Based on interview and record review, the facility failed to protect a resident from resident-to-resident physical abuse for two of three residents (R1, R2) reviewed for physical abuse in a sample of three. Findings include:The facility's Abuse Prevention and Reporting policy, revised 10/24/22, documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. This form documents that physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.R1's electronic face sheet documents the following diagnoses: Congested Heart Failure, Gastro-Esophageal Reflux Disease, Gout, Osteoarthritis, Chronic Kidney Disease, Amnesia, edema, Obesity, Falls, Vascular Dementia, Mood Disturbances, Anxiety.R1's Abuse/Neglect Screening, dated 5/12/25, documents a score of 4, indicating that R1 is a moderate risk for abuse and neglect.R1's current care plan documents that R1 is at risk for abuse/neglect related to Dementia diagnosis. R1's abuse interventions document that R1 will be cared for in a safe manner, and verbalize to staff any incidents of abuse or neglect through review date.R1's Progress Notes, dated 7/12/25 at 4:52am, documents that staff went to R1's room and noticed R2 hitting R1. This form documents that R1 had no complaints of pain. All the required parties were notified.R2's current electronic medical record documents the following diagnoses: Hydrocele, Strabismus, Restlessness and Agitation, Inguinal Hernia, Alzheimer's, Insomnia, Dementia severe with agitation, Hypertension, Hyperlipidemia, Atrial Fibrillation, Atherosclerotic Heart Disease, Coronary Artery Disease, Major Depression, Urinary Tract Infection, Chronic Obstructive Pulmonary Disease.R2's current Care Plan documents that R2 has the potential for aggressive behavior related to dementia. R2's goal is that he will not harm himself or others. This form also documents that R2 has the potential to be verbally aggressive related to dementia, ineffective coping skills, and poor impulse control. R2 can be physically aggressive, related to dementia, and poor impulse control.R2's Progress Notes, dated 7/12/25 at 4:50am, documents that staff witnessed R2 hitting R1. V3, Registered Nurse, asked R2 what happened, R2 stated He pulled me out of my bed. R2 was noted to have an increase in confusion.The facility's Initial Abuse Investigation Report, dated 7/12/25, documents a report of alleged physical contact between two residents (R1, R2).V5's, Certified Nursing Assistant, signed statement, dated 7/12/25, documents that someone was yelling help. (V5 and V4) ran into (R1 and R2's) room and witnessed (R2) swinging fists at (R1), while (R1) was lying in the bed. (R2) was standing over (R1). (R1) was removed away from (R2). (R1) stated He pulled me out of his bed.On 7/14/25 at 1:00pm, V4, Certified Nursing Assistant, stated that she heard yelling and went to R1 and R2's room. V4 stated that R2 was standing over and hitting R1 in the face with his fists. V4 stated that R1 was yelling to call the police. V4 stated that R2 stated that R1 pulled him out of his bed. V4 verified that R1 can not stand or transfer by himself. On 7/14/25 at 1:10PM, V3, Registered Nurse, stated that V4 and V5, Certified Nursing Assistant, told her that R2 was hitting R1, while he was in bed. V3 stated that R2 did not sustain any injuries during the altercation.

Based on observation, interview and record review the facility failed to provide for personal dignity during a transfer for one (R19) of 17 residents reviewed for dignity in a sample of 49. Findings include: The facility's Dignity policy, revised 4/23/28, documents that the facility shall promote care for the residents in a manner and in an environment the maintains or enhances each resident's identity and respect in full recognition of this or her individuality. This form documents that staff carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. The Facility's Resident Rights policy, undated, documents that (the Resident) you have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. On 6/10/24 at 1:30pm, V6, Certified Nursing Assistant, was pushing R19 down the hall on a shower chair. R19's dress was pulled up to her upper waist. R19's upper thighs and buttocks were uncovered. On 06/11/24, at 9:42am, R19 stated she is hardly ever covered when in the shower chair, going to the shower room. R19 verified that she does not like that. On 6/11/124 at 10:00am, V6 verified that R19 should have been covered with a bath blanket while being transported from her room to the shower room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R61's admission History and Physical, dated 11/9/2023, documents, R61 was admitted with a diagnosis of Severe Major Depression with Anxiety, and Suicidal Intent. R61's Progress Notes from the psychiatry clinic, dated 11/29/2023, documents, R61 has the following diagnosis: Major Depressive Disorder, recurrent and moderate, Generalized Anxiety Disorder, Post traumatic stress disorder, Major Neurocognitive Disorder and Suicidal Ideations. R61's Physician Order Sheets, dated 6/12/2024, documents the following medication regimen for R61: Fluoxetine HCL Oral Capsule 40MG (milligram) one time a day for Major Depressive Disorder, Mirtazapine Oral Tablet 7.5MG (milligram) give one tablet in the evening for Major Depressive Disorder, Olanzapine Oral Tablet 5MG one time a day for Major Depression, recurrent severe, Sertraline HCL Tablet 25MG (milligram) for Major Depressive Disorder. R61's Care Plan, dated 5/18/2024, documents: I use psychotropic medications related to Major Depressive Disorder. R61's Psychiatry Note History, dated 11/29/2024, documents,History of Present Illnesses: Major Depressive Disorder, Post Traumatic Stress Disorder, Anxiety Disorder, and Neurocognitive Disorder R61's Notice of PASRR level 1 screen Outcome, dated 11/9/2023, documents the following: PASSR Level 1 Determination- No Severe Mental Illness. R61's Preadmission Screening and Resident Review, dated 11/9/2023, Diagnosis: No mental health diagnosis is. known or suspected. On 6/13/2024 at 11:30AM V1/Administrator stated, Yes, R61 should have a new PASRR done because R61 has a long history of severe mental illness. Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R59 and R61) reviewed for PASARR screening, in the sample of 49. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), dated (reviewed) 11-13-18 documents, It is the policy to screen all potential admissions on a individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criteria for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually and with any significant change of status, the facility will complete the PASARR Level 1 screen for those individuals identified per the Level 11 screen requiring specialized services. 1. R59's current Physician Order Sheet, dated June 2024 documents that R59 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder. R59's current PASAAR screen, provided by V1/Administrator on 6/11/24, documents R59 was originally admitted to (another) Skilled Nursing Facility on 5/3/23 with no diagnosis of Severe Mental Illness. R59's PASSAR screen at that time documented, Your Level 1 screen shows low-level behavioral health symptoms which appear to be situational. The nursing facility will watch your symptoms/behaviors to see if they improve or resolve within 30-60 days of this screen. If they do not, a nursing facility staff member must submit another Level 1 screen to Maximus. This is called a status change. The status change will decide if you need a PASRR Level 11 evaluation for serious mental illness. On 6/11/24 at 12:27 P.M., V14/Director of Social Services verified that R59 has not had a PASAAR rescreen upon admission to the facility, despite R59's diagnoses of severe mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform physician ordered daily weights for one of one resident (R19) reviewed for daily weights in a sample of 49. Findings include: On 6/10/24 at 9:30am, R19 was sitting up in her chair with her feet resting on the floor. Edema was noted on R19's bilateral feet, ankles and to mid-calf. On 6/11/24 at 1:00pm, R19 sitting in her recliner with her feet resting on the floor. On 6/12/24 at 1:00pm, R19 remained up in the recliner with her feet resisting on the floor. Pitting edema noted on her bilateral feet and lower legs. R19 verified that she is not weighed every day as ordered. R19 verified that occasionally she goes to the facility scale to get weighed. R19's Physician Order Sheet, dated 12/19/23, documents to do daily weights (order on the MAR/Medication Administration Record) and notify the medical doctor or the nurse practitioner if resident has a weight gain of 3 pounds in a day or 5 pounds in a week, every day on day shift for Congestive Heart Failure Program related to Chronic Diastolic Congestive Heart Failure. R19's MAR, dated 12/20/23 through 12/31/23, has only one weight documented as being completed on 12/30/24. R19's MAR, dated 1/1/24 through 1/31/24, has only two weights documented. R19's MAR, dated 2/1/24 through 2/29/24, documents 11 daily weights being done. R19's MAR, 3/1/24 through 3/31/24, documents that 24 out of 31 daily weights were done. R19's MAR, dated 4/1/24 through 4/30/24, documents that 20 daily weights were done. R19's 5/1/24 through 5/31/24 documents that only six of 31 weights were done. R19's MAR, dated, 6/1/24 through 6/13/24, has nine of 13 weights were completed. R19's emergency room Progress Notes, dated 1/26/24, documents the following diagnosis: Acute CHF (Congestive Heart Failure) Exacerbation, Dyspnea and Hypoxia on Exertion. R19's hospital notes, documents that R19 weighed 268.8 pounds on 1/26/24 and 256.4 pounds on 1/30/24. R19 was educated on the importance of daily weights, low sodium diet and exercise. R19's Cardiovascular Progress Notes, dated 1/29/24, documents that R19's weight in the past was 225 pounds and current weight is 268 pounds. R19 has been at a skilled nursing facility and there has not been a lot of weight assessment and management there. On 6/11/24 at 11:00am, V2, Director of Nursing, stated that R19's daily weights are not being done consistently. On 6/12/24 at 2:00pm, V1, Administrator, stated that R19's weights are not being done as ordered. V1 stated that R19's daily weights need to be done and her edema assessed. V1 stated that R19 follows up [NAME] cardiologist. V1 stated that R19's diuretics are changed often due to her kidney and heart concerns.

2. The facility's Fall Prevention Program, revised 11/21/17, documents Safety interventions will be implemented for each resident identified at risk. R26's current Physician Order Sheet/POS documents diagnoses including but not limited to Unspecified Dementia, Severe, with agitation; Conversion Disorder with Seizures or Convulsions; Major Depressive Disorder, recurrent, mild; and Anxiety Disorder, unspecified. R26's current Physician Order Sheet/POS documents Helmet: resident must wear when out of bed; document all refusals. Every day and night shift related to Conversion Disorder with Seizures or Convulsions .May remove while in bed. On 6/10/24, at 11:30am, R26 sat in the dining room without a helmet on her head. On 6/10/24, at 1:50pm, V15 Licensed Practical Nurse/LPN, looked up R26's physician orders and stated, It says she is to have it when out of bed and document if refuses. On 6/10/24, at 2:00pm, V20 LPN verified that R26 is not wearing her helmet. V20 stated, Usually the girls (Certified Nursing Assistants/CNAs) will tell me if she refused the helmet, and they did not tell me that. She is supposed to wear it when out of bed. R26's clinical record does not document that R26 refused to wear the helmet on 6/10/24. On 6/10/24, at 2:09pm, R26 sat in the dining room without a helmet. 3. The facility's Elopement Device policy, revised 9/13/19, documents Purpose: To establish procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders and to ensure the security system is inspected to identify malfunctions should they occur. Responsibility: All Facility Staff. Policy: It is the policy of this facility to use elopement alert systems and devices when an assessment has identified the risk of elopement. Procedure: 1. Elopement alert devices will be used as an interventional tool to prevent resident elopements .3. The elopement alert exit door device will be inspected for proper working daily by maintenance and manager on duty .4. The inspection and status of the test will be recorded on a facility-approved log located at the front desk. Maintenance staff and manager on duty will be responsible for maintaining this log .6. The Wanderguard sensors located at the elevators and front door will be checked daily by maintenance and manager on duty and recorded in the log located at the front desk .8. The functionality of the device on resident arm or leg will be checked daily by social services and manager on duty. R31's Physician Order Sheet/POS documents diagnoses that include but are not limited to Alzheimer's disease with late onset; Dementia; Major Depressive Disorder; Restlessness and Agitation. This POS also includes (Wander alarm) on at all times. (Wander alarm) check every shift for decreased safety awareness/elopement risk dated 10/17/23. R31's Minimum Data Set/MDS assessment, dated 4/17/24, documents that a wander/elopement alarm is used daily. R31's Elopement Risk Assessment, dated 4/25/24, documents R31 is at high risk and should be on care plan - wander alert right ankle. R31's current Care Plan includes but is not limited to R26 is an elopement risk/wanderer related to Alzheimer's disease. Interventions include but are not limited to: Wander alert, left ankle. · On 6/10/24, at 1:30pm R31 is in bed without any wander alarm bracelet to either ankle; none on wrists. R31 said he wasn't wearing one. On 6/10/24, at 3:05pm, R31 is standing in the hall near the nurses' station as V20 Licensed Practical Nurse/LPN confirmed R31 is not wearing an alarm device on any of his limbs. She stated He takes it off. He wears it for that side exit door because he will go out that door and has. V20 does not remember when that was. V20 confirmed that V20 charted that he was wearing his alarm device and stated, It was on his wrist. V20 looked in his room at this time with this writer and there was no alarm device found. R31's Progress Note, dated 10/15/23, documents (R31) has been increasingly wandering around front door exit of building. Also found past the first door today, 6pm. 15 min safety checks implemented. On 6/11/24, at 12:52pm, V14 Social Service Director/SSD stated (R31) is not compliant with keeping the alert device on ever since he first came. He came on 2/2/23 and had it placed on 2/4/23. On 6/11/24, at 2:55pm V2 Director of Nursing/DON stated the following: I become aware of when he takes off the device when they document it in the progress notes. He got it placed when he was followed by staff out that door to smoke in October. Staff are to replace it right away when removed. If one is unavailable, they are to monitor him more closely. Nurses are to document that it is on his body and functioning. Maintenance checks the devices with the doors. there are three doors - the front one and two that lead to the parking lot. V2 is not sure how often nurses are to check them - according to however it is ordered. Confirmed that if it was not documented then it wasn't done. R31's Treatment Administration Records/TARs, dated October 2023-February 2024 and April 2024-June 2024 document multiple missing signatures verifying that R31's wander alarm was on and functioning. On 6/13/24, at 2:15pm, V2 DON confirmed the multiple lack of signatures on the above TARs confirming that R31's wander alarm was on R31 and functioning. On 6/12/24, at 8:44am, V10 Maintenance Director stated he tests the door alarms for the Wanderguards every day that V10 is here. V10 confirmed that he is here Monday through Friday, so the doors are not tested by Maintenance on the weekends. The facility's Test Record Door Alarm and (named) Alarm Systems logs, dated October 2023 to current do not include any documentation of the door alarms being tested on the weekends. On 6/12/24, at 3:30pm V1 Administrator stated that the managers on duty are the ones who test the doors on the weekends. They do not sign off on the log. V1 is unable to produce documentation that the doors are being tested on the weekends by the managers. On 6/12/24, at 3:24pm V14 Social Service Director/SSD read the Elopement Device policy and stated she has never been told that she is to test the functionality of the wander alarm devices and is not doing it. Based on observation, interview and record review, the facility failed to implement interventions to reduce a residents' risk of a fall and safety interventions for transfer for two of five residents (R3, R26) and failed to follow their elopement policy, failed to document the testing of the elopement device and doors and failed to ensure an elopement device was in place for one (R31) of one residents reviewed for elopement in a sample of 49. Findings include: The facility policy, Fall Prevention Program, dated (revised) 11-21-17 directs staff, To assure safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assuasive devices are utilized as necessary. Fall/safety interventions may include but are not limited to: Transfer conveyances shall be used to transfer residents in accordance with the plan of care. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Footwear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid. 1. R3's current Physician Order Sheet, dated June 2024 documents R3's diagnoses as: Paroxysmal Atrial Fibrillation, Left-Bundle Branch Block, Occlusion and Stenosis of Right Carotid Artery, History of Transient Ischemic Attack, Cerebral Infarction, Severe Vascular Dementia, Generalized Anxiety Disorder. R3's Fall Risk Assessments, dated 8/5/23, 9/24/23, 12/14/23, 12/16/23 and 3/16/24 document R3 as being high risk for falls. R3's (facility) Fall Occurrences dated 8/5/23, 9/24/23, 12/14/23, 12/16/23 document R3's witnessed/unwitnessed falls in the past year. R3's current Care Plan, dated 3/25/24 includes the following Focus area: ADL (Activities of Daily Living) deficit related to dementia. Also included are the following Interventions: (R3) uses a mechanical lift for transfer assist for episodes of increased weakness. The same Care Plan also includes the following Focus area: Ensure that (R3) is wearing appropriate, non-skid footwear. On 6/10/24 at 9:36 A.M., V 11 and V12/Certified Nursing Assistants (CNA) prepared to transfer R3 from the bed to the wheelchair. Without applying a gait belt and without applying no non-skid socks on R3's feet, grabbed resident under arms at which time R3 yelled, Ow loudly and then V11 and V12 repositioned him back on bed. Grabbing R3 a second time under arms and repositioned him on bed and R3 loudly yelled, Ouch, that hurts. Third CNA (V13) brought mechanical lift in room for use and 2 other CNAs applied gait belt at that time and pulled R3 to standing potion, while yelling Ow. R3 did not bear any weight on his legs as 2 CNAs turned and placed R3 in chair. At that time, V13 said, You should have used the (mechanical lift) on him.

Based on observation, interview and record review, the facility failed to ensure ordered nutritional drink for a resident with weight loss was offered for one (R26) of one resident reviewed for nutrition in a sample of 49. Findings include: The facility's undated Nutrition Intervention Program (NIP) policy documents Policy: Residents identified as needing additional nutrition interventions will be started on the NIP Program. Identified Residents include, but not limited to 1. Significant weight loss at 1 month, 3 month, 6 months. This policy also states, The nutrition interventions can be initiated by the food service manager, dietician, or nursing staff. R26's current Physician Order Sheet/POS documents diagnoses including but not limited to Unspecified Dementia, Severe, with agitation and Conversion Disorder with Seizures or Convulsions. R26's Minimum Data Set/MDS assessment, dated 4/4/24, documents R26 is severely cognitively impaired, requires supervision or touching assistance for eating, and that R26 had a significant weight loss, not physician prescribed. R26's Registered Dietician note, dated 4/15/24, documents that R26 has had a significant weight loss of 14.8% x 2 months and 10.5% x 4 months. She is receiving whole milk TID (three times per day), super cereal with breakfast, and health shake with lunch and supper for extra kcal (kilo calories) to help maintain her weight. Will continue to monitor. No (further) recommendation. On 6/10/24, at 11:30am - 12:05pm, R26 sat in the dining room for lunch. R26's meal tray contained a health shake and container of milk with her food. R26's milk was open with a straw; the health shake remained closed as R26 occasionally picked at the food. No attempts by staff to open/offer the health shake. On 6/10/24, at 12:16pm, V11 Certified Nursing Assistant/CNA removed R26's meal tray and placed it in the cart for the finished meal trays. R26's unopened health shake remained on this tray. On 6/10/24, at 1:46pm, V11 CNA stated the following: I did not assist (R26) to eat at lunch time. She needs some assistance, and we usually do but sometimes she refuses and it causes behaviors. I usually mix her (health) shake into her milk so she will drink it, but it was frozen. V11 was not sure if V11 could get another one that wasn't frozen. V11 verified V11 put R26's unopened health shake on the cart for finished meal trays. On 6/12/24, at 11:57am, R26 sat in the dining room dozing with meal in front of her including an unopened health shake. On 6/12/24, at 12:10pm R26's meal tray is in the cart for finished meal trays with the health shake still unopened. On 6/12/24, at 12:15pm, V17 Licensed Practical Nurse/LPN stated that V17 got R26 to drink some of her milk (half of it). V17 confirmed V17 did not mix the health shake in the milk. On 6/10/24, at 2:15pm, V20 LPN stated It is the CNAs responsibility to make sure the resident drinks the (health) shake as far as I know. It comes from the kitchen staff if ordered by the dietician for weight management since these residents with dementia tend to lose weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform an ongoing assessment of the resident's respiratory status for one resident of one resident (R44) reviewed for oxygen therapy, in a sample of 49. Findings include: The (undated) facility policy, Oxygen Therapy General Standard directs staff, Purpose: To provide adequate tissue oxygenation for problems associated with Reduced oxygen carrying capacity of blood. A licensed nurse will conduct ongoing resident assessments for oxygen administration. A pulse oximeter will be used to determine oxygen saturation levels. R44's current Physician Order Sheet dated June 2024 document R44's current diagnoses as: Chronic Obstructive Pulmonary Disease. This same form documents an order for R44's oxygen therapy, Oxygen 3L (Liters) via NC (Nasal Cannula) PRN (As Needed), to maintain SPO2 (Saturation of Peripheral Oxygen) above 88%. R44's Medical Record documents, 6/11/2024 90%, 6/10/2024 96%, 5/14/2024 95.0%, 5/7/2024 95.0%, 5/6/2024 96.0%, 5/4/2024 95.0%, 5/3/2024 94.0%. No other assessment of R44's respiratory status is present. A review of R44's Medication Administration Records for May and June 2024 shows no documentation of R44's SPO2 levels. On 5/11/24 at 4:15 P.M., V2/Director of Nurses verified R44 was admitted to the facility on [DATE], received oxygen therapy at 3 liters continuously and no ongoing SPO2 levels were monitored by staff until 6/10/24.

Based on observation, interview and record review, the facility failed to assess a resident's dialysis fistula as ordered for one of one residents (R51) reviewed for dialysis, in a sample of 49. Findings include: The Assessment of Resident policy, revised 4/18/22, documents 9. Document resident comments, complaints as appropriate and assessment findings in the nursing progress notes. 10. Notify the physician of significant findings and request necessary change in orders. 12. Initiate Nursing Interventions. On 5/2/24, a Physician ordered Check Bruit and Thrill (a vibration that is palpated above or below the fistula (dialysis access site) to ensure blood flow) of dialysis fistula to left forearm every shift (Y=positive/N=negative) every day and night shift for fistula monitoring. On 6/12/24 at 9:00 AM, V18 (Registered Nurse) demonstrated in the Electronic Medical Record how the bruit and thrill assessments were documented. After the bruit and thrill assessment was entered as completed or not completed, another screen auto populated and asked the question Is behavior observed. V18 stated I don't even know what that means. On 6/12/24 at 9:45 AM, V3 (Assistant Director of Nursing) reviewed R51's physician's order for the bruit and thrill assessments and stated the order requires a Behavior Observed assessment which should be marked yes for a positive thrill and bruit and no for a negative thrill and bruit. The Medication Administration Record (MAR) documents between 5/1/24 and 5/31/24, 39 of 62 bruit and thrill assessments and between 6/1/24 and 6/11/24, 18 of 21 bruit and thrill assessments were documented as No. It was unable to be determined if the bruit and thrill assessment was conducted as ordered or if No referred to the absence of a bruit or thrill. On 6/12/24 at 10:35 AM, R51 states the staff assess R51's fistula Maybe once a day. Not twice. It's not always done (fistula assessment) but sometimes it is.

Based on interview and record review, the facility failed to ensure residents on Psychotropic medications have supporting diagnoses and identified targeted behaviors with monitoring for three (R26, R33 and R44) of three residents reviewed for Psychotropic medications in a sample of 49. Findings include: The facility's Psychotropic Medication - Gradual Dosage Reduction, revised 2/1/18, documents Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. Guidelines: The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/problems, goals and approaches as it relates to the use of psychotropic drug use. 1. R26's Physician Order Sheet/POS documents an order, dated 5/29/24, for Seroquel 50mg (Milligrams), give 75mg by mouth two times a day related to Unspecified Dementia, Severe, With Agitation; Major Depressive Disorder, Recurrent, Mild. R26's POS also documents an order, dated 5/28/24, for Olanzapine Oral Tablet 5mg, give one tablet by mouth every 12 hours as needed for agitation for 14 days. R26's current Care Plan does not include any alternate therapies to attempt for behaviors or any identified target behaviors. On 6/10/24 at 11:30am and 6/12/24 at 11:57am, R26 sat quietly at a dining room table without any behaviors noted. On 6/12/24, at 2:05pm, V2 Director of Nursing/DON stated V2 does not know if the diagnoses of Major Depressive Disorder and Severe Agitation are correct diagnoses or not. V2 is unable to provide documentation for R26's targeted behaviors or alternate therapies attempted. On 6/12/24, at 2:10pm, V1 Administrator stated R26's Seroquel and Olanzapine do not have correct diagnoses. 2. R33's current Physician Order Sheet, dated June 2024 documents the following diagnoses: Paranoid Schizophrenia, Dementia. Also included are the following physician orders: Risperdal (Antipsychotic) 4 MG by mouth two times daily. R33's Care Plan, dated 6/28/22 does not include documentation for specific targeted behaviors for monitoring or non-pharmalogical approaches attempted prior to the start of the antipsychotic medication. An observation of R33 on 6/7/24 at 11:30 A.M., on 6/8/24 at 8:30 A.M. and again at 11:45 A.M. shows R33 seated at a table in the facility Safe Unit Dining/Activity Room calmly eating her meal, conversing with other staff and residents. 3. R44's current Physician Order Sheet, dated June 2024 documents the following diagnoses: Mood Disorder, Anxiety, Dementia. Also included are the following physician orders: Haldol Lactate Oral Concentration 2.5 ML (Milliliters) by mouth two times daily and Quetiapine 25 MG one tablet in the morning and three tablets at bedtime. R44's Care Plan, dated 5/3/24 does not include documentation for specific targeted behaviors for monitoring or non-pharmalogical approaches attempted prior to the start of the antipsychotic medication. An observation of R33 on 6/7/24 at 8:45 A.M. and at 1:00 P.M. shows R33 up and about in his room, watching television. R33 was calm and engaged in conversation easily. On 6/12/24 at 2:30 P.M., V2/Director of Nurses verified that R33 and R44's medical record contained no documentation for targeted behaviors or alternate therapies attempted prior to the start of antipsychotic medications.

Based on interview and record review, the facility failed to ensure residents have knowledge of who the Grievance Official is, how to file a Grievance and where the forms are located for four (R11, R22, R54, and R60) of four residents reviewed for Grievances in a sample of 49. Findings include: The facility's Grievances policy, revised 9/25/17, documents Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus .Guidelines: The resident has the right to voice grievances to this facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal .Grievances may be filed orally (meaning spoken), in writing, or anonymously. Grievances may also be filed anonymously through the Corporate Compliance Hotline .An appointed Grievance Official (usually Social Service Director) is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations and maintaining the confidentiality of all information associated with grievances. On 6/11/24, at 9:57am, the survey Group Meeting was held in the facility with four residents (R11, R22, R54, and R60) present. During this meeting all four residents agreed that they did not know who the Grievance Official is, how to file a grievance nor where the forms were kept. R11 asked Where do you get the forms? The facility's Resident Council Minutes dated from 6-29-23 to 5-30-24 do not include any discussion on how to file a grievance. 06/11/24 1:40 PM V4 Activity Director confirmed the Resident Council meeting minutes do not include any discussion of how to file a Grievance. On 6/11/24, at 12:52pm, V14 Social Service Director/SSD stated the following: I am the Grievance Officer. Any time a grievance occurs I go talk to the resident and bring a sheet. I let the new residents know about how to file a grievance. V14 is unaware there are residents who do not know how to file. I guess I need to round more. I have not discussed the topic at Resident Council but maybe that's what I should do.

Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled correctly. This failure has the potential to affect all 28 residents (R3, R10, R14-17, R26, R27, R29, R31, R33, R35, R36, R38-R40, R44, R46-R49, R52, R53, R57, R59, R65, R68 and R121) currently residing in the facility Safe Unit. Findings include: The (revised) 7/2/19 facility policy, Medication Storage directs staff, Purpose: To ensure proper storage, labeling and expiration dates of medications, biological's, syringes and needles. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines will respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility should ensure that medications are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Refrigeration: 36- 46 degrees. On 6/10/24 at 9:29 A.M., V15/Licensed Practical Nurse (LPN) opened the locked door to the (facility) Back Hall Medication Room. A refrigerator with no temperature log present contained a thermometer in an open freezer section, that was iced to the shelf. V15/LPN, wiggling the thermometer back and forth, was able to loosen and read the thermometer. At that time V15/LPN verified she did not check the temperature of the refrigerator today and had never been instructed to check and record the temperature. On a shelf a 5 ML (Milliliter) bottle of undated Tuberculin, Purified was opened with 1/2 of the contents missing. At that time, V15/LPN verified the undated bottle. A review of the facility Back Hall Medication Refrigerator for January, February, March, April, May and June 2024 documents missing refrigerator temperatures. On 6/13/24 at 9:41 A.M., V2/Director of Nurses verified the temperature of the medication storage refrigerator was to be checked once daily by the night shift nurse. At that time, V2/DON also verified the opened, undated Tuberculin solution and the missing temperatures for January, February, March, April, May, and June 2024. A facility Room Roster dated 6/10/24 and provided by V1/Administrator documents 28 residents currently reside on the facility Safe Unit.

Based on interview and record review the facility failed to provide snacks at bedtime for all residents. This failure has the potential to affect all facility residents. The facility policy, Snacks, undated, documents Policy: Between meal snacks are available to residents per the planned menu or resident preference. Purpose: Too offer additional nourishment between meals. Procedure: 1. The Food and Nutrition Department will send snacks to the nursing stations at the appropriated times .3. Bedtime snacks will be sent to the nursing station(s) in bulk. These snack items are to be offered to each resident. Per facility policy, acceptance or refusals of snacks are to be documented. The facility's Certified Nursing Assistant (CNA) Job Description documents Essential Duties and Responsibilities: Provide assistance with serving meals and feeding; providing fresh water an nourishment between meals. On 6/11/24, at 9:57am, the survey Group Meeting, R11, R22, and R54 agreed they are not offered any bedtime snack. During this meeting, R60 stated I don't get any at bedtime. And the nurse told me I should have a snack at bedtime. I have not seen any snacks sitting out. On 6/11/24, at 1:03pm, V6 Dietary Manager/DM stated we send out snacks (animal crackers, grahams, wafers) with drinks around 7 or 7:30pm for bedtime snacks. My kitchen staff take trays to the halls and the CNAs are to pass them out. On 6/13/24, at 9:40am, V6 DM stated the kitchen provides bedtime snacks for all of the residents. On 6/11/24, at 3:10pm, V2 Director of Nursing/DON stated the CNAs are to offer and pass the bedtime snacks. They probably document it under tasks whether or not it was accepted or refused as per policy. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Center for Medicare and Medicaid/ Services/CMS form 671), dated 6/10/24, and signed by V16 Minimum Data Set Assessment Coordinator, documents 66 residents currently reside in the facility.

Based on observation, interview and record review the facility failed to implement a cleaning procedures and schedule for the kitchen and failed to use appropriate utensils while plating lunch. This has the potential to affect 66 residents residing in the facility. Findings include: The facility's Cleaning Procedures, undated, documents that food service equipment shall be washed, rinsed, and sanitized according to standard procedures. The facility's Cleaning Instructions Ceilings and Walls, dated 2020, documents ceiling and walls will be cleaned on a regular basis. This form documents that walls will be cleaned daily using hot, soapy water to remove dirt, spatters, and food stains, or as needed. Wall will be cleaned and sanitized monthly, or as needed. Use hot, soapy water to wash, then rinse with clean, warm water. In food preparation areas, wipe down with sanitizing solution and allow to air dry. On 06/10/24 at 9:30am, each oven and steamer in the kitchen had black burnt crumbs in the floor. A brown greasy like substance ran down the doors of each oven. The ventilation hood above the cooking area had a brown greasy build up on it. The wall behind the dishwasher had brown/black streaks running down the wall. There was a black crumbly substance on the floor and wall under the dishwasher. There was a brown fuzzy substance on the covering above the dishwasher. On 6/10/24 at 11:45am, V19, Cook, washed her hands and applied gloves. V19 then grabbed a plate dished up and covered the food. V19 grabbed a dinner roll with her gloved hand. V19 repeated this process several times. V19 stated that she should have used tongs to grab the dinner rolls, not her gloved hands. On 6/10/24 at 1:00pm, V5, Dietary Manager, stated that she does not know the last time the kitchen was cleaned. V5 was unable to supply a cleaning schedule. On 6/11/24 at 11:00am, V1, Administrator, stated that the kitchen did not have a cleaning schedule in place. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 6/10/24, documents that 66 residents reside in the facility.

Facility failures resulted in two deficient practices. A.) Based on record review and interviews the facility failed to follow their policy on Water Management Program for Prevention of Legionella Growth, and perform preventative maintenance to stop the growth and spread of Legionella. This has the potential to affect all 66 residents that reside at the facility. B.) Based on observation, interview, and record review, the facility failed to place signage in a location to clearly identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment), to instruct visitors to see the nurse prior to entering the resident's room for one resident (R64) that required transmission-based precautions in a sample of 49 residents and failed to ensure Personal Protective Equipment was donned per policy, and non-contaminated supplies were safe for wound care for one residents (R32) observed for wound care in a sample of 49 residents. Findings include: A) The facility policy, Water Management Program for Prevention of Legionella Growth, revised (5/17/2024) documents the following: Purpose: To identify and reduce the risk of Legionella growth and spread. Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: 1.) The domestic hot water boiler storage tanks verified to be set between 140-160 degrees Fahrenheit. 2.) Thermostat indicating the temperature of water entering the circulating system at the mixing valve is at 120 Fahrenheit or above. 3.) Eye wash stations will be inspected and flushed weekly. 4.) Ice machines will be inspected and cleaned internally at least every 3 -6 months and as needed for leakages or contamination. 5.) Cooling tower (if applicable) will be inspected at least weekly to ensure proper functioning and chemical distribution. 6.) Weekly sanitizing of medical devices such as CPAP (continuous positive airway pressure). The facility was unable to provide a flow diagram of the buildings water system. On 6/12/2024 at 8:45AM V10 (Maintenance Director) stated, I do not have any other information to show that I have been doing any of the preventative maintenance protocols, according to the policy. I just started the eye wash weekly inspection on 5/29/2024. I have not done any temperatures for the water boiler or temperatures of the water entering the circulating system at the mixing valve. The ice machine should be inspected and cleaned every 3-6 months, but that has not been done. I am pretty sure that the weekly sanitizing of medical devices has not been done either. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 6/10/24, documents that 66 residents reside in the facility. B.) 1. R64's Physician Order Sheet, dated 6/1/24 through 6/30/24, documents Foley catheter 16 French with 10CC (centimeter) to drainage and gravity for a diagnosis of urine retention. And Enhanced Barrier Precautions- for an indwelling foley catheter every day and night shift. On 6/10/2024 at 1:30P.M., R64's entry door lacked signage to identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment) and instructions to see the nurse prior to entering the resident's room. The Isolation Room Set Up policy, revised 5/30/14, documents It is the policy of this facility to set up isolation precautions. Procedure: 7. Place sign on door to resident's room for visitors to inquire at nurse's desk prior to entering room. On 6/13/2024 at 1:55 PM V1/Administrator stated, Yes, there needs to be signage on the door when Enhanced Barrier Precautions are in use. The sign was on the wrong door. It is fixed now. B) 2. The Dressing Change (Clean/Non-Sterile) policy, reviewed 1/9/18, documents 2. Prepare a clean, dry work area at bedside. 3. Bring supplies into resident's room. Individual resident supplies may be placed on the over bed table after it has been disinfected and/or a protective barrier placed on the table. 7. Prepare/open any necessary supplies and place on top of clean barrier. 17. In the event more than one wound is present, each wound site is considered a separate treatment. A new pair of non-sterile gloves will be used for the cleaning of each site. The Enhanced Barrier Precautions policy, effective 4/3/24, documents Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The Donning & Doffing PPE (Personal Protective Equipment) guidance, no date, documents 3. Put on isolation gown. Tie all of the ties on the gown. On 5/1/24, a Physician ordered Enhanced Barrier Precautions (chronic wound, indwelling catheter) every day and night related to multi-resistant organisms in the urine. On 5/10/24, a Physician ordered wound care for the sacral wound and for the right buttock wound. 06/11/24 at 1:10 PM, an open box of latex gloves was observed to be opened and lying open side down on the floor in R32's room. V6 (Certified Nurse Aide/CNA) was observed to be providing cares for R32 without having the Personal Protective Gown fully donned and ties were not tied. On 6/11/24 at 1:17 PM, V8 (Licensed Practical Nurse) was observed to pick the box of gloves up off the floor, placed the box of gloves on the clean surface with the dressing change supplies, donned the gloves from the opened box that had been on the floor and conducted wound care on R32.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to conduct a quarterly care plan meeting since admission for one of 6 (R1) residents reviewed for care plans in a sample of 6. Findings Include: The facility policy named, Comprehensive care plan, dated 11/17/2017, documents, The resident and/or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone, or video conference (if available) at least quarterly. R1's Nurses Notes, documents R1 was admitted on [DATE]. R1's Minimum Data Set progress note, dated 5/19/2023, documents, R1's invite to a care plan meeting. On 10/13/2023 at 2:20PM V6/Care Plan Coordinator stated, I have been in this role since March of this year. I did invite V9/R1's daughter to the care plan meeting for R1 on 5/19/2023 for the yearly review. I did not send out an invite for R1's quarterly review in August. I do not know why I did not send a care plan invite for August to have the quarterly care plan prior to March of this year, I could not find any records to show care plans were being done and R1 and family was invited. On 10/13/2023 at 11:45AM V1/Administrator stated, There was Covid-19 in the facility last year, that could be one reason R1's care plans were not done. V6/Care plan Coordinator could not find any other documents besides the 6/18/2022 invite and the 5/19/2023 invite to show R1 had the quarterly care plans.

Based on interview and record review the facility failed to administer medications safely for one of three residents reviewed (R3), in a sample of six. This failure resulted in R3 ingesting R2's medications. FINDINGS INCLUDE: The undated facility policy, Medication Administration General Guidelines, directs staff, medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Five Rights- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc ) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med (medication) pass or for more than one resident. R2's current Physician Order Sheet, dated October 2023 includes the following medications: Aspirin (blood thinner) 81 MG (milligrams) one tablet in the morning; Clopidogrel (antiplatelet)75 MG one tablet in the morning; Ergocalciferol (dietary supplement) 50000 Units one capsule in the morning; Furosemide (diuretic) 40 MG one tablet in the morning; Iron (dietary supplement) 325 MG one tablet in the morning; Isosorbide Monoltrate ER (extended release) (nitrate) 30 MG one tablet in the morning; Jardiance (sodium-glucose co-transporter) 10 MG one tablet in the morning; Pantoprazole (proton pump inhibitor) 40 MG one tablet in the morning; Vitamin D2 (supplement) 50 MCG (micrograms) one tablet in the morning; Carvedilol (beta blocker) 12.5 MG one tablet twice daily; Eliquis (Factor Xa inhibitor) 5 MG one tablet in the morning; Metformin (oral anti-diabetic) 1000 MG one tablet twice daily. On 10/13/23 at 8:10 A.M., R2 was sitting in bed, writing a note. R3 was seated in a wheelchair, next to R2's bed. R2 and R3 were alert, oriented and talkative. R2 and R3 were able to recall the incident of 10/5/23. At that time, R2 stated, It was approximately 8:00 AM, when the nurse (V4/RN) placed two small plastic medication cups, both full of pills, on the table in front of us (R2 and R3). (R3) reached over, grabbed a medication cup and swallowed the pills. When I went to swallow my pills, I realized (R3)'s name was on the cup and refused to take the medications. V4/RN was standing at the table during this time but didn't stop (R3) from taking (my) pills. On 10/13/23 at 9:51 A.M., V4/Registered Nurse stated, I was working the morning of 10/5/23. It was about 8:00 A.M. (R2) and (R3) were seated at the same dining room table, eating their breakfast. I had put all of (R2)'s medications and (R3)'s medications in separate, small, plastic med (medication) cups, took them to their table and set them down. As I was placing cups of water on the table, (R3) reached over and took (R2)'s medications. I called (R3)'s doctor and he told me to hold (R3)'s blood pressure medications and monitor (R3)'s blood pressure hourly. I shouldn't have tried to give (R2 and R3) medicine at the same time. The (facility) Medication Error Form, completed by V4/Registered Nurse, dated 10/5/23 documents, Incident occurring on 10/5/23 at 8:00 A.M. (R3) at dining room table and (R2)'s meds (medications) were sat down. While (V4/RN) was sitting down water and arranging things, (R3) grabbed meds (medications) and took them. (R3)'s MD (Medical Doctor) notified and (R3)'s blood pressure pills held. (Physician order) to monitor blood pressure hourly. (R3) is alert and oriented to person, place, time and situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate an allegation of a potential misappropriation of resident property for one (R9) of three residents reviewed for criminal activity in a sample of three. Findings include: The facility's Abuse Prevention and Reporting - Illinois policy, revised 10/24/22, documents Internal Reporting Requirements and Identification of Allegations: Supervisors shall immediately inform the administrator of person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. R9's current clinical record, documents R9 as moderately cognitively impaired with diagnoses including Unspecified Dementia, moderate, with Agitation. R9's Criminal History Record, dated 1/16/23, documents R9 is a Registered Identified Sex Offender and was convicted for indecent liberty of a child in 1979 and 1980. On 9/19/23, at 12:03pm, R9 was lying in bed with a personal computer located on a desk against the wall across from the entrance to R9's room. At this time R9 stated he does use the WIFI for Internet on his personal computer and that there's porn on there, but you don't have to stay on it. You can skip on by it, ya know? On 9/19/23, at 2:27pm, V1 stated the following: A nurse (V9 Registered Nurse/RN) called me a week ago and said (V21 Certified Nursing Assistant/CNA) reported to (V9) that (V21) suspected (R9) was on a porn site. I asked (V9) if she saw it and (V9) did not. I did not talk to (V21 CNA). At this time, V1 denied doing any investigation for this allegation and was unable to provide any investigation documents. On 9/19/23, at 2:57pm, V21 CNA, stated that V21 walked into R9's room where loud music was playing and saw R9 on his computer viewing young Chinese girls aged 10 to [AGE] years old whose dresses were blowing up exposing their underwear. Each time they put a microphone up to their mouths their dress would fly up. What got me was the phone numbers going across the back. V21 stated she reported this to V9 Registered Nurse/RN but is not sure if anything was done. V21 stated that no one from the facility has asked her anything about this occurrence. On 9/19/23, at 3:32pm, V9 RN stated the following: (V21 CNA) told me that (R9) was watching young girls on porn called 'Chinese Virgins'. I didn't see it. V9 continued to state that (V21) said the Chinese girls looked young but (V21) didn't give me an age. (V21) said the computer screen was flashing Chinese Virgins, across the screen. (V21) wasn't explicit in detail, but said it was porn. I reported it to (V1) and have not heard any feedback since.

Based on observation, interview, and record review the facility failed to develop interventions to address wandering on resident Care Plans for two (R1 and R2) of three reviewed for care plans. Findings include: 1. On 9/14/23, between 9:30am and 10:00am, R2 independently ambulated around the locked unit. R2's current Physician Order Sheet/POS documents R2 has diagnoses including Dementia. R2's Minimum Data Set/MDS assessment, dated 8/29/23, documents R2 is severely cognitively impaired. On 9/14/23, at 10:20am, V5 and V6 Certified Nursing Assistants/CNAs identified R2 as one of the wandering residents in the locked unit. R2's current Care Plan does not include any focus or interventions for wandering. On 9/14/23, at 3:37pm, V13 Social Service Director confirmed R1 and R2 are wandering residents who should have had wandering addressed on their care plans. 2) Current Physician order Summary Report indicates R1 has diagnoses that include Unspecified Dementia, Alzheimer's Dementia with Early Onset and Severe Dementia in other diseases with behavioral disturbance. Current Comprehensive Assessment indicates R1 was identified as having wandering behaviors, occurring daily, and intruding on the privacy of others. On 9/14/23 at 10:20am V5 and V6, CNA's identified R1 as a wanderer with behavior of wandering into to other resident rooms and getting into their beds. V5 stated that R1 is difficult to redirect at times and will shake her fist at staff. Progress Note dated 6/26/23 at 10:12am indicates R1 has chronic wandering behaviors. Progress Note dated 6/27/23 at 8:20am indicates During morning medication pass, (R1) observed laying in another resident bed under the covers watching television. Progress Note dated 7/7/23 at 7:04pm indicates (R1) observed in another residents room sleeping on bed. Note indicates staff are following care plan. Current Care Plan indicates only Behavior Management as focus area. Care Plan does not identify wandering as a target behavior and does not identify interventions to address R1's wandering into other residents' rooms and getting into other resident's beds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete Elopement Risk assessment, failed to include two residents identified as at risk for Elopement in the Elopement Risk Protocol and in the facility's Elopement risk binder for two residents (R1 and R2) Findings include: The facility's Identification of Elopement Risk policy, undated, documents Policy Statement: To identify residents that are at risk for elopement. Policy Interpretation and Implementation: 1. Residents will be evaluated for elopement risk on admission and quarterly. 2. The resident's service plan will be modified to indicate the resident is at risk for elopement episodes, if applicable. 3. Interventions to prevent elopement will be entered into the resident's service plan. 1. On 9/14/23, between 9:30am and 9:40am, R2 independently ambulated around the locked unit and then hovered around the exit door of the locked unit. R2's current Physician Order Sheet/POS documents R2 has diagnoses including Dementia. R2's Minimum Data Set/MDS assessment, dated 8/29/23, documents R2 is severely cognitively impaired. R2's Elopement Risk & Community Survival Skill Assessment, dated 8/25/23 and signed by V14 Social Service Director/SSD, is incomplete. The facility's Elopement binder, located at the nurse's station, does not include R2 on the list of residents identified as Elopement risk. On 9/14/23, at 3:37pm, V13 SSD stated V14 did not complete R2's elopement risk assessment even after receiving further information including R2's diagnosis of Dementia. R2 confirmed that R2 should have been placed on the Elopement Risk Protocol and on the list of residents at risk for elopement in the elopement binder. 2) Current Physician Order Summary Report indicates R1 has diagnoses that include Unspecified Dementia, Alzheimer's Dementia with Early Onset and Severe Dementia in other diseases with Behavioral Disturbance. Current Comprehensive Assessment indicates R1 was identified as having wandering behaviors, occurring daily, and intruding on the privacy of others. Current Social Service Elopement Risk and Community Survival Skills assessment dated [DATE] indicates R1 is at risk to elope and should be placed on the Elopement Risk Protocol and Care Plan for Elopement is indicated. Current Care Plan indicates only Behavior Management as focus area. Care Plan does not identify R1 as an elopement risk and does not identify interventions to address R1's risk of elopement. List of residents identified as Elopement Risk included in the Elopement binder at the nurse's station does not include R1. On 9/14/23 at 3:37pm V13, Social Service Director stated R1 should have been included in the Elopement Risk Protocol including being identified on the list of residents identified as Elopement risks and a care plan should have been developed to address managing and monitoring R1's Elopement Risk.

Based on observation, interview, and record review, the facility failed to ensure resident trust funds were accurate, monies due to residents were credited in a timely manner, and safeguards were in place for managing resident funds for two residents (R3 and R4) of six residents reviewed for resident trust funds in a sample of six. Findings include: The facility's Resident Funds policy, revised 4-29-19, documents Guidelines: This facility manages the personal funds of residents when such request is made by the resident. Resident funds may be managed by any of the following: d. The resident may choose to have the facility hold, safeguard, and manage his/her personal funds. This policy also states 4. Resident funds are deposited into an interest-bearing resident trust fund account which is different from the facility's banking account. And 6. Inquiries concerning the facilities management of resident funds should be referred to the administrator or the business office. 1. R3's Minimum Data Set/MDS assessment, dated 6-4-23, documents R3 is cognitively intact. On 8-23-23, at 11:15am R3 is lying in bed watching television. R3 confirmed that the facility manages R3's funds and R3's stay here is paid out of R3's Social Security money. R3 continued to state the following: Sometime last year $600 was taken from R3's account and never replaced. R3 stated that R3 spoke to the finance person many times about it. R3 was told it was for rent, but rent was already paid. R3 received letters from R3's bank saying R3 was overdrawn. R3 stated I never got any answers or the money back. R3's resident trust fund statements, dated 8-23-23, document that R3's room and board was paid for twice in September 2022. On 9-2-22 there was a Care cost automatic withdrawal for $609.64. On 9-8-22 there was a bank debit of $609.64 into R3's trust fund followed by a payment in the same amount made for R3's room and board. This same statement documents that $609.64 was refunded to R3's trust fund on 10-25-22. R3's resident trust fund statements, dated 8-23-23, document that R3's room and board was paid for twice in May 2023. On 5-3-23 there was a Care cost automatic withdrawal for $682.64. On 5-15-23 there was a bank debit of $682.64 into R3's trust fund followed by a payment in the same amount made for R3's room and board. On 5-19-23 R3 incurred a $53.00 fee for lack of funds. These same statements do not document any refund of $682.64 or $53 for the fee. On 8-23-23, at 1:15pm, V2 Regional Financial Coordinator stated the following: On 9-8-22 there was an auto withdrawal of $609.64 for R3's room and board. On 9-8-22 an auto payment of $609.64 was debited from R3's bank to R3's trust account by V5 the previous Business Office Manager/BOM. R3's $609.64 was refunded back on 10-25-22 to R3's trust account. (V4 Business Office Manager/BOM) should not have put in a debit. It happened again on 5-15-23 with V4 BOM for $682.64. R3's bank returned the money because R3 didn't have enough to cover that one. On 7-17-23 a refund was put into R3's trust fund account for $682.64, but then it was debited back out on 8-11-23 and shouldn't have been. It looks like V7 Corporate Bookkeeper had put it in as PL 5/2023 which means patient liability. We need to refund that amount ($682.64) plus the $53.00 fee that R3 incurred and should not have to pay. On 8-24-23, at 1:20pm, V2 stated As soon as we find out it should be refunded. V2 also stated that per an email V2 received today, check #16 for R3 in the amount of $682.64 was dated 7-26-23, but never deposited into R3's account. It was re-issued and deposited today. 2. R4's Minimum Data Set/MDS assessment, dated 7-7-23, documents R4 is cognitively intact. On 8-23-23, at 11:19am, R4 sat in R4's room. R4 confirmed that the facility manages R4's money. R4 denied any concerns or issues with R4's trust fund account. R4's resident trust fund statements, dated 8-23-23, document that R4's room and board was paid for twice in September 2022. On 9-2-22 there was a Care cost automatic withdrawal of $968.64 for R4's room and board. On 9-8-22 there was a bank debit of $968.64 into R4's trust fund followed by another payment, in the same amount, made for R3's room and board. On 9-15-22 there was a fee of $53.00 for lack of funds. This same statement documents that $968.64 was refunded to R3's trust fund on 10-25-22; there is no documentation of R4's $53.00 fee being refunded. On 8-23-23, at 2:56pm, V2 Regional Financial Coordinator stated the following: We started R4's Social Security money as direct deposit on 5-3-22. On the same date (9-22-22) as what occurred with (R3), V5 previous Business Office Manager/BOM did a direct debit. On 10-25-22 it was refunded back to R4. We owe R4 the $53.00 from the fee R4 incurred on 9-15-22. On 8-23-23, at 2:15pm, V2 stated there are no safeguards in place for what happened here. The debits should not have been done. V2 didn't get notified and doesn't know why. On 8-24-23, at 2:05pm, V1 Administrator stated that it is concerning to V1 that there is no system in place to check for double or over payments. If no one is checking, then it can't be paid back timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R59's current Care Plan documents I am a smoker. R59's current Smoking Safety Risk Assessment, dated 3/29/23, documents that R59 was admitted to the facility on [DATE] and that R59 does not currently smoke. During the survey dates of 6/27/23 through 6/29/23, R59 was not observed smoking during the Facility Smoking Breaks. On 6/29/23 at 9:13 am, V1 (Administrator/ADM) stated, (R59) has not smoked since he has been here. He cannot even get out of bed on his own, let alone smoke, and he is now on Hospice. Based on interview and record review, the facility failed to revise resident care plans for two of 20 residents (R19 and R59) reviewed for care plans in the sample of 33. Findings include: The facility's Comprehensive Care Plan Policy, revised 11/17/17, states, Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. This same policy documents that comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment. The facility's Fall/Incident Occurrence-Assessment and Documentation Guidelines, revised 1/4/16, documents after a resident fall, preventative measures are to be implemented and the resident's service plan is to be updated as indicated. The facility's Fall Prevention Program, revised 11/21/17, documents that resident Care Plans incorporate the following: each resident fall; interventions changed with each fall and preventative measures. 1. R19's Witnessed Fall Report, dated 4/13/23, states, (R19) was ambulating with therapy and fell. (R19) was sent out to the ER (Emergency Room) for an evaluation for a hematoma to the right side of her forehead and returned to the facility. Root cause is weakness. Discussed with IDT (Interdisciplinary Team) and the intervention is to allow (R19) to sit down in the wheelchair when she needs to rest. Plan of care reviewed and updated. R19's current Care Plan documents R19 is at risk for falls and that R19 had an actual fall on 4/13/23. As of 6/27/23, R19's current Care Plan did not document a new fall prevention intervention after R19's 4/13/23 fall. 2. R19's current Face sheet documents R19 with a diagnosis of Schizoaffective Disorder. R19's current Care Plan states, I use antipsychotic medications r/t (related to) Schizophrenia with an initiation date of 3/2/21. R19's Discontinue Order sheet documents an order for Olanzapine (Antipsychotic) 2.5 milligram tablet at bedtime related to Schizoaffective Disorder to be discontinued on 11/25/22. This same sheet documents the Olanzapine order was discontinued related to a Gradual Dose Reduction/GDR. R19's Psychiatry Note, dated 5/26/23, documents R19's Olanzapine medication was discontinued on 11/25/22. As of 6/30/23, R19's current Physician Order Sheet did not document any orders for an Antipsychotic Medication. On 6/29/23 at 11:56 AM, V1 (Administrator) verified that R19 is not currently on any antipsychotic medications and verified that R19's 4/13/23 fall intervention was not added to R19's Care Plan prior to 6/28/23 and should have been. On 6/29/23 at 1:10 PM, V3 (Assistant Director of Nursing) stated that R19's antipsychotic medication was discontinued on 11/25/22. V3 stated the medication should have been removed from R19's Care Plan but was not.

Based on observation, interview, and record review the Facility failed to perform hand hygiene and follow a Physician order during skin care for one (R26) of three Residents reviewed for skin care in a sample of 33. Findings include: Facility Dressing Change/Clean/Non-Sterile Policy, revised 1/9/18, documents: 10. remove soiled dressing and place in plastic trash bag; 11. remove soiled gloves and place in plastic trash bag; 12. wash hands, or if hand are not visibly soiled, alcohol based hand gel may be used to decontaminate the hands; 13. apply clean gloves; 16. apply prescribed ointment and/or dressing per doctor order; and secure dressing in place if needed. R26's Wound Physician's Evaluation & Management Summary, dated 6/28/23, documents a Venous Wound on R26's Right Shin (lower leg). The wound size is 5.5 centimeter/cm by 5.0 cm by 0.1 cm, with a surface area of 27.5 cm, with moderate serous exudate/drainage. R26's treatment order documents on order for medicated ointments (Leptospermum Honey and Alginate Calcium) and a Dry Dressing (Gauze Island with border) to be applied once daily for 30 days. On 6/28/23, at 11:49am, V7 (Registered Nurse) applied gloves, without hand hygiene, removed R26's soiled dressing and applied the medicated ointments (Leptospermum Honey and Alginate Calcium) to R26's Right Shin). V7 then proceeded to apply the Dry Dressing (Gauze Island with border) as V7 was disposing of the new dressing wrappers into the trash receptacle, V7's writing instrument (Magic Marker) fell into the trash receptacle. V7 then picked the writing instrument out of the trash receptacle and put it into V7's clothing pocket, then proceeded to apply the clean dressing. The Dry Dressing was not adhered and did not cover the entire venous wound and the medicated gauze dressing was exposed and not fully covered. V7 did not perform hand hygiene prior to applying gloves for the dressing change or change gloves after removing the contaminated soiled dressing. On 6/28/23, at 11:55am, V7 (Registered Nurse) stated, I am sorry, I just get so nervous, I should have changed my gloves and washed my hands. I should not have picked that marker up out of the trash can either.

Based on interview and record review the facility failed to promptly act upon recommendations of the resident council group residents and failed to demonstrate the facility response to group recommendations for six residents (R10, R15, R38, R45, R56, R123) in the sample of 33. Findings include: Facility Dietary Manager Essential duties and Responsibilities dated 3/23/17 documents: Review departmental complaints and grievances from personnel and make written reports to the Dietician and/or Administrator of action(s) taken. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. All six residents stated food served at mealtimes is not hot when served, meals were not served on time - frequently served 30 minutes to 1 hour late (from the posted mealtimes), they were unaware of the facility grievance procedure and had requested short activity trips outside of the facility. R10 and R15 stated that V10, Activity Director, is the staff member who arranges and attends the Resident Council monthly meetings. During the group meeting, R15 stated they told V10, Activity Director a couple months ago they would like to have bus rides/activity trips out of the facility and never heard any response. R10 stated he has not been out of the facility in two years. On 6/27/23 at 2:40pm V11, Activity Aide stated she was told by R10, R15 and R38 that they would like to go on bus rides. V11 stated she reported the resident requests to V10 and the response from V10 was the bus is busy during the week and there's no one to drive the bus on weekends so there's no way to take residents for offsite trips. Five of six residents (R15, R38, R45, R56, R123) stated they were not offered bedtime snacks and didn't know where they were located or what was available. Resident Council Meeting Minutes dated 5/25/23 at 2pm indicates Meals are served late, some foods are hard to eat, and more shade is needed on the patio. Resident Council Meeting Minutes dated 4/27/23 at 2pm indicates Bread is dry on sandwiches and food isn't very hot. Resident Council Meeting Minutes dated 1/26/23 at 2pm indicates Old Business: Food not hot On 6/28/23 at 12:25pm V12, Dietary Manager stated she did not recall being told about any of the Resident Council group concerns by V10, Activity Director and she should be told if there are any dietary/kitchen concerns. On 6/29/23 at 11:45am V10 stated I just verbally tell the resident group concerns to the staff. I don't document the response or interventions. V10 stated she was aware the residents had requested bus trips I just need to reserve the van calendar a month in advance if we want to use the bus for activity trips. V10 could not provide a reason why she had not been scheduling the activity van trips.

Based on observation, interview, and record review the facility failed to ensure all residents were informed regarding the facility Grievance process. This failure has the potential to affect all 66 residents who reside in the facility. Findings include: Facility Policy/Grievances dated/revised 9/25/17 documents: The resident has the right to voice grievances to this facility or other agency or entity that hears grievances. An Appointed Grievance Official is responsible for overseeing the grievance process. Resident Census and Conditions Report dated 6/27/23 indicates 66 residents in the facility on that date. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. All six residents stated they were unaware of the facility grievance procedure. R10 and R15 stated that V10, Activity Director, is the staff member who arranges and attends the Resident Council monthly meetings. On 6/29/23 at 11:40am V5, SSD (Social Service Director) stated she was the Grievance official and was unsure how the residents get information about the grievance process other than when they are told during admission. V5 stated she was also unaware of any posted Grievance procedure. No posted Grievance process/procedure was found throughout the facility and was confirmed as not posted by V1, Administrator on 6/29/23.

Based on observation, interview, and record review the Facility failed to staff a Certified Dietary Manager. This failure has the potential to affect all 66 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Position Title (Dietary Manager), created 3/23/17, documents: the Dietary Manager is responsible for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current Federal, State and Local standards, guidelines and regulations governing our facility; review the departments procedure manuals and job descriptions, at least annually; and must possess a Food Service Sanitation Manager Certification. V12's (Dietary Manager) Certificate of Completion for Food Service Sanitation Manager Certification, dated 1/8/22, documents that V12 completed the online training. The Certificate of Completion also documents that This is not the Food Service Sanitation Manager Certificate. V12 stated your Food Manager Exam must be scheduled separately, and your official certificate will be issued by the Illinois Department of Public Health or the Chicago Department of Public Health upon passing the exam. On 6/29/23 at 11:28am, V12 stated, I took the Food Service course over a year ago, but I never took the exam. I am not sure why I did not take the exam. On 6/29/23, at 1:00pm, V1 (Administrator) reviewed V12's Certificate of Completion for Food Service Sanitation Manager Certification, dated 1/8/22, and stated, I never noticed that (V12) did not take the Food Manager Exam.

Based on observation, interview, and record review the facility failed to serve meals at the scheduled mealtime. This failure has the potential to affect all 66 Residents residing in the facility. The facility also failed to provide bedtime snacks for five residents (R10, R15, R38, R45, R56) of six residents reviewed for bedtime snacks in the sample of 33. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Mealtimes, undated, documents Facility meal times of 7:00 am, 11:00 am and 5:00 pm. Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot. Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot. Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late. On 6/28/23, at 11:00am through 11:29am, all residents in the [NAME] Side dining room did not have a meal tray. The Facility meal cart was delivered on 6/28/23 at 11:29am and passing of the meal trays began at 11:30am. On 6/29/23, at 11:00am through 11:28am, all residents in the East Dining Room did not have a meal tray. On 6/29/23, at 11:00am through 11:41am, all Residents in the [NAME] Dining Room did not have a meal tray. The East Dining Room meal cart was delivered to the East Dining Room at 11:28am and the [NAME] Hall Dining Room meal cart was delivered at 11:41am. On 6/28/23, at 10:00am, during the Resident Council Meeting, R10, R15, R28, R45, R56 and R123 verified that mealtimes are not served as posted and that meals are served a half-hour to an hour late, also making the food cold. On 6/28/23, at 12:18pm, V12 (Dietary Manager) stated, We do not start serving the main dining rooms until after we serve our Dementia Unit. Our scheduled lunch mealtime is 11:00 am, but we do not usually get the carts out until close to 11:30 am. On 6/29/23, at 11:50am, V12 (Dietary Manager) stated, I had a staffing issue today, so that is why the lunch meal was late. 2) Facility Policy/Snacks and House Supplements: House snacks provide additional calories and meet a resident's individualized nutritional and care plan needs. HS (bedtime) snacks should provide a minimum of a starch or bread serving and fruit drink. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. Four residents (R15, R38, R45, R56) stated they were unaware there were bedtime snacks available, did not know what snacks were supposed to be provided and were not offered bedtime snacks at any time in the evening. R10 stated sometimes staff offered snacks at night, but not always. On 6/28/23 at 12:25pm V12, Dietary Manager stated bowls of graham crackers and other crackers are placed at the nurse's station every night usually between 7 and 7:30pm. V12 stated she doesn't know what happens to them after the bowls are at the nurses station. V12 stated They should be offered to the residents.'

Based on observation, interview, and record review the facility failed to maintain required safe serving/holding food temperatures for Resident meals. This failure has the potential to affect all 66 Residents residing in the facility. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Serving Temperatures for Hot and Cold Foods Policy, dated 2020, documents: food will be served at the following temperatures to ensure a safe and appetizing dining experience; and required meat and vegetable temperatures of 135 degrees Fahrenheit to 170 degrees Fahrenheit. Facility Mealtimes, undated, documents Facility mealtimes of 7:00am, 11:00am and 5:00pm. Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot. Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot. Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late. On 6/27/23, at 11:40am, the meatloaf temperature was 102 degrees (Fahrenheit) and the sliced carrots were 120 degrees (Fahrenheit). On 6/28/23, at 10:00am, during the Resident Council Meeting, R10, R15, R28, R45, R56 and R123 verified that mealtimes are not served as posted and that meals are served a half-hour to an hour late and are often cold. On 6/28/23, at 12:18pm, V12 (Dietary Manager) stated, I do not know why the meatloaf and carrots were that cold, I did not even notice the low temperature. I know we have had prior complaints about the cold food temperature.

Based on interview and record review the facility failed to recognize an allegation of possible neglect for one resident (R4) of four residents reviewed for abuse. Findings Include: The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 defines neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish (42 CFR 483.5) Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident (20 1 ILCS 45/1-117) including deprivation of goods and services by staff. Neglect may be the result of a pattern of failures or the result of one or more failures involving one resident and one staff person. On 6/15/23 at 9:00 AM R4 stated On Tuesday 6/6/23 I asked (V10/CNA) to change my brief. (V10) stated there is no reason for you to not be able to make it to the bathroom, so I am not going to be changing someone who just sits and messes themselves. I felt humiliated, I cannot help it. I can transfer myself to the toilet, but sometimes when I get there, I have already been incontinent, and I want to make sure that I get clean. Ever since last Tuesday, (V10) just ignores me, he literally behaves as if I don't exist. If my call light is on, he comes in here and chats all friendly with my roommate and helps him with whatever but never asks me what I need and then he leaves. A couple of days ago, he did not tell me that the lunch trays were here so by the time I got up and got to the table my lunch was cold. I don't know why (V10) hates me; I don't want him to take care of me anymore. I have talked to the nurses and CNAs about it, it doesn't help. He was assigned to my hallway last night (6/14/23) which means I couldn't ask for anything. I feel so alone and isolated when he is here. On 6/15/23 at 9:05 AM V8 (CNA) confirmed that R4 had told her his concerns regarding V10. V8 stated (R4) always complains about someone, (V10) would never ignore a resident. I told (V7/Social Services Director) about it. On 6/15/23 at 9:10 AM V7 (Social Service Director) stated that (V8/CNA) had told her that (R4) complained that (V10) would not help him when requested. V7 stated I wanted to get a little more background on (R4) first, it sounds like he complains all the time. V7 stated (V10/CNA) has worked here for years, I doubt he would do something like that. On 6/15/23 at 9:30 AM V2 (Director of Nursing) stated Yes, I spoke with (V10/CNA) last night (6/14/23) at the beginning of his shift, (V10) asked me if he had to change (R4) because he felt that (R4) could do it himself. I told him yes that whether or not he feels like the resident can do more, if the resident requests assistance (V10) was required to give it. On 6/15/23 at 9:45 AM V1 (Administrator) stated (V2/Director of Nursing) told me that she spoke with (V10/CNA) because (V10) felt that (R4) could assist himself more than he does, and I told her I agreed with her that (R4) should be changed anytime he asks. No one used the word neglect though, so I didn't really think about that being abuse.

Based on record review and interview the facility failed to protect one resident (R4) after a complaint of neglect of four residents reviewed for abuse. This failure caused R4 stress, anxiety and feelings of isolation. Findings Include: The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 defines neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish (42 CFR 483.5) Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident (20 1 ILCS 45/1-117) including deprivation of goods and services by staff. Neglect may be the result of a pattern of failures or the result of one or more failures involving one resident and one staff person. The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 documents The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated. On 6/15/23 at 9:00 AM R4 stated On Tuesday 6/6/23 I asked (V10/CNA) to change my brief. (V10) said there is no reason for you to not be able to make it to the bathroom, so I am not going to be changing someone who just sits and messes themselves. I felt humiliated, I cannot help it. I can transfer myself to the toilet, but sometimes when I get there, I have already been incontinent, and I want to make sure that I get clean. Ever since last Tuesday, (V10) just ignores me, he literally behaves as if I don't exist. If my call light is on, he comes in here and chats all friendly with my roommate and helps him with whatever but never asks me what I need and then he leaves. A couple of days ago, he did not tell me that the lunch trays were here so by the time I got up and got to the table my lunch was cold. I don't know why (V10) hates me; I don't want him to take care of me anymore. I have talked to the nurses and CNAs about it, it doesn't help. He was assigned to my hallway last night (6/14/23) which means I couldn't ask for anything. I feel so alone and isolated when he is here. On 6/15/23 at 9:05 AM V8 (CNA) confirmed that R4 had told her his concerns regarding V10. V8 stated (R4) always complains about someone, (V10) would never ignore a resident. I told (V7/Social Services Director) about it. On 6/15/23 at 9:10 AM V7 (Social Service Director) stated that (V8/CNA) told her that (R4) complained that (V10) would not help him when requested. V7 stated I wanted to get a little more background on (R4) first, it sounds like he complains all the time. V7 (V10/CNA) has worked here for years, I doubt he would do something like that. V7 confirmed that V10 (CNA) worked on 6/14/23 and was assigned to R4. On 6/15/23 at 9:30 AM V2 (Director of Nursing) stated Yes, I spoke with (V10/CNA) last night (6/14/23) at the beginning of his shift, (V10) asked me if he had to change (R4) because he felt that (R4) could do it himself. I told him yes that whether or not he feels like the resident can do more, if the resident requests assistance (V10) was required to give it. V2 confirmed that V10 (CNA) worked on 6/14/23 and was assigned to R4 On 6/15/23 at 9:45 AM V1 (Administrator) stated (V2/Director of Nursing) told me that she spoke with (V10/CNA) because (V10) felt that (R4) could assist himself more than he does, and I told her I agreed with her that (R4) should be changed anytime he asks. No one used the word neglect though, so I didn't really think about that being abuse. V1 confirmed that V10 (CNA) worked on 6/14/23 and was assigned to R4.

Based on interview and record review the facility failed to record an inventory of resident's belongings for four residents (R1, R2, R3, and R4) of four residents reviewed for inventory of belongings and failed to answer call lights in a timely manner. This failure has the potential to affect all 68 residents who currently reside in the facility. Findings Include: The Facility's Call Light policy dated 11/28/12 documents the purpose of the policy is to respond to residents' requests and needs in a timely and courteous manner. All staff should assist in answering call lights. The Resident Council Meeting Minutes dated 12/29/23 documents Nursing: Sometimes have to wait for lights to be answered. The Resident Council Meeting Minutes dated 1/26/23 documents Nursing: Some feel it takes too long to answer lights. The Resident Council Meeting Minutes dated 3/30/23 documents Nursing: Slow answering lights. On 6/14/23 at 11:00 AM R2 stated Call lights usually take about 30 minutes, that is the norm. If it is a bad night, we can wait 1 1/2 to 2 hours to get our call light answered. On 6/15/23 at 9:00 AM R4 stated It just depends, usually it is around 30 minutes. It can be a couple of hours though. On 6/15/23 at 11:30 AM R5 stated Call lights are always going off. People will walk right by. I usually wait 15-20 minutes then I go looking for someone if I need something, it's quicker. On 6/14/23 V4 (Activity Director) stated I don't keep attendance or track any of the complaints that are brought up in Resident Council Meetings, I tell the appropriate Department Head and assume that the problem is going to be dealt with. I do realize that there are repeat complaints about call lights and dietary issues, I did not follow up with anyone to check if these concerns were being addressed. The Resident Roster dated 6/14/23 lists 68 residents that currently reside in the facility. 2. The Facility's undated Belongings policy documents Resident belongings will be recorded upon admission and whenever brought in. Belongings will be verified upon transfer or discharge. On 6/15/23 V9 (Laundry Supervisor) stated (V11/R1's family member) has provided me a list of missing clothing items with pictures and I am currently searching for missing items. We do not have an admission inventory list so I have no idea if all of these clothes were actually here, I don't remember seeing some of them, but (V11) does (R1)'s laundry so it may just be that I haven't seen them. None of these clothes are in the laundry department or in any other resident's rooms. I have checked. R1's Medical Record does not include a record or list of items brought in upon admission. On 6/14/23 at 11:00 AM R2 stated Laundry is a mess around here, things go missing for weeks. They eventually show back up. R2's Medical Record does not include a record or list of items brought in upon admission. On 6/14/23 at 11:30 AM R3 stated I watch my clothes very carefully because the laundry department does not pay attention. I don't let them leave stuff in here that is not mine. R3's Medical Record does not include a record or list of items brought in upon admission. On 6/15/23 at 9:15 AM R4 stated I stay on them (staff) about my stuff. The laundry department is a joke. It is like a black hole; stuff goes in but never comes back out. I think I have everything now, I keep track. R4's Medical Record does not include a record or list of items brought in upon admission. On 6/15/23 at 12:00 PM V1 (Administrator) stated Every resident should have an inventory done by the admitting staff and it should be updated when the resident or the family brings in anything else.

Based on record review and interview the facility failed to address personal grievances and concerns voiced at monthly resident council meeting minutes. This failure has the ability to affect all 68 residents who currently reside in the facility. Findings Include: The Facility's Grievances policy dated 11/28/2012 documents the purpose of the policy is to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at the campus. Grievances may be filed orally (meaning spoken), in writing, or anonymously. All written grievances shall include: the date the grievance was received; a summary statement of the grievance; department assigned to investigate; steps taken to investigate the grievance; summary of the pertinent findings or conclusions regarding the concern(s).; statement as to whether the grievance was confirmed or not confirmed; corrective action taken by the facility as a result of the grievance, including measures taken to prevent further potential violations of any resident right while the alleged violation is being investigated and the date the written decision was issued to the resident or the complainant. The Facility's undated Purpose and Function of Resident Council Memo documents The Activity Director (or other designee) is available to be in attendance to serve as a liaison between residents and administration and to denitrify simple issues as they arise when invited. According to the Department of Public Health regulations, the council serves to: 1. Obtain and disseminate information; 2. Submit and adopt recommendations for facility programming and improvements.; 3. Identify problems quickly and efficiently; 4. Recommend an orderly resolution of problems. R1's Concern/Grievance Form dated 4/14/23 documents V11 (R1's Health Care Power of Attorney) concern was: Not getting calls back regarding updates-PT (Physical Therapy) and Nursing. Laundry missing. R1's Concern/Grievance Form documents Update from PT and nursing given and laundry notified of missing clothes, family does laundry signs hung up in room. On 6/15/23 at 10:00 AM V1 (Administrator) stated I know therapy called her, but I don't know when or what the concern was. I called her and gave her a nursing update; I did not document any of our conversation. Laundry notified of missing clothes does not answer where the clothes are. R5's Concern/Grievance Form dated 3/7/23 documents R5's concern as Not getting showers or PT (Physical Therapy). R5's Concern/Grievance Form documents Spoke with nursing staff. On 6/15/23 at 10:00 AM V1 (Administrator) stated she Did not know which nursing staff were spoken to, why the resident was not getting their showers or any other information regarding the grievance. R6's Concern/Grievance Form dated 5/4/23 documents R6's concern as Resident stating she is not receiving showers. R6's Concern/Grievance Form documents SSD (Social Service Director) and CNA Scheduler had a conversation as well as spoke with resident. Offered to move shower time she wants to stay on days for showers. On 6/15/23 at 10:00 AM V1 (Administrator) stated I don't know what that answer means. I don't know who was not giving the resident her shower or anything else about it. The Social Service Director was terminated for not doing her job, this would be a good example of that. The Resident Council Meeting Minutes dated 12/29/22 documents Nursing: Sometimes have to wait for lights to be answered. and Dietary: Food sometimes not hot. The Resident Council Meeting Minutes dated 1/26/23 documents Nursing: some feel it takes too long to answer lights and Dietary: Don't always get the dessert that is on the menu. The Resident Council Meeting Minutes dated 2/23/23 documents Nursing: Some residents not getting showers and Laundry/Housekeeping: Missing clothes and Dietary: Veggies are hard and not enough alternative options. The Resident Council Meeting Minutes dated 3/30/23 documents Nursing: Slow answering lights. The Resident Council Meeting Minutes dated 4/27/23 documents Dietary: Bread is dry on sandwiches; food isn't very hot. The Resident Council Meeting Minutes dated 5/25/23 documents Dietary: Meals served late; some food too hard to eat. On 6/14/23 V4 (Activity Director) stated I don't keep attendance or track any of the complaints that are brought up in Resident Council Meetings, I tell the appropriate Department Head and assume that the problem is going to be dealt with. I do realize that there are repeat complaints about call lights and dietary issues, I did not follow up with anyone to check if these concerns were being addressed. The Resident Roster dated 6/14/23 lists 68 residents who currently reside in the facility.

Based on observation, interview and record review the facility failed to implement pressure ulcer interventions to prevent new and worsening pressure ulcers for one resident (R2) of two reviewed for pressure ulcers in a sample of four. Findings include: The facility's Pressure Ulcer Prevention policy, revised 1/15/18, documents to maintain clean/dry skin during daily hygiene measures. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominence as indicated. Use pressure reducing pads in chairs (all types) to protect bony prominences for residents identified as Moderate/High/Severe risk. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes and malleoli as indicated. R2's Braden assessment, dated 3/11/23, documents a score of 12, indicating that R2 is a high risk for pressure ulcers. R2's Wound Evaluation and Management Summary, dated 2/22/23, documents that R2's left ischium full thickness stage four pressure ulcer measures 4cm (Centimeters) by 6.5cm by 1.1cm depth, the entire surface area is 26.00cm. R2's wound has moderate serous exudate. R2's left lateral ankle wound was healed on 2/22/23. V17, Wound Care Physician, documents that R2's left ischium wound has deteriorated since last visit. R2's Wound Evaluation and Management Summary, dated 3/1/23, documents R2's stage four pressure wound of the left ischium wound, measures 4.0 cm by 3.5cm by 0.8cm. V17, Wound Care Physician, documents to apply Santyl (Debriding ointment) once daily for 23 days, then cover with calcium alginate and foam silicone bordered dressing, then apply skin prep to the peri wound. Off-load wound; reposition as in the facility protocol. This note documents the progress of this wound and the context surrounding the progress were considered in greater depth today. R2's Wound Evaluation and Management Summary, dated 3/8/23, documents that R2's wound of the left ischium, measures 7.0cm by 4cm by 1cm, surface area 28.0cm. This wound has a moderate serous exudate. V17 documents to cleanse the wound, apply alginate calcium for 16 days, the apply collagen sheet for 30 days, cover with a silicone bordered dressing daily for 16 days. Apply skin prep to the peri-wound. R2's left ankle wound, reopened as a stage three pressure wound, it measures 1.5cm by 1.5cm by 0.1cm, the surface area measures 2.25cm. R2's wound care orders for the left ankle wound are to apply alginate calcium three time a week for 16 days, then apply collagen sheet three times a week for 30 days. Cover the wound with a foam silicone boarder dressing. Apply skin prep to the peri wound. The left ankle and left ischium wound have orders to be off-loaded On 3/13/23 at 9:30am, R2 was observed lying on his left side with his leg hanging over the side of the bed, with his ankle rubbing on the frame of the bed. R2 did not have a dressing on his left ankle. At 10:15am R2 remained in the same position. At 11:00am-12:15pm, R2 remained in the same position. At 1:30pm, V3, Assistant Director of Nursing, verified that R2 did not have a dressing on his left ankle wound. R2 has a 2cm-by-2cm open area noted on his left outer ankle. V15, CNA, Certified Nursing Assistant, and V14, CNA, rolled R2 over to perform perineal care. V3 verified that R2's left ischium wound was saturated with drainage and would come back to change the dressing. V14 and V15 verified that R2 has not been turned or repositioned since morning care. At 3:30pm, V3 had not returned to change R2's dressings. On 3/14/23 at 10:00am, R2 was observed on his left side, with pillows behind his back. R2's left foot was sitting on the bed. At 1:45pm, V9, Certified Nursing Assistant, verified that R2 has not been turned or repositioned since morning care. V9 and V6, Licensed Practical Nurse, performed perineal care and wound care. V6 performed wound care to R2's left ischium, during wound care, V6 did not apply skin prep as ordered to the peri-wound. The Surveyor pointed to an area above R2's left ankle dressing approximately a 6cm by 2cm abrasion. V6 verified that is a new open area. V6 stated that R2 is to be turned and repositioned at least every two hours and have a pressure relieving boot on at all times. V9 stated that R2 did have a boot, but it was sent to laundry. V9 stated that R2 has not had a pressure relieving boot on for days. R2's current care plan does not contain pressure ulcer interventions or goals to prevent further skin break down. On 3/15/23 at 2:15pm, V1, Administrator, verified that R2 is to be turned and repositioned every two hours or more. V1 also verified that R2's care plan does not address R2's pressure ulcers or wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide timely mobile radiology services for one resident (R1) of three residents reviewed for falls. Findings include: Current Physician Order Sheet indicates R1 was admitted to the facility on [DATE] with diagnoses that include Unsteadiness on Feet, History of Falling, Disorders of Bone Density, Heart Disease, Anxiety Disorder, Unspecified Dementia without Behavioral Disturbance. On 12/1/22 at 9:43am V8, LPN (Licensed Practical Nurse) stated that she was R1's assigned nurse the evening of 11/24/22 and that after R1 fell R1 stated she was sore and continued to refuse to go to the hospital. V8 stated that she ordered an X-ray of R1's left shoulder that night to rule out any injury. V8 stated that she thought she ordered the X-ray STAT, however, was told by Mobile Radiology that they would arrive early am (11/25/22) to complete X-ray. Nurse Note dated 11/27/22 at 6:10pm indicates R1 was sent to the hospital due to (Mobile) X-ray ordered Friday (11/24/22) after fall and radiology company called multiple times in effort to get X-ray done but X-ray still not done. Note indicates R1 had decrease in ROM (Range of Motion) was unable to lift left arm. Progress Note dated 11/27/22 at 9:38pm returned from the hospital with left arm in a sling and diagnosis of hospital stay is left humerus fracture. On 11/29/22 at 10:15am R1 was in bed watching television. R1 had a sling on left arm/shoulder and a pillow supporting her arm. Signed Investigation statement (undated) indicates V10, LPN documented that R1 was offered multiple times over the weekend to go to the hospital and refused offers. V10 documented that Mobile X-ray was called on Saturday (11/26/22) to find out when they would arrive and told by Mobile X-ray, they would be there that day (11/26/22). V10 documented that on Sunday (11/27/22) Mobile X-ray still had not arrived so R1 was sent to the hospital. On 11/30/22 V2, DON (Director of Nursing) stated that she contacted Mobile Radiology and had been in communication with them concerning their failure to respond to the request for X-rays for R1 and was sent the following report: Mobile Radiology Investigation Report dated 11/28/22 indicates: 1. On 11/24/22 at 11:17pm V8, LPN ordered a routine X-ray exam for left shoulder X-ray for R1. 2. On 11/25/22 at 11:25am V14, Nurse called Mobile Radiology to check on ETA (Estimated time of Arrival) for exam in question. Radiology dispatch informed V14 that the technologist would arrive to the facility before 3pm. 3. On 11/25/22 at 8pm Mobile radiology contacted V15, Nurse to reschedule the exam for the next day. 4. ON 11/28/22 at 11:02am Radiology technician arrived at the facility to perform exam and was told R1 had been sent to the hospital on [DATE]. Report Indicates Mobile Radiology failed to inform the facility about delays and rescheduling exams for the next day at the facility. Mobile Radiology Services did not follow the Delay of Service Protocol for routine or STAT exam or Pushed Exam Protocol. Mobile Radiology Client Services Department will be in-serviced regarding calling facility and informing the facility about delays and rescheduling exams. Facility Agreement with Mobile Radiology Services dated 12/1/2020 indicates: Duties and Obligations of Provider: b. Provider shall provide services within 24 business hours or schedule a time for service. The provider will promptly notify the Facility if service time is unable to be met.

**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 falls for one resident (R4) at high risk for falls of three residents reviewed for falls. Findings include: Facility Policy/Fall Prevention Program dated 11/21/17 documents: Methods to identify risk factors and to identify residents at risk. Safety interventions will be implemented for each resident identified at risk. Nursing personnel will be informed of residents who are risk for falling. The fall risk interventions will be identified on the care plan. Fall Incident Investigation Report indicates R4 fell on [DATE] (at 5:45pm). Report indicates R4 was found on the floor in his room with his wheelchair in front of him. Report indicates R4 had a laceration above right eyebrow (wound did not require sutures). Report indicates R4 wanders, actively exit-seeks, confused, impaired memory/ judgment and is wheelchair bound. Report indicates R4 was found by staff lying on the floor next to his bed trying to get himself up off the floor. On 11/30/22 at 11:35am V11, CNA (Certified Nurse assistant) stated that (on 11/19/22) she had just returned from her lunch break and while walking down the unit hallway she heard someone calling for help. V11 stated that R4's door was closed and when she opened it, she found R4 on the floor between his bed and the wheelchair. V11 stated that R4's door is usually left open because he is a fall risk. V11 stated that R4 can physically turn the doorknob but depending on how he is positioned - may not be able to pull the door open and go through. V11 stated that V13, CNA acknowledged that she shut R4's door but didn't give a reason. On 11/30/22 at 12:30pm V12, LPN (Licensed practical Nurse) stated that she was the nurse on duty (11/19/22) when R4 fell. V12 stated that she was told R4's door was shut by V11 and when V11 opened the door, found R4 on the floor. V12 stated that both V11 and V13 denied shutting R4's door. V12 stated that when R4 is in his room, the door should never be shut for (R4's) safety. On 11/30/22 at 12:51pm V6, CNA stated that R4 wanders and exit seeks constantly and should always be under close supervision. V6 stated that R4 should never be in his room with the door shut as R4 is a high fall risk. Current Care Plan was not updated to include to ensure R4's door is open when R1 is in his room or that R4 requires close supervision due to impaired safety awareness.

Based on interview, observation and record review, the facility failed to provide range of motion to a resident with functional limitations for one of six residents (R43) reviewed for range of motion in the sample of 38. Findings include: The facility's Restorative Nursing Program policy (revised 01/04/19) documents the following: If a resident is determined no longer appropriate for a restorative program, a maintenance program will be considered. A maintenance program is established based on the resident specific needs for the program. A care plan is then initiated. A functional maintenance program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers, bathing, etc. Range of motion programs may include Active Assisted Range of Motion, Active Range of Motion or Passive Range of Motion. On 06/06/22 at 10:50 AM, R43 was grabbing and pulling on to the handrails in the hallway to assist herself in propelling her wheelchair towards the dining room. R43 stated that staff does not assist her with any type of range of motion exercises at this time. R43's Annual Minimum Data Set Assessment (dated 04/26/22) documents the following Section G: R43 has impairment on one side of her lower extremities and utilizes a walker and wheelchair. This same assessment documents R43 is, Not steady, only able to stabilize with staff assistance in the following activities: Moving from seated to standing position; Walking (with assistive device if used); Turning around and facing the opposite direction while walking; Moving on and off toilet; and Surface-to-surface transfer (transfer between bed and chair or wheelchair). R43's Care Plan (dated 04/11/22) documents the following focus: I am at risk for limited range of motion and decreased circulation in bilateral lower extremities related to: disease process. This same care plan documents the following goal: I will tolerate ranging of bilateral lower legs with pain scale of less than five. This care plan also documents the following intervention: Demonstrate exercise and have resident return demonstration if able - if not perform exercises for resident. R43's Physical Therapy Plan of Care (dated 04/26/22) documents the following: Patient to be discharged from skilled physical therapy intervention with maximum potential and continue with appropriate long-term care/restorative nursing program in this same facility. On 06/08/22 at 01:44 PM, V3 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated R43 is not currently receiving any restorative or range of motion programming, (R43) has been on a restorative program in the past, but currently has no program in place.

Based on observation, interview and record review, the facility failed to ensure an entrapment risk assessment was completed prior to initiation of bed rails for two of three residents (R18 and R43) reviewed for bed rails in the sample of 38. Findings include: The facility's Side Rails/Bed Rails policy (dated 04/10/18) documents the following: The facility shall ensure prior to the installation of bed rails; the facility has attempted to use alternatives. After alternatives to bed rails have been attempted and determined that these alternatives do not meet the resident's needs, the facility shall assess the resident for risks of entrapment and possible benefits of bed rails. On 06/06/22 at 11:15 AM, R18 was lying in bed with her head of bed elevated approximately 60 degrees watching television. R18's bed had two 1/4 upper bed rails attached to the bed and secured in the upright position. R18 stated she utilizes the bed rails to reposition herself in bed. R18's Acknowledgement of Restraint/Device Use form (dated 05/19/22) documents R18 consented to the use of the following: 3/4 rail left and right upper. R18's Side Rail Assessment documents the assessment was not completed until 06/07/22. On 06/08/22 at 02:25 PM, V2 (Director of Nursing) verified that R18's Acknowledgement of Restraint/Device Use form is inaccurate and stated R18 does not have 3/4 bed rails attached to her bed, rather R18 does have two upper 1/4 bed rails attached. V2 then confirmed an entrapment risk assessment was not completed prior to the initiation of R18's 1/4 bed rails. R43's most recent Side Rail Assessment (dated 04/06/22) documents that there is not a bar or railing attached to R43's bed frame. R43's Acknowledgement of Restraint/Devise Use form (dated 05/19/22) documents R43 gave consent to utilize the following: Quarter rail left and right to promote independence with bed mobility. On 06/07/22 at 02:45 PM, R43 was lying in bed crocheting with her head of bed elevated approximately 60 degrees. R43's bed had two 1/2 upper bed rails attached and secured in the upright position. R43 stated she utilizes the bed rails to reposition herself in bed. On 06/08/22 at 02:25 PM, V2 (Director of Nursing) verified that R43's Acknowledgement of Restraint/Device Use form is inaccurate and stated R43 does not have 1/4 bed rails attached to her bed, rather R43 does have two upper 1/2 bed rails attached. V2 then confirmed an entrapment risk assessment was not completed prior to the initiation of R43's bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide specialized physician ordered diets. This has the potential to affect 20 residents (R6, R9, R11, R20, R22, R25, R28, R31, R32, R36, R38-40, R43, R46, R48, R102, 103, R153, and 154.) who receive therapeutic diets in the sample of 38. Findings include: The facility's Dining Experience policy, dated 2020, documents, Residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining. Meals will be planned to meet nutritional adequacy and according to the resident's plan of care, while not limiting the residents right to make personal choices. The facility's Diet Spread Sheet, dated Spring/Summer 2022 Day 9 Monday, documents, General Lunch: Meatloaf Wrapped in Bacon (3 oz-ounces), Roasted Carrots, Potatoes and Onions (2-4 oz spoons), Dinner roll, Fruit with whipped topping (4 oz spoon). LCS (Low Concentrated Sweets): Meatloaf Wrapped in Bacon (3 oz-ounces), Roasted Carrots, Potatoes and Onions (2-4 oz spoons), Fruit with whipped topping (4 oz spoon) The facility's Diet Spread Sheet, dated Spring/Summer 2022 Day 10 Tuesday, documents, General Lunch: [NAME] Sugar Glazed Ham (3 oz), Fried potatoes (4 oz), Mixed greens (4 oz), Cornbread/Margarine (3 x 2), Chocolate Pudding Cake (3 x 2.5 serving). Heart Healthy (No Added Sodium) Lunch: Pork Patty (3 oz), Low salt fried potatoes (4 oz), Mixed greens (4 oz), one slice of bed, Chocolate Pudding cake (1/2 serving). The facility's Diet Spread Sheet, dated Spring/Summer 2022 Day 10 Tuesday, documents, LCS Lunch: [NAME] Sugar Glazed Ham (3 oz), Fried potatoes (3 oz), Mixed greens (4 oz), Chocolate Pudding Cake (1/2 serving). The facility's Diet Spread Sheet, dated Spring/Summer 2022 Day 11 Wednesday, documents, General Lunch: Buttermilk Ranch Chicken (3 oz.), Parsley Buttered Pasta (4 oz spoon), Seasoned green beans (4 oz spoon), fruit crumble (#8 spoon-1/2 cup.). General LCS: Buttermilk Ranch Chicken (3 oz.), Parsley Buttered Pasta (3 oz spoon), Seasoned green beans (4 oz spoon), fruit crumble (#16 spoon-1/4 cup.). The facility's Diet Spread Sheet, dated Spring/Summer 2022 Day 11 Wednesday, documents, Heart Healthy Lunch: Ranch Chicken (3 oz.), Parsley Buttered Pasta (3 oz spoon), Seasoned green beans (4 oz spoon), fruit crumble (#16 spoon-1/4 cup.). The facility's Diet Type Report, dated 6/6/22, documents that the following residents receive a physician ordered therapeutic specialized diet: R6, R9, R11, R20, R22, R25, R28, R31, R32, R36, R38-40, R43, R46, R48, R102, 103, R153, and 154. 1. On 06/08/22 at 11:28 AM, R28 was served ranch chicken, pasta, green beans, and fruit cobbler. R28's Physician's orders, dated 6/7/22, document that R28 has an order to receive a LCS and NAS diet. The physician's orders also documents that R28 has the following diagnoses: Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 4, History of Myocardial Infarction, Atrial Fibrillation, Heart Failure. R28's Care plan, dated 2/12/22, documents, I am at risk for decreased cardiac output related to: Atrial Fibrillation, Coronary Artery Disease, History of CABG (Coronary Artery Bypass Graft). The care plan also documents the following intervention: Provide diet as ordered. R28's Care plan, dated 2/12/22, documents, I have Diabetes Mellitus and am on a prescribed oral anti-diabetic. The care plan also documents the following intervention: Dietary consult for nutritional regimen and ongoing monitoring. R3's Hemoglobin A1C results, dated 6/3/22, document a value of 8.7 (normal 4.6-6.2). R28's Nutrition Assessment, dated 6/8/22, documents, R28 admitted with Diabetes Mellitus, dementia, and other related comorbidities. He is on the NAS, NCS (LCS), regular, regular diet and is tolerating this well. His appetite is good and he is eating meals with supervision. He has had a gradual weight increase of 16.2 pounds. Weight increase unplanned. His diet is appropriate for Diabetes and Atherosclerosis and Heart failure. Recommend continuing the current diet and monitor. R28's MAR (Medication Administration Record), dated 6/2022, documents that R28 gets Blood Glucose Fingerstick every morning before breakfast at 6:00 a.m The MAR also documents the following results: 6/1-174, 6/2-213, 6/3-123, 6/4-167, 6/5-209, 6/6-183, and 6/7/22-182. On 06/07/22 at 10:16 AM, V9 (Licensed Practical Nurse) stated, (R28's) blood sugar first thing this morning (6/7/22) was 182. He has highs and lows in the morning. He is high for it being that early though. Not following his diet could contribute to him worsening, and may need his medications adjusted. 2. On 06/07/22 at 12:15 PM, R39 was sitting in her room stated she just finished up with lunch and she was served ham, fried potatoes, and chocolate cake. On 06/08/22 at 11:35 AM, R39 was sitting up in her recliner she was served ranch chicken breast, macaroni, green beans, and fruit cobbler. R39's Physician's orders, dated 6/7/22, documents that R39 has an order to receive a NAS (No Added Sodium). The Physician's orders also document that R39 has the diagnoses of Heart failure, Hypertension, and Atrial Fibrillation. R39's Care plan, dated 3/24/22, documents, I am at risk for decreased cardiac output related to: Hypertension, Pacemaker, Atrial Fibrillation, Hyperlipidemia, Heart failure. The care plan also documents the following intervention: Educate resident/family/caregiver regarding (dietary compliance, medication compliance, disease process). 3. On 06/07/22 at 12:05 PM, R48 was sitting at the dining room table eating chocolate cake with white frosting. R48 stated, My piece of cake was big. I don't think I get anything different from the other people here. For lunch, I had ham, fried potatoes, broccoli, and cornbread. On 06/08/22 at 11:28 AM, R48 was served mechanical soft chicken, pasta, green beans, and a bowl of fruit cobbler. R48's Physician's orders, dated 6/7/22, document that R48 has the diagnosis of Hypertension and generalized edema. The Physician's orders also document an order for R48 to receive a LCS (Low Concentrated Sweets) NAS (No Added Sodium) diet. R48's Care plan, dated 3/14/22, documents, I have altered cardiovascular status related to hypertension, Hyperlipidemia. R48's Nutritional assessment, dated 6/7/22, documents, Weight history indicates her weight has increased by 15 pounds up to 225 pounds for June. She continues on the LCS, NAS, mechanical soft, regular diet and is tolerating her diet well. The LCS, NAS, mechanical. soft, regular diet continues to be appropriate for Hypertension, and weight control related to morbid obesity. Will continue the current diet and monitor. On 06/07/22 at 10:16 AM, V9 stated (R48) has issues with swelling in legs. She even has orders to elevate legs whenever possible. On 6/6/22 at 11:33 a.m., V10 (Dietary Manager) stated we have regular, pureed, and mechanical diets. We do not have any specialty diets. We have residents who are LCS and NAS but we don't do anything different they get the same as a regular diet. On 06/07/22 at 12:25 PM, V11(Cook) stated, There are no differences in the food for LCS and NAS. All of the residents receive a regular diet. Today for example, everyone received the same size of servings for all of the options, even the chocolate cake. I do have one resident who is really good about making choices that are better for her Diabetes, like today she refused the cake and potatoes. On 06/08/22 at 11:35 AM, V10 stated, All of the residents got the same amount of all servings even the fruit cobbler. The scoop that was used used for the dessert was a number 8 (1/2 cup) spoon. All of the servings are the same size. On 06/08/22 at 3:24 PM, V4 (Registered Dietician) stated, The facility serves the specialty diets of NAS and LCS. Their menu has spreadsheets specific to those diets. When I've done my resident assessments, I wasn't aware that they weren't serving these diets. This affects the diabetics blood sugars, and the NAS diets would affect those residents' hearts. Surveyor: Heitzler, [NAME] M 4. R6's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Essential Hypertension, Myocardial Infarction, Hypo-Osmolality and Hyponatremia. Also included are the following physician orders: NAS (No Added Salt) Diet, add Sherbet with Lunch and Supper. Add Super Cereal with breakfast. R6's current Care Plan includes the following Focus Area: (R6) has a nutritional problem or potential nutritional problem related to BMI (Body Mass Index), COPD (Chronic Obstructive Pulmonary Disease), diet restrictions, Hyperlipidemia, Hypertension, NAS (No Added Salt) diet. Also included are the following Interventions: Provide and serve diet as ordered. R6's current Nutrition Progress Note, dated 6/7/22 and signed by V4/Registered Dietician documents, (R6) has had a significant weight gain of 7.1% in 1 month, 12.5% in 3 months and 23.2% in 4 months, up to 103.5#. (R6) continues on the NAS diet with Super Cereal with Breakfast and Sherbet with Lunch and Supper. (R6's) fluid restriction has been discontinued. (R6) is eating meals with supervision and intakes vary from 25-75%. (R6) continues on Furosemide (diuretic) for the edema. Although (R6) has edema, her appetite is poor, and weight is below normal with BMI of 17.2. (R6) is monitored daily for weight gain due to edema. Will continue the current diet plan and monitor. On 6/6/22 at 12;30 P.M., R6 was seated at the side of her bed with a meal tray of meatloaf with gravy, roasted potatoes and carrots, a dinner roll with butter and a fruit cup with whipped topping. No Sherbet was present on the tray. A meal ticket on the tray documented, (R6) NAS Diet. Sherbet with Lunch and Supper. The facility Diet Spreadsheet, dated for 6/6/22 Lunch Meal for Heart Healthy Diet (NAS) documents, 3 OZ (Ounces) Meatloaf; (2) 4 oz. spoodles Roasted Carrots, Potatoes and Onions; Dinner Roll (No butter); Fruit with Whipped Topping. On 6/7/22 at 12:05 P.M., R6 was seated on the side of her bed with a meal try of Ham, Fried Potatoes, Mixed Greens, Cornbread and Margarine and a large slice of Chocolate Pudding Cake. No Sherbet was present on the tray. The facility Diet Spreadsheet, dated for 6/7/22 Lunch Meal for Heart Healthy Diet includes: 3 OZ Pork Patty, Low Salt Fried Potatoes, Mixed Greens, 1/2 serving Chocolate Cake. 5. R32's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Essential Hypertension and Atrial Fibrillation. Also included are the following physician orders: NAS (No Added Salt) Diet. R32's current Care Plan includes the following Focus Area: (R32) has a nutritional problem or potential nutritional problem related to Severe Morbid Obesity, Dementia, Depression, Hypertension, No Added Salt Diet. Also included are the following Interventions: Provide and serve diet as ordered. R32's current Nutrition Progress Note, dated 6/7/22 and signed by V4/Registered Dietician documents, (R32) continues on the NAS diet and is tolerating this well. Wt. (weight) is stable at 197.4#. BMI is 37.3 (obese). (R32) eats meals with supervision and intakes vary from 25-75%. Skin is intact per Skin Review of 6/2/22. (R32) continues on Lasix and wearing Compression Hose during the day for possible edema. (R32's) diet continues to be appropriate for edema and hypertension. Will continue the current diet and monitor. On 6/6/22 at 12:30 P.M., R32 was seated in the facility [NAME] dining room with a meal tray of meatloaf with gravy, roasted potatoes and carrots, a dinner roll with butter and a fruit cup with whipped topping. A meal ticket on the tray documented, (R32) NAS Diet. The facility Diet Spreadsheet, dated for 6/6/22 Lunch Meal for Heart Healthy Diet (NAS) documents, 3 OZ (Ounces) Meatloaf; (2) 4 oz. spoodles Roasted Carrots, Potatoes and Onions; Dinner Roll (No butter); Fruit with Whipped Topping. On 6/7/22 at 12:10 P.M., R32 was seated in the facility [NAME] dining room with a meal try of Ham, Fried Potatoes, Mixed Greens, Cornbread and Margarine and a large slice of Chocolate Pudding Cake. The facility Diet Spreadsheet, dated for 6/7/22 Lunch Meal for Heart Healthy Diet includes: 3 OZ Pork Patty, Low Salt Fried Potatoes, Mixed Greens, 1/2 serving Chocolate Cake. 6. R40's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Essential Hypertension, Edema, Type 2 Diabetes Mellitus. Also included are the following physician orders: NAS (No Added Salt) Diet., Mechanical Soft texture. Super Cereal with Breakfast and Double Protein with Breakfast. R40's current Care Plan includes the following Focus Area: (R40) has a nutritional problem or potential nutritional problem related to Depression, Obesity, Hypertension, Hyperlipidemia, Diabetes Mellitus, No Added Salt Diet. Also included are the following Interventions: Provide and serve diet as ordered. R40's current Nutrition Assessment, dated 5/12/22 and signed by V4/Registered Dietician documents, (R40)'s weight is down slightly by 7.2# in the past year. Weight is still in the obese range for BMI. (R40) continues on the NAS, mechanical soft diet for chewing difficulties and hypertension. (R40) eats meals with supervision and her intakes are fair to good. Skin is intact. Will recommend adding double protein for breakfast to increase albumin. Will continue (R40's) diet and monitor. On 6/6/22 at 12:30 P.M., R40 was seated in the facility [NAME] dining room with a meal tray of meatloaf with gravy, a dinner roll with butter and a fruit cup with whipped topping. A meal ticket on the tray documented, (R40) NAS Diet, Mechanical Soft diet. The facility Diet Spreadsheet, dated for 6/6/22 Lunch Meal for Heart Healthy Diet (NAS) documents, 3 OZ (Ounces) Meatloaf; (2) 4 oz. spoodles Roasted Carrots, Potatoes and Onions; Dinner Roll (No butter); Fruit with Whipped Topping. On 6/7/22 at 12:10 P.M., R40 was seated in the facility [NAME] dining room with a meal try of ground Ham, Fried Potatoes, Mixed Greens, Cornbread and Margarine and a large slice of Chocolate Pudding Cake. The facility Diet Spreadsheet, dated for 6/7/22 Lunch Meal for Heart Healthy Diet includes: 3 OZ Pork Patty, Low Salt Fried Potatoes, Mixed Greens, 1/2 serving Chocolate Cake. 7. R153's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Type 2 Diabetes Mellitus. Also included are the following physician orders: LCS (Low Concentrated Sweets) Diet. R153's current Care Plan includes the following Focus Area: (R153) has a nutritional problem or potential nutritional problem related to Diabetes Mellitus. Also included are the following Interventions: Provide and serve diet as ordered. R153's current Nutrition Assessment, dated 6/7/22 and signed by V4/Registered Dietician documents, (R153) admitted with Metabolic Encephalopathy, Morbid Obesity, Type 2 Diabetes Mellitus and other related co-morbidities. (R153) is on the LCS (Low Concentrated Sweets) diet and is tolerating this well.(R153) is eating meals with supervision and her intakes are fair to good. (R153) is receiving treatment to right heel for DTI (Deep Tissue Injury) and right lower leg venous ulcer. Albumin is in the normal range. Will continue with the current LCS diet for weight control/weight loss and BS (Blood Sugar) control. On 6/6/22 at 12:35 P.M., R153 was seated in bed with a meal tray of meatloaf, Roasted/cubed Potatoes, Carrots and Onions, a dinner roll with butter and a fruit cup with whipped topping. A meal ticket on the tray documented, (R153) NCS Diet. The facility Diet Spreadsheet, dated for 6/6/22 Lunch Meal for Low Concentrated Sweets Diet (LCS) documents, 3 OZ (Ounces) Meatloaf; (2) 4 oz. spoodles Roasted Carrots, Potatoes and Onions; (No Dinner Roll) (No butter); Fruit with Whipped Topping. On 6/7/22 at 12:00 P.M., R153 was seated in bed with a meal try of Glazed Ham, Fried Potatoes, Mixed Greens, Cornbread and Margarine and a large slice of Chocolate Pudding Cake. The facility Diet Spreadsheet, dated for 6/7/22 Lunch Meal for Low Concentrated Sweets Diet includes: 3 OZ Ham, 3 OZ Fried Potatoes, Mixed Greens, 1/2 serving Chocolate Cake.

Based on observation, interview, and record review, the facility failed to provide substitutes of equal nutritional value during meals. This had the potential to affect all 51 residents residing in the facility. Findings include: The facility's Alternate Food Selection at Meals policy, no date available, documents, Food alternates will be available at meals for residents that prefer something different than is offered on the pre-planned cycle menu. Alternates for each food group must be available at meals. It is preferable to have more than one alternate per food group, as it is important that the resident is able to choose a preferred food item. The facility's Diet Spread Sheet, dated Spring/Summer 2022 Day 9 Monday, documents, General Lunch: Meatloaf Wrapped in Bacon (3 oz-ounces), Roasted Carrots, Potatoes and Onions (2-4 oz spoons), Dinner roll, Fruit with whipped topping (4 oz spoon). The facility's Diet Spread Sheet dated Spring/Summer 2022 Day 10 Tuesday, documents, General Lunch: [NAME] Sugar Glazed Ham (3 oz), Fried potatoes (4 oz), Mixed greens (4 oz), Cornbread/Margarine (3 x 2), Chocolate Pudding Cake (3 x 2.5 serving). The facility's Diet Spread Sheet dated Spring/Summer 2022 Day 11 Wednesday, documents, General Lunch: Buttermilk Ranch Chicken (3 oz.), Parsley Buttered Pasta (4 oz spoon), Seasoned green beans (4 oz spoon), fruit crumble (#8 spoon-1/2 cup). On 06/07/22 at 12:15 PM R39 sitting in her room and stated that she just finished up with lunch and she was served ham, fried potatoes, and chocolate cake. R39 stated, I didn't like any of it though. The only other thing we can order for a substitute is ham or tuna salad, grilled cheese, or peanut butter and jelly. On 06/07/22 at 12:25 PM, V11 [NAME] stated, The substitute for the broccoli today was carrots or beets. I did not have a substitute for the potatoes. Normally I don't have a starch substitute. On 06/08/22 at 11:35 AM, R39 was sitting up in her recliner. She was served ranch chicken breast, macaroni, green beans, and fruit cobbler. R39 stated, I told them I won't eat any of this, and all they offered me in exchange was a grilled cheese. On 06/08/22 at 11:45 AM, V10 (Dietary Manager) stated, There was no substitute for the starch or vegetable today, and there isn't always an actual substitute for each individual item on the menu. We have the all the time menu that consists of grilled cheese, tuna salad, peanut butter and jelly sandwich, ham and cheese sandwich, and vegetable of the day. On 06/08/22 at 3:24 PM, V4 (Registered Dietician) stated, There is a spreadsheet of substitutes. Each item on the menu should have an equivalent in nutritive value. For instance, if the protein is three ounces of chicken than the substitute should be at a minimum three ounces of some sort of protein. There should always be some sort of substitutes available to the residents. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672 dated 6/7/22 and signed by V3 (Minimum Data Set Coordinator), documents that 51 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to monitor food temperatures after being held in the steam table, maintain safe food temperatures of food being held on the steam table, reheat food to the appropriate temperature, monitor the level of sanitizing solution of the facility dishwasher and three compartment sinks, and monitor the temperatures of the refrigerators and freezers. These failures had the potential to affect all 51 residents residing in the facility. Findings include: The facility's Monitoring Food Temperatures for Meal Service policy, dated 2020, documents, Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. The temperature for each food item will be recorded on the Food Temperature Log. 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: If the serving/holding temperature of a hot food item is not at 135 degrees Fahrenheit or higher when checked prior to meal service, the item will be reheated to at least 165 degrees Fahrenheit for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within two hours. The facility's Refrigerator and Freezer Temperatures policy, dated 2020, documents, To ensure all perishable foods stay fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use. Dining services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. The facility's Dishwashing: Machine Operation policy, dated 2020, documents, Record log documents twice daily for either final rinse temperature or sanitizer concentration. On 06/06/22 at 11:02 AM, V10 (Dietary Manager) was present in the kitchen supervising the meal service. V10 stated, I completed my Dietary Manager course in January, but I haven't taken the certification test yet. On 06/06/22 at 11:04 AM, the kitchen's white freezer temperatures were located on its door with blanks of no recorded temperatures. The facility's Refrigerator/Freezer Temperature log: [NAME] freezer, dated 6/22, has no documentation of temperatures being checked on the mornings of 6/1, 6/4, and 6/5/22 as well as the evenings of 6/2 and 6/3/22. On 06/06/22 at 11:06 AM, the kitchen's cook refrigerator temperatures were located on its door with blanks of no recorded temperatures. The facility's Refrigerator/Freezer Temperature log: [NAME] Fridge, dated 6/22, has no documentation of temperatures being checked on the mornings of 6/1, 6/4-6/6/22 as well as the evenings of 6/2, 6/3, and 6/5/22. On 06/06/22 at 11:10 AM, the kitchen's four door refrigerator temperatures were located on its door with blanks of no recorded temperatures. The facility's Refrigerator/Freezer Temperature log: four door cooler, dated 6/22, has no documentation of temperatures being checked on the mornings of 6/1, 6/4, and 6/5/22 as well as the evenings of 6/2 and 6/3/22. On 06/06/22 at 11:11 AM, the kitchen's milk refrigerator temperatures were located on its door with blanks of no recorded temperatures. The facility's Refrigerator/Freezer Temperature log: Milk Fridge, dated 6/22, has no documentation of temperatures being checked on the mornings of 6/1, 6/4, and 6/5/22 as well as the evenings of 6/2 and 6/3/22. On 06/06/22 at 11:13 AM, the facility's three compartment sink was filled with quaternary solution. Cooking pans, cooking utensils, and holding pans were in the solution. The log for the quaternary solution to be checked three times a day was hanging on the refrigerator next to the sink. The log had blanks of no recorded quaternary solution levels. The facility's Sanitizing Sink Chemical log, dated 6/22, has no documentation of the sanitizing solution being checked during breakfast on 6/1, 6/4, and 6/5/22; lunch 6/1, 6/4, and 6/5/22; dinner 6/1-6/5/22. On 06/06/22 at 11:14 AM, across from facility's sanitizing dishwasher, a log of the concentration of sanitizer was hanging on the refrigerator. The log documented for the dishwasher sanitizer to be checked twice a day. The log had multiple holes of no concentrations being documented. V10 confirmed that the refrigerator/freezer temperatures were supposed to be checked three times a day as well as the quaternary solution in the three-compartment sink and the dishwasher concentration of sanitizer and they were not being done. V10 also confirmed that the food should be temperature checked three different times during the meal, and some meals no temperatures were completed. On 06/06/22 at 11:27 AM, V11 (Cook) was preparing the resident lunch meal trays. On 06/06/22 at 11:33 AM, V11 removed a Styrofoam bowl from a steam table holding pan of pureed meat. The pureed meat had a temperature of 100 degrees Fahrenheit. V12 (Dietary Aide) was pureeing the potatoes and carrots. On 06/06/22 at 11:35 AM, using the microwave, V11 reheated the pureed meatloaf to 130 degrees Fahrenheit and the pureed potatoes and carrots to 120 degrees Fahrenheit. On 06/06/22 at 11:37 AM, V11 placed both the pureed meatloaf and potato/carrots back into the microwave to reheat them again. Then, she removed them from the microwave to check their temperatures. V11 stated the temperature should reach 160 to put it back on the steam table. On 06/06/22 at 11:39 AM, V11 removed the pureed meatloaf and potato/carrots from the microwave after reaching the temperature of 180 degrees Fahrenheit. Both Styrofoam bowls were placed on the steam table to be served. V11 stated, I'm going to serve these, but I'm not sure how to keep them warm. V11 confirmed that food is only to be reheated once and both of these food items were reheated three times, and she was going to serve them. V11 stated, I don't recheck the food holding temperatures after placing the food in the steam table. I will check the pureed, but if it's not warm enough I will reheat it first. On 06/07/22 at 12:25 PM, V11 [NAME] stated, I did not know to check the temperature of the food after it's been in the steam table for a bit. I only check it when it's taken out of the oven, right before I put it on the steam table. The cook is responsible for the temperatures of the refrigerator/freezers and the quaternary solution checking in the 3-compartment sink. On 06/08/22 at 3:24 PM, V4 (Registered Dietician) stated, The food temperatures should definitely be checked more than when it comes out of the oven. That temperature is the cooked to temperature, and you also need to see what the holding temperatures are to see if the steam table is working, and the food is maintaining the heat for food safety. The pureed food should not be in Styrofoam bowls. I told them to put them in small holding pans and place them into the oven until they are ready to serve it. There's no reason for the temperatures to not be checked in the refrigerators and freezers. That is also a food safety issue. They definitely need more education done there. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672 dated 6/7/22 and signed by V3 (Minimum Data Set Coordinator), documents that 51 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to quarantine an unvaccinated resident upon readmission to the facility (R155) and failed to wear the required PPE (Personal Protective Equipment) while performing care for a resident (R153) in quarantine. These failures have the potential to affect all 51 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Infection Control- Covid-19 Policy, dated (revised) 3/24/22 directs staff, If entering a Yellow Zone or Red Zone room under transmission-based precautions, staff must wear full PPE, Including N-95, eye protection, gown and gloves. All new Admissions and Readmissions who are not up to date with Covid-19 vaccinations as recommended by the CDC (Centers for Disease Control) should be placed in 1 10-day quarantine, even if they have a negative test upon admission. Residents in the Yellow Zone and new admissions/readmissions under 10-day quarantine monitoring should not participate in group activities or communal dining and should not smoke with residents in the green or red zone. R153's facility Face Sheet documents that R153 was admitted to the facility on [DATE] with the following diagnoses: Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure. R153's facility Immunization Report, documents R153 has refused the Covid-19 vaccine. R153's current Physician Order Sheet, dated June 2022 includes the following physician order: Covid Quarantine Precautions for 10 days. On 06/06/22 at 12:16 P.M., V5/Vendor Portable X-Ray Technician was in R153's room performing a portable chest X-ray. V5/ was wearing an N95 Mask, goggles and gloves. V5 was not wearing a disposable gown. A sign posted outside of R153's room documented, Quarantine/Observation Yellow Zone Droplet and Contact Precautions. Full PPE (Personal Protective Equipment) to be used: N-95 Mask, Goggles or Face Shield, Gloves, Gown when entering room for any reason. Upon exit from R153's room, V5 verified she did not wear a gown while performing resident care. At that time, V5 stated, I guess I didn't read the sign. I'm on my way to another facility. R155's facility Face Sheet documents that R155 was readmitted to the facility on [DATE] from a local hospital. R155's facility Immunization Report, documents R155 has refused the Covid-19 vaccine. R155's current Physician Order Sheet, dated June 2022 includes the following physician order: Covid Quarantine Precautions for 10 days. On 6/6/22 at 9:30 A.M., V6/Licensed Practical Nurse (LPN) stated, I am the nurse for (R155). She came back to us on Saturday. She is not currently in quarantine. On 6/6/22 at 9:41 A.M., V7 and V8/Certified Nursing Assistants stated, We are assigned this front hall today. The only resident we have in quarantine is (R153). (R155) is not in quarantine. On 6/8/22 at 12:20 P.M., R155 was seated in the facility [NAME] Dining Room with 11 other residents, feeding herself the Noon meal. Two residents, R23 and R102 were seated at the four-person table with R155. Multiple facility staff members were present, including V1/Administrator, V2/Director of Nurses, V6/Licensed Practical Nurse and V7 and V8/Certified Nursing Assistants. At 12:52 P.M., R155 finished her meal and propelled herself back to her room and V7/Certified Nursing Assistant was observed entering a room on the facility East Hall. On 06/06/22 at 1:33 P.M., V1/Administrator stated, (R155) is unvaccinated. On 06/06/22 at 2:12 P.M., V155 was seated in the facility [NAME] Dining Room with 12 other residents and V14/Activity Director, playing Bingo. Three residents were seated at the same table as R155. At 3:10 P.M., V15 remained in the [NAME] Dining Room, playing bingo. On 06/07/22 at 8:04 A.M. R155 was seated in her room at the side of bed, eating the morning meal. At that time, R155 stated, I'm mad. I can't go out of my room, now. They tell me I have to stay in my room because I am in quarantine. All weekend long I could go to the dining room, and now I can't . On 06/07/22 at 8:25 A.M., V13/Certified Nursing Assistant stated, We weren't sure if (R155) was in isolation yesterday, but we have it figured out now. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents Report, form 672, dated 6/7/2022 documents that at the time of the survey 51 residents lived in the facility.