**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegations of verbal abuse were reported immediately to the Administrator of the facility and in a timely manner to the State Agency for 1 of 3 residents (R2) reviewed for verbal abuse in a sample of 5. Findings Include: R2's Face Sheet, original admission date of 11/21/22, documented R2 has diagnoses of but not limited to cerebral infarction, type II diabetes mellitus, major depressive disorder, and hypertension (HTN). R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact, with a Brief Interview for Mental Status (BIMS) of 13 out of 15, and requires some assistance with her activities of daily living (ADLs). On 06/24/25 at 9:25 AM, R2 said V4, Social Service Director (SSD), yelled at her and she didn't want to talk about it. She said she didn't report it to anyone because what was the use in telling, it wouldn't have accomplished anything, no one would have done anything, they never do. On 06/24/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), said, On Wednesday (06/18/25) of last week, (R2) was asking (V4) about going to the assisted living facility, and (V4) started yelling at (R2) and was going through (R2's) drawers and slamming the drawers after going through them. V6 said when she was done talking with R2, V4 even slammed R2's door when she walked out of R2's room. V6 said she didn't report the incident to anyone because there is no one to report it to. On 06/24/25 at 9:15 AM, V7, CNA, said she has heard and seen V4 yelling at R2. She said she was standing out in the hallway, and she saw V4 going through R2's drawers, and when she was done going through them, she slammed the drawer shut. V7 said she was yelling at R2 something about she (V4) just couldn't make the assisted living take her. She said she didn't report it to anyone because nothing would happen if she did report it. On 06/24/25 at 9:45 AM, V8, CNA, said she was here at the facility last week when the incident with V4 and R2 happened. She said she was standing out in the hallway and V4 was in the room yelling at R2. She said she doesn't remember specifically what V4 was saying to R2, but she was yelling at R2. She said she also saw V4 slam shut the dresser drawer, she was tossing things around and slammed the door when she left the room. V8 said she didn't report it because it doesn't do any good, nothing matters to management, and there is no one higher to go to. On 06/25/25 at 1:40 PM, V1, Administrator, said he would expect to be notified immediately if there is an allegation of abuse made. He said they have had multiple in-services since he started here at this facility, and he has made it clear they are to notify him directly with any abuse allegation. He said he always uses this scenario if there are three staff members standing at the nurse's station and they have a resident say someone was mean to them, yelling at them, or rough with them, then he would expect three phone calls. He said he tells them not to have the mentality of 'well I reported it to the nurse, or the other nurse will report it', they should be reporting it. On 06/24/25 at 2:00 PM, R2's Electronic Medical Record (EMR) was reviewed and there was no documentation regarding the alleged verbal abuse that happened on 06/18/25. R2's Illinois Department of Public Health (IDPH) investigation was reviewed and documented the following: Initial Report- June 24th, 2025: On 6/24/25 at approximately 11am, it was reported by an IDPH Surveyor that an allegation of verbal abuse was made by resident R2 regarding V4 (SSD). The investigation has been initiated, and V4 (SSD) has been suspended pending the outcome of the investigation. MD (Medical Doctor) and the local Police Department (Reference #), Ombudsman, and Responsible party are being notified.The final report to follow once the investigation is complete. The facility's Abuse, Prevention, and Prohibition Policy, date approved: 03/2025 documented, Abuse Prohibition Program The facility's abuse prohibition program includes the following sever components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response: The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. It also documented Investigation: Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. It further documented Initiate investigation including initial reporting to all required agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide showers for 1 of 3 residents (R1) reviewed for showers, in the sample of 8. Findings include: 1. R1's Face Sheet, dated 4/29/2025, documents R1 has a need for assistance with personal care. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires substantial/maximal assistance with showers/bathing. R1's Care Plan, dated 3/17/2025, documents R1 has ADL self care performance deficit and requires one staff member for bathing. On 4/24/2025 at 12:27 PM, V13, R1's daughter, stated, (R1) has ESBL (Extended-Spectrum Beta-Lactamase) in her urine. I get why she was on isolation, but I'm upset because the CNAs are telling her they can't give her an actual shower because of it. She is in a room by herself, with a shower attached. They told her she can't use the shower chair in case she peed. The shower chairs can be cleaned. They gave her a bed bath, and not even a good one. I've had to tell them to rinse the soap off afterwards. (R1) is continent most of the time, but she wears a (adult brief) just in case she dribbles. On 4/24/2025 at 5:45 PM, R1 stated she had been in the hospital recently. R1 stated the staff at the hospital told her to poop and pee on herself instead of taking her to bathroom or giving her a bed pan. R1 stated the hospital only gave her bed baths there, so when she got back to the facility she wanted a real shower, but was told she couldn't use the shower chair. On 4/25/2025 at 9:50 AM, V5, Certified Nursing Assistant (CNA), stated she was not aware of R1 not getting her showers. V5 stated R1 had a shower in her private room when she was in isolation, and the staff could have used a shower chair and cleaned it afterwards. On 4/28/2025 at 2:15 PM, V1 stated, I expect staff to re-approach a resident if they refuse the first time or find out why they are refusing. We would switch shower days/times if they have a different preference than when they are scheduled. There is a procedure for cleaning shower chairs. They are made out of PVC (PVC stands for polyvinyl chloride, a versatile and widely used synthetic polymer. It's known for its durability, affordability, and resistance to chemicals, making it suitable for various applications, including construction, medical devices, and packaging) material so that they can be cleaned. On 4/28/2025 at 2:30 PM, V2, Director of Nursing (DON), stated R1 had ESBL in her urine, but had a room with a shower in it. V1 stated the shower chair could be cleaned, and should be cleaned in between every resident either way. The Facility's Grievance Form, dated 4/24/2025, documents the date of occurrence was 4/23/2025, and R1's shower was not given due to isolation, and R1 was given a bed bath instead. The Facility's provided shower sheets for R1 for the Month of April. There were only 4 shower sheets provided dated 3/31/2025, 4/7/2025, 4/23/2025 and 4/25/2025. R1's shower sheet, dated 4/23/2025, documents R1 was given a bed bath. The facility was unable to produce any shower refusal documentation for R1. The Facility's Shower Refusal Documentation Form was reviewed and documents a place for the resident's name, date of refusal, CNA name, times attempted, and reason for refusal. The Facility's Activity's of Daily Living Policy documents, This facility provides each resident with care, treatment and services according to the resident's individualized care plan. Based on individual resident's comprehensive assessment, facility staff will ensure that each resident's clinical condition demonstrates that the decline was unavoidable, including: Bathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to to provide restorative services for 1 of 3 residents (R3) reviewed for nursing programs in a sample of 5. Findings include: R3's admission Record documents R3 was admitted [DATE] with diagnosis of Cerebral Infarction due to Embolism of Right Anterior Artery. R3's Care Plan, dated 2/3/25, documents the resident has an ADL (activity of daily living) Self Care Performance Deficit Impaired balance. RESTORATIVE PROGRAM - Bed Mobility: Staff will assist and encourage R3 to do as much as she can, requires 2 staff to reposition in bed. [RNA,CNA,ResN] (restorative nurse's aide, certified nurse's assistant, restorative nurse) ? Requires documentation. RESTORATIVE PROGRAM - Grooming: R3 requires verbal cueing, Staff will hand R3 a washcloth to bring to face to wash face and will assist with brushing hair. R3's MDS, dated [DATE], documents R3 is cognitively impaired and requires substantial/maximal assist with adls. R3's Electronic Record does not document restorative programs performed. R3's Physical Therapy (PT) Discharge (D/C) Summary, dated 1/28/2025, documents R3 was discharged from PT 2/18/2025. It also documents Discharge instructions: The patient will remain in LTC (Long Term Care) setting on RNP (Restorative Nursing Program) for PROM (Passive Range of Motion) and transfers. Restorative program established/trained = Restorative Range of Motion program, Restorative transfer. R3's Occupational Therapy Discharge summary, dated [DATE], documents R3 was discharged from Occupational Therapy on 2/27/2025. It also documents discharge instructions: Patient d/c'd to this facility. Would benefit from continued therapy services when insurance allows. Restorative Program established/trained = Restorative program on Range of Motion. R3's Care Plan and tasks do not document these restorative programs. On 3/12/2025 at 1:40 PM, V8, CNA, stated showers are not a priority. V8 stated when they are staffed they can get them done. V8 stated because they are short on staff everything can't get done. V8 stated they clean the private areas and clean the residents when they are incontinent or go to the toilet. V8 stated they prioritize, and when they are short, restorative and showers are not priority when you have the hall alone. V8 stated R3 doesn't have any restorative programs. V8 stated R3 was getting therapy. On 3/12/2025 at 2:19 PM, V7, CNA, stated the facility does have a staffing problem. V7 stated when they are short, they have to prioritize. V7 stated showers and restorative are not priority. V7 stated sometimes they don't get done. On 3/12/2025 at 2:05 PM, V6, CNA, stated she works the unit. V6 stated, For the most part, we are staffed on the unit, because we got a staffing tag. At times, there is 1 CNA. The residents are always moving, and require being always watched, and showers are not done. You can't leave the residents unattended for that long. On 3/13/2025 at 1:00 PM, V3, Therapy Director, stated, (R3) came to the facility from hospital with a recent stroke. (R3) initially recieved all 3 disciplines. (R3) is currently reciving speech therapy. (R3) has been discharged from therapy. Upon discharge, a restorative program was put in place, and the nursing staff was trained. The restorative program is to be completed by the nursing department. On 3/13/2025 at 2:42 PM, V11, CNA, stated they don't have restorative aides. V11 stated the CNAs do the programs and document it in the computer when completed. On 3/13/2025 at 3:00 PM, V12, CNA, stated they do the restorative programs. V12 stated they document it in the computer. On 3/13/2025 at 3:10 PM, V10, CNA stated R3 is on therapy and does not get therapy. On 3/13/2025 at 3:30 PM, V2, Director of Nursing stated they currently do not have a Restorative Nurse or aides. V2 stated the duties are split up, and they are working at getting it taken care of. The facility's Restorative Nursing Policy and Procedure, not dated, documents it is the policy of this facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise and provide showers as scheduled for 4 of 4 (R1, R2, R3, R5) residents in a sample of 6. Findings include: The facility's Resident Council Minutes, dated 3/5/205, documents, New Business/Department Discussions: Still short staffed, call lights aren't being answered. There is not enough in house staff, too agency workers that aren't doing their jobs correctly. Administration: Too short staffed, today was shower day but (R2) had to have a bed bath because there wasn't enough staff to care for everyone and still get showers done. 1. R1's Care Plan, dated 5/14/2021, documents R1 has an ADL (activity of daily living) Self Care Performance Deficit. It also documents BATHING: R1 requires supervision with bathing. Staff provide supervision as needed. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. On 3/12/2025 at 1:20 PM, R1 stated he is the president of resident council. R1 stated lack of staff is an ongoing concern. R1 stated this concern is addressed in the resident council meeting. R1 stated they voice these concerns, but feel they are not being heard. R1 stated at times, there is 1 nurse for the entire building. R1 stated the CNAs (Certified Nurse's Assistants) are short as well. R1 stated, Showers are not being completed. It's not enough. You must have staff to do these things and we don't. R1 stated he gets his showers because he does them himself. R1 stated he tells the staff and goes in the shower alone. R1 stated he is not supervised by anyone but himself. R1 stated they tell him if he goes in on his own he can get a shower, because they don't have enough staff to supervise him. R1 stated the staff will tell them that they can't do something because they don't have enough staff. 2. R2's Care Plan, dated 7/7/2021, documents Care/ADL Preferences Staff will honor my preferences while caring for me. I prefer a shower 3 x week in the mornings. It also documents 1/18/2024 R2 has an ADL Self Care Performance Deficit r/t (related to) obesity, respiratory failure, and heart failure. BATHING: the resident requires 1 staff participation with bathing. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires substantial/maximal assistance with bathe/showers. On 3/12/2025 at 11:30 AM, R2 stated she is scheduled to get a shower 3 times a week. R2 stated she does not always get a shower. R2 stated because they have 1 staff on the hall they can't do the shower, and if she wants to be cleaned, she would have to get a bed bath. R2 stated she wants a shower. R2 stated she is a large woman and requires the mechanical lift to get up and get in the shower. R2 stated when there is only 1 staff, they can't use the mechanical lift. R2 stated if there is one person she does not get cleaned well, and its rushed. R2 stated it takes a long time to perform the task. When asked how she knows it's because of staffing? R2 stated the staff tells her this is the reason. 3. R3's admission Record documents R3 was admitted [DATE] with diagnosis of Cerebral Infarction due to Embolism of Right Anterior Artery. R3's Care Plan, dated 2/3/2025, documents the resident has an ADL Self Care Performance Deficit Impaired balance. It continues o BATHING: the resident requires X1 staff participation with bathing. Date Initiated: 01/28/2025 and Revision on: 02/03/2025. R3's MDS, dated [DATE], documents R3 is cognitively impaired and requires substantial/maximal assist with bathing. R3's Shower schedule was Monday and Thursday night shift. On 3/14/2025, R3's Electronic Health Record (EHR) documents Shower/Bath documents No data found for 30 days back. On 3/14/2025 at 10:30 AM, the facility provided R3's Nurse Skin Inspection report, dated 2/27/2025. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/3/2025, 2/6/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/20/2025, 2/24/2025, 3/3/2025, 3/6/2025, and 3/10/2025. On 3/12/2025 at 11:21 AM, when asked if she was receiving showers? R3 stated, No. When asked if she was getting a bath? R3 stated, No. On 3/13/2025 at 3:10 PM, V9, CNA, stated R3 is alert and understands what is being said. R3 has difficulty with words. V9 stated R3 can answer yes and no questions appropriately. 4. R5's Care Plan, dated 2/14/2024, documents the resident has an ADL Self Care Performance Deficit. It continues BATHING: the resident is totally dependent on staff to provide a bath Bi-weekly and as necessary. R5's MDS, dated [DATE], documents R5 is cognitively impaired and dependent on staff for bathing. The facility provided the facility's shower schedule. R3 was scheduled for showers on Tuesday and Saturday. On 3/14/2025 at 10:30 AM, the facility provided R5's Nurse Skin Inspection report, dated 3/1/2025, 3/4/2025, 3/8/2025, and 3/11/2025. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/1/2025, 2/4/2025, 2/8/2025, 2/11/2025, 2/18/2025, 2/22/2025, and 2/25/2025. On 3/12/2025 at 10:00 AM, V2, Director of Nursing/DON, stated they have some staffing challenges and are using agency to help fill in. On 3/12/2025 at 1:40 PM V8, CNA, stated showers are not a priority. V8 stated when they are staffed, they can get them done. V8 stated because they are short on staff, everything can't get done. V8 stated they clean the private areas and clean the residents when they are incontinent or go to the toilet. V8 stated they prioritize, and when they are short, restorative and showers are not priority when you have the hall alone. On 3/12/2025 at 2:19 PM, V7, CNA, stated the facility does have a staffing problem. V7 stated when they are short. they have to prioritize. V7 stated showers and restorative are not priority. V7 stated sometimes they don't get done. On 3/12/2025 at 2:05 PM, V6, CNA, stated she works the unit. V6 stated, For the most part, we are staffed on the unit because we got a staffing tag. At times, is 1 CNA. The residents are always moving and require being always watched, and showers are not done. You can't leave the residents unattended for that long. The showers are documented on the shower sheet, identified the nursing skin sheet, and in the computer. On 3/13/2025 at 3:30 PM, V2, Director of Nursing, stated they do not have a specific policy for showers. V2 stated she was aware of the challenges in the facility, and is working to correct them. The facility's Activities of Daily Living, not dated, documents this facility provides each resident with care, treatment, and services according to the resident's individualized care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs for 1 of 3 residents reviewed for staffing in a sample of 6. This has the potential to affect all residents living in the facility. Findings include: The facility's Resident Council Minutes, dated 3/5/205, documents, New Business/Department Discussions: Still short staffed, call lights aren't being answered There is not enough in house staff, too agency workers that aren't doing their jobs correctly. Administration: Too short staffed, today was shower day but (R2) had to have a bed bath because there wasn't enough staff to care for everyone and still get showers done. 1. R1's Care Plan, dated 5/14/2021, documents R1 has an ADL (activity of daily living) Self Care Performance Deficit. It also documents BATHING: R1 requires supervision with bathing. Staff provide supervision as needed. R1's Minimum Data Set, dated [DATE], documents R1 is cognitively intact. On 3/12/2025 at 1:20 PM, R1 stated he is the president of resident council. R1 stated lack of staff is an ongoing concern. R1 stated this concern is addressed in the resident council meeting. R1 stated they voice these concerns but feel they are not being heard. R1 stated at times there is 1 nurse for the entire building. R1 stated the CNAs (Certified Nurse's Assistant) are short as well. R1 stated, Showers are not being completed. It's not enough. You must have staff to do these things and we don't. R1 stated he gets his showers because he does them himself. R1 stated he tells the staff and goes in the shower alone. R1 stated he is not supervised by anyone but himself. R1 stated they tell him if he goes in on his own because they don't have enough staff to supervise him. R1 stated the staff will tell them that they can't do something because they don't have enough staff. 2. R2's Care Plan, dated 7/7/2021, documents Care/ADL Preferences Staff will honor my preferences while caring for me. I prefer a shower 3 x week in the mornings. It also documents 1/18/2024 R2 has an ADL Self Care Performance Deficit r/t (related to) obesity, respiratory failure, and heart failure. BATHING: the resident requires 1 staff participation with bathing. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires substantial/maximal assistance with bathe/showers. On 3/12/2025 at 11:30 AM, R2 stated she is scheduled to get a shower 3 times a week. R2 stated she does not always get a shower. R2 stated because they have 1 staff on the hall they can't do the shower, and if she wants to be cleaned, she would have to get a bed bath. R2 stated she wants a shower. R2 stated she is a large woman and requires the mechanical lift to get up and get in the shower. R2 stated when there is only 1 staff, they can't use the mechanical lift. R2 stated if there is one person, she does not get cleaned well, and it's rushed. R2 stated it takes a long time to perform the task. When asked how she knows it's because of staffing? R2 stated the staff tells her this is the reason. 3. R3's admission Record documents R3 was admitted [DATE] with diagnosis of Cerebral Infarction due to Embolism of Right Anterior Artery. R3's Care Plan, dated 2/3/2025, documents the resident has an ADL Self Care Performance Deficit Impaired balance. It continues BATHING: the resident requires X1 staff participation with bathing. RESTORATIVE PROGRAM - Bed Mobility: Staff will assist and encourage R3 to do as much as she can, requires 2 staff to reposition in bed. [RNA,CNA,ResN] (restorative nurse's aide, certified nurse's assistant, restorative nurse) ? Requires documentation. RESTORATIVE PROGRAM - Grooming: R3 requires verbal cueing, Staff will hand (R3) a washcloth to bring to face to wash face and will assist with brushing hair. R3's MDS, dated [DATE], documents R3 is cognitively impaired and requires substantial/maximal assist with ADLs. R3's Shower schedule was Monday and Thursday night shift. On 3/14/2025 R3's Electronic Health Record (EHR) documents Shower/Bath documents, No data found for 30 days back. R3's Electronic Record does not document restorative programs performed. On 3/14/2025 at 10:30 AM, the facility provided R3's Nurse Skin Inspection report, dated 2/27/2025. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/3/2025, 2/6/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/20/2025, 2/24/2025, 3/3/2025, 3/6/2025, and 3/10/2025. R3's Physical Therapy (PT) Discharge (D/C) Summary, dated 1/28/2025, documents R3 was discharged from PT 2/18/2025. It also documents, Discharge instructions: The patient will remain in LTC (Long Term Care) setting on RNP (Restorative Nursing Program) for PROM (Passive Range of Motion) and transfers. Restorative program established/trained = Restorative Range of Motion program, Restorative transfer. R3's Occupational Therapy Discharge summary, dated [DATE], documents R3 was discharged from Occupational Therapy on 2/27/2025. It also documents discharge instructions: Patient d/c'd to this facility. Would benefit from continued therapy services when insurance allows. Restorative Program established/trained = Restorative program on Range of Motion. R3's Care Plan and tasks do not document this restorative program. On 3/12/2025 at 11:21 AM, when asked if she was receiving showers? R3 stated, No. When asked if she was getting a bath? R3 stated, No. 4. R5's Care Plan, dated 2/14/2024, documents the resident has an ADL Self Care Performance Deficit. It continues BATHING: the resident is totally dependent on staff to provide a bath Bi-weekly and as necessary. R5's MDS, dated [DATE], documents R5 is cognitively impaired and dependent on staff for bathing. On 3/14/2025 at 10:30 AM, the facility provided R5's Nurse Skin Inspection report, dated 3/1/2025, 3/4/2025, 3/8/2025, and 3/11/2025. The facility provided the facility's shower schedule. R3 was scheduled for showers on Tuesday and Saturday. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/1/2025, 2/4/2025, 2/8/2025, 2/11/2025, 2/18/2025, 2/22/2025, and 2/25/2025. On 3/12/2025 at 10:00 AM, V2, Director of Nursing/DON, stated they have some staffing challenges and are using agency to help fill in. On 3/12/2025 at 1:40 PM, V8, CNA, stated showers are not a priority. V8 stated when they are staffed ,they can get them done. V8 stated because they are short on staff, everything can't get done. V8 stated they clean the private areas and clean the residents when they are incontinent or go to the toilet. V8 stated they prioritize, and when they are short, restorative and showers are not priority when you have the hall alone. V8 stated the showers are documented on the shower sheets, identified the Nurse Skin Inspection report as the shower sheet, and in the computer. On 3/12/2025 at 2:19 PM, V7, CNA, stated the facility does have a staffing problem. V7 stated when they are short, they have to prioritize. V7 stated showers and restorative are not priority. V7 stated sometimes they don't get done. On 3/12/2025 at 2:05 PM, V6, CNA, stated she works the unit. V6 stated, For the most part, we are staffed on the unit because we got a staffing tag. At times, there is 1 CNA. The residents are always moving, and require being always watched, and showers are not done. You can't leave the residents unattended for that long. On 3/13/2025 at 3:10 PM, V9, CNA, stated R3 is alert and understands what is being said. R3 has difficulty with words. V9 stated R3 can answer yes and no questions appropriately. The facility's Sufficient Nursing Staff policy, dated 12/2024, documents, Policy The facility's Sufficient Nursing Staff policy, dated 12/2024, documents There will be sufficient team members with appropriate competencies and skill set available in each unit to provide nursing and related services to the resident as planned by the interdisciplinary team based on resident's assessment(s) to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. Facility leadership will provide sufficient personnel on a 24 hour basis to provide nursing care to all residents in accordance with the residents' individual care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse from occurring for 2 of 2 residents (R2, R3) reviewed for abuse in the sample of 7. Findings include: 1.) R2's face sheet, print date of 2/19/25, documented R2 has diagnoses of Alzheimer's disease with early onset, dementia, major depressive disorder, encephalopathy, amnesia, restlessness and agitation, and personal history of traumatic brain injury. R2's MDS (Minimum Data Set), dated 12/16/24, documented R2 is severely cognitively impaired. R2's care plan, print date 2/19/25, documented R2 has the potential to become aggressive related to dementia diagnosis. R2's progress note, dated 2/8/25 at 6:21 PM, documented R2 is experiencing a change in condition. The change in condition the resident is currently experiencing is hit another resident in the common area. Writer called to the hall and informed writer that R2 had held another resident's right forearm down and hit her closed fist on the left cheek. The incident was witnessed by CNA (Certified Nurse Assistant). R3's face sheet, print date 2/19/25, documented R3 has diagnoses of intellectual disabilities, hypertension, chronic kidney disease, cataracts, and hyperlipidemia. R3's MDS, dated [DATE], documented R3 is severely cognitively impaired. R3's care plan, print date of 2/19/25, documented R3 has the potential to become aggressive related to intellectual disabilities and that R3 has been identified as a vulnerable person related to intellectual disabilities. R3's progress note, dated 2/8/25 at 6:20 PM, documented R3 is experiencing a change in condition. The change in condition the resident is currently experiencing is resident on resident, this resident was hit by another resident. Writer was called to 100 hall by CNA. CNA informed writer that resident was involved in resident on resident in the common area. Another resident held R3's right forearm down and with a closed fist, hit R3 on the left side of her face. Skin assessment done, no redness, no bruising noted. The facility's final investigation, dated 2/14/25, documented on 2/8/25 it was reported to the department that R2 and R3 were involved in an altercation. Staff observed R2 hold R3's right forearm and with a closed fist strike her left cheek. Staff immediately separated the residents. It continues, V9, CNA, reports that she was standing in 100 assisting a family member when another resident yelled (R2) just hit (R3) in the face. When I approached them to separate them, R2 was holding R3's right arm, R3 was holding the left side of her face and said, get him away from me. V9 stated, I notified the nurse to ask for assistance, redirected (R2) away from (R3), and my nurse instructed me to stay with R2 1:1 until R2 is transported to the hospital. 2.) R1's face sheet, print date of 2/19/25, documented R1 has diagnoses of chronic atrial fibrillation, congestive heart failure, diabetes, conduct disorder, dementia, brief psychotic disorder, chronic kidney disease, and hypertension. R1's MDS, dated [DATE], documented R1 is severely cognitively impaired. R1's care plan, print date of 2/19/25, documented R1 has the potential for aggression related to dementia diagnosis. R1's progress note, dated 2/11/25 at 11:46 AM, documented this resident is experiencing a change in condition. The change in condition the resident is currently experiencing is resident hit another resident on the hand and knocked him down. Resident hit another resident causing a skin tear to other resident's right hand. Resident placed on one on one immediately. R2's progress note, dated 2/11/25 at 11:32 AM, documented the resident is experiencing a change in condition. The change in condition the resident is currently experiencing is resident was hit on the hand by another resident. Nurse applied 2 steri-strips and a band-aid per NP (Nurse Practitioner) direction. The facility's initial report to IDPH (Illinois Department of Public Health), dated 2/11/25, documented R1 and R2 were involved in a resident-to-resident altercation. The residents were immediately separated and placed on increased supervision. Licensed Nurse performed a head-to-toe assessment noting a skin tear to the top of R2's hand. The MD (Medical Doctor), POA (Power of Attorney), Ombudsman, and the local police department have been notified. Witness statement, dated 2/11/25, by V5, CNA, documented at10 AM, I was assisting resident going to the bathroom. I heard a resident yell and a couple other residents yelling. I went to check, and I found (R1) on his knees leaning over (R2) saying I told you I was going to hit you, Resident told me He started stuff, so he hit him. (R1) got up and tried to pull (R2) up while dragging him. I asked the resident to let go and step away to distract him. Witness statement, dated 2/12/25, by V10, CNA, documented, around 9:50 stepped out to warm up coffee for (R1) when I came back another resident was on the floor and (R1) said 'I didn't want to have to hit him. I slapped him.' Resident had a wound to right hand when we looked over resident that he said he hit. On 2/19/25 at 12:10 PM, V5, CNA, stated she did not observe R1 hit R2 on 2/11/25, but she did observe R2 lying on the floor with R1 standing over R2. V5 stated she then observed a skin tear on R2's right hand. On 2/19/25 at 2:36 PM, V7, Regional Nurse, stated the altercations did occur between R1 and R2 and between R2 and R3. V7 stated the altercation between R1 and R2 was not witnessed, so the facility is unable to substantiate R2's skin tear was caused by R1. The facility's final investigation of the resident-to-resident abuse between R1 and R2, dated 2/20/25, documented following the investigation, based on interviews from staff, the facility is not able to determine a physical resident-to-resident altercation. Staff stated that (R2) was sitting on the floor, and it appeared that (R1) was attempting to pull him. Staff did report that (R1) was yelling I told you I was going to hit you, but this was not witnessed. (R2) did sustain a skin tear to his right hand, but based on the statements from staff the facility, cannot determine if the skin tear was a result of the fall, or an altercation between the two residents. The facility's Abuse, Prevention and Prohibition Policy, revision date of 1/24, documented, Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Abuse Prohibition Program: The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. It continues, Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abuse behaviors. The facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse. It continues, Resident-to-Resident Altercations: When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options. Residents will be referred for behavior management when indicated. Changes in room assignments and seating arrangements will be recommended as needed. The safety of other resident and employees of the facility is of primary concerns. Not every resident-to-resident altercation result in abuse. For example, infrequent arguments or disagreements that occur during the normal social interactions would not constitute abuse. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accident), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate ('willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. It continues, Definitions: Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and record review, the facility failed to notify law enforcement of an allegation of sexual assault for 1 of 1 resident (R2) reviewed for reporting abuse in a sample of 6. Findings include: Local law enforcement report, dated 1/5/2025, documented, On 01/05/2025 at approximately 0120 hours, I, (V12, officer at local police department), was on routine patrol when my dispatch advised me of a nurse from (Regional Hospital) was needing to speak with me in reference to a sexual assault report she had just recently taken. The nurse, (V13, Sexual Assault Nurse Examiner/SANE, Registered Nurse) RN, was transferred from dispatch to my cell phone. R2's Regional hospital record, dated 1/5/2025, V13, SANE RN, documented, Writer contacted (local police department) and spoke with officer (V12, officer at Local Police Department.) Writer reported what was happening to the officer and officer gave a phone number for writer or (regional law enforcement agency) to contact him. (Regional law enforcement agency) was contacted at 1:15 am. On 1/07/2025 at 10:20 AM, V5, Admissions Coordinator, stated she was the weekend manager on 1/4/2025, in the facility that day, and was talking with R2 to finish her re-admission paperwork. V5 stated R2 stated to her that she was sexually assaulted in a grocery store. V5 continued to state she made sure R2 was safe, she let R2's nurse know what she had said to her, and she immediately called the Director of Nurses, since the Administrator had just quit. The Director of Nurses did not pick up her phone, so she called V2, Assistant Director of Nurses. V2 told her to get the statements from the staff that were there. V5 continued to state R2 has been in and out of the hospital recently and she just got back from the hospital that week. On 1/07/2025 at 12:45 pm, V2, Assistant Director of Nurses, stated she did not call the police because she got busy with the investigation, and then she saw where the hospital notified them in the hospital paperwork, so she did not call the local police. The facility's policy, Abuse, Prevention and Prohibition Policy, dated 1/2024, documented, An employee and agent or any Covered Individual will make or cause a report to be made to law enforcement and the facility.

Based on interview and record review, the facility failed to notify the physician of abnormal blood sugars as ordered in 1 of 8 residents (R2), reviewed for pharmacy services in the sample of 8. Findings Include: R2's Medical Diagnosis Listing, undated, documents R2 has a diagnosis of Type 2 Diabetes Mellitus. R2's Physician Order Sheet documents the following order, dated 12/13/24 through 12/15/24, Novolin 70/30 Subcutaneous Suspension (70-30) 100 Units/ML (Milliliter). Inject as per sliding scale: if 80 - 100 = 7; 101 - 150 = 9; 151 - 200 = 11. Call MD (Medical Doctor) if blood sugar is greater than 200, subcutaneously in the morning. Inject as per sliding scale: if 80 - 100 = 7; 101 - 150 = 6; 151 - 200 = 8 Notify MD greater than 200, subcutaneously in the evening. R2's Blood Sugar Record documents the following: 12/14/24 at 11:08 AM, blood sugar of 215; 12/14/24 at 4:03 PM, blood sugar of 235; 12/14/24 at 8:18 PM; 12/14/24 at 9:00 PM, and 12/15/24 at 7:04 AM, blood sugar of 205. R2's record was reviewed with no documentation that R2's Physician was notified of the blood sugars greater that 200 as ordered. On 12/18/24 at 12:20 PM, V9, Licensed Practical Nurse, stated R2's family wants the physician notified if his blood sugar is above 200 because he is a brittle diabetic. On 12/18/24 at 2:10 PM, V9 stated when the MD is notified on blood sugar levels, it is documented in the nurses notes. On 12/19/24 at 10:00 AM, V2, Director of Nurses, stated she was unable to find any documentation that R2's physician was notified of R2's blood sugars on 12/14/24 or 12/15/24. The Significant Condition Change and Notification policy documents the following: The purpose of the policy is to ensure that a resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: abnormal blood glucose results, or above or below set parameters.

Based on observation, interview, and record review, the facility failed to perform wound care on 1 of 3 residents (R2), reviewed for quality of care in the sample of 8. Findings Include: R2's Medical Diagnosis Listing, undated, documents R2 was admitted to the facility with a diagnosis of Orthopedic Aftercare following a Right Femur Fracture. On 12/18/24 at 9:30 AM, wound care was observed with V3, ADON(Assistant Director of Nurses)/Wound Nurse/IPC (Infection Control Preventionist) . R2 has 3 incisions to the right hip. There was a dressing, dated 12/18/24, covering the two lower incisions. There was no dressing in place to the upper incision. All incision areas had staples in place. On 12/18/24 at 8:30 AM, R2 stated he thinks the nurses look at his hip incision, but don't put a dressing on it every day. R2's TAR (Treatment Administration Record), dated 12/2024, documents R2 has a physician's order, dated 12/12/24, to cleanse the surgical incision sites to the right hip with wound cleanser, pat dry and apply a dry dressing every shift. The TAR fails to show documentation the treatment was administered on 12/16/24, night shift, and 12/17/24, day shift. On 9/19/24 at 11:20 AM, V13, Regional Nurse, stated the nurses are to document when treatments are administered in the TAR. The Wound Prevention Policy, with a review date of 8/2023, documents the following: Create personalized service plans for residents with specific wound needs. Document all wound prevention measures, assessments, and interventions in the resident's service plan and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect residents during abuse investigations to prevent further potential abuse from occurring for 2 of 4 residents (R17, R31) residents reviewed for investigation/prevention/correct alleged violation of abuse in a sample of 57. Findings include: R31's face sheet, dated 9/24/24, documented R31 has diagnoses of COPD (Chronic Obstructive Pulmonary Disease), benign prostatic hyperplasia, muscle weakness, hyperlipidemia, PTSD (post-traumatic stress disorder), depression, hypertension, obstructive and reflux uropathy, chronic migraine, and low back pain. R31's Minimum Data Set (MDS), dated [DATE], documented R31 is cognitively intact. R31's Care Plan, print date of 9/17/24, documented R31 has a behavior problem related to cursing about his loss of independence and showing signs of frustration. R31 suffers from PTSD related to his military background. R31's care plan documented R31 will show signs of PTSD and staff interventions could include: 1. Ensuring resident's and other residents' safety while PTSD is displayed. R17's Face Sheet, dated 9/24/24, documented resident has diagnoses of end stage renal disease, type 2 diabetes mellitus, psychotic disorder with delusions, pseudobulbar affect, muscle weakness, anxiety disorder, major depressive disorder, auditory hallucinations, cerebral infarction, schizophrenia, cognitive communication deficit, legal blindness, cardiomyopathy, heart failure, and hypertension. R17's MDS, dated [DATE], documented resident is moderately cognitively impaired. R17's Care Plan, print date of 9/24/24, documented R17 has a mood problem related to depression and anxiety. R31's Progress Note, dated 8/30/24 at 5:16 PM, documented patient made threatening comments about the neighbor patient yelling. Stating if she keeps doing it, I am going to shove a sock down her throat. Education provided about behaviors and how legal action would be taken if such an event happened. Patient stated, I don't give a s***. R31's Progress Note, dated 9/2/24 at 5:58 PM, documented, (R31) was in the hallway at this nurse's med cart to get medications when another resident, that was sitting in her room, started hollering. (R31) hollered loudly, Shut the f*** up. The other resident stated, you shut up you mother **** **. This resident states, shut the f *** up or I will come in there and rip your f****** throat out. This nurse tried to calm resident and explain to him that he cannot talk to other residents that way. Resident wheeled down the hall to go outside. (V1, Administrator) and Doctor (V20) notified. Will continue to monitor. The facility investigation, undated, documented the Administrator was notified of an incident involving R31 and R17. Staff members reported that R31 yelled at R17 to shut the f*** up and R17 yelled back calling him a mother f*****, R31 then yelled at R17 that he would cut her throat out. This investigation documented both residents' care plans were reviewed and updated. R31 was given instructions to ask staff for assistance if he hears a resident yell out and not to yell back. The resident voiced an understanding. If it continues, Social Services will visit with R31 and R17 twice weekly for 30 days. R17's Care Plan, print date of 9/24/24, did not document how the facility will prevent R17 from any further abuse, and did not document anything regarding Social Service conducting visits with R17 twice weekly for 30 days following. R17's Social Service progress notes from 9/2/24 to 9/19/24 do not document any Social Services visits. R31's Care Plan, print date of 9/24/24, did not document how the facility will prevent R31 from being verbally abusive towards other residents. R31's Social Service progress notes from 9/2/24 to 9/19/24 do not document Social Service is meeting with R31 twice weekly as documented as the intervention to the 9/2/24 abuse investigation of R31 and R17. Throughout the survey from 9/16 through 9/26/24, R17 remained in a room two doors down, across the hall from R31. R31 must pass R17's room to go to nurse's station, courtyard, dining room, activities, and shower. On 9/18/24 at 9:15 AM, V22, Certified Nurse Assistant, (CNA) stated she just kind of monitors R17 and R31 since the abuse incident. V22 stated she has not been told about any other interventions that are in place to prevent any further abuse from occurring between R17 and R31. V22 stated R17 sometimes sings or hollers out and that makes R31 angry. On 9/18/24 at 9:18 AM V21, CNA, stated neither R17 nor R31 have been moved to a different hall since the abuse occurred between them. V21 stated she is not aware of any interventions in place to prevent abuse from occurring again between R17 and R31. V21 stated neither R17 nor R31 were moved to another hall after the abuse occurred between them on 9/2/24. On 9/18/24 at 9:45 AM, V14, Social Service Director, stated she does not meet with R31 any certain number of times per week. V14 stated R31 stops in her office frequently, but she does not document that. V14 stated she is not aware of what intervention was put into place to prevent abuse from occurring again between R17 and R31. On 9/19/24 at 7:45 AM, V14, Social Service Director, stated she does not meet with R17 unless there is a reason. V14 stated she does not know what the facility is doing to prevent R31 from verbally abusing R17. On 9/19/24 at 9:02 AM V40, CNA, stated she was working the evening that R31 yelled and cursed at R17. V40 stated she heard R31 curse and yell that he was going to slit R17's throat. V40 stated she closed R17's door, and then R31 went outside. V40 stated she does not know what intervention the facility put into place to try and prevent this from happening again. On 9/23/24 2:25 PM V1, Administrator, stated she expected V14, Social Service Director, to be meeting with R31 and R17 twice weekly as documented in the facility resident to resident abuse investigation, and she would expect V14 to document these meetings in the EMR (Electronic Medical Record). The facility Abuse, Prevention, and Prohibition Policy, revision date of 1/24/24, documented each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It continues, prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abuse behaviors. The facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document in the resident's Electronic Medical Record (EMR) the reason for discharge, failed to provide written documentation of the reason for discharge and resident rights to appeal the discharge to for 1 of 3 residents (R20) residents reviewed for discharge in a sample of 57. Findings include: R20's Face Sheet, dated 9/24/24, documented R20 has diagnoses of pseudarthrosis after fusion, depression, gastro-esophageal reflux disease, osteoarthritis, anxiety disorder, insomnia due to other mental disorder, chronic pain, alcohol dependence, altered mental status, hypertension, hyperlipidemia, hypokalemia, and hypomagnesemia. R20's Minimum Data Set (MDS), dated [DATE], documented R20 is cognitively intact. R20's Care Plan, print date of 9/24/24, does not document any discharge planning. R20's Progress Note, dated 9/10/24 at 10:53 AM, documented resident seems increasingly confused and agitated this morning. Resident states he's in a lot of pain and needs more pain medication. Resident has had his pain meds including his scheduled hydrocodone 10/325 as well as his PRN (as needed) oxycontin. Staff has advised resident the dangers of taking both medications at the same time as well the risk of addiction. Writer went to take resident his requested medication in room and discovered that resident had his room in complete disarray. All drawers were pulled out, clothes taken out of drawers and closet, bed stripped apart, side table flipped over, food scattered on the floor. Writer asked resident was happened in here and resident states not much, I just wanted to change things up. Resident also mentioned he couldn't sleep and wanted to move some things around. Writer warned resident about the dangers of moving furniture and other objects so soon after having back surgery. Resident just shook his head and didn't seem too concerned. Staff will continue to monitor. R20's Progress Note, dated 9/10/24 at 12:09 PM, documented writer called for emergency services for transport to acute facility at this time. R20's Progress Note, dated 9/10/24 at 12:17 PM, documented local EMTs (Emergency Medical Technicians) x 2 in facility for transport at this time. Writer provided brief report re: purpose of transfer; also provided copies of face sheet, current med orders, POLST (physician orders for life sustaining treatment), bed hold and transfer/discharge forms to EMTs. Prior to assisting resident to stretcher, EMTs asked resident if he had sutures or staples r/t (related to) recent surgery, resident responded with slurring I haven't had any surgery yet. R20's transfer form, dated 9/10/24 at 12:33 PM, documented A&O (alert & oriented) x 4, abnl (abnormal) behaviors began this morning. The facility's investigation of R20's discharge, dated 9/13/24, documented the Administrator spoke with R20 via telephone and explained due to the potential harm he had put his roommate, residents, and staff in by smoking cocaine in his room, he was unable to return. He was told his belongings, including his wallet and phone had been packed up and family could pick them up at any time. When he asked about medications, he was told to ask the hospital for discharge scripts until he could see a physician, and he voiced an understanding and apologized for what had happened. On 9/16/24 at 9 AM, V1, Administrator, stated, (R20) was discharged , and we are not taking him back because he had altered mental status due to consuming cocaine at the facility. We found a rock of it, and a spoon with black marks on it in his room, the police came, got the drugs, tested it, and said it was cocaine. They didn't press charges. We did not notify his wife because she isn't the POA (Power of Attorney) and I just told him over the phone that he cannot come back, I will take the tag. On 9/24/24 at 10:42 AM, V14, Social Service Director, stated she did not do any discharge planning with R20. The facility's Discharge Summary and Plan policy, dated 11/2022, documented the discharge plan will include resident and family/caregiver education needs and will initiate or maintain collaboration between the nursing facility and other post-acute care providers to support the resident's transition to community living. The discharge plan, instructions, & summary provides a recapitulation or summary of the resident's stay. 1. Discharge planning will begin upon admission to the SNF (Skilled Nursing Facility) a. Nursing Admission/readmission Data Collection - admitting nurse will document the resident, family/caregiver stated reason for admission and the resident. Family/caregiver plan for discharge. 2. 48 Hour Meeting a. Members of the interdisciplinary team will meet with resident and family/caregiver within 48 hours of resident's admission to the SNF to discuss discharge plans. b. Documentation of discharge plan will be completed utilizing the Interdisciplinary Care Conference Note 48 Hour Meeting assessment by Social Service Director of Social Service Designee. 3. Care Plan a. Social Service Director or Social Service Designee will initiate and update the discharge plan in the Care Plan section of the resident's record. 4. Discharge Plan, Instructions, & Summary. a. Social Services Director of Social Service Designee will initiate and update the discharge plan in the Care Plan section of the resident's record. b. The IDT (Interdisciplinary Team) will be notified when the assessment is open and incomplete sections will be discussed in morning meeting. c. Social Service Director or Designee will complete sections A, B, D, H. d. Nursing will complete sections C & E; Wound nurse will ensure skin and treatments ae recorded. e. Dietary will complete section F. f. Activities will complete section G. g. Social Service Director or Social Services Designee will ensure all sections are complete and the document is signed and locked. 5. Discharge Education a. Nurse will review discharge instructions and medications with resident/resident representative. Copy of Disposition of Medication form will be given to resident/resident representative and a copy scanned into the record. b. Social Services Director or designee will include the Discharge Plan, Instructions, and summary in the Discharge Packet. 6. Nurse will document discharge note in the progress notes section of the resident record. Discharge note will include skin assessment, who they discharged with, where they are discharging to, what belongings were sent with them and other pertinent information. 7. Social Services will make post discharge follow up call at 72 hours and complete the Discharge Post Discharge Follow Up Phone Call assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure showers, basic grooming, and feeding assistance were provided for 2 of 24 residents (R33 and R145) reviewed Activities of Daily Living (ADLs) in the sample of 57. Findings include: 1. R145's Face Sheet, dated 9/18/2024, documents R145 was admitted to the facility on [DATE], with a diagnosis of Amyotrophic Lateral Sclerosis (ALS- also known as Lou Gehrigsdisease, is a fatal neurological disorder that causes nerve cells in the brain and spinal cord to die. This leads to muscle weakness, paralysis, and eventually the loss of the ability to breathe and control voluntary movements.) R145's Care Plan, undated, documents R145 has ADL (Activities of Daily Living) self-care performance deficit related to ALS, weakness, and osteoarthritis. R145 is totally dependent on one staff member for toilet use. On 9/17/2024 at 11:13 AM, R145 stated she has been at the Facility since 9/11/2024, and has not had a shower or a bed bath. On 9/17/24 at12:53 PM, R145's lunch tray sat untouched on bedside table. R145 stated she needs assistance with eating because she has severe ALS and nerve damage. R145 stated her right shoulder is also frozen. R145 stated the CNA (Certified Nurse's Aide) told R145 she must deliver trays to everyone else before she can feed her. R145 stated, This is just a mess. On 9/17/24 at 3:36 PM, R145 was observed in the hallway in a shower chair, leaving the shower room, smiling. On 9/17/2024 at approximately 3:45 PM, R145 stated she feels so much better and she even had her hair washed. On 9/18/2024 at 10:00 AM, V2, Director of Nursing, stated she only has one shower sheet for R145. R145's shower sheet was dated 9/17/2024. On 9/18/2024 at 11:17 AM, R145 stated, Nobody has offered to help me brush my teeth. They never help me wash my face. My daughter was here Saturday and helped me brush my teeth. On 9/18/2024 at 11:30 AM, V19, Certified Nursing Assistant (CNA), stated R145 was kind of confused, but V19 gave her a bed bath. V19 stated she didn't fill out a shower sheet. On 9/18/2024 at 3:34 PM, V16, CNA, stated when she was giving R145's shower, R145 told V16 that R145 had not have a shower in two weeks. The Facility's Shower Schedule documents R145 should receive showers on Tuesdays and Fridays on day shift. On 9/19/2024 at 9:34 AM, V2, Director of Nursing, stated they do not have a policy pertaining to ADL's. V2 stated they expect staff to follow the best practice guidelines. 2. R33's MDS, dated [DATE], documents R33 has an ADL Self Care Performance Deficit Fatigue, and requires one staff member participation with personal hygiene and oral care. R33's MDS further documents R33 is cognitively intact. On 9/17/24 at 1:31 PM, V22, CNA, stated she has heard R33 complain about not getting showers. On 9/17/2024 at 1:43 PM, V18, Occupational Therapy, stated R33 told V18 she hadn't had a shower and wanted one to make her feel better. On 9/17/2024 at 2:25 PM, R33 stated she does not usually get her showers like she is supposed to. R33 stated V18 did get her a shower recently. R33 stated, even one shower a week would be alright. The Facility's Shower Schedule documents R33 should get showers on Tuesday evenings and Friday Mornings. On 9/19/2024 at 2:30 PM, V27, CNA, stated residents should get showers twice a week and documented on a shower sheet. On 9/18/2024 at 12:19 PM, the Facility did not provide any shower sheets for R33. On 9/19/2024 at 9:34 AM, V2 stated they do not have a policy pertaining to ADLs. V2 stated they expect staff to follow the best practice guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to prevent the deterioration of pressure ulcer, the development of a new pressure, and treat pressure ulcers as order by physician for 1 of 2 residents (R85) reviewed for pressure ulcers in the sample of 57. Findings include: 1. R85's Face sheet, dated 9/19/2024, documents R85 was admitted to the facility on [DATE] with a pressure ulcer (site unspecified). R85's Minimum Data Set, dated [DATE], documents R85 has one stage 3 (full thickness tissue loss) pressure ulcer. R85's Physician's Order Sheet, dated 9/19/2024, documents, Cleanse open area to sacrum with wound cleanser, pat dry, apply sure prep to surrounding skin. Apply Calcium Alginate to wound bed only, cover with dry dressing daily and as needed. On 9/16/2024 at 11:57 AM, R85 stated he had two open areas on his buttocks. On 9/16/2024 at 1:00 PM, V8, Assistant Director of Nursing, and V36, Wound Nurse, were observed exiting R85's room. V8 stated they had changed R85's dressing to his buttocks. V36 stated R85's wound has gotten deeper. R85's Assessment Report, dated 9/17/24, documents, Sacrum Wound- 2 centimeters (cm) length by 0.8 cm depth by 2 cm width. Depth Status- has deteriorated compared to the conclusion of previous visit. Stage 3. Frequency of dressing change. Daily, as needed for soiling, saturation, or unscheduled removal. On 9/18/2024 at 3:00 PM, V23, Registered Nurse (RN), removed R85's adult brief. R85 had a small amount of feces in his incontinence brief. R85 had no dressing intact to his coccyx area (buttocks). There was no dressing in R85's adult brief either, and this information/observation was confirmed by V23. At this time, R85's right buttocks had a reddened area. When asked about the reddened area, V23 stated, It looks like it's trying to be a new spot (second open area). On 9/18/2024 at 3:30 PM, V37, Certified Nurse's Assistant (CNA), stated if she saw an open area on a resident's skin or the dressing to the area became soiled, she would inform the nurse. On 9/18/2024 at 3:34 PM, V16, CNA, stated she was assigned to R85 on 9/17/2024. V16 stated she provided R85 incontinent care after R85 had a bowel movement. V16 stated R85's dressing to his buttocks was soiled, she removed it, but did not notify the nurse. On 9/18/24 at 4:03 PM, V8 stated R85's banshe changed [NAME] to his buttocks 9/17/2024 between 12:30 PM and 2 PM, and it was secure in place. V8 stated she would expect staff to notify the nurse if the bandage becomes soiled and/or is not intact. V8 stated R85's bandage should be intact continuously per physician's orders. The Facility's Wound Care System Requirements Policy, dated 3/2022, documents, Treatment orders are being completed as orders, and are changed if no progress is noted in two weeks. The Facility's Skin Checks Policy, dated 3/2022, documents, Any new wounds or skin conditions will be assessed by the nurse by the nurse finding the wound or skin issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R23's Face Sheet, dated 9/24/24, documented R23 has diagnoses of COPD (Chronic Obstructive Pulmonary Disease), anxiety disorder, muscle wasting and atrophy, cognitive communication deficit, fracture of left femur, neuropathy, acute on chronic combined heart failure, iron deficiency anemia, sleep apnea, spinal stenosis, and depression. R23's MDS, dated [DATE], documented R23 is cognitively intact. R23's MDS documented R23 is frequently incontinent of urine and always incontinent of stool. On 9/17/24 at 9:25 AM, V9, CNA, was observed as she entered R23's room to answer the call light. R23 requested a bedpan. V9 was observed as she donned gloves, without the benefit of hand hygiene. V9 then removed R23's adult diaper. R23's diaper was completely saturated with urine, resulting in R23's linens and mattress to become saturated. R23's adult diaper also contained a large amount of feces. V9 then went into R23's restroom and returned with wet washcloths. V9 placed the wet washcloths on R23's side rail. V9 stated she applied hand soap from the restroom dispenser on the wet washcloths. V10, CNA, then entered to assist V9 with the incontinent care. V9 then proceed to cleanse R23's frontal region, without the benefit of hand hygiene or glove change. V9 cleansed R23's outer labia and inner thigh, but did not cleanse R23's inner labia region. V9 and V10 then repositioned R23 onto her right side and V9 cleansed R23's buttock region without cleansing R23's outer buttocks and hip region. V9 did not change gloves or perform hand hygiene prior to cleansing R23's buttocks. V9 and V10 then turned R23 onto her back, and V10 cleansed the remaining feces from R23's inner thighs. V9 and V10 did not rinse the soap from R23 at any time during the incontinent care, nor did they dry R23's skin. V9 and V10 then proceeded to change R23's bed linens while R23 was still in the bed, without performing hand hygiene and while wearing the same gloves that were worn during the incontinence care. V9 and V10 then removed their gloves and exited R23's room without the benefit of hand hygiene. On 9/17/24 at 12:10 PM, V9 stated she did use hand soap from R23's bathroom hand dispenser to cleanse R23's perineal region. V9 stated if she is supposed to use another type of soap during perineal care, no one has told her. On 9/17/24 at 1:35 PM, V15, CNA, stated she would never use hand soap to wash a resident during peri-care. V15 stated she uses no rinse perineal cleanser when providing incontinent care for the residents. On 9/24/24 at 12:40 PM, V2, Director of Nursing, stated she would expect the CNAs to use no rinse perineal cleanser to clean residents during incontinent care. V2 stated the facility does not have an incontinence care policy and the facility follows best practices. Based on observation, interview, and record review, the Facility failed to provide timely toileting and incontinent care to prevent potential urinary tract infections (UTIs) for 3 of 3 residents (R145, R85, and R23) reviewed for incontinent care in the sample of 57. Findings include: 1. R145's Face Sheet, dated 9/18/2024, documents R145 was admitted to the facility on [DATE], with a diagnosis of Amyotrophic Lateral Sclerosis (ALS- also known as Lou Gehrigsdisease, is a fatal neurological disorder that causes nerve cells in the brain and spinal cord to die. This leads to muscle weakness, paralysis, and eventually the loss of the ability to breathe and control voluntary movements.) R145's Care Plan, dated 9/18/2024, documents R145 has bowel/bladder incontinence and prefers to use a bedpan while in bed, at night. Interventions include observe pattern of incontinence and initiate toileting schedule if indicated. Offer resident toilet at same time each day resident usually has bowel incontinence (after meals). Provide bedpan/besides commode. It also documents to check the resident every two hours and as required for incontinence-wash, rinse, and dry perineum. Goals include: R145 will have less than two episodes of incontinence per day through the review date. R145 will be continent during daytime through the review date. R145's Care Plan continues to document R145 has ADL (Activities of Daily Living) self-care performance deficit related to ALS, weakness, and osteoarthritis. R 145 is totally dependent on one staff member for toilet use. On 9/18/2024 at 9:39 AM, R145's call light was activated. V15, Certified Nursing Assistant/CNA entered R145's room. R145 told V15, CNA, she (R145) put her call light on because she asked for her bedpan an hour ago, was unsure who she asked, but they must have gotten busy and forgot. R145 stated she had an accident and needed cleaned up (provided incontinent care). On 9/18/2024 at 9:44 AM, V15 and V19, CNAs, performed incontinent care to R145. R145's adult brief was saturated with urine and a small amount of feces. V15 applied a new adult brief without drying R145's peri-area. On 9/18/2024 at 4:09 PM, V1, Administrator, and V8, Assistant Director of Nursing, stated they would expect staff performing incontinent care to pat dry the peri-area. V8 stated R145 should have been offered the bedpan when she requested it, prior to her having an incontinent episode. On 9/19/2024 at 9:34 AM, V2 stated they do not have a policy pertaining to incontinent care. V2 stated they expect staff to follow the best practice guidelines. 2. R85's Face Sheet, dated 9/19/2024, documents R85 has a diagnosis of Urinary Tract Infection (UTI) and Extended Spectrum Beta Lactamase Resistance (ESBL- enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam. Infections caused by ESBL-producing bacteria can be difficult to treat and may require complex treatments). F85's Care Plan, dated 8/30/2024, documents R85 has a urinary catheter. Inventions include catheter care every shift and as needed. It further documents R85 has bowel incontinence. Interventions include providing incontinent care after each incontinent episode. On 9/18/2024 at 3:00 PM, V23, Registered Nurse (RN), removed R85's adult brief. R85 had a small amount of feces in his adult brief. R85 had no dressing intact to his coccyx area (buttocks). On 9/18/2024 at 3:44 PM, V16, CNA, wet wash cloths in the bathroom sink. At no time did V16 apply any cleanser to the washcloths. V16 completed R85's catheter care and wiped the feces from R85's buttocks with the washcloths. V16 did not dry R85's peri-area or buttocks prior to applying a new adult brief. On 9/18/2024 at 4:09 PM, V1, Director of Nursing, and V8, Assistant Director of Nursing, stated staff are expected to use body wash or non-rinse peri cleanser, especially after an incontinent episode involving feces. V1 and V8 stated staff should pat the area dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and provide services for residents who verbalizes suicide threats for 1 of 1 resident (R31) reviewed for behavioral health services in the sample of 57. Findings include: R31's Face Sheet, dated 9/24/24, documented R31 has diagnoses of COPD (Chronic Obstructive Pulmonary Disease), benign prostatic hyperplasia, muscle weakness, hyperlipidemia, PTSD (post-traumatic stress disorder), depression, hypertension, obstructive and reflux uropathy, chronic migraine, and low back pain. R31's Minimum Data Set (MDS), dated [DATE], documented R31 is cognitively intact. R31's Care Plan Focus, date initiated on 11/13/23, documents (R31) has suffered a traumatic life event and declines services and intervention at this time. Related to PTSD. The Care Plan Focus, date initiated on 11/27/23, documents The resident has mood problems related to frustration of losing the independence and nursing home placement. (R31) will refuse care from staff at times. R31's Progress Note, authored by V17, Licensed Practical Nurse (LPN), dated 7/5/24 at 5:49 PM documented, patient stated he is at the point that he is done with doctors and insurance. Stated he could just take a gun and end it all. Writer told him that he shouldn't think like that, and patient stated he is dead serious. R31's Care Plan, print date of 9/17/24, does not address R31's voiced suicide threat that was made on 7/5/24. On 9/17/24 at 12:45 PM, V14, Social Service Director, stated she is not sure if R31 has ever voiced any suicide threats or not, since he was admitted to the facility. On 9/17/24 at 1:00 PM, V7, Licensed Practical Nurse/LPN for R31, stated she is not aware of any issues with R31 being suicidal. V7 stated R31 yells and curses frequently, and she re-directs him when he has these behaviors. On 9/17/24 at 1:05 PM V9, CNA, stated R31 is mad every day, curses, and screams, but she has never heard of him making any suicide threats. On 9/17/24 at 1:10 PM, V10, CNA, stated she has never heard anything about R31 threatening suicide in the past while residing at the facility. On 9/17/24 at 1:31 PM V17, LPN, stated she was R31's nurse when he made the suicide threat on 7/5/24. R31 stated she thinks she called R31's doctor but not sure, and she may not have charted it. On 9/17/24 at 2:10 PM V20, R31's Physician, stated he was not notified of R31's suicide threat that was made on 7/5/24. V20 stated he checked R31's medical records and there is no documentation regarding R31 making a suicide threat. On 9/17/24 at 4:52 PM, V20 stated if he would have been notified of R31's threat of suicide that was made on 7/5/24, he would have made an acute visit to see R31, and then would determine if R31 needed to go to the ER (Emergency Room) or not, that he would have had the facility staff search R31's room for dangerous objects, and he would have put R31 on close monitoring until he was transferred, or no longer a suicide threat. On 9/18/24 at 9:37 AM, V21, CNA, stated she is not aware of any recent suicide threats by R31, stated he made one a few months ago when she was working in management, but she does not know what the facility did about it. On 9/18/24 at 4:20 PM, V1,Administrator, stated R31 is going to the hospital because he threatened suicide this afternoon. V1 stated she would have to look at R31's chart to see if R31 has ever voiced any suicide threats previously. R31's Progress Note, dated 9/18/24 at 3:55 PM, documented, (Administrator,V1) came to this nurse and reported that resident needed to be sent out related to stating he was talking about suicide. (CNA, V22) confirmed that he said this. Resident was immediately put on one on one. R31's Progress Note, dated 9/18/24 at 3:57 pm, documented, called Dr. (V20's) office and reported that resident is going to be sent to local hospital ER (emergency room) related to suicidal. R31's Progress Note, dated 9/18/24 at 4:09 PM, documented, 911 called for resident to be picked up and taken to local hospital ER for suicide threats. On 9/23/24 at 10:17 AM, V33, Regional Director, stated when R31 voiced a suicidal threat on 7/5/24, she would have expected R31's nurse to call the Administrator and R31's doctor, update R31's care plan regarding the suicide threat, and have staff stay with R31 to make sure R31 was safe. On 9/23/24 at 10:31 AM, V1, Administrator, stated she was notified of R31's suicide threat that was made on 7/5/24. V1 stated she is not going to speculate on what the facility staff did for R31 after R31 made the suicidal threat on 7/5/24. On 9/23/24 at 10:35 AM, V33, Regional Director, presented R31's care plan and stated R31's care plan does address R31 is a risk to self. This care plan, with a revision date of 9/19/24, documented monitor/record/report to MD (Medical Doctor) prn (as needed) risk for harming self or harming others. This surveyor presented R31's care plan with a print date of 9/17/24 to V33. R31's care plan, print date of 9/17/24, documented monitor/record/report to MD prn risk for harming others. V33 agreed R31's care plan did not address R31 being a harm to himself until the revision date of 9/19/24. The facility's Suicide Threats policy, dated 2/21, documented 1. If a resident makes a suicidal threat, stay with the resident, and immediately notify the nurse. 2. The nurse will assess the resident, notify the DON (Director of Nursing)/designee and medical practitioner and establish a plan of care. 3. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 4. If the resident remains in the facility, all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 5. Staff will document the resident's mood and behavior and update care plans accordingly. 6. The resident's environment will be evaluated, and potentially dangerous items will be removed. (i.e., sharp objects, belts, trash bags, etc.) 7. The IDT (Interdisciplinary Team) will review the resident behaviors and documentation to determine if there is a need to revise the plan of care. Practitioner and resident representative will be notified of any changes in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor, track, and properly document microbiology organisms on infection control log, and failed to monitor and follow up for proper antibiotic use for 2 of 6 residents (R10, R61) reviewed for Antibiotic Stewardship in the sample of 57. The Findings Include: 1. R10's admission Record, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, Dementia, Falls, and COVID-19. R10's Care Plan, dated 7/12/24, documents R10 is incontinent of bowel and bladder. Interventions: : Check frequently for incontinence, wash, rinse and dry perineum, change clothing PRN (as needed) after incontinence episodes, monitor/document/report to MD (Medical Doctor) PRN possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects, uses briefs. It continues R10 a has an Activities of Daily Living (ADL) Self Care Performance Deficit due to Alzheimer's Disease, weakness, muscle wasting and atrophy. Interventions: R10 is able to use the restroom independent, supervision required at times due to dementia. R10's Minimum Data Set (MDS), dated [DATE], documents R10 has a severe cognitive impairment and requires partial/moderate assistance from staff for toileting and bathing and is always incontinent of urine and frequently incontinent of bowel. R10's Urinalysis, dated 8/11/24, documents a Urine Culture will be done. R10's Nursing Note, dated 8/11/24 at 3:36 PM, documents, Resident returned to facility via wheelchair with ER (Emergency Room) nurse at 15:37. ER DX (diagnosis) - UTI (Urinary Tract Infection), given 16 MG (milligram) Rocephin IV (intravenous) and fluids in ER. New orders received for Cipro 250 MG BID (twice a day) for 7 days starting 8/12/24. Check on urine culture in 48 hours. MD notified. R10's Physician Order, dated 8/11/24, documents, Cipro Oral Tablet 250 MG, Give 250 MG by mouth two times a day for UTI until 8/19/2024 23:59. R10's Nursing Note, dated 8/13/24 at 7:57 PM, documents, Remains on ABT (antibiotic) for UTI, no adverse reaction noted. Fluids encouraged. Voiding qs (unknown) incontinent. No acute distress noted. R10's Nursing Note, dated 8/20/24 at 9:58 AM, documents, Resident completed antibiotic today. The Facility's Infection Surveillance Log, dated August 2024, documents R10 had a UTI, dated 8/11/24 with Urine Culture done on 8/11/24. There was no Urine Culture seen in R10's Medical Record, with no follow up in 48 hours as documented in the Nursing Note on 8/11/24 at 3:36 PM. 2. R61's admission Record, undated, documents R61 was originally admitted to the facility on [DATE], with diagnoses of Dementia, Sepsis, Cellulitis, Emphysema, Dysphagia, Psychotic disorder, Chronic Kidney Disease, and COVID-19. R61's Care Plan, dated 7/18/24, documents R61 is incontinent of bowel and bladder. Interventions: Check R61 for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes, monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. It continues R61 has C. Difficile (C-Diff). Interventions: Contact Isolation: Wear gowns and masks when changing contaminated linens, educate resident/family/staff regarding preventive measures to contain the infection. R61 requires isolation - Contact related to C-Diff. Interventions: Isolation per facility protocol. It continues R61 has ADL Self Care Performance Deficit related to weakness and impaired cognition. Intervention: The resident requires one staff participation to use toilet. R61's MDS, dated [DATE], documents R61 has a severe cognitive impairment and is dependent on staff for toileting and bathing. R61 is always incontinent of both bowel and bladder. R61's Stool Culture, dated 8/2/24, documents R61 was positive for Clostridium Difficile (C-Diff). R61's Nursing Note, dated 8/2/24 at 8:24 PM, documents, Received N.O. (New Order) obtain stool specimen for C-Diff toxin. R61's Nursing Note, dated 8/2/24 at 9:10 PM, documents, Stool specimen obtained as ordered for C-Diff, Specimen labeled and taken to lab. R61's Nursing Note, dated 8/3/24 at 9:32 AM, documents R61's stool sample came back positive for C-Diff. Writer called R61's provider and left message to have him contact our facility regarding result of C-diff. R61's Nursing Note, dated 8/3/24 at 9:43 AM, documents, Per (Provider) N.O. for Flagyl 500 MG TID (three times a day) x 10 days. POA (Power of Attorney) aware, order placed in chart. R61's Nursing Note, dated 8/14/24 at 12:49 PM, documents, Resident completed ABT (antibiotic) Flagyl early this AM. No adverse effects noted or observed. Will continue to monitor. Resident currently sitting up in dining room eating lunch. R61's Physician Order, dated 8/3/24, documents, Metronidazole 500 MG Tablet, Give 1 tablet by mouth 3 times a day for C-Diff X 10 Days. The Facility's Infection Surveillance Log, dated August 2024, does not include R61 on this log. On 9/18/24 at 10:30 AM, when asked how she becomes aware of a resident with a new infection, V2, Director of Nursing (DON)/Infection Preventionist (IP), stated, The Nurses will tell us that a resident has an infection, and we will make sure they are on the correct precautions. When asked how they know the resident is on the correct antibiotic, V2 stated, We are supposed to be checking the C&S (Culture and Sensitivity) and see if they are on the correct antibiotic, and if not, call the physician to have the order changed. When asked if this is happening, V2 stated, I'm not going to lie, I don't believe that is getting done. On 9/18/24 at 1:20 PM, V2, DON, and V8, Assistant Director of Nursing (ADON), was interviewed about Infection Control with a Review of the Infection Control book. V2 stated, I print out the numbers off the corporate website that shows the infections in this facility. I will look at the McGeer's criteria and if the infection does not meet those criteria, I put a No in the Treatment Appropriate column of the spreadsheet. When asked what she does with this information after determining the treatment was not appropriate, V2 stated, I guess we don't do anything. Sometimes the antibiotics are already completed by the time I get the information, so it is too late. When asked what the plans or next steps are to correct this, V2 stated, The plan is to retrain the nurses to Stop and Watch, meaning if a resident has signs/symptoms of a UTI (Urinary Tract Infection), for example, they should make sure that resident is hydrated and watch for further symptoms. Sometimes the ball gets dropped and nothing gets done. Upon review of the Infection Control Log, there is nothing documented since the end of August (31st) 2024. V2 stated, With all the DON duties and trying to train (V8) to do Infection Control, I have not had time to do anything with it. On 9/19/24 at 8:30 AM, V2 stated, Just to let you know, I am already working on the POC (Plan of Correction) and working on getting everything updated for September. On 9/25/24 at 8:40 AM, V1, Administrator, stated, I would expect the Infection Preventionist to keep up with the infection surveillance and the antibiotic stewardship daily, weekly, and monthly to make sure residents are on the correct antibiotic and treatments. The Facility's Infection Prevention and Control Policy, dated 2019, documents, It is the policy that this facility's Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program includes: 1. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. 3. An Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. The Facility's Infection Prevention and Control Manual Antibiotic Stewardship & MDROs Policy, dated 2019, documents, Antibiotic Stewardship refers to systematic efforts to optimize the use of antibiotics - not just reduce the total volume used - to maximize their benefits to patients, while minimizing both the rise and antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Stewardship involves identifying the microbe responsible for disease, utilizing evidence based definitions when indicated; selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. The organization will identify positions that will have the authority to hold others accountable for compliance with the facility Antibiotic Stewardship program. Infection Preventionist (IP): The IP will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the DON, Medical and Consultant Pharmacist and ongoing system review. Tracking and Reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to facility policy and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse drug events, antibiotic resistant organisms, C. difficile infections, etc.) will be tracked by the infection preventionist and discussed with the Quality Assurance Committed for action planning. The Facility's Infection Prevention and Control Program, dated 2019, documents the intent of this regulation is to ensure that the facility: *Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually, based upon the facility assessment and as necessary. This would include revision of the IPCP as national standards change. *Establish facility-wide systems for prevention, identification, investigation and control of infections of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. Elements of the program include: *Program oversight including planning, organizing, implementing, operating, monitoring, and maintaining all of the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control. *The facility will designate one or more individuals as the infection preventionist(s) who is responsible for the facility's infection prevention and control program. *Surveillance, including process and outcome surveillance, will include monitoring, data analysis, documentation, and communicable diseases reporting (as required by State and Federal law and regulation). Surveillance activities will be conducted to identify practice, infection trends and early identification of new infections and potential outbreak situations. *Antibiotic Stewardship and review including reviewing date to monitor the appropriate use of antibiotics in the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide education, obtain consents, and administer influenza vaccine to 4 of 8 residents (R61, R77, R82, R23) reviewed for immunizations in the sample of 57. The Findings Include: 1. R61's admission Record, undated, documents R61 was originally admitted to the facility on [DATE], with diagnoses of Dementia, Sepsis, Cellulitis, Emphysema, Dysphagia, Psychotic disorder, Chronic Kidney Disease, and COVID-19. R61's Care Plan, dated 7/18/24, documents R61 is incontinent of bowel and bladder. Interventions: Check R61 for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes, monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. It continues R61 has C. Difficile (C-Diff). Interventions: Contact Isolation: Wear gowns and masks when changing contaminated linens, educate resident/family/staff regarding preventive measures to contain the infection. R61 requires isolation - Contact related to C-Diff. Interventions: Isolation per facility protocol. It continues R61 has ADL Self Care Performance Deficit related to weakness and impaired cognition. Intervention: The resident requires one staff participation to use toilet. R61's Minimum Data Set (MDS), dated [DATE], documents R61 has a severe cognitive impairment and is dependent on staff for toileting and bathing. R61 is always incontinent of both bowel and bladder. R61's Electronic Medical Record, under Immunizations, documents R61 was last given the Influenza vaccination on 10/29/21. There is no further documentation of R61 being offered or given the Influenza vaccination. 2. R77's admission Record, undated, documents R77 was admitted to the facility on [DATE], with diagnoses of Dementia, Osteoarthritis, Osteoporosis, Falls, and Atrial Fibrillation. R77's Care Plan, dated 9/4/24, documents R77 requires droplet isolation related to COVID 19 positive. It continues R77 has an ADL Self Care Performance Deficit Dementia. R77's MDS, dated [DATE], documents R77 has a severe cognitive impairment and requires moderate to substantial assistance from staff for ADLs. R77's Electronic Medical Record, under Immunizations, documents R77 has not received or was offered the Influenza vaccination. There were no consents or refusals documented. 3. R82's admission Record, undated, documents R82 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, Dementia, Major Depressive disorder, Anxiety disorder, and COVID-19. R82's Care Plan, dated 9/4/24, documents R82 will remain in the facility long term. It continues R82 has an ADL Self Care Performance Deficit. R82's MDS, dated [DATE], documents R82 has a severe cognitive impairment and requires partial to substantial assistance from staff for ADLs. R82's Electronic Medical Record, under Immunizations, documents R82 has not received or was offered the Influenza vaccination. There were no consents or refusals documented. 4. R23's admission Record, undated, documents R23 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, Anxiety disorder, Depression, Asthma, Idiopathic Peripheral Neuropathy, and Congestive Heart Failure (CHF). R23's Care Plan, dated 7/30/24, documents R23 has an ADL Self Care Performance Deficit. It continues R23 resident has Asthma. R23's MDS, dated [DATE], documents R23 is cognitively intact and is dependent on staff for ADLs. R23's Electronic Medical Record, under Immunizations, documents R23 has not received or was offered the Influenza vaccination. There were no consents or refusals documented. On 9/18/24 at 1:30 PM, when asked for a list of residents who have refused, consented, or received any vaccinations, V2, DON, stated, I don't have a list. It should be scanned into the resident's medical record if they have one. The CDC (Center for Disease Control) has a large and complicated algorithm to follow for the Pneumococcal and other vaccinations. On 9/19/24 at 8:30 AM, V2 stated Just to let you know, I am already working on the POC (Plan of Correction) and working on getting everything updated for September. On 9/25/24 at 8:40 AM, V1, Administrator, stated, I would expect the Infection Preventionist to keep up with the residents immunizations, including influenza and Pneumococcal when needed. The Facility's Infection Prevention and Control Resident Immunizations and Vaccinations Policy, dated 2019, documents, It is the policy of this facility that residents will be offered immunization against pneumococcal and influenza diseases. Purpose: to reduce the incidence of pneumococcal and influenza diseases and the morbidity and mortality attributed to these infections. The Facility's Infection Prevention and Control Program, dated 2019, documents the intent of this regulation is to ensure that the facility: *Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually, based upon the facility assessment and as necessary. This would include revision of the IPCP as national standards change. *Establish facility-wide systems for prevention, identification, investigation, and control of infections of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. Elements of the program include: *Program oversight including planning, organizing, implementing, operating, monitoring, and maintaining all the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control. *The facility will designate one or more individuals as the infection preventionist(s) who is responsible for the facility's infection prevention and control program. *Surveillance, including process and outcome surveillance, will include monitoring, data analysis, documentation, and communicable diseases reporting (as required by State and Federal law and regulation). Surveillance activities will be conducted to identify practice, infection trends and early identification of new infections and potential outbreak situations. *Antibiotic Stewardship and review including reviewing date to monitor the appropriate use of antibiotics in the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to dispose of an open multi-dose vial of Insulin after 30 days, failed to dispose of an expired bottle of stock medication, and failed to date an open vial of Tuberculin that is used by all staff and residents. This failure has the potential to affect all 93 residents in the facility. The Findings include: On [DATE] at 9:35 AM, the facility's Medication Room was checked with V7, Licensed Practical Nurse (LPN). There was one Medication Refrigerator checked with a Tuberculin (TB) Vial in the box, with a date of delivery of [DATE], was open and did not have an open date. A Lantus Insulin Pen 100Units/Milliliter (ML)/3ML was seen sitting in the fridge, with no resident name or date written on it. V7 stated, There is usually a resident label on the pen, or it should be in a plastic bag from the pharmacy with a resident name on it. On [DATE] at 9:40 AM, V7, LPN, stated, We use that TB vial for all staff and residents when needed. If I found it without a date opened, I would discard it. On [DATE] at 9:50 AM, the Medication Cart behind the nurse's desk was checked with a bottle of Oyster Shell Calcium 500 Milligram (MG) capsules with the bottle appearing mostly full, and showing an expiration date of 8/2024. A vial of Humalog Insulin 10 ML was seen in the original box with a date opened of [DATE], past the 30-days since opened. On [DATE] at 9:32 AM, V7, LPN, stated, Our Medical Records person orders the Over the Counter (OTC) medications and when they come in, she brings them to the nurse, and they go through it and will check expirations. We all check expirations on the medications every month. On [DATE] at 9:45 AM, V8, Assistant Director of Nursing (ADON), stated, The nurses should be putting a date on all medication vials when opened, and the vial should be thrown away after 30-days. All medications in the carts and the med room should be checked for expirations every month. The Facility provided Medication Storage Parameters - Medications requiring discarding before listed expiration date, undated, documents, Insulin Vials: All vials should be dated with beyond use date to discard 28 days after opening. Humulin products can be used up to 31 days after opening. Multi-Dose vials for injection (not insulin): A beyond use date of unused portion to discard is placed 28 days after opening or in accordance with manufacturer's recommendation. Tubersol (Tuberculin): Beyond use date for 30 days after opening. The Facility's Drug Labeling Policy, dated 4/2021, documents, A. The label of each individual container shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, the initials of the pharmacist filling the prescription, and the amount of medication contained in each individual prescription. D. Medication having no labels should be destroyed in accordance with Federal and State laws. The Facility's Storage and Return of Drugs, dated 4/2021, documents, B. Residents' medications shall be properly labeled and stored at or near the nurse's station in a locked cabinet. E. Multi-Dose vials and pens shall be stored and dated per the manufacturers guidance. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated [DATE], documents the total number of residents in the facility was 93.

Based on interview, observation, and record review, the facility failed to perform proper hand hygiene and/or the changing of gloves while plating food, failed to date food when opened and/or cooked, and failed to check and maintain the temperatures of the food, including all diets (regular diets, special diets, and pureed foods) prior to serving the residents to prevent contamination and foodborne illness. These failures have the potential to affect all 93 residents living in the facility. The findings include: On 9/16/24 at 9:15 AM, during the initial tour of the kitchen, V11, Interim Dietary Manager (DM), stated, I can't find the fridge/freezer temperature logs. It's a mess, I'll look for them. Upon assessment of the kitchen, a bag of bacon was seen in the refrigerator and was dated 9/11/24 as opened, but the bag was open and not sealed. A gallon of chocolate milk, half full, was seen with no open date and an expiration date of 9/13/24. A box of cucumbers was seen in the walk-in refrigerator sitting on the floor of the refrigerator. A frozen bag of ground meat was sitting in the sink with hot running water pouring over the meat. When asked what that was, V12, Cook, stated it was for the turkey sloppy joe sandwich for lunch today. V11 provided the temperature logs with the last food temperatures taken on 9/13/24 lunch. On 9/17/24 from 11:50 AM until 1:15 PM, the Kitchen observation for Lunch was completed with V12, Cook. V12 was seen starting to plate food with two pureed scoops of chicken already on plates. When asked about checking the temperatures of the food, V12 stated she took all the temps when the food came out of the oven. When reviewing the temperature log, there were no temperatures written down for lunch. When asked to temp the food, V12 obtained a digital thermometer and ran it under water, then stuck it in the pureed food. The thermometer was not functioning and had an error code on it. V12 asked V11, Interim Dietary Manager (DM), for another thermometer, with V11 bringing a new thermometer from the back and stated that this one is brand new, so it doesn't need to be calibrated. V12 stated she is supposed to calibrate the thermometers every day, but has not done it today yet. V12 used the new thermometer to test the food. The temperature of pureed peas read 159 degrees Fahrenheit (F). V12 took the peas to the electric steamer to warm it up, and after warming, V12 rechecked the temperature which was now reading 163 degrees F. and was placed in the food line to plate. On 9/17/24 during lunch observation from 11:50 AM until 1:15 PM, V12 was seen leaving the serving line numerous times with her gloves on, going to several places in the kitchen gathering utensils, lids, and other supplies, then going back to the serving line to continue to plate the food. V12 used the same gloves throughout the lunch, including serving food, gathering supplies, going to food steamer and back to the food line to serve food, with no changing of gloves and no hand hygiene performed. V12 was seen with a surgical mask only covering her mouth and not her nose. V12's hairnet was not covering all her hair, with sides and back hair hanging out of net. V11's hair was also hanging out of her hairnet, both sides and back. V13, Dietary Aide (DA), was seen with a full beard and no hairnet on while working with the food. V13 was seen working the fryer and assisting to plate specialty plates. V13 was seen wearing the same pair of gloves as he worked several places around the kitchen and handling multiple items. There was no hand hygiene seen done during the entire lunch service. On 9/17/24 at 12:25 PM, while plating food, V12 bumped a tray of plastic bowls that was sitting on top of an uncovered large container of soup, and the tray fell into the soup. V12 pulled the tray and bowls out of the soup and placed it on the bottom shelf of a plastic cart. V12 picked up another tray of bowls on a bottom shelf in the kitchen and placed it on top of the container of uncovered soup again. Once the tray of bowels was removed from the bottom shelf, the shelf appeared to be soiled and very dirty. On 9/17/24 at 12:25 PM, the hamburgers were rechecked with a temperature reading of 145 degrees F. On 9/17/24 at 12:30 PM, V13 opened a bag of buns and used his hands with his soiled gloves to get the buns out, placed a burger on the bun, got a slice of cheese from the fridge, and placed it on the burger, then microwaved the sandwich, bun, and all. V13 did not check the temperature prior to putting fries on the plate and serving it to a resident. V12 was also seen grabbing buns multiple of times from the bag using her soiled gloves and placing the buns on a plate. On 9/17/24 at 12:40 PM, there were no temperatures documented for lunch on the temperature log sheet. There were no refrigerator or freezer temperatures dated 9/17/24 on the log. On 9/17/24 at 12:50 PM, upon further inspection of the kitchen, there was a bag of frozen curly fries that were seen open in the freezer with no date and the bag wide open. The dry stock supplies had five prune juice boxes (1.36L each) that had expiration date of 6/18/24. There was a package of buns on the bread shelf with no date and was not closed, an open country white deli bread that was open with no date, an open loaf of white bread that was tore open and not sealed or dated, and an open bag of bagels seen on top of bread shelf that had five bagels with mold on each of them. On 9/17/24 at 1:10 PM, when asked for alcohol wipes to wipe off the thermometers, V11 stated they are out, and she will have to get some from the nursing department. When asked where they are washing their hands, V13 pointed to a sink, and stated they use that sink with soap and water. When asked how they dry their hands after washing their hands, V13 looked and there were no towels available, so he walked around the kitchen and came back with a couple of hand towels, and stated that was housekeeping's job, and they must have run out of them. On 9/23/24 at 9:00 AM, upon walking into the kitchen, there were no towels seen above the sink to dry your hands, once washed. V13 was seen putting on a beard mask after this surveyor entered the kitchen. V11's hair was seen hanging out of her hair net, both her sides and the back, while she was making cheese sandwiches. The Facility's Grievance Form, dated 7/17/24, documents, Description: Food arrives cold at every meal. Example got chicken and rice soup it came to me ice cold. Investigation: Food covers being used and checked temps. Summary/Findings: Found insulated cover not effective. Action Taken: New insulated covers ordered and put into place. The Facility's Grievance Form, dated 8/6/24, documents, Description: During rounds, new admission surveys several residents on 200-hall had concerns with cold meals. No specific mealtime said it's the majority of them. They don't like to ask the CNAs to reheat due to that causes others to have even colder meals if CNAs have to stop. Investigation: Checked that foods are being temped and delivered promptly. Findings: New domes not being used and plate warmer not working. Action Taken: New plate warmer received and in use. Food saran wrapped during interim. On 9/17/24 at 12:55 PM, V11, Interim DM, stated, I am not certified yet, but we are covered by the (Company's) Certified Dietary Manager (CDM) Certificate. I don't have any policies back here; we would follow the facility's policies. On 9/19/20 at 10:00, V1, Administrator, stated, I would expect all of the kitchen staff to do proper hand washing and glove changes, when necessary, to wear hairnets with all hair tucked inside the hairnet, including any male with a beard. I would expect the cook and/or manager to check the food temperatures when coming out of oven/stove, prior to serving to resident, and throughout the serving time to maintain food at appropriate temperatures, and to thaw out food the proper ways. I would expect all expired foods to be thrown out, all food items should be sealed while storing, and all opened food items should have an open date. We will start some education immediately because this is not acceptable. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, undated, documents, 1. General storage guidelines to be followed: a) All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. c) Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. 2. Refrigerated storage guidelines to be followed: b) Conduct random temperature checks of food items. 3. Frozen storage guidelines to be followed: b) Check freezer temperature regularly. 4. Dry storage guidelines to be followed: c) Store dry food on shelves two inches away from walls to allow ventilation, six inches off the floor to allow for proper sanitation, and 18 inches from the ceiling to ensure fire safety. The Facility's Hair Restraints, undated, documents, Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. 1. Staff shall wear hair restraints in all food production, dishwashing and when serving food from steam or cold table areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. 3. All those delivering plated food to residents will pull all long hair back and/or wear an appropriate hat while serving. Hairnets are discouraged due to the institutional look that may interfere with the desired dining room atmosphere. The Facility's Hand Washing and Glove Usage, undated, documents, All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines. 3. All employees will wash hands upon entering the kitchen from any other location, after breaks, and between all tasks. Hand washing should occur at a minimum of every hour. 4. Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. 5. Gloves are to be used whenever direct food contact is requires. 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break or go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. 8. Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. 9. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. The Facility's Monitoring Food Temperatures for Meal Service, undated, documents Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. 2. The temperature for each food item will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating) will have the new temperature recorded with a circle around it next to the original temperature. 3. Proper procedures are followed to ensure that food temperatures are accurately and safely obtained according to safe food handling practices. These procedures include the following steps: a) A properly functioning and calibrated thermometer will be used when takin temperatures. b) Thermometers are washed, rinsed, sanitized before, and after each meal use. An alcohol swab may be used to sanitize between uses while taking temperatures during the same meal or if contamination of the thermometer occurs. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 9/16/2024, documents the total number of residents in the facility was 93.

Based on interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 93 residents residing in the facility. Findings include: The Facility Assessment, dated 7/11/22 - 7/10/23, did not include the following in the plan: identifying resources provide necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies; evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans; pertinent information about the resident population the facility serves may include race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy or other factors that affect access to care and health outcomes related to health equity; physical environment, equipment (medical and non-medical), assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents; evaluations of the facility's training program to ensure any training needs are met for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment did not include an evaluation of applicable policies and procedures, facility based and community-based risk assessment, utilizing an all-hazards approach that evaluates the facility's ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster, and contingency plan for events or an all-hazards approach. On 09/25/24 at 9:10 AM, V1, Administrator, stated she would have to look to see if she had an updated Facility Assessment for 2024. On 09/25/24 at 10:00 AM, V33, Regional Direction, stated V1 was suspended for an abuse allegation, and they do not have another facility assessment for 2024. On 9/25/24 at 12:41, V33 stated they do not have a policy on facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff donned/doffed Personal Protective Equipment (PPE) on the COVID-19 positive hallway, in a manner to prevent cross contamination; failed to ensure residents were not exposed to staff exhibiting symptoms of COVID-19; failed to implement transmission-based precautions for residents that were COVID-19 positive who were mobile throughout the unit including the hallway and dining/day areas; failed to ensure COVID negative residents were not exposed to COVID positive residents; failed to cohort positive COVID-19 residents together and instead cohorted positive and negatives together; failed to ensure signage posted indicating a positive COVID status; failed to offer/educate COVID vaccinations for residents and staff since 2022; and failed to have a system in place to track, trend and test residents and staff during a COVID-19 outbreak. This failure has the potential to affect all 23 residents residing on the 100 hall of the facility. Findings include: 1. On 09/16/24 at 8:45 AM, upon entering the facility, there was no signage observed indicating the facility was in a COVID-19 outbreak. On 09/16/24 at 9:00 AM, V46, Courtyard Coordinator, V70, Certified Nursing Assistant (CNA), and V71, CNA, were observed on the Covid positive unit wearing only an N95 mask. R82 was observed walking up and down the hall with no PPE (mask) on. (R82 was later identified as COVID positive). V46, V70, and V71 failed to wear eye protection around a COVID positive resident. On 09/16/24 at 12:38 PM, R19, who was COVID positive, was observed sitting at the same table during the afternoon meal as R61, who was COVID negative. (R19 was later identified as COVID positive and R61 later identified as negative for COVID) On 09/17/24 at 12:20 PM, V46, Courtyard Coordinator, V70, CNA, and V71, CNA, were observed wearing only their N95 mask, without any eye protection. R7, R49, R70, and R82 (who were all later identified as COVID positive by V9, CNA) were observed not having on any type of PPE. R49, who was COVID positive, did not have mask on, was observed sitting at the dining room table during the afternoon meal with R66, who was COVID negative. No staff were observed trying to encourage residents to put on a face mask. On 09/18/24 at 2:35 PM, V9, CNA, walked this surveyor down the hall and pointed out who was COVID positive and who was negative. V9 identified the following: R77 who was COVID positive was in the room with R37 who was COVID negative; R82 who is in a room by himself was positive; R19 who is COVID positive and in a room with R66 who is negative; R87 was COVID positive and in a room with R10 who was negative; R50 was COVID negative and in a room with R73 who was COVID positive; R61 who was negative was in a room with R7 who was positive for COVID; R70 who was COVID positive was in a room with R21 who was initially negative but became positive, placed on hospice and later expired; R67 who was negative was in a room with R47 who was COVID positive; and R49 who was COVID positive was in a room with R60 who was COVID negative. On 09/18/24 at 2:22 PM, V34, Licensed Practical Nurse (LPN), and V35, LPN, were observed to have on only an N95 mask without eye protection on the Covid positive unit. On 09/19/24 at 08:35 AM, V25, CNA, observed to be wearing N95 mask without eye protection on the Covid positive unit. On 09/19/24 at 09:23 AM, V46, Courtyard Coordinator, was observed wearing a gown and N95 mask. No eye protection was observed. V46 stated when going into a resident's room who is COVID positive, staff should wear a gown, N95, goggles or face shield, and gloves, and it should be changed after each person who is COVID positive. On 09/19/24 at 09:50 AM, V25, CNA, stated staff should be wearing gown, goggles, gloves, and N95 mask when going into a room with a COVID positive resident. V25 said they try to keep the covid positive residents in their rooms, but it's hard because they like to wander. She said she didn't understand why they didn't move any of the resident's when they were covid positive. On 09/25/24 at 04:22 AM, V63, CNA, stated the facility did not move any of the residents on the unit during the COVID outbreak, and they kept the positives with the negatives. V63 said she questioned the nurses on the unit as to why negative and positive residents stayed together because there were residents on the unit that no longer needed to be and could have been moved out to the other halls. On 9/19/24 at 2:38 PM, V50, R37's Daughter, was seen walking into the COVID positive unit with no Personal Protective Equipment (PPE) on, walked down the hall and into R37's room, and then was seen exiting the hall and out the facility's front door. At no time was any PPE seen put on, or any hand hygiene done. On 09/18/24 at 2:29 PM, V9, CNA, was observed to be only wearing an N95 mask on the COVID unit. She said R77, who is currently out at the hospital, is now COVID positive. She said the man (R21) who just passed was the worst COVID positive one she seen, but she said he also had pneumonia. 2.R21's admission Record, with a print date of 09/19/24, documented R21 has diagnoses of but not limited to Alzheimer's disease, Pneumonia, unspecified organism, and personal history of COVID-19 R21's Minimum Data Set (MDS), dated [DATE], documented R21 is severely cognitively impaired, was dependent on staff for all of his activities of daily living (ADL), and was always incontinent of bowel and bladder. R21's Physician's Orders, dated 08/12/24 at 5:49 PM, documented COVID- May complete antigen testing to rule out COVID 19. R21's Physician's Orders, dated 09/11/24 at 1:47 PM, documented COVID- vital signs (VS) and oxygen saturation (O2) every 4 hours for 14 days every shift. R21's current Physician's Orders were reviewed and documented R21 had COVID- Resident in isolation related to (r/t) active Covid positive. All services to be provided in resident room including therapy, activities, meals, and nursing services every shift for 14 Days. R21's Progress Notes, dated 9/12/2024 at 7:52 PM, documented, Condition poor, head of bed (HOB) elevated, rattling respirations, oxygen (O2) at 5 Liters (L)/mask, skin warm and dry (w/d). Keeping eyes closed, arms flaccid. Difficulty swallowing. Depends on staff for all ADL'S. No mottling noted at this time. Family at bedside. Comfort care. R21's Progress Notes, dated 9/13/2024 at 1:12 PM, documented, resident continues to decline, and family is at bedside. Resident is not swallowing anything. HOB (Head of bed) elevated. Continuous 5L O2. Resident appears to be resting without discomfort. Comfort measures. R21's Progress Notes, dated 9/14/2024 at 9:26 PM, documented, remains on antibiotic (ABT) for pneumonia, no adverse reaction noted. HOB elevated, O2 at 5L/mask. Void x1 incontinent. No by mouth (po) intake. Condition remains poor. Family at bedside. R21's Progress Notes, dated 9/15/2024 01:57 AM, documented, (R21) continues PO ABT for pneumonia. No adverse reactions noted. Resident continues to decline in condition. Daughter has been by his side a good portion of the night. Continues 5L per nasal canula (NC). Resident is not restless or showing signs of pain, although he does have apneic breathing. Resident using as needed (PRN) Ativan. R21's Progress Notes, dated 9/15/2024 at 10:49 AM, documented, Social Services talked to family today. They were hesitant about deciding to set up hospice services. Social Services provided education to family and what hospice offers. R21's Progress Notes, dated 9/15/2024 at 1:51 PM, documented, Family came to Social Services and asked her to send referrals to all companies to try and get R21 admitted immediately to hospice for his comfort. Social Services sent one referral to three different hospice companies, and whichever is able to admit first will be the accepted company. Social Services will continue to follow and see if we can get him admitted today. R21's Physician's Orders, dated 09/15/24 at 5:40 PM, documented R21 was admitted to hospice with a primary diagnosis of Covid 19 and secondary diagnosis of Cerebral Atherosclerosis. R21's Progress Notes, dated 9/15/2024 at 6:06 PM, documented, Resident started on hospice services; resident doing poorly with family still at bedside. R21's Progress Notes, dated 9/18/2024 at 11:20 AM, documented, (R21) continues on Hospice, resident is modeling from the feet, O2 at 85% on 3L O2 via NC, no breakthrough pain or discomfort noted, resident's pulse is greater than (>)110, he has spiked a fever of 101.4, hospice nurse in to see resident and informed her of his condition. Writer let hospice know the family is declining the Tylenol suppository at this time (for fever) and declining the Hyoscyamine as well. They would rather we leave him alone. R21's Progress Notes, dated 9/18/2024 12:25 PM, documented, (R21) passed away at 12:25 PM with family and staff at bedside, very comfortably. Apical pulse auscultated for 1 minute, no pulse found. Hospice called and made aware. Resident's body will go to the Funeral Home of family's choice. R21's death certificate, date of death [DATE], was reviewed and documented cause of death Part I. a. 2019-N COVID Acute Respiratory Disease, b. Alzheimer's Disease, C. Dementia, Severe, without behavioral disturbances. Part II. Pneumonia, unspecified organism. 09/19/24 at 1:49 PM V41, R21's physician was contacted about R21. V41 stated he wasn't aware R21 was in a room with a COVID positive resident prior to R21 getting COVID, and no he didn't think he would cohort residents who are COVID positive with residents who are negative. V41 said it would be hard to say if R21's COVID positive status was one of the reasons R21 was placed on hospice and then later passed away. He said R21 had been ill a long time with aspiration pneumonia off and on. 3. On 09/19/24 at 08:54 AM, R19 was slumped over in his wheelchair and was taken to his room to be laid down. V21, CNA, and V25, CNA, took R19 into his room, with no hand hygiene being done prior and they only had on a gown and N95 mask, no gloves or eye protection were noted. At 8:57PM, V21, CNA, came out of R19's room after lying him down with the same gown on, and then went into the shower room wearing the same gown. At 09:00 AM, V25, CNA, came out of R19's room still wearing the same gown and mask, got a walker from across the hall, and went back into R19's room. At 09:02 AM, V25 came out of R19's room still wearing the same gown, and went over into the dining area, then went into the shower room with the same gown. 4.On 09/23/24 at 08:53 AM, V43, LPN, stated she just had COVID and just came back to work last week. V43 said she has heard other staff have been positive for COVID, but she doesn't know who they are. She said they don't report to her when someone is positive, so she has no idea. On 09/23/24 at 9:00 AM, V46, Courtyard Coordinator, stated they don't test staff unless they have COVID symptoms. On 9/18/24 at 2:00 PM, when asked how many residents in the facility are positive with COVID-19, V2, DON, stated, I really don't know. There may have been some come off the list already. When asked who and when they are testing for COVID-19, V33, Regional Director, stated, Per our policy, we test after our first positive and after day five and day seven, and once we have another positive, we start over again until we are negative. We will put a list of residents who are positive with COVID and who have been tested. On 9/19/24 at 8:30 AM, V2, DON, stated, Just to let you know, I am already working on the POC (Plan of Correction) and working on getting everything updated for September. On 9/23/24 at 8:48 AM, V23, Registered Nurse (RN), stated she was COVID positive on 8/18/24. V23 stated she worked the 100-Unit (later identified as the COVID locked unit) on 8/14/24, and was supposed to work on 8/18/24, but she was not feeling well, so tested for COVID, and noted to be positive. V23 stated she was offered the COVID vaccination in 2021 and 2022, but declined, and has not been offered since. V23 stated she thought they handed out some COVID education papers at one time. V23 stated she usually works on the 100-Unit unless she is extra or the community nurse, then helps everywhere. V23 stated everyone is supposed to wear N-95 mask upon walking through the 100-unit doors and full PPE, gown, gloves, face shield, mask upon walking into a resident room. V23 stated she sees visitors coming and going in and out of the 100-hall doors without anything on, no mask or anything. V23 stated she tries to educate them, but is usually told I don't care. On 9/23/24 8:51 AM, V27, Certified Nursing Assistant (CNA), stated she just started at the facility on 9/3/24 after just getting over COVID 2 weeks prior from a different facility. V27 stated she is aware of some staff getting COVID, but is unsure of names. V27 stated she has never been offered the COVID vaccination at this facility and has not had any kind of COVID education offered. V27 stated she mostly works the 200-hall, but has worked the 100-hall before. V27 stated all she was told she had to wear in the 100-Unit was the N-95 mask, and she has never been told she had to wear gown, gloves, or face shield, and she was unaware that she was supposed to. On 9/23/24 at 9:03 AM, V44, Dietary Aide, stated he was tested two days ago and he tested himself due to the high risk in the facility. V44 stated he is aware of one person in laundry that was COVID positive a month or so ago, and that V13 was also positive. V44 stated he was vaccinated in 2021 and 2022 with boosters, and he went to the local health clinic to get them. V44 believes he did receive COVID information from the facility. V44 stated he only works in the kitchen. V44 stated he uses a mask, gloves, and washes his hands, but does not wear gown or eye protection. On 9/23/24 at 9:06 AM, V11, Dietary Manager, stated she was tested about one and half weeks ago, and she tested negative. V11 stated she had two employees, V48, Dietary Aide, and V13, Dietary Aide. V11 stated she has not been offered the COVID vaccination or COVID education from the facility. V11 stated they don't have to wear PPE in the kitchen, but if staff are going into the 100-unit, they should be wearing gown, gloves, face shield, and mask. V11 stated her staff go into the unit two to three times a day to deliver meals. On 9/23/24 at 9:12 AM, V45, LPN, stated she tested last week on Monday and Thursday and was negative. V45 stated she knows (V49, CNA), tested positive last week, and is now off work. V45 stated she was vaccinated, but it was at other places and not at this facility, has not been offered vaccination or education at facility. V45 stated she works each floor because she is the Restorative Nurse. V45 stated if any staff is going into the 100-Unit, they are supposed to wear a N-95, a gown, gloves, and a face shield, because those residents are walking around everywhere. On 9/23/24 at 10:35 AM, V48, Cook/Maintenance, stated he was PT (part time) Maintenance and PT [NAME] at the facility. V48 stated on either 9/6/24 or 9/13/24, he came into work and wasn't feeling well, and told his mother (V1), and she advised him to test for COVID, and he tested positive. V48 stated V13, DA/Dietary Aide, also tested positive. V48 stated he was not offered the COVID vaccination, and his mom (V1) told him there is a COVID packet of information he could have if he wanted it, and he declined. V48 stated he is a [NAME] and cooks the food for all residents. V48 stated the Dietary Aide typically takes the food to the halls, and he will only do it if someone requests a special tray that he will make up and deliver to that resident. On 9/23/24 at 3:00 PM, V47, Housekeeper, was seen coming out of the 100-hall pushing her housekeeper cart. When asked about the cart, V47 stated she uses the same cart throughout the facility. When asked about her process for coming out of the COVID hall (100-hall), V47 stated she takes her cart and cleans everywhere that needs to be cleaned, halls, resident rooms, restrooms, ect., and when she gets done with the 100-hall, she will take the cart to the housekeeping closet, on the 400-hall, and will put her soiled mop head and rags in a barrel and then dump the mop water and trash. V47 stated the Laundry Department will pick up the soiled mop heads and wash them. V47's housekeeping cart had a large trash container on side of cart that appeared full of trash and not covered. When asked, V47 stated that was from the 100-hall. V47 stated they do have other housekeeping carts in the facility, but was never aware to use one specific cart for the COVID Unit/Isolation rooms. R47 was seen dumping the contaminated mop water from the 100-hall into a large sink in the closet with no gloves or other PPE on. On 9/18/24 at 10:25 AM, V2, Director of Nursing (DON), stated, Both me and (V8, Assistant Director of Nursing/ADON) are certified Infection Preventionist (IP) for this facility, but (V8) does most of the work with it. V2 is the facility's IP with a Certification on file, dated 4/3/22. V8 is also the facility's IP with a Certification on file, dated 6/27/24. On 9/18/24 at 2:15 PM, after being asked for a list of residents and staff who are positive for COVID-19, V1, Administrator, and V33, Regional Director, provided a LTC (Long Term Care) Respiratory Surveillance Line List, handwritten, and dated 8/16/24. This list documents R78 was the only resident, along with two staff members, who were COVID Positive. R78 tested positive on 8/10/24, V6, LPN, tested positive on 8/8/24, and V42, Housekeeper, tested positive on 8/10/24. On 9/18/24 at 2:15 PM, V1 and V33 provided a LTC (Long Term Care) Respiratory Surveillance Line List, dated 9/18/24. This list has seven residents listed who have tested positive with COVID-19, ranging in dates from 9/4/24 to 9/12/24. On 9/19/24 at 9:00 AM, V1 and V33 also provided a LTC (Long Term Care) Respiratory Surveillance Line List, dated 9/19/24. This list has one staff member and one resident who tested positive for COVID. On 9/19/24 at 9:05 AM, V33 also provided a handwritten list of residents who were tested, including the dates tested. This list documents the first positive COVID was on 8/31/24 was R82, which is different than previous list given. There is nothing documented in the Infection Surveillance log since the end of August (31st), including all residents who currently are COVID-19 Positive. V2 stated, With all the DON duties and trying to train (V8) to do Infection Control, I have not had time to do anything with it. On 9/24/24 at 3:00 PM, when asked about offering the residents and staff the COVID vaccination and/or booster, V2, DON, stated, After it was mandated in 2022, I don't recall doing anything after that, but I also was not here in 2022. On 9/25/24 at 8:40 AM, V1, Administrator, stated I would expect all staff to maintain all COVID precautions, including tracking, testing, and offering education and vaccinations as needed' V1, Administrator, stated, I would expect the Infection Preventionist to keep up with the infection surveillance daily, weekly, and monthly to make sure residents are on the correct antibiotic and treatments. On 9/19/24 at 2:04 PM, when asked what his expectations are of the facility vaccinating the residents, V40, Medical Director, stated, All residents in the facility should definitely be vaccinated against COVID and the Influenza. This should have already been started in September. I feel that any resident who gets COVID has the potential for serious harm and/or death. The vaccination, if administered, would improve, or at least diminish, the harm and severity of the disease. I would expect the facility to keep up with the vaccinations, especially COVID and Influenza, and I will be working with them to get this done. The Facility's SARS-CoV-2 Infection Policy, dated 8/22/24, documents, HCP (Health Care Providers), Residents, and Visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. Additionally encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Ensure everyone is aware of recommended IPC (Infection Prevention Control) practices in the facility. Post visual alerts at the entrance and in strategic places. These alerts should include instructions about current IPC recommendations. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The Facility's Infection Prevention and Control Program, dated 2019, documents the intent of this regulation is to ensure that the facility: * Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually, based upon the facility assessment and as necessary. This would include revision of the IPCP as national standards change. *Establish facility-wide systems for prevention, identification, investigation and control of infections of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. Elements of the program include: * Program oversight including planning, organizing, implementing, operating, monitoring, and maintaining all of the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control. * The facility will designate one or more individuals as the infection preventionist(s) who is responsible for the facility's infection prevention and control program. * Surveillance, including process and outcome surveillance, will include monitoring, data analysis, documentation and communicable diseases reporting (as required by State and Federal law and regulation). Surveillance activities will be conducted to identify practice, infection trends and early identification of new infections and potential outbreak situations. *Antibiotic Stewardship and review including reviewing date to monitor the appropriate use of antibiotics in the resident population. The Facility's SARS-CoV-2 Infection Policy, dated 8/22/24, documents: Policy Statement: AS of today, the following COVID policy captures the most up to date information enabling us to be proactive in adopting practices to keep our residents, staff and visitors safe. The community/facility should follow county, state and federal recommendations applicable for SARS-CoV-2 Infection prevention and treatment. Sars-CoV-2 Infection Prevention: COVID-19 Vaccines: HCP (healthcare providers), residents, and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. Additionally encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Ensure everyone is aware of recommended IPC (Infection Control Practices) in the facility. Post visual alerts (eg signs, posters) at the entrance and in strategic places. When to Implement Source Control Measures for Prevention: People particularly those at high risk for severe illness, should wear the most protective mask or respirator they can that fits well and that they will wear consistently. Source control is recommended for individuals in healthcare setting who: have suspected of confirmed SARS-CoV-2 infection or other respiratory infection, had close contact (residents and visitors) or higher risk exposure (HCP) with someone with SARS-CoV-2 infection for 10 days after exposure for skilled nursing facility residents. As SARS-CoV-2 transmission in the community (facility) increases, the potential for encountering asymptomatic or pre-symptomatic residents with SARS-CoV-2 infection also likely increases. In these circumstances healthcare facilities should consider implementing broader use of respirators and eye protection by HCP during resident care encounters as described below: NIOSH approved particulate respirators with N95 filters eye protection (ie goggles or face shield that covers the front and sides of the face) work during all resident care encounters. Optimizing the use of Engineering Controls and Indoor Air Quality: optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other residents from infected individuals (eg physical barriers at reception/triage locations and dedicated pathways to guide symptomatic residents through waiting rooms and triage areas). Take measures to limit crowding in communal spaces explore options in consultation with facility engineers, to improve ventilation delivery and indoor air quality in resident rooms and all share spaces. Recommended infection prevention and control practices when caring for a resident with suspected or confirmed SARS-CoV-2 infection. The IPC recommendations described below (eg resident placement, recommended PPE) and also apply to resident with symptoms of COVID and asymptomatic residents who have met the criteria for empiric Transmission based precautions based on close contact with someone with SARS-CoV-2. However, these residents should NOT be cohorted with residents with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. The empiric Transmission Based Precautions used for SARS CoV 2 if it suspected or confirmed is enhance droplet/contact/eye protection. Asymptomatic residents regardless of vaccination status with close contact with someone with SARS CoV2 infection should have a series of three viral tests for SARS CoV2 infection. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and if, negative again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is 0), day 3, and day 5. Examples of when empiric Transmission Based Precautions following close contact may be considered include: a skilled nursing facility resident is unable to be tested or wear source control as recommended for the 10 days following their exposure, resident is moderately to severely immunocompromised, resident is residing on a unit with others who are moderately to severely immunocompromised, resident is residing on unit experiencing ongoing SARS- CoV2 infection that is not control with initial interventions. Resident Placement with suspected or confirmed SARS-CoV2 infection: Place a resident with suspected or confirmed SARS- CoV2 infection in a single person room and placed in enhanced droplet/contact/eye protection. The door should be kept closed (if safe to do so). Ideally the resident should have a dedicated bathroom. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for residents with SARS- COV2 infection. Personal Protective Equipment: HCP who enter the room of a resident with suspected or confirmed SARS CoV 2 infection should adhere to enhanced droplet/contact/eye protection and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (ie goggles or a face shield that covers the front and sides of face).Resident with cognitive defect and or those resident in memory care: It may be difficult to maintain infection control practices including resident isolation. Every effort will be made to follow infection control practices.

Based on interview and record review, the facility failed to offer, provide, and track COVID vaccines, boosters, and immunizations. This failure has the potential to affect all 93 residents residing in the building. The Findings Include: V2, Director of Nursing (DON), is the facility's Infection Preventionist (IP), with a Certification on file dated 4/3/22. V8, Assistant Director of Nursing (ADON), is also the facility's IP with a Certification on file, dated 6/27/24. On 9/18/24 at 10:25 AM, V2 stated, Both me and (V8) are certified Infection Preventionist for this facility, but (V8) does most of the work with it. On 9/18/24 at 1:25 PM, when asked about resident Influenza and other resident vaccinations, V8 stated, We just received the Influenza vaccination this past Thursday (9/12/24). (V2) started asking residents last week and we have been asking this week as well if they want the vaccination. I will be going through each resident's medical record and checking their immunizations. If needed, I will follow up to make sure they get them. On 9/18/24 at 1:30 PM, when asked for a list of residents who have refused, consented, or received any vaccinations, V2, DON, stated, I don't have a list. It should be scanned into the resident's medical record if they have had one. The CDC has a large and complicated algorithm to follow for the Pneumococcal and other vaccinations. On 9/18/24 at 2:00 PM, when asked how many residents are positive with COVID-19, V2 stated, I really don't know. There may have been some come off already. When asked who and when they are testing for COVID-19, V33, Regional Director, stated, Per our policy, we test after our first positive and after day five and day seven and once we have another positive, we start over again until we are negative. We will put a list of residents who are positive with COVID and who have been tested. On 9/19/24 at 2:04 PM, when asked what his expectations are of the facility vaccinating the residents, V40, Medical Director, stated, All residents in the facility should definitely be vaccinated against COVID and the Influenza. This should have already been started in September. I feel that any resident who gets COVID has the potential for serious harm and/or death. The vaccination, if administered, would improve, or at least diminish, the harm and severity of the disease. I would expect the facility to keep up with the vaccinations, especially COVID and Influenza, and I will be working with them to get this done. On 9/18/24 at 2:15 PM, after being asked for a list of residents and staff who are positive for COVID-19, V1, Administrator, and V33, Regional Director, provided a LTC (Long Term Care) Respiratory Surveillance Line List, handwritten, and dated 8/16/24. This list documents R78 was the only resident, along with two staff members, who were COVID Positive. R78 tested positive on 8/10/24, V6, LPN, tested positive on 8/8/24, and V42, Housekeeper, tested positive on 8/10/24. On 9/23/24 at 8:33 AM, V6 stated at the end of July, he felt kind of sick over a weekend that was his regularly scheduled weekend off. V6 stated he had a little bit of sinus problems, but felt fine by Monday. V6 stated he did not test for COVID when he came back to work, and was never confirmed positive. V6 stated if he thought he had COVID, he would have tested before returning to work. V6 stated he mentioned to coworkers after they had an employee test positive, that maybe he did have COVID at the end of July, however, now he thinks he didn't have COVID. V6 stated he did get boosters from the health department because no one at the facility has offered him a booster. V6 stated he doesn't work the 100-Unit. V6 stated he heard V13, Dietary Aide, was positive last month. On 9/23/24 at 8:48 AM, V23, Registered Nurse (RN), stated she was COVID positive on 8/18/24. V23 stated she worked the 100-Unit on 8/14/24, and was supposed to work on 8/18/24, but she was not feeling well, so tested for COVID, and noted to be positive. V23 stated she was offered the COVID vaccination in 2021 and 2022, but declined and has not been offered since. V23 stated she thought they handed out some COVID education papers at one time. V23 stated she usually works on the 100-Unit, unless she is extra or the community nurse, then helps everywhere. V23 stated everyone is supposed to wear N-95 mask upon walking through the 100-unit doors and full PPE, gown, gloves, face shield, mask upon walking into a resident room. V23 stated she sees visitors coming and going in and out of the 100-hall doors without anything on, no mask or anything. V23 stated she tries to educate them but is usually told, I don't care. On 9/23/24 8:51 AM, V27, Certified Nursing Assistant (CNA), stated she just started at the facility on 9/3/24 after just getting over COVID 2 weeks prior from a different facility. V27 stated she is aware of some staff getting COVID, but is unsure of names. V27 stated she has never been offered the COVID vaccination at this facility, and has not had any kind of COVID education offered. V27 stated she mostly works the 200-hall, but has worked the 100-hall before. V27 stated all she was told she had to wear in the 100-Unit was the N-95 mask and she has never been told she had to wear gown, gloves, or face shield, and she was unaware that she was supposed to. On 9/23/24 at 9:03 AM, V44, Dietary Aide, stated he was tested two days ago and he tested himself due to the high risk in the facility. V44 stated he is aware of one person in Laundry that was COVID positive a month or so ago, and that V13 was also positive. V44 stated he was vaccinated in 2021 and 2022 with boosters, and he went to the local health clinic to get them. V44 believes he did receive COVID information from the facility. V44 stated he only works in the kitchen. V44 stated he uses a mask, gloves, and washes his hands, but does not wear gown or eye protection. On 9/23/24 at 9:06 AM, V11, Dietary Manager, stated she was tested about one and half weeks ago, and she tested negative. V11 stated she had two employees, V48, Dietary Aide, and V13, Dietary Aide. V11 stated she has not been offered the COVID vaccination or COVID education from the facility. V11 stated they don't have to wear PPE in the kitchen, but if staff are going into the 100-unit, they should be wearing gown, gloves, face shield, and mask. V11 stated her staff go into the unit two to three times a day to deliver meals. On 9/23/24 at 9:12 AM, V45, LPN, stated she tested last week on Monday and Thursday and was negative. V45 stated she knows (V49, CNA), tested positive last week, and is now off work. V45 stated she was vaccinated, but it was at other places and not at this facility, has not been offered vaccination or education at facility. V45 stated she works each floor because she is the Restorative Nurse. V45 stated if any staff is going into the 100-Unit, they are supposed to wear a N-95, a gown, gloves, and a face shield, because those residents are walking around everywhere. On 9/23/24 at 10:35 AM, V48, Cook/Maintenance, stated he was PT (part time) Maintenance and PT [NAME] at the facility. V48 stated on either 9/6/24 or 9/13/24, he came into work and wasn't feeling well, and told him mother (V1), and she advised him to test for COVID, and he tested positive. V48 stated V13, DA Dietary Aide, also tested positive. V48 stated he was not offered the COVID vaccination, and his mom (V1) told him there is a COVID packet of information he can have if he wanted it, and he declined. V48 stated he is a [NAME] and cooks the food for all residents. V48 stated the Dietary Aide typically takes the food to the halls, and he will only do it if someone requests a special tray that he will make up and deliver to that resident. On 9/23/24 at 3:00 PM, V47, Housekeeper, was seen coming out of the 100-hall pushing her housekeeper cart. When asked about the cart, V47 stated she uses the same cart throughout the facility. When asked about her process for coming out of the COVID hall (100-hall), V47 stated she takes her cart and cleans everywhere that needs to be cleaned, halls, resident rooms, restrooms, ect., and when she gets done with the 100-hall, she will take the cart to the housekeeping closet, on the 400-hall, and will put her soiled mop head and rags in a barrel and then dump the mop water and trash. V47 stated the Laundry Department will pick up the soiled mop heads and wash them. V47's Housekeeping cart had a large trash container on side of cart that appeared full of trash and not covered. When asked, V47 stated that was from the 100-hall. V47 stated they do have other housekeeping carts in the facility, but was never aware to use one specific cart for the COVID Unit/Isolation rooms. R47 was seen dumping the contaminated mop water from the 100-hall into a large sink in the closet with no gloves or other PPE on. On 9/18/24 at 2:15 PM, V1 and V33 provided a LTC (Long Term Care) Respiratory Surveillance Line List, dated 9/18/24. This list has seven residents listed who have tested positive with COVID-19, ranging in dates from 9/4/24 to 9/12/24. On 9/19/24 at 9:00 AM, V1 and V33 also provided a LTC (Long Term Care) Respiratory Surveillance Line List, dated 9/19/24. This list has one staff member and one resident who tested positive for COVID. On 9/19/24 at 9:05 AM, V33 also provided a handwritten list of residents who were tested, including the dates tested. This list documents the first positive COVID was on 8/31/24 was R82, which is different than previous list given. On 9/24/24 at 3:00 PM, when asked about offering the residents and staff the COVID vaccination and/or booster, V2, DON, stated, After it was mandated in 2022, I don't recall doing anything after that, but I also was not here in 2022. On 9/25/24 at 8:40 AM, V1, Administrator, stated, I would expect all staff to maintain all COVID precautions, including tracking, testing, and offering education and vaccinations as needed. There is nothing documented in the Infection Surveillance log since the end of August (31st), including all residents who currently are COVID-19 Positive. V2 stated, With all the DON duties and trying to train (V8) to do Infection Control, I have not had time to do anything with it. The Facility's SARS-CoV-2 Infection Policy, dated 8/22/24, documents, HCP (Health Care Providers), Residents, and Visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. Additionally encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Ensure everyone is aware of recommended IPC (Infection Prevention Control) practices in the facility. Post visual alerts at the entrance and in strategic places. These alerts should include instructions about current IPC recommendations. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.

Based on interview and record review, the facility failed to ensure Nurse Aides completed the required 12 hours of education per year. This has the potential to affect all 93 residents residing in the facility. Findings include: 1. The facility's employee files documented the following: V73, Certified Nurse Assistant, (CNA) hire date of 10/20/21. V74, CNA hire date of 8/2/2023 V75, CNA hire date of 9/1/2020 V76, CNA hire date of 1/17/2022 V73's computer education report, dated 9/1/23-9/25/23, documents V73 had 1.75 hours of education for the past year. V74's computer eduction report, dated 9/1/23-9/25/23, documents V74 had 0.5 hours of eduction for the past year. V75's computer education report, dated 9/1/23-9/25/23, documents V75 had no education hours documented for the past year. V76's computer eduction report, dated 9/1/23-9/25/23, documents V76 had 2 hours of eduction for the past year. On 9/24/24 at 3:15PM, V2, Director of Nursing, stated she is not sure how many education hours CNA's are required to complete annually. On 9/25/24 at 1:00PM, V33, Regional Director, stated she is unsure how mnay hours CNAs are required to complete annually, but would check. V33 stated the facility's computerized education system does not always give hours for each course, and inservice logs do not say how long trainings are, so she has no way of knowing how many hours CNAs have. On 9/25/24 at 2:09 PM, V33 stated they do not have a policy for CNA education. The Facility's Medicare and Medicaid Application, dated 9/16/24, documents there are 93 residents residing in the facilty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Administrator of an allegation of abuse immediately for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's admission Record, print date of 1/30/24, documented R1 was admitted on [DATE], and has diagnoses of Anxiety and Depression. R1's Minimum Data Set, dated [DATE], documents R1 is cognitively intact. R1's Health Status Note, dated 1/21/24 at 12:36 PM, documents, CNAs reported to writer that resident made accusations against a male midnight CNA that he did not recognize as a regular employee from previous shift. Resident reported to CNAs that this specific CNA made sexually inappropriate comments and touched him sexually. Writer went to resident's room to confirm story. Resident told writer a story. Writer said to confirm with Resident 'Just to be clear and to confirm. The male CNA that worked overnight made sexually inappropriate comments and touched you in an inappropriate sexual manner', (R1) responded 'Yes'. On 1/30/24 at 10:02 AM, V5, Licensed Practical Nurse (LPN), stated, The CNA's (Certified Nurse's Aides V6 and V7) came to me and told me that (R1) stated that the agency night CNA had made inappropriate sexual comments and touching. I went in and talked to (R1). (R1) did confirm that inappropriate comments were made and that he was touched. (R1) was very vague. (R1) said (V4, Agency CNA) made a comment about women's private parts, but that is all that he would say. He was very vague, and I wasn't going to press him. I then went and notified (V1, Administrator). By the time that (R1) said anything, (V4) was already out of the building. On 1/30/24 at 10:21 AM, V6, CNA, stated, I went in to help another aide get (R1) cleaned up. He said there was a man in my room last night and he tried and did touch me inappropriately. I asked him if it was a worker, and he said that he didn't know who it was. (R1) then told something else to my coworker. He was very vague with what had happened. He has a history of making up things on agency staff. I don't want to say that I didn't believe him, but with his history. I just went and told the nurse so she could handle it. On 1/30/24 at 10:35 AM, V7, CNA, stated she came in in the morning and asked R1 how his night was. (R1) said that he thought the night nurse liked him, and that he might have made a pass at him. He was not specific. I told him that now a days some people are attracted to the same sex. Later in the shift he said, 'That agency CNA told me that he had a small weenie and that he couldn't please a woman and that he thought he needed a man.' I immediately went and told (V5) and she went into his room to talk to (R1). She then called (V1) and let her know. On 1/30/24 at 12:07 PM, V9, CNA, stated, (On 1/21/24 dayshift) I got in report from (V4) that (R1) was making inappropriate comments. (V4) told me that is the reason (R1) is still in bed and I would need to get him up. So, I went down and got (R1) up. (R1) said something along the lines of the agency CNA wanted to suck on his penis. I then got transferred to a different hall. I eventually got around to tell (V5, Licensed Practical Nurse/LPN). I was on the unit, and it is very busy over there. V9 was questioned as to what time R1 told her and what time she notified (V5), V9 stated, It was about 6:00 AM. I honestly couldn't tell you when I told (V5), it was a very busy morning. On 1/30/24 at 3:30 PM, V1, Administrator, stated she has educated the staff to notify her immediately and that is the expectation of the facility. The Abuse, Prevention and Prohibition Policy, dated 1/24, documents, Reporting /Response: The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator of his/her designated representative in the Administrators absence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent resident to resident physical abuse for 6 of 6 residents (R2, R3, R4, R8, R9, and R13) reviewed for abuse in the sample of 13. Findings include: 1. R2's Face Sheet documents an admission date of 3/25/22 and diagnoses to include Unspecified Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, and Unspecified Sequelae of Cerebral Infarction. R2's Order Summary Report, dated 11/16/23, documents an order, dated 9/26/23: Brexipiprazole 0.5 milligram (mg) one time a day by mouth related to Alzheimer's Disease, Unspecified. Another order, dated 11/16/23, documents: Brexipiprazole 1 mg one time a day by mouth related to Alzheimer's Disease, Unspecified, increasing R2's daily dose to 1.5 mg/day. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has clear speech, is usually understood, and usually understands others. It documents R2 is severely cognitively impaired, and has a BIMS (Brief Interview for Mental Status) score of 1. This same MDS further documents R2 did not have any physical behaviors towards others during the look-back period for this assessment, and is independent with ambulation. R2's Care Plan, dated 3/25/22, documents a focus area of (R2) has been identified as being a vulnerable person related to his diagnosis of dementia. The goal for this focus area documents Safety will be maintained through the next review date of 2/5/24. The intervention listed documents Frequent rounding is provided by unit staff to maintain safety and ensure resident needs are met and (R2) resides on a closely supervised unit. R2's Care Plan also has a focus area of (R2) has a behavior problem of inappropriate touching with women and physical aggression. The goal for this care plan documents: Resident will have no incidents related to identified offense through next review date of 2/5/24. Interventions for this care plan document: Involve resident in food activities to occupy his time. ; Staff will monitor residents near (R2) and redirect. ; Behavior #1: (R2) at times will attempt to hold female resident's hands and rub their backs. Staff should intervene as necessary and offer activities he enjoys such as talking about sports and reminiscing about his family. : Behavior #2: Physical Aggression- (R2) can become physically aggressive at times. 1) Allow (R2) time to calm down by himself 2) Reapproach at a later time. 3) Have another staff member approach and try to care for (R2). ; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. : Provide a program of activities that is of interest. ; Anticipate and meet the resident's needs. ; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. ; Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. ; Minimize potential for the resident's behaviors by offering tasks which divert attention such as watching sports or talking about his past. No new interventions had been added to this care plan since 9/21/23. On 11/21/23 at 3:23 PM, Emergency Medical Technicians (EMTs) and a Police Officer were observed going back onto the dementia unit, and a few minutes later left with R2 on the stretcher. V2, Director of Nursing (DON), stated she had witnessed R2 hitting the nurse. V2 stated she was not sure if there was another resident involved in the altercation or not. On 11/21/23 at 3:30 PM, V1, Administrator, stated R2 had hit another resident (R8) and then hit V4, Licensed Practical Nurse (LPN), and kicked V9, Certified Nursing Assistant (CNA). V1 stated R2 is being sent to the emergency room (ER) right now, and referrals had been sent to (inpatient psychiatric hospitals). A Facility Reported Incident, dated 11/27/23, documents, On 11/21/23 it was reported to the administrator that (R2) had made physical contact with (R8), a female resident, by hitting her across the face with his open right hand to her left cheek area. The residents were immediately separated by the staff, 911 was called and resident was sent to (local hospital) via Emergency Medical Services (EMS) and accompanied by (local police department) due to continued agitation and behaviors. (R2) later returned from the ER with no new orders. Licensed Staff initiated head to toe assessments, noting no injury. An investigation was initiated, and all parties were notified. Staff was interviewed. Staff observed the physical interaction. When (R2) was asked what happened, (R2) shrugged his shoulders. (R8) does not recall what happened. Several resident were interviewed and voiced no concerns. The facility is aware that physical interaction occurred. Social Service will conduct follow-up visits with (R8) and (R2). Care plans have been reviewed and updated. No further incidents have occurred. The facility's Abuse Investigations were reviewed and document another resident to resident altercation between R2 and R8 that occurred prior to the 11/21/23 incident. R2 demonstrated physical aggression towards R8 on 9/13/23. The Facility Reported Incident, dated 9/18/23, documents: On 9/13/23 at approximately 1:00 PM, Registered Nurse (RN) reported to the administrator that (R2) made physical contact with (R8) by hitting her across the face with his open hand to her left cheek area. Prior to incident (R8) was seen grabbing (R2's) hand in which he pulled away from her and she then grabbed him by the shirt and he yelled, NO and made contact with her left cheek before staff could separate the two. An investigation was initiated, and all parties were notified. Staff was interviewed. Staff observed the physical interaction. When (R2) was asked what happened, (R2) shrugged his shoulders. (R8) does not recall what happened. Several resident were interviewed and voiced no concerns. The facility is aware that physical interaction occurred. Social Service will conduct follow-up visits with (R8) and (R2). Care plans have been reviewed and updated. No further incidents have occurred. 2. The facility's Incident Log documented an incident, dated 11/5/23, documenting Final Incident Description as: Administrator notified of an alleged altercation between (R4), a female resident, and (R2). Per staff interviews, residents (R4) and (R2) were in the hallway talking when (R2) reached out and slapped (R4) across the face. Residents were immediately separated by staff. (R2) is a [AGE] year old male who admitted to the facility on [DATE] as a long-term care resident. (R2) was admitted with dementia, hypothyroidism, gout, umbilical hernia, and knee pain. (R2) requires assist with Activities of Daily Living (ADLs) and has a Brief Interview for Mental Status Score (BIMS) of 2. (R4 ) is a [AGE] year old female who admitted to the facility on [DATE] as a long-term care resident. (R4) was admitted with dementia, unsteadiness on feet, essential hypertension, anxiety, depression, fatigue, and weakness. (R4) requires assistance with ADLs and has a BIMS of 3. Physicians and POA (Power of Attorney) for both residents were notified. (Local police department) notified. Licensed staff initiated a head to toe assessment noting no injury. Care plans for both residents were reviewed and updated. Social Service will visit with residents twice a week. Review of the facility's Abuse Investigations documented there were four other physical altercations between R2 and R4 during which R2 physically assaulted R4 as detailed below: The Facility Reported Incident, dated 9/20/23 at 2:05 PM, documents, Administrator notified of an alleged altercation between resident (R4) and resident (R2). An investigation was initiated. Per staff interviews, residents (R4) and (R2) were in the hallway when (R2) reached out slapped (R4) across the face. Residents were immediately separated by staff. Staff interviews revealed that (R4) touched (R2) on the arm and then he slapped her. Physicians and POA (Power of Attorney) for both residents were notified. (Local police department) notified. Ombudsman was notified. Licensed staff initiated a head to toe assessment noting no injury. Care plans for both residents were reviewed and updated. Social Service will visit with residents twice a week. The Facility Reported Incident, dated 9/15/23, documents, Administrator notified of an alleged altercation between resident (R4) and resident (R2). An investigation was initiated. Per staff interviews, residents (R4) and (R2) were in the hallway talking when (R2) reached out slapped (R4) across the face. Residents were immediately separated by staff. Physicians and POA (Power of Attorney) for both residents were notified. (Local police department) notified. Licensed staff initiated a head to toe assessment noting no injury. Care plans for both residents were reviewed and updated. Social Service will visit with residents twice a week. This incident was discussed and reviewed during QAPI (Quality Assurance Performance Improvement) meeting. The facility's Incident Report, dated 8/9/23 at 2:00 PM, documents, It was reported that (R4) approached (R2) in the hallway and pushed him on his right upper arm then swung at him. (R2) then responded by hitting (R4) in the face with his open hand. Residents were immediately separated by staff and residents were assessed by the nurse. No injuries were noted. Visitor that witnessed the event wrote a statement, staff and residents were interviewed. Care plans for both residents have been reviewed, physicians updated, medications have been reviewed with no new additional orders. Social Service to perform trauma informed assessment on both residents and will perform in person visit with both residents once a week for three weeks. The Facility Reported Incident, dated 8/4/23, documents, It was reported that (R4) approached (R2) in the hallway, threw her hands up and grabbed him by his shoulders and verbally said, Beeped loudly three times in his face. (R2) then pulled his arm loose and made contact to (R4's) left arm with his open hand. Residents were immediately separated by staff and residents were assessed by nurse. No injuries were noted. Staff were interviewed and (V7, Licensed Practical Nurse/LPN) saw the incident and unable to get to them in time to prevent the incident. Care plans for both resident have been reviewed, physicians have been updated, medications have been reviewed with no additional orders. Social Service to perform trauma informed assessment on both residents and will perform in person visit with both residents once a week for three weeks. No further incidents have occurred at this time. 3. The facility's Incident Report, dated 10/31/23 at 11:05 AM, documents, Please accept this as the final report for an allegation of inappropriate physical interaction regarding (R2) and (R13), a female resident. (R2) is a [AGE] year old male who admitted to the facility on [DATE] as a long-term care resident. (R2) was admitted with dementia, hypothyroidism, gout, umbilical hernia, and knee pain. (R2) requires assistance with ADLs and has a BIMs of 2. (R13) is a [AGE] year old female who admitted to the facility on [DATE] as a long-term care resident. (R13) was admitted with a diagnosis of Alzheimer's, Essential Hypertension, Hyperlipidemia, GERD (Gastroesophageal Reflux Disease), difficulty in walking and has a BIMS of 5. On 10/31/23 (V2, Director of Nursing) reported to the administrator that (R2) had made physical contact with (R13) by hitting her open handed across the face. The residents were immediately separated by the staff. Licensed staff initiated head to toe assessments, noting no injury. An investigation was initiated and all parties were notified including POA, PCP (Primary Care Physician), Ombudsman, and (local police department). Staff was interviewed. Staff observed physical interaction. When (R2) was asked what happened, he shrugged his shoulders. (R13) does not recall what happened. Several residents were interviewed and voiced no concerns. The facility is aware that inappropriate physical interaction occurred. Social Service will conduct follow-up visits with (R13) and (R2). Care plans have been reviewed and updated. No further incidents have occurred. 4. The Facility Reported Incident, dated 9/9/23 at 5:00 PM, documents, On 9/9/23 at approximately 6:45 PM (V2, DON) reported to administrator that (R2) had made physical contact with (R3) by grabbing her arm and hitting her in the face. The residents were immediately separated by staff. Licensed staff initiated head to toe assessment, noting no injury. An investigation was initiated and all parties were notified. Staff were interviewed. Staff observed the physical interaction. When (R2) was asked what happened, (R2) shrugged his shoulders. (R3) does not recall what happened. Several residents were interviewed and voiced no concerns. The facility is aware that inappropriate physical interaction occurred. Social Service will conduct follow-up visits with (R3) and (R2). Care plans have been reviewed and updated. No further incidents have occurred. 5. The Facility Reported Incident, dated 8/22/23, documents, Please accept this as the final report for an inappropriate physical interaction regarding (R2) and (R9). (R2) is a [AGE] year old male who admitted to the facility on [DATE] as a long-term resident. (R2) was admitted with hypothyroidism, gout, umbilical hernia, and knee pain. (R2) requires assistance with ADLs and has a BIMS of 2. (R9) is an [AGE] year old female (typo in report-actually male) who admitted with a diagnosis of Vascular Dementia, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease, dysphagia and need assistance with all ADLs. On 8/22/23 at approximately 8:00 PM, (V4, LPN) reported to the administrator that (R2) had made physical contact with (R9) by punching (R9). The residents were immediately separated by the staff. (R9) was assessed and the resident had no injuries. An investigation was initiated and all parties were notified. All staff interviewed and similar reports. (R2) was placed on 15 minute checks. When (R2) was asked what happened, he shrugged his shoulders. (R9) could not recall what happened and he has no injuries. During the investigation, the psychiatrist has been asked to review medications for (R2), no new orders received. Ten other residents were interviewed with no concerns with (R2) and felt safe in facility. The facility substantiates that there was inappropriate physical contact between the two residents. After an investigation, the facility is contributing (R2's) increase in agitation to a clinical concern. Psychiatrist will re-evaluate medications and behaviors in two weeks. Social Services will follow up with (R9) once a week for two weeks to ensure the resident continues to feel safe in the facility. Care plans have been reviewed and Behavior Tracking is in place. No further incidents have occurred. On 11/28/23 at 9:30 AM, V1, Administrator, stated there have been no more behavior issues from R2 since he returned from the hospital. She stated when she asked the family to come in and sit with him in the past, it was not necessarily for 1:1s, but just to see if they could help calm him down and decrease his behaviors. She stated the facility does not do 1:1 with (R2), but do try to keep him in sight of staff when he is up and around other residents. She stated the problem is that sometimes his behaviors are unprovoked. She stated R2 and R8 sort of migrate towards each other, and staff try to keep them separated. She stated she has talked to the ombudsman, R2 has seen the psychiatrist and his doctor sees him. She stated she does not know what else they can do for him. V1 stated R2 was not a nice man when he was living out in the community with his family, so this behavior is not something new for him. V1 stated they sent a referral for R2 to be transferred to an inpatient psychiatric hospital that specializes in geri-psych, but when they first sent the referral in September, they did not have a bed available, and when they did have a bed available, R2 had not had recent enough behaviors so he did not meet their criteria, and now he is on a waiting list, but she does not think his family is going to consent for him to be sent there. The facility's policy, Abuse, Prevention and Prohibition Policy revised 10/22 documents, Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse from anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain or mental anguish. The facility also prohibits misappropriation of resident property. The resident must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. The facility will prescreen potential residents for behaviors, needs and personal histories, which might lead to conflict, neglect or abuse. Prescreening: The facility will identify residents whose personal histories render them at risk for abusing other residents through the prescreening process. Resident to resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with neurological disease who has involuntary movements (e.g. muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby.

Based on observation, interview, and record review, the facility failed to maintain the resident's environment in a clean and sanitary condition. Findings include: On 09/13/23 at 11:15 AM, inspection of the shower on the 300-hallways was done. The commode was observed to have a brown feces stain on the seat. On 09/13/23 at 11:20 AM, inspection of the shower room on the 400-hallway was done. There was a corner in the shower that had a green fuzzy substance. There was no stain noted to the commode seat in this bathroom, but the commode did have dried feces on the inside. On 09/14/23 at 9:44 AM, inspection of the shower room on the 100-hallway was done at this time. There was a green fuzzy substance noted to be along all three sides of the baseboard of the shower and there was dried brown feces on the base of the commode. On 09/14/23 at 2:25 PM, this surveyor and V1, Administrator, went to the shower room on the 100-hallway. V1 was shown the green substance along the baseboards in the shower. The commode was noted to have streaks of feces on the inside of the bowl, and there was dried feces on the outside base of the commode. V1 stated she would get the head of Housekeeping in the shower right away to fix this problem. On 09/14/23 at 12:01 PM, V7, Certified Nursing Assistant (CNA), said, Sometimes the commode seat gets dirty, but Housekeeping will clean it, and if she finds it, she will clean it herself. She said she can't say Housekeeping cleans the shower room on a daily basis, but they do clean them. On 09/14/23 at 2:05 PM, V9, CNA, said, We do have a resident that will take himself to the bathroom, and he will have to wipe the seat off after he gets done using it, because sometimes there is bowel movement, (BM) on it due to him having an accident. She said, The CNA will clean it off, and then housekeeping will come and clean after that. On 09/18/23 at 10:41 AM, V1, Administrator, stated, The shower rooms should be cleaned at least daily and more often if it is needed. She said she had never seen the mold in the bathroom before this surveyor showing it to her. V1 said if the housekeepers were to find mold in the bathroom, she would expect them to report it to her and clean it immediately. She said she would expect the housekeepers to clean the BM off the commodes as soon as it was noticed. The Resident Council meeting minutes, dated 08/02/23, documents Housekeeping: Bathrooms need more attention. The Facility's Policy, Quality of Life Housekeeping and Maintenance, revised date 10/25/2016, documents The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to thoroughly investigate an allegation of abuse in 1 of 4 residents (R2), reviewed for abuse in the sample of 4. Findings include: R2's Face Sheet, undated, documents R2 has a diagnosis of Unspecified Depressive Episode. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 5/4/21, documents R2 has depression. On 8/29/23 at 7:40 AM, R2 was observed in her room. R2's hair appeared dry, was cut short about 1 inch in length, and was a dark brown/black color. R2 stated she had bought some hair dye a while back, but didn't use it because her hair was too long, and she wanted it cut before she applied the hair dye. R2 stated she (R2) cut her hair and a nurse, (unsure of name, later identified as V5, Agency Licensed Practical Nurse(LPN) didn't like it and was going to fix it and put dye on her hair. R2 stated this nurse put the dye on her hair and left it on for 2 hours; she (R2) had to get into the shower to rinse it out. R2 stated the dye was only supposed to be left on for 20 minutes. R2 stated, It is a terrible thing, my hair looks terrible. I was just going to do it myself, leave it on for 20 minutes and then rinse it out. They thought they could do it better. I don't know why they did it that way. It was horrible. I don't like it. I had cut my hair myself, but then that girl, a Certified Nurses Assistant (CNA), (unsure of name, later identified as V6, Agency CNA), thought she could do better so she kept cutting and clipping my hair, there was a bunch of my hair all over the floor and all over me. It was one of the worst things I've ever had to do. I had to get into the shower, it took so long my legs were hurting, and they never did get all the dye out. Then she used a hair thing that burnt my neck. I kept telling her my legs hurt but she didn't listen. It happened about a week ago during the afternoon/evening time. It feels terrible. I don't feel right. I feel like a man. I feel bad, alone and I don't like it. It ruined my hair and I don't feel like a woman. On 8/30/23 at 11:10AM, R2 stated she feels that it was abuse and purposeful when the nurse (V5) left the hair dye on her for 2 hours and when the CNA (V6) cut her hair and when she (R2) was telling the CNA that her legs were hurting, the CNA was arguing with her. R2 stated the CNA kept cutting her hair and ignored her telling her that her legs were hurting. On 8/29/23 at 7:35 AM, V1, Administrator, stated R2 was trying to cut and dye her own hair and an agency nurse (V5) helped her. V1 stated R2 told her V6 was yelling at her and telling her she shouldn't have let them do it. V6 was being rude, not mean. V1 stated V6, Agency CNA, has caused problems in the facility and she has canceled all of V6's upcoming shifts with her agency. On 8/29/23 at 8:05 AM, V4, CNA, stated she was here for part of what had occurred with R2. V4 stated R2 wanted to cut and dye her own hair, there was an agency nurse, unsure of name, that put hair dye all over R2's hair and someone had cut it. V4 stated she is not sure what happened after that as her shift ended and she left the facility. V4 stated when R2 cut her hair it looked cute, and when she (V4) came in the next day, you could tell it had been cut after R2 had cut it. V4 stated R2 was upset about it. On 8/29/23 at 8:15 AM, V6, Agency CNA, stated on 8/26/23 she was working the 6 AM - 6 PM shift and there was an agency nurse, unknown name (later identified as V5), that was working 2 PM-6 PM that cut R2's hair and put hair dye in it. V6 stated R2 had chemical burns to her ears, head/scalp and chin. V6 stated the dye burned R2's hair and there was hair dye everywhere. V6 stated she took R2 into the shower and had to shampoo R2's hair 4 times to get the dye out. V6 stated she was asked by V1, Administrator, to provide a statement, which she did, but hasn't been allowed to come back to the facility. V6 stated V1 canceled all of her future shifts and she is unable to sign up for more. On 8/30/23 at 8:50 AM, V3, Assistant Director of Nurses (DON), stated she was informed by V12, LPN, that R2 applied hair dye on her own hair, the nurse tried to help her and wash it out. V3 stated it had been on her hair a long time, she was told an hour, and then someone else said 2 hours. V3 stated she has not talked to R2 about the incident. On 8/29/23 at 9:30 AM, V5, Agency Nurse, stated she was working on the 200 hall on 8/26/23. V5 stated there were 2 extra nurses working that day and the Wound Nurse, unsure of name or if she was agency or facility staff, dyed R2's hair and that is all she knows about it. V5 denies cutting or dying R2's hair. On 8/30/23 at 10:55 AM V12, LPN, stated she was at the facility at 6 PM when the incident with R2 occurred. V12 stated a staff member, unsure of name, came off of the 300 hall where R2 resides, and told her (V12) that she was leaving, her shift had ended and R2 had hair dye in her hair that needed rinsed out. V6, Agency CNA, stated to her (V12) that she would give R2 a shower to wash the hair dye out. V12 stated she reported it to R2's nurse and she doesn't know of anything that happened after that. On 8/30/23 at 2:00 PM, V1, Administrator, stated she talked to R2 on 8/28/23, and R2 told her that she was cutting her own hair and was going to put hair dye on it; they (V5, Agency LPN and V6, Agency CNA) told her they would assist her because R2 was going to do it and wanted it done. V1 stated R2 told her R2 couldn't tell who it was or what they looked like, that put the hair dye in her hair. V1 stated R2 told her it was the blond aide (V6) that cut her hair because she was already cutting it and they were trying to help her. V1 stated she asked R2 if she needed help and R2 told her she was trying to get it off of her shoulders, so yes. V1 stated R2 told her she felt her hair was too short, but didn't say it made her feel bad. V1 stated R2 did not tell her it was abuse, if R2 would've used that word she would have reported it. V1 stated she told R2 that V6 would no longer be in the building. V1 stated she (V1), put her (V6) on the do not return list with the facility she had CNAs and nurses calling and telling her V6 was being rude to the residents. On 9/1/23 at 10:45 AM, V14, LPN, stated on 8/26/23, she was working on the 400 hall and overheard in report, not sure who the staff member was, asking who dyed R2's hair. V14 stated V6, Agency CNA, stated an agency nurse was dying R2's hair. V14 stated V6 told her (V14) that she had given R2 a shower and had to cut her hair to fix what they had messed up. V14 stated she told V6 to lay R2 down because R2 doesn't like being up for very long because it causes her pain in her legs. V14 stated about 15 minutes later, she went and looked at R2's hair and did not see any redness or anything that resembled chemical burns. V14 stated R2's hair was dyed and cut short. V14 stated R2 told her she hurt a lot, and she didn't like her hair. The Facility Investigation, dated 8/26/23, documents the following: (V6, Agency CNA), called and stated a nurse had colored (R2's) hair and left it on for too long and she felt she (R2) had burns from it. Spoke to (V12, LPN), regarding hair dye incident. She stated an agency nurse found (R2) in her room cutting her own hair and trying to dye it. Nurse tried to help with incident. Black hair dye was left on for about an hour, which was within limits. Hair dye was scrubbed off. Spoke to (V14, LPN), regarding concerns with (V6, Agency CNA), and (V6) working out of her scope. She (V14) stated she and (V19, LPN) went down to talk to (R2) about her hair and (R2) stated (V6) was very rude to her and talked down to her. 8/27/23 - CNA (V6) placed on do not return list from facility due to multiple concerns including the way she talked to resident. Called agency supervisor and reported incident. There were no interviews with other staff or other residents. The facility Initial Report to the Illinois Department of Public Health (IDPH), dated 8/30/23, documents an alleged abuse involving R2. Incident summary: On 8/30/23, Administrator and Social Services followed up with (R2) on an incident that occurred on 8/26/23. (R2) stated today that she felt she was treated poorly by on 8/26/23 by an agency aide (V6) who cut her hair after it had been colored by someone else. (R2) stated she did tell agency aide not to cut her hair while in the shower room, but she (V6) did it anyway. Due to the concerns voiced today, a full investigation was started and report to follow. The Abuse, Prevention and Prohibition policy, dated 10/2022, documents the following: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Two management level staff will conduct interviews with witnesses or other staff, residents, or visitors who could have knowledge of the allegation. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R6's Care Plan, dated 7/21/2023, documents, Staff will honor my preferences while caring for me. (R23) would like his hair to remain trimmed and to be shaved once a week. R6's MDS, dated [DATE], documents R6 requires extensive assistance with personal hygiene, including shaving. On 8/16/2023 at 3:00 PM, R23 was observed to have long scruffy facial hair on his cheeks and chin. At this time, R23 stated he does not like his facial hair to be long and added, I should really get after that. One nurse shaved me one time. It isn't half as long as it was. If I had my electric razor and a mirror, I could do it. On 8/21/2023, V2, Director of Nursing, (DON), stated R23 is taken care of by Hospice as well, but facility staff should be assisting R23 with the set up/and or process of shaving Based on observation, interview, and record review, the facility failed to offer assistance to shave facial hair for 2 of 5 (R6 and R134) residents, reviewed for activities of daily living in a sample of 34. Findings include: 1. R134's Minimum Data Set (MDS), dated [DATE], documented R134's cognition was intact and she required limited assistance of 1 staff member for personal hygiene including shaving. R134's Care Plan did not have documentation regarding Activity of Daily Living, (ADL), such as shaving and bathing and the assistance she required. On 08/15/2023 at 1:47 PM, R134 had a thick patch of facial hair on neck under her chin. On 08/17/2023 at 9:10 AM, R134 facial hair remains on neck. R134 stated they have not offered to assist her to shave, she would usually shave it at home before she left for work, but she hasn't asked. R134 then covered up the hair with her hand. R134's Nursing Skin Inspection Report, dated 07/28/2023, documented she refused a shower, but did not document if her facial hair was removed. R134's Nursing Skin Inspection Report, dated 08/02/2023, documented she refused a shower, but did not document if she had facial hair removed or if a bed bath was offered. R134's Nursing Skin Inspection Report, dated 08/09/2023, documented she received a bed bath and had her facial hair removed. R134's Nursing Skin Inspection Report, dated 08/16/2023, documented she received a shower, but refused to have her facial hair removed. On 08/21/2023 at 3:50 PM, V32, LPN, (Traveling Manager), stated she would expect staff to assist and offer to shave both male and female residents when they are showered. The facility's Skills Check, Shaving, undated, documents, Gather equipment, explain procedure and screen resident for privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform safe transfer for 3 of 3 (R35, R36, R74) residents reviewed for transfer in a sample of 34. Findings include: 1. R35's Care Plan, dated 6/18/19, documents, (R35) has an ADL (Activities of Daily Living) Self Care Performance Deficit related to history of right foot fracture, osteoarthritis and Polyneuralgia Rheumatic. It also documents, Restorative program - Transfer Explain to resident that he/she is going to transfer from the bed to the chair. Ensure bed and w/c (wheelchair) are locked apply gait belt to resident. Verbally cue and/or assist resident to scoot to the edge of the bed. Verbally cue and/or assist resident to stand. Verbally cue and/or assist resident to turn. Verbally cue and/or assist to reach back and grab arms of chair and prior to sitting. Ensure resident is in proper position after transfer and call light is within reach. It also documents, Transfers: Extensive assist of 2 staff member, dependent upon resident mood. On 8/17/2023 at 11:18 AM, V19, Certified Nurse's Assistant (CNA), and V20, CNA, assisted R35 with incontinent care. Upon completion of incontinent care, V19 and V20 assisted R35 to a sitting position on the side of the bed. V20 applied the gait belt around R35's waist. Grabbing under R35's arms and gait belt, V20 and V19 then lifted R35 into the air. The gait belt slipped up under R35's armpits. R35's knees were bent, and R35's feet were not touching the floor. R35 did not participate in the transfer. 2. R36's Care Plan, dated 6/15/21, documents R36 has an ADL Self Care Performance Deficit related to diagnosis of dementia. It continues, Transfer: (R36) requires total assistance with transfers. R36's [NAME], dated as of 8/21/2023, documents, Transfer: (R36) requires total assistance with transfers. If resident can transfer with 2 assists, allow it, but if she cannot at that time or has weakness, use, (Full body mechanical lift). On 8/16/2023 at 11:59 AM, V31, CNA, and V22, CNA, assisted R36 from the reclining wheelchair to the shower chair. V31 and V22 grabbed R36 under arms and attempted to lift R36 without success. V31 and V22 then pulled R36 to the front of the wheelchair, grabbed under R36's arm, and attempted to lift R36 into a standing position, without success. V31 then instructed V22 to grab R36 under her legs. V31 and V22 then grabbed R36 under her arms and grabbed a leg and transferred R36 onto the edge of the shower chair. V31 and V22 then grabbed R36 under the arm and pulled R36 back. V22 and V31 did not apply a gait belt when transferring R36. R36 was dangling during transfer. R36 did not participate in the transfer. 3. R74's Care Plan, documents (R74) has an ADL, (Activities of Daily Living), Self Care Performance Deficit r/t, (related to), weakness, limited mobility, impaired cognition. Transfer: The resident transfers with x1 staff assist and 2 wheeled walker. On 08/16/23 at 9:45 AM, V23, Certified Nurse's Assistant, (CNA), assisted R74 with toileting. V23 assisted R74 into the standing position. R74 then raised his leg and wavered back and forth going down into a squatting position and grabbing a hold of the handrail. V23 then grabbed a hold of R74's pants and assisted R74 with ambulating into the room and sat, plopping down on the bed. R74's balance was poor. R74 was wavering back and forth when walking. V23 did not apply a gait belt and did not utilize walker when transferring R74. On 8/21/23 at 2:08 PM V7, CNA, stated R74 is a 1-person transfer with the use a gait belt. V7 stated R35 requires 2-person transfer with gait belt. V7 stated R35's knees are bent during transfer. V7 stated R36 stands and transfer swith assist. V7 stated, A resident that is dependent is a resident that needs assistance. V7 stated it doesn't say what assist. V7 stated she does not know where to go to find out how much they transfer. V7 stated, Anytime there is a manual transfer, 1- or 2-person transfer, a gait belt is used. The gait belt is placed on the rib area and are supposed to stay there during the transfer. On 8/21/2023 at 2:40 PM,V32, Licensed Practical Nurse/LPN, (Travel Manager), stated, When a resident is manually transferred the resident should be participating in the transfer. If not, then they would be a mechanical transfer. On 8/21/2023 3:20 PM ,V15, CNA, stated, If *R36) can't stand, then she is to transfer with a full body mechanical lift. The facility's Two Person Transfer Skills Check, not dated, documents, Check care plan/resident status sheet for appropriate transfer technique. The facility's Gait Belt Application and Use, not dated, documents, Place the gait belt around the client's waist above pelvic bone and below the rib cage. Adjust it so it is snug but not uncomfortable for the client and check with flat hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform timely and complete incontinent care for 6 of 6 (R6, R23, R25, R35, R49, R75) residents reviewed for incontinent care in a sample of 34. Findings include: 1. R35's Care Plan, dated 6/18/19, documents, (R35) has bladder incontinence r/t, (related to), Disease Process and Impaired Mobility. (R35) is aware of her toileting needs at times, but has incontinent episodes in between, when she states she's not aware that she is voiding, she takes a diuretic. She requires assist of one for toileting needs. (R35) uses disposable briefs, toilet frequently and change if needed. R35's MDS, dated [DATE], documents, R35 is always incontinent of bowel and bladder and totally dependent of 2-persons for toileting. On 8/17/2023 at 11:18 AM, V19, and V20, Certified Nurse Assistants (CNAs), assisted R35 with incontinent care. V19 and V20 turned R35 onto the right side and opened R35's brief, revealing a heavily soiled incontinent brief. Using a wet washcloth, V19 wiped R35's anal area and left buttock. V19 then placed a clean incontinent brief beneath R35. V19 then applied antifungal cream to R35's left buttocks. V19 and V20 then rolled R35 onto her back and pulled down the soiled incontinent brief. V20 then pulled the clean brief up between R35's legs. V19 and V20 rolled R35 over onto her left side, removed the soiled incontinent brief and then fastened the clean incontinent brief. V19 and V20 did not clean R35's right buttock, peri area, groin, or inner thighs. 2. R49's Care Plan, dated 4/5/2023, documents, (R49) has bowel and bladder incontinence. It also documents, BRIEF USE: the resident uses disposable briefs. Change per facility schedule and prn, (as needed). R49's Minimum Data Set, (MDS), dated [DATE], documents, R49 is severely cognitively impaired with both short- and long-term memory problems. It also documents R49 is always incontinent of both bowel and bladder and dependent on 2-staff for toileting. On 8/16/2023 at 11:15 AM, V22 and V23, CNAs, provided incontinent care for R49; he was incontinent of urine. With R49 lying on his back, V22 and V23 opened R49's brief, revealing 2 heavily soiled incontinent briefs and a urine soiled draw sheet. V22 and V23 turned R49 onto his right side, and pulled back the soiled incontinent briefs. Using a wet washcloth and soap, V22 cleansed R49's left buttock and anal area. V22 then placed a clean incontinent brief under R49. V22 and V23 then rolled R49 onto his left side and removed the soiled linen and incontinent briefs. V22 and V23 then rolled R49 over onto his back and applied the incontinent brief. V22 and V23 assisted R49 into a standing position using a mechanical lift and pulled up R49's pants. V22 and V23 did not wash R49's peri area, groin, penis, scrotum, inner thighs, or left buttock. 3. R74's Care Plan, dated 4/5/23, documents, (R74) is incontinent of bladder. It continues, BRIEF USE: (R74) uses disposable briefs. Change every 2 hours and as needed. Incontinent: Check the resident frequently for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. R74's MDS, dated [DATE], documents, R74 is frequently incontinent of bladder and always incontinent of bowel. On 8/16/ 2023 at 9:45 AM, V22, CNA, and V23, CNA, assisted R74 with toileting. R74 was incontinent of urine. R74 was sitting on the toilet, with a heavily urine soiled incontinent brief. R74's incontinent brief was swollen and hanging between R74's knees. R74's pants were soiled with urine. V23 assisted R74 with removing his urine soiled pants and incontinent brief. V23 then applied a clean incontinent brief. R74 pulled the incontinent brief up. V23 then applied R74's pants and R74 pulled his pants up. V23 then assisted R74 from the bathroom to the bed. V23 did not offer, attempt, or provide incontinent care. On 8/21/2023 at 11:55 AM, V2, Director of Nursing, stated she would expect the staff to cleanse all areas when incontinence, including the male's penis, scrotum, inner thighs, and a females peri area, inner and outer labia, urethral area. V2 stated, If a resident is incontinent then the staff are to provide incontinent care. The facility's Peri Care Skills Checklist, (Female), not dated, documents, wash and dry upper thighs covering thighs with bath blanket when finished. Raise the blanket to expose perineal area. Apply soap to wet washcloth. Separate labia and wash urethral area first. Wash between and outside labia in a downward stroke alternating from side to side moving towards thighs. With fresh water and a clean washcloth, rinse area thoroughly with same strokes. Gently pat dry in same direction. position patient on side exposing buttocks towards caregiver apply soap to wet washcloth. Clean rectal area wiping from base of labia over buttocks using a different part of washcloth for each stroke. Rinse and dry anal area thoroughly. The Facility's Peri Care Checklist, (Male), not dated, documents, Wash and Dry upper thighs covering thighs with blanket when finished. Raise blanket to expose perineal area. Apply soap to wet washcloth. Pull Back Foreskin and wash tip of penis using circular motion beginning at urethra. With fresh water and a clean washcloth, rinse, rinse thoroughly with same strokes. Clean Rectal area wiping from base of scrotum over buttocks using a different part of washcloth for each stroke. 4. R23's Minimum Data Set, (MDS), dated [DATE] documents, R23 is totally dependent on staff for toileting needs. On 8/15/2023 at 9:20 AM, R23's wife, V9, stated, We had some issues Friday night. (R23) hit the call light 4 times during the night, (to be cleaned up from incontinence), he was so soaked. The whole bed, even the mattress had pee standing on it. His diaper was so heavy it was making his hip hurt, he was already gaulded. Talk to (V10 and V11, Certified Nursing Assistants CNAs). They (V10 and V11) worked Saturday and said every bed on this hall had to be changed completely. At this time, R23 stated, It made me feel lousy. How would it make you feel? They don't even offer me to use of the urinal. V9 continued, to state that she filed a grievance with the facility. On 8/16/2023 at 8:30 AM, V9 stated, she just put R23's call light on and told the CNA he needed changed. V9 stated, she had been in R23's room since 6:30 AM and no one had been in to check on R23. On 8/16/2023 at 8:43 AM, R23's call light had been turned off. V9 was in R23's room. The CNA turned the call light off and said, she had to find help. On 8/16/2023 at 8:48 AM, R23 had still not being assisted with incontinent care. On 8/16/2023 at 8:50 AM, R23 activated his call light again. On 8/16/2023 at 8:55 AM, V7, CNA, responded to R23's call light and turned it off. R23 stated, he needed changed. V7 stated, Give me just a moment and left the room. At this time, R23 stated, That's what the last gal said. On 8/16/2023 at 8:58 AM, V8, CNA entered R23's room and told R23 she was going to get linens. On 8/16/2023 at 9:07 AM, a staff member, (who was not a CNA or Nurse), entered R23's room and offered R23 water or apple juice. R23 declined and the staff member then left the room. At this time, R23 stated, There goes a third one and re-activated his call light. On 8/16/2023 at 9:10 AM, V7 and V15, CNA entered the room and checked R23 for incontinence. R23's adult brief had blue lines to indicate R23 was wet with urine. R23's scrotum was red and gaulded. V7 stated, she was taking R23 to the shower because, it was his shower day. At this time V7 asked, R23 when the last time the previous checked him for incontinence, and R23 stated, it was around 5:30 AM. On 8/16/2023 at 2:45 PM, V16, Social Service Director, stated, We did receive one grievance in August. It was R23's wife. It went straight to administration for investigation. The Facility's Grievance Form dated 8/12/2023 documents, Resident: (R23). Description: On August 11th I didn't get my shower. Also had my call light on four times the evening of August 11th the CNA came in shut it off and walked away. Never changed me once. My hip got to hurting so bad I had to loosen my diaper because I was soaked. On 8/21/2023 at 11:17 AM, V2, Director of Nursing, (DON), stated, from 8:30 AM until 9:10 AM is too long to wait to be changed after requesting it to be done. 5. On 8/16/2023 at 2:50 PM, R23 stated, The 'ones' here the other night, Friday night, wouldn't take me to the bathroom. I had to have a BM, (Bowel Movement). They kept giving me excuses starting at 6:30 (PM). Then they came in and said they had to clean me up, because a new group of people were coming in at 6 AM. I guess they thought I would mess the bed. I didn't think I could hold it all night, but I managed to keep it in. I told someone and two ladies came in to talk to me, because come to find out, the whole floor, (hall), was complaining. It made me mad, that shouldn't happen to anyone! R23 added that he uses a machine, (mechanical lift), and he uses the toilet normally, because the bedpan hurts. On 8/16/2023 at 2:55 PM, R6 stated, Once in a while they clean it, (his catheter), but not every day. One nurse is really good about 'washing it up'. There is dried blood on the end of it so sometimes I just pluck it off. R6's MDS dated [DATE] documents, R6 is cognitively intact, has an indwelling catheter and is totally dependent on 2 staff for toileting needs. R6's Care Plan dated 7/21/2023 documents R6 has a catheter and catheter care is to be completed every shift and PRN (as needed). The Facility's Grievance Report Form dated 5/17/2023 documents, Name of Resident: (R6) Describe the nature of the grievance/complaint: Resident asked staff to perform peri-care and the staff left without assisting the resident. On 8/21/2023 at 11:17 AM, V2, Director of Nursing (DON) stated catheter care should be performed every shift and as needed. V2 stated there are two shifts a day. V2 reviewed R6's Task Form for catheter care. The Form documents, Was catheter care provided?. V2 confirmed there were days when it was marked Not applicable, meaning it was not provided, as well as days when it was only documented being performed once a day. The days that catheter care was not documented as being performed include 8/2/23, 8/2/23,8/12/23, 8/15/23, 8/26/23. The Facility's Catheter Care Policy dated 1/2017 documents, The following information should be recorded in the resident's medical record 1. The date and time that catheter care was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R74's Minimum Data Set, (MDS), dated [DATE], documents R74 is moderately cognitively impaired. On 8/15/2023 at 9:45 AM, R74 was lying in bed, with multiple flies in R74's room. There were flies on R74's covers, on R74's face and left arm. R74 was swatting at flies. On 8/15/2023at 9:46 AM, R74 stated, They (flies) are always here. I can't get rid of them. R74 stated they bother him. On 8/16/2023 from 9:30 AM to 11:50 AM, with 15-minute intervals, flies were in R74's room on the dresser, overbed table, and on R74's hands and shoulder. R74 was swatting at flies with open hand. On 8/17/2023 at 9:17 AM, flies were R74's room on the overbed table, and on the bed with R74. On 8/21/2023 at 11:32 AM, V7, CNA, stated R74 is alert and can answer questions appropriately. 4. R32's Care Plan, dated 6/27/23, documents R32 is cognitively intact. On 8/16/2023 at 1:25 PM, flies were in R32's room. Flies were on the overbed table, R32's bed, and flying around R32's room. On 8/16/2023 at 1:25 PM, R32 was in R32's room in his wheelchair. R32 stated they have a lot of flies. R32 stated, They are pests and they fly around all day. R32 stated he has a fly swatter, but because of his hands, he can't use the flyswatter to kill the flies. R32 stated, The staff don't kill them either. They act like they don't see them. On 8/21/2023 at 10:55 AM, V24, Maintenance, stated, There are blue lights in the hall that the flies are attracted to at night. When asked what about the flies in resident rooms? V24 stated they are not doing anything for the rooms. V24 stated the facility only provides aerosol, and he doesn't feel comfortable spraying in rooms. V24 stated he does not provide the residents with flyswatters, and not sure who would. When asked what about the flies during the day? V24 stated, The blue lights are on, but flies are attracted to light and it shows at night. The facility policy, Infection Prevention and Control Manual General Policies: Pest Control, dated 2019, documented, The facility maintains an effective pest control program to remain free of pests and rodents. It continues, 1. On-going measures are taken to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice and rats. Based on observation, interview, and record review, the facility failed to prevent and contain flies, for 4 of 4 (R32, R43, R74, R134) residents, reviewed for pest control, in a sample of 34. This failure has the potential to affect all residents living in the facility. Findings include: 1. R134's Minimum Data Set, (MDS), dated [DATE], documented her cognition was intact. R134's Physicians Order Sheet, dated 08/2023, documented diagnoses of Atherosclerotic Heat Disease and Acute Respiratory Failure. On 08/17/2023 at 9:10 AM, R134 stated she has had flies in her room, and this one has been in here all day. There was a fly in her room. 2. R43's Physician Order Sheet, dated 08/2023 documented diagnosis of Displaced Intertrochanteric Fracture of Left Femur and Type 2 Diabetes. On 08/17/2023 at 9:15 AM, 2 flies were in R43's room flying around. R43 stated he has had flies in his room and they were being a nuisance to him.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 85 residents who reside in the facility. Findings include: On 8/8/23 at 3:15 PM, Nursing Staffing Schedules were reviewed with V1, Administrator. V1 stated RN staffing has been pretty good lately. While reviewing each day between July 1, 2023, and August 7, 2023, there was not an RN working in the facility for 8 consecutive hours on the following dates: 7/7/23, 7/9/23, 7/13/23, 7/22/23, 7/29/23, 8/3/23 or 8/5/23. V1 stated she has been the administrator for about six weeks now, and she has been hiring nurses, including RNs and Certified Nurse's Aides. On 8/8/23 at 4:17 PM, V1 stated they try to follow the regulations, but does not have a specific policy for RN coverage. The facility's CMS form 672 documents there are 85 residents residing in the facility at the time of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R2's MDS, dated [DATE], documents R2 requires extensive assistance of one staff member with personal hygiene. R2's Care Plan, dated 6/14/2023, documents, ( R2) has an ADL self-care deficit related to confusion. Check nail length and trim/clean on bath day and as necessary. Report any changes to the nurse. On 7/5/2023 at 9:15 AM, R2 removed his shoes and socks. R2's toenails on both feet were long, discolored (yellow and brown) and thick. The 3rd toenail on R2's left foot was long and curved towards R2's 2nd toe on his left foot. On 7/5/2023 at 9:47 AM, V5, R2's wife, stated, (R2's) toenails should have never gotten this bad. They (staff) shouldn't have let them get like that. I made him an appointment with my podiatrist. I guess one comes here (to the Facility) every 3 months, but you have to sign up for it. They didn't tell me. They said they talked to my daughter about it, but she is not his POA (Power of Attorney). V5 stated she talked to the head honcho (V1) on Monday (7/3/2023) about everything. On 7/5/2023 at 10:00 AM, V4, CNA, stated, (R2) requires help with hygiene. Clipping toenails is kind of 'iffy'. You have to be careful. I just told the nurse a week ago about his nails and him needing to see the podiatrist. When they are thick like that, we don't have the right kind of tools to clip them. I talked to the daughter about it. On 7/5/2023 at 10:05 AM, V7, CNA, stated, (R2) had a hang nail the other day so I filed it down. It was too hard to clip. On 7/5/2023 at 10:45 AM, V1, Administrator, stated, (V5) came in on Monday (7/3/2023) and asked about a podiatrist. (R2) didn't have a consent signedk so they can't see him without one. Podiatry consents are addressed during the resident's admission. (R2) is now on the list. The Podiatrist comes every two months. They (the podiatrist) were just here in May. (V16, Social Service) talked to (V5) about how (R2's) toenails would have to be cut by the podiatrist since they are so thick. On 7/5/2023 at 11:00 AM, V8, Regional Nurse, stated, All I know is there is a Podiatry consent signed now. R2's Progress Notesk dated 6/27/2023k documents, (V5) also notes resident has podiatry appt (appointment) to have toenails trimmed set up by wife on 8/1/23 at 1pm also requesting facility transportation. The Facility's Nail Care-Skills Checklist undated, does not address toenail care. Based on observation, interview, and record review, the facility failed to care for the toenails of 3 of 5 residents (R1, R2, R6) reviewed for assistance with Activities of Daily Living in the sample of 9. Findings include: 1. R1's admission Record, print date of 7/5/23, documents R1 was admitted on [DATE], and has diagnoses of Chronic Obstructive Pulmonary Disease and Retention of Urine. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision of 1 staff member for hygiene. R1's Care Plan, dated 1/9/22, documents, The resident has an ADL (Activity of Daily Living) Self Care Performance Deficit r/t (related to)Impaired balance. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 7/5/23 at 9:22 AM, R1 was sitting in her room in her wheelchair. R1 removed her shoes. V1, Administrator, removed her socks. R1's toenails were extremely long and thick. On 7/5/23 at 9:22 AM, R1 stated, The girls do cut my nails but that they are thick. On 7/5/23 at 9:22 AM, V1 stated, I will get a CNA (Certified Nurse's Aide) in to cut her nails. On 7/5/23 at 12:58 PM, V1 stated, (R1's) toenails were too long and she needs to see the podiatrist. I will be educating my shower aides, and I will fix this problem. 2. R6's admission Record, print date of 7/5/23, documents R6 was admitted on [DATE], and has a diagnosis of Alzheimer's Disease. R6's MDS, dated [DATE], documents R6 is severely cognitively impaired and requires extensive assistance of 1 staff member for hygiene. R6's Care Plan, dated 5/10/21, fails to address the care of toenails. On 7/5/23 at 11:25 AM, V12, CNA, took R6 to the shower room. V12 removed R6's socks. On R6's left foot big toe, the nail is thick, it is curled and growing upward. The length is approximately 1 centimeter. The other toenails are thick and long. On 7/5/23 at 11:25 AM, V12 stated, Those are too thick for me to cut. She needs to see the podiatrist. On 7/5/23 at 12:50 AM, V8, Travel Nurse Manager, stated, (R6's) nails were long and she needs to see the podiatrist. The aides will cut the nails if a resident is not a diabetic. If they are diabetic, the aides tell the nurses and then the nurses cut the toenails. If the nails are too long or thick and the nurses are unable to cut them, we will have podiatry see them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that physician's orders were properly transcribed for accuracy prior to adminsitration to residents for 2 of 3 residents (R2, R3) reviewed for pharmacy services in the sample of 5 . Findings include: 1.R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 3 out of 15, indicating R2 has severe cognitive impairment. R2's Hospital Records, dated 05/24/23, documents, Carbidopa-Levodopa 25-100 mg tablet; tale 1 tablet by mouth 3 (three) times daily. R2's Physician's Order (PO), dated 05/24/23 and discontinued 06/04/23, documents, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 3 tablet by mouth three times a day related to Secondary Parkinsonism, unspecified. R2's PO, dated 06/04/23 and discontinued 06/06/23, documents, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 2 tablet by mouth three times a day related to SECONDARY PARKINSONISM, UNSPECIFIED. R2's PO Physician Order, dated 06/07/23, documents, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 1 tablet by mouth three times a day related to SECONDARY PARKINSONISM, UNSPECIFIED. R2's Health Status Note, dated 06/04/23 at 12:53 AM, documents, Writer was looking through discharge orders put in on 5/24/23 r/t (related to) an appt.(appointment) for a Barium swallow study at (local hospital). Writer noted the order for Carbidopa-Levodopa tablet 25-100 mg (milligram) was incorrect. (V2) DON (Director of Nursing) and on call MD (Medical Doctor) (V9) notified of med error. N.O. (new order) to change (new order) to update POA (Power of Attorney) at 0700 r/t non-urgent per on call MD. Resident stable VS (vital signs) WNL (within normal limits). R2's Health Status Note, dated 06/04/23 at 2:53 PM, documents, Call placed to MD (V9) in regard to possible medication error. order given to taper resident's carbidopa-levodopa. new order given for 2 tabs TID for 2 days, then 1-tab TID going forward. Check CBC (complete blood count) and CMP (comprehensive metabolic panel) on Monday 6/5/23, fax results to MD. On 06/06/23 at 10:50 AM, V3, Licensed Practical Nurse/LPN, stated, Apparently when (R2) returned from the hospital, whoever put in the orders entered the wrong order. Instead of 1 three times a day they entered 3 three times a day. Unfortunately he did get the wrong dose. On 06/06/23 at 11:38 AM, V4, LPN, stated she stated she did take care of R2 before. She did give him the wrong dose of Carbidopa-Levodopa. On 06/06/23 at 2:00 PM, V2, Director of Nursing/DON, stated R2's medication was entered in incorrectly. On 06/07/23 at 1:59 PM, V7, R2's Physician, stated he feels any medication error is a significant error. V7 stated R2 just returned from the hospital from a different medication error, although no harm was done. He stated he spoke with the DON because the facility seems to have an issue that they need to correct. 2.R3's Physician Order (PO), dated 05/25/23, documents, Rheumatoid Arthritis with Rheumatoid factor, unspecified. R3's Hospital Record, dated 05/24/23, documents Azathioprine (Imuran) 50 mg tablet; Take 3 (three) tablets by mouth once daily. R3's PO, dated 05/25/23 and discontinued 05/26/23, documents, Azathioprine Oral Tablet 50 MG (milligram) (Azathioprine); Give 3 tablet by mouth three times a day for Prophylaxis. R3's PO, dated 05/26/23, documents, Azathioprine Oral Tablet 50 MG (Azathioprine); Give 3 tablet by mouth one time a day for Prophylaxis. On 06/06/23 at 8:50 AM, R3 stated she has issues with her medication; either the nurse trying to give her too much or not enough medication. She stated the azathioprine that is a chemotherapy drug that she takes for RA (Rheumatoid Arthritis), she takes once a day, and they were trying to give it to her three times a day, or they were trying to give her a lesser dose. R3 stated, I'm lucky that I am cognizant enough to know my medication. On 06/06/23 at 11:44 AM, V6, Medical Director, stated if the resident would have received azathioprine 150 mg TID (three times daily) instead of 150 mg daily, it would have been a significant med error, although R3 did not receive that dose. On 06/07/23 at 11:00 AM, V2 stated she did not know that there was an issue with R3's azathioprine. She stated she will investigate it. Facility's policy Administration of Medication revised 04/21 documents, A. All medications shall only be administered by Licensed Nursing Personnel in accordance with their respective licensing requirements. All nursing personnel must have either appropriate training, experience, or both, if duties include administration of medications. E. The facility shall check the Physician's Order Sheet and MAR (Medication Administration Record) against the current Physician's Orders, to assure proper administration of medications to each resident. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 3 out of 15 indicating R2 has severe cognitive impairment. R2's Hospital Records dated 05/24/23 documents Carbidopa-Levodopa 25-100 mg tablet; tale 1 tablet by mouth 3 (three) times daily. R2's Physician's Order (PO) dated 05/24/23 and discontinued 06/04/23 documents Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 3 tablet by mouth three times a day related to Secondary Parkinsonism, unspecified. R2's PO dated 06/04/23 and discontinued 06/06/23 documents Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 2 tablet by mouth three times a day related to SECONDARY PARKINSONISM, UNSPECIFIED. R2's PO Physician Order dated 06/07/23 documents Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 1 tablet by mouth three times a day related to SECONDARY PARKINSONISM, UNSPECIFIED. R2's Health Status Note dated 06/04/23 at 12:53 AM documents Writer was looking through discharge orders put in on 5/24/23 r/t (related to) an appt.(appointment) for a Barium swallow study at (local hospital). Writer noted the order for Carbidopa-Levodopa tablet 25-100 mg (milligram) was incorrect. (V2) DON and on call MD (V9) notified of med error. N.O. (new order) to change Carbidopa-Levodopa tablet 25-100 mg back to 1 tablet TID (3 times a day). N.O. to update POA (Power of Attorney) at 0700 r/t non-urgent per on call MD. Resident stable VS (vital signs) WNL (within normal limits). R2's Health Status Note dated 06/04/23 at 2:53 PM documents Call placed to MD (V9) in regard to possible medication error. order given to taper resident's carbidopa-levodopa. new order given for 2 tabs TID for 2 days, then 1-tab TID going forward. Check CBC (complete blood count) and CMP (comprehensive metabolic panel) on Monday 6/5/23, fax results to MD. On 06/06/23 at 10:50 AM, V3, Licensed Practical Nurse/LPN stated apparently when R2 returned from the hospital whoever put in the orders entered the wrong order. V3 stated instead 1 three times a day they entered 3 three times a day. V3 stated Unfortunately he did get the wrong dose. V3 stated he called the doctor and tapered it down to 2 tabs three times a day for 2 days and then 1 tab three times a day starting tomorrow. He stated that the doctor said that it was not toxic, so it was not a big deal. On 06/06/23 at 11:38 AM, V4, LPN stated she stated that she did take care of R2 before. She did give him the wrong dose of Carbidopa-Levodopa. On 06/06/23 at 2:00 PM, V2, Director of Nursing/DON stated that R2's medication was entered in incorrectly. The nurse called the doctor and got an order to taper it down to the correct dose. She started an investigation, but it is not finished. On 06/07/23 at 1:59 PM, V7, R2's Physician stated that he feels that any medication error is a significant error. The resident (R2) just returned from the hospital from a different medication error. He does not feel any harm was done. He feels that the on-call physician did everything right by tapering down the medication. He stated that he spoke with the DON because the facility seems to have an issue that they need to correct. 2.R3's Physician Order (PO) dated 05/25/23 documents RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR, UNSPECIFIED. R3's Hospital Record dated 05/24/23 documents Azathioprine (Imuran) 50 mg tablet; Take 3 (three) tablets by mouth once daily. R3's PO dated 05/25/23 and discontinued 05/26/23 documents azathioprine Oral Tablet 50 MG (milligram) (Azathioprine); Give 3 tablet by mouth three times a day for Prophylaxis. R3's PO dated 05/26/23 documents azathioprine Oral Tablet 50 MG (Azathioprine); Give 3 tablet by mouth one time a day for Prophylaxis. On 06/06/23 at 8:50 AM, R3 stated that she has issues with her medication either the nurse trying to give her too much or not enough medication. She stated that the azathioprine that is a chemotherapy drug that she takes for RA (Rheumatoid Arthritis), she takes once a day, and they were trying to give it to her three times a day or they were trying to give her a lesser dose. On 06/07/23 at 11:00 AM, V2 stated that she did not know that there was an issues with R3's azathioprine. She stated that she will investigate it. Facility's policy Administration of Medication revised 04/21 documents A. All medications shall only be administered by Licensed Nursing Personnel in accordance with their respective licensing requirements. All nursing personnel must have either appropriate training, experience, or both, if duties include administration of medications. E. The facility shall check the Physician's Order Sheet and MAR against the current Physician's Orders, to assure proper administration of medications to each resident. 2.R3's Physician Order (PO) dated 05/25/23 documents Rheumatoid Arthritis with Rheumatoid factor, unspecified. R3's Hospital Record dated 05/24/23 documents Azathioprine (Imuran) 50 mg tablet; Take 3 (three) tablets by mouth once daily. R3's PO dated 05/25/23 and discontinued 05/26/23 documents Azathioprine Oral Tablet 50 MG (milligram) (Azathioprine); Give 3 tablet by mouth three times a day for Prophylaxis. R3's PO dated 05/26/23 documents Azathioprine Oral Tablet 50 MG (Azathioprine); Give 3 tablet by mouth one time a day for Prophylaxis. On 06/06/23 at 8:50 AM, R3 stated that she has issues with her medication either the nurse trying to give her too much or not enough medication. She stated that the azathioprine that is a chemotherapy drug that she takes for RA (Rheumatoid Arthritis), she takes once a day, and they were trying to give it to her three times a day or they were trying to give her a lesser dose. R3 stated I'm lucky that I am cognizant enough to know my medication. On 06/06/23 at 11:44 AM, V6, Medical Director stated that if the resident would have received azathioprine 150 mg TID (three times daily) instead of 150 mg daily it would have been a significant med error. On 06/07/23 at 11:00 AM, V2 stated that she did not know that there was an issue with R3's azathioprine. She stated that she will investigate it. Facility's policy Administration of Medication revised 04/21 documents A. All medications shall only be administered by Licensed Nursing Personnel in accordance with their respective licensing requirements. All nursing personnel must have either appropriate training, experience, or both, if duties include administration of medications. E. The facility shall check the Physician's Order Sheet and MAR (Medication Administration Record) against the current Physician's Orders, to assure proper administration of medications to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a significant medication error for 1 of 3 residents (R2, R3) sampled for significant medications error in the sample of 5. Findings include: 1.R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 3 out of 15, indicating R2 has severe cognitive impairment. R2's Hospital Records, dated 05/24/23, documents, Carbidopa-Levodopa 25-100 mg tablet; tale 1 tablet by mouth 3 (three) times daily. R2's Physician's Order (PO), dated 05/24/23 and discontinued 06/04/23, documents, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 3 tablets by mouth three times a day related to Secondary Parkinsonism, unspecified. R2's PO, dated 06/04/23 and discontinued 06/06/23, documents, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 2 tablet by mouth three times a day related to Secondary Parkinsonism, unspeicified. R2's PO Physician Order, dated 06/07/23, documents, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 1 tablet by mouth three times a day related to Secondary Parkinsonism, unspecified. R2's May 2023 Medication Administration Record (MAR) documents R2 received Carbidopa-Levodopa, oral tablets 25-100mg, three tablets po three times daily from 5/24 through 5/31/23. R2's June 2023 MAR documents R2 received Carbidopa-Levodopa, oral tablets 25-100mg, three tablets po three times daily through 6/3/23. R2's Health Status Note, dated 06/04/23 at 12:53 AM, documents, Writer was looking through discharge orders put in on 5/24/23 r/t (related to) an appt.(appointment) for a Barium swallow study at (local hospital). Writer noted the order for Carbidopa-Levodopa tablet 25-100 mg (milligram) was incorrect. (V2) DON (Director of Nursing) and on call MD (Medical Doctor) (V9) notified of med error. N.O. (new order) to change (new order) to update POA (Power of Attorney) at 0700 r/t non-urgent per on call MD. Resident stable VS (vital signs) WNL (within normal limits). R2's Health Status Note, dated 06/04/23 at 2:53 PM, documents, Call placed to MD (V9) in regard to possible medication error. order given to taper resident's carbidopa-levodopa. new order given for 2 tabs TID for 2 days, then 1-tab TID going forward. Check CBC (complete blood count) and CMP (comprehensive metabolic panel) on Monday 6/5/23, fax results to MD. On 06/06/23 at 10:50 AM, V3, Licensed Practical Nurse/LPN, stated, Apparently, when (R2) returned from the hospital, whoever put in the orders entered the wrong order. Instead of 1 three times a day they entered 3 three times a day. Unfortunately he did get the wrong dose. V3 stated he called the doctor and tapered it down to 2 tabs three times a day for 2 days and then 1 tab three times a day starting tomorrow. He stated that the doctor said it was not toxic, so it was not a big deal. On 06/06/23 at 11:38 AM, V4, LPN, stated she stated she did take care of R2 before. She did give him the wrong dose of Carbidopa-Levodopa. On 06/06/23 at 2:00 PM, V2, Director of Nursing/DON, stated R2's medication was entered in incorrectly. V2 stated the nurse called the doctor and got an order to taper it down to the correct dose. She started an investigation, but it is not finished. On 06/07/23 at 1:59 PM, V7, R2's Physician, stated he feels that any medication error is a significant error. V7 stated R2 just returned from the hospital from a different medication error. He does not feel any harm was done. V7 stated the on-call physician did everything right by tapering down the medication. He stated he spoke with the DON because the facility seems to have an issue that they need to correct. Facility's policy Administration of Medication, revised 04/21, documents A. All medications shall only be administered by Licensed Nursing Personnel in accordance with their respective licensing requirements. All nursing personnel must have either appropriate training, experience, or both, if duties include administration of medications. E. The facility shall check the Physician's Order Sheet and MAR (Medication Administration Record) against the current Physician's Orders, to assure proper administration of medications to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent further weight loss for 3 of 3 residents (R7, R9, R12) reviewed for weight loss in the sample of 18. Findings include: 1. R9's Face sheet documents an admission date of 1/20/2022. Diagnosis Chronic Obstructive Pulmonary Disease, Dysphasia, Anemia, and Heart Failure. R9's Minimum Data Set (MDS), dated [DATE], documents R9 is profoundly cognitively impaired and is totally dependent on one staff for eating. R9's order sheet, dated 6/13/2022, documents regular diet, pureed texture, regular liquid consistency. Provide chocolate milk three times daily with meals for added weight. R9's order sheet, dated 3/15/2023, documents: Resource 2.0 with meals related to muscle weakness (generalized) 90cc three times daily. R9's Dietary Note, dated 2/27/2023 at 09:32 documents, Weight (2/14)-99 lbs. (pounds), BMI (body mass index)-17.5. Significant weight loss triggering -12 lbs. x 6 months (10.8%). Weight stable since 1/25. Noted in hospital 1/20-1/22 which may have contributed to trend down.Receiving regular, puree diet order with chocolate milk with meals and supplement 90 ml (milliliters) TID (three times a day) for nutrition support. Intakes 25-100% at meals with assist for optimal intakes. Weekly weights ordered to monitor. RECOMMEND: supplement change resource 2.0 to house supplement 120 ml TID for nutrition support. R9's Dietary Note, dated 3/13/2023 at 11:20 documents, Weight (3/9)-99.6 lbs., BMI -17.6. Significant weight loss triggering -12.6 lbs. x 6 months (11.2%). Stable since 1/25. Receiving regular, puree diet order with chocolate milk with meals and supplement 90 ml TID or nutrition support. Intakes 25-100% at meals with assist for optimal intakes. Weekly weights ordered to monitor. Continue to encourage intakes and provide alternatives at meals as indicated. RECOMMEND: supplement change resource 2.0 to house supplement 120 ml TID for nutrition support. R9's meal percentage log from 4/25/2023-5/24/2023 documents R9 had 13 meals of 0-25% consumption, 23 meals that were 25%-50% consumed, 12 meals that were 51%-75% consumed, 9 meals that were 75%-100% consumed. R9's Care Plan, updated 1/22/2023, documents R9 has potential for swallowing difficulties related to coughing/choking during meals or swallowing. Interventions include assist R9 to an upright position to eat, drink, and during medication administration. Diet to be followed as prescribed. R9 to eat only with supervision of staff and family. On 5/19/2023 at 8:00AM and 12:00PM, R9 was assisted by staff during breakfast and lunch meal. R9 would put head down on table and required encouragement to continue. High calorie shake offered. On 5/16/2023, R9 was observed in the dining from 5:00PM-6:00PM. R9 was sitting at a table. No resource 2.0 was observed to be administered to R9. Meal tray delivered at 5:20PM. At 5:40PM, tray remained untouched with no staff assist. At 5:55PM, V26, Certified Nursing Assistant (CNA), assisted R9 with a small amount of meal. On 5/25/2023 at 9:30AM, R10 stated, I saw (R9) fed in a hurry and she was holding her head down and not able to swallow that fast. R10 denied knowledge of who staff member was that fed R9 in a rush. 2. R7's Facesheet documents an admission date of 3/17/2021. Diagnoses include Dyphagia, Cerebral Infarction, Hemipareisis and Hemiplegia, and Muscle weakness. R7's MDS, dated [DATE], documents R7 is severely cognitively impaired and requires limited assist of one for eating. MDS does not document any swallowing or choking difficulties. R7's care plan, updated 5/3/2023, documents the resident has a swallowing problem Swallowing assessment results Dysphasia. Interventions include all staff to be informed of resident's special dietary and safety needs. Diet order: Regular, pureed texture, nectar thick liquids. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. R7 weight loss log documents 9/8/2022 02:48 222.0 Lbs, 12/28/2022 10:15 276.0 Lbs, 2/22/2023 12:08 237.2 Lbs, 4/12/2023 20:35 284.4 Lbs, 5/5/2023 16:24 245.6 Lbs, 5/6/2023 17:30 245.0 Lbs. R7's diet order, dated 4/16/2021, documents Regular diet, pureed texture, Nectar thick fluids consistency related to dysphagia following cerebral infarction. Resident to have divided plate, nonskid under plate, built up handled silverware and cups with lids at all meals times for feeding aid. R7's dietary notes dated R7's progress notes, dated 5/22/2023 at 09:41 Dietary Note Note Text: RD (Registered Dietician) NOTE: weight status Weight (5/6)-245 lbs, BMI-31.5. Significant weight loss triggering from out of line weights 4/12 and 12/28. Weight with overall trend up +7.8 lbs x 3 months. Weight hx: 12/28-276 lbs, 9/8-222 lbs, 7/3-223, 3/9-216 lbs, 2/11-214.4 lbs. R7's meal percentage log, dated 4/26/2023-5/24/2023, documents all meals were consumed at 75%-100%. On 5/23/2023 at 12:30PM, R7 was observed lying in bed in room with eyes closed. Meal tray was sitting untouched on a bedside table. At 1:15PM, R7 continued to be lying in bed, with eyes closed and untouched meal tray sitting on the bedside table. 3. R12's Face Sheet documents admission date of 6/26/2018. Diagnoses (dx) includes Chronic Kidney Disease (CKD), Type 2 Diabetes, and Dysphasia. R12's MDS, dated [DATE], documents R12 is severely cognitively impaired and requires supervision and set up for eating. MDS does not show any swallowing difficulties. R12's Care Plan, dated 5/3/2023, (R12) has the potential for a nutritional problem r/t (related to) dx: CKD (Chronic Kidney Disease)and bipolar d/o (disorder). Interventions include HYDRATION- STAFF TO ENC (encourage) (R12) TO DRINK FLUIDS BEFORE AND AFTER CARE AND IN BETWEEN MEALS. Monitor/record weight at least month and report significant weight change to MD (medical doctor) and RD (Registered Dietician). Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Offer boost glucose control BID (twice daily) as supplement BID. Offer increased supervision at meals. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN (as needed). On 5/16/2023 at 5:28 PM, R12 had a nutritional supplement drink with her meal. Nutritional supplement drink was never opened by staff. R12's meal consisted of salad with dressing, turkey and cheese sandwich, brownie, water. No staff was assisting R12 with her meal; husband was sitting at the table with R12. R12 did not have any ice water during her meal. On 5/24/2023 at 4:00PM, V27, Registered Dietician, stated, I would expect the facility to follow whatever the resident's orders for feeding called for. If the resident is to be fed and supervised, then I expect them to be fed and supervised. Facility policy, with a revision date of 9/2012, documents, As part of the initial assessment, the staff and physician will review the individual's current nutritional status (weight, fool/fluid intake, and pertinent laboratory values and identify individuals with recent weight loss and significant risk for impaired nutrient for example high risk resident with acute symptoms such as vomiting diarrhea feces, and infection or those taking medications that may be causing or increasing the risk for anorexia or wight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure flu vaccination was administered appropriately for 1 of 1 resident (R9) reviewed for unnecessary medications in the sample of 18. Findings include: R9's Face sheet documents an admission date of 1/20/2022. Diagnoses include: Chronic Obstructive Pulmonary Disease, Dysphagia, Anemia, and Heart Failure. R9's Minimum Data Set (MDS), dated [DATE], documents R9 is profoundly cognitively impaired. R9's Medication Administration Record (MAR), dated 10/24/2022 and 10/25/2022, document Influenza vaccine administered on 10/25/2022 at 2:16PM; 10/24/2022 on the MAR is blank. R9's Care Plan, updated 5/3/2023, documents R9 has impaired cognitive function/dementia or impaired thought processes, difficulty making decisions, and impaired decision making. Interventions include review medications and record possible cause of cognitive deficit, new medications or dosage increases. R9's Progress Notes, dated 10/25/2022 at 6:00PM, documents V23, R9's daughter, approached V36, Licensed Practical Nurse (LPN), and V5, LPN, and informed them (R9) had received 2 influenza vaccines. No staff were (R9)'s assigned nurse, so V36 told V23 to let us look and see. V23 stated, I want MD (medical doctor) called to see what we can do. Again, V36 informed V23 that issue will be looked into. V23 was still in hallway talking to V36 and V5. V23 then threw up hands and stated, ARE you going to call the Dr or not? V36 informed V23 the computer will have to be checked. V36 and V5 confirmed (R9) did receive 2 influenza vaccines. MD, Corporate Nurse, and Director of Nursing notified. V23 informed no new orders were given. R9's Progress Notes, dated 10/26/2023 at 10:31AM, documents V37, Social Services Director, spoke with (R9)'s Physician to ask if Physician could come and do an assessment on (R9) due to influenza vaccine being given twice. Physician said receiving double influenza vaccine would not harm (R9), and if (R9) is doing well, then there is no need for Physician to assess her. R9's Progress notes, dated 10/28/2022, document, Continuing to monitor (R9) and no adverse effects of medication error noted. On 5/23/2023 at 1:30PM, V14, Corporate LPN, stated, What happened with the influenza vaccine is that one nurse gave it and didn't sign it out. Then when another nurse came along, that nurse gave the vaccine to the resident, because it wasn't signed out. On 5/25/2023 at 10:30AM, V12, Pharmacist, stated Getting 2 influenza vaccines close together shouldn't cause any long-term effects. In the short term, the resident may have a sore arm at the injection site. Facility policy, dated 4/2021, stated, Immediately after a drug is ingested, it should be recorded on the Medication Administration Record. If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record.

Based on observation, interview, and record review, the facility failed to thoroughly investigate resident grievances and ensure staff adhered to the grievance resolution plan for 4 of 4 residents (R3, R8, R18, R19) reviewed for grievances in the sample of 18. Findings include: Grievance Report Form, dated 1/8/2023, documents Resident Council a complaint that showers need to be on a schedule. Grievance report form was signed by V1, Administrator. Grievance Report Form, dated 3/2/2023, documents V9, R8's daughter, has repeatedly complained to administration using a Grievance Report Form that R8 not getting her showers. R8 wants to be clean. Bed baths are not acceptable. R8 enjoys the showers. She does good in the showers, and V9 stated she's been told R8 actually relaxes, moves while getting a shower. So a shower is therapeutic for R8. Grievance Report Form, dated 5/1/2023, documents week of April 17, 2023, V9, R8's daughter, presented V1, Administrator, with a grievance, regarding hostile behavior from V6, CNA, had shown toward her after she was asked to change her mother. V9 requested her mother, R8, be moved to R9's room. V9 said in grievance she spoke with V1, Administrator, and he will handle. Grievance Report Form, dated 5/4/2023, documents Resident Council complaint that showers not being given. Persons involved include R3, R18, R19, and three residents complained they were not getting showers. Signed off by V1, Administrator. Grievance Report Form, dated 5/14/2023, documents V9, R8's daughter, has been reporting problems since last summer, there have been problems with R8 not getting changed or getting her showers. She has repeatedly brought this to supervisory attention. Two weeks ago on Monday 5/10/2023, V1, Administrator, assured her (V9) that V6, Certified Nurse Assistant (CNA), and V7, CNA, would no longer be working together, and V6 would not be allowed on 400 Hall; the following week V9 found V6 working on the 400 Hall. On Friday 05/12/2023, V9 arrived around 5:00 PM and found V6 had been on 400 Hall again. Around 6:00 PM, night shift came in and asked to check R8. R8 had not been changed all day. Night shift had marked the depends when they put them on in the morning, and every one they checked were still wearing the same diapers. On 5/17/2023 at 1:25 PM, V15, CNA, and V16, CNA, removed R8's diaper, which was saturated with urine, with strong /foul odor noted when the incontinent brief was removed. Blue stripes were noted on outside of incontinent brief, indicating the brief was wet. R8's inner upper left and right thighs were noted with red deep creases. Bedspread was noted with a brown colored ring; R8 was urinating after incontinent brief was removed. R8's buttocks were red with deep creases to buttocks, right and left back inner thighs, and creases on back side of upper thighs. Bath blanket was on top of R8's bedspread. Bath blanket noted to have a brown dried ring on top of blanket; urine odor noted at R8's bed. On 5/17/2023 at 1:25 PM, V16 stated the last time R8 was changed was at 6 am and 8 am. V16 stated he usually can't change residents every two hours, due to short staffing. On 5/18/2023 at 1:50PM, R3 was sitting up in wheelchair. A large puddle of urine and several smaller puddles of urine were noted on floor under wheelchair in R3's room. It was noted R3 was sitting on a cushion with a folded bath blanket under her in wheelchair. V19, CNA, asked R3 if the puddles were water. R3 stated, No, its pee. V7, CNA, and V19 transferred R3 from bed to chair via mechanical lift. When V7 and V19 began to remove R3's brief, the brief was noted to be completely saturated with yellow urine, and a large amount of feces in brief. V7 and V19 removed 3 skin fold dry sheets from under R3's abdominal fold, that were yellow and saturated with urine. On 5/18/2023 at 3:00PM, R3 denied she was changed before lunch or asked if she needed to be changed. On 5/17/2023 at 1:49 PM, V14, Licensed Practical Nurse (LPN)/ Corporate Nurse Manager, stated their policy is for residents to be checked and changed every two hours or more frequently as needed, and be changed in a timely manner, showers are to be done twice weekly. On 5/18/2023 at 3:20 PM, V22, LPN/ MDS Coordinator, stated she attends morning meetings most of the time. V22 stated grievances are brought up by V32, Social Services Director, with issues. Only patient care issues are brought up to clinical staff and Administrator. V22 stated she remembers issues with call lights, treatments not getting done, CNAs not passing ice water, showers not getting done consistently, at times residents need more help with being fed. V22 stated V1, Administrator, is aware of any grievances, since they are brought up in morning meeting. V22 stated she does not know how V1 resolved the issues. On 5/18/2023 at 3:29 PM, V2, Registered Nurse (RN)/ Regional Nurse, stated she questioned V1 on Wednesday, 5/17/2023, regarding Grievances that had been reported. V2 stated V1 said he was not aware of any grievances. On 5/26/2023 at 9:02 AM, V32, Social Service Director, stated she sometimes gets Grievances back not signed by V1. V32 stated many times, he would just verbally would state to V32, going to work on it. V32 stated she herself tried to resolve the problems, and will offer solutions to V1, and in the past to V38, Director of Nursing (DON); she wouldn't do anything either, just like V1. On 5/26/2023 at 11:35 AM, V2 and V14 both stated V1, Administrator, was terminated from employment on 5/24/2023, for grievances not being resolved. On 5/26/2023 at 11:40 AM, V14 stated she was not aware of any filed Grievances that residents were not getting changed in a timely manner, or showers not getting done as scheduled. V14 stated she became aware on 5/17/2023, when Illinois Department of Public Health (IDPH) questioned her regarding residents' showers, and residents not getting changed in a timely manner. On 5/26/2023 at 1:30 PM, R18 stated he filed a grievance during Resident Council Meeting because it had been five weeks since he had a shower. R18 stated they gave him a shower yesterday, when the state was in the building. The facility's Grievance Policy & Procedure, dated 2/2021, documents it is the intent of this facility /community and concerns suggestions, complaints, or opportunities for improvement in care of services. This facility/community offers a variety of mechanisms to communicate this is information on of these is the Grievance Process. The policy of the grievance form offers residents, families, or resident representative an opportunity to make written accounts of their concern utilizing the grievance form. Any resident or their representative may complete a grievance concerning his or her treatment, medical care, safety, or other issues without fear or reprisal of any type. The Administrator/Executive Director will act as the family/community designated grievance official. The Administrator with the assistance of the Social Service Designee, will be responsible for the oversight of the grievance process. Each grievance would be investigated and addressed with a response. The actual response may be a department head and will be QA reviewed by the Administrator. Social Service Designee or employee responsible for the process will review the open grievances for the process will review open grievances in the Daily Morning/ Quality Assurance (QA) Meeting with the appropriate department head and/or Administrator/Executive Director. The Administrator /Executive Director will ensure grievances are addressed and resolved written in a five day time frame and final outcome communicated to the person reporting the grievance. The Department Head will investigate the grievance, document the findings, and report the outcome of the investigation to Social Service Designee or employee designated responsible will review the completed grievance with the Administrator. The Administrator will sing all completed grievances, review, and completion. The response will be given to the person completing the grievance with five working days of the finding along any correction action accomplished. Copies of all grievances will be maintained at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide twice a week showers for 4 of 5 residents (R3, R7, R8, R18) reviewed for ADL (activities of daily living) care in the sample of 18. Findings Include: 1. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has no cognitive impairments. R3 is totally dependent on staff for bathing. R3's care plan, updated 5/3/2023, documents R8 has an ADL Self Care Performance Deficit related to obesity, respiratory failure and heart failure. Interventions include bathing and R3 requires 2 staff participation with bathing. On 5/17/2023 at 2:44PM, R3 stated she is supposed to get two showers per week, Monday and Friday, but usually never gets a shower on Mondays, and not always on Fridays. On 5/17/2023 at 2:44PM, R3's Electronic Medical Record (EMR) was reviewed for bathing/showers. It documents for the last 30 days: on 05/05/23 at 12:46 PM, R3 received- physical help in part of bathing activity; on 05/10/23 at 1:59 PM, total dependence; and 05/11/23 at 1:39 PM, activity itself did not occur or family and/or non facility staff provided care 100% of the time for that activity. R3's EMR also documents R3 is to get showers on Mondays, Wednesdays, and Fridays. 2. R7's MDS, dated [DATE], documents R7 is severely cognitively impaired, and is totally dependent on staff for bathing. R7's care plan, updated 5/4/2023, documents R7 has a ADL, self care deficit. Interventions include R7 is totally dependent on staff for biweekly bathing. On 5/17/2023 at 2:57PM, R7's EMR was reviewed for bathing/showers. It documents for the last 30 days: received on 04/09/23 at 1:59 PM, (12 days later) 04/21/23 at 1:39 PM, (5 days later) 04/26/23 at 1:59 PM, and 05/12/23 at 10:31 AM, R7 received total dependence; on (14 days after previous one) 05/10/23 at 1:59 PM, R7 received physical help in part of bathing activity. R7's EMR also documents R7 is to get showers on Wednesdays and Fridays. 3. R8's MDS, dated [DATE], documents R8 is severely cognitively impaired, requires total dependence, 2+ person physical assist with bed mobility, transfer, total dependence, one-person physical assist with dressing, eating, toilet use, personal hygiene, bathing, and she is always incontinent of bowel and bladder. R8's care plan, updated 5/1/2023, documents R8 has an ADL Self Care Performance Deficit. Interventions include R8 requires (1) staff participation with personal hygiene and oral care. On 5/17/2023 at 3:05PM, R8's EMR was reviewed for bathing/showers. It documents for the last 30 days: received on 04/20/23 at 13:00 PM, total dependence, (7 days later) 04/27/23 at 1:59 PM, Supervision- oversight help only, (5 days later) 05/02/23 at 1:59 PM, total dependence, 05/04/23 at 12:12 PM, activity its self did not occur or family and/or non facility staff provided care 100% of the time for that activity, 05/05/23 at 11:41 AM, activity its self-did not occur or family and/or non facility staff provided care 100% of the time for that activity, 05/11/23 at 1:39 PM, total dependence, and 05/16/23 at 13:59 PM, total dependence. She is to get showers on Tuesdays and Thursdays. 4. R18's Facesheet, undated, documents diagnosis includes epilepsy, seizures, anxiety, hypertension, hyperlipidemia, and depression. R18's MDS, dated [DATE], documents intact cognition, requires supervision with set up help only for dressing, requires supervision with one-person physical assist for personal hygiene, requires physical help with one-person physical assist for bathing R18's Care Plan, dated 5/14/2023, documents resident has an Activities of Daily Living (ADL) self-care performance deficit. Interventions include resident requires one staff participation with bathing and dressing. On 5/26/2023 at 11:05 AM, R18 stated he had not had a shower for five weeks, until last week When the state walked in the building. R18 stated he felt grungy and dirty not getting his showers. R18 stated he has complained to the CNAs, but never got his shower. On 5/26/2023 at 1:30 PM, R18 stated he filed a grievance during Resident Council Meeting because it had been five weeks since he had a shower. On 5/17/2023 at 1:49 PM, V14, Regional Licensed Practical Nurse (LPN), stated, I expect residents to get showers or bath at least twice a week. An undated document provided and signed by V14 documents, Showers: Facility follows PCC (Point Click Care) integrated schedule for a minimum of twice weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for 5 of 7 residents (R2, R3, R7, R8, R9) reviewed for incontinent care in the sample of 18. Findings include: 1. R3's Face sheet documents an admission date of 8/28/2019. Diagnoses include History of Cellulitis, Thyroid Disorder, Respiratory failure with Hypoxia, and Morbid Obesity. R3's urine culture dated 9/15/2022 documents Gram Negative Bacilli. R3's order sheet dated 9/19/2022 documents Bactrim DS 800-160MG 1 tablet twice daily for 7 days. R3's Minimum Data Set, MDS, dated [DATE] documents R3 has no cognitive impairments. MDS, dated [DATE], documents R3 is always incontinent of bowel and bladder. R3's care plan, dated 5/4/2023, documents R3 has bladder and bowel incontinence. Goal documents R3 will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions include R3 uses bariatric disposable briefs. Change per facility schedule and prn (as needed). Provide Incontinent management care according to the facility protocol Staff will offer bedpan while in bed. On 5/17/2023 from 9:50 AM to 11:05 AM, based on 15 minutes or less observation intervals, R3 remained sitting up in in her wheelchair without offer or receiving incontinent care. On 5/18/2023 at 1:50PM, R3 was sitting up in a wheelchair. There was a large puddle of urine and several smaller puddles of urine noted on floor under the wheelchair in R3's room. R3 was sitting on a cushion with a folded bath blanket under her in the wheelchair. V19, Certified Nursing Assistant (CNA), asked R3 if the puddles were water. R3 stated, No, its pee. V7, CNA, and V19, CNA, transferred R3 from bed to chair via mechanical lift. When V7 and V19 began to remove R3's brief, it was completely saturated with yellow urine and a large amount of feces was in the brief. V7 and V19 removed 3 skin fold dry sheets from under R3's abdominal fold that were yellow and saturated with urine. During incontinent care task, V7 used 3 bottles of peri wash, and did not at any time, rinse or dry R3's peri area. V7 cleansed R3's labial folds, and did not clean an area of dried feces in the labial fold and in the anal area. V7 was also cleaning from dirty to clean on peri area. It was noted that R3's peri area was dark red to purplish in color and excoriated. When asked when R3 was last changed, V7 said, I asked her at 11am if she had to be changed and she said she did not. R3 denied being asked at 11am if she needed changed. R3's new brief fell to the floor during peri care, and V19 picked the brief up off the floor, and used it on R3. Rags containing feces were observed touching bedside table. Nasal canula was noted to be sitting on urine-soaked chair cushion. In total, incontinent care to R3 took 1 hour and 15 minutes. On 5/18/2023 at 3:00PM, R3 denied she was changed before lunch, or asked if she needed to be changed. 2. R7's Face sheet documents an admission date of 3/17/2021. Diagnoses include: Dysphagia, Cerebral Infarction, and Spastic hemiplegia Affecting Right Dominant Side. R7's MDS, dated [DATE], documents R7 is severely cognitively impaired. MDS documents R7 is always incontinent of bowel and bladder. R7's Care Plan, updated 5/3/2023, documents R7 has bowel and bladder incontinence. Interventions include R7 uses briefs, change frequently. Check R7 for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinent episodes. Monitor and document for signs and symptoms of infection such as pain, burning, cloudiness, blood tinged urine, increased pulse, fever. On 5/17/2023 from 9:50 AM to 11:05 AM, based on 15 minutes or less observation intervals, R7 remained sitting up in his bed, without receiving incontinent care. On 5/17/2023 at 11:30 AM, R7 stated he doesn't remember getting changed this morning. Stated he's been sitting up since breakfast. R7 was still in his gown, incontinent brief saturated with urine, blue bright stripes were noted on brief, indicating the brief was wet. On 5/17/2023 at 11:36 AM, V25, Agency CNA, stated she changed R7 around 9:30 AM to 10:00 AM. She stated she was the only CNA on the hall, and only two CNAs on all three halls with one nurse between 6 am 9:00 AM. On 5/17/2023 at 11:42 AM, V28, CNA, provided perineal care for R7. V28 wet wash cloths in the bathroom sink and put a body wash cleanser that required rinsing on the washcloths. V28 removed incontinent brief that was saturated with urine. The brief was sagging with urine. There was a strong/ foul urine odor noted when brief was removed. There was a large amount of brown stool in brief. V28 swiped front to back to left groin area six times using a washcloth, right groin front to back two times, then washed the abdominal area in a side swipe motion back and forth. V28 did not rinse any of these areas. V28 swiped scrotum one time. V28 did not retract foreskin or wash the tip of the penis. V28 did not rinse scrotum or penis. V28 did not dry scrotum, penis, or groin areas. V28 and V25, CNA, turned R7 to his right side. A large amount of brown stool was noted on his brief and buttocks, and a small amount of dry brown stool on right inner thigh. V28 and V25 turned R7 halfway on his left side. V28 did not cleanse R7's right buttocks, hip area, or right inner thighs. The dried brown stool on R7's right upper inner thighs did not get cleansed. 3. R8's Face sheet documents an admission date of 2/22/202. Diagnoses includes Chronic Kidney Disease, Encephalopathy, Dysphagia, and Alzheimer's. R8's MDS, dated [DATE], documents R8 is severely cognitively impaired, requires total dependence, 2+ person physical assist with bed mobility, transfer, total dependence, one person physical assist with dressing, eating, toilet use, personal hygiene, bathing, and she is always incontinent of bowel and bladder. R8's care plan, updated 5/1/2023, documents R8 has bladder incontinence. Interventions include notify nursing if incontinent during activities, use of briefs, change every 2 hours, encouraged fluids, check for incontinence every 2 hours. Wash, rinse, and dry perineum. Change clothing as needed. On 5/17/2023 from 9:50 AM to 1:05 PM, based on 15 minutes or less observation intervals, R8 remained sitting up in in her wheelchair, without offer or receiving incontinent care. On 5/17/2023 at 1:25 PM, V15, CNA, and V16, CNA, provided perineal care for R8. V15 and V16 removed R8's incontinent brief that was saturated with urine, with strong /foul odor noted when the brief was removed. Blue stripes indicating brief was wet were noted on outside of brief. R8's inner upper left and right thighs were noted with red deep creases. R8 was urinating when the brief was being removed. The bedspread had a brown colored ring. R8's buttocks were red with deep creases to buttocks, right and left back inner thighs, and creases on back side of upper thighs. V16 cleansed right and left groin area using a wet washcloth with body wash that requires no rinsing. V15 cleansed the outside of the labia, but did not separate labia to cleanse. V15 dried groin areas with a towel. V15 put dirty wash cloths and towels on the floor, and did not use a bag. V15 did not cleanse the inner thigh. R8 was not turned on her right or left side for her buttocks or hips to be cleansed. V16 put a cream on R8's buttocks without cleansing the area. V15 put cream and powder in the creases of upper right and left thighs. Bath blanket with a brown dried ring was on top of R8's bedspread. Urine odor noted to R8's bed. On 5/17/2023 at 1:25 PM, V16 stated the last time R8 was changed was at 6 AM and 8 AM. V16 stated he usually can't change residents every two hours, due to short staffing. 4. R9's Face sheet shows an admission date of 1/20/2022. Diagnoses includes Chronic Obstructive Pulmonary Disease, Heart Failure, and Altered Mental Status. R9's MDS, dated [DATE], documents R9 is profoundly cognitively impaired. MDS, dated [DATE], documents R9 is always incontinent of bowel and bladder. R9's Care Plan, dated 5/3/2023, documents R9 has bladder incontinence. Interventions include check R9 for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. On 5/17/2023 at 1:05 PM, V15 and V16 provided perineal care for R9. V15 and V16 removed incontinent brief that was saturated with urine, and dark blue lines showing on outside of the brief (indicating the brief was wet). V15 dropped wet brief on the floor. V15 used disposable no rinse wipes, and swiped left and right groin area with one swipe front to back. V15 did one swipe down the outside of labia; did not separate labia. V15 did not dry the areas cleansed; did not cleanse upper inside right or left thighs; did not turn R9 on either side to cleanse her buttocks area or back side of upper thighs or right or left hip areas; and did not dry any areas that were cleansed with disposable wipes. On 5/23/2023 at 1:30PM, V29, R9's daughter, stated, I came to feed (R9) lunch and she was soaked with urine. The bed was yellow with urine, so she was wet when they got her up to lunch. 5. R2's Facesheet documents an admission date of 1/26/2018. Diagnoses include Dementia, Dysphagia, Nontraumatic Intracranial Hemorrhage, and Neurocognitive Disorder. R2's MDS, dated [DATE], documents R2 is severely cognitively impaired and requires total dependence, 2+ person physical assist with transfer, toilet use, personal hygiene, extensive assistance, 2+ person physical assist with bed mobility, dressing, and is occasionally incontinent of bowel and bladder. R2's Care Plan, dated 3/27/23, documents R2 has bladder incontinence. Interventions include Ensure the resident has unobstructed path to the bathroom. The resident prefers a urinal (where: at the bedside, on the left) (when: ie. while in bed, at night). On 5/18/2023 at 9:15 AM, V19 provided peri care to R2 with assistance from V40, CNA, after R2 has been on the bedpan. V19 used body wash that requires rinsing. V19 swiped in a front to back motion to left and right groin; swiped two times to penis; did not retract foreskin or use a circular motion cleansing penis; and swiped scrotum two times. V19 did not rinse groin area, penis, or scrotum with a washcloth. V19 did not cleanse right or left inner thighs. [NAME] stool was noted on right left upper inner thigh. Dry stool on scrotum was not thoroughly cleansed. R2's upper inner left and right thighs were red and gaulded. V19 applied a barrier cream on penis, scrotum, and upper thighs, without cleansing the upper thighs. V19 did not use a wash basin for peri care; she wet the washcloths in the bathroom sink she applied body wash that requires rinsing on three wash cloths. V19 and V40 turned R2 on his left side, and did not cleanse right side of buttocks where noted brown fecal matter was on right side of buttocks. V19 did three swipes on right side of buttocks, did not rinse, then dried right side of buttocks. Noted brown stool near anal area. V19 did not cleanse anal area. V19 applied barrier cream on R2's left and right buttocks without thoroughly and completing cleansing the buttocks or anal area. V19 did not cleanse either hip, and did not cleanse upper outer thighs. On 5/18/2023 at 10:21 AM, V3, R2's Wife, stated she's marked R2's incontinence brief again, because she knows day shift is not changing R2. On 5/18/2023 at 1:23 PM, V24, CNA, stated on Friday, May 12, 2023, she marked incontinent briefs with a tiny dot on the following residents: R9, R8, R13, R16, R14, and R11. V24 stated every time she follows V7 and V6, the residents are soaking wet. V24 stated, We've found urine puddles underneath (R8) and (R9). V24 stated when V24 arrived back at work at 6:00 PM on May 12, 2023, she found the dots remain on the residents. V24 stated R9, R8, R11, R13, R14, and R16 had the same incontinent briefs on at 6:00 PM. On 5/17/2023 at 2:30PM, V14, Director of Nursing (DON), stated, I expect residents to be changed every 2 hours or more often if needed. On 5/17/2023 at 2:30 PM, V2, Regional Nurse, stated the policy for this facility is best practice minimum of two hours of residents getting changed depending on pressure injury. The policy this facility goes by is the skills checklist.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and maintain adequate infection control practices to prevent cross contamination for 5 of 5 residents (R2, R3, R7, R8, R9) reviewed for infection control in the sample of 18. Findings include: 1. On 5/18/2023 at 1:50PM, R3 was sitting up in a wheelchair. A large puddle of urine, and several smaller puddles of urine, were noted on the floor under the wheelchair in R3's room. R3 was sitting on a cushion with a folded bath blanket under her in the wheelchair. V19, Certified Nursing Assistant (CNA), asked R3 if the puddles were water. R3 stated, No, it's pee. V7, CNA, and V19, CNA, transferred R3 from bed to chair via mechanical lift to perform incontinent care. When V7 and V19 began to remove R3's brief, the brief was noted to be completely saturated with yellow urine, and a large amount of feces was in the brief. V7 stated, I forgot my hand sanitizer. V7 did not use hand sanitizer through entire incontinent care task. R3's new brief fell to the floor during peri care, and V19 picked brief up off the floor and used brief on R3. Rags containing feces were observed to be touching the bedside table. Nasal canula was noted to be sitting on urine-soaked chair cushion. 2. On 5/17/2023 at 11:42 AM, V28, CNA, provided perineal care for R7. V28 removed brief that was saturated and sagging with urine, strong/ foul urine odor was noted when the brief was removed, large amount of brown stool in the brief. V28 did not change gloves during the entire procedure. V28 did not remove gloves, wash hands, or use hand sanitizer before leaving the room. She went to R7's door, opened the door touching the door knob with dirty gloves, and went into the hallway. V28 returned to R7's room with clean towels and wash cloths with gloves on her hands. 3. On 5/17/2023 at 1:25 PM, V15, CNA, and V16, CNA, provided perineal care to R8. V15 and V16 removed R8's breif that was saturated with urine, with strong /foul odor noted when brief was removed. V15 or V16 did not change gloves during entire procedure. V16 put dirty wash cloths, towels, and diaper on the floor; did not put soiled items in a bag. No hand sanitizer was noted at bedside table with wash cloths or towels. V16 did not wash his hands after the procedure, kept his soiled gloves on, and took the mechanical lift out in the hallway, touching R8's doorknob with his soiled gloves. 4. On 5/17/2023 at 1:05 PM, V15 and V16 provided perineal care to R9. V15 and V16 removed incontinent brief that was saturated with urine and dark blue lines showing on outside of brief (indicating the brief was wet). V15 dropped wet brief on the floor. V15 kept gloves on, picked up dirty brief and wipes off the floor, and opened R9's door touching the door knob with soiled gloves. V15 took brief to hallway without putting soiled brief in a bag. 5. On 5/18/2023 at 9:15 AM, V19 provided peri care to R2, with assistance from V40, CNA. V19 nor V40 washed hands or used hand sanitizer prior to giving peri care after R2 has been on the bedpan. R2 had dried feces to perineal area. V19 placed dirty washcloths with the clean towel on the bedside table. V19 did not use any plastic bag for the dirty washcloths or towels. V19 and V40 both stated, We don't have any bags on the cart today. Facility Infection Prevention and Control Program, dated 2019, states The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to investigate an allegation of verbal abuse, and failed to protect residents from potential abuse by failing to remove the accused from resident contact. This failure has the potential to affect all 78 residents in the facility. Findings include: The Initial Abuse Allegation Report, dated 4/17/2023, reported by V9, R8's daughter, that V6, Certified Nursing Assistant (CNA), was verbally rude to R8, and refused to provide incontinent care. The Report documents V6 was suspended pending investigation. The Final Investigation Report, dated 5/17/2023 (one month after the initial allegation), documents it was unsubstantiated that abuse occurred; substantiated that V6 was in R8's room. Customer service education provided, and V6 was terminated for Customer Service. The Initial Abuse Allegation Report, dated 4/24/2023, reported by V9, on 4/22/2023, V30, CNA, was informed by V9 when she entered the building, R8 had dried food on her face, and V6 was rude, loud, and being aggressive, in reference to R8's care. The Report documents Investigation initiated, and V6 suspended pending investigation. The Final investigation Report, dated 5/17/2023 (4 weeks after the incident), documents abuse could not be substantiated. Facility concluded issue was a customer service issue. V6 was terminated from the Facility. This final report was not done and the allegation was not investigated until a month after the initial report. The Facility staff schedule, dated 4/22/2023, documents V6 worked 400 hall. It also documents V6 worked 200 hall on 6am-6pm shift on 4/28/2023. On 5/24/2023 at 12:05PM, V17, Director of Nursing (DON), stated on 4/28/2023, V6, CNA, had access to all residents in the facility. On 5/18/2023 at 10:00AM, V17 stated V17 and V14, Corporate Licensed Practical Nurse (LPN), found files in V1's, Administrator, office on 5/17/2023. V17 stated, We didn't know these investigations were not completed or even began. (V2) is completing them now and sending to IDPH. (V6) worked as needed after being suspended on 4/24/2023. Facility abuse policy, with a revision date of 10/2022, states This facility prohibits mistreatment, neglect, or abuse of residents. It continues, The residents must not be subjected to abuse by anyone. It further documents, When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation. Prosecution or disciplinary action against the employee. The Administrator and or the Director of Nursing will relay this suspension. At that time the alleged staff member will be advised the allegation and encouraged to assist in completing a statement relevant to the facts. The employee shall be instructed that the suspension is without pay and will be in effect as long as the investigation is ongoing. The investigation and due process right of the alleged perpetrators will be observed. If the allegation is found unsubstantiated, the employee will be reinstated with the retroactive pay for any days missed that the employee was originally scheduled to work. If the allegation is substantiated the employee will be terminated.

Based on interview and record review, the facility failed to ensure administration operationalizes and oversees facility's policies and procedures regarding abuse prohibition, resident rights, and resident care to maintain the highest practicable physical, mental, and psychosocial well-being of residents. This has the potential to affect all 78 residents living in the facility. Findings Include: On 5/16/2023 at approximately 6:45 PM, V9, R8's daughter, approached surveyor and stated she was getting ready to leave the facility, and V1, Administrator, came up to her when she was alone. V9 stated V1 pointed his finger at her and told her he'd had it with her - her and another family member. V9 stated she told V1 he could not talk to her like that. V9 stated V1 stated to her, Oh, yes I can. V9 stated she again stated to V1 No, you can't. V9 stated he kept pointing his finger at her in a threatening manner. V9 stated she yelled she needed a witness. V9 stated V2, Registered Nurse (RN) Regional Nurse, came around the corner along with three other facility staff. V9 stated the three staff members tried to calm V1, Administrator, down but he kept repeating to her what he had already said. Grievance Report Form, dated 5/16/2023, documents V9, R8's daughter, reported V1, Administrator, threatened her, followed her, threatened her again, and tried to intimidate her for retaliation for a grievance she filed. From what she just witnessed, she believes he has anger issues and is unsafe around vulnerable people. Grievance Report Form, dated 5/17/2023 at 5:30 PM, documents On May 16, 2023, V3, R2's wife, filed a grievance it states she walked by V1, Administrator, at 5:30 PM in the dining room. He made an aggressive comment, Are you having fun? She felt this was in retaliation because the state was in the building. On 5/17/2023 at 7:13 PM, V2, Regional Nurse, stated she walked V1, Administrator, to the door regarding the allegations of aggressions toward family members that evening. Grievance Report Form, dated 1/8/2023, documents Resident Council complaint showers need to be on schedule. V1, Administrator's signature noted. Grievance Report Form, dated 3/2/2023, documents R8 has repeatedly complained to administration. She's not getting her showers. She wants to be clean. Bed baths are not acceptable. She enjoys the showers. She does good in the showers, and V9, R8's daughter, stated she's been told R8 relaxes, moves while getting a shower. So, it's therapeutic for her. Grievance Report Form, dated 5/1/202,3 documents week of April 17, 2023, V9, R8's daughter, presented V1, Administrator, with a grievance regarding hostile behavior from V6, CNA, had shown toward her after she was asked to change her mother. V9 requested her mother, R8, be moved to R9's room. V9 said in grievance she spoke with V1 Administrator, and he will handle. Grievance Report Form, dated 5/4/2023, documents Resident Council complaint that showers not being given. Persons involved include R18, R19, and R3; all complained they were not getting showers. Signed off by V1, Administrator Grievance Report Form, dated 5/14/2023, documents R8's daughter has been reporting problems since last summer, there has been problems R8 not getting changed or getting her showers. She has repeatedly brought this to supervisory attention. Two weeks ago on Monday 5/10/2023, V1, Administrator, assured her V6, Certified Nurse Assistant (CNA), and V7, CNA, would no longer be working together, and V6 would not be allowed on 400 Hall. The following week, V9 found V6 working on the 400 Hall. On Friday 05/12/2023, V9 arrived around 5:00 PM and found V6 had been on 400 Hall again. Around 6:00 PM, night shift came in and asked to check R8. R8 had not been changed all day. Night shift had marked the depends when they put them on in the morning, and everyone they checked were still wearing the same diapers. On 5/17/2023 at 1:49 PM, V14, Corporate Nurse Manager, stated their policy is for residents to be checked and changed every two hours or more frequently as needed and be changed in a timely manner, showers are to be done twice weekly. On 5/26/2023 at 11:35 AM, V2 and V14 both stated that V1, Administrator, was terminated from employment on 5/24/2023 for allegations from resident's families, grievances not being resolved, allegation of abuse from V6, CNA, to R8 was not investigated by V1, Administrator. On 5/26/2023 at 11:40 AM, V14 stated she was second in command when V1, Administrator, was walked to the door on 5/16/2023 for allegations of aggression toward family members that evening. V14 stated she was not aware of the allegation of V6, CNA, to R8. V14 stated she was not aware of any filed Grievances residents were not getting changed in a timely manner, or showers not getting done as scheduled. V14 stated she became aware on 5/17/2023 when Illinois Department of Public Health (IDPH) questioned her on the allegation of abuse, resident showers, and residents getting changed. The Job Description Administrator, undated, documents under responsibilities, ensure that employees, residents, visitors, and the general public follow established policies and procedures, make routine inspections of the facility to assure that established policies and procedures are being implemented and followed, assist the quality assurance and assessment committee is developing and implementing appropriate plans of action to correct identified quality deficiencies. The In-Service Attendance form, documents V1, Administrator, was educated on abuse prevention on 9/29/2022 and abuse prevention investigations. The facility's Resident Census and Conditions of Residents, CMS 672 dated 05/16/2023, documents the facility has a census of 78 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and interventions to prevent the formation of pressure ulcers for 2 of 3 residents (R2, R3) reviewed for pressure ulcers in the sample of 7. Findings include: 1.R2's Face Sheet documents R2 was admitted on [DATE], with the diagnoses of malignant neoplasm of frontal lobe, hemiplegia, Multiple Sclerosis, seizures, muscle weakness, dysphagia, unsteadiness on feet, abnormalities of gait and mobility. R2's admission Minimum Data Set (MDS), dated [DATE], documents R2 had a pressure ulcer/injury, a scar over bony prominence. R2's Minimum Data Set (MDS), dated [DATE], documents R2 does not have any pressure ulcers. R2's Skin check Weekly and PRN (as needed) document, dated 10/31/2022, documents no new changes this week and no new areas. R2's Skin check weekly and PRN document, dated 12/28/2022, documents no new changes this week and no new areas of skin impairment. R2's document titled Skin and Wound Evaluation, dated 1/4/2023, documents pressure area to sacrum Stage 2: measuring 1.4cm x 1.1cm with partial thickness loss with exposed dermis, in house acquired new wound found while changing urinary catheter and new treatment initiated (xeroform with collagen powder covered with a dry dressing once daily) . Resident will be added to Dr visit list. No physician notification noted on document. Upon review of R2's clinical record there are no other documents regarding R2's sacrum wound. R2's Progress Note, dated 1/14/2023 at 1:47pm, documents, (R2) has a blister on left heel, draining clear serous fluid, faxed MD to advise Tx (treatment), covered with a dressing for now. R2's Care Plan, dated 4/10/2023, documents no intervention or problems related to skin/pressure areas. R2's January 2023 Physician's Order Sheet contains no treatment orders for R2's pressure ulcer to sacrum and left heel. R2's Treatment Administration Record (TAR), dated 1/2023, contains no orders for treatment of sacrum and left heel. R2's medical record documented she discharged from the facility on 1/24/23. On 4/11/2023 at 9:00 AM, V5, Assistant Director of Nursing (ADON), stated she is not aware of any wound or treatment to R2's sacrum or left heel during R2's stay. V5 states she expects staff to turn and reposition residents to prevent pressure ulcers but has no documentation to show that R2 was turned and repositioned during her stay. On 4/11/2023 at 11:40 AM, V3, MDS Coordinator, states she is not aware of any wound or treatment to R2's sacrum during R2's stay. V3 states she is unaware of a blister to R2's left heel during R2's stay. V3 states there are no interventions on R2's care plan for turning or repositioning, nor is there any Certified Nursing Assistant (CNA) documentation to prove that R2 was turned and repositioned during her stay. 2. R3's Face Sheet documents admission date of 12/19/2022, with diagnoses of pressure ulcer left heel, edema, cellulitis, and local infection of skin. R3's admission MDS, dated [DATE], documents R3 had one or more unhealed pressure ulcers/injuries. R3's nursing admission document, dated 12/19/2022, documents right heel redness blanchable. R3's Skin and Wound evaluation, dated 1/4/2023, documents, In house pressure acquired area to right heel measuring 4.5 cm (centimeter) length x 5cm width. Md (Physician) in facility today assessing, wound assessed in person by doctor. MD measured wound and updated chart. On 4/11/2023, R3's April 2023 TAR documents right heal treatment of Apply calcium alginate and Santyl once daily and cover with dry gauze one time a day for wound healing with signature of V2, Licensed Practical Nurse (LPN), as completed on 4/10/2023. On 4/10/2023 at 10:35 AM, V2 was witnessed removing old dressing to right heel, cleansed with wound cleanser, and applied calcium alginate only then covered with dry gauze to right heel. On 4/11/2023 at 10:52 AM, V2 stated, I applied calcium alginate only to right heel yesterday. The order must have been changed and I didn't realize it. I could have sworn the order to the right heel did not include Santyl. 4/11/2023 at 12:15 PM, V6, Nurse Consultant, states she expects staff to turn and reposition residents to prevent pressure ulcers from developing and assist with healing. 4/11/2023 at 9:00 AM, V5 states she expects nurses to follow doctor orders when performing dressing changes. The Facility's pressure ulcer policy, revised 3/2022, states implement, modify, and monitor interventions to attempt to stabilize, reduce or remove underlying risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents are transported safely via automobile and failed to ensure residents are transfered safely to prevent accidents/falls for 1 of 3 residents (R2) reviewed for supervision to prevent accidents in the sample of 7. Findings include: R2's Face Sheet documents admit date of 10/24/2022, with the diagnoses of malignant neoplasm of frontal lobe, hemiplegia, Multiple Sclerosis, seizures, muscle weakness, dysphagia, unsteadiness on feet, abnormalities of gait and mobility. R2's Minimum Data Set (MDS), dated [DATE], documents a brief interview of mental status of 15, which indicates R2 is cognitively intact. MDS documents R2 requires extensive assist of two people with bathing, dressing, toileting, transfers, and personal hygiene. Facility occurrence report, dated 12/2/2022, documents R2 was unable to be properly buckled in with van seatbelt due to the arm rest on her wheelchair. The Report documented maintenance is correcting wheelchair so seatbelt can be used- wheelchair was locked in place properly and did not move. The Report documents, Conclusion includes: the seat belt was not able to be properly secured due to the position of the arm rest of her wheelchair. On 4/11//2023 at 8:15 AM, V4, Certified Nurse's Aide/Van Transport Driver, stated she was transporting R2 to her doctor's appointment, when she had to brake suddenly due to a police chase. V4 states R2 slid to a kneeling position onto her foot pedals. V4 states she was able to slide R2 back up into her wheelchair, and R2 complained of some knee pain. V4 states when she arrived at R2's doctor's office with her, R2 told the doctor what had happened in the van. V4 stated the doctor checked R2 out and suggested V4 take R2 to the hospital for evaluation of knee pain. V4 stated she called the facility and spoke with an unknown person, who directed her to bring R2 back to facility. V4 states she returned R2 to the facility, and R2 received x-rays at the facility. V4 stated the seatbelt would not fasten low on R2's waist like it's supposed to, due to her arm support on the wheelchair. V4 stated if the arm support wasn't on the wheelchair, she thought the seatbelt could properly be applied to R2. R2's Progress Notes, dated 12/2/2022 at 12:25 PM, documents R2 slipped out of wheelchair onto her knees landing on foot pedals. The Note documented R2 was in facility van in transport. R2's Progress Notes, dated 12/2/2022 at 3:41 PM, documents, Writer called Dr's office to see if Dr. has been notified of resident slipping out of chair today. Dr.'s receptionist said on call MD will need to be notified d/t (due to) nobody in the office there to help with this. R2's Progress Notes, dated 12/2/2022 at 4:28 PM, documents, Left message on Dr.'s cell phone to request order for left knee xray - will await return call. R2's Progress Notes, dated 12/2/2022 5:31 PM, documents, Dr. gave verbal auth for left knee xray. Ok portable. R2's Care Plan, dated 4/10/2023, documents interventions of Arm rest on w/c adjusted to allow resident to be properly buckled in with seat belt during transport. On 4/11/2023 at 10:00 AM, V5, Director of Nursing (DON), stated she would have expected V4 to take R2 to the ER if doctor had instructed her to do so. 2. R2's Progress Notes, dated 11/9/2022 at 3:30 PM, documents, While CNA (Certified Nursing Assistant) was transferring (R2) from wheelchair to bed, (R2) expressed to CNA that she could not stand or assist in transfer. (R2) told CNA that she was only a one assist transfer when she in fact is a two assist. CNA was from agency, and this was her first time working with this resident specifically, so she was unaware. CNA slowly and carefully lowered her to the ground. CNA alerted this nurse that resident was on the floor and explained the situation. This nurse assisted CNA in helping resident into bed. Husband was present in room with CNA and witnessed incident happen. Doctor notified. (R2) denies any new onset of pain or any new s/sx (signs and symptoms) as a result of this incident. No injuries resulted from this incident. (R2) did not hit head. (R2) currently resting in bed, watching TV with call light within reach. R2's MDS, dated [DATE], documents R2 requires extensive assist of two people with transfers. R2's Care Plan, dated 4/10/2023, documents interventions of Resident evaluated to always transfer with assistance of two people. Care plan does not address transfer status prior to 4/10/2023. On 4/11/2023 at 12:15 PM, V6, Nurse Consultant, stated, I am aware that (R2's) care plan was not completed prior to 4/10/2023. V6 states they have no documents of R2's transfer status prior the care plan dated 4/10/2023. On 4/11/2023 at 11:40 AM, V3, Licensed Practical Nurse/MDS Coordinator, states she is unable to pull any other information of R2's transfer status prior to care plan date of 4/10/2023. The Facility's policy for falls, revised 9/17/19, documented the facility shall ensure that a fall management program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and provide timely turning and reposition for dependant residents for 1 of 1 residents (R3) reviewed for Risk of skin breakdown in the sample of 9. Findings include: 1. R3's Minimum Data Set (MDS), dated [DATE], documented R3 as severely impaired mental cognition; medical diagnosis of Dementia, Dysphagia and Chronic Kidney Disease and frequently incontinent of bowel and bladder. R3's Braden Assessment, dated 2/24/23, documented R3 is very moist, slight mobility, and at risk for skin breakdown. R3's Care Plan, revised 2/15/23 for skin impairment, documents interventions to include: R3 need pressure redistributing cushion to protect the skin while up in chair, and R3 needs reminders to turn/reposition at least every 2 hours, more often as needed or requested. On 3/20/23 at 10:37AM, V7 and V8, both Certified Nurse Aides (CNAs), transferred R3 from the wheelchair to the toilet. R3's urine soiled incontinent briefs were removed. R3 was toileted. R3 was returned to his wheelchair at 10:45AM, and then propelled to the open nursing station area. R3 remained in his wheelchair from 10:45AM to 3:30 PM, without benefit of repositioning based on 15 minutes or less observation intervals. At 11:30AM, staff propelled R3 to the dining room for the lunch meal service. At 1:00PM, R3 was then propelled from the dining room back in front of the nursing station area, R3 remained in his wheelchair. At 3:25PM, V3, Assistant Director of Nursing (ADON), was notified of the concern. At 3:30PM, V3, with assistance of a nursing staff, propelled R3 to the bathroom, R3 was assisted from his wheelchair to stand-up. R3's incontinent brief was removed. The incontinent brief was soiled with a large amount of urine, and his left and right buttock area was red in color. R3 had linear creases to the skin of his left and right front lower inner groin area. On 3/21/23 at 1:40PM, V3 stated she expects nursing staff to ensure dependant residents are monitored and repositioned every 2 hours or as needed. V3 also stated she observed R3's buttock area to be red in color, and will be addressed. The facility policy and procedure, entitled, Pressure Ulcer/Pressure Injury Prevention, dated 3/2022, documented an individual plan of prevention will be developed to meet the needs of the resident that includes, positioning, mobility, continence, the goal is for the resident to be free of preventable pressure ulcer/pressure injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and provide timely incontinent care for 1 of 6 residents (R3) reviewed for incontinent care in the sample of 9. Findings include: R3's Minimum Data Set (MDS), dated [DATE], documented R3 as severely impaired mental cognition; medical diagnosis of Dementia, Dysphagia and Chronic Kidney Disease and frequent incontinent of bowel and bladder. R3's Braden Assessment, dated 2/24/23, documented R3 is very moist, slight mobility, and at risk for skin breakdown. R3's Physician Order Sheet, dated 3/20/23, documented R3 is administered, Furosemide (water pill) one 20 milligram tablet once a day. R3's Care Plan, dated 6/10/22, documents R3 has bladder incontinence, with the goal to remain free from skin breakdown due to incontinence and brief use. Intervention is to ensure R3 has a clear path to the bathroom. R3's Care Plan does not address incontinent care. On 3/20/23 at 10:37AM, V7 and V8, both Certified Nurse Aides (CNAs), transferred R3 from the wheelchair to the toilet. R3's urine soiled incontinent briefs were removed. R3 after being toileted, staff returned R3 to his wheelchair at 10:45AM, and then propelled to the open nursing station area. R3 remained in his wheelchair from 10:45AM to 3:30 PM, without benefit of toileting or incontient care based on 15 minutes or less observation intervals. At 11:30AM, staff propelled R3 to the dining room for the lunch meal service. At 1:00PM, R3 was then propelled from the dining room back in front of the nursing station area, R3 remained in his wheelchair. At 3:25PM, V3, Assistive Director of Nursing (ADON), was notified of the concern. At 3:30PM, V3, with assistance of a nursing staff, transferred R3 to the bathroom; R3 was assisted from his wheelchair to stand-up. R3's gray pants had a wet area approximately 8 diameter on the buttock /back side of the pants. R3's incontinent brief was removed, and was soiled with a large amount of urine. On 3/21/23 at 1:40PM, V3 stated she expects nursing staff to ensure dependant residents are monitored and provided toileting every 2 hours or as needed. The facility's Policy and Procedure entitled, Pressure Ulcer/Pressure Injury Prevention, dated 3/2022, documented, an individual plan of prevention will be developed to meet the needs of the resident that includes, continence, the goal is Manage moisture, by providing toileting at regular intervals, provide prompt incontinent care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and offer fresh water daily to dependant residents for 4 of 4 residents (R6, R7, R8, R9) reviewed for hydration in a sample of 9. Findings include: 1. R6's on 3/20/23 at 10:20AM, R6's water pitcher was located on a bedside table, empty and not within R6's reach. At 12:03PM and 1:30PM, R6's water pitcher remained empty and without change in the pitchers location. R6's Minimum Data Set (MDS), dated [DATE], documented moderately impaired mental cognition. R6's Physician Order Sheet (POS), dated 6/16/22, documented a medical diagnosis of Dehydration. R6's Care Plan, dated 9/11/22, documented to encourage R6 with adequate fluid intake, monitor liquid intake. 2. On 3/20/23 at 10:30AM, 12:00PM, and 1:30PM, R7 did not have a water pitcher within his room nor holding cups for liquids. R7's MDS, dated [DATE], documented R7 as severly impaired mental cognition. R7's POS, dated 3/20/23, documented a medical diagnosis of failure to thrive, altered mental status and Alzheimer. 3. On 3/20/23 at 10:22AM, R8 had a water pitcher on his bedside table, with warm water and measured 600ml (milliliters). At 11:58AM and 1:20PM, R8's water pitcher remained unchanged from its location and liquid measurement. R8's MDS, dated [DATE], documented R8 as severely impaired cognition. 4. On 3/20/23 at 10:25AM, R9 had a water pitcher on her bedside table, with 800ml of warm water. At 12:00PM and 1:35PM, R9's water pitcher remained unchanged from its location and liquid measurement. R9's MDS, dated [DATE], documented R9 as moderately impaired mental cognition, dementia and impaired vision. On 3/21/23 at 3:50PM, V10, Licensed Practical Nurse (LPN), stated she has encouraged staff, while standing around at the nursing station, to provide fresh water to their assigned residents as this has been an ongoing problem that has been addressed to administrative staff. On 3/21/23 at 1:40PM, V3, Assisting Director of Nursing (ADON), stated she would expect staff to provide hydration to all residents 2 times per their work shift. The facility's Resident Council Meeting Minutes, dated 2/7/23, documented Certified Nurse Aides/Task Aides are not passing ice water. The Facility Policy and Procedure, entitled, Pressure Ulcer/Pressure Injury Prevention, dated 3/2022, documented, an individual plan of prevention will be developed to meet the needs of the resident that includes, hydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report allegations of abuse and injuries of unknown origin to the Administrator and to the Illinois Department of Public Health (IDPH) for 3 of 6 residents (R24, R26, R66) reviewed for abuse in the sample of 51. Findings include: 1. R24's Health Status Note, dated 5/16/22 at 5:48 AM, documents, Res (Resident) scratched his nose causing a skin tear. cleansed with wound cleanser and applied TAO (Triple Antibiotic Ointment). Notified daughter (V14) and she stated that he had a scratch and she said that he probably picked that open. SBAR (Situation Background Assessment Recommendation) sent to MD (Medical Doctor) via fax awaiting on orders. R24's Health Status Note, dated 5/16/22 at 7:41 PM, documents, Skin tear to bridge of nose, purple discoloration starting inner corner RT (right) eye. No acute distress noted at this time. On 6/27/22 at 6:23 PM, V42 stated, I was the nurse working the night (R24) got the scratch. Around 5:00 AM ish, I think, (V7, Certified Nursing Assistant) came and got me and we went down. (R24) had a pretty good gash. I called his daughter (V14) to see if she wanted me to send him to the ER (Emergency Room) to see if he needed stitches. I thought maybe he needed 1 stitch. She said no, so I put TAO (triple antibiotic ointment) on it. He is a picker. I thought he scratched himself. His fingernails were a little long. I notified the doctor of the incident. The next night I came in and saw the bruising, I called and left a message for (V2, Previous Director of Nursing) and told her that this needed to be investigated. I never heard back. I told (V3, Previous Assistant Director of Nursing) the next morning and she said that she would talk to (V2). R24's Health Status Note, dated 5/17/22 at 4:24 AM, documents, Area to self-inflicted skin tear to nose cleansed and tao (triple antibiotic ointment)applied. bruising noted under both eyes left eye worse than right. no signs or symptoms of pain or discomfort. R24's Health Status Note, dated 5/17/22 at 6:45 AM, written by V4, RN, documents, This writer, walked into residents' room to eval (evaluate) resident's nasal area. Resident has bruising under bilateral eyes with noted swelling on his nose and under bilateral eye areas. Resident does have multiple scratches to the nasal area. Resident is unable to state if he is in pain or what has happened due to his disease process. 0700-Writer Contacted POA (Power of Attorney) (V62 AND V14) to notify them of new findings. Writer asked if it was okay to call MD and ask for order for his bilateral orbital area and nasal. Family agrees as long as he can stay in house and he can have a portable done. R24's Health Status Note, dated 5/17/22 at 9:30 AM, documents, (V3, Previous Assistant Director of Nursing), LPN (License Practical Nurse) notified (V2, Previous Director of Nursing) of below information (Health Status Note dated 5/17/22 at 6:45 AM). This was 24-hours after R24's initial injury of unknown origin was found. On 6/22/22 at 9:30 AM, V4 stated, I came in and in report I was told (R24) scratched his nose and that he did it to himself. I went down to look at (R24) and it was a deep wide scratch on his nose with multiple little scratches on his eyebrow area. He had swelling and bruising occurring under his eyes and swelling on the bridge of his nose. I called the doctor to see if we could get a facial x-ray which we did and it showed no fractures. I notified (V14 and V62) of getting the x-ray and what (R24's) face looked like. I did notify (V2) and (V3) of the swelling and the bruising. I don't believe this incident was investigated. R24's X-ray report, dated 5/17/22, documents, Reason: Bruising swelling and scratches in the orbit and nasal areas. Findings: No displaced fractures are identified. The orbital rims and nasal bones are intact. The septum is midline. The visualized sinuses are well aerated without air fluid levels. The surrounding soft tissues are normal. Impression: No acute abnormalities. R24's Initial Incident Report submitted to IDPH, written by V2 (Previous Director of Nurses), dated 5/18/22, documents, This is an initial report to DPH an injury of unknown origin on (R24) (DOB: [DATE]) with the following diagnosis: Alzheimer's Disease, Generalized anxiety disorder, Unspecified dementia, Dysphagia, oropharyngeal phase, Other specified mental disorders due to known physiological condition, Unspecified psychosis not due to substance or known physiological condition, History of falling, Personal history of Covid-19, Gastro-Esophageal Reflux disease without esophagitis. (R24) was found to have what was thought to be a self-inflicted scratch to the right side of the bridge of his nose. By the next morning purplish blue bruising was noted under both eyes with slight swell to top of the bridge of nose. (R24) was unable to verbalize what occurred due to disease process. (R24's) family and primary care provider were contacted about scratch and bruising. New orders were received from primary care provider for radiological exams of facial and orbital bones. X-Rays of (R24's) facial and orbital bones were negative. No other orders were noted at this time. Care plan updated. Final report to follow. R24's Final Incident Report submitted to IDPH, written by V2, dated 5/24/22, documents, This is a final report to DPH an injury of unknown origin on (R24) (DOB: [DATE]) with the following diagnosis: Alzheimer's Disease, Generalized anxiety disorder, Unspecified dementia, Dysphagia, oropharyngeal phase, Other specified mental disorders due to known physiological condition, Unspecified psychosis not due to substance or known physiological condition, History of falling, Personal history of Covid-19, Gastro-Esophageal Reflux disease without esophagitis. (R24) was found to have what was thought to be a self-inflicted scratch to the right side of the bridge of his nose. By the next morning purplish blue bruising was noted under both eyes with slight swell to top of the bridge of nose. (R24) was unable to verbalize what occurred due to disease process. (R24's) family and primary care provider were contacted about scratch and bruising. New orders were received from primary care provider for radiological exams of facial and orbital bones. X-Rays of (R24's) facial and orbital bones were negative. No other orders were noted at this time. (R24) is a resident of the memory care unit in this facility. At his baseline he has impaired cognition and confusion. R24 has poor safety awareness and the logical conclusion of the investigation is that he was attempting to ambulate without assistance and sustained a fall and was to get self-up but unable to self-report. Staff interviews were unremarkable for any kind of abuse. Care plan updated. This report was sent two days after R24's injury of unknown origin was identified. On 7/6/22 at 9:01 AM, V1, Administrator, stated, If staff or a visitor see an injury of unknown origin or abuse, they should report that immediately. If it's an injury of unknown origin, they (staff) had been reporting that to (V2) then she reports that to me. If it abuse, that should be reported to me immediately. (V2) will start an investigation and let me know of the findings for injury of unknown origin. We report to the family, doctor, Ombudsman and to the IDPH. If an injury of unknown origin, the Director of Nurses will start an investigation to find out what happened. At this time since we have no Director of Nurse, the Regional Corporate Nurses are taking over that role for investigating and reporting injuries of unknown origin. The Director of Nurses or the Corporate Nurses will talk to all staff and family and try to figure out a plausible reason for the injury. If at any time they suspect abuse, it is reported to me immediately and if it involves a staff member they are suspended until the investigation is complete. If abuse is reported to me, I notify all parties involved, family, doctor and IDPH. The alleged abuser is put on suspension until the investigation is complete. IDPH is notified within 2 hours and a final report is completed within 5 business days. I expect my staff to notify me immediately of abuse and the Regional Nurse or DON of injuries of unknown origin immediately. On 7/06/22 at 9:24 AM, V6, Regional Corporate Nurse, was questioned as to who did the investigation into R24's injury of unknown origin, V6 stated, (V2). V6 was questioned as to if she knew why the initial investigation was not reported until 5/18/22 when R24 had bruising on both eyes and swelling on the bridge of his nose on 5/17/22, V6 stated, My only thought is she was waiting for the x-ray results before submitting the initial report. Reports need to be filed to IDPH (Illinois Department of Public Health) within 2 hours. Immediately is preferred and a final report within 5 business days. 2. R26's admission Record, print date of 7/7/22, documents R26 was admitted on [DATE] and has a diagnosis of Dementia. R26's MDS, dated [DATE], documents R26 is severely cognitively impaired. On 6/27/22 at 2:23 PM, V13, CNA, stated, I have worked with (V7) before. I have witnessed what I considered verbal abuse on 2 occasions with him. The first was one night in February. (V7) always uses one of the dining room tables as his personal snack table. He will put out 2 liters of soda and food on them. (R26) started walking toward the table and he yelled 'Don't you dare touch that'. The second was (R66) she was walking out of her room and he screamed 'I am not playing with you' and she went back in her room. I thought it was verbal abuse. I went home and thought about it and I reported it to (V3). When time went by, I didn't hear anything. Then I told (V2) nothing happened, so then I told (V65, Human Resource Director) nothing happened so then I told (V6, Corporate Nurse) and still nothing happened. I did not tell (V1); he was never here when I was. On 6/29/22 at 3:50 PM, V6 was questioned if she knew anything about V7 yelling at R26 for going near his snack table or R66 being yelled at by V7, I am not playing with you. by V13. V6 denied every being told of this. On 6/29/22 at 3:55 PM, V1 was questioned if he knew anything about V7 yelling at R26 for going near his snack table or R66 yelling at her, I am not playing with you. by V13. V1 denied every being told of this, and stated he would start an investigation right away. V1 further stated he was not even in this building in February. 3. R66's admission Record, print date of 7/5/22, documents R66 was admitted on [DATE] and has a diagnosis of Alzheimer's Disease. R66's MDS, dated [DATE], documents R66 is severely cognitively impaired. R66's SBAR, dated 5/9/22 at 1:14 PM, Resident sitting in dining room and reported to CNA of the bruise on top of her right hand. 5 cm (centimeter) X 5 cm purple in color. States that it does not hurt at all. Will continue to monitor. (V40) faxed. Left message for guardian to return call to facility. On 7/7/22 at 9:00 AM, V6, Corporate Nurse, stated, I was not aware of this injury of unknown origin. We do not have an investigation on this. I will look and see if maybe she had a blood draw. At that time, (V2, Previous Director of Nurses) or (V1, Administrator) should have been notified and an investigation should have been started. The Facility's Abuse, Prevention and Prohibition Policy, dated 2/2021, documents Reporting/Response: The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriated of resident property, shall immediately report the matter to the facility Executive Director or his/her designated representative in the Executive Directors absence. An employee or agent or any Covered Individual will make or cause a report to be made to law enforcement and the facility. The Executive Director, or his/her designated representative if Executive Director is not present, will notify the Regional Corporate Nurse (if unavailable, the [NAME] President of Clinical Operations will be contacted). The facility Executive Director, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. Such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property will be reported immediately to the Executive Director. The person made aware of allegations of abuse or neglect or the Executive Director will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours after the allegation is made if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, these will be reported to the executive Director immediately and to State Survey Agency not later than twenty-four hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to place the call light within reach of residents, and failed to follow recommendations for getting resident up as desired for 5 of 8 residents (R20, R44, R54, R72, R175) reviewed for accommodation of needs in the sample of 51. Findings include: 1. R20's Care Plan, dated 9/11/2020, documents, The resident is at risk for falls. It also documents, Be sure the call light is within reach and encourage the resident to use it for assistance as needed. It also documents, The resident has a communication problem. It continues, Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. On 6/21/22 from 9:00 AM to 11:00 AM, based on 15 minute observation intervals, R20 remained sitting in her room in wheelchair next to the bed, with call light out of R20's reach, with the cord attached to the wall outlet. On 6/28/2022 at 11:38 AM, V44, Certified Nurse Assistant (CNA), stated R20 can use her call light. V44 stated R20 does yell out for help. V44 stated she has seen R20 use her call light when it is in reach. 2. R54's Care Plan, dated 5/4/2022, documents, The resident is at risk for falls. It continues, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 6/21/2022 at 10:15 AM, R54 was lying in bed with call light on the table next to the bed, and not in reach. When asked if R54 could reach her call light, R54 reached for call light and was unable to reach. On 6/21/2022 at 10:15 AM, R54 stated she needs help from the staff. On 6/28/2022 at 11:38 AM, V44, CNA, stated R54 can use her call light when it is in reach. V44 stated R54 does do a lot for herself, but the call light is always to be in reach. 3. R72's care plan, dated 6/24/2022, documents, The resident is at risk for falls r/t (related to) Deconditioning, Gait/balance problems, Incontinence, Psychoactive drug use, Hemiplegia and Unaware of safety needs. On 6/28/2022 at 12:15 PM, R72 was lying in bed, leaning to the right side against bed rail, with the call light on the floor next to the bed. The call light was out of reach of R72. On 6/28/2022, R72 stated he needed help. R72 stated he needed to be changed. R72 stated his bottom hurts, and it burns when he goes to the bathroom. R72 stated he is in a lot of pain. When asked if he called for anyone, R72 stated he couldn't, and that he didn't have a way to. When asked if he used his call light, R72 stated he did not have one. On 6/30/2022 at 1:50 PM, V43, Social Services Director, stated R72 is alert and able to make his needs known. V43 stated R72 can use his call light if in reach. 4. R175's Care Plan, dated 9/6/2022, documents, The resident is at risk for falls. It also documents, Be sure the call light is within reach and encourage the resident to use it for assistance as needed. On 6/21/22 at 9:30 AM, R175 was sitting in her room in the reclining chair next to the bed, with call light cord on bedside table located behind the chair. Call light was out of reach of R175. On 6/27/22 at 11:15 AM, R175 stated she can use her call light, but sometimes she doesn't have it. R175 stated she has called for help and no one comes. R175 stated she feels she can do some things on her own, but they won't let her, because she is weak and falls. R175 stated she doesn't know what to do. On 6/30/2022 at 12:08 PM, V41, Licensed Practical Nurse (LPN), stated R175 requires assistance with her care. V41 stated R175 is able to make her needs known, and is able to use her call light when in reach. On 6/30/22 at 11:31 AM, V6, Regional Nurse, stated the facility does not have a call light policy. V6 stated she expects the call lights to be in reach and answered timely. 5. R44's Physician Order, dated 5/28/22, documented staff could use full body mechanical lift and could be in a Broda chair as tolerated. R44's Care Plan, revised 6/8/22, for Activity Preferences documents: R44 enjoys playing games, bingo, watch movies with other people and watch nature outside if permissible. R44 is dependent on staff for activities, social interaction, with a Goal of participation in activities of choice when desired. R44 is documented for refusal of care and getting out of bed. R44 also, requires assistance of two nursing staff with bed mobility, toileting and use of a full mechanical lift for transfers. R44's Minimum Data Set (MDS), dated , 5/5/22, documented a mild cognitive impairment, and R44 is not stable with her upper and lower body extremities, which requires two staff for assistance. R44's Occupational Therapist Progress and Discharge summary, dated [DATE], documented, Pt, (R44) was able to utilize motorized w/c (wheelchair) safely in facility for several weeks until recent decline, Pt, (R44) discharging to hospice services. Short Term Goal for (R44) will maintain optimal sitting position in manual wheelchair for 60 minutes for at least 2 meals/day with total assistance to transfer from bed to wheelchair and (R44) and staff educated regarding (R44) is currently no longer safe to use her personal motorized wheelchair. On 6/7/22 at 8:50AM, R44 was in bed. R44 stated she used to get up and was transferred to the dining room, which she enjoyed being around people, and now since her seizure occurrence, the staff do not get her up, and currently she receives a bedpan for toileting and bed baths by the nursing staff. On 6/8/22 at 2:05 PM, V10, Occupational Therapy Aide, stated R44 was progressing in therapy with the use of a motorized wheelchair. V10 stated R44 then had a seizure, and was hospitalized . V10 stated R44 had returned back to the facility, and another motorized wheelchair assessment was completed, and R44 was deemed un-safe to use; therapy ended 5/26/22. V10 stated the staff and family was educated regarding R44 could not use the motorized wheelchair due to safety reasons, and has been authorized to use a manual wheelchair at this time with assistance. On 6/7/22 at 10:30 AM, V5, CNA, stated, (R44) is not to use a wheelchair because she may hurt herself. On 6/8/22 at 2:15PM, V11, CNA, stated R44 requires two staff to assist her in repositioning in bed and transfers and stated, I think she uses a sit to stand but that was a while ago. V11 also states, (R44) is not allowed to get out of bed due to having a seizure is what I heard. On 6/8/22 at 2:25PM, V12, R44's daughter, stated she has a (specialized wheelchair) that she received about 2 weeks ago, and she has not been it. V12 also pointed down the hallway and stated, That's her chair. On 6/8/22 at 3:10 PM, R44 was in her full tilt back chair, with her daughter at her side, both were visiting in the foyer area. A t 3:15PM, V12 stated she just pushed her mom past the nurse's station in her chair, and the nurse stated that is the first time she has seen (R44) up in a long time. On 6/9/22 at 9:00AM, V1, Administrator, stated,the facility does not have a policy or procedure for transfer care provided to dependent residents, and would expect the staff to have communicated the fact R44 can be transferred out of her bed, with assistance to a chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate injuries of unknown origin, and a sexual abuse allegation for 4 of 6 residents (R24, R36, R51, R66) reviewed for abuse in the sample of 51. Findings include: 1. R24's Minimum Data Set (MDS), dated [DATE], documents R24 is severely cognitively impaired, R24 requires extensive assistance of 2 staff members for bed mobility, transfers, walking in his room and on the hall, dressing, toileting and personal hygiene. R24's MDS documents R24 requires limited assistance of 1 staff member for locomotion on and of the unit. R24's MDS also documents R24 is not steady, and only able to stabilize with staff assistance during transitions and walking. R24 does not use any mobility devices, and he has not had any falls in the previous 90 days. R24's Health Status Note, dated 5/16/22 at 5:42 AM, written by V42, Registered Nurse/RN, documents, Res (Resident) scratched his nose causing a skin tear. Cleansed with wound cleanser and applied TAO (Triple Antibiotic Ointment). Notified daughter (V14) and she stated that he had a scratch and she said that he probably picked that open. SBAR (Situation Background Assessment Recommendation) sent to MD (Medical Doctor) via fax awaiting on orders. R24's Health Status Note, dated 5/16/22 at 5:51 AM, documents, Family does not want him sent out to see if he needs a [NAME] on his nose. R24's Health Status Note, dated 5/16/22 at 7:41 PM, documents, Skin tear to bridge of nose, purple discoloration starting inner corner RT (right) eye. No acute distress noted at this time. R24's Health Status Note, dated 5/17/22 at 4:24 AM, documents, Area to self-inflicted skin tear to nose cleansed and TAO (triple antibiotic ointment) applied. Bruising noted under both eyes left eye worse than right. No signs or symptoms of pain or discomfort. On 6/27/22 at 6:23 PM, V42 stated, I was the nurse working the night (R24) got the scratch. Around 5:00 AM ish, I think, (V7, Certified Nursing Assistant) came and got me and we went down (to his room). (R24) had a pretty good gash. I called his daughter (V14) to see if she wanted me to send him to the ER (Emergency Room) to see if he needed stitches. I thought maybe he needed 1 stitch. She said no, so I put TAO (triple antibiotic ointment) on it. He is a picker. I thought he scratched himself. His fingernails were a little long. I notified the doctor of the incident. The next night I came in and saw the bruising, I called and left a message for (V2, Previous Director of Nursing) and told her that this needed to be investigated. I never heard back. I told (V3, Previous Assistant Director of Nursing) the next morning and she said that she would talk to (V2). I think he was rolled into the nightstand. V42 stated, (R24) does not like to roll. He had a night stand next to his bed and 2 nights later it was moved. This was not investigated that I know of. V42 stated, (R24) could not have fallen and gotten himself back up and in bed. He is really rigid. I always use a 2 person assist with him and walking him was really rough. On 6/27/22 at 5:05 AM, V7, CNA, stated, When I went to do my 4:00 AM bed check, he (R24) had a scratch on his nose corner of eye area. He had a little bit of blood on his hands because he was rubbing his face. I went down and got the nurse (V42, RN) to have her come down and look. It took about 4 minutes to get back down to his room and by that time, he was covered in blood. His hands, gown and face because he was rubbing his face. That night I had to chase (R15) out of (R24's) room and I caught (R57) in (R24's) room yelling at him. (R15) can be aggressive. (R15) does get agitated but more when he is frustrated. (R24) will push against you when you try to roll him. I did not hurt him. A month later (V6, Corporate Nurse) called me and suspended me because of an allegation of abuse over (R24). I told her that others were in his room that night she said, 'We are not going there.' V7 stated, Once (R24) is down for bed he doesn't want to move. I doubt he fell and got back into bed. He did not have a nightstand or bed rails on his bed. My only guess is that (R57 or R15) hit him or (R24) scratched himself. I did not hurt him. R24's Health Status Note, dated 5/17/22 at 6:45 AM, written by V4, RN, documents, This writer, walked into residents' room to eval (evaluate) resident's nasal area. Resident has bruising under bilateral eyes with noted swelling on his nose and under bilateral eye areas. Resident does have multiple scratches to the nasal area. Resident is unable to state if he is in pain or what has happened due to his disease process. 0700-Writer Contacted POA (Power of Attorney) (V62 AND V14) to notify them of new findings. Writer asked if it was okay to call MD and ask for order for his bilateral orbital area and nasal. Family agrees as long as he can stay in house and he can have a portable done. R24's Health Status Note, dated 5/17/22 at 9:30 AM, documents, (V3, Previous Assistant Director of Nursing), LPN (License Practical Nurse) notified (V2, Previous Director of Nursing) of below information (Health Status Note dated 5/17/22 at 6:45 AM). On 6/22/22 at 9:30 AM, V4 stated, I came in and in report I was told (R24) scratched his nose and that he did it to himself. I went down to look at (R24) and it was a deep wide scratch on his nose with multiple little scratches on his eyebrow area. He had swelling and bruising occurring under his eyes and swelling on the bridge of his nose. I called the doctor to see if we could get a facial x-ray which we did, and it showed no fractures. I notified (V14 and V62) of getting the x-ray and what (R24's) face looked like. I did notify (V2) and (V3) of the swelling and the bruising. I am not sure what happened to him, but I don't think he did this to himself. (R24) does not get up on his own. When he is in bed, he stays in bed. I can't see him getting out of bed falling and then getting back in bed. (R24) is very hard to roll, he gets stiff. If I had to guess, when (V7) was trying to roll him (V7's) hand slipped and his elbow hit (R24) in the eye nose area. I don't think (V7) did this on purpose. I don't believe this incident was investigated. R24's X-ray report, dated 5/17/22, documents, Reason: Bruising swelling and scratches in the orbit and nasal areas. Findings: No displaced fractures are identified. The orbital rims and nasal bones are intact. The septum is midline. The visualized sinuses are well aerated without air fluid levels. The surrounding soft tissues are normal. Impression: No acute abnormalities. R24's Health Status Note, dated 5/18/22 at 1:26 PM, documents, Resident continues to have discoloration under bilateral eyes and on the bridge of his nose. Resident continues to have swelling noted under bilateral eyes and the bridge of his nose. The Note documents Resident's son, (V62) POA to see resident. On 6/21/22 at 2:32 PM, V14, R24's daughter, stated, I am really upset. My dad (R24) had something happen to him and I want something done. I was notified on 5/16/22 early in the morning that my dad scratched his nose and the nurse asked me if I wanted him sent out for one stitch. Dad doesn't like going out, so I said no. I was not feeling good that day, so I stayed home. The next day I called (V4, Registered Nurse) and asked her to look at him and see what she thought. She called me back and said that it was a scratch on his nose and that he had some other scratches on his nose/face and he was having some swelling and that she would like to get x-rays and that it can be done in house. I had tested positive for Covid that day, so I couldn't come and see him. The next day it was a Wednesday my brother (V62) went to visit Dad. He called me and told me Dad had 2 black eyes and that there was no way that he did this to himself. I spoke with (V2) she said she still had a couple of people she needed to talk to before her investigation would be complete. I never heard back from her. I also spoke with (V43, Social Service Director) and told her I don't want that aide (V7, Certified Nurse's Aide, CNA) taking care of my dad and that he should not even be working here. I don't want him to be unemployed, but he is in the wrong profession. He is still employed here. They suspended him that day, but I saw him come back in over the weekend. Dad requires assistance getting up and walking. He does not fall or roll out of bed. He does not have side rails or a nightstand. Something had to happen to him. R24's Initial Incident Report submitted to IDPH, written by V2 (Previous Director of Nurses), dated 5/18/22, documents, This is an initial report to DPH an injury of unknown origin on (R24) (DOB: [DATE]) with the following diagnosis: Alzheimer's Disease, Generalized anxiety disorder, Unspecified dementia, Dysphagia, oropharyngeal phase, Other specified mental disorders due to known physiological condition, Unspecified psychosis not due to substance or known physiological condition, History of falling, Personal history of Covid-19, Gastro-Esophageal Reflux disease without esophagitis. (R24) was found to have what was thought to be a self-inflicted scratch to the right side of the bridge of his nose. By the next morning purplish blue bruising was noted under both eyes with slight swell to top of the bridge of nose. (R24) was unable to verbalize what occurred due to disease process. (R24's) family and primary care provider were contacted about scratch and bruising. New orders were received from primary care provider for radiological exams of facial and orbital bones. X-Rays of (R24's) facial and orbital bones were negative. No other orders were noted at this time. Care plan updated. Final report to follow. R24's Final Incident Report submitted to IDPH, written by V2, dated 5/24/22, documents, This is a final report to DPH an injury of unknown origin on (R24) (DOB: [DATE]) with the following diagnosis: Alzheimer's Disease, Generalized anxiety disorder, Unspecified dementia, Dysphagia, oropharyngeal phase, Other specified mental disorders due to known physiological condition, Unspecified psychosis not due to substance or known physiological condition, History of falling, Personal history of Covid-19, Gastro-Esophageal Reflux disease without esophagitis. (R24) was found to have what was thought to be a self-inflicted scratch to the right side of the bridge of his nose. By the next morning purplish blue bruising was noted under both eyes with slight swell to top of the bridge of nose. (R24) was unable to verbalize what occurred due to disease process. (R24's) family and primary care provider were contacted about scratch and bruising. New orders were received from primary care provider for radiological exams of facial and orbital bones. X-Rays of (R24's) facial and orbital bones were negative. No other orders were noted at this time. (R24) is a resident of the memory care unit in this facility. At his baseline he has impaired cognition and confusion. R24 has poor safety awareness and the logical conclusion of the investigation is that he was attempting to ambulate without assistance and sustained a fall and was to get self-up but unable to self-report. Staff interviews were unremarkable for any kind of abuse. Care plan updated. The facility provided the surveyors the Initial and the Final report regarding R24's injuries of unknown origin. The facility did not provide the surveyors with the investigation including any interviews as to how V2 determined R24 fell and sustained the injuries. There was no documentation V2 interviewed V7, who initially reported the R24's injuries to V42. On 6/22/22 at 1:19 PM, V16, CNA, stated, (R24) will ambulate with one but most of the time it takes two, rolling him in bed takes 2 and he is incontinent. He has not tried to get out of bed by himself in a long time. On 6/27/21 at 4:21 AM, V58, Registered Nurse (RN), stated, (R24) typically does not get up out of bed. Once he eats supper and gets changed, he then will go to bed and stays there. I doubt he fell out of bed and then got back into bed. On 6/27/22 at 4:45 AM, V45, CNA, stated, I was here the next day after (R24) scratched himself. I was told he scratched himself. He doesn't get up through the night. He stays in the same position. He doesn't even turn side to side. He is a little hard to turn. I doubt (R24) fell out of bed and got back in bed. The management did not interview me about the incident. On 6/27/22 at 2:23 PM, V13, CNA, stated, We help (R24) get out of bed with a walker. I can do it with just myself but if you don't know him it would take 2. He is incontinent and must be fed. He really doesn't talk. It's just gibberish. Once in a while you will get a 'yeah' out of him but not often. When you set him in a chair or bed, he will stay there. He absolutely could not get up if he fell. On 6/28/22 at 12:47 PM, V2, Previous Director of Nursing, stated, (R24's) injury started as a scratch and then it went to black eyes but no swelling. I spoke to staff and I determined that he must have fell and got back up. On 7/6/22 at 9:01 AM, V1, Administrator, stated, If staff or a visitor see an injury of unknown origin or abuse, they should report that immediately. If it's an injury of unknown origin, they (staff) had been reporting that to (V2) then she reports that to me. If it abuse, that should be reported to me immediately. (V2) will start an investigation and let me know of the findings for injury of unknown origin. We report to the family, doctor, Ombudsman and to the IDPH. If an injury of unknown origin, the Director of Nurses will start an investigation to find out what happened. At this time since we have no Director of Nurse, the Regional Corporate Nurses are taking over that role for investigating and reporting injuries of unknown origin. The Director of Nurses or the Corporate Nurses will talk to all staff and family and try to figure out a plausible reason for the injury. If at any time they suspect abuse, it is reported to me immediately and if it involves a staff member they are suspended until the investigation is complete. If abuse is reported to me, I notify all parties involved, family, doctor and IDPH. The alleged abuser is put on suspension until the investigation is complete. IDPH is notified within 2 hours and a final report is completed within 5 business days. I expect my staff to notify me immediately of abuse and the Regional Nurse or DON of injuries of unknown origin immediately. On 7/06/22 at 9:24 AM, V6, Regional Corporate Nurse, was questioned as to who did the investigation into R24's injury of unknown origin, V6 stated, (V2). V6 was questioned as to if she knew why the initial investigation was not reported until 5/18/22, when R24 had bruising on both eyes and swelling on the bridge of his nose on 5/17/22. V6 stated, My only thought is she was waiting for the x-ray results before submitting the initial report. V6 was questioned about the investigation regarding R24's injury. V6 stated, I do know that (V2) did do interviews of staff to figure out what happened, but unfortunately the interviews have disappeared from the file. I did see them before I sent in the final investigation. Now that I have got to know (R24), I agree (R24) did not fall and get himself back up at the time as (V2) concluded at the end of her investigation. When the original investigation was turned in to me for review, I did not know (R24), and I took (V2's) explanation of what happened. I do agree this was not a thorough investigation of this injury. Now that we have done the second investigation that came in as an abuse complaint the only plausible explanation, I can come up with is that he did scratch himself and that is what caused the secondary bruising. (V7) was immediately suspended when we were told of the abuse allegation complaint, and it was reported to IDPH. V6 stated, When I spoke with (V7), he did not tell me that 2 other residents were in (R24's) room that night, because if he had I would have looked further into it and their behaviors. I don't know why he wouldn't have. It would have given another explanation for the injury. After (R24's) family requested that (V7) not work back in the unit, he has not. He has been on the regular halls. On 7/6/22 at 1:57 PM, V43 (Social Service Director (SSD)), stated, (V14) did come and talk to me about (R24's injury of unknown origin) she was upset that (V2) had not completed her investigation and had not notified her of the completed investigations findings. She stated that she did not want (V7) working with her Dad. I told (V2). I know that (V7) never worked in the unit after that. I have never gotten a complaint about (V7) from residents or from staff. On 7/6/22 at 2:39 PM, V9, Corporate Nurse Manager, stated, I was made aware of (R24's) injury of unknown origin after the fact. The injury had already been investigated. I expect an investigation to be thorough with interview, observations and record reviews. 2. R36's admission Record, print date of 6/24/22, documents R36 was admitted on [DATE] and has a diagnosis of Dementia. R36's MDS, dated [DATE], documents R36 is severely cognitively impaired. R51's admission Record, print date of 6/29/22, documents R51 was admitted on [DATE] and has a diagnosis of Alzheimer's Disease. R51's MDS, dated [DATE], documents R51 is severely cognitively impaired. R51's Health Status Note, dated 6/18/22, documents, At 1134-Visitor (V59), came up to writer stating that (R36) was touching this resident's thigh/genital area and was upsetting her. Visitor states that (R36) had the back of his hand on the resident's thigh rubbing it up and down and then turned his hand over and rubber her genital area and (R51) yelled stop it and took her and removed his. At 1135, immediate after being told this information, writer and visitor walked down to resident, which was sitting at round table in the dining room area and (R36) again has his hand between her legs and she said don't touch me there. Writer removed R36. Writer asked (R51) what had happed. (R51) stated, He got inappropriate with me and I had to tell where to go. Writer asked resident if she was hurt, she stated No writer asked what happened again, resident stated, He was touching my breast and I did not appreciate it. (1238---POA (V69) notified of incident.) On 6/27/21 at 4:21 AM, V58, RN, stated a week ago R36 had been inappropriate. I have only been here since April but this is the first time to my knowledge that he was inappropriate. He has not had any further issues that I am aware of. On 6/27/22 at 6:23 PM, V42 RN, stated, I have never seen (R36) act inappropriately before. On 7/6/22 at 9:01 AM, V1, Administrator, stated his investigation included interviews from staff and other residents from the Memory unit, and that he believes this was a one time behavior for R36. V1 was questioned as to why only the 3 staff members (V4, RN, V16, CNA, V18) on duty at that time were questioned about the behavior, when none of them saw it, and if he asked follow up questions as to is this behavior common for R36. V1 stated he did ask the three on duty if it was common behavior for R36 and they stated no. V1 stated he did not ask any other staff members that work on different shifts about R36. V1 also stated R51 is cognitively impaired, as most residents are on the Memory Unit. R51's Investigation, Investigative Questionnaire Employee (V4), dated 6/22/22, documents, Visitor told me (R36) had his hand between (R51's) legs (genital area). (R51) states don't touch me there (R51) removed. V16, CNA, wrote on a piece of paper, dated 6/18/22, didn't see anything. Laying (illegible) down in bed. V18, CNA, wrote on a piece of paper, dated 6/18/22, I was on lunch break. came back on the unit. Nurse said Watch (R36), keep him away from resident. The facility investigation into this incident did not contain any other resident interviews or employee interviews. V1 interviewed only V16, V18 and V4. 4. R66's admission Record, print date of 7/5/22, documents R66 was admitted on [DATE] and has a diagnosis of Alzheimer's Disease. R66's MDS, dated [DATE], documents R66 is severely cognitively impaired. R66's SBAR, dated 5/9/22 at 1:14 PM, Resident sitting in dining room and reported to CNA of the bruise on top of her right hand. 5 cm (centimeter) X 5 cm purple in color. States that it does not hurt at all. Will continue to monitor. (V40) faxed. Left message for guardian to return call to facility. On 7/5/22, V1 was asked for the investigation regarding R66's injury of unknown origin. V1 did not provide an investigation to the surveyors. On 7/7/22 at 9:00 AM, V6, Corporate Nurse, stated, I was not aware of this injury of unknown origin. We do not have an investigation on this. I will look and see if maybe she had a blood draw. At that time, (V2) Previous Director of Nurses or (V1) Administrator should have been notified and an investigation should have been started. The Facility's Abuse, Prevention and Prohibition Policy, dated 2/2021, documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It continues Investigation: Resident abuse must be reported immediately to the Executive Director. The facility Executive Director will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a report of alleged resident abuse within required timelines (Executive Director will see that the report is completed, reviewed and sent). A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the abuse investigation format. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated. Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has a special rapport participate if possible. If the resident is not interviewable, question the roommate and any family or friends who visit frequently with completion of a questionnaire. It continues Protection - Resident to Resident altercations: When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options. Residents will be referred for behavior management when indicated. Changes in room assignments and seating arrangements will be recommended as needed. The safety of other residents and employees of the facility is of primary concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance with grooming and hygiene, and failed to provide oral care to dependent residents for 8 of 18 residents (R5, R24, R29, R30, R43, R51, R53, R63) reviewed for Activities of Daily Living (ADL) in the sample of 51. Findings include: 1. R53's Care Plan dated 1/10/22, documents, (R53) Care/ADL Preferences: prefers to have a shower two times a week. It continues, (R53) has an ADL Self Care Performance Deficit. Interventions: requires one staff participation with bathing, requires one staff participation to dress, requires one staff participation with personal hygiene and oral care, requires two staff participation to reposition and turn in bed. R53's Minimum Data Set (MDS), dated [DATE], documents R53 is cognitively intact, and requires extensive assistance from two staff members for transfers and toilet use. R53 is totally dependent on one staff member for bathing. R53 requires extensive assistance from one staff member for dressing and personal hygiene. R53 is always incontinent of both bowel and bladder. On 6/21/22 at 9:20 AM, R53 was lying in bed, unshaven, dry flakey skin on feet, greasy hair, with a long wild appearing beard and mustache. On 6/22/22 at 8:30 AM, R53 was resting in bed, with a visitor at bedside. R53's hair appeared messy and greasy, and he was unshaven. R53 had a very unkempt appearance. On 6/22/22 at 9:20 AM, R53 stated, I told (V8, Certified Nursing Assistant/CNA), that I needed changed some time around 10:30 AM yesterday, and I was not changed until 8:30 PM. (V8) said he would go get supplies and help and come back and he never did. On 6/22/22 at 11:25 AM, R53's call light was on and a strong smell of urine upon entrance to his room. R53 stated he's soaked with urine. On 6/27/22 at 8:40 AM, R53 lying in bed, appears unkempt, hair greasy and messy. On 6/27/22 at 8:42 AM, R53 stated, I did not get a shower or bed bath this weekend. My last shower was last Tuesday (6/21/22). On 6/28/22 at 9:37 AM, R53 stated, I was cleaned up down there (pointing to groin) this morning after being wet all morning. I still have not received a shower or bed bath since last Tuesday (6/21/22). On 7/05/22 at 1:25 PM, R53 stated, I did not get a shower last Wednesday (6/29/22), so I am hoping for one tomorrow. I usually get one shower a week. It would be nice to get two or more a week though. The Facility's Shower Schedule Book documents R53 is scheduled for a shower every Wednesday and Friday. The Facility's Skin Assessment Log documents R53 did not get a shower on 5/25/22, 5/27/22, 6/1/22, 6/8/22, 6/10/22, 6/17/22, and 6/24/22. 2. R30's Care Plan, dated 5/27/22, documents, (R30) has an ADL Self Care Performance Deficit related to confusion, fatigue, impaired balance and generalized weakness. Interventions: totally dependent on staff to provide a bath two times a week and as necessary, requires two staff participation to reposition and turn in bed, requires one staff participation with personal hygiene and oral care, requires two staff participation to use toilet, requires two staff participation with transfers. It continues, (R30) is at risk for falls due to confusion, incontinence, and unaware of safety needs. Interventions: Assist resident to bathroom as needed, do not leave resident in bathroom unattended. R30's MDS, dated [DATE], documents R30 has severe cognitive impairment and requires extensive assistance from two staff members for bed mobility and transfers. R30 requires extensive assistance from one staff member for personal hygiene and bathing. R30 is total dependent on two staff members for toileting. R30 is frequently incontinent of urine and always incontinent of bowel. On 6/21/22 at 11:25 AM, R30 was resting in bed, appears unkempt, hair uncombed and greasy. On 6/21/22 at 11:26 AM, R30 stated, I used to get showers twice a week but lately I only get maybe one shower a week. On 6/22/22 at 9:05 AM, R30 was sitting up in wheelchair, clean clothes on, hat on, eyeglasses on, gloves on hands, slippers on feet. R30 removed her hat to show her hair remains uncombed and greasy. On 6/22/22 at 9:07 AM, R30 stated, I was cleaned up in bed this morning. I can't remember when my last shower was. On 6/27/22 at 9:05 AM, R30 was sitting up in wheelchair next to her bed, dressed with clean clothes, slippers and hat on. R30's hair under hat appears slightly greasy. On 6/28/22 at 10:30 AM, R30 was sitting up at bedside in wheelchair with clean clothes on and her glasses and hat on. R30's hair appeared messy and slightly greasy. On 6/28/22 at 10:32 AM, R30 stated. I cannot remember when my last shower/bath was. I don't get my teeth brushed every day. I think it is about every other day they come in and brush them. On 6/30/22 at 10:56 AM, V8, CNA, stated, I do the resident's oral care in the morning no matter what the staffing is like. The Facility's Shower Book documents R30 is scheduled to receive a shower on Wednesdays and Fridays. The Facility's Skin Assessment Log documents R30 did not receive a shower on 5/27/22, 6/1/22, 6/8/22, 6/10/22, 6/15/22, 6/24/22. 3. R43's Care Plan, dated 2/15/22, documents, (R43) All about me - Care/ADL Preferences: I prefer a shower twice a week. No day or time preference, prefer to care for my hair at facility Salon, cut every eight weeks. It continues, (R43) has an ADL Self Care Performance Deficit. Interventions: is totally dependent on one staff for repositioning and turning in bed, chooses to not wear briefs, requires staff to brush his teeth and oral care with toothette, requires staff participation with personal hygiene and oral care, is totally dependent on one staff for toilet use, and requires a full mechanical lift with two assist for transfers. R43's MDS, dated [DATE], documents R43 has a moderate cognitive impairment, and requires extensive assistance from one staff member for most of his ADL's. R43 is totally dependent on one staff member for bathing. R43 is always incontinent of both bowel and bladder. On 6/21/22 at 10:45 AM, R43 was seen lying in bed with his mouth open and extremely dry, teeth dry with particles on them, dry and chapped lips, and unshaven with bushy facial hair. No cups of water, and no oral sponges to clean or wet his mouth, were seen in the room. On 6/22/22 at 8:50 AM, R43 was lying in bed visiting with his wife (V24), mouth very dry, lips very dry, hair messy, no drink on tables, no oral sponges to wet his mouth. On 6/27/22 at 8:20 AM, R43 was lying in bed, V24 at bedside, dried crusty eye drainage noted to right eye and down his right face, mouth, tongue, and teeth are extremely dry, plastic cup on table with two oral sponges/toothetes individually wrapped and not opened. There was no water in cup. On 6/28/22 at 9:30 AM, R43 was lying in bed; mouth still appears to be dry. Cup of water on bedside table. Plastic cup with two sponges still sitting on bedside side table unopened. On 6/22/22 at 8:50 AM, V24, R43's wife, stated, My husband (R43) is on Hospice and Hospice takes care of him for the most part. I have several issues here though with the first one being there are times when I come in and he is wet, so I just go get someone to clean him up. His mouth is always very dry and I'm not sure they are doing anything with that. On 6/27/22 at 8:20 AM, V24 stated, They brought these swabs in, but I haven't seen any of them use one yet. On 6/27/22 at 12:35 PM, V33, R43's daughter-in-law, stated, I came in at 12:15 PM today and saw my father-in-law (R43) like this. He has crusty eye drainage that no one wiped off, very dry mouth, soaked sheets with some stool on his sheets. I put the call light on and no one has answered it yet. Some guy came in with a blue dress shirt and asked if I needed something and I told him (R43) was wet and needed changed. He said he would go get someone and I'm still waiting for someone to show up and clean him up. The Facility's Shower Book documents R43 is scheduled for a shower on Mondays and Thursdays. The Facility's Skin Assessment Log documents R43 did not receive a shower on 5/16/22, 6/20/22, 6/24/22 (refused), 6/27/22. On 6/27/22 at 10:350 AM, V8, CNA, stated, There is a shower book at the nurse's desk that tells us which resident's get showers on what days and times. We will fill out a sheet when we do a shower so everyone knows that it was done. Usually, everyone gets a shower twice a week and some get a shower three times a week. On 6/28/22 at 12:45 PM, V43, Social Service Director, stated the Facility's Skin Assessment Log is used to document when a shower has or has not been given to a resident. On 6/30/22 at 10:54 AM, V8, CNA, stated, Showers are a big problem here. Usually, if we have enough staff, we would have one person as a designated shower person. If we don't have enough staff, one person will work the hall while the other starts showering residents. We use the shower book to tell us who gets a shower. We try our best we can, but we need more staff to get things done. On 6/30/22 at 11:10 AM, V23, CNA, stated, Usually, if a resident has dentures, the night shift takes them out and soaks them. In the morning, we will do oral care and put their teeth back in. If a resident has their own teeth, it might be a danger to put a toothbrush in their mouth so we will use the toothettes instead. On 6/30/22 at 12:40 PM, V6, Corporate Nurse, stated, We don't have a policy on ADL Care. We follow the standard of practice. I expect the staff to give the residents their showers twice a week and give oral care daily. We follow the shower book on the desk to know when resident's showers are due. 8. R63's Face sheet, print date of 06/30/22 , documents R63 has a diagnosis Morbid (Severe) Obesity due to excess calories, Abnormalities of gait and Mobility, Muscle Weakness (Generalized), and Acquired Absence of left lower leg below the knee. R63's MDS, dated [DATE], documents R63 is moderately cognitively impaired, and requires total dependence, one person physical assist with bathing. R63's Care Plan, print date of 6/30/22, documents R63's requires (1) staff participation with bathing, and requires (2) staff participation with personal hygiene and oral care. The facility's shower list for the 300 hallway, documents R63's showers are to be given on Monday and Thursday evenings. R63's May 2022 Nursing Skin Inspection Reports document R63 received a bed bath on 5/12/22, and 5/23/22. 11 days elapsed from R63's bed bath on 5/12/22, until she received a bed bath on 5/23/22. No other bathing of any type was documented for the month of May 2022. R63's June 2022Nursing Skin Inspection Reports documents R63 received a bed bath on 6/17/22. 24/25 days elapsed from R63's bed bath on 5/23/22 until she received a bed bath on 6/17/22. No other bathing of any type was documented for the month of June 2022. On 6/22/22 at 11:18 AM, R63 was lying in bed in a hospital gown. R63 was noted to have a very strong body odor and facial hair to her chin. R63 stated she has not been getting her shower like she is supposed to, but she does get bed baths at times. On 6/27/22 at 4:35 AM, V28, CNA, stated she thinks that the facility does not have enough staff working especially since they pushed dinner back. She said that Dinner trays are now passed at 7 PM, and with dinner being pushed back, it hinders them and puts them behind. She stated they can't get the showers done with dinner being at 7 PM. On 6/27/22 at 4:40 AM, V30, CNA, stated it depends on the night whether or not they are able to get their work done. She said that if the residents are on their call lights they have a hard time getting things done, and sometimes they are unable to get the showers done, when they are in a big rush all night. The facility's Resident Council Meeting Minutes, dated 6/01/22, document CNA's/Task Aides: Showers are not being completed. 4. R5's admission Record, print date of 6/29/22, documents R5 was admitted on [DATE] and has a Diagnosis of Dementia with Behavioral Disturbances. R5's MDS, dated [DATE], documents R5 is severely cognitively impaired, and is totally dependent on one staff member for personal hygiene. R5's Care Plan, dated 6/15/21, documents, The resident has an ADL Self Care Performance Deficit. Restorative Program. Grooming Set up supplies needed for am or hs (hour of sleep) care. hand resident a prepared washcloth and instruct him to wash his face and hands. Assist as needed to ensure cleanliness. Dressing: the resident requires 1 staff participation to dress. On 6/27/22 at 9:00 AM, R5 was assisted to his room by V37, CNA. V37 assisted R5 with changing his clothes and incontinent care. V37 told R5 he needed to change his shirt because that was the shirt he was wearing yesterday. V37 assisted R5 with taking his shirt off revealing more shirts on underneath. R5 was wearing a total of 2 long sleeve shirts and 1 short sleeve shirt. V37 dressed R5 in a new shirt, and assisted him out of the bathroom and to his chair. V37 did not offer to help R5 wash his hands or provide oral care for R5. On 6/27/22 at 9:15 AM, V37, CNA, stated, I did not get (R5) up this morning. I think he got himself up because of the way he was dressed, and the socks he had on were regular socks not gripper socks. I know a lot of the residents back here wear their regular clothes to bed at night because that is what they prefer. On 6/28/22 at 11:45 AM, V28, CNA, stated, I didn't get anyone up yesterday morning (V28 worked on the Memory unit until 6:00 AM). Some do go to bed in their clothes. They will just get up and start coming out. When I am back there for a full shift, when they start coming out, I will change them. On 7/6/22 at 10:10 AM, V6, Regional Nurse, stated even if residents get themselves up and come out of their room, they should be taken back to their room and be given am care as in changing clothes, checking for incontinence, oral care, and brushing their hair. On 7/6/22 at 10:45 AM, V16, CNA, stated oral care and morning care should be done when the resident first gets up. 5. R24's Face Sheet, print date of 6/27/22, documents R24 was admitted on [DATE], and has diagnoses of Alzheimer's Disease, Generalized Anxiety Disorder,Dementia, Mental Disorders due to known physiological condition, Psychosis and a history of falling (dated 9/23/20). R24's MDS, dated [DATE], documents R24 is severely cognitively impaired, R24 requires extensive assistance of 2 staff members for in his room and on the hall, dressing and personal hygiene. On 6/27/22 at 6:58 AM, V37, CNA, and V5, CNA, both entered the room to get R24 up for breakfast. R24 was asleep in his bed. V37 woke him up and removed his blanket. R24 was taken to the bathroom for incontinence care. When the care was finished, R24 was then walked to the dining room for breakfast by V5. V37 and V5 both failed to offer to assist R24 with washing his hands or doing oral care for R24. 6. R29's admission Record, print date 6/29/22, documents R29 was admitted on [DATE] and has a diagnosis of Dementia. R29's MDS, dated [DATE], documents R29 is severely cognitively impaired and requires extensive assistance of 2 staff members for personal hygiene. On 6/27/22 at 5:20 AM, R29 was toileted by V5, CNA, and V37, CNA. R29 stood in the restroom, V37 pulled R29's pants down and removed R29's saturated incontinent brief. V5 took a wet wash cloth and wiped R29's face. R29 began rubbing / scratching her legs, buttocks and pubic area before she sat down on the toilet. V37 provided incontinent care and was dressed. V5 walked her back to the hallway for breakfast. V5 and V37 both failed to offer R29 oral care, or to help her wash her hands. 7. R51's admission Record, print date of 6/29/22, documents R51 was admitted on [DATE] and has a diagnosis of Alzheimer's Disease. R51's MDS, dated [DATE], documents R51 is severely cognitively impaired and requires extensive assistance from one staff member for personal hygiene. R51's Care Plan, dated 6/15/21, documents, (R51) has an ADL Self Care Performance Deficit Confusion. Personal Care/ Oral Hygiene. The resident requires 1 staff participation with personal hygiene and set up assistance with oral care. On 6/27/22 at 6:28 AM, V5 and V37 woke R51 up. V5 placed a gait belt on R51. V5 and V37 walked R51 to the bathroom. R51 sat onto the toilet. R51's incontinent brief was saturated with urine. V37 provided incontinence care for R51, using premoistened peri-wash disposable cloths. V5 wiped R51's face with a wet wash cloth. V5 and V37 dressed R51 for the day. V5 and V37 walked R51 to the dining room for breakfast. V5 and V37 failed to offer to wash R51's hands or provide oral care for R51.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. R19's Care Plan, dated 6/27/22, documents (R19) has an ADL Self Care Performance Deficit Limited Mobility. Interventions: requires assistance of one with bathing/showering bi-weekly and as necessary, requires Mechanical lift and assist of two for transfers. It continues, (R19) has limited physical mobility. Interventions: is non weight bearing, is totally dependent on staff for ambulation/locomotion. R19's MDS, dated [DATE], documents R19 is cognitively intact and requires extensive assistance from two staff members for transfers. R19 requires extensive assistance from one staff member for bed mobility, dressing, toilet use, personal hygiene and bathing. R19 is always incontinent of urine and always continent of bowel. On 6/27/22 at 12:10 PM, R19's bed linen and mattress were saturated in urine. V8, CNA, rolled R19 to her side. Stool was seen on R19's buttocks and anal area; mattress under the linen was saturated in urine. V29, CNA, wiped stool off R19's buttocks and anal area, doffed gloves, and without any hand hygiene done, donned clean gloves. V29 did one wipe down each groin, and only one wipe down the middle of R19's vagina. V29 did not dry R19 after care. Both CNA's used their same soiled gloves while dressing R19. There was no hand hygiene done before, during, or after resident care. On 6/27/22 at 12:15 PM, R19 stated, I was cleaned up last by the night shift. I told the nurse this morning when she was giving me my medications that I was wet and the nurse must have forgotten. I think I must have fallen asleep after that and when I woke up, I found myself very wet. 8. R43's Care Plan, dated 2/15/22, documents, (R43) has an ADL Self Care Performance Deficit. Interventions: totally dependent on one staff for repositioning and turning in bed, chooses to not wear briefs, is totally dependent on one staff for toilet use, and requires a full mechanical lift from two staff assist for transfers. It continues, (R43) has limited physical mobility related to Huntington's disease. Interventions: requires staff participation for mobility. R43's MDS, dated [DATE], documents R43 has a moderate cognitive impairment, and requires extensive assistance from one staff member for most of his ADL's, including toileting. R43 is totally dependent on one staff member for bathing. R43 is always incontinent of both bowel and bladder. On 6/21/22 at 10:45 AM, R43 was lying in bed, with no incontinence brief on, no urinal seen. On 6/22/22 at 8:50 AM, R43 was lying in bed visiting with his wife. R43's mouth and lips were very dry. R43's hair appeared messy. There was no drinking cups on his table, and no sponges to wet his mouth. On 6/27/22 at 8:20 AM, R43 was lying in bed with his wife at bedside. R43 had dried crusty eye drainage noted to right eye and down his right cheek. R43's mouth, tongue, and teeth are extremely dry. R43's linen under him appear to be wet. On 6/27/22 at 12:40 PM, V29, CNA, and V8, CNA, entered with supplies to clean R43. V29 rolled R43 to get saturated linen out from under him. V29 wiped the dried stool from R43's buttocks and anal area, rolled R43 over, and wiped once to both groins, around the scrotum and then the penis using the same wash cloth. R43 was not dried after perineal care was done. On 6/22/22 at 8:50 AM, R43's wife stated My husband (R43) is on Hospice and they take care of him for the most part. There are times when I come in and he is wet, so I just go get someone to clean him up. On 6/27/22 at 12:35 PM, V33, R43's daughter-in-law, stated, I came in at 12:15 PM today and saw my father-in-law (R43) like this. He has soaked sheets with some stool noted. I put the call light on and no one has answered it yet. Some guy came in with a blue dress shirt and asked if I needed something and I told him (R43) was wet and needed changed. He said he would go get someone, and I'm still waiting. On 6/28/22 at 11:20 AM, V6, Corporate Nurse, stated, Yes, I would expect the staff to round every two hours and check in between for incontinence. If they are soiled, I would expect the resident to be cleaned up immediately and not left sitting in urine or stool. On 6/28/22 at 11:15 AM, V6, Corporate Nurse, stated, We don't have a specific policy for incontinent care. We have a check list that every employee does to get checked off for that procedure. The Facility's Skills Checklist for Perineal-Care (Male), undated, documents, Wash hands, ensure privacy, put on gloves. It continues Wash and dry upper thighs covering thighs with bath blanket when finished, raise bath blanket to expose perineal area, apply soap to wet washcloth, pull back foreskin and wash tip of penis using circular motion beginning at urethra, use different part of wash cloth for each stroke, with fresh water and a clean washcloth, rinse area thoroughly with same strokes, gently pat dry in same direction, position person on side exposing buttocks toward caregiver, apply soap to wet washcloth, clean rectal area wiping from base of scrotum over buttocks using a different part of wash cloth for each stroke, rinse and dry anal area thoroughly. It continues Remove gloves and wash hands. 9. R53's Care Plan, dated 1/10/22, documents, (R53) Care/ADL Preferences: prefers to have a shower two times a week. It continues, (R53) has an ADL Self Care Performance Deficit. Interventions: requires one staff participation with bathing, requires one staff participation to dress, requires one staff participation with personal hygiene and oral care, requires two staff participation to reposition and turn in bed. R53's MDS, dated [DATE], documents R53 is cognitively intact, and requires extensive assistance from two staff members for transfers and toilet use. R53 is totally dependent on one staff member for bathing. R53 requires extensive assistance from one staff member for dressing and personal hygiene. R53 requires set up assistance for eating. R53 is always incontinent of both bowel and bladder. On 6/22/22 at 8:30 AM, R53 resting in bed with visitor at bedside, sheets under him appear wet. On 6/22/22 at 11:25 AM, R53's call light was on. V9, Corporate Nurse, answered the call light, and told R53 she would go get some help and supplies, and left the room. R53's room has strong smell of urine. R53 stated he's soaked. On 6/22/22 at 11:35 AM, V9 entered with wash cloths, towels, and linen. V22, CNA, entered to help. V22 did not do hand hygiene upon caring for R53. Window blinds were left open, curtain around bed pulled, linen pulled off R53. R53's soiled incontinent brief was removed, and appeared saturated in urine. V22 used a wet wash cloth to wipe R53's bilateral groins, scrotum, and testicles, but did not clean R53's penis. Someone knocked on the door, and V22 used her soiled gloves to move the bedside curtain to see who was at the door. R53 was turned over, and stool noted. V22 wiped R53's anal area and buttocks. With her soiled gloves on, V22 then opened R53's bedside table drawers and searched for cream, and then searched through a bucket of supplies sitting on a table. R53 stated he had to urinate, so V22 held a urinal in front of R53 as he voided. V22 removed the urinal, and did not wipe R53's penis or testicles afterwards. Using the same soiled gloves, V22 went to the restroom to wet more wash cloths, and then returned to wipe under a skin roll of R53. V22 then fastened an incontinent brief to R53. V22 used same soiled gloves, unfastened the incontinent brief, and applied a barrier cream to R53's buttock. V22 doffed her gloves and left the room to get the mechanical lift sling, without hand hygiene. V9 wiped the saturated mattress down, and then dried it with a towel. V22 entered and new gloves donned, with no hand hygiene. R53 rolled to put the full body mechanical lift sling under him, and on top of the saturated mattress. V22 entered the room with the full body mechanical lift and brought it over to R53's bed. No hand hygiene done as V22 donned new gloves. R53's clothes, socks, and shoes were put on him. The full body mechanical lift sling straps were attached to the lift device. R53 lifted off the bed and moved to the wheelchair and lowered. V9 gathered the soiled linen, and put into a plastic bag with her soiled gloves. V9 then doffed her gloves, grabbed the soiled linen bag, and took it down the hall to dirty linen cart. On 6/27/22 at 8:45 AM, V29, CNA, and V8, CNA, in the room to clean R53 and dress for his doctor's appointment. Both CNA's donned gloves, with no hand hygiene prior. V29 had a few wash cloths that she wet and put on R53's bedside table. While R53 was on his back, V29 used a wet wash cloth and wiped R53's bilateral groins and scrotum once. R53's penis and top of his perineal area was not cleaned. R53 was then rolled to his left side, small amount of stool was seen. V29 used same soiled gloves to get a wet wash cloth and wipe R53's anal area and buttocks. No glove change or hand hygiene was done. R53 rolled to his right side, and urine was noticed on bed linen, and running down his left side, and in between skin folds. V29 put a urinal in place while R53 voided urine. After R53 finished, he was rolled back to his back. There was no cleaning of R53's penis, or wiping of urine between his skin fold. A clean incontinent brief was applied to R53. V29 doffed her gloves and began dressing R53. No hand hygiene was done. V8 doffed his gloves and left room to get full body mechanical lift device, without any hand hygiene completed. V8 entered R53's room with gloves on and the lift device. Both CNA's applied the mechanical lift sling straps to the lift device, and R53 was lifted off his bed. V8 doffed gloves and left the room. V29 emptied urinal into toilet, rinsed out the urinal, doffed gloves, and left the room, with no hand hygiene done. On 6/22/22 at 8:30 AM, R53 stated, I told (V8, CNA) that I needed cleaned up some time around 10:30 AM yesterday morning, and I was not actually cleaned up until 8:30 PM last night. (V8) told me he would go get supplies and would get someone to help and then come back and he never did. On 6/28/22 at 11:20 AM, V6, Corporate Nurse, stated, Yes, I would expect the staff to round every two hours and check in between for incontinence. If they are soiled, I would expect the resident to be cleaned up immediately and not left sitting in urine or stool. On 6/28/22 at 11:15 AM, V6, Corporate Nurse, stated, We don't have a specific policy for incontinent care. We have a check list that every employee does to get checked off for that procedure. The Facility's Skills Checklist for Perineal-Care (Male), undated, documents, Wash hands, ensure privacy, put on gloves. It continues Wash and dry upper thighs covering thighs with bath blanket when finished, raise bath blanket to expose perineal area, apply soap to wet washcloth, pull back foreskin and wash tip of penis using circular motion beginning at urethra, use different part of wash cloth for each stroke, with fresh water and a clean washcloth, rinse area thoroughly with same strokes, gently pat dry in same direction, position person on side exposing buttocks toward caregiver, apply soap to wet washcloth, clean rectal area wiping from base of scrotum over buttocks using a different part of wash cloth for each stroke, rinse and dry anal area thoroughly. It continues Remove gloves and wash hands. 10. R69's Care Plan, dated 6/27/22, documents, (R69) has bladder incontinence related to activity Intolerance, disease process, impaired mobility. Interventions: Check the resident per facility schedule and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. It continues, (R69) has oral/dental health problems Poor oral hygiene. Interventions: Provide mouth care as per ADL personal hygiene. It continues, (R69) has an ADL Self Care Performance Deficit due to morbid obesity and lymphedema. Interventions: Assist as needed, requires two staff participation to reposition and turn in bed, requires two staff participation to dress, is totally dependent on staff for toilet use, and requires a full mechanical lift for transfers with two staff members. R69's MDS, dated [DATE], documents R69 has a moderate cognitive impairment, and requires total dependence from one to two staff members for bathing and personal hygiene. R69 requires extensive assistance from two staff members for mobility, transfers, and toileting. R69 requires supervision with set up assistance. R69 is always incontinent of both bowel and bladder. On 6/21/22 at 9:40 AM, R69 stated, I was told to just go to the bathroom in the bed. They put pads down for me. I don't even realize that I am going. On 6/27/22 at 8:35 AM, R69 was lying in bed, eating breakfast, current bed linen is saturated with urine, down past her feet at the end of the bed. On 6/27/22 at 8:37 AM, R69 stated, This morning, someone came in and rolled me and put a new pad down and they did not change my bed sheets. They just put a new pad down and they tell me to use it if I have to go. On 6/27/22 at 10:40 AM, R69 remains on her back in bed, asleep, empty plate of food on her chest from breakfast. Bed linen remains wet down to her feet. On 6/27/22 11:28 AM, V8, CNA, entered R69's room and removed the empty plate. V8 did not check R69 or clean her up before leaving the room. On 6/27/22 at 2:18 PM, R69 stated, They cleaned me up right before lunch was delivered around 12:30 PM or so. On 6/28/22 at 9:42 AM, R69 stated, I just voided in bed again, but I did not put the call light on because I'm hoping they will be in to check on me again soon. On 6/28/22 at 11:15 AM, V6, Corporate Nurse, stated, We don't have a specific policy for incontinent care. We have a check list that every employee does to get checked off for that procedure. The Facility's Skills Checklist for Perineal-Care (Female), undated, documents Wash Hands, Ensure Privacy, put on gloves. It continues Wash and dry upper thighs covering thighs with bath blanket when finished, raise bath blanket to exposes perineal area, apply soap to wet washcloth, separate labia and wash urethral area first, wash between and outside labia in downward strokes alternating from side to side moving outward to thighs, use different part of wash cloth for each stroke, with fresh water and a clean washcloth, rinse area thoroughly with same strokes, gently pat dry in same direction. It continues Clean rectal area wiping from base of labia over buttocks using a different part of wash cloth for each stroke, rinse and dry anal area thoroughly, remove gloves and wash hands. Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care, ensure a resident was not catheterized without an appropriate diagnosis, and provide appropriate urinary catheter care to prevent infection for 10 of 10 residents (R5, R19, R20, R24, R30, R40, R43, R44, R53, R60) reviewed for incontinence, catheters and urinary tract infections (UTI) in the sample of 51. Findings include: 1. R44's Face Sheet, print date of 6/28/22, documents R44 has a diagnosis of Secondary Malignant Neoplasm of Brain, and Dementia without behavioral disturbance. R44's Minimum Data Set, (MDS), print date of 6/28/22, documents R44 is moderately cognitively impaired, and requires extensive assistance, two plus person physical assist with toilet use. R44's Care Plan, print date of 6/28/22, documents R44 will show no s/sx (signs/symptoms) of Urinary infection. Catheter care every shift and PRN (as needed). It further documents monitor/record/report to MD (Medical Doctor) for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, Deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R44's June 2022 Physician's Orders had no order for indwelling catheter placement when reviewed 6/28/22 at 1:00 PM. R44's June 2022 Health Status Notes have no documentation of indwelling catheter placement noted when reviewed 6/28/22 at 1:10 PM. R44's Health Status Note, dated 6/19/22 at 3:38 PM, documents, Power of Attorney (POA) here at this time, requesting a Urinalysis (UA) to be done due to (d/t) color of resident's urine. Urine dark, clean in color. No sediment noted. Resident afebrile. No complaints of (c/o) voiced. Hospice Nurse in facility and informed of resident. Informed Hospice does not do UA's. Writer spoke to resident and informed she can drink more water to see if that helps. Resident states 'I don't like water, I just drink soda.' Resident states 'I will just stick to soda I'm not concerned about the color. Hospice nurse update POA. On 6/22/22 at 12:03 PM, R44 stated she got her catheter about a week ago or so. She stated she requested the catheter due to her being incontinent all the time, and it taking them too long to change her. R44's indwelling catheter was draining clear dark amber colored urine. Catheter bag was below the bladder, hanging from the bed frame of the bed, and was covered. The catheter tubing had no kinks of any kind noted. The hospice book had no documentation from hospice, that documents when R44's indwelling catheter was inserted, or any diagnosis for why the catheter was needed when reviewed 6/28/22 at 1:28 PM. There is no documentation of a Urinalysis (U/A) being done prior to starting R44 on Amoxicillin for urinary symptoms, when reviewed 6/28/22 at 1:28 PM. At that same time, V3, Licensed Practical Nurse (LPN), stated she would call hospice and find out when R44's indwelling catheter was inserted. On 6/23/22 at 10:15 AM, V5, Certified Nursing Assistant (CNA), and V26, CNA, did proper hand hygiene prior to donning gloves for incontinent/catheter care. R44 was lying on her back, when V26 unfastened R44's incontinent brief, which was noted to be soiled with of soft brown stool, and pushed down between R44's legs. V26 cleansed R44's right and left groin area with a disposable wipe. V26 wiped over the top of R44's outer labia, but V26 failed to separate the labia and cleanse the inner labia or around the meatus. V26 took a clean wipe and cleansed the indwelling catheter tubing. Then, V5 and V26 assisted R44 onto her right side. V26 performed hand hygiene and new gloves applied. V26 then used a disposable wipe and wiped R44's left buttock. V26, took a clean wipe and cleansed R44's rectum. V26 used a clean wipe and cleansed R44's rectum again. V26 failed to remove soiled gloves, do hand hygiene, and apply clean gloves prior to getting into R44's bedside table, removing cream, applying the cream to R44's buttocks, and putting the cream back into the bedside drawer. V26 then removed soiled gloves, preformed hand hygiene, and applied clean gloves. V5 and V26 changed sides of the bed, and R44 was then assisted onto her left side, dirty brief remove and V26 cleansed R44's right buttock with a disposable wipe. V5 then removed the cream from R44's nightstand and handed it to V26, so she could apply cream to R44's right buttock. Cream was then returned to R44's nightstand by V5. R44 was made comfortable in bed. Both V5 and V26 failed to secure the indwelling catheter tubing to prevent pulling. On 6/23/22 at 11:45 AM, V27, Licensed Practical Nurse (LPN), stated R44 now has a catheter per her request. He said R44 was concerned with skin breakdown. He said R44 stated that because she is incontinent and less mobile she needed it, and hospice agreed. R44's Health Status Note, dated 6/26/2022 at 1:46 PM, documents, Resident complains of (c/o) pain to low pelvic region that she reports feels like she needs to have a bm (bowel movement). Resident has had 2 rounds of diarrhea today. Resident reports she has had diarrhea past few days. Resident does not have an order for pain medication or antidiarrheal. Residents urine is very thick with sediment and cloudy. Bowel sounds wnl (within normal limits). Abdomen soft and nontender to touch. R44's Health Status Note, dated 6/26/22 at 2:05 PM, documents, Resident was also perspiring throughout entire body upon exam. R44's Health Status Note, dated 6/26/2022 at 2:10 PM, documents, Writer called hospice to update on sx (symptoms) and request prn (as needed) meds (medications). RN (Registered Nurse w/ (with)/ hospice advised BRAT (Bananas, Rice, Applesauce, Toast) diet and she will call back after contacting physician. R44's Health Status Note, dated 6/26/2022 at 2:47 PM, documents, Nurse with Hospice called with new orders from hospice doctor. 1) Imodium 1 tab every (q) 12 hour (hr) as needed (prn), 2) Tramadol 50mg 1 tab q 4 hr prn for pain, 3) Amoxicillin (Amox) 500mg by mouth (po) three times a day( tid) times (x) 5 days for urinary symptoms (sx), 4) Tylenol ([NAME]) 650mg po q 6 hr prn for pain or fever, 5) encourage increased fluids- resident and her daughter and sister aware of new orders. R44's Health Status Note, dated 6/26/2022 at 3:57 PM, documents, Large amount of urine leaking around (urinary) Catheter. 16/30 catheter removed without difficulty. R44's Health Status Note, dated 6/26/2022 at 6:40 PM, documents, New 16 French (fr)/10 cubic centimeter (cc) catheter placed. Dark cloudy urine with large amount of sediment return. R44's Health Status Note, dated 6/26/2022 at 9:30 PM, documents, Resident continues on oral Antibiotics (ABX) for Urinary Tract Infection (UTI). No adverse or unwanted side effects noted thus far this shift. Resident remains afebrile. Foley patent and draining cloudy, tea colored urine. Resident currently denies any pain or discomfort. Continue to monitor for improvement or decline of status. On 6/27/22 at 7:25 AM, V3 LPN, stated R44 requested a urinary catheter be placed due to her having a lot of pain when they turn her. She stated she talked with hospice, and they agreed. R44's Health Status Note, dated 6/28/2022 at 1:59 PM, documents, Hospice nurse returned call. Nurse inserted (urinary) Catheter (Cath) on 6/14/22. On 7/06/22 at 8:53 AM, R44 stated she doesn't have a history of Urinary tract infections. R44, stated, It's probably because of the catheter. R44 said she requested the catheter because she wasn't getting changed, and was continuously wet. R44 said, Now, the only thing they have to worry about is emptying the catheter bag and my bowel movements. On 7/06/22 at 1:58 PM, V6, Corporate Nurse, stated it is not appropriate to place a catheter in someone just because they are not being changed in a timely manner. She said catheter care should be done as needed each shift, and with incontinent care. V6 stated she would expect the CNA's to follow the care plan, and she would expect there to be and order written for placement of an indwelling catheter. On 7/06/22 at 2:10 PM, when V40, Medical Director, was questioned, Is it appropriate for someone to have an indwelling catheter placed because they weren't being changed and cleaned in a timely manner? V40, stated, No. When he was questioned about if having an indwelling catheter placed could increase the risk of developing a UTI, V40, stated, Yes. Catheter Care, Urinary Policy, reviewed date of 02/2021, documents, Purpose, The purpose of this procedure is to prevent catheter-associated urinary tract infections. It further documents, Infection Control, 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the periurethral area with antiseptics to prevent catheter-associated UTI's while the catheter is in place. Routine hygiene (e.g., cleansing meatal surface during daily bathing or showering) is appropriate. It later documents, Steps in procedure, 8. With nondominant hand separate the labia of the female resident tor retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure. 9. Assess the urethral meatus. 10. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. It further documents, 13. Secure catheter. 2. R30's Face Sheet, print date of 6/29/22, documents R30 has a diagnosis of Symptoms and Signs involving cognitive functions and awareness, and Trochanteric Bursitis, Left hip. R30's Minimum Data Set (MDS), dated [DATE], documents R30 is severely cognitively impaired, and requires total dependence, two plus person physical assist with toilet use. R30's Care Plan, print date of 6/29/22, documents, The resident has potential impairment to skin integrity related to (r/t) her increased generalized weakness. It further documents, the resident needs assistance/reminders to turn/reposition every 2 hours, more often as needed or requested, and apply barrier cream to peri area after each incontinent episode, post peri-care to maintain skin integrity. On 6/27/22 at 8:16 AM, V8, Certified Nurses Assist (CNA), and V29, CNA, provided incontinent care for R30. No hand hygiene of any type was performed by V8 or V29 prior to them donning gloves. V29 pulled back R30's bed covers, and the disposable pad was saturated with urine. R30's bottom sheet was wet with urine down past her (R30) knees. V29 then placed a new incontinent brief on R30's legs, and clean socks on R30 prior to cleaning her up. V29 took a wet washcloth, that did not have any soap or peri wash on it, and cleansed both sides both sides of R30's groin area. V29 failed to wash the outer labia, separate the labia and wash the inner labia and meatus. V29 failed to wash R30's inner thighs, and V29 failed to dry off any of the areas she had wiped off. V29 and V8 then assisted R30 onto her left side and rolled the wet bed linen up and tucked it under R30. V29 then cleansed R30's buttocks with a wet washcloth, that had no soap or peri wash on it. V29 failed to cleanse R30's legs that had been lying in urine. V29 failed to dry the areas she cleansed, and apply any ointment to R30's buttocks prior to pulling up the clean incontinent brief on R30. V29 changed her gloves, with no hand hygiene of any kind performed before applying clean gloves. V8 and V29 then transferred R30 into her chair. V8 and V29 failed to perform any kind of hand hygiene during incontinent care for R30. V8 then took R30's dentures to the bathroom, and cleansed them off with water, and then assisted her with putting her dentures in. After V8 and V29 completed R30's care, no hand hygiene was performed before leaving the room. 3. R20's Care Plan, dated 9/16/2020, documents, The resident has an ADL Self Care Performance Deficit It continues, TOILET USE: The resident is totally dependent on staff for toilet use. It also documents R20 is dependent on staff for peri care. R20's MDS, dated [DATE], documents R20 is severely impaired cognitively, always incontinent of both urine and bowel, and is totally dependent on staff for toileting. On 6/27/22 at 10:15 AM, V26, CNA, and V29, CNA, assisted R20 with incontinent care. R20 was heavily soiled, with soft yellow brown foul smelling stool. V26 and V29 assisted R20 into the bed. V26 then removed the heavily soiled undergarment. V26, using wash cloths, cleansed R20's peri area and inner thigh. V26 and V29 then assisted R20 onto her right side and cleansed R20's left buttock, anus and partial right buttock. V26 patted R20 dry, and V29 applied the incontinent brief. V26 did not cleanse all areas, including R20's entire right buttock. On 6/28/2022 at 11:30 AM, V6, Regional Nurse, stated the facility does not have an incontinence care policy. V6 stated the facility uses the standards of practice. V6 stated she expects the staff to cleanse all areas of incontinence, including the inner and outer labia, peri area, penis, scrotum, anus, both buttocks and inner thighs. V6 stated the facility does have a skills check off the the staff are to follow when providing peri care. The facility's Skills Checklist, not dated, documents, Wash and dry upper thigh. It also documents to Apply soap to wet washcloth, separate labia and wash urethral area first. Wash between and outside labia in downward strokes alternating from side to side moving outward to thighs. It continues With fresh water and a clean washcloth, rinse thoroughly with same strokes. Gently pat dry in same direction. Position on side exposing buttocks toward caregiver. Clean rectal area wiping from base of labia over buttocks using a different part of wash cloth for each stroke. Rinse and dry anal area thoroughly. 4. R5's admission Record, print date of 6/29/22, documents R5 was admitted on [DATE], and has a Diagnosis of Dementia with Behavioral Disturbances. R5's MDS, dated [DATE], documents R5 is severely cognitively impaired, requires extensive assistance of 2 staff members for transfer, extensive assistance from 1 staff member for bed mobility, dressing and toileting, supervision for walking in room, eating and is totally dependent on one staff member for personal hygiene. This MDS also documents R5 is frequently incontinent of urine. R5's Care Plan, dated 6/5/21, documents, The resident has bladder incontinence r/t (related to) Alzheimer's Disease. Check the resident q (every) 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episode. On 6/27/22 at 9:00 AM, R5 was assisted to his room by V37, CNA; the back of R5's pants are wet. R5 was seated in his room on his armchair. V37 walked R5 to the restroom. R5's wet pants were removed, and his incontinent brief was saturated with urine. R5 sat on the toilet. V37 wiped R5's penis and thighs with a wet wash cloth. No soap or peri-wash was used. On 6/27/22 at 9:15 AM, V37, CNA, stated, I did not get (R5) up this morning. I think he got himself up because of the way he was dressed, and the socks he had on were regular socks not gripper socks. I know a lot of the residents back here wear their regular clothes to bed at night because that is what they prefer. On 6/28/22 at 11:45 AM, V28, CNA, stated, I didn't get anyone up yesterday morning (V28 worked on the Memory unit until 6:00 AM). Some do go to bed in their clothes. They will just get up and start coming out. When I am back there for a full shift, when they start coming out I will change them. On 7/6/22 at 10:10 AM, V6, Regional Nurse, stated even if residents get themselves up and come out of their room, they should be taken back to their room and be given am care as in changing clothes, checking for incontinence, oral care, and brushing their hair. On 7/6/22 at 10:10 AM, V6, Regional Nurse, stated when incontinent care is provided, peri-wash or peri-wash pre-moistened cloths should be used; all soiled areas should be cleansed and dried. 5. R24's Face Sheet, print date of 6/27/22, documents R24 was admitted on [DATE], and has diagnoses of Alzheimer's Disease, Generalized Anxiety Disorder, Dementia, Mental Disorders due to known physiological condition, Psychosis, and a history of falling (dated 9/23/20). R24's Minimum Data Set (MDS), dated [DATE], documents R24 is severely cognitively impaired, R24 requires extensive assistance of 2 staff members for dressing and toileting. This MDS also documents R24 is always incontinent of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, interview, and record review, the facility failed to provide structured and meaningful activities for 6 of 6 residents (R5, R15, R29, R40, R71) reviewed for Dementia care in the sample of 51. Findings include: 1. R5's admission Record, print date of 6/29/22, documents R5 was admitted on [DATE], and has a Diagnosis of Dementia with Behavioral Disturbances. R5's MDS, dated [DATE], documents ,R5 is severely cognitively impaired, requires extensive assistance of 2 staff members for transfer, extensive assistance from 1 staff member for bed mobility, dressing and toileting, supervision for walking in room, eating, and is totally dependent on one staff member for personal hygiene. On 6/27/22 at 5:09 AM, R5 exited his room. R5 is fully dressed. R5 only has on regular socks. R5 is wandering the Memory Unit hallway. R5 is going into other residents rooms and coming back out. R5 returns to his room multiple times, and then comes back out and wanders the hall again. At this time, there are 2 CNA's, V5 and V37, working in the unit, and both are working with R64 toileting her, so there is no staff present to redirect R5 or to give him a meaningful activity to do at this time. On 6/27/22 at 6:28 AM, R5 is wandering the hallway. R5 goes to the dining room and sits at the dining table. No staff are present in the hallway or dining room. 2. R15's admission Record, print date of 7/7/22, documents R15 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Dementia. R15's MDS, dated [DATE], documents R15 is severely cognitively impaired. On 6/27/22 at 8:15 AM, R15 is wandering the hall. V38, Activity Director, encouraged R15 to sit down and eat breakfast. R15 sat down with his breakfast. R15 sat for 2 minutes, got back up, and began wandering the hall again. R15 kept wandering the hall in and out of residents rooms, and would come back into the dining room, and would sit with R26, and try to give him snacks to eat. R15 took the cookies and threw them, and they broke onto the floor. No staff were in the dining room at this time. No staff encouraged R15 to sit and eat his breakfast, or provide him with a meaningful activity. On 6/27/22 at 10:30 AM, V5, CNA, is doing an activity of coloring with R36, R51, and R17. V5 is charting on her computer, and not paying any attention to the residents. R15 is wandering the hall going in and out of residents rooms. R15 is not encouraged to come and participate in the coloring activity. 3. R29's admission Record, print date 6/29/22, documents R29 was admitted on [DATE] and has a diagnosis of Dementia. R29's MDS, dated [DATE], documents R29 is severely cognitively impaired. R29's Care Plan, dated 8/2/21, documents, The resident is dependent on staff for activities, cognitive stimulation, social interaction. Provide a program of activities that is of interest and empowers encouraging/ allowing choice, self expression and responsibility. Thank resident for attendance at activity function. R29's Care Plan, dated 4/26/21, documents, (R29) is an elopement risk / wander. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. On 6/27/22 at 5:09 AM, R29 exited her room fully dressed, wearing slipper socks. R29 is wandering the hallway on the Memory Unit; no staff are present. R29 went into R10's room. R10 started screaming at R29, Get out of here. R29 left R10's room and walked to the end of the hallway. At no time did staff intervene or redirect R29 with a meaningful activity. On 6/27/22 at 6:43 AM, R29 has been wandering the hallway. R29 goes into the small dining room and begins to play with a baby doll. No staff are present in the hallways or dining room to provide supervision. On 7/5/22 at 10:08 AM, R29 is in the small dining room with head on the table, asleep. 4. R40's admission Record, print date of 6/29/22, documents R40 was admitted on [DATE] and has a diagnosis of Dementia. R40's MDS, dated [DATE], documents R40 is severely cognitively impaired . On 6/27/22 at 8:50 AM, R40 is wandering in the hallway. R40 is wandering in and out of rooms. At 8:53 AM, R40 goes into R36's room, and lays down on the bed. No staff redirected R40 or provided a meaningful activity for R40 to do. R40's Care Plan, dated 4/13/22, documents, (R40) is an elopement risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: to talk. 5. 5. R71's Face Sheet, dated 6/29/22, documents R71 was admitted on [DATE], and has Dementia with Behavioral Disturbance, Anxiety and Major Depression. R71's MDS, dated [DATE], documents R71 is severely cognitively impaired. R71's Care Plan, dated 11/18/22, 11/18/21, documents, The resident has impaired cognitive function / dementia or impaired thought process. Intervention. Break task into small sub tasks to support short term memory deficits. R71's Care Plan does not address activities. R71's Care Plan, dated 12/13/22, documents, (R71) is an elopement risk. provided structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. On 6/21/22 at 11:41 AM, V18, CNA, stated, We try to keep them entertained with music coloring and things, drinks, snacks. We also potty them on a schedule, and of course before and after dinner. We also lay them down when they want to lay down. On 7/05/22 at 10:08 AM, V18, CNA, was questioned about activities, V18 stated, We are suppose to do activities with the residents, but to be honest, they don't get done. V18 showed surveyor a calandar with multiple activities to be held throughout the day. V18 stated, We are to have a higher functioning group and a lower functioning group. If we do activities, who is taking them to the bathroom? Who is giving showers? It is just so busy back here (Memory Unit) we just can't do it all. On 7/6/22 at 12:45 PM, V38, Activity Director, stated, The aides are the ones that do the activities on the Memory Unit. There used to be a coordinator, which I was, and I did the programming and assisted with the activities. It was a nice program for the residents back there. We were able to do the activities with them. In August, the Activity Director quit, and I took over her job, and the facility got rid of the coordinator position. The aides are so busy back there, they really don't have time to do the activities. It really is sad. It was so much better when we had the activity program for them. It kept them busy and safe. I help back there when I can, but I also am doing the activities for the rest of the building. On 7/6/22 at 1:46 PM, V4, RN, stated she does have 15 residents that wander back on the Memory Unit. V4 stated, We don't have an activity program back here. The CNA's try but they are so busy caring for residents there just isn't time for it. I try. I am sure you have seen me dancing around here, but we just don't have time because of the care the residents need. We do always have music playing back here for them. On 7/7/2022 at 9:00 AM, V6, Regional Nurse, stated, I agree that we need to look at the activity program back on the Memory Unit. I spoke with V38, Activity Director, yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to ensure foods were served at safe and palatable temperatures. Findings include: On 6/28/2022 at 12:34 PM, V34, Dietary Manager, stated, We have finished making all of our trays. We get complaints about cold food now and then, but it is always hot when it leaves the kitchen. Nursing just takes a long time to pass out all of the trays. R53's Minimum Data Set (MDS), dated [DATE], documents R53 is cognitively intact. On 6/21/2022 at 9:20 AM, R53 stated, The food is usually cold by the time it gets to me in my room. R47's MDS, dated [DATE], documents R47 is cognitively intact. On 6/21/2022 at 9:45 AM, R47 stated, The food is cold by the time I get it. This hall is the last on the list so we get the food late. R21's MDS, dated [DATE], documents R21 is cognitively intact. On 6/21/2022 at 9:55 AM, R21 stated, The food is cold all the time, even when I eat in the dining room. R48's MDS, dated [DATE], documents R48 is cognitively intact. On 6/21/2022 at 10:00 AM, R48 stated, I eat in my room, and the food is usually cold. R19's MDS, dated [DATE], documents R19 is cognitively intact. On 6/21/2022 at 10:55 AM, R19 stated, I eat in the dining room because we are the last hall to get food, and it is not very warm. On 6/27/2022 at 8:40 AM, R53 stated, My eggs are cold this morning so I will just ask for some new food when I return from my appointment. On 6/28/2022 at 12:42 PM, there was a meal cart sitting in the 400 Hallway with doors closed. No staff were passing trays. On 6/28/2022 at 12:47 PM, the meal cart was still closed, sitting in the 400 Hall. On 6/28/2022 at 12:58 PM, staff began passing trays to residents. On 6/28/2022 at 1:06 PM, test tray temperatures were measured using calibrated metal thermometer on the 400 Hall, after the last resident tray was delivered. Au gratin potatoes measured 119 degrees Fahrenheit (F); Ham measured 92 degrees F; Corn measured 100 degrees F. On 6/28/2022 at 2:10 PM, V29, Certified Nursing Assistant (CNA), stated, Lunch usually doesn't take that long to pass, but today we had a lot more requests than usual. On 6/28/2022 at 2:13 PM, V23, CNA, stated, I was down on the 200 Hall and (V29) was helping in the dining room. Sometimes if the trays come while we are helping other residents they may be sitting there for a while. Also, I don't think the hot carts work very well. Resident Council Meeting Minutes, dated 4/6/2022, documents, Cold food at breakfast and dinner. Resident Council Meeting Minutes, dated 6/1/2022, documents, Trays served on the hall - the food is cold. The Facility's Meal Temperature Policy, dated 1/1/2021, documents, Food and drinks should be palatable, attractive and served at a safe and appetizing temperature, as determined by the type of food, to ensure patients/residents' satisfaction. The Facility's Hot Holding Compliance Plan Policy, which is not dated, documents, Standard: Maintain hot potentially hazardous food at 140 degrees F/60 degrees C (Celsius) or above during display/service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R47's Care Plan, dated 5/26/22, documents (R47) All About Me - Care/ADL Preferences: (R47) is at risk for falls Gait/balance problems. It continues, (R47) has nutritional problem or potential nutritional problem - Obesity 408 and BMI=65.8. It continues, (R47) has an ADL Self Care Performance Deficit related to obesity, respiratory failure and heart failure. Interventions: requires two staff participation with bathing, The resident requires two staff participation to reposition and turn in bed, requires two staff participation to use toilet, requires two staff participation with transfers (full mechanical lift device) lift. It continues, (R47) has limited physical mobility. Interventions: totally dependent on staff for locomotion, uses wheelchair for locomotion. R47's MDS, dated [DATE], documents R47 is cognitively intact, and requires extensive assistance from two staff members for most of her ADL's. On 6/21/22 at 9:45 AM, R47 was lying in bed, stated she's waiting to see if she is going to be able to get up today. On 6/22/22 at 8:40 AM, R47 was lying in bed, stated she is waiting for staff to get her up for breakfast. On 6/27/22 at 8:30 AM, R47was lying in bed eating breakfast. On 6/27/22 at 10:35 AM, R47 was lifted out of bed using a full body mechanical lift device, and placed into a wheelchair. On 6/28/22 at 12:15 PM, R47 stated, I usually get out of bed every day except when they do not have enough staff. It takes two to get me up and sometimes they don't have a second aide on this hall to get me up, so I have to stay in bed. Sometimes it makes me angry that I can't get out of bed. They need more staff here. They have a lot of call offs and some just don't show up to work. 3. R53's MDS, dated [DATE], documents R53 is cognitively intact, and requires extensive assistance from two staff members for transfers and toilet use. R53 is totally dependent on one staff member for bathing. R53 requires extensive assistance from one staff member for dressing and personal hygiene. R53 is always incontinent of both bowel and bladder. On 6/21/22 at 9:20 AM, R53 was lying in bed, unshaven, dry flakey skin on feet, greasy hair, with a long wild appearing beard and mustache. On 6/22/22 at 8:30 AM, R53 was resting in bed with his hair messy and greasy, and remains unshaven. R53 has a very unkempt appearance. On 6/22/22 at 11:25 AM, R53 put his call light on. R53 had a strong smell of urine in his room. R53's bed was saturated in urine. On 6/27/22 at 8:40 AM, R53 was lying in bed, appears unkempt, hair greasy and messy. On 6/28/22 at 9:35 AM, R53 was lying in bed with only a sheet over his groin area. R53 stated he was just cleaned up after being wet all morning. On 6/22/22 at 8:30 AM, R53 stated, I told (V8, CNA,) that I needed changed some time around 10:30 AM yesterday, and I was not changed until 8:30 PM. (V8) said he would go get supplies and some help and come back, and he never did. On 6/27/22 at 8:40 AM, R53 stated, I did not get a shower or bed bath this past weekend. My last shower was last Tuesday (6/21/22). On 6/28/22 at 12:05 PM, R53 stated, It makes me feel dirty and really upsets me when I don't get my showers like I'm supposed to and when they leave me sitting in urine or stool. They definitely need some more help here. On 6/30/22 at 10:54 AM, V8, CNA, stated, Showers are a big problem here. Usually if we have enough staff, we would have one person as a designated shower person. If we don't have enough staff, one person will work the hall while the other starts showering residents. We use the shower book to tell us who gets a shower. We try out best we can but we need more staff to get things done. 4. R69's Care Plan, dated 6/27/22, (R69) has an ADL Self Care Performance Deficit due to morbid obesity and lymphedema. Interventions: Assist as needed, requires two staff participation to reposition and turn in bed, requires two staff participation to dress, is totally dependent on staff for toilet use, requires a full mechanical lift for transfers with two staff members. R69's MDS, dated [DATE], documents R69 has a moderate cognitive impairment, and requires total dependence from one to two staff members for bathing and personal hygiene. R69 requires extensive assistance from two staff members for mobility, transfers, and toileting. R69 requires supervision with set up assistance. R69 is always incontinent of both bowel and bladder. On 6/21/22 at 9:40 AM, R69 stated, I was told to just go to the bathroom in the bed. They put pads down for me. I don't even realize that I am going. On 6/21/22 at 9:40 AM, R69 was lying in bed with hospital gown on, no visible wetness noted to bed linen, however, R69 stated she may be wet under her because she doesn't even realize that she's going. On 6/22/22 at 8:35 AM, R69 was lying in bed, has just been cleaned up for the morning. On 6/27/22 at 8:35 AM, R69's was lying in bed eating breakfast, current bed linen are saturated with urine down past her feet at the end of the bed. On 6/27/22 at 10:40 AM, R69 remains on her back in bed, asleep, empty plate of food on her chest from breakfast. Bed linens remain wet down to her feet. On 06/27/22 11:28 AM, V8, CNA, entered R69's room and removed the empty plate. V8 did not check R69 for incontinence or clean her up before leaving the room. On 6/27/22 at 2:15 PM, R69 was sitting up in bed eating lunch. Bed linen was dry, and R69 stated they finally cleaned her up right before lunch was delivered around 12:30 PM. On 6/28/22 at 12:10 PM, R69 stated, I usually only get one shower a week because they don't have enough help here. It would be nice and make me feel better to at least get a sponge bath in between that one shower. 5. R38's Care Plan, dated 3/17/22, documents, (R38) is at risk for falls related to gait/balance problems and history of falls. Interventions: Call Don't Fall sign, call light is within reach and encourage the resident to use it for assistance as needed. (R38) YOUNITE Story - Care/ADL (Activities of Daily Living) Preferences: prefers to go to bed at 8:00 PM, usually wakes up early in the morning to use the bathroom and then will go back to bed for about an hour. It continues, (R38) has an ADL Self Care Performance Deficit related to impaired balance. Interventions: Ambulation assist walking with resident in her room to and from the bathroom using a gait belt and wheeled walker providing stand by assist to limited assist as needed based on resident's performance and ability, requires one staff participation to use toilet, requires one staff participation with transfers. It continues, (R38) has limited physical mobility. Interventions: requires stand by assistance with a walker to ambulate as desired. R38's MDS, dated [DATE], documents R38 is cognitively intact and requires extensive assistance from one staff member for transfers. R38 requires limited assistance from one staff member for ambulation, dressing, toilet use, personal hygiene, and bathing. R38 is always continent of both her bowel and bladder. R38's Fall Risk Data Collection, dated upon admission on [DATE], documents R38 is a low fall risk. R38's Fall Risk Data Collection, dated 3/13/22, R38's date of fall, documents R38 is a low fall risk. R38's Fall Risk Data Collection, dated 3/26/22, R38's return to the facility after hospitalization from a fall, documents R38 is a high fall risk. R38's Fall Risk Data Collection, dated 6/21/22, R38's date of fall, documents R38 is a high fall risk. On 6/21/22 at 11:05 AM, R38 was lying in bed, fully dressed with fuzzy socks on, and did not have non-skid socks, walker and shoes are at her bedside. On 7/05/22 11:00 AM, R38 was awake, alert and oriented, resting in bed with a hospital gown on. A call don't fall sign posted on the bathroom door, no walker wasseen in the room, and her wheelchair was at the foot of her bed. On 7/6/22 at 12:30 PM, R38 was lying in bed with a hospital gown on. There was no walker seen in her room, her wheelchair was at the foot of her bed, and she had personal belongings located in several places in her room. R38's Progress Note, dated 3/13/22 at 3:43 AM, documents, Resident yelling out help. CNA (Certified Nursing Assistant) entered room and observed resident sitting on the floor. Writer entered room and observed resident sitting on the floor in the corner by bathroom door. [NAME] standing behind resident. Resident states she was bending over to pick up a piece of clothing and lost her balance and fell to her bottom. ROM WNL (Range of Motion within normal limits) and no complaints of pain. Resident was able to stand to feet and skin check completed at this time with no areas noted. Resident ambulated with walker to bed without difficulty. Vital Signs 112/52-56-16-97.8. neuro assessment initiated. MD made aware. Will update POA (Power of Attorney) in am hours. The Facility's Schedule and Daily Assignment sheets provided by V6, Regional Nurse, dated 3/12/22, documents during the date and time of R38's fall (3/13/22 at 3:40 AM), there was only one LPN (Licensed Practical Nurse) and three CNA's (Certified Nursing Assistants) on duty in the facility with a census of 66 residents. On 7/5/22 at 11:00 AM, R38 stated, I remember when I fell in March. I was trying to pick up clothes by the bathroom door. I lost my balance and fell. I didn't bother them because they are so busy and there is not enough help. On 7/7/22 at 11:05 AM, V48, CNA, stated, (R38) usually will try and go to the restroom by herself and if she feels like she needs some assistance, she will put her call light on. That night, (R38) must have gotten up herself and when I walked by her room, she was on the floor. The staffing for our shift is always short staffed. There is always just me, (V67, CNA), and (V68, CNA) working with one to two Nurses for the entire building. It is hard to get to everyone with just a few of us working. Based on observation, interview, and record review, the facility failed to have adequate numbers of staff to meet the needs of the residents, including adequate supervision to prevent falls. This failure has the potential to affect all 81 residents living in the facility. Findings include: On 6/29/22 at 9:50AM, V3, LPN, stated she is over the staffing of the facility, and is temporarily on call. V3 stated, They (V1, Administrator) gives me a number of staff based off of the census. V3 stated, Right now with the census, they are allowed to have 7 CNAs on day shift, 7 CNAs on evening shift, 4-5 CNAs on night shift, 3-4 nurses on days and 3 nurses on nights. V3 stated the nurses do 8 and 12 hour shifts. V3 stated they have a hard time staffing the 2pm-6pm time for nurses and CNAs. V3 stated they are open to all agencies. V3 stated she started being on-call this past Monday (6/27/22) for staffing. V3 states V1 was taking call, but he has no clinical experience, so she said she would do it temporarily. V3 stated the problem is they use agency, and then they don't show up. V3 stated they are offering incentives, pay raises, starting to work with new staffing agencies, and are currently interviewing for CNAs and Nurses. On 6/30/22 at 11:05AM, V1, Administrator, stated the minimum staffing levels are determined through public health regulations. The facility uses the resident census and PPD (per residents, per day) to determine their staffing levels. V1 stated when they put the schedules out, they are staffed to meet the resident's needs, but the schedules change and they have open access to agencies. V1 stated to recruit new staff they did a wage adjustment in February 2022, are offering a sign on bonus, they visit schools, send flyers, and have 2 recruiters. On 6/29/22 at 9:16AM, V1, Administrator, stated they do not have a policy on staffing, they follow the regulations. On 7/07/22 at 2:00 PM, The Resident Census and Conditions of Residents, print date of 6/29/22, was reviewed, and documents the facility has 63 residents that require assist of one or two staff, and 13 residents that are totally dependent on staff for transferring. For bathing, the facility has 39 residents that require an assist of one or two staff, and 42 residents that are totally dependent on staff for bathing. For toilet use, the facility has 69 residents that require the assistance of one or two staff, and 10 residents who are totally dependent on staff for toileting. For dressing, the facility has 68 residents that require the assistance of one or two staff, and 12 residents who are totally dependent on staff for dressing. The facility has 61 residents that are occasionally or frequently incontinent of bladder, 37 residents that are occasionally or frequently incontinent of bowel, and 4 residents that have indwelling or external catheters. The facility has 3 residents that are bedfast all or most of the time, 53 residents that are in a chair all or most of the time, 3 who are independently ambulatory, 22 residents that ambulate with assistance or assistive device, and 29 residents with contractures. Three residents have pressure ulcers, and 72 are receiving preventive skin care. 1. R226's face sheet, undated, documents a diagnosis of Parkinson's Disease and Muscle Weakness. R226's Minimum Data Set (MDS), dated [DATE], documents R226 has severe cognitive impairment, requires an extensive assistance of two staff for toileting and has had falls prior to admission and after admission. R226's care plan, dated 6/10/22, documents R226 is at risk of falls. R226's fall risk assessment, dated 6/10/22, documents R226 is at risk of falls. R226's progress noted, dated 6/24/22 at 2:11PM, documents, Certified Nursing Assistant (CNA) brought resident to bathroom, resident was agitated and walked on through the next bathroom door to the adjoining room. Resident then attempted to punch CNA, and resident fell to the floor. CNA yelled for writer/nurse. Writer arrived in room and noted resident sitting on the floor. Writer asked resident if he was having pain and he responded his hip and neck hurt. Staff did not move resident. 911 called. Emergency Medical Technicians (EMT) arrived and resident lifted with sheet to stretcher. Resident transferred to local hospital via ambulance. R226's hospital history and physical, dated 6/25/22, documents diagnosis of a Left Femoral Neck Fracture. The facility time card reports, documents on 6/24/22 at 2:14PM, there were 3 Licensed Practical Nurses (LPN) and 5 CNAs working at the time of R226's fall. 6. On 6/27/22 at 4:30 AM, V31 LPN, stated, We could use one more aide. At times the call lights are going off and we can't answer them timely. 7. On 6/27/22 at 4:45 AM, V45, Memory Unit CNA, stated, We had enough staff this weekend. I only work until 5:00 AM, then an aide from the main part of the facility will come and sit down here. Then the day girls will come in at 6:00 AM. 8. On 6/27/22 at 5:05 AM, V7, CNA, stated, With all the behaviors we have back here (the Memory Unit) I don't think 1 CNA is enough. You can have multiple people up wandering at the same time it gets difficult. 9. On 6/27/22 at 5:30 AM, V28, CNA, stated, I work the unit on occasion. Since (V45) left I had to leave my hall and come down here and sit so then they are running an aide short for the next hour out there. V44 also stated, Sometimes 1 CNA is not enough back here (Memory Unit) at night because of all the behaviors and resident confusion. 10. On 6/27/22 at 6:23 PM, V42, RN, stated, No, 1 CNA back there (Memory Unit) is not enough there are to many behaviors and residents that require 2 assist. With one CNA, no one is watching the group because that one CNA is busy taking care of one residents needs like toileting, laying down, or what ever that one needs. 11. On 6/22/22 at 9:30 AM, V4, RN, stated, Last Sunday we only had 2 nurses in the building. I did reach out to management and I was told to 'deal with it' by V6, Corporate Nurse. I don't think that 1 CNA back here is enough. A Lot of mornings we come in and residents that need 2 staff assistance are soaked with urine, like (R5,R64 , R26) she is a fighter it takes 2 for her. 12. On 6/22/22 at 1:50 PM, V18 CNA, stated, We usually have 2 on days and evenings and 1 on nights. Some get up early, usually it stays busy back here because the residents wander and they wander at night too. Sometimes we come in and the residents are wet because there is only one but that depends on who is working. 13. On 6/21/22 at 12:41 PM, V59 (R29's Husband), stated, Sometimes they only have one CNA here. I have been here before with just a nurse. That's just not enough people back here. I am private pay it costs me $5,000 a month. They need to pay staff to keep them here and get them to show up. They also are on their 6th Administrator; there is no one running the ship. I come in every day to feed her breakfast and lunch because they don't have enough staff. If I am not here; she will eat with her fingers if she eats at all. I don't like the idea of her eating with her fingers; so I come for 2 meals a day every day; so I know at least she eats well for 2 meals. 14. On 7/6/22 at 1:46 PM, V4; RN, stated, I have 21 residents back on the Memory Unit; 15 of those wander and 8 require a 2 staff member assistance. 15. On 7/7/22 at 9:00 AM, V6, Regional Nurse, stated, We try to have 2 CNA's on the Memory unit on days and evenings and 1 CNA on night shift. We try to staff depending on what's going on the unit because it can change with the moods. 16. On 6/27/22 at 12:12 PM, R57 is telling R24 to eat, and giving him portions of his Lasagna. R24 is a pureed diet. V38, Activities, told R57 to stop trying to get R24 to eat. R57 continues to put a large section of her regular texture Lasagna on his plate and telling him to eat. V20, LPN, told her not to feed him or give him food. R57 continued to yell at R24 to eat. V37, CNA, came to the table and sat and assisted R24 with lunch. On 6/27/22 at 12:21 PM, R64 is feeding R39. V5, CNA, has told her not to do it twice. V5 needed to leave the dining room and help with the readmission. V37 is feeding R24 at this time, so is not watching the rest of dining room. On 7/7/22 at 9:00 AM, V6, Regional Nurse, stated residents should not feed each other, and staff should always be in the dining room for supervision and to help the residnets. The facility provided document, Wanders, documents there are 21 residents on the Memory Unit and 16 wander. The facility provided document, 2 assist documents there are 7 residents that require a 2 staff member assistance at times. The Resident Census and Condition of Residents Form (CMS 672), dated 06/21/2022, documents there are 81 residents living in the facility.

Based observation and interview, the facility failed to have a Registered Nurse (RN) to serve as a full-time Director of Nurses (DON). This failure has the potential to affect all 81 residents living in the facility. Findings include: On 6/21/22, 6/22/22, 6/23/22, 6/27/22, 6/28/22, 6/29/22 and 6/30/22, there was not a DON (Director of Nursing) observed in building. On 6/30/22 at 11:05 AM, V1, Administrator, stated they do not have a DON. V1 stated they do not have a policy for the DON; they follow the regulations. The Resident Census and Condition of Residents form (CMS 672), dated 6/21/22, documents that the facility has 81 residents living in the facility.

Based on observation, interview, and record review, the Facility failed to properly store and label medications, protein supplements, and tuberculosis test vials. This has the potential to affect all 81 residents in the Facility. Findings include: On 6/30/22 at 9:35 AM, the 300 Hall medication cart was inspected. The medication cart contained the following medication in the top drawer: 1. Toujeo Max SoloStar Solution Pen - Injector 300 unit/milliliter, which was dated 6/4/22, but without legible resident name. V27, Licensed Practical Nurse (LPN), stated, I think that is for (R44) because she is the only one on that medication, but I will go ahead and pitch it to be safe. The Toujeo Max SoloStar Manufacturer Instructions document, Do not share your pen(s) with other people, even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them. On 6/30/22 at 9:48 AM, the 200 Hall medication cart was inspected. The medication cart contained the following in the bottom drawer: 2. Open unlabeled Pro-Stat protein supplement V41, LPN, stated, I always label them when I open them. There is nobody on this hall that is getting that right now. On 6/30/22 at 9:52 AM, the Facility's medication storage room was inspected. The refrigerator which was location in the medication room contained the following: 3. Open unlabeled multi dose Tuberculin (TB) vial V41, LPN, stated, It looks like it has been opened. On 6/30/22 at 9:57 AM, V41 stated, We give TB tests to all new admits and annually unless the resident refuses or has proof that they have been tested recently. The tests are all stored in the medication room refrigerator. They are good for 28 days, and they are supposed to be labeled so we know whether or not to use it. On 6/30/22 at 11:20 AM, V6, Corporate Nurse, stated, I would expect all medications to be labeled and dated. The Facility's Drug Labeling Policy, with revision date of April 2021, documents, Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacy for disposal. Medication having no labels should be destroyed in accordance with Federal and State laws. The Facility's Storage and Return of Drugs Policy, with revision date of April 2021, documents, Multi-dose vials and pens shall be stored and dated per the manufacturer's guidance. The Resident Census and Conditions of Residents, CMS 672, dated 6/21/2022, documents that the facility has 81 residents living in the facility.

Based on observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 81 residents living in the facility. Findings include: On 6/28/22 at 9:15 AM, in the standing refrigerator, there was a plate with three slices of meatloaf covered in plastic wrap, with no label or date. V34, Dietary Manager, stated, This is trash, and removed plate from the refrigerator. There were two gallon size plastic bags, one containing bologna and one with turkey. There was no label or date on either of the bags. V34 stated, The labels must have fallen off. They were just put in there last night. On 6/28/22 at 9:20 AM, in the standing freezer closest to the refrigerator, there was a bag of diced white meat that was tied up with no label or date. V34 stated, That is chicken. There was a box of corn dogs, with an inner plastic bag that was not tied up or dated. The corn dogs were exposed to the air. V34 stated, I put the label stickers on each shelf of the refrigerator because they tend to fall off. I rotate everything down to a lower shelf as new stock comes in, so I know everything on that shelf is good. On 6/28/22 at 9:22 AM, in the dry storage room, there was an odor of overripe fruit. V34 looked in open box of apples and stated, That is a rotten apple. I will probably just throw the whole box out. On 6/28/22 at 9:24 AM, in the second walk in freezer there was a box of commercially made cheesecakes, and a box of dinner rolls that had been opened. The inner plastic wraps were not re-sealed, and there were no dates on the packages. On 6/28/22 at 9:26 AM, there were five assorted whole pies sitting next to the prep sink on a large tray. The pies were not covered with plastic wrap, and were open to air. V34 stated they were being served for lunch. On 6/28/22 at 11:30 AM, V34 stated, I do expect all items to be labeled and dated. I already went through the refrigerator and made sure things were right. The Facility's Storage of Food and Supplies Policy, with revision date of December 7, 2020, documents, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages. Sort produce daily to remove spoiled pieces. Wrap food tightly to prevent cross contamination. The Resident Census and Condition of Residents Form (CMS 672), dated 6/21/2022, documents there are 81 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15. R19's Care Plan, dated 6/27/22, documents, (R19) has an ADL Self Care Performance Deficit Limited Mobility. Interventions: Check nail length and trim and clean on bath day and as necessary, requires assistance of one with bathing/showering bi-weekly and as necessary, requires Mechanical lift and assist of two for transfers. It continues (R19) has limited physical mobility. Interventions: is non weight bearing, is totally dependent on staff for ambulation/locomotion. R19's MDS, dated [DATE], documents R19 is cognitively intact and requires extensive assistance from two staff members for transfers. R19 requires extensive assistance from one staff member for bed mobility, dressing, toilet use, personal hygiene, and bathing. R19 is always incontinent of urine and always continent of bowel. On 6/27/22 at 12:10 PM, R19's bed linen and mattress were saturated in urine. V8, CNA, rolled R19 to her side, stool was seen on R19's buttocks and anal area; mattress under the linen was saturated in urine. V29 wiped stool off R19's buttocks and anal area, doffed gloves, then donned clean gloves without performing any hand hygiene. V29 did one wipe down each groin, and only one wipe down the middle of R19's vagina. V29 did not dry R19 after care. Using the same soiled gloves, both CNA's dressed R19. There was no hand hygiene done before, during, or after resident care. On 6/30/22 at 10:48 AM, V8, CNA, stated, I keep hand sanitizer in my pocket all the time. When I go into a room I will wash my hands in the sink with hot water and soap. In between glove changes, I can either use a hand sanitizer or wash my hands. After care to a resident, I wash my hands again. We are supposed to change gloves after every wipe when doing perineal care. On 6/30/22 at 11:02 AM, V23, CNA, stated, If I am just walking into the room to see what the resident needs, I won't necessarily put gloves on. If I am doing care and touch anything dirty, I change gloves and do hand hygiene. Anytime I go from dirty to clean, I change my gloves and perform hand hygiene. 16. R43's Care Plan, dated 2/15/22, documents, (R43) has an ADL Self Care Performance Deficit. Interventions: totally dependent on one staff for repositioning and turning in bed, chooses to not wear briefs, is totally dependent on one staff for toilet use, and requires a full mechanical lift from two staff assist for transfers. It continues, (R43) has limited physical mobility r/t Huntington's disease. Interventions: requires staff participation for mobility. R43's MDS, dated [DATE], documents R43 has a moderate cognitive impairment, and requires extensive assistance from one staff member for most of his ADL's, including toileting. R43 is totally dependent on one staff member for bathing. R43 is always incontinent of both bowel and bladder. 6/27/22 at 12:40 PM, V29, CNA, and V8, CNA, entered with supplies to clean R43. V29 rolled R43 to get saturated linen out from under him. V29 wiped the dried stool from R43's buttocks and anal area, then rolled R43 over and wiped once to both groins, around the scrotum and then to his penis, using the same wash cloth. R43 was not dried after perineal care was done. V29 doffed gloves and applied new ones, with no hand hygiene in between. On 6/28/22 at 11:22 AM, V6, Corporate Nurse, stated Yes, I would expect the staff to perform hand hygiene and glove changes before, during and after resident care. Gloves should be changed when going from dirty to clean areas. On 7/6/22 at 9:25 AM, V9, Corporate Nurse Manager, stated We use the Infection Prevention and Control Manual as our policy on infection control, including hand hygiene and gloves use. 17. R53's Care Plan, dated 1/10/22, documents, (R53) Care/ADL Preferences: prefers to have a shower two times a week. It continues (R53) has an ADL Self Care Performance Deficit. Interventions: requires one staff participation with bathing, requires one staff participation to dress, requires one staff participation with personal hygiene and oral care, requires two staff participation to reposition and turn in bed. R53's MDS, dated [DATE], documents R53 is cognitively intact and requires extensive assistance from two staff members for transfers and toilet use. R53 is totally dependent on one staff member for bathing. R53 requires extensive assistance from one staff member for dressing and personal hygiene. R53 is always incontinent of both bowel and bladder. On 6/22/22 at 11:35 AM, V9 entered with wash cloths, towels and linen. V22, CNA, entered to help. V22 did not do hand hygiene upon caring for R53. R53's soiled incontinent brief was removed and appeared to be saturated in urine. V22 used a wet wash cloth to wipe R53's bilateral groins, scrotum and testicles, but did not wipe R53's penis. Someone knocked on the door, and V22 used her soiled gloves to move the bedside curtain to see who was at the door. R53 was turned over and stool was noted. V22 wiped R53's anal area and buttocks. With her soiled gloves on, V22 then opened R53's bedside table drawers and searched for cream and then searched through a bucket of supplies sitting on a table. R53 stated he had to urinate, so V22 held a urinal in front of R53 as he voided. V22 removed the urinal and did not wipe R53's penis or testicles afterwards. Using the same soiled gloves, V22 went to the restroom to wet more wash cloths and then returned to wipe under a skin roll of R53. V22 then fastened an incontinent brief to R53. V22 used same soiled gloves unfastened the incontinent brief, and applied a barrier cream to R53's buttock. V22 doffed her gloves and left the room to get the mechanical lift sling, without hand hygiene. V9 wiped the saturated mattress down and then dried it with a towel. R53 rolled to put the full body mechanical lift sling under him and on top of the saturated mattress. No hand hygiene done as V22 donned new gloves. V9 gathered the soiled linen and put into a plastic bag with her soiled gloves. V9 then doffed her gloves and then grabbed the soiled linen bag and took it down the hall to dirty linen cart. On 6/27/22 at 8:45 AM, V29, CNA, and V8, CNA, were in the room to clean and dress R53 for his doctor's appointment. Both CNA's donned gloves, with no hand hygiene prior to care. V29 had a few wet wash cloths that she wet and put on R53's bedside table. While R53 was on his back, V29 used a wet wash cloth and wiped R53's bilateral groins and scrotum once. R53's penis and top of his perineal area was not cleaned. R53 was then rolled to his left side, small amount of stool was seen. V29 used same soiled gloves to get a wet wash cloth and wipe R53's anal area and buttocks. No glove change or hand hygiene was done. R53 rolled to his right side and urine noticed on bed linen and running down his left side and in between skin folds. V29 put a urinal in place while R53 voided urine. After R53 finished, he was rolled back to his back; there was no cleaning of R53's penis or wiping of urine between his skin fold. A clean incontinent brief was applied to R53. V29 doffed her gloves and began dressing R53. No hand hygiene done. V8 doffed his gloves and left room to get full body mechanical lift device, with no hand hygiene performed. V29 emptied urinal into toilet, rinsed out the urinal, doffed gloves, and left the room with no hand hygiene done. On 6/30/22 at 10:48 AM, V8, CNA, stated, I keep hand sanitizer in my pocket all the time. When I go into a room I will wash my hands in the sink with hot water and soap. In between glove changes, I can either use a hand sanitizer or wash my hands. After care to a resident, I wash my hands again. On 6/30/22 at 10:50 AM, V8, CNA, stated, We are supposed to change gloves after every wipe when doing perineal care. I put on gloves when entering a resident's room to perform care. On 6/30/22 at 11:02 AM, V23, CNA, stated, If I am just walking into the room to see what the resident needs, I won't necessarily put gloves on. If I am doing care and touch anything dirty, I change gloves and do hand hygiene. Anytime I go from dirty to clean, I change my gloves and perform hand hygiene. On 7/6/22 at 8:50 AM, V6, Corporate Nurse, stated, We really don't have a policy on when to wash your hands or when to change your gloves. I think it is all embedded in other policies and procedures. Like the Perineal Care skills checklist, has to wash your hands and put on gloves. The Facility's Infection Prevention and Control Manual - Standard Precautions, dated 2019, documents Gloves: a) Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. c) Wear disposable medical examination gloves for providing direct patient care. e) Remove gloves after contact with a patient, bodily fluids/excretions, and the surrounding environment (including medical devices) using proper technique to prevent hand contamination. f) Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face, clothing, etc.). It continues Hand Hygiene: Hand hygiene (e.g., hand washing and/or ABHR): consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations. Staff must perform hand hygiene even if gloves are utilized. e) Gloves or the use of baby wipes are not a substitute for hand hygiene. 14. R30's Face sheet, print date of 6/29/22, documents R30 has a diagnosis of Symptoms and Signs involving cognitive functions and awareness, and Trochanteric Bursitis, Left hip. R30's Minimum Data Set (MDS), print date of 4/24/22, documents R30 is severely cognitively impaired, and requires total dependence, two plus person physical assist with toilet use. On 6/27/22 at 8:16 AM, V8, Certified Nursing Assistant (CNA), and V29, CNA, went in to assist R30 with getting up for breakfast. No hand hygiene of any type was performed by V8 or V29 prior to donning gloves. V29 performed incontinent care on R30's front perineum area, and then V8 and V29 assisted R30 on to her left side. No hand hygiene or glove change was done by either V8 or V29 prior to V29 cleansing R30's buttocks. V29 then removed her dirty gloves, but did not do any type of hand hygiene, prior to donning clean gloves. V8 and V29 transferred R30 into her chair. With no hand hygiene or changing of gloves, V8 then went and cleansed R30's dentures off with water, and assisted R30 with putting in her dentures. After care was completed, no hand hygiene was done. 15. R44's Face Sheet, print date of 6/28/22, documents R44 has a diagnosis of Secondary Malignant Neoplasm of Brain, and Dementia without behavioral disturbance. R44's Minimum Data Set, (MDS), print date of 6/28/22, documents R44 is moderately cognitively impaired, and requires extensive assistance, two plus person physical assist with toilet use, and is frequently incontinent of bladder and always incontinent of bowel. R44's Care Plan, print date of06/28/22, documents R44 requires 1-2 staff participation to use toilet, but has no documentation for incontinent care. On 6/23/22 at 10:15 AM, V5, Certified Nurses Assistant (CNA), and V26, CNA, went into do incontinent care/catheter care on R44. Proper hand hygiene was performed prior to donning gloves. V26 then cleansed the front peri area of R44. No hand hygiene or change of gloves was done prior to V26 cleaning R44's indwelling catheter tubing. R44 was then assisted onto her right side by V5 and V26. V26 then removed her gloves, and did hand hygiene before donning clean gloves. V26 then cleansed the bowel movement (BM) off of R44's buttocks and gluteal cleft. No hand hygiene or glove change was done. With dirty gloves, V26 removed the cream from the nightstand drawer, applied cream to R44's buttocks, and then replaced the cream in the nightstand. V26 then removed her gloves, sanitized her hands, and applied clean gloves. V5 and V26 changed places at the bedside, and R44 was assisted onto her left side. V26 cleansed R44's right buttocks, V5 handed V26 the cream out of the nightstand drawer, V26 then applied the cream to R44's buttocks, and then V5 replaced the cream in the nightstand drawer. R44's catheter tubing was not secured to prevent tension or pulling. R44 was then made comfortable in bed. V5 and V26 then removed soiled gloves and did hand hygiene. Based on observation, interview, and record review, the facility failed to ensure infection control guidelines were implemented, including those to prevent and/or contain COVID-19 and other infections by: staff not wearing appropriate masks and eye protection, staff not performing hand hygiene and glove [NAME] during care, staff not sanitizing multi use surfaces 9 of 18 (R19, R24, R30, R43, R44, R50, R53, R66, R175 ) residents reviewed for infection control in a sample of 51. These failures have the potential to affect all residents in the facility. Findings include: 1. On 6/21/2022, the facility provided documentation of 1 current COVID positive, and 2 Isolation precautions due to exposure. Upon entering and exiting the facility on 6/21/22, 6/22/22, 6/23/2022, and 6/27/2022, there was no sign or posting indicating positive COVID in the facility. On 7/7/2022 at 10:35 AM, V9, Travel Corporate Nurse Manager, stated a posting is placed on the front door to alert visitors there is a COVID positive in the facility. When asked why the posting was not there, V9 stated she was not aware of a COVID positive on 6/21/22. On 7/7/2022 at 10:37 AM, V6, Regional Nurse, stated a posting is supposed to be up, indicating COVID positive in facility. When asked why the posting was not in place on 6/21/22, 6/22/22, 6/23/2022, and 6/27/2022, V6 stated she was not sure why it wasn't posted. 2. R175's Physician Order Sheet, dated 6/15/2022, documents Contact/Droplet Isolation for COVID +. The facility posting on on R175's room door frame documented R175 was on Droplet/contact isolation. A posting in R175's room documented How to safely remove Personal Protective Equipment (PPE). It states, There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucus membranes with potential infectious materials. Remove all PPE before exiting the patient room (in bold letters) except for respirator, if worn. Remove the respirator after leaving the patient room and closing the door. On 6/21/22 at 10:35 AM, V70, unit aide, entered R175's isolation room, wearing a N95 mask, gown, and gloves. R175 performed care with R175. V70 then exited the room, and did not remove all Personal protective equipment, leaving mask on. R175 walked down the hall and to the dining room with same mask. 3. On 06/21/22 at 10:34 AM. V39 was observed wearing a surgical mask and eye protection. On 6/21/22 at 10:34 AM, V39, RN, stated, I am not vaccinated. I have religious exemption. I had to request paperwork and have it filled out. I test about 3 times a week. Have had the Covid training. I don't think we have Covid in the building. 4. On 6/21/22 at 11:11 AM, V18, CNA, observed in surgical mask only, and eye protection. 5. On 6/21/22 11:45 AM, V16, CNA, observed in surgical mask and eye protection. 6. On 6/27/22 at 4:30 AM, V31, LPN, observed in surgical mask and regular eyeglasses on. On 6/27/22 at 4:30 AM, V31, LPN, stated, I am not vaccinated, and I have an exemption. V31 stated, We have one Covid on the 200 hall that is ending her isolation. 7. On 6/27/22 at 4:45 AM, V45, CNA, observed with surgical mask and eye protection. On 6/27/22 at 4:45 AM, V45 stated she was not vaccinated, and filled out an exemption. V45 stated she tested 2 times a week. V45 stated, I tested last Wednesday. V45 stated, I did get Covid with the first round; I was quarantined. We have enough PPE. I have had the Covid training. 8. On 6/27/22 at 5:30 AM, V44, LPN, observed wearing a K95 mask with both straps dangling, the mask is being held up in place by a surgical mask and a face shield. On 6/27/22 at 5:30 AM, V44 CNA, stated, I am not vaccinated. I have an exemption. I have had the Covid training in CMS. I am tested 3 times a week. I tested last night. I have had Covid back in November and was quarantined for 14 days. 9. On 6/27/22 at 5:09 AM, V37, CNA, is on the Memory Unit caring for residents wearing a surgical mask and eye protection. 10. On 6/21/22 at 11:10 AM, V20, LPN, was observed with surgical mask with face shield built into it. 11. On 6/21/22 at 11:10 AM, V21, LPN, was observed with surgical mask with face shield built into it. On 6/21/22 at 11:10 AM, V21 stated she thinks there is 1 Covid positive resident on the 200 hallway. 12. On 6/22/22 at 11:15 AM, V5, CNA, was observed with a surgical mask and goggles. 13. On 6/23/22 at 1:50 AM, V6, Regional Nurse stated the staff are to wear the appropriate PPE. The Facility COVID action plan, updated 6/10/22, documents the following, Definitions Community- Independent Living, Assisted Living, Residential Care, Memory Care, Skilled Nursing. It further documents, General Community Guidance when COVID-19 is Present, D. When COVID-19 is identified in the community, all direct care staff will wear the recommended PPE (i.e., eye protection and N95 respirator or higher) for the care of all residents (contingent upon PPE availability) until no new cases have been detected in the last 14 days. 18. On 6/27/22 at 8:39 AM, R50 is brought to the dining table by V5 CNA for breakfast. R50 is seated in the same spot that R71 just finished breakfast. R71's plates were cleared but the dining table was not cleansed before R50 was seated at the table and was served breakfast. On 6/27/22 at 8:50 AM, R66 is brought to the dining table by V5 CNA for breakfast. R66 is seated in the same spot that R40 just finished breakfast. R40's plates were cleared but the dining table was not cleansed before R66 was seated at the table and served breakfast. On 7/7/22 at 9:00 AM, V6 Regional Nurse stated that the tables should be cleaned between uses. 19. R24's Face Sheet, print date of 6/27/22, documents R24 was admitted on [DATE], and has diagnoses of Alzheimer's Disease, Generalized Anxiety Disorder,Dementia, Mental Disorders due to known physiological condition, Psychosis and a history of falling (dated 9/23/20). R24's Minimum Data Set (MDS), dated [DATE], documents R24 is severely cognitively impaired, R24 requires extensive assistance of 2 staff members for bed mobility, transfers, walking in his room and on the hall, dressing, toileting, and personal hygiene. This MDS also documents R24 is always incontinent of bowel and bladder. On 6/27/22 at 6:58 AM, V37, CNA, and V5, CNA, both entered the room to get R24 up for breakfast. R24 was asleep in his bed. V37 woke him up and removed his blanket. V37 and V5 provided incontinet care for R24. During the incontinent care, V37 donned gloves with no hand hygiene, and changed gloves twice, with no hand hygiene between. V5 donned gloves, without hand hygiene first. On 7/6/22 at 10:10 AM, V6, Regional Nurse, stated hand hygiene should be done before putting on gloves, between glove changes, and after taking gloves off. V6 stated gloves should be changed if visibly soiled.V6 stated hands should be washed with soap or alcohol gel. The Resident Census and Condition of Residents Form (CMS 672), dated 06/21/2022, documents there are 81 residents living in the facility.

Based on interview and record review, the facility failed to employee an infection control preventionists to oversee the infection prevention control program. This has the potential to affect all 81 residents living in the facility. Findings include: On 6/21/22 at 9:53 AM, V1, Administrator, stated V3, Licensed Practical Nurse (LPN), was the Infection Control Preventionist (ICP). On 6/21/22 at 2:04 PM, V3, Licensed Practical Nurse (LPN), stated she was not the ICP for the facility, and was not responsible for Infection Control. V3 stated she was the ADON (Assistant Director of Nursing), and stepped down from the position. V3 stated she started the education, but did not complete it. V3 stated she helped V2, previous Director of Nursing, who was the ICP. V3 stated V3 no longer works at the facility. V3 stated she is not aware of who the Infection Control Preventionist is. On 6/21/22 at V6, Regional Nurse, provided documentation of COVID positive resident in facility, with current isolation. On 6/21/22, 6/22/22, 6/23/22, and 6/27/22, upon entry and exit to the facility, no signs or posting of positive COVID in facility. The Facility Line List, provided by V6, Regional Nurse, on 6/21/22, was incorrect and not up to date. The facility's Infection Prevention and Control Program, dated 2019, documents Policy: 7.The facility will designate one or more individual(s) as the infection preventionist(s) (IP)(s) who is responsible for the facility's IPCP. b. Is qualified by education, training, experience or certification. c. Works at least part-time at the facility. d. Has completed specialized training in infection prevention and control. The Resident Census and Condition of Residents Form (CMS 672), dated 06/21/2022, documents there are 81 residents living in the facility.