**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely incontinence care. This applies to 2 of 3 residents (R1 and R4) reviewed for timely incontinence care in the sample of 18. The findings include: 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. R1's care plan, initiated on May 9, 2024 shows: The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, has current urinary incontinence, impaired mobility, loss of peritoneal tone, physical limitations. Multiple interventions, initiated May 9, 2024 show: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence . 2. On February 10, 2025 at 9:18 AM, R4 was sitting in his wheelchair by the nurse's station. R4 said he needed to use the restroom. At 9:25 AM, V6 (CNA/Staffing Coordinator) said R4 frequently states he has to use the restroom when his incontinence brief is already wet. V6 pushed R4 in his wheelchair back to his room to transfer R4 back to bed with V11 (CNA). As V6 and V11 lifted R4 from his wheelchair, the back of R4's sweatpants were soaking wet, approximately 12 inches in diameter about R4's buttocks. V6 said, [R1] drank a lot of water at breakfast this morning. V6 and V11 put R4 in his bed and started to remove his wet pants and incontinence brief. A strong odor of urine and stool was present. When V6 and V11 removed R4's incontinence brief, the brief was wet with urine and stool was present. V6 used disposable wipes to clean the stool from R4's buttocks and sacrum. R4 had an area of redness around his rectal area and sacrum, approximately six inches long by four inches wide. R4 said the area was tender when V6 was using disposable wipes to clean the area. V11 (CNA) said she was assigned to care for R4. V11 said she dressed R4 and provided incontinence care to him prior to breakfast. V11 said she was assigned to care for 12 residents, including two residents who required feeding assistance. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), pain, insomnia, lung cancer, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment, require partial/moderate assistance with eating, substantial/maximal assistance with bed mobility and transfers between surfaces, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. R4 did not have a pressure ulcer at the time of this MDS assessment. R4's care plan, initiated on March 8, 2024 shows: The resident is at risk for incontinence related to ALS, dementia, immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review dated. Interventions: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure electrical wires are not left exposed, near a resident's metal bed frame. This applies to 1 of 4 residents (R1) reviewed for safe environment in the sample of 18. The findings include: On February 6, 2025 at 9:15 AM, R1 was lying in bed in her room. The headboard of R1's bed was up against the wall of her room. The wall behind R1's bed had multiple areas of chipped plaster and paint. On the wall behind R1's headboard, approximately 4 inches from the floor, an electrical outlet box appeared damaged. The outlet box was hanging off the wall. The outlet box was open, and electrical wires were hanging outside of the outlet box. The electrical wires had multiple electric wire connectors in place on the ends of the electrical wires. The exposed electric wires were approximately two to four inches from R1's metal bed frame. R1 said, Oh, every time they boost me in the bed, the whole bed moves and bangs into the wall behind my bed. I know they hit that outlet with my bed, because I hear the staff say, Oh darn, we hit that outlet again. R1 continued to say she is dependent on facility staff to reposition her in bed, and remains in her bed at all times, which is her preference. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. On February 6, 2025 at 11:22 AM, V5 (Maintenance Director) said, I have constant issues with a hanging outlet in [R1's] room. It is behind her bed and the staff keep hitting the outlet with her bed when they boost [R1]. My plan is to shorten that outlet where it won't keep getting knocked off the wall. As long as the box is intact, there is no way she can get electrocuted. The last time it was reported to me was three months ago. During this interview, V5 was made aware of the electrical outlet hanging off the wall with exposed wiring in R1's room by this surveyor. On February 6, 2025 at 2:57 PM, R1 was lying in bed in her room. The broken electrical outlet and exposed wiring continued to be an issue, with no changes noted in the electrical outlet. On February 10, 2025 at 9:37 AM, V5 (Maintenance Director) said he was able to cover the electrical outlet in R1's room. V5 said he had not shortened the outlet or put any interventions in place to ensure the electrical outlet could not become damaged again during repositioning of R1. V5 said, I wouldn't be surprised if that outlet is broken again.

Based on observation and interview, the facility failed to provide a clean, homelike environment when it failed to provide window shades, or equivalent, that are in good repair, without stains or tears. This applies to 13 of 18 residents (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18) reviewed for lack of window shades/curtains and homelike environment in the sample of 18. The findings include: 1. On February 6, 2025 at 9:26 AM, R6 and R7 were sitting in their room. The window in their room had temporary, pleated paper shades over the window. The paper shades were torn. Plastic clips were in place to hold the shade open approximately 12 inches from the bottom of the windowsill. The residents said they are unable to raise and lower the shades to a height of their liking, so the shades remain held open with the plastic clips, in the same position. 2. On February 6, 2025 at 9:30 AM, R8 and R9 were sitting in the room they share at the facility. R8 and R9's room has a large window, approximately 5 feet wide by 5 feet high. R8 and R9's window faces the courtyard/patio of the facility. R8 and R9's window did not have window coverings, including shades, blinds, or curtains. R8 and R9 could not be interviewed due to their cognitive status. On February 10, 2025 at 9:30 AM, R8 and R9 were not sitting in their room. R8 and R9's room did not have window coverings, including, shades, blinds, or curtains. 3. On February 6, 2025 at 9:34 AM, R10 and R11 were sitting in their room. The window in R10 and R11's room had temporary, pleated paper shades over the window. The paper shades were torn in multiple places. The paper shades did not have plastic clips in place to raise or lower the shade to see outside the window. 4. On February 6, 2025 at 9:21 AM, R12 was lying in bed in her room. R12 could not be interviewed due to her cognitive status. R12's room had a large window, approximately 5 feet wide by 5 feet high. R12's window did not have window coverings, including shades, blinds, or curtains. 5. On February 6, 2025 at 9:36 AM, R13 and R14 were sitting in their room. R13 and R14's window was covered by temporary, pleated paper shades. The bottom of the shade was approximately 12 inches from the bottom windowsill and was being held in place with plastic clips. R14 was sitting on the edge of his bed, next to the window. R14 was bent over and trying to look out the window, through the 12-inch opening between the bottom of the shade and the windowsill. R14 said, These shades don't work. You can't make them go up and down, so if I want to look outside, I must bend over to see out. It makes the room feel dark all day. 6. On February 6, 2025 at 9:28 AM, R15 and R16 were sitting in their room. R15 and R16's window was covered by temporary, pleated papers shades. The paper shades were torn in multiple places and did not have plastic clips in place to raise or lower the shades to see outside. 7. On February 6, 2025 at 9:25 AM, R17 and R18 were sitting in their room. R17 and R18's window was covered by a large shade. The window shade was an ivory color. The bottom two feet of the window shade was heavily stained with a dark brownish, red substance. On February 6, 2025 at 11:22 AM, V5 (Maintenance Director) said, They were in the middle of a remodeling update here, but then stopped because of money issues. They are thinking of starting it up in the next six months. V9 (Former Administrator) had started the remodeling, but then never finished it. We had a quote for over $4,000 for window treatments, so he did not go through with it. We had an administration change about six months ago, but we have not restarted the remodeling. V5 continued to say it has been six months or longer that resident rooms have been without permanent window shades.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the ADL (Activities of Daily Living) needs of the residents in the facility. This applies to all 79 residents residing in the facility. The findings include: The Facility Data Sheet dated February 6, 2025 shows the facility census as 79 residents. 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. R1 continued to say she is always sure she has an absorbent under pad to sit on in her bed so when she soaks through her incontinence brief, her bedding does not get soiled. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. R1's care plan, initiated on May 9, 2024 shows: The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, has current urinary incontinence, impaired mobility, loss of peritoneal tone, physical limitations. Multiple interventions, initiated May 9, 2024 show: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence . 2. On February 10, 2025 at 9:18 AM, R4 was sitting in his wheelchair by the nurse's station. R4 said he needed to use the restroom. At 9:25 AM, V6 (CNA/Staffing Coordinator) said R4 frequently states he has to use the restroom when his incontinence brief is already wet. V6 pushed R4 in his wheelchair back to his room to transfer R4 back to bed with V11 (CNA). As V6 and V11 lifted R4 from his wheelchair, the back of R4's sweatpants were soaking wet, approximately 12 inches in diameter about R4's buttocks. V6 said, [R1] drank a lot of water at breakfast this morning. V6 and V11 put R4 in his bed and started to remove his wet pants and incontinence brief. A strong odor of urine and stool was present. When V6 and V11 removed R4's incontinence brief, the brief was wet with urine and stool was present. V6 used disposable wipes to clean the stool from R4's buttocks and sacrum. R4 had an area of redness around his rectal area and sacrum, approximately six inches long by four inches wide. R4 said the area was tender when V6 was using disposable wipes to clean the area. V11 (CNA) said she was assigned to care for R4. V11 said she dressed R4 and provided incontinence care to him prior to breakfast. V11 said she was assigned to care for 12 residents, including two residents who required feeding assistance. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), pain, insomnia, lung cancer, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment, require partial/moderate assistance with eating, substantial/maximal assistance with bed mobility and transfers between surfaces, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. R4 did not have a pressure ulcer at the time of this MDS assessment. R4's care plan, initiated on March 8, 2024 shows: The resident is at risk for incontinence related to ALS, dementia, immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review dated. Interventions: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. 3. On February 10, 2025 at 12:09 PM, V15 (CNA) was passing meal trays to residents. Multiple call lights were going off, and V15 had to stop passing meal trays to attend to the needs of the residents with requests for assistance. V15 answered the call lights, and each resident asked, Where is my lunch tray? V15 explained to multiple residents she was in the process of passing lunch trays and would bring their trays as soon as possible. V15 said she was assigned to care for 14 residents on her shift. Of the 14 residents, 11 need me to help them with incontinence care and toilet hygiene, two of the residents need mechanical lifts to get out of bed, which means I need to find another CNA to help me, and one of the residents needs to be fed by me. The CNAs are also responsible for passing all meal trays to the residents and picking up the empty meal trays after lunch is finished. It is very difficult to do it all, but I always do my best. On February 6, 2025 at approximately 10:30 AM, V2 (DON/Director of Nursing) provided staffing schedules for the period of January 5, 2025 to March 1, 2025. V2 (DON) said, Our CNAs workday shift from 6:00 AM to 2:00 PM, PM shift from 2:00 PM to 10:00 PM, and night shift from 10:00 PM to 6:00 AM. We staff seven CNAs on day shift; four CNAs on the second floor, and three CNAs on the first floor. We staff six CNAs on PM shift; three CNAs on the second floor, and three CNAs on the first floor. We staff four CNAs on the night shift; two upstairs, and two on the first floor. Nurses workday shift from 7:00 AM to 3:30 PM, with two nurses on the second floor and two nurses on the first floor. PM shift is from 3:00 PM to 11:30 PM with two nurses on the second floor and two nurses on the first floor. Night shift is from 11:00 PM to 7:30 AM and is staffed with two nurses total; one upstairs and one on the first floor. On February 10, 2025 at approximately 10:00 AM and 10:50 AM, V6 (Staffing Coordinator/CNA) reviewed the staffing schedules for the period of January 1, 2025 to January 31, 2025. V6 said, Ideally, we would like to have seven CNAs in the facility for day shift so we can have four CNAs on the second floor where the resident care needs are greater, and three CNAs on the first floor. That just isn't always possible. I use agency staff to fill the gaps to get us up to six CNAs on day shift, but I have not been given permission to use agency staff to get us up to seven CNAs. There are a lot of days where we only have six CNAs for the day shift, and it is hard for the staff. Today we had a call-in, so I was pulled to the floor to work as a CNA so we can have six CNAs on the floor. There are a lot of residents with heavy needs. We do the best we can with what we have. We have to use two facility staff to do a transfer with a mechanical lift. V6 continued to say the facility census on February 6, 2025 was 79 residents and the facility had six CNAs working from 6:00 AM to 2:00 PM. V6 also said the ADL needs of the residents in the facility were the same on February 6 and February 10, 2025. During review of the staffing schedules with V6 (Staffing Coordinator/CNA), multiple day shifts were identified where the facility did not have 7 CNAs. The facility census and staffing numbers were confirmed with V6 (Staffing Coordinator/CNA) present. The staffing schedule shows the following dates/resident census/number of CNAs working from 6:00 AM to 2:00 PM: January 6, 2025 - 79 residents - 6 CNAs January 7, 2025 - 78 residents - 6 CNAs January 8, 2025 - 79 residents - 6 CNAs January 9, 2025 - 79 residents - 6 CNAs January 11, 2025 - 80 residents - 6 CNAs January 12, 2025 - 80 residents - 6 CNAs January 14, 2025 - 79 residents - 6 CNAs January 15, 2025 - 82 residents - 6 CNAs January 16, 2025 - 82 residents - 6 CNAs January 20, 2025 - 81 residents - 6 CNAs January 21, 2025 - 80 residents - 6 CNAs January 22, 2025 - 81 residents - 6 CNAs January 24, 2025 - 80 residents - 6 CNAs January 25, 2025 - 81 residents - 6 CNAs January 27, 2025 - 81 residents - 6 CNAs January 28, 2025 - 80 residents - 6 CNAs January 29, 2025 - 81 residents - 6 CNAs January 30, 2025 - 82 residents - 6 CNAs January 31, 2025 - 81 residents - 6 CNAs February 6, 2025 - 79 residents - 6 CNAs February 10, 2025 - 79 residents - 6 CNAs The facility provided a list of residents requiring feeding assistance, a list of residents requiring the use of a mechanical lift device for transfers between surfaces, a list of residents requiring substantial/maximal assistance or are dependent on facility staff for toilet hygiene, a facility census, and CNA staffing assignments for February 6, and 10, 2025. The resident census and resident ADL needs were similar on February 6 and 10, 2025. On February 10, 2025 from 6:00 AM to 2:00 PM, V11 (CNA) was assigned to care for 12 residents. Ten of the residents assigned to V11 required staff assistance with toilet hygiene, 4 residents required mechanical lifts for transfers, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V12 (CNA) was assigned to care for 12 residents. Ten of the residents assigned to V12 required staff assistance with toilet hygiene, 3 residents required mechanical lifts for transfers, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V6 (Staffing Coordinator/CNA) was assigned to care for 12 residents. Seven of the residents assigned to V6 required staff assistance with toilet hygiene, and one resident required a mechanical lift device to transfer between surfaces. On February 10, 2025 from 6:00 AM to 2:00 PM, V16 (CNA) was assigned to care for 14 residents. Eleven residents assigned to V16 required staff assistance with toilet hygiene, 4 residents required a mechanical lift device to transfer between surfaces, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V15 (CNA) was assigned to care for 14 residents. Eleven residents assigned to V15 required staff assistance with toilet hygiene, 2 residents required the use a mechanical lift device to transfer between surfaces, and 1 resident required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V17 (CNA) was assigned to care for 15 residents. Eight of the residents assigned to V17 were dependent on facility staff for toilet hygiene, 1 resident required a mechanical lift device for transfers between surfaces, and 1 resident required feeding assistance. The Facility Assessment Tool, updated on 09/20/24 and reviewed by the QAA/QAPI (Quality Assessment and Assurance/Quality Assurance Performance Improvement on 12/11/24 shows the average daily census for the facility is 74 to 78 residents. The Facility Assessment Tool continues to show: Staffing Plan: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Licensed nurses providing direct care: 10 to 17 total number needed or average or range. Nurse aides: 24 to 26 CNAs. The Facility Assessment Tool continues to show: Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time. Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs. For example: Licensed Nurses: Plan: DON full-time days, ADON (Assistant Director of Nursing/Restorative: 1 LPN (Licensed Practical Nurse) Full-time days, MDS: 1 MDS RN (Registered Nurse) full-time days. Wound Care: 1 LPN Full-time days. RN or LPN Charge Nurse: 1 for each shift, 1 nurse per shift is the charge nurse. Staffing ratio 1 LPN or RN for days and evening shift for 20 residents. The Facility Assessment Tool continues to show the staffing ratio of direct care staff (CNAs) to residents is one CNA to ten residents for day and PM shift, and one CNA to 20 residents for night shift. It will be checked against the state requirements as well as evaluated daily based on census and acuity in the facility and per floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheter was anchored to prevent the catheter from being pulled, tugged, and avoid catheter related trauma. This applies to 1 of 1 resident (R64) reviewed for catheter care in the sample of 18. The Findings include: The EMR (Electronic Medical Record) showed that R64, a [AGE] year-old with diagnoses that includes but not limited to type 2 diabetes mellitus, malignant neoplasm of the prostate, history of urine infection with identified ESBL (Extended Beta Lactamase Spectrum) microorganism, osteoarthritis, congestive heart failure, anemia, diabetic neuropathy, lack of coordination and abnormalities of gait and mobility. R64 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 8/2/24, showed that R64 was cognitively intact. On 9/11/24 at 9:45 AM, R64 was complaining of pain and discomfort in his penis area. R64 was observed with an indwelling urinary catheter draining concentrated urine. R64 was noted with moderate amount of fresh blood around the tip of the penis, and noted a fresh blood that had soaked through the incontinence brief that R64 was wearing. The urinary catheter tubing was not secured and was freely dangling in between R64's legs. The urinary catheter was noted to have been pulled out approximately 4 inches due to the color delineation. The catheter tubing that was pulled out showed a very pale light-yellow color and the remaining color of the catheter tubing was darker yellow. V8 (Registered Nurse) confirmed that the urinary catheter was pulled out and it should have been secured and anchored with a strap to his inner thigh prevent the catheter from being pulled or tugged and may have caused the bleeding. On 9/11/2024 at 9:30 AM, V3 (Assistant Director of Nursing) said that the indwelling catheter tubing should be secured with an anchor device, to prevent the indwelling catheter tubing from being pulled or tugged and avoid catheter related trauma. The care plan dated 8/3/24 showed that R64 has an indwelling catheter, and goal was to maintain comfort and free from infection. Interventions included assessment and notifying physician for any changes. The undated facility's policy and procedure for urinary catheter care showed that urinary indwelling catheter should be secured with a strap to prevent from being pulled and tugged. The policy also showed that this policy be implemented for the purpose of preventing catheter -associated infections, trauma and to maintain comfort of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer and administer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 3 of 5 residents (R1, R22, and R32) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Informed Consent for Vaccinations dated January 16, 2021, showed R1 consented to receive pneumococcal vaccinations. R1's Immunization Report showed R1 received the PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine) on January 18, 2021. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC guidelines for pneumococcal vaccine timing and R1 should have been offered a second pneumococcal vaccine after receiving the PPSV23. The facility does not have documentation to show R1 was offered or received another pneumococcal vaccine. 2. The EMR showed R22 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including epilepsy, anemia, hyperlipidemia, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. R22's Informed Consent for Vaccinations dated October 18, 2020, showed R22's Resident Representative consented for R22 to receive the pneumococcal vaccinations. R22's Immunization Report showed R22 received the PPSV23 on December 15, 2020. On September 11, 2024, at 1:37 PM, V11 said R22 should have been offered a second pneumococcal vaccine after receiving the PPSV23. The facility does not have documentation to show R22 was offered or received another pneumococcal vaccine. 3. The EMR showed R32 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, long term use of systemic steroids, type 2 diabetes mellitus, and hypertension. R32's Pneumococcal Vaccine Information and Consent dated October 2, 2023, showed R32 consented to receiving the pneumococcal vaccine. R32's Immunization Report showed R32 received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) on June 15, 2012. On September 11, 2024, at 1:37 PM, V11 said R32 should have received a second pneumococcal vaccine since she consented to receiving the vaccine. The facility does not have documentation to show R32 received a second pneumococcal vaccine. The facility's policy titled Pneumococcal Vaccine dated April 2022, showed Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: .7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. The CDC's Pneumococcal Vaccine Timing for Adults dated April 1, 2022, showed For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15 (15- valent Pneumococcal Conjugate Vaccine), PCV20 (20-valent Pneumococcal Conjugate Vaccine)). You may administer one dose of PCV15 or PCV20. Regardless of which vaccine is used (PCV15 or PCV20): the minimum interval is at least one year. Their pneumococcal vaccinations are complete . Pneumococcal vaccine timing for adults who previously received PCV14 but who have not received all recommend doses of PPSV23 . Adults 65 years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant: CDC recommends one dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received. Their pneumococcal vaccinations are complete .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer and administer the COVID-19 vaccine to residents. This applies to 4 of 5 residents (R1, R22, R32, and R39) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Immunization Report showed R1's most recent COVID-19 vaccine was received on September 27, 2022. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC (Centers for Disease Control and Prevention) recommendations for COVID-19 vaccinations. V11 continued to say R1 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R1 was offered the 2023-2024 updated COVID-19 vaccine. 2. The EMR showed R22 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including epilepsy, anemia, hyperlipidemia, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. R22's Immunization Report showed R22's most recent COVID-19 vaccine was received on October 27, 2022. On September 11, 2024, at 1:37 PM, V11 said R22 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R22 was offered the 2023-2024 updated COVID-19 vaccine. 3. The EMR showed R32 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, long term use of systemic steroids, type 2 diabetes mellitus, and hypertension. R32's Immunization Report showed R32's most recent COVID-19 vaccine was the COVID-19 bivalent booster on January 19, 2023. On September 11, 2024, at 1:37 PM, V11 said R32 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R32 was offered the 2023-2024 updated COVID-19 vaccine. 4. The EMR showed R39 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, chronic kidney disease, and peripheral vascular disease. R39's Immunization Report showed R39's most recent COVID-19 vaccination was received on February 18, 2022. On September 11, 2024, at 1:37 PM, V11 said R39 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R39 was offered the 2023-2024 updated COVID-19 vaccine. The facility's policy titled COVID-19 Vaccine Policy dated October 2023, showed Policy: All residents and employees who have no medical contraindications to the vaccine will be offered the vaccine/booster annually to discourage and promote the benefits associated with vaccinations against COVID-19. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (residents' legal representatives); for example, risk factors that have been identified with specific age groups or individuals with risk factors such as allergies or pregnancy. Facility will encourage the COVID-18 vaccinations as per guidelines. Procedure: 1. The vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized . 7. Administration of the vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination . The CDC's COVID-1 Vaccine Information Statement dated October 19, 2023, showed .COVID-19 Vaccine: Updated (2023-2024 Formula) COVID-19 vaccine is recommended for everyone six months of age and older . Everyone 12 years and older should get one dose of an FDA (Food and Drug Administration) approved, updated 2023-2024 COVID-19 vaccine. If you have received a COVID-19 vaccine recently, you should wait at least eight weeks after you most recent dose to get the updated 2023-2024 COVID-19 vaccine .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their water management plan. The facility also failed to follow their policy regarding catheter care to prevent infection and to follow Enhanced Barrier Precautions. The facility also failed to perform hand hygiene and glove changes during provisions of care. This applies to all 70 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated September 9, 2024, showed the facility census was 70 residents. The facility's Water Management Program for Prevention of Legionella Growth dated June 27, 2023, showed Purpose: To identify and reduce the risk of Legionella growth and spread . Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: -The domestic hot water boiler/storage tanks verified to be set between 140 to degrees Fahrenheit. -Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120 Fahrenheit or above. -Eye wash stations will be inspected and flushed weekly. -Ice machines will be inspected and cleaned internally at least monthly and as needed for leakages or contamination. -Cooling tower (if applicable) will be inspected at least weekly to ensure proper functioning and chemical distribution. -Weekly sanitizing of medical devices such as CPAP (Continuous Positive Airway Pressure), hydrotherapy, etc. Environmental Services will monitor the identified areas of risk per guidelines above and implement corrective action as indicated . On September 10, 2024, at 2:56 PM, V10 (Maintenance Director) said he does not perform weekly checks and record the temperatures of the hot water boiler/storage tank. V10 continued to say he doesn't flush the eye wash stations weekly. V10 said he checks the flow of the eye wash stations once a month. V1 continued to say he cleans the ice machine every one to two months. V10 said he inspects the cooling tower monthly. The facility does not have documentation to show the temperatures of the hot water boiler/storage tanks and thermostat at the mixing valve was checks at least once weekly. On September 10, 2024, at 3:38 PM, V1 (Administrator) said V10 should be following the facility's water management program for Legionella, including documenting the water temperatures weekly. 2. R48's EMR (Electronic Medical Record) showed R48 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, depression, anxiety disorder, arthropathy, and generalized muscle weakness. R48's MDS (Minimum Data Set) dated June 29, 2024 showed R48 had moderately impaired cognition, was always incontinent of bowel and bladder and was dependent on staff for incontinence care. R48's care plan showed R48 was at risk for incontinence related to inactivity, Alzheimer's disease, confusion, and dementia. The interventions included check and change every two hours and as needed. Staff were to wash, rinse, and dry perineum with each incontinence episode. On September 11, 2024, at 9:15 AM, V4 (Certified Nursing Assistant/CNA) and V5 (CNA) were in the room of R48 and R22 making their beds wearing gloves. R48 was brought back into her room from breakfast. V4 removed her gloves, grabbed a new pair of gloves, and without hand hygiene put on the gloves. V5 finished making V22's bed, removed her gloves, grabbed new gloves, and put on gloves without hand hygiene. V4 placed a gait belt around R48 and V4 and V5 transferred R48 back to bed. R48's pants were removed, and incontinence brief was opened. V5 explained to R48 that she was going to clean her up and change her incontinence brief. V5 used disposable wipes and cleaned all areas of the front perineal area. V5 helped R48 turn onto her left side facing V4 and it was noted she had a small bowel movement. V4 wearing the same gloves used to clean the front perineal area, used disposable wipes to clean the buttocks area. V5 removed her gloves, went to the bathroom, and washed her hands and put on new gloves to apply barrier cream to R48's buttocks. With the same glove used to apply barrier cream, V5 grabbed the clean brief and pulled the brief up in between R48's legs, V4 fastened the brief, V5 removed her gloves and without hand hygiene put on new gloves and fixed R48's covers on the bed. V5 removed her gloves and took the garbage out. V5 came back to the room with a bag for the soiled linen that was laying on the floor. V4 had removed her gloves and set them on the top of a box of gloves, V5 asked V4 to pick up the soiled linen and put in the bag. V4 picked up her gloves off the top of the box of gloves and put them on. V4 then picked up the soiled linen off the floor and placed them into the bag that V5 was holding. V4 removed her gloves and gathered supplies to provide incontinence care to R48's roommate, R22. 3. R22's EMR showed R22's most recent admission date to the facility was May 15, 2021. R22's diagnoses included epilepsy, generalized muscle weakness, overactive bladder, cognitive communication deficit, major depression, and abnormalities of gait and mobility. R22's MDS dated [DATE] showed R22 had moderately impaired cognition, was always incontinent of bladder, frequently incontinent of bowel, and was dependent on staff for incontinence care. R22's care plan showed R22 had the potential for skin impairment related to fragile skin, immobility, and incontinence. Interventions included keep skin clean and dry, use lotion on dry skin. On September 11, 2024 at 9:49 AM, V4 (CNA) and V5 (CNA) had just finished providing incontinence care to roommate R48 and now had prepared to check and change R22. V5 closed the blinds and pulled the curtain in between the two beds. V4 put on gloves, no hand hygiene, placed gait belt on R22 and explained to her what they were going to do. Once R22 was laid down bed, her pants were removed. V4 used disposable wipes and cleaned all area of the front perineal area. V4 turned R22 onto her left side, and without removing her gloves or performing hand hygiene, cleaned the buttocks, wiping from front to back. After cleaning her buttocks V4 removed her gloves, and said she was going to wash her hands in the bathroom. V4 put on new gloves and applied barrier cream to R22's buttocks. V5 grabbed R22's pants and put them on R22 while V4 removed her gloves and without hand hygiene, put on new gloves. V4 helped V5 pull up R22's pants, pull R22 up higher in the bed, and then covered her with her blankets. 4. The EMR (Electronic Medical Record) showed that R64, a [AGE] year-old with diagnoses that includes but not limited to type 2 diabetes mellitus, malignant neoplasm of the prostate, history of urine infection with identified ESBL (Extended Beta Lactamase Spectrum) microorganism, osteoarthritis, congestive heart failure, anemia, diabetic neuropathy, lack of coordination, and abnormalities of gait and mobility. R64 was admitted to the facility on [DATE]. The EMR also showed that R64 was on EBP (Enhanced Barrier Precautions). The MDS (Minimum Data Set) dated August 2,2024 showed that R64 was cognitively intact. On September 9, 2024 at 9:35AM, V7 (CNA) assisted R64 to stand up. While R64 was in a standing position, V7 pulled down R64 pants to check for soiling. V7 assisted R64 back to seating position and said she will get V6 (CNA assigned to R64) to clean R64. V7 did not perform hand hygiene prior to leaving the room and touching R64. V6 came and took R64 to the bathroom. V6 removed the urinary drainage bag from the privacy bag that was hanging behind R64's wheelchair. V6 placed the urinary drainage bag on the floor, and she assisted R64 to get up from his wheelchair and R64 positioned standing behind the toilet seat. V6 wiped R64's penile area with moistened wipes. V6 then left R64's room without performing hand hygiene and V8 (Registered Nurse) returned 5 minutes later. V8 came back to R64's room. V8 then applied an ointment to R64's private area. V8 did not perform hand hygiene. V6 was then noted to step on the urinary drainage bag that was still located on the floor. On September 11, 2024 at 9:30 A.M., V3 (Assistant Director of Nursing) said that R64 was on Enhance Barrier Precaution due to indwelling urinary catheter, history of ESBL and a wound on R64's great toe. V3 said that a gown must be used when V6 and V8 had provided direct care to R64. V3 also said that to prevent infection, it is the facility's practice not to placed urinary catheter drainage bag on the floor. V3 added that staff should have done handwashing/hand hygiene in between providing resident's care, in between care task, task, touching dirty to clean areas and in between gloves changing. 5. On September 9, 2024 at 10:15 A.M., R4 was lying in bed. V6 and V7 (CNAs) were observed providing incontinence care to R4. R4's incontinence brief was soaked with urine. V7 wiped R4's groins, and midline opening of labial folds. V6 wiped R4's rectal area; apply skin barrier, put on a clean brief, fastened the brief; did not changed gloves after the incontinence care and prior to putting clean brief and skin barrier. R4 was then transferred from bed to wheelchair with used of mechanical transfer lift device. V6 and V7 have both removed their gloves, no hand hygiene, then put on a pair of gloves without hand hygiene prior to transferring R4 to the wheelchair. The EMR showed that R4, an [AGE] year-old female with diagnoses of type 2 diabetes mellitus, dementia, and anemia. The undated facility's policy and procedure for urinary catheter care showed that urinary indwelling catheter drainage bag should be off the floor to prevent cross contamination and infection. The undated policy for hand washing/hand hygiene showed hand hygiene be implemented including but not limited to before and after direct contact with residents; before and after handling invasive device such as urinary catheter, and before donning on gloves. The undated policy for Enhanced Barrier Precautions showed to wear PPE (such as gown, gloves, mask) when providing resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident had a care plan to address pain for 1 of 22 residents (R44) reviewed for the development and implementation of a comprehensive care plan in the sample of 22. The findings include: R44's face sheet printed on 11/15/23 showed she was admitted on [DATE] with diagnoses to include, but not limited to, left knee osteoarthritis, cellulitis of left lower limb, pain in right shoulder, and pain in left shoulder. R44's physicians order sheet printed on 11/15/23 showed Acetaminophen-Codeine 300-30mg (milligrams) one tab by mouth two times a day for osteoarthritis, diclofenac sodium external gel 1% apply to skin topically as needed for pain control 4 times a day as needed, Lidocaine pain relieving patch 4% apply to skin topically in the morning for pain control and remove per schedule. R44's Minimum Data Set (MDS) dated [DATE] showed R44 as moderately cognitive impaired. Bed mobility requires limited assistance of one staff, transfers one assist of staff and toileting requires limited assistance with one staff assist. R44 receives scheduled pain medication. R44's Pain assessment dated [DATE] showed R44's pain score as four (4). R44's Care Plan printed on 11/15/23 showed no pain care plan documented. On 11/15/23 at 9:23 AM, R44 said I am doing ok. My pain is always there but they just gave me something. It is there constantly. On 11/15/23 at 9:46 AM, V15 (Registered Nurse) said She (R44) always says pain, pain. But if someone is with her and stays and talks with her, she is fine, there is no pain. She does have a lidocaine patch and she gets Tylenol with codeine twice daily. On 11/15/23 at 10:26 AM, V27 (Social Service Director) said I looked but I didn't see one (pain care plan). I don't do the pain care plan that would be V2 (Director of Nursing/DON). On 11/15/23 at 10:32 AM, V2 (DON) said Yes I do the care plans for nursing. I don't see one for pain (for R44). The facility's policy titled Care Plans, Comprehensive Person-Centered showed 8. the comprehensive, person-centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R70's Face sheet printed on 11/15/23 showed he was admitted on [DATE] with diagnoses to include, but not limited to, fall on same level from slipping, tripping, and stumbling, essential hypertension, osteoarthritis, and gout. R70's Minimum Data Set (MDS) dated [DATE] shows R70 has moderate cognitive impairment. Eating with supervision once the food is placed before the resident. R70's Occupational Therapy notes dated 11/14/23-12/24/23 showed eating: set up or clean up assistance. On 11/14/23 at 9:42 AM, R70 said, I need help with eating I can't raise my arms all the way, I can't open my milk and I drop my food. On 11/14/23 at 12:48 PM, R70 was sitting on the side of his bed at his bed side table attempting to eat his meal. R70 used his right hand to cut sliced potatoes, used a spoon for sliced green beans and the mechanical soft meat. Some green beans fell off the plate and onto the tray. Pieces of potatoes were noted on tray. A blue bowl with an unopened lid remained on the table with a food item inside of the bowl. On 11/14/23 at 12:49 PM, R70 said it's too late now I need someone to help me before I start. On 11/14/23 at 12:59 PM, V10 (CNA) said she asked (R70) if he needed help and he said no. He said he was having difficulty, but he said no. On 11/15/23 at 11:29 AM, V18 (Occupational Therapist/OT) said she is familiar with (R70). We are working with him on both upper extremities. Both shoulders limited with ROM (range of motion), weakness bilateral (both sides). He complains occasionally of pain to his right arm. He has an old fracture to his right hand and the pain is consistent with that. He needs help opening containers and removing the lids from the bowls. On 11/15/23 at 11:40 AM, V21 (CNA) said Yes, I am familiar with (R70). I am taking care of him today. I did pass his trays for him today. If someone does not help him with the lids it could be difficult for him to start eating. He can't get the containers open. The facility's policy titled Assistance with Meals shows residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Based on observation, interview, and record review the facility failed to remove a resident's facial hair and failed to provide set up assistance for meals for 2 of 22 residents (R17, R70) reviewed for activities of daily living in the sample of 22. The findings include: 1. On 11/13/23 at 9:52 AM, R17 was sitting up in her wheelchair. R17 had a mustache and facial hair on her chin and neck. R17 stated I don't like this (and rubbed her chin), and I don't like a mustache either. On 11/14/23 at 8:40 AM, R17 was in her room sitting at the bedside, eating breakfast. R17's facial hair and mustache remained. V8 (Certified Nursing Assistant/CNA) said R17 needs help with activities of daily living. V8 said R17 is supposed to get her face shaved during showers. V8 looked at R17 and stated They must not have done it with her shower over the weekend. R17 doesn't like the hair on her face. I will get the electric razor and take care of it. R17's Minimum Data Set, dated [DATE] shows R17 needs extensive assist of one person for personal hygiene. The undated facility's Shaving Male and Female Residents Policy shows Purpose: To provide cleanliness, comfort, and improved morale. Female residents will be assessed weekly, and assistance provided in accordance with the resident's preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the catheter tubing for an indwelling urinary catheter was kept below the level of the bladder for 1 of 2 residents (R65) reviewed for urinary catheters in the sample of 22. The findings include: R65's Face Sheet printed on 11/14/23 showed he was admitted on [DATE] with diagnoses to include, but not limited to, retention of urine, hypertension, low back pain, and benign prostatic hyperplasia with lower urinary tract symptoms. R65's Physicians order sheet printed on 11/14/23 showed Foley (indwelling urinary catheter) catheter care every shift, monitor urine output via Foley every shift. R65's Minimum Data Set (MDS) dated [DATE] shows R65 is cognitively intact, bed mobility required limited assistance, transfer and toileting required supervision with one-person physical assist for all three. The assessment shows R65 has an indwelling catheter. R65's care plan printed 11/14/23 showed catheter care every shift and as needed. On 11/13/23 at 11:20 AM, R65's catheter bag was hanging on the arm rest of his wheeled seated walker and was above the level of the resident's bladder. Yellow urine was visible inside the tubing along its length. On 11/13/23 at 11:21 AM, R65 said, Look, I have to have it here because it is pulling on my penis, and it may come out. I need it glued to my leg. On 11/15/23 at 09:17 AM, V2 (Director of Nursing) said the urinary catheter should be secured. It should be secured to keep it in place. On 11/16/23 at 11:54 AM, V15 (Registered Nurse) said there is no (backflow prevention) valve on the drainage bags, and you need to keep them below the bladder to keep the urine from going into the bladder. The facility's policy titled Catheter Care, Urinary showed, 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Changing catheters 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: catheter tubing should be strapped to the resident's inner thigh.)

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents were offered and/or received a pneumococcal immunization for 1 of 5 residents (R51) reviewed for immunizations in the sample of 22. The findings include: R51's admission Record dated 11/16/23 shows she was originally admitted to the facility on [DATE] and is [AGE] years of age. R51's Immunization Report dated 11/16/23 shows she last received a Pneumococcal Conjugate Vaccine (PCV13) on 3/23/22. Per current Centers for Disease Control and Prevention (CDC) guidelines, R51 was eligible and recommended for a Pneumococcal Vaccine (PCV20) one year after receiving the PCV13. On 11/14/23 at 2:54 PM, V2 (Director of Nursing/Infection Preventionist) said a resident's vaccination status is assessed on admission and annually. V2 said they offer the Pneumococcal 20 vaccination (PCV20). V2 said she just started reviewing residents' Pneumococcal status. The facility's Influenza and Pneumococcal Immunizations Policy (effective 11/28/12) shows each resident is offered a pneumococcal immunization per CDC recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/13/23 at 12:26 PM, R39's lunch tray was served. R39's lunch tray did not contain milk, pudding, or yogurt. R39 was being assisted to eat and consumed 90% of the meal. R39's meal ticket on the tray showed whole milk with every meal, pudding with meals, yogurt with breakfast and lunch. On 11/14/23 at 8:40 AM, V8 (Certified Nursing Assistant/CNA) was feeding R39 breakfast. There was no yogurt or pudding provided on the meal tray. On 11/14/23 at 12:02 PM, R39 was sitting up feeding herself a few bites of lunch. There was no milk, pudding, or yogurt provided. On 11/15/23 at 9:00 AM, V13 (Dietician) said R39 is supposed to get (fortified cereal) at breakfast, whole milk with meals, pudding at lunch, yogurt at breakfast and lunch, and offered a snack at bedtime. V13 said R39's BMI (Body Mass Index) is 15.5 (underweight) and these supplements are to promote weight gain. V13 said dietary is to provide the supplements and it should be on her meal ticket. R39's Care Plan shows I have diagnosis of late onset Alzheimer's dementia. I consume about 50-75% of meals: I will maintain my weight +/- 5 lbs. by next review, Provide supplements as ordered, Provide diet as ordered, Monitor and document intake every meal, Registered dietician to evaluate and make recommendations as indicated, Monitor and report to MD s/sx (signs/symptoms) malnutrition: emaciation (cachexia), muscle wasting, significant weight loss of 3lb in 1 week, 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. R39's Dietary: Oral/Dehydration/Nutritional assessment dated [DATE] shows gaining weight desired related to underweight Body Mass Index. Current Plan of Care: pudding with meals, yogurt at breakfast and lunch, whole milk at meals. 3. On 11/13/23 at 12:16 PM, R46 was finishing eating lunch. R46 was assisted by staff to eat and had consumed all his pureed meal. There was no pudding provided on the tray. On 11/14/23 at 12:28 PM, R46 was in bed feeding himself lunch. There was no pudding provided on R46's lunch tray. R46's dietary meal ticket showed double portions and pudding tid (three time per day). On 11/15/23 at 9:00 AM, V13 said the goal for R46 is to promote weight gain so he is supposed to get (fortified cereal) at breakfast, pudding with all meals, double portions, (supplement) 4 x day given by the nurse. V13 said R46 is underweight his BMI is 17.1. V13 said the expectation is that the residents should receive these supplements. R46's Dietary: Oral/Dehydration/Nutritional assessment dated [DATE] shows significant weight loss x 3 and 6 months. On (fortified cereal) at breakfast, pudding with meals and double portions. Current nutrition Plan of Care offers kcals and protein to promote weight gain. R46's Care Plan shows provide supplements as ordered. Based on observation, interview and record review the facility failed to put interventions in place for a resident with significant weight loss. The facility also failed to provide ordered nutritional supplements for residents at risk for weight loss. This applies to 3 of 3 resident (R72, R39 and R46) reviewed for weight loss in the sample of 22. The findings include: 1. R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. R72's Weights and Vitals Summary printed on 11/16/23 shows R72's admission weight on 9/18/23 as 139 lbs. (pounds). On 10/26/23 R72's weight was recorded as 128 lbs. (7.91% weight loss in 38 days). R72's Nutrition/Dietary Note written by V13 and dated 10/11/23 states, Increased protein needs related to wound healing as evidenced by stage 2 pressure injury to sacrum. Continue to follow with RD (Registered Dietician) available for consult PRN. The next Nutrition/Dietary Notes was not until 11/8/23 (1 month later) and shows that R72 had a 5.4 % (Significant) weight loss x 1 month. On 11/15/23 at 8:52 AM V13 (Dietician) stated, The weights came in last week, so I was going to see him today. He told me the food is not like home, we got a list of his preferences. He is on (supplements) now. I didn't see him last week because of the COVID outbreak here at the facility but I reviewed his weights and recommended the (supplement) daily. I put a note in on 11/8/23 (2 weeks after the weight loss was found). No one notified me of the weight loss on 10/26. They don't ever notify me. I see them when I come in. I see anyone that triggers for weight loss/gain or any unusual conditions. On 11/15/23 at 9:18 AM V6 (Registered Nurse/RN) stated, We do monthly weights. We notify hospice if the resident is on hospice. V2 (Director of Nursing) lets us know if we need a reweigh. The CNAs (Certified Nursing Assistants) will let me know if a resident is eating less. I don't notify the Dietician directly. We turn in all the weights to the DON or ADON and then they take it from there. On 11/15/23 at 9:29 AM V2 (Director of Nursing) stated, The Staff do the weights monthly. If they need a weekly weight, then they are put in as an order. All monthly weights must be done by the 7th of the month. The Dietician is here every week, and she looks at everything. She has complete access to everything. I don't need to notify her of anything. The facility policy entitled Weights and dated 11/14/12 states, Undesired or unanticipated weight gains/loss of 5%, in 30 days, 7.5% in 3 months or 10% in 6 months shall be reported to the physician, dietician and or dietary manager as appropriate.

Based on interview and record review, the facility failed to test and record the wash and rinse temperatures of their high temperature dishwasher three times a day. This failure has the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS 671 dated 11/13/23 shows there are 68 residents in the facility. During the initial tour of the kitchen on 11/13/23 at 9:33 AM, the facility's Dish Machine Log-High Temp was reviewed for November 2023. No wash or rinse temperatures were recorded under Supper on 11/10/23, 11/11/23, or 11/12/23. On 11/15/23 at 10:05 AM, V17 (Dietary Manager) said she checks the dishwasher temperatures in the morning when she first arrives and before dishes from each meal service are washed. V17 said she will run an empty load first before proceeding to wash dishes in order to verify the temperature is in the correct temperature range. The Dish Machine Log-High Temp dated November 2023 shows, Instructions: Record wash and rinse temperature, and provide initials, three times per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/13/23 at 10:01 AM, V19 (RN) came out of an isolation room that had signs on the door for contact/droplet precaution. She was donned in her isolation gown, gloves, and mask. She removed the gown and gloves on the outside of room door and took them down the hall. V19 did not wash her hands nor sanitize them. She threw the gown and gloves away in her trash on her medication cart. On 11/13/23 at 10:05 AM, V19 said I did not see a trash can inside the room, so I put it here. On 11/16/23 at 8:33 AM, V2 (Director of Nursing) DON said they should dispose of Personal Protective Equipment (PPE) at the door before they come out the room. It is an infection control issue. 11/16/23 at 9:16 AM, V1 (Administrator) said The PPE should be disposed of in the room just before they exit the rooms. That also is potential exposure to others if they touch someone. Based on observation, interview and record review facility failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents. The facility failed to ensure 5 residents (R51, R58, R2, R15, R7) on contact/droplet transmission-based precautions had the required isolation signage outside of their rooms. The facility failed to have an effective system in place to test staff and 5 residents (R68, R48, R61, R23, R60) for COVID-19 during a facility outbreak. The facility failed to ensure COVID negative residents were not exposed to 3 residents (R68, R4, R51) who were COVID positive. These failures resulted in a facility outbreak of COVID-19 which, as of 11/13/23, included twenty-nine positive residents and sixteen positive staff. These failures have the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS-671 dated 11/13/23 shows there are 68 residents residing in the facility. 1. On 11/14/23 at 3:21 PM, V2 (Director of Nursing/DON/Infection Preventionist) said that on Friday, 11/3/23, three residents (R68, R48, and R61) started having a cough and lethargy. V2 said they tested the three residents on 11/3/23 and all three were COVID positive, thus beginning their COVID outbreak. V2 said the three residents were all friends who resided on the first floor. V2 said they did not test staff who cared for R68, R48, and R61 on 11/3/23. V2 said a definitive source was not identified through contact tracing for the COVID outbreak, but speculated the three residents got it from their church group the previous Sunday (10/29/23). V2 said she became ill over the weekend of 11/4/23 and 11/5/23 and tested positive for COVID on 11/6/23. V2 said the nurses tested all residents and staff on the first floor for COVID on 11/6/23. V2 said she told V28 (Assistant DON) to put up contact/droplet isolation signs on the doors of the residents being isolated for COVID-19 but was not in the facility to make sure it was done until Monday, 11/13/23. V2 said V1 (Administrator) who was her back-up during her absence, did not implement any COVID testing when she was out with COVID over the weekend of 11/4/23 or 11/5/23. On 11/16/23 at 8:28 AM, V2 said she could not remember testing staff or residents on 11/3/23, but all staff that worked on the first floor within the previous five days of identifying the COVID outbreak on 11/3/23 and all residents on the first floor were tested on [DATE]. V2 said she did not write out COVID tests on 11/3/23, she just checked the residents off on a printed roster. On 11/16/23 at 10:39 AM, V29 (Licensed Practical Nurse/LPN) said R23 and R60 both reside on the first floor. V29 said R23 was at an appointment on 11/3/23 and R60 was out on pass on 11/3/23, so she knows they were not tested on [DATE]. V29 said she only tested two staff members on 11/3/23. V29 said she does not have copies of the tests she performed; she had a resident census sheet she used to check mark. On 11/16/23 at 8:41 AM, V24 (Receptionist) said she always works at the reception desk on the first floor. V24 said she was tested for COVID on the Monday (11/6/23) after she returned to work from the weekend following the identification of the COVID positive residents. V24 said she was not tested for COVID on 11/3/23. On 11/16/23 at 8:57 AM, V15 (Registered Nurse/RN) said she worked on the first floor on 11/2/23 and was the nurse assigned to R68, R48, and R61. V15 said she was not tested for COVID on 11/3/23 and no one contacted her over the weekend. V15 said she came in Monday, 11/6/23, and tested herself for COVID. On 11/16/23 at 9:18 AM, V25 (Housekeeping Director) said he works in the facility Monday through Friday. V25 said he works all over the building and is everywhere helping his staff. V25 said he was not tested for COVID on 11/3/23 but was sick over the weekend (of 11/4/23 and 11/5/23) and that is why he came into the facility on Monday 11/6/23 and got tested for COVID, for which, he was positive. A document titled Second Floor (undated) was provided by the facility and shows what V2 said are the COVID-19 positive residents as of 11/13/23 on the first floor. It lists five residents. A document titled First Floor (undated) was provided by the facility and shows what V2 said are the COVID-19 positive residents as of 11/13/23 on the first floor. It lists 24 residents. A document with the handwritten title Employees (undated) was provided by the facility and shows what V2 said are the COVID-19 positive employees as of 11/13/23 in the facility. It lists 16 staff members. No proof of COVID-19 testing for residents or staff was provided by the facility for 11/3/23. The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) Policy (last revised 6/16/23) shows a broad-based approach to an outbreak is preferred if all potential contacts cannot be identified with contact tracing. The facility's Interim COVID-19 Testing-Residents and Staff Policy provided by the facility (last revised 5/12/23) shows the facility should perform testing for all residents and health care providers identified as close contacts or on the affected unit(s) if using a broad-based approach. The above referenced Policy also shows under Documentation of Testing: Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests. 2. On 11/13/23 at 11:15 AM, R4 stated Thursday (11/2/23) night my roommate (R68) got sick and was sent out to hospital. When he came back, he was Covid positive and put back in the room with me. They did move him over the weekend, but they should not have put him in the same room with me when he came back from the hospital. I was not tested until Monday and then I tested positive. On 11/16/23 at 08:52 AM, V23 (Licensed Practical Nurse) stated I worked the evening of 11/2/23 when R68 was admitted back from the hospital. He went back into his old room. He came really late that night. R68 was still in his room when I finished my shift in the morning. I spoke to V2 (Director of Nursing) and informed her he was admitted back Covid positive. I was not instructed to do anything. R4's Census List shows R4 is and has been in room YYY-B. R68's Census List shows R68 was in room YYY-A until 11/3/23 at 1:41 PM. R4's Minimum Data Set, dated [DATE] shows R4 is cognitively intact. R4's Progress Note dated 11/6/23 at 2:50 PM (Monday) shows R4 tested Covid-19 positive. R68's Progress Note dated 11/2/23 at 11:40 PM shows R68 returned from the hospital positive for Covid-19. The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) Policy dated 6/14/23 shows Place a patient with suspected or confirmed Sars-Cov-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. 4. R51's Physician's Order Sheet dated November 2023 shows that R51 has a diagnosis of Dementia and Alzheimer's Disease. This same form shows that R51 was placed on contact/droplet isolation precautions (for COVID 19) on 11/10/23. On 11/13/23 at 12:09 PM R51 was seen ambulating down the hallway on the second floor. R51's mask was on but down around her chin. R51 was approached by several staff and assisted to pull her mask up but R51 became very agitated and aggressive and would immediately pull the mask back down. R51 was assisted back to her room by the staff, shown where her snacks were in the room and then the door was shut to try to keep R51 in the room. Within 2 minutes R51 was back at the doorway with the door open, then in the hallway and messing with the PPE on the cart outside of her room, then standing in the doorway of the room across the hall from hers. On 11/13/23 at 12:16 PM V11 (LPN/Wound Nurse) stated to Surveyor, We can't restrain her, and she just doesn't understand. Do you have any suggestions for what we can do with her? On 11/13/23 at 1:00 PM R51 was up and out of her room again. Again, messing with the PPE on the cart outside her room. R1 continued walking up and down the hall, stopping to touch carts, other resident wheelchairs and approached 2 Surveyors, attempting to touch the safety glasses of one of the Surveyors. R51 was again approached by staff multiple times and asked to pull her mask up, but then R51 pulls it down again, gets agitated and pulls away from staff. The facility policy entitled Infection Prevention and Control Interim Guideline for Suspected or confirmed Coronavirus dated 6/14/23 states, Place a patient with suspected or confirmed SARS-CoV2 infection in a single- person room. The door should be kept closed (if safe to do so). 5. On 11/13/23 the facility reported that there were 5 residents positive for COVID residing on the second floor of the facility. The residents included R51, R58, R2, R15 and R7. On 11/13/23 at 9:00 AM, all 5 residents' rooms on the second floor had signs posted showing Contact Isolation. There were no Droplet Isolation signs observed on the doors. Around 10:00 AM V2 (Director of Nursing) was observed posting Droplet Isolation signs on the doors. V2 stated, I wasn't here last week so I am just getting the signs up now. All 5 residents on the second floor came up positive for COVID on 11/9/23. The facility policy entitled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus dated 6/14/23 states, Post signs on the door or wall outside of the resident room to clearly describe the type of precaution needed and required PPE.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide and document post (after) fall nursing assessments for a resident who sustained an unwitnessed fall with injury in accordance with their policy. This failure resulted in a delay in obtaining medical treatment for a resident with a displaced fracture of the leg bone and contusion of the forehead and eye orbit. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was re-admitted to the facility on [DATE], and discharged to the local hospital on July 11, 2023. R1 had multiple diagnoses including Dementia with psychotic disturbance, glaucoma, hypertension, atherosclerotic heart disease, repeated falls, and cognitive communication deficit. R1's most recent fall risk assessment dated [DATE], showed R1 was at high risk for falls. R1's MDS (Minimum Data Set) dated April 18, 2023, showed R1 had severe cognitive impairment, required extensive assistance with bed mobility and transfer, did not walk, and was dependent on staff for locomotion. R1 also required extensive assistance of 1 for dressing, personal hygiene and eating. R1 was always incontinent of bowel and bladder. R1's actual fall care plan-initiated December 6, 2022, with goal revised on June 2023, showed interventions included to Monitor/document/report PRN (as needed) x 72 hours to MD for s/sx. (Signs and symptoms) pain, bruises, changes in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation. R1's EMR showed on July 9, 2023, at 6:30 PM, R1 was found lying on the floor with abrasions to the forehead, under eye and right knee. There was no documentation of any range of motion assessment for R1, or an evaluation for possible injuries to the head, neck, spine, and extremities. R1's EMR showed there were no nursing assessment progress notes on July 9, 2023-night shift (11:00 PM-7:30 AM) and July 10, 2023-day shift (7:00 AM-3:30 PM). R1's EMR showed no documentation regarding a range of motion assessment for any extremity at the time of the fall on July 9, 2023, until transfer to the hospital on July 11, 2023. R1's vital signs record showed vital signs were not documented on July 10, day, evening and night shift or July 11, 2023, day shift. On July 20, 2023, at 9:30 AM, V34 (LPN-Licensed Practical Nurse) stated that she worked on July 10, 2023, day shift and was assigned to R1. V34 stated she did not receive a shift report from V7 (LPN) when coming on duty. V34 stated throughout her shift she was not aware of R1's fall the previous evening and did not do a post fall assessment or neuro checklist on R1 during her shift. On July 18, 2023, at 3:36 PM, V33 (LPN) stated she worked on July 10, 2023, on the evening shift (3:00 PM to 11:30 PM) and was assigned to R1. V33 stated she did not receive a shift report from V34 (LPN) when she came on duty and did not know of R1's fall from the previous day. V33 stated R1 slept in her bed until around 6:30 PM when V33 woke R1 up to take her medication. V33 then noticed R1 had a black eye and bruising to the right side of her face and V33 checked R1's EMR and discovered that R1 had fallen the day before. V33 stated she did not do neuro checklist form in EMR for her shift. V33 also stated she was unsure of what to do for follow up after a resident had a fall. V33 stated she made a late entry progress note for the shift (July 10, 2023, evening shift) on July 12, 2023, when the Supervisor told her how to do it. On July 17, 2023, at 2:31 PM, V6 (RN-Registered Nurse) stated she became aware that R1 had a femur fracture on July 11, 2023, at 9:00 AM when she took the radiology results from the fax machine. V6 further stated R1's left knee was swollen. On July 17, 2023, at 10:33 AM, V9 (LPN) stated she was with V2 (DON-Director of Nursing) on July 11, 2023, in R1's room prior to R1's transfer to the hospital. V9 stated R1's left knee was really swollen and her leg was in a flexed positioned, and her leg looked as if the bone was out of place. V9 also noted there was a break in the skin on the outside of the left knee and it looked as if the bone was protruding through the skin. On July 18, 2023, at 11:18 AM, V2 (DON) stated, on July 11, 2023, V9 (LPN) informed me regarding the small hole on the side of left knee that was described as a bone protruding through the skin. V2 stated at the time of the fall there was an abrasion to the knee, and it is the left knee, the same leg as the one that was fractured. R1's Emergency Department Physician Report dated July 11, 2023, showed R1 had facial hematoma on the right forehead and right upper eyelid. R1 also had left knee deformity with one centimeter skin opening with bone protrusion. R1's hospital record progress note dated July 11, 2023, by V36 (Physician, orthopedic surgeon) showed R1 had an open left distal femur fracture that likely occurred July 9, 2023, two days prior. V36 recommended urgent I&D (incision and drainage) of open fracture site in OR (operating room) with application of knee spanning external fixator. On July 19, 2023, at 4:51 PM, V21 (R1's Physician) stated he relies on the facility nurses to inform him regarding a resident's injury as the nurses are his eyes and ears. V21 further stated he expects nurses to perform neuro checks and nursing assessments for residents who experience an unwitnessed fall or hit their head. V21 stated he did not receive any information regarding injury to R1 until July 11, 2023, at 3:30 AM, via text and he ordered an X-ray of the left knee due to report of the knee swelling. V21 also stated had he been told that R1 had an unwitnessed fall from her wheelchair onto her face that resulted in facial bruising on July 9, 2023, V21 would have ordered to send R1 to the hospital immediately. On July 19, 2023, at 10:38 AM, V2 (DON) stated the expectation following a fall with injury is for documentation of assessment of the resident for 72 hours. When asked if staff is expected to document the assessment each shift V2 stated I hope so. The facility's document titled Falls:, undated, indicated .9. Follow up 72 Hours Post Fall with Neuro checks, Vitals, changes in ROM (range of motion) or LOC (level of consciousness). The facility's policy titled Falls -Clinical Protocol dated March 2018 indicated in paragraph 2, . the nurse shall assess and document /report the following: a. vital signs, b. Recent injury especially fracture or head injury, c. Musculoskeletal function, observing for changes in normal range of motion, weight bearing, etc., d. Change in cognition or level of consciousness e. neurological status f. pain The facility's policy titled Neurological Assessment dated October 2019, indicated under general guidelines section that neurological assessments are to be completed 1. b. following an unwitnessed fall, and 2. When assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure (the difference between systolic and diastolic pressures) This may be indicative of increasing intracranial pressure (ICP).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure newly hired employees received education on the facility's abuse policy and prevention program in a timely manner, resulting in an employee witnessing alleged abuse of a resident and not reporting the alleged abuse for approximately 17 hours. This failure has the potential to affect all 75 residents residing in the facility. The findings include. The Facility Data Sheet dated July 17, 2023, shows the facility census as 75 residents. On July 19, 2023, at 11:21 AM, R8 was lying in bed in his room. No injuries or bruising were visible on R8. Due to his cognitive status, R8 was unable to recall events from June 27 or 28, 2023. The EMR (Electronic Medical Record) shows R8 was admitted to the facility on [DATE]. R8 has multiple diagnoses including, adult failure to thrive, anemia, rectal cancer, hypertension, lack of coordination, and cognitive communication deficit. R8's MDS (Minimum Data Set) dated February 28, 2023, shows R8 has moderate cognitive impairment, requires extensive assistance with toilet use, limited assistance with personal hygiene, supervision with bed mobility, transfers between surfaces, locomotion, dressing, and eating, and can independently walk in the room. R8 is frequently incontinent of urine and has a colostomy. The facility's undated Abuse Investigation Report shows V17 (Administrator in Training) was notified on June 28, 2023, by V14 (Housekeeper), that V14 observed V13 (CNA-Certified Nursing Assistant) providing care to R8 while V14 was cleaning the hallway. V14 reported [V13] was rough with care. On July 18, 2023, at 3:10 PM, V16 (Maintenance Director) translated for V14 (Housekeeper). V16 said V14 does not speak English. V14 (Housekeeper) said she was working at the facility on June 27, 2023, at approximately 3:00 PM. V14 said she was working in the hallway outside of R8's room and saw V13 (CNA) being rough with the resident while providing care and verbally inappropriate when speaking to R8. V14 said she had direct visual sight of R8 and V13. V14 said she did not report the alleged abuse to V17 (Administrator in Training) until June 28, 2023, at approximately 8:00 AM. V14 said she was not sure what procedure to follow and spoke to a fellow coworker the following day, on June 28, 2023, who encouraged her to report the alleged abuse. V14 said she was upset after observing the rough handling of the resident, and was scared to report the abuse to anyone, and feared retaliation if she reported V13 (CNA) to administration. Due to the delay in reporting alleged abuse, V13 (CNA) continued to work in the facility and care for residents on June 27, 2023. V13's timecard for June 27, 2023 shows V13 worked from 1:51 PM to 10:00 PM. On July 18, 2023, at 3:10 PM, V14 (Housekeeper) continued to say, as of July 17, 2023, she had not received abuse training since her date of hire on June 5, 2023. On July 18, 2023, at 3:10 PM, V16 (Maintenance Director) said he is the supervisor for V14 and had been asked multiple times by Human Resources to provide abuse training to V14 (Housekeeper) because V14 does not speak English and requires a translator. V14 said he had been busy and had not been able to provide abuse training to V14 as of July 17, 2023, at 3:10 PM. V16 continued to say, [V14] has worked here for about 90 days, I think. The lady who does our training or orientation does not speak Spanish, so I must do the training. We do not have a Spanish version of the training materials or the employee handbook. [V17] (Administrator in Training) has brought this up to me, that I need to go through the handbook with [V14], but I have not had a chance. On July 20, 2023, at 8:34 AM, V16 (Maintenance Director) said, [V14] (Housekeeper) has worked on all floors of the facility. For the most part, the housekeeping staff are assigned to one floor, but I can tell you she has worked on both floors of the facility. On July 19, 2023, at 12:13 PM, V17 (Administrator in Training) said, Abuse training has to be completed before the staff work on the floor. The Maintenance Director was supposed to train her (V14) (Housekeeper) on abuse. It is our expectation they go through abuse training before they work on the floor. On July 19, 2023, at 12:13 PM, V1 (Administrator) said, [V17] (Administrator in Training) and I are not sure how [V14] (Housekeeper) got through the cracks. On July 20, 2023, at 10:09 AM, V17 (Administrator in Training) said staff sign the abuse training acknowledgement form at the time they receive abuse training. V17 continued to say dietary aides work in the kitchen and leave the kitchen to deliver food carts to the resident floors. V17 also said activity aides work with residents all over the facility. The facility's personnel files show the following facility staff members, their date of hire, and the date of the staff's signed acknowledgement of abuse training: V14 (Housekeeper) - DOH (Date of Hire): June 5, 2023. Abuse Training signed acknowledgement: July 18, 2023. V22 (CNA) DOH: May 23, 2023. Abuse Training signed acknowledgement: June 27, 2023. V23 (CNA/AA-Activity Aide) DOH: June 19, 2023. Abuse Training signed acknowledgement: June 27, 2023. V24 (AA) DOH: June 19, 2023. Abuse Training signed acknowledgement: June 27, 2023. V25 (DA-Dietary Aide) DOH: June 30, 2023. Abuse Training signed acknowledgement: July 19, 2023. V8 (CNA) DOH: March 11, 2023. Abuse Training signed acknowledgement: May 4, 2023. V10 (CNA) DOH: April 10, 2023. Abuse Training signed acknowledgement: April 25, 2023. V11 (CNA) DOH: April 11, 2023. Abuse Training signed acknowledgement: April 25, 2023. V26 (DA) DOH: June 17, 2023. Abuse Training signed acknowledgement: June 27, 2023. V27 (Housekeeping) DOH: March 15, 2023. Abuse Training signed acknowledgement: April 25, 2023. V28 (DA) DOH: March 14, 2023. Abuse Training signed acknowledgement: April 27, 2023 V29 (Housekeeping) DOH: March 31, 2023. Abuse Training signed acknowledgement: April 26, 2023. V30 (DA) DOH: March 15, 2023. Abuse Training signed acknowledgement: May 2, 2023. V31 (DA) DOH: March 27, 2023. Abuse Training signed acknowledgement: April 27, 2023. V32 (Housekeeping) DOH: April 1, 2023. Abuse Training signed acknowledgement: May 10, 2023. V33 (LPN-Licensed Practical Nurse) DOH: May 8, 2023. Abuse Training signed acknowledgement: May 29, 2023. Facility timecards for V8, V10, V11, V14, and V22-V33 show those staff members worked in the facility between their date of hire and the date they signed the abuse training acknowledgement form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to immediately report an allegation of abuse resulting in an employee witnessing alleged abuse of a resident and not reporting the alleged abuse for approximately 17 hours. This failure has the potential to affect all 75 residents residing in the facility. The findings include. The Facility Data Sheet dated July 17, 2023, shows the facility census as 75 residents. On July 19, 2023, at 11:21 AM, R8 was lying in bed in his room. No injuries or bruising were visible on R8. Due to his cognitive status, R8 was unable to recall events from June 27, or 28, 2023. The EMR (Electronic Medical Record) shows R8 was admitted to the facility on [DATE]. R8 has multiple diagnoses including, adult failure to thrive, anemia, rectal cancer, hypertension, lack of coordination, and cognitive communication deficit. R8's MDS (Minimum Data Set) dated February 28, 2023, shows R8 has moderate cognitive impairment, requires extensive assistance with toilet use, limited assistance with personal hygiene, supervision with bed mobility, transfers between surfaces, locomotion, dressing, and eating, and can independently walk in the room. R8 is frequently incontinent of urine and has a colostomy. The facility's undated Abuse Investigation Report shows V17 (Administrator in Training) was notified on June 28, 2023, by V14 (Housekeeper), that V14 observed V13 (CNA-Certified Nursing Assistant) providing care to R8 while V14 was cleaning the hallway. V14 reported [V13] was rough with care. On July 18, 2023, at 3:10 PM, V16 (Maintenance Director) translated for V14 (Housekeeper). V16 said V14 does not speak English. V14 and V16 said V14 had not received abuse training since her date of hire on June 5, 2023. V14 (Housekeeper) said she was working at the facility on June 27, 2023, at approximately 3:00 PM. V14 said she was working in the hallway outside of R8's room and saw V13 (CNA) being rough with the resident while providing care and verbally inappropriate when speaking to R8. V14 said she had direct visual sight of R8 and V13. V14 said, [V13] entered the room and saw the resident being upset because the CNA did not address the situation fast enough. [R8] was upset because he wanted his colostomy bag changed. V14 continued to say she saw the CNA going through R8's room being upset herself, and V13 and R8 had an angry discussion. V14 felt the CNA was being too rough taking the colostomy bag off the resident, and the resident was screaming and got combative with the CNA. V14 said she did not report the alleged abuse to V17 (Administrator in Training) until June 28, 2023, at approximately 8:00 AM. V14 said she was not sure what procedure to follow and spoke to a fellow coworker the following day, on June 28, 2023, who encouraged her to report the alleged abuse. V14 said she was upset after observing the rough handling of the resident, and was scared to report the abuse to anyone, and feared retaliation if she reported V13 (CNA) to administration. Due to the delay in reporting alleged abuse, V13 (CNA) continued to work in the facility and care for residents on June 27, 2023. V13's timecard for June 27, 2023, shows V13 worked from 1:51 PM to 10:00 PM. On July 20, 2023, at 8:34 AM, V16 (Maintenance Director) said, [V14] (Housekeeper) has worked on all floors of the facility. For the most part, the housekeeping staff are assigned to one floor, but I can tell you she has worked on both floors of the facility. On July 19, 2023, at 12:13 PM, V17 (Administrator in Training) said, It became clear to me, after [V14] (Housekeeper) reported the abuse allegation on June 28, 2023, that she had not reported the abuse allegation immediately, and had reported it late to me. The staff are supposed to report abuse immediately. The facility's undated Internal Reporting Requirements and Identification of Allegations Policy shows: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.

Based on observation, interview, and record review the facility failed to provide care in a dignified manner for 1 of 4 residents (R34) reviewed for resident rights in the sample of 22. The findings include: On 2/7/23 at 9:37 AM, R34 was sitting up in her wheelchair. The surveyor asked R34 how she was feeling. R34 stared at the floor and stated, Not too good today. I didn't sleep good last night. I got caught in my bed and couldn't get any help. I had the blankets all wrapped around my feet and arms. I turned my call light on, but no one came. I could hear them (the staff) talking and laughing out there (pointed out her room door. R34's room is located next to the nurses' station with a hallway between R34's room and the desk.). No one was coming, so I started yelling. I kept yelling and shouting Help! I need help! It was over an hour. I know it was because I timed it. This is not the first time this has happened to me, but it's the first time I'm complaining about it. I was so frustrated. It was just awful. It's bad enough that I have to be in a place like this. It's so frustrating that I'm so weak that I can't even get out of my own blankets. Then I turn on my call light and no one comes to help me. I just can't see how they couldn't hear me, when I can hear them talking and laughing. Finally, I found something on my table and started banging it on the table. They still didn't come for a while. The whole thing was over an hour because I was watching the clock. I needed to change my position in bed, but I was all wrapped up in my blankets. I couldn't move myself. My back was hurting pretty bad, but everything hurt because I was stuck in the same position for so long. I'm so glad I told you about it. R34 continued to carry on a conversation about other aspects of her care at the facility, but continued to return to the events of that morning. R34's call light was lying on the bed, out of her reach. On 2/8/23 at 12:43 PM, R34 was in her room after the noon meal. R34 brought up the incident again and repeated the details, as described above. On 2/9.23 at 8:40 AM, R34 was in her room eating breakfast. R34 stated, I haven't had any more issues at night, like I told you about. There were so many other times that it took too long to get help, but I never talked about it. I'm so glad I told you because I was upset and it seems to be better now. R34 described the incident in detail again. The details were the same, as described on 2/7/23. R34's Face Sheet dated 2/8/23 showed diagnoses to include, but no limited to: encephalopathy; CHF (congestive heart failure); diabetes; unspecified mood disorder; pneumonia; dysphagia; abnormalities of gait and mobility; lack of coordination; abnormal posture; and cognitive communication deficit. R34's facility assessment dated . 1/17/23 showed R34 was cognitively intact; had no behaviors; required extensive assistance for bed mobility, transfers, toilet use and personal hygiene. On 2/9/23 at 8:56 AM, V10 (LPN) said R34 is able to make her needs known. R34 is alert and oriented, but can be forgetful. She is able to stand, but needs assistance from at least one staff member. R34 will use her call light when she needs something. I've never heard her yelling or hollering out. She does get concerned about things, like today she has an appointment and she's anxious about being late or missing it. R34's room is close to the nurses' station and this hall isn't very long. If R34 was yelling or hollering out, then the staff should be able to hear her. V10 said if R34 was hollering or yelling, then I would check on her right away because that's not normal for her. On 2/9/23 at 10:28 AM, V2 (Director of Nursing - DON) said R34 hasn't been at the facility very long. The surveyor described R34's concern with V2, DON. V2 said she was not aware of that happening, but her room is close to the nurses' station. They should be answering the call lights in a timely manner and if R34 was hollering, then the staff should be able to hear her. The facility's undated Resident Rights Packet showed, As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to dignity and respect: .You facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life . You rights to safety: . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who needs extensive assistance of one staff member during meals was provided the lunch meal and assisted in a timely manner for 1 of 2 residents (R11) reviewed for activities of daily living (ADLs) in the sample of 22. The findings include: R11's admission Record, printed by the facility on 2/8/23, showed she had diagnoses including dementia, congestive heart failure, dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), muscle weakness, protein-calorie malnutrition and cognitive communication deficit. R11's Order Summary Report, provided by the facility on 2/9/23, showed an order for general/regular diet of mechanical soft consistency texture (foods broken down into smaller pieces or that are softer, making them easier to chew), pleasure feeds as tolerated with aspiration precautions. The Order Summary Report showed R12 was on Hospice care. R11's facility assessment dated [DATE] showed she had severe cognitive impairment (BIMS score of 6 on the brief interview of mental status tool used to determine cognitive level). The facility assessment showed R12 required extensive assistance of one staff member physically assisting her when eating. R11's care plan (no date on care plan received) showed she had impaired cognitive function or impaired thought processes related to dementia, difficulty making decisions, and short-term memory loss. R11's ADL (activities of daily living) care plan (no date) showed she has an ADL self-care deficit related to a stroke. The ADL care plan does not address R11's required needs during meals. R11's care plans showed she had a history of unplanned weight loss and the goal was that she would consume 75% of two or three meals a day. R11's care plans showed she had a potential nutritional problem related to diet restriction of mechanical soft diet. Interventions in place were to Provide, serve diet as ordered. Monitor intake and record every meal. Pleasure feed as tolerated with aspiration precautions. On 2/7/23 at 12:50 PM, V15 (Certified Nursing Assistant-CNA), V16 (Licensed Practical Nurse-LPN) and V17 (Resident Care Assistant-RCA) were collecting trays from resident rooms after the residents were finished eating. V15-V17 were placing the trays back in the tray cart. V15 was asked if R11 was going to be provided with a tray and assisted for the lunch meal. V15 said Oh, hasn't anyone fed her yet. V15 went to the tray cart and got R11's tray. There were 12 trays in the cart. 11 of them were returned trays, from resident's that had already finished the lunch meal. The other tray was R11's. V15 took the tray to R11's room and started assisting her with her meal. On 2/08/23 at 11:21 AM, V18 (R11's daughter) was feeding R11 a cheeseburger and an orange drink for lunch. R11 was eating well and ate all of the cheeseburger. V18 said the only concern she had with the care R11 receives is that sometimes she will come in and R11's breakfast or lunch tray will still be on the bedside table next to her bed and it is not touched. V18 said the silverware will still be clean and the food is not touched. V18 said she is concerned they (staff) are not feeding R11 sometimes. On 2/9/23 at 9:04 AM, V5 (LPN) said whichever CNA is assigned to a room where the resident needs assistance, or needs to be fed, is the one that is responsible for feeding them. On 2/9/23 at 9:05 AM, The facility's Daily Assignments sheet for 2/7/23 showed V15 was the CNA assigned to R11 on 2/7/23. On 2/9/23 at 9:07 AM, V15 CNA said he was in feeding another resident. V15 said he assumed one of the other CNAs had fed R11 her lunch on 2/7/23. On 2/09/23 at 9:15 AM, V2 (Director of Nursing-DON said whoever is assigned the resident is generally the one that feeds them. V2 said all of the staff help out. V2 said R11 doesn't like anyone helping her eat. V2 said staff should still offer her a tray and assist her with the meal. The facility provided document titled (Facility) Meal Hours showed the lunch meal was from 11:40 AM through 1:00 PM, with the second floor meal times being 11:40 AM through 12:20 PM. The facility's Midnight Census Report, printed by the facility on 2/7/23, showed R11 resided on the second floor of the facility. R11's weight history showed a loss of 2.2 pounds from 12/6/22 through 2/7/23. The facility's policy and procedure titled Assistance with Meals, with a revision date of July 2017, showed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents Requiring Full Assistance: 1. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify an area of pressure prior to becoming a stage 3 pressure ulcer. This applies to one of four residents (R23) in the sample of 22 reviewed for pressure. The findings include: The facility face sheet for R23 shows diagnoses to include dementia, congestive heart failure, type 2 diabetes mellitus and severe protein-calorie malnutrition. The facility assessment dated [DATE] shows R23 to have severe cognitive impairment and requires extensive assistance of one for her bed mobility. The same assessment shows R23 to be at risk for developing pressure ulcers/injuries. On 2/8/2023 at 1:20 PM, R23 was observed receiving wound care to her coccyx area. V3 wound nurse said her wound is not getting any better and not getting any worse. V3 said she (R23) is seen weekly by the wound care Nurse Practitioner and was told her wound would be chronic due to her declining health conditions. V3 said the wound was found on 10/5/2023 and was staged as a stage 3 pressure ulcer. V3 said she expects the staff to inspect her skin during all care and report to her any changes in the skin such as redness or changes in the condition of the skin. V3 said pressure ulcers should be found prior to becoming a stage 3 pressure ulcer. On 2/9/2023 at 9:50 AM, V2 Director of Nursing said she would expect the staff to find a pressure ulcer prior to it becoming a stage 3 . The Nurse Practitioner note dated 10/5/2023 shows a stage 3 pressure ulcer to R23's coccyx. The note shows the wound has healthy tissue present and is 1 centimeter (CM) by 0.5 CM and 0.1 CM deep. The following week on 10/12/2023 the Nurse Practitioner note shows the wound is now covered in slough (dead tissue) and was changed to an unstageable pressure ulcer. The area measured 1.3 CM by 0.7 CM and was 0.1 CM deep and had necrotic (dead) adipose tissue exposed. The facility policy dated July 2017 for prevention of pressure ulcers/injuries shows 4. inspect the skin on a daily basis when performing personal care or ADL's. a. identify any signs of developing pressure injuries i.e. nonblanchable erythema, darkly pigmented skin, inspect for changes in skin tone, temperature and consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/7/23 at 9:37 AM, R34 was sitting in her wheelchair, looking at the floor. R34's overbed table was sitting in front of her with a cup of thickened water. R34 stated, I stay in my room for meals. I don't like my water like this, but they say that I have to because I'm not swallowing right. I love to drink water, but not like this. It's disgusting. But, I do what they tell me to. They don't help me eat. Someone just brings in my tray and drops it off. At 12:20 PM, R34 was sitting up in her wheelchair with her lunch tray in front of her. R34 was eating pumpkin pie with her fork. There were no staff members in R34's room while she was eating. There was a veal steak with gravy, green beans, and dressing with a slice of bread under the insulated lid. R34 stated, I guess we'll see how this tastes later. This pie is really good. After finishing her pie, R34 used her spoon to eat the veal steak. R34 coughed several times while she was eating. As of 12:30 PM, none of the nursing staff assisted R34 with dining or observed her eating. V4 (CNA) and V12 (CNA) were answering call lights and assisting other residents. V10 (LPN) and V9 (RN) were passing medications and documenting in the EMR (Electronic Medical Record). On 2/8/23 at 12:43 PM, R34 was sitting in her room drinking thickened water. R34 stated, The lunch was actually pretty good today. I ate most of it. I always eat in my room. The staff doesn't come in here when I eat. They just bring me the food and come back later to pick up my tray. They never stay in the room with me, while I eat. I know I had my swallowing checked, but I don't remember exactly when. That's why I have to have these thick liquids, because I have a swallowing problem. I had to have a test this morning. The doctor wanted a CT of my chest because I keep coughing when I eat. The doctor seems to think that I still have pneumonia. I feel okay, other than the coughing when I eat or drink. I didn't get my results today, so I guess we'll see what the doctor says when I get the results. On 2/9/23 at 8:40 AM, R34 was sitting in her wheelchair, eating breakfast. R34's plate had scraps of sausage and smears of syrup on it. I just had some delicious pancakes and sausage. I don't like the oatmeal because they never bring me milk. I like milk in my oatmeal. There was not staff present in R34's room. V8 (CNA) and V9 (RN) were in the hallway talking to each other. R34's Facehseet dated 2/8/23 showed diagnoses to include, but not limited to: encephalopathy; CHF (congestive heart failure); diabetes; hypertension; GERD (Gastroesophageal Reflux Disease); unspecified mood disorder; pneumonia; dysphagia (difficulty swallowing); lack of coordination; abnormal posture; and cognitive communication deficit. R34's facility assessment dated [DATE] showed R34 was cognitively intact; had no behaviors; required limited assistance of one staff member for eating; and received a mechanically altered diet. R34's Physician Order Sheet showed, Diet: General/Regular diet - Mechanical soft consistency ., nectar - mildly thick consistency (liquids) . R34's Hospital Therapy Notes dated 1/9/23 showed, Speech Language Pathology Daily Note . SLP Diagnosis: Dysphagia, Oropharyngeal phase . Diet Recommendations: Dysphagia - Advanced/soft to chew. Liquid consistency recommendations: Nectar thick liquids. Support strategies recommendations: Alternating solids/liquids, Small bites/drinks, No straws, slow rate, Upright 90 degrees (1:1 supervision when alert) . Assessment: . Throughout session, pt with delayed swallow initiation. Suspect delayed bolus formation. Pt also observed with need for use of multiple swallows per bolus. Suspect pharyngeal residue present . Recommend pt remain on NDD3/NTL (soft to chew food and nectar thickened liquids) with 1:1 feed and above listed swallow strategies . R34's Hospital After Visit Summary dated 1/11/23 showed R34 was hospitalized from [DATE] - 1/11/23 for multifocal pneumonia. This document showed, Speech Feeding & Diet Consistency Recommendations: .Diet: Dysphagia - Mechanically altered ground (NDD2) . Nectar thick liquids . Alternating solids/liquids, Small bites/drinks, no straws, slow rate, upright 90 degrees . 1:1 supervision . R34's undated Care Plan showed, My name is (R34). I am on a mechanical diet and nectar thick liquid . Interventions: Provide diet as ordered . Provide set-up with meals and fluids only. OR Provide cues and supervision with all meals and fluids. OR Provide assistance as needed for meals and fluids. OR Requires total care with food and fluid intake (The facility should have chose the appropriate option for R34. The care plan is not resident specific) . Monitor, document and report signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth. Refusing to eat, appears concerned at meals . Registered dietician to evaluate and make recommendations as indicated . R34's Speech Therapy SLP Evaluation and Plan of Treatment dated 1/12/23 - 1/25/23 showed R34 had dysphagia. This document showed, .Reason for referral: . (R34) was resident at ALF (Assisted Living Facility), brought to hospital s/p (after) altered mental status and increased weakness. Patient was diagnosed in hospital with metabolic encephalopathy and possible multifocal pneumonia due to aspiration . (1/9/23 VFSS (Video Fluoroscopic Swallowing Study) at the hospital with results recommending mechanical soft and nectar thick liquid diet. Deep penetration noted with thin liquids and no aspiration noted t/o study with any consistencies tested.) . Clinical Impressions/Reason for Skilled Services: Patient presents with moderate/mild oropharyngeal dysphagia which necessitates skilled SLP services for dysphagia to restore oral/pharyngeal function, reduce signs and symptoms of aspiration and develop and instruct in compensatory strategies in order to improve ability to safely swallow without signs/symptoms of aspiration, meet primary nutrition/hydration needs and use strategies/compensatory techniques. Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: aspiration, compromised general health, pneumonia, and malnutrition . R34's SLP Recert, Progress Report & Updated Therapy Plan dated 1/26/23 - 2/8/23 showed, .Patient presents with decreased swallowing function/strength which necessitates skilled SLP services for dysphagia to restore oral/pharyngeal function, reduce signs and symptoms of aspiration and assess/evaluate for safest level of oral intake in order to improve ability to safely swallow without signs/symptoms of aspiration, safely consume highest level of oral intake and use strategies/compensatory techniques . On 2/8/23 at 12:43 PM, V20 (Speech Language Pathologist - SLP) said R34 came from the hospital with multifocal pneumonia related to aspiration. R34 had a video swallow study at the hospital, but has not had a video swallow study at the facility. V20 stated, I do see R34 for Speech Therapy. Initially R34 was seen 5 times a week, beginning 1/12/23. I even did a re-certification for her, so she is still on my services. I spoke with her daughter and she hopes R34 can return to an ALF. R34 is on a mechanical soft diet with nectar thick liquids. She eats in dependently, but staff should be supervising here. She usually eats pretty slow on her own, but she does need verbal cues and reminders. She had a repeat chest X-ray here and she still has pneumonia. I think she's having a CT scan soon. V20 said she has not advanced R34's altered diet since she was admitted to the facility. V20 said R34 still needs more therapy. On 2/8/22 at 1:50 PM, V19 (Dietician) said the speech therapist would be responsible for determining the appropriate diet/liquid texture for a resident. V19 stated, I would expect residents that can't safely feed themselves to get assistance with meals. If a resident had a history of aspiration pneumonia, still had dysphagia, and was on an altered diet, then I would expect the resident to be supervised and/or assisted with meals. On 2/9/23 at 12:28 AM, V2 (DON) said before COVID, most of the residents went to the dining room. It is easier for the staff to supervise the meal, when the residents are in the dining room. Many residents are still leery of going to the dining rooms. We just started opening up the dining rooms for lunch. Everyone still eats breakfast in their rooms. A resident assessed for the need for feeding assistance on admission. Therapy will see them and provide recommendations. There is a list of resident's that need feeding assistance at the nurses' station. V2 stated, If a resident in coughing during meals, then the nurse should assess the resident, notify the doctor, and inform Speech Therapy. If a resident has a history of aspiration pneumonia, then they would need a Swallow Study and we would follow the recommendations. Speech Therapy takes over and follows-up with the resident to determine if it is appropriate to advance a diet. If a resident is coughing at meals and they have dysphagia, that's not good. The food could have gone down the wrong pipe. V2 said the facility did not have a policy for resident's with swallowing precautions. The facility's Assisting the Impaired Resident with In-Room Meals Policy (revised 2013) showed, The purpose of this procedure is to provide the appropriate support for residents who need assistance with eating. Preparation: 1. Review the resident's care plan and provide for any special needs of the resident . 3. On 2/7/23 at 12:44 PM, R65 was sitting in the dining room being fed by facility staff. R65 had a divided plate with pureed food. On 2/8/23 at 9:01 AM, R65 was in her room feeding herself breakfast. R65 was shoveling pureed eggs into her mouth with shaking hands. V8 (CNA) and V9 (RN) were in the hallway talking. There was no staff supervising R65 eat. After the surveyor looked into R65's room, V8 (CNA) stopped into R65's room and asked her if she needed any help. R65 denied the need for help and V8 promptly left the room, leaving R65 to finish her pureed breakfast alone. R65's Facesheet dated 2/9/23 showed diagnoses to include, but not limited to: Alzheimer's Disease, dementia, generalized muscle weakness, depression, and dysphagia (difficulty swallowing). R65's facility assessment dated [DATE] showed R65 had severe cognitive impairment; required extensive assistance from one staff member; and was on a mechanically altered diet. R65's Physician Order Sheet dated 2/9/23 showed, .Diet . General/Regular diet. Pureed consistency texture, Regular (Thin) consistency (liquids). Give magic cup/mighty shake at breakfast per resident and POA preference . On 2/8/23 at 12:48 PM, V20 (SLP) said she does not see R65 for Speech Therapy. On 2/9/23 at 8:56 AM, V10 (LPN) R65 requires feeding assistance. The staff have to help her because she's getting more and more shaky. R65 is on a pureed diet because the family requested it. R65 needs a mechanical soft diet because it's hard for her to eat chewier foods, but the family just decided pureed was better for her. Based on observation, interview and record review the facility failed to supervise a wandering resident while he entered another residents room and failed to supervise residents with dysphagia while eating in their rooms. This applies to three of six residents (R72, R34, R65) in the sample of 22 reviewed for supervision. The findings include: On 2/7/2023 at 9:20 AM, room mates R7 and R38 said a resident in a wheelchair will come into their room and touch their things. R7 said one time she pushed his wheelchair backwards and this resident slapped at her arms. R38 said that same resident slapped at her foot as she yelled at him to leave her room. Both R7 and R38 said this resident would yell and swear at them when they yelled at him to leave their room. R38 said she is [NAME] of him. Both residents identified this resident as R72. R7 and R38 could not say when these incidents happen but it is daily occurrence that R72 opens their door and attempts to come in. Sometimes he comes in and sometimes he just looks in and then shuts the door and leaves. The facility assessment dated [DATE] for R7 shows her to cognitively intact. The facility assessment for R38 dated 12/15/2022 shows her to cognitively intact. On the afternoon of 2/7/2023, R72 was observed wheeling himself up and down the halls. Occasionally R72 would attempt to turn the door knobs of the closed doors on the hallway. On 2/8/2023 and 2/9/2023 R72 was observed with the same behavior. The facility face sheet for R72 shows diagnoses to include Alzheimer's Disease and anxiety. The facility assessment dated [DATE] shows R72 to severe cognitive impairment and uses a wheel chair as a mobility device. On 2/9/2023 at 9:05 AM, V4 Certified Nursing Assistant (CNA) said R72 wanders the halls in his wheel chair and will check the doors along the hall. V4 said he needs redirection to stay out of other residents rooms. V4 said both R7 and R38 are alert and oriented. On 2/9/2023 at 9:15, V5 Licensed Practical Nurse (LPN) said she has witnessed R72 enter other resident rooms and he requires close observation to redirect him away from this behavior. V5 said both R7 and R38 are alert and oriented. On 2/9/2023 at 9:35 AM, V6 Social Service said R72's behaviors include wandering in the halls in his wheel chair. R72 was trying all the doors on the halls and entering other residents rooms. On 2/9/2023 at 9:50 AM, V2 Director of Nursing (DON) said he needs close supervision due to his wandering, and needs redirection if seen entering a residents room to prevent an altercation between the residents. The undated care plan for R72 shows cognitive short term and long term memory problems with an intervention to provide him with the level of supervision that he requires and provide him with assistance in decision making tasks and use task segmentation to support his short term memory deficits . The undated care plan for wandering for R72 shows he wanders aimlessly, significantly intrudes on the privacy of activities. Resident wanders into other resident rooms causing disruption. The interventions for this problem include only: assess for fall risk, distraction from wandering, monitor for weight loss and fatigue and provide structured activities. The facility policy for wandering, unsafe resident dated August 2014 shows the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents. 3. The residents care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide wound care in a manner to prevent cross-contamination for 1 of 4 residents (R12) reviewed for infection control in the sample of 22. The findings include: R12's admission Record, printed by the facility on 2/8/23, showed he had diagnoses including hemiplegia and hemiparesis (paralysis and weakness) following cerebrovascular disease (conditions that affect the blood flow and blood vessels in the brain) affecting his left non-dominant side, other abnormalities of gait and mobility, and lumbago with sciatica (pain and/or numbness and tingling radiating from the lower back (lumbar spine) thighs and buttocks, and may radiate into the legs and feet). R12's Order Summary Report, provided by the facility on 2/9/23, showed the following order: Wound care sacrum-Cleanse with saline, pat dry, apply skin prep, cover with hydrocolloid (a dressing that provides an insulated environment to promote wound healing) in the evening every other day and as needed for wound care. R12's most recent Wound Assessment Details Report dated 2/3/23 showed MASD (moisture-associated skin damage) due to incontinence that measured 3.6 cm (centimeters) x 4.5 cm x 0.01 cm. R12's facility assessment dated [DATE] showed he was cognitively intact and required extensive assistance of two staff members for bed mobility and toileting. The assessment showed R12 required extensive assistance of one staff member for personal hygiene and was dependent on one staff member for bathing. The assessment showed R12 had a limitation in range of motion on one side of his upper and lower extremities. The assessment showed R12 was occasionally incontinent of urine and always incontinent of bowels. The assessment also showed R12 had moisture associated skin damage. R12's care plan, printed 2/8/23 by the facility, showed he is dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility and physical limitations. The care plans showed R12 has an actual ADL (activities of daily living) self-care performance deficit related to impaired mobility associated with left-sided hemiplegia from cerebrovascular disease, and generalized muscle weakness with poor trunk control. The care plan showed R12 required the extensive assistance of one staff member to meet his toileting and incontinence needs. On 2/07/23 at 10:23 AM, V3 (Wound Nurse) said R12 has had a wound on his buttocks off and on since she started a year and 2 months ago. V3 had the supplies in her hand and walked into R12's room. V3 did not wash her hands upon entering R12's room. V3 put on clean gloves and rolled R12 over onto his left side. V3 removed the old dressing. R12 had been incontinent of stool V3 cleaned the stool from R12, then changed gloves. V3 did not wash her hands or perform hand hygiene when she changed the gloves. V3 cleaned the wound on R12's sacral area with saline, then changed gloves again without performing any hand hygiene. V3 applied triad paste (a zinc oxide based paste used in wound care) and a dressing ( (a dressing that provides an insulated environment to promote wound healing). with the gloves still on, V3 touched the remote to R12's bed, R12's covers, picked up R12's urinal and emptied the urinal, V3 then removed the gloves and grabbed her supplies and the bag from the waste can and went to the soiled linen room, touching R12's door knob and the door knob to the soiled linen room. V3 then washed her hands. On 2/07/23 at 10:38 AM, V3 said she should clean her hands before performing wound care and anytime she changes her gloves to prevent cross-contamination. On 2/08/23 at 2:03 PM, V3 said It is important to make sure you keep an area with only superficial skin clean and prevent cross-contamination to help with healing. The facility's policy and procedure titled Wound Care, with a revision date of October 2010, showed Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish a clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Put on exam glove. Loosen tape and remove dressing. 5. Pull [NAME] over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 17. Reposition the bed covers. Make the resident comfortable. The facility's policy and procedure titled Handwashing/Hand Hygiene, with a revision date of August 2015, showed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy showed Procedure. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors 7. Use an alcohol-based hand rub containing at east 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty. b. Before and after direct contact with residents .d. Before performing any non-surgical invasive procedures .g. Before handling clean or soiled dressings, gauze pads, etc. After contact with a resident's intact skin. After contact with blood or bodily fluids. After handling used dressings, contaminated equipment, etc. After removing gloves. the policy showed 9. the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The policy also showed Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.

Based on observation, interview, and record review the facility failed to ensure meal trays were delivered in a manner to prevent cross-contamination. This has the potential to affect all the residents residing in the facility. This findings include: The facility's CMS 672 form dated 2/7/23 showed there are 74 residents residing in the facility. On 2/7/23 from 12:09 PM to 12: 20 PM, the surveyor observed lunch, room tray service on the first floor. Two hot carts were parked and plugged in near the nurses' station. The first floor nurses' station is located at the bend in the hallways, with a resident halls extending from the side and rear of the nurses' station. V4 and V12 (CNAs - Certified Nursing Assistants) were obtaining trays from the hot box, stopping at the beverage cart, and proceeding to the resident rooms with the lunch trays. The slice of pumpkin pie was uncovered on all the resident trays. V12's hair was down and resting on her shoulders and upper back. V4 and V12 (CNAs) walked from the hot boxes (a central location) to deliver room trays down each hall. While walking down the hall the pumpkin pie was open to air and they were passing other staff and residents in the hallway. V4 was delivering room trays to residents on the shorter hallway and V12 was delivering meals to the residents on the longer hallway. At one point, V12 was standing in front of the hot box with the door open. V12 was holding the tray with the pumpkin pie uncovered, when V4 walked up behind her and reached directly over the pumpkin pie, to get pull another tray. On 2/7/23 from 12:18 PM to 12:40 PM, the surveyor observed lunch, room tray service on the second floor. V15 (CNA) and V16 (LPN) were obtaining trays from the hot box and taking them to the residents' rooms. The pumpkin pie was uncovered, as they passed through the hallways with other staff and residents in the hallways. On 2/7/23 at 1:36 PM, V7 (Dietary Manager) said the facility just started re-opening the dining room. So, essentially all the residents still received room trays. V7 denied any residents being on tube feeding. V7 said the dietary department delivers the hot box to the units and the nursing staff passes the trays to the residents. V7 said the food is placed in the hot box, in the kitchen. V7 stated, All the food should be in the dome. We've never covered the desserts before. I'm newer here and we are working on new procedures. The nursing staff should be taking the hot box from room to room, so the tray doesn't travel from one end of the hall to the other. The surveyor described the above observations and V7 replied, It shouldn't be happening that way. The food is at risk for cross-contamination. I will see if we have a policy on that. On 2/9/23 at 11:53 AM, V7 (Dietary Manager) said the facility does not have a food handling or food distribution policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure water temperatures were in a consistent and comfortable range. This applies to all 74 residents residing in the facility. The findings include: The facility census and condition of residents from the #672 dated 2/7/23, shows there are 74 residents residing in the facility. On 2/7/23 at 10:10 AM, in room [ROOM NUMBER] and 152, the water in the bathroom sink was too hot for this surveyor to keep his hand under the stream without discomfort, with just the hot water turned on. On 2/07/23 at 10:10 AM, R55 said, try turning the water on for a minute and sticking your hand in it. R55 said, the water in the bath room is so hot he makes his instant coffee with it. R55 said the coffee he makes is hotter than the coffee the serve at the meals. On 2/07/23 at 10:15 AM, R60 said, when the CNA's (Certified Nursing Assistants) gives him a shower sometimes the water is too hot or too cold, and he'll have to tell the CNA's to adjust it. On 2/7/23 at 10:35 AM, V2 DON (Director of Nursing) was asked to send V13 (Maintenance Director) to the conference room for an interview. V13 came to the conference room with a thermometer (even though a thermometer was not requested) and told this surveyor he was in the process of testing resident water temperatures when he dropped the thermometer in water and now it's not working. V13 said, he will go to the local hardware store to purchase another thermometer. On 2/7/23 at 1:08 PM, V13 said, the water temperature fluctuates based on the time of day, where the room is located, and how long the water has been running. V13 tries to adjust the mixing valve based on what the residents or CNA's are telling him, or based on his weekly water test. On 2/9/23 at 10:00 AM, V8 CNA said, the water temperatures vary widely and he is not sure why. V8 said he has told V13 about it. V8 said, it's important to test the shower water with his hand so the resident is comfortable. On 2/9/23 at 2:40 PM, V2 said, V13 said, it could be a mixing valve issue. R55's 12/8/22 MDS (Minimum Data Set) shows he scored a 15 on his brief interview for mental status, indicating he is cognitively intact. R60's 1/15/23 MDS (Minimum Data Set) shows he scored a 13 on his brief interview for mental status, indicating he is cognitively intact. The same document shows he is totally dependant on the facility staff for bathing. A Policy and Procedure for water temperatures was requested but not received.

Based on interview and record review, the facility failed to verify that a facility-transcribed order for Morphine Sulfate ER (Extended Release) should be scheduled for administration every two hours as needed. This applies to 1 of 4 residents (R1) reviewed for medications in a sample of 4. The findings include: R1's Face Sheet showed R1 was admitted for respite care on 12/30/2022. The Face Sheet showed R1's diagnoses include malignant neoplasm of pancreatic duct, malignant neoplasm of liver, and intrahepatic bile duct and neoplasm pain. R1 was discharged home on hospice on 1/3/2023. The medication list from R1's hospice dated 12/29/2022 shows an order for Morphine Sulfate Extended Release 60 milligrams (mg), two tablets every eight hours and Morphine Sulfate Concentrate solution 20 mg/milliliter (ml), give 0.25 ml (5mg) every two hours as needed. R1's Physician Orders from the facility dated 12/30/2022 showed an order for Morphine Sulfate ER 100 mg tablet by mouth every two hours as needed for pain; and Morphine Sulfate concentrate solution 5mg by mouth scheduled every eight hours for pain. On 2/7/23 at 11:49 AM, V23 (Pharmacist, pharmacy for hospice) stated Morphine Sulfate Extended Release is not typically ordered every two hours as needed and is usually ordered as a scheduled medication because it is extended release for 8-12 hours. V23 stated Morphine Sulfate Concentrate, however, is typically ordered every one to two hours as needed for breakthrough pain instead of scheduled. V23 stated she has not seen an order for Morphine Sulfate ER 100 mg every two hours as needed for pain with Morphine Concentrate 5 mg scheduled every eight hours for pain. V23 stated she would question an order for Morphine Sulfate ER 100 mg every 2 hours as needed because she feels that order is a lot of morphine and a resident could die. V23 stated morphine orders are usually given to hospice patients. V23 stated if she saw an order like that, she would question it and would clarify the morphine order to make sure it is not excessive. On 2/3/2023 at 11:35, V15 LPN (Licernsed Practical Nurse) stated she will clarify order for Morphine Sulfate ER 100 mg orally every 2 hours as needed even if the resident is on hospice because the dose is too high, and overdosing might cause death. She stated that order for Morphine Concentrate 20 mg/ml, 0.25 mg order makes more sense to be given every 2 hours. On 2/3/2023 at 11:38, V16 (LPN) stated she will question order for Morphine Sulfate ER 100 mg orally every 2 hours because she feels that order is a lot and a resident might die. She stated Morphine orders are usually given to hospice patients. She stated she will clarify the order to make sure she is not giving excess doses of Morphine. On 2/3/2023 at 10:30 AM, V13 (RN) stated an order for Morphine Sulfate ER 100 mg every 2 hours is too much. V9 stated she will question the order. V9 stated that Morphine concentrate 0.25 mg is the medication that is usually ordered every 2 hours as needed. V9 stated overdosing with Morphine Sulfate ER 100 mg can lead to death. On 1/31/23 at 2:26 PM, V7 (Hospice LPN) stated that R1 was placed in the facility for respite care and she had cared for him at home previously. V7 stated that upon admission, the facility must have somehow inversed the order for Morphine Sulfate Concentrate and Morphine Sulfate ER. V7 stated she discovered the mix up on her visit on 1/1/2023. Upon discovery of the error, V7 informed V9 RN (Registered Nurse) of the error. V7 stated on 1/1/2023, R1 was unsteady when walking and had some difficulties speaking and swallowing, which was a change from R1's norm. The facility's Administering Medication (revised December 2012) showed .5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observation, interview and record review, the facility failed to ensure R1's morphine was transcribed and administered correctly for his cancer pain. This applies to 1 of 4 residents (R1) reviewed for medication errors in a sample of 4 residents. The findings include: R1's Face Sheet showed R1 was admitted for respite care on 12/30/2022. The Face Sheet showed R1's diagnoses include malignant neoplasm of pancreatic duct, malignant neoplasm of liver, and intrahepatic bile duct and neoplasm pain. R1 was discharged back home on hospice on 1/3/2023. R1's Hospice Coordination Notes Report dated 12/29/2022 (the day prior to facility admission) stated clinicals were faxed to V26 (facility Director of Business Development). On 2/3/2023 at 2:41 PM, V21 (Admissions Coordinator) stated there was an admission packet for R1 which included a medication list. V21 stated once the facility knows an admission is coming, a clinical packet is made and sent to department managers. An email is sent to the Admissions Team, which includes the DON (Director of Nursing), nurse managers, dietary and therapy. The DON or nurse manager are responsible for informing the admitting unit and the packet is given to the nurse on the floor. The medication list in the admission packet included written orders for Morphine Concentrate (20 mg [milligram]/ml [milliliter]), give 5 mg every 2 hours as needed for mild pain and air hunger, and a second order for Morphine ER (Extended Release), give 60 mg every 12 hours as needed for moderate pain. R1's Physician Orders from the facility dated 12/30/2022 showed an order for Morphine Sulfate ER 100 mg tablet by mouth every two hours as needed for pain; and Morphine Sulfate concentrate solution 5mg by mouth scheduled every eight hours for pain. R1's Narcotic Proof of Use for the Morphine Sulfate ER 100 mg showed the medication was given at 5:00 PM and 8:00 PM (three hours apart) on 12/30/2022, 8:00 AM, 12:00 PM (four hours apart) and 6:00 PM (six hours later) on 12/31/22, and at 6:00 AM on 1/1/23. On 1/31/23 at 12:18 PM, V5 (LPN-Licensed Practical Nurse) stated R1 did not come with a written medication list. A late entry Nursing Progress note written by V5 on 1/3/2023 at 10:03 AM (the day of discharge), effective for 12/30/2022 at 15:57 (day of admission) showed On admission spoke with the [Business Name] Hospice nurse who stated the nurse was not able to come in. Verbal orders were given for the medication list also stated she would fax over the med list which I did not receive again called and spoke with the Hospice receptionist and she stated she will have a nurse call me back did not receive a call back on my shift. Verbal meds entered into [Electronic Medical Record System]. On 1/31/23 at 2:26 PM, V7 (Hospice LPN) stated that R1 was placed in the facility for respite care and she had cared for him at home previously. V7 stated that upon admission, the facility must have somehow inversed the order for Morphine Sulfate Concentrate and Morphine Sulfate ER. V7 stated she discovered the mix up on her visit on 1/1/2023. Upon discovery of the error, V7 informed V9 RN (Registered Nurse) of the error. V7 stated on 1/1/2023, R1 was unsteady when walking and had some difficulties speaking and swallowing, which was a change from R1's norm. On 2/7/23 at 11:49 AM, V23 (Pharmacist, pharmacy for hospice) stated Morphine Sulfate Extended Release is not typically ordered every two hours as needed and is usually ordered as a scheduled medication because it is extended release for 8-12 hours. V23 stated Morphine Sulfate Concentrate, however, is typically ordered every one to two hours as needed for breakthrough pain instead of scheduled. The facility's Administering Medications policy (revised December 2012) showed .3. Medications must be administered in accordance with the orders, including any required timeframe and medications received from pharmacy and/or home medications appropriately packaged may be used within the facility.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the state agency. This applies to 1 of 4 residents (R1) reviewed for abuse. The findings include: On 1/24/23 at 9:17 AM, V3 (R1's Concerned Party) said R1 was at the facility for respite care from 12/27/22 through 1/6/23. V3 said on 1/20/23, V10 (R1's wife) called and informed her of an alleged physical abuse while R1 was at the facility. V3 said during R1's stay at the facility, on 1/6/23, V10 (R1's wife) informed the staff at the facility that there was an alleged physical abuse against R1. V3 said R1 was unable to identify the staff but described the staff as female and African American. V3 said on 1/20/23, she informed V2 (DON/Director of Nursing) of the allegation of abuse. On 1/24/23 at 12:03 PM, V2 DON said on 1/6/23 after R1 was discharged from the facility, V10 (R1's wife) called and informed the evening supervisor that a large black woman came into his room, pulled him out of bed and scratched his hand. V2 said she initiated an investigation, reviewed R1's chart, and interviewed staff regarding the allegation. V2 said R1 was seen on 1/3/23 by the hospice nurse and on 1/5/23 by the Nurse Practitioner (NP) and there were no documentation regarding the scratches or alleged physical abuse. V2 said that the nurse that took care of R1 on day of discharge did not see any scratches to R1's hands. V2 said she did not report the allegation of abuse to the state agency because from her investigation, there was no indication that the incident/allegation of physical abuse occurred. V2 said on 1/20/23, V3 (R1's Concerned Party) called and reported the alleged physical abuse again; she initiated another investigation. On 1/24/23 at 12:53 PM, V1 (Administrator) said V2 DON informed him of the alleged physical abuse by an African American staff reported by V10 on 1/6/23. V1 said V2 did an internal investigation and there were no implication that the alleged physical incident occurred. V1 said they did not report the incident to the state department on 1/6/23 because they completed an internal investigation and based on the facts, they did not feel the incident occurred. V1 said V3 called on Friday (1/20/23) and reported the alleged physical abuse incident again, and they reported the incident to state agency, investigations are still ongoing. The facility's policy titled Abuse Investigation and Reporting (Revised July 2017) documents under Policy Statement, All Reports of resident abuse, neglect exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.