**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify 1 (R2) of 5 resident representatives of significant changes in status which were reviewed for change in status in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admission date of 12/31/24 with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Minimum Data Set (MDS) dated [DATE] that R2 is severely cognitively impaired. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents that V9 daughter of R2 is designated as agent of power of attorney for healthcare, R2's Nurse's Progress notes dated 5/10/25 documents a late entry: (R2) mistakenly sent to emergency room (ER) due to low blood pressure and low O2 sats. (V25) Medical Director (MD) and (V9) Power of Attorney (POA) were notified. On 5/27/25 at 11:46 AM V9, R2's daughter and power of attorney stated she was unaware of her mother being sent to the hospital until 5/12/25. V9 stated she was informed by the hospice nurse (V27). On 5/27/25 at 3:24 PM V25 medical director stated he had not been notified that (R2) had been sent out mistakenly to the hospital. On 5/28/25 at 10:12 AM V27 Hospice nurse stated she had not been notified until 5/12/25 that R2 had mistakenly been sent to the hospital. On 5/27/25 at 12:37 PM V1 Administrator stated that she was led to believe the assigned nurse (V19) had contacted R2's family. (V19) left things in a mess and we dodged a bullet, we followed policy and it was human error. On 5/28/25 at 11:14 AM V2 Director of Nursing stated she entered the documentation that R2's family had been notified because she thought the nurse (V19) had done so but had not completed her documentation before leaving the facility. R3's undated Face Sheet documents R3 was admitted [DATE] with pertinent medical diagnoses of Human Metapneumovirus as the causes of diseases classified elsewhere, Systemic Inflammatory of Response Syndrome (SIRS) of Non-infectious origin without Acute Organ Dysfunction. R3's Minimum Data Set, dated [DATE] documents she is cognitively intact. On 5/29/25 at 9:35 AM V28 R3's daughter stated she had not been notified on 5/10/25 by the facility that her mother was being transferred to the hospital for further evaluation. According to V28 she was contacted by the hospital for insurance information and during that conversation she discovered that it was not her mother (R3) in the hospital. The facility did not notify her that (R3) did not go to the hospital. On 5/28/25 at 3:24 PM V25 Medical Director stated he was not informed that the resident (R3) had not been sent out. He discovered 5/12/25 when he arrived at the facility for regular visits with residents that (R3) had not been sent out as ordered. V25 stated his expectations are that his orders are carried out and he be notified of any changes that warrant intervention. The facility policy Resident Rights undated documents the facility must provide services to keep your physical and mental health and sense of satisfaction. The facility policy on Transfers and Discharges undated documents A thorough assessment by the attending physician or healthcare provider will determine whether a transfer is medically necessary. This assessment will be documented in the resident's care plan. Notification: The resident and their family (or legal representative) will be notified of the transfer, including the reasons for the transfer and the expected timeline. The family will be given sufficient notice to make appropriate arrangements. Physician will be involved in and informed of resident's transfer. Detailed documentation of the transfer request, reasons, and any family discussions or approvals must be kept in the resident's record. The transfer process will be documented, including the physician's assessment, transfer arrangements, and communication with the resident and family. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review the facility failed to ensure that 1 of 3 (R2) residents or their representative reviewed for hospital transfer received sufficient preparation for transfer to the hospital in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admission date of 12/31/24 with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Minimum Data Set (MDS) dated [DATE] that R2 is severely impaired. R2's Practitioner's Order for Life Sustaining Treatment (POLST) dated 12/31/2024 documents that V9 daughter of R2 is designated as agent of power of attorney for healthcare. On 5/27/25 at 11:46 AM V9, daughter of R2 stated she was not made aware her mother (R2) had mistakenly been sent to the hospital. (R2) cannot speak for herself and is not cognizant, therefore the facility did not have (R2's) or her (V9) consent to send (R2) to the hospital. R2's Nurse Progress notes dated 5/10/25 do not provide documentation the neither (R2) or (V9) received preparation for the transfer to the hospital. The active facility policy on Transfers, Discharges All discharge decisions, including reasons for discharge, discussions with the resident and family, and discharge plans, will be documented in the resident's record. The facility will ensure that all discharge paperwork, including any required notices and appeals information, is provided to the resident and their family. Prior to survey date, the facility took the following actions to correct the non-compliance: All facility nurses and Certified Nurse Assistants were in-serviced between 5/12/25 and 5/23/25 on the vital importance of resident identification, including Certified Nursing Assistants and/or nurse presence in room with Emergency Medical Service before transporting/transferring resident to the hospital. Additionally, Medical provider or Nurse Practitioner and Hospice company (if applicable) should be notified before any transfers or discharges. The Director of Nursing will Audit all hospital transfers for the next 4 weeks and then monthly for a period of 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin for 1 of 2 residents (R23) reviewed for abuse in the sample of 41. Findings include: On 8/27/24 at 11:00 AM, V1, Administrator stated she does not have any investigations of injuries of unknown origin or abuse investigations. R23's Face Sheet documents her diagnoses as Generalized Anxiety, Major Depressive Disorder, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Other Behavioral Disturbances, Unsteadiness on Feet, and Muscle Weakness. R23's Minimum Data Set (MDS) dated [DATE] documents she is severely cognitively impaired and is dependent on staff for toileting, dressing, turning and positioning, and transfers. R23's undated Care Plan documents, Skin Integrity with goal of, The skin will remain intact. Interventions include, Continue with A&D Ointment or zinc oxide daily and as needed for protection, encourage good nutrition and hydration in order to promote healthier skin, monitor for signs and symptoms of infection, weekly skin checks, staff to observe skin daily. R23's Progress Note dated 6/15/24 at 10:22 PM document, Incident Note: Note Text: This resident complained of pain to her right arm when staff was trying to get her ready for a transfer from wc (wheel chair) to bed this eve after supper. The CNAs (Certified Nursing Assistants) x 2 used a gait belt as per the resident's [NAME] in her room and transferred her to her bed. Resident was able to bear weight to assist with the transfer. Once the CNAs undressed the resident to put her night gown on they noted a bruise to resident's right upper arm humerus area. This nurse assessed resident arm and right upper arm is noted with a 10 centimeter (cm) X 9 cm dark purple bruise. Resident is uncooperative as this is her normal behavior and will not cooperate in showing me if she has ROM (Range of Motion) to that right arm. Resident is able to move fingers on her right arm. (Medical Doctor (MD)) was notified and order received to get an x-ray stat of the area. This nurse did report to MD that resident does take Pradaxa 75 milligram (mg) twice a day as well. This nurse called (x-ray company) to order a stat xray of the right humerous and the order was put in as stat but the operator placing the order stated that no further test could be placed for tonight and reason was unavailable to this nurse. This nurse placed a call to (x-ray company management) and left a message to find out why no further testing could be done and I was not given a reason or a time frame on when I could expect it to be performed tomorrow. Resident resting now with eyes closed and no signs or distress noted. On 8/28/24 at 3:40 PM, V2, Director of Nursing (DON) and V3, Assistant Director of Nursing (ADON) came in to discuss R23's bruise she had on 6/15/24. V2 stated the bruise was first observed when staff were providing care for R23 on 6/15/24 and R23 was complaining of pain to her arm. V2 stated this was the first time any staff were aware that R23 had the bruise. V2 was agreeable that initially R23's bruise was an injury of unknown origin. She stated after an investigation they determined R23's bruise on her arm was most likely due to her being combative with care. She stated this was a common behavior by R23 when care was being provided. V2, DON provided the investigation/incident report on R23's bruise. R23's untitled report dated 6/15/24 documents (R23) Injury: Bruise to right upper arm 10 cm x 9 cm. DON Notified: (V2) Comment: Resident complained of pain-as her norm. CNAs x 2 transferred resident from w/c to bed for HS care. CNAs transferred x2 with gait belt and resident was able to bear weight. Once resident was undressed the CNAs noted bruise to right upper arm. This nurse assessed the area to find 10 cm x 9 cm dark purple bruise. Resident not cooperative on assessing ROM. Call place to (V36 Medical Doctor) and order received for stat x-ray to right upper arm. A statement at the bottom of this report documented, This is immediate notification of injury and a full investigation will follow within five days. There was no documentation that the Administrator was notified. This report was signed by V3, ADON who was working that day. R23's Skin Investigation Report dated 6/16/24 and documented: Situation: Resident complained of pain to right arm. Nurse investigated arm. Bruise 10 cm x 9 cm found. Resident recently transferred with gait belt and assist x 2 CNAs. MD notified and x-ray orders received. X-ray not available so sent to ER. Findings: Spoke with CNAs, (V10) on 6/17/24. Confirmed resident was combative with care and transfer. Interventions: Resident transfer status updated. Therapy initiated. A hand written note dated 6/15/24 but untimed documented (V10 CNA) get up toileted x 3 on days. Per (V10) and (unknown CNA) noted after supper with HS (bed time) care. Bruise right upper arm by (V37, CNA) and (V38, CNA). Sent to (local hospital) for xray. On 8/30/24 at 8:55 AM ,V2, DON stated she talked to the CNAs who worked on 6/15/24 the next day about the bruise on (R23's) arm. V2 stated the CNAs reported that they had gotten (R23) up in the morning and she did not have a bruise on her arm . V2 stated (V10), CNA, described how (R23) was resistive to care and combative to the staff and he described how (R23) had swung her right arm back and hit him and she determined that the probable cause of (R23's) bruise was due to her hitting her arm on him. V2 stated she did not write down exactly what (V10) stated but immediately did the report. V2 stated she felt the investigation showed how (R23) sustained her bruise while being combative with care. On 8/30/24 at 10:10 AM, V1 stated (V3) told her about the bruise on (R23's) right arm and told her staff were constantly pulling (R23) up when she slid down in her wheel chair and that (R23) was on blood thinners and that is probably how she got the bruise. V1 stated that was a good enough explanation for her as to how (R23) got the bruise. On 8/30/24 at 10:20 AM, V3 stated the CNAs who were putting (R23) to bed on 6/15/24 came and got her and told her (R23) had a bruise on her right arm. She stated she went down and looked at it and it was a big purple bruise on (R23's) right upper arm. V3 stated she had not had any other staff report anything out of the ordinary related to (R23) during the shift and she did not know what caused the bruise. She stated she immediately notified the Medical Doctor, Administrator, (R23's) family and the Director of Nursing. V3 stated there was a problem with their x-ray company coming out so the MD gave orders to send to the emergency room because (R23) is on blood thinners. On 8/30/24 at 11:10 AM, V10, CNA stated he took care of (R23) on day shift on 6/15/24 and was informed they found a bruise on (R23's) right arm on that night. He stated he never observed a bruise on (R23's) right arm while he was taking care of her on that day. V10 stated he does not remember (R23) having any abnormal behaviors that day. He stated her normal behaviors was yelling out for no reason. V10 stated (R23) was not combative or resistive to care with him that day. He stated someone did call him the next day to ask if he knew anything about her bruise but he could not recall who called him. The facility's policy, Abuse Prevention Program Policy and Procedure updated 9/26/23 documents, Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. An initial written report shall be sent to the Illinois Department of Public Health (IDPH) immediately. The written report should contain the following information if known at the time of the report: Any obvious injuries or complaints of injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure all bruises of unknown origin were thoroughly investigated for 1 of 3 residents (R48) reviewed for bruises of unknown origin in the sample of 41. Findings include: R48's Physician Order Sheet (POS for August 2024) documents a diagnosis of Major Depression disorder, severe with psychotic symptoms, pressure ulcer of left heel, Alzheimer disease, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbances, psychotic disorder with delusions due to known physiological condition, and anxiety and bilateral primary osteoarthritis of hip. R48's Minimum Data Set (MDS) dated [DATE] documents she is severely impaired for cognition for activities of daily living, she has impairments on both sides, she uses a manual wheelchair. She is dependent on staff for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene, Rolling from left to right, sit to stand, chair to bed, toilet transfer tub/shower transfer, and she does not walk and is always incontinent of urine and bowel. R48's Care Plan: (R48) at risk for falls; due to poor safety awareness. Maintain safe environment to room/facility to prevent injuries, well lite environment. Observe resident for any unassisted transfers/ambulation status. Remind to wait assist and assists residents as needed. B & B (bowel and bladder) before meals/after and as needed. Keep resident clean and dry. Resident to use call lights when assist needed. Report any unsteady balance/gait to Nurse. Report any decline in safety awareness to Nurse (PRN). Use of ¼ side rails times 2, check every two hours and as needed. R48's Skin/Wound Note dated 5/18/2024 at 1:28 PM, Note Text: 11 x 6 cm (centimeters) bruise noted to left shin during routine care. Staff reported to this nurse. Leg evaluated on pillow and V13, Nurse Practitioner notified and aware. Will monitor until healed. Author of this note was documented as V12, Licensed Practical Nurse (LPN). R48's Incident/Accident report date of incident 5/18/2024, Staff noticed a 11 x 6 cm light purple bruise to left skin during routine care. Staff reported resident leg was bumped by another resident's wheelchair. The incident report does not document who the staff member was when the injury occurred and or who the other resident was involved in the injury. R48's Incident/Accident report date of incident 5/18/2024 does not document the time or when the physician was notified, and the form was not completely filled out. The Skin Injury Investigation Checklist undated does not document the name of the resident. There was no name, the form documents, Type of skin injury: 'bruise', staff assigned to resident (V10), certified nursing assistant (CNA) and (V11), CNA. How was skin injury found? During routine care. Resident's activity at the time of the skin injury; sitting in wheelchair. What the resident said happened: Unable to voice. Does the resident self-ambulate or self-propel wheelchair around the facility; 'No'. Was there a prior injury to this area recently? 'No'. Does the resident have any behaviors? No. The checklist does not documents which staff member told the other staff an incident had occurred or who the other resident involved was. On 8/29/2024 at 10:41 AM, V12, Licensed Practical Nurse stated, (V11) and (V10) came and got me and told me they had found a bruise on (R48's) leg while they were doing care. I went and looked at it and I did an incident report. I was watching the bruise and they did an investigation on her. (R48) did not walk and was unable to propel herself in the wheelchair. At the time of the incident (R48) was in a manual wheelchair with foot pedals. We think that at mealtime they accidentally hit her foot with the other resident. I do not know who the other resident was, or who the staff member was that was caring for (R48) while they were pushing the other resident under the table, and then they collided. (R48's) bruise was progressively getting worse and I called the Nurse Practitioner and she had me get an x-ray, and when the x-ray came back, we learned she had fractured her leg. I was in shock and blown away because I did not expect (R48's) foot to be fractured from colliding with another resident. On 8/29/2024 at 10:02 AM, all investigations for the bruise of unknown origin were requested. On 8/29/2024 at 2:02 PM, (V11), Certified Nursing Assistant stated, Me and (V10, CNA) were taking care of (R48). We got her up and took her to breakfast. (R48) was in a regular wheelchair with foot pedals. She was not able to propel herself. After breakfast the nursing aid, I do not know her name, she was agency, told me that she had bumped (R48's) leg at the dining room table that morning. When we took (R48) back to her room and laid her down, she winced and even though she could not talk she was grimacing, and you could tell her leg hurt her and she had a red/purple bruise. I went and got the nurse (V12) and had her look at it. (V12) was monitoring it and contacted the doctor and got an x-ray and later we found out she had a fracture. We were all in shock. On 8/29/2024 at 3:32 PM, V2, Director of Nursing stated, I do not have any interviews documented for (R48's) fracture. I did not get any statements from anyone, I did not realize I was supposed to do that as I am new to this position. On 8/30/2024 at 11:03 AM, V10, certified nursing assistant (CNA) stated, I remember taking (R48) back to her room after lunch and when laying her down we, (me and (V11, CNA) noticed a bruise on her leg. We immediately notified the nurse (V12, LPN). Before laying her down she had no prior pain or symptoms. After laying her down she would grimace when we touched the bruise. She cannot talk or tell you what had happened. No staff told me that there was any accident and or injury to (R48). I was working the night shift and I was very surprised to learn that she had a fracture. I am no longer employed at the facility. On 8/29/2024 at 3:42 PM, V1, Administrator stated, I remember the case, but I did not do the investigation, (V2) was in charge of the investigation. On 8/30/2024 at 2:40 PM, V13, Nurse Practitioner stated, The documentation on this case was poor and what we know is that (R48) had a fracture, and we were not sure how she got that fracture. There was a late entry and I have many issues with that because staff should have documented immediately if she was hit by accident or with other residents and at the end, we can only go by what is documented. It is hard to say and an unusual case. Without names and dates I just have issues. The Facility Abuse Policy updated 9/26/2023 documents, The facility affirms the right of our residents to be free from abuse, neglect, misappropriations of property, corporal punishment, and involuntary seclusion. The facility therefore prohibits mistreatment, neglect, or abuse of residents and has attempted to establish a resident-sensitive and secure environment. The purpose of this policy is to assure that the facility is doing all that is within our control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Timely and thorough investigations of all reports of allegations of abuse. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. The Director and/or Assistant Director of nursing is responsible for reviewing the incident report and reporting any findings to the facility administrator. If the resident complaints of physical injuries or physical injuries are noted, the resident's physician and representative will be contacted for further instructions.

3. On 8/27/2024 at 12:00PM, V32 Certified Nursing Assistant (CNA), was sitting at a table providing feeding assistance to R20 and R60. V32 began feeding R20 a spoonful of food and immediately began feeding R60 a spoonful of food. No hand hygiene was completed between feedings. V32 wiped R20's mouth with a cloth. V32 was handling multiple cups and utensils. No hand hygiene completed before V32 began feeding R60. No hand sanitizer on table or nearby. On 8/27/2024 at 12:05PM, V33, Certified Nursing Assistant, CNA, was sitting at a table providing feeding assistance to R28 and R38. V33 began feeding R28 with a spoon and immediately began feeding R38 with a spoon. No hand hygiene was completed between feedings. V33 touched R38's clothing protector and face, with no hand hygiene completed prior to feeding R28. No hand sanitizer on table or nearby. On 8/30/2024 at 8:45AM, V27, Certified Nursing Assistant, CNA, stated We are taught to use hand sanitizer between feeding residents. On 8/30/2024 at 8:40AM, V2, Director of Nursing, DON, stated The CNAs feeding residents are to use hand sanitizer between feeding residents or touching residents. They are to use the same hand to feed a resident and the other hand to feed the other resident. Facility's undated Hand Hygiene policy states Handwashing will be regarded by this facility as the single most important means of preventing the spread of infection. Staff will follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents, and visitors. Hands should be washed for at least 20 seconds using soap and water under the following conditions: Before having direct contact with a resident. After having direct contact with a resident. After handling items potentially contaminated with blood, body fluids, excretions, or secretions. Hand sanitizers containing at least 60% alcohol may be used when soap and water is not readily available. Facility's undated Resident Feeding policy states Residents who are unable to feed themselves will be fed by approved personnel with attention to safety, comfort, and dignity. Staff will sit when feeding residents. Facility's Infection Control Policy updated 7/31/2024 states The facility must establish an infection prevention and control program that must include, at a minimum, the following elements: Written standards, policies, and procedures, for the program, which must include, but are not limited to: The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food if direct contact will transmit the disease, The hand hygiene procedures are to be followed by staff involved in direct resident contact. The Enhanced Barrier Precautions (EBP) Policy and Procedure undated documents, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs), CMS notes that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. Enhanced barrier precautions (EBP) are an infection control measure designed to reduce transmission of multidrug-resistant organisms (MDROs) in the nursing homes. Enhanced Barrier Precautions involve gown and gloves use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices. High-contact resident activities include Wound care: any skin opening requiring a dressing. Gowns and gloves will be available immediately near or outside of the resident's room. Enhanced barrier precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Based on observation, interview and record review the Facility failed to ensure proper infection control guidelines were being followed for 6 of 22 residents (R20, R48, R28, R38, R42 and R60) reviewed for infection control in the sample of 41. Findings include: 1. On 8/27/2024 at 12:11 PM, V39, Certified Nursing Assistant (CNA) was feeding (R42). V39 was wearing a mask and was resting her elbows on the dining room table and both of her hands were on her cheeks. She then proceeded to feed R42 without disinfecting and/or washing her hands. On 8/27/2024 at 12:15 PM, V39, reached over the table and touched R42's bib and then proceeded to feed another resident without disinfecting and/or washing her hands. Then after touching her face again she proceeded to feed R42 without disinfection and /or washing her hands. 2. On 8/30/2024 at 10:33 AM, wound care was provided by V35, Licensed Practical Nurse (LPN). R48's door had a sign on the door documenting EBP (Enhanced Barrier Precautions) and instructed staff to wear PPE (Personal Protective Equipment) including mask, gloves and gowns. V35 was not wearing any gown while providing wound care. On 8/30/2024 at 10:55 AM, V2, Director of Nursing stated, (R48) was on EBP (Enhanced Barrier Precautions) and she would expect for all staff to wear gloves, mask and gowns for all treatments.

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 99 residents living in the facility. Findings include: On 8/27/2024 at 9:13 AM, tour of the facility was conducted. In the kitchen in the sink were 5 large industrial clear bags of frozen chicken. Water was running over one bag, but the other four bags did not have any water running on them. The temperature of the water was taken with a calibrated metal thermometer and the water was 100.0 degrees Fahrenheit (F). There was not a stopper in the sink and the water was running straight down into the drain. The frozen chicken was not submerged in the water. There was about ½ of water in the sink with the water running. Not all of the chicken was in water. On 8/27/2024 at 9:22 AM, in the walk-in refrigerator was a moving tray and on the tray on the top shelves were small clear plastic cups with an orange substance inside of the cups. The orange cups were not covered and were exposed in the air of the refrigerator. There was no date and or label and there were 4 trays with a total of 92 cups. On the next to bottom shelf of the cart was a large industrial box labeled 8 piece cut glazed chicken. The box was leaking, and the entire tray was covered with a bloody liquid that was leaking from the cardboard box. On 8/27/2024 at 9:24 AM, there was a clear container of pineapple with the use by date of 8/11/2024 that was still in the walk-in fridge. On 8/27/2024 at 9:25 AM, there was a clear, large industrial container of corn kernels with no date and/or label. On 8/27/2024 at 9:28 AM, above the stove the hoods were shiny and greasy and in need of a cleaning. On 8/27/2024 at 9:29 AM, V25, [NAME] stated, The menu calls for chicken and I am not sure what happened but the chicken was spoiled and so we are trying to thaw new chicken so we can follow the menu. I am not sure how or why the chicken was spoiled. Our Dietary Manger is not working today, she does not normally work on Tuesdays. We were just trying to get the chicken thawed. On 8/27/2024 at 10:32 AM, V24, Dietary Manager stated, I would expect all food to be dated and labeled. I am not sure what happened with the chicken, but the staff should not have tried to defrost the chicken in the sink without taking into consideration the water temperatures and ensuring they were doing it the correct way. On 8/29/2024 at 8:51 AM, V24 stated, I am not sure when the hoods were last cleaned. I would expect the hoods to always be clean and free of grease. The Meat and Vegetable Cookery Policy undated documents, Meat is defrosted using safe thawing methods (never at room temperature): In the sink, under clean running water <70 F (Fahrenheit). The Labeling and Dating Foods 2020 documents, All food stored will be properly labeled according to the following guidelines. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the 'first in- first out' method of rotation. Once the package is opened, it will be redated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Prepared food or opened food items should be discarded when: The food item is older than the expiration date. The US FDA (Food and Drug Administration) 2022 code documents, 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less Pf; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF) Pf, or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41oF) Pf. 4-204.11 Ventilation Hood Systems, Drip Prevention. Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. The Long Term Care Facility for Application Form for Medicare and Medicaid Form (CMS 671) dated 8/27/2024 documents there were 99 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a system in which staff immediately report allegations of abuse and injuries of unknown origin to the Administrator and State Agency. This has the potential to affect all 96 residents residing in the facility. Findings include: 1.R2's admission Record Form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnosis of dementia, anxiety disorder, age-related nuclear cataract, essential hypertension, dissection of unspecified site of aorta, thoracic aortic aneurysm (without rupture), and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of another specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, and unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's Minimum Data Set, MDS, dated [DATE], documented R2 as being severely cognitively impaired. R2's care plan, dated 6/8/23, documented R2 as requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:20 AM, V14, R2's sister/Power of Attorney (POA), stated that R2 was admitted with a broken hip that was not repaired because of an aneurysm she had. V14 stated that the facility used a mechanical lift to transfer her because she could not stand. V14 stated that the doctor at the hospital said the hip might heal on its own but it didn't. She continued to state that she was visiting R2 one day in August, that she visited every day, and one day noticed her (R2's) leg was swollen, that it was bruised so she told them she wanted something done. V14 stated that they did a doppler and it revealed blood clots. V14 stated they sent her to the local hospital, and the local hospital transferred her to the regional hospital for surgery. V14 stated that V26, R2's orthopedic surgeon, at the regional hospital said it was a new break and the leg was broken this time, not the hip. V14 stated that V26 said it was a twisted break and if they didn't operate it would come through the skin, so they did surgery. She continued to state that V26 told her that this fracture was not from the previous hip fracture and that this was a new fracture of the leg. V14 stated she went to the facility staff and management and told them something caused this and that she wanted to know what did. She continued to state that the facility said that they do not have any documentation and that this was not a new fracture, it was from the hip fracture. V14 stated she tried to explain it wasn't, but that they just kept saying it was the same fracture. On 12/4/23 at 11:30 AM, V14, R2's sister/ POA stated, some of these young kids do not have compassion and some of the (Certified Nurse Assistants (CNA) are rough. I have video of a CNA named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated that it happened a week ago Saturday when the CNA was getting R2 ready for breakfast. V14 stated she went to the Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. On 12/4/23 at 12:10 PM, V1, Administrator, with V2, Director of Nurses (DON) who was on a speaker phone as she was home sick. V2 stated that they tried to explain to, V14, R2's sister/POA that the fracture in August was not a new fracture and that it was from the hip fracture that she was admitted with in January. V1 stated that V2 even tried to explain with anatomy pictures to V14 about the fracture being the same one R2 had when she was originally admitted and that V14 just wasn't comprehending it. V2 stated I attempted multiple times to explain to (V14) that it was a fragility fracture from the hip, and it wasn't new. When V1 was asked for their investigations and root cause analysis of the allegations of abuse and injury of unknown origin, V1 stated We didn't report or investigate the fracture from August because it wasn't a new fracture. V1 continued to state We didn't report the video concerns because we cleared it on the spot when the sister brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, was reviewed by the surveyor and showed R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, documented, V8, CNA, pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand, V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. R2's Facility titled form, dated 11/26/23, documented, Resident wheeled to nurse's station and CNA reported bruise to (right) index finger. R2's Incident Report, dated 11/26/23, documented, Bruise found on right index finger. Area of concern: none. Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurses and CNAs interviewed, and no areas of concern noted. The facility was unable to provide witness statements. On 12/5/23 at 2:35 PM V2, stated, We report any fractures, anyone that goes to the hospital from an incident, or burns that require outside treatment. V2 stated, I know in (R2's) case, she was combative, so we knew the bruise was from that. We did not do an investigation and I know we should have looked into that. V2 stated, I was not involved in the instance with the CNA on the camera. V2 continued to state, What I usually do is clear it with (V1, Administrator), and she usually says we know what happened, so we don't need to report it. On 12/5/23 at 3:08 PM, V1 stated We report to state if there is any kind of injury that requires anything beyond first aid, if they were sent to the hospital from an incident, founded abuse, and allegations of abuse if we know its legit. V1 stated We are not going to hot line until we know its legit, like if the resident has a UTI (urinary tract infection), we will factor that into what they are saying. V1 stated that V2, DON, V23, Assistant Director of Nurses (ADON), and herself collaborate to decide if they need to report it. V1 stated that a serious injury or anything beyond first aid, they would report it. V1 continued to state that with unknown injuries they do a lot of interviewing and that they do not document the interviews with staff and residents. V1 stated that if there's a bruise like on R2, V2, DON, keeps a file on those. V1 continued to state that R2's was a tiny bruise on a finger. V1 stated Honest to God if I did an investigation on every single little bruise, well it's not going to happen. V1 continued to state, On abuse we decide if it is a reportable or not reportable. On 12/4/23 at 12:30 PM, V7, Social Worker, stated When (R2's) family showed me the video, I was adamant that we had to report it to the Administrator. V7 continued to state that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to V14. On 12/6/23 at 10:42 AM, V24, LPN stated that R2 had a fracture earlier this year and there was no surgical intervention. V24 stated there was a follow-up x-ray in March with no change, no healing. V24 stated R2 complained of leg pain in August. V24 stated she knew nothing caused a new injury because there were no incidents in the chart. V24 stated they did another x-ray in August and that is when R2 was sent out to the hospital. V24 stated she recalled the leg being swollen and the family would tell us when they thought she was having pain because R2 could not always tell you when she was hurting. On 12/5/23 at 1:20 PM, V8, Certified Nurse Assistant (CNA), stated, On 11/26/23, I went into (R2's) room to get her dressed for breakfast, she was combative as usual. V8, stated, I got her dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 continued to state, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 stated (V23, Assistant Director of Nursing) came to me later that day and said R2's sister showed her the video. V8 stated, (V23) knows how (R2's) sister is and (V23) didn't want me to get in to trouble. (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated that they did not send her home, they just put her on another hall. On 12/6/23 at 2:49 PM, V25, V26's Orthopedic Registered Nurse, stated that V26, R2's Orthopedic Surgeon, said the fracture in August was from a new injury and was not related to the past hip fracture. R2's x-ray results dated 8/8/23 from the x-ray that was completed in the facility documented there was an acute, displaced spiral fracture of the distal third of shaft of the femur with a conclusion of acute fracture distal femur. The facility failed to investigate the cause of the new fracture. R2's medical record dated 11/26/23 at 3:31 PM documented a bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. The facility's incident report form dated 11/26/23 documented resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility failed to provide documentation of investigation including witness statements. 2. R16's admission record, dated 12/4/23, documented diagnoses of Encephalopathy, Major depressive disorder, and Dementia. R16's MDS, dated [DATE], documented that his cognition was severely impaired. R16's Progress note, dated 10/21/23, documented, CNA notified nurse res is bleeding. Nurse observes dried black blood with scant amount light red blood to R (right) hand. Resident unable to answer, how did this happen. On 12/5/23 at 10:55 AM, R16 was sitting in dining room in wheelchair, activity getting ready to start. Resident was unshaven with food on his face. Resident said hello but did not respond to questions by writer. No bruises were noted. On 12/5/23 at 3:08 PM, V1, Administrator, stated I was looking at (R16's) chart when I sent it to you and the nurse probably assumed it was from picking. The facility had no documentation that nurse reported this to V1 for investigation and was unable to provide an unknown injury investigation including witness statements into the cause of this injury. 3. On 12/05/2023 at 10:00 AM, R1 was sitting up in a high back reclining wheelchair in the hallway. R1 had a fading yellowish/green bruising below both of her eyes and a large, approximately 2 centimeters (cm), greenish/yellow raised area to the right side of the top of her head. R1's facility titled form, dated 10/29/2023, documented, CNA alerted this nurse that res had bump on forehead, purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL (within normal limits). No (signs or symptoms) of pain or distress noted. It also documents, Was incident witnessed? No. R1's Progress Note, dated 10/29/2023 at 9:00 AM, documented, CNA, alerted this nurse that resident has bump on forehead. Purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No s/s of pain or distress noted. There were not any investigative notes, root cause analysis or interviews in R1's progress notes or in R1's electronic medical record. R1's admission Record, dated 12/05/2023, documented diagnoses of Vascular Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. R1's, Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely to never understood, that she had no impairment to her upper or lower extremities and that she was incontinent of bowel and bladder. On 12/05/2023 at 2:35 PM, V2, DON, stated that R1's bump on her head on 10//29/2023, was from the mechanical lift. When asked for investigation, root cause analysis and interviews of staff and residents, V2 stated, We only have what's in the chart. The facility was unable to provide documentation that this incident was reported to V1 for investigation and was reported to the state agency. 4. On 12/05/2023 at 9:45 AM, R17 was sitting up in her wheelchair at the nurse's station. Staff was assisting with putting her hearing aid back in her right ear. R17 stated she was good and asked writers name but was unable to recall anything else regarding skin tears or bruising to her body or how it happened. R17's MDS dated [DATE] documented that her cognition was severely impaired, that she has no impairments to her upper or lower extremities and that she uses a wheelchair and a walker. It also documents that she requires substantial to maximal assistance for most activities of daily living and that she was frequently incontinent of bowel and bladder. R17's Care Plan dated 9/25/2023 documented, Educate resident/family/ caregivers of causative factors and measures to prevent skin injury. R17's Skin/Incident report dated 10/14/2023, documented, CNA alerted this nurse of resident skin tear. Skin tear noted to (right forearm) crescent shaped measuring 6.5cm x 1.0 cm. small amount of serous fluid noted. Cleansed ns. Unable to reapproximate. Xeroform, non-adherent pad and dry dressing applied. Denies pain. no (signs/symptoms) of distress. It continues, Was incident witnessed? No. and it did not document any actions taken. R17's Skin/Incident report, dated 11/6/2023, documented, After resident assisted into bed, noted a 7 x 2 cm skin tear to (left upper arm). Resident was combative when assisted to bed. Steri strips applied (and) a (dressing). (Complain of) pain and (vital signs) stable. It continues, Was incident witnessed? Yes, It continues, Action taken: Resident Education. The facility was unable to provide documentation that this incident was reported to the Administrator and state agency and investigated as an injury of unknown origin. An electronic mail dated 12/06/2023 at 11:23 AM, from V1 documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire and sign a form they received it. ( V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbal, physical or mental abuse in our policy was met by (V8, CNA) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility's Accident/Incident Reporting dated 12/2023 documented, Purpose: All accidents or incidents that result in an injury or illness must be reported to the Administrator, DON, or ADON. Procedure:1. Any accident or incident that results in an injury or illness must be reported within twenty-four (24) hours of the accident or incident. Any incident involving abuse will be reported within 2 hours of first notification. The abuse policy will be followed. 2.The DON will make an initial report of the incident and report it to IDPH through Facility Reported Incident. The following data, as it may apply, must be included on the Accident/Incident Report form: a. Name and address of the facility. b.Date and time the accident/incident occurred. c. Circumstances surrounding the accident/incident. d.Where the accident/incident occurred. e. Name(s) of any witness(es) and his/her account of the accident or incident. f. Name of the injury or illness (e.g., cut, needlestick, bruise, etc.). g.Follow-up information. h.Other pertinent facts as appropriate. Signature and title of the person completing the report. 3. The five-day final investigation report will be submitted through Facility Reported Incidents with in five working days after the incident initial report, a complete written report of the conclusion of the investigation, includes steps the facility has taken in response to the accident/incident. For the protection of the individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with permission of the Administrator or the facility attorney. The facility's Abuse prevention policy and procedure, dated 9/26/23, documented, Upon learning of suspected mistreatment, the administrator or designee shall notify the Illinois Department of Public Health and initiate an investigation. The facilities policy does not address injuries caused by an unknown source. The facility's matrix, dated 12/4/23, documented that there were 96 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly investigate allegations of verbal and physical abuse and injuries of unknown origins for 4 of 4 (R1, R2, R16, R17) residents reviewed for accidents and abuse in a sample of 17. This failure has the potential to affect all 96 residents residing in the facility. Findings include: 1. R2's admission record form, dated 12/3/23, documented R2 was admitted to the facility on [DATE] with diagnosis of dementia, anxiety disorder, age-related nuclear cataract, essential hypertension, dissection of unspecified site of aorta, thoracic aortic aneurysm (without rupture), and fracture of unspecified part of neck of right femur. R2's admission record form documented a diagnosis (with an onset dated 8/9/23) of acute embolism and thrombosis of other specified deep vein of right lower. R2's admission record form documented diagnosis (with onset dates of 8/17/23) of unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified severe protein-calorie malnutrition, and unspecified fracture of unspecified femur, subsequent encounter for closed fracture with routine healing. R2's MDS (Minimum Data Set), dated 11/6/23, documented R2 as being severely cognitively impaired. R2's care plan, dated, documented R2 as requiring a mechanical lift and assist of 2 for all transfers. On 12/4/23 at 11:20 AM, V14, R2's sister/Power of Attorney (POA), stated that R2 was admitted with a broken hip that was not repaired because of an aneurysm she had. V14 stated that the facility used a mechanical lift to transfer her because she could not stand. V14 stated that the doctor at the hospital said the hip might heal on its own but it didn't. She continued to state that she was visiting R2 one day in August, that she visited every day, and one day noticed her R2's leg was swollen, that it was bruised so she told them she wanted something done. V14 stated that they did a doppler and it revealed blood clots. V14 stated they sent her to the local hospital, and the local hospital transferred her to the regional hospital for surgery. V14 stated that V26, R2's orthopedic surgeon, at the regional hospital said it was a new break and the leg was broken this time, not the hip. V14 stated that V26 said it was a twisted break and if they didn't operate it would come through the skin, so they did surgery. She continued to state that V26 told her that this fracture was not from the previous hip fracture and that this was a new fracture of the leg. V14 stated she went to the facility staff and management and told them something caused this and that she wanted to know what did. She continued to state that the facility said that they do not have any documentation and that this was not a new fracture, it was from the hip fracture. V14 stated she tried to explain it wasn't, but that they just kept saying it was the same fracture. On 12/4/23 at 11:30 AM, V14, R2's sister/ POA stated, some of these young kids do not have compassion and some of the (Certified Nurse Assistants (CNA) are rough. I have video of a CNA named, (V8), tossing my sister around back and forth, yanking on her hands, and being rude. V14 stated that it happened a week ago Saturday when the CNA was getting R2 ready for breakfast. V14 stated she went to the Social Worker, and she said she had to report it to the Administrator. V14 stated she showed them both the video and they said they would speak to V8 about it. V14 stated that when she visited R2 on 11/28/23 she observed a large bruise covering R2's right hand. On 12/4/23 at 12:10 PM, V1, Administrator, with V2, Director of Nurses (DON) who was on a speaker phone as she was home sick. V2 stated that they tried to explain to, V14, R2's sister/POA that the fracture in August was not a new fracture and that it was from the hip fracture that she was admitted with in January. V1 stated that V2 even tried to explain with anatomy pictures to V14 about the fracture being the same one R2 had when she was originally admitted and that V14 just wasn't comprehending it. V2 stated I attempted multiple times to explain to V14 that it was a fragility fracture from the hip, and it wasn't new. When V1 was asked for their investigations and root cause analysis of the allegations of abuse and injury of unknown origin, V1 stated We didn't report or investigate the fracture from August because it wasn't a new fracture.' V1 continued to state We didn't report the video concerns because we cleared it on the spot when the sister brought it to me and our Social Worker. While we didn't like her behavior, we didn't feel like it rose to the level of abuse, so we didn't report it. R2's Video and audio footage, dated 11/26/23 at 6:40 AM, documented, R2 was nude and lying in bed. V8, CNA, turned R2 to her left side while placing a disposable undergarment on R2. V8 stated, Stop, let go before you rip it, let go of my finger, man! V8 abruptly pulled her hand away and stated, There's no reason for you to hold on to me and squeeze my fingers like that, that hurts! R2 stated I'm sure it does hurt. V8 replied Then stop! V8 then rolled R2 onto her left side in a rough manner. V8 stated to R2, Put your shirt on, come on put your sweater on, stop holding onto me! R2 continues to be resistant with dressing and V8 was observed tightly holding R2's right hand. R2's Video and audio footage dated 11/26/23 at 6:43 AM, documented, V8, CNA, pulling R2's pants up and R2's sweater down while R2 was lying in bed on her left side. V8 turned R2 onto her back in a rough manner and firmly grabbed R2's right hand, V8 stated Stop digging your nails into my skin now, let go! V8 walked away from R2's bed and left the bed in the high position. V8 retrieved the mechanical lift sling and placed it under R2 as R2 was lying on her left side. V8 turned R2 to her right side in a rough manner while bringing R2's left hand over on top of R2's right hand and then V8 used her left hand and arm to restrain R2's hands. V8 then shifted her body weight to increase pressure on top of R2's hands and wrists. R2 stated. Ow! V8 then turned R2 onto her back. V8 stated to R2, You're terrible! R2 stated, What? and V8 replied You are terrible, why do you keep trying to hit me and pinch me? V8 then lowered the bed and left the room. R2's Facility titled form, dated 11/26/23, documented, Resident wheeled to nurse's station and CNA reported bruise to (right) index finger. R2's Incident Report, dated 11/26/23, documented, Bruise found on right index finger. Area of concern: none. Resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurses and CNAS interviewed, and no areas of concern noted. The facility was unable to provide witness statements. On 12/5/23 at 2:35 PM V2, DON, stated, We report any fractures, anyone that goes to the hospital from an incident, or burns that require outside treatment. V2 stated, I know in R2's case, she was combative, so we knew the bruise was from that. We did not do an investigation and I know we should have looked into that. V2 stated, I was not involved in the instance with the CNA on the camera. V2 continued to state, What I usually do is clear it with V1, Administrator, and she usually says we know what happened, so we don't need to report it. On 12/5/23 at 3:08 PM, V1, Administrator, stated We report to state if there is any kind of injury that requires anything beyond first aid, if they were sent to the hospital from an incident, founded abuse, and allegations of abuse if we know its legit. V1 stated We are not going to hot line until we know its legit, like if the resident has a UTI (urinary tract infection), we will factor that into what they are saying. V1 stated that V2, DON, V23, Assistant Director of Nurses (ADON), and herself collaborate to decide if they need to report it. V1 stated that a serious injury or anything beyond first aid, they would report it. V1 continued to state that with unknown injuries they do a lot of interviewing and that they do not document the interviews with staff and residents. V1 stated that if there's a bruise like on R2, V2, DON, keeps a file on those. V 1 continued to state that R2's was a tiny bruise on a finger. V1 stated Honest to God if I did an investigation on every single little bruise, well it's not going to happen. V 1 continued to state, On abuse we decide if it is a reportable or not a reportable. On 12/4/23 at 12:30 PM, V7, Social Worker, stated When (R2's) family showed me the video, I was adamant that we had to report it to the Administrator. V7 continued to state that V14, R2's sister/POA, said she didn't want to get anyone in trouble. V7 stated In my opinion, I think the CNA could have handled it differently, but we don't feel it was abuse. We didn't feel it was intentional. The CNA apologized the next day to V14. On 12/6/23 at 10:42 AM, V24 LPN stated that R2 had a fracture earlier this year and there was no surgical intervention. V24 stated there was a follow-up x-ray in March with no change, no healing. V24 stated R2 complained of leg pain in August. V24 stated she knew nothing caused a new injury because there were no incidents in the chart. V24 stated they did another x-ray in August and that is when R2 was sent out to the hospital. V24 stated she recalled the leg being swollen and the family would tell us when they thought she was having pain because R2 could not always tell you when she was hurting. On 12/11/23 at 2:04 PM, V29, CNA stated that at one point we when R2 was getting therapy we used a pivot disc and 2 CNAS to transfer. On 12/11/23 at 2:17 PM, V30, CNA, stated that he always used a hoyer lift when transferring R2. He continued to state that therapy mentioning the pivot disc but he never attempted it with R2. On 12/5/23 at 1:20 PM, V8, Certified Nurse Assistant (CNA), stated, On 11/26/23, I went into (R2's) room to get her dressed for breakfast, she was combative as usual. V8, stated, I got her dressed and I felt myself getting worked up, so I lowered her bed and walked out. V8 continued to state, I grabbed her wrist softly at times to redirect her and I did not see any bruises on her hands or wrists. V8 stated (V23, Assistant Director of Nursing) came to me later that day and said R2's sister showed her the video. V8 stated, (V23) knows how (R2's) sister is and (V23) didn't want me to get in to trouble. (V23) told me to talk to the sister, so I did, I apologized, and her sister hugged me and said I am a good CNA. V8 stated that they did not send her home, they just put her on another hall. On 12/6/23 at 2:49 PM, V25, V26's Orthopedic Registered Nurse, stated that V26, R2's Orthopedic Surgeon, said the fracture in August was from a new injury and was not related to the past hip fracture. R2's x-ray results dated 8/8/23 from the x-ray that was completed in the facility documented there was an acute, displaced spiral fracture of the distal third of shaft of the femur with a conclusion of acute fracture distal femur. The facility failed to investigate the cause of the new fracture. R2's medical record dated 11/26/23 at 3:31 PM documented a bruise was noted to R (right) index finger. No s/s (signs or symptoms) of pain noted when assessing finger. ROM (range of motion) WNL (within normal limits). POA (power of attorney) notified. Will monitor. The facility's incident report form dated 11/26/23 documented resident frequently combative with staff. Resident noted to have hands folded on lap frequently. Likely bumped on table at meal or over bed table. Nurse and CNAs interviewed, and no areas of concern noted. The facility failed to provide documentation of investigation including witness statements. 2. R16's admission record, dated 12/4/23, documented diagnoses of Encephalopathy, Major depressive disorder and Dementia. R16's MDS, dated [DATE], documented that his cognition was severely impaired. R16's Progress note, dated 10/21/23, documented, CNA notified nurse res is bleeding. Nurse observes dried black blood with scant amount light red blood to R (right) hand. Resident unable to answer, how did this happen. On 12/5/23 at 10:55 AM, R16 was sitting in dining room in wheelchair, activity getting ready to start. Resident was unshaven with food on his face. Resident said hello but did not respond to questions by writer. No bruises were noted. On 12/5/23 at 3:08 PM, V1, Administrator, stated I was looking at R16's chart when I sent it to you and the nurse probably assumed it was from picking. The facility was unable to provide an unknown injury investigation including witness statements into the cause of this injury. 3. On 12/05/2023 at 10:00 AM, R1 was sitting up in a high back reclining wheelchair in the hallway. R1 had a fading yellowish/green bruising below both of her eyes and a large, approximately 2 centimeters (cm), greenish/yellow raised area to the right side of the top of her head. R1's facility titled form, dated 10/29/2023, documented, CNA alerted this nurse that res had bump on forehead purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No (signs or symptoms) of pain or distress noted. It also documents, Was incident witnessed? No. R1's progress note, dated 10/29/2023 at 9:00 AM, documented, CNA, alerted this nurse that resident has bump on forehead. Purple bruise over bump noted to middle of resident's forehead. Measures 3.5 cm x 3.0 cm. Neuro assessment WNL. No s/s of pain or distress noted. There was not any investigative notes, root cause analysis or interviews in R1's progress notes or in R1's electronic medical record. R1's admission Record, dated 12/05/2023, documented diagnoses of Vascular Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. R1's, Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely to never understood, that she had no impairment to her upper or lower extremities and that she was incontinent of bowel and bladder. R1's Care Plan, dated 11/25/2023, documented, Floor mat x2. Neuro checks, re arrange furniture. On 12/05/2023 at 2:35 PM, V2, DON, stated that R1's bump on her head on 10//29/2023, was from the mechanical lift. When asked for investigation, root cause analysis and interviews of staff and residents, V2 stated, We only have what's in the chart. The facility was unable to provide documentation that this incident was investigated and was reported to the state agency. 4. On 12/05/2023 at 9:45 AM, R17 was sitting up in her wheelchair at the nurses station. Staff was assisting with putting her hearing aide back in her right ear. R17 stated she was good and asked writers name, but was unable to recall anything else regarding skin tears or bruising to her body or how it happened. R17's MDS dated [DATE] documented that her cognition was severely impaired, that she has no impairments to her upper or lower extremities and that she uses a wheelchair and a walker. It also documents that she requires substantial to maximal assistance for most activities of daily living and that she was frequently incontinent of bowel and bladder. R17's Care Plan dated 9/25/2023 documented, Educate resident/family/ caregivers of causative factors and measures to prevent skin injury. R17's Skin/Incident report dated 10/14/2023, documented, CNA alerted this nurse of resident skin tear. Skin tear noted to (right forearm) crescent shaped measuring 6.5cm x 1.0 cm. small amount of serous fluid noted. Cleansed ns. Unable to reapproximate. Xeroform, non adherent pad and dry dressing applied. Denies pain. no (signs/symptoms) of distress. It continues, Was incident witnessed? No. and it did not document any actions taken. R17's Skin/Incident report, dated 11/6/2023, documented, After resident assisted into bed, noted a 7 x 2 cm skin tear to (left upper arm). Resident was combative when assisted to bed. Steri strips applied (and) a (dressing). (Complain of) pain and (vital signs) stable. It continues, Was incident witnessed? Yes, It continues, Action taken: Resident Education. The facility was unable to provide documentation that this incident was investigated and was reported to the state agency. An electronic mail, dated 12/06/2023 at 11:23 AM, from V1, Administrator, documented, Our morning meeting ran over and then Wednesday Medicare Mtg, but I wanted to get you at least the Abuse Policy as it relates to investigations and procedures. Our employees are also given a copy of this entire policy at hire, and sign a form they received it. ( V2, DON, V23, ADON and V1, Administrator) reviewed it again this morning at 8am to make sure we felt we followed the policy. While hindsight is always 20/20, we still don't believe the definition listed of verbal, physical or mental abuse in our policy was met by (V8, CAN) lack of warmth and patience with (R2). Harsh tone, yes. Abrupt care, yes. Willful disparaging and derogatory terms to the resident, threats of harm or isolation were not present. Harassment and threats of punishment, not present. Hitting, slapping, pinching, kicking and corporal behavior, not present. After further discussion, we all agree that (V14, R2's sister/POA) came to (V7, Social Service) saying she had a concern, but asked us not to report (V8, CNA) because she didn't want her to lose her job or get in trouble. Our conclusion was that this was not an allegation of abuse by the sister, but dissatisfaction with level/type of care/attitude/tone. In summary, it didn't meet our policy's definition of abuse as it's laid out. Going forward, we will err on the side of caution, take your advice, and over-report. We feel we followed our policy and did a best practice decision of removing (V8, CNA) from the hall, speaking to her about her tone and abruptness of care, and respecting the family's wishes that she not be fired or be made to be in trouble. It was only after (R2) passed from an unrelated rapid onset medical condition that this concern resurfaced and was escalated beyond what the sister originally asked us to do. We still struggle with the position we were asked to be in, but next time, we will report despite family asking us to handle it internally, per again, erring on the side of caution. Thank you! The facility's Accident/Incident Reporting dated 12/2023 documented, Purpose: All accidents or incidents that result in an injury or illness must be reported to the Administrator, DON, or ADON. Procedure:1. Any accident or incident that results in an injury or illness must be reported within twenty-four (24) hours of the accident or incident. Any incident involving abuse will be reported within 2 hours of first notification. The abuse policy will be followed. 2.The DON will make an initial report of the incident and report it to IDPH through Facility Reported Incident. The following data, as it may apply, must be included on the Accident/Incident Report form: a. Name and address of the facility. b.Date and time the accident/incident occurred. c.Circumstances surrounding the accident/incident. d.Where the accident/incident occurred. e. Name(s) of any witness(es) and his/her account of the accident or incident. f. Name of the injury or illness (e.g., cut, needlestick, bruise, etc.). g.Follow-up information. h.Other pertinent facts as appropriatei. Signature and title of the person completing the report. 3. The five-day final investigation report will be submitted through Facility Reported Incidents with in five working days after the incident initial report, a complete written report of the conclusion of the investigation, includes steps the facility has taken in response to the accident/incident. For the protection of the individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with permission of the Administrator or the facility attorney. The facility's Abuse prevention policy and procedure, dated 9/26/23, documented, Upon learning of suspected mistreatment, the administrator or designee shall notify the Illinois Department of Public Health and initiate an investigation. The facilities policy does not address injuries caused by an unknown source. The facility's matrix, dated 12/4/23, documented that there were 96 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to provide appropriate catheter care for one of four residents (R150) reviewed for catheter care in the sample of 42. Findings Include: R150's Care Plan dated 9/15/23 documents, resident (R150) has a urinary catheter. Interventions catheter care and treatment per current MD, (Medical Doctor), Observe/record/report to MD for signs and symptoms of UTI, (Urinary Tract Infection), which are pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. R150's admission summary dated [DATE] documents, R150 was placed on contact isolation for MRSA, (Methicillin Resistant Staph Aureus), and penile drainage. R150's Genital culture dated 9/13/23 documents, MRSA, (Methicillin-resistant Staphylococcus aureus). R150's Physician Order Sheet, (POS), dated 9/19/23 documents, Linezolid 600mg, (milligrams), by mouth every 12 hours for MRSA in penis. R150's POS dated 9/21/23 documents, (indwelling Catheter), related to retention of urine unspecified. R150's POS for the month of September did not document catheter care. R150's Minimum Data Set, (MDS), dated [DATE] documents, R150 is moderately cognitively impaired. On 9/21/23 at 9:35 AM there is a sign on R150's door, for contact isolation and personal protective equipment outside the door. V20 and V21 CNAs donned gowns and gloves and entered the room. V20 and V21 CNAs told R150, they were going to do catheter care. V20 and V21 washed their hands, and donned gloves. V20 CNA wiped both sides of the peri area with a no rinse disposable incontinent pad. She with the same gloves with no hand sanitization. she cleansed the head of the penis. V20 grabbed more no rinse incontinent wipes and cleaned from the end of the penis down the tubing of the catheter, she then rolled him over, and grabbed more wipes and cleansed the rectum area. V20 did not change gloves or hand sanitize. On 9/22/23 at 10:45 AM, V7 CNA stated, I change gloves quite frequently. I hand sanitize every time I change gloves. On 9/22/23 at 10:47 AM, V23 CNA stated, every time, I touch something dirty. I hand sanitize, every time I take the gloves off. On 9/22/23 at 10:49 AM, V26 CNA stated, I change gloves every time I change an area. You should hand sanitize every time you take off your gloves. The facility's policy entitled Urinary Catheter, (Indwelling), Daily Care dated 6/24/09 documents, The purpose of daily catheter care is to assist in preventing infections and prevent bladder damage due to improper care and handling. Routine catheter care is part of the resident's morning care, and as needed by the resident's specific needs. All residents who have an indwelling urinary catheter will receive catheter care every shift, and whenever necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the privacy and confidentiality of 4 of 6 residents (R5, R31, R70 and R82) in the sample of 42, by displaying identifying information that includes their names, date of birth s, room location, care needs and code status in plain view of the public hanging over the residents' beds. Findings include: 1. R5's Face Sheet undated documents, R5's diagnosis as Severe Protein Malnutrition, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R5's Minimum Data Set, (MDS), dated [DATE] documents, R5's Cognitive Skills for Daily Decision Making as severely impaired. R5 is Total Dependent for bed mobility, transfer, locomotion on and off unit, eating, personal hygiene and toilet use. Extensive Assistance is required for dressing. R5's Visual Bedside [NAME] Report, undated documents, R5's identifying information, (i.e., name. d.o.b. and room location) and admission date, allergies, bathing assistance requirements and toileting assistance needs. 2. R31's Face Sheet undated documents, R31 diagnosis as Acute kidney Failure, Unspecified, Delusional Disorder, Personal history of Covid-19, Dementia in other Disease classified elsewhere, Unspecified Severity, with other Behavioral Disturbance and Anxiety Disorder. R31's Minimum Data Set, (MDS), dated [DATE] documents, a BIMS of 1; Wandering behavior occurred daily, wandering significantly intrudes on the privacy or activities of others. R31 requires Limited Assistance in personal hygiene, toilet use, dressing, walk in corridor, walk in room, transfer, and bed mobility. Independent in locomotion on and off the unit and eating. Balance during transitions and walking- not steady, only able to stabilize with staff assistance, moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet and surface-to surface transfer. R31's Visual Bedside [NAME] Report undated documents, R31's identifying information (i.e., name. d.o.b. and room location) and admission date, allergies, bathing assistance requirements and toileting assistance needs. 3. R70's Face Sheet undated documents, R70's diagnosis as Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Nontoxic Single Thyroid Nodule, Chronic Fatigue, Unspecified, Frequency of Micturition. MDS dated [DATE] documents, a BIMS of 14; R70 is occasionally incontinent of urine and is always incontinent of bowel; R70 is not part of toileting program. R70 requires Extensive Assistance in personal hygiene, Limited Assistance in Toilet use, dressing and bed mobility, supervision in locomotion on and off unit, walk in corridor, walk in room and independent transfer and eating. R70's Visual Bedside [NAME] Report undated documents R70's identifying information (i.e., name. d.o.b. and room location) and admission date, allergies, bathing assistance requirements and toileting assistance needs. 4. R82'sFace Sheet undated documents, diagnosis as Type 2 Diabetes Mellitus with Unspecified, Anxiety Disorder, Unspecified, Insomnia, and Muscle weakness. R82's Minimum Data Set, (MDS), dated [DATE] documents, R82 is cognitively severely impaired; requires Extensive Assistance in personal hygiene, toilet use and dressing. Limited Assistance in Walk in corridor, walk in room and transfer. Supervision in bed mobility and locomotion on unit; Independent in Locomotion off unit and eating. Balance during Transitions and walking- Not steady, only able to stabilize with staff assistance in moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet, surface to surface. R82's Visual Bedside [NAME] Report undated documents, R82's identifying information (i.e., name, d.o.b. and room location) and admission date, allergies, bathing assistance requirements and toileting assistance needs. On 9/21/23 at 3:45 PM V1 Administrator stated, the facility had a lot of agency staff, and we were trying to ensure that they were equipped to care for our residents in the manner we are accustomed. On 9/22/23 at 8:51 AM V13 LPN stated, the [NAME] is used to aid in resident care. If a staff person is rotated or assigned to this unit all the information, they need to adequately care for the resident is right in front of them. Each [NAME] is resident specific. Yes, anyone that enters the room can view the information. 9/22/23 at 10:41 AM V25 CNA, (agency), stated, the [NAME] helps in caring for the residents. The [NAME] includes care plan information, transfer information, toileting, bathing, feeding, and dressing assistance. Had not thought about how she could prevent visitors from viewing the resident's information. The State of Illinois Department on Aging Resident's Rights for People in Long-term Care Facilities undated documents, You have the right to .Privacy: Your medical and personal care are private. Your facility may not give information about you or your care to any unauthorized person(s) without your permission.

Based on observation, interview and record review, the Facility failed to store, prepare, and serve food in a manner which prevents potential contamination. This has the potential to affect all 96 residents living in the Facility. Findings include: On 9/19/23 at 8:44 AM V10, dishwasher, was spraying dirty dishes in the third compartment of the three-compartment sink. The spray resulted in drops of water on the floor approximately three feet away and on the arm of the surveyor standing next to a shelf. The shelf held a container of clean eating utensils and two trays of mandarin oranges that were not covered, potentially allowing a point of entry for the rinse water. On 9/19/23 at 8:47 AM the beverage refrigerator, next to the steam table contained ten individual cups of chocolate pudding that were not covered, labeled, or dated. On 9/19/23 at 8:48 AM the first compartment of the three-compartment sink held a crate with nutritional supplements. There was a pair of dishwashing gloves draped across the faucet that were in contact with the crate. The second compartment of the sink held a crate with 2% milk. The third compartment was full of dirty dishes. On 9/19/23 at 8:55 AM the beverage refrigerator in the dry storage room had a 46-ounce container of grape juice that was opened and half empty but was not dated with opening date. On 9/19/23 at 9:53 AM V9, Dietary Manager, stated, she would expect staff to keep food away from dirty dishes and already told her staff to move the desserts away from the dirty dishes. On 9/21/23 at 3:10 PM, V1, Administrator, stated, she expects staff to follow their food service policies. The Facility's Food and Nutrition Policy updated 3/27/18 documents, (Facility) shall store, prepare, distribute and serve food under sanitary conditions and in a manner that protects it against contamination and spoilage in accordance with food service requirements of Chapter 3717-1 of the Administrative Code. The Facility's Food Storage (Dry, Refrigerated, and Frozen dated 2020 documents, Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. The Facility's Resident Census and Condition of Residents Form (CMS 672) dated 9/19/23 documents there are 96 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide turning, repositioning, and incontinence care to promote the healing of an existing pressure ulcer for 1 of 3 residents (R26) reviewed for pressure ulcers in the sample of 39. Findings include: R26's Face Sheet documents R26 was admitted on [DATE] with a diagnosis of dementia in other diseases classified elsewhere with behavioral disturbance, undifferentiated schizophrenia, Parkinson's disease, other abnormalities of gait and mobility, and pressure ulcer of sacral region, stage 4. R26's Minimum Data Sheet (MDS) dated [DATE] documents R26 is significantly cognitively impaired, requires extensive 2+ person assistance for bed mobility and toileting, and requires total dependence of 2+ persons for transfer. MDS documents R26 is always incontinent of bowel and bladder, is at risk for developing pressure ulcers/injuries, and has one stage 4 pressure ulcer. R26's Care Plan dated 4/14/2022 documents, (R26) is at risk for skin integrity impaired R/T (related to) decreased mobility, inc (incontinent) large amt (amount) of urine, muscle weakness, coccyx wound. Intervention: B&B (bowel and bladder) during the night to help reduce incontinent episodes. B&B before/after meals and PRN (as needed). (Wound Consultant Company) to treat and evaluate. Change of position every two hours and PRN. R26's Physician Order Sheet (POS) for July 2022 documents order to, NS (Normal Saline) cleanse to coccyx, apply skin prep to peri wound, then apply TRIAD to wound bed, cover with hydrocolloid, change q (every) other day and PRN. Every day and evening shift every other day for coccyx ulcer with start date of 6/22/22. (Wound Consultant Company) and treat wound as indicated was ordered on 1/2/2020. R26's (Wound Consultant Company) notes from 7/6/2022 document, F/u (follow up) of this 77 y/o (year old) female with a chronic coccyx pressure ulcer, currently treating with TRIAD and hydrocolloid. Healing complicated by fecal and urinary incontinence. Wound/ulcer #1 coccyx noted 12/30/19. Pressure ulcer/injury stage 4. 100% Epithelium. Measurements: 1.3 centimeters (cm) x 0.2 cm x 0.2 cm. Nursing is repositioning q 2 hours and PRN and providing incontinence care 2 hours and PRN to promote healing. On 7/7/22 at 11:10 AM, R26 was sitting in her wheelchair at a table in the dining room. R26 remained in her wheelchair in the dining room at 1:25 PM. R26 was not taken out of the dining room by staff at any time during the 2 hours and 15 minutes for turning, positioning, or incontinence care. On 7/7/22 at 1:27 PM, V13, Certified Nursing Assistant (CNA) stated, I changed (R26) this morning. I'm not sure what time, but I would guess around 9:45 AM. On 7/7/22 at 1:30 PM, V18, CNA, stated, I have not changed (R26) today. On 7/7/22 at 4:00 PM, V2, Director of Nursing, stated, I would expect staff to reposition residents and provide incontinence care every two hours. On 7/8/22 at 8:11 AM, V21, (Wound Consultant Company) Nurse Practitioner, stated, Typically we expect our patients to be turned and repositioned every two hours. Incontinence care should also be provided every 2 hours. Incontinence is the bigger factor for (R26) because she is always wet. If staff does not provide incontinence care as prescribed, that could definitely impact (R26's) healing. On 7/8/2022 at 9:00 AM, R26's pressure ulcer treatment was observed. V22 and V23, CNAs, positioned the resident on her right side. V12, Licensed Practical Nurse (LPN), removed the old dressing, applied skin prep to the peri wound area, applied wound cream to the wound bed, and then applied a dressing. In between removing the old dressing, applying skin prep, applying wound cream to the wound bed, and applying the clean dressing, V12 removed her gloves and sanitized her hands. Each time V12 sanitized her hands and changed gloves, V22 and V23 positioned the resident to lay directly on the incontinence pad, with no barrier between the pressure ulcer and the pad. On 7/8/2022 at 10:22 AM, V3, Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP), stated, I would not expect staff to leave residents with wound on incontinence pad for any length of time, but during dressing changes, as long as the pad is clean and the resident remains dry, it would be acceptable for a short period of time. On 7/8/22 at 12:45 PM, V3, ADON and ICP, stated, We do not have a policy on turning and repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to treat urinary tract infections timely with the appropriate antibiotics and perform thorough incontinent care for 4 of 10 residents (R34, R37, R52, R77) reviewed for incontinent care and Urinary Tract Infections in the sample of 39. Findings include: 1.R34's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA (urinalysis) reported to NP (Nurse Practitioner) - N.O. (new order) rec'd for Rocephin (antibiotic) 1gm IM X1 - then Macrobid (antibiotic) 100mg PO BID X 7 days - Watch for UA CX (culture) and report to NP ASAP (as soon as possible) to assure ABT (antibiotic) is sensitive to bacteria in urine. R34's Antibiotic was started prior to receiving urine culture results. R34's Lab Report dated 04/18/22 documents Specimen: Escherichia coli. Macrobid (Nitrofurantoin) is Sensitivity<=32. R34's Care Plan dated 01/19/22 documents (R34) is incontinent of bladder. R34's Care Plan documents ADL self-care needs limited to extensive assist of 1 for dressing, toileting, transfers. independent with bed mobility and needs encouragement for eating independent. R34's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 9 out of 15. Resident is moderately impaired. R34's MDS dated [DATE] documents resident requires extensive assistance of one-person for bed mobility. Resident requires limited assistance of one-person for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. Resident is independent with setup help only for eating. Resident requires physical help limited to transfer only with one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses wheelchair and walker for mobility. R34's MDS documents resident is always incontinent of bladder and bowel. 2. R37's Health Status Note dated 07/02/22 at 8:15 PM documents REPORTED UA TO ON CALL DR. N.O. BACTRIM DS (antibiotic) BID X 7DAYS R/T (related to) UTI (urinary tract infection). NP MADE AWARE ON MP. PO (oral) FLUIDS ENC (encouraged) AND TAKEN FAIR. PERI CARE GIVEN Q (every) 2HRS AND PRN (as needed). DENIES ANY PAIN OR DISCOMFORT. WILL MX (monitor). R37's Lab Report dated 07/02/22 documents Detected Pathogen Results Summary: Escherichia Coli. Suggested Antibiotics: Fosfomycin po, Gentamicin, Plazomicin, Tobramycin. E. Coli is Resistive>2/38 to Bactrim (Trimethoprim/Sulfamethoxazole) antibiotic. R37's Physician Order dated 07/03/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 Days until finished R37's Order Note dated 07/05/22 at 3:05 PM documents Resident has a new order to d/c (discontinue) Bactrim order and to start Fosfomycin (antibiotic) 3gm (gram) packet PO x1 dose, A1C (glycated hemoglobin) CMP (complete metabolic panel) CBC (complete blood count) TSH (thyroid stimulating hormone) Vit. D Vit. B12 and lipid to be drawn on 7/11/22. POA (Power of Attorney) NOT AWARE. R37 was started on Bactrim and then had to being started on a Fosfomycin after the results of the urine culture showed that Bactrim was resistant to the bacteria. R37's Physician Order dated 07/06/22 documents Fosfomycin Tromethamine Packet 3 gm; Give 1 packet by mouth one time a day for UTI for 1 day. R37's Physician Order dated 07/07/22 documents Fosfomycin Tromethamine packet 3 gm; give 1 packet by mouth one time a day for UTI for 1 day. On 07/08/22 at 9:25 AM, V13 Certified Nurse's Aide (CNA) and V24, Licensed Practical Nurse (LPN) assisted R37 with incontinent care. No hand hygiene was performed prior to starting. V24 spray wash clothes with Peri Fresh spray. She then handed the washcloth to V13, who wiped R37's right side of leg crease and right side of peri-area. V13 placed the washcloth in the dirty linen bag. V24 handed V13 another wash cloth sprayed with peri fresh. V13 then wiped the center of R37's peri-area and placed the washcloth in the dirty linen bag. V24 handed V13 another wash cloth sprayed with peri fresh. V13 wiped the left leg crease and left side of peri-area. He placed the washcloth in the dirty linen bag and removed his gloves. V13 then donned a new pair of gloves without washing hands or using hand sanitizer. V24 then handed V13 a washcloth with peri fresh to wipe her back side. After wiping her back side, V13 announced that they should change their gloves. Both staff changed their gloves without washing their hands or using hand sanitizer. V24 proceeded to dry R37's back side and peri-area using the same towel. V13 changed gloves 3 times without any hand hygiene. V24 change gloves 4 times without hand hygiene. R37's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. Resident requires limited assistance of one-person for locomotion on unit and locomotion off unit. Resident is independent with setup help only for eating. R37's MDS documents resident is always incontinent of bladder and bowel. 3. R52's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA reported to NP - N.O. rec'd for Rocephin 1gm IM X1 - then Macrobid 100mg PO BID X 7 days - Watch for UA CX and report to NP ASAP to assure ABT is sensitive to bacteria in urine. R52 was started on 2 antibiotics before the knowing the results of the urine culture. R52's Communication with Physician dated 05/16/22 at 11:45 AM documents UA reported to NP - N.O. for Macrobid 100mg PO BID X 7 days. POA NN. R52's Physician Order dated 05/16/22 documents Macrobid 100 mg (Nitrofurantoin); Give 1 capsule by mouth two times a day for UTI for 7 days x 7 days. R52's Urine Culture & Sensitivity Reports dated 05/16/22 documents Organism: E. coli (ESBL producer). Sensitivity<=32 for Nitrofurantoin (Macrobid). R52's Physician Order dated 05/27/22 documents resident on contact isolation r/t ESBL. R52's Urine Culture Report dated 06/29/22 documents Pathogen: Klebsiella pneumoniae. Suggested Antibiotic: Plazomicin, TMP-SMX. R52's Physician Order dated 06/30/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 days. R52's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Resident requires limited assistance of one-person for locomotion on unit, locomotion off unit, and eating. Resident is always incontinent of bladder and bowel. On 07/08/22 at 10:30 AM, observation of incontinent care with V25 and V26, CNAs. V25 and V26 transferred R52 from the wheelchair to the bed using a gait belt. V26 washed her hands in bathroom. V25 applied a gown over R52's clothes. V26 donned gloves. V25 washed her hands in the bathroom and donned gloves. V25 pulled down R52's pants and removed depends. V25 removed gloves and donned new gloves with hand hygiene. V25 spray peri-wash to wet wash cloth and wiped the right leg crease and right side of peri-area. V25 placed wash cloth in linen bag. V25 sprayed a new wet washcloth and proceeded to wipe the center of R52's peri-area. V25 placed wash cloth in linen bag. V25 sprayed a new wet wash clothes and wiped R52's back side. V25 placed wash cloth in linen bag. V25 sprayed a new wet cloth and wiped her buttocks. V25 then took a towel and dry her backside. V25 placed the towel in the linen bag. V25 took another towel and dried R52's peri-area. V26 applied a new depends on R52. V25 removed gloves and washed her hands in the bathroom. V26 applied R52's pants. V26 removed gloves and washed hands in bathroom. 4. R77's Order Note dated 10/19/21 at 12:56 PM documents Urine culture and sensitivity returned. Resident currently taking Macrobid 100mg PO BID - antibiotic noted to be resistant to bacteria present in urine. Urine C&S (culture and sensitivity) reported to NP - awaiting updated orders. R77's Order Note dated 10/19/21 at 1:15 PM documents N.O. rec'd from NP R/T urine culture and sensitivity - D/C Macrobid and start Ciprofloxacin (antibiotic)500mg PO BID (twice a day) X 7 days. R77's Physician Order dated 10/15/21 documents Macrobid capsule 100 mg (Nitrofurantoin Monohydrate); Give 1 tablet by mouth two times a day for UTI for 7 days. R77's Physician Order dated 10/19/21 documents Ciprofloxacin HCL tablet 500 mg; Give 1 tablet by mouth two times a day related to Urinary Tract Infection, Site Not Specified. R77's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, dressing, toilet use, and personal hygiene. Resident is total dependence of two plus persons for transfer. Resident is total dependence of one-person for locomotion on unit, locomotion off unit, and bathing. Resident requires limited assistance of one-person for eating. On 07/8/22 at 12:45 PM, V3, Assistant Director of Nursing (ADON)) stated, I expect my staff to wash their hands in between glove changes if the resident has a bowel movement and they get it on their gloves. Otherwise, I expect them to be using hand sanitizer in between glove changes. On 07/08/22 at 1:00 PM, V3, stated, We don't have a policy specific to UTIs.

Based on interview, observation, and record review the facility failed perform hand hygiene to prevent the spread of infection for 4 of 4 residents' (R37, R52, R71, R74) reviewed for infection control in the sample of 39. Findings include: 1. R37's Health Status note dated 07/02/22 at 8:15 PM documents REPORTED UA (urinalysis) TO ON CALL DR. N.O. (new order) BACTRIM DS (antibiotic) BID (twice a day) X 7DAYS R/T (related to) UTI (urinary tract infection). NP (Nurse Practitioner) MADE AWARE ON MP. POANN. PO FLUIDS ENC AND TAKEN FAIR. PERI CARE GIVEN Q 2HRS AND PRN. DENIES ANY PAIN OR DISCOMFORT. WILL MX (monitor). On 07/08/22 at 9:25 AM, observation of incontinent care performed by V13, CNA (Certified Nursing Aid) and V24, LPN (Licensed Practical Nurse) on R37. No hand hygiene was performed prior to starting. V24 sprayed a washcloth with Peri Fresh spray. She then handed the washcloth to V13, who wiped R37 the right side of leg crease and right side of peri-area. V13 placed the washcloth in the dirty linen bag. V24 handed V13 another washcloth sprayed with peri fresh. V13 then wiped the center of R37's peri-area and placed the washcloth in the dirty linen bag. V24 handed V13 another washcloth sprayed with peri fresh. V13 wiped the left leg crease and left side of peri-area. He placed the washcloth in the dirty linen bag and removed his gloves. V13 then donned a new pair of gloves without washing hands or using hand sanitizer. V24 then handed V13 a washcloth with peri fresh to wipe her back side. After wiping her back side, V13 announced that they should change their gloves. Both staff changed their gloves without washing their hands or using hand sanitizer. V24 proceeded to dry R37's back side and peri-area using the same towel. V13 changed gloves 3 times without any hand hygiene. V24 change gloves 4 times without hand hygiene. 2. R52's Order Note dated 06/30/22 at 11:48 AM documents resident has new order for Bactrim DS (antibiotic) 1 tab PO BID x7 days r/t UTI, POA AWARE. On 07/08/22 at 10:30 AM, observation of incontinent care with V25 and V26. V25 and V26 transferred R52 from the wheelchair to the bed using a gait belt. V26 washed her hands in bathroom. V25 applied a gown over R52's clothes. V26 donned gloves. V25 washed her hands in the bathroom and donned gloves. V25 pulled down R52's pants and removed depends. V25 removed gloves and donned new gloves with hand hygiene. V25 sprayed peri-wash to wet washcloth and wiped the right leg crease and right side of peri-area. V25 placed washcloth in linen bag. V25 sprayed a new wet washcloth and proceeded to wipe the center of R52's peri-area. V25 placed washcloth in linen bag. V25 sprayed a new wet washcloth and wiped R52's back side. V25 placed washcloth in linen bag. V25 sprayed a new wet cloth and wiped her buttocks. V25 then took a towel and dried her backside. V25 placed the towel in the linen bag. V25 took another towel and dried R52's peri-area. V26 applied a new depends on R52. V25 removed gloves and washed her hands in the bathroom. V26 applied R52's pants. V26 removed gloves and washed hands in bathroom. 3. R71's Health Status Note dated 07/02/22 at 10:45 PM documents Spoke with Nurse at (local hospital). Resident has UTI and they are starting her on Macrobid. Will be sending back to facility tonight. Updated DON (Director of Nursing) and POA (Power of Attorney). Sent message on Mxxxxxxxxxx (secure clinical communication tool.) On 7/08/22 at 10:20 AM, observation of incontinent care with V13 and V24. No hand hygiene prior to donning gloves. Assisted R71 to restroom with walker. V13 assisted to pull pants and depends. V13 changed gloves with hand hygiene. V24 wiped R71's peri-area after toileting. V24 removed gloves and assisted R71's to stand. V13 wiped R71's backside. V24 donned gloves with no hand hygiene and assisted R71's with pulling up her depends and pants. V13 changes his gloves with no hand hygiene. V24 washed her hands. V13 flushed the toilet, removed his gloves and washed hands. 4. R74's Order Note dated 10/19/21 at 12:56 PM documents Urine culture and sensitivity returned. Resident currently taking Macrobid 100mg PO BID - antibiotic noted to be resistant to bacteria present in urine. Urine C&S reported to NP - awaiting updated orders. On 07/08/22 at 10:49 AM, observation of incontinent care with V13 and V26. V26 washed her hands in the bathroom and applied gloves. V26 wiped the right leg crease and right side of peri-area with a wet washcloth. V26 placed washcloth in linen bag and grabbed a new wet washcloth. V26 wiped the left leg crease, left side of peri-area, and down the center of peri-area. V13 and V26 both changed gloves with hand hygiene. V26 wiped back side with wet washcloth then dried backside with a towel. V26 changed gloves with hand hygiene. V26 applied a new depend on R74. V13 removed gloves and wash hands in the bathroom. V26 applied R74's pants. V13 donned gloves and assisted V26 with pulling up R74's depends and pants. V13 changed gloves with no hand hygiene. V26 removed gloves and starting untying R74's shoes. V26 washed hands. V13 applied R74's shoes. V13 removed gloves. No hand hygiene. Attached legs to wheelchair. V13 applied new gloves with hand hygiene. Assisted R74 to transferred from the bed to the wheelchair using a gait belt. On 07/08/22 at 12:45 PM, V3, Assistant Director of Nursing stated, I expect my staff to wash their hands in between glove changes if the resident has a bowel movement and they get it on their gloves. Otherwise, I expect them to be using hand sanitizer in between glove changes. Facility's policy Standard Precautions for Infection Control undated documents Wash immediately after gloves are removed and between patient contacts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure antibiotics are effective in treating the infections they are prescribed to treat for 4 of 10 residents (R34, R37, R52, R77) reviewed for antibiotic stewardship in the sample of 39. Findings include: 1.R34's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA (urinalysis) reported to NP (Nurse Practitioner) - N.O. (new order) rec'd for Rocephin (antibiotic) 1gm IM X1 - then Macrobid (antibiotic) 100mg PO BID X 7 days - Watch for UA CX (culture) and report to NP ASAP (as soon as possible) to assure ABT (antibiotic) is sensitive to bacteria in urine. R34's Antibiotic was started prior to receiving urine culture results. R34's Lab Report dated 04/18/22 documents Specimen: Escherichia coli. Macrobid (Nitrofurantoin) is Sensitivity<=32. R34's Care Plan dated 01/19/22 documents (R34) is incontinent of bladder. R34's Care Plan documents ADL self-care needs limited to extensive assist of 1 for dressing, toileting, transfers. independent with bed mobility and needs encouragement for eating independent. R34's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 9 out of 15. Resident is moderately impaired. R34's MDS dated [DATE] documents resident requires extensive assistance of one-person for bed mobility. Resident requires limited assistance of one-person for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. Resident is independent with setup help only for eating. Resident requires physical help limited to transfer only with one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses wheelchair and walker for mobility. R34's MDS documents resident is always incontinent of bladder and bowel. 2. R37's Health Status Note dated 07/02/22 at 8:15 PM documents REPORTED UA TO ON CALL DR. N.O. BACTRIM DS (antibiotic) BID X 7DAYS R/T (related to) UTI (urinary tract infection). NP MADE AWARE ON MP. PO (oral) FLUIDS ENC (encouraged) AND TAKEN FAIR. PERI CARE GIVEN Q (every) 2HRS AND PRN (as needed). DENIES ANY PAIN OR DISCOMFORT. WILL MX (monitor). R37's Lab Report dated 07/02/22 documents Detected Pathogen Results Summary: Escherichia Coli. Suggested Antibiotics: Fosfomycin po, Gentamicin, Plazomicin, Tobramycin. E. Coli is Resistive>2/38 to Bactrim (Trimethoprim/Sulfamethoxazole) antibiotic. R37's Physician Order dated 07/03/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 Days until finished R37's Order Note dated 07/05/22 at 3:05 PM documents Resident has a new order to d/c (discontinue) Bactrim order and to start Fosfomycin (antibiotic) 3gm (gram) packet PO x1 dose, A1C (glycated hemoglobin) CMP (complete metabolic panel) CBC (complete blood count) TSH (thyroid stimulating hormone) Vit. D Vit. B12 and lipid to be drawn on 7/11/22. POA (Power of Attorney) NOT AWARE. R37 was started on Bactrim and then had to being started on a Fosfomycin after the results of the urine culture showed that Bactrim was resistant to the bacteria. R37's Physician Order dated 07/06/22 documents Fosfomycin Tromethamine Packet 3 gm; Give 1 packet by mouth one time a day for UTI for 1 day. R37's Physician Order dated 07/07/22 documents Fosfomycin Tromethamine packet 3 gm; give 1 packet by mouth one time a day for UTI for 1 day. 3. R52's Communication with Physician dated 04/18/22 at 3:58 PM documents Labs and UA reported to NP - N.O. rec'd for Rocephin 1gm IM X1 - then Macrobid 100mg PO BID X 7 days - Watch for UA CX and report to NP ASAP to assure ABT is sensitive to bacteria in urine. R52 was started on 2 antibiotics before knowing the results of the urine culture. R52's Communication with Physician dated 05/16/22 at 11:45 AM documents UA reported to NP - N.O. for Macrobid 100mg PO BID X 7 days. POA NN. R52's Physician Order dated 05/16/22 documents Macrobid 100 mg (Nitrofurantoin); Give 1 capsule by mouth two times a day for UTI for 7 days x 7 days. R52's Urine Culture & Sensitivity Reports dated 05/16/22 documents Organism: E. coli (ESBL producer). Sensitivity<=32 for Nitrofurantoin (Macrobid). R52's Physician Order dated 05/27/22 documents resident on contact isolation r/t ESBL. R52's Urine Culture Report dated 06/29/22 documents Pathogen: Klebsiella pneumoniae. Suggested Antibiotic: Plazomicin, TMP-SMX. R52's Physician Order dated 06/30/22 documents Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 7 days. R52's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Resident requires limited assistance of one-person for locomotion on unit, locomotion off unit, and eating. Resident is always incontinent of bladder and bowel. 4. R77's Order Note dated 10/19/21 at 12:56 PM documents Urine culture and sensitivity returned. Resident currently taking Macrobid 100mg PO BID - antibiotic noted to be resistant to bacteria present in urine. Urine C&S (culture and sensitivity) reported to NP - awaiting updated orders. R77's Order Note dated 10/19/21 at 1:15 PM documents N.O. rec'd from NP R/T urine culture and sensitivity - D/C Macrobid and start Ciprofloxacin (antibiotic)500mg PO BID (twice a day) X 7 days. R77's Physician Order dated 10/15/21 documents Macrobid capsule 100 mg (Nitrofurantoin Monohydrate); Give 1 tablet by mouth two times a day for UTI for 7 days. R77's Physician Order dated 10/19/21 documents Ciprofloxacin HCL tablet 500 mg; Give 1 tablet by mouth two times a day related to Urinary Tract Infection, Site Not Specified. R77's MDS dated [DATE] documents that resident requires extensive assistance of one-person for bed mobility, dressing, toilet use, and personal hygiene. Resident is total dependence of two plus persons for transfer. Resident is total dependence of one-person for locomotion on unit, locomotion off unit, and bathing. Resident requires limited assistance of one-person for eating.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily which has the potential to affect all 83 residents living in the facility. Findings include: The Facility's Nurse Schedule documents the facility did not have a RN scheduled for eight hours on June 25, 2022, or June 26, 2022. On 7/6/22 at 12:39 PM, V2, Director of Nursing (DON), stated, It looks like there was no RN coverage on that Saturday and Sunday (June 25, 2022, and June 26, 2022). On 7/6/22 at 1:32 PM, V1, Administrator, stated, We just follow the regulation for staffing. The Facility's Resident Census and Conditions of Residents form, (CMS 672), dated 7/5/2022 documents there are 83 residents living in the facility.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 83 residents living in the facility. Findings include: On 7/5/22 at 8:28 AM, there was a bag of cheddar Monterey shredded cheese in the walk in cooler that was opened, but not dated. There was a clear plastic tub containing a yellow colored product on third shelf which was not labeled or dated. On 7/5/22 at 8:45 AM, V4, Dietary Manager, stated, What is that? Maybe pureed egg salad? V7, Dietary Supervisor, stated, It's egg salad. It's from Sunday. It was labeled. It must have fallen off. On 7/5/22 at 8:38 AM in the standing freezer there was a five pound bag of blackberries that had been opened, but not dated. There was a clear plastic bag of biscuits that was tied up, but not labeled or dated. There was a clear plastic bag of diced chicken that was tied up, but not labeled or dated. On 7/5/22 at 8:40 AM in the standing freezer there was a box of fully cooked hamburgers that had been opened, but not dated. The inner plastic bag was not sealed, and the hamburgers were open to air. There was an opened 32 ounce bag of whole pearl onions that was not resealed or dated. There was a bag of meat in a sealed plastic bag that was not labeled or dated. V4, Dietary Manager, stated, That's pepper steak. There was a sealed bag of red and yellow peppers that appeared freezer burned and was not labeled or dated. There was a plastic bag of chocolate chip cookies that was tied up, but not labeled or dated. On 7/5/22 at 8:42 AM in the beverage refrigerator, there were two pitchers full of a yellow liquid and one pitcher full of a brown liquid. All were covered with plastic wrap, but none were labeled or dated. On 7/5/22 at 8:50 AM, V4, Dietary Manager, stated, I would expect all items to be labeled and dated after opening. On 7/8/22 at 10:22 AM, V3, Assistant Director of Nursing and Infection Control Preventionist, stated, I would expect the dietary department to follow their policies to the best of their abilities. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2020 documents, All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. The Resident Census and Condition of Residents Form, (CMS 672), dated 7/5/2022 documents there are 83 residents living in the facility.