Based on observation, interview and record review, the facility failed to ensure that staff administer ordered pain medications to residents according to resident's needs and as outlined in their care plan and failed to ensure that resident's medications readily available. These failures affected two residents (R1 and R2) of four residents reviewed for pain management and have the potential to affect all 45 residents on the first floor of the facility. This failure resulted in R1 and R2 missed multiple doses of about 9 different pain medications while at the facility. Findings include: 1.R1's diagnosis includes, but are not limited to Malignant neoplasm of bone and articular cartilage, secondary malignant neoplasm of other parts of nervous system, anemia, benign prostatic hyperplasia without lower urinary tract symptom, wedge compression fracture of first lumbar vertebrae, osteomyelitis unspecified, etc. On 6/23/2025 at12:20PM, R1 was interviewed, and he said that his pain is not being managed because of how staff give his medications, he would like to have something in between Norco, staff always tell him that he is not due for Norco, and they cannot give him anything else. R1 said that they always run out of his lidocaine patch, he did not get any patch this morning, that is supposed to help with his neck pain. Active physician order summary for R1 showed the following: 1. Lidocaine External Patch 4 % (Lidocaine) apply to neck topically in the morning for Take off at 6PM related to acute hematogenous osteomyelitis, multiple sites, order date 6/12/2025. 2. Hydroxyzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 12.5 tablet by mouth every 8 hours as needed for Anxiety for 14 Days, order date 6/17/2025. 3 Gabapentin Oral Capsule (Gabapentin) Give 100 mg by mouth every 12 hours as needed for pain AND Give 200 mg by mouth every 24 hours as needed for Pain. Order date 6/12/2025. 4. Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain moderate to severe. Order date 6/18/2025. 5. Acetaminophen Oral Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for Pain R1's Medication administration record (MAR) for the month of June 2025 showed the following documentations: Lidocaine patch was not signed as given on 6/14/2025, 6/20/2025 and 6/23/2025. Hydroxyzine signed out as given once, on 6/15/2025, Hydrocodone was not given on 6/12, 6/13, 6/14 and 6/17/, 6/19, 620, 6/21, 6/22 and 6/23/2025. Tylenol was given once on 6/13, 6/17 and 6/18/2025. Gabapentin was never signed out as given from the date it was ordered. On 6/23/2025 at 12:27PM, V3 (LPN) said that she did not remove any lidocaine patch from R1, the Surveyor informed V3 that R1 said he did not get his lidocaine patch this morning and does not have any on him right now. V3 then said, we have some house stock, I can go give him one now. On 6/23/2025 at 2:00PM, V2 (DON) was presented with all the days R1 did not get his pain medications and she said that R1 he was getting his pain medications, the nurses are probably documenting only in the narcotic sheet and not in the MAR, medications are supposed to signed out both in the narcotic count sheet and MAR when given. On 6/25/2025 surveyor reviewed medication supply for R1 with V10 (LPN) and noted that R1 did not have any gabapentin or hydroxyzine. V10 said that she could not find any, she will search more in the medication cart for it. At 2:18PM V10 told the surveyor that she did not find any gabapentin or hydroxyzine for R1. On 6/25/2025 at 3:11PM, V2 (DON) was presented with R1's missing gabapentin that was delivered on 6/13/2023, but never signed out as given in the MAR and she said that staff probably ran out, the medication is being re-ordered today. Surveyor asked V2 if she was aware that none of the delivered 30 tablets of gabapentin was signed out as given to R1 in his MAR and none is on hand at this time, she said yes. Facility could not provide any documentation that R1 received any gabapentin since it was ordered. 2. R2's medical diagnosis includes, but are not limited to Unilateral primary osteoarthritis, right knee, generalized muscle weakness, unspecified abnormalities of gait and mobility, lack of coordination, presence of right artificial knee joint, etc. On 6/23/2025 at 11:25AM, R2 was observed in his room, awake and alert and stated that he came to the facility after a knee surgery, the facility is not controlling his pain, he was supposed to be getting Norco for pain, but has not been getting it consistently, the last time he received his Norco was last Thursday, 6/19/2025. R2 said that he is in pain right now and rated his pain as 8 on a scale of 1 to 10. R2 have the following listed in physician order summary: 1. Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for pain, order date 5/30/2025. 2.Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 5 mg by mouth one time only for severe pain for 1 Day. Order date 6/5/2025. 3.Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug*Give 1 tablet by mouth every 12 hours as needed for Pain, order date 6/23/2025. 4.Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathic pain, order date 5/30/2025 discontinued 6/3/2025. Gabapentin Tablet 600 MG Give 1 tablet by mouth as needed for Pain related to presence of right artificial knee joint, three times a day. Order date 6/3/2025. On 6/23/2025 at 12:03PM, surveyor informed V2 (DON) that R2 has been waiting for pain medication and the other nurse on the floor said that his assigned nurse is on break. V2 said that she will follow up on that, the nurse should be returning from break shortly. On 6/23/2025 at 12:35PM, surveyor followed up with R2 who stated that he still did not receive any medication, no one has been to his room. Surveyor spoke to a staff who was sitting at the nursing station V4 LPN) she said that she is the assigned nurse for R2, she was told that resident needed pain medication, she just spoke to the nurse practitioner who said that she will fax a new prescription to pharmacy. V4 added that she will go and pull a dose for the resident from the emergency box. Review of June MAR for R2 showed that his Norco was last given on 6/19/2025 as the resident said, there is no documentation that R2 was medicated for pain on 6/23/2025. R2's gabapentin 600mg was recorded as given once or twice some days, but not given at all on 6/3/2025, 6/4/3035, 6/6/2025, 6/8/2025. 6/9/2025, 6/15/2025, 6/18/2025 and 6/19/2028. There was no entry for tramadol in R2's MAR, or any documentation that R2 was receiving tramadol. On 6/23/2025 at 2:00PM, V2 (DON) said that R2 likes his pain medication, and he runs out, resident's pain medication is supposed to be reordered. 6/23/2025 at 3:30PM, V2 said that the nurse practitioner gave the nurse an order to give R2 tramadol until his Norco is refilled. The NP faxed a new order to pharmacy on the 19th, not sure why it was not delivered. On 6/25/2025 at 11:35AM, surveyor presented R2's MAR to V2 (DON) that did not list any tramadol, and did not have any documentation that R2 was receiving any tramadol and she said, The nurse received an order to give resident tramadol when he ran out of Norco, she just forgot to put the order in or document it in the MAR. V2 added that all medications residents receive are supposed to be documented in the MAR, and signed out when given, the nurse just forgot to do that. On 6/25/2025 at 12:29PM V15 (Nurse Practitioner) said that R2 came to the facility from the hospital post right knee arthroplasty, V15 did a script for his Norco to be refilled on 6/20/2025 and faxed it to pharmacy, not sure why the medication was not delivered. V15 gave an order to give resident tramadol until the Norco comes. Surveyor informed V15 that there is no documentation that R2 was receiving any tramadol in the medication administration record. She said, that part will be for the DON, I am just the NP, all resident medications are supposed to be documented in the medication administration record and signed out when given. Medication administration policy revised 4/2024 states in part: All medications are administered safely and appropriately to aid residents to overcome illness, relive and prevent symptoms and help in diagnosis. Licensed staff will administer medications as ordered by the physician. Under guideline, the policy states, #18 document as each medication is prepared in the medication administration record (MAR). #24, Document reason and response for any PRN medications. Job description for registered nurse and licensed practical nurse (undated) states in part: Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, -----------------, and adherence by staff members to facility policies and procedures. Essential duties #3, Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuous basis. #10. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures.

Based on observation, interview and record review the facility failed to ensure that emergency cart, treatment cart was locked when not in proximity of the nurse and individual medications were locked up safely in the medication cart to prevent tampering and accidental hazard. This failure affected 2 of 2 residents (R3 and R1) in the sample reviewed for medication administration. Findings include: On 06/04/25 at 10:13am, the treatment cart noted in the hallway unlocked and unattended to by Room105. V7 LPN (Wound Care Nurse) confirm that it was the treatment cart stating that it is the treatment cart with treatment medications. V7 stated that the facility policy is to have it locked when not at eyesight level and not in use. At 10:40am, V2 (DON) stated that the treatment cart should be locked when not in visual contact of the nurse. V2 stated that V7 (treatment nurse) has told me about it (not locking the cart). I told her lock to the cart always when not in the eye contact with the cart. On 06/04/25 at 11:24am, crash cart noted in the hallway in front of the elevator unlocked with two plastic locks broken and left on the crash cart. When shown to V20 LPN (Licensed Practical Nurse). V20 stated the cart should be locked always with the red plastic lock so that no one can get into it. V20 stated I did not use the cart this morning and it should be locked; I turned the gray lock but that can be easily turned to unlock. The lock is to make sure that no one can get into its residents /visitors. On 06/05/25 at 11:03pm, R3 noted in the room in bed at the bedside noted 3pills in the medication cup at the bed side. R3 was unable to identify the pills. At 11:09am, from the hallway noted R11 had medication cup on the over bed side table. Upon entering the room there were 8pills noted in the medication cup. R11 stated that the nurse (referring to V9 (LPN) gave him the medications this morning and will have to take it later. At 11:11am, When the surveyor observations were shown to V9 LPN (Licensed Practical Nurse) and was asked about the facility policy for medication pass. V9 stated that the medications for R11 was this morning medication and while having conversation with R11 she forgot to give them to R11 and make sure he took them (Medicine). V9 stated that she should not have signed the MAR (Medication administration Record) has given. V9 checked the POS and the MAR with the surveyor R3's medication that was left at the bedside and told the surveyor that the medication found at R3 bedside is not left on the side table dresser by her and did not know how R3 got the medicines. V9 stated the medications look like tums and stool softener but R3 did not have any order for the medicines. And they should not be left at bedside unless ordered by the doctor to do so. On 06/05/25 at 11:24am, V10 (Nurse Supervisor) stated that we (nurses) not supposed to leave medication at bedside unless ordered by the doctor and the medication should not be signed out as given until after the resident has taken the medication. At 11:42am, V3 ADON (Assistant Director of Nurse's) stated that he cannot for word for word quote the facility policy, but the expectation is for the nurses to follow administration policy and one of it is to observe the patient (resident) take the medicine (Swallow) a document right after it is taken. V3 stated that no medication should be stored at bedside without an order and resident assessment that resident can self-administer. The facility policy on Crash Cart presented with revised date 04/2025 documented that in general the policy is to provide the staff with guidance on Crash cart contents and monitoring. Listed purpose indicated that the Crash Carts are set up for type of life-threatening event expected to occur in this facility (i.e., cardiac, anaphylaxis). Protocol listed includes crash cart will be checked daily by night nurse and department manager; verify the crash cart has not been opened since the previous day by verifying tag number against crash cart checklist. The facility policy Self-Administration of Medications and treatments presented with review date 12/2021 documented that self-administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. Facility policy on Medication Storage in the Facility presented with review date 6/2024 documented in general that medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Responsible party listed nursing. Listed procedure includes but not limited to medication carts and medical supplies are locked or attended by person with authorized access that includes licensed nurses. Facility policy on Medication Administration presented with review date 3/2022 documented in general that all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of responsible party are RN (Registered Nurse), LPN (Licensed Practical Nurse). Listed guidelines includes but not limited to remain with the resident to ensure that the resident swallows the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that resident personal washroom was equipped with toilet tissue/rolls in a timely manner in the resident's bathroom for personal hygiene. This failure affected 4 of 4 residents (R4, R6, R7 and R12) reviewed for personal hygiene equipment toilet rolls. Findings include: On 06/04/25 from 10:13am to 11:30am, the following observations were made: At 10:23am, R7's clothing noted on the bare floor R7 stated they are dirty clothes and stated he has no plastic bag to put the clothes Complain of not having toilet paper in the toilet for days at a time. At 10:42am, on the 1st floor, 1 south room [ROOM NUMBER], room floor noted with yellowish dry colored particles and orange peels. At 10:47am, V15 CNA stated the resident must have spill something, its dry possibly from previous shift. I am the CNA for this morning and the floor has been like that. On the 3floor at 10:54am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. At 10:56am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. At 10:58am, room [ROOM NUMBER], noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. In the same room garbage can with overflowing garbage and used adult incontinent diaper. room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. When all these observations were shown to V16 LPN (Licensed Practical Nurse) she stated that the housekeeping are responsible for replacing the toilet tissue and hopefully they will be getting to it, most of the garbage in the can are not from this shift. The surveyor asked who takes care of the garbage, V16 stated the housekeeping staff but those incontinent diapers should not be left in the room garbage. 06/04/25 at 11:03am, V18 (Housekeeping Director) stated that I (18) came in late this morning, but the rooms are supposed to be cleaned daily, and they are on it now. As for the toilet papers they (Housekeeping staff) are stocking up now. In no time now, all the rooms will be stocked. At 11:22am, in room [ROOM NUMBER] observed no tissue in the bathroom toilet. R4 noted sitting on the edge of the bed. R4 stated for two days now there was no tissue in the bathroom. They (housekeeping staff) came to clean it up but there is no tissue left. I don't know how they want us to wipe off our butt. room [ROOM NUMBER] shared the same bathroom with room [ROOM NUMBER]. On 06/04/25 at 2:06pm, V12 LPN (Licensed Practical Nurse) stated that the housekeeping staff usually are responsible for placing new tissue in the toilet room (washroom). V12 stated no extra tissue papers (rolls) are kept here (Nurse's station) but there should be plastic bags for room cabbage cans left at the Nurse's station. On 06/05/25 at 9:36am, V18 (Housekeeping Director) stated that the housekeepers are to stock up supplies during the cart preparations. The housekeeper for each floor is to stock up the rooms daily in the morning but sometimes they do and sometimes they do not. At times when budget run over it depends then I will put only one roll in the room. On weekends we leave supplies for the staff because I don't work on weekends. V18 stated I (V18) leave it on Friday before I leave. There are 96rolls in each box. The residents are not supposed to run short of toilet rolls, every room must have a supply very day. the surveyor asked do the staff that includes nursing staff have access to where toilet supplies are always kept. V18 stated only the housekeeping staff have access to the housekeeping storage unless there is a manager in the building. The surveyor then asked whether it Is appropriate for residents to be out of toilet tissue and what other plans are in place for them to clean up after using the bathroom. V18 stated logically they can use the towel (cloth towels) to wipe. V18 stated they (towels) are not stock in the bathroom for that purpose. 0n 06/05/25 at 1:49pm, V18 stated that there is no standard policy or SOP (Standard of Operation) given to us by the company, the only thing I (V18) have is the daily housekeeping check list from the hold company. Since the name change I (V18) don't have any policy on housekeeping from the new company. On 06/05/25 at 3:40pm V1 stated that the housekeeping keys will be left at the front desk so there should be no problem with the toilet roils any more, I know we should do better. We have problem with staff taken them home, we will do better.

Based on observation, interview and record review, the facility failed to maintain an available manual resuscitator and failed to provide timely suctioning care for two (R1 and R6) out of three residents with a tracheostomy. Findings include: According to the electronic health record, R1 has diagnosis including s/p tracheostomy, g-tube placement, hypertension, hyponatremia, anemia, sacral decubitus ulcer, chronic respiratory failure, and gastroparesis. R1 is nonverbal. On 3/21/2025 at 9:40 AM, R1 was observed asleep, tracheostomy attached to oxygen concentrator; tracheostomy collar appears clean and dry, no secretions present at the entrance of the tracheostomy tube observed. Manual resuscitator was not available at the bedside. V2, Director of Nursing (DON) confirmed that a manual resuscitator (a handheld medical device used to manually ventilate a patient who is not breathing or is breathing inadequately, often used in emergency situations like cardiac arrest or respiratory failure) was not available at the bedside. V2 further stated that there should be a manual resuscitator always at the bedside of residents with tracheostomies because in an event of an emergency the manual resuscitator is used to manually provide oxygenation to the resident. V2 stated that the facility also has a respiratory treatment cart that has a manual resuscitator and that she is not sure why R1's manual resuscitator is not at the bedside but that she will place a manual resuscitator in R1's room right away. On 3/21/2025 at 9:58 AM, V3, Licensed Practical Nurse, stated that lately she has noted that R1 has been having a lot of secretions so V3 has been suctioning R1 more frequently. V3 stated she had cleaned and changed R1's inner cannula, and that V3 had suctioned R1 once already today. V3 stated that she suctions R1 4 to 6 times during her shift at least. V3 stated that there should always be always a manual resuscitator available in R1's room because in an emergency, the manual resuscitator is used to provide oxygen to R1 for respiratory distress. According to the electronic health record, R6 has diagnosis including cerebrovascular accident, traumatic brain disorder s/p evacuation of subdural hematoma and left occipital lobe epidural hematoma, paraplegia, nonverbal, tracheostomy and gastrostomy tube in place. R6 is non interviewable and is nonverbal. R6's Physician Order Sheet includes a physician order dated 2/8/2025 that documents: Suction as needed. On 3/21/2025 at 2:50 PM, R6 was observed coughing and was noted with obvious thick secretions at the entrance of R6's trach(tracheostomy) tube. V6, Licensed Practical Nurse (LPN) was also at R6's bedside, cleaned the secretions around R6's trach tube but did not suction R6. On 3/21/2025 at 3:00 PM R6 was observed coughing again and additional thick secretions were noted at the entrance of R6's trach tube. V6 stated that she had just suctioned R6 around 11:00 AM and that she would have to check R6's suction orders but that she is pretty sure it is every 3 hours and as needed but not any sooner than every 3 hours. On 3/21/2025 at 3:11 PM, R6 was observed with thick secretions at the entrance of his trach tube. V6 was at the nurses' station and stated that she had not checked R6's orders for suctioning the tracheostomy. V6 stated she would go to the bathroom first and then check the order for R6. On 3/21/2025 at 3:18 PM, while waiting inside R6's room, R6 was observed coughing again and more thick secretions can now be observed at the entrance of R6's trach tube. On 3/21/2025 at 3:28 PM, V6, Licensed Practical Nurse, was observed walking in the hallway past R6's room. V6 did not check R6, nor did she suction R6. On 3/21/2025 at 3:30 PM, surveyor summoned V7, Nursing Supervisor to R6's room to check R6's SPO2 level. V7 stated R6's SPO2 (Saturation of peripheral oxygen which indicates how much oxygen your blood is carrying compared to its maximum capacity. A healthy SPO2 level is typically between 95% and 100%) is 89%. V7 affirmed that R6 needed to be suctioned. V7 affirmed that R6 had thick secretions at the entrance of R6's trach tube and needed to be suctioned. V7 stated that if there are secretions around and at the entrance of R6's trach tube, it is her expectation that the nurse would suction R6 right away since aside from the order for scheduled suctioning, R6 also has an order for PRN (as needed) suctioning. V2, Director of Nursing, also stated that it is her expectation that the nurse will suction the resident right away. V2 stated that she will suction R2 right now. Informed V2 that I have been observing R6 with thick secretions at the entrance of his trach tube since 2:50 PM and that V7 stated that R6's SPO2 level is now only 89%. V2 stated that the nurse should have suctioned R6 right away. Facility Tracheostomy Care policy dated 4/2019 documents in part: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway, that aseptic technique is used during the dressing changes until the tracheostomy is healed, and a physician order is obtained for tracheostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects two (R68, R78) of three residents in the sample for 25 reviewed for accommodation of needs. Findings include: On 02/25/25 at 11:23 AM, R78 observed in bed, with call light behind curtain on top of dresser. On 02/25/25 at 11:24 AM, R68 observed in room with call light behind curtain on top of dresser, R68 said she could not reach it, said it is usually next to her. On 02/25/25 at 11:27 AM, V25 (Restorative aide) made aware of above findings and said that call lights should be within reach, not sure why they were on top of dresser. On 02/26/25 at 1:25 PM, V3 (Director of Nursing) said her expectations for residents call lights are to be within reach at all times and answered promptly. R68 admitted on [DATE] with diagnosis in part but not limited to encounter for surgical aftercare following surgery on the digestive system, bacteremia, hyperlipidemia, diabetes type 2 mellitus without complications, depression. A focused care plan requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) indicated intervention: keep call lights within reach when in bedroom or bathroom. R78 admitted on [DATE] with diagnosis in part but not limited to aphasia, history of falling, hyperlipidemia, other seizures, essential hypertension. A focused care plan requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) indicated intervention: keep call lights within reach when in bedroom or bathroom. Facility's Policy on Call Light Response revised 9/2024 General: To provide the staff with guidance on responding to resident's response and needs. Protocol: 3. Ensure call light is within residents reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide nail and foot care to dependent resident. The facility also failed to incontinence care to dependent and incontinent resident in a timely manner. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Activity of daily living (ADL) Program. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 10:14AM, Observed R108 with V15 CNA (Certified Nurse Assistant) and V14 WCN (Wound Care Nurse) lying in bed. V15 and V14 preparing R108 for wound care treatment. Observed bilateral hands with long and dirty fingernails, bilateral toenails are long thickened and discolored. Both said that CNAs are responsible for nails care and for foot care they usually referred resident to podiatrist. V15 CNA then opened disposable brief of R108 soaked with feces. V15 turned him to his left side, observed disposable brief saturated with fecal matters and leak into the bottom sheet. The sacral wound dressing is contaminated with fecal matters. On 2/25/25 at 1:00PM, Informed V3 DON (Director of Nursing) of above observation, V3 said that CNAs are responsible for nail care as needed during daily ADLs care. The social services are responsible for scheduling resident for podiatrist consult. On 2/26/25 at 1:23PM, Informed V3 of above observation made before wound care that R108 was soaked with feces. V3 said that prolong exposure of wetness, urine or fecal matters are factors in impaired wound healing or worsening of wound. R108 is admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure, Acute kidney failure, Tracheostomy status, Stage 4 Pressure ulcer of sacral region, Gastrotomy status, Cerebral infarction, Intracranial hemorrhage. Comprehensive care plan indicates he has an ADL self-care performance deficit and impaired mobility. Intervention: Personal hygiene and grooming- total assistance. MDS /Resident assessment dated [DATE] indicated Section GG0130 Self-care functional abilities: Toileting and Personal hygiene- 01 (Dependent). Facility's policy on Nail care reviewed 9/2024 indicates: General: To provide care and maintain hygiene the resident's nails. Guideline: 6. Nail care is offered and performed on the resident's shower day and as needed. Facility's policy on Foot care revised 9/2024 indicates: General: Foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown, and promote healing. Guideline: 1. Foot care is provided routinely with the bath and prn. It may also be done more frequently with a physician or nurse practitioner order. Facility's policy on Incontinence care revision date 4/2024 indicates: General: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Facility's policy on ADL (Activities of Daily Living) reviewed 9/2024 indicates: General: 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. 1. The ability of each resident to meet the demands of daily living is determined by licensed Nurse. 2. A program of assistance and instructions in ADL skills is care planned and implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement measures to prevent resident from acquiring pressure ulcer in the facility and updated wound care plan intervention. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Wound/Pressure Ulcer Prevention and management. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. V18 said that R108 developed pressure ulcer on sacral area since last year and still not healing. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 10:14AM, Observed R108 with V15 CNA (Certified Nurse Assistant) and V14 WCN (Wound Care Nurse) lying in bed. V15 and V14 preparing R108 for wound care treatment. V15 CNA then opened disposable brief of R108 soaked with feces. V15 turned him to his left side, observed disposable brief saturated with fecal matters and leak into the bottom sheet. The sacral wound dressing is contaminated with fecal matters. On 2/26/25 at 1:23PM, V3 ADON (Assistant Director of Nursing) said that he is also the wound care Director. He oversees the wound care management for the residents. He said that R108's Braden scale/skin assessment upon admission and most recent assessment indicated that he is at high risk for skin impairment. He has acquired pressure ulcer on sacral area on 10/29/24 full thickness, measures 7cm x 13cm x 0.10cm, 60% deep maroon and 40% bright beefy red tissue, scant amount of serosanguinous drainage, maceration, and bogginess on peri wound area. Reviewed R108's comprehensive wound care plan. Informed V3 that wound care plan intervention was not updated when there was an acquired new pressure. V3 said that he did the wound assessment on 10/29/24 and did not update the intervention because he has already intervention in placed. Informed V3 that their policy indicated that each new wound identified, after assessment and informing physicians for new treatment orders, care plan intervention has to be updated. V3 said R108's most recent wound assessment dated [DATE] indicated Stage 4 pressure ulcer on sacral area, full thickness, and tissue loss, in- house acquired, measures 5cm x 2.9cm x 0.3cm, 30% epithelial tissue, 20% granulation, 50% slough formation, moderate serosanguinous drainage, attached edges. Informed V3 of above observation made before wound care that R108 was soaked with feces. V3 said that prolong exposure of wetness, urine or fecal matters are factors in impaired wound healing or worsening of wound. R108 is admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure, Acute kidney failure, Tracheostomy status, Stage 4 Pressure ulcer of sacral region, Gastrotomy status, Cerebral infarction, Intracranial hemorrhage. Comprehensive care plan indicates he has actual and potential for skin impairment. Intervention: Keep skin and dry. Prompt incontinence care. He has an ADL self-care performance deficit and impaired mobility. Intervention: total assistance. MDS /Resident assessment dated [DATE] indicated Section GG0130 Self-care functional abilities: Toileting hygiene and Personal hygiene- 01 (Dependent). Facility's policy on Skin management: Pressure injury treatment /general wound treatment reviewed date 4/2024 indicates: General: The following treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. However, the facility recognizes that the selection of the treatment protocols is individualized based on the resident condition and health care provider practice patterns. Therefore, these are only guidelines and not all inclusive. An order is required for all treatment orders. General guidelines: * Implement prevention protocol according to resident needs *Moisture: avoid prolonged periods of wetness General treatment guidelines: 11. When the wound care team assess the resident, they will take a picture, measure the wound, review the orders, and update any notes and care plans as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure ongoing assessment was in place for a totally dependent resident who has limited range of motion (ROM) to prevent contractures. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Restorative Nursing Program. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 9:58AM, Observed R108 with V3 DON (Director of Nursing) lying in bed. Observed right hand wrist with extension contraction. V16 LPN (Licensed Practical Nurse) said that R108 does not have splint. On 2/25/25 at 1:51AM, Informed V11 Restorative Nurse of above observation made. She said that she just started and have to check her notes. On 2/26/25 at 12:20PM V11 Restorative Nurse said that she cannot find Restorative admission assessment for R108. She did her assessment yesterday after surveyor asked for R108's restorative assessment. She is aware of R108's limited in range of motion at risk for developing contractures. She referred R108 to OT (Occupational therapy) and started on right hand splint yesterday. V11 presented copy of the 108's functional abilities assessment she completed 2/25/25 indicates that R108 is dependent in ADLs and transfers. Range of motion screen completed on 2/25/25 indicates: 4. right elbow, wrist and fingers has severe loss/less than 50% of norm). V11 presented copy of R108's physician order dated 2/25/25 indicated: Apply splint daily to right hand/wrist secondary to decreased muscle tone. On during AM for up to 2 hours as tolerated. When removing splint, assess for CMS and pain. Perform ADL/hygiene care. On 2/26/25 at 1:27PM, V12 Therapy Director said that he evaluated R108 yesterday as requested by nursing for right hand splint due to decrease in range of motion and prevent hand contractures. Reviewed V12 therapy notes dated 2/25/25 indicated R108 has decreased in hand digits and wrist flexion and recommended use of resting hand splint to prevent contractures starting at 2 hours daily as tolerated. R108's therapy notes dated 2/25/25 indicated V12 Therapy Director was made aware of potential need for right hand/wrist. Assessed right hand digits and wrist in slight flexion. Performed hand hygiene and gentle, low load stretching to digits and wrist. Recommended to restorative director to start patient at 2 hours for donning of resting hand splint to right hand wrist in AM with regular checks of any potential discomfort or skin irritation. Will continue to monitor application of hand splint and notify nursing. On 2/27/25 at 11:00AM, V12 Therapy Director presented copy of R108's Occupational therapy (OT) evaluation and plan of treatment for certification period of 2/26/25 to 3/27/25 indicates: Reason for referral: Patient is [AGE] year-old male with history of polysubstance abuse and intracranial hemorrhage ([DATE]), Seizure (7/2024), Left craniotomy (7/2024), Gastrostomy tube (7/2024), and Trach (7/2024). Referral for skilled OT for right hand splint to prevent contracture. He shows decrease in right hand ROM (range of motion). Recommend right resting hand splint to reduce amount of stiffness, prevent muscle from shortening, to maintain neutral positioning and prevent further contractures. Remove daily for hand hygiene and check skin integrity, swelling and positioning. Musculoskeletal assessment indicated: RUE ROM- shoulder, elbow/forearm, wrist, hand, thumb, index finger, middle finger, ring finger and little finger impaired. R108 is admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure, Acute kidney failure, Tracheostomy status, Stage 4 Pressure ulcer of sacral region, Gastrotomy status, Cerebral infarction, Intracranial hemorrhage. Comprehensive care plan indicates he has an ADL self-care performance deficit and impaired mobility. Intervention: Personal hygiene and grooming- total assistance. MDS /Resident assessment dated [DATE] indicated Section GG0130 Self-care functional abilities: Personal hygiene- 01 (Dependent). Facility's policy on Restorative Nursing Program reviewed date 4/2024 indicates: General: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Policy: 1. Each resident will be screened for restorative programs by the Restorative Nurse upon admission, quarterly, and with any significant change in function. 2. Appropriateness for the restorative program will be determined by the IDT (interdisciplinary team) as needed and may be determined as a continuation of care following a course of physical, occupational and or speech therapy. Facility's policy on Splints reviewed date 10/2024 indicates: General: Adaptive devices will be used as ordered by the physician to prevent deformities or further contractures. Guidelines: 1. Residents will be evaluated for the use of splint based on their assessed deformity or contractures. 2. A physician order will be obtained for any needed splint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision is rendered to dependent resident who is at high risk and had several unwitnessed falls in his room. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Fall prevention program. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. Facility reported unwitnessed fall out from bed twice. He was placed in the far end of the facility as if being ignored away from the nursing station in case an emergency was to occur. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 9:58AM, Observed R108 lying in low air loss mattress. He has tracheostomy tube connected to oxygen at 8LPM (liters per minute). He is awake and nonverbal; he needs total care with ADLs (Activity of Daily Living) and transfers. He has floormat on the left side of the bed. On 2/25/25 at 10:30AM, V16 LPN said R108 jerks and moves to the left side of the bed when he coughs. He worked with him on 2/1/25 when he was found on the floor. He was coughing too much that is why his body moved to the left side of the bed and fell to the floor. R108 is admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure, Acute kidney failure, Tracheostomy status, Stage 4 Pressure ulcer of sacral region, Gastrotomy status, Cerebral infarction, Intracranial hemorrhage. Fall assessment upon admission [DATE]) and most recent fall assessment (2/18/25) indicated that he is at high risk for falls. Comprehensive care plan indicates he is at risk for falls related to current conditions. He has an ADL self-care performance deficit and impaired mobility. Fall admission assessment indicated he is at high risk for falls. Fall incident history indicated: 12/29/24 at 4:09AM, Unwitnessed fall in his room. R108 noted hanging off the bed, upper torso on the floor, bilateral legs on the bed. R108 unable to give description. He was sent to hospital for evaluation. Hospital record dated 12/29/24 indicated Chief complaint: Fall. Patient brought in by emergency medical services (EMS) for unwitnessed fall occurred at 4:09AM. Patient nonverbal, non-ambulatory, on trach collar suctioned by EMS, on heparin. 2/1/25 at 3:30PM, Unwitnessed fall in his room. R108 noted on the floor next to bed. Head, neck and shoulder on feeding pole and feet on the bed. R108 unable to give description. He went to hospital for evaluation. Hospital record dated 2/1/24 indicated Patient arrives via EMS due to unwitnessed fall. Per EMS, patient still on the floor upon their arrival. Patient nonverbal, bed bound, trach per baseline. Per EMS, copious amount of secretions suctioned on route. Patient tachypneic upon arrival. On 2/27/25 at 11:26AM, V3 DON (Director of Nursing) said that she started working in the facility [DATE]. Aside from DON, she is the fall coordinator. She oversees the fall prevention management program. She said that after each fall, fall investigation/ root cause analysis is conducted and developed individualized care plan intervention to prevent fall reoccurrence. Reviewed R108's medical records including fall incident reports with V3. Informed V3 of family concerns that R108 was placed at the far end of the nursing station, and they only moved resident closer to the nursing station as 2 weeks after he fell. Concern also presented to V3 of providing adequate supervision to prevent re-occurrence of 2nd fall. Informed V3 that R108, a totally dependent resident with trach, GT, and stage 4 pressure ulcer, had 2 unwitnessed falls in his room and had visited hospital emergency room for evaluation and undergone with different procedures and X-rays to check for injury. V3 said that they cannot prevent the resident from falling. They provide frequent rounding but did not document it. She added that they cannot document frequent rounding done to all resident at high risk for fall or resident with multiple falls. Facility's policy on fall prevention management reviewed dated 8/2024 indicates: General: This facility is committed to maximizing each resident's physical mental and psychosocial well-being. The facility will identify and evaluate those residents at risk for falls, plan for preventive strategies and facilities as safe an environment as possible. All resident falls shall be reviewed, and resident's existing plan of care shall be evaluated and modified as needed. Facility's policy on Patient monitoring and Safety reviewed 9/2024 indicates: Purpose: To ensure the safety and well-being of patients/residents through effective monitoring and response protocols. Definitions: Patient monitoring: The continuous or period observation of a patient's physical and emotional status, including vital signs and overall condition. Safety protocols: Specific guidelines are designed to monitor patients through various preventive measures. Purposeful rounding: A structured approach where staff routinely check on patients with a specific focus on addressing their needs, reducing fall risk, preventing discomfort and improving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that Medication error rates are not 5 percent or greater. This deficiency affects one (R66) of four residents in a sample of 25 reviewed for medication administration. Findings include: On 2/26/25 at 8:40AM, V19 (Licensed Practical Nurse) during medication administration observation with R66 administered Aspirin 81mg chewable 1 tablet and Senna 8.6mg 1 tablet. On 2/26/25 at 8:45AM, V19 said she follows physician orders from medication administration record. On 2/27/25 at 10:33 AM, V3 (Director of Nursing) made aware of above findings and said nurses should follow physician orders when administering medications. R66 admitted on [DATE] with diagnosis in part of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus without complications, other seizures, gastrostomy status, muscle weakness. R66 Physician order report 2/26/25 Order Summary: Aspirin oral capsule 81mg, give 1 capsule by mouth one time a day and Sennosides tablet 8.6mg, give 2 tablets by mouth one time a day. Facility's Policy on Medication Administration revised 5/2017 General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis Guideline: 6. Check medication administration record prior to administering medication for the right medication, dose, route, patient/ resident, and time. 9. If there is a discrepancy between the MAR and label, check order's before administering medications.

Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices to resident on tracheostomy tube and during medication administration. This deficiency affects all five (R19, R66, R93, R108 and R110) residents in the sample of 25 reviewed for Infection Control. Findings include: On 2/25/25 at 9:58AM, Observed R108 with V3 DON (Director of Nursing) lying in bed with Tracheostomy tube connected to oxygen at 8 LPM (liters per minute). R108 is awake, non-verbal and needs total assistance with ADLs (Activity of Daily Living) and transfers. The tracheostomy corrugated tubing and drainage collection bag touching floor. V3 DON said that it should not be touching the floor for infection control. On 2/25/25 at 12:21PM, Observed R110 with V4 ADON (Assistant Director of Nursing) lying in bed with tracheostomy tube connected to oxygen at 8LPM. R110, non-verbal and needs total assistance with ADLs (Activity of Daily Living) and transfers. The tracheostomy corrugated tubing and drainage collection bag touching the floor. V4 ADON said that it should not be touching the floor for infection control. On 2/26/25 at 11:06AM, Informed V9 Infection Preventionist of above observation and concerns. V9 said that the tracheostomy corrugated tubing and drainage collection bag should not be touching the floor for infection control. Facility unable to provide policy. On 2/26/25 at 8:24 AM, V20 (Registered Nurse) performed a blood pressure check on R19 when completed with blood pressure check V20 did not disinfect blood pressure cuff. V20 said that she is unaware of disinfecting blood pressure cuff in between resident use if resident is not on any enhance barrier precautions or isolation precautions. On 2/26/25 at 8:40AM, V19 (Licensed Practical Nurse) performed a blood pressure check on R66, when completed with blood pressure check did not disinfect blood pressure cuff. On 2/26/25 at 8:56 AM. V19 also performed a blood pressure check on R93 and did not disinfect blood pressure cuff before or after resident use. V19 said that she should have disinfected between residents to avoid any transmission of infections but forgot to do so. On 2/26/25 at 10:17 AM, V3 (Director of Nursing) made aware of above observations and said that all medical equipment should be disinfected before using on the next resident for infection control purposes, regardless of being on isolation or enhanced barrier precautions. On 2/26/25 at 12:45 PM, V9 (Infection Preventionist) said that all medical equipment should be disinfected between resident use to prevent the spread of infections to other residents. Facility's Policy on Equipment Cleaning revised 10/2024 General: To provide guidance on how to clean equipment between residents. Policy: 1. Obtain bleach or disinfectant wipes. 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 manufactures recommendations 5. Remove and discard gloves. Sanitize hands. 6. Repeat process between resident use.

Based on interviews and record review, the facility failed to follow their Laboratory Specimens policy. Facility failed to send urine specimen labeled and with requisition, resulting in laboratory unable to process Urinalysis and Culture/Sensitivity test. This deficiency practice affects one resident (R1) of three residents reviewed for quality of care. Findings Include: R1 admitted in the facility on 8/10/23. BIMS of 15 (Intact Cognition) On 1/14/25 at 11AM, R1 stated that her urine sample was taken twice in the facility, does not recall exactly when in December. The urine sample was taken the same day R1 reported an odor in her urine. First urine sample, R1 was informed that the urine sample was not labeled. And then the second sample was taken, and R1 was informed by the NP, saying that the urine sample says the lab received it, however no result can be found. Stated that NP suggested for a third specimen, R1 refused and decided to go to this primary physician in the community. Stated January 2nd R1went to doctor's appointment. Specimen taken on this appointment and days later her primary called R1 to inform R1 that they submitted antibiotic medication order to her pharmacy for the diagnosis of Urinary Tract Infection. Physician Order Sheet reviewed and noted 2 orders for Urinalysis and Culture/Sensitivity, on 12/17/24 and 12/25/24. Laboratory Result reviewed and noted 12/17/24 that this was cancelled due to an unlabeled sample. Specimen collection will be rescheduled. Specimen on 12/25/2 was reads in part: problem requisition. Received urine -No requisition form received. On 1/15/25 at 12:05PM, V4 (Nurse Practitioner) stated V4 ordered Urinalysis and Culture/Sensitivity on 12/17/24 when seen R1. On 12/20/24, saw again for the same reason because per nursing report, the sample was collected and there was no label. Re ordered and the second urine sample and per nursing report that it was a requisition issue. V4 stated V4 met with R1 again, and V4 spoke to R1 and informed R1 and offered to get another sample, and hope they get the third sample right. However, R1 said she will just get the test done on the 2nd of January with her primary care provider. On 1/15/25 at 1PM, V5 (Lab representative) stated that in order for the lab to process the urine specimen, their expectation is for the facility to send the specimen with 3 identifiers. Labelled correctly and requisition present. Sample of 3 identifiers are name of resident, Birthdate, Physician's name and date of and time of collection. On 1/15/25 at 9:40AM, V2 (DON) stated that staff will collect the specimen, label it and call the lab, then lab will pick up the specimen. V2 stated that V2 was just made aware regarding the missing labs the day of the antibiotic was started which is the 7th of January. V2 stated that if V2 was made aware of the incident earlier, V2 would have done an in-service to educate the nurses of the proper labeling for the urine specimen before sending out a specimen to the lab. Laboratory Specimens Policy with a revision date of 9/2017, reads in part: To provide information on how to accurately collect laboratory specimens. Responsible party: all nursing staff. Guideline: An order is necessary for any lab specimen collection. A requisition should be completed on each lab specimen collected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident has the right to receive unopened personal mail in a timely manner. This failure affected one (R3) resident in a sample of 6 residents reviewed for privacy and resident rights. Findings include, R3 is [AGE] years old with BIMS (Cognition test) score of 15, meaning R3 is cognitively intact. On 12/21/24 at 9:56 am R3 said, he received a letter from IDPH and when he got his letter it was opened and also there was no envelope to send appeal. R3 was not sure if it came with the letter. R3 said, the letter was mailed on 12/4/24 and it was handed to him by the facility on 12/13/24. R3 said, activity brought the letter and it was V14 who handed the letter to him. R3 said, V14 told him when she picked up the letter from downstairs, it was already open like that. R3 provided the letter, and it was opened neatly and looked like it was opened with a letter opener or scissors. R3 said, he does not have scissors or letter opener in his room. On 12/21/24 at 9:49 am V18 (Business Office Manager) said, she collects mail. If it is business, Department of Human Services and social security she will open it and then she gives the mail to activity and it gets distributed on the floor to residents. V18 said, she does not open Illinois Department of Public Health findings as it is personal mail. V18 said, R3 spoke to her, he said one of the mail was opened, and he was upset it was not given to him in a timely manner. V18 said, the turn around process for mail is daily, 2 days at the most and there is no procedure to hold on to mail for 10 days. V18 said, he informed her of this issue and she said she would make sure he gets mail on time. V18 said, she did not complete a written grievance form on this and she should have done a grievance. On 12/21/24 at 11:43 am V14 (Activity) said, she picked up the mail after it was check by business manger (V18), and she delivered mail to R3 and it was opened. V14 said, R3 asked why the letter was opened and she told him that is how she got it from the mail box. V14 said, time turn around for mail is daily, staff check for mail on daily basis. V14 said, she did not delay the delivery of the letter and facility does not hold mail on purpose and they deliver the mail everyday in a timely manner. On 12/21/24 at 12:49 pm, V1 (Administrator) said, facility does not retaliate on residents for filing complaints, that is their right. V1 said, R3 signed consent for facility to open his mail. V1 provided the consent R3 signed when R3 was admitted , however the consent does not include personal mail and correspondence from IDPH. V1 said, the letter was opened by mistake and he will in-service the staff so it does not happen again. Review of the admission contact R3 signed (7/28/22), it documents permission for facility to open the following correspondence: social security checks, pension checks, Veteran Administration checks, correspondence from Department of Human Services and Illinois Department of Healthcare and Family Services, Social Security, Medicare Insurance and Doctor and Hospital Bills. (consent does not include IDPH complaint findings or personal mail) Long Term Care Ombudsman Program Residents Rights for People in Long Term Care Facilities documents in part: Your facility must deliver and send your mail promptly. Your facility may not open your mail without your permission.

Based on interview and record review the facility failed to provide the necessary transportation for a resident to attend a doctor's appointment outside of the facility for 1 of 3 residents (R1) reviewed for necessary care and services in the sample 5. The findings include: R1's appointment note dated 6/28/24 showed R1 had a scheduled appointment to see a dermatologist, on 8/27/24, at a local outpatient clinic. On 9/13/24 at 9:28 AM, R1 stated, I missed my derm (dermatologist) appointment on August 27, 2024. I was supposed to go by the facility van but that van was broken so they couldn't take me. (V12 Facility Van Driver) told me it was because there was something broken in the van. On 9/13/24 at 9:42 AM, V13 Facility Scheduler stated, I was aware of (R1's) appointment on 8/27/24. I wrote it down in the appointment book. I arranged to have our van take her to it. I don't know exactly why she didn't go to the appointment. I think it had something to do with the van. On 9/13/24 at 9:50 AM, V12 Facility Van Driver stated on 8/27/24, There was an issue with the van so I couldn't take (R1) to her to her appointment. I can't exactly remember what was wrong with it. On 9/13/24 at 10:27 AM, V2 Assistant Administrator stated R1 missed her dermatology appointment on 8/27/24 because the wheelchair lift in the facility's van was broken and could not transport her. On 9/13/24 at 10:59 AM, V3 Executive Director stated, We screwed up on this one with (R1). We could have done a better job. I don't know why we didn't arrange alternative transportation for (R1) on August 27th. The facility's Appointments and Transportation policy dated 4/16/24 showed, When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party chooses to make the arrangements themselves . If the family is not making transportation arrangements, the staff nurse or designee will call the transportation company to set up date and time of pick up .

Based on interview and record review the facility failed to obtain medication from the pharmacy for 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 5. The findings include: R2's face sheet shows he has diagnoses including: anxiety disorder, major depressive disorder recurrent, bipolar disorder, and mood disorder. R2's active Physician Order Summary (POS) shows he has an acitve order for Alprazolam 1 MG (milligram). One time a day for anxiety. R2's 8/1-8/31/24 Medication Administration Record (MAR) shows he should receive Alprazolam (xanax) tablet 1 MG. at 5:00 AM for anxiety. This dose of medication is documented in the MAR using a code 9 which indicates (see notes). A eMAR- Medication Administration Note completed on 8/21/24 at 5:10 AM by V6 (Licensed Practical Nurse/LPN) states, out of stock, f/up with pharmacy. insurance order for tomorrow. A Nurse Practitioner progress note completed on 8/21/24 at 9:35 AM states, {R2} was seen today at the request of the nursing staff for a medication refill. He takes xanax 1 mg and 2 mg for anxiety and needs refill. On 9/13/24 at 10:20 AM, V5 (Director of Nursing) said pharmacy delivers medications to the facility every day. There is a cubex (medication dispensing system) on the 2nd floor of the facility if there is a medication that is not at the facility. If a medication is not in the cubex then the nurses should call stat and obtain the medication from the pharmacy. V5 said if a narcotic or controlled medication needs a signature for a refill they call the Nurse Practitioner who is here Monday thru Friday, and obtain a code from the pharmacy to obtain the medication from the cubex to be able to obtain the medication. V5 said she was not aware of the missed xanax dose for R2. On 9/13/24 at 11:20 AM, V4 (Nurse Practitioner) said he did reorder R2's xanax on 8/21/24 but he was not aware that the morning dose was not given as scheduled at 5:00 AM. V4 said the nursing staff could have obtained the medication from the cubex and given it. On 9/13/24 at 11:30 AM, V6 (LPN) said he could not administer R2's 5:00 AM dose of xanax because it was not available from pharmacy. V6 said someone had forgotten to re-order the medication. The facility provided Pharmacy Services policy last reviewed on 4/14/24 shows the facility will provide pharmaceutical services to assure the accurate acquiring and dispensing of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate discharge for a resident upon request and failed to update the discharge care plan to include a desire for transfer or discharge which affected one (R2) of two residents reviewed for discharge planning. Findings include: R2 is [AGE] years old and was transferred to the facility on 4/9/24. Diagnoses listed for R2 include dementia, osteitis (inflammation of bone), convulsions and violent behavior. According to the Minimum Data Assessment of 4/19/24, R2 was assessed to have mild cognitive impairment. On 7/7/24 at 2:19PM V10 and V14, Family Members of R2 said, we have been directly involved in R2's care since transfer into the facility. V10 said, at first the facility primarily contacted (V14), but after a verbal altercation with staff, V6 Director of Nursing asked if V10 could be the primary contact. V14 said the altercation was due to the frustration and lack of help from the staff. V10 and V14 expressed concerns regarding discharge planning, medication administration, therapy and overall nursing care. V10 and V14 said that they have been trying to work with the facility to transfer R2 to another long-term care facility since April, and the facility has not sent any transfer information for consideration to the facility chosen. On 7/8/24 at 10:30AM the admissions department from the receiving facility said, that V10 and V14 inquired over two months ago about a referral, however according to their notes on the matter, they have not received any documentation to review R2's request. V10 provided an email verifying that admissions contact information was given June 10, 2024, to V15 Social Services Director. V15 was unavailable to interview during this survey. On 7/8/24 at 12:08PM V2 Executive Director said, V15 mentioned that R2's family wanted to transfer and said V15 said a transfer packet was sent to the facility they requested. When transfer documents are sent to a facility, we (the facility) should keep a copy of the transmission for our records. When V2 requested the confirmation, V15 was not able to provide it On 7/8/24 at 5:30PM V1 administrator said, our social worker never sent the referral paperwork to the requested facility because when the social worker called, the facility said that no beds were available. V10 requested that R2 be transferred back to our sister facility in April because they wanted R2 to have more therapy, but we explained that R2 would not be receiving more subacute therapy because R2 had already been discharged from therapy services and was appropriate for the nurse led restorative therapy program. The care plan should have been updated to reflect R2 and or the family was requested to be discharged or transferred. R2's care plan was reviewed, however did not include revisions that included R2's desire to transfer to another facility. R2's discharge care plan was created 4/10/24. Focus: Discharge Potential: the tentative plan is for the resident to remain in Long Term Care placement, work on transitioning to her own apartment with her family. Outcome (revised 4/22/24): [R2] will discuss feelings and concerns regarding discharge planning. Interventions: Encourage the resident to discuss desire for discharge and what she needs to do to increase likelihood of success as clinically indicated. The facility provided a policy titled Discharge Summary and Plan revised 5/25/24 however, does not include a process or procedure for resident-initiated discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders for two of two (R2, R3) residents reviewed for medication administration by inaccurately transcribing a medication for R2 and by not ensuring timely ordering of medications for R3. Findings include: R2 is [AGE] years old and was transferred to the facility on 4/9/24. Diagnoses listed for R2 include dementia, osteitis (inflammation of bone), convulsions and violent behavior. According to the Minimum Data Assessment of 4/19/24, R2 was assessed to have mild cognitive impairment. The Physician order sheet active during this survey and the Medication Administration Record (July 2024), include Olanzapine 15mg oral daily which was ordered 6/24/24. On 7/8/24 at 3:47PM V13 Psychiatric PA (Physician's Assistant) said that they manage psychotropic medications for R2. On 6/6/24, V13 assessed R2 and made a recommendation to increase a medication Aripiprazole (antipsychotic) from 10mg to 15mg. When seeing R2 again on 6/20/24, V13 noted that the medication had not been entered on the Physician's Order Sheet and inquired about the order. V13 also said that olanzapine was not ordered or recommended for R2, nor did V13 believe that the collaborating physician made the change from aripiprazole to olanzapine because it was not common practice. Furthermore, as R2 already had previous orders for aripiprazole in 5mg and 10mg dosages, 15mg of the medication should have been available. V13 said that when recommendations were given to adjust or order new medications, it was sent to the Director of Nursing and the Psychotropic Nurse to enter into the electronic health record, because consent is required prior to administering the medication. This practice was confirmed by V6 Director of Nursing on 7/8/24. V13 provided email documentation dated 6/6/24 sent to V6, the Assistant Director of Nursing and the Psychotropic Nurse which stated [R2]: increase [aripiprazole] from 10mg (every day) to 15mg (every day) (due to) psychotic (symptoms) that are causing distress. On 7/8/24 at 4:38PM, V6 Director of Nursing said that they were unaware of the change and was unable to provide any reasoning as to why the Psychotropic nurse would have placed the order for olanzapine instead of aripiprazole as ordered. V6 said that the expectation would have been to transcribe the medication as received by V13. R3 is [AGE] years old was initially admitted to the facility 11/25/15 and has diagnoses that include osteoarthropathy, COPD, lumbar radiculopathy, arthritis and anxiety disorder. R3 was interviewed in the facility on 7/5/24 at approximately 5:30PM. R3 was observed to be alert, coherent, well-groomed, and mobilizing independently. During the interview, R3 said that in June 2024, the facility ran out of medication tizanidine which is prescribed for back spasms for several days. R3 said that there are times when other medications are not ordered timely due to frequency of agency staff working. R3 said that while it was upsetting that the medication was not available, it did not hinder activities of daily living. The medication administration record for R3 was reviewed for the month of June 2024. It was noted that tizanadine hydrochloride 4mg (milligrams) was not administered as signed out June 16th through the 21st. On 7/5/24 at 11:30AM V6 Director of Nursing said R3 is very adamant about taking their medications usually at the same time every day, so much that sometimes he causes a disturbance when the nurse is not available or working with another resident. R3 wants what they want when they want it. R3 takes medications for pain and back spasms and while they are ordered as needed, I would say that he takes the medications daily. I was not made aware of any time any medications were not available. On 7/8/24 at 10:20AM, V6 said, while the facility does not have a written policy regarding when to re-order medications. The expectation is that they order prior to the medication running out. V6 said that although agency nurses are used often, there is always a staff nurse with availability to the convenience machine. It is linked directly to the pharmacy and when medications are removed, the pharmacy sends someone to refill it. The facility was unable to provide any documentation that medications were removed from the convenience machine for R3 and V6 confirmed that no medications from the machine were accessed for R3 in June. Nursing progress notes were reviewed for June 2024 and none were written regarding the missing mediation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer a resident with a new mental health diagnosis for a level II PASARR assessment. This failure applies to one of three residents (R102) reviewed for PASARR assessments. Findings include: R102 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder (as of 08/17/2023), Adjustment Disorder with Mixed Anxiety and Depressed Mood (as of 07/13/2023), who was admitted to the facility 02/19/2023. R102's medical records did not include a PASARR Level II Assessment On 04/24/24 at 01:27 PM V11 (Psychotropic/Falls Nurse) stated, she believes R102 had a stroke at a young age [AGE]. V11 stated she has always been able to sit and talk with R102 and has not had to send him out, but at times he cannot be calmed down or deescalated. V11 stated, she gave R102 a supervised pass but that does not seem to be sufficient. V11 stated she believes R102 does not belong at the facility and maybe belongs in a different type of facility. On 04/25/24 at 02:04 PM V1 (Administrator) reported, the facility does not have a PASARR Policy. As of the exit of the annual certification survey 04/25/2024 the facility could not provide an answer to surveyors inquiry made 04/25/2024 at 12:41 PM of whether R102 should have received a PASARR Level II Assessment due to receiving new mental health diagnoses after his admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for comprehensive care planning by not developing and implementing person centered care plan interventions for a resident who refused ADL (Activities of Daily Living) care, a resident with a history of substance use who was observed to be under the suspicion of substance use, and a resident with a history of aggressive and maladaptive behaviors. This failure applies to three of three residents (R78, R85, and R102) reviewed for care planning. Findings include: 1. R78 is a [AGE] year-old male with a diagnoses history of Cerebral Infarction, Unspecified Symptoms and Signs Involving the Nervous System, and Aphasia following Cerebrovascular Disease who was admitted to the facility 11/10/2022. On 4/23/24 at 11:19 AM surveyor observed R78's gown, linens and body with a strong odor of urine. R78 shook his head no when asked by surveyor if he needed to be changed. R78 shook his head up and down to confirm he wanted to be dressed and get out of bed later. R78's admission Minimum Data Set, dated [DATE] documents he requires supervision and setup for transfers and walking and most activities of daily living and one-person physical assistance for locomotion on and off the unit, toilet use and personal hygiene. On 04/23/24 at 01:24 PM V28 (Family Member) stated, sometimes she comes in at three in the afternoon and R78 has an extremely strong urine smell and is still in the bed, he has not been changed and V28 will get him up. V28 stated R78 can not sit up due to medications and stroke. V28 stated her main concern is R78 getting a little more attention. V28 stated when she comes to visit R78 is in a urine-soaked bed and his gown has a urine smell. V28 stated she is assuming R78 gets changed once a day maybe later at night. V28 stated she would like to see R78 get more assistance, he needs more prompting to get up and get showered. V28 stated sometimes when R78 goes out at night they do not make sure he takes his clothes off when he returns, and he sleeps in his clothes and urinates in them. V28 stated R78 needs help. On 04/24/24 at 03:16 PM V2 (Assistant Administrator) stated, R78 has a history of refusing ADL (Activities of Daily Living) care and the facility regularly has to contact V28 for him to comply with incontinence care and bathing, V2 stated social services are involved because R78 lacks motivation to get out of bed and engage in activities of daily living. V1 (Administrator) and V2 stated these issues are included and addressed in R78's care plan. R78's current care plan documents he is incontinent but prefers to do his own toileting; R78 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to impaired ability with Dressing and Grooming such as: Putting on or take off clothing, unable to obtain or replace article of clothing, unable to fasten clothing, unable to groom self satisfactorily, unable to complete task with personal hygiene, unable to bathe and groom self independently; R78 requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) with interventions including: Assist resident with shower/bathing per schedule, Encourage participation in ADL's; R78 exhibit(s) the symptoms of resisting care by refusing caregiver requests to leave the bed and refusing/resisting ADL assistance (bathing, dressing, grooming, transferring, etc.) with interventions including: Conduct an evaluation of the behavioral symptoms(s) to determine what strength or needs are communicated via the behavior (e.g., resisting care often communicates the emotion of fear and need for control). R78's current care plan does not include personalized interventions to address his refusal of ADL care and does not document the causes of his refusals. R78's Progress notes from March 01/2024 - April 24/2024 does not document refusals of attempts to provide him with ADL care of incontinence, showers, or personal hygiene. R78's Psychotropic progress notes dated 03/21/2024, and 04/04/2024 created by V25 (Psychiatric Nurse Practitioner) document Staff nurse had no complaints and did not report any behaviors. 2. R85 is a [AGE] year-old male with a diagnoses history of End Stage Renal Disease and Nicotine Dependence who was admitted to the facility 09/17/2022. On 04/22/24 from10:55 - 12:13 PM surveyor observed a strong odor of Marijuana outside and in R85's room. Observed R85 with strong Marijuana odor near him. Observed R85 walking through the facility with his eyes red and droopy. On 04/23/24 at 9:12 AM Observed strong Marijuana smell in R85's room. On 04/23/24 at 09:34 AM Observed along with fellow surveyor hallway near R85's room and R85's room with a strong smell of marijuana. On 04/23/24 at 12:40 PM Observed R85 sleeping in bed. R85 stated he had been out of the facility earlier and is often in and out of the facility. On 04/23/24 at 01:00 PM Observed V12 (Licensed Practical Nurse) measure R85's blood pressure. V12 stated R78 blood pressure fluctuates depending on dialysis. Observed R85's eyes to be red and droopy. Observed V12 administer R85's blood pressure and Kidney medication. V12 stated at times R85 smells of marijuana and if observed with this smell social services is notified and they will talk to him. On 04/24/24 at 10:01 AM V4 (Assistant Director of Nursing/Registered Nurse) stated, she is not aware of any residents returning to the facility under the influence of substances. V4 reported that she can check the policy on contraband searches, however the facility may not necessarily search residents upon return from the community. V4 stated if nursing smell marijuana, social services is notified, and the nurse and social service staff inform the resident of the concerns brought to their attention then get permission from resident to fully search their room. V4 stated these situations have occurred at times with residents. V4 stated other signs of marijuana use include eyes blood shot, smell of marijuana on person. V4 stated concerns of marijuana use for residents include that other substances may have been within the marijuana that affect cognition, safety issues, and medication use. V4 stated the nurse would perform a full head to toe assessment including vital signs if residents show any signs they are under the influences of other illegal substances along with marijuana. R85's Progress Notes from February - April 2024 did not include observations of substance use. R85's Current care plan documents he expresses the desire to receive an outside, independent pass, he must make a commitment to behave appropriately while in the community, take medications as prescribed and remain clean and sober but does not include personalized interventions regarding substance use. On 04/24/24 at 01:01 PM V21 (Social Services) stated she has not received any reports of R85 using any substances. V21 stated if it was reported that a resident possibly used marijuana a room search would be conducted and they may possibly receive a clinical assessment or be sent out for evaluation and testing. V21 stated if the resident has an outside pass, they would be restricted if they are showing signs of intoxication. V21 stated due to receiving dialysis, if R85 was using marijuana it could affect his dialysis treatment, and there would also be concerns of bringing substances into the facility, and general safety. 3. R102 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder (as of 08/17/2023), Adjustment Disorder with Mixed Anxiety and Depressed Mood (as of 07/13/2023), who was admitted to the facility 02/19/2023. R102's social service progress notes dated 02/27/2024 documents he attempted elopement. Writer met with R102 to counsel on the importance of making staff aware of issues before he gets too anxious and frustrated in future situations. He expressed understanding. R102 will be on 72 hour follow up. Staff will monitor for aggression and mood changes. Social services will follow up. R102's social service progress note dated 3/5/2024 documents created by V2 (Social Services Director) Day 1: Writer was made aware of resident was presenting with exit-seeking behavior. Writer approached resident and he appeared in an anxious mood at this time. R102 was re-directed and reoriented by writer back to a quiet and safe setting to discuss noted behavior. Writer encouraged R102 to vent feelings or concerns to staff. R102 expressed understanding at this time. Social Services will continue to monitor behaviors. R102 requires constant reminders to decrease in behavior, facility protocols, plan of care, his safety, and a need for daily supervision. R102 has a history of Elopement. Care Plan Updated. R102's Psychiatry/Mental Health progress note created by V25 (Psychiatric Nurse Practitioner) dated 3/13/2024 documents Chief Complaint: Follow up mood. History of Present Illness: [AGE] year-old male with Opioid Use, Unspecified, Uncomplicated and Adjustment Disorder with Mixed Anxiety and Depressed Mood. There were no behavior issues to report. Staff nurse had no complaints and did not report any behaviors. R102's Psychotropic Progress note dated 3/21/2024 documents Chief Complaint: Follow up adjustment disorder. There were no behavior issues to report. Staff nurse had no complaints and did not report any behaviors. R102's Psychotropic Progress note dated 3/29/2024 documents Chief Complaint: Follow up mood.There were no behavior issues to report, and his mood has been baseline per staff. Staff nurse had no complaints and did not report any behaviors. R102's Health Status Progress Note dated 4/4/2024 created by V11 (Psychotropic Nurse) documents a Change In Condition/s reported on this change in condition evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis). R102's Progress note dated 4/4/2024 documents he is being aggressive, being delusional, trying to elope out the front door, and is not able to be redirected. Writer called resident's Psych Physician and left a voice message. Writer asked the Physician. to call back to the facility concerning the resident. Writer notified Director of Nursing to make her aware of resident's behavior. Writer called Insight hospital and gave nursing report. Writer called transportation to schedule pick-up for the resident. R102's Progress note dated 04/6/2024 documents he became verbally and physically threatening to writer. Resident is not able to be redirected after several failed attempts to calm him down. Resident stormed out of the facility unescorted against writer and other staff request . Code yellow was called staff quickly responded to bring him out the courtyard back inside. Physician was notified ordered to send resident out to insight hospital for psychiatric evaluation. R102's social service progress note dated 4/8/2024 by V21 (Social Services) documents Note Text: Behavior monitoring Day 1 of 3. Writer met with (staff member) to conduct well-being check. Resident went outside with writer along with psychotherapist for about an hour. R102's social service progress note dated 4/10/2024 12:37pm documents a code yellow was called to the receptionist area and upon arrival the resident was at the front door trying to elope, being physically/verbally aggressive. Writer tried to talk to the R102, and he continued to scream/yell. R102 was not able to be redirected. The writer informed the V13 (Nurse Practitioner) and orders were to send the resident to hospital. A petition will be sent along with the resident. R102's social health status progress note dated 4/16/2024 documents writer approached resident regarding skin assessment, resident was pacing and appeared upset, writer asked R102 if he was ok, he yelled No and kept walking. Writer later saw R102 on the 2nd floor of the building attempting to get into the social services office, he appeared upset, staff was able to redirect him. Writer unable to complete an assessment on the resident due to aggressive behaviors. R102's progress note dated 4/23/2024 at 2:16 PM documents he is showing aggressive behaviors towards staff physically and verbally. The resident is not able to be redirected. A petition to hospital has been presented to the writer for the resident. The writer has contacted ambulance service for transport to Local Hospital was given. The Director of Nursing and V13 (Nurse Practitioner) is aware of the residents petition/transport; at 3:30 PM Behavior follow up note: documents Writer was made aware by nursing staff that resident was inside of nursing office exhibiting with verbal aggressive behavior and demanding that nursing staff change his current out on pass order from supervised to independent. R102 voiced that he is capable of going out alone and wants order changed immediately. Writer approached resident and he was in an agitated mood. R102 was asked kindly to exit nursing office and go speak to social services in their office. When R102 entered office, he was asked to sit as he was standing in doorway of social services office yelling and screaming stating, I want my pass changed now! I don't understand why I can't go out by myself! R102 was reassured that he was safe and that he ok with staff. Resident was then asked again to sit and calmy express himself, resident refused. Resident was then notified of outside pass procedures, his gait imbalance, poor decision making, and safety awareness. R102 then continued to express agitation towards staff with noted verbal aggression, while resident was in the doorway of social services office another resident approached social services office to notify them of his return from Association House Skills Training. R102 then turned towards peer and yelled loudly, this is my time I'm busy leave now! Peer was immediately assisted out by social service designee to his room. R102 remained in social services office with noted uncontrollable verbal aggressive behavior. Social services continued to encourage resident to speak in a soft tone of voice resident refused. R102 was then asked to be taken on a walk down to his room to calm down. Once R102 reached first floor nursing station he refused to present in a calm manner. Social services was notified by nursing staff to petition resident out for psychiatric evaluation, noted aggression towards staff and peer and uncontrollable verbal outburst. R102 has a history exhibiting with, exit seeking behavior, aggressive/inappropriate behavior, attention seeking behavior, conflicts/altercations with others, and acting impulsively, and erratically. R102's current medical diagnoses are Aphasia Following Cerebral Infarction, Symptoms and Signs Involving Emotional State, Other Symptoms and Signs Involving Appearance and Behavior, Recurrent Major Depressive Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Opioid Use. R102 suffers from a family history of verbal abuse. R102 currently receives psychotherapy and agrees with counseling sessions at this time. Social Services will continue to follow up, intervene, and council resident as needed. R102 is currently petitioned out to hospital for assessment review. Care plan updated. On 04/24/24 at 12:45 PM V21 (Social Services Designee) stated a lot of R102's frustrations are from him wanting to go outside so sometimes staff will take him outside for a walk upon request. V21 stated R102 also visits with psychotherapist 3-4 times per week, engages in activities, and his needs are addressed by social services when expresses them. V21 stated she is not aware of any group programs for residents, but the psychotherapist or social services director may have more information. V21 stated she keeps in touch with V26 (Psychotherapist/Psychologist) often regarding R102's behaviors. V21 stated she believes V25 (Psychiatric Nurse Practitioner) works along with the V11 (Psychotropic/Fall Nurse). V21 stated she only communicates with V26. V21 stated it's pretty important to communicate behaviors to R102's psychotropic care team which is why she tries to communicate consistently with V26 so she can meet with R102. V21 stated R102 wants to be outside probably daily and even wants to go out at times after he's already been out. V21 stated on occasion R102 can be taken outside multiple times a day depending on who's available. V21 stated R102 likes to watch videos on his computers, but mainly likes sitting outside when he can. V21 stated if activities are not being offered enough or R102 isn't able to go outside frequently enough it may contribute to more behaviors. V21 stated R102 exhibits these behaviors sometimes even when offered activities and outside time. V21 stated if activities and outside time are still not adequate for R102 we'll try to work with him and she personally will invite him to her office just to vent his frustrations which can be helpful. V21 stated if none of these options are sufficient they may offer him something from the kitchen, activities, or see if there's anyone he wants to speak to. V21 stated she believes V26 can refer residents to outside services or providers for psychosocial services if needed. R102's current care plan documents he is a younger individual [AGE] years of age and presents with a Substance abuse history and difficulties expressing himself. He may present with poor motivation, lack of energy. May state he is bored or act bored. Interventions include: Assess the need for additional, formal education needs and offer referrals, as appropriate for educational opportunities; Assure the resident is in an appropriate treatment setting. R102 has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior. R102's history includes conflicts/altercations with others, acting impulsively, and erratically by throwing chairs. R102 has been noted flipping over tables when he is stressed and refuse staff redirection/reorientation to setting. On 11/21/23 R102 was noted with aggression towards staff. Interventions include: If R102's symptoms warrant further assessment of ongoing management, Refer him to a mental health professional, including a consulting psychiatrist, for evaluation; Intervene when any inappropriate behavior is observed. Communicate assertively that he must exercise control over impulses and behavior (Social skills training); Provide supportive intervention as needed; R102 demonstrates strong activity participation, may refuse some activities at certain times, goes outside as an activity at his request, also enjoys arts and crafts. Interventions include: Escort the resident to preferred setting as requested; establish a rapport with the family. R102 demonstrate(s) movement behavior that may be interpreted as wandering, pacing or roaming. R102 attempts to leave the facility without a responsible escort (elopement) and will become agitated, oppositional and combative when redirected by staff. R102's care plan does not include personalized behavioral interventions to address causes of or prevent behaviors. The facility's Comprehensive Care Plan Policy reviewed/receive 04/25/2024 states To meet the resident's physical, psychosocial and functional needs, the facility will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and target goals. The Facility IDT will develop and implement a person-centered care plan for each resident/patient in conjunction with resident and his/her family/ or legal representative's participation in care. Care plan interventions or approaches will be based on resident or patient health records, comprehensive assessments, resident/patient preferences and reasonable requests from family/legal representative. The comprehensive, person-centered care plan will be measurable and attainable. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedure for ensuring residents are provided necessary behavioral health care and services to maintain their highest practicable mental and psychosocial wellbeing consistent with a comprehensive assessment and plan of care and for the prevention and treatment of substance use disorders by not developing comprehensive person-centered care plans, and not reporting signs of resident substance use to social services,. This failure applies to two of three residents (R85, and R102) reviewed for behaviors. Findings include: 1. R85 is a [AGE] year-old male with a diagnoses history of End Stage Renal Disease and Nicotine Dependence who was admitted to the facility 09/17/2022. On 04/22/24 from 10:55 - 12:13 PM surveyor observed a strong odor of Marijuana outside of and in R85's room. Observed R85 with strong Marijuana odor near him. Observed R85 walking through the facility with his eyes appearing red and droopy. On 04/23/24 at 9:12 AM surveyor observed strong Marijuana smell in R85's room. On 04/23/24 at 09:34 AM surveyor observed along with fellow surveyor hallway near R85's room and R85's room with a strong smell of marijuana. On 04/23/24 at 12:40 PM surveyor observed R85 sleeping in his bed. R85 stated he had been out of the facility earlier and is often in and out of the facility. On 04/23/24 at 01:00 PM surveyor observed V12 (Licensed Practical Nurse) measure R85's blood pressure. V12 stated R78 blood pressure fluctuates depending on dialysis. Surveyor observed R85's eyes to be red and droopy. Surveyor observed V12 administer R85's blood pressure and Kidney medication. V12 stated at times R85 smells of marijuana and if observed with this smell social services is notified and they will talk to him. On 04/24/24 at 10:01 AM V4 (Assistant Director of Nursing/Registered Nurse) stated, she is not aware of any residents returning to the facility under the influence of substances. V4 reported that she can check the policy on contraband searches, however the facility may not necessarily search residents upon return from the community. V4 stated, if nursing smell marijuana, social services is notified and the nurse and social service staff inform the resident of the concerns brought to their attention then get permission from resident to fully search their room. V4 stated, these situations have occurred at times with residents. V4 stated other signs of marijuana use include eyes blood shot, smell of marijuana on person. V4 stated concerns of marijuana use for residents include that other substances may have been within the marijuana that affect cognition, safety issues, and medication use. V4 stated the nurse would perform a full head to toe assessment including vital signs if residents show any signs that they are under the influences of other illegal substances along with marijuana. R85's Current care plan documents he expresses the desire to receive an outside, independent pass, he must make a commitment to behave appropriately while in the community, take medications as prescribed and remain clean and does not include personalized interventions regarding substance use. R85's Progress Notes from February - April 2024 did not include observations of substance use. On 04/24/24 at 01:01 PM V21 (Social Services) stated, she has not received any reports of R85 using any substances. V21 stated, if it was reported that a resident possibly used Marijuana a room search would be conducted and they may possibly receive a clinical assessment or be sent out for evaluation and testing. V21 stated, if the resident has an outside pass, they would be restricted if they are showing signs of intoxication. V21 stated, due to receiving dialysis, if R85 was using marijuana it could affect his dialysis treatment, and there would also be concerns of bringing substances into the facility, and general safety. 2. R102 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder (as of 08/17/2023), Adjustment Disorder with Mixed Anxiety and Depressed Mood (as of 07/13/2023), who was admitted to the facility 02/19/2023. R102's social service progress notes dated 02/27/2024 documents he attempted elopement. Writer met with R102 to counsel on the importance of making staff aware of issues before he gets too anxious and frustrated in future situations. He expressed understanding. R102 will be on 72 hour follow up. Staff will monitor for aggression and mood changes. Social services will follow up. R102's social service progress note dated 3/5/2024 documents created by V2 (Social Services Director) Day 1: Writer was made aware of resident was presenting with exit-seeking behavior. Writer approached resident and he appeared in an anxious mood at this time. R102 was re-directed and reoriented by writer back to a quiet and safe setting to discuss noted behavior. Writer encouraged R102 to vent feelings or concerns to staff. R102 expressed understanding at this time. Social Services will continue to monitor behaviors. R102 requires constant reminders to decrease in behavior, facility protocols, plan of care, his safety, and a need for daily supervision. R102 has a history of Elopement. Care Plan Updated. R102's Psychiatry/Mental Health progress note created by V25 (Psychiatric Nurse Practitioner) dated 3/13/2024 documents Chief Complaint: Follow up mood. History of Present Illness: [AGE] year-old male with Opioid Use, Unspecified, Uncomplicated and Adjustment Disorder with Mixed Anxiety and Depressed Mood. There were no behavior issues to report. Staff nurse had no complaints and did not report any behaviors. R102's Psychotropic Progress note dated 3/21/2024 documents Chief Complaint: Follow up adjustment disorder. There were no behavior issues to report. Staff nurse had no complaints and did not report any behaviors. R102's Psychotropic Progress note dated 3/29/2024 documents Chief Complaint: Follow up mood There were no behavior issues to report, and his mood has been baseline per staff. Staff nurse had no complaints and did not report any behaviors. R102's Health Status Progress Note dated 4/4/2024 created by V11 (Psychotropic Nurse) documents a Change In Condition/s reported on this change in condition evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis). R102's Progress note dated 4/4/2024 documents he is being aggressive, being delusional, trying to elope out the front door, and is not able to be redirected. Writer called resident's Psych Physician and left a voice message. Writer asked the Physician. to call back to the facility concerning the resident. Writer notified Director of Nursing to make her aware of resident's behavior. Writer called Insight hospital and gave nursing report. Writer called transportation to schedule pick-up for the resident. R102's Progress note dated 04/6/2024 documents he became verbally and physically threatening to writer. Resident is not able to be redirected after several failed attempts to calm him down. Resident stormed out of the facility unescorted against writer and other staff request . Code yellow was called staff quickly responded to bring him out the courtyard back inside. Physician was notified ordered to send resident out to insight hospital for psychiatric evaluation. R102's social service progress note dated 4/8/2024 by V21 (Social Services) documents Note Text: Behavior monitoring Day 1 of 3. Writer met with (staff) to conduct well-being check. Resident went outside with writer along with psychotherapist for about an hour. R102's social service progress note dated 4/10/2024 12:37 documents a code yellow was called to the receptionist area and upon arrival the resident was at the front door trying to elope, being physically/verbally aggressive. Writer tried to talk to the R102, and he continued to scream/yell. R102 was not able to be redirected. The writer informed the V13 (Nurse Practitioner) and orders were to send the resident to local hospital. A petition will be sent along with the resident. R102's social health status progress note dated 4/16/2024 documents writer approached resident regarding skin assessment, resident was pacing and appeared upset, writer asked R102 if he was ok, he yelled No and kept walking. Writer later saw R102 on the 2nd floor of the building attempting to get into the social services office, he appeared upset, staff was able to redirect him. Writer unable to complete an assessment on the resident due to aggressive behaviors. R102's progress note dated 4/23/2024 at 2:16 PM documents he is showing aggressive behaviors towards staff physically and verbally. The resident is not able to be redirected. A petition to hospital has been presented to the writer for the resident. The writer has contacted ambulance service for transport to hospital was given. The Director of Nursing and V13 (Nurse Practitioner) is aware of the residents petition/transport; at 3:30 PM Behavior follow up note: documents Writer was made aware by nursing staff that resident was inside of nursing office exhibiting with verbal aggressive behavior and demanding that nursing staff change his current out on pass order from supervised to independent. R102 voiced that he is capable of going out alone and wants order changed immediately. Writer approached resident and he was in an agitated mood. R102 was asked kindly to exit nursing office and go speak to social services in their office. When R102 entered office, he was asked to sit as he was standing in doorway of social services office yelling and screaming stating, I want my pass changed now! I don't understand why I can't go out by myself! R102 was reassured that he was safe and that he ok with staff. Resident was then asked again to sit and calmy express himself, resident refused. Resident was then notified of outside pass procedures, his gait imbalance, poor decision making, and safety awareness. R102 then continued to express agitation towards staff with noted verbal aggression, while resident was in the doorway of social services office another resident approached social services office to notify them of his return from Association House Skills Training. R102 then turned towards peer and yelled loudly, this is my time I'm busy leave now! Peer was immediately assisted out by social service designee to his room. R102 remained in social services office with noted uncontrollable verbal aggressive behavior. Social services continued to encourage resident to speak in a soft tone of voice resident refused. R102 was then asked to be taken on a walk down to his room to calm down. Once R102 reached first floor nursing station he refused to present in a calm manner. Social services was notified by nursing staff to petition resident out for psychiatric evaluation, noted aggression towards staff and peer and uncontrollable verbal outburst. R102 has a history exhibiting with, exit seeking behavior, aggressive/inappropriate behavior, attention seeking behavior, conflicts/altercations with others, and acting impulsively, and erratically. R102's current medical diagnoses are Aphasia Following Cerebral Infarction, Symptoms and Signs Involving Emotional State, Other Symptoms and Signs Involving Appearance and Behavior, Recurrent Major Depressive Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Opioid Use. R102 suffers from a family history of verbal abuse. R102 currently receives psychotherapy and agrees with counseling sessions at this time. Social Services will continue to follow up, intervene, and council resident as needed. R102 is currently petitioned out to hospital for assessment review. Care plan updated. On 04/24/24 at 12:45 PM V21 (Social Services Designee) stated, a lot of R102's frustrations are from him wanting to go outside so sometimes staff will take him outside for a walk upon request. V21 stated R102 also visits with psychotherapist 3-4 times per week, engages in activities, and his needs are addressed by social services when expresses them. V21 stated, she is not aware of any group programs for residents, but the psychotherapist or social services director may have more information. V21 stated she keeps in touch with V26 (Psychotherapist/Psychologist) often regarding R102's behaviors. V21 stated she believes V25 (Psychiatric Nurse Practitioner) works along with the V11 (Psychotropic/Fall Nurse). V21 stated, she only communicates with V26. V21 stated, it's pretty important to communicate behaviors to R102's psychotropic care team which is why she tries to communicate consistently with V26 so she can meet with R102. V21 stated R102 wants to be outside probably daily and even wants to go out at times after he's already been out. V21 stated, on occasion R102 can be taken outside multiple times a day depending on who's available. V21 stated, R102 likes to watch videos on his computers, but mainly likes sitting outside when he can. V21 stated, if activities are not being offered enough or R102 isn't able to go outside frequently enough it may contribute to more behaviors. V21 stated R102 exhibits these behaviors sometimes even when offered activities and outside time. V21 stated, if activities and outside time are still not adequate for R102 we'll try to work with him and she personally will invite him to her office just to vent his frustrations which can be helpful. V21 stated, if none of these options are sufficient they may offer him something from the kitchen, activities, or see if there's anyone he wants to speak to. V21 stated, she believes V26 can refer residents to outside services or providers for psychosocial services if needed. R102's current care plan documents he is a younger individual [AGE] years of age and presents with a Substance abuse history and difficulties expressing himself. He may present with poor motivation, lack of energy. May state he is bored or act bored. Interventions include: Assess the need for additional, formal education needs and offer referrals, as appropriate for educational opportunities; Assure the resident is in an appropriate treatment setting. R102 has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior. R102's history includes conflicts/altercations with others, acting impulsively, and erratically by throwing chairs. R102 has been noted flipping over tables when he is stressed and refuse staff redirection/reorientation to setting. On 11/21/23 R102 was noted with aggression towards staff. Interventions include: If R102's symptoms warrant further assessment of ongoing management, Refer him to a mental health professional, including a consulting psychiatrist, for evaluation; Intervene when any inappropriate behavior is observed. Communicate assertively that he must exercise control over impulses and behavior (Social skills training); Provide supportive intervention as needed; R102 demonstrates strong activity participation, may refuse some activities at certain times, goes outside as an activity at his request, also enjoys arts and crafts. Interventions include: Escort the resident to preferred setting as requested; establish a rapport with the family. R102 demonstrate(s) movement behavior that may be interpreted as wandering, pacing or roaming. R102 attempts to leave the facility without a responsible escort (elopement) and will become agitated, oppositional and combative when redirected by staff. R102's care plan does not include personalized behavioral interventions to address causes of or prevent behaviors. R102's progress notes do not document any communication with V25 (Psychiatric Nurse Practitioner) or V26 (Psychotherapist/Psychologist) regarding R102's elopement, aggressive, inappropriate, attention seeking or maladaptive behaviors. R102's point of care activities reports from 03/26/2024 - 04/24/2024 documents he primarily engaged in self-directed indoor audio related (such as listening to music) activities daily, and only engaged in indoor group activity once during the month on 03/26/2024 and once in outdoor group activity on 04/17/2024. R102's medical records do not include documentation of referrals for group or supervised outside psychosocial services activities and do not include documentation of him being offered time outside with staff. On 04/24/24 at 01:27 PM V11 (Psychotropic/Falls Nurse) stated, V26 (Psychotherapist/Psychologist) is the psychologist or social therapist that meets with the residents and attempts to visit with residents twice weekly for 30 minutes. V11 stated, If V26 notices behaviors she provides suggestions and then she communicates that to V25 (Psychiatric Nurse Practitioner) who comes in to the facility twice weekly. V11 stated, every week she always updates crystal with a list of all residents on psych medication or with a psych diagnosis and residents that may have had behaviors that week. V11 stated the IDT (Interdisciplinary Team) meets once weekly and discuss behaviors and requests V25 to prioritize these residents when she comes in and conducts her rounds. V11 stated, she believes R102 had a stroke at a young age [AGE]. V11 stated, she is always been able to sit and talk with R102 and has not had to send him out, but at times he cannot be calmed down or deescalated. V11 stated,she gave R102 a supervised pass but that does not seem to be sufficient. V11 stated, she believes R102 does no belong at the facility and maybe belongs in a different type of facility. As of the exit of the annual certification survey the facility did not provide a policy for substance abuse or behavior health services as requested 04/25/2024. The facility's Comprehensive Care Plan Policy reviewed/receive 04/25/2024 states To meet the resident's physical, psychosocial and functional needs, the facility will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and target goals. The Facility IDT will develop and implement a person-centered care plan for each resident/patient in conjunction with resident and his/her family/ or legal representative's participation in care. Care plan interventions or approaches will be based on resident or patient health records, comprehensive assessments, resident/patient preferences and reasonable requests from family/legal representative. The comprehensive, person-centered care plan will be measurable and attainable. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to document medication administration in the Electronic Medical Record in accordance with acceptable clinical practice for seven (R29, R109, R17, R64, R28, R86, R25) residents reviewed for medication administration. Findings include: On 04/23/24 at 08:47 AM V8 (License Practical nurse) stated, I finished passing all my medications for all my patients. The electronic medical record screen displays a yellow color over all residents' names. V8 stated, I did not sign the medications after I passed them. I normally pass the medication first for each resident, then I will sit down and sign them out, even though the facility policy is to sign each medication after the patient takes them, I did not do it today. R29 was admitted on [DATE] with diagnosis that include and are not limited to diabetes and sacral pressure ulcer, per current physician orders dated: 4-2024 reads: 12 medications are due at 9:00am R109 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes and acute kidney failure, Per current Medication administration dated; 4-2024 reads: 9 medications are due at 9:00am. R17 was admitted on [DATE] with diagnosis that include and are not limited to: atrial fibrillation and hypertension, per current Medication administration dated; 4-2024 reads: 14 medications are due at 9:00am. R64 was admitted on [DATE] with diagnosis that include and are not limited to hypertension and prosthetic heart valve, per current Medication administration dated; 4-2024 reads: 5 medications are due at 9:00am. R28 was admitted on 2-22-2020 with diagnosis that include and are not limited to chronic back pain, asthma and polycystic ovarian syndrome, per current Medication administration dated; 4-2024 reads: 14 medications are due at 9:00am. R86 was admitted on [DATE] with diagnosis that include and are not limited to chronic obstructive pulmonary disease and atrial fibrillation, per current Medication administration dated; 4-2024 reads: 14 medications are due at 9:00am. R25 was admitted on [DATE] with diagnosis that include and are not limited to: cerebral infarct and tracheostomy, per current Medication administration dated; 4-2024 reads: 11 medications are due at 9:00am. Per census report dated: 4-23-2024 reads, 14 residents currently in unit 2 north. On 04/23/24 at 08:50 AM V3 (Director of Nursing) stated, my expectation is for the nurses to sign the medications as soon as they are done giving the medication. It is not acceptable to wait and signed them out later. On 4-24-2024 at 1:30pm V4 (Assistant Director of Nursing) stated, my expectation is for the nurses to complete the medication pass and signed the Electronic Medical Administration Record. It is unacceptable to wait until all medications are passed because you need to document vital signs and you can forget if any patient refused any. V4 presented, Facility Policy Title Medication administrations dated 05/18/23 reads, nurse administering medications initials/signs the resident's Electronic Medical Administration Record (EMAR) after giving medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provide shower/bed bath and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected 6 residents (R3, R7, R21, R47, R78, R99) of 11 residents reviewed for ADL care. Findings include: R21 is [AGE] years old and have resided at the facility since 2021, past medical history includes multiple sclerosis, hyperlipidemia, acquired absence of left leg below the knee, history of falling, etc. On 04/22/24 at 10:55AM, R21 was observed in bed, awake and alert and stated that she is doing okay, R21 told surveyor to come closer, because she had something to show surveyor. R21 raised up her head from the pillow and showed surveyor her long hair that was clumped together and matted in the back, with a lump of hair in the middle all tangled up. R21 stated, the facility does not give her showers or bed bath, no one has ever washed or combed her hair since admission, she does not want it washed or combed at this point because it is too painful, she just wants them to cut it off. R21 further stated, her bed baths are scheduled at night while other residents get theirs during the day, and R21 must wait more than 4 hours sitting in urine before getting changed. R21 stated, she has not been changed today, she was last changed last night. R21 added, she has some redness on her bottom from sitting in urine for a long time, they gave her a cream to apply, staff does not help her with brushing her teeth and all she needs is for someone to put toothpaste on her toothbrush, she cannot do that due to a contracture in her right hand, but she can brush her own teeth. Resident's room was noted to be dirty with lots of garbage and used medicine cups and pink liquid on the floor. On 04/22/24 at 11:02AM, V6 (CNA) was observed going into the room. Surveyor asked V6 if he was going to change the resident. V6 stated, yes, he added that he has not changed the resident today, and he started his shift at 8:00AM because he was a little later today. V6 was observed changing resident's incontinence brief that was visibly soiled with urine and brown in color. On 04/23/24 at 9:45AM, R21 was observed in bed, awake and alert and stated she was in pain. The CNA just changed her and moved her around, but the nurse just gave her medications. R21 added that the last time she was changed was last night, and she is still waiting for someone to cut her hair. On 04/24/24 at 10:36AM, surveyor went to R21's room with V4 (ADON) who examined resident's clumped and matted hair, V4 stated, this is unacceptable, she will get someone to take care of it. Resident stated, she does not want her hair to combed at this point because it is very painful, she just wants someone to cut it out. MDS assessment dated [DATE] scores resident with a BIMs score of 14 out of 15, section GG of the same assessment coded resident as being totally dependent on staff for most ADL care needs except for eating and oral hygiene. ADL care plan initiated 4/12/2024 stated that R21 has an ADL care self-care performance deficit related to impaired ability with dressing and grooming and requires total assistance x 1 staff for ADLs. R21 was scheduled for showers on Monday and Saturday on 3PM to 11PM shift. Review of shower sheets for the month of April 2024 showed R21 received 2 bed baths, on 4/13/2024 and 4/15/2024. R3 is a [AGE] year-old female who have resided at the facility since 2009, past medical history includes, but not limited to chronic obstructive pulmonary disease, chest pain, essential primary hypertension, unspecified osteoarthritis, respiratory failure, etc. On 04/22/24 at 11:36AM, R3 was observed in her room, awake and alert. Staff was at the bedside and stated she is about to change resident but is waiting for another staff. R3 stated, she is usually changed after lunch, but she has not been changed today. R3 stated, she was last changed last night. R3 added, she does not get showers and cannot remember the last time she had a bed bath. V22 (CNA) who was in the room at with resident stated, she has not changed resident because they are short staffed, they should have 4 CNAs but they only have 3 and they still have to do breakfast and assist with feeding. V22 further stated, they have 15 residents each and some of them are 2-person assist so it takes a while to get to everyone on time. On 04/23/24 at 9:50AM, R3 was observed again in her room, awake and alert and stated, she is still waiting to be changed, she was last changed early morning around 3:00AM. On 04/24/24 at 10:10AM, R3 was observed in bed and stated, she is still waiting to be changed. V24 (CNA) was in the room and stated, she is about to change resident, she started her shift at 7:00AM, and she is not sure how many residents she has right now. V24 stated, they have 3 CNAs on the third floor, they sometimes have 4 CNAs and it is better when they work with 4. V24 proceeded to give resident a bed bath, when she removed resident's brief, it was visibly soiled with urine and brown in color. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored R3 as 12 for brief interview for mental status (BIMS) Section GG (functional abilities) of the same assessment documented that R3 requires substantial/maximal to total dependence on staff for all ADL care. Care plan initiated 12/06/2023 stated that R3 has ADL self-care performance deficit and requires extensive assist x 1 staff for all ADL care needs. Per shower schedule on the third floor, R3 is scheduled for shower two times a week on Wednesday and Friday, review of shower sheets for the month of April 2024 showed R3 received a bed bath two times on 4/17/2024 and 4/20/2024. R47 is an [AGE] year-old male who have resided at the facility since 2019, with past medical history including, but not limited to unspecified sequelae of cerebral infarction, hyperlipidemia, chronic kidney disease stage 2, presence of cardiac pacemaker, essential primary hypertension, heart failure, etc. 04/22/24 10:55AM, R47 was observed in his room reading a book and stated he is doing okay. R47 asked surveyor to speak to his wife whom is in bed B. Resident was noted with long hair and beard. R47 stated, they do not have enough staff to help residents, and he has not been washed and cannot remember the last time he had a shower or bed bath. R47 further stated, there is no one to help him with trimming his beard or cutting his hair. On 04/23/24 at 10:58 AM, 9:45AM, R47 said that he has not been washed up yet, he has a wound on his bottom, but it will not be changed today, they changed it yesterday, resident still noted with lots of overgrown hair and beard, lying down in a hospital gown. R47 has a BIMs score of 13 and is coded as requiring substantial/maximal assist to total dependence on staff for most ADL care. Care plan dated 1/02/2020 stated that resident has an ADL care performance deficit and impaired mobility related to CVA, COPD and Dementia and requires assistance of 1 staff for ADL cares, bed mobility, transfers, and toileting. R47 is scheduled for showers on Tuesdays and Thursdays, review of shower sheets for April 2024 showed that R47 received a bed bath once on 4/2/2024. On 04/24/24 at 11:10AM, during wound care observation for R47, surveyor asked V18 (LPN) if resident ever refused wound care. V18 stated, :No. R47 was asked in the presence of the wound team if he refuses shower or bed bath and he said that he can never refuse a bed bath. R7 is a [AGE] year-old-male who have resided at the facility since 2020, past medical history includes, but not limited to colostomy status, acquired absence of other specified parts of the digestive tract, gout, rhabdomyolysis, type 2 diabetes, etc. On 04/22/24 at 11:50AM, R7 was observed in his room, alert and oriented and stated that he has been at the facility for a long time, everything is going well except that call light sometimes takes 30 to 40 minutes to be answered. R7 stated, the facility need more staff, sometimes they get agency which helps, he does not get a shower or bed bath, sometimes they help him wash his face, he was asked if he would like to be shaved and he said yes, a staff used to help him trim his beard and hair but he lost his scissors, not sure what happened to it. On 04/23/24 at 10:03AM, R7 was observed again in his room, awake and alert and stated that he got washed up but did not get a shave or haircut. Review of shower schedule showed that R7 is scheduled for showers on Monday and Fridays, shower sheets for the month od April 2024 indicated R7 received a bed bath two times, on 4/4/2024 and 4/10/2024. MDS assessment dated [DATE] scored R7 with a BIMs score of 14, section GG of the same assessment that R7 requires substantial/maximal assistance to total dependence on staff foe all ADL care needs. Care plan initiated 9/27/2022 stated that R7 has ADL self- care deficit related to chronic diastolic congestive heart failure, gout, obesity, type 2 diabetes, etc. On 04/24/24 at 10:01AM, V4 (ADON) stated, she started working at the facility November of 2023 as an ADON. The CNAs are supposed to follow the shower schedule, if a resident refuses shower, a bed bath is offered and if they still refuse bed bath, the CNA should notify the nurse, and sometimes the family or guardian will be contacted. Showers can be done as needed, not just on shower days, the CNAs are supposed to help residents with all ADL needs including dressing, brushing their teeth, nail care and any other help they may need. V4 added, the facility does not have anyone that comes in to give residents haircut, CNAs are supposed to wash resident's hair on shower days and shave the male residents. ADL care policy dated 01/01/2021, revised 7/22/2023 states in part that the facility ensures that residents receive ADL care assistance and maintains resident's comfort, safety, and dignity. The goal is to maximize the residents and staff safety, confidence, independence, and ability to handle everyday activities. Under procedures, the policy states in part: Facility will identify ADL needs of the residents and assess performance and capabilities to complete task on admission, quarterly and as needed. 3. Care plan will be developed to enhance completion of ADLs. 6. Assist the resident to be clean, neat, and well-groomed including nail care and having finger and toenails cut on shower days and as needed. R78 is a [AGE] year-old male with a diagnoses history of Cerebral Infarction, Unspecified Symptoms and Signs Involving the Nervous System, and Aphasia following Cerebrovascular Disease who was admitted to the facility 11/10/2022. On 4/23/24 at 11:19 AM Observed R78 with a strong urine body odor, along with his gown and linens. R78 shook his head no when asked by surveyor if he needed to be changed. R78 shook his head up and down to confirm he wants to get up later when asked by surveyor if he wanted to be dressed and raised out of bed. R78's admission Minimum Data Set, dated [DATE] documents he requires supervision and setup for transfers and walking and most activities of daily living and one-person physical assistance for locomotion on and off the unit, toilet use and personal hygiene. On 04/23/24 at 01:24 PM V28 (Family Member) stated sometimes she comes in at three in the afternoon and R78 has an extremely strong urine smell and still in a bed that has not been changed and she'll get him up. V28 stated R78 can't sit up due to medications and stroke. V28 stated her main concern is R78 getting a little more attention. V28 stated when she comes to visit R78 is in a urine-soaked bed and his gown has a urine smell. V28 stated she's assuming R78 gets changed once a day maybe later at night. V28 stated she would like to see R78 get more assistance, he needs more prompting to get up, get showered. V28 stated sometimes when R78 goes out at night they don't make sure he takes his clothes off when he returns, and he sleeps in his clothes and urinates in them. V28 stated R78 needs help. On 04/24/24 at 03:16 PM V2 (Assistant Administrator) stated R78 has a history of refusing ADL (Activities of Daily Living) care and the facility regularly has to contact V28 for him to comply with incontinence care and bathing, V2 stated social services are also involved because R78 lacks motivation to get out of bed and engage in activities of daily living. V1 (Administrator) and V2 stated these issues are included and addressed in R78's care plan. R78's current care plan documents he is incontinent but prefers to do his own toileting; R78 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to impaired ability with Dressing and Grooming such as: Putting on or take off clothing, unable to obtain or replace article of clothing, unable to fasten clothing, unable to groom self satisfactorily, unable to complete task with personal hygiene, unable to bathe and groom self independently; R78 requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) with interventions including: Assist resident with shower/bathing per schedule, Encourage participation in ADL's; R78 exhibit(s) the symptoms of resisting care by refusing caregiver requests to leave the bed and refusing/resisting ADL assistance (bathing, dressing, grooming, transferring, etc.) with interventions including: Conduct an evaluation of the behavioral symptoms(s) to determine what strength or needs are communicated via the behavior (e.g., resisting care often communicates the emotion of fear and need for control). R78's current care plan does not include personalized interventions to address his refusal of ADL care and does not document the causes of his refusals. R78's Progress notes from March 01/2024 - April 24/2024 do not document refusals of attempts to provide him with ADL care of incontinence, showers, or personal hygiene. R78's Psychotropic progress notes dated 03/21/2024, and 04/04/2024 created by V25 (Psychiatric Nurse Practitioner) document Staff nurse had no complaints and did not report any behaviors. R99 is a [AGE] year-old female with a diagnoses history of Type 2 Diabetes Mellitus, Morbid Obesity, Contracture of Right Knee and Ankle, On 04/23/24 10:25 AM surveyor observed R99 lying in her bed. R99 stated her assigned certified nursing assistant was supposed to bring ice approximately 9:30 AM but never came back. R99 stated call light response times are between 45 minutes to an hour and a half and she just wants to be changed. R99 stated she is supposed to have showers twice week on Mondays and Thursdays from 3-11. R99 stated she typically has to want for 11-7 shift to receive showers and receives bed baths because she requires multiple staff for assistance. R99's current care plan documents she has an ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired Mobility related to Type 2 Diabetes Mellitus, Disorders of tendon of right ankle and foot, Depression, Pruritus, Obesity, Asthma, Rash Skin Eruption, Dislocation of Patella, and Contracture of Right Ankle and Right knee. Interventions include: requiring total assistance with transfer and preferring staff to provide prompt pericare each shift and as needed. On 04/24/24 at 1:44 PM V27 (Restorative Aide) stated, she works with R99 at varying times depending on the week but she is sometimes pulled to the floor to work as a CNA (Certified Nursing Assistant). V27 stated, she is pulled to the floor about 2-3 times per week which is approximately half the time she works during the week. V27 stated R99 has expressed concerns regarding call light response time and receiving assistance or services as requested. V27 stated sometimes she will educate the CNA's on R99's needs and if she observes her call light on will sometimes step in and assist. V27 stated she has not observed R99's call light on for a long period of time but if she sees the light on and observes her to be frustrated, she'll offer her assistance. V27 stated R99 complains about these issues often and has even stated she will call the state. V27 stated she is not sure if these concerns would be considered grievances. V27 stated she is not sure and can not recall being trained on how to handle grievance concerns. On 04/25/2024 at 3:22 PM V1 (Administrator) stated, if a resident feels issues with call light response time and receiving assistance with activities of daily living continues for an extended period or they want to escalate it, a grievance form can be completed. Grievances/Concerns from January - April 2024 were reviewed and did not include concerns from R99 regarding call light response time or receiving assistance with activities of daily living. The facility's Grievance Policy received/reviewed 04/25/2024 states: It is the policy of the facility to allow and encourage residents and their families to express grievances and concerns they may have regarding the facility, services and staff. Responsible Parties Include: All facility staff. Guidelines Include: 2. Any staff member in the facility may receive a grievance or complaint from a resident or family member. 3. All grievances will be overseen by the facility grievance official. 4. If possible, upon receiving the grievance, attempt to resolve the grievance or direct the resident or family member to the appropriate department head or the Administrator. 6. The staff member will submit the grievance form to the appropriate department head/designee for resolution.

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing coverage to adequately meet the residents care needs. This failure has the potential to affect all 45 residents who are currently residing on the third floor. Findings Include: Per daily census report dated 4/22/24 shows that 45 total residents reside on the third floor. On 4/22/24 at 11:36AM, R3 stated, she is usually changed after lunch but she has not been changed at all today. R3 stated, the last time she was changed was last night (4/21/24). R3 stated, the staff get upset when I use my call light. V22 (CNA) stated, R3 has not been changed today because they are short staffed. V22 stated, they need to have four CNA's but they only have three CNA's. V22 stated, a lot of the resident's on the third floor need two person assistance and assistance with meals. This requires a lot of care and takes a while to get all the resident's up out of bed. On 4/23/23 at 10:10AM, V1 (Administrator) was interviewed regarding new facility interventions put into place to help prevent abuse. V1 stated, since 4/16/24, we have implemented a new intervention where male certified nursing assistants (CNA's) are required to have a female CNA present when performing incontinence care. This surveyor asked V1 if she feels as if they have enough staff to perform this intervention. V1 stated, she does not feel as if it is a problem. On 4/24/24 at 9:30AM, V6 (CNA) was interviewed regarding staffing. V6 stated, I do not feel as if we have enough staff to implement this 'care in pairs' intervention. We typically have only three CNA's on the third floor and a lot of resident's need assistance with ADL care. One CNA is responsible to be in the dining room at all times to watch residents who require supervision. Therefore, the two CNA's who are left are responsible to perform incontinence care in pairs. V6 stated, on 4/22/24, we were stretched thin with care and did not have enough staff. I had to perform incontinence care without a female CNA because there were none available. I was late arriving to my shift. R21 was saying she was very soiled and wanted me to provide incontinence care as soon as possible. On 4/24/24 at 10:10AM, R3 said she has been waiting to be changed and has not been changed since the previous shift started before 7:00AM. V23 (CNA) said they have three CNA's assigned to the third floor but it is so much better when they have four CNA's. R3's incontinence brief was observed to be heavily soiled with urine and brown in color. On 4/24/24 at 1:45PM, V27 (Restorative Aide) said she is pulled off the floor 2-3 times a week to work as a CNA because they are constantly short staffed. V27 said she has to work as a CNA on the floor and will not be able to perform her restorative duties when this happens. On 4/24/24 at 3:07PM, V1 (Administrator) was interviewed regarding staffing. V2 said on the third floor, adequate staffing would include 4 CNA's providing each side of the third floor with two CNA's. The residents on the third floor are more dependent and have increased ADL needs. It is not feasible to have three CNA's on the third floor. On 4/24/24 at 3:25PM, R21 was interviewed regarding staffing within the facility. It is to be noted that R21 resides on the third floor. R21 said this new 'care in pairs' procedure they put in place does not make sense since they do not have enough staff as is. R21 said there are times that I work with V29 (Male CNA) and he refuses to change me when there is not a female CNA available. I will have to sit in my urine or feces for over four hours since there is not an available female CNA. R21 was observed to get visibly upset and start crying during interview. R21 was observed to be unkempt, wearing gown, with dreaded hair at time of interview. Facility Assessment Tool states in part but not limited to the following: General staffing plan shows that 1 LPN/RN to 22 residents for all shifts and 1 CNA to 14 residents for all shifts. Per staffing schedules from 3/27/24-4/25/24 and interview with V23 (Nursing Scheduler) on 4/24/24, It is to be noted that on the 11PM-7AM shift, one nurse is scheduled for 45 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were nine (9) medication errors out of 29 medication opportunities, resulting in a 31.03% medication error rate. This applies to 6 residents (R1, R15, R19, R22, R37, R92) of 10 residents observed during medication administration. Findings included: 1. On 04/23/24 at 09:40 AM Medication observation with V10 (license Practical Nurse) completed for R22. R22 has a diagnosis of cerebral vascular disease, Atrial Fibrillation and Congestive Heart failure. V10 gave the following medications crushed and in apple sauce to R22: Isosorbide mononitrate 30mg 1 tab, Aspirin 81mg 1 tab- Per Physician order sheet dated: April 2024 reads: Aspirin Oral Tablet 325 MG (Aspirin) Give 1 tablet by mouth one time a day, identified wrong dose was given. Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day. 2. On 04/23/24 10:00 AM Medication observation with V10 for R37. R37 was admitted on [DATE], with the diagnosis of Diabetes II, and Low back pain. V10 said, the Lidocaine patch is not available. Per Physician order sheet dated: April 2024 reads: Lidocaine External Patch (Lidocaine) Apply to behind neck topically one time a day. 3. On 04/23/24 10:03 AM Medication observation with V10 completed for R19. R19 is a [AGE] year-old female originally admitted on [DATE] with diagnosis that include and are not limited to: fibromyalgia, hypertension and osteoarthritis. 4-23-2024 at 10:05am V10 said, I am holding the medications since her blood pressure is lower than 110. Per Physician order sheet dated: April 2024 reads: Furosemide Tablet 20 MG Give 1 tablet by mouth one time a day was not given, no written parameters to hold medication as per order dated: 11-15-2023. Per Medication administration dated April 23-2024 documentation reads: 5- hold medication. 4. On 04/23/24 at 10:22 AM Medication observation with V10 completed for R15. R15 was admitted to the facility on [DATE] with the diagnosis of Heart failure, Chronic Obstructive pulmonary disease, Chronic Viral Hepatitis C, and Hypertension. V10 said, I am holding R15's blood pressure medication per parameters, I do not have any medications to give R15 now. I am done with R15. Per Physician order sheet dated: April 2024 reads: Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for Elevated MCV- not given. Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhalers orally two times a day- not given. 5. 04/23/24 10:28 at AM Medication observation with V10 completed for R1. R1 was admitted to the facility on [DATE] with diagnoses that include and are not limited to diabetes and heart failure. V10 said, we do not have the Flonase suspension, I must call the pharmacy to reorder the medication. Maybe the night nurse threw it out because it did not have a date open in the box. Per Physician order sheet dated: April 2024 reads: Biofreeze Gel 4 % (Menthol (Topical Analgesic)) Apply to both ankles topically two times a Day- not given. Flonase Suspension 50 MCG/ACT (Fluticasone Propionate)1 spray in both nostrils two times a day- not given. R1 said am not getting the Flonase for 7 days, I keep asking the nurse. 6. On 04/24/24 at 08:55AM Medication observation with V12 (licensed Practical Nurse) completed for R92. R92 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: heart failure, Atrial Fibrillation and hypertension. V12 administered to R1 the following medication: Gabapentin Oral Capsule 100 MG 2 capsule by mouth. Per Physician order sheet dated: April 2024 reads: Gabapentin Oral Capsule 100 MG Give 3 capsule by mouth three times a day. Incorrect dose given. On 04/23/2024 at 12:40 PM, V13 (Nurse Practitioner) said, when blood pressure medications do not have parameters to hold, my expectation is for the nurse to call the provider for further orders. On 04/24/24 at 01:29 PM V4 (Assistant Director of Nursing) said, any extended Released medication should not be crushed, we need to have a doctor's order for the medication to be crushed, after checking R22's physician's orders, V4 said, I do not see any order for R22's for medications to be crushed. On 2-24-2024 at 3:00pm V4 presented: 1. Policy titled: Medication Administration General Guidelines, undated: reads, long acting or enteric coated dosage should not be crushed; alternative should be sought. 2. Policy titled: Meds that should not be Crushed Dated 2/2023, reads crushing extended-release meds can result in administration of a large dose at once.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow its enhanced barrier precaution policy by failing to place any signage with informational material on one (R47) resident door or making personal protective equipment (PPE) available inside or outside resident's room perform hand hygiene between glove changes during wound care observation, failed to clean blood pressure machine and glucose monitor device after used between patients. and failed to keep linen in a closed hamper with the lids closed. These failures affect six (R15, R19, R22, R29, R38, R47) residents reviewed for infection control practices Findings Include: On 04/23/24 at 09:15 am, surveyor observed V10 (License Practical Nurse) taking blood pressure on R15, then on R22 without cleaning the blood pressure cuff. R15 was admitted on [DATE] with diagnosis that include and are not limited to hypertension and heart failure. R22 was admitted on [DATE] with diagnosis of hypertension and cerebral infarction. On 04/23/24 at 10:12 AM surveyor observed V10 taking R19's blood pressure and putting it in top of the cart without cleaning the cuff, when asked if task was completed V10 said, yes. R19 was admitted on [DATE] with diagnosis that include and are not limited to hypertension and heart failure On 4-23-2024 at 10:30 AM V10, said the blood pressure equipment needs to be cleaned with the disinfectant, and I did not do it. On 04/24/24 at 8:50am, during medication pass, V12 (License Practical Nurse) was observed performing blood sugar check for R38, then placed the machine on top of the medication cart, when asked if task was completed, V12 said yes. No cleaning of the equipment observed to be done. V12 said, the blood glucose machine needs to be clean after each resident's use, and I didn't do it. R38 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes type 2 On 04/24/24 at 8:55 am, during medication pass with V12, observed to use bare hands to touch medications and giving it to R22. V12 said I should have not touched the medications with my own hands, I need to perform hand hygiene or wear gloves because is an infection control problem. On 04/24/24 at 9:46 Observed V18 (wound care nurse) performing a dressing change for R29 and after removing soiled dressing V18 donned and doffed gloves on two different occasions without any hand hygiene or hand washing. Surveyor observed a soiled linen and garbage hamper with both lids open in R29's room. V18 said, I am expected to sanitize my hands every time I remove the gloves, but I did not do it, my expectations, the staff is to keep the hamper with soiled linen outside of the room and with the lids closed. R29 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes, pressure ulcer of sacral. On 04/24/24 at 1:29 PM V4 (Assistant Director of Nursing) said, the staff must clean the equipment after each resident used, hampers are not to have the lids open, not supposed to be inside the resident's rooms, hampers are to stay outside the room to be used. I expect for the nurses to perform hand hygiene when performing dressing changes and each time they are changing gloves. On 04/25/24 at 2:30 pm V19 (Infection Preventionist) said, the facility expectation is: blood pressure monitors and blood glucometers are supposed to be sanitized after each resident use, medications can not be touched with bare hands before giving to residents, hampers with soiled linen are to be kept outside the room with the lid closed. Nurses are expected to perform hand hygiene before wound care, after removing the gloves and after each resident. V4 (Assistant Director of Nursing) presented: 1. Policy Titled: Cleaning and Disinfection on the Resident-Care items and Equipment, dated 05/28/23 reads: Reusable Items are cleaned or sterilized between residents. 2. Policy titled: Administering Medications dated: 5-18-2023 reads: staff follows stablished facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves) for the administration of medication as applicable. 3. Policy Titled: Handwashing/Hand Hygiene, dated 04/12/24 reads: Hand Hygiene before and after direct contact with residents, before performing and after handling blood fluids, and after handling used dressings, and contaminated equipment. 4. Policy: Linen Management, dated: 5-18-2023 reads: It is the policy of the facility to ensure linens are handling in a way to prevent cross contamination; dirty linens are contained in a closed container. Based on observation, interview and record review, the facility failed to follow its enhanced barrier precaution policy by failing to place any signage with informational material on resident's door or making personal protective equipment (PPE) available inside or outside resident's room. This failure affected one resident (R47) who is currently receiving wound care at the facility. Findings include: R47 is an [AGE] year-old male who have resided at the facility since 2019, with past medical history including, but not limited to unspecified sequelae of cerebral infarction, hyperlipidemia, chronic kidney disease stage 2, presence of cardiac pacemaker, essential primary hypertension, heart failure, etc. 04/23/24 10:58 AM, 9:45AM, R47 was observed in his room, awake, alert, and oriented and said that he has not been washed up yet, he has a wound on his bottom, but it will not be changed today, they changed it yesterday, and he is due again tomorrow. Resident was not on any type of isolation, there was no signage on the door or any isolation bin inside or outside the room. 04/24/24 11:10AM, observed wound care for resident with V15 (LPN/wound care), V18 (LPN/wound care coordinator) and V20 (Wound care C.N.A) and noted a large area of excoriation on resident's bottom with some spots open and actively bleeding. V18 donned gown and gloves, removed the old dressing and cleaned resident's bottom with normal saline. Staff used hand sanitizer, donned another glove, and applied the ordered treatment to resident. R47 does not have any isolation sign on the door, or any set up for isolation. Surveyor asked V15 if resident was supposed to be on any type of isolation and she said that resident was supposed to be on enhanced barrier precaution, the sign on the door fell off. Surveyor informed V15 that resident have not had any isolation set up or sign on his door since the start of survey 4/22/2024.V15 said, Oh, okay. 04/24/24 12:20PM, V19 (infection prevention Nurse) said that residents on enhanced barrier precaution are those with indwelling catheter, wounds, G-tube or on dialysis. said that she is responsible for setting up the isolation equipment and making sure there is a sign on the door. V19 was asked if she is familiar with R47 and why he is not on any type of isolation and she said that she is not aware that resident needed to be on any isolation, does not know that resident have any wounds, no one communicated that to her. V19 also said that wound team does not give her any report, she mostly goes by word of mouth. A document presented by V1 (Administrator) titled enhanced barrier precaution with a revision date of 3/28/2024 states in part under general: Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multidrug Resistant Organisms (MDRO) EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices. Under Guideline, the document states in part: Enhanced Barrier Precautions applies to all residents with any of the following: Wounds, and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. When a resident is placed in Enhanced Barrier Precautions, gown and gloves will be used during high-contact resident care activities. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE, Enhanced Barrier Precautions signage and informational material should indicate the high-contact resident care activities that require the use of gowns and gloves. Make PPE, including gowns and gloves available, discretion maybe used in placement of PPE (inside or outside of the room) and may not need to be donned prior to entering the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure stock medications, eye drops and insulins were labeled with open and expiration date, failed to label multidose vials and multidose liquid medications and failed to dispose expired medications. These failures affected 8 (R2, R7, R8, R16, R23, R42, R69 and R100,) residents reviewed for medication storage and labeling and have the potential to affect 126 residents receiving medications on all floors. Three out of six medication carts and three out of three medication rooms reviewed for medication storage and labeling. Findings include: On 04/23/24 at 11:00am, medication storage and labeling observation completed with V10 (Licensed Practical Nurse) on the second-floor south medication cart, 1-Humalog insulin vial opened and not dated for R2. 2-Cromolyn Sodium Ophthalmic Solution 4% opened and undated for R69 3- Levetiracetam 100mg/ml for R8 opened and undated. Floor stock Medication observed to be open and undated as follows: 1 Bottle Pro Stat 1 Bottle Bismuth Subsalicylate 1 Bottle Acetaminophen 160mg/ml 1 Bottle Milk of Magnesium 1 Bottle Geri-Tussin (Guaifenesin) 1 Bottle Clear Lax V 10 said, I do not see any open date on the vials eye drops and floor stock medication, the medications should be dated after opening. Per Physician order sheet dated: April 2024 reads: 1. R2 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes mellitus, has a current order for HumaLOG Injection Solution 100UNIT/ML (Insulin Lispro) per sliding, order active as 2-19-2023. 2. R69 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes, has a current order for Cromolyn Sodium Ophthalmic Solution 4% (Cromolyn Sodium) Instill 1 drop in both eyes one time a day, active date 1-13-2023. 3. R8 was admitted [DATE] with diagnosis that include and are not limited to: epileptic syndrome and Cerebral infaction, has a current order for levETIRAcetam Oral Solution 100 MG/ML (Levetiracetam) Give 10 ml by mouth two times a day order active as 2-14-2024. On 4/23/24 12:40pm medication storage and labeling observation completed with V30 (Licensed Practical Nurse) on the First Floor South Medication Cart, 4. Lactulose Suspension 10gm for R42 opened and undated. Floor stock Medication observed to be open and undated as follows: 1 Bottle Milk of Magnesium 1 Bottle Bismuth Subsalicylate 1 ClearLax, Polyethylene Glycol 3350 Powder. First Floor North Refrigerator observed to have a multidose vial of Tuberculin opened and undated. V30 said, we as nurses need to document the date the bottles are open, I do not see any dates documented. 4. Per Physician order sheet dated: April 2024 reads: R42 was admitted on [DATE] with diagnosis that include and are not limited to chronic viral hepatitis has no current order for, Lactulose Oral Solution 10 GM/15ML (Lactulose), order was discontinue on 4-8-2024. 04/23/24 at 01:10 pm, medication storage and labeling observation completed with V14 (Licensed Practical Nurse) on the third Floor South Medication Cart, Briomidine 0.2% eye drop and Latanoprost 0.005% eye drops for R23 opened and undated. Lantus insulin vial for R100 opened and undated. Humalog insulin vial for R7 opened and undated. Haloperidol 2mg/ml for R16with documented expiration date of: 03/21/24. Scolamine gel 2.5mg/ml for R16 with documented expiration date of: 11/1/23 Floor stock Medication observed to be open and undated as follows: 1 Bottle Iron Supplement suspension 220mg/5ml 1 Bottle Geri-Tussin (Guaifenesin) 1. R23 was admitted on [DATE] with diagnosis that include and are not limited to: Cerebral infarct, has a current order for: Latanoprost Ophthalmic Solution 0.005 %(Latanoprost) Instill 1 drop in both eyes at bedtime with active order of 2-2-2024. Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in both eyes every 8 hours with active order of 2-2-2024. 2. R100 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes mellitus has a current order for Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously, with active order 4-16-2024. 3. R7 was admitted on [DATE] with diagnosis that include and are not limited to: diabetes mellitus has a current order for HumaLOG Injection Solution 100UNIT/ML (Insulin Lispro) Inject as per sliding scale, with active order 11-8-2023. 4. R16 was admitted on [DATE] with diagnosis that include and are not limited to: dementia, per April 2024 no current orders for the above medications. On 04/23/24 at 01:30 PM V14 said, the insulin vials, eye medications and floor stock medications must be dated when medication is opened and when it needs to be discarded. On 04/23/24 at 01:35 pm V11 Unit Manager/Psych Nurse said, I expect the staff to discard the medications when expired and they need to date the medications when it is opened. Medication must be returned to pharmacy when residents are discharge from the facility and/ or expired. 04/23/24 at 01:00 PM Director of Nursing (DON) V3 said, the Insulins, eye medications and house stock must be dated when it is opened. V4 (assistant Director of Nursing) presented: 1. Facility Policy: storage of medication, undated: reads; medications and biologicals are store safely, securely, and properly. All expired medications will be removed from the active supply. 2. Administering medications, dated: 05/18/23 reads: the expiration/beyond use date on the medication label, is checked prior to administering. when opening a multi-dose vial-dose container, the date opened is record on the container.

Based on interviews and record reviews, the facility failed to follow its abuse prevention policy to prevent incidents of resident-to-resident abuse. This affected six of eight residents reviewed (R3 - R8) reviewed for resident-to-resident abuse. This failure resulted in R4 stabbing R3 with a butter knife after a verbal disagreement, R8 throwing a walker at and hitting R7 causing a bruise, and R6 slapping R5 in the face with a open hand. Findings include: 1. R3: On 3/29/24 at 1:10pm, R3 was assessed to be alert and oriented x 3. R3 stated that his previous roommate, R4, and he got into a verbal altercation over the volume of the television. R3 stated that R4 then picked up a butter knife and was swinging it at R3. R3 stated that R4 cut him on his head with the butter knife. R3 stated that he informed V24 (former administrator) of this incident. R3 stated that he and R4 were separated. R3 stated that he went to the dining area and R4 remained in R3 and R4's room until R4 was transported to the hospital for psychiatric evaluation. R3 stated that he informed his case manager of this incident on 7/26/23 and she reported it to facility. R3's BIMS (brief interview of mental status) score, dated 3/5/24, notes R3's score is 15 out of 15. R3 is cognitively intact and able to make needs known. On 4/5/24 at 9:30 AM, V2 (assistant administrator) stated that he started working at this facility three years ago as the social service director. V2 stated that he became the assistant administrator in March of this year. V2 stated that the situation between R3 and R4 was reported to the facility by R3's case manager July 2023. V2 stated that he was informed that while R3 and R4 were roommates, R4 was threatening R3 with a butter knife. V2 stated that it was stated that R3 was poked with the butter knife. V2 stated that a skin assessment was completed on 7/26/23 which did not show any signs of injury. When questioned if he would expect to see R3's injury nearly three months after it occurred, V2 responded V2 would not expect to see injury. V2 stated that if an incident occurs, a body check is done, and it should be reported immediately to administration. V2 stated that V2 does not know if it was reported as an allegation of verbal altercation in May 2023. V2 stated that it was reported to him as a verbal dispute over the volume of the television. V2 stated that given the type of resident R4 was with his history of violence and aggressive behavior, R4 was sent to the hospital. V2 stated that a resident's hospital record should be reviewed by the nurse upon re-admission to facility. V2 stated that he is unaware of what was documented in R4's hospital record as he does not review the hospital records. V2 stated that prior to this event on 5/1/23, V2 did point of care charting in the resident's electronic medical record for all well-being checks he conducted with residents. V2 stated that after this event and until V2 changed his job position in March 2024, he did point of care charting for all well-being checks conducted with residents. V2 stated that he conducted well-being checks with R3 in May but did not document in R3's electronic medical record until after 7/26/23 when informed by R3's case manager of the incident involving R3 and R4 with R4 threatening R3 with a butter knife. V2 stated that he did not ask R3 if there was any physical contact or details of incident between R3 and R4 during the late documented well-being checks. When questioned if it is appropriate to not enter documentation into a resident's medical record for nearly 3 months, V2 responded he thought it was a verbal dispute only. V2 stated that R4 was sent for psychiatric evaluation due to his history of aggressiveness and his room was changed upon returning to this facility. On 4/5/24 at 12:06 PM, V21 (social services director) stated that staff are expected to immediately intervene in resident to resident altercations, and counsel both residents, and report to administrator. V21 stated that well-being checks are done on both residents when there is an altercation. V21 stated that social services completes three day behavior charting and counseling both residents involved in the altercation. V21 stated that if the resident is transported to the hospital for psychiatric evaluation, then social service staff should review the hospital records upon the resident's re-admission for psychiatric evaluation and recommendations. V21 stated that admissions staff gets notified when resident ready to return to facility. V21 stated that the resident cannot return to same room if the altercation was with roommate; resident will be placed in another room upon re-admission. V21 stated that there should have be three day follow up and psychotherapy weekly upon the resident returning if it was serious as altercation as it was between R3 and R4. On 4/9/24 at 2:45 PM, V1 (administrator) stated that the expectation is for staff to report immediately any allegations of abuse. V1 stated that staff should intervene, and separate residents involved in a verbal altercation to prevent incident escalating into a physical altercation. This facility's investigation of the allegation of physical abuse involving R3 and R4, dated 7/26/23, notes R3 reported the incident involving R4 to his case manager on 7/26/23. R3 reported that he had a disagreement some months ago with his previous roommate, R4, regarding the volume of the television. During this disagreement R4 attempted to stab him. R3 stated that staff immediately separated both residents. Police were notified. V27 (former ADON - assistant director of nursing) was interviewed on 7/26/23. V27 stated she was made aware of the disagreement between R3 and R4 on 5/1/23. V27 stated when she arrived on the nursing unit, the residents were separated. R4 in room being monitored and R3 went to the common area. V27 stated R4 was delusional and not re-directable at that time. R4 went to hospital for psychiatric evaluation. V44 (agency nurse) was interviewed. V44 heard R3 yelling in his room 'R4 is stabbing me'. The report V44 gave to the emergency department was she was sending R4 out for aggressive behavior towards roommate, R3, and needed evaluation. The butter knife scraped R3 when she did the skin assessment. V27 and V28 were unable to be interviewed during this survey. V44 was unable to be interviewed during this survey. There was no documentation found noting R3 was assessed by V44. On 5/1/23 at 6:15 PM, R4 was petitioned out by V27 (former ADON) and V28 (former DON). R4's medical record notes the following: On 4/12/23 at 4:35 PM, V45 (former social services) notes V45 witnessed R4 expressing delusions and attempting to be aggressive with another resident. V45 re-directed R4, counseled on behavior and made staff aware. Staff will monitor for aggressive actions. On 4/20/23 at 9:46 AM, V47 NP (psychotropic nurse practitioner) noted R4's mood has been stable without worries. Staff nurse had no complaints and did not report any behaviors. On 5/1/23 at 6:39pm, V28 (former DON - director of nursing) noted R3 had dispute with roommate, R4, related to the volume of the television in the room. Staff responded to the dispute and separated the two residents. R4 received medication for agitation. Order received for R4 to be transported to hospital for psychiatric evaluation. Well-being check was conducted on R3. R3 currently in dining room watching television. On 5/8/23 R4 re-admitted to facility. R4 and roommate, R3, not getting along and R4 requested a new room. Placed in room on another nursing unit temporarily until morning staff can change room. On 5/11/23 at 6:32 AM, V47 NP noted per staff, R4 is a re-admit after becoming aggressive with staff and residents. He was sent out on a psychiatric evaluation and came back on more medications. R4 had to change room assignments on his first night back, 5/8, after becoming aggressive towards roommate (R3). On 7/31/23 at 3:20 PM, V2 (assistant administrator) documented a late entry for 5/5/23 at 12:17 PM. V2 noted he was made aware by nursing that R3 got into a peer conflict with his roommate, R4, and V2 met with R3 to conduct a wellbeing check and counsel on appropriate interactions. R3 expressed understanding and stated, Yeah, we got into it. V2 informed R3 that he will not be around the peer from here on out. Staff will monitor for mood changes. Social services will follow up. On 7/31/23 at 3:22 PM, V2 documented a late entry for 5/6/23 at 9:20 AM. V2 noted V2 met with R3 to conduct wellbeing check and remind him to alert staff of any issues he may have with peers and/or staff so that it can be handled immediately. R3 expressed understanding. Staff will continue to monitor. On 7/31/23 at 3:29 PM, V2 documented a late entry for 5/7/23 at 10:22 AM. V2 noted V2 met with R3 to counsel him that the safety of every resident is paramount, and it is important that he make staff aware of any issues so that they can be dealt with in a timely manner. R3 expressed understanding. R4's hospital record, dated 5/2/23-5/8/23, the psychiatric physician noted R4 with a long-standing history of very poorly controlled bipolar disorder and delirium. R4 presented to the emergency department on 5/1/23 after R4 grabbed a knife and threatened R3 with it. The facility feels R4 is in danger of hurting someone. R4 has a low threshold for confrontational behavior. R4's care plan for the presence of abuse and neglect factors, initiated 9/24/2020, notes R4 presents with a host of medical problems and psychiatric history. R4 presents with a risk for becoming a perpetrator of abuse. R4 is known to become upset/agitated and requires medication management and supervision/attention on the unit. R4's behavior symptoms/inappropriate boundaries care plan, initiated 2/3/2023, notes R4 has threatened physical aggression toward peers. R4's history of aggressive/inappropriate behavior care plan, initiated 9/24/2020, notes R4 has a history of aggressive, inappropriate, and/or maladaptive behavior. R4 has history of conflicts/altercations with others, exhibiting delusional behaviors toward others, and acting erratically. 2.R5: R5 no longer resides in facility and was unable to be interviewed regarding incident involving R6. On 4/5/24 at 2:45 PM, V33 CNA (certified nurse aide) stated that she does not recall incident involving R5 and R6 last August. V33 stated that R6 has behaviors, it is random who she may be upset with on any given day. V33 stated that R6 has behavior of kicking residents' chairs. On 4/9/24 at 11:50 AM, V33 reviewed the statement she provided in August regarding the incident involving R5 and R6. V33 stated that the statement she provided to V24 (former administrator) at the time of the incident was a truthful account of what happened. On 4/5/24 at 3:15 PM, V29 LPN (licensed practical nurse) stated that she vaguely recalls the incident between R5 and R6 last August. V29 denied witnessing the incident. On 4/9/24 at 3:40pm, V29 LPN reviewed her statement she provided in August regarding the incident between R5 and R6. V29 stated that the interview she provided at the time of the incident was a truthful account of what happened. The facility's abuse investigation, dated 8/23/23 at 4:20 PM, R5 alleged an allegation of abuse involving R6. R5 stated that R6 made contact with the left side of his face with an opened hand. Both residents separated immediately. Police notified. R6 placed on 1:1 monitoring until sent to the hospital for psychiatric evaluation. V33 CNA stated she was in the dining room when both residents were talking about cigarettes. V33 stated that she heard R5 say that R6 touched his face. V33 immediately separated the residents. V29 LPN stated that she did not witness the alleged incident. V29 recalls hearing R5 and R6 talking. V29 stated that V33 informed her of the altercation. V29 assessed R5, no pain or bruising noted. 3. R7: On 4/2/24 at 1:15 PM, R7 was assessed to be alert and oriented x 3. R7 stated that R8 came to his room and began yelling at him. R7 stated that R8 then picked up his walker and threw it at R7. R7 stated that he raised his arms to block the walker from hitting him. R7 stated that the walker hit his left arm causing bruising. R7 denied any staff member being in R7's room at the time of this incident. R7 stated that he informed the V24 (former administrator) of the incident. The facility's abuse investigation, dated 8/6/23 at 6:55pm, notes R7 reported to V40 (manager on duty) that R8 entered his room and allegedly stated to R7 mind your f***ing business, you are always in my f***ing business and flung his walker at R7. R7 assessed and observed to have bruise to left arm. X-ray ordered. R8 was sent to the hospital for psychiatric evaluation. R8 placed on 1:1 monitoring until transported to hospital. R7 interview noted R7 was sitting on edge of bed with R7's walker in front of him. R8 picked up walker and threw it, R7 raised left arm to block walker causing bruise on left arm. CNA (certified nurse aide) in room at time of incident and responded immediately to separate residents. V32 CNA was interviewed at the time of this incident. V32 stated that he was in R7's room behind privacy curtain. V32 stated that he heard residents yelling at each other. V32 stated that he did not hear what they were saying. V32 denied witnessing R8 throw walker at R7. V39 (agency nurse) was interviewed at the time of this incident. V39 stated that she did not witness the alleged occurrence. V39 stated that she was informed that both residents were hollering at each other and it was a verbal disagreement. R7 reported incident to V40 during her rounds and V40 reported incident to V39. R7's medical records, dated 8/6/23 at 6:41 PM, V39 (agency nurse) noted V39 made aware by R7 that he was in a verbal altercation with R8 and stated that the R8 threw his walker at me. Head to toe assessment completed for injuries, dark red bruising and small skin tear with scant bleeding noted to the left lower arm. As needed acetaminophen given as ordered for comfort. Skin tear cleaned with normal saline solution and bacitracin ointment applied. Physician on call made aware and ordered for urgent x-ray for the lower left arm. R8's history of aggressive/inappropriate behavior care plan notes R8 has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior by becoming easily agitated and exhibiting poor impulse control, as evidenced by exhibiting with covert/open conflict, general intolerance and limited ability to deal with frustration and a history of substance abuse. R8's mood distress-conflict with other persons care plan, notes R8 displays conflictual, difficult behavior with peers and staff. R8 exhibits a difficult time adjusting to life in the long-term care facility, complaints/concerns about other residents, general intolerance and limited ability to deal with frustration and a history of substance abuse. The facility's abuse prevention policy, dated 11/22/2017, notes residents have a right to be free from abuse.

Based on interviews and record reviews, the facility failed to follow its abuse policy and immediately report an incident of resident-to-resident abuse to the regulatory agency. This affected two of six residents (R3, R4) reviewed for abuse policy and reporting. This failure resulted in a delay in reporting for over 2 months. Findings include: On 3/29/24 at 1:10pm, R3 was assessed to be alert and oriented x 3. R3 stated that his previous roommate, R4, and he got into a verbal altercation over the volume of the television. R3 stated that R4 then picked up a butter knife and was swinging it at R3. R3 stated that R4 cut him on his head with the butter knife. R3 stated that he informed V24 (former administrator) of this incident. R3 stated that he and R4 were separated. R3 stated that he went to the dining area and R4 remained in R3 and R4's room until R4 was transported to the hospital for psychiatric evaluation. R3 stated that he informed his case manager of this incident on 7/26/23 and she reported it to facility. R3's BIMS (brief interview of mental status) score, dated 3/5/24, notes R3's score is 15 out of 15. R3 is cognitively intact and able to make needs known. On 4/5/24 at 9:30 AM, V2 (assistant administrator) stated that he started working at this facility three years ago as the social service director. V2 stated that he became the assistant administrator in March of this year. V2 stated that the situation between R3 and R4 was reported to the facility by R3's case manager July 2023. V2 stated that he was informed that while R3 and R4 were roommates, R4 was threatening R3 with a butter knife. V2 stated that it was stated that R3 was poked with the butter knife. V2 stated that a skin assessment was completed on 7/26/23 which did not show any signs of injury. When questioned if he would expect to see R3's injury nearly three months after it occurred, V2 responded V2 would not expect to see injury. V2 stated that if an incident occurs, a body check is done, and it should be reported immediately to administration. V2 stated that V2 does not know if it was reported as an allegation of verbal altercation in May 2023. V2 stated that it was reported to him as a verbal dispute over the volume of the television. V2 stated that given the type of resident R4 was with his history of violence and aggressive behavior, R4 was sent to the hospital. V2 stated that a resident's hospital record should be reviewed by the nurse upon re-admission to facility. V2 stated that he is unaware of what was documented in R4's hospital record as he does not review the hospital records. V2 stated that prior to this event on 5/1/23, V2 did point of care charting in the resident's electronic medical record for all well-being checks he conducted with residents. V2 stated that after this event and until V2 changed his job position in March 2024, he did point of care charting for all well-being checks conducted with residents. V2 stated that he conducted well-being checks with R3 in May but did not document in R3's electronic medical record until after 7/26/23 when informed by R3's case manager of the incident involving R3 and R4 with R4 threatening R3 with a butter knife. V2 stated that he did not ask R3 if there was any physical contact or details of incident between R3 and R4 during the late documented well-being checks. When questioned if it is appropriate to not enter documentation into a resident's medical record for nearly 3 months, V2 responded he thought it was a verbal dispute only. On 4/9/24 at 2:45 PM, V1 (administrator) stated that the expectation is for staff to report immediately any allegations of abuse. V1 stated that staff should intervene, and separate residents involved in a verbal altercation to prevent incident escalating into a physical altercation. This facility's investigation of the allegation of physical abuse involving R3 and R4, dated 7/26/23, notes R3 reported the incident involving R4 to his case manager on 7/26/23. R3 reported that he had a disagreement some months ago with his previous roommate, R4, regarding the volume of the television. During this disagreement R4 attempted to stab him. R3 stated that staff immediately separated both residents. Police were notified. V27 (former ADON - assistant director of nursing) was interviewed on 7/26/23. V27 stated she was made aware of the disagreement between R3 and R4 on 5/1/23. V27 stated when she arrived on the nursing unit, the residents were separated. R4 in room being monitored and R3 went to the common area. V27 stated R4 was delusional and not re-directable at that time. R4 went to hospital for psychiatric evaluation. V44 (agency nurse) was interviewed. V44 heard R3 yelling in his room 'R4 is stabbing me'. The report V44 gave to the emergency department was she was sending R4 out for aggressive behavior towards roommate, R3, and needed evaluation. The butter knife scraped R3 when she did the skin assessment. V27 was unable to be interviewed during this survey. V44 was unable to be interviewed during this survey. There was no documentation found noting R3 was assessed by V44. R3's progress notes, dated 5/1/23 at 6:39pm, V28 (former DON - director of nursing) noted R3 had dispute with roommate, R4, related to the volume of the television in the room. Staff responded to the dispute and separated the two residents. R4 received medication for agitation. Order received for R4 to be transported to hospoital for psychiatric evaluation. Well-being check was conducted on R3. R3 currently in dining room watching television. V28 was unable to be interviewed during this survey. On 5/1/23 at 6:15 PM, R4 was petitioned out by V27 and V28. On 7/31/23 at 3:20 PM, V2 (assistant administrator) documented a late entry for 5/5/23 at 12:17 PM. V2 noted he was made aware by nursing that R3 got into a peer conflict with his roommate, R4, and V2 met with R3 to conduct a wellbeing check and counsel on appropriate interactions. R3 expressed understanding and stated, Yeah, we got into it. V2 informed R3 that he will not be around the peer from here on out. Staff will monitor for mood changes. Social services will follow up. On 7/31/23 at 3:22 PM, V2 documented a late entry for 5/6/23 at 9:20 AM. V2 noted V2 met with R3 to conduct wellbeing check and remind him to alert staff of any issues he may have with peers and/or staff so that it can be handled immediately. R3 expressed understanding. Staff will continue to monitor. On 7/31/23 at 3:29 PM, V2 documented a late entry for 5/7/23 at 10:22 AM. V2 noted V2 met with R3 to counsel him that the safety of every resident is paramount, and it is important that he make staff aware of any issues so that they can be dealt with in a timely manner. R3 expressed understanding. R4's hospital record, dated 5/2/23-5/8/23, the psychiatric physician noted R4 with a long-standing history of very poorly controlled bipolar disorder and delirium. R4 presented to the emergency department on 5/1/23 after R4 grabbed a knife and threatened R3 with it. The facility feels R4 is in danger of hurting someone. R4 has a low threshold for confrontational behavior. R4's care plan for the presence of abuse and neglect factors, initiated 9/24/2020, notes R4 presents with a host of medical problems and psychiatric history. R4 presents with a risk for becoming a perpetrator of abuse. R4 is known to become upset/agitated and requires medication management and supervision/attention on the unit. R4's behavior symptoms/inappropriate boundaries care plan, initiated 2/3/2023, notes R4 has threatened physical aggression toward peers. R4's history of aggressive/inappropriate behavior care plan, initiated 9/24/2020, notes R4 has a history of aggressive, inappropriate, and/or maladaptive behavior. R4 has history of conflicts/altercations with others, exhibiting delusional behaviors toward others, and acting erratically. The facility's abuse prevention policy, dated 11/22/2017, notes abuse means any physical injury upon a resident other than by accidental means. The administrator or designee will notify the resident's representative and physician of the alleged incident and the investigation. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpretrator has been removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for admissions by not ensuring an admitting resident or his representative received and signed admissions paperwork and not including their admissions paperwork procedures in their admissions policy. This failure applies to one of three residents (R2) reviewed for admissions. Findings include: R2 is an [AGE] year old male with a diagnoses history per the facility's face sheet of Gout, Cognitive Communication Deficit, Heart Failure, Malaise, Alcohol Withdrawal, Adult Failure to Thrive, Weakness, Dehydration, Anemias, Altered Mental Status, Severe Protein Calorie Malnutrition, Peripheral Vascular Disease, Dysphagia, Hyperlipidemia, Hypokalemia, and Hypo magnesia who was admitted to the facility 11/16/2022. R2's progress notes from admission [DATE] to being transferred to the hospital 11/23/23 does not include documentation of him receiving any admissions paperwork. On 05/24/23 at 10:55 AM V2 (Director of Nursing) stated admissions is responsible for ensuring residents admission paperwork is completed. V2 stated if a resident is physically impaired and unable to complete admissions paperwork their family is contacted. V2 stated within 72 hours the nursing staff should be able to contact the family to have admissions paperwork complete. On 05/24/23 at 12:11 PM V20 (Assistant Administrator/Admissions Director) stated the facility attempts to complete the admissions process within 3-4 days depending on the patients preferences. V20 stated some residents refuse to sign or want to have family review paperwork prior to signing. V20 stated R2 was very weak during admission so she called V19 (Family Member) and left a message attempting to reach her to complete his admissions paperwork. V20 stated admissions paperwork is the contract between the resident and the facility which includes the facility's rules, their rights, Health Insurance Portability and Accountability Act, Privacy Act, and informing who the administrator is. V20 stated she was not able to have R2's admission paperwork completed because he discharged . V20 stated she didn't have any admissions paperwork for R2's. The facility's admission and readmission Policy reviewed 05/25/23 states: It is the policy of this facility to ensure that the facility complies with federal regulations in terms of admission. It does not include policy/procedures regarding the admissions paperwork.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their resident discharge instructions by not reconciling medications with the physician orders for 1 (R7) resident out of 3 reviewed for discharge. Findings R7 is [AGE] years of age. Current medical diagnoses include but are not limited to: End Stage Renal Disease. R8 is [AGE] years of age. Current medical diagnoses include but are not limited to: Chronic Obstructive Pulmonary Disease. R7 was discharged from the facility on 5/5/2023. R8 was discharged from the facility on 5/18/2023. On 5/22/2023 at 2:43 PM, V15 Family Member was interviewed regarding R7. V15 stated, R7 was in bed C and she had a roommate named R8. My family member was there at the facility when R7 was discharged . I got home and went through her medications and saw there was 1 particular medication Digoxin that wasn't hers. There were 5 individual bingo cards. R7's discharge seemed rushed because that morning they called and said there was a lapse in her insurance, and she would have to pay for her stay. They didn't even reach out to the family before discharging her. They just called and asked if she had a place to stay and transportation. V5 ADON signed her discharge papers. R7 called the facility and they said they would come and get the medication. V5 ADON came and picked up the medication. I was worried about the other resident needing her heart medication. On 5/23/23 at 1:57 PM, V5 ADON was inquired of R7's discharge. V5 stated, The agency nurse V35 Agency Nurse did the medication reconciliation. I did sign the discharge form. I printed out the discharge, I went over the discharge with the agency nurse and explained how we do it with the order summary and I told her to get the resident's medications prepared. I told the nurse to review the medication with the resident. V35 Agency Nurse was not able to be contacted for interview. On 5/24/23 at 2:44 PM, V1 Administrator was inquired of the wrong medication being sent home with R7. V1 stated, I sent V5 ADON to get R8's medication from R7's house. R7 called the facility to say she had R8's medication. R8 didn't miss any doses of her medication. I asked V5 how did this happen with two nurses doing the discharge? V5 said the agency nurse must have grabbed R8's medication by mistake. I provided education to both nurses. R7 and R8's physician orders were reviewed. R8's physician orders indicate Digoxin Oral Tablet 125 MCG (Digoxin), Give 1 tablet by mouth one time a day every other day for heart failure. R7's physician orders did not include Digoxin. Review of the 5/5/23 discharge instructions signed by V5 ADON Assistant Director of Nursing indicates: F. Discharging Nurse b. Medications given to resident or representative upon discharge was reconciled with the list of medications printed and given to resident/responsible party. See attached copy of R7's discharge instructions. On 5/25/23 at 2:11 PM, V2 DON provided the following discharge policy for review, see attached. The revised 7/28/22 Transfer and Discharge Policy states in part: Policy Statement: It is the policy of the facility to allow the resident to remain in the facility unless certain conditions are met: Procedures1. Obtain a physician order for transfers to other facilities or discharge to the community. 6. Provide adequate preparation by giving resident or the responsible party education on the transfer/discharge procedure. The 1/6/23 Discharge Planning and Instruction policy states in part: Policy Statement: It is the policy of this facility to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge on ce a discharge order is obtained from the resident's attending physician. Procedure: 1. Discharge planning shall be initiated by the facility on resident admission and re-evaluated quarterly. 6. Discharge instructions shall be provided by pertinent disciplines consistent to the resident's special needs during discharge. 7. Discharge instructions form shall be completed by the facility and provided to the resident and/or responsible party. 9. Medications will be sent with the resident being discharged to the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to implement fall prevention interventions to prevent a resident from falling. This affects 1 of 5 residents (R9) reviewed for accident hazards in the sample of 29 residents. Findings include: R9 is a [AGE] year old resident with diagnoses listed in part with mild cognitive impairment, heart disease, hypertension, and fracture of the femur. R9's care plan dated 3/9/23 reads in part, (R9) is at risk for falls related to: type 2 DM, history of falling, essential primary hypertension, dementia, and UTI. Goal: will be free of falls through next review period. Interventions: Ensure that I will be able to use the call light. If the light is difficult to press, consider giving me a foam pad call light or other adaptive call lights; I have periods of forgetfulness. I would like staff to frequently reorient me to my surroundings; I need continued skilled therapy intervention to improve my strength and endurance; I prefer to keep all needed items like water pitcher, tissue box, urinal, etc, within reach. On 5/22/23 at 11:50 AM, R9 was observed sitting up in bed that was placed against the wall. R9's call light was hanging from the wall and on the floor away from R9's reach. There were no items that were within R9's easy reach; and there were no assuasive devices or fall prevention devices observed such as fall alarms or fall mats to protect R9 from any future falls. Facility policy revised 5/17/22 titled Fall Occurrence reads: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure: 1. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission, readmission, quarterly, significant change, and annually. 2. Those identified as high risk for falls will be provided fall interventions. An interim Falls Care Plan may be started but a Falls Care Plan is necessary and required after the State required MDS was done. 3. If a resident had fallen, the resident is automatically considered as high risk for falls. Therefore, the nurse does not have to fill out the Fall Risk Assessment to determine if the resident is high risk for falls or not, after the resident had fallen. 4. An incident report will be completed by the nurse each time a resident falls. 5. The Falls Coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 6. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator ' s investigation. 7. Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator ' s investigation identifies a more appropriate intervention for the individual fall. 8. The Falls Coordinator will add the intervention in the resident ' s care plan. 9. The incident may be written in the nurses notes or other parts of the resident ' s medical record that will remain accessible to any person who has the right to access the resident ' s record. 10. The interventions will be reevaluated and revised as necessary.

Based on observation, record review and interview the facility failed to have a resident call cord in reach and failed to answer call lights in a timely manner for 2 of 5 residents (R1 and R3) in the sample. Findings include: 1. On 02/17/2023 at 12:36 PM, observed R1 lying in bed on his back eating cheese puffs. R1 said that he thinks staff do change his dressing as scheduled, then said he has waited like 30 minutes for his call light to be answered. At 12:46 PM, R1 said watch this then pressed his call light. At 12:47 PM, V4 (Staffing Coordinator) entered R1's room. 2. On 02/18/2023 at 10:57 AM, observed R3 lying on her back in bed, call light on the floor. R3 said she has no issues to speak of. At 11:02 AM, surveyor called V7 (Certified Nursing Assistant) to R3's room to locate call light. V7 said R3 just had her dressing changed as she picked up her call light from the floor, handed light to R3 and said it should be within reach. Reviewed resident council meeting minutes and grievance/concern logs for last 6 months with numerous complaints each month indicating poor customer service received from (agency) staff, long wait times for call light to be answered during the night, and medications being administered late with minimal follow up and/or interventions documented. On 02/17/2023 at 3:38 PM, V3 (Director of Nursing) also said follow ups with nursing concerns from resident council meetings and grievance concern logs are usually generalized. When she interviews residents, she asks for specific names, dates, times, specific issue, and shift to properly investigate. V3 instructs residents to notify staff at time of occurrence or following day, not waiting until the next resident council meeting which makes it hard to identify the staff member and/or investigate the issue. V3 (Director of Nursing) said most of the complaints are from agency staff and they are DNR'd (do not return). Then added with facility staff, will re-educate depending on the infraction and speak to HR for level of discipline. V3 added that there shouldn't be long call light wait times because all staff should look on residents not just nursing, other department can assist, utilize resident assistants in the morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary care and services for residents in need of diabetic management, wound care and medication management for 3 of 5 residents (R1, R2 and R4) reviewed for nursing care and services. Findings include: 1. Wound list provided by facility showed R1 has 2 surgical wounds, 3 vascular wounds and 1 pressure ulcer. R1 is a [AGE] year-old male who admitted to facility on 06/08/2021. date of birth is 08/05/1963. He has a past medical history not limited to: Type 2 Diabetes, Essential Hypertension, Transient Ischemic Attack and Cerebral Infarction, Peripheral Vascular Disease, Idiopathic Peripheral Autonomic Neuropathy, Hemiplegia and Hemiparesis, Vascular Dementia, Heart Failure, Dependence on Renal Dialysis, Acquired Absence of Right Leg Below Knee & Left Toes, History of Falling, Lack of Coordination, and Unstageable Pressure Ulcer of Sacral Region. R1's care plan last reviewed 02/07/2023 showed R1 has extensive care needs and requires the support/services of the long-term care setting; is in end stage renal disease with dementia; is incontinent of bowel and bladder; has actual skin impairment and is at risk for additional skin breakdown; recent surgical right below knee amputation (BKA) and left 4th toe amputation (12/2022); nutritional problem or potential nutritional problem related to diet restrictions; receives on-going visits from his family members who are not following his restricted diet implemented by his doctor by bringing in outside fast food for him. R1's current physician orders showed treatments to cleanse left 4th toe/left lateral foot/left medial heel/left proximal medial foot with normal saline, pat dry, apply betadine solution, abdominal pad, with normal saline, pat dry, apply kerlix roll three times a week (MWF) and as needed (PRN); cleanse sacrum with normal saline, pat dry, apply calcium alginate with Medi honey and cover with dry bordered gauze daily and as needed (PRN). On 02/17/2023 at 12:36 PM, observed R1 lying in bed on his back eating cheese puffs. R1 said that he thinks staff do change his dressing as scheduled, then said he has waited like 30 minutes for his call light to be answered. At 12:46 PM, R1 said watch this then pressed his call light. At 12:47 PM, V4 (Staffing Coordinator) entered R1's room. She informed R1 that she would be assisting with his wound care, nurse was gathering the supplies. At 12:51 PM, V4 began prepping R1 for his wound care. V4 removed the blanket from him and observed a dressing to R1's left foot dated 02/13/2023 that had several areas of dried brown/yellow colored drainage visible. When surveyor asked V4 what the date was on the dressing, V4 confirmed and said, the 13th. On 02/17/2023 at 1:00 PM, V5 (Wound Care Coordinator) entered R1's room to perform wound care. At 1:04 PM, V5 removed previous dressing to R1's left foot. When asked to verify date on old dressing, V5 said 02/13/2023. She then said R1's treatment order is for 3 times weekly on Monday, Wednesday, and Friday and should have been changed on 02/15/2023. Observed V5 perform wound care to R1's left foot, bilateral hands and sacrum with no infection control issues or concerns observed. Reviewed R1's February treatment administration record that showed the treatment was documented as being completed on 02/15/2023. R1's treatment administration record reviewed with the following noted: 12/2022 record showed treatment to left ischium and left 3rd toe was not documented as being performed on 12/21; prior to right below knee amputation on 12/25/2022, R1's treatments to his right foot were not documented as being completed on 12/19 or 12/21; treatment to his sacrum was not documented as being completed on 12/21. Reviewed discharge summary provided by facility that showed R1 discharged to local hospital on [DATE]. 01/2023 record showed treatment to left 2nd finger was not documented as being performed on 01/07 and 01/08; treatment to left 3rd toe was not documented as being performed on 01/09, 01/11, or 01/27. 2. R2 is a [AGE] year-old who admitted to facility on 04/06/2018. His date of birth is 11/27/1959. He has a past medical history not limited to: Type 2 Diabetes, Hemiplegia and Hemiparesis, Essential Hypertension, Cerebral Infarction, Chronic Pain, History of Falling, Vascular Disease, Osteoarthritis, Seizures, Lymphedema, Obesity and Cellulitis. R2 had a recent hospitalization from 01/01/2023-01/06/2023 for treatment of Cellulitis. R2's care plan last revised 01/05/2023 showed he is: at risk for fluctuating blood sugars and hypo/hyperglycemia due to diabetes mellitus, diet/medication, blood glucose medications with interventions to administer sliding scale per physician's order; at risk for pain related to Cerebral Vascular Accident with hemiparesis, chronic bilateral lower leg edema and Peripheral Vascular Disease with interventions for provide analgesic as ordered, pain management as needed. On 02/17/2023 at 12:23 PM, R2 said there are many issues with nurses and aides because most of them are agency, then said last week he waited over an hour for his call light to be answered. He added when the nurse finally came in and he informed her of his wait time, she told him that he hadn't waited that long. He added that 2 days ago, an agency aide told him she would shower him but never did, received next night from staff aide. R2 then said he's supposed to get norco every 6 hours when he asks for it, but he doesn't always get it. He continued saying that he asks for norco every day and a month or so ago, he didn't receive it for almost 2 weeks. R2 also said that he doesn't always get his scheduled gabapentin and hasn't had that for about a week. When asked how R2 feels when he does not receive his medication as scheduled, R2 said it saddens him because he knows what he takes and when he takes it. Reviewed R2's active physician orders that showed the following: gabapentin 300mg 1 capsule by mouth 3 times a day; hydrocodone-acetaminophen 5-325mg 1 tablet by mouth every 6 hours as needed for moderate pain; NovoLog insulin inject per sliding scale 180-210=2 units, 211-260=3 units 261-310=5 units 311-360=7 units 361-400=9 units call MD if <70 or >400. Reviewed R2's medication administration record for 12/2022 that showed NI (no insulin required) documented on 12/03, 12/07, 12/8, 12/15, 12/18, 12/21, 12/23, 12/25 and 12/26. R2's blood sugars on all these days were above 180 and should have received 2 units of sliding scale insulin per physician's orders. On 12/10, 12/24 and 12/31 administration record shows no documentation of sliding scale insulin being administered for these days. Reviewed R2's medication administration record for 01/2023 that showed no documentation of sliding scale insulin being administered on 01/16; Reviewed R2's medication administration record for 02/2023 documented under gabapentin OP (out on pass) on 02/10 1300, and DR (drug refused) on 02/12 and OP for his 1100 sliding scale insulin with no documentation of either medication being administered later. On 02/17/2023 at 3:38 PM, interview with V3 (Director of Nursing) who said med times depend on med order time because system have multiple frequencies. When a nurse logs in, it shows the scheduled med times for the shift which allow one-hour windows before and after. On 2/18/2023 V3 (Director of Nursing) then said her expectations of nurses with medication administration and/or treatment orders they be completed as ordered to the right resident at the right times with the correct medication, dose, and route. When asked what an empty box on the administration record means, V3 (Director of Nursing) said she was unsure of what that meant. At 2:42 PM, V3 said when a resident has a medication due but is out on pass, the medication should be put on hold and administered when the resident returns. V3 added if the medication is scheduled multiple times a day and/or is a significant medication, nurses should notify the MD. When asked how often medications should be reordered, V3 said 5 days prior to running out to avoid a lapse in administration. She then said staff should utilize their medication dispensing system as well as back-up insulin boxes in the fridge if a med is unavailable then call pharmacy for med order status. V3 added that stat deliveries are only for new admissions and staff should never borrow from another resident. On 02/19/2022, reviewed medication policy last revised 07/28/2022 that showed it is facility policy to adhere to all Federal and State regulations with medication pass procedures. For injectables: give intradermally, subcutaneously, or intramuscularly as ordered. For by mouth (PO) medications: after medication is administered to each resident, sign medication administration record (MAR) that it was given. Facility did not provide policy on wound care or turning and repositioning. Reviewed incident report policy and fall policy with no issues or concerns. 3. On 02/17/2023 at 4:22 PM, observed V6 (Agency Registered Nurse) leave medication cart unlocked with electronic medication record displayed on computer screen showing resident information. V6 entered R4's room to check his blood sugar but had to return to the cart for diabetic supplies. V6 obtained needed supplies from the cart then said, oh I need to lock the cart and screen. At 4:28 PM, R4's blood sugar result was 494. V6 returned to his med cart and removed an undated and opened bottle of Humalog insulin from inside the cart marked with R4's name. At 4:30 PM, V6 informed R4 that he needed to retrieve another bottle of insulin so he can administer his scheduled insulin. At 4:36 PM, R4 informed surveyor that he has not received insulin all day which happens often. R4 continued saying that medications are late just about every day, most days he gets his morning and afternoon medications at the same time. R4 also said there are long wait times for call light to be answered, especially during the night and on weekends. Observed undated dressing t R4's right foot, said it was done the other day. When asked how it makes him feel to have his medications administered as scheduled, R4 said it is very upsetting and frustrating trying to keep after the nurses to give him his medications. R4's active physician's orders showed gabapentin 300mg 1 capsule by mouth 3 times a day; Humalog insulin inject 17 units subcutaneously before meals, hold is <120. Reviewed R4's 01/2023 medication administration record and noted 0600 dose of gabapentin was not documented as being administered on 01/16/2023; 0600 and 1100 dose of Humalog insulin were not documented as being administered on 01/05/2023 and 1100 dose on 01/06/2023. On 2/18/23 at 2:33 PM, V3 (Director of Nursing) then said her expectations of nurses with medication administration and/or treatment orders they be completed as ordered to the right resident at the right times with the correct medication, dose, and route. R5 Pain Management issue Reviewed fall list for last 6 months, R5 was not listed. Incident Summary dated 11/6/2022 00:15 showed resident was observed on the floor laying on her right side near the bathroom next to her bed. Complete body assessment given, no discoloration or skin tears noted at this time all skin is intact. Writer asked resident what happened, and she stated, I don't know I was leaving the bathroom and I just fell. Writer asked resident did she hit her head resident stated, No I did not hit my head. Resident was assisted into bed via staff. Resident stated she is experiencing pain in her right hip and right knee rating the pain on a 0-10 scale a 7. Progress Note dated 11/6/2022 00:21 showed: MD made aware of incident new order for STAT x-ray to the right knee and right hip per MD orders carried out. All stat portable phoned and STAT x-ray to the right hip and right knee scheduled for 11/6/22 morning, confirmation #236376730. Care dated 11/04/2022 showed R5 is a risk for falls. Fall risk assessment dated [DATE] showed score of 11 indicating she is a high fall risk. On 02/18/2023, R5's daughter was called at 11:33 AM by surveyor to inquire if facility contacts family after any incidents. No answer, message left. She called facility back at 12:00 PM and said she was notified of R5's fall and said at approximately 2a on 11/06/2022, I called facility back and spoke with an agency nurse who said mom was given pain med and x-ray tech was on their way to the facility. I came into facility at 10a, and mom was lying in bed, crying and said, they are lying, they're not doing anything to help me, and get me out of here, I'm in pain. R5 had not yet received an x-ray. I then said either you call 911 or I will. R5's daughter then said the agency nurse said she didn't know what to do and started calling to different floors. Finally, some facility staff came and showed her what to do and the agency nurse made the call to 911. R5's daughter also said that the agency nurse said they offered pain med (Tylenol) but R5 refused it then said the facility was not trying to do anything for her mother. R5 was admitted to hospital with multiple fractures to right lower extremity and did not re-admit to the facility. On 02/17/2023 at 3:38 PM, When asked how many staffing agencies are utilized, V3 said quite a bit and facility is trying to recruit nurses but it's been hard getting staff in here. V3 added new agency staff are given a quick rundown, plus there are agency binders with policies, how to use PCC, risk management, admission, order entry, important phone numbers, extensions, and infection control policy and procedures located at every nursing station. When asked what is done if there's a complaint regarding agency staff, V3 (Director of Nursing) said if it's a customer service complaint, they investigate and talk to the resident and staff. She continued saying if it's a poor customer service, safety concern, attitude, or affects mental well-being, they are DNR'd (do not return). On 2/18/2023 at 12:29 PM, V3 (Director of Nursing) unable to locate documentation of when portable x-ray came to facility and performed x-ray on R5. At 12:57 PM, V3 said she called diagnostic provider and was told they didn't have a tech that morning and facility does not use any other company. V3 added that R5 did not receive an x-ray until she was sent out to the hospital. When asked if the facility should have followed up with their diagnostic provider on day of incident rather then current date, V3 said yes. On 02/19/2022, reviewed incident reporting policy last revised 07/28/2022 that showed process of reporting to IDPH only. Reviewed fall occurrence policy last revised 05/17/2022 which indicated no process of notifying family or providing emergent care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to reposition and provide pressure relief device for 1 of 2 residents (R3) reviewed for pressure ulcer treatment and services. Findings include: R3 is a [AGE] year-old who admitted to facility on 12/20/2019. Her date of birth is 12/18/1965. She has a past medical history not limited to: Obesity; Post-Traumatic Stress Disorder, Major Depressive Disorder; Hypertension; Anxiety Disorder; Osteoarthritis; Cerebral Infarction; Chronic Pain; Peripheral Vascular Disease; Hemiplegia and Hemiparesis; Vascular Dementia; Moderate Protein-Calorie Malnutrition; Methicillin Resistant Staphylococcus Aureus; Pressure Ulcer of Right & Left Buttock, Unstageable. R3 was on the listed with 2 pressure wounds. R3's care plan last revised 01/17/2023 showed: impaired mobility related to knee swelling, Osteoarthritis, chronic pain, degeneration of lumbar discs, fatigue, impaired balance; require extensive to dependent x1-2 physical assistance with activities of daily living, bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene; incontinent of bladder and bowel related to medication side effect, comorbidities, and recent hospitalization; at risk for pressure ulcers. Braden score of 15, core is related to limited mobility; right heel vascular, arterial wound with intervention to administer treatments as ordered and monitor for effectiveness, resident needs to turn/reposition at least every 2 hours, more often as needed or requested. On 02/17/2023 at 1:39 PM, observed R3 sleeping on her back on air mattress covered with bottom sheet and bed pad. Observed positioning wedge next to R3 in bed but not under resident. At 3:48 PM, observed R3 sleeping in bed and remained lying on her back. On 02/18/2023 at 10:57 AM, observed R3 lying on her back in bed, call light on the floor. R3 said she has no issues to speak of. At 11:02 AM, surveyor called V7 (Certified Nursing Assistant) to R3's room to locate call light. V7 said R3 just had her dressing changed as she picked up her call light from the floor, handed light to R3 and said it should be within reach. At 11:02 AM, when asked when R3 was turned last and when she is due to be turned again, V7 had no answer. When asked if R3 is on a turn schedule, V7 said she is turned and repositioned every couple of hours throughout the day. Heels boots observed at foot of bed and not in place. Reviewed R3's active physician orders that showed cleanse right heel with normal saline, pat dry, apply hydrogel, then skin prep to epithelialized deep tissue injury portion and cover with dry dressing three times a week; previous order for daily discontinued on 01/19/2023. Reviewed R3's 12/2022 treatment administration record that showed her right heel dressing (active until 01/19/2023) was not documented as been completed on 12/01, 12/21, and 12/25. On 2/17/2023 at 3:58 PM, V3 added that residents are turned and repositioned every two hours. She then said an announcement is made over the intercom indicating this time as rock and roll time. When informed that surveyor has not heard this announcement since entering the facility this morning, V3 said the receptionist is new and she will educate her. On 2/18/23 at 2:33 PM, when asked how V3 (Director of Nursing) knows if residents are being turned and repositioned as scheduled, that they are receiving adequate care and if their needs are being met, V3 said she is frequently out on the units and follows up with restorative aides on the floor. On 02/18/2023 at 12:04 PM, rock and roll announced over intercom which was the only time announcement heard during course of complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a narcotic pain medication was available to be administered as ordered. This failure led to a delay in R2 getting ordered narcotic pain medication for 4 weeks. This failure applied to one (R2) of one resident reviewed for physician orders. Findings include: R2 is a [AGE] year old female admitted to the facility 10/6/2021 with no hospitalizations of note. Diagnoses include End Stage Renal Disease, Osteoarthritis and Left Above the Knee Amputation. MDS dated [DATE] assesses R2 to be fully alert and oriented with a BIMS of 15 (cognitively intact), requiring extensive one person staff assistance to perform most Activities of Daily Living such as toileting, and personal hygiene. On 1/3/23 at 3:25PM R2 was observed self propelling in wheelchair independently in the hall and supervised going into her room. R2 said, my pain management has been pretty good but I take Tylenol #3 and there was a time in November when it ran out and the nurses told me I had to wait for the doctor to sign the prescription to re-order it. I had been taking regular strength Tylenol which was mostly effective but not as good as Tylenol #3. One day I was asking for the regular Tylenol and the nurse told me that the Tylenol #3 had been filled but I never knew that it was available again. Physician Order Sheet dated 10/14/21 contained an order for controlled substance Tylenol with Codeine #3, 1 tablet by mouth every 8 hours as needed. On 10/6/21 an order for Acetaminophen 2 tablets by mouth was entered and transcribed onto the Medication Administration Record (MAR). MARs were reviewed for November, December 2022 and January 2023 and indicated that nurses were signing out Acetaminophen 2 tablets as given. Drug Control sheets for Tylenol with Codeine #3 were reviewed for October, November, December and January 2023. Control sheets document that the medication was last dispensed on 10/24/22 and 12/17/22. Control Sheets include documentation that Tylenol with Codeine #3 was given at least daily when available. On 11/14/22 the last available dose was given and did not resume until 12/18/22. Review of R2's pain assessment dated [DATE] documents that pain was 8/10 and on 12/13/22 pain was documented as 9/10. On 1/4/23 at 1:40PM V2 Assistant Director of Nursing said, the nurses should reach out to the physician by phone or fax to send a new RX for controlled medications and follow up within 24 hours. If we are unable to get a response from the primary physician, we call the medical director who can provide a prescription. I or the DON were not made aware that the medication for R2 was out. I believe that we were waiting for a prescription to be signed by the physician and we were not aware of the issue and were not able to intervene. According to the pharmacy the last two times the medication was dispensed was 10/24/22 and 12/17/22. We provide house-stock acetaminophen in 325mg and 500mg. Looking at the order for R2, she has an order for acetaminophen 2 tabs that can be given as needed but it does not indicate the dose. Without this, the dose given could possibly be too large or not adequate. On 1/5/23 at 11:58AM V7 Physician for R2 said, controlled substances need a written prescription to be refilled and usually the facility will fax, call, or text me as needed. I don't recall being informed that there was a long period of time the Tylenol with Codeine #3 was not available due to needing a prescription. I don't recall any time that I was informed that R2 was in extreme pain. But I do know that R2 has other medications that she takes such as regular acetaminophen. The facility informed me yesterday that the acetaminophen dose was not written in the order, so I approved the dose of 1000mg.

Based on observation, interview, and record review the facility failed to provide privacy for gastric tube medication administration for one resident (R28) of five residents reviewed for medication administration in the sample of 26. Findings include On 11/30/22 at 12:22 PM R7 (RN-Registered Nurse) administered oxcarbazepine 300 mg via gastric tube to R28. V7 exposed R28's abdomen to administer the medication. V7 did not close R28's privacy curtain. R28 was in the line of sight of R33 (her roommate) and V14 (family member of R33). V7 said, I should have pulled the privacy curtain. On 12/1/22 at 10:48 AM V3 (Director of Nursing) said, the nurses should use the privacy curtain if needed to provide privacy for procedures. Policy: Privacy and Dignity 1/17/2016 Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Procedures: 1. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy. If the privacy curtain is not sufficient to provide full visual privacy, the combination of the privacy curtain and the privacy screen will be used. A privacy screen may also be used by itself if it will provide full visual privacy. Door may also be closed to provide additional layer or privacy during care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement care plans for residents with specialized needs for two (R80, R366) of 12 residents reviewed for care plans in a sample of 26. Findings include: 1. R366's order summary report dated 11/29/2022 indicated orders for Heparin sodium 5000 unit/mL (milliliters) to inject 5000 units subcutaneously every 12 hours for clotting prevention and clopidogrel bisulfate 75mg 1 tablet by mouth one time daily for blood clot prevention with order date of 11/17/2022. Baseline care plan and comprehensive care plan were reviewed and did not indicate R366 is on anticoagulation therapy. On 12/01/2022 at 10:20AM, V6 (Minimum Data Set (MDS) Coordinator) stated that anticoagulants should be included on the baseline care plan and comprehensive care plan. On 12/01/2022 at 10:52AM, V3 (Director of Nursing) said that if a resident is on anticoagulation therapy, there should be a care plan addressing it, including the baseline care plan. R366's Order Summary Report dated 11/29/2022 indicated admission date of 10/13/2022 and diagnoses of but not limited to cerebral infarction, gastritis and acute posthemorrhagic anemia. Facility Policy: Title: Care Plan Revised: 7/27/22 Policy Statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Procedures: 1. During admission, the facility may put in place baseline care plans within 48 hours to address resident's care. 2. The baseline care plan at a minimum should include initial goals based on admission orders, physician orders . 4. After the comprehensive assessment (state/federal - required MDS) is completed, the facility will out in place person-centered care plans outlining care for the resident within 7 days. 5. These will be periodically reviewed and revised by a team of qualified person after each assessment. 2. On 11/30/22 at 1:01 PM R80 was observed in bed using a CPAP (Continuous Positive Airway Pressure) machine. R80 said, this is my machine, I brought it with me when I came here and I've been using it every night. They just give me the distilled water for it. A review of R80's medical record revealed that there is no physician's order or care plan for the CPAP machine use. The face sheet indicates that R80 was admitted on [DATE]. On 12/1/22 at 10:15 AM V6 (Minimum Data Set Coordinator) said, you need an order to proceed with the care plan. The order should have been obtained when he started using the CPAP. I will put the respiratory care plan in if there is an order.

Based on observation, interview and record review, the facility failed to apply compression stockings for one (R72) of one resident reviewed for edema in a sample of 26. Findings include: On 11/29/2022 at 10:48AM during observation, R72 was observed walking in the hallway with left leg larger than the right leg, and no compression stockings were observed. On 11/30/2022 at 9:10AM, R72 was observed standing at bedside with left leg larger than the right leg, and no compression stockings were observed. On 12/01/2022 at 11:05AM, R72 was observed sitting at bedside left leg larger than the right leg, and no compression stockings were observed. On 11/29/2022 at 11:41AM, R72 was observed with V7 (Registered Nurse) and said that R72 has an order for compression stockings, and it should be on at this time. On 12/1/2022 at 12:00PM, V3 (Director of Nursing) observed R72 and stated that if the resident has order for stockings, nurses apply it since it usually appears on their electronic administration record. R72's Order Summary Report dated 11/29/2022 indicated admission date of 09/05/2020, diagnosis of but not limited to lymphedema, and order for compression stockings every shift with order date of 10/07/2020. Medication administration record dated 11/1/2022-11/30/2022 indicated compression stockings (remove daily for skin inspection) every shift and start date of 10/07/2020. Facility unable to provide policy

Based on observation, interview, and record review the facility failed to verify placement of a gastric tube before administering medication to one resident (R28) of five residents reviewed for medication administration in the sample of 26. Findings include: On 11/30/22 at 12:22 PM V7 (RN-Registered Nurse) administered Oxcarbazepine 300 mg (milligrams) to R28 via gastric tube. V7 did not check placement of the gastric tube. V7 did not check for a placement mark on the gastric tube or aspirate the contents and check the pH (power of hydrogen) or inject air into the tube while listening over the stomach. V7 said, I confirmed the placement of her g-tube (gastric tube) when I did her medications this morning at 9:30. We aspirate to check for gastric contents. When asked if the placement should have been verified before administering medication three hours later V7 did not answer. On 12/1/22 at 10:48 AM V3 (Director of Nursing) said, the nurses should check for placement of the g-tube prior to administering medications, water, or anything in the g-tube. If there is no marking for the g-tube, they should aspirate and check the pH of the contents. We have pH strips available. Policy: Medication Pass 1/25/2016 Procedures 1. G-tube Medications: c. Check placement of G-tube by checking if the marker of the actual enteral tube is still located at the G-tube insertion site. Although an unnecessary step, the nurse may also introduce air (in addition to checking the location of the G-tube marker at the insertion site) and listen to the sound of air moving from the G-tube to the stomach. d. If the marker cannot be located or had become too light to see, the nurse will aspirate the gastric content and confirm the pH of the aspirated material (if it is between 1.5 to 5.5, which is the pH range of the gastric content.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain physician orders for a CPAP (Continuous Positive Airway Pressure) machine for one resident (R80) of four residents reviewed for respiratory care in the sample of 26. Findings include On 11/30/22 at 1:01 PM R80 was observed in bed using a CPAP (Continuous Positive Airway Pressure) machine. R80 said, this is my machine, I brought it with me when I came here and I've been using it every night. They just give me the distilled water for it. A review of R80's medical record revealed that there is no physician's order or care plan for the CPAP machine use. The face sheet indicates that R80 was admitted on [DATE]. On 12/1/22 at 10:15 AM V6 (Minimum Data Set Coordinator) said, you need an order to proceed with the care plan. The order should have been obtained when he started using the CPAP. I will put the respiratory care plan in if there is an order. On 12/1/22 at 10:48 AM V3 (Director of Nursing) said, we should contact the physician for orders for treatments including CPAP use. We called the physician yesterday to get an order. (R80) did not remember the name of the doctor who ordered it initially. We left the setting at 15 which is what he has been using. Policy: Physician Orders, 11/10/2014 Policy Statement: It is the policy of the facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). Procedures 1. Upon admission and readmission, the facility will verify transfer orders from the hospital with the resident's attending physician or physician on call. 9. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director.

Based on observation, interview and record review the facility failed to dispose of medications after the use by date in two of three medication carts reviewed for medication and storage. Findings include: On 11/30/22 at 3:50 PM the 1 North medication cart contained glargine insulin for R56 with an opened date of 10/11/22 and a use by date of 11/11/22. The cart contained insulin aspart for R57 with an opened date of 10/22/22 and a use by date of 11/22/22. V3 (Director of Nursing) said, these should have been removed from the cart. On 11/30/22 at 4:15 PM the 2 South medication cart contained timolol 0.25% eyedrops for R2 with an opened date of 10/28/22 and a use by date of 11/28/22. The cart contained dorzolamide 2% eyedrops for R2 with an opened date of 10/27/22 and a use by date of 11/27/22. V13 (RN-Registered Nurse) said, these shouldn't have been put back in the cart. Policy: Medication Pass 1/5/2016 Medication Labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for (insulin detemir) which can be discarded 42 days after opening and (latanoprost) eye drops which can be discarded 6 weeks after opening. 2. Follow pharmacy recommendation as to when the medication should be discarded after opening.

Based on observation and interview, the facility failed to follow their practice of using single layered incontinence briefs for incontinent residents. This failure affected 1 resident (R1) of 3 reviewed for incontinence practices. Findings include: On 11-9-22 at 9:45 AM, R1 was resting comfortably in bed. R1 was agreeable for surveyor and primary nurse to do skin assessment. R1 appeared clean and was wearing a clean gown. No indication of any vomit or mess on her gown. R1's brief was noted with 2 disposable briefs. The 2nd brief was folded inside the other worn brief. Both briefs were saturated with yellow urine. On 11-9-22 at 1:20 PM, V2 (Director of Nursing) said the facility does not allow double briefs for residents because no resident should sit in double amount of soiled briefs. Residents should be changed regularly and not allowed to sit in dirty briefs. V2 said there is no specific policy regarding using double briefs for residents. On 11-9-22 at 12:25 PM, V3 (LPN) said double briefs are not allowed because facility does not want residents to sit in dirty briefs that could cause skin breakdown. On 11-9-22 at 11:07 AM, V4 (CNA) said staff are not allowed to double brief resident because they could sit in dirty brief for long time and staff should be rounding on resident every 2 hours. R3's MDS (ARD 9-5-22) documents R3 is dependent for toileting and is frequently incontinent of bowel and bladder.