Based on interview and record review, the facility failed to provide medical records requested to aide in the survey process for 2 of 2 residents (R3 and R4) reviewed for medication administration in a sample of 19.Findings includeOn 8/14/25, this surveyor reviewed the July 2025 Medication Administration Records (MAR's) for R3 and R4 in their Electronic Health Records. The MAR's for R3 and R4 did not document the actual time the medication was administered.On 8/14/25 at 3:30 PM, this surveyor requested R3 and R4's July 2025 MAR's with documented and timestamped medication administration times from V2, Director of Nurses (DON).On 8/18/25 at 8:00 AM, V2, DON, stated he had been instructed by V24, Chief Operating Officer, not to provide the copies of R3 and R4's MAR's with documentation of the times the medications were administered or allow this surveyor to visualize them in the Electronic Health Record.On 8/18/25 at 3:20 PM, V2, DON, he stated he was instructed by V24 not to turn the time stamped MAR's R3 and R4 over to this surveyor because the facility had started an internal Quality Assurance investigation, and those documents were now considered confidential. V2 stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought it to administration's attention that medications were being administered past the ordered time ranges.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer prescribed medications at the prescribed time. This failure has the potential to affect all 49 residents residing in the facility. Findings include:1. R3's Face Sheet documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, chronic venous hypertension, chronic congestive heart failure, and type 2 diabetes mellitus.R3's Minimum Data Set (MDS), dated [DATE] in section C, documents R3 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. Section N of same MDS documents R3 is ordered the following classes of medications: diuretic, opioid, antiplatelet, and hypoglycemic (insulin).R3's Care Plan, dated 7/17/25, documents a focus area that R3 is on diuretic therapy related to edema. Interventions for this focus area include administering diuretic medications as ordered by physician with an initiation date of 4/10/23. Another focus area documents that R3 has a mood problem. Documented interventions for this focus area include administer medication as ordered with an initiation date of 1/6/23.R3's July 2025 Medication Administration Records (MAR) documents R3 has medications scheduled to be administered at the following times: 7:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R3's MAR provided did not document the actual time the medication was administered.A Resident Grievance form filed by R3, dated 6/19/25, states R3 voiced concerns with timeliness of medication pass at night.On 8/13/25 at 9:54 AM, R3 stated she frequently doesn't get her 8:00 PM medications until midnight. R3 stated in one instance, she did not get her scheduled 8:00 AM medications until 2:00 PM in the afternoon. 2. R4's Face Sheet documents an admission date 2/25/25, with diagnoses including, but are not limited to, depression, hypertension, hypothyroidism, and osteoarthritis.R4's MDS, dated [DATE], documents in section C that R4 has a BIMS score of 13, indicating R4 is cognitively intact. Section N of same MDS documents R4 is on the current class of medications: antidepressant, diuretic, opioid, antiplatelet, and hypoglycemic.R4's Care Plan, dated 8/4/25, documents a focus area of R4 takes a psychotropic medication. A related intervention to the previous focus area includes administering medications as indicated by physician orders, with an initiation date of 8/1/25. Another focus area documents R4 has hypertension. A related intervention is to give antihypertensive medications as ordered, with an initiation date of 5/22/25. Another focus area on the R4's Care Plan documents R4 has diabetes mellitus. A related intervention for this focus area is to administer diabetes medication as ordered by doctor, with an initiation date of 5/22/25. Another focus area listed on R4's CP is she has chronic pain related to other chronic pain, osteoarthritis, carpal tunnel syndrome and depression. A related intervention includes to administer analgesia as per orders, with an initiation date of 2/25/25.R4's July 2025 Medication Administration Records (MAR) documents R4 has medications scheduled to be administered at the following times: 5:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R4's MAR provided did not document the actual time the medication was administered.On 8/13/25 at 9:37 AM, R4 stated she often doesn't get her scheduled 8:00 PM medications until 10:30 PM or 11:00 PM. R4 stated one time she didn't get her 8:00 PM medications until 12:30 AM.On 8/18/25 at 11:34 AM, V7, Licensed Practical Nurse (LPN) stated she is often over the ordered time range of two hours for medication administration, by up to one and a half hours. V7 gave the example of the 8:00 PM medication pass should be completed by 9:00 PM, but she is frequently not finished until 10:30 PM. V7 stated the 8:00 PM medication pass is a large one, and it needs two nurses to get it completed in the ordered time range.On 8/18/25 at 3:20 PM, upon this surveyor asking for July MAR's for R3 and R4 with documented and timestamped medication administration times from V2, Director of Nursing/DON, he stated he was instructed by his superior, V24, Chief Operating Officer, not to turn the time stamped MAR's over to this surveyor because the facility had started an internal Quality Assurance investigation, and those documents were now considered confidential. V2 stated he had been instructed by his superior to not allow this surveyor to even visualize the time stamped MAR's in the Electronic Health Record on V2's computer. V2 stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought it to administration's attention that medications were being administered past the ordered time ranges. V2 stated he has had complaints from floor nurses the medication passes are too large to be completed in the ordered time range of two hours. V2 stated presently, at times, R3 and R4 are continuing to complain medications are being administered past the ordered time range.On 8/13/25 at 1:47 PM, V8, Certified Nurse's Aide (CNA), stated R3 has specifically mentioned to him she had not gotten her medications on time specifically when V4, Registered Nurse (RN), was working.On 8/13/25 at 2:14 PM, V11, CNA, stated she has had complaints from residents about getting their medications late, past the ordered time range, but she was unable to recall any names.On 8/13/25 at 2:32 PM, V13, CNA, stated she has had multiple residents complain that they did not get their medications administered at the correct time. V13 stated in the past, she also has had R3 and R4 complain about their medications being administered late past the ordered time range. V13 also stated she had residents complain to her (couldn't remember who) V4, RN, had left for two hours one evening when she was supposed to have been administering medications.On 8/14/25 at 8:15 AM, V14, CNA, stated she has had multiple complaints from residents about not getting their medications administered at the ordered time frame especially when V4, RN, was working. The residents who mentioned this to her were specifically complaining they were not getting their 5:00 PM or 8:00 PM medications at all.V4, RN, no longer works at the facility and was unable to be reached for an interview.On 8/14/25 at 10:01 AM, V15, CNA, stated she had many residents complain to her they were not getting their medications until past the ordered time range, especially on the midnight shift from 6:00 PM-6:00 AM.On 8/14/25 at 12:44 PM, V2, Director of Nurses (DON), stated there are some nurses, especially on midnight shift, struggling to get medications administered within the ordered time range. On 8/14/25 at 3:00 PM, V23, RN, stated on occasion, she is 1-2 hours out of the ordered time range for administering the medications ordered to the residents.On 8/14/25 at 3:31 PM, V21, RN, stated when she worked the floor, she would be past the ordered time range to administer medications one out of every three shifts on average every week. V21 stated she was up to 30 minutes to one hour past the ordered time range.On 8/18/25 at 10:01 AM, V17, RN, stated she frequently goes over the ordered time range for medication administration by approximately thirty minutes.On 8/18/25 at 10:26 AM, V5, RN, stated she is usually 10-15 minutes up to thirty minutes over the ordered time range for administering medications.The Resident Council meeting minutes, dated 7/17/25 at 2:00 PM, documents residents voiced concerns about not being administered their pain medications on time.The facility's Medication Administration Policy, with a revised date of 9/17/22, states, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe.The facility's Daily Census sheet, dated 8/13/25, documents there are 49 residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to change an indwelling urinary catheter per physician's orders for 1 of 3 residents (R1) reviewed for urinary catheters in a sample of 16. Findings include: R1's admission Record documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, benign lipomatous neoplasm of kidney, and neuromuscular dysfunction of the bladder. R1's Minimum Data Set, dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section H, Bladder and Bowel, documents R1 was indwelling urinary catheter. R1's Care Plan documents a Focus area with an initiation date of 6/8/23 of: High Risk for Urinary Tract Infection due to: Indwelling Catheter. Documented interventions include Change catheter and drainage bag per MD orders with an initiation date of 6/8/23. R1's Order Summary Report, with a print date of 6/17/25, documents an order of, Catheter: 18 FR (french) Coude catheter with 10cc (cubic centimeter) balloon Dx (diagnosis) Neuromuscular Dysfunction of Bladder; change once monthly and PRN (as needed) one time a day every 28 day(s) for infection prevention, with an order date of 6/16/25. R1's Treatment Administration Record (TAR) for April, May, and June 2025 documents an order, dated 3/28/25, to change catheter once monthly and PRN. There is no documentation on the April, May, and June 2025 TAR's indicating R1's catheter was changed. R1's Progress Note's in the Electronic Health Record (EHR), dated 3/28/25, documents, Nurse received N.O. (new order) to insert an 18 Fr 10ml (milliliter) coude catheter d/t (due to) res. (resident) catheter coming out c (with) balloon intact. Nurse inserted c no resistance felt and no c/o (complaints of) pain or discomfort at this time. Catheter patent and drng (draining). There was no documentation in R1's EHR documenting R1's catheter was changed since 3/28/25. On 6/16/25 at 10:47 AM, R1 stated she had not had her indwelling urinary catheter changed since 3/28/25. On 6/17/25 at 10:55 AM, V13 (Medical Doctor/MD) stated his expectations for the facility would be to change R1's indwelling urinary catheter as ordered. V13 stated that means he would expect the indwelling urinary catheter to be changed monthly from March 28th. On 6/16/25 at 2:38 PM, V2 (Director of Nurses/DON) stated indwelling urinary catheters should be changed as ordered by the medical doctor. V2 stated R1's doctor's orders are for R1's indwelling urinary catheter be changed every month. On 6/17/25 at 12:55 PM, V1 (Administrator) stated if the medical doctor's order states the indwelling urinary catheter should be changed every thirty days, then it should be changed every thirty days. V1 stated, As the old saying goes, if it wasn't documented it wasn't done, but facility administration would call all the nurses to check and make sure if it was done and just forgotten to document it. On 6/17/25 at 2:17pm, V2 stated he had called all the nursing staff, and was unable to find a nurse that had changed R1's indwelling urinary catheter in the past two months. V2 stated R1's indwelling urinary catheter was changed on the evening of 6/16/25 by V12 (Registered Nurse/RN), and the doctor was notified it was the first time R1's indwelling urinary catheter had been changed in over two months. On 6/17/25 at 12:04 PM, V12 stated she changed R1's indwelling urinary catheter on the evening of June 16th at request of V2. On 6/17/25 at 12:03 PM, V11 (RN) stated she has been on leave since April 13th, but before that, she doesn't remember changing an indwelling urinary catheter on R1. On 6/17/25 at 2:11PM, V17 (Licensed Practical Nurse/LPN) stated indwelling urinary catheters should be changed as ordered by the physician. V17 stated she had never changed R1's indwelling urinary catheter. V17 stated she doesn't know the last time R1's indwelling urinary catheter was changed. On 6/17/25 at 11:00 AM, V7 (RN) stated she doesn't remember changing an indwelling urinary catheter on R1 in the past two months. On 6/17/25 at 11:04 AM, V10 (LPN) stated she doesn't remember changing an indwelling urinary catheter on R1 in the past two months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure resident care needs are met. This failure has the potential to affect all 47 residents living in the facility. The findings include: 1. R1's admission Record, dated 06/17/25, documents an admission date of 11/23/2022, with diagnoses in part of type 2 diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, chronic kidney diseases, and chronic diastolic (congestive) heart failure. R1's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicates R1 is cognitively intact. Section GG documents eating as setup and clean-up assistance, and toileting, personal hygiene, and showering as dependent. R1's Care Plan, with a revision date of 04/07/23, documents a focus area of R1's requires extensive assistance with ADL's (Activities Daily Living) r/t (related to) reduced mobility, lack of coordination, impaired mobility and weakness. On 06/16/25 at 10:47AM, R1 stated she believes the facility is short of staff. R1 stated everyone at the facility keeps quitting. R1 said at nighttime, all they have is one helper a lot of times, and she needs two staff to assist her at times with positioning. R1 said sometimes it takes over an hour for staff to answer the call light, but other times only 15 minutes. R1 said the longer wait time is usually in the evening and on the weekend. 2. R3's admission Record, dated 06/17/25, documents an admission date of 04/29/25, with diagnoses in part of traumatic subdural hemorrhage, chronic obstructive pulmonary disease, type 2 diabetes, history of falling, and other intervertebral disc degeneration. R3's MDS, dated [DATE], documents in Section C a BIMS score of 13 which indicates R3 is cognitively intact. Section GG documents R3 is independent with most ADL functions. R3's Care Plan, with a revision date initiated of 04/29/25, documents a focus area of needs assistance with ADL'S related to [SIC]. On 06/16/25 at 11:10AM, R3 stated the facility does not have enough staff in the evening and on the weekends. R3 stated he doesn't require much assistance from staff, but he can tell they don't have hardly any workers in the evening or on the weekend most of the time. 3. R4's admission Record, dated 06/17/25, documents an admission date of 02/25/25, with diagnoses in part of type 2 diabetes mellitus, hypertension, diverticulosis, other chronic pain, and unspecified osteoarthritis. R4's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R4 is cognitively intact. Section GG documents R4 is dependent with toileting, showers, dressing, and personal hygiene. R4's Care Plan, with a revision date of 03/27/25, documents a focus area of R4 needs assistance with ADL's related to unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, ataxia. On 06/16/25 at 10:33AM, R4 stated the facility is short of staff. R4 said sometimes the facility only has maybe one or two CNA's (Certified Nurse Assistants) show up to work. R4 said they have even had some staff walk out. R4 said sometimes you have to wait for an hour for someone to answer your call light to get changed. R4 said weekends and midnight and evening shift is when she has to wait the longest. 4. R5's admission Record, dated 06/17/25, documents an admission date of 04/28/25, with diagnoses in part of type 2 diabetes mellitus, chronic respiratory failure, other lack of coordination, neuromuscular dysfunction of bladder, other chronic pain, other kyphosis, and unspecified urinary incontinence. R5's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R5 is cognitively intact. Section GG documents R5 is Set-up and clean up assist with eating, dependent with toileting, and substantial/maximal assistance with showering. R5's Care Plan, with a revision date of 06/04/25, documents a focus area of needs assistance with ADL's related to displacement of internal fixation device of vertebrae, major depressive disorder, kyphosis cervicothoracic region. On 06/16/25 at 10:40AM, R5 stated it takes the staff sometimes two hours to answer the call light. R5 said on averag,e it doesn't take them that long to answer the call light, but sometimes she can be left for quite some time. R5 said the facility has a problem with keeping good staff. 5. R6's admission Record, dated 06/17/25, documents an admission date of 05/19/22, with diagnoses in part of type 2 diabetes mellitus, fibromyalgia, morbid obesity, unspecified dementia, and chronic pain syndrome. R6's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R6 is cognitively intact. Section GG documents R6 requires set-up and clean-up assistance with eating, toileting, dressing, and personal hygiene, and requires substantial/maximal assistance with showering. R6's Care Plan, with a revision date of 03/27/25, documents a focus area of R6 has Self-Care deficit as evidenced by needs assistance with ADL's, dementia, contusion, psychological needs. On 06/16/25 at 11:08AM, R6 stated it takes staff sometimes 30-45mins to answer a call light. R6 said night shift is the worst for being short of staff. 6. R10's admission Record, dated 06/17/25, documents an admission date of 12/06/21, with diagnoses in part of inflammatory polyarthropathy, other chronic pain, morbid obesity, chronic kidney disease, urinary incontinence, and vitreous degeneration. R10's MDS, dated [DATE], documents in Section C a BIMS score of 14, which indicates R10 is cognitively intact. Section GG documents R10 requires setup and clean-up assistance with eating, is dependent with toileting, lower body dressing, and personal hygiene, and requires substantial/maximal assistance with showering. R10's Care Plan, with a revision date of 12/20/21, documents a focus area of Self-care deficit evidenced by: needs assistance with ADL's related to chronic pain, COPD (Chronic Obstructive Pulmonary disease) and gait imbalance. On 06/16/25 at 10:18AM, R10 stated evening shift is short of staff, and she said it takes a long time for staff to answer the call lights. 7. R11's admission Record, dated 06/17/25, documents an admission date of 06/24/21, with diagnoses in part of atherosclerosis, hypertension, osteoarthritis, and hypothyroidism. R11's MDS, dated [DATE], documents in Section C a BIMS score of 10, which indicates R11 has moderately impaired cognition. Section GG documents R11 requires set-up and clean-up assistance with eating, supervision and touching assistance with toileting, and partial/moderate assistance with showering. R11's Care Plan, with a revision date of 03/27/25, with a focus area of R11 has a self-care deficit that may vary throughout the day and requires staff assistance with ADL' S related to weakness, unspecified abnormalities of gait and mobility, unsteadiness on feet. On 06/16/25 at 10:25AM, R11 stated the facility is short of staff in the evening and on the weekends. 8. R12's admission Record, dated 06/17/25, documents an admission date of 05/20/25, with diagnoses in part of cerebral palsy, narcolepsy, myotonic muscular dystrophy, and left bundle branch block. R12's MDS, dated [DATE], documents in Section C a BIMS score of 15, which indicates R12 is cognitively intact. Section GG documents R12 requires set-up and clean-up assistance with eating and partial/moderate assistance with toileting, showering, dressing, and personal hygiene. R12's Care Plan, with a revision date of 05/22/25, documents a focus area of needs assistance with ADL's related to cerebral palsy, unspecified myotonic muscular dystrophy. On 06/16/25 at 10:00AM, R12 stated the facility could use more help, especially on evening and midnights. On 06/16/25 at 1:31PM, V3 (Certified Nurse Assistant/CNA) stated she believes the facility is short of staff as far as CNA's. V3 stated it is hard to do rounds every 2 hours. V3 stated she doesn't feel that they give the best care to the resident because they are short of staff. V3 said the staff is much shorter on night shift. V3 said they are supposed to have one CNA on the locked unit, and three CNA's on the regular hall for every shift. On 06/16/25 at 1:50PM, V4 (CNA) stated she does believe that facility is short of staff in relation to CNA's. V4 said the facility does not have enough staff to care for the resident properly. V4 said that sometimes they have enough staff, but not all the time, most of the time they are short of staff. V4 said that only maybe two days a week they are fully staffed. On 06/16/25 at 2:09PM, V14 (CNA) stated the facility is short of staff most shifts, but it is worse on evening shift and sometimes on the weekend. V14 said he always tries to get all the resident care done to the best of his ability. V14 said sometimes he can't get all the showers done that he is supposed to have completed. On 06/17/25 at 8:42AM, V8 (CNA) stated the facility is short of staff. V8 said that today was her day off and they asked her to come in because they needed help for several days in a row, because you guys (Surveyors) are here. V8 said the weekends are where they are the shortest of staff, especially Sundays. V8 stated showers don't get done, because they don't have enough staff. V8 said they don't have enough staff to be able to provide appropriate care to the residents. V8 said they should have at least 3 CNA's on the regular hall every day, and most of the time they don't. On 06/17/25 at 11:04AM, V10 (Licensed Practical Nurse/LPN) stated short staffing is causing the resident to have to wait longer to receive care that they need. On 06/17/25 at 12:55PM, V1 (Administrator) stated the facility does not have any staffing problems. V1 stated the facility does use agency to pick up shifts if needed. V1 stated she has been trying to lean away from using agency as much. V1 said she believes the facility has enough staff to cover care needs. V1 stated the CNA's work 12-hour shifts, and they have four CNA's on day shift, along with 2 nurses and a activity aid that works the dementia unit. V1 said there are two nurses on day shift until 5:00PM, then there is one nurse until 7:00AM. V1 said on evening into night shift they have 3 CNA's and one nurse. V1 said there has been evening into night shift on a couple of days they only had one nurse and two CNA's for the entire facility. V1 said she thinks that the residents would still be able to get proper care if the right staff are working. V1 stated the facility does not have a policy on staffing. On 06/17/25 at 2:11PM, V17 (LPN) stated she feels the facility is short of staff at times. V17 said times when they only have two aides in the building on nights that they try to give the resident the care they need, but it's very hard to get done. On 06/17/25 at 2:17PM, V2 (Director of Nursing/DON) stated he believes the facility has enough staff to be able to care for the residents on a day-to-day basis. V2 said he believes when they have two CNA's and one nurse on nights they are able to care for the residents properly. V2 said it is difficult, but doable. V2 said they are always working on trying to improve on staffing. The Facility Assessment, dated 04/01/2,5 documents under total number needed of FTE (Full Time Employees) on average or range documents Licensed Nurse providing direct care as 2.67 (FTE) per day, Nurse Aides as 8 (FTE) per day. The daily assignment for 06/02/25 documents from 6PM to 6AM 1 nurse and 2 CNA's. The daily assignment for 05/27/25 documents from 6PM to 6AM 1 nurse and 2 CNA's. The facility Midnight Census Report, dated 6/16/25, documents there are 47 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurately coded for 1 (R9) of 1 resident reviewed for accuracy of assessments in the sample of 28. Findings Include: R9's admission Record documented R9 as a 71 -year -old, with an admission date of 02/22/2024 to the facility. Diagnoses listed are unspecified atrial fibrillation, type 2 diabetes mellitus, edema, primary osteoarthritis of left knee, obesity, venous insufficiency, poly osteoarthritis, pain in leg, and unspecified osteoarthritis. R9's Illinois PASRR (Preadmission Screening and Resident Review) Summary of Findings, dated 03/22/2024, documented, Level II Outcome- Approved No SS (Specialized Services). R9's MDS with an Assessment Reference Date of 07/02/2024 documented this MDS as being an annual assessment. Section A1500. Preadmission Screening and Resident Review (PASRR) asks Is this resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer was documented as a 0 for No. The same MDS section I Active Diagnoses has a checkmark under Psychiatric/Mood Disorder has an X marked next to I5900 Bipolar Disorder, I5950 Psychotic Disorder, and I6000 Schizophrenia indicating these are all active diagnoses for R9. On 05/15/2025 at 11:10 AM, V7 (Licensed Practical Nurse/ MDS) stated he was not the person who completed the July MDS for R9. V7 stated he was not employed at this facility at that time. V7 stated the section A1500 of R9's MDS from 07/02/2024 was not documented appropriately. V7 stated R9 has an annual MDS that he is working on, and will make sure that section is documented appropriately. On 05/15/2025 at 11:54 AM, V1 (Administrator) stated the company does not have a policy for accurately completing MDS assessments. V1 stated the company follows the RAI (Resident Assessment Instrument) Manual for guidance on how to complete the MDS. V1 stated it is her expectation the MDS be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pressure wound treatment per physician's orders for one resident (R31) of three residents reviewed for pressure wounds in the sample of 28. Findings include: R31's admission Record documented an admission Date of 4/7/25, and listed Diagnoses including Chronic Kidney Disease, Polyneuropathy, and Peripheral Vascular Disease. R31's Minimum Data Set, dated [DATE], documented R31 had minimum deficits in cognition, and had one stage 3 pressure ulcer. R31's May 2025 Physicians Orders Sheet (POS) documented a 4/25/25 order for, Wound to Right Buttock/Ischium: Cleanse with wound cleanser, apply barrier wipe to peri wound, cover with calcium alginate, cover with bordered gauze every day shift and as needed. R31's May 2025 Treatment Administration Record (TAR) documented an order, Wound to Right Buttock/Ischium, cleanse with wound cleanser, apply barrier wipe to peri wound, cover with calcium alginate. Cover with bordered gauze every day shift, start date 4/25/25. The TAR documented this treatment was done daily from 5/1/25 through 5/14/25. R31's Wound Assessment and Plan Notes, authored by V10, Wound Care Nurse Practitioner, documented the following: 4/25/25: Wound Location: Right Buttock/Ischium. Wound Type: Pressure Injury. Pressure Injury Stage Upon Completion of Visit: 3. Healing Status: Healing .Wound Onset Date: 04/07/2025 Treatment: Cleanse with wound cleanser, apply barrier wipe to periwound, apply calcium alginate to wound bed then cover with bordered gauze dressing every day and as needed. 5/2/25:Wound Location: Right Buttock/Ischium Wound Type: Pressure Injury. Pressure Injury Stage Upon Completion of Visit: 3. Healing Status: Healing .Wound Onset Date: 04/07/2025. (New) Treatment order: Cleanse with wound cleanser, apply collagen to open areas bed then cover with bordered gauze dressing three times per week and as needed. On 05/14/25 at 02:33 PM, V9 (Licensed Practical Nurse) was observed providing wound care for R31. R31 had a stage 3 pressure wound, with 2 visible open areas to the area of the Right Buttock/Right Ischium. V9 cleansed the wound with wound cleanser, applied a skin barrier agent to the peri-wound area, applied calcium alginate to both open wound beds, and covered the area with a bordered gauze dressing. On 05/15/25 at 12:50 PM, V2 (Director of Nurses), stated he is the staff member responsible for adding new orders to the POS and the TAR, and V2 acknowledged the new 5/2/25 treatment order had not been changed on the TAR and POS. On 05/16/25 at 8:13 AM, V10 stated she would be meeting with V2 to review the process by which her orders are entered into the medical record. A Pressure Ulcer Prevention, Identification, and Treatment Policy, dated 10/16/23, documented, It is the responsibility of the Charge Nurse/Designee to care for pressure areas, and provide treatments as ordered.

Based on interview and record review, the facility failed to provide range of motion services to 1 (R9) of 1 resident reviewed for range of motion in the sample of 28. Findings Include: R9's admission Record documented R9 as a 71 -year -old with an admission date of 02/22/2024 to the facility. Diagnoses listed are unspecified atrial fibrillation, type 2 diabetes mellitus, edema, primary osteoarthritis of left knee, obesity, venous insufficiency, poly osteoarthritis, pain in leg, and unspecified osteoarthritis. R9's Physician's orders, with a print date of 05/15/2025, do not document an order for any range of motion or restorative nursing program. R9's Quarterly MDS (Minimum Data Set), with a date of 03/26/2025, noted R9's BIMS (Brief Interview of Mental Status) of 15, which indicates R9 is cognitively intact. Section GG documents for functional limitation in range of motion that R9 has impairment on both sides of lower extremities. Section GG for self-care documents R9 requires substantial / maximum assist for upper body dressing. Section GG documents R9 is dependent for toileting hygiene, shower / bathe, lower body dressing, putting on taking off footwear, and personal hygiene. Section O of the same MDS documents R9 received 0 days of active range of motion and 0 days of passive range of motion (with a look back period of 7 days.) Review of Care Plan, with a start date of 02/23/2024, documents a focus area of R9 Self-Care Deficit as evidenced by needs assistance with activities of daily living. Interventions listed are assist with toileting / peri care as needed, assist with bed mobility as needed, assist with bathing two times weekly, assist with transfers and ambulation as needed. On 05/15/2025 at 11:29 AM, V2 (Director of Nursing) stated, We do not have a restorative CNA (Certified Nursing Assistant). If the resident is supposed to receive range of motion, the Certified Nurse Assistants would chart it in tasks in the electronic medical record. V2 stated he does not see any charting in R9's electronic medical record to indicate he is receiving range of motion. V2 stated R9 has pain in his lower extremities. On 05/15/2025 at 11:48 AM, V8 (Director of Therapy) stated R9 has been verbally screened by therapy, but has never been on therapy services while at the facility. R9 stated he is not aware of R9 receiving and range of motion. On 05/16/2025 at 8:38 AM, V1 (Administrator) stated R9 will be screened by therapy today to see if he needs any services or range of motion programs. Review of Policy titled Range of Motion Procedure with no date, documented, If there is no order for treatment, contact the attending physician to obtain treatment orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor weights and meal intakes for a resident with significant weight loss for 1 (R45) of 5 residents reviewed for weight loss in the sample of 28. Findings include: R45's admission Record documented an admission Date of 1/30/25, and listed Diagnoses including early onset Alzheimers Disease and Osteoarthritis. R45's Minimum Data Set, dated [DATE], documented R45 had severe deficits in cognition, and required at least partial or moderate assistance for eating. R45's May 2025 Physicians Orders Sheet (POS) documented an order for regular diet with puree texture and thin liquids. This POS also documented an order for weekly weights, with an order date of 4/17/25. R45's Care Plan, dated 2/3/25, documented a problem area, (R45) is at risk for altered nutrition. R45's Meal Documentation Report for April 2025 showed missing documentation of at least one meal on the following dates: 4/1/25, 4/2/25, 4/7/25, 4/8/25, 4/12/25, 4/14/25, 4/16/25, 4/18/25, 4/21/25, 4/22/25, 4/23/25, 4/25/25, 4/26/25, 4/27/25, 4/28/25, and 4/30/25. There was no documentation to indicate if R45 refused these meals. R45's Meal Documentation Report for May 2025 showed missing documentation of at least one meal on the following dates: 5/1/25, 5/3/25, 5/4/25, 5/5/25, 5/6/25, 5/8/25, 5/9/25, 5/10/25,5/11/25, 5/13/25, 5/14/25, and 5/15/25. There was no documentation to indicate if R45 refused these meals. R45's Weight Summary documented the following: 4/1/25 160.8 Lbs. (pounds) -10.0% change, comparison weight 01/30/2025, 184.0 lbs, -12.6%,. 03/06/2025 173.5 Lbs 02/24/2025 176 Lbs 02/06/2025 179.5 Lbs 02/02/2025 183.5 Lbs 02/01/2025 184 Lbs 01/31/2025 184 Lbs 01/30/2025 184 Lbs V6, Registered Dietician, authored the following: 2/10/25 Admission/Mini Nutrition Assessment (MNA) Note: MNA score of 9 on 2/4/25 indicating a risk for malnutrition related to decreased intakes, stress, Dementia. Weight stable since admit weigh slight loss. Admit weight on 1/30/25 184 pounds. BMI (Body Mass Index) 28.1. IBW (Ideal Body Weight) 148 pounds. Resident averages 50 percent (meal intake) and is refusing some. Resident is on a regular diet with puree texture. (V6) recommending to start (trade name supplement) 90 milliliters three times daily to help with weight maintenance. Diagnoses: Alzheimers Disease/Dementia, Osteoarthritis, B Complex Vitamin Deficiency. Medications and chart reviewed. Resident has confusion and noted agitation. Resident appears well nourished, requires assist/dependent with most meals. Walks with assist. No labs to assess. No skin issues noted. (V6) will continue to monitor oral intake, weight, skin, and need for additional nutrition interventions. 4/30/25: Weight Loss Note: Resident is triggering for significant weight loss with 4/1/25 weight of 160.8lb, -7.3 percent from 3/6/25 weight of 173.5lb, -12.6 percent from admit weight of 184lb. Weight is trending down since admit weight of 184lb. BMI (Body Mass Index) 25.2, IBW (Ideal Body Weight) 148lb. Resident averages 26-75 percent (meal intake) and refusing some meals. Resident continues on regular diet with puree texture. Resident continues on (trade name liquid supplement) 90 milliliters three times daily to help with weight maintenance. Resident requires assist/dependent with most meals. (V6) recommending to add fortified cereal with breakfast and fortified pudding with lunch and dinner.(V6) will monitor oral intake, weight, skin, and need for additional nutritional interventions. 5/5/25 Nutrition Risk Assessment, Quarterly: MNA score of 9 indicating at risk for malnutrition related to decreased intakes, stress, Dementia. Current weight 160.8lb, BMI 25.2, within normal limits. Triggers for significant weight loss-7.3 percent in one month, -12.6 percent in three months. Resident meal intakes vary 25-75 percent. Resident is on a regular diet with puree texture with (trade name liquid supplement) 90 milliliters three times daily, super cereal one time daily, and fortified pudding at lunch and dinner. Diagnoses: Alzheimer's Disease/Dementia, Osteoarthritis, B Complex Vitamin Deficiency. Medications/chart reviewed. Resident has confusion and noted agitation, resident appears wellnourished, requires assist/dependent with most meals. Walks with assist. No labs to assess. No skin issues noted. (V6) will continue to monitor oral intake, weight, skin, and need for additional nutritional interventions. On 05/13/25 at 12:28 PM, R45 was observed being fed with 100 percent staff assistance. R45 was alert only to self. On at 05/14/25 at 01:13 PM,V6 stated R45 has experienced significant weight loss as outlined above. V6 stated he did not order the weekly weights, and he assumed the Primary Care Physician did in light of the significant weight loss. V45 stated staff should weigh residents as ordered and document each meal intake, V6 stated if residents refuse a meal, it should be charted as such, not left blank. A Weight Assessment and Intervention Policy, dated 11/22/24, stated, Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 7. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% (percent) weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow enhanced barrier infection control precautions for two residents (R31, R42) of six residents reviewed for infection control in the sample of 28. Findings include: 1. R31's admission Record documented an admission Date of 4/7/25, and listed Diagnoses including Chronic Kidney Disease, Polyneuropathy, and Peripheral Vascular Disease. R31's Minimum Data Set, dated [DATE], documented R31 had one stage 3 pressure ulcer. On 05/14/25 at 2:33 PM, on R31's door was a sign stating, Enhanced barrier precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities: Wound care-any skin opening requiring a dressing. At that time V9, Licensed Practical Nurse, was observed entering the room to provide wound care for R31. V9 donned gloves, but no gown. 2. R42's admission Record documented an admission Date of 3/21/25, and listed Diagnoses including Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Traumatic Brain Injury. R42's Minimum Data Set, dated [DATE], documented R42 had one unstageable pressure ulcer. On 05/15/25 at 10:36 AM, on R42's door was a sign stating, Enhanced barrier precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities: Wound care-any skin opening requiring a dressing. At that time, V9 was observed entering the room to provide wound care for R42. V9 donned gloves, but no gown. At the conclusion of care, V9 stated R31 and R42 are on enhanced barrier precautions due to having pressure wounds, and that staff are to don gown and gloves before entering the room to provide care. On 05/15/25 at 12:50 PM, V2, Director of Nurses, confirmed in both of the above referenced observations, V9 should have donned a gown in addition to gloves prior to wound care treatment. An Enhanced Barrier Precautions Policy, dated 12/10/24, documented, Policy interpretation and implementation: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE(Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi Drug Resistant Organisms) to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with a CDC(Centers for Disease Control)-targeted MDRO when Contact Precautions do not otherwise apply; or, wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to turn and reposition 2 (R5 and R9) of 3 residents reviewed for activities of daily living in the sample of 13. Findings Include: 1. R5's admission Record documented R5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus with diabetic chronic kidney disease, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, chronic kidney disease, stage 3, diverticulitis, and neuromuscular dysfunction of the bladder. R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section GG of R5's MDS documented R5 is dependent for toileting, showers, upper and lower body dressing, and personal hygiene. Section GG goes on to document R5 is dependent for rolling side to side. R5's Care Plan (undated) has a focus area of, (R5) requires extensive assistance with ADL's (Activities of Daily Living) rt (related to) reduced mobility, lack of coordination, impaired mobility and weakness. Interventions documented include: bed mobility- two person physical assistance required, two person assist for pulling resident up in bed, may require one or two person assist for repositioning in bed depending on resident condition, assist to tum and reposition every 2 hours in bed and wheelchair, and mechanical lift required. On 03/11/2025 at 3:09 P.M., R5 stated she doesn't get ice water on a consistent basis. If certain staff do not pass it in the morning, they just pass it in the afternoon. If (V8, Certified Nurse Assistant/CNA) is here she makes sure we get ice water in the morning and at night. R5 stated last week, she went two days with no fresh ice water. R5 stated when she turns her call light on, it takes anywhere from 15 minutes to two hours to get it answered. R5 stated V2 (Director of Nursing) has told the staff they have to check on her every two hours, and the staff are not. R5 stated V2 has written up staff three times for not checking on her every two hours. R5 stated the facility is very short staffed. R5 stated V2 is never here when there are issues. R5 stated she is not getting her showers on weekends. R5 stated she is supposed to get showers on Wednesday and Saturday, and didn't get her shower Saturday 03/08/2025. R5 stated they are short staffed on weekends, so they don't have time for showers. R5 stated they have a shower aide who works Monday through Friday 6 am to 2 pm. R5 stated the last 3 weeks have been worse with staffing. R5 stated a lot of days, there are just two staff working, and she doesn't care what the schedule says. R5 stated she prefers a shower not a bed bath. R5 stated when she can't have a shower, she won't refuse a bed bath, but last weekend she did not get a shower because of staffing, so the night shift CNA gave her a quick bed bath. R5 stated she is supposed to get two showers a week. On 03/11/2025 at 3:20 P.M., V1 (Administrator) stated the facility does not have a staffing policy. V1 stated they utilize the staffing calculator and the staffing guidelines. V1 stated the staff who are scheduled to work the weekends are responsible for completing all tasks including showers. V1 stated staffing needs are based on census and the staffing calculator. The calculator will give hours of staff needed per day based on census. V1 stated the facility tries to staff 5 CNA's on day shift and 3 on night shift. V1 stated some of the CNA's are 12-hour shifts and some are 8 hour shifts. V1 stated when the staff at 2 p.m. leave, they try to get staff to come in and cover. V1 stated if they can't get anyone to cover, they have a CNA who works 5 pm to midnight a few days a week, and they help at that time. V1 stated the MDS nurse's office is on the locked unit. V1 stated he is often here till 6 -7 pm at night and helps the locked unit after 4:30 P.M. V1 stated he is available Monday through Friday. V1 stated she has had a resident state she has waited longer than they wanted to get a shower, but no resident has stated they have not gotten a shower to V1. V1 stated there have been resident complaints on occasion about call light times. On 03/11/2025 at 3:45 P.M., V2 (Director of Nursing) stated corporate cut the staffing the facility was using because they said they were over staffed. V2 stated their PPD (Per Patient Day) was too high, and we had to cut hours per the regional staff. V2 stated there have been issues on night shift with call ins and staff not showing up. V2 stated she cannot find the shower sheets for 03/08/2025. V2 stated she is not sure why the showers were not done. V2 stated she was unaware the residents did not get their showers on 03/08/2025. V2 stated, I am not going to say that we don't need more staff, but it all depends on how many of the staff are 8 hours and 12 hours. V2 stated between 2 pm and 6 pm if it gets busy, she has to help on the floor. V2 stated if the unit gets busy, the MDS nurse will help. V2 stated they try to get staff to cover, but if they can't then she stays over and works. V2 stated R5 has voiced concerns in the past about certain CNA's that would not provide the care that she wants. V2 stated one of those CNA's is no longer working at the facility. V2 said staff were educated about checking on the residents at least every two hours and as needed. The March 2025 Certified Nurse Assistant Day Shift Schedule documented on 03/08/2025 and 03/09/2025 there were two 12 hours shift CNA's on day shift and one 8 hour CNA on day shift. A document titled Facility Shower Schedule documented R5 was to receive showers on Wednesdays and Saturdays of every week. 2. R9's admission Record documents an admission date to the facility of 02/23/2022. Diagnoses listed are sepsis, Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus, hypothyroidism, hyperkalemia, benign prostatic hyperplasia, epilepsy, obstructive and reflux uropathy, gout, essential hypertension, chronic kidney disease stage 3, sleep apnea, and depression. R9's Minimum Data Set (MDS), with a date of 01/06/2025, documented a Brief Interview for Mental Status (BIMS) of 04, indicating R9 is severely impaired cognitively. Section GG of the same MDS documented R9 is dependent for toileting, dressing, and rolling left to right in bed. R9's Care Plan (undated) documents a focus area of self-care deficit as evidenced by: needs assistance with activities of daily living related to impaired mobility. Interventions documented include: Assist to turn and reposition every two hours in bed and wheelchair and bed mobility-two person physical assistance required. On 03/12/2025 the following intermittent observations were made of R9: 9:09 A.M. R9 was observed laying on his back in the middle of the bed. There were no pillows or wedges in the bed positioning R9. 10:23 A.M. R9 was laying in the same position on his back in the middle of the bed with no pillows positioning him to one side or the other. 11:47 A.M. R 9 was laying is the same position on his back with no pillows observed positioning R9. 12:32 P.M. R9 was laying on his back in the middle of the bed. There were no pillows observed repositioning him to his left or right side. 1:37 P.M. R9 was laying on his back in the middle of the bed. 2:40 P.M. R9 was laying on his back in the middle of the bed. 3:53 P.M. R9 was laying on back in bed no position change. There were no pillows observed in the bed for positioning R9. On 3/13/25 the following intermittent observations were made of R9: 8:51 A.M. R9 was on his back in the middle of the bed. 9:57 A.M. R9 was on his back. 10:44 A.M. R9 was on back in the middle of the bed. 11:36 A.M. R9 was on back in the middle of the bed. 12:21 P.M. R9 was observed to be on his back in the middle of the bed. 1:46 p.m. R9 was observed to be laying on his back in bed. 3:14 P.M. R9 was in same position, on his back. There were no pillows or wedge in the bed repositioning R9. On 03/12/2025 at 1:58 P.M., V2 (Director of Nursing) stated it is her expectation for all residents to be turned and repositioned every two hours or as needed, even if they are on hospice. On 03/13/2025 at 3:20 P.M., V7 (Certified Nurse Assistant) stated she thinks she repositioned R9 at some point after 2:00 P.M. today, but is not sure what time she actually turned R9. V7 stated they are supposed to do bed checks every 2 hours. On 03/13/2025 at 3:48 P.M., V11 (Regional Nurse) was made aware R9 had been observed every hour for the last two days in the same position. V11 stated they should do bed checks every 2 hours. The facility policy titled ADL Support, with a revision date of 05/02/2023, documented, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure sufficient staff were scheduled / available to provide timely care to meet the resident's needs. This failure has the potential to affect all 47 residents residing at the facility. Findings Include: 1. R5's admission Record documented R5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus with diabetic chronic kidney disease, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, chronic kidney disease, stage 3, diverticulitis, and neuromuscular dysfunction of the bladder. R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section GG of R5's MDS documented R5 is dependent for toileting, showers, upper and lower body dressing, and personal hygiene. Section GG goes on to document R5 is dependent for rolling side to side. R5's Care Plan (undated) has a focus area of, (R5) requires extensive assistance with ADL's (Activities of Daily Living) rt (related to) reduced mobility, lack of coordination, impaired mobility and weakness. Interventions documented include: bed mobility- two person physical assistance required, two person assist for pulling resident up in bed, may require one or two person assist for repositioning in bed depending on resident condition, assist to tum and reposition every 2 hours in bed and wheelchair, and mechanical lift required. On 03/11/2025 at 3:09 P.M., R5 stated she doesn't get ice water on a consistent basis. If certain staff do not pass it in the morning, they just pass it in the afternoon. If (V8, Certified Nurse Assistant/CNA) is here she makes sure we get ice water in the morning and at night. R5 stated last week she went two days with no fresh ice water. R5 stated when she turns her call light on, it takes anywhere from 15 minutes to two hours to get it answered. R5 stated V2 (Director of Nursing) has told the staff they have to check on her every two hours, and the staff are not. R5 stated V2 has written up staff three times for not checking on her every two hours. R5 stated the facility is very short staffed. R5 stated V2 is never here when there are issues. R5 stated she is not getting her showers on weekends. R5 stated she is supposed to get showers on Wednesday and Saturday, and didn't get her shower Saturday 03/08/2025. R5 stated they are short staffed on weekends, so they don't have time for showers. R5 stated they have a shower aide who works Monday through Friday 6 am to 2 pm. R5 stated the last 3 weeks have been worse with staffing. R5 stated a lot of days there are just two staff working, and she doesn't care what the schedule says. R5 stated she prefers a shower not a bed bath. R5 stated when she can't have a shower, she won't refuse a bed bath, but last weekend she did not get a shower because of staffing, so the night shift CNA gave her a quick bed bath. R5 stated she is supposed to get two showers a week. 2. R9's admission Record documents an admission date to the facility of 02/23/2022. Diagnoses listed are sepsis, Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus, hypothyroidism, hyperkalemia, benign prostatic hyperplasia, epilepsy, obstructive and reflux uropathy, gout, essential hypertension, chronic kidney disease stage 3, sleep apnea, and depression. R9's Minimum Data Set (MDS), with a date of 01/06/2025, documented a Brief Interview for Mental Status (BIMS) of 04, indicating R9 is severely impaired cognitively. Section GG of the same MDS documented R9 is dependent for toileting, dressing, and rolling left to right in bed. R9's Care Plan (undated) documents a focus area of self-care deficit as evidenced by: needs assistance with activities of daily living related to impaired mobility. Interventions documented include: Assist to turn and reposition every two hours in bed and wheelchair and bed mobility-two person physical assistance required. On 03/12/2025 the following intermittent observations were made of R9: 9:09 A.M. R9 was observed laying on his back in the middle of the bed. There were no pillows or wedges in the bed positioning R9. 10:23 A.M. R9 was laying in the same position on his back in the middle of the bed with no pillows positioning him to one side or the other. 11:47 A.M. R 9 was laying is the same position on his back with no pillows observed positioning R9. 12:32 P.M. R9 was laying on his back in the middle of the bed. There were no pillows observed repositioning him to his left or right side. 1:37 P.M. R9 was laying on his back in the middle of the bed. 2:40 P.M. R9 was laying on his back in the middle of the bed. 3:53 P.M. R9 was laying on back in bed no position change. There were no pillows observed in the bed for positioning R9. On 3/13/25 the following intermittent observations were made of R9: 8:51 A.M. R9 was on his back in the middle of the bed. 9:57 A.M. R9 was on his back. 10:44 A.M. R9 was on back in the middle of the bed. 11:36 A.M. R9 was on back in the middle of the bed. 12:21 P.M. R9 was observed to be on his back in the middle of the bed. 1:46 p.m. R9 was observed to be laying on his back in bed. 3:14 P.M. R9 was in same position, on his back. There were no pillows or wedge in the bed repositioning R9. On 03/12/2025 at 1:58 P.M., V2 (Director of Nursing) stated it is her expectation for all residents to be turned and repositioned every two hours or as needed, even if they are on hospice. V2 stated the staff know and have a bed check routine in order to make sure all residents are turned when they are supposed to be. On 03/11/2025 at 3:20 P.M., V1 (Administrator) stated the facility does not have a staffing policy. V1 stated they utilize the staffing calculator and the staffing guidelines. V1 stated the staff who are scheduled to work the weekends are responsible for completing all tasks including showers. V1 stated staffing needs are based on census and the staffing calculator. The calculator will give hours of staff needed per day based on census. V1 stated the facility tries to staff 5 CNA's on day shift and 3 on night shift. V1 stated some of the CNA's are 12-hour shifts and some are 8 hour shifts. V1 stated when the staff at 2 p.m. leave, they try to get staff to come in and cover. V1 stated if they can't get anyone to cover, they have a CNA who works 5 pm to midnight a few days a week, and they help at that time. V1 stated the MDS nurse's office is on the locked unit. V1 stated he is often here till 6 -7 pm at night and helps the locked unit after 4:30 P.M. V1 stated he is available Monday through Friday. V1 stated she has had a resident state she has waited longer than they wanted to get a shower, but no resident has stated they have not gotten a shower to V1. V1 stated there have been resident complaints on occasion about call light times. On 03/11/2025 at 3:45 P.M., V2 (Director of Nursing) stated corporate cut the staffing the facility was using because they said they were over staffed. V2 stated their PPD (Per Patient Day) was too high, and we had to cut hours per the regional staff. V2 stated there have been issues on night shift with call ins and staff not showing up. V2 stated she cannot find the shower sheets for 03/08/2025. V2 stated she is not sure why the showers were not done. V2 stated she was unaware the residents did not get their showers on 03/08/2025. V2 stated, I am not going to say that we don't need more staff, but it all depends on how many of the staff are 8 hours and 12 hours. V2 stated between 2 pm and 6 pm if it gets busy, she has to help on the floor. V2 stated if the unit gets busy, the MDS nurse will help. V2 stated they try to get staff to cover, but if they can't then she stays over and works. V2 stated R5 has voiced concerns in the past about certain CNA's that would not provide the care that she wants. V2 stated one of those CNA's is no longer working at the facility. V2 said staff were educated about checking on the residents at least every two hours and as needed. On 03/11/2025 at 12:15 P.M., V5 (Licensed Practical Nurse) stated, Today is a good day with staffing. It is not every day that we have this many Certified Nurse Assistants working. On 03/11/2025 at 12:30 P.M., V6 (Certified Nurse Assistant) stated, Back on the locked unit, there are two CNA's and one nurse. At 4 P.M. the other CNA leaves and at 4:30 P.M. the nurse leaves. V6 stated it leaves her by herself to care for all 14 residents. V6 stated she cannot get to the residents in a timely manner. On 03/12/2025 at 9:11 A.M., V7 (Certified Nurse Assistant) stated the staffing level in the facility is terrible. V7 stated on the schedule today she is the only CNA after 2 P.M. for the north and south halls. V7 stated there are 29 residents on the north and south halls. V7 stated there is no way she can provide the appropriate care to all 29 residents, especially with all the residents who require two person assist. V7 stated this has been a problem since she started less than two months ago. V7 stated, The staffing issues and being left by yourself is why they can't keep help. V7 stated she was unable to complete showers on 03/08/2025 due to the staffing levels. On 03/12/2025 at 9:18 A.M., V3 (Certified Nurse Assistant) stated she is on the schedule for 6am - 2 pm. V3 stated she works 6am - 2 pm, and was not aware the staffing sheet says that she was staying until 6 p.m. V3 stated she was leaving at 2 p.m. today. V3 stated V8 (Certified Nurse Assistant) was supposed to do showers today, but is working the floor due to a CNA quitting. V3 stated last weekend, she was the only staff member on the locked unit from 6 am to 2 pm, V3 stated the staffing on the weekend is worse than during the week. V3 stated she was not able to do any showers on the locked unit because she was the only staff member on the unit. V3 stated she is not able to provide the care to all the residents. On 03/12/2025 at 9:23 A.M., V8 (Certified Nurse Assistant) stated the facilities staffing level is poor. V8 stated, No matter how short we are, I do my best to provide the care that all the residents need. After 2 P.M., there is lower staffing and usually they do not let anyone stay over. V8 stated she will stay over occasionally. V8 stated she was supposed to be the shower aide, but a CNA quit, so she is working the floor today. V8 stated she typically only works Monday - Friday. V8 stated what she hears from the residents is that they do not receive showers on weekends. On 03/12/2025 at 3:55 P.M., V10 (Licensed Practical Nurse) stated, Staffing is a huge issue. The issue is more on north and south halls versus the locked unit. V10 said she always offers to stay over and help, and most of the time I get told no. V10 stated she is leaving at 4:30pm and she isn't sure who is taking over. V10 stated they sent the transportation aide back to the locked unit and pulled V6 (CNA). V10 stated there are 2 CNA's, 2 nurses, and a transportation aide covering the 47 residents. V10 stated at 4:30 P.M., the north hall nurse is usually responsible for the entire building. V10 stated that is a lot with the acuity they have. V10 stated she makes sure the residents on the locked unit are taken care of. V10 stated staffing was cut because they were told they were over on their PPD. V10 stated they are not staffing the building how it should be. V10 stated last night, there were two nurses on night shift. V10 stated they did that because there are surveyors in the building. On 03/13/2025 at 9:07 A.M., V2 stated staffing agency employees started last night in the building. V2 stated she just got approval. V2 stated with the agency staff, they are able to have four Certified Nurse Assistants on night shift. On 03/13/2025 at 3:14 P.M., V5 (Licensed Practical Nurse) stated, After 2 pm today, it is only (V7, Certified Nurse Assistant) and an agency CNA, who's first day in the building is today. V5 stated they do the best they can when they are left like this. V5 stated she helps a lot on the floor when there are just two CNA's. V5 stated another CNA was supposed to stay over, but she did not, so she will be getting written up. On 03/12/2025 at 2 P.M. ,surveyor observed there to be one certified nurse assistant on the north / south hall with 30 residents. V6 was observed working on the north hall with V7. V10 was observed to be on the locked unit and the transportation aide was back on the locked unit to assist V10. On 03/12/2025 at 2:30 P.M., V10 stated V6 was pulled from the locked unit, and V10 was sent to the locked unit to cover for V6 being pulled to the north hall. The facility document titled Grievance Summary, dated 01/15/2025, under category, the call bell response time was documented. Under grievance details it documents, Residents voiced concern of call bell response time mainly in evenings and nights during the resident council meeting. Summary of actions taken: discussed with all shifts importance of timely call light response. Ads placed for more CNA's for evening / night coverage. The March 2025 Certified Nurse Assistant Day Shift Schedule documented on 03/08/2025 and 03/09/2025 there were two 12 hours shift CNA's on day shift and one 8 hour CNA on day shift. The March 2025 Certified Nurse Assistant Night Shift Schedule documented on 03/02/2025 two CNA's from 6 P.M. to 6 A.M. The same schedule also documents on 03/05/2025 and 03/06/2025 there were two CNA's scheduled from 6 P.M. to 6 A.M. and a third CNA scheduled from 5 P.M. until 12 A.M. The Facility Assessment (undated) documented under the section titled Staffing and Staff Assignments no staffing data. The entire section is left blank. Also attached to this section is a blank staffing calculator. V1 stated that she didn't realize she had to put numbers in the facility assessment for how much staff they use on each shift and daily. The facility Resident Matrix, dated 03/11/2025, documented there were 47 residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (R1) reviewed for medication administration in the sample of 5. Findings Include: R1's admission Record documented R1 was [AGE] years old, with an initial admission date to the facility of 11/23/2022. R1's admission Record documents the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), type 2 diabetes mellitus, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, stage 3 chronic kidney disease, chronic diastolic heart failure, benign lipomatous neoplasm of kidney, neuromuscular dysfunction of bladder, gout, and personal history of healed traumatic fracture. R1's Care Plan, with a revision date of 4/10/23, documents under Focus that R1 is on diuretic therapy r/t (related to) edema. Interventions documented included Administer diuretic medications as ordered by the physician with an initiation date of 4/10/23. R1's current Order Summary for July 2024 documented an order for Furosemide (Lasix) inject 20 mg intramuscularly one time a day on Thursdays and Sundays with an initial order date of 05/03/2023. R1's June 2024 Medication Administration Record (MAR) documented on 06/09/2024 MN in the box for that day. On the last page of the MAR under the Chart Codes it documents that MN indicates medication not available. An Orders -Administration Note, dated 06/09/2024 with a time of 4:25 A.M, documented furosemide inject 20 mg intramuscularly one time a day every Thursday and Sunday related to chronic diastolic congestive heart failure medication unavailable. On 7/5/24 at 10:48 A.M., R1 stated the facility nurses occasionally have trouble locating her Lasix injection. On 07/05/2024 at 9:31 A.M., V2 (Director of Nursing / Registered Nurse) stated the facility has an emergency medication kit and if a nurse does not have a medication on her med cart, they can go to the emergency kit and pull it out. V2 stated there should be no time the resident does not get the medications that are ordered. V2 stated it is her expectation the nurses utilize the emergency kit when needed. V2 was not made aware R1 did not receive her Lasix on 06/09/2024. On 07/05/2024 at 11:23 A.M., V6 (Registered Nurse) stated the pharmacy usually has no issue getting medications to the facility. V6 said there has been times when the pharmacy would be waiting on insurance approval before they would deliver. V6 stated in those cases, he would utilize the back-up emergency kit that the facility has. V6 stated he has all the medications for R1. V6 located the IM (intramuscular) Lasix in the medication cart for R1. V6 stated Lasix is in the emergency kit, so there is no reason for R1 to ever go without it. On 07/09/2024 at 8:45 A.M., V2 stated she spoke with V12 (Licensed Practical Nurse) regarding not giving R1's Lasix on 06/09/2024. V2 stated V12 explained to her the medication was not in the cart. V12 attempted to locate it in the back up box, and the medication was not in the Emergency Kit. V12 stated to V2 she did not contact the physician nor did she pass it on to day shift. V2 stated she has moved the medication to day shift so she can ensure that it is being given. On 7/09/2024 at 9:45 A.M., V12 (Licensed Practical Nurse) stated she did not give the Lasix to R1 because she could not locate it in the medication cart. V12 stated she looked in the emergency kit that night, and Lasix IM was not available. V12 stated she did try to call the pharmacy to see when it was going to be delivered, but was unsuccessful. V12 stated she thought she wrote it on the report sheet that she did not give it and why. V12 further stated that night in question was very hectic and she must have forgotten to write a note about attempting to contact the pharmacy and the physician. A document labeled Inventory on Hand, with a printed date of 07/09/2024 and a time of 12:38 P.M., for the Emergency Kit documented Furosemide 10mg/ml vial has a max count of two. The inventory lists there is one vial on hand with a maximal level of 2 vials, and minimal level of 1 vial. On 07/09/2024 at 2:50 P.M., V13 (Nurse Practitioner) stated she was not notified on 06/09/2024 that R1 did not receive her IM Lasix. V13 stated when the facility has a resident without a medication available, it is her expectation to be notified. The facility policy titled Medication Administration Policy/Procedure, with a revised date of 09/27/2022, documented, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. The facility policy titled Unavailable Medication, with a revision date of 08/2020, documented under the section titled Policy, The facility must make every effort to ensure that medications are available to meet the needs of each resident. The section of the same policy titled Procedure documents The nursing staff shall: 1. Notify the attending physician (or on - call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order.

Based on observation, interview, and record review, the facility failed to allow an independent smoker the right to choose when to smoke for 1 (R44) of 2 residents reviewed for smoking in a sample of 27. Findings include: 1. R44's Face Sheet documented an admission date of 2/13/24, with diagnoses including: fracture of one rib right side, chronic obstructive pulmonary disease, chronic bronchitis, spondylopathies lumbar region, hypertension, fibromyalgia, and generalized anxiety disorder. R44's 2/13/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R44 was cognitively intact. This same MDS documented R44 was independent with lying to sitting, chair/bed- to - chair transfer supervision or touching assistance, partial/ moderate assistance with walking 10 feet, walking 50 feet with two turns was not attempted due to medical condition or safety concerns, independent with wheeling 50 feet with two turns, independent with wheeling 150 feet once seated. R44's Electronic Medical Record (EMR) assessment tab documented no Safe Smoking Assessment had been completed. R44's EMR documented no care plan for smoking. On 3/7/24 at 10:26 PM, V2 (Director of Nursing/ DON) verified R44 did not have a Safe Smoking assessment completed, and R44 did not have a care plan for smoking. V2 said V11 (Activities Director) was responsible to complete the Safe Smoking Assessment. On 3/5/24 at 1:35 PM, R44 walked without assistance with a rollator to the patio smoking area. R44 was handed a cigarette and a lighter by staff, and R44 safely lit her cigarette. R44 safely smoked her cigarette and also extinguished it safely. R44 stood without assistance, and with her rollator, walked back into the facility without assistance. On 3/6/24 at 1:32 PM, R44 walked without assistance with a rollator to the patio smoking area. R44 was handed a cigarette by staff, and was lit by staff. R44 safely smoked the cigarette and extinguished it. R44 walked back into the facility without assistance with her rollator. On 3/6/24 at 1:47 PM, R44 said she had been admitted to the facility for short term rehabilitation and was going to be discharged home. R44 said she was able to walk, without any staff assistance, out to the smoking patio and back into the facility. R44 said she was able to safely light, smoke, and extinguish her cigarette. R44 said the facility had set smoking times. R44 said the facility did not allow anyone to go outside to smoke if it was not the designated smoking time and would just be told no. R44 said, I feel like an inmate not a patient. On 3/5/24 at 1:56 PM, V13 (Registered Nurse/ RN) said if a resident asked to go out to smoke outside of the designated smoking times they would be told no. On 3/8/23 at 11:13 AM, V11 (Activities Director) said she was unsure why R44 did not have a Safe Smoking Assessment completed. V11 said all residents, regardless of ability, were to be assessed as requiring supervision when smoking. V11 said she was unsure why all the residents were to be assessed as needing supervision. V11 said she had been told by management when taking her position in the facility, it was the facility policy that all residents had to be supervised while smoking. V11 said R44 was alert and oriented, not an elopement risk, able to independently walk without supervision, and able to safely light, smoke, and extinguish her cigarette. V11 said all residents who smoke are required to sign the Smoking Safety Contract. V11 said she was unsure what the consequence would be for a resident who refused to sign the Smoking Safety Contract. V11 said if a resident refused to sign, she would speak to V1 (Administrator) about how to proceed. On 3/8/24 at 11:48 AM, V1 (Administrator) said if a resident who smoked refused to sign the Smoking Safety Policy she would document it in their EMR and care plan, and expect the resident to follow the facility's Smoking Policy. V1 said the facility's Smoking Policy said all residents would be supervised while smoking. V1 reviewed the facility's smoking policy and verified it did not state all residents would be supervised while smoking. On 3/8/24 at 10:37 AM, V12 (Therapy Director) said he had been providing physical therapy for R44. V12 said R44 was able to walk independently with a rollator around the facility. V11 said he thought R44 could safely open the door and walk outside to the smoking patio with her rollator unsupervised. The facility had signage posted showing Smoking Times 6:30 AM - 6:45 AM, 8:30 AM - 8:45 AM, 11:00 AM - 11:15 AM, 1:30 PM - 1:45 PM, 3:45 PM - 4:00 PM, 6:30 PM - 6:45 PM, 8:00 PM - 8:15 PM, 9:30 PM - 9:45 PM. No smoking after 9:45 PM. The facility's undated Smoking Safety Contract documented, I understand that I must follow each and every rule governing smoking and should I violate even one rule, even one time, I am aware that the facility may remove my smoking privilege. I ACKNOWLEDGE THAT SMOKING IS A PRIVILEGE AND NOT A RIGHT AND THE FACILITY MAY SUSPEND MY PRIVILEGE AT ANY TIME . I agree to only smoke in the designated outdoor area, at the designated times .I will immediately turn over all smoking materials once re-entering the facility . The facility was unable to produce a signed Smoking Safety Contract for R44. The facility's revised 10/22/23 Smoking Policy documented 2. Residents who smoke will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. The facility shall complete Smoking Safety Assessments upon admission, a quarterly basis, and as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for 1 (R25) of 12 residents reviewed for advanced directives in the sample of 27. Findings Include: 1. R25's face sheet documented an admission date of [DATE], with diagnoses including: displaced avulsion fracture of tuberosity of right calcaneus, chronic obstructive pulmonary disease, hypertension, major depressive disorder, anxiety disorder, and unspecified glaucoma. R25's Illinois Department of Public Health (IDPH) Practitioner order for Life- Sustaining Treatment (POLST) Form documented a selection of Do Not Attempt Resuscitation/ DNR, with a signature of R25's Power of Attorney (POA) on [DATE], and a Physician signature on [DATE]. R25's Order Summary Report, printed [DATE] at 10:40 AM, documented a [DATE] Physician order for Full Code. On [DATE] at 10:28 AM, V5 (Registered Nurse/ RN) said R25 was a full code. V5 said if she found R25 unresponsive she would begin CPR on R25. V5 said a resident's code status could be found on the Medication Administration Record (MAR), Treatment Administration Record (TAR), and the banner at the top the screen when viewing a resident's Electronic Medical Record (EMR). On [DATE] at 10:38 AM, V2 (Director of Nursing/ DON) verified R25's code status in the EMR was Full Code. V2 said R25 did have a signed DNR POLST form. V2 said R25's EMR should reflect Do Not Resuscitate. The facility's revised [DATE] Advanced Directives Policy documented 7. Information about whether or not the resident has executed an advanced directive shall be prominently in the medical record . 20. The Director of Nursing Services or designee will notify the Attending Physician of advanced directives so the appropriate orders can be documented in the resident's medical record and plan of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure referral and coordination of PASARR (Preadmission Screening and Resident Review) Level II Screening was completed for 1 (R7) of 1 resident reviewed for PASARR assessments in the sample of 27. Findings Include: R7's admission Record documents a date of birth of [DATE], and an initial facility admission date of 1/29/21. This same document includes the following diagnoses: Other Schizophrenia with an onset date of 3/25/22, Major Depressive Disorder with an onset date of 11/17/20, and Generalized Anxiety Disorder, with an onset date of 12/17/12. R7's Notice of PASRR Level I Screen Outcome was dated 11/18/2020, prior to admission, and documented No Level II screening required. R7's Annual Minimum Data Set (MDS), dated [DATE], section A1500 - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition - Coded No. On 03/07/24 at 9:41 AM, V7 ( Social Services) stated the business manager was previously responsible for all PASAAR reviews, but that position was eliminated a few weeks ago, and V7 is now in the process of training and taking over this responsibility. V7 stated she submitted a Level II PASARR screening for R44 on 3/6/24. On 03/08/2024 at 10:33 AM, V1 (Administrator) stated the facility did not have a policy for the completion of PASARR's. The facility follows the regulations. The facility was unable to provide any reproducible evidence the PASARR agency had been contacted to refer R7 for a Level II screening after the addition of the Schizophrenia diagnosis was added in March of 2022.

Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed for a resident with a diagnosed mental disorder for 1 (R44) of 1 resident reviewed for PASARR Screening in the sample of 27. Findings Include: R44's admission Record documented an initial admission date to the facility of 2/13/2024. R44's diagnoses listed on this form include, but were not limited to: Bipolar Disorder, Unspecified and Major Depressive Disorder, Recurrent, Moderate. R44's Notice of PASRR Level I Screen Outcome, dated 2/13/2024, documented No Level II Required - No SMI (Serious Mental Illness) The PASRR Outcome Explanation Notice of No PASRR Level II Required report documents, Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. R44's PASRR Level I form section titled Diagnoses documents Mental Health Diagnoses - Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past: with only Depression/Depressive Disorder (including mild or situational) Current listed. Under the section Ascend Outcome the following is documented: Level I Outcome: No Level II Required - No SMI/ID/RC (related condition) .Rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. On 03/07/24 at 9:41 AM, V7 ( Social Services) stated the business manager was previously responsible for all PASAAR reviews, but that position was eliminated a few weeks ago, and V7 is now in the process of training and taking over this responsibility. V7 stated she submitted a Level II PASARR screening for R44 last night. The facility was unable to provide any reproducible evidence the PASARR agency had been contacted to inquire as to why no Level II screening was completed, given the mental health diagnoses of Bipolar Disorder, Unspecified and Major Depressive Disorder that are listed on her admission Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure required bathing assistance was provided to dependent residents for 1 (R8) of 1 resident reviewed for ADL (Activities of Daily Living) care in the sample of 27. The Findings Include: R8's admission record documents an original admission date of 4/26/19, and a most recent re-admission date of 10/16/2023. R8's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Section GG of this same MDS documented R8 requires partial/moderate assistance with showers. (Partial/moderate assistance documents the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). R8's current Care Plan documented a focus area of Self-Care Deficit As Evidenced by: Needs Limited assistance with ADLs (Activities of Daily Living) initiated on 12/28/21. The most recent revision to this was dated 1/10/22, with an intervention added that documented: Bathing - one person physical assist required and Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 03/05/24 at 10:54 AM, R8 stated she is not getting showers, and has been using a wash cloth in her bathroom to get clean. R8 presented as alert and oriented, cleaned, dressed, and well groomed. On 3/06/2024 at 12:24pm, V3 (Certified Nurse Assistant/CNA) stated residents are placed on the shower list that is located in the cart room for each hall, and showers are offered twice a week. On this same date and time, V4 (CNA) stated residents are placed on the shower list that is located in the cart room for each hall and showers are offered twice a week. V4 stated the Director of Nursing will add residents to the shower list within 2 days of admission. V4 stated there are shower/skin sheets located at the nurses station to be completed and given to the nurse to review. V4 stated if a resident refused a shower, the form would be completed as refused and turned in to the nurse for review, then documented in the electronic health record. This surveyor observed/reviewed the shower list located on R8's hallway with V4. R8 is listed to have biweekly showers on Mondays and Thursdays during 6pm-6am shifts. Shower documentation was reviewed in R8's electronic health record for the dates of 2/26/24 - 3/10/24 with no evidence of showers being completed. V4 (CNA) verified and acknowledged there was no documentation entered into R8 electronic health record during that time period. On 3/06/2024 at 12:30pm, V5 (Registered Nurse/RN) stated the skin check/shower sheet is completed and given to the nurse to review. V5 stated she does not recall reviewing a skin check/shower sheet for R8 recently. On 3/6/2024 at 1:12pm, R8 appeared clean, dressed, and well groomed, sitting in a wheelchair located in the dining room. R8 stated she has not had a shower recently, and continues to clean herself with a wash cloth in her bathroom. R8 stated she also washes her hair with the washcloth and whatever soap is in there to use. R8 presented as alert and oriented during this interview. On 3/6/2024 at 1:15pm, V2 (Director of Nursing/DON) stated residents are asked on admission what their preferences are for shower days, times, etc. V2 stated, The nursing staff are to add the residents to the shower list and the certified nurses assistants are to document showers in the electronic health record. If a resident refused a shower, then the staff would ask the resident to sign the skin check/shower sheet, and have the nurse review it. Then staff are to document in the electronic health record. V2 wass unaware R8 is not getting a shower as scheduled and will look into this situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents medication regimens were free from unnecessary psychotropic medications for 1 (R7) of 5 residents reviewed for unnecessary medications in a sample of 27. The Findings Include: R7's admission record documents a date of birth of [DATE], and an initial facility admission date of 1/29/21. This same document includes the following diagnoses: Other Schizophrenia with an onset date of 3/25/22, major depressive disorder with an onset date of 11/17/20, and generalized anxiety disorder with an onset date of 12/17/12. R7's current physician order for the month of March 2024 included the following medication orders: Risperidone 1 milligram, give one tablet by mouth in the evening for schizophrenia with a start date of 9/2/22. Alprazolam 0.25 milligram 1 tablet by mouth in the evening with a start date of 9/2/22. R7's behavior tracking for the last 3 months documented the following behaviors occurring: On 2/28/24, R7 on day shift had an instance of refusal of care/yelling/abusive language/inability to relax. No other behaviors were documented in the resident medical record. On 3/7/24 at 10:00 AM, V2 (Director of Nursing) stated there is no evidence in the chart to show a gradual dose reduction has been recommended or attempted since the start of the psychotropic medications. V2 further stated R7's only behaviors are that at times she refuses dialysis or care, but has no behaviors towards staff or residents. On 3/7/24 at 11:00 AM, V8 (Certified Nurse Assistant) stated R7 does not exhibit any behaviors. During the survey dates of 3/5/24-3/8/24, R7 was observed to be quietly laying in bed sleeping or watching television.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician when prescribed medications were not available for 3 (R1, R5, R6) of 8 residents reviewed for medication administration. Findings include: 1. R1's face sheet documents R1was admitted to the facility on [DATE] with a diagnoses including: Necrotizing Fasciitis and Type 2 Diabetes Mellitus with diabetic polyneuropathy. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score is 15, indicating R1 is cognitively intact. Section GG, Functional Abilities and Goals, Set-up/Clean-up assistance with eating and oral hygiene; independent with toileting hygiene, upper/lower body dressing, personal hygiene, and bed mobility; partial/moderate assistance with showering; and supervision with putting/taking off footwear and transfers. R1's Physician's Orders, dated 1/27/2023, documents Hydrocodone 10/325mg by mouth five times a day for pain with an open-end date. R1's Medication Administration Record (MAR) for December 2023 documents the nurses initials and MN for the order of Hydrocodone 10/325 milligram (mg) on 12/24/2023 at 8:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM and 12/25/23 at 1:00 AM. The Chart Code on the MAR documents that MN means Medication Not Available. R1's Hydrocodone 10/325mg narcotic count sheet documents the last dose given on 12/23/2023, and the next dose that was given was on 12/25/2023. 2. R5's face sheet documents R5 was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set (MDS), dated [DATE], documents Section C, a Brief BIMS score of 15, indicating R5 is cognitively intact. Section GG, Functional Abilities and Goals, documents setup/clean-up assistance with eating and oral hygiene; dependent with toileting hygiene, showering, upper/lower body dressing, bed mobility, and transfers; and partial/moderate assistance with personal hygiene. R5's Physician's Order Sheet documents an order dated 5/04/2022 for Furosemide 20mg intramuscularly one time a day every Thursday/Sunday, and an order dated 12/7/2022 for Isosorbide Dinitrate 30mg two times a day. R5's MAR for December 2023 documents on 12/24/2023 MN (Medication Not Available) for Furosemide 20mg intramuscular injection; and on 12/21/2023 at 5:00 PM and 12/22/23 at 8:00 AM and 5:00 PM for Isosorbide Dinitrate 30mg. On 1/04/2024, at 10:00 AM, Furosemide 20mg intramuscular injection and Isosorbide Dinitrate 30mg were available in the facility's emergency medication kit. On 1/03/2024, at 2:00 PM, R5 stated she did not receive some of her medications last month on 12/21/23, 12/22/23, & 12/24/23. R5 stated she missed her Furosemide injection and Isosorbide Dinitrate 30mg and got worried that she might end up in the hospital. 3. R6's face sheet documents R6 was admitted to the facility on [DATE] with a diagnosis of Obstructive and Reflux uropathy, unspecified. R6's Minimum Data Set (MDS), dated [DATE], documents Section C, a BIMS score is 7, indicating R6 has severe cognitive impairment. Section GG, Functional Abilities and Goals, documents R6 requires setup/clean-up assistance with eating and oral hygiene; and dependent with toileting hygiene, showering, upper/lower body dressing, personal hygiene, bed mobility, and transfers. R6's MAR for December 2023 documents an order dated 12/19/23 of Doxycycline 100mg two times a day x 7 days being ordered on 12/19/2023, and documents MN (Medication Not Available) on 12/19/23 at 5:00 PM. On 1/04/2024, at 10:00 AM, Hydrocodone 10/325mg, Furosemide 20mg intramuscular injection, Isosorbide Dinitrate 30mg, and Doxycycline 100mg were observed as being available in the facility's emergency medication kit. On 1/08/2024, at 9:00 AM, V2 (Director of Nursing) stated if a resident's medication is not available, it is the expectation of the nurses to check the facility's emergency medication kit to see if the medication can be pulled from there until the medication can be delivered. V2 stated if the facility's emergency medication kit does not have the medication available, it is the expectation of the nurses to call the primary physician and notify the physician and receive a new order. V2 stated the facility has recently hired new nurses, and they are not completely aware of how to follow the protocol of ordering medications and utilizing the emergency medication kit. V2 stated the facility's pharmacy representative is coming to the facility on 1/18/2024, at 10:30 AM to give an in-service to all the nurses on how to correctly use the emergency medication kit and reordering of medications. V2 stated the physician was not notified on 12/19/2023 when R6 did not have any Doxycycline 100mg available for administration. On 1/08/2024, at 9:05 AM, V10 (Registered Nurse/RN) stated if a resident runs out of a medication, she checks the emergency medication kit, and if it is not available, she documents medication not available on the MAR. V10 stated she did not notify the physician on 12/23/2023 that R1 needed a refill of the hydrocodone. V10 stated R1's hydrocodone was not available on 12/24/2023. V10 stated R1's next dose of hydrocodone was given on 12/25/2023. V10 stated she did not notify the physician on 12/21/2023 that R5's Isosorbide Dinitrate 30mg was not available. On 1/04/2024, at 3:30 PM, V11 (Primary Physician) stated as a rule, the facility nurses call him and notify him if a resident has missed a medication or if a medication is not available and if there are any consequences, to just give the next dose or get a new order. V11 stated the missed medication that occurred with R1, R5, and R6 would not have caused any harmful adverse effects. V11 stated he does not recall the facility nurses notifying him of R1, R5, or R6's medication not being available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to acquire and administer medications for 3 (R1, R5, R6) of 8 residents reviewed for pharmacy services in a sample of 8. Findings include: 1. R1's face sheet documents R1was admitted to the facility on [DATE], with diagnoses including: Necrotizing Fasciitis and Type 2 Diabetes Mellitus with diabetic polyneuropathy. R1's Minimum Data Set (MDS), dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score is 15, indicating R1 is cognitively intact. Section GG, Functional Abilities and Goals, Set-up/Clean-up assistance with eating and oral hygiene; independent with toileting hygiene, upper/lower body dressing, personal hygiene, and bed mobility; partial/moderate assistance with showering; and supervision with putting/taking off footwear and transfers. R1's Physician's Orders, dated 1/27/2023, documents Hydrocodone 10/325mg by mouth five times a day for pain with an open-end date. R1's Medication Administration Record (MAR) for December 2023 documents the nurses initials and MN for the order of Hydrocodone 10/325 milligram (mg) on 12/24/2023 at 8:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM and 12/25/23 at 1:00 AM. The Chart Code on the MAR documents that MN means Medication Not Available. R1's Hydrocodone 10/325mg narcotic count sheet documents the last dose given on 12/23/2023, and the next dose that was given was on 12/25/2023. 2. R5's face sheet documents R5 was admitted to the facility on [DATE], with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set (MDS), dated [DATE], documents Section C, a Brief BIMS score of 15, indicating R5 is cognitively intact. Section GG, Functional Abilities and Goals, documents setup/clean-up assistance with eating and oral hygiene; dependent with toileting hygiene, showering, upper/lower body dressing, bed mobility, and transfers; and partial/moderate assistance with personal hygiene. R5's Physician's Order Sheet documents an order dated 5/04/2022 for Furosemide 20mg intramuscularly one time a day every Thursday/Sunday, and an order dated 12/7/2022 for Isosorbide Dinitrate 30mg two times a day. R5's MAR for December 2023 documents on 12/24/2023 MN (Medication Not Available) for Furosemide 20mg intramuscular injection; and on 12/21/2023 at 5:00 PM and 12/22/23 at 8:00 AM and 5:00 PM for Isosorbide Dinitrate 30mg. On 1/03/2024, at 2:00 PM, R5 stated she did not receive some of her medications last month on 12/21/23, 12/22/23, & 12/24/23. R5 stated she missed her Furosemide injection and Isosorbide Dinitrate 30mg, and got worried that she might end up in the hospital. 3. R6's face sheet documents R6 was admitted to the facility on [DATE], with a diagnosis of Obstructive and Reflux uropathy, unspecified. R6's Minimum Data Set (MDS), dated [DATE], documents Section C, a BIMS score is 7, indicating R6 has severe cognitive impairment. Section GG, Functional Abilities and Goals, documents R6 requires setup/clean-up assistance with eating and oral hygiene; and dependent with toileting hygiene, showering, upper/lower body dressing, personal hygiene, bed mobility, and transfers. R6's MAR for December 2023 documents and order dated 12/19/23 of Doxycycline 100mg two times a day x 7 days being ordered on 12/19/2023, and documents MN (Medication Not Available) on 12/19/23 at 5:00 PM. On 1/04/2024, at 10:00 AM, Hydrocodone 10/325mg, Furosemide 20mg intramuscular injection, Isosorbide Dinitrate 30mg, and Doxycycline 100mg were observed as being available in the facility's emergency medication kit. On 1/08/2024, at 9:00 AM, V2 (Director of Nursing) stated it is the expectation of the nurses to reorder medications when a resident's medication is down to the last week's supply on their medication card, and if a resident's medication is not available, it is the expectation of the nurses to check the facility's emergency medication kit to see if the medication can be pulled from there until the medication can be delivered. V2 stated if the facility's emergency medication kit does not have the medication available, it is the expectation of the nurses to call the primary physician and notify the physician and receive a new order. V2 stated the facility has recently hired new nurses and they are not completely aware of how to follow the protocol of ordering medications and utilizing the emergency medication kit. V2 stated the facility's pharmacy representative is coming to the facility on 1/18/2024, at 10:30 AM to give an in-service to all the nurses on how to correctly use the emergency medication kit and reordering of medications. V2 stated the Furosemide 20mg intramuscular injection and Isosorbide Dinitrate 30mg ordered for R5 was available in the emergency medication kit, and was not removed from the emergency medication kit on 12/21/2023, 12/22/2023, & 12/24/2023. V2 stated the Doxycycline 100mg ordered for R6 was available in the emergency medication kit and was not removed from the emergency medication kit on 12/19/2023. On 1/08/2024, at 9:05 AM, V10 (Registered Nurse/RN) stated if a resident runs out of a medication, she checks the emergency medication kit and if it is not available she documents medication not available in the medication administration record (MAR). V10 stated she did not notify the physician on 12/23/2023 that R1 needed a refill of her hydrocodone. V10 stated R1's hydrocodone was not available on 12/24/2023. V10 stated that R1's next dose of hydrocodone was given on 12/25/2023. The facility's Emergency Pharmacy Service & Emergency Kits, dated 08/2020, documents, Emergency pharmacy service is available 24 hours a day. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in portable, sealed containers in compliance with applicable state regulations. Procedures step number 5 documents .The ordered medication is obtained either from the emergency box or electronic interim box from the provider pharmacy, or from a back-up pharmacy that is determined by the provider pharmacy. Procedure step number 8 (a) documents the nurse confers with the prescriber to determine whether the order is a true emergency, e.g. (example given), order cannot be delayed until the next scheduled delivery. The nurse may alert the physician to the listing of medications that are readily available in the emergency supply. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to the nurse and directly to the pharmacist, along with details about the situation to verify that it meets the needs of an 'emergency situation.'

Based on record review and interview, the facility failed to report an allegation of abuse for 1 of 1 (R1) resident reviewed for abuse in the sample of 3. The Findings Include: On 9/12/23 at 9:30 AM, V1 (Administrator) stated she had an insurance representative come to her and report R1 reported she had been thrown into bed by V2 (Certified Nurse Assistant/CNA) and V3 (CNA). V1 stated she went down to R1's room and interviewed her regarding this report, and determined that it was not abuse. V1 confirmed at this time, she did not report this allegation of staff to resident physical abuse to the physician, family, police, or state agency and there are no notes in the medical record regarding this event. The facility's abuse policy, with a revision date of 4/18/23, documents , filing accurate and timely investigative reports. Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the administrator and timely to the proper authorities to include Illinois Department of Public Health (IDPH), Ombudsman, Local Police Department, Medical Doctor in a timely manner. The facility will assure that residents involved in allegation of abuse are assessed, documented, and the findings are given to the medical doctor and power of attorney. The facility will immediately and thoroughly investigate all allegations of abuse to include but not limited to interview of residents and staff, visitors, and vendors. The facility will timely report all allegations of abuse (initial/final) to IDPH according to the state and federal guidelines .

Based on record review and interview, the facility failed to thoroughly investigate alleged allegations of abuse for 1 of 1 resident (R1) reviewed for abuse investigations in a sample of 3. The Findings Include: On 9/12/23 at 9:30 AM, V1 (Administrator) stated she had an insurance representative come to her and report R1 reported she had been thrown into bed by V2 (Certified Nurse Assistant/CNA) and V3 (CNA). V1 stated she went down to R1's room and interviewed her regarding this report, and determined that it was not abuse. V1 further stated she spoke with V2 and V3 regarding the allegation of throwing R1 into her bed. V1 stated she questioned them both as to whether they used the patient transfer disc with R1 during the transfer from chair to bed. V1 confirmed at this time, she did not report this allegation of staff to resident physical abuse to the physician, family, police, or State Agency, and there are no notes in the medical record regarding this event. V1 stated she only interviewed R1, V2, and V3. Once she interviewed R1, she determined it was not abuse, and did not interview any other residents or staff. On 9/12/23 at 10:00 AM, V2 (CNA) stated she and V3 were transferring R1, and she is a total assist, and refuses a mechanical lift. The day of this incident, when they hoisted her into bed, she did 'flop' down, but they did not throw her down, and do not feel she was abused. V2 stated she was interviewed by V1 regarding this incident. V2 stated she was never taken off shift during after being asked about this incident. On 9/12/23 at 10:15 AM, V3 (CNA) stated the night they transferred R1 and she claimed she felt 'thrown' to the bed, she lost her footing when they pivoted her to bed. She was not thrown, nor do they feel she was abused. An investigation occurred into potential abuse, and was not founded to her knowledge. V3 stated she was never taken off shift. The undated/timed investigation provided by V1 documents: Interview with (R1): reported by (V8, Insurance Representative) about aides throwing her into bed. (V1) asked (R1) to explain to me what happened with the sides put her into bed. (R1) reported she felt the aides were upset because she asked them to empty her commode, she reported that they took it to clean but hadn't brought it back to her. (R1) asked for it back because she needed to use it. (R1) stated that when they put her to bed they picked her up, she reported she knows they have to do that related to her weight. (V1) asked (R1) if she saw this as abuse, she reported no she knew they had to transfer that way related to her weight and that is how they put her into bed. (R1) stated that she felt it was more poor customer service. The undated/timed interview with V3 documents: V1 asked V3 on how she transferred R1 into bed. V3 reported they had used the assistive device and had to pick her up to get her into bed. This is how they transfer her all the time. The undated/timed interview with V2 documents: V1 asked V2 on how she transferred R1 into bed. V2 stated that they had used the assistive device and had to pick her up to get her into bed. This is how they transfer her all the time. The facility's abuse policy, with a revision date of 4/18/23, documents in part, filing accurate and timely investigative reports. Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the administrator and timely to the proper authorities to include Illinois Department of Public Health (IDPH), Ombudsman, Local Police Department, Medical Doctor in a timely manner. The facility will assure that residents involved in allegation of abuse are assessed, documented, and the findings are given to the medical doctor and power of attorney. The facility will immediately and thoroughly investigate all allegations of abuse to include but not limited to interview of residents and staff, visitors, and vendors. The facility will timely report all allegations of abuse (initial/final) to IDPH according to the state and federal guidelines .

Based on observation, interview, and record review, the facility failed to allow an independent smoker the right to choose when to smoke for 1 of 2 residents (R31) reviewed for smoking in a sample of 24 residents. Findings include: 1. R31's face sheet documented an admission date of 8/15/22, and diagnoses including: necrotizing fasciitis, chronic obstructive pulmonary disease, anemia, insomnia. R31's 4/11/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R31 was cognitively intact. R31's 4/11/23 MDS section G documented R31 was steady at all times when: moving from seated position to standing position, walking (with assisted device if used), turning around and facing he opposite direction while walking, surface to surface transfer. R31's 3/29/23 Elopement Risk Assessment documented R31 was not considered at risk for elopement. R31's 2/3/22 Smoking Safety Screen documented Yes to the following questions: resident expresses understanding that smoking is not allowed near oxygen delivery systems and complies with this practice, resident is alert and oriented, resident's vision is adequate with or without aid, resident has balance while sitting and standing, resident has adequate range of motion of arms and hands, resident has fine motor skills needed to securely hold cigarette, cigar, or pipe, resident is able to enter and exit the designated smoking area independently, resident is able to light cigarette, cigar, or pipe safely, handles lighter securely and safely, ignites lighter without difficulty while holding securely, lights cigarette without bringing flame too close to face and keeps lighter under personal control and possession at all times, smokes without allowing ashes or lit material to fall on clothing or ground, remains alert and aware while smoking, does not forget he/ she is smoking, does not fall asleep holding lit item, smokes without burning clothes or skin, smokes only in designated area, gets ashes into ashtray, smokes without allowing sparks to lit tobacco to fall anywhere other than in the ashtray, if using an ashtray requiring crushing lit items out, crushes all lit material out thoroughly so that leftover item has no lit material that is potentially dangerous, if using a self-extinguishing ashtray, deposits lit item correctly into ashtray. With an IDT (Interdisciplinary Team) review documenting R31 is a safe smoker and may smoke independently. R31's 2/15/23 Safe Smoking Screening documented: R31 does not have a history of smoking related incidents, does not exhibit any signs of confusion, does have the ability to make himself/ herself understood, does remain alert during the course of smoking at all times, is able to communicate the need for help if lit materials fall on them, does not have a visual deficit, does not have dexterity problems or tremors, has the ability to hold a cigarette safely without a device, has the ability to extinguish a cigarette safely, does not use supplemental oxygen, propels wheelchair independently. Then documented D.Other .3. Level of supervision required for resident when smoking: b. Resident requires supervision while smoking . R31's care plan initiated 2/8/23 documented in part . Activity Preferences: smoking . Interventions . Modify ADL (Activities of Daily Living) schedule to accommodate activities of interest as needed . and care plan initiated 2/8/23 documented in part . High Risk for accidental injury; smoking related diseases and conditions related to: Long standing smoking history . Interventions . Educate/ Enforce smoking in designated areas only . Observe/ report unsafe smoking practices . Provide safe receptacles for extinguishing ashes . Smoking Plan: supervised smoking . Safety Modification(s): Staff to retain cigarettes, Staff to retain lighter(s), Supervised smoking times . On 4/19/23 at 9:23 AM, R31 said she was a smoker. R31 said she had been smoking all her life by herself, and did not need help or supervision while smoking. R31 stated she could smoke by herself she was not a child. R31 said the facility had designated smoking times, and staff would not allow any residents outside to smoke if it was not a designated smoking time, or if it was between the hours 10:00 PM through 6:30 AM. R31 said staff only allowed 15 minutes for the smoking time session, and that was not enough time. R31 said there are times she wakes up in the middle of the night and would like to have a cup of coffee and cigarette, because that was what she did at home prior to being admitted to the facility, and staff would tell her no, she could not go outside. R31 said sometimes if the night shift nurse was a smoker, they would be nice, and let R31 go outside with them to smoke, but most of the night shift staff would say you have to wait until morning for the designated smoking time. R31 said, If I was able to go outside to smoke by myself the patio door where the smoking area is locks behind you when you go outside and there is no way to get back in unless a staff sees you and lets you back into the facility. On 4/20/22 at 2:47 PM, R31 was observed to independently ambulate in her wheelchair out of the patio door. R31 was observed to acquire a cigarette and lighter from a visitor, lit the cigarette safely and independently, smoked the cigarette safely and independently, and extinguished the cigarette safely and independently in an ashtray. No staff were present to supervise R31 at that time. On 4/20/22 at 2:33 PM, V9, Certified Nurse's Assistant (CNA), arrived at the patio smoking area with a locked box on a cart containing smoking materials. V9 distributed smoking materials to residents, and R31 independently and safely lit, smoked, and extinguished her cigarette. R31 independently ambulated herself in her wheelchair back into the facility. On 4/21/23 at 1:30 PM, V14 (Regional Director of Operations) said corporate had made the decision all residents were to be documented as needing supervision while smoking, regardless if they were independent with smoking or not. The Reviewed 11/19 Facility Smoking Policy documented in part . The designated smoking area for this facility is: Patio area out Dining Room Door . All residents who smoke will be assessed to determined safety risk . The facility has the right to establish smoking times and to control the distribution of all smoking materials. The following are the established smoking times for the facility: 6:30 AM, 9:00 AM, 10:45 AM, 2:00 PM, 3:45 PM, 6:00 PM, 7:45 PM, 9:45 PM .

Based on record review and interview, the facility failed to complete a discharge summary for 1 of 1 (R40) resident reviewed for discharge in a sample of 24. The Findings Include: R40's admission record documents an admission date of 2/17/23. R40's progress notes documents on 3/7/23 at 11:53 AM, he was being transported by ambulance home for discharge. On 4/21/23 at 11:00AM, V11 (Social Services) stated when a resident is discharged , there is a discharge summary that all departments are to fill out, regarding a summary of their stay here. V11 stated she cannot find where one of these forms was filled out for R40. On 4/21/23 at 11:30 AM, V1 (Administrator) stated she is unable to find a discharge summary at this time on R40.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify significant weight loss of a resident, and failed to notify the dietician and physician of the significant weight loss, for 1 of 2 residents (R11) reviewed for weight loss in the sample of 24. The Findings Include: R11's admission record documents a date of birth of [DATE], and an admission date of [DATE]. Diagnoses listed on this admission record include: Alzheimer's Disease and Dementia. R11's undated care plan does not document any focus area related to weight or intake. R11's Minimum Data Set (MDS), dated [DATE] section G, documents R11 requires supervision (oversight, encouragement or cueing) of one staff at meals. Section K of this same MDS documents under Weight Loss: Loss of 5% or more in the last month or loss of 10% or more is 6 months- Yes, not on a physician prescribed weight loss regimen. R11's Current Physician Order Sheet documents as of [DATE] R11's current diet order is a regular consistency diet with thin liquids, health shakes at lunch. R11's Weights and Vitals Summary documents the following monthly weights: [DATE]: 147.5 pounds, February 6, 2023: 155 pounds, [DATE]: 147 pounds and [DATE]: 147 pounds. No April weight has been obtained at this time per the records. On [DATE] at 3:00 PM, V4 (Dietary Manager) stated a RD (Registered Dietitian) had not been notified of any weight loss by her on R11, because she only went from 155 pounds to 147 pounds. When asked to calculate that weight loss, V4 then realized that it was 5.1% loss in one month. V4 stated no new interventions had been put into place, and the RD had not mentioned any changes or made recommendations that she was aware of. V4 stated at this time, they have just lost their RD, and a temporary one will be here this Monday to see the residents, and she will refer her to review R11's records. R11's Nutritional Risk Assessment/Full, dated [DATE] completed by V5 (Registered Dietitian), documents R11's weight is stable at 156 pounds, and requires daily supplements to maintain the weight trends and current diet is appropriate. The Plan is to continue the diet order and monitor weight, lab and consumption for changes and need to reassess. RD to follow up as needed. There were no progress notes or Registered Dietitian notes found in R11's Medical Records after the [DATE] nutritional risk assessment. R11's Progress notes for the months of [DATE]- present did not contain any notes documenting the weight change, or any notification of weight loss to a RD or physician. On [DATE] at 11:30 AM, V1 (Administrator) confirmed there were no notes regarding weight loss found in the progress notes. During lunch on [DATE] and [DATE] at 12:30 PM, R11 was in the dining room eating at the table with V7 (Certified Nurse Assistant/CNA) next to her for supervision. R11 had the health shakes provided with her meal on these days. At that time, R11 did not appear malnourished on underweight. R11 appeared healthy and was eating with little cueing. On [DATE] at 12:30 PM, V7 stated R11 does not eat a lot, even after encouragement. Her appetite has decreased over the past couple months. They do try to give her snacks throughout the day because she does like sweet/dessert type items. On [DATE] at 3:00 PM, V3 (Registered Nurse) stated R11 has recently seemed to have become tired/lethargic, and her cognition is deteriorating. V3 stated R11 is regularly looking for her deceased husband and sleeps a lot. Along with these cognition changes, she has not been eating very well. On [DATE] at 10:44 AM, V5 (Registered Dietician) stated as of [DATE], V5 going to be temporarily covering the home again. V5 stated she had been there very briefly last year in December, and hasn't been back due to them hiring a RD. However, recently they needed temporary coverage, and she will be there to assess the residents on this upcoming Monday. V5 stated typically the RD and/or MD would be notified if residents are having unplanned weight loss of 5% or greater to determine if there are any interventions that should be implemented. R11's physician was attempted to be reached via phone on [DATE] at 9:41AM, 10:00 AM, and 11:30 AM. No answering service was available to leave a message for a call back. A policy titled Weight Assessment and Interventions dated [DATE] documents under the policy statement: The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Under Policy Interpretation and Implementation it documents .'5. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. 6. The Dietitian will review the weight record at least monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. 7. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a.1 month-5% weight loss is significant b. 3 months-7.5% weight loss is significant, c. 10% weight loss is significant. In this same policy under Policy Analysis it documents .2. The physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. cognitive or functional decline, b. chewing or swallowing abnormalities, c. pain, d. medication related adverse consequences, e. environmental factors, f. increased need for calories and/or protein, g. poor digestion or absorption, h. fluid and nutrient loss in the same policy under Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address to the extent possible: a. the identified cause of weight loss, b. goals and benchmarks for improvement, c. time frames and parameters for monitoring and reassessment .'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label insulin pens with open dates for 4 of 7 residents (R9, R16, R30, and R31) reviewed for medication administration and storage in the sample of 24. Findings include: 1. R9's face sheet documented an admission date of [DATE], and diagnoses including: end stage renal disease, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, spinal stenosis. R9's Physician Order Sheet (POS) documented a [DATE] order for Insulin Aspart inject 6 units subcutaneously before meals . and Insulin Aspart inject as per sliding scale . subcutaneously before meals . and a [DATE] order for Levemir insulin inject 12 unit subcutaneously at bedtime . 2. R16's face sheet documented an admission date of [DATE], and diagnoses including: atherosclerotic heart disease, morbid obesity, Crohn's disease, diverticulitis of large intestine, mayor depressive disorder. R16's POS documented a [DATE] order for Humalog kwikpen inject as per sliding scale . subcutaneously tow times a day . 3. R30's face sheet documented an admission date of [DATE], and diagnoses including: chronic obstructive pulmonary disease, type 2 diabetes mellitus, morbid obesity, hypothyroidism, epilepsy. R30 POS's documented a [DATE] order for Insulin Lispro . inject 6 units subcutaneously before meals . and Insulin Lispro . inject as per sliding scale . subcutaneously before meals . 4. R31's face sheet documented an admission date of [DATE] and diagnoses including: necrotizing fasciitis, chronic obstructive pulmonary disease, anemia, insomnia. R31's POS documented a [DATE] order for Humalog kwikpen inject as per sliding scale . subcutaneously before meals and at bedtime . On [DATE] at 12:42 PM, the north hall medication cart was observed to have R9's Insulin Aspart and Levemir pens open and without open dates, R16's Humalog pen open and without an open date, R30's Insulin Lispro pen open and without an open date, and R31's Humalog pen open and without an open date. At that time, V3, Registered Nurse (RN), said she did not know when R9, R16, R30, and R31's insulin pens were opened, because they did not have an open date on them. V3 said all insulin should be dated when opened due to the insulin will expire 28 to 30 days after it is opened. V3 said R9, R16, R30, and R31's insulin pens would have to be destroyed, and new pens would have to be opened. On [DATE] at 9:23 AM, V2, Director of Nursing, said she expected all insulin pens to have a opened date on them, due to insulin pens expiring in 28 days after being opened. V2 said if there was no open date on the insulin pens, staff would not know when they expired, and the pens would need to be destroyed. The facility's provided an undated Medications with Shortened Expiration Dates list that documented Levemir expires 42 days after first use or removal from refrigerator, whichever comes first. Insulin Aspart expires 28 days after first use or removal from refrigerator, whichever comes first. Humalog expires in 28 days after first use or removal from refrigerator, whichever comes first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall interventions were implemented for 1 of 3 (R3) residents reviewed for falls in the sample of 36. Findings Include: R3's facility admission Record, with a print date of 3/22/23, documents R3 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, diabetes, adult failure to thrive, hypertension, dementia, visual loss, dysthmic disorder, heart disease, and abdominal aortic aneurysm. R3's MDS (Minimum Data Set), dated 1/11/23, documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates R3 has a severe cognitive deficit. R3's undated Care Plan documents a Focus Area of, (R3) is at risk for falls, risk for injury from falls, r/t (related to) unsteady gait/weakness/impaired safety awareness. This same focus area documents the following interventions, 12/14/22 staff to ensure needs of wife are met as well as resident's each time in room, clutter free well lit area, Continue Low bed. Give a reacher when received ordered on 3/22/23, ensure call light in reach, ensure proper footwear, fall mat while in bed, hospice to provide low/zero plane change bed, low bed, Motion alarm r/t frequent falls, non-skid strips in front of toilet in bathroom, Per Hospice Bed/Chair alarm to be in place. There were no dates documented next to each intervention on this care plan. R3's Fall Risk Assessment, dated 3/13/23, documents a score of 19, which indicates R3 is at high risk for falls. R3's Fall reports document the following, 1/23/23- .called to resident room by residents wife, resident fell .lost balance and fell, did not hit head Root Cause: Resident has poor safety awareness, continues to unplug pressure alarm. Intervention: Remove pressure alarm and provide motion alarm. 2/13/23- .Resident found sitting upright on floor in room beside bed. Denies hitting head .Root Cause: Attempting to transfer without assistance. Intervention: Low bed. 2/18/23- .Resident found on the floor next to bed, on fall mat .Root Cause: Impaired balance, forgetful, needed to use toilet. Intervention: Resident toileted. 2/24/23- .Resident found lying beside his bed on his right side. Has skin tear on right side of forehead and skin tear on right arm. Is able to move all extremities without pain or discomfort. No shortening of lower extremities or external rotation Root Cause: Unsteady gait/impaired balance. Intervention: Assist resident with toileting as needed. 3/4/23- .resident noted sitting self on floor .Root Cause: Resident doesn't lie in bed properly, often has feet hanging over the edge and in the bed sideways. Intervention: Refer to Hospice for a zero plane change bed/mattress. 3/13/23- .Upon entering patients room noted patient laying on his back. Holding on to his walker. Appears patient was coming back from the bathroom. No injuries are noted. Patient wife (R9) witnessed the fall. Patient didn't hit his head. ROM (range of motion) WNL (within normal limits) on all extremities, noted call light within reach but not in use. Sensor pad is unplugged but in place. Patient bare foot at the time of fall. Educated on basic safety .Root Cause: ambulating to restroom without assistance, barefoot. Intervention: non-skid socks are worn. On 3/22/23 at 1:25 PM, observed R3's room with V2 (DON/Director of Nurses) present. There was no non-skid strips observed in R3's bathroom, and R3 was observed laying on what appeared to be a regular bed on lowest level, without a special mattress in place. V2 stated she would have to check on the Zero Plane change bed/mattress that was to be implemented after R3's fall on 3/4/23. On 3/22/23 at 2:10 PM, V2 (DON) stated she called Hospice related to the Zero Plan Change bed/mattress, and they said they don't provide that type of bed. V2 stated she would have to order it. When asked why it wasn't followed up on before being brought to their attention by this surveyor, V2 stated she didn't know why and they would also have to get the non-skid strips in place in R3's bathroom. On 3/22/23 at 2:48 PM, V1 (Administrator) stated she wasn't aware Hospice didn't provide the Zero Plane Change bed/mattress. V1 stated she had asked V2 (DON) to notify Hospice. V1 stated she would expect fall interventions to be implemented as recommended. The facility Accidents & Incidents policy, dated 9/15/19, documents, Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. The policy documents under, 4. Investigate and follow up Action: .E. The D.O. N. (Director of Nurses), IDT (Interdisciplinary Team), and/or Designees will conduct an investigation of the accident/incident as well. Findings will be indicated under Risk Management in the appropriate area. The IDT will review with in 24 hours or next business day and discuss and attempt to find out the root cause and implement an appropriate intervention to attempt to prevent further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were assisted with bathing as scheduled for 4 of 11 (R4, R17, R18, and R19) residents reviewed for Activities of Daily Living (ADL's) in the sample of 36. Findings Include: 1. R4's facility admission Record, with a print date of 3/22/23, documents R4 was admitted to the facility on [DATE], with diagnoses that include hemiplegia, hemiparesis, diabetes, morbid obesity, heart disease, anemia, insomnia, anxiety, and atrial fibrillation. R4's MDS (Minimum Data Set) dated 1/4/23, documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R4 is cognitively intact. This same MDS documents under Section G that R4 requires two person physical assistance for bathing. R4's undated current Care Plan documents a Focus Area of Self Care Deficit As Evidenced by: Needs Assist x (times) 2 assistance with transfer Related to Obesity, weakness. This focus area includes interventions of Transfer: Two person physical assistance required. May use Hoyer Lift Only for safe transfer. There is no information included on this care plan related to bathing. The facility Shower Schedule documents R4 is to be assisted with bathing each week on Sunday and Thursday. R4's Documentation Survey Report for bathing, with a print date of 3/22/23, documents R4 is to get assistance with bathing each week on Sunday and Wednesday. This report documents from 3/1/23 to 3/22/23, R4 received assistance with bathing on 3/2/23. There is no other documentation of R4 receiving assistance with bathing from 3/1/23 to 3/22/23. On 3/21/23 at 11:55 AM, R4 stated the facility does assist her with showers, but she didn't get one last week. R4 stated she is supposed to get one twice weekly. 2. R17's facility admission Record, with a print date of 3/22/23, documents R17 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD), diabetes, acute and chronic respiratory failure, insomnia, hypertension, and heart disease. R17's MDS, dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R17 has a moderate cognitive impairment. This same MDS documents under Section G, R17 requires a two person physical assist for showers. R17's Care Plan documents a Focus Area, dated 12/28/21, of Self-Care Deficit as Evidenced by: Needs limited assistance with ADL's at times. related to Intervertebral Disc Degeneration and COPD. This focus area documents interventions that include, Bathing-One person physical assist required. The facility Shower Schedule, dated 3/17/23, documents R17 gets assistance with showers on Monday and Thursday shift from 6 PM to 6 AM shift. R17's Documentation Survey Report for bathing, dated 3/22/23, documents R17 is to get showers each week on Monday and Thursdays. This same report documents R17 received assistance with bathing on 3/18/23 and 3/21/23. This report does not document R17 received any other baths/showers from 3/1/23 to 3/22/23. 3. R18's facility admission Record, with a print date of 3/22/23, documents R18 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, hypertension, anxiety, and unstable angina. R18's MDS, dated [DATE], documents a BIMS score of 13, which indicates R18 is cognitively intact. This same MDS documents under Section G that R18 requires assistance of two staff for bathing. R18's undated current Care Plan documents a Focus Area of (R18) requires staff assistance with ADL's. This focus area documents interventions that include, Bathing- 2x (times) weekly and as needed. The facility Shower Schedule, dated 3/17/23, documents R18 is to receive assistance with showers on Monday and Thursday 6 PM to 6 AM shift. R18's Documentation Survey Report for bathing, dated 3/22/23, documents R18 received assistance with bathing on 3/21/23. This same report does not document R18 received any other assistance with bathing from 3/1/23 to 3/22/23. 4. R19's facility admission Record, dated 3/22/23, documents R19 was admitted to the facility on [DATE], with diagnoses that include polyneuropathy, asthma, dementia, anemia, anxiety, and atrial fibrillation. R19's MDS, dated [DATE], documents a BIMS score of 10, which indicates R19 has a moderate cognitive deficit. This same MDS documents under Section G that R19 requires one person physical assist for bathing. R19's undated Care Plan documents a Focus Area of (R19) requires staff assistance with ADL's. This same Focus Area documents interventions that include, assist with bathing 2 x weekly and as needed. The facility Shower Schedule, dated 3/17/23, documents R19 is to be assisted with bathing on Monday and Friday 6 PM -6 AM shift. R19's Documentation Survey Report for bathing, dated 3/22/23, documents R19 did not receive assistance with bathing from 3/1/23 to 3/22/23. On 3/20/23 at 8:56 PM, V6 (CNA/Certified Nursing Assistant) stated there are three CNA's working tonight. V6 stated three CNA's are not enough to provide care. When asked what care doesn't get provided, V6 stated they weren't able to do any showers tonight (Monday night 3/20/23). On 3/20/23 at 10:42 PM, V3 (LPN/Licensed Practical Nurse) stated she didn't think they had enough staff to provide care. When asked what care didn't get provided, V3 stated not all showers get done the way they are supposed to. On 3/22/23 at 10:31 AM, this surveyor reviewed with V2 (Director of Nursing) the shower schedule and shower reports. V2 stated R18 and R19 did not get a shower or bath on 3/20/23. V2 stated R17 got a shower/bath on 3/18 and 3/21/23, but there is no documentation she got any other shower/bath in 3/2023. V2 stated she would check the shower sheets to see if there was anything other showers/baths documented. There was no other documentation provided to this surveyor by the end of the survey. The facility Bathing Policy, dated 9/18/19, documents, Purpose: To provide guidance to facility nursing staff regarding the expectation of resident bathing. Policy: It is the expectation of this facility that residents will be offered a means of bathing at a time/day of their preference and by means of their choosing (shower, tub bath, bed bath, etc.) at least two times a week. This facility recognizes that residents have the right to refuse cares as a personal choice

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications within the time frame designated for administration for 10 of 20 residents (R1, R14, R19, R20-R25, and R27) reviewed for medication administration in the sample of 36. Findings Include: On 3/20/23 at 7:18 PM, V3 (LPN/Licensed Practical Nurse) was observed beginning the 8:00 PM medication pass. Medications were observed administered until 10:42 PM on this same date. At 10:42 PM, V3 (LPN) stated she still had to pass medications on the last unit (Alzheimer's) at the facility. When asked if these medications would be considered late since she was still passing the 8:00 PM medications and it was 10:42 PM, V3 stated they would not be late since the times the medications were due had been changed for that unit. On 3/21/23 at 11:30 AM, V10 (Vice President) stated if the medications were due to be administered at 8:00 PM, then they would be considered late if they were administered after 10:42 PM. On 3/21/23 at 7:45 PM, V3 (LPN) stated she did not begin passing medications to the residents on the last unit until after this surveyor interviewed her at 10:42 PM on 3/20/23. V3 stated all of the 8:00 PM medications that were administered on that unit were administered late. On 3/22/23 at 3:23 PM, this surveyor reviewed the MAR's with V13 (Regional Nurse Consultant) and asked why the MAR's documented the medications were administered at 8:00 PM when they were administered after 10:42 PM. V13 stated when medications are signed off it shows the time they are supposed to be given not the time it was actually administered. A list provided by V1 (Administrator) documents R1, R14, R19, R20-R25, and R27 all reside on the Alzheimer's Unit. 1. R1's facility admission Record, with a print date of 3/22/23, documents R1 was admitted to the facility on [DATE] with diagnoses that include hypertension, hyperlipidemia, protein calorie malnutrition, and dementia. R1's MDS (Minimum Data Set), dated 1/9/23, documents a BIMS (Brief Interview for Mental Status) score of 02, which indicates a severe cognitive deficit. R1's Order Listing Report, with a print date of 3/22/23, includes the following physician orders; Acetaminophen Tablet give 325 mg (milligrams) by mouth three times daily for pain .Aspirin Capsule 81 mg give 1 tablet by mouth at bedtime for cardio .Cholecalciferol Tablet give 2000 unit by mouth one time a day Depakote Sprinkles Capsule Sprinkle 125 mg .give 2 capsules by mouth three times a day related to unspecified dementia .psychotic disturbances .Melatonin 5 mg Give 5 mg by mouth at bedtime for difficulty sleeping. Potassium Chloride 20 meq/ml (milliequivalent/milliliter) Give 10 mEq by mouth two times a day for supplement. Pro-Heal .Give 30 ml BID (twice daily) for wound management .Quetiapine fumarate tablet 50 mg by mouth at bedtime . R1's MAR (Medication Administration Record), dated 3/1/23 to 3/31/23, documents the following medications are to be administered at 8:00 PM; aspirin 81 mg (1) tablet, cholecalciferol 2000 unit, melatonin 5 mg, quetiapine 50 mg, potassium chloride liquid 10 mEq, proheal 30 ml, acetaminophen 325 mg, and depakote sprinkles 125 mg (2) capsules. 2. R14's facility admission Record, with a print date of 3/22/23, documents R14 was admitted to the facility on [DATE], with diagnoses that include dementia, heart disease, osteoarthritis, anxiety disorder, Vitamin deficiency, history of healed fracture, and atrial fibrillation. R14's MDS, dated [DATE], documents a BIMS score of 04, which indicates R14 has a severe cognitive deficit. R14's Order Listing Report, with a print date of 3/22/23, includes the following physician orders, .Tylenol Extra Strength Tablet 500 mg (Acetaminophen) Give 1 tablet by mouth two times a day related to unspecified osteoarthritis .tramadol 50 mg tab Give 1 tablet by mouth two times a day for Pain Take w/ (with) Acetaminophen ES (extra strength) 500 mg . R14's MAR, dated 3/1/23 to 3/31/23, documents the following medications are to be administered at 8:00 PM, tramadol 50 mg and tylenol extra strength 500 mg. 3. R19's facility admission Record, with a print date of 3/22/23, documents R19 was admitted to the facility on [DATE], with diagnoses that include polyneuropathy, asthma, dementia, osteoarthritis, anemia, anxiety, atrial fibrillation, and history of healed fracture. R19's MDS, dated [DATE], documents a BIMS score of 10, which indicates a moderate cognitive deficit. R19's Order Listing Report, with a print date of 3/22/23, includes the following physician orders, Acetaminophen Tablet Give 1 gram by mouth three times a day for arthritis pain give (2) 500 mg tabs .Lactobacillus Rhamnosus (GG) Capsule Give 1 capsule by mouth two times a day for supplement R19's MAR, dated 3/1/23 to 3/31/23, documents the following medications are to be administered at 8:00 PM, lactobacillus rhamnosus 1 capsule and acetaminophen tablet (2) 500 mg. 4. R20's facility admission Record, with a print date of 3/22/23, documents R20 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, rheumatoid arthritis, hypertension, heart disease, anxiety disorder, depression, osteoarthritis, alcohol dependence, and atherosclerosis. R20's MDS, dated [DATE], documents a BIMS score of 03, which indicates a severe cognitive impairment. R20's Order Listing Report, dated 3/22/23, includes the following physician orders, .lisinopril-hydrochlorothiazide tablet 20-12.5 mg Give 1 tablet by mouth in the evening related to essential hypertension . R20's MAR, dated 3/1/23 to 3/31/23, documents the following medication is to be administered at 8:00 PM, lisinopril-hydrochlorthiazide tablet 20 -12.5 mg. 5. R21's facility admission Record, dated 3/22/23, documents R21 was admitted to the facility on [DATE], with diagnoses that include insomnia, glaucoma, hypertension, atherosclerosis, rhabdomyolysis, and depressive disorder. R21's MDS, dated [DATE], documents a BIMS score of 11, indicating R21 has a moderate cognitive deficit. R21's Order Listing Report, with a print date of 3/22/23, includes the following physician orders, .Latanoprost 0.005% opth (opthalmic) soln (solution) instill 1 drop in both eyes in the evening related to absolute glaucoma mirtazapine 30 mg tab give 1 tablet by mouth in the evening related to insomnia . R21's MAR, dated 3/1/23 to 3/31/23, documents the following medications to be administered at 8:00 PM, latanoprost 0.0005% opthalmic solution one drop both eyes and mirtazapine 30 mg. 6. R22's facility admission Record, dated 3/22/23, documents R22 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction, diabetes, unspecified psychosis, heart disease, schizophrenia, macular degeneration, hyperlipidemia, polyneuropathy, and osteoarthritis. R22's MDS, dated [DATE], documents a BIMS score of 03, which indicates a severe cognitive deficit. R22's Order Listing Report, with a print date of 3/23/23, includes the following physician orders, .Aspirin 81 mg EC tab Give 1 tablet by mouth one time a day related to hypertensive heart disease .Citalopram 20 mg tab give one tablet by mouth one time a day related to other recurrent depressive disorder. Docusate Sodium 100 mg Cap Give 1 capsule by mouth tow times a day for bowel management .Gabapentin 100 mg cap Give 1 capsule by mouth three times a day related to Diptheritic polyneuritis .Lumigan 0.01% Opthl Sol instill 1 drop in both eyes in the evening related to unspecified glaucoma .Preservision Areds 2 cap Give 1 capsule by mouth two times a day related to Glaucoma .Timolol Maleate 0.5% Opth Sol Instill 1 drop in both eyes two times a day related to Glaucoma. R22's MAR, dated 3/1/23 to 3/31/23, documents the following medications to be administered at 8:00 PM, aspirin 81 mg, citalopram 20 mg, lumigan 0.01% opth sol (solution) 1 drop each eye, docusate sodium 100 mg, preservision areds 2 capsules, timolol maleate 0.5% one drop each eye, and gabapentin 100 mg. 7. R23's facility admission Record, with a print date of 3/22/23, documents R23 was admitted to the facility on [DATE], with diagnoses that include fibromyalgia, diabetes, hyperlipidemia, orthostatic hypotension, osteoarthritis, hypertension, anxiety disorder, anemia, chronic pain syndrome, hallucinations, and delusional disorder. R23's MDS, dated [DATE], documents a BIMS score of 10, which indicates a moderate cognitive impairment. R23's Order Listing Report, with a print date of 3/22/23, includes the following physician orders .colace capsule 100 mg Give 100 mg by mouth two times a day for constipation .Cyclobenzaprine HCL tablet 10 mg, Give 1 tablet by mouth at bedtime for muscles, Dicyclomine HCL tablet 20 mg Give 1 tablet by mouth four times a day for intestinal, Fenofibrate Tablet Give 54 mg by mouth one time a day for cholesterol .Fluconazole Tablet 100 mg Give 100 mg by mouth at bedtime for skin maintenance .Hydrocodone-Acetaminophen Oral Tablet 7.5-300 mg (hydrocodone-acetaminophen) Give 1 tablet by mouth three times a day for pain control related to chronic pain syndrome .Iron Tablet 325 (65 Fe) mg (Ferrous Sulfate) Give 1 tablet by mouth two times a day for supplement .Magnesium Oxide Tablet 400 mg Give 1 tablet by mouth two times a day for low mag levels Metoprolol Tartrate Tablet 25 mg Give 0.5 tablets by mouth two times a day for high blood pressure .Rivastigmine Tartrate Capsule 6 mg Give 6 mg by mouth two times a day for memory, and Rosuvastatin Calcium Tablet 20 mg Give 20 mg by mouth in the evening for cholesterol. R23's MAR, dated 3/1/23 to 3/31/23, documents the following medications are to be administered at 8:00 PM, cyclobenzaprine 10 mg, fenofibrate 54 mg, fluconazole 100 mg, rosuvastatin 20 mg, colace 100 mg, iron tablet 325 mg, magnesium oxide 400 mg, metoprolol tartrate 25 mg 1/2 tablet, rivastigmine tartrate 6 mg, hydrocodone-acetaminophen 7.5/300 mg, and dicyclomine 20 mg. 8. R24's facility admission Report, with a print date of 3/22/23, documents R24 was admitted to the facility on [DATE], with diagnoses that include emphysema, hypertension, dementia, and tobacco use. R24's MDS, dated [DATE], documents a BIMS score of 02, which indicates a severe cognitive deficit. R24's Order Listing Report, with a print date of 3/22/23, includes the following physician orders, .buspirone HCL tablet 15 mg Give 1 tablet by mouth four times a day .Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium) Give 3 capsules by mouth two times a day related to unspecified dementia .Metoprolol Tartrate Tablet 50 mg, Give 1 tablet by mouth two times a day related to essential hypertension .Mirtazapine Tablet 7.5 mg Give 1 tablet by mouth at bedtime related to unspecified dementia .Namenda Tablet 10 mg (memantine HCL) Give 1 tablet by mouth two times a day related to unspecified dementia . R24's MAR, dated 3/1/23 to 3/31/23, documents the following medications are to be administered at 8:00 PM, mirtazapine 7.5 mg, depakote sprinkles 125 mg (3) capsules, metoprolol tartrate 50 mg, namenda 10 mg, and buspirone HCL 15 mg. 9. R25's facility admission Record, with a print date of 3/22/23, documents R25 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation, diabetes, chronic obstructive pulmonary disease, hypertension, hypothyroidism, major depressive disorder, insomnia, tachycardia, and anxiety disorder. R25's Order Listing Report, with a print date of 3/22/23, includes the following physician orders, Trazadone HCL Oral Tablet 100 mg (Trazadone HCL) Give 2 tablets by mouth at bedtime related to primary insomnia. Vilazodone HCL Oral Tablet 40 mg (Vilazodone HCL) Give 1 tablet by mouth at bedtime related to Major Depressive Disorder . R25's MAR, dated 3/1/23 to 3/31/23, documents the following medications to be administered at 8:00 PM, trazadone 100 mg and vilazodone 40 mg. 10. R27's facility admission Record, with a print date of 3/22/23, documents R27 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction, candidal esophagitis, mild protein calorie malnutrition, chronic bronchitis, chronic obstructive pulmonary disease, heart disease, anemia, schizophrenia, delusional disorder, hallucinations, and anxiety disorder. R27's MDS, dated [DATE], documents a BIMS score of 09, which indicates R27 has a moderate cognitive impairment. R27's Order Listing Report, with a print date of 3/22/23, includes the following physician orders, .Aripiprazole Tablet 2 mg Give 1 tablet by mouth at bedtime related to schizophrenia .Atorvastatin Calcium Tablet 40 mg Give 1 tablets by mouth at bedtime for cholesterol level Melatonin Capsule 5 mg Give 1 capsule by mouth at bedtime for insomnia . R27's MAR, dated 3/1/23 to 3/31/23, documents the following medications are to be administered at 8:00 PM, aripiprazole 2 mg, atorvastatin 40 mg, and melatonin 5 mg. The facility Medication Administration Policy/Procedure, dated 5/16/20, documents, Purpose: To ensure proper administration of oral medications. Policy: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide staff to ensure timely care was provided to the residents. This has the potential to effect all 39 residents currently residing at the facility. Findings Include: The facility Census and Condition Form, dated 3/20/23, documents 39 residents currently reside at the facility. The Facility Assessment, dated September 2018, includes under Department and Job Structure a list of job titles and the number of staff required. This list includes one registered nurse (RN) and/or licensed practical nurse (LPN) per shift and four CNA's (Certified Nursing Assistance) per shift. The facility staff schedules, dated week of 2/29/23 to week of 3/19/23, documents one nurse each shift on 2/20, 2/21, 2/22, 2/25, 2/26-3/13, 3/16, 3/18, 3/19, 3/21, 3/22, 3/23, and 3/25/2023. These same schedules document one CNA working from 10 PM - 6 AM on 2/20, 3/6, and 3/7; from 6 PM - 6 AM on 2/24, 3/11, and 3/12; and from 12 AM to 6 AM on 3/9/23. The same nursing schedules document two CNA's working from 6 PM - 6 AM on 3/1, 3/3, 3/5, 3/10, 3/16, and 3/17/23; from 10 PM - 6 AM on 2/21, 2/23, 2/26, 2/28, 3/13, 3/15, 3/20, 3/22, and 3/23/23; from 6 PM - 10 PM on 2/25; from 12 AM - 6 AM on 2/27/23; and from 6 PM - 10 PM on 3/4/23. This same schedule documents 3 CNA's working from 6 PM - 6 AM on 3/14, 3/19, and 3/25/23 and from 6 PM to 10 PM on 2/20, 2/23, 2/28, 3/6, and 3/15/23. On 3/20/23 this surveyor entered the facility at 6:50 PM. There was one nurse (V3) and three CNA's observed providing care for 39 residents. 1. R1's facility admission Record, with a print date of 3/22/23, documents R1 was admitted to the facility on [DATE], with diagnoses that include hypertension, hyperlipidemia, protein calorie malnutrition, and dementia. R1's MDS (Minimum Data Set), dated 1/9/23, documents a BIMS (Brief Interview for Mental Status) score of 02, which indicates a severe cognitive deficit. R14's facility admission Record, with a print date of 3/22/23, documents R14 was admitted to the facility on [DATE], with diagnoses that include dementia, heart disease, osteoarthritis, anxiety disorder, Vitamin deficiency, history of healed fracture, and atrial fibrillation. R14's MDS, dated [DATE], documents a BIMS score of 04, which indicates R14 has a severe cognitive deficit. R19's facility admission Record, with a print date of 3/22/23, documents R19 was admitted to the facility on [DATE], with diagnoses that include polyneuropathy, asthma, dementia, osteoarthritis, anemia, anxiety, atrial fibrillation, and history of healed fracture. R19's MDS, dated [DATE], documents a BIMS score of 10, which indicates a moderate cognitive deficit. R20's facility admission Record, with a print date of 3/22/23, documents R20 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, rheumatoid arthritis, hypertension, heart disease, anxiety disorder, depression, osteoarthritis, alcohol dependence, and atherosclerosis. R20's MDS, dated [DATE], documents a BIMS score of 03, which indicates a severe cognitive impairment. R21's facility admission Record, dated 3/22/23, documents R21 was admitted to the facility on [DATE], with diagnoses that include insomnia, glaucoma, hypertension, atherosclerosis, rhabdomyolysis, and depressive disorder. R21's MDS, dated [DATE], documents a BIMS score of 11, indicating R21 has a moderate cognitive deficit. R22's facility admission Record, dated 3/22/23, documents R22 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction, diabetes, unspecified psychosis, heart disease, schizophrenia, macular degeneration, hyperlipidemia, polyneuropathy, and osteoarthritis. R22's MDS, dated [DATE], documents a BIMS score of 03, which indicates a severe cognitive deficit. R23's facility admission Record, with a print date of 3/22/23, documents R23 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, diabetes, hyperlipidemia, orthostatic hypotension, osteoarthritis, hypertension, anxiety disorder, anemia, chronic pain syndrome, hallucinations, and delusional disorder. R23's MDS, dated [DATE], documents a BIMS score of 10, which indicates a moderate cognitive impairment. R24's facility admission Report, with a print date of 3/22/23, documents R24 was admitted to the facility on [DATE] with diagnoses that include emphysema, hypertension, dementia, and tobacco use. R24's MDS, dated [DATE], documents a BIMS score of 02, which indicates a severe cognitive deficit. R25's facility admission Record, with a print date of 3/22/23, documents R25 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation, diabetes, chronic obstructive pulmonary disease, hypertension, hypothyroidism, major depressive disorder, insomnia, tachycardia, and anxiety disorder. R27's facility admission Record, with a print date of 3/22/23, documents R27 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction, candidal esophagitis, mild protein calorie malnutrition, chronic bronchitis, chronic obstructive pulmonary disease, heart disease, anemia, schizophrenia, delusional disorder, hallucinations, and anxiety disorder. R27's MDS, dated [DATE], documents a BIMS score of 09, which indicates R27 has a moderate cognitive impairment. R1, R14, R19, R20-R25, and R27's Medication Administration Records (MAR's), dated 3/1/23 to 3/31/23, documents orders for medications to be administered at 8:00 PM each night. On 3/20/23 at 7:18 PM, V3 (LPN/Licensed Practical Nurse) was observed beginning the 8:00 PM medication pass. Medications were observed administered until 10:42 PM on this same date. At 10:42 PM, V3 (LPN) stated she still had to pass medications on the last unit at the facility. When asked if these medications would be considered late since she was still passing the 8:00 PM medications and it was 10:42 PM, V3 stated they would not be late since the times the medications were due had been changed for that unit. On 3/21/23 at 11:30 AM, V10 (Vice President) stated if the medications were due to be administered at 8:00 PM, then they would be considered late if they were administered after 10:42 PM. On 3/21/23 at 7:45 PM, V3 (LPN) stated she did not begin passing medications to the residents on the last unit until after this surveyor interviewed her at 10:42 PM on 3/20/23. V3 stated all of the 8:00 PM medications that were administered on that unit were administered late. On 3/22/23 at 3:23 PM, this surveyor reviewed the MAR's with V13 (Regional Nurse Consultant) and asked why the MAR's documented the medications were administered at 8:00 PM when they were administered after 10:42 PM. V13 stated when medications are signed off it shows the time they are supposed to be given not the time it was actually administered. On 3/22/23 at 10:07 AM, V11 (RN/Registered Nurse) stated the morning medication pass takes 2 1/2 to 3 hours if there is only one nurse working. When asked how long other medication passes on day shift took, V11 stated she basically goes from one medication pass to the next. When asked what happened if there was an emergency in the facility, V11 stated she takes care of the emergency, and then goes back to passing medications. When asked if medications were administered late when that happened, V11 stated she had been in the red before. When asked what being in the red meant, V11 stated, It means they are late. V11 stated when one nurse was working they were not able to complete their tasks within the prescribed time frames. V11 stated she stays late to do the ordered treatments and the charting. On 3/22/23 at 10:15 AM, V12 (LPN) stated she is not able to provide the care needed within the prescribed time frame. V12 stated she would have to stay late to complete the ordered treatments and her charting. On 3/22/23 at 10:31 PM, V2 (DON/Director of Nursing) stated she worked as a floor nurse on 3/21/23. V2 stated she was able to complete the medication pass within the prescribed time frame. When asked if she was able to finish other tasks that were required/ordered within the prescribed time frames, V2 stated, No, not really. When asked if they needed more than one nurse working on each shift, V2 stated, Yes. V2 stated, I have told Corporate we need more staff scheduled. 2. R4's facility admission Record, with a print date of 3/22/23, documents R4 was admitted to the facility on [DATE], with diagnoses that include hemiplegia, hemiparesis, diabetes, morbid obesity, heart disease, anemia, insomnia, anxiety, and atrial fibrillation. R4's MDS (Minimum Data Set), dated 1/4/23, documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R4 is cognitively intact. This same MDS documents under Section G that R4 requires two person physical assistance for bathing. R4's Documentation Survey Report for bathing, with a print date of 3/22/23, documents R4 is to get assistance with bathing each week on Sunday and Wednesday. This report documents from 3/1/23 to 3/22/23 R4 received assistance with bathing on 3/2/23. There is no other documentation of R4 receiving assistance with bathing from 3/1/23 to 3/22/23. On 3/21/23 at 11:55 AM, R4 stated the facility does assist her with showers but she didn't get one last week. R4 stated she is supposed to get one twice weekly. R17's facility admission Record, with a print date of 3/22/23, documents R17 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD), diabetes, acute and chronic respiratory failure, insomnia, hypertension, and heart disease. R17's MDS, dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R17 has a moderate cognitive impairment. This same MDS documents under Section G, R17 requires a two person physical assist for showers. R17's Documentation Survey Report for bathing, dated 3/22/23, documents R17 is to get showers each week on Monday and Thursdays. This same report documents R17 received assistance with bathing on 3/18/23 and 3/21/23. This report does not document R17 received any other baths/showers from 3/1/23 to 3/22/23. R18's facility admission Record, with a print date of 3/22/23, documents R18 was admitted to the facility on [DATE], with diagnoses that include diabetes, heart disease, hypertension, anxiety, and unstable angina. R18's MDS dated [DATE] documents a BIMS score of 13, which indicates R18 is cognitively intact. This same MDS documents under Section G that R18 requires assistance of two staff for bathing. R18's Documentation Survey Report for bathing, dated 3/22/23, documents R18 received assistance with bathing on 3/21/23. This same report does not document R18 received any other assistance with bathing from 3/1/23 to 3/22/23. R19's facility admission Record, dated 3/22/23, documents R19 was admitted to the facility on [DATE], with diagnoses that include polyneuropathy, asthma, dementia, anemia, anxiety, and atrial fibrillation. R19's MDS, dated [DATE], documents a BIMS score of 10, which indicates R19 has a moderate cognitive deficit. This same MDS documents under Section G that R19 requires one person physical assist for bathing. R19's Documentation Survey Report for bathing, dated 3/22/23, documents R19 did not receive assistance with bathing from 3/1/23 to 3/22/23. The facility Shower Schedule, dated 3/17/23, documents R17, R18, and R19 were to get assistance with bathing on Monday and Thursday from 6 PM to 6 AM. On 3/20/23 at 8:56 PM, V6 (CNA/Certified Nursing Assistant) stated there are three CNA's working tonight. V6 stated three CNA's are not enough to provide care. When asked what care doesn't get provided, V6 stated they weren't able to do any showers tonight (Monday night 3/20/23). On 3/20/23 at 10:42 PM, V3 (LPN/Licensed Practical Nurse) stated she didn't think they had enough staff to provide care. When asked what care didn't get provided, V3 stated not all showers get done the way they are supposed to. V3 stated it is both licensed and certified staffing that she has concerns with. V3 stated they have residents right now who require a lot of care. V3 stated they normally have two CNA's from 10 PM to 6 AM, but there have been nights she has only had one CNA working with her to provide care for all of the residents. On 3/22/23 at 10:07 AM, V11 (RN/Registered Nurse) stated three CNA's on evening shift is probably enough to provide care, but three on day shift is probably not. V11 stated one CNA from 10 PM to 6 AM is not enough to provide care for the residents. On 3/22/23 at 10:15 AM, V12 (LPN) stated she has worked night shift before and has worked with two CNA's from 10 PM to 6 AM. When asked if that was enough to provide the needed care for the residents, V12 stated, I don't think so. V11 stated that is one person providing care for the residents on this hall and indicated from the locked unit double doors to the end of the facility. V11 stated there are 31 residents on that unit and some require assist of two staff. When asked what the CNA does for those residents V11 stated they get her to assist them. When asked who helps the CNA when she is passing medications, V11 just shrugged her shoulders. On 3/22/23 at 10:31 AM, this surveyor reviewed with V2 (Director of Nursing) the shower schedule and shower reports, V2 stated R18 and R19 did not get a shower or bath on 3/20/23. V2 stated R17 got a shower/bath on 3/18 and 3/21/23, but there is no documentation she got any other shower/bath in 3/2023. When asked if three CNA's was enough staff to provide care to the residents on evening shift, V2 stated, I think so. V2 stated she had told corporate they need more staff scheduled. On 3/23/23 at 11:06 AM, V1 confirmed in email the staffing schedules were an accurate reflection of the staff that worked on each day and shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly prevent and/or contain Covid 19 when they failed to ensure staff donned/doffed personal protective equipment (PPE) per current standards of practice. This failure resulted in 18 residents testing positive for Covid 19 and has the potential to affect all 39 residents residing at the facility. Findings Include: The facility Census and Condition Form, dated 3/20/23, documents 39 residents currently reside at the facility. The facility undated Covid Positive Tracking log documents the following residents tested positive for Covid 19; 3/13/23- R12, R24, R28-R30, 3/15/23- R10, R31, R32, 3/16/23- R1, R33, R34, 3/17/23- R6, R8, R21, and 3/20/23- R5, R20, R35, R36. 1. R12's facility admission Record, with a print date of 3/22/23, documents R12 was admitted to the facility on [DATE], with diagnoses that include dementia, anxiety, hypothyroidism, Alzheimer's disease, and dysphagia. R12's MDS (Minimum Data Set), dated 3/16/23, documents R12 has a severe cognitive impairment. The facility undated Covid Positive Tracking log documents R12 tested positive for Covid 19 on 3/13/23. On 3/20/23 at 8:53 PM, V12 (CNA/Certified Nursing Assistant) entered R12's room wearing a gown, gloves, surgical mask and eye protection. There was a sign observed on R12's door indicating R12 was on contact/droplet isolation precautions. V12 exited R12's room and doffed the gown and gloves. V12 did not change the mask or the eye protection. On 3/20/23 at 8:56 PM, V12 (CNA) stated she hadn't tested positive for Covid 19, but she couldn't wear an N95 grade mask since she had an injury to her face. V12 stated she wears the same mask and eye protection from Covid positive resident rooms to Covid negative resident rooms. 2. R31's admission Record, with a print date of 3/23/23, documents R31 was admitted to the facility on [DATE], with diagnoses that include diabetes, athersclerosis, major depressive disorder, heart disease, and hypertension. R31's MDS, dated [DATE], documents R31 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates a moderate cognitive deficit. The facility undated Covid Positive Tracking log documents R31 tested positive for Covid 19 on 3/15/23. On 3/20/23 at 6:57 PM, V5 (CNA/Certified Nursing Assistant) was observed entering R31's room. The door to this room had a sign on it indicating R31 was on droplet/contact isolation precautions. V5 entered the room with an N95 grade mask on. V5 did not don a gown, gloves, or eye protection. V5 exited the room with the same N95 on, sanitized her hands and continued down the hallway passing ice and water to both Covid negative and Covid positive resident rooms. On 3/20/23 at 8:45 PM, V5 (CNA) stated she doesn't change her N95 after entering Covid 19 positive rooms. V5 stated she gets a new N95 each day. V5 stated she doesn't change her eye protection or sanitize it after exiting a Covid 19 positive residents room. 3. R8's admission Record, with a print date of 3/23/23, documents R8 was admitted to the facility on [DATE], with diagnoses that include diabetes, acute and chronic respiratory failure, heart failure, kidney disease, and chronic obstructive pulmonary disease (COPD). R8's MDS, dated [DATE], documents a BIMS score of 13, which indicates R8 is cognitively intact. The facility undated Covid Positive Tracking log documents R8 tested positive for Covid 19 on 3/17/23. On 3/20/23 at 7:49 PM, V3 (LPN/Licensed Practical Nurse) entered R8's room wearing an N95, gloves, and eye protection. There was a sign observed on the door indicating R8 was on contact/droplet isolation precautions. V3 did not don a gown prior to entering this room. V3 stood by the bed and talked with R8. At 7:51 PM, V3 exited the room, sanitized her hands, but did not doff the N95 or the eye protection that she wore into the room. V3 proceeded to pass medications entering residents rooms with no isolation precaution signs on the doors. 4. R10's admission Record, with a print date of 3/23/23, documents R10 was admitted to the facility on [DATE], with diagnoses that include leukemia, COPD, chronic fatigue, iron deficiency anemia, seizers, hypertension, and heart disease. R10's MDS, dated [DATE], documents a BIMS score of 11, which indicates R10 has a moderate cognitive impairment. The facility undated Covid Positive Tracking log documents R10 tested positive for Covid 19 on 3/15/23. On 3/20/23 at 8:27 PM, V3 (LPN) entered R10's room wearing an N95, eye protection, and gloves. V3 did not don a gown. There was a sign observed on R10's door that indicated R10 was on contact/droplet isolation precautions. V3 exited the room, doffed her gloves, sanitized her hands, but did not doff the N95 or eye protection. On 3/20/23 at 10:42 PM, V3 (LPN) stated she changed her N95 and face shield every couple of residents. V3 stated she didn't wear a gown into any Covid positive rooms during the 8:00 PM medication pass, when she was passing medications to both Covid positive and Covid negative residents. On 3/20/23 at 10:19 PM, V7 (CNA) entered R10's room wearing an N95 and eye protection. V7 exited the room without changing her N95 or eye protection. V7 re-entered R10's room at 10:25 PM wearing an N95 and eye protection. V7 did not don a gown or gloves. V7 closed the door and assisted R10. At 10:32 PM, V7 exited R10's room. V7 stated she wears the N95 throughout the facility and changes it every shift. V7 stated when a call light goes off in a Covid positive residents room she doesn't usually put her gown and gloves on until she finds out what the resident needs. V7 stated if she is going to provide care she puts a gown and gloves on, and discards them in the trash before exiting the room. When asked if she put a gown and gloves on when she entered R10's room the second time, V7 stated she didn't put a gown on since the resident was able to change her own depends. V7 stated she did wash her hands before exiting the room. 5. On 3/21/23 at 10:15 AM, V8 (CNA) is observed wearing an N95 with the bottom strap dangling and not in place around her head. V8 is not wearing eye protection and is providing care to both Covid positive and Covid negative residents located on the Alzheimer's unit. On 3/21/23 at 10:20 AM, V8 (CNA) stated she wears an N95 and eye protection when in the facility. V8 stated she just hasn't put her eye protection on yet. V8 stated she got to the facility a little after 6:00 AM. When asked if she had worn eye protection at all since she got to the facility at 6:00 AM, V8 did not answer. On 3/21/23 at 10:29 AM, V9 (CNA) was observed on the Alzheimer's unit wearing a surgical mask. When asked what mask they were supposed to be wearing when in the facility V9 stated no one had ever told her if she was supposed to wear an N95. On 3/20/23 at 8:40 PM, V4 (CNA) stated she does not change her N95 or eye protection after exiting a Covid 19 positive residents room and before entering a Covid 19 negative residents room. On 3/20/23 at 9:09 PM, V2 (DON/Director of Nurses) stated staff should wear gown, gloves, N95, and eye protection into Covid 19 positive rooms, and should remove the PPE when they exit the rooms and hand sanitize. V2 stated they should also wear an N95 and eye protection at all times throughout the facility. V2 stated staff can wear the same N95 and eye protection from Covid positive resident rooms to Covid negative resident rooms. On 3/22/23 at 10:31 AM, V2 (DON) stated staff wear an N95 with a surgical mask covering it when in a Covid positive room, and remove the surgical mask when they exit the room. V2 stated they also wear a gown, gloves, and eye protection and sanitize the eye protection when they leave the room. V2 stated staff were not doing this when this surveyor entered the facility on 3/20/23. The facility Strategies to Prevent and Contain Sars Co-V2 Infection policy dated 2/25/22 documents, .The facility will follow CDC (Center for Disease Control) and CMS (Center for Medicaid Services) guidelines to reduce the risk and prevent the spread of Sars CoV-2 (Covid-19). Responsibility: It is the responsibility of all staff to follow the guidelines when dealing with managing respiratory infection/viruses or influenza PPE requirements when status is unknown (Quarantine) or Covid Positive: .Isolation/Known Positive: N95, eye protection, Gown/Gloves In the event of a positive Covid 19 case: New Onset Case: Outbreak- is defined by CMS as a single positive case of either an associate or a resident New case or suspected case: Pause to Assess, All Staff dons N95 masks and eye protection

Based on interview and record review, the facility failed to ensure a Registered Nurse was working 7 days a week, 8 hours a day. This has the potential to effect all 36 residents residing at the facility. Findings Include: The facility Resident List Report provided to this surveyor on 3/6/23 documents there are 36 residents residing at the facility. The facility nursing schedules, dated 1/29/23 to 3/5/23, document no Registered Nurse (RN) coverage on the following dates 1/30, 1/31, 2/1, 2/2, 2/3, 2/6, 2/7, 2/8, 2/9, 2/12, 2/13, 2/16, 2/17, 2/19, 2/21, 2/23, 2/24, 2/26, 2/28, 3/2, 3/3, 3/7, 3/8, 3/9, and 3/11/23. On 3/7/23 at 1:37 PM, V1 (Administrator) stated they did not have a Registered Nurse working 8 hours a day/7 days a week. V1 stated they did have a Registered Nurse hired and she quit after about a week or so. V1 stated it is very difficult to get RN's in the area since they are so far away from larger cities and towns.

Based on interview and record review, the facility failed to follow physicians medication administration orders for one resident of thirteen residents (R1) reviewed for medication administration in the sample of thirteen. Findings include: R1's Face Sheet documented an 8/15/22 admission date, with diagnoses including Necrotizing Fascitis and Irritable Bowel Syndrome. R1's 11/28/22 Care Plan documented a problem area, '(R1) is at risk for pain/discomfort', with a corresponding intervention,(Give) med(ications) per (physicians) order(s). R1's November 2022 Physicians Order Sheet documented an order for Hydrocodone-Acetaminophen Tablet 10 milligrams-325 milligrams give 1 tablet by mouth every 4 hours for pain at 12:00am, 4:00am, 8:00am, 12:00pm, 4:00pm, and 8:00pm. R1's November 2022 Medication Administration Record (MAR) documented an 11/14/22 12:00am pain level of 8 and documented the medication as being given at that time by V13, Licensed Practical Nurse. The 4:00am pain level was documented by V13 as 8 and indicated the medication was given at that time. A Nursing Progress Medication Administration Note, dated 11/14/22 at 8:29am, documented,(Administered) Oxycodone-Acetaminophen Tablet 10 milligrams-325 milligrams (directions),give 1 tablet by mouth every 4 hours for pain. (The) 4:00 am pain pill (this morning) (was) given late at 7:45 am. Resident Grievances documented the following: October 20th, 2022: Med(ications) not being passed in a timely manner. Summary of actions taken: Inserviceing nursing staff on times of (medication) (administration) addressed. December 5th, 2022: Medications not being passed timely. Summary of actions taken: Education was provided to residents that medication pass will take longer at night time due to one nurse being on shift. On 12/27/22 at 12:40pm, R1 was alert and oriented to person, place, time, and purpose. R1 was observed sitting outside smoking, laughing, and socializing with other residents. R1 stated her pain, on a zero to ten scale, is a 12 all the time, including right now. R1 stated bedtime medications on the 6:00pm to 6:00am shift are frequently passed late, usually three hours or later. R1 stated resident complaints directed to administration about the issue are ignored. R1 stated she is on a narcotic pain medication which is to be given at the 8:00pm pass. On 12/28/22 at 11:45am, V2, Director of Nursing (DON), stated she has been in the DON position for the past two or three months. V2 stated within the past ninety days, there have been no incidents of the narcotic medication reconciliation count being off. V2 stated prior to her accepting the DON position, she worked the 6:00pm to 6:00am shift. V2 stated the main medication pass on that shift is at bedtime, 8:00pm. V2 stated nurses may start passing medications at 7:00pm and end at 9:00pm, and it is considered to be within the clinically acceptable time frame. V2 stated V2 had no difficulty getting medications passed on time. V2 stated the facility has a few residents who are clock watchers, wanting their pain pills when they are too early to be given. V2 stated R1 is one of those residents. V2 stated she was aware of complaints of bedtime medication pass being late, and she has inserviced nursing staff on time management. On 12/28/22 at 1:55pm, V11, Licensed Practical Nurse, stated she works the 6pm to 6am shift. V11 stated the bedtime, 8:00pm, medication pass is often late,sometimes by as much as 11:00pm, or three hours. V11 stated she often feels she needs to stop medication pass and help the Certified Nursing Assistants (CNAs) with resident care. V11 stated there are always two CNAs and one nurse for the full shift and a CNA from 2:00pm to 10:00pm. V11 stated additionally, the facility's medication pass computer program is complex, and it slows her down. On 12/29/22 at 12:30pm, R1 stated she did not specifically remember her pain medication on the morning of 11/14/22 being given late. On 12/30/22 at 1:30pm, V12, Regional Nurse Consultant, stated the facility's medication administration computer program does not allow nursing staff to input the time a medication is given. V12 stated if the medication is given late, such as the 4:00am pain medication on 11/14/22, the nurse is able to indicate the dose was given but cannot document the time given. V12 stated if a medication is not given within clinically acceptable timeframe's, documentation should be made in the Nursing Progress Notes. V12 stated administration will meet with nursing staff to address the concerns with late medications. A Medication Administration Policy, dated 9/27/22, documented,To give Narcotic medication, .ensure date (and) time .are correct. As of the conclusion of the survey, 12/30/22 at 2:00pm, V13 had not returned the surveyors calls to be interviewed.

Based on interview and record review, the facility failed to educate facility staff to follow correct portion size for meal service for three of seven residents ( R1, R2, R3) reviewed for food portions in the sample of thirteen. Findings include: On 12/27/22 at 9:05am, V4, Certified Nursing Assistant, stated residents frequently complain food portions at meals are too small. On 12/27/22 at 12:40pm, R1 was alert and oriented to person, place, and time. R1 stated R1 and other residents have been complaining in the past couple months that the facility is serving too small portions of foods at meals, especially of the entree. R1 stated this occurs most frequently at lunch. R1 stated there is generally not enough entree to get second helpings. R1 stated R1 could get a sandwich but R1 prefers the hot entree. On 12/27/22 at 1:35pm, V6, Activity Director, stated there have been complaints about small food portions in resident council meetings and she has filed grievances based on the complaints. On 12/27/22 at 1:55pm, R2 was alert and oriented to person, place, and time. R2 stated all meals are served with portions which are too small, especially the entree. R2 stated if R2 asks for seconds, R2 is told they are out of food and offer R2 a sandwich or a burger. On 12/27/22 at 2:10pm, R3 was alert and oriented to person, place, and time. R3 stated food portions at meals are too small and when R3 asks for more, the kitchen is usually out of the entree and R3 can only get a sandwich. Resident Grievances documented the following: 10/13/22:Portions are served small. Resolution: (Residents) get seconds when (they) ask. 11/7/22: (Food)serving sizes are too small. Resolution: (V5) will be updating meal cards. 12/5/22:Lunch and supper portions are still small some days. Resolution(V5) has been working with the cooks on (providing the correct)portion size. On 12/28/22 at 9:50am, the surveyor reviewed the above grievances with V5, Dietary Manager. V5 stated resident complaints about portion sizes being too small could be accurate. V5 stated V7, Cook, has been in the position about two months. V5 stated V7 was trained by a cook who is no longer employed at the facility. V5 stated V7 was not trained to follow portion sizes on the dietary spreadsheets, nor to use the appropriately sized ladles and scoops. V5 stated there has always been enough food prepared to ensure all residents are served, but at times there may have not been enough for seconds. V5 stated in those instances, residents are offered other items such as burgers. V5 stated residents can request double portions early in the day and extra portions will be prepared. On 12/28/22 at 10:25am, V7 stated when V7 was trained, V7 was not trained to follow the spreadsheets, nor was V7 familiarized with using ladles and scoops to obtain correct portion sizes. V7 stated they always have enough food for residents, but sometimes there are no extra portions, and residents are then offered a burger or sandwich. On 12/28/22 at 11:45am, V2, Director of Nursing, stated she was aware of the complaints about portion sizes. V2 stated there are very few residents in the facility with weight loss, and those residents are experiencing an overall gradual decline in health. A Food and Nutrition Services/Food Preferences and Portions Policy, dated 9/1/21, documented,Proper portion sizes must be served per the menu based on volume or weight listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain comfortable temperatures and plumbing in good repair for 39 of 47 residents (R2-R40) reviewed for environment in a sample of 47. Findings include: 1. On 11/29/22 at 11:20 AM, V4 (Maintenance/Plant Operations) said about 2 weeks ago, 4 burners went out on one of the boilers. V4 said the heating and air company came to the facility that day and were able to do a temporary fix, and they were able to get the temperatures back up. V4 said the room temperatures have been monitored and the coldest it got was 65.8 degrees Fahrenheit (F), and the average temperature has been 70 degrees F. V4 said some rooms at the end of the hall on the south side stay at about 74-75 degrees F. V4 said a new boiler has been ordered and will be delivered by the end of the day, and will be installed tomorrow (11/30/22). At this time, any recorded room temperatures were requested from the time period that the room temperatures were monitored. On 11/29/22 at 1:20 PM, V4 said the only room temperature logs he could locate were for R3's room. V4 said he was unable to locate any other room temperature logs of other residents' rooms or other rooms in the facility. V4 said the room temperature was only monitored for 2 nights in R3's room because R3 and R3's family complained R3's room was cold. Temperature Logs, dated 11/16/22 and 11/17/22, for R3's room were provided at this time. The Temperature Log documents check every hour at the top of each page. 71 degrees F was the lowest temperature recorded, and was documented 5 times out of 20 recorded temperatures from 11/16/22 and 11/17/22. On 11/29/22 at 3:00 PM, V3 (MDS/Care Plan Coordinator) said when the boiler went out a couple of weeks ago, some of the residents complained of their rooms being cold. V3 said they offered residents extra blankets to keep warm. On 11/29/22 at 11:40 AM, R40 said she is freezing. R40 said she has to stay covered with a blanket and wear thick fuzzy socks to keep warm. R40 said she has lived at the facility for 2 years and doesn't remember it being this cold in the facility. R40 is sitting on her bed, wearing a sweatshirt, thick socks, and is covered with a blanket. The temperature in R40's room was obtained with a calibrated thermometer and is 72.2 degrees F. R40 said she would prefer for her room to be warmer. R40 was alert to person, place, and time. On 11/29/22 at 11:50 AM, R2 said she did not have any heat in her room, and keeps covered with a blanket to keep warm. R2 is observed lying in bed with a large, thick blanket covering R2 and R2's extremities. The temperature of R2's room [ROOM NUMBER].7 degrees F at this time. R2 said she has lived at the facility for three years, and it has never been this cold. R2 was alert to person, place, and time. On 11/29/22 at 12:15 PM, R24 and R4 were observed sitting in the dining room eating lunch. R24 said the dining room always stays hot, but the hall and rooms are cold ,until you get to the double doors on the south hall, and then it is hot. R24 said her room is located on the north hall, and said her room is cold all day long. R24 was alert to person, place, and time. On 11/29/22 at 12:20 PM, R4 said her room is so cold. At 12:25 PM, the temperature of the dining room is 70.5 degrees F. At 12:30 PM, the temperature of R4 and R24's room is 66.7 degrees F. At 12:35 PM, the temperature of R6 and R12's room is 69.4 degrees F. At 12:48 PM, the room temperature of the first shower room on the north hall is 65 degrees F. At 12:55 PM, the temperature of the second shower room on the north hall is 68.2 degrees F. On 11/29/22 at 1:10 PM, R3 said her room is really cold, and her kids bought a digital thermometer to keep in her room. R3's digital thermometer in her room displays 70.2 degrees F. The calibrated thermometer reading is 68 degrees F at this time. R3 said she prefers for it to be warmer. R3 said she wears sweaters to keep warm. R3 said she writes the temperatures down from her digital thermometer, and the coldest it has been in R3's room is 68 degrees on 11/20/22. R3 said the shower rooms are very cold and there is no heat in there. R3 said some new equipment is supposed to arrive at the facility tomorrow, and they are supposed to fix the heat. R3 was alert to person, place, and time. On 11/29/22 at 1:43 PM, V4 checked the room temperature of the first shower room on the north hall with the facilities thermometer and got a reading of 65.1 degrees F. At 1:48 PM, V4 checked the room temperature of the 2nd shower room on the north hall and got a reading of 68.0 degrees F. At 1:50 PM, the first shower room on the south hall was checked per V4 using the facility thermometer and was 64.8 degrees F. The calibrated thermometer was also used at this time with a reading of 65.0 degrees F. At 1:53 PM, the temperature of the second shower room on the south hall was 74.0 degrees, using the facility thermometer and the calibrated thermometer. On 11/30/22 at 10:30 AM, V3 (MDS/Care Plan Coordinator) said a boiler was being replaced and the heating and air technicians have been at the facility to replace the boiler since 7:00 AM. At 2:30 PM, V3 said the technicians were still at the facility working on installing the new boiler. On 11/30/22 at 10:55 AM, V7 (Certified Nurse's Aide/CNA) said she works on the dementia unit located at the end of the south hall. V7 said the unit stays really warm and there have been no issues on the dementia unit with maintaining a comfortable temperature. On 11/30/22 at 1:20 PM, V9 (CNA) said the shower rooms are cold, especially on the north hall and part of the south hall. V9 said they have to run the hot water in the shower room to help warm the shower room up. A document titled Grievance Summaries, dated 11/15/22 and reported by R3, documents under Grievance Details that Resident states that her room is cold and that her water is cold. Under Summary of Investigation and under summary of Findings it documents Boiler was down. The Summary of Action Taken documents that the Boiler up and working about 8pm that night. An invoice from the heating, air conditioning, and plumbing company, dated 11/29/22, under the section titled Description documents Work done on boiler for north wing. Found boiler was not working due to the relay had melted due to the flames rolling out. Found boiler sooted up. Was able to dig the soot out and plug the orifice of burners that were bad. Had to re-wire it to get it to work. Started it up and checked operation. An Invoice from the heating, air conditioning, and plumbing company, dated 12/1/22, under the section titled Description documents No heat. Found no signal from thermostat. Traced wires back. Could not find break in wire. Decided to replace wire to thermostat. Another invoice dated 12/1/22 under the section titled Description documents that Boiler not coming on in middle north hall. Found low voltage transformer burnt. Replaced transformer. The facility policy titled Cold Weather Procedures (undated) documents, The following procedures are followed if there is a loss of heating function during cold weather to prevent hypothermia: When the facility reaches 60 degrees Fahrenheit and remains so for four hours: a. Ensure residents are dressed warmly and have enough blankets/ coverings. b. Cover the heads of the residents and protect other extremities. c. Force fluids. d. Monitor body temperatures. e. Monitor environmental thermometers. f. Evacuate residents if temperatures remain low and resident's safety and welfare is jeopardized. g. Notify the Medical Director. The Daily Census, dated 11/28/22, documents R2-R40 reside in the rooms on the north hall and part of the south hall outside of the dementia unit that are affected by the decreased temperatures. 2. On 11/29/22 at 11:20 AM, V4 (Maintenance/ Plant Operations) said all residents bathrooms are working that he is aware of. V4 said there are a couple of bathrooms that the toilets get clogged, but the residents are still able to use them. V4 said the plumber is in the process of getting them a quote to fix the plumbing problems. V4 said if there are any issues that need to be addressed or fixed, the nurses write it in a log book and he checks the book every day. V4 identified the room numbers that are having issues with their toilets clogging. The Daily Census, dated 11/28/22, documents the identified rooms are the rooms of R2, R29, R25, R26, and R3. On 11/29/22 at 11:50 AM, R2 said is able to use her toilet but it gets clogged all the time. R2 said you can't flush anything or it will get clogged. On 11/29/22 at 12:40 PM, the toilet in the restroom shared by R25, R26, and R3 has a sign on the lid stating no paper in toilet please. The toilet was successfully flushed without paper at this time. On 11/29/22 at 1:10 PM, R3 said she can't put paper in her toilet or have too big of 'turds' or it will clog. The toilet has almost overflowed. A document titled Grievance Summaries reported by R3, dated 11/4/22, documents under Grievance Details that resident reported to maintenance that the toilet was clogged and there was a mess in the bathroom. Under Summary of Action Taken it documents that Housekeeping cleaned bathroom and staff educated on keeping restroom clean and reporting issues as needed. The log of maintenance requests that is reviewed by V4 documents on 10/10/22 room [ROOM NUMBER]'s toilet won't work. It won't flush. An entry on 10/12/22 documents room [ROOM NUMBER] toilet stopped up. An entry dated 10/13/22 documents room [ROOM NUMBER]'s toilet still won't flush. An entry dated 10/27/22 documents toilet stopped up room [ROOM NUMBER] and hall toilet and room [ROOM NUMBER]. An entry dated 11/10/22 documents room [ROOM NUMBER] toilet stop up. An entry dated 11/16/22 documents hall bathroom stop up and room [ROOM NUMBER] and 11. On 11/30/22 at 10:30 AM, V3 (MDS/ Care Plan Coordinator) said they have had a plumber at the facility about 5 times in the last month. V3 said the toilets are usable but get clogged. V3 said at this time, there are 2 toilets that cannot have paper in them because they get clogged. V3 said the plumber has found disposable briefs and wash cloths in the pipes when fixing repairs. An invoice from the heating, air condition, and plumbing company, dated 10/16/22, documents under the section Description that the Sewer was clogged up. Ran big eel through and retrieved a rag out of the sewer. An invoice dated 11/14/22 under Description documents Ran big sewer machine in drain. An invoice, dated 11/21/22, under Description documents Eeled sewer. An invoice, dated 11/29/22, documents Cleaned sewer from cleanout outside. An invoice, dated 12/1/22, documents Sewer was backed up. Ran eel in and got it broke free and flowing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep wound dressings clean and dry for 1 (R2) of 3 residents reviewed for wound treatments in the sample of 3. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Venous Insufficiency (Chronic) (Peripheral), Peripheral Vascular Disease, Chronic Venous Hypertension (Idiopathic) with ulcer and inflammation of bilateral lower extremity. R2's facility document titled, Minimum Data Set (MDS) dated [DATE], section C, Brief Interview for Mental Status (BIMS) documents a score of 13, indicating R2 is cognitively intact. Section G of the MDS, Functional Status documents extensive assistance with physical assist x (times) 2 people with activities of daily living. R2's Nursing Note, dated 8/15/22, documents a referral to (Name of Local Hospital) Wound Services on 8/24/2022 at 2pm d/t (due to) Venous stasis ulcer. A Nursing Note, dated 8/24/22, documents a new order received for Keflex 500mg (milligrams) qid (4 times daily) for 7 days. New treatment order to keep BLE'S (bilateral lower extremeties) wrapped, call (Name of Local Hospital) wound service if wraps slide down, cause increased pain, or drainage through wrap. If cannot reach wound service, remove wraps and cover the wounds with a saline dressing. Use a compression stocking or tubigrip on the leg. Call the wound service as soon as possible for additional instructions. Family notified. Has return appointment 8/31/22 at 1:15pm. R2's Wound Clinic notes, dated 9/7/2022, document, Incidentally, the nurse (before I saw the patient) stated that there was some maggots coming out of her foot, I guess between the toes, and, actually, the nurse got pierced in the eye by one accidentally squirted her (documented by V7, Local Wound Physician). R2's Wound Clinic notes, dated 11/2/2022, documents, Pt (patient) arrived with extremely saturated bilateral wraps that were fallen towards ankle. Pt also had a maggot in between toes. This is the 3rd occurrence of maggots with this patient. (V6, Registered Nurse/RN, Local Wound Clinic). R2's Treatment Administration Record documents 10/31/2022, by V9 (Licensed Practical Nurse/LPN) being the last treatment for bilateral foot wounds documented before R2's Wound Clinic appointment on 11/2/2022. On 11/07/2022 at 2:05 pm, V5 (LPN/Local Wound Clinic) stated she noticed maggots in R2's right foot wound on 11/2/2022. V5 stated they were in between her toes. V5 stated when R2 arrived at the wound clinic her bilateral leg wraps were saturated with drainage, and her shoes had visible drainage noticed on the bottom of the inside of her shoes. On 11/09/2022 at 10:45 am, V6 (RN/Local Wound Clinic) stated she has noticed maggots in R2's right foot wound on 8/31/2022, 9/7/2022 and 11/02/2022. V6 stated on 11/2/2022, R2 came to her appointment with her bilateral leg wraps saturated with drainage, and drainage was also visible on the bottom of the inside of her shoes as well. V6 stated the bilateral leg wraps were not in place when R2 arrived to the wound clinic. V6 stated they were down by the ankles. On 11/09/2022 at 2:30 pm, V7 (Local Wound Physician) stated R2 has shown up to the clinic with maggots in her foot wounds on three different occasions. V7 stated that he does not believe this has caused R2 any harm but is concerned about the cleanliness of the facility, the fact that she has shown up here on three different occasions with maggots in her wounds and her dressings have been saturated. V7 stated one of the nurses got squirted with one of the maggots while changing R2's dressing resulting in this nurse having to flush her eye out and get sent to the Comp Center for further evaluation. V7 stated the facility has been made aware of R2 having maggots in her foot wounds. On 11/07/2022 at 11:30 am, this surveyor observed R2's bilateral leg wraps. The left wrap was down by the left ankle, the right lower leg wrap has drainage leaking through and a foul odor was noted. A fly was noted to the top of R2's left foot on her big toe and another one on R2's privacy curtain. No maggots were observed between her right or left toes at this time. R2 stated she visits the wound clinic once a week, and the facility is suppose to change her leg dressings two times a week, but it doesn't always get done that often. R2 stated she has seen maggots between her toes on two different occasions when she was at the wound clinic. R2 stated flies are bad in her room between 5-6 pm almost every day. On 11/07/2022 at 2:10 pm, this surveyor observed V2 (Director of Nursing/DON) perform R2's bilateral foot wound treatments with V4's (CNA) assistance. R2's right top of foot and inner ankle had extreme redness with swelling noted on top of the right foot, left inner ankle wounds had redness noted, and slight swelling noted to the top of her left foot. R2 tolerated procedure fairly. R2's Wound Clinic notes, dated 11/9/2022, document, Pt arrived to our office with wraps slid down and not in proper place. Right wrap completely saturated with drainage and/or water on lower half (V10, RN/Local Wound Clinic). R2's Treatment Administration Record documents 11/7/2022 by V2 (DON) being the last treatment of bilateral foot wounds documented before R2's Wound Clinic appointment on 11/9/2022. On 11/10/2022, at 1:20 pm, V1 (Administrator) stated she was made aware a maggot was found on R2's foot wound at the wound clinic, but she has never observed any on her foot wounds at the facility. V1 stated R2 has never complained to her about maggots being in her foot wounds. V1 stated R2's bilateral lower leg dressings have been known to drain heavily with drainage. V1 stated if R2's bilateral lower leg dressings were saturated, she would change them right away, and would expect her staff to change them right away as well. V1 stated she believes R2's bilateral lower leg dressings get checked once a shift. R2's Treatment Administration Record documents the months (9/22, 10/22, & 11/22) that right/left ankle wound treatments should get changed two times a week (Monday, Friday) and as needed if they become soiled. R2 gets bilateral foot wound dressings changed at the wound clinic once a week. R2's Treatment Administration Record documents, Keep bilateral lower extremities wrapped, call Wound Clinic if wraps slide down, causes increase pain or drainage through wrap with a start date of 8/24/2022 and discontinued date of 10/26/2022. R2's Wound Clinic notes dated 10/26/2022 document to keep wraps clean and dry.