**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of physical abuse for one (R1) resident out of three residents reviewed for physical abuse. Findings include: R1 (alleged victim) is no longer in the facility. R1's Facesheet documents that R1 was admitted to the facility on [DATE] and discharged on 08/10/2025. R1 has diagnoses not limited to: acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus with hyperglycemia, opioid abuse with intoxication delirium, alcohol-induced persisting dementia, and other schizoaffective disorders. On 08/10/2025 at 10:36AM, V3 (Hospital Social Worker) states R1 was admitted to the hospital on [DATE] and R1 reported allegations of physical abuse against the facility. V3 states she reported the allegations of physical abuse to the state agency on 08/09/2025. V3 states R1 did not give any names or descriptions of the alleged abusers. On 08/10/2025 at 11:32AM, V4 (Licensed Practical Nurse/LPN) states she was the nurse assigned to care for R1 on 08/09/2025 during the 7:00AM to 3:00PM shift. V4 states R1 made allegations that someone kicked him. V4 states R1 did not specify who kicked him but R1 kept saying they kicked me. V4 states immediately after making the allegation, R1 retracted the allegation and said that no one kicked him or did anything to him. V4 states she was standing close to R1's room and could visually see inside of his room. V4 states she did not witness anyone kick or harm R1. V4 states she informed the DON of R1's behavior and that she had called 911 to have R1 sent to the hospital. V4 states she is a mandated reporter and was trained on abuse. V4 states she is aware to report abuse to (V1/Administrator) and to protect residents from abuse. V4 states she has never seen any of the staff abuse the residents in the facility. V4 states if she witnesses abuse, then she will report it immediately. On 11:52AM, V5 (Certified Nursing Assistant/CNA) states she was the CNA assigned to care for R1 on 08/09/2025 during the 7:00AM to 3:00PM shift. V5 states R1 told her that someone had kicked him in the groin but then R1 immediately retracted that allegation. V5 states she saw 911 arrive and R1 told them that someone kicked him in the groin and then R1 immediately retracted the statement again. V5 states R1 never stated who kicked him or gave any description about the allegation. V5 states she was trained on abuse and knows to report abuse to (V1/Administrator), not to ignore abuse, the different types of abuse, the importance of always reporting abuse, and protecting the residents from abuse. V5 states the last abuse in-service was held approximately last month in July 2025. On 08/10/2025 at 2:01PM, V1 (Administrator) states she is the abuse coordinator, and she was made aware by the staff nurses about R1's behavior. V1 states on 08/08/2025, she was made aware by the staff nurses that R1 had escalating behaviors and was blocking the elevators, being irate, and screaming. V1 states R1 then calmed down and was redirectable. V1 states the next day, she was made aware by the nurses that R1 had become aggressive again and made allegations of someone kicking him. V1 states she came into the facility at approximately 3:00PM on 08/09/2025 and R1 made the allegations at approximately 7:00AM on 08/09/2025. V1 states she started a soft file and began an investigation and interviewed residents and staff regarding the allegations. V1 states she usually would report the allegations to the state agency but then R1 retracted his allegations. V1 states since she has been the abuse coordinator, she has never had a resident retract abuse allegations. V1 states since R1 retracted his allegations, she did not report the allegations of abuse to the state agency. Facility Reported Incidents dated 06/21/2025 to 08/10/2025 reviewed and does not document that the facility reported an allegation of abuse for R1. Facility policy dated 10/2022 titled Abuse Policy and Prevention Program documents in part, VIII. External Reporting- 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the low air loss mattress was on the correct setting for the wound care prevention protocol. This failure has the potential to affect 1 (R6) of 3 (R2, R5, R6) residents reviewed for wound care. Findings Include: R6 was readmitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Nontraumatic Subdural Hemorrhage, Intervertebral Disc Degeneration, Thoracic Region, Epilepsy, Iron Deficiency Anemia, Disorder of Thyroid, Gastrostomy, Hyperosmolality And Hypernatremia, Vitamin D Deficiency, Muscle Weakness (Generalized), Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Protein-Calorie Malnutrition, and Hepatic Encephalopathy. R6's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 10 indicating moderate cognitive impairment. R6's weights are documented on 06/23/25 141.4 Lbs. (pounds) 05/06/25 152.2 Lbs., 04/14/25 150.2 Lbs. and 03/31/25 150.0 Lbs. Progress note date 06/20/25 23:42 document in part: Nursing Note: Patient received from hospital. Progress note dated 06/23/25 14:21 document in part: Skin/Wound Note Text: Resident admitted to facility with warm, dry skin presenting with open area to sacrum noted with no drainage nor s/s (signs and symptoms of infection and gastric tube in place to abdomen. Treatment orders and pressure relief interventions in place and carried out. Resident is chairfast and incontinent of bowel and bladder. Wound care to follow until resolved. R6 has Potential/At Risk for alteration in skin integrity due to risk factors associated with Cardio-vascular disease, Cognitive impairment, Diabetes, Immunocompromised, Incontinence (bowel/bladder). Care Plan document in part: R6 has Potential/At Risk for alteration in skin integrity due to risk factors associated with Cardio-vascular disease, Cognitive impairment, Diabetes, Immunocompromised, Incontinence (bowel/bladder). Pressure redistribution mattress Date Initiated: 06/26/25 Created on: 06/26/25, Alteration in skin integrity - R6 has Moisture Associated Skin Damage (MASD. Site: (sacrum) Factor that may inhibit healing: Moisture Date Initiated: 06/24/25. Pressure redistribution mattress Date Initiated: 06/26/25. Braden Scale for Predicting Pressure Sore Risk dated 06/26/25 document in part: Braden Scale of 14. (Moderate Risk). Wound Summary dated 06/20/25 document in part: MASD present on admission. Clinical stage: Erythema. Tissue Type: Bright pink or red =100%. Length 6.00 cm (centimeters) Width 3.00 cm and Depth 0.00 cm. On 06/26/25 at 09:14 AM R6 was observed lying in bed on a low air loss mattress with a setting of 320. Gastric tube feeding Glucerna infusing at 70 ml/hr. On 06/26/25 at 09:16 AM V16 (Licensed Practical Nurse) entered R6 room. Surveyor asked V16 the setting of R6 low air loss mattress. V16 responded, a little after 320. Surveyor asked V16 the weight of R6 and how is the low air loss mattress setting determined. V16 responded, I am not sure what R6 weighs. I think the low air loss mattress is set based on the resident's weight. Surveyor asked V16 does R6 weigh 320 pounds. V16 responded. Not at all. On 06/26/25 at 09:17 AM V19 (Wound Care Tech) entered R6's room and said I am making my rounds now and I am about to update R6's weight. On 06/26/25 at 09:18 AM V19 (Wound Care Tech) stated I have a list downstairs, and I am going to have to print out a new weight label to put on the low air loss mattress machine. The label is put on the low air loss mattress machine so if the staff is done with patient care they can set it back to the correct setting. I know that is not set on R6's weight, that is why I am going to try and fix the issue now. The purpose of the low air loss mattress is to prevent wound break down on their body. If the weight is set to high, the bed will be a little too hard for their body. The low air loss mattress setting is set based on the resident's weight. On 06/26/25 at 09:32 AM V10 (Wound Care Nurse) stated R6 has a MASD (Moisture Associate Skin Damage) to the sacrum and the treatment is zinc daily. The area is open but not staged, just moisture with no drainage. R6 is on a low air loss mattress. R6 had a decline since readmission and does not move as much as he used to. The purpose of the low air loss mattress is for pressure relief and is set based on the resident's weight. It sounds like they just set up the low air loss mattress and it was put in place yesterday 06/25/25. The low air loss mattress should be set based on R6's weight. I would say the setting of 320 would be too firm and there is a potential of skin integrity and not getting the benefit of the low air loss mattress if it is too firm. I did not get the confirmation that R6 was on the low air loss mattress yet. V19 (Wound Care Tech) is the wound care technician, and her responsibility is to make sure the low air loss mattress was in place and on the correct setting. R6 is a readmission. I print the resident's weight on the label and put it on the machine. If the weight change, I will reprint a label. Housekeeping is putting the mattress in place and if they turn the setting up all the way it will fill up faster. Part of V19 role is to make sure the low air loss mattress is functioning properly, but everyone's responsibility is to make sure the low air loss mattress settings are correct. 06/26/25 at 10:29 AM V10 (Wound Care Nurse) stated R6's low air loss mattress was ordered on Monday 06/23/25 and I updated the care plan to include R6's mattress now that it is in place. The low air loss mattress is used if the person is immobile and have sacral wounds. Some residents come with orders or wound care determines if they need a low air pressure relief intervention. R6's low air loss mattress was not in place. We have the pressure relief mattress in house. I had to ask again yesterday where was R6's mattress. Document titled Proactive Medical Products undated document in part: Introduction: Indications; Mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Control Unit: Determine the patient's weight and set the control knob to that weight setting on the control unit. Operating Instructions: Step 6 Determine the patient's weight and set the knob to that weight setting on the control unit. Policy: Titled Skin Care Prevention reviewed 01/25 document in part: All residents will receive appropriate care to decrease the risk of skin breakdown. 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 15. For residents who are bed or chair bound, a chair and pressure reducing mattress is needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a system was in place for documentation of medication disposition. This failure resulted in R4s medication being unaccounted for. Findings Include: R4 was readmitted to the facility on [DATE] with diagnosis not limited to Personal History of Pulmonary Embolism, Cellulitis of Left Lower Limb, Respiratory Failure, Muscle Weakness, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Morbid (Severe) Obesity due to Excess Calories, Depression, Anxiety Disorder, Obstructive Sleep Apnea, Lymphedema, Hypothyroidism, Binge Eating Disorder, Extreme, Adjustment Disorder with Depressed Mood, Lump in Unspecified Breast, Dependence on Wheelchair, Personal History of Other Diseases of the Musculoskeletal System and Connective Tissue, Abnormal Electrocardiogram, Essential (Primary) Hypertension, Personal History of other Diseases of the Respiratory System, Major Depressive Disorder and Tracheostomy Status. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R4's care plan document in part: Dietary: R4 is at nutritional risk as disease progresses, dx (diagnosis): morbid obesity, depression, lymphedema and hypothyroidism. R4 is taking schedule weekly medication Injections for weight loss management. R4 was receiving weight management medication since 04/25/25. R4's Order Summary Report document in part: Patient having tracheostomy placement at Medical Center 06/04/25 in preparation for bariatric surgery. Zepbound Subcutaneous Solution 2.5 MG (milligrams)/0.5ML (milliliter) (Tirzepatide (Weight Management)) Inject 1 pen needle subcutaneously in the afternoon every Wednesday for Weight Loss unsupervised self-administration. Progress note dated 06/04/25 07:32 document in part: Nursing Note: Patient out to an appointment (ENT) Ear, Nose, Throat VIA Ambulance. Progress note dated 06/04/25 15:07 document in part: Nursing Note: Writer spoke with Charge Nurse at Hospital who stated that the patient will be admitted overnight for Observation due to trach placement. Progress note dated 06/09/25 16:55 document in part: Nursing Note: Resident arrived on stretcher via ambulance from Hospital. Resident is in bed with trach 02 (oxygen) mask on. On 06/25/25 at 02:36 PM R4 stated the doctor from the outside prescribed weight loss medications that would be delivered to the pharmacy, my family would pick it up and bring it to the facility. I went to the hospital 06/04/25 - 06/09/25 to have surgery to put in this trach and when I came back the weight loss medication was nowhere to be found. I had received it previously and had 2 more shots left. The pharmacy sends four in the pack, and I got the shot on Fridays. I received a total of 6 shots and the last 2 were never found, I told V21 (PM Supervisor/Licensed Practical Nurse) and V17 (Licensed Practical Nurse). They said they couldn't find them, so I missed 2 doses. They knew I was coming back to the facility. They did not replace the medication they just put in a new order. The medication needs to be in the refrigerator. On 06/25/25 at 02:51 PM V16 (Licensed Practical Nurse) stated I have not given R4 her shot for weight loss; it is kept in the refrigerator. If a resident is gone for a while we send the medication back to the pharmacy or discard it. I don't know what happened to R4's last 2 doses. On 06/25/25 at 02:57 PM V17 (Licensed Practical Nurse) stated R4 receives shots for weight loss and should have received the shot today. Normally when the resident goes to the hospital, they take the medications off the cart and discard them. I am not aware of what happen to R4's shots. We have the shots in my office in the refrigerator since this incident happened. R4 gets the shots once a week. I don't think R4 missed a dose. When R4 came back they ordered the shots, and she was getting them. R4's family was bringing the shots in prior to that. On 06/26/25 at 12:09 PM Per telephone interview V21 (PM Supervisor/Licensed Practical Nurse) stated I remember a conversation and R4 said she did not know where her injections are. I looked on the cart. Usually when a resident goes to the hospital, we send their medication back to the pharmacy. R4 did not tell me that the medication had to be refrigerated, and I was not aware the medication was brought in by the family. We will send the medication back to whatever pharmacy it came from. I told R4 the medication was sent back to the pharmacy and when R4 was readmitted we get orders from the doctor. The protocol is that all orders are discontinued if a resident spend a number of days in the hospital. I did not see any injections and I was not aware that R4 was in the hospital. It should be documented when the medication was sent back to the pharmacy in the electronic medical records. There should not be any documentation if the medication is discarded. Since there was a concern, about the missing medication we would do an investigation. On 06/26/25 at 11:27 AM V3 (Director of Nursing) stated V1 (Administrator) just told me 5 minutes ago that R4's Zepbound medication was missing. I spoke to R4 yesterday and she did not mention the missing medication. If family brought medication to the facility the staff should put the medication in zip lock bags and the manager can keep the injectable's or put them in the lock box. We knew R4 was coming back to the facility, but we did not know the eta (expected time of arrival) and R4's medication should have been put in the lock box. When the resident returns, we are supposed to put all new orders in. If the resident is gone more than 24 hours the orders will be discontinued. R4's procedure was planned. I did not know the medication was coming to the facility from the family. The medication should be on the cart and getting checked out each time it is being used. If the resident is discharged the medication should go back to the family or let the family know that we have the medication in our possession. I will start the investigation. On 06/26/25 at 12:20 PM Per telephone interview V22 (Licensed Practical Nurse) stated R4 injections were kept in the refrigerator in the medication room, and I never gave it to her. On 06/26/25 at 02:05 PM V16 (Licensed Practical Nurse) stated R4 was going to an appointment, they took R4 to the hospital from the appointment and R4 was admitted to the hospital. I did not send anything with R4, and I did not take R4's medication out of the medication cart. R4 was being admitted and they were going to observe her, so I did not remove any medication. I know the Zepbound was here, and it was in the refrigerator because we have to go in the refrigerator for insulin. It was not that particular day that I saw it, but I know it was in there because it was in a box. When I came back, R4 asked me was the medication on the cart. I checked the cart, and it was not on the cart or in the refrigerator. I asked some of the nurses on the floor and V21 (PM Supervisor/Licensed Practical Nurse). V21 said she did not see it. V29 (Licensed Practical Nurse) said it was in the refrigerator. On 06/26/25 at 02:23 PM V29 (Licensed Practical Nurse) stated I saw R4's Zepbound in the refrigerator maybe a few days after R4's discharge to the hospital. I discarded it along with other insulin and medication for residents that were discharged in a sharp's container. After 72 hours we discard the medication. If there are pills, we send them back to the pharmacy. We cannot send back injectables and things like that. There is no sheet because it is not a controlled substance and there is no charting in the electronic medical records for the discarded medications. I administered the Zepbound to R4 on 06/18/25 and 06/25/25. Originally R4 was getting it on Fridays. I documented when I gave the Zepbound on the 06/18/25 but I did not document it on the MAR. R4 should have gotten the Zepbound on the 06/13/25 but I assume it was not here so R4 missed a dose on 06/13/25 and when it came in on the 06/18/25 on the 3-11 shift that is when I administered it to R4. No one asked where the medication was. R4 told me on 06/18/25 that she missed her dose. I told R4 that it just came in and I would administer it to her shortly. I was not aware that this was medication that R4's family had brought in. There is no process if a family member brings the medication in, we have all their medication here that they take. It was only one syringe of Zepbound in the refrigerator. On 06/26/25 at 02:46 PM V1 (Administrator) stated I have no policy on medication deposition. There is no policy for medication brought in by the family and I am not sure the nurses knew that R4's medication was brought in by the family. Resident census was obtained from the Midnight Census Report dated 06/24/25. Policy: Titled Medication Administration reviewed 01/24 document in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to regularly re-evaluate, refer, and document any referrals to the local contact agencies for discharge planning and assessment for one (R3) of three residents reviewed. Findings include: R3 is an individual whose current face sheet documents was admitted to the facility on [DATE]. Medical diagnosis include but not limited to: chronic obstructive pulmonary disease, unspecified, major depressive disorder, recurrent, unspecified, rheumatoid arthritis, unspecified, unilateral primary osteoarthritis, left knee. R3's MDS (Minimum Data Set) section C dated [DATE], documents R3 's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1's cognition is intact. MDS Section GG - Functional Abilities document's R3 requires supervision or touching assistance with eating, oral hygiene, Toileting hygiene, Shower/bathe self, Upper body dressing, Lower body dressing, putting on/taking off footwear. On 04/23/2025, at 10:57 AM, R3 was observed in his room laying on his bed. R3 was well groomed, alert, and oriented to person, place, time, and situation. R3 stated he was waiting for the facility to transfer him to an assisted living facility. R3 stated he met with a social worker who left the facility (no name provided) in November 2024, who told him he refereed R3 to the [NAME] program. R3 stated since then, no one has told him when he will be discharged . V8 (Social Services Assistant) has told him he will be handling his discharge arrangements, but he has not been given any update. R3 stated if the facility does not help him find a place, he has nowhere else to discharge to. R3 stated he does not do much at the facility and just stays in his room. R3 would like to be discharged to assisted living because he is independent with his activities of daily living and uses a cane to ambulate. R3 further stated he takes his medications as scheduled. On 04/23/2025, at 1:05 PM, V7 (Nurse Practitioner) stated R3 could be discharged to the community but he is homeless. V7 does not know the discharge planning process because social services is responsible. V7 stated after social services plans the discharge and informs her there is placement for the resident, she would come evaluate the resident for discharge. On 04/23/2025, at 1:25 PM, V8 (Social Services Assistant) and V3 (Social Services Director) stated residents who have been in the facility for more than 60 days qualify to be referred to the [NAME]-[NAME] program for assistance with housing and discharging into the community. V8 further stated R3 is a resident who would benefit from being referred to the [NAME]-[NAME] program because he is stable. V8 stated R3's care plan was last updated on 10/10/2024. Residents' care plans should be updated every three months to ensure transparency regarding plan of care and potential for discharge to the community. V3 stated R3's initial comprehensive assessment dated [DATE], documents R3 scored Good, and the assessment is supposed to be completed every three months because it indicates a resident's discharge potential. V3 stated residents who score good or excellent are able to be discharged to the community safely.V3 further stated care plan updates are updated every quarter to make sure the residents are being assessed for readiness to discharge in a timely manner. V3 stated she looked in Assessment Pro (referral tool for [NAME] program) and there is no record he(R3) was referred for discharge assessment. V3 stated she just started working at the facility less than week ago and does not know much about which residents are ready for discharge. V3 stated most of the social workers left the facility and she has a new team who started recently. R3's Social Services assessment titled -Social Services Comprehensive Assessment Initial Comprehensive Assessment V2, dated 10/10/2025 documents: -R3's discharge potential is good, R3 is sufficiently alert, oriented, coherent and knowledgeable allowing him to be considered for independent outside pass privileges, R3 is able to move/navigate/negotiate safely on community streets, is able to refrain from self-harm and/or socially inappropriate behavior while in the community. -R3 knows how to ask for help in an emergency or problematic situation while out in the community and has knowledge of potentially dangerous situations while in the community, has no severe debilitating physical impairment, is able to behave with respect in the community, and is medication compliant. -R3 has no aggressive behavior, has potential to be able to integrate into the peer community, minimal risk for aggression. R3's care plan dated 10/10/2024, documents: -Discharge preparations will continue to occur and implemented when local agency is able to provide services. Policy titled Discharges, dated 1/2025 documents: -To establish a plan of how to discharge a resident from the facility to home, another facility or the hospital. -Discharge potential is assessed by Social Services on admission

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a resident's food preference by serving oatmeal instead of grits. This failure affected 1 resident (R10) out of 7 residents reviewed for dietary services, in a total sample of 20 residents. Finding Include: R10's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Malignant neoplasm of supraglottis, moderate protein-calorie malnutrition, cerebral infarction, unspecified asthma, vitamin D deficiency. Minimum Data Set Section (MDS) section C (dated 02/13/2025) documents that R10 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R10's cognition is intact. Care plan (dated 05/28/2024) documents that R10 is at nutritional risk as disease progresses. Diagnoses are supraglottis cancer, moderate protein calorie malnutrition, lymphedema, schizo-affective disorder, nicotine dependence, dysphagia. The care plan documents that R10 has been identified to have some degree of risk to develop malnutrition with a body mass index (BMI) of 20.9. On 03/18/2025, surveyor was conducting a complaint investigation survey in regard to dietary services. At 9:20 AM, surveyor interviewed R10. R10 stated, They keep sending me oatmeal for breakfast. I have oatmeal and I breakout when I eat it. I keep on telling them not to send me oatmeal, but they keep sending it anyway. I told the nurses and the certified nursing assistants (C.N.A.s) that I don't want oatmeal. Yesterday, I spoke to a dietary aide that works in the kitchen and I told her that I hate oatmeal and that I breakout when I eat it. I told the aide not to send me oatmeal, and they still continue to send it. Surveyor assured R10 that surveyor would come and inspect R10's breakfast tray the following day in order to determine if the facility is following R10's dietary preference. The following morning, on March 19, surveyor went to R10's room to inspect R10's breakfast tray. At 9:13 AM, R10's breakfast tray arrived. Surveyor inspected R10's breakfast tray and noted that R10 received oatmeal, which is a type of hot cereal that R10 strongly dislikes. Surveyor inspected R10's meal ticket which was located on R10's tray. The meal ticket read, Dislikes: Oatmeal. R10 was upset when she saw that she was served oatmeal again. R10 stated, See they keep sending me oatmeal, I hate oatmeal. I am allergic to oatmeal and I breakout from it. On 03/19/2025, at 9:40 AM, V7 (registered dietitian) stated,R10 is on a general diet with thin liquids. As far as preferences, oatmeal is listed as a dislike. This is one of the meals that the resident does not like and does not wish to have oatmeal for breakfast. R10 had a 6-month weight loss, and interventions were put into place to prevent R10 from losing weight. R10 has nutritional drink called 2 Kal 3 times per day as a weight loss intervention. On 03/19/2025, at 10:19 AM, V16 (dietary aide) stated, R10 did express to me that she does not like the oatmeal. R10's ticket does state that R10 does not like oatmeal. The oatmeal was placed on her try by accident because myself and my colleague overlooked it. We corrected the problem immediately and sent R10 a bowl of grits. On 03/19/2025, at 10:25 AM, V17 (dietary aide) stated, I know R10 because I have spoken to R10 several times. I do know per R10's meal ticket that R10 dislikes oatmeal for breakfast. R10 received the oatmeal today by accident by grabbing the wrong hot cereal. Residents can receive either oatmeal or grits as hot cereal and the wrong type of hot cereal was grabbed during tray line. As soon as I was informed that R10 received the wrong type of cereal, the grits were immediately sent up for R10. The problem was corrected immediately. R10's Dietary Preference Sheet (dated 02/21/2024) documents that oatmeal is listed as food dislikes. R10's Physician Order (02/21/2024) states: General diet. Regular texture, thin consistency. Diet History, Preferences, Fortified Foods and Meal Add Ons Policy (undated) documents in part: All resident should be interviewed for a diet history with food and beverage preferences documented upon admission, per facility protocol. Their nutritional needs should be assessed regularly by the clinical team, communicated with dietary, and kitchen staff to updated menus to include preferences or fortified foods, as deemed necessary. Purpose: To individualize meal services for each resident's needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to follow their policy and coordinate with the appropriate, state-designated authority to refer one resident with a severe mental disorder for a new PASRR level I screen prior to the resident's PASRR level II short-term approval ended. This failure affected one resident (R7) out of four residents reviewed for resident rights, in a total sample of 20 residents. This failure places residents with related conditions at risk to not receive care and services in the most integrated setting appropriate to their needs. Findings include: On [DATE], 10:45 AM, V20 (Social Services) states that social services are responsible to follow up with PASRR (Pre-admission Screening and Resident Review) process. V20 reports that if a PASRR level II, requires them to update the care plan, rubrics, we just did a level II audit. V20 continues to state when it has an expiration date, it means that they need a new level I assessment. Social services are responsible to check on the expiration date. V20 states that he was not aware that R7's PASRR level II was expired. V20 states that if the PASRR level II is expired, we cannot confirm that he is appropriate for this setting. On [DATE], 11:32 AM, V20 states that R7 has not had any behaviors in the past weeks. R7's current face sheet documents that R7 is a [AGE] year-old individual with diagnoses not limited to: cognitive communication deficit, schizophrenia, schizoaffective disorder, bipolar type. R7's document dated [DATE], titled notice of PASRR level II outcome documents in part short-term approval without specialized services. Date short term approval ends: February 27, 2025. This determination allows you a limited number of days in a Medicaid-certified nursing facility. The short-term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome that came with this letter. If you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen to Maximus. The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. There is no documentation to show that R7 was screened for a new Level I screen since the PASRR level II expired. Facility document dated 01/2024 documents in part the facility has established this policy and is addressing issues related to problems within the PAS (Pre-admission Screening) system. It is the policy of this facility to comply with Illinois standards addressing the PAS assessment/screening process. Review the PAS documents to help assess/ascertain what type of problems, needs, and issues need to be addressed to help the resident function at his/her maximum level of well-being. As indicated, the screening material should be reviewed as a component of the assessment process and treatment suggestions/recommendations should be identified and appropriately addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, the facility failed to provide person-centered care planning for a resident ' s behavioral concern who refused psychotropic medication for 1 (R1) of 3 residents reviewed for inadequate nursing care. This failure impacted 1 resident (R1) who expressed behavioral concerns and continues to refuse medications that may help with behavioral concerns. Without adequate care planning addressing medication refusal, resident (R1) has the potential to continue to express behavioral concerns. Findings include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of mood affective disorder, anxiety disorder, cocaine abuse, bipolar disorder, manic severe disorder. Per MDS (Minimum Data Set) assessment, R1 cognition is intact with a BIMS (Brief Interview for Mental Status) of 15. On 02/27/2025 at 11:17 AM, during initial review, facility staff V4 (Registered Nurse) noted that R1 was out on pass. R3 roommate of R1 was present during this time. R3 said, I think he is a guy that always something ain't right. R3 was asked to elaborate what he means with his statement. R3 stated, Something always wrong with him. I mean he always complaining. At 12:01 PM, V3 (Case Manager of R1 / Emergency Contact of R1) stated that R1 was complaining about mistreatment, and not getting respect he deserves. V3 stated that R1 told him that R1 had a verbal altercation with a staff member. And that R1 has repeatedly spoken his unhappiness in the facility. R1 did not say that staff hit him. V3 said, No, staff not physical aggressive but verbally negligence. V3 made as an example that R1 was asking for Robitussin 4 or 5 times. And after that, staff told R1 that there is no more Robitussin. V3 stated that he was informed by R1 that he refused medication because he does not trust staff in the facility that gives his medication. V3 was asked in his determination, R1 is a victim of abuse. V3 replied, No, I haven't witness it. I could not say that staff are abusive, I only have what he was saying. All I can say is what I witness. I cannot say staff was abusive with him. I can only say what I witness. Review of R1's notes documents multiple behavioral concerns between R1 to staff or other residents. R1 went to the hospital on [DATE] due to aggressive behavior towards staff and peers. Per V7 (Social Worker) notes dated 01/24/2025, it documents that V3 (Case Manager of R1) was given an update about R1's aggression towards staff and peers. R1 returned in facility on 01/29/2025. Per R1's physician orders psychotropic medication were ordered related to R1's behavior. Hydroxyzine HCl 25 MG (antianxiety) to be given twice a day for anxiety and agitation order date 01/22/2025. And Seroquel 50 MG (antipsychotic) to be given every 12 hours for bipolar and manic severe disorder with order date of 01/29/2025. R1's Medication Administration Record (MAR) for January and February 2025 documents that almost every day Hydroxyzine and Seroquel was not given due to refusal. On 02/28/2025 at 10:47 AM, V2 (Director of Nursing) stated that R1 was verbally aggressive to staff and other residents with frequent room changes. R1 was involuntary discharge on [DATE] because of his behavior. V2 stated that R1 aggression was more on verbal. V2 stated that R1 has psychotropic medication Hydroxyzine and Seroquel for his behavior. And that R1 did not take his psychotropic medication. Because R1 did not take his psychotropic medication, it did not help him. V2 stated that if only R1 takes his psychotropic medication it would help with his behavior. V2 said, That is how he (R1) became this behavior. Verbally vocal and disrespectful from the time he wakes up to the time he sleeps. V2 was requested to review full care plan of R1 to address identified problem of refusing psychotropic medication. V2 after reviewing full care plan of R1 and said, I do not see it, about his (R1) refusal of psychotropic medication. I understand it needs to be addressed in the care plan. Care plan policy dated 01/2023 reads: The facility must develop a comprehensive care plan person-centered care plan for each resident. This comprehensive care plan should drive the care and services provided for the resident and allows for the highest level of physical, mental, and psychosocial function based of comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interview and record review the facility failed to keep three residents (R8, R10, R11) safe from a fire incident that occurred on 1/6/25. The facility failed to a.) properly assess and b.) maintain monitoring of R8's motorized wheelchair per the facility preventative maintenance policy in accordance with the manufactures guidelines. This failure resulted in three residents (R8, R10, R11) being involved in a fire and exposed to smoke. This failure has the potential to affect all 221 who reside in the facility. This was identified as an immediate jeopardy situation which began on 01/06/25. On 01/24/25 the administrator was notified of the immediate jeopardy. The abatement plan was sent via e-mail on 1/28/25 and not accepted. The abatement plan was resubmitted on 1/29/25 and 1/30/25 and accepted on 1/31/25. The immediate jeopardy was removed on 02/04/25. However, the deficiency remains at the second level of harm until the facility determined the effectiveness of the implementation of the removal plan. Findings include: R8's admission record showed admission date on 12/7/20 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Dysphagia oral phase, Anemia, Peripheral vascular disease, Absence epileptic syndrome, Other hereditary and idiopathic neuropathies, Encounter for attention to gastrostomy, Hyperlipidemia, Unspecified dementia, Chronic embolism and thrombosis, Gastro-esophageal reflux disease, Crohn's disease, Obstructive and reflux uropathy, Other sequelae of cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Aphasia, Essential (primary) hypertension, Heart failure, Major depressive disorder. MDS (Minimum Data Set) dated 11/14/25 reflects: R8's cognition was severely impaired. R8 needs partial/ moderate assistance with oral hygiene, dependent with toileting hygiene, Substantial / maximal assistance with shower / bathe self, upper and lower body dressing, personal hygiene, chair / bed, and toilet transfer. On 1/21/25 At 12:05pm R8 was sitting up on a motorized wheelchair, alert, and responsive. R8 is non- verbal but able to make needs known by hand and head gestures. During interview R8 was able to recall the fire incident on 1/6/25, R8 nodded her head up and down, indicating yes when asked if she was involved and if she almost got burned. R8 then pointed to where the fire was and pointed and motioned to her left towards the arm and pointed at the back of the wheelchair. R8 then pointed the left side of her shoulder. R8 appeared scared and anxious. Surveyor then asked R8 were you scared? and R8 nodded her head up and down, indicating yes. Surveyor further asked are you still scared and R8 nodded her head again up and down, indicating yes and also appeared to become teary-eyed. Surveyor asked R8 if this was the wheelchair and R8 gestured to the chair and nodded her head up and down, indicating yes that she is still using the same motorized wheelchair. R8 also pointed to her bed. Surveyor observed that R8 was in the same room where the fire incident happened and noted dark brownish and black spots and markings on the side of the railing on R8's bed closest to the door. Surveyor also observed the footboard of R8s bed. The footboard appeared to have small charred circle like markings to the black strip at the top of the footboard, as well as melted portions to the black stripping at the top of the footboard. On 1/21/25 at 3:25 PM, R10 stated she was lying in her bed next to R8's bed and smelled smoke so R10 yelled fire. R10 stated she was concerned about R8 because the fire was on R8's bed and she was worried R8 could get burned. R10 stated she called out to get help, but no one came so R10 stood up and got into her wheelchair to go for help. R10 stated the staff pulled me from the room into the hallway. On 1/22/24 Surveyor Conducted Observations to all 3 floors to review fire extinguishers. It was observed that all fire extinguishers had been recently inspected and one of the fire extinguishers where the fire occurred had been filled on 1/8/25. When conducting observations on 01/22/25 R10 spoke to the surveyor again and stated to the curtain (that separates their beds/personal space) was opened and that was how she could see fire on R8's bed. R10 stated I saw the flames and it was big, big and a lot and it was scary. When asked if R10 had been smoking or had her lighter in the room R10 stated, no. R10 is a [AGE] year-old female admitted to the facility 06/08/2023 with diagnosis included but not limited to Chronic Kidney Disease, Emphysema, Hypertension, Major Depressive Disorder, Opioid Abuse With Withdrawal, Insomnia, Solitary Pulmonary Nodule, Alcohol Abuse, Fall From Bed, Generalized Muscle Weakness, Alcohol Use, Nicotine Dependence Cigarettes, Repeated Falls, Reduced Mobility, Abnormalities Of Gait and Mobility, Need For Assistance At Home and No Other Household Member Able To Render Care, Vascular Dementia. R10's MDS dated [DATE] documents in part, R10 requires supervision/touching assistance with chair/bed to chair transfers and with walking 10 feet, walking 50 feet with two turns, and walking 150 feet. R10 uses a manual wheelchair and smokes. R10's BIMS (Brief Interview for Mental Status) indicates R10 is moderately cognitively impaired. On 1/21/25 at 3:30 PM, R11 stated R11 is blind and cannot see. R11 stated there was a fire in R11's room and R11 could smell the smoke. R11 stated, I was scared. R11 is a [AGE] year-old female admitted to the facility 11/17/16 with diagnosis included but not limited to End Stage Renal Disease, Dependence On Renal Dialysis, Chronic Obstructive Pulmonary Disease, Legal Blindness As Defined In USA, Type 2 Diabetes Mellitus, Cerebral Infarction, Protein Calorie Malnutrition, Hemiplegia and Hemiparesis Following Other Cerebral Vascular Disease Affecting Left Non-Dominant Side, Hypertension, Malignant Neoplasm Of Unspecified Kidney, Heart Failure, Primary Thrombophilia, Open Angle Glaucoma, Chronic Embolism And Thrombosis Of Unspecified Vein, Contracture Of Muscle Left Upper Arm, Dementia, Anemia In Chronic Kidney Disease. R11's MDS dated [DATE] documents in part, R11 is dependent for transfers and R11 does not use a wheelchair and/or scooter. R11's BIMS indicates R11 is cognitively intact. On 01/21/25 at 11:05 AM, V5 (Director of Maintenance) stated fire drills are conducted monthly on alternating shifts and all the facility fire pull stations are connected to a main fire panel located in the basement and this main fire panel is connected directly to the city emergency system. V5 stated anytime a fire alarm pull box is activated in the building the fire department should be notified automatically within seconds. V5 stated this is important because the fire department needs to be notified that there is a fire onsite, so they know to come to fight the fire for the safety of the residents and staff in the building. V5 stated we had a fire in a resident's room on 1/6/25 and staff was in the room when it happened. V5 stated the fire department said the fire was caused by a short in the electrical outlet on the wall which created a spark which then landed on the bedsheet and caught on fire. V5 stated the fire pull alarm on the unit was triggered by a staff but no alarm sounded, no lights were flashing, and the doors did not close. V5 stated someone called 911 to notify the fire department manually about the fire. V5 stated an outside vendor was called and came to the facility on [DATE] and found there was a short in the system and that is why the fire panel system did not trigger the fire department or sound the fire alarm in the building. V5 stated this outside vendor reset the system. On 01/21/25 at 12:12 PM, V9 (Licensed Practical Nursing) stated V9 was assigned to R8's room on 01/06/25 and that after dinner around 6:30 PM V9 heard a Certified Nursing Assistant yell, fire! V9 stated V9 entered the room and saw R8 sitting in R8's motorized wheelchair next to the bed and saw flames coming from R8's bed. V9 stated it looked like R8's mattress was on fire. V9 stated R10 was in R10's wheelchair exiting the room as V9 was entering the room and R11 was lying in bed near the window. V9 stated R8's wheelchair was not moveable and did not work. V9 stated it might have been that the wheelchair sparked the fire and V9 does not know if the wheelchair was plugged in or not. V9 stated V9 and V37 (Licensed Practical Nurse) transferred R8 into a geriatric chair as quickly as they could and R8 was brought down to the unit dining room. V9 stated the flames were close to R8 and if we had not removed R8 there is a potential that R8 could have been burned. V9 stated none of R8's clothing was burned. V9 stated V9 did a full body assessment and took vitals of R8 and R11. V9 stated V9 did not see any injuries on R8 but V9 noted R8 was scared. V9 stated R8 and R11's nurse practitioner (V49), family and V1 (Administrator) was notified and that they were not sent to the hospital. V9 stated everything happened all at once, and there was a lot of commotion. V9 stated V9 never heard any type of fire alarm sound or lights going on. 0n 01/21/25 at 1:10 PM, surveyor went with V5 to R8's room and viewed the location of the outlet. V5 stated the outlet was too far away from the bed to have caused the fire. On 1/21/25 at 1:30 PM, V5 (Director of Maintenance) stated he had made a mistake earlier and that the fire was caused by the R8's motorized wheelchair, not from a faulty electric outlet. V5 stated V5 does not know if the facility has a policy on wheelchair maintenance. V5 stated, I don't do any routine checks or monitoring on the electric wheelchairs because they are owned by the residents, not by the facility and if we do something to the electric wheelchair then we are liable, so it is not part of our responsibility. V5 stated V5 took R8's motorized wheelchair out of the room the night of the fire and V41 (R8's Son) came that same night and replaced a part. V5 stated V5 does not know what part V41 replaced or what R8's son did to the wheelchair. V5 provided document dated Fire Drill Evaluations dated 01/06/25 completed by V5 (Maintenance Director) documents in part, did the fire alarm strobe devices function properly? yes On 01/21/25 at 2:22pm V41 (R8's son) stated that he received a call from V9 (LPN) on 1/6/25 sometime in the evening but can't remember the specific time. He stated V9 told him that there was a fire in R8's room. V41 said as soon as he got the call he drove to the facility and was onsite within 5-10 minutes of receiving the phone call. V41 stated when he arrived, he saw a fire vehicle and a police car in front of the building. When he got up to the 3rd floor R8 was by the nursing station in a Geri chair. V41 said R8 was hysterical, and he could tell she was really scared and nervous. V41 said R8 was shaking her head back and forth and her eyes were big. V41 said he had to sit down to talk to V8 and try to calm her down. V41 stated R8's pillow, sheets and mattress were burned. V41 stated there were no burn marks on the wall but there were holes in the wall caused by R8 backing R8's motorized wheelchair into the wall. V41 stated there is a narrow space between the bed and the nightstand that R8's motorized wheelchair must fit into and so it is important that R8 has a little space on both sides of the wheelchair so that the electrical components of the motorized wheelchair do not scrape up against R8's bed frame. V41 stated R8's motorized wheelchair was still in the room after the fire and V41 could see that the fire department had pulled R8's wheelchair out from between the bed and the nightstand. V41 stated the fire department told V41 that the fire was started by the wheelchair. V41 stated V41 could see that the cord on the motorized wheelchair that connects to the controller on the left arm side of R8's wheelchair had exposed wires. V41 stated V41 could see a red and black wire which are normally contained and covered up by the plastic sheathing. V41 stated V41 thinks the cord that got caught up between the chair and the bed because the staff put the wheelchair too close to the bed and that the wheelchair rubbed up against the metal bed causing the cord to be shredded, thereby exposing the red and black wire, which must have created a spark. V41 stated V41 thinks it is that spark which caused the fire. V41 stated normally, the chair does not touch the bed and if it's touching the bed that means R8 is too close. V41 stated other damage to R8's wheelchair included a turn knob located on the back left side of the wheelchair which was melted to the point wherein all the knobs were no longer there. V41 stated that night V41 replaced the cord and secured it with zip ties. V41 stated on 1/5/25 prior to the fire V41 had replace the electronic charger for R8's motorized wheelchair. V41 stated V41 bought the motorized wheelchair for R8 in May 2024 and that V41 is the one who maintains R8's motorized wheelchair. V41 stated, I do all the repairs and maintenance checks on my mom's wheelchair. V41 stated V41 has experience fixing motorcycles so that is how V41 knows how to do the repairs on R8's motorized wheelchair. On 01/21/25 at 2:50 PM, surveyor met with R8 and V41 (R8's Son) in R8's room. V41 showed the surveyor the melted knob on the back of R8's motorized wheelchair and stated there used to be 4 nubs on the knob but the fire burned them off and now there are none. V41 showed the area on the metal bed frame and stated, See? you can see the spots on the bed frame where the black plastic from the knob melted into clumps onto the bed frame. He said there were 3 black lumps which V41 proceeded to flick off 2 of the 3 spots. V41 also said you can see where the fibers of the plastic sheathing shredded and melted onto the bed frame. V41 then showed the surveyor photos on his cell phone that he took the night of the fire. The pictures showed that the mattress was burned on the side closest to the door/entrance of the room, and bed sheets/linens were charred black in the same area and that there were black charred areas on the bed frame in the same area of the melted plastic. V41 stated on 01/06/25 he could see that the cord on the motorized wheelchair that connects to the controller on the left arm side of R8's wheelchair had exposed wires. V41 stated he thinks the cord got caught up between the chair and the bed because the staff put the wheelchair too close to the bed and that the wheelchair rubbed up against the metal bed causing the cord to be shredded, thereby exposing the red and black wire, which must have created a spark. V41 stated that night V41 replaced the cord and secured it with zip ties. Surveyor requested for V41 to send copies of the photos to the email provided. State agency did not receive the photos via email provided on 1/21/24. On 1/22/25 at 11:45am V1 (Administrator) stated she arrived at the facility around 8:00pm on 1/6/25 and saw R8 who appeared scared surrounding the fire incident. V1 stated she spoke to the fire department staff and V1 stated she spoke with the Fire Investigator/Marshall directly and the Fire Marshall/Investigator stated there was nothing in the room which could have set the fire. V1 stated R8's doctor was notified and V1 asked R8 if R8 wanted to go to the hospital and R8 said no. V1 stated she did not do an investigation or report the incident to the state. V1 stated this fire incident was not reported to IDPH (Illinois Department of Health) because there was no injury and based on the facility's policy this incident was not considered to be an unusual occurrence and it did not need to be reported to IDPH. V1 stated none of the residents were sent to the hospital for evaluation. On 1/22/25 at 12:30pm, V38 (Housekeeper) stated V38 started working at the facility in 11/2024. V38 stated V38 was working on 01/06/25 downstairs in the basement cleaning the dialysis room when around 6:00-6:30 PM V38 stated heard a CODE RED announced overhead but V38 is not familiar with the code so V38 continued cleaning and mopping the dialysis room and did not go up to the unit. V38 stated after cleaning the dialysis room, V38 went up to unit about 15-20 minutes after the code red was announced. V38 stated that is when V38 saw ambulance people, fire people, policemen and residents in the dayroom. On 01/22/25 at 2:50 PM, V32 (Certification Nursing Assistant) stated V32 was walking by R8, R10 and R11's room on 01/06/25 and heard someone saying fire, fire. V32 stated V32 could see flames from the hallway, and it looked like the fire was coming from R8's bed. V32 stated the curtain and the side of R8's mattress was in flames. V32 stated R8 was sitting in R8's motorized wheelchair next to R8's bed which was on fire. V32 stated V32 pushed the mattress away and pulled the privacy curtain away from R8 to try to get R8 away from the flames but could not move R8's motorized wheelchair. V32 assisted R10 out of the room and then went to the nursing station to alert the nurses about the fire. V32 stated V32 went back into the room to retrieve R11, unlocked R11's bed and as V32 was leaving the room with R11, V32 observed two EMT (Emergency Medical Technicians) entering the room. V32 saw the two EMTs grab R8 from R8's motorized wheelchair using sheets and transferred R8 into the geriatric chair. On 01/22/25 at 2:01 PM, via phone interview V46 (Registered Nurse) stated V46 was working on 01/06/25 and sitting at the nursing station when V32 (CNA) walked to the nursing station and said, there is a fire. V46 stated V46 could already see smoke in the hallway and when V46 entered the room, V46 saw R8's bed on fire and R8 was sitting in R8's motorized wheelchair which was right next to the fire. V46 stated V46 could smell burning rubber and saw a white extension cord on the floor which was melted. V46 stated that morning R8's wheelchair was not working correctly and that evening the staff was charging the wheelchair using a white extension cord. V46 stated the smoke and fire alarm did not go off in the room or hallway or the rest of the building so, initially none of the staff knew that there was a fire in the building. V46 stated R8's motorized wheelchair would not move so; we were trying to figure out the best way to move R8. V46 stated there were two EMTs (Emergency Medical Technicians) on the floor because they had just delivered a resident to the floor from the hospital and the EMTs are the ones who [NAME] into action. V46 stated one EMT and the CNA (V32) wrapped R8 in a blanket and transferred R8 into a geriatric chair. V46 stated V46 told someone to make an overhead page to alert the other staff that there was a fire in the building because we needed help removing the residents away from the fire. V46 stated one of the other nurses was directing the other EMT on where to get the fire extinguisher and that is when V46 called 911 right there from the room from V46's personal cell phone because V46 stated the fire didn't stop, it was growing and getting bigger. V46 stated V46 was getting scared. V46 stated then V46 saw the other EMT use the fire extinguisher to put out the fire. V46 stated after the fire was put out it was very smokey in the hallways and in R8's room. V46 stated the fire department who came told the staff that it was an electrical fire cause by the extension cord or motorized wheelchair. On 01/22/25, V11 (Evening Nursing Supervisor, Licensed Practical Nurse) stated after the fire V11 could see cords hanging on the back of the wheelchair and you could tell that someone had tried to fix it because there was black electric tape on the cord, and it was hanging from the wire. V11 stated there was no alarm going off on the floor or anywhere else in the building and there should have been because the fire alarm sound is needed to alert everyone that there is an active fire going on. On 01/22/25 at 2:50 PM, V32 (Certification Nursing Assistant) stated V32 was walking by R8, R10 and R11's room on 01/06/25 and heard someone saying fire, fire. V32 stated V32 could see flames from the hallway, and it looked like the fire was coming from R8's bed. V32 stated the curtain and the side of R8's mattress was in flames. V32 stated R8 was sitting in R8's motorized wheelchair next to R8's bed which was on fire. V32 stated V32 pushed the mattress away and pulled the privacy curtain away from R8 to try to get R8 away from the flames but could not move R8's motorized wheelchair. V32 assisted R10 out of the room and then went to the nursing station to alert the nurses about the fire. V32 stated V32 went back into the room to retrieve R11, unlocked R11's bed and as V32 was leaving the room with R11, V32 observed two EMT (Emergency Medical Technicians) entering the room. V32 saw the two EMTs grab R8 from R8's motorized wheelchair using sheets and transferred R8 into the geriatric chair. On 1/22/25 at 3:32 PM, V37 (Licensed Practical Nurse) stated V37 was working on 01/06/25 and sitting at the nursing station around 6:30-6:50 PM when V37 heard someone yell out fire, fire. V37 stated as V37 was entering the room R10 was in R10's wheelchair by the entrance of the room and V37 quickly moved R10's wheelchair into the hallway. V37 stated V37 entered the room at the same time as V9 (LPN) and that's when V37 saw flames of fire and smoke coming from R8's bed. V37 stated V37 could see that R8 was sitting on that side of the bed near the flames in R8's motorized chair. V37 stated it looked like the flames were coming from behind R8's motorized wheelchair and the wheelchair was so close to the bed that R8 was close to the fire. V37 stated V9 and V37 picked up R8 and one of the CNA brought in a geriatric chair and removed R8 from the room to make sure R8 was safe. V37 stated V37 does not recall hearing any alarms. V37 stated one of the CNAs ran to get the fire extinguisher and when V37 came back into the room the fire had been put out. V37 stated V37 does not remember any EMTs helping. V37 stated V9 is the nurse who conducted the assessment on R8 and R11 and there was no talk about transferring them to the hospital. On 01/22/25 at 4:30 PM, V31 (Certified Nursing Assistant) stated V31 been working at the facility since October 2024 and works at the facility full time. V31 stated V31 usually covers the 11-7 shift but sometimes picks up overtime by working the 3-11 shift. V31 stated V31 was working on 01/06/25 and was at the nursing station doing charting when around 6:45-7:00 PM when V31 heard V9 (LPN) yell fire, fire! V31 stated V31 walked down to the room and in the doorway V31 could see flames coming from the 1st bed and the flames were one to two feet high. V31 stated V31 has never experienced something like that before and it was alarming. V31 stated there were two EMTs in the room helping. V31 stated V31 did not hear any fire alarms or sounds or see any lights but the doors shut. V31 stated since V31 has been working at the facility, we haven't had any fire drills for night shift. V31 stated when the fire box is triggered the fire alarms should go off and make a loud sound. V31 stated the alarms are what alerts the staff so the staff can get the residents to safety. On 01/22/25, V11 (Evening Nursing Supervisor, Licensed Practical Nurse) stated on 01/06/25 at 6:50 PM, V11 was taking a break in V11's office on the 1st floor when V11 received a cell phone call from V9 (LPN) notifying V11 that there was a fire on the floor. V11 stated, I asked her, a real fire? And V9 replied, yeah! V11 stated V11 did not hear any type of fire alarm sounding in the building. V11 stated V11 left V11's office immediately and went passed the receptionist and told the receptionist to announce CODE RED overhead. V11 stated by the time V11 arrived on the unit there was no active fire, only a lot of smoke. V11 stated there were no residents in the room. V11 stated R8's motorized wheelchair was in the hallway and V11 could see cords hanging on the back of the wheelchair. V11 stated you could tell that someone had tried to fix it because there was black electric tape on the cord, and it was hanging from the wire. V11 stated there was no alarm going off on the floor or anywhere else in the building and there should have been because the fire alarm sound is needed to alert everyone that there is an active fire going on. On 01/24/25 at 9:48 AM, V2 (Director of Nursing) stated she was not onsite at the time of the fire. V2 stated all three residents should have been assessed by a nurse that night since they were all in the room at the time of the fire and exposed to the smoke. V2 stated a fire is an unusual event and since it was an unusual event the nurses would need to monitor the residents regularly to make sure they are okay. V2 stated this monitoring should be done every shift for the following 72 hours after the fire by the nurse on duty and documented under the assessments tab listed under skin assessments. With surveyor V2 reviewed R8's EHR (Electronic Health Record) and stated R8 does not have any 72-hour nursing assessments completed after the fire on 01/06/25 but should. V2 reviewed R10 and R11's EHR and verbalized that there are some 72-hour nursing assessments missing and not all the shifts were done. On 01/24/25 at 10:30 AM, observed R8 lying in bed and R8's motorized wheelchair next to R8's bed. V48 (Day Nurse Manager/Licensed Practical Nurse) stated R8's motorized wheelchair was not working. V48 stated, we are trying to figure it out. It won't move. It was on the charger, but it won't turn on. When we press the button to turn it on, it turns right off and I'm going to call the son so he knows it's not working and can fix it. Surveyor observed white sticker on R8's motorized wheelchair for Pride Mobility and listed a web site. On 01/24/25 at 11:40, V5 (Director of Maintenance) stated the nurses told V5 that R8's wheelchair was not working. V5 stated V5 took off the cover on the wheelchair and moved some of the wires around and replaced the cover and it turned back on. On 1/24/25 at 11:54 AM, was interviewed further about the fire incident and her chair not working. R8 indicated by nodding R8's head up and down in a yes motion that there was a fire in R8's room when R8 was sitting in R8's motorized wheelchair. R8 nodded and gestured that the fire was coming from the back left side of R8's wheelchair. R8 gestured to the left side of R8 wheelchair when asked if R8 felt hotness from flames and motioned up and down R8's left arm. R8 indicated that R8 was still using the same motorized wheelchair that was involved in the fire and that it wasn't working again today. R8 indicated by nodding R8's head up and down in a yes motion when R8 was asked if she scared during the fire and if R8 is still scared. R8 appeared to display wide open eyes, raised and furrowed eyebrows, while communicating about the fires R8 gestured and responded no, when R8 was asked if R8 needed to go to the hospital on 1/6/25. R8 indicated that if someone had asked R8 if R8 wanted to go to the hospital the night of 1/6/25, R8 would have said yes, because R8 wanted to be checked after the fire incident. On 01/24/25 at 11:04 AM, V49 (R8 and R11's Nurse Practitioner) stated V49 was called by V9 on the evening of 01/06/25 and was made aware of the fire that occurred. V49 stated V49 was told there was a localized fire in the room and all the residents had been removed from the room. V49 stated V49 takes care of R8 and R11, not R10. V49 stated V49 was aware that R8 and R11 was exposed to fire and smoke. V49 stated V49 was told the fire was caused by R8's motorized wheelchair and that R8 was sitting in the wheelchair when the fire broke out and R11 was also in the room. V49 stated based on what was communicated to V49 there was a fire, and R8 was evacuated, and R8 had no clinical symptoms of smoke inhalation and no burns. V49 stated R8 was the focus of the phone conversation, not R11. V49 stated V49 she was not made aware of the fire alarm system not working. V49 stated if V49 had known that V49's clinical judgment could have been potentially different, but V49 still does not know if V49 would have sent R8 or R11 to the hospital. V49 stated if the fire alarm did not sound this could potential have caused a delay in staff response and longer resident exposure to the fire and smoke. V49 stated it is possible to have smoke inhalation without having overt clinical symptoms. On 01/24/25 at 1:05 PM, V53 (Vice President of Operations for [NAME] Health Care) stated R8's motorized wheelchair is what caused the fire. V53 stated the son helps R8 with the wheelchair and the wheelchair was removed and repaired by the son. V53 stated the facility does not do any repairs because the wheelchair is not owned by the facility. V53 provided the survey team with a printed documents from the facility's internal [NAME] Management portal. It was labeled in part, #1742 other, the date and time was not visible on the top portion of the document. V8's name was also on the top of the 5 pages provided. R10 and R11 were not listed. V53 also provided survey team a printed copy of the Manufacturers Guide for Pride Mobility Motorized Wheelchair for R8. Document titled Pride Mobility Owner's Manual which documents in part, under no circumstances should you modify, add, remove, or disable any feature, part or function of your power chair and do not modify your power chair in any way not authorized by Pride and if you discover a problem, contact your authorized Pride Provider for assistance. General Guidelines include but not limited to avoid knocking or bumping the controller and avoid prolonged exposure of your power chair to extreme conditions, such as heat. Daily, weekly, monthly, and yearly checks listed. On 01/27/25 at 2:13 PM, via phone interview V52 (Service Telephone Support Pride Mobility for R8's Motorized Wheelchair) stated if a Pride motorized wheelchair was involved in a fire and/or within close proximity to a fire, exposed to high temperatures it should be evaluated by an authorized licensed Pride Technician before putting it back in use. V52 stated this is a safety precaution in case anything externally and/or internally got burned or damaged. V52 stated you may not be able to see the defect and it might not be safe for use and should be evaluated by a licensed authorized Pride Technician. V52 stated all replacement parts must be ordered from Pride, be certified Pride parts and repairs should be scheduled through a dealer. V52 stated any parts ordered off internet could be defective and should not be used. V52 stated if non-Pride replacement parts are used this would null and void the warranty on the wheelchair as the dealer cannot ensure the safety of the wheelchair. On 01/29/25 at 9:31 AM, V56 (Director of Rehab/Occupational Therapist I've been working here for 2 years. I screen new admissions to see what they are here for, what they can/cannot do. If they cannot stand and/or transfer, then make a recommendation for them to use a wheelchair. V56 stated all residents who use motorized wheelchairs should be assessed by therapy to see if the resident can safety and independent maneuver the motorized wheelchair. V56 stated it would be important for them to be assessed for their safety and the safety of the other residents living in the facility. If they are on therapy the assessment would be in your documentation. If they are not on therapy, I use a screening sheet which I give to the Administrator. Unless there are concerns or something is brought to our attention by nursing, we don't reassess. The assumption is that the resident will maintain their level of function regarding using the motorized wheelchair safely and independently. We don't do any maintenance on the motorized wheelchair. If I notice any wires hanging, I'd notify the Maintenance Director. I never noticed any hanging wires from R8's motorized wheelchair before or after the fire. R8 is not on my case load but I am familiar with

Based on observation, interview, and record review, the facility failed to properly assess and implement interventions related to the psychosocial needs of one resident (R8) who was involved in and exposed to fire and smoke surrounding a fire related incident that occurred on 1/6/25 in R8's room. These failures resulted in R8 expressing emotional distress and fear after the incident. The findings include: R8's admission record showed admission date on 12/7/20 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Dysphagia oral phase, Anemia, Peripheral vascular disease, Absence epileptic syndrome, Other hereditary and idiopathic neuropathies, Encounter for attention to gastrostomy, Hyperlipidemia, Unspecified dementia, Chronic embolism and thrombosis, Gastro-esophageal reflux disease, Crohn's disease, Obstructive and reflux uropathy, Other sequelae of cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Aphasia, Essential (primary) hypertension, Heart failure, Major depressive disorder. MDS (Minimum Data Set) dated 11/14/25 reflects: R8's cognition was severely impaired. R8 needs partial/ moderate assistance with oral hygiene, dependent with toileting hygiene, Substantial / maximal assistance with shower / bathe self, upper and lower body dressing, personal hygiene, chair / bed, and toilet transfer. On 1/21/25 At 12:05pm R8 was sitting up on a motorized wheelchair, alert, and responsive. R8 is non- verbal but able to make needs known by hand and head gestures. During interview R8 was able to recall the fire incident on 1/6/25, R8 nodded her head up and down, indicating yes when asked if she was involved and if she almost got burned. R8 then pointed to where the fire was and pointed and motioned to her left towards the arm and pointed at the back of the wheelchair. R8 then pointed the left side of her shoulder. R8 appeared scared and anxious. Surveyor then asked R8 were you scared? and R8 nodded her head up and down, indicating yes. Surveyor further asked are you still scared and R8 nodded her head again up and down, indicating yes and also appeared to become teary-eyed. Surveyor asked R8 if this was the wheelchair and R8 gestured to the chair and nodded her head up and down, indicating yes that she is still using the same motorized wheelchair. R8 also pointed to her bed. Surveyor observed that R8 was in the same room where the fire incident happened and noted dark brownish and black spots and markings on the side of the railing on R8's bed closest to the door. Surveyor also observed the footboard of R8s bed. The footboard appeared to have small charred circle like markings to the black strip at the top of the footboard, as well as melted portions to the black stripping at the top of the footboard. On 01/21/25 at 12:12pm V9 (Licensed Practical Nursing / LPN), stated she was assigned to R8's room on 1/6/25 and that after dinner around 6:30pm she heard a Certified Nursing Assistant / CNA yell, fire! V9 stated she entered the room and saw R8 sitting in her motorized wheelchair next to the bed and saw flames coming from R8's bed. V9 stated it looked like R8's mattress was on fire. She stated R8's wheelchair was not moveable and did not work. V9 stated it might have been that the wheelchair sparked the fire. V9 stated the flames were close to R8 and if R8 was not removed there was a potential that R8 could have been burned. V9 stated none of R8's clothing was burned. V9 stated she did a full body assessment and did not see any injuries but R8 was scared. V9 stated the nurse practitioner was notified and R8 was not sent out to the hospital. V9 stated R8 is non-verbal but alert, orientated and can understand what you are saying and will respond to yes/no questions. On 01/21/25 at 2:22pm V41 (R8's son) stated via phone interview that he received a call from V9 (LPN) on 1/6/25 sometime in the evening but can't remember the specific time. He stated V9 told him that there was a fire in R8's room. V41 said as soon as he got the call he drove to the facility and was onsite within 5-10 minutes of receiving the phone call. V41 stated when he arrived, he saw a fire vehicle and a police car in front of the building. When he got up to the 3rd floor R8 was by the nursing station in a Geri chair. V41 said R8 was hysterical and he could tell she was really scared and nervous. V41 said R8 was shaking her head back and forth and her eyes were big. V41 said he had to sit down to talk to V8 and try to calm her down. On 1/21/25 at 2:50pm V41 (R8's son) was in R8's room and showed the surveyor the melted knob on the back of R8's motorized wheelchair and stated there used to be 4 nubs on the knob but the fire burned them off and now there are none. V41 showed the area on the metal bed frame and stated, See?, you can see the spots on the bed frame where the black plastic from the knob melted into clumps onto the bed frame. He said there were 3 black lumps which V41 proceeded to flick off 2 of the 3 spots. V41 also said you can see where the fibers of the plastic sheathing shredded and melted onto the bed frame. V41 then showed the surveyor photos on his cell phone that he took the night of the fire. The pictures showed that the mattress was burned on the side closest to the door, and bed sheets/linens were charred black in the same area and that there were black charred areas on the bed frame in the same area of the melted plastic. Surveyor requested for V41 to send copies of the photos to the email provided. State agency did not receive the photos via email provided on 1/21/24. On 1/22/25 at 11:45am V1 (Administrator) stated she arrived at the facility around 8:00pm on 1/6/25 and saw R8 who appeared scared surrounding the fire incident. On 1/22/25 at 12:36pm V34 (Certified Nursing Assistant / CNA) stated she was working during the fire incident on 1/6/25. V34 said R8 was involved in the fire incident and looked distraught and scared out of her mind. V34 stated R8 is non-verbal but she can communicate with hand and head gestures. V34 said she knows R8 well and could tell R8 was shaken up by the whole experience. V34 said she asked R8 if she was scared, and she nodded her head up and down to indicate yes repeatedly. V34 said it gave her flashbacks herself (from a personal fire experience she was involved in) so she could understand how R8 was feeling. V34 stated R8 kept shaking her head from side to side as if R8 could not understand what had just happened, like R8 was in disbelief or shock. On 1/22/25 at 3:32pm V37 (LPN) stated she was working during the fire incident on 1/6/25 and R8 was shaken up and looked scared. V37 stated she asked R8, are you okay?, R8 shook her head no. V37 asked R8, Are you scared?, R8 shook her head yes. On 1/24/25 at 9:32am V8 ( Social Service Director/SSD ) stated their role includes mainly advocating for residents, checking, and monitoring psychosocial wellbeing and ensure documentation is done in a timely manner. He said SS (social service) department develop an individualized plan of care regarding resident's psychosocial wellbeing. V8 stated care plans would include goals and appropriate interventions in place to guide staff on how to care for the residents. V8 said care plans should be reviewed / revised at least quarterly and as needed to reflect the status and needs of the residents. V8 said psychosocial wellbeing includes emotions / feeling of the resident and Psychotherapy services are being offered in the facility. V8 stated he saw R8 the following day after the fire incident and R8 appeared scared and R8 was holding his hand very tightly. V8 said R8 being involved or experiencing the fire incident on 1/6/25 could be traumatizing to her because it is an unusual event. V8 said R8 should be checked /evaluated and monitored, provide with revisits, support/ reassurance and they ensure any psychosocial concern/issues are being addressed. R8's records were reviewed with V8. There was no documentation that interventions were provided to R8. V8 stated R8's psychosocial wellbeing and care plan should be reviewed / revised to reflect R8's status, any concerns and to evaluate appropriate interventions. V8 stated R8 could benefit with psychotherapy to discuss the fire incident that occurred on 1/6/25 to process her emotions. R8's progress notes from 1/6/25 to 1/14/25 were reviewed and no Social Service documentation was found. R8's care plan did not reflect that it was reviewed / revised to reflect R8's status after the fire incident on 1/6/25. On 01/24/25 at 9:48am V2 (Director of Nursing) stated she was not onsite at the time of the fire. V2 stated a fire is an unusual event and since it was an unusual event, the nurses would need to monitor the residents regularly to make sure they are okay. V2 stated this monitoring should be done every shift for the following 72 hours after the fire incident on 1/6/25 and document would be in resident's EHR (electronic health record). Surveyor reviewed R8's EHR with V2 and there was no documentation found that R8 was monitored 72 hours post fire incident. On 1/24/25 at 10:20AM V60 ( Licensed Clinical Social Worker / LCSW) stated she has been a contracted staff for the facility since March 2024. V60 stated she has been seeing R8 weekly due to diagnosis of MDD (Major Depressive Disorder) with symptoms of self-isolation in her room. V60 said she started seeing R8 in April 2024. She said R8 is alert and oriented x 4, nonverbal, and able to make needs known to staff using hand and head gestures. V60 said she was informed by facility staff that R8 was scared due to being exposed in a Fire incident on 1/6/25. She said she did see R8 on 1/14/25 and the fire incident was not directly discussed. V60 said V8's room change was the main topic of discussion. She said R8's involvement or exposure to fire and smoke incident is a traumatizing event. V60 said R8 could be helped on how to process her emotions by letting her express the traumatizing event. She said staff could provide reassurance that she is safe (presently) to help deal with anxiety that came with traumatic experience. V60 said she would not not recommend or be in favor for R8 to still used the same piece of equipment like the bed or chair with burn markings on it as it would possibly keep the trigger lasting. She said any little things could possibly trigger the traumatizing event. R8's progress notes dated on 1/14/25 created by V60 (LCSW), documentation did not reflect psychotherapy session regarding fire incident on 1/6/25. On 1/24/25 at 11:15am V49 ( Nurse Practitioner/ NP) stated the fire incident on 1/6/25 could be a traumatizing event for R8 and she should have received psychotherapy to process her emotions and provide her with reassurance. V49 said the chair and bed could be a provocative cue and that using the same bed is not ideal. V49 said the facility should switch her bed as that could be triggering for R8. On 1/24/25 at 11:54 AM, was interviewed further about the fire incident and her chair not working. R8 indicated by nodding R8's head up and down in a yes motion that there was a fire in R8's room when R8 was sitting in R8's motorized wheelchair. R8 nodded and gestured that the fire was coming from the back left side of R8's wheelchair. R8 gestured to the left side of R8 wheelchair when asked if R8 felt hotness from flames and motioned up and down R8's left arm. R8 indicated that R8 was still using the same motorized wheelchair that was involved in the fire and that it wasn't working again today. R8 indicated by nodding R8's head up and down in a yes motion when R8 was asked if she scared during the fire and if R8 is still scared. R8 appeared to display wide open eyes, raised and furrowed eyebrows, while communicating about the fires R8 gestured and responded no, when R8 was asked if R8 needed to go to the hospital on 1/6/25. R8 indicated that if someone had asked R8 if R8 wanted to go to the hospital the night of 1/6/25, R8 would have said yes, because R8 wanted to be checked after the fire incident. On 1/30/25 At 10:26am V1 (Administrator) said the fire incident on 1/6/24 could be a traumatizing event for R8. V1 stated Social Services interventions could be utilized such as checking her mood, providing support, and should be documented. V1 said that during R8's Psychotherapy session, the fire incident could have been discussed to process her emotions. Surveyor requested facility's policy related to resident's psychosocial wellbeing, V1 stated facility does not have it. Facility's residents' rights policy dated 11/18 documented in part: Your rights to safety. The facility must provide services to keep your physical and mental health, at their highest practical levels. Facility's comprehensive care plan policy dated 1/2023 documented in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial function. The comprehensive care plan should be reviewed with the resident and/or resident representative and changes made as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide monthly surveillance and maintain patient care equipment, to ensure that it is in safe operating condition. This failure affected one (R8) out of five residents (R4, R8, R12, R13, R14) reviewed for preventative maintenance. Findings include: On 01/21/25 at 1:30 PM, V5 (Director of Maintenance) stated the fire was caused by the R8's motorized wheelchair. V5 stated he does not know if the facility has a policy on wheelchair maintenance. V5 stated, I don't do any routine checks or monitoring on the electric wheelchairs because they are owned by the residents, not by the facility and if we do something to the electric wheelchair then we are liable, so it is not part of our responsibility. V5 stated he took R8's motorized wheelchair out of the room the night of the fire and V41 (R8's Son) came that same night and replaced a part. V5 stated V5 does not know what part V41 replaced or what R8's son did to the wheelchair. On 1/21/25 at 2:22 PM, V41 (R8's Son) stated V41 he was called on 01/6/25 and drove to the facility that same night. V1 stated the fire department told him that the fire was started by the wheelchair, and he could see that the cord on the motorized wheelchair that connects to the controller on the left arm side of R8's wheelchair had exposed wires. V41 stated on 01/05/25, the day prior to the fire V41 had replace the electronic charger for R8's motorized wheelchair. V41 stated he is the one who maintains R8's motorized wheelchair. V41 stated, I do all the repairs and maintenance checks on my mom's wheelchair. V41 stated he has experience fixing motorcycles so that is how he knows how to do the repairs on R8's motorized wheelchair. V41 stated that night V41 replaced the cord and secured it with zip ties. On 01/22/25 at 2:01 PM, via phone interview V46 (Registered Nurse) stated V46 was working on 01/06/25 and sitting at the nursing station when V32 (CNA) walked to the nursing station and said, there is a fire. V46 stated V46 could already see smoke in the hallway and when V46 entered the room, V46 saw R8's bed on fire and R8 was sitting in R8's motorized wheelchair which was right next to the fire. V46 stated V46 could smell burning rubber and saw a white extension cord on the floor which was melted. V46 stated that morning R8's wheelchair was not working correctly and that evening the staff was charging the wheelchair using a white extension cord. V46 stated the smoke and fire alarm did not go off in the room or hallway or the rest of the building so, initially none of the staff knew that there was a fire in the building. V46 stated R8's motorized wheelchair would not move so; we were trying to figure out the best way to move R8. V46 stated there were two EMTs (Emergency Medical Technicians) on the floor because they had just delivered a resident to the floor from the hospital and the EMTs are the ones who [NAME] into action. V46 stated one EMT and the CNA (V32) wrapped R8 in a blanket and transferred R8 into a geriatric chair. V46 stated V46 told someone to make an overhead page to alert the other staff that there was a fire in the building because we needed help removing the residents away from the fire. V46 stated one of the other nurses was directing the other EMT on where to get the fire extinguisher and that is when V46 called 911 right there from the room from V46's personal cell phone because V46 stated the fire didn't stop, it was growing and getting bigger. V46 stated V46 was getting scared. V46 stated then V46 saw the other EMT use the fire extinguisher to put out the fire. V46 stated after the fire was put out it was very smokey in the hallways and in R8's room. V46 stated the fire department who came told the staff that it was an electrical fire cause by the extension cord or the motorized wheelchair. On 01/22/25, V11 (Evening Nursing Supervisor, Licensed Practical Nurse) stated by the time V11 arrived on the unit there was no active fire, only a lot of smoke. V11 stated R8's motorized wheelchair was in the hallway and V11 could see cords hanging on the back of the wheelchair. V11 stated you could tell that someone had tried to fix it because there was black electric tape on the cord, and it was hanging from the wire. On 01/24/25 at 10:30 AM, observed R8 lying in bed with R8's motorized wheelchair next to her bed. V48 (Day Nurse Manager/Licensed Practical Nurse) stated R8's motorized wheelchair was not working. V48 stated, We are trying to figure it out. It won't move. It was on the charger, but it won't turn on. When we press the button to turn it on, it turns right off and I'm going to call the son so he knows it's not working and can fix it. Surveyor observed a white sticker on R8's motorized wheelchair for Pride Mobility and listed a web site. On 01/24/25 at 11:40 AM, V5 (Director of Maintenance) stated the nurses told him that R8's wheelchair was not working. V5 stated he took off the cover on the wheelchair and moved some of the wires around and replaced the cover and it turned back on. Chicago Fire Department Office of Fire Investigation Fire Marshall Report requested and obtained by the surveyor dated, 01/06/25 documents in part, there was no visible fire to the exterior of building; fire alarm system activated - no ; smoke detectors alerting - no ; after a thorough fire scene examination and evaluation it is the considered opinion that this fire incident was caused by the ignition of plastic wiring insulation from electrical energy, then spreading to immediately adjacent cloth/fabric combustibles in the form of bedding. On 1/24/25 at 12:24 PM, via phone interview V51 (Commanding Fire Marshall Deputy District Chief, Chicago Fire Department) stated V51 was not part of the team that responded to the fire on 01/06/25 but he spoke with the Fire Marshall who did respond, who said the fire appeared to be caused by an electrical issue. V51 stated V51 is looking at the Fire Marshall's Report of the incident on 01/6/25 and at pictures taken at the scene. V51 stated the pictures show that the cord in the back of the wheelchair is exposed and severed. V51 stated at one point the cord was one piece and the wires were contained inside the cord, but in the picture, there are two dangling pieces with exposed wires. V51 stated in V51's experience what happens is the cord containing the wires is subjected over time to physical damage either from getting banged, pinched, rubbed against, or perforated in some way. V51 stated the electricity heats up, melts the plastic and escapes from the plastic sheathing and now the electricity can jump and ignite any combustible material nearby. V51 stated in this case it appears the combustible material was the sheets and bed linens which acted as fuel for the fire. V51 stated this could be one of the causes of the fire based on what V51 is seeing in the pictures. V51 stated it is clear from looking at these pictures that the motorized wheelchair was involved in the fire but V51 cannot say definitively what caused the fire, but it appears it was from some type of electrical fire. V51 stated in V51's opinion this motorized wheelchair should be inspected by an electrical engineer before the resident is allowed to use it again. V51 stated It should not just be taped up and put back in service because we don't really know what happened and if there was an electrical event it may not be safe for the resident to continue using it. V51 stated the motorized wheelchair may be malfunctioning inside the wheelchair, but we cannot see it. V51 stated an electrical engineer should do an inspection to make sure the issue that potentially caused the first fire could not create another potential fire. On 01/27/25 at 2:13 PM, via phone interview V52 (Service Telephone Support Pride Mobility) stated if a Pride motorized wheelchair was involved in a fire and/or within proximity to a fire, exposed to high temperatures it should be evaluated by an authorized licensed Pride Technician before putting it back in use. V52 stated this is a safety precaution in case anything externally and/or internally got burned or damaged. V52 stated you may not be able to see the defect and it might not be safe for use and should be evaluated by a licensed authorized Pride Technician. V52 stated all replacement parts must be ordered from Pride, be certified Pride parts and repairs should be scheduled through a dealer. V52 stated any parts ordered off Amazon could be defective and should not be used. V52 stated if non-Pride replacement parts are used this would null and void the warranty on the wheelchair as the dealer cannot ensure the safety of the wheelchair. Document titled Pride Mobility Owner's Manual which documents in part, under no circumstances should you modify, add, remove, or disable any feature, part or function of your power chair and do not modify your power chair in any way not authorized by Pride and if you discover a problem, contact your authorized Pride Provider for assistance. General Guidelines include but not limited to avoid knocking or bumping the controller and avoid prolonged exposure of your power chair to extreme conditions, such as heat. Daily, weekly, monthly, and yearly checks listed. Facility provided policy titled, Preventative Maintenance Plan dated 1/2025 which documents in part, monthly surveillance of all resident rooms for any repairs needed and proper operation of all equipment. If a resident has personal equipment, it should be maintained according to manufacturer's guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the resident's call light device was within reach for two residents (R1, R3) out of three residents reviewed for quality of care. This failed practice placed the resident at risk for not being able to call for help, if needed. Findings include: On 10/22/2024, 10:41 AM R1's call light was on top of 3 pillows without pillowcases that are on top of R1's nightstand. R1 was sleeping, easily arousable, and in no apparent distress. R1 states that she is not sure when she first came to the facility. R1 states I have memory loss, maybe about 6 months ago, I don't like it here. R1 cannot remember the names of the staff that take away her call light. R1 states that when they do come to check on her, R1 states that she forgets what she even yelled out for. R1 cannot remember when she yelled out for help. R1 states that currently, she cannot reach her call button. R1 states look and see they took it away from me, I can't reach it. On 10/22/2024, 10:55 AM V3 (Certified Nursing Assistant) states that call lights must be in reach of the residents. V3 states that she has not heard any resident yell out for help. V3 reports that residents who are more vulnerable and must have their call light within reach is contracted, if a resident has some confusion, or residents that are non-verbal or non-ambulatory. V3 states that residents should not be ignored if they are yelling for help because they might need or want something, or they can be slipping. V3 and surveyor entered R1's room and V3 states that R1's call light is not within reach. V3 grabbed R1's call button that is on top of the pillows on the nightstand and placed it within R1's reach. R1 states thank you. V3 states that she has not taken away call lights form any resident because that is neglect. R1's Face sheet documents that R1 is a [AGE] year-old female admitted to the facility on [DATE], who has diagnoses not limited to: paraplegia, major depressive disorder, insomnia due to other mental disorder, bipolar disorder. R1's Minimum Data Set (MDS) Section C, dated 10/02/2024, documents R1 has a Brief Interview for Mental Status (BIMS) of 12 out of 15, R1 is moderately cognitive impaired. R1's Minimum Data Set (MDS) section GG dated 10/02/2024, documents in part R1 needs substantial/maximal assistance for ability to roll from lying on back to left and right side and return to lying on back on the bed. On 10/22/2024, 11:05 AM R3 was lying in bed, covered in a white sheet, in no apparent distress. R3's call button attached to the lowest part of the right bed side rail. R3 states I need a diaper change; I don't have the call light as R3 looked around for his call button. On 10/23/2024, 10:09 AM R3's call light button noted on the floor. R3 states that his nurse gave him some medicine earlier. On 10/23/2024, 10:12 AM surveyor and V9 (Licensed Practical Nurse) entered R3's room and V9 states that the call button should not be on the floor. V9 states it probably slipped off of him. It was on his chest. I did initially go to him because he pulled the call light. V9 states that she did not move R3's call light away from him. V9 denies any resident complaining of this to her. V9 states that it is important for residents to have their call light within reach just in case an emergency happens or if they ask for something simple as some water. R3's Face sheet documents that R3 is a [AGE] year-old male admitted to the facility on [DATE], who has diagnoses not limited to: adult failure to thrive, history of falling, syncope and collapse, generalized anxiety disorder, major depressive disorder, recurrent, unspecified, legal blindness. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R3 is cognitively intact. R3's care plan dated 5/14/2024 documents in part R3 has a potential for falls. R3 had an actual fall. Interventions include encourage to utilize call light for staff assistance, have commonly used items within reach. Facility policy dated 01/10/2024, titled Call Light Response documents in part, to provide the staff with guidance on responding to residents' requests and needs. Ensure the call light is always within the resident's reach. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of records the facility failed to follow policy in giving/providing a shower/bath to 1 (R1) out of 4 residents reviewed for resident shower or bathing schedule. This failure has the potential to affect 1 resident (R1) in maintaining hygiene through bathing at least once a week. Findings include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis that includes paraplegia and bilateral (right and left) foot drop. On 9/17/2024 at 12:50 PM, R1 was seen in her room laying on her bed. R1 was alert and able to maintain conversation within topic very well. In front of R1 was a moving table with her cell phone and TV remote control. During conversation the cell phone rings that was answered by R1. After R1's phone conversation, R1 stated that it was her daughter on the phone (V7). R1 confirmed that the phone and TV remote control was her own. R1 stated that she had a scheduled surgery but was not able to go. R1 stated that she did not have any formal appointment as to who her power of attorney will be. But V8 (Family of R1/Sister) or V7 (Family of R1/Daughter) can represent her. R1 was asked if V7 is allowed to visit her in the facility. R1 said that V7 brings her food but is not allowed to visit her in the facility. R1 said that it was due to a fight between her (R1) and V7, that V7 hits her (R1) around four (4) years ago. R1 stated that Department of Elderly does not allow V7 to visit her in the facility. R1 stated that V8 was able to visit her in the facility. R1 was asked if she has any concern. R1 replied that staff does not take her to shower for a long time. And that she did not have any shower since May. R1 stated that even before she has shingles, she was not showered for at least more than a month. R1 comb her hair using her fingers and her hair was sticking and hard to detached. R1 said, This feels so sticky and uncomfortable. On 9/17/24 at 1:30 PM at the nurse station, V5 (Restorative Nurse/Licensed Practical Nurse) presented a shower schedule sheet. V5 was asked for the binder of shower that was done by staff. V2 (Regional Nursing Consultant/Former Director of Nursing) took the binder and gave it to writer. There was no record of R1 in the binder containing shower sheets. V2 stated that shower forms are not complete because it is being collected by V6 (Wound Nurse/Licensed Practical Nurse) and bring it to her office on a daily basis. V6 who was at the nurse station went to her office check on all shower sheet that was filed. Upon checking, R1 does not have any record of taking a shower on 9/10/2024 (Tuesday) and 9/13/2024 (Friday) per shower schedule sheet provided by V5. V6 stated, That is the only record I have, I think R1 came from the 3rd Floor. Per R1's census R1 was transferred from 3rd floor to second floor on 9/9/2024. V6 stated, that staff may be doing a bed bath because R1 has shingles. But staff needs to fill out shower form when performing a bed bath. And since R1 was transferred to 2nd Floor from 3rd Floor without record for being showered by staff. 9/9/2024 to present (9/17/2024) is more than a week without shower sheet to support. V6 also reviewed all shower sheets from the previous floor (3rd Floor) of R1 but there was none on the file. On 9/17/2024 at 2:25 PM, V3 (Licensed Practical Nurse) stated that R1 is bedbound due to paraplegia and need to be assisted of her ADLs (Activity of Daily Living). R1 MDS (Minimum Data Set) assessment dated [DATE] documents that bilateral (both) lower extremities of R1 are impaired. And R1 is dependent to staff for shower/bathing. On 9/18/2024 at 1:52 PM, V1 (Administrator) stated that shower of the residents are done by CNA (Certified Nursing Assistant). And the CNAs should fill up the shower form. All the shower forms are being collected by the Wound Nurse (V6) because it serves as a weekly skin assessment. V1 stated that all residents needs to be bath or shower at least once a month. V1 was informed that R1 stated that the last shower she had was on the month of May. And R1's hair does not flow and sticking when she uses her fingers to comb her hair. V1 stated that staff were instructed to include cleaning R1's hair during bed bath because R1 gets a bed bath due to shingles. Bathing policy dated 1/10/2024, reads: All residents are offered a bath or shower at least one time per week. More frequent bathing or showering is given as needed. Under guidelines, if a resident requires a bed bath, a complete bed bath is given one time per week, and a partial bed bath the other days.

Based on observation, interview, and record review the facility failed to provide proper positioning for 1 (R1) resident during dining. This failure has the potential for R1 to be at risk for choking and aspiration during dining experience. Findings Include: R1 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, Essential (Primary) Hypertension, Atrial Fibrillation, Type 2 Diabetes Mellitus, Anxiety Disorder due to Known Physiological Condition and Post-Traumatic Stress Disorder. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impairment. R1's Care Plan document in part: Focus: Bed Mobility: R1 has a self-care deficit in bed mobility r/t (related/to) (Decreased ability to position or reposition self in bed/ Turn from side to side/ Move from lying to sitting or sitting to lying position). Intervention: Position and reposition resident in bed for comfort, joint support, and skin integrity. During the initial tour of the facility on 09/10/24 at 01:05 PM, the surveyor observed R1 in bed in a low fowlers position with the meal tray in front of him while trying to eat lunch from an overbed table. R1's reclined body was level with the overbed table and R1 was drinking thin red liquid from a cup. On 09/10/24 at 01:11 PM Surveyor went to the nurse station and asked V7 (Licensed Practical Nurse) to go to R1's room. Surveyor asked V7 R1's position in bed. V7 responded, R1 is in a low Fowler position. R1 should be up right in bed. The position that R1 is in is not appropriate for eating. There is a potential for choking or R1 may aspirate. On 09/10/24 at 01:14 PM while waiting for staff to reposition R1, R1 was observed coughing. V7 (Licensed Practical Nurse) was standing near the foot of R1's bed then stated, let me get some gloves, I got someone on the way to help pull you (R1) up. On 09/10/24 at 01:22 PM the nurse and certified nurse assistant repositioned R1 in bed. On 09/11/24 at 12:14 PM surveyor asked V9 (Certified Nurse Assistant) what the correct positioning of a resident in bed while eating. V9 responded, the position of the residents while eating in bed is 90 degree. On 09/11/24 at 03:03 PM V11 (3rd floor unit manager) was asked the correct positioning of a resident while eating in bed. V11 responded, the resident should be in an upright position when eating or being fed. On 09/12/24 10:26 AM V17 (Licensed Practical Nurse/Restorative Nurse) stated R1 is a substantial assist with toileting and sitting up in the bed. R1 was supervision with eating up until this week. R1 need assistance with eating because he is not eating well. The position that a resident should be in when eating or being fed in bed should be a semi-Fowler_position, sitting up to prevent aspiration. Document undated document in part: R1 requires assistance with dining. In-Service, Education and Staff Development undated documents in part: Topic: It is the expectation that restorative aides' complete rounds on residents requiring assistance dining to ensure that they are positioned appropriately prior to the arrival of floor trays. In-Service, Education and Staff Development undated documents in part: Topic: Resident should be positioned in semi to high fowler's position during mealtimes to prevent aspiration and/or choking and to promote optimal intake. Policy: Titled Feeding Assistance revised 01/24 document in part: General: To attempt to provide adequate nutrition to a resident. Guideline: 3. Position resident in proper body alignment for eating. Titled Activities of Daily Living reviewed 05/24 document in part: General: A program of activities of daily living is to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. D. Feeding a. Proper positioning for eating is maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to a.) follow their policy and monitor vital signs during a medical emergency and b.) perform needed interventions for a resident who experienced a change in condition for one (R2) resident out of three residents reviewed improper nursing care. Findings include: On 6/9/24 at 11:22 AM V8 (Licensed Practical Nurse/LPN) states that she was doing rounds with the unit manager, and they noticed R2 was shaking, in his bed. V8 states that she performed vital signs on him, and they were high, V8 states that R2 normally has low blood pressure. V8 states that the doctor was called and V8 states that the doctor gave orders to send R2 to the hospital. V8 states that the paramedics informed her that they were transferring R2 to a closer hospital because R2 ' s blood pressure kept spiking and R2 was seizing. V8 states that R2 was not having any seizure when the private ambulance picked him up. V8 states that R2 was antsy and trying to remove his belt and picking at his shirt. V8 states that when she initially saw R2 having a seizure, V8 states that she saw his eyes rolling, and his hands were clinched downward. V8 states that R2 only had one seizure that morning. V8 states that the seizure lasted maybe two minutes, maybe like a minute with his eyes rolling, and two minutes with the jerking. V8 states that she stayed with him the whole time. V8 states R2 ' s seizure occurred maybe around 9:00AM. V8 states that the doctor did not order for R2 to be sent out via 911 because V8 states that the seizure stopped. V8 states that the private ambulance informed her that if R2 had another seizure then to call 911. On 06/09/24 at 1:01 PM V8 states that a set of vital signs are blood pressure, respiration, pulse, temperature, and O2 sat (oxygen saturation). V8 states that a full set of vital signs should be taken after a seizure. V8 states the normal range for O2 sat is between 90%-100%. V8 states that R2 ' s O2 sat reading of 90% could have been caused from him having a seizure that day. V8 states that she does know that when the ambulance arrived, V8 states that R2 was saturating at 88%, and V8 states that the paramedics placed R2 on oxygen. V8 states that R2 was not on oxygen prior to the paramedics arriving to the resident. V8 states that low oxygen saturation can affect the oxygen that is going to R2 ' s brain. On 06/09/24 at 1:33pm V7 (doctor) states that he remembers they called him about R2, and he was sent out. V7 states that he thinks it was ok for resident to be sent to the hospital via private ambulance instead of 911 because the nurse informed him that he was stable. V7 states that he does not remember if he was notified of R2 ' s O2 sat reading of 90%. V7 states that the preferred normal oxygen saturation range is to be in the high 90s unless the resident has COPD (chronic obstructive pulmonary disease), V7 states it is preferred above 90%. V7 states that if 90% is not the resident ' s baseline then V7 states he can start him on oxygen therapy with this number. Surveyor informed V7 of R2 ' s usual O2 sat readings and V7 states that is lower than his normal and V7 states that is a drop. V7 states that the pulse oxygen saturation number gives them a guide, and V7 states that if the resident is short of breath, pale, and even with a normal pulse oxygen number, V7 states that he would still place resident on oxygen therapy. V7 states that if the resident is asymptomatic then they would look at the number. R2's Face sheet documents that R2 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: dementia, epilepsy, personal history of traumatic brain injury. R2's nursing progress note dated 06/06/2024 09:46 AM documents in part: The writer observed a resident in bed displaying seizure activity. The writer remained with the resident until seizure was complete. Resident assessed and v/s as followed. B/P 118/65, RR18, P88, T97.8. No documentation of R2 ' s oxygen saturation post seizure activity. R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's O2 saturation is 90 % (Room Air). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's blood pressure is 109/42 mmHg (millimeter of mercury). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's pulse is 61 bpm (beats per minute). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's temperature is 96.8°F (Fahrenheit). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's respiration is 14 Breaths/min. R'2 nursing progress note dated 06/06/2024 11:54 AM documents in part: Resident transported to the hospital via private ambulance. Facility document, dated 1/2024, titled Medical Emergency Management documents in part, General: Emergency guidelines refer to actions given to residents with urgent and critical needs .take vital signs and provide reassurance to the resident. Vital signs should be taken every 10-15 minutes based on resident need until the resident is stable or transferred . A convulsive seizure is involuntary contractions of muscles resulting from abnormal cerebral stimulation . After the seizure reorient the resident. e. Take vital signs and record. Facility document, dated 1/10/2024, titled Change in Resident Condition documents in part, Policy: nursing will notify the resident's physician or nurse practitioner when: There is a significant change in the resident's physical, mental or emotional status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to follow their policy and procedure (a) to determine and assess a resident if self-administration of medications is appropriate; (b) to obtain a physician's order for medication self-administration; and (c) to implement a person-centered care plan addressing self-administration of medications for 1 (R124) out of 1 resident reviewed for self-administration of medications in the final sample of 35 residents. Findings Include: On 5/21/24 at 12:17 PM R124 was in R124's room. Surveyor noted wound dressings on top of R124's drawer. R124 stated that R124 has colon cancer and uses the dressings for R124's wound on R124's buttock. R124 opened R124's drawer and showed Surveyor the solution R124 uses for R124's wound. R124 stated that the wound care nurse gave the solution for R124 to use. R124 was unable to identify the wound care nurse. Surveyor also noted a bottle of Multivitamins in R124's drawer. R124 stated that R124 takes the multivitamin every morning. On 5/22/24 AM at 10:20 AM, interviewed V2 (Director of Nursing) and stated that before letting the resident self-administer their own medications, the nurse must assess the resident if they are capable. They need to provide education and do return demonstration. V2 stated that the resident must have a doctor's order for medication self-administration and has to be able to do correct return demonstration. V2 stated that the resident must show and demonstrate the right way to administer the medication and the nurse should monitor them. V2 stated that in the resident's electronic health record, the resident should have documentation that education is provided for self-administration. V2 stated that if the resident requests to administer their own medication, the process is to complete the Medication Self-Evaluation Administration Assessment and if the resident is capable to self-administer their own medications, order is obtained from the doctor, education is provided with correct return demonstration from the resident, and it should be addressed in the care plan. Surveyor checked R124's electronic health records with V2 and no documentation showing R124 was assessed to determine if R124 is capable of administering R124's own medication, no documentation if education was provided for medication self-administration, no order obtained from the physician and no care plan addressing R124's medication self-administration. R124's electronic health records show an admission date of 10/30/22 with diagnoses not limited to Auditory Hallucinations, Major Depressive Disorder, Mild Cognitive Impairment, Malignant Neoplasm of Colon, and Malignant Neoplasm of Anal Canal. R124's physician orders with active orders as of 5/22/24 shows no order for medication self-administration. R124 has orders for Dakins Solution to apply to buttocks topically for wound treatment and Multivitamin with Minerals one time a day. R124's Minimum Data Set, dated [DATE] shows R124 is cognitively intact. R124's care plan does not address if R124 if medication self-administration is appropriate for R124. The facility's policy titled; SELF ADMINISTRATION OF MEDICATIONS AND TREATMENTS dated 1/2024 reads in part: GUIDELINE: 1. Self administration of medications and treatments is determined by an order after determining that the resident is able to self administer. PROCEDURE: 1. If it is determined by a member of the interdisciplinary team, or if the resident requests to self administer, it is documented in the chart and the Health Care Provider is called for an order to self administer medications, and keep the medications at bedside. 2. Determination of the ability to self-administer medications will be done by nursing using the form in PCC titled Medication Self-Evaluation Administration. 7. A care plan is for resident who self administer, and documentation should be present in the nursing notes of teaching to self administration of the medications or treatments.

Based on observation, interview, record review facility failed to follow facility policy in reporting an abuse and neglect allegation by one resident (R23) out of a total of 35 residents in the sample. Findings On 05/21/24 at 9:18 AM, R23 approached surveyor and asked Are you with the state? R23 stated They are stealing my money and stuff. R23 stated that she told the administrator. V13 (LPN) approached surveyor and R23 and stated It hasn't reached us yet. Surveyor repeated to V13 R23's statement that They are stealing my money and stuff. R23 stated They also neglect me a lot. They bully people. (V13 did not report the allegation to V1 Administrator) On 05/22/24 at 10:40 AM, V1 (Administrator) was interviewed about the facilities abuse allegation and reporting process. V1 stated that when a resident alleges abuse, V1 is the first person notified. If the allegation is staff-to-resident, the staff member is sent home, resident is sent to the hospital if necessary, and police are called. V1 stated that she then does her investigation. V1 talks to the resident and other residents who may have been witness to the event. V1 also talks to the resident to make sure that the resident feels safe. V1 talks to staff and gets as much detail about the allegation as needed. V1 stated that accusation of stealing money or property falls under the definition of abuse. V1 stated that staff do not take into account the psychiatric state of the resident when deciding if they should report an abuse allegation. They report all abuse. V1 stated that all staff have her phone number. V1 stated that there should be no staff member that says that a resident compliant of stolen money or property or bullying or neglect is not brought to my attention. V1 was asked about R23 and stated that she was not aware of any recent allegations of abuse by R23. V1 was asked what the timeframe for reporting an allegation was. V1 stated that the staff report an allegation to her immediately and then V1 reports the allegation to the state within 24 hours. When V1 was told that R23 made an allegation of stolen money and property and bullying on 5/21/2024 at 9:18 AM, V1 said I was not aware. When V1 was asked if staff should have reported the 5/21/2024 allegation to V1, V1 stated yes. I will investigate. I will report it. On 05/22/24 at 11:10 AM V1 (Administrator) and surveyor met with R23. R23 stated to V1 that she was missing money and also did not get her check. R23 stated that staff bully her. It happened today. V1 asked if resident felt safe. Initially R23 stated yes. On 5/23/2024 at 1:52 PM, V1 (Administrator) provided Facility Reported Incident documentation of R23's allegation. Form was submitted 5/22/2024 at 5:10 PM. Policy titled Abuse Policy and Prevention Program 10/2022 states in part: V. Internal Reporting Requirements and Identification of Allegations Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property that they observe, hear about, or suspect to the administrator immediately to an immediate supervisor who must then immediately report it to the administrator or compliance officer. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two house after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within twenty-four hours.

Based on interview and record review, the facility failed to refer one resident (R3) to the appropriate state designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation out of 5 residents reviewed for PASARR in a total sample of 35. Findings include: R3's OBRA - Initial Screen (Identification for Individuals for Whom There is a Reasonable Basis to Suspect a Developmental Disability or a Mental Illness) completed by state-designated authority dated 11/15/28 documents in part based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (Developmental Delay) or MI (Mental Illness) with the no box checked. R3's diagnosis includes but not limited to Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation. On 05/23/24 at 1:24 PM, V16 (Social Service Director) stated PASARR level I screen is completed prior to admission and depending on the residents added diagnosis and behaviors the facility then requests a PASARR level II assessment. V16 stated diagnosis requiring PASARR level II assessment include dementia, severe mental health diagnosis such as schizophrenia, Schizoaffective Disorder, Depression, Bipolar Disorder, Anxiety, and Major Depressive Disorder. V16 stated the PASARR level II assessment are request and completed within 48 hours of request by an outside agency. V16 stated the PASARR level II evaluation has a score that determines the resident's cognitive ability, mental health needs and tells the facility whether or not the resident is appropriate to stay in the facility, so the PASARR level II is important because the residents need a certain score to determine if this nursing home is the appropriate setting for that resident based on the level of care and services they need. V16 stated for residents who have been living at the facility for an extended period social service are supposed to update the PASARR for residents annually. V16 stated they are in the process of doing an audit to find out who needs PASARR level II assessments. V16 stated V16 submitted a request for R3 to be evaluated on 05/22/24 PASARR level I screen and it was determined that PASARR level II assessment is needed onsite based on R3's diagnosis of mental illnesses. V16 stated V16 submitted PASARR level I screen yesterday because I wasn't aware he (R3) needed a level II until you asked me for it. Facility provide document titled, Notice of PASRR Level I Screen Outcome reported date 05/22/24 documents in part, R3's reason for screening: This nursing facility resident has never had a PASRR level I screen and refer to level I onside, suspect or confirmed PASRR conditions: Mental Health Disability. PASRR Outcome Explanation Notice of PASRR Level II Onside Evaluation Required which documents in part our health care professional completed Preadmission Screening and Resident Review (PASRR) level I screen for you and this screen shows that you need a face-to-face level II evaluation. PASRR level I screen and level II evaluations are required by Federal Law, 42 U.S.C. 1396r(e)(7). Facility provided policy titled PAS Screening dated 1/2024 which documents in part, in accordance with Illinois regulatory standards and recommended practices, this organization requests Level 1 (one) and Level 2 (two, where applicable) Pre-admission Screening documents prior to the individual's arrival at the facility and it is the policy of this facility to comply with Illinois standards addressing the PAS assessment/screening process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 05/21/24 11:13 AM R179 stated No hablo inglés. V13 (LPN) was asked how staff communicate with R179. V13 stated that R179 points to what he wants. V13 initially stated that there was no other way to communicate with R179, but then stated There is also an app that we can use. V13 stated that V9 (CNA) was assigned to R179. V9 stated He speaks English. V9 entered R179's room and asked R179 if he wanted to shower. V9 stated He understands what we are saying. When asked how staff allow R179 to communicate back to the them, V9 said We use V14 (Restorative Aide). R179 said in English Get V14. I speak to her (pointing to surveyor). V14 entered the room and translated for R179. R179 was asked how he communicates with staff. Through V14, R179 stated He asks around to get someone to help him out and interpret. R179 stated through V14 that he asks V14 or a housekeeper to help him, or he asks another resident who speaks Spanish. When V14 interpreted the question Does anyone use an app or their phone or computer to interpret and speak to you? R179 stated no. When asked if anyone uses a communication board where he can point to what he wants to communicate, R179 stated no. Surveyor did not observe a communication board in R179's room. On 5/22/2024 at 3:45 PM, R179's care plan dated 4/26/2025 and created by V7 (LPN) was reviewed. Focus: Communication: Resident is at risk for complications with communication related to Goal: Staff will anticipate and meet all of residents needs on a daily basis throughout next review. Interventions: Encourage use of communication cards/board. Policy entitled Comprehensive Care Plan dated 1/2023 stated in part: The facility must develop a comprehensive person-centered care plan for each resident. Policy. 3. The care plan will include a focus, measurable goal and interventions specific to the resident's medical, nursing, mental and psychosocial needs. On 5/23/2024 V1 (Administrator) was asked for the facilities resident rights policy. The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities was provided. It states in part: You have the right to complete information about your medical condition and treatment in a language that you understand. Policy titled Communications dated 1/2023 stated in part: Policy: (Facility) will take reasonable steps to ensure that persons with limited English proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The policy of (facility) is to ensure meaningful communication with LEP patients/clients and their authorized representatives involving their medical condition and treatment. Based on observation, interview, and record review, the facility failed to (a) provide the necessary care and services to ensure that one (R92) resident was assisted or supervised with personal hygiene / shaving and (b) follow facility policy and standards of professional practice in providing care and communication in one resident's (R179) primary language. These failures affected two (R92 and R179) residents reviewed for activities of daily living (ADL) in a sample of 35. The findings include: R92's health record documented admission date on 2/16/2019 with diagnoses not limited to Alcohol dependence with withdrawal, Esophagitis, Thrombocytopenia, Gastro-esophageal reflux disease with esophagitis, Constipation, Personal history of covid-19, Age-related nuclear cataract bilateral, Tension-type headache, Vitamin d deficiency, Insomnia due to medical condition, Decreased white blood cell count, Spinal stenosis cervical region, Nontraumatic intracerebral hemorrhage, Cervicalgia, Dysphagia following other cerebrovascular disease, Traumatic hemorrhage of cerebrum, Unspecified cirrhosis of liver, Nicotine dependence, Encounter for attention to gastrostomy, Essential (primary) hypertension, Bipolar disorder, Post-traumatic hydrocephalus, Iron deficiency anemia, Presence of cerebrospinal fluid drainage device, Chronic viral hepatitis c. On 5/21/24 at 10:45 AM R92 observed lying in bed, alert and oriented x 3, verbally responsive. Observed with long beard more than 5inches. Stated he can have staff assist him with shaving. He said staff did not offer or assist him with shaving. He said he does not have working shaver. At 11:19 AM Requested V3 (LPN / Licensed Practical Nurse, Restorative Nurse) to R92's room and R92 stated he wanted his beard shaved off. R92 said beard is about 5-6 inches long and he wanted to take off everything. R92 said I have more beard than my actual hair. At 12:20 PM V4 (Certified Nursing Assistant / CNA) said she has been working in the facility for 27 years. Stated she is assigned to R92. She said residents are assisted or supervised with activities of daily living (ADL) such as washing face, clipping nails, toileting needs, personal hygiene, grooming, shaving, bathing / showering. She said shaving is done or offered to resident at least every other week or as needed. Shower is provided 2x per week. She said R92 is ambulatory with walker, needed limited assistance or supervision with most of his ADLs. She said R92 needed assistance or supervision with personal hygiene or shaving. She said she did not offer to shave R92 and was not told that he wanted to be shaved. On 5/22/24 at 10:52 AM V2 (Director of Nursing / DON) stated all residents should receive ADL care including grooming, toileting, personal hygiene / shaving. Staff are expected to assist or supervise residents with ADL care and should be documented if provided or refused. She said staff is expected to assist resident with shaving for hygienic purposes. MDS dated [DATE] showed cognition is moderately impaired. Needed set up/clean up assistance with eating, oral hygiene; Supervision / touching assistance with toileting and personal hygiene, shower / bathe self and upper and lower body dressing, chair / bed and toilet transfer. Care plan dated 2/22/22 documented in part: R92 has an ADL self-care performance deficit. Care plan interventions included but not limited to Personal hygiene: R92 requires supervision to limited assistance x 1 staff participation with personal hygiene. Facility's policy for activities of daily living dated 2/2023 documented in part: - The ability of each resident to meet the demands of daily living is determed by a licensed nurse. - A program of assistance and instruction in ADL skills is care planned and implemented. - Resident's facial hair should be shaved if necessary and appropriate per personal preference.

Based on observations, interview and record review, facility failed to identify and address an alteration in skin integrity for one resident (R147) out of 35 residents in the sample. This failure resulted in unaddressed skin lesions and resident discomfort. Findings: On 05/21/24 at 12:40 PM R147 was observed to have multiple round lesions on the left arm. Some lesions were open and red. Some lesions were scabbed over. R147 showed surveyor his upper back and legs which had multiple lesions that are scabbed over. R147 stated that the lesions were uncomfortable. On 05/22/24 at 12:05 PM V17 (Wound Nurse) was interviewed and stated that wound care was no longer following R147. V17 stated that R147 had MRSA (Methicillin-resistant Staphylococcus aureus) and an infection on his cheek, but that heeled. V27 stated that nursing was previously putting an ointment on R147's arms. We are not aware of any wounds that he currently has. On 5/22/2024 at 12:10 PM, Surveyor and V17 (Wound Nurse) visited R147. R147 showed arms, upper back and legs with lesions present. Several of the lesions on R147's arm were bleeding. V17 stated I didn't know. I will follow up immediately. On 5/22/2024 at 3 PM, interviewed V13(LPN) who stated that she has texted with V35 (Nurse Practitioner) about R147 and Bacitracin was ordered BID (twice daily) and wound care was to follow up. On 5/23/2024 at 9:20 AM, R147 stated that he had not yet had cream put on his arms. On 5/23/2024 at 9;22 AM, V13 (LPN) was asked if the cream for R147 had arrived. V13 stated that Bacitracin was ordered yesterday, and she was waiting to hear from pharmacy. V13 stated I am not sure how medication is run here. On 5/23/2024 at 10 AM, V34 (Infection Prevention Nurse) was asked about the Bacitracin order for R147. V34 stated that from the time of order to initiation of a drug, it should be same day if the order is early enough. V34 accessed the electronic health record and stated that Bacitracin ointment was ordered on 5/22/2024 at 1330. That should have arrived yesterday. V34 stated I was not made aware that R147 was having issues. On 5/23/2024 at 11:27, V34 (Infection Prevention Nurse) stated that V34 and V17 (Wound Nurse) evaluated R147 and spoke with V44 (Wound Doctor). A treatment order was being initiated. R147 will require a dressing to the left arm and upper back. R147 had been placed on EBP. Pharmacy had been contacted and Bacitracin ointment was to arrive for R147 around 3 or 4 PM on 5/23/2025. On 5/23/2024 at 1:47 PM, R147's room was observed to have a sign for EBP (enhanced barrier precautions) on the door and a PPE (Personal protective equipment) cart outside of the room. Policy titled Skin Care Prevention dated 1/2023 and reviewed 1/2024 stated in part: Responsible Party: All Nursing Staff Guideline: 3. All residents will be evaluated for changes in their skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow care plan to ensure pressure redistribution mattress or low air loss mattress was provided as ordered and complete an assessment or tool used to identify resident at risk for pressure ulcer in a timely manner. These failures affected 1 (R90) resident reviewed for pressure ulcer in a sample of 35. The findings include: R90's health record documented admission date on 1/11/2024 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Type 2 diabetes mellitus without complications, Unspecified severe protein-calorie malnutrition, Nontraumatic intracerebral hemorrhage, Neuromuscular dysfunction of bladder, Hyperlipidemia, Gastro-esophageal reflux disease without esophagitis, Chronic atrial fibrillation, Iron deficiency anemia, Acquired absence of other specified parts of digestive tract, Dysphagia oropharyngeal phase, Essential (primary) hypertension, Gastrostomy status, Encounter for attention to colostomy, Gout, Malignant neoplasm of rectum, Primary generalized (osteo)arthritis, Peripheral vascular disease. On 5/21/24 at 10:19 AM R90 observed lying in bed, alert and oriented, verbally responsive, bed on lowest position with floor pads. With g-tube, no feeding infusing. No air mattress in place. Observed bilateral heel lift boots at bedside. With indwelling urinary catheter. On 5/22/24 At 9:22am V17 (Wound nurse) said she started working in the facility in June 2023. Skin check / assessment done upon admission. Skin preventive measures include cushion for wheelchair, air mattress or pressure reducing mattress, heel boots. Braden assessment is done upon admission, weekly x 4 weeks from admission, quarterly thereafter and as needed. Score of 15 and under in Braden scale are considered at risk for skin breakdown / pressure ulcer, should put skin preventive measures to prevent skin alteration. V17 said if there is an order for air mattress, it should be in place because it is an order. Reviewed R90's EHR (Electronic Health Record) with V17 and said Stage IV pressure ulcer on coccyx was healed on 5/8/24. She said R90 is incontinent of bowel and is at risk for skin breakdown. Stated R90 has active order for air mattress. At 10:52 AM V2 (Director of Nursing / DON) said all physician order should be followed because it is an order, it is there for a reason and resident should have it. If there is an order for air loss mattress then it should be provided. R90's order summary report dated 5/21/24 showed an active order not limited to Low air loss mattress while in bed. Braden scale assessment dated [DATE] showed a score of 9.0 (Very High Risk). Care plan dated 1/15/24 documented in part: R90 has potential/at risk for alteration in skin integrity due to risk factors associated with incontinence, immobility, diabetes, anemia. Care plan interventions included but not limited to: Pressure redistribution mattress. Minimum Data Set (MDS) dated [DATE] showed R90's cognition was severely impaired. She needed total assistance / dependent to staff with oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, chair/bed, and toilet transfer. MDS showed R90 had Stage IV pressure ulcer that was noted at the time of admission/ reentry. Facility's policy for skin care prevention dated 1/2024 documented in part: - All residents will receive appropriate care to decrease the risk of skin breakdown. - For residents who are bed or chair bound, a chair cushion and pressure reducing mattress.

Based on observation, interview and record review the facility failed to provide physician ordered oral nutritional supplements and other nutrition interventions. These failures potentially affected 2 residents (R18, R21) of 7 residents reviewed for nutrition in a total sample of 35. Findings include: On 05/21/24, during initial kitchen tour conducted between 8:57-9:55 AM V11 (Dietary Director) stated Magic Cup (fortified high calorie ice cream) supplements are in stock and are put on resident meal trays when listed on the meal ticket. Observed 8-ounce cartons of whole milk in the refrigerator and case of Magic Cup supplement stored in the facility freezer. On 05/21/24 at 12:20 PM, observed R18 eating lunch in the unit dining room. R18 received ground barbeque chicken, macaroni & cheese, spinach, frosted chocolate cake, and fruit punch on R18's lunch tray. R18's meal ticket read double portions, and Magic Cup with lunch. R18 did not to receive double portions and R18 did not receive a Magic Cup supplement or an equivalent substitution on R18's lunch tray. V7 (4th Floor Unit Manager/Licensed Practical Nurse) view R18's lunch plate and another resident's lunch tray and stated R18's portion looked like the same portion that everyone else got. At 12:33 PM, R18 consumed 100% of entire tray. There was no empty container of Magic Cup or other nutritionally equivalent supplement on R18's finished tray. On 05/22/24 at 12:48 PM, observed R21 eating lunch in the unit dining room. R21 received a hot dog on bun cut into smaller pieces, sweet potatoes, mixed vegetables, cake with frosting, and fruit punch. R21's meal ticket read Magic Cup with lunch. R21 did not receive a Magic Cup or ice cream or other nutritionally equivalent supplement. R21 meal ticket did not list whole milk to be served at lunch. R21 did not receive whole milk. On 05/22/24 at 2:43 PM, R21 said, I love whole milk, not that diet milk. R21 stated R21 only drinks whole milk at breakfast but R21 would love to get it spread throughout the day and would like to get it at lunch and dinner. R21 said, it would be good to help me gain weight. On 05/23/24 at 9:52 AM, V46 (Diet Technician) reviewed R21's meal ticket and stated based on the meal ticket R21 should be receiving super cereal (fortified hot cereal) at breakfast, whole milk at breakfast and dinner, and a Magic Cup w/lunch and dinner. V46 stated typically, milk is only served with breakfast and dinner unless ordered or requested by the resident. V46 stated whole milk can be used when it is the resident's preference or as a dietary intervention for weight gain. V46 stated Magic Cup is a fortified ice cream supplement and is also use as a dietary intervention for weight gain or for residents with poor appetite. V46 stated it is the kitchen's responsibility to put these items on the tray during tray line service and there is no storage area on the units so these items can only be provided by the kitchen. V46 stated the potential problem if a resident is not receiving a supplement or dietary intervention it could interfere with what the dietary intervention is trying to resolve for example weight loss, weight gain, wound healing. On 05/23/24 at 10:04 AM, V46 reviewed R18's meal ticket R18 and stated R18 should be receiving double portions with all R18's meals and a Magic Cup at lunch and dinner. V46 stated V46 does not know why these interventions are ordered for R18 but they are listed on the meal ticket so they should be provided to R18. On 05/23/24 at 11:30 AM, during phone interview V45 (Registered Dietitian) stated supplements like Magic Cups are put on the resident meal trays and are used to have residents gain weight, or to give residents extra calories and protein if they are assessed that they need more. V45 stated use of double portions as an intervention to add additional calories to a resident's meal plan can also be used. On 05/23/24 at 11:37 AM, V45 stated per R18's electronic health care record (EHR) R18's diet order is ordered as a mechanical soft, no added salt thin liquids with double portions with all meals and supplements include Magic Cup with lunch and dinner. V45 stated R18's weight was going down at one point, and R18's weights fluctuate but has been stable for one year. V45 stated R18 is on supplements due to history of weight loss. R18's Body Mass Index (BMI) is 23.6. which is within range for BMI for geriatrics (23-30). V45 stated V45 recommends continuing with these nutrition interventions because they are helping to support R18's weight maintenance. V45 stated R18 should have received the Magic Cup if in stock and double portions as ordered. V45 stated double portions means that all the items on the main plate (protein, starch, vegetable) are doubled. On 05/23/24 at 11:47 AM, V45 stated per R21's EHR R21's diet order is mechanical soft, with thin liquids and supplements include Magic Cup with lunch and dinner, Super cereal w/breakfast, and whole milk w/meals. V45 stated R21's BMI is 15.1 which is below desired BMI range for geriatrics (23-30). V45 stated R21's current weight is 77 pounds and this time last year R18 weighed 90 pounds (5/2023). V45 stated R21 has gained weight since (2/2024). V45 stated the goal is for R18 to continue to gain weight and the supplements are in place to promote this weight gain. V45 stated the Magic Cup with lunch should have been provided and the whole milk should be printed on R21's lunch ticket so the staff knows to put it on R21's tray. V45 stated the whole milk could be part of R21's plan for weight gain. V45 stated the potential problem if R21 is not getting the supplements or whole milk is that R21 would maintain R21's weight instead of gaining weight, and place R21 at risk for weight loss if R21's appetite/intake changes because then R21 would potentially not be getting the right nutrition. R18's diagnosis includes but not limited to Alzheimer's Disease, Age-Related Nuclear Cataract Right Eye, Combined Forms of Age-Related Cataract Left Eye, Heart Failure, Unspecified Dementia, Unspecified Osteoarthritis, Hypertension, Hyperlipidemia. R18's Order Summary Report dated 05/21/24 documents in part double portions with all meals and Magic Cup with lunch meal and Magic Cup with dinner meal. R18's MDS (Minimum Data Set) from 04/01/24 BIMS (Brief Interview for Mental Status) was 10 out of 15 indicating moderately impaired cognitive function. R18's nutrition care plan documents in part, R18 at risk for malnutrition and receives double portions all meals and hi (high) calorie frozen dessert afternoon and appropriate to prevent weight loss, malnutrition and per chewing difficulty. R18's printed meal ticket documents in part, Magic Cup at lunch and dinner, double portions at breakfast, lunch and dinner. R21's diagnosis includes but not limited to Spondylosis without Myelopathy or Radiculopathy, Cervical Region, Unspecified Severe Protein Calorie Malnutrition, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Unspecified Cirrhosis Of Liver, Dysphasia, Primary Osteoarthritis Right Wrist, Chronic Viral Hepatitis C, Anemia, Hypomagnesemia, Hypokalemia, Unspecified Dementia, Anxiety Disorder, Encephalopathy, Hypertension, Age-Related Cognitive Decline, Abnormal Weight Loss, Limited Of Activities due to Disability, Reduced Mobility Personal History of Urinary Tract Infections, History of Falling. R21's Order Summary Report dated 05/24/24 documents in part whole milk with all meals, Magic Cup or ice cream with lunch meal, and Magic Cup or ice cream with dinner meal. R21's MDS (Minimum Data Set) from 04/01/23 indicates BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. R21's nutrition care plan dated 02/2024 documents in part, resident had experienced unplanned weight loss and offer whole milk with meals frozen dessert BID (twice per day). R21's printed meal ticket documents in part, Magic Cup with lunch and dinner, whole milk with breakfast and dinner. Whole milk is not listed on lunch meal ticket. Facility provided kitchen policy titled, Supplements undated which documents in part: 1.) Supplements will be passed out as ordered in EMR (Electronic Medical Record) and per physician/RD (Registered Dietitian) recommendations to provide additional calorie/protein. 2.) Supplements are ordered by physician or RD and may include dietary additives such as: fortified foods, might shakes, med pass, magic cup and Ensure/Boost/Glucerna. 3.) Supplements will be provided at mealtimes on trays or nursing staff will pass depending on the supplement ordered. 4.) If a particular supplement is not available, an alternative may be substituted out that is of equivalent or increased nutritional value. Facility provided kitchen policy titled Double and Large Portions dated 09/01/21 which documents in part, increased portions are available for residents requiring extra calories or requesting extra food and double portions are served as double serving of food on the plate. Salad, dessert and beverage are served as standard portions.

Based on observation, interview, and record review the facility failed to provide total volume of prescribed gastrostomy tube feeding as prescribed by physician. These failures could potentially affect 2 (R59, R67) of 2 residents reviewed for nutrition and tube feeding in a sample of 35. Findings include: On 05/22/24 at 09:02 AM, surveyor observed R59's tube feeding hung at bedside and infusing at 65 ml per hour via pump. The tube feeding formula hanging was a 1-Liter (L) bottle of Jevity 1.5 and on the bottle was a label. The label was dated 05/21/24 at 2:00 PM, rate 65 ml per hour. On 05/22/24 at 9:03 AM, surveyor observed R67's tube feeding hung at bedside and infusing at 75 ml per hour via pump. The tube feeding formula hanging was a 1L bottle of Jevity 1.5 and the bottle was labeled with the date 05/21/24 at 2:00 PM, rate 75 ml per hour. On 05/22/24 at 9:12 AM, V20 (Licensed Practical Nurse) stated R59 and R67's tube feedings are turned off from 10 AM to 2 PM daily. V20 stated these tube feeding bottles were hung yesterday at 2 PM and that when nurses hang the tube feeding they label the bottle with the date and time started. On 05/22/24 at 10:04 AM, heard R67's tube feeding pump beeping. V7 (4th Floor Unit Manager/Licensed Practical Nurse) stated R67's tube feeding pump is beeping because the bottle is empty. V7 looked at the label on R67's 1L bottle of Jevity 1.5 and stated this bottle was hung yesterday at 2 PM. V7 stated at 2 PM the nurse on duty will hand a new bottle and tubing. On 05/22/24 at 10:30 AM, V20 looked at the label on R59's 1L bottle of Jevity 1.5 and stated this bottle was hung yesterday at 2 PM. V20 stated the nurses need to label and date the time the tube feeding was started when a new bottle is hung. Observed unmeasurable amount of formula still left in the 1L bottle of Jevity 1.5. Observed on outside of pump to indicate 1032 ml infused. V20 estimated volume of formula left in the 1L bottle to be approximately 250 ml. V20 stated V20 was going to throw this left over formula in the bottle out and would hang a new bottle at 2 PM. On 05/22/23, V2 (Director of Nursing) stated the nurse should be following the tube feed order as prescribed by the physician in the resident's electronic health record and document the volume infused in the MAR. V2 stated if there is still tube feeding formula left in the bottle at the time the order says to turn off the tube feeding then V2 would expect the nurse on duty to call the doctor and get further orders on how to proceed. On 05/23/24 at 11:09 AM, via phone interview V45 (Registered Dietitian) stated residents on tube feedings are at higher nutritional risk because they are getting all their nutrition needs through artificial feedings. V45 stated V45 calculates calorie, protein and fluid needs and then use these estimated needs as a ballpark to determine how much tube feeding formula the residents should have to meet those needs. V45 stated V45 expects a resident receiving tube feedings to receive the total volume of the tube feeding formula ordered so the resident is getting the right amount of tube feedings formula to meet their nutritional needs. V45 stated R59 is NPO (receives nothing by mouth) and is 100% dependent on tube feedings for nutrition and hydration needs. V45 stated R59's current tube feed order is Jevity 1.5 @ 65ml per hour times 20 hours to provide total volume 1300 ml per day on 2 PM, off at 10 AM. V45 stated if R59 has not reached the total volume of 1300 ml by 10 AM then V45 would expect for nursing to leave the tube feeding running until the total volume of 1300 ml is infused. V45 stated this is important because otherwise R59 won't be getting all the calories, and protein needed. V45 stated if nursing is using a 1 liter bottle of Jevity 1.5 hung at 2 PM run at 65 ml per hour continuously there is no way R59 could receive 1300 ml of formula by 10 AM the following day, unless the nurses gave 300 ml via bolus which they would need a physician order to do or if a 2nd 1 liter formula bottle was hung which would have been labeled and dated with that hang time and in which case there would be a lot of extra formula still left in the tube feeding container. V45 stated of there was still tube feeding formula left in R59's same 1 liter bottle hung the day before at 2 PM than it does not sound like R59 received the 1300 ml he (R59) was supposed to, R59 got less. V45 stated R59 is at high nutrition risk and R59's BMI is 16.9 which means R59 is underweight. V45 stated the goal is for R59 to gain weight and there is a potential for R59 not to gain weight if R59 is not getting the total volume of tube feeding as ordered. V45 stated R67 is on a mechanical soft, thin liquids but R67 is refusing meals more than eating them. V45 stated based on staffing documentation of meal intake in R67's EHR it looks like R67 is consuming approximately one meal per day if that. V45 stated R67 is receiving tube feedings because he has a low weight and a history of weight loss but R67's weight has stabilized. V45 stated R67's current BMI is 19.2 which is within desired range for age but given that R67 has a diagnosis of malnutrition V45 wants him to be at a BMI of 21. V45 stated V45 would keep R67's tube feeding the same to promote weight gain. V45 stated R67's tube feeding order is to receive Jevity 1.5 @ 75 ml/hr times 20 hours until total volume of 1500 ml per day is infused, tube feeding on 2PM, off 10AM. V45 stated R67 should have received the full 1500 ml of Jevity 1.5 to make sure R67 is getting the calories calculated for him because we want him to gain weight. V45 stated if V45 is only getting 1 liter of Jevity 1.5 per day then that might be enough calories to maintain R67's weight but not enough for R67 to gain weight. V45 stated, I want him to get 1500 milliliters. R59 has diagnosis which includes but not limited to: Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Right Middle Cerebral Artery, Hemiplegia, Unspecified Affecting Left Dominant Side, Dysphasia Oropharyngeal Phase, Chronic Obstructive Pulmonary Disease, Weakness, Lack Of Coordination, Need Assistance With Personal Care, Underweight, Moderate Protein Calorie Malnutrition, Anxiety, Diverticulosis Of Large Intestine, Adult Failure To Thrive, Encounter For Attention To Gastrostomy, Malignant Neoplasm of Colon, Unspecified Dementia, Gastritis, Major Depressive Disorder. R59's Order Summary Report dated 05/22/24 documents in part NPO diet start date 06/23/23 and enteral feeding order Jevity 1.5 @ 65 milliliters per hour times 20 hours total of 1300 milliliters per day up @ 2PM, off at 10 AM start date 02/14/24. R59's Medication Administration Record (MAR) dated 05/01/24-05/22/24 document in part, enteral feeding order Jevity 1.5 @ 65 milliliters per hour times 20 hours total of 1300 milliliters per day up @ 2PM, off at 10 AM. R59's MAR includes the following information: 1.) Entry dated 05/08/24 documents day shift ml 65 ml, evening shift ml 585 ml, night shift ml 520 ml. Total tube feed volume administered calculated to be 1170 ml. 2.) Entry dated 05/16/24 documents day shift ml 260 ml, evening shift ml 65 ml, night shift ml 520 ml. Total tube feeding volume administered calculated to be 845 ml. 3.) Entry dated 05/17/24 documents day shift ml 260 ml, evening shift ml 65 ml, night shift ml 560 ml. Total tube feeding volume administered calculated to be 885 ml. 4.) Entry dated 05/19/24 documents day shift ml 65 ml, evening shift ml 520 ml, night shift ml 560 ml. Total tube feeding volume administered calculated to be 1145 ml. 5.) Entry dated 05/20/24 documents day shift ml 260 ml, evening shift 65 ml, night shift ml 520 ml. Total tube feeding volume administered calculated to be 845 ml. R59's nutrition care plan documents in part, R59 requires tube feeding related to dysphagia, TF (tube feeding) Jevity 1.5 @ 65 ml per hour times 20 hours total of 1300 ml per day, and interventions include resident will receive tube feeding and water flushes per physician orders. R59's MDS (Minimum Data Set) dated 05/01/24 BIMS (Brief Interview for Mental Status) scores 6 out of 15 indicating severe cognitive impairment. R59's progress note entry titled Monthly Enteral Note documents in part R59 diet NPO, and RD recommendation to continue with Jevity 1.5 @ 65 ml/hr times 20 hours total of 1300 ml per day, no new interventions. R67 has diagnosis which includes but not limited to: Cerebral Infarction, Hemiplegia and Hemiparesis Following Non-Traumatic Intracerebral Hemorrhage Affecting Right Dominant Side, Unspecified Protein-Calorie Malnutrition, Dysphasia, Aphasia, Encounter For Attention To Gastrostomy, Major Depressive Disorder, Adult Failure To Thrive, Thyrotoxicosis (Hyperthyroidism), Major Depressive Disorder, Generalized Anxiety Disorder, Muscle Weakness, Anemia, Seizures, Unspecified Kidney Failure, Syncope And Collapse. R67's Order Summary Report dated 05/22/24 documents in part general diet mechanical soft texture, thin consistency start date 10/20/23 and enteral feeding order Jevity 1.5 @ 75 milliliters per hour times 20 hours total of 1500 milliliters per day up @ 2PM, off at 10 AM start date 02/14/24. R67's Medication Administration Record (MAR) dated 05/01/24-05/22/24 document in part, enteral feeding order Jevity 1.5 @ 75 milliliters per hour times 20 hours total of 1500 milliliters per day up @ 2PM, off at 10 AM. R59's MAR includes the following information: 1.) Entry dated 05/08/24 documents day shift ml 75 ml, evening shift ml 675 ml, night shift ml 600 ml. Total tube feed volume administered calculated to be 1350 ml. 2.) Entry dated 05/16/24 documents day shift ml 300 ml, evening shift ml 70 ml, night shift ml 600 ml. Total tube feeding volume administered calculated to be 970 ml. 3.) Entry dated 05/17/24 documents day shift ml 300 ml, evening shift ml 75 ml, night shift ml 640 ml. Total tube feeding volume administered calculated to be 1015 ml. 4.) Entry dated 05/19/24 documents day shift ml 75 ml, evening shift ml 600 ml, night shift ml 560 ml. Total tube feeding volume administered calculated to be 1235 ml. 5.) Entry dated 05/20/24 documents day shift ml 300 ml, evening shift 75 ml, night shift ml 600 ml. Total tube feeding volume administered calculated to be 975 ml. R67's nutrition care plan documents in part, R67 requires tube feeding, regular pleasure feeding and TF - Jevity 1.5 @ 75 ml per hour times 20 hours total of 1500 ml per day, and interventions include administer tube feeding and water flushes per physician orders. R67's MDS (Minimum Data Set) dated 04/01/24 BIMS (Brief Interview for Mental Status) not conducted, documents in part, resident is rarely/never understood. R67's progress note entry titled Monthly Renal Note dated 03/05/24 documents in part R67 history of significant weight flux and RD recommendation to continue with Jevity 1.5 @ 75 ml/hr times 20 hours total of 1500 ml per day to provide a total of 2250 kcal (kilocalories), 96 grams of protein. R67's Intervention/Task for Amount Eaten dated from 05/01/24 to 05/22/24 document in part NA (Not Applicable) or refusing meal except for the following meal on 05/08/24, 05/10/24, 05/12/24, 05/15/24, 05/16/24, 05/17/24, 05/20/24, 05/21/24. Facility policy titled, Tube Feeding dated 1/2024 documents in part, nasogastric, gastrostomy and jejunostomy tubes are used when an alternate method of nutrition is needed, continuous tube feedings are based upon a 22 hour consumption period or other time frame based on individual resident need per Registered Dietician assessment and delivered over 24 hour period, tube feeding intake is documented on the MAR (Medication Administration Record), the tube feeding will be labeled with the date and time hung as well as the initials of the person hanging the feeding, document tube feeding delivered, and alert healthcare provider of any issues or concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow residents' care plans to ensure physician orders were followed and administer the correct oxygen flow rate for 2 (R39, R148) out of 2 residents reviewed for respiratory care in the final sample of 35. Findings Include: 1) On 5/21/24 at 10:56 AM, R39 was lying in bed alert and able to verbalize needs. R39 was noted using oxygen (O2) via nasal cannula with the flow rate set to 1.5 liters per minute (LPM). When asked R39 if R39 changes the dial on R39's oxygen, R39 answered, The nurse sets that up. I don't touch it. R39 stated that R39 uses oxygen for R39's diagnoses of Asthma and Chronic Obstructive Pulmonary Disease (COPD). On 5/22/24 at 9:53 AM, R39 was resting in bed alert and awake. R39's was using oxygen via nasal cannula with the flow rate set to 1 LPM. R39 denied changing the flow rate. 2) On 5/21/24 at 11:00 AM, R148 resting in bed alert and able to verbalize needs. R148 stated R148 has been in the facility for almost two months. R148 was receiving oxygen via nasal cannula with the flow rate set to 1.5 LPM. R148 stated that the nurses set up how much oxygen R148 is supposed to get. R148 stated R148 has diagnosis of COPD. On 5/22/24 at 09:57 AM, interviewed V18 (Unit Manager/Licensed Practical Nurse) and stated that oxygen is administered to the residents based on the doctor's orders and the Nurses setup the flow rate. Surveyor and V18 checked R39 and R148's physician orders in their electronic health records. R39 has an order for 2-3 liters of oxygen every shift and R148 has an order for 2-4 liters continuous oxygen. On 5/22/24 AM at 10:20 AM, interviewed V2 (Director of Nursing) and stated that there should be a physician's order for how much oxygen the resident is supposed to receive. It's the nurses' responsibility to do rounds to make sure the resident is getting the correct order of the oxygen. If not, they must inform the doctor, educate the resident, and care plan it. V2 stated that the nurses monitor the residents' oxygen, and the Certified Nursing Assistants (CNAs) should be able to look at it and inform the nurse if there is something wrong. V2 stated that the physician's orders should be followed and if the resident can control their own oxygen setting, then there should be an assessment and an order for self-administration. V2 stated that if the resident does not get the correct oxygen setting per physician's order, the resident could potentially de-saturate. R39's electronic health records (EHR) show R9 has diagnoses not limited to Chronic Respiratory Failure with Hypoxia, Asthma, Obstructive Sleep Apnea, Pulmonary Hypertension, and Acute on Chronic Systolic Congestive Heart Failure (CHF). R39's Minimum Data Set (MDS) dated [DATE] shows R39 is cognitively intact. R39's physician orders show an order for: Oxygen (02) @ 2-3 Liters/Minute per nasal cannula, Maintain 02 Saturation @ 92% or greater ordered on 1/13/2023. R39's EHR does not have an order and no assessment for self-administration. R39's care plan with date initiated 1/13/23 documents R39 has oxygen therapy prescribed related to CHF, asthma, history of respiratory failure with one intervention that reads, Administer oxygen per physician orders: see orders. R148's EHR shows R148 has diagnoses not limited to Unspecified Systolic (Congestive) Heart Failure, COPD, Asthma, and Dyspnea. R148's MDS date 4/12/24 shows R148 is cognitively intact. R148's physician orders show an order for: Continuous Oxygen @ 2-4L every shift ordered on 4/3/24. R148's EHR does not have an order and no assessment for self-administration. R148's care plan with date initiated 4/16/24 documents R148 has oxygen therapy prescribed for CHF, COPD, Asthma, and Pneumonia with one intervention that reads in part: Administer oxygen per physician orders. The facility's policy titled; OXYGEN THERAPY dated 1/2024 reads in part: 1. Residents who require oxygen therapy will have a physician order in their medical record which includes amount of O2 to be administered, route of administration, and indication of use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility [A] failed to ensure the physician documented in one [R125] resident's clinical record their assessment, current condition, and medical problems for each visit, [B] failed to ensure the physician sign and date psychotropic narcotic medication. These failures resulted in R125 not receiving a prescribed psychotropic medication for nine days. Findings Include: R125's clinical indicates in part, he is a twenty-eight-year-old admitted on [DATE], with the medical diagnosis of attention-deficit hyperactivity disorder, depression, paraplegia, neuromuscular dysfunction of bladder, essential (primary) hypertension. R125's physician order dated 5/15/24- Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. R125's Progress Notes: Documented in part. Dated 4/28/24- Nursing Note-R125 refused car and weights, he became verbally aggressive, nurse practitioner gave order for psych consult. R125's Progress Notes: Documented in part. 5/14/24- nurse note: R125 request to psychiatrist. 5/15/24- nurse note: [V2 Director of Nursing] Psychiatrist assessed R125 and prescribed new order Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. Carried out orders. Next visit with psychiatrist in one week. 5/15/24 thru 5/23/24- No documentation from V47 [Psychiatrist]. R125's Medication Administration Sheet: 5/15/24- Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. [Medication was not administered 5/15/24 thru 5/23/24. On 5/21/24 at 11:37 AM, R125 stated, I was admitted here on 4/27/24. I requested to see a psychiatrist, but I was not seen until 5/15/24. The psychiatrist [V47] on 5/15/23, reorders my medication, Dextroamphetamine Sulfate that I been taking since I was sixteen years old. On 5/16/24, I did not receive my mediation. I been asking different nurses, why I have not received the Dextroamphetamine Sulfate. Some nurses told me they will call pharmacy, other nurses said they was going to call V47. I don't think the nurses called V47. Not having my medication has made me feel terrible, feeling sad, depressed, tired, disorganized, and not wanting to move around to allow ADL care. I just been staying in my room, not wanting to be bothered. On 5/22/24 at 1:35 PM, (Face to Face Interview) V47 [Psychiatrist] stated, I assessed R125 for the first time on 5/15/24. R125 expressed he needed the medication Dextroamphetamine Sulfate Oral Tablet 5 MG, that he has taken since a teenager. After my assessment it was determined that R125 did in fact need the medication to treat attention-deficit hyperactivity disorder [ADHD]. I completed a form with V2 [Director of Nursing] and she was to fax the form to pharmacy. The sign form to pharmacy will allow any of my orders for narcotics to be filled and delivered, and my signature will remain of file with the pharmacy. I did not receive any notification from nursing staff that R125 did not receive his medication. I was not made aware the pharmacy did not receive the completed form. I did not give an order to place the medication on hold. Not receiving Dextroamphetamine Sulfate, could cause the resident to feel sad, a down mood, tired, and poor concentration. I will go up to R125's room and assess his mood and behavior. I will complete the required forms and submit them to pharmacy, R125 will have his medication today. I did complete R125's psychological assessment. I did not have time to document my encounter. I will complete our encounter today for 5/15/24. On 5/22/24 at 3:10 PM, V2 [Director of Nursing] stated, I placed in the order for R125's medication Dextroamphetamine Sulfate Oral Tablet 5 MG. I received the order from V47 on 5/15/24. V47 was supposed to complete a prescription and fax it to the pharmacy. I did place in the progress note in R125's clinical record. I thought V47 completed the prescription and faxed the order over to pharmacy. I was not made aware that R125 did not receive his medication from pharmacy. The procedure for any narcotic order, a prescription must be completed and faxed to pharmacy. If the medication was not delivered, the nursing staff should first call pharmacy to find out the reason why the resident's medication was not delivered. Then call the physician for any need prescriptions or forms. If a resident does not receive Dextroamphetamine Sulfate, the behaviors potentially can continue or worsen. V47 should document his assessments and encounter with the resident. On 5/23/24 at 12:35PM, R125 stated, I did not receive my Dextroamphetamine Sulfate Oral Tablet 5 MG, today. I did not see V47 yesterday. The first and last time I saw him was on 5/15/24. My nurse V8 [Licensed Practical Nurse] told me the prescription was faxed yesterday (5/22/24). On 5/23/24 at 12:57 PM V8 stated, V47 told me yesterday that he faxed R125's medication to the pharmacy. On 5/23/24 at 1:00 PM, V17[Wound Care Nurse] stated, I will call the pharmacy to find out if the prescription was faxed. V17 phoned the pharmacy on speaker in the presents of V8 and surveyor. The pharmacist said there was no prescription on file. V17 was transferred to the data entry department, it was verified there was no fax, e-script, sent to the pharmacy for R125. V8 stated, I will call V47 for a script. On 5/23/24 at 3:00 PM, R125's clinical record did indicate or note any documentation from V47 assessment encounter for 5/15/24. Policy documented in part: Controlled Substance Orders (No Date) -A controlled substance medication will be dispensed by the pharmacy if all state and federal requirements are met. -A controlled substance prescription will only be accepted and dispensed if the pharmacy receives a valid prescription. -A valid controlled substance prescription can be received by the pharmacy by the following ways. Electronically, fax, or phone call. -Once the valid prescription is received from the physician the medication will be delivered in the next delivery. Facility Assessment Tool dated 11/2023 -Medical record- Tracking of physician visits -Mental Health- Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior. -Identify and implement interventions to help support individuals with issues such as dealing with anxiety, depression, and other psychiatric diagnosis. -Medications, awareness of any limitations of administering medications to assess and management -Facility resources need to provide competent support and care for our resident population every day including medical physician services, and behavior and mental health providers

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy to (a) obtain an informed consent for psychotropic medication use; (b) ensure PRN (as needed) psychotropic medication will have a duration of no longer than 14days; (c) attempt Gradual Dose Reduction (GDR) for psychotropic medication use; (d) complete AIMS (Abnormal Involuntary Movement Scale) test in a timely manner. These failures could potentially affect 3 (R3, R130, R132) residents reviewed for Unnecessary Psychotic medication use in a sample of 35. The findings include: R132's health record documented admission date on 2/20/2024with diagnoses not limited to Malignant neoplasm of supraglottis, Moderate protein-calorie malnutrition, Cerebral infarction, Chronic respiratory failure, Unspecified protein-calorie malnutrition, Unspecified asthma, Tracheostomy status, Periorbital cellulitis, Hypothyroidism, Auditory hallucinations, Major depressive disorder, Somnolence, Hypoxemia, Covid-19, Lymphedema, Opioid dependence, Essential (primary) hypertension, Anemia, Schizoaffective disorder, Nicotine dependence cigarettes, Thrombocytosis, Dysphonia, Opioid abuse with withdrawal, Dysphagia, Anogenital herpesviral infection. On 5/22/24 at11:24 AM R132's order summary report dated 5/21/24 with active order not limited to: FLUoxetine HCl Oral Tablet 20 MG Give 1 capsule by mouth in the morning for MDD (Major Depressive Disorder). QUEtiapine Fumarate Oral Tablet 25 MG Give 12.5 mg by mouth two times a day for schizoaffective disorder. No AIMS (Abnormal Involuntary Movement Scale) assessment and no GDR evaluation or documentation found in R132's EHR (Electronic Health Record). Consultant pharmacist's medication regimen review dated 5/23/24 documented in part: Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. AIMS TEST APPEARS TO BE DUE. Recommend movement test, such as AIMS, be performed initially (within 30 days), and then at least every 6 months while R132 continues on antipsychotic therapy. Care plan dated 3/4/24 documented in part: R132 has the psychotropic medication. Care plan included interventions not limited to MD to consider dosage reduction when clinically appropriate. Monitor/record/report to MD side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking). MDS dated [DATE] showed R132's cognition was intact. She needed supervision / touching assistance with oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, chair/bed and toilet transfer. MDS indicated antipsychotic medication use. On 5/23/23 around 2:20 PM V2 (Director of Nursing / DON) said no GDR documentation for psychotropic medication use found in R132's health record. V2 provided AIMS assessment with signed date on 5/23/24. Facility's policy for psychotropic medication program dated 1/2024 documented in part: The purpose is to promote the safe and effective use of psychotropic medications. To ensure the lowest dose of medication is used, for the shortest time frame. To guarantee a resident's quality of life is enhanced by the medication usage. The resident and or resident representative are aware of the potential side effects and the facility obtains an informed consent for the use of the psychotropic medication. Once a resident is placed on a psychotropic medication the facility monitors the resident for side effects and adverse reactions, addresses the use of the medications in the comprehensive plan of care, and assess the resident for a GDR. PRN psychotropic medications will have a duration of no longer than 14 days unless there are documented behaviors and rationale provided and documented by the Psychiatrist /APN/Primary physician. PRN Antipsychotic medications MAY NOT be extended for a duration of longer than 14 days. These medications must be re-evaluated every 14 days if it is determined the resident requires them on a PRN basis. A baseline AIMS test will be done by the psychotropic nurse or designee prior to starting any new antipsychotic medication and at least every 6 months thereafter. R3's electronic health record (EHR) documented admission date 05/04/21 with diagnosis includes but not limited to Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation. R3's Order Summary Report dated 05/23/24 documents in part, Mirtazapine 15 mg give 1 tablet by mouth every evening shift related to Major Depressive Disorder with start date of 07/10/21 and Olanzapine 5 mg by mouth at bedtime for bipolar disorder with restart date 05/19/24. R3's Consent for Psychotropic Medication provided by V2 (Director of Nursing) for Mirtazapine Tablet 15 mg by mouth every evening shift and Olanzapine Tablet 5 mg by mouth every evening shift dated 10/31/22. Review of R3's EHR on 05/22/24 did not find any recent Consent for Psychotropic Medication forms. On 05/22/24, reviewed in R3's EHR Consultant Pharmacist's Medication Record Regimen Review dated 05/06/24, 04/02/24, 03/05/24, 02/02/24 with no recommendations. On 05/23/24, V2 provided copy of R3's Consultant Pharmacist's Medication Record Regimen Review dated 05/23/24 which documents in part, antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. AIMS TEST APPEARS TO BE DUE. Recommend movement test, such as AIMS or DISCUS, be performed initially (within 30 days), and then at least every six months while this resident continues on antipsychotic therapy. On 05/23/24, V2 provided copy of R3's Psych: AIMS Assessment completed 05/23/24. R3's care plan initiated 05/17/21 documents in part, R3 has psychotropic medication prescribed for bipolar with goal that resident will be/remain free of drug related complications, including movement disorder, gait disturbance, or cognitive/behavioral impairment and consult with pharmacy, MD to consider dosage reduction when clinically appropriate. R130's EHR documented admission date 12/19/23 with diagnosis includes but not limited to Major Depressive Disorder Recurrent, Unspecified Dementia, Anxiety Disorder, Violent Behavior, Suicidal Ideations, Fibromyalgia, Chronic Obstructive Pulmonary Disease. R130's Order Summary Report dated 05/23/24 documents in part, Donepezil 5 mg HS for dementia start date 12/20/23, Haloperidol Lactate Injection 2 mg intramuscular every 6 hours as needed for aggression/agitation start date 12/19/23, Haloperidol Lactate Injection 2 mg by mouth every six hours as needed start date 12/19/23, Lorazepam 1 mg by mouth every 6 hours as needed for aggression/agitation start date 12/19/23, Lorazepam inject 1 mg intramuscularly every 6 hours as needed for agitation start date 12/19/23, Mirtazapine 15 mg by mouth at bedtime for major depression start date 12/20/23, Zolpidem Tartrate 10 mg by mouth every 24 hours as needed for insomnia start date 12/20/23. On 05/22/24, reviewed in R130's EHR Consultant Pharmacist's Medication Record Regimen Review dated 05/08/24, 04/03/24, 03/05/24, 02/06/24 with no recommendations. On 05/23/24, V2 provided copy of R130's Consultant Pharmacist's Medication Record Regimen Review dated 05/23/24 which documents in part, antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. AIMS TEST APPEARS TO BE DUE. Recommend movement test, such as AIMS or DISCUS, be performed initially (within 30 days), and then at least every six months while this resident continues on antipsychotic therapy. On 05/23/24, V2 provided copy of R130's Consultant Pharmacist's Medication Record Regimen Review dated 05/23/24 which documents in part please consider the following psychotropic PRN medications Haloperidol 2 milligram injection solution Quetiapine 25 milligram tablet, Lorazepam 1 milligram tablet, Haloperidol oral concentrate 2 milligrams per milliliter, Zolpidem 10 milligram tablet and REMINDER: PRN Psychotropic Orders are only valid for 14 days UNLESS OTHERWISE STATED ON MEDICATION ORDER. R3's Consent for Psychotropic Medications for Lorazepam Oral Tablet 1 mg, Haloperidol Lactate Oral Concentrate 2 mg/dL, Zolpidem Tartrate Tablet 10 mg, Zoloft Oral Tablet 50 mg, dated 05/20/24 and Consent for Psychotropic Medications for Haloperidol Lactate Injection Solution, Donepezil HCl Oral Tablet 5 mg, Lorazepam Oral Tablet 1 mg, Mirtazapine Oral Tablet 15 mg dated 05/20/24. R130's Psychiatry Progress Note dated 12/20/23 documents change in drug therapy is contraindicated at this time - past reduction attempts have resulted in psychiatric instability. No recent GDR (Gradual Dose Reduction) documentation found for R130 for antipsychotic medication use. On 05/23/24 at 12:51 PM, V2 (Director of Nursing) stated she is the DON and the Psychotropic Nurse. V2 stated before starting any psychotropic medication or when changes are made in the dosage of a psychotropic medication a consent is needed which is entered onto a form electronically and kept in the resident's EHR. Psychotropic medications include medications for depression, anxiety, antipsychotics, sedatives. V2 stated an AIMS test should be done upon admission and then quarterly/annual and as needed and the purpose of the AIMS test is to see if the resident is having any involuntary movements. V2 stated the risk of the psychotropic medications is that they can sometimes cause damage to the body and the risk may not be worth taking. V2 stated sometimes the medication needs to be lowered, altered, or changed. A GDR should be done on the recommendation of the physician or pharmacist. V2 stated the goal is for the residents not to be on any psychotropic medications but some psychotropic medications cannot be stopped but a trial/taper can be done if the doctor orders it. V2 stated as needed or PRN medications are reviewed at 14 days. If they still need to be on them then the doctor needs to address the behavior if it is still happening. V2 stated the psychiatrist completes their documentation electronically and it can be found if available under the miscellaneous section of the EHR. V2 stated, we are trying to get another doctor and you've seen the charts. We are a work in progress. We are trying.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident is free of significant medication errosr to 1 (R134) of 8 residents reviewed for medication administration resulting in administering 4 units of Humalog Insulin one hour before meal instead of with meal. This deficient practice has the potential to place R134 in Hypoglycemia distress. Findings Include: R134's electronic Medication Administration Record (eMAR) as at 5/2024 documents in part: Humalog Solution 100 Unit/ML. Inject as per sliding scale (251-300 = 4 units) subcutaneously with meals. R134's Minimum Data Set (MDS) dated [DATE] shows R134 is cognitively intact. On 5/21/24 at 11:43 AM, surveyor observed V39 (Licensed Practical Nurse/LPN) administering 4 Units of Humalog Insulin subcutaneously at Left Lower Quadrant (LLQ) to R134 before meal was served on the unit. When surveyor asked V39 what V39 should have done before administering the insulin. V39 stated V39 should have waited for the lunch tray to be served to R134. V39 stated V39 administering the 4 units of Humalog Insulin to R134 could lower the blood sugar of R134 and could cause R134 Hypoglycemia distress because it is a fast-acting insulin. On 5/21/24 at 12:45 PM, surveyor observed meal tray arriving on the second floor. On 5/21/24 at 12:55 PM, R134 eating lunch in the dining room. R134 stated R134 does not usually receive R134's insulin with meal even when R134 supposed to. On 5/22/24 at 10:50 AM, V2 (Director of Nursing) stated it is V2's expectation that the nurse will administer Humalog Insulin with meal. Administering Humalog Insulin without a meal is a medication error that can cause R134 to go into hypoglycemia, comatose or death. Documents reviewed but are not limited to: R134 Physician Order Sheet (POS) active order as of 5/22/24 documents in part: Humalog Solution 100 unit/ml, inject as per sliding scale, subcutaneously with meals for Diabetes Mellitus. Facility Meal Serving Time, documents in part: 2nd Floor Lunch at 12:30 PM Facility Medication Administration In-Service, Education and Staff Development, documents in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve, and prevent symptoms. Follow special instructions written on the label. Facility Insulin Injection Administration, documents in part: Follow Medication Administration Record/Doctor orders, if order state with meals the medication must be given with meals.

Based on observation, interview, and record review the facility failed to a.) ensure medications were labeled when opened, b.) ensure expired medications were removed from the medication cart/medication room and c.) ensure medications for discharged residents were removed from the medication cart in 2 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. Findings Include: On 05/12/24 at 10:28 AM the fourth-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). Expired medications were observed in the top drawer of the medication cart including; Enteric Coated Aspirin 325 MG expiration date 09/23, Zinc 50 MG expiration date 01/24, Fish Oil 1000 MG expiration date 04/24, Vitamin E 450 MG expiration date 04/24, Acidophilus with pectin expiration date 03/24, Guaifenesin 400 MG expiration date 03/24, Vitamin B6 100 MG expiration date 02/24, Naproxen 220 MG expiration date 03/24 and Bisacodyl 5 MG expiration date 02/24. Surveyor asked V6 what is done when administering medication, V6 responded, check the MAR (Medication Administration Record), dosage and obviously check the date. I will give the expired medication to the manager and let them dispose of them. If expired medication is given the resident can get sick and it can affect the effectiveness of the medication. On 05/21/24 at 10:45 AM the fourth-floor medication room was reviewed with V7(Licensed Practical Nurse 4th floor Unit Manager). Expired medications were observed in the cabinet including Aspirin 325 MG expiration date 09/23, Vitamin B6 100 MG expiration date 02/24, Thera Multivitamin x2 bottles expiration date 04/24, Calcium 600 + D3 5 MCG (Microgram) expiration date 03/24 and Cranberry 450 MG expiration date 02/24. V7 stated central supply restock the stock medications. V7 was observed disposing of the expired medications in a container named drug buster. On 05/21/24 at 11:01 AM the second -floor medication cart 1 was reviewed with V8 (Licensed Practical Nurse). V8 stated I have worked here for 18 years. Medications that were opened without an open date was observed in the medication cart including: R25 Fluphenazine HCl Injection Solution Inject 2.5 ml intramuscularly one time a day every 21 day(s), R110 Latanoprost Solution 0.005 % Instill 1 drop in right eye Twice a day and Timoptic Solution 0.5% (Timolol Maleate) Instill 1 drop in right eye Twice a day, R100 Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT 1 puff Twice a day and R98 Fluticasone Propionate HFA Inhalation Aerosol 220 MCG/ACT 1 puff inhale orally every 12 hours. Expired medications were observed in the top drawer of the medication cart including Vitamin B6 100 MG expiration date 02/24, Thera Multivitamin x2 bottles expiration date 04/24, Cranberry 450 MG expiration date 02/24 and Meclizine 12.5 MG expiration date 03/24. V8 stated when medication is expired it is disposed of in the medication buster and central supply will come and replace the medication. On 05/22/24 at 10:42 AM V2 (Director of Nursing) stated The nurse should be checking the expiration date of the medications because they cannot give expired medications. The expiration dates are checked on a daily basis and if the medication has expired it should be pulled off the medication cart/medication room and destroyed. If expired medications are given there is a potential that they may not know the strength of the medication anymore and it can be more potent or less effective. The nurse and the clinical team are responsible for checking to make sure expired medications are not in the medication cart and the medication rooms on the floor. Central supply brings up the house stock medications. Medications should be labeled and dated once opened with the opening and expiration date. That is the only way that they will know when it expired because medications like insulin expires based on when the seal is broken. On 05/23/24 at 11:31 AM V2 (Director of Nursing) stated when a resident is discharged from the facility the medications are sent with them. None of the resident medications should remain in the medication cart. In-Service, Education and Staff Development undated document in part: Topic: Medication Administration. All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. 11. Verify that the medication has not expired. In-service sign in sheet attached. Policy: Titled Medication Storage in the Facility reviewed 01/24 document in part: Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. 14. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists.

Based on observations and interviews, and record review the facility failed to repair a hole in the ceiling and replace the missing/stained ceiling tiles in the first-floor dining room and failed to maintain the walls in the residents' rooms in good repair for 3 (R114,R86, R58) residents in a sample of 35. Findings Included: During the facility tour of the first-floor dining room on 05/21/24 at 09:16 AM a missing ceiling tile was observed at the west end of the dining room and 4 ceiling tiles with brown stains. The ceiling that was observed above the missing tile was peeling. There was a large yellow garbage can positioned near the area of the missing tile with what appeared to have water in it. On 05/21/24 at 11:25 AM R112 was observed sitting in the first-floor dining room. When asked by the surveyor does the ceiling leak in the dining room R112 responded water leaks from the ceiling and it bothers me to see the water. They know about it and have not done anything. On 05/21/24 at 11:34 AM R137 was observed in the first-floor dining room. R137 stated I got on maintenance about the holes in the walls. You see that (referring to and pointing at the missing ceiling tile in the first-floor dining room). Don't you see the brown spots on the ceiling tiles. Don't you see the ceiling peeling where the ceiling tile is missing. That problem needs to be taken care of. On 05/21/24 at 11:39 AM surveyor entered R114's room and observed the baseboard at the head of Bed C bed missing with a hole along the base of the wall. 05/23/24 at 10:06 AM V36 (Maintenance Director) stated I started working here on 01/28/24. If they tell me that there is a hole in the wall I go and fix it. This building has been neglected for years. We are going floor by floor and room by room to fix things. Lots of the furniture is broken down that I have started fixing and changing things. There are only two maintenance people in the facility. During the facility tour at 10:10 AM in the first-floor dining room there was a missing ceiling tile with peeling plaster with a hole and ceiling tiles with brown stains near the west wall with a large yellow bucket that appears to have water in it. V36 stated that just got fixed on Thursday When asked why the missing ceiling tile and the ceiling tiles with the brown stains were not replaced. V36 responded the tiles were wet. There were 7 leaks in the facility. Surveyor asked V36 was the large yellow bucket used to catch the water that was leaking from the ceiling, V36 responded yes. I will have the ceiling tiles replaced within two hours. On 05/23/24 at 10:16 AM surveyor entered R114 room with V36 (Maintenance Director) and observed a hole at the base of the wall at the head of the bed measuring approximately 24 inches x 4 inches. V36 stated that need to be calked and put together. We started making repairs on the third floor. V36 opened the bathroom door and stated I need to cut the wall and replace the dry wall. That is from water damage and the bed being pushed up against the wall. On 05/23/24 at 10:16 AM surveyor entered R86's room with V36 (Maintenance Director) and observed the dry wall loose and able to be pushed in with a hole approximately 3 inches x 2 inches above the baseboard to the right near the room entrance. V36 stated that has to be fixed. On 05/23/24 at 10:26 AM surveyor entered room R58 with V36 (Maintenance Director) and observed a hole at the bottom of the wall at the head of R58's bed measuring approximately 9 inches x 4 inches. V36 stated that hole is from the bed being pushed up against the wall. Worked order dated 03/21/24 document in part: R86's room issue: the walls are in very bad shape paint and plaster chipping badly. Policy: Titled Preventive Maintenance Plan reviewed 01/24 document in part: To provide the staff with guidance on preventive maintenance within the facility. Proof of inspections will be recorded in the electronic TELS system or on paper tracker provided. 6. All resident rooms should be inspected for any repairs needed and proper operation of all equipment. Titled Maintenance Director undated document in part: Summary: The primary purpose of the Maintenance Director is to plan, develop, and direct the overall operation of the Maintenance 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 our facility is maintained in a safe and comfortable manner. Essential Duties and Responsibilities: Repair facility/resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Ensure that supplies, equipment, etc., are maintained to provide safe and comfortable environment. Make weekly inspections of all maintenance functions to assure that quality control measures are continually maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to (a) ensure that smoking materials including cigarette and lighter were given to designated staff; (b) complete smoking assessment / evaluation in a timely manner; (c) develop comprehensive care plan and follow plan of care for smoking. These failures could potentially affect 4 (R28, R84, R92, and R132) residents reviewed for smoking in a total sample of 35. The findings include: R92's health record documented admission date on 2/16/2019 with diagnoses not limited to Alcohol dependence with withdrawal, Esophagitis, Thrombocytopenia, Gastro-esophageal reflux disease with esophagitis, Constipation, Personal history of covid-19, Age-related nuclear cataract bilateral, Tension-type headache, Vitamin d deficiency, Insomnia due to medical condition, Decreased white blood cell count, Spinal stenosis cervical region, Nontraumatic intracerebral hemorrhage, Cervicalgia, Dysphagia following other cerebrovascular disease, Traumatic hemorrhage of cerebrum, Unspecified cirrhosis of liver, Nicotine dependence, Encounter for attention to gastrostomy, Essential (primary) hypertension, Bipolar disorder, Post-traumatic hydrocephalus, Iron deficiency anemia, Presence of cerebrospinal fluid drainage device, Chronic viral hepatitis c. R132's health record documented admission date on 2/20/2024 with diagnoses not limited to Malignant neoplasm of supraglottis, Moderate protein-calorie malnutrition, Cerebral infarction, Chronic respiratory failure, Unspecified protein-calorie malnutrition, Unspecified asthma, Tracheostomy status, Periorbital cellulitis, Hypothyroidism, Auditory hallucinations, Major depressive disorder, Somnolence, Hypoxemia, Covid-19, Lymphedema, Opioid dependence, Essential (primary) hypertension, Anemia, Schizoaffective disorder, Nicotine dependence cigarettes, Thrombocytosis, Dysphonia, Opioid abuse with withdrawal, Dysphagia, Anogenital herpesviral infection. On 5/21/24 at 10:28am R132 observed sitting at the side of the bed, alert, and oriented x 3, verbally responsive, with tracheostomy tube at room air. With suction machine and oxygen at bedside. Stated she is using oxygen as needed. Observed a lighter on her bed, stated she is smoking and is keeping the lighter but not the cigarette. At 10:45am R92 observed lying in bed, alert and oriented x 3, verbally responsive, stated he is a smoker and showed a pack of cigarette from his packet. He said he is keeping his own cigarette but not the lighter. Stated he is ambulatory with walker. On 5/22/24 at 9:02am V16 (Social Service Director / SSD) said he started working in the facility in October 2023. Stated smoking assessment / evaluation is done within 48-72 hours upon admission then quarterly, significant change in condition or if there is any behavior related to smoking. He said smoking assessment is to gauge whether resident is safe to smoke independently or needs supervision and if resident is a safe smoker or not a safe smoker. V16 said if smoking assessment is not done as scheduled will not be able to know if resident is safe or not safe to smoke. He said staff observed residents during smoking schedule in the patio if they are safe to smoke or not and smoking care plan is done upon assessment and reviewed quarterly or as needed. Plan of care for smoking will include how much they smoke if resident is smoking safely in the facility and interventions appropriate for the resident. Care plan is a guide for staff to know how to care for resident or it is their plan of care that needed to be followed and reviewed. He said all residents should not have any smoking materials such as cigarette or lighter with them inside the facility whether they are safe smoker or not. If residents carry any smoking materials, they could give to another resident who is not a safe smoker and could start a fire in the facility. Reviewed electronic health record (EHR) of the following residents with V16: - R132 is a smoker. No smoking assessment and care plan found in EHR (Electronic Health Record). - R92's last smoking assessment was completed on 9/11/23. Minimum Data Set (MDS) dated [DATE] showed R92's cognition was moderately impaired. He needed set up/clean up assistance with eating, oral hygiene; Supervision / touching assistance with toileting and personal hygiene, shower / bathe self and upper and lower body dressing, chair / bed and toilet transfer. R92's care plan dated 9/11/2023 documented in part: Smoking preference: Resident makes the choice to continue to smoke and is at risk for SOB. Cigarette lighters are to be kept with cigarettes. Last smoking risk assessment found was dated 9/11/23 in R92's Electronic Health Record (EHR). MDS dated [DATE] showed R132's cognition was intact. She needed supervision / touching assistance with oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, chair/bed and toilet transfer. MDS indicated tobacco use. Last smoking risk assessment found in R132's EHR was dated 12/9/22. No smoking care plan found in R132's EHR. Facility's smoking policy dated 1/2024 documented in part: - All residents who desire to smoke will be assessed by the interdisciplinary team to determine if the individual is appropriate for independent smoking. - Possessing, carrying, or holding materials used to smoke (including, but not limited to, cigarettes, cigars, loose tobacco, pipes, lighters, and matches) by residents is prohibited inside the building. Residents must give smoking materials to designated staff when they enter the building, even if the resident has been assessed to be independent in carrying such materials when off the premises. Findings include: On 05/22/24 at 01:18 PM, during Resident Council Meeting interview R84 stated yes, I smoke, and I keep my stuff on me. Observed R84 remove from R84's pocket an orange color lighter and carton of cigarettes. R84's diagnosis included but not limited to Nicotine Dependence Cigarettes, Dementia, Cerebral Infarction, Hyperlipidemia, Atherosclerotic Heart Disease, Chronic Kidney Disease Stage 2, Heart Failure, Prediabetes, Peripheral Vascular Disease, Venous Insufficiency (Chronic) Peripheral, Hypertension, Alcohol Use. R84's MDS (Minimum Data Set) dated 02/28/24 indicates moderately impaired cognition with BIMS (Brief Interview for Mental Status) 10 out of 15 and tobacco use based on section J - Health Conditions. R84's most recent Smoking Risk Assessment Scored dated 01/28/24 documents in part scored 0-9 - Safe Smoker and monitor per facility safe smoking guidelines. R84's Smoking Behavioral Contract dated 01/28/24 documents in part resident responsibilities include adhere to the facility rules, policies, and guidelines (procedures). R84's smoking care plan dated 10/12/22 documents in part unsafe smoking issues related to behavior and interventions include but not limited to keep resident smoking materials in the medication room or activity closet. On 5/21/24 at 12:28 PM, R28 was up in wheelchair in R28's room alert and able to verbalize needs. When asked if R28 smokes, R28 stated R28 smokes outside on the patio with staff supervision. On 5/22/24 at 1:41 PM, R28 was observed outside the patio smoking. R28 stated R28 keeps cigarettes with R28 but not the lighter. On 5/22/24 at 9:25 AM, Surveyor and V16 (Social Service Director) checked R28's electronic health records. V16 confirmed that the last smoking assessment completed for R28 was in 8/16/23 and smoking was not addressed in R28's care plan.

Based on observation, interview, and record review the facility failed to a.) ensure narcotic medications were administered in accordance with physician orders, b.) ensure the narcotic count was correct at the change of shift and c.) document ordered narcotic medications when given for 2 (R76, R118) of 2 residents reviewed in 2 of 3 medication carts. Findings Include: On 05/21/24 at 09:59 AM the third-floor medication cart 2 was reviewed with V5 (Licensed Practical Nurse). R76 Physicians order document in part: Morphine Sulfate Oral Solution 20 MG (Milligram)/5ML (Milliliter) 0.25 ml sublingually every 8 hours for pain -Start Date- 04/17/24. During the narcotic reconciliation review R76 Individual Controlled Substance Record document: Date received 04/19/24. Quantity received 30 ML (Milliliter) with 43 doses given. First dose dispensed 04/19/24 at 06:00 AM. On the April and May Medication Administration Record dated between 04/19/24 06:00AM and 06:00 AM 05/21/24 there were only seventy-four doses administered out of ninety-seven scheduled doses with twenty-three doses refused. Amount observed on R76 Individual Controlled Substance Record document amount remaining 19.25 ML. Surveyor asked V5 the total that was remaining in the bottle and V5 responded 27 milliliters is in the bottle and is over the 19.25 ml on the narcotic sheet. I will tell the supervisor. The narcotic count is done at the change of shift. R76 receives 0.25 ml of the Morphine Sulfate, and I did not notice it was over this morning. When the count is off, we notify the supervisor. On 05/23/24 the facility provided R76 updated Controlled Substances Proof of Use form document in part: Morphine 20 mg/ml give 0.25 ml every 8 hours sublingual for pain. Amount received 27.0 ml, Date received 05/21/24, Quantity remaining 26.5 ml. On 05/12/24 at 10:28 AM the fourth-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). R118 Physician order document in part: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 5 mg sublingually every 3 hours as needed for Severe Pain Give 5-10 mg or 0.25ml-0.5ml q (every) 3hr (hours). R118 Controlled Substances Proof of Use document: Amount received 30 ML. R118 received Morphine a total of 36 times with a documented quantity remaining of 17.5 ML with only 15 ML observed remaining in bottle. Surveyor asked V6 to verify the amount of Morphine Sulfate remaining in the bottles, V6 responded 15 ML. I did not notice it this morning, I might have been moving too fast. On 05/23/24 the facility provided R118 updated Controlled Substances Proof of Use form document in part: Morphine Sulfate 20 mg/ml give 5-10 mg or (0.25 ml-0.5 ml) every 3 hours prn (as needed) for pain. Amount received 15.0 ml, Quantity remaining 14.0 ml. On 05/22/24 at 10:42 AM V2 (Director of Nursing) stated Narcotics are counted at the change of shift. One nurse checks the medications and one nurse check the narcotic book. They count the medications together and if there is something wrong the nurse let someone know immediately. I heard about the narcotic count was off with the liquids for R76 and R118. We started the education on proper exchange of narcotic keys and to ensure the narcotic count, it is accountability. The nurses are to count with someone not just take the key and go. The count was corrected on the narcotic sheets. When medications are administered the nurse should make sure the medication count is correct. I expect the nurse to count the narcotics and not leave the key and walk off unit. On 05/23/24 at 11:31 AM V2 (Director of Nursing) stated when a resident is discharged from the facility the medications are sent with them. None of the resident medications should remain in the medication cart. In-Service, Education and Staff Development undated document in part: Topic: Medication labeling and storage. Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. In-service sign in sheet attached. In-Service, Education and Staff Development undated document in part: Topic: Controlled substances. In-service sign in sheet attached. Policy: Titled Controlled Substance reviewed 01/10/24 document in part: Medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. 7. While a controlled substance is in use the nursing staff will maintain the following medication records. 8. Record each dose at the time of administration on the following: 9. MAR a. Date b. Time c. Initial of nurse administering dose. 10. Controlled Substances Count Sheet a. Date b. Time c. Signature (which includes minimum of first initials) of nurse who administered dose d. Number of doses remaining. 11. All schedule II-controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: a. Inspect both the drug package and the corresponding count sheet to verify the accuracy of the amount remaining. d. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented. Discrepancies: a. Any discrepancy in the count of controlled substances shall be reported in writing to the responsible supervisor. b. The supervisor shall institute an investigation to determine the reason for the discrepancy. The record shall then be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow professional standards of practice and facility policy to prevent and control infection in the provision of patient care. This failure has the potential to affect all 180 residents in the facility. Findings On 05/21/24 at 9:13 AM V33 (CNA) was observed leaving room R121's room which had a sign for enhanced barrier precautions (EBP) on the door. V33 took the breakfast tray out of room , placed the tray in the return cart, did not perform hand hygiene and then entered room [ROOM NUMBER] which also had a sign for EBP on the door. V33 took the breakfast tray out of R162's room, placed it in the return cart, did not perform hand hygiene and began to push the cart down the hall. V33 was asked about the EBP signage. V33 stated It means that we gown up before doing care. We wear gown and gloves and use hand sanitizer before we put gloves on. If we are going to pass or pick up trays, we put gloves on. I didn't put gloves on. I should have used hand sanitizer before going into the room. On 5/21/2024 at 11:13 AM, R179 was observed to have a PICC line. No EBP signage was on the door of R179's room. On 05/21/24 at 2:50 PM, R70 was observed to have door signage for droplet precautions, contact precautions and EBP. The red bin for PPE disposal was observed to be located along the wall between bed 1 and bed 2 in the resident's room. During interview, V30 (LPN) stated that PPE should be donned in the hallway and doffed before exiting the room. While standing in the doorway, surveyor asked how PPE is disposed of in the red bin. V30 stated I don't know. We take the PPE off after we take care of R70 and dispose of it standing in front of the red bin and then wash our hands in the bathroom and exit the room. When surveyor asked if the location of the red bin for PPE disposal was located so that PPE was being doffed in a clean space, V30 stated no. On 05/21/24 at 3 PM, V34 (Infection Prevention Nurse) was interviewed and stated that staff should don PPE before entering the room and doff PPE in the doorway immediately prior to exiting the room. When surveyor stated that red bin to dispose of PPE is located between bed 1 and bed 2 in R70's room and that staff are reportedly doffing PPE in front of the red bin in the resident's room. V34 stated That is not correct. Staff have been told that they should remove their PPE in the doorway before exiting the room. I will take care of it. On 05/22/24 at 9:30 AM, V34 (Infection Prevention Nurse) was interviewed regarding infection prevention and control practices and stated that she performs surveillance and looks at healthcare acquired infections (HAI) monthly. Staff are reeducated as needed and the surveillance data is discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting. V34 stated Last month, we had a 4.21% HAI. It was related to an increase in UTIs and soft tissue/wound infections. V34 stated that the initiation of EBP is based on criteria. An order is not needed. Residents with G-tube, dialysis, IV/PICC line, wounds, urinary catheters and tracheostomies should all be on EBP. V34 stated that if a resident is on EBP and staff are providing care, then PPE should be worn, which at a minimum is a gown and gloves. When staff are delivering or picking up food trays for patients on EBP, hand hygiene should be performed after picking up a food tray and before going into the next room. On 5/23/2024 at 1:40 PM, red isolation disposal container was observed to be located between beds 1 and bed 2 in R70's room. V34 (Infection Prevention Nurse) stated that staff know that is not correct. Policy titled IC-Enhanced Barrier Precautions (EBP) dated 1/2023 and revised 3/20/2024 was reviewed and stated in part: General: EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Signage for Enhanced Barrier Precautions stated Everyone Must: Clean their hands, including before entering and when leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to provide an adequate supply of linens to meet staff and resident needs in the provision of resident care. This failure has the potential to affect all 180 residents of the facility. Findings: On 5/21/2024 at 2:30 PM observed three CNAs (certified nursing assistant) carts on the 2nd floor. No bath towels were observed on any of the three carts. On 5/21/2024 at 2:35 PM, V9 (CNA) was interviewed. V9 stated that the CNAs start the shift with a linen cart that each CNA puts together. Linens are brought up by the laundry room and put in an alcove in the hallway. Each resident uses three towels to shower or bathe so V9 stated that the staff go through towels quickly. Once the towels are gone, V9 stated that staff call the laundry room to get more. Our shift is over at 3, so there are no towels on the floor. The laundry room will bring new linens for the 3-11 shift. Laundry bring the cart each shift. V9 stated that they sometimes have to wait for linens to come up to the floor. On 5/21/2024 at 3:25 PM V30 (Laundry Aide) was interviewed and stated that linen carts go up to the floors at the start of each shift. Staff come down if they run out of linens during a shift. Staff have to wait to get linens if the laundry has accumulated and linens are not yet clean. I have to clean, dry and sort the linens so staff do run out at times. On 5/22/2024 at 12:15 PM V29 (Laundry Aide) was interviewed and stated that the Daily Linen Delivery chart documents the linen that is sent in three carts (one per floor) for each shift. Par levels are listed on the document. V29 stated that she was not sure what the par levels meant. V29 stated that the laundry aide writes down how much linen is sent to the floor each shift. V29 stated For example, if we write twenty-one bath towels on the sheet, that means that we sent seven bath towels to the second floor, seven bath towels to the third floor, and seven bath towels to the fourth floor. On 5/22/2024 at 12:28 PM V32 (Division Manager Laundry Services) was interviewed and stated that that clean laundry is sent to each floor each shift at 7 AM, 3 PM and 11 PM. V32 stated that the laundry room does not send linens up to the floors at 12 PM. V32 stated that laundry aides should be stocking the linen carts to the par levels. V32 reviewed the document Daily Linen Delivery and stated that the par levels on the sheet were outdated. There should be three bath towels for each resident each shift. For example, if there are two hundred residents, there should be three bath towels sent up for each resident which would total six hundred bath towels (two hundred for each floor) plus some overage for accidents. The par level on the Daily Linen Delivery document says sixty bath towels each shift. V32 stated that the laundry room does not always get linens to wash because the staff do not send them down or the staff throw away linen. We see linens come down as garbage. When asked if there is enough linen in the building, V32 stated I don't think so. V32 stated I have text messages and pictures that I have sent to V1 (Administrator). We don't have enough extra linens on hand. V32 stated that she keeps additional linen stock and the laundry aides know to come to her office to get what they need to get to par level. V32 stated However, the facility does not have bath towels. On 5/22/2024 at 12:45 PM, the linen overstock area was observed with V32 (Division Manager Laundry Services) . V32 stated, and surveyor observed, that there are flat sheets, fitted sheets and washcloths available. There were no bath towels available in the overstock area. On 5/22/2024 at 1:00 PM, the Daily Linen Delivery documents for May 15, 2024 at 7 AM through May 22, 2024 at 7 AM were reviewed. These documents provide the par levels (minimum count) for linen items for each shift and then the number of actual items that we sent to the floors each shift and this document states the facility did not meet minimum count of [NAME] for resident care. On 5/22/2024 at 1:15 PM Concerns about substandard quality of care was discussed with V1 (Administrator). Findings of Daily Linen Delivery logs were discussed, and plan of correction was requested. On 5/22/2024 at 1:44 PM V1 (Administrator) stated that she had ordered linens and spoken to a sister facility who was sending linens to the facility today. On 5/22/2025 at 2:51 PM V1 (Administrator) stated that 300 wash clothes and 98 bath towels had arrived from a sister facility. An additional four hundred and fifty-six bath towels were ordered and four hundred and fifty six wash clothes were ordered and are due to arrive at the facility on Saturday, May 25, 2024. On 5/23/2024 at 9:18 AM V37 (CNA) stated that there are no bath towels on the 2nd floor. On 5/23/2024 at 9:27 AM V28 (CNA) stated that there are 20 bath towels and 45 wash clothes on the 3rd floor. V28 stated that residents will use two to three towels to shower or have a bath. Sometimes we are stocked with linens. Sometimes we are not. V28 explained that residents hide towels because when they need one, they can't get it. On 5/23/2024 at 9:32 AM, V38 (CNA) stated that there were 22 bath towels and 45 wash clothes on the fourth floor. V38 stated that he had fifteen residents assigned to him. There are five CNAs on the unit and each have approximately fifteen residents assigned to them. Each resident will use one or two bath towels during the shift and one or two wash clothes. On 5/23/2024 at 9:48 AM, V1 (Administrator) was made aware that the second floor had no bath towels at 9:18 AM, third floor had twenty bath towels and forth floor had twenty-two bath towels. V1 stated We just added towels yesterday. I will call V32 (Director Laundry Services). RESIDENTS ' RIGHTS LONG-TERM CARE OMBUDSMAN PROGRAM booklet documents in part: Your facility must be safe, clean, comfortable and homelike.

Based on interview and record review, the facility failed to ensure to have sufficient certified nursing assistant (CNA) on weekends to care for residents' needs based on the staffing scheduling, PBJ (Payroll Based Journal) staffing data report and facility assessment. This failure could potentially affect 180 residents residing in the facility as of census 5/21/24. The findings include: On 5/21/24 at 10:45 AM R92 observed lying in bed, alert, and oriented x 3, verbally responsive, with long beard more than 5inches. Stated he can have staff assist him with shaving. He said staff did not offer or assist him with shaving. At 11:19 AM Requested V3 (Restorative Nurse) to R92's room and R92 stated he wanted his beard shaved off. R92 said beard is about 5-6 inches long and he wanted to take off everything. On 5/22/24 at 10:15 AM V19 (Scheduler / Staffing Coordinator) said she has been working in the facility for about 6 months. V19 said, V19 schedules both nurses and CNAs. V19 said, facility does not use agency for both nurses and CNAs. V19 said, the breakdown for staff schedule to work daily is as follows: 2nd floor 7-3 and 3-11 shift should be 4 CNAs and 2 nurses each shift and for 11-7 shift should be 3 CNAS and 1-2 nurses. 3rd floor 7-3 and 3-11 shift should have 3 CNAs and 2 nurses each shift and for 11-7 shift should have 3 CNAs and 1 nurse. 4th floor 7-3 and 3-11 shift should have 4 CNAs and 2 nurses each shift and 11-7 shift 3 CNAS and 1 nurse. Total staff for 7-3 and 3-11 shift = 11 CNAS and 6 nurses each shift. Total staff for 11-7 shift = 9 CNAS and 3-4 nurses. V19 said, total CNAs per day shoud be 31 CNAs and total nurses per day should be 15-16 nurses. V19 said same number of staff (CNAs and nurses) for weekdays and weekends. She said weekends are challenging due to call off, most call off happens on a weekend. Stated we are trying to fill up the shift. Nursing managers are coming if they need to. For the most part, we are keeping the same total number of staff but at times we can't be due to short notice for call off. Surveyor reviewed Daily Schedule from 4/6/24 to 5/19/24 with V19 and the document showed facility did not meet staffing numbers for cna's on 13 days. At 10:52AM V2 (Director of Nursing / DON) stated average CNAs working everyday should be around 10-12 per shift, about 30 CNAs per day. CNA is working 7.5hours per shift. She said at times weekend is a challenge, can't control call off, staff is doing their best to care for residents. Managers are working on the floor if needed. On 5/23/24 at 12:35pm V1 said at least 30-32 CNAs and 3 restorative aides working everyday including weekends to work and care for residents. She said team is always working together and managers working on the floor to meet the needs of the residents. Surveyor reviewed Payroll Based Journal (PBJ) report and showed inadequate staffing from 1/6/24 to 3/10/24 on 15 days. PBJ staffing data report FY (Fiscal Year) 1 2024 (October 1 - December 31) showed: TRIGGERED for Excessively low weekend staffing. FACILITY ASSESSMENT TOOL dated 11/2023 documented in part: Nurse aides including Restorative Aides: 35-39 per day. Direct care staff: CNAs Long Term Care Units 1:12ratio Days; 1:12 ratio Evenings ; 1:12 ratio Nights. Facility's census report dated 5/21/24 showed 180 residents. Facility staffing policy dated 1/2024 documented in part: To have appropriate numbers of staff available to meet the needs of the residents. Staffing is based on the IDPH formula for determining numbers and levels of staff.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated with an opened and use by date, b.) discard expired or spoiled food, c.) keep food storage areas clean, d.) sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 176 residents receiving food prepared in the facility's kitchen. Findings include: On 05/21/24 at 8:57 AM, during initial kitchen tour V11 (Dietary Director) stated everything that comes into the kitchen must be labeled and date and when something is opened it needs to be labeled with the open date and use by date. V11 stated all refrigerated food needs to be used within seven days. V11 stated that even if the item is marked with a manufacturer use by date, the kitchen goes by seven days from when the item is opened, not the manufacturers use by or best by date for when the item should be thrown out. On 05/21/24 at 9:05 AM, observed the following in Refrigerator #2: 1.) Opened case of fresh strawberries dated 05/03/24 observed to shriveled, and some of the strawberries were covered in a white, light gray fuzzy material. V12 (Area Kitchen Manager) stated the strawberries looked dusty. V11 stated these strawberries would not be served to residents because they are passed the 7-day expiration time. 2.) Black/dark gray dust like material covering the refrigerator fan covers and the same black/dark gray material in clusters on the ceiling of the refrigerator. V11 stated the material looks like dust and it should not be there because it could blow on the food. On 05/21/24 at 9:25 AM, observed in Refrigerator #1 opened one gallon barbeque sauce dated with delivery date 04/23/24. There was no open or use by date. V11 stated while the product had not expired based on the delivery date the item should be labeled with an opened date so the staff can keep track of how long the product is good for and know when to discard it. On 05/22/24 between 10:40 AM-12:00 PM, observed V22 (Cook) prepared pureed food items for lunch meal using an industrial blender. At 11:17 AM, observed blender container/lid/blade brought to the 3-compartment sink to be washed. V23 (Dietary Aide/Pot Washer) stated V23 has been working at the facility for 23 years. V23 stated there are 3 sections to the sink, wash in the first sink, rinse in the 2nd sink and sanitize in the 3rd sink. V23 stated the sanitizer in the 3rd sink is needed to make sure the items which are being fully cleaned and sanitized. At 11:22 AM, observed V23 wash blender container, then rinse and then dip blender container into the sanitizing solution for 11 seconds and remove and store on the side of the sink area. At 11:23 AM, observed V23 wash blender blade, then rinse and then dip blender blade into the sanitizing solution for 10 seconds and remove and store on the side of the sink area. At 11:24 AM, observed V23 wash blender lid, then rinse and then dip the blender lid into the sanitizing solution for 16 seconds and remove to store on the side of the sink area. On 05/22/24 at 11:25 AM, V23 stated when V23 is washing items V23 leaves them in the sanitizing solution for 10 seconds. V23 said, I count to 10. On 05/22/24 at 11:27 AM, V11 (Dietary Manager) stated the purpose of the sanitizing solution is to properly clean items to prevent cross contamination. V11 stated if the item if not kept in the sanitizing solution for the correct amount of time the item will not be fully sanitized. V11 stated the item(s) needs to be left in the sanitizing solution for the full minute (60 seconds) to sanitize. On 05/22/24 at 11:47 AM, observed V22 measuring out sweet potatoes and placing into the blender container with blade inside from the dish room area and cover with the blender lid and turn on the blender to puree sweet potatoes to desired consistency. On 05/21/24, facility provided list of diet orders for all residents in the facility printed 05/21/24 at 10:27 AM from the facility electronic health system. Diet order list indicates there are four residents receiving nothing by mouth (NPO). Facility provided policy titled Labeling and Dating Policy undated which documents in part, the purpose to assure the staff are using food that has not expired and meets food safety criteria, leftovers are to be used within 7 days and any items past the use by date will be discarded immediately. Facility provided policy titled Clean and Sanitary dated 09/01/21 documents in part all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition and the Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner including floors, walls, ceilings, lighting, and ventilation. Facility provide policy titled QRT Three Compartment Sink dated 09/01/21 documents in part the dining service staff will be knowledgeable in proper techniques including for the third sink: submerge in the sanitizer sink for at least 60 seconds. Facility provided copy signage posted above the three compartment sink titled Pot and Pan Cleaning & Sanitizing Procedures dated 2021 which documents in part, submerge in sanitizer sink for 1-2 minutes.

Based on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 180 residents who reside in the facility. Findings include: On 05/21/24 at 9:37 AM, turning observation of outside dumpster with V11 (Dietary Manager) observed one large dumpster with two of the three lids wide opened. Also, observed debris and trash on the ground around the dumpster. V11 stated the lids should probably not be left open like that because birds and insects can get inside and feed off the garbage inside. V11 stated there should be no garbage on the ground near the dumpster. On 05/22/24 at 3:28 AM, V32 (Divisional Manager for Laundry and Housekeeping Services) stated the lids to the dumpster must be closed after putting garbage inside and there should be no debris or garbage on the ground around the dumpster. V32 stated the lids should be fully closed to keep rodents from getting in the dumpster because eventually this will lead a trail to the building. V32 stated we don't want rodents to be near the building because it is a health care facility, and it should stay as clean as possible. Facility provided kitchen policy titled, Dispose of Garbage and Refuse dated 09/01/21 documents in part, all garbage and refuse will be collected and disposed of in a safe and efficient manner and the Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. Facility provided policy titled Clean and Sanitary dated 07/04/21 documents in part all trash will be properly disposed of in external receptacles (dumpsters) and then surrounding area will be free of debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R12) of seven residents reviewed for abuse. This failure resulted in R11 and R12 having an altercation. R11 put R12 into a headlock and scratched R12's face. Findings Include: Facility's Investigation Report (dated 02/29/2024) states: R11 noted with agitation while walking with staff member and he began flailing his arms, in the process of flailing his arms resident scratched R12, while he was sitting in the dining area. R12 was immediately removed from common area and placed with social services with de-escalation techniques initiated. MD made aware with orders received to send resident out to [community] hospital for psychiatric evaluation, orders noted and evaluated. Nursing staff and social services were successfully able to deescalate the situation and remove R11 from the common area and place him on 1:1 supervision until he was transferred to [community] hospital for psychiatric evaluation. R12 was evaluated after removal of R11 and stated that he was startled by R11 but that he felt safe and comfortable and exhibited no distress. In conclusion, R11 suffers from altered mental status, legal blindness and schizophrenia. Resident could not see R12 seated in his wheelchair near him. Abuse Prevention Policy (dated 10/2022) states: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. R11's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: legal blindness, as defined blindness, as defined in U.S.A, unspecified psychosis not due to a substance or known psychological condition, unspecified abnormalities of gait and mobility, lack of coordination, schizophrenia, glaucoma, essential hypertension, low back pain, altered mental status. R11's Care plan (dated 11/30/2023) documents that R11 exhibits the symptom of resisting care which is related to his dx. of legal blindness, as defined blindness, as defined in U.S.A, unspecified psychosis not due to a substance or known psychological condition. R11's care plan (dated 02/29/2024) documents that R11 memory is impaired, and resident has difficulty with decision-making, insight. MDS section C (dated 12/31/2023) documents that R11 has a BIMS score of 10, indicating that R1's cognition is moderately impaired. R12's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, cognitive communication deficit, unspecified lack of coordination, abnormal posture, weakness, cerebral infarction. R12's Care plan (dated 02/27/2024) documents that R12 is at risk for falls. R12's comprehensive assessment reveals factors that may increase his/her susceptibility to abuse/neglect including history of substance abuse. MDS section C (dated 03/04/2024) documents that R12 has a BIMS score of 14, indicating that R12's cognition is intact. On 05/02/2024 at 12:50pm V1 (administrator) stated, There was an incident between R11 and R12 on 02/29/2024. R11 walking in the dining area with V17 (activity aide). They were talking, and I guess she said something to R11 that triggered R11, and he just started swinging. R11 is blind. When he started swinging, V17 ran, and R12 was the next thing closest to R11. R11 did not know that R12 was sitting there. R12 is in a wheelchair. R12 sustained scratches to the face. We were able to get social services and security to separate the R12 from R11. Once R11 calmed down, we separated him from other residents. R5 also attempted to help. R12's injuries were superficial, and the wound nurse saw the resident until the scratches healed. I think that R12 was shaken up at first after being scratched. After R12 calmed down, R12 expressed that he was ok and that he understood that he was not attacked on purpose, that he was scratched on accident. I reported this incident to the state agency. Per my investigation, abuse was not substantiated, the incident was an accident, and it was not intention. R11 was discharged . After this incident, the facility tried to do an involuntary discharge, but the hospital did not honor the paperwork. R11 had other incidents where he was aggressive towards staff, so we discharged the resident. On 05/02/2024 at 4:47pm V1 (administrator) stated, I am the abuse prevention coordinator. The facility's policy is the residents have the right to be free of abuse. On 05/02/2024 at 2:00pm V17 (activity aide) stated, On 02/29/2024, I am the one that got R11 out of his room because he was aggressive, and he was throwing things in his bedroom. I decided to bring R11 out of the room just so R11 can listen to music. I was having doing resident activities at the time, and I wanted to have R11 join the activities so that he can listen to music, and I could re-direct R11 so that he can calm down. Every day, I would bring R11 down to activities and I would take R11 to smoke. On that day R11 was already aggressive. R11 was talking about his money, he was agitated regarding his money. R11 was talking about his trust fund and that is what he was agitated about. R11 was sitting in the dining room, when he got up and he was touching the wall, going around in a circle. He almost tripped over a cord, and I got up to prevent him from falling, so I grabbed him to prevent a fall. R11 didn't fall, he just started swinging on me when I held his arm. R11 just started swinging on me, hitting me on the left side of the ear, the top of my lip and my face. As I was trying to move out of the way so that R11 will stop hitting me, R12 was sitting in a circle in his wheelchair and I guess the way he was positioned, R11 grabbed a hold of R12's neck and put him in a choke hold. R11 was holding R12 with his hands around R12's neck. I was screaming for help. Somehow R12 sustained scratches to his face when R11 was holding R12 in a choke hold. The only way I was able to stop the situation was because another resident intervened and helped. Residents had to intervene. R5 assisted me in helping me with getting R11 off of R12. R12 had dropped his money and his cigarettes, and we found the money and gave it to him. We found R12's money, but we could not find the cigarettes. Somehow, R11 found the cigarettes on the floor and picked them up and placed them in his pocket. R11 is legally blind. How the cigarettes were found was by V18 (wound care). V18 was the one that was able to relax R11. V18 was the one that was able to find the cigarettes. The police were called, and I did the police report. The two residents were separated immediately once I was able to get assistance. R11 was sent out to the hospital. R12 had scratches. The incident occurred because R11 got agitated and he is blind and he was having a behavioral episode and R12 just so happened to be close to R11, and that's how R11 was able to grab R12. On 05/02/2024 at 2:58pm V19 (wound care) stated, I remember V12. On 02/29/2024, it is documented that R12 sustained scratches to the face from an altercation. The scratches were not deep and did not require any wound care. The scratches required to be monitored. First aid was rendered, and no treatment was required from the treatment nurse for the scratches. We took pictures of the scratches. The scratches healed. On 05/07/2024 V20 (wound care) stated, On 02/29/2024, I am not sure what took place, and what led to it, but I heard the code. When I got to the floor, R11 was upset, and he was sitting on the floor. I can tell he was upset. I wanted to calm him down and I told him that we can go downstairs and have a cigarette and talk about what happened. R11 just told me that he was ready to leave. R11 didn't tell me what happened. The police came and questioned R11. R11 told me that he picked up a wallet and cigarettes thinking that it was his, but it belonged to R12. R11 is blind and he thought that the cigarettes and wallet he found on the floor belonged to him. R11's Progress Note (02/29/2024) documents, Resident became agitated while walking with staff member, he began flailing his arms and, in the process, he scratched a male co-peer seated in dining area, placed on 1:1 with social services, MD made aware with new orders to send resident out to [community] hospital for psych evaluation, orders noted and implemented. R11's Progress Note (02/29/2024) documents, Writer placed call to [community] hospital and spoke with nurse J. He stated to writer resident was admitted for psych evaluation. R12's Progress Note (dated 02/29/2024) documents, While seated in dining area watching television, resident was scratched by male co-peer, co-peer immediately removed from common area, first aid provided to resident, resident family and MD made aware, social services made aware for any needed support for resident, nursing staff continues to monitor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin to the regional office. This failure affects one of three residents (R9) reviewed for injury of unknown origin in a total sample of 19. Findings include: R9 is a [AGE] year-old male. R9 ' s diagnoses are but not limited to stroke affecting the right side of the body, stroke, aphasia, major depressive disorder, adult failure to thrive, and anxiety. R9 ' s MDS dated [DATE], notes R9 is not alert. Progress note dated 12/10/2023, notes R9 noted with some swelling, redness, pitting edema and warm to touch to right contracted arm. Patient vitals within normal levels. No signs or symptoms of shortness of breath, pain, anxiety, or distress noted. No adverse reactions to antibiotics. For ten days. Patient remains stable and resting currently. Progress note dated 12/10/2023, notes writer endorsed x-ray of right elbow to nurse practitioner with new orders to send patient out to local hospital due to x-ray stating (flexion deformity with fracture of the distal humerus). As needed Tylenol administered per doctor ' s orders. On 05/02/2024, at 1:42 PM, V1 (Administrator) stated, I did the investigation. V22 (Licensed Practical Nurse) notified me of R9 ' s arm. The staff though it was cellulitis at first. The staff and the nurse practitioners were monitoring him, and he was being treated with an antibiotic. This went on for about five days. I believe on the 9th; the nurse practitioner ordered the x-ray. The x-ray showed he had a fracture. I was the administrator at the time. I started my investigation and did not report it. It was not a suspicious because staff had been monitoring the arm. I figured it was something systemic. When I started my investigation, I got statements from the staff that was working for a seven-day period. I got the x-ray results. I got the results from the hospital. I looked at his paperwork when he was first admitted to us, there was nothing mentioned. He had three fractures and two were old. One was comminuted fracture. This means the bone was split in area. The hospital never did anything in depth on this resident due to his drug history. There was no bone scan or testing done to diagnoses osteoporosis or to see if he had some disease. I did ask the staff about abuse as well. If they witnessed or suspected anyone and they said no. The nurse practitioner agreed that it was related to the pathology. On 05/02/2024, at 2:23 PM, V22 stated, The aide is the person that told me about R9 ' s arm. I went in and assessed it. His vitals were normal and there was no temperature. I noticed it was swollen, red, and warm to touch. When I touched it, R9 did grimacing with his face. I did administer Tylenol through his g-tube (stomach tube). I immediately contacted the nurse practitioner and let her know what was going on. At the time, she ordered him some antibiotics. The way I was describing it to her, she believed it was cellulitis. She ordered him some antibiotics. It was the next day; I was not comfortable with his arm. I asked her if I could order an x-ray. I ordered the x-ray. Once the results came back, I relayed the results to the nurse practitioner. The results noted R9 ' s elbow may have been fractured. She stated to send him to the local hospital. He was sent out. When I did see him again, he had a soft splint on his right arm. I contacted his family as well. He used to thrash around in bed a lot. He used to try to move around in the bed. The floor mats were always down on the floor. He would favor the left side of the bed. Staff pushed his bed closer to the wall and put the mats in place. I do not recall if he was a high risk for falls. I do not know if his injury is suspicious because the hospital, he had old fractures. I do believe it should be thoroughly investigated and reported to the state. On 05/02/2024, at 2:37 PM, V23 (Nurse Practitioner) stated, Another nurse practitioner was seeing R9. But for insurance reasons I had to see the resident. On the December 8th, 2023, the other nurse practitioner called me and told me that R9 ' s arm is presenting as cellulitis. He was initiated on Bactrim DS every twelve hours for ten to twelve days. The following day the nurse called me and said that his arm looks worse. He had gotten two rounds of antibiotics. I put in an order for and x-ray and doppler of the upper extremity with labs. I also added Augmentin (antibiotic) for better coverage while everything was pending. The x-ray came back and showed a fracture. R9 was sent out to the hospital. He had a fracture of the distal humerus. The fracture was just above the elbow. This was not suspicious to me. He had a rapid weight loss and other health issues. Staff and I thought it was cancer. I was not surprised that he had a fracture because his overall health is not good. Due to his health history and his health being so poor, it very easily could have been a pathological fracture. Facility policy titled Abuse Policy and Prevention Program, dated 10-2022, notes an injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and he injury is suspicious because the extent of the injury or the location of injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. If classified as an injury of unknown source the person gathering the facts will document the injury, the location and time it was observed, any treatment given and notification of the resident ' s physician responsible party. The Department of Public Health will be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to keep a resident (R6) free from physical abuse. Findings include: On [DATE] at 12:50 PM, R6 said it has been a long time since the altercation with R4 and R6 does not remember details. R6 said R4 bit R6 and R6 had a bloody finger. R6 said R6 thinks it was over the television and R4 wanted to watch a channel. R6 said I'm okay. I'm safe. On [DATE] at 1:00 PM, V1 (Administrator) stated I started as Administrator on [DATE]. When the Facility Reported Incident happened, I was the Director of Nursing. R4 and R6 were roommates. R6 had the television volume up and refused to turn it down. R4 pulled the privacy curtain closed and opened the window. R6 was always cold so R4 opened the window to irritate R6. R6 closed the window and R4 pushed R6. They got into a physical altercation. R4 bit R6 and had bleeding from the mouth. R6 had broken skin on the hand not bleeding. Staff heard the commotion and went to investigate. I was not in the building; it was a weekend. They were separated. R6 declined us from calling the police and R6 was not pressing charges. R4 was ordered out to the hospital. R4 died in the hospital. R4 did not like Black people and was argumentative with staff and residents. I had not heard of R4 being physical before that incident. No behavioral issues with R6. I think the hospital gave R4 a worsening diagnosis and R4 did not deal with it well. We had Social Service try to get R4 to talk/discuss what R4 was going through to gage R4's mood and outlook but R4 was not receptive. There was no precursor that R4 would become aggressive. There was no need for extra supervision. I am the abuse coordinator. Verbal, physical, mental, financial are some types of abuse. I would investigate any forms of abuse. If staff witness abuse, they are to report it to me immediately. Staff have not reported any physical or verbal abuse. The only other reportable within three months was not substantiated. The altercation between R4 and R6 did occur. On [DATE] at 2:50 PM, V13 (Licensed Practical Nurse) stated I was R4 and R6 nurse that day. I did not witness what happened. It occurred in their room. The CNA (Certified Nursing Assistant) told me they had an altercation. R4 had blood coming from the mouth. I believe it was a chipped tooth. R6 had a scratch or mark on the arm. When I came in the room, R4 was angry and cussing at R6. I put R4 in a different room. R4 became verbally aggressive/started going off on me because of the room change. The Psych doctor was notified. Psych doctor ordered to send R4 out for a psych evaluation. R6 was not sent out. On [DATE] at 3:00 PM, V14 (Licensed Practical Nurse) stated I was supervisor that weekend. I did not witness the interaction. R4 had a bloody mouth. We were asking what happened. R4 said they were going back and forward about the window. R4 said R6 punched him in the mouth. R6 stated R4 came on R6 side of the room and reached for the remote control to the television, and they got into a tussle. We removed R4 from the room and assessed R4 mouth. We evaluated R6 and R6 had a bite mark on the hand. There were no injuries. R4 became irate with staff because R4 did not want a room change. R4 was sent out for a psych evaluation/aggressive behavior. Typically, R4 is grumpy. R6 has no behaviors. On [DATE] at 2:09 PM, V21 (Certified Nursing Assistant) stated I did not witness the altercation. R4 told me what happened. R4 and R6 had an altercation. R4 told me R4 hit R6 and R6 hit R4 back. R4 said it was about the television. The television was located at a third bed with no resident. It was straight across from R6 bed. R6 was watching television. I went and got the nurse so R4 and R6 could tell the nurse what they told me. R4 progress note, [DATE], reads in part: Staff member alerted writer that patient had a physical altercation with roommate. R6 progress note, [DATE], reads in part: Staff member alerted writer that patient had a physical altercation with roommate. Facility incident report, [DATE], documents in part: Investigation concluded that R6 was lying in bed when R4 approached regarding turning volume on television down and R6 declined. When R6 was pushed by R4, a physical altercation ensued resulting in R6 sustaining a small bite mark to the index finger. Facility Abuse Policy and Prevention Program, 10/2022, documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation or property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility is committed to protecting out residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on observation, interview and record review, facility failed to ensure wound care orders and wound care interventions are in place in order to be followed for 2 (R1 and R5) out of three residents reviewed for pressure ulcer prevention. Findings include: On 12/12/ 2023 at 10:00 AM, surveyor observed R5 laying flat on her back in her room. R5 is non-verbal. V11 (R5's POA), who is also her sister, was sitting in the room with her. On 12/12/2023 at 11:30 AM, R5's POA stated no one has come in to change her or turn her. She stated that R5 came to see her sister around 10 AM. On 12/12/2023 at 12:00 PM, surveyor went into R5's room and saw R5 was laying flat on her back. On 12/12/2023 at 2:19 PM V12 (Wound Care Nurse) stated that R5 does have a sacral wound. V12 stated that R5's sacral dressing needs to be changed every day, even through the weekends. V12 stated that R5 went out to the hospital and came back Friday 12/08/2023. V12 stated that before R5 went to the hospital, she had a set of wound dressing change orders. V12 stated that those orders got discontinued when R5 went to the hospital. We should have restarted those orders the day she was readmitted . On 12/13/2023 at 11:00 AM, surveyor observed R5 laying flat on her back in her room. R5's POA was sitting in the room with her. R5 stated that they change her wound around 10 AM this morning. On 12/13/2023 surveyor observed R5 laying flat on her back from 11:00 AM to 1:00 PM. On 12/13/2023 at 12:30 PM, surveyor observed R5 laying on her back. Surveyor observed CNA go into room but did not turn R5. On 12/13/2023 at 12:48 PM, surveyor observed R5 laying on her back. R5's POA stated that they haven't turned her. Just changed her wound earlier in the day. On 12/13/2023 at 12:57 PM, surveyor observed V23 (Certified Nursing Assistant) state to V17 (2nd Floor Unit Manager) that she was going on break. Surveyor quickly asked V23 when the last time was, she turned or changed R5. On 12/13/2023 at 1:00 PM, V23 replied that the last time she turned R5 was when the wound care team changed her wound dressing. V23 stated that she is supposed to turn, reposition, and change R5, every two hours. On 12/13/2023 at 1:05 PM, surveyor observed V23 ask V17 if she would turn and reposition R5 before she goes on break. V17 stated yes and V23 went into R5's room to change and reposition her. On 12/13/2023 at 1:15 PM, V12 stated that R5's sacral wound dressing changed this morning at 10:00 AM. R5's wound care plan documents in part: Only intervention for sacrum pressure ulcer; ensure proper body alignment. Surveyor showed R5's wound care plan to V1 (Administrator) and V2 (Director of Nursing). Both V1 and V2 stated that R5's wound care plan should be updated with more interventions appropriately. R5's Treatment Administration Record (12/2023) documents in part: No documentation of sacral wound dressing changes from 12/08/2023 to 12/12/2023. R5's Facesheet documents in part: admission date: 12/08/2023. R5's Physician order sheet documents in part: Left Buttock, foam dressing every day shift. Order date 12/12/2023. On 12/14/2023 at 2:00 PM, V20 (Veterans Affair Registered Nurse at Veterans Contract Nursing Home Program) stated we came and investigated R1's care at the facility and we substantiated that he had a pressure ulcer develop at the facility. R1's Wound Assessment Detail Report (10/16/2023) documents in part: Pressure Ulceration stage 2 sacrum, facility-acquired. 1.50 cm x 1.00 cm x 0.00 cm. Facility's Skin management: Monitoring of Wounds and Documentation documents in part: with each dressing change or at least weekly, an evaluation of the Pressure ulcer should be documented.

Based on observation, interview, and record review, the facility failed to ensure a resident who was self-administering medications, had a self-administration of medications evaluation, a physician's order, and a care plan completed for 1 (R102) of 1 resident reviewed for self-administration of medications in a total sample of 32. Findings Include: On 8/15/23 at 10:01 AM, a medication administration observation conducted with V4 (Licensed Practical Nurse). At approximately 10:12 AM, V4 administered some of R102's morning medications except for R102's nasal spray and eye drops. V4 stated that R102 self-administers the nasal spray and R102 keeps it at bedside. At 10:37 AM, interviewed R102 and stated that R102 keeps the nasal spray in R102's room. R102 stated, I gave it to myself this morning. At 11:18 AM, Surveyor observed V4 enter R102's room with R102's eye drops. R102 stated, I'll do it myself. Surveyor observed R102 administered one drop in each eye without pulling R102's lower eyelids down. R102 then rubbed the solution off R102's eyes using his fingers. On 8/16/23 at 11:45 AM, reviewed R102's electronic medical records and no self-administration of medications assessment was found to determine R102 is able to administer own medications safely and effectively. R102's physician order sheet with active orders as of 8/15/23 has no order for self-administration of medications. R102's comprehensive care plan does not address R102's self-administration of medications. On 8/17/23 at 10:47 AM, V2 (Director of Nursing) stated that if a resident is self-administering medications that there should be a doctor's order and an assessment to determine that the resident is able to administer own meds. V2 stated that the self-administration of medication needs to be completed upon request the resident wants to self-administer their medications. V2 stated that the purpose of the assessment is to determine if the resident can safely take their medications. The facility's policy titled; SELF ADMINISTRATION OF MEDICATIONS AND TREATMENTS dated 1/23 reads in part: GUIDELINE: 1. Self administration of medications and treatments is determined by an order after determining that the resident is able to self administer. PROCEDURE: 1. If it is determined by a member of the interdisciplinary team, or if the resident requests to self administer, it is documented in the cart and the Health Care Provider is called for an order to self administer medications, and keep the medications at bedside. 2. Determination of the ability to self-administer medications will be down by nursing using the form in PCC titled Medication Self-Evaluation Administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow policy for comprehensive care plan to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's needs and problems. This failure can potentially affect 3 (R113, R138, R413) of 3 residents reviewed for comprehensive care plan in the sample of 32. The findings include: R113's health record documented admission date of 1/12/21 with diagnoses not limited to Paroxysmal atrial fibrillation, Essential hypertension, Type 2 diabetes mellitus, Major depressive disorder, Anxiety disorder, Vitamin D deficiency, Gastro-esophageal reflux disease, Hyperlipidemia, Anemia, Nicotine dependence, Heart failure, Atherosclerotic heart disease. R138's health record documented admission date of 9/22/22 with diagnoses not limited to Metabolic encephalopathy, Schizoaffective disorder, Insomnia, Alcohol abuse, Opioid abuse, Cocaine abuse, Hyperlipidemia, Nicotine dependence, Major depressive disorder, Bipolar disorder, Essential hypertension, Atrial fibrillation, Chronic obstructive pulmonary disease, Gastro-esophageal reflux disease, Benign prostatic hyperplasia, Epilepsy. R413's health record documented admission date of 7/11/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Anxiety disorder, Opioid abuse, Cocaine abuse, Heart failure, Chronic respiratory failure, Nicotine dependence, Dependence on supplemental oxygen, Major depressive disorder, Essential hypertension, Insomnia, Asthma, Bipolar disorder. On 8/16/23 at 1:44 pm V14 (Social Service Director / SSD) stated she has been working in the facility since 2019. V14 (SSD) stated that resident who smoke will be evaluated for any unsafe smoking behaviors by completing smoking risk assessment upon admission, quarterly, annually, and as needed. V14 stated that smoking and advance directives / code status care plan should be developed to establish plan of care or guidance to staff that would include goals and interventions appropriate for the identified problem or concern of the resident. V14 stated that social service department is responsible for smoking and advance directives care plan. Reviewed R113's electronic health record (EHR) with V14 and stated that R113's code status order is DNR (Do Not Resuscitate). V14 confirmed that advance directive or code status care plan was not found in R113's EHR. R138's Smoking Risk Assessment reviewed with V14 and confirmed that last smoking risk assessment was completed on 6/16/2023 showed that R138 was potentially unsafe smoker and to develop safe smoking care plan. V14 confirmed that no care plan found in R138's EHR. V14 confirmed that R413 uses oxygen and is an active smoker. V14 confirmed that no care plan for smoking found in R413's EHR. R113's order summary report dated 8/16/23 documented in part: Code status: DNR. MDS (Minimum Data Set) dated 8/3/23 showed that R113's cognition was intact. R113 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. No advance directive or code status care plan found in R113's EHR. R138's order summary report dated 8/16/23 documented in part: Code status: Full code. MDS dated [DATE] showed that R138's cognition was intact. R138 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. MDS showed that R138 with current tobacco use. R138's smoking risk assessment dated [DATE] documented in part: Potentially unsafe smoker. Develop safe smoking care plan. No advance directive / code status and smoking care plan found in R138's EHR. MDS (Minimum Data Set) dated 8/3/23 showed that R413's cognition was intact. R413 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. MDS showed that R413 with current tobacco use. No smoking care plan found in R413's EHR. Facility's policy for comprehensive care plan dated 1/2023 documented in part: - The facility must develop a comprehensive person-centered care plan for each resident. - The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. - The comprehensive care plan should drive the care and services provided for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure an air mattress used for pressure reduction was on the correct setting for 1 (R37) of 2 (R70) residents reviewed for pressure ulcers in a sample of 32. Findings Include: R37 was admitted to the facility on [DATE] with diagnosis not limited to Muscle Weakness, Elevated [NAME] Blood Cell Count, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Protein-Calorie Malnutrition, Acquired Deformity of hand, Left Hand, Sepsis, Paroxysmal Atrial Fibrillation, Chronic Embolism and Thrombosis, Pressure Ulcer of Unspecified Site, Disorder of Muscle, Disorder of Bone Density and Structure, Reduced Mobility, Abnormalities of Gait and Mobility and Lack of Coordination. R37 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. R37 Weights and Vitals Summary dated 08/15/23 document in part: Weight Summary 07/01/23 100.3 pounds and 08/10/23 100.9 pounds. R37 Order Summary Report dated 08/15/23 document in part: Pressure redistribution mattress while in bed every shift for pressure relief. Care Plan document in part: R37 has potential/actual impairment to skin integrity. Date Initiated: 01/21/23. R37 (pressure relieving/reducing mattress, pillows, sheepskin padding etc.) to protect the skin while in bed. R37 has pressure ulcer(s) Date Initiated: 02/08/23. Intervention: The resident requires) (Pressure redistribution device) on (bed/chair). Focus: Alteration in skin integrity - Resident has Pressure Injury. Site: sacrum, right outer ankle, left trochanter, right trochanter Date Initiated: 01/21/23. Intervention: Apply specialty mattress when in bed. On 08/15/23 at 12:12 PM V11 (Second Floor Unit Manager) stated R37 has wounds and is on a low air loss mattress. V11 entered R37 room with the surveyor and stated the low air loss mattress look like it is on 65 kg/140 pounds. On 08/15/23 at 01:45 PM V13 (Wound Care Nurse/Licensed Practical Nurse) stated R37 low air loss mattress was set incorrectly based off R37 weight. The low air loss mattress was set on 140 pounds and R37 weighs 100 pounds. I went and changed the low air loss mattress to the correct setting. R37 has pressure injuries, I think 9 wounds and the one wound on R37 sacrum is improving. Both of R37 hip wounds are not getting better. I have some notes on R37 wounds and hospice take the measurements. R37 last wound measurement was on 08/07/23. On 07/10/23 R37 wounds were documented in the wound rounds and R37 was last seen by the wound care doctor in July 2023. On 08/17/23 at 10:02 AM V2 (Director of Nursing) stated my expectations are that the low air loss mattress is inflated with the proper settings. The purpose the low air loss mattress is so that it can assist in wound prevention and healing. If the low air loss mattress setting is too high, it can have an ill effect on the resident's wounds and the skin. R37 Wound Physicians Progress Note dated 07/18/23 document in part: Signing off on patient who remains in the facility. Patient is being followed by hospice team. Policy: Titled Skin Management: Monitoring of Wounds and Documentation dated 01/23 document in part: General: It is important that the facility have a system in place to assure that the protocol for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Titled Mattress Use dated 01/23 document in part: Guideline: 1. The standard for all mattresses on the bed will be pressure reducing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain was thoroughly assessed and adequately treated for in a timely manner for 1 (R102) of 1 reviewed for pain management in a total sample of 32. Findings Include: During the medication administration observation with V4 (Licensed Practical Nurse) on 8/15/23 at 10:02 AM, R102 requested pain medication from V4. V4 did not assess the type, location, and rate of R102's pain. At 10:12 AM, V4 administered some of R102's morning medications except the pain medication R102 requested. V4 stated that the pain medication ordered for R102 was not available in the medication cart. At 10:37 AM, interviewed R102 and stated that V4 has not given R102 the pain medication R102 requested. R102 stated that R102's pain is at 8 out of 10. R102 stated the R102 has generalized pain related to arthritis and also takes the pain medication for gout. At 11:13 AM, V4 administered R102's pain medication. V4 did not further assess R102's pain. 8/17/23 at 9:54 AM, V2 (Director of Nursing) stated that when a resident complains of pain, the expectation is for the nurse to assess the resident's severity of pain and location, administer medication per doctor's order and then document. V2 stated that depending on the severity of the pain, the nurse would notify the doctor also and pain medication should be given to the resident as soon as possible. R102's clinical records show listed diagnoses not limited to rheumatoid arthritis (RA), peripheral vascular disease, gout, and hereditary and idiopathic neuropathy. R102's physician order sheet shows an order of Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Pain Level 1-4 ordered on 3/13/20. R102's Minimum Data Set, dated [DATE] shows R102 is cognitively intact. R102's care plan initiated on 3/20/20 shows R102 is at risk for alteration in comfort/pain due to frostbite hands/fingers, RA, Gout, and neuropathy with one intervention that reads, Administer medication as ordered and monitor for effectiveness of relief. The facility's Medication Admin Audit Report for R102 dated 8/15/23 shows pain medication was administered to R102 at 11:12 AM. The facility's policy titled, PAIN MANAGEMENT dated 1/23 reads in part: GUIDELINE: Pain management is a multidisciplinary care process that includes the following: Observing for the potential for pain Effectively recognizing the presence of pain Identifying the characteristics of pain Addressing the underlying causes of the residents pain Developing and implementing approaches to pain management Identifying and using specific strategies for different levels and sources of pain Monitoring for the effectiveness of intervention; and modifying approaches as necessary.

Based on interview and record review, the facility failed to follow their policy and procedure for Psychotropic Medication Program and ensure that a gradual dose reduction (GDR) was attempted for a resident receiving antipsychotic medication. This failure has the potential to affect 1 (R42) of 5 residents reviewed for psychotropic medications in a total sample of 32. Findings Include: On 8/17/23 at 9:28 AM, reviewed R42's Medication Administration Record (MAR) for August 2023 and revealed R42 was receiving antipsychotic medication SEROquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth in the morning related to ADJUSTMENT DISORDER WITH ANXIETY (F43.22) AND Give 12.5 mg by mouth in the evening related to ADJUSTMENT DISORDER WITH ANXIETY (F43.22). R42's progress notes dated 10/12/22 at 10:07 AM written by V41 (Psychiatry Nurse Practitioner) shows R42 was started on Seroquel 12.5mg twice a day. R42's electronic health records (EHR) do not show any documentation that facility attempted a GDR for R42's antipsychotic medication. R42's psychotropic notes dated 11/1/22, 12/20/22, 1/5/22, 2/28/22, 3/28/22, and 6/22/23 show no documentation of attempted GDR. Surveyor requested to provide a copy of R42's GDR for R42's psychotropic medication, but facility was unable to provide. At 10:11 AM, interviewed V42 (Assistant Director of Nursing) and stated that GDRs should be documented in the resident's EHR. V42 stated that the facility's objective is to decrease the residents' use of psychotropic medications, and if GDR is contraindicated then the Psychiatrist should provide the reason for contraindication and document in the resident's EHR. The facility's policy titled; PSYCHOTROPIC MEDICATION PROGRAM dated 1/23 reads in part: GENERAL: The purpose is to promote the safe and effective use of psychotropic medications. To ensure the lowest dose of medication is used, for the shortest timeframe. To guarantee a resident's quality of life is enhanced by the medication usage. The third purpose of this guideline is once a resident is placed on a psychotropic medication the facility monitors the resident for side effects and adverse reactions, addresses the use of the medications in a comprehensive plan of care, and assesses the resident for a GDR (Gradual Dose Reduction). GRADUAL DOSE REDUCTIONS: 1. Gradual dose reductions (GDR) are required to be attempted twice within the first year in 2 separate quarters and at least one month in between attempts. After the first year of therapy, GDRs should be attempted annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that MDS (Minimum Data Set) assessments were transmitted within 14 days of the final completion date to thCenters for Medicare and Medicaid Services (CMS) system. This failure can potentially affect 11 (R4, R16, R17, R31, R51, R62, R72, R92, R93, R109, R112) of 11 residents reviewed for resident assessment in a sample of 32. The findings include: R4's health record documented admission date of 8/22/21 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Type 2 diabetes mellitus, Peripheral vascular disease, Gastro-esophageal reflux disease, Chronic kidney disease stage 3A, Heart failure, Major depressive disorder, Hyperlipidemia, Essential hypertension, Anemia, Atherosclerotic heart disease. R16's health record documented admission date of 6/20/16 with diagnoses not limited to Cerebral infarction, Heart failure, Cognitive communication deficit, Insomnia, Vitamin D deficiency, Polyosteoarthritis, Spondylosis thoracic and lumbar region, Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Aphasia following unspecified cerebrovascular disease, Major depressive disorder, Hyperlipidemia, Peripheral vascular disease, Gastro-esophageal reflux disease, Essential hypertension. R92's health record documented admission date of 4/3/23 with diagnoses not limited to Rhabdomyolysis, Chronic osteomyelitis right tibia and fibula, Non pressure chronic ulcer right lower leg, Peripheral vascular disease, Anemia, Opioid dependence, Nicotine dependence, Chronic atrial fibrillation, Systolic congestive heart failure, Chronic obstructive pulmonary disease, Asthma, Malignant neoplasm of prostate, Major depressive disorder. On 8/17/23 at 9:03 am V34 (Minimum Data Set / MDS Coordinator, Licensed Practical Nurse / LPN) stated that she has been working with the company for 16 years and 4-5 years in the facility. V35 (MDS Coordinator, Registered Nurse / RN) stated he has been working in the facility since 1995. V35 stated that MDS is a compilation of datas from different department and different assessment areas triggers CAA (Care Area Assessment) and care planning. V35 stated that MDS in an interdisciplinary process that impacts quality of care, care planning, reimbursement, quality measures. V35 stated that MDS is a framework to proceed with care planning. V34 stated that MDS is a snapshot of resident during assessment window, giving a picture of the resident. V35 stated that MDS is a regulation / federally mandated process for clinical assessment of all residents. V34 and V35 stated that they are following CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) user's manual policy in completing and transmitting MDS assessment. V35 stated that timeframes for MDS Quarterly, ARD (Assessment Reference Date) is set within 92 days from the last assessment, could be earlier but not later than 92 days. V35 stated that it should be completed within 14 days from the ARD and transmission date is another 14 days from the completion of MDS assessment. V35 stated that MDS Annual, ARD is set within 366 days from the last annual and 92 days from the last quarterly. V35 stated that is should be completed within 14 days from the ARD including CAA. V35 stated that care plan completion date is CAA completion date + 7 calendar days. V35 stated that transmission date is care plan completion date + 14 calendar days. MDS assessments for the following residents reviewed with V35: 1. R4's Annual ARD 7/10/23, completed on 7/24/23. V35 stated that it was batched and submitted to national data base on 7/31/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/7/23. 2. R16'S Quarterly ARD 7/12/23 - completed on 7/26/23. V35 stated that it was batched and submitted to national data base on 8/2/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/9/23. 3. R17's Quarterly ARD 7/10/23, completed on 7/24/23. V35 stated that it was batched and submitted to national data base on 7/31/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/7/23. 4. R31's Quarterly ARD 7/13/23, completed on 7/27/23. V35 stated that it was batched and submitted to national data base on 8/2/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/10/23. 5. R51's Quarterly ARD 7/12/23, completed on 7/26/23. V35 stated that it was batched and submitted to national data base on 7/31/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/9/23. 6. R62's Annual ARD 7/11/23, completed on 7/25/23. V35 stated that it was batched and submitted to national data base on 7/31/23 but was not accepted and there was no validation report. V35 stated that R62's MDS assessment should have been transmitted and accepted with validation report not later than 8/8/23. 7. R72's Quarterly ARD 7/12/23, completed on 7/26/23. V35 stated that it was batched and submitted to national data base on 8/2/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/9/23. 8. R92's Quarterly ARD 7/10/23, completed on 7/24/23. V35 stated that it was batched and submitted to national data base on 7/31/23 but was not accepted, no validation report. V35 stated that R72's MDS assessment should have been accepted with validation report not later than 8/7/23. 9. R93's Annual ARD 7/11/23, completed on 7/25/23. V35 stated that it was batched and submitted to national data base on 8/2/23 but was not accepted, no validation report. V35 stated that R109's MDS assessment should have been accepted with validation report not later than 8/8/23. 10. R109's Quarterly ARD 7/11/23, completed on 7/25/23. V35 stated that it was batched and submitted to national data base on 7/31/23 but was not accepted, no validation report. V35 stated that R109's MDS assessment should have been accepted with validation report not later than 8/8/23. 11. R112'2 Quarterly ARD 7/11/23, completed on 7/25/23. V35 stated that it was batched and submitted to national data base on 8/2/23 but was not accepted, no validation report. V35 stated that R109's MDS assessment should have been accepted with validation report not later than 8/8/23. V35 stated that MDS assessment transmitted to national data base (CMS system) has a final validation report that it was accepted. Facility's record for Batch #3114 dated 8/17/23 documented in part: Batched accepted date of 8/2/23 with the following residents R17, R51, R62, R92, R109. Facility was not able to provide validation report that it was transmitted and accepted to CMS system. Facility's record for Batch #3117 dated 8/17/23 documented in part: Batched accepted date of 8/2/23 with the following residents R4, R16, R31, R72, R93, R112. Facility was not able to provide validation report that it was transmitted and accepted to CMS system. CMS'S (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 manual dated October 2019 Chapter 2 page 2-16 and 2-17 RAI OBRA-required Assessment Summary documented in part: Annual (Comprehensive) - MDS Completion Date (Item Z0500B) No Later Than ARD + 14 calendar days. CAA(s) Completion Date (Item V0200B2) No Later Than ARD + 14 calendar days. Care Plan Completion Date (Item V0200C2) No Later Than CAA(s) Completion Date + 7 calendar days. Transmission Date No Later Than Care Plan Completion Date + 14 calendar days. Quarterly (Non-Comprehensive) - MDS Completion Date (Item Z0500B) No Later Than ARD + 14 calendar days. Transmission Date No Later Than Care Plan Completion Date + 14 calendar days. SOM (State Operations Manual) page 217 documented in part: Transmitted means electronically transmitting to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, an MDS record that passes CMS' standard edits and is accepted into the system, within 14 days of the final completion date, or event date in the case of Entry and Death in Facility situations, of the record. Transmitting data refers to electronically sending encoded MDS information, from the facility to the QIES ASAP System. 08/17/23 12:23 PM R62 admitted [DATE]. Diagnosis list includes: Spinal Stenosis, Lumbar Region Without Neurogenic Claudication, Hypokalemia, Venous Insufficiency (Chronic) (Peripheral), Heart Failure, Type 2 Diabetes Mellitus Without Complications, Gastro-Esophageal Reflux Disease Without Esophagitis Insomnia, Vitamin D Deficiency, Low Back Pain, Muscle Spasm of Back, Constipation,Lack Of Physical Exercise, Cannabis Use, Obesity, Psychoactive Substance Abuse,Spinal Stenosis, Cervical Region, Cocaine Abuse, Nicotine Dependence, Cigarettes,Peptic Ulcer, Site Unspecified, Unspecified as Acute Or Chronic, Without Hemorrhage Or Perforation, Hyperlipidemia, Localized Edema, Opioid Dependence, Hypertension, Morbid (Severe) Obesity Due To Excess Calories. 08/17/23 12:46 PM R51 admitted [DATE]. Diagnosis list include: Type 2 Diabetes Mellitus Without Complications, Hypertension, Schizoaffective Disorder, Type 1 Diabetes Mellitus Without Complications, Pulmonary Hypertension, Elevated [NAME] Blood Cell Count, Personal History Of COVID-19, Disease Of Upper Respiratory Tract, Bradycardia, Vitamin D Deficiency, Unilateral Primary Osteoarthritis, Left Hip, Obstructive Sleep Apnea (Adult), Allergic Rhinitis, Gastro-Esophageal Reflux Disease Without Esophagitis, Tachycardia, Primary Osteoarthritis, Morbid (Severe) Obesity Due To Excess Calories, Dyspnea, Nicotine Dependence, Cigarettes, Alcohol Abuse, Hyperlipidemia, Schizoaffective Disorder, History Of Falling. R109 admitted on [DATE], with clinical diagnosis of; type II diabetes, chronic obstructive pulmonary disease, hyperlipemia, peripheral vascular disease, chronic kidney disease stage 2, gastritis, ocular hypertension, major depression, opioid dependence with withdrawal, anemia, ascites, long QT syndrome, cerebral infarction, convulsions, alcohol dependence, pure hypercholesterolemia with delirium, and chronic gastric ulcer with perforation. R51 admitted on [DATE], with clinical diagnosis of; type II diabetes, essential hypertension, schizoaffective disorder, type I diabetes, pulmonary hypertension, elevated white blood cell count, bradycardia, osteoarthritis, obstructive sleep apnea, and schizoaffective disorder. R93 admitted on [DATE], with clinical diagnosis of; left ventricular failure, dysphagia, insomnia, keratoconjunctivitis sicca of right eye, atrophy of globe-right eye, blindness right eye, alcohol dependence with alcohol induced psychotic disorder, acute respiratory failure, atrioventricular block, essential hypertension, asthma, paranoid schizophrenia, cardiac arrest, encephalopathy and sleep apnea. R72's clinical record shows an admission date of 4/2/21 with listed diagnoses not limited to Cerebral Infarction, Peripheral Vascular Disease, and Stage 3 Chronic Kidney Disease. R31's clinical record shows an admission date of 3/21/19 with listed diagnoses not limited to Dementia, Type 2 Diabetes Mellitus, and Essential Hypertension. R17 admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Nontraumatic Intracranial Hemorrhage, Disorder of Urinary System, Hemiplegia and Hemiparesis Cerebrovascular Disease, Dementia, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Cortical Age-Related Cataract, Chronic Kidney Disease, Presbyopia, Hyperlipidemia, Major Depressive Disorder, Anxiety Disorder, Anemia, Dysphagia and Vitamin D Deficiency. R112 admitted to the facility on [DATE] with diagnosis not limited to History of Falling, Chronic Obstructive Pulmonary Disease, Essential (Primary) Hypertension, Benign Neoplasm of Cerebral Meninges, Pulmonary Embolism, Constipation, Anemia, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity, Asthma, Major Depressive Disorder, recurrent, Vitamin D Deficiency, Mood [Affective] Disorder, Hereditary and Idiopathic Neuropathy, Glaucoma, Morbid (Severe) Obesity, Hyperglycemia, Type 2 Diabetes Mellitus, Muscle Weakness, Personal History of COVID-19, Acute Kidney Failure, Insomnia, Intervertebral Disc Degeneration, Lumbar Region, Leiomyoma of Uterus, Intervertebral Disc Degeneration, Thoracic Region, Thoracolumbar and Lumbosacral Intervertebral Disc Disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure incontinence care was provided in a timely manner for a resident (R13) who is dependent in toileting, and to ensure nail care was provided to 3 (R69, R3, R42) of 4 residents who are dependent with personal hygiene reviewed for activities of daily living (ADL) in a total sample of 32. Findings Include: 1. On 8/15/23 at 11:26 AM, R69 was still lying in bed alert wearing a hospital gown, alert and able to verbalize needs. R69's fingernails were noted approximately 2.0 centimeters (cm) long with black substance under R69's fingernails. R69 does not remember the last time R69's fingernails were cut and cleaned. R69's clinical records show diagnoses not limited to End-Stage Renal Disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Weakness, Adult Failure to Thrive, and Cognitive Communication deficit. R69's Minimum Data Set (MDS) dated [DATE] shows R69's is moderately impaired in cognition and requires extensive one staff assistance with personal hygiene. R69's ADL care plan initiated on 11/15/21 shows R69 has an ADL self-care performance deficit. 2. On 8/15/23 at 11:51 AM, R3 was lying in bed alert and able to verbalize needs. R3's fingernails were noted approximately 0.5 cm long with thick and hard black substance finger R3's fingernails. R3 stated that R3 does not remember when the last time staff cut R4's fingernails. R3 stated, They need to be cut. R3's clinical records show diagnoses not limited to Dementia, Cognitive Communication Deficit, Adult Failure to Thrive, and Major Depressive Disorder. R3's MDS dated [DATE] shows R3 is moderately impaired in cognition and requires extensive one staff assistance with personal hygiene. R3's ADL care plan initiated on 4/14/22 shows R3 has an ADL self-care performance deficit. 3. On 8/15/23 at 11:53 AM, R13 was lying in bed alert and awake. Surveyor noted a wet diaper with stool on the floor by R13's bed. When Surveyor asked R13, R13 stated, My diaper was wet I took it off. At 11:56 AM, V16 (Certified Nursing Assistant) entered R13's room. R13 stated, I was here around 8:30 AM and [R13] was dry then. That was the last time I checked on [R13]. R13's clinical records show diagnoses not limited to Dementia, Alzheimer's Disease, [NAME] Blindness, and Major Depressive Disorder. R13's MDS dated [DATE] shows R13 is severely impaired with cognition and requires extensive one staff assistance with personal hygiene. R13's ADL care plan initiated on 4/3/16 shows R13 has ADL self-care performance deficit. R13's care plan also shows R13 has impaired visual function date initiated on 4/17/15. 4. On 8/15/23 at 12:16 PM, R42 was eating lunch in the 4th floor dining room with bare hands noted fingernails approximately 2.0 cm long with thick yellowish substance under R42's fingernails. On 8/17/23 at 9:26 AM, R42 stated that R42 needs staff to cut and clean R42's fingernails. R42's clinical records show diagnoses not limited to Dementia, Altered Mental Status, End Stage Renal Disease, and Type 2 Diabetes Mellitus. R42's MDS dated [DATE] shows R42 moderately impaired cognition and requires supervision one staff assistance with personal hygiene. R42's ADL care plan with date initiated on 12/21/22 shows R42 has an ADL self-care performance deficit. On 8/17/23 at 9:54 AM, interviewed V2 (Director of Nursing) and stated that it is V2's expectation for the nursing staff to keep residents clean and dry. V2 stated that nurses and Certified Nursing Assistants (CNAs) should alternately make rounds to the residents every hour. V2 stated that incontinence care should be provided to the residents at least every two hours and as needed. V2 stated that nurses and CNAs should provide nail care to the residents daily during ADL care and as needed especially for dependent and cognitively impaired residents. V2 stated that the residents are scheduled twice a week for shower days. The facility's policy titled; NAIL CARE dated 1/1/23 reads in part: GENERAL: To provide care and maintain hygiene for the resident's nails. GUIDELINE: 3. Remove dirt from underneath fingernails. 4. Trim nails with a nail clipper, cutting straight across. Round edges with an emery board. 6. Nail care is offered and performed on the resident's shower day and as needed. The facility's policy titled; INCONTINENCE CARE dated 1/23 reads in part: GENERAL: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility: 1. Failed to ensure emergency tracheostomy care equipment was readily accessible for 2 (R70, R82) of 2 residents reviewed for tracheostomy care. 2. Failed to ensure that oxygen liter flow ordered by physician is followed for 3 (R33, R104, R413) residents. 3. Failed to place oxygen in use sign outside the room for 3 (R33, R104, R413) residents. 4. Failed to ensure oxygen cannula tubing is place in bag when not in use for 1 resident (R155). 5. Failed to ensure that oxygen cylinder / tank was in a cylinder stand for 2 (R104 and R413) residents. These failures have the potential to affect 6 (R33, R70, R82, R104, R155, R413) of 6 residents reviewed for respiratory care in the sample of 32. The findings include: R33's health record documented admission date of 4/16/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Neoplasm of trachea, bronchus and lung, Major depressive disorder, Unspecified dementia, Schizoaffective disorder, Atherosclerotic heart disease, Alcoholic cirrhosis, Folate deficiency anemia, Hyperlipidemia, Nicotine dependence, alcohol dependence, Asthma, Essential hypertension, Vitamin D deficiency, Peripheral vascular disease. R104's health record documented admission date of 1/23/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Anemia in chronic kidney disease, Hyperlipidemia, Type 2 diabetes mellitus, Cocaine abuse, Opioid abuse, Anxiety disorder, Nicotine dependence, Essential hypertension, Atherosclerotic heart disease, Cardiomyopathy, Chronic diastolic congestive heart failure, Asthma, Chronic kidney disease stage 3, Dependence on supplemental oxygen. R413's health record documented admission date of 7/11/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Anxiety disorder, Opioid abuse, Cocaine abuse, Heart failure, Chronic respiratory failure, Nicotine dependence, Dependence on supplemental oxygen, Major depressive disorder, Essential hypertension, Insomnia, Asthma, Bipolar disorder. On 8/15/23 at 11:35 am Observed R104 lying in bed, alert and verbally responsive, with oxygen at 4L/min via nasal cannula. R104 stated that she is using oxygen continuously due to her diagnosis of COPD (Chronic obstructive pulmonary disease). R104 stated that she used to smoke. Observed with oxygen tank / cylinder standing alone without stand / holder by the oxygen concentrator. V15 (Licensed Practical Nurse / LPN) requested to R104's room and confirmed that oxygen liter flow is at 4L/min via nasal cannula. V15 stated that oxygen tank at bedside was kept due to issue with the concentrator. V15 stated that oxygen tank should have a stand for safety. At 11:50 am Observed R33 alert and verbally responsive, observed sitting at the side of bed. Observed with oxygen via nasal cannula at 4L /min. Requested V17 (Registered Nurse / RN) confirmed that oxygen liter flow is at 4L/min; V17 stated that it should be 3L/min. V17 stated that R33 can adjust the oxygen regulator / knob. V17 stated it oxygen liter flow should be monitored. At 1:00 pm Observed R413 up and about in room, alert and verbally responsive, with oxygen at 2L/min via nasal cannula. R413 stated that she is using oxygen for her COPD. Observed oxygen cylinder / tank lying horizontally on the rack below the rollator / rolling walker seat. On 8/17/23 at 11:37 am V2 (Director of Nursing / DON) stated that she has been with the company since 2011 and started working in the facility on July 10th, 2023. V2 stated that oxygen is administered per doctor's order that would include oxygen liter flow and method of administration. V2 stated that oxygen tank / cylinder cannot stand alone and should be in oxygen holder for safety. V2 stated that clear plastic bag should be available in the room by the oxygen concentrator to keep the oxygen tubing when not in use for infection control. V2 stated that there should be a door signage for use of oxygen for safety purposes. V2 stated that oxygen should be monitored closely to make sure that oxygen liter flow is administered per doctor's order. R33's order summary report dated 8/16/23 documented in part: 02 (oxygen) @ 3/L per nasal cannula prn. Care plan dated 4/16/23 and 6/19/23 documented in part: R33 has oxygen therapy prescribed at 3L per nasal cannula related to chronic respiratory illness. R33 has Emphysema/COPD. Care plan interventions included but not limited to: Give / administer oxygen therapy as ordered by physician. MDS (Minimum Data Set) dated 7/19/23 showed R33's cognition was intact. R33 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. MDS showed that R33 was continent of bowel and bladder. R104's order summary report dated 8/16/23 documented in part: Oxygen (02) @ 2-3 Liters/Minute per Nasal Cannula, Maintain 02 Saturation @ 95% or greater every shift for SOB (shortness of breath). Care plan dated 1/24/23 documented in part: R104 has Oxygen Therapy 2-3 liters per NC (nasal cannula) to maintain O2 saturation greater than or equal to 95%. Care plan interventions included but not limited to: Administer oxygen per physicians orders: 2-3LPM per NC to maintain O2 sat @ 95% or higher. MDS dated [DATE] showed R104's cognition was intact. R104 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. MDS showed that R104 was continent of bowel and bladder. MDS showed that R104 received oxygen therapy. R413's order summary report dated 8/16/23 documented in part: Oxygen (02) @ 4-5 Liters/Minute per nasal canula continuous, Maintain 02 Saturation @ 92 or greater every shift for SOB. Care plan dated 7/24/23: R413 has Oxygen Therapy prescribed 4-5 liters to maintain O2 saturation greater than or equal to 92%. Acute/chronic respiratory failure. CHF, COPD. Care plan intervention included but not limited to: Administer oxygen per physicians orders. MDS (Minimum Data Set) dated 8/3/23 showed that R413's cognition was intact. R413 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. Facility's Oxygen therapy policy dated 9/2022 documented in part: - Residents who require oxygen therapy will have a physician order in their medical record which included amount of oxygen to be administered, route of administration, and indication of use. Facility's Oxygen cylinder safety policy dated 1/2023 documented in part: - Storage of oxygen cylinder: small cylinders, E tank, should be attached to a cylinder stand or to a therapy apparatus. On 08/15/23 at 12:20 PM, observed R155 in wheelchair receiving oxygen from portable oxygen tank located on the back of wheelchair. Oxygen concentrator observed at bedside with nasal cannula seen hanging on the top of the bed, on the bed controller. Nasal cannula was not in a plastic bag or container. On 08/15/23 at 12:21 PM, R155 stated, I put that there. I leave it hanging there when I'm not using it, so it doesn't fall on the floor. They never gave me a container to put it in. On 08/15/23 at 12:37 PM, V4 (Licensed Practical Nurse) observed R155's nasal cannula draped over R155's bed uncovered and stated the oxygen tubing should be stored in a bag to be kept clean when not in use due to infection control concerns. On 08/16/23 at 01:02 PM, observed R155 sitting in wheelchair inside the hallway near the smoking patio. R155 was not receiving oxygen but had a portable oxygen tank on the back of his wheelchair with his oxygen tubing attached to the oxygen tank and the nasal cannula wrapped around the back of his wheelchair. The oxygen tubing was not covered in a bag or container. R155 has diagnosis not limited to Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease, Pneumonia, Unspecified Asthma, Shortness of Breath, Lack Of Coordination, Disorder of Muscle, Malaise, Dysphagia, Insomnia, Gastroesophageal Reflux Disease Without Esophagitis, Hypertension, Chronic Viral Hepatitis C, Opioid Dependence, Encephalopathy, Heart Failure, Generalized Edema. R155's Order Summary Report dated 08/17/23 documents in part PRN: oxygen at 2-3 liters per minute per nasal cannula ordered 05/17/23. R155's Care Plan dated 05/17/23 documents in part R155 has oxygen therapy 2-3 liters to maintain oxygen saturation at or greater than 92% per orders. Diagnosis COPD, chronic hypoxic, respiratory failure, CHF, asthma and history of pneumonia R155's MDS (Minimum Data Set) dated 05/23/23 indicates intact cognition, extensive assistance required with bed mobility, transfer, locomotion on/off unit, dressing, bathing, toilet use and personal hygiene, wheelchair normally used for mobility, lower extremity functional limitation on one side, and R155 uses oxygen therapy while being a resident at the facility. Surveyor requested facility policy on oxygen storage on numerous occasions between 08/16-08/18/23 however none was provided. R70 was admitted to the facility on [DATE] with diagnosis not limited to Encounter for Attention to Tracheostomy, Chronic Respiratory Failure with Hypoxia, Dysphagia, Pressure Ulcer of Sacral Region, Stage 4, Chronic Obstructive Pulmonary Disease, Anoxic Brain Damage and Gastrostomy. R70 Order Summary Report dated 08/15/23 document in part: Tracheostomy Size 6. Resp (Respiratory) Ambu Bag and Downsize Trach at bedside every shift. Care Plan document in part: R70 has Tracheostomy. Potential for complications r/t (related/to) the trach. Intervention: 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. On 08/15/23 at 10:24 AM R70 was observed lying in the bed. The Ambu bag was observed in a bag hanging on the feeding pump pole. There was no step down emergency trach observed in R70 room. On 08/15/23 at 10:31 AM surveyor entered R70 room with V10 (Licensed Practical Nurse). Surveyor asked V10 the location of R70 step down emergency trach. V10 looked in the bag containing the Ambu bag and R70 drawers then responded it used to be in the bag. There should be a step-down trach, but I don't see it. If R70 trach came out, I would get a trach off the crash cart. The last time that I saw the emergency trach it was in the bag. Let me call respiratory and tell her we need one. R70 trach size is a number 6. On 08/15/23 at 10:36 AM V11 (Second Floor Unit Manager) stated R70 emergency trach was right up there above the light. The crash cart is locked and there is not a stepdown trach on the crash cart list. I am going downstairs to get R70 emergency trach. On 08/15/23 at 10:59 AM V11 (Second Floor Unit Manager) stated I went downstairs, and they are going to look for an emergency trach for R70 now. R82 was admitted to the facility 08/10/17 with diagnosis not limited to Malignant Neoplasm of Hypopharynx, Epigastric Pain, Gastritis, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Solitary Pulmonary Nodule, Sialoadenitis, Aphonia, Malignant Neoplasm of Oropharynx, Dysphagia and Encounter for Attention to Tracheostomy. R82 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R82 Order Summary Report dated 08/16/23 document in part: Resp: Ambu Bag and Downsize trach at bedside shiley size 5 every shift for prophylaxis. Tracheostomy Cannula Type shiley size 6. Care Plan document in part: R82 has a Tracheostomy; potential for complications. Date Initiated: 08/10/17. Intervention: 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 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. On 08/15/23 at 03:13 PM V4 (Licensed Practical Nurse) entered R82 room with the surveyor and when asked where the step-down emergency trach was located V4 searched and could not find the emergency trach. R82 pointed towards the window, cover his trach with his finger and stated I do not have one. They put this trach in in the hospital. When told by the surveyor the concern if his trach came out, R82 stated it would not come out. R82 stated the trach size is 6. V4 stated the step-down emergency trach would be a size 5 and it is usually in the room. If the trach comes out, I will call 911 or try to put that one back in. On 08/17/23 at 10:02 AM V2 (Director of Nursing) stated my expectation for a resident with a trach is to maintain a patent airway, trach care at least every shift and prn (as needed) and suctioning is provided. The supplies are trach care supplies, a step-down trach, ambu bag and suction machine. If there is no emergency step down trach available there is a potential for a medical emergency, and it could compromise the resident airway. Policy: Titled Tracheostomy Care dated 01/23 document in part: General: To prevent infection and preserve the patency of the airway. Procedure: 1. Verify physician's order.

Based on observations, interviews and record reviews, the facility failed to properly date opened multi-dose inhaler, nasal spray, and multi-dose insulin pens and vial for 4 residents (R42, R150, R413, R86), and to properly store medications according to the manufacturers' guidelines for 2 residents (R2, R11) from three of three medication carts inspected for medication storage and labeling. Findings Include: On 8/15/23 at 12:26 PM, inspected 4th floor's medication cart 2 with V18 (Licensed Practical Nurse). The following were noted: -R11's opened Lorazepam liquid oral concentrate stored inside the narcotic locked box. Label shows to STORE IN REFRIGERATOR. -R42's opened Novolog insulin vial without the date opened written on the label. At 12:32 PM, inspected 2nd floor's medication cart 2 with V17 (Registered Nurse). The following were noted: -R86's opened Fluticasone nasal spray without the date opened written on the label. -R2's unopened Lispro insulin pen that shows on the label to Refrigerate until opened. -R150's opened Lispro insulin pen without the date opened written on the label. At 1:01 PM, inspected 3rd floor's medication cart 1 with V15 (Licensed Practical Nurse). The following was noted: -R413's opened Budesonide inhalation without the date opened written on the label. On 8/17/23 at 9:54 AM, interviewed V2 (Director of Nursing) and stated that insulin vials and pens, inhalers, and nasal sprays should be dated when opened. V2 stated that unopened insulin pens and vials, and liquid Lorazepam should be refrigerated. R11's physician order sheet (POS) with active orders as of 8/17/23 shows an order for LORazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml sublingually every 4 hours as needed for Agitation; Restlessness. R42's POS with active orders as of 8/17/23 shows an order for Novolog insulin sliding scale. R86's POS with active orders as of 8/17/23 shows an order for Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril in the morning for allergies. R2's POS with active orders as of 8/17/23 shows orders for scheduled Lispro insulin pen and sliding scale. R150's POS with active orders as of 8/17/23 shows orders for scheduled Lispro insulin pen and sliding scale. R413's POS with active orders as of 8/17/21 shows Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD rinse mouth with water and spit back into cup after each use. The facility's policy titled; MEDICATION STORAGE IN THE FACILITY dated 1/23 reads in part: GENERAL: Medications and biologicals are stored safety, securely, and properly following the manufacturer or supplier recommendations. The drugs manufacturers' guidelines from the facility's contracted pharmacy dated 9/22 shows the following: Lorazepam Solution should be refrigerated at 2 degrees Celsius to 8 degrees Celsius. Budesonide should be discarded 3 months after removal from foil pouch. Novolog insulin vial is used within 28 days of initial use. Lispro insulin pen is used within 10 days of initial use and should be refrigerated until opened.

Based on record reviews and interviews, the facility failed to a.) administer the pneumococcal vaccination to 1 (R131) resident with a signed consent and b.) the facility failed to assess the residents for eligibility and ensure residents were offered the pneumococcal vaccination for 3 (R70, R82, R90) of 4 (R215) residents reviewed for immunization in a sample of 32. Findings Include: R70 has diagnosis not limited to Encounter for Attention to Tracheostomy, Chronic Respiratory Failure with Hypoxia, Dysphagia, Pressure Ulcer of Sacral Region, Stage 4, Chronic Obstructive Pulmonary Disease, Anoxic Brain Damage and Gastrostomy. R70: Pneumovax (There was no documentation) R82 has diagnosis not limited to Malignant Neoplasm of Hypopharynx, Epigastric Pain, Gastritis, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Solitary Pulmonary Nodule, Sialoadenitis, Aphonia, Malignant Neoplasm of Oropharynx, Dysphagia and Encounter for Attention to Tracheostomy. R82: Pneumovax (There was no documentation) R90 has diagnosis not limited to End Stage Renal Disease, Psychosis, Essential (Primary) Hypertension, Hypertensive Urgency and Dependence on Renal Dialysis R90: Pneumovax (There was no documentation). R131 has diagnosis not limited to Diarrhea, Peripheral Vascular Disease, Obesity, Nicotine Dependence, Hallux Valgus, Opioid Dependence, Hyperlipidemia, Atrial Flutter, Fournier Gangrene, Essential (Primary) Hypertension, Periodontal Disease and Type 2 Diabetes Mellitus with Diabetic Nephropathy. R131 Consent Pneumonia Vaccine dated 07/17/23 document in part: Consent decision to receive Pneumonia vaccine a. Consent to vaccination. Consent /Declination 1. Consent to vaccination as recommended by CDC (Centers for Disease Control and Prevention). R131: Pneumovax (Consent was signed with no evidence that the pneumococcal vaccination was given). On 08/16/23 at 01:58 PM V3 (Licensed Practical Nurse/Infection Preventionist) stated the nurses were not offering the pneumococcal vaccination on admission and an in-service was given. Report of Continuing Education In-Service undated document in part: Topic of Education: All Nurses are to offer Pneumovax upon admission and chart responses. If the individual wants/needs this vaccine, please chart adverse reactions for 72 hours. On 08/17/23 V3 (Licensed Practical Nurse/Infection Preventionist) presented the surveyor with the document Titled Immunization Report Type of Immunization: Pneumococcal Vaccine dated 08/15/23 with no documented pneumococcal vaccinations for (R70, R82, R90 or R131). On 08/17/23 at 10:45 AM V2 (Director of Nursing) stated if the vaccination administration is not documented it cannot be proven or verified that the vaccination was given. Policy: Titled Pneumococcal Vaccinations dated 01/23 document in part: General: To provide information on the process for giving the pneumococcal vaccination. 1. All current residents or the resident's responsible party will be screened and offered the pneumonia vaccine within the first week of admission and annually if eligible per CDC guidelines. 2. A consent will be obtained and serves as the education tool for the vaccine. If the Resident has previously received any of the pneumonia vaccines previously, the date and location will be entered into the Immunization Tab of the EHR (Electronic Health Record). 3. If the resident or responsible party signs the consent, an order will be obtained. If the vaccine is contraindicated or the resident Responsible party refuses the specific reason for refusal of both vaccines will be documented in the Immunization Tab of the EHR. The vaccine will be obtained from the stock received from pharmacy, given, and signed on the eMAR (Medication Administration Record) and in the Immunization Tab of the EHR. 6. If the resident or responsible party declines the vaccine, this information will be documented in the Immunization Tab of the EHR.

Based on observation, interview, and record review the facility failed to serve food as planned on the cycle menu, and failed to ensure standardized recipes were followed during food preparation. This has the potential to affect all 157 residents receiving food prepared in the facility's kitchen. Findings Include: On 08/15/23 at 10:42 AM, V6 (Cook) stated for lunch residents on regular diet consistencies would be receiving fried chicken, white rice, and salad. The residents on mechanical soft diets would be receiving ground chicken, white rice and green beans. The residents on pureed diets would be receiving pureed chicken, pureed rice and pureed green beans. V6 stated they are in the 4th week of the cycle menu and pointed to the menu posted on the bulletin board near the food preparation area. Surveyor observed four weeks of cycle menus posted on the bulletin board. Week At a Glance Week 4 Menu for lunch meal listed the following items to be served: Chicken Piccata, Garlic Buttered Fettuccini, Caesar Salad, Seasonal Fresh Fruit, Dinner Roll/Margarine, Beverage. On 08/15/23 at 10:44 AM, observed V6 begin to prepare pureed food items for lunch. V6 stated the facility only has three residents on a pureed diet. Observed V6 tip over a bag of ready to use diced chicken and added an unmeasured amount of the diced chicken to the blender container. Surveyor asked how much chicken was added to the blender and V6 replied, I don't measure it out because I only have three residents on pureed, so I estimate it. Surveyor observed V6 add an unmeasured amount of chicken broth to the diced chicken in the blender. The final product of the pureed chicken appeared watery, not thick. On 08/15/23, at 10:50 AM, observed V6 add an unmeasured amount of green beans to the blender and pureed the green beans. V6 stated, I didn't measure it. On 08/15/23 at 11:01 AM, observed V6 add cooked rice and chicken broth to the blender. The amount of rice and chicken broth added to the blender was not measured out. During the pureed lunch meal preparation did not observe V6 review a recipe for ingredients, portions, or procedure. V6 did not make any pureed dinner roll or bread. On 08/15/23 at 11:32 AM, observed the following items being put on the tray line for lunch service: fried chicken, white rice, diced chicken, pureed chicken, green beans, pureed green beans and pureed rice. Lettuce in bowls, regular canned fruit and pureed canned fruit were on trays in carts for tray line service. On 08/15/23 at 3:40 PM, V7 (Dietary Manager) stated the facility is on week four of the cycle menu and whatever menu is posted for that day is the one the kitchen follows. V7 stated there are recipes for the cook to follow which include portion sizes of food items to include and that these recipes should be followed by the cook. V7 stated the cycle 4 menu for today's lunch read Chicken Piccata, Garlic Buttered Fettuccini, Caesar Salad, Seasonal Fresh Fruit, Dinner Roll/Margarine. V7 stated that V6 did not follow the menus, spreadsheets or recipes and served the residents whatever V6 wanted to serve which was Fried Chicken, [NAME] Rice, Salad, Canned Fruit. V7 stated V6 should have followed the menu, spreadsheets, and recipes for cycle 4 and that all the ingredients V6 would need in order to make the items listed on the menu were in stock and available for use. On 08/16/23 at 4:25 PM, V21 (Regional Dietary Manager) stated the cook cannot make the decision to make changes to the menu and that any menu changes need to be approved by the Registered Dietitian. V21 stated, I don't think the RD was called yesterday to approve items served at lunch. V21 stated it is important for the cook to follow the recipe to make sure the residents get the right amount of protein, starch, and vegetables and for menu variety. V21 stated it is also important for the cooks to follow the menus for pureed items carefully to make sure the portion of food and liquids is correct to make sure too much liquid is not added which would water down the protein content. V21 stated the residents on a pureed diet should receive the same food as the residents on a regular diet except in pureed form. On 08/17/23 at 09:20 AM, V32 (Consultant Registered Dietitian) stated during phone interview that a Registered Dietitian from the food service company reviews the menus for adequacy based on set nutritional guidelines. V32 stated V32 did not receive any phone calls this week about food substitutions being needed or approved. V32 stated the cooks should follow the menus and recipes as posted and scheduled because otherwise they are just guessing at the portion sizes and potentially if the recipe and spreadsheets are not being followed then a resident may not meet their nutritional needs, and this could potentially lead to weight loss. V32 stated it is also important for the cooks to follow the spreadsheets for menu variety. V32 stated residents on pureed diets are at higher nutritional risk for weight loss and it is important for the cook to follow the recipe, so the pureed consistency is correct, and not too thin. Kitchen Diet Spreadsheet Cycle 4 dated spring/summer 2023 for lunch meal documents the following items to be served on Regular Diet: Chicken Piccata, Garlic Buttered Fettuccini, Caesar Salad, Seasonal Fresh Fruit, Dinner Roll/Margarine, Beverage. Kitchen Diet Spreadsheet Cycle 4 dated spring/summer 2023 for lunch meal documents the following items to be served on Mechanical Soft Diet: Ground Chicken Piccata, Chopped Garlic Buttered Fettuccini, Chopped [NAME] Beans, Sliced Banana, Dinner Roll/Margarine, Beverage. Kitchen Diet Spreadsheet Cycle 4 dated spring/summer 2023 for lunch meal documents the following items to be served on Pureed Diet: Pureed Chicken Piccata, Pureed Garlic Buttered Fettuccini, Pureed [NAME] Beans, Pureed Banana, Pureed Buttered Dinner Roll, Beverage. Kitchen Recipes titled Chicken Piccata, Garlic Buttered Fettuccini, Caesar Salad, Fresh Seasonal Melon, Dinner Roll, Pureed Chicken Piccata, Pureed Garlic Buttered Pasta, Pureed [NAME] Beans, Pureed Banana, Pureed Dinner Roll. Kitchen policy titled Standardized Recipes dated 2016 documents in part, standardized recipes will be available in the kitchen and will be used in food preparation, foods will be prepared according to standardized recipes provided by the menu source. Kitchen policy titled Job Description for Director of Food and Nutrition Services - Duties dated 2016 documents in part serve the food as planned on the cycle menu for the clients on general, therapeutic, and texture-altered diets, and ensure the use of the standardized recipes in food preparation. Facility job description for position title [NAME] undated, documents in part essential duties to prepare, season and cook dishes according to standardized recipes and to follow all policies and procedures of the Dietary Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a.) kitchen staff wearing hair net and beard coverings b.) food items were properly labeled, dated, and stored, c.) to discard moldy food, d.) properly rotate food by first in, first out practice, e.) store scoops in separate area from bulk food container. This failure has the potential to affect all 157 residents receiving food prepared in the facility's kitchen. Findings include: On 08/15/23 at 8:59 AM, entered kitchen for initial tour and observed V6 (Cook) walking around the kitchen, not wearing a hairnet. When surveyor introduced self to V6, V6 quickly put on a hair net. Dietary Director was not in the building at the time. Initial tour conducted with V6 (Cook). V6 stated V6 has been working at the facility for over 19 years. On 08/15/23 at 09:02 AM, observed in 1st walk-in refrigerator the following items: Opened 48 ounces Concord Grape Jelly with delivery date 08/01/23. Opened 1-gallon Sweet Pickle Relish dated with delivery date 07/21/23. Opened 1-gallon Mayonnaise dated with delivery date 06/30/23. Opened 1-gallon Yellow Mustard dated with delivery date 04/18/23. All these items were not labeled with an open or use by date. On 08/15/23 at 09:07 AM, observed in 2nd walk-in refrigerator slices of ham wrapped in plastic wrap (not in original container) dripping with liquid not dated or labeled and slices of turkey wrapped in plastic wrap (not in original container) not dated or labeled. V6 stated V6 did not know how long those items have been in there. On 08/15/23 at 09:09 AM, observed in 2nd walk-in refrigerator a half case labeled as Potato Yam Red Garnet dated 05/23/23. The yams in the case were all covered in light gray, green, white fuzzy substance. V6 stated that food is no good and that looks like mold. On 08/15/23 at 09:12 AM, observed in 2nd walk-in refrigerator a full case labeled Sweet Potatoes packed on 06/03/23 not labeled with a delivery date. Sweet potatoes in the case were covered in light gray, green, white fuzzy substance. V6 stated, I wouldn't serve this to the residents. On 08/15/23 at 9:14 AM, observed in 2nd walk-in refrigerator a full case labeled Sweet Potatoes dated with delivery date 06/02/23. Sweet potatoes in the case were covered in light gray, green, white fuzzy substance. V6 stated, it is messed up and the potatoes are covered in mold. On 08/15/23 at 9:15 AM, observed in dry storage area 15 1-gallon containers of [NAME] Slaw dated 7/14, 7/7, and 6/20. The [NAME] Slaw containers labeled 6/20 were in the back of the shelf, and the containers labeled 7/14 were in the front of the shelf. V6 stated the containers need to be rotated because the containers dated 6/20 are supposed to be in the front so the old stuff gets used first. On 08/15/23 at 9:20 AM, observed bin container full of flour with large plastic scoop left inside the container. V6 stated the scoop should not be left in the container. On 08/15/23 at 10:28 AM, observed V8 with facial hair on his chin and lower cheeks working in the kitchen. V8 was not wearing a beard protector. V8 acknowledged V8 did not have on a beard protector and stated, I'll put on one now. Observed V8 obtain a beard protector from a large supply of beard protectors located by the kitchen entrance. On 08/15/23 at 10:40 AM, V7 (Dietary Director) stated every food item should be dated with a delivery date, an opened date and use by date and that moldy or expired food items should be thrown out immediately. V7 stated stock should be rotated following the first in, first out rule so that the old product is use first as a good standard of practice. V7 stated the scoops should be stored separately and not left in the bin containers due to infection control concerns. V7 stated the staff need to wear hairnets and beard protectors (as needed) as soon as they enter the kitchen because they are handling, preparing, and serving food to residents and without a hairnet or beard protector hair could fall into the resident's food. On 08/15/23 at 11:45 AM, V7 provided list of residents by diet orders including a list of residents who receive nothing by mouth. Kitchen policy titled Hair Restraints/Jewelry/Nail Polish dated 2016 documents in part, food and nutrition services employees shall wear hair restraints and beard guards, hair nets will be worn at all times in the kitchen, and beard guards or masks will be worn as indicated. Kitchen policy titled Labeling and Dating Foods dated 2016 documents in part, to decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Kitchen policy titled Storage of Refrigerated Foods dated 2017 documents in part, refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality, food in the refrigerator is labeled and dated with a use by date and open products that gave not been properly sealed and dated are discarded. Kitchen policy titled Storage of Dry Goods/Foods dated 2017 documents in part, scoops are stored in scoop holders or in a clean designated place. Kitchen policy titled First-In-First-Out dated 2016 documents in part to assure food quality and food safety, food products are rotated, the first food product placed in storage is the first one removed and used, new food products are placed on the shelf behind the food products on hand, and products with the earliest expiration date are stored in front of products with later dates so that the older food is used first.

Based on observation, interview and record review, the facility failed to ensure the dumpsters was covered to prevent the harborage and feeding of pests. This failure has the potential to affect all 161 residents who reside in the facility. Findings include: On 08/15/23 at 9:28 AM, V8 (Dietary Aide) brought surveyor to compacter room which contained six dumpsters. The compactor room was a large room attached to the building. Four of the six dumpsters in the room had lids wide open with two of these dumpsters piled very high with garbage. Gnats were observed flying in swarms all over opened dumpsters and live gnats covering the ceiling tiles, walls, and doorway of the compacter room. When surveyor and V8 walked by the gnats on the walls and doorway the gnats started to fly all around. Surveyor observed standing water on the floor and large drain in the middle of the floor. V8 stated the dumpster lids should be closed to keep the flies away and they that they have a problem with flies. On 08/15/23 at 3:29 PM, V7 (Dietary Manager) and V21 (Regional Dietary Manager) went with surveyor to the compactor room. Surveyor pointed to the ceiling and asked V7 and V21 to identify what was on the ceiling. V21 stated that's mold on the ceiling, oh, wait, no those are gnats! Observed four of the six dumpster containers with lids wide open and garbage piled high in two of the dumpsters with the lids opened. V7 and V21 stated the lids to the dumpsters should always be closed to prevent gnats from being attracted to the garbage. On 08/15/23 at 3:49 PM. V1 (Administrator) observed gnats swarming around the opened dumpsters and live gnats covering the ceiling in the compactor room. V1 stated that V1 could see the gnats and that they should not be there and acknowledged there is the potential for the gnats to get other places in the facility because the compactor room is located inside the building. On 08/15/23 at 3:50 PM, V22 (Housekeeping Floor Technician) observed the swarms of gnats in the compactor room over the opened dumpsters and stated the lids should be closed. V22 stated V22 could see live flies everywhere and that that was not sanitary. On 08/16/23 at 2:44 PM, met with V19 (Environmental Service Director) and V20 (Area Manager for Environmental Services). V19 stated it is the floor technician responsibility to remove the garbage from the nursing units three times per day and bring the garbage to the compact room. V19 stated the floor technicians should always close the lid to the dumpsters after use because otherwise the odor and smell of the garbage could attract gnats. V19 and V20 stated they had both been to the compactor room yesterday and viewed the gnats swarming around the uncovered dumpsters and the gnats covering the ceiling, walls, and doorway. V19 stated if the lids of the dumpster were closed the bugs could not get into the dumpster. V20 stated there should not be the number of gnats seen in that room if all the lids were kept closed. On 08/16/23 at 2:58 PM, V19 stated they had moved two of the dumpsters outside and wanted to show surveyor the dumpsters outside. Outside surveyor observed one of the dumpsters full of garbage and the lid of this dumpster was wide open, not closed. V19 stated this is another example of when the lid of the dumpster was left uncovered and that the lid should be closed to prevent issues with pests and flies. Facility job description for Housekeeping Aide undated documents essential duties in part, disposes of garbage safely, promptly and in a sanitary manner, reports promptly any indication of pests, and maintains clean storage area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to affirm the right of the resident to be free from physical abuse. This deficient practice affected 4 (R1, R5, R6, R8) of 8 residents reviewed for abuse. This failure resulted in R1 and R2 having an altercation, R2 slapping R1 in the face, R5 pulling R6's hair and R6 hitting R5 in response, R7 hitting R8 in the face, resulting in a scratch to R8's right eye. Findings Include: Abuse Prevention Program (dated November 22, 2017) states: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Facility's Final Reportable (05/08/2023) regarding R1 and R2 documents in part: Upon Investigation, R2 and R1 were in their room. Around 10:15pm, R1 was on his phone talking to the speaker and R2 told R1 to keep it down so he can sleep. R1 refused to turn off the speaker and R2 insisted on the speaker be off so he can sleep. This verbal argument led to R2 getting up from his bed to R1, slapped him on his face and then returned to bed. R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Opioid Dependence, Opioid Abuse, Uncomplicated, Poisoning by Heroin, Accidental, Subsequent Encounter, Other Psychoactive Substance Abuse, Nicotine Dependence, Cigarettes, Non-Pressure Chronic Ulcer of Unspecified Part of Unspecified Lower Leg With Unspecified Severity, Acute Kidney Failure, Cerebral Infarction, Venous Insufficiency, Chronic Venous Hypertension With Ulcer of Bilateral Lower Extremity, Disorder Of Nose And Nasal Sinuses, Weakness, Chronic Viral Hepatitis. Care plan (dated 04/27/2023) documents that R1 may be at risk for potential abuse. MDS section C (dated 03-22-23) scores R1 as (15) indicating that R1 is cognitively intact. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: ESSENTIAL (PRIMARY) HYPERTENSION, OTHER PSYCHOACTIVE SUBSTANCE ABUSE, UNCOMPLICATED, GOUT, UNSPECIFIED, ALCOHOL ABUSE, UNCOMPLICATED, COCAINE ABUSE, UNCOMPLICATED, DERMATITIS, UNSPECIFIED, OBESITY, UNSPECIFIED, PRIMARY OPEN-ANGLE GLAUCOMA, BILATERAL, INDETERMINATE STAGE, PERIPHERAL VASCULAR DISEASE, UNSPECIFIED, AGE-RELATED NUCLEAR CATARACT, BILATERAL, ANEMIA. Care plan (dated 04/04/2023) documents that R2 has a Potential for falls and at risk for injury from falls r/t weakness. MDS section C (dated 04/10/2023) scores R2 as (15) indicating that R2 is cognitively intact. On 06/06/2023 at 9:24am R1 stated, R2 was my roommate for about 6 months. On 05/08/2023, R2 was upset because the facility would not give him more money and R2 was irritated and aggravated because R2 wanted the facility to give more money. R2 walked in the room as I was on the phone. As soon as R2 came into the room, R2 started telling me that I better get off the phone. I was sitting in the wheelchair inside my room, talking on the phone, and R2 started threatening me, for me to get off the phone. I said, Excuse me. That is when R2 came up to me, he was screaming at me and R2 smacked me. I did not expect R2 to hit me, I was shocked that R2 just smacked me. R2 is a big guy, and you would be surprised how hard R2 hits. I was caught off guard. Once someone hits me, that is my limit. The physical altercation could have been avoided when I alerted the staff two days prior to the incident, when I alerted staff that R2 was behaving aggressively towards me. On 06/06/2023 9:48am R2 stated, I was telling R1 to get off the speaker phone, when R1 was talking to his friend or wife on the phone. I should not be listening to R1's conversation all night long. When I asked R1 to get off the speaker phone, R1 rolled up on me on his wheelchair, so I pushed R1's face away with my hand. R1 went to tell staff that I hit R1. I never smacked R1 at all. I only pushed R1's face back with my hand. I was moved into another room after the incident occurred. On 06/06/2023 at 11:52am V2 (social service director) stated, On 05/08/2023, an incident occurred because R1 and R2 were roommates and they got into a verbal argument. R2 slapped R1 after they got into an argument. R1 and R2 were separated. R1 and R2 resident on the 3rd floor, which is the floor for residents with behaviors and drug or alcohol abuse. R1 and R2 do not have any documented violent behaviors prior to this incident. On 06/07/2023 at 12:40pm V1 (administrator) stated, I am the abuse prevention coordinator. The residents in the facility have the right to be free from abuse. Abuse can by physical mental, chemical, sexual, financial. When a resident hit another resident, it is considered abuse and we have to do an investigation and report it to the state agency. On 06/08/2023 at 9:33am V13 (licensed practical nurse) stated, On 05/08/2023 close to 11pm, R1 came up to the nursing station and informed me that R2 hit R1 in the face. I advised R1 to stay at the nursing station, and I went to talk to R2. R2 said that R1 was on his phone all night and sad that R1 was having his tv on too load, and R2 was irritated. R2 denied hitting R1, however, R1 was on the phone with his relative and the relative that was on the phone heard the whole incident and confirmed that R2 did in fact hit R1. R2 slapped R1 because he was irritated that R1 was on the speaker phone. We immediately separated R1 and R2 and R1 requested to file a police report, which I assisted R1 with doing so. R2 was moved out of the room, and R1 remained in the room in which he resided in. R1 was hit on the left side of the face, to the best of my recollection. R1's SBAR (dated 05/09/2023) documents, REASON FOR REPORT: alleged physical altercation res stated he was slapped on left side of face with small amt of redness no other problems noted vs wnl both parties immediately separated police notified. R1's Progress Note (dated 05/09/2023) documents, Res involved in alleged physical altercation with peer both parties immediately separated administrator and nursing supervisor aware MD. and family also notified no apparent injuries noted v/s wnl will monitor police made aware per resident. R2's Progress Note (dated 05/08/2023) documents, Shortly after 2200, this resident returned back to his room and got into a verbal then physical altercation with roommate. Staff intervened and separated residents by taking roommate into parlor temporarily. Statements were taken from both which seem to contradict each other as this resident denies becoming physical. Protocol initiated. Head to toe assessments negative, no injuries, no c/o pain or discomfort. 911 called. DON/ADON reached and notified. Abuse coordinator and attending MD notified. Resident with no emergency contacts listed. 911 arrived at facility around 2230, did not leave a report but did give writer an event number for their intervention This resident was moved to another room and will be monitored closely due to safety, SS to f/u in AM. Facility Final Investigation (dated 05/11/2023) states: Upon investigation, per staff statement, R5 and R6 were sitting next to each other in the dining room. R6 pushed her chair back to get up. While R6 pushed her chair back to get up, she bumped into R5's Geri chair from the side position. That's when R5 pulled R6's from the back and in response, R6 hit R5 back. R5's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY, CERVICAL REGION, DYSPHAGIA, OROPHARYNGEAL PHASE, PRIMARY OSTEOARTHRITIS, RIGHT WRIST, CONSTIPATION, UNSPECIFIED, SPONDYLOLYSIS, CERVICAL REGION, ANEMIA, UNSPECIFIED, HYPOMAGNESEMIA, SYNCOPE AND COLLAPSE, UNSPECIFIED CIRRHOSIS OF LIVER, ALTERED MENTAL STATUS, CHRONIC VIRAL HEPATITIS C, ABNORMAL WEIGHT LOSS. Care plan (dated 10/12/2022) documents that R5 may be at risk for potential abuse. MDS section C (dated 03/20/2023) scores R5 as (13) indicating that R5's cognition is intact. R6's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: MIXED HYPERLIPIDEMIA, ESSENTIAL (PRIMARY) HYPERTENSION, MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED, ANXIETY DISORDER, UNSPECIFIED, CATARACT, ALZHEIMER'S DISEASE, UNSPECIFIED, NONPSYCHOTIC MENTAL DISORDER, UNSPECIFIED, PNEUMONIA DUE TO OTHER SPECIFIED INFECTIOUS ORGANISMS, DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED. Care plan (dated 02/28/2023) documents that R6 has a psychosocial well-being problem actual r/t Anxiety, Social isolation. MDS Section C (dated 03/20/2023) documents that R6 has a BIMS score of 9, indicating that R6's cognition is moderately impaired. On 06/06/2023 at 10:40am, R5 stated, Nothing really happened. On 05/11/2023, R5 and R6 as well as other residents were in the dining room. R6 started to scoot R6's chair back into my space. R5 started to swing her arms. I told R6 that R6 is pushing her chair back too far and that is when R6 hit me. R6 started to swing her hands backwards and R6 hit me. I was not trying to hit R5 or hurt R5 at all. This was not intentional, and this was just something that happened. R5 is blind so she wings her hands. On 06/08/2023 at 9:51am R6 stated, I don't remember having my hair pulled. On 06/06/2023 at 11:52am V2 (social service director) stated, On 05/11/2023, R5 was sitting in the 4th floor dining room, and R6 was also present in the dining room. R6 has a vision impairment and R6 scooted herself back in her chair, since R6 cannot see, and R6 came too close to R5's space. R5 misunderstood and felt that R6 was too close and into her personal space. R5 pulled R6's hair. When R5 pulled R6's hair, R6 was not sure what was happening and started to scratch R5 in self-defense. The staff intervened and separated R5 and R6. R5 and R6 did not intend to be violent and did not intend to hurt each other. On 06/07/2023 V11 (licensed practical nurse) stated, On 05/11/2023, I heard from the V12 (certified nursing assistant), that R6 hit R5 in the dining room. I was sitting at the nursing station, and I heard V12 scream for assistance. I got up from the nursing station and went into the day room, where R5 and R6 were. When I got inside the day room, V12 informed me that R6 hit R5. R5 and R6 were immediately separated. On 06/07/2023 at 1:59pm, V12 (certified nursing assistant) stated, On 05/11/2023, I went into the dining room because I heard a commotion. When I got there, I saw R6 attacking R5. I separated R5 and R6 away from each other. R6 told me that R5 backed her chair into R5. I took R6 into her room and she said that R5 pulled R6's hair. R6 started crying and said that R5 pulled her hair. When I spoke to R5, R5 said that R6 backed her chair into R5 and that R6 started scratching. When I entered the parlor, I saw that R6 was attacking R5. I saw R6 hitting R5, because I saw R6's hand movement and it was the hand movements of R6 hitting R5. Both residents were immediately separated. R5's Progress Note (dated 05/11/2023) documents, Writer was informed by staff that resident had physical altercation with peer. Resident was struck in face by peer. Resident was immediately separated and place o 1:1. Writer assessed resident no bruised noted or observed. Resident stated, She hit my glasses. NP called and made aware. Daughter called and made aware. Social Service will be notified. Administer informed. R6's Progress Note (dated 05/11/2023) documents, Resident pushed her chair back into another resident then turned around, started smacking her arm and then hit her left side of face slight as well, staff frequently intervened and separated them. Unit manager, administrator and police department called, no injury upon inspection observed to either resident. Facility Final Investigation Report (dated 05/05/2023) states: Upon investigation, R7 did not give a response on why he hit R8. During R8 interview, R8 stated that he doesn't know why R7 hit him. R8 said that he was in his bed watching tv, him and his visitor. R7's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: ABNORMALITIES OF GAIT AND MOBILITY, LACK OF COORDINATION, MUSCLE WEAKNESS (GENERALIZED), INSOMNIA, UNSPECIFIED, UNSPECIFIED DEMENTIA, SEVERITY, WITH AGITATION, PATIENT'S NONCOMPLIANCE WITH OTHER MEDICAL TREATMENT AND REGIMEN, BRIEF PSYCHOTIC DISORDER, DYSPHAGIA, ATTENTION-DEFICIT HYPERACTIVITY DISORDER, PREDOMINANTLY INATTENTIVE TYPE, ACUTE KIDNEY FAILURE, HYPOTHYROIDIS. Care plan (dated 08/19/2022) documents that R7 has a behavior problem such as throwing things through the window, refusing care, fighting the staff. MDS section C (dated 05/05/2023) documents that R7 has a (BIMS) score of 12, indicating that R7's cognition is moderately impaired. R8's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: SEQUELAE OF CEREBRAL INFARCTION, CEREBRAL INFARCTION, UNSPECIFIED, NON-PRESSURE CHRONIC ULCER OF UNSPECIFIED PART OF UNSPECIFIED LOWER LEG WITH UNSPECIFIED SEVERITY, ACUTE KIDNEY FAILURE, UNSPECIFIED, MUSCLE WEAKNESS (GENERALIZED), OTHER ABNORMALITIES OF GAIT AND MOBILITY, OTHER LACK OF COORDINATION, ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE. MDS section C (dated 04/20/2023) documents that R8 has a BIMS score of 15, indicating that R8 is cognitively intact. Care plan (dated 03/28/2023) documents that R8 has diagnosis of Peripheral Vascular Disease with chronic bilateral wounds to lower extremities & feet. On 06/06/2023 at 2:16pm, V8 (licensed practical nurse) stated, On 05/05/2023, I was passing my medication and I was standing outside R7 and R8's room, when I heard R7 and R8 arguing. R7 was in R8's face and I saw R7 hitting R8 several times. R8 was just holding R7, but R8 did not hit R7. I saw R7 punching R8 a few times. I separated R7 and R8 immediately. The unit manager came into the room and to assist me with monitoring. R7 was sent out to the hospital. R8's left eye was hit, however, R8 refused to go to the hospital. I heard that R7 and R8 were arguing over some food and that is how the argument began. On 06/06/2023 at 2:19pm V9 (restorative aide) stated, On 05/05/2023, I was in the facility from 7am 3pm. Before I left the facility, R7 was laying down sleeping in his bed around 2:40pm, and R8 had a visitor in his room. R8 asked me for a lunch tray for the visitor, and I said that I did not have an extra tray. R8 told me that if R7 does not wake up, that R8 would eat his tray, to which informed R8 that he cannot do that. I believe that when I left the room, I believe that R8 was plotting to take R7's tray. I believe that R7 was provoked by R8, because R8 was plotting to take R7's lunch tray and give it to his visitor. On 06/06/2023 at 2:23pm V10 (social worker) stated, I am not sure what happened on 05/05/2023, and what actually let to the physical altercation between R7 and R8. I was the one who was monitoring R7 for a 1 to 1 supervision post the altercation. When I was providing the 1 to 1 for R7, I asked R7 what triggered R7 to attack R8, however, R7 did not have any recollection of the incident. R7 did not recall and had no explanation as to what led to the incident. On 06/07/2023 at 9:41am, surveyor attempted to interview R7, however, R7 did not wish to speak to the state surveyor regarding the incident with R8. On 06/07/2023 at 10:22am R8 stated, On 05/05/2023, R7 was sitting in his bed, as we were roommates. I told R8 to eat his food. R7 is paranoid and at times does not trust to eat his food. I reminded R7 to eat his food and that's why R7 started screaming at me. R7 threatened to cut my throat and kill me. I stopped talking to R7, and turned my face away to watch tv, until R7 walked up to me and hit me. I did not try to hit R7 at all, and I was not posing a threat to R7. R7 came up and hit me and attempted to hit me again and I held R7 until staff came in and took R7 away from me. R7's Progress Note (dated 05/05/2023) documents, Writer in hall overheard resident yelling. Writer turned around and witnessed resident hitting his roommate. Resident separated immediately resident place on 1:1 head to assessment no injury noted when writer ask resident what happen resident was quiet and nonchalant did not give a reason to why he did it DR. and Dr.S call with order to send to Hospital Administrator ,DON and S/S made aware. R8's Progress Note (dated 05/05/2023) documents, Writer in hall overheard resident yelling. Writer turned around and witnessed resident hitting resident in the chest resident stated roommate hit him in r eye as well resident separated immediately. Head to assessment completed no injury except a small knot noted to r eye ice pack offered resident refuse NP call made aware with order to X-Ray the r side of face Administrator, DON and S/S.

Based on interview and record review, the facility failed to provide a certified nursing assistant (CNA) on the night shift (11:00 pm to 7:00 am) to provide resident care. This failure has the potential to affect the residents on the 2nd and 3rd floors in the facility. Findings include: Facility Daily Staffing Schedule dated 5/5/23, documents, in part, that on the 11:00 pm to 7:00 am, only one CNA (V21) is noted working on the 4th floor with V21's initials next to V21's name. No CNA is noted as working on the 2nd and 3rd floors from 11:00 pm to 7:00 am on 5/5/23. Facility Census Report dated 5/5/23, documents, in part, that 61 residents resided on the 2nd floor and 58 residents resided on the 3rd floor with a total of 119 residents with no CNA working. Facility Daily Staffing Schedule dated 5/12/23, documents, in part, that on the 11:00 pm to 7:00 am, only one CNA (V22) is noted working on the 4th floor with V22's initials next to V22's name. No CNA is noted as working on the 2nd and 3rd floors from 11:00 pm to 7:00 am on 5/12/23. Under the 11:00 pm to 7:00 am shift column on the 5/12/23 Daily Staffing Schedule, in handwriting, a statement is documented as one CNA worked in the building. Facility Census Report dated 5/12/23, documents, in part, that 60 residents resided on the 2nd floor and 56 residents resided on the 3rd floor with a total of 116 residents with no CNA working. On 5/17/23 at 4:55 pm, V1 (Administrator) and V3 (Former Administrator) stated that their nurses and CNAs staff punch in and out when working on the floors in the facility. On 5/18/23 at 10:10 am, this surveyor requested from V1 (Administrator) the timecards (punch in and punch out) for all nursing staff working in the facility on 5/5/23 and 5/12/23 night shifts from 11:00 pm to 7:00 am. Facility timecards reviewed for the 11:00 pm to 7:00 am shift on 5/5/23 which documented, in part, that only one CNA worked with V21 punching in at 11:08 pm on 5/5/23 and punching out at 6:54 am on 5/6/23. Four LPNs (Licensed Practical Nurses) noted punching in and out for the 5/5/23 11:00 pm to 7:00 am shift for the 2nd, 3rd, and 4th floors. Facility timecards reviewed for the 11:00 pm to 7:00 am shift on 5/12/23 which documented, in part, that only one CNA worked with V22 punching in at 3:11 pm on 5/5/23 and punching out at 7:08 am on 5/6/23. Four LPNs (Licensed Practical Nurses) noted punching in and out for the 5/12/23 11:00 pm to 7:00 am shift for the 2nd, 3rd, and 4th floors. On 5/17/23 2:11 pm, V2 (Director of Nursing, DON) stated that V2 and V15 (Assistant Director of Nursing, ADON) have been working together since April 2023 to ensure that there is enough nursing staff scheduled and working in the facility. V2 stated, I (V2) do play role to ensure we have enough staff. V2 stated that for the 11:00 pm to 7:00 am shift, the facility staffs for 5 nurses for the 2nd, 3rd and 4th floors, and We can't always meet that. V2 stated that for CNA staff for the 11:00 pm to 7:00 am shift, V2 stated that V2 staffs 2 CNA's per floor (2nd, 3rd and 4th floors). V2 stated, It's a challenge. This surveyor showed V2 the 5/5/23 and 5/12/23 daily nursing schedules with only 1 CNA working in facility on the 11:00 pm to 7:00 am shift. When asked how safe and adequate care can be provided to all residents in the facility with one CNA working the shift, V2 stated, I (V2) don't have an answer for that. V2 stated that V2 was not aware of these dates with only one CNA working in the entire facility. V2 stated that V14 (Evening Supervisor, Registered Nurse, RN) had the staffing phone for those dates. V2 stated that the facility uses no agency staff to supplement when staff call from work. On 5/17/23 at 3:53 pm, V15 (ADON) that V15 was filling in to assist with the staffing coordinator duties in the facility since April 2023 and that the new scheduling coordinator (V18) just started in the facility this week (of 5/15/23). V15 stated that for the 11:00 pm to 7:00 am shift, we are slotted for 5 nurses. V15 stated that for the 11:00 pm to 7:00 am shift, V15 staffed 2 CNA's on each floor (2nd, 3rd and 4th floors). V15 stated that the supervisor (V14, Evening Supervisor) would be responsible for handling call offs before the night shift and is to notify V15 of staffing call offs. This surveyor showed V15 the 5/5/23 and 5/12/23 daily nursing schedules with 1 CNA working in facility from 11:00 pm to 7:00 am. When asked can safe and appropriate care be provided to all residents in facility with one CNA, V15 stated, No ma'am. I (V15) have never known anything about this. This could affect patient care really bad. We have to do patient care. (V14) didn't call me (V15). On 5/18/23 at 8:08 am, V14 (Evening Supervisor, RN) stated that as the evening supervisor, V14 is responsible for the staffing of nurses and CNAs in the facility for the 11:00 pm to 7:00 am shifts as V14 works as the supervisor on Monday through Fridays from 7:00 pm to 7:00 am. V14 stated that V14 was alternating with the V15 with the staffing phone and would handle call offs from staff for the night shift. V14 stated that V14 text V2 and V15 with the staff from 11:00 pm to 7:00 am that would call off and will then adjust the schedule or find a replacement. V14 stated, For a long time, we had 1 nurse across the floors, and it was doable. It was until just recently as the acuity and census is up, we are putting 2 nurses on the 2nd floor with the biggest need for 11:00 pm to 7:00 am shift, and 2 nurses on the 4th floor if available, so 2-1-2 (2 nurse on 2nd floor, 1 nurse on 3rd floor, 2 nurses on 4th floor). When asked about the staffing numbers for CNAs on the 11:00 pm to 7:00 am shift, V14 stated, I (V14) try to get 2 CNAs across all floors. Sometimes on the 3rd floor with more independent residents, I (V14) will put 1 CNA if I can't find a 2nd CNA. V14 stated that for the 11:00 pm to 7:00 am shift, I (V14) have 5 CNAs scheduled with the worst-case scenario being 4 CNAs. I staff with 2 CNAs on the 2nd floor which is the heaviest and then 2 CNAs on the 4th floor with dementia, incontinent residents. When asked if there has been a date when 1 CNA is working for 11:00 pm to 7:00 am shift for the entire facility (all 3 floors), V14 stated, That's not good. It's happened. When asked about the daily nursing schedules with 5/5/23 and 5/12/23 with one CNA listed working in the entire facility, V14 stated that V14 couldn't remember which specific dates when there was only one CNA working 11:00 pm to 7:00 am, but they were rough days. Facility document titled (Facility) Assessment Tool and undated, documents, in part, Requirement: (Facility) will conduct, document, and annually review the facility-wide assessment, which included both their resident population and the resources the facility needs to care for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decision about your direct care staff needs . ensuring that each resident is provided care that allows for the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Staffing plan 3.2: Staff: Direct care staff. Plan: 12 CNA's: floor 11 (pm) - 7 (am). Facility policy dated March 2022 and titled Staffing, documents, in part, General: To have appropriate numbers of staff available to meet the needs of the residents. Responsible Party: Administrator, DON, Nursing Supervisors. Guideline: 1. Staffing is based on the Regulatory Body (State and Federal) formula for determining numbers and levels of staff. 2. Staffing is then increased based on the needs of the resident population . 4. Staffing is supplemented as needed by outside agencies . 6. It is the staff members responsibility to be at work when they are scheduled.

Based on observations, interviews, and record reviews, the facility failed to provide a call light that was within easy reach of a resident (R4) for 1 of 4 residents reviewed for call lights. Findings include: R4's face sheet documents in part diagnoses of general muscle weakness, abnormalities of gait and mobility, lack of coordination, displaced fracture of the right lower leg, and displaced fracture of the left lower leg. On 04/19/2023 at 09:49 AM, surveyor entered R4's room for interview. R4 was alert and oriented to person, place, time, and situation. During the time of the interview, R4 was sitting up in a wheelchair towards the foot of the bed. R4 stated [R4's] call light is not easily accessible. Observed the call light system near the head of the bed with a string less than a foot long hanging from the socket. R4 stated [R4] cannot reach the call light string from the bed. R4 stated [R4] must get out of bed, transfer to the wheelchair, and pull it. R4 maneuvered wheelchair towards the head of the bed. R4 had difficulty turning in wheelchair and getting up close to the call light system. R4 had to lean forward in wheelchair and reach out with arm to pull call light string. When R4 pulled the string, it came off the system socket. At 10:05 AM, V14 (Certified Nurse Aide) answered the call light. V14 walked up to the call light system to turn it off but did not address its accessibility to R4. Facility's Call Light Answering policy, created 10/2021, documents in part: When the patient or resident is in bed or confined to bed or chair, provide the call light within easy reach of the patient or resident.

Based on observations, interviews, and record reviews, the facility failed to follow their policy to conduct repairs as soon as possible, maintain maintenance records, and provide a homelike environment for 3 (R2-R4) of 4 residents reviewed for homelike environment. Findings include: R2's face sheet documents in part admission date of 03/09/2023. R2's census documents in part that R2 remained in the same room until discharge. On 04/18/2023 at 10:39 AM, surveyor briefly peaked into R2's previous room. No resident occupying the room but observed a resident's belongings in bags in an open closet. Observed rectangular cut holes on the wall near the entrance (wall to the left of the windows). Observed tiles missing around the heater under the windows. After exiting the room, surveyor saw V3 (Assistant Director of Nursing) in the hallway making rounds. V3 stated no resident occupy the room. R3 used to reside in the room but facility transferred R3 to a different room yesterday evening. This was confirmed by V5 (Unit Manager) at 10:40 AM. At 10:45 AM, surveyor interviewed R3 in [R3's] new room. R3 stated previous room had holes in the wall and missing tiles in the bathroom. R3 stated could not recall how long it has been in that state but has been in the previous room for at least a couple of months. At 10:54 AM, surveyor returned to R2 and R3's previous room. There were 5 rectangular cut holes in the north wall (same side as the entrance to the room). There were at least 14 floor tiles missing near the heater. The bathroom had white tiles missing near the toilet. The rubber wall base molding was falling. At 12:50 PM, surveyor observed V9 (Maintenance Assistant) repairing holes in R2 and R3's previous room. V9 stated [V9] started at the facility 2 months ago and doesn't know how long the holes have been in the room. V9 stated there were 5 holes on the same wall. V9 stated staff push the residents' beds too close to the wall. When the residents or staff raise the bed, the bed frame catches the guard rail attached to the wall and rips the rail off the wall causing the holes. V9 pointed to a guard rail that's now on the floor. V9 stated [V9] cut the rectangle holes in preparation for the repairs. Surveyor pointed out the missing tiles near the heater and in the bathroom. V9 stated [V9] doesn't know how long the tiles have been missing but will fix everything. On 04/19/2023 at 9:59 AM, surveyor interviewed R4. R4 was alert and oriented to person, place, time, and situation. R4 stated [R4] previously resided in the same room as R3. R4 was in that room for about a week or so. R4 stated there were holes in the wall and tiles missing from the bathroom. R4 stated the room was in that condition when [R4] first came into the facility. At 11:33 AM, V16 (Maintenance Director) brought in the work orders for the building. V16 stated [V16] started at the facility around 03/01/2023 and does not know where all the work orders are but provided surveyor with those that [V16] can find. Reviewed binder with V16, no work order or file for R2-R4's previous room. V16 stated facility informed [V16] about the repairs needed for the room at the start of V16's employment. V16 stated there was a list of damaged rooms and R2-R4's previous room was one of them. At 11:52 AM, V5 (Unit Manager) stated there were holes in R2's room while [R2] resided in it. Facility's undated Preventative Maintenance & Inspections policy documents in part: Regular inspection, testing and replacement or repair of equipment and operational systems contribute to preservation of equipment and facilities assets. Replacement and/or repair of all furnishings and equipment is completed as soon as possible. A system for work orders is established among all staff, residents and employees that provide rapid communication regarding equipment issues. The system includes documentation of the following: The problem, Date the problem was identified, Who was notified, Corrective action taken, Completion date.

Based on interviews and record reviews, the facility failed to follow their policy and provide discharge instructions to a resident (R2) who chose to discharge Against Medical Advice (AMA) for 1 of 4 residents reviewed for discharge. Findings include: V4's (SSD, Social Services Director) progress note dated 03/28/2023 2:13 PM for R2 documents in part: The family insisted on taking the resident out of the facility and SSD explained to them that if they took [R2] out that [R2] would be leaving against medical advice and [R2] would not get any medication or anything from the facility other then the clothing which [R2] came here in. On 04/18/2023 at 1:14 PM, V7 (Nurse) stated [V7] took care of R2 during discharge. V7 stated [R2] went down for a care plan meeting and all of a sudden they were telling me [R2] was leaving and signing out AMA. V7 stated R2 never returned to the unit. V7 stated [V7] did not print any discharge instructions or medication lists for discharge. At 3:20 PM, V4 stated there were multiple family members involved during R2's care plan meeting. Facility informed the family and R2 that there were no discharge orders so if they elect to take R2 out of the facility, it is leaving AMA. Facility informed them that if R2 does leave AMA, R2 would have no medication and no discharge paperwork. V4 stated they elected to take R2 out of the facility anyway and R2 signed the AMA paperwork. V4 read AMA statement out loud - [R2] family decided during care plan meeting to take resident out the facility knowing [R2] gets no medication or any paperwork. V4 stated V20 (Nurse Practitioner) was on the phone explaining this to family as well. V4 stated V20 did not provide orders or medications. At 3:42 PM, V2 (Director of Nursing) stated [V2] was also part of the care plan meeting with R2 and family. V2 stated facility and V20 explained to them that R2 would not get medications. Surveyor requested copies of any discharge instructions provided to R2 and family upon leaving AMA from V1 (Administrator) around noon on 04/18/2023. At 1:35 PM, V1 provided all other documents pertaining to R2 but no discharge paperwork noted. None provided at the completion of the survey. V1 provided surveyor a copy of facility's Discharges policy last revised 06/2022. Under the section 'Discharge Against Medical Advice,' it documents in part: The resident will be given information to allow for them to as safely as possible care for themselves in the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility failed to follow their elopement policy for one resident (R3) out three resident reviewed for elopement/supervision. This failure resulted in R3 leaving the facility without permission and not being located until several hours later via cell phone. Finding Include: R3's minimum data set denotes cognitive score 15/15. R3's 1/11/2023 12:23 Health Status/Progress Note Text denotes: Received this AAM at this time from hospital via stretcher accompanied by two attendants, Awake, AoX3,NAD , denies pain ,able transfer down to standing position, steady , make all needs known and understanding communication of this writer, room [ROOM NUMBER]Aat Symphony, skin intact , vitals taken and recorded as t-97.2,p-100,r-18, BP 118/71 spo2 99% on room air , wt.taken-110.4 standing , calling MD to verify order. R3's 1/11/2023 14:28 admission Note Text denotes: Met with to explain DUET program, to explain our expectations and to hear any concerns or challenges with the program. No concerns or challenges were voiced. He signed the contract. Explained that he is very tired and once he takes a nap, he will supply up with emergency contact information. His cell phone needed to be charged as he keeps all phone numbers in the cell phone. He agrees to continue with Suboxone. Call light within reach, cell phone on nightstand. He said he ate lunch and was requesting a nap. He agreed to begin substance groups tomorrow. He asked to be reminded at breakfast. R3's 1/13/2023 10:36 R3 Skilled Look Back Note Text denotes: Resident is A and Ox3 up in wheel chair in room no acute distress noted. He denies needing pain meds @ this time. Appetite good 100% of breakfast. Set up assistance c ADL this AM. He is calm able to make needs known. Denies any concerns @ this time. V/S stable call light within reach care ongoing. R3's 1/19/2023 19:22 R3 Health Status/Progress Note Text: Writer made aware that resident has not returned to facility at this time. Resident has agreed with and signed duet contact and is aware of what is expected. SS made and MD notified Resident is responsible for self. V2 (Licensed Practical Nurse) stated on 1/31/23 at 12:00pm she works the 3-11 shift and that the day R3 eloped (1/19/23), it was her first day ever working with R3. V2 stated she got to work and did rounds around 3:30-4pm and did not see R3 in his room and was told by another staff member that R3 might have gone out for an appointment or on pass. V2 stated since they have a lot of residents that go out on pass and/or to their methadone appointments she did not pursue the matter. V2 stated in a couple of hours when she did her second set of rounds, she still did not see R3 in his room and told the Unit Manager (V1) that R3 was not in his room or on the floor. V2 stated V1 told her that she would look into it and find out what was going on. V2 stated the Unit Manager (V1) came back up to the unit and told her that she was still looking into the matter then left the unit and never returned to their unit. V2 stated was not told what happened to R3 or where he went after he left the facility. V2 stated she has been trained if they cannot find a resident to do a head count, search the building, and then notify the doctor and the family. V2 stated she did not call to the front desk to see if R3 went out on pass but did do a head count and notified the physician. V1 (Licensed Practical Nurse/Unit Manager) stated on 1/31/23 at 11:00am she has been working at the facility since March as the third floor Unit Manager. V1 stated she was about to get off work one evening when V2 approached her and reported that R3 had not returned to the facility. V1stated, she alerted the Social Worker (V3) and the Director of Nursing (V4) and made them aware that R3 was not in the facility. V1 stated she did not know if R3 eloped or went out on pass and did not return. V1 stated if R3 had eloped she would have done the same thing, notify V3 and V4. V1 stated she was not told to do a building check and did not tell any staff to check outside the building. V1 stated her duties are not to tell staff to do a building search or call the police it is the job of Social Service, Director of Nursing or the Administrator. V3 (Social Worker) she stated on 1/31/23 at 1:50 pm R3 was under her caseload and R3 was assessed to be safe to go into the community. V3 stated R3 had to wait 14 days until he received a pass to go out of the facility. V3 stated she explained that to R3 since he just arrived and that he had to wait 14 days before he can go out on pass, and he verbalized that he understood. V3 stated she was shocked and surprised that R3 left the building without telling anyone. V3 stated on the day that R3 left she had just come back from a late lunch and was doing paperwork. V3 stated last time she saw R3 was earlier that day twice in passing. V3 stated she was told by V1 he (R3) left the facility without permission. V3 stated she did not tell anyone to go outside to look for R3. V3 stated she did not see anyone go outside to look for R3. V3 stated the next day R3's Community Care Coordinator called to see how R3 was adjusting to the facility. V3 stated she told the Community Care Coordinator that R3 left the facility without permission. V3 stated R3's Care Coordinator told her she would try to reach R3 on his cell phone and when she does, she would call her back. V3 stated the Care Coordinator called her back and told her she was able to reach R3 on his phone and that he was okay. V3 stated the Care Coordinator told her she would update about if R3 would be willing to return to the facility, but the care coordinator never called her back. V3 stated they do an elopement assessment on all residents and residents that are at risk are placed on a secure floor where they are monitored. V3 sated R3 was not an elopement risk because he was not cognitively impaired at all. V4 (Director of Nursing) stated on 1/31/23 at 2:30pm she received a phone call a phone call from V1 in the evening that R3 had not been seen for a little while. V4 stated she asked V1 if they had looked, and she replied yes. V4 stated R3 was not to be going out on pass. V4 stated the facility will follow the substance abuse program that if a resident left, he or she is leaving against medical advice because. V4 stated all residents in the substance abuse must be alert times three to even be in the program. V4 stated they did not consider that R3 eloped because he knew what he was doing. V4 stated their policy is that if a resident is assessed to be an elopement risk to put interventions in place. V4 stated a resident that is known to elopement risk or classified to be an elopement risk leave the facility there is an announcement over the intercom, then staff are to look inside and outside the facility looking for the resident. V4 stated after resident is not located then they call all pertinent parties like police, doctor, family and the local hospital. V4 stated when they found out R3 left the facility they were able to reach R3 on his cell phone and he told them he did not want to come back to the facility. V4 stated the substance abuse contract that R3 signed denotes if they leave the facility they are leaving against medical advice.V4 stated going forward they will not use that part of the contract and explain to staff that part of the contract can no longer be enforced. V4 stated going forward even residents that are alert that leave without permission will be considered to have eloped. V14 (Administrator) stated on 1/31/23 at 3:00pm the facility follows the substance abuse program contract that stipulates if a resident leaves the facility he or she is leaving against medical advice. V14 state residents in the substance abuse program are all of sound mind, alert and oriented times four. V14 stated they did not consider that R3 eloped because he was not confused and knew what he was doing. V14 stated that evening (1/19/23) when she was notified by staff that R3 left the building. V14 stated she called R3 on his cell phone and was able to reach R3 on his cell phone. V14 stated R3 told her he did not want to come back to the facility and no longer wanted to live in a nursing home. V14 stated she told R3 that he should come back to the facility and be properly discharged . V14 stated R3 told her he was safe, okay and then hung up his phone on her. V14 stated she made several more attempts to call R3 but he did not answer his phone. V14 stated because there are questions about the substance abuse contract regarding a resident leaving without permission they will just follow the elopement policy for all residents in the substance abuse program and omit the part of the substance abuse contract that states if a resident leaves they are leaving against medical advice. Facility elopement policy denotes the facility has a plan in case of an elopement of a resident from the facility. This enables the missing resident to be found as quickly as possible and to maintain the resident's safety, dignity and privacy. If a resident is discovered missing notify the Administrator and/or DON immediately and announce facility code overhead. Immediately begin a thorough search of the facility grounds. If the resident is not located the facility contact the police department and surrounding area hospitals.

Based on interview and record review, the facility failed to schedule a residents care plan conference. This failure affected one resident (R1) out of 3 residents reviewed for care planning. On 01/04/23 at 11:02 am, V7 (Minimum Data Set, MDS, Licensed Practical Nurse, LPN) was interviewed regarding R1's care plan conferences and V7 stated that R1 had a care plan conference in July 2022 and September 2022. V7 explained that R1's last care conference was scheduled in December 2022 however, R1's care conference was canceled after V7 received a directive from V1 (Administrator) and V4 (Social Service Director) to cancel R1's December 2022 care plan conference. V7 stated V7 never rescheduled R1's care plan conference for December 2022 and that V1 was waiting on the directive from V1 to reschedule R1's December 2022 care plan conference. When V7 was asked regarding if R1's December 2022 care plan conference will be rescheduled V7 stated, They (referring to R1's family) will have to wait for R1's next care conference scheduled for March 2023. When V7 was asked what the importance of a residents having a care plan conference, V7 stated, So the resident and the residents family can receive information regarding the residents progress and care. On 01/04/23 at 11:24 am, V4 (Social Service Director) was interviewed regarding R1's care plan conferences and V4 stated, V1 (Administrator) gave the directive to cancel R1's care conference for December 2022. I (V4) don't remember why it (referring to R1's December 2022 care plan conference) was canceled or what the follow up was. On 01/04/23 at 11:37 am, V1 (Administrator) was interviewed regarding R1's care plan conferences and stated, I (V1) canceled R1's care plan conference for December 6, 2022, because an unknown visitor who stated that they was R1's grandson and was not listed on R1's face sheet came to the facility to attend the care conference. I (V1) could not get in touch with R1's Power of Attorney to verify if the unknown visitor was allowed to attend. I (V1) did not ask R1 regarding the unknown visitor. I (V1) gave the directive to cancel R1's care plan conference. I (V1) never said the care plan conference could not take place. It (referring to the care plan conference) just could not take place with the unknown visitor. It (referring to the care plan conference) would have had to be the Power of Attorney (POA), or someone listed on the face sheet to attend the care plan conference. R1's care plan conference for December should have taken place or rescheduled in December 2022 by V7. I (V1) am not sure why it (referring to the care plan conference) was not. R1's Brief Interview for Mental Status (BIMS) dated 12/06/22 documents in part that R1 has a BIMS score of 12 indicating that R1 has some moderate cognitive impairment. R1's Initial Care Plan Conference Attendance sheet for June 2022 requested and facility unable to provide. V7 stated, The MDS coordinator who has it is on vacation. R1's Care Plan Conference Attendance Sheet dated 09/08/22 reviewed and documents that R1 had a care plan conference on 09/08/22 with R1 and V23 (R1's Family Member 1). On 01/04/23 at 11:02 am, Surveyor requested R1's Care Plan Conference Attendance sheet for December 2022 from V7 and V7 stated, We (referring to the facility staff) did not have a care conference for R1 in December 2022. R1's Progress note dated 12/08/22 authored by V7 (Minimum Data Set, MDS Coordinator) reviewed with concerns. Progress note dated 12/08/22 and authored by V7 documents, in part that V7 was informed by V1 and V4 to not give out information pertaining to R1's care related to ongoing investigation with Adult Protective Services (APS) and that V7 had to cancel R1's care plan conference scheduled for December 08, 2022, at 1:00 PM. Facility's Policy dated review dated 05/21 and titled Care Plan Conference documents, in part: General: An interdisciplinary care plan conference, which includes the resident and their significant other, is necessary to coordinate residents needs and establish obtainable goals. By inviting the resident and/or significant other to the care plan conference , it ensures their right to participate in planning of care and treatment . Policy: . 3) The initial care plan is held approximately 14 days after admission and approximately 90 days thereafter . 6.) the Care Plan/MDS Coordinator is responsible for running the Care Plan Conference.

Based on observations, interviews, and record reviews, the facility failed to ensure resident's call device was within reach of a resident. This failure affected 1 (R2) resident of 3 residents reviewed for call device. Findings include: On 01/03/2023 at 11:21am, R2 was on bed. R2's call light was clipped to R2's roommate (R11)'s privacy curtain on the left side, not within easy reach of R2. This surveyor inquired if R2 could raise R2's left upper extremity to reach the call light. R2 stated, No. This surveyor inquired if R2 could raise R2's right upper extremity and reach the call light. R2 stated, I (R2) can raise my (R2) right hand but I (R2) can't reach the call light from there (referring to R11's privacy curtain). On 01/03/2022 at 11:24am, this surveyor inquired about R2. V12 (Licensed Practice Nurse) stated, (R2)'s is weak on the left hand and strong on the right hand. This surveyor then inquired where the call device should be located for R2. V12 stated, On his (R2) strong side. This surveyor requested V12 to check for the location of R2's call device. V12 stated, On (R2)'s weak side. This surveyor then inquired if R2 could reach R2's call device which was clipped to R2's roommate (R11)'s privacy curtain. V12 stated, (R2) can't reach it. On 01/04/2023 at 10:50am, surveyor inquired about R2's call device placement. V2 (Director of Nursing) stated, Obviously, where he (R2) can reach it. On his (R2) right side if that is his (R2) stronger side. It should be within his (R2) reach. R2's admission Record documented that R2's diagnoses include but not limited to: unspecified injury at C1, C2, and C5 level of cervical spinal cord. R2's (12/08/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R2's mental status is cognitively intact. Section G. Functional Status. G0110 Activities of Daily Living (ADL) Assistance. B. Transfer - How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position: 3/2 coding Extensive assistance/One person physical assist. I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfer on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. 2/2 coding Limited assistance / One person physical assist. R2's (12/01/2022) Call Light Ability Screen documented, in part 1. Resident is able to use the call light. The (undated) Certified Nursing Assistant Job Descriptions documented, in part The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisor. Personal Nursing Care Functions. Answer resident calls as promptly as feasible. The (10/2021) Call Light Answering documented, in part GENERAL: To provide the staff with guidance on responding to resident's request and needs. RESPONSIBLE PARTY: IDT. PROCEDURE: 5. When the resident is in bed . provide the call light within easy reach of the patient or resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a family representative of a change in condition which affected one (R19) of four residents (R19, R20, R21, R22) reviewed for policy and procedure. Findings include: R19's Minimum Data Set (MDS) dated [DATE], documents, in part that R19's Brief Interview for Mental Status (BIMS) score is a 6 which indicates that R19 has severe cognitive impairment. R19's admission Record documents, in part, that R19's diagnoses are dementia, nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis following unspecified cerebrovascular disease and COVID-19. R19's Emergency Contact #1 is documented as (V37, R19's Family Member 1). On 1/4/23 at 10:38 am, when R19 was asked who is R19's emergency contact, R19 said (V37, R19's Family Member 1). R19's Laboratory Report documented, in part, with COVID-19 specimen collected on 12/29/22 at 10:00 am and resulted on 12/31/22 at 12:10 am, for COVID-19 (SARS COVID rt-PCR {polymerase chain reaction} DETECTION) with result of POSITIVE. On 1/4/23 at 9:36 am, V27 (Infection Preventionist) stated that facility's contract laboratory (lab) company directly notifies V27 by phone with each positive COVID-19 test result. V27 stated that on 12/31/22, R19's COVID-19 positive test result was communicated to V27 by phone on 12/31/22 by the lab company and that V27 then notified V1 (Administrator), V2 (Director of Nursing, DON), V3 (Assistant DON) and V6 (Unit Manager/Licensed Practical Nurse, LPN) via a phone message on 12/31/22 about R19's COVID-19 positive test result. V27 stated that on 12/31/22, V27 was not in the facility and had trouble accessing the facility's electronic medical record (EMR) system. V27 stated that V27 then personally called V6 about where to move R19 for a COVID-19 isolation room in the facility. When asked if V27 notified R19's family member of R19 testing positive for COVID-19 on 12/31/22, V27 stated No, and that V6 spoke with R19's family member. On 1/4/23 at 11:55 am, V6 (Unit Manager/LPN) stated that on 12/31/22, V27 informed V6 of R19's positive COVID-19 test by phone and that V27 was not in the facility. V6 stated that V6 then called V31 (Registered Nurse, RN) at the facility, and informed V31 of R19's positive test result and to move R19 to a specific private room for COVID-19 isolation. When asked if V31 notified R19's family member of R19's positive COVID-19 result on 12/31/22, V6 stated, I (V6) can't speak on if (V31) did or not. V6 stated that on 1/3/23 (4 days after R19's positive COVID-19 result), during a phone call with V37, V6 stated that V37 said that nobody from the facility notified V37 of R19's positive COVID test on 12/31/22. On 1/4/23 at 12:57 pm, V31 (RN) stated that V31 was R19's primary nurse on 12/31/22 and that V6 called V31 on 12/31/22 to relay the COVID-19 positive test result for R19 with instructions to move R19 to a specific private room. V31 stated (R19's) family was notified as well of the positive (COVID-19) result. When asked if V31 personally called to notify R19's family member/emergency contact of R19's positive COVID-19 test result on 12/31/22, V31 stated, No, I (V31) didn't personally. I (V31) assumed that the management team would have. V31 stated that the Infection Preventionist or the DON make notifications of a resident's positive COVID-19 test results unless specifically told to do that (notify the family member). When asked about if V31 documented in R19's EMR about family member notification on 12/31/22 of R19's positive COVID-19 results, V31 stated, I (V31) do, but I (V31) don't recall at this moment. I (V31) am not sure, but it seems like there should be (documentation) for a positive test. It's a gray area. When this surveyor explained to V31 that upon R19's EMR review, there was no documentation from V31 on 12/31/22, V31 stated, Then obviously, I (V31) didn't do it if you (surveyor) don't see nothing. On 1/4/23 at 3:18 pm, V2 (DON) was asked who is responsible for notifying the family member/emergency contact of the resident who tested positive for COVID-19, and V2 stated, Typically it's (V27). (V27) will reach out to the family member. V2 stated that a resident testing positive for COVID-19 is considered a change in the resident's condition. V2 was asked if documentation of notification should be done by the nurse of the affected resident's family member, and V2 stated Yes. When asked the purpose of notifying a resident's family member of a positive COVID-19 test affecting the resident, V2 stated, To keep them (family member) up to date on the resident's condition. When asked which staff member notified R19's family member of R19's COVID-19 positive test result on 12/31/22, V2 stated, I (V2) assumed that (V27) talked to (R19's family). On 1/4/23 at 2:15 pm, V3 (ADON) stated that R19 has a diagnosis of dementia and has intermittent confusion. This surveyor reviewed R19's Progress Notes in the EMR which document, in part, an absence of progress note documentation on 12/31/22 for R19's family member notification as evidenced by a psychotropic note dated 12/27/22 at 1:44 am with the next health status progress note documented on 1/3/23 at 2:00 pm. R19's Resident/Family Education form that was authored by V27 on 1/3/23, for effective date of 12/31/22, documented, in part, that participant of education was resident/guest and family/care giver for the topic of education being resident (R19) made aware of positive COVID-19 result and temporary room change. Resident (R19) voiced no concerns. V27's documentation of family/care giver being educated on 12/31/22 about R19's positive COVID-19 result contradicts V27's statement above to this surveyor. R19's Care Plan, initiated on 12/30/21, documents, in part, a focus of (R19) has confirmed COVID-19 infection . confirmed testing for COVID-19 . 12/31/22 with an intervention of keep resident and resident representative informed of any condition changes. Facility policy dated June 2021 and titled, Change in Resident's Condition, documents, in part, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP (nurse practitioner) and resident's responsible part of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: . b. There is a significant change in the resident's physical, mental or emotional status . e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. 3. Once the physician/NP has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record and other appropriate documents.

Based on interview and record review, the facility failed to ensure Healthcare Worker Background Checks were done in a timely manner and were documented in an effort to prevent abuse. This failure has the potential to affect all 160 residents residing in the facility. Findings include: The (01/03/2023) Facility census was 160residents. On 01/04/2023 at 9:26am, this surveyor and V29 (Director of Human Resources) initiated review of the staff Health Care Worker Background check. On 01/04/2023 at 9:29am, V29 stated that V13 (Certified Nursing Assistant) was hired on 11/03/2018 and that Healthcare Worker Background check was initiated on 06/21/2019. Review of V13 Health Care Worker Registry and the facility (As of 01/03/2023) Anniversary List by Organization affirmed V29 statement. On 01/04/2022 at 9:30am, surveyor inquired about the importance of the Healthcare Worker Background Check. V29 (Director of Human Resources) stated, We (facility) are supposed to run the background check before staff come in, before they start working. The importance of doing the background check is to make sure there is no abuse allegation towards staff or resident; or that staff are eligible to work in a nursing home. Crimes committed will make staff not eligible to work in a nursing home. Some crimes, you get a waiver and some cannot. Most part, I (V29) do the background check prior to hiring, I (V29) did check V13 (Certified Nursing Assistant), but probably not printed it, since she (V13) worked here before. The date on the left top corner of the form was the date I (V29) ran the background check. On 01/04/2022 at 9:43am, surveyor inquired about V15 (Licensed Practice Nurse) Healthcare Worker Background Check. V29 stated, I (V29) just ran her (V15) background check today. She (V15) started 11/01/2021, I (V29) know I (V29) ran it around that time. I (V29) don't know what happened to her (V15) file. I (V29) know that if it is not documented, it never happened. Review of V15 Health Care Worker Registry and the facility (As of 01/03/2023) Anniversary List by Organization documented that V15's last hire date was on 11/05/2021 and not on 11/01/2021 as stated by V29. On 01/04/2023 at 9:49am, V29 stated that V18 (Licensed Practice Nurse) was hired on 06/02/2004 and the Healthcare Worker Background check was dated 3/27/2006. Review of V18 Health Care Worker Registry and the facility (As of 01/03/2023) Anniversary List by Organization affirmed V29 statement. On 01/04/2023 at 9:50am, surveyor inquired about V18 (Licensed Practice Nurse) Healthcare Worker Background Check. V29 stated, That was well before I (V29) came in, I (V29) have no clue why it's late. I (V29) started as HR Director on 7/31/2018. On 01/04/2023 at 9:57am, V29 stated that V31 was hired on 09/20/2013 and the Healthcare Worker Background Check was dated 05/19/2016. Review of V31 Health Care Worker Registry documented that it was initiated on 09/10/2019 and not on 05/19/2016; and the facility (As of 01/03/2023) Anniversary List by Organization affirmed V29 statement about V31's last hire date. On 01/04/2023 at 9:58am, surveyor inquired about V31 (Registered Nurse) Healthcare Worker Background Check. V29 stated, I (V29) was not here when she (V31) was hired. I (V29) don't know what happened to her (V31) background check. The (As of 01/03/2023) Anniversary List by Organization documented that V13's last hire date was on 11/03/2018, V15's last hire date was on 11/05/2021, V18's last hire date was on 06/02/2004, and V31's last hire date was on 09/20/2013. On 01/04/2023 at 10:51am , surveyor inquired about Healthcare Worker Background check. V2 (Director of Nursing) stated, We ran the background check prior to starting to work, to see if there is previous issue like anything criminal, to avoid or prevent any type of abuse. On 01/04/2023 at 11:30am, surveyor inquired about Health Care Worker Background Check. V1 (Administrator) stated, This needs to be done within 10days of hire. That's the regulation. We should be following the regulation. The (undated) Director of Human Resources Job Description documented, in part Purpose of your Job Position. The primary purpose of your job position is to direct human resources department in accordance with current applicable federal, state, and local standards, guidelines, and regulations . Administrative Functions. To ensure that appropriate documentation concerning the employee's right to work in this country is verified in accordance with current laws, regulations, and guidelines concerning such matters, and that appropriate documentation of such review is filed in the employee's personnel record within the specified time frame. The (undated) Pre-hire Screening Helpful Information Background Checks documented, in part Purpose: (Facility) is required to conduct various background check including fingerprinting and reference checks. These item are examined during State inspection therefore it is a crucial part of the file and must be in order. All these checks must be done and completed prior to a prospective candidate beginning work. The HR (Human Resources) Manager/BOM (Business Office Manager is responsible for ensuring the timely and accurate request of all background checks, fingerprint portal registry check and professional reference checks. Procedure: BACKGROUND CHECKS. A series of background checks must be initiated for all candidates after a conditional employment offer has been made and before their first official day. The (undated) Abuse Prevention Program - Policy documented, in part Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. His include but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. PURPOSE: The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents form abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: conducting pre-employment screening of employee .

Based on observation, interview and record review, facility failed to follow their policy to maintain a resident's dignity by placing a Foley catheter drainage bag in a drainage cover for 1 (R83) resident out of 3 residents reviewed for Foley catheter care in a sample of 24. The facility also failed to provide privacy during an insulin injection for 1 (R125) of 7 (R63, R78, R91, R121, R163, R171) residents reviewed during medication administration. Findings include: R125 has diagnosis not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Cerebral Infarction. Order Summary Report dated 06/22/22 document in part Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Milliliter) (Insulin Aspart) Inject 15 unit subcutaneously with meals and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD (Medical Doctor)., subcutaneously with meals. On 06/22/22 at 11:08 AM during medication administration observation V16 (Licensed Practice Nurse) retrieved a vial of Novolog insulin from the medication refrigerator. V16 drew up 10 units of Novolog insulin into an insulin syringe which was verified by the surveyor. R125 was observed sitting in a wheelchair in the dining room. V16 entered the dining room, explained to R125 that insulin was being given, wipe R125 right upper arm with an alcohol wipe then administered 10 units of Novolog insulin. V16 then exited the dining room and documented in the electronic medical records that the insulin was given. On 06/22/22 at 11:20 AM surveyor asked V16 (Licensed Practical Nurse) why was R125 insulin given in the dining room. V16 stated the insulin should have been given in privacy, in R125 room. On 06/23/22 at 8:38 V2 (Director of Nursing) stated a resident insulin should be given in a private area. It is a dignity issue. 06/21/22 10:43 AM surveyor observed R83's urinary bag is uncovered. On 06/23/2022 at 11:00 AM, V2 (Director of Nursing) stated Foley bags should be placed in a privacy bag. It should be hanging on the bed and not on the floor. Foley bags should be placed in a privacy bag because it is a dignity issue. On 06/23/2022 at 11:06 AM, surveyor saw R83's Foley bag still uncovered. On 06/23/2022 at 11:08 AM, V22 (Licensed Practical Nurse) stated that Foley care is done every day. She (V22) stated that the Foley bag should be hanging off the bed, below the resident and it should be covered. On 06/23/2022 at 11:09 AM, surveyor asked V22 to check if R83's Foley bag is covered. Surveyor and V22 walked to R83's room and saw that the Foley drainage bag was not covered. V22 stated that the bag was not covered and that she (V22) will get the blue Foley bag cover to put the Foley bag in. Facility's Foley catheter care policy documents in part: Provide resident dignity by placing the drainage bag in a dignity bag. Record review of Residents' Rights for People in Long Term Care Facilities document in part: Privacy Your medical and personal care are private. Policy: Titled Insulin Administration revised 10/21 document in part: To safely and accurately inject insulin into the subcutaneous tissue. 5. Explain procedure and provide Privacy.

Based on observation, interview and record review the facility failed to ensure a resident who was self-administering medication had a physician's order, self-administration of medications assessment and a care plan completed. This failure has the potential to affect 1 resident (R91) for taking medication without supervision. Findings Include: R91 was readmitted to the facility 05/26/21 with diagnosis not limited to Unspecified Dementia, Mild Cognitive Impairment, Unspecified Glaucoma, Altered Mental Status and Post Traumatic Stress Disorder. Order Summary Report dated 06/23/22 document in part: Brimonidine Tartrate Solution 0.2% Instill 1 drop in both eyes at bedtime, Brimonidine Tartrate Solution 0.2% Instill 1 drop in both eyes in the afternoon, Brimonidine Tartrate Solution 0.2% Instill 1 drop in both eyes in the morning, Timolol Maleate Solution 0.5% Instill 1 drop in both eyes in the evening and Timolol Maleate Solution 0.5% Instill 1 drop in both eyes in the morning. Record review of sign posted at R91 bedside document in part Latanoprost 0.005% 1 drop both eyes once/bedtime with no documented physician order. Timolol Maleate 0.5% 1 drop both eyes twice per day. Brinzolamide/brimonidine 1 drop both eyes 3 times a day. Wait 5 minutes between drops. On 06/22/22 at 10:59 AM R91 was observed sitting in bed. Multiple boxes with eye drop bottles were observed on a ledge on the left side of R91 bed with a sign of the schedule for the eye drop instillation posted on the wall at the bedside. R91 stated I have my eye drops there and put them in myself. On 06/21/22 at 11:42 AM V5 (Licensed Practical Nurse) stated R91 does his (R91) own eye drops. R91 will watch the clock and know when to take the eye drops. On 06/23/22 at 8:38 V2 (Director of Nursing) stated if R91 is self-administering medications an order, care plan and assessment should have been completed for self-administration. On 06/23/22 at 11:01 V2 (Director of Nursing) stated there is no assessment, care plan or orders for R91 self-administration of the eye drops. On 06/23/22 at 11:34 V2 (Director of Nursing) stated the eyedrop schedule that is on R91 wall is something that came from the Veteran Administration. I asked R91 about it and R91 said the nurse from the Veteran Administration gave it to him (R91). Policy: Titled Self-Administration of Medication and Treatments reviewed 02/05/21 document in part: Self-Administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. 1. Self-administration of medications and treatments is determined by an order after determining that the resident is able to self-administer. 2. Medications and treatments for self-administration are kept in a locked drawer/box in the resident room. Procedure: 1. If it is determined by a member of the interdisciplinary team, or if the resident requests to self-administer, it is documented in the chart and the Health Care Provider is called for an order to self-administer medications and keep the medications at bedside. The order shall specify that the medications shall be kept at bedside for each medication that applies to self-administration. 2. Determination of the ability to self-administer medications will be done by nursing using the tool (Self-Administration of Medication). 3. Resident teaching will be performed and documented by nursing staff. 6. A care plan is for resident who self-administer, and documentation shall be present in the nursing notes of teaching related to self-administration of medications and treatments.

Based on observation, interview and record review the facility failed to provide tube feedings as ordered for 1 (R108) of 2 (R41) residents reviewed for tube feeding. R108 has diagnosis not limited to Encounter for Attention to Gastrostomy, Cognitive Communication Deficit, Dysphagia, Cerebral Infarction and Gastritis. On 06/21/22 10:55 AM R108 was observed in bed in a semi-Fowler_position with the Enteral feeding infusing at 65 ml/hr (Milliliter/hour) per pump amount delivered 29 ml. On 06/21/22 at 11:42 AM V5 (Licensed Practical Nurse) entered R108 room with the surveyor. V5 stated R108 enteral feeding infuses at 65 ml/hr from 06:00 AM - 12:00 midnight. R108 enteral feeding pump was observed to be turned off. V5 stated I had to hang another bottle at 10:00 AM. I don't know who turned it off. It may have been a Certified Nurse Assistant. R108 Physician Orders document in part: in the afternoon related to Dysphagia following Cerebral Infarction Jevity 1.5 @ 65 ml/hr x 18 hours (start 2pm; end 8 am) and in the morning related to Dysphagia following Cerebral Infarction Jevity 1.5 @ 65 ml/hr x 18 hours (start 2 pm; end 8 am). On 06/23/22 10:02 AM V2 (Director of Nursing) stated the order says to start the feeding at 2pm and end at 8am. It should not have started until 2pm. If there was a change in the orders, they should have rewritten the order. There is a potential that having the feeding infusing when it should not be infusing could cause GI (Gastrointestinal) upset if R108 is being overfed and it could affect R108 appetite. On 06/23/22 at 11:09 AM V21 (Licensed Dietician) stated R108 tube feeding may be exceeding his (R108) needs. R108 receives 40 calories/kilogram. I was concerned about R108 weight loss, and I changed the tube feeding order last month (May 2022) during breakfast and lunch. The rate is the same, but the time was changed from 06:00 AM - 12:00 AM to 02:00 PM - 08:00 AM. R108 was losing weight and the gastric tube feeding was started in January 2022. The weight on 02/22 were 121.4 pounds, 03/22 125.9 pounds, 04/22 112.6 pounds, 05/22 110.1 pounds and in 06/22 we got R108 weight up to 113.4 pounds. If the gastric tube feeding is infusing when it should not be there is a potential that R108 will not be fed when R108 is supposed to be fed, R108 would be getting over fed, vomiting indicating over feeding, receiving too many calories and a decrease in appetite when R108 receives the pureed diet. Policy: Titled Enteral Tube review date 06/21 document in part: Nasogastric, gastrostomy and jejunostomy tubes are used when an alternate method of nutrition is needed. 3. Enteral bottles are hung based on manufacturer's guidelines and the physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop a person-centered dementia care plan for 1 (R103) out of 1 resident reviewed for dementia care in a sample of 34 residents. Findings include: R103 was initially admitted to the facility on [DATE]. R103 has a diagnosis, that is not limited to, Unspecified Dementia without Behavioral Disturbance. According to R103's most recent minimum data set (MDS), R103 is cognitively impaired. On 06/22/22 at 01:30 PM R103's entire care plan was reviewed. No individualized dementia care plan with interventions was identified in R103's electronic medical record. On 06/22/22 at 01:30 PM A printout of R103's social service care plans were provided by V1 (Administrator) and no individualized dementia care plan with interventions identified in R103's electronic medical record. On 06/23/22 at 11:03 AM V23 (Social Worker) stated, R103 does have a diagnosis of dementia. R103 should have a dementia care plan. On 06/23/22 at 12:07 AM V23 (Social Worker) stated, a dementia care plan is required for residents with dementia so staff can be aware of the resident's needs and what interventions are required. All staff should be following the interventions in the dementia care plan. I have been R103's social worker for 3 months. R103 does have a diagnosis R103's previous social worker did not create a dementia care plan. I created a dementia care plan for R103 today.

Based on observation, interview and record review the facility failed to ensure that all medications were administered without an error rate of 5% or more. for 3 of 7 residents (R121,R163, R125) During Medication administration on 06/22/22 the surveyor observed 3 nurses administer medication to 7 residents. There were 25 opportunities for error and 5 errors were observed. This deficient practice resulted in a medication administration error rate of 20%. Findings Include: 1. R121 has diagnosis not limited to Essential (Primary) Hypertension, Vitamin D Deficiency, Heart Failure, Dementia, Syncope and Collapse. Order Summary Report dated 06/22/22 document in part: Aspirin Tablet Chewable 81 MG by mouth in the morning and Cholecalciferol Tablet Give 2000 unit by mouth in the Morning. On 06/22/22 at 08:49 AM V15 (Registered Nurse) was observed preparing R121 medications. V15 put Aspirin Tablet Chewable 81 MG (Milligram), Cholecalciferol Tablet Give 2000-unit, (Vitamin D3 25 mcg 1000 IU (International Unit), was given), Cyanocobalamin Tablet 500 MCG Give 2 tablet, Ferrous Sulfate Tablet 325 (65 Fe) MG, Risperidone Tablet 0.5 MG, Tamsulosin HCl (Hydrochloride) Capsule 0.4 MG in a medication cup. V15 entered R121 room, handed R121 the medication cup and a cup of water. R121 poured the pills into his (R121) mouth then drank the water. The bottle containing the Cholecalciferol read Vitamin D3 25 mcg 1000 IU, order document Cholecalciferol Tablet Give 2000 unit. Aspirin Tablet Chewable 81 mg was not given separately and was swallowed whole by R121. 2. R163 has diagnosis not limited to Essential (Primary) Hypertension, Type 2 Diabetes Mellitus and Acute Respiratory Failure with Hypoxia. Order Summary Report dated 06/22/22 document in part: Aspirin Tablet 81 MG by mouth in the morning. On 06/22/22 at 08:57 AM V15 (Registered Nurse) was observed preparing R163 medications. V15 put Aspirin Tablet 81 MG, (Aspirin Tablet Chewable 81 MG was given), Folic Acid Tablet 1 MG, Keppra Tablet 500 MG, Levothyroxine Sodium Tablet 25 MCG (Microgram), Lisinopril Tablet 5 MG, Prednisone Tablet 5 MG, Vitamin B1 Tablet 100 MG and Vitamin B-12 Tablet 500 in a medication cup. V15 (Registered Nurse) stated there are 8 pills in the medication cup. Pill count in medication cup verified by surveyor. V15 entered R163 room and handed R163 the medication cup and a cup of water. R163 poured the pills into her (R163) mouth then drank the water, swallowing the pills. The bottle containing Aspirin 81 mg read Aspirin Chewable 81 mg. Aspirin Tablet Chewable 81 mg was not given separately and was swallowed whole by R163. On 06/22/22 at 09:01 AM V15 (Registered Nurse) stated we have chewable and enteric coated aspirin. The 81 mg Chewable Aspirin is the only one that we have. The order can be changed to the chewable aspirin. The house stock medications come up from central supply. 3. R125 has Diagnosis not limited to Chronic Kidney Disease, Cerebral Infarction, Type 2 Diabetes Mellitus, Cognitive Communication Deficit and Major Depressive Disorder. Order Summary Report dated 06/22/22 document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with Meals. On 06/22/22 at 11:08 AM V16 (Licensed Practice Nurse) drew up 10 units of Novolog insulin into an insulin syringe which was verified by the surveyor. R125 was observed sitting in a wheelchair in the dining room. V16 entered the dining room, explained to R125 that insulin was being given, wipe R125 right upper arm with an alcohol wipe then administered 10 units of Novolog insulin. V16 then exited the dining room and documented in the electronic medical records that the insulin was given. Resident # 125 Order Summary Report document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals, Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with meals. On 06/22/22 at 11:18 AM V16 (Licensed Practice Nurse) stated I can still give this one (Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit) with meals because R125 haven't eaten lunch yet. It should have been a total of 25 units given. Do you need to see me give that one? The blood glucose was 370. During Medication Administration Observation Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals was not given) and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with meals. 10 units was given before the meal in the right deltoid in the dining room). On 06/22/22 at 12:09 PM the lunch trays arrived at the nursing unit. On 06/22/22 at 12:21 PM R125 was served the lunch tray in the dining room. On 06/22/22 at 12:42 PM R125 completed consuming lunch and the Certified Nurse Assistant covered the tray, R125 proceeded to exit the dining room. R125 was not given the Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals. On 06/23/22 at 8:38 (Director of Nursing) stated medications that are ordered to be given with meals should be administered when the resident get the meal tray. If the medication is given before or after a meal it is not following doctor orders. Because the resident was supposed to receive 15 units of insulin in addition to the sliding scale and it was not given there is a potential for hyperglycemia. Medications are signed out as they are given. We have chewable and enteric coated aspirin based on whatever the doctor order. Chewable aspirin should not be given with medications, it should be separated. Enteric coated can just be swallowed. If the medication is given incorrectly the medication may not be effective. On 06/23/22 at 09:52 V19 (Central Supply) stated there are 4 types of aspirin baby aspirin 81 mg, baby aspirin chewable 81 mg, 325 mg enteric coated and regular aspirin 325 mg in the house stock. Policy: Titled Insulin Administration revised 10/21 document in part: To safely and accurately inject insulin into the subcutaneous tissue. 5. Explain procedure and provide Privacy. Titled Resident-Centered Medication Administration Policy (Block Charting Medication Administration) dated created 05/21 document in part: To provide each patient with an evidence-based, person-centered care approach across the entire medication use process in the facility. 3. Obtain an order from each resident's provider that s/he may participate in the resident-centered medication administration program at the facility and enter the order into each resident's medical record and care plan. 6. This resident-centered medication administration policy will exclude and not apply to the following medication categories: a. Time-Critical Scheduled Medications, II. Certain medications that require administration within a specified period of time before, after, or with meals - examples include short acting insulins. Titled Insulin Administration reviewed 11/21 document in part: To safely and accurately inject insulin into the subcutaneous tissue. 1. Insulin is only given as ordered. 9. Recorded on the MAR (Medication Administration Record) that insulin was given and site, rotating site.

Based on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error related to insulin administration for 1 (R125) of 7 residents reviewed for medication administration. Findings Include: R125 has Diagnosis not limited to Chronic Kidney Disease, Cerebral Infarction, Type 2 Diabetes Mellitus, Cognitive Communication Deficit and Major Depressive Disorder. Order Summary Report dated 06/22/22 document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with Meals. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit was given at 11:02 AM (which was not given) and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale was given on 06/22/22 at 11:08 AM for a blood glucose of 370. Accucheck AC (Before Meals) and HS (Hour of Sleep) before meals and at bedtime. Care Plan document in part R125 has Diabetes Mellitus, potential for complications. Accu Check per MD (Medical Doctor) orders and document. Diabetes medication as ordered by doctor On 06/22/22 at 11:08 AM V16 (Licensed Practice Nurse) drew up 10 units of Novolog insulin into an insulin syringe which was verified by the surveyor. R125 was observed sitting in a wheelchair in the dining room. V16 entered the dining room, explained to R125 that insulin was being given, wipe R125 right upper arm with an alcohol wipe then administered 10 units of Novolog insulin. V16 then exited the dining room and documented in the electronic medical records that the insulin was given. On 06/22/22 at 11:18 AM V16 (Licensed Practice Nurse) stated I can still give this one (Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit) with meals because R125 haven't eaten lunch yet. It should have been a total of 25 units given. Do you need to see me give that one? The blood glucose was 370. During Medication Administration Observation Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals was not given) and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with meals. 10 units was given before the meal in the right deltoid in the dining room). On 06/22/22 at 12:09 PM the lunch trays arrived at the nursing unit. On 06/22/22 at 12:21 PM R125 was served the lunch tray in the dining room. On 06/22/22 at 12:42 PM R125 completed consuming lunch and the Certified Nurse Assistant covered the tray, R125 proceeded to exit the dining room. R125 was not given the Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals. On 06/23/22 at 8:38 (Director of Nursing) stated medications that are ordered to be given with meals should be administered when the resident get the meal tray. If the medication is given before or after a meal it is not following doctor orders. Because the resident was supposed to receive 15 units of insulin in addition to the sliding scale and it was not given there is a potential for hyperglycemia. Medications are signed out as they are given. Policy: Titled Insulin Administration revised 10/21 document in part: To safely and accurately inject insulin into the subcutaneous tissue. 5. Explain procedure and provide Privacy. Titled Resident-Centered Medication Administration Policy (Block Charting Medication Administration) dated created 05/21 document in part: To provide each patient with an evidence-based, person-centered care approach across the entire medication use process in the facility. 3. Obtain an order from each resident's provider that s/he may participate in the resident-centered medication administration program at the facility and enter the order into each resident's medical record and care plan. 6. This resident-centered medication administration policy will exclude and not apply to the following medication categories: a. Time-Critical Scheduled Medications, II. Certain medications that require administration within a specified period of time before, after, or with meals - examples include short acting insulins. Titled Insulin Administration reviewed 11/21 document in part: To safely and accurately inject insulin into the subcutaneous tissue. 1. Insulin is only given as ordered. 9. Recorded on the MAR (Medication Administration Record) that insulin was given and site, rotating site.

Based on observation, interview and record review, facility failed to follow their call light policy to ensure call lights are placed within reach for 5 (R331, R15, R88, R108, R160) residents reviewed for call lights in a final sample of 24. Findings include: 06/21/22 10:43 AM, surveyor saw R331's call light on the floor. R331 stated she does not know where her call light was. She (R331) also stated that it's been a couple hours since a nurse or CNA have come in the room. On 06/23/2022 at 1:55 PM, V2 (Director of Nursing) stated, hourly rounding is done every two hours. As soon as they see a call light, the nurse or CNA should tend to it. Call light should be placed within reach of the resident. If the call light is not within reach, they cannot call for their needs. On 06/22/22 at 10:53 AM R88 was observed sitting on the bed removing his (R88) Tee-Shirt and putting on a shirt. R88 call light was observed on the floor, between the bed and near the head of the bed, not within R88 reach. On 06/21/22 at 10:55 AM R108 was observed in bed in a semi-Fowler_position. R108 call light was observed hanging over the light fixture at the head of the bed, out of R108 reach. On 06/21/22 at 11:15 AM R160 was observed asleep in bed. R160 call light was observed behind the headboard and underneath the bed, out of R160 reach. On 06/21/22 at 11:19 AM R15 was observed in bed on a low air loss mattress, the call light was not within R15 reach. On 06/21/22 at 11:40 AM V5 (Licensed Practical Nurse) entered R88 room with the surveyor. V5 stated R88 call light is on the floor and it should be on the bed. V5 proceeded to pick up and place R88 call light on R88 bed, within R88 reach. On 06/21/22 at 11:42 AM V5 (Licensed Practical Nurse) entered R108 room with the surveyor. V5 stated R108 call light is hanging on the light. V5 proceeded to remove R108 call light from the light fixture and placed it on R108 bed, within R108 reach. On 06/21/22 at 11:46 AM V5 (Licensed Practical Nurse) entered R160 room with the surveyor. V5 stated R160 call light is on the floor. V5 unlocked R160 bed, used the bed remote to raise R160 bed then pulled the call light from underneath R160 bed and placed it on R160 bed, within R160 reach. On 06/21/22 at 11:48 AM V5 (Licensed Practical Nurse) entered R15 room with the surveyor. R15 stated the call light is back there, and I cannot reach it. V5 went to the head of the bed then stated R15's call light is on the other bed. V15 removed the call light from the bed next to R15 then placed it on R15 bed, within R15 reach. On 06/22/22 at 11:00 AM R88 was observed asleep in bed with the call light between the beds on the floor and not within R88 reach. On 06/23/22 at 10:02 AM V2 (Director of Nursing) stated the call light should be located within reach of the resident. If the resident need assistance and cannot reach the call light there is a potential that the resident will not be able to call. Facility's Call Light Answering policy (10/2021) documents in part: When the patient or resident is in bed or confined to bed or chair, provide the call light within easy reach of the patient or resident.

Based on observation, interview and record review, the facility failed to follow their policy's on Physician's Orders and Weighing of residents, for 4 residents (R28, R43, R134 and R122) reviewed for quality of care. Findings Include: On 6/22/22 at 10:20 AM during record review of R28, R43, R134 and R122. Residents noted with physicians orders for bi-weekly weights to be done on Tuesday and Friday. Record review showed from the date order was placed on 2/16/22, for R28, R43, R134, R122, recordings to the electronic medical record inconsistent to said order, noted multiple weights not recorded. R28 was admitted to facility on 8/14/20; with a diagnosis, not limited to, Congestive Heart Failure (CHF). One weight recorded on 6/3/22, up to date of survey entrance of 6/21/22. One weight recorded on 5/5/22, no other weights recorded for May. R43 was admitted to facility on 3/15/21; with a diagnosis, not limited to, CHF. One weight recorded on 6/3/22, up to date of survey entrance, 6/21/22. One weight recorded on 5/5/22, no other weights for May noted. R122 was admitted to facility on 11/30/18; with a diagnosis, not limited to, CHF. One weight recorded on 6/3/22, up to date of survey entrance, 6/21/22. One weight recorded on 5/5/22, no other weights for May noted. R134 was admitted to facility on 9/11/20; with a diagnosis, not limited to, CHF. One weight recorded on 6/3/22, up to date of survey entrance, 6/21/22. One weight recorded on 5/5/22, no other weights for May noted On 6/22/22 at 11:50 AM V17 (Licensed Practical Nurse) stated the bi-weekly weights are done by the Restorative Aides and given to the Restorative Nurse. V18 stated, V18 was unaware where weights are kept. On 6/22/22 at 12:20 PM V18 (LPN) stated Restorative Aides weigh the residents and she receives the results on paper by the Aides, and manually records to the electronic chart. However, V18 stated I am behind. V18 stated the dialysis resident refuses to get weighed because he gets weighed in dialysis. V18 was unable to recall name of the resident on dialysis to be weighed. Surveyor did not find documentation of any of the 4 residents R28, R43, R134 and R122 refusing weights to be done. V18 denied informing attending physician of resident's refusal to be weighed. On 6/23/22 at 10:15 AM V2 (Director of Nursing) stated Restorative takes care the weighing of residents; the Restorative nurse documents weights into the record, this also allows for trending of the weights recorded. Any refusals of weights should be documented, physician notified and educating the resident. V2 stated not following physician orders can present adverse effects to the resident's care. Physician order: 2/16/22, for the following, R28, R43, R134, and R122, reads: Congestive Heart Failure: Weigh and record weight every day shift every Tue, Fri weigh at same time of day Congestive Heart Failure care plan for R28, R43, R134, and R122, intervention states, Weigh per MD orders/facility protocols. Physician's Orders Policy (8/1/21) states in part: The purpose of this policy is to provide guidance for licensed nurses and licensed therapist to accurately document physician and provider orders as determined by licensee's Scope of Practice. Execution of Order and Notifications (Policy 8/1/21) cont.: The nurse that takes the physician order will be responsible for executing the order or providing for the safe hand-off to the next nurse. Weight Policy (7/08): To establish a policy for the consistent, timely monitoring and reporting of resident weights.

Based on observation, interview, and record review, the facility failed to a.) ensure medications were not pre-poured during one medication pass, b.) ensure expired medications were removed from the medication cart c.) ensure items other than medications were not stored in the medication refrigerator and d.) ensure the temperature was monitored in one of 2 medication refrigerators during the Medication Labeling and Storage and the Medication Administration observation. Findings Include: R55 has diagnosis not limited to Type 2 Diabetes Mellitus, Dementia and Mild Protein-Calorie Malnutrition. Order Summary Report dated 06/22/22 document in part: Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units at bedtime. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: R55 received Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units 5 times from 06/16/22 - 06/21/22. R55 care plan document in part R55 has Diabetes Mellitus. R162 has diagnosis not limited to Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease and Chronic Kidney Disease. Order Summary Report dated 06/22/22 document in part: Humalog Solution 100 UNIT/ML (Milliliter) (Insulin Lispro) Inject 12 unit subcutaneously three times a day and Humalog Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 250 = 1unit; 251 - 300 = 2units; 301 - 350 = 3units; 351 - 400 = 4units; 401 - 450 = 5units >450 call MD, subcutaneously three times a day. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: R162 received insulin Lispro insulin15 times from 06/16/22 - 06/21/22. R162 care plan document in part: R162 has Diabetes Mellitus. At risk for complication r/t (Related to) diabetes. On 06/21/22 at 12:04 PM During Medication Labeling and Storage observation of the fourth floor Medication Cart #1 Floor stock: Zinc 500 mg (Milligram) Expired on 05/22 and Daily Vitamin Formula with Iron Expired on 10/21. V4 (Licensed Practical Nurse) stated the expired medication should be stored in the medication room and replaced with a new one. We let the Director of Nursing know, they pick up the expired medications and discard them. R55 Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units at bedtime filled and labeled as opened 05/16/22 discard date 06/16/22. V4 stated today is 06/21/22, the insulin should have been discarded five days ago on 06/16/22. Once insulin is opened it is good for 30 - 31 days depending on the month. R162 Lispro U100 Sliding scale Three times a day, filled, and labeled as opened 05/16/22 discard date 06/16/22. V4 stated R55 and R162 both receive insulin. R162 insulin should have been discarded 06/16/22. On 06/21/22 at 12:19 PM During Medication Labeling and Storage observation of the fourth floor Medication room with V5. V5 (Licensed Practical Nurse) stated once the insulin is opened it is good for 28 days. A-16-ounce bottle of Creamy Salad Dressing was observed in the medication room refrigerator. V5 stated the salad dressing should not be in the medication refrigerator. On 06/21/22 at 12:30 PM During Medication Labeling and Storage observation of the third Floor Medication Cart #1 Floor stock: Sodium Bicarbonate 10 gr (gram) 650 mg 1000 tablet bottle Expired 12/21. V6 (Licensed Practical Nurse) stated when the medication expired it is to be tossed out and get another one. On 06/21/22 at 12:39 PM During Medication Labeling and Storage observation of the third-floor medication room with V6, a 20-ounce bottle of Arizona Fruit Punch was observed in the medication refrigerator. V6 (Licensed Practical Nurse) stated I don't know who put that in there, but it should not be in the refrigerator. On 06/21/22 at 12:40 PM there was no thermometer observed in the third-floor medication refrigerator and the last temperature on the Third Floor Refrigerator Temperature Log was documented on 06/07/22. On 06/22/22 at 08:46 AM During medication administration observation with V15 (Registered Nurse), 5 medication cups with pills in them were observed in the top drawer of the medication cart. On 06/22/22 at 09:01 AM V15 (Registered Nurse) stated the medications that are in these 5 medication cups are for residents that were not on the unit. I just put the medications in the medication cups right here in the top drawer of the medication cart for the residents when they come back. Surveyor asked V15 do she (V15) make sure the resident is present before pouring the medications. V15 stated when I made rounds everyone was present. Some of the residents go downstairs for smoke break from 09:00 am - 10:00 am. I try to get to them before they disappear. Upon observation one medication cup had a 19 written with a black marker on the side. V15 stated that was R121 medication, I gave R121 his (R121) medications. V15 proceeded to discard R121 medications and the medication cup in the sharp's container. V15 stated the medication cup with pills and 17 written on the side with a black marker was for R181. V15 stated the Certified Nurse Assistants were doing patient care for R181. A medication cup with pills and 21 written on the side with a black marker was observed inside of another medication cup with 21 written on the side with a black marker in the top drawer of the medication cart. V15 removed the medication cup from inside of the other medication cup marked with 21. V15 stated those were for R163, and I just gave her (R163) medications. V15 proceeded to discard R163 medications and the medication cup in the sharp's container. A medication cup with pills and 21 written on the side with a black marker was observed in the top drawer of the medication cart. V15 stated R182 is right there in the bed. A medication cup with pills and 20 written on the side with a black marker was observed in the top drawer of the medication cart. V15 stated R104 just disappeared. V15 stated I should not have pulled the medication, we are not supposed to pre-pour the medications. On 06/23/22 at 8:38 AM (Director of Nursing) stated expired medications are remove from the floor, medication room and is discarded. One insulin is good for is 28 days and one is good for 30 - 31 days. If the expired medication is given there is a potential that the medication could not be effective. Insulin should be discarded after use by date. There is nothing but medications and supplements that should be stored in the refrigerator or it can cause contamination. There should have a thermometer in each medication refrigerator, and it is checked daily, overnight. There should be a temperature log on the refrigerator. The items in the refrigerator can become contamination if the temperature was not at an appropriate level. Medications should be given to residents at the time of preparing them. If the medications are pre-poured there is a potential for the medications being mixed up and given to the wrong person. Insulin Stability Chart undated document in part: Humalog (Lispro) and Lantus open stability refrigeration/room temp: 28 days. Policy: Titled Resident-Centered Medication Administration Policy (Block Charting Medication Administration) dated created 05/21 document in part: To provide each patient with an evidence-based, person-centered care approach across the entire medication use process in the facility. Titled Insulin Pen Usage dated 06/21 document in part: To provide the staff with guidance on accuracy of insulin administration and dosing. 2. Insulin pens should be dated with the date open and expiration day. The expiration day will be 28 days after opening. 6. The nurse will verify that there is a Physician/NP (Nurse Practitioner)/PA (Physician Assistant) order for insulin administration. Titled Medication Return and Disposal, Disposal of Medications undated document in part: To provide a process for removing medications from the medication area when necessary. Policy: 1. Discontinued medications that are not returnable to the pharmacy for credit will be removed from the medication area and destroyed. Procedure: 1. Authorized personnel only will handle disposal of medications in the facility. 2. All medications that are discontinued or expired will be removed from the resident's tray, medication or treatment cart, refrigerator, medication room or other place of storage. Titled Medication Dispensing Medication Labeling undated document in part: To ensure that all medications within the facility are labeled in a consistent manner. 1. All resident specific medications will be labeled with the following minimum information: k) Expiration date. 10. All medications will follow the manufacturer recommended expiration date and overall best practices. A. Medications with shortened expiration dates need to have the date opened and date to discard documented on the unit.

Based on observation, interview and record review the facility failed to ensure proper infection control practices were performed to prevent cross contamination when using blood glucose testing supplies. This deficient practice has the potential to affect 8 residents (R3, R50, R55, R61, R75, R79, R127, R162) receiving blood glucose monitoring on the 4th floor. The facility also failed to follow policy related to urinary catheter care by placing a urinary catheter bag directly on the floor for 1 (R177) of 4 residents with history of urinary tract infection (UTI) in a sample of 34. Findings include: On 6/21/22 at 11:05 AM, R177 was observed sleeping comfortably in bed. Surveyor noted urinary catheter drainage bag was placed directly on the floor with no privacy bag and approximately 80% full. At 11:18 AM, surveyor requested the assistance of V3 (Restorative Aide). Upon entering R177's room with V3, R177's urinary catheter drainage bag was seen on the floor with light yellow cloudy urine and no privacy bag. V3 checked urine output in the bag with approximately 1700 milliliters. V3 stated that the urinary bag should not be touching the floor and that it should be hooked on the side of R177's bed with a privacy bag. V3 stated that if urinary bag is touching the floor, it could cause infection. V3 further stated urinary bag should be emptied every shift. R177's electronic health record (EHR) shows an initial admission date of 9/28/21 with listed diagnoses not limited to other cystitis without hematuria, neuromuscular dysfunction of bladder, paraplegia, and muscle weakness. V7's (Infectious Disease Nurse Practitioner) progress note dated 2/24/22 at 1:37 PM and V8's (Nurse Practitioner) progress note dated 5/12/22 at 12:37 PM indicate R177 was on antibiotic therapy for UTI. On 6/22/22 at 10:45 AM, an interview conducted with V13 (Infection Control Nurse). V13 stated, Urinary catheter should be in a privacy bag, hanging low and off the floor. It should not be touching the ground because it is unsanitary. If the urinary bag is touching the floor bacteria could get into the bag and cause and infection. The urinary catheter bag should never be on the floor. A review of the facility's policy titled Indwelling Catheter with review date of 10/21 reads in part: CARE OF INDWELLING CATHTERS: 2. Keep the drainage bag below the level of resident's bladder 3. Keep drainage bag off the floor 5. Provide dignity by placing the drainage bag in a dignity bag 6. Empty the drainage bag every shift Diagnosis Report dated 06/22/22 document in part: Residents residing on the 4th-floor as having Type 2 Diabetes Mellitus, R3, R50, R55, R61, R75, R79, R127 and R162. R3 has diagnosis not limited to Type 2 Diabetes Mellitus. Order Summary Report Dated 06/23/22 document in part: Accucheck two times a day. R50 has diagnosis not limited to Type 2 Diabetes Mellitus with Hyperosmolarity with Coma. Order Summary Report Dated 06/23/22 document in part: Blood glucose monitoring Daily (AM). R55 has diagnosis not limited to Type 2 Diabetes Mellitus. Order Summary Report Dated 06/23/22 document in part: Accucheck two times a day. R61 has diagnosis not limited to Type 2 Diabetes Mellitus. Order Summary Report Dated 06/23/22 document in part: Blood Glucose Monitoring four times a day. R75 has diagnosis not limited to Type 2 Diabetes Mellitus and Hypoglycemia. Order Summary Report Dated 06/23/22 document in part: Blood sugar before meals and bedtime. R79 has diagnosis not limited to Type 2 Diabetes Mellitus. Order Summary Report Dated 06/23/22 document in part: Accucheck three times a day. R127 has diagnosis not limited to Type 2 Diabetes Mellitus with Hyperglycemia. Order Summary Report Dated 06/23/22 document in part: Accucheck two times a day. R162 has diagnosis not limited to Type 2 Diabetes Mellitus. Order Summary Report Dated 06/23/22 document in part: Accucheck before meals three times a day. On 06/22/22 at 10:08 AM V4 (Licensed Practical Nurse) was observed entering R127 room with a blue plastic tray (caddy) containing lancets, alcohol wipes and glucose test trips. V4 placed the blue plastic tray (caddy) on R127 bed. Using supplies from the blue plastic tray (caddy) V4 wiped R127 finger with an alcohol wipe, used a lancet to prick R127 finger, removed a test strip from the test strip container applied a drop of blood and wiped R127 finger with an alcohol wipe. On 06/22/22 at 10:10 AM V4 picked up the blue plastic tray (caddy) then exited R127 room. V4 placed the blue plastic tray (caddy) on the medication cart and cleaned the glucometer. On 06/22/22 at 10:12 AM V4 placed the blue plastic tray (caddy) into the drawer of the medication cart. V4 stated R127 blood glucose was 199 and coverage start at 201. I put the tray on the bedside table then V4 stated no I placed it on the bed. By placing the blue plastic tray (caddy) on R127 bed could cause the transmission of bacteria. I should take out the supplies that I need. On 06/22/22 at 01:50 PM V13 (Infection Preventionist) stated I will see if there is something more specific for infection control for the blood glucose. There is a potential for cross contamination by the nurse putting the blue plastic tray on the resident bed. On 06/23/22 at 8:38 (Director of Nursing) stated there is nothing but medications and supplements that should be stored in the refrigerator or it can cause contamination. When checking the blood glucose, get material together and take the items being used into the room so that everything else will not get contaminated. The nurses use a blue plastic caddy for the blood glucose supplies. If the blue plastic caddy is taken into the resident's room, there is a potential for cross contamination. On 06/23/22 at 9:14 AM V13 (Infection Preventionist) stated by placing the plastic tray on the bed there is a potential for cross contamination. We do not have a policy that specifically states that. Policy: Titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 02/22 document in part: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers For Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. d. Reusable items are cleaned and disinfected or sterilized between residents. e. Single use items are disposed of after a single use. 5. Only equipment that is designated reusable shall be used by more than one resident. 6. Single use items will be discarded after a single use. Titled Blood Glucose Monitoring revised 05/21 document in part: To provide a guideline for blood glucose monitoring. Guideline: 1. Collect equipment in a clean area.

Based on interview and record review, the facility failed to follow their policy on immunization protocol and failed to provide documentation on the educational component on why the influenza and the pneumococcal vaccines are important for the elderly or immunocompromised residents for 6 residents (R37, R40, R57, R83, R332 and R433) reviewed for vaccines in the sample of 24 residents. Findings include, R433's Consent/Pneumonia Vaccine PCV 13 with education documents in part: Consent to Vaccination. R433's immunization records documents in part: R433 has no influenza or pneumonia vaccination administered. R332's immunization records documents in part: R332 has no pneumonia vaccine offered, or refusal documented. Reviewed R332's medical records, progress notes and physician orders. No documentation of benefits and risks of pneumonia vaccination education was noted. R57's immunization record documents in part: R57 not vaccinated for influenza and pneumonia. Reviewed R57's medical records, progress notes and physician orders. No documentation of benefits and risks of pneumonia vaccination education was noted. R40's immunization record documents in part: No vaccination for pneumonia vaccine 23. Reviewed R40's medical records, progress notes and physician orders. No documentation of benefits and risks of pneumonia vaccination education was noted. R83's immunization record documents in part: No vaccination for pneumonia vaccine or influenza. Reviewed R83's medical records, progress notes and physician orders. No documentation of benefits and risks of pneumonia vaccination or influenza vaccination education was noted. R37's Consent/Pneumonia Vaccine PCV 13 with education (11/30/2017) documents in part: Consent to Vaccination R37) immunization records documents in part: R433 has no influenza or pneumonia vaccination administered. On 06/22/2022 at 12:30 PM, V13 (infection prevention nurse) stated that all consents and education should be documented that it was completed in the resident's electronic medical record. On 06/22/2022 at 12:31 PM, surveyor asked if V13 and the surveyor could review R433, R332, R57, R40, R83, and R37's immunization record together. V13 stated sure. After reviewing R433, R332, R57, R40, R83, and R37's immunization record, V13 stated that R332, R57, R40, and R83 did not receive pneumonia vaccination. V13 also stated that she (V13) cannot find the pneumonia vaccination education provided to R332, R57, R40, and R83. V13 stated that if she (V13) cannot find it in their (R332, R57, R40, and R83) medical record that means the pneumonia vaccine education was not provided to them (R332, R57, R40, and R83). V13 stated that providing education is important so resident can make an informed decision about what it is they are refusing. On 06/23/2022 at 11:30 AM, V13 (infection prevention nurse) stated that when a resident consents to a vaccine, the facility orders it that day and it is delivered to the facility by their pharmacy that same day or the next day at the latest. V13 stated that R433 and R37 have consents to receive the pneumonia vaccine. After surveyor reviewed R433 and R37's immunization records with V13, she (V13) stated that R433 and R37 should have received the pneumonia vaccine and that she (V13) is unsure why R433 and R37 did not receive the pneumonia vaccine. Facility's Influenza and Vaccination policy (11/25/2020) documents in part: In the event that a new patient or resident is admitted after the influenza vaccination program has concluded in the facility, the benefits of vaccination maybe discussed, education material will be provided. Facility's Pneumococcal Vaccination policy (11/2027) documents in part: Nursing will assess the pneumococcal vaccination status of each resident upon admission/readmission. In any event, it is reasonable to expect administration and documentation of pneumococcal vaccine by the first assessment.

Based on observations, interviews, and record reviews, the facility failed to follow their policy of dating opened boxes of food, and canned goods, in the refrigerator, freezer, and pantry. This had the potential to affect all 171 resident who reside at the facility. Findings include: On 6/21/22 during the initial kitchen tour the following were observed. On 06/21/22 at 11:42 am two open boxes of frozen Spinach without date opened. On 06/21/22 at 11:44 am, one 10lb open box of frozen Bratwurst without date opened. On 06/21/22 at 11:48 am, one open box of 6 Idaho Potatoes Flakes without date opened. On 06/21/22 at 11:50 am, large can fruit without date received. On 06/21/22 at 11:52 am, four large cans of tuna without date received. On 06/21/22 at 11:56 am, two boxes of Thicket(oral fluid thickener) open without date opened. On 06/21/22 at 12:16 PM V9 (Dietary Manager) stated staff is to put date on opened food so everyone can know if food can still be used, or it can get people sick. Facility policy titled, Labeling and Dating Foods, (2016) states in part: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened, and the date by which the item should be discarded. Canned food and other shelf stable items such as cake mixes are labeled with the date received