Based on interview and record review, the facility failed to provide notice of Medicare non coverage to 3 for 3 (R24, R99, and R100) residents reviewed for beneficiary notices in a sample of 43. Findings include: On 4/14/2025 at 8:41 AM an electronic mail was sent to V2, Director of Nurses with the Beneficiary Notice- Resident discharged Within the Last Six Months, worksheet to be filled out. On 04/15/2025 at 04:06 PM, an electronic mail was sent to V2, Director of Nurses, with R24's, R99's and R100's, Skilled Nursing Facility Beneficiary Protection Notification Review forms to be filled out. On 04/16/2025 at 11:26 AM, V1, Administrator, stated that she did not have R24's, R99's and R100's Beneficiary notices but she did have 1 on the list and that was R101. On 4/16/2025 at 12:56 PM V1 sent an electronic mail that stated, We are unable to locate any more of the list. I am so sorry. The facility's, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC),undated, documented, When to Deliver the NOMNC: A Medicare provider or health plan ( Medicare Advantage plans and cost plans collectively referred to as Plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. the NOMNC must be delivered at least two calendar days before Medicare covered service end or the second to last day of service if care not being provided daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 4/15/2025 at 7:30 AM, R37 was taking a nebulizer treatment of Albuterol Sulfate. R37's nebulizer treatment mouthpiece, medication cup dispenser and tubing had a date on it of 3/8/2025. On 04/15/2025 at 10:32 AM, R37 had oxygen flowing at 3 liters per minute via nasal canula but there was no date on the oxygen tubing or humidifier bottle. R37 then stated that her oxygen tubing was changed on 3/30/2025. R37's MDS, dated [DATE], documented that her cognition was intact and that she receives oxygen therapy. R37's Physicians Order Sheet, dated 4/15/2025, documented diagnoses of Chronic Obstructive Pulmonary Disease. It continued to document, Change (nebulizer) tubing weekly every night shift, every 7 day(s). It also documented, Change oxygen tubing every week at bedtime every 7 day(s). It continued to document an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 (milligrams)/3 (milliliters) 0.083% (Albuterol Sulfate) 2.5 (milligrams) inhale orally every 4 hours as needed. For inhale of 2.5 milligrams (every 4-6 hours PRN for bronchospasm rinse mouth out with water after each use. R37's physician order sheet continued to document an order for Oxygen at 3 (liters per minute) via (nasal canula) continuous. R37's April 2025 treatment administration record did not document that her oxygen tubing was changed on 4/12/2025. R37's Care Plan, undated, documented, Give medications as ordered by physician. Monitor/document side effects and effectiveness. It continued, OXYGEN SETTINGS: (oxygen) via (nasal canula) (at) 3 (liters) continuously. Humidified. On 4/15/25 at 3:41 PM, V6, licensed practical nurse (LPN) stated she thinks the oxygen tubing, humidification and nebulizer equipment should be changed out weekly or monthly, but midnights complete that task so she's not sure; they should all be labeled. On 4/16/25 at 8:59 AM, V15 (LPN) stated the NC tubing, oxygen humidification containers and nebulizer equipment should all be changed out and dated weekly. On 4/16/25 at 9:34 AM, V9, registered nurse (RN) stated the NC tubing, oxygen humidification containers and nebulizer equipment are supposed to be labeled and dated so we know when it was changed; night shift is supposed to be doing that once a week. On 4/15/25 at 3:40 PM V2, director of nursing (DON), stated R19's oxygen humidification container was dated 4/3/25 and R24's oxygen tubing, humidification container and nebulizer equipment do not have dates either. V2 stated the oxygen tubing, humidification container and nebulizer administration equipment should be dated and changed weekly. The facility's Oxygen Administration Policy dated 7/1/23 documented the procedure for oxygen administration included to care plan oxygen use, label humidifier with date opened, and tubing will be changed and dated weekly. Based on interviews, observations, and record reviews the facility failed to date nasal cannulas, oxygen humidification containers and nebulizer administration equipment for 5 out of 5 residents (R24, R19, R30, R7, R37); reviewed for respiratory care in a sample of 41. Findings include: 1.R24's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, fracture of the lumbar vertebra, pulmonary hypertension, heart failure and chronic kidney disease. R24's Minimum Data Set (MDS) dated [DATE], documented she was moderately cognitively impaired and at the time did not require oxygen. R24's Care Plan last updated 4/15/25 documented no care plan for oxygen use. R24's orders dated 4/14/25 at 2:00 PM, documented oxygen at 4 LPM (liters Per Minute). R24's orders dated 1/17/25 at 10:00 PM, documented change oxygen tubing every week, every night shift, every 7 days. R24's orders dated 4/13/2025 at 12:46 PM, documented 3 ml(milliliters) inhale orally every 6 hours as needed for shortness of breath or wheezing. On 4/14/25 at 9:46 AM and 11:54 AM as well as on 4/15/25 at 10:44 AM, R24's oxygen NC (nasal cannula) tubing with humidification container and nebulizer equipment was not dated. 2.R19's face sheet dated she was admitted to the facility on [DATE] with diagnosis of, in part, polyneuropathy, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. R19's MDS dated [DATE] documented she is cognitively intact and requires oxygen therapy. R19's Care Plan last revised 4/16/25, documented no care plan for oxygen use. R19's orders dated 1/23/2025 at 6:00 PM documented oxygen at 4 LPM via NC continuous. R19's orders dated 1/23/2025 at 8:00 PM documented change oxygen tubing every week. On 4/14/25 at 9:46 AM and 11:54 AM and 4/15/25 at 10:44 AM, R19's oxygen humidification bottle was dated 4/3/25 with no date on her NC tubing. 3.R7's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure. R7's MDS dated [DATE] documented she was cognitively intact and required oxygen therapy. R7's Care Plan dated 3/12/24 documented she has oxygen therapy. R7's orders dated 10/28/2024 at 6:00 PM documented oxygen at 2 LPM via NC continuous. R7's orders dated 3/4/2024 at 8:00 PM documented change oxygen tubing every week. On 4/15/25 at 8:00 AM, R7's oxygen humidification was dated 4/7/25 with no date on her NC tubing. 4.R30's face sheet documented she was admitted on [DATE] with diagnosis of, in part, type two diabetes mellitus, heart failure and hypertension. R30's Care Plan last revised 2/24/25, documented no care plan for oxygen use. R30's MDS dated [DATE] documented she was cognitively intact and did not require oxygen use at that time. R30's orders dated 4/8/2025 at 3:30 AM documented oxygen at 2L(liters)/NC to keep saturations above 90. On 4/14/25 at 9:52 AM, R30's oxygen NC tubing did not have a date labeled.

Based observation, interview and record review, the facility failed to perform hand hygiene after touching clothing, hair and cellular phone during meal service for 18 of 18 (R1, R3, R4, R5, R10, R11, R12, R13, R16, R22, R26, R27, R29, R32, R34, R36, R38, R40) residents reviewed for infection control in a sample of 41. Findings include: On 04/14/2025 at 12:40 PM, V8, Certified Nurse Assistant (CNA), was in the dining room, was touching hair and face, with her bare hands. Then without performing hand hygiene, V8 was pouring cups of coffee for the residents. V8 then served the coffee to R34 then to R10 and then to R40. Then the meal service began, and V8 touched her glasses and rubbed her nose, and then without benefit of hand hygiene, passed meal trays to R32 and R29. V8 was waiting on the meal trays from the kitchen, she touched her glasses and nose again, and retrieved the meal trays for R4 and R12, and without benefit of hand hygiene, distributed those meal trays. She then cut R12's meat. V8 returned to the kitchen and did not perform hand hygiene, took lunch trays to R3 and then to R34. V8, without benefit of hand hygiene, carried a bowl of mashed potatoes, by the rim with her fingers to R10. V8, without the benefit of hand hygiene, made a cup of coffee for R12 and took it to him. V8 then returned to the kitchen opening, where the ABHR dispenser was, did not use it or perform hand hygiene any other way and retrieved meal trays for R26 and R13 and passed out those meal trays and cut up R13's meal. V8 did not perform hand hygiene and retrieved the meal trays for R1 and R11, passed their meal trays to them and then went and got a cup of coffee and gave it to R1. V8 returned to the kitchen opening, waiting for more meal trays, took her cellular phone out of her pocket, and was touching her screen of her cellular phone. Then the kitchen had 2 more meal trays ready for her to pass and without benefit of hand hygiene, she took R5's meal to him and assisted him with set up and then took R40's meal tray to her. V8 returned to the kitchen opening and retrieved R38's and R36's meal trays and delivered those to the residents without benefit of hand hygiene. She then went back to the kitchen opening and while waiting on more meal trays, she was touching her scrub shirt. She was given R27's meal to take to him and without benefit of hand hygiene passed R27's meal to him. V8 severed R22's meal tray to her and then sat down and assisted R16, with his meal. V8, CNA did not perform hand hygiene during the whole meal service. On 4/24/2025 at 1:30 PM, the alcohol based hand rub dispenser at the kitchen opening was operational with product. On 04/16/2025 at 09:20 AM, V19, Certified Nurse Assistant, (CNA) stated that she would wash her hands using the Alcohol Based Hand Rub available at the kitchen door in between passing trays to residents if she touches her hair or clothes during meal tray pass. On 04/16/2025 at 09:25 AM, V11, CNA, stated that he washes his hands in between passing meal trays to the residents and if he touches his clothes, hair or cell phone he will wash his hands. On 04/16/2025 at 09:30 AM, V3, CNA, stated that she washes her hands when passing meal trays to each resident and that she doesn't carry her cellular phone when at work. The facility's policy, Hand Hygiene, Hand Washing, undated, documented, K. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . It continues, O. Before and after assisting a resident with meals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview,and record review, the facility failed to properly store and discard expired medication. This failure has the potential to effect all 48 residents residing in the facility. Findings include: On [DATE] at 9:40 AM the facility's 100 Hall Medication Cart was inspected. The medication cart contained the following: R19's opened and labeled multi dose Aspart insulin Pen. The multi-dose vial was labeled with open date of [DATE]. R19's open and labeled multi dose Glargine insulin pen. The multi-dose vial was labeled with open date of [DATE]. On [DATE] at 9:45 AM V5, Licensed Practical Nurse, verified that the multi dose vials were open and in use. V5 stated that when opening an insulin pen the resident's last name and open date is placed on the multi dose pen. V5 stated that they only 30 days to use the insulin when opened. V5 stated that R19's Aspart and Glargine was discontinued in January and the insulins should have been removed from the cart and destroyed. On [DATE] at 9:50 AM the facility 200 hall medication room was inspected. The refrigerator located in the medication room contained the following: An opened box of Bisacodyl 10mg Suppository, with expiration date, 1/2025. R199's bottle of Glycerin suppositories with expiration date 3/2025. On [DATE] at 9:50 AM V5, LPN, stated that the Bisacodyl are stock medication and are used for everyone as long as they don't have an allergy. V5 stated tht R199 died in January and this medication should have been removed from the refrigerator and destroyed. On [DATE] at 3:15 PM V2, Director of Nursing, stated that she would expect that expired medication be destroyed. V2 stated that she would expect that any discontinued medication and medication of a deceased resident would be taken out of circulation and destroyed. The Resident's Census and Conditions of Resident, CMS 671, dated 4/14//2025, documents that the facility has 48 residents living in the facility. The facility's Medication Storage policy, dated [DATE], documents PURPOSE: To provide guidance to facility nursing staff on the proper storage of medication. POLICY INTERPRETATION AND IMPLEMENTATION 4. Drug containers that have missing, incomplete, Improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician's orders for a resident with a rash for 1 of 3 residents (R3) reviewed for pharmacy services in a sample of 4. Findings include: R3's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, aphasia, Parkinson's disease and dementia, no skin rash diagnosis was documented. R3's Skin Inspection assessment dated [DATE] rash continues to BUE (bilateral upper extremities), BLE (bilateral lower extremities) and torso, 11/9/2024 current skin concerns: back/upper arm clearing rash, tx (treatment) in place, 11/16/2024 current skin concerns: rash to torso, arms and thighs. R3's Nurse's Notes, dated 11/18/2024, documents, Resident seen by MD this afternoon new orders to D/C (discontinue) Clopidogrel and start Triamcinolone and Clotrimazole topically BID (twice a day.) Follow up in 1-2 weeks. R3's Physician's Order Sheet (POS), dated 11/18/2024 through 11/27/2024 documents no physician's order for Triamcinolone or Clotrimazole BID. R3's Treatment Administrator Record (TAR), dated 11/18/2024 through 11/27/2024 documents no Triamcinolone or Clotrimazole was administered. On 11/27/2024 at 11:30 AM V2, Director of Nurses (DON) stated on 11/18/2024 the nurse notified the physician that they needed clarification on the dosage for the Triamcinolone and Clotrimazole and the communication fell through, so the medications were not ordered and therefore the nursing staff have not administered the medications per physician's orders. V2 stated she got the medication dosage clarified today and the medications will be delivered to the facility within the next 8 hours. V2 expected all physician's orders to be followed and to follow up with clarification of medications within the same shift. On 11/27/24, at 10:07 AM V8, Certified Nurse Aide (CNA) was showering R3 and he had a red raised rash on back and abdomen and legs all over. V8 stated they use (brand named) soap, and she puts regular lotion on his skin but nothing else, physician prescribed lotion is applied by the nurse. The Facility's Physician Orders Policy, initiated 7/1/2023 documents the purpose of this policy is to establish uniform guidelines in the receiving, recording, and processing of physician orders. This facility will obtain, process, and implement physician orders given by a licensed physician and received by a licensed nurse. It is the responsibility of the Director of Nursing/designee to ensure that all licensed healthcare workers within the facility to know the physician order process. The Facility's Medication Orders Policy, initiated 9/17/2019 documents when recording orders for medications, specify the type, route, dosage, frequency, strength, and rationale of use for the medication ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R36's Face sheet documents an admission date of 9/29/2023 with diagnoses of Anxiety Disorder, Cerebral Palsy, Heart Failure. R36's Minimum Data Set, MDS, dated [DATE] documents R36 has no cognitive deficits. R36's Care Plan updated 4/22/2024 has no documentation for abuse. On 5/02/2024 at 8:39 AM R36 stated I do not know when it happened, but there is a predator here. It's (R41). He is an Alzheimer's patient, and he goes in women's rooms. He was pounding on my bathroom door and another time he walked in my doorway. I lunged at him, and he left. The facility put a banner up in my doorway, but (R41) walked right under it. My brother and I talked to the Administrator. I know he is on another hall right now and I haven't seen him. R36 stated I woke up one night and (R41) was sitting in a chair looking at me. I raised up and said 'You need to leave. This is not your room,' and he left.' R36 is unsure of when incident occurred. R36's progress notes dated 1/1/2024 at 1:15PM documents Power of Attorney, POA, wants hydroxyzine held until he talks to Nurse Practitioner on 1-2-24 also stated that R36 has been upset with a male resident yelling all night and her not being able to sleep. The resident has come into her room and (R36) is uncomfortable. On 5/2/2024 at 4:00PM V23, R36's Power of Attorney, POA, stated (R36) and I talked to (V1) about (R41) going into the women's rooms. (R36) told (V1) that she was afraid of (R41). I don't think (R41) ever touched (R36). For a while they put a Velcro banner on (R36)'s doorway. B. R29's Facesheet documents an admission date of 1/13/2023. Diagnosis include Nondisplaced Intertrochanteric Fracture of Left Femur, Chronic Pulmonary Edema, Spondylosis, Dementia. R29's Minimum Data Set, MDS, dated [DATE] documents R29 is moderately cognitively impaired, is dependent for sitting to standing, chair to bed transfers, and toilet transfers. R29's fall risk assessment dated [DATE] documents R29 is at high risk for falls. R29's Care Plan updated 4/22/2024 document R29 is risk for falls and injuries related to medications, decreased cognition, attempts to transfer/walk without assist. Interventions include assess toileting needs, bed in lowest position, orient to room, provide adequate lighting, provide/reinforce use of assistive devices. R29's Progress Notes dated 3/20/2024 at 9:40AM documents R29 observed on floor in room laying on left side. Roommate stated that R29 got her feet tangled up in blankets while getting up. Assessed R29. R29 complained of pain to left hip and left foot extended out. Called physician and Power of Attorney, POA, notified and agreed to send R29 out to hospital. R29's Progress Notes dated 3/23/2024 at 9:40PM R29 arrived from local hospital after hip pinning for fracture to left hip. R29 is weight bearing as tolerated. R29 was walking with a walker only with therapy at hospital. Recommendations were made for use of sit to stand or pivot transfer. R29 may shower and has 3 incisions with daily dressing to let hip. R29 complains of pain at times. R29 is alert and oriented times two with intermittent confusion. R29 is oriented to call light, bed in low position and call light in reach. R29's History and Physical dated 3/20/2024 documents Chief Complaint: hip pain. Assessment and Plan: Closed left hip fracture of unspecified part of neck of left femur. Initial encounter for closed hip fracture. Procedure notes dated 3/21/2024 procedure performed Open Reduction and Internal Fixation of left hip. Intertrochanteric fracture with cephalomedullary nail. R29's fall investigation dated 3/20/2024 documents R29 on floor in room laying on left side. Roommate stated she got her feet tangled up in blankets while getting up. Assessed R29. R29 complained of left hip pain. Left foot extended out. Called physician and ordered to sent to local hospital. R29 stated I fell and my hip hurts. Facility fall log documents R29 sustained falls on 3/20/2024, 3/7/2024 and 2/21/2024. On 5/1/2024 at 8:07AM R29 observed up in restroom unassisted. R29's pressure alarm sounding. No staff in room. V10, Certified Nursing Assistant, CNA, entered room and assisted R29 back to wheelchair and assisted to dining room. On 5/1/2024 at 9:25AM R29 observed up to restroom unassisted. Surveyor entered room. No staff in room. R29's pressure alarm not sounding. On 5/2/2024 at 2:30PM observed R29's pressure alarm sounding with door closed and no staff in room or entering room within 1 minute. On 5/1/2024 at 9:25AM V10, CNA, stated The pressure alarms are pretty sensitive. Not sure why it did not go off. On 5/1/2024 at 9:40AM V2, Director of Nursing, DON, stated I put new batteries in (R29)'S alarm at 7:00AM this morning. Explained to V2 that R29 was observed by herself washing hands in restroom, and alarm did not sound. V2 stated We will have to test it and replace it. On 5/2/2024 at 1:50PM V2 stated If a resident's alarm is going off, I would expect any staff to check on the resident. It doesn't just have to be nursing. On 5/2/2024 at 2:00PM V21, Certified Nursing Assistant, CNA, stated We try to get in here as soon as we hear an alarm. (R29) likes to be very independent. On 5/3/2024 at 9:25AM V24, Physician, stated (R29) has been a challenge with getting up without assistance. If (R29) has an alarm, then I would expect the alarm to sound off if (R29) gets up. They should be checking the alarms. Facility fall policy dated 7/1/2023 states All accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. An accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers. A. Based on interview and record review the Facility failed to ensure residents were being supervised to prevent wandering for 2 of 8 residents (R36, R41) reviewed for supervision to prevent wandering in the sample of 33. B. Based on observation, interview and record review, the facility failed to respond to a pressure alarm for a resident with a high risk of falling and a recent hip fracture in 1 of 8 residents (R29) reviewed for supervision to prevent falls the sample of 33. Findings include: A. 1.R41's Physician Order Sheet for May, 2024 docuemnts diagnoses of Alzheimer late onset, dementia, psychotic disturbances, mood disturbances and anxiety. R41's Care Plan dated 3/5/2024 documents R41 has a history of wandering. 4/2/204, R41's Care Plan documents, Potential to be physically aggressive related to Alzheimer's disease. Abuse investigations for the past year were reviewed and there was no investigation for R41 related to wandering into any female rooms. No abuse investigations were available to review or provided to surveyors. On 5/1/2024 at 3:04 PM, V1, Administrator stated We have given you all of the abuse investigations. On 5/1/2024 at 2:32 PM, V12, Registered Nurse (RN) stated, We had one resident (R41) who likes to wander into residents' rooms, and he is now on one on ones. (R41) has been on one on ones for about a month or so, I believe. He used to be on this hall, but he was moved to the 100 hall. Some of the women when they see him, they get worked up about him. On 5/1/2024 at 2:35 PM, V13, Licensed Practical Nurse (LPN) stated (R41) is harmless, and he does wander into female residents' rooms. (R41) is on the 100 hall now. The ladies freak out when they see him and will say, 'there he is' and point at him. (R41) on occasion has been found in female rooms. (R41) does wander into female rooms but is harmless and is easily redirected. I don't think he would do anything or hurt a fly. I am not sure when he was moved. On 5/1/2024 at 2:27 PM, R41 was on the 100 hall sitting in a chair next to (V11, CNA). R41 was on one on ones with her. R41 is confused and is able to greet you but is not able to hold a conversation. On 5/1/2024 at 2:38 PM, V11, Certified Nursing Assistant (CNA), stated, (R41) is on one on ones because he is a wanderer and likes to go into female residents' rooms. He has been on one on ones for almost two months now. He is a sundowner, and has behaviors. We are watching him to make sure he does not go into anyone's room or upset anyone. R41's Progress Notes dated 1/1/2024 at 7:00 PM, documents, Resident went into another resident's room and was sitting on their bed. Resident was walked to his room at that time. Resident has been seen going in and out of other resident's room. (There was no incident report or any abuse allegations for this incident on 1/1/2024). R41's Progress Notes dated 1/1/2024 t 7:30 PM, documents, Resident went into a female resident's room and took some of her snacks. Female resident came and reported to nurse. Stated she would not tolerate this man coming into her room. R41's Progress Notes dated 1/3/2024 at 7:45AM documents, Ambulating in hallway at beginning of shift, easily redirected to own room and went to bed. No acute distress noted. Alert to self only. R41's Progress Notes dated 1/5/2024 at 7:25 AM, documents, Up all night, roaming hallways, easily redirected to room but ineffective, comes right back out into hallway. No acute distress noted. R41's Progress Notes dated 1/08/2024 at 8:15 PM documents, Resident went into females' room [ROOM NUMBER] and urinated in the floor. One of the ladies came out of the room to tell staff. Her socks were wet with urine. Male Resident was walked to his room and assisted into bed. R41's Progress Notes dated 01/11/2024 at 12:37 AM documents, Up ambulating independently, wandering went to exit door setting off alarm x1, redirected away from door and started going into other residents' rooms. Taken to BR (bathroom), snacks and fluids given then to his bed and slept. R41's Progress Notes dated 01/11/2024 at 7:16 PM documents, Resident went into female's room and shut the door and scared resident. R41's Progress Notes dated 02/09/2024 at 7:23 PM documents, Resident went into another resident's room and got into altercation with other resident. Resident spilled soda on both residents in their rooms. There was no incident report or abuse investigation for this incident on 2/9/2024. R41's Progress Notes dated 02/19/2024 7:53 PM documents, CNA reports that she went to change resident's undergarments, resident grabbed her wrists and blocked her in the bathroom. CNA states he let go of her wrists, and then went to leave bathroom. Resident then hit CNA in left arm with fist on her way out. CNA denied injury. R41's Progress Notes dated 03/10/2024 at 9:18 AM documents, Staff was cleaning dining room, when resident got up she tried to help get across the wet floor so he would not fall and he tried to smack the staff, she did explain to him that she just wanted to help him on the wet floor and he stated no you not wise up. R41's Progress Notes dated 03/15/2024 at 4:31AM documents, At 0035 staff making rounds and went into the resident's room and found him urinating on his roommate and a large puddle of urine on the floor. Resident assisted back to his bed and he laid down. Staff changed roommates linen and cleaned up floor. R41's Progress Notes dated 03/28/2024 at 3:25AM documents, Combative with staff, hitting, kicking and scratching, wandering in hallway at this time, redirection ineffective, continue 15 minute checks. R41's Progress Notes dated 04/01/2024 at 2:12PM documents, resident walking in hall and urinated in hall. R41's Progress Notes dated 04/04/2024 at 4:40 PM documents, A resident wandering into rooms on the hall, resident is hitting staff. R41's Progress Notes dated 04/09/2024 at 4:38AM documents, Wandering, combative with staff, hitting, cursing, difficult to redirect. Interventions ineffective. R41's Progress Notes dated 04/18/2024 at 9:47AM documents, Notified POA of room move today. POA (Power of Attorney) agreeable. R41's Progress Notes dated 04/19/2024 at 2:35 AM documents, Wandering in hallway, redirected, taken to BR (bedroom), snacks and fluids given, Interventions ineffective. R41's Progress Notes dated 04/30/2024 at 10:14 AM documents, This am during med pass resident combative and punched this nurse in the stomach. Redirected to put his shirt on. Sitting on side of bed. With call light in reach. On 5/2/2024 at 4:02 PM, V1, Administrator stated, Nobody ever expressed to me or told me they were scared or any allegation of abuse regarding (R41). (R41) had behaviors and he had wandered into other residents' room, but it was more of a behavior. On 5/3/2024 at 12:36 PM, V1, Administrator stated there was no policy on Supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely incontinent care for 1 of 9 residents (R8) reviewed for Urinary Tract Infections (UTI) in the sample of 33. Findings include: On 4/30/24 at 11:35 AM V3 Certified Nursing Assistant (CNA) was observed transferring R8 with a sit to stand mechanical lift from her reclining wheel chair (w/c) to the toilet. The seat of R8's wheel chair was visibly wet and R8's pants were saturated with urine . V3 transferred R8 into the bathroom with the lift and pulled down her pants that were wet and removed her saturated adult incontinence brief. There was a strong foul urine odor in R8's room and the bathroom. V3 stated, That is probably from her wheel chair because it has urine on it too. V6, CNA, entered the room because V3 had put on R8's call light. V3 informed V6 she needed some towels and washcloths to clean R8 up. After V6 returned with towels, she stayed to assist V3. V3 cleansed R8's groin, thighs and vagina with soap and water, rinsed her with clean, wet wash cloths, and then dried all areas. V3 and V6 then used the mechanical lift to lift R8 off toilet and V3 cleansed her buttock and rectum with soap and water, rinsed and then dried her skin. V3 applied a new adult diaper and clean pants and then they transferred R8 back to her w/c after V3 wiped it off with a wash cloth. When asked when the last time R8 would have been checked and changed, V3 and V6 both stated she would have been changed before the night shift got her up before 7:00 AM this morning. R8's Face Sheet documents her diagnoses to include: Personal History of Urinary Tract Infections. R8's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and is always incontinent of bowel and bladder. R8's Care Plan, undated, documents, The resident is at risk dehydration or potential fluid deficit r/t history of chronic UTI and need for assist and encouragement for adequate fluid intake. The interventions for this care plan include, Report PRN (as needed) any s/sx (signs and symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. R8's Care Plan, undated, documents, ADL (Activities of Daily Living) Self Care Performance Deficit r/t Dementia, Impaired balance. Interventions for this care plan include, Toilet Use: incontinent of bowel and bladder; assist of 2 with sit to stand lift for toileting transfer. On 5/03/24 at 8:25 AM V4, CNA stated they normally do rounds and check and change residents every two hours. She stated if they are able to do that with R8 she usually does pretty good with toileting. V4 stated on the day R8 was observed to be soaked, they had one CNA call off, and were late getting residents from the dining room and had to lay down the residents who use full body mechanical lifts first, so she was running late. V4 stated she was not trying to make excuses because R8 should never have been left wet that long and should have been checked and changed or toileted within two hours of the last time she was changed. V4 stated she did not know if R8 had had any recent UTIs. On 5/3/24 at 12:15 PM V2, Director of Nursing (DON) stated she expects staff to make rounds at least every 2 hours and should provide incontinent care as needed during rounds. She stated she would not expect an incontinent resident to not be checked for four and a half hours for any reason, even if CNAs are running a little behind. The facility's policy, Incontinence Care Policy issued 7/1/23 documents, Purpose: To provide guidelines to all nursing staff for providing proper incontinence care in order to keep skin clean, dry, free of irritation and odor. Policy: All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required.

Based on interview and record review, the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 4 of 4 residents (R8, R25, R31 and R150) reviewed for antibiotic stewardship, in the sample of 33. Findings include: 1. R25's Progress Notes, dated 03/28/2024 at 11:01 AM, documented, Received call from ER (Emergency Room), reports has UTI (urinary tract infection) starting on Macrobid at ER (emergency room) and script being sent to (Pharmacy). Placed call to family to update on results of ER visit. R25's Progress Notes, dated 04/04/2024 at 9:55 PM, documented, ABT (antibiotic) completed this shift. No adverse reactions noted. Continue encouraging fluids. Denies any s/s (signs or symptoms) of UTI such as burning, pain, and frequency. R25's Physician Order Sheet (POS), dated 3/1/2024 to 4/30/2024, documented, Nitrofurantoin microcrystal capsule 100 milligrams (mg), give 1 capsule by mouth every 12 hours for UTI Prophylaxis for seven days. R25's Lab Report, collection date 3/28/2024 and verification date 3/29/2024, documented, Mixed genital flora isolated. These superficial bacteria are not indication of a urinary tract infection. R25's Medication Administration Record (MAR), dated April 2024, documented, Nitrofurantoin microcrystal capsule 100 milligrams (mg), give 1 capsule by mouth every 12 hours for UTI (urinary tract infection) for 7 days. Start date 3/28/2024. On 5/2/2024 at 10:00 AM, a Culture and Sensitivity Report (C&S) was requested, and no C&S was provided for R25. 2. R150's Progress Notes, dated 04/20/2024 at 10:49 AM, documented, Resident cont. (continues) ABT (antibiotic) for tx (treatment) of UTI (urinary tract infection), no adverse effects noted. R150's POS, dated 4/19/2024, documented an order for cefdinir oral capsule 300 mg, give 1 tablet by mouth two times a day for UTI for six days. R150's MAR for April 2024, documented that R150 received for cefdinir oral capsule 300 mg, give 1 tablet by mouth two times a day for UTI for six days. R150's Progress Notes, dated 04/28/2024 at 8:59 PM, documented, Remains on antibiotic for UTI. No adverse effects noted. Able to make needs known. Resident denies s/s of UTI this shift. Able to make needs known. R150's Lab results from local hospital, that was collected on 4/16/2024, documented that a urine culture was taken but did not document any culture or sensitivity for the use of cefdinir. The facility was unable to provide a culture and sensitivity (C&S: a lab test to attempt to grow bacteria, viruses, or fungi and then test which medications will effectively work to stop the infection) for R150 when requested. On 5/3/2024 at 9:32 PM, V2, Director of Nursing, stated, My expectations are that anytime any resident is started on antibiotics we have a culture and sensitivity for it and the organism was identified before any antibiotic was given. A lot of times, the hospitals will not send us the C & S and we will have to follow up. I just started this position in April. We also have some issues with the hospice too. 3. R8's Physician Order Summary, dated 5/2/24, documented, 9/2/22: Keflex Capsule 250 MG (Cephalexin) Give 250 milligrams (mg) by mouth in the morning related to Personal History of Urinary Tract Infections. It also documented that this antibiotic was not discontinued until 3/21/24. R8's Medication Administration Records, dated 5/2023 to 3/2024, documented that R8 received Keflex 250 mg every day while she was in the facility for past year. R8's Progress Notes and Lab results, dated 5/2023, were reviewed, and there was no documentation for a diagnosis of UTI nor was there any abnormal urinalysis found. 05/03/24 at 09:43 AM, V2, Director of Nursing, stated that she talked to the physician and got R8's Keflex order discontinued, and she was started on UTI-Stat pm 3/21/24 to help prevent UTIs. 4. R31's Physician Order Summary, dated 4/1/24 to 5/1/24, documented, 4/3/24: Acyclovir 400 mg by mouth every 12 hours for UTI for 5 days and Cefdinir 300 mg by mouth every 12 hours for UTI for 5 days. R31's MAR, dated 4/1/24 through 4/30/24, documented that R31 received all ordered doses of her Acyclovir and Cefdinir from 4/4/24 to 4/8/24. R31's Urinalysis Culture results, dated 4/2/24, documented, Urine Culture Final; Result: Mixed genital flora isolated. These superficial bacteria are not indicative of a urinary tract infection. No further organism identification is warranted on this specimen. The antibiotic Stewardship Policy, revision date of 12/13/2023, documented, Antibiotics are powerful tools for fighting and preventing infections. However, widespread use of antibiotics has resulted in an alarming increase in antibiotic resistant infections and a subsequent need to rely on broad-spectrum antibiotics that might be more toxic and expensive. In addition to the development of antibiotic resistance, antibiotic use is associated with an increased risk of Clostridium difficile infections and adverse drug reactions. Since antibiotics are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. Antibiotics stewardship consists of coordinated resident safety and the reduction of adverse events. First line treatment recommendations. There are no definitive practice guidelines that specifically address treatment of UTI in elderly patients in the LTCF (Long term care facility). Prescribers will base treatment recommendations on the following factors: facility specific culture and antibiotics sensitivity data.

Based on observation, interviews and record reviews, the facility failed to ensure there was an air gap in the ice machine between the floor sewage drain and the ice machine and there were no signs of water damage from sewage lines and or/pipelines. This has the potential to affect all 45 residents living in the facility. Findings include: On 5/1/2024 at 8:33 AM, the ice machine was in the dining area. Behind the ice machine there was water present on the floor. Behind the machine there were also 2 orange cones with the words wet floor that were placed behind the machine. On 5/1/2024 at 8:39 AM, Behind the ice machine there was a white pipe that went into another pipe into a drain. The pipe was going directly into the drain, and no air gap was observed. The air gap was not twice the diameter of the water outlet from the fixture and the fixture's flood-level rim and there was the potential for backflow or back siphonage. The white pipe was also covered with black spots covering the entire pipe, and was wet with moisture. On 5/1/2024 at 8:55 AM, on the walls behind the ice machine, the walls were protruding, and appears patchy clusters of raised areas on the drywall with black specks. The area affected was approximately five feet in length and four feet in width and covered the entire area behind the ice machine. The large pipes coming out of the back of the machine behind the ice machine were also covered with black spots with moisture present. The dry wall was not smooth, and was puffy in appearance. On 5/1/2024 at 9:00 AM, V28, Dietary Manager, stated, I am not sure why it is wet back there or why the area has the orange cones. I think it is from the ice melting. On 5/3/2024 at 9:19 AM, V22, Environmental Health Director, stated, Those orange cones behind the ice machine are put there by dietary staff not by me. They are always behind the ice machine. We use different cones for wet floors. I am not sure why the floor is wet but it has been like that for a while. I could not say exactly how long. It has been a few weeks. Again, I don't do anything with that area. On 5/3/2024 at 9:24 AM, V25, Cook, stated, Those cones have been there for awhile. We get water back there. I am not sure how long it has been like that. On 5/3/2024 at 9:45 AM, V25, [NAME] President of Operations Maintenance, stated, There was water behind the ice machine. I believe with the temperature of the outside wall and the temperature of the actual ice makes it is causing moisture to cling to the surface. I am going to have staff scrap the area, repair the walls from the moisture damage and hit it with some products to reduce the moisture and prevent future moisture. When I got back there and pulled things out the air gap was not to code, and I will address that as well. We will incorporate some new panes behind them as well so they can be wipes and are cleanable. On 5/3/2024 at 10:02 AM, V28, Dietary Manager, stated, The ice machine that is in the dining room is the only ice machine in the building. We use the ice for all meal preparations and meal services, passing out ice, and water coolers. On 5/3/2024 at 10:31 AM, V1, Administrator, stated, We do not have a policy on air gaps but we follow all state and local ordinances. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 4/30/2024, documented that the facility had a census of 45 residents.

Based on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 45 residents living in the facility. Findings Include: On 5/2/2024 at 10:22 AM, an infection control log was provided but did not have any dates or organisms listed or documented. On 5/2/2024 at 10:33 AM, V2, Director of Nursing (DON), stated, I was just hired and just finished taking the ICP (Infection Control Preventionist) course. I am new to this position, and this is the only surveillance I have. I will look and see what else I can find. I do not have a book, but I will call corporate and see what she has. A second list of Infection control log was provided and contained two and half pages. Not all urinary tract infections had organisms documented and were not provided when requested. There were 10 Urinary Tract Infections documented on the log but only two of ten had documented organisms. The Facility Infection Control Program Policy issue, dated 09/15/2020, documented, Purpose to provide guidelines and guidance for all staff regarding the facility established infection control program that investigates, controls and prevents infections. Surveillance for nosocomial infections will be done to provide a format for the surveillance of infections occurring within the facility. The facility will establish and maintain the program in order to provide a safe and sanitary environment, and to help prevent the development and transmission of disease and infection. Infections will be investigated, controlled, and prevented, and isolation precautions will be determined on an individual basis. The Infection Report Form will be kept on those residents who are receiving antibiotics or have an infection. Data will be compiled, and a report completed monthly. Data will be discussed during the QA Meeting. The Infection Control Coordinator will track and trend infections and ensure proper training of staff and ongoing interventions to prevent the spread of infections. Infection Surveillance: the collection of data on nosocomial infections that is used primarily to plan control activities, educational programs and to prevent epidemics. An important reason for collecting and analyzing data is for the early detection and prevention of infectious disease outbreaks. Procedure for infection surveillance: surveillance data will be collected on ongoing basis. Recording, reviewing, analyzing, and reporting of infection case data will be done monthly, quarterly, and annually to detect trends. Surveillance data shall be used for planning control efforts, detecting epidemics, directing in-service education, and identifying individual resident problems for intervention. Analysis of surveillance data will include at least the following elements on each infection to detect clusters and trends: date of onset, body site, geographic location, and appropriate culture information. Data collection: Continuous collection of data is necessary to determine what an infection is, when it is present, and whether it is nosocomial in origin. Data may incorporate the number of infections, type of infections, and related issues which may be present. Monthly reports will include: the incidence of all types of infections. The incidence of community acquired infections. Rates for various types of nosocomial infections. Predisposing infectious organisms in types of nosocomial infections. Any recommendations made regarding isolations or cross infections. The infection control log should be updated on an ongoing basis. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 4/30/2024, documented the facility had a census of 45 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers and consistent with professional standards of practice for two of three (R1, R2) residents reviewed for pressure ulcers, in a sample of four. Findings include: 1. R1's Facesheet documents an admission date of 11/2/2023. Diagnosis include Chronic Obstructive Pulmonary Disease, Pancytopenia, Multiple Myeloma, Cardiomegaly. R1's Minimum Data Set (MDS), dated [DATE] documents R1 has no pressure ulcers and is at risk for the development of pressure ulcers. R1's MDS, dated [DATE] documents R1 is cognitively impaired. R1's MDS dated [DATE] documents R1 requires set up and clean up with eating. Is dependent on staff for showering. R1's care plan dated 2/22/2024 documents Actual Pressure Ulcer; Site(s): Left heel, Stage 3. Right heel, Stage 4. Requires assist with turning and repositioning: Poor Nutritional status, requires assist with turning and repositioning, Incontinence. Healing may be unattainable due to ongoing medical decline and decrease in appetite. R1's Braden Scale assessment dated [DATE] documents R1 is at risk for the development of pressure ulcers. R1's Bruise/Skin Assessment, dated 2/26/2024, documents, Nursing description, purplish discoloration noted to left dorsal foot. (R1) unable to give description. Immediate action taken, Upon assessing (R1) wears foam heel protectors with velcro straps that are placed over dorsal area of both feet. Discoloration aligns with strap. (R1) voices no pain, discomfort. Heel protectors removed. Dc'd with heels to be floated. (R1) receives Xarelto, Aspirin, and Hydrocodone with all increased risk for bruising. Notes left dorsal foot noted to have purplish discoloration. (R1) wears heel protectors with Velcro which is applied to top of foot. Root Cause: (R1) receives anticoagulant daily which increases risk of bruising. Heel protectors DC'd with heels to be floated. R1's progress notes, dated 2/26/2024 at 6:41PM, documented, (R1) Has new bruising and open abrasion to R (Right) dorsal foot and bruising to L (left) dorsal foot. R 5th digit toenail appears to be pulling off. Resident does not report any pain and does not recall any event that would cause injury. Area's measured and cleaned; dressing applied. Notifications completed. R1's skin and wound assessment dated [DATE] documents, Stage 3 pressure wound to left heel, in house acquired .5cm (centimeters) X .7cm x .9cm slow to heal, improving. R1's skin and wound assessment dated [DATE] documents, Right heel stage 4 full thickness in house acquired 4.6cm x 2.0cm x unable to determine. On 3/5/2024 V8, Wound Company Physician's Assistant, measured wounds to R1's dorsal left and right feet. Left dorsal foot wound measured 0.1cm x 0.1cm x 0.1cm. Right dorsal superior foot wound measured 0.3cm x 0.3cm. Right dorsal inferior foot wound measured 0.9cm x 2,4cm x 0.1cm. On 3/5/2024 at 11:00AM V1, Administrator, stated (R1) was wearing the float boots and the straps caused the bruising on top of her heals. She takes an anticoagulant, aspirin, and an anti-inflammatory also. We now stopped using the boots and are just floating her heals. On 3/5/2024 at 11:15AM V3, MDS Coordinator, Licensed Practical Nurse, LPN, stated, (R1) received the bruising from the float heals she was wearing. So now they aren't to be used and are to just float her heels. We found wounds on her feet fresh and knew what caused them. On 3/5/2024 at 2:45PM V12, Certified Nurse Assistant (CNA), stated, I took care of (R1) and saw the bruises to the tops of her feet. It was from the floating boots she was wearing. They must have been on too tight. Now we aren't using the float boots. We are using a pillow and floating her heels that way. The residents get repositioned and incontinent care every 2 hours. 2. R2's Face sheet documents an admission date of 10/22/2023. Diagnosis includes Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Dementia, Chronic Kidney Disease. R2's MDS dated [DATE] documents R2 is cognitively impaired. R2 requires partial to moderate assist with eating. R2 is dependent for toileting, requires substantial assistance with showering, is dependent for dressing and walking 10 feet not attempted. R2's MDS dated [DATE] documents R2 had no pressure ulcers or skin tears. R2's Braden scale for pressure sore development documents R2 is at risk for pressure sore development. R2's Progress Notes dated 1/28/2024 documents Hospice nurse here new order, clean area on buttocks with wound cleanser and apply medicated ointment to wound bed and cover with calcium alginate and apply (foam wound dressing) daily. R2's Skin/wound assessment dated [DATE] documents Penis in house acquired, new 0.5cm x 0.9cm x 0.8cm scab. Coccyx in house acquired, new.2cm x .6cm x .5cm Left elbow lateral in house acquired 4.4cm x 5.1cm x 2.2cm. V5, Registered Nurse, RN and V3, Licensed Practical Nurse, LPN, provided wound care to R2. Treatment to coccyx as ordered. R2's peri area very reddened and excoriated. On 3/1/2024 at 1:00PM V11, CNA, stated, We change and reposition residents every 2 hours, especially those with sores. On 3/5/2024 at 10:00AM, V7, Wound nurse, stated We aren't going in R2's room for wound care. He is actively dying, and a lot of family are there. Facility policy with a revision date of 8/31/2023 states To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. Prevention program including turning and positioning will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. The facility will initiate an aggressive treatment program for those residents who have pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's physician and family of a fall with an injury for one of three (R1) residents reviewed for notification in a sample of nine. The findings include: R1's face sheet, dated 1/25/24, documents resident was admitted to the facility on [DATE]. It also documents that R1's medical diagnosis includes Alzheimer's disease, dementia, chronic heart failure, type 2 diabetes, atrial fibrillation, atherosclerotic heart disease, hypertension, psychotic disorder with hallucinations, osteoarthritis, major depressive disorder, hypothyroidism, and anxiety disorder. R1's Care Plan, dated 11/24/23, documents that R1 is at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and psychoactive drug use. Care Plan interventions: assistive device/reacher, tab alarm placed on 1/16/24, remind resident to ask for assist when she feels unable to complete a task, assist resident with keeping her reacher near her while in her room, be sure call light is within reach and encourage resident to use it for assistance as needed, ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair and remind resident to ask for assistance when needed. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is moderately cognitively impaired and requires partial/moderate assistance with toilet transfers. R1 progress note, dated 1/16/24 at 8:53 AM, documents that on 1/15/24 R1's daughter reported that R1 told her she fell and hurt her head. It continues, Upon physical exam this writer noted that there was an approximately 2.5 by 2.5 cm (centimeter) red area to (R1's) forehead above her right eye at R1's hairline. (R1) unable to tell this writer what happened. She states she thinks she fell but is unsure if she was in her room, bathroom or hallway. Denied any pain or discomfort to her head. R1 progress note, dated 1/17/24 at 12:39 PM, documented, Late entry for 1/15/24 1 pm. Resident taken to ER (Emergency Room) accompanied by one sttaff member for evaluation, daughter notified and asks that resident be allowed to each lunch prior to taking her to the ED (Emergency Department). On 1/22/2024, V11, R1's daughter/POA (Power of Attorney) stated, I left the facility just before 7:00 PM on 1/14/2024 and Mom had to use the bathroom before she did her therapy. The next day she was slouched down in her chair and had a great big knot on her forehead. She told me I fell'. I never received a phone call about the fall and it was not charted. I was told the system (Electronic Medical Record/Phones) was down. I personally got ahold of (V14, Medical Director) and he wanted her sent out. A resident who was across the hall from Mom's old room told me about it the next day. V11continued to state that R1's eye had been red and looked like it was getting ready to bleed. V11, continued to state that she told the nurses about it for about a week before, but was ignored, until V9, Licensed Practical Nurse, (LPN) got ahold of the doctor and got an eye ointment. On 1/23/24 at 11:30 AM, V3, RN (Registered Nurse), stated that on 1/14/24 she was working her first weekend on her own after completing new hire orientation and that towards the end of her 16 hour shift the CNAs(Certified Nursing Assistant) informed her that R1 was leaning in the bathroom and they had to lower her to the floor. V3 stated that she assessed R1 and did not find any injuries. V3 stated that she went to put the fall in the computer and that she had locked herself out of the electronic medical record. V3 stated, We didn't have a DON (Director of Nursing) so I called the new Administrator and she said she didn't have a way to reset me in the EMR (electronic medical record) so I didn't fill out an incident report. I hate it but I couldn't because I was locked out. V7, CNA and V8, CNA was with me. I didn't call the doctor or the family because I thought she was okay. On 1/24/24 at 10:30 AM, V8, CNA, stated I went in there after the family left and asked (R1) if she needed to use the restroom and she said yes. (V7, CNA) and I put her on toilet. (R1) said she wanted to sit awhile so I educated her on using the call light. When we came back into the bathroom a few minutes later she was laying on the floor. (V3, RN) assessed her and she did not have any injuries. On 1/24/24 at 3:20 PM, V7, CNA, stated On 1/14/24 around 7:00 PM, me and (V8, CNA) transferred (R1) onto the toilet. (R1) said she needed to sit for awhile. We came back and found her laying on the bathroom floor. The nurse assessed her and we didn't see any injuries. I don't remember if we put a gait belt on her or not. I am not sure how we determine who we are supposed to use gait belts on. The facility fall investigation for R1, dated 1/15/24, documented the root cause of R1's fall on 1/14/24 was R1 attempted to transfer self without activating her call light. New intervention was to trial with a chair alarm. On 1/24/24 at 2:04 PM, V2, Regional Nurse/DON, stated that she would expect CNA's and nurses to use a gait belt when transferring residents. V2 also stated that she would expect the facility nurses to complete incident/accident reports on the shift it occurred on and to notify the resident's physician and family of the incident/accident. The facilities Accidents and Incidents Policy, dated 7/1/23, documented, The purpose is to provide staff with guidelines for investigating, reporting, and recording accidents and incidents. The policy is all accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. Definition: an accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers. Responsibility: It is the responsibility of the Charge Nurse to complete the accident and incident in the electronic medical record, notify attending physician and responsible parties and document information accordingly. It continues, Procedure: 1. Reporting an accident and incident: A. Accident and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/Incident Report should be completed on the shift that the accident or incident occurred. It continues, 3. Medical Attention: B. The Medical Director or the resident's personal physician shall be notified of Accident/Incident. It continues, 4. Investigate and follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. B. The Accident/Incident report must be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy to ensure a safe transfer for one of three residents (R1) reviewed for accidents, in a sample of nine. The findings include: R1's face sheet, dated 1/25/24, documents resident was admitted to the facility on [DATE]. It also documents R1's medical diagnoses of Alzheimer's disease, dementia, chronic heart failure, type 2 diabetes, atrial fibrillation, atherosclerotic heart disease, hypertension, psychotic disorder with hallucinations, osteoarthritis, major depressive disorder, hypothyroidism, and anxiety disorder. R1's Care Plan, dated 11/24/23, documents that R1 is at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and psychoactive drug use. It continues, Care Plan interventions: assistive device/reacher, tab alarm placed on 1/16/24, remind resident to ask for assist when she feels unable to complete a task, assist resident with keeping her reacher near her while in her room, be sure call light is within reach and encourage resident to use it for assistance as needed, ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair and remind resident to ask for assistance when needed. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 was moderately cognitively impaired and requires partial/moderate assistance with toilet transfers. On 1/24/24 at 9:15 am V4, CNA (Certified Nurse Assistant), transferred R1 from her wheelchair onto the toilet without the benefit of a gait belt. R1 progress note, dated 1/16/23 at 8:53 AM, documents that on 1/15/24, (R1's) daughter reported that (R1) told her she fell and hurt her head. It continues, Upon physical exam this writer noted that there was an approximately 2.5 by 2.5 cm (centimeter) red area to (R1's) forehead above her right eye at (R1's) hairline. (R1) unable to tell this writer what happened. She states she thinks she fell but is unsure if she was in her room, bathroom or hallway. Denied any pain or discomfort to her head. R1 progress note, dated 1/17/24 at 12:39 PM, documents late entry for 1/15/24 1 pm. Resident taken to ER (Emergency Room) accompanied by one staff member for evaluation, daughter notified and asks that resident be allowed to each lunch prior to taking her to the ED (Emergency Department). On 1/22/2024 V11, R1's daughter/POA stated, I left the facility just before 7:00 PM on 1/14/2024 and Mom had to use the bathroom before she did her therapy. The next day she was slouched down in her chair and had a great big knot on her forehead. She told me I fell. I never received a phone call about the fall and it was not charted. I was told the system (Electronic Medical Record/Phones) was down. I personally got a hold of (V14, Medical Director) and he wanted her sent out. A resident who was across the hall from Mom's old room told me about it the next day. It takes two people to transfer mom since she's so weak and incontinent. On 1/23/24 at 11:30 AM, V3, RN (Registered Nurse), stated that on 1/14/24 she was working her first weekend on her own after completing new hire orientation and that towards the end of her 16 hour shift the CNAs informed her that R1 was leaning in the bathroom and they had to lower her to the floor. V3 continued to state that she assessed R1 and did not find any injuries. V3 stated that she went to put the fall in the computer and that she had locked herself out of the electronic medical record. V3 stated, We didn't have a DON (Director of Nursing) so I called the new Administrator and she said she didn't have a way to reset me in the EMR (electronic medical record) so I didn't fill out an incident report. I hate it but I couldn't because I was locked out. (V7, CNA and V8, CNA) was with me. I didn't call the doctor or the family because I thought she was okay. On 1/24/24 at 10:30 AM, V8, CNA, stated I went in there after the family left and asked (R1) if she needed to use the restroom and she said yes. (V7) and I put her on toilet. (R1) said she wanted to sit awhile so I educated her on using the call light. When we came back into the bathroom a few minutes later she was laying on the floor. (V3) assessed her and she did not have any injuries. On 1/24/24 at 3:20 PM, V7, CNA, stated, On 1/14/24 around 7:00 PM, me and (V8) transferred (R1) onto the toilet. (R1) said she needed to sit for awhile. We came back and found her lying on the bathroom floor. The nurse assessed her and we didn't see any injuries. I don't remember if we put a gait belt on her or not. I am not sure how we determine who we are supposed to use gait belts on. The facility fall investigation for R1, dated 1/15/24, documented the root cause of R1's fall on 1/14/24 was that R1 attempted to transfer self without activating her call light. New intervention was to trial with a chair alarm. On 1/24/24 at 2:04 PM V2, (Regional Nurse/DON), stated that she would expect CNAs and nurses to use a gait belt when transferring residents. V2 also stated that she would expect the facility nurses to complete incident/accident reports on the shift it occurred on and to notify the resident's physician and family of the incident/accident. The facilities Accidents and Incidents Policy, dated 7/1/23, documents, The purpose is to provide staff with guidelines for investigating, reporting, and recording accidents and incidents. The policy is all accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. Definition: an accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers. Responsibility: It is the responsibility of the Charge Nurse to complete the accident and incident in the electronic medical record, notify attending physician and responsible parties and document information accordingly. It continues, Procedure: 1. Reporting an accident and incident: A. Accident and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/Incident Report should be completed on the shift that the accident or incident occurred. It continues, 3. Medical Attention: B. The Medical Director or the resident's personal physician shall be notified of Accident/Incident. It continues, 4. Investigate and follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. B. The Accident/Incident report must be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to administer/apply a pain patch as ordered for 1 of 3 residents reviewed for medications in a sample of 9. The findings include: R1's face sheet, dated 1/25/24, documents resident was admitted to the facility on [DATE]. R1's medical diagnosis includes Alzheimer's disease, dementia, chronic heart failure, type 2 diabetes, atrial fibrillation, atherosclerotic heart disease, hypertension, psychotic disorder with hallucinations, osteoarthritis, major depressive disorder, hypothyroidism, and anxiety disorder. R1's Care Plan, dated 11/24/23, documented that R1 has and is at risk for pain. The Care Plan goal is R1 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The Care Plan interventions are to evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. It continues, my pain is alleviated/relieved by medication and movement. R1's Minimum Data Set (MDS), dated [DATE], documented R1 is moderately cognitively impaired. On 1/22/2024, V11, R1's daughter/POA (Power of Attorney) stated, Mom's pain patch is supposed to be put on every morning. On her right shoulder for arthritis. There have been at least three to four times she didn't even have it on. For example, the day I found her with the big knot on her head I told the nurse she didn't have it on. (V3, LPN) said they ran out, so they just put (another arthritis ointment) on it. I then asked (V13,LPN) and she said they were not out of the patches. They were in the drawer (of the medication cart). On 1/24/24 at 9:12 AM, V6 CNA (Certified Nurse Assistant) lowered and raised R1's shirt to see if R1's pain patch had been applied to R1's right shoulder as ordered at 8:00 AM. The pain patch was not observed and V6 confirmed that the patch was not on R1. R1's medication administration record, dated 01/2024, documented that R1's pain patch was applied at 8:12 am by V10 RN (Registered Nurse). On 1/24/24 at 9:35 AM, V9 LPN (Licensed Practical Nurse) documented that R1's pain patch was put on late this am due to being in dining room at breakfast, MD (Medical Doctor) notified. On 1/24/24 at 3:08 PM, V10 RN stated that she had initially applied R1's pain patch when R1 was in bed before the CNAs got R1 up for breakfast but she could not recall what time that was. On 1/24/24 at 3:15 PM, V9 LPN stated that she applied R1's pain patch after breakfast and that she notified the doctor regarding the pain patch being applied late. V9 stated that the pain patch was only applied once today and that it wasn't applied earlier because R1 was already in the dining room when V10 was passing medications. On 1/24/24 at 2:04 PM, V2, DON (Director of Nursing)/Regional Nurse, stated that she would expect the facility nurses to administer medications as ordered and sign the medication off on the MAR (Medication Administration Record) after it was administered. The facility Medication Administration Policy/Procedure, dated 7/1/23, does not address transdermal patch application/administration. The policy does document the purpose is to ensure proper administration of oral medication. Policy: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. It continues, policy interpretation and implementation: 8. Follow the specific instructions listed for each type of medication to be given. It continues, 12. Chart the medication administered on the electronic medication record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent employee to resident verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 8. Findings include: R3's Face Sheet documents R3's diagnoses to include: Vascular Dementia, Mild, With Other Behavioral Disturbance; Major Depressive Disorder, Recurrent, Unspecified, Unspecified Hearing Loss and Encounter for Palliative Care. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and requires assist from staff for Activities of Daily Living (ADLs). The facility's document, Report Form-IDPH (Illinois Department of Public Health) Notification, documents: Date of incident: 7/17/23, not reported until 7/21/23. R3 was identified as the resident involved. The report documents the type of incident as alleged abuse, verbal. Per the report, Another staff member reported inappropriate verbal interaction between a staff member and a resident. Staff member immediately suspended pending investigation. Resident assessed; no physical or psychosocial injury noted. Final to follow. Per the report, R3's Power of Attorney (POA), Medical Doctor (MD) and the police were notified on 7/21/23. Under Verification of Incident Investigation/Administrative Summary the report documents the type of incident as allegation of verbal/physical abuse. A brief description of the incident/event is documented as, A C.N.A. (Certified Nursing Assistant) of the facility reports that another C.N.A. used inappropriate language and attempted to make a resident sit down in her wheelchair. At the time of the event, the resident was having behaviors of exit seeking and walking without an assistive device unsafely. Individuals with direct knowledge of incident/event and/or those interviewed were identified as (V16) CNA, (V9) CNA and (V4) Licensed Practical Nurse (LPN). Per the report, V4, V9 and V16 were interviewed on 7/21/23. Under Immediate Actions Taken (assessments, reporting, suspensions, etc.) it documents R3's Primary Care Physician and family/POA (Power of Attorney), local police, Medical Director and IDPH were notified, and incident was reported to the administrator on 7/21/23, and V9 was suspended pending the investigation. The Verification of Incident Investigation/Administrative Summary dated 7/26/23 documents, Follow-up Actions taken: in servicing the LPN on duty regarding abuse/neglect, in servicing certified nursing staff on abuse/neglect and resident rights, trauma assessment, updated care plan, and social service director to meet with resident x 2 weeks to assure no psychosocial issues. The report does not document whether the allegation of abuse was substantiated or not after investigation completed. A staff interview with V4, LPN dated 7/21/23 was included in the abuse investigation and documented V4's statement as, Staff told me that (V9) was a little rough with (R3). (V9) was in a bad mood all night, just frustrated and she was saying, I'm over this. I just want to go home. The next day I spoke to (V9) concerning the issue. I asked her if she was rough with (R3). (V9) told me I was short with her. I counseled her on the behavior, telling her that it was unacceptable and how she can't take it out on a resident. I told her if she gets frustrated to walk away and get another staff. There was a hand-written question on V4's typed statement that documented question/answer: Did she describe what she meant by short? No, she didn't. I didn't ask all the details. I checked on (R3) to check her blood sugars and she was fine. The blood sugars were a normal check. At the bottom of the statement another handwritten statement documented, If (V9) raised her voice, sometimes (R3) just looks past you and won't acknowledge you. She might have been trying to get her attention. I believe that whole heartedly. This document had V4's name on it and was signed by V1, Administrator and labeled as phone interview 7/21/23. V16, CNA's written statement, dated 7/17/23 documents, As we were serving supper (R3) started getting agitated and trying to get up, wanting to leave. I told (V4) that it might be a good idea to give (R3) something to calm her down as the day before she had done something to the point she was going after other residents. I assumed she did and the next thing I know she was at the nurse's desk, and the chair alarm was going off. I came down the hall and (V9) was going on about she wasn't dealing with it. I told her to let her go that I would take care of her. I walked down one hall with her, and she turned to go to employee entrance exit so I walked with her not really letting her get around me. We were about to room (xxx) when (V9) approached with (R3's) wheelchair (w/c). As (R3) had her back to (V9), with (V9) behind the chair, she grabbed her waist and forcefully put her in the chair. As she did, she said, Sit the f*** down. (R3's) eyes got big and she became more agitated and started swinging her hands. I again stated to (V9) that I had (R3) and to walk away. Within an hour of this, as (R3) and I was down the hall further by room (xxx) (V9) stood in front of the exit door telling me to let her (R3) go. By this point I had (R3) calmer and it was almost as if (V9) was trying to provoke her (R3). At around 6:15 PM (V9) and (unknown CNA) came out of the breakroom and one of them had made the comment they were getting her chair and she WILL sit down. At this point I almost lost it and told them no one was getting the chair and I had her calmed down and to leave her alone. I told the nurse about the incident. She asked where (V9) was, but by then she was off, and she said she'd let (V2) know. I contacted the administrator the next day, but I was unable to reach her. This handwritten statement was signed by V16. On 12/14/23 at 3:33 PM V1 stated the abuse report regarding V9 and R3 does not say whether the abuse allegation was substantiated or not, but stated it was not substantiated because it was on person's word against another's and there was no proof that it happened. V1 stated she did interviews with staff and residents and the allegation was unfounded due to lack of evidence. The facility's policy, Abuse Policy revised 9/15/23 documents, Purpose: To provide guidance and procedures to the facility and staff to assure residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and /or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the administrator (Abuse Coordinator). Procedure: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; and filing accurate and timely investigative reports. This policy further documents: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA, and MD in a timely manner.

Based on interview and record review, the facility failed to immediately report abuse for 1 of 3 residents (R3) reviewed for reporting of abuse allegations in the sample of 8. Findings include: The facility's document, Report Form-IDPH (Illinois Department of Public Health) Notification, documents: Date of incident: 7/17/23, not reported until 7/21/23. R3 was identified as the resident involved. The report documents the type of incident as alleged abuse, verbal. Per the report, Another staff member reported inappropriate verbal interaction between a staff member and a resident. Staff member immediately suspended pending investigation. Resident assessed; no physical or psychosocial injury noted. Final to follow. Per the report, R3's Power of Attorney (POA), Medical Doctor (MD) and the police were notified on 7/21/23. Under Verification of Incident Investigation/Administrative Summary the report documents the type of incident as allegation of verbal/physical abuse. A brief description of the incident/event is documented as, A C.N.A. (Certified Nursing Assistant) of the facility reports that another C.N.A. used inappropriate language and attempted to make a resident sit down in her wheelchair. At the time of the event, the resident was having behaviors of exit seeking and walking without an assistive device unsafely. Under Immediate Actions Taken (assessments, reporting, suspensions, etc.) it documents Verification of Incident Investigation/Administrative Summary dated 7/26/23 documents, Follow-up Actions taken: in servicing the LPN on duty regarding abuse/neglect, in servicing certified nursing staff on abuse/neglect and resident rights, trauma assessment, updated care plan, and social service director to meet with resident x 2 weeks to assure no psychosocial issues. A staff interview with V4, LPN dated 7/21/23 was included in the abuse investigation and documented V4's statement as, Staff told me that (V9) was a little rough with (R3). (V9) was in a bad mood all night, just frustrated and she was saying, I'm over this. I just want to go home. The next day I spoke to (V9) concerning the issue. I asked her if she was rough with (R3). (V9) told me I was short with her. I counseled her on the behavior, telling her that it was unacceptable and how she can't take it out on a resident. I told her if she gets frustrated to walk away and get another staff. V16, CNA's written statement, dated 7/17/23 documents, As we were serving supper (R3) started getting agitated and trying to get up, wanting to leave. I told (V4) that it might be a good idea to give (R3) something to calm her down as the day before she had done something to the point she was going after other residents. I assumed she did and the next thing I know she was at the nurse's desk and the chair alarm was going off. I came down the hall and (V9) was going on about she wasn't dealing with it. I told her to let her go that I would take care of her. I walked down one hall with her, and she turned to go to employee entrance exit so I walked with her not really letting her get around me. We were about to room (xxx) when (V9) approached with (R3's) wheelchair (w/c). As (R3) had her back to (V9), with (V9) behind the chair, she grabbed her waist and forcefully put her in the chair. As she did, she said, Sit the f*** down. (R3's) eyes got big and she became more agitated and started swinging her hands. I again stated to (V9) that I had (R3) and to walk away. Within an hour of this, as (R3) and I was down the hall further by room (xxx) (V9) stood in front of the exit door telling me to let her go. By this point I had (R3) calmer and it was almost as if (V9) was trying to provoke her. At around 6:15 PM (V9) and (unknown CNA) came out of the breakroom and one of them had made the comment they were getting her chair and she WILL sit down. At this point I almost lost it and told them no one was getting the chair and I had her calmed down and to leave her alone. I told the nurse about the incident. She asked where (V9) was, but by then she was off, and she said she'd let (V2) know. I contacted the administrator the next day, but I was unable to reach her. On 12/14/23 at 3:33 PM V1 stated she would expect to be notified immediately if abuse is suspected and stated she should have been notified on 7/17/23 when the alleged abuse occurred but she was not notified until 7/21/23. V1 stated V16, CNA told her she tried to call the next day after the alleged abuse occurred but V1 was in a meeting so V16 was unable to get in touch with her. V1 stated V4, LPN, did not notify her of the alleged abuse after V16 informed V4 on 7/17/23. V1 stated there should have been no delay in contacting her to report the alleged abuse. She stated she suspended V9 as soon as she was aware of the allegation of abuse on 7/21/23 but stated V9 did continue to work for the next 3 days after the abuse allegedly occurred. The facility's policy, Abuse Policy revised 9/15/23 documents, Purpose: To provide guidance and procedures to the facility and staff to assure residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and /or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the administrator (Abuse Coordinator). Procedure: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; and filing accurate and timely investigative reports. This policy further documents: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA, and MD in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated timely and the alleged perpetrator of abuse was removed from direct patient contact while the allegation was investigated for 1 of 3 residents (R3) reviewed for abuse in the sample of 8. Findings include: R3's Face Sheet documents her diagnoses to include: Vascular Dementia, Mild, With Other Behavioral Disturbance; Major Depressive Disorder, Recurrent, Unspecified, Unspecified Hearing Loss and Encounter for Palliative Care. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and requires assist from staff for Activities of Daily Living (ADLs). The facility's document, Report Form-IDPH (Illinois Department of Public Health) Notification, documents: Date of incident: 7/17/23, not reported until 7/21/23. R3 was identified as the resident involved. The report documents the type of incident as alleged abuse, verbal. Per the report, Another staff member reported inappropriate verbal interaction between a staff member and a resident. Staff member immediately suspended pending investigation. Resident assessed; no physical or psychosocial injury noted. Final to follow. Per the report, R3's Power of Attorney (POA), Medical Doctor (MD) and the police were notified on 7/21/23. Under Verification of Incident Investigation/Administrative Summary the report documents the type of incident as allegation of verbal/physical abuse. A brief description of the incident/event is documented as, A C.N.A. (Certified Nursing Assistant) of the facility reports that another C.N.A. used inappropriate language and attempted to make a resident sit down in her wheelchair. At the time of the event, the resident was having behaviors of exit seeking and walking without an assistive device unsafely. Individuals with direct knowledge of incident/event and/or those interviewed were identified as (V16) CNA, (V9) CNA and (V4) Licensed Practical Nurse (LPN). Per the report, V4, V9 and V16 were interviewed on 7/21/23. Under Immediate Actions Taken (assessments, reporting, suspensions, etc.) it documents R3's Primary Care Physician and family/POA (Power of Attorney), local police, Medical Director and IDPH were notified, and incident was reported to the administrator on 7/21/23, and V9 was suspended pending the investigation. The report does not document whether the allegation of abuse was substantiated or not after investigation completed. A staff interview with V4, LPN dated 7/21/23 was included in the abuse investigation and documented V4's statement as, Staff told me that (V9) was a little rough with (R3). (V9) was in a bad mood all night, just frustrated and she was saying, I'm over this. I just want to go home. The next day I spoke to (V9) concerning the issue. I asked her if she was rough with (R3). (V9) told me I was short with her. I counseled her on the behavior, telling her that it was unacceptable and how she can't take it out on a resident. I told her if she gets frustrated to walk away and get another staff. V16, CNA's written statement, dated 7/17/23 documents, As we were serving supper (R3) started getting agitated and trying to get up, wanting to leave. I told (V4) that it might be a good idea to give (R3) something to calm her down as the day before she had done something to the point she was going after other residents. I assumed she did and the next thing I know she was at the nurse's desk and the chair alarm was going off. I came down the hall and (V9) was going on about she wasn't dealing with it. I told her to let her go that I would take care of her. I walked down one hall with her, and she turned to go to employee entrance exit so I walked with her not really letting her get around me. We were about to room (xxx) when (V9) approached with (R3's) wheelchair (w/c). As (R3) had her back to (V9), with (V9) behind the chair, she grabbed her waist and forcefully put her in the chair. As she did, she said, Sit the f*** down. (R3's) eyes got big and she became more agitated and started swinging her hands. I again stated to (V9) that I had (R3) and to walk away. Within an hour of this, as (R3) and I was down the hall further by room (xxx) (V9) stood in front of the exit door telling me to let her go. By this point I had (R3) calmer and it was almost as if (V9) was trying to provoke her. At around 6:15 PM (V9) and (unknown CNA) came out of the breakroom and one of them had made the comment they were getting her chair and she WILL sit down. At this point I almost lost it and told them no one was getting the chair and I had her calmed down and to leave her alone. I told the nurse about the incident. She asked where (V9) was, but by then she was off, and she said she'd let (V2) know. I contacted the administrator the next day, but I was unable to reach her. This handwritten statement was signed by V16. V9's Time Sheet documents she continued to work every day after alleged abuse occurred including 7/18/23, 7/19/23, and 7/20/23. On 12/14/23 at 3:33 PM V1, Administrator, stated the abuse report regarding V9 and R3 does not say whether the abuse allegation was substantiated or not, but stated it was not substantiated because it was on person's word against another's and there was no proof that it happened. V1 stated she did interviews with staff and residents and the allegation was unfounded due to lack of evidence. V1 stated she would expect to be notified immediately if abuse is suspected and stated she should have been notified on 7/17/23 when the alleged abuse occurred but she was not notified until 7/21/23. V1 stated V16, CNA told her she tried to call the next day after the alleged abuse occurred but V1 was in a meeting so V16 was unable to get in touch with her. V1 stated V4, LPN, did not notify her of the alleged abuse when V16 informed V4 on 7/17/23. V1 stated there should have been no delay in contacting her to report the alleged abuse. She stated she suspended V9 as soon as she was aware of the allegation of abuse on 7/21/23 but stated V9 did continue to work for the next 3 days after the abuse allegedly occurred. The facility's policy, Abuse Policy revised 9/15/23 documents, Purpose: To provide guidance and procedures to the facility and staff to assure residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The administrator and /or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the administrator (Abuse Coordinator). Procedure: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; and filing accurate and timely investigative reports. This policy further documents: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA, and MD in a timely manner.

Based on observation, interview and record review, the facility failed to maintain appropriate infection control practices while administering medications to 4 of 7 residents (R8, R15, R24, R89) reviewed for infection control in the sample of 30. Findings include: On 2/7/23 from 4:25 PM to 5:01 PM, V13, Licensed Practical Nurse (LPN), was observed during PM medication administration pass. V13 failed to maintain appropriate infection control practices while administering medications to the following residents: 1. At 4:25 PM, V13 administered R8's PM medications including Atorvastatin 20 milligrams (mg), Buspirone 10 mg, Gabapentin 400 mg, Hydroxyzine 20 mg, Carafate 1 Gram (gm), Tylenol 650 mg, and Mylanta 15 milliliters (ml). V13 placed all the tablets into a small plastic pouch to crush them and poured the contents into a medication cup, and then opened R8's Gabapentin capsule with her bare hands and poured the contents of the capsule into the medication cup, added some applesauce and administered this to R8 with a spoon. 2. At 4:39 PM, V13 administered R24's PM medications including Cephalexin 500 mg and Depakote 125 mg. V13 opened both the Cephalexin capsule and Depakote capsule with her bare hands, poured the contents of each capsule into a medication cup, added some applesauce and administered this to R24 with a spoon. 3. At 4:47 PM, V13 administered R15's PM medications including Risperdal 0.5 mg, Buspirone 10 mg, Eliquis 5 mg, Iron 324 mg, Gabapentin 100 mg, Eye Caps Vitamin, and Tylenol 1000 mg. V13 placed all the tablets in a small plastic pouch and crushed them, and then poured the contents into a medication cup. V13 then opened R15's Gabapentin capsule with her bare hands and poured the contents into the medication cup, added applesauce and administered this to R15 with a spoon. 4. At 5:01 PM, V13 administered R89's PM medications including Eliquis 5 mg, Gabapentin 300 mg, and Tylenol 500 mg. V13 placed the tablets in a small plastic pouch and crushed them and poured the contents into a medication cup. V13 then opened the Gabapentin capsule with her bare hands and poured the contents into the medication cup, added applesauce and administered this to R89 with a spoon. On 2/9/23 at 9:56 AM, V2, Director of Nursing (DON), stated if a nurse must open a capsule to administer medications to a resident, that nurse should put on gloves before touching the medication. The facility's policy, Medication Administration, dated 1/11/10, documents, Objective: To provide accuracy during medication pass to assure quality care for residents. The policy does not address opening capsules during medication administration.

Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for 4 of 5 residents (R32, R238, R240, R241) reviewed for antibiotic stewardship in the sample of 30. Findings include: 1. The Facility's Infection Prevention & Control Monthly Log for October 2022 documents the Organism No Growth as cause for R32's urinary infection. The log documents R32 was treated with the antibiotic Macrobid. R32's Urine Culture collected at (Local Hospital) on 10/10/22 documents, Result: No Growth. R32's Progress Note written by V3, Infection Control Preventionist, on 10/17/22 at 6:47 PM documents, Final UA (urinalysis) results noted no growth, call to MD (medical doctor) asking if he would like to shorten duration. R32's Order Review Report printed 2/7/23 documents order for Macrobid Capsule 100 mg (milligrams) - Give 100 mg by mouth two times a day for UTI (urinary tract infection) for 10 days with start date of 10/12/22 and end date of 10/18/22. R32's October 2022 Medication Administration Record (MAR) documents R32 received 13 doses of Macrobid. 2. The Facility's Infection Prevention & Control Monthly Log for November 2022 does not document an organism causing R238's urinary infection. R238's Urine Culture collected at (Local Hospital) on 11/17/22 documents, Result: No Growth. R238's Order Review Report printed 2/7/23 documents order for Cephalexin Capsule 500 mg - Give 500 mg by mouth every 8 hours for UTI for 7 days. R238's November 2022 MAR documents R238 received 21 doses of Cephalexin. 3. The Facility's Infection Prevention & Control Monthly Log for October 2022 documents the Organism <10,000 single gram neg (negative) organism as cause for R240's urinary infection. R240's Urine Culture collected at (Local Hospital) on 10/20/22 documents, Result: Less than 10,000 CFU/mL (colony forming units per milliliter) of single Gram-negative organism isolated. No further testing will be performed. If clinically indicated, recollection using a method to minimize contamination, with prompt transfer to Urine Culture Transport Tube, is recommended. R240's Order Review Report printed 2/7/23 documents order for Levofloxacin Tablet 250 mg - Give 250 mg by mouth every 48 hours for UTI for 5 administrations with start date 10/24/22 and end date of 10/24/22. There is a second order for Levofloxacin Tablet 250 mg - Give 250 mg by mouth every 48 hours for UTI for 5 administrations with start date of 10/26/22 and end date of 11/5/22. R240's October and November 2022 MARs documents R240 received 6 doses of Levofloxacin. 4. The Facility's Infection Prevention & Control Monthly Log for November 2022 does not document an organism as the cause for R241's UTI. On 2/7/23 at 10:45 AM, a urine culture for R241's UTI in November 2022 was requested from V2, Director of Nursing (DON). R241's Progress Note written by V3, Infection Control Preventionist, on 11/29/22 at 1:49 PM documents, MD (medical doctor) notified. MD was notified of UA (urinalysis) done over in ED (Emergency Department) on 11/26/22. Abx (antibiotic) was ordered. Followed up with C&S (culture and sensitivity) and that was no (not) done in ED. MD notified of this situation and wanted to know if he would like to D/C (discontinue) Abx or if to continue due to elevated WBC (white blood cell) of 14. R241's Order Review Report printed 2/7/23 documents order for Sulfamethoxazole-Trimethoprim Tablet 800-160mg - Give 1 tablet by mouth every 12 hours for UTI per hospital for 20 administrations with start date of 11/27/22 and end date of 12/1/22. R241's November and December 2022 MARs documents R241 received 8 doses of Sulfamethoxazole-Trimethoprim Tablet. On 2/9/23 at 9:57 AM, no culture for R241's UTI was received by the Facility. V2, DON, stated, It is the company's expectation to get residents off inappropriate antibiotics. We try to notify the doctors and educate them, but we cannot write the orders. The Facility's Antibiotic Stewardship Protocol, undated, documents, The World Health Organization has reported that antibiotic resistance is one of the major threats to human health, especially because some bacteria have developed resistance to all known classes of antibiotics. According to the CDC (Centers for Disease Control), improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Diseases caused by these bacteria are increasing in long-term facilities and contributing to higher rates of morbidity and mortality. It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. Leadership: A written statement of leadership support to improve antibiotic use is in place. (This support is also present at the corporate level as needed). The Medical Director will assist in communicating the facility's expectations for antibiotic use to prescribing clinicians as needed. The antibiotic stewardship review is a part of the Infection Prevention and Control Program in this facility and is overseen by the Infection Prevention and Control Committee. The Medical Director, Director of Nursing, Infection Preventionist and the consultant pharmacist are all considered leads for antibiotic stewardship activities. As a team they will: Review infections and monitor antibiotic usage patterns on a regular basis; Obtain and review antibiograms from admitting hospitals when available for trends of resistance. Facility optimizes the use of diagnostic testing following physician's orders. The Infection Preventionist will be responsible for infection surveillance and MDRO (multi-drug resistant organism) tracking. The Infection Preventionist will collect and review data such as: McGeer Criteria for positive signs of infection; Antibiotic used and route of administration; Whether appropriate tests such as cultures were obtained before ordering antibiotic; Whether the antibiotic was correct based on the sensitivity report; Whether the antibiotic was changed during the course of treatment.

Based on observation, interview and record review, the facility failed to label a Tubersol (used to aid diagnosis of tuberculosis infection) vial when opened per standards of practice. This has the potential to affect all 36 residents residing in the facility. Findings include: On 2/8/23 at 8:20 AM, the Medication Room on the 200 Hall was observed with V5, Registered Nurse (RN). V5 pulled a bottle of Tubersol test solution from the refrigerator that was opened but not dated. V5 stated she does not know when the Tubersol was opened. The undated Tubersol insert documents, A vial of Tubersol which has been entered and in use for 30 days should be discarded. On 2/9/23 at 9:56 AM, V2, Director of Nursing (DON), stated whoever opens the Tubersol vial first should write the date on the bottle or box documenting the date it was opened, and it should be discarded after 30 days. V2 stated the facility does not have a policy for medication storage. V2 stated the Tubersol is used for any new admits on admission and could be used on anybody due for their TB (tuberculosis) tests. The facility's document, Resident Census and Conditions of Residents dated 2/7/23 documents there are 36 residents residing in the facility.