended Release 20meq as ordered on 6/5/2025 at 12:00 PM.On 7/22/2025 at 10:20 AM V2, Director of Nursing (DON), stated when a medication is given, the medication should be documented as soon as is dispensed on the resident's MAR. V2, DON, stated if the resident's MAR does not have any documentation on a day, then the medication was not given.The Facility's Medication Administration Policy last revised 5/2017 documents All medication are administered safely and appropriately to aid residents to overcome illness relieve and prevent symptoms and help in diagnosis. Document as each medication is prepared on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to answer call lights in a timely manner in 6 (R37, R14, R64, R18, R51, R61) of 6 residents reviewed for call lights in the sample of 33. Findings include: On 6/10/2025 at 1:45PM R37 stated They are understaffed here. They won't answer call lights, and I have sat on the bedpan for an hour before. R37's Minimum Data Set, MDS dated [DATE] documents R37 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R14 stated Staff ignore call lights even when I am in the shower. They know they put me in the shower, but they don't look for me to be done. R14's MDS, dated [DATE] documents R14 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R18 stated Staff ignore call lights. R18's MDS, dated [DATE] documents R18 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R51 stated Staff ignore call lights. R51's MDS, dated [DATE] documents R51 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R61 stated Staff ignore call lights. R61's MDS, dated [DATE] documents R61 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R64 stated Staff ignore call lights. My roommate will need something, and I will yell for him because no one comes in. R64's MDS, dated [DATE] documents R64 has no cognitive deficits. On 6/13/2025 at 10:00AM V30, Assistant Director or Nursing, ADON, stated I expect the call lights to be answered in at least 2 minutes. Facility call light policy with a revision date of 9/2022 states To provide the staff with guidance on responding to residents' requests and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to follow its Fall Prevention and Management policy and complete a root cause analysis after each fall, failed to implement interventions after each fall, and failed to implement fall interventions according to resident care plans for 3 of 4 residents (R2, R3, R6) reviewed for falls in the sample of 15. Findings Include: 1. R2's medical diagnosis form, print date of 5/21/25, documented R2 has diagnoses including aphasia following cerebral infarction, apraxia, cerebrovascular disease, hemiplegia, type 2 diabetes mellitus, depression, anxiety, hypertension, heart disease, contractures of lower extremities, and dementia. R2's MDS (Minimum Data Set), dated 2/24/25, documented R2 is severely cognitively impaired and dependent on staff for all ADLS (Activities of Daily Living). R2's fall risk evaluation, dated 2/18/25, documented R2 is at high risk for falls. R2's care plan, undated, documented R2 is at high risk for falls related to poor communication/comprehension, gait/balance problems, incontinence secondary to CVA (cerebrovascular accident). R2's care plan does not document R2's fall on 5/17/25 nor any new fall prevention interventions to reduce R2's fall risk. R2's fall report, dated 5/17/25 at 10 AM, documented this RN (Registered Nurse) was preparing medications at the med cart for another client at the end of 300 hall. This RN observed from the end of the hall R2 lying on the floor in the hallway in front of her wheelchair. RN questioned CNA (Certified Nurse Assistant) on hall if she saw resident fall. CNA denied witnessing fall. Both CNA and this RN had observed resident in wheelchair in hallway moments ago and several times throughout the morning. RN questioned multiple staff about incident due to this RN and CNA assigned to the floor are new staff and unfamiliar with resident's norms. All staff deny witnessing the fall and confirm this is unusual for R2. Immediate Action Taken: This RN and nurse from 400 hall assessed R2 for injuries and obtained vital signs, called 911. This form does not document a root cause analysis of this fall nor any interventions to reduce the risk of R2 sustaining further falls. R2's EMR (electronic medical record) does not document this fall in R2's progress notes, does not document that R2 went to a local emergency room for treatment after the fall, nor is there any post fall monitoring of R2 documented after she fell on 5/17/25. R2's local Emergency Department reports, dated 5/17/25, documented reason for visit was a fall, R2 is a [AGE] year-old female with a history of apraxia and aphasia presenting to the ED (Emergency Department) via EMS (emergency medical services) for an unwitnessed fall. Patient was found on the floor next to her wheelchair. It continues, no definite injury noted at the time. CT (computed tomography) without obvious intracranial acute finding. Patient can be discharged to follow up with primary physician. On 5/21/25 at 2:17 PM V2, DON (Director of Nursing) stated R2 did recently have a fall from her wheelchair, was sent to the ER but they did not find any injuries, and that the paramedics told the facility nurses that R2 needs to be tied down in her chair. Surveyor asked V2 if she expects the nurses to document falls and follow up monitoring on residents who fall and V2 replied normally the nurses are supposed to document falls, complete a fall report in risk management, monitor the resident for 3 days after the fall, assess pain, and complete post fall evaluations. V2 stated she does not know why this was not done for R2's fall. On 5/29/25 at 2:43 PM, V1 Administrator and V2 DON stated R2's intervention is on her care plan. Surveyor pulled care plan history, and it documented R2's fall intervention was added to her care plan on 5/23/25 after surveyor entered on the complaint on 5/21/25. V2 confirmed the intervention was added on 5/23/25. 2. R6's face sheet, print date of 5/27/25, documented R6 has diagnoses including dysphagia following cerebral infarction, chronic obstructive pulmonary disease, unsteadiness on feet, schizoaffective disorder, depression, anxiety disorder, peripheral vascular disease, osteoarthritis, and repeated falls. R6's MDS, dated [DATE], documented R6 is moderately cognitively impaired and requires partial to moderate assistance and a wheelchair with transfers and mobility. R6's Fall Risk Evaluation form, dated 4/14/25, documented R6 is high risk for falls. R6's care plan, undated, documented resident is at high risk for falls related to cognition, CVA (cerebrovascular accident), and frequent falls prior to admission to facility. She is non complaint with her transfer status and continues to transfer self. R6 slid out of her wheelchair on 2/19. R6 fell out of bed on 3/4. 5/23 (non-skid) tape applied to resident's wheelchair to prevent further falls due to sliding out of wheelchair. 3/25 trying to transfer into her chair when the chair moved. 4/14 fall. 4/26 fall. This care plan documented interventions including on 3/25 new wheelchair was given to resident for transfer, on 4/14/25 side rails applied to bed, and on 7/25/24 floor mats while in bed. R6's incident report, dated 3/26/25, documented CNA alerted that resident was on the floor, this nurse goes to access resident, resident sitting on her bottom in front of the bed. Resident stated that she did not hit her head, resident c/o (complained of) right leg pain when asked how she fell resident stated she was trying to transfer into her chair when the chair moved. This nurse educated resident on using call light and asking for help, this nurse gave resident PRN (as needed) pain med for pain. This nurse and CNA transferred resident into the chair. Resident description: resident stated she was trying to transfer into her chair when the chair moved. This form documents additional areas to be completed including predisposing environmental factors, predisposing physiological factors, predisposing situation factors, and predisposing situation factors and all are blank. This form does not document a root cause analysis of the fall was completed, nor a new fall intervention was implemented. R6's incident report, dated 4/14/25, documented this nurse was notified that resident was on floor next to bed. Witnessed by staff, resident rolled out of the bed trying to sit up to get out of bed. No injuries noted, no complaints of pain or discomfort. Resident stated that she rolled out of the bed when trying to get up. The remainder of this form is blank including mental status, predisposing environmental factors, predisposing physiological factors, predisposing situation factors, nor is there a root cause analysis documented. This incident report does not document a new intervention was implemented to reduce R6's risk of experiencing further falls. R6's care plan, undated, documented side rails were added to R6's bed on 4/14/25. R6's incident report, dated 4/18/25, documented resident was in room yelling for help. When this writer entered room resident was lying on the floor on back near bed. Resident attempted to self-transfer. Noted resident's call light was within reach, but resident did not utilize call light for assistance. Resident was wearing grip socks at time of fall. Resident stated, I hit my head, my head and right leg hurt. Resident sent to ER d/t (due to) hitting head, and c/o pain in right leg and head. This incident report does not document a root cause analysis of the fall nor that a new intervention was implemented to reduce R6's risk of experiencing further falls. R6's care plan was not updated with a new fall prevention intervention following this fall she sustained on 4/18/25. R6's progress note, dated 4/19/25 at 2:55 AM, documented resident returned from hospital via ambulance. No noted injuries seen at this time. On 5/27/25 at 10:30 AM R6 was observed sleeping on her bed. R6's bed did not have side rails attached to either side of the bed, there was no mat on the floor next to the bed, and no non-skid mat on R6's wheelchair that was sitting next to her bed. On 5/27/25 at 2:48 PM V2 DON stated the root cause analysis of each fall, and the new fall prevention intervention should be documented on the incident report and added to the care plan. 3. R3's medical diagnosis form, print date of 5/21/25, documented R3 has diagnoses including vascular dementia with mood disturbance, cerebral infarction, aphasia, hemiplegia, schizoaffective disorder, hypertension, depression, hyperlipidemia, and mood disorder. R3's MDS, dated [DATE], documented R3 is severely cognitively impaired and dependent of staff for all ADLS (activities of daily living). R3's fall risk evaluation, dated 4/25/25, documented R3 is high risk for falls. R3's care plan, undated, documented R3 is at high risk for falls, R3 experienced 2 falls on 4/25/25, and an intervention of activities will offer diversion activities. R3's incident report, dated 3/27/25 at 8:30 AM, documented called to the front door by staff who stated that resident barreled through the front door. When staff tried to pull him back in, he slid out of his w/c (wheelchair) landing on his buttock in the entry way. When asked if he was hurt, he shook his head no. Residents speech is altered and difficult to understand, he wouldn't talk to staff. Resident assessed and assisted to his w/c (wheelchair) with 2, he tried to put himself on the ground again while pulling back into the facility. This incident report does not document a root cause analysis of this fall nor an intervention to reduce the risk of R3 experiencing additional falls. R3's care plan does not document an intervention was added after this fall. R3's incident report, dated 4/25/25 at 5:30 PM, documented I saw resident going through the front doors as I was coming out of the kitchen, I went to the front door to stop him. I tried to push him back in and he planted his feet and grabbed the door to keep me from bringing him back inside. 2 CNAs came to the front to try and encourage him to return back in the door and he kept planting his feet and grabbing at things to avoid returning back inside. The 2 CNAs then pick up the w/c and resident put himself on the floor, refusing to cooperate with staff, they did a 2-man lift returning resident to his w/c, when attempting to bring him back and away from the door, he put himself in the floor a 2nd time. Resident unable to communicate and be understood. This incident report does not document a root cause analysis nor an intervention to reduce R3's risk of further falls. R3's incident report, dated 4/25/25 at 5:45 PM, documented Nursing Description: again, upon trying to return resident to his room he refused and for the 2nd time he put himself on the floor again. Resident Description: Again, resident is difficult to understand. Resident was 2 man lifted into his w/c and remains at the front door. This report does not document a root cause analysis of this fall nor a fall intervention to decrease R3's risk of experiencing more falls. R3's activity attendance records, dated 4/30/25 - 5/28/25, documented R3 only attended 1 activity between these dates. On 5/29/25 at 8:52 AM V15, Activity Director, stated R3 does not come to activities, she does not know what fall interventions R3 has in place, and no one has informed her of R3's fall interventions. On 5/29/25 at 10:57 AM V15 Activity Director stated R3 has not had an activity assessment completed since he was admitted to the facility. V15 stated it should have been completed on admission and quarterly. On 5/29/25 at 2:32 PM V1, Administrator, stated the nurses or DON are supposed to complete a root cause analysis after each fall, a new intervention is supposed to be care plan and implemented after each fall, and fall interventions should be in place according to the care plan. The facility's Fall Prevention and Management policy, dated 5/2015, documented General: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Responsible Party: RN, LPN (Licensed Practical Nurse), DON. Guidelines; Upon admission: 1. A fall risk evaluation will be completed on admission, readmission, and quarterly significant change and after each fall. 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP (Individual Service Plan) with interventions implemented to minimize fall risk. Facility Guideline following a fall incident: 1. Evaluate the resident for any injury and notify the physician and emergency contact. 2. Complete a fall incident report in the (EMR) risk management portal. 3. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicated the resident is at high risk for falls. 4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 5. Complete the follow-up monitoring form every shift for 72 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations were thoroughly investigated for 2 of 6 residents (R1, R6) reviewed for abuse investigation in the sample of 12. Findings include: 1-R1's Face sheet dated 5/13/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Cerebral Palsy, Epilepsy, Schizophrenia, and Major Depressive Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires the use of a wheelchair. R1's Care Plan, dated 2/14/25, documents R1 is at risk for abuse and neglect. R1's Care Plan, dated 3/18/25: Alleged sexual assault. R1's Care Plan, dated 5/12/25: Recipient of alleged sexual assault. Interventions: 3/18/25 Social Service Director had conversation with resident about inappropriate behavior. Residents not able to sit together in dining room, if seen together to separate. R1's Care Plan, dated 3/18/25: placed on enhanced supervision. R1's Care Plan, dated 5/12/25 Notified abuse coordinator, observe the resident for signs of fear and insecurity during delivery of care, take steps to calm the resident and help him feel safe, 1:1 Supervision, Social Services to meet with resident as needed, assess resident for abuse and neglect upon admission and quarterly. It continues R1 has diagnosis of Schizophrenia and may display symptoms that include but are not limited to being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness. It continues R1 requires assistance with daily care needs. R1's Care Plan does not address R1 being bullied and/or any resident asserting dominance over him. On 5/28/2025 at 10:02 R1's Behavior Tracking was requested. No behavior tracking was provided to the surveyor for R1. The Facility's Identified Offender lists document R1 and R6 both as Identified Offenders, with R6 being convicted of second-degree murder in 1990. On 5/28/2025 at 2:03 PM, R1 was lying in bed. R1 appeared very thin in appearance and his body was leaning to the right side. On 5/29/2025 at 3:01 PM, R1 stated, (R6) and him were alright, but he would not call them friends. (R6) does buy him food at times, candy and soda. He stated (R6) still thinks they are in prison and treats him like they are still in prison. He has always bullied him, and he is constantly telling him he is going to mess him up and stab him or fuc* him over if he does not do what he tells him to do. I can't do much anyway, so it does not matter. Things changed for me when he came into my room, woke me up and was playing with my butt and stuck something up my butt. I want a lawyer. I am not sure why he did it, I think he wants me to know he is the boss of me. I know I am not in prison anymore and (R6) abuses me like we are still in prison. I see him mostly during smoke breaks. I don't like to leave my room now. R1 appeared upset and teary eyes while discussing this incident and his voice was shaky while he was talking about (R6). On 5/14/25 at 10:55 AM, R7 stated I always see (R6) trying to dominate (R1). (R6) grabs (R1) by the back of his neck or pinches his shoulders and will tell him things like 'I'm going to play with you like a fidget [NAME]'. I know they were both in prison together and some things might have started there. The look on (R1's) face and the tear in his eyes showed me he was clearly upset over this. I totally believe that incident happened in (R1's) room because I've seen him treating (R1) like that before. I know that since that incident, they have put both on 1:1 supervision and they moved (R1) out of his room to another hall. It seems like they are punishing (R1) while protecting (R6). There is no doubt in my mind that (R6) is abusing (R1). On 5/29/2025 at 10:03 AM, R7 stated, I have seen (R6) during smoke breaks harass (R1) and I know staff have seen it too, but everyone is afraid to speak up because nobody wants to get in trouble and/or lose their job, but (R1) is not in prison anymore and should not have to, live in fear and be bullied. Like I told the other surveyor, (R6) tries to dominate (R1) and I don't think it is right. I have heard him tell him he is going to hurt him and/or play him like a fidget [NAME]. I know since the incident occurred (R1) has been staying in his room more. On 5/14/25 at 10:40 AM, V5, Restorative Certified Nursing Assistant (CNA), stated I work with (R1) all the time for therapy, and we have a really good relationship. I also heard a while back that (R1) and (R6) have had things going on for a long time, because (R7) stated that (R6) is always picking on (R1) and flicking his ear and telling (R1) he is going to treat him like he was treated in the joint. I told the previous Administrator about all of this at that time, and she brushed it off and acted like it never happened. Then this happened to (R1) and he cannot really defend himself. This is terrible and very serious and hope that something gets done. On 5/14/25 at 11:35 AM, V4, Director of Rehab, stated I have overheard (R6) has been victimizing (R1) and bullies and picks on him all the time, and that they were in prison together and (R6) victimized him in prison too. (V7, NP) told me that (R6) threatened to kill her and that she was surprised that (R6) is still in the facility. It's awful for (R1) to be treated like that. On 5/14/25 at 11:45 AM, V7, Nurse Practitioner (NP), stated, I, myself, was threatened by (R6). (R6) really likes his pain medications and his insurance was declining his Oxycodone, so I had to change him to Percocet, and he hysterically flipped on me and told me I had to watch my back. I talked to my fiancée because I was scared, and I cried every time I would have to come to the facility for a good two weeks. He gets passes out to the community and then comes back so who knows what he is getting out there, drugs or weapons. (R6) scares me, and he doesn't need to be here. He is a threat to everyone in here, residents and staff. On 5/30/2025 at 1:48 PM, V7 stated, (R6) was upset with me because of his medication change and he said several things to me and told me to watch my back and threatened me. I told V34, the former Administrator. (R1) came into the therapy room and alleged that he had been sexually abused by (R6). At that time staff started talking and they were saying (R6) had a history with (R1) and he had been bullying (R1). (V34) was aware of it. I am not sure what their policy is regarding abuse. I can only go by my experience, and I think (R6) is dangerous and at times can be unhinged. If a resident was being bullied by another resident, I would not expect the other resident to ever be alone with that resident. On 5/30/2025 at all abuse investigations for R1 were requested for the past six months. On 5/30/2025 at 2:00 PM, V1, Administrator stated I have only been working in the facility since the end of March and I have went through all of the previous abuse investigations for the past six months and there were no abuse investigations filed by (V34, Former Administrator) and or any abuse investigations related to (R1) and (R6) not getting alone and/or (R1) being bullied by (R6). V1 stated if someone made an allegation of (R6) bullying (R1) she would expect a reportable to be completed. This is the first I am learning of it. The DON (Director of Nursing) is also new to the position. Staff stated (R6) and (R1) were incarcerated together at (V32, Correctional Facility). They do have a history. From my understanding they were both in the same gang in prison, so they were not rivals. I am not aware of any issues they had when they were in prison. They are both identified offenders. (R1) initially reported to the CNA (certified nursing assistant) that he was sexually assaulted by (R6). (R1) told me (R6) came into his room and held his head down and he was sexually abused. But the stories were conflicting and kept changing. I was not able to substantiate it. On 5/30/2025 at 12:54 V34, Former Administrator at facility stated, I don't recall anything related to (R1) and (R6) but I was only at the facility for a few months. I did not really know either of them. 2- R6's Progress Notes dated 8/15/2024 at 3:37 PM document he was admitted to the facility. R6's POS dated May 2025 documents a diagnosis of Aftercare following joint replacement surgery, Chronic Obstructive Pulmonary Disease Unspecified, Unspecified Lack of Coordination, Difficulty In Walking, Unsteadiness On Feet, Weakness, Major Depression, Chronic Pain, Chronic Kidney Disease Stage 2, Periprosthetic Fracture Around Internal Prosthetic Right Shoulder Joint, Displayed Fracture Of Glenoid Cavity Scapula. R6's MDS dated [DATE] document he is cognitively intact for decision making for activities of daily living and has no impairment on his upper and/or lower extremities. R6's Care Plan document dated 4/12/2024 documents AMBULATION: has a self-care deficit in ambulation r/t inability to walk independently/ history of unsteady gait/ walks for short distances but uses the w/c for longer distances, with guided practice has the opportunity for continued progress. R6's Care Plan does not document anything related to abuse. R6's Progress Notes do not document anything related to him being on one on ones and/or the allegation of sexual abuse made against him by R1. R1 and R6's medical records do not document any bullying between (R1) and (R6). R6's Care Plan does not document R6 was bullying R1 and R1's Care Plan does not document R1 was being bullied. The Facility did not have any documentation related to R1 making an allegation of abuse even though a few staff were aware of the allegation. Not reportable was submitted to the State Agency for an allegation of abuse for R1 and R6. No investigation was completed and/or reported. V1's investigation on R1 and R6 sexual abuse allegation, dated 5/12/25, documents (R1) alleged that he was sexually assaulted by resident (R6) last night. He stated that (R6) came to his room and gave him pizza and breadsticks and then later came back and assaulted him. Family, Physician, and (Local Police Department) notified. (R1) declined assessment from nurse and declined hospital transfer. (R6) denied allegation and stated he only entered his room to offer pizza. Both residents immediately placed on 1:1 with staff. Video surveillance reviewed shows (R6) entering (R1) room with a pizza box and exiting the room within 1 minute without the box. Per footage, (R6) did not enter his room again. Investigation Initiated. Final to follow. All residents in the facility were interviewed using an Abuse Investigation [SIC] Questionnaire with some residents asked Are you aware of any sexual behavior between residents?, some residents asked Have you ever witnessed anyone touching any resident inappropriately?, some residents asked Have you ever witnessed any inappropriate touching with staff and residents?, and then some residents (including R7) was asked Has anyone here touched you inappropriately? R7 was never asked if he had witnessed any behaviors, only if anyone had touched him inappropriately. The final report states as follows: (R1) initially told (V18, CNA) and (V27, CNA) on the morning of 5/12/25 that on 5/11/25 when it was dark outside, (R6) returned to his room after dropping off the pizza and held his head down and Raped him. He also told (V28, LPN) that (R6) penetrated him. Then later that morning, he told the therapist and restorative aide that (R6) stuck his fingers in his butt. He said he yelled out and then (R6) held his head down and when he left, he yelled out again. (R6) told the Administrator he took a pizza and breadsticks to his (R1's) room I asked him if he wanted the pizza, he said yes, I put the box on his table and walked out. (R6) stated that was the only time he was in his room. The Administrator told (R6) that there was an allegation of sexual interaction between him and (R1). He stated, I only like women. Video footage reviewed and showed (R6) exiting his room at 21:59, walking across the hall with a pizza box and his cane, entering (R1's) room and exiting and reentering his own room at 21:59. Total time was 20-seconds. According to video footage (R6) did not enter (R1's) room again. Per CNA (V14) was his care giver from 3P to 7AM on 5/11/25. Statement conveys the CNA was doing 10PM rounds and noted (R1) laying [SIC] in bed fully dressed. He sleeps in his clothes all the time because he says he's cold all the time. At no time did residents have an altercation verbally or physically. Video footage showed CNAs rounding the hall frequently. Residents and staff were interviewed regarding any sexual behaviors witnessed between residents with no adverse findings. Summary: (R1) suffers from Schizophrenia and has a history of psychiatric hospitalizations related to accusing his dead brother of hurting him. (R1) was also witnessed laying in his bed fully dressed the night of the alleged incident and the morning after. (R6) left his room at 21:59:08, entered (R1) room with pizza box at 21:59:18 and exited the room without the pizza box at 21:59:38. The conclusion of this investigation is that the alleged abuse is unsubstantiated based on video footage and interviews. Physician reviewed (R1's) medication and completed follow-up with both residents. Referral to psych pending for (R1) and (R6). Residents will remain on 1:1 with periodic re-evaluation to determine the need. Plan of care to be updated for both residents. A Handwritten Note, dated 5/12/25, documents I (V5), was doing restorative program with (R1) when he stated (R6) was a booty banger and he said he pulled his blankets down and was holding him down by his neck and felt someone playing with his bottom. He started screaming. He stated he was playing with his a**. A Handwritten Note, dated 5/12/25, documents On this date May 12th (R1) was in therapy room for therapy and stated that (R6) was a booty banger. He continued to say (R6) pulled his blankets off him and was holding him down by his neck and that the resident was playing with his a**. (R1) stated he was asleep, and this woke him up. signed by V4, Director of Rehab. R1's Nurses Note, dated 5/12/25 at 12:15 PM, documents Resident reported that he was sexually assaulted by resident (R6) in his bedroom while laying [SIC] in his bed. Resident stated that resident (R6) entered his room sexually assaulted him then exited the room. Resident stated he did not see the resident's face but, he did recognize who the resident was because he knows his voice and noticed him while he was walking out the door. Nursing staff attempted to assess resident, but resident refused. Administrator, Director of Nursing (DON), and NP notified and made aware. (Local Police Department) notified and resident interviewed. Residents separated; Resident placed on 1:1 supervision; Resident relocated; All previous interventions in place; Care plan updated. The Police Report, dated 5/12/25, documents On 5/12/25 at approximately 11:29 hours, I (V31, Police Officer) was dispatched to (this facility) for a report of a criminal sexual assault. It should be noted; this incident is merely a summation of my contacts with the aforementioned individuals. For specific statements, quotes, and a specific timeline of events, refer to the available body-worn camera footage of this incident. Upon arrival, I contacted facility manager (V1, Administrator), who advised resident (R1) had report being sexually assaulted by his neighboring resident, (R6). (V1) then contacted staff members, who brought (R1) to the management office in order for me to speak with him regarding the incident. Upon (R1's) arrival, he advised (R6) had responded to his room (XXX) late in the evening on 5/11/25. (R1) stated (R6) briefly entered the room to bring him pizza and left the room a short time later. (R1) advised, at what he believed to be approximately an hour later, he was naked and asleep in his bed when he felt a hand fondling his a**. (R1) only provided a brief and vague recollection of the actions that occurred. However, (R1) advised the suspect held his head down into the pillow to prevent him calling for assistance, and the suspect then digitally penetrated his rectum before fleeing the room. (R1) advised he was unable to see the suspect ' s face during the alleged incident, but (R1) advised he observed the suspect walk out of the room, at which time he identified (R6) as the suspect, due to recognizing (R6's) gait. (R1) was unable to provide any further evidentiary information regarding this incident. I then responded to room xxx and contacted (R6). (R6) advised he had responded to (R1's) room during the evening hours of 5/11/25, at which time he brought (R1) pizza, and left promptly afterwards. (R1) advised, throughout the remainder of the night, he only left his room on (1) other occasion, at which time he did not go into or walk past (R1's) room. (R1) denied being involved sexually with (R1) in any capacity, and he provided no further information at this time. I then spoke with (V1) again, at which time (V1) advised she had begun the process of reviewing the facilities cameras to see if any footage was available to substantiate (R1's) claims of sexual assault. (V1) advised she had already reviewed security footage which covered the evening hours of 5/11/25 and early morning hours of 5/12/25. (V1) advised the footage captured (R6) entering (R1's) room (while holding a pizza box) at approximately 2200 (10:00 PM) hours on 5/11/25. (V1) advised the footage showed (R6) exiting (R1's) room less than (60) seconds later. (V1) advised the footage captured (R6) exiting his room an additional time at 2236 (10:36 PM) hours and return to his room at approximately 2250 (10:50 PM) hours. However, (R6) was observed to walk in an opposite direction from (R1's) room, and (R6) never walked in the direction of/into (R1's) room at that time. (V1) advised the footage confirmed (R6) did not leave his room for the remainder of the evening/early morning hours. (V1) advised she intended to review security footage from the past several days, to confirm the incident reported by (R1) had not occurred on an alternative date. (V1) advised she would contact me if any suspicious activity was observed on camera. As of the completion of this report, (V1) has not contacted this agency with any additional information. Of note, (V1) also advised (R6) and (R1) have known each other for years, after having served several years together in (Local Correctional Center), prior to residing together at (this facility). (V1) was unsure if their history together had any contribution to this incident. (V1) also advised (R1) has been diagnosed with Schizophrenia, which may have played a part in (R1's) report. Prior to my arrival, (V1) and faculty members offered to arrange for (R1) to be medically evaluated. However, (R1) refused any evaluation or medical assistance. Due to lack of current evidence substantiating (R1's) recollection of events, no charges have been authorized at this time. Body-worn camera footage of this incident is available. Any additional information will be documented in a supplemental report. The Police Report, dated 5/14/25, documents I (V26, Police Officer) contacted (R7) who advised he wished to provide me further information in regard to report 25-12823 which involves (R1) and (R6). (R7) advised he is (R1's) best friend and has been for approximately seven months while they have both been in the facility. (R7) stated he has previously observed (R6) place his hand on (R1's) shoulder and whisper sexual innuendo's into (R1's) ear. (R7) stated he spoke to (R1) about what was report under report number 25-12823. (R7) stated he feels as if (R1) is too scared of retaliation for (R6's) friends or gang to speak with police. (R7) stated he believes (R6) kept putting his hand on (R1's) shoulder and whispering sexual innuendoes in an attempt to show dominance. (R7) additionally advised he feels that (R6) should have been taken into police custody during report 25-12823. (R7) was advised his feelings and thoughts would be documented however, cannot be utilized in the advancement of report 25-12823. No further police action taken. CB2209. V1's investigation failed to provide consistency in questioning the residents. Some residents were asked if they were aware of any sexual behavior between residents, some were asked if they have ever witnessed anyone touching any resident inappropriately, some were asked if they have ever witnessed any inappropriate touching with staff and residents, and some were asked if anyone has touched you inappropriately in the facility. R7 was asked if anyone has touched him inappropriately, which he commented No', however, if R7 was asked if he had ever witnessed anyone, staff or resident, touching a resident inappropriately, he would have told what he witnessed between R1 and R6, as he stated to the Police Officer. The Facility's Abuse Prevention Program Policy, dated 9/2017, documents in part The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. VII: Internal Investigation: 2. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 3. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 5. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide residents with the correct diet as ordered by the physician for 4 of 4 residents (R3, R8, R11, R12) reviewed for residents receiving the correct diets in the sample of 12. The Findings include: 1. R3's admission Record, dated 5/19/25, documents R3 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Type 2 Diabetes Mellitus (DM), Alzheimer's disease, Asthma, Hypertension, Idiopathic Neuropathy, Left Below Knee Amputation (BKA). R3's Care Plan, dated 4/29/25, documents R3 is at risk for altered nutrition and hydration. Interventions: Honor fluid/food preferences based on MD orders and Dietary Restrictions, ST as needed, Therapeutic diet as ordered. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a severe cognitive impairment and is dependent on staff for Activities of Daily Living (ADLs). R3 requires supervision/touching assistance from staff for eating. R3's Physician Order, dated 4/17/25, documents NAS (No Added Salt) diet, Pureed texture, Thin Liquids Consistency. R3's Physician Order, dated 5/9/25 at 2:35 PM, documents Weighted Spoon and Fork. OT (Occupational Therapy) notified with meals, weighted Spoon and Fork with meals ordered. On 5/14/25 at 8:53 AM, R3 stated she gets the same food as everyone else at the table. On 5/14/25 at 2:30 PM, V10, Speech Therapist, stated I have been working with (R3) for at least three different assessments and it was determined that (R3) can only be on a Pureed diet at this time. I was told by staff that (R3) can take up to two hours to eat a meal because she is always pocketing and chewing on her food, therefore, making her a high aspiration risk. (R3's) daughter keeps bringing her regular food and we can walk past her room and see her still chewing on something and her daughter even makes her spit it out after a while. When I'm working with (R3), she will comment I can't chew this, then after we gave her Pureed foods, she would comment This is much better and eat her meals. On 5/15/25 at 8:30 AM, R3 was sitting in dining room while breakfast tray was delivered. R3 received eggs, bowl of hard round cereal, and toast. There was no meal slip indicating what type of diet she should be on. R3 was seen chewing on toast for a long time without swallowing it. On 5/15/25 at 8:31 AM, V16, Certified Nursing Assistant (CNA), stated I have no idea what type of diet (R3) is on, I was just setting up her tray for her. On 5/15/25 at 8:32 AM, V2, Director of Nursing (DON), stated I don't know what (R3's) diet is. It should be on her meal slip at the table, but she doesn't have one. On 5/15/25 at 8:35 AM, V15, Dietary Manager, stated (R3) is supposed to be a hall tray that is why she did not get a meal slip. That's the problem here, the CNAs don't tell us when they bring the resident to the dining room and they just go to the warmer and get a normal plate of food and pass it out to the residents waiting for their meal. V15 walked into the kitchen and provided a list of residents who are on a special diet. Upon review of the list, R3 was not listed on the list for Pureed Diet. V15 stated I have only been here about a month, so the list has not been updated. I see there are people on this list that are no longer here even. 2. R8's admission Record, dated 5/19/25, documents R8 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis, Type 2 DM, Aphasia, Contracture right hand/shoulder, Epilepsy, and Hypertension. R8's Care Plan, dated 3/19/25, documents R8 has a nutritional problem or potential nutritional problem. Interventions: Assist with tray setup as needed, explain and reinforce to R8 the importance of maintaining the diet ordered, provide, serve diet as ordered: Consistent-Carbohydrate, Mechanical (Mech) Soft texture, thin liquids, R8 to sit at assistive table in dining room for all meals. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and requires partial/moderate assistance from staff for eating. R8's Physician Order, dated 2/12/24, documents CCD (carbohydrate-controlled diet) diet, Mech/Soft texture, Thin Liquids consistency. On 5/15/25 at 8:40 AM, R8 received eggs, dry hard cereal, and toast for breakfast. R8's meal ticket on the table indicated that R8 is a Mechanical Soft diet. On 5/19/25 at 12:20 PM, R8 was seen eating in dining room with the same plate of food that everyone else had in the dining room. R8's meal ticket indicated R8 is on a Mechanical Soft Diet. R8 was given noodles and beef, a cup of vegetables/tomatoes, and a cup of fruit. On 5/19/25 at 10:55 AM, R8 stated he gets a regular diet, same food as everyone else, the staff helps him eat, and he chews the meat the best he can and swallows it. 3. R11's admission Record, dated 5/20/25, documents R11 was admitted to the facility on [DATE] with diagnoses of Intracerebral hemorrhage with Ataxia, Dementia, Epilepsy, COPD, Bell's Palsy, Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder, and Idiopathic Neuropathy. R11's Care Plan, dated 3/28/25, documents R11 has nutritional problem or potential nutritional problem r/t variable appetite, refusing to eat at times and behaviors and forgetful at times when she has eaten. Interventions: Assist with tray setup as needed, explain and reinforce to R11 the importance of maintaining the diet ordered, provide, serve diet as ordered. R11's MDS, dated [DATE], documents R11 has a severe cognitive impairment and requires set-up or clean-up assistance from staff for eating. R11's Physician Order, dated 4/15/25, documents NAS diet, Mech/Soft texture, [NAME] Liquids consistency. On 5/15/25 at 8:40 AM, R11 received eggs, hard cereal, and toast which was the same as every resident sitting in the dining room. On 5/19/25 at 12:25 PM, R11 seen eating in dining room with same plate of food as every resident which was noodles with beef, bowl of vegetables, and bowl of fruit. On 5/19/25 at 10:50 AM, R11 stated she gets a regular diet, same food as everyone else. R11 stated she gets meats, potatoes, and vegetables. PO - NAS/Mech Soft, Thin Liquid consistency. 4. R12's admission Record, dated 5/20/25, documents R12 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction with Hemiplegia and Hemiparesis, Aphasia, Type 2 DM, Asthma, Contracture of left hand, Vitamin Deficiency, Major Depressive Disorder (MDD), and Anxiety Disorder. R12's Care Plan, dated 5/9/25, documents R12 is at nutritional risk as disease progresses: Obesity, DM2, Aphasia, Dehydration, MDD. Interventions: Provide diet as ordered, provide supplements as ordered. R12, MDS, dated [DATE], documents R12 has a severe cognitive impairment and requires supervision/touching assistance from staff for eating. R12's Physician Order, dated 5/2/25, documents Regular diet, Mech/Soft texture, Thin Liquids consistency. On 5/15/25 at 8:40 AM, R12 received a bowl of cereal, eggs, and toast for breakfast which was the same as every resident in the dining room. On 5/19/25 at 12:27 PM, R12 was seen eating in the dining room with same plate of food as every resident which was noodles with beef, bowl of vegetables, and a bowl of fruit. On 5/19/25 at 10:53 AM, R12 stated she gets a regular diet, the same food as everyone else. R12 stated she does not like meats so usually doesn't eat it but gets it on her plate anyhow. On 5/19/25 at 12:05 PM, V15, Dietary Manager, stated for the mechanical soft diet, they grind up the meats and anything tough or hard. V15 stated that bread and toast are ok to eat. On 5/19/25 at 12:10 PM, All residents observed and interviewed had the same plate of food which was noodles and meat, a bowl of tomatoes/vegetables, and a bowl of fruit. When asked, V29, Cook, stated This is all considered a Mechanical Soft Diet because the noodles are soft, and the meat is small pieces. On 5/19/25 at 4:30 PM, V15, Dietary Manager, stated I probably would have done things differently. The noodles and meat, I would have chopped up the noodles more and had them separate from the meat, which I would have ground up more to make it a Mechanical Soft diet. I told the CNAs to make sure they get the resident's meal ticket, so they know what meal to serve them. On 4/19/25 at 4:35 PM, V1, Administrator, stated I'm not sure what to say about dietary. They should be following each resident's diet as ordered by the physician. The Facility's Texture and Consistency-Modified Diets Policy, undated, documents in part Texture and consistency-modified diets will be individualized with modifications made by the speech-language pathologist (SLP) and physician in conjunction with the registered dietitian nutritionist (RDN) or designee and director of food and nutrition services. A written order needed. The person-centered approach to diet, and providing individualized intervention is most important. Procedure: 2. Individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing of food, inability to manipulate food in the mouth, wet, gurgled voice, etc.) will be referred to SLP for evaluation of dysphagia. 3. The SLP may request testing to assess the individual's condition. Once a diagnosis has been made, the SLP will work with the RDN or designee to make appropriate recommendations for proper food and fluid consistency. 4. Nursing staff will notify the director of dining services of consistency changes ordered by the physician or designee using the Diet Order Form or other facility communication. 5. The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3(R3) residents reviewed for providing care according to professional standards. Findings include: R3's Census Report, not dated, documents that R3 was admitted to the facility on [DATE] and discharged from the facility on 4/7/2025 with the following diagnoses: AKI/Acute Kidney Injury on CKD/Chronic Kidney Disease Stage IV non anion gap Metabolic Acidosis Prostatomegaly, Complicated UTI/Urinary Tract Infection bladder stents, Fracture of left Humerus, Pacemaker, Accelerated Hypertension, Ataxia, Coronary Artery Disease status post CABG/Coronary Artery Bypass Graft, Chronic Diastolic Congestive Heart Failure, Anemia of Chronic Disease, Paroxysmal Atrial Fibrillation Mobitz second degree block, Prolonged QTc/corrected QT interval, Non-insulin dependent Diabetes Mellitus/DM, Uncontrolled Diabetes, Hyperglycemia, paraspinal disease, CVA/Cerebrovascular Accident, TIA/Transient Ischemic Attack, PVD/Peripheral Vascular Disease status post Stents, CAD/Coronary Artery Disease status post CABG, Hypertension, Hyperlipidemia, GERD/Gastroesophageal Reflux Disease, Hypotension. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact. R3's Hospital Discharge Orders, dated 4/2/2025 at 9:52 AM, documents the following 1. Isosorbide Dinitrate Oral Tablet 30 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 2. Aspirin Oral Tablet Delayed Release 81 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) 3. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for supplement. 4. Levothyroxine Sodium Oral Tablet 50 MCG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for thyroid. 5. glipizide Oral Tablet 10 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for DM before meals. 6. Cephalexin Oral Tablet 500 MG: 1 tablet by mouth two times a day. Give 1 tablet by mouth two times a day for infection. 7. hydralazine HCl Oral Tablet 25 MG: 1 tablet by mouth three times a day. Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) every 8 hours. 8. Metoprolol Tartrate Tablet 50 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 9. Simvastatin Oral Tablet 40 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day for cholesterol. 10. Xarelto Oral Tablet 15 MG: 1 tablet by mouth one time a day. Give 1 tablet by mouth one time a day related to ATRIOVENTRICULAR BLOCK, FIRST DEGREE (I44.0) R3's Physician Order Sheet (POS) and Medication Administration Record (MAR), dated April 2025, documents that R3's Hospital discharge orders were transcribed to the POS and the MAR on 4/5/2925. R3's Medication Administration Record (MAR), dated April 2025, documents no orders for 4/2, 4/3, and 4/4. R3's MAR documents orders transcribed 4/5/2025, 4/7/2025 and 4/8/2025. On 5/1/2025 at 12:12 PM V4, Previous Director of Nursing (DON), stated that his last day was 4/3/2025 and he is not familiar with R3. V4 stated that the process for new admission is that the admitting nurse will transcribe the orders in PCC (Point Click Care) so that it can be sent to pharmacy. The orders are sent to the pharmacy through the PCC. There is a triple check system that is in place to assure that the admission is completed correctly. On 5/1/2025 at 12:41 PM, V3, Assistant Director of Nursing (ADON), stated that she was interim Director of Nursing after V4 left. V3 stated that the admission process is completed by the floor nurse regardless of if they work for the facility or agency. V3 stated that she became aware of R3 not receiving his medications on the Sunday prior to his transfer to hospital. V3 stated that the medication should have been transcribed upon admission. V3 stated that it takes 24 hours for an admission to be completed but the medications are to be transcribed within the first couple hours of the admission. V3 stated that she is not sure why the medications were not transcribed. V3 stated that the admitting nurse was from an agency. V3 stated that the agency nurses can and are expected to complete the admission. V3 stated that there is a triple check system that is in place but was not done either. V3 stated that this would have been completed by the following nurses which were agency nurses as well. V3 stated that they only have 4 facility staffed nurses and they are all scheduled on the other side of the building. V3 stated that the nurses that provided care for R3 was agency. On 5/1/2025 at 2:33 PM V5, Licensed Practical Nurse (LPN), stated that she was in the facility when R3 was admitted , and V5 sent R3 to the hospital. V5 stated that the night of the admission she worked on the other hall and the nurse had 3 admissions. V5 stated that she took an admission, V8, Registered Nurse (RN), took one and V3, ADON, took one. V5 stated that V3 took R3's hospital records home so she could work on them remotely. V5 stated that the orders did not get transcribed until the 5th. The facility's Physician Order policy, dated 2/2024, documents that GENERAL: Drugs will be administered only upon a clean, complete and signed order of a person lawfully authorized to presc1ibe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted. RESPONSIBLE PARTY: Nursing POLICY: Documentation of the Medication Order: I. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). 2· The following steps are initiated to complete documentation: a. Clarify the order b. Enter the orders with administration schedule in PCC and transmit to pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Power of Attorney for the use of a narcotic and refusing therapy for 1 of 3 residents (R6) reviewed for notification in the sample of 21. Findings include: R6's Face Sheet, print date of 3/20/25, documents R6 was admitted on [DATE] and has diagnoses of Schizophrenia, Dementia, Alzheimer's Disease, and Dependence on Renal Dialysis. This Face Sheet also documents V3 as R6's legal guardian. R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired. R6's Physician Progress Note, dated 2/26/25, documents, Interval history: Patient seen and examined today for acute care visit. Nursing staff reports patient is having difficulty sleeping at night. Staff also reports patient having concerns with pain unrelieved by PRN (as needed) Tylenol. Patient reports severe chronic pain in both feet and all over at times. Patient is unable to use NASIDs (Non-Steriodal Anti- Inflammatory) due to HD/ESRD (Hemodialysis/ End Stage Renal Disease). will add PRN Tramadol 50 mg (milligrams) Q (every) 12 hr (hour) for pain control and Trazadone 50 mg QHS (every hour of sleep) nightly. R6's Physician Order, dated 2/27/25, documents, traMADol HCl Oral Tablet 50 MG (Tramadol HCl). Give 1 tablet by mouth every 12 hours as needed for Pain. R6's Controlled Drug Receipt Record/ Disposition Form, dated 2/26/25, documents R6 received 7 doses of Tramadol 50 milligrams between 2/28/25 and 3/16/25. R6's Therapy Notes documents R6 started Speech Therapy on 1/31/25 and was released from Speech Therapy on 2/26/25. R6 started Physical Therapy on 2/1/25 and was released from Physical Therapy on 2/21/25. R6's Electronic Medical Record Fails to document V3 was notified or gave consent for the use of Tramadol. R6's Electronic Medical Record Fails to document V3 was notified of R6's refusal of therapy and termination of therapy. On 3/19/25 at 4:25 PM, V3 (R6's Power of Attorney), stated she was never notified of R6 being ordered Tramadol for pain in R6's feet. V3 stated, I would have never given consent for this. Pain medication makes her crazy. The strongest thing she can have is Tylenol. I want to know exactly what she is getting so I can monitor her behaviors since she has Dementia and from what I am reading a lot of medications will have negative results with Dementia. I have told them that. I was never notified of R6 refusing therapy. On 3/18/25 at 11:03 AM, V9, Therapy Director, stated R6 would refuse therapy often. She would get hateful about it. R6 is a Medicaid resident. The facility will pay for 6 visits at a time. Once a resident refuses 3 times in a row we discharge them from the program for non-participation. I am not sure if her Power of Attorney was contacted about refusal or not. I will check into it. On 3/18/25 at 11:33 AM, V1, Administrator, stated that she does not know if therapy notified V3. On 3/19/25 at 8:50 AM, V9, stated she was unable to find any documentation of V3 being notified of R6 refusing therapy but V12, Physical Therapy Assistant, did say she called and left a message but V3 never called back. On 3/19/25 at 12:28 PM, V12, stated V3 wanted to know how R6 was doing. I did make a phone call to her. It wasn't answered. I did not leave a voice mail because of privacy issues. R6 would refuse therapy often. On 3/19/25 at 12:35 PM, V2, Director of Nurses, stated V3 should have been notified before the Tramadol was started. The policy change in Resident Condition, dated 10/2024, documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change of condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental or emotional status. c. There is a pattern of refusing treatments or medications. d. the resident wants to be discharged AMA (against medical advice). e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 3. Communication with the resident and their responsible party as well as the physician will be documented in the resident's medial record or other appropriate documents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a final abuse investigation report for 2 of 5 residents (R19, R20) reviewed for abuse reporting in the sample of 21. Findings include: R19's and R21's Initial Serious Injury Incident and Communicable Disease Report, incident report of 2/7/25, dated 2/7/25, documents, it was reported that a possible altercation happened between (R19) 58 yr (year) year old male and (R21) [AGE] year-old male. Assessments completed, no injuries to note. Residents were separated immediately. R19's Nurses Note, dated 2/7/25 at 1:13 PM, documents, Resident was involved in an altercation with another resident. Coffee was thrown on patient. No obvious scars or blisters to be noted at this time. Both residents denied the altercation. Eyewitness from the dietary department claims to have seen this resident hitting the other. Administrator aware. Patient is his own responsible party. Resident denies pain and discomfort. Resident remains in the dining room eating lunch. R21's Nurses Notes, dated 2/7/2025 14:19, documents, It was reported to this writer that resident had an altercation with another resident (R21) in the dining room, this resident was reported to had thrown coffee at another resident. It was stated by nursing staff that the two-resident started swinging at each other, but they didn't witness any physical contact, dietary staff stated that the other resident had hit this resident, and she had physically pulled the other resident off of him. Statements from both residents were obtained and both parties denied any physical altercation. Assessment completed upon this resident; no injury noted at this time. resident denies any pain or discomfort. Vs/vital signs: T-97.1 P-81, R-16, BP- 163/93, O2-97% RA. resident is now sitting up by the nurses station, will continue to monitor. Resident is his own responsible party, Emergency contact call (V21 R21's Power of Attorney) with no answer voicemail left, Admin made aware. On 3/24/25 at 12:49 PM, V2, Director of Nurses, stated, I did report the initial report on 2/7/25. I think what happened is V1, old Administrator, investigated the incident on 2/7/25 and 2/9/25 together since they were so close together. On 3/24/25 at 12:55 PM, V1, current Administrator, stated that she could not find a file on the incident on 2/7/25 and the only documentation that she can find came from V2's email that documents the initial report was made. The Abuse Policy and Prevention Program, dated 10/22, documents, The facility affirms the right to our residents to be free from abuse. It continues, Abuse: Abuse mean any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. It continues, The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective actions taken to the Department of Public Health within five working days of the reported investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct an investigation for 2 of 5 residents (R19, R21) reviewed for abuse reporting in the sample of 21. Findings include: R19's and R21's Initial Serious Injury Incident and Communicable Disease Report, incident report of 2/7/25, dated 2/7/25, documents, it was reported that a possible altercation happened between (R19) 58 yr (year) year old male and (R21) [AGE] year-old male. Assessments completed, no injuries to note. Residents were separated immediately. R19's Nurses Note, dated 2/7/25 at 1:13 PM, documents, Resident was involved in an altercation with another resident. Coffee was thrown on patient. No obvious scars or blisters to be noted at this time. Both residents denied the altercation. Eyewitness from the dietary department claims to have seen this resident hitting the other. Administrator aware. Patient is his own responsible party. Resident denies pain and discomfort. Resident remains in the dining room eating lunch. R21's Nurses Notes, dated 2/7/2025 14:19, documents, It was reported to this writer that resident had an altercation with another resident (R21) in the dining room, this resident was reported to had thrown coffee at another resident. It was stated by nursing staff that the two-resident started swinging at each other, but they didn't witness any physical contact, dietary staff stated that the other resident had hit this resident, and she had physically pulled the other resident off of him. Statements from both residents were obtained and both parties denied any physical altercation. Assessment completed upon this resident; no injury noted at this time. resident denies any pain or discomfort. Vs : T-97.1 P-81, R-16, BP- 163/93, O2-97% RA. resident is now sitting up by the nurses station , will continue to monitor. Resident is his own responsible party, Emergency contact call (V21 R21's Power of Attorney) with no answer voicemail left, Admin made aware. On 3/24/25 at 12:49 PM, V2, Director of Nurses, stated, I did report the initial report on 2/7/25. I think what happened is V1, old Administrator, investigated the incident on 2/7/25 and 2/9/25 together since they were so close together. On 3/24/25 at 12:55 PM, V1, current Administrator, stated that she could not find a file on the incident on 2/7/25 and the only documentation that she can find came from V2's email that documents the initial report was made. The Abuse Policy and Prevention Program, dated 10/22, documents, The facility affirms the right to our residents to be free from abuse. It continues, Abuse: Abuse mean any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. It continues, Any incident or allegation involving abuse, neglect, exploitation, mistreatment of misappropriation of resident property will result in an investigation. It continues, The appointed investigator, will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable, any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provide care, and employees with whom the accused has regularly worked, will be interviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a consent from a Power of Attorney for a psychotropic medication for 1 of 4 residents (R6) reviewed for psychotropic medications in the sample of 21. Findings include: R6's Face Sheet, print date of 3/20/25, documents R6 was admitted on [DATE] and has diagnoses of Schizophrenia, Dementia, Alzheimer's Disease, and Dependence on Renal Dialysis. This Face Sheet also documents V3 as R6's legal guardian. R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired. R6's Physician Progress Note, dated 2/26/25, documents, Interval history: Patient seen and examined today for acute care visit. Nursing staff reports patient is having difficulty sleeping at night. It continues, Trazodone 50 mg QHS (every hour of sleep) nightly. R6's Physician Order, dated 2/27/25, documents, Trazodone HCl Tablet 50 MG (milligram) Give 1 tablet by mouth at bedtime for Insomnia Give 1 at night for insomnia. R6's Medication Administration Record, dated 2/2025 and 3/2025, documents between 2/28/25 and 3/18/25 R6 received 16 doses of Trazodone 50 mg. On 3/19/25 at 4:25 PM, V3, R6's Guardian, stated she was never notified of R6 being ordered Trazodone for sleep. V3 stated, I would have never given consent for this. Pain medication and sleep medications make her crazy. The strongest thing she can have is Tylenol. I want to know exactly what she is getting so I can monitor her behaviors since she has Dementia and from what I am reading a lot of medications will have negative results with Dementia. I have told them that. On 3/18/25 at 3:20 PM, V1, Administrator, and V2, Director of Nurses, both stated that there should be consent obtained and a consent form filled out for psychotropic medications before they are given. On 3/19/25 at 1:45 PM, V17, Regional Nurse Consultant, stated, I did a house wide audit and R6 was the only one without a consent for a psychotropic medication. The policy Psychotropic Medication Program, dated 10/24, documents, If a new order for psychotropic medication is obtained, the resident, resident's representative, or POA (Power of Attorney) must be informed of the risks and benefits of the medication. The facility must obtain informed consent. If the family or resident's representative is not able to sign the consent at the time of the order, a verbal consent will be obtained by the nurse and documented on a psychotropic consent form until written consent can be obtained. This form will be part of the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer a nighttime snack for 4 of 6 residents (R2, R3, R4, R5) reviewed for snacks in the sample of 21. Findings include: 1. R2's Face Sheet, print date of 3/19/25, documents R2 was admitted on [DATE] and has a diagnosis of End Stage Renal Disease. R2's Minimum Data Set (MDS), dated [DATE] documents R2 is cognitively intact. On 3/17/25 at 11:34 AM, R2 stated, I am not offered a snack at bedtime. 2. R3's Face Sheet, print date of 3/19/25, documents R3 was admitted [DATE] and has a diagnosis of dependence on Renal Dialysis. R3's MDS, dated [DATE], documents R3 is moderately cognitively impaired. On 3/17/25 at 9:05 AM, R3 stated, R3 stated sometimes he gets a snack at night but not every night. 3. R4's Face Sheet, print date of 3/19/25, documents R3 was admitted on [DATE] and has a diagnosis of Diabetes Mellitus. R3's MDS, dated [DATE], documents R4 is cognitively intact. On 3/17/25 at 1:35 PM, R4 stated I am a diabetic and they never offer me a snack. The aides will bring out a box of like oatmeal pies but there are 4 residents that wait for that cart and take all the snacks so there is nothing left for everyone else. Nurses have even had to go to the vending machine and buy me a snack with their money because my sugar was so low. They shouldn't have to do that. 4. R5's Face Sheet, print date of 3/19/25, documents R3 was admitted on [DATE] and has diagnosis of Bipolar Disorder. R5's MDS, dated [DATE], documents R5 is cognitively intact. On 3/17/25 at 1:40 PM, R5 stated, they never offer snacks at night. On 3/18/25 at 8:45 AM, V1, Director of Nurses stated, Residents can have snacks whenever they want. We keep them at the nurse's station so the nurses can pass them out when someone asks for them. The Resident Council Meeting minutes, dated 12/18/24, documents, 'Dietary. No snacks after they leave. The policy Snacks, dated 10/2022, documents, Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to prevent verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 7. Findings include: R3's Face Sheet, print date of 1/16/25, documents that R3 has diagnoses of Polyarthritis and Chronic Obstructive Pulmonary Disease. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact. The facility Long Term Care - Serious Injury Incident and Communicable Disease Report, dated 1/13/25, documents, Final. Upon investigation, it was founded that the dietary staff (V3) did curse at (R3) on 1/7/25 during breakfast time in the dining room. The employee was immediately suspended and sent home after writing her statement. In her statement she said she did curse at (R3) and she knew it was wrong. The employee is effectively terminated as of 1/7/25. V3's written statement, dated 1/7/25, documents, I cussed at (R3), and I knew it was wrong. V4's written statement, dated 1/7/25, documents that V3 yelled at R3 and stated, yall worried about yall F'ing drinks or how many you can have. On 1/16/25 at 8:51 AM, R3 stated that he was sitting in the dining room and talking to a newer resident about the food. I let him know that once every month or two months we have fried chicken, and it is really good. I said to (V3) isn't that right we get fried chicken? She yelled at me F*** the fried chicken and F*** you. She then walked away back into the kitchen. V1 did talk to me about it, and he told me that (V3) was fired. I told him not to fire her, but he said that no one should talk to us like that. On 1/16/25 at 9:35 AM, V1 stated that V3 was removed from the dining room immediately and that the only time again she saw residents is when she was walking to his office to write out her statement. In her statement, she said that she cussed at R3, and she knew it was wrong. She was fired immediately. The unnamed policy, dated 9/2027, documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. It continues, Verbal Abuse: is the use by a licensee, employee or agent of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of a individual's age, ability to comprehend, or disability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate and report allegations of sexual abuse for 1 of 3 residents (R2) reviewed for sexual abuse in the sample of 11. Findings include: R2's Care Plan, dated 10/23/24, documents ABUSE: At risk for abuse and neglect r/t (related to). It continues Assess resident for abuse and neglect upon admission and quarterly. Assure the resident that staff members are available to help, and department heads maintain an open door policy. Continue to in-service the staff about abuse and neglect. Continue to monitor medication, ADLs, status and behaviors. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. R2's Minimum Data Set, dated [DATE], documents that R2 is cognitively intact. R2's Progress Note, dated 10/13/2024 at 4:02 PM, documents Nurses Notes Late Entry: Note Text: Resident came to nursing station with another female resident. second female resident looked at this resident and stated, Tell her what he did. Then this resident stated a male resident touched her inappropriately while they were standing in the hallway waiting to go out for a smoke break. This nurse went with this resident to the hallway so resident can show this nurse which male resident touched here. Male resident removed from hallway and separated from this resident. Male resident took back to male side of the building and this nurse notified his nurse of incident. second nurse stated she would notify MD (medical doctor) and Admin (administrator) of incident. R2's Progress Note, 10/22/2024 at 8:02 PM, documents Nurses Notes Note Text: At approximately 4:40pm, Resident (R5), came to the nurses desk, and reported to 100 hall nurse (who was sitting at first computer at nurses desk by 200 hall) and myself, (who was sitting at the second computer at the desk by the far wall from 200 hall) that (V2, Director of Nurses) was saying that another resident has been touching her vagina. I notified (V5) the wound nurse/management, of this. She stated to separate (V2) from the resident that (V2) stated was doing this. And put the resident touching her, on one-on-one supervision. She also said for this nurse to get statements from any witnesses. I obtained a statement from Resident, (R5), that resident, (R6), was present at the time the accused resident was touching (R2) inappropriately. I then asked (R2) what happened and if anyone, but the accused resident was present when he was touching her. She also named (R6) and stated that he witnessed it. I then asked (R6) if he was present at the time of the incident and he stated that the resident in question was (R3) and that he was present when (R3) was touching (R2) and that he himself told (R3) he needed to stop and not to do that ever again. (R3) was outside coming inside from smoke break. I questioned (R3) with reality orientation questions to establish his alertness level. Such as what is your first and last name, where are you, etc. (R3) stated his first and last name and responded, do you think I am stupid? I went to college, and I have a degree he proceeded to tell me where he was and where he went to college and where he got a degree from. I asked him if he knew what was going on at the moment. He replied, I don't know. I asked him do you know what's going on with her. ((R3) was not present. I did not say her name.) (R3) responded We're consenting adults. I told (R3) she is saying she isn't consenting. (R3) did not say anything further and did not talk any further with this nurse. On 10/31/2024 at 9:44 AM, R2 stated that she was inside the building standing in line for the smoke break. R2 stated that (R3) grab her vagina with his hand. R2 stated that she yelled stop. R2 stated that it was not her leg it was her vagina. R2 stated that she has a past history of sexual abuse and that this triggered her. R2 stated that (R7) was there, and (R7) went with her to report it. On 10/31/2024 at 9:47 AM, R7 stated that she was standing in line between (R3) and (R2). R7 stated that out the corner of her eye she saw (R3) reach out towards (R2) and hand went across her legs. R7 stated that she did not see (R3) grab (R2's) vagina. R7 stated that she heard (R2) say stop. R7 stated that (R2) informed R7 of what happened and R7 took her to the nurse. On 10/13/2024 at 10:14 AM, R3 stated that he likes (R2) and finds her attractive. R3 stated that they talk. R3 stated that he has not touched (R2). R3 stated that he does not remember grabbing (R2). R3's Care Plan, dated 10/21/24, documents that the resident displays behavioral Symptoms related social interaction which is manifested by touching others to get their attention. Resident is at wheelchair height and reaches out to get to where he is going. It also documents Intervene when any inappropriate behavior is observed. Attempt to educate and redirect. Provide supportive group. 1:1 PRN intervention. Refer the resident to the consulting psychiatrist for a psychiatry evaluation, as warranted. R3's MDS, dated [DATE], documents that R3 is cognitively intact. R3's Medical Diagnosis list Mild Cognitive Impairment of Uncertain or Unknown Etiology, Schizoaffective Disorder, Unspecified, Alcohol Dependence, Uncomplicated. On 10/31/2024 at approximately 1:00 PM, V9, Regional Director of Operations, stated that they were made aware of the incident that occurred on 10/22/24. V9 stated that (V2), Director of Nursing, and (V5), Wound Nurse, came up to facility. V9 stated that they were notified that (V6), Staffing Coordinator, was outside on smoke break and that no event occurred out there. V9 stated that no further investigation was done and it was not reported to outside agency because they did not believe it was necessary because (V6) did not witness anything outside. V9 stated that in the days following they were made aware of the incident that occurred on 10/13/2024. V9 stated that this was not reported or investigated. V9 verified that the facility has cameras and that they had not viewed the [NAME] footage. The facility's Abuse Policy, dated 10/2022, documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. VII. Internal Investigation 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. External Reporting 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee shall notify Department of Public Health's regional office immediately by telephone or fax. 2. Five-day Final Investigation report. Within five working days after the report of occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate its Abuse Prevention policy for 1 (R2) of 3 three residents reviewed for sexual abuse in the sample of 11. Findings include: On 10/31/2024 at approximately 1:00 PM V9, Regional Director of Operations, stated that they were made aware of the incident that occurred on 10/22/24. V9 stated that (V2), Director of Nursing, and (V5), Wound Nurse, came up to facility. V9 stated that they were notified that (V6), Staffing Coordinator, was outside on smoke break and that no event occurred out there. V9 stated that no further investigation was done and it was not reported to outside agency because they did not believe it was necessary because (V6) did not witness anything outside. V9 stated that in the days following they were made aware of the incident that occurred on 10/13/2024. V9 stated that this was not reported or investigated. V9 verified that the facility has cameras and that they had not viewed the [NAME] footage. On 10/31/2024 at approximately 1:03 PM, V2, Administrator, stated that the incidents from 10/13 and 10/22 were not reported to outside agency. The facility's Abuse Policy, dated 10/2022, documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. VII. Internal Investigation 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. External Reporting 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee shall notify Department of Public Health's regional office immediately by telephone or fax. 2. Five-day Final Investigation report. Within five working days after the report of occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to measure, assess, monitor, and treat wounds when identified and obtain orders to treat wounds for 1 of 1 (R4) reviewed for wounds in the sample of 11. Findings include: R4's admission Record, print date of 11/4/24, documents that R4 was admitted on [DATE] with diagnoses of Osteomyelitis, Diabetes Mellitus. R4's Minimum Data Set, dated [DATE], documents that R4 is cognitively intact. R4's admission Note, dated 10/8/2024 22:30, documents, 18) Left elbow left elbow infection osteomyelitis. R4's Nurses Note, dated 10/8/2024 22:24, documents, The patient arrived to facility via EMS (Emergency Medical Services). Patient alert and oriented times 3. Patient oriented to room, call light within reach, Left elbow infection/wound noted. R4's Nurses Note, dated 10/9/2024 12:55, created date of 10/16/2024 15:58:26, documents, Late Entry: Resident admitted to (facility) on IV (intravenous) antibiotics due to osteomyelitis, resident admitted with a venous wound relate to a wound from the inside out. Wound will be treated daily with a hydro mix with collagen and Silvadene cream daily. Will monitor daily. R4's Physician Orders, dated 10/16/24 documents, Cleanse wound on left elbow with wound cleanser, apply santyl and cover with a 4x4 bordered gauze daily and prn (as needed) until healed. Monitoring for s/s (signs and symptoms) of infection, notify MD (Medical Director). R4's Physician Orders, dated 10/23/24, documents, cleanse wound on right second toe with wound cleanser, mix hydrogel, collagen, and Silvadene cream and cover with a dry dressing daily and prn until healed. Monitoring for signs and symptoms of infection, notify MD. R4's Treatment Administration Record, dated 10/2024, fails to document any treatment for R4's left elbow before 10/17/24. R4's Treatment Administration Record, dated 10/2024, fails to document any treatment for R4's right second toe before 10/23/24. R4's Skin and Wound Note, dated 10/11/2024 05:49, documents, Date of Service: 10/11/2024 10:49 AM Evaluation of her skin today reveals no open wounds, sores, or lesions; skin is intact. R4's Skin & Wound Evaluation, dated 10/16/2024 3:32 PM, documents, Midline infiltration caused from the inside. Location left elbow present on admission. Area 4.6 cm (centimeters) 2 2. Length 2.2 cm 3. Width 2.7 cm. There is no other documentation regarding the wound on this Skin & Wound Evaluation. This is the first documentation of R4's left elbow measurements. R4's Skin and Wound Note, dated 10/18/2024 05:30, documents, Date of Service: 10/18/2024 10:30 AM WOUND ASSESSMENT: Wound: 1 Location: left elbow Primary Etiology: Abscess Stage/Severity: Full Thickness Wound Status: Present on admission Odor Post Cleansing: Mild Size: 3.1 cm x 2 cm x 0 cm. Calculated area is 6.2 sq cm. Wound Base: , 100% eschar Wound Edges: Attached Periwound: Intact Exudate: Moderate amount of Sanguineous. Wound: 2 Location: right second toe Primary Etiology: Diabetic Foot Ulcer (DFU) Stage/Severity: Full Thickness Wound Status: New Odor Post Cleansing: None Size: 0.9 cm x 0.8 cm x 0.1 cm. Calculated area is 0.72 sq cm. Wound Base, 100% granulation Wound Edges: Attached Periwound: Intact, Callous Exposed Tissues: Epithelium, Dermis Exudate: Scant amount of Serous. This is the first full documentation for R4's left elbow and right second toe. On 11/4/24 at 9:45 AM, V5, Licensed Practical Nurse, LPN, stated that R4 should have wound measurements and treatments documented because she thought she did them. On 11/12/24 at 11:55 AM, V2, Director of Nurses, stated that wounds should be measured and described when found, then weekly, or if they get worse. The doctor should be notified of the wound and orders for treatment should be obtained. On 11/13/24 at 10:14 AM, V5, Wound Nurse Licensed Practical Nurse (LPN), stated, If a resident is admitted or readmitted to the facility, the nurse will do a skin assessment, but I don't know if they measure the wounds are not. I will have to look into that. V5 agreed that there is no full beginning assessment of the wounds or pressure ulcers if one is not completed upon admission, readmission, or when found. The policy Skin and Wound Management Guidelines, undated, documents, admission or Readmission. Staff Nurse. 1. Complete the Comprehensive Nursing Assessment including the skin with thorough and descriptive documentation of any alteration in skin integrity. 2. Complete the Braden Assessment 2. Complete the Braden Assessment 3. If there is a wound present on admission: Ensure there is a treatment order. Ensure specialty mattress is in place if needed. Ensure cushion is provided for wheelchair if needed. Wound Care Nurse: 1. Review new admissions and readmissions and assess, measure, photograph, and document in Wound Rounds on any wound identified. This includes Stage I's and significant skin tears. It continues, Ensure the treatment order is in place and appropriate. New Facility Acquired Wounds: Staff Nurse. 1. Notify wound care nurse of new alteration in skin integrity. If the wound care nurse is not in the facility, then you must notify the physician and obtain treatment order. It continues, 1. Assess, measure, photograph, and document in Wound Rounds. 2. Complete the Braden Assessment. 3. Obtain or ensure appropriate treatment order is in place. This policy fails to document ongoing wound or pressure ulcer assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to assess and monitor pressure ulcers, provide Physician prescribed treatment, and maintain clean dressings for 2 of 3 residents (R1, R11) reviewed for pressure ulcers in the sample of 11. Findings include: 1. On 10/31/24 at 3:00 PM, R1 is lying in bed. R1 has no dressing on his left heel. R1's right heel protector boot is positioned on the middle of his calf. R1's right heel dressing is at his ankle and his mid foot. R1's dressing is red, tan and brown in color with drainage. R1's sheet has fresh and old blood stain in multiple areas at the bottom half of the right side of the sheet. On 10/31/24 at 3:00 PM, R1 stated that his heel has been bleeding all night. R1 stated that it has been a problem for the last 3 or 4 days. R1 stated that his right heel dressing was last changed yesterday or the day before. R1 stated that his left heel never has a dressing on it. On 10/31/24 at 3:10 PM, V3, Assistant Director of Nurses, entered R1's room to do dressing changes to R1's heels. V3 raised R1 left heel and cleansed it with wound cleanser, applied betadine-soaked gauze, and wrapped with a border foam dressing. The pressure ulcer was 5 centimeters (cm) x 4 cm. The middle of the pressure ulcer was dark brown. The outer area of the pressure ulcer was light red. On 10/31/24 at 3:53 PM, V3, attempted to remove the old dressing from R1's right foot. The dressing was dry and stuck on R1's skin at the heel. V3 saturated the gauze with wound cleanser to loosen the dressing. The abdomen (abd) pad was saturated with brown drainage and dried blood. The pressure ulcer was from the back of his heel to just below his midfoot approximately 9 cm in length. The pressure ulcer extended the width of his foot. The pressure ulcer was also at the back of his heel extending from the sole of his foot up approximately 4 cm. This area was actively bleeding. V3 cleansed the pressure ulcer with wound cleanser, applied a hydrogel, silvadene, and collagen mixture,then Santyl, placed an abd pad, and then wrapped the right foot in gauze. On 11/4/24 at 9:41 AM, V3, stated R1's old right foot dressing on 10/31/24 was not in good condition and it should have been addressed sooner. I don't know how old that was, but it was stuck on there. There was suppose to be no Santyl put on the right heel. The order wasn't updated. R1's admission Record, print date of 11/4/24, documents that R1 was admitted on [DATE] and has diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease, dependency on Renal Dialysis, and Osteomyelitis acquired 10/15/24. R1's Minimum Data Set, dated [DATE], documents that R1 is cognitively intact and dependent on staff for all mobility. R1's Braden Scale for predicting Pressure Ulcer Sore Risk evaluations, dated 7/11/24 - 10/14/24, all document that R1 is at risk for developing pressure ulcers. R1's Skin & Wound Evaluation, dated 8/26/24, documents, WOUND ASSESSMENT: Wound: 1 Location: Right heel Primary Etiology: Pressure Stage/Severity: Stage 3 Wound Status: Improving despite measurements Odor Post Cleansing: None Size: 5 cm x 5.5 cm x 0.5 cm. Calculated area is 27.5 sq (square) cm. Wound Base: , 30% granulation , 70% slough Exposed Tissues: Subcutaneous, Adipose Wound Edges: Attached Periwound: Fragile, Macerated Exudate: Heavy amount of Serosanguineous Wound Pain at Rest: 0. R1's Skin & Wound Evaluation, dated 9/4/24, documents, Patient was unable to be evaluated by the skin and wound team today; patient was not in facility at the time of visit. Hospital. R1's Skin & Wound Evaluation, dated 9/13/24, documents, Patient was unable to be evaluated by the skin and wound team today; patient at dialysis during time of visit. R1's Electronic Medical Record fails to document R1's right heel pressure ulcer between 8/26/24 and 9/16/24. R1's Skin & Wound Evaluation, dated 9/16/24, documents, WOUND ASSESSMENT: Wound: 1 Location: Right heel Primary Etiology: Pressure Stage/Severity: Stage 3 Wound Status: Stalled Odor Post Cleansing: Malodorous Size: 5 cm x 6 cm x 0.5 cm. Calculated area is 30 sq cm. Wound Base: , 10% granulation , 90% slough Exposed Tissues: Epithelium, Dermis, Subcutaneous, Adipose Wound Edges: Attached Periwound: Fragile, Macerated Exudate: Heavy amount of Serosanguineous Wound Pain at Rest: Insensate (lacks sensation). R1's Electronic Medical Record fails to document R1's right heel pressure ulcer between 9/16/24 and 9/27/24. R1's Skin & Wound Evaluation, dated 9/27/24, documents, WOUND ASSESSMENT: Wound: 1 Location: Right heel Primary Etiology: Pressure Stage/Severity: Stage 3 Wound Status: Stable Odor Post Cleansing: Malodorous Size: 5 cm x 6.7 cm x 0.5 cm. Calculated area is 33.5 sq cm. Wound Base: , 80% granulation , 20% slough Exposed Tissues: Epithelium, Dermis, Subcutaneous, Adipose Wound Edges: Attached Periwound: Fragile, Macerated Exudate: Heavy amount of Serosanguineous Wound Pain at Rest: Insensate. R1's Skin & Wound Note, dated 10/2/2024 09:39, documents, WOUND ASSESSMENT: Wound: 1 Location: Right heel Primary Etiology: Pressure Stage/Severity: Stage 3 Wound Status: Stable Odor Post Cleansing: Malodorous Size: 9 cm x 10 cm x 0.5 cm. Calculated area is 90 sq cm. Wound Base: , 80% granulation , 20% slough Exposed Tissues: Epithelium, Dermis, Subcutaneous, Adipose Wound Edges: Attached Periwound: Fragile, Macerated Exudate: Heavy amount of Serosanguineous Wound Pain at Rest: Insensate. R1's Wound Care Note, dated 10/7/2024 10:47, documents, Resident sent to hospital, treatment not done, resident admitted , will continue treatments upon readmission to building. R1's Nurses Note, dated 10/14/2024 18:37, documents, Resident; black 70 y.o. (year old) black male; returned from (Hospital) and was transported to this facility via (Ambulance) at 6:25 pm. It continues, New discharge order for ABT (antibiotic) for PNE (pneumonia)and Osteomyelitis to R (right) heel. Resident has right foot debridement and right heel bone biopsy 10/11. R1's Hospital Discharge summary, dated [DATE], documents that R1 has bilateral heel pressure ulcers. R1's Daily Skilled Nurses Note, dated 10/18/24, documents that R1 has a pressure ulcer on both the right and left heels. This Nurses Note fails to document size or assess the pressure ulcers. R1's Electronic Medical Record fails to document R1's left heel pressure ulcer before 10/18/24. R1's Treatment Administration Record, dated 10/24, documents, Cleanse left heel with wound cleanser, dab with betadine soaked gauze, cover with bordered gauze daily and PRN (as needed) until healed. Start date of 10/17/24. R1's Skin & Wound Note, dated 10/22/2024 , documents, Location: Right heel Primary Etiology: Pressure Stage/Severity: Stage 3 Wound Status: Stable Odor Post Cleansing: Malodorous Size: 8.5 cm x 8 cm x 0.5 cm. Calculated area is 68 sq cm. Wound Base: , 80% granulation , 20% slough Exposed Tissues: Epithelium, Dermis, Subcutaneous, Adipose Wound Edges: Attached Periwound: Fragile, Macerated Exudate: Heavy amount of Serosanguineous Wound Pain at Rest: Insensate. Wound: 4 Location: left heel Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Present on admission Odor Post Cleansing: None Size: 6 cm x 7 cm x 0 cm. Calculated area is 42 sq cm. Wound Base, 100% eschar Wound Edges: Attached Periwound: Fragile. This is the first full assessment of R1's bilateral pressure ulcers since readmission on [DATE]. R1's Skin & Wound Note, dated 10/30/2024, documents, Patient was unable to be evaluated by the skin and wound team today; patient at dialysis during time of visit. R1's Skin & Wound Note, dated 11/6/2024 12:24, documents, WOUND ASSESSMENT: Wound: 1 Location: Right heel Primary Etiology: Pressure Stage/Severity: Stage 4 Wound Status: Stable Odor Post Cleansing: None Size: 8 cm x 8 cm x 2 cm. Calculated area is 64 sq cm. Wound Base: , 100% granulation , 0% slough Exposed Tissues: Epithelium, Dermis, Subcutaneous, Adipose, Muscle/Fascia Wound Edges: Attached Periwound: Intact, Fragile Exudate: Heavy amount of Seropurulent Wound Pain at Rest: 2 Wound: 4 Location: left heel Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Present on admission Odor Post Cleansing: None Size: 4.5 cm x 6.5 cm x 0.1 cm. Calculated area is 29.25 sq cm. Wound Base: , 20% granulation , 80% slough , 0% eschar Wound Edges: Attached Periwound: Fragile, Intact Exudate: Moderate amount of Serous Wound Pain at Rest: 0. On 11/13/24 at 10:14 AM, V5, Wound Nurse Licensed Practical Nurse (LPN), stated, I do rounds with the Wound Nurse Practitioner every week. If a resident is not able to be seen by the Wound Nurse Practitioner I do still measure their wounds and document on them. If a resident is admitted or readmitted to the facility, the nurse will do a skin assessment, but I don't know if they measure the wounds are not. I will have to look into that. V5 agreed that there is no full beginning assessment of the wounds or pressure ulcers if one is not completed upon admission, readmission or upon finding. V5 was unable to state why (R1) did not have weekly pressure ulcer assessments or readmission pressure ulcer assessments. On 11/13/24 at 2:19 PM, V18, Nurse Practitioner, stated that (R1) has many disease processes: Dialysis, Diabetes, Peripheral Vascular Disease, and Osteomylitis. V18 stated that with his health his pressure ulcers are very difficult to heal. They would be hard to heal in a healthy person but for him it is really difficult. V18 stated, I am not sure why they haven't amputated that right foot yet. When I saw him today, he had his heel protector up on his leg too. He does that himself. V18 felt that his pressure ulcers not being measured every week really did not cause him any harm. On 11/12/24 at 11:55 AM, V2, Director of Nurses stated that wounds and pressure ulcers should be measured and described when found, then weekly, or if they get worse. The doctor should be notified of the wound and orders for treatment should be obtained. 2. R11's admission Profile, print date of 11/14/24, documents that R11 was admitted on [DATE] and has diagnoses of Chronic Respiratory Failure and a Pressure Ulcer to the Sacrum Stage 4. R11's MDS, dated [DATE], documents he is cognitively intact. R11's Physician Order, dated 9/7/24, documents, cleanse wound on sacrum with wound cleanser,apply medihoney and collagen and cover with bordered gauze daily and prn until healed. Monitor for s/s of infection and, notify MD. On 11/13/24 at 9:34 AM, V5 prepared the pressure ulcer dressing for (R11's) coccyx. She placed a mixture of hydrogel, collagen, and silvadene onto a calcium alginate square then placed that on top of a bordered dressing. V5 entered R11's room, cleansed the pressure ulcer with wound cleanser and then applied the dressing. The pressure ulcer was 2 cm in length and 0.5 cm in width. The center of the pressure ulcer was dark red. On 11/13/24 at 9:58 AM, V5 was questioned why her treatment of (R11's) pressure ulcer did not match what was on his Physician Orders of medihoney and collagen, V5 stated, No he is suppose to get the hydrogel, collagen, and silvadene mixture. V5 reviewed (R11's) Physician Orders, V5 stated, I took the order from the wound Nurse Practitioners Wound Assessment. I must have written the wrong order into the system. V5 further stated, When the wound Nurse Practitioner writes orders on the Wound Assessment Report, I go back and enter the order into the system which will transfer it to the Physician Orders in the PCC (Point Click Care) (computer) system and populate onto the TAR (Treatment Administration Record). V5 agreed that if she was not the nurse that did the pressure ulcer dressing change (R11's) pressure ulcer would have been treated with the wrong treatment. On 11/13/24 at 2:19 PM, V18, Wound Nurse Practitioner, stated that (R11) receiving the wrong pressure ulcer treatment of medihoney and collagen did not harm him. The policy Skin and Wound Management Guidelines, undated, documents, admission or Readmission. Staff Nurse. 1. Complete the Comprehensive Nursing Assessment including the skin with thorough and descriptive documentation of any alteration in skin integrity. 2. Complete the Braden Assessment 2. Complete the Braden Assessment 3. If there is a wound present on admission: Ensure there is a treatment order. Ensure specialty mattress is in plae if needed. Ensure cushion is provided for wheelchair if needed. Wound Care Nurse: 1. Review new admissions and readmissions and assess, measure, photograph, and document in Wound Rounds on any wound identified. This includes Stage I's and significant skin tears. It continues, Ensure the treatment order is in place and appropriate. New Facility Acquired Wounds: Staff Nurse. 1. Notify wound care nurse of new alteration in skin integrity. If the wound care nurse is not in the facility, then you must notify the physician and obtain treatment order. It continues, 1. Assess, measure, photograph, and document in Wound Rounds. 2. Complete the Braden Assessment. 3. Obtain or ensure appropriate treatment order is in place. This policy fails to document ongoing wound or pressure ulcer assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to replace a loose dressing for 1 of 2 residents (R4) reviewed for Peripherally Inserted Central Catheter (PICC) lines in the sample of 11. Findings include: On 10/31/24 at 12:13 PM, V3, Assistant Director of Nurses / Registered Nurse (RN) entered R4's room. V3 disconnected the Intravenous (IV) antibiotic from R4's left upper arm Peripherally Inserted Central Catheter (PICC) line, flushed the line with 5 milliliters of normal saline, and capped the lumen. The PICC line dressing was not attached at the bottom of the dressing. V3 washed her hands and left the room. On 10/31/24 at 4:16 PM, V3 stated that she was aware that (R4's) PICC line dressing was not attached at the bottom. I told the night RN that just came in about it so she would change it. R4's admission Record, print date of 11/4/24, documents that R4 was admitted on [DATE] with diagnoses of Osteomyelitis and Diabetes Mellitus. R4's Physician Orders, dated 10/28/2024, documents, Change PICC line dressing weekly and prn (as needed) using sterile technique. On 11/12/24 at 12:00, V2, Director of Nurses, stated that if a RN notices a PICC line dressing that is not secure they should stop and change it. The policy Central Venous Catheter Maintenance, dated 8/24/24, documents, 5. Proper procedure will be used for catheter site dressing monitoring/changes. Apply clear dressings every 7 days or more frequently if soiled, damp, or loose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to support the resident's right for the Power of Attorney (POA) to access their family's personal medical records and honor their written request for records for 1 of 3 residents (R2) reviewed for medical records in the sample of 6. Finding include: R2's Face sheet printed 9/19/2024 documents a diagnoses of sepsis, transient cerebral ischemic attack, type 2 diabetes, morbid obesity, difficulty in walking, unsteadiness on feet, cognitive communication deficit, weakness, anemia, Alzheimer disease, anxiety disorder, severe sepsis with septic shock. R2's Face sheet also documents she was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS) dated [DATE] documents (R2) is moderately impaired for cognition for decision making of activities of daily living. R2's Care Plan for ADL (activities of daily living) document she (R2) requires assist with daily care needs related to recent hospitalization for severe sepsis, weakness, and TIA (transient ischemic attack). Resident has a diagnosis of dementia and/or Alzheimer's and may display moods/behaviors related to diagnosis. R2's Progress Notes dated 1/10/2024 at 3:45 PM, documents, Transport here, resident transported to ER. (Emergency Room). R2's Progress Notes do not document anything related to the family and or resident requesting records. On 10/11/2024 at 10:45 AM, V5, family of R2 stated, We need (R2's) medical records and have been requesting them since February of 2024. (R2) was a patient back in January 2024. My husband is the POA (Power of Attorney), and he has filled out the privacy form several times. He has made several trips trying to get her records and we just recently met with the new Medical Records person (V9) and were trying to get her records. It has been one excuse after the other, first it was the weekend. We have met physically with multiple people, talked on the phone and still no records. Everything has been filled out multiple times. We have called and asked and have not received any records. The facility never talked to me about a fee for the records and have never asked or told us we had to pay. I don't have any issues with paying any reasonable amount fee for her records. We just want her medical records. I don't have any problem paying for her records, but nobody has ever told us how many papers it is or what it costs. We don't understand why we can't get her medical records and why we have to call the state to get her records. This is crazy and I am sorry I had to get you involved. You would think something like this could easily be done in two to three business days. On 10/11/2024 at 10:49 PM, V9, Medical Records, stated, I have only been here for three months. If someone wants records, they must fill out a form and then it goes to up to legal, they get back to me and let me know, once they have paid the fee then they get their records. (R2's) name sounds familiar I believe they just made a request not that long ago. I believe we already sent them her records. I will check and get back to you. On 10/11/2024 at 11:41 AM V6's Regional Health Information Medical Records phone number was provided. On 10/11/2024 at 11:43 AM, the phone number provided for V6 was a general number for the (Facility). A voice message was left. On 10/11/2024 at 1:32 PM, V9 stated she had a file on (R2) and gave it to (V4, AIT Administrator in Training) and was told she could not give me any other information. On 10/11/2024 at 4:00 PM, no proof of any medical records being sent to R2's family was provided by the facility. On 10/11/2024 at 4:03 PM, no Regional Medical Records staff member returned call or shared any information related to R2's medical records. On 10/11/2024 at 4:03 PM. The facility provided R2's medical records but there was no documentation in the records documenting any request of records had been shared with R2's family. The Resident Right Policy with a revision date of 11/2018 documents, Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge from the facility for 1 of 3 residents (R1) reviewed for discharge in the sample of 6. Findings include: R1's Physician Order Sheet (POS) for diagnoses of cerebral infarction due to embolism of left middle cerebral artery, type 2 diabetes mellites without complications, acute respiratory failure, unsteadiness on feet, lack of coordination, abnormal posture, chronic allergic conjunctivitis, bipolar, unspecified convulsion, acute kidney failure, acquired absence of right leg above knee, and depression. R1's POS documents he was taking levetiracetam oral tablets 750 milligrams two tablets twice a day related to epilepsy, oxcarbazepine tablet 600 mg., give 1 tablet by mouth two times a day (seizures), and spironolactone tablet 25 mg one time by mouth, one time a day (high blood pressure and heart failure). R1's Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively intact for decision making of activities of daily living. R1 requires a wheelchair, and he has impairment on his lower extremity, R1's Care Plan with a date initiated for 4/19/2023 documents, Discharge planning: The resident and guardian express the desire for the resident to continue long term. The resident's discharge potential and discharge planning needs have been assessed by the IDT (Interdisciplinary Team) and it has been decided to continue long term care. He would ultimately like to return home. Although he and family understand the need for long term care (LTC) placement. R1's Care Plan does not address or document any other discharge for R1. On 10/11/2024 at 1:23 PM, V23, Licensed Practical Nurse stated, All I remember is that (R1) had a planned discharge, and they said the aunt came and picked him up, but nobody knew about it and the aunt had to come back later and pick up his medication. (V4, Administrator in Training) was telling everyone (R1) was not supposed to be discharged until later but I guess there was a mix up and the family came before they were supposed to and there were some issues with his medications. On 10/11/2024 at 12:43 PM, V7, Family of R1 stated when they discharged (R1), they did not discharge him with all of his medication. I called the facility and left a message with (V2, Director of Nursing). (V2) called me back and they did not give me any scripts or any pills. I did not get any oral medication pills until three days later. It was a planned discharge and we had discussed it before, and I picked him up when they told me to pick him up. V7 started crying and saying (R1) was so neglected, and the facility attitude was they could care less. (R1) needs his medication and it is not like I can just go to the grocery store and get it. They acted like I was bothering them when I was just trying to get his medication to make sure he had everything he needed. R1's Progress Notes dated 10/6/2024 at 7:38 PM, Patient discharged from facility today around 2:30 PM with his aunt. I attempted to go over medication with resident and aunt, but resident was busy on his phone. I sent all medications with him. Aunt and another family member took all belongings with them. Apparently, he will be living on the property of his aunt's home on his own and be responsible for his own medication administration along with his insulin. R1's Progress Notes do not document any medication was sent with R1. The Resident discharge Policy-Not Hospital Policy with a revision date of 1/2024 documents, To provide direction other than the hospital. Complete nursing section of Discharge Instructions for in PCC (electronic computer program) this form is opened by Social Service and completed by nursing prior to discharge. Once completed, instructions should be printed along with a medication list and reviewed with the resident/resident representative. After review, the resident/representative should sign the discharge instructions sheet, a copy should be given to them and the original scanned into the medical record. All appropriate medications should be given to the resident at the time of discharge per physician order. Do not complete the discharge without receiving the order from the Medical Doctor/NP (Nurse Practitioner).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain consent for an antipsychotic medication prior to administering antipsychotic and antidepressant medication for 2 of 3 residents (R3, R4) reviewed for informed treatment/treatment decisions in a sample of 8. Findings include: 1. R3's Care Plan, dated 9/3/2024, documents PSYCHOTROPIC MEDS: (R3) requires the use of psychotropic medication (Zoloft) to assist with managing mood and behavior r/t (related to) Depression. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact. R3's Physician Order Sheet (POS) documents Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for major depressive order for 90 Days. R3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documents that R3 received Zoloft 25 mg from 8/31/2024 to 9/13/2024. On 9/17/2024 at 11:00 AM a review of R3's electronic health record (EHR) was reviewed. No psychotropic consent documented in chart for Zoloft. On 9/17/2024 at approximately 1:20 PM V2, Director of Nursing, provided a blank Consent for Psychotropic form. V2 stated that the consents are in the EHR. R3's Consent for Psychotropic Medication, dated 9/17/2024 at 2:31 PM, documents verbal consent received 8/23/2024. On 9/17/2024 at 1:56 PM R3 stated that he did not give the consent to take any antidepressant. R3 stated that he was not informed of any risk vs benefits, and he did not give verbal or written consent for this medication. R3 stated that he found out by accident. R3 stated that the nurse told him that she had forgot his antidepressant. R3 stated at that time he asked when he started taking it and that he was not aware of that he was taking the medication. On 9/17/2024 at approximately 3:15 PM V1, Administrator, stated that once checked, after question of surveyor, it was noted that there were multiple residents that did not have consent documentation. V1 stated that she educated V2, and the consent documentations were put in place. V1 stated that she is aware that this is a problem and is in the process of trying to correct it. V1 stated that V2 is new and is still learning his role at the facility. V1 stated that she instructed V2 to get the consents and document in computer and assure that they put today's date as this is the date it was completed. On 9/18/2024 at approximately 9:15 AM V13, LPN, stated that most of the residents in the facility are on an antipsychotic. V13 stated that when the medication is ordered a consent is received from the resident or the family in order for the medication to be given. 2. R4's Care Plan, dated 8/20/2024, does not address R4's psychotropic medication use. R4's MDS, dated [DATE], documents that R4 is cognitively intact. R4's POS, documents 9/12/2024 Trazodone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime related to Major Depressive Disorder, Single Episode Mild. 9/12/2024 There is a black box warning associated with this order. 9/12/2024 Duloxetine HCl Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth one time a day related to Major Depressive Disorder, Single Episode Mild. 9/12/2024 There is a black box warning associated with this order. On 9/18/2024 at 12:29 PM R4's EHR was reviewed. No psychotropic consent documented in chart. On 9/18/2024 at 9:52 AM R4 stated that he is new to the facility. R4 stated that he does not take any antidepressants and antipsychotic medication. R4 stated that he has not given any verbal or written consent for those types of medication. R4 stated that he saw a doctor at the facility and told them that he was having some problems sleeping. R4 stated that he was not told that he was getting new medication. R4 stated that no one has explained any adverse reactions I think that's what it's called to him. R4 stated that he assumed his medication from the hospital followed him here. The facility's Psychotropic Medication Program, dated 9/2022, documents GENERAL: The second purpose of this process is to ensure the resident is evaluated and the indication for the medication is documented within the medical record including but not limited to the nursing staff, social services, activities, and the physician. Also, the resident and or resident representative are aware of the potential side effects and the facility obtains an informed consent for the use of the psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide tracheostomy (trach) care for 1 of 1 resident (R3) reviewed for trach care in a sample of 8. Findings include: 1. R3's Care Plan, dated 9/3/2024, documents R3 is at risk for complications r/t (related to) tracheostomy placement (trach tube) #6. It continues to document that staff should assess for signs and symptoms (s/s) of infection such as erythema, swelling, unusual drainage or odor or presence of a fistula, at noc (night) place on a Venturi mask with 28 % per trace collar at 10-15 Umin. Perform trach care as ordered and as needed. Trach collar with 28% humidified air continuous. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact. R3's Medication Administration Record (MAR) and Treatment Record (TAR) documents 8/28/2024 Change Trach collar twice weekly and as needed The MAR documentation of R3's trach collar changes for August and September 2024. In addition, the order, dated 8/28/2024, documents Cleanse Trach every shift using sterile technique does not document procedure completed on 8/29, 8/30, 9/4, and 9/9 7a-&p shift, 9/2, 9/3, 9/4, 9/8, and 9/9/2024 for the 7p-7a shift. R3's Progress Note, dated 8/23/2024, documents that R3 was admitted to the facility with trach. The Progress Note documented that the trach was to be capped in day and placed on mask at night. R3's Progress Note, dated 8/26/2024 at 3:26 PM, documents Nurses Notes Note Text: resident noted to be SOB (shortness of breath) out in the dining on 2 litters of 02 (oxygen), resident stats (oxygen saturation levels) were 75 (percent) upon initial assessment. resident was brought back to his room and was given a prn duo neb, residents stats came up to 84% on 2 liters after about 5 mins resident stats increased to 87% then dropped back down to 82%, DON (Director of Nursing) was present in room and contacted the providers whom gave orders to place resident on 10liters of 02 for via trach collar, after about 10mins residents 02 is back up to 87% , will continue to monitor. R3's Progress Note, dated 8/27/2024, documents that trach care was performed. No documentation in Electronic Health Record of Trach care performed prior to 8/27/2024. R3's Progress Note, dated 9/3/2024 at 21:22 Nurses Notes Note Text: Cleaned resident's inner cannula with aseptic technique and sterile water. Tolerated well with no complaints of pain. Has yellow drainage around outer part of dressing changed. On L of oxygen per nasal cannula. R3's Progress Note, dated 9/9/2024 at 4:57 PM, documents Nurses Notes Note Text: Trach care provided. NP (Nurse Practitioner) made aware of discolored discharge and redness ordered CXR (chest x ray) and sputum culture. Res (resident) made aware. R3's Progress Note, dated 9/12/2024 at 6:28 AM, documents Nurses Notes Note Text: Trach care and breathing tx (treatment) c/o (complaint of) pain, still awaiting sputum culture ordered by NP. R3's Progress Note, dated 9/13/2024 at 1:46 PM, documents Nurses Notes Note Text: Res sent out to (local hospital) r/t (related to) labored breathing, c/o pain at trach site, and trouble breathing. Res trach site reported to be coming loose when eating, red, warm to discolored secretions. (V20) NP (Nurse Practitioner) made aware. R3's Local Hospital Records, dated 9/13/2024, documents Chief Complaint Patient presents with Trach Issue History of respiratory failure, tracheostomy. Patient has green sputum coming from the tracheostomy site. His tracheostomy tube is capped. Patient has chronic shortness of breath. On 9/17/2024 at 1:56 PM R3 stated that he was admitted to the facility with his trach. R3 stated that it took over a week before he received trach care. R3 stated that his trach should be cared for a couple of times a day. R3 stated that because he didn't have any trach care he became short of breath and his oxygen levels plummeted. R3 stated that he received trach care that day. R3 stated the sometimes receive trach care but it is not every day and it's not more than once in that day. R3 stated that he had drainage coming from his trach and that it smelled. R3 stated that the people of that facility were scared to take care of the trach. R3 stated that when he was up his trach is capped but he is supposed to be placed on a mask at night and this has not happened. R3 stated that his trach stays capped. R3 stated that he is afraid that he will not make it out of that facility. When asked what he means by that statement R3 stated that he is afraid that he will die there because the staff won't and does not know how to take care of him. On 9/17/2024 at approximately 12:00 PM V12, Licensed Practical Nurse, LPN, stated that she has care for R3 and has provided him with trach care. V12 stated that she can't speak for anyone else but when she is at the facility, she performs trach care. V12 stated that R3 has complained that he was not receiving trach care, but she is not sure of why or if that was true. On 9/18/2024 at V13, LPN stated that she has been assigned to R3. V13 stated that she has worked with him on midnights. V13 stated that she has not performed trach care on R3. V13 stated that R3 would do it himself. V13 stated that R3 had oxygen on with his catheter and cannot say that he had a mask on. On 9/24/2024 at 3:37 PM, V1, Administrator, stated that she would expect her staff to perform trach care. The facility Equipment Change Schedule, dated 8/2023, documents 2. TRACHEOSTOMY: a) Replace disposable inner cannula daily (unless ordered otherwise) and prn. b) Trach tube is changed every three (3) months and prn (unless ordered otherwise) by a respiratory therapist/MD or a trained nurse. c) Clean permanent inner cannulas Q shift and prn. Provide trach care Q shift and prn with 50% Peroxide/Sterile saline solution. d) Tracheostomy: Dressing change Q shift and prn. e) Velcro trach collars and trach ties changed every 3 days and prn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure food was served in the appropriate portions for 8 of 13 (R2, R7, R8, R9, R10, R11, R12, and R13) residents reviewed for food services. Finding includes: 1. The facility menu Week 2 Wednesday documents Supper: Chicken Nuggets (7 ea (each)= 3 oz (ounces)pro (protein)), Barbecue Sauce (I Tbsp (tablespoon)), Crispy French Fries (4 oz spdl = 1/2 cup), Seasoned Mixed Vegetables (#8 scoop= 1/2 cup), Powdered Sugar Brownie (I piece), 2% Milk (8 oz), Coffee/Hot Tea (6 oz), Condiments (1 ea). R2's Fall Assessment, dated 8/23/2024, documents that R2 is alert and oriented. The facility provided a roster and identified R2 as interviewable. On 9/3/2024 at 11:00 Am R2 stated that he has been at the facility for 7 days. R2 stated that the food is horrible and that the portion sizes are small. R2 stated that the facility served chicken nuggets one evening for supper. R2 stated that he was given 4 nuggets and a few fries. R2 stated that when asked if he could have more, he was told that there wasn't any. R2 stated that he was not given any vegetables and was informed that he can't have vegetables with all his meals. R2 stated that today he was informed that he can get so much a day and if they put green and red peppers in the eggs it counts towards the overall vegetable for the day. R2 stated that he is a large man, and he can't live off of the amount of food given. 2. R12's Minimum Data Set, dated [DATE], documents that R12 has moderate cognitive impairment. R12's Dietary Assessment, dated 8/30/2024, documents that R12 is at moderate risk for weight loss. On 9/5/2024 at 9:37 AM R12 stated that the portion sizes are small and sometimes they run out. R12 stated that the cook, V21, is good and will try to get me something else but there may not be anything. R12 stated that the night of the chicken nuggets was a joke. R12 stated that he got a few nuggets and maybe 4 or 5 fries. R12 stated that he did not receive any vegetable. R12 stated that they bring snacks ot the nurse's station, but he doesn't get any. R12 stated that he guesses he would have to ask for it. On 9/3/2024 at 11:55 AM V21, Cook, stated that she was the cook that served the chicken nugget meal. V21 stated that she gave 5 nuggets for regular and 6 for double portions. V21 stated that she doesn't run out of food because she has the alternate but sometimes the main meal is out, and it is substituted with the alternate. On 9/3/2024 at 12:06 PM V22, Cook, stated that they run out of food all the time. 3. The facility menu Week 3 Tuesday documents Lunch: Tender Pork Roast (3 oz pro), Bread Dressing (#8 scoop= 1/2 cup), California Blend Vegetables (#8 scoop= 1/2 cup Banana (1 ea), Bread (1 slice), Margarine (1 tsp), Decaf Coffee/Hot Tea (6 oz) Condiments (1 ea), On 9/3/2024 at 12:08 PM to approximately 12:40 PM the noon meal service in the Main Dining Room was observed. Dietary staff were serving food from the steam table in the Dining Room. V21 was using tongs to pick up a serving of the pork meat entree. R7, R8, R9, R10, R11, and R12 were served regular pork and bread dressing. At no time was the meat weighed. Using a #6 scoop V21 partially filled scoop when serving. R7, R8, R9, R10, R11, and R12 received various portion sizes of pork and bread dressing ranging from small to large. 4. R13's MDS (minimum data set), dated 7/29/2024, documents that R13 is cognitively intact. On 9/3/2024 at 10:53 AM R13 stated that the food is not good. R13 stated that they don't get enough food. R13 stated that they must spend money on door dash and get food because there is none. R13 stated that they are paying over $1000 a month and they should get a good meal and enough food. On 9/3/2024 at approximately 1:15 PM V21 stated that she was not sure of what portion size to give but was just told 3oz. V21 stated that when serving she does not have a way to measure the portion size of the pork. V21 stated that she tries to make sure that everyone gets enough. On 9/3/2024 at approximately 2:10 PM V1, Administrator, stated that they do not have a policy that relates to serving appropriate portion sizes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transcribe and carry out a physician order for a specialist appointment for 1 of 1 resident (R57) reviewed for quality care, in the sample of 43. Findings Include: R57's admission Record, dated 3/28/24, documented that R57 had a diagnosis of unspecified cirrhosis of liver, malignant neoplasm of the colon, ascites, thrombocytopenia unspecified and decreased white blood cell count unspecified that were added to the diagnosis list on 4/19/24. R57 Minimum Data Set (MDS), dated [DATE], documented that R57 was moderately cognitively impaired. R57's Physician Order Sheets, (POS), dated 4/19/24, documented, Refer to the hematologist diagnoses Leukopenia and Thrombocytopenia one time only related to decreased white blood cell count and unspecified Thrombocytopenia. R57's POS, dated 4/27/24, documented, Refer to hematologist for Leukopenia and Thrombocytopenia. On 5/6/24 at 10:00, V20 Transportation/Appointment [NAME], stated, I was not aware of that appointment. On 5/7/24 at 1:00 PM, V3, ADON (Assistant Director of Nursing), stated, We print off the order and give it to (V20 Transportation/Appointment [NAME]), and she calls them, if they need paperwork sent to the doctor, she (V20) notifies me. I pull the paper and she (V20) sends it off to the doctor so we can get the appointment. On 5/9/24 at 11:35 AM, V20, Physician, stated, This is a chronic issue this guy (R57) has Cirrhosis of the liver and receives paracentesis. It will not make any difference that the appointment was delayed. R57's Lab Results Report, dated 4/22/24, documented that R57's WBC (White Blood Count) was low at 2.5, which was indicative of Leukopenia. and the Normal range was 3.9- 10.6. It continued to document that R57's Platelet Count was 56 which was indicative of thrombocytopenia, and the normal lab value range was 150-399. R57 Lab Results Report, dated 4/19/24, documented that R57's WBC (White Blood Count) was 1.9 and the normal is 3.9-10.6. R57's Platelet Count was 51 and the normal is 150-399. R57's Nurses Note, dated 4/18/24, documented, Lab called this nurse with critical labs WBC 1.9 and Platelets 51. The Facility Policy, Appointments and Transportation, dated 8/2018, documented. The staff nurse or designee will call the place of appointment to verify the date, time, and location. If the resident is unable to keep the appointment, it is the staff nurse responsibility to cancel the appointment and reschedule it at the earliest time. The facility did not have a policy that covered the making of initial appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and properly document code status for 5 of 6 residents (R58, R261, R264, R265, R266) reviewed for advanced directives, in the sample of 43. Findings include: 1. R261's Face Sheet, undated, documented that R261 was admitted to the facility on [DATE] with diagnoses including type 1 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. On [DATE] at 2:00 PM, R261's Electronic Health Record did not list a Code Status. On [DATE] at 2:10 PM, requested R261's Physician Orders and the State Agency Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form from V2, Director of Nursing (DON). R261's Order Summary Report, printed [DATE] at 2:55 PM, documented that R261 was a Full Code as of [DATE]. There was no Code Status listed prior to [DATE]. R261's State Agency Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], documented, Yes CPR: Attempt cardiopulmonary resuscitation (CPR). 2. R58's Face Sheet, undated, documented that R58 was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, chronic obstructive pulmonary disease, and paranoid schizophrenia. On [DATE] at 2:00 PM, R58's Electronic Health Record did not list a Code Status. On [DATE] at 2:10 PM, requested R58's Physician Orders and POLST Form from V2, DON. R58's Order Summary Report, printed [DATE] at 2:58 PM, documented that R58 was a Full Code as of [DATE]. There was no Code Status listed prior to [DATE]. R58's POLST Form, dated [DATE], documented, Yes CPR: Attempt cardiopulmonary resuscitation (CPR). 3. R266's Face Sheet, undated, documented that R266 was admitted to the facility on [DATE] with diagnoses including encephalopathy, systolic heart failure, and end stage renal disease on dialysis. On [DATE] at 2:00 PM, R266's Electronic Health Record did not list a Code Status. On [DATE] at 2:10 PM, requested R266's Physician Orders and POLST Form from V2, DON. R266's Order Summary Report printed [DATE] at 2:56 PM documents R266 is a Full Code as of [DATE]. There was no Code Status listed prior to [DATE]. R266's POLST Form dated [DATE] documents, Yes CPR: Attempt cardiopulmonary resuscitation (CPR). 4. R264's Face Sheet documents R264 was admitted to the facility on [DATE] with diagnoses including femur fracture, cerebral infarction, and acute kidney failure. On [DATE] at 2:00 PM, R264's Electronic Health Record did not list a Code Status. On [DATE] at 2:10 PM, requested R264's Physician Orders and POLST Form from V2, DON. R264's Order Summary Report, printed [DATE] at 3:00 PM, documented that R264 is a Full Code as of [DATE]. There was no Code Status listed prior to [DATE]. R264's POLST Form, dated [DATE], documented, No CPR: Do Not Attempt Resuscitation (DNAR). 5. R265's Face Sheet, undated, documented that R265 was admitted to the facility on [DATE] with diagnoses including acute myocardial infarction, atherosclerotic heart disease, and cocaine and alcohol abuse. On [DATE] at 2:00 PM, R265's Electronic Health Record did not list a Code Status. On [DATE] at 2:10 PM, requested R265's Physician Orders and POLST Form from V2, DON. R265's Order Summary Report, printed [DATE] at 2:58 PM, documented that R265 was a Full Code as of [DATE] and there was no Code Status listed prior to [DATE]. R265's POLST Form, dated [DATE], documented, Yes CPR: Attempt cardiopulmonary resuscitation. On [DATE] at 3:22 PM, V2, Director of Nursing (DON), stated that V11, Social Services Director, was currently collecting the POLST forms for the above residents. She also stated they were all new admissions, so they were getting them now. On [DATE] at 10:09 AM, V1, Administrator, stated that the Code status was part of the admission paperwork and if residents do not already have a Code Status, the facility talks to the residents if they are able to make their own decisions. V1, continued to state that if they are unable to make their own decisions, the facility talks to their family about their wishes, then contacts the physician. V1, also stated that if there was no Code Status listed, residents are considered to be Full Code. On [DATE] at 12:35 PM, V2, DON, stated that the Code Status should be addressed as soon as possible after admission. The Facility's Advance Directives and DNR Policy, reviewed 9/2021, documented, When a resident is admitted to the facility, a discussion of advance directives will take place between the resident and family, if the resident is unable to make decisions. This enables the staff to readily and clearly ascertain how to treat the resident in advance of an emergency. It continues, Under state and federal law, people have the right to make decisions regarding health care treatment. This includes their right to determine in advance what life-sustaining treatment will be provided, if any, in the future if they are unable to communicate those desires themselves. It continues, It is the policy of this facility to follow an individual's physician order made in accordance with state law regarding advance directives limiting life-sustaining treatment. It continues, A DNR order is valid with a POLST or IDPH Uniform DNR form completed and/or a physician order is completed. It continues, A Full Code/DNR order will be noted in the resident's medical record. It continues, The POLST form should be scanned into the medical record and must accompany the resident when they are transferred or discharged from the facility. It continues, The POLST Form should be reviewed when the resident is transferred from one care setting to another, there is a substantial change in the residents' health status or the resident treatment preference changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure palatable and appetizing meals for 5 of 5 residents (R18, R13, R24, R33, R267) reviewed for food palatability and temperature in the sample of 43. Findings include: 1-R18's Face Sheet documents R18 was admitted to the facility on [DATE]. R18's Minimum Data Set (MDS) dated [DATE] documented R18 was cognitively intact. R18's Physician Order dated 2/12/24 documents R18 is on a regular diet. On 5/5/24 at 9:52 AM, R18 stated the food is not good, and even when it is decent, it is always still cold. 2-R13's Face Sheet documents R13 was admitted to the facility on [DATE]. R13's MDS dated [DATE] documented R13 was cognitively intact. R13's Physician Order dated 2/12/24 documents R13 is on a regular diet. On 5/5/24 at 11:40 AM, R13 stated the food is horrible. R13 stated she has to order meals from outside the Facility. 3-R24's Face Sheet documents R24 was admitted to the facility on [DATE]. R24's MDS dated [DATE] documented R24 was cognitively intact. R24's Physician Order dated 2/12/24 documents R24 is on a regular diet with double portions. On 5/6/24 at 12:20 PM, R24 made the statement about the Facility food, Usually it's crap on a plate. 4-R33's Face Sheet documents R33 was admitted to the facility on [DATE]. R33's MDS dated [DATE] documented R33 was cognitively intact. R33's Physician Order dated 2/12/24 documents R33 is on a regular diet with double portions and fortified pudding with meals twice per day. On 5/6/24 at 12:22 PM, R33 stated the food could be better. 5-R267's Face Sheet documents R267 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition, weakness, and end stage renal disease requiring dialysis. R267's MDS dated [DATE] did not evaluate R267's cognitive status. R267's Physician Order dated 3/4/24 documents R267 was on a mechanical soft diet with no bananas, oranges, orange juice, or tomatoes. R267's Grievance Form dated 7/7/23 documents breakfast food was cold. This Grievance was confirmed. The Facility's Grievance Form from Resident Council Meeting dated 5/25/23 documents vegetables are overcooked at times. This Grievance was confirmed. On 5/9/24 at 8:13 AM, test tray temperatures were obtained on the 300 Hall after last resident hall tray was served. The scrambled eggs measured 112° Fahrenheit (F), the orange juice measured 60°F, and the cranberry juice measured 61°F. On 5/9/24 at 11:48 AM, V1, Administrator, stated she expects staff to follow food service policies. The Facility's Untitled Policy dated 2014 documents, Hot foods should be served at 135° F or higher. Cold foods should be served at or below 41° F. The Facility's Dining and Food Preferences Policy revised 9/2017 documents, Individual dining, food, and beverage preferences are identified for all residents/patients. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternative selection of comparable nutrition value.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to follow their alternative menu for 6 of 6 residents reviewed for alternative food choices in the sample of 43. Findings include: 1-R40's Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, chronic obstructive pulmonary disease, and atherosclerotic heart disease. R40's Minimum Data Set (MDS) dated [DATE] documented R40 was cognitively intact. R40's Physician Order dated 2/12/24 documents R40 is on a NAS (No Added Salt) diet. On 5/5/24 at 10:05 AM, R40 stated there is too much pork served at meals and no good substitutes offered. 2-R263's Face Sheet documents R263 was admitted to the facility on [DATE] with diagnoses including functional dyspepsia, cerebral infarction, and dysphagia. R263's MDS dated [DATE] documented R263 was independent with cognitive skills for daily decision making. R263's Physician Order dated 2/12/24 documents R263 is on a NCS/NAS (No Concentrated Sweets/No Added Salt) diet. On 5/5/24 at 10:17 AM, R263 stated the Facility never cooks enough food, and the substitute is always grilled cheese. 3-R24's Face Sheet documents R24 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, human immunodeficiency virus, and hemiplegia and hemiparesis following cerebral infarction. R24's MDS dated [DATE] documented R24 was cognitively intact. R24's Physician Order dated 2/12/24 documents R24 is on a regular diet. On 5/6/24 at 12:20 PM, R24 stated, If we don't like the meal, all we get is a grilled cheese. It would be nice if we got something different. Sometimes we get leftovers but . (nothing else). 4-R33's Face Sheet documents R33 was admitted to the facility on [DATE] with diagnoses including essential hypertension, chronic obstructive pulmonary disease, and unsteadiness on feet. R33's MDS dated [DATE] documented R33 was cognitively intact. R33's Physician Order dated 2/12/24 documents R33 is on a general diet. On 5/6/24 at 12:22 PM, R33 stated the food alternative is always grilled cheese. On 5/7/24 at 1:00 PM during the Group Resident Council Meeting, R6 and R55 stated grilled cheese is the only alternative if you do not want the meal served. On 5/7/24 at 1:55 PM, V16, Dietary Manager, was asked what alternatives were served for lunch today. She stated, We had spaghetti (regular menu item), we had grilled cheese, we had green beans, mashed potatoes, and lunch meat sandwiches. On 5/7/24 at 1:58 PM, V15, Certified Nursing Assistant (CNA), stated, (If residents do not like the meal item served), I try to offer grilled cheese, and I think they just started (offering) hamburgers. There's not a lot of options, but I usually try to offer grilled cheese and hamburgers. On 5/7/24 at 2:24 PM, V17, Regional Ombudsman, stated, For the past 7 years, the only alternatives have been grilled cheese or leftovers. If they didn't like the meal the first time, they are not going to like it leftover. I have had so many discussions with the Facility, but nothing has changed. It's still grilled cheese and leftovers. On 5/9/24 at 11:48 AM, V1, Administrator, stated she expects staff to follow food service policies. The Facility's Dining and Food Preferences Policy revised 9/2017 documents, Individual dining, food, and beverage preferences are identified for all residents/patients. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternative selection of comparable nutrition value. The Facility's Undated Always Available Menu documents deli sandwich, jelly sandwich, grilled cheese, mixed fruit cup, cottage cheese, side, salad, and mashed potatoes are always available.

Based on Observation, Interview, and Record Review, the facility failed to maintain infection control during dialysis treatment on 7 residents (R266, R41, R10, R30, R261, R53, R32) in the sample of 43. Findings Include: R266's Face sheet documents an admission date of 5/1/2024 and diagnosis includes Encephalopathy, Cirrhosis of the Liver, End Stage Renal Disease, Ascites. R266's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R41's Face sheet documents an admission date of 9/20/2022 and diagnosis includes End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Vascular Prosthetic, Type 2 Diabetes, Bacteremia. R41's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R10's Face sheet documents an admission date of 7/29/2019 and diagnosis include End Stage Renal Disease, Toxic Encephalopathy, Respiratory Failure, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease. R10's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R30's Face sheet documents an admission date of 3/21/2024 and diagnosis include End Stage Renal Disease, Chronic Kidney Disease, Type 2 Diabetes. R30's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R261's Face sheet documents an admission date of 4/19/2024 and diagnoses include End Stage Renal Disease, Type 1 Diabetes Mellitus with Diabetic Neuropathy, Chronic Embolism and Thrombosis. R261's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R53's Face sheet documents an admission date of 9/22/2023 and diagnosis include End Stage Renal Disease, Polyneuropathy, Acute Kidney Failure, Obstructive and Reflux Uropathy, Morbid Obesity. R53's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R32's Face sheet documents an admission date of 4/8/2024 and diagnosis includes End Stage Renal Disease, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Pleural Effusion. R32's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. On 5/6/2024 at 9:30 AM Observed in house dialysis by dialysis company. Staff present were V12, RN (Registered Nurse) and V13 PCT (patient care technician). Six hemodialysis stations were present on the unit. The dialysis home provides hemodialysis for seven residents. Six residents are provided dialysis five days a week Monday through Friday. One resident is provided dialysis four days a week Monday, Tuesday, Thursday, and Friday. On 5/6/2024 at 9:30 AM V12 and V13 not wearing gloves, gowns, or masks. Observed six syringes with clear liquid inside of each syringe laying on the counter behind the nurse's desk. Observed the six syringes labeled with each resident's name. When asked V13, PCT what was in each of the syringes. V13, PCT stated it was heparin flush solution. The syringes were labeled with the names of R261, R53, R41, R10, R30, and R266. On 5/7/2024 at 8:30 AM V12, RN and V13, PCT observed with dialysis residents, without proper PPE (gown, gloves, and mask). V12 and V13 applied PPE after surveyor entered the unit. Observed V13 disconnect R30 from the dialysis machine and placed pressure onto the right arm of R30 for 10 minutes, taped the arm of R30 without using a dressing. V13 stated he was applying a dressing gauze to the site of the arm of where he removed the needle. V13 stated that they were out of the dressing kits at this time. Asked V12 if the unit was limited of dressing kits and needles used to stick the residents to connect to the dialysis machines, she checked and was unaware. V13 stated that supplies have been ordered and they should be in on 5/8/24. On 5/7/2024 at 8:45AM V13 removed R41 off the dialysis machine placed tubing and filter into the bag hanging on the IV pole, removed the bag off the IV pole then tossed the bag into a red bag into a box. V13 removed his gloves and tossed into the box. V13 proceeded to apply more gloves without using hand sanitizer. On 5/7/2024 at 8:45 AM observed V13 go towards the rear window place his gloved hand into the box with the red bag and pull an item unrecognizable into his hand and drop into the sharp's container next to the box with the red bag. V13 proceeded to remove his gloves discarded into the box and put on another pair of gloves without using hand sanitizer or washing hands. On 5/7/2024 at 8:45AM, R53 removed himself from the dialysis chair and transferred to scooter. R53 left the dialysis floor, due to illness. V6, CNA, brought R32 into the dialysis unit into wheelchair. V6 did not apply PPE (personal protective equipment) gown, gloves or mask and proceeded to push R32 to the dialysis chair of R53. V6 was getting ready to transfer R32 into the dialysis chair. Dialysis chair had not been cleaned or sanitized since R53 left the unit. Surveyor asked V12 if the chair had been cleaned. V12 yelled to V6 not to transfer him, she stated that she had to clean that chair. V12 went to the sink and removed a paper towel from a container (resembled a transparent shoe box) with clear liquid filled halfway in the container. V12 walked down to the station and clean the chair, the side table, IV pole, and dialysis machine with the same wet paper towel. V12 told the resident and V6 not to place the resident into the chair yet. V12 returned to the desk. This writer asked V12 what was in the container, she stated bleach and water. Asked V12 the strength of bleach was, she stated 10%. Asked V12 how much water should be added with the bleach, she did not answer at that time. On 5/7/2024 at 8:30AM, V12 stated the proper technique to maintain infection control of dialysis sites after inserting and removing the dialysis needles. V12 stated to make sure the site is covered with a sterile gauze and tape. On 5/9/2024 at 12:30PM, V2, Director of Nursing, DON, stated she would expect all staff, including dialysis staff, to utilize proper infection control practices. Facility policy dated 4/2024 states To provide guidance to the facility on how to care for the dialysis resident.

Based on Interview and Record Review, the facility failed to provide timely access to medical records, for 2 of 2 (R3, R4) residents, reviewed for rights to access medical records, in a sample of 12. Findings Include: R3's Face sheet, undated, documented an admission date of 12/16/2023. On 4/18/2024 at 3:00PM, V10, R3's daughter, stated I have asked for (R3's) medical records and still have not received anything. I emailed (V5, Medical Records) worker, all the required documents on 2/9/2024. I then followed up with (V5) on 2/15/2024 and needed to send another proof of identification. I sent that proof in the same day and have not heard anything. I sent (V5) an email in March to see if (V5) had heard anything about (R3's) medical records, and she emailed back that she sent everything to the corporate office and knew nothing else. I still have none of (R3's) medical records. On 4/18/2024 at 11:00AM V5, Medical Records, stated, R3's Power of Attorney, POA, put in a request for (R3's) medical records. The facilities do not give out medical records. The records are sent from the corporate office. I send in the request form. The family must provide a copy of the death certificate and identification. After I have the required documents, I send everything on to our corporate office. After that it is out of my hands. I do not get updates and don't know anything beyond when I send the documents in. (R3's) daughter sent me an email for an update on (R3's) records and I explained in the email that I do not get any updates. R4's Face sheet, undated, documented an admission date of 11/16/2022. On 4/19/2024 V9, R4's Guardian, stated, I have had a terrible time dealing with the facility. I spoke with (V1, Administrator), in the beginning of March, about getting (R4's) medical records. (V1) said yes, I could get them. (V1) did not get back to me. On 3/28/2024, I spoke with (V3, Social Services Director) and explained I needed (R4's) medical records. (V3) said he would get back to me. He did not call me back. I then called on 3/29/2024 and spoke with (V5, Medical Records) worker. I explained to (V5) that I needed (R4's) medical records. On 4/1/2024, (V5) told me I had to pay for the medical records. (V5) then called me back on 4/2/2024 and I re-explained everything again. On 4/2/2024 (V5) sent the documents that I was to fill out and I sent the required documents back on 4/2/2024 with the correct attachments. It looks like I received an invoice to pay for the records on 4/12/2024. I did not see this email until today. I still do not have any medical records. On 4/18/2024 at 2:45PM, V11, Corporate Consultant, stated, Requests for medical records are sent on to a data processing company. I do not have access to that information. On 4/18/2024 at 3:30PM V12, Data Processing Company Employee, stated, I received the request for (R4's) medical records and the invoice was sent to (V9, R4's Guardian) email on 4/12/2024. Once the fee is paid the medical records will be released. I have not received any request for R3's medical records. On 4/19/2024 at 10:35AM, V1, Administrator, stated, I knew (V7, R3's daughter), and (V10, R3's daughter), requested medical records, but they said they would not pay the fee. I don't know anything after that. V1(Administrator) also stated, (V9, R4's Guardian), has requested records in the past. I didn't know anything about her wanting more records. The facility's policy, MR Procedure for Medical Records, dated 2/26/2023 does not document a time frame for which the facility has to request medical records for residents and/or their power of attorney from their Health Information Management group.

**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 mental abuse for 2 of 7 (R1, R2) residents reviewed for abuse in the sample of 8. Findings include: 1- R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, morbid obesity, asthma, acute respiratory failure with hypoxia, anxiety, hypothyroidism, and major depressive disorder. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact and ambulated via wheelchair and walker. R1's Care Plan documents R1 was at risk for abuse and neglect related to needing assistance and behaviors at times. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizophrenia, acute respiratory failure, heart failure, generalized anxiety disorder, and major depressive disorder. R3's MDS dated [DATE] documented R3 was independent with cognitive skills for daily decision making and required supervision or touch assistance with transferring. R3's Care Plan documents R3 was at risk for abuse and neglect and had a history of peer-to-peer altercations at previous facility. The Facility's Initial Report sent to the State Agency on 1/27/24 at 12:14 PM documents, Resident (R3) was banging on the bedroom door of resident (R1) threatening to beat her up if she continues to talk about her. Staff was in the room with resident (R1) and resident (R3) wasn't able to get in the room. (R3) has a diagnosis of schizophrenia. Resident (R3) was separated from residents (R1) bedroom door. The admin (administrator) was notified, the DON (Director of Nursing) and the Physician. The Physician ordered the resident be transferred to (Local Hospital) to be evaluated for behaviors. Staff remained with resident (R3) until the police and EMS (Emergency Medical Services) arrived. R3's Progress Note by V8, Licensed Practical Nurse (LPN), dated 1/26/24 at 3:30 PM documents, sometime before 15:00 resident became belligerent and started yelling verbal accusations in the middle of 400 hall. resident accused another resident of speaking about her. this writer than requested help from (V7). On 2/28/24 at 9:53 AM, V1, Administrator, stated V8, LPN, was no longer working in the Facility and was unavailable for interview. R3's Progress Note by V7, Social Services Director, dated 1/26/24 at 4:05 PM documents, Resident overheard another resident talking about her. Became upset and started beating on the resident's door. Police was called and writer informed (V2) and (V1). On 2/28/24 at 9:53 AM, V1, Administrator, stated V7, Social Services Director, was no longer working in the Facility and was unavailable for interview. V2, Director of Nursing, provided an undated Witness Statement documenting, On 1/26/2024, this RN (Registered Nurse) walked out of her office to hear a resident (R3) screaming I am going to bash your head in while sitting in her wheelchair outside another resident's door. (R3) was banging on the door. Staff were trying to deescalate the situation by calming (R3) down and were physically holding (R3)'s wheelchair back. Upon seeing what was going on, this RN physically placed herself at the entrance of the resident's door that (R3) was attempting to harm. (R3) started yelling I am going to be in pain because I did not get my paid {sic} medication. This RN introduced herself to (R3) as the new DON and asked what I could do in this situation to help calm (R3) down and deescalate the situation. This RN offered to get (R3) her afternoon medication if she went to her room to calm down and talk to the social worker. (R3) agreed. (R3) given her evening medication in her room while talking to the social worker. (R3) still very upset regarding the situation and was having trouble calming herself. This RN called (V12), (R3)'s psychiatrist, and updated him on pt's (patient's) behavior. Per (V12), (R3) was to be sent via EMS (Emergency Medical Services) to (Local Emergency Room) for a psych (psychiatric) consultation regarding threatening to physically assault another resident. EMS and 911 called by nursing staff. EMS arrived and police arrived at approximately 1600 (4:00 PM). (R3) refused to get on the stretcher for EMS. (R3) was irate claiming that I should follow through with bashing her head in next time since I'm going to get sent away anytime this happens anyway. EMS and police officer asked (R3) many times to get on EMS stretcher and (R3) kept refusing. (R3) educated that if she did not cooperate a call would be made to get an order for a sedative for her to help her cooperate. After much convincing, (R3) complied and got on the stretcher for EMS. On 2/28/24 at 7:52 AM, V1, Administrator, stated V2, Director of Nursing, was out of the Facility and unavailable for interview. On 2/27/24 at 1:40 PM, R1 stated, (R3) heard me talking to a nurse about (her relationship with another resident) and (R3) got mad at me. (R3) flipped around and started yelling at me and said she was going to bash my head in. I then went and filed a restraining order. (R3) is supposed to be 30 feet from me. The judge dismissed the restraining order because the facility is a relatively small area. The day she threatened to bash my head in, the staff had to barricade my door so she couldn't get in my room. On 2/27/24 at 2:13 PM, R4 stated, (R1) was saying something to someone. (R3) got mad and said she wanted to bash her head in. I was in (R1)'s room when (R3) came in the room and lunged at her. The staff stopped (R3) before she made contact. The Facility's Final Report submitted to IDPH on 2/1/24 by V1, Administrator, documents the allegation of R3 making threats to R1 was verified and substantiated. On 2/28/24 at 1:32 PM, V1, Administrator, stated she expects the Facility to follow its abuse policy. The Facility's Abuse Policy and Prevention Program 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide feeding assistance with meals for 2 of 3 residents (R3, and R7) reviewed for ADL (activities of daily living) assistance in the sample of 8. Findings include: 1. On 10/26/2023 during the noon meal there was one Certified Nursing Assistant. (CNA), in the dining room providing hands on assistance to residents. R3 was not observed being assisted with his meal. During that meal R2's fortified pudding in bowl untouched at the end of meal V2, Director of Nursing, (DON), walked over and placed spoon in R3's pudding and at that time R3 ate 75% of his fortified pudding. R3's Care plan dated 5/8/2023 documents that R3 is at nutritional risk as disease progresses Diabetes Mellitus, colon cancer. R3's care plan documents R3 has experience unplanned weight loss due to cancer and is currently on hospice care and weight loss is expected to continue. R3's care plan documents, the following interventions 3/13/2023 supervision of meals at assisted table in the dining room. R3's Minimum Data Set, (MDS), dated [DATE] documents, that R3 has severe cognitive impairment. R3's MDS documents, that R3 requires supervision and one-person physical assist with eating. 2. On 10/26/2023 during the noon meal, R7 was not provided assistance with his meal. R7's Minimum Data Set, (MDS), dated [DATE] documents, eating supervision and one-person physical assist. R7's care plan dated 10/3/2023 documents, DIETARY: R7 has experienced unplanned weight loss related to decreased appetite/PO intake. R7's care plan documents, the following interventions - Encourage PO intake and provide assistance with meals. The facility policy feeding assistance dated revision 10/2022 documents, to try to provide adequate nutrition to a resident unable to feed themselves by handfeeding them. The policy documents residents who are unable to feed themselves are encouraged, instructed, assisted and/or fed by a qualified staff member. On 11/02/2023 at 9:15AM V18, Certified Dietary Manager asked by surveyor if there are times not enough staff are in dining room providing feeding assistance to residents, and V18 stated, yes sometimes. On 11/2/2023 at 10:47AM V1 Administrator stated, she would expect staff to provide feeding assistance in the dining room, and for Dietary supplements to be provided as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to submit an initial resident abuse allegation to the state agency within the 2-hour time frame for allegation of abuse for 1 of 3 resident (R13) reviewed for abuse on the sample of 27. Findings include: R13's Care Plan, dated 3/30/23, documents ABUSE: At risk for abuse and neglect r/t, (related to), behaviors at times. It continues: Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect throughout next review. Immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. R13's Minimum Data Set, dated [DATE], documents, that R13 is cognitively intact. R13's Incident report, dated 8/27/2023, documents, Nursing Description: Reported to this Nurse per RN, (Registered Nurse), resident in w/c, (wheelchair), (R13) tried to go around Res, (resident), 2 had made open handed contact with the back of her head. Resident Description: Resident stated, Res 2 smacked her (R13) in back of the head when she (R13) was trying to go around him. A written statement, dated 8/27/2023, documents, Interviewed (R13) regarding getting smacked on the back of the head. She stated, he did not smack her on the back of the head she was going around him, and he touched her hair. She has no injuries and did not feel he intentionally hit her. Signed by V1, Administrator and V13. On 9/28/2023 at 11:18 AM V22, Licensed Practical Nurse, (LPN), stated, that it was reported to her by V23, RN and a Certified Nurse Assistant, (CNA). V22 stated, that the CNA witnessed R24 slap R13 in the head. V22 stated, that the CNA wrote a statement. V22 stated, that she documented, the event in R13's chart and completed a report. On 9/28/2023 at 1:27 PM V23, stated, that she was a Nurse at the facility on the day that R13 was hit in the head. V23 stated, that she worked 7AM to 7PM. V23 stated, that it occurred right at shift change. V23 stated, that she was notified by a CNA that R13 was slapped in the head by R11. V23 stated, that she and the Aide notified, V22, who was assigned to the residents involved. V23 stated, that she did not report it to anyone else, because she reported to the Nurse and thought that she would take care of it. On 9/25/2023 at approximately 9:30 AM, V1, Administrator, stated, that she did not report the incident. V1 stated, that once she was notified, she asked R13 and R13 denied that she was hit. On 9/26/23 at 9:35 AM R13 stated, that she remembers the incident between her and R11. R13 stated, that she was passing R11 in the hall. R13 stated, that R11 hit her in the back of head when she passed him. R13 stated, that it did not hurt, but she did not like being hit. R13 stated, that R11 lives across the hall from her. R13 stated, that when she goes pass R11 she is careful, cautious, guarded and tries to stay out of his reach. R13 stated, that they need to do something with him. R13 stated, that she is not afraid of R13 she just doesn't like to be hit. R13 stated, that no one has talked to her about the incident. R13 stated, that she has not spoken to V1 about the incident. On 9/28/23 at 3:52 PM V1 stated, that she was not immediately notified of the incident. V1 stated, that when the surveyor requested the incident logs and during a review, she was made aware of the incident. V1 stated, that she went and asked R13 and she denied it occurred. On 9/28/23 at 3:58 PM V18 stated, that V1 spoke with V22, and she (V22) stated, that she did not report it to anyone. The facility's Abuse Policy and Prevention Program 2022, not dated, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility therefore this facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. VIII. External Reporting 1. Initial reporting Allegations: When an allegation of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents of residents have been made, the administrator or designee shall notify Department of Public Health's regional office immediately by telephone or fax.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain walls and floors in good repair for 11 of 27 residents (R11, R15, R14, R16, R17, R18's, R19's, R20, R21, R22's and R23's) reviewed for Physical Environment on the sample list of 27. Findings include: 1. R11's Minimum Data Set, dated [DATE], documents, that R11 is cognitively impaired. On 9/25/2023 at 11:50 AM, observed large hole in wall in R11's room. On 9/26/2023 at approximately 2:00 PM V13, Maintenance Director, stated, that he was working on the hole, but at this point was not able to complete. V13 stated, that the pipes were exposed, but did not verify mold. V13 measured the hole at 5ft, (foot), x 1.2ft. V13 stated, that he was not sure how the hole occurred. 2. On 9/27/2023 at 9:00 AM a walkthrough, of 100-hall and 200-hall were completed and revealed: A large hole, approximately 1ft x 2ft, behind the toilet in R15's bathroom and a large hole, approximately 1 ft x1 ft in R14's bathroom. A large hole approximately 2ft x 1ft in R16 and R17 room next to the sink. The wall is moveable and not attached to the floor. A large whole, approximately 3ft x1ft, in R18's, R19's, R22's and R23's bathroom. A large whole in wall next to sink, approximately 2.4ft x 3ft, in R20's and R21's room. On 9/27/2023 at 9:08 AM R15 stated, that she uses this bathroom and does not like that there is hole in the wall. R15 stated, that she is not sure when the hole got there. On 9/27/2023 approximately 9:08 AM R14 stated, that he uses the bathroom. R14 stated, that he does not how long the holes has been there, or how it happened. R14 stated, that it was there when he was put in the room. R14's MDS, dated [DATE], documents, that R14 is cognitively intact. On 9/27/2023 at approximately 9:15 AM R20 stated, that the wall has been like this since he has been in the room, and he has been in the room for months. R20's MDS, dated [DATE], documents, that R20 is cognitively intact. On 9/27/2023 at approximately 9:30 AM V13 stated, that the facility has put a plan in place. V13 stated, that a room audit was performed, and rooms have been identified. V13 stated, that as of today they are working on getting 100-hall and 300-hall complete. V13 stated, that they will then move to the 200 and 400-hall after that. On 9/27/2023 at approximately 9:33 AM V17 stated, that a facility audit was completed last night with areas identified. V17 stated, that they are working on a plan and will fix the areas. The facility's Resident Environmental Quality Policy, dated November 2017, documents Policy: It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there were sufficient Nursing Staff in the facility to provide adequate care and assistance for residents, resulting in residents not gotten out of bed for meals and residents not receiving showers. This failure has the potential to affect all 64 residents in the living in the facility. Findings include: 1. On 10/2/2023 at 8:04 AM a walk through of 100-hall and 200-hall revealed no staff on the halls. On 10/2/23 at 8:08 AM V25, Licensed Practical Nurse, (LPN), stated, that she got to the facility at 7AM and no CNAs were at the facility. V25 stated, that there has not been a CNA since 6 AM. V25 stated, that this has not been the first time that this has happened. V25 stated, that this effects the care that is given. V25 stated, that V7, Restorative Aide, is helping, but she is not assigned to the hall. V25 stated, that at this time none of her CNAs have shown up and that she does not have any staff at this time for hall-100 and 200 besides herself. V25 stated, that there is only 1 CNA on the other side of the building. 2. On 10/2/23 at 8:11 AM the hall trays were placed at 100-hall and 200-hall Nurses Station. At 8:23 AM V7 passed the first tray. On 10/2/2023 at 8:25 AM V7 stated, that she was on the other side of the building helping get someone up. V7 stated, that currently she is the only CNA for 100/200 hall. On 10/2/23 8:30 AM V5, CNA, stated, that she is the only CNA on the hall. V5 stated, that she does not have help and is caring for the halls alone. 3. On 9/26/23 at 10:10 AM R28 stated, that he is the President of Resident Council. R28 stated, that the facility does not have enough staff. R28 stated, that when they are short staff, the trays are late and the food is cold. R28 stated, that he does not get his showers. R28 stated, that he has notified the staff that he would like his showers after lunch. R28 stated, that the staff will come to him and try to get him to take the shower in the morning or late at night. R28 stated, that because, they don't have staff, they will then put him down as refusing. R28 stated, that he has gone without showers, when they are short staff. R28's MDS, dated [DATE], documents, that R28 is cognitively intact. 4. On 9/27/2023 at 9:30 AM R8 stated, that she has not had a shower in this month. R8 stated, that the staff have washed her private areas. R8 stated, that more than that needs to be washed. R8 stated, that she goes to Dialysis and she has an odor. R8's MDS, dated [DATE], documents, that R8 is moderately impaired cognitively. R8's Shower sheet for the month of September, is blank for 9/2, 9/6, 9/9, 9/13, 9/16, 9/20 and 9/23/23. On 10/2/2023 at 1:20 PM V8, LPN, stated, that R8 is alert and oriented and able to make her needs known and answer questions appropriately. On 10/2/23 1:54pm V5, CNA, stated, that the staff changes from day to day. V5 stated, that some days they have staff and other days they don't. V5 stated, that this effects other areas of care. V5 stated, that the call lights take longer to answer because they are in rooms with residents and they are the only ones there. V5 stated, that they have choose what care is priority and what is not. V5 stated, that showers are not given. V5 stated, that for the residents that can take themselves, in the shower can take them, but if you must take them in there and give the shower it is impossible. V5 stated, that residents are not gotten up in the AM. V5 stated, that she sets the residents up for the meal and after the meal goes one by one and gets them up. On 10/2/23 at 3:06 PM V26, CNA, stated, that the facility staffing is short. V26 stated, that when they are short this causes things to be delayed. V26 stated, that it takes longer to answer call lights and provide the care that the residents need. V26 stated, that residents are not gotten up, because there are not staff to get them up or put them back to bed. V26 stated, that she works from 2pm to 6am and worked last night. V26 stated, that she left at 6 AM. V26 stated, that when she left the nurse was the only one on the hall. V26 stated, that when she leaves the nurse is responsible for the hall. The facility Staffing policy, dated 9/2017, documents, General: To have appropriate numbers of staff available to meet the needs of the residents. Guideline: 1. Staffing is based on the IDPH formula for determining numbers and levels of staff. 2. Staffing is then increased based on the needs of the resident population. 3. A schedule is made on a monthly basis and reviewed on an ongoing basis. 4. Staffing is supplemented as needed by outside agencies. 5. Staff is required to review their schedule and discuss any problems regarding their schedule with their supervisor. 6. It is the staff members' responsibility to be at work when they are scheduled.

2. R2's Facility-Reported Incident Form Initial Report documents, (V18), LPN (Licensed Practical Nurse) contacted (V1), Administrator, at 8:41 AM on 4/22/2023 that (R2) was in the dining room and requested for more milk for his cereal from Dietary Worker (V21). (V21) asked (R2) to say please, and (R2) got upset. (V21) made a statement to (R2) that was witnessed by (V18). (V21) was immediately sent home. MD (Medical Doctor)/POA (Power of Attorney) notified. Police Contacted. Investigation initiated. R2's Facility-Reported Incident Form Follow-Up Investigation Report documents, (V18), LPN, contacted (V1), Administrator, at 8:41 AM on 4/22/2023 that (R2) was in the dining room and requested for more milk for his cereal from (V21). (V21) asked (R2) to say please and (R2) got upset. (V21) was immediately sent home pending the outcome of investigation. MD/POA notified. Police contacted. Staff noted that (V21) stated to (R2) to say please when asking for milk. (R2) cursed at (V21) and (V21) responded in an unprofessional manner towards (R2). Staff interviews conducted and stated that (V21) did react to (R2) in an unprofessional manner. Conclusion: Not Verified. Unsubstantiated. In conclusion, the facility can not substantiate abuse. (R4) reports he did not feel threatened, nor has he experienced any mental anguish. He reports feeling safe in the facility. V23's Hand-Written Statement dated 4/22/23 documents, I was sitting at the desk when I heard yelling from the dining room. I walked in and (R2) and kitchen worker (V21) was yelling at each other. I immediately told (R2) to go to his room. He stayed and (V21) came back out the kitchen and they started yelling and threatening each other. They both said they was gonna beat each other's a**. While these two continued yelling and threatening each other l ushered (R2) out the dining room and another kitchen worker kept (V21) away. After getting back to the hall (R2) told us this all started over him asking for a glass of milk for his cereal. R2's Nurse's Note by V18, Licensed Practical Nurse (LPN), on 4/22/22 at 11:09 AM documents, It was reported to this nurse by another resident that this resident asked for a glass of milk and was told to please say please, and this resident got upset and said he didn't have to say pleas (please) and then he walked off and went to his room, this nurse went to asked this resident what had happened and he stated nothing happened, 'I asked for another glass of milk to eat my bowl of cereal with and was told I needed to say please, I'm not going to say please when it comes to eating my cereal with and was told I needed to say please , I'm not going to say please when it comes to me eating my food so I got upset and to keep me from going off I got up and left and went back to my room.' On 6/14/23 at 3:18 PM, V18, LPN, stated, From what I remember, (R2) wanted extra food and they told him to say please to be nicer. One of them said meet me outside and (R2) said that didn't happen and was told to leave the dining room after he threw his food on the floor. I was not in the room at the time it happened. On 6/15/23 at 1:46 PM, V23, Certified Nursing Assistant (CNA), stated, I was working down the hall when I heard yelling coming from the dining room. When I got down there (R2) was yelling at (V21), and (V21) was yelling back. (R2) was calling (V21) names and was upset about milk. (V21) was threatening to beat his a** because he was being so rude. (R2) was my patient, so I took him out of the dining room. R12's Witness Statement dated 4/22/23 documents, All I know is (R2) wanted some milk, he got up to get it his self and a CNA told him he couldn't get his own milk. Then (R2) told (V21) he was going to beat his a**. Then (V21) said he was going to beat his a** back. I feel safe around the kitchen workers. On 6/14/23 at 3:54 PM, R12 stated, Both (R2) and (V21) were saying bad words to each other in the dining room. Both were talking about hitting one another and calling each other b*****. It was all over a thing of milk. On 6/15/2023 at 4:24 PM, V1, Administrator stated, I was only following the corporate guidelines and I did what they told me to do. I did not substantiate the findings because that is what I was told to do. I am not saying that (R9) had the intentions of having sex with (R7) and/or abuse did not occur for (R7) or (R2). I was just following orders. The Abuse Policy with a revision date of 9/2017 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitations, misappropriation of property or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including but limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is willful inflictions of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that required medical attention (whether or not actually given). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact. Employees are required to report any incident, allegation of suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a complaint hotline or compliance officer, in the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Reports will be documented, and a record kept of the documentation. Any incident or allegation involving abuse or neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. Final Investigation Report, the investigator will report the conclusions of the investigation in writing to the administrator or designee. The administrator or designee in the administration's absence will review the report and a final written report of the results of the investigation will be forwarded to the (State) within five working days of the reported incident. The final report shall contain Conclusion of the investigation based on known facts. Based on interview and record review the Facility failed to substantiate abuse through investigation when abuse occurred for 2 of 3 residents (R2 and R7) reviewed for abuse investigation in the sample of 12. Findings includes: 1. R7's Facility-Report Incident Form, Initial Report, date the Incident Occurred, 5/9/2023, documents, abuse, sexual was checked. Physical Abuse was not checked and/or documented for R7. R7's Facility-report Incident Form, Follow-up Investigation Report, with date of Incident as 5/9/2023, documents Alleged victim (R7) reports she was reclining in her chair, reading a book when the alleged perpetrator (R9) knocked on her door. R9 alleged perpetrator identified himself when she asked who was there. R7 alleged victim states she allowed alleged perpetrator in, he shut the door. She asked him why he shut the door and he stated he wanted to talk to her, she sat back into her recliner, alleged perpetrator approached her stating he wanted sex, she pushed her call light and started yelling for help, at that time, the alleged perpetrator put his hand over her mouth pressing against her glasses. Staff came in the room and took him out. The Report documented Resident states she was 'shaken up' and doesn't want to see or speak to the resident again. The Report documented Witnesses report hearing resident scream, upon staff member entering room from next door, alleged perpetrator was standing over alleged victim with 'his hand over her face, and he struck her a couple times. The Report documents Upon conclusion of thorough investigation, the facility can not substantiate allegation of sexual abuse. The rapid response of the staff to the call light/resident screaming prevented the alleged perpetrator from carrying out actions related to his stated desire of 'having sex.' R7 alleged victim denies that resident (R9) touched her in any sexual manner. (BIMS/Brief Interview for Mental Status score of 10, good historian) she (R7) denies he (R9) struck her. R9 alleged perpetrator has been discharged from facility, no plan to return to the facility. Based on resident interview, staff interview, record review resident observation no sexual abuse occurred. On 6/13/2023 at 2:02 PM, R7 stated, (R9) lived here and he was blind, and he has a cane. I heard a knock at my door, and it was (R9). He said, 'I need to talk to you,' and then he closed the door. I said 'hi, why did you close the door?' and he said, 'I want to have sex with you,' and I said, 'oh no you are not!' and he said, 'Oh yes I am,' and he came over and put his hand over my mouth to keep me from yelling and I turned my head and started screaming really loud. He began pushing my glasses into my face and nose and he was really hurting me. He is no longer here but I still get so upset just thinking about it scared me so much! He did hurt me, but he did not get what he wanted. I feel sick to my stomach just talking about it, it was awful! On 6/14/2023 at 9:12 AM, V9, Certified Nursing Assistant (CNA) stated, I remember that day I was in another room close to (R7's) room laying a patient down when I heard (R7) screaming. That was not like her to scream so I ran into her room, and I saw (R9) standing over her and (R9) was hitting her in the face and she was covering her face with both of her hands. She was crying and upset, and I immediately separated the two and grabbed (R9) and contacted my supervisor on duty and the nurse. (R9) was not wanting to be redirected and leave and we called the police. I eventually got (R9) back to his room. (R7) told me that (R9) had come into her room and shut the door and (R9) told her he wanted to f*** her and she was very upset and crying and told me 'No' he was not. She said he put his hand over her mouth so he could stop her screams and she was shaking. I know she was upset, and angry afterwards. She has calmed down now but she gets nervous with male staff/visitors and is fearful of males even today when they are entering her room and/or with her door being closed. I know she will always remember it. On 6/14/2023 at 3:22 PM, V18, Licensed Practical Nurse (LPN) stated, The CNA (V9) came and got me and told me (R9) had to be pulled off of (R7) because he had went into (R7's) room and he had his hand over her mouth, and he was hitting her with his other hand in her face/head area. (R9) had already been removed from (R7's) room and when I went into (R9's) room (R9) was j****** off and had his penis in his hand. When I went to check on (R7) she was hysterical, she was crying and upset. (R7) said (R9) told her he was going to have sex with her, so she started screaming and then he put his hands over her mouth. When the police came and started asking him questions (R9) kept acting like he had not done anything, but he was caught hitting (R7) in the face. R7's Police Report documents, On 05/09/2023 at approximately 6:23 PM, hours, I was dispatched to (Facility) in reference to a report of a PATIENT-ON-PATIENT BATTERY. It should be noted that through prior police experiences, I am aware that (Facility) is a living facility for individuals with mental and/or physical disabilities. I arrived on scene and contacted employee, (V18), who reported a male patient, (R9), battered a female patient, (R7), after she refused to have sexual intercourse with him. (V18) advised a coworker, (V9), had witnessed the battery. I contacted (V9), who stated she had heard (R7) yelling for help from her (R7's) room. (V9) stated the door to (R7's) room was closed and when she opened it, she observed (R9) holding his hand over (R7's) mouth and hitting her in the face. (V9) was unable to describe the strikes, but stated she separated (R7) and (R9) and placed (R9) back in his own room. It should be noted that (R7) does not move well without assistance and mostly sits in a chair or her bed. It should also be noted that (R9) is blind, bi-polar and utilizes a wheelchair. I contacted (R7). (R7) was actively shaking and crying, stating that she was scared. (R7) stated she was sitting in her room with the door open, watching television. (R7) stated (R9) entered the room and immediately shut the door. (R7) stated she asked (R9) what he wanted; at which time he said something similar to Will you have sex with me? (R7) stated she told (R9) No. (R7) stated (R9) then approached her and attempted to grab her. (R7) stated she began to yell for help at which time (R9) placed his hand over her mouth and hit her. (R7) was unable to describe the strikes. (R7) stated a nurse then entered her room and removed (R9). I observed (R7) to have a small abrasion, approximately the size of a fingernail, in the center of her left cheek. (R7) refused medical treatment, but repeatedly stated she was very scared and did not want (R9) to come back. I utilized a departmental issued camera to photograph (R7), and the photographs were later downloaded and attached to this case. (R7) was advised on how to obtain an order of protection. (R7) stated she was desirous of criminal charges against (R9). I allowed (R7) to sign a departmental agree to prosecute form. The form was later downloaded and attached to this case. Signed by V19, Officer/Sergeant of Local Police.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to develop a discharge summary for 1 of 5 residents (R13) reviewed for discharge summary in the sample of 17. Findings include: R13's Face sheet document he was admitted to the facility on [DATE]. R13's Hospital admission Diagnosis with an encounter date of 2/27/2023 at 7:18 PM, document a diagnosis of aggressive behavior, dementia, dementia with agitation, dementia with behavioral disturbances. R13's Minimum Data Set (MDS) Discharge assessment dated [DATE] documents R13 has memory problems and has modified independence for decision making of Activities of Daily Living (ADLs). R13's Social Service Notes dated 6/22/2023 at 12:51 PM, Resident was discharged home. Called resident's wife to let them know that they are on their way because wife stated she did not have transportation to pick resident up from facility. Resident's wife okay with discharge and stated where to have resident dropped off with belongings. Social Service Director received a call from resident's primary from [NAME] and they asked why resident was discharged . Doctor ordered discharge since resident was adamant about going home. R13's Medical Records does not document any discussions with wife before this discharge. R13's Care Plan addressing Activity of Daily Living document, Resident requires assist with daily care needs related to dementia. Date initiated 3/8/2023. Mechanical lift with 2 staff assists for transfers. Discharge Planning: The resident and guardian express the desire for the resident to continue with long term care placement. Resident and wife express desire for placement in (different town) to be closer to family after his therapy is completed, date initiated 5/4/2023. R13's Care Plan does not document the reason why they were not honoring his previous documentation related to long term care placement and why it was changed to discharge to home. On 6/27/2023 at 12:44 PM, V3, Assistant Director of Nursing, stated, (R13) was discharged home because he wanted to go home, it was his choice. R13's Medical Records reviewed and does not document any Care Plan Meeting was held or anything related to R13 discharging home. No post discharge plan was documented regarding arrangements that were discussed or made for the resident's follow up care and any post discharge medical services. R13's Transfer/Discharge Report documents, Date of transfer 6/22/2023 at 10:10 AM, transfer/discharge to private home/apartment with no home health services: Home. On 6/30/2023 at 9:01 AM, V5, MDS/Care Plan Coordinator, stated, I am not sure why I did not care plan (R13) going home. The Discharge Policy dated June 2015 documents, Discharge potential is assessed by Social Services on admission. When the IDT, (interdisciplinary team) in conjunction with the resident/patient and family determine that a resident/patient is ready to be discharged , the physician is contacted for an order. Social Services will meet with the resident/patient and/or family to set up outside services and equipment. A Discharge Instruction Form is initiated by Social Services or Discharge Planner and finished by the IDT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent a significant medication error for one of three residents (R5) reviewed for significant medication error in the sample of 17. Findings include: On 6/27/2023 at 12:00 PM R5 was up in his wheelchair sitting in his room. R5 was alert and pointed to an IV (intravenous) pump and stated the nurse puts the medication in the pump then into his arm and pointed to a PICC (peripherally inserted central catheter) line in his upper inner right arm. R5's Face Sheet documents an admission date of 12/17/2022 with diagnoses including acute osteomyelitis right ankle and foot, non-pressure chronic ulcer of right heel and midfoot with necrosis of bone, cellulitis of right lower limb and diabetes. R5's Undated Care Plan, documents resident is at risk for infection, IV (intravenous) ABT (antibiotic) for osteomyelitis (bone infection) of right foot at this time. Goal: resident will remain free from infection throughout next review. Intervention: medication as ordered. R5's Quarterly Minimum Data Set (MDS), dated [DATE] documents R5 was alert. The MDS documents R5's diagnoses as acute osteomyelitis right ankle and foot, non-pressure chronic ulcer of right heel and midfoot with necrosis of bone, cellulitis of right lower limb and diabetes. The MDS documents that R5 had one surgical wound. R5's Hospital Discharge Paperwork, dated 6/7/2023 documents physician's orders: Cefazolin (antibiotic) 2,000 milligrams (mg) into a venous catheter (IV) every 8 hours for diagnosis of bone/joint skin/soft tissue infection. Ceftriaxone (antibiotic) 2,000 mg into venous catheter every 24 hours. R5's Nurse's Progress Note, dated 6/7/2023 at 11:38 PM, documents, Resident returned from local hospital at 2:30 PM 6/7 via ambulance, complete skin assessment done, resident has bruising in the left antecubital, and 2 lumen PICC (peripherally inserted central catheter) line to the right upper arm, resident continues with wound to right foot, which resulted in the osteomyelitis returned on IV push ABT (antibiotic), returned to same room. Reoriented to the room, medications entered into the computer, V/S (vital signs) were as follows: B/P (blood pressure) 115/60, T (temperature) 98.2 degrees, R (respiration) 20, P (pulse) 68 will continue to monitor, resting well in bed and not signs of pain or discomfort, resident also denies any pain at this time. R5's Order Summary Report documents 2 physician's orders for Cefazolin 2,000 mg IV every 8 hours and Cefazolin 2,000 mg IV four times a day. Both Cefazolin orders were to be started 6/8/2023 and were documented discontinued with no end date documented. R5's Medication Administration Record (MAR) dated 6/8/2023 documents Cefazolin 2 grams into a venous catheter every 8 hours documents: blank for 6:00 AM, 9 other see nurses note for 12:00 PM and staff documented IV antibiotic was administered at 9:00 PM. R5's Nurse's Progress Note, dated 6/8/2023 at 3:23 PM, documents, Cefazolin IV 2 grams medication not here from pharmacy, this writer spoke with pharmacy regarding dispensing the medication. R5's MAR dated 6/9/2023 Cefazolin 2 grams into a venous catheter every 8 hours documents: blank for 6:00 AM and 12:00 PM and staff documented IV antibiotic was administered at 9:00 PM. R5's Nurse's Progress Note, dated 6/9/2023 at 3:23 PM, documents, IV ABT continues. PICC line to right upper arm for surgical wound to right foot infection osteomyelitis. No ASE noted. RN (registered nurse) on duty monitoring PICC & IV ABT. R5's MAR dated 6/9/2023 Cefazolin 2 grams into a venous catheter every 8 hours documents: 6/10/2023 6:00 AM staff documented IV antibiotic was administered, 9 other see nurses note for 12:00 PM and 9:00 PM. R5's Nurse's Progress Note, dated 6/10/2023, documents, Cefazolin use 2000 mg (2 grams) intravenously three times a day for infuse 20 milliliters (ml) into a venous catheter every 8 hr (hour). R5's MAR dated 6/11/2023 Cefazolin 2 grams into a venous catheter every 8 hours documents: medication was discontinued. No documentation that Ceftriaxone was administered per hospital discharge paperwork dated 6/8/2023 through 6/11/2023. R5's Pharmacy's Medication Delivery Manifest dated 6/12/2023 at 3:23 PM documents Ceftriaxone IV 2 grams was delivered to the facility. R5's Order Summary Report, Ceftriaxone IV 2 grams order was documented ordered on 6/12/2023 and to start 6/12/2023 but was documented discontinued. R5's MAR, dated 6/12/2023 documents Ceftriaxone IV 2 grams was documented administered on 6/12/2023. R5's Order Summary Report, documents Ceftriaxone 2 grams IV every 24 hours for osteomyelitis until 7/13/2023 was an active order ordered on 6/13/2023 and started on 6/14/2023. R5's MAR dated 6/13/2023 there was no documentation R5 received Ceftriaxone IV 2 grams. R5's MAR dated 6/14/2023 through 6/27/2023 documents staff administered Ceftriaxone 2 grams IV every 24 hours per physician's orders. On 6/27/2023 at 2:35 PM, V14, Pharmacist, stated the Cefazolin IV antibiotic was dispensed on 6/8/2023 but she wasn't sure what day the medication was delivered to the facility. V14 stated Cefazolin IV antibiotic was discontinued on 6/12/2023. V14 didn't have a diagnosis listed for the use of the Cefazolin antibiotic. V14 stated Ceftriaxone 2 gm IV every 24 hours was ordered by the facility on 6/12/2023 and was delivered to the facility the same day. V14 stated the reason Ceftriaxone was ordered was to treat osteomyelitis. V14 stated she didn't know the extent of the osteomyelitis infection (R5) had and stated it was a physician question to see if these missed IV antibiotics medications was significant. On 6/27/2023 at 1:57 PM, V3 Assistant Director of Nurses (ADON) stated R5's IV antibiotics was a medication error from the hospital. V3 stated before R5 was readmitted to the facility she spoke to the hospital physician, and they agreed to discontinue the antibiotic that was scheduled IV 3 times a day because she told them they couldn't accept R5 back to the facility on three times a day IV antibiotic (Cefazolin) because they don't have an RN at the facility on every shift. The hospital physician agreed to discontinue the three times a day IV antibiotic and have the resident be readmitted to the facility on antibiotic once a day (Ceftriaxone.) V3 stated she knew it was a medication error when she was working midnights (date unknown) and went to run orders and noted the 2 IV antibiotics were ordered for R5 not just one. V3 stated she had to get ahold of the hospital infectious disease physician to get the Cefazolin discontinued and that this was not the facility's fault as this three times a day IV antibiotic should have been discontinued before R5) was even readmitted to the facility. V3 stated she expected nursing staff to let her know the three times a day antibiotic was on R5's MAR and there was no RN to administer it. V3 stated she expected staff to administer all medications per physician's orders and to follow facility's policies and procedures. On 6/27/2023 at 3:27 PM V28, R5's On-Call Physician, stated R5's Physician is out of the country, and he is covering for him. V28 stated R5 shouldn't have been discharged from the hospital on 2 IV antibiotics, only one of the IV antibiotics should have been prescribed and V28 didn't know why the hospital physician would have prescribed 2 IV antibiotics. V28 stated R5 didn't receive the right dose or right IV antibiotic medication for 4 or 5 days and that was considered a significant medication error but R5's right foot wound didn't get any worse due to not receiving the IV antibiotic for 4 or 5 days. V28 expected staff to administer medications including IV antibiotics per physician's orders and to follow facility's policies and procedures. The Facility's Medication Administration Policy revised 5/2017, documents All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. If the physician's orders cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record. If medication is ordered, but not present check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. Check medication administration record prior to administering medication for the right medication, dose, route, resident, and time.

Based on interview and record review, the Facility failed to have a Registered Nurse (RN) for at least eight consecutive hours daily. This has the potential to affect all 70 residents living in the Facility. Findings include: Staffing schedules were reviewed for the past 14 days. The Facility's May 2023 Nurse Schedule for RN (Registered Nurse) and LPN (Licensed Practical Nurse) hours worked was provided for 5/1/23 through 6/14/23. This documents the Facility did not have a RN for eight consecutive hours on 5/13/23, 5/15/23, 6/11/23 and 6/12/23. On 6/14/23 at 10:48 AM, V1, Administrator, stated she would expect the Facility to have RN coverage for at least 8 hours daily, every day. On 6/13/23 at 3:44 PM, V3, Regional [NAME] President, stated there were some days without RN coverage, but she would expect the Facility to have RN coverage for at least 8 hours daily. On 6/14/23 at 8:32 AM, V3, Regional [NAME] President, stated the Facility did not have a policy specific to RN staffing. The Facility Assessment with a revision of May15, 2023 documents, The licensed nursing staff will provide IV therapy, medication by injections and inhaling and specialty would care. Facility Resources and Staff Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Nursing Services (e.g., DON (Director of Nursing), Assistant Director of Nursing, QA Nurse, Registered Nurse. The Facility's Resident Census and Conditions Form (CMS 672) dated 6/13/23 documents there are 70 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 5/30/23 at 5:20 AM, V9, CNA, stated It seems like we are always out of incontinence briefs. V9 stated last week we were totally out, and they had to call other facilities to get some. V9 stated one of our CNAs went to the store and bought some herself so the residents could have some. We were also low on peri-wash because I remember only having a tiny bit in a couple gallons. On 5/30/23 at 5:45 AM, V10, CNA, stated It seems like we always run out of incontinence briefs. I can remember at least twice that we were completely out of them here. On 5/30/23 at 7:42 AM, V13, Staffing Coordinator, stated I order supplies every Monday and will receive them the following Wednesday. When we were out of incontinence briefs, the company stated they were backordered. I ordered them on 5/15/23, the order was approved by corporate on 5/16/23 or 5/17/23, then they were not delivered until 5/24/23. V13 stated I placed an order on 5/1/23 and 5/15/23 and will be placing one today 5/30/23. V13 stated yesterday was a holiday. I did not place an order on 5/8/23, and not sure why, but I just didn't place one that week. I don't have anything that I can show you that says they were backordered. On 6/5/23 at 11:43 AM, V1, Administrator, stated (V2, DON) will be monitoring supplies going forward and will be checking the supply closets before every weekend to make sure we have enough to get us through. Also, (V13, Staffing Coordinator), will be placing supply orders earlier and not waiting until we are low or out of something. The facility's Purchase Order, submitted by V13 on 5/17/23 at 8:47 AM, documents supplies were ordered, including incontinence briefs, at that date/time. The facility was unable to produce any documentation showing that supplies were on backorder from the supply company. The facility's Supply Policy, dated 9/2017, documents To ensure that staff has the necessary supplies to care for the residents. 1. Supplies are ordered as determined by the facility based on the needs of the residents. 3. Nursing staff is responsible for notifying the supply person or nursing supervisor if they are missing a supply. 4. If the nursing staff is not able to get the supplies they request, they should alert the DON or Administrator for follow-up. Based on observation, interview, and record review the facility failed to provide timely and complete incontinent care and provide incontinent supplies for 3 of 3 residents (R6, R8, R9) reviewed for incontinence care in the sample of 12. Findings include: 1. R6's Face sheet, undated, documents R6 was admitted to the facility on [DATE]. R6's electronic medical record, documents R6's Diagnoses include Cognitive Communication Deficit, Blind Right Eye, and Traumatic Brain Injury. R6's Care Plan, dated 5/3/23, documents, R6 has an ADL Self Care Performance Deficit r/t (related to) Generalized Weakness and Morbid Obesity. R6 refuses to wear clothes, only gowns. Interventions: Requires limited to extensive assist of 1-2 staff participation to use toilet, requires limited to extensive assist of 1-2 assist staff participation with transfers, requires staff participation with bathing. R6's Minimum Data Set, MDS, dated [DATE], documents R6 is cognitively intact and requires extensive assistance of one staff member for dressing, toilet use, personal hygiene, and bathing. R6's MDS documents R6 requires limited assistance from one staff member for all other ADLs. R6's MDS documents R6 is always continent of both bowel and bladder. On 5/30/23 at 10:12 AM, R6 stated I don't use incontinence briefs but I do know that they were out of them for a while. I'm part of the resident council and I talk to a lot of the residents here, and quite a few of them comment on not having enough supplies. They quit ordering wipes to clean us up so now they use washcloths. On 5/30/23 at 10:15 AM, R6 stated he put his call light on to get someone to help him get a clean hospital gown on his backside so he can get up to his wheelchair. V20, CNA (Certified Nursing Assistant) Supervisor, entered to assist R6. V20 gave R6 two clean gowns. R6 put one on his front and one was for his back once he got up. Upon R6 standing upright to pivot to his wheelchair, a large amount of loose stool appeared to be on the incontinence pad lying on the bed, and visible on R6's upper coccyx area, and between R6's buttocks. V20 folded up the incontinence pad and put it into a plastic bag. V20 did not provide incontinence care to R6 and allowed R6 to sit in his wheelchair and go to the dining room. On 6/1/23 at 8:32 AM, R6 was observed laying in bed with his wheelchair sitting next to his bed with an incontinence pad on the seat with had dried stool visible on the pad. R6 stated The facility always seems to be out of supplies. Yesterday, they did not have pads to put on my wheelchair. They quit ordering wipes and now they use washcloths to clean me up when I have an accident, I have to use those same washcloths to wipe my face. That is kind of gross to think of that. I heard one CNA tell another CNA in the dining room that the facility was out of incontinence briefs. On 6/1/23 at 8:35 AM R6 stated I have not been out of bed yet today. That dirty pad was from yesterday when they got me up. I had an accident in bed bowel movement (BM) and V20 helped me get a clean gown on so I could get into my wheelchair. V20 did not clean me up and the dried bowel movement on the pad was from yesterday. R6 stated it really depends on what CNA is working if I get cleaned up or not, some are just lazy and won't help. One day last week, around 11:00 PM, I was put on the bedside commode and when I was done, I put my call light on. I waited over an hour, and no one answered the light so I called the facility with my cell phone and an agency nurse answered and she said she would get someone to come help me. About 15 minutes later, that same nurse came in and told me that she could not find a CNA, but she was still looking. It took a while for them to come in to clean me up. On 6/1/23 at 8:55 AM, V1, Administrator, and V2, Director of Nursing/DON, went into R6's room to see and speak to R6. R6 told V1 and V2 that he had an accident (BM) in his bed yesterday and the CNA V20 gave him a gown to wear and V20 never cleaned him up. The wheelchair is still sitting by his bedside from yesterday when he got back into bed, and the pad on the wheelchair still has feces on it. On 6/1/23 at 8:58 AM, V1 stated I will have staff come in to clean you up immediately. On 6/1/23 at 9:05 AM, V2 stated Yes, I would have expected V20 to clean R6 up at that time. I would expect any staff to take care of a resident like that. On 6/1/23 at 9:07 AM, V1 stated I was a CNA before becoming an administrator. I expect rounds to be completed, and residents checked every two hours at least. On 6/5/23 at 10:14 AM, R6 was seen laying in his bed with his wheelchair sitting next to his bed with a soiled incontinence pad with feces on it. R6 stated he has not gotten out of bed yet today and that dirty pad was from yesterday when he got back into bed. R6 stated the CNA brought him his breakfast this morning and did not do anything with the pad or ask to clean him up. R6 stated that the DON talked to him and stated that he was to let them know when he is soiled. R6 stated they can see my backside better than he could and they should know. On 6/5/23 at 10:21 AM, V24, CNA, was in R6's room and overheard the discussion about his soiled pad in his wheelchair. R6 came over and removed the soiled incontinence pad from his wheelchair. V24 stated I guess I must have seen that and just delivered his breakfast and left. I am new and still trying to figure out all the residents. On 6/5/23 at 10:25 AM, R6 stated When they don't clean me up, like the other day when they didn't clean me up and I went to the dining room like that, it makes me feel like a homeless shelter person not getting taken care of. I'm always asking the staff if they would like for their loved ones to be cared for like this. On 6/5/23 at 12:53 PM, V2 stated I'm having the staff use the white board in R6's room whenever they do care. V2 stated I want the date/time and who done it so I can follow up on it and hold them responsible when I see things like we've seen. 2. R8's Face Sheet documents an admission date of 5/4/2023 with diagnoses of Cerebral Palsy, Intellectual Disabilities, and Paraplegia. On 5/31/2023 at 10:30 AM, V18, CNA was observed assisting R8 into R8's electric wheelchair. On 5/31/2023 at 2:40 PM, R8 remained up in wheelchair. R8 stated she had not been changed since her shower at 10:30AM that morning. R8's shorts were visibly wet with urine. At 2:50 PM V17, CNA, and V18 assisted R8 to bed via full body mechanical lift. R8's adult brief, clothes, and mechanical lift pad appeared wet with urine. R8's MDS, dated [DATE], documents R8 has no cognitive deficits. R8's MDS documents R8 is always incontinent of bowel and bladder. R8's Care Plan, dated 5/5/2023, Activities of Daily Living (ADL's): R8 requires assist with daily care needs related to Cerebral Palsy and Intellectual Disabilities. R8 utilizes an electric wheelchair and uses a button seatbelt occasionally that she can open and close independently. R8 is dependent on staff for all ADL's, which is resident's baseline. Interventions include: Assist resident with ADL's, encourage/assist with turning and repositioning every two hours and as needed. Keep clean and dry after each incontinent episode. Monitor skin integrity during routine care and report abnormal findings. On 5/31/2023 at 12:50 PM V21, R8's Power of Attorney, stated on 5/28/23, I went to visit my sister and two CNAs were coming out of her room. When I went in her room there was bowel movement on her, her bed sheets, and the floor. I couldn't believe the CNAs would leave my sister in a mess like that. 3. R9's Face sheet documents an admission date of 8/12/2022 with diagnoses of s Obesity, Multiple Sclerosis, Nondisplaced Fracture of Lateral Malleolus of Left Fibula, Subsequent encounter for Closed Fracture with routine healing and Lymphocytopenia On 5/31/2023 at 8:30 AM, R9 stated I was changed last night at 8:00 PM and haven't been changed since. I have to wait all the time on staff. I wait hours. V16, CNA, and V17, CNA, provided incontinent care to R9. R9's incontinence brief was visibly wet with yellow stains. The incontinence pad R9 was laying on was visibly wet. R9 had dried stool on buttocks. V16 was observed with two wash cloths and used the first wash cloth to wipe R9's buttocks and the second one to dry R9's buttocks. Surveyor observed dried stool remained on R9 when V16 and V17 put on a new incontinence brief. On 6/1/23 at 10:35 AM, R9 stated The facility was out of depends and I had to go with nothing on. If the staff tell you they don't run out of supplies, they are lying. My roommate needs XXL incontinence brief and they never have that size either. R9's MDS, dated [DATE], documents R9 has no cognitive deficits. R9's MDS documents R9 is frequently incontinent of bowel and bladder. R9's Care Plan, dated 4/26/2023, documents R9 requires assist with daily care needs related to Obesity and Multiple Sclerosis. R9's Care Plan Interventions document to assist resident with ADL's, encourage/assist with turning and repositioning every two hours and as needed, monitor for changes with daily care abilities and provide more or less assist, monitor skin integrity during routine care and report abnormal findings. The facility's Resident Council meeting minutes, dated 3/16/2023, documents concern with residents' two-hour incontinence checks. The facility's Incontinence Care policy, with a revision date of 3/2022, documents Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. 5. Clean peri area with appropriate cleaner and dry. Appropriate clean can mean soap and water, peri-wash, etc. Cleansing should always be from front to back. 6. If resident needs more cleaning than above, then a bath or shower may be given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 4 of 4 residents (R6, R8, R9, R12) reviewed for ADL (Activities of Daily Living) care in the sample of 12. Findings includes: 1. R8's Face Sheet documents an admission date of 5/4/2023 with diagnoses of Cerebral Palsy, Intellectual Disabilities, and Paraplegia. On 5/31/2023 at 10:30AM, facility shower sheets documented R8 went from 5/19/2023 through 5/30/2023 without a shower. R8's shower days are scheduled on Wednesdays and Fridays. On 5/31/2023 at 12:50 PM, V21, R8's Power of Attorney (POA), stated R8 has not had a shower since 5/12/2023. On 6/1/2023 at 9:45 AM, R8 was observed wearing the same clothes she was dressed in on 5/31/2023 at 2:50 PM. R8's hair appeared disheveled, and clothes appeared to have food stains. R8's Minimum Data Set, (MDS) dated [DATE], documents R8 has no cognitive deficits. R8 is totally dependent on staff for bathing. R8's Care Plan, dated 5/5/2023, Activities of Daily Living (ADL's): R8 requires assist with daily care needs related to Cerebral Palsy and Intellectual Disabilities. R8 utilizes an electric wheelchair and uses a button seatbelt occasionally that she can open and close independently. R8 is dependent on staff for all ADL's, which is resident's baseline. Interventions include: Assist resident with ADL's. On 5/31/2023 during record review R8's last shower documented was 5/19/2023. On 6/1/2023 at 11:00 AM when making copies of the shower sheets dates on the form were filled out that weren't there prior. Shower sheet shows same handwriting and same ink pen used. 2. R9's Face Sheet documents R9 was admitted on [DATE] with diagnoses of Obesity, Multiple Sclerosis (MS), Nondisplaced Fracture of Lateral Malleolus of Left Fibula, Subsequent encounter for Closed Fracture with routine healing, and Lymphocytopenia. On 5/31/2023 at 8:30 AM, R9 was observed in bed with hospital gown on and unkept. R9 voiced she was very wet and hadn't been changed all night. R9 used call light and stated she was wet. V16 CNA, and V17 CNA provided incontinent care to R9. R9's incontinence brief was visibly wet with yellow stains. R9's incontinence pad was visibly wet. R9 had dried stool on buttocks. V16 was observed with two wash cloths and used the first wash cloth to wipe R9's buttocks and the second one to dry R9's buttocks. observed dried stool remained on R9 when V16 and V17 put on a new incontinence brief. On 6/1/2023 at 10:15 AM R9 stated I haven't had a shower or a bed bath in 4 weeks. They came in a couple nights ago (5/30/2023) at 10:15 PM at night. I was already asleep, and they wanted me to take a shower then. I said no. I don't want a shower after I'm already asleep. My shower days are supposed to be Tuesday and Friday. On 5/31/2023 Facility shower sheets for month of May document R9 refused shower on 5/30/2023. There was no other documentation that R9 received showers in May 2023. R9's MDS dated [DATE] documents R9 has no cognitive deficits and R9 needs assist with part of bathing activity. R9's Care Plan, dated 4/26/2023, documents ADL: R9 requires assist with daily care needs related to Obesity and MS. Interventions include: Assist resident with ADLs, Encourage/Assist with turning and repositioning every two hours and as needed. 3. R6's Face Sheet, undated, documents R6 was admitted on [DATE] with diagnoses of Morbid Obesity, Acute Respiratory Failure with Hypercapnia, Unsteadiness on feet, Blindness in Right Eye, Traumatic Brain Injury, and Arthritis. R6's Care Plan, dated 5/3/23, documents, R6 has an ADL Self Care Performance Deficit r/t (related to) Generalized Weakness and Morbid Obesity. R6 refuses to wear clothes, only gowns. Interventions: Requires limited to extensive assist of 1-2 staff participation to use toilet, requires limited to extensive assist of 1-2 assist staff participation with transfers, requires staff participation with bathing. Encourage resident to accept showers per shower schedule. Resident refuses showers at times. R6's MDS, dated [DATE], documents R6 is cognitively intact and requires extensive assistance of one staff member for dressing, toilet use, personal hygiene, and bathing. R6's MDS documents R6 requires limited assistance from one staff member for all other ADLs. On 5/30/23 at 10:12 AM, R6 was seen sitting on the side of his bed, appears unkempt, unshaven, hair messy, and dried blood on his chin. On 6/1/23 at 8:32 AM, R6 was observed laying in bed, appears unkempt, unshaven, and blood still on his chin. On 6/1/23 at 8:35 AM, R6 stated I am supposed to get a shower on Mondays and Thursdays, but my last shower was last Thursday (5/25/23). I did not get one on Monday and I'm lucky if I get one once a week. Every time I get a shower, I ask if I could get shaved and they always tell me that they are too busy and maybe the next time. I believe it has been two to three weeks since my last shave. I heard the Administrator talking to the CNAs about showers, and it did improve for a week or so, but now they are back at not giving them. It really depends on what CNA is working if I get cleaned up or not, some are just lazy and won't help. The Facility's Shower Schedule documents R6 is scheduled for showers on Monday and Thursday days. The Facility Shower Sheets for May 2023, documents R6 received a shower/bed bath on 5/8/23, 5/15/23, 5/25/23. Shower documented on 5/30/23, during this investigation, however, R6 stated he did not get one and he still has the dried blood on his chin and appears very unkempt. 4. R12's Face sheet, undated, documents R12's diagnoses include Aphasia, Apraxia following Cerebral Infarction, and Contractures to Right Ankle, Right Knee, Left Ankle, and Left Knee. On 5/31/2023, during record review the facility's shower sheets dated 5/2023, documents R12 received a shower on 5/3/2023. No other showers documented for May 2023. R12's MDS, dated [DATE], documents R12 is severely cognitively impaired and is totally dependent on staff for bathing. R12 has an ADL Self Care Performance Deficit related to Cerebral Vascular Accident (CVA). R12 is long term care, she is unable to live in community safely and independently on her own related to CVA with hemiplegia requiring staff assistance. R12 is incontinent of bowel and bladder. Interventions include: Bathing. R12 is totally dependent on staff to provide a bath. On 6/1/2023 at 1:00 PM V1, Administrator, stated Resident showers are given every day. Residents are to be offered two showers a week and more often if residents request it. Facility shower policy dated 9/2022 states All residents are bathed or showered at least one time per week. More frequent bathing or showering is given as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to implement interventions to address supervision needs of residents and provide supervision for residents at risk for elopements/exit seeking behaviors, resident-to-resident altercations, smoking risks and falls for 5 of 5 residents (R1, R2, R4, R5, R7) reviewed for supervision to prevent accidents in the sample of 12. Findings include: 1. R2's admission record, undated, documents R2 was admitted to the facility on [DATE]. R2's Care Plan, dated 3/31/23, documents R2 is at high risk for falls r/t (related to) cerebral palsy, intellectual disabilities, and epilepsy. R2's Care Plan Interventions document the following: 12/16/22 low bed, 12/23/2022 - environmental assessment of room conducted, 12/23/22 brightly colored visual cues reminding to call for assistance prior to transfers, 4/11/2023 resident to remain on enhanced supervision, encourage appropriate use of assistive device, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, if noted agitation while up in chair, assist to bed and continue enhanced supervision, keep bed in lowest position, keep frequently used items within reach, monitor for any changes in condition, notify MD (Medical Doctor) and family of any new fall, orient resident to surroundings frequently, including location of bathroom, dining room, bedroom and activity locations, promote placement of call light within reach and assess residents ability to use. R2 has a history of becoming verbally and physically aggressive, inappropriate. The Care Plan Interventions are as follows : 1:1 with SSD (social service director/designee) as needed, conduct a review of past behavior, and evaluate the likelihood for aggressive/inappropriate behavior during the initial assessment process, give psycho-active medications as ordered. Record behavioral symptoms (e.g., verbal/physical aggression, dyskinesia, anticholinergic effects), If noted aggression, remove from populated area, intervene when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses and behavior (Social skills training), refer the resident to a mental health professional including a consulting psychiatrist for evaluation if the resident's symptoms warrant further assessment or ongoing management. R2 has diagnosis of Schizophrenia and may display symptoms that include but not limited to: being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Resident has a H/O (history of) taking off clothes and refusing to dress. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a moderate cognitive impairment and requires extensive assistance from one to two staff members for all his ADLs (Activities of Daily Living). R2's Fall Risk Evaluation, dated 4/11/23, documents R2 is a high fall risk with a score of 24. Scoring a 10 or higher makes resident High Risk for falls. R2's Fall Risk Evaluation, dated 3/30/23, documents R2 is a high fall risk with a score of 29. Scoring a 10 or higher makes resident High Risk for falls. R2's Incident Audit Report, dated 4/8/23 at 3:58 PM, documents CNA (Certified Nursing Assistant) notified this nurse because resident's nurse was on break that resident launched himself from his wheelchair to the floor, resident is baseline confused. CNA stated that resident hit his head on the floor. It appeared he has some swelling of about half inch on his forehead with about a 2cm (centimeter) cut, bleeding was cleaned and stopped. Resident was found sitting on the floor sideways, both legs slightly flexed, he was located in front of his wheelchair. The room was brightly lit, no clutter or wet floor noted. Resident was assisted up to his bed with two staff assist and gait belt to his bed. R2's Enhanced Supervision Monitoring sheet documents, dated 4/8/23, documents R2 had checks completed every (Q) 15-minutes. R2's Nurse's Note, dated 4/9/23 at 11:41 AM, documents Patient continues to be monitored for post fall injuries. Patient on COVID isolation precautions, temp 98.7, denies pain/discomfort on assessment. Patient took all his AM meds with no difficulties. Patient continues on 1-1 (one-on one) monitoring. Nurse continues to monitor patient through the shift. R2's Incident Audit Report, dated 4/11/23 at 9:45 AM, documents Writer was called by clinical supervisor to resident's room at approximately 9:50 AM to assess resident. Writer entered resident's room and noted resident on floor near his dresser, wheelchair beside him. Resident was in the fetal position. Resident was awake and alert and responsive. No acute distress noted. VS (vital signs) taken and WNL (within normal limits). Writer and CNA assisted resident back onto his bed. Assessed resident and noted a large, raised area to crown of head. R2's Nurse's Note, dated 4/11/23 at 10:16 AM, documents Resident sent to (local hospital) ER (Emergency Room) via EMS (Emergency Medical Service) for assessment d/t (due to) unwitnessed fall from wheelchair. Resident has large bump to top of head, and a small area of blood noted to left upper occipital area. Bleeding controlled. Resident has prior fall with laceration to upper forehead and noted to be healing well. Resident has bilateral bruising noted to both knees. Resident voices c/o (complaint of) right knee pain. Neuro vitals intact and resident appears to be at baseline. Report called to ER. R2's Nurse's Note, dated 4/11/23 at 4:21 PM, documents (Local hospital) ER called, and report taken from RN (Registered Nurse). Resident did not have CT (Computerized Tomography) scan due to refusal and ER MD did not sedate as resident is at nl (normal) baseline. Resident assessed upon arrival and remains awake and alert and at baseline. Sitter remains at bedside. Report to nurse. R2's Nurse's Note, dated 4/16/23 at 10:15 AM, documents Resident displaying maniac behavior, yelling and screaming in his room. Speech is rapid displaying paranoid ideations stating staff is trying to kill him. Appetite poor, has generalized weakness, remains 1:1 to ensure safety of self and others. Given Haldol injection 5 MG (milligram) IM (intramuscular) one time dose on evening shift, med was ineffective. NP (Nurse Practitioner) notified, new order received to send to (regional hospital) for evaluation and treatment. Nursing management and Guardian notified of resident's condition and sending to hospital. VS are T97.8, P (pulse) 72, R (respirations) 20, B/P (blood pressure) 138/92. R2's Nurse's Note, dated 4/23/23 at 10:21 PM, documents Resident remains on enhanced monitoring r/t (related to) safety. resident resting in bed at this time with eyes closed. call light is in reach and operable. no s/s (signs/symptoms) distress/discomfort noted. No behaviors noted so far this shift, resident has remained calm and in bed. Safety measures in place, fall mat on floor with enhanced monitoring. R2's Nurse's Note, dated 5/20/23 at 2:17 PM, documents R2 had a resident-to-resident altercation and was put on enhanced supervision and taken away from other residents to avoid further altercations. R2's Nurse's Note, dated 5/20/23 at 3:11 PM, documents At around 8:50 AM, CNA immediately notified this nurse that there was a confrontation between residents in front of the nurse's station. Per CNA, this resident was by the nurse's station and was yelling out loud while the other resident was passing by, both were in their wheelchairs. The other resident yelled shut up because of the yelling. This resident in turn, triggered him to have a violent outburst of yelling and swinging, making contact to the the other residents face. R2's Nurse's Note, dated 5/26/23 at 10:49 PM, documents Resident has been very aggressive this evening he has scratched and punched the CNAs multiple times, grabbed brooms and attempted to hit the staff and the residents. One of the residents was trying to protect himself and he started to hit resident with his cane, we stopped him before he could get it done. One CNA's arm is very hurt from him getting ahold of her. This is day 3 of him being awake so I am sending him out. R2's Nurse's Note, dated 5/27/23 at 7:04 PM, documents Resident was found on the floor laying next to the mats by the door, assigned nurse is aware. fall was unwitnessed. FYI. R2's Physician Order, dated 4/20/23, documents Enhanced supervision. R2's Enhanced Supervision Monitoring documents, dated 5/12/23, has no documented checks from 6:30 AM until 7:15 AM, then from 2:45 PM until 4:00 PM. R2's Enhanced Supervision Monitoring documents, dated 5/13/23, has no documented checks from 6:30 AM until 10:00 AM, then from 1:15 PM until 3:00 PM, then from 3:15 PM until 7:00 PM. R2's Enhanced Supervision Monitoring documents, dated 5/14/23, has no documented checks from 6:30 AM until 7:15 AM, then from 6:15 PM until 8:30 PM, then from 5:15 AM until 6:15 AM. R2's Enhanced Supervision Monitoring documents, dated 5/15/23, has no documented checks from 6:30 AM until 8:30 AM, then from 10:15 PM until the next day. R2's Enhanced Supervision Monitoring documents, dated 5/16/23, has no documented checks from 6:30 AM until 7:15 AM, then from 10:45 AM until 12:15 PM, then from 7:15 PM until 8:45 PM. R2's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until the next day. R2's Enhanced Supervision Monitoring documents, dated 5/18/23, has no documented checks from 6:30 AM until 7:00 AM. R2's Enhanced Supervision Monitoring documents, dated 5/19/23, has no documented checks from 6:45 AM until 7:45 AM. On 5/30/23 at 5:38 AM, R2 was seen laying on the floor, naked with blanket pulled over his groin. There was trash and a sheet are also laying on the floor next to R2 with stool spread all over the floor. There were three mattresses laying side by side on the floor instead of a bed, a soft mat lying on the floor in the middle of the room and a tall wheelchair in the room. R2 has non-slip socks on. On 5/30/23 at 5:35 AM, V9, CNA, stated We have three residents who are supposed to be Q (every) 15-minute checks. Two of them may be elopement risks, (R5 and R6), and the other one R2 for behaviors and/or falls. I have not had anyone to document my 15-minute checks, so I did not do them last night. When there is only one CNA for a hall, it is impossible to take care of all the residents and do 15-minute checks. R2 is supposed to be a 1:1 (one because of his falls and his behaviors but we don't have the staff to do this. On 5/30/23 at 5:39 AM, V7, CNA, stated R2 is supposed to be a 1:1 but we don't have the staff for that. R2 used to stand up off his bed and fall. They have since put these mattresses on the floor so now R2 just rolls off and moves everywhere in the room. R2 has a tendency to throw his incontinence brief at us and all around the room. On 5/30/23 at 6:30 AM, V6, CNA, stated The Staffing Coordinator found out you were here and called me and told me to come over and sit with R2 until 7:00 AM. I am supposed to fill out this 15-minute check sheet. I do not see one from last night, I guess they didn't do it. On 5/30/23 at 3:10 PM, V1, Administrator, stated I understand that if we have a one-on-one resident, we really need to have a staff member available to make sure someone is actually assigned to that resident at all times. Corporate cut our staffing pattern so we really can't staff any extra people for one-on-one monitoring. I will have to clear it with corporate to be able to put an extra CNA on for this, but that makes since. On 5/30/23 at 3:15 PM, V2, Director of Nursing, stated I guess if we have a resident who is one-on-one, we probably should not include that staff member in the regular staffing matrix and just have them on the schedule as one-on-one with that resident. On 6/1/23 at 11:05 AM, V1, stated I only have residents Enhanced Monitoring tools for May, maybe a few from April. The managers who were here previously shred a lot of things and I think those may have been shredded because we did not find them anywhere. On 6/5/23 at 8:35 AM V1 stated I'm not sure of the definition of Enhanced Monitoring, but it provides an extra layer of protection for the resident. All staff have been trained on Enhanced Monitoring and the Enhanced Monitoring form tells the staff what is to be done, every fifteen-minute checks, every hour checks, one-on-one, etc. If a resident is a one-on-one, there should be a staff member at that resident's side at all times. If that staff member has to take a break. They must find someone to replace them to watch the resident. 2. R5's admission Record, undated, documents R5 was admitted to the facility on [DATE]. R5's Care Plan, dated 5/24/23, documents R5 is at risk for falls r/t unsteady gait at times, HTN (Hypertension), and CKD (Chronic Kidney Disease). Interventions: Encourage resident to keep room free of obstacles/clutter. Evaluate multiple falls to determine commonalities or patterns. Fall risk assessment quarterly and as needed. Keep frequently used items within reach. Promote placement of call light within reach and assess residents' ability to use. Provide proper, well-maintained footwear. R5 requires assist with daily care needs r/t unsteady gait at times, HTN, and COPD. Interventions: Assist resident with ADLs. Monitor skin integrity during routine care and report abnormal findings. R5 uses tobacco products and is at risk for complications. Interventions: If resident continues to be unsafe with smoking. Staff will keep resident's cigarettes and lighter and give to resident at smoking times. Monitor for any declines in smoking ability PRN. Monitor resident while smoking. Provide and arrange education on smoking. Provide smoking apron as indicated. R5's MDS, dated [DATE], documents R5 has a severe cognitive impairment with a BIMS of 5. R5 requires limited assistance from one staff member for bathing and toilet use and requires supervision for the rest of her ADLs. R5's Elopement Risk Assessment, dated 5/16/23, documents R5 is a Low Risk for elopement with a score of 9. R5's Elopement Risk Assessment, dated 5/9/23, documents R5 is a No Risk for elopement with a score of 1.0. R5's Physician Order, dated 5/11/23, documents Record number of episodes if targeted behavior of Exit Seeking/Attempting to Leave occurs. Every shift Record the number of times observed. On 5/30/23 at 5:40 AM, R5 was seen outside smoking with two other residents R1, and R4. No staff were present. R5's Enhanced Supervision Monitoring documents, dated 5/13/23, has no documented checks from 6:30 AM until 12:00 PM, from 1:45 PM until 7:00 PM, from 10:15 PM, until 2:00 AM, from 2:15 AM until 5:00 AM, then from 5:15 AM until 6:15 AM. R5's Enhanced Supervision Monitoring documents, dated 5/16/23, has no documented checks from 6:30 AM until 5:00 PM. R5's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 8:30 AM, then from 7:00 PM until the next day. R5's Enhanced Supervision Monitoring documents, dated 5/18/23, has no documented checks from 7:15 AM until 7:00 PM. R5's Enhanced Supervision Monitoring documents, dated 5/20/23, has no documented checks from 7:15 PM until the next day. R5's Enhanced Supervision Monitoring documents, dated 5/21/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until the next day. R5's Enhanced Supervision Monitoring documents, dated 5/22/23, has no documented checks from 6:30 AM until 3:00 PM, then from 5:15 AM until the next day. R5's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 6:00 PM until 7:00 PM. 3. R7's admission Record, undated, documents R7 was admitted to the facility on [DATE]. R7's Care Plan, dated 4/13/23, documents R7 is at high risk for falls r/t CVA (Cerebral Vascular Accident), DM (Diabetes Mellitus), and Decreased Mobility. Resident impulsive and has cognition issues and poor safety awareness. Interventions: 1/3/23 Brightly colored visual cue. Fall mat next to bed, 3/14/23- staff educated to lay resident down directly after meals, 3/22/23-Res. to be encouraged or redirected by staff to common areas while awake, 3/30/23 Hourly checks while up in wheelchair, 3/8/23 Keep bed in lowest position, 4/18/23 Staff educated on safety risks of leaving an unsteady resident sitting on side of bed without supervision and directed to immediately assist and safety positioning upon transferring resident to bed, 4/22/23 Enhanced supervision. Encourage appropriate use of Assistive Device. Encourage resident to keep room free of obstacles/clutter. Evaluate multiple falls to determine commonalities or patterns. Fall risk assessment quarterly and as needed. Keep frequently used items within reach. Promote placement of call light within reach and assess residents' ability to use. Provide proper, well-maintained footwear. R7's MDS, dated [DATE], documents R7 has a severe cognitive impairment and requires extensive assistance from two staff members for all ADLs. R7 is dependent on one staff member for bathing. R7's Nurse's Note, dated 3/8/23 at 4:12 PM, documents CNA reported resident to be on the floor lying next to his bed resident was trying to get out of bed by himself. Resident assessed with no visible injuries noted at this time. Education on call light done and CNA educated on more frequent rounds for this resident. Vital Signs (VS) WNL (within normal limits). NP (nurse practitioner) and daughter made aware. R7's Nurse's Note, dated 3/8/23 at 10:29 PM, documents RN (Registered Nurse) received a report that resident had a fall during the day, with no visible injuries noted, resident assessed at 8 PM with no c/o pain raised, vitals done and within normal ranges, A/O (alert and oriented) x (times) 3, meds given and tolerated, Lidocaine patch placed on lower back. Bed placed in low position and use of call light emphasized. R7's Nurse's Note, dated 3/21/23, documents CNA reported resident to laying on floor next to his bed. when this nurse arrived, resident was laying on his left side, residents roommate stated resident was trying to get out of bed and walk when resident went down to the floor. Assessment completed with no visible injuries, but resident is complaining of left knee pain. NP notified, and stat x-ray orders given. POA notified with no answer voice mail left to give the facility a call back. R7's Nurses Note, dated 3/30/23 at 3:51 PM, documents Staff notified this nurse that resident had fallen in his bathroom. As soon as this nurse arrived, resident was on his right side, head leaning on the furthest bathroom door and he was facing the toilet, left leg straight and right leg slightly bent. Resident was alert. Resident was assisted from the floor with 2 staff and gait belt to his wheelchair. When asked what he was doing, resident stated that he was trying to go to the bathroom to poop. The bathroom was well lit, there were no clutter on the floor and the floor was dry. Performed skin assessment: no noted deformities, abrasions, bruising or tenderness. Resident is denying any pain or discomfort, is not showing any signs of distress. Performed ROM (range of motion) assessment, WNL per baseline. VS 13,0/79, 66, 97.7% 18. Notified NP, she stated that resident is on Hospice. Called (local) Hospice and spoke with nurse as well as resident's POA and they both agreed not to send resident out to the hospital. Hospice Nurse will order landing strips for each side of the bed as well as a bedside commode. We will do neuro checks to monitor resident. DON and ADON is aware. R7's Nurse's Note, dated 4/18/23 at 11:03 AM, documents CNA reported resident sitting on the side of the bed when she walked past 5 mins later, she walked pass again and he was on the floor, this nurse asked resident where he was trying to go and if he needed to go to his bathroom. resident stated he was trying to hold his poop in. resident was taken to the bathroom and re-educated on call light use, CNA made aware to do more frequent bathroom rounding's, assessment completed no visible injuries noted at this time. Hospice nurse and daughter notified will continue to monitor resident. R7's Nurse's Note, dated 4/22/23 at 11:50 AM, documents CNA reported that resident was found on floor laying next to his bed. When this nurse arrived, resident was laying on his right side, resident stated he was trying to get up to get into his wheelchair. Assessment completed with no visible injuries noted at this time, resident is complaining of right knee pain, PRN (as needed) pain meds given. VS WNL, NP Notified with new orders to get X-ray to right knee, Daughter and Hospice nurse both made aware of situation. R7's Nurse's Note, dated 5/31/23 at 1:32 PM, documents Nursing staff informed this writer that resident was on the floor. when this nurse went in to assess resident. resident was laying on his back. resident roommate states this resident was leaning over messing with the wheels of his wheelchair and tumbled out onto his back, resident roommate stated this resident did not hit his head. Resident assessment competed ROM and VS WNL, small skin tear noted to the back of resident's hands in between resident thumb and pointer finger. resident states he does not have pain anywhere else. TAO (topical antibiotic ointment) and band aid applied to skin tear. responsible party. Administrator, Hospice call center, and wound nurse all made aware. R7's Enhanced Supervision Monitoring documents, dated 5/12/23, has no documented checks from 6:30 AM until 7:00 AM, then from 3:45 PM until the next day. R7's Enhanced Supervision Monitoring documents, dated 5/13/23, has no documented checks from 6:30 AM until 7:00 AM, then from 8:15 AM until 11:45 AM, then from 1:15 PM until the next day. R7's Enhanced Supervision Monitoring documents, dated 5/15/23, has no documented checks from 6:30 AM until 6:45 PM. R7's Enhanced Supervision Monitoring documents, dated 5/16/23, has no documented checks from 3:00 PM until 4:45 PM, then from 4:45 PM until 7:45 PM. R7's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until the next day. R7's Enhanced Supervision Monitoring documents, dated 5/18/23, has no documented checks from 1:45 AM until the next day. R7's Enhanced Supervision Monitoring documents, dated 5/19/23, has no documented checks from 6:30 AM until 8:00 AM, then from 7:00 PM until the next day. R7's Enhanced Supervision Monitoring documents, dated 5/21/23, has no documented checks from 6:30 AM until 7:30 AM, then from 10:15 PM until the next day. R7's Enhanced Supervision Monitoring documents, dated 5/22/23, has no documented checks from 6:30 AM until 6:45 PM. R7's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 7:15 AM until 11:00 PM. R7's Enhanced Supervision Monitoring documents, dated 5/28/23, has no documented checks from 6:30 AM until 7:00 PM. On 5/30/23 at 3:35 PM, R7's Enhanced Supervision Monitoring Document, for fall risk, with the last documentation/check done at 12:45 PM. On 5/31/23 at 9:10 AM, R7's Enhanced Supervision Monitoring documents, dated 5/31/23, documents R7 was last monitored at 6:45 AM. On 5/30/23 at 10:05 AM, R7 sitting in his tall back wheelchair, tennis shoes on, call light on bedside table and behind the resident, signs on wall Don't forget to use your call light to ask for help. and Pull your call light for assistance before transferring. On 5/30/23 at 10:07 AM, R7 stated I fell a little while ago while trying to get out of bed. I had to use the restroom, I put my call light on, but it was taking them too long, so I tried to get up on my own. I was not supposed to do that, but I couldn't wait any longer. I think the floor was wet and I slipped and fell. They put this mat on the floor for me after that. 4. R4's admission Record, undated, documents R4 was admitted to the facility on [DATE]. R4's Care Plan, dated 4/13/23, documents R4 Risk for Wandering/Elopement Identified. 5/1/23-Res. left (local hospital) ER without supervision. Interventions: Enhanced supervision precautions. Provide care in a calm and reassuring manner. Provide clear, simple instruction, and provide reorientation to surroundings, environment. R4 uses tobacco products and is at risk for health problems. Resident was found to be smoking in his room. Resident needs to be monitored to make sure he is not taking smoking materials to be used in the building. Interventions: If resident continues to be unsafe with smoking, staff will keep resident's cigarettes and lighter and give to resident at smoking times. Monitor for any declines in smoking ability PRN. Monitor resident while smoking. Provide and arrange education on smoking, Remind resident of smoking times and areas. R4 is at risk for falls r/t Confusion, Gait/balance problems, amputation of toe on LT (left) foot. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear non-skid socks and/or shoes when ambulating or mobilizing in w/c (wheelchair), follow facility fall protocol, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. R4's MDS, dated [DATE], documents R4 has a moderate cognitive impairment with a BIMS of 12. R4 requires supervision/set up help with assistance of one staff member for all ADLs. R4's Physician Order, dated 5/1/23, documents Enhanced supervision. R4's Elopement Evaluation, dated 5/1/23, documents R4 is a High Risk for elopement with a score of 29. R4's Social Service Note, dated 5/1/23 at 12:40 PM, documents Resident came to me asking if he could be sent out to gateway for psych evaluation and was raising his voice. Notified the nurse, DON and ADON and is in the process of trying to send him out to gateway. R4's Nurse's Note, dated 5/1/23 at 1:05 PM, documents Doctor notified, new orders received to send resident to Gateway Regional Hospital to evalauate and treat per resident request. Resident c/o (complaints of) anxiety stated if he doesn't go to the hospital, he will leave. DON and ADON notified of new order. R4's Nurse's Note, date 5/1/23 at 5:58 PM, documents Call placed to (local hospital) to follow-up on resident status. Spoke with male ER Nurse. Per ER Nurse resident was not seen by ER for care. ER Nurse transferred my call to Hospital psych Intake Nurse. Per Intake Nurse Resident has not been admitted and was not evaluated. Resident was last treated for Psychiatric care at Psych through (local hospital) on March 9th. ADON notified that resident was not at (local hospital). Awaiting further instructions. R4's Nurse's Note, dated 5/1/23 at 9:00 PM, documents House supervisor contacted facility and writer asking about the whereabouts of the resident was, that the police had no information on what was going on asked for writer to face sheet to give to the police, contacted the ADON she stated that the police were notified a missing person report was put into effect, and that they found resident and 911 was picking him up and taking him to (local hospital) ADON stated she would contact the hospital she had given report to the ER nurse in regards to the resident and his condition. Will follow up with hospital on time of arrival and nurse treating. On 5/30/23 at 5:40 AM, R4 was seen outside smoking with no staff member present. On 5/30/23 at 5:53 PM, R4 stated The staff will sit out with us during designated smoking times. Anyone can go out the front door, all you have to do is push it. If it alarms, the staff will come and turn the alarm off. Sometimes I go out to smoke outside the smoking times, and I will fill out a form that allows me to go out. R4's Enhanced Supervision Monitoring documents, dated 5/16/23, has no documented checks from 6:30 AM until 7:45 PM R4's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 7:00 AM, from 9:45 AM until 12:00 PM, from 1:00 PM until the next day. R4's Enhanced Supervision Monitoring documents, dated 5/19/23, has no documented checks from 1:45 PM until 10:45 PM. R4's Enhanced Supervision Monitoring documents, dated 5/20/23, has no documented checks after 7:00 AM for the entire day. R4's Enhanced Supervision Monitoring documents, dated 5/22/23, has no documented checks from 6:30 AM until 7:00 AM, from 3:15 PM until next day. R4's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 3:15 PM until the next day. R4's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until 10:45 PM. R4's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until 10:45 PM. On 5/30/23 at 3:45 PM, R4's Enhanced Supervision Monitoring Tool, dated 5/30/23, documents no reason for monitoring documented nor any instructions; one-to-one, Q 15-minute, Q 30 minute, or QH observation checked. The last documentation check was done at 11:45 AM 5/30/23. On 5/31/23 at 9:20 AM, R4's Enhanced Supervision Monitoring Tool, dated 5/31/23, documents R4 was last monitored at 8:45 AM. 5. R1's admission Record, undated, documents R1 was admitted to the facility on [DATE]. R1's electronic medical record, documents R1's diagnosis include: Malnutrition, Respiratory Failure, DM, Pancreatitis, COPD, Cachexia, Metabolic Encephalopathy, Anxiety disorder, Hyperlipidemia, Polyneuropathy, PVD (Peripheral Vascular Disease), HTN, and Alcohol dependence. R1's Care Plan, dated 4/13/23, documents (R1) uses tobacco products and is at risk for exacerbation of COPD due to smoking. Interventions: Monitor resident while smoking, monitor for any declines in smoking ability PRN, provide and arrange education on smoking, provide and arrange education on smoking. R1 is at risk for falls r/t poly med use and independently ambulates throughout the facility. Interventions: Evaluate cause of falls, explain call light and assess resident's ability to use, gather and assess information on past falls, monitor for and document perceptual changes, observe for gait unsteadiness, observe for s/sx of blurred vision and vertigo. R1's MDS, dated [DATE], documents R1 has a moderate cognitive impairment with a BIMS of 12. R1 MDS documents R1 requires supervision of one staff member for all ADLs. On 5/30/23 at 5:42 AM, Signs were seen at each nursing station. One sign documented All residents are on Supervised Smoking, also, Do Not provide the residents with the access code to the door. A second sign documented Please do not tell residents the front door code. Thank you. On 5/30/23 at 5:40 AM, R1 was seen outside smoking with no employee present. On 5/30[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient number of staff to care for resident's needs including answering call lights timely, timely incontinent care, monitoring residents who are on Enhanced Supervision to prevent falls and/or injuries, and monitoring residents outside while smoking. This has the potential to affect all 75 residents living in this facility. Findings include: 1.On 5/30/23 at 5:00 AM, the facility was staffed with two nurses covering the 300 and 400-halls and one nurse covering the 100 and 200-halls. There was one Certified Nursing Assistant (CNA) on each hall, for a total of four CNAs in the building. Residents were seen walking around the facility, standing around the front door and the nurse's desks. On 5/30/23 at 5:07 AM, V5, Licensed Practical Nurse/LPN, stated I came on at 7:00 PM last evening and I will get off at 7:00 AM this morning. I have worked here before when I was the only nurse covering both the 300 and 400 halls and that is tough. On 5/30/23 at 5:09 AM, V6, CNA, stated I came on at 3:00 PM yesterday and will get off at 7:00 AM this morning. I have had the 300-hall by myself since 11:00 PM last night. We usually work with three CNAs back here (300-400 halls) and two CNAs on the other side (100-200-halls). I guess because of the holiday, they didn't have anyone to work. On 5/30/23 at 5:13 AM, V7, CNA, stated I came on at 7:00 PM last night. We are always short staffed at night. There are times when we only have one CNA for an entire side (two halls). This affects the care of the residents with only one CNA. We can't keep up with everything, provide enhanced monitoring, and take care of the residents when we are short staffed. On 5/30/23 at 5:15 AM, V8, LPN, stated I'm agency here and I came on at 7:00 PM last evening. I have heard from the staff how short they are of Nurses and CNAs, especially at night. On 5/30/23 at 5:20 AM, V9, CNA, stated I came on at 7:00 PM last night. We usually only have one CNA on the 100 and 200-hall. We have three residents on Q (every) 15-minute checks, and we can't keep up with those, answer call lights, and take care of resident's needs. On 5/30/23 at 5:34 AM, this surveyor was told that there was another CNA working on the 400-hall. As of this time, the additional CNA has not been seen. On 5/30/23 at 5:45 AM, V10, CNA, was seen coming in the front door from outside. Stated I usually work by myself on one hall. On 5/30/23 at 5:35 AM, V9, CNA, stated We have three residents who are supposed to be Q (every) 15-minute checks. Two of them may be elopement risks, (R5 and R6), and the other one (R2) for behaviors and/or falls. I have not had anyone to document my 15-minute checks, so I did not do them last night. When there is only one CNA for a hall, it is impossible to take care of all the residents and do 15-minute checks. (R2) is supposed to be a 1:1 because of his falls and his behaviors but we don't have the staff to do this. On 5/30/23 at 5:40 AM, three residents, R1, R4 and R5, were seen outside smoking by themselves with no staff present. On 5/30/23 at 10:12 AM, R6 stated They are working with skeleton crews here, especially in the evenings and nights. There are times when there are only two CNAs on duty for the entire building. One day last week, around 11:00 PM, I was assisted to the bedside commode and when I was done, I put my call light on. I waited over an hour, and no one answered the light so I called the facility with my cell phone and an agency nurse answered and she said she would get someone to come help me. About 15 minutes later, that same nurse came in and told me that she could not find a CNA, but she was still looking. It took a while for them to actually come in to clean me up. I think they were short staffed that day too. On 5/30/23 at 10:42 AM, V15, Licensed Practical Nurse/LPN, stated They used to staff with three nurses working the night shift, now they only staff with two, one on each side. That makes it really hard. On 6/1/23 at 10:30 AM, R9 stated Weekends and nights are worst for getting staff in here to help you. On 6/1/23 at 10:35 AM, R10 stated The night shift is when it seems like no one is here. The facility's Daily Staffing Assignment sheet, dated 5/29/23, documents the night shift had one Nurse and one CNA for the 100/200-halls, one Nurse and one CNA for the 300-hall, and one nurse and two CNAs for the 400-hall. On 5/30/23 at 7:35 AM, V2, Director of Nursing, DON, stated I believe our staffing patterns are for days, we have three nurses, two on the 300-400-halls, and one on the 100-200-halls, then we run with six to seven CNAs. For the night shift, we have two nurses, one on each side, and four CNAs, two on each side. We do twelve hour shifts here. Basically, we have eleven CNAs and five nurses in a 24-hour period. On 5/30/23 at 7:42 AM, V13, Staffing Coordinator, stated I staff with three nurses and seven to nine CNAs for Days and a minimum of two nurses and three CNAs for nights. I try to staff with four to five CNAs for nights. 2. R2's Care Plan, dated 3/31/23, documents (R2) is at high risk for falls r/t (related to) Cerebral Palsy, Intellectual Disabilities, and Epilepsy. Interventions: dated 12/16/22 low bed, 12/23/2022 - environmental assessment of room conducted, 12/23/22 brightly colored visual cues reminding to call for assistance prior to transfers, 4/11/2023 resident to remain on enhanced supervision, encourage appropriate use of assistive device. Evaluate multiple falls to determine commonalities or patterns. Fall risk assessment quarterly and as needed. If noted agitation while up in chair, assist to bed and continue enhanced supervision. Keep bed in lowest position. Keep frequently used items within reach. Monitor for any changes in condition. Notify MD (Medical Doctor) and family of any new fall. Orient resident to surroundings frequently, including location of bathroom, dining room, bedroom and activity locations. Promote placement of call light within reach and assess residents' ability to use. R2's Fall Risk Evaluation, dated 4/11/23, documents R2 is a high fall risk with a score of 24. Scoring a 10 or higher makes resident High Risk for falls. R2's Fall Risk Evaluation, dated 3/30/23, documents R2 is a high fall risk with a score of 29. Scoring a 10 or higher makes resident High Risk for falls. On 5/30/23 at 5:38 AM, R2 was seen laying on the floor, naked with blanket pulled over his groin. There was trash and a sheet are also laying on the floor next to R2 with feces spread all over the floor. There were three mattresses laying side by side on the floor instead of a bed, a soft mat laying on the floor in the middle of the room and a tall wheelchair in the room. On 5/30/23 at 5:39 AM, V7, CNA, stated R2 is supposed to be a 1:1 but we don't have the staff for that. R2 used to stand up off his bed and fall. They have since put these mattresses on the floor, so now R2 just rolls off and moves everywhere in the room. R2 has a tendency to throw his incontinence brief at us and all around the room. R2's Incident Audit Report, dated 4/8/23 at 3:58 PM, documents CNA notified this nurse because resident's nurse was on break that resident launched himself from his wheelchair to the floor, resident is baseline confused. CNA stated that resident hit his head on the floor. It appeared he has some swelling of about half inch on his forehead with about a 2cm (centimeters) cut, bleeding was cleaned and stopped. Resident was found sitting on the floor sideways, both legs slightly flexed, he was located in front of his wheelchair. The room was brightly lit, no clutter or wet floor noted. Resident was assisted up to his bed with two staff assist and gait belt to his bed. R2's Enhanced Supervision Monitoring documents, dated 4/8/23, has documented checks every fifteen minutes. R2's Incident Audit Report, dated 4/11/23 at 9:45 AM, documents R2 was found on the floor with a large, raised area to the crown of R2's head. There was no Enhanced Supervision Monitoring Document for 4/11/23. R2's Physician Order, dated 4/20/23, documents Enhanced Supervision. R2's Enhanced Supervision Monitoring documents, dated 5/12/23, has no documented checks from 6:30 AM until 7:15 AM, then from 2:45 PM until 4:00 PM. R2's Enhanced Supervision Monitoring documents, dated 5/13/23, has no documented checks from 6:30 AM until 10:00 AM, then from 1:15 PM until 3:00 PM, then from 3:15 PM until 7:00 PM. R2's Enhanced Supervision Monitoring documents, dated 5/14/23, has no documented checks from 6:30 AM until 7:15 AM, then from 6:15 PM until 8:30 PM, then from 5:15 AM until 6:15 AM. R2's Enhanced Supervision Monitoring documents, dated 5/15/23, has no documented checks from 6:30 AM until 8:30 AM, then from 10:15 PM until the next day. R2's Enhanced Supervision Monitoring documents, dated 5/16/23, has no documented checks from 6:30 AM until 7:15 AM, then from 10:45 AM until 12:15 PM, then from 7:15 PM until 8:45 PM. R2's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until the next day. R2's Enhanced Supervision Monitoring documents, dated 5/18/23, has no documented checks from 6:30 AM until 7:00 AM. R2's Enhanced Supervision Monitoring documents, dated 5/19/23, has no documented checks from 6:45 AM until 7:45 AM. R2's Nurse's Note, dated 5/27/23 at 7:04 PM, documents Resident was found on the floor lying next to the mats by the door, assigned nurse is aware. fall was unwitnessed. FYI. The facility's Daily Staffing Assignment sheet, dated 5/27/23, documents three Nurses and four CNAs on duty in the building, with only two of the CNAs and no Nurse assigned to the 100-200-hall during R2's fall. On 5/30/23 at 6:30 AM, V6, CNA, stated The Staffing Coordinator found out you were here and called me and told me to come over and sit with R2 until 7:00 AM. I am supposed to fill out this 15-minute check sheet. I do not see one from last night, I guess they didn't do it. On 6/1/23 at 11:05 AM, V1, Administrator, stated I only have Enhanced Monitoring tools for May, maybe a few from April. The managers who were here previously shred a lot of things and took things with them and I think those may have been shredded because we did not find them anywhere. I think the April schedules and assignment sheets were part of it as well because we don't have them either. 3. On 5/30/23 at 5:40 AM, R4 was seen outside smoking with no staff member present. Throughout the survey, there are signs posted at each nursing station. One sign documents All residents are on Supervised Smoking, also, Do Not provide the residents with the access code to the door. Another sign documents Please do not tell residents the front door code. Thank you. On 5/30/23 at 5:53 AM, R4 stated The staff will sit out with us during designated smoking times only. Anyone can go out the front door, all you have to do is push it. If it alarms, someone will come and turn the alarm off. I go out other times to smoke and there is no staff with me. R4's Care Plan, dated 4/13/23, documents (R4) Risk for Wandering/Elopement Identified. 5/1/23-Res (resident) left (local hospital) ER (emergency room) without supervision. Interventions: Enhanced supervision precautions, provide care in a calm and reassuring manner. Provide clear, simple instruction. Provide reorientation to surroundings, environment. R4 uses tobacco products and is at risk for health problems. Res was found to be smoking in his room. Res needs to be monitored to make sure he is not taking smoking materials to be used in the building. Interventions: If resident continue to be unsafe with smoking, staff will keep resident's cigarettes and lighter and give to resident at smoking times. Monitor for any declines in smoking ability PRN (as needed). Monitor resident while smoking, Provide and arrange education on smoking. Remind resident of smoking times and areas. R4 is at risk for falls r/t Confusion, Gait/Balance problems, Amputation of toe on LT (left) foot. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear non-skid socks and/or shoes when ambulating or mobilizing in w/c (wheelchair). Follow facility fall protocol. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. R4's MDS, dated [DATE], documents R4 has a moderate cognitive impairment with a BIMS (Basic Interview for Mental Status) of 12. R4's Physician Order, dated 5/1/23, documents Enhanced supervision. R4's Elopement Evaluation, dated 5/1/23, documents R4 is a High Risk for elopement. R4's Enhanced Supervision Monitoring documents, dated 5/16/23, has no documented checks from 6:30 AM until 7:45 PM R4's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 7:00 AM, from 9:45 AM until 12:00 PM, from 1:00 PM until the next day. R4's Enhanced Supervision Monitoring documents, dated 5/19/23, has no documented checks from 1:45 PM until 10:45 PM. R4's Enhanced Supervision Monitoring documents, dated 5/20/23, has no documented checks after 7:00 AM for the entire day. R4's Enhanced Supervision Monitoring documents, dated 5/22/23, has no documented checks from 6:30 AM until 7:00 AM, from 3:15 PM until next day. R4's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 3:15 PM until the next day. R4's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until 10:45 PM. R4's Enhanced Supervision Monitoring documents, dated 5/23/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:15 PM until 10:45 PM. On 5/30/23 at 3:45 PM, R4's Enhanced Supervision Monitoring Tool, dated 5/30/23, documents no reason for monitoring documented nor any instructions; one-to-one, Q (every)15-minute, Q-30 minute, or Q-H (hour) observation checked. The last documentation check was done at 11:45 AM 5/30/23. On 5/31/23 at 9:20 AM, R4's Enhanced Supervision Monitoring Tool, dated 5/31/23, documents R4 was last monitored at 8:45 AM. 4. On 5/30/23 at 5:40 AM, R1 was seen outside smoking by himself with no staff present. On 5/30/23 at 1:15 PM, R1 was seen outside on the patio smoking. There was no employee seen outside with residents. On 6/1/23 at 8:23 AM, R1 stated The facility only has one person working on this hall on nights and weekends. It takes a long time for someone to answer the call light then. The facility use to use a lot of agency CNAs, but they quit doing that and only use agency for nurses. They definitely need more help on nights and weekends. R1's Care Plan, dated 4/13/23, documents R1 uses tobacco products and is at risk for exacerbation of COPD (Chronic Obstructive Pulmonary Disease) due to smoking. Interventions: Monitor resident while smoking. Monitor for any declines in smoking ability PRN. Provide and arrange education on smoking. Provide and arrange education on smoking. R1 is at risk for falls r/t poly-med use and independently ambulates throughout the facility. Interventions: Evaluate cause of falls. Explain call light and assess residents' ability to use. Gather and assess information on past falls. Monitor for and document perceptual changes. Observe for gait unsteadiness and for s/sx (signs/symptoms) of blurred vision and vertigo. 5. On 5/30/23 at 5:03 AM, R3 was seen pushing the front door open with the alarm going off. R3 was seen using the keypad to put in code to turn the alarm off, and then went out the door. There was no staff seen by the front door, or outside with the resident. Resident refused to speak with surveyor. R3's Care Plan, dated 5/17/23, documents R3 is at risk for falls r/t BLE (bilateral lower extremity) BKA, DM (diabetes mellitus), and overactive bladder. Interventions: Encourage appropriate use of Assistive Device. Encourage resident to keep room free of obstacles/ clutter. Evaluate multiple falls to determine commonalities or patterns. Fall risk assessment quarterly and as needed. Keep frequently used items within reach. Promote placement of call light within reach and assess residents' ability to use, Provide proper, well-maintained footwear. R3 uses tobacco products and is at risk for complications r/t multiple comorbidities. Interventions: If resident continue to be unsafe with smoking, staff will keep resident's cigarettes and lighter and give to resident at smoking times. Monitor for any declines in smoking ability PRN. Monitor resident while smoking. Provide smoking apron as indicated. Remind resident of smoking times and areas. R3's Fall Risk Evaluation, dated 5/22/23 at 2:08 PM, documents R3 is not a high fall risk with a score of 7. Scoring a 10 or higher makes resident High Risk for falls. R3's Physician Order, dated 3/30/23, documents Monitor behavior every shift. Smoking in room. R3's Enhanced Supervision Monitoring documents, dated 5/12/23, has no documented checks from 6:30 AM until 7:00 AM, then from 3:30 PM until the next day. The Facility's Daily Staffing Assignment sheet, dated 5/12/23, documents only two Nurses and three CNAs on duty for the night shift. R3's Enhanced Supervision Monitoring documents, dated 5/13/23, has no documented checks from 6:30 AM until 12:00 PM, then from 1:00 PM until the next day. The Facility's Daily Staffing Assignment sheet, dated 5/13/23, documents only two Nurses and three CNAs on duty for the night shift. R3's Enhanced Supervision Monitoring documents, dated 5/17/23, has no documented checks from 6:30 AM until 7:00 AM, then from 7:00 PM until the next day. The Facility's Daily Staffing Assignment sheet, dated 5/17/23, documents only two Nurses and CNAs on duty for the night shift. R3's Enhanced Supervision Monitoring documents, dated 5/19/23, has no documented checks from 6:30 AM until 8:10 AM, then from 7:00 PM until the next day. R3's Enhanced Supervision Monitoring documents, dated 5/20/23, has no documented checks from 6:30 AM until 7:30 AM, then from 7:00 PM until the next day. R3's Enhanced Supervision Monitoring documents, dated 5/21/23, has no documented checks from 6:30 AM until 7:30 AM, then from 8:00 PM until the next day. R3's Enhanced Supervision Monitoring documents, dated 5/22/23, has no documented checks from 7:15 AM until 11:00 PM. R3's Enhanced Supervision Monitoring documents, dated 5/30/23, has no documented checks from 9:00 AM until 1:00 PM. 6. On 5/30/23 at 1:15 PM, R5 was seen outside on the patio smoking. There was no employee seen outside with residents. R5's Care Plan, dated 5/24/23, documents R5 is at risk for falls r/t unsteady gait at times, HTN (Hypertension), and CKD (Chronic Kidney Disease). Interventions: Encourage resident to keep room free of obstacles/clutter. Evaluate multiple falls to determine commonalities or patterns. Fall risk assessment quarterly and as needed. Keep frequently used items within reach. Promote placement of call light within reach and assess residents' ability to use. Provide proper, well-maintained footwear. R5 requires assist with daily care needs r/t unsteady gait at times, HTN, and COPD. Interventions: Assist resident with ADLs. Monitor skin integrity during routine care and report abnormal findings. (R5) uses tobacco products and is at risk for complications. Interventions: If resident continue to be unsafe with smoking. Staff will keep resident's cigarettes and lighter and give to resident at smoking times. Monitor for any declines in smoking ability PRN. Monitor resident while smoking. Provide and arrange education on smoking. Provide smoking apron as indicated. R5's MDS, dated [DATE], documents R5 has a severe cognitive impairment with a BIMS of 5. R5 requires limited assistance from one staff member for bathing and toilet use and requires supervision for the rest of her ADLs. R5's Physician Order, dated 5/11/23, documents Record number of episodes if targeted behavior of exit seeking/attempting to leave occurs. Every shift Record the number of times observed. R5's Physician Order, dated 5/11/23, documents Record number of episodes if targeted behavior of wandering and taking things from others occurs. On 5/30/23 at 10:32 AM, V14, Receptionist, stated I try to keep an eye on residents going out the front door. If it is not someone I normally see, then I will let the managers know and they will check on it. I believe the residents sign out in a book at each nurses station if they want to go out on unscheduled smoking times. On 5/30/23 at 10:45 AM, V15, LPN, stated R5 goes outside all the time to smoke. I believe she is an elopement risk as well. I think the residents are supposed to sign out in the book if they are going outside, just in case they don't come back, however, I doubt that R5 is able or ever signs out. On 5/30/23 at 3:05 PM, V1, Administrator, stated We do have a couple of residents who are with it and will go outside by themselves to get some fresh air and/or smoke, and I believe they are care planned as such. There should be a staff member with all residents who are outside smoking. We rotate staff among departments to make sure someone is out with them. (R5) should not be outside by herself. We have changed the combination to the door so many times since I have been here and somehow, the residents are getting the code. I will have it changed again today. The Facility's Smoking Times, posted on the hallway wall, documents Smoking times are: 7:00 AM - 7:30 AM, 9:00 AM - 9:30 AM, 11:00 AM - 11:30 AM, 1:00 PM - 1:30 PM, 4:00 PM - 4:30 PM, 6:00 PM - 6:30 PM, 9:00 PM - 9:30 PM. Smoke breaks are 30 minutes. Please be on time. 7. R7's Care Plan, dated 4/13/23, documents R7 is at high risk for falls r/t CVA (Cerebral Vascular Accident), DM (Diabetes Mellitus), and Decreased Mobility. Resident impulsive and has cognition issues and poor safety awareness. Interventions: 1/3/23 Brightly colored visual cue, Fall mat next to bed, 3/14/23- staff educated to lay resident down directly after meals, 3/22/23-Res. to be encouraged or redirected by staff to common areas while awake, 3/30/23 Hourly checks while up in wheelchair, 3/8/23 Keep bed in lowest position, 4/18/23 Staff educated on safety risks of leaving an unsteady resident sitting on side of bed without supervision and directed to immediately assist and safety positioning upon transferring resident to bed, 4/22/23 Enhanced supervision. Encourage appropriate use of Assistive Device. Encourage resident to keep room free of obstacles/clutter. Evaluate multiple falls to determine commonalities or patterns. Fall risk assessment quarterly and as needed. Keep frequently used items within reach. Promote placement of call light within reach and assess residents' ability to use. Provide proper, well-maintained footwear. R7 is under Hospice care due to a terminal diagnosis of CVA. R7 requires assist with daily care needs r/t CVA with deficits and decreased mobility. Interventions: Assist resident with ADLs. Monitor for changes with daily care abilities and provide more or less assist if needed. Monitor skin integrity during routine care and report abnormal findings. R7's MDS, dated [DATE], documents R7 has a severe cognitive impairment and requires extensive assistance from two staff members for all ADLs. R7 is dependent on one staff member for bathing. The facility's Floor 300-400 Enhance Supervision book has an Enhanced Supervision form for R7 as indicated for R7 being a fall risk. On 5/30/23 at 10:05 AM, R7 sitting in his tall back wheelchair. Signs seen on the walls Don't forget to use your call light to ask for help. and Pull your call light for assistance before transferring. On 5/30/23 at 10:07 AM, R7 stated I fell a little while ago while trying to get out of bed. I had to use the restroom, I put my call light on, but it was taking them too long, so I tried to get up on my own. I was not supposed to do that, but I couldn't wait any longer. I think the floor was wet and I slipped and fell. They put this mat on the floor for me after that. On 5/30/23 at 3:35 PM, R7's Enhanced Supervision Monitoring document, dated 5/30/23, documents R7 was last monitored at 12:45 PM. On 5/31/23 at 9:10 AM, R7's Enhanced Supervision Monitoring document, dated 5/31/23, documents R7 was last monitored at 6:45 AM. On 6/1/23 at 8:25 AM, R7 stated I use the call light and most of the time it takes quite a while to get help, especially at night and on weekends when they don't have the people here. On 5/30/23 at 3:10 PM, V1, stated I understand that if we have a one-on-one resident, we really need to have a staff member available to make sure someone is actually assigned to that resident at all times. Corporate cut our staffing pattern so we really can't staff any extra people for one-on-one monitoring. I will have to clear it with corporate to be able to put an extra CNA on for this, but that makes since. On 5/30/23 at 3:15 PM, V2, DON, stated I guess if we have a resident who is one-on-one, we probably should not include that staff member in the regular staffing matrix and just have them on the schedule as one-on-one with that resident. 8.R8's Face Sheet, undated, documents an admission date of 5/4/2023. R8's Face Sheet documents R8 has diagnoses of Cerebral Palsy, Intellectual Disabilities, and Paraplegia. On 5/31/2023 at 10:30 AM, V18, CNA, R8 assisted into electric wheelchair. On 5/31/2023 at 2:40 PM, R8 remained up in wheelchair. R8 stated she had not been changed since her shower at 10:30AM that morning. R8's shorts were visible wet with urine. At 2:50 PM V17, CNA, and V18 assisted R8 to bed via full body mechanical lift. R8's adult brief, clothes, and mechanical lift pad wet were with urine. R8's MDS, dated [DATE], documents R8 has no cognitive deficits. R8's MDS documents R8 is always incontinent of bowel and bladder. R8's Care Plan dated 5/5/2023 Activities of Daily Living (ADL's), documents R8 requires assist with daily care needs related to cerebral palsy and intellectual disabilities. She utilizes an electric wheelchair. She also uses a button seatbelt occasionally. She can open and close this independently. She is dependent on staff for all ADL's, which is R8's baseline. Interventions include the following: Assist resident with ADL's; Encourage/ assist with turning and repositioning every two hours and as needed; Keep clean and dry after each incontinent episode; Monitor skin integrity during routine care and report abnormal findings. 9. R9's Face sheet documents an admission date of 8/12/2022 with diagnoses of s Obesity, Multiple Sclerosis, Nondisplaced Fracture of Lateral Malleolus of Left Fibula, Subsequent encounter for Closed Fracture with routine healing. On 5/31/2023 at 8:30 AM, R9 stated I was changed last night at 8:00 PM and haven't been changed since. I have to wait all the time on staff. I wait hours. V16, CNA, and V17, CNA, provided incontinent care to R9. R9's incontinence brief was visibly wet with yellow stains. The incontinence pad R9 was laying on was visibly wet. R9 had dried stool on buttocks. The facility's Staffing policy, dated 11/2017, documents The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week unless waived. 10. The Facility's Resident Census and Condition of Residents form, CMS 672, dated 6/1/23, documents the facility has 75 residents living in the facility.

Based on observation and interview, the facility failed to operate a Registered Nurse to serve as the Director of Nursing (DON). This has the potential to affect all 74 residents in the facility. Findings include: On 4/17/23 at 9:20AM, V1, Administrator stated, she was prepared for the state surveyor, as the Director of Nursing left on 4/11/23 after the state survey of 4/6/23 and before the follow- up to survey 4/14/23. V1 also, stated, the current resident census as of 4/17/23 is 74. On 4/17/23 at 10:30AM, V5, Director of Staffing, stated the Director of Nursing (DON) resigned on 4/11/23. On 4/19/23 at 11:15AM, V22, Minimum Data Set Coordinator (MDS) stated that the facility does not have a DON, a Corporate Registered Nurse (RN), is kept in-formed of issues and in the process of hiring. On 4/20/23, at 9:00AM, V26, Corporate Registered Nurse, introduced herself to the state surveyor for the first time since the investigation began on 4/17/23. On 4/20/23 at 2:00PM, V26, stated, she was on a personal leave this week. The facility's presented on 4/20/23, entitled, Regional Nurse Consultant-Job Description, dated 9/10/16, documented, Function as the clinical lead (DON) of the facility in the absence of a facility director of nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide tube feedings as ordered by the physician for 1 of 1 resident (R29) reviewed for tube feedings in the sample of 37. Findings include: R29's Electronic Medical Record documents R29's medical diagnoses include Type 2 Diabetes Mellitus, COVID-19, Dysphagia, Major Depressive Disorder, Atherosclerotic Heart Disease, Adult failure to thrive, Gastrostomy. On 4/3/23 at 10:40 AM, R29 stated, I have a feeding tube, and I take care of it myself. I give myself a feeding bolus twice a day, flush the tube, and then clean and put a new dressing on it. The nurses really don't do anything for my tube feedings. On 4/4/23 at 8:55 AM, R29 stated, I am not going to give myself any tube feeding this morning, because my blood sugar was too high. I usually give myself a feeding twice a day and will flush it afterwards. Guess I will not be flushing my tube this morning either since I'm not giving myself a feeding. On 4/5/23 at 2:50 PM, R29 stated, The nurses never touch my gastric tube. They have not checked placement since sometime this past winter. They make sure I have enough tube feeding in my room, and they bring me a new syringe and water container about every two weeks. The nurse checks my blood sugar four times a day and after the morning and evening checks, they let me know if I can give myself my morning tube feeding. I did not give myself any this morning because my blood sugar was high. This is how I usually do my feeding, I use the middle port, hook the syringe to it, pour eight ounces of feeding into the syringe, then 300 ML of water and let it go in by gravity. I don't check residual, they never told me I had to do that. I do clean my tube site every day with an alcohol pad and put a new gauze dressing on it. R29's Care Plan, dated 1/17/23, documents (R29) has nutritional problem or potential nutritional problem r/t (related to) swallowing deficit of dysphagia and adult failure to thrive. He has a PEG (percutaneous endoscopic gastrostomy)-tube in place. He administers his own tube feeding as needed when unable to consume meals by mouth. Interventions: Check placement of tube as ordered, Flush tube as ordered by physician, Head of bed elevated to 30-45 degrees, (R29) has expressed a desire to self-administer bolus tube feeding, Provide tube feeding as ordered, Staff to provide tube feeding in correct amount to (R29) when doing own tube feeding. Staff to watch him at each time to assure proper technique. It continues (R29) requires tube feeding at times when unable to consume meals orally. (R29) self-feeds himself through his peg-tube by choice and has orders for PRN (as needed) tube feedings. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record, Monitor/document/report to MD (Medical Doctor) PRN: Aspiration - fever, SOB (shortness of breath), Tube dislodged, Infection at tube site, Self-Extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration, Provide local care to G-Tube (gastric-tube) site as ordered and monitor for signs/symptoms of infection, The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed. R29's Minimum Data Set (MDS), dated [DATE], documents that R29 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R29's MDS documents R29 requires supervision with set-up only assistance for eating. R29's Physician Order, dated 2/10/23, documents Flush enteral tube with 30 ML (milliliters) of water before and after feedings and before and after medication administration, two times a day related to Dysphagia. R29's Physician Order, dated 2/10/23, documents Check residual. If greater than and/or equal 100 ML hold feeding. If feeding held: Check residual after one hour and if residual still greater than or equal to 100 ML notify MD, two times a day related to Gastrostomy Status. R29's Physician Order, dated 2/10/23, documents Enteral Feed, two times a day related to Dysphagia. R29's Physician Order, dated 2/9/23, documents Elevate head of bed equal to or greater than 30 degrees during feedings and 30 minutes after feedings as tolerated for aspiration precaution, Every day and night shift related to Dysphagia. R29's Physician Order, dated 2/9/23, documents Check tube for correct placement and patency before administration of medication, administration of feeding and tube flushes, every day and night shift related to Gastrostomy Status. R29's Physician Order, dated 2/1/23, documents Flush G-Tube with 50 ML of water once daily to maintain patency, every shift for Prophylaxis. R29's Physician Order, dated 2/1/23, documents Monitor enteral tube site for signs and symptoms of infection, every shift. R29's Physician Order, dated 2/1/23, documents Check placement of G-Tube using auscultation before administering foods/meds/fluids and daily, every shift. R29's Physician Order, dated 7/21/21, documents Change enteral feeding piston syringe, every night shift. R29's Physician Order, dated 7/21/21, documents Cleanse feeding tube site with normal saline and apply dressing daily, every night shift and as needed. R29's Nurse's Note, dated 3/17/22 at 9:19 AM, (R29) has expressed a desire to be able to self-administer bolus tube feeding. Licensed staff will instruct and monitor return demonstration, in an effort to provide resident with a feeling of independence. R29's Nurse's Note, dated 3/18/22 at 1:11 PM, documents Patient was able to perform own tube feeding without problems. patient performed tube feeding in front of nurse so patient can do own tube feeding when he wants to during scheduled times. nurse will still do blood sugar and insulin. patient in bed resting with call light in reach. R29's Nurse's Notes, dated 3/20/22 at 11:45 AM, documents Patient continues to do own tube feedings with no complications. R29's Medication Administration Record (MAR), dated April 2023, documents Check Placement of G-Tube using Auscultation before administering food/meds/fluids and daily every day shift. This has been signed as completed by the nurse every day, and each shift at 7:00 AM. R29's MAR, dated April 2023, documents Check residual. If greater than and/or equal 100 ML hold feeding. If feeding held: Check residual after one hour and if residual still great than or equal to 100 ML notify MD, two times a day related to Gastrostomy Status. This has been signed off as completed by the nurse every day, and each shift at 9:00 AM and 9:00 PM. R29's MAR, dated April 2023, documents Check tube for correct placement and patency before administration medication, administration of feeding and tube flushes every day and night shift related to Gastrostomy Status. This has been signed off as completed by the nurse every day, and each shift at 7:00 AM and 7:00 PM. R29's MAR, dated April 2023, documents Enteral Feed Order two times a day related to Dysphagia, Oropharyngeal Phase, 2cal 237 ML. This has been signed off as completed by the nurse every day, and each shift at 9:00 AM and 9:00 PM. R29's MAR, dated April 2023, documents Flush enteral tube with 30 mL of water before and after feedings and before and after medication administration. two times a day related to Dysphagia, Oropharyngeal Phase. This has been signed off as completed by the nurse every day, and each shift at 9:00 AM and 9:00 PM. R29's MAR, dated April 2023, documents Flush G-Tube with 50 ML of water once daily to maintain patency, every shift for Prophylaxis. This has been signed off as completed by the nurse every day, and each shift at 7:00 AM and 7:00 PM. R29's MAR, dated April 2023, documents Monitor enteral tube site for signs and symptoms of infection every shift. This has been signed off as completed by the nurse every day, and each shift at 7:00 AM and 7:00 PM. On 4/5/23 at 2:55 PM, V6 (Licensed Practical Nurse/LPN) stated, (R29) takes care of all of his tube feeding stuff. I really don't think I have ever seen him give himself some tube feeding while I was here. I do check his residual and his placement once a shift, but it is not until the end of my shift. I usually get off between 7:00 PM and 8:00 PM, so I will check it then. I have not checked it yet today. (R29) did not get his feeding this morning because his glucose was 94 before breakfast, from prior shift, and I checked it after breakfast and it was 183, so I told him to hold his tube feeding. On 4/5/23 at 3:15 PM, V6 (LPN) stated, I should not have documented that I gave (R29) his tube feeding this morning, or yesterday morning, or that I checked his placement. I thought that his order was PRN. I guess I still should not have documented his feeding as given. On 4/6/23 at 11:12 AM, V1 (Administrator) stated, I would expect the nurses to follow the physician's orders and to document accurately in the resident's medical record. On 4/6/23 at 12:35 PM, V2 (Regional Director) stated, We are aware of the tube feedings being documented and not given. We have since discontinued the order. On 4/6/23 at 12:55 PM, V5 (Director of Nursing/DON) stated, (R29) should have been trained by a nurse with a return demonstration for him to do self-administration of his tube feeds. The Facility's Tube Feeding Policy, dated 9/2022, documents 2. Tube feeding amounts will be recorded on the MAR. 4. Feeding tube is flushed and clamped when not in use. The Policy documents 6. The Health Care Provider should be notified if tube-feeding amount not infused as ordered. 16. Flush with at least 30 cc of water every four hours, and/or prior to administering and after disconnecting tube feedings. Flush with at least 15 cc of water pre and post medication administration. Check for placement using auscultation prior to flushing. The Policy documents Bolus Feeding: 1. Ensure head of bed is 30-45 degrees. 2. Explain procedure, provide privacy, cleanse hands and done gloves. 3. Check tube placement by aspiration or air insertion. 4. Instill formula and run over appropriate time frame, monitoring resident for signs and symptoms of aspiration. 5. Flush tube with amount of water ordered at end of tube feeding. 6. When feeding complete, disconnect and cover the end of the feeding set. 7. Document feeding and alert the Health Care Provider of any issues or problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 4 of 8 residents (R8, R24, R25, R43) observed for activities of daily living (ADL) in the sample of 37. Findings include: 1. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record documents that R8's diagnoses include Asthma, Morbid Obesity, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Schizoaffective Disorder, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. (R8) primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: Bathing: (R8) requires total care with bathing. Personal Hygiene: (R8) requires extensive assistance with personal hygiene. R8's Minimum Data Set (MDS), dated [DATE], documents that R8 has a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. R8 is totally dependent on one staff member for bathing and personal hygiene, is totally dependent on two staff members for bed mobility, transfers, dressing, and toilet use. R8 is always incontinent of both bowel and bladder. On 4/3/23 at 11:15 AM, R8 stated, I haven't showered in about two weeks now, and I really need one. I don't even get a bed bath. I think they have enough staff here to do it, but the staff just don't want to help anyone out. On 4/4/23 at 11:05 AM, R8 stated, I just want a shower. I still have not gotten a shower in the past two weeks. I am supposed to get one every Wednesday, but they did not give me one last Wednesday, so it must have been the previous Wednesday since my last one. On 4/5/23 at 10:55 AM, R8 stated, I'm mad this morning. I still have not had a shower. It has been over two weeks now. I'm supposed to have one on Wednesdays and today I have a doctor's appointment and probably won't get one today either. I feel gross and I really need a shower. It makes me feel like I'm dirty and I really want a good shower. I have never refused a shower; I like getting them. The Facility's shower list/schedule documents that R8 is scheduled for a shower on Wednesday and Saturday Evenings. R8's Shower sheet for the month of March 2023 has a documented shower/bed bath on 3/1/23 and on 3/8/23 only. R8's Shower sheet for the month of April 2023 is blank with no documented baths or showers given. On 4/5/23 at 11:10 AM, V18 (Certified Nursing Assistant/CNA) stated, We document on the shower sheets in the shower book when we give a bath/shower. We will also go into the electronic medical record and document under PRN (as needed)/Tasks when it is done. On 4/6/23 at 11:10 AM, V1 (Administrator) stated, I would expect the staff to provide residents showers/baths as scheduled in the shower book and documenting them when done. 4. R25's Care Plan, dated 11/29/2022, documents that (R25) has an ADL Self Care Performance Deficit r/t generalized weakness and morbid obesity. He refuses to wear clothes, only gowns. It continues BATHING: requires staff participation with bathing. Encourage resident to accept showers per shower schedule. Resident refuses showers at times. It also documents (R25) is resistive to care r/t related to refuses showers and bed baths at times. He prefers to wear only hospital gowns. Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time. Provide resident with opportunities for choice during care provision. R25's MDS, dated [DATE], documents that R25 is cognitively intact and is totally dependent on staff for showers. The facility's 100/200 Shower List, not dated, documents that R25 showers are scheduled Mondays and Thursday. R25's Bath and Skin Report Sheet, dated March 2023, documents Refused 3/2, 3/13 and 3/22. R25's Bath and Skin Report Sheet shows no documentation of received and/or refusal of showers on 3/6, 3/9, 3/16, 3/20, 3/23, 3/27 and 3/30. On 4/4/2023 at 9:30 AM, R25 stated that he is not getting his showers as scheduled. R25 stated that he has refused to take showers and that the staff have him sign a form saying that he refused. R25 stated, But what about the days that they don't offer me my showers. R25 stated that there are days that he is not even asked about his showers. The Facility's Activities of Daily Living Policy, dated 9/2022, documents A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. 2. A program of assistance and instructions in ADL skills is care planned and implemented. A. Hygiene: f. Showers or baths are scheduled and assistance is provided when required. 2. The Facility's 100/200 Shower List does not list R24. R24's Face Sheet dated 4/6/2023 documents R24 has diagnoses of Multiple Sclerosis (MS), chronic pain and weakness. R24's MDS dated [DATE] documents R24 requires assistance for personal hygiene and is cognitively intact. R24's MDS further documents, Rejection of care - 0 behavior exhibited. R24's Care plan dated 3/30/2023 documents R24 has self-care deficit related to MS. On 4/04/23 at 2:15 PM, R24's hair was in a disheveled braid and greasy. R24 was wearing a gray shirt with a brown stain. R24 was wearing this same gray shirt all day. At this time R24 stated, I would like a shower more than once a week. At least twice a week wound be better. On 4/5/23 at 1 PM, R24's hair remained in the disheveled, greasy braid. R24's Bath and Skin Report Sheet dated March 2023 documents 3/21/2023 - refused. It continues to document no lotion, shaving or nail trimming was performed. This is the only documentation for March. 3. The Facility's 100/200 Shower List documents R43 is scheduled for Tuesdays and Fridays. R43's Care Plan dated 1/20/2023 documents, ADL (Activities of Daily Living): Resident requires assist with daily care needs related to MS (Multiple Sclerosis) and immobility. Intervention: Assist resident with ADLS. On 4/3/2023 at 12:21 PM, R43 stated, I've been trying all week to get this dirt from under my nails. I want them cut and cleaned. You can see all the buildup. At this time R43's fingernails had a dark matter underneath and around the nail beds. R43's left hand balled into a fist. R43 opened his left hand with his right hand and revealed his nails were approximately 1 centimeter (cm) longer than R43's fingertips on both the right and left hands. R43 continued to state, I prefer bed baths, but they only want to give me showers because it's quicker. I don't like showers because the water splashes in my face. On 4/6/2023 at 9:15 AM, R43's nails remained long and dirty. R43's Bath and Skin Report Sheet dated March 2023 documents Documentation of refusals and interventions must be recorded on the reverse of this report and in the resident record. It continues to document 4/4/2023 - no lotion, shaving or nail trimming was performed. This is the only documentation for March/April regarding bath/showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe transfer for 4 of 4 residents (R8, R33, R40, R43) reviewed for safe transfers in the sample of 37. Findings include: 1. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents that R8's diagnoses include Morbid Obesity, Dysphasia, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Polyosteoarthritis, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. She primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: Bathing: (R8) requires total care with bathing. Personal Hygiene: (R8) requires extensive assistance with personal hygiene. Transfer: (R8) requires extensive assistance to dependence with transfers. R8's Minimum Data Set (MDS), dated [DATE], documents that R8 has a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. R8 requires total dependence from one staff member for bathing and personal hygiene, requires total dependence from two staff members for bed mobility, transfers, dressing, and toilet use. R8 is always incontinent of both bowel and bladder. On 4/4/23 at 11:02 AM, V14 (Certified Nursing Assistant/CNA) and V15 (CNA) put the lift device sling under R8 with the (Full Body Mechanic Lift Device) next to her bed. The lift device was attached to sling, and R8 was lifted off the bed. V15 was holding the wheelchair as V14 moved the lift device over to the wheelchair. R8 was freely swinging in the air during transfer to wheelchair. R8 was lowered to the wheelchair and was disconnected from the lift device. 2. R33's admission Record, dated 5/9/23, documents that R33 was admitted to the facility on [DATE]. R33's Electronic Medical Record, documents that R33's diagnoses include Hemiplegia/Hemiparesis, Cerebral Vascular Accident (CVA), End Stage Renal Disease/Acute Kidney Failure, Dependence on Renal Dialysis. R33's Care Plan, dated 1/23/23, documents (R33) is at risk for a decrease of functional mobility in LUE (left upper extremity) r/t: weakness/discomfort when moving. Interventions: 1. Ask resident to participate with exercise program. 2. Escort/assist/provide materials needed to perform exercises. 3. LUE exercise x's (times) five-ten reps (repetitions) in sitting. 4. Provide an entertaining and enjoyable environment. 5. Instruct/demonstrate exercise to range joints. 6. Praise/applause participation. 7. Provide verbal cues for safety issues. It continues (R33) is at high risk for falls r/t CVA with right dominant side weakness. Her primary mode of locomotion is wheelchair. She has poly med use. She is incontinent of B&B (bowel and bladder). Interventions: 3/27/23 staff educated on safe transfers for this resident, with return demonstrations. Evaluate cause of falls. Staff to assist as needed. It continues (R33) has an ADL (activities of daily living) Self-Care Performance Deficit r/t Hemiplegia. Her primary mode of locomotion is wheelchair. She is incontinent of B&B. She requires assist with ADL care tasks. (R33) has been provided with a Reacher to assist with safely reaching personal items. Interventions: Transfer: (R33) requires Mechanical Aid (Full Body Mechanical Lift) for transfers. R33's MDS, dated [DATE], documents that R33 has a moderate cognitive impairment with a BIMS score of 11. R33 is total dependence on one to two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. On 4/3/23 at 11:05 AM, R33 stated, I'm all bruised up because I fell out of the (Full Body Mechanical Lift) and onto the floor. They were trying to put me into my wheelchair, and they missed, and they dropped me all the way to the floor. They sent me to the hospital to be checked, but I was ok. R33's Nurses Note, dated 3/27/23 at 7:06 AM, documents CNAs called writer to resident room and writer observed resident sitting on the floor in a sitting position in front of the CNA. CNAs told writer that resident was lowered to the floor due to the wheelchair tipping backward while lowering resident into the wheelchair. No injuries sustained and resident was able to perform PROM (passive range of motion) without difficulty. Family, MD (Medical Doctor), and DON (Director of Nurses) have been made aware. R33's Nurses Note, dated 3/27/23 at 10:48, documents Resident sent this AM for fall f/u (follow-up) precautions to (Local Hospital) E.R. (Emergency Room). POA (Power of Attorney) and NP (Nurse Practitioner) made aware. R33's Nurses Note, dated 3/27/23 at 7:28 PM, documents Resident returned from (Local Hospital) E.R. at dinner time. N.N.O. (no new orders). NP and POA made aware. R33's Fall Investigation, dated 3/29/23, documents CNAs called writer to resident room and writer observed resident sitting on the floor in a sitting position in front of the CNA. CNAs told writer that resident was lowered to the floor due to the wheelchair tipping backward while lowering resident into the wheelchair. No injuries sustained and resident was able to perform PROM without difficulty, family, MD, and DON have been made aware. On 4/6/23 at 10:55 AM, V1 (Administrator) stated, I would expect the staff to maintain contact with the resident at all times during a transfer using a full body mechanical lift device. I would expect the staff to hold the wheelchair when transferring a resident from the bed to the wheelchair using a full body mechanical device. On 4/6/23 at 11:05 AM, V1 (Administrator) stated, I did not do the investigation for (R33) when she fell from the (full body mechanical lift), that was the Regional people. It doesn't sound right to me. If the wheelchair tipped over, why would the CNA lower the resident to the floor when the resident would be hanging in the air. It seems like they could have just picked up the wheelchair. On 4/6/23 at 11:10 AM, V25 (CNA) stated, If we are transferring a resident to a wheelchair using a (full body mechanical lift device), we always have at least two people and one of them should hold the wheelchair while the other one operates the (lift device). We should always maintain contact with the resident during the transfer. On 4/6/23 at 11:12 AM, V26 (CNA) stated, When transferring a resident to a wheelchair, one of us should be holding onto the wheelchair so it doesn't move. We should always hold onto the resident while they are being transferred. 3. R40's Care Plan, dated 8/28/2022, documents Transferring: has a selfcare deficit in transferring r/t hemiplegia. It continues Use adaptive equipment: (full body mechanical) lift with assist of 2 staff. R40's MDS, dated [DATE], documents that R40 is cognitively intact and requires extensive assist of 2 persons for transfers. On 4/3/2023 at 11:27 AM, V11 (CNA) and V27 (CNA) assisted R40 into the bed using the full body lift. V11 and V27 applied the straps to the lift. With V27 working the controls and V11 holding onto R40, V11 and V27 assisted R40 into the bed. V11 and V27 performed incontinent care. Upon completion of incontinent care, V11 and V28 assisted R40 from the bed back to the wheelchair. V27 operating the machine lifted R40 off of the bed. With R40 swinging in the lift, V27 moved R40 from the bed to wheelchair in front of closet. No staff was in contact with R40. V11 walked around from the opposite side of the bed and grabbed ahold of wheelchair and positioned it as V27 was lowering R40 into the wheelchair. 4. R43's MDS dated [DATE] documents R43 is cognitively intact and is totally dependent on staff for transfers. R43's Care Plan dated 1/20/2023 documents, Fall: Resident is at risk for falls due to diagnosis of MS and Immobility. On 4/3/2023 at 10:15 AM, R43 stated he just got back from the hospital. R43 was sitting in a transport wheelchair. R43 was slumped down. At this time, R43 stated, Ahh, s**t! I'm falling. I told you I was going to, ahh s**t! V11 (CNA) and V23 (CNA) were observed transferring R43 from the transport wheelchair to bed. Neither V11 nor V23 locked the wheelchair. After the transfer, V11 and V23 stated the chair R43 had been in prior to the transfer is not R43's chair. The Facility's Electronic Patient Lift Operation Guide, undated, documents, How to operate the electric patient lift: f. Lift patient until his/her feet will swing easily off the bed keeping patient facing the attendant. g. Unlock rear casters and transfer patient to and above commode or wheelchair. Lock brakes of both lifter and commode or wheelchair. The Facility's Mechanical Lift Policy dated 10/2022, documents, Procedure: 6. one caregiver is to focus on the resident's head and body positioning while the other is operating the lift. Tell the resident that he or she will be lifted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely and complete incontinence care and catheter care for 4 of 4 residents (R28, R40, R43, R53) residents reviewed for incontinent care/catheter care in a sample of 37. Findings include: 1. R28's Electronic Medical Record documents R28's diagnoses include Type 2 Diabetes Mellitus (DM), Cerebral Infarction, Aphasia, Hemiplegia/Hemiparesis, Epilepsy, Hypertension, and Dysphagia. R28's Care Plan, dated 3/29/23, documents (R28) has bladder incontinence r/t (related to) history of CVA (Cerebral Vascular Accident) with residual deficits. Interventions: Brief Use: The resident uses disposable briefs. Change every two hours and PRN (as needed). Incontinent: Check the resident every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. It continues (R28) has bowel incontinence r/t history of CVA with residual deficits. Interventions: Check resident every two hours and as needed, Provide peri-care after each incontinent episode. It continues (R28) has an ADL (activities of daily living) self-care deficit r/t CVA with right side hemiplegia residual deficit, DM, aphasia, and muscle weakness. (R28) utilizes a (high back reclining wheelchair) for locomotion. He is incontinent of bowel and bladder. Interventions: Toilet Use: (R28) requires total assistance with toileting. R28's Minimum Data Set (MDS), dated [DATE], documents that R28 has a severe cognitive impairment and requires total dependence of one to two staff members for all of his ADLs. R28's MDS documents R28 is always incontinent of both bowel and bladder. On 4/4/23 at 12:40 PM, V17 (CNA) and V18 (CNA) went in the room to perform incontinence care on R28. V17 and V18 washed hands, donned gloves, and placed a basin of water with peri-wash in the water with towels/washcloths on table. R28's incontinence brief was removed and was slightly wet. V17 used one washcloth and wiped R28's penis, wiped R28's scrotum, then folded the same washcloth and wiped each groin. V17 doffed her soiled gloves and with no hand hygiene completed, applied a new pair of gloves. V18 rolled R28 over and V17 wiped R28's buttocks and anal area, a small amount of stool noted. V17 dried R28's buttocks and applied a new incontinence brief. R28's pubic area, and bilateral groins were not dried and still appeared saturated. On 4/6/23 at 11:08 AM, V1 (Administrator) stated, I would expect the staff to perform complete incontinent care, including drying the resident, and using more than one washcloth when needed. 2. R40's Care Plan, dated 8/25/2022, documents Resident is incontinent of bowel and bladder. It also documents interventions as provide incontinence care at routine timely intervals. Keep skin clean, dry, and moisturized. R40's MDS, dated [DATE], documents that R40 is always incontinent of urine and bowel and requires extensive assist of 2 staff for toileting. On 4/3/2023 at 11:27 AM V11 (CNA) and V27 (CNA) performed incontinent care on R40. R40 was incontinent of urine. V11 and V27 assisted R40 into the bed using a full body mechanical lift. V27 then pulled down R40's urine soiled pants and opened R40's incontinent brief and rolled it between her legs. V27 then using a wet washcloth wiped down each side of R40's groin. V27 then using a washcloth cleansed R40's inner labia. V11 and V27 rolled R40 onto her left side and cleansed her right buttock and partial left buttock. V27 then removed R40's heavily soiled incontinent brief. V27 then placed a new incontinent brief under R40. V11 and V27 then assisted R40 onto her back and fastened the incontinent brief and pulled up the urine soiled pants. V11 and V27 then assisted R40 into the wheelchair. V27 did not cleanse R40's pubic area, inner thighs, back of thighs and R40's entire left buttock during incontinent care. On 4/6/2023 at 1:15 PM V5 (DON) stated that she would expect the staff to cleanse all areas of incontinence including the inner thighs, back of thighs and entire buttocks. 3. R53's Care Plan, dated 9/30/22 documents ADL: Resident requires assist with daily care needs r/t obesity, COPD, and right sided hemiplegia s/p CVA. It continues Assist resident with ADLs. R53's MDS, dated [DATE], documents that R53 is cognitively intact and requires limited assist with toileting. On 4/6/2023 at 8:50 AM, V14 (CNA) assisted R53 with incontinent care. R53 was incontinent of urine. V14 opened the incontinent brief. V14 then using a washcloth and no rinse soap wiped the perineal area. V14 then assisted R53 onto her left side and cleansed R53's right buttock and partial left buttock. V14 then removed the soiled incontinent brief and applied a new one. V14 then pulled up R53's pants and left the room. 4. R43's MDS dated [DATE] documents R43 is cognitively intact and is totally dependent on staff for toilet use. On 4/3/2023 at 10:15 AM R43 was sitting in a transport wheelchair. R43 was slumped down. R43 was then mechanically lifted from the wheelchair to the bed. There was a pad beneath R43 that was soiled with a ring around it. R43 also had a catheter. At this time R43 stated, I told them my catheter was leaking. At this time, V11 (CNA) and V23 (CNA) began to provide incontinent/catheter care without the benefit of hand hygiene. V23 cleansed around the head of R43's penis and both sides of R43's groin. V23 then rolled R43 over and cleansed one side R43's buttocks. V23 failed to roll R43 over and cleanse the other buttocks. V23 also failed to cleanse down the catheter. On 4/4/2023 at 9:30 AM, R43 was in bed. R43's catheter bag was observed laying on the floor. R43's floor was extremely sticky. R43's Progress Notes dated 3/29/2023 at 9:13 AM documents R43's catheter was clogged with sediment and was sent to the emergency room (ER). R43's Progress Notes dated 4/2/2023 at 3:41 PM documents R43 began complaining of pain at the catheter site, the nurse attempted to flush it, and met resistance. It further documents R43 was sent to the ER. R43's Progress Notes dated 4/3/2023 at 10:22 AM documents, Resident returned from ER with script for (antibiotic). R43's Progress Notes dated 4/4/2023 at 2:15 PM that R43 continues on antibiotic therapy for UTI (Urinary Tract Infection). R43's Physician's Orders Sheet (POS) documents, Change (catheter) once monthly every fourth and as needed, every day shift starting on the 4th and ending on the 4th every month for urinary retention. R43's Face Sheet dated 1/6/2023 documents R43 has a diagnosis of infection and inflammatory reaction due to urinary catheter. R43's Treatment Administration Record (TAR) dated 2/1/2023-2/28/2023 documents to change R43's catheter every forth of every month. It further documents it was not done 2/4/2023. On 4/6/2023 at 11:26 AM, V2 (Regional Director) stated, I would expect staff to follow our policy regarding infection control, incontinent care and catheter care. I would not expect the catheter bag to be on the floor for infection control purposes. The Incontinence Care Policy, revision date 3/2022, documents Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. The policy documents 4. Remove soiled clothing and linen. 5. Clean peri area with appropriate cleanser and dry. Appropriate cleanser can mean soap and water, periwash etc. Cleansing should always be from front to back. The Facility's Indwelling Catheter Care Policy dated 9/2022 documents, Policy: Daily and PRN (as needed) catheter care will be done to promote comfort and cleanliness. It further documents, Procedure: wash your hands before beginning the procedure as well as Wash catheter itself by holding on to catheter at the insertion site, wash with one stroke downward, using the same procedure for rinsing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents that R8's diagnoses include Malnutrition, Asthma, Morbid Obesity, Dysphagia, End Stage Renal Disease (ESRD), COVID-19, Dependence on Renal Dialysis, Obstructive and reflux uropathy, Anemia, Seizures, Transient Ischemic Attack (TIA), Schizoaffective Disorder, Major Depressive Disorder, Psychosis, Polyosteoarthritis, Atherosclerotic Heart Disease, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. She primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: BATHING: R8 requires total care with bathing. PERSONAL HYGIENE: R8 requires extensive assistance with personal hygiene. TRANSFER: R8 requires extensive assistance to dependence with transfers. R8's Minimum Data Set (MDS), dated [DATE], documents that R8 has a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) of 10. R8 requires total dependence from one staff member for bathing and personal hygiene, requires total dependence from two staff members for bed mobility, transfers, dressing, and toilet use. R8 is always incontinent of both bowel and bladder. On 4/3/23 at 1:18 PM, there was a sign on R8's door identifying that R8 was on Enhanced Barrier Precautions. V11 (CNA) walked into R8's room with no PPE on. V11 exited the room to get assistance from V12 (CNA). Both CNAs walked back into the room and turned and repositioned R8 with no PPE on. No hand hygiene was done prior to or upon exiting the room. On 4/4/23 at 11:02 AM, V14 (CNA) and V15 (CNA) put the lift device sling under R8 with the (Full Body Mechanic Lift Device) next to her bed. The lift device was attached to sling, and R8 was lifted off the bed. V15 was holding the wheelchair as V14 moved the lift device over to the wheelchair. R8 was freely swinging in the air during transfer to wheelchair. R8 was lowered to the wheelchair, was disconnected from the lift device. Both CNAs doffed their gloves and left the room with no hand hygiene completed prior to care and after care was completed. 5. R28's Face Sheet, dated 4/5/23, documents that R28 was admitted to the facility on [DATE]. R28's Care Plan, dated 3/29/23, documents (R28) has bladder incontinence r/t (related to) history of CVA (Cerebral Vascular Accident) with residual deficits. Interventions: Brief Use: The resident uses disposable briefs. Change every two hours and PRN (as needed). Incontinent: Check the resident every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. It continues (R28) has bowel incontinence r/t history of CVA with residual deficits. Interventions: Check resident every two hours and as needed, Provide peri-care after each incontinent episode. It continues (R28) has an ADL (activities of daily living) self-care deficit r/t CVA with right side hemiplegia residual deficit, DM, aphasia, and muscle weakness. (R28) utilizes a (high back reclining wheelchair) for locomotion. He is incontinent of bowel and bladder. Interventions: Toilet Use: (R28) requires total assistance with toileting. R28's MDS, dated [DATE], documents that R28 has a severe cognitive impairment and requires total dependence of one to two staff members for all of his ADLs. R28 is always incontinent of both bowel and bladder. On 4/4/23 at 12:40 PM, V17 (CNA) and V18 (CNA) entered R28's room to perform incontinence care. Both CNAs washed hands, gloves donned, and placed basin of water with peri-wash in the water and towels/washcloths on table. R28's incontinence brief was removed and appeared slightly wet. V17 used one washcloth and wiped R28's penis, wiped R28's scrotum, then folded the same washcloth and wiped each groin. V17 doffed her soiled gloves and with no hand hygiene completed, applied a new pair of gloves. R28 was rolled over by V18, and V17 wiped R28's buttocks and anal area; a small amount of stool noted. V17 dried R28's buttocks and a new incontinence brief was applied. R28's pubic area and bilateral groins were not dried and still appeared saturated. V18 held the soiled linen, blankets, and a pile of clean towels against her body while V17 opened a plastic bag and placed the soiled linen in the bag. Both CNAs doffed gloves and left the room with the soiled bags of linen and no hand hygiene was done by either CNA upon leaving the room. On 4/6/23 at 11:02 AM, V1(Administrator) stated, I would expect the staff to perform hand hygiene before, during, and in between glove changes. The Facility's Hand Hygiene Policy dated 1/2021 documents, General: Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. Responsible Party: All Facility staff. Guideline: 1. hand hygiene is done before and after resident contact, before and after any procedure, after using a (tissue) or the rest room, before eating or handling food, when hands are obviously soiled and regardless of glove use. The Facility's Indwelling Catheter Care Policy dated 9/2022 documents, Policy: Daily and PRN (as needed) catheter care will be done to promote comfort and cleanliness. It further documents, Procedure: wash your hands before beginning the procedure and well as Wash catheter itself by holding on to catheter at the insertion site, wash with one stroke downward, using the same procedure for rinsing. 3. R40's MDS, dated [DATE], documents that R40 is always incontinent of urine and bowel and requires extensive assist of 2 staff for toileting. On 4/3/2023 at 11:27 AM V11 (CNA) and V27 (CNA) entered R40's room to perform care. R40 was incontinent of urine. V11 placed a dry towel over R40's overbed table, wet 3 wash cloths with water and placed them on the towel on the table. V11 then using a wet washcloth wiped down each side of the groin. V27 then placed the soiled washcloth on the towel on the table with the clean washcloths. V27 then, using a washcloth from the table with the soiled towels, cleansed R40's inner labia and placed that washcloth on the table with the clean towels. V11 and V27 rolled R40 onto her left side and cleansed her right buttock and partial left buttock. V27 then removed R40's heavily soiled incontinent brief. Using the same gloves V27 then placed a new incontinent brief under R40. V11 and V27 then assisted R40 onto her back and fastened the incontinent brief and pulled up the urine soiled pants. V11 and V27 then assisted R40 into the wheelchair. On 4/6/2023 at 1:15 PM V5 (DON) stated that she would expect the staff to change gloves and wash hands when handling clean items. V5 stated that she expects the staff to change the resident's urine soiled clothing when performing incontinent care. 2. R43's Face Sheet dated 1/6/2023 documents R43 has a diagnosis of infection and inflammatory reaction due to urinary catheter. R43's Minimum Data Set (MDS) dated [DATE] documents R43 is cognitively intact and is totally dependent on staff for toilet use. On 4/3/2023 at 10:15 AM, R43 stated he just got back from the hospital. R43 was sitting in a transport wheelchair. R43 was slumped down. R43 was then mechanically lifted from the wheelchair to the bed. There was a pad beneath R43 that was soiled with a ring around it. R43 also had a catheter. At this time R43 stated, I told them my catheter was leaking. At this time, V11 (CNA) and V23 (CNA) began to provide incontinent/catheter care without the benefit of hand hygiene. After providing care, V23 threw the dirty, urine soiled pad and two wash clothes on the floor. Based on observation, interview and record review, the facility failed to wear required personal protective equipment (PPE), perform hand hygiene and handle linens in a manner which prevents the spread of infection for 6 of 9 residents (R8, R28, R33, R40, R43, R47) reviewed for infection control in the sample of 37. Findings include: 1. On 4/4/2023 at 11:20 AM, V7 (Infection Preventionist) exited R47's room. There was a sign on the door, identifying that the resident in this room requires Enhanced Barrier Precaution. The sign documented that staff must clean their hands before entering the room and when leaving the room. The Sign documented that staff must wear gloves and a gown for the high-contact resident care activities including changing briefs or assisting with toileting and transferring. V7 was exiting R47's room with 2 shelved metal carts on wheels with multiple packages of oxygen tubing and humidification bottles. V7 had surgical mask on only and did not sanitize hands upon exiting room. V7 the pushed cart down the hall and entered R33's room, which identified the room as requiring enhanced barrier precautions. V7 did not sanitize hands prior to entry and entered with same surgical mask on. State surveyor knocked on door and questioned V7. V7 stated, I did not know this was isolation room.

Based on observation, interview and record review, the facility failed to store medication, label insulin and Tubersol in accordance with standards of practice. This has the potential to affect all 76 residents living in the facility. Findings include: 1. On 4/3/2023 at 9:22 AM 200-Hall medication cart was observed. The medication cart contained the following: 4 liquid medication cups with multiple pills in them; 1 cup had 20 yellow pills, 1 cup 15 black pills, 1 cup with 12 yellow pills, 1 cup with 17 red capsules. R61's opened and used multi dose Humalog pen was not labeled with an opened date. R274's multi dose Novolin R Insulin vial was not labeled with an open date. R274's Electronic Medical Record documents that R274 was admitted to the facility 7/26/22 and discharged on 8/4/22. 2. On 4/3/2023 at 10:20 AM 100 and 200-Hall medication room was observed. The medication room contained the following: An open bottle of Geri Lanta with expiration date of 11/2022. An open bottle of Geri-Kot (Senna 8.6 handwritten on bottle) expiration date 8/2022. An open bottle of Vitamin D3 50,000 expiration date 11/2022. An open bottle of Cranberry pills with expiration date 5/2022. The refrigerator in the 100/200 hall medication room contained an open multidose vial of Tubersol without an opened date. On 4/3/2023 at 9:02 AM V19 (Registered Nurse/RN) stated that the pills in the medication cups were aspirin, iron, and Colace. V19 stated that she had not poured the medication in the bottle and that the medication was there when she came on. V19 stated that she assumes that this is what is in the cups. V19 stated that the medication should not be in the medication cup, it should be in the original container. V19 stated that the Aspirin, Iron and Colace are stock medication and that all residents can have the medication with an order. V19 stated that insulins are supposed to have opened dates on them. V19 stated that the expiration date is 28 to 32 days after opening, and the open date is what is used to determine that date. On 4/3/2023 at 9:40 AM V19 stated that the medication in the med room is stock medications. V19 stated that she would use this medication to give to the residents and restock her cart. V19 stated that if a resident had an order for TB to be given, she would use the TB in the medication room. V19 verified that the TB was opened and in use. V19 stated that it should have an opened date when opened. On 4/5/2023 at 10:00 AM V5 (Director of Nursing) stated that the insulin vials have a different expiration date once the bottle is opened. V5 stated that multi dose vials of insulin and Tubersol have a different expiration date from what's on the bottle once open and should be thrown away after this date. V5 stated that the insulin and TB vials are to be labeled with an opened date when put in use. V5 stated that labeling the medication with an opened date lets the nurses know when the expiration date is. V5 stated that the medications are to be stored in its original container and not in a liquid medication cup located in the top drawer of the medication cart. V5 stated that she is not sure why R274's insulin was in the medication as R274 had been previously discharged . V5 stated that when a resident is discharged from the facility their medication is either returned to pharmacy for credit or sent with the resident. V5 stated this is her expectation of her staff and the vial of insulin should not have been in the medication cart and not in use. 4. On 4/03/23 at 10:15 AM, the medication cart on the 400-hall contained the following: one opened bottle of Lantus insulin 100u/cc with no opened date and the bottle did not identify which resident it belonged; a bottle of regular insulin with no opened date and the bottle did not identify which resident it belonged; and Basaglar insulin pen that did not identify the resident it belonged. On 4/03/2023 at 10:16AM V6, Licensed Practical Nurse (LPN) stated I need to get that stuff out of the cart. The facility's Storage of Medications policy, revised date 9/2017, documents Storage of Medications: 2. The pharmacy dispenses medication in containers that meet legal requirements, including for good manufacturing practices. Medications are to be kept in these containers. Transfer of medications from one container to another can only be done by the pharmacy. The Policy documents 11. Outdated, contaminated, or deteriorated medications-and those in containers that are cracked, soiled or without secure closers should be immediately removed from stock and disposed of according to medication disposal procedure. 12. Outdated, contaminated, deteriorated medications will be removed from the medication cart and placed in the pharmacy return bin within the Medication room. The Policy documents 14. When a patient is transferred out of the facility for greater than ten days will have their medications returned to pharmacy. The Resident Census and Condition of Residents form (CMS 672), dated 4/3/2023, documents that the facility has 76 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 report abuse for 1 of 3 residents (R2) reviewed for abuse reporting in the sample of 9. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact and has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). R2's Nurses' Notes, dated 2/17/2023 at 6:08 PM, document: Note Text: (R2) and another resident exchanged a few words back and forth, the other resident called for (V12) (Human Resources) to come over and get the resident because he had come in the dining room starting stuff. this nurse (V13, Licensed Practical Nurse/LPN) and V12 walked over to see what was going on. by the time this nurse and V12 made it over to the residents, (R2) got more upset and tried throwing his coffee cup at the other resident. the coffee cup ended up hitting a different resident in the head and bouncing off of him and hitting another resident in the shoulder. this nurse as well as other staff members redirected the residents. (R2) was instructed to go back to his room so he could calm down. this resident was sent out to the hospital for a psych eval. EMT (Emergency Medical Technician) called, resident going to (local hospital) for further evaluation. (V14) NP (Nurse Practitioner), V1 (Administrator) made aware. The facility's Follow-up Investigation Report, not dated, documents: Interview with (R2) revealed that him and (R7) were having a disagreement about their shared bathroom and (R2) does not deny swinging his cup in attempt to hit (R7) with it and he missed and accidentally hit (R5). (R2) was apologetic for his actions and was educated about his inappropriate behavior. It also documents Conclusion of the investigation: On 2/17/2023 @approximately 4:50pm, staff reported possible resident to resident physical altercation between (R2) a [AGE] year male whose diagnosis includes Schizoaffective Disorder, Bipolar Type and (R5) a [AGE] year male whose diagnosis including Cognitive Communication Deficit. While in dining room preparing for dinner meal, (R7) and (R2) were having an argument about their shared bathroom when (R2) tossed his coffee cup at (R7) missing him and making contact with (R5's) forehead. The cup did bounce off (R5's) head and make contact with (R6's), a fellow peer, right shoulder, however she has no injuries or psychosocial harm. On 2/27/2023 at 11:38 AM, R2 stated that he did throw his cup with hot coffee in it. R2 stated that R7 was poking and poking and poking at him. R2 stated that he became so upset that he threw the cup. R2 stated that he intended to throw the cup. R2 stated that it was deliberate. R2 stated that it didn't hit the person (R7) that was bothering him. R2 stated, It hit the nicest guy (R5) you could ever meet. R2 stated that he is sorry that it hit R5. R2 stated that he just wanted R7 to shut up. R2 stated that he does not eat in the dining room. R2 stated that he does go in the dining room to get coffee. On 2/28/2023 at 2:28 PM, V1 (Administrator) stated that he is aware of the incident that occurred. V1 stated that R2 and R7 were arguing in the dining room. R2 threw his cup of coffee at R7 and missed. V1 stated that the cup of coffee missed its intended target. V1 stated that the cup then hit R5 and R6. V1 stated that R5 sustained an injury. V1 stated that R5 had a hematoma to his head. V1 stated that R2 intended to hit R7. V1 stated that he had a sentinel call with corporate and this incident was discussed. V1 stated that at that time, this event was not viewed as abuse and because the injury was not serious the event was not reported. The facility Abuse Policy and Prevention Program 2022, not dated, documents: This facility affirms the right if our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. It documents the definition of Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. It continues: The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It also documents: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on observation, interview, and record review the Facility failed to provide a RN (Registered Nurse) 8 hours a day 7 days a week. This has the potential to affect all 70 residents in the facility. Findings include: On 2/1/23 at 2:50 PM, V9 (R2's Mother) stated When I got to the facility the morning of 1/29/23, there was only one nurse and one CNA (Certified Nursing Assistant) on duty at 6:00 AM. I know they called in another CNA who came in around 8:30 AM. I had both (V12, LPN/Licensed Practical Nurse), and (V6, CNA), tell me this. I believe the facility is always short staffed because I had to change my daughter (R2) when she was wet, and they didn't have the staff to do it. On 2/1/23 at 10:10 AM, V4 (Assistant Director of Nursing/ADON) stated Right now we don't have any staffing problems. We're one of the few buildings who are pretty well staffed. For days, we staff with three nurses until 11:00 PM, then we drop down to two for nights. For CNAs we use two to three for the 100-200 halls and four for the 300-400 halls. For call-offs, we have a call schedule for the managers to come in when needed. We also have some PRNs (as needed) that can come in and help out at times. Last resort would be Agency staff. We really haven't had to use them much. On 2/1/23 at 10:25 AM, V6 (CNA) stated Things are getting much better lately, but the weekends are the hardest to staff. I got called in this past Sunday and when I got here there were two nurses, one on each side, and one CNA on the hall, and she was quite upset because she was by herself on the side. Usually we have three CNAs on 300-hall, two CNAs on 400-hall, and three CNAs on 100-200 halls. On 2/2/23 at 11:30 AM, V2 (Director of Nursing/DON) stated We only have two RNs that work here, so we do not have RN coverage every day like we're supposed to have. The Facility's December 2022 Nursing Schedule documents that there was an RN on duty only on 12/5/22, 12/6/22, 12/7/22, 12/10/22, 12/14/22, 12/15/22, 12/19/22, 12/20/22, 12/21/22, 12/24/22, and 12/28/22. The remaining twenty days the facility was without an RN on duty for a minimum of eight hours per day seven days a week for December 2022. The January 2023 Nursing Schedule documents that there was an RN on duty only on 1/3/23, 1/4/23,1/7/23, 1/8/23, 1/11/23, 1/15/23, 1/22/23, and 1/28/23. The remaining 23 days in January was without an RN on duty for a minimum of eight hours per day seven days a week. On 2/2/23 at 12:59 PM, V1 (Administrator) stated We don't have a policy on staffing. I was told we just follow the State Guidelines. The Resident's Census and Conditions of Residents, CMS 672, dated 2/2/23, documents that the facility has 70 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the Facility failed ensure toilets in resident's rooms are functional for 5 of 10 residents (R2, R3, R7, R8, R9) reviewed for safe/functional/sanitary/comfortable environment the sample of 10. Findings include: 1. R2's admission Record, dated 12/19/22, documents that R2 was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact and requires supervision with set up assistance only for all of his Activities of Daily Living. R2's MDS documents R2 is always continent of both bowel and bladder. On 12/19/22 at 9:15 AM, R2 was sitting in a chair in his room with a very angry scowl on his face, yelling and cursing about his restroom and the staff not doing anything to help him. A sign was seen posted on his restroom door Do Not Use!!! Use Bathroom on Hall 1 and 2. On 12/19/22 at 9:15 AM, R2 stated Everything about this place is a joke. The guy in the room that shares my restroom always has poop all over and they never clean it up. I have to clean it up before I use it. (V1, Administrator) told me that there is some sort of sewer problem here because the toilet floods every time I flush it and (V1) is not doing anything to fix the problem. This past Friday (12/16/22), someone put a sign on my restroom door that says I have to use a restroom in the 100-200 halls. That is ridiculous, if I have to go, I have to go, and don't want to go across the building just to use the restroom. The doctors gave me six months to live. I get Chemotherapy and have to use the restroom quite often. On 12/19/22 at 12:30 PM, V1 stated I am not aware of any toilet that is out of order for a resident. We have had some plumbing issues which I have had in every building that I have worked in, they're old buildings. Any resident whose toilet is out of order should be using the toilet in the shower room or ones by the nurse's desk and should not be using another resident's restroom. This place has a lot of problems, (Previous Owner) never took care of anything. On 12/19/22 at 3:45 PM, V7, Housekeeper, stated There is usually poop on the toilet in (R2's) restroom. I believe it is from (R9). I always get in there and clean it at least once a day and whenever someone asks me to. 2. R3's admission Record, dated 12/19/22, documents that R3 was admitted to the facility on [DATE]. On 12/19/22 at 9:10 AM, R3 stated See that sign on my restroom door, it has been there all weekend. Is that what it says that I have to use a restroom on 100-200 halls? I don't even know where that is. On 12/19/22 at 9:10 AM, R3 was sitting in his wheelchair. There was a sign posted on R3's restroom door Do Not Use!!! Use bathroom on Hall 1 and 2. 3. R7's MDS, dated [DATE], documents that R7 is cognitively intact and requires supervision with one staff member physical assist for all of her ADL's. R7's MDs documents R7 is always continent of bowel and bladder. On 12/19/22 at 11:25 AM, R7 stated Last week we went for three days without a toilet. They tried to fix it on Friday, and it wasn't until Monday that it was fixed. I had to go use another resident's toilet. She (R10) had a private room and didn't mind if I used her toilet. The restroom up front does not fit a wheelchair in it so we can't use it. It did not make me feel very comfortable and I was even a little embarrassed that I had to use someone else's toilet, but I didn't have a choice. This place is falling apart. On 12/19/22 at 1:15 PM, R10 stated I had a total of three residents come to use my restroom recently. I didn't mind it because I know this building is falling apart and the toilets don't work well all the time. 4. R8's MDS, dated [DATE], documents that R8 requires extensive assistance from one to two staff members for all of her ADL's. R8's MDS documents R8 is occasionally incontinent of both bowel and bladder. On 12/19/22 at 11:30 AM, R8 stated I had to use the restroom in the room across the hall from me because they were working on our toilet for a few days. It was a pain in the butt, but we did it. No one likes to use someone else's toilet, but we had to do it. 5. On 12/19/22 at 9:10 AM, R9 was sitting in his wheelchair. A sign was posted on R9's restroom door Do Not Use!!! Use bathroom on Hall 1 and 2. R9 was seen in his wheelchair on the 200-hall coming out of restroom. R9's MDS, dated [DATE], documents that R9 requires supervision with one staff member assistance for toileting and limited assistance from one staff member for transfers. R9's MDS documents R9 is always continent of both bowel and bladder. On 12/19/22 at 12:50 PM, R9 stated I just had to use a restroom by the nurse's desk, on the other hall, on other side of the building. I didn't like it at all. On 12/19/22 at 12:40 PM, V6, Maintenance Director, stated I have been working on a few toilets lately. They are always clogged because they put wipes, towels, and everything else down there. I know we have some tree roots that have grown into the pipes. I am not aware of any toilet that is out of order right now. Let me look at my messages to see if someone sent me a message. No, it doesn't look like anyone told me about a toilet not in service. On 12/19/22 at 12:45 PM, V1, Administrator, stated The toilet in (R2's) room is working, we just tested it and took the sign down. I am not sure who put the sign up, but it is working now. On 12/19/22 at 1:05 PM, V6, Maintenance Director, stated I usually get a group text on my cell phone when staff has something that needs fixed. I do have books at each nurse's station for them to fill out a Work/Repair Order, but no one uses that. Once I get the messages, I try to arrange them by priority and will have my assistant start to work on them. On 12/20/22 at 9:20 AM, V1 stated We don't really have a maintenance policy, it's more of a standard practice that they would verbally tell maintenance issues or text them or use the logbook. The Facility's Housekeeping Daily Cleaning Procedures, not dated, documents 7. Clean Restroom. Complete the following steps in the restroom: a. Restock all supplies - paper towel, toilet paper, soap, etc. b. Empty trash. c. High dust - lights, vents. d. Disinfect sink area. e. Disinfect toilet area - including handrails, call lights and tub/shower. The Facility's Accommodation of Needs and Preferences and Homelike Environment policy, dated 9/2022, documents The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. It continues It is the policy of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a home-like environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable, and home-like environment, allowing the resident to use his or her personal belongings to the extent possible.

Based on interview and record review, the facility failed to secure medications to ensure residents do not have access for one of one resident (R9) reviewed for 1 of 1 accident investigations in a sample of 48. Findings include: R9's Nurse's Note, dated 11/28/21 at 7:16 PM documents R9 was sent out to the hospital. R9's Nurse's Note, dated 11/29/21 at 12:50 PM documents During investigation of incident that occurred on 11/28/2021 (R9) admitted to taking medication that was not her medication. She also stated she is slowly dying and wanted to make things easier on her mom by killing herself. Suicidal precautions were initiated immediately. Q5-10 min (every 5 to 10-minute) visual checks initiated, and MD notified. Received orders to send to (local hospital) for psych (psychiatric) eval (evaluation) and monitoring r/t (related to) suicidal ideations with a plan. POA (power of attorney) is to be updated related to (R9) being sent out to hospital per floor nurse. R9's Nurse's Note, dated 11/29/21 at 12:58 PM documents R9 was sent to local hospital vial ambulance service transport for evaluation and treatment related to suicidal ideation. R9's Nurse's Note, dated 11/29/21 at 1:29 PM documents R9 gave EMS (emergency medical services) consent and left willingly with EMS x 2 attendants to be seen at local hospital. On 1/6/21 at 2:10 PM V9, Licensed Practical Nurse (LPN) stated he recalled the medication incident regarding R9 at the end of November 2021. V9 stated a newly admitted resident arrived to the facility at approximately 3:00 PM. V9 stated he was at the nurse's station putting the physician's orders in the computer and the newly admitted resident's medication cards were on the nurse's station at that time. V9 stated R9 was at the nurse's station on the phone when he left the nurse's station to assist another resident. V9 stated there was one card of Ativan with 29 pills on it and approximately 10-15 medication cards of general medications that were rubber banded together, including a high blood pressure medication, Amlodipine. V9 stated when he returned to the nurse's station at approximately 3:30 PM he observed R9 self-propelling in her wheelchair down the hallway back to her room. V9 stated when he realized the Ativan medication card was missing and he looked everywhere for it. V9 stated he called V1, Administrator, and V23, Staffing Coordinator, but no one called him back immediately. V9 stated he started administering medications and passing dinner tray between 4:00 - 4:30 PM. V9 stated after 6:00 PM he still could not find the Ativan medication card and noted R9 was acting weird, she had increased slurred speech and she slid/fell out of her wheelchair. V9 asked R9 if she took the medication and R9 confessed to taking it. V9 stated he did not know if R9 took all 29 Ativan pills or not and did not ask her that. V9 stated R9's physician was at the facility and said to either observe her or send her to the emergency room for evaluation. V9 stated he transferred R9 to the local hospital. V9 stated he completed a lengthy incident report. V9 could not recall what day this occurred but stated the incident report was time stamped. V9 stated he could not recall if R9 gave him back the Ativan medication card or not prior to going to the hospital. On 1/6/21 at 9:30 AM, V8, Corporate Nurse, stated she was not employed at the facility when this incident occurred. V8 stated she expects residents' medications should be locked up at all times. On 1/6/21 at 11:08 AM, V1, the Administrator stated V9 called her with a medication concern at the end of November 2021. V1 stated V9 told her another resident was about to fall and he went to assist him, and a medication card was left on the nurse cart at that time. V1 stated after V9 returned to the medication cart he found 19 pills of Ativan was missing off the card. V1 stated when V9 realized the medication was missing he looked everywhere for it. V1 stated V9 noted R9's speech was slurred, and she had increased confusion. V1 stated V9 called 911 and R9 was transferred to the local hospital. V1 stated she was on leave at the time and thought another corporate nurse did the investigation. V1 also stated Ativan was a controlled substance and should always be always under double lock. V1 stated Ativan is stored in the medication cart in a separate lock box and the medication cart is locked and when Ativan is stored in the medication room it is locked in a cabinet and the medication room is locked as well. After multiple requests, on 1/5/2022 and 1/6/2022, the facility did not provide an investigation regarding R9 taking medications that were not hers on 11/28/21. The facility's policy storage of medications revised 2021 documents policy statement the facility shall store all drugs in a safe, secure, and orderly manner. Compartments containing drugs shall be locked when not in use and carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor and assess the hemodialysis shunt sites for 2 of 4 residents (R12, R21) reviewed for dialysis in the sample of 48. Findings Include: 1. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired. R12's Hemodialysis Care Plan documents dated 1/7/22 documents observe access site for infection redness, drainage, swelling, and pain every shift. R12's December 2021 Treatment Administration Record (TAR) documents that R12's hemodialysis access site was only assessed 30 times for 3 shifts for the month of December (should have been 90 times). On 1/6/22 at 3:00 PM, R12 stated, I don't know if they check it or not. 2. R21's MDS dated [DATE] documents R21 is moderately cognitively impaired. R21's Hemodialysis Care Plan dated 1/7/22 documents observe access site for infections redness, drainage, pain and swelling every shift. R21's December 2021 TAR documents that R12's hemodialysis access site was only assessed 34 times for all three shifts for the month of December (should have been 90 times). On 1/5/21 at 1:00 PM, R21 couldn't state whether or not they check her shunt site. On 1/7/22 at 1:00 PM, V2 Interim Director of Nurse's (DON) stated I would like the nurses to check thrill and bruit, and check that the site is in intact without redness or signs and symptoms of infection. The facility policy entitled Hemodialysis Access Care dated September 2010 documents Check for signs of infection (warmth, Redness, tenderness, or edema) at the access site when performing routine care, and at regular intervals. Check pantency of the site at regular intervals. Palpate the site to feel for thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access.

Based on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 25 opportunities with 2 errors resulting in an 8% medication error rate. The errors involved 2 residents (R54, R108) in the sample of 48 out of 3 residents observed during the medication administration. Findings include: 1. On 1/6/22 at 8:10 AM, V13, Registered Nurse (RN), administered medication to R54. V13 did not administer Carvedilol 3.125 milligrams (mg) to R54. V13 stated she thought all medications were administered to the resident that were ordered by the physician. She does not know what occurred that the medication was not administered. R54's Physician's Order Sheet (POS), dated 1/1/2022 documents an order to administer Carvedilol Tablet 3.125 MG 1 tablet by mouth two times a day for Hypertension. There was no nurse's note regarding the missed dose of Carvedilol Tablet 3.125 mg. 2. On 1/6/2022 at 8:42 AM, V14, RN, handed R108 an Advair inhaler and told R108 to take 2 puffs. V14 did not educate/instruct R108 to wait 1 minute between puffs per manufacture's guidelines. R108 took 2 puffs by mouth one after the other. V14 stated R108 rinses her mouth after she uses the inhaler, but she did not know the manufacture's guidelines to wait 1 minute between puffs. R108's POS, dated 1/1/2022 was reviewed and checked for administration accuracy. The POS showed a physician's order to administer Advair inhaler 2 puffs for allergy symptoms. 3. The facility's administration medications policy and procedure, revised 12/2012, documents policy statement: medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation: medications must be administered in accordance with the orders, including any required time frame. If a dosage is believed to be inappropriate, the person administrating the medication shall contact the resident's attending physician or the facility's Medical Director to discuss the concerns. The individual administering the medication must check to verify the right route of administration before giving the medication. No information was in the facility's policy regarding following medications manufacture's guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately document in the medical record a resident's change in condition which required emergency care for one of one resident (R255) reviewed for documentation in a sample of 48. Findings include: R255's admission Nurse's Note dated [DATE] at 5:01 PM documents report received from local hospital. The Note documented R255 originally came to hospital for Atrial fibrillation (irregular heartbeat). The Note documented R255 was a [AGE] year-old man who, resides at a local nursing home, he was COVID positive as of today and will be coming to facility for 10-day quarantine and then will return to prior facility. The Note documented R255 displays no COVID symptoms, on room air, no respiratory distress. The Note documented R255 is alert to self, has schizophrenia and wanders. On [DATE] at 11:00 AM, R255 was on oxygen per nasal cannula, he was asleep in bed. R255's Physician Order Sheet (POS), dated 1/2022 documents full code/attempt cardiopulmonary resuscitation (CPR.) R255's Nurse's Note, dated [DATE] at 7:59 AM documents R255 passed away at 6:45 AM. The Note documented the coroner was contacted and released the body; family contacted at 7:45 AM. The Note documented the family will contact facility with funeral home arrangements. Coroner needs to be contacted with name of funeral home. Physician notified that resident has expired. R255's Nurse's Note, dated [DATE] at 10:39 AM documents expired. Further review of R255's electronic medical record documents no documentation 911 was called or that Cardiopulmonary Resuscitation was provided. On [DATE] at 6:20 PM V18, Licensed Practical Nurse (LPN) stated he works night shift 7:00 PM through 7:00 AM and was familiar with R255. V18 stated R255 was COVID positive and was admitted to the facility on [DATE]. V18 stated he had a recent pulmonary embolism and required continuous oxygen per nasal cannula. V18 was assigned to R255 on the night of [DATE] into [DATE]. V18 stated at approximately 6:31 AM R255 was not responsive, he was warm to the touch, no respirations, and no dilated pupils. V18 stated R255's fingers and toes were cyanotic (bluish or purplish discoloration.) V18 sated he asked another nurse V22, LPN to assess him. V18 stated V22 called 911 because R255 was not breathing. V18 stated he did a sternal rub, and the resident did not respond. V18 stated he knew R255 was a full code because he looks over resident code status every shift. V18 stated he immediately started CPR; he did 30 chest compressions to 2 mouth breaths. V18 stated he always has a pocket mouthpiece on him and used it while administering CPR. V18 stated V21, Certified Nurse's Aide (CNA) was in the room while he administered CPR but it did not help. V18 stated he did CPR until emergency medical services (EMS) arrived at the facility at approximately 6:40 AM. V18 stated he did not use the facility's crash cart he immediately started CPR. V18 stated he should have documented 911 was called and CPR was administered but he did not because R255 was unresponsive, he had over 6 admissions that shift and he kept calling R255's family to them know of the resident's dying. On [DATE] at 5:50 PM, V22, LPN stated she worked night shift on [DATE] into [DATE] from 7:00 PM through 7:00 AM and was assigned to 200 hall. V22 stated at approximately 6:00 AM, V18 reported something was not right with R255. V22 stated she entered R255's room and he was pale with no signs of life, his mouth was wide open, pupils erect and no respirations. V22 stated V18 initiated CPR and she went to the nurse's station and called 911 and looked up the resident's code status in the computer, he (R255) was a full code. V22 stated by the time she got back to R255's room EMS was at the facility. V22 stated when a resident is found unresponsive you are to document everything you did to treat the resident in the electronic medical record. During an interview on [DATE] at 2:35 PM V8, corporate nurse stated when a resident is found unresponsive staff are expected to document everything, they do for the resident in the resident's electronic record including 9-1-1 was called and CPR was immediately initiated. V8 stated it is very important to document everything that was done so everyone knows what staff did for the resident. The facility's Charting and Documentation policy, revised 7/2017, documents All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Implementation section documents 2) The following information is to be documented in the resident's medical record: a) objective observations; b) treatments or services performed; c) changes in the resident's condition. The Policy documents Documentation in the medical record will be objective, complete and accurate. The Policy documents Documentation of procedures and treatments will include care-specific details including: a) the date and time the procedure/treatment was provided; b) the name and title of the individual(s) who provided the care; c) the assessment data and/or any unusual findings obtained during the procedure/treatment and how the resident tolerated the procedure/treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to clean the CPAP (continuous positive airway pressure) as ordered for 5 of 5 residents (R2, R3, R10, R14, R39) reviewed for respiratory care in the sample 48. Findings include: 1. R2's Minimum Data Sheet (MDS) dated [DATE], documents R2 uses a CPAP. R2's Face Sheet documents his diagnoses include the following: Chronic Obstructive Pulmonary Disease, Other Asthma, Chronic Obstructive Pulmonary Disease with (Acute Exacerbation). R2's Order Summary Report, dated 01/11/22 documents, Place CPAP mask and tubing into a sink with warm soapy water. Use a small amount of mild dish detergent. Agitate these supplies in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all the moisture is gone, every day- shift for CPAP. Start Date: 12/24/21. R2's Care Plan dated 12/30/2019 documents R2 diagnoses Emphysema/COPD and asthma related to history of smoking. The goal for this care plan is, (R2) will be free of signs and symptoms of respiratory infections. Interventions for this focused care plan include staff encouraging R2 to use CPAP. Assist R2 with placement of CPAP and ensure machine is working properly. The Care Plan did not address daily cleaning of the CPAP mask and tubing. R2's December 2021 Electronic Treatment Record (eTAR) documents a START DATE of 12/24/21 at 7:00 AM for the cleaning the of CPAP mask and tubing. The eTAR for 12/24/21, 12/29/21 and 12/31/21 does not document that cleaning the CPAP equipment was completed. R2's January 2022 eTAR for 01/04/22 does not document that cleaning the CPAP was completed. There was no observation of R2's CPAP being cleaned or drying from being cleaned throughout this survey. On 01/07/2022 at 3:45 PM, R2 stated, I am legally blind, I don't know if they clean the machine until they tell me. Sometimes they clean the machine while I am out smoking. I don't think they have a specific time to clean the machine. 2. R3's MDS, dated [DATE], documents R3 uses a CPAP. R3's Order Summary Report, dated 01/11/22, documents, Place CPAP mask and tubing into a sink with warm soapy water. Use a small amount of mild dish detergent. Agitate these supplies in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all the moisture is gone, every day- shift for CPAP maintenance. Start Date: 12/24/21 R3's Care Plan, initiated 5/21/21 and revised 7/2/21, documents the intervention to encourage the use of CPAP. The Care Plan did not address daily cleaning of the CPAP mask and tubing. R3's December 2021 Electronic Treatment Record (eTAR) documents a START DATE of 12/24/21 at 7:00 AM for the cleaning the of CPAP mask and tubing. The eTAR for 12/24/21, 12/29/21 and 12/30/21 does not document that cleaning the CPAP equipment was completed. 3. R10's MDS dated [DATE] documents CPAP usage. R10's Order Summary Report, dated 1/5/22, documents Place CPAP mask and tubing into a warm soapy water. Use a small amount of mild dish detergent. Agitate these supplies in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all moisture is gone, every day shift for CPAP maintenance. Start Date: 12/24/21. R10's Care Plan, dated 5/21/2021, documents to encourage the use of CPAP. The Care Plan did not address daily cleaning of the CPAP mask and tubing. R10's December 2021 eTAR with a START DATE of 12/24/21 at 7:00 AM for 12/24/21 and 12/29/21 does not document that cleaning the CPAP equipment was completed. R10's January 2022 eTAR for 01/03/22 and 01/06/22 does not document that cleaning the CPAP was completed. 4. R14's MDS dated documents R14 uses CPAP. R14's Order Summary Report, dated 01/11/22 documents Place CPAP mask and tubing into a warm soapy water. Use a small amount of mild dish detergent. Agitate these supplies in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all moisture is gone, every day shift for CPAP maintenance. Start Date: 12/24/21 at 7:00 AM. R14's Care Plan dated 12/06/19 documents to encourage the use of CPAP. The Care Plan did not address daily cleaning of the CPAP mask and tubing. R14's December 2021 eTAR documents a START DATE of 12/24/21 at 7:00 AM that for the dates 12/24/21, 12/29/21 and 12/31/21 does not document that cleaning the CPAP equipment was completed. R14's January 2022 eTAR for 01/04/22 does not document that cleaning the CPAP was completed. There is no observation of staff cleaning R14's CPAP or drying from being cleaned throughout this survey. 5. R39's MDS dated documents uses CPAP. R39's Order Summary Report, dated 01/11/22, documents Place CPAP mask and tubing into a warm soapy water. Use a small amount of mild dish detergent. Agitate these supplies is in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all moisture is gone, every day shift for CPAP maintenance. Start Date: 12/24/21 at 7:00 AM. R39's Care Plan, dated 12/06/2019, documents to encourage the use of CPAP. The Care Plan did not address daily cleaning of the CPAP mask and tubing. R39's December 2021 eTAR documents a START DATE of 12/24/21 at 7:00 AM for the cleaning the CPAP and tubing. On the dates 12/25/21,12/26/21 and 12/31/21 does not document that cleaning the CPAP equipment was completed. R39's January 2022 eTAR documents that on the date 01/04/22, the eTAR was not initialed or signed off that cleaning the CPAP and tubing was completed. On 01/07/2022 at 3:15 PM, R39 stated, The nurses do not clean my machine like they should. If they do clean, its' never the same time. My mask is dirty. On 01/11/22 at 9:30 AM, V13, Registered Nurse (RN), observed cleaning R39's CPAP mask and tubing. R39 mask was torn and V13 promised to look at replacing the mask. 01/7/2022 at 3:00 PM, V2, Director of Nursing (DON), stated, The day shift RN is responsible for the cleaning of the CPAP. My expectations are that they are doing that and documenting that it is done. No specialized training required for cleaning the machines. We do expect them to practice good hand hygiene. The settings for the machines are set by the manufacturer according to the doctor's orders and cannot be changed by staff. Nurses are to contact the doctor if a resident refuse to wear the non-invasive mechanical ventilator mask and document that refusal. We do have a backup generator in case of power failure. If there is a malfunction with the machine , staff notify the doctor first and then notify the DON. The DON will contact the manufacturer. On 01/11/2022 at 8:00 AM, V25, Certified Nursing Assistant (CNA), stated, The CNAs don't touch the machines. That is the nurses' job. I have seen the nurse clean the machine. On 01/11/2022 at 8:10 AM, V13, RN, stated, I have cared for most of the residents with a CPAP. I usually clean the machines after med pass. I clean the machines in the resident's room and hang the tubing over the resident sink. The facility's policy on CPAP/BiPAP Support dated 2001 and revised April 2007 documents General guidelines for Cleaning: (1). These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturers/supplier of the PAP device. (2). These guidelines are for single-resident use cleaning. (3) Machines must be preprocessed for use between residents by the supplier of the device. (4). Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Filter cleaning: (a) Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. (b). Replace disposable filters monthly. (6). Masks, nasal pillows, and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. (7). Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry.

Based on observation, interview and record review, the facility failed to date opened insulin pens and to ensure physician's orders have the appropriate route for 4 of 4 residents (R54, R12, R22, R27) reviewed for medications in the sample of 48. Findings include: 1. On 1/6/22 at 8:10 AM, upon investigation of the 300-hall medication cart with V13, Registered Nurse (RN), R54's Restasis (medication for dry eyes) EMU 0.05% is labeled as give one drop by mouth two times a day for dry eyes. During an interview on 1/6/22 at 10:00 AM, V13 stated she noted Restasis route was by mouth on R54's medication bottle and on the electronic medical record but the route should be eye not by mouth. V13 contacted R54's physician. 2. On 1/6/22 at 1:48 PM, upon investigation of the 400-hall medication cart with V14, RN, R12's Humalog insulin was not dated. V14 stated insulin should be dated once opened per manufacturer's guidelines. On 1/6/22 at 1:00 PM, upon investigation of the 300-hall medication cart with V10, Licensed Practical Nurse (LPN). 3. R22's Lantus insulin pen was not dated. 4. R27's Basaglar insulin pen and Humalog insulin were not dated. V10 stated the resident's insulin should be dated when staff open and start using them so they know when they expire. The facility's labeling of medication containers policy and procedure, revised 2020, documents policy: all medications maintained in the facility shall be properly labels in accordance with current state and federal regulations. Policy interpretation and implementation: labels for individual drug containers shall include all necessary information such as the expiration date. The facility's administration medications policy and procedure, revised 12/2012, documents policy statement: medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation: the expiration/beyond use date on the medication list must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to provide residents with food according to their food plan/preferences for 4 of 25 residents (R29, R30, R39, R106) reviewed for food choices in the sample of 48. Findings include: 1. R30's Physician Order Sheet (POS) for January 2022 document an order for vegetarian diet, regular texture, thin liquids. R30's Minimum Data Set (MDS) dated [DATE] document he was cognitively alert for decision making of activities of daily living. R30's Care Plan document he has a potential nutritional problem related to diagnosis of schizophrenia and drug induced dyskinesia. Appetite good. R30's January 2022 Diet Card documents no meat, eggs, and cheese, milk or milk products, Vegetarian. On 1/5/2021 at 1:00 PM, during the group meeting R30 stated he was a vegetarian and did not eat meat and the facility was not honoring his wishes and was serving him the same food as everyone else including meat. R30 stated My family brought in some cans of beans for me and I asked them to get them for me and they just served the meal with no beans and meat. 2. R29's POS dated January 2021 document low concentrated sweets. The POS does not document a vegetarian diet. R29's Diet Card for January 2022 document, Regular Diet: Diet Other: No red meat, cooked vegetables, eggs, breakfast sausage, oatmeal, grits. R29's MDS dated [DATE] document R29 was cognitively alert for decision making of activities of daily living. During the group meeting on 1/15/2021 at 1:00 PM, R29 stated she was a vegetarian and had told the facility she does not eat meat however the facility does not honor her lifestyle and gives the same food as everyone else. R29 stated I have met with dietary and gave them a list of what foods I can eat and she wrote them all down but nothing changed and I get the same meal as everyone else including meat which I do not eat. They give me eggs every day and meat and I do not eat either one of these because I am a vegetarian. R29's Grievance dated 7/8/2021, documents, Dietary, Does not like the food served and this is why she is not eating at the facility. Resident sent in a list of her likes and dislikes. Her food dislikes are on her menu card. The list was attached to the grievance. The list documents R29 will not eat red meat, cooked vegetables, eggs, breakfast sausage, oatmeal, or grits. 3. R39's MDS dated [DATE] document R39 was cognitively intact decision making of activities of daily living. During the group meeting on 1/15/2022 stated food was cold, and facility does not honor food preferences, does not get snacks. I really like fried eggs and I have requested fried eggs and they put on my meal ticket, fried eggs when available however, eggs are never, ever available, how hard is it to get fresh eggs. I cannot even remember the last time I got fried eggs. R39's Dietary Card documents Eggs when available at breakfast. 4. R106's Physician Order Sheet dated 12/18/21 documents R106 is on a regular diet, regular texture thin liquids consistency. No milk or Ice cream. R106's Minimum Data Set, dated [DATE] documents R106 is severely cognitively impaired. On 1/4/22 at 9:00 AM R106 was in his room sitting in his wheelchair. At 9:04 AM R106 stated, The food is not good, and they give me oatmeal every morning, and I have to put milk in the oatmeal. I'm lactose intolerant, and they give me milk. On 1/5/21 at 12:00PM V7 Dietary Manager stated, No I did not know he gets oatmeal with milk. I know he is not supposed to have ice cream and milk. I will go down and talk to him to see if he wants another milk other than cow's milk or if he wants dry fruit loops or something. R106's Meal Card documents a regular diet no milk or ice cream On 1/7/21 the facility did not have a policy on food preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide residents with flavorful and properly cooked food for 5 of 25 residents (R29, R34, R39, R108 and R157) reviewed for palatable food in the sample of 48. Findings include: 1.R39's MDS dated [DATE] document R39 was cognitively intact decision making of activities of daily living. During the group meeting on 1/15/2022 at 1:00 PM, R39 stated, Food is cold and it was even worse now because of COVID we are eating in our rooms and we are served on Styrofoam containers. There is no insulation or anything to keep the food hot. Staff are so busy they do not have time to heat up your cold food and if you ask them, they tell you we do not have time. 2. During the group meeting on 1/15/2022, R108 stated the food is cold and served cold for all of our meals. R108 stated We are eating in our rooms now and they serve us on Styrofoam, and it does not keep the food cold. A lot of times the food is sitting there on the trays waiting for staff to pass the food out. 3. R29's MDS dated [DATE] document R29 was cognitively alert for decision making of activities of daily living. During the group meeting on 1/15/2021 at 1:00 PM, R29 stated the food is cold and staff are too busy and do not want to mess with heating up your plate. R29's Grievance dated 7/8/2021, documents, Dietary, does not like the food served and this is why she is not eating at the facility. Resident sent in a list of her likes and dislikes. Her food dislikes are on her menu card. The list was attached to the grievance. The list documents R29 will not eat red meat, cooked vegetables, eggs, breakfast sausage, oatmeal, or grits. 4.R157's grievance dated 9/7/2021, document, Resident complaint that Food is cold and unable to eat it. State Resolution if possible, Explained to her food hot. Suggested that ask CNA to reheat the food or bring it to dietary and ask to have it warmed it. 5. R34's MDS dated [DATE] document R34 was moderately impaired for cognition. During the group meeting on 1/15/2021 at 1:00 PM, R34 stated the food was cold at most meals, breakfast, lunch and dinner. On 1/15/2021 at V1, Administrator stated there was no policy on food preferences.

Based on interview, and record review, the facility failed to employ a Registered Nurse (RN), 8 hours per day, 7 days per week. This has the potential to affect all 71 residents living in the facility. Findings Include: On 1/4/2022 at 4:34 PM, V1, Administrator, stated, I have been here since October 2021 and we have had corporate in the building working. I am not aware of any issues with not having a RN. We have not had an RN every day consecutively working the floor but we have had an RN working in the building. (V8) was working as the RN. We do not have a full time Director of Nursing (DON) but (V2) is working as the interim DON. On 1/04/2022 at 4:13 AM, V8, Corporate Regional Nurse, stated, I am aware we have been struggling to find an RN full time and meeting 8 hours a day seven days a week. We have been using agency, but it has been difficult. I have not been working the floor. Facility staffing schedules were reviewed dated from 12/22/2021 to 01/04/2022 and fail to document an RN as working on the day, afternoon, and/or night shifts for 12/22/2021, 12/23/2021, 12/26/2021 and 12/30/2021 (4 days no RN coverage). The Facility Assessment Tool dated 11/1/2021 documents staffing needs as 1 Full time DON, 3 nurses for days, evenings and 2 for nights. On 1/7/2022, V8 stated there was no policy on staffing.

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 71 residents living in the facility. Findings include: 1.On 01/04/22 at 8:58 AM, during the initial tour of the facility's kitchen freezer, the temperature gauge read 5 degrees Fahrenheit (F). Upon opening the freezer door icy condensation was noted on the flaps leading into the freezer. A block of ice approximately 4 inches long had formed in the upper right corner of the flaps. The meat on the middle and bottom shelfs remained frozen solid. The frozen vegetables on the top shelves also remain frozen solid. None of the freezer foods in the freezer were noted in a thawed or thawing state. On 01/04/22 at 9:15 AM, V7, Dietary Manager stated, The freezer needs a seal around the door. I notified maintenance and the administrator. The maintenance man is out sick, and I do not have access to his records. The door seal has been missing for about a month. I do not have a record of the request to have the freezer door repaired. I normally just call him and leave it up to maintenance to do it. On 01/11/22 at 9:00 AM V12, Regional Director of Operations stated, My expectations are that the Dietary Manager report the problem immediately to the Maintenance Supervisor or to the Administrator. Asking staff to chip the ice off the flaps is not a long-term solution. If it is training a staff to close the upper lock, I would expect that to have occurred. I will look into it. 2. On 01/06/22 at 9:45 AM, during the follow-up kitchen tour, the oven was not in working order. On 01/06/22 at 9:45 AM, V7 stated, We only have one oven working. The other oven has been out for about 3 weeks. I contacted maintenance and he ordered a part for it, but it was the wrong part. So, we are waiting for the right part to come in. Only having one oven, slows us down a bit but we have been able to manage. No, I do not think the residents have been impacted by the facility having only one working oven and the freezer needing a door seal. 01/11/22 at 8:20 AM V24, Regional Maintenance Director stated, I don't have maintenance logs for the appliances. I mostly take care of the things on the outside, like the condenser. (V7) usually calls me to let me know what needs to be repaired. I was not informed about the refrigerator because it is not broke. Usually, staff will go in and just break off the ice that is forming. No that is not fixing the problem. There is a hook at the top of the freezer that closes the door. Staff will need to take time to make sure that lock is engaged. I ordered a part for the oven, and it was the wrong part. I reordered the part and it is on backorder, we have no idea when it is coming in. On 01/11/22 at 11:30 AM V13 Regional Director of Operations stated, We do not have a policy on the Maintenance of freezer or oven. 3. On 01/04/22 at 8:58 AM during the initial tour and follow-up tour on 01/06/22 at 9:30 AM of the kitchen the following dry foods were found opened and did not contain an open or expiration date: 1. (2) bags of Panko breadcrumbs opened and enclosed in a 1-gallon storage baggie. 2. (3) 17.5 ounces/ pack of soft Taco Shells in original packaging. 3. (2) 32-ounce bags of powdered sugar open and enclosed in a 1- gallon storage baggie. 4. (1) 10 lb. (pound) of bacon bits in its original packaging and had no closure ties. 5. (1) bag of 16-ounce coconut flakes were opened, enclosed in a 1- gallon storage baggie. 6. (1) bag of 32 ounces raisins was open and enclosed in 1-gallon storage baggie. 7. (1) 10 lb. bag of pasta in its original packaging open and spilling onto floor. 8. (1)10 lb. bag of open Macaroni in its original packaging. On 01/04/22 at 8:58 AM during the initial tour and follow-up tour on 01/06/22 at 9:30 AM the following refrigerated items were found to be unlabeled and/or without an open or expiration date: 1. (3) 1- gallon pitchers with liquid (1 red, 1 orange and 1 brown) were no labeled with a date. 2. (1) 1-gallon container of ranch dressing. The policy on Food and Storage dated 2001 and revised July 2020 documents: Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: dry foods that are stored in bins will be removed from original packaging, labeled and dated. 4. On 1/6/2022 at 8:10 AM, a crate full of unpasteurized shell eggs was on a tray on the third shelf in the walk-in refrigerator. There was a 10-pound box of yellow onions sitting directly below the eggs on the bottom shelf. The eggs were not being stored below the onions. On 1/16/2022 at 8:15 AM, V7, Dietary Manager stated, The eggs are raw, but they do not stay there on that shelf I just moved them over. We just put them there while we are serving in case, we need to get to them. We will put them back when we are done serving breakfast. On 1/6/2022 at 8:17 AM, when asked what (V7) would do if the eggs when cracked were dripping on the onions during the breakfast service she did not reply to the question or answer the question. On 1/6/2022 at 9:38 AM, V7 stated, eggs should always be stored below the onions. 5. On 1/7/2022 at 8:35 AM, in the kitchen was a large industrial clear tub with no date or label on it that appeared to be some type of grain. On 1/7/2022 at 8:36 AM, V15, [NAME] stated the item in the tub was oats. On 1/7/2022 8:37 AM, The top of the stove had hand protection laying on top with lots of crumbs, and dust. On 1/7/2022 at 8:38 AM, above the stove there were 2 lights that were covered in grease and were slimy in appearance with dust clinging to them. The vents above the stove were greasy and dusty. On 1/7/2022 at 8:42 AM, inside the microwave there was a used paper towel and grease lines on the inside of the door and dried crumbs on the bottom of the microwave. On 1/7/2022 at 8:43 AM, inside the refrigerator was a metal pan with turkey breast lunch meat that was 2 pounds, 23 ounces and was dated 12/21/2021. Next to it was a clear 4-quart container with orange cheese slices. The cheese container was not dated or labeled. On 1/7/2022 at 8:44 AM, in the refrigerator there was a clear plastic bag with margarine that was partially opened and was not dated or labeled. On 1/7/2022 at 8:45 AM, on the top shelf in the walk-in refrigerator was 2 Styrofoam cups with lids on them but no date or label. On 1/7/2022 at 8:47 AM in the refrigerator the shelving unit had dried substances on the racks. On 1/7/2022 at 8:46 AM, inside the freezer was a large industrial tray of fish with parchment paper placed on top. Not all of the fish was being covered and with the circulation of the freezer the parchment paper was being blown and the fish was being exposed to the air. On 1/7/2022 at 8:48 AM, in the dry storage area there was a bag of baking chocolate that was opened and not sealed, a 32-ounce bag of opened powder sugar bag 32 ounce- approximately 20 ounces left, not sealed or put into other containers and was exposed to air. On 1/7/2022 at 8:51 AM, in the dry storage area there was a gray package 14 ounce, opened with no date or label. On 1/7/2022 at 8:52 AM, there was a large 10-pound box of bacon bits that were opened and not closed and was exposed to the air. The Food Receiving and Storage Policy dated 2001 with revision date of July 2020 documents, Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will always maintain clean food storage areas. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. Such foods will be rotated using a first in - first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Wrappers of frozen foods must stay intact until thawing. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. Beverages must be dated when opened and discarded after twenty-four (24) hours. Other opened containers must be dated and sealed or covered during storage. 6. The Facility's Resident Census and Census and Conditions of Residents form, CMS 672, dated 01/05/2022 documented the facility had a census of 71 residents.

Based on interview and record review the facility failed to develop an ongoing infection control program that collects data to calculate and analyze infection rates and failed to implement infection control procedures that prevents the spread of COVID-19 and other infections. This has the potential to affect all 71 residents living in the facility. Findings Include: 1.On 1/5/2022 at 9:01 AM, documentation regarding how the facility identifies, analyzes data, and provides surveillance of infections within the facility was requested for the past year including pathogens and organisms. The October 2021 infection and antimicrobial log/surveillance Log provided by the facility only documented 6 residents with one urinary tract infection documented. 2. R25's Physician Order Sheet (POS) for the month of October 2021 document he was on nitrofurantoin macrocrystal capsule 100 milligrams (mg) by mouth two times a day related to urinary tract infection (UTI). R25's information regarding R25's UTI was not on the October 2021 Infection and Antimicrobial Log/Surveillance Log. 3. R54's POS for the month of November 2021 document R54's was receiving Bactrim Double Strength 800 to 160 milligrams (MG) (Sulfamethoxazole Trimethoprim) give 1 tablet orally two times a day every 1 day (s) for UTI until 12/4/2021, 8:00 PM 1 tablet by mouth two times a day for 5 days. (Start date 11/29/2021). R54's information regarding R54's UTI was not documented on the Infection Control Log for the month of November 2021 including the causative organism which caused R54's infection. 4. R35's POS for the month of November 2021 document he was on Keflex Capsule 500 mg one tablet four times a day related to cellulitis of other sites. R35's information regarding R35's infection was not documented on the Infection Control Log for the month of November 2021. R35's Medication Administration Record (MAR) for the month of November 2021 documents R35 was to receive Keflex capsule 500 mg (cephalexin) give 1 capsule my mouth four times a day related to cellulitis of other sites. R35's MAR document he received all doses. 5. R21's August POS document R21 was to Keflex Capsule 500 mg (cephalexin) give 500 mg by mouth three times a day for UTI. R21's MAR for August document Keflex Capsule 500 mg (cephalexin) give 500 mg by mouth three times a day for UTI with a start date 8/21/2021. There was no information on the August 2021 Infection Control log regarding R21 having a UTI or the causative organism causing the infection. 6.On 1/7/2021 at 12:47 PM, the facility provided a list of residents with COVID-19 for December 2021 and the following residents R50, R51, R155 and R265 were documented as having COVID-19. The December 2021 Infection control log did not document R50, R51, R155 and R265 as having COVID-19 infection. On 1/5/2021 at 4:30 PM, V8, Corporate Nurse, stated, I know there are a lot of holes with the infection control log. I just started doing it and I am trying to get it up and running. On 1/6/2021 at 1:07 PM, V2, interim Director of Nursing stated, I would expect all organisms to be documented on the infection control log. The person in charge of that is no longer working with us and (V8) has just recently picked up doing the log. The Antibiotic Stewardship Log dated January 2018 document, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The Infection Preventions will conduct ongoing surveillance for Healthcare Associated Infections (HAI's) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 7. On 1/4/22 at 10:00 AM, when entering the Persons Under Investigation Unit (PUI), you entered through a door. There was no signage on the door regarding isolation procedures and required Personal Protective Equipment (PPE). There was a plastic drawer system for PPE as you entered the unit. There were no gloves available. On 1/6/22 at 12:00 PM, when entering into the COVID-19 unit. There was a plastic sheet that you entered. Behind the plastic sheet was an area containing a plastic drawer system for PPE. There were no gowns or gloves available. There was no signage outside the COVID-19 unit regarding isolation procures and required PPE. On 1/6/22 at 12:00PM, V16, Certified Nursing Assistant (CNA) stated There are no gowns or gloves out there. On 1/6/22 at 12:05 PM V3 Assistant Director of Nursing stated, I don't know why there are no gloves out there. On 1/6/22 at 2:00 PM V2 interim Director of Nursing stated, We had signage on all of the doors. I don't know where they went. V2 stated We always keep extra gowns in the bottom of the cabinet in the bubble (COVID-19 unit). The facility's Resident Grievance/ Concern Follow-up Form dated 4/27/21 documents the isolation bins were not stocked outside the PUI ( person under investigation) rooms. The Infection Control Policy COVID-19 with a revision date of October 2021 document, Post signs on the door or wall outside of the resident room and/or dedicated unit that clearly describe the type of precautions needed and required PPE (Personal Protective Equipment). Make PPE, including facemasks, eye protection, gowns and gloves, available immediately outside of the resident room when it's determined PPE is needed for the resident. PPE optimization will be used as recommended by the CDC (Center for Disease Control). 8.The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 1/5/22, documents there were 71 residents living in the facility.