Based on interview and record review, the facility failed to ensure the services of a Registered Nurse for 8 consecutive hours per day, 7 days a week. This has the potential to affect all 32 residents living at this facility.The facility's Nursing schedule for August and September 2025 revealed the facility did not have 8 consecutive hours of RN (Registered Nurse) coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25.On 9/9/2025 at 8:50am, V1 (Administrator) said the facility did not have the required 8 hours of continuous RN coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25.On 9/8/2025 at 11:00am, V2 (Director of Nursing) said she realizes the facility does not have 8 continuous hours of RN coverage during the weekends. V2 said the facility is actively advertising to hire more Registered Nurses to meet the requirement. V2 said V8 (RN) was the only RN providing RN coverage on 9/6/25 and 9/7/25, but V8 only worked 4 hours each day. V2 agreed the facility did not have the required 8 consecutive hours or RN coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 and 8/9/25.On 9/8/2025 at 1:00pm, V8 (RN) said she worked on Saturday, 9/6/25 and Sunday, 9/7/25, due to the facility having residents with IV (intravenous) therapy going, but she only worked 4 hours per day. V8 said no other Registered Nurses worked over the weekend.The facility's matrix with print date of 9/8/25 documented 32 residents reside at this facility.Facility policy titled Staffing, Sufficient and Competent Nursing (dated 2001) documents the following in part: Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 3.) A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (R1 and R6) of 3 residents reviewed for abuse in the sample of 9.1. R1's admission Record documented an initial admission date to the facility on [DATE] and included diagnoses of hemiplegia affecting left nondominant side, chronic obstructive pulmonary disease, asthma, type 2 diabetes mellitus, morbid obesity, osteoarthritis, obstructive sleep apnea, disorder of prostate, generalized anxiety disorder, major depressive disorder, calculus of ureter, and abdominal pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/01/2025, R1 reported that V4 (Licensed Practical Nurse/LPN) spoke inappropriately to him. V4 was sent home, and investigation immediately initiated.A typed letter dated 08/08/2025 documented it was the follow up to the initial report of a nurse speaking inappropriately to R1. R1 reported that V4 spoke inappropriately to him when he requested his as needed pain medication. V4 explained to R1 that it was not time for his pain medication. R1 reported that this frustrated him. During the investigation, the resident reported that he has a temper and was in pain. The nurse was educated about customer service and approach.The facility's investigation folder provided by V1 (Administrator in Training) included a handwritten letter from R1 that documented R1 turned on his call light at an unknown time. V6 (Certified Nurse Assistant/CNA) answered the call light and went to report (R1's) pain to V4 (LPN). R1 documented that V4 came into his room yelling at R1 saying very loud I guess you want an ambulance too. I was in pain, so I yelled back at him. There was no documentation of this incident in R1's electronic medical record. On 08/12/2025 at 1:02 PM, R1 stated that V4 (LPN) had come in sometime around 8:30 PM and brought R1 medications. R1 said that he fell asleep and woke up 4-5 hours later. R1 stated he turned on the call light and asked V6 (CNA) to ask V4 if it was time for pain medication. R1 stated that V4 said I guess you want a damn ambulance after telling him that it wasn't time for medications. R1 stated that when he woke up, he did not know what time it was. R1 stated that he understands that there is a time frame that has to pass for him to receive his medications. R1 stated that the nurse (V4) was out of line when he yelled at me. R1 stated that he (R1) shouldn't have raised his voice, but he was in severe pain. R1 stated that he had written down what happened on a piece of paper and given the facility a copy of it. On 08/12/202 at 1:19 PM, V1 (Administrator in Training) stated that she was on vacation when this incident occurred between R1 and V4. V1 stated that V11 (Regional Director) completed the investigation. On 08/12/2025 at 1:55 PM, V11 (Regional Director) stated she got a call from V2 (Director of Nursing/DON) regarding the incident that occurred with R1 and V4. V11 stated that she was informed that R1 had upset V4 over pain medication. V11 stated that she did not speak to any of the staff that gave statements. V11 reiterated that R1 stated he was upset and loud. V11 stated that V4 (LPN) has an intellectual issue and does not believe he would yell at anyone. V11 stated that if V4 raised his voice it was to talk over R1. On 08/12/2025 at 2:28 PM, V4 (LPN) stated that one of the CNA's told him that R1 was wanting a pain pill. V4 stated that he went into the room to tell R1 that it was too early. V4 stated that R1 accused him of yelling at R1. V4 stated I was not trying to yell at R1, I was trying to explain that he would have to wait one more hour because it was not time. V4 said he asked R1 if he needed an ambulance. V4 stated that V11 (Regional Director) nor V2 (DON) called V4 to speak about this incident. On 08/13/2025 at 11:30 AM, V10 (LPN) stated she was the on call nurse the night of this incident. V10 said she never took a statement from V4, he was crying so much she could not understand him.On 08/13/2025 at 1:16 PM, V11 (Regional Director) stated that she only briefly spoke with V4, that she did not do an interview with him. V11 stated that she thought that V2 (DON) or V10 (LPN) spoke with V4.On 08/13/2025 at 1:35 PM, V2 (DON) stated that she did not do the investigation, that V11 completed the investigation because V1 was out of town. V2 stated that she spoke to V4 briefly, but he did not say much during the time she spoke to him. V2 stated she asked V4 what occurred but barely got any information out of him because he was still upset. On 08/15/2025 at 10:35 AM, V1 (Administrator in training) stated that she has no documentation of education for V4 for customer service and approach. V1 stated that she has reached out to V11 (Regional Director) to see if she has the education.2. R6's admission Record documented a facility admission date of 11/03/2016 and included diagnoses of Alzheimer's Disease, hyperlipidemia, dementia, type 2 diabetes mellitus, dysphagia, developmental disorder of speech and language, convulsions, and essential hypertension. R6's MDS assessment dated [DATE] documented a BIMS score of 06, indicating R6 has severe cognitive impairment. R6's Care Plan with a revision date of 06/03/2025, includes a focus area of R6 has a communication problem as evidenced by disruption in ability to speak. R6 is non-verbal but does nod yes and no with her head. The interventions listed are acknowledge resident at each greeting, allow extra time for resident to respond, allow resident to complete thought process before responding, do not finish sentences for resident and anticipate and meet needs.A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/13/2025, R1 reported that he has witnessed a staff member, V4, was yelling at a certain resident and other residents. R1's handwritten letter (referenced above) also documented that R1 has heard V4 yell at R6 and other residents. On 08/13/2025 at 1:16 PM, V11 (Regional Director) stated she did not complete a separate investigation for the allegation of abuse to R6. V11 stated she just looked at it as one case. V11 stated that she did read the allegation on the handwritten letter that R1 gave to her that had the allegation on it. On 08/13/2025 at 2:37 PM, V13 (Regional) stated they are starting an investigation regarding the allegation pertaining to R6. Facility policy titled Abuse, Neglect, Exploitation or Misappropriation - reporting and investigating documented under policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The same policy documents under section Investigating Allegations 1. All allegations are thoroughly investigated.7. The individual conducting the investigation at a minimum: . E. interviews any witnesses to the incident. H. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. I. documents the investigation completely and thoroughly.

Based on interview and record review, the facility failed to provide 8 hours per day, 7 days per week Registered Nursing (RN) coverage for the facility. This failure has the potential to affect all 37 residents residing in the facility. The facility's June 2025 Nurse Schedule documents on 06/01/25, 06/14/25, 06/15/25, 06/28/25 and 06/29/25 the facility did not have a Registered Nurse (RN) scheduled. On 06/04/25, 06/06/25, 06/09/25, 06/12/25, 06/20/25, and 06/26/25, V2 (Director of Nursing/DON) was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on the dates of 06/04/25, 06/06/25, 06/09/25, 06/12/25, and 6/26/25, V2 worked 7.5 hours, and on 06/20/25, V2 worked 7 hours. The facility's July 2025 Nurse Schedule documents on 07/05/25, 07/06/25, 07/26/25 and 07/27/25, the facility did not have an RN scheduled for 8 hours. On 07/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 07/09/25, V2 worked 7.5 hours. The facility's August 2025 Nurse Schedule documents on 08/06/25 and 08/10/25, the facility did not have a RN scheduled. On 08/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 08/09/25, V2 worked 3 hours. On 08/15/2025 at 9:47 AM, V2 (DON) stated that she is aware there is not RN coverage every day on the schedule. V2 stated that there is a PRN (as needed) nurse who has recently started and is helping cover shifts. V2 stated the facility is advertising for a Registered Nurse position. V2 stated that this month is better than the last two with Registered Nurse coverage. On 08/15/2025 at 10:33 AM, V1 (Administrator) stated she is aware that they are short on RN coverage. V1 stated there is a RN job posted on Indeed for some time.The Minimum Data Set (MDS) Resident Matrix with a date of 08/12/25, documented 37 residents are residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the doctor and obtain treatment orders when a change to a pressure area was detected and failed to apply heel protectors to prevent further skin breakdown for 3 of 4 residents (R3, R4, R5) reviewed for pressure areas in the sample of 27.Findings include:1. R4's admission record documents an admission date of 11/25/2015 with the following diagnoses in part; multiple sclerosis, chronic pain syndrome and autonomic neuropathy in diseases not elsewhere classified. R4's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 7, indicating R4 is severely cognitively impaired. Section M-Skin Conditions documents that R4 has pressure ulcers.R4's Order Summary Report documents R4 has treatment orders to her left ischial tuberosity, Right heel, right medial lower leg, right calf and behind her left knee.R4's Treatment orders on for her right heel document; Right medical heel: Apply barrier wipe q (every) shift and PRN (as needed) everyday shift for DTPI (Deep Tissue Pressure Injury) with a start date of 7/4/25 and a discontinue date of 7/9/25.R4's Treatment Administration Record for July documents that R4 received this treatment every day from 7/4-7/9, 2025. On 7/9/25 at 1:05pm, wound care was observed on R4 and administered by V4 (Licensed Practical Nurse/LPN) and assisted by R3 (LPN). V4 went to apply the barrier wipe to R4's right medial heel, there was a boarder dressing on the right heel dated 7/7. Upon removal of the dressing on R4's heel by V4, the dressing was noted to have a dark bloody tinged drainage on it. R4's right heel was noted to have a small open area approximately 2cmx2cm that was draining. V4 checked the order to ensure she had read it correctly. V4 confirmed it was only the barrier wipe ordered and left the dressing intact. V4 went to notify the Nurse Practitioner and to receive new treatment orders.R4's progress notes document on 7/9/25 at 2:35pm, Floor nurse reported a decline in wound on right medial heel. (Name of wound care provider) NP (Nurse Practitioner contacted, new order received as follows: Cleanse wound with wound cleanser, apply collagen to wound bed, cover with bordered gauze dressing q2d (every 2 days) and PRN (as needed). Order Processed. On 7/9/25 at 1:23pm, V4 stated that the nurse practitioner should have been notified and new orders received when the area was noticed and before any new treatment was applied. 2. R3's admission record documents an admission date of 4/28/25, with the following diagnoses listed in part; adult failure to thrive and muscle weakness.R3's Current Care Plan documents R3 has severe impaired cognitive function or impaired thought processes as evidenced by a BIMS score of 3 related to Dementia, date initiated 5/12/25.R3's Order summary sheet documents an order with a start date of 5/29/25, Heel protectors to be worn in bed every shift for pressure injury.R3's Treatment Administration Record for July, with a print date of 7/9/25 documents an order for heel protectors on while in bed, nursing staff documented that treatment was in place every day from July 1-9, 2025.On 7/7/25 at 1:52pm R3 was observed in bed, without heel protectors on.On 7/8/25 at 1:02pm, R3 was observed lying in bed without heal protectors on and there were no heal protectors anywhere in her room.On 7/9/25 at 9:35am, R3 was observed lying in bed without heel protectors on, V5 did not even have heel protectors anywhere around her.On 7/9/25 at 1:39pm, V3 and V4 both stated they were not sure if R3 should have had heel protectors on while lying in bed. V3 and V4 stated if R3 had an order for them, they should be put on her while she is in bed.On 7/10/25 at 1:41pm, V5 (Certified Nursing Assistant/CNA) stated she was not sure where V3's heel protectors were, but she would locate a pair for her.3. R5's admission record documents an admission date of 3/10/22 with the following diagnoses in part; Type 2 diabetes Mellitus without complications, pressure ulcer of other site, stage 3, and other specified disorders of muscle.R5's Minimum Data Set (MDS) dated [DATE] documents no brief interview for mental status was conducted due to resident is rarely/never understood.R5's Order Summary Report documents the following order, Heel protectors while in bed-Monitor wearing q (every) shift. Ensure heel protectors are on while in bed. With a start date of 5/31/25.R5's Treatment Administration Record for July, with a print date of 7/9/25 documents an order for heel protectors on while in bed, nursing staff documented that treatment was in place everyday from July 1-9, 2025.On 7/7/25 at 1:52pm R5 was observed in bed, without heel protectors on.On 7/8/25 at 1:02pm, R5 was observed lying in bed with her heal protectors laying on her bedside table.On 7/9/25 at 9:35am, R5 were observed lying in bed without heel protectors on.On 7/9/25 at 1:38pm, R5 was observed in bed, and did not have heel protectors in place, they were sitting on her bedside table. V# (LPN) grabbed them and put them on R5.On 7/9/25 at 1:39pm, V3 and V4 both stated that R5 should have had heel protectors on while lying in bed.On 7/9/25 at 2:15pm, V2 (Director of Nursing) stated all treatments performed must have an order, if a treatment is to be changed, the doctor would need to be contacted for further instruction.Facility Policy titled Wound Care with a revision date of October 2010 documents under the section titled, preparation; Verify that there is a physician's order for this procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely drain a full indwelling catheter bag, increasing the resident's risk for infection for 1 of 3 (R2) residents reviewed for catheters in the sample of 27.Findings Include:R2's admission record documents an admission date of 6/12/17 with the following diagnoses listed in part; cerebral infarction, retention of urine, neuromuscular dysfunction of bladder and urinary tract infection, site unspecified.R2's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) was not completed due to resident is rarely/never understood.R2's Order Summary Report documents an active order to replace bedside drainage bag with leg bag each morning.R2's care plan documents resident has an indwelling catheter. resident will show no s/sx (signs and symptoms) of Urinary infection. with interventions including empty the drainage bag when needed.On 7/9/25 at 1:42pm, R2's leg catheter drainage bag was observed to be completely full, and urine was backing up into tubing.On 7/9/25 at 1:43pm, V3 (licensed Practical Nurse) stated that R2's leg bag was so full of urine that it was backing up into the tubing, and that was a good way to get an infection. V3 stated R2 gets frequent Urinary Tract Infections and staff should be checking her drainage bag often since she has a leg bag to ensure it doesn't get so full.Per CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html Section III Proper Techniques for Urinary Catheter Maintenance documents Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container.

Based on interview, observation, and record review the facility failed to maintain floors, sinks and shower rooms in a clean, safe and sanitary condition for 20 of 20 (R2, R4, R6, R7, R8, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R26, and R27) residents reviewed for environment in a sample of 27. Findings include:On 07/09/25 at 8:12 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad.On 07/09/25 at 9:15 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad. On 07/09/25 at 9:30 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad. On 07/09/25 at 9:45 AM the soiled/wet bed pad and soiled brief had been removed from R2's floor. On 07/09/25 at 12:45 PM, R6's floor was sticky, surveyor's shoes were sticking to the floor when walking over to the bed to speak with R6. On 07/09/25 at 1:40 PM, there was dried spilled liquid of the approximate size of 12 inches by approximately 6 inches on the floor of R4's room near the waste can. On 07/10/25 at 9:10 AM the south hall shower room contained a black substance along the bottom of the left wall and approximately four inches up the wall of the shower stall and up to approximately 24 inches up the wall in the grout. The back wall contained a black substance between the floor and the wall of the back wall up to approximately 20 inches in the grout between the tiles. The right side wall of the shower stall contained a black substance between the floor and the wall to approximately three inches up the wall. The wall also contained a black substance in the grout to approximately 16 inches up the wall in the grout. On 07/11/25 at 11:37 AM R8's bathroom sink contained a black substance covering an area of approximately 7.5 inches from the middle of the back of the sink to the top of the sink by approximately 6 inches wide. This area surrounded the overflow opening in the sink. The porcelain contained cracks under the black substance and extending over an inch past the black substance with the black substance being into and under the cracks.On 07/10/25 at 12:59 PM, V15 (Maintenance) stated R8's bathroom sink should not look like that, it should be replaced. He will send a picture of the sink to his supervisor to see if he can get it replaced. On 07/14/25 at 11:19 AM, V7 (Minimum Data Set Coordinator) stated, she does work the floor on occasion. V7 stated the residents listed under South Hall on the (facility name) Room List reside on the south hall and utilize the shower room on the south hall, V7 stated, the shower room should not contain the black substance on the walls of the shower stall and in the grout of the shower stall. On 07/14/25 at 12:52 PM V15 stated, the shower room on the south hall should not contain the black substance on the walls and in the grout of the shower stall. The undated facility document titled, (facility name) Room List documents R6, R7, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, and R27 reside on the south hall. The facility policy dated 07/2013 titled Cleaning and Disinfecting Residents' Rooms documents: General guidelines: 1. housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 6. 6. Floor mopping solution will be replaced every three resident rooms, or changed no less often than at 60- minute intervals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide substantial evening snacks to residents. This failure has the potential to affect all 37 residents residing at the facility. Findings include:Facility matrix dated 7/7/25 documents there are currently 37 residents living in the facility. On 07/10/25 at 9:30 AM the sign posted on the snack cart documents: breakfast 8:00 AM, lunch 12:00 PM, and dinner 5:00 PM.On 07/10/25 at 10:20 AM, R6 Who is alert and oriented, stated, the staff do not come and ask between after dinner and before bedtime if he would like a snack or a substantial snack such as a half a sandwich or a yogurt. On 07/10/25 at 11:40 AM, R8 who is alert and oriented, stated the staff do not come and ask if she would like a snack in the evening, after dinner. On 07/10/25 at 12:46 PM, R27 who is alert and oriented, stated, they (the staff) do not ask if he would like a snack after dinner in the evening time, but it would be nice if they did. On 07/10/25 at 12:49 PM, R22 who is alert and oriented, stated, the staff do not ask if he would like a snack after dinner in the evening. On 07/10/25 at 12:54 PM, R19 who is alert and oriented, stated, they do not come around and ask if he would like a snack in the evening but if he asks earlier in the day they will bring him a [NAME] bar or something similar.On 07/10/25 at 1:05 PM, R4 who is alert and oriented, stated, she does not remember anyone asking her if she would like a snack in the evening. On 07/14/25 at 11:50 AM, V7 (Minimum Data Set Coordinator) stated, breakfast is at 8:00 AM, lunch is at 12:00 PM, and dinner is at 5:00 PM. On 07/14/25 at 11:13 AM, V9 (Certified Nurse Aide/CNA) stated, sometimes they have snacks for the evening, sometimes not very many. V9 stated the amount of snacks they have depends on how many snacks the kitchen leaves for them before they leave. The kitchen is locked after the kitchen staff leaves. Sometimes they do not have enough snacks for all the residents. The snacks are usually oatmeal cream pies or maybe a plastic bag of chips. V9 stated, very rarely do they have sandwiches or anything like that. On 07/14/25 at 12:08 PM, V13 (CNA) stated, they have some snacks in the evening, depending on how many snacks the kitchen leaves them. The usual snacks are chips, graham crackers, or sometimes yogurt. V13 stated, they do not always have enough snacks for all the residents.On 07/14/25 at 12:11 PM, V14 (CNA) stated, she works every other weekend in the evening. V14 stated, she usually has snacks for the evening, usually oatmeal cream pies or graham crackers and sporadically a half a sandwich. On 07/14/25 at 12:15 PM, V16 (Cook) stated, he will leave snacks for the evening before he leaves. He leaves whatever they have sometimes oatmeal pies, chips, or cookies. V16 stated, sometimes he will put out some sandwiches if they already have some made. The facility policy dated 07/2017 titled, Frequency of Meals documents 6. evening snacks will be offered routinely to all residents. Timing of the snack will consider relevant factors. 7. residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen (14) hours. Nourishing snacks are items from the basic food groups, offered either separately or with each other.

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours per day, 7 days per week. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: The facility's May 2025 Nurse Schedule documents on 05/03, 05/04, 05/17, 05/18, 05/26, and 05/31/25 the facility did not have a Registered Nurse scheduled. On 05/07, 05/08, 05/09, 05/12, 05/15, 05/20, 05/21, and 05/23/25, V2 (Director of Nursing/DON) was the RN Scheduled for 8 hours. The Employee Timecard Report for V2 documented on 05/07, V2 worked 7.5 hours, on 05/08, V2 worked 7.5 hours, on 05/09, V2 worked 5.25 hours, on 05/12, V2 worked 7.25 hours, on 05/15, V2 worked 7.25 hours, on 05/20, V2 worked 7.5 hours, on 05/21, V2 worked 7 hours, and on 05/23, V2 worked 7.5 hours. The facility's June 2025 Nurse Schedule documents on 06/01, there was no RN scheduled. On 06/04 and 06/06, V2 (DON) was the RN scheduled for 8 hours. V2's Employee Timecard Report documented on 06/04, V2 worked 7.5 hours and on 06/06, V2 worked 7.5 hours. On 06/11/2025 at 9:40 AM, V2 (DON) stated that they have had an RN quit and that has left some days with no RN coverage. V2 stated they are trying to hire another RN. V2 stated that if she is in the building and there is not an RN working, then she would be the RN coverage scheduled for 8 hours that day. V2 stated at this time the facility does not utilize agency staffing. On 06/11/2025 at 11:11 AM, V1 (Administrator in Training) stated she is aware that there are not RNs in the building every day. V1 stated that until recently they had enough RNs, but recently had one quit. V1 stated that they have advertisements posted on the Internet for a day shift and a night shift RN. The MDS (Minimum Data Set) Resident Matrix with a date of 06/11/2025, documents that 34 residents are currently residing at the facility. The facility policy titled Staffing, Sufficient, and Competent Nursing with a revision date of August 2022 documents under Sufficient Staff, 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hour, seven (7) days a week.

Based on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 1 (R3) of 1 resident reviewed for hospitalizations in a sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day, along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident and/or their representative were notified of the hospital transfer and/or admission via phone. V1 confirmed that documentation is not provided to the resident representative in writing. V1 stated R3 is not cognitively intact as their baseline status.

Based on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R3) of 1 resident reviewed for notice of bed hold policy upon transfer in the sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident representative was notified of the bed hold policy via phone and sent with the resident. V1 confirmed documentation was not provided to the resident representative in writing. V1 stated R3 is not cognitively intact as their baseline status. The facility did not provide evidence of a policy and procedure for bed holds upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 3 (R8, R9, and R21) of 12 residents reviewed for accuracy of assessments in the sample of 24. Findings Include: 1. R9's admission Record documented an initial admission date of 08/02/2024. Diagnoses listed on this document include chronic obstructive pulmonary disease, cerebrovascular disease, spastic hemiplegia, chronic kidney disease, sleep apnea, unspecified dementia, gastro-esophageal reflux disease, bipolar disease, anxiety, and retention of urine. R9's Notice of PASRR Level II Outcome dated 07/22/2022 documented that You have a Level II PASRR Condition of Bipolar Disorder Level II Outcome: Level II - Approved No SS. R9's MDS with an Assessment Reference Date of 10/12/2013 documented this MDS as being an annual assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asks Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability .or a related condition? The answer was documented as a 0 for No. This same MDS in Section I Active Diagnoses has a checkmark under Psychiatric/Mood Disorder with an X marked for I5900 Bipolar Disorder, indicating this is an active diagnosis for R9. On 09/19/2024 at 11:03 A.M. V13 stated she is not sure why Section A1500 is coded as a No. V13 stated she is aware that R9 has a diagnosis of Bipolar Disorder and a Level II PASARR. V13 stated that she will complete a correction MDS. 2. R21's admission Record documented an initial admission date of 07/21/2021. Diagnoses listed on this document include chronic obstructive pulmonary disease, depression, delusional disorders, unspecified dementia, alcohol abuse with alcohol induced psychotic disorders with delusions, anxiety, and cardiomyopathy. R21's Notice of PASARR Level 1 Screen with a date of 08/01/2023, documented No Level II Required. R21's MDS with an Assessment Reference Date of 07/01/2024 documented this MDS as being an annual assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asks Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability .or a related condition? The answer was documented as a 0 for No. This same MDS in Section I Active Diagnoses has a checkmark under Psychiatric/Mood Disorder with an X marked for I5950 Psychotic Disorder, indicating this is an active diagnosis for R21. On 09/19/2024 at 10:32 AM, V13 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated that she was not sure why the MDS was coded that way. V13 stated that she double checks the diagnosis list. On 09/19/2024 at 10:58 AM, V13 stated that the system automatically pulls the diagnosis list and puts them in the MDS Section I. V13 stated that she did not double check the list and should have unclicked Section I5950 Psychotic disorder (other than schizophrenia) and changed the yes to a no. V13 stated that R21 has no delusions and that this is inaccurate. V13 stated she will complete a correction MDS. On 09/19/2024 at 11:30 AM, V13 stated that the MDS had been corrected and resubmitted for R21. 3. R8's admission Record documented an admission date of 11/25/15 and included the following diagnoses: schizoaffective disorder, borderline personality disorder, and major depressive disorder. R8's annual MDS dated [DATE] Section A 1500 completed by V13 documented an answer of No to the question: Is the resident currently considered by the State Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition? This same document in section I5700 documented that R8 has an anxiety disorder, depression, and schizophrenia. R8's medical record included documentation of R8 receiving a Level I and II OBRA (Omnibus Budget Reconciliation Act) screen from a previous facility completed on 12/26/08, which noted that R8 was suitable for long term care placement and required no special services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide scheduled daily activities that met resident goals and preferences for six (R2, R3, R7, R12, R30 and R34) of six residents reviewed for activities in the sample of 24. Findings Include: 1. R2's admission Record documented an admission date of 3/1/24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, and multiple sclerosis. R2's Minimum Data Set (MDS) assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people and doing favorite activities was somewhat important to R2, and going outside for fresh air when weather is good was very important to R2. 2. R3's admission Record documented an admission date of 7/21/2006 with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, muscle weakness and bipolar disorder. R3's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices was all somewhat important to R3. 3. R7's admission Record documented an admission date of 5/8/2010 with diagnoses that included bipolar disorder, unspecified, anxiety disorder unspecified and obesity. R7's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines was somewhat important to R7, and listening to music, being around animals, doing things with groups of people, doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices was very important to R7. 4. R12's admission Record documented an admission date of 9/22/2022 with diagnoses that included major depressive disorder, anxiety disorder and cerebral infarction. R12's MDS assessment dated [DATE] under Interview for Activity Preferences documented that keeping up with the news, going outside for fresh air when weather is good and participating in religious services or practices was somewhat important to R12, and having books, newspapers, magazines, listening to music, being around animals, doing things with groups of people, and doing favorite activities was very important to R12. 5. R30's admission Record documented an admission date of 3/10/2023 with diagnoses that included chronic obstructive pulmonary disease, unspecified, dysphagia, oropharyngeal, and muscle weakness. R30's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices was all somewhat important to R30. 6. R34's admission Record documented an admission date of 7/13/2024 with diagnoses that included depression, muscle weakness and post-traumatic stress disorder. R34's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, and doing things with groups of people are somewhat important to R34, and doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices are very important to R34. On 9/18/2024 at 10:24 AM during the resident council meeting, R2, R3, R7, R12, R30 and R34 were all alert and oriented to time and place. When asked about daily activities, R2, R3, R7, R12, R30 and R34 all stated, there are no activities scheduled on the weekends and all stated they would like to have activities scheduled over weekends. On 9/17/24 at 1:55 PM, V12 (Activity Director) stated she does not schedule any resident activities for the weekend. V12 stated, she leaves that up to the nurses and certified nurse assistants to have activities for the residents. On 9/19/2024 at 9:47 AM, V1 (Administrator) stated multiple times she has discussed scheduling and documenting resident activities for the weekend staff to complete with V12 (Activity Director). V1 stated, the facility does not have a policy on activities, that the facility follows the regulations. The facility's September 2024 activities calendar shows no activities scheduled for 9/1/2024, 9/6/2024, 9/8/2024, 9/13/2024, 9/14/2024, 9/15/2024, 9/21/2024, 9/22/2024, 9/27/2024, 9/28/2024 and 9/29/2024.

Based on observation, interview and record review, the facility failed to prepare food in the proper form of the diet order for 5 of 5 (R1, R16, R18, R19 and R30) residents reviewed for menus meeting resident needs in the sample of 24. The Findings Include: 1. R1's current order summary report lists diet order as: regular diet, pureed texture. 2. R16's current order summary report lists diet order as: regular diet, pureed texture. 3. R18's current order summary report lists diet order as: regular diet, mechanical soft texture. 4. R19's current order summary report lists diet order as: regular diet, mechanical soft texture. 5. R30's current order summary report lists diet order as: regular diet, mechanical soft texture. On 9/17/24 at 12:00 PM, during lunch meal observation, V4 (Cook) was preparing the altered diets for residents on mechanical soft and puree. V4 stated that she did not have to prepare the meal any different for the mechanical soft diets because it was meat loaf. V4 then pureed the meat loaf, spinach and Au Gratin potatoes and did not use any liquid in the food processor while blending the food. V4 did not use a spoon tilt test to determine if the proper food consistency was obtained for the mechanical soft and puree food items. The menu for 9/17/24 was listed as: Meatloaf, Au Gratin Potatoes, Club Spinach, Bread/Margarine, and a Fresh Fruit Cup on the Week 2 spreadsheet for menus. On 9/17/24 at 12:45PM, the staff were starting to pass trays and R1, R18, and R30 received regular meatloaf at the lunch meal service prior to V1 (Administrator) stopping the tray line to make sure that Mechanical Soft residents received mechanical soft meatloaf. At this time, it was observed that R30 was coughing while eating, but did not choke. The recipe for mechanical soft meatloaf includes the following directions: 1. Place prepared meatloaf into the processor and pulse until lump particles the size of 4 mm(millimeters). 2. Prepare gravy mix and add to the minced meatloaf to add moisture and bind. 3. Minced and Moist foods must pass the IDDSI (The International Dysphagia Diet Standardization Initiative) Fork Test and IDDSI Spoon tilt test. The recipe for the puree meatloaf includes the following directions: 1. Measure out pureed portions required for the recipe. 2. Add to food processor and process to a fine consistency. 3. Prepare broth by dissolving soup base in hot boiling water. 4. Combine hot broth and commercial thickener. Gradually add to meat while processing. All liquid may not be required. 5. Scrape down sides of processor and process for additional 30 seconds. The recipe for puree club spinach includes the following directions: 1. Measure out pureed portions required for the recipe (omit bacon). 2. Add to food processor and process to a fine consistency. 3. Add liquid and thickener and process until smooth. All liquid may not be needed for recipe. 4. Scrape down sides of processor with a rubber spatula and process for additional 30 seconds. The recipe for Au Gratin potatoes includes the following directions: 1. Measure out pureed portions required for the recipe. 2. Add to food processor and process to a fine consistency. 3. Add liquid and process until smooth. All liquid may not be needed for recipe. 4. Heat to serving temperature. On 9/17/2024 at 11:08 AM, V23 (Family) stated that the pureed food needs some help. V23 stated that the pureed food is not consistent, some days the food is very thin and runny and other days it is too thick. On 9/17/24 at 1:00 PM, V4 confirmed that she did not chop or grind the meatloaf until V1 (Administrator) told her to, and that she did not have gravy prepared for the meal. V4 stated that she doesn't add liquid to the puree or mechanical soft diets because it may make it too runny, so that was why for the puree food items she didn't add any liquid to the food in the food processor. V4 also stated that she forgot to make the pureed bread for that meal, so no puree diets got the bread/margarine. On 9/19/24 at 1:00 PM, the lunch dessert was observed to be fruit in a red liquid served in a bowl. The menu for the day listed the dessert as fruited gelatin. At this time, R8 who is alert to person, place and time stated that she isn't sure what the dessert is, but it looks like canned fruit in red juice. On 9/19/24 at 1:30PM, V4 stated that she is unsure why the fruited gelatin did not set and was runny because she made it two days in advance to ensure that the gelatin would not be liquid. On 9/19/24 at 2:00 PM, V6 (Certified Nurse Assistant/CNA) stated that she was previously a kitchen employee and trained V4 on how to puree, and she taught her to always use a hot liquid to puree the food items to get it to the correct consistency. A Diet Type Report provided by V1 on 9/20/24 at 2:00 PM, lists R18, R19, and R30 as receiving a Mechanical Soft diet. This same report lists R1 and R16 as receiving a puree diet.

Based on interview, observation, and record review, the facility failed to follow Infection Control practices for 9 of 12 residents (R1, R2, R4, R6, R8, R9, R11, R12, and R17) reviewed for infection control in the sample of 24. The Findings Include: 1. On the initial tour of the facility on 09/17/2024 beginning at 9:30 AM, there were no resident rooms observed in the facility with signage on the doors indicating residents were on enhanced barrier precautions. On 09/17/2024 a Matrix for Providers (form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On 09/18/2024 at 08:30 AM, during screening of residents, there were no resident rooms observed in the facility with signage on the doors indicating residents were on isolation or enhanced barrier precautions. On 09/18/2024 at 11:01 AM, V2 (Director of Nursing/DON) stated that there is no one currently on isolation. V2 stated that Enhanced Barrier Precautions are for residents with wounds and catheters. V2 stated the facility has no open wounds, so no one is on Enhanced Barrier precautions. V2 stated residents with catheters are not being isolated because they are not growing anything in their urine. On 09/18/2024 at 11:06 AM, V1 (Administrator) stated that all staff know to wear PPE (Personal Protective Equipment) when providing care to residents with wounds and catheters. V1 stated no one is currently on isolation for Enhanced Barrier Precautions. On 09/19/2024 at 9:00 AM, V1 stated the facility has not implemented Enhanced Barrier Precautions yet. V1 stated the regional nurse is coming today to assist V2 in implementing Enhanced Barrier Precautions. On 9/19/2024 at 2:00 PM, V16 (Licensed Practical Nurse) stated that Enhanced Barrier Precautions were new, and the facility just implemented them this afternoon. On 09/20/2024 at 10:45 AM, V2 stated she has talked to staff that have been working but has not done an all staff in-service yet. V2 stated she put education in the care binder for staff to read. V2 stated she will do an in person all staff education on 09/25/2024. R1's admission Record documented an Initial admission Date of 05/21/2005 and included the following diagnoses: cerebral infarction, chronic kidney disease, bradycardia, hemiplegia, obstructive sleep apnea, gastro-esophageal reflux disease, unspecified dementia, epilepsy, chronic obstructive pulmonary disease and schizoaffective disorder. R1's Order Summary Report dated 09/19/2024 documented an active order to monitor output and color of BIL (bilateral) nephrostomy urine tube everyday shift and night shift. The same document also documented an order for suprapubic urinary catheter change monthly and as needed. R2's admission Record documented an Initial admission Date of 03/01/2024 and included the following diagnoses: hemiplegia, unspecified atrial fibrillation, type 2 diabetes mellitus, multiple sclerosis, obstructive sleep apnea, hyperlipidemia and essential hypertension. R2's Order Summary Report dated 09/19/2024 documented an active order for suprapubic catheter 18 F / 30 ml (18 French with 30 milliliter) bulb change every 28 days and as needed. R4's admission Record documented an admission Date of 07/31/2024 and included the following diagnoses: chronic obstructive pulmonary disease, cellulitis of lower limb, iron deficiency anemia, hypothyroidism, hyperlipidemia, anxiety, bipolar disease, type 2 diabetes mellitus, and acute kidney failure. R4's Order Summary Report dated 09/20/2024 documented an active treatment order for right posterior thigh; right post lateral leg, cleanse area with normal saline, apply collagen to wound bed, apply barrier wipe to peri-wound then hydrocolloid every 3 days and as needed. R6's admission Record documented an Initial admission Date of 01/22/2024 and included the following diagnoses: chronic respiratory failure, gastro-esophageal reflux disease, anemia, hypokalemia, essential hypertension, type 2 diabetes mellitus, neuromuscular dysfunction of bladder and heart failure. R4's Order Summary Report dated 09/19/2024 documented an active order for urinary catheter 16 F / 30 ml (16 French with 30 milliliter) bulb change monthly and as needed. R8's admission Record documented an Initial admission Date of 11/25/2015 and included the following diagnoses: multiple sclerosis, schizoaffective disorder, pressure ulcer of left buttock stage three, gastro-esophageal reflux disease, anxiety, major depressive disorder, hypothyroidism, and chronic obstructive pulmonary disease. R4's Order Summary Report dated 09/19/2024 documented an active order for left ischial tuberosity, cleanse with normal saline, apply barrier wipe to peri wound, apply collagen to wound bed, cover with dressing every three days and as needed. R9's admission Record documented an Initial admission Record of 08/02/2018 and included the following diagnoses: chronic obstructive pulmonary disease, cerebrovascular disease, spastic hemiplegia, chronic kidney disease, sleep apnea, unspecified dementia, gastro-esophageal reflux disease, bipolar disease, anxiety and retention of urine. R9's Order Summary Report dated 09/19/2024 documented an active order for suprapubic 20 F / 30 (20 French with 30 milliliter) bulb to be changed monthly and as needed. R11's admission Record documented an Initial admission Record of 04/01/2024 and included the following diagnoses: major depressive disorder, chronic kidney disease, anemia in chronic kidney disease, type 2 diabetes mellitus, essential hypertension, chronic kidney disease stage 4, end stage renal disease, peripheral vascular disease, and dependence on renal dialysis. R11's Order Summary Report dated 09/19/2024 documented an active order for dialysis site - HD (hemodialysis) tunneled double right jugular venous access. R12's admission Record documented an Initial admission Date of 09/22/2022 and included the following diagnoses: major depressive disorder, anxiety, hypothyroidism, chronic combined systolic and diastolic heart failure, chronic obstructive pulmonary disease, hyperlipidemia, gout, and disorder of the kidney and ureter. R12's Order Summary Report with a date of 09/19/2024 documented an active order for urinary catheter 16 F / 20 ml bulb, change every month and as needed. R17's admission Record documented an Initial admission Date of 06/24/2022 and included the following diagnoses: cerebral infarction, essential hypertension, type 2 diabetes mellitus, bipolar disorder, retention of urine, and atherosclerosis of coronary artery bypass graft. R17's Order Summary Report with a date of 09/19/2024 documented an active order for urinary catheter, 18 F / 30 ml bulb, change monthly and as needed. A facility provided document labeled Enhanced Barrier Precautions with a date of 07/13/2023, documented Enhanced Barrier Precautions should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, and infection or colonized with a MDRO (Multidrug-Resistant Organisms). Enhanced Barrier Precautions require the use of a gown, and gloves during high - contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. According to https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Under the heading Implementation documents: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 2. On 09/17/2024 at 11:45 AM, V14 (Licensed Practical Nurse/LPN) completed a blood glucose check on a R6. V14 pulled the test strip out of the glucometer and discarded it with her gloves. V14 then sat the glucometer on top of her medication cart. At 12:08 PM, V14 completed another blood glucose test on R4 using the same glucometer. V14 did not clean the blood glucose machine in between resident use. On 09/20/2024 at 12:26 PM, V2 (DON) stated that she would expect the nursing staff to disinfect the blood glucose testing machine in between each resident use. The facility policy titled Cleaning and Disinfecting of Glucometer with an updated date of 12/07/2018 documented Policy: The blood glucose meters will be cleaned between each resident test to avoid cross contamination issues. Under the section titled procedure: 1. Cleaning and disinfecting with a Bleach Disposable Wipe will be completed each time the blood glucose meter is used with a pre-moistened towelette. 3. On 09/19/2024 at 2:54 PM, V11 (LPN) provided catheter care to R9. The area around R9's suprapubic catheter was cleaned, and a new dressing applied. V11 cleaned R9's coccyx area and removed sheet from bed, placed it on the floor, then placed dirty wash cloth on the sheet on the floor. V11 stated she forgot a trash bag. V11 then completed R9's treatment to coccyx. On 09/19/2024 at 3:10 PM, V1 stated that she would expect staff to have a trash bag or to throw the washcloths in the trash can. V1 stated it was not the facility policy to place linens on the floor. 4. On 9/19/2024 at 10:45 AM, V8 (Certified Nurse Assistant/CNA) was observed passing ice to residents in their rooms across the hall from the facility conference room. V8 dropped the lid to the ice cooler on the floor, picked the cooler lid up and placed the cooler lid back on the cooler. V8 continued to pass ice to residents in their room. V8 stated she did drop the lid to the cooler on the floor and placed in back on the cooler without cleaning it. On 9/19/2024 at 10:52 AM, V1 (Administrator) stated she would expect V8 not to use the cooler lid after it hit the floor and to follow policy and procedure for infection control. On 9/20/2024 at 11:48 AM, V2 (DON) stated she would expect for staff to follow policy and procedure for infection control and not return a lid back on the cooler that fell on the floor while passing ice to the residents.

Based on interview and record review, the facility failed to have a full time Registered Dietitian or full time Certified Dietary Manager on staff. This has the potential to affect all 34 residents residing in the facility. The Findings Include: On 9/17/24 on 9:00 AM, V4 (Cook) stated that they currently do not have anyone in the Dietary Manager role in the kitchen. V4 stated that there was someone, but they quit a couple days after she started. On 9/20/24 at 2:00 PM, V1 (Administrator) stated that she has not had anyone in the dietary manager role in the kitchen since June of 2024. V1 further stated that she is trying to find someone to fill that role but has not had any luck. V1 stated that they do have a Registered Dietitian come in once a month to review resident nutritional needs, but not full time. Review of the facility's Quality Assurance monthly meeting sign in sheets does not show a Dietary Manager attending the meetings since June (2024). On 9/20/24 at 2:00 PM, V1 stated that the Registered Dietitian provides the necessary information for the quality assurance meeting. The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/17/24, documents 34 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 34 residents residing in the facility. The Findings Include: During the initial tour of the kitchen on 9/17/24 at 9:20 AM, the following observations were made: -No paper towels were available at the hand wash sink -Stove top gas burners were dirty with burnt, dried up, and spilled food items on them -The sides of the oven were dirty with spilled food and grease down each side -The flat top grill on the stovetop grease/crumb trap was full of old food crumbs and grease -The floor around the oven had dried food matter under the oven -A non-handle scoop/Styrofoam cups were found in fortified powder, brown sugar and sugar bulk containers -A towel was stuck in the back door to keep it open On 9/17/24 at 12:15PM, a fan was observed sitting in the kitchen window with a screen blowing air into the kitchen from the outside. The fan had flies and dirt on the kitchen side of it, blowing onto drinks to be served at lunch that were not on ice/not covered. On 9/17/24 at 12:35PM, a cart was observed sitting near the serving line with glasses of milk, water and lemonade. The glasses were not covered and were not in an ice bath. V3 (Cook) was asked at this time to take the temperature of the uncovered glass of milk sitting on a kitchen cart. The temperature was found to be 59 degrees. V3 stated that he thought that was a little high on temperature, but they needed to start serving because they were late so there wasn't anything he could do about it. On 9/17/24 at 12:40 PM, V1 (Administrator) came in and told kitchen staff they could not serve the drinks and that they had to be dumped out and new drinks poured. At this same time, V1 stated that they will get the fan cleaned so as to not blow debris potentially onto the food. On 9/17/24 at 2:00 PM, V4 (Cook) stated there is no cleaning log in the kitchen currently. On 9/18/24 at 12:00 PM, V3 (Cook) was observed handling dirty and clean dishes without hand washing or using gloves. A cleaning schedule with a revision date of 10/14 was provided by V1 on 9/19/24. It states that it is the policy of (Long Term Care Facility) to provide a system for determining frequency and cleaning and to document the completion of a particular cleaning task. 1. The Food Services manager shall develop a cleaning rotation form that lists all cleaning tasks required for proper sanitation of the food preparation and serving areas. 2. Tasks are divided into categories that must be completed daily, weekly, and monthly. 3. Each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency. The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/17/24, documents 34 residents reside in the facility.

Based on observation, interview and record review the facility failed to provide services of a Registered Nurse for eight consecutive hours per day, seven days a week. This has the potential to affect all 38 residents residing at the facility. Findings include: On 3/26/2024 at 9:30am, V1 (Administrator) was asked to provide documentation of the facility having the services of a Registered Nurse, 8 consecutive hours a day, for seven days a week. At around 1:00pm, V1 provided the facility's nurse schedules for the months of January 2024, February 2024 and March 2024. The facility's March 2024, February 2024 and January 2024 Nurses Schedules document only V5, V6, V12 -V20 LPN's (Licensed Practical Nurses) were scheduled to provide patient care during the months provided. There were no RN's (Registered Nurses) documented as working during those three months. On 3/26/2024 at 2:00pm, V6 (LPN) reviewed the March 2024, February 2024 and January 2024 Nurses Schedules and verified all nurses on the schedule (V5, V6, V12-V20) were all LPN's and none of the nurses on the schedule, who had worked, were RN's. V6 said V2 (Director of Nursing/DON) was the only RN who worked at this facility during that time. On 3/26/2024 at 4:10pm, V1 said she did not have a written schedule of the RN's who provided the facility's RN coverage. V1 said instead she would provide the timecard punches as documented proof of the required RN coverage. V1 said V21 (Minimum Data Set Coordinator/RN) and V22 (DON) were employed at a sister facility, and they had provided the Registered Nurse coverage for this facility. V1 provided separate documentation for V2, V21, and V22; and Time Clock Reports for the dates of 3/1/2024 through 3/26/2024. The documents provided for V2 were without title, had separate columns indicating their times clocked in and clocked out, but did not indicate which facility V2 had worked at. The documents for V21 provided the same information and did not indicate which facility V21 had worked at. The documents for V22 also provided the same information and did not indicate which facility V22 had worked at. On 3/28/2024 at 10:31am, V12 (LPN) said the only RN that works at this facility was V2 (DON). On 3/28/2024 at 9:30am, V11 (Regional Director of Operations) said V1 would not be available today because she was working that evening. V11 was asked for the documented proof of the facility's 8 consecutive hours of RN coverage 7 days a week for the period of 1/5/2024 through 3/28/2024. At 10:31am, V11 presented the same timecard punch documentation for V2, V21 and V22 as V1 had provided on 3/26/2024 for the periods of 3/1/2024 through 3/26/2024. V11 was asked to provide proof of which facility V21 and V22 had worked at since V21 and V22 worked full time at a sister facility, V11 replied she had no way of providing the proof. At 11:01am, V11 said neither she nor V1 could provide written documentation of which facility V21 and V22 had worked at and could not provide a schedule or other documentation of this facility providing the required 8 consecutive hours of RN coverage, seven days a week for the period of 1/5/2024 through 3/28/2024. The facility's Census dated 3/26/2024 documents 38 residents reside at this facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from mental abuse/mistreatment for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage (R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress. R2 stated V9 (LPN/Licensed Practical Nurse) said, this is fu**ing bulls**t and when R2 asked V9 if it was directed at her V9 didn't respond. R2 stated a different nurse, and the nurse's husband witnessed the interaction, and she believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, upon being informed of a potential allegation of abuse by surveyor, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start an investigation immediately and suspend V9 (LPN). On 1/4/24 at 2:03 PM, V9 (LPN) stated she had never cursed or yelled at any of the residents. V9 stated on 12/27/23, R2 told her she was upset with her because V9 yelled at her (R2) on Christmas. V9 stated she explained to R2 that she couldn't have yelled at R2 on Christmas because V9 didn't work on Christmas. On 1/4/24 at 2:57 PM, V10 (Social Service Director/SSD) stated last week she walked down the hall and R2 was sitting in her chair by the nurse's station. V10 stated she heard V9 tell R2 that she didn't remember saying something but if she did, she was sorry. V10 stated she stopped and talked with R2, and R2 and V9 were joking around so she didn't think there was an allegation to report. V10 stated R2 will usually have a staff member get V10 if R2 has a concern or issue with anything. The facility's undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present During the investigation residents many residents (sic) were interviewed by the QAC (Quality Assurance Committee) to assess their interactions with (V9) and to directly ask if they had witnessed, heard of, or encountered any form of abuse by her .none of them reported a grievance, negative interactions, or reported witnessing or encountering abuse of any form .Staff interviews: V13 (CNA) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN that it was her boyfriend (V12) that called it in, that it had allegedly occurred when he came to the building (bringing a friend of his who was an employee something to drink). When I asked (V13) if she knew about the alleged allegation prior to this, she reported she did not. It was after it was already reported, and the investigation had begun that she was informed of it. When asking (V13) if she was provided any details of what the alleged abuse was, she reported that (V14) did not tell her that. Thus, being unsure of the nature of the allegation. When this alleged incident was originally reported to this writer, (State Survey Agency) nor the resident could pinpoint a time or a [NAME] (day) of when this event occurred. However, after interview with staff an in reviewing the schedule (as it was reported that during this alleged abuse, V14 was not present) the date of the event came to be of 12/23/2023. After further investigation and interviewing those on the shift of 12/23/2023, it came to reasoning that R2 had an issue with her iPad charger. This then leads me to the next set of interviews to portray the night of 12/23/2023. (V9/LPN) was asked to write a statement of the events of her shift on 12/23/2023 regarding (R2) and her iPad charger. This was her statement, (there is no statement attached). (V15), CNA was on shift during the time of the alleged interaction: (V15) asked if he knew of the events surrounding the night of 12/23/2023, he stated he had heard hearsay statements but that he had not witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. (V16), CNA was on shift during the time of the alleged interaction: Staff denied having witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. When asking if she had any encounter surrounding (R2's) charger, she indicated that (R2's) charger broke and that she let (R2) use hers. This writer then asked that if during this time when (R2) was requesting a charger, if (V9) was present. She reported she was at the North Hall Nurses Station (25 feet approx.(approximately) from the location of which (R2) was sitting. This writer then asked (V16) if during this time (V9) made any commentary about (R2's) iPad or the charger, (V16) stated no. When asked if (V9) said any cuss words or derogatory remarks, she stated no (V14/LPN) stated that he in fact did call this in, but she was present in the building at the time of this event. (On 1/16/24 at 2:38 PM, V1 clarified that V14 stated V12 called it in and V14 was not present in the building at the time of the event). Resident (R2) interview: he is the one who told me she said, that that's f**king bullshit, and said she said a bunch of other s**t, but it's been so long ago, and I don't care. (R2) was asked if she felt threatened or abused or unsafe, she denied. When interviewing (V9), the following was her report she was not sure of any event occurring. When informed of the allegation she stated, I have never cussed at her or any resident. The only recent encounter we had was I walked by her, and she asked, What the f**k did I do to you? I told her I was not sure what she was talking about. And she rolled her eyes at me. I went to (V10/SSD) and informed her of this encounter and asked her if there was a grievance or anything that I didn't know, and she said there wasn't. (V10) and I went back to (R2) and asked her she was talked about, and she said somebody told her that I said she was an impatient bi**h. (V9) reported she did not say any of that. She did say that one point her and (V16) were speaking behind the nurse's station regarding things non work related and she may have used a cuss word, but she was unclear of if she did or not. But that she doesn't recall or would have ever spoke to or about a resident in such regard .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! The text messages from V12 to V1 (Administrator), indicate that V1 was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 10:07 AM, V13 (CNA/Certified Nursing Assistant) stated she had been off work for a couple of days and returned to work on 1/6/24. V13 stated she could tell there was a lot of tension, so she asked V14 (LPN) if something happened. V13 stated V14 (LPN) told her something had happened between R2 and V9 (LPN), and a visitor that she knew had called a complaint in to the state agency. V13 stated she didn't work on 12/23/23 and she hadn't witnessed abuse. When asked if she provided care to R2 and if R2 had reported anything to her, V13 stated she knew R2 was upset that weekend (of 12/23/23) because her IPAD wasn't working. V13 stated that is one thing R2 looks forward to and she couldn't use it. V13 stated they tried different chargers, and they weren't helping. On 1/16/24 at 12:29 PM, V14 (LPN) stated she was not working on 12/23/23. V14 stated, V12 (Visitor) told her about an interaction between V9 (LPN) and R2, that he was upset about it, and she told V12 to report it to V1 (Administrator). V14 stated that V12 attempted to contact V1, and she didn't answer so V12 sent V1 a text message. V14 stated that on 1/8/24, V14 had to go to the facility to chart and that V12 went with her. V14 stated when they arrived at the facility, V1 questioned them both asking why they called a complaint to the state agency. V14 stated V12 told V1 they could talk in the office and V1 refused to go to the office with them. V14 stated V1 kept asking why they called state and when V12 told V1 he wasn't going to talk about it there, V1 stormed off towards her office. On 1/16/24 at 3:20 PM, V15 (CNA) stated he worked on 12/23/23. When asked if he witnessed any interaction between V9 and R2 on 12/23/23, V15 stated, Not in particular. V15 denied hearing V9 curse at or around R2. V15 stated R2 did mention to him that she was tired of talking about it. V15 stated R2 told him she was overwhelmed with the amount of people asking her about it. V15 stated R2 told him she was upset with everything and didn't want to talk about it anymore. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation, V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the person who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (on 1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated that V14 (LPN) and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 1:40 PM, this surveyor asked V1 (Administrator) for a list of staff who worked on 12/23/23. The list that was provided to this surveyor included V17 (CNA) and V18 (LPN). When asked if she interviewed V17 and V18 as their interviews are not included in the investigation provided to this surveyor, V1 stated she had a meeting and asked anyone with information to stay and talk with her. V1 stated she didn't realize V17 had worked that day and she wasn't sure how she missed interviewing him. On 1/16/24 at 1:46 PM, V17 (CNA) stated he did work on 12/23/23 but didn't have any knowledge of V9 (LPN) cursing at R2. V17 stated V1 had not interviewed him related to the allegation. On 1/16/24 at 1:55 PM, V18 (LPN) stated he did work on 12/23/23. V18 stated he hadn't witnessed V9 curse at or around residents. V18 stated no one had asked him about the allegation prior to this interview. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V1 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work here. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Under definitions the policy describes verbal abuse as 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 their age, ability to comprehend, or disability. The policy describes mistreatment as, inappropriate treatment or exploitation of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the facility abuse policy when they neglected to identify an allegation of abuse, and timely and thoroughly investigate an allegation of abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present Staff interviews: (V13/CNA-Certified Nursing Assistant) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN that it was her boyfriend (V12/Visitor) that called it in, that it had allegedly occurred when he came to the building (bringing a friend of his who was an employee something to drink). When I asked (V13) if she knew about the alleged allegation prior to this, she reported she did not. It was after it was already reported, and the investigation had begun that she was informed of it. When asking (V13) if she was provided any details of what the alleged abuse was, she reported that (V14) did not tell her that. Thus, being unsure of the nature of the allegation. When this alleged incident was originally reported to this writer, (State Survey Agency) nor the resident could pinpoint a time or a [NAME] (day) of when this event occurred. However, after interview with staff an in reviewing the schedule (as it was reported that during this alleged abuse, (V14) was not present) the date of the event came to be of 12/23/2023. After further investigation and interviewing those on the shift of 12/23/2023, it came to reasoning that (R2) had an issue with her iPad charger. This then leads me to the next set of interviews to portray the night of 12/23/2023. (V9/LPN) was asked to write a statement of the events of her shift on 12/23/2023 regarding R2 and her iPad charger. This was her statement, (there is no statement attached). (V15), CNA (was on shift during the time of the alleged interaction): (V15) asked if he knew of the events surrounding the night of 12/23/2023, he stated he had heard hearsay statements but that he had not witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. (V16), CNA (was on shift during the time of the alleged interaction): Staff denied having witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. When asking if she had any encounter surrounding (R2's) charger, she indicated that (R2's) charger broke and that she let (R2) use hers. This writer then asked that if during this time when (R2) was requesting a charger, if (V9) was present. She reported she was at the North Hall Nurses Station (25 feet approx.(approximately) from the location of which (R2) was sitting. This writer then asked (V16) if during this time (V9) made any commentary about (R2's) iPad or the charger, (V16) stated no. When asked if (V9) said any cuss words or derogatory remarks, she stated no (V14/LPN) stated that he in fact did call this in, but she was present in the building at the time of this event. (On 1/16/24 at 2:38 PM, V1 clarified that V14 stated V12 called it in and V14 was not present in the building at the time of the event). Resident (R2) interview: he is the one who told me she said, that that's f**king bullshit, and said she said a bunch of other s**t, but it's been so long ago, and I don't care. (R2) was asked if she felt threatened or abused or unsafe, she denied. When interviewing (V9), the following was her report she was not sure of any event occurring. When informed of the allegation she stated, I have never cussed at her or any resident. The only recent encounter we had was I walked by her, and she asked, What the f**k did I do to you? I told her I was not sure what she was talking about. And she rolled her eyes at me. I went to (V10/SSD) and informed her of this encounter and asked her if there was a grievance or anything that I didn't know, and she said there wasn't. (V10) and I went back to (R2) and asked her she was talked about, and she said somebody told her that I said she was an impatient bi**h. (V9) reported she did not say any of that. She did say that one point her and (V16) were speaking behind the nurse's station regarding things non-work related and she may have used a cuss word, but she was unclear of if she did or not. But that she doesn't recall or would have ever spoke to or about a resident in such regard .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage (R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress. R2 stated V9 (LPN) said, this is fu**ing bullsh** and when R2 asked V9 if it was directed at her, V9 didn't respond. R2 stated a different nurse and her husband witnessed the interaction, and R2 believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, upon being informed of a potential allegation of abuse by surveyor, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start an investigation immediately and suspend V9 (LPN). On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the one who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated V14 and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 1:40 PM, this surveyor asked V1 (Administrator) for a list of staff who worked on 12/23/23. The list that was provided to this surveyor included V17 (CNA) and V18 (LPN). When asked if V1 interviewed V17 and V18 as their interviews are not included in the investigation provided to this surveyor, V1 stated she had a meeting and asked anyone with information to stay and talk with her. V1 stated she didn't realize V17 had worked that day and she wasn't sure how she missed interviewing him. On 1/16/24 at 1:46 PM, V17 (CNA) stated he did work on 12/23/23 but didn't have any knowledge of V9 (LPN) cursing at R2. V17 stated V1 had not interviewed him related to the allegation. On 1/16/24 at 1:55 PM, V18 (LPN) stated he did work on 12/23/23. V18 stated he hadn't witnessed V9 curse at or around residents. V18 stated no one had asked him about the allegation prior to this interview. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V12 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work here. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! This indicates V1 (Administrator) was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. Under definitions the policy describes verbal abuse as 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 their age, ability to comprehend, or disability. The policy describes mistreatment as, inappropriate treatment or exploitation of a resident. Under Internal Reporting Requirements and Identification of Allegations the program documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observed, hear about, or suspect to a supervisor and the administrator .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation Under Protection of Residents the program documents, The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse, or misappropriation of resident property shall not complete their shift as a direct care provider to residents. Under Internal Investigation of Allegations and Response the program documents, .Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident .Under External Reporting of Potential Abuse, the program documents, 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health Informing Law Enforcement Authorities. If there is clear evidence of abuse by an employee, the Department of Public Health will notify the Health Care Worker Registry or the Department of Financial and Professional Regulation. The Department of Public Health will also notify the State Police for further investigation of the employee. If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Survey Agency for 1 of 1 (R2) resident reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage(R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress observed. R2 stated V9 (LPN/Licensed Practical Nurse) said, this is fu**ing bullsh** and when R2 asked V9 if it was directed at her V9 didn't respond. R2 stated a different nurse, and her husband witnessed the interaction, and she believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start the investigation immediately and suspend V9 (LPN). A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! This indicates V1 (Administrator) was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the one who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated V14 and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA/Certified Nursing Assitant) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V12 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work here. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. V1 stated the allegation was not reported to the local law enforcement since it was an allegation of verbal abuse and not an allegation of physical abuse. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. Under Internal Reporting Requirements and Identification of Allegations the program documents, .Upon learning of the report, the administrator or designee shall initiate an investigation . Under External Reporting of Potential Abuse, the program documents, 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health Informing Law Enforcement Authorities .If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely and thoroughly investigate an allegation of abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 19. Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage(R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress. R2 stated V9 (LPN/Licensed Practical Nurse) said, this is fu**ing bullsh** and when R2 asked V9 if it was directed at her V9 didn't respond. R2 stated a different nurse, and her husband witnessed the interaction, and she believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, upon being informed of a potential allegation of abuse by surveyor, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start an investigation immediately and suspend V9 (LPN). On 1/4/24 at 2:03 PM, V9 (LPN) stated she had never cursed or yelled at any of the residents. V9 stated on 12/27/23, R2 told her she was upset with her because V9 yelled at her (R2) on Christmas. V9 stated she explained to R2 that she couldn't have yelled at her on Christmas because V9 didn't work on Christmas. On 1/4/24 at 2:57 PM, V10 (Social Service Director) stated last week she walked down the hall and R2 was sitting in her chair by the nurse's station. V10 stated she heard V9 tell R2 that she didn't remember saying something but if she did, she was sorry. V10 stated she stopped and talked with R2 and R2 and V9 were joking around so she didn't think there was an allegation to report. V10 stated R2 will usually have a staff member get her if she has a concern or issue with anything. The facility's undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present During the investigation residents many residents (sic) were interviewed by the QAC (Quality Assurance Committee) to assess their interactions with (V9) and to directly ask if they had witnessed, heard of, or encountered any form of abuse by her .none of them reported a grievance, negative interactions, or reported witnessing or encountering abuse of any form .Staff interviews: V13 (CNA) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN that it was her boyfriend (V12) that called it in, that it had allegedly occurred when he came to the building (bringing a friend of his who was an employee something to drink). When I asked (V13) if she knew about the alleged allegation prior to this, she reported she did not. It was after it was already reported, and the investigation had begun that she was informed of it. When asking (V13) if she was provided any details of what the alleged abuse was, she reported that (V14) did not tell her that. Thus, being unsure of the nature of the allegation. When this alleged incident was originally reported to this writer, (State Survey Agency) nor the resident could pinpoint a time or a [NAME] (day) of when this event occurred. However, after interview with staff an in reviewing the schedule (as it was reported that during this alleged abuse, (V14) was not present) the date of the event came to be of 12/23/2023. After further investigation and interviewing those on the shift of 12/23/2023, it came to reasoning that R2 had an issue with her iPad charger. This then leads me to the next set of interviews to portray the night of 12/23/2023. (V9/LPN) was asked to write a statement of the events of her shift on 12/23/2023 regarding R2 and her iPad charger. This was her statement, (there is no statement attached). (V15), CNA (was on shift during the time of the alleged interaction): (V15) asked if he knew of the events surrounding the night of 12/23/2023, he stated he had heard hearsay statements but that he had not witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. (V16), CNA (was on shift during the time of the alleged interaction): Staff denied having witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. When asking if she had any encounter surrounding (R2's) charger, she indicated that (R2's) charger broke and that she let (R2) use hers. This writer then asked that if during this time when (R2) was requesting a charger, if (V9) was present. She reported she was at the North Hall Nurses Station (25 feet approx.(approximately) from the location of which (R2) was sitting. This writer then asked (V16) if during this time (V9) made any commentary about (R2's) iPad or the charger, (V16) stated no. When asked if (V9) said any cuss words or derogatory remarks, she stated no (V14/LPN) stated that he in fact did call this in, but she was present in the building at the time of this event. (On 1/16/24 at 2:38 PM, V1 clarified that V14 stated V12 called it in and V14 was not present in the building at the time of the event). Resident (R2) interview: he is the one who told me she said, that that's f**king bulls**t, and said she said a bunch of other s**t, but it's been so long ago, and I don't care. (R2) was asked if she felt threatened or abused or unsafe, she denied. When interviewing (V9), the following was her report she was not sure of any event occurring. When informed of the allegation she stated, I have never cussed at her or any resident. The only recent encounter we had was I walked by her, and she asked, What the f**k did I do to you? I told her I was not sure what she was talking about. And she rolled her eyes at me. I went to (V10/SSD) and informed her of this encounter and asked her if there was a grievance or anything that I didn't know, and she said there wasn't. (V10) and I went back to (R2) and asked her she was talked about, and she said somebody told her that I said she was an impatient bi**h. (V9) reported she did not say any of that. She did say that one point her and (V16) were speaking behind the nurse's station regarding things non work related and she may have used a cuss word, but she was unclear of if she did or not. But that she doesn't recall or would have ever spoke to or about a resident in such regard .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! The text messages from V12 to V1 (Administrator), indicate that V1 was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 10:07 AM, V13 (CNA/Certified Nursing Assistant) stated she had been off work for a couple of days and returned to work on 1/6/24. V13 stated she could tell there was a lot of tension, so she asked V14 (LPN) if something happened. V13 stated V14 (LPN) told her something had happened between R2 and V9 and V12 (Visitor) had called a complaint in to the state agency. V13 stated she didn't work on 12/23/23 and she hadn't witnessed abuse. When asked if she provided care to R2 and if R2 had reported anything to her, V13 stated she knew R2 was upset that weekend (of 12/23/23) because her IPAD wasn't working. V13 stated that is one thing R2 looks forward to and she couldn't use it. V13 stated they tried different chargers, and they weren't helping. On 1/16/24 at 12:29 PM, V14 (LPN) stated she was not working on 12/23/23. V14 stated, V12 told her about an interaction between V9 (LPN) and R2 that he was upset about, and she told him to report it to V1 (Administrator). V14 stated, V12 attempted to contact V1, and she didn't answer so he sent V1 a text message. V14 stated on 1/8/24 she had to go to the facility to chart and V12 went with her. V14 stated when they arrived at the facility, V1 wanted to know why they called a complaint to the state agency. V14 stated V12 told V1 they could talk about it in the office and V1 refused to go to the office with them. V14 stated V1 kept asking why they called state and when V12 told V1 he wasn't going to talk about it there V1 stormed off towards her office. On 1/16/24 at 3:20 PM, V15 (CNA) stated he worked on 12/23/23. When asked if he witnessed any interaction between V9 and R2 on 12/23/23, V15 stated, Not in particular. V15 denied hearing V9 curse at or around R2. V15 stated R2 did mention to him that she was tired of talking about it. V15 stated R2 told him she was overwhelmed with the amount of people asking her about it. V15 stated R2 told him she was upset with everything and didn't want to talk about it anymore. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the one who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated V14 and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 1:40 PM, this surveyor asked V1 (Administrator) for a list of staff who worked on 12/23/23. The list that was provided to this surveyor included V17 (CNA) and V18 (LPN). When asked if she interviewed V17 and V18 as their interviews are not included in the investigation provided to this surveyor, V1 stated she had a meeting and asked anyone with information to stay and talk with her. V1 stated she didn't realize V17 had worked that day and she wasn't sure how she missed interviewing him. On 1/16/24 at 1:46 PM, V17 (CNA) stated he did work on 12/23/23 but didn't have any knowledge of V9 (LPN) cursing at R2. V17 stated V1 had not interviewed him related to the allegation. On 1/16/24 at 1:55 PM, V18 (LPN) stated he did work on 12/23/23. V18 stated he hadn't witnessed V9 curse at or around residents. V18 sated no one had asked him about the allegation prior to this interview. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V12 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work her. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. Under definitions the policy describes verbal abuse as 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 their age, ability to comprehend, or disability. The policy describes mistreatment as, inappropriate treatment or exploitation of a resident. Under Internal Reporting Requirements and Identification of Allegations the program documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observed, hear about, or suspect to a supervisor and the administrator .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation Under Protection of Residents the program documents, The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse, or misappropriation of resident property shall not complete their shift as a direct care provider to residents. Under Internal Investigation of Allegations and Response the program documents, .Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident .Under External Reporting of Potential Abuse, the program documents, 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health Informing Law Enforcement Authorities. If there is clear evidence of abuse by an employee, the Department of Public Health will notify the Health Care Worker Registry or the Department of Financial and Professional Regulation. The Department of Public Health will also notify the State Police for further investigation of the employee. If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a resident an advanced written notice of involuntary discharge with appeal rights for 1 (R1) of 3 residents reviewed for discharge in the sample of 19. Findings Include: R1's admission Record with a print date of 1/4/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include quadriplegia, adjustment disorder with anxiety, adjustment disorder with mixed disturbance of emotions and conduct, spastic hemiplegia, neurogenic bowel, and pressure ulcers. R1's BIMS (Brief Interview for Mental Status) dated 11/03/23 documents a score of 15, which indicates R1 is cognitively intact. R1's MDS (Minimum Data Set) dated 12/12/23 documents under Section G, R1 is dependent on staff for all Activities of Daily Living (ADL's). Under Section I, this same MDS documents a diagnosis of quadriplegia. R1's undated Care Plan documents a Focus area with an initiation date of 11/04/23, Dependent for ADLs- Unable to assist/Assists only minimally. Not a candidate for Restorative Programming. Further decline in ability/participation likely due to Quadriplegia. Resident is dependent on 2 assist via Hoyer lift for transfers/ADLs. The interventions documented for this Focus area include, Place in wheelchair for positioning while up and all transport Provide bathing, hygiene, dressing and grooming per Resident's preference as able Provide oral care with am and pm cares Scheduled repositioning program .Transfer Resident using mechanical device of Hoyer and 2 staff members . This same Care Plan documents a Focus area with an initiation date of 11/06/23 of, Resident (R1) is known to display/has history of paranoid thoughts/behaviors and/or open conflict/criticism with others including false accusations. Resident refuses care, then accuses staff of denying him care. Adjustment disorder w (with)/mixed disturbances of emotions and conduct. The interventions documented for this care area include, Administer psychotropic medications as ordered by physician . Allow resident time and opportunity to express feelings, anger, or frustration. Provide empathy and validation of feelings while orienting to reality. Ensure 2 staff members are present for care and services to minimize risk of false accusations Investigate any reality basis and share facts w/resident. Provide reality orientation as possible .Psychotherapy services as needed/desired/tolerated by resident . R1's Progress Notes dated 12/12/23 documents, Res (resident/R1) showing s/s (signs/symptoms) of AMS (altered mental status) with hallucinations and delusions. Res making statements that he fell out of bed. Res is paraplegic and unable to get himself in/out of bed. Res transported to (name of local hospital) via (name of local ambulance service). On 1/2/2024 at 2:16 PM, V3 (Hospital Case Manager) stated R1 was sent to the local hospital for evaluation on 12/12/23. V3 stated R1 was discharged from the hospital and cleared to return to the facility on that same day. V3 stated the facility refused to re-admit R1 to the facility. V3 stated the facility hand-delivered discharge papers to R1 while in the hospital emergency room. V3 stated R1 remained in the hospital emergency room from 12/12/23 to 12/18/23. V3 stated on 12/18/23 they were able to get R1 admitted to their in-house hospice and R1 remained in the hospital in a hospice room. V3 stated they have attempted to find placement for R1 and have been unable to find a facility that will accept him. The facility Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 12/12/23 documents under Federal Proceeding.This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and long-term care facility .the reason for this proposed transfer or discharge is: your welfare and needs cannot be met in this facility, as documented in your clinical record by your physician .the safety of individuals in this facility is endangered .the health of individuals in the facility would otherwise be endangered, as documented by a physician in your clinical record . The notice documents R1 will be relocated to the local hospital and the effective date of the transfer is documented as 12/12/23. R1's local hospital record with an admission date of 12/12/23 documents the following progress notes. 12/12/23 9:02 AM, Patient (R1) is a .quadriplegic who was sent in from nursing home for shoulder pain. Patient was discharged from the nursing home while patient was in the ER (Emergency Room) due to staff at the nursing home being unable to deal with him. Currently we are looking for placement for the patient . 12/12/23 1:41 PM, This RN (Registered Nurse) spoke with V2 (Director of Nurses) at (name of facility). Again, let V2 know that patient was up for discharge and clarified with her that they will not be allowing patient to return. Requested documentation of refusal to allow the patient to return be faxed to the ER, V2 stated they would be happy to fax written documentation of this refusal. 12/12/23 3:59 PM, This patient (R1) has requested to go elsewhere than his current NH (nursing home) facility . 12/12/23 5:13 PM, V1 (Administrator) and V2 (Director of Nurses) from (name of facility) dropped of PT (patient/R1) D/C (discharge) papers and took documenters name as recipient. 12/12/23 6:59 PM, Patient (R1) .male history of quadriplegia presenting from the nursing home for musculoskeletal pain. Patient was sent to the ER by the nursing home and then discharged from the nursing home 12/16/2023, I again assumed care of this patient .at 7 PM on 12/14. Patient (R1) is refusing any medical treatment, is desiring to be on hospice, is no longer welcome at his living facility, so case management is working on placement at an alternative facility. 12/18/23 9:45 AM, Reviewed Hospice philosophy and desire for hospice care. Patient (R1) understands his choices and able to decipher benefit vs (versus) burden. He is requesting comfort care. Patient informed all long-term care referrals have been declined. Agreeable to plan for possible transfer to accepting hospice house. On 1/4/24 at 11:29 AM, R1 stated he was not aware he was being discharged from the facility when he went to the emergency room on [DATE]. R1 stated he didn't want to return to the facility because he felt like he would just get revenge care. When asked why he was discharged from the facility R1 stated he thought it was because he called the state agency on the facility. R1 stated when the director (no name given) delivered the discharge papers to the hospital she told him he should never have called the police. R1 stated the hospital is currently looking for other options for him. When asked if there was any harm related to his discharge R1 stated, Absolutely. R1 stated he knew it was revenge. R1 stated he told them it was illegal to evict someone for no reason. At 3:03 PM on this same date, when asked how he felt about the involuntary discharge, R1 stated it was devastating and embarrassing. R1 stated he felt abandoned, afraid, and didn't know what was going to happen to him. On 1/4/24 at 3:18 PM, V2 (Director of Nursing) stated R1 was sent to the local hospital because he was demanding to be sent. V2 stated they heard he was trying to press criminal charges against staff and staff were upset about how R1 had treated them the night before. V2 stated after talking with their corporate office and medical director they determined it was in everyone's best interest to discharge R1. V2 stated there were no charges that were brought against any staff and the allegations were investigated by the facility and the local police. V2 stated she was not aware of R1 targeting any residents. V2 stated it was unsettling for residents to lay in bed at night and listen to R1 be so insulting. V2 stated she was only aware of R4 complaining regarding R1's behavior and that was because her room was close to R1's and she was alert and oriented. On 1/4/23 at 3:37 PM, V1 (Administrator) stated on the morning of 12/12/23, R1 requested to be transferred to the local emergency room and to call the police. V1 stated she advised the staff to send R1 out per his request. V1 stated R1 reported to the local hospital he wanted to press charges on facility staff for battery. V1 stated the allegation of abuse was investigated by the facility and local law enforcement and there were no findings, and no charges were filed against any staff. V1 stated they had been reviewing a possible discharge for R1 since they couldn't meet R1's needs. V1 stated hospice had been in and R1 refused hospice services with four different providers. V1 stated they reviewed R1's refusal of care. V1 stated on night shift prior to R1 being transferred to the local hospital on [DATE] R1 had been shouting and it was bothering R4. V1 stated after reviewing the information with the interdisciplinary team they came to the conclusion it was better for the psychosocial care of our other residents to discharge R1 from the facility. V1 stated there were only three staff members R1 liked so medical care was met with resistance from R1. V1 stated R1 told hospice and the local law enforcement on 12/12/23 at the hospital that he didn't want to return to the facility, so that helped make the decision in moving forward with the involuntary discharge. V1 stated R1 was not allowed to return to the facility from the hospital. V1 stated R1 was transferred to the hospital on [DATE] and was given the immediate involuntary discharge papers while at the hospital on [DATE]. V1 stated she knew there were residents who complained about how R1 talked to the staff and him cursing. V1 stated R1 did not yell at other residents. R1 was just vocal and vulgar. When asked if R1 was capable of physically harming someone, V1 stated, No, R1 only had control of his left arm. The undated facility Transfer and Discharge Policy and Procedure documents, It is the policy of (name of corporation) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility .3. The safety of individuals in the facility is endangered In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the resident's welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Type of Transfer and discharge: Less than 30-day notice. Transfers and discharges with less than 30 days' notice may occur in limited circumstances. 1. The health or safety of others in the facility is endangered; 2. The health of the resident has improved to allow more immediate transfer or discharge; 3. The residents urgent medical needs require more immediate transfer; 4. The resident has not resided in the facility for 30 days. Under Involuntary transfers or discharge the policy documents, Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record .In all other instances of involuntary transfer or discharge the mandated federal and state 30 day 'Notice Transfer or Discharge will be issued, and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents' representative and/or the person or agency responsible for the resident's placement, maintenance, and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing including the names of those in attendance. The summary shall be made a part of the resident's clinical record. 3. A physician's discharge order shall be obtained in the residents record prior to discharge. 4. Prior to transfer or discharge the Social Services Director shall counsel the resident and summarize the counseling session in the resident record.

Based on observation, interview and record review the facility failed to provide services of a Registered Nurse for eight consecutive hours a day seven days a week. This has the potential to affect all 43 residents residing at the facility. Findings Include. The facility document dated November 2023 titled, Nurses Schedule documents V2, as the only registered nurse working 11/20, 11/21, and 11/22 with an X in the box for her name. The key under the schedule documents: x = 6a-6p or 6p - 6a. On 11/20/23 at 11:00 AM, V2 (Director of Nursing) was observed arriving at the facility. On 11/21/23 at 9:15 AM, V2 was observed arriving at the facility. At 9:20 AM, V2 was observed leaving the facility and returned at approximately 9:50 AM. On 11/21/23 at 1:50 PM, V2 stated, she had to leave today at approximately 2:00 PM. On 11/21/23 between 2:15 PM and 3:45 PM there was no RN observed at the facility. On 11/21/23 at 2:15 PM, V12 (Minimum Data Set Coordinator) stated, V2 had left, she stated, she did not know if or when V2 was returning. On 11/22/23 at 9:45 AM, V2 was not at the facility. On 11/22/23 between 10:00 AM and 2:15 PM there was no RN at the facility including V2. On 11/22/23 at 10:30 AM, V14 (Licensed Practical Nurse) stated, V2 is currently not at the facility. V14 stated, V3 (Registered Nurse/RN) was at the facility earlier, but she already left, he is not really for sure when she left or when or if V2 is coming in. On 11/22/23 at 12:35 PM, V1 (Administrator) stated, V2 worked four hours this morning and sometime this afternoon V2 will be back to work. V1 stated, she does not have a timeframe of when V2 will be back to work. On 11/22/23 at 1:15 PM, V1 stated, the schedule that she has provided is the schedule they utilize. She stated, she does not have time punches for V2 because she is salary, so she does not clock in or clock out. V1 stated she does not have any method to document that the facility has RN coverage eight consecutive hours a day seven days a week. V1 stated she is unaware of how they turn in the information for the payroll-based journaling. When a nurse staffing policy was requested, the following was provided: A white sheet of paper with no title and no date that read, For nursing staffing, we follow regulations. The Facility Room List dated 11/20/23 documents there are 43 residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to serve meals at the facility's designated scheduled times. This has the potential to affect all 43 residents residing at the facility. Findings include: The facility document dated 06/06 titled, Meal Times states: The facility will serve at least three meals per day with no more that fourteen (14) hours between the serving of supper and breakfast. Procedure: 1. Meal service begins at: Breakfast - 8:00 AM (with the 8:00 handwritten in), Lunch - 12:00 PM (with the 12:00 handwritten in) and Supper - 5:00 PM (with the 5:00 PM handwritten in). On 11/20/23 at 1:30 PM, V1 (Administrator) stated, last week on Tuesday lunch did come out after 1:00 PM, she knows there was some unhappy people. On 11/21/23 at 1:50 PM, V5 (Dietary Manager) stated, she has worked here since August. Breakfast is at 8:00 AM, lunch is at 12:00 PM, and dinner is at 5:00 PM. V5 stated, the halls trays go out first then the dining room trays. V5 stated, some of her staff is new and they are working on getting the kitchen procedures down, getting temperatures correct and general food safety. Sometimes they do run a little behind because after breakfast they need to get the dishes washed, the dining room cleaned, and the food cooked and ready for lunch. Right now, there are times it is just her by herself, they are working on getting more staff. V5 stated, she does remember last week when they were over an hour late, some of the food was not at temperature and lunch was late. On 11/20/23 at 12:28 PM the hall trays came out of the kitchen, at 12:33 PM the dining room trays started coming out. On 11/20/23 at 12:10 PM, R8 was yelling out at the dining room table. At 12:35 PM, R8 received his food and quit yelling out. R8's MDS dated [DATE] documents a BIMS score was not performed due to resident is rarely understood. On 11/21/23 at 8:50 AM breakfast trays were still being delivered. On 11/21/23 at 9:00 AM, R7 stated she received breakfast which was just passed at 8:30 AM. R7 stated, that is about typical, the meals have been late, but they have been better. R7's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. On 11/21/23 at 9:05 AM, R5 and R6 stated, they received breakfast around 8:45 AM, they stated, meals have been late recently. They ate in their room today for breakfast and the hall trays were served first. R5 and R6 stated, last week lunch was really late, Tuesday they believe, but meals have been late in general. R5's MDS dated [DATE] documents a BIMS score of 14 indicating cognitively intact. R6's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. On 11/21/23 at 12:30 PM, R10 asked where lunch was. R10's MDS dated [DATE] documents a BIMS score of 09 indicating moderately impaired. On 11/21/23 at 12:30 PM lunch trays started coming out of the kitchen for the hallways. At 12:35 PM lunch trays started being served to the dining room. On 11/21/23 at 12:15 PM, R8 was yelling out at the dining room table. At 12:42 PM, R8 received his lunch tray and quit yelling out. On 11/21/23 at 12:15 PM, V28 (Family) stated, the lunches have been late lately. Last week on Tuesday lunch was not served until after 1:10 PM. She comes to the facility to feed R1 for lunch and last Tuesday she had an appointment and had to miss it because lunch was so late. V28 stated, R8 will yell out once he is brought to the dining room until he is given food. A few times she has brought snacks for R1 and asked if R8 could have some, once he was given some, he quit yelling out and he doesn't yell out after he is done eating, she thinks he just wants food. On 11/21/23 at 12:20 PM, R2 stated, lunch was really late last week, lunch has been late lately. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired. On 11/20/23 at 10:30 AM, R12 stated the meals are typically late, that is nothing new. R12 was alert and oriented to person, place and time. On 11/20/23 at 12:15 PM, R4 stated, the meals tend to be late here, and they are not great. R4's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. On 11/21/23 at 2:10 PM, V15 (Certified Nurse Aide) stated, sometimes the meals are late. The hall trays are supposed to start at 12:00 PM and the dining room is served after the hall trays leave the kitchen. On 11/21/23 at 2:13 PM, V13 (Licensed Practical Nurse) stated, the meals can be late sometimes. There was a day last week that the lunch trays did not come out until after 1:00 PM. On 11/21/23 at 12:10 PM, V17 (Certified Nurse Aide) stated, lunch is supposed to be at 12:00 PM, sometimes it is late. Last week on Tuesday it was served after 1:00 PM. The Facility Room List dated 11/20/23 documents there are currently 43 residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 12 (R37) residents reviewed for assessments in a sample of 42. The Findings Include: A quarterly MDS assessment dated [DATE] documents in Section K0300 that R37 has not had weight loss of 5% or more in one month or 10% in six months and Section K0510 documents no indicating that R37 is not on a mechanically altered diet. R37's Physician's Order Sheet (POS) dated May 1st, 2023, to May 31st, 2023, documents a diet order of Regular, Pureed, thin liquids. R37's monthly weight grid documents a February weight of 153.6 pounds, March weight of 149.2 pounds, April weight of 138.8 pounds, and a May weight of 137 pounds. On August 22, 2023, at 1:00 PM, V12 (MDS Coordinator) stated that those were coded in error on the May MDS and will be corrected on this upcoming MDS that is due in August.

Based on interview and record review the facility failed to develop a person-centered comprehensive care plan for 1 of 12 (R37) residents reviewed for weight loss in a sample of 42. The Findings include: R37's face sheet documents an admit date of 1/25/23 and includes the following diagnosis: dementia, Alzheimer's, dysphagia, and feeding difficulties. R37's current physician order sheet documents a diet order of a regular diet/pureed texture, regular/thin consistency, supercereal at breakfast. and magic cup supplement at lunch and 90 milliliters of 2.0 calorie supplement twice daily. R37's order for the supercereal and magic cup original order date is 4/29/23 and 90 milliliters of 2.0 supplement once daily start date of 6/6/23 and was increased to two times a day on 8/17/23. A dietary note made on 8/4/23 recommended to increase the 2.0 calorie supplement to twice daily from once a day due to the resident having weight loss trends over 6 months. On 8/22/23 at 11:45 AM, V1 (Administrator) confirmed that R37's weight loss and dietary supplementation were not documented anywhere in the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dining assistance to residents as needed for 2 of 11 residents (R26, R34) reviewed for dining in the sample of 42. Findings Include: On 08/16/23 at 12:41 PM, R34 and R26 were observed sitting at the same table in the dining room. No staff were observed as being present at the table. R34 and R26 had been served a regular diet of tuna noodle casserole, mixed vegetables, roll, and cup of applesauce as their meal. R34 was observed attempting to drink her applesauce out of the cup, with no success. R34 was then observed using her fork to scoop tuna noodle casserole off of her plate and into her full applesauce cup. On 8/16/23 at 12:45 PM, R34 was again attempting to drink her applesauce cup with tuna noodle casserole on top of it, with no success. No staff were present at table, intervening or assisting R34. On 8/16/23 at 12:46 PM, R26 began eating mixed vegetable off of her plate with her fingers. Silverware was observed being present, but not utilized. On 8/16/23 at 12:48 PM, R34 was observed shifting positions of her plate, drinking glasses, and applesauce cup around on table, looking at food with silverware present but did not initiate eating. This surveyor asked R34 if she needed help, in which she replied yes. R34 was alert to person only at this time. On 8/16/23 at 12:49 PM, R34 was observed being red faced and tearful, eating her mixed vegetables with her hands. When asked why she was crying, not understood mumbling speech was noted. On 8/16/23 at 12:51 PM, V3 (Certified Nurse Assistant, CNA) approached R34 at the table and asked, Are you done? What's wrong? Do you need to use the bathroom? Inaudible speech was noted by R34 and V3 wheeled R34 away from the table, leaving the dining room. Greater than 50% of R34's meal was still observed with foods mixed in the dishes, on the table, and on the floor. Continuous observation was conducted regarding R26 and R34 on 8/16/23 from 12:41 PM - 12:51 PM with no staff assistance offered. On 08/17/23 at 09:33 AM, V1 (Administrator) stated that most of the time R26 can feed herself and R34 needs feeding prompts. V1 stated if residents were struggling to feed themselves, she would expect staff to intervene and assist. V1 confirms that both R26 and R34 are not cognitively intact. V1 stated that R34 has being having crying episodes since having a rejected knee replacement requiring surgical intervention, which was confirmed via R34's clinical record. V1 stated that the facility has been working with the physician to address these crying concerns. V1 stated that she spoke with V3 regarding providing resident's dining assistance, in which V1 reported V3 told her she was trying to do the best she could. On 08/17/23 at 12:58 PM, R26 was again observed feeding herself with no staff present at the table. R26 was observed wiping her mouth with the tablecloth, which was also witnessed by V1. V1 then instructed CNA staff to come sit with R26 and assist her. On 08/18/23 at 01:13 PM, V7 (CNA) stated that R34 and R26 are both confused. V7 stated both R34 and R26 require supervision with meals, and at times need assistance getting the food on their fork. On 8/18/23 at 1:20 PM, V8 (CNA) stated that both R34 and R26 require supervision with meals and sometimes cueing. V8 stated that normally, a staff member does not sit exclusively at the table with R34 and R26 as there are other residents who also need assistance being fed, as well as staff having to be back on the halls to help residents. V8 stated staff members walking by the table try to keep an eye out and provide assistance to R26 and R34 as they see is needed. Review of R34's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating she is not cognitively intact. This same MDS documents in section G0110, that R34 required limited assistance of one person physical assist. Limited assistance is defined in the document as, resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Review of R26's MDS dated [DATE] documents a BIMS score as not being able to be performed due being rarely or never understood. Section G0110 of the same MDS documents R26 requires Supervision with setup help only. Supervision is defined as, oversight, encouragement or cueing. Review of the policy titled, Dining Room Procedure with a most recent revision date of 10/16 stated, 6.As the meal is delivered, a staff member will assist with and/or prepare the food as needed (i.e. - cut up meat, open milk, butter bread) .Staff shall ensure that residents receive assistance as needed and check for the availability of ice water, coffee and substitutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a residents medications were available for administration for one of seven residents (R7) reviewed for medication administration in the sample of forty-two. Findings include: R7's Face Sheet documented an admission date of 7/28/23, and diagnoses including Chronic Obstructive Pulmonary Disorder, Insomnia, and Bipolar Disorder, Unspecified. On 8/17/23 at 10:05am, R7 was alert and oriented to person, place, and time. R7 stated she was in special education services throughout school, and that she cannot read or write. R7 stated, Earlier this month, (August 2023), I went a few days without some of my psych(iatric) med(ications), they said they didn't have them here, I'm not sure what the problem was. I was having problems before that though, with not sleeping and feeling like I am going crazy sometimes, maybe because when I went to the ER (Emergency Room) on 7/31/23, they took me off some of my psych meds because I had low sodium. I went back to ER on [DATE] partly because I'm upset because my husband is in the hospital. I can't say I'm any worse since I missed the doses of the medications. I'm not sure which ones they were out of, but they finally got them in from the pharmacy. R7's August 2023 POS (Physicians Order Sheet) documented orders for Trileptal 300mg (milligrams) one tablet twice daily for Bipolar Disorder, and Ambien 10mg one tablet at bedtime for a diagnosis of Bipolar Disorder. R7's August 2023 MAR (Medication Administration Record) documented that R7 did not receive Trileptal on 8/7/23 through 8/11/23 as it was unavailable. The same MAR documented that R7 did not receive Ambien on 8/5/23 through 8/11/23 as it was unavailable. R7's Nurses Notes read as follows: 8/5/23, 8/6/23, 8/7/23, 8/9/23, 8/10/23, 8/11/23: Ambien not administered, on order through pharmacy. There were no Nurses Notes to indicate the pharmacy was contacted. 8/7/23, 8/8/23, 8/10/23, 8/11/23: Trileptal not administered, on order from pharmacy. There were no Nurses Notes to indicate the pharmacy was contacted. On 8/17/23 at 12:41pm, V2, Director of Nurses, acknowledged the gap in Ambien and Trileptal administration as outlined above, stating nursing staff had notified her the medications had not been delivered. V2 stated the error was due to the pharmacy not sending the medications. V2 stated there had been some confusion that the Ambien could not be e-scripted and required a hard copy of the script. V2 stated she is not sure why the Trileptal was not sent. V2 stated the nurses who noticed the medication had not been delivered should have contacted the pharmacy and documented it in the nurse's notes. V2 stated the facility has a backup pharmacy which for whatever reason was not contacted. V2 stated R7's struggling with symptoms of bipolar disorder predate the missed doses of medication, and R7's symptomatology has not been worse than she has been in the past few months. On 8/22/23 at 11:06am, V10, Pharmacy Technician, stated the Trileptal order was received on 8/4/23, but was not delivered until 8/15/23. V10 stated there are no notes to indicate why it was not sent before then. V10 stated they received a hard script from the facility for the Ambien on 8/11/23 along with a STAT (as soon as possible) request from the facility, and it was dispensed on that day. A Medication Administration Policy dated 11/18/17 stated, Drug administration shall be defined as an act in which a single dose of a prescribed drug is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. #21. If the medication is not available for a resident, call the pharmacy and notify the Physician when the drug is expected to be available.

Based on observation, interview, and record review the facility failed to serve foods at the desired palatable temperature for 33 (R2, R3, R4, R5, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R29, R31, R32, R33, R34, R35, R36, R38, R39, R40) of 33 residents reviewed for palatability in the sample of 42. Findings Include: On 08/15/23 at 10:30 AM, R17 stated that he eats his meals in his room and the food is normally cold. R17 is alert to person, place and time at this encounter. On 08/15/23 at 12:33 PM, R11 was observed being served Salisbury Steak, which she reported was, barely warm at best. R11 was observed as being alert and oriented to person, place, and time during this encounter. On 08/16/23 at 1:00 PM, V11 (Family Member) stated that she is here for every lunch meal. V11 states that the trays take a while to get down there to her husband's room, and more often than not the food is barely warm. On 08/18/23 at 12:35 PM, a test tray was requested with temperatures of the foods being taken by V4 (Cook) with V1 (Administrator) present, utilizing their own facility thermometer. The potato wedges were noted as being 91.8 F (Fahrenheit). V4 and V1 acknowledged the potato wedges were below the desirable palatable temperature. On 08/18/23 at 12:40 PM, R11 stated her potato wedges were cold. R11 was alert and oriented to person, place, and time during this interview. On 08/18/23 at 12:43 PM, R10 stated her potato wedges were cold. R10 was alert and oriented to person, place, and time during this interview. Review of the policy titled, Dining Room Procedures with a most recent revision date of 10/16 documents, It is the policy of (company) that all residents will receive attractive and nourishing meals at the proper temperature and within a pleasant atmosphere. Review of the Diet Type Report dated 8/16/23 documents the following resident receive a regular or mechanical texture diet, which would have had potato wedges utilized during the mealtime: R2, R3, R4, R5, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R29, R31, R32, R33, R34, R35, R36, R38, R39, R40.

Based on observation, interview, and record review the facility failed to provide diets as ordered and failed to follow pre-planned menus and standardized recipes. This failure has the potential to affect all 37 residents who reside in the facility. Findings Include: 1. On 8/16/23 at 12:53 PM, R12 was observed being served a puree diet of tuna noodle casserole, mixed vegetables, apple sauce, and a (name brand) supplement cup. Review of R12's meal card documented R12 should receive double protein portions, which was not observed being served. On 8/16/22 at 12:55 PM, V4 (Cook) confirmed R12 was not served a double protein portion by mistake. At 1:00 PM, V4 was observed providing R12 an additional serving of tuna noodle casserole. On 08/17/23 at 09:33 AM, V1 stated that it her expectation that prescribed diets are followed as ordered. On 08/18/23 at 12:26 PM, R12 was observed receiving her meal tray. No (name brand) supplement cup was noted on the tray. V1 (Administrator) was notified of the lack of a supplement cup served, which she acknowledged, and retrieved one for R12. Review of R12's current Physician Orders document a diet order of, Puree Texture, Regular/Thin consistency, Double Portions at all meals, (name brand supplement cup) 2x/day . Review of R12's current diet card documents the (name brand) supplement cup is to be given at lunch and dinner daily. Review of R12's Plan of Care documents a problem area of, Resident in need of additional nutrition in form of increased protein, calories, vitamins and minerals .(Name) has been reeducated multiple times about the importance of eating and taking supplements to promote healing of her decubs. An additional problem area includes, Pressure Ulcer Present: (name) is under the care of wound specialist, (company) wound care for Stage 4 pressure ulcers . 2. R20's August 2023 POS (Physician's Order Sheet) includes a diet order for mechanical soft texture dated 08/01/23. On 08/17/23 at 12:46 PM, R20 was served her lunch meal. R20 was served roast turkey with gravy. The turkey was not prepared in a mechanical soft consistency but instead had been shredded into approximately 2 to 3 inch stringy pieces. R20 who was alert to person, place and time picked up a piece of turkey meat and stated, This is awfully stringy, and some pieces are really long. I don't think I can eat this. R20's meal card placed next to her plate also documented she is to receive mechanical soft texture. 3. R22's August 2023 POS documents an order for mechanical soft texture dated 08/01/23. R22's meal card also documents R22 is to receive mechanical soft texture diet. On 08/17/23 at 12:41 PM, R22's noon meal consisted of roast turkey and gravy that contained large chunks of turkey meat. At 12:50 PM, V1 (Administrator) stated R20 and R22's meat was not prepared in a mechanical soft consistency as ordered. 4. On 8/15/23 at 12:15 PM, V4 (Cook) was observed while pureeing the meat and vegetables. Once the food reached the desired pureed consistency V4 placed the food in 4 separate bowls to serve residents without using a proper measuring scoop to ensure that all residents were receiving the proper amount of food. 5. On 8/16/23 all residents received applesauce as the dessert item due to the German chocolate cake not being completed in time for the lunch food service. During lunch observation on this date at 12:30 PM, V11 (Family member) stated that R37 does not like applesauce and would not eat it and put it on the side of the tray out of the way. On 8/16/23 at 2:30 PM, V4 stated that the cake was not done baking in time to be served for lunch due to the pilot light being out in the oven. On 8/16/23 no residents received the tomato slices that were on the pre- planned menu. The week at a glance menu provided by V1 (Administrator) lists the following planned meals. Tuesday 8/15/23: Salisbury steak, mashed potatoes, brown gravy, sunshine carrots, bread/margarine, and ice cream. Wednesday 8/16/23: tuna noodle casserole, tomato slices, Normandy Grande classic vegetable medley, bread/margarine and German chocolate cake. Thursday 8/17/23: roast turkey, turkey gravy, parsley noodles, sugar snap peas, roll/margarine, and a brownie. The meal for 8/15/23 menu breakdown lists mechanical soft diet orders would receive: 1 ground Salisbury steak and the puree diet would receive one #10 scoop of pureed Salisbury steak and one #8 scoop of pureed bread/roll. The meal for 8/17/23 menu breakdown lists mechanical soft diet orders would receive: 3 ounces of ground turkey with gravy and the puree would receive a #8 scoop of pureed turkey and a #20 scoop of pureed bread/roll. The recipe for ground Salisbury steak and ground turkey list to measure out the appropriate portions for the amount being mechanically altered and to place in the food processor to grind to desired consistency. 6. No bread was observed on pureed diet lunch trays on 8/15/23 and 8/17/23, V4 (cook) confirmed this on 8/17/23 at 2:00 PM. V4 stated that she has never pureed bread for residents. On 8/17/23 at 2:00 PM, V4 was asked why she did not puree bread on 8/15/23 through 8/17/23 and she stated that she does not ever puree the bread. V4 confirmed those residents on a pureed diet did not receive the planned bread for the lunch meal. At this time V4 also confirmed that she did not chop/grind the mechanical soft meat as the recipe instructs. V4 stated that she cut up the Salisbury steak on 8/15/23 with a knife after she plated the meal on the residents and just tried to give the turkey pieces that were smaller and not large hunks on 8/17/23. A diet order report provided on 8/16/23 by V1 (Administrator) documents that R1, R12 and R37 receive pureed diets. This same report documents that R3, R7, R8, R20, R22, R31, R36, R39, and R40 receive mechanical soft diets. The Resident Census and Condition of Residents form dated 8/17/23 documents 37 residents reside in the facility.

6. The Facility Food Preference Interview policy dated 10/13 documents it is the policy of the facility to provide a tool to obtain a detailed list of resident's food preferences. The procedure states: The food preference questionnaire form shall be used when interviewing newly admitted resident and his/her family members, using major categories of foods (i.e., meat, vegetables, fruit, etc). It shall used to identify food allergies and intolerance's. The completed food preference questionnaire shall be filed in the active medical record. A copy shall be kept on file in the kitchen until the resident is discharged . Food dislikes or intolerance's shall be written on the resident's tray card so that appropriate substitutions can be provided. Food preferences and food dislikes shall be updated as necessary. The dietary manager or designee shall review the information as part of the dietary assessment process, or when meeting with the resident who has a food complaint. On 8/17/23 at 2:00 PM, V5 (Dietary Supervisor) stated that he had not been completing the resident food questionnaires, so he had none to review or place in the resident record. The Resident Census and Condition of Residents form dated 8/17/23 documents 37 residents reside in the facility. Based on observation, interview and record review the facility failed to offer meal substitutes and honor resident preferences. This has the potential to affect all 37 residents residing in the facility. The Findings Include: 1. On 8/15/23 at 10:30 AM, R17 stated that he does not get options of alternate foods offered at mealtime. R17 stated that he does not know what is being served until he gets it delivered and most of the time the food is delivered late. R17 was alert to person, place and time. 2. On 8/16/23 at 1:00 PM, V11 (Family Member) stated that her husband R37 has been in the facility since January 2023 and hasn't been asked food preferences. During lunch mealtime on this day V11 stated that they sent R37 applesauce, and he does not like that. The menu for the lunch meal had German chocolate cake as the planned dessert. R37's meal card did not have preferences or supplements listed on it. V11 does not recall being asked R37's food preferences upon admit. On 8/16/23 all residents received applesauce as the dessert item due to the German chocolate cake not being completed in time for the lunch food service. On 8/16/23 at 2:30 PM, V4 stated that the cake was not done baking in time to be served for lunch due to the pilot light being out in the oven. 3. On 8/17/23 at 12:36 PM, R2 who was alert to person, place and time requested coffee and sweetener to V14 (Activities). V14 replied that she would get her coffee, but they were out of sweetener. V14 returned to the table with a coffee and R2 found a sweeter she was able to use in her own personal condiment bag she carried. V14 was asked what the kitchen was offering in place of sweeter for drinks, in which she stated she didn't know. On 8/18/23 at 1:20 PM, V8 (Certified Nursing Assistant) stated it is a common occurrence that the kitchen is out of basic food condiment items, such as sweetener. V8 stated several times in the past she has purchased sweetener with her own money for resident use. V8 stated staff report to the kitchen items they are out of, but by that time the facility is already out of the item. 4. On 8/16/23 at 12:15 PM, while in the kitchen doing lunch observations V5 (Dietary Manager) stated that no one could get a grilled cheese today due to not having any bread. When asked at this time who would be offered grilled cheese, V5 stated that when residents do not like what is offered, they can have a peanut butter and jelly sandwich, grilled cheese or ham sandwich. 5. Resident Council Minutes for 5/24/23 documented an issue of: Residents would like meal substitutions better communicated. The response was: Administration educated food service of issue. Administration informed food service supervisor to add substitution options to the daily menu board.

Based on observation, interview, and record review the facility failed to execute dietary services for timely meal distribution. The failure has the potential to affect all 37 residents residing in the facility. Findings Include: Mealtimes as provided by the facility documents lunch is at 12:00 PM. On 08/15/23 at 12:33 PM, the first meal tray was observed being served in the dining room. On 8/17/23 at 12:20 PM, R10 was observed placing her head on the dining room table while waiting for her meal and falling asleep. On 8/17/23 at 12:32 PM, the first meal tray was observed being served in the dining room. On 08/18/23 at 11:42 AM, staff were observed wheeling residents into the dining room, sitting them at tables for lunch. On 08/18/23 at 12:14 PM, resident hall trays were observed leaving the kitchen for delivery. On 08/18/23 at 12:15 PM, the first meal tray was observed being served in the dining room. On 8/17/23 at 12:40 PM, R2 stated that meals generally run late, but it has been worse lately. R2 stated mealtimes had recently been moved from 11:30 AM to 12:00 PM, but it makes no difference what time they say they'll be, because they never are. R2 was alert and oriented to person, place and time during this interview. On 8/17/23 at 12:20 PM, V13 (family member) stated that mealtime is supposed to be at 12 PM. V13 stated that the kitchen rarely serves on time. V13 stated the meal service time has really been late, especially over the past 2 weeks. V13 stated luckily, she visits on the days she doesn't work so she isn't in as much of a hurry. V13 stated she wishes the meal service would be more timely and worries about the people who don't eat a good breakfast having to wait so long for lunch. On 08/18/23 at 01:13 PM, V7 (Certified Nurse Assistant, CNA) stated that meals occasionally are served late. On 8/18/23 at 1:20 PM, V8 (CNA) stated that meals are occasionally served late. On 8/15/23 at 12:00 PM, V4 (Cook) stated that the meal was late being served today because the pilot light was out on the stove and that caused a delay on food being done for planned start time of 12:00 PM. On 8/17/23 at 2:00 PM, V4 (Cook) stated that lunch was served late on 8/16/23 due to not having the all the food items on the menu and having to substitute the food items out and then get them cooked. The Resident Census and Condition of Residents form dated 8/17/23 documents 37 residents reside in the facility.

Facility policy titled, Personal Hygiene and Dress Code with a most recent revision date of 10/16 stated, It is the policy of (company) that the Food Service Employees adhere to the facility's dress code that will ensure safe, sanitary meal production and service and presents a professional appearance. The same policy goes on to state, .8. Hair net or appropriate hair coverings, including facial hair covering, while involved in food production and clean-up activities. The Resident Census and Condition of Residents form dated 8/17/23 documents 37 residents reside in the facility. Based on observation, interview and record review the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This has the potential to affect all 37 residents residing in the facility. The Findings Include: During the initial walk through of the kitchen on August 15th at 9:00 AM the following items were found: Raw beef was thawing on the rack above fresh produce in the refrigerator. V5 (Dietary Supervisor) was observed to have facial hair without being properly restrained. The countertop mixer was observed to have dried old food splatter in and around the mixer. The refrigerator unit next to the countertop where food is prepared was splattered with old, dried food. The oven top and side of oven was covered in old dried splattered food. The gas pipe leading to the stove had a thick layer of dust and grease accumulated on it and is located directly over the cooks preparation table. The open shelves under the countertop where cooks prepare food was found to have old, dried food particles and dried spilled liquids on the shelving. The cart next to the steam table in the kitchen that trays, clean plates and plate covers are stored was found to have dust, dried food and dried spilled liquids on it. The bottom shelf of the steam table was found to have dirt and dried spilled liquids on it. The sanitizer level in the bucket that is used to wipe countertops and surfaces was tested by V6 (Cook) and was at 200 parts per million chlorines (PPM). A scoop without a handle was found in the bulk flour bin. An exterior door located in the back of the kitchen had gaps around the edge which potentially would allow pests in from the outside. During the initial walk through of the kitchen V6 was asked what the recommended level of sanitizer is for the bucket used to sanitize equipment and countertops, and how she mixes the solution. V6 stated that she just uses a couple capfuls of chlorine bleach and adds water to the bucket. V6 stated she thinks between 100-200PPM is where the level should be. V5 (Dietary Supervisor) was asked at this time what the recommended level of sanitizer is for bleach sanitizing solution and replied 100-200 PPM. V5 was also asked how the staff are to mix the bucket sanitizer solution to wipe down countertops and stated that they just mix up a bucket, that there is not a premixing station or directions on the ratio of bleach to water. During the lunch observation on 08/15/23 at 12:15 PM a cup without a handle was found in the bulk food thickener that is used to thicken pureed food. Food temperatures were taken at this time on 08/15/23 at 12:15 PM. V6 using a facility thermometer checked the temperature of the pureed tuna noodle casserole and it was 106 degrees Fahrenheit, and the pureed mixed vegetable was 125 degrees Fahrenheit at serving time. When V6 was asked if these temperatures were appropriate/safe levels she asked V5 what the level should be. V5 told her fish needs to be above 145 degrees Fahrenheit. V6 then place a lid on the pureed food items and turned up the heat on the steam table to try to get the food levels to the safe serving temperature. At this same time V4 (Cook) was asked if she checked the pureed food temperatures prior to placing them in the steam table after pureeing them, and she stated that she had not done that and was unaware of that step of the pureeing process. V4 stated that she is new to the job by just a few weeks, and she just wants to puree the food right before the meal is served in hopes that it stays hot enough. On 08/15/23 at 12:42 PM, V3 (Certified Nurse Assistant) was observed going in and out of the kitchen food production area, delivering trays, with a hair net only covering the back portion of her hair, leaving bangs and hair side pieces exposed. On 08/16/23 at 1:00 PM the door located in the kitchen to the outside was wide open with no one seen coming in or out. At this time V5 was asked why the door was open and his reply was I try to remind them to close the door. On 08/16/23 at 1:15 PM the door was again found to be standing wide open to the outside with no staff present. V1 (Administrator) went to the kitchen to close the door. A Kitchen Sanitization Policy with a revision date of 10/2020 documents that is the Policy of the facility to comply with public health standards and local and state sanitization regulations. The procedures is: The Food Service Manager will monitor satiation of the Dietary Department on a regular basis. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen and specify which chemical and personal protective equipment shall be used for each task. In-Service training should be scheduled periodically to review sanitation standards. A Dietary Sanitation -QA (Quality Assurance) Review with a revision date of 10/2020 documents the following hair nets should be at each entrance of the kitchen. Hair net to be worn by all entering kitchen: bangs covered, facial hair covered Hot foods are served at or above 135 degrees Fahrenheit Ensure red sanitation bucket of food contact sanitizer solution for chlorine is 100 ppm Refrigerators-No raw product above produce/ready to eat foods; shelving/floor/ceiling; no indication of spills vents/pipes are clean, ceiling/walls clean, floors and baseboards are clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a nurse working in the facility had an active license. This has the potential to affect all 41 residents residing in the facility. Findings include: On [DATE] at 9:15 a.m., V1 (Administrator) stated that V6 (Licensed Practical Nurse/ LPN) works for the company nursing pool and fills in as needed at the facility and other facilities owned by the company in the region. V1 stated V6 has a corporate supervisor (V5-Regional Operations Officer) that works for the company that monitors her nursing license status. V1 stated that she would not allow a nurse on staff at the facility continue to work if they did not have an active nursing license. V1 stated that she keeps a binder full of all the nursing staff and their nursing licenses. V1 stated all the nursing staff at the facility have active nursing licenses. V1 said that V6 is the only nurse from the company nursing pool that has worked at the facility. V1 said that V6 has not worked a shift at the facility since May. On [DATE] at 1:00 p.m., V5 stated that the nursing staff get a reminder sent out from the company when it is time for them to renew their license. V5 stated V6 (LPN) got a reminder sent out to her and it was assumed that she renewed her license. V5 stated that V6 continued to work as needed for the company and the only place she worked at during February - [DATE] has been Effingham Rehabilitation & Health Care. V5 said she was unaware that V6's license were expired. On [DATE] at 12:45 p.m., V6 (LPN) stated that she paid her renewal fee by check in [DATE] and completed the CEUs and just thought everything had been taken care of. V6 stated she has had a lot going on personally and didn't think to check on the status of her nursing license. V6 stated she has contacted Illinois Department of Financial & Professional Regulation (IDFPR) to see if they have received her renewal fee and is following up tomorrow ([DATE]) on the status of her nursing license. The IDFPR license look up (from the website https://online-dfpr.micropact.com/lookup/licenselookup.aspx) documents the status of V6's Licensed Practical Nurse license of not renewed with an expiration date of [DATE]. The facility's working schedules were reviewed from [DATE] to [DATE]. V6 was documented on the schedules as working on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility's policy Nursing Services with revised date of [DATE] documents It is the policy of (name of Long Term Care Company) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related services to attain or maintain each resident's highest practical physical, mental, and psychological well-being based on the comprehensive assessment of the resident and consistent with the resident's preferences, needs, and choices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely report and address a skin concern for 1 of 3 residents (R1) reviewed for wounds in a sample of 4. Findings include: R1's Profile Face Sheet documents that R1 was admitted to the facility on [DATE]. R1's June 2023 Physician's Order Sheet (POS) documents diagnoses including systolic and diastolic heart failure, End Stage renal Disease (ESRD), Diabetes Mellitus type 2 (DM II), macrocytic anemia. R1's Minimum Data Set assessment dated [DATE] documents in section C, Cognitive patterns, that R1 has a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 is cognitively intact. On 6/7/23 at 2:20 PM, R1 said that V17 (Certified Nurse Aide) gave her a shower on 5/20/23. R1 said that V16 told her she had some loose skin to the bottom of her left foot, and she was going to take care of it. R1 said V17 then went to the cabinet in the bathroom and grabbed something out that looked like clippers or scissors. R1 said she started working on her feet. R1 said she couldn't see what V17 was doing but whatever she did to her foot hurt afterwards. R1 said that on 5/25/23 that V17 gave her another shower. R1 said her foot was hurting more that day. R1 said that V17 went and got the nurse (V4 Licensed Practical Nurse) that day because she had an open area on that foot. R1 said that V4 was angry at V17 because she clipped the skin on 05/20/23 and didn't tell her. On 6/7/23 at 1:15 PM, V5 (Licensed Practical Nurse/ Resident Care Coordinator) was observed performing the treatment to R1's Left planter wound. R1's left plantar wound appeared to be healing with calloused skin surrounding the wound bed. The wound appeared to be approximately 1 centimeter (cm) by 1 cm. A Nurse's Note authored by V4 (License Practical Nurse) in R1's Medical Record dated 5/25/23 documents that V17 reported to this nurse that resident foot was bleeding. I followed (V17) to North Hall shower room and saw that on the bottom of resident left foot there was an open spot. I cleaned the area and applied TAO (Triple Antibiotic Ointment) and dry dressing. ADON (Assistant Director of Nursing) and administrator notified, MD (Medical Doctor) aware skin packet completed. R1's Aim for Wellness sheet dated 5/25/23 documents open area to bottom of left foot wound with callous was torn off tearing open area. A review of Quality Assurance Committee (QAC) in R1's Medical Record dated 05/26/23 at 4:11pm documents QAC team met to review grievance made to QAC team regarding new skin concern on her (R1's) left great toe. (V4) brought concern to (V2-ADON); (V2) brought concern to administrator: Promptly QAC team began to investigation skin concern staff appropriately interviewed. MD aware, dietitian aware, wound doctor consult ordered .QAC team concluded (V17) needed educated on appropriate in timely concerns to nursing. This has been completed (education and disciplinary action implemented) QAC will continue to monitor and follow up if any new grievances or findings are found. R1's May 2023 POS documents an order dated 5/26/23 for Keflex 500 milligrams (mg) by mouth (PO) twice a day (BID) x 7 days and referral for wound care. On 6/7/23 at 2:24 PM, V1 (Administrator) said an internal investigation was done on the incident with R1 and V17 was interviewed. V1 said that V17 said that she did not clip any skin off R1's foot, that she just pushed the piece of skin back up on her foot, so she didn't pull it off when she was drying her. V1 said that V17 said she didn't report it because she forgot, and she got pulled out to take care of another resident. V1 said that V17 did give R1 another shower on 05/25/23 then reported the area to the nurse. V1 said that V17 was wrote up for failure to notify the nurse of a skin issue in a timely manner. R1's Shower Sheet dated 5/20/23 documents no new findings signed by V17. On 6/8/23 at 10:30 AM, V4 (Licensed Practical Nurse) said that V17 notified her of an area to the bottom of R1's left foot during her shower. V4 said the area looked like some skin rubbed off. V4 said the resident started telling her that on her last shower day on 05/20/23, V17 had got some clippers out and cut off a piece of skin on her foot, but then R1 changed her story that V17 did not clip anything off. V4 said she reported the incident to V2(Assistant Director of Nursing) (ADON) who reported it to V1(Administrator). On 6/7/23 at 2:45 PM, V17 (Certified Nurse's Aide) said that R1 asked for a shower on her off-shower day on 5/20/23. V17 said she gave her a shower and was applying lotion to her legs after the shower when she noticed a piece of skin hanging down from her foot. V17 said she pushed the piece of skin back up and never grabbed any clippers or scissors out of the cabinet. V17 said that she only grabbed lotion out of the cabinet when R1 saw her. V17 said she did document no new findings on the 5/20/23 shower sheet, because she got busy and forgot to document it and notify the nurse. V17 said then on 05/25/23 she gave R1 another shower and noticed some blood on the towel when she was drying her. V17 said she then notified the nurse of the area. V17 said that she was written up for not notifying the nurse of the area along with not writing it down. R1's care Plan dated 5/15/23 documents an intervention of assess skin-if open or bruised area noted, report to MD and responsible party under R1's risk for pressure ulcers. The facility job summary for Certified Nurse's Aides (undated) documents under the section titled Responsibilities- makes appropriate decisions regarding notifying the nurse responsible for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's family member/Power of Attorney (POA) of a new psychotropic medication and when there was a change in the resident's condition that required evaluation and treatment at the local hospital for 1 (R3) of 3 residents reviewed for notification in a sample of 7. Findings Include: R3's Face sheet documents an admission to the facility on [DATE] with diagnoses to include dementia with behaviors (10/01/22), anxiety, depression, psychosis (05/26/22), restless leg (05/26/22), difficulty in walking (04/07/23). This face sheet also lists V12 (Family Member) as R3's POA (Power of Attorney) with phone number provided. R3's Annual Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 7, indicating R3 has severe cognitive impairment. R3's admission Physician's Order Sheet (POS) dated 05/19/22 documents aggressiveness as R3's behavior and an order for Risperidone 0.5mg po (milligram by mouth) daily dated 05/19/22, and Trazodone 50mg po qd hs (daily at hour of sleep). R3's prescriptions for these two medications remain unchanged until October 2022 at which time the October POS documents R3 was diagnosed with urinary tract infection and started on Cefdinir 300mg po bid (twice daily) for 7 days, acidophilus therapy, and increase fluids dated 10/02/22; Risperidone 0.5mg po qd is decreased to 0.25mg po qd, and a new order to begin Prozac 10mg po qd for a diagnosis of mood dated 10/15/22, as recommended after psychiatric consultation on 10/14/22. R3 is diagnosed with a second urinary tract infection and started on another course of Cefdinir 300mg po bid for 7 days on 10/26/22. R3's December 2022 POS includes a third prescription for Cefdinir 300mg po bid for 7 days for a diagnosis of urinary tract infection, an increase in Risperidone from 0.25mg po qd to 0.5mg po bid, along with Ativan 0.5mg po to be given no earlier than hs, both dated 11/27/22. R3's January 2023 POS documents includes the following orders - Risperidone 0.5mg po bid dated 01/17/23 for a diagnosis of aggressive behaviors; Trazodone 50mg po hs dated 05/19/22 for a diagnosis of insomnia; and Ativan 0.5mg po hs for a diagnosis of anxiety dated 11/28/22. R3's February POS includes an order for Celexa 10mg take 1 tablet po q am; and Celexa 20mg take 1 tablet po q am for a total of 30mg per day dated 02/14/23. R3's March 2023 POS includes the following changes - Increase Ativan from 0.5mg po hs to 0.5mg po tid dated 03/10/23; and an increase Risperidone from 0.5mg po bid to 1mg po bid due to aggressive behaviors dated 03/10/23. R3's progress note dated 03/10/23 at 10:00 AM documents NP (V12 - Nurse Practitioner) in house and informed of R3's increase in anxiety, agitation, and aggressive behaviors. New order to increase Ativan to tid (three times daily) and Risperidone to 1mg bid. V12 called to give telephone consent. No answer left message to return call. R3's progress note dated 03/11/23 at 6:00 AM - 6:00 PM by V6 includes - resident arguing with a resident, She is talking about . oh yeah, not you, shut up. Called V12 with no answer, left message to call the facility to give Ativan 0.5mg tid. Received order to do urinalysis and culture due to behaviors. R3's April 2023 POS includes the following changes - Celexa 30mg po qd (started on 02/14/23) was decreased to Celexa 20mg po qd dated 04/21/23 due to seeing increased weepiness and increased agitation; Risperidone was increased from 1mg po bid to Risperidone 2mg po am and 1mg po evening on 04/16/23; Trazodone was decreased from 50mg po hs to Trazodone 25mg po q hs dated 04/18/23; and Haldol 2mg po daily PRN (as needed) was added for increased anxiety, aggression, signs of psychosis x 14 days dated 04/18/23. R3's progress note dated 04/03/23 at 6:00 AM - 6:00 PM by V6 documents - Resident arguing with other resident. Resident using foul language. Resident does not listen to reason . encourage to sit down in bed due to I don't feel very good. Resident denied dizziness. BP (blood pressure): 94/52. Resident would not sit still. Lisinopril held for BP less than 60 . On 04/04/23, R3's April POS also documents administration of a one-time Haldol 2mg IM (intramuscularly) injection. There is no documentation or rationale (including non-pharmacological interventions or behavior tracking) provided for the use of a Haldol injection dated 04/04/23, nor was there any documentation provided V12 was contacted for approval prior to this injection. R3's progress noted dated 04/13/23 at 7:00 PM by V6 - Resident picking argument with roommate and calling her names. Nurse spoke with resident and pulled privacy curtain, talked to resident. At 7:10 PM, V6 writes - resident staying in her bed. No words spoken. R3's progress note dated 04/16/23 at 10:30 AM by V20 documents that resident tearful again, yelling at staff about lack of care, coffee, and food. Staff had just gotten her a fresh cup of coffee and she just ate breakfast. Filled out AIMS (Abnormal Involuntary Movement Scale) form and contacted NP (V2). Received new order to increase morning dose of Risperidone. Attempted to call POA. Phone out of order. R3's progress note dated 04/19/23 at 2:00 PM by V19 (Former LPN) - Continues with med change. Resident tearful this am. Stated she hadn't had any coffee, and no one cares . this nurse had (illegible) a cup. Resident wandering with walker tearfully. R3' progress note dated 04/20/23 with no time by V19 - Continue with psych med changes. Trazodone decreased to 25mg, and Risperidone increased to 2mg am and 1mg evening. Resident continues to ambulate with walker throughout the facility. Steady gait noted. Resident continues with obsessive request for coffee after having coffee. Tried to encourage water. Resident tearful this am about being scared to die. 1:1 (one on one) given without success. Continue to monitor resident for behaviors. R3's progress note dated 04/22/23 10:00 AM by V7 (LPN) - Resident showing signs of anxious behavior. Resident following staff and yelling at them for not helping her. When asked what she needs help with resident stated, you don't even care. Nobody cares about me. Resident then became tearful. Staff encourage resident to lay down or watch television. Resident refused. Resident began yelling at staff saying we haven't fed her in three days. Resident reminded she just had breakfast. Resident stated, Well I didn't get any! You people are trying to starve me. Snack offered; resident refused. PRN Haldol given for increase in behaviors. Not effective. There is no other rationale in R3's record for the use of Haldol nor was there any documentation provided of R3 becoming physically aggressive with staff. R3's progress note dated 04/23/23 at 9:30 AM by V7 - Resident at nurse's desk asking for a cup of coffee five times since 9:00 AM. Resident was given a cup of coffee at 8:45 AM. There is currently no coffee made. Staff explained this to resident . resident became angry and said, I haven't had a cup of coffee all day! You people are a bunch of liars. Water and juice offered. Resident refused. PRN Haloperidol given at 7:30 AM. Not effective. There is still no documentation in R3's record indicating V12 was notified that Haldol was being given to R3. R3's progress noted dated 04/28/23 at 6:20 PM by V19 documents that resident wandered with walker most of the day, laid down for nap at 4:00 PM, was not able to wake up enough to medicate. R3's progress note dated 05/08/23 at 2:00 PM by V24 (LPN) - At 9:00 AM, resident fell to the floor onto left side of body - laying on arm and bumped head on way to floor. Resident was assessed and neuros were initiated. BP: 74/56; Pulse: 102; Temperature: 97.3; Respirations: 16; Oxygen saturation: 90% (percent). Resident out to (name of hospital). There is no documentation in this note indicating any notifications were made to V12. V1 provided a progress note from the QA (quality assurance) team dated 05/08/23 interviewing V24, who stated she was not able to make contact with V12, so she called the second emergency contact (V13 - Family Member) asking that he have V12 contact the facility. V12 did not call back. However, V24 reported the hospital contacted her and reported they had been in conversation with V12, and he was aware R3 was being admitted to the hospital . V24 reported attempting to contact V12 again but was unable to reach him. R3's emergency department provider notes dated 05/08/23 include - Chief complaint: Fall, weakness. HPI (History of Present Illness: Patient is in [AGE] year-old female past medical history of Alzheimer's dementia on Risperidone, Haldol, Ativan who was sent to the ER (emergency room) for evaluation of fall, low blood pressure, and elevated heart rate. Patient was at rehab facility, fell, and hit her head. Patient has also been having some altered mental status and incontinence which is not usual for her. Patient does have a history of dementia. Patient not able to provide much of a history . R3's Hospitalist Discharge Summary documents admission on [DATE] with discharge on [DATE]. Primary diagnoses: Altered mental status secondary to polypharmacy and dementia. discharged condition: Stable. Indication for admission: Altered mental status. Hospital Course: [AGE] year-old female presented from skilled care nursing facility with altered mental status and falling. She had a CT (computerized tomography) head and CTA (computerized tomography angiography) head and neck that did not show any acute abnormality but did show chronic mild global cerebral volume loss and chronic small vessel ischemic changes as well as an old right occipital infarct. Infectious work-up was unrevealing with a negative UA (urinalysis), negative chest x-ray, no acute skin or abdomen findings. Patient returned to baseline fairly quickly upon arrival to the ER (emergency room) and upon admission. Patient does have a history of dementia/Alzheimer's with behavioral disturbance. She used to live with her son as he was her primary caretaker, but she started having violent outbursts approximately 1 year ago, so she was moved to skilled nursing facility. She has been receiving Haldol 2mg po daily (milligram by mouth) that was started in mid-April and did receive a Haldol injection mid-April. She was also on what appears to be scheduled Ativan 0.5mg 3 times daily. It also appears her Risperdal was increased to 2mg bid twice daily on 05/06/23. I had a conversation with (V12) as patient is not decisional due to her dementia. He states that he has asked the nursing home not to give her Haldol and only give her the Ativan. He was unaware of the Risperdal increase. Today he seems very frustrated and upset that she had been getting those medications without checking with him first. No same medication has been held while in the hospital and she has returned to her normal baseline mental status. We discussed discharging her back to skilled nursing facility however (V12) stated that he is her primary caretaker does not want her back to the nursing home. He states he is able to care for her 24/7 at home and will be taking her home instead. She is having home health set up. We have given her prescriptions for her chronic medications and have changed her Haldol to as needed daily as well as her Ativan to 3 times daily as needed and have decreased her Risperdal back down to 1mg twice daily. AMS (altered mental status) likely secondary to polypharmacy, Fall. On 05/22/23 at 10:19 AM, V1 (Administrator) was asked if V12 was notified of R3's medication changes and being sent to the hospital. V1 stated they did attempt to notify him, and he did not answer or respond. V1 stated they did contact R3's second emergency list (V13) on 05/08/23 prior to sending R3 to the hospital and he gave the message to V12 who never returned their call. When asked if he had ever spoken with the facility regarding polypharmacy, V1 stated he had mentioned to V15 (Former DON) in the past, he did not want his mom overmedicated. At that time, we began adjusting R3's medication in conjunction with V2's orders and MidAmerica Psychiatric Associations recommendations. V1 stated she reminded V12 that each medication prescribed and administered to R3 was consented to by V12. V1 stated she asked that he communicate with staff if he felt he did not want R3 on a medication and they would move forward. V1 assured V12 they had worked with V12 regarding safe medication orders. On 05/22/23 at 1:37 PM, V2 (Nurse Practitioner) stated she saw R3 twice a week in the facility on Tuesdays and Fridays when she rounded. V2 stated R3 was mentally unstable. Her level of agitation would get so high we were concerned about falls. V12 stated, Every time I would see her, I would evaluate the meds being too much or not enough. One of my notes say I spent two hours referencing guidelines for geriatric psychotropics. We have to be very careful and just document the medication adjustments and why, behaviors, results, or adverse reactions. There was never a fine line where we could get her comfortable. When asked if she had ever spoken with V12 regarding R3's care or medication changes, V2 stated, I've never met the family and the hospital did not contact me when she was sent out on 05/08/23. If I was an ER (emergency room) person seeing what she was on, I could see why they would think that she had polypharmacy. That's why I documented carefully, and it was an extreme situation. It was sad and hard. I always go back to see if there is something I'm missing. It was constant. V2 stated there is a psychiatric service that visits the facility every 3 months and R3 was in their care, but this does not help in the acute situations with her. V2 stated she would just have to go to the geriatric psychiatric guidelines. When asked if she saw R3 on 04/04/23 when R3 was given the one-time injection of Haldol, V2 stated the nurses would have contacted me. V2 stated, If those days correlated with the IM Haldol, then yes I did see her, otherwise the nurse would have called me. She was not only agitated but was extremely distressed. April 4, 2023 was a Tuesday but there is no documentation other than the hand written order on R3's April POS to administer Haldol 2mg IM one dose only. On 05/22/23 at 2:33 PM, V12 stated that he had been concerned with the medications R3 was on at the facility. V12 stated he never gave consent for the Risperdal, Haldol, or the increases in Celexa. V12 stated he asked that R3 only be given Ativan. When asked if the facility notified him on the medication changes and being sent out to the hospital on [DATE], V12 stated they did not. V12 stated the hospital basically told him she was extremely overmedicated. V12 stated R3 was doing great at this time, and he had placed her in another facility closer to home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were safe from misappropriation of controlled substance medication for 1 of 3 residents (R2) reviewed for misappropriation in a sample of 7. The findings include: R2's facility Initial Report titled Fax Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 02/14/23 at 4:00 PM signed by V1 (Administrator) includes - Date of Incident: 02/11/23. Time of Incident: 6:45 PM . Description of Accident, Causes, Injuries and Action Taken by Establishment as a Result of Accident: Writer notified of narcotic misplaced during narcotic count. Investigation initiated. Final report to follow. Type of Incident: Missing medication. Alleged Abuse: Misappropriation of Personal Property. Accident: Non-fatal. hospitalized : No. The following notification were made on 02/14/23 at 4:00 PM - M.D. (Medical Doctor) Notified: Yes. Family/Rep. (Representative Notified: Yes. Police Notified: Yes. R2's facility Final Report dated 02/11/23, received 05/17/23 at 10:26 AM documents in part - . Summary of Complaint: Writer notified of narcotic misplaced during narcotic count. Investigation initiated. (V9 - Licensed Practical Nurse - LPN) notified administrator that during narcotic count he could not find (R2's) prn (as needed) oxycodone . In addition, the following was initiated/completed: Initial report sent to IDPH, Interview with Resident(s), Interviews with staff, All appropriate parties have been notified (V1, V15 - Former Director of Nursing/DON, V17 - Regional Director of Clinical Operations, V14 - Medical Director, and Local Police Department - Police Report number: P23-02080 . Resident Interviews: (V4 - Assistant DON) notified resident (R2) of missing medication. He responded back to her, okay. Residents (R2) BIMS (brief interview for mental status) score is a 99 (unable to complete interview). (V16 - Power of Attorney/POA) was also notified by (V4) . Staff Interviews: (V9 - LPN) - I took the oxycodone (0.25ml) in box into resident's room and drew the dose up to administer to resident at 8:45 PM, 2-10-23, after giving the dose melatonin. After administering PO (by mouth) meds I applied TAO (triple antibiotic ointment) to blister on resident's groin area. I then left the room; I then would have carried the oxycodone out of the room and placed it back in the narcotic box. I did not have oxycodone on me when I went in to see the next resident. When next shift nurse arrived at facility at 7:30 AM the next shift nurse took over cart. I noticed that medication was missing at med count when I next came in the night of 2-11-23. When I noticed med was missing, I asked day shift nurse if she knew what had happened to the med, she stated that she had not seen med because she did not give the med. I then called the DON and administrator to let them know that the med was missing. I have never witnessed abuse or neglect to any resident. (V6 - LPN) - Writer came to work on 2/10/2023. 2-6 scheduled hours narcotic count was done with next shift. On 2/11/2023 writer came to work approximately 6:30 AM. Nurse from night shift was at nurse cart. Then this writer and night shift nurse sat down to give report. Night shift nurse then started to chart, finishing night shift charting. This writer went to medication cart and began passing medications. Writer stated we can count. Night shift nurse stated, I am back at 6:00 PM tonight. This writer began passing medications. Writer did not go into the narcotic box for resident (R2) because he did not have pain on 6a-6p. I signed out my narc's and made sure count was correct when dispensing narcs on day shift (compared to what was wrote down). All meds were correct. I did not take a liquid box of oxycodone that shift because resident denied pain, this writer as my resident during pill pass time. On 2/11/23 at 6:00 PM started report and then counted. At this time Night shift nurse stated, Where is (R2's) Oxycodone, writer stated, I didn't see it today. All witness statements denied any knowledge of the incident and reported that they have not witnessed any forms of abuse or neglect. On the following in-service all staff was educated on the abuse policy; all staff present were asked if they were aware of the events surrounding this investigation, all staff stated they were unaware. All staff was asked if they had seen, heard, or knew of the whereabouts of said oxycodone, all reported they were unaware. All staff were asked if they have ever witnessed or heard of abuse or neglect during their time of employment, all stated they had not. All staff and the QAC (Quality Assurance Committee) team were asked to assist in searching for this medication. This writer and the Regional Director of Clinical Operation led this search and overseen it. This writer, the Regional Director of Clinical Operations (V17), and the Quality Assurance Committee also had Nurse (V9) come into the facility to do a mock walk through of the night and the last dosing of medication to further aide in the investigation as well as search his vehicle, work coat, and work bag. The investigation team also searched each room, overturned mattresses, checked laundry and all linens, hallways, closets, storage and stock rooms, all trash cans, and all trash in the dumpster (however, later learning that the trash from 2/11/2023 from the dumpster had already been picked up). The investigation team went to great lengths in this search; however, the medication did not appear. Investigation Conclusion: Through this search, the bottle of oxycodone was not found. All appropriate persons were notified, and a new bottle was obtained from (Pharmacy). Through further investigation it is noted that this resident was not medically harmed as he did not miss any dosing of his medication and properly assessed for pain management. In conclusion, the Quality Assurance Committee reviewed each controlled substance for all residents, noting that all medications were accounted for appropriately; also reviewing each controlled substances proof of use, and PRN medication information. The QAC also implemented auditing the controlled substances with a witness at random and implemented overseeing shift change during the narcotic count at random as our Corrective action plan. To date, there have been no new findings. All staff has been in-serviced of the Abuse Policy and Controlled Substance Policy. R2's Face Sheet documents he was admitted to this facility on 08/23/21 with diagnoses in part of Aphasia following cerebral infarction, personal history of transient ischemic attack, osteoarthritis, low back pain, chronic pain, anxiety, and depression. R2's Physician's Order Sheet (POS) contains a handwritten note dated 11/23/22 as follows - Admit to (Name of Hospice) effective 11/08/22. Contact hospice nurse prior to administering comfort pack meds. R2's POS dated 11/24/22 documents an order for Oxycodone 0.25ml po q (every) 2 hr (hour) prn pain with a start date of 11/08/22. On 05/17/23 at 12:53 PM, V10 (Hospice Registered Nurse) stated R2 was admitted to their care on 11/08/22. V10 stated, We did order the prescription for Oxycodone and this medication was on hand in the facility on 11/08/22. However, we did not fill that first prescription. We filled the 12/29/22 and 02/15/23 prescription refills for Oxycodone liquid (30ml bottle), and these were the only two times we filled the prescription. On 12/29/22 the order was for .25 ml which is 5 mg q 2 hour dispensed as 100mg (milligram)/5ml. That was the order both times we filled the prescription. V10 stated they did tell the facility they had the liberty to administer 5 ml doses if R2's pain warranted an increased dose. V10 confirmed R2 discharged from their care on 05/04/23. At this time, V10 stated she will provide their flow sheet which documents the amount of any pain medication given by hospice in a 24-hour period including his prescription for Oxycodone. R2's local pharmacy delivery sheet dated 12/01/22 to 12/31/22 and 01/01/23 to 05/17/23 confirm delivery of Oxycodone HCL 100mg/5ml solution, quantity 30ml was delivered to the facility on [DATE] and 02/15/23. R2's November 2022 through May 2023 PRN Medication Administration Record (MAR) and coinciding Controlled Substance Proof of Use narcotic sheets were reviewed. On 02/10/23, V9 documents on the narc sheet that 27.75 ml remain after the evening dose at 8:45 PM, at which time the facility reported was the last time this particular bottle of oxycodone was seen. On 02/15/23, this narc sheet documents a new 30ml bottle of oxycodone was utilized with the first dose being given on 02/16/23 It should be noted that between November 2022 and April 2023 there were doses of R2's medication signed out on the narcotic sheet that were not documented on the MAR as being administered, as well as doses of this medication documented on the MAR as being administered, but not signed out on the narcotic sheet. The above calculations accounted for those discrepancies and now the discrepancies are listed as follows - Oxycodone 100mg/5ml give 0.25ml po q 2 hr pain was signed out on the narcotic sheet but not the MAR as follows - 11/15 11:30 AM, 11/24 at 12:45 PM, 11/28 at 9:30 AM, 11/29 at 10:00 AM, 12/08 at 1:00 PM, 12/10 at 10:30 AM, 12:30 PM, 2:30 PM, 12/11 at 8:00 AM, 11:00 AM, 3:00 PM, 12/17 at 4:35 PM, 12/22 at 10:00 PM, 12/25 at 4:30 AM, 3:30 PM, 12/? at 9:00 PM, 01/04 at 8:00 AM, 1:45 PM, 01/16 at 12:00 PM, 01/24 at 11:00 AM, 02/10 at 9:45 AM, 02/17 at 10:30 AM, 5:30 PM, and 02/28 at 12:00 PM. Oxycodone 100mg/5ml give 0.25ml po q 2 hr pain was signed as given on the MAR but not the narcotic sheet - 11/28 at 10:40 AM, 11/29 at 1:00 PM, 12/04 at 7:00 PM, 12/14 at 7:40 PM, 01/11 at 4:15 PM, 01/27 at 10:00 AM, and 03/02 at 7:34 PM. On 05/17/23 at 10:07 AM, when asked if V6 and V9 conducted a shift-to-shift narc count when she arrived to work on 02/11/23, V6 stated it was not done. When asked why, she stated V9 seemed very frazzled and wanted to get his charting done before he left, so she did not want to overstimulate him because he had a bad night. V6 stated V9 charted for about 1 ½ hours, then went home. V6 stated she began to pass her meds and took it upon herself to do her own count at around 8:30 AM. She stated it was at that time she noticed R2's oxycodone bottle was not in the narc drawer. When asked if she let V9 know this, she stated she did not. When asked if she reported this to anyone at all, she stated she did not. V6 stated V9 was scheduled to return for his shift that evening at 6:00 PM and she just figured they would reconcile at that time and she would let him know the narc was missing. V6 stated she waited to report this because she wanted to get the story from V9. V6 stated they looked everywhere and could not find it. When asked if she understood that one nurse does not do a narc count by herself, she said she did and added she was given an in-service on how to do narc counts and that you are required to do this with your co-worker so two people are present. On 05/17/23 at 2:22 PM, when asked to recount the events of 02/11/23 when R2's oxycodone went missing, V9 stated, I gave (R2) a dose of oxy the evening of 02/10/23 at 8:45 PM. I gave him a dose that night because he said he was needing some. When asked if he could recall the steps he took after administering the medication and that his written statement indicated he took the bottle into the resident's room to draw up the dose, he stated, I have done that before, so I would have put the vial back in the box and placed it back in the med cart and locked it in the narc box. When asked if there had been anything unusual going on that evening that would have disrupted his routine, V9 stated, I don't remember anything unusual that evening that would have altered my routine. V9 stated on the morning of 02/11/23, V6 was actually late getting to the facility, so he had started passing medications for her and when she arrived, she took over the med cart. V9 stated he did stay over to do his paperwork on the morning of 02/11/23. V9 stated there would have been no one else that had access to the keys to my med cart other than himself and V6. V9 stated, I had not had any issues with missing narcotics prior to or since 02/11/23. When told that the nurse (V6) who came on shift the morning of 02/11/23 reported to this surveyor she did her own narc count at 8:30 AM and discovered the oxycodone liquid missing, V9 confirmed V6 did not say anything to him about that before he left the facility the morning of 02/11/23. When asked if narc count was done between V6 and himself prior to him leaving the morning of 02/11/23, he stated they did not do one. V9 stated when he returned for his shift at 6:00 PM later that evening on 02/11/23 he and V6 did the usual narc count together. When asked if V6 then reported to him the narc was missing, V9 stated, I'm pretty sure I was the first one who said something about the narc not being in the box as we were doing count. V9 confirmed the oxycodone was kept in the narc box and not the refrigerator. On 05/23/23 at 2:25 PM, when told about the numerous discrepancies in R2's narc sheet and MAR documentation, V1 stated that she believed this was 100% (percent) staff either being lazy or simply forgetting to document. The facility Abuse Prevention Program revised 11/28/16 includes - Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property .

Based on interview and record review the facility failed to report immediately a missing narcotic medication to V1 (Administrator) and failed to report the results of an abuse/theft investigation to the Department of Public Health within 5 working days for 1 of 3 residents (R2) reviewed for misappropriation in a sample of 7. The findings include: R2's facility Initial Report titled Fax Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 02/14/23 at 4:00 PM signed by V1 (Administrator) includes - Date of Incident: 02/11/23. Time of Incident: 6:45 PM . Description of Accident, Causes, Injuries and Action Taken by Establishment as a Result of Accident: Writer notified of narcotic misplaced during narcotic count. Investigation initiated. Final report to follow. Type of Incident: Missing medication. Alleged Abuse: Misappropriation of Personal Property. Accident: Non-fatal. hospitalized : No. The following notification were made on 02/14/23 at 4:00 PM - M.D. (Medical Doctor) Notified: Yes. Family/Rep. (Representative Notified: Yes. Police Notified: Yes. On 05/17/23 at 10:00 AM, when asked for the final report to the Facility Report Incident of 02/11/23, V1 stated she had faxed that a long time ago with a bunch of other things and was under the impression we had received the final report. At this time, V1 forwarded R2's facility Final Report dated 02/11/23. R2's facility Final Report dated 02/11/23, was received by this surveyor on 05/17/23 at 10:26 AM and documents in part - . Summary of Complaint: Writer notified of R2's narcotic misplaced during narcotic count by V6 (Licensed Practical Nurse - LPN) and V9 (LPN) during 6:00 PM shift change on 02/11/23 . Investigation Conclusion: Through this search, the bottle of oxycodone was not found. All appropriate persons were notified, and a new bottle was obtained from (Pharmacy). Through further investigation it is noted that this resident was not medically harmed as he did not miss any dosing of his medication and properly assessed for pain management. In conclusion, the Quality Assurance Committee reviewed each controlled substance for all residents, noting that all medications were accounted for appropriately; also reviewing each controlled substances proof of use, and PRN medication information. The QAC also implemented auditing the controlled substances with a witness at random and implemented overseeing shift change during the narcotic count at random as our Corrective action plan. To date, there have been no new findings. All staff has been in-serviced of the Abuse Policy and Controlled Substance Policy. R2's Face Sheet documents he was admitted to this facility on 08/23/21 with diagnoses in part of Aphasia following cerebral infarction, personal history of transient ischemic attack, osteoarthritis, low back pain, chronic pain, anxiety, and depression. R2's Physician's Order Sheet (POS) contains a handwritten note dated 11/23/22 as follows - Admit to (Name of Hospice) effective 11/08/22. Contact hospice nurse prior to administering comfort pack meds. R2's POS dated 11/24/22 documents an order for Oxycodone 0.25ml po q (every) 2 hr (hour) prn pain with a start date of 11/08/22. On 05/17/23 at 10:07 AM, when asked if V6 informed V1 immediately that she noticed R2's Oxycodone missing when she did her own count at 8:30 AM, she stated she did not. On 05/17/23 at 2:22 PM, V9 confirmed V6 did not say anything to him about that before he left the facility the morning of 02/11/23. The facility Abuse Prevention Program revised 11/28/16 includes - Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property . 5. Final Investigation Report: . The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within 5 working days of the reported incident . VII. External Reporting of Potential Abuse: Initial Reporting of Allegations: The facility must ensure that all alleged violations involving . misappropriation of resident property, and reasonable suspicion of a crime are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to accurately document narcotic medication administration, and failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice for 1 of 3 residents (R2) reviewed for narcotic medication in a sample of 7. The findings include: R2's facility Initial Report titled Fax Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 02/14/23 at 4:00 PM signed by V1 (Administrator) includes - Date of Incident: 02/11/23. Time of Incident: 6:45 PM . Description of Accident, Causes, Injuries and Action Taken by Establishment as a Result of Accident: Writer notified of narcotic misplaced during narcotic count. Investigation initiated. Final report to follow. Type of Incident: Missing medication. Alleged Abuse: Misappropriation of Personal Property. Accident: Non-fatal. hospitalized : No. The following notification were made on 02/14/23 at 4:00 PM - M.D. (Medical Doctor) Notified: Yes. Family/Rep. (Representative Notified: Yes. Police Notified: Yes. R2's facility Final Report dated 02/11/23, received 05/17/23 at 10:26 AM documents in part - . Summary of Complaint: Writer notified of narcotic misplaced during narcotic count. Investigation initiated. (V9 - Licensed Practical Nurse - LPN) notified administrator that during narcotic count he could not find (R2's) prn (as needed) oxycodone . In addition, the following was initiated/completed: Initial report sent to IDPH, Interview with Resident(s), Interviews with staff, All appropriate parties have been notified (V1, V15 - Former Director of Nursing/DON, V17 - Regional Director of Clinical Operations, V14 - Medical Director, and Local Police Department - Police Report number: P23-02080 . Resident Interviews: (V4 - Assistant DON) notified resident of missing medication. He responded back to her, okay. Residents BIM (brief interview for mental status) score is a 99 (unable to complete interview). (V16 - Power of Attorney/POA) was also notified by (V4). This writer also contacted (V16) who visited (R2) during this time frame; asking if she had seen the medication (presenting examples of in the bed, bedside table .). (V16) reported she had not. All cognitive residents were interviewed by investigation team, asking if they have encountered any or all types of abuse (educated of types of abuse), witnessed, or heard of any or all abuse occurring at this facility- all residents that were interviewed denied. Of these residents, it was also asked if they felt safe and if they felt properly cared for, all of which indicated that they did. These residents were also re-educated on how to report concerns. Staff Interviews: (V9 - LPN) - I took the oxycodone (0.25ml) in box into resident's room and drew the dose up to administer to resident at 8:45 PM, 2-10-23, after giving the dose melatonin. After administering PO (by mouth) meds I applied TAO (triple antibiotic ointment) to blister on resident's groin area. I then left the room; I then would have carried the oxycodone out of the room and placed it back in the narcotic box. I did not have oxycodone on me when I went in to see the next resident. When next shift nurse arrived at facility at 7:30 AM the next shift nurse took over cart. I noticed that medication was missing at med count when I next came in the night of 2-11-23. When I noticed med was missing, I asked day shift nurse if she knew what had happened to the med, she stated that she had not seen med because she did not give the med. I then called the DON and administrator to let them know that the med was missing. I have never witnessed abuse or neglect to any resident. (V6 - LPN) - Writer came to work on 2/10/2023. 2-6 scheduled hours narcotic count was done with next shift. On 2/11/2023 writer came to work approximately 6:30 AM. Nurse from night shift was at nurse cart. Then this writer and night shift nurse sat down to give report. Night shift nurse then started to chart, finishing night shift charting. This writer went to medication cart and began passing medications. Writer stated we can count. Night shift nurse stated, I am back at 6:00 PM tonight. This writer began passing medications. Writer did not go into the narcotic box for resident (R2) because he did not have pain on 6a-6p. I signed out my narc's and made sure count was correct when dispensing narcs. on day shift (compared to what was wrote down). All meds were correct. I did not take a liquid box of oxycodone that shift because resident denied pain, this writer as my resident during pill pass time. On 2/11/23 at 6:00 PM started report and then counted. At this time Night shift nurse stated, Where is (R2's) Oxycodone, writer stated, I didn't see it today. All witness statements denied any knowledge of the incident and reported that they have not witnessed any forms of abuse or neglect. On the following in-service all staff was educated on the abuse policy; all staff present were asked if they were aware of the events surrounding this investigation, all staff stated they were unaware. All staff was asked if they had seen, heard, or knew of the whereabouts of said oxycodone, all reported they were unaware. All staff were asked if they have ever witnessed or heard of abuse or neglect during their time of employment, all stated they had not. All staff and the QAC (Quality Assurance Committee) team were asked to assist in searching for this medication. This writer and the Regional Director of Clinical Operation led this search and overseen it. This writer, the Regional Director of Clinical Operations (V17), and the Quality Assurance Committee also had Nurse (V9) come into the facility to do a mock walk through of the night and the last dosing of medication to further aide in the investigation as well as search his vehicle, work coat, and work bag. The investigation team also searched each room, overturned mattresses, checked laundry and all linens, hallways, closets, storage and stock rooms, all trash cans, and all trash in the dumpster (however, later learning that the trash from 2/11/2023 from the dumpster had already been picked up). The investigation team went to great lengths in this search; however, the medication did not appear. Investigation Conclusion: Through this search, the bottle of oxycodone was not found. All appropriate persons were notified, and a new bottle was obtained from (Pharmacy). Through further investigation it is noted that this resident was not medically harmed as he did not miss any dosing of his medication and properly assessed for pain management. In conclusion, the Quality Assurance Committee reviewed each controlled substance for all residents, noting that all medications were accounted for appropriately; also reviewing each controlled substances proof of use, and PRN medication information. The QAC also implemented auditing the controlled substances with a witness at random and implemented overseeing shift change during the narcotic count at random as our Corrective action plan. To date, there have been no new findings. All staff has been in-serviced of the Abuse Policy and Controlled Substance Policy. R2's Face Sheet documents he was admitted to this facility on 08/23/21 with diagnoses in part of Aphasia following cerebral infarction, personal history of transient ischemic attack, osteoarthritis, low back pain, chronic pain, anxiety, and depression. R2's Physician's Order Sheet (POS) contains a handwritten note dated 11/23/22 as follows - Admit to (Name of Hospice) effective 11/08/22. Contact hospice nurse prior to administering comfort pack meds. R2's POS dated 11/24/22 documents an order for Oxycodone 0.25ml po q (every) 2 hr (hour) prn pain with a start date of 11/08/22. On 05/17/23 at 12:53 PM, V10 (Hospice Registered Nurse) stated R2 was admitted to their care on 11/08/22. V10 stated, We did order the prescription for Oxycodone and this medication was on hand in the facility on 11/08/22. However, we did not fill that first prescription. We filled the 12/29/22 and 02/15/23 prescription refills for Oxycodone liquid (30ml bottle), and these were the only two times we filled the prescription. On 12/29/22 the order was for .25 ml which is 5 mg q 2 hour dispensed as 100mg (milligram)/5ml. That was the order both times we filled the prescription. V10 stated they did tell the facility they had the liberty to administer 5 ml doses if R2's pain warranted an increased dose. V10 confirmed R2 discharged from their care on 05/04/23. At this time, V10 stated she will provide their flow sheet which documents the amount of any pain medication given by hospice in a 24-hour period including his prescription for Oxycodone. R2's local pharmacy delivery sheet dated 12/01/22 to 12/31/22 and 01/01/23 to 05/17/23 confirm delivery of Oxycodone HCL 100mg/5ml solution, quantity 30ml was delivered to the facility on [DATE] and 02/15/23. A Pain Medication Dose Record provided by V10 documents the following doses of Oxycodone were administered to R2 by hospice - 02/17/23: .5ml; 02/24/23: 0.25ml; 02/27/23: 0.25ml x 2 doses; 03/01/23: 0.25ml; 03/10/23: 0.25ml; 03/17/23: 0.25ml; and 03/20/23: 0.25ml for a total of 2.25ml of oxycodone liquid being administered by hospice. R2's November 2022 through May 2023 PRN Medication Administration Record (MAR) and coinciding Controlled Substance Proof of Use narcotic sheets were reviewed. On 11/08/22 R2's narc sheet documents one bottle of oxycodone 0.25ml (5mg), 30ml bottle is on hand. Between 11/09/22 and 11/30/22, 22 doses of this medication at 0.25ml per dose were administered to R2 for a total of 5.5ml (24.5ml remain). In December 2022, 48 doses were given to R2 totaling 12ml (12.5ml remaining). In January 2023, 30 doses were administered to total 7.5ml (facility calculation is 8.5ml and documented on the narc sheet to have been found dumped in the cart). A new narc sheet was started indicating the facility began administering from the oxycodone 30 ml bottle delivered on 12/29/22. On 02/10/23, V9 documents on the narc sheet that 27.75 ml remain after the evening dose at 8:45 PM, at which time the facility reported was the last time this particular bottle of oxycodone was seen. On 02/15/23, this narc sheet documents a new 30ml bottle of oxycodone was utilized with the first dose being given on 02/16/23. In February 2023, 13 doses were given to total 3.25ml (26.75ml remaining). In March 2023, 7 doses at 0.25ml and 1 dose of .5ml were given to total 2.25ml (24.5ml remaining). In April 2023, 6 doses of .5 ml were given to total 3ml (21.5ml remaining). The facility documents on 05/02/23 on the narc sheet that 20ml remain. It should be noted that between November 2022 and April 2023 there were doses of R2's medication signed out on the narcotic sheet that were not documented on the MAR as being administered, as well as doses of this medication documented on the MAR as being administered, but not signed out on the narcotic sheet. The above calculations accounted for those discrepancies and now the discrepancies are listed as follows - Oxycodone 100mg/5ml give 0.25ml po q 2 hr pain was signed out on the narcotic sheet but not the MAR as follows - 11/15 11:30 AM, 11/24 at 12:45 PM, 11/28 at 9:30 AM, 11/29 at 10:00 AM, 12/08 at 1:00 PM, 12/10 at 10:30 AM, 12:30 PM, 2:30 PM, 12/11 at 8:00 AM, 11:00 AM, 3:00 PM, 12/17 at 4:35 PM, 12/22 at 10:00 PM, 12/25 at 4:30 AM, 3:30 PM, 12/? at 9:00 PM, 01/04 at 8:00 AM, 1:45 PM, 01/16 at 12:00 PM, 01/24 at 11:00 AM, 02/10 at 9:45 AM, 02/17 at 10:30 AM, 5:30 PM, and 02/28 at 12:00 PM. Oxycodone 100mg/5ml give 0.25ml po q 2 hr pain was signed as given on the MAR but not the narcotic sheet - 11/28 at 10:40 AM, 11/29 at 1:00 PM, 12/04 at 7:00 PM, 12/14 at 7:40 PM, 01/11 at 4:15 PM, 01/27 at 10:00 AM, and 03/02 at 7:34 PM. On 05/17/23 at 10:07 AM, when asked if V6 and V9 conducted a shift-to-shift narc count when she arrived to work on 02/11/23, V6 stated it was not done. When asked why, she stated V9 seemed very frazzled and wanted to get his charting done before he left, so she did not want to overstimulate him because he had a bad night. V6 stated V9 charted for about 1 ½ hours, then went home. V6 stated she began to pass her meds and took it upon herself to do her own count at around 8:30 AM. She stated it was at that time she noticed R2's oxycodone bottle was not in the narc drawer. When asked if she let V9 know this, she stated she did not. When asked if she reported this to anyone at all, she stated she did not. V6 stated V9 was scheduled to return for his shift that evening at 6:00 PM and she just figured they would reconcile at that time, and she would let him know the narc was missing. V6 stated she waited to report this because she wanted to get the story from V9. V6 stated they looked everywhere and could not find it. When asked if she understood that one nurse does not do a narc count by herself, she said she did and added she was given an in-service on how to do narc counts and that you are required to do this with your co-worker so two people are present. On 05/17/23 at 2:22 PM, when asked to recount the events of 02/11/23 when R2's oxycodone went missing, V9 stated, I gave (R2) a dose of oxy the evening of 02/10/23 at 8:45 PM. I gave him a dose that night because he said he was needing some. When asked if he could recall the steps he took after administering the medication and that his written statement indicated he took the bottle into the resident's room to draw up the dose, he stated, I have done that before, so I would have put the vial back in the box and placed it back in the med cart and locked it in the narc box. When asked if there had been anything unusual going on that evening that would have disrupted his routine, V9 stated, I don't remember anything unusual that evening that would have altered my routine. V9 stated on the morning of 02/11/23, V6 was actually late getting to the facility, so he had started passing medications for her and when she arrived, she took over the med cart. V9 stated he did stay over to do his paperwork on the morning of 02/11/23. V9 stated there would have been no one else that had access to the keys to my med cart other than himself and V6. V9 stated, I had not had any issues with missing narcotics prior to or since 02/11/23. When told that the nurse (V6) who came on shift the morning of 02/11/23 reported to this surveyor she did her own narc count at 8:30 AM and discovered the oxycodone liquid missing, V9 confirmed V6 did not say anything to him about that before he left the facility the morning of 02/11/23. When asked if narc count was done between V6 and himself prior to him leaving the morning of 02/11/23, he stated they did not do one. V9 stated when he returned for his shift at 6:00 PM later that evening on 02/11/23 he and V6 did the usual narc count together. When asked if V6 then reported to him the narc was missing, V9 stated, I'm pretty sure I was the first one who said something about the narc not being in the box as we were doing count. On 05/23/23 at 2:25 PM, when told about the numerous discrepancies in R2's narc sheet and MAR documentation, V1 stated that she believed this was 100% (percent) staff either being lazy or simply forgetting to document. V1 stated this has been an ongoing issue that has been talked about repeatedly. The facility Controlled Substances policy dated 10/06, revised 11/02/17, reviewed 11/06/18 contained - Policy: It is the policy of the facility that all drugs listed as schedule II drugs are subject to specified handling, storage, disposal, and record keeping. Responsibility: All Licensed Nurses . Procedure: . 7. The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year . 9. Discrepancies must be reported immediately to the Director of Nursing . When loss, suspected theft, or an error in administration of regulated drug occurs, a report will be filed with the Pharmacist and the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from use of unnecessary psychotropic medications, including PRN (as needed) anti-psychotic drugs for 1 (R3) of 3 residents reviewed for unnecessary medications in the sample of 7. Findings Include: R3's Face sheet documents an admission to the facility on [DATE] with diagnoses to include dementia with behaviors (10/01/22), anxiety, depression, psychosis (05/26/22), restless leg (05/26/22), difficulty in walking (04/07/23). R3's Annual Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 7, indicating R3 has severe cognitive impairment. R3's admission Physician's Order Sheet (POS) dated 05/19/22 documents aggressiveness as R3's behavior and an order for Risperidone 0.5mg po (milligram by mouth) daily dated 05/19/22, and Trazodone 50mg po qd hs (daily at hour of sleep). R3's prescriptions for these two medications remain unchanged until October 2022 at which time the October POS documents R3 was diagnosed with urinary tract infection and started on Cefdinir 300mg po bid (twice daily) for 7 days, acidophilus therapy, and increase fluids dated 10/02/22; Risperidone 0.5mg po qd is decreased to 0.25mg po qd, and a new order to begin Prozac 10mg po qd for a diagnosis of mood dated 10/15/22, as recommended after psychiatric consultation on 10/14/22. R3 is diagnosed with a second urinary tract infection and started on another course of Cefdinir 300mg po bid for 7 days on 10/26/22. R3's December 2022 POS includes a third prescription for Cefdinir 300mg po bid for 7 days for a diagnosis of urinary tract infection, an increase in Risperidone from 0.25mg po qd to 0.5mg po bid, along with Ativan 0.5mg po to be given no earlier than hs, both dated 11/27/22. R3's January 2023 POS documents the following orders - Risperidone 0.5mg po bid dated 01/17/23 for a diagnosis of aggressive behaviors; Trazodone 50mg po hs dated 05/19/22 for a diagnosis of insomnia; and Ativan 0.5mg po hs for a diagnosis of anxiety dated 11/28/22. R3's February POS 2023 the following additional order - Celexa 20mg take 1 ½ tab po qd for a diagnosis of depression dated 02/14/23, and on 02/19/23 an order to send R3 to the emergency room for evaluation and treatment of a syncopal episode, uneven pupils non-reactive per nursing judgement. R3's February 2023 Behavior tracking includes - 1) Diagnosis: Dementia with behavioral disturbances. Psychotropic Medication: Risperidone. Target Behaviors: Yelling at others. Goal: To have decreased behaviors before next review date. Interventions: 1. Advise resident that it is not acceptable behavior. 2. Redirect to an activity. 3. Remove resident from public areas. R3 was documented to have no behaviors on third shift. R3's documented behaviors on first and second shift include behaviors 2 to 3 plus times per shift, 13 out of 28 days. Staff document utilizing intervention 1-3 providing an outcome of the behavior decreasing, a one-time outcome of R3's behavior stopping on 02/07/23, and the remaining outcomes of R3's behavior increasing on 5 occasions. Outcome Code: 1=Behavior Stopped; 2=Behavior Decreased. 3-Behavior Increased. 4=Other (See Nurse's Note). 2) Diagnosis: Insomnia. Psychotropic Medication: Trazodone. Target Behavior: Restlessness. Goal: To have decreased behaviors before next review. Interventions: 1. Keep hallway lights down. 2. Limit noise around resident room. 3. Encourage routine for sleep times. R3 experienced no documented behaviors on third shift. R3's documented behaviors on first and second shift include behaviors 2 to 3 plus times a shift, 12 out of 28 days. Staff document utilizing intervention 1-3 which provided a decrease in behavior on both shifts and an increase in behavior on second shift on 02/02, 02/25, and 02/26. R3's February progress notes include the new order for Celexa dated 02/14/23 by V2. R3's progress note dated 02/19/23 at 9:00 AM includes - . resident ambulating with walker in lobby, made a noise, and started to fall backwards. Staff member witnessed syncope episode and escorted resident to floor to protect head. Resident found to have altered mental status, pupils uneven, and unresponsive to light. 911 called, V12 (Power of Attorney - POA) notified . R3's progress note dated 02/19/23 at 2:30 PM documents - Resident returned from hospital via private auto after signing out AMA (against medical advice) from (name of hospital). Resident received Rocephin intravenous in the emergency room for mild urinary tract infection. Hospital will call with any changes as labs come back. CT (computerized tomography) showed negative for CVA (cerebral vascular accident). Resident resumed normal behaviors. R3's progress note dated 02/20/23 at 6:00 AM - 6:00 PM by V6 (Licensed Practical Nurse - LPN) includes - Resident ambulating with walker with no complaints . R3's February progress notes have no additional documentation of interventions related to R3's behaviors. No behavior tracking documentation was provide for February 2023 for the medication Celexa or Ativan. R3's March 2023 POS includes the following changes - Increase Ativan from 0.5mg po hs to 0.5mg po tid dated 03/10/23; and an increase Risperidone from 0.5mg po bid to 1mg po bid due to aggressive behaviors dated 03/10/23. R3's progress note dated 03/10/23 at 10:00 AM documents NP (V12 - Nurse Practitioner) in house and informed of R3's increase in anxiety, agitation, and aggressive behaviors. New order to increase Ativan to tid (three times daily) and Risperidone to 1mg bid. V12 called to give telephone consent. No answer left message to return call. R3's progress note dated 03/11/23 at 6:00 AM - 6:00 PM by V6 (Licensed Practical Nurse-LPN) includes - resident arguing with a resident, She is talking about . oh yeah, not you, shut up. Called V12 with no answer, left message to call the facility to give Ativan 0.5mg tid. Received order to do urinalysis and culture due to behaviors. R3's progress note dated 03/11/23 at 6:00 AM - 6:00 PM by V6 - Received verbal consent from V12 to increase medications. V12 provided a new reachable number. There is no other rationale in R3's record to explain an increase in anxiety, agitation, or aggressive behaviors for the month of March 2023. R3's March 2023 Behavior Tracking document the facility continues to track the same behaviors and medications with no change in interventions from her February 2023 Behavior Tracking. R3 is again noted to have experienced no behaviors on third shift. R3's Risperidone for the diagnosis of dementia with behavioral disturbances with the behavior of yelling indicated she experienced between 2 to 5 plus incidents of yelling at others on first shift for 16 out of 31 days. Staff document interventions of 1-3 resulting in R3's behavior both decreasing and increasing. R3 experienced 13 episodes of yelling 2 to 3 plus occasions on second shift with staff also utilizing 1-3 interventions. R3 is documented to have mainly an increase in this behavior on second shift after staff attempted interventions. R3's Trazodone for the diagnosis of insomnia with the behavior of restlessness documents no behaviors on first shift. R3 experienced 2 to 3 plus episodes on second shift 8 out of 31 days. All interventions listed were attempted with decreased behaviors on 3 days and increased behaviors on the other 5 days. R3 experienced 3 plus behaviors on second shift for 7 out of 31 days. Staff document all interventions attempted with only an increase in behaviors. R3's progress note dated 03/15/23 at 6:00 AM to 6:00 PM by V6 documents in part that resident had an increase in Ativan and Risperdal with no signs/symptoms of adverse effects. R3's progress note dated 03/17/23 at 2:30 AM by V9 (LPN) document nurse was alerted to resident room where resident was sitting on floor next to bed. R3 reported she had been walking back from the bathroom without her walker when she fell. V9 documents R3 was assessed with no pain on range of motion and no injuries noted . V12 also notified. R3's progress note dated 03/30/23 at 6:00 AM - 6:00 PM by V6 includes that a CNA had reported R3 seemed groggy, ambulating slowly, and hand slipped on siderail in shower (no fall). V6 documents she held R3's Ativan 0.5mg at 11:30 AM . asking to collect urinalysis with culture and sensitivity if indicated . There was no documentation provided of behavior tracking in March 2023 for Celexa or Ativan. There is no additional documentation in R3's record to indicate other non-pharmacological interventions were attempted in March 2023. R3's April 2023 POS includes the following changes - Celexa 30mg po qd was decreased to Celexa 20mg po qd dated 04/21/23 due to seeing increased weepiness and increased agitation; Risperidone was increased from 1mg po bid to Risperidone 2mg po am and 1mg po evening on 04/16/23; Trazodone was decreased from 50mg po hs to Trazodone 25mg po q hs dated 04/18/23; and Haldol 2mg po daily PRN (as needed) was added for increased anxiety, aggression, signs of psychosis x 14 days dated 04/18/23. A handwritten order dated 03/30/23 was also included for a urinalysis with culture and sensitivity if indicated due to increased behaviors. R3's progress note dated 04/03/23 at 6:00 AM - 6:00 PM by V6 documents - Resident arguing with another resident. Resident using foul language. Resident does not listen to reason . encourage to sit down in bed due to I don't feel very good. Resident denied dizziness. BP (blood pressure): 94/52. Resident would not sit still. Lisinopril held for BP less than 60 . On 04/04/23, R3's April POS also documents administration of a one-time Haldol 2mg IM (intramuscularly) injection. There is no documentation or rationale (including non-pharmacological interventions or behavior tracking) provided for the use of a Haldol injection dated 04/04/23. R3's progress note dated 04/13/23 at 6:00 AM - 6:00 PM by V6 - Resident ambulatory with walker back and forth from television room to bedroom, Where's my room? Complaining of having to sit down because of her legs. Resident looks tired. Resident directed back to sit . relax legs. Ativan held at this time due to resident stating, I'm so tired. My legs hurt. R3's progress noted dated 04/13/23 at 7:00 PM by V6 - Resident picking argument with roommate and calling her names. Nurse spoke with resident and pulled privacy curtain, talked to resident. At 7:10 PM, V6 writes - resident staying in her bed. No words spoken. On 05/22/23 at 10:14 AM, when asked about non-pharmacological interventions for R3's behaviors, V6 stated the facility was tracking her behaviors, had interventions in place, but a lot of the times the interventions were not successful. V6 stated that she would just try and talk with R3 to calm her down; .sometimes this worked and sometimes it did not. R3's progress notes dated 04/15/23 at 10:30 AM by V20 (LPN) documents - Resident tearful this morning, took a nap and calm down some. R3's progress note dated 04/16/23 at 10:30 AM by V20 documents that resident tearful again, yelling at staff about lack of care, coffee, and food. Staff had just gotten her a fresh cup of coffee and she just ate breakfast. Filled out AIMS (Abnormal Involuntary Movement Scale) form and contacted NP (V2). Received new order to increase morning dose of Risperidone. Attempted to call POA. Phone out of order. R3's progress note dated 04/19/23 at 2:00 PM by V19 (Former LPN) - Continues with med change. Resident tearful this am. Stated she hadn't had any coffee, and no one cares . this nurse had (illegible) a cup. Resident wandering with walker tearfully. R3' progress note dated 04/20/23 with no time by V19 - Continue with psych med changes. Trazodone decreased to 25mg, and Risperidone increased to 2mg am and 1mg evening. Resident continues to ambulate with walker throughout the facility. Steady gait noted. Resident continues with obsessive request for coffee after having coffee. Tried to encourage water. Resident tearful this am about being scared to die. 1:1 (one on one) given without success. Continue to monitor resident for behaviors. R3's progress note dated 04/21/23 at 4:00 PM by V8 (LPN) she consulted with V2 who decreased R3's Citalopram to hopefully help mood swings. R3's progress note dated 04/23/23 at 9:30 AM by V7 - Resident at nurse's desk asking for a cup of coffee five times since 9:00 AM. Resident was given a cup of coffee at 8:45 AM. There is currently no coffee made. Staff explained this to resident . resident became angry and said, I haven't had a cup of coffee all day! You people are a bunch of liars. Water and juice offered. Resident refused. PRN Haloperidol given at 7:30 AM. Not effective. R3's April 2023 behavior tracking continues to track the same behaviors and medications as indicated on the February and March 2023 Behavior Tracking forms. Relating to her prescription of Risperidone, R3 is again noted to have experienced no behaviors on third shift. R3 is documented to have 2 to 5 episodes of yelling at others on first shift for 14 out of 30 days. Staff indicated that of the same three interventions attempted her behavior decreased one time on 04/07/23, increased the remainder of the time, and on 04/22 asks to refer to nurse's note (documented above). R3 is documented to have 3 to 5 plus episodes of yelling on second shift 15 out of 30 days, again with the same three interventions marked as attempted. R3's behavior worsened each day except on 04/24, 04/25, and 04/26 where staff document here behavior decreased. R3's April 2023 Behavior Tracking for Trazodone due to insomnia/restlessness include - No behaviors on third shift, 8 out of 30 days marked on first shift ranging from 2 to 3 plus behaviors per shift with a mixture of decreased behaviors and increased behaviors. On second shift, R3 was documented 7 out of 30 days to experience 3 plus behaviors which increased after interventions were attempted. R3's April 2023 Behavior Tracking dated 04/20/23 was initiated for Ativan, Celexa, and Haldol to include to include - Diagnosis: Anxiety. Psychotropic Medication: Ativan. Target Behavior: Paces back and forth from room to dining area. Goal: To have decreased behaviors through next review. Interventions: 1. Redirect to activity of choice. 2. Offer snack. 3. Provide resident 1:1 visits as needed. On 04/26/23 during third shift, R3 was documented to have two behaviors with all interventions attempted and her behavior stopped. R3 experienced 3 plus to 5 plus behaviors during the first shift 9 out of the 11 days tracked. All three interventions were attempted with increased behaviors. R3 also experienced 3 plus to 4 behaviors on second shift 9 out of 11 days tracked with the same interventions attempted resulting in increased behaviors. On 04/22/23 (first and second shift), V21 (CNA) documents R3 experienced 4 episodes of restless resulting in R3 pacing back and forth from room to dining room. All, three interventions attempted, with a reference to see progress note. R3's April 2023 Behavior Tracking dated 04/20/23 - 04/28/23 includes - Diagnosis: Anxiety. Psychotropic Medication: Haldol. Target Behavior: Physical aggression towards staff. Goal: To have decreased behaviors through next review. Interventions: 1. Offer reassurance. 2. Redirect if necessary. 3. Reapproach with different staff. R3 experienced no documented behaviors on third shift. On first shift, R3 experienced 3 to 4 behaviors, 5 of 11 days tracked, all three interventions attempted with an increase in behavior. On second shift, R3 experienced 3 to 4 behaviors 3 of 11 days tracked, all interventions attempted with increased behavior. On 04/22/23 (first and second shift), V21 (CNA) documents R3 experienced 4 episodes of anxiety resulting in physical aggression towards staff, all three interventions attempted, with a reference to see progress note. R3's progress note dated 04/22/23 10:00 AM by V7 (LPN) - Resident showing signs of anxious behavior. Resident following staff and yelling at them for not helping her. When asked what she needs help with resident stated, you don't even care. Nobody cares about me. Resident then became tearful. Staff encourage resident to lay down or watch television. Resident refused. Resident began yelling at staff saying we haven't fed her in three days. Resident reminded she just had breakfast. Resident stated, Well I didn't get any! You people are trying to starve me. Snack offered; resident refused. PRN Haldol given for increase in behaviors. Not effective. There is no other rationale in R3's record for the use of Haldol nor was there any documentation provided of R3 becoming physically aggressive with staff as documented in the Behavior Tracking log. R3's April 2023 Behavior Tracking dated 04/20/23 - 04/28/23 continues to include - Diagnosis: Depression: Psychotropic Medication: Celexa (Citalopram). Target Behavior: Tearfulness. Goal: To have decreased behaviors through next review. Interventions: 1. Allow resident to voice feelings and concerns. 2. Redirect to an activity. 3. Offer reassurance as needed. Again, R3 experienced no behaviors on third shift. First shift documents 3 plus to 4 behaviors, 9 out of 11 days tracked. All interventions documented as attempted with only increased behaviors. Second shift documents 3 plus to 4 behaviors for this shift, 8 out of 11 days tracked. Interventions attempted with increased behaviors. V21 documents to refer to the same progress note dated 04/22/23. R3's progress noted dated 04/28/23 at 6:20 PM by V19 (LPN) documents that resident wandered with walker most of the day, laid down for nap at 4:00 PM, was not able to wake up enough to medicate. R3's May 2023 Behavior Tracking was reviewed with a stop date of 05/09/23 when R3 discharged from the facility. Documentation includes - 1) Diagnosis: Anxiety. Psychotropic Medication: Ativan. Target Behavior: Paces back and forth from room to dining area. Goal: To have decreased behaviors through next review. Interventions: 1. Redirect to activity of choice. 2. Offer snack. 3. Provide resident 1:1 visits as needed. No behaviors on third shift. R3 experienced 2 to 3 plus behaviors during the first shift out of the 8 days tracked. All three interventions were attempted with 2 days of behavior decreasing and the rest increased behaviors. R3 experienced 2 to 3 plus behaviors on second shift 5 out of 8 days tracked with the same interventions attempted resulting in increased behaviors. R3's May 2023 Behavior Tracking continues to document - 2) Diagnosis: Anxiety. Psychotropic Medication: Haldol. Target Behavior: Physical aggression towards staff. Goal: To have decreased behaviors through next review. Interventions: 1. Offer reassurance. 2. Redirect if necessary. 3. Reapproach with different staff. R3 experienced no documented behaviors on third shift. On first shift, R3 experienced 2 behaviors, 2 of 8 days tracked, all three interventions attempted with one day documented and decreased and the other day blank. On second shift, R3 experienced 2 behaviors 1 out of 8 days tracked, all interventions attempted with decreased behavior; 3) Diagnosis: Depression: Psychotropic Medication: Celexa (Citalopram). Target Behavior: Tearfulness. Goal: To have decreased behaviors through next review. Interventions: 1. Allow resident to voice feelings and concerns. 2. Redirect to an activity. 3. Offer reassurance as needed. No behaviors on third shift. First shift documents 3 plus behaviors, 7 out of 8 days tracked. All interventions documented as attempted with increased behaviors. Second shift documents 2 to 3 plus behaviors for this shift, 4 out of 8 days tracked resulting in a decreased behavior with the rest increased; 4) Diagnosis: Dementia with behavioral disturbances. Psychotropic Medication: Risperidone. Target Behaviors: Yelling at others. Goal: To have decreased behaviors before next review date. Interventions: 1. Advise resident that it is not acceptable behavior. 2. Redirect to an activity. 3. Remove resident from public areas. R3 was documented to have no behaviors on third shift. R3's behaviors on first and second shift occurred 2 to 3 plus times per shift, 7 out of 8 days. Staff document utilizing intervention 1-3 providing an outcome both a decrease and increase in R3's behavior; 5) Diagnosis: Insomnia. Psychotropic Medication: Trazodone. Target Behavior: Restlessness. Goal: To have decreased behaviors before next review. Interventions: 1. Keep hallway lights down. 2. Limit noise around resident room. 3. Encourage routine for sleep times. R3 experienced no documented behaviors on third shift. R3's documented behaviors on first and second shift include 2 to 3 plus behaviors a shift, 6 out of 8 days. Staff document utilizing intervention 1-3 which provided a mixed result of decreased and increased behaviors. R3's progress note dated 05/08/23 at 2:00 PM by V24 (LPN) - At 9:00 AM, resident fell to the floor onto left side of body - laying on arm and bumped head on way to floor. Resident was assessed and neuros were initiated. BP: 74/56; Pulse: 102; Temperature: 97.3; Respirations: 16; Oxygen saturation: 90% (percent). Resident out to (name of hospital). There is no documentation in this note indicating any notifications were made to V12. R3's record contains the most recent visit dated 04/14/23 by V2(Nurse Practitioner) documents in part - chief complaint of routine visit, chronic care management and medication management for dementia, major depressive disorder, and anxiety. History of Present Illness or Interval History: [AGE] year-old white female nursing home resident since 05/19/22. Patient is sitting in activity room, calm and cooperative, alert with daily confusion, onset prior to admission, related to progressing dementia, poor short and long-term memory, worse with infection, off topic easy, does well with redirection and reassurance. History of depression, onset at admission, denies depression in the last month, staff reports last month tearful episodes saying no one care about her or is helping her, forgets she ate and reports no one feeds her, history of anxiety, onset at admission, report no symptoms in the last month, paranoia noted, 04/04/23 threatened to hit others and given IM Haldol and effective, found to have UTI on 04/04/23 with a trace of leukocytes and blood that could be contributing to behavioral symptoms, 04/12/23 fell, 04/16/23 Risperdal increased per medical, has been responding well to increase, calmer and easier to redirect, dose have PRN Haldol available for further crisis, history of insomnia, no episodes in last month, stable on Trazodone, care conference with staff, behavior tracking active, continue to use non-pharmaceutical intervention for behavior management. Staff reports no concerns. If patient's gait becomes affected or shows lethargy with increased Risperdal may need dosage adjust. Psychiatric Medications: Risperdal 2mg po daily and 1mg po at bed increased on 04/16/23; Ativan 0.5mg po tid increased 03/10/23; Trazodone 25mg po at bedtime; Celexa 30mg po daily; Haldol 2mg po daily PRN. Diagnosis: Dementia with behavioral disturbance, Alzheimer's disease with late onset, MDD, anxiety, insomnia, psychosis. Recommendation: Increase Celexa to 40mg po daily. Gradual dose reduction contraindicated. Lowest effective dosages prescribed. Reduction may result in relapse of behaviors or decrease in quality of life. R3's record contained no diagnosis of UTI in April or May 2023, there were no further progress notes mentioning a UTI, and R3 was not prescribed an antibiotic per R3's April or May POS/MAR. V2's (Nurse Practitioner) progress note dated 03/17/23 with chief complaint of patient not feeling good. She is an ambulatory female evaluated last week related to anxiety, verbal agitation, and aggression. Nursing states she is improved in terms of calling out, being insulting to other residents, and seems calmer. Patient states today, I'm just tired more. Assessment and plan to include orthostatic hypotension acute/moderate, monitor blood pressure orthostatic twice daily for 5 days, reassess adequate fluids, affective psychosis chronic/moderate with acute changes, recent med change reported to be effective, continue other meds and monitor, goal to decrease anxiety/agitation levels - improved . V2's progress note dated 04/14/23 includes chief complaint/reason for visit to review psychotropic use and any side effects. Nursing reports patient is occasionally aggressive physically with others. She is currently on a dose of medicine that seems to be correct dose as it helps decrease her level of aggressive behavior, her overall mood comes and goes with one minute calm, and then can be very angry. Overall sleep good currently on Trazodone 50mg, BP stable. Assessment/plan to include orthostatic hypotension acute/moderate resolved . affective psychosis chronic/moderate with acute changes, recent med change nursing reports effective. No changes recommended at this time, continue same meds and supportive environment, improved agitation. V2's progress note dated 04/18/23 documents a chief complaint of ongoing decline related to dementia.presents with her perseverating frequently on a need or topic; then escalating verbally at times in her understanding of the issues. Her environment has been supportive, staff have been working with her for her needs; she attempts to have greater than 5 cups of coffee per morning and becomes argumentative if discussion that more will come later .Chart review related to medications - she is on psychotropics that staff state have helped including Risperdal am dose now of 2 mg. She is on BP meds and does run less than 120/80 so meds reviewed. Decrease Lisinopril to 20mg, decrease Trazodone to 25mg and stop Zyrtec . Assessment and plan to include orthostatic hypotension chronic/moderate resolved but still at risk so: decrease Lisinopril to 20mg daily/from 40mg daily; decrease Trazodone to 25mg as may have side effects; affective psychosis chronic/moderate with acute changes with med changes and nursing reports effective, no changes recommended at this time. V2's progress note dated 04/21/23 documents . I have been asked to evaluate related to following ongoing course: Patient is intermittently agitated. She gets up every few minutes to ask for cup of coffee, diversion or sub of water or tea is helpful somewhat. Certain times of day she has increased weepiness that nobody cares, this is random and not in line with any time of day or events. She is eating and drinking o.k. Review of labs done. Review of med x 8 weeks done - Recent meds attempted: Citalopram 30mg today since 02/14/23 and we schedule Tylenol bid in case pain origin; Gabapentin has been ongoing since 05/22 and no recent adjustment; Trazodone 50mg no new changes since 05/22 until last week was deceased to 25mg in pm due to lower BP; Risperidone start 03/12/23 at 1mg bid then was increased to 2mg am and 1mg pm on 04/16/23 with no drastic improvement; Lorazepam tid with no recent changes . Assessment and plan: Decrease Lisinopril to 20mg daily/from 40mg daily; lowered the Trazodone to 25mg as may have side effects; affective psychosis chronic/moderate with acute changes. Researched algorithm/complex info regarding dementia with depression x 35 minutes related to ongoing issues concerns for this patient's needs dementia/depression/agitation/weepiness. Plan: Increase Gabapentin to 300mg tid. Decrease Celexa to 20mg daily as may be agitating. Continue same Risperdal. Trazodone was decreased within the week to decrease low BP risks. Improved on Risperdal 2mg am and 1mg pm. Continues with Ativan as schedule. PRN Haldol x 14 days only has been ordered if worsening psychosis. V2's progress note dated 04/25/23 included chief complaint of notification by nursing that patient had lower extremity generalized weakness. Vitals were fairly stable. Patient was placed into bed for further evaluation .patient has been seen frequently secondary to psychiatric and risk for falls as well as injury secondary to progressive dementia. Last week I increased her Celexa as I felt it was activating and decreased from 30mg to 20mg. yesterday she was seen by psychiatric services, and it was increased back up to 40mg. Discussion with nursing regarding this fact. Nursing reports today that patient is ambulatory and seems less weak. She continues to be occasionally agitated verbally and repetitive regarding coffee. Our goal was to have the tolerance of an increased dose of the Gabapentin secondary to research regarding depression, dementia, agitation. Patient denies any pain issues or concerns today with my interview . Assessment and plan include affective psychosis chronic/moderate with acute changes. She is tolerating increased Gabapentin to 300mg tid. Decrease Celexa to 20mg daily as she may agitated/keep it there for now; when psych comes in, I can meet with them. Continue same Risperdal. Trazodone was decreased within the last week to decrease low BP risk. Improved on 2mg Risperdal in am and 1mg pm. Continue with scheduled Ativan. R3's emergency department provider notes dated 05/08/23 include - Chief complaint: Fall, weakness. HPI (History of Present Illness: Patient is in [AGE] year-old female past medical history of Alzheimer's dementia on Risperidone, Haldol, Ativan who was sent to the ER (emergency room) for evaluation of fall, low blood pressure, and elevated heart rate. Patient was at rehab facility, fell, and hit her head. Patient has also been having some altered mental status and incontinence which is not usual for her. Patient does have a history of dementia. Patient not able to provide much of a history . R3's Hospitalist Discharge Summary documents admission on [DATE] with discharge on [DATE]. Primary diagnoses: Altered mental status secondary to polypharmacy and dementia. discharged condition: Stable. Indication for admission: Altered mental status. Hospital Course: [AGE] year-old female presented from skilled care nursing facility with altered mental status and falling .Patient returned to baseline fairly quickly upon arrival to the ER (emergency room) and upon admission. Patient does have a history of dementia/Alzheimer's with behavioral disturbance. She used to live with her son as he was her primary caretaker, but she started having violent outbursts approximately 1 year ago, so she was moved to skilled nursing facility. She has been receiving Haldol 2mg po daily (milligram by mouth) that was started in mid-April and did receive a Haldol injection mid-April. She was also on what appears to be scheduled Ativan 0.5mg 3 times daily. It also appears her Risperdal was increased to 2mg bid twice daily on 05/06/23. I had a conversation with (V12) as patient is not decisional due to her dementia. He states that he has asked the nursing home not to give her Haldol and only give her the Ativan. He was unaware of the Risperdal increase. Today he seems very frustrated and upset that she had been getting those medications without checking with him first. No same medication has been held while in the hospital and she has returned to her normal baseline mental status. We discussed discharging her back to skilled nursing facility however (V12) stated that he is her primary caretaker does not want her to back to the nursing home. He states he is able to care for her 24/7 at home and will be taking her home instead. She is having home health set up. We have given her prescriptions for her chronic medications and have changed her Haldol to as needed daily as well as her Ativan to 3 times daily as needed and have decreased her Risperdal back down to 1mg twice daily. AMS (altered mental status) likely secondary to polypharmacy, Fall. On 05/22/23 at 10:19 AM, when asked if he had ever spoken with the facility regarding polypharmacy, V1 (Administrator) stated he did. A few weeks ago, V12 came into the facility and spoke with the nurse caring for R3 that day. V12 became verbally combative with the nursing staff (V15 - Former DON and V18 - CNA) and was yelling. V1 stated she was in her office and stepped out into the hall with V19 (LP[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure floors and bathrooms in resident rooms and common areas were maintained in a clean and sanitary manner for 7 of 7 residents (R1, R3, R4, R5, R6, R7, and R8) reviewed for environment in a sample of 8. Findings Include: 1. On 1/17/23 at 10:40 AM, R1 who was alert to person, place and time said the housekeeping needs to be better. R1 said, I wanted to change my sheets today, before the night shift (staff) left, and they said no, they didn't have time. R1 said there have been complaints brought up in the monthly Resident Council meetings. R1 said her bedroom and bathroom floors had not been swept or mopped today and she was not sure when it was last done. The floors of R1's shared room and bathroom were in need of being swept and mopped. There were crumbs of food and other debris on the floors and black smudges of grime. The old, tiled floors were stained and dull. R1 said the trash does not get emptied in a timely manner and the trash cans are too small. 2. On 1/17/23 at 2:00 pm. The floor in R3's room was in need of sweeping and mopping. There was a large 12 x 3 dried brownish stain on the floor beneath one of the 3 beds in the room, having the appearance of spilled tea or coffee that had dried on the floor. There were pieces of white tissue or napkins balled up on the floor and an orange colored candy or breath mint under the same bed. The connected resident bathroom had an unflushed toilet and there was a musty smell. The bathroom floor was in need of mopping and the small trash receptacle was full. 3. On 1/17/23 at 10:25 AM, R4 was awake and alert reclining in bed with V10 (Family) at bedside. R4 who was alert to person, place and time and V10 said the floor in the room and connected bathroom had not been swept or mopped today and they aren't sure how often they're cleaned. The toilet in this bathroom was unflushed and there was a strong urine odor. There was a dried brown substance smeared on the rim of the toilet bowl and the gray elevated toilet seat. The small trash receptacle in the bathroom was not full. Both R4 and V10 said the facility could do better with cleaning the floors and overall cleaning. 4. On 1/17/2023 at 9:50 AM, R5 who was alert to person, place and time stated the staff do pick up her dirty cups. Said she did not have her floor swept or mopped today and she was not sure when it was done last. 5. On 1/17/23 at 10:00 AM, R6 who was alert to person, place and time stated he didn't see housekeeping staff in his room yet today, and his floor had not been mopped or swept. R6 said he did not see staff empty his trash can today. The small trash can was full and overflowing. The connected bathroom to R6's bathroom had a strong urine smell and was in need of mopping and cleaning. There was a dried brown smear on the toilet seat. 6. On 1/17/23 at 10:35 AM, R7 was alert to person, place and time said the housekeepers had not swept, mopped or cleaned her floor or the bathroom today. R7 stated, I guess they only do it when they want to. R7 said the housekeeping needs to be done more regularly. 7. On 1/17/23 at 10:50 AM, R8 was alert to person, place and time said the housekeeping staff had not been in his room to sweep, mop or clean today and he was not sure when it was done last. R8's room and connected bathroom floors were both in need of being swept and mopped. The toilet was unflushed, there was a strong urine odor, and the toilet seat and bowl were both heavily soiled and splattered with a dried brown substance. 8. On 1/17/23 at 10:15 AM, in the 100 hall shower room there were orange colored cracker crumbs on the floor of the shower room, next to 2 mechanical lift slings positioned partially on the floor. The shower room floor was in need of sweeping and mopping throughout the day on 1/17/23 and the orange cracker crumbs remained present on the floor on 1/18/23 at 1:30 PM. On 1/17/23 at 11:15 AM, V1 (Administrator) stated the facility, doesn't really have any policies regarding general housekeeping duties or cleaning, but we're still looking for them. V1 said they have had housekeeping issues mentioned in the Resident Council meetings and Grievances. V1 said, It has been difficult to hire housekeeping and laundry staff, so nursing staff are expected to help out with keeping the facility clean. V1 said they now have a full time Housekeeping Supervisor, so she is looking forward to improvement with the cleanliness of the facility. V1 said the old, tiled flooring in the resident rooms, bathrooms and shower rooms is difficult to keep clean and renovations are planned for these areas. On 1/17/23 at 11:30 AM, V3 (Housekeeping Supervisor) stated that she has been the facility's Housekeeping Supervisor for almost a month. V3 stated that she knows the facility had difficulty hiring staff for the Laundry and Housekeeping positions during the past year. V3 said the Housekeeper Schedule was not currently accurate, because they had to make some changes due to a family illness. V3 stated she would like to have more staff, Ideally we should have 2 Housekeepers and 1 Laundry staff on day shift. I'd like to have Housekeeping staff on second shift and nights. V3 said, There is 1 girl working nights right now. V3 said they mop at least once a day in all resident rooms, but housekeeping comes later today and will mop the floors. V3 said she has an abundance of cleaning supplies because the facility just ordered the same amount each month, before there was a Housekeeping Supervisor to order just what they needed. V3 stated V1 (Administrator) told her to create a Wish List of what was needed to help improve the facility's housekeeping overall. V3 said she just took over the position and is looking forward to improving the overall cleanliness of the resident rooms and common use areas. V3 said, Once a month every resident room gets deep cleaned. V3 said they try to keep the same day of the month for each room. V3 said, For example today room [ROOM NUMBER] is being deep cleaned. V3 said some resident rooms can be more challenging to keep clean because they toilet themselves and are [NAME]. V3 described a resident who chooses to only leave her room in the evening. V3 said, So we clean her room when she is out for dinner, and also for the monthly deep cleaning. V3 said, CNAs (Certified Nurse Aides) make beds in the morning and sheets get changed twice weekly on shower days. V3 said sheets also get changed as needed. V3 said she thinks the floors and bathrooms will be much easier to keep clean once the renovations are completed. On 1/18/23 at 9:25 AM, V1 (Administrator) said she had an Inservice with staff yesterday regarding general cleanliness of the facility and the need for staff to clean up after themselves and to maintain cleanliness of the facility. V1 stated, Staff are aware of how much better it is to have a clean facility and that we need to keep that as a priority. On 1/18/23 at 1:30 PM, V2 (DON) and V9 (Certified Nurse Aide/CNA Supervisor) both stated they would expect nursing staff to use the mop when needed and whenever housekeeping was not available. Both V2 and V9 confirmed the 100 hall shower room floor needed to be swept and mopped. The Housekeeping Schedule provided by V1 for January 2023 documents there were 3 staff scheduled to work on 1/17/23: (V5) 8:00 AM - 4:30 PM, (V6) 10:30 PM - 6:30 AM, and (V7) 6:00 AM to 6:30 PM. This Schedule documents 9 of 31 days when 3 Housekeeping staff are assigned, 9 days when 2 Housekeepers are assigned, and 12 days when just 1 Housekeeper is assigned and 1 day when there was no Housekeeper assigned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform wound tracking measurements and wound care as ordered for 1 of 3 residents (R15) reviewed for wounds in the sample of 24. Findings Include: Review of R15's Face sheet dated 12/27/21 documents R15 was admitted to the facility on [DATE]. Review of the Facility Matrix, provided by the facility on 7/19/22, documents R15 has a facility acquired stage IV pressure wound. Review of active physician orders dated for 7/2022 documents a wound treatment order to: left ischial tuberosity; cleanse with wound cleanser, apply sure prep periwound, apply collagen then calcium alginate to wound bed cover with border gauze daily and as needed. On 7/21/22 at 2:37 PM, V19 Licensed Practical Nurse (LPN) was observed providing wound care to R15's left ischial tuberosity. R15 was observed cleansing the wound bed with wound cleanser, then placing collagen in a medication cup and pouring normal saline over the collagen. R15 then applied the moistened collagen to the wound bed. A dry piece of calcium alginate was placed over the collagen, then the wound was covered with a bordered gauze. No sure prep was observed being used to the periwound areas. On 07/22/22 at 9:20 AM, R15's wound care order was reviewed with V19 in which it was expressed it was not noted in the physician order that the collagen was to be moistened with normal saline before application, nor was any skin prep used to the periwound area. V19 stated she provided R15's wound care the way she did because when the wound care physician was previously coming to the facility to provide care, that is how staff at that time were taught to do the dressing. V19 stated that the wound care physician had since retired a while back and no longer comes to the facility. Review of R15's Current Plan of Care documents a problem area of R15 having a Stage 4 pressure wound. A current goal with an initial date documented as 10/25/21 listed for this problem area states, Pressure ulcer will reduce in size, through course of treatment as ordered by physician, AEB (as evidence by) improvement in weekly wound measurement sheet over the next 90 days. Review of R15's Clinical Record documents no measurements performed by the facility of R15's wound for June or July 2022. Review of R15's Treatment Administration Record documents no refusal of wound treatment for June or July 2022. On 07/22/22 at 11:19 AM, Although requested, V21(Regional Clinical Director) could not provide documentation of wound measurements being completed by the facility for R15. V21 clarified that no wound measurements tracking the wound progress or decline are available and the facility can therefore not say if the wound is improving or deteriorating. V21 was able to provide R15's last consultation with the wound clinic physician's office dated 5/17/22. Review of R15's wound clinic physician's office note dated 5/17/22 documents R15 was being treated for a Stage 4 Pressure Wound of the Left Ischium Full Thickness. This wound is documented as measuring 3.2 cm (centimeters) in length, 3.0 cm width, and 0.6 cm depth, with a surface area measurement of 9.60 cm squared. The Dressing Treatment Plan documented on this consult states for the dressing: collagen sheet with silver, apply once daily for 9 days; alginate calcium with silver apply once daily for 9 days and covering with a gauze island with skin prep applied to the peri wound. This wound note also documents surgical excisional debridement of the wound was conducted on this date in which 1.92 cm squared of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.7 cm and healthy bleeding tissue was observed. Review of the local hospital wound clinic documents R15 was seen in the clinic on 7/5/22. On this date the ischial tuberosity wound is documented as being 4.8 cm in length and 3.9 cm in width with no depth documented. Orders from this appointment document a wound vac to wound continuously to be placed as soon as possible. Until the wound vac could be obtained, the following dressing order is noted: cleanse wound with wound cleanser, apply collagen which is moistened with normal saline or sterile waster and place in wound bed, cover with an Aquacel foam dressing adhesive twice a week. Once wound vac was obtained, the dressing order was to be discontinued. On 07/22/22 at 9:45 AM, V20 (local hospital wound clinic registered nurse) verified R15 was last seen at the wound healing center on 7/5/22 with a 2 week follow up that was needed but canceled by the facility due to a positive covid status. V20 stated at the time R15 was seen on 7/5/22, orders were to start a wound vac as soon as possible, with dressing orders until the wound vac was received to be: clean wound with wound cleanser, moisten collagen with NS or sterile water and place in wound bed, and Aquacel foam dressing adhesive 2x week. V20 stated he does not see any documented communication the facility had with the wound clinic regarding the inability to obtain a wound vac or ordered wound supplies from the 7/5/22 consult, only to re-schedule R15's next appointment. 07/22/22 at 12:08 PM, V1 (Administrator) stated that there has been a delay in obtaining a wound vac for R15 due to insurance. V1 was not aware of any reason the wound consult dressing orders wouldn't have been initiated as ordered until the wound vac could be obtained. V1 stated the facility has been in contact with the wound clinic today to notify them of the delay in obtaining a wound vac and receive order clarification. V1 confirmed R15 should be getting weekly wound measurements and it is her expectation for staff to provide wound care as ordered exactly by the physician. V1 stated if the if wound size increases or deteriorates, they are to contact the physician immediately. Review of the facility policy titled Decubitus Care/Pressure Areas with a revision date of 1/18 stated, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. This policy goes on to state, Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. This assessment must include: i) Characteristic (i.e., size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) treatment and response to treatment.

Based on record review, observation, and interview, the facility failed to check the placement of a gastrointestinal tube (G tube) prior to administering medication and a water flush for 1 resident of 1 resident (R134) reviewed for G tubes in the sample of 24. Findings include: R134's July 2022 Physicians Order Sheet documented an order for Haldol 2 milligrams one tablet twice daily per PEG (Percutaneous Endoscopic Gastrostomy) tube, flush with 60cc(cubic centimeters) of water before and after medications. On 07/19/22 at 11:34am, V6, Registered Nurse, was observed administering a Haldol 2 milligram tablet and a water flush for R134. V6 crushed the Haldol tablet and mixed it with 60 cc of water. Using a large syringe, V6 then administered into the PEG tube 60cc of water, the Haldol mixed with water, and another 60cc of water. V6 did not check the placement of the tube prior to the administration. When the surveyor asked V6 if she was supposed to check for placement prior to the administration, V6 stated, No, we never do that here. Guidance at https://www.in.gov/health/files/l52.pdf, documents Administering Medications Through a G tube, documented, Implementation of medication administration through a G tube: Check placement(of the tube) by auscultating the resident's abdomen about three inches below the sternum with a stethoscope. Gently insert 10 cc of air into the tube. You should hear the bubble enter the stomach. A Facility Tube Fed Resident Policy dated 10/13 documented, It is the policy of (the facility) to ensure tube feedings are accurately ordered, administered, and managed .The policy and procedures of the facility are not intended to replace the prevailing standard of care.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours per day seven days per week. This failure has the potential to affect all 41 residents living in the facility. Findings include: Review of the July 2022 Nursing Schedule documents no RN coverage was provided at the facility on 07/16/22 and 07/17/22. On 07/22/22 at 10:15am, V1 (Administrator) confirmed that there was no Registered Nurse (RN) coverage at the facility on the weekend of 07/16/22 and 07/17/22. V1 stated they have adequate RN staff, but none were scheduled to work that weekend. V1 stated an RN was available on call that weekend. The Resident Census and Conditions of Residents Form, dated 07/19/22 documents there are currently 41 residents living in the facility. A Nurse Staffing Policy dated 12/7/17 documented, It is the policy of (the facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial wellbeing of each resident. Nurse staffing will be based on resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health.

Based on observation, interview and record review the facility failed to ensure that dishes were properly sanitized, and food was handled in a manner to prevent cross contamination. This had the potential to affect all 41 residents residing in the facility. The Findings Include: On 7/19/22 at 11:30 AM, V3 (Cook) was observed to be mechanically altering the lunch meal to be served to the mechanical soft and puree diets. During this process V3 was observed to be opening drawers to kitchen utensils, lifting lids off the steam table, using serving utensils and patting down the ground meat into the serving scoop to ensure that it was full with the same pair of disposable gloves on. At this same time in the kitchen V4 (dishwasher) was asked to check the sanitizer level in the dish machine. V4 stated that she does not usually do this task but would check it. V4 brought back a test strip that was lightly tinged purple. When asked what the level should be per manufacturer guidelines for a chlorine sanitizer V4 stated she is unsure because she does not have anything to compare the strip to determine proper level. A pile of test strips was observed to be laying on the counter with no container that includes the color coding to determine if the sanitizer level is within recommended limits. This surveyor then used her own test strip kit for a chlorine sanitizer, and it was determined the level was not within suggested level of 50-100 parts per million. V4 confirmed that the test strip was not registering that enough sanitizer was present in the machine to properly sanitize the items being washed. V3 and V4 both stated at this time that they do not check the level of sanitizer normally, but it should be done three times a day. V4 stated that the dietary supervisor did this morning prior to having to leave for an appointment. No other staff were working in the kitchen at this time. The dish washer temperature and sanitation log laying on the cart next to the sink at that time was left blank from July 9-14 and July 15-present so there was no way to tell how long the dish machine sanitizer concentration level was low. On 7/20/22 at 11:00 AM, V1 (Administrator) stated that V3 is a new employee and will be sure to retrain her on proper glove change and how to properly handle the food. V1 also stated that she is going to call the company that services the dish machine again to get them in here to fix the sanitizer level. In the meantime, they have been using the manual sink to wash dishes. The Resident Census and Conditions of Resident Form dated 7/19/21 documents that 41 residents reside in the facility.