Every finding on record at Asbury Court Nursing & Rehab

Based on observation, interview, and record review, the facility failed to ensure food was stored under sanitary conditions by failing to discard expired food items and failing to follow the facility policy regarding food storage guidelines. This deficiency has the potential to affect all residents (71 out of 71 residents in the sample) who receive food from the kitchen.Findings include: On 06/29/2026 at 9:40 AM, during the initial tour of the kitchen, the following items were observed in the walk-in refrigerator:Celery in metal food service tray dated 05/25/2026 (facility policy states 3-7 days is safe for storage)Celery in cardboard box dated 06/09/2026 (facility policy states 3-7 days is safe for storage)Lemons in cardboard box dated 06/09/2026 (facility policy states 3-7 days is safe for storage)Bacon in plastic packaging inside carboard box dated 06/05/2026 (facility policy states 7 days is safe for storage)Green Onions in plastic packaging inside cardboard box dated 05/05/2026 (facility policy states 3-7 days is safe for storage)Ham in metal container covered in plastic wrap, labeled with a use by date of 06/23/2026Egg Salad in metal container covered in plastic wrap dated 06/23/2026 (facility policy states 3-5 days is safe for storage)Ground Beef in plastic wrapping inside a metal container dated with use by date of 06/28/2026 (facility policy states 1-2 days is safe for storage)Sausage Crumbles inside plastic bag inside cardboard box dated 06/12/2026 (facility policy states 3-4 days is safe for storage)Fully Cooked Chicken Breasts in a plastic bag inside a cardboard box dated 06/26/2026 were inside refrigerator and were thawed (soft to the touch). Box stated, Keep Frozen. On 06/29/2026 at 10:00 AM salad dressing containers on a dry storage shelf have manufacturer packaged date printed on bottles and handwritten dates on caps of the bottles. V7 (Dietary Assistant Director) stated the dates on the top of the bottles are the dates the kitchen received the items. V7 stated the expiration date may have been on the box but that information was not transferred to these bottles.On 06/29/2026 at 10:30 AM, an interview with V7 (Assistant Dietary Director) and V8 (Head Cook) took place, and the walk-in refrigerator was observed after the initial findings at 9:40 AM. The expired items (listed above) remained in the walk-in refrigerator at this time. V7 stated the kitchen staff refer to the facility policy named Storing Food Guidelines which is posted on the outside of the walk-in refrigerator for guidelines for managing food storage and expired food items. V7 stated if a box is labeled Keep Frozen, that package is to be only kept inside the freezer and cooked from frozen. V7 stated the produce that is past the 3-7-day guideline on our policy, is expired and should be thrown away. V7 stated that the ham with the use by date labeled use by 06/23/2026, should be thrown away due to it being 06/29/2026, which is past the use by date of 06/23/2026. V7 stated the expectation for all kitchen staff is to follow the facility policy regarding the proper storage and maintenance of food items held within the kitchen. V8 stated, if the policy says something, we need to go by what it says. V8 then stated the expired items in the walk-in refrigerator should be removed according to facility policy.On 06/29/2026 at 10:40 AM, V6 (Dietary Director) who began working at the facility last week. V6 stated the kitchen staff follow the policy named, Storing Food Guidelines which is posted on the outside of the walk-in refrigerator in terms of food storage and guidelines. V6 stated their expectation is for food items that are expired, according to the facility policy, to be removed from the refrigerator or dry storage area and disposed of.On 06/30/2026 at 10:15 AM, V1 (Administrator) stated the kitchen staff typically meet 1-2 times weekly about kitchen inventory and meal planning. V1 stated they expect the facility policy to be followed regarding food storage and expiration parameters. V1 stated their expectation is for kitchen staff to review items in the refrigerator and throw away any expired items, according to facility policy. V1 stated there are no residents in the facility that do not receive food from the kitchen. V1 stated 71 residents receive food from their kitchen and the kitchen also provides food for their assistive/supportive living facility due to it being a shared kitchen.Facility policy named, Storing Food Guidelines, not dated, states in part but not limited to:Guide for keeping perishable foods safe and at peak quality.Fresh Food:Ground Meat 1-2 Days in RefrigeratorLeftover Cooked Meats 3-4 Days in RefrigeratorBacon 7 Days in RefrigeratorFruit 1-3 Weeks in RefrigeratorVegetables 3-7 Days in RefrigeratorMayonnaise (unopened in dry storage) 2-3 Months

Based on observation, interview, and record review, the facility failed to have a working call light system. This has the potential to affect all 71 residents currently at the facility. Findings include:On [DATE] at 3:25 PM, observed the call light for room XXX to be on for approximately 12 minutes and observed the nursing station call monitor panel with an error message. V19 (Certified Nursing Assistant) stated I was walking in the hallway when I saw the call light, and I was not aware that the call light was not working. V19 turned the call lights on in six different rooms. The call lights were on, and flushing but no call light alarm or notification was observed from the call light system by the nursing station. V5 (Registered Nurse) said that the last time that she heard the call light was earlier today around 9:30-10:00 AM today. V20 (Maintenance Director) said that the system is all connected and the whole unit system is not working, and he would call a technician to check the system.On [DATE] 10:13 AM, the surveyor rounded on the facility, and the call light system in the facility was still not working properly. The light would turn on with no sound or notification from the nursing station was seen, only an error message.On [DATE] 10:24 AM V2 (Director of Nursing) said that the technician is on the way to fix it today.On [DATE] 12:35 PM, observed an outside technician on the unit working to fix the call light system.On [DATE] 11:26 AM, the surveyor rounded the facility, and the call lighting system was still not working.On [DATE] at 1:24 PM, V1(Administrator) said the call light system will be fixed, and the parts will be available on Monday. We are going to continue to have the staff placed on the hallway and do frequent rounds, and the staff will be using walkie-talkies to call for assistance and communicate.According to the CMS 671 form, dated [DATE], there are 71 residents in the facility. The facility provided a list of 20 residents who required total assistance.According to the Facility Assessment tool dated 6-2025 through 5-2026, the following is noted: Physical environment and building plan needs. Section 4.9. List physical resources and describe the process to ensure adequate supplies and equipment are maintained to protect and promote the health and safety of residents. Under other physical plant needs: nurse call system.On [DATE] at 3:44 PM, V1 provided the facility policy titled, Call Lights: Accessibility and Timely Response, revised dated 5/2025. Which reads in part (but not limited to),Policy:The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines:8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include replace call light, provide a bell or whistle, increase frequency of rounding, etc.)9.Ensure the call system alerts staff members directly or goes to a centralized staff work area.

Based on observation, interview, and record review, the facility failed to post the required [NAME] and [NAME] Consent Decree Program information in locations that were readily accessible to residents. This failure had the potential to affect all 10 residents residing in the facility who participate in the program. Findings include:On 06/30/2026 12:41 PM the surveyor round the facility looking for [NAME] and [NAME] Decree program signage and none were found on the first and second floor. V1(Administrator) provided the list of the residents under the program. There are 10 residents under the [NAME] and [NAME] Decree Program. On 06/30/2026 at 1:27 PM, V17 (Social Service Director) said she gets the list of residents under the [NAME] and [NAME] Decree Program from V18 (Director of Business Officer) and is not responsible for the program. The surveyor toured the building with V17, who thought the signage for the [NAME] and [NAME] Decree was posted on the bulletin board, but none was found. On 6/30/2025 at 2:06 PM, V18 said, I get the list of the residents in the program and send it to the social work in the building to assist with the program. On 07/01/2026 at 1:13 PM, V1 (Administrator) said that the facility is expected to post the [NAME] and [NAME] signage and make sure that the residents and families are able to see the signage and have information about the program. Our Social worker V17 has computer access to check who can be part of the program and will be taking over the program from V18 from our corporate office and will run the program. V1 said that V17 will receive proper training to be able to assist families and residents that are in the program and have questions. On 07/01/2026 at 1:45 PM, V2 (Director of Nursing) said that V2 was not familiar with the [NAME] and [NAME] Decree Program until yesterday, and we will comply and make sure that the proper signage will be placed on the bulletin board with the other information for all the residents and family to see. On 07/01/2026, V1 (Administrator) provided the facility policy titled, [NAME] Consent Decree Program (revised date 02/2023), reads in part (but not limited to):PolicyThe facility will support the rights of eligible residents to receive information, outreach, assessment, appeal assistance, and transition services under the [NAME] Consent Decree. The facility will not interfere with or retaliate against a resident who expresses an interest in moving from a nursing facility into the community.Purpose:To establish guidelines for identifying potential [NAME] Class Members, responding to requests for outreach or assessment, protecting resident rights, cooperating with transition agencies, and documenting communication related to the [NAME] Consent Decree Program.Definitions:[NAME] Consent Decree refers to the court-approved agreement resulting from [NAME] v. [NAME], a class-action lawsuit filed under the Americans with Disabilities Act against the State of Illinois. The Consent Decree requires the State to provide eligible Class Members an opportunity to receive services in the least restrictive environment appropriate to their needs and to provide housing assistance to individuals transitioning into the community.[NAME] Class Member refers to a person with a disability who is Medicaid-eligible or enrolled in Medicaid, resides in a nursing facility in [NAME] County, and wants to move into the community and receive community-based services. Maximus refers to the agency responsible for outreach and in-person assessments for the [NAME] program. Prime Agency refers to an agency assigned after assessment to assist the Class Member with transition planning, including development of a personalized service plan and arrangement of housing and community supports. Community Transition Initiative (CTI) refers to a process through which some individuals transition into the community with assistance from their Medicaid Managed Care Organization (MCO).

Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted in a location readily accessible to residents and visitors. This deficient practice has the potential to affect all seventy-one residents living in the facility. Findings include: On 06/29/2026 at 9:15 AM, the Surveyor entered through facility's main entrance/front desk area and could not find the facility's nurse staffing information displayed. On 06/30/2026 at 8:30 AM, the Surveyor entered through facility's main entrance/front desk area and could not find the facility's nurse staffing information displayed. On 06/30/2026 at 12:30 PM, the Surveyor observed the front desk area to see if the required nurse staffing information was posted. Once again, the Surveyor was unable to locate the data sheet. On 06/30/2026 at 12:21 PM, the Surveyor asked V2 (Director of Nursing) if he could provide the daily nurse staffing sheet and V2 said he did not have it because the facility never posted it. On 07/01/2026 at 2:21 PM, V1 (Administrator) said the facility did not post the daily nurse staffing sheet at the facility on Monday, 6/29/26, or Tuesday, 6/30/26, but should have done so. The CMS-671 form, dated 6/29/26, noted 71 residents presently living at the facility. The facility's Nurse Staffing Posting Information policy, dated 04/2025, reads in part, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. The policy also states, The facility will post the Nurse Staffing Sheet at the beginning of each shift. The policy further states, The Nurse Staffing Sheet will be posted on a daily basis and will contain the facility name, the current date, the facility's current resident census, and the total number and the actual hours worked by registered nurses, Licensed Practical Nurses/Licensed Vocational Nurses, and Certified Nurse Aides.

Based on the interview and record review, the facility failed to provide adequate supervision and failed to have effective and individualized, resident-specific interventions to prevent a resident from having a fall with injury. This failure affected one (R1) of three residents reviewed for accidents and supervision. These failures resulted in R1 having a witnessed fall requiring emergency transfer to a local hospital and being diagnosed with a hematoma of the scalp. Findings Include: R1 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia, osteoarthritis of the knee, gait and mobility abnormality, depressive disorder, and anxiety. On the (MDS) Minimal Data Set assessment on 4/7/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 1/15, indicating severe cognitive impairment. Minimum Data Set assessment (MDS) of 4/7/2026, Section GG documents that R1 requires substantial/maximal assistance for toileting hygiene, personal hygiene, chair/bed to chair transfer, and toileting transfer. Helpers do more than half of the effort. Helper lifts, holds, or supports the trunk or limbs. But R1 provides less than half effort. R1's care plan, 4/2/26 initiated date, includes in part to encourage the resident to participate in activities that promote exercise; keep bed in lowest position; be sure the resident's call light is within reach; anticipate and meet the resident's needs. The facility's fall incident report dated 5/14/2026 documented, R1 had a witness fall and slid from the wheelchair and hit her head on the floor with a visible head contusion. R1 was transferred to a local hospital and returned with documented discharge diagnoses of head injury and scalp hematoma, hospital records dated 5/14/2026. The Computed Tomography results of the brain dated 5/14/2026 showed focal swelling in the left frontal scalp. On 6/16/26 at 2:00 PM, V7 (Licensed Practical Nurse/LPN) said, I witnessed R1's fall on 5/14/2026. I was sitting at the nursing station on my computer, and R1 was sitting at the middle table in the dining room. R1 was sitting in a wheelchair, and I saw her midway going down. Her wheelchair turned on its side, and R1 fell on her left side and bumped her head on the floor. I don't recall any bleeding. We all ran over there. The on-duty nurse started to assess the R1, and I helped with ice and vital signs. R1 eats breakfast in the dining room from 7:30 AM until 8:30AM. The R1 was sleeping on and off in the dining room. The active person was at the other table and not close to her. I don't know why the staff did not put her back to bed. On 6/16/26 at 2:20PM, V4 (Activity Aide) stated, I was running an activity for the residents, and I was not physically looking at R1 when she fell. It was a small group with 13 residents, and I was helping a visually impaired resident to find a number on her card when I heard a thump, and someone said R1 fell. I had my back way from the R1, and I was about 15 feet away. V4 said, I cannot monitor everyone at one time. On 6/16/26 at 2:29PM, V5 (Certified Nursing Assistant/CNA) said, I was not taking care of R1 when she fell, but I am familiar with R1 and provide care to R1 when I am here. Every day when I get here, R1 is already up in the dining room. I am not sure how early R1 gets up, but I assist her back to bed around 1:00PM-1:30PM. R1 usually is up and stays up for breakfast and lunch in the dining room, and R1 sleeps on and off in her wheelchair, and sometimes R1 tries to push herself away from the table. On 6/16/26 at 2:38 PM, V2(Director of Nursing) said, R1 is a new resident to the long-term unit. My expectation is for the staff to lay down the residents to rest when they are tired and sleeping in the dining room. I think that one activity aide to monitor residents and do activities for 13 residents is not sufficient to watch the residents and run the activity at the same time. On 6/16/2026 at 3:15PM, observed R1 sleeping in her wheelchair, sitting at the middle table with her shoulder relaxed, and a bluish discoloration noted on the left forehead. R1 was alert to herself and only answered yes when questioned if she was sleeping, and R1 said yes to if she was tired. V8 (Activity Aide) was doing an activity with a group closer to the kitchen serving area. V8 had to get something for the game and left the dining area, and no nursing staff were seen at the nursing station for about 2 minutes. The surveyor asked V8 if she needed to let anyone know if she needed to go out of the unit, and V8 said no because there is always someone around. When questioned about no one being at the nursing station when she left, V8 did not answer. The surveyor counted approximately 19 residents in the dining room, and only one table was participating in the activity. V8 had her back toward the middle table and focused on the activity with the residents participating. On 6/18/2026 at 12:15PM V9 (CNA) said, R1 is on the night shift resident get-up list. V9 stated V9 gets here at 6:30AM. V9 said, When R1 fell on 5/14/26, R1 was already up in the dining room that day. Breakfast was served at 7:30AM, and I usually assist with her meals. R1 finished eating at 8:45AM. If R1 is active, I will not put her back to bed until around 4:30PM, because she is a fall risk. If she is doing a lot of movements sometimes, she stays up, and sometimes I put her down. The facility policy titled, Accidents and Supervision dated 10/2025, which reads in part but not limited to:Policy:The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:1.Identifying hazard(s) and risk(s).2. Evaluating and analyzing hazard(s) and risk(s).3.Implementing interventions to reduce hazard(s) and risk(s).4.Monitoring for effectiveness and modifying interventions when necessaryFall Prevention programPolicy:Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.b. Implement routine rounding schedule.c. Monitor for changes in residents' cognition, gait, ability to rise/sit, and balance.

Based on interview and record review, the facility failed to protect a resident from theft. This affected one resident (R1) of three residents reviewed for misappropriation of property.On 4/14/26 at 12:30pm, R1 stated that $1800 was taken from her bank account without her consent but has been refunded by her bank and that she manages her own finances. On 4/14/26 at 10:00am, V1(Administrator) stated she was informed by one of her staff that R1 made a concern about a missing check. V1 stated that she interviewed R1 who accepted, and she called the police who took over the investigation. V1 stated that this was the second time V5 (Agency Certified Nursing Assistant/CNA) had worked in the facility. V1 stated that during an investigation, it was discovered that V5 worked on Thursday (3/26/26) the day the $1800 check was cashed out, and on 3/28/26 when the second check was missing. V1 stated that R1 has a BIMS (Brief Interview for Mental Status) of 15 and handles all her banking issues. V1 stated the facility offered R1 a safe but R1 decided to keep her check books in her room. V1 stated that during investigation from the police, V5 stated that she did not have any belongings but after a search of the empty rooms, V5's belongings were found in an empty room because she refused to put her belongings in the staff break area. V1 stated that a search was conducted and V5's belongings contained resident financial items from other states. V5 was escorted out of the building by the police, and the case was handed to the police. V1 stated that the facility received a cleared background from the agency prior to V5 working. V1 stated that a follow up was conducted by V4(social Service Director) on residents who carry out their financial transactions and the facility has not had any issues with any residents' finance, and a notification was sent to all residents and POA (Power of [NAME]) notifying them of the incident and to reach out to the facility with any concerns. V1 stated the facility was safe but R1 decided to keep her check books. V1 stated that facility offered R1 transportation if she wanted to go to the bank, and recommendation to freeze her accounts, but R1 stated that her family is handling the situation.On 4/14/26 at 11:06am, V3 (R1's Nursing Assistant) stated that she was informed by R1 after returning from Physical Therapy (PT) and pulling up her bank statement that a check was cashed for $1800 which she did not approve, and she also noticed that another check was missing which she had before going for PT. V3 stated that she informed the nurse, and then googled the business name on the check and also searched on social media and saw V5's profile attached to the account, and who was presently working on the unit. V3 stated that she immediately reported the incident to V1 who started an investigation. V3 stated that she worked with V5 on 3/28/26 (The day of the missing check). Facility policy titled: Abuse, Neglect and Exploitation revised 7/2025 reads, Policy:It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definition: Misappropriation of Resident Property Means the deliberate misplacement, exploitation, or wrongful, temporarily or permanent, use of a resident's belongings or money without the residence consent.111. Prevention of Abuse, Neglect and ExploitationThe facility will implement Policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that chiefs. B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/ or misappropriation of resident property is more likely to occur with the deployment of training and qualifying, registered, license, and certify staff on each shift in sufficient numbers to meet the needs of the residents and assured that these staff assign have knowledge of the individual residents care needs and behavioral symptoms

Based on interview and record review, the facility failed to follow its safe resident handling and transfer policy by not having two people assist with the transfer of a resident using a mechanical lift. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfer and safety. These failures resulted in R1 falling during the transfer and had to be transferred to local emergency room for head laceration that required 5 staples.The findings include:R1 was admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documented that R1 is dependent on char/bed-to-chair transfer.R1's care plan (date initiated 10/19/23) documents R1 is dependent on the (mechanical) lift for all transfers.R1's care plan updated 3/4/26 documents Neuro checks initiated, resident sent out to ER for further eval; Staff re-educated on steps and procedures involving proper mechanical lift transfers-return from hospital with staples in back of head.A review of the reportable documented an incident of a fall during transfer using a mechanical lift transfer with a head injury, causing 5 staples to be reported to the state surveying agency on 3/4/26.On 4/7/26 at 9:15 AM, V5 (Registered Nurse/RN) stated, I heard V4 (Certified Nursing Assistant/CNA) didn't use the proper sling and transferred R1 by herself. There should be at least two people with a mechanical lift transfer.On 4/7/25 at 10:45 AM, V3 (R1's Nurse on 3/4/26) stated, V4 had been transferring R1 alone using a mechanical lift, despite knowing that at least 2 staff were required. After the incident, I was called by the CNA, and I assessed the resident, who had minor head bleeding and pain after hitting her head on the machine. The resident was sent to the hospital, received five staples, and returned within a few hours.On 4/7/26 at 12:45 PM, V4 (CNA) stated, It was a busy morning. After the sponge bath, I placed a sling under R1 to help her up using the mechanical lift. The lift wasn't working, so I set the bed to the lowest position to make it work with R1. Both shoulder slings broke when I lifted her up, and she was only two feet above the ground as the bed was in its lowest position. I went to get a nurse, and she assessed her and found a little blood on R1's head. We called 911 and sent her out to the local hospital, and came back after 3 hours with 5 staples on her head.On 4/7/26 at 10:45 AM, V2 (Director of Nursing) stated that the V4 was alone while transferring R1 using a mechanical lift. She also didn't use the proper sling to transfer R1. V4 is not working for us anymore.The facility presented the Safe Resident Handling/Transfers policy (2025) statement document: It is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.10. Two staff members must be utilized when transferring residents with a mechanical lift.

Based on interview and record review, the facility failed to protect a resident (R4) from sexual abuse by another resident. This failure affects one of two residents (R4) reviewed for abuse in a total sample of five residents. Findings include: R4 is a [AGE] year-old female. R4's diagnoses are but not limited to dementia without behaviors, adult failure to thrive, Parkinson's disease, vascular dementia, and high blood pressure. R4's BIMS (Brief Interview for Mental Status) dated [DATE], notes R4 is not alert. R4's care plan notes R4 has impaired cognitive function and Alzheimer's disease. R5 is a [AGE] year-old male. R5's diagnoses are but not limited to Alzheimer's disease, depression, major depression, anxiety disorder, and dementia without behaviors. R5's BIMS (Brief Interview for Mental Status) dated [DATE], notes R5 is alert. R5's care plan notes R5 needs behavior management due to episodes of physical and verbal aggression. R5 has poor impulse control. R5 displays behavioral symptoms related to socially being inappropriate and touching others inappropriately. R5 has impaired cognitive function related to dementia and short-term memory defects. Nurse's note dated [DATE], notes R4 was involved in an inappropriate interaction with another resident. R4 was immediately separated from another resident. R4 not in any mental or physical distress. Behavior notes dated [DATE], notes at around 4:40 PM, it was brought to this writer's attention that R5 was observed acting inappropriate towards another resident in hallway. R4 and R5 were immediately separated from each other, and R5 was placed on 1:1 observation. Police, doctor, family, DON (Director of Nursing) and Administrator all notified. On [DATE], at 12:42 PM, R5 stated, I do not remember this incident. I do not have any other concerns. On [DATE], at 12:55 PM, R4 was in the dining room eating lunch. R4 did not respond to surveyor ' s questions. On [DATE], at 2:53 PM, V2 (Director of Nursing) stated, I did a lot of the investigation with R4 and R5. I was here and staff informed me of the incident. I do not think this was willful abuse. R5 is attracted to R4, and R5 stated she likes him to. R5 is alert but he has impaired judgment. The residents were separated, and R5 was put on a one to one. Law enforcement was contacted. He was sent to behavioral health. According to R5's statement, R4 reminds R5 of his deceased girlfriend that used to reside in the facility. R4 did not have any injuries of any kind and she was smiling. R5 lives on the first floor now instead of the second floor. He is allowed to go to activities when he goes up, but someone is always watching him. There was no harm done. Her family was informed. No other incidents have happened like that since then. On [DATE], at 4:01 PM, V1 (Administrator) stated, R4 looks like R5 ' s former girlfriend. He has some confusion. He told me that when he sees her, he is seeing his girlfriend because it reminds him of his girlfriend. He has not done this to anyone else. He has not done this again to R4. He is attracted to her due to her similarities to his former girlfriend. He was brought downstairs due to the incident. He is being closely monitored to make sure he does not have any interaction. On [DATE], at 9:56 AM, V8 (Registered Nurse) stated, I mainly work on the 1st floor. I was the nurse on duty when this incident occurred. My aide was the first one who saw the incident and reported it to me. We rushed right over. R5 reached under R4 ' s sweater. They were facing against each other. R5 ' s left hand was already underneath R4 ' s sweater. It was around R4's chest area. I presumed it was on R4's chest. Upon seeing this, I grabbed R5's hand and stopped what happened. R4 is non-verbal and not alert. R4 always smiles. The police officer asked her if she tried to scream or ask for help. The officer was trying to find out if there was any consent. He asked if there was any resistance. First, thing I did was inform my manager right away, the co-director of nursing, and the administrator. R5 is alert but it is hard to understand what he is saying. I worked with him two to three times. Interventions put in place were putting R5 on and a one to one and separate them. Since then, this incident has not occurred again. On [DATE], at 10:19 AM, V9 (Social Services Director) stated, I know R5 very well. He does have issues with short term memory and recall. I did talk to him after this incident occurred. R5 said, I know I should not have touched her. He did not say why he did it. He admits to it, but it does not know why he did it. R4 has always had some cognitive issues. After R4's hospital stay she has declined. R4's family was alright with her having a relationship. R5 has only had this with R4, no one else. Prior to R5 coming to us, he had a girlfriend in supportive living. She passed away and he declined to where he needs skilled care. He is used to having a girlfriend. R4 was flirtatious with R5 before she declined. There have not been any issues with other residents. Just these two. She would smile at him and had a few boyfriends before coming to us. I do not know if they had a relationship before because I do not work on the other side. Facility Abuse Policy dated ,d+[DATE], notes sexual abuse is non-consensual contact of any type with a resident.

Based on interview and record review, the facility failed to ensure one resident (R1) was kept safe from falls and failed to implement effective fall prevention interventions. This failure resulted in R1 falling seven times in one month (11/13/24, 11/15/24, 11/20/24, 11/27/24, 12/1/24, 12/2/24, and 12/6/24) which resulted in R1 sustaining a subdural hematoma and a head laceration that required sutures. Findings include: R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to remain in the facility. R1 has multiple diagnoses including but not limited to the following: dementia, type II DM, head injury, repeated falls, psychosis, and traumatic subdural hemorrhage. Per facility fall incident log show R1 experienced a fall on 11/13/24, 11/15/24, 11/20/24, 11/27/24, 12/1/24, 12/2/24, and 12/6/24. Facility reported incident dated 11/27/24 shows R1 was observed on floormat next to R1's bed. R1 sent to hospital. Hospital records indicate R1 sustained a traumatic subdural hematoma after an unwitnessed fall and received sutures to a head laceration. Facility reported incident dated 12/2/24 shows R1 was observed on the floor in front of the toilet in the bathroom. R1 was sent to the hospital due to R1 stating she hit her head. Hospital records indicate a diagnosis of a subdural hematoma. Following investigation, R1 had been assisted to the toilet by V5 (Certified Nursing Assistant/CNA) who then stepped out of the bathroom to obtain assistance for R1. Upon returning, R1 had fallen. On 12/16/24 at 11:20AM, V4 (CNA) was interviewed regarding R1 and fall on 12/2/24. V4 said I was R1's assigned CNA that day. It was during lunch service, and I was in the dining room passing trays. V5 came up to me in the dining room and told me she had assisted R1 to the toilet and wanted me to assist her when R1 had finished. V4 said I immediately ran to the bathroom in her room. When I walked in, I saw R1 on the floor in front of the toilet and she was saying my head, my head. V4 said R1 is a high fall risk, and she should never be left alone in the bathroom. V5 should have known this. R1 has had many falls and sometimes she needs more than one person assistance depending on her behaviors. On 12/16/24 at 11:56AM, V3 (Co-Director of Nursing) was interviewed regarding R1 and falls. V3 said R1 is a resident that is very at risk for falls. R1 has had many falls, and we are constantly putting interventions to prevent her from falling. V3 said V5 assisted R1 to the bathroom during lunch. V5 left R1 in the bathroom and grabbed V4 for assistance. When they returned, R1 had fallen. The staff should be aware of the importance to not leave R1 in the bathroom unattended. V3 said on 11/27/24, R1 sustained a subdural hematoma from the fall. The hospital records from 12/2/24 indicated that the hematoma had grown and there was new blood present. R1's Minimum Data Set (MDS) dated [DATE] shows R1 requires maximum assistance when using the toilet. On 12/16/24 at 1:05PM, V8 (CNA) and V9 (CNA) told this surveyor that if a resident is a high fall risk and requires maximum assistance with toileting that they should never be left unattended in the bathroom. Facility Fall Prevention Policy with last revision date of 2/2023 states in part but not limited to the following: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Provide interventions that address unique risk factors. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness.

Based on interview and record review the facility failed to have a system in place which prevents a cognitive impaired male resident (R1) from making an inappropriate sexual action towards a female resident (R2). This has the potential to affect 2 of 4 sampled residents (R1 and R2). Findings include: The facility submitted an incident report with an incident date of 8/19/24 and a time of 12:30pm involving R1 and R2. The description of occurrence was written as: The Certified Nurse's Aide (CNA) witnessed R2 with his had in the brief of R2. R2 did not appear or verbalize any distress. According to a face sheet, R1 is a [AGE] year-old male with diagnoses including but not limited to Atherosclerotic heart disease, [NAME] ataxia, anxiety disorder, major depressive disorder, mild dementia, and muscular dystrophy. According to R1's minimum data set assessment with the reference date of 7/12/2024, R1 has a BIMS of 11, mildly cognitively impaired. The section for indication for daily decision-making regarding tasks of daily life was not scored. On 10/12/24 at 11:15 AM, R1 was seated in his wheelchair attending an activity in the dayroom area with other residents and V5 (Activity aide) overseeing the residents and heading the activity session. R1 stated that he was fine, knew the year and where he resided. R1 indicated he could not recall the incident several months ago that occurred with R2. According to a face sheet, R2 is a [AGE] year-old female with diagnoses including but not limited to Parkinson's Disease, Hypertension, Vascular dementia, and Alzheimer's Disease. According to the incident report R2 had a BIMS of 06, indicating severe cognitive impairment. On 10/12/2024 during the onsite investigation, R2 was in the hospital but unrelated to the incident of 8/19/24. On 10/11/24 at 10:40 AM, V4 (CNA) was questioned about the incident of 8/19/2024 between R1 and R2. V4 stated, (R1) was at the table and I saw him put his hand in R1's incontinent brief in the dining room so I quickly told him to take his hands off R2 and I called the nurse. Once I told him to back off, R1 had some difficulty taking his hands out. I never seen him do this to anybody before. I pulled him away and I told the nurse, and she did the whole-body inspection, and he (R1) was taken to his room and cops were called. No other staff were around me in the dining room but me. I was charting in the I was in front of the nursing station that's when I saw R1 starting to creep up on her(R1). R2 was on tables on the edge and facing the windows and R1 was on the table next to hers. On 10/11/24 at 10-:30 AM V3 (Licensed Practical Nurse/LPN) said (R1) is alert and oriented times 2 to 3. About a month or 2 ago he touched resident in the dining room and the CNA saw him. It was around lunchtime on August 19, and I was passing my medications further down the hall. It was in the afternoon. Then CNA V4, came right away. I never saw anything. They already separated him when I got to the dining room. I checked the resident that was touched. I did my visual in the dining room and asked her if she's in any pain. And I pulled her right away to the bathroom close to the dining room and checked on her. I told her she was touched towards the bottom. I don't remember if I wrote any incident report. According to other nurses that R1 has behavior of touching R2 but no other people. I think he thinks she is his girlfriend or something. On 11/12/2024, V1 (Administrator) was asked provided any documentation of R2's behavior of flirting with or talking with other male residents. A social service note dated 8/20/2024 reference a conversation with R2's daughter /POA. According to the note the staff spoke to the daughter (V7) regarding R2 having relationships and the extent of the relationship with male residents. It was reported R2 like the attention from men and wants to have a boyfriend. The V7 (R2's Daughter/Power of Attorney) gave consent for R2 to have limited physical contact with male residents. On 11/13/2024 between 1:47pm-1:59 via phone, V7 (R2's Daughter/Power of Attorney) was interviewed regarding her knowledge of the reported 8/19/2024 incident involving R1, and statements made in the progress notes documented on 8/20/2024 in R1's medical record. V7 stated she was told about the incident and was not surprised nor upset about. She talked with facility staff who report to her staff witnessed a male resident touching R2 inappropriately. V7 also reported she discussed with staff her mother's behavior in the past. She reported while living on the assisted living side of the facility, her mother had a boyfriend/finance. During the interview the surveyor asked, would you interpret the action the male resident did to your mother as appropriate? V7 responded by saying, she didn't interpret it like that. Her mother is not capable of giving any consent. She did explain, she came in agreement with the facility that her mother could have a non-sexual relationship with a male (a companion agreement) under the supervision of staff.

Based on interview and record review, the facility failed to prevent a resident from physically abusing two other residents in the facility. This failure applied to three of three (R1, R2, R3) residents reviewed for abuse. Findings include: R1 is a [AGE] year-old male with medical diagnoses that include: Unspecified Dementia, Hemiplegia affecting left side, Unsteadiness on feet, Need for assistance with personal care, and Reduced mobility. MDS (minimum data set) assessment dated [DATE] documents that R1 has severe cognitive impairment. R2 is a [AGE] year-old female with medical diagnoses that include: Heart failure, COPD, Palliative Care, Osteoarthritis, Parkinson's Disease, and Gout. MDS, dated [DATE], documents that R2 has a BIMS (brief interview of mental status) score of 11 (moderately impaired). R3 is a [AGE] year-old female with medical diagnoses that include Chronic A-fib, Alzheimer's Disease, Bipolar Disorder, Dementia, and Unspecified anxiety disorder. MDS dated [DATE], documents that R3 has a BIMS (brief interview of mental status) score of 11 (moderately impaired). A review of facility reportable documents shows that on 8/17/24, R1 was transferred to a local hospital for evaluation of aggressive behavior. On 9/13/24 at 2:54PM, V4 (RN) stated that on the date of the incident (8/17/24), R1 was not his baseline starting around dinner time. V4 said that R2 told him that R1 hit her. Upon assessment, R2 had some redness on her neck. No bruising. R3 was trying to diffuse the situation with R1 and R1, then hit R3 on the forearm, and she got a skin tear. R1 was transferred to the hospital and diagnosed with a UTI. Now he's back to normal. They had their back to me so I couldn't see R3's arm (during the incident). Upon assessment, R3's skin tear looked fresh, it was pink. On 9/13/24 at 1:14PM, V1 (Administrator) stated that R1 was displaying physical aggression towards R2 in the dining room. He has dementia, and he hit R2 or attempted to, but staff separated them. We sent R1 out via a 911 call and had him assessed. He has dementia, but we sent him out, and he had a UTI. Upon return, we had him assessed by psychiatry. This is not his normal behavior at all. He had a UTI. He has dementia, but he doesn't normally hit residents. He's not aggressive and has no history of behaviors. There were a couple of staff in the dining room right after dinner. Staff witnessed this in the dining room. Review of R1's hospital records from 8/17 to 8/20 (admitted ). admitted for aggressive behavior; found to have pyuria in urine; UTI dx; afebrile; Started on Cephalexin 500mg (1) capsule 4x/day. Witness statement provided and signed by V11 (CNA), regarding this incident, documents that R2 was heard screaming in the dining room and that R2 reported being hit in the back by R1. Nursing Progress Note written 8/17/2024 19:37 Behavior Note by V4 (RN) reads: Note Text: (R1) sent out to (local hospital) ER, transported using a stretcher, via an ambulance. Resident profile and order summary given, and an involuntary petition to the paramedic's team leader, as well as a brief behavioral history of the resident and medical condition. A Police officer came after a few minutes and investigated the incident. This writer informed the officer of what happened in the incident and also provided a brief summary of the patient's behavior and medical condition. POA made aware, NP informed through text message. DON informed. Nursing Progress Note written 8/17/2024 17:30 Behavior Note by V4 (RN) reads: Note Text: (R1) noted displaying physical aggression by repeatedly punching resident repeatedly and landed on the face that caused redness on the resident's face. Resident has ongoing physical aggression toward staff and other resident. PCP made aware, POA made aware regarding the behavior and was informed that an involuntary petition was filled out and will be sent to (local hospital) for further evaluation and treatment. DON informed. The resident is currently being monitored by staff until paramedics arrive. Nursing Progress Note written 8/18/2024 10:01 Nurses Note by V4 (RN) reads: Note Text: (R2) observed after the incident, calm and pleasant, denies pain or discomfort. Still has good appetite, able to take due medication and tolerated well. Plan of care ongoing. Nursing Progress Note written 8/18/2024 06:38 Nurses Note by V14 (RN) reads: Note Text: S/P incident: (R2) is alert and Ox1-2. Denied pain/discomfort to L cheek, no redness/swelling noted. Nursing Progress Note written 8/17/2024 17:30 Nurses Note by V4 (RN) reads: Note Text: (R2) was punched in the left side of her face while eating her dinner at the dining area. This writer immediately responded and de-escalated the situation. Resident stated that he punched her, but it was not serious and was not strong punch. Assessment was made, neuro check was made no swelling no bruising was present however a redness was noted on the left side of her mandible was observed. Resident denies pain. Immediately sent to her room and made comfortable. POA made aware and came to check the resident. Hospice made aware and stated they will send a nurse to evaluate the patient. MD made aware; DON made aware. Nursing Progress Note written 8/17/2024 20:27 Nurses Note by V4 (RN) reads: Note Text: at around 5:40pm (R3) was hit by another resident on her right forearm. a skin tear was noted having a skin tear on her right forearm, measuring 1.5cm x 0.5cm. MD notified treatment orders in place. POA notified however wasn't able to get a hold of her, a voicemail was left stated what happened and a call back number was also given. Provided comfort and sent to her room, made comfortable, call light in easy reach. bed set to lowest setting. DON made aware. Nursing Progress Note written 8/17/2024 18:42 Nurses Note by V4 (RN) reads: Late Entry: Note Text: (R3) was reporting to this writer that a resident hit her in her arm, and she had a skin tear. Resident was calm not in distress and composed while reporting the incident. That guy hit me as verbalized. Immediately responded and assessment completed, a skin tear was noted measuring 1.5cm x .5cm on her right arm. Skin tear is not bleeding, pinkish in color. Patient was escorted to her room and provided therapeutic communication and calm approach throughout the conversation. Resident was not displaying signs of distress after the incident. Immediately notified PCP with treatment orders in place. Several attempt to contact POA however she was unavailable and just left a voicemail regarding the incident and also left with a good callback number for further questions or concerns. DON made aware. Facility abuse policy, last revised 10/2022, reads: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . I. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to sexual contact will be made and where this documentation will be recorded, and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions; F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. II. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source 4. Resident reports of theft of property, or missing property 5. Verbal abuse of a resident overheard 6. Physical abuse of a resident observed 7. Psychological abuse of a resident observed 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame . III. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on the interview and record review, the facility failed to ensure that a resident was free of a significant medication error. This failure resulted in a resident receiving the incorrect dose of Hydromorphone and applied to one (R4) of four residents reviewed for medication administration. This past non-compliance occurred from 7/5/2024 to 7/21/2024. Findings include: R4 is an [AGE] year-old male admitted to the facility with medical diagnoses that include: Parkinson's Disease, Dementia, Repeated falls, and Other low back pain. R4 is currently on hospice. A review of medical records documents that on 7/5/24, R4 Physician Orders included an order for Hydromorphone 0.25ml. Current Physician Orders for R4 include: HYDROmorphone HCl Oral Liquid 1 MG/ML (Hydromorphone HCl) Give 1 mg/ml by mouth every 2 hours as needed for Breakthrough Pain, Active 08/31/2024. The facility provided a copy of the Employee Corrective Action Notice dated 7/16/24 for V5 (RN). Notice documents the following Corrective Action Issue: On 7/5/24, a dosage of 1ml of Hydromorphone was given to a resident. The correct dosage should have been 0.25ml. It is expected that the correct dosage will be checked before administering the medication. Also, the dressing was not changed for resident BM as scheduled. It is expected that treatments will be performed as scheduled. In an interview with V5 (RN) on 9/14/24 at 2:29PM, V5 was asked about the incorrect medication dose given to R4. V5 said, Usually, he would get 1mL. I gave him the correct dose but wrote the wrong amount on the file. I told the DON, but he gave me the correction. I have not had any issues with medication administration. I'm sure I gave him the right dosage, but I just wrote it down wrong. In an interview with V2 (Director of Nursing) on 9/13/24 at 4:12PM, V2 said There was one person, V5 (RN), who got written up because they gave the wrong medication. She gave too much of the medicine. We caught it by looking at the NARC sheet. I did write her up and sat down with her. The order was written wrong - it was 4g/mL, and we changed the order to get it corrected. It was hospice, so they gave us that particular dosage. The way the order was written, it should have been the 0.25mL. We are going over all the skills with new hires and, then every six months with existing staff. The co-DON (new position), we watch the staff and go through the checklist to make sure that they are doing all the right things. No other staff have had issues with medication administration. R4 did not have any side effects. We didn't even notice until we went back and looked at the NARC count after the fact. The facility provided Medication Administration policy last revised 02/2023, which reads: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 1. Review MAR to identify medication to be administered. 2. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. c. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.) . 6. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. 7. If medication is a controlled substance, sign narcotic book. 8. Report and document any adverse side effects or refusals. 9. Correct any discrepancies and report to the nurse manager. Prior to the survey date, the facility took the following actions to correct the non-compliance. 1. The Director of Nursing (DON) conducted one-to-one education with staff involved V5 (RN) on 7/16/2024. 2. The Director of Nursing (DON) and/or designee completed in-service training with nursing staff starting on 7/16/2024 regarding facility policy and procedure regarding medication administration. The training of nursing staff was completed on 7/21/2024. At the time of this survey, there onsite observations and/or concerns were identified related to current non-compliance with F760.

Based on observation, interview and record review, the facility failed to correctly check the dishwasher temperature using the recommended testing label. The facility also failed to keep a daily record of the dishwasher temperature. This deficiency has the potential to affect all 67 residents receiving food from the facility's kitchen. Findings include: On 7/24/24 at 10:15 am during the tour of the kitchen, the dish machine log was noted with no recorded temperature from July 18th to July 23, 2024. V3 (Food Service Director) was asked to perform a temperature check on the dishwasher using the recommended dishwasher temperature sensor label. V3 placed the label on a dishwasher rack and ran it through the dishwasher. There was no change of color from silver to black. At 10:30 am, V4 (Area Manager) also performed a temperature check by placing the sensor on a plate and ran it through the dishwasher. The strip did not change from silver to black. During an interview at 10:20am, V3 stated that temperature should be recorded daily. V3 also said I do not understand why the color did not change. It's supposed to change colors. During an interview at 10:30am V4 stated that the color should completely turn black. V4 stated I will have (proper name) to come and check. Facility policy dated 9/1/21 Reads; Manual: Food & Nutrition Services, Section: Nutrition Quality. Standard: all dishware, service ware, and utensils will be cleaned and sanitized after each use. Guideline: 2. All dish machine water temperature will be maintained in accordance with manufacturer's recommendation for high temperature or low temperature machines. Dish machine will be checked periodically for correct PPM (Parts Per Million). 3. Temperature and /or sanitizer concentration logs will be completed, as appropriate.

Based on observation, interview, and record review the facility failed to place the nebulizer mask in a plastic bag after use for 2 of 8 (R24, R39) residents in a sample of 24. Findings include: On 7/23/24 at 11:10 AM, R24's nebulizer mask was observed on top of the bedside counter without any covering. On 07/23/24 at 11:20 AM, observed R39's nebulizer mask inside the drawer without a covering. On 07/25/24 at 11:41 AM, observed R39's nebulizer mask inside the drawer without a covering. On 7/23/24 at 11:24 AM, V15 (Licensed Practical Nurse) opened the drawer and said R39's nebulizer mask should be covered and not just placed inside the drawer. On 7/23/24 at 11:26 AM, V15 (Licensed Practical Nurse) said R24's nebulizer mask should be covered in a bag when not in use. On 07/25/24 at 11:43 AM, V2 (Director of Nursing) opened R39's drawer and the nebulizer mask was without a covering. V2 said the nebulizer mask should be covered when not in use. Facility's policy on Nebulizer Therapy- Revised 5/2023. Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: Care of the Equipment 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.

Based on interview and record review the facility failed to complete a root cause analysis of falls and develop effective interventions to prevent falls and injury for one resident (R49) of six residents reviewed for falls in the sample of 19. This failure resulted in R49 falling and sustaining fractures to the left 6th, 7th, and 8th ribs. Findings include: R49's medical record indicates that he had a fall on 11/27/22. The progress notes of 11/27/22 at 12:48 PM indicates that R49 was found on the bathroom floor in lying position, leaning against the wall. 911 was called and R49 was transferred to a hospital. He returned to the facility on [DATE]. A progress note by V31 (Nurse Practitioner) indicates that a CT (computerized axial tomography) scan revealed a small acute subdural hematoma on the right measuring two mm (millimeters). Repeat CT at 9PM revealed stable right frontal and left parietal infarcts, decreased density periventricular white matter bilaterally consisted with chronic small vessel ischemic changes. The previously noted two mm small subdural hematoma seen on the previous CT was not seen on the follow up study. The documentation of the fall provided by the facility did not contain a root cause analysis. The root cause analysis was requested. On 6/22/23 at 12:00 PM V22 (Care Plan Coordinator) said we discuss the falls in the morning meeting. The Director of Nursing, Assistant Director of Nursing, and Nurse Consultant update the Care Plan. I do not update those Care Plans. I do the initial Care Plan. I do not do the root cause analysis. On 6/22/23 at 12:20 PM V28 (Nurse Consultant) said we did not identify the root cause for R49 for the falls. That could impact the interventions. The interventions added to the Care Plan on 11/28/22 are neuro (neurological) checks per protocol, assist with ADLs (activities of daily living) as indicated. Monitor for seizures and follow seizure precautions. PT/OT (Physical Therapy/Occupational Therapy) evaluate and treat. A progress notes of 11/28/22 at 2:56 PM indicates a Fall Risk Evaluation score of 15 which means that R49 is at high risk for falls and should be on the fall prevention program. R49's medical record indicates that he had a fall on 5/11/23. The progress notes of 5/11/23 at 11:01 AM indicates that R49 was found on the floor of his room at around 8 AM. He was grimacing and shaking while up in the wheelchair. R49 was sent to the hospital for evaluation and treatment. V30 (Registered Nurse) said that she was in report and had not made rounds on R49. A (Certified Nursing Assistant/CNA) notified her that R49 was on the floor. A CT scan of the chest was performed at the hospital. IMPRESSION: 1. Acute fractures involving the posterior aspects of the left sixth, seventh, and eighth ribs. 2. Hemorrhagic left pleural effusion. No pneumothorax. 3. Air noted within the subcutaneous tissues of the left posterior chest wall at the fracture sites. 4. Nonspecific left upper lobe lung nodule. The intervention added to the Care Plan R49 returned to the facility on [DATE] is sent to the ER (emergency room ) for evaluation c/o (complains of) pain increased shaking. Date initiated 5/22/23 On 6/23/23 at 10:20 AM V2 (Director of Nursing) said that the fall prevention program was to put a yellow tag on the name plate for his room and put a yellow tag on his walker. On 6/23/23 at 10:10 AM V30 (Registered Nurse) said (R49) has a yellow tag on his door which means he's a fall risk. He is ambulatory but we check on him often, every two to three hours. Policy: Fall Prevention Program revised [DATE] Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 6. High Risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. c. Provide interventions that address unique risk factors measured by the risk assessment tool: d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter if indicated iv. Medication regimen review v. Low bed vi. Alternate call system vii. Scheduled ambulation or toileting assistance viii. Family caregiver or resident education ix. Therapy services referral 9. When any r3esident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated.

Based on interview and record review the facility failed to provide written notice of transfer to four residents (R8, R12, R36, and R49) of four residents reviewed for hospital transfer in the sample of 19. Findings include: The progress notes for R8 on 4/14/23 at 12:33 AM indicates that she was transferred to a hospital due to shortness of breath and low oxygen levels. There is no indication that a notice of transfer was provided or sent. The progress notes for R12 on 3/22/23 at 10:00 PM indicates that she was transferred to a hospital for hyperventilating. There is no indication that a notice of transfer was provided or sent. The progress notes for R36 on 7/24/22, 12/11/22, and 3/25/23 indicates that he was transferred to a hospital for respiratory distress. There is no indication that a notice of transfer was provided or sent. The progress notes for R49 on 11/27/22 at 12:48 PM and 5/11/23 at 11:01 AM indicates that he was transferred to a hospital for evaluation after falls. There is no indication that a notice of transfer was provided or sent. On 6/22/23 at 11:49 AM V2 (Director of Nursing) said the family is notified by phone call of a hospital transfer. There is no written notice sent. On 6/23/23 at 10:10 AM V30 (Registered Nurse) said we do not send a notice of transfer we notify the family verbally.

Based on interview and record review the facility failed to provide written notice of bed hold to four residents (R8, R12, R36, and R49) of four residents reviewed for hospital transfer in the sample of 19. Findings include: The progress notes for R8 on 4/14/23 at 12:33 AM indicates that she was transferred to a hospital due to shortness of breath and low oxygen levels. There is no indication that a notice of bed hold was provided or sent. The progress notes for R12 on 3/22/23 at 10:00 PM indicates that she was transferred to a hospital for hyperventilating. There is no indication that a notice of bed hold was provided or sent. The progress notes for R36 on 7/24/22, 12/11/22, and 3/25/23 indicates that he was transferred to a hospital for respiratory distress. There is no indication that a notice of bed hold was provided or sent. The progress notes for R49 on 11/27/22 at 12:48 PM and 5/11/23 at 11:01 AM indicates that he was transferred to a hospital for evaluation after falls. There is no indication that a notice of bed hold was provided or sent. On 6/21/23 at 10:50 AM V1 (Administrator) said we never give a notice of bed hold. We must hold the bed for 10 days for Medicaid residents. We don't bill them. I think the notice of bed hold is in the contract. On 6/22/23 at 11:49 AM V2 (Director of Nursing) said there is no notice of bed hold. On 6/23/23 at 10:10 AM V30 (Registered Nurse) said we do not send a notice of bed hold; we notify the family verbally. Policy Bed Hold Notice Upon Transfer revised [DATE] At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the; bed-hold policy and addresses information explaining the return of the resident to the next available bed. 1.Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or representative written information that specifies: a. The duration of the state bed -hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility: b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility. 2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies as stipulated in the State's plan.

Based on observation, interview, and record review, the facility failed to monitor in-room refrigerator temperatures for 4 residents (R21, R24, R34, and R63) of 4 reviewed for in-room refrigerators temperatures in a sample of 19. Findings include: On 6/20/23 at 11:04 AM R63 and R24's refrigerator was observed with no temperatures recorded on the log for the month of June 2023. On 6/20/23 at 11:15 AM R34's refrigerator was observed with one temperature recorded on the log for today and nothing from 6/1/23 through 6/19/2023. The mini refrigerator log is in a clear sleeve on the front of the refrigerator. R34 states she shares the refrigerator with R21 who her roommate is. On 6/21/23 at 9:55 AM in R63's room with V17 (Certified Nurse Assistant/CNA), V17 stated the CNAs don't check the refrigerator temperatures. Surveyor observed a temperature recorded for today and yesterday only. R63 states her and R24 share the refrigerator. On 6/21/23 09:59 AM with V5 (Staffing Coordinator) in R21 and R34's Room. Observed in-room refrigerator has a temperature recorded on the log for today and yesterday only. Observed food and drinks in the refrigerator. On 6/22/23 at 11:03 AM with V17 (CNA) in R63 and R24's room, observed no recording for temperatures for the night shift for refrigerators for today on R63 and R24's refrigerator that they share. Observed food and drinks in the refrigerator. On 6/22/23 at 11:45 AM V2 (DON) stated CNAs and nurses during night shift fill out temperature logs on refrigerators daily. On 6/22/23 at 11:03 AM V12 (Nurse) stated in-room refrigerators should be checked daily by night shift. On 6/22/23 at 2:45 PM V2 (DON) stated they do not have a policy for in-room resident refrigerators. V2 stated they will be working on a policy. The facility's Date marking for Food safety Policy documents the following: The facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 1) refrigerated, ready to eat, time/temperature control for safety (i.e., perishable food) shall be held at a temperature of 41-degree Fahrenheit or less for a maximum of 7 days.

Based on observation, interview, and record review, the facility failed to provide privacy during administration of topical medication for one (R34) of two residents observed for topical medication administration in a sample of 19. Findings include: On 06/20/23 at 12:00 PM during medication administration observation, V13 (Licensed Practical Nurse) was observed applying topical Diclofenac sodium 1% gel to R34's left shoulder while R34 is in the dining room during lunch time with other residents at the table. On 06/22/23 at 1:20PM, V2 (Director of Nursing) stated that she expects the nurses to provide privacy before applying any topical ointments on residents. Facility Policy: Title: Medication Administration Date Reviewed/Revised: February 2023 Policy Explanation and Compliance Guidelines: 7. Provide privacy.

Based on observation, interview and record review, the facility failed to provide necessary services to maintain personal hygiene for a resident who is unable to carry out toileting needs for one (R2) of one resident reviewed for activities of daily living in a sample of 19. Findings include: On 06/21/2023 at 1:19PM during wound care observation, R2 was observed with two disposable briefs. R2 said that most of the time, staff put two disposable briefs on her because they said she wets fast and heavily. On 06/21/2023 at 1:27PM, V18 (Registered Nurse) stated that there should only be one disposable brief on the resident. On 06/21/2023 at 1:37PM, V2 (Director of Nursing) said that she expects staff to place only one disposable brief on incontinent residents. R2's Order Summary Report dated 6/21/2023 indicated admitted [DATE], diagnoses including anxiety disorder and retention of urine. Minimum Data Set Section G dated 5/8/2023 indicated R2 needs extensive assistance with toilet use. Braden Scale for Predicting Pressure Ulcer Risk dated 5/10/2023 indicated score of 13 with category of moderate risk, and clinical suggestions including utilize incontinent products after each incontinence period. Care plan reviewed and did not indicate rationale for placing two disposable briefs on R2. Facility unable to provide policy.

Based on observation, interview, and record review the facility failed to develop a plan of care with interventions to prevent and/or reduce the risk of diabetic complications leading to foot injury, the facility also failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures affect 4 of 4 residents (R3, R4, R5,R6) reviewed for quality of care. This failure resulted in R3 foot becoming decolored, R3 being sent to the local hospital, and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R3 R3 is readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan indicates that she has potential for impairment to skin integrity related to weakness and urinary incontinence. R3 has an ADL self-care performance deficit related to weakness and deconditioning requiring staff extensive assistance. She has Diabetes Mellitus with [CONDITION(S)]. No care plan intervention for diabetic foot care. On 10/19/21 at 11:16am, V11 (Licensed Practical Nurse/LPN) said that on 10/3/21, V6 (R3 family member) came to visit. R3 complaint to V6 of foot pain and when he removed her shoes observed 3rd middle toe pad on left foot discoloration of brownish black and reported it to her. R3 did not complaint of pain to her. V11 assessed R3's left foot 3rd toe brownish black discoloration measures 1.7 cm x 1.8 cm x depth undetermined. V11 notified V12 (Primary Care Physician/PCP) and gave orders for blood test, arterial doppler studies of LLE and wound consult. V11 said that R3 has tight ill-fitting shoes provided by family. V11 said that she was not aware of the discoloration of R3's foot when V6 informed her. V11 said that the CNA (Certified Nurse Assistant) is the one dressing R3, so she did not see her foot. The CNA did not inform her of any changes in R3's foot. V11 added that R3 does not take off her socks. Review R3's progress notes with V11 that she documented indicates that on 10/4/21, Doppler report of Left lower extremity revealed no flow in proximal left superficial femoral artery. Stenosis in rest of visualized arteries: Severe in distal superficial femoral and the dorsalis pedis arteries. V12 came to see R3 at the facility and sent R3 to the hospital for evaluation after talking to R3's family. R3 was admitted with infection. R3's Hospital emergency record dated 10/4/21 indicates that R3 presents with complaint left 3rd toe color changes over the past week. R3 was sent to hospital over concern for dry gangrene to the left 3rd toe. R3 is notice redness and swelling over the dorsum of the left foot and left ankle, states she has not had any fever or chills. R3 states she otherwise feels generalized weakness and fatigue, endorses decreased po (oral) intake. Physical Exam: Skin: dry gangrene noted to left 3rd toe distal swelling noted circumferentially, redness/[CONDITION(S)] and warmth spreading over dorsum of foot to left ankle and left shin, mild tenderness palpation over left 3rd toe. R3's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's weekly skin assessment dated [DATE], 9/9/21, 9/15/21 and 9/30/21 were not marked/not done. No record of podiatrist consult. On 10/19/21 at 12:55pm V3 (Director of Nursing/DON) said that there is no wound coordinator person, the nurses on the floor do the wound care/treatment, make rounds with the wound care physician, and does the weekly skin/wound documentation as scheduled. On 10/21/21 at 10am, V1 (Executive Director/ED) said that R3 was not seen by podiatrist during R3 stay at the facility. On 10/21/21 at 12:38pm, V12 (PCP) said that R3's necrotic tissue on middle toe left foot spread fast due to infection. He said that the necrotic /gangrene of R3's toes is unavoidable due to no circulation and no sensation based on doppler studies due to significant peripheral arterial disease. She has history of amputation of R foot toe 3 years ago. She has compromise condition and poor prognosis. He said that staff told him that the family cause the problem because they brought the ill-fitting shoes that cause a problem. Informed V12 that Therapist (V24 Physical Therapist and V25 Occupational Therapist) said that they used the shoes during ambulation therapy period from 8/26 to 9/21/21. R3 did not complaint of pain on her feet when wearing her shoes. V12 said that R3 will not complaint of pain because she does not have sensation on her feet due to no circulation at all. Asked V12 (PCP) why he did not order a podiatrist consult for R3 during his stay at the facility if R3 has is risk for developing diabetic complications. V12 said he is not aware that R3 was not seen by podiatrist. R4 R4 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's care plan indicates that she has potential for impairment to skin integrity related to weakness. Intervention: Monitor/ document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 has an ADLs self-care performance deficit related weakness requiring extensive assistance with ADLs function. On 10/19/21 at 11:46am, Observed R4 lying in bed with a multi-purpose elasticated tubular bandage to both bilateral extremities and socks. V11 (LPN) removed both socks. Observed long toenails and dry skin. Observed both heel with non-blanchable redness and bluish discoloration on left heel. R4 complaint on tenderness when V11 touches her bilateral heel. V11 cut the multi-purpose elasticated tubular bandage/sleeves on both lower legs because it was too tight. V11 said that she is not aware of R4's bilateral heel redness and bluish discoloration. V11 added that the night shift is the one who applied the lower leg sleeves. V11 said she will do change in skin condition assessment. V3 (DON) notified of observation made. Review R4's most recent weekly skin assessment with V11 (LPN) dated 10/17/21 indicates none noted. On 10/20/21 at 12:52pm, review R4's changes of skin condition/assessment done by V11 (LPN) dated 10/19/21 called V3 (DON) and informed the observation reported to her yesterday of R4's bilateral heel non blanchable redness with tenderness and bluish discoloration on left heel was not documented in change of skin condition. V3 DON said that V11 should do a skin assessment/evaluation on any changes in skin condition and call the physician for treatment order and notify family member. Skin assessment includes measurement and description. V3 said that V11 should get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/20/21 at 1:00pm, V3 (DON), V21 (LPN) and V15 (CNA) came to R4's room to assess her bilateral heel. Observed R4 lying in bed, with bilateral socks on. V15 removed both socks and elevate both heels. R4 complaint of pain when heels are being touch. Observed non blanchable redness with tenderness on bilateral heels and bluish discoloration on left heel. V3 DON instructed V21 to call the nurse practitioner in the building to see R4 and get order for bilateral heel protectors. On 10/20/21 at 1:24pm, telephone interview with V11 (LPN). V11 said that she forgot to include the observation yesterday with surveyor of R4's bilateral heel non blanchable redness on both heels with tenderness and bluish discoloration on left heel in her skin assessment documentation. She said did not notify the physician and family member. Review R4's progress notes dated 10/20/21 documented by V21 (LPN) indicates R4 notes with redness to left heel measuring 3cm x 3cm x0cm. R4 also noted with slight bluish discoloration to center of reddened area measuring 1cm x .5cm x 0cm. Skin remains intact. Nurse practitioner of V12 PCP called with new orders for pressure relieving boots to both feet and consult with wound care physician. On 10/21/21 at 9:51am, the surveyor observed R4 up in wheelchair in the dining room with bilateral pressure relieving boots on that were touching the floor. R4 does not wear socks. The surveyor observed reddish purplish skin color of the lower extremities, still with long toenails. On 10/21/21 at 1:02pm, called V23 (Registered Nurse/RN) and showed R4's discoloration on both lower extremities and dependent [CONDITION(S)]. V23 said that R4 has insufficient circulation due to the reddish purplish discoloration of bilateral lower extremities. V23 said she will call the physician for venous and arterial doppler studies for bilateral lower extremities. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/22/21 at 12:12pm, V1 (Executive Director) said that the venous and arterial doppler will done not until Monday. On 10/25/21 at 4:12pm, R4's bilateral duplex lower extremity arterial ultrasound done on 10/22/21 indicates no flow right posterior tibial artery. Stenosis in the rest of the bilateral intrapopliteal especially in the left posterior tibial artery. R5 R5 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Care plan indicates that he has right heel wound observed with [CONDITION(S)] and is being treated with oral antibiotics. Right heel wound stage 3, sacrum wound stage 3, left lateral ankle stage 4, and shearing right buttocks. R5 has an ADLs self-care performance deficit requiring staff extensive assistance. R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] solution 10% apply to left heel topically every shift for pressure ulcer, leave open to air. [MEDICATION(S)] ointment apply to sacrum topically every night shift and as needed for pressure ulcer after cleansing with 0.9% NS cover with border foam. On 10/19/21 at 1:34pm, the surveyor observed R5 lying in bed with bilateral heel protectors/boots. R5 is not on low air loss mattress. V11 LPN open the Velcro of R3's left heel protector/boots. V11 said they placed disposable diaper underneath the left foot to protect the heel protector from [MEDICATION(S)] stain. Observed left heel 100 % necrotic is soaked with [MEDICATION(S)] gauze. V11 said that she just did the [MEDICATION(S)] paint and applied gauze and placed the disposable diaper underneath then apply the heel protector/boots the secure with Velcro. Observed right heel wrapped with kerlix. V11 said that the night shift does the right heel dressing. She does not know the wound condition. V11 used scissors from her pocket to cut the kerlix then put it back to her pocket without disinfecting. The surveyor observed right heel with stain of [MEDICATION(S)] cover with non-adhesive gauze and abdominal pad with moderate amount of brownish greenish drainage. V11 removed the right heel dressing. The surveyor observed necrotic right heel with greenish slough formation. V11 left the room to review wound treatment orders and get R5's wound dressing. On 10/19/21 at 1:55pm, V11 (LPN) irrigate with normal saline solution right heel and applied [MEDICATION(S)] ointment using the same gloves. V11 applied calcium alginate and wrapped with kerlix. Review R5's wound treatment orders with V11 (LPN). V11 did not follow treatment orders of R5 for both right and left heel. Left heel was not left open to air after [MEDICATION(S)] paint. V11 acknowledged that the night nurse who does the dressing used [MEDICATION(S)] paint to right heel based by night [MEDICATION(S)] stain marking. Non-adhesive dressing was used instead of calcium alginate. V11 did not used abdominal pad to cover before applying kerlix bandage. V11 did not clean the right heel with normal saline solution instead just irrigate it. V11 did not perform hand hygiene after wound irrigation before applying [MEDICATION(S)] ointment. V11 did not sanitize scissors after using it and put it back to her pocket. R5 has also sacral wound that was not observed. On 10/19/21 at 2:17pm, V11 (LPN) performed wound care on sacral area. Observed 100 % greenish slough formation. R5's weekly wound documentation dated 10/14/21 done by V2 (Clinical Executive Director) indicates R5 usage of low air loss mattress as preventive measures. R5's weekly skin check dated 10/2/21 and 10/6/21 were not marked/not done. R5 is not on low air loss mattress. Informed V1 (Executive Director), V2 (Clinical Executive Director) and V3 (DON) of above observation. V3 said that V11 should disinfect her scissors after using to cut the kerlix dressing. Hand hygiene is performed after cleaning wound and don new pair of gloves when applying treatment/medication to right heel. R6 R6 is readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Care plan indicates R6 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 has potential for impairment of skin integrity related to urinary incontinence. R6 has an ADLs self-care performance deficit requiring staff extensive assistance. Care plan intervention does not include foot care. R6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Triple antibiotic ointment apply to left 1st toe medial grove topically every night shift for open area daily until healed. R5's [DATE] Treatment record administration does not include the [MEDICATION(S)] and Triple antibiotic ointments treatment to left big toe and left 1st toe. On 10/20/21 at 9:59 am the surveyor observed R6 transferred from wheelchair to bed by V19 (CNA). V20 (RN) placed all treatment medications and dressing on bedside tray table. R6 is on low air loss mattress with fitted sheet, cloth pad and wears disposable adult brief. The surveyor observed band aid to both right great toe and left great toe. The surveyor asked V20 what happened to his great toes, she said the podiatrist cutting too close. V20 removed the band aid on right great toe, cleanse with normal saline solution, applied [MEDICATION(S)] ointment and covered with band aid using the same gloves. Right great toe is swollen and reddened particularly on the side of the toenail. V20 removed left great toe band aid, no redness /swelling, open wound noted. She said she will leave it open and will call the physician. V19 turned R6 to his right side and removed the disposable brief and observed redness on sacral area. V20 cleansed sacral area with normal saline solution and applied moisture barrier ointment to sacral area. V20 took the medications - [MEDICATION(S)] ointment and moisture barrier ointment tubes and placed it back inside the treatment cart without disinfecting. V20 said that she should disinfect it before putting it back inside the cart. Informed V19 that she did not remove gloves and performed hand hygiene after cleansing the right toe. She uses same gloves for performing wound care on right great toe. V20 did not response. V20 did wound dressing on right great toe without order. Both treatment orders are for left toe. V20 said that [MEDICATION(S)] should be on right great toe. On 10/21/21 at 9:54am, V23 (RN) said that they do weekly skin assessment which includes head to toe assessment - including foot assessment especially for diabetic resident. CNAs does daily skin checks during personal care and hygiene. CNAs report to the nurse observation outside the normal skin condition. The nurse then will assess resident, call physician for treatment order and notify the family. On 10/21/21 at 10:26am V18 (MDS/Care Plan Coordinator) said that the foot care in care plan for diabetic resident is included in skin prevention/impairment care plan because when nurse does the skin weekly assessment, the foot assessment is included. V18 said he depends on the nursing report for him to update the care plan. If he was not notified, he cannot update the care plan. Review R6's weekly skin documentation and weekly wound assessment with V18 and no documentation was done. The surveyor informed observations to V1 (Executive Director) and V3 (DON) of above concerns. On 10/21/21 at 2:30pm V1 presented new forms called skin alert that they will use for skin/wound monitoring to improve their documentation and communication in wound care including foot. Facility's policy on Nursing care of the resident with Diabetic Mellitus: Purpose: 4. Recognize, manage and document the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Skin and foot care: 6. Encourage the use of non-constricting, well-ill-fitting shoes slippers and hose. 8. Toenails should be trimmed by qualified personnel Documentation: 3. Assessment of the skin including the following: a. Color, moisture and temperature and b. any redness, ulcers, irritation, abrasions and/or pruritis (itching) 12. Assessment of the feet should include the following: c. Color; d. Circulation; g. Condition of the toes and toenails Facility's policy on Prevention of Pressure ulcer/injury indicated: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and intervention for specific risk factors. Risk assessment: 4. Inspect the skin on daily basis when performing or assisting with personal care and ADLs. Monitoring: 1. Evaluate, report and document changes in the skin. Facility's policy on Pressure ulcer/injury risk assessment: The purpose of this procedure guidelines for the structured assessment and identification of residents at risk for developing pressure ulcer/injuries Steps in procedure: 4c. If new skin alteration is noted, initiate a (pressure/non pressure) form related to the type of alteration in skin 5. Develop the resident centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition and the resident's stated wishes and goals. Documentation: 12. Documentation in medical record addressing physician notification if new skin alteration noted with change of plan of care 13. Notifying attending physician if new skin alteration noted. Facility's policy on Change in a resident's condition or status: Our facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/ mental condition and or status. Facility's policy on Medication and Treatment orders: Orders for medications and treatments will be consistent with principles of safe and effective order writing. 1. Medication shall be administered only upon written order of a person duly licensed and authorized to prescribe such medication in this state. Facility's policy on handwashing/hand hygiene indicates: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy and implementation: 6. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations: g. Before handling clean or soiled dressing, gauze pads k. After handling used dressing, contaminated equipment Facility's policy on Cleaning and disinfection of resident care items and equipment: Resident equipment includes reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne pathogens standard.

Based on observation, interview, and record review, the facility failed to monitor and supervise a cognitively impaired resident with a history of known elopement risk; failed to implement interventions to address resident assessment of being at risk of elopement; failed to follow the facility's policy of implementing interventions of having a personal door alarm device; and failed to educate all employees of interventions for elopement prevention and to train all staff on the identification of residents who are at risk for elopement. As a result, a cognitively impaired resident (R1) with a known behavior of wandering exited out of the facility through an unsecured and unmonitored back door with no alarm or video surveillance. R1 walked out onto a main road/intersection and then onto a busy highway on 5/29/21. The immediate jeopardy was identified on 6/17/2021. The Administrator was notified on 06/23/2021. The immediate jeopardy began on 5/29/2021when R1 eloped from the facility. The surveyor confirmed by observation, interview, and record review, that the immediate jeopardy was removed on 6/18/2021 but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's interventions (including staff in-services). This deficient practice has the potential to affect R3, R4, and R5 who were identified as an elopement risk and reside on the same floor as R1. Findings include: R1 is a 71 old admitted to the facility on [DATE] with the diagnosis of the following: Alzheimer's disease, [CONDITION(S)] (Post traumatic stress disorder), type 2 diabetes, dysphasia, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] with behavioral disturbance. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 has a Brief Interview for Mental Status (BIMS) Score of 3 indicating that the resident has severe cognitive impairment. On 6/17/21 at 11:20 AM surveyor observed R1 on the second-floor main dining room seated with three other residents. R1 appeared restless and was observed getting up from his chair and walking aimlessly in the hall. He was fully dressed but wearing only socks and was observed with no identification band or wearing any alarm-type device to alert staff of his movements. R1's care plan dated 9/29/20 states, Behavior problem, (R1) is non-compliant with care, refuses care at times, takes others belongings, history of exit-seeking, history of verbalizing need to jump out of this room, breaking window glass, wanders into other resident rooms. Goal: (R1) will accept care from staff without resistance and participate in care by performing task with set up and cueing. Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control; encourage as much participation interaction by the resident as possible during care activities; give clear explanation of all care activities prior to as they occur during each contact; provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs. Caregiver and routine as much as possible. 6/17/21 at 10:50 am, V2 (Regional Consultant) stated to surveyor that there were no reportable incidents in the recent weeks or months pertaining to R1 but later revealed that R1 had eloped from the building at the end of last month which was not reported to the department (IDPH). On 6/17/21 at 11:40 AM, V7 (Certified Nurse Assistant/CNA) stated, I'm (R1's) CNA today and I was also the CNA when he escaped from the facility last month. At that time, I was doing patient care and the last time I saw (R1) was after he ate dinner at around 4:15 PM. We try to redirect him when he wanders off as he wanders the floor a lot. The surveyor asked what interventions are done to prevent R1 from leaving again. V7 stated, We're supposed to accompany all visitors on the elevators before they get in so what happened with R1 doesn't happen again. The surveyor asked what other residents on the floor were at risk for elopement. V7 stated, I don't think anyone else, really just R1. Surveyor asked to show where R1's room was, V7 accompanied surveyor to R1's room which was two rooms away from the nearest elevator and did not have a direct line of sight to the closest nurses' station. On 6/21/21 at 2:30 PM, V15 (Agency - LPN/Licensed Practical Nurse) stated, I remember (R1). I was working a 12-hour shift and I started at 7 AM. At 3:15 PM I told the CNAs I was going on my break so that was the last time I remember seeing (R1). I remember delaying my break to 4:15 PM instead, so when I came back at 5:15 PM to give R1 his evening medication, he was not in his room. R1 doesn't sit still and walks about and wanders and he is in different rooms sleeping so I wasn't that worried yet. I told (V7) that (R1) wasn't in his room. I started checking all the rooms on 2nd floor and then 1st floor. I remember no one on the 1st floor helped, it was just me and the 2 CNAs on the second floor. I asked two CNA's to go to security while I was still checking rooms. When they came back from security, I called the director of nurses (V3) three times and she did not answer. I also called the assistant director of nursing twice and she didn't pick up either and then called the administrator but she said she didn't work there anymore and didn't seem concerned and that I should call the deputy administrator (V1), so I got frustrated and called the police. When I got off the phone with the previous administrator, I was told by the other nurse (V17-RN/Registered Nurse) on the floor that R1's wife called and spoke to hospital and that R1 was picked up walking the street on to the highway. He was picked up by an ambulance and brought to the hospital. So then finally I got a call back from (V3) and I told her that I did not know the protocol for elopement, and nobody told me either. I told her nobody said anything about elopement or orient me to that while working here. The CNAs said that that this was not the first time R1 did this and it was done before and that R1 left the building another time but was found down the road previously. I told V3 that R1 was missing and she did not sound at all concerned or give me any clear direction but I told her that I already called the police because I couldn't get a hold of anyone and the other nurse (V17) and she was not helpful or tell me what to do in case of an elopement. In fact, she didn't even help look for the patient and just kept passing her medications. I worked over 10 times in that building and I was never told of any at risk elopement residents. Surveyor asked when she received any in-service training for elopement at the facility and V15 stated, The day after R1 eloped was when I was in-serviced but never before or any other time when he left the building. I know that he was always wandering even before that and even was able to get off the second floor, but I was not told about any elopement protocol. On 6/22/21 at 1:28 PM, V17 (RN) stated, I was the other nurse on duty when (R1) eloped the building. I think it was around 3:15 PM when I was told that he was not on the floor or something like that, so the other nurse started looking for him. I was at my medication cart by the nursing station when I heard this, and I was busy getting ready to do insulin checks on my residents before dinner. The surveyor asked if she was part of the search team for R1. V17 stated, Not really, I didn't leave the floor if that's what you're asking. On 6/22/21 at 2:09 PM, V21 (CNA) stated, I was not (R1)'s CNA. I was working on the other side of the hall and when I found out (R1) was gone it was about 4:50 or 5:00 (PM). Before that at about 4:30 PM I was wheeling the food cart to the main dining room to organize the food trays after I passed the trays out to the rooms and I then passed the rest of the trays in the dining room. On 6/22/21 at 2:30 PM, V22 (CNA) stated, I was on duty the day (R1) went missing. I didn't see him earlier because he wasn't my patient and I think I was in a patient room taking someone to the toilet when the nurse (V15) told me to help her look for her patient which was around 5:00 (PM) I think. I'm not surprised they lost him because he is always trying to escape, and he's gotten out before. The agency nurse (V17) asked me to go downstairs and look for him and I went with V7 and looked all over, and we talked to the security guard (V12), but he didn't see (R1) either. The surveyor asked when (R1) got out prior to the past incident. V22 stated, It was about a week before that because I know he ended up on the street and they walked him back inside. On 6/17/21 at 12:15 PM V3 (Director of Nurses) stated, I got the call about R1 missing from the facility around 5:30 PM and I was told by (V15) that one of the residents was missing when she tried to go and give medications. She said that V7 (CNA) last saw R1 eating dinner so that would have been around 4:30 PM. I found out that R1 was dropped off at the emergency room by someone unknown but then the doctor (V6) called over to the facility and said that R1 was in the hospital emergency room . The surveyor asked how R1 was able to elope. V3 stated, It was a really busy day and there were a lot of visitors. I was told and lots of vendors like pharmacy and hospice nurses visiting too so we don't really know how (R1) got out. The surveyor asked if she was aware of R1's behavior or what he was care planned for. V3 stated, I know that he paces back and forth a lot and he's confused. The surveyor asked what they've done differently since R1 eloped to prevent another elopement. V3 stated, Well I know that we changed the code on the elevators and all the other codes, and we monitor him more. The surveyor asked what monitoring more meant. V3 stated, Well we try to do 1:1 with R1 and we observe him more. The surveyor asked if there was a particular staff assigned on each shift to do 1:1 with R1. V3 stated, No, not really just everyone takes turns doing 1:1. The surveyor asked if there were any 1:1 forms showing this intervention. V3 stated, I don't think we use any 1:1 forms. On 6/17/21 at 11:00 AM, V1 (Administrator) stated, We believe that (R1) was able to leave the facility by following one of the visitors out or he may have followed a visiting nurse off of the unit floor. (R1) either went down the staircase or elevator and out the door. It was a busy day of visitors, but we don't know which door he may have exited. The visitors go out to where we have the security guard (located on the senior living hallway) but (R1) must have gone out an alternate door. On 6/17/21 at 1:10 PM, the surveyor asked about R1's elopement incident of 5/29/21. V1 (Administrator) stated, At 5:30 PM, I got a call from nursing staff. They told me that they were unable to located (R1). (V15 - Agency LPN) told me she called the police and the police came right out and as the police got here, they got a call from the hospital saying they found R1 and he was in the emergency room . V15 told me she didn't see him in his room when she was going to give him his medications at around 5:15 PM so she searched with other CNAs but still couldn't find him. Surveyor asked what procedures they had in place to keep R1 or other residents from eloping the building. V1 stated, We've done elopement drills and we've changed the code for all doors. Staff on the floors all now have to escort out all visitors to the elevators. They used to just provide the visitors with the code to get out. We don't do that anymore. Surveyor asked V1 to show where the possible point of egress was that R1 could have exited from. V1 walked with surveyor towards a hallway that lead to the senior living building. There were two double doors where a code had to be entered to disarm the door alarm prior to going through the double doors that lead to the senior living hallway. Immediately after and to the right of the double doors was a short hallway with a glass exit door. V1 explained that this door lead to the back of the building and that this exit door had no alarm and could just be pushed open. V1 pushed the metal bar and opened the door. Surveyor asked if there were any alarms for the door or any other alarm that would alert staff, V1 stated, No. On the left-hand wall before the same exit door was video camera that was plugged into an electrical outlet and appeared temporarily glued to the wall. V1 stated, That (camera) doesn't work. The maintenance man put that there for some reason, but it doesn't stream anywhere so I'm not sure why we even have it there. While outside the building, to the left of the doors appeared to be several parked cars and trucks and a small courtyard that appeared to be for senior living residents. V1 stated, Mostly housekeeping and other vendors go this way and to the west is a road leading to the front of the building. There were no visible cameras or alarms observed in or outside the exit door. Surveyor pointed to the road to get orientated to the exterior of the building and asked V1 stated, That is the front of the building and yes that's the main road. The surveyor came back inside with V1 and asked why the exit door shown to the surveyor was not locked. V1 stated, It's locked from the outside but you're correct it is not locked from inside or alarmed. You can push it open from the inside and the door will open. On 6/17/21 at 12:35 PM, V6 (Physician) stated, I am R1's doctor, yes, I remember I got a phone call from the emergency room doctor who told me that my patient was there. I was pretty surprised no one from the facility called me. The surveyor asked if he was told where R1 was found. V6 stated, I think the ER doctor mentioned something about him walking on the highway. He was covered in mud and was very dirty. The surveyor asked whether R1 had any orders to be by himself out in the community. V6 stated, Of course not, he is very confused as you can see. He should not have been allowed to leave the building without anyone with him. He is quite confused, that is why he is here. He needs 1:1 supervision because he is constantly wandering and he has fallen multiple times because I get a call when he falls so I am surprised I did not get a call when he was found and in hospital. Facility Elopement Policy (dated 2/5/11) states that it is the policy of this facility to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. At the time of screening and/or upon admission, ask the resident, resident representative, family members, referring source and past care fivers if the resident has a history of wandering or elopement. The facility will complete the elopement risk assessment upon and/or within 8 hours of admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon high risk determination. A facility staff member will take a photograph of the resident upon or within admission. The photograph will be placed in the electronic medical record. Any resident assessed to be at high risk for elopement will have their photograph and basic identifying information placed in a special folder or binder to be maintained throughout the facility. Department supervisors will be provided with a listing of residents at high risk for elopement. Each department supervisor will confidentially disclose this information to their employees as necessary. The interdisciplinary team will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high-risk resident's plan of care to minimize risk factors. Communication of these interventions will be made to direct care staff through exposure to the resident's plan of care and periodic review and disclosure of the contents of elopement file/binder. Interventions of personal door alarm devices and monitoring will be initiated as deemed necessary by the interdisciplinary team and documented in the individual resident's plan of care. Any high-risk resident will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or resident room when noted to be near an exit door. Revision of elopement risk assessment will be completed upon a resident's significant change in condition and as needed determined by the interdisciplinary team. The plan of care for minimizing elopement risks will be reviewed each time the Risk assessment is completed with initials and dating of the care plan by a member of the interdisciplinary team present for review. All employees will be educated within a reasonable timeframe of hire and throughout the year with elopement education of the location of the elopement file/binder and elopement prevention policy. Resident photographs will be updated as needed. The immediate jeopardy that began on 5/29/2021 was removed on 6/18/2021 when the facility took the following actions to remove the immediacy: On 5/29/21, all door alarms were immediately checked for proper functioning with no issues identified. Completed by Area Plant Operations Director. On 05/28/21 and 05/29/21, reviewed responses to door alarms on relevant dates and confirmed staff complied with policy for responding to door alarms. Completed by Area Plant Operations Director and Administrator. On 05/29/21, door alarm codes were changed and will be changed monthly and as needed. Completed by Area Plant Operations Director. Starting on 5/30/21, all staff were in-serviced across multiple shifts on the elopement policy and prevention along with unsafe wandering of residents. All staff that were not on duty at the time of in-service trainings were given in-service training prior to starting their next shift. This will continue to be reviewed each day and orientation materials, new hires and Agency staff will be oriented to facility Elopement policy and prevention prior to working on the floor. Completed by Area Plant Operations Director, Administrator, Staff Scheduler, and Director of Nursing. On 5/30/21, elopement drills were completed with all staff on multiple shifts. Staff who were not present were in serviced prior to starting their next shift. Completed by Area Plant Operations Director. On 5/30/2021, facility reviewed and reassessed all residents for elopement risk/unsafe wandering. Residents determined to be at risk for elopement or unsafe wandering had confirmed care plans to be current, accurate, and updated to include the potential risk and patient-specific interventions to prevent elopement. Four residents were identified and current care profile on the EMR was also updated. Completed by Regional Consultant. On 6/17/21 facility added camera to monitor North exit door to outside and cameras that face the stairwell door, fire doors that exit the skilled side, and North fire exit. Completed by Area Plant Operations Director and Maintenance. On 6/18/21, facility placed signage on all eight doors and two elevators, inside and out, for each floor to remind visitors to contact facility staff if any resident tries to exit the facility. Completed by Administrator. On 6/18/21, facility added door alarms to five other campus doors (Supportive Living area doors) in case any resident is able to pass through secured doors or elevators accidentally. Completed by Area Plant Operations Director and Maintenance Director. Starting 6/24/21 new audit sheet tool will be used to indicate door alarm functioning. Completed by Maintenance Department. Starting 6/24/21 and daily for 30 days elopement drills will be conducted. To be completed by Maintenance and Administrator.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to meet the needs of a cognitively impaired resident who was assessed to be at risk and verbalized intention of elopement from the facility. This failure applied to one resident (R1) reviewed for care planning and resulted in R1 eloping from the facility, where he was then found walking on a major highway, was then picked up by emergency medical service staff and taken to local hospital. Findings include: R1 is a 71 old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documented that R1 has a Brief Interview for Mental Status (BIMS) Score of 3 indicating that the resident has severe cognitive impairment. 9/18/20 An initial elopement risk assessment dated [DATE] shows R1 with an elopement score = 2.0 (Anything >1 is at risk for elopement). Clinical Suggestions: Staff notified of resident's elopement risk. Identification bracelet utilized, in place. Resident's location frequently monitored. Staff notified of resident's wandering risk. Resident-specific behavior(s) documented on behavior log. On 6/17/21 at 11:20 AM, the surveyor observed R1 to be confused and wandering aimlessly from dining room to the hallway with no identification bracelet. R1 was not wearing an identification bracelet and there was no specific staff member monitoring R1. V3 DON (Director of Nurses) was asked to provide any documented behavior log as part of R1's interventions but did not provide any documentation during the course of this survey. R1's care plan dated 9/29/20 does not follow or address the clinical suggestions listed on the elopement risk assessment and states, Behavior problem, (R1) is non-compliant with care, refuses care at times, takes others belongings, history of exit-seeking, history of verbalizing need to jump out of this room, breaking window glass, wanders into other resident rooms. Goal: (R1) will accept care from staff without resistance and participate in care by performing task with set up and cueing. Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control; encourage as much participation interaction by the resident as possible during care activities; give clear explanation of all care activities prior to as they occur during each contact; provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs. Caregiver and routine as much as possible. On 6/17/21 at 11:00 AM, V1 (Administrator) stated, We believe that (R1) was able to leave the facility by following one of the visitors out or he may have followed a visiting nurse off of the unit floor. (R1) either went down the staircase or elevator and out the door. It was a busy day of visitors, but we don't know which door he may have exited. The visitors go out to where we have the security guard (located on the senior living hallway) but (R1) must have gone out an alternate door. On 6/17/21 at 12:35 PM, V6 (Physician) stated, I am R1's doctor. I remember I got a phone call from the emergency room doctor who told me that my patient was there and pretty surprised no one from the facility called me. Surveyor asked if he was told where R1 was found. V6 stated, I think the ER doctor mentioned something about him walking on the highway. He was covered in mud and was very dirty. Surveyor asked whether R1 had any orders to be by himself out in the community and V6 stated, Of course not, he is very confused as you can see. He should not have been allowed to leave the building without anyone with him. He is quite confused, that is why he is here. He needs 1:1 supervision because he is constantly wandering, and he has fallen multiple times. I get a call when he falls so I am surprised I did not get a call when he was found and in hospital. Hospital emergency department records dated 5/29/21 at 8:26 PM document that (R1) was found walking on interstate highway with altered mental status and chest pain 9 out of 10 (severity). On 6/24/21 at 11:40 AM, V23 (Regional Consultant) stated, I consult for this building and I oversee the care plans created by the current care plan coordinator among other responsibilities. As for the behavior care plan for R1, I do agree that there should have been more interventions created otherwise R1 would not have eloped the building. When the actual elopement did occur (5/29/21), there should have been an actual elopement care plan created to address the elopement that occurred and not wait until 6/21/21. That is a big gap in time I agree. On 6/24/21 at 11:50 AM, V24 (MDS/Care Plan Coordinator) stated, I am aware that R1 eloped from the facility and would agree that there should be more interventions to prevent R1 from eloping the facility other than the one listed. I do see that there is one created for 6/21/21 addressing his elopement risk but I agree there should have been one created immediately after he had already eloped the building on 5/29/21. R1's care plan dated 6/21/21 states, (R1) opened north side lounge exit door and walk out through the stairs. CNA (Certified Nurse Assistant) and Nurse on duty redirected patient to the 2nd floor, patient was really agitated and aggressive that time and stated, I want to leave this place, I will go home tonight, I know how to get out of this building. Interventions: (R1) will not elope and be safe; Close staff supervision while up; Educate staff on elopement triggers; Every 15 minutes checks while sleeping. On 6/24/21 at 2:20 PM, V3 (Director of Nurses) was asked to provide evidence of the 15 minute checks referred to on the care plan dated 6/21/21, V3 stated, I can't provide you with any of that because I cannot prove that this was done. They're supposed to do it on the 24-hour report, but it doesn't really show 15-minute monitoring. I spoke with V2 (Regional Consultant) and we are going to start a new form effective today so we can demonstrate that these 15-minute checks are being done. Policy dated 11/2017 titled, Care Plans, Comprehensive Person-Centered includes: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interviews and record reviews, this facility failed to prevent misappropriation and exploitation of money by facility staff for one resident (R2) out of three residents reviewed for misappropriation of funds. This failure has resulted in R2 becoming isolated and withdrawn. Findings include: On 4/14/2021 at 12:40 pm, V11 (Business Office Manager) stated that R2 set up automatic withdrawal with R2's bank to pay for R2's stay at this facility. V11 stated that when corporate office went to withdraw money on 3/8/21, it was denied due to insufficient funds in R2's bank account. V11 stated that V11 spoke with R2 regarding funds and R2 informed V11 that R2's debit card had been stolen. V11 stated that V11 called R2's bank in the presence of R2. R2 gave permission for bank to speak with V11. V11 stated that the bank informed V11 and R2 that R2's account was closed due to insufficient funds too many times or due to not enough money in account to keep it open. R2 requested the last 10 transactions posted, R2 was not aware of any of these transactions. R2 requested the address listed on R2's bank account; R2 did not recognize the address. R2 informed V11 that R2 believes this related to wallet being stolen. V11 stated that the banker on the phone was not able to disclose any further transactions and gave R2 a phone number at the bank R2 could call for further information. V11 stated that R2 was overwhelmed and did not want to call the number that day. V11 stated that V11 did not have any further communication with R2 after that day. V11 is unaware if R2 ever called the phone number the bank gave R2. V11 stated that V11 informed V1 (Administrator) of the incident and gave V1 the information gathered from the phone call with R2's bank. On 4/14/2021 at 1:00 pm, V1 (Administrator) stated that V1 spoke with R2 upon notification by V11 (Business Office Manager) of concern regarding R2's funds. V1 stated that R2 informed V1 that R2 can't get access to R2's bank account. V1 stated that R2 informed V1 that R2 wanted to press charges against the former staff responsible. V1 stated that the local police department was notified of an allegation of misappropriation of R2's property. V1 stated that a police officer came to this facility to interview V1 and initiate a police report. V1 stated that on 3/14/21 a police detective came to this facility to interview R2. V1 stated that R2 informed V1 that police were not welcome here. R2 changed his mind and did not want to press charges against the former staff members. V1 stated that there is nothing else V1 can do if R2 does not want to press charges. V1 denied speaking with all residents currently residing in this facility and/or their families regarding their resident funds to determine if other resident(s) were affected as well. V1 acknowledged that V15 (former CNA) received a verbal warning on 10/8/2020 for exhibiting verbal aggression in a threatening manner with confrontational behavior towards a staff member. V1 acknowledged that on 11/10/2020 V15 was terminated for intimidating another staff member affecting resident care. When questioned regarding the possibility of V15 exhibiting the same inappropriate behaviors with residents, V1 did not respond. V1 stated that this facility does not have an inventory list of R2's belongings when R2 was admitted to this facility on 2/14/2020. V1 stated that this facility started inventorying resident belongings with new admissions starting in March 2021. V1 acknowledged that it is unknown what belongings R2 had at the time of R2's admission to this facility in February 2020 as well as if any other belongings are missing. When questioned regarding this facility's plan to prevent future occurrence(s) of misappropriation of resident property, V1 stated that this facility is trying to have R2's social security funds deposited into a resident fund for R2 that will be managed by this facility. V1 stated that V1 does not recall if V2 (Social Services Director) was notified of the two allegations, 9/17/20 and 3/8/21, of misappropriation of property involving R2. On 4/14/2021 at 1:05 pm, V12 (Executive Director of Senior Living) stated that on 3/8/21, V12 was notified by V11 (Business Office Manager) that R2's payment check had bounced. V12 stated that V11 informed V12 that V11 spoke with R2 regarding this matter and R2 did not know what was going on with R2's bank account. V12 stated that R2's bank account was closed by the outside bank due to insufficient funds. V12 stated that review of the past 10 transactions posted to R2's account noted money transfers to a person that R2 did not know. V12 stated that V12 spoke with R2 to see if R2 wanted to press charges, R2 was agreeable, and a police officer spoke with R2. V12 stated that about one week later a police detective came to the facility to speak with R2; R2 refused to speak with the detective. V12 stated that the name associated with the money transfers was V22 (former CNA/Certified Nurse Assistant) that worked at the senior living center attached to this facility. V12 stated that V22 (former CNA) worked for three days between 7/21/2020 and 7/31/2020 and then did not show up to work anymore. V12 stated that V15 (former CNA and relative of V22) worked on this facility's skilled nursing unit. V12 stated that V15 worked at this facility 7/9/2020 to 11/10/2020 when V15 was terminated due to insubordination with a supervisor. When questioned regarding the possibility of V15 exhibiting the same inappropriate behaviors with residents, V12 did not respond. On 4/16/2021 at 3:00 pm, V2 (Social Services Director) stated that R2 is alert and oriented x3 and able to make needs known. V2 stated that V2 is responsible for completing cognitive status, mood interview, and behavior interview on each resident's comprehensive assessment (MDS/Minimum Data Set) upon admission, quarterly, annually, and with significant changes. V2 stated that even though V2 conducted the comprehensive assessment with R2 on 3/31, V2 was not aware R2's mood interview score increased/worsened to 18 out of 27. V2 stated that V2 was not involved with the investigation into the allegation of misappropriation of property involving R2 and would only get involved if V1 asks V2 to assist. V2 stated that V2 was recently made aware of the allegation of misappropriation of property involving R2 and former staff members that occurred in March 2021. V2 stated that V2 has not spoken with R2 because R2 was admitted to the local hospital prior to V2's knowledge of these allegations of misappropriation of property. V2 stated that V2 does not recall meeting with R2 after R2's first allegation of misappropriation of property involving R2's wallet and money missing last September. V2 stated that V2 did not observe any weight loss with R2. V2 acknowledged that R2's worsening mood score and weight loss could be related to the allegations of abuse. On 4/21/2021 at 11:40 am, V21 (Activities Director Senior Living) stated that V21 was asked by V11 (Business Office Manager) to accompany V11 to speak with R2 regarding R2's funds. V21 stated that V21 has known R2 since R2 was admitted to the senior living center attached to this facility and has a good relationship with R2. V21 stated that V21 witnessed the telephone call between V11, R2, and R2's bank. V21 stated that V11 documented the past transactions posted to R2's bank account. V21 stated that the name attached to several transactions sounded familiar; the name was of V22 (former CNA) that worked at the senior living center. V21 stated that V21 did not speak with R2 after the telephone call with R2's bank. Review of R2's medical record, notes R2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's progress notes: On 8/11/20, nurse noted R2 appears more depressed per nurse practitioner when rounded this morning. Psychiatric nurse practitioner notified. V18 NP (nurse practitioner) noted R2 with flat affect, unkempt, wet diaper and clothes noted, per V15 (former CNA), refused care this morning. Instructed V15 to offer care again. On 9/17/20 at 8:34 am, R2 is refusing to go to [CONDITION(S)]. R2 is not even willing show the catheter site. Not giving any reason. Informed DON (Director of Nursing) and ADON (Assistant Director of Nursing). Informed outside [CONDITION(S)] center. [CONDITION(S)] rescheduled for Saturday, 9/19/20. At 5:15pm, R2 stated that R2 could not find wallet and is missing $300. V15 worked on the same unit as R2 on 9/17/20 from 7:00am to 7:00pm. On 9/18/20, R2 agreed to go to [CONDITION(S)] this coming Saturday, 9/19/20. V15 was not scheduled to work on 9/19/20. On 10/8/20, V15 was present in this facility but per schedule, V15 was not scheduled to work that day. V15 exhibited unprofessional conduct towards coworkers as evidenced by verbal aggression in a threatening manner with confrontational behavior. On 11/10/20, V15 CNA in verbal altercation with V14 RN (registered nurse) in front of residents, regarding putting R2's lunch away so other resident would not eat it while R2 was at [CONDITION(S)]. On 11/28/20, V13 RD (registered dietitian) noted R2 has steadily weight loss since September (-7.7%, -23.2lbs). R2's weights: on 10/29/20, 285 pounds, on 9/5/20, 303 pounds. On 12/31/20, V13 RD noted continued weight loss. R2's weight 277.7 pounds. On 3/4/21, V13 RD noted continued weight loss. R2's weight 267.7 pounds. On 3/8/21, R2 informed bank account closed due to insufficient funds. On 4/1/21, R2 refused to go to [CONDITION(S)] today. R2 was verbally aggressive towards V3 (Clinical Director). R2 stated Just leave me alone. R2 also refused breakfast and lunch. On 4/6/21, R2 refused all care even after given education, R2 didn't eat any meals, all meals refused. Education given all the time, still insisting. Will continue to educate and redirect R2. R2 refused to go for [CONDITION(S)], Writer educated about importance of [CONDITION(S)], R2 still insisted. Asked R2, does R2 want to go for [CONDITION(S)] on Wednesday, refused. R2 ate 25% dinner, some medications refused. On 4/12/21, R2 transported to local hospital for unstageable pressure ulcers on heels and [CONDITION(S)] (skin infection) of left lower leg. As of 4/22/2021, R2 is still in the hospital. This surveyor attempted on 6 occasions during this survey to speak with R2 but was unsuccessful. R2's nurse at the hospital informed this surveyor that R2 is refusing to speak with anyone on the telephone as well as refusing in-person visits with anyone. Review of R2's BIMS (Brief Interview of Mental Status) score, dated 3/31/2021, notes R2's score is 14 out of 15. R2 is able to make needs known. Review of R2's MDS (Minimum Data Set), dated August 2020 to March 2021, notes on 8/6/20 R2's mood was 4 out of 27; on 9/12/20 R2's mood was 4 out of 27; on 10/8/20 R2's mood increased/worsened to 10 out of 27; on 1/4/21 R2's mood improved to 4 out of 27; and on 3/31/21 R2's mood increased/worsened to 18 out of 27. Review of R2's medical record does not note a care plan was initiated or updated related to R2's risk for abuse or allegation of misappropriation of resident property. Per whitepages.com, the address listed on R2's bank account is associated with V15 (former CNA). Review of this facility's abuse prevention policy, undated, notes this facility affirms the right of our residents to be free from abuse or misappropriation of property. This facility will prevent occurrences of abuse and misappropriation of property by: establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse and misappropriation of property, implementing systems to promptly and aggressively investigate all reports and allegations of abuse and misappropriation of property, and making the necessary changes to prevent future occurrences.