Based on record review and interview, the facility failed to provide an ABN (Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) form to notify a resident or their responsible party that they no longer required daily skilled services in 3 of 3 residents (R5, R25, R77) when reviewed for Medicare Coverage Notices in the sample of 37. Findings Include: 1. R5's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, documents R5 began Medicare A skilled services on 3/5/25 and the last covered Medicare A service date was 4/3/25. The SNF ABN for was not provided due to Social Worker did not realize she had to issue ABN. R5's NOMNC, dated, 5/19/25, documents the notification was not provided prior to the end date of 4/3/25. 2. R25's SNF Beneficiary Protection Notification Review, documents R25 began Medicare A skilled services on 4/18/25 and the last covered Medicare A service date was 6/1//25. The SNF ABN for was not provided due to Social Worker did not realize she had to issue ABN. The NOMNC was not provided due to Social Worker was not aware NOMNC was issued. 3. R77's SNF Beneficiary Protection Notification Review, documents R77 started on Medicare A skilled services on 2/18/25 and the last covered Medicare A service date was 3/24/25. The SNF ABN for was not provided due to Social Worker did not realize she had to issue ABN. R77's NOMNC, dated, 5/1/25, documents the notification was not provided prior to the end date of 3/24/25. 06/24/25 10:53 AM V5, MDS, stated V4, SSD, didn't realize she was to do the ABNs and NOMNCs, but she has been educated and will be doing them. 06/25/25 08:10 AM V4, SSD, stated she was doing both the ABN and NOMNCs but was told by prior administration only the NOMNCs were required. V4 stated she was educated by V5, MDS, to do both when required. The facility Beneficiary Notice Guidelines, with a copyright date of 2021, documents an ABN and NOMNC are to be provided to the resident or their representative when a Medicare part A stay ends because the SNF determines the beneficiary no longer requires daily skilled services, the resident has days remaining in the benefit period and the resident will remain in the facility. Notice is to be delivered in writing to the resident with at least two days' notice even if he/she agrees with the notice/decision.

Based on observation, interview and record review, the facility failed to provide an RN (Registered Nurse) for at least eight hours per day when reviewed for staffing. This failure has the potential to affect all 108 residents residing in the facility. Findings Include: On 6/24/25, there were 4 LPNs (Licensed Practical Nurses), 9 CNAs (Certified Nursing Assistants), and V3, RN/ADON (Assistant Director of Nurses)/ICP (Infection Control Preventionist) working in the ADON/ICP role. The Daily Nursing Shift Assignment Sheets were reviewed and on 6/12/25, 6/14/25, 6/15/25, 6/17/25, 6/18/25, 6/19/25, 6/20/25, 6/21/25, and 6/22/25, there was not a designated RN working for at least 8 hours. On 6/24/25 at 11:50 AM, V1, Administrator, stated even with V3, ADON/IPC, they don't have enough RNs. The Daily Staffing Summary, dated 6/3/23, documents it is the goal of the facility to meet or exceed nursing staff levels required to provide quality care to the residents. The CMS (Centers for Medicare & Medicaid Services) for 671, dated 6/24/25, documents there are 108 residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer oxygen therapy as prescribed and provide signage on doors where oxygen is in use for residents receiving oxygen therapy for 2 of 3 residents (R2, R3) reviewed for respiratory care in the sample of 11. Findings include: 1. R2's Face Sheet dated 8/28/2024 documents R2 has diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Respiratory Failure. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R2's Order Audit Report dated 1/11/2024 documents, Oxygen continuous at 2 Liters/Minute per nasal cannula every shift for chest pain/SOB (shortness of breath). On 8/27/2024 at 10:20 AM, there was no oxygen in use signage located in R2's room or on R2's door regarding oxygen being utilize in this room. R2 stated she takes her portable oxygen tank to the dining room for lunch and the nurse must fill it with oxygen. On 8/27/2024 at 12:05 PM, R2 was in her room and stated she had no oxygen in her portable tank when she went to the dining room. R2 stated when she notified staff, R2 was told by an unknown staff member to try to eat as much as she could and see how she does without her oxygen. On 8/27/2024 at 1:17 PM, V10, Assistant Director of Nursing (ADON) stated R2 should have a humidification bottle on her concentrator. R2 proceeded to tell V10 about what occurred at lunch with her oxygen. R2 told V10, She (unknown staff member) couldn't do anything about it at the time, said just eat as much as you can. V10 replied to R2, Everyone should know how important oxygen is. V10 stated she would expect if a resident reports they are out of oxygen, the CNA (Certified Nursing Assistant) should notify the nurse so it could be re-filled. 2. R3's Face Sheet dated 8/28/2024 documents R3 has diagnoses of Chronic Obstructive Pulmonary Disease (COPD). R3's MDS dated [DATE] documents R3 is cognitively intact. R3's Order Audit Report dated 8/19/2024 documents, May use Oxygen at 2 Liters/Minute per nasal cannula continuously as tolerated, may titrate as needed every shift related to COPD. On 8/27/2024 at 1:11 PM, R3's oxygen concentrator was observed with two filters on both sides of the machine. Both filters were 100% covered in dust. V10 agreed that the state of the filters was unclean and covered in dust. V10 stated R3 should have a humidification bottle on his concentrator but does not know where the water bottle would go. On 8/27/2024 at 2:02 PM, V2 Director of Nursing (DON) stated she did not see R3's concentrator filters but, by the looks of it (concentrator), I can just imagine what they looked like. V2 stated the maintenance man would have the information on cleaning the filters. V2 stated not everyone on oxygen requires humidified water because the doctors order does not specify. V2 stated it is per resident preference. R3 stated he does prefer to have humidified oxygen because it keeps the air from being too dry. On 8/28/2024 at approximately 11:45 AM, V14, Maintenance Director, stated he did not have the information for R3's oxygen concentrator. On 8/28/2024 at 12:05 PM, V9, Certified Nursing Assistant (CNA) verified with surveyor that there were no oxygen in use signs in either R2's or R3's rooms. V9 stated there should be. The Facility's Policy Oxygen Administration dated October 2010 documents, Purpose: The purpose of this procedures is to provide guidelines for safe oxygen administration. It continues, The following equipment and supplies will be necessary when performing this procedure: 1. Portable oxygen cylinder 2. nasal cannula, nasal catheter, mask (as ordered) 3. humidifier bottle 4. No smoking/oxygen in use sign 5. regulator 6. personal protective equipment (as needed). It further documents, Check the mask, tank, humidifying jar, etc. to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through and Periodically re-check water level in humidifying jar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure coordination of care with residents' community-based physician including preventative care to maintain the highest practicable physical well-being for 1 of 6 residents (R3) reviewed of quality of care in the sample of 6. Findings include: R3's admission Record, not dated, documents R3 was admitted [DATE]. R3's Brief Interview for Mental Status, dated 5/3/2024, documents R3 is cognitively intact. R3's Progress Note, effective date 6/11/2024 at 12:30 PM, documents created dated 6/14/2024 at 11:57 AM Late Entry: Note Text: Resident was concerned over his Cologuard being sent out and asked what time the mail ran. I informed him they picked up at around 2pm and he had time to get it ready. He then stated he did not need to go now, and he would have to wait until Wednesday. On 6/12/2024 at 9:40 AM R3 stated he was admitted to the facility on [DATE]nd. R3 stated shortly after he went to his primary physician which is outside of the facility. R3 stated he saw his physician and was informed he needed a colonoscopy. R3 stated because of his breathing issues his physician did not feel it was safe to put him under. R3 stated a (non-invasive, at home prescription stool DNA test) was then ordered. R3 stated when he returned to the facility, he notified the nurse about it. R3 stated he waited for the stuff to be delivered. R3 stated he asked about it but was told and no one had seen it. R3 stated on 6/7/2024 he was giving his box of supplies. R3 stated the box was delivered on 5/24/2024. R3 stated he was upset because he had another appointment following Monday and his primary physician wanted the results. R3 stated he was very upset and voiced this to the nursing staff. R3 stated V4, Unit Manager/Licensed Practical Nurse, LPN, spoke with him about it. R3 stated V4 came up with a plan for it to be sent out on Tuesday and but it is still here on Wednesday. On 6/12/2024 at 9:40 AM a delivery box with stool specimen equipment, dated 4/24/2024 at 5:33 AM, observed in R3's room. On 6/12/2024 at 11:24 AM V2, Director of Nursing, stated she was not aware of the box being delivered. V2 stated R3 makes his own appointments and does not communicate with the facility. V2 stated she became aware of it on Friday 6/7/24. V2 stated R3 is alert and able to do it himself. On 6/12/2024 at 11:26 AM V3, Assistant Director of Nursing, stated she became aware of the issue on 6/7/2024 and stated she tried to speak with R3. V3 stated R3 was upset. V3 stated the box should have been delivered when it arrived. V3 stated they are working with R3 to get it done. On 6/12/2024 at 11:30 AM V5, LPN, stated it was her fault. V5 stated there were some problems with R3's medication and they were waiting to get them in the mail. V5 stated when the box was sitting back there it was not the medication, so she didn't think too much of it. On 6/12/2024 at 11:36 AM V8, Medical Assistant, stated R3 was seen by V7, Physician, on 5/8/2024. V8 stated at that time V7 ordered the Cologuard test to be performed. V8 stated the Cologuard was ordered to rule out colon and rectal cancer. V8 stated on his visit on 5/8/2024 they were not aware R3 was at a skilled facility and was not notified by the skilled facility. V8 stated because of this the communication was with R3. V8 stated they are now aware of R3 residing at a skilled facility. V8 stated they send the order to the company and the company contacts the facility and/or patient. On 6/17/2024 at 9:43 AM V11, Licensed Practical Nurse (LPN), stated when a resident returns from a doctor's appointment they return with paperwork. V11 stated this paperwork is given to the nurse. V11 stated they must verify any new orders or follow up appointments. V11 stated sometimes the residents come back and don't have paperwork. V11 stated they talk with the resident and family. On 6/17/2024 at 9:50 AM V10, LPN, stated she works for the facility. V10 stated when a resident goes to the doctor V6 (Transportation Aide) goes with them. V10 stated paperwork is sent with them. V10 stated the paperwork is given to the resident if they are alert or V6 if they are not. V10 stated when the resident returns the nurse is notified and the paperwork is then given to the nurse. V10 stated they must verify there aren't new orders or follow up appointments. V10 stated the nurse will speak with the resident and the family if they went along. On 6/17/2024 at 9:54 AM V9, LPN, stated she is an employee of the facility. V9 stated when a resident goes to the doctor paperwork is sent with the resident. V9 stated they have a staff member goes with the residents if needed. V9 stated when the resident returns the paperwork is given to the nurse. V9 stated they do have residents keep their paperwork. V9 stated if they don't receive any paperwork, they call the office to make sure there isn't any new orders or follow up appointments. V9 stated if a resident receives a delivery they first check to see if its medication and then the box is given to the resident. On 6/17/2024 at 10:14 AM V6, Transportation Aide, stated she took R3 to his doctor's appointment on 5/8/2024. V6 stated R3 had recently admitted to facility and notified her of his appointment. V6 stated she was able to fit R3 in the schedule and went with him. V6 stated she waited for R3 in the waiting area. V6 stated R3 is alert and did not want V6 to go into the exam with him. V6 stated when R3 returned to the waiting room she asked if he had any paperwork and R3 stated he didn't. V6 stated when returning to the facility V6 notified the administrator and the nurse R3 had returned. V6 stated when taking a resident to the doctor V6 makes copy of paperwork. V6 stated she copies the face sheet with insurance and physician order sheet. V6 stated usually the resident has a summary that is provided by the office. On 6/17/2024 at 10:35 AM V12, Receptionist, stated when a resident gets mail or delivery those items are taken to the nurse's station and given to the nurse. V12 stated those items are not given directly to the resident. The Residents' Rights for people in Long-Term Care Facilities, dated 11/18, documents, You have the rights to choose your own doctor. Your facility must deliver and send your mail promptly. The facility's Physician Orders for Resident Appointments policy dated 7/6/2023, documents on the day of the scheduled appointment, the resident's nurse will document a progress note when the resident leaves facility, with any required information, and then a second progress note upon the resident's return to the facility, with any required information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure abuse did not occur for 4 of 5 residents (R40, R49, R74, R75) reviewed for abuse in the sample of 42. Findings include: 1. R49's Physician Order Sheet for May 2024, documented a diagnosis of anxiety disorder, dementia in other diseases classified elsewhere, moderate with agitation, alcohol abuse with other alcohol induced disorder, alcoholic hepatitis without ascites, cocaine abuse with cocaine induced disorder. R49's Minimum Data Set (MDS), dated [DATE], documented R49 was severely impaired for cognition of activities of daily living. Partial/moderate assist for most activities of daily living and he is in a wheelchair. R49's Care Plan, undated, documented, (R49) has impaired cognitive function related to his Dementia. R49's Care Plan does not address abuse. R49's Progress Notes, dated 3/3/2024 at 9:03 PM, documented, Note Text: 10:00 PM resident involved in resident to resident altercation. This resident observed standing over another resident punching resident near head. Multiple staff approached and separated residents, no acquired injuries, resident sister made aware of altercation, ADON (Assistant Director of Nursing) made aware via phone call, MD (Medical Director) made aware. R49's Final Report, dated 3/7/2024, documented, On 3/3/2024 (R68) resident was seen getting up out of wheelchair, and made contact with another resident (R74). This occurred at the nurse's station by hall D at around 10:30 PM. This was a witnessed situation. Neither resident is an identified offender. Family and physician notified. Local police also notified. Residents were immediately separated. Nurses and CNAS were at the nurse station at the time but could not get to (R68) quick enough. No injury noted. During this investigation and the use of cameras that are on site shows (R68) did get out of his wheelchair, stood up and made contact with (R74) on his head with right fist. (R68) is on 15 minute checks. Both residents redirected to other activities. Facility encourage staff to keep them apart, if possible, with other activities. 2. R75's MDS, dated [DATE], documented R75 was moderately impaired for cognition for activities of daily living. R75's Care Plan, undated, documented, (R75) has a behavior problem. Diagnosis of anxiety and cognitive communication deficit. (R75) has potential to be verbally aggressive and scream at others r/t Ineffective coping skills & cognitive communication deficit. R75's Progress Notes, dated 3/3/2024 at 10:27 PM, documented, Note Text: resident was sitting at nursing station sitting area when another resident physically attacked him, given blows to the head. No injury noted. Resident stated, I'm tired of this mother fuc*er talking sh*t I'm go hit again. Resident was separated move to different areas DON (Director of Nursing, MD (Medical Director) POA (Power of Attorney) notified. No injury noted. Resident is sitting in wheelchair with no complaints. On 5/29/2024 at 10:50 AM, V5, Licensed Practical Nurse (LPN), stated, I remember (R49) started the resident-to-resident altercation back in March. (R49) hit (R75). Both residents are aggressive and both residents are confused. I remember I intervened immediately, and no resident was hurt and/or had any injury from the altercation. On 5/29/2024 at 8:41 AM, V1, Administrator, stated, I reviewed the cameras and (R49) got out of his wheelchair back in March and hit (R75) on the head with his right fist. Neither resident was hurt. On 5/29/2024 at 10:22 AM, V2, Director of Nursing (DON), stated, I believe the altercation with (R49) and (R74) occurred in the evening back in March. They are both very confused. At one time they were roommates. They both have a history of hitting staff. On 5/29/2024 at 1:32 PM, V3, Assistant Director of Nursing, stated, I vaguely remember the incident. I know both (R49) and (R74) both have a history of combative behaviors and had an altercation. (R49) gets in and out of his wheelchair and I believe (R49) hit (R74), but neither resident was injured. At one time they were roommates. 3. R36's MDS, dated [DATE], documented that R36 was cognitively intact for decision making of activities of daily living. 05/28/24 at 1:36 PM, R6 stated, I was involved in a fight with (R40) because she was going through stuff in my room, I don't like her going through my stuff or my roommate's stuff. It's not right. R36's Progress Note, dated 5/26/2024 at 9:44 AM, documented, Note Text: writer made aware approximately 9:08 AM, resident made physical contact with (R40) CNA states that (R36) said (R40) was going through roommates belongings and attempted to redirect (R40) & licks were exchanged; resident separated; [NAME] on call and made aware at 0922; [NAME] administrator called approximately 9:32 AM and instructed to have CNA (witness) to write a statement and place it under her door; resident daughter & POA (power of attorney), made aware; POA asked if she had any bruises; writer informed no injuries/bruising noted; states that (R36) had informed her that someone had been coming into her room and touching her things; writer informed POA that we have dementia patients that wander and go into other resident room, however physical contact is not appropriate as mean of redirection; understanding voiced; states she will be to visit resident later; no further needs voiced; will monitor. 4. R40's MDS, dated [DATE], documented that R40 had memory problems and was severely impaired for cognition for activities of daily living. R40's Care Plan, undated, documented, (R40) is an elopement risk/wanderer related to diagnosis of Alzheimer, confusion. On 5/28/2024 at 9:01 AM, V30, Licensed Practical Nurse, stated, (R40) is very confused and she has a habit of wandering around the facility and has a habit of wandering into resident's room. R40's Progress Notes, dated 5/27/2024 at 5:55 PM, documented, Note Text: observation r/t (related) resident to resident altercation, resident denies pain rom (Range of Motion) wnl (within normal limits), no s/s (signs and symptoms) of distress, up in wc (wheelchair) propelling self about facility. On 5/31/2024 at 9:46 AM, V1, Administrator, stated, I did an initial and will have the final report finished today. It looks like (R40) entered (R37's) room and (R37) became upset and started hitting her. The Abuse Prevention Program Policy with a revision date of March 2018, documented, The facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medial symptoms. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. Physical abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 2 of 4 residents (R40, and R74, ) viewed for antibiotic stewardship in the sample of 42. Findings include: 1. R40 was documented on the April 2024 Infection Control Log for a urinary tract infection. The log documented, Cephalexin Oral Tablets 500 milligrams give 500 mg (milligrams) by mouth two times a day for UTI (urinary tract infection) for 10 days. R40's Progress Notes, dated 4/16/2024 at 11:51 AM, documented, ABT (antibiotic) ordered and awaiting delivery for UTI (urinary tract infection). R40's Physician Order Sheet (POS) for April 2024, documented, Cephalexin Oral tablet 500 MG (milligrams) (cephalexin) give 500 mg by mouth two times a day for UTI for 10 days. Order date 4/17/2024, end date 4/27/2024. R40's Medication Administration Record (MAR), dated 4/1/2024 to 4/30/2024 documented, Cephalexin oral tablet 500 MG (cephalexin) give 500 mg by mouth two times a day for UTI for 10 days. Start date 4/17/2024. On 5/29/2024 at 10:00 AM, a Culture and Sensitivity Report (C&S) was requested for R40, and no C&S was provided for R40 to ensure Cephalexin Oral Tablets 500 milligrams was the correct medication for the urinary tract infection for April 2024. 2. R74 was documented on the Infection Control Log for May 2024 for a urinary tract infection. The log documented, Levofloxacin Oral Tablet 750 mg give 1 tablet by mouth one time a day related to urinary tract infection site not specified. R74's Progress Note, dated 5/19/2024 at 10:27 PM, Note Text: Due to (R74's) agitation and aggressiveness today and yesterday. (Doctor) gave new orders to recheck him for UTI. R74's POS, dated May 2024, documented, UA (urinary analysis), C&S one time only related to urinary tract infection. Start date 5/21/2024. Cefepime HCL Intravenous Solution 2 GM (Grams)/100ML (milliliters) (Cefepime HCL) use 2 grams intravenously every 12 hours for infection related to urinary tract infection for five days. Start date 5/13/2024, end date 5/19/2024. Cefepime HCL intravenous solution 2 GM/100 ML (Cefepime HCL) use 2 grams intravenously two times day for infection related to urinary tract infection. Start date 5/13/2024 end date 5/16/2024. Cefepime HCL intravenous solution 2 GM/100ML (Cefepime HCL) Use 2 gram intravenously two times a day for infection related to urinary tract infection for 2 days. Start date 5/13/2024 end date 5/15/2024. R74's MAR for May 2024, documented, Levofloxacin oral tablet 750 MG (levofloxacin) give 1 tablet by mouth one time a day related to urinary tract infection, start date 5/13/2024, d/c date 5/13/2024. It also documented that one dose was given on 5/13/2024. On 5/29/2024 at 10:02 AM, a Culture and Sensitivity Report (C&S) was requested for R74, and no C&S was provided for R74 for May 2024. On 5/31/2024 at 10:12 AM, V3, Infection Control Preventionist/Assistant Director of Nursing stated, I just recently was hired and took over as the infection control preventionist back in March. I have completed this course and got my certificate. All the surveillance, everything should be in the book. I am new to this position, and I just have not gotten the surveillance/infection control where it needs to be at. I know there are no organism listed and I do not always get the Culture and Sensitivity back when residents go out to the hospital. The Antibiotic Stewardship Program with an effective date of 2017, documented, Antibiotic Stewardship refers to the appropriate use of antibiotics when they are actually needed and using the right antibiotic for the right infection. Antibiotic resistant occurs when bacteria adapt so that the drugs used to treat infection as less effective or do not work at all. Overexposures to antibiotics creates drug-resistance strains of bacteria and healthcare-associated infections. When this occurs, it is difficult to treat infections residents may develop complications leading to hospitalization and mortality. Cultures will be obtained to ensure appropriate diagnosis when possible. The facility's IP (Infection Preventionist) will monitor results of cultures routinely to ensure MDROs (multi drug resistance organisms) are addressed appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure call lights were being answered in a timely manner for 5 of 7 residents (R32, R36, R70, R77, R82) reviewed for call lights in the sample of 54. Findings include: On 5/28/2024 at 8:45 AM, V7, Activity Director, was asked to bring 4-5 residents to a group meeting that were able to answer questions and were interviewable. The following residents were brought to the meeting; R32, R36, R70, R77 and R82. During the group meeting on 5/29/2024 at 8:45 AM, R32, R36, R70, R77 and R82 all stated they were having issues with the call lights not being answered in a timely manner on all shifts. They stated the average wait time is probably 30 minutes with some times even longer depending on what is going in in the facility. R32's Minimum Data Set (MDS), dated [DATE], documented that R32 was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 8:52 AM, R32 stated, We have been having issues with call lights and we have talked about it at the resident council meeting. It does not seem to be getting better. It depends on the day and what else is going on but for those of us that need help we have to wait and call light has been a big problem here. R70's MDS, dated [DATE], documented, R70 was moderately impaired for cognition for decision making of activities of daily living. On 5/29/2024 at 8:54 AM, R70 stated, I am in a wheelchair, and I do not even use the call light because why bother when they never answer it. Thankfully, I just yell for help or go and find someone when I need help. R72's MDS dated [DATE], documented R72 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 8:56 AM, R72 stated, I am getting ready to leave soon. I have been in a wheelchair, and I need help. The call lights are a big problem because staff are not answering them or worse, yet they come in and answer the call light then turn off the light and never come back. R82's Minimum Data Set (MDS), dated [DATE], documented R82 was moderately impaired for decision making of activities of daily living. On 5/29/2024 at 8:59 AM, R82 stated, I can do most things by myself, but everyone has been complaining (that needs help) about the call lights taking a long time to answer. R77's MDS, dated [DATE], documented, R77 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 9:00 AM, R77 stated, I am fortunate that I can do most things by myself. I have been coming to these meetings for about four months and residents have been complaining about call lights not being answered. Residents needing help and residents not getting help. R36's MDS, dated [DATE], documented that she was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 9:01 AM, R36 stated, Call lights are a problem and we have told (V1) and the ombudsman but they are still not answered in a timely manner. Resident Council Meeting Minutes, dated 5/20/204, documented, Call lights need answered ASAP. Resident Council Meeting Minutes, dated 2/26/2024, documented, Long call light time. Resident Council Meeting Minutes, dated 3/26/2024, documented, Call lights take time to be answered. R190's Grievance, dated 2/27/2023, documented, No one answer call lights. Do not work together. Findings of investigation: Ongoing issues, Put in place call light audit. Plan to resolve Complaint: Call light audit, in-services. Grievance was not resolved. Resident Council Meeting Minutes, dated 4/25/2023, documented, Call lights not being answered timely or coming in and saying, I'll be back then not returning. On 5/29/2024 at 10:02 AM, V6, Ombudsman, stated, I have been having a lot of complaints from residents and family members regarding call lights for the past three months. I have approached (V1, Administrator) and she tells me she is going to address it, but it is still happening and nothing has changed. On 5/29/2024 at 3:02 PM, V1, Administrator stated, We have had in-services on call lights. I have been told there are some issues with call lights. I am not sure when the last audit was done or what the results were from that audit. On 5/29/2024 at 4:02 PM, V1 stated, There was no policy on call lights. The Resident Right Policy with a revision date of 11/18, documented, Nursing home residents have the right to: Dignity, respect and a comfortable living environment. The Resident Right Policy with a revision date of 11/18, documented, Nursing home residents have the right to: Dignity, respect and a comfortable living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident clothes were being maintained, cleaned, and returned in a timely manner for 5 out of 7 residents (R32, R36, R70, R77, R82) reviewed for laundry in the sample of 42. Findings include: On 5/28/2024 at 8:45 AM, V7, Activity Director, was asked to bring 4-5 residents to a group meeting that were able to answer questions and were interviewable. The following residents were brought to the meeting R32, R36, R70, R77 and R82. During the group meeting on 5/29/2024 at 8:45 AM, R32, R36, R70, R77 and R82 all stated they were having issues with missing laundry and the facility was not doing anything about it. 1.R36's Minimum Data Set (MDS), dated [DATE], documented that she was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 9:01 AM, R36 stated, We have issues with laundry too and things go missing and they never find it or replace it. It's not right! 2.R72's MDS, dated [DATE], documented that R72 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 8:56 AM, R72 stated, I have had lots of missing clothing lost and never returned and not replaced. 3. R82's Minimum Data Set (MDS), dated [DATE], documented that R82 was moderately impaired for decision making of activities of daily living. On 5/29/2024 at 8:59 AM, R82 stated, Clothes are always going missing and staff do not really help you or really care. I have lost lots of clothes, told them about it and they were never replaced. 4. R77's MDS dated [DATE] documented, R77 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 8:52 AM, R77 stated, We have some issues with clothes going missing and the facility not even trying to find them or replace them. This has been going on for months now. They lose your clothes and don't care or even try to find you something different. I went inside the laundry room because they told me any clothing without labels is put in a bin for residents to go through. When I asked, I was told the bin was empty because they had donated the clothes. That does not make sense to me. Why would you donate our clothes? How does that make sense nobody told me there was a bin of unidentified clothes I could go through. 5- R32's Minimum Data Set (MDS), dated [DATE], documented that R32 was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 8:52 AM, R32 stated, They don't care about our clothes. They lose our clothes and don't find them or replace them. R58's Resident Family Grievance, dated 12/27/2023, documented, Resident stated that CNA's take her clothes out of her room for laundry but not returning them. She's missing about 10 pair of slacks shirts and socks. R60's Resident Family Grievance, dated 3/6/2024, documented, Rude answer about my clothing. Plan to resolve: This writer spoke to housekeeping/laundry supervisor in regards to clothes. Supervisor will get with (R60) resident was advised to have name marked in clothing so laundry will know they belong to him. I am missing tons of shirts and pants. R62's Resident / Family Grievances, dated 1/5/2024, documented, Resident's father stated that resident's blue sweat suit that he received as a gift for Christmas is missing, it's a pullover hoodie no zipper with pants to match. Resident's father wants a replacement. Findings of investigation, Resident clothes were not found. POA (Power of Attorney) did not want to go to laundry to identify belongings. Plan to Resolve: Have resident's POA identify clothing in laundry. On 5/29/2024 at 10:08 AM, V6, Ombudsman, stated, I have been having a lot of complaints from residents and family members regarding laundry being lost and never found or replaced. I talked with (V1) about for several months, but it does not seem to improve or get better. V18, Laundry Supervisor, stated that residents sign a contract when they come in the facility that their clothing is to be marked with their name on it and clothing will be thrown away if not claimed after 60 days. We contact the POA (Power of Attorney) or family representative and tell them to come in and go through the lost and found clothing before the items are thrown away. We only have so much room for storage. On 5/31/2024 at 10:10 AM, A review of admission contract was reviewed, and it does not document that clothing with no name will be discarded after 60 days. On 5/31/2024 at 10:36 AM, in the laundry room with the wheelchairs was a rack with 5 large boxes approximately 24 inches by 18 inches by 24 inches each box contained resident clothing that was not labeled. (e.g., shirts, pants, pajamas). On 5/31/2024 at 10:39 PM, V18, Laundry Supervisor, stated, These 5 boxes have clothes that do not have labels or names. The Resident Right Policy with a revision date of 11/18, documented, Nursing home residents have the right to: Dignity, respect and a comfortable living environment. The Notification of Policy Regarding Personal Property, undated, documented, This facility understands the value and importance of everyone's personal property. Because we care, we make every effort to assure that your possessions are not lost, misplaced or stolen.

Based on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 88 residents living in the facility. Findings Include: The facility Infection Control Log was requested for the entire year since the last survey. On 5/28/2024 at 9:02 AM, An infection control log was provided but did not have any dates or organisms listed or documented. On 5/28/2024 at 10:43 AM, V3, Assistant Director of Nursing (DON) stated, I just recently was hired and took over as the infection control preventionist in March. I have completed this course and got my certificate. All of the surveillance, everything should be in the book. I am new to this position, and I just have not gotten the surveillance/infection control where it needs to be at. I know there are no organism listed. The infection control book provided by V3 on 5/28/2024 listed residents' names and identified urinary tract infections along with the medication but none of the urinary tract infections had organisms documented and no organisms were provided for the entire book. The book was incomplete. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 5/28/2024, had a census of 87 residents. The Facility Infection Control Program Policy revision date or 8/2017 documented, The facility will maintain an infection control program that is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The ICP (Infection Control Preventionist) will investigate, control and prevent the infections in the facility by monitoring laboratory reports and physician orders and following symptomatic trends within the facility that may indicate patters of infection.

Based on interview and record review, the facility failed to provide services of a Registered Nurse (RN) for at least 8 hours daily 7 days per week. This has the potential to affect all 83 residents living in the Facility. Findings include: On 1/19/24 at 1:00 PM, Nurse Staffing Schedules for the past 90 days were requested from V1, Administrator. On 1/19/24 at 2:00 PM, V1, Administrator, provided available documentation and stated she was unable to locate Nurse Staffing Schedules for 10/25/23 through 11/21/23. The Facility's Nurse Staffing Schedules for 9/27/23-10/24/23, 11/22/23-12/19/23, and 12/20/23-1/16/24 were reviewed. There was no RN coverage for 8 hours a day on the following dates: 9/27/23, 9/28/23, 10/2/23-10/5/23, 10/9/23-10/10/23, 10/12/23, 10/16/23, 10/19/23-10/24/23, 11/22/23-11/23/23, 11/27/23-11/30/23, 12/4/23-12/7/23, 12/11/23-12/14/23, 12/18/23-12/19/23, 12/20/23-12/21/23, 12/25/23-12/28/23, 1/1/24-1/4/24, 1/8/23-1/11/23, and 1/15/23-1/16/23. On 1/19/24 at 2:00 PM, V1, Administrator, stated the facility does not have a RN staffing policy, but she expects to follow the regulations. V1 stated she has been working with V2, Director of Nursing (DON), to hire RNs. The Facility Census, dated 1/19/24, documented that there were 83 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 immediately report bruises of unknown origin to the administrator/or designee for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30. Findings include: 1. On 12/27/23 at 10:06 AM, V20 Certified Nursing Assistant (CNA) and V21 CNA provided incontinent care for R20 who had been incontinent of urine and feces. They unfastened R20's adult diaper and V21 used disposable wipes to wash away feces from R20's labia, groin and inner thighs. After feces was removed, there were two curved deep purple lines on her inner thighs where the diaper's elastic had been. It was bruised and did not fade after diaper removed. They then rolled R20 onto her right side and V21 cleansed the feces from her buttocks and rectum. After feces was removed there were two more easily visible dark purple linear bruises on R20's right and left lower buttocks where the elastic from the diaper was. These were bruises and did not fade after diaper removed. V21 stated, Those are from the diaper being too tight. I am leaving the diaper off and am going to report them to my charge nurse and the wound nurse. I am not going to put any cream on them until they look at these bruises because they won't be able to see them good with the cream on them. She doesn't need to be wearing a diaper and I am only going to leave the pad under her. R20's Face Sheet documents her diagnoses to include Rectal Cancer, Chronic Obstructive Pulmonary Disease, Anxiety, and Alcohol Abuse. R20's Minimum Data Set (MDS) dated [DATE] documents R20 is moderately cognitively impaired, has impaired range of motion to both lower extremities, is dependent on staff for toileting and transfers and assist with bed mobility, and is incontinent of bowel and bladder. R20's undated Care Plan documents: (R20) is at risk for skin breakdown and/or pressure ulcer formation d/t (due to) decreased mobility and bowel incontinence. No reddened or opened areas noted at present. Goal: will remain free of reddened or open areas through next review date. Interventions: Assist with T&P (Turning and Positioning) Q (every) 2 hrs. while in bed for pressure relief. Barrier cream after each episode to peri-area. Cushion to wheelchair. Pressure relief mattress to bed. Prompt incontinent care after each episode. Skin checks weekly. R20's Progress Note dated 12/25/2023 at 12:49 PM documents, C hall CNA report bruise this shift. Resident has bruise to the inner thigh left and right /front to back red in color shape of a line. Look like it may been produced by pulling of a depend. three small bruises on back red in color. Wound nurse made aware and ADON (Assistant Director of Nursing). There was no documentation of investigation of cause of these bruises or notification of Administrator, Family or Doctor. R20's Progress Note dated 12/27/2023 at 12:21 PM documents, Skin/Wound Note (HC): resident has a discoloration line from her right groin around her right buttock from her brief. hospice notified and new orders to cleanse area with NS (normal saline) or WC (wound cleanser), apply Calmoseptine and leave open to air, do not strap on brief. Monitor for s/s (signs and symptoms) of infection and notify md (medical doctor) if present. POA (Power of Attorney) and physician notified. There was no documentation of the bruises to R20's left groin and left buttock. 2. R21's Face Sheet documents her diagnoses to include Anemia, Hypertension, End Stage Renal Disease, Diabetes Mellitus, Hyperlipidemia, Alzheimer's Disease, Anxiety, and Depression. R21's MDS dated [DATE] documents she is severely cognitively impaired, dependent on staff for all Activities of Daily Living (ADLS). It documents staff propel her in her w/c and she is always incontinent of bowel and bladder. Per the assessment, R21 had no pressure ulcers or falls during this assessment look back. R21's Progress Note dated 12/14/23 at 5:42 PM documents, Checked resident blood sugar @4:32 PM level at 548. 15 units given per sliding scale, rechecked at 5:40 PM level at 529. Called (V28, Medical Doctor), per phone order he directed this nurse to give resident 8 units of lispro and recheck blood sugar in 2 hours. This nurse repeated order back to physician and he confirmed. Also notified physician of patient having edema on right leg and bruising under left breast that appears dark purple. Resident leg and left arm are in pain when moved. Will continue to monitor resident, she is in bed with call light in reach. There is no documentation of notification of Administrator regarding bruise of unknown origin under R21's left breast. On 12/26/23 at 9:36 AM, V31, Hospital Wound Nurse stated R21 had been discharged from the hospital on [DATE] and readmitted to the hospital on [DATE]. V31stated there were pictures taken in the hospital of a bruise on R21's left lateral breast that were taken on 12/16/23. V31 stated it was more on the rib side of breast. V31 stated there were also pictures of bruises on R21's labia on 12/18/23, two days after she was admitted to the hospital. V31 stated the facility did not send any information regarding bruises or pressure ulcers when resident was admitted to hospital on [DATE]. V31 stated R21 was admitted with COVID and Altered Mental Status. V31 stated she saw R21 on 12/18/23 in the afternoon and saw deep purple-red bruises on R21's labia about a third of the way down her labia, area behind her vagina, up to rectum and some bruising around her rectum. V31 stated there was an area about midway down her thigh that could have been an abrasion that could have been from picking or if her diaper had been on too tight. V31 stated when she was trying to look at the bruises, R21 kept trying to pull the blanket back up and stated she has had other residents/patients do this when being examined and could be s/s of trauma or not. On 12/26/23 at 12:44 PM, V6, Director of Nursing (DON) stated she does not have any other abuse investigations or investigations of bruises of unknown origin in the last three months besides a resident-to-resident altercation between R29 and R30. The investigation regarding possible sexual abuse towards unknown resident by unknown staff that was reported to her on 12/21/23 by a surveyor. On 12/27/23 at 11:55 AM, V6, DON and V25, MDS Coordinator came in to talk to writer and had V1, Administrator on speaker phone on V6's cell phone. V1 stated the bruise on R21's breast was not reported to either of them or V2, Assistant Director of Nursing (ADON). V1 stated if it had been reported she would have sent in the initial report to IDPH (Illinois Department of Public Health (IDPH) and started the investigation immediately. V1 stated any bruise of unknown origin is treated that way. On 12/27/23 at 1:30 PM, V6 DON stated, We did have a report of bruises of unknown origin today for (R20) today and have sent the report and started an investigation. V6 stated the police and MD were notified. This investigation was started two days after the bruises were first documented in R20's progress notes on 12/25/23. On 12/27/23 at 5:45 PM, V27 Licensed Practical Nurse (LPN) stated she documented a bruise was noted on R21's breast on 12/14/23. V27 stated a CNA was changing R21 and saw the bruise and reported this to V27. V27 stated V6 (DON) was working, and she asked her to look at the bruise and stated they went in and looked at it together. V6 stated she could tell the bruise was old by the color of it. V27 stated she did a full body assessment at the time and there were no other bruises noted. V27 stated she reported the bruise to V28, MD but he didn't really address it because he was more concerned with R21's high blood sugar readings and addressed those but disregarded the report of the bruise. V27 stated she is a new nurse, having just completed her boards in October, and that is why she asked V6 to assess the bruise on R21's breast because V6 had more experience. V27 stated R21 did appear to have pain with movement of her arm and leg so they took precautions of not lifting her arms during care. On 12/28/23 at 9:00 AM, V6 DON stated she does not remember the nurse showing her the bruise on R21's breast on 12/14/23 but stated she is not stating it didn't happen, she just doesn't remember because she has been so busy. V6 stated if she did see it she should have reported it to V1 immediately and an investigation should have been started right away. On 12/28/23 at 9:24 AM during phone interview, V29, CNA stated she did see bruise on R21's breast and on her right side above her hip, under her arm. V29 stated she did not see any bruises in R21's vaginal area or rectal area. V29 stated she did not remember exact date, but it was on 2 PM to 10 PM shift and she reported it to the nurse (could not remember her name). V29 said she and another nurse went to assess R21. V29 stated nobody asked her anything about it since she first reported it to the nurse. The facility's policy, Reporting of Abuse, Neglect, Theft and Crimes revised 2/2023 documents, Policy: It is the policy of this facility to establish internal reporting guidelines for facility staff in the event they become aware or formulate a reasonable suspicion that abuse, neglect, mistreatment, including injuries of unknown source, exploitation, theft or a crime has been committed against a resident of the facility. Policy Guidelines and Interpretation: 1. Internal Reporting: a. All covered individuals are required to immediately report any occurrences of potential mistreatment, abuse, neglect, mistreatment, including injuries of unknown source, adverse events, exploitation, theft, or crimes committed against a resident that they observe, hear about, or suspect to the administrator or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in administrator's absence. External Reporting: a. Upon receipt of an allegation or upon the formulation of a reasonable suspicion that abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, theft or that a crime has occurred against a resident, the facility Administrator or his/her designee will initiate external reports to the following: i. the Department: 1. The Administrator or his/her designee will immediately contact the department. ii. Law Enforcement: The facility will immediately contact local law enforcement authorities in the following situations: 2. Sexual abuse of a resident or the reasonable suspicion that sexual abuse has been committed by a staff member, another resident, or a visitor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to operationalize their abuse policy and thoroughly investigate bruises of unknown origin for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30. Findings include: 1. On 12/27/23 at 10:06 AM, V20 Certified Nursing Assistant (CNA) and V21 CNA provided incontinent care for R20 who had been incontinent of urine and feces. They unfastened R20's adult diaper and V21 used disposable wipes to wash away feces from R20's labia, groin and inner thighs. After feces was removed, there were two curved deep purple lines on her inner thighs where the diaper's elastic had been. It was bruised and did not fade after diaper removed. They then rolled R20 onto her right side and V21 cleansed the feces from her buttocks and rectum. After feces was removed there were two more easily visible dark purple linear bruises on R20's right and left lower buttocks where the elastic from the diaper was. These were bruises and did not fade after diaper removed. V21 stated, Those are from the diaper being too tight. I am leaving the diaper off and am going to report them to my charge nurse and the wound nurse. I am not going to put any cream on them until they look at these bruises because they won't be able to see them good with the cream on them. She doesn't need to be wearing a diaper and I am only going to leave the pad under her. R20's Face Sheet documents her diagnoses to include Rectal Cancer, Chronic Obstructive Pulmonary Disease, Anxiety, and Alcohol Abuse. R20's Minimum Data Set (MDS) dated [DATE] documents R20 is moderately cognitively impaired, has impaired range of motion to both lower extremities, is dependent on staff for toileting and transfers and assist with bed mobility, and is incontinent of bowel and bladder. R20's undated Care Plan documents: (R20) is at risk for skin breakdown and/or pressure ulcer formation d/t (due to) decreased mobility and bowel incontinence. No reddened or opened areas noted at present. Goal: will remain free of reddened or open areas through next review date. Interventions: Assist with T&P (Turning and Positioning) Q (every) 2 hrs. while in bed for pressure relief. Barrier cream after each episode to peri-area. Cushion to wheelchair. Pressure relief mattress to bed. Prompt incontinent care after each episode. Skin checks weekly. R20's Progress Note dated 12/25/2023 at 12:49 PM documents, C hall CNA report bruise this shift. Resident has bruise to the inner thigh left and right /front to back red in color shape of a line. Look like it may been produced by pulling of a depend. three small bruises on back red in color. Wound nurse made aware and ADON (Assistant Director of Nursing). There was no documentation of investigation of cause of these bruises or notification of Administrator, Family or Doctor. R20's Progress Note dated 12/27/2023 at 12:21 PM documents, Skin/Wound Note (HC): resident has a discoloration line from her right groin around her right buttock from her brief. hospice notified and new orders to cleanse area with NS (normal saline) or WC (wound cleanser), apply Calmoseptine and leave open to air, do not strap on brief. Monitor for s/s (signs and symptoms) of infection and notify md (medical doctor) if present. POA (Power of Attorney) and physician notified. There was no documentation of the bruises to R20's left groin and left buttock. 2. R21's Face Sheet documents her diagnoses to include Anemia, Hypertension, End Stage Renal Disease, Diabetes Mellitus, Hyperlipidemia, Alzheimer's Disease, Anxiety, and Depression. R21's MDS dated [DATE] documents she is severely cognitively impaired, dependent on staff for all Activities of Daily Living (ADLS). It documents staff propel her in her w/c and she is always incontinent of bowel and bladder. Per the assessment, R21 had no pressure ulcers or falls during this assessment look back. R21's Progress Note dated 12/14/23 at 5:42 PM documents, Checked resident blood sugar @4:32 PM level at 548. 15 units given per sliding scale, rechecked at 5:40 PM level at 529. Called (V28, Medical Doctor), per phone order he directed this nurse to give resident 8 units of lispro and recheck blood sugar in 2 hours. This nurse repeated order back to physician and he confirmed. Also notified physician of patient having edema on right leg and bruising under left breast that appears dark purple. Resident leg and left arm are in pain when moved. Will continue to monitor resident, she is in bed with call light in reach. There is no documentation of notification of Administrator regarding bruise of unknown origin under R21's left breast. On 12/26/23 at 9:36 AM, V31, Hospital Wound Nurse stated R21 had been discharged from the hospital on [DATE] and readmitted to the hospital on [DATE]. V31stated there were pictures taken in the hospital of a bruise on R21's left lateral breast that were taken on 12/16/23. V31 stated it was more on the rib side of breast. V31 stated there were also pictures of bruises on R21's labia on 12/18/23, two days after she was admitted to the hospital. V31 stated the facility did not send any information regarding bruises or pressure ulcers when resident was admitted to hospital on [DATE]. V31 stated R21 was admitted with COVID and Altered Mental Status. V31 stated she saw R21 on 12/18/23 in the afternoon and saw deep purple-red bruises on R21's labia about a third of the way down her labia, area behind her vagina, up to rectum and some bruising around her rectum. V31 stated there was an area about midway down her thigh that could have been an abrasion that could have been from picking or if her diaper had been on too tight. V31 stated when she was trying to look at the bruises, R21 kept trying to pull the blanket back up and stated she has had other residents/patients do this when being examined and could be s/s of trauma or not. On 12/26/23 at 12:44 PM, V6, Director of Nursing (DON) stated she does not have any other abuse investigations or investigations of bruises of unknown origin in the last three months besides a resident-to-resident altercation between R29 and R30. The investigation regarding possible sexual abuse towards unknown resident by unknown staff that was reported to her on 12/21/23 by a surveyor. On 12/27/23 at 11:55 AM, V6, DON and V25, MDS Coordinator came in to talk to writer and had V1, Administrator on speaker phone on V6's cell phone. V1 stated the bruise on R21's breast was not reported to either of them or V2, Assistant Director of Nursing (ADON). V1 stated if it had been reported she would have sent in the initial report to IDPH (Illinois Department of Public Health (IDPH) and started the investigation immediately. V1 stated any bruise of unknown origin is treated that way. On 12/27/23 at 1:30 PM, V6 DON stated, We did have a report of bruises of unknown origin today for (R20) today and have sent the report and started an investigation. V6 stated the police and MD were notified. This investigation was started two days after the bruises were first documented in R20's progress notes on 12/25/23. On 12/27/23 at 1:00 PM, V6 provided the investigation of the allegation of sexual abuse that was presented to them by surveyor on 12/21/23. It documented: Initial Report: 12/21/23: Surveyor reported to this writer that someone complained of an employee sexually abusing a resident. No other details known at this time. Will update when more details are known. Thank you. Investigation started immediately. Final to follow. Police notified. On the back of this document there were handwritten notes that documented: 1:40 PM Attempted to get a hold of local police; could not get through. 2:00 PM Left message. 3:50 pm Left message for ombudsman-out of office. (Local) Police arrived 12/21/23 4:05 PM to get report from this writer. V6 stated all alert and oriented residents were interviewed during investigation, but no staff were interviewed because V6 and V1 felt this may have been called in by a disgruntled employee. V6 stated all the residents interviewed stated no one had been inappropriate towards them or touched them inappropriately. On 12/27/23 at 1:48 PM, V6 stated V1 Administrator had talked to a few of the department heads, including V6 but had not interviewed any nurses or CNAs yet regarding the allegation of sexual abuse related to the complaint. On 12/27/23 at 5:45 PM, V27 Licensed Practical Nurse (LPN) stated she documented a bruise was noted on R21's breast on 12/14/23. V27 stated a CNA was changing R21 and saw the bruise and reported this to V27. V27 stated V6 (DON) was working, and she asked her to look at the bruise and stated they went in and looked at it together. V6 stated she could tell the bruise was old by the color of it. V27 stated she did a full body assessment at the time and there were no other bruises noted. V27 stated she reported the bruise to V28, MD but he didn't really address it because he was more concerned with R21's high blood sugar readings and addressed those but disregarded the report of the bruise. V27 stated she is a new nurse, having just completed her boards in October, and that is why she asked V6 to assess the bruise on R21's breast because V6 had more experience. V27 stated R21 did appear to have pain with movement of her arm and leg so they took precautions of not lifting her arms during care. On 12/28/23 at 9:00 AM, V6 DON stated she does not remember the nurse showing her the bruise on R21's breast on 12/14/23 but stated she is not stating it didn't happen, she just doesn't remember because she has been so busy. V6 stated if she did see it she should have reported it to V1 immediately and an investigation should have been started right away. On 12/28/23 at 9:24 AM during phone interview, V29, CNA stated she did see bruise on R21's breast and on her right side above her hip, under her arm. V29 stated she did not see any bruises in R21's vaginal area or rectal area. V29 stated she did not remember exact date, but it was on 2 PM to 10 PM shift and she reported it to the nurse (could not remember her name). V29 said she and another nurse went to assess R21. V29 stated nobody asked her anything about it since she first reported it to the nurse. The facility's policy, Abuse Prevention Program, revised 2/2023 documents, Purpose: This facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. This facility therefore prohibits acts of mistreatment, neglect, and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. Under Definitions, the policy documents, Injuries of Unknown Source are defined as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the sources of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (for example the injury is located in an area not generally vulnerable to trauma) ore the number of injuries observed at one particular point in time or the incidence of injuries over time. 4. The facility will develop and implement policies and procedures to assist in the identification and reporting of events, trends, and patterns that may constitute abuse or that may require further investigation. 5. Facility staff will investigate and report any allegations of abuse within timeframe's required by Federal law. 7. Any allegation of abuse will be reported immediately to the facility administrator or his/her designee who will follow Federal requirements for reporting to the following entities: a. State Licensing agency responsible for licensure of the facility, b. Law enforcement officials, c. The resident's representative, d. The resident's primary physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was sufficient nursing staff resulting in 6:00 AM medications not being passed for 6 of 10 residents (R1, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30. This failure has the potential to affect all 83 residents residing in the facility. Findings include: 1. R1's Face Sheet, dated 12/19/23, documents R1 has diagnoses of pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, end stage renal disease, and dependence on renal dialysis. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision/or touching assistance with oral hygiene, personal hygiene, eating, dependent with toileting hygiene, toilet transfer, tub/shower transfer, and substantial/maximal assistance with shower/bathe. R1 is always incontinent of bowel and bladder. R1's Physician's orders reviewed on 12/11/23, documents R1 is to get the following medications at 6:00 A: Protonix 40 milligrams (mg), Gabapentin 100mg, Sevelamer 800mg, Calcium Carbonate 500mg two tabs, Dextran 70-Hypromellose Ophthalmic Solution 0.1-0.3 % one drop to both eyes, Acetaminophen 500mg, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. R1's Medication Administration Record (MAR), for the month of December documents 9 (see nurses notes) on all his 6:00 AM medications on 12/11/23. R1's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 2. R3's Face Sheet, dated 12/19/23, documents R3 has diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, seizures, and hypertension (HTN). R3's MDS, not dated, documents R3 is severely cognitively impaired and is dependent on staff for all her ADLs including assisting with meals (eating). R3 is always incontinent of bowel and bladder. R3's Physician's Orders reviewed on 12/11/23, documents R3 is to receive the following 6:00 AM medications, Escitalopram 5mg, Furosemide 20mg, Omeprazole suspension 20mg, Eliquis 5mg, Keppra solution 100mg/milliliter (ml) dose of 5ml, Metoprolol 100mg, and Vimpat solution 10mg/ml dose of 10ml. R3's MAR, for the month of December 2023, documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R3's Progress notes, dated 12/11/23, documents No nurse available to pass medications. 3. R12's Face Sheet, dated 12/19/23, documents R12 has diagnoses of pneumonia, venous insufficiency, urinary tract infection, and acute kidney failure. R12's MDS, not dated, documents R12 is cognitively intact and is dependent on staff for most of her activities of daily living (ADLs). R12's Physician's Orders, were reviewed on 12/12/23, and documents R12 is to receive the following 6:00 AM medications: Baclofen 5mg and Gabapentin 100mg. R12's MAR, for the month of December 2023 documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R12's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 4. R13's Face Sheet, dated 12/19/23, documents R13 has diagnoses COVID-19, dementia, and HTN. R13's MDS, not dated, documents R13 is severely cognitively impaired supervision or touching assistance with transfer, toilet hygiene, shower, and bath, independent with dressing, bed mobility, and sit to stand. R13's Physician's Orders documents R13 is to receive the following 6:00 AM medication: Levothyroxine 25 micrograms (mcg). R13's MAR, for the month of December 2023 documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R13's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 5. R19's Face Sheet, dated 12/19/23, documents R19 has diagnoses dementia and cerebral infarction. R19's MDS, not dated, documents R19 is severely cognitively impaired and is dependent on staff for most of her ADLs. R19's Physician's Orders, were reviewed on 12/19/23, and documents R3 is to receive the following 6:00 AM medications, Famotidine 20mg and Lidoderm patch 5%. R19's MAR, for the month of December 2023, was reviewed and documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R19's Progress notes, dated 12/11/23, documents no nurse available to pass medications. 6. R20's Face Sheet, dated 12/19/23, documents R20 has diagnoses fracture of unspecified part of neck of left femur, fracture of upper end of left humerus, and chronic obstructive pulmonary disease. R20's MDS, not dated, documents R20 is moderately cognitively impaired and is dependent on staff for showering, dressing, and personal hygiene. R20's Physician's Orders documents R20 is to receive the following 6:00 AM medications: Lidoderm patch 5% and Meclizine 25mg. R20's MAR, for the month of December 2023 documents 9 (see nurses notes) on all her 6:00 AM medications on 12/11/23. R20's Progress notes, dated 12/11/23, documents no nurse available to pass medications. On 12/20/23 at 12:57 PM, V9, Interim Director of Nursing (DON) stated she would expect the scheduled meds to be passed on time and to all the residents. The facility's Daily staffing summary policy, with revision date of 06/03/23, documents Policy: It is the goal of the facility to meet or exceed nursing staff levels required to provide quality care to our residents. The CMS-671, dated 12/21/23 at 9:53 AM, documents there are 83 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to ensure staff maintained an infection prevention and control program to help prevent the development and transmission of a communicable disease by staff not donning appropriate personal protective equipment (PPE) before entering a COVID positive resident's room, failed to have the correct signage in place for residents who were COVID positive, failed to provide bio-hazard receptacles in resident's rooms close to the door for proper discarding of PPE, failed to properly sanitize blood glucose monitors and failed to adhere to proper hand hygiene practices. This failure has the potential to affect all 83 residents residing at the facility. Findings include: On 12/13/23 at 8:35 AM, R7's and R10's room which is a COVID-19 isolation room was observed and there was an isolation sign on the door that documented droplet isolation (keep door closed), the door was observed open at this time, and there were no bio-hazard bins observed in the room at this time. On 12/13/23 at 8:37 AM, R8's room, a COVID-19 room, was observed to be an isolation room. There was an isolation sign on the door that said, 'contact isolation'. There was no droplet signage observed on the door or on the wall beside the room. There were no bio-hazard bins for trash or soiled linen observed in the room, the door to the room was open, and there was a yellow disposable gown observed in the regular trash receptacle in the room. On 12/13/23 at 8:38 AM, R9's and R11's room which is a COVID-19 room, was observed to have a contact isolation sign hanging on the door. There was no droplet signage noted. There were no bio-hazard receptacles for trash or linen noted to be in the room and the door to the room was observed to be open at this time. On 12/13/23 at 8:40 AM, R14's room is a COVID-19 room, was observed to have only a contact isolation sign on the door. The door was observed to be open, and there were bio-hazard receptacles observed in the room, but they were located across the room by the sink and not by the door. On 12/13/23 at 9:42 AM, V11, Housekeeper was observed mopping R8's room with only a surgical mask on. V11 did not have on a gown, gloves, eye protection, or a N95 mask. V11 brought out the mop and rinsed it in the mop bucket then she went back into R8's room and mopped the rest of the floor. After V11 was done mopping the room, she then left the room without removing her mask, or gloves. V11 then went to her housekeeping cart and changed her gloves without performing any type of hand hygiene. On 12/13/23 at 9:46 AM, After finishing in R8's room V11, housekeeper went across the hallway into another room which did not have of any residents in it at this time and emptied the trash and mopped the floor with the same water. On 12/13/23 at 9:51 AM, V11, housekeeper then went into R14's room with no gown, gloves, eye protection, or N95 mask. V11 was observed still wearing the same mask she wore into R8's room. V11 did not perform hand hygiene or change her mask before leaving the room. On 12/13/23 at 9:54 AM, V11, housekeeper was observed leaving the 600 hallway. On 12/13/23 at 10:02 AM, V11, housekeeper was observed leaving the 200 hallway, which is on the other side of the building from the 600 hallway. V11went back down the 600 hallway and back into a room with no residents residing in it. On 12/13/23 at 10:12 AM, V11, housekeeper was observed leaving the 600 hallway again and was observed going to D (400) hallway. On 12/14/23 at 8:14 AM, V12, Licensed Practical Nurse (LPN) was observed giving insulin to R15 without wearing any gloves. On 12/14/23 at 8:19 AM, V12, LPN was observed wiping her hands off with a sanitation cloth and donning her gloves prior to obtaining R16's blood sugar. After obtaining R16's blood sugar V12 went to the medication cart, placed the glucometer on top of the cart without sanitizing it and retrieved R16's Novolog and Glargine insulin pens from one of the medication cart drawers wearing the same gloves. V12 proceeded to get the insulin pen needles and place them on the insulin pens after cleaning off the tops of the insulin pens. Wearing the same gloves V12 then went back into R16's room and gave R16 both of her insulin injections. When V12 finished giving R16 her insulin V12 went back to the medication cart and put R16's insulin pens back into the medication cart drawer. With the same gloves on V12 then pushed the medication cart down to R17's room. On 12/14/23 at 8:24 AM, V12, LPN was observed still wearing the same gloves from the previous resident. V12 touched the computer mouse with the dirty gloves and pulled up R17's medication information. V12 then got into the medication cart with the same pair of gloves and retrieved R17's insulin pen and needle. After preparing the insulin pen, V12 went into R17's room, cleansed R17's right lower abdomen and injected the insulin wearing the same dirty gloves. When V12 was finished giving R17's insulin she went back out to the medication cart and put R17's insulin pen back into the medication cart. V12 then got back into the computer and marked where she had given the insulin, and she continued to wear the same dirty gloves. On 12/14/23 at 8:31 AM, Wearing the same dirty gloves V12, LPN pushed the medication cart down to R18's room. V12 cleaned off the top of the medication cart and placed the glucometer, that had not been cleaned, back into the top drawer of the medication cart. V12 then removed the gloves and wiped her hands off with a sanitation wipe. On 12/19/23 at 2:39 PM, V9, Infection Preventionist stated there are 45 residents who are COVID-19 positive at this time. V9 said there are some that will be coming off isolation soon. V9 stated she would expect housekeeping who went into an COVID isolation room to have on gown, gloves, N95 mask, and eye protection. V9 said everyone who is on isolation for COVID-19 should also be on droplet precautions. On 12/21/23 at 8:40 AM, V15, Housekeeping and Laundry Supervisor stated it would depend on what type of isolation the resident was in on what PPE they would wear. V15 said if it was contact isolation, and the housekeepers would not have any contact with the resident then the housekeeper wouldn't need to use a gown. V15 stated if it was a resident who was on isolation for COVID he would expect the housekeeper to wear full PPE (gown, gloves, mask, and eye protection). On 12/26/23 at 9:55 AM, V2, Assistant Director of Nursing (ADON) stated she believes each of the medication cart has two glucometers on them so they would have one to use while the other one is being cleaned. V2 said she would expect the nurses to follow the infection control policy and what was in the instruction manual. The facility's COVID-19 Prevention and Control policy, revision date of 05/11/23, documents Policy: It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents, employees and visitors with Clinical Features and a Epidemiologic Risk for the COVID-19, RSV, and Flu, and to adhere to recommended prevention and transmission precautions. It further documents Health care workers must use proper PPE when exposed to a resident with suspected or confirmed COVID-19. If a resident is suspected or confirmed to have COVID-19 or other respiratory illnesses, at a minimum, HCP must wear an N95 respirator, eye protection, gown, and gloves. If the facility is experiencing an outbreak of COVID-19 or other respiratory illnesses, at a minimum, HCP must wear a well fitted mask while on the unit or floor experiencing an outbreak. In addition, facility may consider requiring an N95 respirator and eye protection (goggles, or a face shield) during all resident care, on the affected unit or floor. It further documents Hand Hygiene Hand Hygiene is a core infection control prevention measure and should be performed frequently to reduce the spread of organisms and the virus that causes COVID-19. It also documents Management of Positive Residents Facilities are not required to have a dedicated COVID-19 unit unless the number of positive residents would warrant such a unit. If residents can be safely managed in the general population, a facility can place a COVID-19 positive resident in a single room with appropriate isolation signage, and staff wearing N95 respirator, eye protection, gown, and gloves upon entry to room. The blood glucose monitoring system owner's manual version 1.0 dated January 2020, documents Take care of your meter and strips to avoid the meter and test strips getting dirt, dust or other contaminants, please wash and dry your hands thoroughly before use. Cleaning 1. Tol clean the meter exterior, wipe with a cloth moistened with tap water or a mild cleaning agent, then dry the device with a soft and dry cloth. Do not flush with water. 2. Do not use organic solvents to clean the meter. The CMS-671, dated 12/21/23 at 9:53 AM, documents there are 83 residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy on the reporting of the allegation of injuries of unknown origins for resident (R2). This failure had the potential to affect one resident (R2) one in a sample of one. Findings include: R2's Face Sheet undated documents, medical diagnosis as Altered Mental Status, Amnestic Disorder due to Known Physiological Condition, Encephalopathy, Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with /Routine Healing, alcohol Use Unspecified with Withdrawal Delirium. R2's Minimum Data Set, (MDS), dated [DATE] documents R2's Cognitive Skills for Daily Decision-Making Skills is severely impaired. R2 is totally dependent for bed mobility, transfer, locomotion on and off unit, dressing, eating, personal hygiene and bathing. R2 is incontinent of bowel and bladder. A skin Incident report dated 8/18/23 9:12 AM documents, a CNA noticed bruising and cuts on the right and left forearm of R2. Areas are dry no bleeding, but reddish in color. R2 unable to voice what happen. No injuries observed at time of incident, R2 wheelchair bound, oriented to person; no injuries observed post incident; predisposing physiological factors confused: incontinent, impaired memory; no predisposing situation factors and no witnesses. R2's Skin Incident Report dated 8/18/23 at 9:41 AM documents, R2 was noticed with abrasion on left and right arms with bruising. Resident unable to voice description of what happened. Injury Type: Abrasion-Location: Right antecubital. Injury type not selected- Location: top of scalp, Injury type: Hematoma. Injury location- right antecubital. Mental status-oriented to self; no injuries observed post incident. No witnesses found. Nurse's Progress Notes dated 8/18/2023 09:33 AM Patient was up in chair at nurses' station and was notice by CNA, the abrasions and bruising on patient. Patient has about a four-inch abrasion on left forearm that had been bleeding but dry blood and intact. She also has on left forearm several bruising. On the right-side forearm, she has an inch abrasion the has dry blood and intact not bleeding and couple of bruising on arm. Patient continues to toss and turn in chair when touch. Nurse's Progress Notes dated 8/18/2023 09:47 documents, Patient was noticing this morning before going to breakfast she has abrasion on left forearm about four inches with dry blood on abrasion and now dry intact and several bruising on the left arm. She also, has an inch abrasion on right forearm and couple of bruising on forearm. She has no other bruising, abrasion on body. She continues to throw self around in chair when touch. On 8/25/23 at 3:30 PM V1 Administrator stated, I was unaware R2 suffered an injury. Did you check with (V2) to see if she investigated? On 8/25/23 at 3:35 PM V2 DON presenting the Skin incident reports stated, we did conduct the investigation. We knew the bruising was from her thrashing about and took methods to prevent further injury. The facility's policy on Abuse, Neglect, Theft and Crimes Investigation, effective date 01/01/2012, last revision date 2/23, documents, the facility does not condone any form of resident abuse. The facility will take all reports of resident abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, theft, or other criminal actions against its residents seriously and will attempt to investigate allegations with the intent of detecting any wrongdoing, determining causative factors and, when indicated implementing corrective actions to prevent reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide evidence, that the allegation of injuries of unknown origin was investigated. This failure affected 1 resident (R2) in a sample of 1. This failure exposed (R2) to potential harm and further injury. Findings include: R2's Face Sheet undated documents, medical diagnosis as Altered Mental Status, Amnestic Disorder due to Known Physiological Condition, Encephalopathy, Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with /Routine Healing, alcohol Use Unspecified with Withdrawal Delirium. R2's Minimum Data Set, (MDS), dated [DATE] documents R2's Cognitive Skills for Daily Decision-Making Skills is severely impaired. R2 is totally dependent for bed mobility, transfer, locomotion on and off unit, dressing, eating, personal hygiene and bathing. R2 is incontinent of bowel and bladder. A skin Incident report dated 8/18/23 9:12 AM documents, a CNA noticed bruising and cuts on the right and left forearm of R2. Areas are dry no bleeding, but reddish in color. R2 unable to voice what happen. No injuries observed at time of incident, R2 wheelchair bound, oriented to person; no injuries observed post incident; predisposing physiological factors confused: incontinent, impaired memory; no predisposing situation factors and no witnesses. R2's Skin Incident Report dated 8/18/23 at 9:41 AM documents, R2 was noticed with abrasion on left and right arms with bruising. Resident unable to voice description of what happened. Injury Type: Abrasion-Location: Right antecubital. Injury type not selected- Location: top of scalp, Injury type: Hematoma. Injury location- right antecubital. Mental status-oriented to self; no injuries observed post incident. No witnesses found. Nurse's Progress Notes dated 8/18/2023 09:33 AM Patient was up in chair at nurses' station and was notice by CNA, the abrasions and bruising on patient. Patient has about a four-inch abrasion on left forearm that had been bleeding but dry blood and intact. She also has on left forearm several bruising. On the right-side forearm, she has an inch abrasion the has dry blood and intact not bleeding and couple of bruising on arm. Patient continues to toss and turn in chair when touch. On 8/25/23 at 3:30 PM V1 Administrator stated, I was unaware R2 suffered an injury. Did you check with (V2) to see if she investigated? On 8/25/23 at 3:35 PM V2 DON presenting the Skin incident reports stated, we did conduct the investigation. We knew the bruising was from her thrashing about and took methods to prevent further injury. The facility's policy on Abuse, Neglect, Theft and Crimes Investigation, effective date 01/01/2012, last revision date 2/23 documents within twenty-four hours following the occurrence/allegation a written report shall be sent to the Department unless it was originally submitted with or as the initial report. The written report can be in a standardized format but should contain the following information, if known at the time of the report: i. Name, age, diagnosis, and mental status of the resident allegedly abused, neglected or the alleged victim of the report. ii. Type of event/crime reported (physical, sexual, mistreatment, including injuries of unknown origin, exploitation, theft, neglect, verbal, or mental abuse). iii. Date, time, location, and circumstances of the alleged incident iv. Any obvious injuries or complaints of injury v. Names of the individual(s) reporting the event or formulating the reasonable suspicion that a crime was committed against a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess and/or develop, a baseline Care Plan to furnish to attain or maintain residents' highest practicable physical, mental and psychosocial well-being for 1 of 1 resident (R2) Findings include: R2's Face Sheet undated documents, R2 was admitted on [DATE] with medical diagnosis of Altered Mental Status, Amnestic Disorder, due to Known Physiological Condition, Encephalopathy, Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with /Routine Healing, Alcohol Use Unspecified with Withdrawal Delirium. R2's Minimum Data Set, (MDS), dated [DATE] documents, R2's Cognitive Skills for Daily Decision-Making Skills is severely impaired. R2 is totally dependent for bed mobility, transfer, locomotion on and off unit, dressing, eating, personal hygiene and bathing. R2 is incontinent of bowel and bladder. R2's Nurses' Progress Notes dated 8/20/23 documents, that R2 was sent to the emergency room of a local hospital on 8/20/23 and was subsequently admitted , until her (R2) discharge to another facility on 8/23/23. On 8/24/23 V2 Director of Nursing, (DON), stated, the admission nurse completes the Care Plan and that she (V2) would need to check with the MDS Coordinator about the Comprehensive Care Plan and the updates. The facility did not have a baseline care plan for R2. The facility did not provide a policy on Care Plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate use of Antibiotics to treat a Urinary Tract Infection, (UTI), for four (R5, R6, R8 and R20) of five residents reviewed for unnecessary medication use in the sample of 18. Findings include: The undated, Facility Antibiotic Audit Log documents, the orders for Antibiotics for Urinary Tract Infections from 5/31/23 to 8/8/23. 30 residents were documented, as having a UTI, however, 5 did not have Organisms documented on the Antibiotic Audit log. According to the facility's Antibiotic Audit Log, R5 was placed on the Antibiotic, Ceftriaxone for a UTI on 7/12/23. No Organisms were documented. R5s Face Sheet undated documents, diagnosis as Chronic Obstructive Disorder, chronic embolism and Thrombosis of Unspecified Vein, Hyperlipidemia, Unspecified, Congenital Mitral Insufficiency, Pleural Effusion not elsewhere classified, Essential (primary) Hypertension. R5's Minimum Data Set, (MDS), dated [DATE] documents, Cognitive Skills for Daily Decision Making is moderately impaired. R5 is frequently incontinent of bowel and occasionally incontinent for bowel. R5 is not on a bowel or bladder toileting program. No Antibiotics are documented, as a medication that R5 received and no UTI's in the last 30 days were documented. R5's Physician Order Summary, dated 07/01/2023-07/30/23 documents, orders for Cephalexin Oral Capsules, (Cephalexin), 500 mg capsule by mouth four times as for UTI for 7 days. Order date: 7/11/2023. Start date: 7/12/23; Ceftriaxone Sodium Solution Reconstituted 1 GM. Inject 1 gram intramuscularly, (IM), STAT, (Immediately), for UTI. Order date: 8/22/23, Start date: 8/22/23. Urinalysis with Culture and Sensitivity, (C&S), was ordered on 7/12/23 with a discontinue date of 8/16/2023. R5's Physician Order Summary dated 08/01/23-08/31/23 did not document, any orders for Antibiotics. Urinalysis with Culture and Sensitivity was ordered on 8/16/23 with no discontinue date. R5's Electronic Medication Administration Record, (eMAR), dated July 2023 documents, 28 out of 28 doses of Cephalexin 500 milligrams, (mg), 1 capsule by mouth, four times per day for 7 days. Start date: 7/12/23. R5's eMAR dated, July 2023 documents, a STAT order for Ceftriaxone Sodium Solution Reconstituted 1 GM. Inject 1 gram Intramuscularly STAT for UTI. Order date: 8/22/23, Start date: 8/22/23. No doses were given for the month of July. R5 eMAR dated, July 2023 documents, a Urinalysis with Culture and Sensitivity was ordered on 7/12/23 with a discontinue date of 8/16/2023. No Urinalysis with Culture and Sensitivity were documented, for the month of July. R5's eMAR dated, August 2023 documents, a STAT order for Ceftriaxone Sodium Solution Reconstituted 1 GM. Inject 1 gram intramuscularly STAT for UTI. Order date: 8/22/23, Start date: 8/22/23. R5's eMAR dated, August 2023 documents, a Urinalysis with Culture and Sensitivity was ordered on 8/16/23 with no discontinue date. No Urinalysis with Culture and Sensitivity were documented, for the month of August. Nurse's Progress Notes do not document an Antibiotic Time Out, (ATO). 2. According to the facility's Antibiotic Audit Log, R6 was placed on the Antibiotic, Cephalexin for a Urinary Tract Infection on 7/8/23. No organisms were documented. R6's Face Sheet undated, documents, medical diagnosis as Essential (primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hypokalemia, Anemia, Repeated falls, Displaced Subtrochanteric Fracture of left Femur, Subsequent encounter for Closed Fracture with Routine Healing, other pulmonary embolism with Acute Cor Pulmonale, Acute and Chronic Respiratory Failure with Hypoxia, Heart Failure, unspecified. R6's Minimum Data Set, (MDS), dated [DATE] documents, Cognitive Skills for Daily Decision Making is moderately impaired. R6 is always incontinent of bowel and bladder. R6 is not on a bowel or bladder toileting program. 1 day of Antibiotics documented, as a medication that R6 received and no UTI's in the last 30 days were documented. R6's Physician Order Summary dated, 07/01/2023-07/30/23 documents, orders for Cephalexin Oral Capsules, (Cephalexin), 500 mg capsule by mouth two times a day for UTI until 7/18/23. Order date: 7/7/2023. Start date: 7/8/23. R6's Physician Order Summary dated 08/01/23-08/31/23 did not document, any orders for Antibiotics. R6's Electronic Medication Administration Record, (eMAR), dated July 2023 documents, no doses of Cephalexin 500 milligrams, (mg), 1 capsule by mouth two times per day for UTI were given. Start date: 7/7/23. D'C date: 7/7/23. R6's Electronic Medication Administration Record, (eMAR), dated July 2023 documents, 22 out of 22 doses of Cephalexin 500 milligrams, (mg), 1 capsule by mouth two times per day for UTI. Start date: 7/8/23 until 7/18/23. Nurse's Progress Notes do not document, an Antibiotic Time Out, (ATO). 3. According to the facility's Antibiotic Audit Log, R8 was placed on the Antibiotic, Bactrim 6/28/23 for a Urinary Tract Infection, no organisms were documented. R8s Physician Order Summary, (POS), undated documents, pertinent diagnosis as Tubulointerstitial Nephritis, (Kidney Diseases), Cystitis, Unspecified without hematuria, Type 2 Diabetes Mellitus without complications and Urinary Tract Infections. R8's Minimum Data Set, (MDS), dated [DATE] documents, Cognitive Skills for Daily Decision Making is moderately impaired. R8 is always incontinent of bowel and bowel. R8 is not on a bowel or bladder toileting program. No Antibiotics are documented, as a medication that R8 received and R8 has had UTI's in the last 30 days. R8's Physician Order Summary dated on or after 6/1/23 documents, orders Urology consult re: frequent UTI per hospital discharge recommendations-notify Provider of time/date. Order date:6/19/23; orders for Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give for 7 days 1 tablet by mouth, one time only for UTI for 7 days. Order date 6/15/23. Start date: 6/16/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet by mouth, two times per day, for UTI for 6 days. Order date 6/17/23. Start date: 6/17/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth every 12 hours, for Bacterial Infection for 14 days. Order date 6/27/23. Start date: 6/28/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth every 12 hours, for Bacterial Infection for 5 days, was ordered prior to Surgery and 14 days-will complete on 7/12/23. Order date 7/7/23. Start date: 7/7/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth, two times per day for 14 days. Start 7 days before procedure. Order date 7/6/23. Start date: 7/6/23. R8's Physician Order Summary dated, on or after 6/30/23 documents, orders for Urology consult re: frequent UTI per hospital discharge recommendation- notify Provider. Order date 6/19/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth every 12 hours, for Bacterial Infection for 14 days. Order date 6/27/23. Start date: 6/28/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth every 12 hours, for Bacterial Infection for 5 days, was ordered prior to Surgery and 14 days-will complete on 7/12/23. Order date 7/7/23. Start date: 7/7/23; Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth two times per day, for 14 days. Start 7 days before procedure. Order date 7/6/23. Start date: 7/6/23. R8's Electronic Medication Administration Record, (eMAR), dated, May 2023 documents, 1 out of 1 dose of Bactrim DS Oral Tablet 500 milligrams, (mg), 1 tablet by mouth, two times per day for UTI. Start date: 5/31/23. D'C date 6/13/23. R8's Electronic Medication Administration Record, (eMAR), dated, June 2023 documents, 23 out of 23 doses of Bactrim DS Oral Tablet 500 milligrams, (mg), 2 capsules by mouth, two times per day for UTI. Start date: 5/31/23. D'C date 6/13/23. R8's Electronic Medication Administration Record, (eMAR), dated June 2023 documents, 12 out of 12 doses of Bactrim DS Oral Tablet 500 milligrams, (mg), 1 tablet by mouth, two times per day, for UTI for 6 days. Start date: 5/31/23. D'C date 6/13/23. Nurse's Progress Notes do not document, an Antibiotic Time Out, (ATO). R8's Electronic Medication Administration Record, (eMAR), dated June 2023 documents, 1 out of 1 dose of Bactrim DS Oral Tablet 500 milligrams, (mg), 1 tablet by mouth, one time only for UTI for 7 days. Start date: 6/16/23. D'C date 6/17/23. R8's Electronic Medication Administration Record, (eMAR), dated July 2023 documents, 10 out of 11 doses of Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet, by mouth every 12 hours, for Bacterial Infection for 14 days. Start date: 6/28/23, D'C date: 7/6/23. R8's Electronic Medication Administration Record, (eMAR), dated July 2023 documents, 10 out of Bactrim, (Sulfamethoxazole-Trimethoprim), 800-160 milligrams, (mg), Give 1 tablet by mouth, two times per day for 14 days. Start 7 days before procedure will complete on 7/12/23. Start date: 7/7/23. 4. R22's Physician Order Summary, (POS), undated on documents, R20's pertinent medical diagnosis as Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms and Chronic Kidney Disease, stage 3A. R22's Minimum Data Set, (MDS), dated [DATE] documents, R20's Cognitive Skills for Daily Decision Making is modified independence; has an indwelling catheter; is occasionally incontinent for bowel and bladder; has no UTI's in the last 30 days and has not received any Antibiotics during the last 7 days. According to the facility's Antibiotic Audit Log, R22 was placed on the Antibiotics, Doxycycline and Ceftriaxone for a Urinary Tract Infection on 6/2/23 and 6/3/23, respectively. No organisms were documented. R22's hospital records dated 5/31/23- 6/1/23 documents, R22 was diagnosed with Urinary Tract Infection and placed on Ceftriaxone 50 milliliters, (mL), 1 gram in 50 ml of Normal Saline for 10 days and Doxycycline 100 milligram, (mg), every 12 hours for 10 days. R22 was released pending Urine Culture and Sensitivity results. R22's Nurse's Progress Notes dated 6/1/23 documents, R22 returned to the facility with Culture and Sensitivity lab results pending. R22's Nurse's Progress Notes do not document, an Antibiotic Time Out, (ATO). On 8/25/23 at 2:45 PM V15 Infection Control RN stated, some of the residents come into the facility already on Antibiotics or from the hospital on Antibiotics. The Culture and Sensitivity reports are requested, but they are not always received. On R12 the organism is listed in the Doctor's notes, but I do not have the actual report. On 8/25/23 at 3:00 PM V2 Director of Nursing, (DON), stated, she is aware of the need for Culture and Sensitivity, before the prescribing of Antibiotics, but have allowed the Infection Control Nurse take care of that, since she had taken on the scheduling of staff. The facility's policy on Antibiotic Stewardship Program dated v.2017.10 documents, Actions To Improve Use: Cultures will be obtained to ensure appropriate diagnoses when possible. An antibiotic review process called an antibiotic time out, (ATO), will be done for each resident who has received an order for Antibiotics prior to the return of the Culture results. The ATO will be done 72 to 96 hours after the initiation of treatment. This will allow the prescribing Practitioner the opportunity to reassess the residents' symptoms, review the Culture and Sensitivity report and ensure that the appropriate Antibiotic is prescribed and necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a treatment in place as ordered for a pressure ulcer for 1 of 3 residents (R4) reviewed for pressure ulcers in the sample of 13. Findings include: On 8/11/23 at 1:42 PM V14 (Licensed Practical Nurse/LPN) was standing next to R4's bed and stated she was going to have to put a dressing on R4's left hip per his treatment order. V14 lifted R4's sheet off of him and he had a hand towel draped across his peri area that was saturated with brown colored urine. V14 rolled R4 towards his right side and a small dime size open area with a pink base was observed to his mid-outer left thigh. There was no dressing on the stage 2 pressure ulcer. V14 stated she does not know where the dressing is and that it must have fallen off when he was incontinent. V14 donned gloves and pushed R4 onto his right side and cleansed the pressure ulcer with wound cleanser, then applied a new bordered foam dressing over the area. On 8/11/23 at 1:55 PM, V15 (Certified Nursing Assistant/CNA) stated she had been called in at 10:00 AM, so she does not know who last changed R4 or performed incontinent care. She stated he is in her section, and this is the first R4 will have been changed since she got here. R4's Face Sheet documents his diagnoses to include Hemiparesis and Hemiplegia, Diabetes Type 2, Anemia and Atherosclerotic Heart Disease. R4 Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired and is dependent on staff for all Activities of Daily Living (ADLs). It documents that he is always incontinent of bowel and bladder and had two stage 2 pressure ulcers at the time of that assessment. R4's Care Plan revised 11/11/22 documents R4 has potential/actual impairment to skin integrity. The interventions for this care plan include, Keep R4's skin clean and dry. R4's Physician Order Summary (POS) includes an order dated 7/1/23 which documents Cleanse left hip with wound cleanser and cover with foam dressing every day (QD) and as needed (prn). On 8/15/23 at 11:00 AM, V5 (Wound Nurse) stated hospice just gave the ok for R4 to be seen by the wound doctor. He stated R4's pressure ulcer to his left hip should have a dressing on it. He stated right now they are cleaning it with wound cleanser and covering it with a foam dressing, but the wound physician will evaluate on next visit and will probably change that. V5 stated the staff should let him or the nurse for that hall know if R4's dressing comes off so it can be replaced. On 8/16/23 at 1:25 PM, V1 (Administrator) stated they have a PAR (Patients at Risk) meeting every Thursday. She stated residents who have pressure ulcers are reviewed at this meeting, so she was aware R4 had a small open area on his hip. V1 stated R4's treatment should have been in place as ordered. In an email dated 8/17/23 at 11:43 AM, V5 (Wound Nurse) documents, I looked back at the notes, and it looks like (R4's) hip wound was first noted on 6/21. It was noted as a superficial abrasion at that time and not a pressure ulcer and measured 2.5 centimeters (cm) length by 2.0 cm width and no depth. It doesn't look like any measurements were done in the meantime and it was only brought to my attention last week as he wasn't on the list of residents with wounds that V2 (Director of Nursing/DON) gave me to start with. I agree that it looks like a superficial abrasion that is likely being exacerbated by moisture and not any kind of pressure wound. The last two weeks of measurements I have are: Last week 2.6 cm x2.6 cm x no depth and this week 2.6 cm x 2.5 cm x no depth. The facility's policy, Skin Ulcer-Wound Policy, dated 8/15/18 documents All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations. Purpose: to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations. Skin ulcer prevention: a. Turn and position every two hours as appropriate. e. promotion of clean, dry, and well moisturized skin. 2. If the nurse assesses and determines there is a skin condition present, facility protocol will be followed: 4. Incontinent residents will be checked and changed as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely incontinent care for a dependent resident for 1 of 3 residents (R4) reviewed for incontinence in the sample of 13. Findings include: On 8/11/23 at 1:42 PM, V14 (Licensed Practical Nurse/LPN) was standing next to R4's bed and stated she was going to have to put a dressing on R4's left hip per his treatment order. V14 lifted R4's sheet off of him and he had a hand towel draped across his peri area that was saturated with brown colored urine. On 8/11/23 at 1:55 PM, V15 (Certified Nursing Assistant/CNA) stated she had been called in at 10:00 AM so she does not know who last changed R4 or performed incontinent care. She stated he is in her section, and this is the first R4 will have been changed since she got here. V15 stated, We could not change him at 12:00 PM because it was lunch time. V15 stated, Whoever changed him before I got here must have put the towel over his peri-area. I don't know why they did that. V27 (CNA) walked into R4's room to help with incontinent care and stated, Oh no, I'm not doing this. and left the room, stating she was going to go get her paper signed. V15 (CNA) stated she needed help to turn R4 during incontinent care and left the room to find help. Both V15 and V27 came back into the room a few minutes later. V15 filled a wash basin with warm water and no-rinse peri-wash and put several washcloths in the water. She then washed down R4's right and left groin, folding the washcloth to a clean area between swipes. With each swipe, the washcloth was soiled to a brown color, not feces. V27 cleansed R4's penis and scrotum, with wash cloth again being brown after each area cleansed. V27 assisted R4 to turn onto his right side and V15 cleanses his buttocks and posterior thighs. R4 had fecal material around his rectum and V15 used disposable wipes to cleanse the feces from his rectum. After R4 was clean, V15 dried all areas and placed a dry hand towel over his peri area and covered him with the sheet. After V15 placed the call light within R4's reach and care were completed, surveyor asked V15 what the hand towel over R4's peri-area was for and V15 stated, Oh, did I leave that there. I didn't mean to. She then removed the hand towel from across R4's peri-area and covered him with a sheet. R4's Face Sheet documents his diagnoses to include Hemiparesis and Hemiplegia, Diabetes Type 2, Anemia and Atherosclerotic Heart Disease. R4 Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired and is dependent on staff for all Activities of Daily Living (ADLs). It documents he is always incontinent of bowel and bladder and had 2 stage 2 pressure ulcers at the time of that assessment. R4's Care Plan revised 11/11/22 documents R4 has potential/actual impairment to skin integrity. The interventions for this care plan include, Keep R4's skin clean and dry. Another Care Plan focus in R4's Care Plan documents, R4 has bladder incontinence, and includes the intervention to clean peri-area with each incontinent episode. On 8/16/23 at 1:25 PM, V1 (Administrator) stated she does not understand why they would leave a towel over R4's peri-area after providing incontinent care. V1 stated R4 should be checked for incontinence at least every two hours per the facility's protocol, and if V15 came in at 10:00 AM, R4 should have been checked and changed before 1:30 or 2:00 PM, which was 3.5 or 4 hours later. On 8/17/23, V1 (Administrator) emailed the following when asked for the facility's Incontinence Policy: Bowel and Bladder Incontinence Critical Element Pathway dated 11/2017. This pathway documents, Use this pathway for a resident identified with concerns related to bladder or bowel incontinence. Observations (if a resident is incontinent of bowel or bladder, determine the following: If the resident had an incontinent episode: How long the resident was in wet, soiled clothing, incontinent briefs, or linens before staff changed resident and the condition of the resident's skin (for example, reddened, macerated, or irritated).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that call lights are accessible to residents for 1 of 5 residents (R8) reviewed for accommodations of needs in a sample of 14. Findings include: R8's Physician Order Summary (POS) undated documents R8's diagnoses as Need for Assistance with Personal Care and Unspecified Lack of Coordination. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has severe cognitive impairment, requires extensive assistance in bed mobility, toilet use, transfer, locomotion on and off toilet, dressing, eating (set up only) and personal hygiene. R8's MDS documents R8's balance during transitions and walking are not steady, only able to stabilize with staff assistance in seated to standing position, moving on and off toilet and surface to surface transfer. On 7/26/23 at 1:21 PM, R8 stated you call push the call light, but they won't show up. R8's call light was noted to be wedged between the wall and bed and not accessible to R8. It took moving the bed to get to the call light. On 7/26/23 at 1:35 PM, V2 (Director of Nursing/DON) stated we do training after training because we want our residents needs to be met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respond to call lights to meet residents' needs for 4 of 5 residents (R8, R10, R11, R16) reviewed for residents' rights and dignity in the sample of 14. Findings include: 1. R16's Physician Order Summary (POS) undated documents R16's diagnoses as Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with routine healing, Unspecified; Fracture of Upper End of Left Humerus Subsequent Encounter for Fracture with routine healing; Muscle Weakness (Generalized); History of Falling and Primary Osteoarthritis Unspecified site. R16's Minimum Data Set (MDS) dated [DATE] documents R16 has moderate cognitive impairment and is totally dependent for dressing and toilet use. The MDS documents R16 is occasionally incontinent of bowel and bladder. On 7/27/23 at 4:00 PM, the call light in R16's room was activated. V16 (Certified Nursing Aide/CNA) responded to call light within a minute, went into the room, turned off the call light and came back out. Approximately 2 minutes later, V16 was observed retrieving linen from the linen cart. V16 stated, I told (R16) that I would be back as soon as I finished with the resident in Rm XX. Two other CNAs, V7 and V15, were already noted to be in Rm XX. On 7/27/23 at 4:05 PM, R16 stated, Where is she? I have to go poop! They always cut the light off and say they will be back. 2. R10's Physician's Order Sheet (POS) undated documents R10's diagnoses as Parkinson's Disease, Neuromuscular Dysfunction of bladder and Dysphagia, Oropharyngeal Phase. R10's MDS dated [DATE] documents R10 is cognitively intact and requires extensive of two with bed mobility and is totally dependent for toileting, dressing; personal hygiene and relies on tube feeding for nutrition. On 7/26/23 at 8:30 AM, R10 stated on 7/16, 7/19, 7/20, 7/21 and 7/22/23 staff came into his room and cut his call light off and said they would be back. R10 stated staff did not come back for 30 minutes to 1 hour later. On 7/28/23 at 8:18 AM, V10 ( R10's family) stated, At the last Care Plan meeting, administrator suggested (R10) keep a record of the problems he is encountering. V10 stated she has read R10's journal and throughout R10 has documented staff's refusal to respond to his call light or they would come in his room, cut off the light, and not address R10's needs. 3. R8's Physician Order Summary (POS) undated documents R8's diagnoses as Need for Assistance with Personal Care and Unspecified Lack of Coordination. R8's MDS dated [DATE] documents R8 has severe cognitive impairment and requires extensive Assistance in bed mobility, toilet use. R8's MDS documents R8's balance during transitions and walking are not steady only able to stabilize with staff assistance in seated to standing position, moving on and off toilet and surface to surface transfer. On 7/26/23 at 1:21 PM, R8 stated that you call push the call light, but they won't show up. 4. R11's Physician Order Summary (POS) undated documents R16's pertinent diagnoses as Glaucoma secondary to other eye disorders, unspecified eye, stage unspecified, Systemic Inflammatory Response Syndrome of Non-Infectious origin with Acute Organ Dysfunction. R11's MDS dated [DATE] documents R11 is cognitively intact and requires extensive assistance in bed mobility, toilet use and personal hygiene. R11's MDS documents R11 has occasional bowel and bladder incontinence. On 7/28/23 at 11:40 AM R11 stated due to his eyesight he was unable identify the staff person that was rude to him. R11 states he got upset with the staff person because they came in and cut his call light off and did not return. R11 states he did not report the incident to anyone. On 7/28/23 at 8:11 AM, V17 (Ombudsman) stated call lights have been an on-going issue, but things appear to be improving with the new Administrator. On 7/28/23 at 1:30 PM, V1 (Administrator stated there were complaints about staff not responding to call lights, but I thought we had taken care of the matter. I am disappointed to hear that the problem persists. My expectations are for staff to respond to call lights promptly and not to cut the light off if they are not ready to address the residents' needs. The facility's policy regarding call lights was requested and did not receive throughout the survey.

Based on interview and record review, the facility failed to staff a Registered Nurse (RN) 8 hours a day, 7 days a week. This failure affects all 86 residents living in the facility. Findings include: On 7/28/23 1:30 PM, V1 (Administrator) stated, We had RN coverage for every day except for the regular days off of our RN staff. On 7/28/23 at 1:35 PM, V2 (Director of Nurses/DON) stated, I think our staffing has been pretty good. The Facility's Nurse's Schedule from 7/5/23-8/1/23 had no documentation there was RN coverage on July 8th and July 9th of 2023. The facility's Resident Matrix provided on 7/26/23, documented there were 86 residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the family of a change in the resident's condition in 1 of 33 residents (R190), reviewed for notification of changes in condition in the sample of 33. Findings include: R190's Face Sheet, undated, documents R190 has a diagnosis of Stage 3 Pressure Ulcer of the Sacral Region. R190's Minimum Data Set, dated [DATE], documents R190 has moderate cognitive impairment with daily decision making. R190's Wound Care Note, dated 11/10/22, documents the following: Coccyx is an acute unstageable pressure injury. Measurements are 0.5 centimeters (cm) x 0.2cm x 0.1cm. There is a moderate amount of drainage noted. Wound bed has 76-100% bright red granulation, no slough, no eschar, and no epithelialization present. R190's Wound Care Note, dated 11/17/22 documents the following: Coccyx is an acute unstageable pressure injury. Measurements are 0.9cm x 0.5cm x 0.2cm. There is a moderate amount of drainage noted. Wound bed has 76-100% slough, no granulation, no eschar, and no epithelialization present. Peri-wound skin does not exhibit signs or symptoms of infection. Unable to tolerate debridement. R190's Progress Notes and Wound Care Note were reviewed, and there is no documentation that R190's family was notified of the decline in R190's pressure wound. On 4/6/23 at 2:55 PM, V22 (R190's Daughter) states R190 was not being taken care of while at the facility, wasn't being turned and had a hole in her butt. V22 states she knew R190 had an open area, but she thought it was getting better and didn't know how bad it was until R190 was at the hospital emergency room and she saw it, it stunk, was down to the bone, and was necrotic. On 4/7/23 at 10:26 AM, V3 (Assistant Director of Nursing/ADON) stated it is their policy to notify the physician and family with changes in a resident's condition. The Notification of Changes in Condition dated 1/28/20, documents in the policy statement that it is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychological status.

Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 27 residents (R39) reviewed for significant medication errors in the sample of 33. Findings include: R39's Physician Order Sheet (POS) for February 2023 documents diagnoses of acute osteomyelitis, left ankle and foot, cellulitis, and diabetes mellitus without complications. R39's February 2023 POS has an order for Ceftriaxone Sodium (an antibiotic) intravenous (IV) solution reconstituted 2 GM (ceftriaxone Sodium), use 2 grams intravenously one time a day for cellulitis and osteomyelitis for 33 days. Start dated 2/3/2023 and end dated 2/10/2023. R39's POS for February 2023 also has and order for Daptomycin Intravenous Solution Reconstituted (Daptomycin). Use 574 milligrams intravenously one time a day for Cellulitis and Osteomyelitis for 34 days. Start Date 2/3/2023 to 2/10/2023. R39's POS documents PICC Line (Peripherally Inserted Central Catheter) Insertion by (Company Name) Vascular Access Company, start dated 2/7/2023; end date 2/10/2023. R39's POS also documents an order for Daptomycin Intravenous Solution Reconstituted 500 MG (milligrams) (Daptomycin). Use 575 mg intravenously one time a day for antibiotic treatment for 34 days. Start date 2/14/2023 and end date 3/8/2023. R39's POS also documents she has an order for Ceftriaxone Sodium intravenous solution reconstituted 2 grams (GM) (ceftriaxone Sodium). Use 2 gram intravenously one time a day for antibiotic treatment for 33 days. Start date 2/15/2023 and end date 3/8/2023. R39's Medication Administration Record (MAR) for February 2023 documents from 2/4/2023 to 2/10/2023 document R39 did not receive 3 doses of ceftriaxone sodium intravenous solution. R39's MAR for 2/16/2023 to 2/28/2023 documents R39 missed 5 out of 13 doses of Ceftriaxone Sodium intravenous solution. R39's MAR for February 2023 does not document any doses of Daptomycin intravenous solution reconstituted 575 mg dose or the 500 mg doses were ever administrated to R38 for the month of February. R39's Progress Notes dated 3/8/2023 at 9:27 AM, Note Text: Antibiotic per PICC for osteomyelitis Left foot/great toe continues with no adverse effects or allergic reactions. Scab present to bottom of left great toe. No drainage, redness or swelling present. Denies pain or discomfort. PICC site free of signs or symptoms of redness or swelling. Antibiotic administered as ordered per IV certified nurse. On 4/7/2023 at 4:34 PM, V5 (Corporate Nurse) stated, I would expect all of the staff to fill out the MAR. If a medication was not given, I would expect the MAR to reflect it and for staff to notify the physician. I am not sure why R39's MAR has holes in it and why it was not documented. I am not sure if there were any leftover doses of the medicine. On 4/11/2023 at 10:30 AM, V31 (Nurse Practitioner/NP) stated, I would expect all Physician Orders should be followed and documented in the MAR. If a medication was not given, I would expect staff to notify me that it was not given. On 4/11/2023 at 10:55 AM, V32 (Pharmacist) stated, I would expect all antibiotics to be given, and if R39 does not have proof that the medication was given, then I would be considered it to be a significant medication error. The Medication Administration Policy with a revision date of 5/14/2020 documents, Medication will be administered in a safe, efficient and accurate manner to residents for who they are prescribed and in accordance with current acceptable nursing practice. If a drug is withheld, refused, or given at a time other than the scheduled time, or not given for any other reason, the individual administrating the medication shall initial and place the appropriate chart code /follow up code in the EMAR (Electronic Medication Administration Record) which will indicate the reason medication was not administered as ordered. A progress Note may be required.

Based on interview and record review, the facility failed to answer call lights in a timely manner for 7 of 23 residents (R4, R10, R31, R37, R42, R52, R62) reviewed for call lights in the sample of 33. Findings include: On 4/4/2023 at 12:45PM, V19 (Ombudsman) stated, Call lights continue to be a major issue at the facility, and I am still getting complaints about the call lights not being answered in a timely fashion. On 4/6/2023 at 2:00 PM, R37 stated the problem is the nights because it takes too long a time for staff to answer call lights. R37 also stated weekends are the worst. On 4/4/2023 at 9:30AM, R42 stated she has waited over an hour for her call light to be answered on the night shift. On 4/5/2023 at 3:00 PM during the group meeting, R4, R10, and R31, all stated call lights take a long time and they had complained to the facility but nights and weekends waiting for the call lights can take an hour or more for someone to come and help you. They stated they had complained to the facility, but the call lights are still slow on nights and weekends. The facility Grievance dated 2/27/2023 documents no one answers call lights, and issues is ongoing. On 4/7/2023 at 12:00 PM, V1 (Administrator) stated, Call lights should be answered timely. On 4/7/2023 at 12:10 PM, V5 (Regional Nurse) stated, I would expect call lights to be answered immediately. For a resident even 1 minute is too long. On 4/5/2023 at 9:40 PM, R52 stated, The staff that are here are working hard, but there are a lot of no shows, so we do not always have enough staff, it is worse at night. On those nights, we have to wait hours for the call light to be answered, and that is not right. I have waited for over 2 hours on some evening. Again, I don't want you to think the staff are bad because the staff are good, but they need more help, and I am not sure they always have help. The day shift is good, it is the night shift when I have to wait for the call lights. I used to be a nurse. I can't walk anymore, and I have to stay in bed most of the day. I have a pressure ulcer on my coccyx, but it is improving and getting better. But when I push the button for assistance, I need help and should not have to wait for hours. It is humiliating when you are waiting, and nobody is coming and then you have an accident and just have to lay there. On 4/5/2023 at 9:55 PM, R62, stated, I am going home in a week. They have set up home health to come and assist me. They can't keep staff here, especially a Director of Nursing. I just heard yesterday that we lost another one. Call lights are really bad here at night. I think they have a lot of call offs. I have waited 2 plus hours for staff at night to come and help. This is why I am here. I think I will do better at home than being here. Nobody should have to wait for hours for staff to answer a call light. If I could do things by myself, then I would have been out at home. On 4/7/2023 at 4:34 PM, V1 (Administrator) stated, I have not been here for very long, but I would expect staff to answer call lights in a timely manner as I realize sometimes things could happen and there could be a delay, but I would not expect any resident to be waiting over 20 minutes for their call light to be answered. We just have to do better job at answering call lights. The Resident Right Policy dated 11/2018 documents, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable and homelike. The Facility Call Light policy undated documents, All staff members are responsible for answering call signals even for resident who are not part of their assignment. Know the various signals for resident rooms, bathrooms, etc. In general, a regular signal should be answered within 3 minutes and an emergency signal within 1 minute.

Based on observation, interview, and record review, the facility failed to provide adequate linens to provide a homelike environment for 7 of 23 residents (R4, R10, R28, R31, R43, R52 and R62) reviewed for homelike environment in the sample of 33. Findings include: On 4/5/2023 at 3:00, PM, during group meeting R4, R10, R28, R31 and R43, all stated the facility does not provide enough towels and washcloths when they need them. These residents stated the facility has run out of towels, washcloths, and bed pads on multiple occasions. On 4/7/2023 at 12:00, PM, V5 (Corporate Registered Nurse/ Corporate RN) We have been having some issues with the linen. We think what happened is some of the CNAs (Certified Nursing Assistants) and some of the residents were hoarding the towels and washcloths in the residents' rooms. If the linens are being hoarded, then we would have enough of them when staff need them. On 4/4/23 at 4:10 PM through 4:15 PM, the linen carts on the 100 hall, 300-hall, 200-hall, and 600-hall did not have washcloths, towels, and cloth incontinent pads. On 4/5/2023 at 8:49 PM, V24 (Licensed Practical Nurse/LPN) stated, I am not sure what is going on with washcloths and pads, but I have gotten complaints from residents about the facility running out of supplies and/or residents wanting them and not being able to find one. On 4/5/2023 at 8:53 PM, V14 (Certified Nursing Assistant/CNA) stated, I only work part time, but there are issues with not having enough washcloths and pads. I do the best that I can with what I have. We are supposed to go into the main Clean Linen Room, get out the supplies, and then go back and stock the carts. There are no washcloths tonight in the clean linen room and there are not enough pads to stock our carts. On 4/5/2023 at 8:55 PM, on the 100-hall there was a clean linen cart and V27 (CNA) stated, This is what I have for the night. There are no washcloths or pads in the clean linen closet for me to stock my cart. I do not have any washcloths and only 1 pad. There were not any in the clean linen room. This is all I have. On 4/5/2023 at 8:56 PM, tour of the Clean Linen Closet was conducted, and there were no washcloths available for staff, and only one pad was in the available in the clean linen storage. On 4/5/2023 at 9:04 PM on the 200-hall cart, there were no washcloths and 1 pad on the cart available for use. On 4/5/2023 at 9:15 PM on the 600-hall, was a clean linen cart but it did not contain any washcloths or incontinent pads. On 4/5/2023 at 9:40 PM, R52 stated, Staff are always running out of washcloths and towels stuff like that. I think they need to order more. If I was at home, I would have clean towels and washcloths. On 4/5/2023 at 9:55 PM, R62 stated, I think I will do better at home than being here. They are always running out of washcloths, towels, and pads. It just is not right that they don't have enough supplies to meet my needs. On 4/5/2023 at 10:02 PM, V13 (Housekeeping Supervisor) stated, Staff are supposed to go into the clean linen room, get the clean supplies, and then restock their carts. I think a lot of staff are putting the linen in the resident's room and then I have to do a sweep and try and find all of the washcloths, towels, pads, and anything that has been left in the rooms. I got a call from the facility tonight telling me that they were having issues and running low on supplies, so I came out here to run a load and throw some washcloths in the wash and I just stocked the Clean Linen Closet with the newly washed 50 washcloths. The Resident Right Policy dated 11/2018 documents Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable and homelike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R52's Face sheet documents admission date of 4/10/2019 with diagnoses of Diabetes, Stage 4 Pressure Ulcer to Coccyx, Polyneuropathy. R52's MDS, dated [DATE] documents R52 has no cognitive deficits. On 4/6/2023 at 12:30PM, R52's coccyx pressure ulcer wound site appeared deep, beefy red, tunneling noted, with moderate amount of pink drainage. R52's order sheet dated 11/21/2022 documents clean coccyx area with soap and water, pat dry, apply a skin protectant to the outside of the wound, Collagen Powder 1 gram to base of wound, Santyl, calcium alginate to the wound base, cover with silicone border daily and as needed. R52's progress notes document R52 was out of facility from 12/29/2022 until 1/18/2023. R52's 1/2023 TAR documents Santyl Ointment 250Unit/Gm Collagenase. Apply to coccyx area topically every day shift for wound healing, cleanse wound with soap and war, apply Santyl, calcium alginate and silicone foam border every day and prn. There is no documentation R52 received treatments to coccyx on 1/22/23, 1/25/2023, 1/26/2023, 1/29/2023, and 1/31/2023. R52's Braden assessment dated [DATE] documents score of 10.0. High risk of pressure ulcers. R52's Care Plan updated 2/24/2023 documents R52 has Stage 4 pressure ulcer to right buttock with potential for further progression of pressure ulcer related to immobility, obesity, Diabetes Mellitus with neuropathy, refuses to reposition self, refuses to get out of bed, refuses referrals to physicians out of facility. Interventions include: R52 educated to use trapeze device to assist with repositioning. R52 to be followed by Wound Company. R52 to use air flow mattress. R52's progress notes document R52 was out of facility 2/7/2023-2/21/2023. R52's hospital discharge records dated 2/21/2023 document Wound Care: Wet to dry normal saline moistened kerlix cover with mepilex. R52's 2/2023 TAR documents clean coccyx area with soap and water, pat dry, apply a skin protectant to the outside of the wound. Collagen powder 1 gram to base wound. Santyl, calcium alginate to the wound base, cover with silicone border daily and prn every shift. R52's February TAR has no documentation of treatments done on 2/1/23 on day shift and evening shift and 2/2/23 on evening shift. R52's February TAR has no documentation of treatments done from 2/18/2023 through 2/28/2023. R52's wound care notes dated 2/23/2023 documents left coccyx wound measurements are 7cm X 6.5cm X 3.3cm. R52's wound care notes dated 2/23/2023 documents Left Coccyx is an acute full thickness Osteomyelitis and has received a status of Not Healed. Measurements are 7cm length X 6.5cm width X 3.3cm depth, with an area of 45.5 sq cm and a volume of 150.15cubic cm. Bone is exposed. Undermining has been noted at 9:00 and ends at 11:00 with a maximum distance of 5cm. There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has 26-50% pink granulation, no eschar, and no epithelization present. The peri-wound skin exhibited: Friable, Moist, Peri wound skin does not exhibit signs or symptoms of infection. R52's TAR has no documentation of any treatments done from 3/1/23 through 3/12/2023. On 4/7/2023 at 12:00PM, V5 stated I can't find any documentation on the dressing changes for R52 between when she came back from the hospital on 2/18/23 and 3/13/2023. I have the notes from the Wound Company is all I have. R52's TAR dated 3/1/2023-3/31/2023 document Cleanse coccyx with soap and water, apply collagen powder, Santyl ointment, calcium alginate and cover with a foam dressing. Daily and as needed. Once daily. Start date 3/13/2023 at 7:00AM. R52's TAR has no documentation of any treatments done on 3/15/23, 3/23/23, 3/29/23 and 3/31/2023. R52's wound care notes dated 3/3/2023 document left coccyx measurements 5cm X 6cm X 3.2cm. Bone is exposed. Undermining present. R52's order sheets dated 3/13/2023 documents Cleanse coccyx with soap and water, apply collagen powder, Santyl ointment, calcium alginate and cover with a foam dressing. Daily and as needed. R52's wound care notes dated 3/16/2023 document left coccyx measurements 4.8cm X 5.3cm X 2.5cm. Bone is exposed. Undermining present. R52's wound care notes dated 3/21/2023 document left coccyx measurements 5.3cm X 6.5cm X 2cm. Bone is exposed. Undermining present. R52's wound care notes dated 3/30/2023 document left coccyx measurements 4.5cm X 5.7cm X 1.5cm. Bone is exposed. Undermining present. R52's Wound Care Plus notes dated 4/4/2023 documents wound assessment Left Coccyx is an acute full thickness osteomyelitis and has received a status of not healed. Measurements are 4.5cm length X 6.5cm width X 1.5cm depth, with an area of 29.25 sq cm and a volume of 43.875 cubic cm. Bone is exposed. Undermining has been noted at 9:00 and ends at 11:00 with a maximum distance of 2.7cm. There is moderate amount of sero-sanguineous drainage noted with no odor. Wound bed has 1-25% slough, 76-100% pink granulation, no eschar, and no epithelialization present. On 4/5/2023 at 9:20 PM, R52 stated I have a pressure ulcer on my coccyx, but it is improving and getting better. I can't reposition myself and I have to remind them to turn me. On 4/6/2023 at 12:30PM, V6 (LPN) provided wound care to R52. V6 stated R52's wound is looking much better. Based on observation, interview, and record review, the facility failed to ensure treatments were administered for the care of pressure ulcers for 5 of 6 residents (R9, R52, R65, R85, and R190) reviewed for pressure ulcers in the sample of 33. Findings include: 1. R85's face sheet, undated, documents R85 has diagnoses of Adult Failure to Thrive, Anemia and COVID. R85's Minimum Data Set (MDS), dated [DATE], documents R85 is cognitively intact. R85's Care Plan, dated 2/11/23, documents R85 has an actual impairment to skin integrity and was admitted with a stage 3 pressure ulcer to the coccyx with an intervention to monitor/document location, size, and treatment of skin impairment. R85's Wound Care Note, dated 4/4/23, documents R85 has a stage 4 pressure ulcer to the coccyx measuring 4.3 centimeters (cm) x 3cm x 0.7cm with undermining at 12 o'clock at 3.9cm. Bone is exposed. Moderate amount of serosanguineous drainage. Wound bed has 76-100% bright red granulation, no slough, no eschar, and no epithelialization present. R85's Treatment Administrator Record (TAR), dated 3/2023 and 4/2023, document the following order - 3/15/23 - cleanse coccyx with soap and water, apply calcium alginate, Santyl ointment and cover with a foam dressing daily. R85's TAR has no documentation that the treatment was completed on 3/28/23, 3/29/23, 3/31/2 or 4/3/23. On 4/4/23 at 9:15 AM, wound care was observed with V6 (Licensed Practical Nurse/LPN) and V7 (Wound Care Provider). There was no dressing in place to the wound. Wound bed beefy red, bone exposed in 2 spots, bleeding. R85 was shaking during assessment of wound and complaining of pain. Measurements obtained by V7: 4.3cm x 3cm x 0.7cm with undermining at 12 and 12 at 3.9cm. On 4/4/23 at 9:15 AM, V6 (LPN) states R85 was admitted to the facility with the pressure ulcer. V6 states he has not had any wound infections since he has been at the facility. On 4/4/23 at 9:15 AM, V7 (Wound Care Provider) states the wound was breaking itself down so it now has the ability to heal. V7 states the exposed bone is new and wasn't there last week, and that R85 was only complaining of pain with turning and positioning but today the wound is visibly tender to the resident. V7 instructed V6 to contact R85's physician for stronger pain medications. V7 states the pain could be from the exposed bone and because it is trying to heal, or it could be due to osteomyelitis. V7 states the wound does not look infected, however, now that the bone is exposed, she is going to order an x-ray to rule out osteomyelitis. 2. R9's Face Sheet, undated, documents R9 has a diagnosis of Stage 4 Pressure Ulcer of the Sacral Region. R9's MDS, dated [DATE], documents R9 has moderate cognitive impairment and has a stage 3 pressure ulcer. R9's Care Plan, dated 12/23/22, documents R9 has a stage 4 pressure ulcer to the coccyx, wound vacuum to the coccyx area for wound healing, change the wound vacuum twice weekly and to administer treatments as ordered. R9's Physician Order Sheet (POS), documents an order dated 3/7/23 for the wound vacuum to be changed every Monday and Thursday. If the wound vacuum is not in place, cleanse the area with wound cleanser, pack the area with a 4x4 gauze and cover area with a foam dressing. R9's Wound Care Note, dated 4/4/23, documents R9 has a stage 4 pressure ulcer to the coccyx measuring 7cm x 11cm x 2cm. Bone is exposed. Undermining noted at 9 o'clock and ends at 11 o'clock with a maximum distance of 0.7cm. There is a moderate amount of serosanguineous drainage noted which has no odor. Wound bed has 1-25% slough, 76-100% bright red granulation, no eschar, and no epithelialization present. R9's Progress Note, dated 4/3/2023 at 4:35 PM, Resident wound (trade name) negative-pressure wound therapy device not in place. Treatment nurse stated it will be replaced on 4/4/23. R9's Progress Note, dated 4/4/2023 at 3:55 PM, Wound nurse stated she will replace the wound (trade name) negative-pressure wound therapy device on 4/4/23 and place a dressing on it. R9's Progress Note, dated 4/4/2023 at 11:23 PM, Wound (trade name) negative-pressure wound therapy device reapplied 4/4 at11pm. Wound care came to assess resident on 4/4 so the area was cleaned, packed with 4x4 gauze and covered with a foam dressing until now. The area was 75% red granulation. Moderate amount of serous sanguineous drainage noted. No odor present. No complaints of pain. Wound (trade name) negative-pressure wound therapy device is attached and suctioning properly at 125mm. On 4/4/2023 at 4:51 PM, V5 (Corporate Nurse) states, There is no TAR for R9. R9 has order for wound treatment, and she is being seen by the Wound Doctor every Thursday. I have no proof for the TAR for Tuesday (4/3/23). I made up a sheet today. R9 did not previously have a TAR for April 2023. R9's TAR, dated 2/2023, documents an order dated 12/26/22 with a discontinued date of 2/2/23 for a wound vacuum to the coccyx (sacrum). Change every Monday and Thursday. Make sure the device is plugged in, seal is tight, and it is draining properly. If vacuum is accidently removed, clean area with soap and water, apply skin prep around the coccyx, pack area with 4x4 gauze and cover with a silicone bordered dressing. The TAR has no documentation that the treatment was completed on 2/13/23, 2/16/23 or 2/20/23. R9's TAR, dated 3/2023, documents an order dated 3/1/23 with a discontinued date of 3/9/23, to change the dressing to the coccyx daily for wound care. The TAR has no documentation that the treatment was completed on 3/1/23, 3/7/23, 3/8/23 or 3/9/23. The 3/2023 TAR goes on to document an order dated 3/1/23 with a discontinued date of 3/7/23. The TAR has no documentation that the treatment was completed on 3/1/23 or 3/7/23. R9's TAR, dated 4/2023, documents an order with a start date of 4/5/23 at 9:00 AM for a wound vacuum dressing, change every Monday and Thursday. If wound vacuum is not in place, cleanse area with wound cleanser, pack with 4x4 gauze and cover with a foam dressing. Since the 4/2023 TAR was not initiated until 4/5/23, there is no documentation that the wound vacuum was changed on 4/3/23. On 4/6/23 at 10:02 AM, wound care was observed with V6 (LPN). Wound bed pink, no signs, or symptoms of infection. On 4/6/23 at 10:02 AM, V6 (LPN) states R9's pressure ulcer was acquired while in the facility. V6 states R9 went out to the hospital (unsure of date), had the wound debrided and was sent back to the facility. V6 states R9 has not had any recent wound infections. On 4/07/23 at 8:20 AM, V3 (Assistant Director of Nurses/ADON) states the nurses are to document when treatments are completed on the TAR. 3. R190's Face Sheet, undated, documents R190 has a Stage 3 Pressure Ulcer to the Sacral (Coccyx) Region. R190's MDS, dated [DATE], documents R190 has an unstageable pressure ulcer. R190's Care Plan, dated 11/17/22, documents R190 is at risk of pressure ulcer development and has an unstageable pressure ulcer. R190's Progress Note, dated 8/18/2022 at 9:17 PM, documenting R190 had a red area /blister to the coccyx. R190's Wound Care Progress Note, dated 11/10/22, documents the coccyx has an acute unstageable pressure injury. Measurements are 0.5cm x 0.2cm x 0.1cm. There is a moderate amount of drainage noted. Wound bed has 76-100% bright red granulation, no slough, no eschar, and no epithelialization present. R190's Wound Care Progress Note, dated 11/17/22, documents the coccyx has an acute unstageable pressure injury. Measurements are 0.9cm x 0.5cm x 0.2cm. There is a moderate amount of drainage noted. Wound bed has 76-100% slough, no granulation, no eschar, and no epithelialization present. Peri-wound skin does not exhibit signs or symptoms of infection. Unable to tolerate debridement. R190's TAR, dated 9/2022, documents the following: 8/26/22 - 9/19/22 - Cleanse coccyx with soap and water, apply barrier cream daily - not documented as completed on 9/3/22, 9/9/22, 9/13/22 and 9/14/22. R190's TAR, dated 11/2022, documents the following: 11/8/22 - 11/29/22 - Cleanse coccyx area with wound cleanser, apply skin protectant, calcium alginate and silicone foam dressing daily - not documented as completed 11/10/22 and 11/13/22. 5. R65's Braden Scale assessment dated [DATE] documents that R65 is a moderate risk for pressure ulcers. The Facility Pressure Ulcer Weekly Report dated 3/21/23 documents R65 has a pressure ulcer to his right medial back. R65's right medial back pressure ulcer has an onset date of 3/7/23. R65's right medial back pressure ulcer was facility acquired. The Facility Pressure Ulcer Weekly Report dated 3/21/23 also documents the treatment and frequency: cleanse with soap and water skin prep, Santyl, and Calcium Alginate with an absorbent dressing daily and whenever necessary. (An order for this was not found in the Physician order sheet (POS). The Facility's Pressure Ulcer Weekly Report dated 3/9/23 and 3/16/23 did not document any measurements for the right medial back pressure ulcer. The facility Pressure Ulcer Weekly Report dated 3/16/23 documents all wound measurements are in centimeters (cm). R65's coccyx wound measures 6 x 6 x 0.8 R65's treatment is Ca Alginate and an absorbent dressing daily. The right lateral foot measurements are 1.3 x 1.5 x 0.3. R65's right hip wound measures 1.5 x 1.3 x 0.2. R65's General Wound Report dated 3/21/23 documents his Coccyx wound measures 5.5 x 5.5 x 0.7, and treatment is Calcium Alginate and absorbent dressing, R65's right lateral foot wound measures 1.5 x 2 x 0.3 cm. R65's right hip wound measures 2 cm x 1.3 cm x 0.2. Right Medial Back measures 15.2 x 7.5 cm x 0.2. R65's Pressure Ulcer Weekly Report dated 3/30/23 documents Coccyx wound measures 6.3 x 4.7 x 0.6, Right lateral foot measures 1.3 x 1.5 x 0.3, Right Hip measures 3 x 2 x 0.2, right medial back measures 14 x 9 x 1. Pressure Ulcer Weekly Report dated 4/4/23 Coccyx 6 x 3.5 x 0.5, right lateral foot 1.3 x 1.5 x 0.3, right hip 0.2 x 2.3 x 0.3, Right medial back 12 x 8.5 x 1 cm. R65's Weekly Skin Observation dated 3/7/23 documents (R65) has three stage 3 pressure ulcers. One on coccyx, one on the right hip and the other on the right outer lateral foot. This Weekly Skin Observation did not document anything about the right medial back pressure ulcer with an onset of 3/7/23. R65's Local Hospice Wound Record Report for the month of March with the dates of 3/10/23 through 3/30/23 documents three wounds sacral mid unstageable, lateral right mid dorsum stage 3, and right greater trochanter unstageable. The local Hospice Wound Report did not document a pressure ulcer to the right medial back, or its measurements. R65 POS dated 4/5/23 documents cleanse right upper back with soap and water, apply a nickel thick amount of Santyl ointment, calcium alginate and cover with a foam dressing.

Based on observation, interview, and record review, the facility failed to provide a nourishing snack to residents when there were more than 14 hours between a substantial evening meal and breakfast for 5 of 23 residents (R4, R10, R31, R52 and R62) reviewed for frequency of meals and snacks in the sample of 33. Findings include: On 4/4/2023 at 7:51 AM, V30 (Dietary Manager) stated, We serve breakfast at 7 AM, Lunch is at 11 AM and Dinner is at 4 PM. We will make up the HS (bedtime) snacks ahead of time and will send them out on trays that are at the nurse's station. It is the responsibility of the CNAs (Certified Nurse's Aides) to make sure the residents get those snacks. They are supposed to pass them out at 7 PM. I have gotten some complaints about the snacks not being passed out, but the kitchen staff is making those snacks. If there is a problem with snacks it is coming from the nursing staff not passing out the snacks because we make them up every day. We make up peanut butter sandwiches, pudding, orange juice, milk, and cookies. The mealtimes posted by the facility documents Breakfast is at 7:00 AM, Lunch at 11:00 AM, and Dinner at 4 PM. (15 hours from dinner to breakfast). On 4/5/2023 at 9:17 PM, there were two trays of snacks sitting at the nurse's station. The tray had orange juice, milk, pudding, sandwiches labeled peanut butter wrapped in plastic, and graham crackers. On 4/5/2023 at 9:20 PM, R52 stated, I do not get snacks at night. I am not sure why they do not pass them out, but I am supposed to get a snack because of my diabetes, and we do not have breakfast until 7 AM and sometimes that is really hard on my body. On 4/5/2023 at 9:21 PM, V28 (Licensed Practical Nurse/LPN) stated, I am not sure why the snacks have not been passed out. Snacks are supposed to be passed out at 7 PM. On 4/5/2023 at 9:55 PM, R62 stated, Nobody brings us snacks at night or comes by the room and asks us if we would like anything. We eat supper around 4 PM so by the time breakfast comes around I get hungry, and I have to be careful with my blood sugar levels. I am supposed to have a snack at night. During the group meeting on 4/6/2023 at 11:00 AM, R4, R10, and R31 all stated they do not get any evening snacks, and nobody is passing out snacks to them or bringing a cart around with snacks. They also stated they get hungry before breakfast and would like to have a night snack and they would eat them if they were offered. On 4/7/2023 at 4:33 PM, V1 (Administrator) stated, I would expect the nursing staff to be passing out the bedtime snacks and not let them just sit at the nurse's station.

Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility on 3/23/2024 for 8 consecutive hours and that there was a full time Director of Nursing (DON). This failure has the potential to affect all 87 residents living in the facility. Findings include: On 4/4/2023 at 8:02 AM, there was no Director of Nursing (DON) working at the facility. On 4/5/2023 at 10:02 AM, V1 (Administrator) stated that DON was not working in the facility and was off today. On 4/5/2023 at 1:32 PM, V5 (Corporate Nurse) stated, Our DON is not returning and has officially given her notice. On 4/7/2023 at 10:01 AM, V1 (Administrator) stated, I am not aware of any issues with not having a Registered Nurse (RN) working seven days a week for 8 consecutive hours every day. We are good and have not had any issues. Staffing schedules were reviewed from 3/22/2023 to 4/4/2023 and document that there was no RN coverage for 8 consecutive hours on 3/23/2023. On 4/6/2023 at 4:30 PM, V5 (Corporate RN) stated, We have RNs working on 3/23/2023 that were working on 3/28/2023. (V4, RN, V25, RN, and V26, RN) were all working that day and meet the state requirements. Timecards were pulled for V4, V25 or V26 and do not document on 3/23/2023 that any RN worked for 8 consecutive hours. On 4/6/2023 at 4:14 PM, V3 (Assistant Director of Nursing/ADON), stated, I would expect the facility have an RN working for 8 consecutive hours, for seven days a week. R39's Physician Order Sheets document she was on an intravenously solution and requires administration of medicine by a RN and her Medication Administration Records document she did not receive her medication on 3/23/2023. The Facility Assessment, dated 2023 documents, Staffing will be met or increased above regulatory PPD (Per Patient Day) requirements to ensure resident accommodations and care are met. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 4/4/2023 documented the facility had a census of 87 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the POA's/families and keep them update on loved one's progress and condition for 1 of 3 (R6) residents reviewed for notification in the sample of 33. Findings include: R6's Physician Order Sheet for December 2022 documents diagnoses of heart failure, morbid obesity, personal history of other mental and behavioral disorder, localized edema, rhabdomyolysis, acute kidney failure, hypertension, anemia, atherosclerotic heart disease. R6's MDS dated [DATE] document R6 was moderately impaired for cognition. R6's Care Plan dated 7/15/2022 document R6 has impaired cognitive function. R6's Care Plan also document The resident has little, or no activity involvement related to Disinterest, resident wishes not to participate. On 1/13/23 at 1:46 PM, V25 (R6 family), stated R6 was sent to the hospital on [DATE]. The facility failed to notify me she was even sent out on 12/7/2022 but not when she returned. Just a few days later, R6, was sent to the emergency room on [DATE] and came back to the facility afterwards, and again I was not notified of either. I came to visit the other day and R6 was in her wheelchair getting ready to go to a kidney doctor. I did not know about that either and I would like to know about these doctor's appointments so I can go with her. I talked to V1 (Administrator) and V2 (Director of Nursing/DON) and told them we expected to be informed going forward. We expect a care plan conference very soon and are waiting for them to get back with me very soon. I want to know when R6 is sick and when R6 is being sent out to the hospital. I want to know when her doctor's appointments are so I can go and be with her, hold her hand, and make sure she is getting the best care. If I do not know these things and I am not kept updated, how can I help R6? I want the facility to keep me updated and posted on all things concerning R6. R6 is easily confused and she is not always able to tell me what is happening when she is sent out to appointments or hospitals. On 1/20/2023 at 9:06 AM, V1 (Administrator) stated, The family came in and filed a grievance and I was having the staff look into it. I know the family was upset because they were not kept up to date on R6's care. I am not sure why you did not get the grievance or was provided with it, but I will look into it and make sure you get a copy. On 1/13/ 2023 at 1:32 PM, V27 (Licensed Practical Nurse/LPN) stated, I received an order from V11 (Nurse Practitioner/NP) regarding some lab works and she said to send R6 out to the hospital. I was filling in that day and I was not familiar with the protocol, and I did not notify the family that R6 was being sent out. I talked with the family afterwards and apologized and let them know my mistake. Moving forward I will make sure the family is notified. R6's Nurse's Notes dated 12/29/2022 at 3:02 PM, Late Entry: Note Text: This nurse spoke with the family of R6 today in regard to the resident's care here at (Facility). V25 (R6 family) made note that she loved the facility and how great we are in taking care of her sister but, was disappointed when she or the resident's daughter didn't receive a call-in regard to when the resident was last sent out the hospital. This nurse apologized on behalf of the company and made her aware that we have addressed this with the nurses and have also held an in-service in regard to notifications and documentation in the event a resident is sent out for evaluation. V25 expressed how that made them feel and wanted to be made aware when the resident is sent out. Reassured V25, we would contact the POA-daughter (V61) first then her, in the event, she needs to be transferred out again. V25 was happy to know that the staff will make sure that everyone is notified. This nurse again apologizes, ensuring her that we would make sure that doesn't happen again. Sister felt reassured and appreciated the time taken out of our busy day to listen to her concerns. This nurse let (V26) know that the pleasure was all mine and if she had any other questions or concerns to don't hesitate to reach out to me personally with those concerns. On 1/16/2023 at 4:11 PM, V2 (DON) stated, I would expect all staff to keep family members informed and update on their loved one's care and any change of condition. R6's family should have been contacted and kept up to date with her condition. Resident Family Grievance dated 12/28/2022 document, R6 went to the emergency department on 12/7/2022 and facility did not notify family. R6 returned to facility on 12/23/2022, and again, family was not notified. Would also like to attend Care Plan Meeting. Employee Education Form dated 12/23/2022 documents, Resident Power of Attorney wasn't notified that resident returned to the facility. Nurse educated that POA needs to be notified of all health and status change. Documentation, in-service and verbal education provided. The Facility Notification Change of Condition Policy dated 1/28/2020 documents, It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status. Following notification of the physician, licensed nursing personnel will contact the resident's responsible party/emergency contact/family member/POA or Guardian to inform him/her of the change. For acute changes in condition this should occur immediately when practicable and after addressing the resident's immediate needs and for non-urgent changes in condition the notification should occur within 72 hours of the noted change. All notifications should be documented and should include: the date and time of the notification; the name of the individual contacted; the specific reason for the notification; and any specific responses that were given by the person contacted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents belongings were returned in a timely manner for 1 of 3 residents (R3) reviewed for resident property in the sample of 33. Findings include: R3's Medical Records documents R3 was admitted to the facility on [DATE] and left the faciity on [DATE]. On 01/12/2023 at 1:01PM, V9, Family of R3 stated, when R3 came to the facility, she had brought her medication with her, and they were in a clear (plastic zipper bag). The nurse took the medication from her and when I asked if we could take it home, she told me that she had to keep it and that we could get it back when she left the facility. When we left the facility, they could not find the medication. Now, R3 is on a fixed income, and we feel that the facility should either reimburse her for the medication or replace the medication because they were the ones that took the medication to begin with. On 01/10/2023 at 10:44AM, V2 (Director of Nursing/DON) stated, R3 came to our facility from the hospital. When she came here, she had a clear plastic bag full of medications that we took from her to make sure the medication was safe. Then R3 left AMA (Against Medical Advice) and wanted her medication, and then we could not find her medication. Her family was here when she was admitted , I am not sure why they did not send the medication home with her (V9). I would have expected the staff to send her medication home with her family. On 01/18/2023 at 4:11PM, V1 (Interim Administrator) stated, If a resident would bring in outside medication from their home to the facility, I would expect staff to contact the facility and have them pick it up. If the family was still here, then I would just expect staff to send the medicine home with them. On 1/24/2023 at 12:03PM, V41 (Licensed Practical Nurse/LPN) stated, If a resident had outside medication when they entered the facility, I would contact the family and have them come and get the medication. I would have them chart it and right down what the medication was and make sure it was secure. If the family was here, then I would just send the medicine home with them. On 01/26/2023 at 3:02PM, V44 (General Practical Nurse/GPN) stated, If a resident would bring in medications to the facility, I would send it back with the Power of Attorney. We try not to ever keep medication here that is not ours. We don't really know what is in the medications. If the resident's family is not with the resident I would secure the medication, write down everything that the resident brought and ask the family to come and get it and makes sure it was in a safe place. A statement from V9 (Family of R3) documents, R3 came to facility and arrived with plastic zipper bag of her own medication from her house, they were inside of her purse. She had this same bag of medication at (area hospital). Once R3 got settled in her room. I lined the medication on the heater in her room next to her bed. She had the following: Melatonin, trazadone, Tylenol, levothyroxine, and her blood thinner a small pink pill (clopidogrel). The nurse took R3's pills, and I tried to get them from her so I could take them to R3's house. I was told 'she'll get them back once she leaves.' (R3) sent home on [DATE] now that she's back home. I tried to ask the facility for her medication back, but they are nowhere to be found. The facility misplaced R3's medication. In order for R3 to receive new medication she has to pay out of pocket. I am asking the facility to reimburse R3 for the medication the facility lost. R3 never received her medication back. She didn't lose her own medicine. This facility misplaced medicine that they took from her. If not a reimbursement, then at least supply R3 with her medication. R3's Grievance Form dated 01/05/2023 documents, Resident left the facility. Stated that she brought medication with her. Searched medication cart at East Hall spoke with nurses. Cannot find alleged. The Facility's Abuse Prevention Program, revised 03/2018 documents this facility affirms the right of our residents to be free from physical abuse. Facility staff will investigate any allegations of abuse within timeframes required by Federal Law. Any allegation of abuse will be investigated immediately to the facility. Residents will be protected from harm and/or further abuse during an abuse investigation. Upon completion of the investigation the facility will provide a verbal report to the resident and/or their legal representative. Within 5 business day from the report the facility will submit a report to IDPH that will contain the following: a description of the initial investigation, a description of the investigation and the facts obtained including a summary of all interviews conducted, a brief conclusion based on the information obtained during the investigation, a description of any corrective actions taken if necessary. Misappropriate of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent.

Based on interview and record review, the facility failed to ensure complete incontinence care was provided for 2 of 12 residents (R8, R9) reviewed for incontinence care in the sample of 33. Findings include: R8's Physician Order Sheet for January 2023 documents diagnoses of multiple sclerosis, muscle weakness, and Radiculopathy cervical region. R8's Minimum Data Set (MDS) Quarterly dated 12/9/2022 document R8 is cognitively intact for decision making. The MDS documents R8 required extensive assist of one staff member for bed mobility, totally dependent upon two staff for transfers and was always incontinent of bowel and bladder. R8's Care Plan with a revision date of 12/7/2022 documents, R8 has an activities of daily living self-care performance deficit related to Multiple sclerosis. R8 has limited physical mobility, bladder, and bowel incontinence. On 1/18/2023 at 4:56 PM, R8 stated, I don't have a problem with day shift, the problem is with evenings and the weekends shifts. On Monday, I did report it to the Director of Nursing (DON) about the long wait time. I used to be a CNA (Certified Nursing Assistant) and I know they can do better. Staff get in a hurry, and they do not clean us up properly. They just throw a new diaper on us without wiping us. I did complain and told V2 (Director of Nursing/DON) but nothing has gotten any better. It is the weekends- all shifts. V2 knows it is happening. Staff get in a hurry, and they do not clean us up properly. They just throw a new diaper on us without wiping us. I did complain and told V2 and V38 (Ombudsman) but nothing has gotten any better. It is the weekends - all shifts. V2 knows it is happening. It happens with me and with my roommate (R9). I see them do the same thing with her because half the time they do not even close the curtain when they give care. On 1/18/23 at 10:13 AM, V38 (Ombudsman) stated, I have had complaints from residents about not being cleaned up in a timely manner and/or not cleaning them properly before putting on the clean diaper. I am not sure who to talk to, as right now they have the Interim Administrator, and we have talked about it, but I am still getting the same complaints, and that is not being done on the weekends. R9 did complaint to me about them not cleaning her and just throwing on a new diaper. R9 said this was on the weekends. On 1/18/2023 at 4:56 PM, R9 shook her head 'no' when asked if they clean her up with wipes or washcloths on the weekends. On 1/13/23 at 9:47 AM, V2(DON) stated, R8 complained about incontinent care about 3 weeks ago. I wrote it up and addressed it. We in-serviced the CNAs about perineal care. I expect residents to be cleaned, wiped after every incontinence episode. The Facility's Investigation regarding R8, dated 12/19/22, documents, Perineal care is not being done correctly. Post-Investigation-Held a meeting with the CNA's working on E-hall in regards to proper perineal care on residents. Reiterated the importance of proper peri-care as demonstrated at our Blist last year, which our ADON (Assistant Director of Nursing) taught and ran. Spoke on good hand hygiene and making sure they have exactly what is needed to do proper perineal care. Made staff aware of the volume of their voices carry down the hallways and to keep the volume down. Staff stated they would adjust the volume when speaking in the hallways. Resident has been checked on every Monday to make sure her weekend was a success. CNAs appropriately doing perineal care and making sure her needs are being met. Resident has no other concerns at this time. The Perineal Incontinence Care Policy with an effective date of 1/1/2006, documents, To provide cleanliness and comfort, prevent irritation and infection in the perineal area during the daily bath and after voiding or defecating. Perineal skin cleansing should be performed properly after each incontinence episode.

Based on observation, interview and record review, the facility failed to provide a homelike environment by ensuring wash clothes were available to all residents. This has the potential to affect all 85 residents living in the facility. Findings include: On 01/13/23, at 7:53 AM, there were no washcloths on the shelves in the laundry room. V19 (Laundry Aid) pointed to an empty shelf and stated, They usually go right here, but they are being washed now. We will put them out as soon as they are dry. I don't know what the nurses would do if there were not any on the halls and they needed more. On 01/13/23 at 10:10 AM, R8 stated, CNAs (Certified Nursing Assistants) will just put on a clean diaper and not clean me up. I told the DON (Director of Nursing) about this. On 01/13/23 at 10:50 AM, R9 stated, They never give us wash rags. On 01/12/23 at 9:41 AM, R16 stated, I think my sister called and complained about the room I was in, being run down. On 01/12/23 at 4:00 PM, V16 (Certified Nursing Assistant/CNA) stated washcloths have been a problem ever since she started working here about 5 months ago. She stated, she is responsible for stocking her own linen cart in the laundry room and they are always running out of wash clothes. On 01/13/23 at 8:03 AM, V21, EHS (Environmental Health Supervisor), stated, We have had complaints about not having enough washcloths. I think the CNAs may have a hard time accessing them because, the laundry room is always locked, and we don't have anyone there overnight. On 01/13/23 at 9:11 AM, V2 (Director of Nursing/DON), We have had complaints from residents about not having enough washcloths, so we addressed with the previous Administrator (V5), and he started ordering more. If a resident is not cleaned up well during incontinent care, that could increase their risk of UTI, (Urinary Tract Infection). On 01/13/23 at 9:47 AM, V2 (DON) stated, R8 complained about incontinent care about 3 weeks ago. I wrote it up and addressed it. We in-serviced the CNAs about peri care. I expect residents to be cleaned, by being wiped off after every incontinence episode. The facility has 6 halls A, B, C, D, E and F halls. On 01/12/23 at 4:07 PM, the C hall linen cart contained 3 washcloths. On 01/12/23 at 4:12 PM, the F hall linen cart contained no washcloths. On 01/12/23 at 4:13 PM, the A hall linen cart contained 2 washcloths. On 01/13/23 at 7:58 AM, the C hall linen cart contained 4 washcloths. The Facility's (R8) Investigation 12/19/22 documents, Peri care is not being done correctly. Post-Investigation-Held a meeting with the CNAs working on E-hall regarding proper peri care on residents. Reiterated the importance of proper peri-care as demonstrated at our Blist last year that our ADON (Assistant Director of Nursing) taught and ran. Spoke on good hand hygiene and making sure they have exactly what is needed to do proper peri-care. Resident has been checked on every Monday to make sure her weekend was a success. CNAs appropriately doing peri care and making sure her needs are being met. Resident has no other concerns at this time. On 01/13/23 at 1:40 PM, facility invoices were provided by V1 (Administrator). There was no documentation that any washcloths were ordered after August 2022. The Facility's undated Residents' Rights Policy written by the Illinois Long-Term Care Ombudsman Program documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable and homelike. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 01/18/2023 documented the facility had a census of 85 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of physical abuse per the facility's abuse policy within prescribed timeframe. This has the potential to affect all 85 residents living in the facility. Findings include: 1. On 01/19/2023 at 10:45AM, V16 (Certified Nurse Assistant/CNA) stated on an evening in December 2022 (date and time unknown), V16 witnessed, V18 (Certified Nurse Assistant/CNA) pry V30's (Certified Nurse Assistant/CNA) hands from the doorway coming out of the dining room and he was being rough with R30. V16 stated, she waited until the next day to report it to V43 (Licensed Practical Nurse/LPN), V5 (Former Administrator), V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) because she had worked 2 double shifts in a row, and she was exhausted. On 01/19/2023 at 11:52AM, V5 (Former Administrator) stated that he recalled V16 (CNA) reported she had a concern regarding how V18 (CNA) treated R30. V5 couldn't recall details of what V16 reported and the date and time was unknown. V5 expected V3 (ADON) to report the allegation of abuse to Illinois Department of Public Health (IDPH.) V5 was terminated from the facility on 01/09/2023 and didn't know if the abuse allegation was reported to IDPH. On 01/19/2023 at 11:57AM, V43 (LPN) stated that she works evening shift 2:00PM through 10:00PM. V16 (CNA) spoke to her at the end of December 2022 (actual date unknown), and she reported she witnessed V18 (CNA) being rough with R30 in the dining room (date unknown.) V43 (LPN) reported, what V16 told her, to V5 (Former Administrator) and V2 (DON). On 01/20/2023 at 12:00PM, V3 (ADON) stated, V5 (Former Administrator) called him, (date and time unknown) and stated V16 (CNA) reported she witnessed V18 (CNA) being rough with R30 in the dining room. V3 didn't know if what V16 reported, occurred on Christmas Day 2022 or New Year's Day 2022. V3 interviewed V18 the next day (date and time unknown) regarding what occurred. V3 doesn't report allegations of abuse to the IDPH, that was V5's responsibility. On 01/20/2023 at 12:23PM, V2 (DON) stated she thinks V5 (Former Administrator) called her and V3 (ADON) on a 3 way call in December 2022 or January 2023 (date and time of call unknown). V5 stated V16 reported to him and V1 (Corporate Interim Administrator) that 24 hours prior V18 handled R30 roughly in the dining room. V2 stated she didn't know if the allegation of abuse was true or not and before it was reported to IDPH she wants to ensure abuse occurred. V5 was responsible for reporting allegations of abuse to IDPH, if it was abuse, he would have been responsible for reporting it. On 01/20/2023 at 2:26PM, V60 (Regional Generalist) stated V5 called him on 12/31/2022 (time unknown) and stated, V16 reported V18 was rough with R30 in the dining room the night before (12/30/2022). R16's Employee Record Folder on 01/26/2023 at 1:50PM the resident abuse policy was signed by V16 and dated 01/17/2023 and documents, I have received the Abuse Prohibition Policy and have read and understood all of the above implications. I also, know that it is my responsibility to report any witnessed abuse situation to the Administrator immediately; or I may, for reasons of confidentiality, report any such cases directly to the Corporate Office. V16's Employee Set-Up Sheet, documents she was hire date of 10/14/2022. 2. R29's MDS dated [DATE] document R29 was moderately impaired for cognition. Bed mobility (3/3), extensive assist with two plus staff members. Transfer (4/3), total dependence with two plus staff members, toilet use (3/2) extensive assist of one staff member, and she is always incontinent of bowel. R29 has an (indwelling catheter) for urine. 01/19/2023 at 10:45AM, V16 (CNA) stated, V59 (R29's family representative) told V16 in November or December 2022 (actual date and time unknown), that she doesn't want V18 to assist R29 with any activities of daily living (ADLs), because R29 is deathly afraid of V18. V16 stated, she reported what R29 told her to V43(LPN). On 01/20/2023 at 11:32AM, V59 (R29's family member) stated, There was a male nurse (V18) who was a CNA and R29 was afraid of him. I talked with V43 (LPN) and he no longer takes care of R29. No staff came and asked me any specific questions, or nobody questioned me as to why R29 is afraid of (V18). All I know is she is afraid of him. On 01/19/2023 at 11:57AM, V43 (LPN) stated in December 2022 (actual date unknown), V59 (R29's family representative) voiced to her that R29 was deathly afraid and scared of V18 and she didn't want him to be assigned to or assist in any ADL's for R29. V43 didn't report what R59 told her, regarding R29 fearing V18, because she told the staff that were there that day and thought it would be communicated in nurse shift report to other staff. On 01/20/2023 at 12:00PM, V3 (ADON) stated that he wasn't aware of residents or resident's family members that reported, a resident was afraid of a staff member at the facility. Staff concerns go initially to the Charge Nurse, and if the Charge Nurse feels the concern needs to be elevated to management, they are responsible for doing so. If a resident or resident's family member reported this to any staff, he would want to know immediately because he wants to know if abuse is going on in his building. V3 stated that he had no knowledge of V59 reporting that R29 was afraid of V18. On 01/20/2023 at 12:23PM, V2 (DON) stated it was not communicated to her, that R59 reported to staff that R29 was afraid of V18. V2 stated that she would want to know if a resident is afraid of staff so she can ask additional questions as to why the resident is afraid of the staff member. 01/19/2023 at 2:04PM, V54 (CNA) stated, she would report allegations of abuse to V2 (DON) or Charge Nurse. 01/19/2023 at 2:06PM, V14 (Activity Director) stated that she would report allegations of abuse to V2 (DON). 01/19/2023 at 2:09PM, V55 (Transportation) stated, she would report allegations of abuse to V3 (ADON). 01/19/2023 2:13PM, V57 (CNA) stated that she is a new CNA at the facility, and she would report allegations of abuse to V2 (DON). On 01/20/2023 at 1:04PM, V1 (Corporate Interim Administrator) stated that she vaguely remembered V5 (Former Administrator) called her on a Saturday in December 2022 or January 2023 (date and time unknown). V1 couldn't recall the details of what V5 reported to her, when he called but, that it was an allegation of abuse. V1 stated, she thought V5 said he reported the allegation to IDPH, V1 didn't know why this allegation of abuse wasn't reported to IDPH. V1 stated that when there is an allegation of physical abuse it is considered assault and that it a crime which must be reported to IDPH within 2 hours. The Facility's Abuse Prevention Program, revised 3/2018 documents this facility to establish internal reporting guidelines for facility staff in the event they become aware or formulate a reasonable suspicion that abuse, or a crime has been committed against a resident of the facility. All covered individuals are required to immediately report any occurrences of potential abuse or crimes committed against a resident that they observe, hear about, or suspect to the administrator or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator. Facility staff will report any allegations of abuse within timeframe required by Federal Law. Any allegation of abuse will be reported immediately to the facility Administrator or his/her designee, who will follow Federal requirements for reporting to the following entities: state licensing agency responsible for licensure of the facility (IDPH), law enforcement officials, the resident's representative, and the resident's primary physician. On 01/19/2023 at 2:29PM, V48 (CNA) stated that if she saw or suspected abuse, she would report it to the Nurse on duty immediate. On 01/19/2023 at 2:32PM, V50 (GPN) stated, if she saw or suspected abuse, she would report it to the Charge Nurse. On 01/19/2023 at 2:35PM, R49 (Activity Assistant) stated that if she saw or suspected abuse, she would Report it to the Charge Nurse. No initial or final abuse allegations were sent to IDPH for any abuse allegation from (Facility) for staff member V18 and/or residents R29 and R30. No initial report and/or final report was sent for either one of them was sent to IDPH. Resident Census and Conditions of Resident 672 noted census of 85 residents which this effect all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent further potential of abuse by allowing, V18 to continuing to work after an allegation of abuse were reported. This had the potential to affect all residents. Findings include: 1. R30's quarterly MDS, (Minimum Data Set) dated 10/08/2022 documents he is rarely/never understood. Long term and short-term memory problems. Physical behavioral symptoms directed towards others including hitting, kicking, pushing, scratching, grabbing occurred 1 to 3 days. R30's Care Plan, dated 10/10/2022 documents R30 has ADL self-care deficit requiring extensive assist with most ADLs due to impaired cognition and history of impaired walking. R30 is alert and oriented to self only, short term and long-term memory deficit with impaired decision-making skills and judgment due to diagnoses of Alzheimer's Disease and Dementia, depends to family and staff to assist with daily decision making. R30 has impaired balance, incontinence of bowel and bladder. He has the ability to propel own wheelchair, does not follow commands and is resistant to care. R30 uses psychotropic, antipsychotic and antianxiety medications related to behavior management, easily agitated, difficult to redirect, refusal of care and gets extremely anxious. R30's care plan does not address abuse or identify R30 as being at risk for abuse. R30's Weekly Skin Observation Notes, dated 12/13/2022 at 11:55AM, 12/18/2022 at 10:17PM, 12/21/2022 at 3:03PM documents, No skin issues present. R30's Electronic Medical Record dated 12/20/2022 through 01/19/2023 no documentation regarding an allegation of abuse or a skin assessment post allegation of abuse. On 01/19/2023 at 10:45 AM, V16 (Certified Nursing Assistant/CNA) stated, R30 has a history of grabbing onto doorways and not letting, go so staff pushing him in his wheelchair wouldn't be able to get him through the doorway. On an evening in December 2022 (date and time unknown), V16 witnessed, V18 prying V30's hands from the doorway coming out of the dining room, and he was being rough with R30. R30 was yelling and V18 continued to hold his hands forcefully down the hall so R30 didn't hit V18. V16 stated that R30 had bruises on his hands and forearms after the incident, and a nurse, (name unknown), told V16 that R30 fell, but he didn't fall. V30 isn't alert and cannot report what occurred. After V16 observed the bruises on R30's forearms and hands, she knew she had to report the allegation of abuse to management. V16 fears the allegation of abuse fell on deaf ears because, V18 continued to work at the facility after she reported the allegation of abuse, V18 was never suspended and continued to take care of R30. V16 spoke to V5 (Former Administrator) a few days after she reported the allegation and he told her the allegation of abuse was investigated and reported to IDPH. On 01/19/2023 at 2:30PM, V50 (R30's family member) stated, R30 isn't alert and has severe dementia, R30 is on hospice. No staff notified her of an allegation of abuse. V50 recalled, R30 had bruises on his hands and arms late December 2022, but staff (name unknown) told her he fell. R30's Electronic Medical Record dated December 2022 documents no falls. On 01/19/2023 at 11:52AM, V5 (Former Administrator) stated, he recalled V16 reported she had a concern regarding how V18 (CNA) treated R30. V5 couldn't recall details of what V16 reported and the date and time was unknown. V5 stated that he didn't investigate the allegation, he delegated that to V3 (ADON). On 01/19/2023 at 11:57AM, V43 (LPN) stated, she works evening shift 2:00PM through 10:00PM. V16 (CNA) spoke to her at the end of December 2022, (date and time unknown) and she reported she witnessed V18 (CNA) being rough with R30 in the dining room. V43 stated, this was a casual conversation with V16 as she didn't present it as an allegation of abuse, it was more of a casual conversation. V43 stated that if it was a true allegation of abuse, V16 would have been more upset when talking to her about it. V43 didn't assess R30 for injuries. V43 reported what V16 told her, to V5 (Former Administrator) and V2 (Director of Nursing/DON). She didn't know if the allegation was investigated, because she is a floor nurse and she is not in charge of investigating allegations of abuse. No one from management asked her questions about the allegation, and she wasn't asked to write a statement. V43 stated, no staff, including V18 were restricted to what residents they could take care of. V43 didn't have issues or concerns with staff including V18 at the facility. V43 stated, R30 had bruised hands and forearms at the end of December 2022, a nurse (name unknown) reported to her that R30 fell around that time and that was how his hands got bruised. On 01/20/2023 at 12:00PM, V3 (Assistant Director of Nursing/ADON) stated, he and V2 (DON) are responsible for investigating allegations of abuse at the facility. He does some interviews, and V2 does other interviews. V3 stated, V5 (Former Administrator) called him (date and time unknown) and stated V16 (CNA) reported she witnessed V18 (CNA) being rough with R30 in the dining room. V5 instructed V3 and V1 to interview V16 and V18 regarding the allegation of abuse. V3 didn't know if what V16 reported occurred on Christmas Day 2022 or New Year's Day 2022. V3 interviewed V18 the next day (date and time unknown) regarding what occurred. V18 denied being rough or aggressive with R30. V18 told V3 that R30 grabbed the dining room table and wouldn't let go, he grabbed R30's hands and held them together so R30 let go of the table and he wouldn't hit him. V3 stated, the investigation was concluded on 01/12/2023 and the final report was typed at the bottom of the one-page typed investigation. V3 stated, it was determined that V18 didn't abuse R30, because R30 has a history of grabbing things, including tables and doorways and V18 assisted R30 to let go of the dining room table and perhaps V16 (CNA) thought V18 didn't speak to R30 appropriately at that time, but it wasn't abuse, it was considered a customer service issue. V3 stated that to his knowledge there were no other staff, other than V16 and V18 were involved in the allegation and no other residents were interviewed, because they were not directly involved in the incident. V3 didn't assess R30 for injuries, because it wasn't an allegation of abuse, it was a customer service issue. On 01/20/2023 at 12:23PM, V2 (DON) stated she thinks V5 (Former Administrator) called her and V3 (ADON) on a 3 way call in December 2022 or January 2023 (date and time of call unknown.) V1 stated that she and V3 were not at the facility when V5 called them. V5 reported to them that V16 reported to him and V1 (Corporate Interim Administrator) that 24 hours prior, V18 handled R30 roughly in the dining room. V2 stated that the next day she interviewed V16 and she stated, she walked in the dining room and witnessed R30 grabbing the dining room table tightly and observed V18 aggressively prying R30's hands from the table. V16 reported that V18 was aggressive and abusive toward R30 at that time. V2 was not sure if the facility security cameras were reviewed, she didn't review them. V2 didn't go to the facility after being informed of the allegation of abuse and didn't assess R30 for injuries nor did V2 call the facility to have a nurse assess R30. V2 thinks V43 assessed R30 for injuries after the allegation, but it wasn't documented in R30's electronic medical record. V2 stated, she assessed R30 the next day or the following day (date and time unknown) after the allegation of abuse was reported to her for injuries, but she didn't document in R30's electronic medical record, no bruising was assessed. The initial report from V16 was an allegation of abuse, but the final investigation determined abuse did not occur. After the allegation was reported, V2 removed V18 from R30's hall so he no longer took care of him. At no time was V18 sent home or suspended pending the abuse investigation, V18 continued to work with residents, just not R30's hall. To V2's knowledge no other residents were in the dining room at the time of the incident, so no other residents were involved, that's why no other residents were interviewed in the investigation. The abuse investigation consists of a one-page typed statement that includes V16's statement, V18's statement, and the investigation's conclusion. V2 stated the abuse investigation was completed the same week the allegation was reported (date unknown.) On 01/20/2023 at 2:26PM, V60 (Regional Generalist) stated, V5 called him on 12/31/2022 (time unknown) and stated, V16 reported V18 was rough with R30 in the dining room the night before (12/30/2022). V60 stated, he came to the facility and watched the dining room security camera footage dated 12/30/2022 from 4:00PM to 10:00PM, there was a party balloon in the way of the security camera so he couldn't see what occurred the dining room during that time. On 01/24/2023 at 9:35AM, R30 lay in bed asleep. V48 (Certified Nursing Assistant/CNA) entered the room and pull back his covers, no bruising assessed. The resident was asleep and wasn't interviewable. Facility Staffing Pattern dated 12/25/2022 through 01/15/2023 documents V18 (CNA) worked the following days and was assigned to the following halls, 12/25/2022 not documented as working on the staffing pattern, 12/27/2022 evening E hall and night C and E hall, 12/30/2022 day shift C and E halls, evening shift E hall, 12/31/2022 evening shift F hall; left at 8:00PM, 01/01/2023 day shift F hall, 01/02/2023 evening shift E hall, 01/03/2023 evening shift B hall, 01/06/2023 day shift C hall and C/E F hall evening, 01/06/2023 day shift C hall, 01/11/2023 day shift F hall, 01/12/2023 day shift E hall and evening shift C hall, 01/13/2023 day shift F hall evening shift C hall, 01/14/2023 evening shift B hall, 01/15/2023 evening hall C hall and 01/16/2023 evening C hall NS/NC (no call no show). V18's Time Card Report, dated 12/09/2022 through 01/16/2023, documents V18 worked the following dates and times: 12/09/2022 12:00PM to 2:01PM, 12/16/2022 2:00PM to 9:59PM, 12/17/2022 1:43PM to 5:56AM on 12/18/2022, 12/18/2022 2:08PM to 10:12PM, 12/22/2022 10:23PM to 2:26PM, 12/26/2022 2:00PM to 10:14PM, 12/27/2022 1:51PM to 6:00AM on 12/28/2022, 12/28/2022 2:11PM to 9:54PM, 12/30/2022 6:19AM to 8:30PM, 12/31/2022 2:12PM to 7:30PM, 01/03/2022 7:38AM to 9:52PM, 01/03/2023 2:08PM 9:58PM, 01/06/2023 6:18AM to 5:51PM, 01/09/2023 6:08AM to 7:37PM, 01/12/2023 8:35AM to 9:52PM, 01/13/2023 8:12AM to 9:56PM, 01/14/2023 2:00PM 9:21PM, 01/15/2023 2:02PM to 9:56PM, 01/16/2023 11:40AM to 12:49PM. On 01/20/2023 at 1:04PM, V1 (Corporate Interim Administrator) stated when an allegation of abuse is reported, staff are expected to keep the residents safe by removing the abuser, they must leave the building immediately and are suspended pending the investigation's findings. V1 stated, she was the Corporate Interim Administrator at the time and vaguely remembered V5 (Former Administrator) called her on a Saturday in December 2022 or January 2023 (date and time unknown) and spoke to her about something that occurred between V18 and R30, but it didn't sound like an allegation of abuse to her. V1 couldn't recall the details of what V5 reported to her when he called, but that it was an allegation of abuse. The Facility's Abuse Prevention Program, revised 3/2018 documents this facility affirms the right of our residents to be free from physical abuse. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. The facility desires to establish a resident sensitive and resident secure environment. It is the policy of this facility to develop a mechanism to reduce the risk of abuse and/or crimes from being committed against the residents of this facility. This will be done by implementing the following systems and/or practices. Facility staff will investigate any allegations of abuse within timeframes required by Federal Law. 2. R29's Physician Order Sheet, (POS) dated January 2023 documents a diagnosis of chronic kidney disease, stage 4, Altered Mental Status, Type 2 diabetes with hyperglycemia, unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbances, mood disturbance and anxiety. R29's MDS dated [DATE] document R29 was moderately impaired for cognition. Bed mobility (3/3), extensive assist with two plus staff members. Transfer (4/3), total dependence with two plus staff members, toilet use (3/2) extensive assist of one staff member, and she is always incontinent of bowel. R29 has an (indwelling catheter) for urine. R29's Care Plan: dated 03/28/22 documents, The resident has Activities of Daily Living self-care performance deficit related to activity intolerance. R29 is an elopement risk/wanderer. R29's Care Plan does not address abuse or identify R29 as being at risk for abuse. 01/19/2023 at 10:45AM, V16 (CNA) stated V59 (R29's family representative) told V16 in November or December 2022 that she doesn't want V18 to assist R29 with any ADLs, because R29 is deathly afraid of V18. V16 stated that V59 didn't tell her the details of why she doesn't want V18 to take care of R29 just that she's deathly afraid of him. On 01/20/2023 at 11:32AM, V59 (R29's family member) stated, There was a male nurse (V18) who was a CNA, and my mom was really afraid of him. I do not think it had anything to do with him being a man. She would just get scared if she would see him. One time he delivered a lunch tray, and she became agitated and scared. I talked with V43 (LPN) and told her we did not want (V18, CNA) to provide any care to R29 because she was afraid of him. My mom needs assistance with the bathroom, and she is not able to transfer by herself and I am really not sure what happened. We requested that (V18) no longer provide any services to my mom (date unknown.) My mom gets urinary tract infections very easily and sometimes she can overreact, everything at times hurts her. She has bad knees. I am not sure what exactly happened between (V18) and my mom but all I can say is something happened and (V18) is not allowed to provide care to her anymore. I talked with V43, and he no longer takes care of my mom. No staff came and asked me any specific questions, or nobody questioned me as to why my mom is afraid of (V18). All I know is she is afraid of him. On 01/19/2023 at 11:33AM, when R29 was asked if she had ever been mistreated by any staff member she looked away and would and failed to respond. R29 was responding to other questions but would not talk about abuse. On 01/24/2023 at 10:13AM, R29 stated, I talk with V59 (Family of R29) she takes care of me when asked about if any staff member had ever hurt her. R29 would not talk anymore and stared into space. 01/19/2023 at 2:20PM, V58 (LPN) stated, to her knowledge there are no staff that are not allowed to take care of specific residents. On 01/19/2023 at 11:57AM, V43 (LPN) stated that in December 2022 (actual date unknown) V59 (R29's family representative) voiced to her that R29 was deathly afraid and scared of V18 and she didn't want him to be assigned to or assist in any activities of daily living for R29. V43 didn't know why R29 was scared of V18, and she didn't ask V59 any details. V43 didn't report what R59 told her regarding R29 being scared of V18 because she told the staff that were there that day and thought it would be communicated in nurse shift report to other staff. V43 stated she told V18 not to take care of R29, and he voiced understanding (actual date unknown.) V43 didn't assess or interview R29 when V59 voiced that she didn't want V18 taking care of R29. V18 stated, she is not management and that she was getting her nursing responsibilities completed so she could go home at the end of the shift. On 01/20/2023 at 12:00PM, V3 (ADON) stated that he wasn't aware of residents or resident's family members that reported a resident was afraid of staff at the facility. Staff concerns go initially to the Charge Nurse, and if the Charge Nurse feels the concern needs to be elevated to management, they are responsible for doing so. If a resident or resident's family member reported this to any staff, he would want to know immediately because he wants to know if abuse is going on in his building. V18 wasn't assigned to one of the facility halls (date and time unknown of when this occurred) but it was because him and V43 (LPN) didn't get along, it had nothing to do with how V18 treated residents. On 01/20/2023 at 12:23PM, V2 (DON) stated, it was not communicated to her that R59 reported to staff that R29 was afraid of V18. V2 stated, she would want to know if a resident is afraid of staff, so she can ask additional questions as to why the resident is afraid of the staff member. After the allegation of abuse with R30, (date unknown) V18 was taken off R30's hall, which is also where R29 resides, so V18 wouldn't have been assigned to R29 from the date of the allegation (date unknown) of abuse with R30 on. R29's Physician Order Sheet, (POS) dated January 2023 documents a diagnosis of chronic kidney disease, stage 4, Altered Mental Status, Type 2 diabetes with hyperglycemia, unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbances, mood disturbance and anxiety. R29's MDS dated [DATE] document R29 was moderately impaired for cognition. Bed mobility (3/3), extensive assist with two plus staff members. Transfer (4/3), total dependence with two plus staff members, toilet use (3/2) extensive assist of one staff member, and she is always incontinent of bowel. R29 has an (indwelling catheter) for urine. R29's Care Plan: dated 03/28/22 documents, The resident has Activities of Daily Living self-care performance deficit related to activity intolerance. R29 is an elopement risk/wanderer. R29's Care Plan does not address abuse or identify (R29) as being at risk for abuse. On 01/19/2023 at 11:33AM, When R29 was asked if she had ever been mistreated by any staff member she looked away and failed to respond. R29 was responding to other questions but would not talk about abuse. On 01/24/2023 at 10:13AM, R29 stated, I talk with V59 (Family of R29), she takes care of me when asked about if any staff member had ever hurt her. R29 would not talk anymore and stared into space. On 01/20/2023 at 11:32AM, V59 stated, There was a male nurse V18 who was a certified nursing assistant, (CNA) and my mom was really afraid of him. I do not think it had anything to do with him being a man. She would just get scared if she would see him. One time he delivered a lunch tray, and she became agitated and scared. I talked with (V43, Licensed Practical Nurse) and told her we did not want V18 (CNA) to provide any care to her because she was afraid of him. My mom needs assistance with the bathroom, and she is not able to transfer by herself and I am really not sure what happened. This all happened right after Christmas. We requested that V18 no longer provide any services to my mom. My mom gets urinary tract infections very easily and sometimes she can overreact, everything at times hurts her. She has bad knees. I am not sure what exactly happened between V18 and my mom, but all I can say is something happened, and V18 is not allowed to provide care to her anymore. I talked with V43 (LPN), and he no longer takes care of my mom. No staff came and asked me any specific questions, or nobody questioned me as to why my mom is afraid of V18. All I know is she is afraid of him. R29's medical records does not document anything regarding V18 and or any reason for V18 not being able to provide care for R29. On 01/18/2023 at 4:11PM, V1 (Interim Administrator) stated, That is all of the abuse investigations I have, I am not aware of any more investigations. I do not have any abuse investigations for R29. On 01/19/2023 at 4:12PM, there were no abuse investigations provided by the facility for R29 and V18. The Facility's Abuse Prevention Program, revised 3/2018, documents that this facility affirms the right of our residents to be free from physical abuse. Facility staff will investigate any allegations of abuse within timeframes required by Federal Law. Any allegation of abuse will be investigated immediately to the facility. Residents will be protected from harm and/or further abuse during an abuse investigation. Upon completion of the investigation the facility will provide a verbal report to the resident and/or their legal representative. Within 5 business day from the report the facility will submit a report to IDPH that will contain the following: a description of the initial investigation, a description of the investigation and the facts obtained including a summary of all interviews conducted, a brief conclusion based on the information obtained during the investigation, a description of any corrective actions taken if necessary. Resident Census and Conditions of Resident 672 noted census of 85 residents which this effect all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the potential spread of COVID-19 by ensuring staff who test positive for COVID-19 do not work. This has the potential to affect all 85 residents living in the facility. Findings include: On 1/18/2023 at 10:45 AM, V16 (Certified Nurse Assistant/ CNA) stated she tested positive for COVID-19 on 12/31/2022. V16 stated she let V3 (Assistant Director of Nurses/ADON) know but he told her not to tell anyone she tested positive because he needed staff to work. V16 stated she had symptoms at that time of a sore throat and a low-grade fever. V16 stated she worked 12/31/2022 and 1/1/2023 COVID positive. The Facility's COVID Positive Chart documents that V17 (Certified Nurse Assistant/ CNA) tested positive for COVID on 12/20/2022. V17 didn't have symptoms of COVID. The chart documents V16 tested positive for COVID on 1/1/2023 and the chart documented V16 had a fever when tested. V16's COVID Point of Care Testing Requisition dated 1/2/2023 documents V16 was tested positive for COVID. Symptoms: fever/chills, cough, sore throat, and congestion/runny nose were circled yes. The requisition documented V16's temperature was 99.8 degrees Fahrenheit (F). The form was signed by V61, Licensed Practical Nurse (LPN) dated 1/2/2023 at 5:31. V16's Timecard Report, dated 12/31/2022 through 1/1/2023 documents she worked the following days and times: 12/31/2022 2:08 PM to 6:17 AM, 1/1/2023 2:16 PM to 5:36 AM. V17's Timecard Report documents she worked 12/20/2022 2:02 PM to 4:00 PM and she was documented to come back to work on 12/24/2022 worked from 2:05 PM to 10:18 PM. On 1/19/2023 at 10:55 AM, V2 (Director of Nursing/DON) stated staff are tested for COVID twice a week. V16 (CNA) was tested on [DATE] at 5:30 AM, V2 forwarded the positive COVID test result to V53 (Infection Preventionist), and V16 was taken off the work schedule. V2 stated V16 didn't work while she was COVID positive. To V2's knowledge no staff have worked at the facility without being sent home to quarantine. 1/19/2023 at 10:15 AM, V53 (Infection Preventionist) stated that staff are tested for COVID every Monday and Thursday. V53 stated that she has the COVID tests set up in a room and staff test themselves and she reads the tests afterwards. V53 stated 6 staff tested positive since 12/20/2022. V53 stated when staff test positive for Covid they are sent home for 5 days, even if they are asymptomatic, and if they develop symptoms, staff have to stay home for 10 days. V53 was not aware of staff continuing to work after testing positive for COVID. On 1/20/2023 at 12:00 PM, V3 (ADON) stated V16 was the last employee to test positive for COVID. V16 stated that V53 or the Charge Nurse test employees twice a week. V3 stated when the COVID test results are positive, the employee is sent home immediately. V3 stated he had no knowledge V16 tested positive for COVID prior to testing positive at the facility on 1/2/2023 and he didn't instruct her to work being COVID positive. V3 stated V1 (Administrator) will call additional staff in if needed to ensure the facility is staffed properly. On 1/20/2023 at 2:00 PM, V3 (ADON) provided a copy of his text messages from his cell phone dated 12/31/2022 from V16 to him. A text message dated 12/31/2022 at 11:41 AM documents, V16 text I've been trying to contact you because when I test at doctor's office it was negative for COVID, decided I might want to take one at work just to make sure that I had took one it came back positive I wanted to know what you wanted me to do like go to the hospital and get a PCR test, been trying to contact you since last night I've called V53 (Infection Control Preventionist) and V2 (DON) nobody's answering. No further text messages were reviewed. On 1/26/2023 at 11:40 AM, V53 (Infection Control Preventionist) stated when staff are done testing for COVID they throw the test away and the list of positive staff are text messaged to her. She does not have a COVID Point of Care Requisition Form for V17, and she didn't know why. The day staff test positive for COVID is day zero and they are required to quarantine for 5 days so V17 tested positive for COVID on 12/20/2022 and she should have come back to work on 12/25/2022. V53 was not aware of staff that tested positive for COVID coming back to work before being quarantined for 5 days because that could put all residents at risk for getting COVID. On 1/26/2023 at 12:15 PM, V17 (CNA) stated she tested positive on 12/20/2022 she came into work and tested for COVID and left the test on the table. A few hours later while she was passing ice to residents V53 came running down the hall and told her she was COVID positive, and she had to go home. V17 stated she was very upset because she knew she wouldn't get paid for the missed days and V53 tested her again and the COVID test was again positive. She called the facility on 12/24/2022 and spoke to V2 (DON) who told her she can come back to work, so she did. On 1/26/2023 at 12:25 PM, V53 stated when staff test positive for COVID she reads the test and sends them home immediately. She didn't know V17 was working the floor COVID positive. V53 stated V17 was upset about the test results so they tested her again and it was positive, and she was sent home. The Facility's COVID-19 Prevention and Control Policy revised 12/6/2022 documents It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify employees with clinical features and an epidemiologic risk for the COVID-19. Employee screening and surveillance: employees will be encouraged not to come to work while sick and/or exhibiting signs or symptoms of respiratory disease. The facility will promote practices to encourage employees to remain at home sink including non-punitive attendance policies and allowing use of personal time off or sick time outside of normal policies. All employees at the beginning of their shift will be screened for signs or symptoms of a respiratory infection such as fever, cough, shortness of breath, anosmia, sore throat or has had contact with someone with confirmed or under investigation for Covid-19. Employees who present during screening with one or more new or worsening symptoms of a respiratory illness: fever (>100.0 F), cough, shortness of breath and/or sore throat will be required to don a facemask and will be sent home. They will be encouraged to seek follow-up care through their personal physician or the local health department. Employees with prolonged close contact with someone with laboratory-confirmed or under investigation for COVID-19 or with symptoms of a respiratory infection will be restricted from working until the status of the contact is confirmed. Employee who develops symptoms to COVID-19 will be instructed to not report to work and referred to their physician for testing, medical evaluation recommendations and return to work instructions. Employees who develop symptoms may be tested on site as appropriate. Employees who develop symptoms on the job will be instructed to immediately stop work and provided with a facemask. Instructed on self-isolation at home. The infection preventionist or facility designee will work with the employee to identify individuals, equipment and locations the employee encountered. COVID testing: routine testing surveillance testing will be conducted in accordance with state and federal guidelines and in accordance with facility testing plan but, in the event, may occur more frequently than mandated by state and/or federal guidelines. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 1/18/2023 documented the facility had a census of 85 residents.

Based on observation, interview and record review, the facility failed to ensure hot water heaters/equipment were in working order to supply hot water to the kitchen, showers, and resident rooms. This has the potential to affect all 85 residents living in the facility. Findings include: On 1/10/2023 at 8:03 AM, at the nurses' station there is an area approximately 4 feet by 4 feet area with yellow tape all around it and plastic. Moving the plastic and looking inside one can see part of the floor has been removed and there was a large round metal plate the size of a tea saucer. The tiles are gone and there is fresh dried cement around the metal plate. On 1/18/2023 at 3:00 PM, V1 (Administrator) stated the facility had a pipe burst from the extreme cold outdoor temperatures on 12/25/2022 and they were in the process of repairing things. On 1/18/2023 at 9:15 AM, V62 (Maintenance Director) stated, Over Christmas the temperatures outside got really cold, and we had some pipes that froze. The pipes were in the kitchen, and we had to have some repairs completed. I am replacing the tiles right now because when the pipes froze the ceiling collapsed in the kitchen and we had to shut down the water. Some of the valves were not in working order so we are switching them out now. We did have to shut the water off but only for about 12 hours, less than a day. We have 3 water heaters in the kitchen and one of the tanks became damaged and we are in the process of getting bids for its replacements. This tank was the one that was for the hot water for the coffee and iced tea. On 1/18/2023 at 3:15 PM, V62 stated When the pipe burst on 12/25/2022 it caused a ripple effect of other issues at the facility. It effected one of the three hot water heaters and the facility's pressure regulator. The pressure regulator does just as it says, it regulates water pressure, this has been an issue at the facility for some time, but administration keep putting a band-aid on it and doesn't fix it properly, so the issue keeps coming up. Because the pressure regulator is being affected by the pipe burst this is having an effect on the hot water heaters and the hot water in the facility. V62 stated having to have one of the facility hot water heaters off caused the kitchen not to have hot coffee or hot tea for a while as they had to remove one of the hot water heaters and did not replace all the hot water heaters. V62 didn't know when the hot water heater or the facility's pressure regulator would be fixed, the facility was in the process of getting bids for the work now. V62 stated V46 (Assistant Maintenance Director) is supposed to be checking the water in the shower rooms daily and documenting it on the temperature flow sheet. The hot water in the resident shower room on the halls has been lukewarm. The hot water should be between 100 degrees - 105 degrees (Fahrenheit, F) and it is not even close to that temperature. This affects the resident's room with sinks and the showers because the water is not hot. On 1/18/2023 at 3:30 PM, V46 stated no one instructed him to take water temperatures in the resident shower rooms daily, if they did, he would have been taking them. V46 stated R24 and R11 had to move rooms that day, which was most likely related to the facility's pressure regulator not working properly and the water was coming into their room through the floor. On 1/18/2023 at 3:32 PM, R24's room had water on the floor throughout the room. On 1/18/2023 at 4:00 PM, V46 went with the IDPH surveyor to take water temperatures of all shower rooms at the facility using a calibrated thermometer. At 4:05 PM, in the B hall shower room, the hot water temperature was 63 degrees (°) Fahrenheit (F). At 4:08 PM, in the C hall shower room at the shower fixture the hot water temperature was 72 °F. At 4:11 PM, in the D hall shower room, the hot water temperature at the shower fixture was 78 °F. V46 stated that the water is cold but that is because the facility's pressure regulator isn't working properly and that is affecting the facility's hot water flow. V46 stated he was aware what the temperature of the hot water should be at the facility. On 1/26/2023 at 10:06 AM, V46 stated, I just started yesterday as the new Maintenance man. I replaced the former Maintenance. I was Maintenance Assistant before that. I started just before Christmas. I was not in the building when the pipes burst at Christmas. I came in the following day, and I was told there was a water main break over the dishwasher dining room area. They had a plumber come in and fix the pipes, so they were no longer squirting water. The valves were shut off at the hot water heaters that ran up to the ceiling to stop the water. This in turn cause the ceiling to collapse. The valves were a different issue. The valves on the floor were about a week later when we were trying to move the dishwasher room, and there were some pipes that were leading to the dishwasher and needed to be capped. The plumber came out and turned off the valves. When they went to turn it back on, the valves were old and needed replaced. It was the main valve. I was not aware of the specifics. I am not sure about the pressure regulator again, I just started. V46 stated I knew somebody was out to replace the coffee machine, but I really do not know what was going on with the coffee. We try and make sure residents have privacy and enough space for their belongings. On 1/26/2023 at 10:07 AM, V63 (Maintenance at Sister Facility) stated, I work at the sister facility. I assisted with things when the pipes burst at Christmas. V62 called my phone and I tried to assist him, and I told him to call the plumber because there was a leak in the dining room. This happened on Christmas. I came after New Year's and looked at the ceiling that had collapsed in the dish room (2 separate room) and dining room. I first noticed the dining room and dish room. V62 said there was a frozen pipe in the ceiling that was leaking. It affected the dietary dining area and the dish room. This was separated by a door. After that, I am not sure what V62 did I told him to contact the plumber. I do not know what he said to the plumber. After New Year's, when I came out V62 told me that they had got the water off but when they tried to turn the water back on the valves were damaged. We had to have the valves replaced. The water heater in the kitchen was disconnected, not sure when it was disconnected. I tried to come over here and help assist. I am not sure about the water heater in the kitchen or the pressure regulators. The Facility's January 2023 Daily Water Temperature Log had no documentation hot water temperatures were taken in the B, C, D and E Hall showers on 1/1/2023 and 1/2/2023, 1/7/2023 through 1/10/2023 and 1/12/2023 through 1/17/2023. No other dates were documented as being completed. The B Hall shower room water temperatures that were documented ranged from 92 °F to 96°F. The C Hall shower room water temperatures that were documented ranged from 88 °F to 97 °F. The D Hall shower water temperatures that were documented ranged from 74 °F to 78°F. The E Hall shower room water temperatures that were documented ranged from 92 °F to 98 °F. The Facility's January 2023 Daily Water Temperature Log for the residents' rooms documented no temperatures of the hot water were taken on 1/1/2023, 1/2/2023, 1/4/2023, 1/7/2023 through 1/10/2023, and 1/12/2023 through 1/17/2023. In Room XXX the hot water temperatures were documented as 102 °F on 1/3/23, 102 °F on 1/5/23, and 96 °F on 1/6/2023. In Room XXY, the hot water temperatures were documented as 89 °F on 1/3/2023, 87 °F on 1/5/2023, 85 °F on 1/6/2023, and 87 °F on 1/11/2023. In Room YYY, the hot water temperatures were 81 °F on 1/3/2023, 82 °F on 1/5/2023, 80 °F on 1/6/2023, and 83°F on 1/11/2023. In Room AAA, the hot water temperatures were documented as 87 °F on 1/3/2023, 87 °F on 1/5/2023, 89 °F on 1/6/23 and 87 °F on 1/11/23. In Room AAB, the hot water temperatures were documented as 94 °F on 1/3/2023, 98 °F on 1/5/23, 97 °F on 1/6/2023, and 95 °F on 1/11/2023. On 1/18/2023 at 2:25 PM, the coffee and hot tea machines were not in use in the kitchen. V45 (Cook) stated that a pipe burst on 12/25/2022 the facility hasn't been able to serve coffee or hot tea to residents because the hot water heater doesn't work back there, they have hot water in the kitchen sink, just not for the coffee and tea machines. V45 stated they got the residents instant coffee that on 1/18/2023 but the facility had not been able to make any hot water since Christmas. V45 stated many residents were upset about not having access to their morning coffee or hot tea. On 1/18/2023 at 1:30 PM, R27 stated he loves hot coffee with meals, but they haven't had any since the pipe burst which was weeks ago. On 1/18/2023 2:25 PM, R24 stated and her roommate R11 had to move rooms that day due to their room flooding with water. R24 stated she hasn't taken a shower at the facility in a while because ever since the pipe burst on 12/25/2022 the shower water has been freezing. On 1/18/2023 at 2:40 PM, R11 stated she loves coffee but a few weeks ago something broke at Christmas and they have not had coffee since. On 1/26/2023 at 10:23 AM, V46 stated the hot water temperatures should be between 100-110 Fahrenheit (F), V63 (Sister Facility Maintenance Man) instructed V43 of that on 1/25/2023, he didn't know what the hot water temperatures should be prior to today. He and V63 took the water temperatures today and noted they are not within 100-110, they turned up the hot water heater a few temperatures and the temperature came up a little bit, approximately 3-5 degrees; the temperatures were still not in the 100-110 ° range. On 1/26/2023 at 10:23 AM, V63 (Sister Facility Maintenance Man) stated he reviewed the water temperatures documented for 1/2023 and he stated they are unacceptable. The hot water temperature should be 100-110 degrees. On 1/26/2023 at 11:00 AM, V64 (New Administrator) as of 1/22/2023 stated she wasn't aware of any hot water temperature issues or what the hot water temperature should be at the facility. On 1/26/2023 at 1:47 PM, V64 stated the facility doesn't have a water temperature policy. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 1/18/2023 documented the facility had a census of 85 residents.

On 1/26/2023 at 2:57 PM, V44 (Graduate Practical Nurse/GPN) stated he started working at the facility on 1/6/2023 and was in-serviced on abuse before he worked with residents and also on 1/18/2023. V44 stated he was not in-serviced on dementia. On 1/26/2023 at 3:01 PM, V41 (Licensed Practical Nurse/LPN) stated she had not received any in-services on dementia. On 1/26/2023 at 3:05 PM, V57 (Certified Nursing Assistant/CNA) stated that she started working at the facility on 1/6/2023 and had received abuse and dementia training at that time. V57 couldn't recall what staff educated her on dementia residents. On 1/26/2023 at 3:10 PM, V65 (Licensed Practical Nurse/LPN) stated she was not in-serviced on dementia. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 1/18/2023 documented the facility had a census of 85 residents. Based on interview and record review, the facility failed to ensure staff receive dementia training. This has the potential to affect all 85 residents living in the facility. Findings include: On 1/24/2023 at 4:10 PM, all in-services and training were requested for all staff. The following trainings were documented as being completed: Reporting of Abuse, Neglect, Theft and Crimes, Perineal Care, Transfers, and fire drills were documented. No dementia management training was documented as being completed by any staff member. On 1/25/2023 at 3:07 PM, V3 (Assistant Director of Nursing/ADON) stated, We have provided perineal training for staff, transfers, abuse and neglect, reporting. We had a plan of corrections, so we addressed falls, transfers, mechanical lifts, and fire drills this year. On 1/26/2023 at 3:21 PM, V3 stated, I did not realize dementia training was required. We have not in-serviced or provided any dementia management training to the staff. I am in charge of training, and I did not realize we needed to train staff in dementia management. On 1/26/2023 at 3:31 PM, V64 (New Administrator) stated, I just started a few days ago, and I know staff are required to have the dementia training. We do not have a policy on which trainings are required or dementia training.