Every finding on record at Barry Healthcare & SR Living

Based on observation, interview and record review, the facility failed to assess one newly admitted resident 1 of 1 resident (R69) reviewed for pain management in the sample of 30. The facility also failed to administer PRN (as needed) pain medication and to get report from the previous facility. This failure resulted in a nonverbal resident (R69) yelling/screaming out for over 18 hours without being assessed for pain. A reasonable person who was yelling/screaming for hours would feel intense and overwhelming sensations of pain causing emotional distress. Findings include:R69's Previous Facility Documentation states she arrived at the facility with documented diagnosis including chronic pain and Lupus (an inflammatory disorder.) Physician's orders from previous facility included PRN (when needed) pain medication.R69's Unsigned and Handwritten Baseline Care Plan, dated 1/15/2026 documents R69 is dependent with bed mobility, locomotion, bathing, toileting, transfers, dressing and eating. No documentation that resident is yelling/screaming, cognition and communication of verbal or nonverbal not documented.R69's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Lupus, anxiety and insomnia, no chronic pain diagnosis documented on R69's face sheet.R69's Health Status Note dated 1/15/2026 at 2:00 PM V10, Licensed Practical Nurse (LPN) documented resident admitted from previous nursing home in a van via geri chair. Resident yelling out. Resident very restless, grabbing at groin area. No pain assessment documented.On 1/16/2026 from approximately 2:00 PM to 2:45 PM Illinois Department of Public Health (IDPH) surveyors heard R69 yelling continually as she lay in bed. R69's Physician's Order Sheet (POS), dated 1/15/2026 documents Tylenol 650 milligrams (mg) PRN for mild pain and Ativan 1 mg PRN for severe anxiety. No scheduled pain medication was ordered.R69's Medication Administration Record (MAR) dated 1/15/2026 no documentation PRN Tylenol was administered. At 8:25 PM V12, LPN documented Ativan 1 mg was administered and documented E for effective. No documentation of an assessment. No documentation of a pain assessment every shift documented either.R69's Progress Notes, dated 1/15/2026 no documentation of assessment for R69 when V12 administered Ativan 1 mg PRN at 8:25 PMR69's Electronic Medical Record dated 1/16/2026 at 9:15 AM no documentation of a pain assessment or admission nurse assessment documented or baseline care plan documented.R69's MAR documents R10 administered PRN Tylenol on 1/16/2026 at 8:20 AM. The pain was documented a 6 and was documented ineffective.R69's POS dated 1/16/2026 at 10:44 AM staff documented pain assessment every shift for admission protocol. No documentation prior to this time of an admission pain assessment.R69's Pain Evaluation with Interview, dated 1/16/2026 at 12:54 PM documents the resident is rarely or never understood. Staff assessment for pain: non-verbal sounds (e.g. crying, whining, gasping, moaning or groaning.) Frequency with which resident complains or shows evidence of pain or possible pain: indicators of pain 1 to 2 days. What makes the pain better: Fibromyalgia. What makes the pain worse: moving around a lot. Received scheduled pain medication regimen: No. Received PRN pain medications or was offered and declined: Yes. Describe administration patterns, any side effects and effectiveness: PRN Tylenol. Received non-medication intervention for pain? Yes. Describe interventions and effectiveness: Positioning. No comments documented.On 1/16/2026 at 9:00 AM through 10:20 AM R69 was observed laying in bed yelling/screaming out. R69 didn't respond to surveyor's questions and was not verbal at that time. On 1/16/2026 at 11:25 AM V14, CNA (Certified Nurse Aide) and V15, CNA transferred R69 from bed to geri chair with a Hoyer lift. R69 yelled/screamed during the transfer.On 1/16/2026 at 11:29 AM V14, CNA stated she was assigned to R69 today and she started at 6:00 AM and when she got to the facility R69 was yelling/screaming and the nurse (name unknown) told her, That's just what she does. R14 stated R69 was a new resident and she didn't know anything about her but she seemed to be in pain and stated R69 is nonverbal and doesn't respond to questions.On 1/16/2026 at 11:31 AM V15, CNA stated she worked on 1/15/2026 and was here when R69 was admitted to the facility, and she was yelling/screaming upon admission. V15 stated she left the facility at approximately 2:00 PM and so she didn't know much about R69. V15 stated she got to work today at 6:05 AM and the night shift CNA (name unknown) gave her report that R69 was awake yelling/screaming all night long other than for an hour. V15 stated R69 was nonverbal and doesn't respond to questions.On 1/16/2026 at 12:15 PM R69 was observed up in a geri chair in the dining room yelling/screaming out while staff attempted to feed her lunch.On 1/17/2026 at 10:45 AM V10, LPN stated she admitted R69 on 1/15/2026. R69 arrived to the facility at approximately 2:00 PM and she was restless and yelling upon admission. V10 stated R69 was admitted from another nursing home but she didn't get nurse report from the previous nursing home because no one from that facility called her back so she didn't know if R69 being restless and yelling out was normal for her or if she had a change in condition. V10 stated she assessed R69's skin and completed some of the admission paperwork but she had a lot going on with other resident's so when the night shift nurse (V12, LPN) at approximately 6:00 PM so gave report that R69 had been yelling out since she was admitted to the facility at 2:00 PM that day and that the nurse admission assessment wasn't completed including the baseline care plan and she expected V12 to work on it during the night shift. V10 stated when she left the faciity on 1/15/2026 at approximately 7:00 PM R69 was laying in bed yelling out continuously. V10 stated she understood R69 had a diagnosis of chronic pain and Lupus but she didn't administer PRN pain medication and V10 stated she didn't know why she didn't. V10 stated the admission pain assessment is part of the admission nursing assessment so it hadn't been done yet. V10 stated when she got to work on 1/16/2026 at approximately 6:00 AM she heard R69 yelling out and the night shift nurse, V12 gave her report that R69 started yelling at approximately 5:30 AM. V10 stated she assessed R69 while she administered her morning medications on 1/16/2026 at 8:15 AM and she administered PRN Tylenol at 8:20 AM for possible pain and she reassessed R69 at 9:20 AM and stated the PRN Tylenol was ineffective. V10 stated she dropped the ball and she should have assessed and documented a nonverbal pain assessment when R69 was admitted to the facility and should have administered PRN Tylenol after the assessment as well and she should have notified the provider to let them know the resident was admitted to the facility and was yelling out.On 1/16/2026 at 12:32 PM V12, LPN stated she worked 12 hours night shift on 1/15/2026 into 1/16/2026 and she arrived to the facility at 5:58 PM. V12 stated she immediately heard a resident yelling out from the 300 hall. V12 asked the day shift nurse, V10 who was yelling and why and V10 gave her report that R69 arrived a few hours ago and that she continuously yells. V12 stated V10 told her she started R69's admission nurse assessment but that it wasn't complete, so V12 planned on completing it at some point that shift. V12 stated that night was crazy meaning a lot of residents needed a nurse and she was running all over the facility so she didn't complete R69's admission nurse assessment or her baseline care plan. V12 stated she administered bedtime medications to R69 and she recalled R69 continued to yell out. V12 stated she assessed a pain assessment on R69 which consisted of her placing her hand on R69's shoulder and asked if she was in pain. R69 stated R69 was nonverbal and didn't respond to her questions and continued to yell out. V12 stated looking back she didn't document that she assessed R69 for pain and she didn't do a nonverbal comprehensive pain assessment either. V12 stated she didn't have time to review R69's previous facility's medical records and she didn't know R69's diagnoses. V12 stated if she knew R69 had diagnoses of chronic pain and Lupus and she would have administered the PRN pain medication to see if it was effective. V12 stated she thought R69 was anxious, so she administered a PRN anti-anxiety medication to her instead of pain medication. V12 stated she was running around the entire facility that shift and from what she could recall she thought R69 slept from approximately 10:30 PM to 5:30 AM but she could be wrong because she was working with residents on other halls that shift and wasn't on 300 hall all night. V12 stated she didn't have time to complete R69's admission nursing assessment that shift and she let V10 know that when she arrived to the facility on 1/16/2026 at 6:00 AM.On 1/16/2026 at 1:10 PM V2, DON (Director of Nursing) stated she was concerned R69 was in pain due to her yelling and screaming out so she reached out to R69's provider via fax on 1/15/2026 at approximately 2:30 PM and documented R69 has Lupus, and the resident was in pain and requested something stronger for pain. V2 stated she didn't receive a response back from that fax that she's aware of and didn't know anything about a new order for Celebrex for R69. V2 stated she spoke to V11 (Nurse Practitioner 2) and she stated she would come and assess R69 sometime today, but she didn't say when and she didn't mention the Celebrex new order either. V2 stated when a resident is nonverbal, she expects staff to do a nonverbal comprehensive pain assessment which includes assessing if the resident is yelling out, facial grimacing and/or guarding. V2 stated when a resident is in pain you can usually visually tell. V2 expected staff to review R69's medical record for diagnoses of pain and expected the admitting nurse to assess R69 for pain and to administer the Tylenol PRN if it was needed and to document the pain assessment in R69's progress notes and should have documented the provider was faxed regarding a stronger pain medication. V2 stated she didn't know if R69 slept the night of 1/15/2026 into 1/16/2026. V2 stated the admission pain assessment is part of the nursing admission assessment and the admitting nurse should have documented the pain assessment upon admission and if it's not done the next shift nurse should have the nursing admission assessment completed but staff have 24 hours to complete the admission assessment. V2 stated when R69 was admitted to the facility she expected the admitting nurse to assess her including for pain and document that assessment in R69's progress notes. V2 stated it is standards of nursing practice to call and get nurse report from the facility the resident is being admitted from because then staff understand the resident's baseline. Staff didn't get ahold of the previous facility regarding R69. Staff reported to her they called three times, but no one called back. V2 stated she expected staff to report to her if they couldn't get report for a resident being newly admitted because it's important to have a baseline on the resident.On 1/16/2026 at 12:43 V14, CNA clarified that she got report from a night shift CNA (name unknown) and that she told her the R69 only slept 1 hour during the night and she yelled out the rest of the night.On 1/16/2026 at 4:00 PM V13, CNA stated she worked night shift on 1/15/2026 into 1/16/2026 and when she arrived to the facility at approximately 6:00 PM she heard R69 hollering out but she and another CNA V16, CNA swapped assignments and she didn't work with R69 that night but she spoke to V16 in the morning on 1/16/2026 before she left the facility at approximately 5:45 AM and V13 recalled V16 told her that R69 yelled all night long.On 1/16/2026 at 12:17 PM V11 (Nurse Practitioner 2) stated when a resident is admitted to the facility, she expects a nurse to assess the resident within 2-4 hours of admission and to document the assessment, including a pain assessment and to notify her as soon as possible if the facility has concerns. When a resident is nonverbal and yelling/screaming out the nurse should have assessed her for pain and then reviewed R69's medical record to see if she has a pain diagnosis and if she has pain medication prescribed. V11 stated she expected staff to administer the PRN pain medication and then to reassess her an hour later to see if the pain medication administered was effective, if the pain medications wasn't effective, she expected staff to notify her as soon as possible to let her know what the resident's status is so she can make a professional decision on how to proceed. V11 stated she received a fax from the facility on 1/15/2026 at 2:43 PM that documented R69 has Lupus and they requested something stronger for pain. V11 stated she responded to the fax before she left the office on 1/15/2026 and gave an order to start R69 on Celebrex 50 milligrams (mg) a day for the treatment of Lupus because it's a anti inflammatory and that should help with the Lupus pain. V11 stated she expected staff to call the previous facility and get nurse report on the resident prior to the resident's arrival so they know what her baseline is as that is standard practice.The Facility Pain Policy, revised 10/2022 states The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establishes treatment goals. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated.The Facility admission Assessment and Follow Up: The Role of the Nurse Policy, revised 9/2012 documents the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instructions. Conduct supplement assessment including pain assessment. Reporting: notify the supervisor and the attending physician of immediate needs that the resident may have. Report other information in accordance with the facility policy and professional standards of practice.

Based on observation, interview and record review, the facility failed to implement and document new fall interventions after a fall for 1 (R50) of 4 residents who was assessed to be high fall risk upon admission to the facility. This failure resulted in R50 falling, sustaining a hematoma to her head and 2 rib fractures, and subsequently being transferred to the emergency room for treatment. Findings include:R50's Undated Face Sheet documents R50 was initially admitted to the facility on [DATE] with diagnosis of dementia and osteoarthritis.R50's Care Plan, dated 12/29/2024 and revised 11/24/2025 documents the resident is a high risk for falls R/T (related to) history of falls. The resident will not sustain serious injury through the review date. The resident will be free of falls through the review date.R50's Quarterly Minimum Data Set (MDS) dated [DATE] documents R50 was cognitively impaired, had a history of falls and uses a wheelchair.R50's Fall Risk Data Collection, dated 8/15/2025 documents she was high risk for falls.R50's Progress Note, dated 8/23/2025 9:11 PM, documents CNA (Certified Nurse Aide) informed writer that she heard the resident yelling while in another patient's room. Writer went to assess the situation and found R50 lying in the middle of the floor. Her feet facing the door, while entrapped in the bottom of the isolation bin. Her head facing the bathroom door. Her wheelchair was sitting next to her legs, on the right side, unlocked. A basin full of water sat by her head. Water spilled all over the floor. She is wearing regular socks. No shoes. Call light is on the bed, not in use. Writer asked resident how she ended up entangled in the isolation bin on the floor. Resident stated she was trying to get in her car and thinks she may have fell. Writer assessed the resident and found redness to the back. No complaints of pain or discomfort to the back area. Resident had complaints of pain to the BLE (bilateral lower extremities.) 7+. writer assessed the area and found that she only had complaints of pain to the areas where edema is present. Scheduled narcotic given and effective. Neuro (neurological) checks initiated. ROM (Range of Motion) completed on all extremities with no difficulty to upper extremities and little difficulty to lower extremities. Dr (doctor) office notified. DON (Director of Nurses) notified as well.R50's Care Plan, dated 8/23/2025 an intervention documented ensure non-skid socks are on.R50's Health Status Note, dated 10/1/2025 at 5:11 AM documents, resident had an unwitnessed fall around 4:30 AM. She has a new skin tear on her L (left) elbow which was cleaned and dressed. She denies hitting her head. Resident has no other new marks or injuries.R50's Care Plan, dated 10/1/2025 an intervention documented remind resident to wear non-skid footwear and remind staff to make sure she has them on when needed. R50's Health Status Note, dated 10/3/2025 at 11:17 PM, documents CNA notified writer that when she was walking down the hall, she heard a faint help me. She opened bedroom doors and found resident sitting on the floor. Writer immediately went to assess the situation and found resident sitting on the floor in front of her dresser. The two bottom drawers were on the floor. Her wheelchair was in the corner, unlocked. Her walker was next to the bed. She had on regular socks and a depend. Blood was behind her on the floor. Writer asked resident how did she end up on the floor. Resident told writer to worry about someone else. She knows what she is doing. Skin tear to left hand cleanse and dry dressing applied. Has a hematoma to the left side of the forehead. Complaints of hitting head when fallen. Complaints of head and bilateral knee/hip pain. 8/10. ROM (Range of Motion) completed on all extremities. Mild difficulty to lower extremities. Eyes slow to react from neuro check. Speech began to slur. CNA's lifted from ground into wheelchair. Placed in pajamas. Ambulance called and arrived at 2300 (11:00 pm) to transport to hospital. Message faxed to doctor.R50's Serious Injury Incident and Communicable Disease Report, dated 10/3/2025 documents R50 fell on [DATE] at 11:00 PM CNA notified nurse that when she was walking down the hall she heard a faint, help me. She opened bedroom doors and found resident sitting on the floor. Nurse immediately went to assess the situation and found resident sitting on the floor in front on her dresser. The two bottom drawers were on the floor. Her wheelchair was in the corner, unlocked. Her walker was next to the bed. She had on regular socks and a depend. Blood was behind her on the floor. Nurse asked resident how did she end up on the floor. Resident told nurse to worry about someone else. She knows what she is doing. Skin tear to left hand cleanse and dry dressing applied. Has a hematoma to the left side of the forehead. Complaints of hitting head when fallen. Complaints of head and bilateral knee/hip pain. 8/10. Ice pack applied to head and neuros started. ROM completed on all extremities. Mild difficulty to lower extremities. Eyes slow to react from neuro check. Speech began to slur. Ambulance arrived at 11:00 PM to transport resident to the hospital. MD (physician) and POA (Power of Attorney) contacted. ER (Emergency Room) at hospital per RN (registered nurse) called with report with 2 fx (fracture) ribs one on each side. Incentive spirometry use as often as possible per doctor at ER. Resident returned to facility at 2:01 AM Resident still non-complaint with asking for assistance after re-educated about call light and needing assist. R50's Emergency Department (ED) Clinical Care Summary, dated 10/3/2025 and 10/4/2025 documents chief complaint: fall. The resident had extensive tests done, including CT head and chest and a left shoulder x ray. R50 sustained right 10th a left 2nd rib fractures was documented. Discharge diagnoses includes rib fractures.On 1/15/2025 at 11:05 AM R50 was sitting up in her wheelchair in her room. R50 was awake and stated, Everyone keeps asking me all about that fall when I hit my head and broke my ribs and I don't want to talk about it anymore, I don't remember what happened and I don't care to remember. There was a call don't fall sign above R50's bed and in her bathroom as well.On 1/15/2026 at 10:56 AM V2, Director of Nurses (DON) stated when a resident falls staff call the on-call staff which is her, V3 ADON (Assistant Director of Nurses) or V1, Administrator which is an LPN (Licensed Practical Nurse) and they ask what exactly occurred regarding the fall and what injuries, if any were sustained. V2 stated when a resident falls, she tells staff an immediate intervention then she reassesses the intervention when she works again to ensure the intervention is appropriate. V2 stated after a fall the intervention should be a new intervention and not an intervention that was already documented on the resident's care plan. The point of the intervention post fall is to prevent future falls. V2 stated R50 was admitted from an assisted living facility, and she has always been noncompliant with waiting for staff to assist her prior to getting up. V2 stated when staff added the intervention for nonskid socks to R50's care plan on 8/23/2025 she expected staff to ensure R50 had nonskid socks on at all times then she fell again on 10/3/2025 V2 stated she read R50 didn't have the nonskid socks on and she was transferred to the emergency room because staff assessed her and she had hit her head. V2 stated R50 had a hematoma on her head and the emergency room called and reported R50 sustained two fractured ribs as well.On 1/16/026 at 10:30 AM V9, Nurse Practitioner (NP) stated when a resident is assessed to be a high fall risk, she expects that to be addressed in the resident's care plan along with interventions to prevent falls. When a resident falls staff are expected to implement and document the new intervention on the resident's care plan. She expects staff to assess if that intervention is effective and if not to change it. V9 stated she expected staff to follow the facility's fall policy and to put implement a different/progressive intervention between falls on the resident's care plan. The facility's Fall Policy Revised 3/18, documents if falling recurs despite initial interventions staff will implement additional or different interventions. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of or category of falling, until falling is reduced or stopped. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 56 residents living in the Facility.Findings include:The Facility's Daily Staffing Schedules were reviewed for 12/1/25 through 1/15/26. These schedules do not document a RN worked for at least eight hours on 12/6/25, 12/7/25, 12/14/25, 12/20/25, 12/21/25, 12/28/25, 1/3/26, 1/4/26, 1/11/26, or 1/14/26.On 1/13/25 at 10:00 AM, V1, Administrator, stated there are occasionally days without RN coverage in the building.On 1/15/26 at 10:04 AM, V1 stated the Facility does not have a policy regarding RN staffing and just follows the regulations.The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 1/13/26 documents there are 56 residents living in the Facility.

Based on interview and record review, the Facility failed to track infectious organisms in the Facility for 1 of 1 residents (R53) reviewed for infection control in the sample of 30.Findings include: The Facility's Infection Control Log for October 2025 does not list a causative organism for R53's Urinary Tract infection (UTI). The Log documents R53 received the antibiotic Cipro. On 1/15/26 at 11:20 AM, V3, Infection Preventionist, stated R53's urine was not cultured, so the Facility does not know which infectious organism caused R53's UTI. On 1/16/26 at 9:53 AM, V1, Administrator, stated she expects the Facility to track infectious organisms in the Facility. The Facility's Surveillance for Infections Policy revised 4/2025 documents, The infection preventionist conducts ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions.

Based on interview and record review, the Facility failed to follow its antibiotic stewardship policy to help prevent antibiotic resistance for 1 of 1 resident (R53) reviewed for infection control in the sample of 30.Findings include:R53's Face Sheet documents R53 was admitted to the facility on [DATE] with diagnoses including dementia and congestive heart failure.The Facility's Infection Control Log for October 2025 does not list a causative organism for R53's Urinary Tract Infection (UTI) and documents R53 received the antibiotic Cipro.On 1/15/26 at 1:20 PM, V3, Infection Preventionist, stated the family requested the antibiotic and the physician ordered it, so no culture was ever obtained.R53's Revised McGeer Criteria for Infection Surveillance Checklist dated 10/24/25 documents UTI criteria was not met.R53's Physician Order dated 10/24/25 documents Cipro 250 mg (milligram) oral tablet, give one tablet by mouth two times a day for 7 days for UTI.R53's Medication Administration Record for October 2025 documents R53 received 13 doses of the antibiotic Cipro.R53's Progress Note dated 10/24/25 documents new order for 250 mg Cipro twice daily for 7 days for UTI.R53's Progress Notes dated 10/25/25-10/30/25 document R53 was receiving antibiotic for UTI.The Facility's Antibiotic Stewardship Policy revised December 2016 documents, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.On 1/16/26 at 9:53 AM, V1, Administrator, stated she would expect urine cultures to be obtained prior to starting an antibiotic for a UTI.

Based on interview, observation, and record review the facility failed to administer medications per physician's orders for 4 of 4 residents (R1, R2, R3, R5) reviewed for pharmacy services in the sample of 15. Findings include: 1. R1's Face Sheet undated documents R1's admitting diagnoses as Paraplegia, Secondary Malignant Neoplasm of Bone, Unspecified Severe Protein-Calorie Malnutrition, Malignant Neoplasm of Prostate and Chronic Pain Syndrome. R1's Physician Order Summary (POS) dated February 2025 documents medications as Fentanyl Transdermal Patch 72 hours, 25 micrograms (mcg) /hr (Pain), Thiamine 100 milligrams (mg) Daily (low B1), Magnesium 400 milligrams Daily (supplement), Vitamin B6 Daily (supplement), Vitamin K2 100 mcg Daily (supplement), Vitamin B12 500 mcg Daily (vitamin), Oxycodone 10 mg every 6 hours as needed (pain), Potassium 10 Milliequivalent Daily (diuretic use), Senna Plus 50-8.6 mg twice a day (constipation), Lasix 20 mg Daily (edema), Eliquis 5 mg twice day (Deep Vein Thrombosis), Vitamin D3 50000 Units once a week (Vitamin D deficiency), Juven Daily (wound healing) and Baclofen 10 mg Daily (muscle spasms). R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, rates pain 2/10, receives scheduled, PRN (as needed) pain medications and non-medication interventions, experiences pain occasionally and pain interferes with daily activities occasionally. R1's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents several of R1's medications were administered 2 hours or more past scheduled times. On 2/6/2025 10 milligrams Oxycodone was scheduled 12:00 PM but was administered at 4:06 PM. On 2/7/2025 20 milligrams Lasix, 10 Milliequivalent Potassium, 100 Milligram Thiamine, 50000 Units Vitamin D3, 500 Micrograms Vitamin B12, 5 Milligram Eliquis, 400 Milligram (mg) Magnesium, and 50 Milligram (mg), Vitamin B6 was scheduled for 8:00 AM was administered at 10:03 AM. On 2/7/2025 10 Milligram (mg) Oxycodone was scheduled for 12:00 PM was administered at 2:37 PM. On 2/11/2025 Fentanyl Transdermal Patch 72 hour 25 Micrograms (mcg/hr.) was scheduled for 8:00 PM was administered 10:36 PM. On 2/12/2025 500 Micrograms (mcg) Vitamin B12, 100 Milligram (mg) Thiamine, Multivitamin with Minerals, 10 Micrograms (mEq) Potassium, 20 Milligram (mg) Lasix 50 Milligram (mg) Vitamin B6, 5 Milligram (mg) Eliquis was scheduled for 8:00 AM but was administered at 11:11 AM. On 2/12/202 100 Microgram (mcg) Vitamin K2 and 400 Milligram (mg) Magnesium was scheduled for 9:00 AM but was administered at 11:11 AM. On 2/22/2025 400 Milligram (mg) Magnesium, 100 Microgram (mcg) Vitamin K2, 500 Microgram (mcg) Vitamin B12, 100 Milligram (mg) Thiamine, 10 Milliequivalent (mEq) Potassium and 20 Milligram (mg) Lasix was scheduled for 8:00 AM but was administered at 11:19 AM. On 2/25/2025 Juven for wound healing was scheduled for 8:00 AM but was not administered until 2:48 PM. On 2/28/25 at 12:07 PM V8, Licensed Practical Nurse, LPN, stated R1's medications are late because sometimes he (R1) requests them to be given later. R1 was either talking on the telephone, outside smoking or taking a shower. She had not notified the doctor that the meds were being administered later than the scheduled time. R1's Nurse Progress notes dated 2/4/25 at 9:19 AM documents Late Entry: Resident yelled at this nurse due to was late coming in with medication. Tried to explain to resident that it was a few minutes, and we had an emergency. He stated, what was the emergency? Explained to resident that we could not let resident know other residents' information. Resident yelled at this nurse and said, I just want you to do your damn job! Explained to resident that I was and unfortunately things happen. Resident continued to yell at this nurse and stated he was reporting me. This nurse left his room. R1's Nurse Progress Notes dated 2/12/25 at 11:56 AM documents Med taken to resident at 7am and didn't want them until he ate his breakfast. I approached him at 8am and he did take them then as I stood there and watched him, I did not get meds signed off until later due to an emergency at that time. On 2/27/25 at 12:00 PM R1 stated he does argue with them about his medication because it's always an ordeal. He knows what medications he takes and when they short him on his medications. The vitamins are important to his well-being and his dealing with the cancer. Rather than saying they made a mistake the staff want to argue with him. On 2/27/2025 at 3:45 PM, V6 LPN stated she had not had to call the doctor because her meds are not late. R1 has accused her of messing with his meds and asked that she not be assigned to him anymore. 2. R2's Face Sheet undated documents R2's admitting diagnoses Disruption of External Operation (surgical) wound, not elsewhere, Classified, subsequent encounter, Acquired absence of other Genital Organ (s), Unilateral Primary Osteoarthritis, left hip, Lymphedema, not elsewhere classified, Neurocognitive Disorder with Lewy Bodies and Secondary Parkinson, unspecified. R2's Physician Order Summary (POS) dated February 2025 documents medications as 24 Microgram (mcg) Amitiza twice a day (Irritable Bowel Syndrome), 15 Milliliters (ml) Mouth/Throat solution 12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day (Hypothyroidism), 850 Milligram (mg) Metformin (Type 2 Diabetes Mellitus), 500 Milligram (mg) Levetiracetam (tremors), 2.5 Milligram (mg) Eliquis (atrial fibrillation), 25 Milligram (mg) Metoprolol twice a day (primary hypertension) and Refresh Plus Ophthalmic Solution 0.5% (dry eyes). R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact and has medical conditions of coronary heart disease, hypertension, neurogenic bladder, diabetes mellitus, hyperlipidemia, Non-Alzheimer dementia. R2's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following R2's medications were administered 2 hours or more past scheduled times: On 2/4/2025 40 Milligram (mg) Furosemide, 500 Microgram (mcg) Cyanocobalamin, Peridex Mouth/Throat Solution 0.12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 %, 40 Milligram (mg) Lisinopril, 40 Milligram (mg) Protonix, 400 Microgram (mcg) Folic Acid were scheduled for 7:45 AM but were administered at 11:59 AM; on 2/4/2025 600 Milligram (mg) Guaifenesin ER, 10 Milliequivalent (mEq) Potassium Chloride Extended Release, 10 Milligram (mg) Zyrtec, Aspirin Enteric Coated (EC) Low Strength and 10 Milligram (mg) Amlodipine was scheduled for 8:00 AM but was administered at 11:59 AM; on 2/4/2025 Peridex Mouth/Throat Solution 0.12%, 25-100 Milligrams (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 % were scheduled for 5:00 PM but was administered at 9:05 PM; on 2/18/2025 600 Milligram (mg) Guaifenesin Extended Release, 40 Milligram (mg) Atorvastatin were scheduled for 8:00 PM but were administered at 10:02 PM; on 2/21/2025 Peridex Mouth/Throat Solution 0.12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 % were scheduled for 5:00 PM but was administered at 7:52 PM. 3. R3's Face Sheet undated documents R3's admitting diagnoses Non-pressure Chronic Ulcer of Other Part of Left Foot with Unspecified Severity, Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Vascular Dementia, Unspecified Severity, with other Behavioral Disturbances, Encephalopathy, Unspecified, Hyperlipidemia, Unspecified. R3's Physician Order Summary (POS) dated February 2025 documents R3's medications as 40 Unit Lantus (Diabetes), 500 Milligram (mg) Metformin (Diabetes), 5 Milligram (mg) Lisinopril (hypertension), 50 Milligram (mg) Diclofenac (arthritis), 100 Milligram (mg) Gabapentin (pain), 325 Milligram (mg) Ferrous Sulfate (65 Fe), 81 Milligram (mg) Aspirin (supplement), 40 Milligram (mg) Omeprazole (Gastro-Esophageal Reflux Disease) and 100 Milligram (mg) Docusate (constipation) R3's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following R2's medications were administered 2 hours or more before or after scheduled times; On 2/01/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 2:04 PM; on 2/02/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 3:43 PM; On 2/05/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 4:09 PM ; on 2/06/2025 100 Milligram (mg) Gabapentin was scheduled for 7:00 AM but was given at 9:22 AM ; On 2/06/2025 500 Milligram (mg) Metformin was scheduled for 4:00 PM but was given at 6:17 PM; On 2/06/2025 50 Milligram (mg) Diclofenac and 100 Milligram (mg) Docusate was scheduled for 9:00 AM but was given at 11:24 AM ; On 2/06/2025 500 Milligram (mg) Metformin was scheduled for 4:00 PM but was given at 6:17 PM; On 2/12/2025 25 Milligram (mg) Quetiapine was scheduled for 2:00 PM but was given at 12:14 PM; On 2/13/2025 100 Milligram (mg) Gabapentin was scheduled for 7:00 AM but was given at 9:02 AM ; On 2/22/2025 100 Milligram (mg) Metformin was scheduled for 7:00 AM but was given at 9:10 AM ; On 2/23/2025 100 Milligram (mg) Docusate was scheduled for 9:00 AM but was given at 11:12 AM ; On 2/06/2025 50 Milligram (mg) Diclofenac was scheduled for 9:00 AM but was given at 11:11 AM. 4. R5's Face Sheet undated documents R5's admitting diagnosis Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Unspecified Asthma, Uncomplicated, Type 2 Diabetes Mellitus without Complications, Morbid (Severe) Obesity due to Excess Calories, Neuromuscular Dysfunction of Bladder, Unspecified, Fibromyalgia and Hypokalemia. R5's Physician Order Summary (POS) dated February 2025 documents medications as Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)Milligram/3 Milliliters (short of breath),80 mg Simethicone (gas) , 5 Milligram (mg) Oxycodone (pain) , 5 Milligram (mg) Diazepam (anxiety), 24 Microgram (mcg) Amitiza (Irritable Bowel Syndrome), 1.25 Milligram (mg) Ergocalciferol (supplement), 50 Microgram/ACT Fluticasone Propionate Nasal Suspension (allergies), 300 mg Bupropion, 325 mg Ferrous Sulfate (65 Fe), 40 Microgram (mg) Furosemide, 20 mg Furosemide (edema), 20 Milliequivalent (mEq) Potassium Chloride (supplement), 20 Milligram (mg) Prednisone (Pneumonia), 25 Milligram (mg) Lamictal (seizure), 25 Milligram (mg) Metoprolol (hypertension), 175 Microgram (mcg) Levothyroxine (low thyroid hormone) and 360 Milligram (mg) Cardizem (hypertension), 300 Milligram (mg) Bupropion Extended Release (depression) and 200 - 5 Microgram (mcg)/ ACT Milligram (mg) Dulera Inhalation Aerosol. R5's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following of R5's medications were administered 2 hours or more before or after scheduled times ; On 2/3/2025 24 Microgram (mcg) Amitiza was scheduled for 6:00 AM but was given at 8:23 AM; On 2/3/2025 360 Milligram (mg) Cardizem, 200-5 Microgram (mcg)/ACT Dulera Inhalation, 40 Milligram (mg) Pepcid, 175 Microgram (mcg) Levothyroxine and 25 Milligram (mg) Metoprolol was scheduled for 8:00 AM but were administered between 5:39 and 5:41 AM ; On 2/3/2025 80 Milligram (mg) Simethicone and 0.5-2.5 (3) Milligram (mg)/3 Milliliter Ipratropium-Albuterol was scheduled for 12:00 PM but was given at 8:23 AM; On 2/5/2025 3 Milligram (mg)/3 Milliliter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 6:00 PM but was given at 10:43 PM; On 2/6/2025 3 Milligram (mg)/3 Millimeter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 12:00 AM but was given at 2:51 AM; On 2/7/2025 3 Milligram (mg)/3 Milliliter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 12:00 PM but was given at 2:01 PM; On 2/8/2025 40 mg Pepcid, 500 Microgram (mcg)Milligram (mg) Cyanocobalamin, 325 Milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 Milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Milligram/ACT Nasal Suspension, 40 Milligram (mg) Furosemide, 100 Milligram (mg) Docusate, 200-5 Microgram (mcg)/ACT Dulera Inhalation Aerosol, and 300 Milligram (mg) Bupropion Extended Release was scheduled for 8:00 AM but was administered at 12:50 PM; On 2/10/2025 1.25 Milligram (mg) (50000 Unit) Ergocalciferol was scheduled for 7:45 AM but was administered at 12:32 PM ; On 2/10/2025 40 Milligram (mg) Pepcid, 500 Microgram (mcg) Cyanocobalamin, 325 Milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 Milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Microgram (mcg)/ACT Nasal Suspension, 40 mg Furosemide, 100 mg Docusate, 200-5 mcg/ACT Dulera Inhalation Aerosol, and 300 mg Bupropion ER was scheduled for 8:00 AM but was administered at 12:32 PM; on 2/11/2025 80 mg Simethicone, 3 mg/3 ml Ipratropium-Albuterol Inhalation Solution 0.5-2.5 were scheduled for 12:00 PM but were administered at 2:12 PM ; On 2/12/2025 325 mg Ferrous Sulfate (65 Fe) and 40 mg Pepcid was scheduled for 8:00 AM but was administered 10:09, 10:12 AM, respectfully; On 2/12/2025 5 Milligram (mg) Apixaban, 500 Microgram (mcg) Cyanocobalamin, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem and 300 Milligram (mg) Bupropion, 200-5 Microgram (mcg)/ACT Dulera Inhalation Solution, 100 Milligram (mg) Docusate Sodium, 50 Microgram (mcg)/ACT Fluticasone Propionate Nasal Suspension and 10 Milligram (mg) Escitalopram, 40 Milligram (mg) Furosemide, 20 Milligram (mg) Furosemide , Lactobacillus and 25 Milligram (mg) Lamictal, 25 Milligram (mg) Metoprolol, Multivitamin, 20 Milliequivalent (mEq) Potassium Chloride Extended Release, 20 Milligram (mg) Prednisone and Lidocaine Patch 4% were scheduled for 8:00 AM but were administered between 10:06 AM and 10:16 AM; On 2/14/2025 5 Milligram (mg) Baclofen 1 Milligram (mg) Mirapex, 3 Milligram (mg) Melatonin and 80 Milligram (mg) Simethicone Lidocaine External Patch 4 % were scheduled for 8:00 PM but were administered at 10:38 PM and 10:46 PM ; On 2/22/2025 40 mg Pepcid, 500 Microgram (mcg) Cyanocobalamin, 325 milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Microgram (mcg)/ACT Nasal Suspension, 40 Milligram (mg) Furosemide, 100 Milligram (mg) Docusate, 200-5 Microgram (mcg)/ACT Dulera Inhalation Aerosol, and 300 Milligram (mg) Bupropion Extended Release was scheduled for 8:00 AM but was administered between 11:25 and 11:26 AM; On 2/24/2025 80 mg Simethicone, Lidocaine External Patch 4%, 5 mg Baclofen and 3 Milligram (mg) Melatonin was scheduled for 8:00 PM but was administered between 9:58 and 10:00 PM; On 2/26/2025 Clobatesol Propionate External Cream 0.05% was scheduled for 6:00 AM but was not administered to 10:09 AM; On 2/26/2025 Clobatesol Propionate External Cream 0.05% was scheduled for 6:00 PM but was not administered to 10:07 PM. On 3/1/2025 at 12:17 PM V8, LPN stated she has not contacted the doctor when she is late with med administration. It was inevitable because you have to address a resident's need if they come to you while you are passing medications. It does cause a delay. On 3/3/2025 at 12:53 PM V9 Wound Care Nurse Practitioner stated she might have been contacted about late medications once, but she was uncertain. The staff are pretty good about notifying her or the medical director if there is a problem. V9 could not say there was any harm in the delay of administering medications. They would like for the orders to be followed as prescribed. On 3/3/2025 at 1:52 PM V10 LPN stated neither she or any nurses in the building contacted the nurse practitioner or doctor when the medications were administered after the scheduled time. V10 LPN stated the medication rounds are too heavy, most of the residents' medications were shifted from the night shift to days and evenings therefore the medications cannot be administered in the allotted time frame. They have complained to the administration about the medication passes being too heavy, but nothing is being done about it. The Facility's Policy Administering Medications revised April 2019 documents medications are administered in accordance with prescribed orders, including any time frames. Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review, the facility failed to obtain Physician Orders for a change of condition for 1 of 15 residents (R150) reviewed for quality of care in the sample of 41. This failure resulted in R150 being delayed treatment for mouth sores, nausea, and a sore throat. Findings include: On 12/04/23 at 10:52 AM, R150 stated, They just put me on a new medicine, and it has been awful. I got canker sores all over my mouth. I couldn't figure out what was going on. On Friday (12/1/23) or Saturday (12/2/23) I told the nurses, and they looked in my mouth and said it was canker sores. Nothing from doctor yet but they are going to talk to him today. My throat is sore, and I have been very nauseous. It's a new medicine for arthritis. R150 is sitting in her room in her wheelchair. R150 appears to be in discomfort and is very pale. R150's Health Status Note, dated 12/3/2023 at 06:55 AM, documents, res (resident) noted to have canker sores to inner upper lip and inner bottom lip. c/o (complaint of) sore throat. nausea. vomiting. Vs (vital signs) - 186/76 (blood pressure) - 72 (pulse) - 98.2 (temperature) - 20 (respirations) - 95% RA (room air). Fax written and sent to MD (Medical Doctor). On 12/5/23 at 11:55 AM, V10, Nurse Practitioner, stated that she saw R150, and she does have stomatitis (condition that causes painful swelling and sores inside the mouth) in her mouth and that she has sores inside her mouth. V10 stated that today was the first time she had heard of it, and she has ordered her a mouth rinse for it. R150's Physician Order, dated 12/5/23, documents, Nystatin Mouth/Throat Suspension (Nystatin (Mouth-Throat)). Give 15 ml (milliliter)/hr (hour) by mouth after meals and at bedtime for oral stomatitis for 14 Days magic mouthwash with equal ratios of diphenhydramine12.5mg (milligram) elixir, Maalox susp (suspension). nystatin 100,00 unit/gram-swish 15ml for as long as tolerated, then spit out. On 12/11/23 at 2:30 PM, V1, Administrator, stated that there was a misplaced fax related to this, but she agreed the nurses should have followed up when they did not hear back from the doctor in a timely fashion. The policy Change in a Resident's Condition or Status, dated 2/2021, fails to document what to do if Physician fails to answer notice of change of condition.

Based on observation, interview and record review the facility failed to provide sufficient staffing to meet the needs of the residents at the facility by providing care and assistance for Activities of Daily Living. This failure has the potential to affect all 52 residents at the facility. Findings include: 1. On 12/4/23 at 10:30 AM, R29 had a very shaky voice and tears coming down her face during an interview related to staff On 12/04/23 10:27 AM, R29 stated, Our girls are good. It might take them a bit, but they are good. Agency staffing is horrible. They just don't care about us. They are here for a paycheck. Last week I had my light on and he came in and asked what I needed. I told him I had to go to the bathroom. He told me that I had an (incontinent brief) on and to just go in my brief. It will take agency staff over 30 minutes to answer a light. They just make me feel worthless. R29 stated that she did tell the nurses and they told her that she is ok. R29 stated that they walk around and talk on their phones with those things they put in their ears instead of working. R29's Admission Profile, print date of 12/8/23, documents that R29 was admitted on [DATE] and has diagnoses Hemiplegia and hemiparesis following a stroke and Heart Failure. 2. On 12/04/23 at 09:48 AM, R45 stated, I don't think they have enough staff. They bring in agency and it takes them forever to get things done. I have waited for a half an hour for my call light. I get one shower a week and I don't think that is enough. I took a shower every other day at home, and they just don't have enough staff to do that here. 3. On 12/04/23 at 10:10 AM, R25 stated that he doesn't think there is enough staff. It takes about 30 minutes or more for them to come and answer the light. Over the weekend it took them an hour and a half to come and put me in my recliner from my wheelchair. I only get one shower a week and that is not enough my hair starts itching. I have talked to the Care Plan person in our meeting about this, but they don't have enough staff. R25's Admission Profile, print date of 12/11/23, documents that R25 was admitted on [DATE] with diagnoses of Dementia and Type 2 Diabetes. R25's Care Plan, dated 10/2/20, documents, I enjoy participating in scheduled activities. Interventions: I prefer a shower 2 times per week at morning time of day. 4. On 12/04/23 at 9:36 AM, R42's call light was on. R42 stated that she has had her light on for awhile. R42 stated, You can't judge them on the one here today. It always takes her a long time. I want to get up and get out of bed. 32874 5. During Resident Council Meeting on 12/5/2023 at 10:24AM, R35, R24, R37 and R27 all stated the facility does not have enough staff to provide care. R35, R24, R37, and R27 all stated it takes too long for call lights to be answered due to lack of staff. R24's Minimum Data Set (MDS) dated [DATE] documents that R24 is cognitively intact. R24's Care plan dated 10/16/2019 documents R24 requires supervision and set up for bathing. R27's MDS dated [DATE] documents R27 is cognitively intact. R35's MDS dated [DATE] documents R35 has moderate cognitive impairment. The facility's Resident Council Minutes dated 11/28/2023 documents under old business kids are brought to work. New business documents not enough staff to serve meals. Call lights are taking too long 30 minutes. Resident council minutes dated August 2023 documents it takes a long time to get call lights answered because there is not enough staff. On 12/11/23 at 03:51 PM V6, Director of Nursing (DON) stated the facility has 2 nurses on days and 2 nurses on nights as the nurse's work 12-hour shifts. 4 CNAs on days 3 on nights with an additional CNA coming in from 6-10PM. V6 stated the facility has enough staff if they are being utilized right. V6 stated she would expect that call lights be answered in 15-20 minutes. V6 stated she expects call lights to be answered timely and residents to get their showers. The facility did not provide a staffing policy. The Facility's CMS 671, Long Facility Application For Medicare and Medicaid, dated 12/5/2023, documents facility census at 52.

Based on observation, interview and record review, the facility failed to securely seal, date and label refrigerated and frozen food. This failure has the ability to affect all 52 residents residing in the facility. Finding include: On 12/4/23 at 8:40 AM, the kitchen was entered. 1. The freezer had a pan covered in aluminum foil. The foil had holes in it, it was not labeled or dated as to what food and when the food was prepared. 2. The refrigerator had a pan of left-over roast beef that was dated 11/19/23, unknown if made date or expiration date. 3. The refrigerator had a large stainless pan that was covered with aluminum foil that was not labeled of what it was, when made or when it expires. On 12/4/23 at 9:00 AM, V11, Dietary Manager, stated that all foods should be labeled with expiration date, the date prepared, name of the food and all foods should be sealed tightly. At the time of exit the facility was unable to provide a facility policy on how to store refrigerated or frozen food items. The Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23, documents that 52 residents reside in the facility.

Based on interview, observation and record review, the facility failed to have a system in place to assess for efficacy of antibiotic use. This failure has the potential to affect all 52 residents living in the facility. Findings include: 1.On 12/11/23 at 2:00 PM, V2, Infection Preventionist, stated that she does not have enough time to devote to the infection control program as she once did so there are pieces missing in her infection control tracking. V2 stated, I really don't understand all of the infection control stuff. I used to have an infection control program on the computer that would generate all my tracking and infections but apparently it is not here anymore. On 12/11/23 at 3:10 PM, V6, Director of Nurses, was questioned if the facility has updated infection control and antibiotic stewardship policies, V6 stated, I just pulled off the policies from Medpass. 2. On 12/11/23 at 1:35 PM, V2 stated that if the nurse enters the antibiotic correctly when it is ordered the computer system will automatically generate a McGreer's report for a suspected urinary tract infection. V2 was questioned if R23 had a McGreer's report available for review. V2 stated that R23 did not. V2 stated V10, Nurse Practitioner, started R23 on Keflex (an antibiotic) before the urine culture report was available for review and then the antibiotic was changed to Fosfomycin. R23's Health Status Note, dated 12/3/2023 2:27 PM, documents, N.O. (new order) received on 11/28/23 from (V10) 1. Notify office if bleeding continues 2. Collect Straight cath (catheter) UA (urinalysis) - send to(Lab) Dx (diagnosis): Hematuria, suprapubic tenderness. 3. Follow-up 1 week. R23's Health Status Note, dated 12/7/2023 11:33 AM , documents, Progress note from (V10). Stop Keflex. urine culture grew e coli ESBL (Escherichia coli extended spectrum beta-lactamase), contact isolation. treat with Fosfomycin 3 G packet (mixed with 4 oz (ounce) cold water) x1 dose. repeat urine culture (only) 7 days after receiving Fosfomycin. R23's Medication Administration Record (MAR), dated December 2023, documents that R23 received 1 dose of Fosfomycin on 12/7/23 and 5 doses of Keflex from 12/5/23 until 12/6/23. The facility is unable to provide the urine culture at this time. 3. On 12/11/23 at 1:40 PM, V2 stated that R6 does not have a McGreer's report for a suspected upper respiratory infection and that R6 did not receive a chest Xray. V2 stated, (R6) started with upper respiratory symptoms and was put on an Azithromycin. R6's MAR, dated November 2023, documents R6 received Azithromycin from 11/18/23 until 11/22/23. 4. On 12/11/23 at 1:50 PM, V2 stated that R44 did not have a McGreer's report completed for a suspected urinary tract infection and that 3 days to receive an antibiotic is too long. V2, stated, The nurses should have followed up with (V10) for orders. R44's Health Status Note, dated 12/2/2023 10:15 AM, documents, UA culture results available--e. coli, faxed to (V10's) office. R44's Physician Orders, dated December 2023, documents, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day for uti for 5 Days. Start Date of 12/5/2023 09:00 AM. The facility is unable to provide the urine culture at this time. The policy Surveillance for Infections, dated 9/2017, documents, The infection preventionist will conduct ongoing surveillance for healthcare - associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission - based precautions and other preventative interventions. The Antibiotic Stewardship Order for Antibiotics, dated 12/2016, documents, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. This policy fails to document what clinical criteria are met for a clinical definition of an active infection or suspected sepsis.' The Antibiotic Stewardship - Orders for Antibiotics, dated 12/2016, documents, Antibiotic usage and outcome date will be collected and documented using a facility approved antibiotic surveillance tracking form. This data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. The Long - Term Care Facility Application for Medicare and Medicaid, dated 12/5/23, documents that 52 residents reside in the facility.

Based on observation and record review, the facility failed to ensure medications are under direct supervision of nurse for 2 of 24 residents (R24, R45) reviewed for medication storage in the sample of 41. Findings include: 1. On 12/04/23 at 09:43 AM, V3, Licensed Practical Nurse (LPN) took a full medication up into R45's room. At 09:45 AM, V3 was observed leaving the room. On 12/04/23 at 09:48 AM, R45's room was entered. R45's bedside table had a medication cup full of pills on it. On 12/04/23 at 09:48 AM, R45 was questioned what pills those in the cup were. R45 stated, Well I woke up late. So, she (V3) just got them to me. 34964 2. On 12/4/23 at 10:25 AM, R24 was standing next to her dresser in her room, and she had two 1-ounce medication cups sitting on her bedside table. One of the medication cups contained one tablet that R24 identified as her Tums, and the other cup contained several tablets and capsules. R24 stated, That is my morning medication that (V4, LPN) gave me a little while ago. I will take it sometime before I go to lunch pretty soon. R24 stated she has a good roommate but stated she, (R17) is not in her right mind and can't remember what she did or said five minutes after it happens. R24's Minimum Data Set (MDS) dated [DATE] documents she is alert and oriented. R17 propelled herself out of the bathroom in her and R24's room and rolled past R24's bedside table that still had R24's medications unsecured in medication cups. R17 sat in her chair for a couple minutes listening to R24 talk. R24's medications were within easy reach for R17. R17's MDS dated [DATE] documents R17 is severely cognitively impaired. On 12/4/23 at 10:30 AM, V4, was standing by her medication cart in the hall a few doors down from R24's and R17's room. V4 stated, I thought (R24) was going to take her medications right away after I left them sit there for her. She already had breakfast which is what she usually waits for before taking her medications. I will go in right away and make sure she takes her medicine now. I know I am supposed to stay with the resident until they actually take their medications. I screwed up there. The facility's policy, Administering Medications, revised, April 2019, documents, Medications are administered in a safe and timely manner and as prescribed. Under Policy Interpretation and Implementation the policy documents: #4. Medications are administered in accordance with prescriber orders, including any required time frame. #20. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medications.

Based on interview and record review, the facility failed to supervise to prevent injury while smoking and elopement for 2 of 17 residents (R46, R47) reviewed for supervision in the sample of 41. Finding include: 1. R46's Admission Profile, dated 12/8/23, documents that R46 was admitted on [DATE] with a diagnosis of Dementia. R46's Minimum Data Set, (MDS), dated [DATE], documents that R46 is moderately cognitively impaired and independent with ambulation. R46's Elopement Assessment, dated 9/8/23, documents that R46 is a risk for elopement. R46's Health Status Note, dated 10/20/2023 at 3:36 PM, documents, resident was found walking on street near stop sign by property. resident was able to be redirected and brought back into facility by staff. (Resident monitoring device) bracelet replaced to ensure proper function. notified regional nurse of incident. On 12/7/23 at 1:20 PM, V1, Administrator, stated that R46 did not get to the stop sign on the side of the property. V1 said she made it to the one at the end of the drive. (There is no stop sign at the end of drive). V1 stated that she is not sure what happened or if the door alarm went off. V1 stated that there were people outside. V1 stated that she had the staff replace the (resident monitoring device) just in case it was faulty. On 12/7/23 at 1:25 PM, V1 stated that at that time there was not clear documentation that (resident monitoring device) were checked to see if they were working. The policy Wandering and Elopement policy, dated 3/2019, documents, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. R47's Admission Profile, print date of 12/8/23, documents that R47 was admitted on [DATE] and has diagnoses of Bipolar Disorder, Major Depressive Disorder, Anxiety and Vascular Dementia. R47's MDS, dated [DATE], documents that R47 is cognitively intact and is independent with ambulation. R47's Care Plan, dated 7/10/23, documents, The resident is a smoker. Interventions: Resident is supervised while smoking. Smoking materials are kept secured by staff. Smoking per facility protocol. R47's Smoking Evaluation, dated 7/10/2023, documents that R47 is to be supervised while smoking. (There is no other Smoking Evaluation available for review). On 12/4/23 at 10:10 AM, R47 stated, I smoke 3 times a day. I take myself outside and smoke behind the building. I keep my cigarettes and lighter. On 12/06/23 at 12:05 PM, V2, Registered Nurse, stated that R47 does go out to smoke by himself. On 12/06/23 at 12:05 PM, V1, Administrator, stated that R47 needs be evaluated to see if he is safe to smoke by himself. The Smoking Policy - Residents, dated 8/2022, documents, 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. it continues, 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on interview and record review, the facility failed to ensure that residents maintain current level of urinary continency and receive timely treatment for urinary tract infections (UTI) for 2 of 3 residents (R44, R101) reviewed for continency and urinary tract infections in the sample of 41. Findings include: 1. On 12/11/23 at 1:50 PM, V2, Infection Preventionist, stated that R44 did not receive an order for antibiotics to treat a urinary tract infection for 3 days. V2 stated that 3 days to receive an antibiotic is too long. V2, stated, The nurses should have followed up with (V10) for orders. R44's Health Status Note, dated 12/2/2023 10:15 AM, documents, UA (urinalysis) culture results available--e. coli (Escherichia coli), faxed to (V10's) office. R44's Physician Orders, dated December 2023, documents, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 5 Days. Start Date of 12/5/2023 09:00 AM. On 12/11/23 at 3:00 PM, V6, Director of Nurses, stated that the nurses should continue to reach out to the Doctor for orders until they receive one. The policy Change in a Resident's Condition or Status, dated 2/2021, fails to document what to do if Physician fails to answer notice of change of condition. 32874 2. R101's Face Sheet dated 12/11/2023 documents in part that R101 has a diagnosis of Cerebral infarction with hemiplegia and hemiparesis affecting the dominant right side and aphasia following the cerebral infarction. R101's care plan dated 11/13/2023 documents R101 has an Activity of Daily Living (ADL) self-care performance deficit. R101's care plan documents that R101 is totally dependent on staff for toilet use. On 12/04/23 at 10:31AM, V15, R101's daughter, stated R101 was admitted to the facility from the hospital last Tuesday. V15 stated that R101 had a stroke. V15 stated R101 was not incontinent prior to her admission and R101 is wearing an adult diaper and is being told to go in the diaper. On 12/11/23 at 10:57 AM, V15 stated that she had spoken to the facility about her concern and was told the problem is the mechanical lift will not fit in the bathroom. On 12/11/23 at 11:04 AM, V2, Infection Preventionist/ Nurse Manager stated the expectation for a resident admitted to the facility who is incontinent of urine if the mechanical lift will not fit in the bathroom, a bedside commode should be offered instead of just having resident go in adult diaper. On 12/11/23 at 11:22 AM, V16, Certified Nursing Assistant (CNA) stated (R101) is a (full body mechanical lift) and all (full body mechanical lifts) use a bedpan because the (full body mechanical lift) won't fit in bathroom. When asked by surveyor if a bedside commode had been utilized, V16 stated she had not thought of using a bedside commode. The facility policy Activities of Daily Living (ADL), supporting dated, revised March 2018 documents residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL. The policy documents residents will be provided care, treatment, and services to ensure their ADL's do not diminish. The facility policy Behavior programs and toileting plans for urinary incontinence dated, revised October 2010 documents to review the resident's care plan to assess for any special needs of the resident and to provide treatment and services to address factors that are potentially modifiable. For example, providing adaptive equipment for residents with mobility problems.

Based on observation, interview and record review, the facility failed to supply a sufficient number of staff, Certified Nursing Assistants, (CNA), to care for the residents. This failure has the potential to affect all 53 residents residing in the facility. Findings include: On 9/20/23 at 10:15 AM, R5 stated, she must wait 45-50 minutes for her call light to be answered. R5 stated, this happens on day shift all the time. R5 stated, she is continent of her bladder & bowels, but because she must wait, she goes on herself. R5 stated, now she has resorted to screaming out for help so that someone will help her. R5 stated, she uses the bed pan and needs help getting on it. R5 stated, she feels humiliated and angry when she goes on herself. R5 stated, they need more CNAs. R5 stated, she doesn't blame the CNAs or Nurses, because they cut the number of staff due to census. R5 stated, they only have 1 CNA on the 100-hall, 2 on the 300-hall and a floater. R5 stated, the floater is assigned to help on all the halls and go to the 200-hall as needed. R5 stated, 9 times out of 10, that CNA is busy on the 300-hall. R5 stated, she is here due to Terminal Cancer, and she has been to the facility before and wanted to come back here, because it was home. R5 stated, the CNAs are willing to help, but there's just not enough to care for her in a timely manner. R5's Minimum Data Set, (MDS), dated [DATE], documents, R5 is cognitively intact. On 9/21/23 at 8:45 AM, R9 stated, they need more CNAs on 1st and 2nd shift. R9 stated, occasionally it takes longer to get care, because they need more help. R9's MDS, dated , 9/18/23, documents, R9 is cognitively intact. On 9/21/23 at 8:50 AM, R6 stated, they need more CNAs, when they're short staffed it takes more time to get help and it takes longer for his call light to be answered. R6's MDS, dated [DATE], documents, R6 is cognitively intact. On 9/21/23 at 9:15 AM, V8, CNA, they started this morning with only 3 CNAs and then pulled a CNA that works in Dietary to come and work the floor. V8 stated, they need more CNAs on all shifts. V8 stated, the residents aren't getting the care they should, because they have too many residents and not enough CNAs. V8 stated, she believes they have applications and hired one that started on nights last night and she trained one on days for 2 days, she was off and when she came back, the new CNA had a circle around her name on the schedule, so she is not sure if she called off or quit. V8 stated, staff have voiced to Management about the need for more CNAs, but it hasn't happened. On 9/21/23 at 1:00 PM, V11, Licensed Practical Nurse, (LPN), stated, they need more CNAs on all shifts. V11 stated, they can't give the proper care that is needed due to staffing. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, staffing hasn't been bad, but she hopes it gets better. V2 stated, they are recruiting and V1, Administrator, has went to different hiring events. V2 stated, they just placed open positions on a hiring website and had around 15 applicants that they have called. On 9/21/23 at 2:25 PM, V13, Registered Nurse, (RN), stated, they need more CNAs, and because of this they are slower to answer the call lights. On 9/21/23 at 2:35 PM, V14, CNA, stated, there isn't enough staff, but that is all around, and they do the best they can to make sure the residents are taken care of. On 9/21/23 at 2:40 PM, V15, CNA, stated, they need more CNAs. V15 stated, this evening they only have 2 CNAs, and the DON is supposed to be staying over to help. V15 stated, this happens all the time so it's hard to give quality care to the residents. V15 stated, she's not sure what the facility is doing to get more staff. On 9/22/23 at 8:40 AM, V9, CNA, stated, they need more CNAs, it makes it harder to get showers done. On 9/22/23 at 8:45 AM, V16, LPN, stated, they need more CNAs, because of the staffing it makes it harder to give showers, timely care, and answer call lights. On 9/20/23 at 1:00 PM, there were 4 CNAs observed in the building working, 1 on 100-hall, 2 on 300-hall and 1 mainly on 300-hall but going over to 200-hall to answer call lights. On 9/21/23 at 9:10 AM, there were 4 CNAs observed working in the facility, 2 on 300-hall, 1 on 100-hall and 1 on 200-hall. On 9/21/23 at 2:30 PM, there were 2 CNAs observed working in the facility. V2, DON, was observed in the dining room assisting with the ice cream social. The Reporting Direct Care Staffing Information Policy, dated 8/2022, documents, direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The Resident Census and Conditions of Residents form dated 9/20/23, documents, there are 53 residents residing in the facility.

Based on interview, and record review, the facility failed to identify, continued weight loss in 2 of 4 residents (R6, R8) reviewed for weight loss in the sample of 12. Findings include: 1. R6's Face Sheet, undated, documents, R6 has an admitting diagnosis of Chronic Obstructive Pulmonary Disease. R6's Minimum Data Set, (MDS), dated [DATE], documents, R6 is cognitively intact and is independent with eating. R6's weights document the following: 3/21/23 - 174 lbs., (pounds), 6/21/23 - 152.4 lbs.; 8/23/23 - 149.3 lbs.; 9/20/23 - 140.6 lbs. - significant loss in 6 months, 3 months, and 30 days. R6's Physician Order Sheet, (POS), documents, an order dated 7/18/23 for a Regular Diet. R6's Progress Note, dated 7/6/23, documents, R6 is at 149 lbs. and is stable for 2 months after unusual loss. Med pass supplement was discontinued, due to resident refusal. Recommend to remove no concentrated sweets restriction from diet order and will continue to monitor for stable weight pattern or gain. There is no other documentation identified in R6's Progress Notes of R6's continued weight loss. On 9/21/23 at 8:50 AM, R6 stated, he started losing weight before he came to the facility, because he couldn't cook for himself any longer, so he started eating microwave food. R6 stated, since he's been at the facility, he's been eating better, but is still losing weight. 2. R8's Face Sheet, undated, documents, R8 has a diagnosis of Dementia. R8's MDS, dated [DATE], documents, R8 has severe cognitive impairment and is independent with eating. R8's weights document the following: 3/7/23 - 120 lbs.; 6/7/23 - 116 lbs.; 8/1/23 - 111.4 lbs.; 9/1/23 - 105.3 lbs. - Significant weight loss in 6 months, 3 months, and 30 days. R8's POS, documents, an order dated, 3/31/21 for a no added salt, Mechanical Soft Diet and 9/16/22 Med pass 60 milliliters, (ml), every morning and at bedtime for weight loss. R8's Progress Note, dated 7/6/2023, documents, R8 is at 111.8 lbs. with 5 lb. loss over 6 months. Recommended weight is 95-115 lbs. Diet is Mechanical Soft no added salt with 60 ml Med Pass Supplement twice daily. Would change supplement to 90 ml BID. Will monitor for stable weight pattern and adequate intake. There is no other documentation identified in R8's Progress Notes of R8's continued weight loss. On 9/21/23 at 1:00 PM, V11, Licensed Practical Nurse, (LPN), stated, the Nurses are the ones that put the weights in the computer, so they know if a resident has a weight loss or gain, and if so, they notify their Doctor and document it in the Nurse's Notes. On 9/21/23 at 1:10 PM, V12, Dietary Manager, stated, they get the information for the diet cards from the Physician Orders. V12 stated, they have Care Plan Meetings every week and she is notified if a resident has a weight loss in those meetings. Stated if they've had a weight loss, they have Nutritional Drinks they can give them to help them gain weight. V12 stated, she just recently took over the Dietary Manager position and has not met the Dietician yet. V12 stated, she is not sure if they review the residents monthly or quarterly or if they are notified of weight losses/gains. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, she hasn't received any Dietary recommendations from the Dietician yet. V2 stated, the Dietician does not come to the building, she reviews the resident's information remotely and she isn't sure who they review monthly or quarterly. The Weighing and Measure the Resident Policy, dated 3/2011, documents, the purpose of this procedure is to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident.

Based on interview, observation and record review, the facility failed to honor a resident's rights in 1 of 7 residents (R5) reviewed for resident rights in the sample of 12. Findings include: On 9/20/23 at 10:15 AM, R5 was observed in bed and was tearful. R5 stated, she must wait 45-50 minutes for her call light to be answered. R5 stated, this happens on day shift all the time. R5 stated, she is continent of her bladder & bowels but because she must wait, she goes on herself. R5 stated, now she has resorted to screaming out for help, so that someone will help her. R5 stated, she uses the bed pan and needs help getting on it. R5 stated, she feels humiliated and angry when she goes on herself. R5 stated, she has asked to talk to V1, Administrator, about her concerns. R5 stated, V1 came to her room this morning and told her she needed to talk with her this morning, because she would be out of the building this afternoon, and then she stated she would be back to talk with her. R5 stated, V1 has not returned to her room. R5 stated, she is here due to Terminal Cancer, and she has been to the facility before and wanted to come back here, because it was home. R5 stated, the Doctors gave her 2 months to 1 year to live, and she wants to have a good quality of life. R5 stated, she talked to V3, Registered Nurse, (RN), Infection Control Preventionist, (ICP), and V6, Minimum Data Set, (MDS), Nurse and V6 told her she had a Care Plan meeting on 11/3/23 and she needed to notify the person in charge of what issues she is having. R5 stated, she talked with V7, Social Services Director, (SSD), that she was having issues getting staff to put her on the bed pan and a lack of communication with V1. R5 stated, this is her home, she was welcomed by the prior Administrator, Director of Nurse, (DON), and staff, but they don't have enough staff now. R5 stated, the staff are wonderful to her and it's not their fault, they need more help. R5's Face Sheet, undated, documents, R5 has a diagnosis of Malignant Neoplasm of the Pancreas. R5's MDS, dated [DATE], documents, R5 is cognitively intact and is occasionally incontinent of urine and bowels. R5's Care Plan, dated 8/8/23, documents, R5 has bladder incontinence and utilizes incontinence briefs and to change as needed. The Resident Rights Policy, undated, documents, it is the policy of the facility that all residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. On 9/21/23 at 1:15 PM, V2, DON, stated, she would expect staff to respect the resident's rights.

Based on interview, observation and record review, the facility failed to provide a Therapeutic Diet as ordered by the Physician in 1 of 4 residents (R11) reviewed for Therapeutic Diets in the sample of 12. Findings include: On 9/20/23 at 12:05 PM, R11 was observed in the dining room eating lunch. R11 was eating a Regular cheese sandwich and cheese puffs, the meal was not Pureed as per orders. R11's drinks were Regular Consistency and not Nectar Thick as ordered. On 9/21/23 at 12:15 PM, R11 was observed in the dining room. R11 was served and was eating a cheese sandwich, mashed potatoes with gravy and pumpkin pie. R11's drinks were regular consistency. R11 was not served a Pureed Diet or nectar thick liquids as ordered. R11's Face Sheet, undated, documents, R11 has a diagnosis of Dysphagia, Oropharyngeal Phase. R11's Minimum Data Set, (MDS), dated [DATE], documents, R11 has severe cognitive impairment, is independent with eating and is on a Mechanically Altered Diet. R11's Care Plan, dated 3/22/21, documents, R11 is at risk of choking. R11's Physician Order Sheet, (POS), documents, an order dated 8/4/22, for a Regular Diet, Pureed Texture, and Nectar Consistency Liquids. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, she would expect the residents to be served the Diet Ordered by the Physician.

Based on interview and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 6 residents (R41, R206) reviewed for abuse in the sample of 23. This failure resulted in R41 being sexually fondled by R206 without her ability to consent and based upon a reasonable person approach this would have caused feelings of violation, anxiety, fear, humiliation, and anger. Findings include: R41's Resident Information Sheet documents R41 has diagnoses of unspecified dementia and anxiety disorder. R41's Minimum Data Set (MDS) dated [DATE] documents a Brief interview of mental status score of 00, which indicates severe cognitive impairment. R206's MDS dated [DATE] documents a brief interview of mental status score of 15, which indicates R206 is cognitively intact. R206's Care Plan Focus, with initiation date of 3/3/22, documents The resident has a behavior problem. The Care Plan Intervention, initiation date of 4/25/22, documented Resident has had multiple incidents of inappropriate touching of female staff. The Facility's Resident Abuse Investigation Report regarding R41 and R206 documented a sexual abuse incident occurred on 5/31/22 at 10:45 PM at the nurse's station which was witnessed by V4, Licensed Practical Nurse (LPN). The Report documented V4 walked around nurse's station and found R206 with his hand under R41's shirt fondling R41's breast. R41's Progress Note dated 5/31/2022 at 10:45 PM documented Walked around nurses' station to find male resident fondling res. (resident) breast. Male res. redirected and sent to room. Will inform Day shift nurse to inform proper persons. R41's Progress Note dated 6/1/2022 at 6:50 AM documents Heard residents talking walked around nurses' station and found resident with his hand in female resident's shirt fondling her breast, redirected resident, and sent resident to his room. Message sent for DON (Director of Nursing) to call. R206's Progress Notes dated 5/31/2022 at 10:45 PM documents Walked around nurses station found res. with his hand inside a female residents shirt fondling her breast, res. redirected and sent to his room. On 12/14/22 at 9:39 AM, V2, Director of Nursing (DON) stated on 5/31/2022 at 10:45 PM an abuse allegation occurred between R41 and R206, and V2 was notified at 6:30 AM on 6/1/2022 of this abuse allegation. V2 states that V4, Licensed Practical Nurse (LPN) was the employee who witnessed the sexual abuse on 5/31/2022 at 10:45 PM between R41 and R206. V2 states that R206 had multiple sexual behaviors with staff prior to this occurrence and that R206 has had multiple medication changes to decrease this behavior. V2 states she is not aware of what R206 stated to R41. V2 states she did not ask V4 what R206 said to R41. V2 stated that V4 was an agency nurse and no longer works at the facility. The Facility's Abuse, Prevention and Prohibition Policy, revised November 2018, documents the Statement of Intent as Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends, or other individuals.

Based on interview and record review, the facility failed to provide resident centered medical management including monitoring and evaluation of residents' responses to psychotropic medications and failed to limit use of as needed (PRN) psychotropic medications without physician justification to 14 days for 4 of 5 residents (R13, R35, R38, R47) reviewed for psychotropic medications in the sample of 23. Finding include: R47's Admission Profile, print date of 12/14/22, documents that R47 was admitted on [DATE] with diagnoses of Alzheimer's Disease with Late Onset, Psychotic Disorder with Delusions, Anxiety, Major Depressive Disorder and Dementia. R47's Care Plan Focus, created on 9/16/21, documents The resident has a behavior problem. The Care Plan Focus does not document what the behaviors R47 specifically displays. The Care Plan Interventions documented Administer antipsychotic mediations as ordered. Monitor/document for side effects and effectiveness. The Intervention, initiated date of 9/16/21, documented Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons, involved and situation. Document behavior and potential causes. R47's Care Plan Focus, with revisions on 6/22/21, documents I have dx of depression. I reported feeling down and having trouble sleeping. The Interventions document Bupropion as ordered. Caregivers to closely observe for increased suicidal thinking and behavior as well as hostility, agitation, and depressed mood and to contact health care provider immediately should these occur. The Interventions continued to Monitor/document/report to MD prn ongoing s/sx (signs/symptoms) of depression, unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg (negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/ appetite, fear of being alone or with other, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. The Care Plan documents Administered medications as ordered, monitor/document for side effects and effectiveness. R47's Order Summary Report, print date of 12/14/22, documents, Escitalopram Oxalate Tablet 10 MG (milligram). Give 1 tablet by mouth one time a day for Depression with start date of 6/23/22. The Report documents Seroquel Tablet 50 MG. Give 100 mg by mouth at bedtime for dementia with psychosis with start date of 5/18/22. The Report documents Wellbutrin XL Tablet Extended Release 24 Hour 300 MG. Give 1 tablet by mouth one time a day related to Anxiety Disorder, Major Depressive Disorder with start date of 10/1/21. The Report documents Xanax Tablet 0.25 mg by mouth every 8 hours as needed for anxiety. Start date of 1/3/22. R47's Medication Administration Record (MAR), dated 12/2022, documents that R47 has been given 8 doses of the as needed Xanax from 12/1 through 12/12/22. R47's Electronic Medical Record does not document how the facility is documenting/monitoring R47's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. On 12/14/22 at 2:25 PM, V2, Director of Nurses (DON), stated, We do not have resident or drug specific behavior tracking. 2. R13's Admission Record, print date of 12/14/22, documents that R13 was admitted on [DATE] and has diagnoses of Dementia with other behavioral disturbance, anxiety, Depression and Anxiety. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 0.25 mg by mouth in the afternoon for anxiety with start date of 7/13/22. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 0.25 mg by mouth in the morning for anxiety with start dated of 7/1/22. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 1mg by mouth in the evening related to Unspecified Dementia with behavioral disturbance with start date of 11/22/22. R13's Order Summary Report, dated 12/14/22, documents, Amitriptyline HCL Tablet 50 MG. Give 1 tablet by mouth at bedtime related to Depression with start date of 1/28/22. R13's Order Summary Report, dated 12/14/22, documents, Bupropion HCL ER (XL) Tablet Extended Release 24-hour 300 mg. Give 1 tablet by mouth in the morning related to Depression with start date of 1/29/22. R13's Order Summary Report, dated 12/14/22, documents, Duloxetine HCL Capsule Delayed Release Sprinkle 60 mg with start date of 1/29/22. R13's Order Summary Report, dated 12/14/22, documents, Quetiapine Fumarate Tablet 50 mg. Give 50 mg by mouth two times a day for increased agitation with start date of 7/6/22. R13's Care Plan Focus, initiation date of 2/4/22, documents that R13 has actual/potential for verbally and physically aggressive behavior problem related to dementia with behavior disturbances. The Focus documents R13 has diagnoses of anxiety and depression. The Care Plan focus documents that R13 has been noted to be verbally and physically aggressive with others. R13's Care Plan Intervention, initiated on 11/25/22, document Administer medications as ordered. Monitor/document for side effects and effectiveness.' R13's Care Plan Intervention, initiated on 11/25/22 documents Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations, document behavior and potential causes. R13's Electronic Medical Record does not document how the facility is documenting/monitoring R13's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. 3. R35's Admission Record, print date of 12/14/22, documents that R35 was admitted on [DATE] with a diagnosis of Major Depressive Disorder. R35's Order Summary Report, dated 12/14/22, documents, Lexapro Tablet 10 MG (milligram) (Escitalopram Oxalate). Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE with start date of 4/2/21. R35's Care Plan Focus, initiated on 10/6/20, documents I have a dx (diagnosis) of depression. The Care Plan Intervention, initiated on 10/6/20, documented Care Management Committee will review my medication quarterly and sooner as needed to address effectiveness and possible GDR (gradual dose reduction). R35's Care Plan Intervention, initiated on 10/6/20, documents Administer Lexapro as ordered. Monitor/document for side effects and effectiveness. Black Box Warning. R35's Electronic Medical Record does not document how the facility is documenting/monitoring R35's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. 42636 R38's Face Sheet, undated, documents R38 has a diagnoses of Vascular Dementia, Major Depressive Disorder and Anxiety Disorder. R38's Care Plan, dated 3/30/33, documents R38 has anxiety with an intervention to monitor/document side effects and effectiveness. The care plan goes on to state that R38 has Depression with an intervention to monitor/document as needed any ongoing signs or symptoms of depression: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. R38's Medication Administration Record (MAR), documents orders for the following: 9/2/22 - Alprazolam 0.5mg at bedtime; 9/2/22 - Alprazolam 0.25mg every 24 hours as needed for anxiety and 8/17/22 - Lexapro 10mg daily for Major Depressive Disorder. R38's MAR has no documentation that the facility is monitoring the side effects, effectiveness or signs or symptoms of depression. R38's Electronic Medical Record does not document how the facility is documenting/monitoring R38's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. On 12/19/22 at 11:10 AM, V2, Director of Nurses, stated that she was unaware the residents that are on psychotropics need behavior tracking for the medications and their specific behaviors. The Facility's Psychotropic Medication Use Policy, reviewed 2/2021, documents The staff will observe, document, regarding the effectiveness of any interventions, including psychotropic medications.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 of 13 residents (R41 and R206) reviewed for abuse investigations in the sample of 23. Findings include: R41's Progress Note dated 5/31/2022 10:45 PM documents Walked around nurses' station to find male resident fondling res. breast. Male res. redirected and sent to room. Will inform Day shift nurse to inform proper persons. R206's Progress Notes dated 5/31/2022 at 10:45 PM documents Walked around nurses station found res. with his hand inside a female residents shirt fondling her breast, res. redirected and sent to his room. R41's and R206's Resident Abuse Investigation Report, with date of investigation completed as 6/6/22, contains documentation of interview with V4, Licensed Practical Nurse who witnessed R206 fondling R41's breast. The Investigation Report contains no documentation that R206 was interviewed regarding this incident although R206 is cognitively intact and the perpetrator. There are no documentation other residents were interviewed, or other staff were interviewed regarding this incident. On 12/14/22 at 9:39 AM V2, Director of Nursing (DON) states on 5/31/2022 at 10:45 PM there was an abuse situation which occurred between R41 and R206, and she was notified at 6:30 AM on 6/1/2022 of abuse allegation. V2 states that V4 was the employee who witnessed the occurrence on 5/31/2022 at 10:45 PM between R41 and R206, and that V4 was educated on notifying V1 and V2 immediately of abuse allegation. V2 states all employees were re-in serviced on immediate notification of abuse allegations. V2 states that an interview was conducted with R206 by the Social Service director who is no longer employed at the facility, and they do not have documentation of that interview with R206. V2 states she is not aware of what R206 stated to R41. V2 states she did not ask V4 what R206 said to R41. V2 states she does not have any documentation that she spoke to other residents. V2 states she does not have any documentation that she spoke to other staff members working during the occurrence on 5/31/2022. V2 states she does not have any documented interviews with R206 and R41 is not interviewable. Facility abuse prevention and prohibitions policy, Revision date November 2018, page 3 titled investigation documents Every employee will be interviewed who was working on the specific hall/wing the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete as statement if indicated.

Based on interview and record review, the facility failed to provide supervision to prevent falls, investigate falls and to identify causal factors for 2of 7 residents (R20 and R260 and failed to serve drinks at proper temperatures to prevent [CONDITION(S)] for 1 of 7 residents (R3) reviewed for accidents in the sample of 49. This failure resulted in R20 falling, sustaining a second fracture to the right hip, in the same location that was previously surgically repaired, and requiring hospitalization . Findings include: 1. R20's Face sheet, dated 11/17/21, documents, an admission on 5/5/2021 for skilled treatment/therapy following a right hip fracture post surgery. R20s's Minimum Data Set (MDS), dated [DATE], documented, R20 has no recall to the year, month, day, unable to repeat words, requires extensive assistance with toileting due to urinary incontinence and requires stabilization of staff with transfers. R20's, Fall Risk Data Collection, dated 5/5/21, documented R20 at risk for falls and oriented to self only. R20's Care Plan, initiated date of 5/5/21, documented, I am at risk for falls d/t (due to) a right hip fx. (fracture) and poor safety awareness. Fall Interventions put in place on 5/5/21: 1. Care givers are to make sure that all of my wants and needs are met before leaving room. 2. Low bed, mat placed at bedside. 3. Make sure the bed is always locked, also a fall star located outside of residents entry door. The facility's Fall Incident Report, documented R20's fall history that occurred on; 5/5/21, 5/7/21, 6/19/21, 6/28/21, 7/2/21 and 7/21/21. R20's Fall Incident Report, dated 5/5/21, documented, R20 found on the floor in room, lying on stomach, with no injuries noted. R20's Fall Incident Report, dated 5/7/21, documented, R20 ws found on the floor, in room, in front of a wardrobe. Right hip rotated, R20 states that right hip hurts and hit head on the wardrobe table. R20 was transferred to a local emergency department for medical evaluation. No injuries reported. R20's Progress Note, dated 5/8/21 at 11:22AM, documented, R20 is alert but forgetful. R20's Progress Note, (Daily Skilled Nurse Note), dated 5/28/21 at 8:55PM, documented, R20 is confused, has short and long term memory problems with decision making impaired. R20's Progress Note, dated 6/17/21 at 4:52AM, documented, R20 has not been sleeping all night. R20's Progress Note, dated 6/18/21 at 5:09AM, documented, R20 has been restless throughout the night. Attempted to transfer self, unable to be redirected at times and has had some confusion. R20's Fall incident Report, dated 6/19/21, documented R20 was sitting in wheelchair in front of the nurse's station and at 8:00AM, attempted to stand up from chair, unassisted. fell , lying on the floor on right side and with wheelchair on top of R20. This event was unwitnessed. When (R20) is restless, staff are to be 1 on 1 with resident and make sure staff is in reach when up in wheelchair. admitted to a local hospital on 6/21/21, sustaining a right hip fracture to the same right hip, previously surgically repaired prior to admission. R20's Regional hospital documentation, dated 6/22/21, documented a date of service of 6/19/21, with present medical history of; Periprosthetic fracture around internal prosthetic right hip joint and R20, who had sustained a fall at the nursing home and recently had a hemiarthoplasty of the right hip in May. (hip fracture with surgical hardware and re-fractured around the hip socket surgical hardware, due to fall of 6/19/21). On 11/17/21 at 3:00PM, V1, Administrator, stated she would have expected staff to be visibly present when R20 is at the nursing station. On 11/18/21 at 4:55PM, V21, R20's Physician, stated R20 probably should have been supervised by staff , if left unattended, in a wheelchair, at the nursing station. The facility's Fall Policy, dated as reviewed 9/17/19, documented, The facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety. 2. R3's Facility Reported Investigation (FRI) dated 11/7/21 documents, Initial Report on incident documents, During breakfast, (R3) was observed spilling hot tea on right side. She was taken to her room and assessed. There was some redness to right abdomen and thigh. A cool compress was applied at that time and she denied any pain. Her POA (power of attorney) and MD (medical doctor) were notified. Later, the evening nurse noted a broken blister on right abdomen and one on right thigh. [MEDICATION(S)] was applied at that time and nurses to monitor the areas daily and as needed. Both areas are healing well at this time. R3's Final report, not dated, documents, Final report, An investigation was started immediately. Investigation was completed and all kitchen staff were in-serviced on the Serving Hot Beverages and Soup policy in place. They each expressed understanding of the policy and a copy has been hung up in the kitchen, So they have easy access to it, if they have any questions. The IDT (interdisciplinary team) met and agreed that all new hires will be in-serviced on this policy on their initial orientation and the dietary manager and Administrator will do periodic audits to make sure staff are in compliance with this policy. Nursing continues to apply silvadine and a dressing to the areas, until completely healed. See attached policy and in-service. R3's Physician Order Sheet dated 11/14/2021 documents, Change right lower quadrant (RLQ) and Right upper leg dressing daily. Cleanse burn wound apply [MEDICATION(S)], and nonadherent dressing, one time a day for burn. On 11/17/21 at 2:50 PM, V13, Dietary worker, stated, I did not check the temp of the tea the day (R3) spilled tea and was burned. The tea is brewed in the coffee machines. On 11/18/21 at 11:05 AM, V2, Director of Nurses (DON), stated, I would expect dietary staff to check the temperatures of food and drinks before serving to the residents. The facility Policy and Procedure for Serving Hot Beverages and Soup dated July 2007 documents , Policy: The Food Service Department will monitor the temperature of all hot liquids being prepared to ensure that hot liquids are served at a temperature that will prevent [CONDITION(S)] if they should come into contact with skin. Procedure: 1. The Food Service Manager will monitor temperature that coffee is brewed at. 2. Drip coffee machines need to be at least 180 degrees F to brew coffee. However, many coffee machines are turned up to 195 degrees F or greater. Please test the temperature at which the coffee is being brewed and contact the coffee machine owners for instructions on how to turn the temperature down to 180 F. 3. The coffee should be chilled to 120-130 degrees (118-124 degrees was hand-written on the policy) before being served to residents. 4. The Food Service Department is responsible for ensuring that all hot beverages leave the kitchen at the proper temperature. This includes hot beverages for activities. 3. R26's health status note dated 9/15/2021 at 02:19pm documents that R26 had a fall at 1:30 AM. R26's note documents R26 appears to have hurt right shoulder or arm, it was protruding at an awkward angle. Sent to the hospital. R26's health status note dated 9 /15/2021 at 08:42 pm documents that R26 returned from hospital ER (emergency room ) at this time by ambulance. Sling in place on RUE (right upper extremity) d/t (due to) humerus (upper arm bone) fracture. R26's note documents that R26 denies pain upon arrival. R26's note does document that R26 did return to the facility with orders for pain medication. The facility long term care initial report to the Department dated 9/15/2021 documents alert resident found lying on the floor in room next to bed and stated fell and hurt arm. R26 assessed and complaining of right shoulder pain. Report documents area assessed and noted abnormal positioning of upper arm/shoulder. Form documents returned to the facility with sling to right arm and diagnosis of proximal right humerus fracture. The facility serious injury final report to the Department dated 9/23/2021 documents that R26 was found unresponsive and sent back to the hospital on 9/16/2021 and admitted for severe [CONDITION(S)]. The report documents upon admission R26 was found to have a displaced right femur (thigh bone) fracture. On 11/18/21 08:20 AM, V1, Administrator, stated when R26 had initial fall was sent to local hospital and diagnosed with fractured proximal humerus which V1 stated documented on initial report. V1 stated R26 had an unresponsive episode, was sent to a different hospital, and was found with a non-displaced fracture of right femur. V1 stated they assume it was from the first fall. V1 stated the facility has no investigation when femur fracture identified nor was public health notified when fracture identified but sent in final report of humerus fracture. R26's CT (computerized tomography) scan report dated 9/17/2021 documents comminuted fracture of the right greater trochanter with mild to moderate displacement of the greater trochanter. and small intramuscular hematoma in the lateral right gluteus muscle. R26's hospital discharge notes dated 9/22/2021 documents weight-bearing as tolerated to RLE (right lower extremity). The facility Fall Policy dated, revised documents following any falls, the facility staff completes and occurrence Report. Details of the fall will be recorded, and potential causal factors identified and investigated. Interventions will be implemented, and Care Plan updated.