**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist a resident with incontinence care in a timely manner to promote dignity for 1 of 10 residents (R1) reviewed for dignity in a sample of 10. Findings include:R1's admission Record documents an admission date of 2/15/22 with diagnoses including in part: paranoid schizophrenia, post traumatic seizures, insomnia, anxiety disorder, essential tremor, and personal history of traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is rarely/never understood. The same MDS documents R1 is dependent with toileting hygiene, the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. R1's current Care Plan documents R1 is at risk for impaired skin integrity related to impaired cognition and R1 is known to refuse incontinence care at times. On 9/11/25 at 8:15 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 at 8:43 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 starting at 9:15 AM, R1 was under constant observation by surveyor that lasted until 11:51 AM. On 9/11/25 at 9:15 AM, R1 was sitting on the couch in the dining room with his legs crossed, and his pants were visibly wet in the front left groin area. On 9/11/25 at 9:28 AM, R1 uncrossed his legs and there was a large wet circle on the front of R1's pants. On 9/11/25 at 9:33 AM, V5 (Certified Nursing Assistant/CNA) was walking a resident through the dining room and walked in front of R1 while he was sitting on the couch watching TV. V5 said, Good morning to R1 then R1 responded with a smile and a wave. R1's pants were still visibly wet. On 9/11/25 at 10:28 AM, R1 was still sitting on the couch watching the television with visibly soiled pants. V6 (Activities Assistant) went to R1 with a cart of snacks and drinks and offered R1 a snack and drink. R1 was pointing at the cart and V6 was trying to figure out what he was pointing at. V6 finally figured out he was pointing at the ice that snacks were sitting in. On 9/11/25 at 10:49 AM, V8 (CNA) walked by R1 while he was sitting on the couch, R1 still had visibly soiled pants. V8 did not look at R1. On 9/11/25 at 10:50 AM, V2 (Director of Nursing/DON) walked by R1 while he was sitting on the couch, still had visibly soiled pants. V2 did not look at R1. On 9/11/25 at 10:56 AM, V7 (CNA Supervisor) walked by R1 and didn't look at R1. R1 was still visibly wet. On 9/11/25 at 10:59 AM, V9 (CNA) walked by R1 and didn't look at him. R1 was still visibly wet. On 9/11/25 at 11:00 AM, V8 (CNA) walked by R1 to the resident sitting 2 down from him and took his vital signs. R1 was still visibly wet. On 9/11/25 at 11:03 AM, R1 stood up with visibly wet pants and walked to the door to the back patio area for smoke break. R1 sat down on a bench in the smoking area. On 9/11/25 at 11:05 AM, V10 (Housekeeping) lit R1's cigarette and sat outside with R1 and other residents while they smoked. R1 still had visibly wet pants. On 9/11/25 at 11:16 AM, V10 walked R1 back into the building after he finished smoking. R1's pants were still visibly wet. On 9/11/25 at 11:17 AM, R1 was sitting on the couch and still had visibly wet pants. V7 walked R1 to the scale in the dining room and weighed him. V7 then asked R1 if he wanted to take a shower. R1 did not respond and walked back to the couch in the dinner room to watch the television. On 9/11/25 at 11:24 AM, V8 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:25 AM, V7 asked R1 if he wanted to go take a shower and R1 held his pointer finger up at V7. V7 responded with, 1 hour and R1 shook his head yes. R1's pants were still visibly wet. On 9/11/25 at 11:36 AM, V8 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:39 AM, V2 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:41 AM, V6 walked up to R1 and asked him if he is ready for lunch. V1's pants were still visibly wet. On 9/11/25 at 11:46 AM, V8 was near R1, this surveyor pointed out to V8 that R1 had visibly wet pants. V8 asked R1 if she could take him to change his pants and R1 held up his pointer finger at her. V8 said they can usually get R1 to change his pants if they catch him at his smoke breaks, when he is already up off the couch. V8 stated around 8am today she asked R1 if he wanted to shower, and he told her no.On 9/11/25 at 11:50 AM, V7 come up to R1 while this surveyor and V8 were talking to him and asked him if she could take him to the shower after lunch and R1 shook his head yes. V7 stated R1 should be checked on every 2 hours and cleaned up if he is wet as soon as someone notices it. V7 stated R1 does refuse getting cleaned up at times but sometimes it just takes a new face to get him to agree to care. V7 stated if he refuses to one person then a different person should ask and sometimes, he will agree. On 9/11/25 at 1:07 PM, V7 took R1 to the shower room and shaved R1's face. Then stood R1 up and pulled his pants and depends down. R1 had redness on his buttocks and in his groin. V7 then set R1 in the shower chair in the shower room. On 9/11/25 at 2:41 PM, V5 stated she checked on R1 around 9:30 AM. V5 stated she asked him if he wanted to go to the bathroom and he said no. On 9/11/25 at 2:43 PM, V3 (Assistant Director of Nurses) stated she started her morning rounds at 8:00 AM today and when she talked to him this morning, he wasn't visibly wet. On 9/11/25 at 2:51 PM, V10 stated when she took R1 out to smoke around 11:00 AM today she did not notice he had wet pants. On 9/11/25 at 2:54 PM, V6 (Activities Assistant) stated she was over by R1 when he was sitting on the couch around 8:30 AM or 9:00 AM this morning and she smelled a strong urine smell so she asked R1 if he needed to use the bathroom and he told her no. V6 stated when she was passing snacks to R1 at 10:28 AM this morning she did not notice his pants were wet and she did not ask him if he needed to use the restroom or needed cleaned up. On 9/11/25 at 3:26 PM, V4 (Regional Director of Clinical Services) stated residents should be checked at least every 2 hours for incontinence. V4 stated he couldn't find a policy regarding how often residents should be checked for incontinence or a policy related to dignity/visibly wet pants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure call lights were answered timely for 6 of 8 (R1, R4-R8) residents reviewed for call lights in the sample of 18. Findings Include: 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide peri care after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also documents the Focus Area of (R1) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated: 04/12/2025 . On 6/24/25 at 8:09 AM, R1 stated they don't have enough staff working to do every two-hour bed checks/incontinence care. R1 stated sometimes they only have two CNAs in the facility and when they do it takes longer for them to answer the call light. R1 stated it takes up to an hour at times. R1 stated she only had three showers in the month of June due to them not having enough staff to assist her with them. 2. R4's admission Record with a print date of 6/24/25 documents R4 was admitted on [DATE] with diagnoses that include heart disease, diabetes, hypertension, necrosis of left femur, acquired absence of left leg below the knee. R4's current Care Plan documents a Focus area of (R4) is incontinent of bowel and bladder. He requires staff assistance for transfers to the facilities and hygiene care after use of facilities or incontinence episodes. Date Initiated: 04/28/2025 This Focus area includes interventions of . Check (R4) as needed for incontinence Date Initiated: 04/28/2025 . R4's MDS dated [DATE] documents a R4 has a BIMS score of 12, which indicates R4 has a moderate cognitive deficit. On 6/24/25 at 10:55 AM, R4 stated they don't have enough staff to provide timely care. R4 stated he has to wait a long time for assistance to go to the bathroom and has incontinent episodes while waiting. 3. R5's admission Record with a print date of 6/24/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, hemiparesis, cerebral infarct, unspecified acquired deformity of left lower leg. R5's MDS dated [DATE] documents a BIMS score of 08, indicating R5 has a moderate cognitive impairment. This same MDS documents R5 is dependent on staff for toileting and bathing. R5's current Care Plan documents a Focus area of (R5) has an ADL Self Care Performance Deficit r/t (R5) is dependent upon staff for ADL's. (R5) has Hemiplegia/hemiparesis on one side d/t (due to) recent stroke. Date Initiated: 09/20/2022 This Focus area includes intervention of, Toilet Use: (R5) is not toileted. Date Initiated: 09/20/2022 On 6/24/25 at 10:58 AM, R5 had difficulty answering questions but did indicate with yes/no answers the facility doesn't always have enough staff to answer his call light timely. 4. R6's admission Record with a print date of 6/24/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include epilepsy, depression, muscle weakness, abnormalities of gait and mobility, and repeated falls. R6's MDS dated [DATE] documents a BIMS score of 09, indicating R6 has a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assist for toilet transfers. R6's current Care Plan documents a Focus area of (R6) has bladder incontinence. Date Initiated: 03/16/2025 . This Focus area includes the following intervention, Establish voiding patterns. Date Initiated: 03/16/2025 This same Care Plan includes the Focus area of, (R6) has bowel incontinence. Date Initiated: 03/16/2025 . This Focus area includes the intervention, Provide peri care after each incontinent episode. Date Initiated: 03/16/2025 . On 6/24/25 at 4:40 AM, R6 stated they don't have enough staff to help on the weekends. R6 stated it takes too long to answer the call lights. R6 stated she wasn't sure how long it took but it was long enough she had an incontinent episode. 5. R7's facility admission Record with a print date of 6/24/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include morbid obesity and history of falling. R7's MDS dated [DATE] documents a BIMS score of 08, indicating R7 has a moderate cognitive deficit. This same assessment documents R7 requires substantial/maximal assistance for bathing and toilet hygiene. R7's current Care Plan documents a Focus area of (R7) is incont (incontinent) of urine at times. Date Initiated: 04/03/2025 . This Focus area includes the intervention of, Check (R7) as required for incontinence . On 6/24/25 at 10:44 AM, R7 stated they don't always have enough staff to meet her needs timely. R7 stated it takes longer to answer the call light when they don't have enough staff working. R7 stated she wasn't sure how long it took but it probably feels longer than it actually is. 6. R8's facility admission Record with a print date of 6/24/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include fracture of humerus, osteoarthritis, and malaise. R8's entry MDS dated [DATE] does not document a BIMS score or ADL assessment. R8's current Care Plan provided to this surveyor does not document a Focus area for bathing or toileting. On 6/24/25 at 11:11 AM, R8 stated she got a shower today because she had an incontinent episode. R8 stated they don't always have enough staff, but they work very hard. R8 stated she has had incontinent episodes because she has had to wait for assistance. On 6/24/25 at 5:06 AM, V10 (CNA/Certified Nursing Assistant) stated they have approximately forty resident and they have one nurse and three CNA's working. V10 stated sometimes that is enough and sometimes it isn't. V10 stated they don't always have three CNA's. V10 stated when they had less staff, they weren't able to answer call lights timely, provide timely incontinence care, and/or give showers as scheduled. On 6/24/25 at 5:29 AM, V9 (CNA) stated she has worked night shift at the facility for about a month. V9 stated a week or so ago she was the only CNA in the facility for about three hours. V9 stated she got everyone she could to bed and waited for another CNA to come in and assist with the ones she couldn't. V9 stated one nurse and one CNA cannot meet the needs of the residents. V9 stated they have residents who require two people to transfer, bed alarms, and incontinence care. On 6/24/25 at 5:45 AM, V8 (CNA) stated this is his third shift working at the facility. V8 stated on the first day of his training the CNA training him was also training another new CNA and they were the only three CNA's working on that shift. V8 stated then his next night working he was the only CNA working from 2 AM to 3:30 AM. V8 stated he has been a CNA since 2010 but he didn't know the residents and/or the facility systems and was not comfortable working by himself. V8 stated he wasn't able to answer all of the call lights timely. On 6/24/25 at 6:08 AM, V6 (CNA) stated on 6/19/25 and 6/21/25 there were only two CNA's working from 6 AM to 3 PM. V6 stated they were not able to meet the needs of the residents timely. V6 stated they can't get showers done and/or call lights answered timely. On 6/24/25 at 6:17 AM, V5 (LPN/Licensed Practical Nurse) stated they don't have enough staff to meet the needs of the residents timely. V5 stated when they only have two CNA's it is hard to get all of the scheduled showers done and provide timely incontinence care. V5 stated most of the time they have three CNAs on the schedule, but people call in or quit. On 6/24/25 at 1:37 PM, V1 (Administrator) stated in a perfect world she would expect them to get all of the showers done as scheduled. When asked if two CNAs were enough to meet the needs of the residents timely, V1 stated ideally, she would want two and a half CNAs on each shift. V1 stated they also have two nurses on day shift who should help out on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide timely assistance with activities of daily living (ADL's) for 8 of 8 (R1-R8) reviewed for ADLs in the sample of 18. Findings Include: 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated: 04/12/2025 . This Focus area does not include an intervention specific to bathing or toileting. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. The facility undated Shower List (Day Shift) documents R1 should receive assistance with bathing every Tuesday and Friday. R1's Skin Monitoring: Comprehensive CNA Shower Review sheets document R1 received assistance with bathing on 6/3, 6/10, and 6/17/25. This indicates R1 went 6 days between showers and was not assisted with her scheduled showers on 6/6, 6/13, and 6/20/25. On 6/24/25 at 8:09 AM, R1 stated they don't have enough staff working to do every two-hour bed checks/incontinence care. R1 stated sometimes they only have two CNAs in the facility and when they do it takes longer for them to answer the call light. R1 stated it takes up to an hour at times. R1 stated she only had three showers in the month of June due to them not having enough staff to assist her with them. 2.R2's admission Record with a print date of 6/24/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, hemiplegia, hemiparesis, heart failure, major depressive disorder, convulsions, hypertension, difficulty in walking, weakness, and need for assistance with personal care. R2's MDS dated [DATE] documents R2 has a BIMS score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus area of ADL: (R2) requires assist with daily care needs r/t impaired mobility with hemiplegia/hemiparesis to RUE/RLE (right upper extremity/right lower extremity) Date Initiated: 12/17/2024 . This Focus area includes the intervention of, .Keep clean and dry after each incontinence episode. Date Initiated 12/17/2024 . R2's Care Plan does not document any specific Focus areas or interventions related to bathing. The undated facility Shower List (Day Shift) documents R2 should receive assistance with bathing every Monday and Wednesday. R2's Skin Monitoring: Comprehensive CNA Shower Reviews document R2 received assistance with bathing on 6/2, 6/10, 6/12, 6/17, 6/19, and 6/23/25. This indicates R2 did not receive assistance with bathing as scheduled on 6/4/25. On 6/24/25 at 10:48 AM, R2 stated she gets her showers twice weekly, but she asked for them three times weekly and they told her they won't do it. R2 stated she asks the facility CNA staff to give her extra ones and they tell her they don't have time. 3. R3's facility admission Record with a print date of 6/24/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, altered mental status, atrial fibrillation, tachycardia, Parkinsonism, heart disease, abnormalities of gait and mobility, and history of falls. R3's MDS dated [DATE] documents R3 has a BIMS score of 14, which indicates R3 is cognitively intact. This same MDS documents R3 requires substantial/maximal assistance for tub/toilet transfers. R3's current Care Plan does not document a Focus area and/or interventions related to ADL care including bathing and toileting. The undated facility Shower List (Day Shift) documents R3 should receive assistance with bathing every Wednesday and Saturday. R3's Skin Monitoring: Comprehensive CNA Shower Reviews document R3 received assistance with bathing on 6/4, 6/7, 6/11, 6/14, and 6/18/25. This indicates R3 did not receive assistance with bathing as scheduled on 6/21/25. On 6/24/25 at 10:58 AM, R3 stated they have enough staff but sometimes have problems keeping them. R3 stated she received showers as scheduled. R3's family member (V7) was present in the room and stated R3 doesn't always get her showers as she should. V7 stated R3 hadn't received assistance with bathing since last week. V7 stated they don't have enough staff to meet the needs of the residents timely. V7 stated some days they only have two CNAs for the facility and that is not enough. 4. R4's admission Record with a print date of 6/24/25 documents R4 was admitted on [DATE] with diagnoses that include heart disease, diabetes, hypertension, necrosis of left femur, acquired absence of left leg below the knee. R4's current Care Plan documents a Focus area of (R4) is incontinent of bowel and bladder. He requires staff assistance for transfers to the facilities and hygiene care after use of facilities or incontinence episodes. Date Initiated: 04/28/2025 This Focus area includes interventions of . Check (R4) as needed for incontinence Date Initiated: 04/28/2025 . R4's MDS dated [DATE] documents a R4 has a BIMS score of 12, which indicates R4 has a moderate cognitive deficit. On 6/24/25 at 10:55 AM, R4 stated they don't have enough staff to provide timely care. R4 stated he has had to wait a long time for assistance to go to the bathroom and has incontinent episodes while waiting. 5. R5's admission Record with a print date of 6/24/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, hemiparesis, cerebral infarct, unspecified acquired deformity of left lower leg. R5's MDS dated [DATE] documents a BIMS score of 08, indicating R5 has a moderate cognitive impairment. This same MDS documents R5 is dependent on staff for toileting and bathing. R5's current Care Plan documents a Focus area of (R5) has an ADL Self Care Performance Deficit r/t (R5) is dependent upon staff for ADL's. (R5) has Hemiplegia/hemiparesis on one side d/t (due to) recent stroke. Date Initiated: 09/20/2022 This Focus area includes interventions of, Bathing: (R5) is totally dependent on staff to provide a bath twice weekly and as necessary. Date Initiated: 09/20/2022 Toilet Use: (R5) is not toileted. Date Initiated: 09/20/2022 The undated Facility Shower List (Day Shift) documents R5 is to receive assistance with bathing every Wednesday and Saturday. R5's Skin Monitoring: Comprehensive CNA Shower Review documents R5 received assistance with bathing on 6/5, 6/7, 6/11, and 6/18/25. This indicates R5 did not receive showers as scheduled on 6/14/25 and 6/21/25. On 6/24/25 at 10:58 AM, R5 was lying in bed and his hair appeared greasy. R5 had difficulty answering questions but did indicate with yes/no answers the facility doesn't always have enough staff to answer his call light timely. 6. R6's admission Record with a print date of 6/24/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include epilepsy, depression, muscle weakness, abnormalities of gait and mobility, and repeated falls. R6's MDS dated [DATE] documents a BIMS score of 09, indicating R6 has a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assist for toilet transfers. R6's current Care Plan documents a Focus area of (R6) has bladder incontinence. Date Initiated: 03/16/2025 . This Focus area includes the following intervention, Establish voiding patterns. Date Initiated: 03/16/2025 This same Care Plan includes the Focus area of, (R6) has bowel incontinence. Date Initiated: 03/16/2025 . This Focus area includes the intervention, Provide peri care after each incontinent episode. Date Initiated: 03/16/2025 . On 6/24/25 at 4:40 AM, R6 stated they don't have enough staff to help on the weekends. R6 stated it takes too long to answer the call lights. R6 stated she wasn't sure how long it took but it was long enough she had an incontinent episode. 7. R7's facility admission Record with a print date of 6/24/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include morbid obesity and history of falling. R7's MDS dated [DATE] documents a BIMS score of 08, indicating R7 has a moderate cognitive deficit. This same assessment documents R7 requires substantial/maximal assistance for bathing and toilet hygiene. R7's current Care Plan documents a Focus area of (R7) is incont (incontinent) of urine at times. Date Initiated: 04/03/2025 . This Focus area includes the intervention of, Check (R7) as required for incontinence . This same Care Plan includes a Focus area of, (R7) has an ADL Self Care Performance Deficit r/t (R7) requires assist with ADL's d/t cognitive impairment and difficulty with balance Date Initiated: 04/02/2023 This Focus area includes the intervention of, Bathing: (R7) requires assistance (sic) physical assistance with bathing/showering. Date Initiated: 04/03/2023 . The undated facility Shower List (Day Shift) documents R7 should receive assistance with bathing every Wednesday and Saturday. R7's Skin Monitoring: Comprehensive CNA Shower Review documents R7 was offered and/or received assistance with bathing on 6/4, 6/5, 6/7, 6/11, 6/14, and 6/17/25. This indicates R7 was not offered and/or did not receive assistance with bathing on 6/21/25 as scheduled. On 6/24/25 at 10:44 AM, R7 was sitting at the dining room table, a strong foul body odor was noted. R7 stated they don't always have enough staff to meet her needs timely. R7 stated it takes longer to answer the call light when they don't have enough staff working. R7 stated she wasn't sure how long it took but it probably feels longer than it actually is. 8. R8's facility admission Record with a print date of 6/24/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include fracture of humerus, osteoarthritis, and malaise. R8's entry MDS dated [DATE] does not document a BIMS score or ADL assessment. R8's current Care Plan provided to this surveyor does not document a Focus area for bathing or toileting. The undated facility Shower List (Day Shift) documents R8 should receive assistance with bathing every Tuesday and Friday. R8's Skin Monitoring: Comprehensive CNA Shower Review documents R8 received assistance with bathing on 6/17, and 6/20/25. This indicates R8 did not receive assistance with bathing on 6/9 and 6/13/25 as scheduled. On 6/24/25 at 11: 11 AM, R8 stated she got a shower today because she had an incontinent episode. R8 stated they don't always have enough staff, but they work very hard. R8 stated she has had incontinent episodes because she has had to wait for assistance. On 6/24/25 at 5:06 AM, V10 (CNA/Certified Nursing Assistant) stated they have approximately forty resident and they have one nurse and three CNA's working. V10 stated sometimes that is enough and sometimes it isn't. V10 stated they don't always have three CNA's. V10 stated when they had less staff, they weren't able to answer call lights timely, provide timely incontinence care, and/or give showers as scheduled. On 6/24/25 at 5:29 AM, V9 (CNA) stated she has worked night shift at the facility for about a month. V9 stated a week or so ago she was the only CNA in the facility for about three hours. V9 stated she got everyone she could to bed and waited for another CNA to come in and assist with the ones she couldn't. V9 stated one nurse and one CNA cannot meet the needs of the residents. V9 stated they have residents who require two people to transfer, bed alarms, and incontinence care. On 6/24/25 at 6:08 AM, V6 (CNA) stated on 6/19/25 and 6/21/25 there were only two CNA's working from 6 AM to 3 PM. V6 stated they were not able to meet the needs of the residents timely. V6 stated they can't get showers done and/or call lights answered timely. V6 stated on 6/21/25 they were not able to do R3 and R5's showers. On 6/24/25 at 6:17 AM, V5 (LPN/Licensed Practical Nurse) stated they don't have enough staff to meet the needs of the residents timely. V5 stated when they only have two CNA's it is hard to get all of the scheduled showers done and provide timely incontinence care. V5 stated most of the time they have three CNAs on the schedule, but people call in or quit. On 6/24/25 at 6:25 AM, V3 (Nurse) stated they were always short staffed. V3 stated there had been some shifts were there was only one CNA, and a nurse would work the floor to help. V3 stated it takes longer for incontinence care, and that is not ok. V3 stated they do their best. On 6/24/25 at 7:09 AM, V4 (CNA) stated they don't always have enough staff to meet the needs of the residents timely. V4 stated she worked midnight shift on 6/19/25 and day shift hadn't been able to do the showers that were scheduled so she did as many of them as she could before residents went to bed for the night. On 6/24/25 at 3:29 PM, V12 (CNA) stated she had worked at the facility since 6/12/25 and they had enough staff to meet the needs of the residents timely. V12 stated she had never worked in the facility by herself, but she did come to work one day and V8 (CNA) was the only CNA, but he had only been there by himself for about an hour. V12 stated on 6/21/25 she came to work and gave showers to the residents who were scheduled. V12 stated there was only one shower she did. V12 stated the other residents refused or had already had one. When asked why the shower she gave and/or the refusals weren't documented, V12 stated she guessed she forgot to fill out the shower sheets. On 6/24/25 at 1:37 PM, V1 (Administrator) stated in a perfect world she would expect them to get all of the showers done as scheduled. When asked if two CNAs were enough to meet the needs of the residents timely, V1 stated ideally, she would want two and a half CNAs on each shift. V1 stated they also have two nurses on day shift who should help out on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 39 residents who currently reside at the facility. Findings Include: The facility Daily Census dated 6/23/25 documents there are 39 residents currently residing at the facility. 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated: 04/12/2025 . This Focus area does not include an intervention specific to bathing or toileting. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. The facility undated Shower List (Day Shift) documents R1 should receive assistance with bathing every Tuesday and Friday. R1's Skin Monitoring: Comprehensive CNA Shower Review sheets document R1 received assistance with bathing on 6/3, 6/10, and 6/17/25. This indicates R1 went 6 days between showers and was not assisted with her scheduled showers on 6/6, 6/13, and 6/20/25. On 6/24/25 at 8:09 AM, R1 stated they don't have enough staff working to do every two-hour bed checks/incontinence care. R1 stated sometimes they only have two CNAs in the facility and when they do it takes longer for them to answer the call light. R1 stated it takes up to an hour at times. R1 stated she only had three showers in the month of June due to them not having enough staff to assist her with them. 2.R2's admission Record with a print date of 6/24/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, hemiplegia, hemiparesis, heart failure, major depressive disorder, convulsions, hypertension, difficulty in walking, weakness, and need for assistance with personal care. R2's MDS dated [DATE] documents R2 has a BIMS score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus area of ADL: (R2) requires assist with daily care needs r/t impaired mobility with hemiplegia/hemiparesis to RUE/RLE (right upper extremity/right lower extremity) Date Initiated: 12/17/2024 . This Focus area includes the intervention of, .Keep clean and dry after each incontinence episode. Date Initiated 12/17/2024 . R2's Care Plan does not document any specific Focus areas or interventions related to bathing. The undated facility Shower List (Day Shift) documents R2 should receive assistance with bathing every Monday and Wednesday. R2's Skin Monitoring: Comprehensive CNA Shower Reviews document R2 received assistance with bathing on 6/2, 6/10, 6/12, 6/17, 6/19, and 6/23/25. This indicates R2 did not receive assistance with bathing as scheduled on 6/4/25. On 6/24/25 at 10:48 AM, R2 stated she gets her showers twice weekly, but she asked for them three times weekly and they told her they won't do it. R2 stated she asks the facility CNA staff to give her extra ones and they tell her they don't have time. 3. R3's facility admission Record with a print date of 6/24/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, altered mental status, atrial fibrillation, tachycardia, Parkinsonism, heart disease, abnormalities of gait and mobility, and history of falls. R3's MDS dated [DATE] documents R3 has a BIMS score of 14, which indicates R3 is cognitively intact. This same MDS documents R3 requires substantial/maximal assistance for tub/toilet transfers. R3's current Care Plan does not document a Focus area and/or interventions related to ADL including bathing and toileting. The undated facility Shower List (Day Shift) documents R3 should receive assistance with bathing every Wednesday and Saturday. R3's Skin Monitoring: Comprehensive CNA Shower Reviews document R3 received assistance with bathing on 6/4, 6/7, 6/11, 6/14, and 6/18/25. This indicates R3 did not receive assistance with bathing as scheduled on 6/21/25. On 6/24/25 at 10:58 AM, R3 stated they have enough staff but sometimes have problems keeping them. R3 stated she received showers as scheduled. R3's family member (V7) was present in the room and stated R3 doesn't always get her showers as she should. V7 stated R3 hadn't received assistance with bathing since last week. V7 stated they don't have enough staff to meet the needs of the residents timely. V7 stated some days they only have two CNAs for the facility and that is not enough. 4. R4's admission Record with a print date of 6/24/25 documents R4 was admitted on [DATE] with diagnoses that include heart disease, diabetes, hypertension, necrosis of left femur, acquired absence of left leg below the knee. R4's current Care Plan documents a Focus area of (R4) is incontinent of bowel and bladder. He requires staff assistance for transfers to the facilities and hygiene care after use of facilities or incontinence episodes. Date Initiated: 04/28/2025 This Focus area includes interventions of . Check (R4) as needed for incontinence Date Initiated: 04/28/2025 . R4's MDS dated [DATE] documents a R4 has a BIMS score of 12, which indicates R4 has a moderate cognitive deficit. On 6/24/25 at 10:55 AM, R4 stated they don't have enough staff to provide timely care. R4 stated he has had to wait a long time for assistance to go to the bathroom and has incontinent episodes while waiting. 5. R5's admission Record with a print date of 6/24/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, hemiparesis, cerebral infarct, unspecified acquired deformity of left lower leg. R5's MDS dated [DATE] documents a BIMS score of 08, indicating R5 has a moderate cognitive impairment. This same MDS documents R5 is dependent on staff for toileting and bathing. R5's current Care Plan documents a Focus area of (R5) has an ADL Self Care Performance Deficit r/t (R5) is dependent upon staff for ADL's. (R5) has Hemiplegia/hemiparesis on one side d/t (due to) recent stroke. Date Initiated: 09/20/2022 This Focus area includes interventions of, Bathing: (R5) is totally dependent on staff to provide a bath twice weekly and as necessary. Date Initiated: 09/20/2022 Toilet Use: (R5) is not toileted. Date Initiated: 09/20/2022 The undated Facility Shower List (Day Shift) documents R5 is to receive assistance with bathing every Wednesday and Saturday. R5's Skin Monitoring: Comprehensive CNA Shower Review documents R5 received assistance with bathing on 6/5, 6/7, 6/11, and 6/18/25. This indicates R5 did not receive showers as scheduled on 6/14 and 6/21/25. On 6/24/25 at 10:58 AM, R5 was lying in bed and his hair appeared greasy. R5 had difficulty answering questions but did indicate with yes/no answers the facility doesn't always have enough staff to answer his call light timely. 6. R6's admission Record with a print date of 6/24/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include epilepsy, depression, muscle weakness, abnormalities of gait and mobility, and repeated falls. R6's MDS dated [DATE] documents a BIMS score of 09, indicating R6 has a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assist for toilet transfers. R6's current Care Plan documents a Focus area of (R6) has bladder incontinence. Date Initiated: 03/16/2025 . This Focus area includes the following intervention, Establish voiding patterns. Date Initiated: 03/16/2025 This same Care Plan includes the Focus area of, (R6) has bowel incontinence. Date Initiated: 03/16/2025 . This Focus area includes the intervention, Provide peri care after each incontinent episode. Date Initiated: 03/16/2025 . On 6/24/25 at 4:40 AM, R6 stated they don't have enough staff to help on the weekends. R6 stated it takes too long to answer the call lights. R6 stated she wasn't sure how long it took but it was long enough she had an incontinent episode. 7. R7's facility admission Record with a print date of 6/24/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include morbid obesity and history of falling. R7's MDS dated [DATE] documents a BIMS score of 08, indicating R7 has a moderate cognitive deficit. This same assessment documents R7 requires substantial/maximal assistance for bathing and toilet hygiene. R7's current Care Plan documents a Focus area of (R7) is incont (incontinent) of urine at times. Date Initiated: 04/03/2025 . This Focus area includes the intervention of, Check (R7) as required for incontinence . This same Care Plan includes a Focus area of, (R7) has an ADL Self Care Performance Deficit r/t (R7) requires assist with ADL's d/t cognitive impairment and difficulty with balance Date Initiated: 04/02/2023 This Focus area includes the intervention of, Bathing: (R7) requires assistance (sic) physical assistance with bathing/showering. Date Initiated: 04/03/2023 . The undated facility Shower List (Day Shift) documents R7 should receive assistance with bathing every Wednesday and Saturday. R7's Skin Monitoring: Comprehensive CNA Shower Review documents R7 was offered and/or received assistance with bathing on 6/4, 6/5, 6/7, 6/11, 6/14, and 6/17/25. This indicates R7 was not offered and/or did not receive assistance with bathing on 6/21/25 as scheduled. On 6/24/25 at 10:44 AM, R7 was sitting at the dining room table, a strong foul body odor was noted. R7 stated they don't always have enough staff to meet her needs timely. R7 stated it takes longer to answer the call light when they don't have enough staff working. R7 stated she wasn't sure how long it took but it probably feels longer than it actually is. 8. R8's facility admission Record with a print date of 6/24/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include fracture of humerus, osteoarthritis, and malaise. R8's entry MDS dated [DATE] does not document a BIMS score or ADL assessment. R8's current Care Plan provided to this surveyor does not document a Focus area for bathing or toileting. The undated facility Shower List (Day Shift) documents R8 should receive assistance with bathing every Tuesday and Friday. R8's Skin Monitoring: Comprehensive CNA Shower Review documents R8 received assistance with bathing on 6/17, and 6/20/25. This indicates R8 did not receive assistance with bathing on 6/9 and 6/13/25 as scheduled. On 6/24/25 at 11:11 AM, R8 stated she got a shower today because she had an incontinent episode. R8 stated they don't always have enough staff, but they work very hard. R8 stated she has had incontinent episodes because she has had to wait for assistance. On 6/24/25 at 5:06 AM, V10 (CNA) stated they have approximately forty residents and they have one nurse and three CNA's working. V10 stated sometimes that is enough and sometimes it isn't. V10 stated they don't always have three CNA's. V10 stated when they had less staff, they weren't able to answer call lights timely, provide timely incontinence care, and/or give showers as scheduled. On 6/24/25 at 5:29 AM, V9 (CNA) stated she has worked night shift at the facility for about a month. V9 stated a week or so ago she was the only CNA in the facility for about three hours. V9 stated she got everyone she could to bed and waited for another CNA to come in and assist with the ones she couldn't. V9 stated one nurse and one CNA cannot meet the needs of the residents. V9 stated they have residents who require two people to transfer, bed alarms, and incontinence care. On 6/24/25 at 5:45 AM, V8 (CNA) stated this is his third shift working at the facility. V8 stated on the first day of his training the CNA training him was also training another new CNA and they were the only three CNA's working on that shift. V8 stated then his next night working he was the only CNA working from 2 AM to 3:30 AM. V8 stated he has been a CNA since 2010 but he didn't know the residents and/or the facility systems and was not comfortable working by himself. V8 stated he wasn't able to answer all of the call lights timely. On 6/24/25 at 6:08 AM, V6 (CNA) stated on 6/19 and 6/21/25 there were only two CNA's working from 6 AM to 3 PM. V6 stated they were not able to meet the needs of the residents timely. V6 stated they can't get showers done and/or call lights answered timely. V6 stated on 6/21/25 they were not able to do R3 and R5's showers. On 6/24/25 at 6:17 AM, V5 (LPN) stated they don't have enough staff to meet the needs of the residents timely. V5 stated when they only have two CNA's it is hard to get all of the scheduled showers done and provide timely incontinence care. V5 stated most of the time they have three CNAs on the schedule, but people call in or quit. On 6/24/25 at 6:25 AM, V3 (Nurse) stated they were always short staffed. V3 stated there had been some shifts were there was only one CNA, and a nurse would work the floor to help. V3 stated it takes longer for incontinence care, and that is not ok. V3 stated they do their best. On 6/24/25 at 7:09 AM, V4 (CNA) stated they don't always have enough staff to meet the needs of the residents timely. V4 stated she worked midnight shift on 6/19/25 and day shift hadn't been able to do the showers that were scheduled so she did as many of them as she could before residents went to bed for the night. On 6/24/25 at 3:29 PM, V12 (CNA) stated she had worked at the facility since 6/12/25 and they had enough staff to meet the needs of the residents timely. V12 stated she had never worked in the facility by herself, but she did come to work one day and V8 (CNA) was the only CNA, but he had only been there by himself for about an hour. V12 stated on 6/21/25 she came to work and gave showers to the residents who were scheduled. V12 stated there was only one shower she did. V12 stated the other residents refused or had already had one. When asked why the shower she gave and/or the refusals weren't documented, V12 stated she guessed she forgot to fill out the shower sheets. On 6/24/25 at 1:37 PM, V1 (Administrator) stated in a perfect world she would expect them to get all of the showers done as scheduled. When asked if two CNAs were enough to meet the needs of the residents timely, V1 stated ideally, she would want two and a half CNAs on each shift. V1 stated they also have two nurses on day shift who should help out on the floor. The facility Employee Timecards and schedules were reviewed and document on 6/21/25 there were two CNA's working from 6 AM to 3 PM and two CNA's from 6 AM to 11 AM on 6/19/21. They also document there were two CNA's working from 6 PM on 6/17/25 until 2 AM on 6/18/25 and then was only one CNA working from 2 AM until 3 AM. The Facility Assessment Tool dated 9/5/24 was reviewed and does not document any facility specific information related to staffing requirements for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain an effective bed bug control program to ensure the facility was free of bed bugs. This has the potential to affect all 36 residents residing in the facility. The findings included: The facility Midnight Census Report dated 4/30/2025 documented 36 residents living in the facility. On 4/30/2025 at 9:00 AM, R2 stated, she had been the first person to find a bed bug in her room around 3/19/2025. R2 stated, that she seen the bug on the floor by her bed and she smashed it with her foot. R2 stated, she did notify a staff member but is unable to remember whom, but they did take the bug for evidence. R2's Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) of 15 which indicated she is cognitively intact. On 4/30/2025 at 8:10 AM, V3 (Housekeeping/Laundry Supervisor) stated, there had been a bug found in R2's room located on the B-Hall on 3/19/2025. V3 stated, the pest control company came in and treated. V3 stated V13 (Pest Control Technician) did advise them to not use any wet liquids to clean beds, mattress, beside tables, etc. for 2-3 months because it can remove the treatment. V3 stated, her staff had been made aware and are using dry towels to clean. V3 stated, she is not aware of any facility policy for bed bugs and had not been educated by the facility on bed bugs. On 4/30/2025 at 8:47 AM, V4 (Certified Nurse Assistant/CNA Supervisor) stated, she had not been educated on bed bugs by the facility. V4 stated, the first bed bug inspection documentation started on 4/29/2025 which had been completed by her and V10 (Maintenance/Transportation). On 4/30/2025 at 8:52 AM, V5 (CNA) stated, she is aware that there had been a bed bug reported in the facility but does not know who found it first. V5 stated, she is not aware if the facility completed an inspection or monitoring of the other rooms for bed bugs when R2 and R3's rooms were treated on 3/19/2025. V5 stated, she had not received any education on bed bugs by the facility. On 4/30/3025 at 9:03 AM, V6 (CNA) stated, she is aware that there had been reports of bed bugs in the facility. V6 stated, she had not been educated by the facility on bed bugs and is not aware of any monitoring of rooms for bed bugs after 3/19/2025. On 4/30/2025 at 9:10 AM, V7 (Licensed Practical Nurse/LPN) stated, she is not aware of any monitoring for bed bugs in the facility after the first report of a bug on 3/19/2025 in R2's room. V7 stated, she had not received any education from the facility on bed bugs. V7 stated, she had observed a bug in a medicine cup on 4/25/2025 that was found by V8 (LPN) in the laundry room. On 4/30/2025 at 9:22 AM, V1(Administrator) stated, there had been a previous employee that turned in a report to her about a bed bug being found and sent her a picture around 3/18/2025. V1 stated, there had been a confirmation with the local pest company of the bed bug. V1 stated she and V3 had been notified, by V13 (Pest Control Technician) not to use any wet liquids to clean beds, mattress, beside tables, etc. for 2-3 months because it can remove the treatment. V1 stated, there had been 2 more reports (4/21/2025 and 4/25/2025) of bugs seen in the facility. V1 stated, she did start a monthly inspection log for bed bugs for all rooms and offices to be monitored that included walls, ceilings, frames/bed boards, mattress, nightstand, base boards, chairs/wheelchairs and initialed by V4 (CNA Supervisor) and V10 (Maintenance) that took effect on 4/29/2025. V1 stated, no education had been given to employees on bed bugs. On 4/30/2025 at 10:03 AM, V9 (Housekeeping) stated, she had been notified by V3 that a bug had been found in a room. V9 stated, she had not been working at the time of the first reported bug in March 2025. V9 stated, around 4/21/2025 it had been reported that a bug had been seen in R4's room but not sure who reported it. V9 stated, they were instructed by the pest control company not to use any wipes or liquid cleaning on the mattresses, bed rails, headboards, etc. of rooms that had been treated until the pest company gives the go ahead for them to return to normal cleaning routine. V9 stated, she had been wiping down 2 of the rooms that had been treated (A-7 &A-9) on 4/25/2025 with bleach because she did not know that they had been treated. V9 stated, she thought the only rooms not cleaned with liquid or wipes were A6 & A8. On 5/1/2025 at 9:46 AM, V8 (LPN) stated, she had been working on 3/19/2025 when R2 came to her and notified her that there had been a bug in her room that she smashed with her foot. V8 stated, she did collect the specimen and give it to the previous maintenance employee who did notify V1 (Administrator) and gave the specimen to the local pest control company for confirmation. V8 stated, she had also been working on 4/25/2025 when another bug had been found in the laundry room. V8 stated, she did collect the bug in a specimen cup and notified V1. On 5/1/2025 at 10:49 AM, V13 (Pest Control Technician) stated, he had been the technician to come out and treat the facility on 4/25/2025 and 4/28/2025. V13 stated, he did not confirm a bug on the 4/25/2025 visit. V13 stated, he treated all six rooms (A6-A9 initial, B15-B16 and follow up). V13 stated, he did return on 4/28/2025 were he confirmed 2 bed bugs with V2 (Business Office Manager). V13 stated, V2 showed him a bug in a medicine cup that he confirmed and then also one she had removed off a shoulder and placed in tape that he confirmed as well. V13 stated, he did advise V3 and V1 not to clean any of the beds, bed rails, etc. with any liquid cleaning supplies or wipes because it will remove the chemical treatment. V13 stated, he did tell V3 and V1 that they could vacuum mattress if needed. A statement of the summary of services from the contracted pest control company dated 3/19/2025 documents services of .Targeted Pest: Bed Bug. Device of Application: Resident Room. Equipment Used: Compressed Sprayer. Recommendations: Other Areas: Pipes extending through wall allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Severity: Medium. Status: New. Date 11-4-2024. Site: Patient Room. Pest: Bed Bug. Infestation: 1. A statement of the summary of services from the contracted pest control company dated 4/25/2025 documents services of .Targeted Pest: Bed Bug. Device of Application: Resident Room. Equipment Used: Compressed Sprayer. A statement of services from the contracted pest control company dated 4/28/2025 documented services of: Target Pest Bed Bugs. Areas: Laundry Room. There was no documentation provided by the facility for education given to staff, monitoring/inspections of rooms, or recommended areas being inspected after confirmation of bed bugs on 3/19/2025. The facility Bed Bugs, Preventing and Managing Infestations of policy revised August 2015 documented in part, Purpose, staff will employ infection control strategies to prevent and manage infestations of bed bugs (cimex lectularius). Preparation, Staff should be trained to recognize bed bugs and bed bug infestation and know what their specific roles will be should an infestation occur. Monitoring and Investigation, 1. Thoroughly screen newly admitted residents, as well as those who returning from a stay away from the facility .3. Regularly inspect mattresses, box springs, bed frames, and headboards following current published guidelines for inspection and identification. Documented under Evaluation and Continued Monitoring, 1. After treatment methods have been applied it is important to follow up by monitoring for subsequent infestations. Even if eradication of adult bed bugs was successful, eggs may have survived and hatched . 5. Monitor for bed bugs on a regular basis. 6. Seal cracks and crevices to remove hiding places.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent physical abuse of a resident from another resident with a known history of abuse for 1 of 3 residents (R16) reviewed for abuse in the sample of 32. The findings include: The Final IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification, with an incident date of 9/20/23, documents, It was reported by staff that on 9/20/23 (R85) (resident) entered (R16's) (resident) room. (R16) loudly told her to leave her room. (R85) became startled and made contact with (R16). (R16) alerted nearby staff who immediately intervened and separated both residents. Nursing assessed both residents for any injuries. Slight bruising to (R16's) upper lip was noted. Nursing provided first aid to the affected area. (R85) was easily redirected and provided with additional activities. (R16) was provided with comfort and support. No further issues were noted Abuse is substantiated The Final IDPH Incident and/or Abuse Notification, with an incident date of 9/13/24, documents, An unwitnessed allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with her (R16) (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues. Nursing assessed both residents for any reddened areas or injuries. None were noted. (R85) is care planned for behaviors with impaired cognitive/thought processes. (R16) is care planned for delusional behavior and anxiety. These behaviors can impair both residents' ability to make good decisions and affects their safety awareness. This is an unwitnessed altercation with no injuries noted. (R85) is un-interviewable and cannot recall the incident (R85) and (R16) has a prior history of interactions. (R16) has delusional behaviors with anxiety and can fixate on past experiences. Based on these contributing factors along with a comprehensive investigation through staff and resident interviews, the IDT (Interdisciplinary Team) finds the allegation of abuse to be unsubstantiated . On 09/16/24 at 1:18 PM, R16 stated R85 gave me a bloody lip a few months ago. R16 stated yesterday or the day before (could not remember exact day), R85 tried to take a towel and her walker and R85 hit her in the arm and the mouth. R16's Progress Notes document the following: 9/13/24 at 6:04 PM, .Resident (R16) was hit in the mouth by another resident (R85). Incident unobserved by staff. Family informed. 9/16/24 at 12:26, Per Nurse - On 9/13/24 at approximately 18:12pm (6:12 PM) a resident-to-resident interaction occurred. The nurse immediately separated both residents and assessed them for signs and symptoms of injury, pain, or any other changes in clinical status. None were noted. 9/16/24 the incident was identified this am and the nurse at the time did not report to the Administrators. Both residents were reassessed. No injuries noted. The administrator was immediately notified. An investigation was immediately implemented. On 9/19/24 at 7:52 AM, R7 stated she was with R16 in the dining room when R85 came up and started getting into stuff in R16's walker. R7 stated R16 asked her not to do that and R85 hit R16 in the shoulder and the mouth. R7 stated she couldn't remember the exact day, but it was one day last week. R7 stated she couldn't remember if staff were there when it happened but knows an unknown nurse came up to R16 after it happened. R7 stated R16 was ok and didn't appear injured. On 09/18/24 at 3:18 PM, V1 (Administrator) stated she was not notified of the allegation of abuse until she was reviewing notes on 9/16/24 and that is when she started an investigation. On 9/19/24 at 7:57 AM, this surveyor reviewed the abuse investigation for the incident that occurred on 9/13/24, with V1 (Administrator). V1 stated she was the one who did the abuse investigation for R16 and R85. When asked if she interviewed R16 she stated she did. V1 stated R16 did not report any witnesses to her. This surveyor shared with V1, R16 reported to this surveyor R7 witnessed the altercation. V1 stated she would have to speak to her corporate office and amend the investigation. V1 provided this surveyor with an amended Final IDPH Incident and/or Abuse Notification that documents, After a final report was made and investigation was completed, new evidence was presented to Administrator and investigation was re-opened. An allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with Her (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues In the original investigation no witnesses were found. But a resident has since voiced she witnessed the incident. The IDT reopened the investigation and has determined the allegation of abuse to be substantiated. This is the final report . R16's admission Record with a print date of 9/18/24 documents R16 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder, major depressive disorder, bipolar disorder, and anxiety disorder. R16's MDS (Minimum Data Set) dated 7/16/24 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R16 is cognitively intact. R16's current Care Plan includes the Focus area of Abuse: (R16) is at risk for abuse and neglect r/t (related to) immobility Date Initiated 11/10/2021 The interventions documented for this Focus area include, 11/18/22 ask for assistance from staff when intervening with other residents and 2/11/22 (R16) will allow staff to redirect and intervene with other residents. R85's admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's current Care Plan documents a Focus area of (R85) has a behavior problem r/t (related to) impulsive behaviors. (R85) is known to have physical behaviors such as hitting and kicking others, repetitive behaviors, pacing, slamming doors, packing items and exit seeking. (R85) also has a history of inappropriate touching. Date Initiated: 05/31/2023. The interventions documented for this Focus area include Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/31/2023 .Anticipate (R85's) needs. Date Initiated: 05/31/2023 .Assist (R85) to develop more appropriate methods of coping and interacting. Encourage (R85) to express feelings appropriately. Date Initiated: 05/31/2023 .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 05/31/2023 . The facility Abuse Prevention Program-Policy dated 2022 documents, Residents have the right to be free from abuse, neglect, exploitations, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms Protection B. If the alleged perpetrator is a resident, the resident will be separated from the alleged victim and the resident's condition will be evaluated as soon as reasonably possible to determine the most suitable therapy and placement for the resident. This will be done taking in consideration the safety of other residents and employees of the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility staff failed to report an allegation of resident to resident physical abuse to the Administrator immediately for 1 of 3 (R16) residents reviewed for abuse and neglect in the sample of 32. The findings include: The Final IDPH Incident and/or Abuse Notification date of incident 9/13/24 documents, An unwitnessed allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with Her (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues. Nursing assessed both residents for any reddened areas or injuries. None were noted. (R85) is care planned for behaviors with impaired cognitive/thought processes. (R16) is care planned for delusional behavior and anxiety. These behaviors can impair both residents' ability to make good decisions and affects their safety awareness. This is an unwitnessed altercation with no injuries noted. (R85) is un-interviewable and cannot recall the incident (R85) and (R16) has a prior history of interactions. (R16) has delusional behaviors with anxiety and can fixate on past experiences. Based on these contributing factors along with a comprehensive investigation through staff and resident interviews, the IDT (Interdisciplinary Team) finds the allegation of abuse to be unsubstantiated . On 09/16/24 at 1:18 PM, R16 stated R85 gave me a bloody lip a few months ago. R16 stated yesterday or the day before (could not remember exact day), R85 tried to take a towel and her walker and hit her in the arm and the mouth. R16's Progress Notes document the following: 9/13/24 at 6:04 PM, .Resident (R16) was hit in the mouth by another resident (R85). Incident unobserved by staff. Family informed. 9/16/24 at 12:26, Per Nurse - On 9/13/24 at approximately 18:12pm (6:12 PM) a resident-to-resident interaction occurred. The nurse immediately separated both residents and assessed them for signs and symptoms of injury, pain, or any other changes in clinical status. None were noted. 9/16/24 the incident was identified this am and the nurse at the time did not report to the Administrators. Both residents were reassessed. No injuries noted. The administrator was immediately notified. An investigation was immediately implemented. On 09/18/24 at 3:18 PM, V1 (Administrator) she was not notified of the allegation of abuse until she was reviewing notes on 9/16/24 and that is when she started an investigation. R16's admission Record with a print date of 9/18/24 documents R16 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder, major depressive disorder, bipolar disorder, and anxiety disorder. R16's MDS (Minimum Data Set) dated 7/16/24 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R16 is cognitively intact. R16's current Care Plan includes a Focus area of Abuse: (R16) is at risk for abuse and neglect r/t (related to) immobility. Date Initiated: 11/10/2021 The interventions documented for this Focus area include, 11/18/22 ask for assistance from staff when intervening with other residents and 2/11/22 (R16) will allow staff to redirect and intervene with other residents. R85's admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's current Care Plan documents a Focus area of (R85) has a behavior problem r/t (related to) impulsive behaviors. (R85) is known to have physical behaviors such as hitting and kicking others, repetitive behaviors, pacing slamming doors, packing items and exit seeking. (R85) also has a history of inappropriate touching. Date Initiated: 05/31/2023. The interventions documented for this Focus area include Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/31/2023 .Anticipate (R85's) needs. Date Initiated: 05/31/2023 .Assist (R85) to develop more appropriate methods of coping and interacting. Encourage (R85) to express feelings appropriately. Date Initiated: 05/31/2023 .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 05/31/2023 . The facility Abuse Prevention Program-Policy dated 2022 documents, .Internal Reporting. Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must them immediately report it to the administrator

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a resident or representative and the Ombudsman with a written notice of discharge with appeal rights for 1 of 1 resident (R185) reviewed for discharge in the sample of 32. The Findings include: R185's Face sheet, dated 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on 06/18/24 with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or delusions, no physical behavioral symptoms directed towards others, no verbal behavioral symptoms, other behavioral symptoms not directed towards other (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of the 7 day look back period, did not reject evaluation or care, and wandering 1 to 3 days out of the 7 day look back period. Section GG documents R185 was dependent for toileting, dressing, and personal hygiene and set-up and clean up for transfers. R185's Care Plan, with a cancelled date of 06/18/24, documents focus areas of: 1. (R185) is disoriented to place and time. (R185's) memory is similarly impaired. Consequently. (R185) has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. (R185) is known to be impulsive at times. This problem it related to Dementia. Strengths and abilities include her ability to be easily redirected. 2. (R185) has a behavior problem r/t (related to) (R185) is known to wander and lacks safety awareness. (R185) is easily redirected by staff most of the time. (R185) has a hx. (History) of agitation r/t dementia. (R185's) son reports (R185) has a known trend of doing bad things out of defiance then laughing when confronted. Recently (R185) has started to defecate in inappropriate places. (R185) appears to like attention even when it is negative attention for doing wrong as reported by (R185's) son. 3. (R185) has no discharge potential r/t poor safety awareness, cognition, and inability to care for self. A documented goal for this focus was (R185) will remain in the facility long term. R185's Progress Notes dated 06/14/24 at 8:16AM (Late entry) documents in part Called Her (R185's) son (V13) and left message that she (R185) was being moved. R185's Progress Note dated 06/18/24 at 10:05AM documents SSD (Social Services Director/V3) mailed a letter to (R185's) son (V13) telling him where (R185) has been sent to and the address and phone number where (R185) can be reach [sic]. R185's Care Plan Summary/Participation record for R185, dated 03/28/24, documents in part R185 and V13 did not attend meeting. Goals for care document D/C (Discharge) is feasible, but resident/responsible party goal remains for long term placement. Other changes/Updates document no family attended. R185 (Res) will be looking at discharge to another facility when their lock down wing is complete. R185's Discharge Planning Review/Summary documents in part under Medication Reconciliation 2. Has post-discharge medication list been discussed with resident/family? R185 (Resident). Under signatures 1. Resident signature and date documents R185 name typed in with date of 06/18/24. 3 staff signature documents V3 (Social Service Director) with typed in name and date of 06/18/24. On 09/18/24 at 8:50AM, V13 (Family Member) stated that the facility never contacted him about R185 moving to another facility. V13 said he received a phone call from an unknown number stating that it was a new facility, and they were admitting R185 and wanted to review R185's medication with him. V13 stated that he asked the new facility if R185 was at the other facility she had been at, and they stated no that R185 was transferred to them today from the other facility on 06/18/24. V13 said he was very upset and mad. V13 said that he told the new facility that no one had notified him that R185 had been discharged and moved. V13 said the new facility that she was transferred to was around 2 hours away from his house. V13 said the facility that R185 was in was only 15 minutes away from his house. V13 said he hasn't been able to visit often and that with covid and the fact that R185 doesn't know who he was most of the time was upsetting to him. V13 stated the facility did not notify him about R185 being transferred and there were no messages left regarding a transfer. V13 said the facility did talk to him about 3 or 4 months ago about maybe moving R185 to another facility, but they never said they were for sure moving her. V13 said the facility never mentioned any other facilities that they were thinking about moving R185 to that he could remember. V13 said they talked about discharging R185, but it was brief and nothing definite. V13 said the facility could of at least called him to let him know that R185 was moving. V13 said the facility calls him for all kinds of other things like when she has eloped, medication changes, and other stuff; why not when they transferred R185? V13 said that he did not receive any paperwork from the facility other than a bill and no information on where R185 went or information on her moving at all. V13 said that he would have preferred for R185 to stay at the facility, because it was closer to him. On 09/18/24 at 10:16AM, V14 (Facility Administrator at R185's new facility) stated that they did receive R185 as a new resident at their facility. V14 said that R185 was admitted to a locked memory care unit at their facility. V14 said they did call V13 to verify R185's medications. V14 said that V13 was very upset and stated that he didn't know that R185 was discharged from the facility, and he knew nothing about R185 being admitted to a new facility. V14 said that V13 was very angry when they were talking to him because he was not made aware of any transfer or discharge. V14 said that R185 has seemed to adjust well to the new facility. V14 said that R185 did have some increased behaviors and some crying episodes at first, but that was expected some with her current diagnoses. V14 said that she didn't have a lot of concerns with R185's discharge and transfer other then V13 not knowing anything about the transfer and discharge. On 09/18/24 at 12:30PM, V3 (Social Service Director/SSD) stated that the facility initiated R185's discharge. V3 said that R185 was sent to another facility that had a locked unit. V3 said that she did try to contact V13 but was unable to get ahold of him. V3 said she tried several times to get a hold of V13 but was unable to get ahold of him to tell him that R185 was moving. V3 said that she did not document all the times she tried to get a hold of V13. V3 said she left messages, but V13 never returned her calls. V3 said she doesn't know why other staff were able to get a hold of V13 at times. V3 said V13 never called her back so she mailed him information telling him, where we sent R185 along with address and phone number of the new facility on the day R185 was discharged to other facility. V3 said that 3 months ago they did start talking about sending R185 to another facility. She said that the V13 and R185 were invited to Care Plan and V13 never showed up. V3 said they had started working on the discharge then. V3 said she was not able to get ahold of V13 since the Care Plan meeting on 03/28/24. V3 doesn't remember how many times she attempted to call V13, but that she did leave him a message. V3 said it states on the discharge summary that R185 initiated discharge. V3 said R185 does have a BIMS score of 00 which indicates that R185 has severely impaired cognition, but that R185 is able to understand. V3 said that the BIMS score is 00 because R185 is nonverbal most of the time. V3 said she knows R185 understands, and she seemed happy about transferring to another facility. V3 said she believes that R185 was capable of making her own decisions. V3 said that she never attempted to contact any other family members on R185 contact list because they weren't the POA (Power of Attorney), and she was only told to get ahold of the POA. V3 said that she did not try to contact V13's wife who is also listed on R185's contact list. V3 stated that she thinks V1 (Administrator) or V2 (Director of Nursing) might have gotten ahold of V13 on the day R185 transferred, but she wasn't sure. V3 doesn't know if any forms were sent to V13 other than the information about the new facility she sent on the day of discharge on [DATE]. On 09/18/24 at 12:40PM, V1 (Administrator) stated that the facility did initiate R185's discharge. They sent her to a facility with a locked unit. V1 said that she did believe that a notice was sent to V13, but she didn't know when that was. V1 said she knows that they did talk about notifying the son. She thought V3 took care of that. V1 said that V3 worked on R185's discharge planning. V1 said that R185 could understand and answer appropriately at times. V1 knows that R185 has a low BIMS score which indicates severely impaired cognition but V1 said that R185 knows what is going on. V1 said she would expect V13 to be notified of the discharge and transfer before it was made. V1 said that she didn't know what the policy was for involuntary facility-initiated discharges. On 09/19/24 at 7:55AM, V1 stated that they did not complete a notice of involuntary transfer form or notify the ombudsman concerning R185's involuntary facility-initiated discharge. V1 said at the time they were discharging R185 she wasn't thinking of it as an involuntary facility-initiated discharge. V1 stated that she does see it was now. V1 stated that she does not know why V13 wasn't notified other then they could not get a hold of him. V1 said that they should of documented all the attempts the facility made to get a hold of V13, but she said they didn't. V1 agreed that V13 could not have done an appeal since he didn't know about the discharge. V1 said that she never told V3 that she could not call any of the other contacts on R185's contact list other than the POA. V1 stated that V3 is still learning the Social Service Director job and probably didn't know she could have contacted others on R185 contact list. On 09/19/24 at 3:30PM, V1 stated that she could not find a policy regarding Involuntary Facility Initiated Non-Emergent discharges. The Facility Policy titled Transfer or Discharge, preparing a Resident for Discharge with a revised date of 12/2016 documents under Policy statement Residents will be prepared in advance for discharge Policy Interpretation and Implementation documents in part 1c. Providing the resident or representative (sponsor) with required documents. The Facility Policy titled Transfer or Discharge, Emergency revised 12/2016 documents in part under Policy interpretation and Implementation 2. If a resident exercises his or her right to appeal a transfer or discharge notice, he or she will not be transferred or discharged while the appeal is pending unless the failure to discharge or transfer would endanger the health and safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, home, or other setting our facility will implement the following procedures. 4a. Notify the resident's attending physician. 4e. Notify the representative (Sponsor) or other family member. The facility policy titled Discharge Summary and Plan revised 12/2016 documents under policy statement When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new environment. Under Policy Interpretation and Implementation 12. A member of the IDT (Interdisciplinary Team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan: and c. The discharge summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a discharge summary for 1 of 1 resident (R185) reviewed for discharge in a sample of 32. The findings include: R185's Face Sheet, with a print date of 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on 06/18/24 with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or delusions, no physical behavioral symptoms directed towards others, no verbal behavioral symptoms, other behavioral symptoms not directed towards other (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of the 7 day look back period, did not reject evaluation or care, and wandering 1 to 3 days out of the 7 day look back period. Section GG documents R185 was dependent for toileting, dressing, and personal hygiene and set-up and clean up for transfers. R185's Care Plan, with a cancelled date of 06/18/24, documents focus areas of: 1. (R185) is disoriented to place and time. (R185's) memory is similarly impaired. Consequently. (R185) has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. (R185) is known to be impulsive at times. This problem it related to Dementia. Strengths and abilities include her ability to be easily redirected. 2. (R185) has a behavior problem r/t (related to) (R185) is known to wander and lacks safety awareness. (R185) is easily redirected by staff most of the time. (R185) has a hx. (History) of agitation r/t dementia. (R185's) son reports (R185) has a known trend of doing bad things out of defiance then laughing when confronted. Recently (R185) has started to defecate in inappropriate places. (R185) appears to like attention even when it is negative attention for doing wrong as reported by (R185's) son. 3. (R185) has no discharge potential r/t poor safety awareness, cognition, and inability to care for self. A documented goal for this focus was (R185) will remain in the facility long term. R185's Progress Note dated 06/18/24 at 7:01AM documents in part Resident discharged via facility transporter with personal clothing et (and) medication to receiving facility. R185's Care Plan Summary/Participation record for R185, dated 03/28/24, documents in part R185 and V13 did not attend meeting. Goals for care document D/C (Discharge) is feasible, but resident/responsible party goal remains for long term placement. Other Changes/Updates document no family attended. Res (R185) will be looking at discharge to another facility when their lock down wing is complete. R185's Discharge Planning Review/Summary documents in part under Discharge Goals/General Information 1. Who initiated discharge? Resident (box checked). 2.Reason for discharge: She (R185) went to other facility. 3. Recap of resident's stay: The resident was a long-term resident that needed a locked down unit, and we transfer her to the other facility for better care .5. Initial discharge goals- remain in facility (box checked) . 8. Resident's goals of care and treatment preferences: to be able to stay in the facility. Under Medication Reconciliation it documents .2. Has post-discharge medication list been discussed with resident/family? Resident (box checked). Under Activity Summary, 1. Social Service it documents the Resident was excited that she was going to the [sic]. Under the section 2. Nursing Service it documents 1. Medical Summary-Medication was sent with her (R185). Under signatures 1. Resident signature and date documents R185 name typed in with date of 06/18/24. 3 staff signature documents V3 (Social Service Director) with typed in name and date of 06/18/24. On 09/18/24 at 12:30PM, V3 (Social Service Director/SSD) stated the discharge summary was not completed until 09/17/24 she stated that she did not know she had to complete a discharge summary when they transfer to another facility. V3 said she had started one on paper but got rid of it. The facility policy titled Discharge Summary and Plan revised 12/2016 documents under policy statement When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new environment. Under Policy Interpretation and Implementation 12. A member of the IDT (Interdisciplinary Team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place . 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan: and c. The discharge summary.

Based on observation, interview and record review the facility failed to follow physician's orders as prescribed for one (R14) of one resident reviewed for respiratory concerns in a sample of 32. The findings include: R14's face sheet documents an admission date of 03/26/2021 with diagnoses including: chronic obstructive pulmonary disease, moderate persistent asthma with (acute) exacerbation, dementia, and anxiety disorder. R14's Nurse's Note dated 09/14/24 at 4:23 PM documents: R14 came up to this nurse and stated, I don't feel well at all. This nurse asked the resident what was wrong, and she stated, I cannot stop coughing and I feel SOB (short of breath). This nurse assessed R14 and R14 has wheezing noted in all lung fields. The resident has some shortness of breath and a nonproductive cough that has been constant. R14 expresses that she is very tired as well. Covid test is negative. Vital signs are as follows: T (temperature) 97.5 (degrees Fahrenheit) P (pulse) 86, R (respirations) 20, BP (blood pressure) 151/82, and O2 (oxygen) 95% on 4L (liters). V15 (Medical Physician) notified of the above information and awaiting response at this time. The plan of care is ongoing. R14's Nurse's Note dated 09/14/24 at 5:46 PM documents: V15 responded back and stated, get a chest x-ray, start Prednisone 40 mg for 5 days and Duoneb q (every) 6 (hours) PRN (as needed). The orders are noted and processed. The plan of care is ongoing. R14's Physician's Order Sheet documents an order for Ipratropium-Albuterol solution (Duoneb) 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) with an order date of 09/14/2024 and a start date of 09/16/24. R14's Physician's Order Sheet documents an order for Prednisone 40 milligrams with an order date of 09/14/2024 and a start date of 09/16/24. R14's Medication Administration Record (MAR) documents the first administration of Prednisone was 09/16/24. R14's MAR documents there was no administration of Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML as of 09/19/24. R14's Nurse's Note dated 09/16/24 at 12:48 AM documents: R14's CXR (chest x-ray) shows that she has PNA (pneumonia) and will start abx (antibiotic) today, as well as Prednisone. R14's O2 sat (oxygen saturation) on 3 lpm (liters per minute) was 88%. O2 (oxygen) was increased to 4 lpm, the O2 sat is now 92%. No s/sx (signs or symptoms) of distress. There is no sob (shortness of breath), her HOB (head of the bed) was elevated 30 degrees. Will monitor. On 09/16/24 at 8:35 AM, R14 stated she was short of breath and on oxygen at 4 liters. R14 asked (surveyor) if her oxygen could be turned up. On 09/16/24 at 8:35 AM, R14 was having labored breathing and was short of breath. R14 was showing abdominal breathing. The surveyor notified the nurse at this time. On 09/16/24 at 8:37 AM, V2 (Director of Nursing) was observed entering R14's room to assess her. As of 09/19/24 there was no Nurse's Note or assessment available in R14's Electronic Health Record documenting V2's assessment. On 09/18/24 at 11:07 AM, V6 (Registered Nurse) stated R14's Prednisone and Ipratropium-Albuterol nebulizer were not started until 09/16/24. V6 stated, he does not see anywhere why they held the order until the 09/16 when he can see the order came in on 09/14. On 09/18/24 at 11:42 AM, V2 stated, she did not know why the Prednisone and the Ipratropium-Albuterol solution was started on 09/16/24 instead of 09/14/24. She stated she would have to ask V16 (Licensed Practical Nurse) if V15 (Medical Physician) wanted the medication held for some reason. On 09/19/24 at 9:40 AM, V2 stated she had not heard from V16 yet. On 09/19/24 at 1:40 PM, R14 was laying in her bed, she was having difficulty breathing and was short of breath. Her abdomen was sharply rising and falling while she was trying to breathe, and she was having difficulty with conversation. R14 stated, she was still having difficulty breathing. This surveyor notified V6 (Registered Nurse) at this time. There was no Nurse's Note or assessment available in R14's Electronic Medical Record of an assessment being completed on 9/19/24. On 09/20/24 at 8:50 AM, V15 stated he ordered the Prednisone and the Ipratropium-Albuterol on 09/14/24 for shortness of breath and he was expecting it to be given on 09/14/24, he would not have expected either of those medications to be held and not given until 09/16/24. He stated he ordered a chest x-ray on 09/14/24 which he received the results for on 09/15/24 and ordered an antibiotic for pneumonia that was started on the 16th, but he didn't want to give the antibiotic until he knew she had pneumonia for sure. On 09/23/24 at 10:33 AM, V2 stated she did not know why R14 had not received the Ipratropium-Albuterol nebulizer treatment or the prednisone on the 14th, she stated she has not been able to talk to V16. On 09/23/24 at 10:33 AM V1 (Administrator) stated, she did know why R14 had not received the Ipratropium-Albuterol nebulizer treatment or the prednisone on the 14th. R14's Care Plan documents an undated focus area of: Respiratory: potential for respiratory complications r/t (related to) recent acute respiratory failure, asthma with status asthmaticus, asthma with exacerbation and comorbidity of obesity with undated interventions listed as: administer medications as ordered, administer oxygen as ordered, and assess respiratory status: rate, depth, pattern, and skin color. The facility policy dated January 2024 titled, Administering Medications documents: 3. Medications must be administered in accordance with the orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supplements as ordered and follow the facility policy for weight management for 2 (R27 and R15) of 4 residents reviewed for nutrition in a sample of 32. Findings include: 1. R27's face sheet documents an admission date of 08/06/24 with diagnoses including: unspecified physeal fracture of lower end of right fibula, dementia, muscle weakness, and chronic kidney disease. R27's Minimum Data Set (MDS) dated [DATE] documents: a Brief Interview for Mental Status of 04, indicating R27 has severe cognitive impairment, section GG documents eating assistance is: supervision or touching assistance. R27's Physician Order Sheet documents a dietary order of: regular diet with mechanical soft texture, and thin liquids with an order date of 08/06/24 and no end date listed. R27's weights are documented as: 8/6/2024 at 2:57 PM: 118.0 Lbs (pounds), 8/8/2024 at 3:56 PM: 118.0 Lbs, 8/22/2024 at 5:45 PM: 100.0 Lbs, 8/23/2024 at 2:14 PM: 99.5 Lbs, and 9/5/2024 at 10:26 AM: 100.4 Lbs. R27's Dietary Notes dated 8/27/2024 at 2:37 PM document: Initial Nutritional Review: R27's weight 99.5# (pounds), her diet order is regular diet with mechanical soft texture. R27's weights reflect a 15.7% weight loss since admission, her current weight is within IBW (Ideal Body Weight) range. R27's BMI (Body Mass Index) is 18.8 %. Her intake is reported as 50%-100% of most documented meals. R27 is currently COVID positive status. No labs are currently available for review. There are no skin concerns reported. R27's estimated nutrient needs are 1260 kcals (kilocalories)/day, 45 grams protein/day and 1350 ml (milliliters) fluid/day. (V17-Registered dietician) recommend's health shake with meals to provide additional nutritional support. R27's Nurse's Note dated 08/21/24 at 3:51 PM documents: R27 is COVID positive on 08/19/24. On 09/17/24 at 12:20 PM, R27 attempted to take a drink of her health shake through her straw, and none came up, she put the carton down and started moving away from the table. On 09/17/24 at 12:23 PM, R27's health shake was frozen with a straw in it and there was a full carton still present. On 09/17/24 at 12:23 PM V2 (Director of Nursing) stated, they need to get those health shakes thawed. On 09/18/24 at 2:20 PM, V1 (Administrator) stated their policy states, residents should be weighed weekly as a new admission, she does not know why R27 was not weighed on 08/14 or 08/15. If she had weight loss, then V17 should have been notified. On 09/23/24 at 10:35 AM, V1 stated she does not know why there is not an order for a health shake for R27. On 09/23/24 at 10:35 AM, V2 stated, she did have a weight for R27 on 08/13/24 of 107.5 pounds, it was written in a notebook. She stated, she does have R27 at 118 pounds on 08/06/24 that would have triggered a significant weight loss for R27. R27's Electronic Health Record does not contain any documentation of a weight for R27 on 08/13/24 or any documentation of notification of V17 of R27's weight loss on 08/13/24. 2. R15's Face Sheet documents an admission date of 07/07/23 with diagnoses including: anemia, muscle weakness, vitamin D deficiency, and other fatigue. R15's MDS date 08/30/24 documents no BIMS score listed. Section C documents: cognitive skills for daily decision making as: moderately impaired. R15's Physician's Order Sheet documents a dietary order for: regular diet, regular texture with thin liquids consistency, super cereal daily, med pass 2.0 60 cc (cubic centimeters) TID (three times a day) with meals, extra dessert at lunch for dietary with an order date of 09/04/2024 and no end date listed. R15's Physician's Order Sheet documents an order for: admit to residential hospice with a start date of 09/04/24 with no end date listed. R15's Care Plan (undated) documents a Focus area of (R15) is under Hospice care due to a terminal diagnosis of Atherosclerosis of native coronary artery. On 09/17/24 at 12:13 PM, R15 did not receive extra dessert with lunch. On 09/18/24 at 12:10 PM, R15 did not receive extra dessert with lunch. On 09/19/24 at 12:15 PM, R15 did not receive an extra dessert at lunch. R15 stated, he only gets one dessert with lunch. At this time, R15 was alert and oriented to person, place and time. R15's Nurse's Notes dated 8/1/2024 at 12:08 PM document: R15 is noted with weight loss, a new order for extra dessert at lunch. R15's Dietary Notes dated 6/17/2024 at 7:48 PM documents: R15 was reweighed at 128#(pounds) which is stable with his usual weight, weight is maintained within IBW range. R15's intake is reported as 50%-100% of documented meals. Continue with present diet order of Regular with super cereal at breakfast and med pass 2.0 60cc tid and weigh monitoring. R15's Dietary Notes dated 7/30/2024 at 6:42 AM documents: Annual Nutritional Review: R15's weight 133# (pounds) his diet order is: regular diet; super cereal at breakfast; and med pass 2.0 60cc tid. R15's weight is within IBW range and BMI is 22.1 %, his intake varies between 50%-100% of most meals. There are no labs currently available for review. There are No skin concerns reported. R15's estimated nutrient needs are 1680 kcals/day, 60 grams protein/day and 1800 ml fluid/day. R15's diet is appropriate to provide for estimated needs. R15's weights are documented as: 02/12/24 at 9:53 AM as 145.0 Lbs (pounds), 03/11/24 at 10:19 AM as 145 Lbs, 04/25/24 at 2:48 PM 132.5 Lbs, 04/29/24 at 12:29 PM as 130.5 Lbs, 05/27/2024 at 2:32 PM as 128 Lbs, 06/11/24 at 10:13 AM as 123 Lbs, 07/29/24 at 2:20 PM as 133 Lbs, and 08/12/24 at 10:19 AM as 129 Lbs. On 09/19/24 at 2:37 PM, V17 (Registered Dietician) stated, she would expect to be notified of any significant weight loss and she would expect all residents to receive supplements that are ordered, and, in a manner, they can consume them or to be given assistance to consume them. On 09/23/24 at 10:35 AM V2 stated, that R15 had an incorrect weight entered in R15's weight record and it threw off R15's weight triggers. Therefore R15 would have triggered a weight loss and not triggered for a weight gain, thus showing V17 that R15 had a significant weight loss. The facility policy dated 2023 titled, Weight Assessment and Intervention documents: Weight Assessment: 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter. 3. 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. Verbal notification must be confirmed in writing. 4. The dietitian will review the unit weight record by the 15th of the month 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.

Based on observation, interview and record review the facility failed to provide diets as ordered for 2 (R18 and R24) of 4 residents reviewed for nutrition in a sample of 32. The findings include: R18's face sheet documents an admission date of 07/05/23 with diagnoses including: dementia and diastolic heart failure. R18's Physician's Order Sheet documents an order for: regular diet with mechanical soft texture, thin liquid consistency, cut meats, super cereal, and snack between meals. Ice cream at lunch and supper. Extra dessert at lunch and supper, health shakes twice daily after breakfast and after lunch with an order date of 07/22/2024 and no end date listed. R18's care plan documents an undated focus area of: R18 is as risk for comprised nutritional status related to Diagnosis of Alzheimer's disease or related dementia. R18 is on a mech (sic) soft regular diet per her request as she has difficulty at times chewing meats with her partial dentures with an undated intervention of regular mech soft diet, cut meats and super cereal, ice cream for lunch and supper. R24's face sheet documents an admission date of 01/13/23 with diagnoses including: dementia, Alzheimer's disease, and prediabetes. R24's Physician's Order Sheet documents an order for NAS (no added salt) diet with mechanical soft texture, thin liquids consistency, assist resident as needed with meals, Finger food at mealtimes. Resident to use plastic cutlery for safety. No napkin. 60 cc (cubic centimeters) of 2.0 daily with lunch. Health shakes three times daily with meals. Extra sauces and gravy with an order date of 08/09/2024 and no end date listed. R24's care plan documents an undated focus area of nutrition; R24 is at risk for complications with weight and nutrition r/t (relating to) dementia. R24 is on a NAS regular texture diet with undated interventions listed include: diet: NAS mechanical soft with thin liquids. The facility document dated day 18 Wednesday titled, Diet Spreadsheet documents: regular diet: crispy rice dessert bar 3 (inch) x 2-1/2 and the dental soft (Mech soft) diet documents: soft sugar cookies - 2 cookies. On 09/18/24 at 12:10 PM, R18 received the crispy rice dessert bar for lunch. R18 took a small bite of the crispy rice bar tried to chew for a bit and did not try to eat the rest. R24 received the crispy rice dessert bar for lunch. R24 took a bite of the crispy rice bar, chewed for a bit and sounded like he cleared his throat and got up and started walking over to another table. On 09/19/24 at 2:37 PM, V17 (Registered Dietician) stated she would expect all residents to receive the diet they are ordered, so the mechanical soft diet should get all the items that are included with the specific diet texture, including the dessert. The facility policy dated 2022 titled, Therapeutic Diets documents: 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets.

Based on observation and interview the facility failed to provide a dignified and respectful dining experience by removing plates from the table while other residents are still eating for 4 (R30, R27, R16 and R18) of 4 residents reviewed for dignified dining. Findings include: On 09/18/24 at 12:25 PM, V10 (Dietary) was rolling a cart through the dining room with a white bucket (approximately 5 gallon size) on the cart and would pick up residents plates, scrape the leftover food into the bucket and stack the plates on the cart and place the silverware into another bucket. At the first table, R30 was finished while three residents were still eating. Right after V10 took R30's plate, R27 put her silverware down and rolled away from the table. At 12:27 PM, V10 went to the next table and removed R16's plate and glass, and R16 stated hey, I am not done with that. V10 gave her the glass back. There were three residents still eating at the table. V10 then attempted to take R18's plate and with her hand on the plate asked, are you finished, R18 stated, no, there were two residents still eating at the table. On 09/19/24 at 12:28 PM, V10 stated she has never been told not to pick up the resident's plates right away, so she will pick them up as soon as she sees someone that looks done and will take their plate no matter how many people are still eating at the table. V10 stated that makes sense to leave them as not to make the confused residents feel rushed. On 09/19/24 at 2:43 PM, V1 (Administrator) stated, she does not have a policy on dining cleaning procedures.

Based on observation, interview and record review the facility failed to provide a clean and sanitary bathroom for 14 (R3, R24, R23, R14, R17, R21, R10, R22, R28, R29, R18, R19, R5 and R30) of 14 residents reviewed for environment in a sample of 32. The findings include: On 09/18/24 at 11:20 AM, the shower stall floor of the shower room on the B hall is cracked around the drain with the floor peeling away. There was an uneven cracked floor with large peeling area on the floor with areas of non-smooth peeling spots of over 2 feet by 2 feet, 6 inches by 5 inches, and mold around the bottom between the wall and the floor of the shower stall. There was a 2.5 inch gap between the wall and the floor on the right side of the toilet. In the front of the toilet in the second restroom on the B hall, there was a black accumulation around the bottom with an approximate 2 inch gap with approximately 0.25 inches of water accumulation. There is no restroom or shower room located on the C hall. On 09/18/24 at 11:51 AM, the room labeled men's bathroom on the B hall had an accumulation of dirt and debris causing an accumulation of a black substance approximately two inches out from in front of the toilet. On 09/19/24 at 12:02 PM, V1 (Administrator) stated the shower stall should be repaired and cleaned. The room roster dated 09/16/24 documents R3, R24, R23, R14, R17, R21, R10, R22, R28, R29, R18, R19, R5 and R30 reside on the B and C Halls and utilize the B Hall shower and restrooms. The facility policy dated 2021 titled, Maintenance Service documents: 2. Functions of maintenance personnel include but are not limited to: b. maintaining the building in good repair and free from hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure transmission based precautions were implemented, and failed to ensure hand hygiene was performed per current standards of practice for 2 of 6 (R85 and R3) residents reviewed for infection control in the sample of 32. Findings Include: R85's admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's Order Summary Report dated 9/19/24 documents a physician order with a start date of 9/11/24 of Transmission based precautions until 9/22/2024 R85's current Care Plan documents a Focus area of (R85) has tested positive for Covid 19. Date Initiated: 09/10/2023. Revision on: 09/12/2024. This Focus area includes the following interventions.Administer medications as ordered. Monitor for potential side effects and effectiveness. Date Initiated: 09/12/2024 Contact/droplet isolation precautions per protocol. Date Initiated: 09/12/2024 . R85's Progress Notes document the following: 9/6/24 9:24 AM, Staff told nurse that resident has been acting different . resident is very lethargic. Opening her eyes but not responding. Resident is usually walking around building all day and is currently laying in bed with no response. Resident is usually aggressive with care but isn't even responding to care at this time. Resident is shaky and clammy to touch. Vital signs are as followed: T (temperature) 98.4, P (pulse) 91, O2 (oxygen) 97%, BP (blood pressure) 101/61, R (respirations) 18. Blood sugar is 155. Covid test negative . (name of physician) stated, send resident to ER (emergency room) for further evaluation. 9/6/24 7:15 PM, Call received from (name of local hospital) stating resident is being admitted there with DX (diagnosis): Pneumonia. 9/7/24 9:35 AM, Called (name of hospital) for update on Resident, nurse stated that resident is doing ok, they are monitoring her respiratory symptoms, stating she is having some wheezing and SOB (shortness of breath), they also stated that resident is positive for Covid-19. 9/10/24 3:56 PM, .Res (resident) just arrived back to the facility via EMS (emergency medical services) Res vital signs are T 99.0, P 89, R 16, BP 90/44, O2 95% on room air . 9/11/24 9:46 PM, Resident has been up ambulating independently about facility w/o (without) gait disturbance noted Resident is on transmission-based precautions r/t (related to) dx (diagnosis) of covid 19 positive while in (name of local hospital) 9/12/24 8:02 AM, .Res up in the dining room eating breakfast at this time. Res ambulating this morning with no problems . 9/12/24 10:48 PM, . Resident walked around the facility as usual. Offered snacks throughout the shift . 9/15/24 8:32 AM, The resident is up in the dining room ambulating around. Res has no complaints at this time. No signs or symptoms of distress or discomfort. Plan of care on going. On 9/16/24 at 12:24 PM, R85 walked through the dining room, carrying her dessert of apple crisp, eating it with her fingers. R85 stopped at a table where peers were sitting and continued eating her dessert. R85 then walked to a second table of peers and stood eating her dessert. R85 set her dessert on the table near R4's dessert. An unknown certified nursing assistant walked R85 to a different table, had R85 sat down, and assisted her to eat her meal. R85's dessert was left on R4's table near his dessert. At no time throughout these observations did staff encourage R85 to eat in her room, wear a mask, or keep her distance from peers. On 9/17/24 at 12:12 PM, R85 stood in the dining room within two feet of peers with no mask on and staff did not encourage R85 to go to her room or don a mask. At 12:13 PM, R85 walked to V2 (Director of Nurse) office and stood. V2 walked past R85 and did not encourage her to wear a mask or go to her room. V3 (Social Services Director) assisted R85 to adjust her pants and did not encourage R85 to wear a mask or go to her room. R85 then walked down the hall her room was located on. On 9/18/24 at 4:38 PM, V2 (Director of Nurses) stated R85 returned from a hospital stay and it was reported to the facility R85 tested positive for Covid 19 while at the hospital. V2 stated they were never given any lab report documenting the positive test, but they placed R85 on isolation precautions since it was reported to them, she had tested positive. This surveyor shared the observation of R85 eating in the dining room and being in the dining room throughout the survey process without a mask on and no staff observed encouraging R85 to wear a mask or eat in her room. V2 stated she would think staff should encourage R85 to stay in her room and/or wear a mask if she was out and about in the facility. On 9/19/24 at 10:25 AM, this surveyor walked through the dining room following V2. R85 was sitting at a table, with peers, eating a cookie. This surveyor asked V2 if R85 was off isolation. V2 got V15 (Licensed Practical Nurse) and asked her to encourage R85 to go to her room or put a mask on. The undated facility Infection Control Policy Covid 19 documents, The facility has established appropriate guidelines pursuant to recommendations from the Illinois Department of Public Health and the Federal Centers for Disease Control. The policy addresses staff and visitor behavior and responsibilities to try to prevent the transmission of communicable disease Policy Interpretation and Implementation .2. To prevent the spread of respiratory germs within the facility .: a. Monitor employees prior to starting their shift for fever or respiratory symptoms b. Restrict residents with fever or acute respiratory symptoms to their room and place on droplet precautions. If they must leave the room for medically necessary procedures, have them wear a facemask (if tolerated) 2. R3's admission Record with a print date of 9/19/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include retention of urine, acute cystitis without hematuria, and mild cognitive impairment. R3's MDS dated [DATE] documents a BIMS score of 02, which indicates a severe cognitive deficit. R3's current Care Plan documents a Focus area of (R3) is at risk for complications related to foley catheter placement related to Urinary Retention Date Initiated: 02/26/2024 This Focus area documents interventions that include, .2/21/24 Foley Cath care q (every) shift On 9/18/24 at 3:50 PM, V8 (Certified Nursing Assistant) provided catheter care to R3 per current standards of care. V8 changed gloves three times during catheter care and did not perform hand hygiene. When asked why she didn't perform hand hygiene with each glove change, V8 stated she forgot to do it. On 9/18/24 at 4:38 PM, V2 (Director of Nurses) stated she would expect hand hygiene to be performed between glove changes. The facility Handwashing/Hand Hygiene policy dated 8/2015 documents, This facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations .m. after removing gloves .

Based on observation, interview, and record review the facility failed to provide a method to call for assistance while in the shower stall. This has the potential to affect all 32 residents residing at the facility. Findings include: On 09/18/24 at 11:20 AM the shower stall on the B hall does not contain a method to call for assistance from the shower stall, there is no access to a call light. On 09/18/24 at 11:30 AM the shower stall on the A hall does not contain a method to call for assistance from the shower stall, there is no access to a call light. On 09/19/24 at 12:02 PM V1 (Administrator) stated, the shower stalls should have a method to call for assistance that can be accessed from the floor if someone was in there, so another call box in the shower stall or a way to make the other call box string accessible from the shower. On 09/19/24 at 2:30 PM V1 stated, they do not have a policy regarding call light presence. The long term care facility application for Medicare and Medicaid dated 09/16/24 documents a census of 32 residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation the facility failed to provide privacy and security of possessions for 3 (R4, R12, & R20) of 3 residents reviewed for resident rights in a sample of 41. The findings include: 1. R20's Profile Sheet documents being admitted to the facility on [DATE] with a diagnosis of hypothyroidism. R20's Minimum Data Set (MDS) dated [DATE], documents Section C, Brief Interview for Mental Status (BIMS) score is 15, indicating that R20 is cognitively intact. On 7/31/2023, at 9:30 a.m., R20 stated that R17 comes into her room often and likes to go through her belongings at times. R20 stated that she keeps a lock on her closet door and fridge to keep R17 from taking her things. At this time, a lock is observed on R20's fridge and closet door. R20 stated she is just tired of her coming into her room unannounced. 3. R4's Profile Sheet documents being admitted to the facility on [DATE] with a diagnosis of Type II Diabetes Mellitus with Hyperglycemia. R4's MDS, dated [DATE], documents in Section C, a (BIMS) score of 15, indicating that R4 is cognitively intact. On 7/31/2023, at 10:00 a.m., R4 stated that R17 comes into her room and goes through her belongings at times. R4 stated that she has observed R17 go into other residents' rooms and get into their beds and falls asleep. R4 stated she is just tired of her coming into her room. 4. R12's Profile Sheet documents being admitted to the facility on [DATE] with a diagnosis of Type II Diabetes Mellitus with Hyperglycemia. R12's MDS, dated [DATE], documents Section C, a (BIMS) score of 15, indicating R12 is cognitively intact. On 8/01/2023, at 9:30 a.m., R12 stated that R17 comes into his room quite often at times and tries to get into his stuff. R12 stated that he has seen R17 go into other residents' rooms. R12 stated that R17 use to have her room close to his and was always coming into his room. R12 stated that they moved R17 to a different hall and she does not come in his room like before. On 7/31/2023, at 9:50 a.m., R17 was observed ambulating independently into R2's room and got into R2's bed independently. On 8/01/2023, at 1:00 p.m., R17 was observed ambulating independently and entered the room of R7 and got into R7's bed. On 8/07/2023, at 1:05 p.m., observed R17 in roommate's bed, (R1), sleeping with the covers pulled over her head. R17's medical record Profile Sheet documents that R17 was admitted to facility 10/22/2021 with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia, severe, with other behavioral disturbance. R17's Minimum Data Set (MDS) dated [DATE], documents Section C, a Brief Interview for Mental Status (BIMS) score of 00, indicating R17 has severe cognitive impairment. R17's Care Plan (7/13/2023) documents R17 has a behavior problem related to R17 is known to wander and lacks safety awareness. R17 is easily redirected by staff most of the time. R17 has a history of agitation related to dementia. On 8/2/2023, at 3:15 p.m., V2 (Director of Nursing), stated that the staff utilize a lot of redirection with R17 to keep her out of other residents' rooms. V2 stated that's all we can really do, she has dementia. V2 stated that it is hard to keep R17 occupied for any period of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure allegations of abuse were reported to the Administrator/designee immediately for 1 of 1 (R2) residents reviewed for abuse in the sample of 41. Findings Include: R2's admission Record with a print date of 8/7/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include unspecified convulsions, history of traumatic brain injury, muscle weakness, major depressive disorder, mild cognitive impairment, and unspecified mental disorder. R2's MDS (Minimum Data Set) dated 7/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates a severe cognitive impairment. On 8/2/2023 at 8:45 AM, V6 (Certified Nursing Assistant/CNA) stated she worked on 7/28/2023, at night and during that shift, V14 (LPN/Licensed Practical Nurse) reported to V6 she witnessed on 7/24/2023, V15 (CNA) punch R2 twice in the head. V6 stated she reported this incident to V2 (Director of Nursing) on Saturday morning, 7/29/2023. On 8/2/23 at 1:09 PM, V14 (Licensed Practical Nurse/LPN) stated she had never witnessed a resident being hit by any staff member at the facility. V14 stated she was working on the night of 7/28/23 and tempers were a little high. V14 stated two CNA's (V6 and V15) got into a verbal argument on the morning of 7/29/23. V14 stated she told them to stop and there was no cursing or threatening on either side. V14 stated she doesn't know why V6 brought her name into it because she has never seen or said that she saw V15 hit R2. On 8/2/23 at 1:33 PM, V15 (CNA) stated she was not aware of an allegation of a resident being hit. V15 stated she hadn't been to work since 7/29/23. V15 stated she had never hit a resident. On 8/2/23 at 9:40 AM, V8 (CNA) stated she was taking R2 to the bathroom with V6 present, on 8/1/23. V8 stated R2 reported to them V15 (CNA) hit her in the head (date unknown) because she wasn't getting on the toilet fast enough. V8 stated R2 told her she couldn't tell anyone because V15 would hurt her if she did. V8 stated they reported it to V2 (Director of Nurses). On 08/02/23 at 9:35 AM, R2 stated no staff had ever hurt her in anyway. R2 stated she does have a hard time remembering stuff at times. R2 stated her mother used to hit her in the head and began to tear up. R2 stated when she has had problems with staff she reports it to administration and they will take care of it. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated on 7/29/23 at approximately 6:15 AM she received a phone call at home from V6 and V6 sounded emotionally upset. V2 stated V6 told her V15 had yelled and cursed at her at the nurse's station. V2 stated V6 reported to her, V15 is mean and wanted to take her (V6) outside and fight her. V2 stated V6 reported no residents were around and/or heard the altercation. V2 stated she received another call from V6 around 1:00 PM on 7/29/23 and V6 stated to V2 that she had to report to her, V15 had yelled at and hit R2 in the head. V2 stated V6 reported it was the day V15 was working by herself (7/24/23). V2 stated V1 (Administrator) was out of town and she attempted to contact her but didn't hear back so she and V5 (MDS/Care Plan Coordinator) started the process of the investigation with the assistance of another administrator. V2 stated she called the nurse working and told her to have V15 leave the floor. V2 stated they submitted the initial report and notified the police. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she interviewed R2, V6, and V15 related to the allegation of abuse. V1 stated she told V6 she hadn't reported it right away and V6 confirmed to V1 that she hadn't. V1 stated her investigation was still ongoing at this time and she still had peer reviews to complete. The undated Final IDPH Incident and/or Abuse Notification documents, On 7/29/23 an allegation of abuse was reported by staff involving (R2). Nursing assessed (R2) for any injuries with none noted. An investigation immediately began. (V6) reported to (V2) that (V14) told her that she witnessed (V15) make contact with (R2). V14 denied the conversation and the incident ever occurred. She stated that (V6) was not accurate. (V15) denied the incident occurred. (R2) denied that any incident involving staff member had ever occurred. (R2) did not exhibit any new behaviors nor did she seem emotionally distressed. Based on a comprehensive investigation which included statements and interviews, abuse could not be substantiated citing conflicting information. Both (V14), (V15), and the resident denied that incident occurred .ID (Interdisciplinary Team) reviewed (R2's) clinical record which included behavior tracking, care plan, and medication records. In addition, a review of the incident/accident log, behavior tracking, grievance log, and the resident council meeting minutes was completed. (V15's) employment record was reviewed for disciplinary actions regarding abuse. None were noted. Her employment background check was updated along with the Healthcare Workers Registry Verification. No issues noted. (V6) was disciplined for failing to notify Administration of the incident in a timely manner. (R2) was monitored for any emotional distress or change in her demeanor. None noted. The facility Abuse Prevention Training Program dated 2022 documents, The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention Under Internal Reporting the program documents, Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Any employee who knows or suspects that abuse has occurred and has not reported the abuse or makes false allegations of abuse will face possible termination

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a thorough investigation was completed after an allegation of abuse was reported to the facility for 1 of 1 (R2) resident reviewed for abuse in the sample of 41. Findings Include: R2's admission Record with a print date of 8/7/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include unspecified convulsions, history of traumatic brain injury, muscle weakness, major depressive disorder, mild cognitive impairment, and unspecified mental disorder. R2's MDS (Minimum Data Set) dated 7/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates a severe cognitive impairment. The undated Final IDPH Incident and/or Abuse Notification documents, On 7/29/23 an allegation of abuse was reported by staff involving (R2). Nursing assessed (R2) for any injuries with none noted. An investigation immediately began. (V6) reported to (V2) that (V14) told her that she witnessed (V15) make contact with (R2). V14 denied the conversation and the incident ever occurred. She stated that (V6) was not accurate. (V15) denied the incident occurred. (R2) denied that any incident involving staff member had ever occurred. (R2) did not exhibit any new behaviors nor did she seem emotionally distressed. Based on a comprehensive investigation which included statements and interviews, abuse could not be substantiated citing conflicting information. Both (V14), (V15), and the resident denied that incident occurred .ID (Interdisciplinary Team) reviewed (R2's) clinical record which included behavior tracking, care plan, and medication records. In addition, a review of the incident/accident log, behavior tracking, grievance log, and the resident council meeting minutes was completed. (V15's) employment record was reviewed for disciplinary actions regarding abuse. None were noted. Her employment background check was updated along with the Healthcare Workers Registry Verification. No issues noted. (V6) was disciplined for failing to notify Administration of the incident in a timely manner. (R2) was monitored for any emotional distress or change in her demeanor. None noted. On 8/2/2023 at 8:45 AM, V6 (Certified Nursing Assistant/CNA) stated that she worked on 7/28/2023, at night and during this shift, V14 (LPN/Licensed Practical Nurse) reported to V6 on 7/24/2023, she witnessed V15 (CNA) punch R2 twice in the head. V6 stated she reported this incident to V2 (Director of Nursing) on Saturday morning, 7/29/2023. On 8/2/23 at 1:09 PM, V14 (Licensed Practical Nurse/LPN) stated she had never witnessed a resident being hit by any staff member at the facility. V14 stated she was working on the night of 7/28/23 and tempers were a little high. V14 stated two CNA's (V6 and V15) got into a verbal argument on the morning of 7/29/23. V14 stated the told them to stop and there was no cursing or threatening on either side. V14 stated she doesn't know why V6 brought her name into it because she has never seen or said that she saw V15 hit R2. On 8/2/23 at 1:33 PM, V15 (CNA) stated she was not aware of an allegation of a resident being hit. V15 stated she hadn't been to work since 7/29/23. V15 stated she had never hit a resident and was trained on abuse/neglect. On 8/2/23 at 9:40 AM, V8 (CNA) stated she was taking R2 to the bathroom with V6 present, on 8/1/23. V8 stated R2 reported to them V15 (CNA) hit her in the head (date unknown) because she wasn't getting on the toilet fast enough. V8 stated R2 told her she couldn't tell anyone because V15 would hurt her if she did. V8 stated they reported it to V2 (Director of Nurses). On 08/02/23 at 9:35 AM, R2 stated no staff had ever hurt her in anyway. R2 stated she does have a hard time remembering stuff at times. R2 stated her mother used to hit her in the head and began to tear up. R2 stated when she has had problems with staff, she reports it to administration, and they will take care of it. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated on 7/29/23 at approximately 6:15 AM she received a phone call at home from V6 and V6 sounded emotionally upset. V2 stated V6 told her V15 had yelled and cursed at her at the nurse's station. V2 stated V6 reported to her, V15 is mean and wanted to take her (V6) outside and fight her. V2 stated V6 reported no residents were around and/or heard the altercation. V2 stated she received another call from V6 around 1:00 PM on 7/29/23 and V6 stated to V2 that she had to report to her, V15 had yelled at and hit R2 in the head. V2 stated V6 reported it was the day V15 was working by herself (7/24/23). V2 stated V1 (Administrator) was out of town, and she attempted to contact her but didn't hear back so she and V5 (MDS/Care Plan Coordinator) started the process of the investigation with the assistance of another administrator. V2 stated she called the nurse working and told her to have V15 leave the floor. V2 stated they submitted the initial report and notified the police. When asked if anyone spoke with R2, V2 stated she spoke to R2 on 8/1/23. V2 stated she gave R2 enough information to let R2 know what they were talking about but R2 was unable to give any clear information. V2 stated she didn't know if anyone asked R2 about the allegation on the day it was reported, but V5 may have. V2 stated V15 has been suspended but V15 believes she was suspended because she and V6 got into an argument. On 08/07/23 at 10:13 AM, V5 (MDS Coordinator/LPN) stated she was notified by V2 they had a reportable on 7/29/23. V5 stated she spoke with R2 briefly on 7/29/23. V5 stated R2 appeared fine and is cognitively impaired so she didn't want to upset her. When asked if a physical assessment was done V5 stated, Just briefly. V5 stated she didn't see anything with the brief physical assessment. V5 stated her understanding was the alleged incident happened a few days earlier. V5 stated she knew R2 had a traumatic past and may bring that up. When asked if she had asked R2 if she had been physically harmed by a staff member, V5 stated she asked R2 if she was doing ok. V5 stated R2 was doing a puzzle in the dining room and other staff seemed to think it was over an issue with two employees, so she didn't want to upset the care environment. When asked where an assessment of R2 would be documented if someone had assessed her, V5 stated it would be on her risk assessment that was completed by V2. V5 provided the risk assessment report with no title, dated 7/29/23 to this surveyor and it documented, DON (Director of Nurses/V2) notified by CNA of alleged abuse of resident (R2) by another staff member. Resident showing no s/s (signs/symptoms) of injury or emotional distress as assessed by V5 (MDS) that day of report. Resident unable to give description. On 8/7/23 at 10:41 AM, V5 stated she didn't do a full body assessment of R2 after the allegation of abuse was reported. R2's progress notes did not document an assessment or documentation related to the allegation of abuse. R2's assessments tabs in the Electronic Health Record did not document an assessment related to the allegation of abuse. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she interviewed R2, V6, and V15 related to the allegation of abuse. V1 stated she interviewed R2 on 7/31/23 and again on 8/1/23. V1 stated R2 was talking about a history of abuse with her mother. V1 stated she interviewed V15 on 7/31/23 and V2 spoke with V15 and V6 on 7/29/23. V1 stated when V2 reported the allegation to her on 7/29/23 she told her she let V15 assume she was suspended for an issue with V6. V1 stated she made V15 aware of the allegation of abuse. V1 stated her investigation was still ongoing at this time and she still had peer reviews to complete. Review of the peer interviews documents peers (staff and residents) were asked the following question, Have you witnessed V15 (CNA) act physically inappropriate with R2. All of the responses are documented as no. There are no other peer interview questions documented. On 08/07/23 at 11:35 AM, V9 (Regional Director of Clinical Operations) stated she would expect a skin assessment and an emotional assessment to be done as soon as an allegation of abuse was reported. V9 stated it didn't matter if the abuse was alleged to have occurred several days prior to the report. The facility Abuse Prevention Training Program dated 2022 documents, The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention Under Investigation the program documents, As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designees will initiate an investigation into the allegation which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident; The alleged victim (if the victim is unable to be interviewed, this shall be documented); The alleged perpetrator (if the alleged perpetrator is a resident who cannot be interviewed, this shall be documented); Any witnesses or potential witnesses to the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other residents, family or visitors; A review of the medical record, including care plan; A review of all circumstances surrounding the incident; and Physicians will be notified of any incident and any medical treatment will be done as ordered Under Final Report and Follow Up the program documents, Report Contents. The final report shall include the following, as appropriate: name, age, diagnosis, and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; the original allegation (note day, time, location, the specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received incontinence care and showers for 2 of 2 (R36 and R87) residents reviewed for Activities of Daily Living (ADL's) in the sample of 41. Findings Include: 1. R87's admission Record dated 8/1/23 documents R87 was admitted to the facility on [DATE] with diagnoses that include traumatic hemorrhage of cerebrum, disorientation, sepsis, nontraumatic subarachnoid hemorrhage, heart failure, hypertension, and hypothyroidism. R87's MDS (Minimum Data Set) dated 6/11/2023 documents R87 has a BIMS (Brief Interview for Mental Status) score of 00, which indicates R87 has a severe cognitive deficit. R87's MDS documents under Section G, R87 requires extensive assistance of two staff for toileting. R87's undated care plan documents a Focus Area of, (R87) has an ADL Self Care Performance Deficit r/t (related to) Confusion, Impaired balance, Limited Mobility, and falls. This focus area has an initiation date of 6/16/2023. The interventions documented for this focus area include, Toilet Use: (R87) requires, assistance wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet to use toilet (sic). R87's progress notes dated 7/9/23 document R87 was transferred to the local hospital emergency room via emergency medical services for evaluation of possible dehydration related to diagnosis of clostridium difficile (C-diff). On 7/31/23 at 7:05 PM, V20 (local hospital-Registered Nurse) stated she provided care to R87 when he was transferred from the facility to the local hospital emergency room on 7/9/23. V20 stated R87 had a diagnosis of C-diff/diarrhea and upon admission to the emergency room, R87 was covered in dried feces. V20 stated it took several hospital staff an hour to clean the feces off R87. V20 stated the feces was dried so she knew it had been on R87 for a while. V20 stated the emergency medical technicians (EMT's) knew R87 had feces on him when they transported R87 to the hospital. When asked if it was documented in R87's hospital records that he had dried feces on him when he arrived at the emergency room, V20 stated she should have but didn't document it in R87's hospital record. On 08/01/23 at 4:07 PM, V21 (Paramedic) stated he remembered the facility telling him to wear gloves when he transported R87. V21 stated he remembered R87 wasn't cleaned prior to him being transported. V21 stated he also remembered the nurse at the emergency room asking his partner why they weren't wearing gloves since R87 had C-diff and there was feces present on R87. When asked if it would be documented if R87 was incontinent while on the ambulance, V21 stated it would and he knew R87 had not been incontinent of bowel while in the ambulance. On 8/2/23 at 3:54 PM, V16 (Hall Monitor) stated he normally worked night shift and he couldn't remember if he was working on the night of 7/9/23. V16 stated he didn't really go in and provide care to the residents, so he didn't have any specific knowledge related to R87's care and/or needs. On 8/3/2023 at 4:05 PM, V17 (Certified Nursing Assistant/CNA) stated he was working and provided care to R87 on the night of 7/9/23, when R87 was transferred to the hospital. V17 stated C-diff was wreaking havoc on R87 and the nurse (V22) and himself were worried about R87 being dehydrated. V17 stated on 7/9/23 he did rounds when arriving to work and reported to V22 that R87 looked worse than he did when V17 had last worked. V17 stated V22 asked him to make sure R87 got plenty of fluids and so he was offering him drinks often. V17 stated then V22 told him R87 needed to go to the hospital for evaluation and so he cleaned R87 up and then the EMT's were there to transport him to the hospital. V17 stated he couldn't remember who was working with him on that night, but believed it was him and another CNA. V17 stated he didn't remember if it was V16 (Hall Monitor) V17 stated V16 is a Hall Monitor and can't do resident care. V17 stated he had worked with V16 and a nurse before. V17 stated when that happens, they do the best they can to provide the needed care. When asked what care doesn't get provided when he is working with V16 and a nurse, V17 stated, I can't do bed checks like I should. V17 stated he tries to do a minimum of three bed checks but when he is working with just V16 and a nurse, he does good to do two bed checks. The CNA and Hall Monitor Schedule dated July 2023 documents on 7/9/23 V17 worked with V16 (Hall Monitor) from 6 PM to 6 AM. On 08/01/23 at 5:01 PM, V22 (Registered Nurse/RN) stated she couldn't remember if R87 had an incontinence episode prior to being transferred to the hospital on 7/9/23. On 08/07/23 at 8:35 AM, V23 (CNA) stated she didn't remember working on the evening R87 was sent to the hospital. V23 stated she remember R87 had declined and had diarrhea but was not able to provide information related to the care R87 was provided prior to being transferred to the local hospital on 7/9/23. On 8/2/23 at 1:56 PM, V2 (Director of Nurses/DON) stated she had not been made aware of any concerns/complaints of a resident being transferred to the hospital with dried feces on them. When asked if it was possible for someone to go to the hospital with dried feces on them, V2 stated, Yes. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she was not aware of any complaints/concerns residents weren't being provided timely incontinence care. 2. R36's admission Record with a print date of 8/1/23 documents R36 was admitted to the facility on [DATE] and discharged on 6/13/23 with diagnoses that include diabetes, sepsis, muscle weakness, kidney failure, heart disease, and acquired absence of left and right legs above the knee. R36's MDS dated [DATE] documents R36 had a BIMS score of 15, which indicates R36 is cognitively intact. This same MDS documents under Section G that R36 is totally dependent on staff for bathing. R36's undated Care Plan documents a Focus Area of (R36) has an ADL Self Care Performance Deficit r/t (related to) R36 requires weight bearing assist with ADL's. R36 is a bilateral amp (amputee) to both LE (lower extremities). (R36) uses a trapeze for positioning while in bed. (R36) continues to work with therapy for slide board transfers. This focus area has an initiation date of 6/9/23. The interventions documented for this Focus Area include, (R36) is totally dependent on staff to provide a bath 2x/wk (times per week) and as necessary. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated they are short staffed all the time. V4 stated there are times she has one CNA (Certified Nursing Assistant) and herself providing care to the residents. When asked if there was care that didn't get provided when she was working with less CNA staff, V4 stated, showers, bed checks, ADL's. V4 stated the residents just don't get the proper care. On 8/2/23 at 1:09 PM, V14 (LPN) stated staffing was hit or miss. V14 stated some shifts are staffed really well and then the next day they may have a couple of call ins. V14 stated she had worked with just one CNA. When asked if everyone was provided with necessary care, V14 stated they were but it was not as much as she would have preferred. When asked if residents were given showers, V14 stated showers weren't done on that shift. Review of R36's electronic health record did not document showers/baths were provided throughout R36's stay at the facility. On 08/02/23 at 12:50 PM, V9 (Regional Director of Clinical Operations) stated they were unable to locate documentation R36 had received showers/baths. On 8/7/23 at 11:41 AM, V9 stated they don't have an ADL policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R25's Face sheet documents R25 is a [AGE] year old female with diagnosis including: Bacterial Meningitis, Sequelae of Cerebral Infarction, Aphasia, Dysphagia following Cerebral Infarction, Paraplegia, Muscle Weakness, Psychosis not due to a Substance or known Physiological condition, Dementia with mild Agitation, Cerebral Aneurysm, Enthesopathy, and Cognitive Communication Deficit. R25's Order Summary Report date 08/01/23 documents: Referral to GI (Gastrointestinal) Specialist for diarrhea with an order date of 07/14/23 and an end date of 07/15/23 and documented as completed. R25's Order Report for 07/01/23 and 08/01/23 does not document any appointment for R25 for the GI specialist. On 08/01/23 at 4:00 PM, V9 (Regional Director of Clinical Operations) stated, V11 (transportation/appointments) would have made the appointment for R25 to see the GI specialist and would know when that appointment was. On 08/01/23 at 4:15 PM, V2 (Director of Nursing/DON) stated, R25 still has diarrhea, it will get better for a day or two then it will go back to being watery. On 08/02/23 at 7:55 AM, V11 (transportation/appointments) stated, she had not made an appointment for R25 to see the G I specialist. She stated she does not even know who the specialist is, she did not know that she was supposed to find that information out. On 08/02/23 at 8:55 AM, V6 (Certified Nurse Aide/CNA) stated, she does provide care for R25. V6 stated, R25 is still on isolation precautions for C. diff (Clostridium difficile) and still has diarrhea and it is bad. On 08/02/23 at 9:33 AM, V7 (CNA) stated, R25 is still on isolation precautions for C. diff and still has diarrhea. She stated yesterday she thought it might have looked better but today it does not look good again and it is kind of green and slimy. On 08/02/23 at 11:15 AM, V9 (Regional Director of Clinical Operations) stated, she could not find the appointment for R25 to see the GI specialist, she did see the referral on 07/14/23 and the appointment should have been made. On 08/02/23 at 3:55PM, Peri care was given to R25 by V6 (CNA) and V7 (CNA). V6 and V7 donned goggles, gloves, gown, foot covers which was the appropriate PPE (Personal Protective Equipment) for C-diff precautions. During peri care a large amount of loose slimy brown stool was noted in R25's brief. R25's Bowel Movement documentation documents: between 07/18/23 to current (08/07/23) R25 has had episodes of diarrhea every day except 07/24/23 and 07/25/23 with response not required documented and 07/28/23 with a checkmark in the box for formed/normal. R25's Order Summary Report date 08/01/23 documents: Difficid oral tablet 200 mg (milligrams) for 10 days with an order date of 06/28/23, Flagyl Oral tablet 500 MG every 8 hours for diarrhea for 10 days with an order date of 06/28/23, Flagyl Oral tablet 500 MG 500 mg every 8 hours for diarrhea for 14 days with an order date of 07/14/23, Metronidazole oral tablet 500 mg one tablet by mouth three times a day for C. diff diarrhea for 14 days with an order date of 05/31/23. R25's Care Plan with an initiated date of 05/18/23 documents: R25 will have no complications related to C. difficile through the review date with interventions listed including: give all meds (medications) and IV (intravenous) therapy as ordered and give anti-emetics, antipyretics and analgesics for complaints of discomfort. Monitor/document for side effects and effectiveness. Based on interview and record review the facility failed to ensure wounds were identified, assessed, and treated for 2 of 2 (R36 and R87) residents reviewed for wounds. The facility failed to ensure appointments with a specialist were obtained for 1 of 1 (R25) resident reviewed for infection control in the sample of 41. Findings Include: 1. R87's admission Record with a print date of 8/1/23 documents R87 was admitted to the facility on [DATE] with diagnoses that include traumatic hemorrhage of cerebrum, sepsis, non-traumatic subarachnoid hemorrhage, heart failure, hypothyroidism, hypertension, history of falls, and a cardiac pacemaker. R87's MDS (Minimum Data Set) dated 6/11/23 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates a severe cognitive deficit. R87's undated Care Plan documents a Focus Area of, (R87) is incontinent of B&B (bowel and bladder) and requires assist with ADL's (Activities of Daily Living). (R87) currently has no pressure wounds. (R87's) skin is fragile. Date Initiated: 6/16/23. The interventions for this focus area include, 7/5/23 tx (treatment) as directed to blister on left heel 6/16/23- follow facility policies/procedures for the prevention/treatment of skin breakdown, 6/16/23 inform (R87)/family/caregivers of any new area of skin breakdown' 6/16/23- monitor/document/report to MD (physician) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. R87's progress notes dated 7/9/23 at 7:00 PM documents, Called V18 (Physician) regarding (R87) order for bumex 2 mg (milligrams). (R87) is still having loose stools. Monitoring for signs of dehydration. VS (vital signs) 96.8- 74- 22- 99% on RA (room air)- 101/60. Received order to D/C (discontinue) bumex and have CMP (comprehensive metabolic panel) and CBC (complete blood count) with Diff (differential) drawn in AM (morning). Call results to V18. Remains on contact isolation. In bed at this time. Cont (continue) with plan of care. R87's progress notes dated 7/9/23 at 8:24 PM documents, V18 called back, and V/S were given to him. Order to send to hospital for dehydration related to C-diff (Clostridium difficile) infection. Also (R87) still actively having watery stools. Called V2 RN, DON (Registered Nurse/Director of Nurses) and gave her the info (information) also. On 7/31/23 at 7:05 PM, V20 (local hospital/Registered Nurse) stated she provided care to R87 at the hospital emergency room on 7/9/23. V20 stated R87 had wounds/open areas on his left heel, spine, coccyx, groin, penis, and testicles. V20 stated the assessment of the areas would be located in R87's hospital medical record. R87's local hospital record with an admission date of 7/9/23 documents the following wounds that were all present on admission to the hospital; penis- described as yellow, crusted wound with no measurements documented. groin- described as moist pink wound with no measurements documented. medial back- described as pink wound, with no measurements documented. heel- described as moist, black, red, shallow, shiny blister with no measurements documented. coccyx- described as pink, red, blanchable wound with no measurements documented. On 08/01/23 at 4:07 PM, V21 (Paramedic) stated he transported R87 from the facility to the local hospital on 7/9/23. V21 stated the facility did not report any wounds to him prior to transporting R87. On 08/01/23 at 5:01 PM, V22 (RN) stated the facility did weekly skin assessments on R87 and he had skin tears on his arms that he would pick at and a pressure ulcer/blister to his left heel that was being treated at the facility. On 8/2/23 at 8:28 AM, V6 (Certified Nursing Assistant/CNA) stated the only wound R87 had prior to going to the hospital was the area on his heel and some skin tears. On 8/2/23 at 9:40 AM, V8 (CNA) stated R87 had wounds on his heel and arms and had what looked like herpes blisters on his penis. V8 stated she had another CNA look at it and reported it to an unknown nurse. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated R87 had a wound on his heel and skin tears but she didn't recall any other wounds. On 8/2/23 at 1:09 PM, V14 (LPN) stated she didn't remember any wounds on R87's testicles, groin, back, or coccyx. On 8/3/2023 at 4:05 PM, V17 (CNA) stated he provided care to R87 on 7/9/23 and assisted in getting R87 ready for transfer to the local hospital. V17 stated he didn't remember any wounds other than the one on R87's heel and the skin tears. On 08/07/23 at 8:35 AM, V23 (CNA) stated R87 had sleeves on his arms because his skin would tear very easily. V23 stated they turned and repositioned R87 and used wedges to off-load him. V23 stated she didn't remember R87 having any wounds/pressure ulcers. R87's shower sheets dated 6/7/23, 6/21/23, 6/24/23, 6/28/23, and 7/5/23 document no new skin breakdown areas. R87's Initial Skin Alteration Record dated 3/29/23 documents, (R87) has multiple scabbed areas to BUE/BLE (bilateral upper extremities/bilateral lower extremities) et (and) abrasions to right elbow r/t (related to) falls @ (at) home. Noted dark purple sized area to mid abdomen. R87's Initial Skin Alteration Record dated 6/8/23 documents, Has scabby areas that are covered by dressing from (name of local hospital). (R87) picks at there (sic) areas constantly. Skin very dark and scaly bilateral forearms. R87's Initial Skin Alteration Record dated 6/25/23 documents, (R87) has multiple scabbed areas and S.T. (skin tear). (R87) has pulled off steri-strips and made into open areas on BUE. Tx (treatment) cont (continues) as prior to hospital. R87's Initial Skin Alteration Record dated 7/5/23 documents, appears to be ruptured blister to the left heel with skin remaining over the area that can be moved. The date of onset is documented as 7/5/23 and the area is measured at 3 x 3 cm (centimeters). The treatments are documented as provide relief on bed, turning and repositioning, wound care. R87's Initial Wound Evaluation and Management Summary dated 7/6/23 documents, At the request of the referring provider . a thorough wound care assessment and evaluation was performed today Details about current wound(s) and any skin conditions are outlined below Under Focused Wound Exam (Site 1) the summary documents a Stage 3 pressure wound of the left heel that measures 6 x 4 x 0.1 centimeters (cm). The summary documents treatment orders for calcium alginate and betadine to be applied daily and documents a surgical debridement was done. Under Focused Wound Exam (Site 2) the summary documents a skin tear on the left forearm that measured 2 x 2 x not measurable cm. The summary documents treatment orders for calcium alginate, collagen powder, and silver sulfadiazine (SSD) to be applied daily. R87's Order Summary Report dated 8/1/23 documents the following physician orders; 7/5/23 apply betadine, calcium alginate to left heel and wrap with kerlex daily and 7/5/23 apply SSD, collagen, and calcium alginate to skin tear and cover with border gauze daily. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated she was aware of the wound on R87's heel and skin tears. When asked if she was made aware of any other wounds prior to R87 being transferred to the hospital on 7/9/23, V2 stated she had heard the wound specialist say that when someone is actively dying their skin can break down within an hour or two. When asked if she had the impression R87 was actively dying prior to being transferred to the hospital V2 stated she didn't. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she had never received a complaint or a concern that residents were not receiving wound care. V1 stated she would expect the nursing staff to follow the clinical standards of practice for wound care. 2. R36's admission Record with a print date of 8/1/23 documents R36 was admitted to the facility on [DATE] and discharged from the facility on 6/13/2023. This same admission Record documents R36 was admitted with diagnoses that include sepsis, acquired absence of right and left leg above the knee, kidney failure, anemia, heart failure, peripheral vascular disease, and diabetes. R36's MDS dated [DATE] documents a BIMS score of 15, which indicates R36 was cognitively intact. This same MDS documents under Section G, R36 requires assist of two staff for dressing, bathing, transferring, and toileting. R36's Order Summary Report dated 8/1/2023 documents a physician order for a weekly skin check but does not document any wound treatment orders. R36's undated Care Plan documents a Focus Area of, (R36) has Amputation of r/t (related to) (sic) of both lower ext (extremities). (R36) recently had a R (right) AKA (above the knee amputation). This focus area as an initiation date of 6/9/23. The interventions for this focus area includes, Check and document on wound daily for s/sx (signs/symptoms) of infection, drainage, bleeding, any breakdown of skin and impaired circulation (edema or pain). Date Initiated: 06/09/2023. On 8/2/23 at 8:28 AM, V6 (Certified Nursing Assistant/CNA) stated R36's surgical incision to right knee looked really bad in the week prior to being transferred to the hospital on 6/9/23. V6 stated R36 would throw himself on to the floor and scoot around. V6 stated the incision was dirty looking. V6 stated they would try to keep it clean and R36 would get it dirty again. V6 stated the incision line was ripped open so you could see the inside of his (R36's) flesh showing. V6 stated the incision looked like this longer than a couple of days. V6 stated the nurses were aware of it. On 8/2/23 at 9:40 AM, V8 (CNA) stated R36's surgical incision to the right knee looked, bad. V8 stated it was partially open and looked infected. When asked what the nursing staff was doing to treat the area, V8 stated, I don't think anything. V8 stated she didn't think they were doing anything because R36 wouldn't stay in the wheelchair and liked to pull himself around on the floor. V8 stated she thought the area always looked like that but began to look worse. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated she was working on 6/9/23 when R36 was sent to the hospital but V2 (Director of Nurses) assessed and sent R36 to the hospital. V4 stated the surgical incision line was closed up and she never saw any drainage from the area. V4 stated they weren't doing a treatment and she would assume they would do one if the area was opened. On 8/2/23 at 9:17 AM, V7 (CNA) stated R36's surgical incision to his right knee was open a smidge and had pus in it but was unable to recall when she last saw it. On 8/2/23 at 1:09 PM, V14 (LPN) stated when R36 first admitted to the facility the surgical incision line looked red. V14 stated by the time R36 was transferred to the hospital on 6/9/23 the area looked infected. V14 stated it was her understanding the facility wound specialist was going to see R36 when he did rounds at the facility. V14 was unable to recall who told her the wound specialist was going to see R36 and/or when he would be seen. V14 stated R36 was very reluctant with care so a lot of time it was just a quick look in his room. V14 stated it was just a visual assessment that she was not able to complete a physical assessment of the area. R36's Progress Notes were reviewed from 5/24/23 to 6/13/23 and document the following: 5/24/23, Resident (R36) admitted to this facility via EMS (Emergency Medical Services) from (name of regional hospital) .(R36) is a Bilateral AKA with most recent amputation on 05/21/23. Assessment reveals there are 31 intact staples to operative incision; free of s/s infectious process; no drainage or edema noted . 5/25/23, (R36) in low bed for safety precautions. Is double amputee. Rt (right) AKA with surgical incision with surgical staples intact. Incision is well approximated and has no drainage. Receives Norco for post surgical pain. Is effective for pain at surgical site RT AKA is open to air. Call light in reach. Did go to ER (emergency room) today for eval (evaluation) regarding mood. Cont (continue with plan of care.) 5/28/23, (R36) in low bed for safety precautions. Is double amputee. Incision RT amputee staples intact and well approximated. Open to air. Has been deconstructing room. 5/29/23, Incision RT amputee staples intact and well-approximated. Resident is a double amputee. Resting quietly at this time. 5/29/23, Staples to R stump intact. No s/sx of infection noted. Resting comfortably with call light in reach. 5/29/23, Staples to R stump dry/intact, no s/s of infections noted. PRN (as needed) pain medication given for pain control w/(with) fair results. Resident frequently refuses care and becomes very agitated w/staff. (R36) is not easily redirected . 5/31/23, This DON (Director of Nurses) was in (R36's) room discussing his future plans when he stated he was going to electrocute himself with the call light cords. He said he was going to die. Sad persons scale completed with a score of 9. (name of physician) consulted and ordered psych eval at (name of hospital). (name of physician) also ordered this nurse to communicate to the (name of hospital) that the patient had AKA on 5/21 and needed evaluation of surgical site for staple removal. RN (Registered Nurse) called (name of hospital) nurse to give thorough report. 911 called for ambulance . 5/31/23, (R36) returned at 1920 (7:40 PM) per EMS from (name of hospital) Staples removed and steri strips applied. RN stated that (R36) stated that he will not keep them on 6/1/2023, (R36) in bed. Call light in reach. RT AKA incision well healed. Steri Strips intact. Incision is dry . 6/1/23, (R36) post amputation. Wound edges well approximate. (R36) cont (continues) to have behaviors and is throwing food around room . 6/5/23, (R36) left the facility at this time via ambulance for altered mental status. (R36) appeared weak and had trouble verbalizing needs . 6/5/23, (R36) returned to facility via (name of ambulance). He was taken to (name of local hospital) for evaluation. All tests completed and no new orders received . 6/6/23, R36 was transferred to local hospital for a psychiatric evaluation after threatening to break an unknown staff member's legs. R36 returned to the facility the same day with an order for an antibiotic. 6/9/23 at 10:45 AM, (R36) transferred to (name of local hospital) d/t (due to) wound infection and drainage from L (left) (sic) stump. Transferred via ambulance. Stable at time of transfer. 8/7/23, .(R36) was discharged from (name of local hospital) to a healthcare facility (name of brother) did stated that his brothers (R36) stump was healing well. R36's weekly skin record dated 6/9/23 at 2:59 AM, and signed by V22 documents, No open areas. Incision RT AKA is well approximated. (R36) took steri strips off incision site. No drainage well-healed. The facility was unable to provide reproducible evidence R36's surgical incision line to right leg amputation was assessed daily per the care plan intervention. On 08/01/23 at 4:55 PM, V22 (Registered Nurse/RN) stated R36 was admitted to the facility three days post operative. V22 stated R36 was evaluated at the local hospital for psychiatric evaluations a couple of times after admitting to the facility. V22 stated she thought R36 intentionally infected the surgical site. V22 stated she charted that it was almost healed. When asked how he would have intentionally infected the surgical site, V22 stated, He must have found a very weak spot. V22 stated the last time she saw the surgical site (6/9/23) it looked good. V22 stated, It is a total mystery. I just don't know. V22 stated the area was well approximated with no drainage and she just didn't know what happened. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated the first time R36 had any symptoms that concerned her was on 6/9/23 when she sent him to the hospital for evaluation. V2 stated the Nurse Practitioner was at the facility on 6/8/23 and the area was open about two millimeters and had a few steri strips on it. When asked if the Nurse Practitioner did an assessment of the area, V2 stated not that she could find. V2 stated she (V2) also didn't document the assessment. V2 stated the next day (6/9/23) the area was open between seven and eight centimeters. When asked to compare her descriptions of the surgical site on 6/8/23 and 6/9/23 to V22's assessment on 6/9/23, V2 stated she would say there was no difference in the assessments. V2 stated it didn't show in the documentation, but they treated R36 well. V2 stated there was no treatment orders for the area, but a dry dressing was being place on it. V2 stated she would have expected the nurses to document assessments. On 8/2/23 at 3:35 PM, V1 (Administrator) stated R36 had not been followed by the wound specialist while at the facility. V1 stated she would expect a nurse to assess surgical wound sites and then document the assessments. The facility Skin Care-Wound Care Teaching Protocols dated January 2014 documents under CNA's .Report any changes in skin to the charge nurse Charge Nurse .Report wound area to physician during same shift discovered when possible. Obtain order for treatment of wound .Initiate daily skin check on TAR (treatment administration record) per risk score .Document on in Nurses Note notification, interventions, and current skin condition/wound description .Notify the physician of any changes in skin integrity or lack of progress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide supervision. This failure led to an elopement of 1 (R17) of 1 resident reviewed for elopement in a sample of 41. The findings include: R17's medical record Profile Sheet documents that R17 was admitted to facility 10/22/2021 with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia, severe, with other behavioral disturbance. R17's Minimum Data Set (MDS) dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 00, indicating that R17 has severe cognitive impairment. Section G, Functional Status documents that R17 requires extensive assistance with one person physical assist with bed mobility, supervision with two person physical assist with transfers, limited assistance with one person physical assist with ambulation and eating, extensive assistance with two person physical assist with dressing, personal hygiene, and toilet use. Section E, Behavior, under Wandering-Presence & Frequency, it documents that behavior of this type occurred daily. Under Wandering - Impact it documents yes that wandering places the resident at significant risk of getting to a potentially dangerous place, and significantly intrudes on the privacy or activities of others. R17's Care Plan documents under Focus that R17 is at risk for elopement related to dementia and poor safety awareness, R17 likes to walk to the doors and windows, R17 has a history of elopements with an initiation date of 3/15/2022 and a revision date of 2/02/2023. Under the section Goal it documents that R17 will remain free from making elopement attempts throughout next review with an initiation date of 3/15/2022 and a target date of 9/24/2023. Documented Interventions (last revision date 5/19/2023) include 15 minute checks for R17's whereabouts with an initiation date of 5/22/2023, 1:1 with staff until R17's behavior deescalates, adjust timer to door alarm with an initiation date of 6/13/2022 and 8/1/2023, 15 minute checks until directed otherwise with an initiation date of 8/2/2023, allow concerns to be expressed, encourage R17 to keep busy with activities, primary physician notification as needed, praise R17 when cooperative, reality orientation if appropriate, redirect R17 to activities of choice or social services group, and wander-guard in place with an initiation date of 3/15/2022. R17's admission Elopement/Wandering Risk Assessment dated 10/22/2021 documents under section 1a. Summary of Elopement Assessment, 1. Resident is at risk for elopement at this time, 2a. Summary of Wandering Assessment, 1. Resident is at risk for wandering at this time. The most recent Elopement/Wandering Risk Assessment dated 4/07/2023 documents under section 1a. Summary of Elopement Assessment, 1. Resident is at risk for elopement at this time, 2a. Summary of Wandering Assessment, 1. Resident is at risk for wandering at this time. R17's Physician's Orders dated 08/01/2023 documents Monitor Wander guard every shift to maintain functioning every day and night shift for elopement risk with a start date of 3/24/2022 with an open end date. On 8/01/2023, at 3:30 p.m., R17 was observed entering the facility by ambulating independently through the front door with staff from the neighboring long term care facility who was returning R17 to the facility. R17's wander-guard alarm was sounding and V5 (MDS/Licensed Practical Nurse-LPN) was observed going to the front door and reset the wander-guard alarm. On 8/02/2023, at 8:45 a.m., (V6, Certified Nursing Assistant-CNA), stated she has worked at the facility for 4 1/2 years and is familiar with R17's care. V6 stated that R17 wanders in and out of other residents' rooms and she has observed R17 go into other residents' rooms. V6 stated that R17 has gotten hurt by other residents by entering their rooms. V6 stated that R17 is very fast when she walks, and she tries to keep her occupied by having her sit with her while she is charting but R17 will not sit long enough to do any kind of activity. V6 stated that R17 wears a wander-guard and the only door that alerts the wander-guard is the front door. V6 stated that the wander-guard alarm was not working about a month ago and when that happens, a staff member sits by the front door. V6 stated all the exit doors have a code that has to be put in to get out the door. V6 stated that the door alarm will sound if the code is not put in. V6 stated that she has observed R17 follow staff out the exit doors that do not have a wander-guard alarm on them. V6 stated she has talked to other staff members about keeping a closer eye on where R17 is when they go out the exit doors to make sure she does not follow them out. V6 stated that R17 has probably gotten out of the facility within the past year approximately 50 times or so. V6 stated that R17 is usually brought back to the facility by the neighbor nursing center staff when she leaves the facility. On 8/2/2023, at 9:15 a.m., V7 (CNA) stated that she was working yesterday, 8/1/2023, (6:00 a.m. - 6:00 p.m. shift) and did not hear any wander-guard alarm sound. V7 stated that she thinks V5 (MDS/ LPN), and the other nurses check the wander-guards to see if they are working or not. V7 stated that the front door is the only exit door that has the wander-guard alarm. V7 stated the other exit doors in the facility have a code you have to punch in to get out and those doors do not activate the wander-guard alarms. V7 stated that she tries to redirect R17 when she attempts to leave the facility but R17 usually does not stay interested in any activity for very long. On 8/2/2023, at 9:45 a.m., V8 (CNA) stated that she was working yesterday, 8/01/2023, (6:00 a.m. - 6:00 p.m. shift), and did not hear a wander-guard alarm sound yesterday. V8 stated that she observed R17 being brought through the front door and did not know she had left the facility. V8 stated that R17 has been known to follow staff out the exit doors that do not have a wander-guard alarm and walk over to the neighboring long term care facility where she once lived. V8 stated she is not sure who checks the wander-guards to see if they work. V8 stated she tries to redirect R17 as much as possible when she attempts to leave the facility. V8 stated that she will offer R17 something to eat and drink at times and give her a book to look at. On 8/2/2023, at 10:45 a.m., V4 (LPN), stated that she worked yesterday, 8/01/2023, and was not aware that R17 had left the facility unattended until she was notified by V1 (Administrator) that R17 had left facility and was brought back by the neighboring long term care facility staff. V4 stated that she was told by V1 that the back door alarm had been turned off by maintenance and they forgot to turn the alarm back on. On 8/2/2023, at 3:00 p.m., V1 (Administrator) stated that R17 left the facility yesterday unattended and was brought back by the neighboring long term care facility staff. V1 stated she did not know how long R17 had been gone from the facility. V1 stated that the root cause of R17's elopement was the maintenance staff had turned the back door alarm off and forgot to turn it back on. V1 stated the facility has a total of five exit doors. V1 stated the front door is the only exit door that uses the wander-guard alarm. V1 stated the nurse checks the wander-guards daily and if there is ever a time that the alarms are not working, a staff member is placed at the front door to monitor residents. V1 stated that recently the Social Service's Director and Activity Director had been switching off spending more 1:1 time with R17 but the Social Service's Director has recently broke her leg and the Activity Director has resigned recently. V1 stated she brings in staff from other departments to help provide activities for all the residents. V1 stated that it has been talked about with upper management to place a secure fence around the building to keep residents from eloping. V1 stated that R17 has eloped at least three times that she knows of, and the staff use redirection, offers R17 something to eat, drink, and 1:1 staff when available. R17's Progress Notes dated 8/1/2023, at 3:33 p.m., documents responded to doorbell at front door. Greeted by R17 and 2 staff members from neighboring nursing center with this resident. R17 smiling when greeted. Wander-guard sounding upon entering facility. R17 nonverbal for the most part and offered no explanation. R17 smiling and showed no signs or symptoms of distress. R17 brought into facility and assessed. No apparent signs or symptoms of acute distress. No red areas and/or wounds noted. V/S 97.6-77-158/79-16-99%. R17 given glass of ice water. V1 (Administrator) aware of incident. V12 (Nurse Practitioner/NP) and V13 (Family) notified. R17's Progress Notes dated 6/1/2023, at 3:09 p.m., documents front doorbell sounding. R17 present with staff from nursing home behind this facility. The neighboring nursing center staff reported observing R17 getting out and redirected her back to our facility. R17 assessed no apparent injury. All parties updated. R17's Progress Notes dated 4/2/2023 at 7:00 p.m., documents nurse answered front doorbell. Staff from neighboring nursing center present with this resident. Staff from neighboring nursing center stated they saw R17 and brought her back, knowing she was ours. R17 assessed with no signs or symptoms of injury. Door alarms checked to make sure they are properly functioning. All parties notified and updated. R17's Progress Notes dated 3/27/2023, at 4:33 p.m., documents CNA staff witnessed R17's left forearm being grabbed by R12 and then R12 proceeded to punch R17's upper right arm. R12 upset that R17 continued to set off door alarm. Residents separated. Incident reported to V2 (Director of Nursing/DON) and V1 (Administrator). V12 (Nurse Practitioner/NP) notified. V1 reported to police and public health dept. R17's Progress Notes dated 2/12/2023 at 12:18 p.m., documents R17 walked into another resident's room, other resident punched R17 in stomach and then R17 hit other resident in head. Both residents separated and assessed for injuries, none noted. V13 (Family), V12 (Nurse Practitioner), & V1 (Administrator) notified of situation. R17's Progress Notes dated 1/23/2023, at 8:45 a.m., documents a state surveyor came to nurse's station and stated R17 was in a room on a different hall and was eating yogurt and using a fingernail polish brush as a spoon. Found R17 in R5's room with yogurt in her hand. Nail polish sitting on top of mini fridge in R5's room. R17 making a face and when asked if it tasted bad, she shook her head yes. When R17 was asked if she got nail polish in mouth resident shook head yes. Nail polish removed. V12 (NP) notified and informed nurse to call poison control. Spoke with poison control regarding R17 ingesting nail polish. Poison control stated to monitor resident as she may vomit once or twice if enough was ingested. V1 (Administrator) aware and report given to V5 (LPN/MDS). R17's 15 minute checks dated 8/01/2023 - 8/05/2023 documents no checks being documented on 8/02/2023 (4:45 a.m. - 5:45 a.m. & 5:00 p.m. - 6:00 p.m.), 8/03/2023 (12:00 a.m. - 5:45 a.m. & 9:00 p.m. - 11:45 p.m.), 8/04/2023 (2:30 a.m. - 10:00 a.m. & 5:00 p.m. - 5:45 p.m.), & 8/05/2023 (12:00 a.m. - 5:45 a.m. & 6:00 p.m. - 11:45 p.m.). On 8/2/2023, at 3:15 p.m., documentation for 15 minute checks prior to 8/01/2023 was requested but the facility was unable to provide any further documentation prior to 8/01/2023. On 8/07/2023, at 3:15 p.m., V3 (CNA), stated that R17 has 15 minute checks that are supposed to be documented every shift for elopement and wandering risk. V3 stated that she always documents R17's 15 minute checks when she works. R17's Behavior Tracking Record (Wandering) documents wandering with frequency of 10-20 times every shift daily for March 2023, 15-20 times every shift daily for April 2023, 20 times every shift daily for May 2023, 15-20 times every shift daily for June 2023, and 20 times every shift daily for July 2023. R17's Behavior Tracking Record (Exit Seeking) documents exit seeking frequency of 10-20 times every shift daily for March 2023, 15-20 times every shift daily for April 2023, 20 times a shift daily for May 2023, 10-20 times a shift daily for June 2023, and 10-20 times a shift daily for July 2023. Resident Council meeting minutes dated 7/14/23 document under Discussion Topic residents who wander-extra activities for wanderers. Elopement policy (March 2015) statement: Staff shall investigate and report all cases of missing residents.

Based on interview, observation and record review the facility failed to provide food in the form that is ordered by a physician for 7 of 7 residents 7 (R9, R17, R22, R27, R32, R33, and R237) reviewed for mechanical soft diet in a sample of 41. Findings include: 1. The facility document titled, Diet Spreadsheet dated week 2, Day 9 - Monday, documents: Dental Soft (Mech (Mechanical soft) Soft) Lunch: Grnd (Ground) Herb Chicken with Gravy, Creamy Noodles, Chopped Soft [NAME] Beans and Chopped Strawberry Shortcake. The facility document titled, Grnd (Ground) Chicken with Gravy documents: 8. Portion #8 dipper, or adjusted dip size based on test weight, of ground meat on plate. Ladle an additional 1-2 oz (ounces) gravy on top. The facility document titled, Chopped Soft [NAME] Beans documents: Before serving, chop vegetables, as needed, chop vegetable into bit-size pieces (one-half inch or no bigger than 1.5 cm (centimeter) x 1.5 cm (centimeter), which is about the width of a standard dinner fork. One-half inch equals 1.27 cm (centimeter). On 07/31/23 at 12:00 PM as lunch trays were being plated it was noted that R9, R17, R22, R27, R32, R33, and R237 were plated Brussel sprouts, with some of the Brussel sprouts not being chopped and remaining whole and the ground chicken was served without any gravy on top. On 07/31/23 at 12:00 PM R9, R17, R22, R27, R32, R33, and R237 were all noted in the dining room and received the lunch trays that included Brussel sprouts, with some of the Brussel sprouts not being chopped and remaining whole and the ground chicken was served without any gravy on top. 2. The facility document titled, Diet Spreadsheet dated week 2, Day 10 - Tuesday, documents: Dental Soft (Mech (Mechanical) Soft) Lunch: Ground Baked Pork Chop w/Gvy (with gravy), chp (chopped) soft baked Potato w (with)/ sour cream & margarine, Chopped soft Cooked Vegetable Medley, Soft Sugar Cookies. The facility document titled, Ground Baked Pork Chop w/(with) Gravy documents: Portion #8 dipper of ground pork onto plate and ladle 1-2 oz (ounces) prepared gravy over the top. On 08/01/23 at 12:05 PM R9, R17, R22, R27, R32, R33, and R237 were all noted to be sitting in the dining room and for their lunch meals they received pork that was ground with no gravy on top of the pork. 3. The facility document titled, Diet Spreadsheet dated week 2, Day 11 - Wednesday, documents: Dental Soft (Mech (Mechanical) Soft) Lunch: Ground Fiesta Hamburger Steak w (with)/ salsa, Spanish rice- no bacon w (with)/ sauce, creamed corn, and Chopped Soft Cinnamon Baked Apples. The facility document titled, Ground Fiesta Hamburger Steak with Salsa documents: 5. Place cooked patties into a washed and sanitized food processor and grind to the size and texture of fine hamburger. Portion #8 dip ground meat and ladle 1 to 2 oz (ounces) of salsa over the top. On 08/02/23 at 12:15 PM R9, R17, R22, R27, R32, R33, and R237 were all noted to be in the dining room and for their lunch meals they received hamburger steak that was not ground and only cut into pieces, and the baked apples were not cut into pieces, some of the pieces of apples were approximately 2.5 inches long. On 08/02/23 at 2:10 PM, V9 (Regional Director or Clinical Operations) stated, the menus and recipes for the mechanical soft diet should be followed as stated on the menu spreadsheet and made as per the recipes' directions. On 08/07/23 at 1:00 PM, Dietary Manager stated, the menus and the recipes for the mechanical soft diet should be followed. The mechanical soft diet residents should not be given whole Brussel sprouts, the meat should be ground with gravy on top, and vegetables and fruit should be bite size. R9's face sheet documents diagnosis including: Non traumatic Subacute Subdural Hemorrhage, Hemiplegia unspecified affecting Left Non-Dominant Side, Dysphagia Oropharyngeal Phase, Bell's Palsy and Other Symptoms and Signs Concerning Food and Fluid Intake. R9's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Low Concentrated Sweets Diet: Mechanical soft texture with an order date of 05/24/2023. R17's face sheet documents diagnosis including: Cerebral Infarction due to unspecified Occlusion or Stenosis of Unspecified Cerebral Artery, Aphasia following Cerebral Infarction, and Unspecified Dementia, Severe, with other Behavioral Disturbance. R17's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular diet: Mechanical soft texture with an order date of 03/23/2022. R22's face sheet documents diagnosis including: Alzheimer's Disease, Anxiety Disorder, and Shortness of Breath. R22's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular Diet: Mechanical soft texture with an order date of 06/07/2022. R27's face sheet documents diagnosis including: Hydronephrosis, Alzheimer's Disease, Dementia with agitation, and Bipolar Disorder. R27's Order Summary Report dated 08/02/23 documents: Dietary- Diet: NAS (No Added Salt) diet, Mechanical soft texture, Extra Sauces and Gravy with an Order Date of: 06/19/2023. R32's face sheet documents diagnosis including: Cerebral Infarction, Dysphagia following Cerebral Infarction, Aphasia and Hemiplegia unspecified affecting right dominant side. R32's Order Summary Report dated 08/02/23 documents: Regular diet - Mechanical soft texture with an order date of 07/10/23. R33's face sheet documents diagnosis including: Metabolic Encephalopathy, Other Symptoms and Signs Involving the Nervous System, and Anxiety Disorder. R33's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular diet: Mechanical soft texture with an order date of 07/10/2023. R237's face sheet documents diagnosis including: Dementia, severe with other Behavioral Disturbance, Unspecified Intestinal Obstruction, and Simple Chronic Bronchitis. R237's Dietary profile dated 07/26/23 documents: chewing problems. R237's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular diet: Mechanical soft texture with an order date of 07/26/23.

Based on interview and record review the facility failed to provide adequate staff to meet the care needs of the residents. This has the potential to affect all 34 residents residing at the facility. Findings Include: The Resident Census and Conditions of Residents dated 7/31/23 documents there are 34 residents residing at the facility. This same form documents 17 residents require assist of one or two staff for bathing and 17 residents are dependent on staff for bathing, 34 residents require assist of one or two staff for dressing, 33 residents require assist of one or two staff and one resident is dependent on staff for transferring, 34 residents require assist of one or two staff for toileting, and 33 residents require assist of one or two staff for eating, with one resident documented as dependent on staff for eating. The Midnight Census reports provided to this surveyor on 8/7/23 by V1 (Administrator) document, three residents (R1, R13, R26) require a mechanical lift to transfer and all 34 residents residing at the facility are incontinent and require assist of staff for showers. The facility CNA (Certified Nursing Assistant) and hall monitor schedule dated July 2023 documents the following: 7/2, 7/13, 7/20, 7/23, 7/29, and 7/30/23- two CNA's- 6 AM to 6 PM, 7/14/23- two CNA's-6 AM to 12 PM and one CNA-12 PM to 6 PM, 7/17 and 7/28/23- two CNA's - 12 PM to 6 PM, 7/24/23- one CNA - 6 AM to 6 PM, 7/31/23- two CNA's from 12 PM to 6 PM, 7/4, 7/9, 7/10, 7/16, 7/17/23 - one CNA and a hall monitor (HM)- 6 PM to 6 AM, 7/5, 7/7, 7/11, 7/12, 7/26, 7/27/23- two CNA's - 6 PM to 6 AM, 7/6/23 one CNA - 6 PM to 6 AM 7/8/23- one CNA and a hall monitor from 12 AM to 6 AM. On 8/2/23 at 1:33 PM, V15 (Certified Nursing Assistant/CNA) stated they don't always have enough staff to provide residents with the care they need. V15 stated on days they are fully staffed the residents get the care they need. V15 stated the facility administration said fully staffed is three CNA's. On 8/2/23 at 9:40 AM, V8 (CNA) stated sometimes she didn't know if she was going to have help while working. V8 stated they normally have three CNA's working on each shift unless someone calls in, then they work with just two. When asked if they were able to provide care with two CNA's, V8 stated, I don't think so. When asked what care was not able to be provided, V8 stated, incontinence care every two hours. V8 stated they have four people who require a mechanical lift for transfers. When asked if she has ever worked as the only CNA on a shift, V8 stated she had. V8 stated she tried to do her best and get to everyone when that happened. When asked if it was safe working with just one or two CNA's, V8 stated, No. V8 stated if they have to assist someone who requires a two person assist then there is no one to answer the call lights and there are residents who wander out the doors and they aren't able to monitor them to ensure they don't leave. V8 stated the alarm system doesn't always work the way it should. When asked if they have had residents wander out of the building, V8 stated, Yes, R17. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated they were short staffed all the time. V4 stated on 7/24/23 there was only her and one CNA working on day shift (6 AM- 6 PM). V4 stated on 7/23/23 there was only one CNA working but she came in and worked as a CNA for them. V4 stated on 7/31/23 she had two CNA's, but one only worked until noon, someone came in and covered until 3 but she worked for 3 1/2 hours on 7/31/23 with only one CNA. When asked what care doesn't get provided when they are short staffed, V4 stated, showers, bed checks, ADL's (activities of daily living). V4 stated, They just aren't getting the proper care. On 8/2/23 at 1:09 PM, V14 (LPN) stated staffing was hit or miss. V14 stated some shifts are staffed really well and then the next day they may have a couple of call ins. V14 stated she had worked with just one CNA before. When asked if everyone was provided with necessary care, V14 stated they were but it was not as much as she would have preferred. When asked if residents were given showers, V14 stated showers weren't done on that shift. On 8/3/2023 at 4:05 PM, V17 (CNA) stated he had worked with a hall monitor and a nurse before. V17 stated when that happens, they do the best they can. When asked what care doesn't get provided if he is working with a nurse and a hall monitor, V17 stated, I can't do the bed checks like I should. V17 stated he tries to do a minimum of three bed checks but when he is working with just a hall monitor and nurse, he does good to do two bed checks. The schedule documents V17 works 12 hour shifts. On 8/2/23 at 1:56 PM, when asked if they had enough staff to meet the needs of the residents, V2 (Director of Nurses/DON) stated she was new to long term care (LTC). V2 stated she started on 1/30/23. V2 stated some days they have enough staff and some days it is a struggle. This surveyor reviewed with V2 there were days they only had one CNA working and V2 stated, Yes. When asked if they were able to provide care and keep the residents safe, V2 stated, I am not sure how to answer that question. V2 stated, I am new, and I have been told that is the way it always is in LTC and so we make do. On 8/2/23 at 3:35 PM, V1 (Administrator) stated they have enough staff to meet the needs of the residents. When asked if two staff (one licensed and one certified) could meet the needs of the residents, V1 stated, Well, I try not to have two staff working. V1 stated she always has a hall monitor working if they only have one CNA working. This surveyor reviewed with V1 the interviews with staff saying they worked with just one CNA, V1 stated, Well, that is not what I want. When asked if one nurse and one CNA working would be able to meet the needs of the residents, V1 stated, it would depend on the residents in the building, the time of day, and what was needed for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment free of excessive flies. This has the potential to affect all 34 residents residing in the facility. Findings include: On 7/31/2023, at 10:00 AM, 4 flies were observed in R27's room. On 8/01/2023, at 11:30 AM, 3 flies were observed in R33's room. On 07/31/23 at 9:15 AM, three flies were flying around R31's room periodically trying to land on him with him swatting them away. At that time R31 stated the flies are bad. R31's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 13 indicating cognitively intact. On 07/31/23 at 12:30 PM, R29 had two fly strips in her room, one with 5 dead flies and one with 7 dead flies on it with two more flies flying around the room. At that time R29 stated, there are a lot of flies in here. R29's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 07 indicating severely impaired. On 07/31/23 at 12:30 PM, the air conditioning (AC) unit in R9's room had a one inch gap under the AC unit and a 0.5 inch gap under the AC unit's mounting side panel. There were 3 flies flying around his room. R9 was not in the room at that time. On 08/01/23 at 12:20 PM R9 stated, there are a lot of flies here, while sitting in the dining room. On 07/31/23 at 10:15 AM, R8 stated she does not go to the dining room at times due to there being too many flies present. R8's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/01/23 at 12:18 PM, R18 was trying to sleep when a fly kept landing on her arm, and she kept swatting at it. Finally, the fly left her arm and landed on her food that was left from lunch. On 08/01/23 at 3:30 PM R18 stated, these flies are horrible, I was trying to sleep because I wasn't feeling good, and they kept landing on me. R18's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/02/23 at 7:45 AM there was a fly on R27's food while he was eating in the dining room. After this R27 did pick up his plate and go eat on the couch on the other side of the dining room. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/02/23 at 12:30 PM R23 was laying in his bed watching TV with two flies repetitiously landing on him and he kept swatting them away. At that time R23 stated, these flies are bad in here. R23's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/02/23 at 12:15 PM, R32 had a fly walking on the rim and inside of her milk glass while sitting in the dining room. R32 did not say anything about the fly she just stared past it. R32's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/02/23 at 12:15 PM, R237 was in the dining room and had a fly flying around her, landing on her and her food. R237's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/01/23 at 11:45 AM, V11 (transportation/appointments) stated, there are flies in here but that happens with the doors always being opened with residents going outside and coming back in. On 08/02/23 at 1:10 PM, V1 (Administrator) stated, there are flies, but it is just that time of the year. Resident council minutes dated 07/14/23 document under New Business: under the category Maintenance flies. No additional information was provided. The facility policy titled. Pest Control dated 2021 documents: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The Resident Census and Condition of Residents form dated 07/31/23 documents there are currently 34 residents residing at the facility.

Based on interview and record review, the facility failed to ensure a resident received appropriate treatment and services for enteral feeding upon admission for 1 (R3) of 2 residents reviewed for tube feeding management in a sample of 4. Findings include: R3's face sheet documented an admission date of 7/1/22 and diagnoses including: encounter for surgical aftercare following surgery on the digestive system, partial intestinal obstruction, dysphasia, muscle weakness, bariatric surgery, gastrostomy status. R3's 7/1/22 hospital discharge packet documented an order for Peptamen 1.5 with Prebio continuous tube feeding at 55 ml/ hr (milliliters per hour) via J-Tube (jejunostomy tube). R3's Physician Order Sheet (POS) documented a 7/3/22 at 6:00 AM order for .Enteral Feed Order every shift 55 ml/ hr per enteral pump per J tube . R3's Medication Administration Record (MAR) documented R3 did not receive any enteral feeding on 7/1/22 or 7/2/22. On 1/13/23 at 8:01 AM, V3 (Registered Nurse/RN) said she was the nurse who completed R3's admission orders on 7/1/22. V3 said R3 was alert and oriented at the time of R3's admission to the facility. V3 said during R3's admission assessment, R3 said she was capable of eating and had a past surgical history of gastric bypass. V3 said R3 said her (R3's) J-Tube was not used and had been placed as a precaution. V3 said she did see the order for continuous J-Tube feeding documented on R3's admission orders. V3 said she tried to start administering R3's continuous feeding at the time of R3's admission but the facility's tube feeding pump was not working. V3 said she then administered bolus feedings to R3. V3 said she is unsure why she did not document any tube feeding for R3. On 1/12/23 at 10:10 AM, V4 (Licensed Practical Nurse/LPN) said when a resident is admitted to the facility the nurse admitting them will review and put the admitting orders in the resident's Electronic Medical Record (EMR). V4 said if she questioned an order, she would call the resident's medical provider for clarification. V4 said if a resident had an order for continuous tube feeding and the tube feeding pump was not working, she would call the resident's medical provider for an order change until the tube feeding pump could arrive to the facility. On 1/11/23 at 3:09 PM, V2 (Regional Director of Operations) said she expected staff to follow physician orders as written. V2 said she expected staff to place resident orders in the EMR upon the resident's admission to the facility. On 1/12/23 at 10:25 AM V6 (Nurse Practitioner) said she expected facility staff to follow physician orders. The facility's December 2018 Enteral Tube Medication Administration policy documented in part .The facility assures the safe and effective administration of enteral formulas . 1. The selection of the enteral formula, equipment, route of administration and rate of flow is determined by the physician .

Based on interview and record review the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 8 residents (R22) reviewed for comprehensive assessments in a sample of 29. Findings include: R22's admission Record documented, admission date of 7/30/2022 and initial admission date of 10/8/2022. Diagnosis included, Pressure ulcer of right elbow, stage 4 effective and Pressure Ulcer of sacral region, stage 4. R22's Minimum Data Set (MDS) dated on 7/18/2022 documented in part, section c. Brief Interview for Mental Status (BIMS) a score of 00 which indicates severe cognitive impairment. The Section G. for Functional Activities of Daily Living (ADL) assessment documented resident required extensive assistance of 2 staff for bed mobility, transferring, and toileting. On Section M. skin assessment resident was at risk for pressure ulcer development and no pressure ulcers or other skin issues were present. R22's Initial Skin Alteration Record dated on 7/18/2022 documented in part, wound to right elbow measuring 2 x 2 centimeter non blanchable ulcer with some slough and open. Stage 2, pressure injury, wound bed pink, slough (yellow/stringy/gray). Comments: Resident being sent out to hospital for Covid related symptoms. Signed by V7 (previous Director of Nurses). R22's Hospital Records dated on 7/30/2022 documented in part, Discharge Summery, Physical Exam: Skin: right elbow and sacrococcygeal area pressure injury pictures noted in Electronic Medical Record (EMR). R22's Physician Orders Sheet (POS) dated on 7/30/2022 documented in part, Barrier cream to buttocks as needed for minor skin irritation due to episodes of bowel and bladder incontinence. Every 6 hours for excoriation. R22's MDS dated on 8/3/2022 documented, on section G. totally dependent for bed mobility, and transfers. Section M. Skin assessment Documented 1 unstageable pressure ulcer had acquired in the hospital. Section M did not document any other skin issues were present. On 9/8/2022 at 12:20 PM, V7 Previous Director of Nurses (DON) stated, she assessed (R22)'s right elbow on 7/18/2022 before he was sent to the hospital for Covid symptoms, and she may have documented a stage 2 pressure ulcer in error and was not sure what the stage of it was, but it could have been unstageable or a stage 3. V7 also stated, (R22) was very sick and sent out to the hospital for Covid symptoms on the same day of 7/18/2022. On 9/8/2022 at 12:30 PM, V8 MDS Nurse stated, she completed (R22)'s MDS assessments on 7/18/2022 and 8/3/2022. V8 stated, she gathers assessment information by speaking with staff, reviewing notes, physician orders, and hospital records. V8 stated, she was not aware of (R22)'s right elbow pressure ulcer findings on 7/18/2022 by (V7) and thought the unstageable right elbow pressure ulcer was originated from the hospital stay. V8 also stated, she was made aware of the error and was currently completing a correction MDS for the 7/18/2022 MDS assessment. On 09/09/22 at 7:41 AM, V2 Regional Nurse, stated, she agreed (R22)'s MDS inaccurately coded the 7/18/2022 assessment for skin and should have been documented. V2 stated, she would expect the MDS nurse to accurately code the MDS. According to CMS.gov resource dated copywrite 2017, entitled, Medicare-Required SNF PPS Assessments, documented in part, The MDS 3.0 is a core set of elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The screening, clinical, and functional status items in the MDS 3.0 standardize communication about resident problems and conditions. The MDS 3.0 contains items that reflect the acuteness of the resident's condition, including diagnoses, treatments, and functional status. MDS 3.0 assessment data is personal information SNFs must collect and keep confidential by Federal law Conducting the Assessment: Each assessment must include all of these: - Accurately reflect the resident's status. -Be conducted or coordinated by a registered nurse with the appropriate participation of other health care professionals. -Include direct observation as well as communication with the resident and direct care staff on all shifts. -Cover the Observation (Look Back) Period, which is the time period when the resident's condition is captured by the MDS assessment. Do not code anything on the MDS that did not occur during the Observation Period.

Based on observation, interview and record review the facility failed to maintain adequate levels of quaternary sanitizer used to sanitize food contact surfaces and stationary equipment. This has the potential to affect all 25 residents living in the facility. The Findings Include: On 9/6/22 at 9:30 AM, during the initial tour of the kitchen it was observed that there was a bucket of sanitizing solution setting in the sink with a rag in it. V3 (Cook) stated that this is a quaternary ammonium solution that is used to wipe down surfaces and stationary equipment. V3 checked the solution for the sanitizer level in the bucket with a hydrion test strip to detect quaternary levels. V3 stated the level was below manufacturer suggested level of 200 PPM (parts per million) likely due to being setting out for a few hours. V3 stated at this time she would dump out this bucket of solution and make a new one. On 9/7/22 at 11:15 AM, V3 checked the sanitizer level in the bucket used for sanitizing stationary surfaces and again it was found to be below suggested the manufacturer recommendations of 200 PPM for Quaternary Ammonium and a new solution was made using the dispenser and the level was within recommended level. The resident census and conditions of residents dated 9/6/22 documents 25 residents residing in the facility.