Based on observation, interview, and record review, the facility failed to ensure the plumbing system provided comfortable hot water temperatures for resident use for 10 of 15 residents (R1, R2, R3, R8, R9, R10, R11, R12, R14 and R15) reviewed for safe in the sample of 15. Findings include: On 4/1/2025 at 9:28 AM, water temperatures were taken with a metal calibrated thermometer. On 4/1/2025 at 9:32 AM, R2 stated water is always cold, she shares a sink in bathroom and shower room. The water is cold at her sink and in the shower room. R1, R2 and R3 all share a bathroom sink. On 4/1/2025 at 9:33 AM, V1, Administrator stated she was not aware of any issues with water temperatures. On 04/01 /2025 at 9:47 AM, R8 stated, The water was cold today. The showers are cold too. I tried to wash my hair, but it was too cold today to wash my hair, I just can't do it. R8 shares a room with R9. R9 was not interviewable. On 4/1/2025 at 9:57 AM, R8 and R9's sink registered 69.5 degrees Fahrenheit (F). This sink is shared with R8, R9, R10 and R11. On 4/1/2025 at 10:04 AM, R14 stated the water was cold today in her room. R14 shares a room with R15. On 4/1/2025 at 10:05 AM, R14 and R15's sink was 69.5 degrees F. This sink is shared with R14 and R15. On 4/1/2025 at 1:14 PM, V9, Sister Facility Maintenance Man stated, I got called in today because they said State was here in the building and our water temperatures were off. I was able to find out the circulatory pump needed repaired, so we were not getting hot water everywhere. The Illinois Department on Aging Residents' Rights for People in Long-Term Care Facilities revised 11/18 documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interviews and record reviews the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in ice machine and staff had warm water to wash their hands. This has the potential to affect the 61 residents living in this facility. Findings include: On 4/1/2025 at 9:32 AM, the metal thermometer was calibrated. On 4/1/2025 at 9:38 AM, the kitchen staff washing sink station water temperature was taken after running for one minute and the temperature was 69.5 Fahrenheit (F). On 04/01 /2025 at 9:42 AM, the ice machine was observed in sprinkler/employee break room. There was a hose that extended from the back through the wall to underneath leading to the outside. The hose to the ice storage bin of the ice machine was submersed into to pipe with no visible gap between the end of the hose and the drain to ensure that no sewage could back up into the ice machine. On 4/1/2025 at 9:49 AM, V1, Administrator stated, I am not sure what you are referring to regarding an air gap. Our machine has always been like that and the tubes in the ice machine were installed years ago. On 4/1/2025 at 10:03 AM, V8, Dietary Manager stated, We only have one ice machine in the building. The ice machine is in the 'Employee break room.' We use that ice for all the residents' drinks and for cooling and preparation of food. I am not sure how long the water has been cold at the hand washing station. On 4/1/2025 at 1:11 PM, V9, Sister Facility Maintenance Man stated, I would expect the kitchen hand washing sink to be warm for hand washing. Something is off and they called me here to look at it. I am looking into it now. That water should be a lot warmer, at least in the 100's degrees. The Resident Roster dated 4/1/2025 documents there are 61 residents living in the Facility.

Based on interviews and record review the facility failed to provide services to residents with gastrostomy tube to restore/maintain eating skills for one of one resident (R40) reviewed for tube feedings in the sample of 65. Findings include: R40's Face Sheet, date 8/1/2024, document diagnoses of Schizophrenia, major depressive disorder, anxiety, Chronic Obstructive Pulmonary Disorder (COPD), Parkinson, benign prostatic hyperplasia, Hypertension, hyperlipidemia, Gastroesophageal reflux disorder, insomnia, and protein calorie malnutrition. R40's clinical record does not document any dysphagia or swallow issues. R40's physician orders dated 4/2024, prior to hospitalization on 4/23/2024 documents R40 was ordered a REGULAR diet, Mechanical Soft, Ground Meat texture, thin consistency on 4/1/2024. R40's Progress Note, dated 4/23/2024 at 7:52pm documented R40 was admitted to local hospital for COPD exacerbation and pneumonia. R40's Facility's progress notes dated 4/24/2024 at 11:32AM documented R40's plan of care. R40's progress note documented R40 is noncompliant and refusing majority of care currently, was admitted for pneumonia and on 4L (liters) of O2 (oxygen) NC (nasal cannula). The Note documented the hospital stated when R40 is more compliant they will attempt a swallow study and agree that R40 needs a dysphagic diet plan/ purred foods, thickened liquids if R40 will tolerate. R40's Progress Note, dated 4/29/2024 at 3:33 PM documents R40 returned to facility from hospital with admitting diagnosis of aspiration pneumonia. R40's physician orders dated 4/29/24 documents NPO (nothing by mouth), 1.5 Cal/Fiber. R40's Behavior progress note dated 5/14/2024 at 9:36 AM documents R40 noted to be putting cups of ice under his bed and eating/sucking on it when he wants. R40 educated on the risks of eating ice when he is NPO. Resident mad but voiced understanding. R40's Nurse Practitioner (Psychiatric Nurse Practitioner) dated 5/30/204 documents R40's mood is irritable. R40 states he is not doing good, because he went to the hospital and the new medicine they give him burns when they put it through the g-tube. R40 states he wants to go back to a regular diet. R40 appears irritable due to this, with some yelling but otherwise calmly in his seat. R40's progress note dated 6/15/2024 at 9:05pm documents, attempted to give R40 his G-tube feeding. R40 became belligerent and yelling obscenities at writer. Was unable to finish his feeding due to resident refusing to continue with feeding when writer attempted to calm him down. R40 yelled get out of here you stupid b****. He then came out of his room yelling obscenities at his roommate and while in the dining room continued to yell obscenities. R40's progress note dated 6/17/2024 at 3:14pm documents R40 is getting money from other residents to buy snacks. R40 was educated on the importance of not eating due to him having a feeding tube and being NPO and that we cannot get money from other residents. R40's Behavior progress note dated 7/24/2024 at 3:56 pm documents R40 has been hateful, yelling, cursing, at staff. Difficulty to redirect. Yelled at insurance nurse and refused to sign paperwork. Refused medications and noon feeling, cussing, and calling staff cuss names. Another resident gave resident a cup of soda. Took soda away from resident, which caused him to become angrier. Sitting at table in dining room yelling out. On 7/30/2024 at 2:00 PM R40 stated that he wanted to eat and drink he didn't like the tube. R40 stated he want to drink soda and he can't. R40 asked surveyor to do something so he can eat and drink again. R40 stated he is mad. On 7/31/2024 at 11:00 AM V4, Certified Nursing Assistant, CNA, stated that R40 has outburst of anger, that R40 still goes to dining room for meals but isn't supposed to be eating anything. V4 stated that R40 will get snacks out of the vending machine hide it in under his shirt or in his pants and take it back to his room to eat it. V4 stated R40 yells if you tell him he isn't supposed to eat. V4 stated R40 gets mad is his tube feeding is late. V4 stated that the first week after R40 came back from the hospital with his G tube R40 told V4 that he was supposed to be getting speech therapy so he could eat. V4 stated R40 is not receiving any speech therapy. On 7/30/2024 at 2:15 PM V2, Director of Nursing, stated there is no plan for R40 to eat or be evaluated for any oral intake. V2 stated she will ask medical director on 8/1/2024 if R40 can have a swallow study done. V2 stated that R40 did not have any orders for Speech Therapy. V2 stated the facility does have Speech Therapy services. V2 states R40 refuses his tube feeding at times and gets angry. On 8/1/2024 at 8:45 AM V2 stated that R40 has the tube feeding placed in 4/2024 because of aspiration pneumonia. V2 stated that R40 does not currently have aspiration pneumonia. On 8/1/2024 at 9:00 AM V2 stated that the facility does not have a policy on restoring eating skills.

Based on interview, observation, and record review, the facility failed to provide 8 consecutive hours of Registered Nurse Coverage. This has the potential to affect all 61 residents residing in the facility. Findings include: On 7/30/2024, V2, Director of Nurses (DON), stated that the facility does have days that the facility is unable to staff 8 consecutive hours of Registered Nurse coverage. V2 stated she has been trying to hire Registered Nurses but hasn't had any applicants lately. On 7/31/24 at 8:30 AM, V2, stated the facility does not have a policy on 8 hours of consecutive Registered Nurse hours but she tries to meet the regulation. On 7/30/24, V2 was the only Registered Nurse in the building. The Nursing Unit Postings from 6/1/2024 - 7/29/2024 were reviewed. The facility failed to have 8 hours of consecutive Registered Nurses coverage on: 6/3/24, 6/8/24, 6/9/24, 6/17/24, 6/28/24, 7/2/24, 7/6/24, 7/7/24, 7/20/24, and 7/29/24. The Long-Term Care Application for Medicare and Medicaid dated 7/29/24, documents 61 residents reside in the facility.

Based on interview, observation, and record review, the facility failed to wear hair nets covering the hair, store food at a safe temperature, document food temperature after taking them, and have clean and sanitary equipment to prevent potential food contamination and food-borne illness. This failure has the potential to affect all 61 residents residing in the facility. Findings include: 1.On 7/29/24 from 12:05 PM until 12:26 PM, V9, Preparation Cook, was observed without out a hair net covering her hair. V9 is assisting V8, Cook, placing uncovered food items onto the resident's tray and then placing the tray onto the service counter for staff to deliver to the residents in the dining room. V9 has past the shoulder braided hair that is pulled into a ponytail. V9 's hair net is at the end and side of the ponytail caught in the hair but not covering any hair. 2.On 7/31/24 at 11:44 AM the kitchen was entered. The thermometer was calibrated and shown to V7, cook. The noon meal food items were corn dogs, stewed tomatoes, cold macaroni salad and peach cake. The macaroni salad was 60.2 degrees Fahrenheit (F) and on a preparation table. V7 stated she was going to put it on ice and that it just came out of the refrigerator. On 7/31/24 at 12:00 PM, the food temperature log was observed to be not filled out. V7 stated she was going to take them now. V7 stated that the macaroni salad temperature she got was 56 degrees. V7 failed to document the temperatures she had taken on the temperature log. At 12:07 PM V7 began to serve the meal. 7/29/24 at 1:45 PM, the can opener blade was covered in a thick black substance. On 7/31/2024 at 1:55 PM, V6, Dietary Manager, stated, (V7) should have chilled the macaroni salad down more or thrown it away. The safe temperature is 41 degrees for cold items. I don't think I can clean that can opener. I just need a new one. Everyone should wear a hair net covering their hair. The undated cleaning schedule failed to document the can opener. The Kitchen Sanitation policy failed to address hair net. The facility policy Monitoring Food Temperature for Meal Service dated, last revised 9/2023 documents if the serving/holding temperature of a cold food item or beverage is not at 41 degrees Fahrenheit (F) or below (for less than four hours in duration) when checked prior to meal service, the item will be chilled on ice or in the freezer until it reaches 41 degrees F (or less) before service. The Long-Term Care Application for Medicare and Medicaid, dated 7/29/24, documents there are 61 residents living in the facility.

Based on interviews and record review the facility failed to always maintain a nurse on duty to meet the needs and safety of all residents. This failure has the potential to affect all 62 residents that reside in the facility. On 4/23/2024 at 12:27pm, V5, (Ambulance staff), stated that on 4/19/2024 around 8pm, V5 was returned R2 to the facility via ambulance transfer. V5 stated, there was no Nurse on duty in the building when they arrived to receive R2 back into the facility for care. V5 stated, V4, (Certified Nursing Assistant, CNA), told her that V3 had left and would be back shortly. V5, (Ambulance staff), stated 15-minutes passed with no signs or return to the facility of V3, (LPN). On 4/23/2024 at 2:30pm, V4, (CNA), stated, that on 4/19/2024 around 8pm, R2 returned from the hospital via Ambulance and V3, (LPN), was not in the facility. V4 stated, she called V3, and V3 will be back shortly. V4 stated, the Ambulance waited for a few minutes and then made a phone call, then left R2 at the facility with V4. On 4/23/2024 at 3:00pm, V3, (LPN), stated, that on 4/19/2024, she left the facility to deal with a family emergency, she was gone for about 15-min. V3 stated she was not present when the Ambulance arrived to returned R2. V3 stated she was the only Nurse on duty in the facility that shift. V3 did not call her Management to let them know she was out of the facility. V3 stated, there was no Nurse covering, while she was out of the facility. On 4/24/2024 at 8:30am, V1, (Administrator), and V2, (Director of Nursing), stated, they did not know until 4/23/2024 that V3 had left the faciity on 4/19/2024, with no Nurse covering while she was gone out of the facility. V1 and V2 both stated, they expect the Nurse to stay in the facility when they are the only Nurse on duty. V1 and V2 both stated V3 should have called someone to cover her during her time away from the facility. V1 stated she expects there to always be always a nurse in the facility. On 4/23/2024, facility schedule for 4/19/2024 showed V3 scheduled as the only Nurse on duty on the second shift. R2's Patient Care Report dated 4/19/2024 from Ambulance transfer on 4/19/2024 at 8:00pm, documents, We were informed no RNs at the facility at this time, due to one taking care of personal problem. We informed them that we needed one for transfer of care. We waited approximately 10-minutes for one to arrive. While waiting, (V3) spoke with Medical Control, to inform them that we could not do a proper transfer of care. On 4/24/2024 at 8:30am, V1 stated the facility does not have a staffing policy, but the facility is supposed to follow the regulations for staffing.

Based on record review and interviews the facility failed to provide the services of a Registered Nurse for 8 consecutive hours on the dates of 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. This failure has the potential to affect all 62 residents that reside in the facility. On 04/23/2024 at 1:00pm, V1 (Administrator) stated there are some days that the facility does not have a Registered Nurse for 8 consecutive hours a day. V1 stated current census is 62 and noted by the Matrix obtained from V1. On 04/23/2024 at 1:30pm, Facility provided the Nursing schedules with no RN scheduled to work on the following dates 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. On 04/23/2024 at 2:30pm, V4 (Certified Nursing Assistant) stated there are some days that there is no RN working in 24-hours. On 04/24/2024 at 8:30am, V1 stated the facility does not have a staffing policy but the facility is supposed to follow the Regulations for staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of narcotic pain meds, for 1 of 3 (R2) residents, reviewed for abuse, in a sample of 4. Findings include: R2's Minimum Data Set, dated [DATE], documented his cognition was moderately impaired. On 1/29/2024 at 2:00 pm, R2 stated he told the staff he wasn't getting his pain meds and he was told by them he has to ask for it. R2 stated he originally was getting his pain meds three times a day but now he only gets it when he asks for it. R2 stated the head nurse told him he had to ask for it or he won't get it. R2 stated, I am confused but if I ask for my pain medication, I do get it. On 1/29/2023 at 9:45am, V1, Administrator, stated V3, Nurse Consultant, received a compliance line call from R2's ex-wife stating R2 was not receiving his narcotic pain medication and R2 believes someone is taking his medications. V1 stated this was investigated and the Director of Nurses conducted an audit of R2's narcotic sheets and the count was accurate and V3 conducted facility audit of the narcotic count and it was accurate. On 1/29/2024 at 2:02pm, V2, Director of Nursing (DON), stated she looked at the narcotic count sheet for R2 and the count was correct, so she was not concerned about anyone taking R2's pain meds. On 1/30/2024 at 11;00am, V1, Administrator, stated she did not interview any staff nurses because V2, DON, checked the narcotic count, and it was accurate for R2. V1 stated V3, Nurse Consultant, did an audit of the other residents who receive narcotics, and she had no concerns. V1 stated she does not know what V3 looked at in her audit. On 1/30/2024 at10:45am, V3, Nurse Consultant, stated for the investigation, she did an audit of the narcotic count for all residents in the facility and the count was accurate. V3 continued to state V1, Administrator, was responsible for the rest of the investigation and she (V3) was not aware if any floor nurses were interviewed. V3 stated she only looked at narcotic count sheets, they were accurate, and was all she looked at. R2's Investigation File, dated 1/25/2024, there was an Electronic Mail (email) from V3 (Nurse consultant) to V1 (Administrator) documented R2's family member indicated R2 believes someone was taking his narcotic medication but could not say who. The facility's Grievance form, dated 1/25/2024, documented a complaint about R2 not receiving his medications during bedtime. R2 stated on form They just don't give it to me. R2's Progress notes, dated 1/30/2024, documented, (R2) was involved in an allegation of theft/misappropriation. The alleged perpetrator was unknown at the time of the initial/final report. (R2) identified to family he believes his (Narcotic) medication was taken. Resident interviewed. Facility conducted a (Narcotic) Audit. R2's Physicians Orders, dated January 2024, documented an order for hydrocodone APAP I tablet every 6 hours as needed for pain. R2's Narcotic count sheet, dated 1/1/2024-1/29/2024, documented 75 entries. R2's Medication administration record, dated 1/1/2024 to 1/29/2024, documented at noon only contains 15 administrations of hydrocodone APAP I tablet every 6 hours as needed for pain. Facility provided Abuse Prevention policy, dated 10/2022, documented, The facility will promptly and aggressively investigate allegations of misappropriation of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document narcotic pain medication administration for 4 of 4 (R1, R2, R3 and R4) residents reviewed for medication administration, in a sample of 4. Findings include: 1. R1's Physician Order sheets, dated 1/2024, documented, an order for Hydrocodone-Acetaminophen (APAP) Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain. R1's Narcotic count sheet, dated 1/14/2024 to 1/28/2024, documented, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain contained 25 entries. R1's Medication administration record, dated, 1/14/2024 to 1/28/2024, documented 5 entries of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain. R1's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. On 1/29/2024 at 1:30pm, R1 stated that she receives her pain when she needs them including on second and night shift. 2. R2's Physicians order sheet, dated January 2024, documented, an order for Hydrocodone APAP I tablet every 6 hours as needed for pain. R2's Narcotic count sheet, dated 1/1/2024 to 1/29/2024, documented, hydrocodone APAP I tablet every 6 hours as needed for pain contained 75 entries. R2's Medication administration record, dated 1/1/2024 to 1/29/2024, documented, 15 administrations of hydrocodone APAP I tablet every 6 hours as needed for pain. R2's MDS, dated [DATE], documented that his cognition was moderately impaired. On 1/29/2024 at 2:00pm, R2 stated that he told the staff that he wasn't get his pain meds and he was told by them that he has to ask for it. R2 stated that he originally was getting his pain meds three times a day but now he only gets it when he asks for it. R2 stated that the head nurse told him he had to ask for it or he won't get it. R2 stated, I am confused but if I ask for my pain medication. 3. R3's Physicians order sheet, dated January 2024, documented an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10. R3's Narcotic count sheet, dated 1/23/2024 to 1/29/2024, documented, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10 contains 17 entries. R3's Medication administration record, dated 1/23/2024 to 1/29/2024, documented, 3 administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10. R3's MDS, dated [DATE], documented that her cognition was intact. On 1/29/2024 at 1:51pm, R3 stated that she receives her pain when she needs them including on second and night shift. 4. R4's Physicians order sheet, dated January 2024, documented an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth two times a day for pain. R4's Narcotic count sheet, dated 1/15/2024 to 1/30/2024, documented 32 entries for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth two times a day for pain. R4's Medication administration record, dated 1/15/2024 to 1/30/2024, documented 30 administrations of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain score 8-10. R4's Physicians order sheet, dated January 2024, documented an order for tramadol HCl Oral Tablet 50 MG1 tablet by mouth every 12 hours as needed for pain. R4's Narcotic count sheet, dated 1/20/2024 to 1/29/2024, documented 19 entries for tramadol HCl Oral Tablet 50 MG 1 tablet by mouth every 12 hours as needed for pain. R4's Medication administration record, dated 1/20/2024 to 1/29/2024, documented 10 administrations of tramadol HCl Oral Tablet 50 MG 1 tablet by mouth every 12 hours as needed for pain. On 1/30/2024 at 10:45am, V3, Nurse Consultant, stated that she expects the nurses to document pain medication on the medication administration record. On 1/29/2024 at 1:15pm, V5, Licensed Practical Nurse, stated that when a resident asks for a pain medication, they are supposed to document it on the medication administration record in the resident's chart and on the narcotic count sheets. The facility's, Medication Administration Policy, dated 1/2015, documented, Controlled substance is to be documented on the resident's medication administration record and the controlled substance record.

Based on observations and interviews the facility failed to provide a safe environment by having toilets that were not securely bolted to the floor for 8 of 20 residents (R4, R5, R7, R8, R9, R10, R11 and R12) and failed to have toilet in hallway A shower room securely bolted to floor with the potential to affect 23 of 24 residents. Findings include: On 9/27/2023 at 1:15pm V1, (Administrator), stated she was not aware of toilets not being bolted securely to the floor. On 9/27/2023 at 1:00pm observations of R7's toilet not secured to floor. R7's toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 1:10pm observations of shower room on B hallway with toilet not secured to floor. Toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 3:00pm observations of room A8's toilet not secured to floor. A8's toilet had rusted bolts that no longer held toilet securely to floor. R8 and R9 reside in this room. On 9/27/2023 at 3:12pm observations of R5's toilet not secured to floor. R5's toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 3:30pm observations of room A16's toilet not secured to floor. A16's toilet had rusted bolts that no longer held toilet securely to floor. R4 and R10 reside in this room. On 9/27/2023 at 3:30pm observations of B8's toilet not secured to floor. B8's toilet had rusted bolts that no longer held toilet securely to floor. R11 and R12 reside in this room. On 9/27/2023 V1 stated R4, R5, R7, R8, R9, R10, R11 and R12 all had toilets that were not secured to the floor. V1 stated the toilets have now been tightened to secure them to the floor. V1 stated shower room on hallway A toilet has also been repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Physician's Assessments were completed upon admission in a timely fashion for 1 of 4 residents (R10) reviewed for Physician's Services in the sample of 11. Findings include: The Facility's admission Report documents, R10 was admitted on [DATE]. On 8/8/2023 at 11:20 AM, V11, Registered Nurse, (RN), stated, V4, Medical Director mentioned to V11 that he doesn't always know when the facility gets a new admission. V11 stated, That's something we need to work on. On 8/8/2023 at 2 PM, V4, Medical Director stated, they (V4 and facility staff) have been working on a new system but stated, he (V4) was not always notified when there was a new admission. On 8/9/2023 R10's EMR does not include an initial H&P or any additional Physician's Progress Notes. On 8/9/2023 at 1:45 PM, V2, Director of Nursing verified there were no Physician's Notes in R10's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide continuity of care and documentation of Physician's Assessments in the Electronic Medical Record, (EMR), in a timely fashion for 4 of 4 residents (R1, R4, R10 and R11) reviewed for Physician Services in the sample of 11. The findings include: On 8/8/2023 at 8:45 AM V1 Administrator, stated, (V4, Medical Director, MD) was working for (local hospital) but, now he has his own clinic. He (V4) is a little behind on Progress Notes, but he said he will be in today. On 8/8/2023 at 10:00 AM V1 stated, V4 is the current Medical Director, (MD). V1 stated, V4, MD, does his own Progress Notes after his visits. On 8/8/2023 at 10:43 AM, V1 stated, I was telling (V2, Director of Nurses, DON) I was concerned he (V4) hadn't put notes in the (EMR, electronic medical records). On 8/8/2023 at 11 AM, V2 stated, the facility does not have a policy pertaining to Physician's documentation. On 8/8/2023 at 11:57 AM, V4 stated, he used a different charting system up until May (2023) and his nursing staff would fax the Progress Notes to the facility. V4 also stated, I am a little behind, so I am just now writing the July visits. On 8/8/2023 at 2:11 PM, V1 stated, she asked V4 to reach out to (local hospital) to see if he (V4) could get the notes. On 8/9/2023 at 12:45 PM, V8, Registered Nurse, (RN), and V5, RN, stated Physician's Notes should be documented under the miscellaneous tab of the EMR and there were no Physician's Progress Notes for R1, R4, R10 and R11. On 8/9/2023 at approximately 1:15 PM, all Physician's Notes and H&P's for R1, R4, R10 and R11 were requested. 1. The Facility's admission Report documents, R1 was admitted on [DATE]. R1's EMR Progress Notes documents, R1 had a History and Physical, (H&P), completed by V4 Effective 7/10/2023. It further documents, the entry was created on 8/8/2023. 2. The Facility's admission Report documents, R4 was admitted on [DATE]. R4's EMR documents, R4 had her Initial H&P completed on 6/7/2023. R4's EMR does not include any documentation, of R4 being seen in July. 3. The Facility's admission Report documents, R10 was admitted on [DATE]. R10's EMR does not include an initial H&P or any additional Physician's Progress Notes. On 8/9/2023 at 1:45 PM, V2, Director of Nursing verified there were no Physician's Notes in R10's EMR. 4. The Facility's admission Report documents, R11 was admitted on [DATE]. R11's Physician's Notes document, R11 had a H&P completed, by V4 Effective 7/24/2023. It further documents, the entry was created on 8/8/2023. On 8/9/2023 at 1:51 PM, V2 stated, she would expect the facility nurses to know where the Physician's Progress Notes are and for them to be accessible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure mechanical lifts are in working order to transfer residents for 1 of 1 resident (R8) reviewed for resident care equipment in the sample of 13. Findings include: R8's Minimum Data Set, MDS, dated [DATE], documents R8 has no cognitive impairments and R8 is totally dependent on two staff person physical assistance for transfers. R8's Care Plan, dated 2/17/2023 documents R8 has an Activities of Daily Living (ADL) Self Care Performance Deficit related to activity intolerance, disease process schizoaffective. R8's Care Plan Interventions document R8 uses a wheelchair for transportation and requires assist of sit to stand with two staff for transfer. On 07/05/2023 at 11:05AM, R8 stated she was in bed for seven days because the sit to stand mechanical lift was not working. R8 stated, It was broke. R8 stated she remained in bed from Friday, 6/23 through Thursday 6/29/23. R8 stated she felt alone because she prefers to get up out of her bed and go to the dining room. R8 stated on Thursday, 6/29/2023, the city tornado sirens were sounding. R8 stated she could hear the tornado siren going off while lying in her bed. She stated she was scared, crying, fearful, and alone. R8 stated her window curtains was pulled, curtain drawn, and door shut and that made her feel scared, fearful, and alone. She stated the power went off and she felt more scared when the electricity went out and she was left alone in her room. On 7/5/23 at 11:05AM V2 Regional Operations stated she requested a rental sit to stand for the facility. Sit to stand was not working. On 7/5/23 1:03 PM, V22 Certified Nurse Assistant (CNA), stated R8 transfers with a sit to stand lift. V22 stated the sit to stand has been broken and R8 had to remain in bed for seven days a rental sit to stand was ordered. V22 stated when the rental got to the facility it would not work because no battery was brought with the rental sit to stand. On 7/5/23 at 1:51 PM, V6, CNA stated she knows the sit to stand was not working the day of the tornado warning because R8 was left in bed that day. V6 stated because the sit to stand was not working, We had no way to transfer (R8) to her wheelchair. On 7/6/23 at 2:43PM, V20, CNA stated sit to stand was broken for three or four days and R8 remained in bed. On 7/6/2023 at 3:17PM, V21, CNA stated sit to stand was broke for four or five days. R8 was in bed those days. V21 stated, (R8) would never have stayed in bed if sit to stand was working. She likes to get up and go to the dining the room. On 7/7/23 at 9:55AM, V9, CNA, stated when she worked Monday, 7/3/23 morning the sit to stand was not working. V9 stated R8 had to stay in bed. V9 stated R8 had to stay in bed probably three to four days. V9 stated the sit to stand was reported to V18 Maintenance Director. On 7/7/23 at 10:00AM, V22 CNA, stated she complained to V2, [NAME] President of Regional Operations, regarding the sit to stand. V22 stated, V27 Regional Nurse Consultant was here, and she reported to her as well. V22 stated they told management something needed to be done getting a new sit to stand. V22 stated State was in the building so management got a rental that did not work. On 7/7/23 11:24PM, V18 Maintenance Director stated, V2 [NAME] President of Regional Operations requested he look at the sit to stand. V18 stated at that time he was not able to fix the sit to stand. V18 was given a verbal request and not written request by V2. V18 stated we use to have Work Order Sheets and staff would put the word orders underneath his door soiled utility room or hand them to him. V18 stated he checks the sit to stand weekly but not daily. V18 stated it should be in the logbook. V18 stated they got a rental sit to stand but it did not work when arrived at the facility as the rental did not send a battery. On 7/7/23 at 1:28PM, V24, CNA, stated for three or four days R8 had to stay in bed because the sit to stand wasn't working. V24 stated she reported to V18 Maintenance Director the sit to stand was not working. V24 stated V18 came and looked at the sit to stand on Tuesday, 6/27/2023. V18 assessed the machine, but it would not turn on. V24 stated V18 already knew the sit to stand was not working. V24 stated they use to do work orders but stated she's not seen work orders in a minute. On 7/11/2023 at 3:30PM, V26, Senior Regional Maintenance Director, stated some facilities do monthly checks on the sit to stands but the facility elected to do weekly sit to stand checks. V26 stated he expects the maintenance director to follow the detailed inspection of Direct Supply the Equipment Lifecycle System (TELS). V26 should have followed the instructions of TELS and what's occurring with the broken issue. V26 stated if any part of that inspection that fails it should be taken out of service upon inspection and repaired to working proper condition. V26 stated he was not aware the sit to stand at the facility was having problem. Maintenance should have pulled the sit to stand until it was fixed and safe for the residents. V26 stated he looked at facility report and stated nobody is using the TELS system. V26 sent V3 DON a report from the TELS system but there was no documentation noted that Maintenance used the system or sit to stand was checked by TELS. This report is to conduct mobile lift system inspection. On 7/11/2023 at 3:42 PM, V26 provided Direct Supply TELS, resident lifts inspect mobile lifts documentation. Documentation had no check marks where sit to stand had been inspected by maintenance at the facility. Policy and Procedure for Transfers Manual Gait Belt, and Mechanical Lift dated, 2/2008, documents Mechanical lifting device shall be used for any resident needing a two person assist or cannot be transferred comfortably and/or safely by normal transfer technique. Mechanical lift shall be made readily available and accessible to staff 24 hours a day. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that equipment remains in good working order.

Based on staff interview and record review the facility failed to provide a Registered Nurse (RN) for a least 8 consecutive hours a day 7 days a week. This failure has the potential to affect all 64 residents residing at the facility. Findings include: On 6/27/23 at 9:45 AM, V5, Licensed Practical Nurse, LPN, stated RN staffing is good right now. V5 stated 6/24/23 and 6/25/23. We didn't have an RN. On 6/28/2023 at 2:35 PM, V3, Director of Nursing (DON), stated they did not have a Registered Nurse (RN), 8 hours on 6/24/23 and 6/25/23. On 6/29/23 at 10:25 AM, V15, Assistant Director of Nursing (ADON), stated she tried to cover the weekend on 6/24/23 and 6/25/23 for RN Coverage. V15 stated no RNs would cover any shifts. On 6/30/2023 V2, [NAME] President of Regional Operations stated, The facility tries to follow the regulation for RNs. The Facility's daily schedules documents there was no RN for 06/24/23 and 06/25/23. The Facility's Resident Census and Conditions of Residents form, CMS 672, documents there are 64 residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to promote residents dignity by protecting their right to a sense of well-being and safety for 1 of 1 resident (R37) reviewed for dignity in the sample of 65. Finding include: On 6/12/23 at 10:00 AM, R37 was walking up the hall and stated, I'm tired of them smoking the marijuana in my room. It's not right. When asked who he was talking about he said, (R7) and (R18). I'm tired of it. Can you do something about it? When asked about when this happened, R37 stated, I don't know, maybe a week ago. When asked if he had reported this to anyone who works in the facility. R37 stated, No, I'm reporting this to you. On 6/12/23 at 1:00 PM, R37 stated he talked to V17, Psychosocial Rehab Service Coordinator, about the other residents smoking in his room. On 6/14/23 at 10:40 AM, V26, Housekeeping, called for R7 to come outside for smoke time. V26 opened R7's bedroom door at the same time R7 came out of R37's and R9's room. V26 asked R7 what R7 was doing. R7 stated he was just visiting and began to walk up the hall toward V26. When R7 walked past, he had a very strong odor of marijuana. R37's and R9's room had very strong odor of marijuana. On 6/14/23 at 10:43 AM, R37's and R9's room and bathroom both had a very strong odor of marijuana. On 6/14/23 at 10:43 AM, R37 asked, Do you smell that smoke? (R7) was in my bathroom smoking pot. I hate that smell. On 6/15/23 at 8:28 AM, R37 stated, I hate that he (R7) comes into my room and smokes pot in my bathroom. It makes me very angry, and it is very dangerous for him to do in my bathroom. On 6/15/23 at 8:40 AM, V1, Administrator, stated, We have started doing psychosocial counseling on him (R37) daily after the incident yesterday because he (R37) was upset. I agree he should not have to deal with someone coming into his bathroom and smoking marijuana. R37's admission Record, print date of 6/14/23, documents R37 was admitted on [DATE] and has diagnoses of Schizoaffective Disorders, Anxiety, and Insomnia. R37's Minimum Data Set, dated [DATE], documents that R37 is cognitively intact. The Residents' Rights for People in Long-Term Care Facilities, dated 11/18, documents, Your rights to safety: Your facility must be safe, clean comfortable and homelike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide supervision to prevent residents with substance abuse disorders from acquiring and smoking marijuana for one of 14 residents (R7) reviewed for supervision in the sample of 65. Findings include: On 6/12/23 at 10:00 AM, R37 stated, I'm tired of them smoking the marijuana in my room. It's not right. When asked who he was talking about he said R7. R37 stated I'm tired of it. Can you do something about it? When asked about when this happened, R37 stated, I don't know, maybe a week ago. On 6/12/23 at 1:00 PM, R37 stated he talked to V17, Psychosocial Rehab Service Coordinator (PSRC), about the other residents smoking in his room. R7's admission Record Sheet, with print date of 6/14/23, documents R7 has diagnoses that included bipolar disorder, schizophrenia, major depressive disorder. R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental Status Score as 15 which indicates R7 is cognitively intact. R7's MDS documents that R7 requires supervision with bathing, dressing, toileting, transfers, and personal hygiene. R7's Care Plan, undated, documents that R7 has a history of Drug/Alcohol Abuse. The Care Plan documents (R7) is not able to receive a community pass at this time. The Care Plan documented R7 is no longer going to (regional mental health facility) for counseling. R7's Care Plan Interventions include: R7 will identify ways of maintaining a healthy lifestyle and discuss the importance of not using substances while in the facility or living in the community, allow resident to voice feelings of frustration related to situation, no alcohol use. R7 was given substance abuse material. R7's outside pass has been discontinued. R7's outpatient substance abuse service discontinued. R7's Progress Note, dated 5/18/2023 documents marijuana found in R7's room. The Note documented the scent of marijuana was lingering from his room and bathroom. The Note documented R7 initially denied smoking in his room. PRSC informed R7 his room will be searched. R7 then handed the evidence to CNA inside of an eyeglass case. R7 refused to state where or who the product came from. R7 has been counselled by PRSC and nurse. R7 appears down and depressed. PRSC will call regional community substance use program to restart services. R7's Guardian has been notified by email. On 6/14/23 at 10:40 AM, V28, Housekeeping, called for R7 to come out for smoke time. V28 opened R7's bedroom door at the same time R7 came out of R37's and R9's room. V28 asked R7 what he was doing. R7 stated he was just visiting and began to walk up the hall toward V28. R7 had a very strong odor of marijuana. R37's and R9's room had a very strong odor of marijuana. On 6/14/23 at 10:43 AM, R37 stated, Do you smell that smoke? (R7) was in my bathroom smoking pot. I hate that smell. On 6/14/23 at 10:43 AM, R37's and R9's room and bathroom had a very strong odor of marijuana. On 06/14/23 at 11:07 AM, V4, Licensed Practical Nurse LPN, stated R7 has not left the facility in several months since the last time he was he caught smoking pot. On 06/14/23 at 11:58 AM, V17, Psychosocial rehab Service Coordinator, stated R37 complained to her earlier this week that R7 was smoking marijuana in R37's bathroom. V17 stated she searched R7's room and did not find any marijuana in his room. V17 stated R7 had been caught smoking marijuana last month and they have referred R7 to regional substance use services. V17 stated the regional community substance program has not been set up yet. V17 stated R7 is set up in group counseling at the facility and R7's guardian is working on discharge planning to get R7 back into the community. V17 stated R7 stopped attending his regional community substance meetings in April 2023. On 6/14/2023 at 1:20 PM, V7, Certified Nursing Assistant, stated R7 had smoked pot about a month ago in R37's room and they searched R7's room but did not find any pot. V7 stated that they can smell it when R7 smokes pot but never find any pot when they search his room. V7 stated she does not know how R7 gets the pot because R7 doesn't leave the facility. On 6/14/2023 at 1:15 PM, V27, Care Plan Coordinator, stated R7 has a history of smoking pot in the facility and the last time was about a month ago. V27 stated the facility does search his room when he is caught smoking pot, but they haven't found any. On 6/14/23 at 2:15PM, R7 stated, I'm sorry, I'm sorry. I did it because of the state, and (friends name), my friend visited me on the weekend about a month ago and was one time and gave me a joint, roach. On 6/14/2023 at 2:55 PM V28, CNA, stated R7 came out of R37's room and when R7 got close to V28, she could smell marijuana. V28 stated she told R7 she was going to tell management. V28 stated she told V17 about smelling the pot. V28 stated she is aware R7 has a history of smoking pot in the facility and R7 is not supposed to be smoking pot in the building. V28 stated she does not see any visitors come visit R7. On 6/14/2023 at 2:00 PM, V1, Administrator, stated she expects that residents do not bring drugs into the facility. On 6/15/2023 at 8:30 AM V21, Psychiatrist, stated that he expects the facility to keep R7 from smoking marijuana. That he expects them to educate R7 and to ensure that R7 avoids smoking marijuana. V21 stated the smoking of marijuana can be harmful when it interacts with his medications. V21 stated the different strains of marijuana contain different components and could interfere with R7's medications differently and that could be dangerous since we don't know where R7 is getting the marijuana from. Facility policy titled substance use disorder guidelines dated 10/2022 documents the following in part: Staff should be prepared to address emergencies related to substance use by providing increased monitoring. The facility shall provide the necessary behavioral health care and services to support the resident in attaining or maintain the highest practicable physical, mental, and psychosocial well-being. These interventions may include but are not limited to, identify, address and or obtain necessary services for the care needs of residents. Develop and implement person centered care plans that include and support the care needs identified in the comprehensive assessment, develop individualized interventions relates to the residents diagnosed conditions ( assuring residents have access to community substance use services), review and revises care plans that have not been effective and or when the resident has a change in condition, learn the residents history and prior level of functioning in order to identity appropriate goals and interventions, providing substance use treatment services such as behavioral health, medication assisted treatment, alcoholic/narcotics anonymous meetings, working with eh resident and the family (if appropriate) to address goals related to their stay in the nursing home and increased monitoring and supervision. Identify individual resident responses to stressors and utilize person centered interventions, developed by the IDT to support each resident, or achieve expected improvements or maintain the expected stable rate of decline based on the progression of the residents' diagnosed conditions. Residents with a history of substance use disorder may be at increased risk for leaving the facility without notification and/or for illegal or prescription drug overdose if the resident continues using substance while residing in the nursing home. Residents with a history of substance use disorder should be assessed for these risks, and care plan interventions should be implemented to ensure the safety of all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Pneumococcal vaccine for 4 of 4 residents (R4, R5, R35, R64) reviewed for immunizations in the sample of 65. Findings include: 1. R35's admission Sheet, print date of 6/14/23, stated R35 was admitted on [DATE] and his date of birth is 1/31/1954. R35 is [AGE] years old. This admission Sheet documents stated R35 has diagnoses of Anxiety, Dementia, Hypertension and Chronic Obstructive Pulmonary Disease. R35's Minimum Data Set (MDS), dated [DATE], documents stated R35 is cognitively intact. R35's Authorization and Release for Pneumococcal (PCV13&PPSV23), dated 3/1/23, documents stated R35 consented to receiving the PCV13 and the PPSV23 vaccine. There was no documentation in R35's medical record R35 received the PCV13 and the PPSV23 vaccine. 2. R4's admission Sheet, print date of 6/14/23, documents R4 was admitted on [DATE] and her date of birth is 9/29/1945. R4 is [AGE] years old. This admission Sheet documents stated R4 has diagnoses of Acute Respiratory Failure and Septic Pulmonary Embolism with Acute Cor Pulmonale (a condition which causes right side heart failure. R4's MDS, dated [DATE], documents stated R4 is cognitively intact. R4's Authorization and Release for Pneumococcal (PCV13&PPSV23), dated 2/16/23, documents stated R4 consented to receiving the PCV13 and the PPSV23 vaccine. There was no documentation in R4's medical record R4 received the PCV13 and PPSV23 vaccine. 3. R5's admission Sheet, print date of 6/14/23, stated R5 was admitted on [DATE] and his date of birth is 6/5/1963. R5 is [AGE] years old. This admission Sheet documents stated R5 has diagnoses of Schizophrenia and Anxiety. R5's MDS, dated [DATE], documents stated R5 is cognitively intact. R5's Authorization and Release for Pneumococcal (PCV13&PPSV23), dated 2/10/23, documents stated R4 consented to receiving the PCV13 and the PPSV23 vaccine. There is no documentation in R5's medical record, R5 received the PCV13 and the PPSV23 vaccine. 4. R64's admission Sheet, print date of 6/14/23, stated R64 was admitted on [DATE] and his date of birth is 8/28/1974. R64 is [AGE] years old. This admission Sheet documents stated R64 has diagnoses of Schizophrenia and Hypertension. R64's MDS, dated [DATE], documents stated R5 is cognitively intact. R64's Authorization and Release for Pneumococcal (PCV13&PPSV23), dated 5/15/23, documents stated R64 consented to receiving the PCV13 and the PPSV23 vaccine. There was no documentation in R64's medical record, R64 received the PCV13 and the PPSV23 vaccine. On 6/14/23 at 10:05 AM, V3, Infection Preventionist, was questioned about why R4, R5, R35 and R64 have not been given the Pneumococcal vaccine as they requested upon admission, V3 stated, We don't vaccinate them for it because they are under [AGE] years old. Most of our building is under 65. On 6/14/23 at 11:16 AM, V2, Director of Nurses, (DON), stated, I have pulled the CDC (Center for Disease Control) guidance on Pneumococcal vaccines and moving forward we will do an audit and figure out who needs the Pneumococcal vaccine. The facility Age Summary & Average Age, dated 6/14/23, documents the facility has 63 residents and 27 residents are 65 or older. The policy Influenza and Pneumococcal Immunizations, dated 11/22, documents, Pneumococcal Immunization: Before offering the Pneumococcal immunization, each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. Each resident is offered a Pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. A second Pneumococcal vaccine will be offered only when necessary, according to the CDC guidelines. The resident or the resident's representative has the opportunity to refuse immunization. The resident's medical record includes documentation stated indicates, at a minimum, the following. Stated the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and stated the resident either received or did not receive the Pneumococcal immunization due to medical contraindications or refusal.

Based on observation, interview, and record review, the facility failed to store, serve, and sanitize food and dining surfaces in a manner to prevent potential contamination and food borne illness. This failure has the potential to affect all 63 residents living in the facility. Finding include: On 6/11/23 at 8:03 V11, Dietary Aide, and V5, Cook, were in the kitchen finishing up serving the morning meal. V5 was not wearing a beard protector. V5 had a substantial beard. The dry storage room had one large box containing many smaller boxes of Raisin Bran cereal, a case of canned fruit mix, a case of pan liners, a large case of spaghetti sauce, a large box of dried rice and a case of potatoes are on the storage room floor with multiple boxes of food products stacked on top of them. On 6/11/23 at 8:30 AM, V11 was in the dining room clearing off and cleaning the dining room tables. V11 was asked what she was using to sanitize the tables, V11 stated, The sanitizer that I get from the sink. V11 stated, This stuff right here. You just turn it on and fill the bucket. The sanitation solution was an Oasis quaternary-based solution. The bucket of solution V11 was using at the time to clean the tables was tested using a quaternary test strip. The test strip showed 100 parts per million (ppm). V11 stated, Is that good? What is it supposed to be? On 6/11/23 at 12:05 PM, V5 and V12, Dietary Manager, were serving the noon meal. V5 and V12 were not wearing beard protectors. V12 had a short, trimmed beard. On 6/12/23 at 12:00 PM, the kitchen was entered to observe the meal service. The meal was turkey, mashed sweet potatoes, corn, dinner roll and a cookie. The meal is served off a steam table. V12, V13, Cook, and V14, Dietary Aide were all present in the kitchen. V13 was the main staff member serving food with V14 assisting. V12 was baking cookies and making grilled cheese sandwiches. V12 was not wearing a beard protector. V13 failed to use a serving utensil to place the dinner roll on the plate. V13 moved throughout the kitchen touching multiple surfaces and items while wearing the same gloves. V13 changed gloves 2 times without hand hygiene in between. V14 changed gloves 3 times without hand hygiene in between. V12 changed gloves 2 times without hand hygiene. On 6/12/23 at 12:30 PM, V12 stated food or kitchen products should not be stored on the floor in the storage room. On 6/13/2023 at 9:50 AM, V12 stated, The quaternary solution should test at 150 to 400 ppm. V12 was informed that on 6/11/23 when the solution V11 was using to sanitize the dining room tables was tested and it registered at 100 ppm and that V11 did not know 100 ppm was not sufficient. V12 stated, She should have known. I do in-services on all the new products. She knows how to test it. V12 further stated, (V5) should have been wearing a beard protector. He knows that. I didn't think I needed one. (V13) should have been using tongs with the rolls of course. We should be washing our hands between glove changes most definitely. The policy Food Storage (Dry, Refrigerated, and Frozen), dated 2020, documents, 4. Dry storage guidelines to be followed: It continues, C. Store dry food on shelves two inches away from walls to allow ventilation, six inches off the floor to allow for proper sanitation, and 18 inches from the ceiling to ensure fire safety. The policy Hair Restraints, dated 2020, documents, 1. Staff shall wear hair restraints in all food production, dishwashing and serving areas. 2. Hair restraints, hats, and / or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. The policy Proper Hand Washing and Glove Use, dated 2020, documents, 6. Hands are washed before donning gloves and after removing gloves. It continues, Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hand again. The Facility's Resident Census and Condition of Residents form, CMS 672, dated 6/12/2022, documents the facility has 63 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review record the facility's physician failed to assess and provide an accurate active medical diagnosis for 4 of 4 residents (R1, R2, R3, R4) reviewed for Chronic Obstructive Pulmonary Disease (COPD) in the sample of 4. Findings include: 1. R1's untitled paper, documented 10/31/22, R2's name, birth date and shortness of breath was checked. Further documents, I would like to write a query for possible diagnosis of COPD (J44.9). Yes, please add ICD-10, (International Classification of Diseases) code to patient's list of ICD-10 codes and signed by V3 (Nurse Practitioner -NP) on 11/01/22. R1's Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD that was initiated as a medical diagnosis on 11/04/22 from an assessment that V9 (MDS Coordinator) completed. R1 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. R1's POS documents, head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, which noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 05/25/23 at 12:20PM, R1, stated, he does not smoke, does not have breathing issues, does not take any medications or sleep with his head of bed up. On 05/25/23 at 12:20PM, R1 was lying flat in bed watching television. 2. R2's, Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD that was initiated as a medical diagnosis on 11/04/22 from an assessment V9 completed. R2 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. R2's POS documents head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, which noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 05/25/23 at 12:06PM, R2 stated, she does not smoke, does not have COPD, does not receive inhalers or breathing treatments. On 05/25/23 at 12:06PM, R2 was observed in her room in a wheelchair, eager to speak to surveyor, no shortness of breath noted, no oxygen being used. 3. On 05/25/23 at 12:15PM, V3 stated, the untitled form is a respiratory screening and R3 has no indication in her medical chart to be documented for COPD. However, R3's untitled form documented date of 10/31/22, with R3's name and birth date, showed a statement shortness of breath, and history of tobacco use was checked by V9. The form further documents, I would like to write a query for possible diagnosis of COPD (J44.9). Please add ICD-10 code to patient's list of ICD-10 codes, assessment done by V9 and the form signed by V3 (NP) on 11/01/22. R3's, Physician Order Sheet (POS), dated May 1-31st, 2023, documented a diagnosis of COPD that was initiated as a medical diagnosis on 11/04/22 from an assessment V9 completed. R3 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. R3's POS documents, head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, MDS Coordinator, which she noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 5/30/23 at 9:15AM, V6, Certified Nurse Aide (CNA) stated, R3 does not smoke. On 05/30/23 at 9:25AM, R3 stated, she use to smoke but quit. On 05/30/23 at 9:25AM, R3 was lying on her left side and flat in bed. 4. R4's untitled paper, dated 10/31/22, documents R4's name and birth date, and shortness of breath, was checked. Further documents, I would like to write a query for possible diagnosis of COPD (J44.9). Yes, please add ICD-10, code to patient's list of ICD-10 codes. Signed by V3 (NP) on 11/01/22. R4's, Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD, was initiated as a medical diagnosis on 11/04/22 from an assessment V9 completed. R4 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. MDS dated [DATE], R4's POS documents head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9 noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 05/30/23 at 10:00AM, V6 stated, R4 has been here for about 5 years and has never smoked. On 05/30/23 at 10:05AM, R4 was lying in bed on his belly in a flat position. On 05/30/23 at 12:50PM, V9 stated, the untitled form she had completed on 10/31/22 on R1, R2, R3, R4 and other residents was to be used as a screening assessment only to alert V3. If a PFT (Pulmonary Function Test) was needed to be ordered treatment or medications in the future, not to provide a medical diagnosis of COPD. The form was not the actual PFT testing. V9 stated, she is aware that the MDS will have to be modified dating back to the date the inaccurate medical diagnosis was coded on the RUGS (Rate utilization Group) which reimbursement will apply. On 05/30/23 at 2:58PM, V8, Interim Administrator stated, the facility does not have a policy and/or procedure to assure Physician accuracy with documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review record the facility's Physician failed to assess and provide an accurate active medical diagnosis for 4 of 4 residents (R1, R2, R3, R4) reviewed for Chronic Obstructive Pulmonary Disease, (COPD), in the sample of 4. Findings include: 1. R1's, untitled paper, documented, a date of 10/31/22, R2's name and birth date, and shortness of breath, was check. Further documents, I would like to write a query for possible diagnosis of COPD (J44.9), Yes, please add ICD-10, (International Classification of Diseases), code to patient's list of ICD-10 codes and signed by V3, R2's Nurse Practitioner, (NP), on 11/01/22. R1's, Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD, that was initiated as a medical diagnosis on 11/04/22 from an assessment that V9, MDS Coordinator, completed and R1 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. R1's POS documents, Head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, MDS Coordinator, which she noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 05/25/23 at 12:20PM, R1, stated, he does not smoke and does not have breathing issues, and that he does not take any medications or sleep with his head of bed up. On 05/25/23 at 12:20PM, R1 was lying flat in bed watching television. 2. R2's, Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD, that was initiated as a medical diagnosis on 11/04/22 from an assessment that V9, MDS Coordinator, completed and R2 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. R2's POS documents, Head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, MDS Coordinator, which she noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 05/25/23 at 12:06PM, R2 stated, she does not smoke, does not have COPD, does not receive inhalers or breathing treatments. On 05/25/23 at 12:06PM, R2 was observed in her room in a wheelchair, eager to speak to surveyor, no shortness of breath noted, no oxygen being used. 3. On 05/25/23 at 12:15PM, V3, NP, stated, the untitled form was a respiratory screening and R3 has no indication in her medical chart to be documented for COPD. The only thing was, R3's, untitled, documented, a date of 10/31/22, with R3's name and birth date, and a statement shortness of breath, and history of tobacco use was checked, by V9, MDS Coordinator. Further documents, I would like to write a query for possible diagnosis of COPD (J44.9), Then, yes, please add ICD-10 code to patient's list of ICD-10 codes, assessment done by V9, MDS Coordinator and the form signed by V3, R3's Nurse Practitioner (NP) on 11/01/22. R3's, Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD, that was initiated as a medical diagnosis on 11/04/22 from an assessment that V9, MDS Coordinator, completed and R3 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. R3's POS documents, Head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, MDS Coordinator, which she noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 5/30/23 at 9:15AM, V6, Certified Nurse Aide, (CNA), stated, R3 does not smoke. On 05/30/23 at 9:25AM, R3 stated, she uses to smoke but quit. On 05/30/23 at 9:25AM, R3 was lying on her left side and flat in bed. 4. R4's, untitled paper, documented, a date of 10/31/22, R4's name and birth date, and shortness of breath, was check. Further documents, I would like to write a query for possible diagnosis of COPD (J44.9), Yes, please add ICD-10, code to patient's list of ICD-10 codes and signed by V3, R2's Nurse Practitioner, (NP), on 11/01/22. R4's, Physician Order Sheet, (POS), dated May 1-31st, 2023, documented a diagnosis of COPD, that was initiated as a medical diagnosis on 11/04/22 from an assessment that V9, MDS Coordinator, completed and R4 has no respiratory medication/inhalers/oxygen ordered to the diagnosis. MDS dated [DATE] R4's POS documents, Head of bed elevated to prevent to shortness of breath. Resident has shortness of breath while lying flat. This assessment was written by V9, MDS Coordinator, which she noted was related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). On 05/30/23 at 10:00AM, V6 stated, R4 has been here for about 5 years and has never smoked. On 05/30/23 at 10:05AM, R4 was lying in bed on his belly in a flat position. On 05/30/23 at 12:50PM, V9, Minimum Data Set Coordinator, (MDS), stated, the untitled form, she had completed on 10/31/22 on R1, R2, R3, R4 and other residents was to be used as a screening assessment only, to alert V3 if a PFT, (Pulmonary Function Test), would be need to be ordered treatment or medications in the future, not to provide a medical diagnosis of COPD, as the form was not the actual PFT testing. V9 continued to state, that she is aware that the MDS, will have to be modified dating back to the date the inaccurate medical diagnosis was coded on the RUGS, (Rate utilization Group), in which reimbursement will apply. On 05/30/23 at 2:58PM, V8, Interim Administrator stated, the facility does not have a policy and/or procedure to assure Physician accuracy with documentation.

Based on observation, record review and interview, the facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week and failed to designate a Registered Nurse to serve as the Director of Nursing on a full-time basis. This failure has the potential to affect all 63 residents living in the facility. Findings include: On 1/6/2023 at 8:47 AM, V2, Licensed Practical Nurse (LPN)/Director of Nurses (DON), stated IDPH was here last month for RN coverage and we still have a few holes in the schedule without an RN every day. V2 said she is the DON at the facility, We don't have an RN for this position. V2 stated she knows that the DON position needs to be an RN. V2 stated she is performing the duties of the Director of Nursing. On 1/6/2023 at 9:02 AM, V1, Administrator, stated, We've had a couple of days with no RN's for the eight hour coverage per day. (V2) is the Director of Nursing, and she is an LPN. On 1/6/ 2023 at 10:03 AM, V4, RN, stated they've had couple of holes on the schedule in December without an RN the past couple of weeks. V4 stated V2 is an LPN and she is the DON, they don't have an RN as DON. The Staffing schedules for (dates) document there was no Registered Nurse working on 12/16/2022, 12/17/2022, and 12/22/2022. During this investigation on 1/6/2022 and 01/10/2023, V2, LPN, was working as the DON in the facility. The Resident Census and Conditions of residents, CMS 672, dated 12/5/2022 documents that the facility has 63 residents living in the facility.

Based on observation, record review and interview, the facility failed provide a registered nurse for at least 8 consecutive hours a day, 7 days a week on the dates of 12/2/2022 and 12/3/2022 and failed to designate a registered nurse to serve as the director of nursing on a full-time basis. This failure has the potential to affect all 61 residents living in the facility. Findings include: On 12/5/22 at 1:30 PM, V3, MDS (Minimum Data Set) Coordinator, stated that V2, Director of Nurses (DON), is the DON and that V2 is a LPN (Licensed Practical Nurse). On 12/5/22 at 1:30 PM, V1, Administrator, and V2 both stated that V2 is the Director of Nursing. V2 acknowledged that she is an LPN. V2 stated she is aware that the DON position needs to be an RN (Registered Nurse). V2 stated she is performing the duties of the Director of Nursing, but she is an LPN. V2 stated the facility is having a difficult time hiring RN's. On 12/5/22, V2 was the only Director of Nursing of the facility. The Staffing schedules were reviewed for the past 4 days. On the dates of 12/2/2022 and 12/3/2022 there was no documented Registered Nurse on those days. The Resident Census and Conditions of residents, CMS 672, dated 12/5/2022 documents that the facility has 61 residents living in the facility.

Based on observation, record review and interview, the facility failed provide a Registered Nurse for at least 8 consecutive hours a day, 7 days a week and failed to designate a Registered Nurse to serve as the Director of Nursing on a full-time basis. This has the potential to affect all 62 residents living in facility. Findings include: On 11/30/2022 at 8:00 AM, V3, Licensed Practical Nurse, (LPN), stated, that V2, Director of Nurses, (DON), is the DON and that V2 is a LPN. On 11/30/2022 at 2:00 PM, V1, Administrator and V2 both stated, that V2 is the Director of Nursing. V2 acknowledged that she is an LPN. On 11/30/2022 at 3:30 PM, V2 stated, she is aware that the DON position needs to be an RN. V2 stated, she is performing the duties of the Director of Nursing, but she is an LPN. V2 stated, the facility is having a difficult time hiring RN's. The Staffing schedules were reviewed for the past 30 days. On the dates of 11/4/2022, 11/10/2022 and 11/18/2022 there was no documented Registered Nurse on duty those days. During this investigation it was observed that V2 was functioning as the Director of Nursing of the facility. The Resident Census and Conditions of residents, CMS 672, dated 11/30/2022 documents that the facility has 62 residents living in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report a resident-to-resident altercation as a potential abuse for 2 of 6 residents (R32, R44) reviewed for abuse in the sample of 65. Findings include: 1. R44's Current Face Sheet document R44 was admitted to the facility on [DATE] with diagnosis of schizophrenia, major depressive disorder and anxiety. R44's MDS dated [DATE] document R44 is cognitive intact and requires supervision for ambulation locomotion. R44's Care Plan documents a focus area of history of criminal behavior. R44 has identified offense; disorderly conduct, criminal trespassing and behavior problem related to schizophrenia, anxiety with interventions to appropriate supervision and observations and provide psychoactive medications as ordered; trauma informed care related to history of suicidal ideations, substance abuse and periods of homelessness (4/22/20) with interventions to ensure safety to residents and others; R44 became physical aggressive with staff related to schizophrenia, Major depression disorder, recurrent, R44 chased another worker down the hall (2/10/22) with interventions to monitor observed behavior and attempted interventions in behavior log; wandering poor safety awareness related to wandering risk assessment (7/18/22); R44 is at risk for abuse neglect related to SMI (serious mental illness). R44's Nurses Notes dated 8/3/22 documents R44 increasingly upset and hit another resident in the chest. R44's 72-hour note dated 8/3/22 document a follow up assessment of resident-to-resident altercation. 2. R32's Current Face Sheet documents R32 waws admitted [DATE] with diagnosis of schizophrenia, anxiety and major depressive disorder. R32's Minimum Data Set 7/6/22 documents R32 is cognitively intact and requires supervision for ambulation and locomotion. R32's Care Plan dated 4/17/20 documents a focus area of trauma informed care emotional abuse, history of criminal behavior (2/7/20) with intervention to provide psychoactive medication as ordered and record behavior symptoms and side effects; behavior problem yelling at others, becomes verbal abusing (4/28/20); has the potential to be physically aggressive related to past aggravated battery, R32 became physically aggressive toward his roommate (2/7/20) with interventions of when resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmy in conversation; wandering poor safety awareness with intervention to provide a program of activities that is of interest and accommodate resident status, ask what he enjoys and encourage to participate; has mood problem related to major depression schizophrenia, paranoia, anxiety, and insomnia, can be easily confused and experience some cognitive loss related to symptoms of SMI (serious mental illness( and long term psychotropic medication use (11/8/2019); has potentially high risk for abuse neglect related to depression and mental illness. A facility note dated 8/4/22 signed by R44 documents he does not remember exactly what happened with R32. R32's Nurses Notes dated 8/3/22 documents at 9:29PM R32 was hit by another resident. R32's Nurses Note dated 8/4/22 documents a follow up assessment of resident-to-resident altercation. R32's Nurses Note dated 8/4/22 documents V1, Administrator interviewed R32 regarding incident with another resident and R32 states they bumped into one another- this was just an accident. On 08/24/22 at 11:15 AM, V1, Administrator, stated when she interviewed both R32 and R44 they said they bumped elbows. V1 stated she did not report to anyone else. On 8/29/22 at 12:20PM, V2, Director of Nursing stated she did not recall the incident. V2 stated staff calls either V1 or V2 with any resident to resident and she doesn't remember. The Facility's audit tool for abuse allegations and investigations for the week of 8/1/22 documents none to be reported. The Facility's Abuse Policy dated 4/22 documents the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. External reporting: Public Health shall be informed that an occurrence of potential abuse, neglect exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly investigate a resident-to-resident altercation as a potential abuse for 2 of 6 residents (R32, R44) reviewed for abuse in the sample of 65. Findings include: 1. R44's Current Face Sheet document R44 was admitted to the facility on [DATE] with diagnosis of schizophrenia, major depressive disorder and anxiety. R44's MDS dated [DATE] document R44 is cognitive intact and requires supervision for ambulation locomotion. R44's Care Plan documents a focus area of history of criminal behavior. R44 has identified offense; disorderly conduct, criminal trespassing and behavior problem related to schizophrenia, anxiety with interventions to appropriate supervision and observations and provide psychoactive medications as ordered; trauma informed care related to history of suicidal ideations, substance abuse and periods of homelessness (4/22/20) with interventions to ensure safety to residents and others; R44 became physical aggressive with staff related to schizophrenia, Major depression disorder, recurrent, R44 chased another worker down the hall (2/10/22) with interventions to monitor observed behavior and attempted interventions in behavior log; wandering poor safety awareness related to wandering risk assessment (7/18/22); R44 is at risk for abuse neglect related to SMI (serious mental illness). R44's Nurses Notes dated 8/3/22 documents R44 increasingly upset and hit another resident in the chest. R44's 72-hour note dated 8/3/22 document a follow up assessment of resident to resident altercation. 2. R32's Current Face Sheet documents R32 waws admitted [DATE] with diagnosis of schizophrenia, anxiety and major depressive disorder. R32's Minimum Data Set 7/6/22 documents R32 is cognitively intact and requires supervision for ambulation and locomotion. R32's Care Plan dated 4/17/20 documents a focus area of trauma informed care emotional abuse, history of criminal behavior (2/7/20) with intervention to provide psychoactive medication as ordered and record behavior symptoms and side effects; behavior problem yelling at others, becomes verbal abusing (4/28/20); has the potential to be physically aggressive related to past aggravated battery, R32 became physically aggressive toward his roommate (2/7/20) with interventions of when resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmy in conversation; wandering poor safety awareness with intervention to provide a program of activities that is of interest and accommodate resident status, ask what he enjoys and encourage to participate; has mood problem related to major depression schizophrenia, paranoia, anxiety, and insomnia, can be easily confused and experience some cognitive loss related to symptoms of SMI (serious mental illness( and long term psychotropic medication use (11/8/2019); has potentially high risk for abuse neglect related to depression and mental illness. A facility note dated 8/4/22 singed by R44 documents he does not remember exactly what happened with R32. R32's Nurses Notes dated 8/3/22 documents at 9:29PM R32 was hit by another resident. R32's Nurses Note dated 8/4/22 documents a follow up assessment of resident-to-resident altercation. R32's Nurses Note dated 8/4/22 documents V1, Administrator interviewed R32 regarding incident with another resident and R32 states they bumped into one another- this was just an accident. On 08/24/22 at 11:15 AM, V1, Administrator, stated she does not have an investigation on R32 and R44 from 8/3/22. V1 stated when she interviewed both R32 and R44 they said they bumped elbows and it was not founded as abuse and that should be stricken out from the record. When asked how she knows abuse didn't occur if she did not do a thorough investigation, V1 stated that if residents say they aren't abused then that's it. V1 stated that is their policy. V1 stated she has staff put allegations of abuse in risk management and then when they ask the residents if it was abuse, they strike it out in the record when they say no. V1 stated she did not ask other residents or staff what occurred and there's no investigation. On 8/29/22 at 12:20PM, V2, Director of Nursing stated she did not recall the incident. V2 stated staff calls either V1 or V2 with any resident to resident and she doesn't remember. The Facility's audit tool for abuse allegations and investigations for the week of 8/1/22 documents none to be reported. The Facility's Abuse Policy dated 4/22 documents the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or inappropriate of resident property will result in an investigation. Investigation procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Resident to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed to determine whether anyone has witnessed any prior abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide adequate services for range of motion (ROM) to maintain and/or improve function for 2 of 2 residents (R33, R56) reviewed for ROM in the sample of 65. Findings include: On 8/23/2022 at 2:30 PM, R56 was sitting up on the edge of his bed. His wheelchair was next to his bed with a right arm and hand wheelchair support cushion. R56 shook his head no when asked if staff do exercises with his right arm and hand. On 8/24/2022 at 9:38 AM, R56 was lying in bed in his room. R56 shook head no when asked if staff have exercised his right arm. R56 gestured and mouthed I don't know when asked if his right arm mobility has changed since he came to the facility. R56's Face Sheet documents R56 was admitted to the facility on [DATE] and has diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, and age related osteoporosis without current pathological fracture. R56's Minimum Data Sheet (MDS) dated [DATE] documents R10 is moderately cognitively impaired and requires extensive one person assistance for bed mobility, transfer, dressing, toileting and personal hygiene. R56's Restorative Observations dated 7/28/2022 and 8/24/2022 document R56 does not have current or newly initiated restorative programs for PROM (passive range of motion) or AROM (active range of motion). On 8/24/2022 at 9:32 AM, V3, MDS Coordinator and Restorative Nurse, stated, I just put (R56) on ROM for his arm today because he was resistant to do it at first. No documentation was received regarding facility attempt to initiate ROM on admission. The Facility's Restorative Nursing Program Policy with revision date of 1/2019 documents, Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. To determine a restorative need for a new admission: Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitations with ROM and/or pain. Develop an individualized program based on the resident's restorative needs, and include the restorative program on the care plan. A functional maintenance program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers, bathing, etc. 2. On 8/24/2022 at 11:25AM, V11, CNA, stated R33 does get range of motion. V11 stated when she works, she does R33's ROM before R33 gets up. V11 stated that R33 is paralyzed on one side and does not do that sides. On 8/25/2022 at 11:18AM, R33 stated that he does not get any type of range of motion/ movement on extremities. When asked by surveyor, R33 physically unable to lift right arm or wrist. R33's right wrist had wrist drop and fingers to right hand bent towards R33's right hand. R33's care plan dated 7/12/2022 documents that R33 has limited range of motion in rt. arm, shoulder, elbow, wrist, hand, fingers r/t: contractor, Right Lower Extremity (RLE) flaccid, disease process post CVA (stroke). R33's Care plan documents the following interventions: · AROM to LUE (left upper extremity)/LLE (left lower extremity) 10 reps (repetitions) BID (2 times a day) x 7 per week. · Staff will complete Passive Range Of Motion Program staff will perform ROM to RUE (right upper extremity)/RLE 10 reps BID 6 to 7x per week. · Assess pain. · Assist to position of comfort for exercise. · Demonstrate exercise and have resident return demonstration. · Encourage socialization during exercise · Provide encouragement · Provide pain medication prior to exercise. R33's Minimum Data Set (MDS) dated [DATE] documents that R33 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide monitoring and supervision for 1 of 16 residents (R50) reviewed for supervision in the sample of 65. Findings include: R50's admission Record, print date of 8/25/22, documents R50 was originally admitted to the facility on [DATE] and that R50 has diagnoses of Bipolar Disorder, Major Depressive Disorder and Schizophrenia. R50's Minimum Data Set, dated [DATE], documents that R50 is cognitively intact and that R50 has behaviors not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal / vocal symptoms like screaming, disruptive sounds) and that these behaviors significantly interfere with the resident's participation in activities or social interactions. The most current 3 Resident Sign in and out sheets were reviewed. The first sheet documents that R50 dated the log 4/16 at 6:21 there is no staff signature of when resident came back to the facility. The date entered is assumed to be wrong because the entry before R50's is 8/17. On this sheet there are 13 residents that signed out and only 1 resident is signed back in by a staff member with the time. The second sheet reviewed documents dates of 8/18/22 - 8/20/22 and it documents R50 left the building 4 times. On 8/18/22 at 4:00, 8/19/22 at 6:00 and 7:35 and 8/20 at 4:30. All 4 of these entries are missing a staff member signing R50 back in and if the times are AM or PM. On this sheet there are 14 entries of residents leaving the building and none have been signed back into the building correctly. The third sheet which was the current sheet being utilized on 8/25/22 has no dates it documents R50 went out at 4:30 and 5:48. This sheet documents 8 entries of residents leaving and retuning to the facility none of these entries have been signed back into the facility by staff. R50's Group Social Service Note, dated 07/28/2022 at 2:30 PM, documents, spent 30 minutes in this group. (R50) attended Other (describe) group. The group topic discussed included: The purpose of the group is to educate the residence of the importance of focusing on their wellbeing without substances whether they are in the community with family or planning to live in the community independently. R50 responded to others in a(n) (R50) agreed to attend group and its purpose and discuss his hx (history) of substance use prior to nursing home and complete assignments. manner. (R50) Discussed topics, such as (R50) agreed to attend group and its purpose and discuss his hx (history) of substance use prior to nursing home and complete assignments. The plan for (R50) is to Continue group sessions. The interdisciplinary goal for (R50) is to understand and implement the plan of care to reduce distressing symptoms. group will be encouraged to help educate the importance of focusing on maintaining a healthy lifestyle. R50's Social Service Note, dated 8/5/22, documents, No outside services are needed at this time regarding substance abuse issues. R50's Social Service Note, dated 8/8/22, documents, (V15, R50's State Guardian) grants him permission to go into the community as long as he follows the facility policy of signing out and in. She also encouraged him to ensure he is in the facility for meals and medication. On 8/23/22 at 1:43 PM, V15, State Guardian, stated, I recently gave consent for (R50) to sign himself in and out of the building. The facility contacted me about it because he wanted it. I am curious to see how he does because he has been locked up in there for a couple years. On 8/24/22 at 8:30 AM, V14, Licensed Practical Nurse (LPN), was questioned about how do residents utilize the sign in and out sheet. V14 stated that when the resident leaves they are to sign out and let a nurse know that they are leaving and when they come back they should let us know and then we sign them back in. The form should be dated, timed and signed. On 8/24/22 at 10:12 AM, V4, Registered Nurse (RN), stated that she did not realize that (R50) had been going out. V4 stated that it must be something new. She stated he just goes up to the gas station and comes back. He has been coming back sober with no issues. V4 stated, Once he did take another resident's money to buy her things and he did not come back with all the correct change, so social service had to talk to him about that. V4 was questioned about if R50 has delusions, V4 stated, Yes, he has delusions about living in the community and that is is not at all realistic. I don't see how he could do that. On 8/25/22 at 10:20 AM, V12, Certified Nurses Aide (CNA), stated that R50 has been going out recently. R50 would go in and out. I would ask him what is he doing because it was just in and out. He said that he was just going out. I haven't caught him with any drugs but I think he is up to something. On 8/25/22 at 10:37 AM, V13, CNA, brought the survey team a paraphernalia smoking pipe and a moderate amount of marijuana that was rolled into a ball. V13 stated that she found it in R50's room. On 8/25/22 at 11:00 AM, V1, Administrator, stated, I have just been made aware of marijuana being found in R50's room. I am going to remove his outside privileges. I will notify his state guardian. I will talk with him. We will see about getting him into an AA (Alcoholic's Anonymous) program since he is actively using. V1 was questioned about how did they determine he was safe to go out, V1 stated, We did a community assessment on him, we interviewed him, educated him on being safe in the community, what he can and can't do. We also got permission from his state guardian. V1 stated that when a person comes back from and outing they are searched by staff to look for contraband. V1 was asked then how did R50 get marijuana in the building, V1 stated that some of the residents really hide the contraband on their person. V1 was showed the sign in and out log and asked how the log works, V1 stated that the log should be dated and timed on when the resident left. When the resident comes back the staff should enter the time and date it and then sign it and then they would search for contraband. V1 agreed that the log was not filled out properly. V1 stated that she believed V22, Social Service Director, had been working with R50 on preparing him for going out into the community with one to one sessions. On 8/25/22 at 11:45 AM, R50 was questioned about the marijuana, R50 stated, I had a friend get me the drugs. I didn't know. I am sorry. R50 was questioned if he got the drugs when he was out in the community or if his friend brought the drugs into the facility, R50 refused to answer. R50 stated, I just got able to go out. I messed up. I want to be able to get my own place. I am sorry. I didn't know. On 8/25/22 at 2:20 PM, V20, Medical Doctor, stated that the use of marijuana is not good for someone like R50 or anyone with mental illness. V20 stated that it can increase his delusions and paranoia. V20 also stated that he was not consulted if R50 to be out in the community by himself and that he is going to have the facility ask him also before someone can have a community pass. On 8/30/22 at 2:00 PM, V22, Psychiatric Rehabilitation Services Coordinator (PRSC), stated that she had spoken to (R50) about drug abuse out in the community and the proper way to use the sign in and sign out sheet. On 8/25/22 at 12:32 PM, R50's Electronic Medical Record was reviewed. R50 did not have a Community Assessment or any one to one sessions with Social Service available for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct medication reviews for 3 of 5 residents (R32, R35, R64) in the sample of 62 reviewed for medication reviews. Findings include: 1. F64's Current Face sheet document R64 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, major depression disorder, and anxiety disorder. R64's [DATE] Physician Order Sheet documents R64 takes the following medications: carbamazepine, Risperdal, Tegretol, Ativan, Eliquis, clopidogrel R64's MDS dated [DATE] documents R64 is cognitively intact and frequency of symptom score of 19 which indicates R64 has moderate severe depression R64's Care Plan documents focus areas of the following: behavior problem begging for money and snack from peers and staff related to schizophrenia ([DATE]); resistive to care, showers ([DATE]); risk for falls related to psychotropic medication use ([DATE]); has depression related to major depression disorder ([DATE]). R64's Care Plan fails to document psychotropic medication use with interventions and fails to document interventions for R64's behaviors. R64's Psychotropic Medication Observation assessment dated [DATE] documents R64 attends in house programming, has psychotic features of delusions, social skill impairment, memory impairment and abnormal thinking and has behaviors of angry, agiat3ed, depressed, needy, demanding, restless. R64's assessment documents psychotropic medications of risperidone 3mg twice daily, mirtazapine 30mg daily, Ativan 0.5mg twice daily, and Vistaril 25mg twice daily. R64's Clinical Record failed to document Monthly Medication Regime review from [DATE] to [DATE]. R64's Clinical Record failed to document Gradual Dose Reductions. [DATE] 01:00 PM V19, Corporate Nurse Consultant stated they have had 3 pharmacies in the last year. V19 stated she has never heard of a regulation that you have to do a medication regime review and in a resident's clinical record. 2. F35's Current Face sheet document R35 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. R35's [DATE] Physician Order Sheet documents R35 takes the following medications: Zyprexa. R35's MDS dated [DATE] documents R35 is cognitively intact and frequency of symptom score of 19 which indicates R35 has moderate depression R35's Care Plan documents focus areas of R35 has diagnosis of schizophrenia and has a grandiose delusion reporting he is a doctor and has died twice. R35 reports that he was male raped by 11 men 30-35 times at outside facility ([DATE]) with interventions of encourage R35 to follow mental health treatment plans, provide psychiatric management to monitor psycho-active medications, provide support and enhance structure, staff to monitor and document all behaviors, teach stress/anxiety, management techniques to cope with anger, poor ability to deal with frustrating situation, impulsive and impatient behavior. R35 has the following behaviors ([DATE]). R35 has the following behaviors: R35 tells falsehoods about other residents or staff and will urinate in inappropriate places. Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential cause R35's Clinical Record failed to document Monthly Medication Regime review from [DATE] to [DATE]. R35's Clinical Record failed to document Gradual Dose Reductions. 3. R32's Current Face Sheet documents R32 waws admitted [DATE] with diagnosis of schizophrenia, anxiety and major depressive disorder. R32's [DATE] Physician Order Sheet documents R32 takes the following medications: mirtazapine 15mg daily, trazodone 140mg daily, aripiprazole 20mg daily, Ativan 0.5mg four times a day, Haldol 50mg IM every 30 days, Haldol 1mg twice a day, Latuda 20mg daily, R32's MDS dated [DATE] documents R32 is cognitively intact and frequency of symptom score of 19 which indicates R32 has moderate depression R32's Care Plan documents focus areas of R32 has a behavior problem yelling at others, becomes verbally abusive using foul language, intimidation with words and hand gestures, easily agitated related to mood. R32's Nursing Note dated [DATE] document GDR requests faxed to doctor, awaiting reply. No documentation found in R32's record of response. R32's Clinical Record failed to document Monthly Medication Regime review from [DATE] to [DATE]. R32's Clinical Record failed to document Gradual Dose Reductions. On [DATE] at 12:50PM, after multiple requests for facility's policy medication review and dose reduction, V2, Director of Nursing stated she was not sure if they had one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident centered behavior tracking that included resident specific drug and behaviors for 4 of 4 residents (R32, R35, R44, R64) reviewed for unnecessary medications in the sample of 65. Findings include: 1. F64's Current Face sheet document R64 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, major depression disorder, and anxiety disorder. R64's [DATE] Physician Order Sheet documents R64 takes the following medications: carbamazepine, Risperdal, Tegretol, Ativan, Eliquis, clopidogrel R64's MDS dated [DATE] documents R64 is cognitively intact and frequency of symptom score of 19 which indicates R64 has moderate severe depression R64's Care Plan documents focus areas of the following: behavior problem begging for money and snack from peers and staff related to schizophrenia ([DATE]); resistive to care, showers ([DATE]); risk for falls related to psychotropic medication use ([DATE]); has depression related to major depression disorder ([DATE]). R64's Care Plan fails to document psychotropic medication use with interventions and fails to document interventions for R64's behaviors. R64's Psychotropic Medication Observation assessment dated [DATE] documents R64 attends in house programming, has psychotic features of delusions, social skill impairment, memory impairment and abnormal thinking and has behaviors of angry, agitated, depressed, needy, demanding, restless. R64's assessment documents psychotropic medications of risperidone 3mg twice daily, mirtazapine 30mg daily, Ativan 0.5mg twice daily, and Vistaril 25mg twice daily. R64's Behaviors Monitoring and Interventions Report dated [DATE] to [DATE] documents response not required multiple times throughout review dates and are not resident specific. A facility log of group attendance for behavior programming dated [DATE] through [DATE] does not document R64 attended any session. [DATE] 01:00 PM V19, Corporate Nurse Consultant stated they have had 3 pharmacies in the last year. V19 stated she has never heard of a regulation that you have to do a medication regime review and in a resident's clinical record. 2. F35's Current Face sheet document R35 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. R35's [DATE] Physician Order Sheet documents R35 takes the following medications: Zyprexa. R35's MDS dated [DATE] documents R35 is cognitively intact and frequency of symptom score of 19 which indicates R35 has moderate depression R35's Care Plan documents focus areas of R35 has diagnosis of schizophrenia and has a grandiose delusion reporting he is a doctor and has died twice. R35 reports that he was male raped by 11 men 30-35 times at outside facility ([DATE]) with interventions of encourage R35 to follow mental health treatment plans, provide psychiatric management to monitor psycho-active medications, provide support and enhance structure, staff to monitor and document all behaviors, teach stress/anxiety, management techniques to cope with anger, poor ability to deal with frustrating situation, impulsive and impatient behavior. R35 has the following behaviors ([DATE]). R35 has the following behaviors: R35 tells falsehoods about other residents or staff and will urinate in inappropriate places. Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential cause R35's Behaviors Monitoring and Interventions Report dated [DATE] to [DATE] documents response not required multiple times throughout review dates and are not resident specific. 3. R32's Current Face Sheet documents R32 waws admitted [DATE] with diagnosis of schizophrenia, anxiety and major depressive disorder. R32's [DATE] Physician Order Sheet documents R32 takes the following medications: mirtazapine 15mg daily, trazodone 140mg daily, aripiprazole 20mg daily, Ativan 0.5mg four times a day, Haldol 50mg IM every 30 days, Haldol 1mg twice a day, Latuda 20mg daily, R32's MDS dated [DATE] documents R32 is cognitively intact and frequency of symptom score of 19 which indicates R32 has moderate depression R32's Care Plan documents focus areas of R32 has a behavior problem yelling at others, becomes verbally abusive using foul language, intimidation with words and hand gestures, easily agitated related to mood. R32's Behaviors Monitoring and Interventions Report dated [DATE] documents response not required or Not applicable multiple times throughout review dates and are not resident specific. A facility log of group attendance for behavior programming dated [DATE] through [DATE] does not document R32 attended any session. 4. R44's admission Record, print date of [DATE], documents that R4 was admitted on [DATE] and has diagnoses of Schizophrenia, Major Depressive Disorder and Anxiety Disorder. R44's MDS, dated [DATE], documents R44 is cognitively intact, hallucinates and delusions, behavioral symptoms not directed towards other occurred 4 to 6 days, R44's behaviors put him at significant risk for physical illness or injury, interfered with his care and his participation with activities or social interaction. R44's [DATE] Order Summary, documents, Clozapine Tablet give 100 mg by mouth at bedtime relate to unspecified schizophrenia, Lamictal Tablet 150 mg Give 150 mg by mouth at bedtime related to major depressive disorder and Seroquel tablet 50 mg. 50 mg by mouth twice a day related to Schizophrenia. R44's Behavior Tracking fails to document R44's specific psychotropic medications. R44 behavior tracking sheet, dated 8/22, is blank from [DATE] to [DATE]. This behavior monitoring form documents R44 was only aggressive on [DATE] night shift and 29 shifts had no documentation. On [DATE] at 2:30 PM, V1, Administrator, agreed the behavior tracking sheets are not resident specific.

Based on observation, interview and record review, the facility failed to safely administer medications for 5 of 5 residents (R7, R20, R28, R30, R52) reviewed for medication storage in the sample of 65. Findings include: On 8/24/22 at 7:35 AM, V4, Registered Nurse, was observed passing medications. In V4's top drawer of her medication cart were 5 medication cups with names on them and pills in the cup. R28's cup had 3 pills in it. R7's cup had 8 pills in it. R52's cup had 10 pills in it. R20's cup had 7 pills in it. R30's cup had 4 pills in. On 8/24/22 at 7:35 AM, R4 was questioned about the filled medication cups, R4 stated, I got them ready earlier. I get like 4 medication cups ready at a time. The pills are for the 7 - 8 AM medication pass. What's wrong, I can't do that? On 8/24/22 at 10:30 V2, Director of Nurses, stated, The nurses know that they shouldn't pre-pop medications. The facility policy and procedure Medication administration Policy, dated 5/22, documents, Medications may not be pre - poured, e.g., only prepare and administer medications for one resident at a time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. F64's Current Face sheet document R64 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, major depression disorder, and anxiety disorder. R64's August 2022 Physician Order Sheet documents R64 takes the following medications: carbamazepine, Risperdal, Tegretol, Ativan, Eliquis, clopidogrel. R64's MDS dated [DATE] documents R64 is cognitively intact and frequency of symptom score of 19 which indicates R64 has moderate severe depression. R64's Care Plan documents focus areas of the following: behavior problem begging for money and snack from peers and staff related to schizophrenia (3/12/21); resistive to care, showers (3/29/21); risk for falls related to psychotropic medication use (9/28/20); has depression related to major depression disorder (10/8/20). R64's Care Plan fails to document psychotropic medication use with interventions and fails to document interventions for R64's behaviors. R64's Psychotropic Medication Observation assessment dated [DATE] documents R64 attends in house programming, has psychotic features of delusions, social skill impairment, memory impairment and abnormal thinking and has behaviors of angry, agitated, depressed, needy, demanding, restless. R64's assessment documents psychotropic medications of risperidone 3mg twice daily, mirtazapine 30mg daily, Ativan 0.5mg twice daily, and Vistaril 25mg twice daily. R64's Behaviors Monitoring and Interventions Report dated May 2022 to August 2022 documents response not required multiple times throughout review dates. A facility log of group attendance for behavior programming dated May 2022 through August 2022 does not document R64 attended any session. 3. F35's Current Face sheet document R35 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. R35's August 2022 Physician Order Sheet documents R35 takes the following medications: Zyprexa. R35's MDS dated [DATE] documents R35 is cognitively intact and frequency of symptom score of 19 which indicates R35 has moderate depression. R35's Care Plan documents focus areas of R35 has diagnosis of schizophrenia and has a grandiose delusion reporting he is a doctor and has died twice. R35 reports that he was male raped by 11 men 30-35 times at outside facility (1/22/2016) with interventions of encourage R35 to follow mental health treatment plans, provide psychiatric management to monitor psycho-active medications, provide support and enhance structure, staff to monitor and document all behaviors, teach stress/anxiety, management techniques to cope with anger, poor ability to deal with frustrating situation, impulsive and impatient behavior. R35 has the following behaviors (6/20/22). R35 has the following behaviors: R35 tells falsehoods about other residents or staff and will urinate in inappropriate places. Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential cause R35's Behaviors Monitoring and Interventions Report dated May 2022 to August 2022 documents response not required multiple times throughout review dates. A facility log of group attendance for behavior programming dated May 2022 through August 2022 does not document R35 attended any session. 4. R32's Current Face Sheet documents R32 waws admitted [DATE] with diagnosis of schizophrenia, anxiety and major depressive disorder. R32's August 2022 Physician Order Sheet documents R32 takes the following medications: Zyprexa. R32's MDS dated [DATE] documents R32 is cognitively intact and frequency of symptom score of 19 which indicates R32 has moderate depression R32's Care Plan dated 4/17/20 documents a focus area of trauma informed care emotional abuse, history of criminal behavior (2/7/20) with intervention to provide psychoactive medication as ordered and record behavior symptoms and side effects; behavior problem yelling at others, becomes verbal abusive using foul language intimidation with words and hand gestures, easily agitated related to mood (4/28/20); has the potential to be physically aggressive related to past aggravated battery, R32 became physically aggressive toward his roommate (2/7/20) with interventions of when resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmy in conversation; wandering poor safety awareness with intervention to provide a program of activities that is of interest and accommodate resident status, ask what he enjoys and encourage to participate; has mood problem related to major depression schizophrenia, paranoia, anxiety, and insomnia, can be easily confused and experience some cognitive loss related to symptoms of SMI (serious mental illness) and long term psychotropic medication use (11/8/2019); has potentially high risk for abuse neglect related to depression and mental illness. R32's Behaviors Monitoring and Interventions Report dated May 2022 to August 2022 documents response not required multiple times throughout review dates. A facility log of group attendance for behavior programming dated July 2022 through August 2022 does not document R32 attended any session. R32's Social Service note dated 4/19/2022 documents When interviewing (R32), for his quarterly assessment, (R32) disclosed that he feels that he would be better off dead, and he feels this way nearly every day. (R32) has no plan, however. The nurse was notified. On 08/22/22 at 9:55 AM, R32 was walking out in hallway walking with walker towards front of the hallway. V9, CNA, asked R32 what is wrong and then states you're mad at me because I'm the only one on the hallway. No interventions were provided to R32. On 08/22/22 at 10:20 AM, R32 was yelling Get me out of this shit hole. R32 continued to yell two more times before unidentified staff passing by asked R32 what he wanted, and he stated he wanted his coffee. No intervention provided to R32. V4, Activity aide, then went over to R32 and asked R32 what he needed. No intervention provided to R32. On 08/22/22 at 10:45 AM, R32 was yelling out walking back to his room. No staff intervention for R32. On 08/23/22 at 09:13 AM, V5, activity aide, states it is too early in the morning yet for (R32) to be yelling and to just wait. V5 states R32 wanted someone to go to the store yesterday for coffee because he wanted his own can. V5 stated they told R32 they were making a run later this week to the store. On 08/25/22 at 10:11 AM, R32 yelled down hallway what are you laughing at? I'm going to hurt you! and flexed his bicep. V12 went down hall and asked R32 what was wrong with no interventions. On 08/25/22 at 11:10 AM, R32 was in the dining room yelling at table mate R56. R32 then stood up from the table and put his fist up towards R32 and started shaking it at R56 and continuing to yell. V2, Director of Nursing was seated at a table adjacent to R32 and stood up next to R32. R32 then independently sat at a nearby table continuing to yell with no staff intervention. On 08/25/22 at 10:05 AM, V4, Registered Nurse, states R32 always has the yelling out behavior. V4 states she is very familiar with R32, and he gets agitated and yells. V4 states she thinks the CNAs do behavior tracking but not sure what is done with it. V4 states she has had R32 make statement about wanting to die or kill himself and he doesn't have a plan, so she just talks to him or do a 1:1 if R32 lets her. V4 states if it got to a point she would call doctor or send R32 out. On 08/25/22 at 10:11 AM, V12, CNA, stated R32 yells out all the time. V12 stated they didn't have coffee this morning so R32 is mad and yelling out. V12 stated she check marks behaviors in the computer but there are no interventions. V12 states no one tracks it or asks CNA staff about resident behaviors so how can there be interventions? V12 stated there are no interventions for the residents and social services is nowhere to be found. V12 states she tries to talk to R32, but he constantly yells out and is agitated. On 8/29/22 at 11:48AM, V22, Social Service Director, states she is not aware R32 says he feels like he'd be better off dead or statements of wanting to die. V22 states she would just try to talk to him or try a 1:1 but he gets so agitated that he won't talk. V22 states there is no behavior programming other than just trying to talk to R32. V22 states she just asks R32 Is something wrong and he usually won't talk. 5. R1's admission Record, print date of 8/25/22, documents R1 was admitted on [DATE] and has diagnoses of Major Depressive Disorder, Traumatic Brain Disorder, Schizoaffective Disorder, Anxiety Disorder, Cannabis Abuse and other stimulant Use. R1's MDS, dated [DATE], documents that R1 is cognitively intact and has a behavior of delusions. R1's Order Summary, dated 8/25/22, documents, Aripiprazole (antipsychotic) tablet 5 mg (milligram). Give 2.5 mg by mouth in the morning, Trazadone HCL tablet 100 mg. Give 1 tablet by mouth at bedtime related to Major Depressive Disorder. On 8/25/22 at 2:00 PM, R1 stated, I used to use drugs and that is how I ended up in here. I overdosed on Methamphetamine. I was in a coma for 5 weeks. I think I have done every kind of drug out there. I only use pot now when I go home on visits. My Mom knows I do it. I go over to a friend's house to do it. That's the one thing I won't give up. I never use it here. R1 was questioned if he attends any groups or talks to anyone about his mental health, R1 stated, No, I don't. I am getting out of here soon. I have a house. There are squatters in there now and my mom is going to make them leave and then I can go back home. R1's Care Plan, dated 6/15/21, documents that R1 has poor judgement and impaired decision making, has a ADL (Activities of Daily Living) self-care performance deficit r/t (related to) TBI (traumatic brain injury), schizoaffective. R1 have a behavior problem verbally abusive / aggressive r/t Schizoid - effective Bipolar type. (R1) made a threatening statement to another resident I will pull your pee bag out when he was accuses of poisoning another peer. (R1) is at risk of for suicidal issues AEB (as evidenced by) voicing suicidal thoughts and / or intentions. (R1) admits having attempted suicide by overdose on all medications in the past. R1 becomes non complaint with smoking policy, going to the patio and smoking a short he had from last smoke time and sharing it with peers instead of throwing it away and having a lighter in his possession. R1 is at risk for depression AEB Schizoaffective Bipolar Type. (R1) have diagnosis and history of severe mental illness Schizoaffective _ Bipolar Type as manifested by delusions - unrealistic, Paranoia. R1 believes the Nazis are responsible for his pureed diet and states to hope that the Nazis does not come in his room and take his belongings. (R1) believes that he has a home ant that his mother is having it remolded for him to remove in soon. R1's Care Plan does not address R1 history of substance abuse. On 8/23/22 at 1:30 PM, V8, Social Services, stated that at the current time no one is in substance abuse therapy because no residents are actively abusing drugs or alcohol at this time. On 8/29/22, V22, Social Service Director (SSD), stated that (R1) was missed for group related to substance abuse and that he has been added back onto the group list. On 08/25/22 at 1:41 PM, R1's Electronic Medical Record was reviewed. There is no documentation of R1 receiving Social Service one to one sessions or group therapy since 3/16/22. 6. R4's admission Record, print date of 8/24/22, documents that R4 was admitted originally on 9/17/2015 and has diagnoses of Schizoaffective Disorder, Polydipsia (excessive thirst), anxiety disorder and Hypo-Osmolality and Hyponatremia (low sodium level). R4's MDS, dated [DATE], documents that R4 is cognitively intact, has hallucinations and delusions, Verbal behavioral symptoms directed toward others and behavioral symptoms not directed towards others that occurred 1 to 3 days. This MDS also documents that R4's behaviors put R4 at significant risk for physical illness or injury, significantly interfere with R4's care and R4's ability to participate in activities or social interaction. This MDS also documents R4's behaviors place other residents at risk for physical injury, intrudes on others privacy or activity and significantly disrupts care or living environment. This MDS also documents that R4 does wander and his wandering places him in significant risk of getting to a potentially dangerous place and it impacts other residents. R4's Census Log and Electronic Medical Record documents that R4 has been admitted to the hospital 6 times since 4/21/22 because of excessive water consumption. On 08/22/22 at 10:10 AM, R4 stated that he hates the fluid restrictions, and the doctor doesn't know a thing. R4 stated that he is on fluid restriction because it makes his sodium go low. On 8/22/22 at 10:20 AM, V17, Licensed Practical Nurse (LPN), stated that R4 is non complaint with his fluid restrictions and that he will sneak fluids whenever he can. V17 stated that R4 has been hospitalized often due to low sodium. On 08/23/22 at 8:59 AM - 9:15 AM, R4 is walking with his cup from his room to the hallway. R4's cup is half full of ice water. R4 kept going back in and out of his room. R4 went into the bathroom with his cup. R4 went back to his room. On 8/23/22 at 9:15 AM, R4 was sitting on his bed. R4 was drinking from his cup which holds 1000 milliliters of fluid. R4's cup is 3/4's full of water. R4 drank the entire glass of water during the interview. At this time, R4 stated that he drinks the water because he is going to die anyway and that he has to drink the water, or he will die. On 8/23/22 at 9:30 AM, R4 is yelling that someone took his cup. R4 came out of his room with a cup and went down to R64 's room. R4 went into R64's bathroom and filled up his cup. R4 then went back to his room. On 8/23/22 from 8:59 AM to 9:30 AM, R4 appeared to be agitated and anxious at this time. At this time, no staff interacted with R4 to monitor his fluid intake or intervene with a distraction or a talk. On 8/23/22 at 10:20 AM, V9, CNA, stated that they do the best they can to limit R4's water intake. V9 stated, He (R4) will go into other rooms and get water. He will go into the bathroom and get water. I have caught him drinking shower water before. He will hide a cup in the bathroom. He is fussing right now because someone took his cup away. On 8/24/22 at 10:20 AM, V12, CNA, stated, All the CNA's will tell him he is on fluid restrictions. He goes all day looking for ice. He will sneak in the bathroom. V12 was questioned about what she does to try and prevent R4 from drinking so much water, V12 stated that she just tells him he is on fluid restrictions. On 8/25/22 at 2:10 PM, V20, Medical Director, stated that he is very familiar with R4. V20 stated that R4 has been in the hospital multiple times and 2 of those times he has needed to be put into ICU because his sodium level was so low. R4 will just drink water in excess. V20 was questioned as to the medical consequences that could happen to a person with low sodium, V20 stated, Well it could lead to a coma, but he has done this for so long that his body has become used to having low sodium level. He will get headaches, get weak and have nausea from the low sodium level. Also, he knows when he has drank too much water and he will call 911 because he knows how he feels when he gets low. V20 stated that he has spoken to R4 multiple times about not drinking so much water, but he doesn't know how much he retains because of his mental condition. V20 stated that when R4 shows signs of having a bad day and drinking excessively the staff should supervise him more to monitor water consumption and try to distract him. V20 added that distracting him maybe difficult because he gets agitated, and he is a very big guy and staff need to keep a distance from him for their own safety. V20 also stated that it is important to educate R4 on his good days because hopefully he is more receptive. On 8/29/22 at 12:22 PM, V2, Director of Nurses, stated that R4 is on fluid restriction and that he will try and sneak water. V2 stated that R4 has been hospitalized many times for low sodium. V2 was questioned about how the staff should intervene when R4 starts water seeking, V2 stated that she would need to look at his (R4's) Care Plan to see what interventions are in place. R4's Care Plan, revision date of 4/25/22, documents, Is non complaint with 2300 cc (cubic centimeters) fluid restriction. Intervention: Monitor and document weight. Notify Dr regarding any significant weight change. Monitor Skin Report weekly. Serve diet as ordered. Access likes and dislikes. Substitute likes for dislikes. Will encourage compliance with fluid restriction. R4's Care Plan, revision date of 4/29/22, documents, (R4) have a behavior problem: making self vomit r/t (related to) schizophrenia. (R4) drinks more water than ordered and will throw it up stating. I drank too much now I'm sick. (R4) continues to overhydrate water and throw up claiming he is sick, heart racing, I feel weak. Interventions: Administer medications as ordered. Monitor / document for side effects and effectiveness. Anticipate and meet the resident's needs, remind (R4) of the purpose of the fluid restriction order. Minimize potential for the resident's disruptive behaviors not following fluid restriction by offering tasks which divert attention. On 8/30/22 at 2:00 PM, V22, Psychiatric Rehabilitation Services Coordinator (PRSC), stated that the staff should redirect him when R4 is water seeking. V22 was questioned about what other interventions should be used and V22 stated that she would need to review R4's Care Plan to see what interventions should be tried when R4 is water seeking. 7. R44's admission Record, print date of 8/4/22, documents that R4 was admitted on [DATE] and has diagnoses of Schizophrenia, Major Depressive Disorder and Anxiety Disorder. R44's MDS, dated [DATE], documents R44 is cognitively intact, has hallucinations and delusions, behavioral symptoms not directed towards other occurred 4 to 6 days, R44's behaviors put him at significant risk for physical illness or injury, interfered with his care and his participation with activities or social interaction. R44's August 2022 Order Summary, documents, Clozapine Tablet give 100 mg by mouth at bedtime relate to unspecified schizophrenia, Lamictal Tablet 150 mg Give 150 mg by mouth at bedtime related to major depressive disorder and Seroquel tablet 50 mg. 50 mg by mouth twice a day related to Schizophrenia. R44's Health Status Note, dated 8/3/22, documents, approached by cna (Certified Nurse Assistant) stating she is being chased by (R44) i asked (R44) what was wrong he stated he wanted a urinal a urinal was given to him he became increasingly upset and hit another resident in the chest md (Medical Doctor) notified instructed to send he to (hospital) to be evaluated (V2) notified and i attempted to call family phone numbers on file are no longer active. R44's Health Status Note, dated 8/4/22, documents, Writer interviewed resident regarding the incident with another resident. Resident states him and the other resident bumped into one another- this was just an accident. R44's Social Service Note, dated 8/16/22, documents, PRSC was informed by housekeeping aide, that (R44) was eating his roommate's snacks and she informed him to not eat his roommates food. (R44) appeared angry and chased her across the hall. He then yelled out, you made me mad. (R44) then walked away and went back into his room. R44's Health Status Note, dated 8/22/22, documents, Roommate came back late and res got upset and hit roommate with a reacher. It continues, Separate residents. Res is own POA (Power of Attorney). Police notified and interviewed resident. Police filed a report. Res became agitated with police and staff threatened staff began stomping on police feet. Res taken to (hospital) by ambulance and police. Would not allow staff to take VS (vital signs) (V16 Psychiatrist) notified. R44's Health Status Note, dated 8/22/22, documents, Patient returned from ER (Emergency Room) with no new orders and he received Haldol IM (intramuscular) injection no other medication changes patient is in his room at this time. R44's Social Service notes were reviewed and the last group therapy or one to one session R44 had was on 3/21/22. On 8/23/22 at 10:16 AM, V9, Certified Nurse Aide (CNA) stated, He (R44) usually isn't a problem I have been here for 9 years but in last 6 months he has been having issues. I don't know what is going on with him. I think sometimes it's the way you approach him. I do know that he has had issues with some CNA's. On 8/24/22 at 10:15 AM, V4, Registered Nurse (RN), stated, He (R44) has changed recently. He does get aggressive. I am not sure what is going on. It is like his medicine isn't working anymore. I always check and make sure that he swallows them. He is really good about showing his mouth after you have given him his medicine. V4 was questioned if the doctor knew of his increased behaviors, V4 stated, I will let V16 (Physiatrist) know when he comes around, I guess. Well on second thought, I will call him and let him know. On 8/24/22 at 10:30 AM, V13, CNA, stated, (R44) has had an increase in behaviors. He has started to be a threat to staff. He used to never be like this. On 8/30/22 at 2:00 PM, V22, stated that she has noticed a change in R44 also, but she cannot get him to talk to her about what is troubling him. V22 stated that R44 is nonreceptive to therapy. V22 was questioned if there was an incentive or bonus program in place to increase participation, V22 stated, We are putting one in place now. On 8/25/22 at 2:20 PM, V20, Medical Doctor, stated that the use of marijuana is not good for someone like R50 or anyone with mental illness. V20 stated that it can increase delusions and paranoia. V20 further stated that the facility should provide meaningful activities / programs for the residents and encourage their participation. V20 stated that sitting in their room all day long doing nothing is not good because they have no one to talk to, they just sit there and think about their problems. V20 stated that he will speak with V16, Psychiatrist, and see if they can set up a program. On 8/30/22 at 2:00 PM, V22, stated that her degree is in Human services but that she has had experience dealing with the mentally ill at a (local hospital) behavioral health program. V22 stated that she also has a corporate consultant she can refer to if needed. V22 stated that the facility had reached out to a local addiction group and that we can set up services with them if anyone is actively using. On 8/30/22 at 2:05 PM, V1, Administrator, stated that (V8, Social Service) has a degree in Psychology and she is unsure if she has had training in mental illness. V1 stated that the aides did take Mental Illness training, but it was through their insurance company as more of a risk watch thing on how to keep themselves safe. V1 agreed that the facility is a mental illness building and not the regular nursing home type building. On 8/30/22 at 4:30 PM, V16, stated that residents would benefit from a structured programming and social services. V16 stated it may not fix them, but it would certainly help them. V16 stated that once a person is having delusions, it does not matter what is said to them at that point they need one to one supervision but that is a strain on the facility. During this survey, no group therapy sessions were offered or observed. The only activity observed was smoking, bingo or coloring. On 8/25/22 at approximately 1PM, V3, MDS/Care Plan nurse provided the survey team a handwritten document that states there is only one resident (R21) residing in the facility that does not have a psychiatric diagnosis. The Facility's Resident Census and Condition dated 8/22/22 documents there are 60 residents with behavioral healthcare needs and 58 have individualized support to them, however documents there are 62 residents residing in the facility. Based on observation, interview and record review the facility failed to implement behavior programing. This has the potential to affect all 62 residents in the facility. Findings include: 1. On 08/23/22 09:46 AM, R3 wandering up to front by door to office. R3 redirected then sat back down at table in dining area. On 08/24/2022 at 11:20 AM, R3 observed in dining room with head on table. On 08/25/22 09:38 AM R3 in bed asleep with clothes and shoes on. On 8/23/22 09:40 AM R3 sitting table dining area drinking tea. Hair uncombed. R3's Face sheet dated 8/12/2013 documents a diagnosis of schizophrenia unspecified, anxiety disorder, major depressive disorder, hypo-osmolality and hyponatremia, and mild intellectual disabilities. R3's order summary report dated 8/24/2022 documents that R3 is prescribed antipsychotic medication including Chlorpromazine 100mg (milligrams) four times a day, and Haldol Deaconate sodium 150mg intramuscularly every 14 days. R3's Minimum Data Set (MDS) dated [DATE] documents that R3 is not interviewable and not cognitively intact. R3's Care plan dated 5/12/2022 documents wandering/poor safety awareness related to wandering risk assessment with 11 and above high risk for wandering. R3's care plan documents the following interventions; 5/12/2022 complete elopement risk assessment upon admission if triggered by wandering risk assessment then upon quarterly, with significant change in condition and /or as needed. R3's Care plan fails to document any type of behavior programming in place for R3. R3's Behavior monitoring, and intervention report dated 7/1/2022- 7/26/2022 documents a list of behaviors not resident specific. The report section documents interventions attempted and outcome. The interventions documented are not specific to each resident. R3's intervention section for the month of July documents response not required or same/unchanged. R3's behavior tracking for the month of July documents 3 episodes of accusing others, 4 episodes of expressing frustrations, 1 episode of disruptive sounds, 2 episodes in disrobing in public, 6 episodes agitated, 5 episodes anxious, restless, o episodes elopement/exit seeking, 3 episodes of hallucinations insomnia 3 episodes, wandering 5 episodes. R3's behavior monitoring, and interventions report fails to document any interventions implemented for identified behaviors. On 8/24/2022 at 11:15AM V1, Administrator, stated the facility does do behavior tracking. V1 stated the facility does not have a formal behavior management program. V1 stated that R3 does not have a formal behavioral program for wandering. V1 stated that R3 is all over the building and is always looking for money or mail. V1 stated that R3 will not participate in anything unless involves 7up. V1 stated that R3 is supposed to have individualized interventions in her care plan. On 8/25/2022 at 2:19PM, V20, physician, stated that that he would expect the facility to have a form of behavior programming. V20 stated that he would expect the program to include activities and skills training. On 8/29/2022 at 10:42AM, V1, Administrator, stated the facility does not have a policy for behavior programming. V1 stated the facility implements interventions for the behaviors.

Based on observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 62 residents living in the facility. Findings include: On 8/23/2022 at 8:47 AM in the storeroom there was an approximately 4 inch piece of bread crust on the floor. The edges of the floor were dark with dust and dirt. The floor was sticky, and there were shoe prints on the floor. There was a 6 pound dented can of ready to serve cheddar cheese sauce on the can rack. V6, Dietary Manager, stated he is not planning on using it and placed it on the shelf with other dented cans. On 8/23/2022 at 8:51 AM the trash can outside the store room had grease and debris around the rim, and there was a fly swarming around it. There were small pieces of debris on the floor and a 1 inch piece of onion peel under the microwave. There was grease buildup on the stove handles and the stove top. The stove top had crusty areas with previously cooked food items, and there were grease splatters on the backsplash and wall. The oven had a piece of cardboard measuring approximately 2 inches by 2 inches in the door holding it together. V6 stated he has requested maintenance, but they say it's just an old oven. V6 stated, We still use it. On 8/23/2022 at 8:55 AM there was a small piece of toilet paper, a piece of paper towel, and a creamy yellow colored substance on the floor near the prep table and handwashing sink. V7, Cook, pointed to the yellow substance and stated, That is butter. On 8/23/2022 at 8:56 AM there were three boxes of 120 count dinner rolls stacked on top of a stool with the label Keep frozen. The rolls inside the packages were not cool to the touch. On 8/23/2022 at 8:57 AM, the surveyor stepped in clear liquid substance on the floor near the ice chest. On 8/23/2022 at 8:58 AM in the first refrigerator, there was a container with approximately 12 ounces of creamy liquid inside that was dated, but not labeled. V6 stated, That is a supplemental pudding. There was a large plastic bag with approximately 20 bunches of kale that was tied up but not labeled or dated. In the second standing refrigerator there was a stainless steel container of diced pears that was dated, but not labeled. On 8/23/2022 at 8:59 AM, there was a fan covered in dust that was running, blowing in the direction of the steam table. V7, Cook, stated that fan is kept running all day. Next to the fan on the floor under the beverage table, there was a significant amount of dust and dirt and two bread ties. On 8/23/2022 at 9:00 AM, there were crumbs on the bottom inside of the freezer and an amber colored substance leaking over the outside vents. V6, Dietary Manager, stated I have no idea what that is. On 8/23/2022 at 9:01 AM there were brown splatters behind the steamtable. On 8/23/2022 at 9:03 AM there was dirt and debris below the dishwasher. On 8/23/2022 at 10:00 AM V7, Cook, pointed toward the boxes of dinner rolls and stated, Those came in on Saturday. They have been sitting there since. They have not been in the freezer. On 8/23/2022 at 12:04 PM staff were serving lunch from the steam table. The dust covered fan was blowing in the direction of the steam table, causing papers taped to the wall to rustle. On 8/23/2022 at 12:11 PM, V6, Dietary Manager, was wearing his face mask below his nose at the serving line. On 8/23/2022 at 12:23 PM, V6, Dietary Manager, was wearing his face mask below his nose while serving resident trays. On 8/24/2022 at 12:22 PM, V1, Administrator, stated, I would expect staff to follow food storage policies for the refrigerator and freezer. I would expect staff to have masks covering their noses while serving food. The Facility's Labeling and Dating Foods (Date Marking) dated 2020 documents, Date marking for refrigerated storage food items - Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. The Resident Census and Condition of Residents Form, (CMS 672), dated 8/23/2022 documents the facility has 62 residents residing in the facility.

Based on observation and interview, the Facility failed to maintain a sanitary, comfortable, homelike environment. This has the potential to affect all 62 residents living in the facility. Findings include: On 8/25/2022 at 9:33 AM, the blue framed mirror in the A Hall was cracked from top to bottom, creating an approximate 2 foot vertical crack down the mid-section of the mirror. On 8/25/2022 at 9:34 AM in the A Hall shower room, there was missing tile on the floor measuring approximately 8 inches x 6 inches. The shower curtain was not attached to the rod on the first 5 holes, leaving the shower head region of the tub visible when the curtain is pulled. The wall to the left on entry had a thin covering that had separated from the wall, leaving a gap between the sheet of covering and the wall. This gap measured approximately one inch at the top and widened to two inches at the bottom, exposing brown material on the underlying wall. There was a single nail poking out at approximately 6 feet high which could be easily removed. On 8/25/2022 at 9:38 AM, the fan in the dining room on the end closest to B Hall was not in use, but was covered in dust and aimed toward a resident table. On 8/25/2022 at 9:40 AM, the opposite end of the dining room had another fan that was not in use, but was dust covered and aimed toward another resident table. On 8/25/2022 at 9:45 AM, the top of the door frame in the B Hall bathroom was not attached on one side. On 8/25/2022 at 9:46 AM in the bathroom beside the dining room, there were broken tiles on 3 of 4 walls, exposing dirt underneath. There were 6 white tiles that had fallen on the floor. On 8/25/2022 at 9:57 AM, V12, Certified Nursing Aid (CNA), stated, It's really terrible. Look at these stained bedspreads. I feel bad for them. Look here, the baseboards are coming off the wall and the bugs are crawling out of there at night. That would be really easy for maintenance to fix, but it isn't getting any better. On 8/25/2022 at 10:23 AM, in room A9, the baseboards were falling off two of the walls. On 8/25/2022 at 1:45 PM, the latch on the bathroom door next to the dining room was broken and the door would not stay closed. The front cover of one of the soap dispensers was broken off and in the trash can. On 8/25/2022 at 2:30 PM, V2, Director of Nursing (DON), stated, I just put in a request for maintenance to fix the bathroom door. The maintenance man is off today and tomorrow and I don't know when he will be coming back. On 8/25/2022 at 3:00 PM, V2, DON, stated, We do not have a policy on environment. The Residents Census and Conditions of Residents (CMS 672) documents there are 62 residents living in the facility.