Based on interview, and record review the facility failed to ensure residents were safe from misappropriation of a controlled substance medication for 1 of 3 residents (R2) reviewed for misappropriation in a sample of 8. The findings include: R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been made. The facility has initiated an investigation into the matter. A final report will follow. R2's facility Final Report dated 8/26/24 documents in part: The purpose of this letter is to notify The Department of our conclusion of the investigation into a possible drug diversion. Licensed staff had administered the resident's 8 am dose. At 10 am when the Licensed Nurse went to administer the morphine, the bottle of morphine could not be located. The physician, POA (Power of Attorney), (City) Police and the Ombudsman were notified. The Administrator and Nursing Administration initiated a search of the facility and facility grounds. The medication was not located. An investigation was initiated. The Licensed Nurse, (V4) was overseeing the medication cart. He was suspended pending the outcome of the facility. The hospice nurse was notified of the Morphine bottle not being located. The facility asked Hospice to replace the Morphine and bill the facility. The Morphine was replaced. Licensed staff initiated a pain assessment. (R2) showed no changes in his pain level. Residents were interviewed. Residents were not aware of any issues with medications and had not observed the medication. All staff working were interviewed. Staff stated that they had not observed the morphine out of the cart and had no knowledge of where the medication was. (V11) LPN (Licensed Practical Nurse) was the night shift nurse and was still working till approximately 10:30 am finishing the charting for her shift. (V11) stated that the medication cart was in front of the nurse's station. She stated that (V4) had administered the 8 am dose of Morphine. (V11) said that she did not observe (V4) place the Morphine bottle in the cart and lock it as she had her back to him charting at the nurse's desk. (V11) stated at approximately 10:00 am (V4) went to the medication cart to administer the 10:00 am dose of Morphine and he stated it was not in the cart. She stated that he began looking for the medication and Nurse Management was notified. (V11) was asked if she observed the bottle of Morphine on top the cart and she stated No, she did not. She was also asked if the medication cart was locked. She stated that she was finishing charting, and her back was toward the cart. (V4) LPN was interviewed by the Director of Nursing and Regional Nurse via phone. He stated that he had given the resident his 8 am dose of medication. (V4) stated he placed the empty syringe back into the morphine box and placed everything in the medication cart and locked the cart. He stated that at approximately 10 am he went to the cart, unlocked the cart, and was going to give the medication but was unable to locate the morphine in the cart. (V4) stated that he searched the cart and could still not locate the medication. He stated that he checked the trash can on the med cart and at the nurse's desk. (V4) stated that he checked the second medication cart and the treatment cart but was not able to locate the medication. He then notified Nurse Management and Nurse Management began looking for the Morphine. (V4) was asked if he placed the medication back in the cart and locked the cart after administering the 8 am dose and he said yes, that is my routine. He was asked if he unlocked the cart when he was getting ready to administer the 10 am dose and he said yes. (V4) said after he was sent home, he was retracing his steps in his head and was second guessing everything he did. (V4) denied taking the medication and volunteered for drug testing. (V4) submitted a drug test, and the results were negative. An audit of all narcotics in the facility was completed and no other issues were noted. Following the investigation, based on interviews, the facility is not able to determine what happened to the morphine and cannot substantiate drug diversion. There is no evidence indicating (V4) took the medication. The facility is unable to locate the Morphine, and the search is ongoing. The morphine was replaced at the cost of the facility. All Licensed staff were educated by the Director of Nursing regarding Medication Administration, medication storage, and narcotic count between shifts. (V4) will be allowed to return to work. Prior to returning to work, the Director of Nursing completed education regarding Medication Administration, medication storage, and narcotic count between shifts. R2's admission record documents an admission date of 6/26/24 and a discharge date of 9/29/24. with diagnoses in part; encounter for palliative care (admitting diagnosis), atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, chronic pain, colostomy status, cervicalgia, osteoarthritis, chronic pulmonary embolism. R2's order summary report documents in part an order dated 7/29/24, resident is under Transition hospice care. R2's Medication Administration Record (MAR) for September, with a print date of 10/8/24 documents an order for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth every 2 hours for pain with a start date of 8/24/24. R2's MAR documents that he received his scheduled doses of Morphine at 8:00 and 10:00am on 9/20/24. A facility document titled INDIVIDUAL RESIDENT CONTROLLED SUBSTANCE RECORD dated 8/19/24 with R2's name handwritten on it documents the medication as Morphine Sulfate 20mg/ml and the quantity received as 30ml. The last documented dose administered on this document is on 8/20/24 at 9:00am, the amount given is 0.5 with 24ml remaining. R2's ordered dose was 0.5mg, indicating there were 48 doses left in the bottle. On 10/8/24 at 12:03pm, V5 (Licensed Practical Nurse/LPN) stated she was here the day the morphine went missing, everyone was looking for it. It was never found. There was big investigation done and lots of education and inservice. On 10/9/24 at 12:29pm, V2 (Director of Nursing) stated as soon as they were alerted that morphine was missing, they contacted hospice and started the process of getting a replacement. V2 stated they received the medication very quickly; the pharmacy delivered it and R2 received the dose within the appropriate time frame. V2 stated R2 was being assessed for pain frequently while waiting for the replacement bottle. V2 stated the missing bottle was never located after a search of the property and investigation. On 10/9/24 at 03:15pm, V4 (LPN) stated there was no narcotic count completed between himself and V11 (LPN) after he took over the med cart. V4 stated he counted by himself at one point, and everything was fine. V4 stated he is certain he drew up R2's medication and locked the bottle back into the cart, as that is his common practice. V4 stated that since this incident happened, he has been replaying it in his mind and second guessing himself, however he stated he sees no reason why he would have done things any differently. V4 stated he was the only one suspended and investigated. V4 stated the other nurse working with him told him and administration there was a CNA that does transport standing by his cart, she then went to the bathroom and went to a patient room. V4 stated that this CNA was questioned, but not investigated. V4 stated the medication was never found. The Facility's Abuse, Prevention and Prohibition Policy revised 1/24 documents in part, This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent residents from receiving medical treatment without a doctor's order for 1 (R1) of 3 residents reviewed for physician's orders in a sample of 8. Findings include: R1's admission record documents an admission date of 02/20/24 with diagnoses in part; type II diabetes mellitus with hypoglycemia without coma, paroxysmal atrial fibrillation, other seizures, unspecified convulsions. R1's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview for mental status) of 12, indicating that R1 is cognitively intact . R1's order summary sheet documents an order for ACCUCHECK every two hours from the ER (Emergency Room) for hypoglycemia with a start date of 3/4/24 and a discontinue date of 6/20/24. On 3/19/24 R1's Medication Administration Record documented accuchecks every two hours, most of R1's accuchecks were between 80 and 162, which is not considered to be hypoglycemic. There is an accucheck at 12pm of 46, which is considered hypoglycemia, but there is no further documentation in R1's clinical record, including progress notes. R1's order summary sheet documents an order for Glucagon Emergency Injection Kit, 1 MG (milligram) (Glucagon (rDNA))-Inject 1 application intramuscularly as needed for low blood sugar with a start date of 2/20/24. There is no documentation that the glucagon was administered on 3/19/24. On 10/8/24 at 1:40pm, R1 stated his blood sugars have been pretty good lately and he could not recall if anyone tried to start an IV on him in this facility. On 10/8/24 at 1:51pm, V2 (Director of Nursing/DON) stated they had an incident in March involving V3 (Licensed Practical Nurse/LPN) attempting to start an IV (intravenous) without a physician's order. V2 stated V3 was not successful starting the IV, no medications were administered, but V3 was disciplined, and staff education was done. V2 stated V3 had spoken with V6 (the nurse at the doctor's office) previously about this resident and V6 stated if R1 continued to have such drastic drops in his blood sugar they would need to get a standing order to give dextrose via IV. V2 stated V6 did not give a standing order at that time. V2 stated that they do not have a specific policy or protocol to low blood sugars, but each resident who is under blood glucose monitoring should have standing orders for such situations. On 10/08/24 at 1:51pm, V2 (DON) provided a copy of facility document titled Employee disciplinary action form for V3 with an incident date of 03/19/24 stated V3 did not follow departmental Policies and procedures. This document further stated that V3 did not get an order from MD prior to initiating a medical procedure/medication and that there was no documentation of residents low CBG (Capillary Blood Glucose). V2 provided a statement from V6 that she did not give a standing order for IV dextrose and a signature sheet from their staff in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate supervision for residents with dementia for 2 (R3 and R4) of 5 residents reviewed for dementia care services in the sample of 8. Findings include: A facility incident report dated and timed 9/15/24 at 11:08am, documents the following incident description in part: A Housekeeper helping another patient to her room walking in room [ROOM NUMBER]. When opened room [ROOM NUMBER] housekeeper witnessed (R4) standing in front of female patient with his pants open and down-with suspenders holding pants part way up. Female resident was in her room on her bed, fully clothed. Female patient had her mouth open providing oral sex to (R4). (R4) turned around and pulled up his pants, he told staff he was receiving help with is belt. Both patients immediately separated themselves, he went to his room. Female patient states she thinks (R4) is her husband and she wants to be with him. When staff asked (R4) if he knew her, he says he doesn't know her, just some lady around here. He said he needed help adjusting his belt. He denied what was going on. He asked if they were in trouble . An investigation was initiated following the interaction. Staff present at the time of the incident were interviewed. (R3) stated she didn't understand why staff won't let me be with my husband. Both residents were put on 1:1 for 24 hours after the incident. Both resident's Physicians were notified, and no new orders were received. There have been no further incidents. Residents were interviewed. The residents interviewed have had no issues with either of the residents involved. (R3) was interviewed. She does not recall the incident. (R4) was interviewed. He does not recall the incident. The Ombudsman was notified and stated that both parties were consenting. A trauma assessment was completed for both residents, identifying no new issues. Behavior tracking was initiated for both residents. Their care plans were reviewed and updated. Social services will visit with each resident twice weekly for 30 days. After reviewing the incident, it is our conclusion that during the incident both residents were consenting adults. A facility correspondence with IDPH titled Final Report dated 09/20/24 documents in part: The purpose of this letter is to notify The Department of our conclusion to a reported incident. On 9/15/24, staff observed an interaction between two residents, (R3) and (R4). Staff immediately separated the residents. Licensed Staff initiated a head-to-toe assessment noting no injuries. MD( Medical Doctor) and POA (Power od Attorney) made aware. Local police were notified. Ombudsman was notified. On 10/08/24 at 2:51pm, V1 Administrator stated that the incident on 9/15/24, between R3 and R4 was consensual, but provided no evidence during this investigation that R3 and R4 had been screened and identified as having the cognitive ability to provide consent. 1. R4's admission record documents an admission date of 8/27/2024 with the diagnoses in part: Alzheimer's disease, other symptoms and signs involving cognitive functions and awareness, altered mental status. R4's Minimum data set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 3, indicating that R4 is severely cognitively impaired. R4's current care plan documents a focus area of inappropriate sexual behavior. With an initiation date of 9/16/24 and a revision date of 9/27/24 with interventions including in part: Behavior #1: Inappropriate sexual conduct towards others (i.e.: inappropriate touching, purposeful exposure of genitals to others, etc.) Remove from area, ensure (R4)'s safety, encourage to discuss feelings, try a different care giver, offer to call family. Monitor behavior episodes and attempt to determine underlying cause. R4's POC response history with a print date of 10/8/24 documents that R4 displayed inappropriate sexual conduct toward others on 9/24/24 and 10/1/24, intervention used for both occurrences was redirection. R4's progress notes document in part the following: On 9/15/24 at 1:42pm, (R4) was looking for female friend and went into her room looking for her .staff asked him to get out of her room and he became agitated. On 9/15/24 at 2:02pm, (R4) was standing outside lady friend's room, waiting on her to come to her room it appears. Staff asked him what he was doing. He said he's looking for someone. Asked to stay out of room [ROOM NUMBER]. Informed him 121 was a female room. He opened the door twice and was inside once. On 09/16/2024 at 4:20pm, SSD (Social Services Director) met with (R4) today and conducted BIMS, PHQ9 (Patient Health Questionnaire-9) , and trauma informed consent. (R4) states he feels safe in his environment. No other concerns at this time. On 9/22/24 at 2:48am, Resident was seen wandering into another resident's room, resident went into a female resident's room and was trying to wake her to leave, resident was redirected back to bed by staff, continue to monitor closely. Continue current plan of care. On 9/27/24 at 9:05am, Resident went into a female resident's room and was trying to get her to go with him. On 9/27/24 at 1:59pm, Resident was in another female resident's room. Redirected back to his room. On 10/1/24 at 10:01am, Resident tried to get female resident to go in his room. The other resident refused, and he stated, I guess you don't want to have sex with me. On 10/9/24 at 12:30pm, V8 (Registered Nurse/RN) stated it is known that they are supposed to keep a close eye on R4 but there really isn't anything specifically laid out in his care plan or behavior tracking related to his level of supervision. V8 stated that R4 was supposed to be one on one for the first 24 hours after the incident happened. V8 stated she was not familiar if there was anything that the CNA's were supposed to chart specifically but nurses were expected to chart on R4 any time a behavior is observed. On 10/9/24 at 1:15pm, V9 (Restorative Aide) stated that everyone on the unit is to be under close supervision. V9 stated he was not sure if there was any specific supervision in place for R4. 2. R3's admission record documents an admission date of 7/16/24 with diagnoses including in part; Alzheimer's and dementia. R3's Minimum Data Set (MDS) documents a Brief Interview for Mental status (BIMS) of 07, indicating that R3 is severely cognitively impaired. R3's current care plan documents a focus area of inappropriate sexual behavior. With an initiation date of 9/16/24 with interventions including in part: Behavior #1: Inappropriate sexual conduct towards others (i.e.: inappropriate touching, purposeful exposure of genitals to others, etc.) Remove from area, ensure (R3)'s safety, encourage to discuss feelings, try a different care giver, offer to call family. Monitor behavior episodes and attempt to determine underlying cause. On 9/15/2024 at 11am, Roommate came to housekeeper and said she needed help getting in her room. Housekeeper was helping 121-2 patient back to her room, she knocked on the door 121 and opened it for roommate to walk in. Housekeeper witnessed (R3) sitting on bed fully clothed with her mouth open giving oral sex to a male patient. Male patient was standing in front of her with his pants open and down-with suspenders holding pants part way up. Male resident turned around and pulled up his pants, he said he was receiving help with is belt. (R3) and male patient immediately separated themselves, he went to his room. (R3)'s face was red. She appeared embarrassed. She asked why she can't be with her husband . (her husband is not here/alive) Re-oriented her that she is in nursing home and her husband is no longer around. (R3) insist we separated her from her husband and is asking why. (R3) said she brought him to her room. Male patient says he doesn't know her, just some lady around here he said . On 9/16/24 at 4:17pm, SSD (Social services director) met with (R3) today. Conducted BIMS, PHQ9 (Patient Health Questionnaire-9), and trauma informed consent. (R3) was very confused today and displayed disorganized thinking. She states she feels safe in her environment. On 10/9/24 at 1:21pm, R3 was observed ambulating down the hallway away from her room. R3 stopped and proceeded to stand in R4's doorway and then walked inside while R4 was laying on his bed. Staff was alerted and redirected R3. On 10/9/24 at 1:27pm, V10 (CNA/Certified Nursing Assistant) stated everyone on the locked unit is under close supervision. V10 stated R3 and R4 were both in the unit on 9/15/24. V10 stated R3 and R4 were both one on one supervision for the first 24 hours after the incident. V10 stated they really try to prevent anyone going into the room of someone of the opposite sex. V10 stated that they do chart behaviors if R4 has them, but that they do not have any specific time frame for checking on him. There is no documentation in R3 or R4's current clinical records of any discussion or education with them, their representative, or physician regarding consent. There is nothing in R3 and R4's care plans regarding consent. Facility document titled, Abuse, Prevention and Prohibition with a revision date of 1/24, under the section titled Protection, The facility will immediately remove any alleged perpetrator from any further contact with any resident. Further on in this document in the section Resident capacity to consent to sexual activity it states generally, sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. This document states that if there are 2 residents who wish to have a sexual relationship, the following steps will be followed: A one-on-one discussion with each individual must be held to ensure they are consenting to an intimate relationship with the other resident. The discussion will define the type of relationship that is desired. For a resident who DOES NOT have the capacity to consent, the Resident Representative will be contacted to discuss resident wishes. If the Resident Representative DOES NOT AGREE with the resident choice, then there will be a resident, Resident Representative, IDT meeting to discuss plan of care. Provider will be notified of resident and Resident Representative wishes. Discussion and consents to be documented in the clinical record and care plan updated to reflect the resident and/or Resident Representative wishes. Education will be provided to both residents involved and when appropriate the Resident Representative on risk vs. benefits of the relationship, what is consented by both parties, and any safety information needed. The Education provided will be documented in the clinical record and the care plan updated.

Based on interview and record review, the facility 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 8. The findings include: R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been made. The facility has initiated an investigation into the matter. A final report will follow. R2's facility Final Report dated 8/26/24 documents in part an undated and untimed interview with V11 (LPN/Licensed Practical Nurse). V11 stated she stayed over from midnight shift to help pass the back half of 300 hall medications. V11 stated she and V4 (LPN) counted the narcotics for the front part of the hallway but not the back because she was still using the cart to pass medications. V11 stated R2's narcotic medication was on the cart for the back half of the hall. V11 stated she gave V4 the keys for the cart for the back half between 9:00am and 9:15am and they did not perform a count. On 10/9/24 at 03:15pm, V4 (LPN) stated there was no narcotic count completed between himself and V11 (LPN) after he took over the med cart. V4 stated he counted by himself at one point, and everything was fine. On 10/8/24 at 12:03pm, V5 (LPN) stated count should be done anytime a nurse is taking over responsibility of a med cart from another nurse. On 10/9/24 at 10:07am, V7 (RN/Registered Nurse) stated count should be done anytime you are assuming responsibility from someone else for those medications. On 10/09/24 at 2:20pm, V2 (DON) stated that narcotics should be counted any time that a nurse is taking over responsibility for the cart and before anyone leaves. A facility document titled, Employee corrective action form for V4 dated 8/20/24 documents in part a failure to follow departmental policies and procedures, by not counting narcotics with nurse from previous shift and not properly storing narcotics after administration. A facility document titled, Employee corrective action form for V11, dated 08/20/24 documents in part a failure to follow departmental policies and procedures, by not counting narcotics with oncoming nurse. Facility controlled substance policy documents in part; The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the oncoming licensed nurse here applicable and the off-going licensed nurse where applicable.

**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 verbal abuse for 1 of 3 (R3) residents reviewed for abuse in a sample of 11. This failure resulted in (V21), Registered Nurse telling R3 to go away and get lost she was too tired for this nonsense and if he didn't she was going to kick him in the forehead. This would cause a reasonable person to react with feelings of fear, anxiety, and humiliation. This past non-compliance occurred between 5/26/24 and 5/28/24. Findings Include: The initial incident report received by the Illinois Department of Public Health on 5/26/24 documents an incident date of 5/26/24. The Initial Incident Description documents Resident: (R3). The purpose of this letter is to notify the Department of allegations reported by staff regarding alleged verbal abuse between a nurse and resident. The untitled document dated 5/31/24 documents it is the Final report of an abuse allegation related to R3. This same report documents, It was immediately reported to the Director of Nursing that (R3) had propelled himself to the nurse's desk where two staff members were sitting and asked if they knew anything about small motors. The C.N.A. (Certified Nursing Assistant-V4) sitting at the desk reported it was at that time the Registered Nurse (V21) said to the resident (R3) 'go away, and get lost, I am too tired for this nonsense.' She also stated that if he didn't, she would 'kick him in the forehead.' This nurse was immediately suspended, and her agency was notified of the incident. POA (power of attorney), ombudsman, local police, and MD (physician) were notified. An investigation was initiated. (R3) was interviewed. He does not recall the incident. Staff were interviewed. Other than the staff member reporting the incident, no one had knowledge of the incident and reported that they have not heard or observed (V21) be abusive. Residents were interviewed. Residents had no concerns regarding care by this nurse. Residents interviewed were not aware of any abuse. Following the investigation, based on statements, the facility substantiated the allegation. The abuse was reported to the agency she (V21) works for. She was put on a DO NOT return list for our facility. Social services will follow up with (R3) twice a week for 30 days to ensure no further issues. R3's admission Record with a print date of 6/24/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include heart disease, dementia, anxiety disorder, and mild cognitive impairment. R3's Minimum Data Set, dated [DATE] documents R3 has a severe cognitive impairment. R3's current undated Care Plan documents a Focus area of (R3) has a potential psychosocial well-being problem .5/27/24 (R3) was in an incident with a staff member with an allegation of verbal abuse The Interventions include, Social services will meet with (R3) twice weekly for 60 days to ensure he has no effects of alleged verbal abuse. On 6/20/24 at 2:53 PM, V4 (Certified Nursing Assistant/CNA) stated she was working with V21 (RN/Registered Nurse) and she had been stand-offish towards the residents. V4 stated she was sitting at the nurse's station charting and R3 rolled behind the desk and was sitting next to her. V4 stated R3 asked if they knew anything about small motors and V21 stated to R3, get out of here. V4 stated she suggested R3 go to his room or the dining room. V4 stated R3 stayed at the nurse's station and V21 told R3, I said get out of here, go on, get. V4 stated then V21 stated, If you don't get out of here on the count of 5, I am going to kick you in the forehead. V4 stated V21 then said and you don't know how high I can jump. V4 stated she backed R3 up and rolled him to his room and asked him to stay there. V4 stated she answered a call light and told V21 she would be back. V4 stated she went to the other hall and told the other nurse what had happened who reported it to the charge nurse. V4 stated the administrator was called and the other nurse's working walked V21 to the conference room. V4 stated they talked with V21 and then walked with her down the hall to do a narcotics count before walking her out the door. When asked if she felt like what occurred was abuse, V4 stated, Yes, the look on her (V21) face made it look like she meant it. V4 stated it was a hey, get away from me or else I am going to hurt you. When asked if she felt like the facility handled it appropriately, V4 stated, Yes, they walked her out. V4 stated as far as she knows V21 had not been back to the facility. The untitled statement included in the abuse investigation signed by V21 (RN,Registered Nurse ) documents, (R3) approached desk CNA and nurse were at. He (R3) said something very sexual. I was upset, as I've been assaulted before and have not slept in nearly 24 hours. I don't recall what I said beyond trying to get him away On 6/25/24 at 2:03 PM, V2 (Director of Nurses) stated administration was notified V21 had threatened to kick R3 in the forehead. V2 stated they immediately got V21 and had her count narcotics with another nurse, and then sent V21 home. V2 stated they contacted V21's agency employer and told them they had sent her home due to an allegation of abuse. V2 stated they started the investigation and determined abuse had occurred. V2 stated they notified V21's employer that the allegation was founded. V2 stated V21 said she didn't recall her exact words to R3. V2 stated they educated all staff on abuse/neglect on 5/27/24, they conducted a QAPI (Quality Assurance and Performance Improvement) meeting on 5/28/24, interviewed the residents on 5/27/24, and are completing on-going audits. The facility Abuse, Prevention and Prohibition Policy dated 01/24 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Under Prevention the policy documents, the resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. R3 was assessed and no injuries were noted. R3 was interviewed and does not recall the incident. 2. The nurse, V21 was immediately sent home. 3. Direct care staff were provided education on the abuse policy and customer service on 5/27/24. 4. All residents have the potential to be affected by the alleged deficient practice. Only one (R3) was identified. 5. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting held on 5/28/24, with the IDT (Interdisciplinary) team, the plan to address the area of concern was discussed. 7. On 5/26/24 and 5/27/24 interviewed all alert residents on (R3's) hall to ask if they have had any issues with staff abuse. 6. Administrative team will monitor 3 times weekly for 60 days using monitoring form designated for this PNC (past non-compliance). All patterns and trends will be brought to QAPI for changes as needed.

Based on interview and record review, the facility failed to provide daily denture/oral hygiene care for 4 of 4 residents (R1, R7, R5, R6) reviewed for ADL (Activities of Daily Living) care in the sample of eleven. Findings include: 1. R1's Face Sheet documented an admission Date of 12/27/23 and listed diagnoses including Congestive Heart Failure, Anxiety Disorder, and Chronic Kidney Disease. R1's 1/5/24 Minimum Data Set (MDS) documented that R1 had severe deficits in cognitive function and required moderate assistance from staff for oral hygiene and denture care . On 6/4/24 at 8:20am, V4, Family Member of R1, stated she had noted on several occasions that R1's dentures were yellow, odorous, and covered with layers of caked on food particles. 2. R7's Face Sheet documented an admission Date of 8/19/17 and listed diagnoses including Multiple Sclerosis and Diabetes Type 2. R7's 3/2/24 MDS documented that R6 had minimal deficits in cognitive functioning, had range of motion impairment to both upper extremities, and requires set up and clean up assistance for oral hygiene and denture care. On 6/5/24 at 9:40am, R7 was alert and oriented. R7 stated staff do not offer to help or remind her to clean her dentures. R7 stated staff will help her to clean them only if she asks, and, Some (staff) are more willing than others. 3. R5's Face Sheet documented an admission Date of 1/12/24 and listed diagnoses including Diabetes Type 2 and history of Cerebral Infarction. R5's 4/18/24 MDS documented that R5 had minimal deficits in cognitive functioning, and that R5 requires set up and clean up assistance for oral hygiene and denture care. On 6/5/24 at 10:10am, R5 was alert and oriented. R5 stated she took out her top dentures and put them on the bedside table 2 weeks ago and hasn't seen them since, despite staff searching for them. R5 stated she has a dental appointment later this week to get impressions made for a new set. R5 stated she has some of her own teeth on the bottom. R5 stated the only time staff assist her with denture and oral care is when they have CNA (Certified Nursing Assistant) students working. R5 stated CNA staff are usually too busy to assist with denture care. 4. R6's Face Sheet documented an admission Date of 5/18/22 and listed diagnoses including Atrial Fibrillation, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. R6's 5/6/24 MDS documented that R6 had severe deficits in cognitive functioning, had restricted range of motion in both upper extremities, and that R6 required set up and clean up assistance for oral hygiene and denture care. A Grievance Form dated 5/12/24 completed by V5, Power of Attorney for R6, documents I am still not seeing workers posting on (R6's) calendar when they are brushing her teeth. On 6/6/24 at 12:45pm, V5 stated R6 has memory problems as well as a torn right rotator cuff and cannot lift her arm to do her own denture care. V5 stated when she took R6 to the dentist shortly after her May 2022 admission to the facility, the dentist showed her R6's top partial denture plate, Which was caked with layer upon layer of old food. He said she needed to have her teeth and dentures cleaned at least once daily. They (staff) weren't doing it so finally I put a calendar in her room and asked the CNA's to initial it whenever they did her oral care. I haven't put the June (2024) one up, there is probably no point, because nobody is initialing the calendar. I guess it's possible they're doing it but forgetting to mark it down. Whenever I ask the CNA's about why they're not doing it, whichever shift I'm talking to blames another shift. I did a grievance with the Administrator about it about mid May 2024. On 6/6/24 at 1:10pm, a large May 2024 calendar was observed in R6's room, which had been initialed on 5/2/24, 5/13/24, 5/16/24, and 5/20/24. On 6/6/24 at 1:20pm, V1, Administrator, confirmed V5 filed a grievance on 5/12/24 stating that CNA's were not taking care of R6's dentures and teeth, and that V5 had put a calendar in R6's room to initial when they performed oral care. V1 stated she believes staff are doing the oral care but not initialing it on the calendar. V1 stated there is nowhere in the electronic medical records to document when oral/denture care is done. On 6/5/25 at 2:20pm, V13, CNA, stated CNA's are to take out the dentures at bedtime, brush them, and soak them overnight with a cleaning tablet. V13 stated there have been occasions during morning care when he has noted that residents dentures have not been cleaned and soaked overnight. On 6/6/24 at 11:50am, V12, CNA, stated at bedtime, dentures are to be removed, cleaned, and soaked overnight. V12 stated dentures and teeth should also be brushed after meals. On 6/11/24 at 10:00am, V1 stated the facility does not have a denture care/oral hygiene policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify resident representatives in writing of hospital transfers for 2 of 2 (R36, R71) residents reviewed for hospitalization in a sample of 51. The Findings Include: 1. R36's admission profile documents and admission date of 9/12/23. This same document lists V8 (Family Member) as the Power of Attorney (POA). R36's Quarterly Minimum Data Set (MDS) dated [DATE] documents a 7 for a Brief interview of Mental Status (BIMS) indicating a cognitive impairment. R36's progress notes document that 4/22/24 R36 was transported to the local emergency room after experiencing a change in condition. 2. R71's admission profile sheet documents an original admission date of 8/7/23. This same document lists V9 (Family Member/Power of Attorney) as the emergency contact. R71's 4/21/24 Quarterly MDS documents a BIMS score of 9 indicating a cognitive impairment. R71's progress notes documents that on 11/23/23 R71 was transported to the local emergency room due to experiencing a change of condition. On 5/23/25 at 2:00 PM, V1 (Administrator) stated that they call the resident family/Power of Attorney (POA) via phone when a resident is being transferred, but only send transfer paperwork with resident to the receiving hospital. V1 confirmed that they do not provide written documentation to the POA or family member regarding hospital transports including reasons of transport and bed hold policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify resident representatives in writing of the bed hold policy during resident transfer for 2 of 2 (R71 and R36) residents reviewed for hospitalization in a sample of 51. The Findings Include: 1. R36's admission profile documents and admission date of 9/12/23. This same document lists V8 (Family Member) as the Power of Attorney (POA). R36's Quarterly Minimum Data Set (MDS) dated [DATE] documents a 7 for a Brief interview of Mental Status (BIMS) indicating a cognitive impairment. R36's progress notes document that 4/22/24 R36 was transported to the local emergency room after experiencing an change in condition. 2. R71's admission profile sheet documents an original admission date of 8/7/23. This same document lists V9 (Family Member/Power of Attorney) as the emergency contact. R71's 4/21/24 Quarterly MDS documents a BIMS score of 9 indicating a cognitive impairment. R71's progress notes documents that on 11/23/23 R71 was transported to the local emergency room due to experiencing a change of condition. On 5/23/25 at 2:00 PM, V1 (Administrator) stated that they call the resident family/Power of Attorney (POS) via phone when a resident is being transferred, but only send transfer paperwork with resident to the receiving hospital. V1 confirmed that they do not provide written documentation to the POA or family member regarding hospital transports including reasons of transport and bed hold policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to revise a care plan to include medications ordered for a Urinary Tract Infection (UTI) for 1 (R115) of 24 residents reviewed for care plans in the sample of 51. Findings Include: R115's admission Record documented R115 as a [AGE] year old with an admission date to the facility of 03/29/2024. Diagnosis listed include other nontraumatic intracerebral hemorrhage, Type 2 Diabetes Mellitus, Parkinsonism, Aphasia following nontraumatic intracerebral hemorrhage, obstructive and reflux uropathy, gastrostomy, muscle weakness, cerebral infarction, hyperlipidemia, essential hypertension, obstructive sleep apnea. R115's MDS (Minimum Data Set) dated 4/5/24 documented 0 under section C0100 titled Should brief Interview for Mental Status be conducted?, indicating the resident is rarely / never understood. R115's current Order Summary Report documented Bactrim 800-160 mg (milligrams) two times a day for bacterial infection with an order date of 05/20/2024. Review of document labeled local hospital laboratory result, with a date of 05/15/2024, documented a urine culture result of >100,000 Proteus Mirabillis with a sensitivity to Bactrim. R115's Current Care Plan documents a Focus area of: R115 has a catheter: obstructive uropathy. Date initiated 4/26/24. An intervention included: Monitor/record/report to MD (Medical Doctor) for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date initiated 4/26/24. R115's Care Plan does not document that R115 is on antibiotics for a UTI. On 05/24/2024 at 9:20 A.M. V2 (Regional Nurse) stated it is her expectation that any medication should be care planned. On 05/24/2024 at 9:25 A.M. V2 (Regional Nurse) stated the facility does not have a policy on care plans. They follow state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure as needed psychotropic medications were ordered for a specific duration for 2 (R52, R103) of 7 reviewed for unnecessary medications in the sample of 51. Findings Include: 1. R103's admission Record documented R103 as being an [AGE] year-old male with an original admission date to the facility as 9/13/23. Diagnoses on this form included but were not limited to: Generalized Anxiety Disorder; Restlessness and Agitation; Unspecified Dementia, Unspecified Severity, with Agitation. R103's Order Details include an order with a start date of 2/28/24 for, LORazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for behaviors and increased anxiety. No duration for the use of this medication was noted. 2. R52's admission Record documented R52 as being a [AGE] year-old female with an original admission date to the facility as 12/27/23. Diagnoses on this form included but were not limited to: Generalized Anxiety Disorder. R52's current Physician Orders include an order with a start date 2/5/24 for, LORazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 0.5 mg by mouth every 12 hours as needed for Anxiety. No duration for the use of this medication was noted. On 05/23/24 at 9:10 AM, V2 (Regional Nurse) stated that she had spoken with pharmacy and was under the impression no end date for an as needed anti-anxiety medication was needed if clinical rationale for the continued use was documented. Review of the facility policy titled, Psychotropic Medication Use with a reviewed date of 09/2022 documented, .8. The timeframe for PRN (as needed) psychotropic medications, which are not antipsychotic medications, will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to respond to resident call lights in a timely manner for 4 (R23, R32, R56, R92, R103) of 5 residents reviewed for resident rights in the sample of 51. Findings Include: 1. R32's admission Record documented R32 as being a [AGE] year-old male with an initial admission date to the facility as 2/6/23. Diagnoses on this form included but were not limited to: Chronic Obstructive Pulmonary Disease; Chronic Respiratory Failure with Hypoxia; Type 2 Diabetes Mellitus without complications. On 05/21/24 at 10:58 AM, R32 was observed being alert and oriented to person, place, and time during this interview. R32 stated his only complaint he has is the amount of time it takes staff to answer the call lights. R32 stated he can't say it consistently occurs on a specific shift or time, but stated the average wait time to have his call light answered is 15 minutes. R32 stated he is able to confirm the times expressed by evidence of watching the clock, which was visible. R32 stated he has had to wait up to 45 minutes before, which he finds unsatisfactory. 2. R92's admission Record documented R92 as being a [AGE] year-old female with an initial admission date to the facility as 1/31/23. Diagnoses on this form included but were not limited to: Pain Right Hip; Other Heart Failure; Atrioventricular Block. On 05/21/24 at 11:55 AM, R92 was observed as being alert and oriented to person, place, and time during this interview. R92 stated call light answer times is her only complaint. R92 stated on average it takes 15 minutes she'd say to have the light answered, but stated recently it was 2 hours she had to wait. R92 stated she mostly utilizes her call light for restroom needs and finds 15 minutes to be longer than she'd prefer, but 2 hours to be way too long. R92 stated staff will say they've been busy helping other residents when they finally respond to her light. R92 stated she is able to confirm the times expressed by evidence of watching the clock, which was visible. 3. R103's admission Record documented R103 as being an [AGE] year-old male with an original admission date to the facility as 9/13/23. Diagnoses on this form included but were not limited to: Generalized Anxiety Disorder; Restlessness and Agitation; Unspecified Dementia, Unspecified Severity, with Agitation. On 05/21/24 at 10:50 AM, V5 (Family Member) stated call lights aren't always answered timely. V5 stated she has witnessed it firsthand when she has been here visiting R103. V5 stated on average she would say it takes staff 20 minutes to answer a call light routinely. R103's Current Plan of Care with a date initiated of 9/19/23 documented a focus area of impaired cognitive function/dementia or impaired thought process. 4. R56's admission Record documented an original admission date to the facility as 7/1/22. R56 is documented as being a [AGE] year old female with diagnoses including but not limited to: Secondary Parkinsonism, Unspecified; End Stage Renal Disease; Nontraumatic Subarachnoid Hemorrhage, Unspecified, etc. R56's Minimum Data Set (MDS) with an Assessment Reference Date of 2/27/24 documented a Brief Interview for Mental Status Score of 13, indicating she's cognitively intact. On 05/21/24 at 09:53 AM, R56 was observed sitting in her wheelchair in her room, with a mechanical lift sling underneath her. R56 was observed being alert and oriented to person, place, and time. R56 stated her only concern with the facility is the amount of time it takes staff to answer call lights, specifically to use or get off the toilet. R56 stated that the average time it takes for call lights to be answered is 30 minutes she would say, but up to 2 hours. R56 stated she can confirm these times by the use of the clocks in her room, clocks visualized during this interview. R56 stated this seems to be the worst first thing in the morning, and then after lunch and around 2 PM. R56 stated she has experienced incontinence episodes waiting for staff to take her to the restroom, as well as neck pain, waiting so long for staff to get her off the commode. On 5/22/24 at 12:31 PM, V3 (Certified Nurse Assistant, CNA) stated that she works from 6 AM - 2 PM at the facility, usually on 200 hall. V3 stated that she feels like the facility has enough staff, as there are generally 4 CNA's and a nurse staffed on 200 hall. V3 stated that 200 hallway is just heavy care with several residents requiring the assistance of two staff at a time for tasks. V3 stated she answers the call lights in the order she sees them illuminate, and as quickly as possible. V3 stated at times residents are having to wait for staff assistance, it is because staff are busy working with other residents. On 5/22/24 at 12:38 PM, V4 (CNA) stated that he normally works from 6 AM - 2 PM on the 200 hall. V4 stated that he feels like the facility has enough staff. V4 stated that there are just times when multiple heavy care residents need assistance, which takes up time and the amount of staff available to assist others. V4 stated when residents are having to wait for assistance, it is due to staff being with other resident's, not that they are just standing around. On 5/23/24 at 2:00 PM, V6 (CNA) stated although she cannot give specific resident names, she acknowledges she has had resident's complain to her regarding call light answer times and recognizes staff response times could be improved. V6 stated that on the 200 hall for the 2 PM- 10 PM shift, there are usually 3 CNA's scheduled and one nurse. V6 stated that 200 hall has heavy care resident's that require a lot of staff time. On 5/22/24 at 12:54 PM, V1 (Administrator) stated that the facility does not have a staffing policy, and the facility follows regulatory guidelines for staffing needs. V1 stated that there have been concerns presented to her on and off, stemming from resident council meetings regarding long call light wait times. V1 stated that the facility will go through periods where the times will be reported as being better, then worse again. V1 stated the facility has explored different options to try and improve call light wait times, including dispersing heavy care residents on different halls in the facility, looking at the staffing needs, staff productivity, etc. On 5/23/24 at 1:50 PM, V1 stated that her expectation is that call light be acknowledged by staff within 5 minutes. Review of the Resident Council meeting minutes as provided by the facility made the following concern notations: 12/18/23 - Nursing: Call light times are better. Still takes a little time @ (at) shift change & meal times but is better. 1/29/24 - Nursing: Don't feel like nurses or CNA's listen to concerns. Long call light wait times 2/28/24 - Nursing: Long wait times between shift changes. Esp. (especially) between 1st & 2nd shift. 3/27/24 - Nursing: Long call light wait times .Nursing not prioritizing resident needs over other duties. 4/24/24 - Nursing: CNA Nurses always huddled at desk. CNA on phone too much. A Grievance Form dated 1/29/24 with the Resident Name listed as Resident Council documented, .Call light wait time is too long. Difficulty getting staff to get them up in time for activities, especially in the afternoon. Resident has fallen asleep waiting for call light to be answered and when he wakes up, it has been turned off . Review of the 200 hall (Facility Name) Daily Census dated 5/22/24, provided by V2 (Regional Nurse) documented 8 (R3, R7, R8, R12, R56, R63, R68, R84) of 35 residents residing on the hall utilize a mechanical lift, requiring the assistance of 2 staff. 5. R23's Face Sheet documented an admission Date of 4/4/24 and listed diagnoses including Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Diverticulosis, Osteoarthritis, Unspecified Heart Failure, and Anxiety Disorder. R23's Minimum Data Set (MDS) dated [DATE] documented that R23 has no deficits in cognitive function, has limited range of motion on both sides of the body both upper and lower, is non ambulatory, and is dependent on staff for ADLs (Activities of Daily Living), bed mobility, and transfers. R23's Care Plan documented a problem area, (R23) has an ADL Self Care Performance Deficit, with corresponding intervention, (R23) (requires a mechanical) lift with 2 staff participation with transfers. On 05/21/24 at 01:03 PM, R23 was alert and oriented to person, place, time and purpose. R23 stated he is non ambulatory and requires the use of a mechanical lift to get out of bed. R23 stated call lights are slower to be answered on on evenings and nights. R23 stated during these times it can take up to 2 hours for staff to answer his call light. R23 stated he has never been left wet or soiled while waiting on the call light as he has an indwelling urinary catheter and a colostomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident in writing of the reason for transfer/discharge for 1 of 1 (R5) residents reviewed for transfer/discharges in the sample of 7. Findings Include: R5's admission Record with a print date of 5/7/24 documents R5 was admitted to the facility on [DATE] with diagnoses that include Wernicke's encephalopathy, dementia, alcohol dependence with alcohol induced dementia, anxiety, insomnia, other seizures, and alcohol abuse with unspecified alcohol induced disorder. R5's Minimum Data Set (MDS) dated [DATE] documents in Section C that Cognitive skills for daily decision making are severely impaired. A Brief Interview of Mental Status was unable to be completed due to R5 rarely/never understood. R5's MDS (Minimum Data Set) dated 2/26/24 documents under Section GG, R1 is independent for all functional abilities, except he requires supervision for tub/shower transfer. R5's Care Plan with an admission date of 1/20/24 documents a focus area of R5 has impaired cognitive function/dementia or impaired thought process. The interventions listed for this focus area are as follows: break tasks into small sub tasks to support short term memory deficits. Communicate with R5/family/caregivers regarding residents capabilities and needs. Used preferred name and identify yourself at each interaction. Face R5 when speaking and make eye contact. Reduce any distractions, turn off TV, radio, close door, etc. R5 understands, consistent, simple and directive sentences. Provide R5 with the necessary cues-stop and return if agitated. Engage R5 in simple, structured activities that avoid overly demanding tasks. Keep R5's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. R5 wanders in other residents rooms but does not interact with other residents. Nursing progress note from 5/3/2024 by V29 (Licensed Practical Nurse/LPN) documents R5 entered R2's room and R2 stood up and told R5 to get out and R5 shoved her in the chest causing R2 to fall. R2 landed on her bottom. R2 hit her mid back on the side rail of the bed but did not hit her head. V29 notified POA (Power of Attorney) and physician. No new orders at this time due to no injury noted. On 5/7/24 at 1:05PM, V10 (CNA) stated that she was working the day the incident occurred when R5 wandered into R2's room. When R2 told him to leave he mumbled something and shoved R2 which caused her to stumble and fall hitting her back on the bed. V10 stated that she witnessed R2 stumble and fall on her bottom but did not hit her head. V10 went on to state that R2 does not remember the incident and has not had any behavioral concerns resulting from this happening to her, nor has she had any lasting effects. V10 stated that she was assessed immediately. On 5/14/24 at 12:30 PM, V26 ( Registered Nurse/RN) stated on the morning of 5/4/24 R5 took his morning medications with no problems and was asked to go to the dining room for breakfast. V27 stated that he began pacing the dining room and kept wandering into R2's room. V27 stated that he had to be redirected 3 times within 15 minutes and got very angry with her resulting in him cursing her and using the middle finger at her. V27 stated that she was in R2's room assisting her with the door closed and he punched the door attempting to get in the room. V27 stated that he then went out to the dining room and reared his fist back at a male resident but staff intervened prior to R5 hitting anyone or anything with his fist. V27 stated that she called V27 (Physician) and was directed to send to the emergency room for behaviors. V27 stated that she then called the family member and let her know R5 was being sent to the ER and would be discharged from the facility. V27 stated that she let the nurse know in the emergency room as well that R5 would not be allowed to return. V27 provided the hospital with V1's contact information should they have any further questions. On 5/10/24, at 10:00 AM, V1 (Administrator) stated that R5's involuntary discharge is not new, as it was originally initiated in January. V1 stated that placement had been attempted to several places and no one had accepted him. V1 stated that V6 (Family Member) was notified of the discharge being initiated on 1/12/24 and was OK with it. V1 stated that they had kept him longer than the 30 days post initiation of the involuntary discharge being filed due to his behaviors being slightly improved and he had gone to a local psychiatric unit and appeared that his behaviors were improved. V1 stated that they and tried several medication changes and the psychiatric nurse practitioner was very involved in his care, however when this event happened with R2 it was a safety issue for the residents if he remained in the facility. V1 stated that the hospital was notified that he would not be returning when they gave report and his wife was called and notified. V1 stated that she did not fill out any emergency discharge paperwork because she wasn't aware that she needed to and thought the January paperwork was enough. On 5/7/24 at 1:00 PM, V6 stated that the facility notified her in January that they would be discharging R5, but did not this time. V6 stated that R5 had been to a Psychiatric Hospital and came back to the facility and she assumed he was better because she had not heard anything else from the facility. V6 then stated that the nurse called her on 5/1/24 and said that he was sent to the hospital and would not be allowed to return. V6 stated that he is now accepted to a psychiatric facility out of state and that is where he will be going from the hospital. R5's progress notes entry documents on 5/4/24 at 15:59 (3:59PM) that V30 (Registered Nurse) phone facility requesting paperwork. Faxed face sheet/demographics, current orders/medication list and POLST (Physician Orders for Life Sustaining Treatment), V1 phone number given to V30 (Registered Nurse/RN-Hospital). R5's progress notes entry documents on 5/4/24 at 15:20 (3:20 PM) Resident left facility wearing blue jeans, red hoodie, socks, undergarments, shoes with his cell phone in his pocket. R5's progress notes entry documents on 5/4/24 at 15:20 (3:20 PM) that at 1450 (2:50 PM) that V27 (Medical Doctor) was phoned. At 1454 (2:54 PM) 911 dispatched, at 1455 (2:55 PM) report given to Emergency Room, at 1456 (2:56 PM) V6 was notified, at 1500 (3:00 PM) police officers x4 directed R5 off the unit due to safety concerns of other residents, at 1520 (3:20 PM) emergency room was phone to ensure R5 arrived and was then notified the facility will not be accepting R5 back here. Was served involuntary discharge papers prior to this happening. On 5/8/24 at 10:00 AM, V30 (Registered Nurse/RN-Hospital) stated that he called to the facility to confirm they would not be taking R5 back and that was confirmed by V1 (Administrator). V30 stated R5 is now being discharged to an out of state psychiatric facility for further care to manage his diagnosis. The facility's undated Resident Involuntary Discharge policy documents in part, It is the policy of the facility to only initiate involuntary discharge proceedings when the below listed situations exist. The facility's primary concern is for the health and safety of the affected resident and for the health and safety of the other residents, visitors, and staff members Resident notification. Prior to discharge, the resident and family members, surrogate or legal representative must be notified of the reasons for discharge. All conversations regarding potential discharge will be documented in the resident record Written notice must be provided at least 30 days in advance and include the following: the reason for discharge, the effective date of discharge, the resident's right to appeal the discharge with the State, and the telephone number and address of the appropriate office .The 30 day advance notice is not required under the following circumstances: When the resident is an endangerment to the health or safety of others in the facility. In the above cases notice must be provided as soon as is practicable before the transfer, but must be given before the resident leaves the facility. The notice will contain the same information as is given in the 30 day notice. The notice must also be provided to the resident's guardian or family member or durable power of attorney prior to discharge. In addition advise the facility receiving the resident, that you have discharged the resident and will not be accepting him/her back to your facility.

Based on observation, interview and record review the facility failed to serve meals at the facility's designated scheduled times for 3 of 3 residents (R1, R2, R4 and R5) reviewed for meal service in the sample of 6. Findings include: The undated Facility document titled, Dining Service Meal Times documents: 4. Meals and snacks will be served at the following times: lunch 12 (with 12 handwritten in). 6. Meals will be served no more than 30 minutes after scheduled meal times. On 12/02/23 while watching the lunch meal service it was noted at 1:20 PM R4 received her lunch, at 1:26 PM R2 received his lunch and at 1:28 PM R1 received his lunch. On 12/02/23 at 1:30 PM, V2 (Director of Nursing) stated, they last lunch tray has just been delivered (at 1:30 PM). V2 stated, lunch was to be served at 12:00 PM. On 12/03/23 at 10:00 AM, V3 (Dietary Manager) stated, breakfast is at 7:30 AM, lunch is at 12:00 PM and dinner is at 5:00 PM. V3 (Dietary Manager) stated, she is new, she has only been at the facility for three weeks and is trying to get some procedures worked out in the kitchen. V3 stated, there have been times that the food has come out later than it should have and has taken over an hour to get out. Yesterday (12/02/23) the last tray was served at approximately 1:30 PM. On 12/02/23 at 12:15 PM, R1 stated lunch will not be arriving for a while yet, it doesn't usually arrive until after 1:00 PM usually close to 1:30 PM maybe 1:45 PM. R1's MDS (Minimum Data Set) dated 11/15/23 documents a BIMS (Brief Interview of Mental Status) score of 14, indicating cognitively intact. On 12/02/23 at 12:30 PM, R4 stated the food is not on time. The food never comes at the same time, they just bring it whenever they get good and ready to bring it. R4's MDS (Minimum Data Set) dated 11/15/23 documents a BIMS (Brief Interview of Mental Status) score of 14, indicating cognitively intact. On 12/02/23 at 11:30 AM, R5 stated lunch may come whenever. Sometimes it can be as late as 1:30 PM to 1:45 PM. R5's MDS (Minimum Data Set) dated 10/09/23 documents a BIMS (Brief Interview of Mental Status) score of 15, indicating cognitively intact. On 12/02/23 at 12:20 PM, R2 stated lunch usually comes after 1:00 PM. R2's MDS (Minimum Data Set) dated 11/17/23 documents a BIMS (Brief Interview of Mental Status) score of 14, indicating cognitively intact. On 12/03/23 at 9:15 AM, V4 (Certified Nurse Aide) stated meals have been known to come out late. Lunch has come out after 1:00 PM before with the last tray being delivered after 1:30 PM. The Resident Council minutes dated 11/29/23 document: Dietary: serving time too long /late. The Resident Council minutes dated 10/30/23 documents: Dietary: long wait times.

Based on interview, record review and observation the facility failed to develop and implement a plan of care for the use of a physical restraint for 1 of 1 (R57) resident reviewed for physical restraints in a sample of 39. Findings included: Per R57's EHR (electronic health record) under Diagnosis tab documents R57 was admitted to this facility on 1/24/2020 with diagnoses of Unspecified Dementia with Agitation, Reduced Mobility, Anxiety Disorder, Restlessness and Agitation and History of Falls among others. On 4/17/2023 at 10:30am, V2 (Director of Nursing/DON) said R57 was the only resident who was physically restrained at this facility. V2 said the restraint is a tabletop that buckles behind R57's chair and prevents R57 from standing up and falling. V2 said they call the restraint an Activity Table. V2 said R57 has a high fall occurrence, and every other type of intervention has been tried before applying the tabletop restraint. V2 said the nursing staff monitor and document the tabletop restraint usage, including when it's removed and reapplied. V2 said the restraint is on R57's care plan. On 4/19/2023 at 1:30pm, V16 (Licensed Practical Nurse) said she is R57's primary nurse and normally is assigned to work the 200 hall where R57 lives. V16 said R57 is supposed to have the tabletop restraint on at all times while up and it is to be removed at mealtimes and then reapplied. V16 said the nurses don't generally monitor the restraint, but instead this is done by the Certified Nursing Assistants/CNA. V16 said she does not know where R57's restraint monitoring is documented by the CNAs. On 4/19/2023 at 1:45pm, V9 (Certified Nursing Assistant/CNA) said she usually works the 200 hall and would consider herself a primary caretaker for R57. V9 said the CNAs do not monitor R57's restraint, but instead the nurses are supposed to do this. V9 said R57 is to have his tabletop restraint removed at mealtimes and then it is to be reapplied. V9 said after R57 eats his lunch, she pushes his wheelchair up by the nurse's station so R57 can look out the window until supper time. According to R57's POS (Physician's Order Sheet) dated April 2023, a physician's order dated 2/10/23 documents the following, Activity board to wheelchair for trial period, remove during meals. There are no directions specified on the order for monitoring R57 while the restraint is in place or the duration of the order. According to R57's plan of care, under Focus it documents R57 is high risk for falls due to hx (history) of actual falls. Under Goals it documents R57 will be free of minor injury through the review date. Under the Interventions it documents Activity Board in place when up on wheelchair. Date initiated 03/24/2023 and Activity table to w/c (wheelchair) when up, off at meals times, date initiated 2/14/2023. No other information concerning R57's restraint is located on the care plan. On 4/18/2023 at 2:00pm, R57 was observed on the 200 hall by the nurse's station after lunch. R57 was seen sitting in his wheelchair with a tabletop restraint applied. R57 was asleep with his mouth open, head tipped back unsupported and facing upwards. On 4/19/2023 at 1:55pm, R57 was observed on the 200 hall by the nurse's station. R57 was observed sitting in his wheelchair, restrained with tabletop restraint buckled behind his wheelchair, asleep with his head tilted backwards unsupported and mouth fully open. On 4/20/2023 at 9:30am, R57 was observed sitting on the 200 hallway by the nurse's station with the tabletop restraint applied. R57's had laid his head down on the tabletop restraint and was asleep. On 4/20/2023 at 11:00am, V2 (DON) reviewed R57's care plan and could not find a plan of care for how the facility staff were to provide restraint care for R57. V2 said R57's restraint is to be removed every 2 hours but could not find this information anywhere in R57's EHR. By the end of the survey, V2 was not able to provide reproducible documentation of a plan of care for R57's restraint, including why, when and how long the restraint is to be used for R57. V2 verified R57 cannot remove the tabletop restraint after it is applied to his wheelchair and thus, she considers it as a physical restraint. A facility policy titled Use of Restraints with review date of 11/2019 documented the definition of Physical Restraint as any method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body .Examples of devices that are considered physical restraints include lap cushions and trays that the resident cannot remove .Restraints shall only be used upon written order of a physician .The order shall include the following: the type of restraint and period of time for the use of the restraint .Restraints will be checked and released frequently, during meal times, activity programs, and during care while supervised Care plans for residents with restraints will reflect interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely care assistance as an intervention to prevent a fall for 1 (R75) of 5 residents reviewed for accidents in the sample of 58. Findings Include: R75's admission Record documents a most recent admission date to the facility as 2/26/22. R75's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating he is cognitively intact. The same MDS documents R75 requires extensive assistance of two plus persons physical assist for toilet use. R75's Fall Risk Data Collection dated 3/18/22 documents an assessment score of 28, indicating he is at high risk for falls. R75's plan of care documents a focus area stating R75 is at risk for falls due to gait/balance problems. An intervention listed in this plan of care stated, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed Educate the resident/family/caregivers about calling for assistance prior to care and what to do if a fall occurs. On 3/22/22 at 12:45 PM, V2 (Director Of Nursing) was observed speaking with R75 providing education about R75 sitting in the dining room without his face mask on, putting him at greater risk for Covid-19. V2 stated it was his choice if he chose not to wear a mask and accept the risks. R75 was heard replying, Were there risks the other day when nobody could help me in time, and I finally had to take myself to the toilet and fell? V2 apologized to R75. On 3/22/22 at 12:50 PM, R75 stated that he did recently have a fall. R75 stated he was sitting in his bedroom, needed to use the restroom, and had called for assistance using his call light. R75 stated no one ever came after waiting for quite a while and he couldn't wait any longer, so he took himself to the restroom and fell. R75 states he wasn't seriously injured with his fall. R75 is alert and oriented to person, place, and time. On 3/23/22 at 1:58 PM, V7 (Certified Nurse Assistant, CNA) stated that she was an aide working on 3/18/22 when R75 fell. V7 states she was putting another resident to bed, and when she came out from tending to that resident, she responded to R75's bedroom call light which was illuminated. V7 stated she went to answer the call light and observed R75 in his bathroom sitting on the floor. V7 stated R75 said that he had been waiting a while for staff assistance. V7 states what she determined had happened was R75 had turned on his bedroom call light for assistance with toileting, ended up toileting himself when staff weren't available to respond in time, and fell while doing so. V7 stated while she cannot say exactly how long R75 would have been waiting for toileting assistance, she acknowledged it would have been a while as she was tending to another resident. V7 stated staff do their best to get the job done, but it would be fair to say there are times if there were more staff the timeliness of care would be improved. On 3/24/22 at 8:45 AM, V2 stated she would expect call lights to be answered in less than 10 minutes. A facility Occurrence Report dated 3/18/22 at 7:50 PM documents R75 experienced a fall in the bathroom with the assigned care giver being V7. This report documents the bathroom call light not in use. R75 had transferred self to toilet. Urine on floor. R75's statement is documented as being, I was taking a sh*t, anything else you want to know, flush the toilet. I went down on my knees, I hit my head on the wall. On 3/25/22 at 9:50 AM, R75 confirms that the evening he recently fell, while he cannot give the exact amount of time, he was waiting for staff to answer his call light, he can say with certainty it was greater than 10 minutes. A facility policy titled Fall Prevention Policy (S.A.F.E) with a revision date of February 2021 states, Residents found to be at high risk for falls are placed on the S.A.F.E. program, and specific interventions are implemented to meet individual needs. The policy states S.A.F.E. program promotes safety assessment, fall prevention and education to both staff and residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dementia care services promoting the highest practicable level of functioning for 1 (R287) of 3 residents reviewed for dementia care in the sample of 58. Findings Include: R287's admission Record documents an original admission date to the facility as 3/17/22. This same document included diagnoses of Dementia in other diseases classified elsewhere with behavioral disturbance and Alzheimer's Disease with late onset. R287's Minimum Data Set (MDS) dated [DATE] provided by the facility has a handwritten note on it, indicating it is still pending finalization, however the section for Brief Interview for Mental Status (BIMS) is completed with a score of 03, indicating R287 has severe cognitive impairment. This same MDS shows entries in Section E, Behavior, coded as 0 for verbal/vocal symptoms like screaming, disruptive sounds. A score of 0 is defined as behavior not exhibited, whereas a score of 3 is defined as behavior of this type occurred daily. On 3/22/22 at 2:00 PM, R287 was observed residing on the transition unit. This unit is observed at the end of the 400 hallway, behind closed double doors which is labeled as being a droplet precaution isolation area for Covid-19. On 03/22/22 at 02:27 PM, V6 (Family Member) stated R287 is a new admission to the facility and suffers from dementia. V6 stated you can tell her something and 5 minutes later she forgets. V6 stated R287 resides in the transition unit at the facility, for a reason unknown to him. V6 stated he comes every noon and evening meal to help R287 eat. V6 stated staff are not assigned to stay on the transition unit. V6 stated R287 doesn't remember to use her call light if she needs assistance, and with the doors closed the staff cannot always hear her yelling for help. V6 stated he recently arrived at the facility to help R287, entered the transition unit to hear R287 yelling for help, having soiled herself, and bowel movement all over her hands. V6 stated he understands staff cannot be everywhere but wishes they would check on her more and ensure she doesn't need assistance. On 03/22/22 at 02:21 PM, V3 (Assistant Director Of Nursing) stated R287 is currently on the Covid-19 precaution unit for 14 days since she is not fully vaccinated for Covid19. On 03/22/22 at 03:32 PM, while interviewing R55 on the 400 hall, R287 could be heard screaming for help from the transition unit located at the end of the 400 hall. On 3/22/22 at 3:43 PM, this surveyor entered transition unit where R287 had been heard repeatedly yelling for help and assistance with continuous observation of no staff entering the transition unit or being already on the unit when surveyor entered. R287 is observed stating, Hello! Can somebody help me please? Hello! Help me, help me, help. At 3:49 PM, R287 had continued yelling, stating she needs help out of here and needs to go to Chicago. R287 is observed sitting in a wheelchair in her room with the call light in reach. R287 was leaning forward and pushing the foot pedals up on her chair. R287 was alert to person only. On 03/22/22 at 03:52 PM, R288 who is directly across hall from R287, had his call light illuminated. R288 stated he turned on his call light so they will come and help R287. R288 stated, she just keeps yelling and it's driving me crazy! R288 is alert and oriented to person, place, and time. R287 and R288 are the only two residents observed as residing on the transition unit during this time. On 03/22/22 at 03:56 PM, R288's call light was answered by V9 (Certified Nurse Assistant/CNA). R288 stated he needed nothing, just for them to help R287. V9 exited R288's room and entered R287's room. V9 stated that R287 is a screamer. V9 asked R287 what she needed, in which R287 stated to get out of here. V9 re-oriented R287 to location and situation, then asked R287 if she would like to lay down in bed, in which R287 agreed. V9 stated she would have to go get help and left the transition unit. V9 stated V6 (Family Member) comes to sit with R287 frequently. At 04:01 PM, V9 returned to the transition unit with a mechanical lift. On 03/22/22 at 04:04 PM, R55, whose room is located outside of the transition unit, stated that he hears R287 frequently and she repeatedly screams for help. R55 stated he doesn't know if they finally gave R287 some medication the previous night to calm her or if she screamed herself to sleep, but states it was bad. On 3/24/22 at 8:45 AM, V2 (Director of Nursing) stated that the facility staffing levels are ok to meet resident needs in a timely manner. V2 stated she would expect call lights to be answered in less than 10 minutes. V2 stated they have no residents currently positive for Covid 19. V2 stated the two residents residing on the transition unit are there for precautionary measures since they are new admissions and not fully vaccinated. V2 stated that the 400 hall and the transition unit on the 400 hall are staffed with the same staff members. V2 stated she has heard that R287 yells, but is unsure if she yells a lot. V2 stated if R287 was hollering for help, she would expect staff to tend to her. On 3/24/22 at 9:46 AM, V1 (Administrator) stated that she has heard from other residents they are concerned with R287's yelling. V1 stated she believes the nursing staff are addressing R287 as having anxiety/pain. V1 stated if R287 was yelling out, she would expect staff to tend to her. On 03/24/22 at 10:10 AM, R287 was heard screaming for help from the 400 hallway. R75 was in the hallway next to the transition unit and stated his room wall backs up to her room. R75 stated What are they going to do with her? She yells all the time. R75 states, Actually, you hear her now? She's yelling now. On 03/24/22 at 10:11 AM, R287 was observed screaming I need some help! I've got to poop. Can I get some help? Can I get some help please? Can I please get some help? I've got to poop. I don't want to poop in this chair. Why won't anyone help me? Please help me. I need help. Can I please get some help? Can somebody help me? Can I please get help? I need help. Hello? Call my family if you don't want to help me. Can you please help me? I need help. No staff were observed present on the transition unit. The double doors were closed separating the transition unit from the rest of the 400 hallway. R287's call light was on her wheelchair arm within reach, but her call light was not illuminated. At 10:25 AM, R287 stated Now I'm peeing and I can't help it! Could you please help me?! On 03/24/22 at 10:26 AM, V4 (CNA) and V5 (CNA) responded to R287's room. At 10:42 AM, V4 and V5 exited R287's room. On 03/24/22 at 10:43 AM, V4 stated she works the 400 hallway, which includes the transition unit where Covid precautionary residents reside. V4 stated that there are currently 2 CNA's and 1 nurse working the hall, which is their normal staffing count for the hall. V4 stated that she feels having another staff member working on the hallway would be helpful since they have some residents who are 2 assist. V4 stated that residents are understanding usually if they cannot tend to them in a timely manner because they know the staff are busy and that it may take them longer to get to them at times if they are helping someone else. V4 stated they they check on the residents residing on the transitions unit at least every 2 hours, if not more often. V4 stated R287's normal status is confused. V4 stated R287 yells and is not cognitively intact. V4 stated that sometimes R287 can be heard yelling from the other side of the double doors yelling if they are down the hall towards the transitions unit. V4 stated if they hear R287 yelling, they will go back there to check on her and see what she needs. V4 stated that R287 had urinated in her incontinence brief just now when they checked her. V4 stated that R287 doesn't not always use her call light due to her dementia status. On 03/24/22 at 10:50 AM, V5 stated that R287's normal status is confused. V5 stated R287 does yell at times. V5 stated when she currently went in to check on R287, she had urinated. V5 stated herself and V4 put R287 in bed, removed her soiled incontinence brief, placed R287 on the bedpan, and then applied a new incontinence brief and placed R287 back in her wheelchair. V5 stated that R287 usually uses an incontinence brief, but will use the bed pan appropriately at times. V5 stated it seems R287 can tell when she needs to go but 9 times out of 10 has already gone by the time staff tend to her. V5 stated the staff that cover 400 hall also cover the transition area where Covid precautionary residents reside. V5 stated that staff check on the residents on the transition unit every hour, if not more often. V5 stated if they hear R287 yelling, they will go check on her. V5 stated it is possible if staff could get to her sooner, she could have less incontinence episodes, but stated with R287's cognitive status, she does not always use her call light appropriately. V5 stated that she feels staff due the best they can to tend to residents in a timely manner, but realizes there are times staff are tending to other residents, which takes up their time, not allowing them to tend to others in a timely manner. V5 stated the 400 hallway could benefit from another aide. V5 stated while tasks are completed, they could be done more thoroughly if there were more staff. V5 stated the nursing staff will help when they can, but also have their duties they are completing. R287's Plan of Care documents a focus area of Impaired Cognitive function/dementia or impaired thought processes with date initiated on 3/23/22. Goals include R287 will maintain current level of cognitive function and be able to communicate basic needs on a daily basis through the review date. Interventions listed for this focus area include, but are not limited to: break tasks into small sub tasks to support short term memory deficits .provide the resident with necessary cues- stop and return if agitated Keep R287's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. There are no interventions listed in this focus area to address R287's memory issues as it relates her lack of ability to consistently remember to use the call light and instead often yells for help. This same Plan of Care has a focus area of ADL (Activities of Daily Living) Self Care Performance deficit, with date initiated of 3/24/22. The goal states resident will improve current level of function in ADL score through review date. Interventions listed for this focus area include but are not limited to: Res (resident) does yell out. Res known how to use call light and ask for help. Staff to check on res frequently when yelling out in room for safety and care. The intervention for Toilet Use documents The resident requires (X2) staff participation to be checked for incontinence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide staffing levels in order to meet resident needs in a timely manner for 4 (R70, R75, R55, R287) of 18 residents reviewed for staffing in the sample of 58. Findings Include: 1. On 3/22/22 at 12:45 PM, V2 (Director Of Nursing/DON) was observed speaking with R75 regarding being educated about sitting in the dining room without his face mask on putting him at greater risk for Covid-19. V2 stated it was his choice if he chose not to wear a mask and accept the risks. R75 was observed replying, were there risks the other day when nobody could help me in time and I finally had to take myself to the toilet and fell? V2 apologized to R75. On 3/22/22 at 12:50 PM, R75 stated that he did recently have a fall. R75 stated he was sitting in his bedroom, needed to use the restroom and had called for assistance using his call light. R75 stated no one ever came after waiting for quite a while and he couldn't wait any longer, took himself to the restroom and fell. R75 states he wasn't seriously injured with his fall. R75 is alert and oriented to person, place, and time. Review of an Occurrence Report dated 3/18/22 at 7:50 PM documents R75 experienced a fall in the bathroom with the assigned caregiver being V7. This report documents the bathroom call light not in use. Resident had transferred self to toilet. Urine on floor. The resident statement is documented as being, I was taking a sh*t, anything else you want to know, flush the toilet. I went down on my knees, I hit my head on the wall. On 3/23/22 at 1:58 PM, V7 (Certified Nurse Assistant/CNA) states that she was an aide working on 3/18/22 when R75 fell. V7 states she was putting another resident to bed, and when she came out of tending to that resident, she responded to R75's bedroom call light, which was on. V7 stated she went to answer the call light and observed R75 in his bathroom sitting on the floor. V7 stated R75 said that he had been waiting a while for staff assistance. V7 states what she determined had happened was R75 had turned on his bedroom call light for assistance with toileting, ended up toileting himself when staff weren't available to respond, and fell while doing so. V7 stated while she cannot say exactly how long R75 would have been waiting for toileting assistance, she acknowledges it would have been for a while as she was tending to another resident. V7 stated staff do their best to get the job done, but it would be fair to say there are times if there were more staff, the timeliness of care would be improved. On 3/25/22 at 9:50 AM, R75 confirms that the evening he recently fell, while he cannot give the exact amount of time, he was waiting for staff to answer his call light, he can say with certainty it was greater than 10 minutes. 2. On 03/22/22 at 02:27 PM, V6 (Family Member) stated R287 is a new admission to the facility and suffers from dementia. V6 stated you can tell her something and 5 minutes later she forgets. V6 stated R287 resides in the transition unit at the facility, for a reason unknown to him. V6 stated he comes every noon and evening meal to help R287 eat. V6 stated staff are not assigned to stay on the transition unit. V6 stated R287 doesn't remember to use her call light if she needs assistance, and with the doors closed the staff cannot always hear her yelling for help. V6 stated he recently arrived at the facility to help R287, entered the transition unit to hear R287 yelling for help, having soiled herself, and bowel movement all over her hands. V6 stated he understands staff cannot be everywhere but wishes they would check on her more and ensure she doesn't need assistance. On 03/22/22 at 03:32 PM, while interviewing R55 on the 400 hall, R287 could be heard screaming for help from the Transition unit located at the end of the 400 hall. On 3/22/22 at 3:43 PM, this surveyor entered the transition unit where R287 has been heard repeatedly yelling for help and assistance. With continuous observation, no staff was observed entering the transition unit or being on the unit when the surveyor entered. R287 is observed stating, Hello can somebody help me please? Hello! Help me, help me. Help. At 3:49 PM, R287 has continued yelling stating she needs help out of here .Needs to go to Chicago. R287 was sitting in her room in her wheelchair, with the call light within reach. R287 was leaning forward and pushing foot pedals up on her chair. R287 was alert to person only. On 03/22/22 at 03:52 PM, R288, who is directly across the hall from 287, was observed as having his call light illuminated. R288 stated he turned on his call light so they will come and help R287. R288 states, she just keeps yelling and it's driving me crazy! R288 is alert and oriented to person, place, and time. R287 and R288 are the only two residents observed as residing on the transition unit during this time. On 03/22/22 at 03:56 PM, R288's call light was answered by V9 (Certified Nurse Assistant/CNA). R288 stated he needed nothing, just for them to help R287. V9 exited R288's room and entered R287's room. V9 stated that R287 is a screamer. V9 asked R287 what she needed, in which R287 stated get out of here. V9 reoriented R287 to location and situation, then asked resident if she would like to lay down in bed, in which R287 agreed. V9 stated she would have to go get help and left the transitions unit. V9 stated V6 (Family Member) comes to sit with R287 frequently. At 04:01 PM, V9 returned to the transition unit with a mechanical lift. On 03/22/22 at 04:04 PM, R55, whose room is located outside of the transition unit states that he hears R287 frequently and repeatedly scream for help. R55 stated he doesn't know if they finally gave R287 some medication the previous night to calm her or if she screamed herself to sleep, but states it was bad. On 3/24/22 at 8:45 AM, V2 (DON) stated that the facility staffing levels are ok to meet resident needs in a timely manner. V2 stated she would expect call lights to be answered in less than 10 minutes. V2 stated they have no residents currently positive for Covid 19. V2 stated the two residents residing on the transition unit are there for precautionary measures since they are new admissions and not fully vaccinated. V2 stated that the 400 hall and the transition unit on the 400 hall are staffed with the same staff. V2 stated she has heard R287 yell but is unsure if she yells a lot. V2 stated if R287 was hollering for help, she would expect staff to tend to her. On 3/24/22 at 9:46 AM, V1 (Administrator) stated that she has heard from other residents they are concerned with R287's yelling. V1 stated she believes the nursing staff are addressing R287 as having anxiety/pain. V1 stated if R287 was yelling out, she would expect staff to tend to her. On 03/24/22 at 10:10 AM, R287 was heard screaming for help from the 400 hallway. R75 was in the hallway next to the transitions unit and stated his room wall backs up to her room. R75 stated What are they going to do with her? She yells all the time. R75 stated, Actually, you hear her now? She's yelling now. This surveyor noted someone was yelling Help audibly. On 03/24/22 at 10:11 AM, R287 was screaming I need some help! I've got to poop. Can I get some help? Can I get some help please? Can I please get some help? I've got to poop. I don't want to poop in this chair. Why won't anyone help me? Please help me. I need help. Can I please get some help? Can somebody help me? Can I please get help? I need help. Hello? Call my family if you don't want to help me. Can you please help me? I need help. No staff were present on transition unit. The double doors were closed, separating the transition unit from the rest of the 400 hallway. R287's call light was observed on the wheel chair arm in resident reach. The call light was not illuminated. At 10:25 AM, R287 states Now I'm peeing and I can't help it! Could you please help me?! On 03/24/22 at 10:26 AM, V4 (CNA) and V5 (CNA) responded to R287's room. At 10:42 AM, V4 and V5 exited R287's room. On 03/24/22 at 10:43 AM, V4 stated she works the 400 hallway which includes the transition unit where Covid precautionary residents reside. V4 stated that there are currently 2 CNA's and 1 nurse working the hall, which is their normal staffing count for the hall. V4 stated R287's normal status is confused. V4 stated R287 yells and is not cognitively intact. V4 stated that sometimes R287 can be heard yelling from the other side of the double doors if they are down the hall towards the transitions unit. V4 stated if they hear R287 yelling, they will go back there to check on her and see what she needs. V4 stated that R287 had urinated in her incontinence brief just now when they checked her. V4 stated that R287 doesn't always use her call light due to her dementia status. V4 stated that they check on the residents residing on the transitions unit at least every 2 hours, if not more often. On 03/24/22 at 10:50 AM, V5 (CNA) stated that R287's normal status is confused. V5 stated R287 does yell at times. V5 stated when she currently went in to check on R287 she had urinated. V5 stated herself and V4 put R287 in bed, removed her soiled incontinence brief, placed R287 on the bedpan, and then applied a new incontinence brief and placed R287 back in her wheelchair. V5 stated that R287 usually uses an incontinence brief but will use the bed pan appropriately at times. V5 stated it seems R287 can tell when she needs to go, but 9 times out of 10 has already gone by the time staff tend to her. V5 stated the staff that cover the 400 hall also cover the transition area where Covid precautionary residents reside. V5 stated that staff check on the residents on the transition unit every hour, if not more often. V5 stated if they hear R287 yelling, they will go check on her. V5 said it's possible if staff could get to her sooner, she could have less incontinence episodes, but stated with R287's cognitive status, she does not use always use her call light appropriately. 3. On 03/22/22 at 11:56 AM, R70 stated he has experienced incontinence episodes waiting on his call light to be answered for toileting assistance. R70 stated the staff the facility has are good, there are just not enough of them. R70 stated at times he has had to wait 30 plus minutes for his call light to be answered. R70 is alert and oriented to person, place, and time. Review of R70's admission Record documents a most recent admission date to the facility as 2/24/22. Review of R70's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, which indicates he is cognitively intact. The same MDS documents in Section G that R70 requires Extensive Assistance of two plus persons physical assist. 4. On 03/22/22 at 03:25 PM, R55 stated that on average it takes his call light 35 minutes to be answered but has taken up to 55 minutes. R55 stated call light answer times seem to be worse at night and on the weekend. R55 stated there are many staff who are great and do a good job, there just seems to be a problem with there not being enough of them to tend to everyone in a timely manner. R55 stated that he understands there aren't many people who want to work these days, so he tries to be understanding. R55 is alert and oriented to person, place, and time. Review of R55's admission Record documents a most recent admission date to the facility as 2/17/22. R55's diagnosis listed on this document includes Unsteadiness on feet, Difficulty in walking; not elsewhere classified. On 3/24/22 at 8:45 AM V2 (DON) stated she believed that the facility staffing levels are ok to meet resident needs in a timely manner. V2 stated as far as staffing goes for 400 hall, day shift has 2 nurses and 2 or 3 CNA's (Certified Nurse Assistant), evening shift 2 nurses and 2 or 3 CNA's (sometimes 1 nurse after 7:30 PM), night shift 1 nurse and 1 CNA or 2 nurses and 1 CNA. V2 stated she doesn't have residents complain specifically of staffing levels but stated residents will complain saying things such as they've had to wait for care, which it is implied staffing issues she considers. V2 stated she would expect call lights to be answered in less than 10 minutes. On 03/24/22 at 10:43 AM, V4 stated that she feels having another staff member working on the hallway would be helpful since they have some residents who are 2 assist. V4 stated that residents are usually understanding if they cannot tend to them in a timely manner because they know the staff are busy and that it may take them longer to get to them at times if they are helping someone else. V4 stated that they check on the residents residing on the transitions unit at least every 2 hours, if not more often. On 03/24/22 at 10:50 AM, V5 (CNA) stated that she feels staff do the best they can to tend to residents in a timely manner, but states there are times staff are tending to other residents, which doesn't always allow them to tend to others in a timely manner. V5 stated the 400 hallway could benefit from another aide. V5 stated while tasks are completed, they could be done more thoroughly if there were more staff. V5 stated the nursing staff will help when they can, but also have their own duties they are completing. Review of the Resident Council meeting minutes for the 9/29/21 meeting document the concern area of long call lights. In response to this concern area the plan of action taken by the facility is documented as stating, DON and team will continue to monitor staffing and mealtime and response to call lights Team has an incentive in place to encourage applicants. Nursing admin will continue to assist on the hall and during mealtimes. On 3/25/22 at 9:38 AM, V2 (Director of Nursing) states on the 400 hall, there are 9 residents who require the assist level of 2 staff. Review of the daily census list provided by the facility dated 3/21/22 documents 20 residents reside on the 400 hallway. On 2/32/22 at 11:00 AM, V2 states that staffing levels for the facility are determined based on the census and a formulary figure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the planned menu and recipes for 28 (R5, R8, R13, R14, R21, R23, R27, R47, R49, R50, R52, R53, R55, R56, R58, R64, R65, R70, R74, R75, R79, R80, R82, R284, R285, R286, R287 and R288) of 28 residents reviewed for menu accuracy in a sample of 58. The Findings Include: On 3/22/22 at 12:15PM, V8 (Dietary Manager) was observed to be preparing the pureed foods to be served at lunch. The menu had listed shepherd's pie as the main meal option for the day. V8 had a separate container of plain ground beef in one, and carrots and peas in the other. These were each pureed individually and placed in separate containers on the steam table for service. Review of the corporate recipe for Shepard's pie notes the following for pureed: separate mashed potatoes and beef mixture. Measure out desired number of separate servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if product needs thickening. On 3/22/22 at 1:00 PM during lunch meal observation, it was noted that no carrots were being served to the 400 hall residents. V13 (Cook) was asked at this time, as he was serving the trays from the steam table, where the glazed carrots were. V13 replied that he did not have any carrots other than what was in the Shepard's pie. R5, R8, R13, R21, R27 and R56's current order summary report documents that they receive a pureed diet. On 3/22/22 at 2:30 PM, V8 stated that there should have been carrots back on the 400 hall, and that she should have pureed the Shepard's pie mixture as a dish and not made separate foods because they were not prepared in the same manner as the Shepard's pie recipe. Review of resident council minutes has a complaint from 2/23/22 to the dietary department that they are not receiving menu items listed on the main menu. R79's facility face sheet dated 3/25/22 documents R79 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease and dysphagia. R79's Order Summary Report dated 2/24/22 documents R79 has an order for pureed consistency diet. R23's facility admission record dated 3/25/22 documents R23 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease and unspecified dementia. R23's facility Order Summary Report dated 2/24/22 documents an order for a pureed consistency diet. On 3/24/22 at 12:35 PM, R79 was observed sitting in the main dining room and was served four pureed food items for lunch. On 3/24/22 at 12:40 PM R23 was observed sitting in the main dining room and was served four pureed food items for lunch. The facility week at a glance (week 3) menu dated 2/16/22 documents crispy baked chicken, pickled beets and onion salad, macaroni and cheese, cornbread, and pumpkin pie were being served for the noon meal, which indicates R79 and R23 should have been served five pureed food items. On 03/24/22 at 1:26 PM, V12 (Cook) stated the cornbread was missed and not sent out to the residents who were on a pureed diet. V12 stated they served the cornbread to R23 and R79 after it was brought to their attention by this surveyor.

Based on observation, interview and record review the facility failed to serve food at an appetizing temperature for 4 (R3, R55, R70, and R258) of 4 residents reviewed for food palatability in a sample of 58. The Findings Include: During the resident council meeting held on 3/22/22, R3 stated that her food is generally cold by the time she is served in her room. R3 typically just eats it that way because she hates to complain and knows they are busy. Review of resident council minutes have documented complaints on 9/29/21 that residents have to wait a long time for food and it is cold when it arrives, and on 10/27/21 that meals are late and food is cold. On 03/22/22 at 12:08 PM, R70 stated food is consistently cold and late. R70 stated he has told staff the food is cold. R70 stated they microwave it for him, but the food isn't as good microwaved. R70 states soup or sandwich is available as a substitute, but he normally will just eat snacks or provide his own food now. On 3/22/22 at 3:30 PM, R55 stated that meals are often late, cold, overcooked causing food to be tough, and poor tasting overall. R55 stated alternatives are available but are usually no better than the meal being served. R55 stated he has been served dinner as late as 8 PM. On 03/24/22 at 10:43 AM, V4 (Certified Nurse Assistant, CNA) stated she has had complaints regarding meals being late and cold. V4 stated that general statements can be overheard from residents complaining that the food is cold and states staff will take the plates when they hear resident's complain and microwave the food. V4 stated meals seems to generally run late due to waiting on the kitchen staff to get the food ready. V4 stated she cannot name a specific resident that has made complaints regarding food, it is again what she has overheard residents talking about while being in the dining room waiting on meals. On 03/24/22 at 10:50 AM, V5 (CNA) acknowledged she has had repeated complaints from residents regarding the food. V5 stated residents will complain of the food taste and being cold. On 3/24/22 at 8:45 AM, V2 (Director Of Nursing) stated she has received complaints of cold food temps in the past, specifically with French fries being cold. V2 stated V1 (Administrator) opened an action plan in which the facility started utilizing the 400 hall kitchen area again instead of transporting trays from the main kitchen to the 400 hall dining room. On 3/24/22 at 9:46 AM, V1 described it as being hit or miss with food complaints involving temperature as well as meals being timely. V1 states that they have worked to try and help resolve food complaints by utilizing the kitchen area on the 400 unit instead of just utilizing the main dining room kitchen. On 3/24/22 at 10:00 AM, R285 states that food is cold, no taste, cake dry, food overcooked.

Based on observation, interview and record review the facility failed to provide minimum level of staffing to effectively carry out the functions of the food and nutrition service department. This has the potential to affect all 83 residents residing in the facility. Findings Include: On 3/22/22 at 10:15 AM during the initial walk through of the kitchen, V8 (Dietary Manager) was in the kitchen along with V11 (dish washer). V8 stated that she had not even started lunch yet because she was there alone and the truck delivery had come in and needed to be put up but was hoping that help would show up soon. V8 stated at this time that meal times are 7:30 AM, 12:30 PM, and 5:30 PM. On 3/22/22 at 12:00 PM, V10 (Certified Dietary Manager) stated that she had just arrived after picking up a kitchen staff member who had no transportation to work that day. The kitchen staff now have started to prepare the lunch meal and finish putting the truck stock food away. On 03/22/22 at 12:08 PM, R70 stated that the food is consistently cold and late when asked how the meal service was at the facility. On 3/22/22 at 2:00 PM, R3 stated during the resident council meeting that she eats her meals in her room. R3 states that her room is at the end of the hall and it is common for her to get her lunch around 1:45 PM -2:00 PM and her evening meal gets to her about 6:30 PM and the food is generally cool but she eats it anyway. On 3/22/22 at 3:30 PM, R55 states that meals are often late, cold, overcooked causing food to be tough, and poor tasting overall. R55 stated alternatives are available but are usually no better than the meal being served. R55 stated he has been served dinner as late as 8 PM. On 3/22/22 at 1:45 PM, R42 was observed to be seen receiving her lunch tray at 1:45 PM. On 3/24/22 at 9:46AM, R285 stated that his food is cold, no taste, overcooked, and late. On 03/24/22 at 2:05 PM, V8 stated that 'it is a 4 man show in here.' Sometimes they have only 2 persons that are in the kitchen and that is what had happened on Tuesday 3/22/22 and it makes it hard to get everything completed timely. V8 went on to state that on 3/24/22 the district manager and V10 came in to assist with the kitchen duties, but they are only here a couple times a week and during survey, so they are not here on a regular basis to count on them to help perform the daily duties. V8 stated that the dish washer doesn't generally help with the cooking and serving meals duties. Additionally, V8 stated that there are positions posted for kitchen staff and will be hopefully hiring someone soon after the background check is complete. On 3/24/22 at 10:43 AM, V4 (Certified Nurse Assistant) states she has had complaints regarding meals being late and cold on the 400 hall. V4 states that general statements can be overheard from residents complaining that the food is cold and states staff will take the plates when they hear them complain and microwave the food. V4 stated meals seem to generally run late due to waiting on the kitchen staff to get the food ready. On 3/24/22 at 3:00 PM, V1 (Administrator) stated that it is not uncommon that tray line starts after the posted time and also not uncommon that the last tray for lunch would be delivered around 2 PM. V1 went on to state she feels that this has improved after creating action plans to improve this process. The schedule provided by V10 shows that on 3/22/22 that 2 staff were scheduled to work at 5:30 AM. and a dishwasher at 7:00 AM for that day. V10 stated at 12 PM on 3/22/22 that she had went and picked up the other staff member that had a broke down car and go them to work finally. Resident Council minutes from 9/29/21 and 10/27/21 documented complaints that meals are late and food is cold. The Resident Census and Conditions dated 3/25/22 documents that 83 residents reside in the facility.