Based on interview and record review, the facility failed to update a resident care plan as exacerbation of neurological symptoms began to occur. This failure affected 1 (R3) resident reviewed for care plan in the total sample of 5 residents. Findings include: On 05/05/2025 at 2:20pm, V2 (Director of Nursing) stated R3 was doing spastic movement of her upper extremities, flexion and extension. R3 never had this jerking movement before. It was as if she was trying to get out of her chair. It was just severe so we put her on 1:1 supervision. If you (staff) were with her, there is no spastic movement but as soon as you (staff) leave, R3 would have spastic movements of both her upper and lower extremities. I really think her cerebral palsy is exacerbating. There is a change on her baseline signs and symptoms. The exacerbation of R3's symptoms should be care planned. It is a problem that we need to focus on, we have to create a goal and add interventions. R3's careplan for cerebral palsy and spastic movement was not updated with new interventions. R3's careplan should be revised to include new interventions. I (V2) will update it today. R3's admission Record documented that R3's diagnoses (include but not limited to) cerebral palsy, metabolic encephalopathy, and reduced mobility. R3's (02/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 Memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Section I0020. Indicate primary medical condition. 07. Other neurological conditions. I0020B. primary Medical Condition. Cerebral Palsy. R3's care plan (date initiated: 05/05/2023) documented, in part The resident has an alteration in musculoskeletal status r/t (related to) hx (history) of muscle wasting and atrophy, spasticity and involuntary/impaired movements of the limbs and trunk d/t (due to) Cerebral Palsy. Date Initiated: 05/05/2023. Revision on: 05/05/2025. Revision by: V2 (Director of Nursing). Give medication as prescribed. Date Initiated: 05/05/2025. Created on: 05/05/2025. Created by: V2 (Director of Nursing). Neurology/Psychiatrist referral PRN. Date Initiated: 05/05/2025. Created on: 05/05/2025. Created by: V2 (Director of Nursing). Of note, revision was made on day one of survey. The (10/20/2024) Care plans, comprehensive Person Centered documented, in part Policy Statement: A comprehensive, person-centered careplan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and implementation. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas. 13. Assessments of the resident are ongoing and care plan are revised as information about the residents and the resident's condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its abuse policy of reporting incidents and/or allegations of abuse for 1 (R1) out of 4 residents reviewed for abuse. This failure affected 1 resident (R1) who experienced pulling of her hair by another resident (R2). Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's cognition is intact with BIMS (Brief Interview of Mental Status) of 15 dated 10/03/2024. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking in the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision and it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail. R1 stated that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her scared of her safety. R1 stated that there are two (2) other residents that R2 did some physical aggression, and these residents were R3 and R4. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November but nothings being done. R1 said, I spoke to V5 the social worker. Who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 by V6 (Registered Nurse) documents R2 pulled R1's hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and assaulted R1 by pulling her hair. Another incident dated 10/23/2024 by V8 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attacked by her several times. I don't want her killing me before they realize she is not supposed to be here. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's cognition is moderately impaired with BIMS (Brief Interview of Mental Status) of 9 dated 09/05/2024. On12/17/24 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024) when R2 pulled R1's ponytail. According to V1, none of the facility staff told her about what happened, and that V6 (Registered Nurse) was expected to report to her any incident or allegation of abuse. V1 stated that the facility does not have any designated abuse coordinator during weekend because she still accepts calls. V1 stated that when she came on Monday (12/16/2024) before she left for the day, R1 told her about the incident that R2 pulled her hair. V1 said, that was the time I knew that R2 pulled the hair of R1. V1 then said that she did a grievance form for R1. V1 was asked why she did not do a reportable after she knew what happened between R1 and R2. V1 replied that abuse incidents or allegations need to be reported immediately, or within 2 hours upon knowing the incident, and since the incident happened on 12/14/2024, it was too late to report and investigate. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her, and the act of R2 to R1 causes an effect, physically or mentally. Per V1 one on one monitoring to R2 is ongoing and R2's transfer to hospital for psych eval will take place when there is an available bed. V1 stated that currently R2 is being monitored one on one, and arrangement is being made to transfer R2 to the hospital for psych evaluation. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/17/2024 at 03:49 PM, V6 (Registered Nurse) stated that the incident between R1 and R2 happened on 12/15/24 around 09:30 AM, the time she was passing medication. V6 stated that she heard R1 yelling. V6 said, I saw R1 behind R2 and R1 said R2 pulled my hair. Per V6 the CNA (Certified Nursing Assistant) assigned to R2 was attending to another resident during the incident. V6 stated she just documented the incident and did not report to her supervisor. Per V6 abuse incidents need to be reported immediately but she forgot. V6 stated that abuse happened when R2 pulled the hair of R1, and it needs to be reported immediately. Abuse Policy dated 01/04/2024, reads: This facility affirms the right of the residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of the residents. This will be done by immediately protecting residents involved in identifying reports of possible abuse. Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to supervisor or the administrator. Initial report of allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Illinois of Department of Public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its abuse policy on investigating incidents and/or allegations of abuse for 1 (R1) of 4 residents reviewed for the right to be free from abuse. This failure affected 1 resident (R1) who suffered hair pulling by another resident (R2). Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's BIMS (Brief Interview of Mental Status) dated 10/03/2024 is 15 out of 15 indicating that R1's cognition is intact. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking in the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision, and that it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail, and that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her (R1) scared of her safety. R1 stated that there are two (2) other residents, R3 and R4, that had also experience physical aggression from R2. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November, but nothing has been done. R1 said, I spoke to V5 the social worker, who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 by V6 (Registered Nurse) documents R2 pulled R1 hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and assaulted R1 by pulling her hair. Another incident dated 10/23/2024 by V8 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attack by her several times. I don't want her killing me before they realize she is not supposed to be here. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's cognition is moderately impaired with BIMS (Brief Interview of Mental Status) of 9 dated 09/05/2024. On 12/17/24 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024) when R2 pulled R1's ponytail. According to V1, none of the facility staff told her about what happened, and that V6 (Registered Nurse) was expected to report to her any incident or allegation of abuse. V1 stated that the facility does not have any designated abuse coordinator during weekend because she still accepts calls. V1 stated that when she came on Monday (12/16/2024) before she left for the day, R1 told her about the incident that R2 pulled her hair. V1 said, that was the time I knew that R2 pulled the hair of R1. V1 then said that she did a grievance form for R1. V1 was asked why she did not do a reportable after she knew what happened between R1 and R2. V1 replied that abuse incidents or allegations need to be reported immediately, or within 2 hours upon knowing the incident, and since the incident happened on 12/14/2024, it was too late to report and investigate. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her, and the act of R2 to R1 causes an effect, physically or mentally. Per V1 one on one monitoring to R2 is ongoing and R2's transfer to the hospital for psych eval will take place when there is an available bed. V1 stated that currently R2 is being monitored one on one, and arrangement is being made to transfer R2 to the hospital for psych evaluation. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/17/2024 at 03:49 PM, V6 (Registered Nurse) stated that the incident between R1 and R2 happened on 12/15/24 around 09:30 AM, the time she was passing medication. V6 stated that she heard R1 yelling. V6 said, I saw R1 behind R2 and R1 said R2 pulled my hair. Per V6 the CNA (Certified Nursing Assistant) assigned to R2 was attending to another resident during the incident. V6 stated she just documented the incident and did not report to her supervisor. Per V6 abuse incidents need to be reported immediately but she forgot. V6 stated that abuse happened when R2 pulled the hair of R1, and it needs to be reported immediately. Abuse Policy dated 01/04/2024, reads: This facility affirms the right of the residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of the residents. This will be done by implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences. Facility will appoint an investigator. Once an allegation has been made, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident. The final investigation will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files, and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of records the facility failed to identify and provide behavioral services to 1 (R1) out of 4 residents reviewed for all services provided by the facility. These failures do not conform with facility's Behavioral Assessment, Intervention, and Monitoring policy and affected 1 resident (R1) who expressed anguish, fear of her safety, and danger from harm. Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's BIMS (Brief Interview of Mental Status) dated 10/03/2024 is 15 out of 15 indicating that R1's cognition is intact. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking on the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision, and that it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail, and that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her (R1) scared of her safety. R1 stated that there are two (2) other residents, R3 and R4, that had also experienced physical aggression from R2. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November, but nothing has been done. R1 said, I spoke to V5 the social worker, who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 written by V6 (Registered Nurse) documents R2 pulled R1 hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and that R2 assaulted R1 by pulling her hair. Another incident note by V8 dated 10/23/2024 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attack by her several times. I don't want her killing me before they realize she is not supposed to be here. On 12/17/2024 at 01:40 PM, R3 confirms that R2 hit her back multiple times, punching with her fist behind her head (R3 made a punching motion behind the right side of her back). R3 said that she turned to R2, and R2 just laughed. Per R3, staff allowed R2 to do those things. R3 states she (R3) just keeps distance with R2, as long as R2 keeps distance from her. Behavioral notes dated 07/22/2024 by V9 (Registered Nurse) documents that in the dining room, R2 hit R3 and threw milk on R3's face. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's cognition is moderately impaired with BIMS (Brief Interview of Mental Status) of 9 dated 09/05/2024. On 12/17/24 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024), when R2 pulled R1's ponytail. According to V1 none of the facility staff told her about what happened and that V6 (Registered Nurse) was expected to report to her (V1) any incident or allegation of abuse. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her. V1 states that the act of R2 to R1 causes an effect on R1, physically or mentally. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/18/2024 at 09:37 AM, V3 (Director of Nursing) state that incidents like pulling of R1's hair will affect R1 mentally. V3 said, If I were in her (R1) shoes, I will feel scared too. V3 stated that it may lead to a more aggressive actions than pulling of hair. V3 reviewed the full care plan of R1, and after review, V3 said, I don't see anything that addresses abuse incidents. V3 said that care plan should be done for both because both residents (R1 and R2) are affected. R1's care plan does not address R2's aggressive behavior toward R1. V5's (Director of Social Services) psychosocial notes do not document any of R1's incidents with R2. On 12/18/2024 at 12:06 PM, V5 (Director of Social Services) stated that all of his notes are under psychosocial and were written in general. V5 was asked about R1's psychosocial notes and why all the notes do not address any incidents from R1's encounter with R2. V5 stated that the last time he saw R1 was 11/7/2024 and there were no particular concerns for R1. V5 was asked about addressing the abuse incidents that R1 encountered in the care plan's intervention to prevent further abuse from occurring. V5 stated that since R1 is not at risk for doing abuse or does not participate back during a physical aggression, a general statement of at risk of abuse behavior was placed. V5 was asked if interventions were placed in R1's care plan would it help to prevent another incident of abuse from happening. V5 did not directly answer the question. V5 stated that if he only knew R1 felt unsafe or scared, he would go out of his way to transfer R1 into another facility. V5 was informed that the incidents of R1 and R1 expressing feelings of unsafety and fear were documented in the behavioral notes and were readily accessible. V5 did not comment. V5 was asked how he would feel if the same thing happened to him. V5 stated that he would be scared too, and added, Next time I will do better. Behavioral Assessment, Intervention and Monitoring policy dated 01/04/2024, reads: Under general guidelines, behavior is the response of an individual to a wide variety of factors. These factors may include psychosocial, emotional, psychiatric, or environmental causes. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including emotional, psychiatric and/or psychological stressors for example anxiety; and/or fear. Under management, the interdisciplinary team will evaluate behavior symptoms in the resident to determine the degree of severity, distress, and potential safety risk of the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.

Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one (R12) out of four residents reviewed in a total sample of 14 for call lights. Findings include: On 10/08/24 at 12:05 PM, R12 was observed lying in bed in R12's room. Call light was not visible. Call light was not within R12's reach. Observed yellow sign above R12's bed titled -Fall Precaution Checklist- which listed interventions including but not limited to call light at reach. R12 said, where is the call light? I don't see it. Observed pull string call light on R12's roommate side of the privacy curtain. Observed two strings attached with one long string which reached to R12's roommates bed and the other string was very short. This short string was not long enough to reach R12's side of the room. On 10/08/24 at 12:15 PM, V12 (Certified Nursing Assistant) stated the call lights should be within reach of the resident(s). V12 observed R12 lying in bed. Observed V12 trying to locate R12's call light. V12 went on the other side of R12's privacy curtain and observed the short string attached to the call light. V12 said, something happened to the string, it is too short. It won't reach him (R12). The string needs to be longer. V12 stated the call light should always be within reach of the resident for the resident's safety. V12 stated even if the resident can walk on their own the call light should be within their reach in case the resident falls and cannot get up. On 10/09/24 at 11:42 PM, observed R12 lying in bed in R12's room. Call light not visible. Call light not within R12's reach. R12 said, I cannot reach my call light. On 10/09/24 at 11:45 PM, V5 (Registered Nurse) observed R12's call light out of reach and stated, he cannot reach it and it needs to be made longer. Observed V5 looking for the call light string. V5 observed the very short string attached to the call light on the other side of R12's privacy curtain and noted the string is too short to reach R12. V5 stated the call light should be within reach of the resident so they can get the help they need and the potential problem if the call light is not within reach, the resident could fall. On 10/08/24 at 3:58 PM, V3 (Director of Nursing/Infection Preventionist) stated the call lights should be within easy reach of the resident so they can pull it when they are need of assistance. V3 stated all call lights should be within reach of the resident even if the resident is ambulatory. V3 stated if a call light is out of reach of a resident, then the resident could be in distress, or be having a life-threatening event or they could have fallen and they would not be able to alert the staff of the need for help. V3 stated this may make the resident feel as if no one cares for them. R12 has diagnoses which include but not limited to Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Alcohol Abuse, Gastro-Esophageal Reflux Disease, Unspecified Psychosis, Major Depressive Disorder, Conversional Disorder with Seizures or Convulsions. R12's MDS (Minimum Data Set) from 08/29/24 BIMS (Brief Interview for Mental Status) score is 06 out of 15 indicating severely impaired cognition and section G (Functional Status) documents in part R12 requires supervision/touch assistance with toileting hygiene and transfers. R12's Fall Risk Assessment completed 08/29/24 documents in part, score of 12 indicating high fall risk category. R12's care plan documents in part, R12 is at risk for falls related to gait/balance problems and diagnosis seizures and interventions include but not limited to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Facility provided policy titled, Call Light undated documents in part, the purpose is to respond to the resident's requests and needs in a timely and courteous manner and all residents shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. Facility provided policy titled, Fall Prevention Policy dated 12/01/22 documents in part, to identify and establish plan of care of resident with increased risk of falling as identified by a fall assessment risk and please make sure the following is complete before leaving out: call light within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to accurately document advanced directives code status for 1 resident (R12) out of a four residents reviewed in a total sample of 14 residents for advance directives. Findings include: R12 was admitted to the facility on [DATE]. R12 has diagnosis which includes but not limited to Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Alcohol Abuse, Gastro-Esophageal Reflux Disease, Unspecified Psychosis, Major Depressive Disorder, Conversional Disorder with Seizures or Convulsions. R12's MDS (Minimum Data Set) from [DATE] BIMS (Brief Interview for Mental Status) score is 06 out of 15 indicating severely impaired cognition On [DATE] at 3:00 PM, surveyor reviewed R12's IDPH (Illinois Department of Public Health) Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form signed by V10 (R12's Surrogate), dated [DATE] and documents in part Do Not Attempt Resuscitation/DNR and Selective Treatment: Primary goal of treating medical conditions with selective medical measures. On [DATE] at 3:05 PM, surveyor reviewed R12's Certification of Surrogate Decision-Making Form which documents in part the cause and nature of the qualifying condition Traumatic Brain Injury, Cognitive Impairment, and documents surrogate decision maker as V10 signed and dated [DATE]. On [DATE] at 3:10 PM, surveyor reviewed R12's Face Sheet which documented in part, Advance Directive FULL CODE. On [DATE] at 3:12 PM, surveyor reviewed R12's Order Summary Report which documents in part FULL CODE ordered [DATE]. On [DATE] at 3:15 PM, surveyor reviewed R12's care plans and could not locate care plan for advance directives and/or code status. On [DATE] at 3:28 PM, V10 (R12's Surrogate) stated via phone interview R12's wishes regarding advance directives is Do Not Resuscitate with Selective Treatment. V10 stated R12 does not want any heroic means to keep R12 alive, no CPR, but would consider use of antibiotics and hospitalization if recommended. V10 stated V10 keeps a copy of R12's POLST form at V10's home and stated R12's POLST form was revised and signed on [DATE]. V10 stated the POLST form was redone [DATE] when R12 was in the hospital and that prior to this R12 was full code. On [DATE] at 2:55 PM, V4 (Registered Nurse) stated a resident's code status is listed in the Electronic Health Record (EHR) in the Resident Profile and physician orders. V4 stated V4 is taking care of R12 today. V4 reviewed R12's EHR and stated R12 is a FULL CODE which would mean V4 would administer CPR (Cardiopulmonary Resuscitation) if indicated. On [DATE] at 4:00 PM, V3 (Director of Nursing/Infection Preventionist) stated the resident's wishes regarding code status on the POLST form should be followed as written per family/guardian preference and should also match the doctor's order in the EHR. V3 stated this is to make sure everyone is on the same page and there should be no conflicts. V3 stated this is important to make sure the resident preferences are being followed regarding code status. V3 stated it would be a problem if there is a discrepancy between the code status listed on the POLST form to that code status listed on the face sheet and physician order sheet because the potential is that the nurse could administer CPR when the resident's wishes is for DNR. On [DATE], 4:15 PM, V3 stated POLST forms for the residents who have them are kept in a book in the nursing station. Surveyor and V3 reviewed Advance Directives binder located at the nursing station and could not find a copy of R12's POLST form. V3 stated if R12 has a POLST form it should be kept in that binder, so the nurses have easy access to it and can cross check it with the information in R12's EHR. V3 stated the Advance Directive binder needed to be updated. Facility policy titled, Advance Directives dated [DATE] documents in part the purpose of this policy is to reflect residents wishes about receiving Cardiopulmonary Resuscitation (CPR) and life sustaining treatment such as medical interventions and artificial administration nutrition. It allows a resident, in consultation with their healthcare professional, to decide an (in) advance about CPR and other life sustaining decisions in the event the residents breathing and or heartbeat stop or they are at the end of life. At the time of admission residents will be interviewed regarding their code status and or preference and will be documented in their electronic health record. Facility policy titled, In-House DNR Policy undated, documents in part, it is the facility's policy to ensure that residents who DNR (Do Not Resuscitate) receive no resuscitation when found without vital signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policies and procedures for the Preadmission Screening and Annual Resident Review (PASARR) process for 2 (R2, R8) residents reviewed for a Level 2 PASARR Screening for Mental Disability (MD) and Intellectual Disability (ID) in a total sample of 14. Findings Include: 1. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively impaired. According to the admission Record, R2 is [AGE] years old, R2 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. There is no documentation to show that R2 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 10/09/24 at 3:10 PM, the surveyor asked V2 (Assistant Administrator) for a Level 2 PASARR screening for R2. V2 provided the surveyor with a Level 1 PASARR screening dated 4/20/15 for R2. V2 was unable to provide a Level 2 PASARR screening for R2. V2 stated that V2 has no Level 2 PASARR for R2. 2. R8's admission record showed initial admission date on 7/1/2012 with diagnoses not limited to Malignant neoplasm of unspecified site of right female breast, Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, Unspecified dementia, Essential (primary) hypertension, Other specified peripheral vascular diseases, Bipolar disorder, Anemia, Chronic kidney disease. MDS dated [DATE] showed R8's cognition was intact. On 10/09/24 at 10:56 AM No PASARR found in R8's health record. On 10/9/24 at 11:13am V2 (Assistant Administrator) stated when a resident is admitted to the facility, assessment pro becomes accessible. V2 stated he can't check the PASARR prior to admission. Social worker/discharge planner from the hospital is checking it (PASARR) prior to admission, the facility is not checking PASARR prior to admission. He (V2) said PASARR is done to determine if resident is eligible for nursing care or appropriate for placement. He (V2) stated R8's PASARR was not obtained. Facility unable to provide PASARR evaluation for R8. The facility policy titled, Preadmission Screen and Resident Review (PASRR) dated 12/2022 documents read in part: Prior to admission and upon any changes in status, residents will be screened for a known or suspected diagnosis of severe mental illness, developmental disability, or intellectual disability to ensure resident is appropriate for nursing facility services.

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5% for 3 (R6, R22, R27) of 11 residents reviewed for medication administration. There was a total of 28 opportunities with 4 errors observed, which resulted in a medication error rate of 14.29%. Findings Include: On 10/08/24 at 11:31 AM, Surveyor observed V4 (Registered Nurse) checked R6's blood glucose. R6's blood glucose reading was 218. V4 stated, based on R6's insulin sliding scale order, R6 will be getting 1 unit of Fiasp insulin injection. At 11:59 AM, V4 was about to prepare R6's insulin injection, but V4 was unable to find R6's Fiasp insulin medication in the medication cart or the convenience box. V4 stated R6 will not be receiving the ordered insulin injection since it's not available. R6's physician orders show R6 to receive 1 unit of Fiasp Injection (Insulin Aspart) for blood glucose reading of 181-220 (ordered on 8/08/24). R6's progress notes written by V4 dated 10/08/24 at 12:52 PM documents in part, Fiasp Injection Solution 100 UNIT/ML(milliliters) (Insulin Aspart) not administered, awaiting pharmacy delivery later today. On 10/09/24 at 8:55, V8 (Registered Nurse) was obsereved preparing R22's morning medications. V8 prepared Metoprolol 100 mg, Amlodipine 5 mg (milligrams), Benztropine 2 mg, Haloperidol 10 mg, Lorazepam 0.5 mg, Losartan Potassium 50 mg, and Multivitamin 1 tablet for R221. At 9:00 AM, R22 took the oral pills. At 9:02 AM, V8 stated [V8] completed R22's medication pass and continued to R27's room. R22's 10/09/24 Medication Administration Record (MAR) documents in part a 9:00 AM dose for Flonase Nasal 1 spray in both nostrils. V8 did not administer it during 10/09/24 medication administration observations. On 10/09/24 at 9:07 AM, V8 prepared R27's morning medications. Surveyor observed V8 preparing Aspirin 81 mg, Seroquel 25 mg, Metoprolol 12.5 mg, and Buspirone 5mg for R27. V8 stated R27's Levetiracetam solution (anticonvulsant medication) is not available and R27 will not be receiving it. At 9:09 AM, R27 took the oral pills and was notified by V8 that R27 will miss a dose of R27's Levetiracetam solution. R27's 10/09/24 MAR documents in part 9:00 AM dose for Levetiracetam Solution 100 MG/ML to give 1 ML by mouth for seizure activity, Aspirin 325 mg 1 tablet, Seroquel 25mg, Metoprolol 12.5 mg, and Buspirone 5 mg. R27 did not receive the ordered dose of Levetiracetam and only received Aspirin 81 mg (ordered Aspirin 325 mg). On 10/09/24 at 11:59 PM, interviewed V3 (Director of Nursing) and stated that for medication administration, the nurses should be following the 6 Rs right resident, right route, right medication, right time, right dose, and right for education. V2 stated nurses are supposed to be following physician orders when administering medications to the residents. Facility's Quality Assurance in Medication Administration policy (no date) documents in part: The medications must be administered in accordance with the written orders of the physician. Therefore, medication administration record (M.A.R.) must be used while passing the medications. The medication must be given in correct strength, route, and dosage form and at correct time.

Based on observations, interviews, and record reviews, the facility failed to ensure that two residents (R6, R27) were free of any significant medication errors out of eleven residents reviewed for medication administration. Findings include: On 10/08/24 at 11:31 AM, Surveyor observed V4 (Registered Nurse) checking R6's blood glucose. R6's blood glucose reading was 218. V4 stated, based on R6's insulin sliding scale order, R6 will be getting 1 unit of Fiasp insulin injection. At 11:59 AM, V4 was about to prepare R6's insulin injection, but V4 was unable to find R6's Fiasp insulin medication in the medication cart or the convenience box. V4 stated R6 will not be receiving the ordered insulin injection since it's not available and V4 will follow up with pharmacy. R6's face sheet documents in part a medical diagnosis of Type 2 Diabetes Mellitus Without Complications. R6's physician orders show R6 to receive 1 unit of Fiasp Injection (Insulin Aspart) for blood glucose reading of 181-220 (ordered on 8/08/24). R6's care plan documents in part, R6 has Diabetes Mellitus with one intervention that includes, Diabetes medication as ordered by doctor. R6's progress notes written by V4 dated 10/08/24 at 12:52 PM documents in part, Fiasp Injection Solution 100 UNIT/ML (milliliters) (Insulin Aspart) not administered, awaiting pharmacy delivery later today. On 10/09/24 at 9:07 AM, V8 (Registered Nurse) prepared R27's morning medications. Surveyor observed V8 prepare Aspirin, Seroquel, Metoprolol, and Buspirone for R27. V8 stated R27's Levetiracetam solution (anticonvulsant medication) is not available and R27 will not be receiving it. V8 stated V8 will follow up with pharmacy. At 9:09 AM, interviewed R27 and stated R27 has not received R27's Levetiracetam medication for four days now. R27 stated R27 is taking it for seizures. R27's face sheet documents in part a medical diagnosis of Anoxic Brain Damage and Cerebral Infarction. R27's 10/09/24 Medication Administration Record (MAR) documents in part a 9:00 AM dose for Levetiracetam Solution 100 MG/ML (milligrams/milliliters) to give 1 ML by mouth two times a day for seizure activity. V8 did not administer it during 10/09/24 observations and was not signed off on the MAR as given. R27's progress notes written by V8 dated 10/09/24 at 11:48 AM documents in part, LevETIRAcetam Solution 100 MG/ML Give 1 ml by mouth two times a day for seizure activity medication on order. A follow-up call was placed over to the pharmacy staff. On 10/09/24 at 11:59 PM, V3 (Director of Nursing) stated that nurses are to administer residents' medications according to physician's orders. V2 stated if medications are not administered as ordered, there could be adverse reactions. V2 stated nurses must call the physician and follow up with the pharmacy. V2 stated insulins, anticonvulsants, cardiac medications are high alert medications. V2 further stated that if residents miss their anticonvulsant medication, the resident could possibly have seizure activity and if a resident misses their insulin, there could be an adverse reaction such as hyperglycemia. Facility's Quality Assurance in Medication Administration policy (no date) documents in part: The medications must be administered in accordance with the written orders of the physician. Therefore, medication administration record (M.A.R.) must be used while passing the medications. The medication must be given in correct strength, route, and dosage form and at correct time.

Based on observation, interview, and record review the facility failed to provide and follow menus and recipes to ensure menu variety for three (R2, R5, R15) out of three residents reviewed for pureed menus in a final sample of 14. Findings Include: On 10/08/24 at 10:20 AM, V14 (AM Cook) stated there are no recipes in the kitchen to follow for pureed diet consistencies. V13 (Dietary Manager) stated the kitchen does not follow any production or spreadsheets and that the cooks know how to prepare and what to serve different diets because they have been working here a long time. On 10/08/24 at 12:55 PM, observed regular diets receiving Hawaiian Chicken with pineapple, white rice, broccoli, and fruit cocktail. Residents on pureed diets appeared to receive pureed white meat, mashed potatoes, pureed green vegetable and pureed canned fruit. On 10/09/24 at 11:15 AM, observed V14 prepare pureed food for lunch. V14 stated residents on a regular and mechanical soft diet are receiving spaghetti with meatballs in tomato sauce, mixed vegetables, cornbread, and chocolate water cookies. V14 stated residents on a pureed diet are receiving pureed meatballs in tomato sauce, mashed potatoes, pureed mixed vegetables and applesauce. V14 stated V14 does not puree the spaghetti for the pureed diets because the pureed spaghetti is ick so that is why V14 is serving mashed potatoes to the pureed diets. V14 stated V14 does not puree rice either and that yesterday when the regular and mechanical soft diet received rice the pureed diets all received mashed potatoes. V14 stated the pureed diets are also not receiving pureed cornbread today, only the regular and mechanical soft diets are getting cornbread. On 10/09/24 at 12:20 PM, V15 (PM Cook) stated V15 is the cook that made dinner for the residents on 10/08/24. V15 stated residents on regular diets received chili dogs, tater tots, and applesauce and the residents on pureed diets received mashed potatoes, pureed string beans, pureed chicken patty and applesauce. V15 stated V15 always gives residents on pureed diets mashed potatoes at every meal. V15 stated V15 does not puree tater tots, or potato wedges, Au Gratin potatoes, rice, or spaghetti. V15 stated on evening meals when the regular and mechanical soft diets are receiving cold sandwiches for dinner V15 does not give the pureed diets pureed a cold sandwich, V15 substitutes a hot meal (pureed meat, pureed hot vegetable and mashed potatoes). On 10/09/24 at 12:38 PM, V13 stated residents on pureed diets should receive the same food that the regular diets receive only in pureed form when possible. V13 stated the kitchen does not puree corn, beans, rice, raw vegetables, or processed meats. V13 stated there are no recipes for pureed foods available in the kitchen for the cooks to follow. V13 stated last night on 10/08/24 the regular and mechanical soft diets received chili dogs, tater tots and applesauce for the dinner meal. V13 stated the residents on pureed diets get whatever the kitchen has available which is usually leftovers from two days ago assuming they did not have that already to eat. V13 stated the cooks do not have anything to follow like a spreadsheet or production sheet but the cooks know the pureed diets need a starch, a vegetable and protein and a dessert so it is up to the cook to determine what they want to serve the pureed diets for a particular meal based on food availability. V13 stated residents on pureed diets get mashed potatoes at every lunch and dinner every day. V13 said, they must get tired of receiving the same thing every day. I don't know why it is like that here. That is just the way it has always been done here. V13 stated applesauce was given to the pureed diets today, not pureed cookies and the pureed diets received applesauce last night for their dessert at dinner so the pureed diets received applesauce 2 days in a row which is not varied menu. V13 stated the cornbread was not pureed because it probably doesn't puree up well. On 10/09/24 at lunch meal observed regular diets receiving spaghetti with meatballs in tomato sauce, cornbread, mixed vegetables, and sandwich wafer cookies. Residents on pureed diets received pureed meatballs, mashed potatoes, pureed mixed vegetables and applesauce. Pureed diets did not receive pureed cornbread, pureed cookies, or pureed spaghetti. On 10/10/24 at 11:52 AM, V6 (Registered Dietitian) stated the menus have been created to ensure nutritionally adequacy and the menus should be followed to make sure the residents receive a variety of different foods. V6 stated residents should not receive the same foods over and over so they do not get bored getting the same items. V6 stated the cooks should be following the menus and recipes, and it is not okay for the cook to make substitutions on their own they would need to be approved by V6. V6 stated the potential problems if the kitchen staff are not following a menu and recipe is that the residents may not be getting enough calories, protein, or micronutrients and this could also cause problems with menu variety. V6 stated when the cooks are preparing pureed foods, they should be following a recipe. V6 stated basically you can puree any regular item as long as it reaches a pureed consistency (no lumps, or pieces or participles). V6 stated residents receiving a purred diet should receive same food as regular just in pureed form assuming the item can be safely pureed. V6 stated items such as rice, spaghetti, tater tots, hotdogs, cornbread can all be pureed with the right preparation which is why it is important for the cooks to follow recipes. Residents on pureed diets should not receive mashed potatoes with lunch and dinner every day or applesauce back-to-back for dessert because they should have a more variety of foods in their meals. R2 has diagnosis which includes but not limited to Parkinson's Disease, Type 2 Diabetes Mellitus, Bipolar Disorder, Schizoaffective Disorder, Major Depressive Disorder, Hypertension, Gastrostomy Status, Dysphagia, Dementia, Cerebral Infarct Due To Unspecified Occlusion Or Stenosis Of Unspecified Cerebral Artery. R2's Order Summary Report printed 10/09/24 documents in part, pureed diet texture, thin consistency order date 08/16/22. R2's MDS (Minimum Data Set) dated 08/07/24 BIMS (Brief Interview for Mental Status) was 5 out of 15 indicating severe cognitive impairment and R2 requires mechanically altered, therapeutic diet. R5 has diagnosis not limited to Dementia, Parkinson's Disease, Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Unspecified Cerebral Artery, Dysphasia Following Cerebral Infarction, Bell's Palsy, Moderate Intellectual Disabilities, Schizoaffective Disorder, Malignant Neoplasm Of:, Morbid Severe Obesity Due To Excess Calories. R5's Order Summary Report printed on 10/09/24 documents in part, pureed texture, nectar consistency ordered 05/19/22. R5's MDS (Minimum Data Set) dated 09/07/24 BIMS (Brief Interview for Mental Status) was not able to be assessed and R5 requires mechanically altered, therapeutic diet. R15 has diagnosis not limited to Cerebral Palsy, Acute Respiratory Failure, Dysphasia, Reduced Mobility, Moderate Protein Calorie Malnutrition, Repeated Falls, Muscle Wasting Atrophy, Difficulty In Walking, Encounter For Attention To Gastrostomy, Major Depressive Disorder, Anxiety Disorder, Pain. R15's Order Summary Report printed on 10/09/24 documents in part, pureed texture, thin consistency order date 09/04/24. R15's MDS (Minimum Data Set) dated 08/16/24 BIMS (Brief Interview for Mental Status) was not able to be assessed and R15 requires mechanically altered, therapeutic diet. Kitchen policy titled, Standardized Recipes dated 10/02/23 documents in part, standardized recipes for menu items will be used to help ensure consistent quality, portion size and cost control. Recipes are standardized for the facility and will accompany the menu, all recipes will be followed as written. Kitchen policy titled, Cycle Menu dated 09/26/23 documents in part, the facility will follow a cycle menu planned at least 4 weeks in advance. Menus are planned using established national guidelines to assure the menu meets nutritional needs.

Based on observation, interview, and record review the facility failed to label and date food items in resident personal refrigerators and failed to discard unlabeled/undated spoiled foods in resident personal refrigerators. This has the potential to effect one resident (R29) out of four residents reviewed for personal food storage in a total sample of 14. Findings include: On 10/08/24 at 11:25 AM, observed personal refrigerator in R29's room next to R29's bed. R29 gave surveyor permission to look inside R29's refrigerator. R29 said, I cannot reach inside the refrigerator, so I don't know what's in there. R29 stated R29 likes to buy himself food from outside the facility. Observed the following items inside R29's refrigerator: 1.) Opened one-pound plastic container of Turkey Bologna 50% full, not labeled or dated with an open or use by date. The turkey bologna had a sour, off-putting smell to it. 2.) Opened plastic container of hotdogs with two hot dogs left in the package. The plastic wrapping was covered in black to dark gray spots and the two hotdogs were discolored with a green tint to them. The container was not labeled or dated with an open or use by date. 3.) Opened 32-ounce container of Almond Milk 80% full, not labeled or dated with an open or use by date. The container had manufacturer guidelines printed as follows refrigeration not needed before opening, once opened refrigerate 7-10 days. On 10/08/24 at 11:35 AM, R29 stated R29 did not realize the hotdogs and turkey bologna were still in R29's refrigerator. R29 stated R29 buys food but cannot open or reach items because R29 does not have enough hand strength. R29 stated no one ever told R29 that the food inside R29's refrigerator should be labeled and dated. R29 said, see? I keep markers on the side on my refrigerator which can be used to label my food. R29 stated R29 did not know the almond milk should be discarded once it is opened after 10 days. R29 said, thank you for telling me that. On 10/08/24 at 11:46 AM, V13 (Dietary Manager) stated V13 is responsible for checking the resident's personal refrigerators daily to check the temperatures inside the refrigerators and to look for any old or expired foods. V13 stated the items inside should be dated but it is not V13's responsibility to date them. V13 stated the food items inside should be dated because otherwise staff have no way of knowing how long an item has been inside the refrigerator or when to throw away the item so residents do not eat the spoiled food which could potentially make the residents sick. V13 opened the package of hot dogs and stated V13 does not know what the black spots are or why the hotdogs are greenish in color. V13 acknowledged the bad smell of the turkey bologna. R29 asked V13 to throw out the hotdogs and turkey bologna. R29 stated R29 had opened the almond milk 2-3 days so R29 did not want to throw it out but stated someone could write an open date on the container. On 10/10/24 at 12:20 PM, V6 (Registered Dietitian) stated food items inside resident's personal refrigerators should be labeled and dated so the staff/resident knows when item needs to be thrown out. V6 stated it is important that residents do not consume expired items because that could potentially make them sick. R29's diagnosis which includes but not limited to Cachexia, Unspecified Severe Protein-Calorie Malnutrition, Anemia, Type II Diabetes Mellitus, Orthostatic Hypertension, Weakness, Adult Failure to Thrive, Abnormal Weight loss, Neuromuscular Dysfunction of Bladder, Retention of Urine, Fatty Liver. R29's Order Summary Report dated 10/10/24 documents in part general diet, regular texture dated 09/22/23. R29's MDS (Minimum Data Set) dated 09/27/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. Facility provided policy titled, Food Policy From Outside Sources undated documents in part, food and beverages brought in from the outside will be labeled and dated with the resident's name, room number and the date the items was brought into the facility for consumption/storage, they will be appropriately labeled and dated when accepted for storage and discarded after 48 hours and staff will be responsible for checking resident personal refrigerator daily for proper labeling, temperature recording.

Based on interview and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 13 (R31, R11, R32, R4, R2, R35, R37, R5, R12, R19, R15, R24, R20) out of 26 residents reviewed for comprehensive resident assessments. Findings Include: On 10/09/24 at 2:27 PM, record reviews of the following Minimum Data Set (MDS) assessments revealed the following: 1. R31's Annual MDS assessment with assessment reference date (ARD) of 5/29/24, date signed assessment as complete on 7/15/24. 2. R11's Annual MDS assessment with ARD of 10/29/23, date signed assessment as complete on 12/3/23. 3. R32 Annual MDS assessment with ARD of 7/18/24, date signed assessment as complete on 9/19/24. 4. R4's Annual MDS assessment with ARD of 7/25/24, date signed assessment as complete on 9/19/24. 5. R2's Annual MDS assessment with ARD of 4/26/24, date signed assessment as complete on 7/1/24. 6. R35's admission MDS assessment with ARD of 5/5/24, date signed assessment as complete on 7/18/24. 7. R37's admission MDS assessment with ARD of 5/15/24, date signed assessment as complete on 7/21/24. 8. R5's Annual MDS assessment with ARD of 5/15/24, date signed assessment as complete on 7/2/24, and care areas completed on 7/10/24. 9. R12's Annual MDS assessment with ARD of 11/29/23, date signed assessment as complete on 1/25/24. 10. R19's Annual MDS assessment with ARD of 11/5/23, date signed assessment as complete on 12/24/23. 11. R15's Annual MDS assessment with ARD of 5/16/24, date signed assessment as complete on 7/2/24, and care areas completed on 7/10/24. 12. R24's Annual MDS assessment with ARD of 10/19/23, date signed assessment as complete on 11/16/23. 13. R20's Annual MDS assessment with ARD of 5/15/24, date signed assessment as complete on 7/11/24. On 10/10/24 at 10:14 AM, V17 (Licensed Practical Nurse MDS/Care Plan Coordinator) stated [V17] follows RAI guidelines including timeframe of every MDS assessment which are admission, annual, quarterly, and significant change. V17 stated that admission MDS ARD is set within 14 days from admission and completed 14 days from the ARD. Example if resident is admitted today 10/10/24, ARD should be set within 10/10 to 10/23/24. Care Area Assessments (CAA) completed by the 14th day from admission. Transmission is within 14 days from the completion date. V17 stated that Annual MDS ARD is set every year and should be completed 14 days from the ARD. Chapter 2 of the RAI (October 2024) manual page 17 titled RAI OBRA-required Assessment Summary indicates that admission MDS assessment's completion date is no later than the 14th calendar day of the resident's admission, and the Annual MDS assessment's completion date is no later than 14 days from the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete MDS (Minimum Data Set) assessments using CMS - specified Resident Assessment Instrument (RAI) process within the regulatory timeframes. This failure can potentially affect 13 (R1, R6, R9, R13, R17, R21, R23, R26, R27, R30, R33, R34, R38) out of 26 residents reviewed for resident assessment. The findings include: On 10/09/24 02:30 PM Surveyor reviewed the following MDS assessments and showed the following: 1. R1 Quarterly MDS dated [DATE] showed completion date on 9/27/24. 2. R6 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 3. R9 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 4. R13 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 5. R17 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 6. R21 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 7. R23 Quarterly MDS dated [DATE] showed completion date on 9/30/24. 8. R26 Quarterly MDS dated [DATE] showed completion date on 9/27/24. 9. R27 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 10. R30 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 11. R33 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 12. R34 Quarterly MDS dated [DATE] showed completion date on 9/30/24. 13. R38 Quarterly MDS dated [DATE] showed completion date on 9/30/24. On 10/10/24 at 10:14am V17 (MDS/Care Plan coordinator, LPN-Licensed Practical Nurse) stated she has been working in the facility for 2 years. MDS is an assessment to determine resident's ADL (activities of daily living), cognitive function, urinary / bowel function, current diagnosis, medication use, skilled therapy, and any falls. She said they follow RAI (Resident Assessment Instrument) guidelines including timeframe of every MDS assessment which are admission, annual, quarterly, and significant change. Quarterly ARD (Assessment Reference Date) is set every 91 days or prior from the last ARD. Completion date should be 14 days from the ARD. If not following the RAI guidelines required timeframe there would be problem with acceptance of the MDS assessment and it can potentially affect the care of the resident. Reviewed EHR (electronic health record) with V17 for the following residents: R6's Quarterly MDS ARD was on 7/24/24 and was completed on 9/19/24. V17 said R6's MDS assessment should have been completed 8/7/24. R38's Quarterly MDS ARD 8/21/24 was completed on 9/30/24. V17 sated R38's MDS assessment should have been completed 9/4/24. She said the MDS assessments have a late completion date. V17 stated she has been sick and maybe did not lock the assessment within the timeframe stated by RAI guideline. CMS'S (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 manual dated October 2024 page 2-17 documented in part: Quarterly (Non-Comprehensive) MDS Completion Date (Item Z0500B) No Later Than ARD + 14 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each Minimum Data Set (MDS) assessment was certified as complete by a registered nurse (RN) for 7 (R6, R17, R23, R27, R30, R34, R38) out of 26 residents' assessments reviewed. The findings include: 1. R6 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN/Licensed Practical Nurse). 2. R17 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN). 3. R23 Quarterly MDS dated [DATE] showed completion date on 9/30/24 and signed by V17 (LPN). 4. R27 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN). 5. R30 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN). 6. R34 Quarterly MDS dated [DATE] showed completion date on 9/30/24 and signed by V17 (LPN). 7. R38 Quarterly MDS dated [DATE] showed completion date on 9/30/24 and signed by V17 (LPN). On 10/10/24 at 10:14am V17 (MDS/Care Plan coordinator, LPN-Licensed Practical Nurse) stated she has been working in the facility for 2 years. MDS is an assessment to determine resident's ADL (activities of daily living), cognitive function, urinary / bowel function, current diagnosis, medication use, skilled therapy, and any falls. She said they follow RAI (Resident Assessment Instrument) guidelines including timeframe of every MDS assessment which are admission, annual, quarterly, and significant change. State Operations Manual (SOM) dated 08-08-24 page 222 documented in part: Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's needs. This failure can potentially affect 5 (R1, R8, R27, R28, R39) of 5 residents reviewed for comprehensive care plan in the sample of 14. The findings include: R1's admission record showed initial admission date on 1/24/2022 with diagnoses not limited to Chronic obstructive pulmonary disease, Essential (primary) hypertension, Alzheimer's disease, Epilepsy, Gastro-esophageal reflux disease, Overactive bladder, Body mass index 19.9 or less, adult, Anemia in other chronic diseases classified elsewhere, Ventral hernia without obstruction or gangrene, Paranoid schizophrenia, Other specified arthritis multiple sites. MDS (Minimum Data Set) dated 8/10/24 showed R1's cognition was severely impaired. R1's POS (physician order sheet) dated 10/10/24 showed FULL CODE. No care plan found in R1's health record regarding code status. R8's admission record showed initial admission date on 7/1/2012 with diagnoses not limited to Malignant neoplasm of unspecified site of right female breast, Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, Unspecified dementia, Essential (primary) hypertension, Other specified peripheral vascular diseases, Bipolar disorder, Anemia, Chronic kidney disease. MDS dated [DATE] showed R8's cognition was intact. R8's POS (physician order sheet) dated 10/9/24 showed code status: DNR (Do Not Resuscitate). No care plan found in R8's health record regarding code status. R28's admission record showed initial admission date on 3/2/2023 with diagnoses not limited to Malignant neoplasm of pancreas, Type 2 diabetes mellitus without complications, Chronic obstructive pulmonary disease, Heart failure, Essential (primary) hypertension, Atherosclerotic heart disease of native coronary artery, Presence of cardiac pacemaker. MDS dated [DATE] showed R28's cognition was intact. R28's POS (physician order sheet) dated 10/9/24 showed FULL CODE. No care plan found in R28's health record regarding code status. R39's admission record showed initial admission date on 5/25/2024 with diagnoses not limited to Malignant neoplasm of unspecified site of right female breast, Anemia, Restlessness and agitation, Acute embolism and thrombosis of other specified deep vein of left lower extremity, Major depressive disorder, Other schizophrenia, Encounter for screening for unspecified developmental delay, Gastro-esophageal reflux disease without esophagitis. MDS dated 9/5//24 showed R39's cognition was moderately impaired. R39's POS (physician order sheet) dated 10/9/24 showed FULL CODE. POS showed active order of Alprazolam (antianxiety medication) and Haldol (antipsychotic medication). No care plan found in R39's health record regarding code status, use of anti-anxiety and anti-psychotic medication. On 10/10/24 at 10:14am V17 (MDS-Minimum Data Set/Care Plan coordinator, LPN-Licensed Practical Nurse) was interviewed and stated the following: (V17) has been working in the facility for 2 years. Care plans (CP) are done or developed for every resident and should be individualized according to resident's needs/problem. A care plan is important so staff know what kind of care or treatment the resident needs. If there is no care plan, staff might not know how much care the resident's needs. Care plans are completed by the interdisciplinary team. Seizure diagnosis needs to be care planned. Residents on psychotropic medication, a CP should be done by category of psychotropic medications (separate care plan for antidepressant, antipsychotic, antianxiety, hypnotic medication) because each medication has different side effects and should have different interventions. Advance directives should be care planned. Staff need to know the code status of the resident. A CP includes interventions on how to care for the residents. EHR (electronic health records) were reviewed with V17. V17 was unable to locate a plan for advance directive for R1, R8, R28 and R39. No care plan found for antipsychotic or antianxiety medication use for R39. Facility's policy for care plan, comprehensive person-centered (undated) documented in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his / her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. On 10/09/24 at 9:09 AM, R27 stated R27 has not received Levetiracetam medication for four days now. R27 stated R27 is taking it for seizures. At 11:00 AM, Surveyor requested for R27's care plan for anticonvulsant medication use. At 11:59 AM, V3 (Director of Nursing) stated R27 has no care plan addressing the anticonvulsant medication use for seizures. R27's face sheet documents in part a medical diagnosis of Anoxic Brain Damage and Cerebral Infarction. R27's physician orders document in part: Levetiracetam Solution 100 MG/ML to give 1 ML by mouth two times a day for seizure activity.

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure emergency supplies in the crash cart were securely locked at all times when not in used. This failure has the potential to affect 19 ambulatory residents residing in the facility (R12, R32, R33, R6, R22, R17, R19, R4, R35, R9, R39, R30, R37, R27, R28, R31, R13, R20, R10). Findings Include: On 10/08/24 at 9:47AM, observed emergency crash cart parked in the hallway easily accessible to anyone walking by the front lobby and the nurses' station. The emergency crash cart was not locked and some of the items found inside were intravenous (IV) line kits, multiple sizes needles, oxygen tubing, and four 1 Liter IV fluid bags. On 10/08/24 at 10:28 AM, V4 (Registered Nurse) and V5 (Registered Nurse) stated the night shift nurse checks the emergency crash cart. V4 stated that the cart is supposed to be locked. V4 and V5 stated they do not know how long the cart has been unlocked. Both denied unlocking it. Both stated any resident can potentially access what's inside if it's not locked and it would be a safety issue if a resident was to access the needles. On 10/08/24 at 10:45 AM, V3 (Director of Nursing) stated that the emergency crash cart is supposed to be locked when not in use, but the facility has no lock for it. V3 stated, V2 (Assistant Administrator) is in the process of ordering a new one. When I came in August it did not have a lock. We put a temporary lock, but it did not work. The IV fluids, needles, gowns, blood glucose machine, and oxygen tubing are inside the crash cart. I check it when I'm here. The nurses should be checking it every shift. We don't have a lock for it. The residents do not touch it. If a resident walks by it and opens it, then that would be a potential safety hazard. They could get the needles out of the cart, and they can open up the IV fluids and take it to their room. Out of 38 residents from the facility's residents' roster dated 10/08/24, restorative provided a list of residents who are ambulatory, and it revealed a total of 19 residents. The facility's Crash Cart policy and procedure (no date) documents in part: The crash cart will be locked at all times to ensure that all supplies are available during the course of a medical emergency. The crash cart will be checked daily to ensure that the crash cart lock is intact. If the lock is not intact the nurse will verify that all supplies are present in the crash cart and then relock the cart. Any time that the crash cart is used for a medical emergency, the crash cart will be restocked and relocked as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform monthly medication regimen review (MRR) for 4 (R8, R28, R35, and R39) residents reviewed for psychotropics in a sample of 14. Findings Include: R35 was admitted to the facility on [DATE] with diagnoses not limited to Bipolar disorder, Major depressive disorder, Metabolic Encephalopathy, Long term use (current) of anticoagulants, and Anoxic brain damage. R35's MDS shows R35 is moderately cognitively impaired. On 10/10/24 at 10:04 AM, V3 (Director of Nursing/DON) stated that Medication Regimen Review (MRR) should be done monthly by the pharmacist, but V3 does not have any MRR done for R35 or any residents in this facility. V3 stated that it is important for the pharmacist to perform monthly MRR to evaluate the effectiveness, adverse reaction, and the safety of the medication to R35 or any residents. Surveyor requested for the MRR policy from V1, and V3 multiple times on 10/9/24 and 10/10/24 but the facility could not provide the policy. R35's Minimum Data Set (MDS) dated [DATE] shows R35 is moderately cognitively impaired. R35's Physician Order Sheet (POS) with active orders as of 10/10/24 shows an order for Fluoxetine HCL oral tablet 10 mg (milligrams) by mouth one time a day related to depressive disorder. R35's Medication Administration Records (MAR) dated 09/24 to 10/24 shows R35 is currently on Fluoxetine HCL oral tablet 10 mg daily for depressive disorder, and Valproic Acid oral solution 25ml (milliliters) via peg tube every 12 hours related to major depressive and bipolar disorder. Reviewed the only R35's Pharmacist's Medication Review (MRR) dated 71/24 and 7/10/24. The facility's policy titled: Psychotropic Drug Program dated 6/2000 documents read in part: All residents on psychotropic drugs will be evaluated upon admission for medication review. On 10/10/24 at 9:51 AM Surveyor reviewed R39's physician order sheet (POS) and showed order including but not limited to: ALPRAZolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 Days. Haloperidol Tablet 5 MG Give 1 tablet by mouth two times a day. TraZODone HCl Tablet 150 MG Give 1 tablet by mouth at bedtime for insomnia At bedtime. Medication review regimen (MRR) not found in R39's electronic health record. At 11:20 AM Surveyor reviewed R8's physician order sheet (POS) and showed order not limited to: ALPRAZolam Tablet 0.25 MG Give 1 tablet by mouth two times a day Sertraline HCl Tablet 100 MGGive 200 mg by mouth at bedtime. Medication review regimen (MRR) not found in R8's electronic health record. At 1:29 PM Surveyor reviewed R28's physician order sheet (POS) and showed order including but not limited to: PARoxetine HCl Oral Tablet 10 MG (Paroxetine HCl) Give 1 tablet by mouth at bedtime for Generalized Anxiety Disorder. ( Give with 40mg for a total dose of 50 mg). PARoxetine HCl Oral Tablet 40 MG (Paroxetine HCl) Give 1 tablet by mouth at bedtime for Generalized Anxiety Disorder. (Give with 10mg for a total dose of 5mg). Medication review regimen (MRR) not found in R28's electronic health record. On 10/10/24 at 11:52am V3 (Director of Nursing / DON) said she started working in the facility in August 2024. V3 stated a MRR should be done at least monthly by pharmacy, looking for effectiveness, side effects, compatibility with some other medications. V3 stated a MRR is a wholistic review of resident medications and evaluation if medication is needed for safety of medication administration. Several attempts were made to request MRR of R8, R28 and R39, facility was not able to provide.

Based on observation, interview, and record review, the facility failed to properly date opened multi-dose inhalers for 4 residents (R2, R23, R28, R31) and to dispose a house stock medication after the expiration date from one out of one cart reviewed for medication storage and labeling. Findings include: On 10/08/24 at 9:28 AM, the facility's medication cart was inspected with V5 (Registered Nurse). There was a bottle of house stock Famotidine 10 mg (milligrams) medication with expiration date of 9/24 labeled on the bottle. There were also R23's Breo inhaler without the opened date on the label; R28's Incruse inhaler without the opened date on the label and shows to discard 6 weeks after opening; R31's Advair inhaler without the opened date on the label and shows to discard 30 days after opening; and R2's Fluticasone Furoate inhaler without the opened date on the label and shows to discard 42 days after opening. On 10/09/24 at 11:59 PM, V3 (Director of Nursing) stated all inhalers should be labeled with the date it was opened, and discard based on the label. V3 stated over-the-counter medications are supposed to be discarded on the expiration date and are not to be given or be stored in the medication cart over the expiration date. V3 stated all medications should be discarded by the expiration date. R2's physician orders document in part: Fluticasone Furoate Aerosol Powder Breath Activated 1 puff inhale orally every 24 hours as needed. R23's physician orders document in part: Breo Inhalation Aerosol Powder Breath Activated 1 puff inhale orally one time a day. R28's physician orders document in part: Incruse Ellipta Inhalation Aerosol Powder Breath Activated 1 puff inhale orally one time a day. R31's physician orders document in part: Advair Diskus Aerosol Powder Breath Activated 2 puff inhale orally two times a day. The facility's ID1: STORAGE OF MEDICATIONS policy (revised 11/22) documents in part: Expiration Dating (Beyond-use dating) C. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, inhalants, blood glucose testing solutions and strips, once opened, require an expirations date shorter than the manufacturer's expiration date to insure medication purity and potency. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

R1's admission record showed initial admission date on 1/24/2022 with diagnoses not limited to Chronic obstructive pulmonary disease, Essential (primary) hypertension, Alzheimer's disease, Epilepsy, Gastro-esophageal reflux disease, Overactive bladder, Body mass index 19.9 or less, adult, Anemia in other chronic diseases classified elsewhere, Ventral hernia without obstruction or gangrene, Paranoid schizophrenia, Other specified arthritis multiple sites. MDS (Minimum Data Set) dated 8/10/24 showed R1's cognition was severely impaired. On 10/8/24 at 12:50pm Observed R1 lying in bed, alert and verbally responsive with confusion. Lunch tray was provided with pureed food consistency. R1 can feed self post tray set up. On 10/9/24 at 1:04pm R1 resting in bed, lunch tray was served with pureed food consistency. At 1:46PM V13 (Dietary Manager) has been working in the facility for more than 3 years. V13 stated diets should be served according to doctor's order. He (V13) said if a diet order is not followed it could potentially harm the resident. V13 stated R1 is on a Pureed diet. R1's physician order was reviewed with V13 and order showed Mechanical soft. He (V13) said facility is not following diet order of R1 as prescribed by physician. On 10/10/24 at 11:52am V3 (DON) said she started working in the facility in August 2024. V3 stated diet should always be followed according to doctor's order for safety of the resident. R1's POS (physician order sheet) dated 10/10/24 showed: Mechanical Soft texture, thin consistency. Order date 1/31/22. Care plan dated 03/07/2022 documented in part: R1 unable to consume regular consistency foods and requires a mechanically altered diet. Provide diet as ordered. R25 has diagnosis not limited to Type 2 Diabetes Mellitus, Severe Morbid Obesity Due To Excess Calories, Hypertension, Hyperlipidemia, Acute Kidney Failure, Heart Failure, Atherosclerotic Heart Disease, Anemia, Glaucoma. R25's Medication Review Report printed on 10/09/24 documents in part, renal dialysis diet order date 02/16/24. R25's MDS (Minimum Data Set) dated 08/01/24 BIMS (Brief Interview for Mental Status) score 15/15 indicating intact cognition and R25 requires therapeutic diet. R25's nutrition care plan documents in part, the resident is on a therapeutic diet. At risk for potential alteration in nutritional status. R25's copied meal card list diet as renal diet. On 10/09/24 at 12:40 PM, R25 was observed sitting in the dining room eating lunch meal. R25's meal ticket read Renal Diet. R25 received meatballs served in tomato sauce over spaghetti, mixed vegetables (potatoes, carrots/green beans), and corn bread. R25 consumed 100% of the meal. On 10/09/24 at 3:22 PM, V15 (PM Cook) stated R25 used to be on a renal diet but R25 is done with R25's treatments so R25 is not on that special diet anymore. V15 stated right now R25 is not on any dietary restrictions. V15 stated R25's diet card says renal diet, but it says that because it hasn't been changed yet to regular diet which is what the kitchen is giving R25. V15 stated the kitchen staff used to follow a list posted in the kitchen which listed the foods R25 could and could not be served but the list has been removed now because R25 is not on any diet restrictions anymore. V15 stated a renal diet is not allowed fish, or salt but V15 is not sure of what else the renal diet is not allowed. On 10/09/24 at 3:30 PM, V13 (Dietary Manager) stated R25 is on a regular diet with no dietary restrictions. V13 stated R25's meal ticket lists renal diet but the renal diet was discontinued when R25 stopped dialysis and the kitchen just never changed R25's meal ticket. V13 stated when R25 was on a renal diet, there was a list posted which said what foods R25 was allowed and what R25 was not allowed to eat so the kitchen staff would know what R25 could and could not have. V13 stated verbally one of the nurses told V13 that R25's renal diet was discontinued but V13 does not remember the name of the nurse or when this happened. V13 stated V13 pulled the list that used to be posted in the kitchen so the kitchen staff does not restrict R25's diet, but V13 did not update R25's meal ticket to reflect the change to regular diet but everyone in the kitchen knows R25 is no longer on that diet anymore. R5 has diagnosis not limited to Dementia, Parkinson's Disease, Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Unspecified Cerebral Artery, Dysphasia Following Cerebral Infarction, Bell's Palsy, Moderate Intellectual Disabilities, Schizoaffective Disorder, Malignant Neoplasm Of:, Morbid Severe Obesity Due To Excess Calories. R5's Order Summary Report printed on 10/09/24 documents in part, pureed texture, nectar consistency ordered 05/19/22. R5's MDS (Minimum Data Set) dated 09/07/24 BIMS (Brief Interview for Mental Status) was not able to be assessed and R5 requires mechanically altered, therapeutic diet. R5's copied meal card list diet as pureed. It does not list R5 should receive nectar thickened liquids. R15 has diagnosis not limited to Cerebral Palsy, Acute Respiratory Failure, Dysphasia, Reduced Mobility, Moderate Protein Calorie Malnutrition, Repeated Falls, Muscle Wasting Atrophy, Difficulty In Walking, Encounter For Attention To Gastrostomy, Major Depressive Disorder, Anxiety Disorder, Pain. R15's Order Summary Report printed on 10/09/24 documents in part, pureed texture, thin consistency order date 09/04/24. R15's MDS (Minimum Data Set) dated 08/16/24 BIMS (Brief Interview for Mental Status) was not able to be assessed and R15 requires mechanically altered, therapeutic diet. R15's copied meal card list diet as pureed. On 10/10/24 at 8:10 AM, observed R5 sitting in the unit dining room eating breakfast meal. R5's meal ticket read pureed diet. Observed R5 drinking a thin orange flavored liquid from a Styrofoam cup. R5 consumed 100% orange flavored drink. On 10/10/24 at 8:12 AM, observed R15 sitting in the unit dining room being fed by V20 (Restorative Certified Nursing Assistant). R15's meal ticket read pureed diet. Observed R15 drinking thickened water from a Styrofoam cup. R15 consumed 100% thickened water. On 10/10/24 at 8:15 AM, V10 (Certified Nursing Assistant) stated R5 is on a pureed diet with thin liquids. V10 stated R5 is not given thickened liquids, the staff gives R5 thin liquids. V10 stated R15's liquids have to be thickened to nectar consistency using a powder. On 10/10/24 at 11:15 AM, V20 (Restorative Certified Nursing Assistant) stated V20 fed R15 breakfast this morning and R15 consumed 100% water thickened to nectar consistency. V20 stated V20 knows R15 should get thickened liquids because it was communicated to V20 verbally by the other staff. V20 stated it does not say that R15 requires thickened liquids on R15's meal card. On 10/10/24 at 11:25 AM, V13 (Dietary Manager) stated R15 requires nectar thickened liquids, R5 does not. V13 stated R5 receives thin liquids. V13 stated it is the nursing staff's responsibility to let V13 know about any changes to resident's diet orders. V13 stated V13 was not aware that R5 has an order for nectar thick liquids and R15 has an order for thin liquids. On 10/10/24 at 12:08 PM, V6 (Registered Dietitian) stated diet orders are physician generated and should be followed as ordered. V6 stated each resident has a meal ticket which list the diet order including therapeutic restrictions, food/liquid consistency, and any special requests such as likes/dislikes or food allergies. V6 stated it is dietary departments responsibility to make sure the diet orders in the electronic health record (EHR) match the diet orders listed on the resident's meal tickets including their diet consistency, liquid consistency, and therapeutic diet order. It is important for the meal tickets to be correct because this tells the kitchen and nursing staff what food/liquids to serve the resident. V6 stated if there is a discrepancy, there is the potential for the resident to receive the wrong diet. V6 stated if a resident has a doctor order for a pureed diet but receives mechanical soft a resident could choke. V6 stated if a resident on nectar thick liquids receives thin this could cause aspiration and lead to pneumonia. V6 stated if a resident is receiving thickened liquids but they have an order for thin liquids there is no medical risk, but it could create a palatability issue. V6 stated if a resident does not need to be on thickened liquids, they should not receive it. V6 stated residents on a renal diet should not have been given spaghetti with meatballs in a tomato sauce because tomatoes are high in potassium and if you have impaired kidney function then the ability to metabolize potassium is decreased which can cause potassium to build up. V6 stated even though R25 is no longer receiving dialysis V6 would not take R25 off the renal diet unless the doctor ordered to liberalize the diet. V6 stated R25 should have received spaghetti with plain meatballs, not in any tomato sauce. Facility policy titled Tray Pass Policy dated 10/2020 documents in part, ensure trays have proper meal ticket; appropriate resident name and appropriate diet. Based on observations, interviews, and record reviews, the facility failed to provide therapeutic diets as prescribed by the physician for 5 (R1, R5, R10, R15, R25) out of 5 residents reviewed in a total sample of 14. Findings Include: On 10/08/24 at 12:02 PM, R10's physician orders document a diet order of NCS (No Concentrated Sweets) diet, Pureed texture, Thin consistency (ordered on 4/28/24). R10's last Dietary Notes dated on 6/28/24 at 9:14 AM written by V18 (Former Dietitian) revealed R10's Diet: NCS, pureed texture, thin liquids. R10's face sheet documented in part medical diagnoses of Unspecified Dementia and Neurocognitive Disorder with Lewy Bodies. On 10/08/24 at 1:12 PM R10 was eating lunch in the dining room. R10 received chunks of chicken and pineapples, rice (no sauce), broccoli, canned mixed fruits, thin juice and water. R10's meal ticket shows STD-mechsoft. On 10/09/24 at 1:43 PM, interviewed V13 (Dietary Manager) and stated, I get the diet order from the nurses they give me a pink slip with the diet order, name, room number and the type of diet. The type of diet should be ordered by the physician. They give me a pink slip every time there is a new admission and re-admission. The diet order should reflect on the diet card. Currently I have [R10] as a mechanical soft. [R10] was a pureed. [R10] was hospitalized came back as pureed. A lot of those changes are verbal. The nurses told me that [R10] was mechanical I don't remember when. I don't remember if they give me a pink slip. The facility's DIET ORDERS policy (revised 11/1/23) reads in part: Upon resident admission or diet change, the nurse will verify the diet order with the physician. The diet is recorded in the medical record. The diet is communicated to the food and nutrition department on a Diet slip. Pureed Diet: General diet with texture adjusted so that foods are blended smooth in consistency, like pudding or mashed potatoes, for those with chewing and/or swallowing problems.

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled, dated, and stored, failed to properly rotate food using First In, First Out (FIFO) guidelines, and failed to ensure kitchen staff were wearing appropriate hair coverings. These failures have the potential to affect all 38 residents receiving food prepared in the facility's kitchen. Findings include: On 10/08/24 at 9:38 AM, V13 (Dietary Manger) stated perishable items should be dated with the date it was prepared, a use by date and used within three days. V13 stated the kitchen staff follows the manufacturer label if there is a use by or best by dates printed on the product. V13 stated for shelf- items which need to be refrigerated after being opened such as salad dressing, mayonnaise, and sauces get labeled with a delivery date, an open date and a use by date which is within 30 days of the item being opened. V13 stated it is important for food items to be labeled and dated with opened and use by dates to prevent food-borne illness which could harm the residents. On 10/08/24 at 9:40 AM, observed the following items in the Walk-In Refrigerator: 1.) Opened 30-Fluid Ounce glass bottle Barbeque Marinade 50% full with manufacturer best by date 04/24/24 printed on the side of the bottle. No opened date labeled on the item. V13 stated the Marinade sauce was used on chicken served to the residents last week for a cookout. V13 viewed the best by date of 04/24/24 printed on the side of the bottle and said, I would still use this for residents because the vinegar inside it would kill any bacteria in the marinate. 2.) Opened 1-gallon Golden Italian Dressing labeled with an open date of 10/04/24. Item was not labeled with a use by date. 3.) Opened 1-gallon Honey Mustard Dressing labeled with an open date 09/24/24. Item was not labeled with a use by date. 4.) Opened 1-gallon Soy Sauce dated with an open date 06/09/24. Item was not labeled with a use by date. 5.) Opened 1-gallon Mayonnaise dated with an open date 07/18/24. Item was not labeled with a use by date. 6.) Opened 1-gallon Pickle Chips labeled with an open date 08/28/24. Item was not labeled with a use by date. 7.) Opened 64-ounce plastic container Mayonnaise. Not labeled with an opened date. On 10/08/24 at 9:50 AM, V13 stated those items in the Reach-In Refrigerator not labeled are used so frequently that labeling them with a use by date is not necessary because V13 said, we go through the items quickly. On 10/08/24 at 9:55 AM, when touring the dry storage room, V13 stated all items must be labeled with a delivery date and the items are organized according to First In, First Out (FIFO). V13 stated FIFO means the newest or most recently delivered item is stored in the back and the oldest item is stored in the front. V13 stated this is important to rotate the food items so that the older items are used first. On 10/08/24 at 9:58 AM, observed the following items in the dry storage room: 1.) #10 can Dark Red Kidney Beans - not labeled with delivery date. V13 stated V13 knows when that was delivered but the delivery date should be written on the can. 2.) #10 can Diced Beets - not labeled with delivery date. V13 stated the delivery date should be written on the can. 3.) 5 of 6 - #10 cans Cut Waxed Beans labeled with delivery date 08/29/24 and 1 of 6 #10 can Cut Waxed Beans labeled with delivery date 04/18/24. The can dated 04/18/24 was in the very back behind the cans dated 08/29/24. V13 stated the can dated 04/18/24 should be in the front so it is used before the other cans dated 08/29/24. 4.) Separate bins filled with Breadcrumbs, Farina, Parboiled Rice, Oatmeal, Flour, Sugar. None of the bins were labeled with the item name, open or use by dates. V13 stated since there are no labels on the bin items you cannot tell when they were opened and the potential problem with that is the kitchen could be using items over the expiration date without realizing it. On 10/08/24 at 10:06 AM, V13 stated spices are good for two years. Observed in the cook's prep station near the stove the following spices: 1.) Opened 10-ounce bottle titled Poultry Seasoning labeled with delivery date 12/14/2020. Not labeled with an open or use by date. There was no manufacturer's best by date printed on the bottle. 2.) Opened 8-ounce bottle titled Ground Sage labeled with delivery date 07/15/21. Not labeled with an open or use by date. There was no manufacturer's best by date printed on the bottle. On 10/08/24 at 10:29 AM, observed V15 (PM Cook) in the kitchen organizing meal tickets. V15 had a mustache and beard which was not covered with a beard protector or any type of covering. V15 stated V15 is not wearing a beard protector over V15's beard right now because V15 is doing the meal tickets and emptying the garbage. V15 stated V15 only wears the beard protector when V15 is dealing with food, not necessarily every time V15 enters the kitchen. On 10/09/24 at 3:20 PM, observed V15 in the kitchen walking around food prep area in front of the oven with uncovered food on the stove. V15 stated V15 is preparing the food for the dinner meal tonight. V15 had a mustache and beard which was not covered with a beard protector or any type of covering. On 10/09/24 at 3:30 PM, V13 stated hair and beard restraints should be put on before crossing the threshold into the kitchen regardless of whether or not someone is handling food. V13 stated the kitchen is currently out of beard protectors and in the meantime, the kitchen is using the white hairnets in place of the beard protectors. V13 stated any facial hair needs to be covered regardless of the length. V13 stated the purpose of wearing hair coverings including beard protectors is to prevent hair from falling into the food because this would contaminate the food. V13 stated V15 is the only staff down in the kitchen right now and is the cook on duty so V15 is working with food and should have a beard protector or white hairnet over V15's beard. On 10/10/24 at 11:45 AM, V6 (Registered Dietitian) stated labeling and dating are important so the kitchen staff is aware of when a food item is expired so it is not served to the residents. V6 stated serving food after the best by or used by date to the residents could potentially cause an overgrowth in bacteria which could lead to food borne illness. V6 stated food items should have a receive date (delivery date), and then once opened labeled with an opened and a use by date or expiration date. V6 stated if the items are not labeled with an open or use by date the staff won't know when the items are no longer any good and when they should be discarded. Facility provided document titled, Diet Type Report dated 10/10/24 listing residents with their diet orders. There are no residents who are NPO (receiving nothing by mouth). V3 and V13 stated none of the residents living at the facility are NPO. Facility provided policy titled Employee Health & Personal Hygiene dated 09/17/23 which documents in part, hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. Facility provided V15's signed job description dated 07/09/24 which documents in part, hair covering must be worn while cooking or food handling. Any facial hair (beards) must be covered while in the kitchen. Facility provided policy titled, Date Marking and Labeling dated 05/27/24 which documents in part, 1.) All foods that are stored will be properly dated and labeled to ensure food safety. 2.) Date marking is an identification system that helps identify the name of the food, when the food was prepared and when it is to be discarded 3.) When to date mark: the food requires refrigeration, a commercially prepared food item is opened, when potentially hazardous (PHF/TCS) food are stored, when purchased, ready-to-eat foods are removed from their original packaging/container. 4.) When to discard refrigerated items that are opened must be discarded or used in 7 days, the item has expired according to the manufacturer's expiration date. Facility provided policy titled First In First Out (FIFO) dated 09/18/23 which documents in part the facility will follow safe food handling and storage practices and newly arrived food stock items will be placed at the back of the shelf and the older food items to the front of the shelf. The old stock items will be used first.

Based on observation, interview and record review, the facility failed to handle linen in a manner to prevent cross contamination, failed to conduct an annual review of its infection control policy and procedures, failed to post Enhanced Barrier Precautions (EBP) signage outside 2 residents (R21, R38) rooms with active wounds, and failed to have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These failures could potentially affect all 38 residents residing in the facility. Findings Include: R21's Treatment Administration Record (TAR) dated 9/1/24 to 9/30/24 shows R21 has venous wound of the left lateral leg with daily treatment. Progress note dated 10/10/24 documents in part: R21 on ABT Doxycycline 100mg PO bid x 10 days wound infection on the left leg. R38's TAR dated 10/1/24 to 10/31/24 shows R38 has treatment to lower legs every shift for skin infection. On 10/08/24 10:48 AM, R21 is obserevd lying in bed with left leg wound. No signage of EPB on R21's door. On 10/08/24 10:46 AM, R38 is observed in bed with skin peeling on both legs. No enhanced barrier precaution (EBP) signage on R38's door. On 10/08/24 at 10:50 AM, V4 (Registered Nurse/RN) stated that Enhanced Barrier Precautions (EBP) signage should be posted outside the door of any resident with wounds, Feeding tube, Foley Catheter, and central line. V4 stated it is important to have EBP signage to ensure that staff are wearing the necessary Personal Protective Equipment (PPE) required before providing care for R21 and R38. 10/08/24 at 12:13 PM, surveyor V3 (Director of Nursing/Infection Preventionist) observed R21 and R38's door without the EBP signage. V3 stated that R21, and R38 have wounds, there should be a EBP signage by the door to alert staff to know the type of PPE to wear before providing care to R21, and R38. V3 stated that not having the signage by R21, and R38's door, is a potential for transmission of infection. On 10/08/24 at 12:08 PM, surveyor reviewed the water management area with V16 (maintenance Director). Surveyor asked V16 for measures in place to prevent the growth of Legionella. V16 stated V16 is not sure, and V16 could not provide any documentation. V16 stated V16 will ask V1. On 10/09/24 at 1:01 PM, V1(Administrator) stated that Legionella is checked yearly, and V1 has not checked for Legionella this year. V1 stated that the last time the water was checked for Legionella was 1/11/23 which is over one year. V1 stated that V1 will call the company to come over later. V1 stated that failure to perform an annual check for Legionella, is a potential for waterborne infection. V1 stated that the infection control policy is reviewed or revised yearly, but V1 provided surveyor undated infection policy. V1 stated that the date should have been November 2023, but it was an oversight. On 10/08/24 at 12:53 PM, the laundry room was obsereved with V7 (Laundry/Housekeeping Aide). Surveyor observed V7 pick up the dirty mop from the laundry room without wearing a pair of gloves, and V7 used the same dirty hand to pick up clean resident gowns from the folding table. V7 stated that V7 is sorry because, V7 forgot to sanitize V7's hand before picking up the clean gowns from the folding table. Surveyor asked V7 if the clean gowns are now contaminated and should be rewashed. V7 responded yes. On 10/08/24 at 12:58 PM, the chute was observed with V7, surveyor observed V7 walking in the hallway with a dirty pair of gloves. Surveyor asked V7 if the dirty gloves can result in spreading of bacteria. V7 responded Yes. On 10/09/24 at 1:10 PM, V3 stated that it is the expectation of V3 that staff will wear a pair of gloves to pick up a dirty mop and perform hand hygiene before handling clean gowns or clean linen. V3 stated that the potential problem of handling clean gowns with a dirty hand may result in spreading of bacteria. V3 stated that, no staff should be wearing gloves when walking in the hallway to prevent the spread of infection. The facility policy titled Hand Hygiene dated 12/17/19 documents read in part: Hand hygiene is the single most efficient means of preventing the spread of infection. The facility policy titled Linen Handling dated November 2023 documents read in part: Wash hands after handling soiled linen and before handling clean linen. The facility policy titled Enhanced Barrier Precautions (EBP) dated 3/21/24 documents read in part: Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required Personal Protective Equipment (PPE). The facility policy undated, titled Infection Control and Procedure. A copy of EBP documents read in part: Wear gloves and a gown for wound care, any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and report an allegation of abuse for one of three residents (R1) reviewed for abuse. Findings include: R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Arthritis, Multiple Sites; Type 2 Diabetes Mellitus, Acute Kidney Failure, Auditory Hallucinations, Visual Hallucinations, and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R1's MDS (Minimum Data Set of 5/30/2024) documents a BIMS (Brief Interview for Mental Status) of 6 or severe cognitive impairment. 8/29/2024 at 10:26 AM, V5 (Clinical Manager) said during a visit to see ophthalmologist on 8/16/2024, R1 alleged multiple staff (unknown) members punched and slapped resident. R1's escort (V4), who was present in the exam room, left exam room, went outside and called facility's DON (V2-Director of Nursing). V5 said upon V4's return, V4 said she spoke with V1 who said R1 has dementia; allegation was not true. V5 said per the ophthalmologist, R1 is always lucid when they see R1. V5 added, R1 said abuse has been going on for several months and hasn't been reported (by R1) because she is afraid to let anyone know. 8/29/2024 at 1:10 PM, R1 said she is experiencing ongoing physical abuse that started approximately 3 1/2 months ago; unable to offer any information about alleged abusers other than they are female and are not residents. R1 said the abuse occurs in her room, in the dining room. R1 said one of the alleged abusers hit R1 on her upper arm then later her hand (demonstrates by pushing Surveyor on their upper arm, then slapping Surveyor multiple times in rapid succession on the dorsum of Surveyor's hand) this morning. R1 added that alleged abuser works at the library. When asked by Surveyor if there are any witnesses to any of these incidents, R1 said yes, the lady who was buying bread in the cafeteria; I don't remember her name. R1 said all the other times it happened, I would cry and cry. My doctor said it's okay to report it. I never reported it, because I was afraid of retaliation. I don't feel safe (in the facility). 8/29/2024 at 1:55 PM V4 (Escort) via telephone said she escorted R1 to an appointment to the eye doctor on 8/16/2024. V4 said R1 was confused when V4 arrived at the facility that day, requiring a lot of cueing and re-direction that day. V4 said R1 told the doctor They beat me up. The doctor said who? He (the doctor) looked at me, I said I don't know anything about that. I left the room and called V2 (DON-Director of Nursing); I told her what R1 said. V2 told me, R1 is a little unbalanced, R1 has dementia; if someone beat her, why doesn't she have a black eye? 8/29/2024 at 2:27 PM via telephone, V2 (DON-Director of Nursing) said, R1 went to an appointment on 8/16/2024; I think she told one of the doctors that someone hit her in the eye. V2 continued, if they saw her diagnosis (dementia), she just had discoloration to the sclera of her eye. No one abused her; we don't tolerate that at (the facility). I did speak with someone at the doctor's office. I informed them that no one hit R1. I told them that she was confused; that she has diagnoses including dementia, she (R1) makes things up. No one would ever mistreat her at (the facility). R1 talks to herself, residents with dementia say different things, that's their baseline. I looked at her (R1) when she returned to the facility. I would be making reportables (incident reports) all the time; would take R1 seriously if she were slumped over, not saying different things, doing something against her baseline. But nothing was wrong with her; there were no obvious signs of anything (skin discoloration, no altered level of consciousness). R1 never mentioned anything to anyone at the facility. This is what she (R1) does. 8/29/2024 at 3:00 PM V1 (Administrator) said abuse should be reported immediately. V1 said I wasn't told; I didn't find out until today about R1's abuse allegation. V1 added, I think an investigation was done; a reportable (alleged incident wasn't reported to IDPH-Illinois Department of Public Health) wasn't done. V1 said, R1 can't give you a description (of alleged abusers), a date or time. If she's not in bed, she's in the dining room, we have cameras in the facility. They (staff) were always putting eye drops in her eyes, was she confusing that with abuse. Facility incident reports for abuse (6/2024-8/2024) were reviewed; no report was found for R1's allegation of abuse (from 8/16/2024). Facility's Abuse Prevention Program Worksheet (2/2017, page 12) documents: This process is implemented where there is an allegation or reasonable cause to suspect that abuse, neglect, or exploitation of theft may have occurred. Name of the Resident who is the subject of the allegation, Date of Occurrence, and Primary Investigator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain dignity for three (R1, R2, R3) residents reviewed for dignity bag on indwelling catheter. Findings include: 1.R1 is a [AGE] year-old individual, with diagnoses as listed in the current face sheet to include but not limited to: : unspecified severe protein-calorie malnutrition, cachexia, adult failure to thrive, abnormal weight loss. R1's Minimum Data Set (MDS) section C (Cognitive Status), dated 12/31/2023, documents R1 has a BIMS (Brief Interview for Mental Status) score of 15/15, indicating R1 has intact cognation. R1's MDS(Minimum Data Set) section H (bladder and Bowel), dated 10/03/2023, documents have an Indwelling catheter. R1's POS (Physician Order Set) documents: 10/18/2023 -Foley catheters change 18th of every month on day shift. starting on the 18th and ending on the 18th every month for Prophylaxis. Change Foley bag on the 11th and 25th of every month. On 2/4/2024 at 9:47am, R1 was observed with the urinary bag hang on the side of his bed below the bladder. R1's bag was observed with no cover for dignity and was facing his roommate's side, visible to the roommate. The urinary bag had 300 cc of light-yellow urine. R1 said he did not like his urinary bag to show the urine draining to everyone. R1 said he is not able to reach the bag to cover it himself. 2. R2 is an [AGE] year-old individual admitted to the facility on [DATE]. R2's medical diagnoses as documented in current face sheet include but not limited to: spondylosis, unspecified, Parkinson's disease, urinary calculus, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's MDS section C, dated 11/8/23, documents R2's BIMS was not assessed, and last scored BIMS is dated 1/24/2023, with R2's BIMS documented at 6/15, indicating R2 has severe cognitive impairment. R2's MDS section H (Bladder and Bowel) documents R2 has an Indwelling catheter. R2's POS (Physician Order Set) documents: 9/11/2023 -Foley catheters change 11th of every month on day shift. Starting on the 11th and ending on the 11th every month for Prophylaxis On 1/4/2024 at 10:22am, R2 was observed laying in bed awake. R2's indwelling catheter was observed on the bed frame below the bladder. R2 said she was not aware her bag was not covered, and said she would like it covered so her roommates don't see her urine. 3. R3 is an [AGE] year-old individual admitted to the facility on [DATE]. R3's MDS is in progress and sections C & H are not completed. On 2/4/2024 at 10:30am, R3 was observed sitting in his room on his wheelchair. R3's indwelling catheter bag was observed with no dignity bag. R3 said he would not go out of his room with the urinary bag not covered saying this looks terrible. V6 (Certified Nursing Assistant) was in the room when R3 stated his urinary bag looked terrible without the dignity bag. On 1/4/2024 at 10:22am, V6(Certified Nursing Assistant-CNA) said the facility does not have dignity bags. V6 said every indwelling catheter should have a cover for residents' dignity. 02/04/2024 at 11:31am, V2 (Director of Nursing) said catheter bags should have a privacy bag for resident dignity. Facility policy, dated 10/23, and titled Urinary Catheters Policy documents: -The dignity bag is covered for dignity and privacy

Based on observation, interview, and record review, the facility failed to ensure one resident's (R2) indwelling catheter drainage bag was covered. This failure affected one resident (R2) reviewed for dignity in the sample of 24 residents. Findings Include: R2's admission record include diagnoses of hypertension, diabetes, cerebral infarction, urinary calculous, leiomyoma of uterus, and hydronephrosis with renal and urethral calculous obstruction. R2's (7/27/23) Resident Assessment Instrument documented, Section C. is blank. BIMS (Brief Interview for Mental Status) section C is blank. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. R2's (Active as of 11/8/23) Order Summary Report documented, 16 French (indwelling) and insert 10 ml (Milliliter) balloon. R2's (6/6/23) Care plan documents, Problem: R2 has (indwelling) Catheter. On 11/6/23 at 10:55 AM, R2's indwelling catheter drainage bag was hanging from the bed frame, not covered in a privacy bag. On 11/8/23 at 11:30 AM, V2, DON (Director of Nursing), stated, The (indwelling) catheter should be covered in a privacy bag for dignity of the resident. On 11/8/23 at 1:50 PM, V8, RN (Registered Nurse), stated, All (indwelling) catheters should have a dignity bag for the privacy of the residents. Facility Urinary Catheter Policy (undated) documents, Care of catheter: E. The drainage bag is covered for dignity and privacy. Facility Residents Rights for people in long-term care Facilities, documents, Your rights to dignity and respect, your rights to privacy and confidentiality: you have a right to privacy and confidentiality of your personal and medical records. Your medial and personal care are private.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's call light was accessible within reach to call for staff assistance, which affected two (R1 and R10) residents in the sample of 24 reviewed for accommodation of needs. Findings include: 1) On 11/6/23 at 10:51 AM, R1 was observed in bed, turned to right side, with the red call light string not within R1's reach, being wedged in the bed frame under the side rail where it connects with the bed frame. On 11/7/23 at 11:00 AM, R1's red call light string remained in the same position as observed on 11/6/23, with it wedged in between the bed frame and the right bed side rail, and was not within R1's reach. R1's admission Record documents diagnoses of chronic obstructive pulmonary disease, hypertension, epilepsy, Alzheimer's disease, schizophrenia, arthritis, ventral hernia, and osteoarthritis. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 5, which indicates that R1 has severe cognitive impairment. R1's Function Status for bed mobility and transfer is coded as extensive assistance with staff support of two + (plus) persons physical assist. R1's Care Plan, date initiated 2/16/22, documents R1 has a focus of an ADL (Activities of Daily Living) self-care performance deficit, with an intervention of encourage (R1) to use bell to call for assistance. R1's Care Plan, date initiated 9/13/23, documents R1 has a focus of at risk for falls due to gait and balance problems and unaware of safety needs with an intervention of be sure (R1's) call light is within reach and encourage the resident to use it for assistance as needed. (R1) needs prompt response to all requests for assistance. 2) On 11/6/23 at 11:15 AM, R10 was observed ambulating with a walker from the bathroom with V5 (Certified Nursing Assistant, CNA) performing stand by assist. R10 was then then laying in bed, and V5 exiting the room. R10's red call light string was pinned to the privacy curtain, which was bunched up together against the wall behind R10's bed and chair. R10's call light was not within R10's reach. On 11/6/23 at 11:17 AM, R10 was asked if R10 was able to reach R10's red call light string from R10's bed, R10 stated, No. R10's admission Record documents, in part, diagnoses of rheumatoid arthritis, muscle weakness, hypertension, morbid obesity, malignant neoplasm of breast, peripheral vascular diseases, osteoporosis, embolism and thrombosis of unspecified deep veins of lower extremity, major depressive disorder, anxiety disorder, COVID-19, and chronic kidney disease. R10's MDS, dated [DATE], documents a BIMS score of 15, which indicates R10 is cognitively intact. R10's Function Status for bed mobility and transfer is coded as extensive assistance with staff support of one-person physical assist. R10's Care Plan, date initiated 1/11/17, documents R10 has a focus of an ADL self-care performance deficit with an intervention of encourage (R10) to use bell to call for assistance. R10's Care Plan, date initiated 3/18/21, documents R10 has a focus of at risk for falls due to generalized weakness, balance problems with ambulating and during transitions and psychoactive drug use with an intervention of be sure (R10's) call light is within reach and encourage the resident to use it for assistance as needed. (R10) needs prompt response to all requests for assistance. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated residents call light must be placed within the residents reach. When asked the purpose of having the call light within reach, V2 stated, Because the call light is a life line for any resident. V2 stated it must be placed conveniently within the residents reach, either attached to the pillow or the mattress. V2 stated residents use the call light to call for staff assistance, and We don't know if the resident needs something. It could be respiratory distress, and they shouldn't have to be struggling to find the call light. Facility policy titled Call Light, dated April 2014, documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner . Standards: 1. All residents shall have the nurse call light system available at all times and within easy accessibility to the residents at the bedside or other reasonable accessible location. Facility job description undated and titled Certified Nursing Assistant, documents, Certified Nursing Assistant. Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . answering call lights and requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a doctor's order and document the code status in one resident's (R17) electronic medical record. This failure affected one resident (R17) reviewed for Advanced Directives in a sample of 24 residents. Findings include: R17's admission record includes a diagnoses of but not limited to cerebral palsy, acute respiratory failure, dysphagia, and encephalopathy. R17's ([DATE]) Resident Assessment Instrument documented Section C. is blank. BIMS (Brief Interview for Mental Status) section C is blank. R17's Physician Order Sheet (POS) active orders, dated [DATE], indicate no order obtained for an Advanced Directive. R17's face sheet printed on [DATE] at 12:26 PM indicates no code status in the Advance Directives section. On [DATE] at 11:30 AM, V2, DON (Director of Nursing), stated, There should be an order from the doctor for an Advanced Directive. The nurses get the orders for an Advanced Directive. V2 stated the code status should be in the electronic medical record, and the purpose for an Advanced Directive is to know the code status of the residents. On [DATE] at 1:50 PM, V8, RN (Registered Nurse), stated, A resident's code status should be in the computer. Surveyor asked V8 it there was a code status and a physician order in the computer for R17. V8 looked into the computer and stated, I do not see a code status or physician's order for (R17) in the computer. There should be a physician's order and a code status should be in (R17's) records in the computer. Facility Advance Directives Policy (revised [DATE]), documents, The purpose of this policy is to reflect residents wish about receiving Cardiopulmonary Resuscitation (CPR) and Life- Sustaining treatments such as medical interventions and artificial administered nutrition. At the time of admission residents will be interviewed regarding their code status and/or preference and will be documented in their electronic health record. Facility Job description titled, Registered Nurse, documents, Essential Duties and Responsibilities: Complete and file required record keeping forms/charts upon the resident's admission, transfer and/or discharge. Receive and transcribe orders for physician and record on the care provided to the resident as well as the residents response to the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident's low air loss (LAL) mattress was not layered with multiple linen layers, which affected one resident (R9) in the sample of 24 residents reviewed for pressure ulcers. Findings include: On 11/6/23 at 12:11 PM, R9 was in bed on a LAL (low air loss) mattress, after being provided care and repositioning in bed by V5 (Certified Nursing Assistant, CNA), V6 (CNA) and V8 (Registered Nurse, RN). R9's sacral wound dressing observed intact, with date marked 11/6/23. This surveyor observed the following layers of linens under R9's body on the LAL mattress: bath blanket, incontinence pad and then a quadruple folded bath blanket (6 linen layers). R9 observed positioned in a supine position on the 6 linen layers on R9's LAL mattress. Surveyor asked R9 if surveyor could observe wound care on 11/7/2023, and R9 refused surveyors request. R9's admission Record documents, diagnoses of severe sepsis with paraplegia, pressure ulcer of other site (stage 3), hypertension, localized edema, atrial fibrillation, COVID-19, arthritis, septic shock, neuromuscular dysfunction of bladder, reduced mobility, and unspecified hearing and visual loss. R9's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates R9 has no problems with short and long term memory, and R9's Cognitive Skills for Daily Decision Making is modified independence. R9's Skin Conditions (section M) documents R9's Skin and Ulcer/Injury Treatments include a pressure reducing device for bed. R9's Weekly Observation Tool, dated 10/6/23, documents an air mattress is used for special equipment/preventative measures. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated, A low air loss mattress is used as a prevention and treatment for residents with pressure ulcers. The air circulation helps by reducing pressure of a resident's body from the air that comes from the low air loss mattress, like the resident is floating. The low air loss mattress is different from the ordinary mattress, which can be hard on the body. When asked what linens the nursing staff are to place on top of the LAL mattress (linens in between the top of the LAL mattress and the resident), V2 stated, If linens are to be used at all, then it should be a light linen than can be in between the torso to the knee for repositioning purposes. V2 stated, It should be one layer which allows the purpose of the functioning of the air circulating to really work on the resident. When asked if there are multiple layers of linen used, like a bath blanket, incontinence pad, and then a quadruple folded bath blanket on a LAL mattress, what would be the effect on the resident, V2 stated, It's ineffective with 6 layers. R9's Wound Evaluation and Management Summary, dated 10/24/23, V17 (Wound Physician) documents R9's bed support surface is Group 2 for R9's Stage 3 sacral pressure wound, full thickness. In Center for Medicare and Medicaid Services article, dated 4/7/22 and titled Pressure Reducing Support Surfaces - Group 2 - Policy Article, documents styles of Group 2 powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following: an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress, and inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and a surface designed to reduce friction and shear, and can be placed directly on a hospital bed frame. Facility policy, dated 5/19/17, and titled Wound Management Program: Pressure Injury Prevention, documents, Policy: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible. Purpose: The purpose of this policy is to establish and provide consistent measure for the prevention of pressure injuries based upon the assessment of pressure injury risk. Procedure: . A. Sensory deficits, mobility impairment, and activity limitations: . support surfaces including pressure reduction and pressure relief devices will be used as appropriate; devices may include gel, static air, foam, or alternating air. Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents the facility must provide services to keep your physical and mental health, at their highest practical levels. Facility job description undated and titled Registered Nurse (RN), documents, Registered Nurse. Summary: The RN is responsible for providing direct nursing care to residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision (must) be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be required by the Director of Nursing to endure that the highest degree of quality of care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistance . Provide leadership to nursing personnel assigned to your unit/shift. Facility job description undated and titled Certified Nursing Assistant, documents, Certified Nursing Assistant. Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . provide assistance in ambulating, turning, and positioning residents . performs other duties assigned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an extra tracheostomy (trach) tube was stored at a resident's bedside, which affected one (R15) resident in the sample of 24 residents reviewed for tracheostomy status. Findings include: On 11/6/23 at 1:19 PM, R15 was in R15's room, with R15's trach tube secured in placed with trach ties (foam ties with self fasteners) around R15's neck. R15 showed this surveyor R15's type of trach tube, which is a cuffless trach tube. No extra trach tube is observed stored in R15's room, on the bedside table, drawers, or in R15's bags. This surveyor asked R15 is there was an extra trach tube in R15's room, and R15 pointed to the trach tube cleaning kit, which is not an extra trach tube. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated an extra trach should be available and close to R15's room for safety to secure R15's airway if R15's trach tube comes out of the trachea stoma and is not able to be reinserted. This surveyor informed V2 there was no back up (extra) trach tube at R15's bedside, and V2 stated it was at the nurse's station. On 11/8/23 at 10:51 AM, V2 walked to the only nurse's station in the facility to retrieve R15's extra trach tube. Per V2's request, V8 (Registered Nurse, RN) checked the two treatment/supply carts in the nurse's station, and R15's extra trach tube was not observed. R15's admission Record, documents, in part, diagnoses of encounter for attention to tracheostomy, malignant neoplasm of larynx, chronic obstructive pulmonary disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, peripheral vascular disease, hypertension, and solitary pulmonary nodule. R15's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates R15 has no problems with short and long term memory, and R15's Cognitive Skills for Daily Decision Making is modified independence. R15's Care Plan, with revision date of 5/13/23, documents for R15's tracheostomy maintenance, an intervention is Tube Out Procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB (head of bed) 45 degrees and stay with resident. Obtain medical help immediately. Facility policy, dated October 2018, and titled Tracheostomy: Care and Suctioning, documents, Policy: Care and suctioning of a tracheostomy will be done upon physician's order and as needed, by nurse, respiratory therapist or speech therapist, to maintain a patent airway to facility the removal of accumulated tracheal secretions. Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents the 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. Facility job description undated and titled Registered Nurse (RN), documents the RN reports to the Director of Nursing (DON), and Registered Nurse. Summary: The RN is responsible for providing direct nursing care to residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision (must) be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be required by the Director of Nursing to endure that the highest degree of quality of care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistance . Administer professional services . as required . performs other duties as assigned. Facility job description undated and titled Director of Nursing Service, documents, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current Federal, State and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that the highest degree of quality care can be maintained at all times. Major Duties and Responsibilities: . 18. Assure that the Residents' Rights are followed by nursing service personnel at all times . 23. Assure that nursing service personnel follow established safety regulations in the use of equipment and supplies, providing care/services, etc. (and the rest), at all times. 24. Assure that the department is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained and operable to perform such duties and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a thermometer for four resident (R10, R30, R33, and R37) refrigerators; failed to properly log refrigerator temperatures for four residents (R10, R30, R33, and R37); failed to discard expired food from a resident (R10) refrigerator; and failed to clean a resident (R33) refrigerator. These failures affected R10, R30, R33 and R37 in the sample of 24 residents. Findings include: 1. R33 has diagnoses which includes, but is not limited to: unspecified severe protein-calorie malnutrition, cachexia, anemia, specified diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus with diabetic neuropathy, orthostatic hypotension, weakness, adult failure to thrive, abnormal weight loss, enterocolitis due to clostridium difficile, fatty liver, and retention of urine. R33's Brief Interview for Mental Status (BIMS), dated 09/30/23, documents R33 has a BIMS score of 15, which indicates R33 is cognitively intact. On 11/06/23 at 11:31 AM, R33's personal room refrigerator was unclean, with visible black dirt throughout the inside of the refrigerator surface, a thick layer of a dried red liquid adhered to the bottom shelf of the refrigerator and the door of the refrigerator, missing refrigerator temperature logs for 11/04/23 and 11/05/23, and without a temperature thermometer. On 11/07/23 at 11:57 AM, R33's personal room refrigerator remained unclean, with visible black dirt throughout the inside of the refrigerator surface, a thick layer of a dried red liquid adhered to the bottom shelf of the refrigerator; missing refrigerator temperature logs for 11/04/23 and 11/05/23, without a temperature thermometer, and a temperature log recorded for 11/06/23 for 35 degrees Fahrenheit (F). On 11/07/23 at 12:00 PM, V1 (Administrator) stated the Dietary and Housekeeping department at the facility oversee the residents personal refrigerators. V1 stated V12 (Dietary Manager) is responsible for cleaning and logging the residents personal refrigerator temperatures. V1 was asked how often the temperatures are logged for the residents personal refrigerators. V1 stated, I don't know. You would have to ask (V12). On 11/07/23 at 12:10 pm, V12 (Dietary Manager) stated V12 was delegated the responsibility a few weeks ago to oversee the residents personal refrigerators in the facility. V12 stated the housekeepers are responsible for cleaning the residents refrigerators weekly and V12 is responsible for logging the residents personal refrigerators temperatures daily. V12 was asked regarding the residents personal refrigerator thermometers. V12 stated all the residents personal refrigerators should have a thermometer, and V12 is aware the residents personal refrigerators were missing thermometers. V12 explained V12 ordered new refrigerator thermometers for the residents personal refrigerators that should be arrive to the facility by the end of the week. V12 was asked regarding how often the residents personal refrigerator temperatures are logged V12 stated, Every day. When V12 was asked regarding the importance of keeping the residents personal refrigerators clean, ensuring that the resident personal refrigerators have a thermometer and residents personal refrigerator temperatures are logged every day, V12 stated, For safety and so the residents don't get sick with Salmonella or diseases. The facility's document titled Temp (Temperature) Log Cooler shows no temperature was recorded/logged for 11/04/23 and 11/05/23 for R33's personal refrigerator. The facility's document, dated 11/15, and titled Refrigerators (Resident) Policy for Maintaining and Cleaning, documents, Purpose: To ensure that all resident refrigerators are in proper working order and are kept clean. Procedure: 1. Dietary/Housekeeping staff is responsible for ensuring that a resident's refrigerator is in proper working order and clean upon the resident/family bringing in the refrigerator. 2. Dietary is responsible for overseeing care for a resident with a refrigerator and will check all contents for proper date of food items and check for cleanliness of the refrigerators on a daily basis. 3. If the Dietary Team finds that the refrigerator has outdated food, Dietary will dispose of all outdated food and will notify the resident . 5. The Dietary/Housekeeping staff will clean resident refrigerators on a weekly and as needed basis. 6. The Dietary/Housekeeping supervisor will ensure all resident refrigerators are in working order and kept clean. 7. A thermometer will be kept in the resident's refrigerator and the temperature will be taken and recorded daily. 2. R10's admission Record documents, in part, diagnoses of rheumatoid arthritis, muscle weakness, hypertension, morbid obesity, malignant neoplasm of breast, peripheral vascular diseases, osteoporosis, embolism and thrombosis of unspecified deep veins of lower extremity, major depressive disorder, anxiety disorder, COVID-19 and chronic kidney disease. R10's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R10 is cognitively intact. On 11/6/23 at 11:01 AM, R10's resident refrigerator in R10's room was observed with an empty thermometer log taped to the side of the refrigerator. Inside R10's refrigerator, the following was observed: no thermometer; an opened 2% milk container (236 milliliters), approximately half full, with an expiration date of 10/17/23; and a bag of snack size candy bars and cookies. On 11/6/23 at 11:17 AM, when asked how often staff are checking the temperature readings and contents of R10's refrigerator, R10 stated, They don't come in often to check my refrigerator. 3. R37's admission Record documents diagnoses of heart failure, cardiomyopathy, hypertension, atrial fibrillation, and cellulitis of right and lower limbs. R37's MDS, dated [DATE], documents a BIMS score of 15 which indicates that R37 is cognitively intact. On 11/6/23 at 11:57 AM, R37's resident refrigerator in R37's room was observed with an empty thermometer log taped to the side of the refrigerator. R37 stated R37 hasn't seen any staff check inside the refrigerator. 4. R30's admission Record documents diagnoses of hypertension, cardiac arrest, acute respiratory failure, cerebral infarction, and anoxic brain injury. R30's MDS, dated [DATE], documents a BIMS score of 15 which indicates that R30 is cognitively intact. On 11/6/23 at 12:04 PM, R30's resident refrigerator in R30's room was observed with an empty thermometer log taped to the front of the refrigerator. When asked if staff are checking the temperature and items inside R30's refrigerator, R30 stated, No. Honestly, no. When asked if they are cleaning inside the refrigerator, R30 stated, No. Not unless I tell them. Inside R30's refrigerator, the following were observed: no thermometer, an opened apple juice container (64 fluid ounces); one opened chocolate candy bar (full size 1.55 ounces); and two chocolate and raspberry chocolate bars (unopened, 3.5 ounces). Facility temperature logs (empty) posted in R10, R30 and R37's rooms on 11/6/23, document Temp Log - Cooler with the date, time, temperature and initials for the temperature readings, with no documentation. On 11/6/23 at 12:33 PM, V5 (Certified Nursing Assistant/CNA) was requested to come to R10's room and asked for the copy of the posted refrigerator log on the side of R10's refrigerator. V5 confirmed R10's refrigerator log is blank with no staff initials, dates or temperatures. V5 retrieved R10's empty refrigerator log and made a copy. On 11/6/23 at 12:35 PM, V5 viewed inside R37's room that the posted refrigerator log on R37's refrigerator is blank with no staff initials, dates or temperatures. On 11/6/23 at 12:36 PM, V5 viewed inside R30's room that the posted refrigerator log on R30's refrigerator is blank with no staff initials, dates or temperatures. When asked who is responsible for completing the temperature checks and log for resident refrigerators, V5 stated, I don't do this. When asked again who is responsible, V5 stated, The kitchen. On 11/7/23 at 11:34 AM, V12 (Dietary Manager) visited R30's room to examine the refrigerator with no thermometer present inside the refrigerator. V12 stated there is no thermometer designated in R30's refrigerator, and V12 ordered more refrigerator thermometers that will be arriving this Thursday. V12 stated V12 checks the resident refrigerators daily for the inside refrigerator thermometer readings. V12 stated, This is brand new to me to make these checks and V12 is over heading it. V12 stated, I try to fit it (refrigerator temperature checks) in, and they put it on me. When asked what is V12 responsible for during these refrigerator checks, V12 stated, I am supposed to check the dates (of food and drinks) and if they are expired. I would be responsible to take it out if the food or drink item is expired. When asked if the expired food or drink item remains in the refrigerator, what could be the possible effect to the resident, V12 stated, It's major. Resident can get sick or can cause death. When asked if V12 checked R10's refrigerator's temperature and completed log, V12 said, Yes. V12 opened the door to view R10's refrigerator log. V12 stated, No. I haven't done it yet today. V12 stated V12 did not go into R10's room to perform a refrigerator viewing and temperature check. This surveyor informed V12 there was no thermometer in R10's refrigerator on 11/6/23 with an opened, expired milk carton from 10/17/23 present. When asked about R37's refrigerator temps, and V12 stated, I have not assessed (R37's) refrigerator yet. On 11/7/23 at 12:05 PM, V12 (Dietary Manager) stated the appropriate temperature within the residents' personal refrigerators should be 34 to 40 degrees Fahrenheit (F). Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents the 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.

Based on observation, interview, and record review, the facility failed to store biologicals in a safe manner, and failed to label opened multi dose vials. These failures have the potential to affect all 35 residents using this medication refrigerator. Findings include: On 11/07/2023 at 11:19 AM, during observation of medication storage room and refrigerator with V10 (Registered Nurse/RN) the following were observed: The medication refrigerator temperature was -18 degrees Fahrenheit (F) and was confirmed by V10. Located in this refrigerator were: R11's unopened Lantus 100/ml with icicles formed on the vial. R287's Novolog 100/ml (back Label states store at 36-46 degrees F, Avoid Freezing). 2 House stock vials of Tuberculin PPD (purified protein derivative). One Tuberculin vial was unopened, and the second Tuberculin vial was opened with no label of when it was opened. The tuberculin label states store at 36-46 degrees Fahrenheit and do not freeze. V10 stated she will discard all these medications and order new ones. V10 also stated the temperature of the refrigerator should be between 31-40 degrees Fahrenheit. Also located in this refrigerator was an employees' COVID-19 nasopharyngeal sample Specimen. V10 confirmed the COVID-19 nasopharyngeal sample Specimen was for an overnight shift nurse, and stated there is a different fridge for these specimens, and this should not be in here. On 11/07/2023 at 11:40 AM, V2 (Director of Nursing/DON) stated, 'COVID-19 specimens should be in a different fridge and the temperature should be between 31-41 degrees Fahrenheit. V2 stated she will waste the medications that are in the medication fridge that is reading -18 degrees, and will reorder. V2 stated the medication is not effective if frozen. On 11/07/23 at 11:36 AM with V10 during observation of the medication cart the following was observed: R33's opened Insulin Lispro 100/ml, without a date showing when it was opened. On 11/07/23 at 1:40 PM V2 stated, Insulin should be refrigerated, and other medications that are recommended by pharmacy. The refrigerator should be between 30-40 degrees Fahrenheit, and when opening a multi dose vial it should be dated when opened. The opened medication expires 28 days after or what pharmacy recommends. The COVID-19 specimen samples have their own refrigerator, and should not be stored in the medication refrigerator, because it can cause infection. V2 stated medications in the refrigerator that was -18 degrees Fahrenheit were disposed of, and new medications were ordered ASAP (as soon as possible). Facility presented policy titled, Storage of Medications, with revised date of 9/19, stated, The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Ensure insulin is properly labeled with resident's name and date of opening, dispose of 28 days after opening. Re-order if necessary. Facility presented another policy titled, LTC (Long Term Care) Facility Pharmacy Services and Procedures Manual: Storage of Medications, with revised date of 11/20. This policy states: Refrigerated 36 degrees Fahrenheit to 46 degrees Fahrenheit (2 degrees Celsius to 8 degrees Celsius) with a thermometer to allow temperature monitoring. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. R29 has diagnoses which includes iron deficiency anemia, repeated falls, lymphedema, difficulty in walking, essential hypertension, trauma subdural hemorrhage without loss of consciousness, reduced mobility, COVID 19, and low back pain. R29's Brief Interview for Mental Status (BIMS), dated 07/26/23, documents R29 has a BIMS score of 15, which indicates R29 is cognitively intact. R29's Care Plan documents: Problem: (R29) have an infection of the COVID 19 strict isolation: Droplet & Contact for COVID 19 positive all services to be provided in room . Interventions: Follow facility policy and procedure for line listing, summarizing and reporting infections. R29's Order Summary Report (POS/Physician Order) shows R29 has an order for COVID 19 test, dated 11/02/23. R29's test result: COVID 19, dated 11/02/23, shows that R29 positive for COVID 19. R29's progress note, dated 11/02/23, documents R29 tested positive for COVID 19 and was placed on strict contact and droplet isolation. On 11/06/23 at 11:13 AM, R29's room door had an isolation sign stating, Contact Precautions with an isolation bin set up out of R29's room. No Droplet Precaution isolation signage, no N95 mask or face protection (face shield, goggles) observed in isolation bin. 6. On 11/07/2023 at 11:19 AM, during observation of medication storage room and refrigerator, an employee's COVID-19 nasopharyngeal Specimen was found. V10 (Registered Nurse/RN) stated, This is a night shift employee's COVID-19 nasopharyngeal specimen sample that needed to be tested for COVID-19. There is a different fridge for these specimens; this specimen sample should not be in here. On 11/07/2023 at 11:40 AM, V2 stated, COVID specimens should be in different fridge and the temperature should be between 31-41 degrees Fahrenheit. Based on observation, interview, and record review, the facility failed to perform proper hand hygiene; failed to appropriately don and doff personal protective equipment (PPE) for a contact and droplet isolation room; failed to post a contact and droplet precautions isolation sign outside a positive COVID-19 resident's isolation room; failed to provide a resident with a tracheostomy covering to prevent transmission of COVID-19 droplets when a COVID-19 positive resident exits out of the isolation room; failed to ensure a contaminated item removed from a contact and droplet isolation room does not contaminate surfaces outside of the isolation room; failed to ensure a nasopharyngeal COVID-19 test sample was not stored in the facility's medication refrigerator; and failed to follow the facility's COVID-19 policy and procedures. These failures affected R1, R9, R10, R15 and R29 and has the potential to affect all 35 residents in the facility. Findings include: 1. On 11/6/23, V3 (Assistant Administrator) provided this surveyor with a document titled Residents with Isolation Status documenting R1, R9, R10, R15 and R29's names. Floor plan document, updated on 11/6/23, documents R1, R9, R10, R15 and R29's are on COVID-19 isolation. R1's admission Record documents diagnoses of COVID-19, chronic obstructive pulmonary disease, hypertension, epilepsy, Alzheimer's disease, schizophrenia, arthritis, ventral hernia, and osteoarthritis. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 5, which indicates R1 has severe cognitive impairment. R1's Care Plan, date initiated 11/7/23, documents R1 has a focus of an infection of the COVID-19 with strict isolation - Droplet and Contact for COVID-19 positive. All services to be provided in the room. R1's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. R10's admission Record documents, in part, diagnoses of COVID-19, rheumatoid arthritis, muscle weakness, hypertension, morbid obesity, malignant neoplasm of breast, peripheral vascular diseases, osteoporosis, embolism and thrombosis of unspecified deep veins of lower extremity, major depressive disorder, anxiety disorder, and chronic kidney disease. R10's MDS, dated [DATE], documents a BIMS score of 15, which indicates R10 is cognitively intact. R10's Care Plan, date initiated 11/7/23, documents R10 has a focus of an infection of the COVID-19 with strict isolation - Droplet and Contact for COVID-19 positive. All services to be provided in the room which includes an intervention of staff will maintain proper use of PPE donning and disposal of equipment used. R10's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. On 11/6/23 at 10:46 AM, a contact precautions isolation sign observed posted on R1's and R10's room door, with no droplet precautions isolation sign noted. Facility isolation sign (undated), titled Contact Precautions, documents, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. On 11/6/23 at 10:55 AM, V5 (Certified Nursing Assistant, CNA) was observed entering R1's and R10's room wearing an isolation gown, gloves, and surgical face mask, with no face shield or goggles. V5 stated V5 was entering the room to attend to R10 who was in the bathroom, but R10 said (through the door) R10 needed more time. V5 doffed gown and gloves and exited R1's and R10's room (used alcohol based hand rub {ABHR} when exiting the room). On 11/6/23 at 11:07 AM, V5 entered R1's and R10's room bringing in linens, towels, and an incontinence brief to perform care for R1. V5 was observed wearing a gown, gloves, and surgical face mask, with no face shield or goggles. V5 assisted R1 in turning in bed to the left side to open R1's soiled incontinence brief, and V5 was observed leaning V5's body and making contact with R1's left side of bed. V5's bottom of isolation gown at knee level was observed lifted up on top of R1's bed linens, and the inside of R1's isolation gown was in contact with R1's bed linens. V5 completed R1's incontinence care and then doffed V5's gloves while in R1's and R10's room. V5 did not perform hand hygiene. V5 retrieved another pair of gloves from V5's uniform under R1's isolation gown, and donned the gloves. V5 went into the bathroom wearing the same isolation gown V5 cared for R1 with, and the new donned gloves to perform care for R10. On 11/6/23 at 11:15 AM, R10 was observed walking out of the bathroom with a walker with V5's stand by assistance to get R10 to bed. V5 assisted with elevating R10's feet up onto the bed. On 11/6/23 at 11:16 AM, V5 was observed walking towards R1's side of the room near the door. V5 doffed V5's gloves and discarded the gloves in the red garbage bin inside the room near the door. V5 moved R1's bedside table with V5's bare hands to reach R1's bed controls on the left side of the bed. V5 touched R1's bed controls and elevated R1's head of the bed. V5 then doffed V5's gown by pulling the front of the gown away from V5's body (with bare hands) to remove the gown, discarded the gown, and exited the room. 2. R9's admission Record documents diagnoses of severe sepsis with COVID-19, paraplegia, pressure ulcer of other site (stage 3), hypertension, localized edema, atrial fibrillation, arthritis, septic shock, neuromuscular dysfunction of bladder, reduced mobility, and unspecified hearing and visual loss. R9's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates R9 has no problems with short and long term memory and R9's Cognitive Skills for Daily Decision Making is modified independence. R9's Care Plan, date initiated 11/7/23, documents R9 has a focus of an infection of the COVID-19 with strict isolation - Droplet and Contact for COVID-19 positive. All services to be provided in the room which includes an intervention of done (don) proper PPE. R9's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. On 11/6/23 at 12:11 PM, R9's contact and droplet precautions isolation sign observed posted on R9's door. V5 (Certified Nursing Assistant/CNA), V6 (CNA), and V8 (Registered Nurse/RN) were in R9's room wearing a gown, gloves, and surgical face masks, and assisting R9 with repositioning and activities of daily living (ADL) care. No face shields or goggles observed on V5, V6 and V8. Facility isolation signs (undated) with the left side of sign titled Contact Precautions and the right side of the sign titled Droplet Precautions observed with bold lettering of N95/Face shield on the far right side of the dual isolation posting. The Contact Precautions sign documents, in part, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Picture images of a gown and gloves are indicated on the contact precautions sign. The Droplet Precautions, documents, in part, Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Picture images of a person wearing a face mask and a face shield and a person wearing a face mask and goggles are indicated on the droplet precautions sign. 3. R15's admission Record, documents diagnoses of encounter for attention to tracheostomy, malignant neoplasm of larynx, chronic obstructive pulmonary disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, peripheral vascular disease, hypertension, and solitary pulmonary nodule. R15's Minimum Data Set (MDS), dated [DATE], documents the Staff Assessment for Mental Status indicates that R15 has no problems with short and long term memory and R15's Cognitive Skills for Daily Decision Making is modified independence. R15's Care Plan, date initiated 11/6/23, documents R15 has a focus of (R15) has infection of the COVID-19 with strict droplet/contact isolation. R15's Care Plan, date initiated 11/6/23, documents, Droplet/Airborne isolation precautions related to: COVID-19 infection with interventions of all services are rendered in resident room and maintain droplet, airborne precaution. R15's COVID-19 laboratory test document, with a test date of 11/2/23, documents a positive (+) result for COVID-19. On 11/6/26 at 12:45 PM, R15 was observed sitting at a chair in the nurse's station of the facility while staff are passing lunch trays to residents in rooms. R15 then walked to R15's room for the lunch tray. R15's contact and droplet precautions isolation sign were observed posted on R15's door. On 11/6/23 at 12:49 PM, R15 walked out of R15's contact and droplet isolation room with a face mask over R15's nose and mouth; however, audible respiratory congestion can be heard with R15's breathing through R15's tracheostomy, which is not covered with a mask. R15 is attempting to mouth to this surveyor, and then R15 walks back to the nurse's station to obtain R15's white board that R15 left on the ledge of the nurse's station desk. R15 stood in hallway writing and communicating with surveyors with audible respiratory congestion noted from R15's uncovered tracheostomy. 4. On 11/6/23 at 1:08 PM, V5 (CNA) donned gown and gloves while wearing surgical face mask and entered R9's contact and droplet isolation with R9's lunch meal tray. V5 did not apply a face shield or goggles. V5 set up the bedside table and R9's tray for R9 to eat in bed. V5 removed gloves and doffed V5's gown by pulling the front of the gown away from V5's body (with bare hands) to remove the gown, discarded the gown, and exited the room. On 11/6/23 at 1:11 PM, V5 donned gown and gloves while wearing surgical face masks and entered R1's and R10's contact and droplet isolation while holding R1's and R10's lunch meal trays and entered their room. On 11/6/23 at 1:15 PM, V5 doffed V5's gloves and gown inside R1's and R10's room and exited the room without performing hand hygiene. V5 touched the Dietary meal tray cart door in the hallway, and moved the meal tray cart. V5 then used ABHR. 5. On 11/7/23 at 11:00 AM, R1's and R10's room door was closed, with only the contact precautions isolation sign posted. R10 was sitting in the chair telling V9 (CNA) which clothes of R10's were dirty. V9 picked up R10's dirty clothes and put them in plastic bags per R10's directions. V9 was wearing a surgical face mask, gown, and gloves, with no face shield or goggles. V9 then doffed V9's gown and gloves and exited R1's and R10's room. On 11/7/23 at 11:08 AM, V9 (CNA) donned gloves and a gown while wearing a surgical face mask, and then entered R1's and R10's room carrying an empty plastic bag. On 11/7/23 at 11:10 AM, V9 exited R1's and R10's isolation room, as V9 was throwing away the doffed gown, gloves, and V9's surgical face mask in red garbage bin inside the room by door. V9 pulled out the tied plastic bag with R10's dirty clothing item from inside the room and set on the floor outside of the room. V9 reached inside the box of clean surgical face masks on top of the PPE bin right outside R1's and R10's door, and placed another face mask on V9's face. V9 performed hand hygiene. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON/Infection Preventionist) stated hand hygiene is the number one way to prevent the spread of infection. V2 stated staff are to wear gloves when providing ADL care to residents, but wearing gloves does not substitute for staff to perform hand hygiene. V2 stated staff are to perform hand hygiene before resident care, after resident care, and in between different resident's care. V2 stated when a staff member removes his or her gloves during resident care, the staff member must perform hand hygiene before donning a new pair of gloves. Gloves don't replace hand hygiene. Microorganisms and bacteria are invisible bacteria and can be there if they have gloves on. Staff must do hand hygiene before putting gloves on. When asked the purpose of hand hygiene, V2 stated, To break the chain of the spread of infection. V2 stated staff are to teach residents to mask properly to prevent the spread of COVID-19 and to keep residents healthy. We (staff) don't want to spread COVID-19. V2 stated residents should stay inside their isolation rooms, and if residents do come out of their isolation rooms, then staff are to redirect them back into their room. V2 stated, We want to contain the spread (of infection). Break the chain. V2 stated if a staff member touches items with bare hands or comes in contact with surfaces inside a resident's contact and droplet isolation room, then everything is soiled that the staff member came in contact within the isolation room. V2 stated staff must do hand hygiene before the staff member comes out of the isolation room. V2 stated residents who test positive for COVID-19 are placed on droplet and contact precautions. Droplet precautions isolation is used for positive COVID-19 residents because droplets are expelled and go into the air, and we can inhale it. We use masks to prevent it from spreading. V2 stated the COVID-19 droplets are expelled from COVID-19 positive residents via the nose and mouth. Eye protection like goggles or faces shields are to donned by staff when entering a positive COVID-19 contact and droplet precautions isolation room because COVID-19 microorganisms can go through the eyes, mucous membranes. Droplets are absorbed through mucous membranes. When asked about R15's tracheostomy, V2 stated COVID-19 microorganisms can be expelled out R15's tracheostomy stoma. When asked how are staff providing coverage over R15's tracheostomy to prevent transmission of COVID-19 droplets, V2 stated, I don't have an answer for that. When this surveyor informed V2 about R15 having R15's white board on the nurse's station desk on 11/6/23, V2 was asked what could happen to anyone else who comes in contact with the area where R15's white board was located, and V2 stated, It's cross contamination. V2 stated contact precautions isolation dictates that staff wear gloves and gown. Resident has infection, and it can be in the room. V2 stated the purpose of wearing gloves and a gown is to prevent the infection from coming onto staff. They (staff member) have it on your clothes or you embrace something. Staff can spread to someone else if (staff member) touches that person. When asked how are staff or visitors to know what PPE is to be worn going into an isolation room, V2 stated, We have a sign and put it on there outside the room. Sign should tell them what PPE to don. V2 stated the contact and droplet signs posted on the resident room doors have pictures on them of what staff are supposed to wear. V2 stated steps to donning PPE for a contact and droplet isolation room are for staff to don the gown first, then put on face mask (if not already wearing one), next to put on goggles or face shield, and lastly to don gloves. When asked what type of mask that staff are to wear when entering a positive COVID-19 resident's room (contact and droplet isolation), V2 stated, N95 (mask). V2 stated N95 masks are more secure that ordinary (surgical) masks which are more permeable than N95 masks. V2 stated the isolation gown when donned covers a staff member from neck down to a staff member's knees (depending on height). When asked if the inside of a staff member's isolation gown comes in contact with the environment in a positive COVID-19 resident's room, V2 stated, Staff have to change to put on another gown. It's contaminated. When asked if a staff member doffs gloves while still in a positive COVID-19 resident's room and touches surfaces with bare hands, V2 stated, Staff have to wash hands first before putting on gloves or before touch anything else in room. V2 stated the process to doff PPE before exiting a contact and droplet isolation room for the staff member is to remove gloves first due to gloves have been touching a lot of things (in room) and are contaminated. V2 stated the next step in doffing PPE is to remove the gown by uniting the ties behind the neck and then to pull the gown off from the inside of the gown and roll it inside out. V2 stated gloves and gowns are to be removed and discarded inside the resident's room, then the staff member steps outside the room, performs hand hygiene, then can remove the face shield or goggles to disinfect. V2 stated face masks are not doffed inside the room, and can be replaced after hand hygiene outside the room. When 2 residents who are positive for COVID-19 the same room together, PPE must be changed in between resident care along with hand hygiene. V2 stated this practice is safer for infection control. V2 stated staff exiting a room with bagged soiled linen from a positive COVID-19 isolation room should make sure not to drag it on floor in the hallway due to cross contamination concerns. On 11/6/23, V1 (Administrator) verified there are 35 residents residing in the facility. Facility policy, dated September 2023, and titled Infection Control Policy/Procedures: General Infection Control. Purpose: To establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases. Responsibility: All employees and Quality Assurance Committee. Policy: It is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate when possible the development and transmission of disease an infection . 7. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections . Components: . 2. Transmission Based Precautions: additional precautions are applied when the transmission characteristics of, or impact of, infection with a specific microorganism are not fully prevented by routine practices. Additional precautions include: Contact precautions, for epidemiologically significant microorganisms or microorganisms with very low infective dose or situations when heavy contamination of the resident's environment is anticipated. Droplet precautions, for microorganisms primarily transmitted by the large droplet route . 3. Respiratory Etiquette: A combination of measures to be taken by the infected person designed to minimize the transmission of respiratory microorganisms . Includes covering cough, hand hygiene, wearing a mask if unable to contain cough. Facility policy dated September 2023 and titled Infection Control Policy/Procedures: Hand Hygiene, documents, in part, Purpose: Hand hygiene is the most effective way of preventing the transmission of healthcare-associated infection to resident, staff, and visitors. 1. Hand hygiene shall be performed: Before contact with a resident or resident's environment. Before a clean or aseptic procedure. After exposure or risk of exposure to blood and/or body fluids. After contact with a resident or resident's environment. 2. Alcohol-based hand rubs (ABHR) containing 60-90% (percent) alcohol may be used for performing hand hygiene . 10. Handwashing is essential. Alcohol based hand rubs/gels and handwashing are the Gold Standard of Prevention. Facility policy dated September 2023 and titled Infection Control Policy/Procedures: Selection/Use of Personal Protective Equipment (PPE), documents, in part, Purpose: Personal Protective Equipment (PPE) is an essential element in preventing the transmission of disease causing microorganisms. If used incorrectly, PPE will fail to prevent transmission and may facilitate the spread of disease. Appropriate PPE will also protect staff from exposure. The following shall apply when selecting in using PPE: . 2. Staff shall be trained in correct use and donning/doffing procedures for PPE. 3. Gloves and other single-use PPE (e.g. {for example} gowns, masks) shall be worn once for a single resident/procedure and shall be discarded following use . 5. Gloves: . shall be worn when handling contaminated equipment or devices and when cleaning and disinfecting contaminated surfaces or equipment. Hand hygiene must be performed before putting on and after removing gloves. 6. Masks, Eye Protection and Face Shields: Masks, eye protection, and face shields work together to protect the mucous membranes (i.e. eyes, nose, and mouth) from droplets, splashes or sprays of blood or body fluids (e.g. cough or sneeze, release of drainage from skin lesions, etc.). Proper eye protection must protect eyes in all directions and should be worn when splashes, sprays, or droplets of fluid are expected . 7. Gowns: Long-sleeved gowns protect uncovered skin and clothing during procedures and resident care activities likely to produce soiling or generate splashed or sprays of blood, body fluids, secretions, or excretions. Gowns should cover the front and back of the staff from the neck to mid-thigh . 8. PPE must be donned (applied) and doffed (removed) using the following specific sequence to prevent contamination of staff and the environment. Donning (Applying PPE): 1. Perform hand hygiene. 2. Put on gown with opening to the back. Fasten closures. 3. Put on mask. Secure ties to head or elastic loops behind ears. Mold the flexible band to the bridge of nose. Ensure snug fit to face and below chin with no gaping or venting. 4. Put on protective eyewear or face shield. 5. Put on gloves by pulling the gloves over the cuffs of the gown. Doffing (Removing) PPE: 1. Remove gloves by grasping the outside cuff of one glove near the wrist and peel away from the hand, turning the glove inside out. Hold the glove in the opposite gloved hand. Slide finger or thumb under the wrist of the remaining glove and peel the glove off and over the first glove. Discard gloves in the garbage. 2. Remove gown by unfastening closures and grasping the outside of the gown at the back of the shoulders, pulling the gown down over the arms. Turn the gown inside out during removal. 3. Remove protective eyewear or face shield by grasping the headband or earpieces and carefully pulling away from face. Do not touch front of eyewear or shield. 4. Carefully remove mask by bending forward slightly, touching only the ties or elastic loops. Discard the mask in the garbage. 5. Perform hand hygiene. Facility policy dated 5/15/23 and titled Coronavirus (COVID-19) Policy/Surveillance, documents, in part, Policy: This policy is to educate, prevent the spread, identify and treat the Coronavirus. Responsibility: All Staff and Visitors . High-Risk Exposure: Exposure of a staff member to a person with COVID in any of the following circumstances: Staff member not wearing either face mask or respirator. Staff member not wearing eye protection . Respiratory germs prevention spread within your facility: . Restrict residents to their rooms as much as possible during outbreak. If they must leave room for any reason, have them wear a facemask . support and encourage hand and respiratory hygiene etiquette by residents, staff and visitors. Encourage staff hand hygiene according to CDC (Centers for Disease Control and Prevention) Guidelines including before and after resident contact, after contaminated surface and equipment contact and after removing personal protective equipment (PPE) . Any resident warranting isolation precautions or restrictions, post sign on door or wall clearly identifying this . Encourage hand hygiene before entering and exiting residents' rooms . Staff to wear appropriate PPE (gown, gloves, N95 respirator, eye protector) daily during care of COVID + (positive) . Core Principles of COVID-19 Infection Prevention: Hand Hygiene: Alcohol based hand rub preferred . PPE worn appropriately . Facemasks/KN95/N95 Usage: . N95 required to enter COVID + room. Facility policy dated 4/3/13 and titled Infection Control, documents, in part, Policy: It is the policy of this facility to provide guidelines for appropriate precautions regarding individuals known or suspected to have infection or colonization of drug resistant organism confirming to the Center for Disease Control, State/Federal Regulations. Procedure: . 5. Staff nurse shall be responsible in carrying out all the functions of the isolation procedures . 6. Staff nurse is responsible for the following: . c. Post the appropriate sign by the door so that all personnel and visitors will be alerted of the isolation precautions. Facility policy undated and titled Residents' Rights for People in Long Term Care Facilities, documents, in part, that the 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. Facility job description undated and titled Certified Nursing Assistant, documents, in part, Certified Nursing Assistant. Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Facility job description undated and titled Registered Nurse (RN), documents, in part, that the RN reports to the Director of Nursing (DON), and Registered Nurse. Summary: The RN is responsible for providing direct nursing care to residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision (must) be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be required by the Director of Nursing to endure that the highest degree of quality of care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistance . Administer professional services . as required . performs other duties as assigned. Facility job description undated and titled Director of Nursing Service, documents, in part, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current Federal, State and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that the highest degree of quality care can be maintained at all times. Major Duties and Responsibilities: . 18. Assure that the Residents' Rights are followed by nursing service personnel at all times . 23. Assure that nursing service personnel follow established safety regulations in the use of equipment and supplies, providing care/services, etc. (and the rest), at all times. 24. Assure that the department is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained and operable to perform such duties and services . 39. Develop, maintain, and implement infection control policies and procedures to assure that a sanitary environment is maintained at all times and that aseptic and isolation techniques are followed by all personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform wound care treatment as ordered by physician on 06/05/2023 and 06/06/2023 for 2 out of 2 residents (R1 and R6) reviewed for wound care. Findings Include: 1. R1's Face Sheet, dated 6/30/23, documents R1 is a [AGE] year-old with diagnoses including but not limited to: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. Minimum Data Set (MDS) section C (dated 06/14/2023) scores R1 as 15, indicating R1 is cognitively intact. R1's Wound Treatment Order (June 2023) documents: Cleanse wound with normal saline daily and apply silver collagen first, then apply calcium alginate. Keep dressing intact ABD pad and kerlix daily. R1's Wound Treatment Record (month of June 2023) indicated that R1 did not receive wound care treatment on 06/01/2023, 06/03/2023, 06/04/2023, 06/05/2023, 06/07/2023, 06/08/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/13/2023, 06/15/2023, 06/16/2023, 06/18/2023, 06/20/2023, 06/25/2023, 06/27/2023, 06/30/2023. 2. R6's Face Sheet documents R6 is a [AGE] year-old with diagnoses including but not limited to: Paraplegia, Severe Sepsis with Septic shock, Arthritis Multiple Sites, Pressure Ulcer of Left Heel Stage 3, Pressure Ulcer of Other Site Stage 3, Impacted Cerumen Bilateral, Visual Loss, Pain in Leg Unspecified, Localized Edema, Essential (Primary) Hypertension, and Unspecified Atrial Fibrillation. MDS section C (dated 04/19/2023) scores R6 as 13, indicating R6 is cognitively intact. R6's Wound Treatment Order (updated 08/15/2023) documents: Cleanse bilateral leg wounds with normal saline irrigation, ¼ strength dakins solution, and paint with betadine. Apply collagen dressing and apply calcium alginate dressing on top of collagen. Then, apply ABD PAD and wrap dressing with Kerlix daily. R6's Wound Treatment Record (month of June 2023) indicated that R6 did not receive wound care treatment on 06/05/2023, 06/06/2023, 06/13/2023, 06/15/2023, 06/18/2023, 06/22/2023, 06/23/2023. On 07/06/2023 at 10:30 am, R6 stated, No one administered my medications or changed my wounds sometime in June when there was no nurse. I was in a lot of pain. On 07/26/2023 at 1:30 pm, R1 stated, The facility has not been consistent about my wounds. The day there was no nurse in the facility, no one changed my wounds then. I am not sure if it is getting better. On 07/28/2023 at 9:37 am, V1 (Administrator) stated, On 06/05/2023, I was notified by the Director of Nursing (DON) that she was going to be leaving early that day for her appointment. I did not ask the DON to come back to the facility after the appointment when the staff nurse called in and there was no nurse coverage. I was trying to find a nurse to come in, and I sent out a blast via text to try and find someone to come in, but I was not able to find a nurse. There was no nurse on duty on 06/06/2023 as well. On 08/02/2023 at 12:53 pm, V1(Administrator) stated, The facility has only 2 residents with wounds and require wound care. The nurse on duty is the one who performs the wound car treatments. We do not have a wound care nurse because we only have two residents who require wound care treatments. The wound care doctor comes to the facility once a week, and that's on a Tuesday. When the wound care doctor comes on Tuesday, the doctor does the wound care treatment for the two residents. When there is no nurse on duty in the facility, the wound care treatments are not done. Wound Dressing Policy and Procedure (undated) states: Change the dressing clean technique according to physician orders. Frequency of wound dressing changes and the type of wound dressing will be specified in the physician orders.

Based on observation, interview, and record review, the facility failed to complete grievance forms to document and explain in detail the nature of resident concerns from August 2022 utill July 2023, for residents who reside in the facility. This failure has the potential to affect all 37 residents who resident at the facility. Findings Include: On 06/29/2023 at 9:19 am,V1 (Administrator) was asked for the resident concern/grievance binder. V1 presented the facility grievance binder with the last resident concern documented in August 2022. On 06/29/2023 at 9:57 am, V1 (Administrator) stated, The grievance binder has resident concerns from August of 2022. There are no documented resident concerns after August of 2022. I stopped writing the resident concerns down because they were not legitimate concerns. I listen to the resident concerns and if it's not a legitimate concern, then I don't write them down. I address the resident concerns, but if they are not important, then I won't write them down in the concern binder. If I wrote down every single concern that these residents have then I would be writing things down all day. A legitimate concern is abuse, for example. The Social Service Director is supposed to write down resident concerns in the concern binder, but if they are not legitimate concerns, then we don't write them down. On 06/29/2023 at 11:29 am, R1 stated, On 06/05/2023 and 06/06/2023, there was no nurse on duty at all, and I did not receive my medications. I have a lot of pain because I had a neck surgery, and I have other medical problems that cause me a lot of pain. During those dates, there were shifts that I did not receive my medications, which includes my scheduled Morphine. I have extended-release Morphine that is scheduled, and I have fast acting Morphine that is scheduled, and I did not receive either of them. Those shifts when there was no nurse to pass medications caused me a lot of pain. If I don't take my pain medications when it is scheduled, the pain builds up and it becomes intolerable. Those two days that I did not receive my pain medications, my pain got so bad that it caused my anxiety to get worse. The days I did not receive my pain medicine, my pain became 10/10. I cannot tolerate the pain when it builds up due to missed pain medications. My anxiety gets out of hand when I am in pain. Them not having a nurse to pass medications happens often. This is not the first time that there was no nurse on duty to pass medications. The staffing in this facility is an issue. Its 11:30 am, and I still did not receive my scheduled 9 am medications, and of course I am in pain, and I am uncomfortable. I never receive my 9 am medications on time, it's always given to me late, usually around noon time. I have expressed my concerns regarding not receiving my medications and receiving my medications late to the Social Service Director and the Administrator and nothing is done. It's the same problem every day. I have told them many times about my concerns with the medication administration. The last time I expressed my concern to the Administrator and the Social Service director was 2 weeks ago, when I did not receive my scheduled medications during 2 shifts on 06/05 and 06/06. My concerns were not addressed by the administration. On 06/29/2023 at 11:58 am, R2 stated, I don't receive my medications on time. Some days I don't receive my medications at all. I am in pain when I don't get my pain medications. I have expressed my concern with my medications to the Administrator and the Social Service Director. On 06/29/2023 at 12:10 pm, R3 stated, I don't get my scheduled medications at all sometimes. This causes me pain, as I have scheduled Tramadol for pain. I have expressed my concerns with getting my medications late and not getting my medications at all to the Administrator and the Social Service Director about 2 weeks ago, and nothing was done about it. On 07/06/2023 at 10:56 am, V4 (Social Service Director) stated, I am the Social Service Director. It is in my job description to receive and deal with resident and family concerns. When a resident expresses a concern, I will let the administration know and I will address the concern together with the administration. I will write the concern down, and I will let the administration know about the concern. I have a notebook that I write the concern down. If I am in the administrative office,we will discuss the concern, and however the administrator wants to proceed with the resident concern, we might write the concern down on a grievance form. I am supposed to write down all resident concerns on the concern form. Residents Grievance Policy (dated 08/20/2019) states: It is the policy of this facility to treat all residents with dignity and respect. If residents' rights are denied or violated, then a grievance may be made with the administration. Residents or family members may contact administration to discuss the concern at hand. The administrator or designee will compete the grievance form and explain in detail the nature of the concern. The grievance form will indicate if the concern was resolved and the responsible department.

Based on observation, interview, and record review, facility failed to have the services of a full time Director of Nursing. This failure has the potential to affect all 37 residents residing in the facility. Findings include: On 06/29/2023 at 1:00 pm, V1 (Administrator) stated, There is supposed to be one nurse per shift with 4 certified nursing assistants from 7:00 am to 3:00 pm, 3 certified nursing assistants from 3:00 pm to 11:00 pm, and 1 certified nursing assistant from 11:00 pm to 7:00 am. There was no nurse on 06/05/2023 from 5:00 pm till 11:00 pm. There was no Director of Nursing during this time either. The Director of Nursing is part time. V2 (Director of Nursing) works Tuesday, Thursday and Saturday from noon till 10:00 pm. On 06/29/2023 at 3:14 pm, V2 (Director of Nursing) stated, Currently, I am working part time. I only work Tuesday, Thursday and Saturday from noon to 8:00 pm. Today is the first day that I started working at this facility. I am unsure what happens when a nurse calls in. Facility's Staffing Policy (05/25/23) documents in part: It is the policy of this facility to minimum staffing ratios of 3.8 hours of nursing and personal care each day for each for each resident needing skilled care and 2.6 hours of nursing and personal care for each resident needing intermediate care are met. Nurse Managers may be required to work the nursing units when necessary. Facility's Nursing Shortage Policy (11/2022) documents in part: It is the responsibility of the Director of Nursing to ensure that the facility always has nursing coverage. The Director of Nurses will call all in-house nurses to obtain coverage. The Director of Nurse will cover the shift if need a charge nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to administer medications in accordance with the written order of the physician. This failure resulted in all residents in the facility (R1-R37) not receiving medications as ordered by the physician on 6/5/23 and 6/6/23. Findings Include: 1.R1's Face Sheet, dated 6/30/23, documents R1 is a [AGE] year-old with diagnoses including but not limited to: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. R1's Minimum Data Set (MDS) section C (dated 06/14/2023) scores R1 as 15, indicating R1 is cognitively intact. R1's Medication Administration Audit Report documents: Pramipexole Dihydrochloride Tablet 0.5mg 06/05/2023 17:00- not administered. Furosemide Tablet 20 mg 06/05/2023 17:00- not administered. Lyrica Oral Capsule 300 mg 06/05/2023 17:00- not administered. Morphine Sulfate ER Tablet Extended Release 15mg 06/05/2023 21:00- not administered. clonidine HCL Tablet 0.1mg 06/05/2023 21:00- not administered. Furosemide Tablet 20 mg 06/06/2023 17:00- not administered. Pramipexole Dihydrochloride Tablet 0.5mg 06/06/2023 17:00- not administered. Lyrica Oral Capsule 300 mg 06/06/2023 17:00- not administered. clonidine HCL Tablet 0.1mg 06/06/2023 21:00- not administered. Morphine Sulfate ER Tablet Extended Release 15mg 06/06/2023 21:00- not administered. On 06/29/2023 at 11:29am, R1 stated, On 06/05/2023 and 06/06/2023, there was no nurse on duty at all, and I did not receive my medications. I have a lot of pain because I had a neck surgery and I have other medical problems that cause me a lot of pain. During those dates there were shifts that I did not receive my medications, which includes my scheduled Morphine. I have extended-release Morphine that is scheduled, and I have fast acting Morphine that is scheduled, and I did not receive neither of them. Those shifts when there was no nurse to pass medications, caused me a lot of pain. If I don't take my pain medications when it is scheduled, the pain builds up and it becomes intolerable. Those two days that I did not receive my pain medications, my pain got so bad that it caused my anxiety to get worse. The days I did not receive my pain medicine, my pain became 10/10. I cannot tolerate the pain when it builds up due to missed pain medications. My anxiety gets out of hand when I am in pain. Them not having a nurse to pass medications happens often. This is not the first time that there was no nurse on duty to pass medications. The staffing in this facility is an issue. Its 11:30am and I still did not receive my scheduled 9am medications and of course I am in pain, and I am uncomfortable. I never receive my 9am medications on time, it's always given to me late, usually around noon time. I have expressed my concerns regarding not receiving my medications and receiving my medications late to the social service director and the administrator and nothing is done. It's the same problem every day. I have told them many times about my concerns with the medication administration The last time I expressed my concern to the administrator and the social service director was 2 weeks ago, when I did not receive my scheduled medications during 2 shifts on 06/05 and 06/06. My concerns were not addressed by the administration. 2. R2's Face Sheet documents R2 is a [AGE] year-old with diagnoses including but not limited to: Displaced Subtrochanteric Fracture of Left Femur, Gastrointestinal Hemorrhage, Urinary Track Infection, Cerebral Infarction, Malignant Neoplasm of Colon, Resistance to Multiple Antimicrobial Drugs, Diverticulosis of Large Intestine Without Perforation or Abscess Without Bleeding, and Pain Unspecified. R2's MDS section C (dated 06/06/2023) scores R2 as 10, indicating R2 is moderately cognitively impaired. R2's Medication Administration Audit Report documents: Gabapentin Oral Capsule 100mg 06/05/2023 17:00- not administered. Carvedilol Oral Tablet 25mg 06/05/2023 17:00- not administered. Eliquis Oral Tablet 5mg 06/05/2023 17:00- not administered. hydralazine HCL Oral Tablet 25mg 06/05/2023 17:00- not administered. Sertraline HCL Oral Tablet 50mg 06/05/2023 21:00-not administered. Depakote Oral Capsule 250mg 06/05/2023 21:00- not administered. Carvedilol Oral Tablet 25mg 06/06/2023 17:00- not administered. Gabapentin Oral Capsule 100mg 06/06/2023 17:00- not administered. Eliquis Oral Tablet 5mg 06/06/2023 17:00- not administered. hydralazine HCL Oral Tablet 25mg 06/06/2023 17:00- not administered. Sertraline HCL Oral Tablet 50mg 06/06/2023 21:00-not administered. Depakote Oral Capsule 250mg 06/06/2023 21:00- not administered On 06/29/2023 at 11:58am, R2 stated, I don't receive my medications on time. Some days I don't receive my medications at all. I am in pain when I don't get my pain medications. I have expressed my concern with my medications to the Administrator and the Social Service Director. 3. R3's Face Sheet documents R3 is a [AGE] year-old with diagnoses including but not limited to: Rheumatoid Arthritis, Morbid Obesity, Essential (Primary) Hypertension, Muscle Weakness (Generalized), Peripheral Vascular Disease, Osteoporosis Without Current Pathological Fracture, Major Depressive Disorder. R3's MDS section C (dated 06/17/2023) scores R3 as 15, indicating R3 is cognitively intact. R3's Medication Administration Audit Report documents: Tramadol HCL Tablet 50mg 06/05/2023 17:00- not administered. Enalapril Maleate Tablet 5mg 06/05/2023 17:00- not administered. Gabapentin Capsule 100mg 06/05/2023 17:00- not administered. Famotidine Tablet 20mg 06/05/2023 17:00- not administered. Alprazolam Tablet 0.25mg 06/05/2023 17:00- not administered. Ursodiol Capsule 300mg 06/05/2023 17:00- not administered. Sertraline HCL Tablet 100mg 06/05/2023 21:00- not administered Famotidine Tablet 20mg 06/06/2023 17:00- not administered Tramadol HCL Tablet 50mg 06/06/2023 17:00- not administered Enalapril Maleate Tablet 5mg 06/06/2023 17:00- not administered Ursodiol Capsule 300mg 06/06/2023 17:00- not administered Alprazolam Tablet 0.25mg 06/06/2023 17:00- not administered Gabapentin Capsule 100mg 06/06/2023 17:00- not administered Sertraline HCL Tablet 100mg 06/06/2023 21:00- not administered Zanaflex Tablt 4mg 06/06/2023 21:00- not administered Atorvastatin Calcium Tablet 80mg 06/06/2023 21:00- not administered On 06/29/2023 at 12:10 pm, R3 stated, I don't get my scheduled medications at all sometimes. This causes me pain, as I have scheduled Tramadol for pain. I have expressed my concerns with getting my medications late and not getting my medications at all to the Administrator and the Social Service Director about 2 weeks ago, and nothing was done about it. 4. R4's Face Sheet documents R4 is a [AGE] year-old with diagnoses including but not limited to: Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus, Hyperlipidemia, Unspecified, Post-Traumatic Stress Disorder, and Major Depressive Disorder, Recurrent, Unspecified. R4's MDS section C (dated 05/15/2023) scores R4 as 15, indicating R4 is cognitively intact. R4's Medication Administration Audit Report documents: Keppra Oral Tablet 750mg 06/05/2023 17:00- not administered Tramadol HCL Oral Tablet 50mg 06/05/2023 20:00- not administered Gabapentin Tablet 600mg 06/05/2023 20:00- not administered Olanzapine Tablet 5mg 06/05/2023 21:00- not administered Minipress Oral Capsule 2 mg 06/05/2023 21:00- not administered Mirtazapine Oral Tablet 30mg 06/05/2023 21:00- not administered Keppra Oral Tablet 750mg 06/06/2023 17:00- not administered Tramadol HCL Oral Tablet 50mg 06/06/2023 20:00- not administered Gabapentin Tablet 600mg 06/06/2023 20:00- not administered Olanzapine Tablet 5mg 06/06/2023 21:00- not administered Minipress Oral Capsule 2 mg 06/06/2023 21:00- not administered Mirtazapine Oral Tablet 30mg 06/06/2023 21:00- not administered On 07/06/2023 at 10:24 am, R4 stated, There was a date in beginning June when there wasn't a nurse to give me my medications, especially my pain medications. I was in a lot of pain. 5. R5's Face Sheet documents R5 is a [AGE] year-old with diagnoses including but not limited to: Unspecified, Arthritis, Multiple Sites, Essential (Primary) Hypertension, Chronic Obstructive Pulmonary Disease, Acute Hematogenous Osteomyelitis, Cellulitis of Right Lower Limb, Osteoarthritis, Anemia, and Acute on Chronic Combined Systolic and Diastolic (Congestive) Heart Failure. R5's MDS section C (dated 06/01/2023) scores R5 as 15, indicating R5 is cognitively intact. R5's Medication Administration Audit Report documents: Carvedilol Tablet 12.5mg 06/05/2023 17:00- not administered Gabapentin Capsule 300mg 06/05/2023 20:00- not administered Norco Oral Tablet 10-325mg 06/05/2023 20:00- not administered Tamsulosin HCL Capsule 0.4mg 06/05/2023 21:00- not administered Atorvastatin Calcium Tablet 40mg 06/05/2023 21:00 - not administered Carvedilol Tablet 12.5mg 06/06/2023 17:00- not administered Gabapentin Capsule 300mg 06/06/2023 20:00- not administered Norco Oral Tablet 10-325mg 06/06/2023 20:00- not administered Tamsulosin HCL Capsule 0.4mg 06/06/2023 21:00- not administered Atorvastatin Calcium Tablet 40mg 06/06/2023 21:00 - not administered On 07/06/2023 at 11:00 am, R5 stated, I did miss my medications sometime in June. I was in a lot of pain when I missed my medications. 6. R6's Face Sheet documents R6 is a [AGE] year-old with diagnoses including but not limited to: Paraplegia, Severe Sepsis with Septic shock, Arthritis Multiple Sites, Pressure Ulcer of Left Heel Stage 3, Pressure Ulcer of Other Site Stage 3, Impacted Cerumen Bilateral, Visual Loss, Pain in Leg Unspecified, Localized Edema, Essential (Primary) Hypertension, and Unspecified Atrial Fibrillation. R6's MDS section C (dated 04/19/2023) scores R6 as 13, indicating R6 is cognitively intact. R6's Medication Administration Audit Report documents: Doxycycline Hyclate Tablet 100mg 06/05/2023 17:00- not administered. Morphine Sulfate Oral Tablet 15mg 06/05/2023 21:00- not administered. Ciprofloxacin HCL Oral Tablet 500mg 06/06/2023 17:00- not administered. Morphine Sulfate Oral Tablet 15mg 06/06/2023 21:00- not administered On 07/06/2023 at 10:30 am, R6 stated, No one administered my medications or changed my wounds sometime in June when there was no nurse. I was in a lot of pain. 7. R8's Face Sheet documents R8 is a [AGE] year-old with diagnoses including but not limited to: Arthritis, Type 2 Diabetes Mellitus, and Acute Kidney Failure. R8's MDS section C (dated 04/24/2023) scores R8 as 6, indicating R8 is cognitively impaired. R8's Medication Administration Audit Report documents: Carvedilol Tablet 6.25mg 06/05/2023 17:00- not administered. Carvedilol Tablet 6.25mg 06/06/2023 17:00- not administered. On 07/26/2023 at 12:23 pm, R8 stated, There was no nurse on 06/05/2023 and 06/06/2023. During that time, they missed all my medications. I was very upset. 8. R9's Face Sheet documents R9 is a [AGE] year-old with diagnoses including but not limited to: Cerebral Palsy, Major Depressive Disorder, and Insomnia. R9's MDS section C (dated 06/09/2023) scores R9 as 15, indicating R9 is cognitively intact. R9's Medication Administration Audit Report documents: Gabapentin Capsule 300mg 06/05/2023 17:00- not administered. Tamsulosin HCL Capsule 0.4mg 06/05/2023 21:00-not administered. Gabapentin Capsule 300mg 06/06/2023 17:00- not administered. Tamsulosin HCL Capsule 0.4mg 06/06/2023 21:00-not administered. On 07/26/2023 at 12:59 pm, R9 stated, There was no nurse on 06/05/2023 and 06/06/2023. 9. R10's Face Sheet documents R10 is a [AGE] year-old with diagnoses including but not limited to: Arthritis, COPD, Angina Pectoris, Bipolar Disorder, Acute Respiratory Failure, Heart Failure, and Tachycardia. R10's MDS section C (dated 05/30/2023) scores R10 as 13, indicating R10 is cognitively intact. R10's Medication Administration Audit Report documents: Tamsulosin HCL Capsule 0.4mg 06/05/2023 21:00- not administered. Risperdal Oral Tablet 4mg 06/05/2023 21:00- not administered. Pravastatin Sodium Tablet 20mg 06/05/2023 21:00- not administered. Ativan Tablet 0.5mg 06/05/2023 21:00- not administered. Gabapentin Capsule 400mg 06/05/2023 21:00- not administered. Descovy [NAME] 200-25mg 06/06/2023 17:00- not administered. Tamsulosin HCL Capsule 0.4mg 06/06/2023 21:00- not administered. Risperdal Oral Tablet 4mg 06/06/2023 21:00- not administered. Pravastatin Sodium Tablet 20mg 06/06/2023 21:00- not administered. Ativan Tablet 0.5mg 06/06/2023 21:00- not administered. Gabapentin Capsule 400mg 06/06/2023 21:00- not administered. On 07/26/2023 at 12:16 pm, R10 stated, There was no nurse on June 5th and June 6th. That day they failed to give me my Norco for my arthritis and neuropathy. It was an aching and burning pain all over my body. I also do use oxygen. My pain was at a 10 out of a 10. 10. R12's Face Sheet documents R12 is a [AGE] year-old with diagnoses including but not limited to: Fracture of T11-T12 Vertebra, COPD, Rheumatoid Arthritis, Atherosclerotic Heart Disease, Schizoaffective Disorder , Anemia, Bipolar Disorder, and Anxiety Disorder. R12's MDS section C (dated 06/04/2023) scores R12 as 13, indicating R12 is cognitively intact. R12's Medication Administration Audit Report documents: Midodrine HCL Tablet 5mg 06/05/2023 17:00- not administered. chlorpromazine HCL Tablet 100mg 06/05/2023 17:00- not administered. Divalproex Sodium Tablet Delayed Release 250mg 06/05/2023 17:00- not administered. Fenofibrate Tablet 160mg 06/05/2023 20:00- not administered. Melatonin Tablet 5mg 06/05/2023 21:00- not administered. Clozapine Tablet 100mg 06/05/2023 21:00- not administered. Metoprolol Tartrate Tablet 25mg 06/05/2023 21:00- not administered. Midodrine HCL Tablet 5mg 06/06/2023 17:00- not administered. chlorpromazine HCL Tablet 100mg 06/06/2023 17:00- not administered. Divalproex Sodium Tablet Delayed Release 250mg 06/06/2023 17:00- not administered. Fenofibrate Tablet 160mg 06/06/2023 20:00- not administered. Melatonin Tablet 5mg 06/06/2023 21:00- not administered. Clozapine Tablet 100mg 06/06/2023 21:00- not administered. Metoprolol Tartrate Tablet 25mg 06/06/2023 21:00- not administered. On 07/26/2023 at 12:55 pm, R12 stated, There was a time on 06/05/2023 and 06/06/2023 where there was no nurse, and I felt anxious and terrible because there was no nurse to give me medications at the facility. 11. R27's Face Sheet documents R27 is a [AGE] year-old with diagnoses including but not limited to: COPD, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease, Hypertension, and Dementia. R27's MDS section C (dated 05/29/2023) scores R27 as 13, indicating R27 is cognitively intact. R27's Medication Administration Audit Report documents: Symbicort Inhalation Aerosol 160-4.5 mcg/act 06/05/2023 17:00- not administered. Hydralazine HCL Oral Tablet 25mg 06/05/2023 17:00- not administered. Symbicort Inhalation Aerosol 160-4.5 mcg/act 06/06/2023 17:00- not administered. Hydralazine HCL Oral Tablet 25mg 06/06/2023 17:00- not administered. On 07/26/2023 at 12:40 pm, R27 stated, I did not get any medications this morning. When I don't get my medications, my legs ache from my hips down to the ankle. My pain is at a 9 out of 10, 10 being the worst pain possible, when I don't receive my medications. 12. R29's Face Sheet documents R29 is a [AGE] year-old with diagnoses including but not limited to: schizoaffective disorder. R29's Medication Administration Audit Report documents: Haloperidol Tablet 1mg 06/05/2023 17:00- not administered. Ativan Oral Tablet 0.5mg 06/05/2023 21:00- not administered. Haloperidol Tablet 1mg 06/06/2023 17:00- not administered. Ativan Oral Tablet 0.5mg 06/06/2023 21:00- not administered. On 07/26/2023 at 12:46 pm, R29 stated, I was admitted to the facility since May 30th. There was no nurse June 5th, and June 6th. I was worried because there was no one to run the place. 13. R31's Face Sheet documents R31 is a [AGE] year-old with diagnoses including but not limited to: Arthritis, Traumatic Subarachnoid Hemorrhage, Prostatic Hyperplasia, Dementia, Alzheimer's Disease, Atherosclerotic Heart Disease, Heart Failure, Chronic Kidney Disease, Prostatic Hyperplasia, Major Depressive Disorder, Hypothyroidism, Hyperlipidemia, and Hypertension. R31's MDS section C (dated 04/11/2023) scores R31 as 14, indicating R31 is cognitively intact. R31's Medication Administration Audit Report documents: Lipitor Tablet 10mg 06/05/2023 17:00- not administered. Trazodone HCL Tablet 50mg 06/05/2023 20:00- not administered. Tamsulosin HCL 0.4mg 06/05/2023 20:00- not administered. Lipitor Tablet 10mg 06/06/2023 17:00- not administered. Trazodone HCL Tablet 50mg 06/06/2023 20:00- not administered. Tamsulosin HCL 0.4mg 06/06/2023 20:00- not administered. On 07/26/2023 at 12:48 pm, R31 stated, I take pain medication for my knees. The pain can get really bad if I don't get it. 14. R37's Face Sheet documents R37 is a [AGE] year-old with diagnoses including but not limited to: Schizophrenia, Type 2 Diabetes Mellitus, Arthritis, Acute Kidney Failure, Chronic Pain, and Hypertension. R37's MDS section C (dated 04/27/2023) scores R37 as 12, indicating R37 is cognitively intact. R37's Medication Administration Audit Report documents: Gabapentin Capsule 100mg 06/05/2023 17:00- not administered. Atorvastatin Calcium Tablet 10mg 06/05/2023 20:00- not administered. Aricept Tablet 5mg 06/05/2023 21:00- not administered. Melatonin Oral Tablet 3mg 06/05/2023 21:00- not administered. Lantus Subcutaneous Solution 100 unit/ml 06/05/2023 21:00- not administered. Novolog Solution 100 unit/ml inject 6 units 06/06/2023 16:00- not administered. Gabapentin Capsule 100mg 06/06/2023 17:00- not administered. Atorvastatin Calcium Tablet 10mg 06/06/2023 20:00- not administered. Aricept Tablet 5mg 06/06/2023 21:00- not administered. Melatonin Oral Tablet 3mg 06/06/2023 21:00- not administered. Lantus Subcutaneous Solution 100 unit/ml 06/06/2023 21:00- not administered. On 07/26/2023 at 12:53 pm, R37 stated, When I don't get my medications, my foot starts to ache, and pain is at a 4 out of 10. 15. R7's Medication Administration Audit Report documents: Acetaminophen Tablet 325mg 06/05/2023 17:00- not administered. Warfarin Sodium Tablet 2.5mg 06/05/2023 21:00- not administered. Acetaminophen Tablet 325mg 06/06/2023 17:00- not administered. Warfarin Sodium Tablet 2.5mg 06/06/2023 21:00- not administered 16. R11's Medication Administration Audit Report documents: Valproic Acid Solution 250mg/5ml 06/05/2023 21:00- not administered. Valproic Acid Solution 250mg/5ml 06/06/2023 21:00- not administered. 17. R13's Medication Administration Audit Report documents: Prednisolone Acetate Suspension 1% 1 drop in both eyes- not administered. Depakote Tablet Delayed Release 125mg 06/05/2023 17:00- not administered. Brimonidine Tartrate-Timolol Solution 0.2-0.5% 06/05/2023 17:00- not administered. Lidocaine Ointment 5 % 06/05/2023 20:00- not administered. Carvedilol Tablet 3.125mg 06/05/2023 21:00- not administered. Latanoprost Solution 0.005% instill 1 dose in both eyes 06/05/2023 21:00- not administered. Depakote Tablet Delayed Release 125mg 06/06/2023 17:00- not administered. Brimonidine Tartrate-Timolol Solution 0.2-0.5% 06/06/2023 17:00- not administered. Lidocaine Ointment 5 % 06/06/2023 20:00- not administered. Carvedilol Tablet 3.125mg 06/06/2023 21:00- not administered. Latanoprost Solution 0.005% instill 1 dose in both eyes 06/06/2023 21:00- not administered. 18. R14's Medication Administration Audit Report documents: Furosemide Tablet 20mg 06/05/2023 17:00- not administered. Valproic Acid Solution 250mg/5 ml 06/05/2023 17:00- not administered. Carbidopa-Levodopa Tablet 25-100mg 06/05/2023 17:00- not administered. Midodrine HCL Tablet 10mg 06/05/2023 17:00- not administered. Primidone Tablet 50mg 06/05/2023 17:00- not administered. Clonazepam Tablet 06/05/2023 22:00- not administered. Furosemide Tablet 20mg 06/06/2023 17:00- not administered. Valproic Acid Solution 250mg/5 ml 06/06/2023 17:00- not administered. Carbidopa-Levodopa Tablet 25-100mg 06/06/2023 17:00- not administered. Midodrine HCL Tablet 10mg 06/06/2023 17:00- not administered. Primidone Tablet 50mg 06/06/2023 17:00- not administered. Clonazepam Tablet 06/06/2023 22:00- not administered. 19. R15's Medication Administration Audit Report documents: Apixaban Tablet 5mg 06/05/2023 17:00- not administered. Atorvastatin Calcium Tablet 80mg 06/05/2023- not administered. Apixaban Tablet 5mg 06/06/2023 17:00- not administered. Atorvastatin Calcium Tablet 80mg 06/06/2023- not administered. 20. R16's Medication Administration Audit Report documents: Eliquis Oral Tablet 5mg 06/05/2023 17:00- not administered. Divalproex Sodium ER Oral Tablet Extended Release 06/05/2023 20:00-not administered. Flomax Oral Capsule 0.4mg (Tamsulosin HCL) 06/05/2023 21:00- not administered. Allopurinol Oral Tablet 100mg 06/05/2023 21:00- not administered. Eliquis Oral Tablet 5mg 06/06/2023 17:00- not administered. Divalproex Sodium ER Oral Tablet Extended Release 06/06/2023 20:00-not administered. Flomax Oral Capsule 0.4mg (Tamsulosin HCL) 06/06/2023 21:00- not administered. Allopurinol Oral Tablet 100mg 06/06/2023 21:00- not administered. 21. R17's Medication Administration Audit Report documents: Carbidopa-Levodopa Tablet 25-100mg 06/05/2023 17:00- not administered. Levetiracetam Tablet 250mg 06/05/2023 17:00- not administered. Valproic Acid Solution 750mg 06/05/2023 17:00- not administered. Levetiracetam Tablet 1000mg 06/05/2023 17:00- not administered. Melatonin Tablet 5mg 06/05/2023 21:00- not administered. Atorvastatin Calcium Tablet 06/05/2023 21:00- not administered. Levetiracetam Tablet 1000mg 06/06/2023 17:00- not administered. Valproic Acid Solution 750mg 06/06/2023 17:00- not administered. Levetiracetam Tablet 250mg 06/06/2023 17:00- not administered. Carbidopa-Levodopa Tablet 25-100mg 06/06/2023 17:00- not administered. Melatonin Tablet 5mg 06/06/2023 21:00- not administered. Atorvastatin Calcium Tablet 06/06/2023 21:00- not administered. 22. R18's Medication Administration Audit Report documents: Zyprexa Tablet 5mg 06/05/2023 17:00- not administered. Memantine HCL Tablet 10mg 06/05/2023- not administered. Donepezil HCL Tablet 10mg 06/05/2023 20:00- not administered. Atorvastatin Calcium Tablet 20mg 06/05/2023- not administered. Tamsulosin HCL Capsule 0.4 06/05/2023- not administered. Trazodone HCL Tablet 50mg 06/05/2023 21:00- not administered. Cogentin Solution 1mg 06/05/2023 21:00- not administered. Melatonin Tablet 5mg 06/05/2023 21:00- not administered. Zyprexa Tablet 5mg 06/06/2023 17:00- not administered. Memantine HCL Tablet 10mg 06/06/2023- not administered. Donepezil HCL Tablet 10mg 06/06/2023 20:00- not administered. Atorvastatin Calcium Tablet 20mg 06/06/2023- not administered. Tamsulosin HCL Capsule 0.4 06/06/2023- not administered. Trazodone HCL Tablet 50mg 06/06/2023 21:00- not administered. Insulin Detemir Solution inject 40 units subcutaneously 06/06/2023 21:00- not administered. Cogentin Solution 1mg 06/06/2023 21:00- not administered. Melatonin Tablet 5mg 06/06/2023 21:00- not administered. 23. R19's Medication Administration Audit Report documents: Metoprolol Tartrate Tablet 50mg 6/05/2023 21:00- not administered. Risperidone Tablet 3mg 06/05/2023 21:00- not administered. Simvastatin Tablet 40mg 06/05/2023 21:00- not administered. Enalapril Maleate Tablet 10mg 06/05/2023 21:00- not administered. Lorazepam Tablet 0.5mg 06/05/2023 22:00- not administered. Metoprolol Tartrate Tablet 50mg 6/06/2023 21:00- not administered. Risperidone Tablet 3mg 06/06/2023 21:00- not administered. Simvastatin Tablet 40mg 06/06/2023 21:00- not administered. Enalapril Maleate Tablet 10mg 06/06/2023 21:00- not administered. Lorazepam Tablet 0.5mg 06/06/2023 22:00- not administered. 24. R20's Medication Administration Audit Report documents: Glycopyrrolate Oral Tablet 1mg 06/05/2023 17:00- not administered. Gabapentin Oral Solution 06/05/2023 20:00- not administered. Acetaminophen Oral Liquid 20.31ml 06/05/2023 20:00- not administered. Tamsulosin HCL Oral Capsule 0.4mg 06/05/2023 21:00- not administered. Trazodone HCL Oral Tablet 100mg 06/05/2023 21:00- not administered. Melatonin Oral Tablet 10mg 06/05/2023 21:00- not administered. Quetiapine Fumarate Tablet 25mg 06/05/2023 21:00- not administered. Budesonide Suspension 0.5mg/2ml 06/05/2023 21:00- not administered. Hydralazine HCL Oral Tablet 25mg 06/06/2023 16:00- not administered. Glycopyrrolate Oral Tablet 1mg 06/06/2023 17:00- not administered. Gabapentin Oral Solution 06/06/2023 20:00- not administered. Acetaminophen Oral Liquid 20.31ml 06/06/2023 20:00- not administered. Tamsulosin HCL Oral Capsule 0.4mg 06/06/2023 21:00- not administered. Trazodone HCL Oral Tablet 100mg 06/06/2023 21:00- not administered. Melatonin Oral Tablet 10mg 06/06/2023 21:00- not administered. Quetiapine Fumarate Tablet 25mg 06/06/2023 21:00- not administered. Budesonide Suspension 0.5mg/2ml 06/06/2023 21:00- not administered. 25. R21's Medication Administration Audit Report documents: Midodrine HCL Tablet 5mg 06/05/2023 17:00- not administered. Chlorpromazine HCL Tablet 100mg 06/05/2023 17:00- not administered. Divalproex Sodium Tablet Delayed Release 250mg 06/05/2023 17:00- not administered. Fenofibrate Tablet 160mg 06/05/2023 20:00- not administered. Melatonin Tablet 5mg 06/05/2023 21:00- not administered. Clozapine Tablet 100mg 06/05/2023 21:00- not administered. Metoprolol Tartrate Tablet 25mg 06/05/2023 21:00- not administered. Midodrine HCL Tablet 5mg 06/06/2023 17:00- not administered. Chlorpromazine HCL Tablet 100mg 06/06/2023 17:00- not administered. Divalproex Sodium Tablet Delayed Release 250mg 06/06/2023 17:00- not administered. Fenofibrate Tablet 160mg 06/06/2023 20:00- not administered. Melatonin Tablet 5mg 06/06/2023 21:00- not administered. Clozapine Tablet 100mg 06/06/2023 21:00- not administered. Metoprolol Tartrate Tablet 25mg 06/06/2023 21:00- not administered. 26. R22's Medication Administration Audit Report documents: Thiamine HCL Oral Tablet 250mg 06/05/2023 6:00- not administered. 27. R23's Medication Administration Audit Report documents: Lidocaine Patch 5% 06/05/2023 20:59- not administered. Melatonin Tablet 3mg 06/05/2023 21:00- not administered. Gabapentin Capsule 300mg 06/05/2023 21:00- not administered. Seroquel Oral Tablet 25mg 06/05/2023 21:00- not administered. Flomax Capsule 0.4mg 06/05/2023 21:00- not administered. Gabapentin Capsule 300mg 06/06/2023 16:30- not administered. Lidocaine Patch 5% 06/06/2023 20:59- not administered. Flomax Capsule 0.4mg 06/06/2023 21:00- not administered. Seroquel Oral Tablet 25mg 06/06/2023 21:00- not administered. Melatonin Tablet 3mg 06/06/2023 21:00- not administered. Gabapentin Capsule 300mg 06/06/2023 21:00- not administered. 28. R24's Medication Administration Audit Report documents: Metformin HCL Oral Tablet 500mg 06/05/2023 17:00- not administered. Dicyclomine HCL Oral Capsule 10mg 06/05/2023 17:00- not administered. Creon Oral Capsule Delayed Release 12000-38000 unit 06/05/2023 17:00-not administered. Neurontin Oral Capsule 300mg 06/05/2023 17:00- not administered. Dicyclomine HCL Oral Capsule 10mg 06/05/2023 20:00- not administered. Lantus Subcutaneous Solution 100 unit/ml 06/05/2023 21:00- not administered. Melatonin Oral Tablet 5mg 06/05/2023 21:00- not administered. Atorvastatin Calcium Oral Tablet 80mg 06/05/2023 21:00- not administered. Humalog Injection Solution 100 unit/ml 06/06/2023 16:00- not administered. Metformin HCL Oral Tablet 500mg 06/06/2023 17:00- not administered. Dicyclomine HCL Oral Capsule 10mg 06/06/2023 17:00- not administered. Creon Oral Capsule Delayed Release 12000-38000 unit 06/06/2023 17:00-not administered. Neurontin Oral Capsule 300mg 06/06/2023 17:00- not administered. Dicyclomine HCL Oral Capsule 10mg 06/06/2023 20:00- not administered. Lantus Subcutaneous Solution 100 unit/ml 06/06/2023 21:00- not administered. Melatonin Oral Tablet 5mg 06/06/2023 21:00- not administered. Atorvastatin Calcium Oral Tablet 80mg 06/06/2023 21:00- not administered. 29.R25's Medication Administration Audit Report documents: Metformin HCL ER Oral Tablet Extended Release 750mg 06/05/2023 17:00- not administered. Gabapentin Oral Capsule 400mg 06/05/2023 17:00- not administered. Naproxen Tablet 500mg 06/05/2023 17:00- not administered. Atorvastatin Calcium Tablet 80mg 06/05/2023 21:00- not administered. Metoprolol Tartrate Tablet 25mg 06/05/2023 21:00- not administered. Insulin Glargine Solution 100 unit/ml inject 50 units 06/05/2023 21:00- not administered. Zanaflex Tablet 4mg 06/05/2023 21:00- not administered. Humalog Injection Solution 100 unit/ml 06/06/2023 16:30- not administered. Metformin HCL ER Oral Tablet Extended Release 750mg 06/06/2023 17:00- not administered. Gabapentin Oral Capsule 400mg 06/06/2023 17:00- not administered. Naproxen Tablet 500mg 06/06/2023 17:00- not administered. Atorvastatin Calcium Tablet 80mg 06/06/2023 21:00- not administered. Metoprolol Tartrate Tablet 25mg 06/06/2023 21:00- not administered. Insulin Glargine Solution 100 unit/ml inject 50 units 06/06/2023 21:00- not administered. Zanaflex Tablet 4mg 06/06/2023 21:00- not administered. 30. R26's Medication Administration Audit Report documents: Vitamin A&D Skin Protectant External Ointment 06/05/2023 17:00- not administered. Vitamin A&D Skin Protectant External Ointment 06/06/2023 17:00- not administered. 31. R28's Medication Administration Audit Report documents: Divalproex Sodium Tablet Delayed Release 125mg 06/05/2023 17:00- not administered. Docusate Sodium Oral Tablet 06/05/2023 17:00- not administered. Donepezil HCL Tablet 10mg 06/05/2023 20:00- not administered. Divalproex Sodium Tablet Delayed Release 125mg 06/06/2023 17:00- not administered. Docusate Sodium Oral Tablet 06/06/2023 17:00- not administered. Donepezil HCL Tablet 10mg 06/06/2023 20:00- not administered. 32. R30's Medication Administration Audit Report documents: Metformin HCL ER Oral Tablet Extended Release 06/05/2023 17:00- not administered. Atorvastatin Calcium Oral Tablet 80mg 06/05/2023 21:00- not administered. Carvedilol Oral Tablet 12.5mg 06/05/2023 21:00- not administered. Seroquel Oral Tablet 50mg 06/05/2023 21:00- not administered. Melatonin Oral Tablet 5mg 06/05/2023 21:00- not administered. Metformin HCL ER Oral Tablet Extended Release 06/06/2023 17:00- not administered. Melatonin Oral Tablet 5mg 06/06/2023 21:00- not administered. Seroquel Oral Tablet 50mg 06/06/2023 21:00- not administered. Carvedilol Oral Tablet 12.5mg 06/06/2023 21:00- not administered. Atorvastatin Calcium Oral Tablet 80mg 06

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide daily treatment as ordered, and failed to ensure multiple layers of sheets were not used when using a low air loss mattress for 3 (R1, R2 and R4) residents who are at risk for developing pressure injuries out of 4 residents reviewed for pressure injuries. Findings include: 1. R1 is a [AGE] year old male, admitted to the facility on [DATE], with the following diagnoses: Osteomyelitis of Vertebra, Sacrum and Sacrococcygeal Region, Mood Disorder, Pressure Ulcer of Sacral Region, Stage 4, Essential Hypertension, Urinary Tract Infection, Type 2 Diabetes Mellitus, Anemia, Paraplegia, Severe Protein-Calorie Malnutrition, Paraplegia, Major Depressive Disorder, Bipolar Disorder and Neuromuscular Dysfunction of Bladder. R1 was transferred to the hospital on [DATE], and did not come back to the facility. Review of preadmission hospital records document R1 had wounds the left hip, sacral area with 2 separate sites, right ischium, left ankle and posterior left heel. R1 was admitted to the facility with multiple pressure injuries. Interview with V2, Licensed Practical Nurse, on 2/24/2023 at 10:57 AM, also affirms R1 was admitted with multiple wounds. V2 stated, I am familiar with (R1). (R1) had 7 wounds/sites. We were doing daily dressing changes for 5 of them and then weekly for the two other sites. The dressing changes are usually in the evening. (R1's) wounds were really clean looking, it's just he had no fat tissues on his bottom so it was hard to heal. I've never seen his motorized wheelchair. R1's Braden Scale for Predicting Pressure Sore Risk, dated 11/2/2022, documents a score of 12 which indicates that R1 is at high risk for developing pressure injuries. R1's Physician Order Sheet, with a start date of 12/06/2022, documents: Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to Sacral wound topically one time a day for wound infection Cover with dry sterile dressing. Review of R1's January 2023 Treatment Administration Records document on the following days above treatment orders were not signed off as being administered by the nurse: January 1, 2, 5, 11, 19 and 27. Review of R1's Progress Notes did not show any documentation R1 refused wound treatment on those days. 2. R2 is a [AGE] year old female admitted to the facility on [DATE], with the following diagnoses: Fracture of the Lower end of Left Femur, Arthritis, Fracture of Left Acetabulum, Urinary Tract Infection, Severe Sepsis with Septic Shock, Paraplegia, Neuromuscular Dysfunction of Bladder, Pressure Ulcer of Left Heel, Stage 3, Pressure Ulcer of Other Site, stage 3, Severe Protein-Calorie Malnutrition, Hypokalemia, Candidiasis of Skin and Nail, Pulmonary Embolism, Essential Hypertension, and Atrial Fibrillation. On 2/24/2023 at 10:57 AM, in the presence of V2, Licensed Practical Nurse/LPN, R2 was observed with special mattress with 1 flat sheet, one washable chuck, and another folded flat sheet on top of the special mattress. R2 was also wearing an incontinence brief while in bed. R2 had wedge cushions on her feet. Dressing was observed, dated 2/23/23, intact and clean. Spoke to R2 by writing questions on her whiteboard. R2 stated staff have been changing her dressings daily, answers her call light promptly, and treats her well. R2 states she is happy with the stay here in the facility. On 02/24/2023 at 11:17 AM V2, LPN, confirmed one flat sheet, chuck pad, and another folded flat sheet was on top of the special mattress. V2 stated, That's how they make the bed. I don't know if it's okay to have multiple sheets on top of the mattress. She has no wound on her sacrum or back. The purpose of using special mattress is to prevent bedsores. R2's Braden Scale for Predicting Pressure Sore Risk, dated 04/23/2021, documents a score of 15 which indicates that R2 is at risk for developing pressure injuries. 3. R4 is a [AGE] year old female admitted to the facility on [DATE], with the following diagnoses: Cerebral Palsy, Acute Respiratory Failure with Hypercapnia, Pneumonitis due to inhalation of food and vomit, Dysphagia, Moderate Protein-Calorie Malnutrition, Metabolic Encepalopathy, Repeated Falls, Muscle Wasting and Atrophy, Retention of Urine, Major Depressive Disorder, Anxiety Disorder and Pain, Unspecified. On 2/24/2023 at 2:15 PM, in the presence of V2, Licensed Practical Nurse, R4 was observed sitting on her wheelchair. R4's bed has a special mattress with 1 flat sheet and a washable chuck on top of the special mattress. R4 was also wearing an incontinence brief. V2 stated, I asked my Director of Nursing/DON and she stated it shouldn't be that way, but the Certified Nursing Assistants/CNAs are doing it so that it's easier for them to lift the residents. R4's Braden Scale for Predicting Pressure Sore Risk, dated 06/24/2022, documents a score of 15 which indicates R4 is at risk for developing pressure injuries. Facility presented an undated policy titled Low Air Loss Mattress which documents in part under Procedure: 5. Any resident on a low air loss mattress will be provided blue air permeable chucks for episodes of incontinence. A single non-fitted sheet may be used on the mattress for assistance with repositioning.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 1 (R5) out of 6 residents reviewed in a total sample of 12 for call lights. Findings include: R5 was admitted to the facility 4/30/19, with diagnoses which included but not limited to: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Osteoarthritis, Unsteadiness on Feet, Chronic Embolism and Thrombosis of Deep Veins of Unspecified Lower Extremity, Generalized Muscle Weakness, History of Falling, Pain in Lower Leg. R5's MDS (Minimum Data Set) from 7/26/22 documented BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognition, and section G (Functional Status) documents in part R5 requires extensive assistance with 2+ persons physical assist with bed mobility and transfer. R5 does not have a fall risk care plan. R5's nursing care plan for impaired mobility documents, in part, impaired mobility is related to generalized weakness, history of cerebrovascular accident with right side weakness, osteoarthritis, and pain. On 12/13/22 at 11:18 AM, R5's call light cord was attached to the switch on the wall and hanging down from the switch against the wall, touching the floor. The end of the call light cord did not have a clip, and the end of the cord was 3-4 feet behind R5, out of reach. R5 had a yellow sign titled, Fall Precaution Checklist posted on the wall behind her bed. On 12/13/22 at 1:10 PM, V2 (Director of Nursing) stated call lights must be within reach for all the residents so residents can ask for help if needed. V2 stated the staff round in the beginning of their shift, and every 2 hours thereafter. V2 pointed to the yellow sign on the wall titled, Fall Precaution Checklist, which documented the call light should be within reach of the resident. V2 stated having the call lights within reach of the resident is part of their fall prevention program. V2 stated the call light cord should not be on the floor. On 12/14/22 at 10:34 AM, R5 stated she (R5) could not reach her call light because the string is too short to reach her, and there is no way to attach the call light to her sheets because the clip is missing. R5 stated she spoke with the maintenance staff to fix it. On 12/15/22 at 9:38 AM, R5's call light was out of reach of R5. R5 stated to surveyor, See? I cannot reach my call light. R5 stated, It's too far away, I need a clip added to the call light cord so I can clip it close to me. R5 stated she usually has to yell to get someone's attention, but that even when she yells, some people tell her to stop yelling and don't help. R5 stated she needs to yell because she does not have a call light to get staffs attention, and she needs help caring for herself, otherwise, she'd try to do things on her own. On 12/15/22 at 9:40 AM, surveyor showed V18 (Certified Nursing Assistant) the location of R5's call light, and V18 stated R5 could not reach the call light cord where it was. On 12/15/22 at 12:32 PM, V1 (Administrator) stated all residents should have a call light, and the call light should be within reach of the resident. V1 stated all call lights have a clip on the end of the cord. Facility policy titled, Call Light undated, documents, in part that the purpose is to ensure that there is prompt response to the resident's call for assistance, the facility ensures the call systems is in proper working order. Nursing staff shall check all call lights daily and report any defective call lights to the administrator/maintenance immediately for repair. Facility policy titled, Fall Prevention Policy undated documents in part that resident identified as at risk for all will be placed on fall prevention program and to make sure call light is within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, interviews and records review, the facility failed to follow their medication administration policy for one resident (R183) reviewed for safe medication administration, in a sample of 12 residents reviewed. Findings include: R183 is a [AGE] year-old individual admitted to the facility on [DATE]. R183's MDS (Minimum Data Set) section C, dated 11/04/2022, documents R183's BIMS (Brief Interview for Mental Status (BIMS) as 15/15. R183's medical diagnoses are not listed in R183's Electronic Health Medical records. R184's section G, Activities of Daily Living (ADL) Assistance, dated 12/13/22,, document R183 as needing extensive assistance with ADL care. On 12/13/2022 at 11:06 AM, R183 was observed laying in bed watching TV. R183 said R183 has not been taking medication Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium). R183 reached for R183's black hat, and pulled a tissue out and unwrapped it. R183 showed surveyor seven orange pills wrapped in a tissue, placed inside a black hat. R183 said, These are Depakote pills. I don't have any depression or mental health issues and never have. I don't know why I was started on these pills. I have not taken these pills since I came here. R183 said R183 has been putting all the Depakote pills in a milk carton after saving them, and giving the staff to throw them away. On 12/13/2022 at 12:28 PM, surveyor called V2 (Director of Nursing) to R183's room, and R183 showed V2 the medications R183 had in R183's room. V2 said residents should not be having medications by the bedside because it is a safety issue. V2 said the only time a resident's medication can be left with the resident is when a resident has been assessed for safe self-medication administration, and the physician has given an order for the resident to self-administer medications. V2 said nurses should not leave a resident's medications on the bedside table. V2 said the nurses should make sure when they administer medications, that the resident takes the medication. V2 said nurses should check for pocketing of medications. V2 said if resident is not checked to make sure they took their medications, or if the resident's medication is left on the bedside by the nurse, the resident can hoard the medication, then later take the medication all at once. V2 said this can lead to overdose. V2 said other residents might take the medication left on a resident's bedside, and this can cause adverse side effects. V2 said leaving medications on the bedside table is mismanagement of resident care. V2 said nurses should make sure they let the resident know all the medications they are receiving. V2 said If a resident refuses a medication, it should be documented as refused, and the nurse should notify the doctor of medication refusal. V2 said R183 should not be having medications in R183's room. R183's Electronic Medication Administration Record(eMAR) documents R183's Depakote medication (Depakote) as given. Facility policy titled Quality Assurance in Medication Administration, no date, documents; -The medications must be administered in accordance with the written orders of the physician. Facility Policy titled Medication Administration, no date, documents; -Remain with the resident to ensure that the medication is swallowed. -Circle initials on MAR(Medication Administration Record) if medication is not administered as ordered and record reason PRN/Omission Medication section of the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement adequate fall prevention precautions during transfer for one resident (R182) of 12 residents reviewed for falls. Findings include: R182 is a [AGE] year-old individual admitted to the facility on [DATE]. R182's medical diagnosis includes but not limited to: Chronic Obstructive Pulmonary Disease, unspecified, Acute Hematogenous Osteomyelitis, unspecified site, Cellulitis of right lower limb, Osteoarthritis, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, Lymphedema, not elsewhere classified. R182's MDS (Minimum Data Set), section C -Cognitive Patterns, documents a Brief Interview for Mental Status (BIMS), dated 09/16/2022, as 15/15. R182's MDS Section G - Functional Status, dated 12/14/2022, documents R182 needs extensive assistance in bed mobility, transfer, walking in room, dressing, toileting. R182's Moving from seated to standing position assessment, dated [DATE], documents R182 is not steady, only able to stabilize with staff assistance. R182's weight, dated12/6/2022, is documented as 244.2 Lbs R182's care plan, dated 08/22/2022, documents R182 is at risk for fall/injury from weakness and tiredness related to obesity COPD(Chronic Obstructive Pulmonary Disease) and inability to move independently. Facility did not provide copies of R182's care plan, POS (physician Order Sheet), MDS(Minimum Data Set) section C&G, or R182's care plan which were requested for several times during the survey. On 12/13/2022 at 9:15 AM, V4(Certified Nurses Assistant-CNA) was observed transferring R182 to R182's wheelchair with a mechanical lift, alone. V4 was observed struggling to stabilize R182 on the mechanical lift, and R182 was observed swaying from side to side on the mechanical lift as V4 was lifting R182. On 12/13/2022 at 11:30 AM, V4 (CNA) said there should have been two people using the mechanical lift to transfer R182. V4 said transferring R182 with the mechanical lift alone is dangerous, and R182 could have fallen and got injured. V4 said, Something could have gone wrong when I was transferring (R182) with the (mechanical life) alone. I should not have transferred (R182) alone. On 12/13/2022 at 11:36 AM, V2 (Director of Nursing) said the mechanical lift should be used by two people to make sure resident is safe during transfer, and mechanical lift should never be used by one person alone to transfer residents. V2 said when a resident is being transferred with the mechanical lift by one staff, the resident can feel anxious thinking they will fall, and this can cause anxiety. V4 said resident is at risk of falling and getting injured while being transferred via mechanical lift by one staff member, because the mechanical lift will not be stable. On 12/13/2022 at 11:58 AM, R182 was observed sitting on wheelchair in the hallway. R182 said today, V4(Certified Nurses' Assistant-CNA)transferred R182 to R182's wheel chair using the mechanical lift. R182 said R182 sometimes feels unsafe being transferred by one staff member using the mechanical lift, because the lift swings back and forth and is not stable when used by one staff member. Facility's Fall policy dated 12/1/2022 documents: -Residents identified as a risk for fall will be placed on the Fall Prevention Program while in the facility.

Based on observation, interview, and record review, the facility failed to date and prevent nasal cannula from touching the floor for 1 (R20) out of 1 resident reviewed for oxygen usage in a sample of 12. Findings include: R20 has diagnoses not limited to: Chronic Obstructive Pulmonary Disease, Sleep Apnea, Acute Respiratory Failure with Hypoxia, Heart Failure, Morbid Obesity, Weakness, Lack of Coordination, and Reduced Mobility. R20 ' s MDS (Minimum Data Set), signed on 11/13/22, documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive response, and section O documents in part R2 is receiving oxygen. R20 ' s physician order sheet documents in part oxygen at 2 liters via nasal cannula as needed for shortness of breath, dated 07/07/20, and change oxygen tube once a week (Friday) and as needed, dated 11/26/20. R20 ' s care plan, dated 05/10/21, documents, in part, R20 has altered respiratory status/difficulty breathing related to acute respiration failure with hypoxia. On 12/13/22 at 11:37 AM, R20's nasal canula oxygen tubing was lying the floor, on top of garbage and other items (papers, bottles of cream). R20's nasal cannula tubing and humidification bottle attached to the oxygen concentrator were not dated. No protective bag observed at bedside. R20 stated she uses the oxygen every night, and sometimes during the day. R20 stated she was not aware of any storage bag provided for her to put the oxygen tubing in when not using. On 12/13/22 at 12:06 PM, R20 was lying in bed with nasal cannula oxygen tubing in her nose and oxygen concentrator running. On 12/13/22 at 12:34 PM, V2 (Director of Nursing) stated oxygen tubing is changed weekly and more often as needed. V2 stated oxygen tubing should be dated, and the nasal cannula tubing should be stored in a storage bag so that the tubing does not fall on the floor and get contaminated, which could potentially make a resident sick. V2 inspected R20's oxygen tubing and stated, I don ' t see a date on the tubing and there is no date on the water humidification bottle either. V2 stated, in part, she did not see a storage bag for the nasal cannula to be put into, and usually the storage bag is wrapped around the handle of the oxygen concentrator. Facility policy titled, Administration of Oxygen by Nasal Cannula, dated 11/06, documents in part to change cannula, connecting tubing and humidifier every 72 hours and write date on tubing.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for 3 of 4 residents (R183, R86, R27) in the sample reviewed. There were 35 opportunities and 10 errors, resulting in a 28.57% medication error rate. Findings include: 1. Record review of R183's order summary, dated 12/15/22, reads in part: Lactulose Oral Packet 10 GM (Lactulose) Give 10 mg by mouth two times a day; Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 1 application inhale orally every 12 hours changed to as needed on 12/14/22; Vitamin D2 Oral Tablet (Ergocalciferol) Give 50000 unit by mouth one time a day for supplement On 12/13/22 at 9:47 AM, medication administration observation was conducted with V6 (Licensed Practical Nurse). V6 prepared R183's medication: Lactulose Oral Packet 10 mg; Vitamin D2 Oral Tablet 50000 unit; Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 1 application inhale were not available and were not given to R183. V6 stated that Lactulose and Symbicort inhaler were already ordered in the pharmacy, and were not delivered yet. V6 stated Vitamin D2 is a house stock, and she (V6) will check in the medication supply room. R183 stated, Symbicort inhaler was not available and was not given to me for a week now. 2. Record review of R86's order summary, dated 12/15/22, reads in part: Polyvinyl Alcohol Solution Instill 1 drop in both eyes two times a day; Artificial Tears Solution 1 % Instill 2 drop in both eyes two times a day. On 12/13/22 at 10:46 AM, medication administration observation conducted with V6 continued. V6 prepared R86's medication: Artificial Tears Solution 1 % Instill 2 drop in both eyes; Polyvinyl Alcohol Solution Instill 1 drop in both eyes were not available, and were not given. V6 stated both eye drops were already ordered in the pharmacy, and were not delivered yet. R86 stated, Both eye drops were not available and were not given to me for almost 6 days. 3. Record review of R27's order summary, dated 12/15/22, reads in part: Bactrim DS Oral Tablet 800-160 MG Give 1 tablet by mouth two times a day; Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day; Furosemide Tablet 20 MG Give 1 tablet by mouth two times a day; Lyrica Capsule 100 MG Give 1 capsule by mouth two times a day; Morphine Sulfate ER Tablet Extended Release 15 MG Give 1 tablet by mouth every 12 hours. On 12/13/22 at 12:32 PM, medication administration observation conducted with V6 continued. V6 prepared R27's medications: Bactrim DS Oral Tablet 800-160 MG 1 tablet two times a day scheduled at 9 AM; Morphine Sulfate ER Tablet Extended Release 15 MG 1 tablet every 12 hours scheduled at 9 AM; Lyrica Capsule 100 MG 1 capsule two times a day scheduled at 9 AM; Furosemide Tablet 20 MG 1 tablet two times a day scheduled at 9 AM; Eliquis Tablet 5 MG 1 tablet two times a day scheduled at 9 AM. R27 observed taking the medications by mouth at 12:35 PM, and stated these medications should have been given at 9 AM. On 12/14/22 at 11:09 AM, V2 (Director of Nursing) stated that the expectation is for the nurse to follow the 5 rights (Right patient, medication, route, time, dose) in giving medications. V2 stated nurses are expected to provide education regarding medication to resident. V2 stated the nurse is expected to administer medication 1 hour before and 1 hour after the medication ordered time, and it should be the facility's policy in giving medications also. V2 stated if medication is given an hour after the ordered time, nurse is expected to notify physician. V2 stated the medication could not get its therapeutic effect if medication is given an hour after the ordered time. V2 stated medications should be ordered in the pharmacy before it becomes low, and that house stock medication should be available in the medication supply room. V2 further stated physician should be informed if medication is not available. Facility's policy titled Quality Assurance in Medication Administration undated reads in part: The medication must be given in correct strength, route and dosage form and at correct time. AC (before meal) medications should be given half to 1 hours before meal and PC (after meal) medications should be given 1 to 2 hours after a meal. Policy for medication related errors undated reads in part: Procedure: 4. Administration errors: In the event of an administration error, facility staff should follow facility policy relating to medication administration errors. Examples of administration errors include, but are not limited to: 4.7 Administration time error: Facility administers to the resident a mediation dose greater than sixty (60) minutes from its scheduled administration time or if administration exceeds the time in relation to meals. 4.9 Omission error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 (R27) of 4 residents observed for medication administration was free of significant medications errors. R27 is a [AGE] year old male admitted on [DATE] with medical diagnoses that include and are not limited to low back pain, unspeficied; spinal stenosis, cervical region; fibromyalgia. R27's order summary report, dated December 15, 2022, reads in part: Bactrim DS Oral Tablet 800-160 MG Give 1 tablet by mouth two times a day; Morphine Sulfate ER Tablet Extended Release 15 MG Give 1 tablet by mouth every 12 hours; Lyrica Capsule 100 MG Give 1 capsule by mouth two times a day; Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day. R27's care plan, initiated on 4/17/2022, reads in part: The resident has a deep vein thrombosis (DVT) r/t disease process. Care plan interventions read in part: Give medications as ordered. Monitor/document for side effects and effectiveness. On 12/13/2022 at 12:32 PM, V6 (Licensed Practical Nurse) was passing out medications on the first floor. V6 stated she is the only nurse for 36 residents. V6 stated she was still passing out morning medications scheduled for 9 AM. V6 observed preparing and administered medications :Bactrim DS Oral Tablet 800-160 MG 1 tablet; Morphine Sulfate ER Tablet Extended Release 15 MG 1 tablet; Lyrica Capsule 100 MG 1 capsule; and Eliquis Tablet 5 MG 1 tablet. R27 took medications by mouth, R27 stated, Those medications should have been given at 9 AM. On 12/14/22 at 11:09 AM, V2 (Director of Nursing) stated the expectation is for the nurse to follow the 5 rights (Right patient, medication, route, time, dose) in giving medications. V2 stated nurses are expected to provide education regarding medication to resident. V2 stated the nurse is expected to administer medication 1 hour before and 1 hour after the medication ordered time, and it should be the facility's policy in giving medications also. V2 stated if medication is given an hour after the ordered time, nurse is expected to notify MD (medical doctor). V2 stated the medication could not get its therapeutic effect if medication is given an hour after the ordered time. Facility's policy titled Quality Assurance in Medication Administration undated reads in part: The medication must be given in correct strength, route and dosage form and at correct time. AC (before meal) medications should be given half to 1 hours before meal and PC (after meal) medications should be given 1 to 2 hours after a meal. Policy for medication related errors undated reads in part: Procedure: 4. Administration errors: In the event of an administration error, facility staff should follow facility policy relating to medication administration errors. Examples of administration errors include, but are not limited to: 4.7 Administration time error: Facility administers to the resident a mediation dose greater than sixty (60) minutes from its scheduled administration time or if administration exceeds the time in relation to meals. 4.9 Omission error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindications.

Based on interview and record review, the facility failed to follow their policy and procedure to ensure antibiotic use is monitored and to determine if antibiotics are ordered accordingly based on appropriate diagnosis or based on corresponding assessment tool for 2 (R20, R27) of 2 residents reviewed for antibiotic stewardship. Findings include: On 12/13/22 at 10:17 AM, 1:38 PM and 1:54 PM, and on 12/14/22 at 9:36 AM and 12:11 PM, Surveyor made multiple requests from V2 (Director of Nursing), V1 (Administrator), and V3 (Assistant Administrator) to provide a copy of the facility's September, October, November, and December infection and antibiotic log and tracking that includes assessment tools used to assess residents to start and monitor antibiotic therapy, and a copy of the facility's Antibiotic Stewardship Program, but none were provided. On 12/13/22 at 2:45 PM, R20 and R27's electronic health records were reviewed. R20's physician order sheet (POS) reads in part, BACTRIM DS Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Prophylaxis Take 1 Tablet By Mouth Every MON WED FRI indefinitely, with a start date of 7/8/2020. The reason for this antibiotic is not indicated in R20's POS. R20's 12/14/22 04:48 PM MRR completed by pharmacist on 11/30/22, 9/30/22, 8/31/22, 7/31/22, 6/30/22, 5/31/22. Psychiatric progress note, dated 11/7/22, documents in part GDR indicated - no and past reduction attempts have resulted in psychiatric instability. On Bactrim 3x/week. indefinite - no reason specified in order. R27's POS reads in part, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for infection *NEED STOP DATE* started on 12/9/22. R27's last lab results were dated 9/22/2022. R27's type of infection was also not indicated on R27's POS. On 12/15/22 at 9:15 AM, Surveyor received a list of residents on antibiotics from September to December 2022, with a header that reads, Infection Control. This log has no corresponding lab results and/or assessment tools used to assess residents to start and monitor antibiotic therapy. This log also does not indicate the type of microorganisms for the residents' infection. R20 is not included in the antibiotic log, and does not have any corresponding assessment or lab results for R20's antibiotic use. R27 was found in the log, but the type of infection for the use of R27's antibiotic was not indicated, and there was no corresponding assessment or lab results. At 2:26 PM, V2 (Director of Nursing) stated residents have risk of being resistant to antibiotics if overused. V2 stated residents are also at risk in having adverse reactions if antibiotics are not use appropriately. V2 stated labs are taken to make sure antibiotics are prescribed accordingly. V2 stated she is not sure why R20 is not on the antibiotic log, and V2 will double check. Facility's policy titled, Infection Control Program and Procedure, dated 12/17/2019, reads in part: Procedure: 3. The DON or designee will receive a monthly report from pharmacy of who receive antibiotics at the facility. Report will be analyzed to determine if antibiotics are order accordingly, based on appropriate diagnosis or based on a corresponding lab result. 4. If a resident develops an infection, the nurse will notify the DON or designee so that the occurrence of infection can be recorded. The resident's attending physician will be notified to obtain treatment for the infection.

Based on observation, interview, and record review, the facility failed to provide non-disposable cutlery and dishware including cups, bowls, and plates at all meals. These failures affected 4 (R3, R5, R23, R31) of 6 residents reviewed for homelike, de-institutionalized environment in the sample of 12 residents. Findings include: On 12/13/22 at 12:34 PM, CNA (Certified Nursing Assistants) was distributing lunch trays and beverages to residents. R3, R5, R23, and R31 received meals in disposable plates, bowls, cups, and silverware. On 12/13/22 at 12:44 PM, R31 was eating lunch from disposable dishware with a plastic fork. R31 stated, They serve on these kinds of plates all the time and always give us plastic silverware. On 12/13/22 at 12:50 PM, R3 stated, They used to give us regular knives, forks, spoon and plate ware, however, now it is (disposable dishes) all the time. I'd like to see my food on a regular plate because the food doesn't look good on these kinds of plates. On 12/13/22 at 11:52 PM, R5 stated, Yes, they serve us all of our food on (dispoable dishes). If I was home, I wouldn't use disposable dishes and plastic silverware. On 12/13/22 at 11:54 PM, R23 stated if she was living at home, she would not eat off of (disposable dishes) or use plastic silverware and that she'd prefer regular plates and metal silverware. On 12/13/22 at 5:10 PM, CNAs were distributing dinner trays and beverages to residents. The food was on disposable plates, bowls, cups, and plastic silverware was provided for use. V16 (Certified Nursing Assistant) stated all residents receive their meals on plastic plates. On 12/14/22 at 11:30 AM, V12 (Registered Dietitian) stated she was not aware residents were receiving all meals on disposable dishware and cutlery and stated, This is not a common practice. V12 stated disposable dishware and utensils may be used in the event the kitchen dishwasher is broken. V12 stated if the dishwasher is not broken, then it would not be acceptable for residents to receive disposable plate, cups, and utensils, because it does not provide a homelike environment. V12 stated residents would prefer metal utensils and non-disposable plate ware. On 12/15/22 at 9:46 AM, V19 (Dietary Aide) stated the kitchen dish machine is not broken, and the kitchen staff uses the dish machine regularly, but not for plates, silverware. V19 stated the residents are not served on regular dishes because it is COVID time. V19 stated she does not think anyone in the facility has COVID currently, but the kitchen serves all residents using the disposable items because Administration told them to do it. On 12/15/22 at 9:52 AM, V3 (Dietary Manager) stated the residents have been served on disposable dish ware and silverware for over 2 years, and he (V3) is doing this per direction of the Administrator. On 12/15/22 at 12:27 PM, V1 (Administrator) stated there are currently no COVID cases or suspected COVID cases in the building, and V1 does not want COVID in the building. V1 stated she feels serving the residents on disposable plate ware and utensils helps to keep COVID out of the building. V1 stated none of the residents have complained to her about the disposable plates, and the facility has been doing this for about two years. Facility provided the document titled, Residents' Rights for People in Long-Term Care Facilities undated from the Illinois Department on Aging which documents in part, your facility must be safe, clean, comfortable, and homelike. Facility provided policy titled, Isolation Trays/Carts, dated on 11/2022, documents in part residents on isolation (airborne, droplet, or contact) do not require disposable dish wares, this includes dishes, glasses, cups, and eating utensils. Residents on isolation precautions will receive meals on regular dishes and trays. The combination of hot water and detergent used by the Food Service Department in ware washing is sufficient to decontaminate dishes, glasses, cups and eating utensils used by residents requiring isolation precautions. Residents on COVID isolation protocol will receive disposable dishware or per state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the quarterly Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 21 residents (R6, R27, R21, R17; R24; R1; R5; R28; R86; R11; R31; R20; R87; R26; R16; R19; R14; R7; R2; R32; R84) of 32 residents reviewed for resident assessment. Findings include: On [DATE] at 9:30 AM, Telephone interview was conducted with V17 (Minimum Data Set Coordinator - Licensed Practical Nurse). V17 stated, I am working part time 3 times per week. I've been working in the facility for 2 years. V17 stated the facility is following Resident Assessment Instrument (RAI) manual as policy in completing Minimum Data Set (MDS) assessment. V17 stated the Director of Nursing (DON) is a Registered Nurse (RN), and is signing the MDS assessment completion. Remote electronic record review was completed with V17 for R9's MDS assessment, and V17 stated Assessment Reference Date (ARD) was [DATE], and completion date should be [DATE], but assessment was still in progress and was not completed yet. V17 stated she was not able to come to the facility for 2-3 weeks because her husband died in November, 2022. V17 stated, Unfortunately, no one was able to come to cover me. V17 stated MDS assessments for October and November were not done, and MDS assessments were all late. V17 also stated, I don't have a transmission report for October and November because I did not transmit any MDS assessments. V17 stated, Potentially we could not get the full reimbursement rate and we could get a default rate for late MDS assessment completion and transmission. V17 also stated comprehensive care plan including nursing, restorative and ADLs (Activities of Daily Living), the restorative nurse is responsible for doing it. Record review of facility's MDS (Minimum Data Set) assessments: 1. R6 MDS quarterly ARD (Assessment Reference Date) [DATE], not completed, still in progress. 2. R27 MDS quarterly ARD [DATE], completed on [DATE] 3. R21 MDS quarterly ARD [DATE], not completed, still in progress. 4. R17 MDS quarterly ARD [DATE], not completed, still in progress. 5. R24 MDS quarterly ARD [DATE], not completed, still in progress. 6. R1 MDS quarterly ARD [DATE], not completed, still in progress. 7. R5 MDS quarterly ARD [DATE], completed on [DATE]. No recent MDS assessment opened. 8. R28 MDS quarterly ARD [DATE], not completed, still in progress. 9. R86 MDS quarterly ARD [DATE], not completed, still in progress. 10. R11 MDS quarterly / medicare 5day ARD [DATE], not completed, still in progress. 11. R31 MDS quarterly ARD [DATE], was completed on [DATE]. 12. R20 MDS quarterly ARD [DATE], was completed on [DATE]. 13. R87 MDS quarterly ARD [DATE], not completed, still in progress. 14. R26 MDS quarterly ARD [DATE], not completed, still in progress. 15. R16 MDS Quarterly ARD [DATE], not completed, still in progress. 16. R19 MDS quarterly ARD [DATE], not completed, still in progress. 17. R14 MDS quarterly ARD [DATE], not completed, still in progress. 18. R7 MDS quarterly ARD [DATE], not completed, still in progress. 19. R2 MDS quarterly ARD [DATE], date completed on [DATE]. 20. R32 MDS quarterly ARD [DATE], not completed, still in progress. 21. R84 MDS quarterly ARD [DATE], not completed, still in progress. Reviewed Facility policy titled Resident Assessment Instrument MDS 3.0 undated reads in part: The facility follows the resident assessment instrument (RAI) process, which includes the minimum data set (MDS) version 3.0. Policy specifications: 1. Within 14 days of the resident's admission, comprehensive assessment of the residents' needs will be made by the interdisciplinary you took this appointment assessment team. 2. The interdisciplinary assessment team must use MDS's 3.0 forms currently mandated by federal and state regulations to conduct all resident measurements. Chapter 2 of the RAI manual pages 16-17 titled RAI OBRA-required Assessment Summary indicates that quarterly MDS assessments should be completed no later than 14 days from the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative treatment services to prevent the potential for decrease in range of motion for 4 residents (R2, R5, R20, R23) out of 5 residents reviewed for range of motion in a total sample size of 12. Finds include: 1. R23 has diagnoses not limited to Spastic Diplegic Cerebral Palsy. R23's MDS (Minimum Data Set), signed on [DATE], documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive response and functional status (section G) functional limitation in range of motion to upper and lower extremity impairment on both sides and extensive assistance with bed mobility, dressing, toileting, personal hygiene and total dependence with transfers. R23's care plan documents, in part, R22 is at risk for contracture development due to impaired mobility, generalized weakness and Cerebral Palsy and interventions include to encourage range of motion activities. R23 Tasks include provide restorative active range of motion technique practice 15 minutes per day 6,7 days per week and restorative bed mobility program 15 minutes per day 6.7 days per week. On [DATE] at 11:20 AM, R23 was lying in bed, with knees in bent position, and right wrist flexed back. R23 stated no one does any type of exercises with her. 2. R2 has diagnoses not limited Dementia, Type 2 Diabetes Mellitus, Parkinson's Disease. R2's MDS (Minimum Data Set) from [DATE] docuemnted a BIMS (Brief Interview for Mental Status) score of 06, indicating severe cognition impairment, and section G (Functional Status) indicates extensive assist with bed mobility, and total dependence with transfer, toilet use and personal hygiene. R2's care plan documents, in part, risk for contracture develop due to physical inactivity, weakness, CVA, Parkinson's Disease, cognitive impairment and interventions include provide range of motion exercise to the affected extremities per facility protocol, perform active range of motion exercises x10, 3 sets daily for 15 minutes per day. R2 Tasks include provide restorative active range of motion program 6,7 days per week, 15 minutes per day and restorative bed mobility exercises 6.7 days per week, 15 minutes per day. 3. R5 has diagnoses not limited to Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Osteoarthritis, Unsteadiness on Feet, Chronic Embolism and Thrombosis of Deep Veins of Unspecified Lower Extremity, Generalized Muscle Weakness, History of Falling, Pain in Lower Leg. R5's MDS (Minimum Data Set) from [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition, and section G (Functional Status) documents in part R5 requires extensive assistance with 2+ persons physical assist with bed mobility and transfer. R5's nursing care plan for impaired mobility documents in part that impaired mobility is related to generalized weakness, history of cerebrovascular accident with right side weakness, osteoarthritis, and pain and functional limitation of range of motion to upper extremity impairment on one side. R5 Tasks include provide restorative active range of motion program 6,7 days per week, 15 minutes per day and restorative bed mobility exercises 15 minutes per day 6.7 days per week. 4. R20 has diagnoses not limited to Chronic Obstructive Pulmonary Disease, Sleep Apnea, Acute Respiratory Failure with Hypoxia, Heart Failure, Morbid Obesity, Weakness, Lack of Coordination, Reduced Mobility. R20's MDS (Minimum Data Set), signed on [DATE], documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive response and functional status (section G) functional limitation in range of motion to upper extremity and limited assistance with bed mobility, transfer, walking, dressing and extensive assistance with personal hygiene. R20's care plan documents, in part, R20 is at risk for development of contractures due to generalized weakness, arthritis, pain, stiffness and shortness of breath and interventions include to provide range of motion exercises to the affected extremities per facility protocol. R20 Tasks include provide restorative active range of motion program 15 minutes per day 6,7 days per week and restorative ambulation program 15 minutes per day 6.7 days per week. On [DATE] at 5:23 PM, V2 (Director of Nursing) stated the Restorative Director position has been vacant for approximately 2 months, and the facility has not had a Restorative Aide since the beginning of 2022. V2 stated the Certified Nursing Assistants (CNA) can help provide restorative services to the residents, but the CNAs are not documenting when this is done. On [DATE] at 10:53 AM, V11 (Physical Therapist/Therapy Director) stated there has not been a Restorative Nurse for a couple of months, or a Restorative Aide since early 2022. V11 stated not having the residents receive restorative services has the potential for residents to develop further contractures. V11 stated no one is monitoring if the restorative exercises are being done because there is no restorative staff, and the CNAs are not trained to do range of motion exercises. V11 stated the therapist would only see a resident if they were referred for therapy, and the therapists are not doing daily range of motion exercises with the residents. On [DATE] at 9:40 AM, V18 (Certified Nursing Assistant) stated he is not doing exercises with the residents every day. On [DATE] at 12:32 PM, V1 (Administrator) stated the Restorative Director died 2 weeks ago, but was calling in sick for 6 weeks prior to dying. V1 stated the facility used to have a Restorative Aide, but the position converted to a CNA. V1 stated the CNAs are doing some of the range of motion exercises with the residents, and the facility is actively trying to hire someone for the Restorative Nurse position. On [DATE] at 1:35PM, V2 stated the CNAs help out with range of motion exercises when they can and it should be charted but it's not. On [DATE] at 1:39PM, V4 (Certified Nursing Assistant) stated sometimes she does the exercises with the residents, if the resident wants to do them. On [DATE] at 1:53PM, V11 (Physical Therapist) stated restorative services should be provided to residents with limitations for maintenance of baseline function. V11 stated if range of motion exercises are not done, then the residents run the risk of developing worsening contractures. V11 stated when a resident is screened or transferred off of therapy, the recommendation is for the resident to receive restorative services, so they do not lose function and potentially get worse. V11 stated when staff does the restorative exercises with a resident it should be documented. Facility policy titled, Restorative Nursing Policy & Procedure undated documents, in part the program description is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible, a licensed nurse supervises the restorative nursing programs, documentation of the interventions are the resident's response will be completed with each implementation, and all nursing personnel carrying out any of the restorative programs will be trained in the technique appropriate for that program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to follow policy on Influenza and Pneumococcal Vaccine for 4 (R25, R10, R83, R183) out of 6 residents who did not receive influenza and/or pneumococcal vaccination, and documentation as to person, time and date of education was provided prior refusal. These failures affect 4 residents (R25, R10, R83, R183) reviewed for vaccine(s). Findings include: On 12/14/22 at 10:31 AM, the electronic health records (EHR) were reviewed for the following residents: 1. R25 is [AGE] years old with diagnosis not limited to COVID-19, and was admitted on [DATE]. R25's EHR (Electronic Health Record) shows pneumococcal vaccine received on 5/26/22, but there was no influenza immunization record found, and there was no documentation as to the person, time, and date R25 was given education as to the benefits and risks of receiving influenza vaccine. R25's physician order sheet (POS) does not have order for an Influenza vaccination. 2. R10 is [AGE] years old with diagnosis not limited to COVID-19, and was admitted on [DATE]. R10's EHR shows influenza and pneumococcal consents refused on 7/17/20, but no information found for R10's 2021 and 2022 vaccinations in the EHR, and there was no documentation as to the person, time, and date R10 was given education as to the benefits and risks of receiving pneumococcal vaccines. R10's POS does not have orders for the influenza and pneumococcal vaccinations. 3. R83 is [AGE] years old with diagnosis not limited to Essential Hypertension and was admitted on [DATE]. R83's EHR shows no records if R83 received influenza and pneumococcal immunizations, and there was no documentation as to the person, time, and date R83 was given education as to the benefits and risks of receiving influenza and pneumococcal vaccines. R83's POS does not have orders for the influenza and pneumococcal vaccinations. 4. R183 is [AGE] years old with diagnosis not limited to Chronic Obstructive Pulmonary Disease and was admitted on [DATE]. R183's EHR shows no records if R183 received influenza and pneumococcal immunizations, and there was no documentation as to the person, time, and date R183 was given education as to the benefits and risks of receiving influenza and pneumococcal vaccines. R183's POS does not have orders for the influenza and pneumococcal vaccinations. On 12/14/22 at 10:41 AM, V2 (Director of Nursing) stated if residents refuse the influenza and pneumococcal vaccines, they need to sign the consents, and are educated of risks of not getting the vaccines. Surveyor requested copies of the consents and documentation as to the person, time, and date R10, R25, R83, and R183 were given education as to the benefits and risks of receiving influenza and pneumococcal vaccines. On 12/15/22 at 9:02 AM, the facility provided R10's unsigned influenza immunization consent with education of benefits and risks. The facility was not able to provide documentation as to the person, time, and date R25, R83, and R183 were given education as to the benefits and risks of receiving influenza vaccines. The facility was also not able to provide documentation as to the person, time, and date R10, R83, and R183 were given education as to the benefits and risks of receiving pneumococcal vaccines. Facility policy titled Influenza and Pneumococcal Vaccine with no date reads in part, Policy: 1. All residents are vaccinated, except those with a history of egg allergy, previous severe reaction to vaccination, or history of acute neurological disease following vaccination. (Guillain-Bare-Syndrome). 2. Consent from the resident or responsible party needed. 3. Physician Orders to Administer the vaccine are written on the POS Procedure: 1. Consent for vaccine must be signed by resident or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the annual Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 35 (R6, R9, R27, R183, R21, R22; R17; R24; R23; R1; R5; R30; R28; R86; R11; R31; R20; R87; R3; R26; R16; R29; R19; R14; R25; R8; R82; R4; R7; R83; R2; R32; R84; R182; R10) of 35 residents reviewed for resident comprehensive assessment. Findings include: On [DATE] at 9:30 AM, V17 (Minimum Data Set Coordinator - Licensed Practical Nurse) stated, I am working part time 3 times per week. I've been working in the facility for 2 years. V17 stated the facility is following Resident Assessment Instrument (RAI) manual as policy in completing Minimum Data Set (MDS) assessment. V17 stated the Director of Nursing (DON) is a Registered Nurse (RN) and is signing the MDS assessment completion. Remote electronic record review was done with V17 for R9's MDS assessment and V17 stated Assessment Reference Date (ARD) was [DATE], and completion date should be [DATE], but assessment was still in progress and was not completed yet. V17 stated she was not able to come to the facility for 2-3 weeks because her husband died in November, 2022. V17 stated, Unfortunately, no one was able to come to cover me. V17 stated MDS assessments for October and November were not done, and MDS assessments were all late. V17 also stated, I don't have a transmission report for October and November because I did not transmit any MDS assessments. V17 stated Potentially we could not get the full reimbursement rate and we could get a default rate for late MDS assessment completion and transmission. V17 also stated comprehensive care plan including nursing, restorative, and ADLs (Activities of Daily Living), the restorative nurse is responsible for doing it. Record review of facility's MDS (Minimum Data Set) assessments: 1. R6 MDS admission ARD (Assessment Reference Date) [DATE], date completed [DATE]. R6 admission date was on [DATE] 2. R9 MDS annual ARD [DATE], date completed [DATE]. 3. R27 MDS admission ARD [DATE], date completed [DATE]. R27 admission date was on [DATE]. 4. R183 MDS admission ARD [DATE], date completed [DATE]. R183 admission date was on [DATE] 5. R21 MDS annual ARD [DATE], date completed [DATE]. 6. R22 MDS Annual ARD [DATE], not completed still in progress. 7. R17 MDS annual ARD [DATE], date completed [DATE]. 8. R24 MDS admission ARD [DATE], date completed [DATE]. R24 admission date was on [DATE]. 9. R23 MDS annual ARD [DATE] date completed [DATE] 10. R1 MDS admission ARD [DATE] date completed [DATE]. R1 admission date was on [DATE]. 11. R5 MDS annual ARD [DATE] date completed [DATE] 12. R30 MDS admission ARD [DATE] date completed [DATE]. R30 admission date was on [DATE] 13. R28 MDS annual ARD [DATE], date completed [DATE]. 14. R86 MDS Annual ARD [DATE], not completed still in progress. 15. R11 MDS annual ARD [DATE], date completed [DATE]. 16. R31 MDS admission ARD [DATE], date completed [DATE]. R31 admission date was on [DATE]. 17. R20 MDS annual ARD [DATE], date completed [DATE]. 18. R87 MDS annual ARD [DATE], date completed [DATE]. 19. R3 MDS annual ARD [DATE], date completed [DATE]. 20. R26 MDS annual ARD [DATE], date completed [DATE]. 21. R16 MDS annual ARD [DATE], date completed [DATE]. 22. R29 MDS Annual ARD [DATE], not completed still in progress. 23. R19 MDS admission ARD [DATE], date completed [DATE]. R19 admission date was on [DATE]. 24. R14 MDS annual ARD [DATE], date completed [DATE]. 25. R25 MDS admission ARD [DATE], date completed [DATE]. R25 admission date was on [DATE]. 26. R8 MDS admission ARD [DATE], date completed [DATE]. R8 admission date was on [DATE]. 27. R82 MDS admission ARD [DATE], not completed still in progress. R82 admission date was [DATE]. 28. R4 MDS admission ARD [DATE], date completed [DATE]. R4 admission date was on [DATE]. 29. R7 MDS annual ARD [DATE], date completed [DATE]. 30. R83 MDS admission ARD [DATE], completed on [DATE]. R83 admission date was on [DATE]. 31. R2 MDS last annual ARD [DATE]. R2 MDS assessments: Quarterly ARD [DATE]; Quarterly ARD [DATE]; Quarterly ARD [DATE]; discharged return anticipated ARD [DATE]; Reentry ARD [DATE]; discharged return anticipated ARD [DATE]; Reentry ARD [DATE]; Quarterly ARD [DATE] 32. R32 MDS Annual ARD [DATE], date completed [DATE]. 33. R84 MDS Annual ARD [DATE], not completed still in progress. 34. R182 MDS Annual ARD [DATE], not completed still in progress. 35. R10 MDS Annual ARD [DATE], completed [DATE]. Reviewed Facility policy titled Resident Assessment Instrument MDS 3.0 undated reads in part: The facility follows the resident assessment instrument (RAI) process, which includes the minimum data set (MDS) version 3.0. Policy specifications: 1. Within 14 days of the resident's admission, comprehensive assessment of the residents' needs will be made by the interdisciplinary you took this appointment assessment team. 2. The interdisciplinary assessment team must use MDS's 3.0 forms currently mandated by federal and state regulations to conduct all resident measurements. Chapter 2 of the RAI manual pages 16-17 titled RAI OBRA-required Assessment Summary indicates that admission MDS assessments should be completed no later than 14 days of the resident's admission. Annual MDS assessments should be completed no later than 14 days from the ARD.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for all 36 (R6, R9, R85, R27, R183, R21, R22, R17, R24, R23, R1, R5, R30, R28, R86, R11, R31, R20, R87, R3, R26, R16, R29, R19, R14, R25, R8, R82, R4, R7, R83, R2, R32, R84, R182, R10) residents. Findings include: On 12/14/22 at 11:15 AM, V2 (Director of Nursing) stated she started working in the facility August, 2022. V2 stated, I think the nurse on the floor is the one doing the baseline care plan. V2 was unable to find baseline care plan in electronic health record. At 11:23 AM, V13 (Licensed Practical Nurse/LPN) stated she is a fulltime nurse, and has been working in the facility for 3 years. V13 stated, I have been doing admission and I am only doing the nursing assessment; I have not heard about base line care plan. V13 further stated, I never did base line care plan. On 12/15/22 at 9:30 AM, V17 (Minimum Data Set (MDS) Coordinator/ LPN) stated, Baseline care plan should be done by nurse on duty, and I believe it is not being done. At 12:15 PM, V2 stated the baseline care plan is supposed to be done by the nurse on duty, and should be completed upon admission. V2 stated baseline care plan is being done to help facility determine the care to be done to the residents. V2 further stated baseline care plan would also help in assessing resident and to determine if the interventions are effective or not. Electronic record reviewed with V2; unable to find baseline care plan for all 36 residents as of census 12/13/22. Reviewed facility policy titled Resident Care Planning, revised date 9/18/22, reads in part: The plan of care is initiated on admission, Interim care plan is to be completed within 48 hours and a copy will be provided to the resident and/or representative and comprehensive care plan fully developed by day 21.

Based on observation, interview, and record review, the facility failed to ensure food stored in the freezer was stored in a sanitary manner. This failure has the potential to affect 35 residents who are on an oral diet. Findings include: On 12/13/2022 at 9:35 AM, Observed with V3 (Dietary manager), raw fish fillets in the freezer stored in a plastic bag knotted on top. Next to the fish fillet were two ready to eat cheesecakes. V3 stated, I don't know who put these raw fish fillets in this freezer. These fish fillets are supposed to be in the other freezer with the other raw meats. V3 stated storing raw foods with cooked or ready to eat foods should not be stored together because of close contamination, which can cause residents to get sick. On 12/14/2022 at 11:14a AM, V12 (Dietitian) said all raw meats including raw fish need to be stored in the raw meet freezer on the lower shelf of the freezer, and never on the same shelf with ready to eat food, to prevent cross contamination with ready to eat foods. V12 said, It is an unacceptable practice to sore raw food near ready to eat foods. V12 said raw foods might contain a lot if germs because it is not cooked and can cause food borne illness to residents. Facility policy titled Food storage procedures, No date, documents; To prevent cross contamination, do not store meat items above other food items in the cooler.

R2 has diagnosis not limited Urinary Calculus, Urogenital Implants, Hydronephrosis with Renal & Ureteral Calculous Obstruction, Urinary Tract Infection, Dementia, Type 2 Diabetes Mellitus, Parkinson ' s Disease. R2's MDS (Minimum Data Set) from 10/24/22 BIMS (Brief Interview for Mental Status) score is 06, indicating severe cognition impairment. Per R2's progress notes, dated 11/18/22 and 12/6/22, R2 was treated with antibiotics for Urinary Tract Infection for ten days starting on 11/18/22. On 12/13/22 at 12:00 PM, surveyor observed urinary catheter storage bag containing urine lying on the floor next to R2's bed. On 12/13/22 at 1:10 PM, V2 (Director of Nursing) stated urinary catheter storage bags should not be on the floor because that could cause contamination, which could lead to an infection for the resident. V2 stated it is everyones responsibility to keep the urinary catheter storage bags off the floor. V2 and surveyor observed R2's urinary catheter storage bag lying on the floor next to R2's bed. V2 stated, That should not be on the floor and quickly removed the urine catheter storage bag from the floor. Based on observation, interview, and record review, the facility failed to (a) screen visitors and staff upon entering the facility and inform visitors of appropriate infection prevention and control actions to take while in the facility; (b) failed to review their Infection Prevention and Control Program (IPCP) at least annually; and (c) failed to ensure appropriate infection procedures were followed for one residents (R2). These failures have the potential to affect all 36 residents residing in the facility reviewed for infection prevention and control and infection surveillance for COVID-19. Findings include: 1. On 12/13/22 at 9:12 AM, surveyors entered the facility. V8 (Receptionist) did not perform COVID-19 screening at the front desk. V8 did not inquire with the survey team to regarding signs and symptoms of COVID-19, or discuss appropriate infection prevention and control measures to take while in the facility. Survey team did not see any signage posted at the facility entrance alerting visitors when they should not enter the facility such as symptoms of illness, under quarantine, or if tested positive for COVID-19. At approximately 9:20 AM, V1 (Administrator) let survey team enter the rehabilitation/conference room. V1 also did not inform survey team to monitor signs and symptoms of COVID-19 and what appropriate infection prevention and control measures to take while in the facility. At 10:49 AM, V8 stated the facility stopped doing the COVID screening, and V8 just makes sure visitors are wearing masks. V8 stated the facility has no signage alerting visitors when not to enter the facility. At 12:12 PM, V3 (Dietary Manager) stated V3 enters the facility using the front entrance. V3 stated the facility is not doing COVID-19 screening anymore. V3 stated facility stopped the COVID-19 screening approximately 30 days ago. On 12/14/22 at 10:47 AM, V11 (Physical Therapist) stated V11 entered the facility using the front door. V11 stated she was not screened for COVID-19. V11 stated the facility stopped the COVID-19 screening early this year or late last year. On 12/15/22 at 9:00 AM, two surveyors entered the facility. There was no one available at the front desk. Surveyors were not screened for COVID-19, and were not informed of any infection prevention and control measures. At 2:26 PM, V2 (Director of Nursing) stated, The front desk still should be screening for COVID and asking visitors and staff for any signs and symptoms of COVID, or if they have been in close contact with anyone with COVID. The Receptionist should be the one screening, but if the Receptionist is not available the nurses should be the one to screen. Facility provided a copy of their policy titled, Infection Control Program Policy and Procedure, revised on 12/17/2019. Facility was not able to provide a revised policy. Facility's policy titled Coronavirus (COVID-19) with no date reads in part: Coronavirus Disease 2019 (COVID-19) It is the policy of this facility to meet federal, state, and local guidelines with, the Illinois publich health system who is currently responding to an outbreak of SARS-CoV-19 is a new virus that has emerged, and the disease it causes has been named coronavirus disease, or COVID-19. Symptoms Clinical features are fever or sign/symptoms of lower respiratory illness. Symptoms may include: Fever Cough Shortness of breath Human coronaviruses can sometimes cause lower-respiratory tract illness, such as pneumonia or bronchitis.

Based on interview and record review, the facility failed to designate at least one qualified Infection Preventionist (IP) who is responsible for the facility's Infection Prevention and Control Program (IPCP) that has completed the specialized training in infection prevention and control. This failure has the potential to affect all 36 residents residing in the facility. Findings include: Per facility's Resident Census and Condition Form, dated 12/13/22, facility has a census of 36 residents. On 12/13/22 at 10:17 AM, V2 (Director of Nursing), stated, Been a DON here since August 2022. We don't have an Infection Control Nurse. I'm just helping out with some things in regard to infection control. Surveyor requested to see a copy of V2's certification with infection prevention and control. V2 stated, I don't have the certification because I'm not the infection control nurse. Facility's policy titled, Infection Control Program and Procedure, dated 12/17/2019, has no information regarding Infection Preventionist. Surveyor requested copies of the facility's policies on orientation and inservice training, and the job description/responsibilities of the Infection Preventionist, but facility did not provide.

Based on interview and record reviews, the facility (a) failed to develop policies and procedures of COVID-19 immunizations for the residents; (b) failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine to 4 (R8, R10, R30, R183) of 8 residents that refused the COVID-19 vaccine; and (c) failed to document the dates and each dose of COVID-19 vaccine administered to the residents. These failures affect all 36 residents residing in the facility. Findings include: On 12/13/22 at 10:17 AM, 1:38 PM and 1:54 PM, and on 12/14/22 at 9:36 AM and 12:11 PM, Surveyor made multiple requests from V2 (Director of Nursing), V1 (Administrator), and V3 (Assistant Administrator) to provide a copy of the facility's policy on residents' COVID-19 Immunization, but facility was unable to provide. On 12/14/22 at 9:41 AM, surveyor received a residents' vaccination log with no header. V1 (Administrator) stated it's the facility's COVID-19 vaccination log for all their residents. This log has no documentation of the dates and each dose of COVID-19 vaccine administered to the residents. This log shows R8, R10, R30, and R183 refused the COVID-19 vaccine. At 10:31 AM, R8, R10, R83, and R183's electronic health records (EHR) were reviewed. No documentation was found regarding these residents' COVID-19 vaccination status, and there were no documentations found if education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine were provided to R8, R10, R83, and R183. At 10:41 AM, V2 (Director of Nursing) stated if residents refuse the COVID-19 vaccine, they need to sign the consents and are educated of risks of not getting the vaccines. Surveyor requested copies of the consents and education provided for COVID-19 vaccine for R8, R10, R83, and R183. On 12/15/22 at 9:02 AM, Surveyor received copies of R8, R30, and R10's COVID-19 BOOSTER VACCINE CONSENT FORM. These consents were not signed by R8, R30, and R10 or their representatives, but instead it indicates Refused. These consents also do not indicate if education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine were provided to R8, R30, and R10. Facility did not provide anything for R183. Surveyor was unable to review the facility's policy on residents' COVID-19 Immunization because it was not provided after multiple requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to assure the social work staff assessed 3 (R2, R5, R6) of 3 residents reviewed for discharge planning, for discharge potential and document significant information related to discharge. Findings include: On 11/12/22 at 11:50 AM, R5 stated I've talked to (V8, Social Worker) every once in a while, once every couple of weeks. (V8) is like a ghost. Two to three months ago, (V8) said we will work on a discharge plan when the time comes. I feel I'm physically ready to go, I just need a place. My infection is being worked on outpatient. I shower myself. The facility feeds me, washes my clothes, and gives my medication. I can do all that myself. On 11/12/22 at 12:30 PM, R7 stated We don't see (V8) that much. On 11/12/22 at 12:36 PM, R6 stated I feel I'm ready for discharge. I can do everything on my own. I'm approved for a homemaker. (V8) is lazy. I don't know (V8's) name. I told (V8) to contact (housing agency). (V8) never came back. On 11/12/22 at 1:06 PM, V2 (Assistant Administrator) stated, Social Worker duties include admission orientation, address the overall needs of the residents, coordinate the needs of the resident with outside services such as the [NAME] Program. On 11/12/22 at 1:26 PM, V8 (Social Worker) stated, Some documentation is in the system, not all. On 11/12/22 at 5:47 PM, V2 (Assistant Administrator) stated, There are no social work progress notes for (R5) and (R6). Record review indicates R2 was admitted to the facility 6/10/2022. Discharge care plan was created on 11/12/2022 (surveyors in the facility on this day investigating/requesting documentation on discharge planning). Record review indicates R5 was admitted to the facility 2/28/2022 and does not have a discharge care plan. The facility's Discharge Planning Policy, Protocol and Procedure, not dated, documents in part: 1. To promote a smooth transition from the skilled nursing facility into a community-based living situation. 6. To assure the involvement of the social work staff in assessing discharge potential, documenting significant information related to discharge and coordinating community health care services.