**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R8's Physician Order Sheet (POS) for April 2025 documents a diagnosis of unspecified lack of coordination, abnormities of gait and mobility, hallucinations, insomnia, repeated falls, Parkinson's disease, other urticaria, hallucinations, mononeuropathy of right upper limb, including shoulder, generalized anxiety, major depression, restless leg syndrome, generalized skin eruption due to drugs and medicaments taken. The April POS also document Gocovri oral capsule extended release 24 hours 137 MG (milligrams) (amantadine HCL (hydrocholoride). Give 1 capsule by mouth at bedtime related to Parkinson disease without dyskinesia, without mention of fluctuations. The POS also documents, R8 has an order for amantadine (generic name for Gocovri). R8's Care Plan with a date initiated of 12/10/2024 document (R8) has Parkinson's disease. Interventions: Give medications as ordered by the Physician. Monitor/document side effects and effectiveness, dated initiated 12/10/2024. R8's Minimum Data Set (MDS) dated [DATE] document she is cognitively intact for decision making of activities of daily living. On 4/29/2025 at 1:11 PM, R11, Husband of R8 stated there were some issues with medications and (R8) did not receive all of her medications something to do with them not being at the Facility. R8's MAR dated April 2024 document R8 did not receive her Gocovri oral capsule extended release 24 hours 137 MG (milligrams) or (Amatadine) for seven out of 28 days, 4/2/2025, 4/20/2025, 4/24/2025, 4/26/2025 and 4/28/2025. R8's Progress Note dated 4/2/2025 at 6:28 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations. Waiting for pharmacy. R8's Progress Note dated 4/20/2025 at 6:00 PM, Gocovri Oral Capsule extended release 24 hour 137 MG give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations. On order. R8's Progress Note dated 4/24/2025 at 11:24 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations, waiting on medication for delivery. R8's Progress Note dated 4/26/2025 at 8:04 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations, Waiting on arrival on medication. On order. R8's Progress Notes dated 4/28/2025 does not document anything related to the Gocovri oral capsule. On 4/29/2025 at 1:11 PM, V2 stated, Gocovri is a medication that they use for (R8's) Parkinson disease. If the medication was given there should be a check mark on the MAR and an initial of whoever gave the medication. I see there are holes on the (R8's) MAR and she did not get the medicine every day. I know we had samples of that medication but if staff gave her the samples, they still should have marked it on the MAR. 4. R10's POS for April 2025 documents a diagnosis of Type 2 diabetes mellitus without complications, paraplegia, chronic pain, generalized anxiety disorder, major depression, cognitive communications deficit, abnormalities of gait and mobility. R10's Care Plan does not address her estrogen replacement. R10's MDS dated [DATE] document R10 was cognitively intact for decision making of activities of daily living. On 4/30/2025 at 1:30 PM, R10 stated she had missed a few doses of her estrogen R10's POS dated April 2024 document and order for Premarin Cream 0.625 MG/GM, (Estrogens, Conjugated), Insert 1 gram vaginally at bedtime every other day for hormone replacement -Start Date- 01/09/2025 7:00 PM. R10's April MAR document R10 missed four doses of Premarin Cream in April: 4/7/2025, 4/8/2025, 4/19/2025 and 4/20/2025. R10's Progress Notes does not document anything related to (R10) not receiving her estrogen cream. On 4/30/2025 at 11:12 AM, V2, Director of Nursing stated, We recently lost our Medical Director who use to come to the facility twice a week. We have a new company and have zoom meetings but there has been some delay in certain medications. I am not sure why (R10) did not get her estrogen. On 4/30/2025 at 2:49 PM, V18, Pharmacist stated, This is a specialty drug that (R8) is taking. It is important at all times to always follow the doctor's order. This drug it used to treat Parkinson's disease and if (R8) misses a dose it would not be ideal. By missing a dose it would increase her symptoms related to Parkinson's which would increase her tremors, and anything else related to her Parkinson. Ideally, we would not want to miss any doses. Based on interview and record review the facility failed to administer physician ordered medication for 4 (R3, R5, R8, R10) of 4 reviewed for medication administration in the sample of 10. 1. R3's Face sheet documents an admission date of 1/27/2025. Diagnosis include Respiratory Syncytial Virus Pneumonia, End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes. R3's MDS dated [DATE] documents R3 has no cognitive deficits. R3's Care Plan dated 2/9/2025 documents R3 has pain Diabetic neuropathy. Interventions include monitor/record/report to Nurse R3's complaints of pain or requests for pain treatment. Anticipate the R3's need for pain relief and respond immediately to any complaint of pain. R3's order sheets documents on 4/10/2025 Pregabalin Oral Capsule 75 MG (Pregabalin) *Controlled Drug. Give 1 capsule by mouth two times a day for pain/discomfort. R3's medication administration sheets (MARS) dated 4/1/2025-4/29-2025 documents Pregabalin Oral Capsule 75 MG (Pregabalin) *Controlled Drug. Give 1 capsule by mouth two times a day for pain/discomfort. Start 4/13/2025 at 5:00AM. Doses not documented as administered 4/18/2025 PM dose. 4/19/25- 4/22/2025 no AM or PM dose. Chart code #6 documented as reason for missed medication as to see progress notes. R3's progress notes dated 4/17/2025 at 11:00AM document Called to pharmacy for Pregabalin refill. Per pharmacy tech written script is required for further refills. New prescription form faxed to pharmacy at this time. R3's progress notes dated 4/22/2025 at 12:07AM documents Pharmacy unable to get Lyrica here until next run at this time. Pharmacist reported calling and speaking with Medical Doctor, MD. R3 reports pain in bilateral legs and hips at a 4 out of 10. R3 reports her tolerable pain level is at about a 5 or 6. R3 instructed to put on call light if pain increases past tolerable pain level. R3 repositioned by Certified Nursing Assistants, CNAs, at this time to promote comfort. R3's progress notes dated 4/22/2025 at 2:23AM documents Writer has spoken with MD three times regarding facility needing a script sent to local pharmacy. Pharmacist also spoke with MD and reported she has asked MD to send script as well and he has agreed to that but has not transmitted medication script at this time. Writer and pharmacist unable to do anything further at this time. R3 observed with eyes closed at this time with even non labored breaths. Writer and CNAs continue to round on R3. On 4/25/2025 at 1:45PM R3 sitting in bed eating her lunch. Stated I was out of Lyrica for a few days. I have neuropathy in my feet and I was in pain not having the Lyrica. I have not missed any other meds than I am aware of. 2. R5's Face sheet documents an admission date of 1/23/2025. Diagnosis include Obesity, Type 2 Diabetes, Hypertension, Hypomagnesemia. R5's MDS dated [DATE] documents R5 has no cognitive deficits. R5 requires maximum assist with mobility and transfers. R5's care plan dated 2/4/2025 documents R5 is on pain medication, therapy related to neuropathy. Interventions include administer medication as ordered. R5's order sheet dated 1/27/2025 documents Pregabalin Oral Capsule 100 MG (Pregabalin) *Controlled Drug*Give 2 tablet by mouth every 8 hours for Seizures. R5's April MARS dated 4/1/2025-4/28/2025 documents Pregabalin Oral Capsule 100 MG (Pregabalin) *Controlled Drug*Give 2 tablet by mouth every 8 hours for Seizures. Start date 1/27/2025 at 1:00PM. Doses not documented as administered 4/12/2025 5:00AM dose, 4/16/2025 5:00AM dose, 4/20/2025 5:00AM dose, 4/23/2025 5:00AM dose and 9:00PM dose, 4/24/2025 5:00AM dose. On 4/29/2025 at 9:40AM R5 sitting up in chair in dining room. Stated I am out of my Lyrica all the time. I was out for 5 days in February. Got the Lyrica in and then out after a week. It took another 3 days to get more in. I ran out again yesterday and they did get it in and I got a dose this morning. If I don't get my Lyrica I feel like I am standing on shards of glass. I am to get Lyrica 3 times a day. On 4/29/2025 at 10:00AM Director of Nursing, DON, stated We have been having issues with a new system. Typically, the Doctor writes the script for 90 days. Pharmacy sends us 30 days or 1 blister pack at a time. When blister pack is getting low the nurse clicks refill and another card is sent. We are working with a new medical system. Sometimes narcotics have been an issue. We are in the process of getting a new medical director. We have a Nurse Practitioner but she does not have a Drug Enforcement Administration license. On 4/25/2025 at 2:00PM V4, Licensed Practical Nurse, LPN, stated she was unaware that R3 was missing her Lyrica. On 4/25/2025 at 3:00PM V17, Complainant, stated I just felt bad for the resident (R3). She was in pain and was out of her pain meds (medication) and I know what that is like. I have had surgery and been in pain. Facility policy dated 4/21 states All medications shall only be administered by licensed nursing personnel in accordance with their respective licensing requirement. All nursing personnel must have eighter appropriate training, experience, or both, if duties include administration of medications. PRN medication cards are to be ordered as needed not necessarily on a monthly basis. Do not wait until the card is empty to notify the pharmacy of a needed refill.

Based on interview and record, the facility failed to prevent employee to resident verbal abuse for one of six residents (R41) reviewed for abuse in the sample of 44. Findings include: 1. R41's Face Sheet date 6/11/24 documents R41 has diagnoses of mental disorder and altered mental status. R41's Alleged Verbal Abuse Incident Report dated 6/4/2024 documents R62's predisposing physiological factors are behaviors, confusion, and impaired memory. The Facility's Report of Alleged Resident Abuse dated 6/4/24 at 6:15 AM documents there was an allegation of verbal mistreatment and abuse and two employees, V13, Licensed Practical Nurse, LPN and V14, LPN who were suspended. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. It continues to document, Three staff members report that (R41) was at the nurses' desk where nurses were completing shift change. (R41) persistently told the staff she did not want to live at the facility and wanted to go to (another local town) to see her son. Circumstances beyond her control prevent her son from visiting the Facility but (R41) is not able to understand this. (R41) has diagnoses of altered mental status, symptoms including cognitive function and awareness and mental disorder not classified. It further documents, (V15, Medical Records) reports observing and hearing both (V13, LPN (Licensed Practical Nurse) and V14, LPN) telling (R41) to 'shut up'. These observations are corroborated from two other staff members. R41's Care Plan dated 6/4/2024 documents R41 has a potential psychosocial well-being problem related to possible abuse. On 6/24/24 at 9:30 AM, V1, Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13, LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told (V21, Business Office Manager), and (V21) called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. By this time (V13) had already gone home because it was the end of shift. (V14) was pulled off of the floor and statements were taken. (V14) was told to go home. Both (V13 and V14) were both suspended at that time. After the investigation the abuse was substantiated, and both were terminated. On 6/25/2024, at 3:04 PM, V9 Registered Nurse (RN), stated, I was at the nurses' station doing shift change in the morning. (R41) was saying over and over again that she wanted to go home. (V13) asked (R41) to be quiet several times so they could get report and count. (V13 and V14) told her (R41) to shut up. I heard it all. I didn't do anything with it, and I should have. V9's, Registered Nurse (RN)'s statement undated, documents, Resident was at nurses station yelling, saying, she doesn't live here. Nurse was giving report and doing narc (narcotics) count. (V13) yelled at resident, told her to shut up. Resident still continued to yell. (V14) then told her to shut up and wheeled resident to the dining room. V15's statement dated 6/4/2024 documents, Around the time of 6:15-6:30 am while nurses and CNAs were giving report at the nurses station. (R41) repeatedly kept saying, 'I don't live here'. It continues, That is when (V14) yelled to (R41),' Shut up all ready. Go somewhere else. We don't need you to live here'. (V13) was at the nurses' station stated/almost yelling, We get it you don't think you live here. (V13) then pushed (R41) into the dining room in front of the DON (Director of Nursing) office door and said, We need you to shut up. We are trying to give our morning reports and get our jobs done. We can't do that if you keep yelling you don't live here. I stated to the nurses at the nursing station that this is not ok. I walked in the dining room and told (V40, CNA) and said this was not ok when we seen (V13) together in the dining room. On 6/26/2024 at 12:25 V15, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our f**king job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the f**k up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/2024 at 10:38 AM V40, Certified Nursing Assistant (CNA) stated, I was in the dining room early in the morning. I heard a nurse scream at her to shut up. It was (V14, LPN). I heard (V13, LPN) saying stuff can't remember what exactly. It was not appropriate, and it was her tone. (V15, Medical Records) and I looked at each other, like Is it abusive/reportable? did we just hear what we think we just heard? I told (V21, Business Office Manager) what I heard. (V21) said it needed to be reported and called (V1, Administrator). V40's statement dated 6/4/2024, documents, At around 6:15 AM I was sitting in the dining room sorting (meal) tickets when I heard (R41) at the nurses' desk asking for her clothes. She said, 'Where are my clothes. I don't live here'. (V13) replies, very loudly, 'I don't care if you live here or not, go away'. (R41) repeated herself again and the nurse (V14) screamed at her, 'shut up'. (V15) stopped next to me and just looked stunned. I asked (V15). 'Since when is it ok to talk to a resident like that or tell a resident to shut up?' I reported to (V21) as soon as she got here. On 6/27/24 at 10:45 AM, V21 stated, I called (V1). (V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. The Facility's Abuse, Prevention, and Prohibition Policy dated 1/2024 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends, or other individuals' misappropriation of resident property. The residents must not be subjected to abuse by anyone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. It continues to document, Three staff members report that (R41) was at the nurses' desk where nurses were completing shift change. (R41) persistently told the staff she did not want to live at the facility and wanted to go to (another local town) to see her son. Circumstances beyond her control prevent her son from visiting the Facility but (R41) is not able to understand this. (R41) has diagnoses of altered mental status, symptoms including cognitive function and awareness and mental disorder not classified. It further documents, (V15, Medical Records) reports observing and hearing both (V13, Licensed Practical Nurse, LPN) and (V14, LPN) telling (R41) to 'shut up'. These observations are corroborated from two other staff members. On 6/24/24 at 9:30 AM, V1 Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13 LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told (V21, Business Office Manager), and (V21) called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. By this time (V13) had already gone home because it was the end of shift. (V14) was pulled off of the floor and statements were taken. (V14) was told to go home. Both (V13 and V14) were both suspended at that time. After the investigation the abuse was substantiated, and both were terminated. On 6/25/2024, at 3:04 PM, V9, Registered Nurse (RN), stated, I was at the nurses' station doing shift change in the morning. R41 was saying over and over again that she wanted to go home. (V13) asked (R41) to be quiet several times so they could get report and count. (V13 and V14) told her (R41) to shut up. I heard it all. I didn't do anything with it, and I should have. On 6/26/2024 at 12:25 V15, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our fucking job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40, CNA) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the fuck up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/2024 at 10:38 AM V40, Certified Nursing Assistant (CNA) stated, I was in the dining room early in the morning. I heard a nurse scream at her to shut up. It was (V14, LPN). I heard (V13, LPN) saying stuff can't remember what exactly. It was not appropriate, and it was her tone. (V15, Medical Records) and I looked at each other, like Is it abusive/reportable? did we just hear what we think we just heard? I told (V21, Business Office Manager) what I heard. (V21) said it needed to be reported and called (V1, Administrator). On 6/27/24 at 10:45 AM, V21 stated, I called (V1). (V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. The Facility's Abuse, Prevention, and Prohibition Policy dated 1/2024 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends, or other individuals. Policy- This facility prohibits mistreatment, neglect, or abuse of residents. It continues, The facility administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the administrator is not available to address this role, the administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. It further documents, Prevention- The resident has the right to be free from verbal, mental, sexual, exploitation or physical abuse; corporal punishment and involuntary seclusion. It continues, Investigation- Resident abuse must be reported immediately to the administrator. The Facility administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. Implement steps to prevent further potential abuse. Initiate investigation including reporting to all required agencies. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents, or visitors, who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has a special rapport participate if possible. If the resident is not interviewable, question the roommate an any family or friends who visit frequently with completion of a questionnaire. Complete and summarize the investigation within 5 business days. Review outcome of investigation report with the Regional Nurse. Notify the employee in question of their reinstatement or termination. The policy continues, Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. Employee Allegations: when an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. Employee Allegations: When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with resident through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. The administration and or the Director of Nursing will replay this suspension. At that time, the alleged staff member will be advice of the allegation and encouraged to assist in completing a statement relevant to the facts. Reporting/Response: The Facility employee or agent, who becomes aware of abuse or neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in the administrator's absence. The Facility administrator, employee or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegation of abuse or neglect, or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made. Based on interview and record review, the facility failed to operationalize their abuse policies and procedures for conducting thorough investigation of allegations of abuse, protect residents during abuse nvestigations, and report allegations of abuse to the administrator immediately for two of 6 residents (R5, R41) reviewed for abuse policy and procedures in the sample of 44. Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated, A few weeks ago we were sitting in the dining room, there is a resident (R41) that repeats she wants to go home. (V11, Certified Nurse Aide, CNA) got right in her face and told her, You are never going to go home again to see your son because he is in prison. R5 was questioned if he told anyone of this, R5 stated, I told (V10, Social Service Director, (SSD) and (V1, Administrator). They came back and told me that (V11) needed to be retrained. I think that it was mental abuse. On 6/25/24 at 2:30 PM, V11, CNA, stated that he has never been involved in an allegation of abuse for R41. V11 stated that R41 is hard of hearing, and she always says that she wants to go home over and ever. On 6/25/24 at 3:03 PM, V9, Registered Nurse, (RN), stated, I was at the nurses station doing shift change in the morning. V14 LPN (Licensed Practical Nurse) was up there too. (V13) was giving report to her nurse. (R41) was saying over and over again that she wanted to go home. (V13) and (V14) both told her to shut up. I did not notify (V1) of it, but I know someone did. At this time, (V11) was not present. I do know that when he came in for his shift, he was not allowed to work the hall. I don't know why though. On 6/26/24 at 7:15 AM, V20, CNA, stated, I was told by (V11) when I came in that when he (V11) came to work he was not allowed to go onto the hall because 2 residents had complained about him. He was told that (R5 and R43) had made complaints about the way he treated (R41). He told me that he was told to stay off of their halls when he was able to work on the floor later in the day. He was never suspended while they did the investigation. V20 was questioned if the allegation of abuse had to do with the allegation of (R41) being told to shut up, V20 stated, No it was another allegation that they (R5 and R43) had made about the way V11 treated R41. On 6/26/24 at 12:09 PM, V10, stated, I had interviewed (R5) while I was interviewing residents regarding the incident involving 2 nurses (V13 and V14) and R41. R5 told me that he thought (V11) was rough and loud in his voice while working with her. He said that he had yelled at her. I wrote the statement and gave it to V1, Administrator. I wrote word for word of what he said, read it back to him and then gave it straight to the Administrator. V1 said that she would take care of it. V1 did the follow up with R5. V2, Director of Nurses, was also involved in it too. On 6/26/24 at 3:17 PM, V1, stated that interviews were being taken from residents related to (V13 and V14) telling R41 to shut up. V1 stated I had collected all interviews and put them into a pile. I did not review them because I was still gathering information. I sent all the information to (V43, Regional Nurse Consultant), to let her review. I had a meeting that day from 4:00 PM to about 5:40 PM. Later that evening or the next day, I can't remember which, she (V43) called me and asked me if I had seen (R5's) statement. I told her no. (V2, Director of Nursing), came to me on 6/4/24 after my meeting and told me that we have an issue regarding V11. V11 was already working on the floor. He starts at 2:00 PM. He was pulled from the floor. I am not sure of what time it was. We both went down and talked to (R5). At that time, he said that she felt that (V11) was making fun of (R41). At no time, did he say that (V11) got in her face and yelled at her like his statement says. I then interviewed (V11). He said that he did not make fun of her. He said that he was trying to reorient her to reality. I and (V2) felt that it was a misunderstanding and we retrained him on effective communication, and he went back to work. I did not get any other interviews from other residents or staff about (V11). R5's admission Record, print date of June 25,24, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Minimum Data Set, dated [DATE], documents that R5 is cognitively intact. R5's Abuse Investigation Investigative Questionnaire, dated 6/4/24, untimed, documents, (V11) kept teasing resident (R41) who wanted to go to [NAME] to her son, (V11) yelled in residents' face shut up, ain't no one in [NAME] want you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Facility's Report of Alleged Resident Abuse dated 6/4/24 at 6:15 AM documents there was an allegation of verbal mistreatment and abuse and two employees, V13 and V14 were suspended. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. On 6/24/24 at 9:30 AM, V1 Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13 LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told (V21, Business Office Manager), and (V21) called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. On 6/25/2024, at 3:04 PM, V9 Registered Nurse (RN), stated, I was at the nurses' station doing shift change in the morning. R41 was saying over and over again that she wanted to go home. (V13) asked (R41) to be quiet several times so they could get report and count. (V13 and V14) told her (R41) to shut up. I heard it all. I didn't do anything with it, and I should have. On 6/26/2024 at 12:25 V15, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our fucking job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the fuck up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/2024 at 10:38 AM V40, Certified Nursing Assistant (CNA) stated, I was in the dining room early in the morning. I heard a nurse scream at her to shut up. It was (V14, LPN). I heard (V13, LPN) saying stuff can't remember what exactly. It was not appropriate, and it was her tone. (V15, Medical Records) and I looked at each other, like Is it abusive/reportable? did we just hear what we think we just heard? I told (V21, Business Office Manager) what I heard. (V21) said it needed to be reported and called (V1, Administrator). On 6/27/24 at 10:45 AM, V21 stated, I called (V1). (V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. The Facility's Abuse, Prevention, and Prohibition Policy dated 1/2024 documents, The facility administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the administrator is not available to address this role, the administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Reporting/Response: The Facility employee or agent, who becomes aware of abuse or neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in the administrator's absence. The Facility administrator, employee or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegation of abuse or neglect, or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made. Based on interview and record review, the facility failed to immediately report an allegation of abuse to administrator and the State Survey Agency for 2 of 24 residents (R5, R41) reviewed for reporting of abuse in the sample of 44. Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated, A few weeks ago we were sitting in the dining room, there is a resident (R41) that repeats she wants to go home. (V11, Certified Nurse Aide, CNA)) got right in her face and told her, 'You are never going to go home again to see your son because he is in prison.' R5 was questioned if he told anyone of this, R5 stated, I told (V10, Social Service Director, SSD) and (V1, Administrator). They came back and told me that (V11) needed to be retrained. I think that it was mental abuse. On 6/26/24 at 12:09 PM, V10, stated, I had interviewed (R5) while I was interviewing residents regarding the incident involving 2 nurses (V13, CNA and V14, CNA) and (R41). R5 told me that he thought (V11) was rough and loud in his voice while working with her. He said that he had yelled at her. I wrote the statement and gave it to (V1). I wrote word for word of what he said, read it back to him and then gave it straight to the Administrator. V1 said that she would take care of it. (V1) did the follow up with (R5). (V2, Director of Nurses), was also involved in it too. On 6/26/24 at 3:17 PM, V1, stated that interviews were being taken from residents related to (V13 and V14) telling R41 to shut up. V1 stated I had collected all interviews and put them into a pile. I did not review them because I was still gathering information. I sent all the information to (V43, Regional Nurse Consultant), to let her review. I had a meeting that day from 4:00 PM to about 5:40 PM. Later that evening or the next day, I can't remember which she called me and asked me if I had seen (R5's) statement. I told her no. (V2) came to me on 6/4/24 after my meeting and told me that we have an issue regarding (V11). (V11) was already working on the floor. He starts at 2:00 PM. He was pulled from the floor. I am not sure of what time it was. We both went down and talked to (R5). At that time, he said that he felt that (V11) was making fun of (R41). At no time, did he say that (V11) got in her face and yelled at her like his statement says. I then interviewed (V11), he said that he did not make fun of her. He said that he was trying to reorient her to reality. I and (V2) felt that it was a misunderstanding and we retrained him on effective communication, and he went back to work. There was no documentation that this allegation of abuse was reported to Illinois Department of Public Health (IDPH). R5's Abuse Investigation Investigative Questionnaire, dated 6/4/24, untimed, documents, (V11) kept teasing resident (R41) who wanted to go to [NAME] to her son, (V11) yelled in residents' face shut up, ain't no one in [NAME] want you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Facility's Final Investigation dated 6/11/2024 documents, In the morning of June 24th, staff members at (Facility) reported to the Administrator (ADM) that two nurses had an inappropriate verbal interaction with a resident (R41). An investigation was initiated, and staff members were suspended. On 6/24/24 at 9:30 AM, V1 Administrator, stated, I was notified that (V14 Licensed Practical Nurse, LPN) and (V13 LPN) had told (R41) to shut up during shift change. (R41) is confused and can be very repetitive. The staff did not notify me directly they had told V21, Business Office Manager, and V21 called me. There was a bit of a delay. The incident happened around 6:15 AM and I was notified at 7:30 AM. By this time V13 had already gone home because it was the end of shift. V14 was pulled off of the floor and statements were taken. V14 was told to go home. Both V13 and V14 were both suspended at that time. After the investigation the abuse was substantiated, and both were terminated. On 6/26/2024 at 12:25 V15, CNA, stated, I came in early that day (6/4/2024). I was by the nurse's station. (V13 and V14) were yelling and cussing at (R41). They said, 'We don't care where you live. She doesn't realize. She's confused. They also said, 'We can't do our fucking job'. At that point, I said, 'this is not ok'. I walked into the dining room and (V40) was in there and agreed. I witnessed (V13) wheel (R41) into the dining room by the DON's office. She got right up in her face and was intimidating her, saying, 'Shut the fuck up'. I did not report it in a timely manner. I didn't have my cell phone and I had to go on a transport. I know you are supposed to immediately report it. (V1) wasn't here but (V21) notified her. (V14) stayed on the floor (providing patient care) even though they were made aware. They made her stay until the DON came in. I know I am a mandated reporter. I felt it was wrong. I know the policy. Corporate told me anyone in the building could walk anyone out, even if they are nurses. On 6/27/24 at 10:45 AM, V21 stated, I called (V1). V40) reported it to me. I text (V1), and she was on her way. I didn't see or hear anything, but I felt it was my responsibility to report. I am not sure what time (V14) left but I know it wasn't right away, even after (V1) got here. V14's Timecard dated 6/4/2024 documents V14 clocked in at 5:51 AM and clocked out at 8:35 AM. Based on interview and record review, the facility failed to protect residents and prevent further potential abuse during abuse investigations and conduct thorough abuse investigations for 2 of 6 residents (R5, R41), reviewed for investigation/prevention/corrections of alleged violation of abuse in the sample of 44. Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated, A few weeks ago we were sitting in the dining room, there is a resident (R41) that repeats she wants to go home. (V11, Certified Nurse Aide, CNA) got right in her face and told her, You are never going to go home again to see your son because he is in prison. R5 was questioned if he told anyone of this, R5 stated, I told (V10, Social Service Director, (SSD) and (V1, Administrator). They came back and told me that (V11) needed to be retrained. I think that it was mental abuse. On 6/25/24 at 2:30 PM, V11, CNA, stated that he has never been involved in an allegation of abuse for R41. V11 stated that R41 is hard of hearing, and she always says that she wants to go home over and ever. On 6/25/24 at 3:03 PM, V9, Registered Nurse, (RN), stated, I was at the nurses station doing shift change in the morning. V14 LPN was up there too. V13 was giving report to her nurse. R41 was saying over and over again that she wanted to go home. V13 and V14 both told her to shut up. I did not notify V1 of it, but I know someone did. At this time, V11, CNA was not present. I do know that when he came in for his shift, he was not allowed to work the hall. I don't know why though. On 6/26/24 at 7:15 AM, V20, CNA, stated, I was told by (V11) when I came in that when he came to work, he was not allowed to go onto the hall because 2 residents had complained about him. He was told that (R5 and R43) had made complaints about the way he treated (R41). He told me that he was told to stay off of their halls when he was able to work on the floor later in the day. He was never suspended while they did the investigation. V20 was questioned if the allegation of abuse had to do with the allegation of (R41) being told to shut up, V20 stated, No it was another allegation that they (R5 and R43) had made about the way (V11) treated (R41). On 6/26/24 at 12:09 PM, V10, stated, I had interviewed (R5) while I was interviewing residents regarding the incident involving 2 nurses (V13 and V14) and R41. R5 told me that he thought (V11) was rough and loud in his voice while working with her. He said that he had yelled at her. I wrote the statement and gave it to V1, Administrator. I wrote word for word of what he said, read it back to him and then gave it straight to the Administrator. V1 said that she would take care of it. V1 did the follow up with R5. V2, Director of Nurses, was also involved in it too. On 6/26/24 at 3:17 PM, V1, stated that interviews were being taken from residents related to (V13 and V14) telling R41 to shut up. V1 stated I had collected all interviews and put them into a pile. I did not review them because I was still gathering information. I sent all the information to (V43, Regional Nurse Consultant), to let her review. I had a meeting that day from 4:00 PM to about 5:40 PM. Later that evening or the next day, I can't remember which she called me and asked me if I had seen (R5's) statement. I told her no. (V2, Director of Nursing) came to me on 6/4/24 after my meeting and told me that we have an issue regarding (V11). (V11) was already working on the floor. He starts at 2:00 PM. He was pulled from the floor. I am not sure of what time it was. We both went down and talked to (R5). At that time, he said that he felt that (V11) was making fun of (R41). At no time, did he say that (V11) got in her face and yelled at her like his statement says. I then interviewed (V11), he said that he did not make fun of her. He said that he was trying to reorient her to reality. I and (V2) felt that it was a misunderstanding and we retrained him on effective communication, and he went back to work. I did not get any other interviews from other residents or staff about (V11). R5's Abuse Investigation Investigative Questionnaire, dated 6/4/24, untimed, documents, (V11) kept teasing resident (R41) who wanted to go to [NAME] to her son, (V11) yelled in residents' face shut up, ain't no one in [NAME] want you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notice of bed hold policy to the resident and/or resident representative upon transfer to hospital for 1 of 1 resident (R7) reviewed for notice of bed-hold in a sample of 44. Findings include: R7's Face Sheet, dated 5/1/24 documented R7 was readmitted from the hospital on 5/1/24 and documents diagnoses of COPD (chronic obstructive pulmonary disease) and pneumonia. R7's Minimum Data Set (MDS) dated [DATE] documents cognitive impairment with a BIMS (Brief Interview Mental Status) of 3. R7's Progress Notes dated 4/26/2024 documents R7 was admitted to (local hospital). Review of R7 record review fails to document any bed-hold notification was provided to R37 and/or V36, Power of Attorney (POA). On 6/25/204 at 2:05 PM, V16 Licensed Practical Nurse (LPN) stated that a face sheet, medication list, order summary, code status is sent with the resident when they go to the hospital. On 6/25/2024 at 2:15 PM, V10 Social Worker, stated, The ombudsman (resident advocate) is sent a batch email at the end of the month. V10 stated a bed-hold sheet and transfer/discharge paperwork should be sent with the resident. V18 stated they are sent with a SBAR, face sheet, advanced directive, bed hold policy and transfer policy. She states that the nurses document this in the progress notes. On 6/25/2024 at 2:20 PM, V18, Licensed Practical Nurse, LPN, stated that the nurses should document the bed-hold policy in the progress notes. On 6/26/2024 at 12:00 PM, V1, Administrator, states that her expectation is that staff should follow the policy on what papers should be sent and be retrained if they don't know what this policy is.

2. On 6/24/24 at 12:15 PM, R38 was lying in her bed. R38 was lying onto her left side. R38 had a large abdomen that lays onto the mattress. R38 stated that she only lays this way. R38 stated that she has been dealing with the pressure ulcer on the abdomen for a long time. She stated that it will heal and then it will open back up. R38 stated that she does have an area on the back of her leg near her bottom. On 6/25/24 at 2:45 PM, V3, Assistant Director of Nurse, (ADON) and V39, Certified Nurse's Aide (CNA) entered R38's room to look at pressure ulcer dressings. R38's left gluteal fold has cream and a small open area which is difficult to see related to R38's position. On 6/25/24 at 2:45 PM, R38 and V39 both stated that the left gluteal fold has a pressure ulcer. On 6/27/24 at 9:33 AM, V8, Wound Nurse / Licensed Practical Nurse, (LPN) entered R38's room to change R38's pressure ulcer dressing and wound dressings. The left gluteal fold pressure ulcer is approximately 0.5-centimeter (cm) x 0.5 cm. The wound bed is red. V8 cleansed with normal saline, applied calcium alginate, and applied a foam dressing. On 6/26/24 at 3:15 PM, V3 was questioned why there was no documentation of the left gluteal fold pressure ulcer in R38's medical record. V3 stated that she did not know, and she would review the record. On 6/27/24 at 9:30 AM, V8 stated that she looked at R38's gluteal fold pressure ulcer the evening before (6/26/24). V8 stated she was unaware of the pressure ulcer or how long it has been there. R38's Pressure Ulcer Weekly Wound Evaluation, dated 6/26/24, documents that R38 has a new stage 2 pressure ulcer to the left gluteal fold measuring 1 cm x 0.5 cm x 0.1 cm which first presented on 6/26/24. The policy Pressure Ulcer / Pressure Injury Prevention, dated 3/22, documents that all residents should have a daily skin observation of the skin during care given by the CNAs. This policy fails to document assessment, measurement, and documentation of the pressure ulcer, notification of the doctor, and obtaining orders for the pressure ulcer. Based on observation, record review and interview the facility failed to identify, assess, and treat pressure ulcers for 2 of 7 residents (R38 and R125) reviewed for pressure ulcers in the sample of 44. Findings include: 1. On 06/24/24 at 9:30AM, R125 was sitting in wheelchair in his room. R125 was observed with both bare feet on the floor and pressure sores to bilateral heels without any type of dressing on them. R125 stated They are leaving them open to air. On 6/27/2024 10:29 AM V8, Wound Nurse, and V42, Licensed Practical Nurse, LPN, provided treatment to R125's pressure ulcers. There were dressing in place to bilateral heels prior to treatment. V8 removed dressings cleansed wounds and applied debridement ointment, calcium alginate and foam border dressing. R125's right heel unstageable per V8. V8 stated R125 was to have treatments done as ordered and heels are not to be left open to air. R125's Physician Orders (PO) dated 6/14/2024 documents Cleanse wound to left heel, apply Santyl, calcium alginate and cover with dry dressing every night shift for vascular wounds AND as needed for soiling or unscheduled removal. R125's PO dated 6/14/2024 documents Cleanse wound to right heel, apply Santyl and cover with dry dressing every night shift for vascular wounds AND as needed for soiling or unscheduled removal. R125's Care Plan, dated 6/19/2024 documents R125 has potential/actual impairment to skin integrity related to pressure (right hip) Venous R (right) anterior knee, R lateral knee, left heel, right heel, left shin. The facility policy Pressure Ulcer/Pressure injury prevention, revised 3/2022, documents if pressure ulcer /pressure injury is present, provide treatment to heal it and prevent the development of additional pressure ulcers/pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an occlusive dressing for a Peripherally Inserted Central Catheter (PICC) for 2 of 2 residents (R33, R175) reviewed for Intravenous Therapy in the sample of 44. Findings include: 1. On 6/24/24 at 1:25 PM, V6, Registered Nurse, (RN) entered R175's room to hang an Intravenous (IV) medication through a PICC (Peripherally Inserted Central Catheter) line. V6 told R175 that she was going to hang her IV (Intravenous) antibiotic. R175 extended her right arm showing a double lumen PICC line in the right upper arm. The dressing was not adhered to the skin at the bottom and the right side of the dressing. The dressing was dated 6/19/24. R175 stated, Do you see my dressing? V6 stated, Yes, I have got to get you an IV pole. V6 returned with an IV pole and hung the IV medication without changing the dressing. On 6/26/24 at 8:58 AM, V6, was questioned why she did not change R175's PICC line dressing was not changed when she noticed it was not occlusive anymore, V6 stated, I am not sure. I did go back and change it when the IV was finished. V6 stated that the PICC line dressing should be changed once a week. On 6/26/24 at 9:02 AM, V3, Assistant Director of Nurses (ADON), stated that the PICC line dressing should be changed every week or when it becomes loosened. R175's admission Record, print date of 6/26/24, documents that R175 was admitted on [DATE] with a diagnosis of abscess of the salivary gland. R175's June 2024 Medication Administration Record or Treatment Administration Record fails to document a PICC line dressing change every week or as needed. 2. On 06/24/24 at 03:04 PM, R33 was sitting in dining room with a dual lumen PICC line the dressing is dated 6/11/24 the bottom or the right side of the occlusive dressing is not attached. R33 stated that she gets an IV every day and it is hung in the morning. R33's admission Record, print date of 6/26/24, documents that R38 was admitted on [DATE] with diagnoses of Renal and Perinephric Abscess and Urogenital Implant. R33's Medication Administration Record, dated June 2024, documents that R33's Ertapenem Sodium Injection Solution Reconstituted 1 GM (gram) was hung on the day shift (6:00 AM - 6:00 PM) R33's June 2024 Treatment Administration Record documents that R38's PICC line dressing was not change on the day shift. R33's Health Status Note, dated at 6/24/2024 at 6:45 PM, documents, Resident has had no reaction noted to ABT (antibiotic) r/t (related to abscess). Changed dressing to PICC, area looks good, intact, PICC in place, no s/s (sign and symptom) of infection noted. Resident pleasant, makes needs known. The Organizational Aspects of IV Therapy, dated 7/2016, documents, 5. Caring for and maintaining infusion equipment and catheters 9peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, site rotation, changing IV tubing and needleless connection devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to change nebulizer therapy tubing on a weekly basis for 1 of 8 residents (R65) reviewed for respiratory therapy in the sample of 44. Findings include: 1. On 06/26/24 at 03:00 PM R65's nebulizer machine and tubing were on nightstand beside the bed. R65's tubing dated 6/2/2024. R65 stated oxygen tubing and nebulizer tubing used to be changed on a weekly basis. R65's Minimum Set (MDS) dated [DATE] documents R65 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. R65's Face Sheet dated 6/27/2024, documents a diagnosis in part of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea. R65's Physician Order (PO) dated 3/11/2024 documents Ipratropium-Albuterol Solution 0.5-2.5 (3) Milligram (MG) /3 Milliliter (ML) inhale orally every 6 hours as needed for Shortness of Breath (SOB). R65's PO, dated 2/19/24, documents oxygen tubing-change weekly every night shift, every Sunday. On 7/1/2024 at 7:55AM, V18, MDS coordinator stated the facility does not have a specific policy for nebulization tubing, but the tubing is to be changed weekly same as the oxygen tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure physician ordered medication was readily available for administration for 1 of 5 residents (R62) reviewed for pharmacy services and procedures in the sample of 44. Findings include: On 6/24/2024 at 10:30 AM, R62 stated she has been out of her Effexor, which she takes for depression. R62 continued to state, They let me run out of my Effexor. It is an anti-depressant and I have to have it. I take it twice a day and I didn't have it last night or this morning. It's completely out of my system. I have withdrawals and it makes me sick. Please check on it. I can already feel it in my body that I missed doses. It's ridiculous. R62's Minimum Data Set (MDS) dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a mood problem related to her diagnosis of Depression and R62 receives an antidepressant. It further documents, Administer medications as ordered. R62's Physician's Orders dated 6/27/2024 documents, Venafaxine (Effexor) HCL Oral Tablet 100 mg-Give one tablet by mouth every morning and at bedtime for antidepressant. R62's Medication Administration Record dated June 2024, documents 6 for one dose on 6/23/24 and two doses on June 24, 2024. It further documents that 6 indicates See Progress Note. On 6/26/24 at 10:24 AM, V3, Assistant Director of Nursing (ADON) stated she was aware R62 had ran out of her depression medication and did not receive doses as prescribed. V3 further stated, If it gets down to the last one the card there is a re-order button on the MAR. It should be re-ordered when it turns blue on the card about 7 days prior. She (R62) told me Monday (6/24/2024) she was out of her Effexor (depression medication). I called pharmacy and had it e-ran (emergency delivery from pharmacy). It came in a little after lunch (Monday 6/24/24). On 7/1/2024 at 9:20 AM, V3 stated there was not an entry made in R62's Progress Notes on 6/23/2024 for the missing medications dose. On 7/1/2024 at 9:33 AM, V3 provided two Progress Notes from 6/24/2024, on at 9:10 AM and one at 8:14 PM, that documented N/A, which V3 verified indicated that the medication was not available. The Facility provided an Hours of Operation & Cutoff Times document that states, The facility staff should specifically request any items that cannot wait until the next regularly scheduled pharmacy delivery. The after-hours representative will arrange for a local pharmacy to fill a 3-day supply of the requested items and coordinate a delivery with a driver to take it directly to the home. The Facility's General Pharmacy Information dated 4/2021 documents, Refills after above time will be sent with the next day's delivery unless the nurse indicates that it is needed that day. Refills are to be communicated either electronically through the interface or by faxing the refill re-order form that contains the prescription barcode. The Medication Fact Sheet dated January 2016 from the website American Association of Psychiatric Pharmacists (aapp.org) documents, Missing doses of venlafaxine may increase your risk for relapse in your symptoms. Stopping venlafaxine abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paresthesis (prickling, tingling sensation on the skin).

Based on observation, interview, and record review, the facility failed to remove outdated medication from the medication refrigerator, date an insulin pen after opening, and ensure medications are labeled for 3 of 18 residents (R1, R68, R125) reviewed for labeling and storage of medication in the sample of 44. Findings include: 1. On 06/25/24 at 09:15 AM, the medication storage room was inspected and contained R1's Cephalexin 250 milligrams (mg) oral suspension. Open date of 06/08/24 and the directions read to discard after 14 days. On 06/25/24 09:20 AM, V3, Assistant Director of Nursing (ADON) confirmed that the Cephalexin should have been discarded after 14 days. 2. 06/25/24 at 09:33 AM, the medication cart on the A hallway was inspected and contained2. R68's Humalog Kwik Pen was opened but did not have an open dated on the pen. V16, Licensed Practical Nurse (LPN) stated the pens are good for 30 days after opening. She said R68 uses a pen in less than 30 days so she knows it is probably still good, but she will dispose of the pen and get her a new one since there is no open date on it. On 06/27/24 at 10:50 AM, V3 stated she would expect for the nursing staff to always date any medication after opening it and to check the medication before using. The facility's policy for Delivery, Storage, and Return of Drugs or Supplies, with a revision date of 12/21, documents F. Residents' medications shall be properly labeled and stored at or near the nurse's station in a locked cabinet, a locked medication room, or in one or more locked mobile medication carts of satisfactory design for such storage. All mobile medication carts, when not stored either in a locked room or otherwise made immobile, shall be under the visual control of the responsible nurse at all times. G. The medications of each resident shall be kept and stored in their originally received containers. Medications shall not be transferred between containers. It further documents I. Multi-dose vials and pens shall be stored and dated per the manufacturer's guidance. 3. On 06/24/24 at 11:11 AM during medication pass, R1's fluticasone Propionate suspension nasal spray in box in medication cart without a pharmacy label. V35, Licensed Practical Nurse, LPN stated the medications should be labeled. R1's Medication Administration Record (MAR)dated June 2024 documents Fluticasone Propionate suspension 2 sprays in each nostril one time a day as needed for congestion. 4. On 6/27/2024 at10:29 AM during wound treatments V8, Wound Nurse, removed tube of wound debridement ointment from treatment cart for R125. R125's medication did not have a pharmacy label. R125's name was handwritten on the tube of medication. V8stated she does not know what happened to box with label. V8 stated the medication should have a pharmacy label. R125's physician order (PO) dated 6/14/2024 documents Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to AFFECTED AREA topically everyday shift for WOUND CARE.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to answer call lights in a timely manner for 4 of 24 residents (R5, R22, R38, R50) reviewed for dignity in the sample of 44. Findings include: 1. On 06/24/24 at 12:30 PM, R38 was questioned if call light response is timely, R38 stated, Sometimes it takes hours for them to come. R38 was questioned how it makes her feel when she has to wait that long, R38 stated, Abandon like no one fxxxxxg cares. R38 was asked if she knew why it takes so long, R38 stated, They just say we are really backed up. R38's admission Record, print date of 6/25/24, documents that R38 was admitted on [DATE] with diagnoses of Chronic Respiratory Failure and Chronic Kidney failure. R38's Minimum Data Set (MDS), dated [DATE], documents that R38 is cognitively intact, dependent on staff for toileting, bed mobility, and uses a wheelchair. 2. On 6/24/24 at 11:26 AM, R22 was questioned if her call light is answered timely, R22 stated, At night it can take over an hour. R22 was questioned as to how that made her feel waiting, R22 stated, You wait so long then you have an accident. It is beyond degrading to sit in something that should be in the toilet. It just makes me feel worthless. R22's admission Record, print date of 6/25/24, documents that R22 was admitted on [DATE] with diagnoses of Major Depression Disorder and Edema. R22's MDS, dated [DATE], documents that R22 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, requires partial / moderate assistance for hygiene, substantial / maximal assistance for bed mobility, and dependent on staff for bed to chair transfer. 3. On 6/24/24 at 12:35 PM, R50 was questioned about how timely the staff answer the call light, R50 stated, On the weekends, the staff can take hours for them to come in and answer the light because there is not enough staff. R50 was questioned how this makes her feel, R50 stated, I feel neglected. R50's admission Record, print date of 6/27/24, documents that R50 was admitted on [DATE] with diagnoses of Obesity, Type 2 Diabetes and End Stage Renal Disease. R50's MDS, dated [DATE], documents that R50 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, bed mobility, transfers, and is frequently incontinent of bowel and bladder. 4. On 06/25/24 at 10:00 AM, R5 stated, They don't have enough staff on night shift last night. I sat on the bedside commode for an hour and 15 minutes last night. R5 was questioned if the aides told him why it took so long, R5 stated, There was 2 CNA's for A and B hall. The one aide was working on both halls because the other aide was agency and she said, I am pregnant, and I am not doing a thing. R5 was questioned how waiting this long made him feel, R5 stated, It is what it is. R5's admission Record, print date of June 25,24, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Minimum Data Set, dated [DATE], documents that R5 is cognitively intact, uses a wheelchair, requires touch / supervision assist for toileting, hygiene, bed mobility, partial / moderate assistance for transfers. occasionally incontinent of urine, and frequently incontinent of bowel. On 6/26/24 at 4:05 PM, V18 MDS / Care Plan Licensed Practical Nurse, stated, The facility does not have a policy on call light answer times. V18 stated the expectation is that the light is answered in 3 to 5 minutes. The Resident Council meeting Minutes, dated 6/5/24, documents Call lights not being answered for 30 -45 minutes. The Illinois Long Term Care Ombudsman, dated 10/17, documents, The program strives to protect and promote the rights and quality of life for those who reside in long-term care facilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R62's MDS dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a catheter and a wound to the back of her right thigh. On 6/24/2024 at 10:30 AM, R62 stated she has open wounds and a urinary catheter. R62 stated she needs cleaned up (provided incontinent care). On 6/25/2024 at 10:40 AM, V29, CNA entered R62's room and R62 informed V29 that R62 needed incontinent care. R62 had a small soft bowel movement (BM). There was also BM on R62's catheter tubing. V29 began to provide incontinent care to R62 without donning a gown. V29 cleansed the area of R62's buttocks. R62's dressing to R62's open wound to R62's buttocks was soiled with BM. V29 removed R62's dressing with the same gloves used to cleanse the feces off R62's buttocks. V29 then cleansed R62's catheter tubing, without the benefit to hand hygiene or changing gloves. V29 then rolled R62 over and cleansed R62's groin area. At this time, R62 thanked V29 and stated, Usually they just clean my backside and not the front (peri/groin area) and I don't want any more infections. On 6/25/2024 at 10:55 AM, V8, Wound Nurse, entered R62's room to replace R62's dressing to her buttocks. V8 stated R62 also had an open wound to R62's right gluteal fold. When V8 lifted R62's right buttock cheek, there was still feces remaining in the crevice. V8 cleansed the remaining feces. Based on interview, observation, and record review, the facility failed to provide complete incontinent care for 4 of 5 residents (R57, R59, R62, R128) reviewed for incontinence care in the sample of 44. Findings include: 1. On 06/26/24 at 2:35 PM, V38, Certified Nurse Aide, (CNA) and V39 CNA entered R57's room to provide incontinent care. R57's incontinent brief was moderately saturated with urine. V38 with disposable peri-wash cloths wiped the right groin, then left groin, and gently wiped over the labia twice. R57 was rolled over onto her right side and the rectal area and both buttocks were cleansed. V38 placed a new incontinent brief on R57. V38 failed to spread and cleanse the labia and cleanse the inner thighs. R57's admission Record, print date of 6/26/2024, documents that R57 was admitted on [DATE] with diagnoses of Functional Urinary Incontinence, Paranoid Schizophrenia, and need for assistance with personal care. R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is severely cognitively impaired, requires substantial / maximal assistance from staff for toileting, personal hygiene, Partial / moderate assistance with mobility, and is frequently incontinent of bowel and bladder. On 6/26/24 at 2:55 PM, V18, MDS / Care Plan Licensed Practical Nurse (LPN), stated, The facility does not have an incontinent care policy. We expect the nursing staff to follow standards of practice. On 6/27/24 at 11:20 AM, V41, Regional Directors of Operations, stated that the expectations of staff are that complete incontinent care will be provided. 3. On 06/24/24 at 11:54 AM V7, CNA, and V3, Assistant Director of Nursing (ADON) provided R59 incontinence care. V7 removed R59's pants and undid R59's adult diaper. V7 stated R59 has pooped and was incontinent of urine. V7 rolled the adult diaper under R59. V7 turned R59 to left side. V7 used disposable wipes and cleansed rectal area from front to back. V7 did not cleanse buttocks. V7 then placed R59 on back. V7 cleansed left groin, then right groin. V7 separated labia and made one swipe with disposable wipe from front to back. V7 did not cleanse inner thighs prior to drying R59. R59's Care Plan dated 2/21/2024 documents that R59 has bladder incontinence. R59's care plan documents wash, rinse, and dry perineum. 4. On 06/26/24 at 08:46 AM V22 CNA and V23, Certified Occupational Therapist Aide, COTA, went into R128's room transferred R128 from sit to stand to the toilet. V22 removed R128's adult diaper. R128's adult diaper was full of liquid stool. R128 stated he still needed to go to the bathroom. At 9:11 AM, V24 CNA and V22 with sit to stand lift lifted R128 to standing position. V24, with disposable wipes reached in from behind R59 and swiped from front to back using numerous wipes until no visual stool. At no time did V22 or V24 cleanse R128's scrotum or peri area during incontinent care. R128's Care Plan, dated 6/14/2024 documents R128 has bladder incontinence, and impaired m mobility. R128's Care Plan documents wash, rinse and dry perineum after incontinent episodes. On 7/1/2024 at 10:25AM V25, CNA, stated that when providing incontinent care on a male resident the scrotum is to be cleansed, the penis and the foreskin is to be pulled back and cleansed. 3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide enough staff to care for residents in a timely manner for (R38, R22, R50, R5) reviewed for sufficient nursing staff in the sample of 44. Findings include: 1. On 06/24/24 at 12:30 PM, R38 was questioned if call light response is timely, R38 stated, Sometimes it takes hours for them to come.R38 was asked if she knew why it takes so long, R38 stated, They just say we are really backed up. R38's Minimum Data Set (MDS), dated [DATE], documents that R38 is cognitively intact, dependent on staff for toileting, bed mobility, and uses a wheelchair. 2. On 6/24/24 at 11:26 AM, R22 was questioned if her call light is answered timely, R22 stated, At night it can take over an hour. R22's MDS, dated [DATE], documents that R22 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, requires partial / moderate assistance for hygiene, substantial / maximal assistance for bed mobility, and dependent on staff for bed to chair transfer. 3. On 6/24/24 at 12:35 PM, R50 was questioned about how timely the staff answer the call light, R50 stated, On the weekends, the staff can take hours for them to come in and answer the light because there is not enough staff. R50's MDS, dated [DATE], documents that R50 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, bed mobility, transfers, and is frequently incontinent of bowel and bladder. 4. On 06/25/24 at 10:00 AM, R5 stated, They don't have enough staff on night shift last night. I sat on the bedside commode for an hour and 15 minutes last night. R5 was questioned if the aides told him why it took so long, R5 stated, There was 2 CNAs for A and B hall. The one aide was working on both halls because the other aide was agency and she said, I am pregnant, and I am not doing a thing. R5's MDS, dated [DATE], documents that R5 is cognitively intact, uses a wheelchair, requires touch / supervision assist for toileting, hygiene, bed mobility, partial / moderate assistance for transfers. occasionally incontinent of urine, and frequently incontinent of bowel. On 7/1/24 at 8:23 AM, V44, CNA scheduler stated, The CNAs work on 8-hour shifts; 6 AM to 2 PM, 2 PM - 10 PM, 10 PM - 6 AM. Most CNA's work 8-hour shifts but I do have a few that work 12-hour shifts. Depending on the census, on day shift the highest is 9 which is 80 or above and the lowest 70 or less is 6. The evening shift, the highest is 8 and lowest is 5. The night shift highest is 5 and lowest is 3. 3 CNAs on night shift is not enough. The fall pod requires 1 CNA just for those 4 residents, then we need at least 3 other CNAs for the other residents. Before the fall pod R57 really needed one to one supervision because she was a fall risk. It is ridiculous for it to take the CNAs over an hour to answer the call lights. I come in and work that shift if we are shorthanded and there is no reason for that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to perform hand hygiene, and utilize appropriate Personal Protective Equipment (PPE) to prevent the spread of infection for 4 of 24 residents (R62, R20, R59, R175) reviewed for infection control in the sample of 44. Findings include: 1. R62's Minimum Data Set (MDS) dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a catheter, impairment to skin integrity to her sacrum and right posterior (backside) of her thigh, as well as requires Contact isolation. On 6/24/2024 at 10:30 AM, R62 stated she has open wounds and a urinary catheter. There was no signage for any kind of isolation precautions on R62's door nor any Personal Protective Equipment (PPE). R62 stated she needs cleaned up (provided incontinent care) On 6/25/2024 at 10:40 AM, V29, Certified Nursing Assistant (CNA) entered R62's room and R62 informed V29 R62 needed incontinent care. R62 had a small soft bowel movement (BM). There was also BM on R62's catheter tubing. V29 began to provide incontinent care to R62 without donning a gown. V29 cleansed the area of R62's buttocks. R62's dressing to R62's open wound to R62's buttocks was soiled with BM. V29 removed R62's dressing with the same gloves used to cleanse the feces off R62's buttocks. V29 then cleansed R62's catheter tubing, without the benefit to hand hygiene or changing gloves. V29 then rolled R62 over and cleansed R62's groin area. At this time, R62 thanked V29 and stated, Usually they just clean my backside and not the front (peri/groin area) and I don't want any more infections. V29 then applied opened the bedside drawer and applied a clean adult brief with the same gloves used to cleanse areas of fecal contamination. On 6/25/2024 at 10:55 AM, V8, Wound Nurse, entered R62's room to replace R62's dressing to her buttocks. V8 set R62's dressing supplies on R62's bed, without a barrier. V8 then moved the supplies to a bedside table. V8 began cleansing the open area with a wound cleanser. V8 did not apply a gown prior to providing care to R62's open wound. V8 removed and disposed of the gloves but did not perform hand hygiene prior to applying new gloves and proceeded to complete the dressing change to R62's buttocks. V8 stated R62 also had an open wound to R62's right gluteal fold. When V8 lifted R62's right buttock cheek, there was still feces remaining in the crevice. V8 cleansed the remaining feces and again, changed gloves, but did not perform hand hygiene. On 6/27/2024 at 1:00 PM, V3, Assistant Director of Nursing (ADON) stated she would expect hand hygiene in between glove changes and when providing care between dirty areas and clean areas. V3 also stated, Anyone with a wound, (catheter), or anything that would make them more susceptible to infections should be on enhanced barrier precautions. Sometimes the sign (announcing precautions) falls off the door. V3 stated she was not aware R62's door did not have an enhanced barrier precaution sign or Personal Protective Equipment (PPE) readily available. On 7/1/2024 at 9:20 AM, V3 stated R62 is enhanced barrier precautions and staff should be wearing a gown when providing wound or catheter care. At this time, V18, Licensed Practical Nurse/MDS coordinator added R62 is on enhanced barrier precautions due to her wounds and catheter. 2. On 6/24/24 at 1:25 PM, V6, Registered Nurse, (RN) entered R175's room to hang an Intravenous (IV) Medications through a PICC (Peripherally inserted central catheter) line. R175's room door had enhanced barrier precaution sign on the door. V6 entered room without donning a gown or performing hand hygiene. Once in the room. donned gloves with no hand hygiene, hung, cleansed the lumen, changed gloves without hand hygiene and administered the IV medication. V6 removed her gloves, donned another pair of gloves, then cleansed the red lumen with 10 milliliters (mls) of Normal Saline followed by 5 ml of Heparin. On 6/26/24 at 10:45 AM, V6 was questioned as to why she did not follow the enhanced barrier precautions by wearing a gown and perform hand hygiene with donning and doffing gloves, V6 stated, I just forgot. 3. On 6/25/24 at 8:45 AM, V16, Licensed Practical Nurse (LPN), was observed administering medications to R20. V16 donned without hand hygiene at th3e beginning of the medication preparation. The policy Infection Prevention and control Manual - Enhanced Barrier precautions, undated, documents, Enhanced barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) acquisition (such as residents that have wounds or indwelling medical devices). High contact resident care activities where a gown and gloves should be used include: Transferring residents from one position to another (for example, from bed to wheelchair). Changing briefs or assisting with toileting. Caring for or using an indwelling medical device. Performing wound care. The Infection Prevention and Control Manual, dated 2019, documents, Wear gloves when it can reasonably anticipated that contact with blood or other body potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin. 4. On 6/24/2024, at 11:54 AM V7 provided incontinent care on R59. R59 was incontinent of urine and bowel movement. V7 donned gloves. V7 did not sanitize hands prior to donning gloves. V7 then began going through wardrobe and drawers looking for pants for R59. V7 removed R59's pants and incontinent brief and did not sanitize hands prior to donning gloves after rolling a soiled adult incontinent brief under R59. R59's Care Plan dated 2/21/2024 documents that R59 has bladder incontinence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of their property for 1 of 3 residents (R2) reviewed for medications in the sample of 12. This past non-compliance occurred between 1/3/2024 and 1/5/2024. Findings include: R2's Face Sheet, printed 5/22/24, documented that she had diagnoses of Acute Respiratory Failure with Hypoxia, Saddle Embolus of Pulmonary Artery with Acute Cor Pulmonale, Malignant Neoplasm of the Cecum and Encounter for Palliative Care. R2's Physician Order Summary Report, dated 5/22/24, documented that she had an order that dated 5/18/23 for Lorazepam Tablet 1 MG (milligram) Give 1 tablet by mouth every 2 hours as needed for Anxiety. R2's Physician Order Summary Report, dated 5/22/24, documented that she had an order that was dated 5/16/23 for Morphine Sulfate (Concentrate) solution 20 mg/ml (milliliter) Give 0.25 ml by mouth every 2 hours as needed for Pain. R2's Minimum Data Set (MDS), dated [DATE], documented that R2 was moderately cognitively impaired. R2's Care Plan, dated 5/24/23, documented, (R2) is on pain medication therapy r/t (related to) cancer. Interventions for this focus included: Administer medication as ordered. The facility's document, Facility Reported Incidents, dated 1/3/24 at 5:33 PM, with the Resident/Victim identified as (R2), and the Incident Category as Drug Diversion. This document includes a narrative description signed by V2, Director of Nursing which documented, On January 3, 2024, at approximately 2:30 PM, the (consultant pharmacy) representative was conducting an audit of the facility medication carts. During the audit, a discrepancy was noted with the color of morphine sulfate 20 mg/ml for resident, (R2) (6/7/1930). MD (Medical Doctor), (local) Police Department (ref #24-300), and Responsible Party notified. Investigation in progress and final report to follow once the investigation complete. Another Facility Reported Incident, dated January 9, 2024, identified R2 as the Resident/Victim, with the Incident Category as Drug Diversion, and Incident Descriptions as: Initial report of alleged drug diversion sent on 1/3/24. Follow up regarding the investigation sent on 1/8/24. On 1/8/24, a random audit was conducted of the medication carts as well as the narcotic counts. During this audit it was identified that there was a discrepancy with resident (R2) Lorazepam (1 mg tablet). Pharmacy, MD, Responsible Party, and (local) Police Department (#24-900) were notified of the discrepancy. (V9) LPN (Licensed Practical Nurse) was suspended pending outcome to the investigation. Please accept this as an update to the investigation and final report to follow once the investigation is complete. A Final Report, dated 3/15/24, was presented on 5/22/24 by V1, Administrator as part of the facility investigation of drug diversion of R2's Morphine Sulfate and Lorazepam 1mg. This final report documented, On 1/3/2024, the pharmacy representative was conducting an audit at the facility, and it was identified that the morphine belonging to (R2) (date of birth [DATE]) had been tampered with. Discoloration of the medication was identified and per lot number, this medication should be blue in color and was light green in color. The medication was immediately removed from the medication cart and an investigation was initiated. MD, (local) Police Department, Ombudsman, and Responsible Party were notified. An audit was completed of all narcotics on all medication carts and no other issues were identified. The facility replaced the morphine that was identified as being tampered with and there was no negative outcome for the resident. Through the QAPI program, the facility initiated a plan of correction related to the issue, which included random audits of the medication carts and narcotic counts. On 1/8/2024, an audit was completed on the C-Hall medication cart. During the audit it was identified the back of the Lorazepam 1 mg medication card belonging to (R2) was torn and the medication in the pill slot was an OTC (over the counter) medication, not the Lorazepam 1 mg pill. (V9) LPN, was immediately suspended pending the outcome of the investigation. MD, (local) Police Department, Ombudsman, and the Responsible Party were notified. (V26) Attorney General, was notified and provided with the information related to the findings along with details of the investigation and interviews outcomes. (Local) Police Department was contacted, and (V27) detective was provided with information related to investigation and assisted with follow up interviews. The facility has been pending a conclusion with this investigation due to outcomes of the interviews with (V27). Per follow up conversation with (V27), he is unable to substantiate that a person responsible for diverting the medication. Staff members with access to the medication cart during these two incidents were interviewed by the Administrator and Director of Nursing but were unable to substantiate the person responsible for diverting the medication. (V9) has remained suspended throughout this entire investigation. Audits have remained in place and no further issues have been identified. The facility will continue to work with (V27) related to any additional information obtained related to the investigation. (V9) is termed from the facility receiving a Category 1 Offense for improperly handling and notifying the proper nursing management of narcotics on 1/8/24, as identified through the investigation. Currently, the facility is unable to substantiate a perpetrator through this investigation. Please accept this as the final report for this investigation and the facility will report any additional findings, if identified. The facility's policy, Abuse, Prevention and Prohibition Policy, revised 10/22, documented, Statement of Intent: Each resident had the right to be free form abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It continues, Policy: this facility prohibits mistreatment, neglect or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and maintain physical, mental and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. the facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including the definitions pertaining to abuse and neglect. Annually the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. This policy documents the definition of Misappropriation of Resident Property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Prior to the Survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 1/5/2024. In attendance was V2, Director of Nurses, V12, Former Administrator now Regional Staff, V16, MDS Coordinator and V24, Medical Director. 2. Measures put into place/systematic changes to ensure the deficient practice does not recur: a. 100% in-servicing with the nurses on the 5 Rights of medication administration. b. 100% in-servicing with the nurses on the inspections of seals on the controlled substances and inspection the medication for changes in color and consistency and to notify the DON or ADON of any discrepancies. c. An emergency QA meeting was held with the Medical Director (via Telephone), Administrator, DON, ADON, and MDS Coordinator to review the past non-compliance plan, and plan of correction. 3. Plan to monitor performance to ensure solutions are sustained: This will be done 3 times a week for 8 weeks, 2 times a week for 8 weeks and monthly to ensure there are no discrepancies noted. Any Deficient practice will be corrected immediately. Patterns or trends will be reported to QA Committee for further recommendations and follow-up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of property for one (R3) of three residents reviewed for abuse. Findings include: R3's face sheet, dated 9/25/2023, documents R3 was admitted on [DATE] and discharged on 8/23/2023, with diagnoses including Osteomyelitis, Hypothyroidism, Muscle Weakness, and Morbid Obesity. On 9/20/2023 at 11:50am, V3, (R3's Power of Attorney/POA), stated he purchased a new phone, earbuds, and charger for R3 on 8/18/2023 and left it with him at the facility, around 3-4pm on 8/18/2023. V3 stated he spoke on the phone with R3 on 8/19/2023 around 9-10am and R3 stated he couldn't find his earbuds or charger. V3 stated it was confirmed by caregiver the earbuds and charger were missing, later that evening on 8/19/2023. V3 stated V1, Administrator, was aware of the missing items, and V3 has not heard any more from V1. Facility investigation, dated 8/19/2023, contains interviews with day shift Nursing and Therapy staff that worked on the day of 8/18/2023. Facility investigation does not include any staff interviews of staff that worked second shift or night shift on 8/18/2023 when the earbuds and charger went missing. Facility investigation does not include any non-nursing staff, who also had access to R3's rooms on the date of 8/18/2023. On 9/21/2023 at 1:30pm, V1, (Administrator), stated she only interviewed Nursing staff that primarily took care of R3. V1 stated she should have interviewed other staff that had access to R3's room when the earbuds went missing. V1 stated she interviewed the primary staff that took care of R3, but did not interview other staff from other departments. On 9/21/2023 at 1:05pm, V7, CNA, (Certified Nursing Assistant), stated he had not been interviewed about R3's missing items. V7 stated he is not aware of R3 having earbuds or a phone charger in his room. V7 stated he was not aware of R3 missing these items. V7 stated there is only Nursing staff in the building on night shift. No other departments work night shift. V7 stated he works 6:00pm-6:00am. Facility Abuse Prevention Policy states facility will thoroughly investigate allegations of abuse.

Based on observation, interview, and record review, the facility failed to provide assessment to ensure that pain medications are effective and are controlling pain when needed for 1 of 6 residents (R24) reviewed for pain in the sample of 42. Findings include: R24's Face Sheet, dated 7/19/2023, documents R24 has diagnoses of polyneuropathy, Stage IV pressure ulcers of right and lower back and above right knee amputation. R24's Care Plan, revision date of 5/15/23, documented that R24 has actual impairment to his skin including pressure ulcers/injuries and wounds. The Care Plan Intervention, dated 3/6/23, documented Treat pain as orders prior to treatment/turning etc. to ensure the resident's comfort. R24's Care Plan, dated 3/17/23, documents he is receiving opioid medications for pain. The Care Plan Intervention, dated 3/17/23, documents Administer medications as ordered. R24's Physician order sheet (POS) dated 7 /21/2023 documents Tramadol 50 Milligram (mg), give 1 tablet by mouth three times a day for moderate to severe pain. On 7/25/2023 at 1:37 PM, V20 (Licensed Practical Nurse/LPN) provided dressing changes and treatments to R24 coccyx and lower back. During wound care R24 complained of pain and rated his pain at a 10 (10 being the worse pain). V20 stated would provide pain medication and do dressing to left outer ankle later. On 7/26/2023 at 11:06 AM, R24 stated he always has pain with repositioning and treatments including dressing changes. On 7/26/2023 at11:10 AM, V16 (LPN) entered room and administered Tylenol 325 mg 2 tabs, V16 did not ask R24 to rate his pain level. R24's Progress Note, dated 7/26/2023 at 12:54 PM documents, Nurse Practitioner (NP) at bedside to see resident N.O. (new order) received stop tramadol when Norco (hydrocodone/acetaminophen) arrives. Start Norco 7.5/325 1 tab PO four times a day r/t (related to) pain. NP will follow up in 2 weeks. On 7/27/2023 at 11:03 AM, V3 (Minimum Data Set Coordinator/Care Plan Coordinator) stated that the facility does not have policy on pain. V3 stated that this issue may be covered in the change of condition policy. V3 stated she would expect residents to be assessed for pain and meds administered for pain control.

Based on observation, interview, and record review, the facility failed to ensure medications are store at required temperatures and multi-dose medication vials are labeled as to when first accessed/opened for 2 of 4 residents (R217, R218) reviewed for medication storage in the sample of 42. Findings include: On 7/25/2023 at 9:40 AM, the medication storage room was observed with V17 (Licensed Practical Nurse/LPN). At this time, V17 stated it was the responsibility of the night shift nurses to check and document the temperature of the medication storage refrigerator. At this time, there were two medication storage refrigerators. One of the refrigerators contained 3 bags of Intra Venous (IV) medication. This refrigerator did not have a thermometer. There was a box with a vial of Tuberculin (TB) Serum in it. The outside of the box was written opened 6/15/2023 and the manufactory print on the box documented, Discard opened product after 30 days. On 7/25/2023 at 11:05 AM, V2 (Director of Nursing/DON) stated the 3 bags of IV medications (Vancomycin) belonged to R218. V2 stated, Staff are supposed to take temps every night shift. I would prefer temps be taken every shift because these are IV meds. At this time, V2 confirmed there was no thermometer in the refrigerator that R218's IV medications were stored. V2 then removed a vial of TB serum, and the vial was dated 7/20/2023. At this time, V2 stated, There are two different dates. There is no way to know when it was opened. It will have to be wasted. The Facility's Temperature Log for Refrigerator- Fahrenheit Form dated 7/2023 documents, Monitor temperatures closely! 1. Write your initials below in staff initials and note the time in exact time 2. Record temps (temperatures) twice each workday. This form did not document temperature values on 7/3/2023, 7/5/2023, 7/6/2023, 7/10/2023, 7/12/23 ,7/13/2023, 7/17/2023, 7/19/2023, 7/20/2023, and 7/24/2023. The Facility's Immunization Report date range 6/15/2023-7/20/2023 documents R217 received a dose of Tuberculin PPD (purified protein derivative) on 7/19/202. R217's Medication Administration Record (MAR) documents, Tuberculin PPD Solution- inject 0.1 ml (milliliter) intradermally every 365 days. It further documents R217 received it 7/19/2023. The Facility's Storage and Return of Drugs Policy dated 4/2021 documents, Drug supplies for the facility shall be stored under proper conditions, sanitation, temperature, light, refrigeration and moisture. It continues, E. Multi-dose vials and pens shall be stored and dated per manufacturers guidance.

Based on observation, interview, and record review, the facility failed to perform hand hygiene when performing medications administration, contact with potentially infectious material, and upon contacting residents for 3 of 6 residents (R5, R7, R27) reviewed for infection control in the sample of 42. Findings include: 1. On 07/25/2023 at 7:20 AM, V7 (Licensed Practical Nurse/LPN), was at the medicine cart, she pulled out the medication for R5. V7 then locked the med cart and administered medication to R5 without benefit of hand hygiene. V7 returned to the medication cart, performed hand hygiene with alcohol-based hand rub (ABHR). She then removed stock medication of Vitamin C, Cetirizine HCI, and Stool softener for R27 and placed them in a pill cup. She then pulled on her surgical mask with her right hand and then flipped her hair back out of her face with her left hand. Without doing hand hygiene, took the medication cards out of the medicine cart, placed the individual pills in a medicine cup for R27. V7 then locked the med cart, and without hand hygiene, administered medications to R27. V7 exited R27's room used ABHR, unlocked her medicine cart, and retrieved medication for R7. V7 removed a stock bottle of medication out of the medication cart, and she then rubbed her right ear with her right hand and moved the left side of her hair away from her face with her left hand. She continued, without benefit of hand hygiene, removing medication from the medication packages. V7 poured a cup of water for R7, took her glasses off and put them on the top of her head, locked medication cart, and administered medications to R7 without the benefit of hand hygiene. 2. On 07/26/2023 at 9:45 AM, V3 (LPN) cleansed R5's wound with soap and water, performed hand hygiene and donned gloves. She then opened the abdominal pad package with gloved hands and with the same gloved hands placed abdominal pad on the resident's wound bed. She then opened another abdominal pad package and applied it to the wound bed. She then wrapped it with a gauze dressing, all without the benefit of hand hygiene or glove changes. V3 then doffed her gloves, performed hand hygiene, donned a clean pair of gloves, opened a betadine sticks package, and painted the left heel. She then opened the border gauze dressing package with the same gloved hands and applied it to the left heel without the benefit of hand hygiene. V3 doffed gloves, performed hand hygiene, got into the treatment cart, and cleaned the bandage scissors with alcohol-based hand rub. She then performed hand hygiene, donned gloves. V3, with the same gloves on, took the scissors, cut the xeroform gauze, placed it in R5's wound bed, then took the same scissors, cut a 2nd piece of xeroform gauze, and placed it in the wound bed, she then, with the same gloved hands, cut a 3rd piece of xeroform gauze and placed it in the wound bed. V3 took a piece of clean gauze and cleaned the blood off of R5's leg. V3 then performed hand hygiene, and donned a new pair of gloves, she then opened a package of abdominal pad and applied it to the wound, with the same gloved hands, opened a 2nd package to the lower part of the left leg wound and then opened a package of gauze wrap and wrapped the area and secured it with tape all without the benefit of hand hygiene or glove changes. 3. On 7/24/2023 at 9:25 AM, during incontinent care for R7, V4 (Certified Nursing Aide/CNA) and V5 (Certified Nursing Aide/CNA) donned gloves but did not wash or sanitize hands prior to donning gloves. V5 with right gloved hand cleansed R7's rectal area from front to back with wipes. V5 doffed gloves from left hand then with right-hand donned new gloves. V5 did not sanitize hands prior to donning new gloves. After care, V5 and V4 removed gloves and did not sanitize hands. On 07/27/2023 at 10:20 AM, V1 (Administrator) stated that she would expect the nurse to perform hand hygiene after touching their clothing, hair, or skin prior to giving medication to a resident. She continued to state that she would expect them to perform hand hygiene and change gloves after opening dressing packages and placing them on the residents. On 07/27/2023 at 11:20 AM, V20 (LPN) stated that she did not think the facility had a when to perform hand hygiene or glove changes policy. The facility's policy, Influenza, Prevention and Control of Seasonal., dated, 08/2011, documented, B. Hand hygiene: 1. Staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. It continues, C. Gloves: 1. Gloves will be worn for any contact with potentially infection material. 2. Gloves will be removed after contact, followed by hand hygiene.

Based on record review and interview, the facility failed provide a Registered Nurse for at least eight consecutive hours a day, 7 days a week and failed to designate a Registered Nurse to serve as the Director of Nursing on a full-time basis. This failure has the potential to affect all 68 residents living in the facility. Findings include: On 5/30/2023 at 9:45 AM, V1 (Administrator) states she had an Interim Director of Nursing (Interim DON) that left on 5/19/2023 but has a new Interim DON starting today 5/30/2023. V1 states she was without a DON last week (5/20/2023- 5/29/2023). The Facility's Nursing schedules document no Registered Nurse (RN) on schedule for dates of 5/15/2023, 5/16/2023, 5/21/2023, 5/27/2023 and 5/29/2023. The Facility's Nursing schedules also document no DON on the dates of 5/20/2023 -5/29/2023. On 5/30/2023 at 11:00 AM, V3 (Scheduler) states she knows she needs to schedule an RN 8 hours a day, seven days a week. V3 states it is hard to find an RN. V3 states the only RN they have is V2 (Director of Nursing) right now otherwise they rely on agency to get them an RN. V3 states on the dates of 5/15/2023, 5/16/2023, 5/21/2023, 5/27/2023 and 5/29/2023, there was no RN working. On 5/30/2023 at 11:11AM, V2 (Interim Director of Nursing) states that she is the Interim DON starting 5/30/2023. V2 states she will be working full time hours. V2 states she is an RN. The Resident Census and Conditions of residents, CMS 672, dated 5/30/2023 documents that the facility has 68 residents living in the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments and interventions to prevent skin wounds and promote healing for 2 of 4 residents (R1, R2), reviewed for wounds in the sample of 4. Findings include: 1. On 4/13/23 at 1:25 PM, R1 was lying on her left side with bilateral soft boots on. R1 had no (trade name)skin protective sleeves on her arms or legs. On 4/13/23 at 3:30 PM, R1 remained lying in bed, arms and legs curled up, lying on her left side. R1 had no (trade name) skin protective sleeves on her arms or legs. R1's admission Record/Face Sheet, documents R1's has diagnoses include dementia, lumbar compression fracture, contracture of left knee, left hip replacement, falls. The Facility's Wound/Pressure Ulcer Log, dated 1/14/23 through 4/13/23, documented R1 had an abrasion to her left shin measuring 1.6 centimeters (cm) x 0.6 cm. R1's Care Plan, dated 3/3/23, documents (R1) has actual impairment to skin integrity related to urinary incontinence and decreased mobility, chronic discoloration to bilateral lower extremities, scarring to left scapula, sacrum and right hip, abrasions to left shin and left lateral calf. R1's Care Plan documents Ensure appropriate protective devices geri-sleeves are applied to bilateral lower extremities and bilateral upper extremities. The Care Plan Interventions documented Monitor dressing when providing care to ensure it is intact and adhering. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has severe cognitive impairment and is totally dependent on one to two staff members for all activities of daily living (ADLs). R1's MDS documents R1 is always incontinent of both bowel and bladder. R1's MDS documents R1 is at risk of pressure ulcers and has a stage 4 pressure ulcer over bony prominence. R1's MDS documents R1 requires pressure-reducing device for chair and bed, is on a turning and repositioning program, nutrition, or hydration intervention to manage skin problems, pressure ulcer care, and the application of ointments/medications and dressings. R1's Physician's Order, dated 3/19/23 documented Apply (trade name) skin protective sleeves to BUE (bilateral upper extremities) and BLE (bilateral lower extremities) every dayshift for preventions. R1's Physician Order, dated 3/28/23, documents Apply skin sleeves daily. every night shift for skin care related to other Non-thrombocytopenic Purpura. R1's April 2023 Treatment Administration Record (TAR), has no documentation R1 had skin sleeves applied every night on 4/5 and 4/11/23. R1's March 2023 TAR, has no documentation R1's geri sleeves were applied on 3/24/23. R1's April 2023 TAR has no documentation R1's skin protective sleeves were applied on 4/12 and 4/13/23. R1's Physician Order, with start date of 3/7/23 and discontinued date of 4/2/23, documents Clean skin tear to left elbow daily with normal saline. Apply TAO (triple antibiotic ointment) to wound and cover with dry dressing until healed. R1's March 2023 TAR has no documentation R1 received treatment to her left elbow skin tear on 3/7, 3/9, 3/14 and 3/15/23. R1's Physician's Order, with start date of 2/23/2023 and discontinued date of documents Cleanse abrasion to left shin & left lateral calf with wound cleanser, apply xeroform to wound bed, cover with ABD (abdominal pad-highly absorbent pad), wrap with gauze bandage roll, secure with tape every night shift. R1's March 2023 TAR documents R1 did not receive the treatment to left shin and left lateral calf on 3/6 and 3/7/23, 3/9, 3/13, 3/14 and 3/15/23. R1's April 2023 TAR documents R1 did not receive the treatment to left shin and left lateral calf on 4/5 and 4/11/23. On 4/17/23, at 2:00 PM, R1 was wearing no (trade name) skin protective sleeves. There were no skin protective sleeves located in her room. On 4/17/23 at 2:40 PM, V10 (Certified Nursing Assistant/CNA) stated, We haven't seen R1's skin-sleeves in a long time. If I know R1, she probably took them off and they disappeared. I don't remember even seeing R1 with them on. R1's April 2023, dated 4/17/23, documented R1 was wearing skin protective sleeves although they were unavailable. 2. R2's admission Record, dated 4/13/23, documents that R2 was admitted to the facility on [DATE] and was discharged on 4/5/23 with diagnoses of Atherosclerosis of native arteries of bilateral lower extremities, Traumatic brain injury, Pressure ulcer Sacrum Stage 3, Falls, UTI's (Urinary Tract Infections), Neuromuscular dysfunction of bladder, TIA (Trans ischemic Attack), Left upper arm amputation. R2's Care Plan, dated 3/2/23, documents R2 has actual impairment to skin integrity r/t (related to) fragile skin, History of pressure wounds to left lateral shin, right medial shin, right posterior heel, left lateral heel, left lateral ankle, left great toe, left foot 1st digit, left foot 2nd digit, left medial heel, pressure to sacrum. Interventions: Apply offloading boots as resident will allow, Avoid mechanical trauma: Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, Improper shaving, vigorous massage, avoid shearing while repositioning when in bed, carefully dry between toes, needs pressure redistributing cushion to protect the skin while up in chair, needs pressure relieving boots to bilateral feet at all times, needs turned and repositioned every two hours and more frequently if needed, encourage good nutrition and hydration in order to promote healthier skin, float heels while in bed as tolerated, low air loss mattress to bed, monitor/document/report to MD PRN for s/sx of infection: [NAME] drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever, observe extremities for s/sx or poor tissue perfusion: Poor cap refill, poor pulses, cyanosis, clubbing, lack of sensation, cold to touch. Document changes from baseline. Report significant findings to MD. R2's MDS, dated [DATE], documents that R2 was cognitively intact and is totally dependent of one to two staff members for most of his ADLs. R2's MDS documents R2 had suprapubic catheter in and was always incontinent of bowel. R2's MDS documents R2 is at risk for pressure ulcers and requires a pressure reducing device for chair and bed, is on the turning & repositioning program, and requires the application of dressings. R2's PO, start date of 1/25/23, documents Apply skin prep to left foot 2nd digit daily every night shift for healing. R2's TAR, dated March 2023, documents no skin prep was done to R2's left foot/second digit and great toe (every day) on 3/6/23, 3/7/23, 3/9/23, 3/14/23, and 3/23/23. R2's PO, start dated of 1/25/23, documented Apply skin prep to left medial heel daily every night shift for healing. R2's March 2023 TAR, documents no skin prep was done to this left media heel on 3/6, 3/7/3/9, 3/14 and 3/23/23. R2's PO, start date of 3/23/23, documents Cleanse left lateral shin with wound cleaner, apply Calcium alginate AG to wound bed, cover with ABD pad, wrap with gauze bandage roll, secure with tape and apply (brand) elastic supportive bandage, over bandage daily and PRN till healed every night shift for healing. R2's March 2023 TAR had no document a treatment was completed on the R2's left lateral shin on 3/6, 3/7, 3/9, 31/4 and 3/23/23. R2's Health Status Note, dated 4/6/23 at 8:04 AM, documents Wound Nurse had spoken with V6 (Wound Doctor) to clarify his assessment, it stated (R2) had a stage 4 pressure area to left ankle lateral aspect, the wound bed assessment is arterial, clarified that his areas are arterial due to non-compressible veins. On 4/13/23 at 10:30 AM, V3 (Minimum Data Set Coordinator), stated, R2 had uncompressible veins and had constant wounds on his legs. All of his wounds were arterial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely turning and repositioning, pressure relief, and pressure ulcer treatments per physician's orders for 4 of 4 residents (R1, R2, R3, R4), reviewed for pressure ulcers in the sample of 4. Findings include: 1. On 4/13/23 at 1:15 PM, R3 was lying in bed with an arterial ultrasound being done on her left lower extremity. R3 has a right below-the-knee amputation. R3 had a left ankle dressing which was dry/intact and dated 4/13/23. A soft boot seen sitting on the floor by the wall at foot of her bed. R3 was lying on her back. On 4/13/23 at 1:18 PM, R3 stated R3 stated, The staff never puts the soft boot on my left foot or lifts my foot off the bed. I didn't have the boot on last night (4/12/23) or all day today while I was in bed. I somewhat turn myself in bed because the staff never come and turn me. They do come in and change my dressing just about every day, but there have been days when no one changed it at all. On 4/13/23 at 3:50 PM, R3 remained in her bed, on her back with her head of the bed elevated, soft boot remains on the floor. On 4/13/23 at 3:52 PM, R3 stated My boot is still on the floor, they still have not put it on me today. On 4/17/23 at 9:33 AM, R3 stated, They changed my dressing yesterday (Sunday 4/16/23) but no one changed it on Saturday (4/15/23). R3's admission Record, dated 4/13/23, documents that R3's had diagnoses of Sepsis, Lymphedema, Anemia, Type 2 DM (Diabetes Mellitus), Pressure Ulcer left ankle Stage 3, Cognitive communication deficit, HTN (Hypertension), Acute Ischemic Heart disease, Venous Insufficiency, CKD (Chronic Kidney Disease). R3's Care Plan, dated 3/27/23, documents R3 has actual impairment to skin integrity r/t pressure left ankle. Interventions: Administer treatments as ordered and monitor for effectiveness. Avoid shearing while repositioning when in bed, needs to turn/reposition at least every 2 hours, more often as needed or requested, needs pressure redistributing cushion to protect the skin while up in chair, encourage good nutrition and hydration in order to promote healthier skin. Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, float heels while in bed as tolerated, Inform the resident/family/caregivers of any new area of skin breakdown, Pressure redistributing mattress on bed. It continues R3 has bladder incontinence Impaired Mobility. Interventions: Brief Use: R3 uses disposable briefs. Change PRN, Incontinent: Check R3 every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact with a BIMS (Basic Interview for Mental Status) of 13. R3 requires extensive assistance from one to two staff members for all her Activities of Daily Living. R3's MDS documents R3 is at risk for pressure ulcers and has a stage 4 pressure ulcer over bony prominence. R3 MDS documents R3 requires a pressure reducing device for his chair and bed, is on the Turning & Repositioning program, Nutrition, or hydration interventions to manage skin problems, pressure ulcer care, application of ointments/medications and dressings. The Facility's Electronic Wound/Pressure Ulcer Log dated 1/14/23 through 4/13/23, documents R3 has a Stage IV pressure ulcers to her left heel. On 4/17/23 at 11:25 AM, V3 (MDS Nurse) stated, I was told that R3's dressing was not done on Saturday, and I will be talking to that nurse. Just like they tell us in Nursing School, if it is not documented, it was not done. R3's Braden Scale Assessment, dated 3/23/23, documents that R3 is at risk for pressure sores with a score of 15. A Braden Score of 15-18 = at risk, 13-14 = moderate risk, 10-12 = high risk, 9 or below = very high risk. R3's Braden Scale Assessment, dated 12/9/22, documents that R3 is at risk for pressure sores with a score of 15. A Braden Score of 15-18 = at risk, 13-14 = moderate risk, 10-12 = high risk, 9 or below = very high risk. R3's Physician Order, dated 3/28/23, documents Gentamicin Sulfate External Cream 0.1 % (Gentamicin Sulfate (Topical). Apply to left lateral malleolus topically every shift for wound healing related to pressure ulcer of left ankle, stage 3, cleanse area with generic wound cleanser. then apply Gent ointment, cover with Calcium Alginate and secure with silicone foam. R3's Physician Order, dated 4/10/23, documents LLE (left lower extremity) arterial doppler and ABI (ankle-brachial index) BLE (bilateral lower extremities) for wound to left ankle exposed to muscle layer. dx (diagnosis): venous insufficiency, weak pedal pulse, swelling LLE, Breakdown of wound to muscle. R3's Skin and Wound Evaluation, dated 4/11/23, documents that R3 has a pressure ulcer Stage 4 to left lateral malleolus, in-house acquired, size 3.9 CM (centimeters) X 3.6 CM X 2.0 CM. No evidence of infection, moderate serous drainage. Progress: Improving - area smaller in size per (V6, Wound Physician) evaluation, treatment as ordered. R3's TAR, dated March 2023, documents no pressure ulcer treatments were done to R3's left ankle on 3/3/23, 3/5/23, 3/24/23, and 3/29/23. No heel protector was applied to R3's left foot (every shift) on 3/2/23, 3/3/23, 3/5/23, 3/7/23, 3/8/23, 3/9/23, 3/16/23, 3/22/23, 3/24/23, 3/26/23, and 3/29/23. R3's TAR, dated April 2023, documents no pressure ulcer treatments were done to R3's left ankle (every shift) on 4/3/23, and 4/11/23 X 2. No heel protector was applied to R3's left foot (every shift) on 4/11/23 X 2, and 4/15/23. 2. R4's admission Record, dated 4/13/23, documents that R4 was admitted to the facility on [DATE] and has diagnoses of Respiratory failure, CHF (congested heart failure), Hemiplegia/Hemiparesis, Flaccid-Hemiplegia, Dysphagia, COVID-19, MRSA (Methicillin-Resistant Staphylococcus Aureus), Ventricular premature depolarization, GERD (Gastroesophageal reflux disease), ESRD (end stage renal disease), UTI, Anxiety disorder, Major depressive disorder, Cerebral infarction, Type 2 DM, Hypothyroidism, HTN, Atrial Fibrillation. R4's Care Plan, dated 3/3/23, documents (R4) has an actual impairment to skin integrity r/t fragile skin. Stage 3 PI (pressure injury) to left buttock. Interventions: Avoid shearing while repositioning when in bed, encourage good nutrition and hydration in order to promote healthier skin. Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, float heels while in bed as tolerated, needs pressure redistributing cushion to protect the skin while up in chair, is to have cushion in chair at dialysis, needs assistance with turning and repositioning every two hours and more frequently if needed, monitor dressing when providing care to ensure it is intact and adhering. Report lose dressing to nurse, monitor skin rashes for increased spread or signs of infection, pressure redistributing mattress on bed, provide protein for healing per RD recommendation. R4's MDS, dated [DATE], documents that R4 is cognitively intact with BIMS 15. R4 requires total dependence on two staff members for transfers, toilet use, and bathing. R4's MDS documents R4 requires extensive assistance from one or two staff members for all other ADLs. R4's MDS documents R4 is always incontinent of both bowel and bladder, at risk for pressure ulcers, and has a Moisture Associated Skin Damage (MASD). The MDs documents R4 requires pressure reducing device for chair and bed, is on the Turning & Repositioning program, and requires the application of ointments/medications and dressings. R4's Braden Scale Assessment, dated 3/23/23, documents that R4 is at risk for pressure sores with a score of 15. R4's Braden Scale Assessment, dated 10/27/22, documents that R4 is at moderate risk for pressure sores with a score of 14. On 4/13/23 at 2:30 PM, R4 stated, I can turn myself to my left side, but I have to ask the staff to turn me to my right side due to paralysis. The staff do not routinely come in and turn or reposition me, and that is why I have to ask. The nurses will change my dressing most of the time, but there have been times when no one came in to do it. On 4/17/23 at 2:25 PM, R4 was back from Dialysis, lying in bed on her back. R4 had a pillow under her right leg/foot elevated off bed. R4 stated, My foot is getting mushy, and it hurts when it is sitting on the bed. They did change my dressing on my butt today. R4's Physician Order, dated 3/8/23, documents Cleanse left buttock wound with wound cleanser. Pat dry. Apply collagen powder and calcium alginate nightly and PRN. R4's TAR, dated March 2023, documents no wound care and/or treatments were done to R4's buttocks on 3/7/23, 3/9/23, 3/14/23, and 3/23/23. No Calazime ointment applied to R4's buttocks on 3/1/23, and 3/7/23. R4's TAR, dated April 2023, documents no pressure ulcer treatments were done to R4's buttock on 4/5/23, 4/10/23, and 4/11/23. 3. On 4/13/23 at 1:25 PM, R1 was lying on her left side with bilateral soft boots on. R1 was on a soft canoe mattress, and a cushion was seen on her wheelchair. R1's Face Sheet, dated 4/13/23, documents that R1 has diagnoses of dementia, lumbar compression fracture, contracture of left knee, left hip replacement, falls. The Facility's Wound/Pressure Ulcer Log dated 1/14/23 through 4/13/23, documented R1 had a Stage IV Pressure Ulcer to her left lateral malleolus. R1's Care Plan, dated 3/3/23, documents R1 has actual impairment to skin integrity related to urinary incontinence and decreased mobility, chronic discoloration to bilateral lower extremities, scarring to left scapula, sacrum and right hip, abrasions to left shin and left lateral calf. Pressure area to left lateral malleolus. Interventions: Administer treatments as ordered and monitor for effectiveness, Avoid shearing while repositioning when in bed, Encourage good nutrition and hydration in order to promote healthier skin, Ensure appropriate protective devices geri-sleeves are applied to bilateral lower extremities and bilateral upper extremities, Float heels while in bed as tolerated, Heel Protectors on when in bed, needs pressure redistributing cushion to protect the skin while up in chair, needs turned and repositioned every 2 hours and more frequently if needed, Monitor dressing when providing care to ensure it is intact and adhering. Report loose dressing to charge nurse, Monitor pressure areas for changes in color, sensation, temperature and report any change to nurse, Monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of infection: [NAME] drainage, Foul odor, Redness and swelling, Red lines coming from the wound, Excessive pain, Fever, Observe extremities for s/sx or poor tissue perfusion: Poor cap refill, Poor pulses, Cyanosis, Clubbing, Lack of sensation, cold to touch. Document changes from baseline. Report significant findings to MD, Pressure redistributing mattress on bed. R1's MDS, dated [DATE], documents R1 has severe cognitive impairment and is totally dependent on one to two staff members for all Activities of Daily Living (ADLs). R1's MDS documents R1 is always incontinent of both bowel and bladder. R1's MDS documents R1 is at risk of pressure ulcers and has a stage 4 pressure ulcer over bony prominence. R1's MDS documents R1 requires pressure reducing device for chair and bed, is on a turning and repositioning program, nutrition, and hydration interventions to manage skin problems, pressure ulcer care, and the application of ointments/medications and dressings. R1's Braden Scale Assessment, dated 3/13/23, documents that R1 is a High Risk for pressure sores with a score of 12. A Braden Score of 15-18 = at risk, 13-14 = moderate risk, 10-12 = high risk, 9 or below = very high risk. R1's Physician's Order (PO), with start dated of 3/15/23, documents Cleanse area to left ankle with wound cleanser, pat dry. Apply xeroform to wound bed. Cover with dry dressing every dayshift for wound healing. R1's March 2023 TAR has no documentation R1 received treatment to her left ankle on 3/15 and 2/24/23. R1's PO, with start date of 3/26/23, documents that R1 should have calazime cream to coccyx every shift for shearing. R1's March 2023 TAR has no documentation R1 received the calazime treatment on 3/29/23. R1's PO, with start dated of 9/25/22, documents that R1 should have skin prep to boney prominence to bilateral feet every shift. R1's March 2023 TAR has no documentation R1 received treatment to boney prominence to bilateral feet on evening shift on 3/7 and night shift on 3/6 and 3/7/23. R1's PO, dated 4/3/23, documents, Cleanse shearing to sacrum with wound cleanser, apply calcium alginate and cover with dry dressing. Every night shift for Shearing. R1's April 2023 TAR has no documentation R1 received the treatment to her sacrum on 4/5 and 4/11/23. R1's Physician Order, dated 4/9/23, documents, Cleanse area to left ankle with wound cleanser. Pat dry. Apply xeroform to wound bed. Cover with dry dressing daily and PRN. Every night shift for wound healing. R1's April 2023 TAR, has no documentation R1 received the above treatment to her left ankle on 4/11/23. 4. R2's admission Record, dated 4/13/23, documents that R2 was admitted to the facility on [DATE] and was discharged on 4/5/23 with diagnoses of Atherosclerosis of native arteries of bilateral lower extremities, Traumatic brain injury, and Pressure ulcer Sacrum Stage 3. R2's Care Plan, dated 3/2/23, documents R2 has actual impairment to skin integrity r/t (related to) fragile skin, history of pressure wounds to left lateral shin, right medial shin, right posterior heel, left lateral heel, left lateral ankle, left great toe, left foot 1st digit, left foot 2nd digit, left medial heel, pressure to sacrum. Interventions: Apply offloading boots as resident will allow, Avoid mechanical trauma: Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, Improper shaving, vigorous massage, avoid shearing while repositioning when in bed, carefully dry between toes, needs pressure redistributing cushion to protect the skin while up in chair, needs pressure relieving boots to bilateral feet at all times, needs turned and repositioned every two hours and more frequently if needed, encourage good nutrition and hydration in order to promote healthier skin, float heels while in bed as tolerated, low air loss mattress to bed, monitor/document/report to MD PRN for s/sx of infection: [NAME] drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever, observe extremities for s/sx or poor tissue perfusion: Poor cap refill, poor pulses, cyanosis, clubbing, lack of sensation, cold to touch. Document changes from baseline. Report significant findings to MD. R2's MDS, dated [DATE], documents that R2 is cognitively intact and is totally dependent of one to two staff members for most of his ADLs. R2's MDS documents R2 had suprapubic catheter in and was always incontinent of bowel. R2's MDS documents R2 is at risk for pressure ulcers and requires a pressure reducing device for chair and bed, is on the turning & repositioning program, and requires the application of dressings. R2's Braden Scale Assessment, dated 3/23/23, documents that R2 is a high risk for pressure sores with a score of 11. R2's PO, dated 1/25/23, documented Apply foam dressing to sacrum daily. Every night shift for preventative. R2's March 2023 TAR has no documentation that the foam dressing was applied on 3/6 and 3/7/23. R2's PO, dated 3/7/23, documents Apply sure prep to boney prominence of feet/digits nights every night shift for wound healing/preventative. R2's March 2023 TAR has no documentation the sure prep was applied to boney prominence of feet /digits on 3/7, 3/14/ and 3/23/23. R2's PO, dated 8/19/22, documented Offload heels with heel protectors every shift for wound healing. R2's March 2023 TAR has no documentation R2's heels were offloaded on 3/1 during the day and evening shift, 3/6 during the night shift, 3/7 and 3/9 during the evening and night shift, 3/14 during the night shift, 3/22 during the evening shift, 3/22 during the evening shift, 3/23 during the evening and night shift and on 3/29/23 during the evening shift. R2's April 2023 has no documentation R2's heels were offloaded on 34/3 during the evening shift. R2's Health Status Note, dated 3/25/23 at 11:02 PM, documents Area to sacrum has gotten larger and now requires a tx (treatment) of Calcium Alginate and cover with dry dressing. PCP (Primary Care Physician) aware. On 4/13/23 at 3:00 PM, V4 (Wound Care Nurse) stated, I do the facility's wound report/log, the residents monthly skin checks, the once-a-week wound measurements, and I round with V6 (Wound Physician) once a week. I also do rounds on the floors, usually once in the morning and again in the afternoon, to make sure the residents are getting turned and repositioned, heels are floated, etc. The floor nurses are the ones who actually change the dressings daily. On 4/18/23 at 9:50 AM, V1 (Administrator) stated, I would expect the staff to turn and reposition a resident, float heels, and apply skin-sleeves as indicated in their respective Care Plan. I would expect the Nurses to change the residents' dressings as ordered by the Physician. The Facility's Pressure Ulcer / Pressure Injury Prevention Policy, dated 3/2022, documents A pressure ulcer / injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's. 1. Assessment: A standardized pressure ulcer / pressure injury risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcer / pressure injury. This assessment will be completed upon admission, weekly X 4 weeks, quarterly and when a significant change in the resident's condition is noted. 2. Planning: An individual Plan of Preventions will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual. 3. Implementation: Interventions for the prevention of pressure ulcer / pressure injury will be individualized to meet the specific needs of the resident. Interventions will consider the assessment of risk and skin condition of the resident. Minimize Pressure: Turning and Repositioning - every two to three hours when in bed, or more frequent depending on the need of the resident. Every hour as tolerated when in a chair. Relieve pressure to heels by using pillows or other devices.

Based on interview and record review, the facility failed to communicate with outside hospital of the return of a resident, failed to find placement and comply with transfer and discharge requirements for 1 of 1 resident (R7) reviewed for involuntary transfer/discharge in the sample of 9. Findings include: R7's, admission Record, documented an initial admission date of 2/27/23. R7's, Discharge Report, documented, R7 discharged to local hospital, dated 3/9/23. R7's Progress note, dated 3/9/23, documented, R7 displayed physical behaviors with V1 (Administrator), biting V1's arm, resulting in V1 receiving medical attention. R7 was then escorted by local police to outside local hospital on 3/9/23 for evaluation and treatment due to verbal, and destructive behaviors. R7's Police Report, dated 3/9/23 at 3:50PM, documented, Battery to two victims (staff), property damage. R7's Progress note, dated 3/10/23, documented, local hospital contacted the facility that R7 will be transferred out of state to a Behavioral facility for further evaluation and treatment on 3/10/23, and documentation ends on this date 3/10/23, no further documentation, specific of R7's needs, that could not be met. On 4/5/23 at 9:00AM, V1 (Administrator) stated that on 4/3/23, he received a telephone call from the receiving facility on 4/3/23, regarding R7's return to nursing facility. V1 stated, he informed the receiving mental health hospital of R7's mental health concerns and that a police report and Petition for Involuntary/Judicial admission was faxed on 3/9/23. The facility's fax transmittal sheet, dated 4/3/23 at 11:42AM, documented police report and petition for involuntary discharge was faxed, the documentation submitted, was entitled, Petition for Involuntary/Judicial Admission, dated 3/9/23. On 4/6/23 at 1:02PM, V8 (Social Services) stated, she never reached out with the receiving mental health center of R7's anticipated return. V8 stated, it was not until 4/3/23 that she was informed that the mental health center had contacted the facility regarding R7's return to facility. V8 continues to state that it was not until 4/3/23, when she reached out to outside facilities to locate placement for R7. On 4/4/23 at 3:14PM, V9 (Regional Nurse) stated that the facility should have followed written policy's provided notice of discharge, communicated with the outside facility, and located placement for R7. The facility's policy and procedure, entitled, Involuntary Transfer and Discharge Policy, dated 2/2014, documents, The facility shall give notice to resident if applicable, of resident, notice of transfer or discharge and to include information regarding the right to appeal a transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely turning and repositioning for pressure relief for 3 of 3 residents (R1, R3, R4) reviewed for risk of existing pressure ulcer/risk for skin breakdown in the sample of 9. Findings include: 1. R3's, Minimum Data Set, (MDS), dated [DATE], documented mild mental cognition, requires assistance from nursing staff of two for bed mobility, transfer, (full mechanical lift) and toileting, incontinent of bowel and bladder. R3's skin conditions, documented risk of developing pressure ulcers, documented for a one or more unhealed pressure ulcer, documented for a stage 2 and stage 3 current unhealed pressure ulcers. Medical diagnosis of Diabetes, Muscle wasting, Abnormal posture, R3's, Braden Skin Assessment, dated 3/23/23, documented, R3 is bedfast, slight limited with mobility and very moist with skin, resulting in moderate risk for skin impairment. R3's, Care Plan, entitled, Focus, R3 has actual impairment to skin integrity r/t, (related to), fragile skin. Hx, (history) of left knee surgery with scarring. abscess left knee scabbed left heel stage 3 scattered scabs' right knee arterial right 2nd toe. Stage 2 right buttock initiated 12/28/21, revision date 4/3/23. Interventions: float heels while in bed and turn and reposition every 2 hours and more frequently if needed. R3's, Wound Care Assessment, dated 3/28/23, documented, a stage 3 pressure ulcer to left heel, with measurements of 0.5cm, (centimeters), x, (by), 0.5cm x 0.1cm with wound progress as no change, from wound documentation dated, from previous week assessment dated [DATE]. Recommendations, to off load, reposition and use (Brand) pressure-relieving boots. On 4/3/23 at 9:00AM, R3 was lying in bed on his right side with both feet exposed from outside the bed linen, which revealed R3 was wearing red non-skid socks, and his heels were flush with the bed mattress and no pressure-relieving boots or a pillow to offload R3's heels from the mattress as documented in his Care Plan. R3 was again observed at 9:15AM, 9:30AM, 10:00AM, 10:30AM, 10:45AM and11:00AM, where he remained in bed lying in the same bodily position with no support to his heels to off load. At 11:36AM, was transferred to the dining room for lunch meal service. 2. R1's, MDS, dated [DATE], with impaired mental cognition, assistance of one staff with bed mobility, transfers, dressing, and toilet use. R1 is documented as having an unstable gait that can only be stabilized with staff assistance with turning and surface-to-surface transfers and frequently incontinent of bladder and continent of bowel. Skin conditions document for 1/26/23, with resident at risk for developing pressure ulcers, had an unhealed pressure ulcer, had a stage 3 pressure ulcer. R1's, Care Plan, dated 3/6/23 revision, documented, R1 needs to be turn and repositioned at least every 2 hours or more often, requires 1-2 staff participation. R1 needs a pressure-redistributing cushion to protect the skin while up in chair, imitated in 4/19/22 due to impaired skin integrity. R1 uses incontinence briefs, check every 2 hours, and as required for incontinence, requires 1-2 staff participation. R1's Wound Assessment, dated 3/11/23, documented R1 with a healed stage 3 pressure ulcer to right foot 2nd digit, (toe). On 4/3/23 at 9:44AM, R1 was in her room in a wheel chair asleep. R1 did not have a pressure relieving cushion in her wheelchair where she was sitting. At 10:00AM, 10:30AM, 10:40AM, 11:05AM remains in her room asleep in her wheelchair. At 11:20AM received a visitor (V7, R1's friend). At 11:53AM, V7, wheeled R1 in her wheelchair to the dining room for meal service where she still had no pressure relieving cushion in her wheelchair. On 4/3/23 at 2:00PM, V5 and V6 both Certified Nurse Aides (CNAs) stated that R1 is independent to toilet herself. On 4/5/23 at 3:10PM, V4 (Licensed Practical Nurse/Minimum Data Coordinator) stated that R1 is not independent with toileting and should be reminded and assisted with toileting. On 4/5/23 at 3:00PM, V4 stated, she was not aware that R1 did not have a pressure-relieving cushion in her wheelchair and will assure this is acted on immediately and to expect nursing staff to care for residents and residents identified with impaired skin integrity and to follow their plan of care interventions. 3. R4's, MDS, dated [DATE], documented impaired mental cognition, requires assistance of two nursing staff with transfers. R4 is incontinent of bowel and bladder, impaired mobility, requires nursing assistance of two with bed mobility, transfers, dressing and frequent incontinent of bowel and bladder. Also, to include medical diagnosis of: Dementia, muscle weakness, history of falling, dysphagia, etc. R4's, Wound Assessment Evaluation, dated 3/31/23, documented that R4 has a deep tissue injury to left heel as a new occurrence, with measurements of 1.4cm x 0.9cm x 2.0cm, wound bed at 100% covered and scabbed. Intervention of no treatment, only generic wound cleaner, and additional care as heels need to be suspended. R4's Care Plan focus area, dated 3/20/23, documented that R4 has actual impairment to skin integrity due to urinary incontinence and decreased mobility. Interventions include the following: Float heels while in bed. On 4/3/23 at 1:25PM, V5 and V6 (CNAs) laid R4 into bed after lunch service, covered with bed cover, they both stated, they were just putting R4 into bed. At this time, V5 and V6 removed the bed cover away from R4's feet to reveal that R4 was wearing socks while in bed and feet were not up as being off-loaded. V6 stated, they should be off the bed mattress. The facility's policies and procedure, entitled, Pressure Ulcer/Pressure Injury Prevention, dated 3/2022, documented, an individual plan of prevention will be developed to meet the needed resident that will include positioning, mobility, continence. The goal is for the resident to be free from preventable pressure ulcer/ pressure injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse/misappropriation/theft in 5 of 10 residents (R1, R3, R7, R8, R10) reviewed for abuse/misappropriation/theft in the sample of 10. Findings include: 1. On 1/10/23 at 8:30 AM, R1 stated his friend brought him $50 to purchase a phone card. R1 stated he had the money in his wallet, which he kept in a fanny pack that he kept on him. R1 stated he took the wallet out of his fanny pack and put it in his bedside drawer before going to bed, and the next morning, the money from his wallet was gone, someone had taken it during the night. R1 stated the facility never found out who did it, but they did replace his $50. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Abuse/Theft Investigation Initial Report, undated, documents R1 had $50 dollars in his pouch that is missing. The facility Final Report, undated, documents they were unable to determine misappropriation of resident funds. At this time, facility reimbursed the $50. The Investigation did not contain any evidence that staff or other residents were interviewed during the investigation. 2. On 1/6/23 at 2:20 PM, R3 was observed in bed resting comfortably with no signs or symptoms of pain. R3's Face Sheet, undated, documents R3 has an admitting diagnosis of Unspecified Convulsions. R3's MDS, dated [DATE], has severe cognitive impairment and has facial expressions of pain. R3's Abuse/Theft Investigation Initial Report, dated 12/16/22, documents V6 (Licensed Practical Nurse/LPN), informed V2 (Registered Nurse (RN)/Director of Nurses/DON), and V4 (Licensed Practical Nurse/LPN) that the color of the Roxanol (pain medication) for a hospice patient (R3) did not appear to be the right color. Roxanol is a light blue color, and the medication pulled was clear. Hospice was here and also looked at bottle and agreed it was not the same medication. The Final Report, with a compliance date of 12/19/22, documents An investigation was started, and a complete audit was conducted with all controlled substances. All licensed staff were in services on Controlled Substance policy and procedure. DON or designee will continue to review all controlled substance logs and orders for discrepancies. Audits will be completed 5 days a week for the next 60 days. The prior days-controlled substance log will be audited 100% on Tuesday and Friday. On Monday's the previous Friday, Saturday and Sundays' resident-controlled substance logs will be audited. Any noted issues will be immediately addressed and reviewed in the QAPI (Quality Assurance Performance Improvement) process. Compliance achieved date 12/19/22. There was no evidence that no other staff or residents were interviewed during the investigation. 3. On 1/6/23 at 2:15 PM, R7 stated he had $30 stolen recently. R7 stated his ex-father-in-law brought him in $30, and he had it in his wallet. He states went to dialysis, came back to the facility, and his money was gone out of his wallet. R7 stated he also had a box of cheese crackers missing at the same time. R7 stated the facility replaced the crackers but not the money. R7 stated the facility wasn't sure who took the money but thought it could have been an agency worker. R7's MDS, dated [DATE], documents R7 is cognitively intact. R7's Abuse Investigation Initial Report, dated 12/1/22, documents V1 (Administrator) was notified that resident advised he was missing money. The Abuse Investigation Final Report, dated 12/2/22, documents V1 (Administrator) interviewed resident and was advised that the Wednesday before Thanksgiving his father-in-law brought him $20. This was unable to be verified. V1 attempted to reach father-in-law and was unable to reach him. Resident advised on 12/2/22, he looked in his wallet to get his money and it was gone. He advised that it was folded up inside the center of his wallet. Resident did not implicate any certain person had taken the money when asked and stated that he is away 3 days a week for dialysis and would not have known if someone was in his room. The allegation was unsubstantiated. There was no evidence that staff or other residents were interviewed during the investigation. 4. R8's Face Sheet, undated, documents R8 had an admitting diagnosis of Morbid Obesity. R8 no longer resides in the facility. R8's MDS, dated [DATE], documents R8 was cognitively intact. R8's Abuse Investigation Final Report, dated 12/2/22, documents on 11/30/22, V1 (Administrator) was notified that R8 was missing money. V1 notified that resident was asking if the missing $600 from her bag was going to be reimbursed. Administrator was notified and an investigation was initiated immediately. Resident stated that on 11/19/22, V11 (R8's Son) brought her in $600 all in $20 bills. V11 confirmed that he did bring in the $600 for her. Resident states she had the money in her bag that she always keeps it on her. Resident stated at approximately 2:30 PM, V12 (Certified Nursing Assistant/CNA) asked her if she would like her bed made. Resident exited the room out into the hallway by her room door. Resident stated she had the bag laying on her bed when she went out into the hall. Resident stated she ordered a pizza, and when it showed up, she went to retrieve her money from her bag, and it was gone. V13 (Police Department) was notified and came to the facility to interview resident. Administrator called V12 (CNA) to let her know that all of her future shifts were canceled until the investigation was completed. V12 stated the resident asked her to make her bed. Upon entering the resident's room, the resident left the room and went out into the hallway. V12 states that the resident was in view of her (R8) and was speaking to her while the bed was being made. V12 states that she asked the resident where she would like the bag on the bed and resident told her to put it on the table next to the bed. V12 states she couldn't put the bag on the table because it was full of other items, so she (V12) put it to the right side at the end of the bed. The allegation was unsubstantiated. There was no evidence that other staff or residents were interviewed during the investigation. 5. R10's Face Sheet, undated, documents R10 had an admitting diagnosis of Cholecystitis. R10 no longer resides at the facility. R10's MDS, dated [DATE], documents R10 is cognitively intact. During an allegation of misappropriation of resident property, the facility identified that R10 could have been affected. The investigation, undated, documents the following: On 12.12.22 at approximately 3 PM, V1(Administrator) was notified via text message from V16 (Past Certified Nursing Assistant (CNA) Coordinator) that V14 (Agency Registered Nurse/RN) and V3 (Past LPN/Assistant Director of Nurses (ADON), had been pocketing medications and putting on paper they had destroyed them. Also, on 12/12/22 at approximately 9 PM, V1 (Administrator) was made aware of allegation to V9 (Licensed Practical Nurse/LPN) that also came from V16 (Past CNA Coordinator) that stated that medications were not properly destroyed by V3 (Past LPN/ADON) and V14 (Agency RN) on 12/09/22. V16 (Past CNA Coordinator) advised V9 (LPN) via text message on 12/12/22 that on 12/09/22 she (V16) witnessed V3 (LPN/ADON) and V14 (Agency RN) destroying medications in an illegal manner. V16 advised V9 (LPN) through text messages that on Friday 12/09/22 that V3 and V14 were making it appear as though they were destroying Vicodin of a resident (R10) currently in the hospital. V16 (Past CNA Coordinator) stated that the medications that V3 and V14 were destroying was not Vicodin but Tylenol, and V3 and V14 had split the Vicodin medication between the two of them (V3, LPN/ADON and R14, Agency RN) and put them in their pockets. V16 (Past CNA Coordinator) stated she walked into the ADON office and witnessed the incident while it was occurring. V16 did not report this information immediately to the Administrator (V1) or Director of Nursing (V2) at the time of incident. V3 and V14 were removed from duties pending investigation. V14 (Agency RN) was requested by V1 (Administrator) and V2 (DON) to submit to a drug test before being removed from the facility and she (V14) refused. V1 (Administrator) notified agency manager of allegation and investigation. V14 has been removed from all scheduled shifts for the facility and due to refusing drug test will no longer be permitted to fill shifts at the facility. V16 (Past CNA Coordinator) was contacted by the Administrator (V1) to obtain further information and written statement regarding this investigation and has not responded to any communications from Administrator (V1). Administrator (V1) attempted to contact V16 (Past CNA Coordinator) on 12/14/22 and 12/15/22. V16 has remained non-responsive to all communication attempts made by the Administrator (V1). V16 has been terminated by Administrator, (V1), due to not reporting incident immediately and not responding to assist in further investigation. V3 (Past LPN/ADON) was not working at the facility on Monday 12/12/22 and Administrator (V1) attempted to contact her (V3) to notify of suspension pending investigation but was unable to contact V3 as she was non-responsive to communication attempts. V3 has remained non-responsive to all communications by V1 to obtain information for the investigation. Administrator (V1) attempted to contact V3 on 12/12/22 at 9:42 PM via text, 12/13/22 at 10:27 AM via text and (social media) and multiple calls were made to V3's cell phone on 12/12/22, 12/13/22, 12/14/22, all with phone immediately responding the phone is not taking calls at this time. V3 has been terminated from her position for failure to respond to all communications from Administrator (V1) to aide in this investigation. Due to lack of evidence proving the medications were in fact taken by V3 (Past LPN/ADON) and V14 (Agency RN) and not properly destroyed, along with V16's (Past CNA Coordinator) failure to provide any further information or written statement on the allegation towards V3 and V14 of illegal destruction and theft of the medications is found unsubstantiated. On 1/10/23, V4 (LPN/MDS) stated that there are no other interviews with staff or residents if they were included in the abuse investigation. The Abuse, Prevention and Prohibition Policy, with a review date of 2021, documents: Investigation: The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. Interview the resident if they are cognitively able to answer questions. If the resident is not interviewable, question the roommate and any family or friends who visit frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide thorough indwelling urinary catheter care for 1 of 4 residents (R3) reviewed for Urinary Tract Infections (UTI) in the sample of 6. Findings include: On 11/2/22 at 1025 AM, V8, (Certified Nursing Assistant/CNA) went into R3's bathroom and returned with two wet washcloths and laid them directly on R3's bedside table next to some of R3's personal items. V8 did not place any type of barrier down before putting the clean washcloths on the table. V8 assisted R3 to pull her pants and adult diaper down to her knees, with R3's feet hanging off the side of the bed. V8 then took one washcloth and wiped R3's right outer labia and right groin in a back-and-forth motion, then took the other washcloth and repeated the same action on R3's left outer labia and groin and then swiped the washcloth up R3's indwelling urinary catheter. V8 then pulled up R3's diaper and pants. V8 did not spread R3's labia to cleanse around the insertion site of her catheter and did not rinse or dry R3's skin after washing it. V8 had cleansed some white grainy material from R3's skin folds in her groin areas and stated, I'm going to let the nurse know she (R3) might have a yeast infection because she has some white stuff on her skin. V8 still did not spread R3's labia to inspect her inner folds or cleanse her thoroughly. R3 stated, I have had bladder infections before. R3's Minimum Data Set (MDS) dated [DATE] documents she was admitted on [DATE] and is alert and oriented. It documents she requires extensive assist with toileting, transfers, and bed mobility. The MDS documents she has an indwelling urinary catheter and is frequently incontinent of bowel. R3's Care Plan dated 10/14/22 documents she is to receive catheter care every shift. R3's Progress Note dated 10/14/2022 at 3:43 PM documents, was admitted to (hospital) on 9/6/22 with UTI. On 11/3/22 at 11:10 AM, V2 (Director of Nursing/DON) stated when staff are performing catheter care on a female resident with an indwelling urinary catheter, they should use soap and water and clean all sides of catheter at least 12 inches from insertion point outwards. V2 stated the staff should spread the resident's labia and thoroughly cleanse all the inner folds of the vagina around the insertion site where the catheter is inserted into the urethra. V2 stated after all areas are thoroughly cleansed, all areas should be rinsed and dried. The facility's undated policy, Skills Checklist/Catheter Care documents, Explain procedure to resident, provide privacy. Fill wash basin with warm water. Position resident, cover with sheet, exposing only perineal area. Separate labia or retract foreskin and maintain that position throughout procedure. For female-use washcloth with warm water and soap to cleanse labia. Change the position of the washcloth for each downward stroke. Change position of washcloth and cleanse around meatus. With clean washcloth, rinse with warm water using same technique.

Based on observation, interview and record review the facility failed to identify and provide treatment for pressure ulcers for 2 of 4 residents (R122 and R126) reviewed for pressure sores in the sample of 42. Findings include: 1. R122's Care Plan dated 5/11/2022 documents that R122 has actual impairment to skin integrity related to pressure right rear calf abrasion left rear calf, scattered bruising across iliac crest hips and buttocks abrasion left elbow scabbed pressure to left foot 4th and 2nd digit and tight foot 5th and 1st digits. R122's Care Plan documents the following interventions: R122 needs to turn/reposition at least every 2 hours, more often as needed or requested; R122 needs pressure redistributing cushion to protect the skin while up in chair. On 7/27/2022 at 10:53AM, V29 (Certified Nursing Assistant/CNA), assisted R122 up in the wheelchair with a gait belt. V29 did not place a cushion in R122's wheelchair. R122 was observed to be up in his wheelchair at 1:30 PM when lunch trays being passed. R122 observed up in his wheelchair at 2:44 PM without pressure relief in his wheelchair. On 07/27/22 at 2:44 PM, V30 (Certified Nursing Assistant/CNA), stated that she is the only CNA on the hall and R122 has been up in his wheelchair since he was got up prior to lunch at 11:15 AM 2. R126's Care Plan dated 6/29/2022 documents that R126 has actual impairment to skin integrity related to being admitted with stage 4 pressure ulcer to left buttock, Diabetic sole of left foot unstageable to left heel. R126's care plan document the following interventions: inform the resident/family/caregivers of any new area of skin breakdown. On 7/26/2022 at 11:15 AM, V18 (Licensed Practical Nurse/LPN/wound nurse) stated that R126 was admitted to the facility with pressure sores. R126 was tuned on left side facing the door, there was no dressing present to pressure sore on R126's buttock as verified by V18. No dressing present in adult brief. R126's adult brief had tan drainage from pressure sore. V18 stated there should be a dressing in place. V18 stated the treatment had been changed to calcium alginate and dressing. During treatment open area to Right hip observed per V18, who stated she had not been made aware of this new pressure ulcer. V18 stated the first layer of skin is gone. R126's new pressure ulcer was the shape of upside-down triangle bright red flesh with no active bleeding. R126's Physician Order (PO) dated 7/16/2022 documents to cleanse left buttock with wound cleanser apply calcium alginate with silver and cover with gauze Island dressing daily till healed and as needed. The facility policy Wound Care System Requirements, revised 3/2021, documents individualized turning and repositioning schedules per individualized needs, treatments are being completed as ordered, CNAs will observe skin during care daily. Any changes will be reported to the licensed nurse for follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide safe infection control practices including sanitizing hands before and after glove changes, changing of gloves when soiled and going from a dirty area to a clean area, and following isolation precautions as posted on resident's doorways for 3 of 18 residents (R42, R68 and R121) reviewed for infection control practices in the sample of 42. Findings include: 1. R42's Care Plan dated 7/2/22, documents R42 has bladder incontinence. Interventions: uses disposable briefs, encourage fluids during the day to promote prompted voiding responses, check, and change every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. R42's Minimum Data Set (MDS), dated [DATE], documents that R42 is cognitively intact and is totally dependent on two staff members for transfers and bathing. R42 requires extensive assistance from one staff member for bed mobility, dressing, toileting, and personal hygiene. R42 is always incontinent of urine and frequently incontinent of bowel. On 7/27/22 at 10:45 AM, V19 (Certified Nursing Assistant/CNA) and V16 (Certified Nursing Assistant/CNA) entered to put R42 back to bed and to do perineal care. V16 donned gloves with no hand hygiene prior. R42's soiled incontinent brief was opened and tucked underneath her bottom. V16 then changed her gloves with no hand hygiene done prior to putting on clean gloves. R42 was then turned to her right side and the incontinence brief was removed. V16 did one wipe to R42's buttocks and one wipe to anal area. R42 was not dried as a clean brief was put down on her bed. V16 changed gloves again with no hand hygiene done. R42 then rolled onto her back and V19 wiped once to both of R42's groins, down the middle of R42's vagina and then the top of R42's perineal area with no drying done. A clean incontinence brief was applied. V16 doffed her gloves and without hand hygiene, turned R42 to her side and placed a wedge under her with no gloves on and no hand hygiene performed after care. 2. R68's MDS, dated [DATE], documents that R68 has a moderate cognitive impairment (BIMS 12) and is totally dependent on two staff members for transfers, total dependence on one staff member for locomotion and bathing, extensive assistance from one staff member for bed mobility and dressing, extensive assistance from two staff members for toilet use and limited assistance from one staff member for personal hygiene. R68 is always incontinent of both bowel and bladder. On 7/25/22 at 9:05 AM, V14 (Certified Nursing Assistant/CNA) and V6 (Certified Nursing Assistant/CNA) entered to perform perineal care on R68. V14 got one towel and wet it in the sink. V6 donned gloves without any hand hygiene done prior to putting on clean gloves. R68 was turned to her left side while V6 used the one wet towel and with wiped once between R68's legs from the front to the back, then folded the towel and wiped once to R68's right buttock. Using the same soiled gloves, V6 put a clean incontinence brief down on the bed and rolled R68 onto her right side. While on her right side, V14 stated Oh, R68 has some poop coming out. and then pulled the clean incontinence brief up and secured it to R68. Both CNAs rolled R68 back over and covered her up with a sheet without cleaning up the bowel movement. V6 and V14 doffed their gloves and left the room without any hand hygiene completed. 3. On 07/25/22 at 12:56 PM, V10 (Housekeeper) with N95 and goggles, donned gown, and gloves, did not sanitize hands prior to donning gloves. V10 removed toilet brush and container from cleaning cart and entered R121's room. V10 then exits R121's room with toilet brush and holder and placed it on cart. V10 did not doff gloves, sanitize hands, and don new gloves prior to reentering R121's. Sign on wall outside R121's room documents that R121 requires isolation Droplet precautions. On 7/28/2022 at 1:25PM, V3 (MDS coordinator) stated she would expect staff to sanitize hands between glove changes and after coming out of isolation room. The Facility Action Plan- COVID-19, dated, updated 7/7/2022 documents if performing cleaning or sanitation services in the transitionally or recovery areas, housekeeping staff must wear Personal Protective Equipment (PPE): N95 respirator or higher, secondary face coverings, proper eye protection, goggles, or face shield. PPE should also be applied when entering areas, removed when exiting each room and area. On 7/28/22 at 1:15 PM, V3, MDS Nurse, stated The facility does not have a policy on changing gloves, but I would expect the staff to follow the CDC guidelines for hand hygiene and glove changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner which promote residents' dignity by concealing urinary catheter drainage bags and answering call lights timely for 7 of 7 residents (R5, R26, R34, R42, R45, R51 and R67) reviewed for dignity in the sample of 42. Findings include: 1. R45's Care plan dated 7/6/22, documents R45 has Catheter: Neurogenic bladder. Interventions: Catheter care every shift and PRN (as needed), position catheter bag and tubing below the level of the bladder and away from entrance room door. R45's Minimum Data Set (MDS) dated [DATE], documents that R45 is cognitively intact and requires extensive assistance from one staff member for all ADL's. R45 requires extensive assistance from two staff members for transfers. R45 is always incontinent of urine and occasionally incontinent of bowel. On 7/25/22 at 11:10 AM, R45 lying in bed with a urinary catheter and bag hanging off of his bed with cloudy yellow urine and the bag uncovered and visible from the hallway and upon entrance into his room. On 7/28/22 at 1:30 PM, V3 (MDS Nurse) stated Yes, the urinary catheter tubing and bag are supposed to be covered at all times and not visible from the hall or resident's doorway. 2. R67's Care Plan, dated 7/9/22, documents R67 has supra pubic catheter: Neurogenic bladder. Interventions: Catheter care every shift and PRN, has #20 French catheter. Position catheter bag and tubing below the level of the bladder. R67's MDS, dated [DATE], documents that R67 is cognitively intact and is totally dependent on two staff members for transfers, total dependence on one staff member for locomotion and bathing, requires extensive assistance from one staff member for bed mobility, dressing, toilet use and personal hygiene. R67 is always incontinent of bowel and has suprapubic catheter for urine. On 7/25/22 at 8:50 AM, R67's urinary catheter and bag was seen hanging off his bed, was not covered and was within sight of anyone walking in the hallway in front of his room. 4. R5's Care Plan, revision date 4/22/22, documents R5 has Catheter: dx; neurogenic disorder. It also documents CATHETER: R5 has (trade name) catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. R5's Physician Order Sheet, dated 1/7/22, documents (trade name) catheter 22g 10cc. On 7/25/2022 at 8:40 AM, R5 observed lying in bed with door open. R5's call light was on the floor at the foot of R5's bed. Out of R5's reach. R5's urine filled catheter tubing and bag was exposed and not covered. The Residents' Rights for People in Long-term Care Facilities, dated 5/18, documents that You have the right to privacy. 5. R34's MDS, dated [DATE], documents that R34 is cognitively intact. On 7/26/2022 at 10:10 AM, R34 stated that it does take a long time to answer the call light. R34 stated that it makes her angry. R34 stated that sometimes there is only 1 CNA on the hall, and it takes a while. 6. R42's MDS, dated [DATE], documents that R42 is cognitively intact. On 7/25/22 at 11:25 AM, R42 stated I will always put the call light on and if they don't come, I start to yell for help. It takes quite a while to get the call light answered, sometimes it will take an hour or so I just start yelling and they get mad at me for that. 7. R51's MDS, dated [DATE], documents that R51 is cognitively intact. On 7/25/22 at 11:35 AM, R51 stated I just got voted as the Resident Council President at our last meeting. I have to tell you; they need more help here. I know they are very short staffed here. The call light can take up to an hour and half to get answered. Yesterday I put my call light on around 3:00 PM and it was not answered until 3:40 PM. That is a common thing here. There are times there are only three CNAs in the whole building. There was a time my roommate, who is not here now, was put on the toilet and left there for forty-five minutes. (R57) fell in her room and was yelling, I had to put my call light to get some help and it still took forty-five minutes for someone to come help her. During the Resident Council Meetings, all the residents complain of the same things and all the managers tell us is that they are working on it. R57's MDS, dated [DATE], documents that R57 is cognitively intact. On 7/26/22 at 10:45 AM, R57 stated I fell asleep in my wheelchair once and fell out of it and couldn't reach my call light. I had to start yelling and (R51) put her call light on to get me some help. I had to lay there about forty-five minutes before someone came to help me, even with (R51's) call light on. I have no problems with the nurses here but there are sometimes they seem to need more help. The aides though, they never seem to have enough of them. That is one reason why residents don't get their showers. There are times when they are down to only three aides in the building. 3. R26's Care Plan fails to document that R26 has an indwelling urinary catheter. On 7/28/2022 at 1:25 PM, V3 (MDS Nurse) stated that R26 has not always had a indwelling urinary catheter and the care plan needs updated. On 07/25/22 at 8:29 AM, R26 sitting in wheelchair in the dining room with indwelling urinary catheter urine collection bag hanging under wheelchair with no covering over the bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R42's Care Plan dated 7/2/22, documents R42 is at risk for falls. Interventions: Be sure her call light is within reach and encourage the resident to use it for assistance as needed. R42's MDS, dated [DATE], documents that R42 is cognitively intact and is totally dependent on two staff members for transfers and bathing. R42 requires extensive assistance from one staff member for bed mobility, dressing, toileting, and personal hygiene. R42 is always incontinent of urine and frequently incontinent of bowel. On 7/26/22 at 11:05 AM, R42's call light was seen on the foot of her bed and not within reach of R42. R42 stated I can't reach my call light, it's at the foot of my bed. This is a common problem here. On 7/27/22 at 10:25 AM, R42 sitting in her room in her wheelchair with the call light sitting on the foot of her bed and not within reach of R42. Based on observation, interview and record review, the facility failed to ensure call lights are accessible and within reach of residents for 4 of 24 residents (R5, R18, R42, R65) reviewed for reasonable accommodation of needs in this sample of 42. Findings include: 1. R5's Care Plan, revision date 6/29/21, documents (R5) is at risk for falls related to decreased mobility it also documents Be sure his call light is within reach and encourage the resident to use it for assistance as needed. R5's Minimum Data Set (MDS), dated [DATE], documents that R5 is cognitively intact and requires extensive assist of 1 physical assist for bed mobility. On 7/25/2022 at 8:40 AM, R5 was lying in bed with door open. R5's call light was on the floor at the foot of R5's bed, out of R5's reach. On 7/25/2022 at 8:45 AM, R5 stated that he could not reach his call light when it is at the foot of his bed. R5 stated that if he needs something he has to wait for someone to come in. 2. R18's Care Plan, revision date 6/29/2022, documents R18 is at risk for falls related to hx (history) (history) of falls and impaired gait and balance. It also documents Be sure her call light is within reach and encourage the resident to use it for assistance as needed. On 7/25/2022 at 8:20 AM, R18 was sitting in the wheelchair in her room. R18's call light observed across the room draped over the top of the over the bed light, out of R18's reach. On 7/25/2022 at 8:36 AM, R18 was yelling out for help because she had no call light to activate. On 7/25/2022 at 2:15 PM, R18 was lying in bed. R18's call light was draped over the top of the over the bed light, out of R18's reach. On 7/26/2022 at 8:40 AM, R18's call light was draped over the top of the over the bed light, out of R18's reach. On 7/28/2022 at 8:46 AM, V3 (MDS Coordinator) stated that the facility does not have a call light policy. V3 stated that the expectation is for the call lights to be answered in a timely manner and in reach at all times. V3 stated that a call light draped over the over bed light, a call light on the floor on the opposite side of the be than a resident is sitting and a resident sitting in a wheelchair and call light attached to the wall is not in reach. On 7/28/2022 at 2:12 PM, V32 (Unit Aide) stated that all call lights are to be in reach. V32 stated that a call light draped over an over bed light is not in reach. On 7/28/2022 at 2:15 PM, V25 (Activity Director) stated that call lights are to be in reach. V25 stated that a call light located on the opposite side of the bed on the floor is not in reach. 3. R65's Care Plan, dated 4/4/22, documents R65 is at risk for falls Gait/balance problems. It also documents Be sure R65 call light is within reach and encourage the resident to use it for assistance as needed. On 7/26/2022 at 8:25 AM, R65 was sitting in wheelchair in room and call light on the floor behind the bedside table, not in R65's reach. On 7/27/2022 at 1:23 PM, R65 was lying in bed with call light on the floor across the room, out of R65's reach. The Resident Council Grievance, dated 5/4/22, document Call lights are not being placed in reach of resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R42's Care Plan dated 7/2/22, documents R42 has bladder incontinence. R42's Care Plan documents Uses disposable briefs, encourage fluids during the day to promote prompted voiding responses, check, and change every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. R42's MDS, dated [DATE], documents that R42 is cognitively intact and is totally dependent on two staff members for transfers and bathing. R42 requires extensive assistance from one staff member for bed mobility, dressing, toileting, and personal hygiene. R42 is always incontinent of urine and frequently incontinent of bowel. On 7/25/22 at 11:25 AM, R42 stated I am wet now and I am still waiting to get cleaned up. On 7/27/22 at 10:45 AM, V19 (Certified Nurse Assistant/CNA) and V16 (Certified Nurse Assistant/CNA) entered to put R42 back to bed and to do perineal care. V16 donned gloves with no hand hygiene prior to. R42's soiled incontinent brief was opened and tucked underneath her bottom. V16 changed gloves with no hand hygiene done, R42 turned to right side, brief removed, one wipe to R42's buttocks and one wipe to anal area. R42 was not dried as a clean brief was put down on her bed. V16 changed gloves again with no hand hygiene done. R42 rolled onto her back and V19 wiped once to both of R42's groins, down the middle of R42's vagina and then the top of R42's perineal area with no drying done. A clean incontinence brief was applied. V16 doffed her gloves and without hand hygiene, turned R42 to her side and placed a wedge under her with no gloves on and no hand hygiene performed. 5. R63's Care Plan dated 6/3/22, documents R63 has bladder incontinence The Care Plan documents uses disposable briefs, change PRN (as needed), encourage fluids during the day to promote prompted voiding responses, check every two hours and as required for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes. R63's MDS, dated [DATE], documents R63 has a moderate cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfer, toileting, and bathing. R63 requires extensive assistance from one staff member for locomotion, dressing and personal hygiene. R63 is occasionally incontinent of urine and always incontinent of bowel. On 7/26/22 at 9:35 AM, V16 (CNA) and V17 (Certified Nurse Assistant/CNA) entered to provide incontinent care to R63. V16 wet several washcloths while V17 gathered one dry towel, V17 wiped R63's groins, scrotum, and penis. R63 rolled to his left and V17 wiped his buttocks and anal area. R63 was not dried after cleansed. R63 was only cleansed with wet wash cloths and without any soap or cleansing foam. There was a lot of old cream not wiped off of R63's anal area and buttocks when V189 (Licensed Practical Nurse/LPN) entered and applied more cream on top of the old cream. On 7/25/22 at 8:40 AM, R63 stated It takes a while for them to answer the call light. You better know in advance or plan ahead if you need assistance or have to pee. I used to get upset about it but they're so short staffed that it takes a while to get to me. If I am in a wheelchair or walker, I will use the restroom but if I am in bed, I just wet myself in my (Brand) incontinence brief and will sit in it for a while until they clean me up. The other day I sat in my pee from 8:30 PM until 7:30 AM. I used the call light to let them know and someone came in and turned it off and said they would be right back and never did. 6. R68's Care Plan, dated 7/14/22, documents R68 has an ADL Self Care Performance Deficit Impaired balance. Interventions: Active Range of Motion, requires one staff participation with bathing, requires one to two staff participation to reposition and turn in bed, requires one staff participation to dress, requires one staff participation with personal hygiene and oral care, requires two staff participation to use toilet, requires two staff participation with mechanical lift to transfer. R68's MDS, dated [DATE], documents that R68 has a moderate cognitive impairment (BIMS 12) and is totally dependent on two staff members for transfers, total dependence on one staff member for locomotion and bathing, extensive assistance from one staff member for bed mobility and dressing, extensive assistance from two staff members for toilet use and limited assistance from one staff member for personal hygiene. R68's MDS documents R68 is always incontinent of both bowel and bladder. On 7/25/22 at 8:55 AM, R68 stated I do not go to the restroom and will use an incontinent brief. I'm wet now and I am still waiting to get changed. I use the call light all the time, but they don't answer it quickly. Someone will come in and shut it off and then don't come back to help me. On 7/25/22 at 9:05 AM, V14 (CNA) and V6 (Certified Nurse Assistant/CNA) entered to perform perineal care on R68. V14 got one towel and wet it in the sink. V6 donned gloves without any hand hygiene done. R68 was turned to her left side while V6 used the wet towel and with wiped once between R68's legs from the front to the back, then folded the towel and wiped once to R68's right buttock. Using the same soiled gloves, V6 put a clean incontinence brief down on the bed and rolled R68 onto her right side. While on her right side, V14 stated Oh, (R68) has some poop coming out. and then pulled the clean incontinence brief up and secured it to R68. Both CNAs rolled R68 back over and covered her up with a sheet without cleaning up the bowel movement. V6 and V14 doffed their gloves and left the room without any hand hygiene completed. The facility's Skill Checklist Peri Care (Female), not dated, documents Wash and dry upper thighs covering thighs with blanket when finished; Raise bath blanket to expose perineal area, apply soap to wet washcloth; Separate labia and wash urethral area first; Was between and outside labia in a downward strokes alternating from side to side moving outward to thighs, Gently pat dry in same direction; Position patient on side exposing buttocks toward caregiver; Apply soap to wet washcloth; Clean rectal area wiping from base of labia over buttocks using a different part of washcloth for each stroke; Rinse and dry anal area thoroughly. The Facility's Skills Checklist - Peri Care (Male), undated, documents Place basin of warm water and cleansing solution on over-bed table, Wash and dry upper thighs covering thighs with bath blanket when finished, Raise bath blanket to expose perineal area, Apply soap to wet wash cloth, Pull back foreskin and wash tip of penis using circular motion beginning at urethra, Rinse area thoroughly, Gently pat dry, Position patient on side exposing buttocks toward caregiver, Apply soap to wet wash cloth, Clean rectal area wiping from base of scrotum over buttocks using a different part of washcloth for each stroke, Rinse and dry anal area thoroughly. Based on observation, interview and record review the facility failed to perform complete and timely incontinent care for 5 of 5 residents (R14, R42, R63, R65, R68, R220) residents reviewed for incontinent care in a sample of 42. Findings Include: 1. R14's Care Plan, revision date 9/29/21, documents R14 has bladder incontinence Impaired Mobility. R14's Care Plan documents INCONTINENT: Check R14 every 2 hours and as needed and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. R14's Minimum Data Set (MDS) dated [DATE], documents that R14 is cognitively impaired and is totally dependent on 1 staff for toileting and is always incontinent of bowel and bladder. On 7/26/2022 at 10:10 AM, V5 (Certified Nurse Assistant/CNA) and V14 (Certified Nurse Assistant/CNA), performed incontinent care on R14. R14 was incontinent of bowel. V5 and V14 unfastened R14's brief and rolled between R14's legs. V14 then using premoistened wipes cleansed side of groin and one swipe down the front vaginal area. V14 and V5 turned R14 over onto her left and right side cleansing R14's anus and buttocks. V5 and V14 did not open and cleanse R14's inner and outer labia. On 7/27/2022 at 2:00 PM, V3 (Minimum Data Set Coordinator) stated that the facility does not have an incontinent or Peri care policy. On 7/27/2022 at 10:40 AM, V3 stated that she would expect the staff to cleanse all areas of incontinent. V3 stated that this would include the peri area, groin, both buttocks, inner and outer labia, inner thighs. V3 stated that if a resident is incontinent of urine and staff takes them to the toilet and they then void in toilet the staff would perform incontinent care. 2. R65's Care Plan, revision dated 4/4/22, documents R65 has bladder incontinence History of UTI (urinary tract infection). It also documents INCONTINENT: Check R65 every 2 hours and more frequently) and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. It continues R65 has an ADL (activities of daily living) Self Care Performance Deficit. It continues TOILET USE: R65 requires 2 staff participation to use toilet. R65's MDS, dated [DATE], documents that R65 is cognitively impaired, R65 is always incontinent of bowel and bladder, and she requires extensive assist with toileting. On 7/26/22 at 12:31 PM, V14 (CNA) assisted R65 with incontinent care. R65 was heavily soiled with urine through pants, bed pad and sheet. V14 assisted R65 to the wheelchair and onto the toilet. V14 assisted R65 onto the toilet and R65 voided. V14 handed R65 premoistened wipe and instructed her to wipe herself. R65 wiped vaginal area revealing stool on wipes. R65 then proceeded to cleanse R65's anus with one wipe. V14 then assisted R65 with applying clothing and transferred R65 into the wheelchair. V14 did not cleanse all areas of incontinence. V14 did not cleanse the labia inner thighs entire buttock peri area. 3. R220's Care Plan does not address R220's incontinence. On 07/25/22 at 8:40 AM, V5 (CNA) assisted R220 with incontinent care. R220 was heavily soiled with urine through incontinent brief and bed pad. V5 opened R220's incontinent brief and rolled between her legs. V5 then wiped R220 's peri area and then assisted her onto her left and right side and cleansed her buttocks and anal area. V5 did not cleanse inner labia and inner thighs. On 7/25/2022 at 8:43 AM, R220 stated that she has not been changed since the night shift. R220 stated that the aide had cleaned her around 4 AM and have not been cleansed since. R220 stated that it makes her mad and it hurts her to lay in the pee. On 7/28/2022 at 2:07 PM, V31 (Certified Nurse Assistant/CNA) stated that when cleansing a resident, you clean all areas incontinent including the lower back. V31 stated that you gather items and drape the resident for privacy, gather water basin and towels, 2 bags at the end of the bed, cream, explain to resident what you're doing, clean straight down the middle then each side of the groin using a different washcloth, roll resident side to side and cleanse the buttocks. V31 stated that a resident waiting four hours to be cleansed is not timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate care and assistance for residents, resulting in residents not gotten out of bed for meals, residents not receiving timely incontinent care and residents call lights not answered timely. This has the potential to affect all 70 residents in the living in the facility. Findings include: 1. R34's MDS, dated [DATE], documents that R34 is cognitively intact. On 7/26/2022 at 10:10 AM, R34 stated that it does take a long time to answer the call light. R34 stated that it makes her angry. R34 stated that sometimes there is only 1 CNA on the hall, and it takes a while. 2. R220's admission Nursing Assessment, dated 7/20/22, documents that R34 is alert to person, place, time and situation. On 7/25/2022 at 8:43 AM, R220 stated that she has not been changed since the night shift. R220 stated that the aide had cleaned her around 4 AM and have not been cleansed since. R220 stated that it makes her mad and it hurts her to lay in the pee. R220 stated they don't have enough staff. R220 stated she has been told multiple times by staff that they don't have enough staff. 3. R42's MDS, dated [DATE], documents that R42 is cognitively intact. On 7/25/22 at 11:25 AM, R42 stated I will always put the call light on and if they don't come, I start to yell for help. It takes quite a while to get the call light answered, sometimes it will take an hour or so I just start yelling and they get mad at me for that. 4. R16's MDS, dated [DATE], documents that R16 is cognitively intact. On 7/25/22 at 11:05 AM, R16 It depends on when I go pee in my brief. If it is around dinner or something like that, I will sit in it for a while because they are busy with that and don't have enough people to come help. 5. R51's MDS, dated [DATE], documents that R51 is cognitively intact. On 7/25/22 at 11:35 AM, R51 stated I just got voted as the Resident Council President at our last meeting. I have to tell you; they need more help here. I know they are very short staffed here. The call light can take up to an hour and half to get answered. Yesterday I put my call light on around 3:00 PM and it was not answered until 3:40 PM. That is a common thing here. There are times there are only three CNAs in the whole building. There was a time my roommate, who is not here now, was put on the toilet and left there for forty-five minutes. (R57) fell in her room and was yelling, I had to put my call light to get some help and it still took forty-five minutes for someone to come help her. During the Resident Council Meetings, all the residents complain of the same things and all the managers tell us is that they are working on it. 6. R57's MDS, dated [DATE], documents that R57 is cognitively intact. On 7/26/22 at 10:45 AM, R57 stated I fell asleep in my wheelchair once and fell out of it and couldn't reach my call light. I had to start yelling and (R51) put her call light on to get me some help. I had to lay there about forty-five minutes before someone came to help me, even with (R51's) call light on. I have no problems with the nurses here but there are sometimes they seem to need more help. The aides though, they never seem to have enough of them. That is one reason why residents don't get their showers. There are times when they are down to only three aides in the building. 7. R26 MDS, dated [DATE] documents that R26 is cognitively intact. R26's Grievance Report Form dated July 22, 2022, documents that on July 21, 2022, aides refused to get R26 up at supper time saying they were too short on aides to get her up. It also documents that Action Taken: Staff Re-educated on residents rights/needs and signed by V2 (Director of Nursing/DON). On 8/1/2022 at 9:39 AM, R26 stated that she had put her call light on and when she asked to get up, she was told no there was not enough staff. R26 stated that she did not get up. On 7/27/22 at 2:15 PM, V25 (Activity Director) stated Staffing is a big problem here, especially if there is a call off. We simply don't have enough people to get residents up when they need it. On 7/27/22 at 2:45 PM, V28 (Certified Nursing Assistant/CNA) stated I'm an agency CNA and just came on at 2:00 PM today. I am the only one on this hall and I can't get these people up because most of them require two people and the lift. They told me someone would be here to help me but didn't know what time. I had to go get V27 (Certified Nursing Assistant/CNA) from the other hall (XX-Hall) to come help me get R68 back to bed. On 8/1/2022 at 10:42 AM, V2 (Interim DON) stated that she is the only RN. V2 stated that the facility does have staffing problems. V2 stated that she is using agency but at times they do not show up or call off. V2 stated that corporate has put in ads. V2 stated that they give out bonuses for shifts. V2 stated that she is aware of the lack of staff and how it is affecting the care of the residents. V2 stated that she is aware of residents not getting out of bed because if short staff. V2 stated that she in-service the staff and notified them that even if they are short of staff the resident has the right to get out of bed. On 8/1/22 at 10:56 AM, V3 (Minimum Data Set Coordinator/MDSC) stated that they do not have a policy on staffing. V3 stated that they use the CMS guidelines. The facility's Resident Council Meeting Minutes dated 2/09, documents not enough staff. Not caring for them, not changing them, not feeding them. On 8/1/22 V3 (MDSC) verified that this is February 9, 2022. The Resident's Census and Conditions of Resident, CMS 672, dated 7/25/2022, documents that the facility has 70 residents living in the facility. The CMS 672 documents 43 residents are frequently incontinent of bladder and 25 residents are frequently incontinent of bowel. The CMS 672 documents 7 residents are bedfast, 47 residents are in a chair all or most of the time. The CMS 672 documents 8 residents have pressure ulcers with 70 residents receiving preventive skin care.

Based on interview and record review, the facility failed to provide consecutive 8-hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 70 residents in the facility. Findings include: On 8/1/22 at 10:38 AM, the Nursing Working staffing schedule from January 1, 2022, through July 25, 2022, was reviewed with V2 (Interim Director of Nursing/ Interim DON). The facility did not have consecutive 8-hour RN coverage for the following days: 5/29, 5/30, 5/31, 6/11, 6/13, 6/16, 6/17, 6/18, 6/19, 6/23, 6/27, 6/28, 6/29, 6/30, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13,7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/23, and 7/24. On 8/1/2022 at 10:50 AM, V3 (Minimum Data Set Coordinator) stated that V2 became the Director of Nursing on 5/15/2022. On 8/1/2022 at 10:42 AM, V2 (Interim DON) stated that she is the only RN. V2 stated that the facility does have staffing problems. V2 stated that she is using agency but at times they do not show up or call off. V2 stated that corporate has put in ads. V2 stated that they give out bonuses for shifts. V2 stated that she is aware of the lack of staff and how it is affecting the care of the residents. V2 stated that she is aware of residents not getting out of bed because if short staff. V2 stated that she in-service the staff and notified them that even if they are short of staff the resident has the right to get out of bed. On 8/1/22 at 10:56 AM, V3 stated that they do not have a policy on staffing. V3 stated that they use the CMS guidelines. The Resident's Census and Conditions of Resident, CMS 672, dated 7/25/2022, documents that the facility has 70 residents living in the facility. The CMS 672 documented that one resident requires Intravenous therapy, 1 resident is on Hospice, 2 residents receive dialysis, and 8 residents have pressure ulcers.

Based on observation, interview and record review, the facility failed to properly store medication, label multidose vials with open dates, and discard expired medications. This has the potential to affect all 70 residents living in the facility. Findings include: On 7/25/2022 at 1:12 PM, the XX Hall medication cart was inspected. The medication cart contained the following medication: 1. R27's Novolog, multi dose, Vial with open date 5/26/22 handwritten on the bottle. 2. Unlabeled, with name, multi dose vial of Insulin Glargine (Lantus) with the open date of 6/25/22 handwritten on the Vial. 3. R24's Multi dose vial of Humulin R with open date 6/1/22 handwritten on the Vial. 4. Unlabeled, with name and open date, Toujeo 300-unit pen. 5. R15's unlabeled, with open date, multi dose vial of Novolog Insulin. 6. Multiple pills in a plastic basket located in the top drawer of the medication cart, not in the original packaging. The pills were identified: 6 Famotidine 100 milligram (mg), 4 Loperamide 2mg, 8 Guaifenesin 600mg On 7/25/2022 at 1:18 PM, V12 (Licensed Practical Nurse/LPN) stated that the Novolog, Humulin, Glargine vial and Toujeo pen were open and in use. On 7/25/2022 at 1:18 PM, the facility's medication storage room was inspected. The refrigerator, located in the medication storage room contained the following: 7. Tubersol multi dose vial. The vial was unlabeled with an open date. Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of The TUBERSOL which has been entered and in use for 30 days should be discarded. The facility's Insulin Storage Recommendations, posted on the wall in the Medication Storage room, documents Novolog and Lantus vials should be stored opened 28 days refrigerated or unrefrigerated. It also documents that Humulin R vials should be stored opened 31 days refrigerated or unrefrigerated. It continues to document Toujeo pen should be stored open for 42 days. On 7/25/22 at 1:20 PM, V12 (LPN) stated that the Tubersol was open and in use. V12 stated that the vial did not have an open date and that it should have one. V12 stated that the insulin and Tubersol vials are to be labeled with an open date when put in use. V12 stated that this vial is used for everyone in the facility unless they have an allergy. V12 stated that the vials of insulin and Tubersol are good for 28 days and should be thrown away after this date. V12 stated that labeling the medication with a date open lets them know when the expiration date is. V12 stated that medications that are expired are to be disposed of. On 7/28/2022 at 10:40 AM, V3 (Minimum Data Set Coordinator/MDSC), stated that the medications are to stay in their originally packaging and not removed for staff convenience. V3 stated that the multi dose vials are to have an open date on them because they expire at different date then packaging when open. On 7/28/2022 at 11:00 AM, V3 stated that the Insulin Storage Recommendations, posted in the medication room, are followed by the facility for insulin storage. The facility's Medication Storage policy documents, C. The medications of each resident shall be kept and stored in their originally received containers. Medications shall not be transferred between containers. It also documents, E. Multi-dose vials and pens shall be stored and dated per the manufacturers guidance. The Resident's Census and Conditions of Resident, CMS 672, dated 7/25/2022, documents that the facility has 70 residents living in the facility.

Based on interview and record review, the facility failed to conduct quarterly meetings for their Quality Assurance and Performance Improvement (QAPI) committee. This has the potential to affect all of the 70 residents living in the facility. Findings include: The Facility's Monthly QA (Quality Assurance) Meeting document, dated 11/2018, documents Purpose: The meeting is to review the results of the Quality Data the committee has reviewed. When: Monthly-ideally on a designated same day to better facilitate attendance. Who Attends: Administrator, DON (Director of Nursing), Medical Director, Infection Preventionist, Social Services, Food Service Director, Activities Director, Maintenance Director, AMC (Admissions Marketing Coordinator), Recruitment/Retention Coordinator, Payroll Clerk, Pharmacy Consultant (Quarterly). The Facility's only Quality Assurance Committee Minutes dated 7/15/22, documents that V1 (Administrator), V3 (Minimum Data Set Nurse/MDS Nurse) V25 (Activity Director), V18 (Wound Nurse) and the Medical Director (via phone) attended this meeting. On 7/27/22 at 12:05 PM, V3 (MDS Nurse) stated We have had a lot of Interim Administrators here this past year and we have only had one Quality Assurance meeting on 7/15/22. They were not getting scheduled or done. On 7/28/22 at 1:50 PM, V1 (Administrator) stated We have only had one QA meeting since I have been here. We have no way to identify issues because we don't meet on a regular basis. I identified a problem with our call lights from the Resident Council Meeting and have done some in-services with the staff. The Resident's Census and Conditions of Residents, CMS 672, dated 7/25/22, documents that the facility has 70 residents living in the facility.