**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to report an allegation of abuse to the State Survey Agency within 24 hours of being made aware of a potential abuse allegation from a resident. This failure applied to one resident (R70) reviewed for abuse in a total sample of 35. Findings include: R70 is a [AGE] year-old resident admitted to facility on 02/29/2024 with medical diagnoses including but not limited to: legal blindness, muscle weakness, paroxysmal atrial fibrillation- on a blood thinner, polyneuropathy, essential hypertension, prediabetes, and moderate protein-calorie malnutrition. R70 has a Brief interview mental status (BIMS) score of 14/15 dated 06/04/2024 which means cognitively intact. R70 requires partial/moderate assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene according to minimum data set (MDS) section GG dated 6/4/2024. R70 requires substantial/maximal assistance for shower/bathe self, lower body dressing and putting on/taking off footwear according to MDS section GG dated 6/4/2024. R70 is on an anticoagulant medication. In physical therapy note written by V11 (physical therapy manager) dated 5/27/24 at 01:51 PM reads He (R70) reported that somebody tried to wrench his arm when he was attempting himself to get to the toilet. On 5/27/2024 at 01:56 PM x-ray was completed on R70 left shoulder, complete 2 views. Report documents slightly swollen and c/o (complaint of) pain. Impression: No acute skeletal injuries of the left shoulder. On 06/10/24 at 10:37 AM R70 was interviewed by surveyor in his room. He was alert and oriented to person and place. R70 stated I believe the guy's name is V12 first name. I woke up very early in morning and was very confused and V12 or whatever his name is got all excited because I was out of my bed and calling mommy or help to get help to go to the bathroom. He wrenched my arm. It didn't hurt that day, but it started hurting. I told V11 the next day and they took pictures. V11 is the head of Physical therapy. It happened in March or April. I don't know when the last time I seen him work. I have been putting heat compresses on it. I am on blood thinners. I think the staff rotate shifts. He speaks with an accent. I think he is Filipino. My biggest problem with him is his attitude like he is the boss and doesn't take your side of the story. You can't reason with V12. R70 left upper arm was noted to be purple and yellow almost full length of upper arm to elbow on front side and stated that it is spreading; it doesn't hurt now. On 06/10/24 at 11:46 AM Another surveyor observed bruise on R70 with this surveyor and resident changed story on when it happened. Large bruise ranging from about 1 inch below shoulder to 1 inch above elbow scattered purplish and yellow in color on anterior aspect of left arm. He now says it happened a week ago Sunday. On 06/11/24 at 10:47 AM Interview with V7 certified nursing assistant (CNA). I am a CNA. I saw the bruise on R70's arm yesterday and told V3 (regional director) about it. R70 is independent and I only help R70. R70 did not tell me how that happened, I just reported seeing it. On 06/11/24 at 10:56 AM Interview with V11 (physical therapy manager). V11 stated my therapist (V29) reported to me limitation of motion and a little swelling to left upper arm on 5/27/2024. I did not directly speak with R70 about it that day. I spoke to him the following day regarding this. R70 told me somebody wrenched my arm. R70 couldn't remember who. He told me it happened on the night shift. V29 told me she told the nurse of the arm limited motion and swelling. If someone tells me something that we suspect abuse, we are to report it right away. I told the floor nurse V12 that R70 said somebody wrenched his arm. It was reported already so I am assuming the nurses have it already. It would be considered abuse if somebody wrenches someone's arm in my book. That is exactly what is documented in my notes. On 06/11/24 at 10:58 AM Interview with V3 (regional director) stated investigation is ongoing. V3 provided us with copies of investigation what has been done so far. I am unaware of R70 stating someone wrenched his arm. He did not tell me that yesterday. I will take it one step further with my investigation. On 06/11/2024 V3 presented unusual occurrence report form dated 6/10/2024 documents V7 (CNA) reported discoloration to resident's R70 left upper arm - when asked resident what happened he stated that he got up at night, I was confused. He said that later his arm hurt, they did xray, they told me That it was old man stuff. On 06/11/24 at 12:17 PM V3 (Regional director) notified by surveyor that R70 accused V12 of wrenching his arm. Also asked for update of investigation once she finishes it. On afternoon of 6/11/2024 surveyor was provided with Facility reported incident report for this incident and was told that V12 was suspended pending ongoing investigation. On 06/11/24 at 03:15 PM Interview with V2 Abuse coordinator. When asked how you go about investigation V2 stated immediately report and look at the details of event. It is not reportable if it is witnessed. Avoid abuse, we work as a team we start an investigation immediately. We train staff on abuse and abuse reporting, Staff report to nurse on the floor and myself or director of nursing (DON). Staff must report immediately. When asked why the x-ray was ordered V2 stated we ordered x-ray because resident reported pain. Nurse called doctor and got the order. Morning nurse called doctor and did x-ray. I am not aware of communication between V11 and V12. When asked if therapy staff should have reported this right away V2 stated yes either to me or his supervisor. This resident uses a lot of interesting language to describe something, like yesterday he said I have old man bones. He describes he got up and was looking for something, he thinks it was his mother and got confused and he thinks it was V12 but not sure that V12 was who caught him. My DON is in Italy, and I am unsure if she started an investigation or not. She can start investigation without me .If R70 didn't use the word wrenched, then she may not have. R70 did not fall. I cannot reach DON. We don't see any communication between DON and staff of another investigation started by DON. When asked if this can be, she stated yes, she could have started an investigation on paper and not on the computer. There is a nurses note. I saw the 27th maybe he said something about his knees buckling and nurse got him back to bed. You know you don't lose your balance neatly. So, it is not necessarily graceful, and it prevented a fall. We investigate like crazy. Yesterday we started an investigation just because of the discoloration. Abuse & Neglect Policies/Procedures in Administrative Manual with a revised date of September 2016 received and reviewed on 6/11/2024 reads: V. Internal Reporting Requirements and Identification of Allegations: All employees are required to report any incident, allegation or suspicion or potential abuse or mistreatment they observe, hear about, or suspect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate an investigation in a timely manner for an allegation of abuse for one of one resident (R70) reviewed for abuse in a total sample of 35. Findings include: R70 is a [AGE] year-old resident admitted to facility on 02/29/2024 with medical diagnoses including but not limited to: legal blindness, muscle weakness, paroxysmal atrial fibrillation- on a blood thinner, polyneuropathy, essential hypertension, prediabetes, and moderate protein-calorie malnutrition. R70 has a Brief interview mental status (BIMS) score of 14/15 dated 06/04/2024 which means cognitively intact. R70 requires partial/moderate assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene according to MDS section GG dated 6/4/2024. R70 requires substantial/maximal assistance for shower/bathe self, lower body dressing and putting on/taking off footwear according to MDS section GG dated 6/4/2024. R70 is on an anticoagulant medication. In physical therapy note written by V11 (physical therapy manager) dated 5/27/24 at 01:51 PM reads He (R70) reported that somebody tried to wrench his arm when he was attempting himself to get to the toilet. On 5/27/2024 at 01:56 PM x-ray was completed on R70 left shoulder, complete 2 views. Report documents slightly swollen and c/o (complaint of) pain. Impression: No acute skeletal injuries of the left shoulder. On 06/10/24 at 10:37 AM R70 was interviewed by surveyor in his room. He was alert and oriented to person and place. R70 stated I believe the guy's name is V12 first name. I woke up very early in morning and was very confused and V12 or whatever his name is got all excited because I was out of my bed and calling mommy or help to get help to go to the bathroom. He wrenched my arm. It didn't hurt that day, but it started hurting. I told V11 the next day and they took pictures. V11 is the head of Physical therapy. It happened in March or April. I don't know when the last time I seen him work. I have been putting heat compresses on it. I am on blood thinners. I think the staff rotate shifts. He speaks with an accent. I think he is Filipino. My biggest problem with him is his attitude like he is the boss and doesn't take your side of the story. You can't reason with V12. R70 left upper arm purple and yellow almost full length of upper arm to elbow on front side. States it is spreading. It doesn't hurt now. On 06/10/24 at 11:46 AM Another surveyor observed bruise with this surveyor and resident changed story on when it happened. Large bruise ranging from about 1 inch below shoulder to 1 inch above elbow scattered purplish and yellow in color on anterior aspect of left arm. He now says it happened a week ago Sunday. On 06/11/24 at 10:56 AM Interview with V11 (physical therapy manager). V11 stated my therapist (V29) reported to me limitation of motion and a little swelling to left upper arm on 5/27/2024. I did not directly speak with R70 about it that day. I spoke to him the following day regarding this. R70 told me somebody wrenched my arm. R70 couldn't remember who. He told me it happened on the night shift. V29 told me she told the nurse of the arm limited motion and swelling. If someone tells me something that we suspect abuse, we are to report it right away. I told the floor nurse V12 that R70 said somebody wrenched his arm. It was reported already so I am assuming the nurses have it already. It would be considered abuse if somebody wrenches someone's arm in my book. That is exactly what is documented in my notes. On 06/11/24 at 10:58 AM Interview with V3 (regional director) stated investigation is ongoing. V3 provided us with copies of investigation what has been done so far. I am unaware of R70 stating someone wrenched his arm. He did not tell me that yesterday. I will take it one step further with my investigation. On 06/11/2024 V3 presented unusual occurrence report form dated 6/10/2024 documents V7 (CNA) reported discoloration to resident's R70 left upper arm - when asked resident what happened he stated that he got up at night, I was confused. He said that later his arm hurt, they did xray, they told me That it was old man stuff. On 06/11/24 at 12:17 PM V3 (Regional director) notified by surveyor that R70 accused V12 of wrenching his arm. Also asked for update of investigation once she finishes it. On afternoon of 6/11/2024 surveyor was provided with Facility reported incident report for this incident and was told that V12 was suspended pending ongoing investigation. On 06/11/24 at 03:15 PM Interview with V2 Abuse coordinator. When asked how you go about investigation V2 stated immediately report and look at the details of event. It is not reportable if it is witnessed. Avoid abuse, we work as a team we start an investigation immediately. We train staff on abuse and abuse reporting, Staff report to nurse on the floor and myself or director of nursing (DON). Staff must report immediately. When asked why the x-ray was ordered V2 stated we ordered x-ray because resident reported pain. Nurse called doctor and got the order. Morning nurse called doctor and did x-ray. I am not aware of communication between V11 and V12. When asked if therapy staff should have reported this right away V2 stated yes either to me or his supervisor. This resident uses a lot of interesting language to describe something, like yesterday he said I have old man bones. He describes he got up and was looking for something, he thinks it was his mother and got confused and he thinks it was V12 but not sure that V12 was who caught him. My DON is in Italy, and I am unsure if she started an investigation or not. She can start investigation without me . If R70 didn't use the word wrenched, then she may not have. R70 did not fall. I cannot reach DON. We don't see any communication between DON and staff of another investigation started by DON. When asked if this can be, she stated yes, she could have started an investigation on paper and not on the computer. There is a nurses note. I saw the 27th maybe he said something about his knees buckling and nurse got him back to bed. You know you don't lose your balance neatly. So, it is not necessarily graceful, and it prevented a fall. We investigate like crazy. Yesterday we started an investigation just because of the discoloration. Abuse & Neglect Policies/Procedures in Administrative Manual with a revised date of September 2016 received and reviewed on 6/11/2024 reads: V. Internal Reporting Requirements and Identification of Allegations: All employees are required to report any incident, allegation or suspicion or potential abuse or mistreatment they observe, hear about, or suspect. VII. Internal Investigation of Allegations and Response: Incident or allegation involving abuse or mistreatment will result in an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for abuse for one (R70) of one resident reviewed for abuse in a total sample of 35. Findings include: R70 is a [AGE] year-old resident admitted to facility on 02/29/2024 with medical diagnoses including but not limited to: legal blindness, muscle weakness, paroxysmal atrial fibrillation - on a blood thinner, polyneuropathy, essential hypertension, prediabetes, and moderate protein-calorie malnutrition. R70 has a Brief interview mental status (BIMS) score of 14/15 dated 06/04/2024 which means cognitively intact. R70 requires partial/moderate assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene according to minimum data set (MDS) section GG dated 6/4/2024. R70 requires substantial/maximal assistance for shower/bathe self, lower body dressing and putting on/taking off footwear according to MDS section GG dated 6/4/2024. R70 is on an anticoagulant medication. In physical therapy note written by V11 (physical therapy manager) dated 5/27/24 at 01:51 PM reads He (R70) reported that somebody tried to wrench his arm when he was attempting himself to get to the toilet. On 06/12/24 at 02:37 PM During Interview with V3 and V21 RN. V3 Regional Director stated we do not do abuse risk assessments on residents when they are admitted . Residents have a care plan for behavior or history of abuse or behavior of a resident. We do not do a separate abuse risk assessment; it may be brought up in social history but not as a separate assessment. I will continue to look in the charts, but we do not do an abuse risk assessment on residents when they are admitted . On 06/13/2024 at 09:28 AM V13 (Clerical supervisor and schedule coordinator) stated Per V3, we checked the medical records and do not have abuse care plans or risk assessments at this time for R70. On 06/13/24 at 11:00 AM, during phone interview with V4 (social service consultant), V4 said, I am an outside consultant with them; I have worked at the facility for about seven weeks now. I was hired to do MDS's and updating their care plans. I do not have anything to do with assessments when residents are admitted . I am not aware if there are any abuse risk assessments done on admission. I do not do any of the assessments. I do part of their care plans. When considering an abuse care plan, I ask residents if they have any history of drug abuse, suicidal issues, physical emotional or verbal abuse in the past. I would consider a dementia patient at risk for abuse. I would also consider a blind resident at risk for abuse. Both of those incidents would constitute an abuse care plan if they had definitive cognitive loss. But if resident is blind yes, an abuse care plan should be put in there. I also agree all dementia residents should have an abuse care plan as these residents are at risk for abuse. I just did R70's MDS, so the care plan is the next thing I am working on. I am unaware of any abuse care plan or abuse risk assessments for V70 as I am very part time and I have to go in and review it. Abuse & Neglect Policies/Procedures in Administrative Manual with a revised date of September 2016 received and reviewed on 6/11/2024 reads: Resident Assessment: As part of the resident social history assessment, and the MDS assessments, staff will identify residents with increased vulnerability for abuse, mistreatment or who have needs behaviors that might lead to conflict (i.e., combative behavior, verbal outbursts.) Through the care planning process, staff will identify any problems, goals and approaches, which would reduce the chances of abuse, mistreatment. Staff will continue to monitor the goals and approaches on a regular basis. Comprehensive care plan policy with a revised date of 11/17 reads: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident 7 days after the completion of the comprehensive assessment. 2. The comprehensive care plan is based on a thorough assessment that includes but is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems.

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures by not properly labeling and storing food. This failure applies to all 77 residents in the facility who receive meals from the kitchen. Findings include: On 06/10/2024 from 09:43 AM - 10:20 AM during kitchen observations observed an unlabeled partially closed bag of green beans stored in a freezer; Observed freezer number 5 outside thermometer temperature fluctuating from 4-17 degrees; Observed a large tub of ice-cream in freezer number 5 was soft; Observed 9 unlabeled packs of English muffins, and 9 unlabeled packs of plain bagels stored in the freezer; Observed one pack of raisin bagels with a sell by date of 05/17/2024 stored in the freezer; Observed a large, opened pack of chocolate chip muffins with a use by date of 05/15/2024 stored in the freezer; Observed 3 unlabeled large boxes of muffins stored in the freezer; Observed 2 packs of soft tortillas with a use by date of 02/20/2024 stored in the freezer. Observed a 1.57-pound pack of hamburger buns with a use by date of 03/12/2024 stored in the freezer. Observed five 6lb cans of canned foods stored with undented canned foods in the dry storage area; Observed a separate area for storing dented cans. Observed 2 unlabeled large 20ML bins containing oatmeal stored in the dry storage area. Observed 2 unlabeled 20ML bins containing dry milk powder stored in the dry storage area. Observed refrigerator number 7 with 8 heads of wilted lettuce stored inside. Observed a cart with a cup of coffee, a cup of juice, a bowl of cornflakes, and a partially eaten pastry sitting on the elevator with no staff around. On 06/12/24 at 10:35 AM V17 (Dietary Manager) stated when items are taken out of their original package the printed used by date is placed on the item before placing in the freezer for storage. V17 stated items should have use by dates to ensure consumption before expiring. V17 stated if the use by date of tortillas is February 2024 they are expired and should be discarded. V17 stated if the package date of hamburger buns is March 2024, they are no longer good to consume. V17 stated dented cans should be placed by the door or sent back right away. V17 stated we wouldn't want the dietary staff to use dented cans because they are not safe. V17 stated freezer temperatures should be below zero. V17 stated if ice cream is soft and the freezer temperatures showing higher than below zero this may mean the freezer isn't cold enough which could cause issues with proper storage and contamination. V17 stated the milk powder and oatmeal were delivered last week but they should have a visible date labeled on them. V17 stated if a food cart with a cup of juice, cup of coffee, bowl of cornflakes, and partially eaten pastry is left on the elevator unattended the residents could consume them and there is a risk of contamination, allergy, or possibly swallowing issues. The facility's Food Return/Rejection Policy received/reviewed 06/12/2024 states: Any item which is past the use by date should be rejected. Storage of dry items including all shelf-stable dried foods includes visible labeling. Any canned item without a label should be rejected. Storage of Fresh Fruits and Vegetables including all fresh produce that is either whole or cut should have no wilting. The facility's Policy for Receiving and Storage of Food Items Policy received/reviewed 06/12/2024 states: Upon delivery, food items are to be kept in their original packaging for storage. Once a food item (without a printed expiration date) is removed from the original box or packaging, the item is then to be labeled with the date of delivery.

Based on observation, interview, and record review the facility failed to provide dignity during meal time by standing over a resident while feeding. This failure affected 1 resident (R1) reviewed for dignity in a total sample of 21. Findings include: On 8-1-23 at 12:58 PM, R1 was seated at the table in the main dining room. R1 was being fed dessert by V21 (Activity Aide) who was standing at R1's left side. Noted that there was no chair available for V21. On 8-1-23 at 12:07 PM, V21 (Activity Aide) said he would have sat down if there was a chair and V21 thought standing while feeding a resident is optional. On 8-1-23 at 12:10 PM, V3 (DON) said V21 is a CNA and any staff assisting with feeding should be seated. On 8-3-23 at 12:22 PM, V3 said staff should be sitting while feeding assistance for dignity and comfort of the staff and resident. Feeding Policy (no date) was reviewed. Residents' Rights Booklet (no date) documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation and interview, the facility failed to ensure that 2 residents were free from physical restraints. This failure affected 2 residents (R51 and R57) reviewed for restraints in a total sample of 21. Findings include: On 8-1-23 and 8-2-23, observed R51 and R57 seated in an armed chair (unable to get up from the side of the chair) with their seatbacks against the wall (without space to move backwards) and the table directly in front of the resident (without space to move forward) with other residents seated around the table. The table was noted extending over the resident's lap without the possibility of the resident standing up unless the table was moved forward as witnessed by V5 (Certified Nursing Assistant/CNA), V3 (Director of Nursing/DON), and V22 (Regional Director). On 8-2-23 at 12:11 PM, V6 (Registered Nurse/RN) said a physical restraint prevents a resident from moving freely and physical restraints are not used at the facility. On 8-2-23 at 12:13 PM, V5 (CNA) said physical restraints do not allow a resident to have free movement from the bed or chair. V5 said restraints are allowed with a MD order. On 8-2-23 at 12:15 PM, V3 (DON) said a physical restraint is a barrier that prevents a person from freely moving. V3 said the facility is restraint free unless ordered by MD. V3 said she will adjust the chairs and tables to allow more space for the residents to move their seat backwards from the table. On 8-3-23 at 9:00 AM, R51 and R57 were observed seated at the table with more space from the wall and the seatback of the chair which would allow R51 and R57 more space to move the chair backwards to get up from their chair. Residents' Rights Booklet documents: You have a right to be free from physical or chemical restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to correctly use pressure relieving mattress for residents at risk for skin alteration for three of four residents (R11, R28, R69) reviewed for pressure ulcers in a sample of 21. Findings include: On 08/01/2023 at 10:45AM, during observation, R69 was observed lying on low-air-loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 10:47AM, R11 was also observed lying on low air loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 10:53AM, R28 was also observed lying on low-air-loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 11:10AM, during observation with V3 (Director of Nursing/DON), R69, R11 and R28 were again observed under the same circumstances. On 08/01/2023 at 11:10AM, V3 said that there should only be one flat sheet between the resident and the mattress if they are on a low air loss mattress because if there are multiple layers of linen between the resident and the mattress, the benefit of the low-air-loss mattress cannot be maximized. R69's Order Summary Report dated 08/03/2023 indicated admission date 3/15/2023, and diagnoses including unsteadiness on feet, other lack of coordination, and other abnormalities of gait and mobility. R69's Braden Scale for Predicting Pressure Sore Risk (pressure ulcer risk assessment) dated 7/27/2023 indicated score of 16 which is categorized as at risk. R69's care plan revised on 3/15/2023 indicated R69 is at risk for alteration in skin integrity and interventions include R69 needs pressure relieving/reducing mattress to protect skin while in bed. Minimum Data Set (MDS) dated [DATE] indicated R69 is totally dependent with locomotion on and off unit and uses wheelchair as mobility device. R11's Order Summary Report dated 08/03/2023 indicated admission date 02/04/2021, and diagnoses including unsteadiness on feet, other lack of coordination, and restless leg syndrome. R11's pressure ulcer risk assessment dated [DATE] indicated score of 17 which is categorized as at risk. R11's care plan revised on 7/12/2023 indicated R11 is at risk for skin breakdown and interventions include pressure relieving mattress when in bed. MDS dated [DATE] indicated R11 is totally dependent with locomotion off unit, needs extensive assistance with locomotion on unit, and uses wheelchair as mobility device. R28's Order Summary Report dated 08/03/2023 indicated admission date 4/29/2021, and diagnoses including unsteadiness on feet, other lack of coordination, other abnormalities of gait and mobility, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R28's pressure ulcer risk assessment dated [DATE] indicated score of 14 which is categorized as at risk. R28's care plan revised on 10/27/2022 indicated R28 is at risk for skin breakdown and interventions include pressure relieving mattress when in bed. MDS dated [DATE] indicated R28 is totally dependent with locomotion on and off unit and uses wheelchair as mobility device. Facility Documents: Title: Braden Scale for Predicting Pressure Sore Copyrighted 2001 At Risk (score of 15-18) - Pressure-reduction support surface if bed- or chair-bound Title: Manufacturer's Manual Copyright 2014 Intended Use: This product intends to help reduce the incidence of pressure ulcers while optimizing patient comfort.

Based on observation, interview and record review, the facility failed to follow its standard precaution policy for one resident (R59) of twelve residents, observed for infection control practices during dining observation in a sample of 21 residents. Finding include: On 8/2/23 at 12:00pm, during dining observation, V9 (Activity Aid) was observed picking R59's fruit cup from the floor. V9 failed to perform hand hygiene after picking up R59's fruit cup from the floor. V9 proceeded to open the fridge to look for an extra fruit cup, V9 then received a new fruit cup from V8 (Food Service Supervisor) without washing her hands or applying hand sanitizer. On 8/2/23 at 12:00pm, V9 stated, I should've washed my hands or used hand sanitizer after picking the cup from the floor. On 8/2/23 at 12:05pm, V8 (Food Service) stated that staff should clean their hands after picking an object from the floor. Facility policy titled Standard Precautions revised 2/2014 reads: Policy Statement; standard precaution will be used in the care of all residents regardless of their diagnosis, or suspected confirmed infection status . Standard precautions include the following practice: 1. Hand hygiene a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or using alcohol-based hand rub (gels, foams, rinses) that do not require access to water. b. Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such and before eating and after using the restroom.

Based on observation, interview and record review, the facility failed to follow their controlled substance policy. The facility failed to store and maintain controlled substance in a locked refrigerator. This failure effects one of two medication rooms reviewed for medication storage. The facility also failed to do accurate count of controlled drugs by failing to document in shift change accountability record for controlled substances form, and controlled drug receipt record form. This failure effects two of two medication carts reviewed for medication storage. This deficient practice affects 5 residents reviewed for medication storage in a total sample of 21 residents. Findings include: On 8/1/23 at 10:37 AM, first floor medication storage observation conducted with V14 (RN). Medication cart and binder for shift change accountability record for controlled drugs reviewed. Noted shift change accountability record for controlled substances in July 2023: 21st 3rd shift OFF, 25th 1st shift OFF, and 31st 3rd shift OFF are all empty and no initials. August 1st, 2023, shift OFF is also noted with no nurse initial. In addition, controlled drug receipt/record/disposition form reviewed and noted 2 forms for R47 and R2 were in the binder, however the form was incomplete. The signature of the nurse receiving medication, number of doses and date portion are empty and not filled in. R47's-controlled medication has a date received on 7/26/23 with 30 pills, and R2's-controlled medication has a date received on 6/17/23. On 8/1/23 at 10:45 AM, V3 (Director of Nursing/DON) stated that shift to shift count should be done by both incoming and off going nurses and both nurses must initial and document in the form. Our nursing practice if for the receiving nurse to fill in the portion number of doses and date, and nurse's signature when the controlled medication was received by the nurse on duty. On 8/1/23 at 11:00 AM, first floor medication room observation conducted with V14 (Registered Nurse/RN). Medication room needs to be unlocked by V14. Inside this first-floor medication room, observe a refrigerator, unlocked and with 2 controlled substances for R20's liquid hydromorphone and R69's liquid lorazepam. On 8/1/23 at 11:05 AM, V3 (DON) checked the first-floor medication room refrigerator, inserted the key, and locked it. Unable to pull the refrigerator open. V3 then talked to V14 stating that in order for refrigerator to be locked, V14 need to turn the key all the way. V14 answered saying that V14 checked the refrigerator in the morning, and it is locked. Also stating that surveyor pulled it hard and so the refrigerator opened. Confirmed with V3 that refrigerator should not open if it is locked. On 8/1/23 at 11:30 AM, second floor medication storage observation conducted with V7 (Registered Nurse/RN). Medication cart and binder for shift change accountability record for controlled drugs reviewed. Noted R53 has a controlled medication initiated on 7/10/23 with 30 pills, and on 7/31/23 with 8 pills left. Medication Bingo card reviewed and there are 9 pills left in the card. V7 stated she does not know why there is an extra pill left when it supposed to be 8. V7 stated that she worked 2 days in a row, and she knows she gave the medication to R53. V7 also stated that she did the controlled medication count with the off going shift nurse this morning, also stated she might have overlooked the pills and the form. On 8/3/23 at 1:00 PM, V3 (DON) stated that she spoke to V7 (RN) and V7 (RN) cannot explained why there is an extra pill for R53's Alprazolam 0.25mg. V7 reported to V3 that she gave the medication and counted the medication with another nurse every time she worked the floor.V3 also state she does not also have an explanation why there is an extra pill if this was given daily to R53. Controlled Substances policy (not date) reads in part: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. All controlled substances are stored and maintained in a locked cabinet compartment. If refrigeration is required, the refrigerator or container kept in the refrigerator is locked. Policy for Controlled Substances dated August 2017, reads in part: In addition, a PROOF OF USAGE SHEET shall be used to record their administration. This form shall become part of the resident's permanent record. The shift change accountability record for controlled substances must also be completed by the nurses for each shift change. All Class II controlled substances will be locked in the narcotic box.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain safeguards and systems in place to control, account for, and correctly reconcile controlled medications in order to prevent loss, diversion, or accidental exposure. These failures affected one of one resident (R59) reviewed during medication administration. Findings include: On [DATE] at 1:19pm, Narcotic count completed on the first floor with V2 (Licensed Practical Nurse/LPN) surveyor noted R59 Controlled Drug Receipt/ Record /Disposition form for her Morphine Sulfate IR 15mg tablets. According to the form there should be 22 tablets left on the bingo card, on the actual card there is 21 tablets left. During interview, V2 (LPN) said, I don't know what happened to it. No, I didn't count with the nurse this morning she was already gone when I got here. We are supposed to count with another nurse at the beginning and at the end of our shift. No, we should not count by our self. On [DATE] at 1:38pm, Second floor medication room checked. Surveyor noted a bottle with 17mls of Lorazepam oral concentration with no name or room number noted on the bottle, there is no narcotic sheet attached or noted in the Control substance book. V3 (Registered Nurse/RN) said I don't know who this belongs to, I can try to find out. No, it should not be in here like this. On [DATE] at 9:46am, V8 (Director of Nursing/DON) said, They forgot to take the sheet out of the book when pharmacy came to do the audit; the medication was expired and they took the medication. The nurses are supposed to do the Narcotic count at the beginning and the end of their shift. No, she should wait until another nurse comes, it has to be two nurses to count. When wasting medication there should be two nurses to witness the wasting. The Controlled Drug Receipt/ Record/Disposition is use to prevent loss or misuse and accountability. If there is a discrepancy, they are supposed to call the supervisor, then we will do a search and report it to administration and they will start an investigation. If the medication is in the refrigerator, it should be labeled properly with the name of the person, drug and doses, and it has to be labels that are printed by pharmacy. If the label is missing, it should not be stored in the refrigerator; the nurse should give it to the supervisor so it can be disposed of properly. On [DATE] Document submitted by the facility Title Preparation and General Guidelines Controlled substances. With the revision date of [DATE]. Under Policy states: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Under procedures Letter E states. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR) 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record) 3) Remaining quantity (Accountability Record) 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record) On [DATE] Record review of a document titled Storage of Medications under policy statement states the facility shall store all drugs and biologicals in a safe, secure and orderly manner. Under Policy Interpretation and Implementation number one states: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R43 is an [AGE] year old female admitted into the facility on [DATE] with the Diagnosis of but not limited to Shortness of breath, Chronic respiratory failure, abdominal pain. 07/21/22 11:43 AM, R43 said, I'm supposed to get my shower twice a week but they told me that my regular CNA was not here so I have to wait for them to come back to get my showers. I only had one shower this month. I was supposed to have a shower yesterday and it was not done because my regular CNA was not here. Record review of R43'sCNA flow sheet noted R43 only had one shower which was on July 10th. There are no more showers noted. 07/21/22 12:21 PM Record review of R37's CNA flow sheet noted R37 has not had a shower for the month of July. 07/21/22 12:16 PM Record review of R72's CNA flow sheet noted R72 have not had a shower the month of July. On 07/20/2022 at 11:35am, V8 (DON) said the residents are showered twice a week. We have a schedule, the shower schedule is on the daily assignment sheets for them to see. They should chart on the flow sheet . The nurse on the floor should check to make sure it's completed. The CNA (certified nursing assistant) should check and if they see anything on their skin they should report it to the nurse and document on the flow sheet. On 07/20/2022 at 11:44am, interview with V16 (CNA) said: We shower them twice a week if they refuse we will leave them alone and check back later if they still refuse we have to tell the nurse and they will talk to them. No, we don't document the nurse will document, if we give the shower we will put an S in the shower book flow sheet. Based on observation, interview, and record review, the facility failed to ensure that residents were receiving showers twice a week per facility protocol and failed to provide documentation that bath were given as scheduled. This failure applied to seven of seven residents (R14, R37, R42, R43, R49, R72, R79) reviewed for ADL's Activities of Daily Living. Findings include: On 07/19/22 at 9:30 AM, V28 (Ombudsman) said, One of the things the facility can improve on is showering and grooming of residents' nails. At 11:52 AM, R14's family member (V19) said: I would like for R14 to have lotion applied after bathing, I supply the lotion. They need to clean between her toes when bathed too. R14 is unable to provide an interview due to having a diagnosis of Dementia. On 07/20/22, V22 (Certified Nurse Assistant/CNA) said, R14's bath schedule is due for a shower tomorrow, Thursday. Observed, a posted shower schedule on the wall behind the nurse station, it reads: R14's showers are on Sunday 3PM-11PM shift and Thursday 7AM-3PM shift. Observed, at the nurse station a binder labeled: daily skin assessment, dated: June 22 the form is not completed. There is no daily skin assessment form started for any days in July 2022. The July 2022 bath/showers flow sheet to be completed by CNA's observed to be without any documentation. 7/20/22 at 10:32 AM, V6 (Registered Nurse/RN) said, I do not have R14's bath/shower sheet and daily skin assessment forms, you have to ask V8 (Director of Nursing/DON). The CNAs are responsible to fill out the forms and tell me what they find out. The CNA would call me if it's okay, I don't fill out anything. I'm not always available, so I rely on them. I document if they tell me they find something, I will do a skin assessment. I do not have any assigned skin assessment in my shift; it's only by exception. The CNA gives the shower, they don't necessarily call me to check the patient. At 10:48 AM, V8 (DON) said, the CNAs are responsible for filling out the bath/shower record and doing the showers. I don't see any signatures from the CNAs for bath and showers. The nurse makes sure the baths and showers are given; they just may have failed to document. The nurse makes sure the showers are done before the end of the shift. The documentation doesn't mean the shower was done. At 10:54 AM, observed R79's CNA flow record for bath/showers with no documentation for July 2022. There is no daily skin assessment form for July 2022. V8 (DON) said R79 is new to us, she just came two weeks ago. I don't see it, the daily skin form or flow sheet. R79 got here on 6/22, seems I will have to in-service. It's the same CNA not filling out the forms. At 11:01 AM, observed R42's CNA bath/shower flow record and daily skin assessment with no documentation. V8 (DON) said I think it's the same CNA, I will in-service her. No, it's not filled out, both forms. The nurse is the supervisor for the floor, and I supervise the nursing department. The nurse has to check the daily activities for the CNA's. At 11:04 AM, R49 does not have a bath/shower flow record for 7/2022. There is no documentation on the daily skin assessment sheet dated 6/22. There is no daily skin assessment for July 2022. V8 (DON) said, He was in and out of the hospital this month. He doesn't have the forms. He came back on July 3rd. I don't know why he doesn't have the bath sheet; they should have documented on the skin assessment. The person who fills out the bed/shower sheets is no longer with us. On 07/21/22 at 02:04 PM, V11 (Regional Director) said, Our CNAs know to give the residents a shower or bed bath two times a week. The nurse makes sure the aide does the shower; she doesn't document it. The nurse is in charge of making sure the aides do them, we don't have a policy for the nurse to document the showers. Facility presented: undated policy- Patient Care Policy indicates: All patients must be washed daily and given a 2x (times) weekly bath or sponge bath if refused.

Based on observation, interview, and record review, the facility failed to properly clean medication carts and dispose of multiple loose medications in the medication cart, failed to properly label a controlled substance medication bottle in the medication room refrigerator and failed to correctly store resident medication. This failure applied to one of one (R238) resident reviewed during medication storage task. Findings include: On 07/18/2022 at 12:45pm first floor cart checked with V2 (Licensed Practical Nurse/LPN) on the cart surveyor noted a daily medication organizer with medications in the compartments. The organizer did not have a resident name room number or type of medications label. V2 (LPN) said, The medication is for R238, she came in yesterday and the family wants us to use the rest of these medications first. The family did the medication at home and they want us to use this. Surveyor noted 3 nights of unknown medications and two days of unknown medications. In the daily organizer for Tuesday, there are 6 unknown medications, Wednesday has 7 unknown medications. The night medications as follows: Sunday night has 7 unknown medications, Monday has 8 unknown medications, and Tuesday has 7 unknown medications. On 07/18/2022 at 1:38pm, second floor cart checked with V3 (Registered Nurse/RN) surveyor noted 12 loose unidentified medications (Capsules and tablets) on the cart. Second floor medication room checked bottle of 17mls of Lorazepam oral concentration with no name or room number noted on the bottle there is no narcotic sheet attached or noted in the Control substance sheet. V3 (RN) said, I'm not sure who the medication belongs to, I will try to find out. No, it should not be in here like this. 07/21/22 12:58 PM, interview with V8 (Director of Nursing/DON) said, Nurses should not be giving any medications that are not identifiable. The nurses are not supposed to be taking medications from any container that they did not prepare themselves. So, this particular patient came from home; they kept it in a locked cart to make sure that the resident had medications. The resident was admitted Sunday and the medications were picked up on Monday and removed from the cart. On 07/19/2022 Record review of a document titled Storage of Medications under policy statement states the facility shall store all drugs and biologicals in a safe, secure and orderly manner. Under Policy Interpretation and Implementation number one states: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain the spread of COVID-19 as evidenced by not ensuring that residents and staff consistently and correctly wear face masks as required; failed to keep a COVID-19 positive resident on isolation precautions per protocol; failed to perform hand hygiene while in the dining room assisting residents with their meals; failed to prevent cross contamination of clean and dirty linens; and failed to doff PPE after exiting an isolation room. These failures affected three of 18 (R49, R58, and R84) residents reviewed for infection control and have the potential to affect all 30 residents currently residing on the 3rd floor of the facility. Findings include: On 07/18/22 at 11:54 AM, R49's room observed with a PPE (Personal Protective Equipment) bin set up at the door with Contact/Droplet isolation signs posted at room entrance. The door is open to the hallway. Currently there are no other positive cases of Covid-19 on the unit. At 11:55 AM, V17 (Certified Nurse Assistant/CNA) observed applying PPE at the entrance of R49's room, she did not perform hand hygiene prior to donning a gown and gloves. V17 (CNA) was inquired of steps to don (apply) PPE. V17 stated, I should wash my hands or use hand sanitizer. At 12:37 PM, R49 observed sitting in his wheelchair with the room door open to the hallway. R49 is not wearing a face mask and is currently positive for Covid-19. V6 (Registered Nurse/RN) was inquired of R49. V6 (RN) stated, I think he had a positive result on Saturday for Covid. I'm unable to close his door because he has a tendency to get up and fall. He took his mask off; he was wearing one. Source control is not provided to prevent the spread of Covid-19 on the unit. There is no face mask on R49's lap or face. There is no face mask on his over bed table sitting in front of him at the door. At 12:41 PM, record review of Physician Order Sheets (POS) from 7/3/22 indicates: Fall precautions, alarms on wheelchair and bed to serve as a reminder. Resident to wait for assistance before exiting. On 07/19/22 at 12:48 PM, interview with V11 (Regional Director/ Infection Preventionist) regarding infection control and signage of active Covid-19 in the facility. V11 was inquired of Covid-19 signage upon entrance to the facility on 7/18/22. V11 stated, We send out letters to the families, I didn't know there weren't any signs. We have a letter at the front on the window of the office. On 07/21/22 at 02:04 PM, V11 (Regional Director) provided the in-service training records for V17 (CNA) regarding Covid-19 infection prevention in the health care setting, Infection Control Covid-19 and Donning and Doffing PPE video in-service. 07/21/22 02:09 PM, V11 inquired of the steps to put on PPE Personal Protective Equipment. V11 stated, On the CDC forms, it says to perform hand hygiene between steps. We also do hand washing or use hand sanitizer before putting it on. We have hand sanitizer near the rooms. We use the updated CDC (Centers for Disease Control) guidance for staff to use full PPE when taking care of residents that are Covid positive. Facility provided their Policy and Procedure: Covid-19 states in part: Purpose: To reduce the risk of transmission of the Corona Virus Disease (Covid-19) in this healthcare setting. Policy: The facility will conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of Covid-19. The facility will follow and implement recommendations and guidelines in accordance with the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Illinois Department of Public Health (IDPH) and the local health department. Elements of Corona/Covid-19 Virus Plan: Facility will monitor for spread of respiratory/Covid-19 virus type symptoms in the facility and use these results to implement preventative precautions. Staff education: Signs are posted from the CDC about the Corona Virus/Covid-19 Virus. Staff will be in-serviced regularly regarding infection control procedures such as, but is not limited to: Hand hygiene, Gown and glove use, Accu-check policy and procedures, Donning/Doffing PPE, Social Distancing, Isolation Procedures for Droplet and Contact, cleaning and disinfecting and specimen collection procedures. Staff will use Universal/Contact and Droplet Precautions with symptomatic residents and will be placed in isolation. The Illinois Department of Public Health Covid-19 Updated March 22, 2022 Interim Guidance for Nursing Homes and other Licensed Long-Term Care Facilities states in part: The core principals of Covid-19 infection prevention: Source Control (masks, face coverings and other respiratory protection) Hand hygiene (use of alcohol-based hand rub is preferred) Physical distancing Appropriate use of personal protective equipment (PPE) Instructional signage throughout the facility and communication Hand Hygiene: the facility must train and validate competencies of all staff on hand hygiene. Source control: It is safest for residents and visitors to wear source control and physically distance, particularly if either are at risk for severe disease or are not up to date with Covid-19 vaccinations. Universal PPE (Personal Protective Equipment) for HCP Healthcare Personnel If a resident is suspected or confirmed to have Covid-19 or is not up to date with Covid-19 vaccinations, and the resident is identified to be a close contact, HCP must wear an N95 respirator, eye protection, gown and gloves. Management of Residents- Updated Residents with Confirmed Covid-19: Single room, door closed (if safe to do so). Isolate using transmission- based precautions Staff wear full PPE (N95 respirator, gown, gloves, eye protection). On 07/18/22 at 11:04 AM, observed R84 in hall not wearing mask over mouth and nose and not redirected by V10 (Administrator) to readjust her mask over her nose and mouth. On 07/18/22 at 11:18AM, observed R58 came out of her isolation room without a mask and asked about lunch. On 07/18/22 at 11:27 AM, observed V20 (Certified Nursing Assistant/CNA) set up R6's tray and adjust her in bed with gloved hands, then doff gloves and grab a clean towel from the clean linen cart while carrying removed gloves without performing hand hygiene. On 07/18/22 at 11:42 AM, observed V21 (Activities) remove R3's mask and place on table without performing hand hygiene then continue to assist other residents to in the dining area. V21 stated, (R3) needs more assistance and so she removed her mask. Observed R3 multiple times with some slight sounds of congestion. On 07/19/22 at 07:58AM, observed V18 (Receptionist) in the first floor hallway with no mask on. On 07/19/22 at 08:18AM, V18 (Receptionist) stated he was not wearing his mask earlier because he was hot. On 07/19/22 at 08:42 AM, V23 (Certified Nursing Assistant/CNA) dropped multiple clean clothing protectors on the floor and placed them on the clean linen cart. On 07/19/22 at 08:45 AM, observed V24 (Certified Nursing Assistant/CNA) enter an isolation room, donned gown and exited the isolation room wearing the gown, and walked through hall with multiple residents and staff present, then returned to the isolation room and doffed gown. On 07/20/22 at 1:35 PM, V8 (Director of Nursing) stated if a gown is donned and worn in an isolation room it should be removed before leaving the room to prevent contamination. V8 stated that placing clothing protectors that fell on the floor back on the clean linen cart could cause contamination. V8 stated that R58 is difficult to redirect to stay in her room while on isolation and forgets why she is on isolation. V1 stated R58 usually comes out of her room and sits right outside the administration office. 07/21/22 11:57 AM, V8 (DON) stated, staff should remind residents to wear their mask if observed not doing so and staff must wear masks. V8 stated there is a risk for transmission if staff don't instruct residents to wear masks or if staff are not wearing masks. V8 confirmed that R58 was positive for COVID on 07/18/2022.

Based on observation and interview, the facility failed to follow their kitchen sanitation practices by not wearing hair coverings properly while preparing food and while in the food preparation area and failed to practice proper hand hygiene while in the kitchen. This failure has the potential to affect all 82 residents currently in the facility. Findings include: 07/19/22 at 09:07 AM, observed V25 (Cook) hair exposed from hairnet on sides and back of head while preparing purees. 07/19/22 at 10:48 AM, observed V25's hair exposed from underneath her hair net while preparing meal trays; observed V7 (Dietitian) hair exposed from hairnet on the sides of her head while assisting with meal prep. 07/19/22 at 11:25 AM, observed V10 (Administrator) in the kitchen prep area with hair exposed from underneath her hairnet on both sides of her head. Observed V10 touched her face mask multiple times without performing hand hygiene and laid her hands down on the food prep table. 07/20/22at 2:25PM, V7 (Dietitian) stated that the pitcher sitting in the pitcher that was sitting in the 10ppm sanitizer solution in the three-compartment sink on 07/18/2022 is the pitcher used to refill the sanitizer bucket. V7 stated the almond milk that was open and labeled in the refrigerator had been opened by staff that morning and was required to be labeled as opened by the end of the shift. V7 stated the maintenance staff stated the freezer with the ice buildup needs a new part but is still maintaining temperatures properly. V7 stated hairnets should completely cover hair while working in the kitchen to prevent contamination. V7 confirmed if staff touch their face mask without performing hand hygiene then touch a food preparation surface this could cause contamination.