Based on observation, interview, and record review, facility failed to follow their policy to ensure call light is within reach for 1 (R86) out of 3 residents reviewed for call lights in a total sample of 35. Findings Include: On 05/27/2025, at 11:30 AM, surveyor observed R86's foot of the bed is by the call light switch. R86's call light string was hanging on the floor. R86 was unable to reach her call light. R86 stated she cannot find her call light. R86 stated that she asked the staff multiple times to place the call light switch by her head. On 05/27/2025, at 11:35 AM, surveyor asked V18 (Registered Nurse) to come to R86's room. V18 stated R86 is totally dependent and needs help getting out of bed out of bed. V18 stated that R86 needs help transferring to the wheelchair. Surveyor asked V18 if she could locate R86's call light. V18 found R86's call light on the floor at the foot of R86's bed. V18 then picked up the call light and clipped it to R86's gown. V18 stated that she will call someone to better locate R86's call light. V18 stated that it is important for residents to have their call lights within reach so they can voice their needs. V18 stated that if call lights are not within reach, residents are unable to voice their needs. On 05/28/2025, at 2:00 PM, V3 (Director of Nursing) stated that all call lights are to be within reach of the residents. It should be within reach so the residents can voice their needs. V3 stated that if call lights are not within reach, residents are unable to voice their needs. R86's fall care plan documents in part: Keep call light within reach of the resident. R86's care policy documents in part: Place call lights within the reach of the resident. Facility's Answering the call lights policy (08/2008) documents in part: When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that medications were refilled and readily available for 2 residents (R60, R96) out of 8 residents reviewed for controlled substance medications in a sample of 35. The facility also failed to b.) keep an accurate count of all narcotic medications for two (R55, R118) residents, c.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 12 out of 237 shifts. These failures have the potential to affect 61 residents residing in the facility. Findings Include: R60's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Lymphedema, hypertensive heart disease without heart failure, chronic obstructive pulmonary disease, unspecified, Muscle wasting and atrophy, not elsewhere classified, unspecified site, abnormalities of gait and mobility. Minimum Data Set Section (MDS) section C (dated 03/24/2025) documents that R60 has an Interview for Mental Status (BIMS) score of 15, indicating that R60's cognition is intact. Care plan (dated 03/24/2025) documents that R60 has complaints of chronic pain. Care plan documents that R60 has a diagnosis of lymphedema and is at risk for circulatory complications, swelling, pain, cardiac distress and decreased mobility. R96's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, Bipolar disorder, Major depressive disorder, anxiety disorder. Minimum Data Set Section (MDS) section C (dated 03/19/2025) documents that R96 has an Interview for Mental Status (BIMS) score of 15, indicating that R96's cognition is intact. Care plan (dated 01/02/2025) documents that R96 is at risk for alteration in sleep patterns related to insomnia. On 05/27/2025, surveyor was conducting resident interviews during an annual licensure and recertification survey. At 1:22 PM, R60 stated, I am in a lot of pain. They did not give me my pain medication for a few days now because they ran out and did not reorder my pain medications. I take Tylenol with Codeine. The last time that they gave me my pain medication was two days ago. My pain is really bad. My pain is 10 out of 10. They said that they ran out of my medication because it was not ordered fast enough. They let my pain medication run out, and they did not re-order the pain medication before it ran out. They let my medications run out, and they are supposed to refill the medications before they run out. Now they want to give me regular Tylenol for my pain, but I told them that the regular Tylenol is not strong enough to manage my pain. I am in pain, and I am not comfortable without my Tylenol with Codeine. On 05/27/2025, at 1:38 PM, surveyor interviewed R96. R96 stated, I have a concern. They keep running out of my Lunesta sleeping medication. They continuously run out and they don't refill it before it runs out. I get the Lunesta at nighttime to aide me with sleep. Last night the nurse did not give it to me because she said they were out. I did not sleep the entire night without the Lunesta. This happened many times and I am so frustrated that they continue to run out of my sleeping medication. I am tired because without the Lunesta, I cannot sleep. On 05/27/2025, at 1:56 PM, surveyor inspected the 3rd floor nursing cart with V11 (licensed Practical Nurse) to determine if R60's Tylenol with Codeine pain medication and R96's Lunesta medication for sleep aide were stocked in the medication cart. Based on the inspection, surveyor observed that the two medications were not in the cart. V11 stated, I am the nurse for R60 and R96. R60's Tylenol with Codeine is not in the medication cart, because they ran out of the resident's pain medications. R60 told me that he is in pain and all I was able to give R60 is regular Tylenol. According to the controlled substance ledger, the last time that R60 got his Tylenol with Codeine was on 05/25/2025 at 9:00 PM. I faxed over the order for the pain medication to the pharmacy. Hopefully they will deliver it. R96's Lunesta medication is out of stock. R96 told me that last night she did not receive her scheduled Lunesta medications because the facility ran out. R96 told me that she did not sleep all night because she did not receive the Lunesta medications. They reordered the medication for R96. We are waiting for the pharmacy to bring it. On 05/28/2025, at 10:46 AM, V3 (director of nursing) stated, The expectation is that when there are 3 or 4 pills left in the resident's bingo card, the nurses are supposed to reorder the medications. Nurses are not supposed to wait to the last minute to reorder resident's medications. All medications are supposed to be reordered before they run out. Controlled Substance Disposition Form indicated that that last time that R60 received Tylenol with Codeine 15mg for pain management was on 05/25/2025, at 9:00 PM. R60's Progress Note (dated 05/27/2025) documents, Resident complained of pain to the nurse and requested for his codeine. The medication was not available at this time. Doctor was notified immediately that we have tramadol in the convenient box. Doctor insisted we give Tylenol 1000mg PO and have pharmacy contact him for script. The order was noted and carried out. Pharmacist was called and medication will be delivered STAT (immediately). Resident was made aware. His emergency contact was notified. Resident was assessed for pain, complained of pain to the lower back rated 3/10. Tylenol 1000mg PO was given, well tolerated. Staff will continue to monitor. R60's Physician Order (dated 05/28/2025) documents: Acetaminophen-codeine - Schedule III tablet; 300-15 mg; amount: 1 tablet; oral Special Instructions: Give at 8:00 AM, 2:00 PM, 8:00 PM, as scheduled. R96's Physician Order (dated 11/06/2024) states: Lunesta (eszopiclone) - Schedule IV tablet; 1 mg; amount: 3 mg; oral tablet. Controlled Substance Prescriptions Policy (dated 10/25/2014) documents in part: Refill requests for CIII-CV, and partial fill quantity (CIIs) remains and medications are not automatically refilled by the pharmacy, refills are: Written on a medication order form or ordered by peeling the reorder tab from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy four (4) days in advance of need to assure an adequate supply is on hand. Findings include: On 05/27/2025, at 10:25 AM, surveyor and V14 (Licensed Practical Nurse/LPN) located on the 5th floor of the facility performing a controlled substance count and record review. Surveyor observed the following: A medication bingo card labeled R118's name, Lorazepam 0.5mg. Surveyor observed there were 15 pills inside of the medication bingo card. R118's controlled drug receipt record documents a count of 16 pills. A medication bingo card labeled R55's name, Lorazepam 1mg, surveyor observed there were 4 pills inside of the medication bingo card. R55's controlled drug receipt record documents a count of 5 pills. V14 states he administered the medications to R55 and R118 this morning and forgot to document that he administered them. On 05/27/2025, at approximately 11:00 AM, review of the Controlled Substances Check Form for the month of May 2025 for the third-floor medication cart indicated for 2 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/13/25, 2nd shift (3:00 PM-11:00 PM) On 05/17/25, 2nd shift (3:00 PM-11:00 PM) On 05/27/2025, at approximately 11:00 AM, V16 (LPN/Wound Care Coordinator) states it is important to count and document all controlled substances to prevent drug diversions in the facility. V16 states if controlled substances are not documented, then it means that the control substances were not counted. On 05/27/2025, at approximately 11:20 AM, review of the Controlled Substances Check Form for the month of May 2025 for the second floor Cart B medication cart indicated for 4 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/18/25, 3rd shift (11:00 PM-7:00 AM) On 05/19/25, 1st shift (7:00 AM-3:00 PM) On 05/23/25, 1st shift (7:00 AM-3:00 PM), 2nd shift (3:00 PM-11:00 PM) On 05/27/2025, at approximately 11:40 AM, review of the Controlled Substances Check Form for the month of May 2025 for the second floor Cart A medication cart indicated for 6 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/01/25, 3rd shift (11:00 PM-7:00 AM) On 05/03/25, 3rd shift (11:00 PM-7:00 AM) On 05/04/25, 1st shift (7:00 AM-3:00 PM) On 05/19/25, 2nd shift (3:00 PM-11:00 PM) On 05/24/25, 3rd shift (11:00 PM-7:00 AM) On 05/25/25, 2nd shift (3:00 PM-11:00 PM) Facility policy dated 10/25/2014 titled Controlled Substance Storage documents in part, E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses. F4. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Form: Controlled Substance Count Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and records review, the facility failed to discontinue or get an order to continue as needed psychotropic medications and failed to get psychotropic consent from Power of Attorney (POA) for one (R52) resident of seven reviewed in a total sample of 35 Findings include: R52's current face sheet documents R52 is a [AGE] year-old individual with medical diagnosis that include but not limited to Major depressive disorder, recurrent severe without psychotic features, Schizophrenia, unspecified, schizoaffective disorder, bipolar type, other psychotic disorder not due to a substance or known physiological condition, anxiety disorder, unspecified. Minimum Data Set (MDS) section C-Cognitive Patterns dates 05/14/2025, document R52's BIMS as 3/15, indicating R52 has severe cognitive impairment. R52's BIM scores dated 05/08/2025, 05/01/2025. BIMS dated 04/23/2025 is 3/15. On 05/27/25, 12:28 PM, R52 was observed sitting in the dining room with staff supervising him. R52 was observed with stacks of papers with pens. R52 stated he likes to write a lot. R52 was observed oriented to person/place and was confused about situation or time. R52 was not able to answer most of the questions that were asked. Review of R52's psychotropic consent forms document R52 consented for psychotropic medications on 05/08/2025: -Clonazepam - Schedule IV tablet; 1 mg; 1 tablet; oral Twice A Day As needed (PRN). -Zolpidem 5mg 1 tablet at bedtime -Olanzapine 10 Mg 1 Tablet PO(Oral) BID (two times day) Review of R52's psychotropic consent forms document R52 consented for psychotropic medications on 05/11/2025: -Lorazepam, 2mg/mL 1 mL Q6hrs PRN (As needed) Review of R52's face sheet and electronic Health Records document R52 has a POA for health. On 05/29/2025, V3 (Director of Nursing) stated although R52 has a BIMS score of 3/15 which means he is severely cognitively impaired, he can still sign for his psychotropic medications. The nurses document in progress notes that R52 is alert and oriented times two, which means R52 is alert and oriented to name and place. V3 stated he did not know if R52 can make decisions based on understanding. V3 stated the nurse on duty on 5/82025, notified R52's Power of Attorney (POA) that R52 was back in the facility, but there is not documentation that the POA was notified of R52's psychotropic medications. V3 stated if it's not documented it is not done. Reviewed of R52's progress notes dated 5/8/2025, document R52's POA was notified of R52's return to the facility but no documentation R52's POA was notified R52 was started on psychotropic medications and psychotropic consent was signed by R52. V3 stated as needed (PRN) psychotropic medication orders are active for only 14 days and should be discontinued after the 14 days or an order for medication continuation should be given by the physician. R52's Physician Order Sheet (POS) dated 5/11/2025 documents: Prescription Lorazepam - Schedule IV solution; 2 mg/mL; amt (Amount) 2 mg; injection Every 6 Hours -05/11/2025, Open Ended PRN Medications Prescription Lorazepam - Schedule IV tablet; 2 mg; : 1 Tab; oral Every 6 Hours -05/11/2025, Open Ended PRN Medications Policy titled MAC Rx Pharmacy Policies and Procedures Manual dated 10/25/2014, documents: -Effective 11/28/2017, CMS (Centers for Medicare & Medicaid Services) redefined the class definition of psychotropic medications to include the below listed drug classes. The PRN (as needed) psychotropic are time limited to a maximum day supply of 14-day duration for SNF (Skilled Nursing Facility). A continuation Psychotropic Medication Policy dated February 2014, documents: -Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian or other authorized representative. R52's Physician Order Sheet dated 05/08/2025, document: Prescription benztropine tablet; 1 mg; amt (amount) 1 tablet; oral. Twice A Day 9:00 AM, 5:00 PM. 05/08/2025, Open Ended Medications. Prescription Clonazepam - Schedule IV tablet; 1 mg; amt: 1 tablet; oral Twice A Day 9:00 AM, 5:00 PM. 05/08/2025, Open Ended Medications. Prescription Olanzapine tablet; 10 mg; amt: 1; oral Twice A Day 9:00 AM, 5:00 PM, 05/08/2025, Open Ended Medications Prescription Zolpidem - Schedule IV tablet; 5 mg; amt: 1; oral At Bedtime 9:00 PM, 05/08/2025, Open Ended Medications

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for one (R1) out of four residents reviewed for medication administration in a total sample of 35 residents reviewed, resulting in a 7.69% error rate. Findings Include: On 05/28/2025, at 9:22 AM, surveyor located on the 4th floor of the facility with V11 (Licensed Practical Nurse/LPN) during a medication administration pass. V11 administers Acetaminophen 500 mg: 2 tablets by mouth to R1. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Acetaminophen 325 mg- 2 tablets by mouth every 6 hours as needed. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg: 1 tablet by mouth twice a day scheduled at 9:00 AM and 5:00 PM. On 05/28/2025, at 9:22 AM, surveyor observes that this medication was not given to R1 during the 9:00 AM medication administration pass with V11 (LPN). V11 states she is finished administering all of R1's scheduled morning medications. On 05/28/2025, at 2:52 PM, V11 (LPN) states she did not administer R1's Bactrim medication during the morning medication pass while surveyor was present because she did not see the order in R1's MAR. V11 states she checked the facility's 24-hour communication report and saw that R1 was prescribed antibiotics. V11 states she then checked R1's MAR again and saw the Bactrim order on R1's MAR. V11 states she then administered R1's Bactrim medication to him at approximately 10:30 AM, after the surveyor had already left the 4th floor. V11 states she is aware that she should triple check the resident's MAR to check medications orders. V11 states it is important to read and re-check resident's MARs to prevent medication errors from occurring. Facility policy dated 10/25/2014, titled Medication Administration documents in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: 4.) FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. b. Check #2: Prepare the dose- The dose is removed from the container and verified against the label and the MAR by reviewing the five rights. 5.) Prior to administration, the medication and dosage schedule on the on the resident's medication administration record (MAR) are compared with the medication label. 2) Medications are administered in accordance with written orders of the prescriber. 5) When PRN medications are administered, the following documentation is provided: a.) Date and time of administration, dose, route of administration.

Based on interview and record review, facility failed to follow their policy to offer, educate and receive consent for influenza and pneumococcal vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35. Findings include: On 05/28/2025, at 12:00 PM, R66 stated she doesn't remember the facility offering her influenza and pneumococcal vaccination. On 05/28/2025, surveyor reviewed R66's immunizations with V19 (Infection Preventionist). On 05/28/2025, at 12:37 PM, V19 stated that she cannot find R66's consent for influenza or pneumococcal vaccine. V19 stated she is pretty sure she offered it. V19 stated that R66 did not receive her influenza or pneumococcal vaccine, nor does she have education or consent. V19 stated that she does not know what happened and why R66 does not have her pneumococcal or influenza vaccine or was educated on the benefits of these vaccines. V19 stated that it is important for these residents to have their vaccination to protect them from influenza and pneumonia related infections. On 05/29/2025, at 2:05 PM, V3 (Director of Nursing) stated that upon admission, residents' immunizations are reviewed. V3 stated that if a resident did not receive the influenza or pneumococcal vaccination, we educate them the importance and benefits of the vaccine. V3 stated that then they can make an informed decision to give consent for the administration of the influenza or pneumococcal vaccine. V3 stated that we document every time we educate residents on the benefits of the immunization. If it is not documented, then it was not done. R66's immunization record documents in part: There was no influenza or pneumococcal vaccine offered in 2024. No pneumococcal or influenza vaccine administered. No documentation of education or consent for influenza or pneumococcal vaccination. Facility's Influenza and Pneumococcal Immunization Policy (undated) documents in part: Each resident or when appropriate resident representative, will be educated regarding the benefits and potential side effects of both influenza and pneumococcal immunizations and will be provided the opportunity to accept or refuse them. The facility will document both the education provided and the resident's decision in the resident's clinical record.

Based on interview and record review, facility failed to follow their policy to offer, educate and receive consent for COVID-19 (corona virus) vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35. Findings include: On 05/28/2025, at 12:00 PM, R66 stated she doesn't remember the facility offering COVID-19 vaccination or educating her about it. On 05/28/2025, surveyor reviewed R66's immunizations with V19 (Infection Preventionist). On 05/28/2025, at 12:37 PM, V19 stated that she cannot find R66's consent for COVID-19 vaccine. V19 stated she is pretty sure she offered it. V19 stated that she is not sure if R66 received her COVID-19 vaccine nor does she have education documented. V19 stated that she does not know what happened and why R66 did not receive her COVID-19 vaccine. V19 stated that it is important for these residents to be educated and have their vaccination to protect them from COVID-19 infection. On 05/29/2025, at 2:05 PM, V3 (Director of Nursing) stated that upon admission, residents' immunizations are reviewed. V3 stated that if a resident did receive the COVID vaccination, we educate them the importance and benefits of the vaccine. V3 stated that then they can make an informed decision to give consent for the administration of the COVID-19 vaccine. V3 stated that we document every time we educate residents on the benefits of the immunization. If it is not documented, then it was not done. R66's immunization record documents in part: There was no COVID-19 vaccine offered nor administration history. No documentation of education or consent for COVID-19 vaccination. Facility's COVID-19 Immunization Policy (01/2021) documents in part: The facility shall notify all residents of the COVID-19 vaccination and shall provide or arrange for vaccination for all residents. The facility shall provide all residents with education about the benefits of COVID-19 vaccine and potential consequences of COVID-19 illness. The facility shall include documentation of each person either accepted the offer or declined the offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new Level I screen for residents with a known mental illness for four (R76, R110, R116, R152) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35 residents reviewed. Findings include: R76's Facesheet documents that R76 was admitted to the facility on [DATE], with diagnoses not limited to: Schizoaffective disorder and bipolar disorder. R76's Interagency Certification of Screening Results dated [DATE], does not indicate if there is a reasonable basis for suspecting DD (Developmental Delay) or MI (mental illness). R76's Minimum Data Set (MDS) Section I dated [DATE], indicates active diagnoses of anxiety disorder and bipolar disorder. There is no documentation to show that R76 has a Level II PASARR screening. R110's Facesheet documents that R110 was admitted to the facility on [DATE], with diagnoses not limited to: Schizophrenia, major depressive disorder, manic episodes, and suicidal ideations. R110's Interagency Certification of Screening Results OBRA-I Initial Screen dated [DATE], indicates that R110 has no reasonable basis for suspecting DD (Developmental Delay) or MI (mental illness). There is no documentation to show that R110 has a Level II PASARR screening. R116's Facesheet documents that R116 was admitted to the facility on [DATE], with diagnoses not limited to: Schizoaffective disorder, delusional disorders, major depressive disorder. R116's Level II PASARR/Preadmission Screening and Resident Review screening dated [DATE], documents that R116 is excluded from a Level II PASARR because R116 has No diagnosis- no LOC. R152's Facesheet documents that R152 was admitted to the facility on [DATE], with a diagnosis of schizophrenia. R152's Level I PASARR/Preadmission Screening and Resident Review screening dated [DATE], documents that R152 does not require a Level II PASARR because R152 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. On [DATE], at 9:37 AM, V21 (Social Services Director) states V22 (Admissions Director) is responsible for inputting residents' PASARR/Preadmission Screening and Resident Review information into the screening agency website. V21 states V22 is also responsible for ensuring that a resident's PASARR screening is accurate. V21 states he is responsible for inputting resident's information and referring residents for a new PASARR screening once it expires. V21 states to his understanding, residents who have been admitted to the facility prior to 2022, do not need a new PASARR screening in the new screening system. V21 states any resident admitted to the facility after 2022, should have a PASARR screening in the new screening system. V21 states the PASARR screenings should be completed at the hospital before a resident is admitted to the facility. V21 states he checks the screening agency system daily for expired PASARR screenings and there should not be any PASARR screenings that are outdated. V21 states if a resident experiences any psychiatric mental health issues while residing in the facility, then the nursing home is responsible for ensuring that the resident is still suitable to live in the nursing home setting. On [DATE], at 11:14 AM, V22 (Admissions Director) states he has been working at the facility for 2 months and he is responsible for making sure PASARR screening are valid upon resident admission. V22 states a resident's PASARR screening is considered valid if all pertinent information is entered correctly. V22 states V21 (Social Services Director) is responsible for making sure the PASARR screenings are updated. V22 states a PASARR is a screening that needs to be done by the transferring facility prior to a resident being admitted to the facility. V22 states the transferring facility is usually the hospital or another nursing home. V22 states residents who have been admitted to the facility prior to [DATE] has been grand-fathered in and do not require a PASARR screening through the new screening system. Facility policy dated 12/2023 titled Preadmission Screening and Residential Review (PASRR) documents in part, Policy: 1. Comply with Federal, State, and the appointed screening agency in standards addressing the PASARR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission. 3. Review the PASRR 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. Procedure: 3. The hospital/screening agency/referral source may be contacted, as indicated and asked to provide any missing or incomplete documents. The screenings are now expected to be located in the screening agency's system and accessible by the facility. 4. 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.

Based on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in one of five medication carts reviewed, b.) remove and discard expired enteral feedings located in one of four medication storage rooms reviewed, and c.) ensure medications were locked and secured while unattended. These failures have the potential to affect 59 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 05/27/2025, at 11:07 AM, surveyor and V11 (Licensed Practical Nurse/LPN) located on the 3rd floor of the facility at the medication cart. Surveyor observes the following: one open house stock medication bottle labeled Meclizine 12. 5mg inside of the medication cart. Meclizine medication observed with an expiration date labeled 02/2025. V11 states the Meclizine medication should not be stored in the medication cart and should have been discarded once it expired on 02/2025. V11 states it is not safe to administer expired medications to residents and they could experience adverse reactions if given expired medications. On 05/27/2025, at 11:13 AM, surveyor located inside of the third-floor medication storage room with V11 (LPN). Surveyor observes the following: four house stock enteral feeding containers labeled Glucerna with Carbsteady 1.5 CAL 33.8 ounces with an expiration date labeled 04/01/2025. V11 states the enteral feeding containers should not be stored in the medication storage room for resident use and should have been discarded once it expired on 04/01/2025. V11 states residents receiving enteral feedings could potentially get sick if expired enteral feedings are administered to them. On 05/27/2025, at 11:16 AM, surveyor located on the second floor of the facility. Surveyor observes a medication cart (identified as Cart B) unlocked and unattended. V10 (Registered Nurse/RN) observed exiting a resident's room and locks the Cart B medication cart. On 05/27/2025, at 11:18 AM, V10 states she normally locks the medications cart when she leaves it unattended. V10 states she must have been rushing this time when she left the medication cart unlocked and unattended. V10 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V10 states then residents could potentially self-administer the medications and overdose or have an adverse reaction. Facility census dated 05/27/2025, documents a total of 30 residents resides on the third floor of the facility and 29 residents reside on the second floor of the facility. Facility document titled Residents on Tube Feeding lists a total of 4 residents residing in the facility who have gastronomy tubes for enteral feedings. Facility policy dated 10/25/2014, titled Storage of Medications documents in part, Procedures: B. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Expiration Dating: H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interviews and records review, the facility failed to follow proper sanitation and food handling practices. This failure has the potential to affect all 178 residents receiving food from the kitchen. Findings include: On 05/27/2025, at 9:39 AM, during tour of the kitchen with V4 (Dietary Manager), observed two silver baking pans wrapped with foil paper on top in the cooler, placed on top of a food cart. V4 stated inside the pans were meat loaf which was being thawed for next day's meal. Observed a pool of a white liquid spilled on top of one of the pans. V4 identified the liquid as milk. V4 stated the milk should not be spilt on the foil wrapping the meat loaf because it can drip inside the meat loaf. This could cause contamination and some residents could be allergic to milk. On one of the shelves in the cooler was observed two big cartoons, one containing cabbage and another containing oranges. Three cabbages were observed to be yellowing/brownish in color with brownish stuff dripping out. V4 stated the cabbages should have been thrown out because they were no longer good for resident consumption and can cause illnesses if cooked for residents. Observed the carton of oranges with some oranges having a grayish substance on them. The oranges were very squishy and broke open when V4 touched them. V4 stated the oranges were rotten and the grayish substance on the oranges was mold which can cause cross contamination and cause residents to become ill. V4 stated kitchen staff should be checking for spoiled food in the cooler and dispose of it to prevent cross contamination which can cause residents to become ill. The cooler temperature was observed at 51 degrees F. V4 stated the cooler temperature should be below 41 degrees F. In the freezer was a box of open waffles with no date when opened. V4 stated food should be labeled with date opened so that staff can know when the food is expired to prevent food borne illnesses. There were two black food carts, one the in cooler and one in the kitchen near a countertop were with whitish substances and black stains on the shelves of the carts. V4 stated the whitish substance was from spills from food and the carts were dirty. V4 further stated the staff who was responsible for cleaning all the food carts and checking the cooler for spoiled food quit over a week ago. V4 was trying to keep up with completing the staff who quit responsibilities and was not able to complete them all because he was also supervising the kitchen. V4 stated unsanitary or dirty food carts can contaminate residents' food and cause illnesses. On 05/27/2025, at 10:13 AM, V4 and surveyor observed V7 (dietary Aide) Rinsing dirty dishes and loading them into the dishwasher. V7 was observed walking over to the other side of the machine to take out the cleaned dishes. V7 did not wash her hands or wear gloves before touching the clean dishes. V4 stated V7 should wash her hands and/or wear gloves before touching the clean dishes and loading them on the clean rack. V4 stated R7 was contaminating the clean dishes by not following sanitary dish washing procedure and V7's actions can cause residents to become ill due to cross contamination. On 05/27/2025, at 11:35 AM, V6 (cook) was observed preparing puree and mechanical soft foods in the puree machine. V6 put cream style corn in the puree machine, pureed it and emptied it in a small baking pan. V6 walked over to the sink and rinsed the puree bowl. V6 came back and put the country style steak in the puree machine and pureed it. V6 stated as long as he was using the puree machine constantly without stopping for more than five minutes. V6 stated he does not need to sanitize or wash it, rinsing is enough. V6 stated there is only one puree machine and this is how he has been pureeing the foods. Facility policy titled Blender, no date documents: -Thoroughly wash unit and remove all food particles from blade. Check cleanliness of top of unit. -Rinse and Sanitize -Air dry Facility polity titled Storage of Refrigerated foods dated 08/24 documents: - Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality -Refrigerated foods are stores at 41* or below. Facility polity titled Dishroom Sanitation, dated 08/24 documents: -Hands must be washed after handling dirty dishes before handling clean dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report alleged abuse allegations to the proper authorities within the prescribed time frame for one [R1] of three [R3, R4] residents reviewed for abuse. Findings Include: R1 clinical record indicate the following: R1 is a thirty-nine-year-old admitted with medical diagnosis including but not limited to cerebral palsy, schizoaffective disorder, chronic obstructive pulmonary disease, morbid obesity, hypertensive heart disease, sleep apnea, psychosis, bipolar disorder, and mood affective disorder. R1's minimum data set brief interview indicates R1 is cognitive intact. R1's care plan: 12/23/24, R1 has persistent mental illness. R1 experienced psychosis in the form of both auditory hallucinations [hearing voices, information in her head often of a negative nature] and delusional [falsely believing things that never happened, not true nor valid]. R1 made an allegation against staff member that may be the result of a disordered thinking R1 told a staff member certified nurse assistant, broke her legs while receiving patient care. R1 psychosis, hallucinations, and delusions will not interfere with R1's participation in ADL care. R1 will work with staff to reality test her thoughts and beliefs. 11/27/23, R1 is at risk due to verbal aggression, poor symptom management and treatment noncompliance. R1 made an allegation of abuse against staff, history of refusing care despite encouragement. 12/10/24, R1 has dysregulated behavior. Display multiple behavior symptoms. R1 has chronic mental illness and thinking, and judgement are compromised. R1 becomes angry, agitated, and impulsive. R1 has limited ability to manage distress. 12/10/23, R1 grabbed and hit a certified nurse assistant that came into my room to provide assistance. R1's progress notes: V7 [Registered Nurse]: 11/15/2024, 1:25 PM, The CNA [V8 Certified Nurse Assistant] taking care of R1 called me to R1's room. R1 is being verbally rude and aggressive and not wanting V8 to care for her. Writer went and asked R1 if she wanted V8 to continue the care and R1 said 'yes it's her job, V8 should change me and get me up so I can call the police and tell them V8 hit me. Writer said that is fine and the CNA [V8] completed her work and writer helped get R1 up in her wheelchair. R1 then proceeded to call the police. Social service was called and informed of the situation. V7 [Registered Nurse]: 11/19/2024, 1:49 PM, R1 made false accusations towards a CNA who was not assigned to her, that the CNA was digging his hands into his pants while standing in front of the nursing station, with other resident and staff around. Interviews: On 2/1/25, at 10:20 AM, R1 stated, All the staff members have fondled my breast all time every day. I do not know their name or what they look like. I have very large breasts and the staff like to play with them while washing me up and changing my clothes. The staff be lifting up my breast and moving them around washing underneath them, but I don't like them touching my breast. I could hold up my breast while the staff wash me, but I will not hold up my breast, they are heavy. The staff is getting paid to wash me up, I should not have to help them. When I got clean up today and dressed, my breast was not fondled. The president of the United States told me I can run any marathon I want to be in. I called the police, because I heard the current president is sending people back to where they belong. It is a lot of Africans here and I will call the police today so they can come and round up all the Africans and send them back to [NAME], before they touch my breast again. I be wet all the time the nurse assistants don't want to clean me up, because they do not like me. I have a menstrual cycle every month. My menstrual cycle came in November, December, and January. I do not have any concerns regarding my monthly cycle. I like being here in this facility. I have not been abused and I feel safe here. No one has called me any names, because I would have called the police. On 2/1/25, at 1:30 PM, V7 [Registered Nurse] stated, On 11/15/24, Certified Nurse Assistant [V8] asked me to speak to R1 because she was being verbally abusive to her [V8]. I asked R1 did she want V8 to continue given her [R1] ADL care and to get her dressed. R1 told me it was okay because it was V8's job to provide care. R1 also said, once I get dressed and, in my wheelchair, I'm going to call the police and tell them that V8 hit me. I told her that was fine and V8 continued to get R1 cleaned, dressed and I assisted V8 placing R1 into her wheelchair. R1 did in fact call the police. I did not report the allegation of abuse to the administrator, because R1 makes false allegations often. I documented the incident as a behavior note. I did not notify the administrator, director of nursing nor nursing supervisor, because I felt it was a behavior. On 11/19/24, R1 said the male certified nurse assistant put his hands inside of his pants at the nursing station facing her [R1]. I was at the nursing station typing. I could not see everything and everyone was moving around the nursing station. I did not report the allegation to the administrator or director of nursing because I felt the allegation was not true. I completed abuse training a few months ago. The abuse coordinator is the administrator. I know when to report abuse. For R1, her allegations are behavioral and delusional. On 2/1/25, at 2:15 PM, V8 [Certified Nurse Assistant] stated, On 11/15/24, R1 started to yell and swear at me during the ADL care process. R1 sometimes would be in a different mood and start yelling for no apparent reason. R1 was easily agitated, and tried to hit me, but a moved out the way. I left the room and got the nurse [V7] to assist me. I told V7 that R1 tried to hit me while I was providing care. V7 came into the room and spoke with her and calmed R1 down and asked was it alright if I proceeded to get her [R1] dressed and washed up. R1 said it was okay and that it was my job to do so anyway. R1 also reported to the nurse [V7] that I hit her after she knew that she tried to hit me. Also, R1 told me and V7 that once she gets up, she was going to report me to the police. V7 and I got her up in the wheelchair and R1 called and reported me to the police. I did not report the incident to the administrator nor director of nursing because I thought V7 was going to report the incident. On 11/19/24, I was not present at the nursing station to witness any male staff placing their hands in their pants. I received abuse training around December. The abuse coordinator is the administrator. On 2/2/25, at 8:52 AM, V16 [Licensed Practical Nurse] stated, R1 is smart, manipulative, and likes attention. R1 also has a lot of delusions with everyone. I hear her on her cell phone all the time having delusional conversations with the president of the United States and other people, but no one is on the other end of the phone. R1 likes to control everything, refuses care all the time. On all three shifts from time to time I work all three shifts and I'm very familiar with R1. There is a two person assist at all times with R1, due to so many accusations of abuse and delusions. However, if R1 tells me of any allegations I will report the allegation to the abuse coordinator. It is not up to me if the allegation is false or not. R1 has not reported staff calling her names. R1 receives care and supervision appropriately, from two person assist. On 2/2/25, at 9:30 AM, V17 [Licensed Practical Nurse] stated, R1 makes frequent allegations in the past, but R1 has two person assist at all times, which has slowed down the allegations. One day R1 told me that my hair was ugly and rough, that I need to be deported back to [NAME] and R1 called the police to come pick me up and deport me back to [NAME]. Even if I am having a conversation with another staff or resident R1 would join the conversation and think we were talking about her [R1]. Often R1 refuses ADL care, even if she is wet. Until she feels like being changed. R1 has not reported to me that staff or other residents has called her names. If R1 reported an allegation of abuse to me, I would immediately report it to the administration. If it involved a staff member, I would separate the two. The administrator is the abuse coordinator, I received abuse training about four months ago. On 2/1/25, at 3:15 PM, V1 [Administrator] stated, I was the assistant administrator here for five years, and the administrator for two weeks. If there were any abuse allegations while I was the assistant administrator, I would have been involved and made aware. I was not made aware of the reported allegations to V7 on 11/15/24, and 11/19/24 involving R1. I was not made aware on any recent allegation from R1 alleging staff members had fondled her [R1] breast, until today. I will submit the initial report to IDPH (Illinois Department of Public Health) today and start an investigation. All new hires receive abuse training and a test during orientation. All staff receives abuse training annually and as needed. I make rounds and talk with R1 often at least a few times per week. R1 has not reported any allegations of abuse. R1 does have delusions, psychosis, and bipolar disorder. Due to R1's delusions, R1 requires at all times two person assist. All staff received abuse training and know to notify the administrator of all alleged abuse allegations for proper investigations. V7 should have reported all allegations from R1 to me, immediately. It is not his responsible to determine if the allegations were true or not. V7 will be educated today. On 2/1/25, at 3:35 PM, V15 [Nurse Consultant] stated, I been working with this facility for three years. I am familiar with R1. All staff knows to report all allegations to administrator. If is not up for staff to determine if the allegation was substantiated or not. Licensed Practical Nurses [V10, V11, V14] and Certified Nurse Assistants [V8, V12, V13] all said they received abuse training, and the abuse coordinator is the administrator. They all said they report any allegations of abuse immediately to the administrator. Policy documents in part: Facility affirms the right of our residents to be free from abuse. Employees are required to report any incident, allegation or suspicion of potential abuse. Staff to observe, hear about, or suspect to the administrator. When an allegation of abuse has been made, the administrator shall notify IDPH, local law enforcement within two hours.

Based on interviews and records review, the facility failed to assess and conduct investigations for allegations of physical abuse for one (R1) resident in a sample of three reviewed. Findings include: R1's medical diagnosis includes but not limited to: Cerebral Palsy, unspecified, Schizoaffective disorder, unspecified, Morbid (severe) obesity, Unspecified Psychosis not due to a substance or known physiological condition, Bipolar disorder, unspecified. R1's MDS (Minimum Data Set) section C dated 01/06/2023 documents R1's Brief Interview for Mental Status (BIMS) as 13/15, indicating R1 has intact cognitive functional abilities. MDS section GG-Functional Abilities documents R1 needs Substantial/maximal assistance, dependent on staff for Activities of Daily Living (ADL) care, uses a mechanical lift for transfer and uses a manual wheelchair for mobility. On 02/01/2025, at 1:33 PM, R1 stated that last year (no date provided) during a mechanical lift transfer, staff hurt her knee and she thought staff did it intentionally, therefore R1 called emergency services because she was in pain, and she also informed V7(Registered Nurse-RN) but nothing was done. Nursing progress noted dated 10/07/2024, document R1 reported to V7 (Registered Nurse-RN) that R1 called emergency services stating staff hurt her during mechanical lift transfer. On 02/01/2025, at 12:44 PM, V7 (Registered Nurse-RN) stated he was R1's nurse on 10/07/2024, when R1 reported to him that during mechanical transfer, staff had injured her knee. V7 stated he did not assess R1, and he did not notify R1's physician because R1 has behavioral health issues and V7 did not think R1 was injured during transfer, therefore V7 notified Social Services instead. V7 stated he should have assessed R1 for any injuries and based on his findings, notify R1's physician and V1 (Administrator), so that R1's allegation of being hurt by staff during mechanical lift transfer can be investigated. On 02/01/2025, at 3:03 PM, V2 (Director of Nursing-DON)stated when R1 reported to V7 that during mechanical lift transfer, R1's knee was hurt by staff, V7 should have assessed R1 to make sure there were no injuries, notified R1's physician, V1 and V2 so that the physician can give orders for R1 and allegation of physical abuse can be investigated to determine if R1 was hurt intentionally or if it was an accident. V2 stated assessing and investigating allegations of abuse helps prevent resident abuse. V2 stated if V7 did not document his findings, then it was not done. On 02/01/2025, at 3:26 PM, V1(Administrator) stated that when R1 notified V7 that R1 was hurt during mechanical transfer on 10/07/2024, and that R1 had called emergency services, V7 should have notified R1's physician, V1 and V2 so that the allegation can be investigated to determine if R1 needed to be sent to the hospital for further assessments and possible treatment. V1 stated not reporting an allegation of abuse or incident can put a resident in danger. V2 stated she does in-services for reporting incident report to staff once a year and as needed. Policy titled: Abuse Prevention Policy dated 10/2022 documents: -Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Policy titled Hoyer (Mechanical) Lift documents: A Hoyer (Mechanical) lift assists staff to lift and move a resident as safely and as easily as possible.

Based on observations, interviews, and record review the facility failed to ensure that the residents indwelling catheter drainage bag is covered. This failure affected one resident (R165) reviewed for dignity in the sample of 59 residents. Findings Include: R165's admission record includes diagnoses of malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. R165's (5/11/24) Minimum Data Set documented, in part Section C. Cognitive Patterns. BIMS (Brief Interview for Mental Status) score is 15. R165 is cognitively intact. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. On 6/23/24 at 10:40 am, R165 indwelling catheter drainage bag was hanging from the bed frame facing the hallway not covered with a privacy bag. On 6/23/24 at 10:50 am, V24 LPN (License Practical Nurse) stated that the urinary drainage bag should be covered with a privacy bag for dignity. On 6/25/24 at 10:00am, V4 DON (Director of Nursing) stated that the urinary drainage bag should be covered in a privacy bag to allow privacy and dignity to the residents. On 6/25/24 at 12:05 pm, V8 ADON (Assistant Director of Nursing) stated that urinary drainage bag should not be on the floor and should be covered in a privacy bag for the dignity of the residents. R165's (6/25/24) Physician Order Report documents in part, Catheter-Indwelling Catheter, Size: 16 French. R165's (4/10/24) Care Plan documents, in part, requires a urinary catheter related to diagnosis of presence of urogenital implants. The facility LPN (License Practical Nurse) job description documents, in part, Purpose: Provide License nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. DUTIES/RESPONSIBILITIES/FUNCTION: 2. Ensure that all CNA (Certified Nursing Assistant) personal assigned to your unit/area comply with all written policies and procedures established by the facility. The facility CNA (Certified Nursing Assistant) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 30. Follow HIPPA (Health Insurance Portability and Accountability Act) confidentiality requirements. Assure each resident's privacy in all facets. Facility Residents Rights for people in long-term care Facilities, documents in part, Your rights to dignity and respect, your rights to privacy and confidentiality: you have a right to privacy and confidentiality . Your medical and personal care are private. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to rescreen a resident to determine if specialized services under the Preadmission Screening and Resident Review requirements are necessary. This failure affected 1 (R153) resident reviewed for PASRR screening in the total sample of 59 residents. Findings include: R153's ([DATE]) Notice of PASRR (pre-admission screening and resident review) Level I Screen Outcome documented, in part PASRR Level Review Date: [DATE]. PASRR Level I Determination: Convalescence Categorical. Approval period: 60 days. Suspected or confirmed PASRR condition(s): Mental Health Disability. PASRR outcome explanation. Notice of criteria met for convalescence categorical-no PASRR Level 2 required. Your Level one screen shows you have evidence of serious mental illness. Further PASRR evaluation is not required because you meet criteria for a short term convalescence admission. This means you may stay for a limited number of days in a Medicaid certified nursing facility without further PASRR evaluation. If you or your care provider thinks you need to stay longer than the number of approved days listed on the notice of PASRR Level one screen outcome that came with this letter, a nursing facility staff member must submit a new Level one screen to M****** . This must be completed by or before the last approved date after your admission to the nursing facility. This Level I screen is good within 90 calendar days of the notice date listed on the notice of PASRR Level one screen outcome. After that time, any nursing facility you admit to must submit an updated Level 1 screening form to M****** . Outcome. Rationale: 60 day convalescent care approval- a 60 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 60 day if the individual is expected to remain in the nursing facility beyond the authorization time frame. On [DATE] at 10:47am, V26 (Psychiatric Rehabilitation Services Director) stated the purpose of pre-admission screening is to determine the need of the resident. In reference to the PASRR recommendation, V26 stated the expectation is to follow the recommendation stipulated in the PASRR. On [DATE] at 10:49am, this surveyor showed V26's R153 Notice of PASRR Level I Screen Outcome. V26 stated it means the person needs to be re assessed within 60 days from the date written in the M****** (PASRR). He (R153) is expected to be rescreened on 03/2023. I (V26) will check with admission Director (V20) if there's another PASRR for him (R153). On [DATE] at 11:34am, V26 stated we don't have PASRR for him (R153) after the 01/2023 screening. The only thing we (facility staff) have is the expired 1/2023 screening. On [DATE] at 2:20pm, V26 stated his (R153) rescreening is submitted today. It was not done within the 60 days per 01/2023 PASRR recommendation. R153's ([DATE]-[DATE]) Physician Order Report documented, in part Diagnoses: Bipolar disorder. R153's ([DATE]) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R153's mental status as cognitively intact. Section I. Active Diagnoses. Psychiatric/Mood Disorder. I5900. Bipolar Disorder. Section N - Medications. N0415. High risk drug classes: use and indication. A. Antipsychotic. N0450. Antipsychotic Medication Review. A. Did the resident received antipsychotic medications since admission/entry or reentry or the prior OBRA assessment? 1- yes. R153's ([DATE]) State PASRR (pre-admission screening and resident review) documented, in part Reason for Screening. What is the purpose of this Level I screen. A previous PASRR short -term approval for nursing facility stay has expired (e.g. Convalescence.) Assessment Submitted by V26. The (Undated) Social Service Designee Job Description documented, in part Purpose Of Your Job Position. The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facilities social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Administrative function. Participate in resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to clean and correctly log refrigerator temperatures for one resident's (R135) personal refrigerator. Findings include: On 06/23/2024 at 11:15am observed a black colored refrigerator in R135's room. Observed a temperature log affixed on the front of the refrigerator door. The temperature log was missing the documentation of a temperature reading for the following dates: 6/14/2024, 6/20/2024 and 6/21/2024. Observed a black substance on the thermometer located on the top shelf inside the refrigerator. The refrigerator contained two Styrofoam cups with drinks inside and a bottle of water. On 06/23/2024 at 12:15pm R135 stated the staff clean the refrigerator in my room once a month and the staff check the temperature in the refrigerator once a month. On 06/25/2024 at 10:29am R135 stated staff have not told me I need to clean my personal refrigerator. R135 stated I don't know what that black stuff is on the thermometer in the refrigerator. On 06/25/2024 at 10:43am V18(Housekeeper) stated I am responsible for cleaning the resident's personal refrigerator. V18 stated the housekeepers are responsible for taking the temperature in the resident's personal refrigerator and logging the temperature for the day. V18 stated I don't know what that black substance is on the thermometer in the resident's personal refrigerator. On 06/25/2024 at 12:06pm V19(Maintenance Director) stated the housekeeping staff are to check and log the temperature in the resident's personal refrigerator daily. V19 stated it is my expectation that the housekeeping staff check the temperature in the resident's personal refrigerator daily. V19 stated the housekeeping staff is to clean the resident's personal refrigerator daily. On 06/25/2024 reviewed the undated Housekeeping Aid job description which documents, in part, the primary purpose of this position is to: Provide housekeeping services to assure that a clean, orderly, and homelike environment is maintained in accordance with current federal, state, and local regulations. Clean all equipment and furniture as assigned. All other duties as assigned. On 6/25/2024 reviewed the facility's policy titled Use and Storage of Outside Foods in Resident's Room dated 10/01/2022 which documents in part, Refrigerator in Resident's room [ROOM NUMBER]. Check and monitor internal temperatures. R135's diagnosis includes but are not limited to, Multiple sclerosis, schizoaffective disorder, unspecified, Hemiplegia, unspecified affecting left nondominant side, Hereditary and idiopathic neuropathy, unspecified, Hyperlipidemia, unspecified, and Hereditary and idiopathic neuropathy, unspecified. R135's Brief Interview for Mental Status (BIMS) dated 04/23/2024 documents R135 has a BIMS score of 11 which indicates that R135's cognition is moderately impaired.

Based on observation, interview and record review, the facility failed to ensure a resident's adaptive equipment was functional. This failure affected 1 (R68) resident reviewed for adaptive equipment in the total sample of 59 residents. Findings include: On 06/23/24 at 12:16pm, R68 was sitting on a wheelchair. R68 stated I (R68) have an issue with my (R68) wheelchair. The brakes are both broken. I (R68) got the wheelchair a couple of months ago. This surveyor requested R68 to engage the brakes; the brake on the right was not touching the rear wheel and the brake on the left was loose. The wheelchair moved while the brakes were engaged when R68 propelled the wheelchair. On 06/23/24 at 12:23 PM, this surveyor requested V8 (Assistant Director of Nursing) to check R68's wheelchair and R68 stated the wheelchair brakes are not tight; the one on the right is loose and the one on the left need's adjustment. We (facility) are going to provide a new wheelchair immediately. The purpose of the wheelchair brakes is to steady the wheelchair; for safety, to prevent falls. It is a concern. The restorative is responsible for checking the wheelchair every day; to make sure the wheelchairs are functional and safe to use. On 06/23/2024 at 12:43pm, V10 (CNA/Restorative Aide) stated I (V10) don't know how long she (R68) has been using the wheelchair. On 06/26/2024 at 9:55am, V4 (DON) stated the reason for maintaining the wheelchair, is for the safety of the resident because we (facility staff) don't want the resident to fall or cause any harm to the resident. If broken and not functioning, it may cause harm to the resident; they may fall. Or the resident might not use it and be limited and prevent them from moving around. R68's (05/24/2024-06/24/2024) Physician Order Report documented, in part Diagnoses: cervical disc degeneration and quadriplegia. R68's (05/01/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R68's mental status as cognitively intact. Section GG. GG0120. Mobility Devices: C. Wheelchair. GG0170. Does the resident use a wheelchair? 1- yes. R68's (11/03/2023) care plan documented, in part Problem: at risk for deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit. Goal: will not deteriorate in ADL (activities of daily living). The (undated) Restorative Care Nurse Job Description document that, in part The primary purpose of your job position is to perform restorative nursing procedures that maximizes the resident's existing abilities emphasize independence instead of dependence and minimize the negative effects of this ability with an attitude of realistic optimism under the supervision of restorative nurse. Equipment and supply function. Provide necessary equipment for resident to perform required therapy or treatment. The (02/2014) EVALUATION CRITERIA FOR MEDICAL EQUIPMENT PROGRAM documented, in, part Policy Specifications: 1. All medical equipment used in the care of residence will be evaluated prior to use based on functions and physical risk associated with maintenance requirement.

Based on observation, interviews and records reviewed, the facility failed to ensure residents on enhanced barrier precautions (EBP) had EBP signs posted at their rooms, that staff were using Personal Protective Equipment (PPE) when providing care for residents and that the residents' PPE bins were available and stocked. These failures affected 4 (R24, R43, R83, R165) residents and has the potential to affect all 174 residents in the facility. Findings include: On 06/23/2024 at 11:14 am, observed V12, Certified Nursing Assistant (CNA) with no gloves or gown on, adjusting R43's diaper, under pad and sheets. R43 observed with indwelling foley catheter. There was no Enhanced Barrier Precaution sign on the door of R43's room. The was no Personal Protective Equipment (PPE) bin outside R43's room. On 06/23/2024 at 11:20 am, V12 (CNA) stated Enhanced barrier isolation is pretty much when you gown and glove up. We use isolation when there is a sign on the door, or the nurses will let us know who to use isolation on. The resident R43, that I was just caring for is not on isolation. Normally we have in-services on infection control, or we would ask the nurse or treatment nurse. On 06/23/2024 at 11:27 am, V11 (Licensed Practical Nurse/LPN) stated, I am supposed to use EBP when hands on care to the resident is being done. We use EBP for everybody that has a sign on the door, for residents with wounds and foleys to protect them (residents) from us (staff). R43's room does not have a sign on the door. R43 should have an EBP sign on R43's door because he has a foley. On 06/23/2024 at 12:13 pm, V11 placed EBP sign to R43's door. R43's diagnosis includes but are not limited to Benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, presence of urogenital implants: indwelling urinary catheter. R43 has a pressure ulcer to left ear, last documented assessment 06/20/2024. Current wound care orders to left posterior ear, cleanse with normal saline pat dry and apply dry dressing 3 times a week and prn. R43's Care plan dated 05/01/2024, in part R43 is on enhance barrier precautions r/t indwelling catheter, wound. Place sign on door. Wear gown and glove for: dressing, grooming, bathing, showering, transfers, changing of linens and briefs, hygiene care, toileting. Wear gown and gloves for care of indwelling catheter. R43's active physician order dated 06/01/2024 include but not limited: Enhanced Barrier Precaution R/T wound and Foley. The facility's Infection Control Policy dated June 2020 in part 5. The facility provides personnel protective equipment (PPE) which refer to barriers used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. PPE used is based upon the nature of the interaction with the resident and/or the likely mode of transmission. During times when PPE is not sufficient in supply the facility will utilize CDC guidance for Optimizing PPE. Types of PPE include a. Glove, b. Gowns, c. Masks, d. Eye Protection Goggles and/or Face Shields. 9. Systems for monitoring resident care areas, such as urinary catheters, incontinence, wound care, skin care, infusion therapy, dialysis, mechanical ventilation and associated risks. The facility's Enhanced Barrier Precautions Policy dated 04/28/24, in part: 8. Post clear signage on the door/wall outside resident room. 9. Personal Protective equipment is required for all staff providing high-contact resident care activities to include: iv. Providing hygiene, v. changing linen, vi. Changing briefs or assisting with toileting. 19. Enhanced Barrier Precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device. R165's admission diagnoses include but not limited to malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. On 6/23/24 at 10:38 am, R165 had an Enhance Barrier Precaution (EBP) sign on R165's door with a PPE (Protective Precaution Equipment) bin outside of R165's door with no gowns in the bin. R165's Physician Order Report documents in part, Enhance Barrier precaution r/t (related to) indwelling catheter. R165's care plan documents in part, Problem: R165 is on enhance barrier precautions r/t indwelling catheter, colostomy . Approach: .Keep bin place outside of R165's door stocked with PPE. R24's admission diagnoses include but not limited to diabetes, mellitus, hypertension, benign prostatic hyperplasia, gastro-esophageal reflux disease, and urogenital implants. On 6/23/24 at 10:45 am, R24 had an Enhance Barrier Precaution sign on R24's door, with no PPE bin outside of R24's door. R24's Physician Order Report documents in part, Enhance Barrier precaution r/t (related to) indwelling catheter/ G-tube (Gastrostomy-tube). R24's care plan documents in part, Problem: R24 is on enhance barrier precautions r/t peg tube, stoma site. Approach: Wear gown and gloves for care of g-tube and feedings. On 6/25/24 at 10:00am, V4 DON (Director of Nursing) stated that the supply person should restock the PPE bins. The nurse and CNA (Certified Nursing Assistant should notify the supply person when supplies are needed. PPE supplies consist of gloves, mask, and gowns. They should be available for care at all times. On 6/25/24 AT 12:05 PM. V8 ADON (Assistant Director of Nursing) stated that every resident on EBP should have a bin that contains the gloves mask, gown. The nurse or CNA should notify the stock person when stock is needed. Every resident in an Enhance Barrier Precautions room should have supplies available when needed for care. The bin should be outside the resident's rooms. The facility EBP sign documents in part, Provider and Staff must wear gloves and gown for the following high contact Resident Care Activities .Device care or use: .urinary catheter, feeding tube . The facility CNA (Certified Nursing Assistant) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 14. Make sure that necessary supplies are available . The facility LPN (License Practical Nurse) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 11. Ensure that an adequate supply of floor stock .supplies and equipment is on hand to meet the nursing needs of the residents . On 06/23/24 at 10:42 AM, there was an 'Enhanced Barrier Precaution' sign posted by R83's door. There was no PPE bin outside of the room. This observation was pointed out to V13 (Restorative Nurse/LPN) and V13 stated there is no PPE bin outside of his (R83) room. I (V13) think he (R83) is on extra barrier precaution due to his (R83) wound. This surveyor and V13 went inside R83's room to check for PPE bin. V13 stated there is no PPE bin inside his (R83) room. On 06/23/24 at 10:52 AM, V4 (Director of Nursing) stated EBP (Enhanced Barrier Precautions) are for residents with g-tube, foley catheter, colostomy, and wounds. The purpose of placing residents on enhanced barrier precaution is for infection control; to prevent splashes of infection. The sign should be up and there should be a PPE bin outside the resident's room. On 06/23/2024 at 10: 53am, V4 went inside R83's room and stated I (V4) don't see a PPE bin inside the room and there is none outside the room too. R83's (04/18/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R83's mental status as cognitively intact. R83's Census documented that R83 was moved to a new room on 04/08/2024. R83's (05/24/2024-06/24/2024) Physician Order Report documented, in part Diagnoses: peripheral vascular disease. General: Start date: 05/30/2024 - Open Ended. Enhance Barrier Caution r/t (related to) wound. Treatment Flow sheet. General: Start date: 05/15/2024. End Date: 06/23/2024 (DC- discontinued Date) Description: Site: BKA (below knee amputation) cleanse wound with normal saline o wound cleanser. Pat periwound dry. Collagen and xeroform every 3 days and PRN (as needed) if loose/solid (soiled). General. Start Date: 06/23/2024. End Date: Open Ended. Description. Site: _ BKA cleanse wound with normal saline or wound cleanser. Pat peri wound dry. Foam (dressing) three times a week and PRN if loose /solid (soiled). The (06/19/2024) Resident Extra Barrier Precaution list included R83 (for wound). The (undated) Enhance Barrier Precautions policy documented, in part Policy. Enhanced Barrier Precautions is designed to reduce transmission of multi drug resistant Organism (MDRO) and extensive drug resistant Organism (XDRO) in nursing homes. It is the policy of this facility that Enhance Barrier Precautions, in addition to standard and contact precautions will be implemented during high contact resident care activities when caring for residents that have an increased risk for acquiring a multi drug resistant Organism such as a resident with wounds. Overview. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs (multidrug resistant Organism) to employee's hands and clothing during cares beyond situations in which staff anticipate exposure to blood or body fluids. Pathogen-based approach will be used in the facility which will involve the use of gown and gloves during high contact activities for resident. A risk based approach will be used when residents have increased risk for acquiring MDRO or XDRO such as residents with wounds. Procedure 9. Personal protective equipment is required for all staff providing high contact resident care activities to include: viii. Wound care: any skin opening or requiring a dressing.

Based on observation, interview and record review the facility failed to ensure food in the walk-in cooler/freezer was labeled with a date indicating when the item was placed into the walk-in cooler/freezer. This failure has the potential to affect all 174 residents in the facility who are receiving an oral diet. The findings include: On 6/23/2024 at 9:50am while inside the walk-in cooler, observed one 48-ounce package of chopped spinach not in a case and not labeled with the date it was placed in the walk-in cooler and one opened box (10 cans in the box) of non-diary whipped topping not labeled with a date it was placed in the walk-in cooler. On 6/25/2024 at 2:15pm V5 (Dietary Supervisor) stated the purpose of labeling/dating the food containers in the walk-in cooler and freezer is so that staff can monitor when to use the foods that are put into the walk-in cooler and freezer. V5 stated the staff has 30 days to keep the food items in the walk-in cooler and freezer once the food items have been dated with an in- date. V5 stated the cooks and dietary aids are responsible for labeling food items when the food items are placed in the walk-in cooler and freezer. V5 stated it is my expectation that the kitchen staff label food items when the food items are initially placed into the walk-in cooler and freezer. V8 stated if a food item is not labeled with a date it was placed into the walk-in cooler or freezer, the food item is at risk for expiring. V5 stated if a resident consumes expired food, the resident can get sick. V5 stated there are no residents in the facility who are NPO (nothing by mouth). Reviewed the Facility's Policy Labeling and Dating Foods (Date Marking) from the Health Technologies, Inc. Guideline & Procedure Manual, 2016 Edition which documents in part, Guideline: All foods stored will be properly labeled according to the following guidelines. Procedure 3. Date marking for freezer storage food items. Unopened cases of frozen food items will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Reviewed the facility's undated Dietary Aid Job Description which documents in part, Ensure that safe food handling procedures are being consistently maintained. Follow all dietary policies and procedures. This includes, but is not limited to, Proper sanitation procedures, proper food, and chemical storage procedures.

Based on observation, interview and record review the facility failed to ensure resident environment remains free of accidental hazards and the environment is free of sharp objects that could harm the residents. This failure affected R5 and R18 who has sharps stored on their bed side table and has the potential to affect all 31 residents residing on the 4th floor of the facility. Findings include: On 02/28/24 at 11:45, in R5's room on the bedside table observed 23 disposable shaving razor sticks, 1 pair of scissors and two nail clippers. At 11:46am, V12 LPN (Licensed Practical Nurse) restorative nurse who stated that she is the medication nurse and in charge of the floor was made aware of the observation and shown the 23 disposable shaving razor sticks, 1 pair of scissors and two nail clippers. V12 counted the razora with the surveyor and stated it's 23, I'm not sure why (R5) would have this many razors. V12 counted and stated five (5) of the razors were used and they should be thrown away in the dirty utility room in the sharp container and the clean shaving razors are kept in the clean utility room, the CNAs' (Certified Nurse's Aides) closet. No sharps are to be kept in the residents' rooms. At 11:47am, 1 razor and 1 pair of scissors was observed on R18's bed side table. R18 stated I (R18) keep it there so I can use it whenever I want to. At 4:03pm, V4 ADON (Assistant Director of Nurse's) stated the facility policy & protocol on sharps is that razors are kept in the nurse's station or kept in the supply room, used ones should be disposed /thrown away in the sharp's disposable bin. The facility Safety /Hazard surveillance policy with effective date February 2014 documented that the policy purpose is to promote an environment for residents, staff and visitors that is free from safety hazards and assure all facility areas in compliance with local and state regulations. The facility Sharp Objects Policy with effective date February 2014 documented in part that the policy is to assure that sharp objects are properly contained, promoting a safe environment. Listed policy specification includes but not limited to placing any sharp objects in a sharp container.

Based on observation, interview, and record review the facility failed to ensure that the treatment cart was safely locked up when not in the vicinity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all 28 residents residing on the 2nd floor of the facility. Findings include: On 02/28/24 at 11:13am, one treatment cart was noted in the hallway unlocked and not in the visual vicinity of the nurse. V5 RN (Registered Nurse) was made aware of this observation and when asked about the facility protocol/policy on medication cart storage; V5 identified the cart as a treatment cart and stated I (V5) don't know why the cart is not locked. V5 called V8 (Care Plan Manager) the floor supervisor and showed the treatment unlocked cart to V8. V8 stated the treatment cart is broken after checking the cart and stated we must rectify this because the cart must be locked always when not in use. At 4:05pm, when this observation was brought to V2 DON (Director of Nurses) attention and was asked about facility policy/protocol on medication /treatment cart storage; V2 stated in part that all medication/treatment carts should be locked when not in use and must be placed where the nurses can visually see it. The facility policy on Storage of Medication documented in part that medication supply is accessible only by licensed nursing personnel, pharmacy, or staff members lawfully authorized to administer medications. Listed procedure includes but not limited to medication carts and medication carts are locked when not attended by persons with authorized access.

Based on observation, interviews and record reviews, the facility failed to follow their policy to ensure correct food temperatures were maintained prior to delivering food to residents for three (R1, R3, R4) out of three residents reviewed for dietary services. Findings include: On 1/30/24 at 11:06 AM R1 stated that the food is never warm. On 01/30/24 at 11:25 AM R3 stated that the food is cold occasionally. On 01/30/24 at 1:18 PM R4 stated the food is cold nine times out of ten. R4 stated that she eats her meals in the dining area and the food is always cold and arrives thirty to forty minutes late. R4 stated that she has personally told dietary department about the cold food. R4 reported that once she brought it up the following day, her food was hot or warm, but it returned to being cold after two days. On 1/31/24 at 11:25 AM surveyor observed the dietary staff on tray line. V6 (Dietary Manager) stated that dietary staff will be starting to serve trays for all residents. On 01/31/24 at 12:38 PM, surveyor observed the last meal tray that was handed out to the resident. On 01/31/24 At 12:39 PM, surveyor requested a test tray. Test tray consisted of BBQ Pork Riblette. Surveyor took the temperature of the BBQ Pork Riblette. Temperature came out to be 113.4-degree Fahrenheit. On 01/31/24 at 1:26pm V6 (Dietary Manager) stated that the food temperature when the meal trays leave from the kitchen should be 145 degrees or more Fahrenheit. V6 stated that the food should still hold at the same temperature on the floors. V6 stated that if the food temperature drops below the appropriate temperature, the residents can get sick. V6 stated that the facility has one microwave in the staff break room and another in the kitchen. V6 stated that there are no microwaves on the floors where resident reside. Facility presented documents: 1. Monitoring Food Temperatures for Meal Service(undated): documents in part, Guideline: Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. If the serving/holding temperature of a hot food item is not at 135 degrees Fahrenheit or higher (check your state specific regulations: some states require 140 degrees Fahrenheit minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165 degrees Fahrenheit for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within two hours. 2. Resources: Minimum internal cooking food temperatures (undated): documents in part: pork or beef steak or chops: minimum temperatures at 145 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R5 is a [AGE] year-old individual admitted to the facility on [DATE]. R5's current medical diagnosis, as documented in R5's face sheet includes but not limited to: Unspecified dementia, moderate, with psychotic disturbance, Hypertensive heart disease without heart failure, Complete traumatic amputation of left lower leg, level unspecified, sequela, schizoaffective disorder, unspecified. R5's BIMS (Brief Interview for Mental Status) dated 12/20/2023 document R5 has a BIMS score of 14/15, indicating R5 has intact cognation. On 01/3/2023 at 12:44pm, R5 said he was experiencing leg pain and pointed to his amputated leg. R5 said he remembers a staff member make bad comments about his missing limb, but he does not remember who it was, because it was a while ago. On 01/03/2024 at 11:25am V1(Administrator) said R5 come to V1 and was really upset and said V15 had called him names and was making fun of R5's missing (amputated) leg. V1 said she called V15 to question her and start investigations, and when V15 got to V1's office V1 said V15 told her Don't bother to do you little binny investigation because I said it and I quit. V1 said that's verbal abuse because V15 humiliated R5 and he (R5) was in tears about it. V1 said she is the abuse coordinator and named types of abuse. V1 said both V11 and V15 both received abuse training and in-services before hire and when they were working at the facility. On 01/03/2024 at 10:15am, V3(Social Services Director) said that R5 had not been happy about the way the food trays were being passed, and V15 (Former Certified Nursing Assistant-CNA) responded to R5 in an unprofessional way, making fun of R5's missing limb, and made some derogatory comments about R5. V3 said R5 told him he was hurt by what V15 said to him, and V15 was reprimanded for her behavior. V3 said staff should not engage with residents because staff are here to help residents with their issues and staff should not be part of resident issues. R5's Progress notes dated 09/25/2023 documents R5 reported to social services regarding a verbal aggression towards him. Facility Reported Incident Report (FRI) dated 09/27/2023 documents on 09/20/2023, R5 reported to V1(Administrator) that V15 (Former Certified Nursing Assistant-CNA) hurt his feelings by referring to his leg appearance. The FRI concluded that V15 was discourteous in her interaction with R5 making an inappropriate comment about R5's appearance, and V15 admitted that she said it. Facility Abuse policy titled Abuse Prevention Policy, dated 10/2022, documents: -Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. -Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability, to comprehend, or disability. -Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. -Misappropriation of Resident Property means deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. Based on observations, interviews and record review, the facility failed to follow their abuse policy to protect residents from physical and verbal abuse for three (R1, R5, R11) residents reviewed for abuse in a sample of six. Findings include: On 01/02/2024 at 10:55 AM, surveyor observed R1 walking from the elevator to the dining area. R1 stated that she had somebody scream at her yesterday. R1 stated that it was V18 (Activity Aide). R1 stated that she hasn't had a chance to tell anybody yet, but she will today. R1 stated that V17 screams at us routinely. R1 stated that V19 (Activity Aide) swears and screams at her all the time. R1 stated that she always says, I'm not putting up with her bullshit. On 01/02/2023 at 11:20 AM, R13 stated that he has heard V19 (Activity Aide) swear at residents all the time. On 01/02/2023 at 11:28 AM, R14 stated that he has heard V19 swears at other residents. R14 stated that he has heard V17 (Certified Nursing Assistant) yell and swear at residents. On 01/02/2023 at 10:00 AM, surveyor observed R5 laying in his bed. R5 stated he has seen staff members be verbally aggressive with residents. R5's progress note by staff member (09/20/2023) documents: The resident alleged that the staff verbally abused him. The writer asked what went on and the resident used inappropriate words which he claimed he used while speaking to the staff. The social service was called, and the administrator was informed. The staff was called and interviewed and later went home. MD called and notified, and a family member was called and notified. R5's facility incident report final intake (09/27/2023) documents in part: The facility's findings indicate that the staff member was discourteous in her interaction with R5 and making an inappropriate comment about the resident's appearance. R5's Progress note by V12 (Social Worker) on 09/21/2023 documents in part: PRSC has met 1:1 with R5 for well-being check after he was involved with verbal altercation with resident and staff. Resident reports I'm just glad she is not here anymore. I am feeling fine. R1's MDS Section C Cognitive Patters (11/29/2023) documents in part: R1's BIMS score is 14 which means R1 is cognitively intact. R5's MDS Section C Cognitive Patters (12/20/2023) documents in part: R5's BIMS score is 14 which means R5 is cognitively intact. R13's MDS Section C Cognitive Patters (12/07/2023) documents in part: R13's BIMS score is 15 which means R13 is cognitively intact. R14's MDS Section C Cognitive Patters (01/03/2024) documents in part: R14's BIMS score is 15 which means R14 is cognitively intact. R10 is a [AGE] year-old male. R10 's diagnoses are lung disease, schizoaffective disorder, high cholesterol, heart disease, thyroid disorder, reflux, high blood pressure, depression, anxiety, auditory hallucinations, psychotic disorder with delusions due to known physiological condition. R10's MDS (Minimum Data Set) dated 09/29/2023, notes R10 is alert. R10's care plan notes R10 displays behavioral symptoms. R11 is a [AGE] year-old male. R11's diagnoses are heart disease, major depressive disorder, recurrent severe without psychotic features, psychosis not due to a substance or known physiological condition, anxiety disorder, antisocial personality disorder, high blood pressure, schizoaffective disorder, bipolar type, violent behavior, personal history of traumatic brain injury, and cognitive communication deficit. R11 MDS (Minimum Data Set) dated 09/25/2023, notes R11 is alert. There are no behaviors listed on R11's care plan. Progress note dated 09/15/2023, notes R11 was hit by peer in the face, nose, and back of neck while waiting to go for smoke break in the hallway. No visible injury, bruising, or redness present currently. R11 was placed in a different room, pending peers transfer to the hospital. On 1/02/2024, at 1:05 PM, R11 stated, I was sitting here in line, and R10 hit me in the back of the head. I was trying to talk to R10, and he hit me. I like to joke with people and have fun. This should be on camera. I do not remember who the staff was or the residents. Residents were lined up behind me. I believe staff intervened. I forgot about it. All I remember is I could have killed him, but I do not know how to do it. On 1/02/2024, at 12:54 PM, V12 (Psychiatric Rehabilitation Services Coordinator) stated, I did not witness this incident. R10 had aggression, was impulsive and sometimes he may have been slightly provoked. R10 was sent to the hospital due to behaviors. It may have been due to this incident. He has been to several floors. He was physically aggressive. He got moved to the third floor, which was the floor R11 was on. On 1/03/2024, at 2:15 PM, V1 (Administrator) stated, The camera records and keeps it for five to six days. I did review camera. It started out being a verbal altercation. On 1/04/2024, at 10:57 AM, V25 (Registered Nurse) stated, What I saw was a line by the elevator, R10 was in the line. I am not sure what R11 said to R10. I saw R10 hit R11 on the head or in the back. R10 walks around. We went there to intervene. I cannot remember the name of the other staff member. When R10 hit R11, it was in the back of the head. R11 then got into a defensive position. R11 did not hit R10 back. I did not see any bruising on R11's face. R10 had a lot of behaviors. R10 was very aggressive. Staff had to watch their backs. R10 liked to walk around and beg things from the residents. When R10 came to the facility he started on the second floor. R10 was sent out and then moved to the seventh floor. R10 was sent out again and R10 was moved to the third floor. Yes, I think there were interventions in place to protect the resident. Staff was monitoring him with these behaviors. We do our best to monitor the residents. I believe I assessed R11. R11 was complaining of a headache, and he was sent to the hospital and returned. I told the hospital that R11 was having double vision. This was towards the end of my shift. When I came back the next day, R11 was back in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to follow their policy for Misappropriation of Resident Property and Exploitation. This failure resulted in three (R6, R7, R8) residents' being exploited by V11 (Former Certified Nursing Assistant), who took/borrowed their money, and did not buy them stuff or refund them their money as promised. Findings include: Facility Reported Incident Report (FRI) dated 10/02/2023 documents on 09/26/2023, R6, R7, R8 reported they gave V11 a total of $226 to purchase snacks for them as follows: -R6 gave V11 $160, R7 gave V11 $44 and R8 gave V11 $22. Resident Concerns Forms dated 10/20/2023 documents R6 reported $160 stolen from him, R7 reported $25 stolen from him, and R8 reported $41 stolen from her. On 01/03/2024 at 11:25am V1(Administrator) said R6, R7, and R8 all reported at different times that they had given V11 some money to get them different things but V11 did not buy the items for the said residents and did not give them their money back. V1 said she asked V11 if he took resident's money, but V11 only owned up to owing R7 $25 dollars, and that he (V11) would send the money for R7 to V1, but V11 never did. V1 said she reimbursed all three residents their money as follows: R6- $160, R7- $25, and R8- $41. V1 said Social Services or V1 are the only ones allowed to buy residents items, and the transaction has to be witnessed and signed off. V1 said staff are not supposed to use resident money, because that's taking advantage of the residents, and that's a form of abuse. V1 said V11 was terminated right away. R6 is [AGE] year-old individual admitted to the facility on [DATE]. R6's current medical diagnosis, as documented on R6's face sheet includes but not limited to: schizoaffective disorder, unspecified, Mild cognitive impairment of uncertain or unknown etiology, and Congenital renal failure. R6's BIMS (Brief Interview for Mental Status) dated 12/05/2023 documents R6's BIMS as 15/15, indicating R7 has intact cognition. On 01/02/2024 at 11:07am, R6 was in his room siting on his wheelchair and was alert, oriented to person, place, time and situation. R6 said a while ago (R6 cannot remember the exact dates and times), there was a staff V11 (Elevator Monitor) who used to ask for money from him and other residents. R6 said V11 would ask for money every week when R6 gets his stipend money, a $20 dollar, here, a $50 there, up to $160, and V11 said he would give R6 the money back in double. R6 said this went on for two months, and V11 took the money and never gave the money back to R6. R6 said he felt taken advantage of and used by V11. V6 further said there were other residents V11 took money from. R6 said V1(Administrator) called the residents who V11 had taken money from and reimbursed it to all of them. R7 is a [AGE] year-old individual, admitted to the facility on [DATE]. R7's current medical diagnosis, as documented on R7's face sheet includes but not limited to: Type 2 diabetes mellitus with unspecified complications, schizoaffective disorder, unspecified, bipolar disorder, current episode mixed, unspecified, Major depressive disorder, recurrent, unspecified, Generalized anxiety disorder. R7's BIMS (Brief Interview for Mental Status) dated 11/26/2023 documents R7's BIMS as 15/15, indicating R7 has intact cognition. On 01/02/2023 at 12:27pm, R7 stated R7 does not remember who took his money, and he gets $30 a month for stipend, and it's not a lot. R8 is a [AGE] year-old individual admitted to the facility on [DATE]. R8's current medical diagnosis, as documented on R8's face sheet includes but not limited to: Paranoid schizophrenia, Unspecified psychosis not due to a substance or known physiological condition, Major depressive disorder, single episode, unspecified. R8's BIMS (Brief Interview for Mental Status) dated 11/02/2023 documents R8's BIMS as 15/15, indicating R8 has intact cognition. On 01/04/2023 at 12:45pm, R8 said she forgot who she gave her money to because it was a while ago, but it was a staff member here at the facility, and V1(Administrator) gave her the money back. R6, R7, and R8's funds ledger dated 08/01/2023-09/30/2023 documents R6, R7, R8 received funds in their accounts. Facility Abuse policy titled Abuse Prevention Policy, dated 10/2022, documents: -Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. -Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. -Misappropriation of Resident Property means deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing coverage per their assessed staffing needs to ensure adequate care and support. This failure has the potential to affect all 176 residents that reside in the facility. Findings include: On 01/02/2024, V21 (Staffing Coordinator) provided surveyor with the nursing staff schedules dated 09/01/2023 to 12/31/2023. On 01/03/2024 at 10:49AM, V21 stated this was the entire nursing staff schedule which reflects the actual names and amount of nursing staff who worked in the facility during that time frame. V21 states whenever there is a change to the schedule, she updates it as soon as possible to ensure an accurate schedule. V21 states the facility does use agency staff to supplement staffing at the facility. V21 also states the facility no longer utilizes resident aides/RAs since November 2023. V21 states she staffs according to the budget that is given to her from V1 (Administrator) and V2 (DON). V21 states this is how she determines how many nursing staff she is able to staff per day. V21 states V1 and V2 show her the budget sheet and the budget sheet reflects daily staffing as 28 CNAs daily and 16 nurses daily. V21 states any daily staffing in the facility that is below 28 CNAs, and 16 nurses is considered below the minimum daily staffing and is considered low staffing. Facility nursing staff schedules reviewed for nurses and CNA's from 09/01/2023 to 12/31/2023 for weekend shifts. The nursing staff schedule documents that out of the 35 weekend days reviewed, there were 7 days that did not meet the minimum requirements of 28 CNA's and 16 nurses per V21 (Staffing Coordinator). The following reflects the daily amount of staff who worked in the facility providing direct patient care: 09/03/2023- 14 nurses worked in facility. 09/09/2023- 14 nurses and 25 CNAs worked in the facility. 09/10/2023- 13 nurses worked in the facility. 10/14/2023- 14 nurses and 27 CNAs worked in the facility. 10/15/2023- 12 nurses and 24 CNAs worked in the facility. 12/17/2023- 14 nurses worked in the facility. 12/30/2023- 14 nurses worked in the facility. Facility census dated 01/02/2024 documents that a total of 176 residents reside in the facility. Facility assessment dated [DATE] documents in part, Staffing plan 3.2 Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. The following is our general staffing for the facility: Position- Licensed nurses providing direct patient care- 8 Registered Nurses, 8 Licensed Practical Nurses. Position- Nurse's Aide- 28 CNAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews and records review, the facility failed to report and initiate an investigation of alleged abuse in a timely manner by failing to identify and ensure the reporting of a suspected abuse. This failure affected 2 residents (R1, R2) out of 3 residents reviewed for abuse. Finding include: R1's face sheet shows R1's diagnosis in part of hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, overactive bladder, and anxiety disorder. R1's Brief Interview of Mental Status (BIMS) dated 09/08/23 score 14 out of 15, indicating R1 has intact cognitive function. On 10/24/23 at 09:05 am R1 observed lying in bed, alert, oriented to self, place, time and situation. R1 says she can walk a little bit but uses the wheelchair for mobility, needs assistance with transfers and she uses an incontinence brief during the night. R1 says the incident happened in August, and it was about 3 am when a male Certified Nursing Assistant (CNA) came to her room. R1 says the CNA put his hands under her buttock, squeezed it and said something like I thought you were thin, but you are thick, and then the CNA left. R1 says that the next day she told V6 (Social Service) about the incident and V6 had said she would do something. R1 says I guess she did because the CNA has not worked with me since then. R1 says she has seen the CNA after the incident working on her floor, even in her room. R1 describes the CNA as a black, tall man. R1 says it was a one-time incident and she had never seen that CNA before the incident happened. R1 states I just want to leave because of what that man did to me. That made me feel mad. R1 says her leg is hurting and she wants the CNA to come get her up. R1 pulls the call light cord. A few minutes later a CNA goes to R1's room and assists R1 to transfer to the wheelchair. On 10/24/23 at 10: 01 am R1 is in front the elevator. R1 was asked if she recognizes any of the male CNAs that are working on the floor this morning as the alleged perpetrator, R1 says it was none of them. There were 2 male CNAs working the morning shift on the 3rd floor. On 10/24/23 at 10:24 am R2 was interviewed as part of the sample regarding R1's complaint investigation. R2 said I've been here in this facility for a little bit over a month, it happened either Friday or Saturday, (10/20 or 10/21), this guy came to my room about 6:30 am, turned the light on and said what are you doing in bed? I was laying in my side and trying to understand why he was saying that, and then he came close to the bed and uncovered me without asking permission. I was kind of shocked. What is happening? It was still early to get up. I had my shorts and my pajama's top, but I felt very uncomfortable. He said I need to help you to get dressed, I said, I can do it myself. He had no badge or any other identification. Then he said okay and left. I told the nurse (V8) right after breakfast. I believe she knows his name. I can recognize the nurse. She is very nice. She asked his name. I believe she found out his name and said she would report it. Today (10/24/23) she told me that she has already reported it. I'm nervous if he'll come back today or later. When I talk about this, I get nervous. I'm glad I talked to you. I'm not scared to be here, but I'm nervous about the incident. I want to be respected. I'm a woman and I believe he crossed the line when he uncovered me. As long as he doesn't approach me in the same way, and maybe he doesn't go to my room or say, I was wrong, I shouldn't have done that, acknowledges that, maybe, I'll be okay with him working with me again. He was black, bald, had no hair, average body, not thin, but not fat. A little taller than me, like 5'8. I've seen him before on this floor, but this was the first time this happened. He's never talked to me before. He had not provided any care for me before. On 10/24/23 at 10:55 am V2 (Assistant Administrator-AADM) says the abuse coordinator is the Administrator (V1). The surveyor asked if the reportable folders provided by the facility contained all the reportable incidents, V2 responds yes, these are all the reportable incidents we have. On 10/24/23 at 11:30 am V8 (Licensed Practical Nurse-LPN) states I work 4 days a week, 8 hours a shift, 7am to 3:30pm. I work Saturday, Sunday, Tuesday and Wednesday. On Saturday, as I was getting ready to leave, around 3:30 pm, R2 approached me and said that on Friday night a male CNA came to her room, snatched her cover off and told her to get up. She didn't say what time the CNA came in, but the way she said it was like it was early in the morning. She makes it sounds like it happened early in the morning, late Friday or early Saturday. She didn't give the time. It had to be in the morning, because why did he (CNA) want her to get up during the night? R2 does not need help getting up or getting dressed. R2 does everything herself. I went to find out who was the CNA working that Friday night. I asked security for the schedule. Once they showed me, he was the only male CNA working Friday night and he was bald and short, I figured out who he was. R2 had told me the CNA was short and bald. His last name starts with K. I told the resident that I was going to report it. I tried to find out who is on duty, as a manager. I knew that V1 (ADM) would come later in the day because she was the manager on duty. I wrote a note and slid it under V1's (Administrator's) door. I wrote down what R2 said happened. I didn't say the name of the CNA, but I wrote the name of the resident. V2 (Assistant Administrator) came in on Sunday morning and I told him the same thing R2 told me. He didn't say anything to me. Once I report it, I don't know what they do. R2 was calm, but said she wasn't feeling good about it. The CNA should first greet residents and then ask if they need help. I believe the CNA was new to the facility and did not know the resident. Even not knowing them, the CNA should have knocked on the door because it is a ladies' room, then he should have greeted them and then asked if they needed help. This morning I saw the Director of Social Services (V5) and reported the incident to him. It was about 2 hours ago. It is 11:32 am, and V8 describes the types of abuse saying: there is verbal abuse, seclusion, financial and sexual abuse. I don't know how to characterize this incident. I just leave it to the big people to characterize. Sexual assault is putting your hands on someone without their consent or a sexual act, period. R2 said the CNA made her uncomfortable. It still warranted me to find out who was the staff involved, because if it was sexual abuse, I don't want to have my residents having sexual abuse. The incident was out of character and that is what I reported. On 10/24/23 at 11:48 am V2 (Assistant Administrator) states I am familiar with investigating abuse. If the staff sees something or suspects any type of abuse, they should immediately take it to V1 (ADM) or me or V5 (Social Services Director- SSD) if they cannot contact V1. If anyone uncovers the resident without permission, staff should report it. The nurse told me that the staff went to the resident's (R2) room in the middle of the night and woke her up. I don't think it's okay. I wrote down the resident's name and was going to ask, but I didn't have the chance. We usually investigate right away, but it depends on what is reported to us. I probably should have investigated it right away. It didn't sound like abuse, but I should have investigated it. There is no investigation initiated at this time, not yet. The nurse was V8. I told V1 today. Honestly, I forgot to report this to V1. I didn't think much about it. It was just a resident complaining about someone waking them up during the night, I didn't think of it as abuse. On interview V2 says he is not aware about any allegations of abuse involving R1 and a staff member and denies any knowledge of an investigation being conducted regarding R1's sexual abuse allegation. On 10/24/23 at 12:08 pm V5 (SSD) sates I believe I did speak with the nurse (V8) today. V8 told that me I need to talk to R2, that maybe somebody pulled the covers off of the resident (R2). I'm not sure when. V8 told that R2 told her that somebody pulled the cover off her. I was still getting the information, trying to find out what exactly happened. Going back and talk to R2, talk to V8 to get her statement. If someone brings me any information, I will follow up and report it to the Administrator. I didn't do it because V8 told me she already told V1, DON and ADON. V5 says he is not aware about any allegations of sexual abuse involving R1 and denies any knowledge of an investigation being conducted regarding R1's allegation prior to this day. On 10/24/23 at 12:27 pm V6 (PRSC) was interviewed regarding R1's complaint. V6 states This happened a long time ago. It was not in September. R1 told me that a CNA came into her room in the middle of the night, and I guess he was supposed to give her care, you know turning her or changing her, I don't know. R1 didn't go to any details, and said she was not sure if the CNA had been inappropriate, but she felt like he was inappropriate. I did a concern form and gave it to V5. I give all my concerns to him. After that, the facility does an investigation into any residents who felt someone had been inappropriate. It wasn't specific because of this information; they were doing some kind of sweep of this area. R1 told me it was a male CNA. I can't say he was inappropriate. I think R1 came to me and said she wanted to talk to me, and said she wasn't sure if the CNA was inappropriate, but in the middle of the night he came in and stood by her bed. R1 said the CNA touched her, but I don't remember R1 saying that the CNA had touched her buttocks. R1 said she was not sure he had been inappropriate, but she felt he had been inappropriate. R1 didn't know who he was because it was late and dark. V6 says she had been trained on abuse allegations and says abuse can be sexual abuse, inappropriate touching and comments. V6 says if someone told me that staff touched her inappropriately yes, it is definitely a type of abuse and worth investigating. I thought I had reported it by doing the resident's concerns. If abuse is suspected or reported by a resident, I should call my supervisor. My supervisor is V5. I didn't call him. I did a concern form. I didn't call him because R1 said it was a CNA and she wasn't sure if he was inappropriate. That's on my part. I can't say it was abuse, but because she told me I should have told V5. The Administrator is the abuse coordinator. On 10/24/23 at 1:53 pm V5 states I spoke to V6 (PRSC) after she had spoken to you (surveyor), and she reported that there was a concern with R1 involving one of the CNAs. The concern is that R1 does not know whether the CNA was inappropriate in providing care to R1. V6 does not know when this information was received. V6 said she wrote it down in the concern form, but she doesn't know where it is. This was just brought to my attention, and I informed V1. The staff has to inform the abuse coordinator about suspected abuse and V1 will delegate who will investigate it. V1 will make the determination if it will be investigated, do a reportable, if it's abuse or not. V1 does the reportable. I believe that situation should have been reported to the Administrator because we don't know if it was abuse or not and the Administrator would do her due diligence. If the resident tells staff that other staff touched her inappropriately, it is an allegation of abuse and should have been reported to V1. On 10/24/23 at 2:46 pm V1 (Administrator) states, I see R1 all the time, she is in the lobby when I make my rounds, but she never said anything. I spoke with V6 today and she told me that R1 said something to her a month ago and that R1 was not clear of what happened. It was something about Activity of Daily Living/ADL. Then V1 says she will talk to V6 again to make sure she (V1) is getting the right information. V1 said she just learn today about this incident involving R1 and a staff member and that V6 had told her it was about ADLs. V1 states If anybody see's something that looks like abuse or suspected abuse, they should report it to me. Nobody told me R1 has reported being touched inappropriately. We are going to do the initial investigation about R1's allegation. It's unacceptable. Regarding the second incident identified during this investigation involving R2 and a staff member, V1 sates V2 (Assistant Administrator-AADM) told me today that R2 said that a CNA uncovered R2 and asked if R2 needed help getting dressed and that R2 had said no, and that the CNA had left the room. V2 said it was reported by the nurse on Sunday. I never got that incident report. V2 admitted to me that he was supposed to report it. Right now, we are doing the investigation. I'm going to do the initial investigation today, because it should be done ASAP. Any abuse allegation should be investigated right away or in 2 hours, and that is our policy, and it was not done. We had training a few months back for all staff about abuse. We had another one scheduled for October with a consultant, but he has been deployed to [NAME]. We had to reschedule it. I do the abuse training in-house as well. On 10/24/23 V3 (Director of Nursing) and V4 (Assistant of Director of Nursing) denied any knowledge of R1's sexual abuse allegation. On 10/26/23 at 09:00 AM V1 states I was here on Saturday (10/21/23), briefly. I came in. I did some rounds and stayed about an hour. I did not receive any note, I did not receive any call from any staff regarding R2 allegation. R1 told me that the CNA put his hands under her pampers. R1 did not say the CNA squeezed her buttock and made some comments. If a resident is feeling not comfortable, it has to be investigated, the staff suspended, and the resident made safe. The staff knows they have to report any suspected abuse. They are not to determine if there is abuse, they only have to report it. You not reporting things? Putting a note under the door? This is not what should be happening. Review of the reportable binders showed no investigation regarding R1's complaint, nor regarding R2's complaint that was identified during this investigation. The concerns log was reviewed from January 2023 to October 2023. There was no documentation of R1's allegation. V6 provided another batch of copies of concerns forms filled out by her and there is no documentation of this allegation being addressed. Asked where this concern form possibly would be, V6 says she doesn't know. R1 and R2's progress notes and event forms were reviewed and showed no documentation of the alleged abuse situation reported by R1 and R2 and whether it had been reported to the Administrator. All notes found were written after the facility became aware of the allegations during this investigation. Facility's abuse policy and procedure revised in 10/2022 reads: 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. And continues reads: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This will be done by: Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations pf abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; Filling accurate and timely investigative reports

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Involuntary Transfer and Discharge Process policy and failed to provide their bed hold policy upon discharge to hospital for one of one resident (R1), reviewed for involuntary discharge. Findings include: R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 2.8.2023 with diagnoses including but not limited to: Non-traumatic intracerebral hemorrhage in brain stem, Chronic obstructive pulmonary disease, Adult failure to thrive, and latent syphilis. R1's Petition For Involuntary/Judicial Admission dated 2.19.2023, completed and signed by V9 (LPN-Licensed Practical Nurse), documents in part: I assert that (R1) is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; I base the foregoing assertion on the following: 3:30 (PM) 2.19.23 The resident is agitated, noted experiencing mood distress, not easily redirected. Resident continues to yell at staff making threatening remarks. Staff continues to provide comfort counseling with poor response. On 8.16.2023 at 11:32 AM, surveyor spoke with R1 via telephone; the call took place at homeless shelter where resident currently resides with resident's case manager in attendance and on speaker. R1 said, The nurse, we ended up arguing. He came into my room, pulled the curtain. I said (to him) I know what you're doing. He hit me in the mouth. I told him to get the f*** away from me when he put his thing (penis) on me. I asked to speak with the police, they wouldn't let me. I was told that I would have to go to the hospital if I wanted to fill out a report (police). I told them, you can let me go AMA. R1 said she was not issued any IVD paperwork when she was petitioned to the hospital. R1 said I wanted to return to the facility. The doctor in the emergency room called the facility and was told they would not accept me back. The doctor in the emergency room said, we won't participate in whatever the facility is trying to do to (R1). I was told that they would keep me in the hospital in order to find placement to another facility. Emergency Department Progress Note written by V16 (Physician) on 2.19.2023 at 8:43 PM states in part, History of Present Illness, (R1) got into a verbal altercation with a nurse at the nursing home. The patient alleged the nurse slapped her in the mouth. Medical Decision Making Patient at this time is displaying very good understanding of the current situation, does not appear to be in acute psychosis. The allegations she made seem plausible. Patient is okay going back to the nursing home however when I spoke with nursing home nurse (V9) she states the patient cannot go back to that particular nursing home and V15 (Physician) wants (R1) admitted . Social admission for placement: Transferred to our hospital after she had a conflict and claimed she was hit by a nurse in the nursing home. The patient ('s) nursing home (is) hesitant to take the patient back because of behavioral issues. However, since the presentation (to ED) the patient did not show any signs of aggressiveness or abnormal behavior that would require any psychiatric evaluation at this moment. Patient showing good judgement and normal behavior. V16 was not available for interview. 8.16.2023 at 1:01, V9 (LPN-Licensed Practical Nurse) said, I was working at facility on 2.19.2023 and did the paperwork (petition) for R1. She was sent out. I believe she is the person who had something with a staff member. She made some allegations about the nurse. The PCP (Primary Care Physician) was called and wanted her sent out for a psych evaluation. Yes, that is correct, I did tell the hospital that we could not take her back. But I don't make that decision, it comes from higher up. I believe it was V2 (PRSD-Psychiatric Rehabilitation Service Director); I was in contact with him. On 8.18.2023 at 11:35 AM, V2 (PRSD-Psychiatric Rehabilitation Service Director) said, (R1) was petitioned out of the facility to (local hospital); she was not involuntarily discharged from the facility and did not receive involuntary discharge paperwork. I called the hospital on 8.24.2023 to follow up; I spoke with a Social Worker; she (Social Worker) said (R1) was no longer at the hospital and had been discharged to another facility. We would have accepted (R1) back after she was discharged from the hospital. On 8.18.2023 at 10:21 AM, V14 (NP-Nurse Practitioner) said, I don't remember the resident (R1). I don't remember the facility calling me about her. It's up to the discretion of the facility whether a resident will be accepted back (from the hospital). On 8.18.2023 at 9:45 AM, V15 (Physician) said, I don't remember (R1) or if hospital called me about (R1). It's a team approach (regarding petitioning a resident to the hospital). I go by what the staff tell me. If the decision is made to send the resident to the hospital, the resident is evaluated in the ED (Emergency Department) where the decision is made to admit or discharge (back to facility). Facility's Involuntary Transfer and Discharge Process policy (undated) documents in part: II. Discharge when facility is unable to meet the resident's needs. A. Emergency Transfer: Physical safety of resident, other residents, facility employees or visitors at the facility -State forms (Notice of ITD and Request for Hearing) must be given to the resident when at the time of Transfer. -A person initiating the discharge should write Emergency on the Notice of ITD form. -Need physician to confirm that the transfer was necessary (need physician's order). Reasons for discharge must be clearly documented in resident's medical record. -The resident has the right to return to the facility pending an appeal of any facility-initiated discharge unless the return would endanger the health or safety of the resident or other individuals in the facility. Facility must document the danger that the failure to transfer or discharge would pose. Facility's Bed Hold Policy Notification (undated), states in part: This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide their bed hold policy upon discharge to hospital for one (R1) of one resident reviewed for discharge. Findings include: On 8/10/23 at 11:30am, V1(Administrator) said, I am not aware of any abuse allegations involving R1. Residents are not denied to come back after involuntary petitions are given. R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 2.8.2023 with diagnoses including but not limited to: Non-traumatic intracerebral hemorrhage in brain stem, Chronic obstructive pulmonary disease, Adult failure to thrive, and latent syphilis. On 8/16/2023 at 11:32 AM, surveyor spoke with R1 via telephone. R1 said in part, she was not issued any paperwork, including the facility's bed hold policy, when she was petitioned to the hospital after an altercation with a nurse (V3-RN). R1 said, I wanted to return to the facility. Emergency Department Progress Note written by V16 (Physician) on 2.19.2023 at 8:43 PM states in part, History of Present Illness, (R1) got into a verbal altercation with a nurse at the nursing home. The patient alleged the nurse slapped her in the mouth. Medical Decision Making, Patient at this time is displaying very good understanding of the current situation, does not appear to be in acute psychosis. The allegations she made seem plausible. Patient is okay going back to the nursing home however when I spoke with nursing home nurse (V9) she states the patient cannot go back to that particular nursing home and V15 (Physician) wants (R1) admitted . Social admission for placement: Transferred to our hospital after she had a conflict and claimed she was hit by a nurse in the nursing home. The patient ('s) nursing home (is) hesitant to take the patient back because of behavioral issues. However, since the presentation (to ED) the patient did not show any signs of aggressiveness or abnormal behavior that would require any psychiatric evaluation at this moment. Patient showing good judgement and normal behavior. V16 (Hospital Physician) was not available for interview. On 8/16/2023 at 1:01pm, V9 (LPN-Licensed Practical Nurse) said, I was working at facility on 2.19.2023 and did the paperwork (petition) for R1. She was sent out. I believe she is the person who had something with a staff member. She made some allegations about the nurse. The PCP (Primary Care Physician) was called and wanted her sent out for a psych evaluation. Yes, that is correct, I did tell the hospital that we could not take her back. But I don't make that decision, it comes from higher up. I believe it was V2 (PRSD-Psychiatric Rehabilitation Service Director); I was in contact with him. R1's Progress Note, written by V4 (RN) on 2.19.2023 at 7:10 PM, documents in part, Petition FOR INVOLUNTARY/JUDICIAL admission papers given to ambulance staff. No documentation is found regarding the facility's bed hold provided to resident. Facility's Bed Hold Policy Notification (undated), states in part: This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one resident (R1) of one reviewed for discharge. Findings include: On 8/10/23 at 11:30am, V1(Administrator) said, I am not aware of any abuse allegations involving R1. Residents are not denied to come back after involuntary petitions are given. R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 2.8.2023 with diagnoses including but not limited to: Non-traumatic intracerebral hemorrhage in brain stem, Chronic obstructive pulmonary disease, Adult failure to thrive, and latent syphilis. On 8/16/2023 at 11:32 AM, surveyor spoke with R1 via telephone; the call took place at a homeless shelter where R1 currently resides. The doctor in the emergency room called the facility and was told they would not accept me back. The doctor in the emergency room said, we won't participate in whatever the facility is trying to do to (R1). I was told that they would keep me in the hospital in order to find placement to another facility. On 8/16/2023 at 1:01pm, V9 (LPN-Licensed Practical Nurse) said in part, Yes, that is correct, I did tell the hospital that we could not take her (R1) back. But I don't make that decision, it comes from higher up. I believe it was V2 (PRSD-Psychiatric Rehabilitation Service Director); I was in contact with him. On 8/18/2023 at 9:45 AM, V15 (Facility Physician) said, I don't remember (R1) or if hospital called me about (R1). It's a team approach (regarding petitioning a resident to the hospital). I go by what the staff tell me. If the decision is made to send the resident to the hospital, the resident is evaluated in the ED (Emergency Department) where the decision is made to admit or discharge (back to facility). On 8/18/2023 at 10:21 AM, V14 (NP-Nurse Practitioner) said, I don't remember the resident (R1). I don't remember the facility calling me about her. It's up to the discretion of the facility whether a resident will be accepted back (from the hospital). On 8/18/2023 at 11:35 AM, V2 (PRSD-Psychiatric Rehabilitation Service Director) said, I called the hospital on 8.24.2023 to follow up; I spoke with a Social Worker; she (Social Worker) said (R1) was no longer at the hospital and had been discharged to another facility. We would have accepted R1 back after she was discharged from the hospital. Emergency Department Progress Note written by V16 (Emergency Department Physician) on 2.19.2023 at 8:43 PM states in part, Medical Decision Making, Patient at this time is displaying very good understanding of the current situation, does not appear to be in acute psychosis. Patient is okay going back to the nursing home however when I spoke with nursing home nurse (V9-LPN) she states the patient cannot go back to that particular nursing home and V15 (Physician) wants (R1) admitted . Social admission for placement: Transferred to our hospital after she had a conflict and claimed she was hit by a nurse in the nursing home. The patient ('s) nursing home (is) hesitant to take the patient back because of behavioral issues. However, since the presentation (to ED) the patient did not show any signs of aggressiveness or abnormal behavior that would require any psychiatric evaluation at this moment. Patient showing good judgement and normal behavior. V16 was not available for interview. Facility's Bed Hold Policy Notification (undated), states in part: Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room.

Based on interviews and record reviews, the facility failed to ensure 1 [R7] of 3 [R4, R10] residents responsible family members were notified of facility acquired wounds. Findings include: Reviewed R7's wound care notes dated from 3/2023 to 6/2023. They indicate facility acquired wounds and worsening of wounds, with no responsible party notified of changes in skin conditions. On 6/22/23 at 11:04 AM, V2 [Director of Nursing] stated, There is no documentation that R7's family was made aware of the facility acquired stage-3 left lateral heel wound noted on 3/15/23, sacrum area with moisture associated skin damage on 3/8/23, or worsening of the wound on 6/21/23, categorized as facility acquired wound stage 4 pressure ulcer, or worsening of a stage 3 pressure wound. Families should be made aware of any change of conditions and documented in the resident's progress notes. My expectations of the nurses to notify the family and document immediately or at least before the shift ends. The wound nurse or the staff nurse should notify the family of any skin alterations. R7's clinical record documents in part; diagnosis: Chronic embolism and thrombosis of unspecified deep veins of left lower extremity, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Bipolar disorder, Pressure ulcer of right hip, stage 4, Encysted hydrocele, Personal history of COVID-19. R7's minimum data set [MDS] Brief Interview Mental Status score= 99. Indicates R7 is severely cognitively impaired. Policy: Documents in part; Notification of resident change of condition dated 11/2016 -Promptly notify the resident, their legal representative and attending physicians of changes in the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R158's admission record includes but not limited to diagnoses of Diabetes, schizoaffective disorder, and convulsions. R158's (2/20/23) BIMS (Brief Interview of Mental Status) documents a score of 15 (Cognitively intact). On 5/15/23 at 12:25 pm R158 stated, The activity aide (V18) accused me of stealing cigarettes in front of other residents in the day room. I went out on a pass and took my cigarettes with me. When I came back from the pass, I went down for a smoke break and V18 told me to grab a smoke off the table. V18 accused me of stealing cigarettes. I told V18 to look at the camera. R158 stated I did not appreciate being called a thief, I am not a thief or a liar. I got upset because V18 stated I stole something in front of other residents and that was humiliating to me (R158). On 5/16/23 at 11:35 am V14 PRSD (Psych Rehab Service Director) stated that R158 when out on a pass and got his cigarettes. When R158 came back to the facility R158 did not turn his cigarettes back into the smoke monitor staff. R158 got upset because someone accused him of stealing. V14 stated that R158 was so upset, and no one could talk to R158 at that time. On 5/16/23 at 12:53 pm V17 Activity Aide stated, when R158 returned to the facility from a pass,R158 did not turn in his cigarettes to the staff and preceded back to his room. When R158 came down for a cigarette break, V18 (Activity Aide) said that R158 did not return his cigarette when R158 returned to the facility. Then V18 said to R158 you are trying to get a facility cigarette so you can keep your cigarettes, so that's stealing. In the day room there was about 7 or 8 residents that heard V18 say you stole the cigarette. V17 stated that R158 said I did not steal any cigarette I didn't have any left when I came back to the facility, I'm not a theif, and I do not appreciate being called that. V17 stated that R158 stated run the camera back if you don't believe me, and I will accept whatever punishment that comes with it. Put me out if that's the punishment. R158 stated that R158 pulled out his phone and said he's reporting this to the state. V17 stated that V18 behavior was not appropriate, the staff is not supposed to say a resident is stealing in front of other residents. V17 stated that V18 was supposed to tell the Social Service Director and not confront the resident. On 5/17/23 at 11: 35 am, V18 Activity Aide, stated R158 came down for a cigarette break, I told R158 to grab a cigarette off the table then remembered that when R158 came back from his pass, R158 did not turn his cigarettes back in. V18 stated, I told R158 that he did not turn his cigarettes back in. V18 stated that R158 stated I did not give him any cigarettes. R158 kept calling me a liar. V18 stated I never told R158 that he stole the cigarettes. R158 was saying to run the cameras back. There were other residents in the room when this incident happened. On 5/17/23 at 2:00 pm V1 Administrator stated, the smoke monitor alleges that R158 was given his cigarettes when he went out on a pass and did not return them. V1 stated, I heard R158 and V18 (activity Aide) going back and forth. They were not agreeing with each other. R158 felt like V18 was calling him a liar. This incident happened in the dining area and other residents were there. V1 stated the situation should have been moved to another area, not in an open area. Facility Dignity policy was not presented after multiple requests from the surveyor. Based on observation, interview and record review, the facility failed to ensure that one resident's (R139) urinary catheter drainage bag was covered with a privacy cover and failed to provide dignity for one resident (R158) who was accused by facility staff of stealing in the presence of other residents, resulting in R158 feeling humiliated. These failures affected two residents (R139 and R158) in a sample of 58 residents. Findings include: On 5/16/2023 at 10:52 am R139's urinary catheter bag was observed hanging off the bed frame on the left side of R139's bed. R139's bed is the first bed upon entering the room and the urinary catheter drainage bag was visible upon walking past R139's room door when the door was open. On 5/16/2023 at 11:41am this observation was brought to the attention of V16 (RN/Registered Nurse). V16 stated the cover for the urinary catheter bag comes snapped to the bag. V16 stated the Certified Nursing Assistant must have taken the cover off the urinary catheter bag. V16 stated the Certified Nursing Assistant is to make sure the privacy cover is on the urinary catheter bag. V16 stated the bag is used to cover the urine in the bag, anyone walking past the resident's room does not want to walk past and see urine in the bag. V16 stated most residents are embarrassed about having a urinary catheter. On 5/17/2023 at 1:13pm V2(DON/Director of Nursing) stated there should be a privacy cover on the urinary catheter bag. V2 stated the nurses are responsible for making sure a privacy cover is on the urinary catheter bag. V2 stated the purpose of the privacy cover for the urinary catheter bag is to provide privacy for the resident. R139's Face sheet documents that R139 has diagnosis that include, but are not limited to, Unspecified Mental disorder due to known physiological condition, encysted hydrocele, hypertensive heart disease without heart failure. R139's MDS (Minimum Data Set) dated 4/21/2023 documents in Section C. C1000. Cognitive Skills for Daily Decision Making is scored a 3 indicating severely impaired-never /rarely made decisions. R139's MDS dated [DATE] documents in Section H. HO100. Appliances A. Indwelling catheter and HO200. Urinary Continence 9. Not rated, resident had a catheter (indwelling, condom) urinary ostomy, or no urine output for the entire 7 days. Reviewed the undated Contract Between Resident and Facility Attachment G: Statement of Resident Rights which documents, in part, No resident shall be deprived of any rights, benefits or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community, nor shall a resident forfeit any of the following rights: 2. The right to respect for bodily privacy and dignity at all times, especially during care and treatment.

Based on observation, interview and record review, the facility failed to ensure a safe and functional homelike environment for one resident (R76) out of 7 residents reviewed in the total sample of 58 residents. Findings include: On 5/15/23 at 11:33 AM, R76, who was noted to be hunched over when ambulating, was observed attempting to hang his (R76) jacket inside the closet in his (R76) room but was having difficulty due to one of the sliding closet doors being noted off the hinges and fallen into the closet onto the clothes. R76 stated, It is broken. It does make it difficult. The surveyor inquired how long the closet door has been this way. R76 replied, Long time. Probably before I (R76) came in the room. On 5/15/23 at 11:47 AM, this observation was brought to the attention of V30 (Maintenance Director) who stated, It's off the hinges. I'll fix it right now. On 5/17/23 at 2:55 PM, V1 (Administrator) stated, They could get hurt by that. There could be an injury. V1 added that maintenance does rounds daily so she (V1) would expect the fallen closet door to be replaced or repaired. R76's Face Sheet documents diagnoses including but not limited to spondylosis without myelopathy or radiculopathy, lumbosacral region; schizoaffective disorder and chronic obstructive pulmonary disease. R76's 4/5/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating that R76's cognition is intact. The 10/1/22 Environment of Care Policy documents, in part, Policy: It is the policy of this facility to provide an environment of care for the resident, which is safe, functional, effective and as near a home-like environment as possible. The Director of Maintenance job description documents, in part, Makes daily rounds to ensure that maintenance personnel are performing required duties and ensure that appropriate maintenance procedures are being followed to meet the needs of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that an accurate Community Access Observation was complete for one resident (R45), who was reviewed for timely and accurate assessments. This failure has the potential to affect all residents that reside at the facility. Findings include: R45 is [AGE] year old with diagnosis including but not limited to: History of COVID, Type 2 Diabetes Mellitus, Hyperlipidemia, Gastro-esophageal reflux disease and weakness. R45 has a BIMS (Brief Interview for Mental Status) Score of 15, which indicates cognitively intact. R45's face sheet documents an original admission date of 3/11/2009. On 5/17/23, R45 was observed sitting in the day room. Surveyor inquired about how R45's day was going. On 5/17/23 at 10:30 am, R45 said, They treat me like a slave in here (referring to the facility). My rights have been violated. I can't come and go as I please. I have been here for about 14 years, and can't get a grounds pass. I lost my grounds pass over 10 years ago and this place won't give it back to me. I can't even remember why I lost the pass but it was for a stupid reason. They won't even tell me why I can't have a grounds pass. I'm ready to get out of this place and move on my own. The only time that I can leave this place is when my family signs me out. I have not violated any laws and I haven't posed any threat to myself or anyone else. I feel like I'm in prison here, so I try to sleep the day away most of the time. I am depressed and feel like my rights have been violated. I'm [AGE] years old and they treat me like a child in here. I am in the ADAPT Program here but can rarely make the groups because it is hard to even get off of the unit. I can barely get an elevator in this building because they are always full. On 5/17/23 at 11:45 am, V30 (Qualified Mental Health Practitioner/ QMHP) said, I work for ADAPT, which is a program that contracts with nursing homes and facilities in the State of Illinois. I am familiar with R45, I am his case worker. Surveyor inquired about R45's grounds pass status and the reason for R45 not being allowed a grounds pass. V30 said, It was quite a while ago when R45's grounds pass was taken. R45's pass was taken many years ago. I can't quite remember why R45's pass was taken but I believe it had something to do with R45 attempting to register for school and applying for some type of financial aid without informing the facility. I am not sure if R45 has been re-evaluated for a pass. I believe it is the Social Service Department here that re-evaluates the residents for passes. I think that R45 would be a good candidate to transition out of this facility and move on his own into an apartment. I don't have any worries about R45 doing his best to stay stable when living on his own. If he is safe enough to live on his own, he is certainly safe enough to go out into the community alone. On 5/17/23 at 2:15 PM, V27 (PRSC/ Psychiatric Rehab Services Coordinator) said, I am relatively new here. I'm not too familiar with R45. When I completed R45's Community Access assessment, I went off of his previous record. I based R45's Community Access Observation assessment (completed 5/4/2023) on the previous assessment (completed 11/10/2022 by a previous employee). I (V27) am new and am still learning. Surveyor asked if V27 believe that R45 had physical or cognitive barriers. V27 said, No, R45 does not have any physical or cognitive barriers. He is fine whenever I talk to him. Surveyor inquired about why the 'Navigation of Community' Section of the Community Access assessment was not complete since R45 has no physical or cognitive barriers. V27 said, I'm not sure why the Navigation of Community section was not complete. I just went off of his previous assessment and used the information from that assessment to complete his new assessment. Surveyor inquired about how V27 can document that: R45 is not able to participate in this Community Access Observation; and R45 may not access the community independently related to safety factor. V27 said, I know it is not an accurate way to assess a resident by going off of a previous assessment. I cannot say that R45 is unsafe to access the community independently. No, I cannot say that the assessment is correct (referencing the Community Access Observation dated 5/4/23). On 5/17/23 at 2:58 PM, V14 (Psychiatric Rehab Service Director/ PRSD) said, I am familiar with R45. I have not assessed R45 though. I (V14) can't say that he (R45) is not safe to navigate the community independently. I have not seen any behaviors in the facility. I am not sure why R45's grounds pass was taken. I've only been in this facility since January 2023. Surveyor presented V14 with R45's Community Access Observation dated 5/4/23 and asked V14 if the assessment appeared to be correct and complete. On 5/17/23 at 3:05 PM, V14 said, No R45's Community Access assessment is not complete. No, we are not supposed to solely base our assessments off of the previous assessment. This assessment is not based on all of the facts (referring to the 5/4/23 Community Access assessment). If he (R45) was not assessed properly, no I (V14) cannot say that he (R45) is unsafe to go out into the community. On 5/18/23 at 10:45 am, V36 (ADAPT Program Director) said, I wasn't aware that R45 was taken out into the community and assessed for a grounds pass. Usually, I would know. I don't feel that R45 is a threat to himself or others. I believe that R45 would be safe in the community independently. R45's Community Access Observation completed by V27 and dated 5/4/23 documents, R45 refuses to work with staff on improving skills of independent living, and R45 may not access the community independently related to safety factor. R45's Community Access Observation completed by V34 (previous employee) and dated 11/10/2022 documents, R45 refuses to work with staff on improving skills of independent living, and R45 may not access the community independently related to safety factor. R45's Community Access Observation completed by V35 (previous employee) and dated 8/17/2022 documents, R45 refuses to work with staff on improving skills of independent living, and R45 may not access the community independently related to safety factor. Facility policy titled Community Access policy, documents, If a resident is deemed not capable of possessing an unsupervised pass by the IDT (Inter-Disciplinary Team), the resident will be informed of the reasoning behind the decision. PRSD or designee will discuss with the resident the skills that require improvement in order to earn an independent pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to check placement of the Gastrostomy tube (G-tube), failed to check residual amount of enteral formula and failed to administer medications in accordance with Professional Standards for one resident R26. This failure affected one resident (R26) out of a sample 5 residents. Findings: R26 is a [AGE] year-old male with a diagnosis of Polyosteoarthritis, Schizoaffective disorder, Type 2 diabetes Mellitus, Chronic Respiratory failure with hypoxia, Gastrostomy Malfunction, and Dysphagia. R26 has a Brief Interview of Mental Status of 15 that indicates cognitively intact. On 5/15/2023 at 9:44am, surveyor observed V29 (LPN) crush R26's medications (Chlorpromazine HCL 200mg, Cyclobenzaprine tab 5mg and Finasteride tab) together and pour into one cup. Surveyor also observed V29 mix R26's Omeprazole and liquid Famotidine together and pour into one cup without cleaning and storing the medication syringe in a plastic bag. On 5/15/2023 at 9:57am V29 stated that he was to follow doctor's orders, use a stethoscope to check for g-tube placement and use a 60ml catheter-tipped syringe to check for residual of enteral feeding, but he did not have a stethoscope on the medication cart and that medications should have been administered separately. V29 said, no, I should not have given them (R26's medications) together and I should have flushed between each medication given via R26's g-tube. On 5/17/2023 at 9:50am surveyor observed V29 flush R26's g-tube with 50 ml of water but V29 did not check for g-tube placement or residual amount. On 5/17/2023 at 9:51am surveyor observed V29 administer R26's crushed medications via g-tube. At 9:53am surveyor observed V29 administer R26's mixed solution of Omeprazole and liquid Famotidine via g-tube. V29 did not flush with water between giving R26's medications. On 5/17/2023 at 10:23am V3 (Assistant Director of Nursing-ADON) stated nurses are supposed to follow the doctors' orders, check for g-tube placement by using a stethoscope, check for residual enteral formula and the medication must not be given together. V3 stated that the doctors' orders should be followed, and each medication must be given separately, and the nurse should flush with water after each medication is given via g-tube. On 5/17/2023 at 2:45pm V2 (Director of Nursing) stated check for g-tube placement, residual enteral feeding, elevate head of bed to 30 to 45 degrees, and check g-tube for patency by flushing. V2 stated that g-tube medications must be given separately, and the nurse must flush the g-tube after administering medications. On 5/18/2023 at 11:00am V2 stated nurses are expected to follow the doctors' orders and nurses are expected to clean and store medication syringe in a plastic bag for infection control. R26's Physician Order Report dated 4/17/2023-5/17/2023 documents check enteral feeding tube placement every shift and check enteral feeding tubing for residual. Policy titled Enteral Tube Medication Administration with an effective date of 10/25/2014 documents, in part, the facility assures the safe and effective administration of medications via enteral tubes, check for proper tube placement using air and auscultation only, check gastric content for residual feeding and flush with 5-10ml warm water between each medication. Undated Job description for LPN/Charge Nurse documents, in part, provide licensed care to assigned residents as ordered by physician and in accordance with facility, federal, state and local standards, guidelines and regulations, and ensure that equipment is on hand to meet the nursing needs of the residents.

Based on observation, interview and record review, the facility failed to label and date oxygen tubing per the facility policy. This failure affected one resident (R46) reviewed for oxygen equipment, in a total sample of 58 residents. Findings include: On 5/16/23 at 10:59am, surveyor observed R46 in bed awake and alert. R46 was observed with 2 liters oxygen via nasal cannula tubing in place unlabeled and not dated. When R46 was asked regarding R46's nasal cannula oxygen tubing, R46 stated, The nurse came in to change the tubing on yesterday (referring to 5/15/23). On 5/16/23 at 11:41am V16(RN/Registered Nurse) stated the nurse is to put a sticker on the oxygen tubing with the date the oxygen tubing was changed. V16 stated I usually place a piece of tape with the date the oxygen tubing was changed. V16 stated the nurse is responsible for changing the oxygen tubing every week or as needed. V16 stated the change of the oxygen tubing is usually done on the 3pm to 11pm shift. On 5/17/2023 at 1:13pm V2(DON/Director of Nursing) stated the nurses are responsible for changing the oxygen tubing. V2 stated the oxygen tubing should be changed every seven days, at least weekly. V2 stated the nurses should label and place a date on the label indicating the date the oxygen tubing was changed. R46's Face Sheet documents that R46 has a diagnosis that includes, but not limited to chronic obstructive pulmonary disease, chronic diastolic(congestive) heart failure and pulmonary hypertension. R46's Brief Interview for Mental Status (BIMS) dated 04/06/23 documents that R46 has a BIMS score of 14, which indicates that R46 is cognitively intact. R46's Physician Order Report dated 05/17/23 documents, in part, Oxygen 2L(liters) via nasal cannula PRN (as needed). R46's Physician Order Report dated 05/17/23 documents, in part, change O2(oxygen) tubing, oxygen water bottle and mask every Saturday 3pm-11pm once a day on Saturday 5:00pm. The facility's policy dated 10/01/2022 and titled Equipment Change Schedule Policy documents, in part, The facility shall have a schedule for changing disposable equipment at regular intervals as determined by the manufacturer's recommendations. Nasal Cannula-on admission and weekly (Monday) and PRN (as needed).

Based on observation, interview, and record review, the facility failed to maintain the walls and base boards of the fourth-floor dayroom, shower room, and hallway in good repair. This failure has the potential to affect all 29 residents on the fourth floor. Findings include: On 5/15/23 at 10am during the entrance conference, V1(Administrator) presented the facility's census that shows that 29 residents live on the fourth floor. On 5/16/23 between 11am and 1pm during observation of residents on the fourth floor, the following were observed: Dayroom/Dining Room radiator cover was broken, and the broken piece was left on the floor by the radiator close to one of the dining tables where residents were sitting. Broken drywall in the dining room; Peeling paint at the hallway entrance to rooms 403, 407, 410, and 411; Broken drywall and broken base board at the entrance to the shower room. On 5/17/23 between 10am and 11:45am, the above listed maintenance issues remained the same. On 5/17/23 at 11am, V30(Maintenance Director) was interviewed regarding the above listed issues. V30 stated that he(V30) would ensure that the repairs are completed. The surveyor mentioned to V30 to remove the broken piece of the radiator cover as soon as possible, and V30 stated he would do it right away. Facility's policy titled Preventative Maintenance with effective date 10/1/2022 states: To assure that all equipment included in the preventative maintenance program includes testing, maintenance and repair information at the established intervals. The maintenance department checks for preventative maintenance program equipment work orders and evaluates and repairs the malfunction described. Facility's document Director of Maintenance Job Description states in part Assists in establishing a preventative maintenance program. Makes daily rounds to ensure that maintenance personnel are performing required duties and ensure that appropriate maintenance procedures are being followed to meet the needs of the facility. Complete carpentry and other building repairs within the scope of expertise.

Based on observation, interview and record review, the facility failed to follow proper food storage practices and label/date food items; failed to ensure staff's personal food items were not stored in the kitchen; failed to ensure the cleanliness of the stand-alone freezer; and failed to follow proper sanitation guidelines to prevent foodborne illness. These failures have the potential to affect all 173 residents receiving a meal tray from the kitchen. Findings include: On 5/15/23 at 10:04 AM, the garbage can under the hand-washing station sink had no trash bag in place. V8 (Dietary Director) stated that there should be a trash bag in the trash can to prevent a mess, bugs, and smell. On 5/15/23 at 10:08 AM, the stand-alone freezer in the kitchen appeared dirty with visible splash marks on the outside doors. Inside the freezer were 7 individual scoops of vanilla ice cream in small foam bowels wrapped with clear, plastic wrap that were not labeled. V8 stated, They didn't put the date on it. V8 added that there should be a label on the food item to indicate the date it was opened or prepared and when it should expire. The surveyor inquired about the cleanliness of the freezer. V8 stated, It's dirty. I'll clean it myself. On 5/15/23 at 10:14 AM, the surveyor observed V9 (Dietary Aide) wearing disposable gloves while loading the dirty dishes onto a dish rack. At 10:16 AM, the surveyor observed V9 using the same gloves to remove the clean dishes from the rack. V8 stated, She's (V9) supposed to change gloves. V8 added that the reason for changing gloves is to prevent cross-contamination of germs from the dirty plates onto the clean plates. On 5/15/23 at 10:19 AM, upon entry into the dry storage room, the surveyor observed V8 taking items off the shelf. V8 stated that it was personal items. The surveyor observed V8 holding a plastic bag with food and a personal water bottle. V8 stated that the items should be stored in the staff's locker. On 5/15/23 at 10:21 AM, three brooms were noted lying in between two bulk containers of cereal. V8 stated that the brooms should not be in the dry storage room as there is a rack for them in the kitchen. On 5/15/23 at 10:25 AM, the surveyor observed a cup of Greek yogurt and a bottle of pop that had a label with a dietary aide's name on it in the walk-in cooler. V8 took the items and stated that personal food items should not be stored in the refrigerator. A crate of approximately 10 milk cartons was observed sitting on the floor of the walk-in cooler. V8 again affirmed that personal food items should not be kept in the cooler. V8 added that there should not be anything stored on the floor of the cooler due to infection control. On 5/15/23 at 10:28 AM, two plastic water bottles were observed in the walk-in freezer. On 5/16/23 at 10:56 AM, V8 stated that there is no policy for personal food in kitchen because, They ain't supposed to do that. On 5/17/23 at 9:42 AM, the surveyor observed V23 (Cook) using a moist, cloth-like towel that was sitting on top of the table to wipe down the table after pureeing chicken and green beans. The surveyor asked to test the sanitization bucket (sani-bucket) water to check for the appropriate concentration of sanitizing solution used to wipe the table. V8 went over to the sink and grabbed a green bucket that was empty. The surveyor inquired what V23 was wiping with if the sani-bucket was empty. V23 stated that the disposable cloth sometimes has a little soap on it. On 5/17/23 at 3:05 PM, V11 (Assistant Dietary Manager) stated that the sani-buckets should be filled, In the morning when they first come in and then they change the water as needed. V11 added that the risk of not wiping surfaces with the correct sanitizing solution is that Somebody can get sick, bacteria can grow on the tables, anything. The surveyor inquired if the disposable cloth should have sanitizing solution on it when wiping an area that may have food remnants from pureeing. V11 replied, Yes. On 5/18/23 at 10:19 AM, V1 (Administrator) confirmed that there is one resident in the facility who currently does not receive a meal tray from the kitchen. The facility census as of 5/15/23 lists 174 residents. The Kitchen Daily Cleaning Schedule and the Thursday Cleanup List were reviewed and neither include cleaning the freezer. The 2011 Food Storage (Dry/Refrigerated/Frozen) policy documents, in part, Wrap food properly. Never leave any food item uncovered and not labeled .when freezing food that has been prepared on site, ensure clear labeling of the item .six inches off the floor to allow for proper sanitation. The 2011 Sanitation Solution policy documents, in part, Guideline: Employees shall refer to the manufacturer guidelines for the proper use of sanitizer solution .6. This solution can be used for sanitizing equipment and food contact surfaces. All rags used for sanitizing must be kept in sanitizing solution when not in use. The revised 10/1/22 Cleaning Schedule policy documents, in part, To maintain a clean working department, the food service department will have a cleaning schedule identifying cleaning tasks, staff to complete the work and day work is to be completed. The 10/1/22 Garbage Disposal policy documents, in part, Purpose: To prevent odors, minimize breeding places for insects and rodents, and keep service areas clean .3 .Use garbage bags liner in the garbage cans.

Based on interview and record review, the facility failed to ensure that facility staff receive behavioral health training to safely and effectively respond to residents' behaviors and failed to have a process in place to track staff's participation in the training. These failures have the potential to affect all 124 residents in the facility who have diagnoses of SMI (Serious Mental Illness). Findings include: On 5/15/23 at 10:35am, V1(Administrator) presented the facility's census as 174 residents. Also, on 5/17/23 at 2:26pm, V14(Social Services Director/PRSD-Psychiatric Rehabilitation Services Director) presented a list of 124 residents out of the 174 residents that have diagnoses of severe mental illness (SMI) with behaviors. On 5/17/23 at 2:45pm, V1 presented the facility's records of resident-to-resident physical altercations within the past 3 months. A review of these records showed that there were seven residents to resident physical altercations between 1/9/23 and 4/7/23. V1 was asked if she(V1) thinks that Behavior Health Training could help reduce the incidents; V1 responded that more training will definitely help. V1 added that the facility gives abuse training to staff and will find the records of staff attendance. On 5/17/23 at 1:05pm, V27(PRSC-Psychiatric Rehabilitation Services Coordinator) was interviewed regarding individualized approach to help manage residents with aggressive behaviors to prevent them from being aggressive towards other residents. V27 stated that he(V27) has been at the facility for only 3 months and not yet familiar with some of the residents. Regarding Behavior Health Training, V27 stated that he has not had any such training. V27 stated that he(V27) had CPI from another facility. On 5/17/23 at 1:10pm, V28(PRSC) was asked the same question. V28 stated that he's been at the job for about 4 months and has not had any behavior health training. On 5/17/23 at 1:11pm, V14(Social Services Director/PRSD-Psychiatric Rehabilitation Services Director) was interviewed about the role of behavioral health training in helping staff who care for a large population of residents with mental health diagnoses and behavior issues. V14 stated I know some staff have CPI training from another facility. V14 was asked why the training is important for staff that work in a facility like this; V14 stated: The training helps staff to know how to prevent injury to both staff and residents. V14 was asked about the required trainings for staff to reduce the frequency of resident injuries during behavior escalation and physical altercations involving residents at the facility. V14 responded that all staff are supposed to have training and they would start to work on it. On 5/17/23 at 12:30pm, V1(Administrator) was asked about how many of the staff members have any kind of behavior health training, apart from abuse prevention training, and V1 responded that there was a training last year on behavior health, but not sure where to find the records of the staff who attended. On 5/17/23 at 1:45pm, V4(Human Resources Director) was interviewed about the records of Behavior Health training. V4 stated I only keep the records of staff training that are done upon hire and have the records for the COVID-19 training for staff. I am not sure who is supposed to track the Behavior Health Training. But I think I will start to keep the records and track to know who is missing which training. Facility's undated documents titled social services designee job description states: assist in the development of a participate in regularly scheduled orientation and in service training programs in relation to the social, emotional, and medical needs of the residents. Facilities documents titled Job description for Director of Social Services states in part: Develop and participate in the planning, conducting, scheduling of timely and service training classes that provide instructions on how to do the job, and ensure well educated social services department. Facility's undated policy titled Orientation and in service training policy was reviewed. This policy states: it is the policy of this facility to ensure competency of each employee by providing orientation and continuing education in service programs for all employees which are planned and conducted for the development and improvement of skills, and clothing training related to problems in specific job assignment. #1 states: The facility makes every attempt to abide by all appropriate state and federal requirements specified regarding orientation and in-service training, as well as any additional requirements mandated by the corporation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assure the right of the resident to be free from abuse in 1 (R2) of 3 residents in the sample (R1, R2 and R3) . Facility failed to prevent mental abuse of the resident. Findings include: R2 is a [AGE] year-old male resident with a diagnosis including Schizoaffective Disorder bipolar type and Diabetes Mellitus. R2 was admitted to the facility 7/16/20. R2 has a BIMS of 15/15. Review of facility abuse allegation investigation shows on 1/12/23 the facility investigated an allegation of mental abuse of R2. On 1/12/23, R2 made an allegation of mental abuse against V4 (Housekeeper). R2 stated that V4 gave him the middle finger because he is always annoying him while he is working. The facility investigated the alleged incident and V4 was terminated. On 2/3/23 10:20AM V1 (Administrator) stated that the allegation of mental abuse from the staff was verified, and the housekeeper was terminated. We followed our abuse prevention policy/procedure. On 2/3/23 V5 (Maintenance Director) stated V4 gave the finger to R2. It happened on 1/12/23. We checked the camera. It was on camera. He admitted it. He stated I'm tired of R2. He showed no remorse, so we let him go. He is terminated. I called him days later to find out why he did this. He was here for 15 years. On 2/3/23 2:22PM R2 stated I was telling the housekeeper (V4) how to mop the floor. V4 gave me the finger. I don't know why. They saw it on camera. He's gone now, he got fired. It didn't bother me that he gave me the finger. I just reported it because he did it. Facility policy titled Abuse Prevention Policy includes the statement, 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.