Every finding on record at Integrity HC of Herrin

Based on observation, interview, and record review the facility failed to assist a resident with incontinence care in a timely manner to promote dignity for 1 of 10 residents (R1) reviewed for dignity in a sample of 10. Findings include:R1's admission Record documents an admission date of 2/15/22 with diagnoses including in part: paranoid schizophrenia, post traumatic seizures, insomnia, anxiety disorder, essential tremor, and personal history of traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is rarely/never understood. The same MDS documents R1 is dependent with toileting hygiene, the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. R1's current Care Plan documents R1 is at risk for impaired skin integrity related to impaired cognition and R1 is known to refuse incontinence care at times. On 9/11/25 at 8:15 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 at 8:43 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 starting at 9:15 AM, R1 was under constant observation by surveyor that lasted until 11:51 AM. On 9/11/25 at 9:15 AM, R1 was sitting on the couch in the dining room with his legs crossed, and his pants were visibly wet in the front left groin area. On 9/11/25 at 9:28 AM, R1 uncrossed his legs and there was a large wet circle on the front of R1's pants. On 9/11/25 at 9:33 AM, V5 (Certified Nursing Assistant/CNA) was walking a resident through the dining room and walked in front of R1 while he was sitting on the couch watching TV. V5 said, Good morning to R1 then R1 responded with a smile and a wave. R1's pants were still visibly wet. On 9/11/25 at 10:28 AM, R1 was still sitting on the couch watching the television with visibly soiled pants. V6 (Activities Assistant) went to R1 with a cart of snacks and drinks and offered R1 a snack and drink. R1 was pointing at the cart and V6 was trying to figure out what he was pointing at. V6 finally figured out he was pointing at the ice that snacks were sitting in. On 9/11/25 at 10:49 AM, V8 (CNA) walked by R1 while he was sitting on the couch, R1 still had visibly soiled pants. V8 did not look at R1. On 9/11/25 at 10:50 AM, V2 (Director of Nursing/DON) walked by R1 while he was sitting on the couch, still had visibly soiled pants. V2 did not look at R1. On 9/11/25 at 10:56 AM, V7 (CNA Supervisor) walked by R1 and didn't look at R1. R1 was still visibly wet. On 9/11/25 at 10:59 AM, V9 (CNA) walked by R1 and didn't look at him. R1 was still visibly wet. On 9/11/25 at 11:00 AM, V8 (CNA) walked by R1 to the resident sitting 2 down from him and took his vital signs. R1 was still visibly wet. On 9/11/25 at 11:03 AM, R1 stood up with visibly wet pants and walked to the door to the back patio area for smoke break. R1 sat down on a bench in the smoking area. On 9/11/25 at 11:05 AM, V10 (Housekeeping) lit R1's cigarette and sat outside with R1 and other residents while they smoked. R1 still had visibly wet pants. On 9/11/25 at 11:16 AM, V10 walked R1 back into the building after he finished smoking. R1's pants were still visibly wet. On 9/11/25 at 11:17 AM, R1 was sitting on the couch and still had visibly wet pants. V7 walked R1 to the scale in the dining room and weighed him. V7 then asked R1 if he wanted to take a shower. R1 did not respond and walked back to the couch in the dinner room to watch the television. On 9/11/25 at 11:24 AM, V8 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:25 AM, V7 asked R1 if he wanted to go take a shower and R1 held his pointer finger up at V7. V7 responded with, 1 hour and R1 shook his head yes. R1's pants were still visibly wet. On 9/11/25 at 11:36 AM, V8 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:39 AM, V2 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:41 AM, V6 walked up to R1 and asked him if he is ready for lunch. V1's pants were still visibly wet. On 9/11/25 at 11:46 AM, V8 was near R1, this surveyor pointed out to V8 that R1 had visibly wet pants. V8 asked R1 if she could take him to change his pants and R1 held up his pointer finger at her. V8 said they can usually get R1 to change his pants if they catch him at his smoke breaks, when he is already up off the couch. V8 stated around 8am today she asked R1 if he wanted to shower, and he told her no.On 9/11/25 at 11:50 AM, V7 come up to R1 while this surveyor and V8 were talking to him and asked him if she could take him to the shower after lunch and R1 shook his head yes. V7 stated R1 should be checked on every 2 hours and cleaned up if he is wet as soon as someone notices it. V7 stated R1 does refuse getting cleaned up at times but sometimes it just takes a new face to get him to agree to care. V7 stated if he refuses to one person then a different person should ask and sometimes, he will agree. On 9/11/25 at 1:07 PM, V7 took R1 to the shower room and shaved R1's face. Then stood R1 up and pulled his pants and depends down. R1 had redness on his buttocks and in his groin. V7 then set R1 in the shower chair in the shower room. On 9/11/25 at 2:41 PM, V5 stated she checked on R1 around 9:30 AM. V5 stated she asked him if he wanted to go to the bathroom and he said no. On 9/11/25 at 2:43 PM, V3 (Assistant Director of Nurses) stated she started her morning rounds at 8:00 AM today and when she talked to him this morning, he wasn't visibly wet. On 9/11/25 at 2:51 PM, V10 stated when she took R1 out to smoke around 11:00 AM today she did not notice he had wet pants. On 9/11/25 at 2:54 PM, V6 (Activities Assistant) stated she was over by R1 when he was sitting on the couch around 8:30 AM or 9:00 AM this morning and she smelled a strong urine smell so she asked R1 if he needed to use the bathroom and he told her no. V6 stated when she was passing snacks to R1 at 10:28 AM this morning she did not notice his pants were wet and she did not ask him if he needed to use the restroom or needed cleaned up. On 9/11/25 at 3:26 PM, V4 (Regional Director of Clinical Services) stated residents should be checked at least every 2 hours for incontinence. V4 stated he couldn't find a policy regarding how often residents should be checked for incontinence or a policy related to dignity/visibly wet pants.

Based on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 39 residents who currently reside at the facility. Findings Include: The facility Daily Census dated 6/23/25 documents there are 39 residents currently residing at the facility. 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated: 04/12/2025 . This Focus area does not include an intervention specific to bathing or toileting. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. The facility undated Shower List (Day Shift) documents R1 should receive assistance with bathing every Tuesday and Friday. R1's Skin Monitoring: Comprehensive CNA Shower Review sheets document R1 received assistance with bathing on 6/3, 6/10, and 6/17/25. This indicates R1 went 6 days between showers and was not assisted with her scheduled showers on 6/6, 6/13, and 6/20/25. On 6/24/25 at 8:09 AM, R1 stated they don't have enough staff working to do every two-hour bed checks/incontinence care. R1 stated sometimes they only have two CNAs in the facility and when they do it takes longer for them to answer the call light. R1 stated it takes up to an hour at times. R1 stated she only had three showers in the month of June due to them not having enough staff to assist her with them. 2.R2's admission Record with a print date of 6/24/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, hemiplegia, hemiparesis, heart failure, major depressive disorder, convulsions, hypertension, difficulty in walking, weakness, and need for assistance with personal care. R2's MDS dated [DATE] documents R2 has a BIMS score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus area of ADL: (R2) requires assist with daily care needs r/t impaired mobility with hemiplegia/hemiparesis to RUE/RLE (right upper extremity/right lower extremity) Date Initiated: 12/17/2024 . This Focus area includes the intervention of, .Keep clean and dry after each incontinence episode. Date Initiated 12/17/2024 . R2's Care Plan does not document any specific Focus areas or interventions related to bathing. The undated facility Shower List (Day Shift) documents R2 should receive assistance with bathing every Monday and Wednesday. R2's Skin Monitoring: Comprehensive CNA Shower Reviews document R2 received assistance with bathing on 6/2, 6/10, 6/12, 6/17, 6/19, and 6/23/25. This indicates R2 did not receive assistance with bathing as scheduled on 6/4/25. On 6/24/25 at 10:48 AM, R2 stated she gets her showers twice weekly, but she asked for them three times weekly and they told her they won't do it. R2 stated she asks the facility CNA staff to give her extra ones and they tell her they don't have time. 3. R3's facility admission Record with a print date of 6/24/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, altered mental status, atrial fibrillation, tachycardia, Parkinsonism, heart disease, abnormalities of gait and mobility, and history of falls. R3's MDS dated [DATE] documents R3 has a BIMS score of 14, which indicates R3 is cognitively intact. This same MDS documents R3 requires substantial/maximal assistance for tub/toilet transfers. R3's current Care Plan does not document a Focus area and/or interventions related to ADL including bathing and toileting. The undated facility Shower List (Day Shift) documents R3 should receive assistance with bathing every Wednesday and Saturday. R3's Skin Monitoring: Comprehensive CNA Shower Reviews document R3 received assistance with bathing on 6/4, 6/7, 6/11, 6/14, and 6/18/25. This indicates R3 did not receive assistance with bathing as scheduled on 6/21/25. On 6/24/25 at 10:58 AM, R3 stated they have enough staff but sometimes have problems keeping them. R3 stated she received showers as scheduled. R3's family member (V7) was present in the room and stated R3 doesn't always get her showers as she should. V7 stated R3 hadn't received assistance with bathing since last week. V7 stated they don't have enough staff to meet the needs of the residents timely. V7 stated some days they only have two CNAs for the facility and that is not enough. 4. R4's admission Record with a print date of 6/24/25 documents R4 was admitted on [DATE] with diagnoses that include heart disease, diabetes, hypertension, necrosis of left femur, acquired absence of left leg below the knee. R4's current Care Plan documents a Focus area of (R4) is incontinent of bowel and bladder. He requires staff assistance for transfers to the facilities and hygiene care after use of facilities or incontinence episodes. Date Initiated: 04/28/2025 This Focus area includes interventions of . Check (R4) as needed for incontinence Date Initiated: 04/28/2025 . R4's MDS dated [DATE] documents a R4 has a BIMS score of 12, which indicates R4 has a moderate cognitive deficit. On 6/24/25 at 10:55 AM, R4 stated they don't have enough staff to provide timely care. R4 stated he has had to wait a long time for assistance to go to the bathroom and has incontinent episodes while waiting. 5. R5's admission Record with a print date of 6/24/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, hemiparesis, cerebral infarct, unspecified acquired deformity of left lower leg. R5's MDS dated [DATE] documents a BIMS score of 08, indicating R5 has a moderate cognitive impairment. This same MDS documents R5 is dependent on staff for toileting and bathing. R5's current Care Plan documents a Focus area of (R5) has an ADL Self Care Performance Deficit r/t (R5) is dependent upon staff for ADL's. (R5) has Hemiplegia/hemiparesis on one side d/t (due to) recent stroke. Date Initiated: 09/20/2022 This Focus area includes interventions of, Bathing: (R5) is totally dependent on staff to provide a bath twice weekly and as necessary. Date Initiated: 09/20/2022 Toilet Use: (R5) is not toileted. Date Initiated: 09/20/2022 The undated Facility Shower List (Day Shift) documents R5 is to receive assistance with bathing every Wednesday and Saturday. R5's Skin Monitoring: Comprehensive CNA Shower Review documents R5 received assistance with bathing on 6/5, 6/7, 6/11, and 6/18/25. This indicates R5 did not receive showers as scheduled on 6/14 and 6/21/25. On 6/24/25 at 10:58 AM, R5 was lying in bed and his hair appeared greasy. R5 had difficulty answering questions but did indicate with yes/no answers the facility doesn't always have enough staff to answer his call light timely. 6. R6's admission Record with a print date of 6/24/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include epilepsy, depression, muscle weakness, abnormalities of gait and mobility, and repeated falls. R6's MDS dated [DATE] documents a BIMS score of 09, indicating R6 has a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assist for toilet transfers. R6's current Care Plan documents a Focus area of (R6) has bladder incontinence. Date Initiated: 03/16/2025 . This Focus area includes the following intervention, Establish voiding patterns. Date Initiated: 03/16/2025 This same Care Plan includes the Focus area of, (R6) has bowel incontinence. Date Initiated: 03/16/2025 . This Focus area includes the intervention, Provide peri care after each incontinent episode. Date Initiated: 03/16/2025 . On 6/24/25 at 4:40 AM, R6 stated they don't have enough staff to help on the weekends. R6 stated it takes too long to answer the call lights. R6 stated she wasn't sure how long it took but it was long enough she had an incontinent episode. 7. R7's facility admission Record with a print date of 6/24/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include morbid obesity and history of falling. R7's MDS dated [DATE] documents a BIMS score of 08, indicating R7 has a moderate cognitive deficit. This same assessment documents R7 requires substantial/maximal assistance for bathing and toilet hygiene. R7's current Care Plan documents a Focus area of (R7) is incont (incontinent) of urine at times. Date Initiated: 04/03/2025 . This Focus area includes the intervention of, Check (R7) as required for incontinence . This same Care Plan includes a Focus area of, (R7) has an ADL Self Care Performance Deficit r/t (R7) requires assist with ADL's d/t cognitive impairment and difficulty with balance Date Initiated: 04/02/2023 This Focus area includes the intervention of, Bathing: (R7) requires assistance (sic) physical assistance with bathing/showering. Date Initiated: 04/03/2023 . The undated facility Shower List (Day Shift) documents R7 should receive assistance with bathing every Wednesday and Saturday. R7's Skin Monitoring: Comprehensive CNA Shower Review documents R7 was offered and/or received assistance with bathing on 6/4, 6/5, 6/7, 6/11, 6/14, and 6/17/25. This indicates R7 was not offered and/or did not receive assistance with bathing on 6/21/25 as scheduled. On 6/24/25 at 10:44 AM, R7 was sitting at the dining room table, a strong foul body odor was noted. R7 stated they don't always have enough staff to meet her needs timely. R7 stated it takes longer to answer the call light when they don't have enough staff working. R7 stated she wasn't sure how long it took but it probably feels longer than it actually is. 8. R8's facility admission Record with a print date of 6/24/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include fracture of humerus, osteoarthritis, and malaise. R8's entry MDS dated [DATE] does not document a BIMS score or ADL assessment. R8's current Care Plan provided to this surveyor does not document a Focus area for bathing or toileting. The undated facility Shower List (Day Shift) documents R8 should receive assistance with bathing every Tuesday and Friday. R8's Skin Monitoring: Comprehensive CNA Shower Review documents R8 received assistance with bathing on 6/17, and 6/20/25. This indicates R8 did not receive assistance with bathing on 6/9 and 6/13/25 as scheduled. On 6/24/25 at 11:11 AM, R8 stated she got a shower today because she had an incontinent episode. R8 stated they don't always have enough staff, but they work very hard. R8 stated she has had incontinent episodes because she has had to wait for assistance. On 6/24/25 at 5:06 AM, V10 (CNA) stated they have approximately forty residents and they have one nurse and three CNA's working. V10 stated sometimes that is enough and sometimes it isn't. V10 stated they don't always have three CNA's. V10 stated when they had less staff, they weren't able to answer call lights timely, provide timely incontinence care, and/or give showers as scheduled. On 6/24/25 at 5:29 AM, V9 (CNA) stated she has worked night shift at the facility for about a month. V9 stated a week or so ago she was the only CNA in the facility for about three hours. V9 stated she got everyone she could to bed and waited for another CNA to come in and assist with the ones she couldn't. V9 stated one nurse and one CNA cannot meet the needs of the residents. V9 stated they have residents who require two people to transfer, bed alarms, and incontinence care. On 6/24/25 at 5:45 AM, V8 (CNA) stated this is his third shift working at the facility. V8 stated on the first day of his training the CNA training him was also training another new CNA and they were the only three CNA's working on that shift. V8 stated then his next night working he was the only CNA working from 2 AM to 3:30 AM. V8 stated he has been a CNA since 2010 but he didn't know the residents and/or the facility systems and was not comfortable working by himself. V8 stated he wasn't able to answer all of the call lights timely. On 6/24/25 at 6:08 AM, V6 (CNA) stated on 6/19 and 6/21/25 there were only two CNA's working from 6 AM to 3 PM. V6 stated they were not able to meet the needs of the residents timely. V6 stated they can't get showers done and/or call lights answered timely. V6 stated on 6/21/25 they were not able to do R3 and R5's showers. On 6/24/25 at 6:17 AM, V5 (LPN) stated they don't have enough staff to meet the needs of the residents timely. V5 stated when they only have two CNA's it is hard to get all of the scheduled showers done and provide timely incontinence care. V5 stated most of the time they have three CNAs on the schedule, but people call in or quit. On 6/24/25 at 6:25 AM, V3 (Nurse) stated they were always short staffed. V3 stated there had been some shifts were there was only one CNA, and a nurse would work the floor to help. V3 stated it takes longer for incontinence care, and that is not ok. V3 stated they do their best. On 6/24/25 at 7:09 AM, V4 (CNA) stated they don't always have enough staff to meet the needs of the residents timely. V4 stated she worked midnight shift on 6/19/25 and day shift hadn't been able to do the showers that were scheduled so she did as many of them as she could before residents went to bed for the night. On 6/24/25 at 3:29 PM, V12 (CNA) stated she had worked at the facility since 6/12/25 and they had enough staff to meet the needs of the residents timely. V12 stated she had never worked in the facility by herself, but she did come to work one day and V8 (CNA) was the only CNA, but he had only been there by himself for about an hour. V12 stated on 6/21/25 she came to work and gave showers to the residents who were scheduled. V12 stated there was only one shower she did. V12 stated the other residents refused or had already had one. When asked why the shower she gave and/or the refusals weren't documented, V12 stated she guessed she forgot to fill out the shower sheets. On 6/24/25 at 1:37 PM, V1 (Administrator) stated in a perfect world she would expect them to get all of the showers done as scheduled. When asked if two CNAs were enough to meet the needs of the residents timely, V1 stated ideally, she would want two and a half CNAs on each shift. V1 stated they also have two nurses on day shift who should help out on the floor. The facility Employee Timecards and schedules were reviewed and document on 6/21/25 there were two CNA's working from 6 AM to 3 PM and two CNA's from 6 AM to 11 AM on 6/19/21. They also document there were two CNA's working from 6 PM on 6/17/25 until 2 AM on 6/18/25 and then was only one CNA working from 2 AM until 3 AM. The Facility Assessment Tool dated 9/5/24 was reviewed and does not document any facility specific information related to staffing requirements for the facility.

Based on interview and record review the facility failed to ensure call lights were answered timely for 6 of 8 (R1, R4-R8) residents reviewed for call lights in the sample of 18. Findings Include: 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide peri care after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also documents the Focus Area of (R1) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated: 04/12/2025 . On 6/24/25 at 8:09 AM, R1 stated they don't have enough staff working to do every two-hour bed checks/incontinence care. R1 stated sometimes they only have two CNAs in the facility and when they do it takes longer for them to answer the call light. R1 stated it takes up to an hour at times. R1 stated she only had three showers in the month of June due to them not having enough staff to assist her with them. 2. R4's admission Record with a print date of 6/24/25 documents R4 was admitted on [DATE] with diagnoses that include heart disease, diabetes, hypertension, necrosis of left femur, acquired absence of left leg below the knee. R4's current Care Plan documents a Focus area of (R4) is incontinent of bowel and bladder. He requires staff assistance for transfers to the facilities and hygiene care after use of facilities or incontinence episodes. Date Initiated: 04/28/2025 This Focus area includes interventions of . Check (R4) as needed for incontinence Date Initiated: 04/28/2025 . R4's MDS dated [DATE] documents a R4 has a BIMS score of 12, which indicates R4 has a moderate cognitive deficit. On 6/24/25 at 10:55 AM, R4 stated they don't have enough staff to provide timely care. R4 stated he has to wait a long time for assistance to go to the bathroom and has incontinent episodes while waiting. 3. R5's admission Record with a print date of 6/24/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, hemiparesis, cerebral infarct, unspecified acquired deformity of left lower leg. R5's MDS dated [DATE] documents a BIMS score of 08, indicating R5 has a moderate cognitive impairment. This same MDS documents R5 is dependent on staff for toileting and bathing. R5's current Care Plan documents a Focus area of (R5) has an ADL Self Care Performance Deficit r/t (R5) is dependent upon staff for ADL's. (R5) has Hemiplegia/hemiparesis on one side d/t (due to) recent stroke. Date Initiated: 09/20/2022 This Focus area includes intervention of, Toilet Use: (R5) is not toileted. Date Initiated: 09/20/2022 On 6/24/25 at 10:58 AM, R5 had difficulty answering questions but did indicate with yes/no answers the facility doesn't always have enough staff to answer his call light timely. 4. R6's admission Record with a print date of 6/24/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include epilepsy, depression, muscle weakness, abnormalities of gait and mobility, and repeated falls. R6's MDS dated [DATE] documents a BIMS score of 09, indicating R6 has a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assist for toilet transfers. R6's current Care Plan documents a Focus area of (R6) has bladder incontinence. Date Initiated: 03/16/2025 . This Focus area includes the following intervention, Establish voiding patterns. Date Initiated: 03/16/2025 This same Care Plan includes the Focus area of, (R6) has bowel incontinence. Date Initiated: 03/16/2025 . This Focus area includes the intervention, Provide peri care after each incontinent episode. Date Initiated: 03/16/2025 . On 6/24/25 at 4:40 AM, R6 stated they don't have enough staff to help on the weekends. R6 stated it takes too long to answer the call lights. R6 stated she wasn't sure how long it took but it was long enough she had an incontinent episode. 5. R7's facility admission Record with a print date of 6/24/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include morbid obesity and history of falling. R7's MDS dated [DATE] documents a BIMS score of 08, indicating R7 has a moderate cognitive deficit. This same assessment documents R7 requires substantial/maximal assistance for bathing and toilet hygiene. R7's current Care Plan documents a Focus area of (R7) is incont (incontinent) of urine at times. Date Initiated: 04/03/2025 . This Focus area includes the intervention of, Check (R7) as required for incontinence . On 6/24/25 at 10:44 AM, R7 stated they don't always have enough staff to meet her needs timely. R7 stated it takes longer to answer the call light when they don't have enough staff working. R7 stated she wasn't sure how long it took but it probably feels longer than it actually is. 6. R8's facility admission Record with a print date of 6/24/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include fracture of humerus, osteoarthritis, and malaise. R8's entry MDS dated [DATE] does not document a BIMS score or ADL assessment. R8's current Care Plan provided to this surveyor does not document a Focus area for bathing or toileting. On 6/24/25 at 11:11 AM, R8 stated she got a shower today because she had an incontinent episode. R8 stated they don't always have enough staff, but they work very hard. R8 stated she has had incontinent episodes because she has had to wait for assistance. On 6/24/25 at 5:06 AM, V10 (CNA/Certified Nursing Assistant) stated they have approximately forty resident and they have one nurse and three CNA's working. V10 stated sometimes that is enough and sometimes it isn't. V10 stated they don't always have three CNA's. V10 stated when they had less staff, they weren't able to answer call lights timely, provide timely incontinence care, and/or give showers as scheduled. On 6/24/25 at 5:29 AM, V9 (CNA) stated she has worked night shift at the facility for about a month. V9 stated a week or so ago she was the only CNA in the facility for about three hours. V9 stated she got everyone she could to bed and waited for another CNA to come in and assist with the ones she couldn't. V9 stated one nurse and one CNA cannot meet the needs of the residents. V9 stated they have residents who require two people to transfer, bed alarms, and incontinence care. On 6/24/25 at 5:45 AM, V8 (CNA) stated this is his third shift working at the facility. V8 stated on the first day of his training the CNA training him was also training another new CNA and they were the only three CNA's working on that shift. V8 stated then his next night working he was the only CNA working from 2 AM to 3:30 AM. V8 stated he has been a CNA since 2010 but he didn't know the residents and/or the facility systems and was not comfortable working by himself. V8 stated he wasn't able to answer all of the call lights timely. On 6/24/25 at 6:08 AM, V6 (CNA) stated on 6/19/25 and 6/21/25 there were only two CNA's working from 6 AM to 3 PM. V6 stated they were not able to meet the needs of the residents timely. V6 stated they can't get showers done and/or call lights answered timely. On 6/24/25 at 6:17 AM, V5 (LPN/Licensed Practical Nurse) stated they don't have enough staff to meet the needs of the residents timely. V5 stated when they only have two CNA's it is hard to get all of the scheduled showers done and provide timely incontinence care. V5 stated most of the time they have three CNAs on the schedule, but people call in or quit. On 6/24/25 at 1:37 PM, V1 (Administrator) stated in a perfect world she would expect them to get all of the showers done as scheduled. When asked if two CNAs were enough to meet the needs of the residents timely, V1 stated ideally, she would want two and a half CNAs on each shift. V1 stated they also have two nurses on day shift who should help out on the floor.

Based on observation, interview, and record review the facility failed to provide timely assistance with activities of daily living (ADL's) for 8 of 8 (R1-R8) reviewed for ADLs in the sample of 18. Findings Include: 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated: 04/12/2025 . This Focus area does not include an intervention specific to bathing or toileting. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. The facility undated Shower List (Day Shift) documents R1 should receive assistance with bathing every Tuesday and Friday. R1's Skin Monitoring: Comprehensive CNA Shower Review sheets document R1 received assistance with bathing on 6/3, 6/10, and 6/17/25. This indicates R1 went 6 days between showers and was not assisted with her scheduled showers on 6/6, 6/13, and 6/20/25. On 6/24/25 at 8:09 AM, R1 stated they don't have enough staff working to do every two-hour bed checks/incontinence care. R1 stated sometimes they only have two CNAs in the facility and when they do it takes longer for them to answer the call light. R1 stated it takes up to an hour at times. R1 stated she only had three showers in the month of June due to them not having enough staff to assist her with them. 2.R2's admission Record with a print date of 6/24/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, hemiplegia, hemiparesis, heart failure, major depressive disorder, convulsions, hypertension, difficulty in walking, weakness, and need for assistance with personal care. R2's MDS dated [DATE] documents R2 has a BIMS score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus area of ADL: (R2) requires assist with daily care needs r/t impaired mobility with hemiplegia/hemiparesis to RUE/RLE (right upper extremity/right lower extremity) Date Initiated: 12/17/2024 . This Focus area includes the intervention of, .Keep clean and dry after each incontinence episode. Date Initiated 12/17/2024 . R2's Care Plan does not document any specific Focus areas or interventions related to bathing. The undated facility Shower List (Day Shift) documents R2 should receive assistance with bathing every Monday and Wednesday. R2's Skin Monitoring: Comprehensive CNA Shower Reviews document R2 received assistance with bathing on 6/2, 6/10, 6/12, 6/17, 6/19, and 6/23/25. This indicates R2 did not receive assistance with bathing as scheduled on 6/4/25. On 6/24/25 at 10:48 AM, R2 stated she gets her showers twice weekly, but she asked for them three times weekly and they told her they won't do it. R2 stated she asks the facility CNA staff to give her extra ones and they tell her they don't have time. 3. R3's facility admission Record with a print date of 6/24/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, altered mental status, atrial fibrillation, tachycardia, Parkinsonism, heart disease, abnormalities of gait and mobility, and history of falls. R3's MDS dated [DATE] documents R3 has a BIMS score of 14, which indicates R3 is cognitively intact. This same MDS documents R3 requires substantial/maximal assistance for tub/toilet transfers. R3's current Care Plan does not document a Focus area and/or interventions related to ADL care including bathing and toileting. The undated facility Shower List (Day Shift) documents R3 should receive assistance with bathing every Wednesday and Saturday. R3's Skin Monitoring: Comprehensive CNA Shower Reviews document R3 received assistance with bathing on 6/4, 6/7, 6/11, 6/14, and 6/18/25. This indicates R3 did not receive assistance with bathing as scheduled on 6/21/25. On 6/24/25 at 10:58 AM, R3 stated they have enough staff but sometimes have problems keeping them. R3 stated she received showers as scheduled. R3's family member (V7) was present in the room and stated R3 doesn't always get her showers as she should. V7 stated R3 hadn't received assistance with bathing since last week. V7 stated they don't have enough staff to meet the needs of the residents timely. V7 stated some days they only have two CNAs for the facility and that is not enough. 4. R4's admission Record with a print date of 6/24/25 documents R4 was admitted on [DATE] with diagnoses that include heart disease, diabetes, hypertension, necrosis of left femur, acquired absence of left leg below the knee. R4's current Care Plan documents a Focus area of (R4) is incontinent of bowel and bladder. He requires staff assistance for transfers to the facilities and hygiene care after use of facilities or incontinence episodes. Date Initiated: 04/28/2025 This Focus area includes interventions of . Check (R4) as needed for incontinence Date Initiated: 04/28/2025 . R4's MDS dated [DATE] documents a R4 has a BIMS score of 12, which indicates R4 has a moderate cognitive deficit. On 6/24/25 at 10:55 AM, R4 stated they don't have enough staff to provide timely care. R4 stated he has had to wait a long time for assistance to go to the bathroom and has incontinent episodes while waiting. 5. R5's admission Record with a print date of 6/24/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, hemiparesis, cerebral infarct, unspecified acquired deformity of left lower leg. R5's MDS dated [DATE] documents a BIMS score of 08, indicating R5 has a moderate cognitive impairment. This same MDS documents R5 is dependent on staff for toileting and bathing. R5's current Care Plan documents a Focus area of (R5) has an ADL Self Care Performance Deficit r/t (R5) is dependent upon staff for ADL's. (R5) has Hemiplegia/hemiparesis on one side d/t (due to) recent stroke. Date Initiated: 09/20/2022 This Focus area includes interventions of, Bathing: (R5) is totally dependent on staff to provide a bath twice weekly and as necessary. Date Initiated: 09/20/2022 Toilet Use: (R5) is not toileted. Date Initiated: 09/20/2022 The undated Facility Shower List (Day Shift) documents R5 is to receive assistance with bathing every Wednesday and Saturday. R5's Skin Monitoring: Comprehensive CNA Shower Review documents R5 received assistance with bathing on 6/5, 6/7, 6/11, and 6/18/25. This indicates R5 did not receive showers as scheduled on 6/14/25 and 6/21/25. On 6/24/25 at 10:58 AM, R5 was lying in bed and his hair appeared greasy. R5 had difficulty answering questions but did indicate with yes/no answers the facility doesn't always have enough staff to answer his call light timely. 6. R6's admission Record with a print date of 6/24/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include epilepsy, depression, muscle weakness, abnormalities of gait and mobility, and repeated falls. R6's MDS dated [DATE] documents a BIMS score of 09, indicating R6 has a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assist for toilet transfers. R6's current Care Plan documents a Focus area of (R6) has bladder incontinence. Date Initiated: 03/16/2025 . This Focus area includes the following intervention, Establish voiding patterns. Date Initiated: 03/16/2025 This same Care Plan includes the Focus area of, (R6) has bowel incontinence. Date Initiated: 03/16/2025 . This Focus area includes the intervention, Provide peri care after each incontinent episode. Date Initiated: 03/16/2025 . On 6/24/25 at 4:40 AM, R6 stated they don't have enough staff to help on the weekends. R6 stated it takes too long to answer the call lights. R6 stated she wasn't sure how long it took but it was long enough she had an incontinent episode. 7. R7's facility admission Record with a print date of 6/24/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include morbid obesity and history of falling. R7's MDS dated [DATE] documents a BIMS score of 08, indicating R7 has a moderate cognitive deficit. This same assessment documents R7 requires substantial/maximal assistance for bathing and toilet hygiene. R7's current Care Plan documents a Focus area of (R7) is incont (incontinent) of urine at times. Date Initiated: 04/03/2025 . This Focus area includes the intervention of, Check (R7) as required for incontinence . This same Care Plan includes a Focus area of, (R7) has an ADL Self Care Performance Deficit r/t (R7) requires assist with ADL's d/t cognitive impairment and difficulty with balance Date Initiated: 04/02/2023 This Focus area includes the intervention of, Bathing: (R7) requires assistance (sic) physical assistance with bathing/showering. Date Initiated: 04/03/2023 . The undated facility Shower List (Day Shift) documents R7 should receive assistance with bathing every Wednesday and Saturday. R7's Skin Monitoring: Comprehensive CNA Shower Review documents R7 was offered and/or received assistance with bathing on 6/4, 6/5, 6/7, 6/11, 6/14, and 6/17/25. This indicates R7 was not offered and/or did not receive assistance with bathing on 6/21/25 as scheduled. On 6/24/25 at 10:44 AM, R7 was sitting at the dining room table, a strong foul body odor was noted. R7 stated they don't always have enough staff to meet her needs timely. R7 stated it takes longer to answer the call light when they don't have enough staff working. R7 stated she wasn't sure how long it took but it probably feels longer than it actually is. 8. R8's facility admission Record with a print date of 6/24/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include fracture of humerus, osteoarthritis, and malaise. R8's entry MDS dated [DATE] does not document a BIMS score or ADL assessment. R8's current Care Plan provided to this surveyor does not document a Focus area for bathing or toileting. The undated facility Shower List (Day Shift) documents R8 should receive assistance with bathing every Tuesday and Friday. R8's Skin Monitoring: Comprehensive CNA Shower Review documents R8 received assistance with bathing on 6/17, and 6/20/25. This indicates R8 did not receive assistance with bathing on 6/9 and 6/13/25 as scheduled. On 6/24/25 at 11: 11 AM, R8 stated she got a shower today because she had an incontinent episode. R8 stated they don't always have enough staff, but they work very hard. R8 stated she has had incontinent episodes because she has had to wait for assistance. On 6/24/25 at 5:06 AM, V10 (CNA/Certified Nursing Assistant) stated they have approximately forty resident and they have one nurse and three CNA's working. V10 stated sometimes that is enough and sometimes it isn't. V10 stated they don't always have three CNA's. V10 stated when they had less staff, they weren't able to answer call lights timely, provide timely incontinence care, and/or give showers as scheduled. On 6/24/25 at 5:29 AM, V9 (CNA) stated she has worked night shift at the facility for about a month. V9 stated a week or so ago she was the only CNA in the facility for about three hours. V9 stated she got everyone she could to bed and waited for another CNA to come in and assist with the ones she couldn't. V9 stated one nurse and one CNA cannot meet the needs of the residents. V9 stated they have residents who require two people to transfer, bed alarms, and incontinence care. On 6/24/25 at 6:08 AM, V6 (CNA) stated on 6/19/25 and 6/21/25 there were only two CNA's working from 6 AM to 3 PM. V6 stated they were not able to meet the needs of the residents timely. V6 stated they can't get showers done and/or call lights answered timely. V6 stated on 6/21/25 they were not able to do R3 and R5's showers. On 6/24/25 at 6:17 AM, V5 (LPN/Licensed Practical Nurse) stated they don't have enough staff to meet the needs of the residents timely. V5 stated when they only have two CNA's it is hard to get all of the scheduled showers done and provide timely incontinence care. V5 stated most of the time they have three CNAs on the schedule, but people call in or quit. On 6/24/25 at 6:25 AM, V3 (Nurse) stated they were always short staffed. V3 stated there had been some shifts were there was only one CNA, and a nurse would work the floor to help. V3 stated it takes longer for incontinence care, and that is not ok. V3 stated they do their best. On 6/24/25 at 7:09 AM, V4 (CNA) stated they don't always have enough staff to meet the needs of the residents timely. V4 stated she worked midnight shift on 6/19/25 and day shift hadn't been able to do the showers that were scheduled so she did as many of them as she could before residents went to bed for the night. On 6/24/25 at 3:29 PM, V12 (CNA) stated she had worked at the facility since 6/12/25 and they had enough staff to meet the needs of the residents timely. V12 stated she had never worked in the facility by herself, but she did come to work one day and V8 (CNA) was the only CNA, but he had only been there by himself for about an hour. V12 stated on 6/21/25 she came to work and gave showers to the residents who were scheduled. V12 stated there was only one shower she did. V12 stated the other residents refused or had already had one. When asked why the shower she gave and/or the refusals weren't documented, V12 stated she guessed she forgot to fill out the shower sheets. On 6/24/25 at 1:37 PM, V1 (Administrator) stated in a perfect world she would expect them to get all of the showers done as scheduled. When asked if two CNAs were enough to meet the needs of the residents timely, V1 stated ideally, she would want two and a half CNAs on each shift. V1 stated they also have two nurses on day shift who should help out on the floor.

Based on interview and record review the facility failed to maintain an effective bed bug control program to ensure the facility was free of bed bugs. This has the potential to affect all 36 residents residing in the facility. The findings included: The facility Midnight Census Report dated 4/30/2025 documented 36 residents living in the facility. On 4/30/2025 at 9:00 AM, R2 stated, she had been the first person to find a bed bug in her room around 3/19/2025. R2 stated, that she seen the bug on the floor by her bed and she smashed it with her foot. R2 stated, she did notify a staff member but is unable to remember whom, but they did take the bug for evidence. R2's Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) of 15 which indicated she is cognitively intact. On 4/30/2025 at 8:10 AM, V3 (Housekeeping/Laundry Supervisor) stated, there had been a bug found in R2's room located on the B-Hall on 3/19/2025. V3 stated, the pest control company came in and treated. V3 stated V13 (Pest Control Technician) did advise them to not use any wet liquids to clean beds, mattress, beside tables, etc. for 2-3 months because it can remove the treatment. V3 stated, her staff had been made aware and are using dry towels to clean. V3 stated, she is not aware of any facility policy for bed bugs and had not been educated by the facility on bed bugs. On 4/30/2025 at 8:47 AM, V4 (Certified Nurse Assistant/CNA Supervisor) stated, she had not been educated on bed bugs by the facility. V4 stated, the first bed bug inspection documentation started on 4/29/2025 which had been completed by her and V10 (Maintenance/Transportation). On 4/30/2025 at 8:52 AM, V5 (CNA) stated, she is aware that there had been a bed bug reported in the facility but does not know who found it first. V5 stated, she is not aware if the facility completed an inspection or monitoring of the other rooms for bed bugs when R2 and R3's rooms were treated on 3/19/2025. V5 stated, she had not received any education on bed bugs by the facility. On 4/30/3025 at 9:03 AM, V6 (CNA) stated, she is aware that there had been reports of bed bugs in the facility. V6 stated, she had not been educated by the facility on bed bugs and is not aware of any monitoring of rooms for bed bugs after 3/19/2025. On 4/30/2025 at 9:10 AM, V7 (Licensed Practical Nurse/LPN) stated, she is not aware of any monitoring for bed bugs in the facility after the first report of a bug on 3/19/2025 in R2's room. V7 stated, she had not received any education from the facility on bed bugs. V7 stated, she had observed a bug in a medicine cup on 4/25/2025 that was found by V8 (LPN) in the laundry room. On 4/30/2025 at 9:22 AM, V1(Administrator) stated, there had been a previous employee that turned in a report to her about a bed bug being found and sent her a picture around 3/18/2025. V1 stated, there had been a confirmation with the local pest company of the bed bug. V1 stated she and V3 had been notified, by V13 (Pest Control Technician) not to use any wet liquids to clean beds, mattress, beside tables, etc. for 2-3 months because it can remove the treatment. V1 stated, there had been 2 more reports (4/21/2025 and 4/25/2025) of bugs seen in the facility. V1 stated, she did start a monthly inspection log for bed bugs for all rooms and offices to be monitored that included walls, ceilings, frames/bed boards, mattress, nightstand, base boards, chairs/wheelchairs and initialed by V4 (CNA Supervisor) and V10 (Maintenance) that took effect on 4/29/2025. V1 stated, no education had been given to employees on bed bugs. On 4/30/2025 at 10:03 AM, V9 (Housekeeping) stated, she had been notified by V3 that a bug had been found in a room. V9 stated, she had not been working at the time of the first reported bug in March 2025. V9 stated, around 4/21/2025 it had been reported that a bug had been seen in R4's room but not sure who reported it. V9 stated, they were instructed by the pest control company not to use any wipes or liquid cleaning on the mattresses, bed rails, headboards, etc. of rooms that had been treated until the pest company gives the go ahead for them to return to normal cleaning routine. V9 stated, she had been wiping down 2 of the rooms that had been treated (A-7 &A-9) on 4/25/2025 with bleach because she did not know that they had been treated. V9 stated, she thought the only rooms not cleaned with liquid or wipes were A6 & A8. On 5/1/2025 at 9:46 AM, V8 (LPN) stated, she had been working on 3/19/2025 when R2 came to her and notified her that there had been a bug in her room that she smashed with her foot. V8 stated, she did collect the specimen and give it to the previous maintenance employee who did notify V1 (Administrator) and gave the specimen to the local pest control company for confirmation. V8 stated, she had also been working on 4/25/2025 when another bug had been found in the laundry room. V8 stated, she did collect the bug in a specimen cup and notified V1. On 5/1/2025 at 10:49 AM, V13 (Pest Control Technician) stated, he had been the technician to come out and treat the facility on 4/25/2025 and 4/28/2025. V13 stated, he did not confirm a bug on the 4/25/2025 visit. V13 stated, he treated all six rooms (A6-A9 initial, B15-B16 and follow up). V13 stated, he did return on 4/28/2025 were he confirmed 2 bed bugs with V2 (Business Office Manager). V13 stated, V2 showed him a bug in a medicine cup that he confirmed and then also one she had removed off a shoulder and placed in tape that he confirmed as well. V13 stated, he did advise V3 and V1 not to clean any of the beds, bed rails, etc. with any liquid cleaning supplies or wipes because it will remove the chemical treatment. V13 stated, he did tell V3 and V1 that they could vacuum mattress if needed. A statement of the summary of services from the contracted pest control company dated 3/19/2025 documents services of .Targeted Pest: Bed Bug. Device of Application: Resident Room. Equipment Used: Compressed Sprayer. Recommendations: Other Areas: Pipes extending through wall allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Severity: Medium. Status: New. Date 11-4-2024. Site: Patient Room. Pest: Bed Bug. Infestation: 1. A statement of the summary of services from the contracted pest control company dated 4/25/2025 documents services of .Targeted Pest: Bed Bug. Device of Application: Resident Room. Equipment Used: Compressed Sprayer. A statement of services from the contracted pest control company dated 4/28/2025 documented services of: Target Pest Bed Bugs. Areas: Laundry Room. There was no documentation provided by the facility for education given to staff, monitoring/inspections of rooms, or recommended areas being inspected after confirmation of bed bugs on 3/19/2025. The facility Bed Bugs, Preventing and Managing Infestations of policy revised August 2015 documented in part, Purpose, staff will employ infection control strategies to prevent and manage infestations of bed bugs (cimex lectularius). Preparation, Staff should be trained to recognize bed bugs and bed bug infestation and know what their specific roles will be should an infestation occur. Monitoring and Investigation, 1. Thoroughly screen newly admitted residents, as well as those who returning from a stay away from the facility .3. Regularly inspect mattresses, box springs, bed frames, and headboards following current published guidelines for inspection and identification. Documented under Evaluation and Continued Monitoring, 1. After treatment methods have been applied it is important to follow up by monitoring for subsequent infestations. Even if eradication of adult bed bugs was successful, eggs may have survived and hatched . 5. Monitor for bed bugs on a regular basis. 6. Seal cracks and crevices to remove hiding places.

Based on interview and record review, the facility failed to serve an appropriate non-emergent involuntary discharge and allow the resident and resident's family time to appeal the notice for 1 of 1 resident (R185) reviewed for discharge in the sample of 32. This failure resulted in R185 being removed from her environment and suffering psychosocial harm that any reasonable person would after being placed over two hours away from her family and friends without notice. The findings include: R185's Face sheet, dated 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or delusions, no physical behavioral symptoms directed towards others, no verbal behavioral symptoms, other behavioral symptoms not directed towards other (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of the 7 day look back period, did not reject evaluation or care, and wandering 1 to 3 days out of the 7 day look back period. Section GG documents R185 was dependent for toileting, dressing, and personal hygiene and set-up and clean up for transfers. R185's Care Plan, with a cancelled date of 06/18/24, documents focus areas of: 1. (R185) is disoriented to place and time. (R185's) memory is similarly impaired. Consequently. (R185) has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. (R185) is known to be impulsive at times. This problem it related to Dementia. Strengths and abilities include her ability to be easily redirected. 2. (R185) has a behavior problem r/t (related to) (R185) is known to wander and lacks safety awareness. (R185) is easily redirected by staff most of the time. (R185) has a hx. (History) of agitation r/t dementia. (R185's) son reports (R185) has a known trend of doing bad things out of defiance then laughing when confronted. Recently (R185) has started to defecate in inappropriate places. (R185) appears to like attention even when it is negative attention for doing wrong as reported by (R185's) son. 3. (R185) has no discharge potential r/t poor safety awareness, cognition, and inability to care for self. A documented goal for this focus was (R185) will remain in the facility long term. R185's Physician Orders document no order for discharge on 06/18/24 to another facility. R185's Progress Notes dated 06/14/24 at 8:16AM (Late entry) documents in part Called Her (R185's) son (V13) and left message that she (R185) was being moved. R185's Progress Note dated 06/18/24 at 7:01AM documents in part Resident (R185) discharged via facility transporter with personal clothing et (and) medications to receiving facility. R185's Progress Note dated 06/18/24 at 10:05AM documents SSD (Social Services Director/V3) mailed a letter to (R185's) son (V13) telling him where (R185) has been sent to and the address and phone number where (R185) can be reach [sic]. R185's Care Plan Summary/Participation record, dated 03/28/24, documents that R185 and V13 did not attend the meeting. Goals for care document D/C (Discharge) is feasible, but resident/responsible party goal remains for long term placement. Other changes/Updates document no family attended and Res (R185) will be looking at discharge to another facility when their lock down wing is complete. R185's Discharge Planning Review/Summary documents in part under Discharge Goals/General Information 1. Who initiated discharge? Resident (box checked). 2.Reason for discharge: She (R185) went to other facility. 3. Recap of resident's stay: The resident was a long-term resident that needed a locked down unit, and we transfer her to the other facility for better care .5. Initial discharge goals- remain in facility (box checked) . 8. Resident's goals of care and treatment preferences: to be able to stay in the facility. Under Medication Reconciliation it documents .2. Has post-discharge medication list been discussed with resident/family? Resident (box checked). Under Activity Summary, 1. Social Service it documents the Resident was excited that she was going to the [sic]. Under the section 2. Nursing Service it documents 1. Medical Summary-Medication was sent with her (R185). Under signatures 1. Resident signature and date documents R185 name typed in with date of 06/18/24. 3 staff signature documents V3 (Social Service Director) with typed in name and date of 06/18/24. On 09/18/24 at 8:50AM, V13 (Family Member) stated that the facility never contacted him about R185 moving to another facility. V13 said he received a phone call from an unknown number stating that it was a new facility, and they were admitting R185 and wanted to review R185's medication with him. V13 stated that he asked the new facility if R185 was at the other facility she had been at, and they stated no that R185 was transferred to them today from the other facility on 06/18/24. V13 said he was very upset and mad. V13 said that he told the new facility that no one had notified him that R185 had been discharged and moved. V13 said the new facility that she was transferred to was around 2 hours away from his house. V13 said the facility that R185 was in was only 15 minutes away from his house. V13 said he hasn't been able to visit often and that with covid and the fact that R185 doesn't know who he was most of the time was upsetting to him. V13 stated the facility did not notify him about R185 being transferred and there were no messages left regarding a transfer. V13 said the facility did talk to him about 3 or 4 months ago about maybe moving R185 to another facility, but they never said they were for sure moving her. V13 said the facility never mentioned any other facilities that they were thinking about moving R185 to that he could remember. V13 said they talked about discharging R185, but it was brief and nothing definite. V13 said the facility could of at least called him to let him know that R185 was moving. V13 said the facility calls him for all kinds of other things like when she has eloped, medication changes, and other stuff; why not when they transferred R185? V13 said that he did not receive any paperwork from the facility other than a bill and no information on where R185 went or information on her moving at all. V13 said that he would have preferred for R185 to stay at the facility, because it was closer to him. On 09/18/24 at 10:16AM, V14 (Facility Administrator at R185's new facility) stated that they did receive R185 as a new resident at their facility. V14 said that R185's old facility contacted them about 3-4 months ago and wanted to admit R185 to their facility. V14 said at that time they didn't have any beds available for R185. V14 said that they were in the middle of construction at that time for their locked unit and would have beds available soon. V14 doesn't remember off hand who she spoke to. V14 said they called the facility to let them know they had a bed available for R185. V14 said the facility worked on discharging R185 right away. V14 said when R185 was transferred to the new facility they did give all of R185's medical information. V14 said that R185 was admitted to a locked memory care unit at their facility. V14 said they did call V13 to verify R185's medications. V14 said that V13 was very upset and stated that he didn't know that R185 was discharged from the facility, and he knew nothing about R185 being admitted to a new facility. V14 said that V13 was very angry when they were talking to him because he was not made aware of any transfer or discharge. V14 said that R185 has seemed to adjust well to the new facility. V14 said that R185 did have some increased behaviors and some crying episodes at first, but that was expected some with her current diagnoses. V14 said that she didn't have a lot of concerns with R185 discharge and transfer other then V13 not knowing anything about the transfer and discharge. On 09/18/24 at 12:30PM V3 (Social Service Director/SSD) stated that the facility initiated R185's discharge. V3 said the facility initiated the discharge because they were unable to care for R185. V3 said R185 needed a locked facility because she kept trying to elope every day. V3 said the facility sent R185 to another facility that had a locked unit. V3 said they do have other resident that are elopement risks, but they don't usually get out like R185 did. V3 said they tried to do one on ones and extra activities but none of that worked. V3 said the one on one's didn't work, because R185 kept getting away from staff. V3 said R185 wouldn't stay with the person providing one on one's. V3 said the new facility has a locked unit and all we had was a medical alert device that the resident wears and locks the doors when she goes up to the door, but she would take off the medical alert device all the time. V3 said they determined the capability for care prior to admission by reviewing hospital or discharge records and talking to the family. V3 said she was not employed by the facility when R185 was admitted . V3 said that R185 has wandered since she has been employed by the facility. V3 said all of the elopement risk residents they have now have never actually eloped. V3 said the facility reviews discharge planning every three months on all residents, but most residents are long term. V3 said that R185 was sent to another facility that had a locked unit. V3 said R185's son V13 didn't have much to do with her. V3 said that she did try to contact V13 but was unable to get ahold of him. V3 said she tried several times to get a hold of V13 but was unable to get ahold of him to tell him that R185 was moving. V3 said that she did not document all the times she tried to get a hold of V13. V3 said she left messages, but V13 never returned her calls. V3 said she doesn't know why other staff were able to get a hold of V13 at times. V3 said V13 never called her back so she mailed him information telling him, where we sent R185 along with address and phone number of the new facility on the day R185 was discharged to other facility. V3 said that 3 months ago they did start talking about sending R185 to another facility. She said that V13 and R185 were invited to Care Plan and V13 never showed up. V3 said they had started working on the discharge then. V3 said she was not able to get ahold of V13 since the Care Plan meeting on 03/28/24. V3 doesn't remember how many times she attempted to call V13, but that she did leave him a message. V3 stated the discharge summary was not completed until 09/17/24. She stated that she did not know she had to complete a discharge summary when they transfer to another facility. V3 said she had started one on paper but got rid of it. V3 said she didn't know if there was a physician's order or not because that is something she doesn't deal with. V3 said it states on the discharge summary that R185 initiated discharge. V3 said R185 does have a BIMS score of 00 which indicates that R185 has severely impaired cognition, but that R185 is able to understand. V3 said that the BIMS score is 00 because R185 is nonverbal most of the time. V3 said she knows R185 understands, and she seemed happy about transferring to another facility. V3 said she believes that R185 was capable of making her own decisions. V3 said that she never attempted to contact any other family members on R185's contact list because they weren't the POA (Power of Attorney), and she was only told to get ahold of the POA. V3 said that she did not try to contact V13's wife who is also listed on R185's contact list. V3 stated that she thinks V1 (Administrator) or V2 (Director of Nursing) might have gotten ahold of V13 on the day R185 transferred, but she wasn't sure. V3 doesn't know if any forms were sent to V13 other than the information about the new facility she sent on the day of discharge on 06/18/24. On 09/18/24 at 12:40PM, V1 (Administrator) stated that the facility did initiate R185's discharge when they sent her to a facility with a locked unit. V1 said that R185 was always escaping and trying to elope. V1 stated they do have other resident who are at risk for eloping, but that they have never gotten out. V1 said they have been planning the discharge for several months. V1 said that they were waiting for the other facility to have a room available for R185. V1 said that the other facility called and told them they had a bed available. V1 said that she did believe that a notice was sent to V13, but she didn't know when that was. V1 said that they did try to keep R185, she was placed on one on ones, but we couldn't do that forever. V1 said that R185 actually got out of the facility several times. V1 said they did do extra stuff like extra activities, small groups, one on ones, and a medical alert device that locks the doors. V1 said R185 was at the facility when she started. V1 said she knows that they did talk about notifying the son and she thought V3 took care of that. V1 said that V3 worked on R185's discharge planning. V1 doesn't know if there were any discharge orders or not, but she would look and see if she could find any orders. V1 said that she did call around to different facilities that are closer, but no one around could take her because they were full or just wouldn't take R185. V1 doesn't know if it was documented all the places that they tried to get ahold of to take R185. V1 said that they did notify R185 that they were transferring her to another facility. V1 said that R185 could understand and answer appropriately at times. V1 knows that R185 has a low BIMS score which indicates severely impaired cognition but V1 said that R185 knows what is going on. V1 said she would expect V13 to be notified of the discharge and transfer before it was made. V1 said that she didn't know what the policy was for involuntary facility-initiated discharges. On 09/19/24 at 7:55AM, V1 stated that they did not complete a notice of involuntary transfer form or notify the ombudsman concerning R185 involuntary facility-initiated discharge. V1 said at the time they were discharging R185 she wasn't thinking of it as an involuntary facility-initiated discharge. V1 stated that she does see that it was now. V1 stated that she does not know why V13 wasn't notified other than they could not get a hold of him. V1 said that they should have documented all the attempts the facility made to get a hold of V13, but she said they didn't. V1 agreed that V13 could not have done an appeal since he didn't know about the discharge. V1 said that she never told V3 that she could not call any of the other contact on R185's contact list other than the POA. V1 stated that V3 is still learning the Social Service Director job and probably didn't know she could have contacted others on R185's contact list. The Facility Policy titled Transfer or Discharge, Preparing a Resident for Discharge with a revision date of 12/2016 documents under Policy Statement Residents will be prepared in advance for discharge Policy Interpretation and Implementation documents in part 1a. Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment. 1c. Providing the resident or representative (sponsor) with required documents. The Facility Policy titled Transfer or Discharge, Emergency revised 12/2016 documents in part under Policy Interpretation and Implementation 2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending unless the failure to discharge or transfer would endanger the health and safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, home, or other setting our facility will implement the following procedures. 4a. Notify the resident's attending physician . 4e. Notify the representative (Sponsor) or other family member. The facility policy titled Discharge Summary and Plan revised 12/2016 documents under Policy Statement When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new environment. Under Policy Interpretation and Implementation it documents 12. A member of the IDT (Interdisciplinary Team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary.

Based on observation, interview, and record review the facility failed to ensure transmission based precautions were implemented, and failed to ensure hand hygiene was performed per current standards of practice for 2 of 6 (R85 and R3) residents reviewed for infection control in the sample of 32. Findings Include: R85's Admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's Order Summary Report dated 9/19/24 documents a physician order with a start date of 9/11/24 of Transmission based precautions until 9/22/2024 R85's current Care Plan documents a Focus area of (R85) has tested positive for Covid 19. Date Initiated: 09/10/2023. Revision on: 09/12/2024. This Focus area includes the following interventions.Administer medications as ordered. Monitor for potential side effects and effectiveness. Date Initiated: 09/12/2024 Contact/droplet isolation precautions per protocol. Date Initiated: 09/12/2024 . R85's Progress Notes document the following: 9/6/24 9:24 AM, Staff told nurse that resident has been acting different . resident is very lethargic. Opening her eyes but not responding. Resident is usually walking around building all day and is currently laying in bed with no response. Resident is usually aggressive with care but isn't even responding to care at this time. Resident is shaky and clammy to touch. Vital signs are as followed: T (temperature) 98.4, P (pulse) 91, O2 (oxygen) 97%, BP (blood pressure) 101/61, R (respirations) 18. Blood sugar is 155. Covid test negative . (name of physician) stated, send resident to ER (emergency room ) for further evaluation. 9/6/24 7:15 PM, Call received from (name of local hospital) stating resident is being admitted there with DX (diagnosis): Pneumonia. 9/7/24 9:35 AM, Called (name of hospital) for update on Resident, nurse stated that resident is doing ok, they are monitoring her respiratory symptoms, stating she is having some wheezing and SOB (shortness of breath), they also stated that resident is positive for Covid-19. 9/10/24 3:56 PM, .Res (resident) just arrived back to the facility via EMS (emergency medical services) Res vital signs are T 99.0, P 89, R 16, BP 90/44, O2 95% on room air . 9/11/24 9:46 PM, Resident has been up ambulating independently about facility w/o (without) gait disturbance noted Resident is on transmission-based precautions r/t (related to) dx (diagnosis) of covid 19 positive while in (name of local hospital) 9/12/24 8:02 AM, .Res up in the dining room eating breakfast at this time. Res ambulating this morning with no problems . 9/12/24 10:48 PM, . Resident walked around the facility as usual. Offered snacks throughout the shift . 9/15/24 8:32 AM, The resident is up in the dining room ambulating around. Res has no complaints at this time. No signs or symptoms of distress or discomfort. Plan of care on going. On 9/16/24 at 12:24 PM, R85 walked through the dining room, carrying her dessert of apple crisp, eating it with her fingers. R85 stopped at a table where peers were sitting and continued eating her dessert. R85 then walked to a second table of peers and stood eating her dessert. R85 set her dessert on the table near R4's dessert. An unknown certified nursing assistant walked R85 to a different table, had R85 sat down, and assisted her to eat her meal. R85's dessert was left on R4's table near his dessert. At no time throughout these observations did staff encourage R85 to eat in her room, wear a mask, or keep her distance from peers. On 9/17/24 at 12:12 PM, R85 stood in the dining room within two feet of peers with no mask on and staff did not encourage R85 to go to her room or don a mask. At 12:13 PM, R85 walked to V2 (Director of Nurse) office and stood. V2 walked past R85 and did not encourage her to wear a mask or go to her room. V3 (Social Services Director) assisted R85 to adjust her pants and did not encourage R85 to wear a mask or go to her room. R85 then walked down the hall her room was located on. On 9/18/24 at 4:38 PM, V2 (Director of Nurses) stated R85 returned from a hospital stay and it was reported to the facility R85 tested positive for Covid 19 while at the hospital. V2 stated they were never given any lab report documenting the positive test, but they placed R85 on isolation precautions since it was reported to them, she had tested positive. This surveyor shared the observation of R85 eating in the dining room and being in the dining room throughout the survey process without a mask on and no staff observed encouraging R85 to wear a mask or eat in her room. V2 stated she would think staff should encourage R85 to stay in her room and/or wear a mask if she was out and about in the facility. On 9/19/24 at 10:25 AM, this surveyor walked through the dining room following V2. R85 was sitting at a table, with peers, eating a cookie. This surveyor asked V2 if R85 was off isolation. V2 got V15 (Licensed Practical Nurse) and asked her to encourage R85 to go to her room or put a mask on. The undated facility Infection Control Policy Covid 19 documents, The facility has established appropriate guidelines pursuant to recommendations from the Illinois Department of Public Health and the Federal Centers for Disease Control. The policy addresses staff and visitor behavior and responsibilities to try to prevent the transmission of communicable disease Policy Interpretation and Implementation .2. To prevent the spread of respiratory germs within the facility .: a. Monitor employees prior to starting their shift for fever or respiratory symptoms b. Restrict residents with fever or acute respiratory symptoms to their room and place on droplet precautions. If they must leave the room for medically necessary procedures, have them wear a facemask (if tolerated) 2. R3's Admission Record with a print date of 9/19/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include retention of urine, acute cystitis without hematuria, and mild cognitive impairment. R3's MDS dated [DATE] documents a BIMS score of 02, which indicates a severe cognitive deficit. R3's current Care Plan documents a Focus area of (R3) is at risk for complications related to foley catheter placement related to Urinary Retention Date Initiated: 02/26/2024 This Focus area documents interventions that include, .2/21/24 Foley Cath care q (every) shift On 9/18/24 at 3:50 PM, V8 (Certified Nursing Assistant) provided catheter care to R3 per current standards of care. V8 changed gloves three times during catheter care and did not perform hand hygiene. When asked why she didn't perform hand hygiene with each glove change, V8 stated she forgot to do it. On 9/18/24 at 4:38 PM, V2 (Director of Nurses) stated she would expect hand hygiene to be performed between glove changes. The facility Handwashing/Hand Hygiene policy dated 8/2015 documents, This facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations .m. after removing gloves .

Based on observation, interview, and record review the facility failed to provide a method to call for assistance while in the shower stall. This has the potential to affect all 32 residents residing at the facility. Findings include: On 09/18/24 at 11:20 AM the shower stall on the B hall does not contain a method to call for assistance from the shower stall, there is no access to a call light. On 09/18/24 at 11:30 AM the shower stall on the A hall does not contain a method to call for assistance from the shower stall, there is no access to a call light. On 09/19/24 at 12:02 PM V1 (Administrator) stated, the shower stalls should have a method to call for assistance that can be accessed from the floor if someone was in there, so another call box in the shower stall or a way to make the other call box string accessible from the shower. On 09/19/24 at 2:30 PM V1 stated, they do not have a policy regarding call light presence. The long term care facility application for Medicare and Medicaid dated 09/16/24 documents a census of 32 residents residing at the facility.

Based on observation and interview the facility failed to provide a dignified and respectful dining experience by removing plates from the table while other residents are still eating for 4 (R30, R27, R16 and R18) of 4 residents reviewed for dignified dining. Findings include: On 09/18/24 at 12:25 PM, V10 (Dietary) was rolling a cart through the dining room with a white bucket (approximately 5 gallon size) on the cart and would pick up residents plates, scrape the leftover food into the bucket and stack the plates on the cart and place the silverware into another bucket. At the first table, R30 was finished while three residents were still eating. Right after V10 took R30's plate, R27 put her silverware down and rolled away from the table. At 12:27 PM, V10 went to the next table and removed R16's plate and glass, and R16 stated hey, I am not done with that. V10 gave her the glass back. There were three residents still eating at the table. V10 then attempted to take R18's plate and with her hand on the plate asked, are you finished, R18 stated, no, there were two residents still eating at the table. On 09/19/24 at 12:28 PM, V10 stated she has never been told not to pick up the resident's plates right away, so she will pick them up as soon as she sees someone that looks done and will take their plate no matter how many people are still eating at the table. V10 stated that makes sense to leave them as not to make the confused residents feel rushed. On 09/19/24 at 2:43 PM, V1 (Administrator) stated, she does not have a policy on dining cleaning procedures.

Based on observation, interview and record review the facility failed to provide a clean and sanitary bathroom for 14 (R3, R24, R23, R14, R17, R21, R10, R22, R28, R29, R18, R19, R5 and R30) of 14 residents reviewed for environment in a sample of 32. The findings include: On 09/18/24 at 11:20 AM, the shower stall floor of the shower room on the B hall is cracked around the drain with the floor peeling away. There was an uneven cracked floor with large peeling area on the floor with areas of non-smooth peeling spots of over 2 feet by 2 feet, 6 inches by 5 inches, and mold around the bottom between the wall and the floor of the shower stall. There was a 2.5 inch gap between the wall and the floor on the right side of the toilet. In the front of the toilet in the second restroom on the B hall, there was a black accumulation around the bottom with an approximate 2 inch gap with approximately 0.25 inches of water accumulation. There is no restroom or shower room located on the C hall. On 09/18/24 at 11:51 AM, the room labeled men's bathroom on the B hall had an accumulation of dirt and debris causing an accumulation of a black substance approximately two inches out from in front of the toilet. On 09/19/24 at 12:02 PM, V1 (Administrator) stated the shower stall should be repaired and cleaned. The room roster dated 09/16/24 documents R3, R24, R23, R14, R17, R21, R10, R22, R28, R29, R18, R19, R5 and R30 reside on the B and C Halls and utilize the B Hall shower and restrooms. The facility policy dated 2021 titled, Maintenance Service documents: 2. Functions of maintenance personnel include but are not limited to: b. maintaining the building in good repair and free from hazards.

Based on interview and record review the facility failed to prevent physical abuse of a resident from another resident with a known history of abuse for 1 of 3 residents (R16) reviewed for abuse in the sample of 32. The findings include: The Final IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification, with an incident date of 9/20/23, documents, It was reported by staff that on 9/20/23 (R85) (resident) entered (R16's) (resident) room. (R16) loudly told her to leave her room. (R85) became startled and made contact with (R16). (R16) alerted nearby staff who immediately intervened and separated both residents. Nursing assessed both residents for any injuries. Slight bruising to (R16's) upper lip was noted. Nursing provided first aid to the affected area. (R85) was easily redirected and provided with additional activities. (R16) was provided with comfort and support. No further issues were noted Abuse is substantiated The Final IDPH Incident and/or Abuse Notification, with an incident date of 9/13/24, documents, An unwitnessed allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with her (R16) (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues. Nursing assessed both residents for any reddened areas or injuries. None were noted. (R85) is care planned for behaviors with impaired cognitive/thought processes. (R16) is care planned for delusional behavior and anxiety. These behaviors can impair both residents' ability to make good decisions and affects their safety awareness. This is an unwitnessed altercation with no injuries noted. (R85) is un-interviewable and cannot recall the incident (R85) and (R16) has a prior history of interactions. (R16) has delusional behaviors with anxiety and can fixate on past experiences. Based on these contributing factors along with a comprehensive investigation through staff and resident interviews, the IDT (Interdisciplinary Team) finds the allegation of abuse to be unsubstantiated . On 09/16/24 at 1:18 PM, R16 stated R85 gave me a bloody lip a few months ago. R16 stated yesterday or the day before (could not remember exact day), R85 tried to take a towel and her walker and R85 hit her in the arm and the mouth. R16's Progress Notes document the following: 9/13/24 at 6:04 PM, .Resident (R16) was hit in the mouth by another resident (R85). Incident unobserved by staff. Family informed. 9/16/24 at 12:26, Per Nurse - On 9/13/24 at approximately 18:12pm (6:12 PM) a resident-to-resident interaction occurred. The nurse immediately separated both residents and assessed them for signs and symptoms of injury, pain, or any other changes in clinical status. None were noted. 9/16/24 the incident was identified this am and the nurse at the time did not report to the Administrators. Both residents were reassessed. No injuries noted. The administrator was immediately notified. An investigation was immediately implemented. On 9/19/24 at 7:52 AM, R7 stated she was with R16 in the dining room when R85 came up and started getting into stuff in R16's walker. R7 stated R16 asked her not to do that and R85 hit R16 in the shoulder and the mouth. R7 stated she couldn't remember the exact day, but it was one day last week. R7 stated she couldn't remember if staff were there when it happened but knows an unknown nurse came up to R16 after it happened. R7 stated R16 was ok and didn't appear injured. On 09/18/24 at 3:18 PM, V1 (Administrator) stated she was not notified of the allegation of abuse until she was reviewing notes on 9/16/24 and that is when she started an investigation. On 9/19/24 at 7:57 AM, this surveyor reviewed the abuse investigation for the incident that occurred on 9/13/24, with V1 (Administrator). V1 stated she was the one who did the abuse investigation for R16 and R85. When asked if she interviewed R16 she stated she did. V1 stated R16 did not report any witnesses to her. This surveyor shared with V1, R16 reported to this surveyor R7 witnessed the altercation. V1 stated she would have to speak to her corporate office and amend the investigation. V1 provided this surveyor with an amended Final IDPH Incident and/or Abuse Notification that documents, After a final report was made and investigation was completed, new evidence was presented to Administrator and investigation was re-opened. An allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with Her (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues In the original investigation no witnesses were found. But a resident has since voiced she witnessed the incident. The IDT reopened the investigation and has determined the allegation of abuse to be substantiated. This is the final report . R16's Admission Record with a print date of 9/18/24 documents R16 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder, major depressive disorder, bipolar disorder, and anxiety disorder. R16's MDS (Minimum Data Set) dated 7/16/24 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R16 is cognitively intact. R16's current Care Plan includes the Focus area of Abuse: (R16) is at risk for abuse and neglect r/t (related to) immobility Date Initiated 11/10/2021 The interventions documented for this Focus area include, 11/18/22 ask for assistance from staff when intervening with other residents and 2/11/22 (R16) will allow staff to redirect and intervene with other residents. R85's Admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's current Care Plan documents a Focus area of (R85) has a behavior problem r/t (related to) impulsive behaviors. (R85) is known to have physical behaviors such as hitting and kicking others, repetitive behaviors, pacing, slamming doors, packing items and exit seeking. (R85) also has a history of inappropriate touching. Date Initiated: 05/31/2023. The interventions documented for this Focus area include Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/31/2023 .Anticipate (R85's) needs. Date Initiated: 05/31/2023 .Assist (R85) to develop more appropriate methods of coping and interacting. Encourage (R85) to express feelings appropriately. Date Initiated: 05/31/2023 .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 05/31/2023 . The facility Abuse Prevention Program-Policy dated 2022 documents, Residents have the right to be free from abuse, neglect, exploitations, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms Protection B. If the alleged perpetrator is a resident, the resident will be separated from the alleged victim and the resident's condition will be evaluated as soon as reasonably possible to determine the most suitable therapy and placement for the resident. This will be done taking in consideration the safety of other residents and employees of the facility

Based on interview and record review the facility staff failed to report an allegation of resident to resident physical abuse to the Administrator immediately for 1 of 3 (R16) residents reviewed for abuse and neglect in the sample of 32. The findings include: The Final IDPH Incident and/or Abuse Notification date of incident 9/13/24 documents, An unwitnessed allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with Her (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues. Nursing assessed both residents for any reddened areas or injuries. None were noted. (R85) is care planned for behaviors with impaired cognitive/thought processes. (R16) is care planned for delusional behavior and anxiety. These behaviors can impair both residents' ability to make good decisions and affects their safety awareness. This is an unwitnessed altercation with no injuries noted. (R85) is un-interviewable and cannot recall the incident (R85) and (R16) has a prior history of interactions. (R16) has delusional behaviors with anxiety and can fixate on past experiences. Based on these contributing factors along with a comprehensive investigation through staff and resident interviews, the IDT (Interdisciplinary Team) finds the allegation of abuse to be unsubstantiated . On 09/16/24 at 1:18 PM, R16 stated R85 gave me a bloody lip a few months ago. R16 stated yesterday or the day before (could not remember exact day), R85 tried to take a towel and her walker and hit her in the arm and the mouth. R16's Progress Notes document the following: 9/13/24 at 6:04 PM, .Resident (R16) was hit in the mouth by another resident (R85). Incident unobserved by staff. Family informed. 9/16/24 at 12:26, Per Nurse - On 9/13/24 at approximately 18:12pm (6:12 PM) a resident-to-resident interaction occurred. The nurse immediately separated both residents and assessed them for signs and symptoms of injury, pain, or any other changes in clinical status. None were noted. 9/16/24 the incident was identified this am and the nurse at the time did not report to the Administrators. Both residents were reassessed. No injuries noted. The administrator was immediately notified. An investigation was immediately implemented. On 09/18/24 at 3:18 PM, V1 (Administrator) she was not notified of the allegation of abuse until she was reviewing notes on 9/16/24 and that is when she started an investigation. R16's Admission Record with a print date of 9/18/24 documents R16 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder, major depressive disorder, bipolar disorder, and anxiety disorder. R16's MDS (Minimum Data Set) dated 7/16/24 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R16 is cognitively intact. R16's current Care Plan includes a Focus area of Abuse: (R16) is at risk for abuse and neglect r/t (related to) immobility. Date Initiated: 11/10/2021 The interventions documented for this Focus area include, 11/18/22 ask for assistance from staff when intervening with other residents and 2/11/22 (R16) will allow staff to redirect and intervene with other residents. R85's Admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's current Care Plan documents a Focus area of (R85) has a behavior problem r/t (related to) impulsive behaviors. (R85) is known to have physical behaviors such as hitting and kicking others, repetitive behaviors, pacing slamming doors, packing items and exit seeking. (R85) also has a history of inappropriate touching. Date Initiated: 05/31/2023. The interventions documented for this Focus area include Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/31/2023 .Anticipate (R85's) needs. Date Initiated: 05/31/2023 .Assist (R85) to develop more appropriate methods of coping and interacting. Encourage (R85) to express feelings appropriately. Date Initiated: 05/31/2023 .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 05/31/2023 . The facility Abuse Prevention Program-Policy dated 2022 documents, .Internal Reporting. Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must them immediately report it to the administrator

Based on interview and record review the facility failed to provide a resident or representative and the Ombudsman with a written notice of discharge with appeal rights for 1 of 1 resident (R185) reviewed for discharge in the sample of 32. The Findings include: R185's Face sheet, dated 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or delusions, no physical behavioral symptoms directed towards others, no verbal behavioral symptoms, other behavioral symptoms not directed towards other (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of the 7 day look back period, did not reject evaluation or care, and wandering 1 to 3 days out of the 7 day look back period. Section GG documents R185 was dependent for toileting, dressing, and personal hygiene and set-up and clean up for transfers. R185's Care Plan, with a cancelled date of 06/18/24, documents focus areas of: 1. (R185) is disoriented to place and time. (R185's) memory is similarly impaired. Consequently. (R185) has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. (R185) is known to be impulsive at times. This problem it related to Dementia. Strengths and abilities include her ability to be easily redirected. 2. (R185) has a behavior problem r/t (related to) (R185) is known to wander and lacks safety awareness. (R185) is easily redirected by staff most of the time. (R185) has a hx. (History) of agitation r/t dementia. (R185's) son reports (R185) has a known trend of doing bad things out of defiance then laughing when confronted. Recently (R185) has started to defecate in inappropriate places. (R185) appears to like attention even when it is negative attention for doing wrong as reported by (R185's) son. 3. (R185) has no discharge potential r/t poor safety awareness, cognition, and inability to care for self. A documented goal for this focus was (R185) will remain in the facility long term. R185's Progress Notes dated 06/14/24 at 8:16AM (Late entry) documents in part Called Her (R185's) son (V13) and left message that she (R185) was being moved. R185's Progress Note dated 06/18/24 at 10:05AM documents SSD (Social Services Director/V3) mailed a letter to (R185's) son (V13) telling him where (R185) has been sent to and the address and phone number where (R185) can be reach [sic]. R185's Care Plan Summary/Participation record for R185, dated 03/28/24, documents in part R185 and V13 did not attend meeting. Goals for care document D/C (Discharge) is feasible, but resident/responsible party goal remains for long term placement. Other changes/Updates document no family attended. R185 (Res) will be looking at discharge to another facility when their lock down wing is complete. R185's Discharge Planning Review/Summary documents in part under Medication Reconciliation 2. Has post-discharge medication list been discussed with resident/family? R185 (Resident). Under signatures 1. Resident signature and date documents R185 name typed in with date of 06/18/24. 3 staff signature documents V3 (Social Service Director) with typed in name and date of 06/18/24. On 09/18/24 at 8:50AM, V13 (Family Member) stated that the facility never contacted him about R185 moving to another facility. V13 said he received a phone call from an unknown number stating that it was a new facility, and they were admitting R185 and wanted to review R185's medication with him. V13 stated that he asked the new facility if R185 was at the other facility she had been at, and they stated no that R185 was transferred to them today from the other facility on 06/18/24. V13 said he was very upset and mad. V13 said that he told the new facility that no one had notified him that R185 had been discharged and moved. V13 said the new facility that she was transferred to was around 2 hours away from his house. V13 said the facility that R185 was in was only 15 minutes away from his house. V13 said he hasn't been able to visit often and that with covid and the fact that R185 doesn't know who he was most of the time was upsetting to him. V13 stated the facility did not notify him about R185 being transferred and there were no messages left regarding a transfer. V13 said the facility did talk to him about 3 or 4 months ago about maybe moving R185 to another facility, but they never said they were for sure moving her. V13 said the facility never mentioned any other facilities that they were thinking about moving R185 to that he could remember. V13 said they talked about discharging R185, but it was brief and nothing definite. V13 said the facility could of at least called him to let him know that R185 was moving. V13 said the facility calls him for all kinds of other things like when she has eloped, medication changes, and other stuff; why not when they transferred R185? V13 said that he did not receive any paperwork from the facility other than a bill and no information on where R185 went or information on her moving at all. V13 said that he would have preferred for R185 to stay at the facility, because it was closer to him. On 09/18/24 at 10:16AM, V14 (Facility Administrator at R185's new facility) stated that they did receive R185 as a new resident at their facility. V14 said that R185 was admitted to a locked memory care unit at their facility. V14 said they did call V13 to verify R185's medications. V14 said that V13 was very upset and stated that he didn't know that R185 was discharged from the facility, and he knew nothing about R185 being admitted to a new facility. V14 said that V13 was very angry when they were talking to him because he was not made aware of any transfer or discharge. V14 said that R185 has seemed to adjust well to the new facility. V14 said that R185 did have some increased behaviors and some crying episodes at first, but that was expected some with her current diagnoses. V14 said that she didn't have a lot of concerns with R185's discharge and transfer other then V13 not knowing anything about the transfer and discharge. On 09/18/24 at 12:30PM, V3 (Social Service Director/SSD) stated that the facility initiated R185's discharge. V3 said that R185 was sent to another facility that had a locked unit. V3 said that she did try to contact V13 but was unable to get ahold of him. V3 said she tried several times to get a hold of V13 but was unable to get ahold of him to tell him that R185 was moving. V3 said that she did not document all the times she tried to get a hold of V13. V3 said she left messages, but V13 never returned her calls. V3 said she doesn't know why other staff were able to get a hold of V13 at times. V3 said V13 never called her back so she mailed him information telling him, where we sent R185 along with address and phone number of the new facility on the day R185 was discharged to other facility. V3 said that 3 months ago they did start talking about sending R185 to another facility. She said that the V13 and R185 were invited to Care Plan and V13 never showed up. V3 said they had started working on the discharge then. V3 said she was not able to get ahold of V13 since the Care Plan meeting on 03/28/24. V3 doesn't remember how many times she attempted to call V13, but that she did leave him a message. V3 said it states on the discharge summary that R185 initiated discharge. V3 said R185 does have a BIMS score of 00 which indicates that R185 has severely impaired cognition, but that R185 is able to understand. V3 said that the BIMS score is 00 because R185 is nonverbal most of the time. V3 said she knows R185 understands, and she seemed happy about transferring to another facility. V3 said she believes that R185 was capable of making her own decisions. V3 said that she never attempted to contact any other family members on R185 contact list because they weren't the POA (Power of Attorney), and she was only told to get ahold of the POA. V3 said that she did not try to contact V13's wife who is also listed on R185's contact list. V3 stated that she thinks V1 (Administrator) or V2 (Director of Nursing) might have gotten ahold of V13 on the day R185 transferred, but she wasn't sure. V3 doesn't know if any forms were sent to V13 other than the information about the new facility she sent on the day of discharge on 06/18/24. On 09/18/24 at 12:40PM, V1 (Administrator) stated that the facility did initiate R185's discharge. They sent her to a facility with a locked unit. V1 said that she did believe that a notice was sent to V13, but she didn't know when that was. V1 said she knows that they did talk about notifying the son. She thought V3 took care of that. V1 said that V3 worked on R185's discharge planning. V1 said that R185 could understand and answer appropriately at times. V1 knows that R185 has a low BIMS score which indicates severely impaired cognition but V1 said that R185 knows what is going on. V1 said she would expect V13 to be notified of the discharge and transfer before it was made. V1 said that she didn't know what the policy was for involuntary facility-initiated discharges. On 09/19/24 at 7:55AM, V1 stated that they did not complete a notice of involuntary transfer form or notify the ombudsman concerning R185's involuntary facility-initiated discharge. V1 said at the time they were discharging R185 she wasn't thinking of it as an involuntary facility-initiated discharge. V1 stated that she does see it was now. V1 stated that she does not know why V13 wasn't notified other then they could not get a hold of him. V1 said that they should of documented all the attempts the facility made to get a hold of V13, but she said they didn't. V1 agreed that V13 could not have done an appeal since he didn't know about the discharge. V1 said that she never told V3 that she could not call any of the other contacts on R185's contact list other than the POA. V1 stated that V3 is still learning the Social Service Director job and probably didn't know she could have contacted others on R185 contact list. On 09/19/24 at 3:30PM, V1 stated that she could not find a policy regarding Involuntary Facility Initiated Non-Emergent discharges. The Facility Policy titled Transfer or Discharge, preparing a Resident for Discharge with a revised date of 12/2016 documents under Policy statement Residents will be prepared in advance for discharge Policy Interpretation and Implementation documents in part 1c. Providing the resident or representative (sponsor) with required documents. The Facility Policy titled Transfer or Discharge, Emergency revised 12/2016 documents in part under Policy interpretation and Implementation 2. If a resident exercises his or her right to appeal a transfer or discharge notice, he or she will not be transferred or discharged while the appeal is pending unless the failure to discharge or transfer would endanger the health and safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, home, or other setting our facility will implement the following procedures. 4a. Notify the resident's attending physician. 4e. Notify the representative (Sponsor) or other family member. The facility policy titled Discharge Summary and Plan revised 12/2016 documents under policy statement When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new environment. Under Policy Interpretation and Implementation 12. A member of the IDT (Interdisciplinary Team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan: and c. The discharge summary.

Based on interview and record review the facility failed to provide a discharge summary for 1 of 1 resident (R185) reviewed for discharge in a sample of 32. The findings include: R185's Face Sheet, with a print date of 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or delusions, no physical behavioral symptoms directed towards others, no verbal behavioral symptoms, other behavioral symptoms not directed towards other (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of the 7 day look back period, did not reject evaluation or care, and wandering 1 to 3 days out of the 7 day look back period. Section GG documents R185 was dependent for toileting, dressing, and personal hygiene and set-up and clean up for transfers. R185's Care Plan, with a cancelled date of 06/18/24, documents focus areas of: 1. (R185) is disoriented to place and time. (R185's) memory is similarly impaired. Consequently. (R185) has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. (R185) is known to be impulsive at times. This problem it related to Dementia. Strengths and abilities include her ability to be easily redirected. 2. (R185) has a behavior problem r/t (related to) (R185) is known to wander and lacks safety awareness. (R185) is easily redirected by staff most of the time. (R185) has a hx. (History) of agitation r/t dementia. (R185's) son reports (R185) has a known trend of doing bad things out of defiance then laughing when confronted. Recently (R185) has started to defecate in inappropriate places. (R185) appears to like attention even when it is negative attention for doing wrong as reported by (R185's) son. 3. (R185) has no discharge potential r/t poor safety awareness, cognition, and inability to care for self. A documented goal for this focus was (R185) will remain in the facility long term. R185's Progress Note dated 06/18/24 at 7:01AM documents in part Resident discharged via facility transporter with personal clothing et (and) medication to receiving facility. R185's Care Plan Summary/Participation record for R185, dated 03/28/24, documents in part R185 and V13 did not attend meeting. Goals for care document D/C (Discharge) is feasible, but resident/responsible party goal remains for long term placement. Other Changes/Updates document no family attended. Res (R185) will be looking at discharge to another facility when their lock down wing is complete. R185's Discharge Planning Review/Summary documents in part under Discharge Goals/General Information 1. Who initiated discharge? Resident (box checked). 2.Reason for discharge: She (R185) went to other facility. 3. Recap of resident's stay: The resident was a long-term resident that needed a locked down unit, and we transfer her to the other facility for better care .5. Initial discharge goals- remain in facility (box checked) . 8. Resident's goals of care and treatment preferences: to be able to stay in the facility. Under Medication Reconciliation it documents .2. Has post-discharge medication list been discussed with resident/family? Resident (box checked). Under Activity Summary, 1. Social Service it documents the Resident was excited that she was going to the [sic]. Under the section 2. Nursing Service it documents 1. Medical Summary-Medication was sent with her (R185). Under signatures 1. Resident signature and date documents R185 name typed in with date of 06/18/24. 3 staff signature documents V3 (Social Service Director) with typed in name and date of 06/18/24. On 09/18/24 at 12:30PM, V3 (Social Service Director/SSD) stated the discharge summary was not completed until 09/17/24 she stated that she did not know she had to complete a discharge summary when they transfer to another facility. V3 said she had started one on paper but got rid of it. The facility policy titled Discharge Summary and Plan revised 12/2016 documents under policy statement When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new environment. Under Policy Interpretation and Implementation 12. A member of the IDT (Interdisciplinary Team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place . 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan: and c. The discharge summary.

Based on observation, interview and record review the facility failed to follow physician's orders as prescribed for one (R14) of one resident reviewed for respiratory concerns in a sample of 32. The findings include: R14's face sheet documents an admitted [DATE] with diagnoses including: chronic obstructive pulmonary disease, moderate persistent asthma with (acute) exacerbation, dementia, and anxiety disorder. R14's Nurse's Note dated 09/14/24 at 4:23 PM documents: R14 came up to this nurse and stated, I don't feel well at all. This nurse asked the resident what was wrong, and she stated, I cannot stop coughing and I feel SOB (short of breath). This nurse assessed R14 and R14 has wheezing noted in all lung fields. The resident has some shortness of breath and a nonproductive cough that has been constant. R14 expresses that she is very tired as well. Covid test is negative. Vital signs are as follows: T (temperature) 97.5 (degrees Fahrenheit) P (pulse) 86, R (respirations) 20, BP (blood pressure) 151/82, and O2 (oxygen) 95% on 4L (liters). V15 (Medical Physician) notified of the above information and awaiting response at this time. The plan of care is ongoing. R14's Nurse's Note dated 09/14/24 at 5:46 PM documents: V15 responded back and stated, get a chest x-ray, start Prednisone 40 mg for 5 days and Duoneb q (every) 6 (hours) PRN (as needed). The orders are noted and processed. The plan of care is ongoing. R14's Physician's Order Sheet documents an order for Ipratropium-Albuterol solution (Duoneb) 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) with an order date of 09/14/2024 and a start date of 09/16/24. R14's Physician's Order Sheet documents an order for Prednisone 40 milligrams with an order date of 09/14/2024 and a start date of 09/16/24. R14's Medication Administration Record (MAR) documents the first administration of Prednisone was 09/16/24. R14's MAR documents there was no administration of Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML as of 09/19/24. R14's Nurse's Note dated 09/16/24 at 12:48 AM documents: R14's CXR (chest x-ray) shows that she has PNA (pneumonia) and will start abx (antibiotic) today, as well as Prednisone. R14's O2 sat (oxygen saturation) on 3 lpm (liters per minute) was 88%. O2 (oxygen) was increased to 4 lpm, the O2 sat is now 92%. No s/sx (signs or symptoms) of distress. There is no sob (shortness of breath), her HOB (head of the bed) was elevated 30 degrees. Will monitor. On 09/16/24 at 8:35 AM, R14 stated she was short of breath and on oxygen at 4 liters. R14 asked (surveyor) if her oxygen could be turned up. On 09/16/24 at 8:35 AM, R14 was having labored breathing and was short of breath. R14 was showing abdominal breathing. The surveyor notified the nurse at this time. On 09/16/24 at 8:37 AM, V2 (Director of Nursing) was observed entering R14's room to assess her. As of 09/19/24 there was no Nurse's Note or assessment available in R14's Electronic Health Record documenting V2's assessment. On 09/18/24 at 11:07 AM, V6 (Registered Nurse) stated R14's Prednisone and Ipratropium-Albuterol nebulizer were not started until 09/16/24. V6 stated, he does not see anywhere why they held the order until the 09/16 when he can see the order came in on 09/14. On 09/18/24 at 11:42 AM, V2 stated, she did not know why the Prednisone and the Ipratropium-Albuterol solution was started on 09/16/24 instead of 09/14/24. She stated she would have to ask V16 (Licensed Practical Nurse) if V15 (Medical Physician) wanted the medication held for some reason. On 09/19/24 at 9:40 AM, V2 stated she had not heard from V16 yet. On 09/19/24 at 1:40 PM, R14 was laying in her bed, she was having difficulty breathing and was short of breath. Her abdomen was sharply rising and falling while she was trying to breathe, and she was having difficulty with conversation. R14 stated, she was still having difficulty breathing. This surveyor notified V6 (Registered Nurse) at this time. There was no Nurse's Note or assessment available in R14's Electronic Medical Record of an assessment being completed on 9/19/24. On 09/20/24 at 8:50 AM, V15 stated he ordered the Prednisone and the Ipratropium-Albuterol on 09/14/24 for shortness of breath and he was expecting it to be given on 09/14/24, he would not have expected either of those medications to be held and not given until 09/16/24. He stated he ordered a chest x-ray on 09/14/24 which he received the results for on 09/15/24 and ordered an antibiotic for pneumonia that was started on the 16th, but he didn't want to give the antibiotic until he knew she had pneumonia for sure. On 09/23/24 at 10:33 AM, V2 stated she did not know why R14 had not received the Ipratropium-Albuterol nebulizer treatment or the prednisone on the 14th, she stated she has not been able to talk to V16. On 09/23/24 at 10:33 AM V1 (Administrator) stated, she did know why R14 had not received the Ipratropium-Albuterol nebulizer treatment or the prednisone on the 14th. R14's Care Plan documents an undated focus area of: Respiratory: potential for respiratory complications r/t (related to) recent acute respiratory failure, asthma with status asthmaticus, asthma with exacerbation and comorbidity of obesity with undated interventions listed as: administer medications as ordered, administer oxygen as ordered, and assess respiratory status: rate, depth, pattern, and skin color. The facility policy dated January 2024 titled, Administering Medications documents: 3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review the facility failed to provide supplements as ordered and follow the facility policy for weight management for 2 (R27 and R15) of 4 residents reviewed for nutrition in a sample of 32. Findings include: 1. R27's face sheet documents an admitted [DATE] with diagnoses including: unspecified physeal fracture of lower end of right fibula, dementia, muscle weakness, and chronic kidney disease. R27's Minimum Data Set (MDS) dated [DATE] documents: a Brief Interview for Mental Status of 04, indicating R27 has severe cognitive impairment, section GG documents eating assistance is: supervision or touching assistance. R27's Physician Order Sheet documents a dietary order of: regular diet with mechanical soft texture, and thin liquids with an order date of 08/06/24 and no end date listed. R27's weights are documented as: 8/6/2024 at 2:57 PM: 118.0 Lbs (pounds), 8/8/2024 at 3:56 PM: 118.0 Lbs, 8/22/2024 at 5:45 PM: 100.0 Lbs, 8/23/2024 at 2:14 PM: 99.5 Lbs, and 9/5/2024 at 10:26 AM: 100.4 Lbs. R27's Dietary Notes dated 8/27/2024 at 2:37 PM document: Initial Nutritional Review: R27's weight 99.5# (pounds), her diet order is regular diet with mechanical soft texture. R27's weights reflect a 15.7% weight loss since admission, her current weight is within IBW (Ideal Body Weight) range. R27's BMI (Body Mass Index) is 18.8 %. Her intake is reported as 50%-100% of most documented meals. R27 is currently COVID positive status. No labs are currently available for review. There are no skin concerns reported. R27's estimated nutrient needs are 1260 kcals (kilocalories)/day, 45 grams protein/day and 1350 ml (milliliters) fluid/day. (V17-Registered dietician) recommend's health shake with meals to provide additional nutritional support. R27's Nurse's Note dated 08/21/24 at 3:51 PM documents: R27 is COVID positive on 08/19/24. On 09/17/24 at 12:20 PM, R27 attempted to take a drink of her health shake through her straw, and none came up, she put the carton down and started moving away from the table. On 09/17/24 at 12:23 PM, R27's health shake was frozen with a straw in it and there was a full carton still present. On 09/17/24 at 12:23 PM V2 (Director of Nursing) stated, they need to get those health shakes thawed. On 09/18/24 at 2:20 PM, V1 (Administrator) stated their policy states, residents should be weighed weekly as a new admission, she does not know why R27 was not weighed on 08/14 or 08/15. If she had weight loss, then V17 should have been notified. On 09/23/24 at 10:35 AM, V1 stated she does not know why there is not an order for a health shake for R27. On 09/23/24 at 10:35 AM, V2 stated, she did have a weight for R27 on 08/13/24 of 107.5 pounds, it was written in a notebook. She stated, she does have R27 at 118 pounds on 08/06/24 that would have triggered a significant weight loss for R27. R27's Electronic Health Record does not contain any documentation of a weight for R27 on 08/13/24 or any documentation of notification of V17 of R27's weight loss on 08/13/24. 2. R15's Face Sheet documents an admitted [DATE] with diagnoses including: anemia, muscle weakness, vitamin D deficiency, and other fatigue. R15's MDS date 08/30/24 documents no BIMS score listed. Section C documents: cognitive skills for daily decision making as: moderately impaired. R15's Physician's Order Sheet documents a dietary order for: regular diet, regular texture with thin liquids consistency, super cereal daily, med pass 2.0 60 cc (cubic centimeters) TID (three times a day) with meals, extra dessert at lunch for dietary with an order date of 09/04/2024 and no end date listed. R15's Physician's Order Sheet documents an order for: admit to residential hospice with a start date of 09/04/24 with no end date listed. R15's Care Plan (undated) documents a Focus area of (R15) is under Hospice care due to a terminal diagnosis of Atherosclerosis of native coronary artery. On 09/17/24 at 12:13 PM, R15 did not receive extra dessert with lunch. On 09/18/24 at 12:10 PM, R15 did not receive extra dessert with lunch. On 09/19/24 at 12:15 PM, R15 did not receive an extra dessert at lunch. R15 stated, he only gets one dessert with lunch. At this time, R15 was alert and oriented to person, place and time. R15's Nurse's Notes dated 8/1/2024 at 12:08 PM document: R15 is noted with weight loss, a new order for extra dessert at lunch. R15's Dietary Notes dated 6/17/2024 at 7:48 PM documents: R15 was reweighed at 128#(pounds) which is stable with his usual weight, weight is maintained within IBW range. R15's intake is reported as 50%-100% of documented meals. Continue with present diet order of Regular with super cereal at breakfast and med pass 2.0 60cc tid and weigh monitoring. R15's Dietary Notes dated 7/30/2024 at 6:42 AM documents: Annual Nutritional Review: R15's weight 133# (pounds) his diet order is: regular diet; super cereal at breakfast; and med pass 2.0 60cc tid. R15's weight is within IBW range and BMI is 22.1 %, his intake varies between 50%-100% of most meals. There are no labs currently available for review. There are No skin concerns reported. R15's estimated nutrient needs are 1680 kcals/day, 60 grams protein/day and 1800 ml fluid/day. R15's diet is appropriate to provide for estimated needs. R15's weights are documented as: 02/12/24 at 9:53 AM as 145.0 Lbs (pounds), 03/11/24 at 10:19 AM as 145 Lbs, 04/25/24 at 2:48 PM 132.5 Lbs, 04/29/24 at 12:29 PM as 130.5 Lbs, 05/27/2024 at 2:32 PM as 128 Lbs, 06/11/24 at 10:13 AM as 123 Lbs, 07/29/24 at 2:20 PM as 133 Lbs, and 08/12/24 at 10:19 AM as 129 Lbs. On 09/19/24 at 2:37 PM, V17 (Registered Dietician) stated, she would expect to be notified of any significant weight loss and she would expect all residents to receive supplements that are ordered, and, in a manner, they can consume them or to be given assistance to consume them. On 09/23/24 at 10:35 AM V2 stated, that R15 had an incorrect weight entered in R15's weight record and it threw off R15's weight triggers. Therefore R15 would have triggered a weight loss and not triggered for a weight gain, thus showing V17 that R15 had a significant weight loss. The facility policy dated 2023 titled, Weight Assessment and Intervention documents: Weight Assessment: 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met.

Based on observation, interview and record review the facility failed to provide diets as ordered for 2 (R18 and R24) of 4 residents reviewed for nutrition in a sample of 32. The findings include: R18's face sheet documents an admitted [DATE] with diagnoses including: dementia and diastolic heart failure. R18's Physician's Order Sheet documents an order for: regular diet with mechanical soft texture, thin liquid consistency, cut meats, super cereal, and snack between meals. Ice cream at lunch and supper. Extra dessert at lunch and supper, health shakes twice daily after breakfast and after lunch with an order date of 07/22/2024 and no end date listed. R18's care plan documents an undated focus area of: R18 is as risk for comprised nutritional status related to Diagnosis of Alzheimer's disease or related dementia. R18 is on a mech (sic) soft regular diet per her request as she has difficulty at times chewing meats with her partial dentures with an undated intervention of regular mech soft diet, cut meats and super cereal, ice cream for lunch and supper. R24's face sheet documents an admitted [DATE] with diagnoses including: dementia, Alzheimer's disease, and prediabetes. R24's Physician's Order Sheet documents an order for NAS (no added salt) diet with mechanical soft texture, thin liquids consistency, assist resident as needed with meals, Finger food at mealtimes. Resident to use plastic cutlery for safety. No napkin. 60 cc (cubic centimeters) of 2.0 daily with lunch. Health shakes three times daily with meals. Extra sauces and gravy with an order date of 08/09/2024 and no end date listed. R24's care plan documents an undated focus area of nutrition; R24 is at risk for complications with weight and nutrition r/t (relating to) dementia. R24 is on a NAS regular texture diet with undated interventions listed include: diet: NAS mechanical soft with thin liquids. The facility document dated day 18 Wednesday titled, Diet Spreadsheet documents: regular diet: crispy rice dessert bar 3 (inch) x 2-1/2 and the dental soft (Mech soft) diet documents: soft sugar cookies - 2 cookies. On 09/18/24 at 12:10 PM, R18 received the crispy rice dessert bar for lunch. R18 took a small bite of the crispy rice bar tried to chew for a bit and did not try to eat the rest. R24 received the crispy rice dessert bar for lunch. R24 took a bite of the crispy rice bar, chewed for a bit and sounded like he cleared his throat and got up and started walking over to another table. On 09/19/24 at 2:37 PM, V17 (Registered Dietician) stated she would expect all residents to receive the diet they are ordered, so the mechanical soft diet should get all the items that are included with the specific diet texture, including the dessert. The facility policy dated 2022 titled, Therapeutic Diets documents: 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets.

Based on observation, interview, and record review the facility failed to provide the required 80 square feet of floor space per resident for 8 of 8 (R6, R7, R14, R15, R17, R22, R28, and R32) residents reviewed for room size in the sample of 32. Findings include: On 09/19/24 at 7:23AM V1 (Administrator) accompanied by this surveyor measured R15 and R32's room with a measuring tape, the room measured 147 inches by 150 inches which equals 153.13 sq. square (sq) feet, which indicates 76.56 sq feet per person the room contained: 2 bed, 2 nightstands, 2 bedside tables, 1 oxygen concentrator, 2 wheelchairs, 1 portable oxygen tank, and a cabinet. On 09/19/24 at 7:24AM R15 who was alert to person, place, and time, stated he had no concerns with his room size. On 09/19/24 at 7:30AM V1 accompanied by this surveyor measured R17 and R14's room with a measuring tape, the room measured 142 inches x 150 inches which equals 145.83 square (sq) feet, which indicated 72.92 sq feet per person the room contained: 2 beds, 1 chair, 2 nightstands, 1 miniature refrigerator, 2 bedside tables, 1 oxygen concentrator, 1 wheeled walker, and a cabinet. On 09/19/24 at 7:35AM R17 was sitting in her room laying down. R17 who was alert to person, place and time, stated she had no concerns with the size of her room. On 09/19/24 at 7:40AM V1 accompanied by this surveyor measured R22 and R28's room with a measuring tape, the room measured 142 inches x 150 inches which equals 145.83 square (sq) feet, which indicated 72.92 sq feet per person the room contained: 3 beds, 3 nightstands, 2 bedside tables, 1 walker, 1 portable oxygen tank, 1 fan, 1 cabinet, 1 wheelchair, and 1 oxygen concentrator. On 09/19/24 at 7:44AM R22 was lying in bed. R22 who was alert to person, place, and time, stated that she had no concerns regarding her room size. R22 stated she has enough space in her room. On 09/19/24 at 7:47AM V1 accompanied by this surveyor measured R7 and R6's room with a measuring tape, the room measured 144 inches x 144 inches which equals 144 square (sq) feet, which indicates 72 square (sq) feet per person, the room contained: 2 beds, 3 nightstands,1 wheeled walker, 1 wheelchair, 3 bedside tables, 1 cabinet, and 1 miniature refrigerator. On 09/19/24 at 7:50AM R7 was observed sitting up in bed eating. R7 who was alert to person, place and time, stated that she has enough space in her room. R7 had no concerns regarding room size or space. On 09/19/24 at 10:15AM V1 stated all of the rooms at the facility are double occupancy except room number one and room [ROOM NUMBER] which is being used as offices. V1 stated rooms 3-12 on A hall were Medicaid certified and rooms 14-22 on B hall and 23-26 on C hall were Medicare/Medicaid certified. V1 stated that they have 27 skilled beds and 22 intermediate beds. The facility Bed Management Tool dated 09/16/24 documents R6, R7, R14, R15, R17, R22, R28, and R32 reside in the rooms observed and measured by V1. Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms.

Based on interview and record review the facility failed to provide adequate staff to meet the care needs of the residents. This has the potential to affect all 34 residents residing at the facility. Findings Include: The Resident Census and Conditions of Residents dated 7/31/23 documents there are 34 residents residing at the facility. This same form documents 17 residents require assist of one or two staff for bathing and 17 residents are dependent on staff for bathing, 34 residents require assist of one or two staff for dressing, 33 residents require assist of one or two staff and one resident is dependent on staff for transferring, 34 residents require assist of one or two staff for toileting, and 33 residents require assist of one or two staff for eating, with one resident documented as dependent on staff for eating. The Midnight Census reports provided to this surveyor on 8/7/23 by V1 (Administrator) document, three residents (R1, R13, R26) require a mechanical lift to transfer and all 34 residents residing at the facility are incontinent and require assist of staff for showers. The facility CNA (Certified Nursing Assistant) and hall monitor schedule dated July 2023 documents the following: 7/2, 7/13, 7/20, 7/23, 7/29, and 7/30/23- two CNA's- 6 AM to 6 PM, 7/14/23- two CNA's-6 AM to 12 PM and one CNA-12 PM to 6 PM, 7/17 and 7/28/23- two CNA's - 12 PM to 6 PM, 7/24/23- one CNA - 6 AM to 6 PM, 7/31/23- two CNA's from 12 PM to 6 PM, 7/4, 7/9, 7/10, 7/16, 7/17/23 - one CNA and a hall monitor (HM)- 6 PM to 6 AM, 7/5, 7/7, 7/11, 7/12, 7/26, 7/27/23- two CNA's - 6 PM to 6 AM, 7/6/23 one CNA - 6 PM to 6 AM 7/8/23- one CNA and a hall monitor from 12 AM to 6 AM. On 8/2/23 at 1:33 PM, V15 (Certified Nursing Assistant/CNA) stated they don't always have enough staff to provide residents with the care they need. V15 stated on days they are fully staffed the residents get the care they need. V15 stated the facility administration said fully staffed is three CNA's. On 8/2/23 at 9:40 AM, V8 (CNA) stated sometimes she didn't know if she was going to have help while working. V8 stated they normally have three CNA's working on each shift unless someone calls in, then they work with just two. When asked if they were able to provide care with two CNA's, V8 stated, I don't think so. When asked what care was not able to be provided, V8 stated, incontinence care every two hours. V8 stated they have four people who require a mechanical lift for transfers. When asked if she has ever worked as the only CNA on a shift, V8 stated she had. V8 stated she tried to do her best and get to everyone when that happened. When asked if it was safe working with just one or two CNA's, V8 stated, No. V8 stated if they have to assist someone who requires a two person assist then there is no one to answer the call lights and there are residents who wander out the doors and they aren't able to monitor them to ensure they don't leave. V8 stated the alarm system doesn't always work the way it should. When asked if they have had residents wander out of the building, V8 stated, Yes, R17. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated they were short staffed all the time. V4 stated on 7/24/23 there was only her and one CNA working on day shift (6 AM- 6 PM). V4 stated on 7/23/23 there was only one CNA working but she came in and worked as a CNA for them. V4 stated on 7/31/23 she had two CNA's, but one only worked until noon, someone came in and covered until 3 but she worked for 3 1/2 hours on 7/31/23 with only one CNA. When asked what care doesn't get provided when they are short staffed, V4 stated, showers, bed checks, ADL's (activities of daily living). V4 stated, They just aren't getting the proper care. On 8/2/23 at 1:09 PM, V14 (LPN) stated staffing was hit or miss. V14 stated some shifts are staffed really well and then the next day they may have a couple of call ins. V14 stated she had worked with just one CNA before. When asked if everyone was provided with necessary care, V14 stated they were but it was not as much as she would have preferred. When asked if residents were given showers, V14 stated showers weren't done on that shift. On 8/3/2023 at 4:05 PM, V17 (CNA) stated he had worked with a hall monitor and a nurse before. V17 stated when that happens, they do the best they can. When asked what care doesn't get provided if he is working with a nurse and a hall monitor, V17 stated, I can't do the bed checks like I should. V17 stated he tries to do a minimum of three bed checks but when he is working with just a hall monitor and nurse, he does good to do two bed checks. The schedule documents V17 works 12 hour shifts. On 8/2/23 at 1:56 PM, when asked if they had enough staff to meet the needs of the residents, V2 (Director of Nurses/DON) stated she was new to long term care (LTC). V2 stated she started on 1/30/23. V2 stated some days they have enough staff and some days it is a struggle. This surveyor reviewed with V2 there were days they only had one CNA working and V2 stated, Yes. When asked if they were able to provide care and keep the residents safe, V2 stated, I am not sure how to answer that question. V2 stated, I am new, and I have been told that is the way it always is in LTC and so we make do. On 8/2/23 at 3:35 PM, V1 (Administrator) stated they have enough staff to meet the needs of the residents. When asked if two staff (one licensed and one certified) could meet the needs of the residents, V1 stated, Well, I try not to have two staff working. V1 stated she always has a hall monitor working if they only have one CNA working. This surveyor reviewed with V1 the interviews with staff saying they worked with just one CNA, V1 stated, Well, that is not what I want. When asked if one nurse and one CNA working would be able to meet the needs of the residents, V1 stated, it would depend on the residents in the building, the time of day, and what was needed for the residents.

Based on observation, interview, and record review the facility failed to provide an environment free of excessive flies. This has the potential to affect all 34 residents residing in the facility. Findings include: On 7/31/2023, at 10:00 AM, 4 flies were observed in R27's room. On 8/01/2023, at 11:30 AM, 3 flies were observed in R33's room. On 07/31/23 at 9:15 AM, three flies were flying around R31's room periodically trying to land on him with him swatting them away. At that time R31 stated the flies are bad. R31's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 13 indicating cognitively intact. On 07/31/23 at 12:30 PM, R29 had two fly strips in her room, one with 5 dead flies and one with 7 dead flies on it with two more flies flying around the room. At that time R29 stated, there are a lot of flies in here. R29's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 07 indicating severely impaired. On 07/31/23 at 12:30 PM, the air conditioning (AC) unit in R9's room had a one inch gap under the AC unit and a 0.5 inch gap under the AC unit's mounting side panel. There were 3 flies flying around his room. R9 was not in the room at that time. On 08/01/23 at 12:20 PM R9 stated, there are a lot of flies here, while sitting in the dining room. On 07/31/23 at 10:15 AM, R8 stated she does not go to the dining room at times due to there being too many flies present. R8's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/01/23 at 12:18 PM, R18 was trying to sleep when a fly kept landing on her arm, and she kept swatting at it. Finally, the fly left her arm and landed on her food that was left from lunch. On 08/01/23 at 3:30 PM R18 stated, these flies are horrible, I was trying to sleep because I wasn't feeling good, and they kept landing on me. R18's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/02/23 at 7:45 AM there was a fly on R27's food while he was eating in the dining room. After this R27 did pick up his plate and go eat on the couch on the other side of the dining room. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/02/23 at 12:30 PM R23 was laying in his bed watching TV with two flies repetitiously landing on him and he kept swatting them away. At that time R23 stated, these flies are bad in here. R23's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/02/23 at 12:15 PM, R32 had a fly walking on the rim and inside of her milk glass while sitting in the dining room. R32 did not say anything about the fly she just stared past it. R32's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/02/23 at 12:15 PM, R237 was in the dining room and had a fly flying around her, landing on her and her food. R237's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/01/23 at 11:45 AM, V11 (transportation/appointments) stated, there are flies in here but that happens with the doors always being opened with residents going outside and coming back in. On 08/02/23 at 1:10 PM, V1 (Administrator) stated, there are flies, but it is just that time of the year. Resident council minutes dated 07/14/23 document under New Business: under the category Maintenance flies. No additional information was provided. The facility policy titled. Pest Control dated 2021 documents: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The Resident Census and Condition of Residents form dated 07/31/23 documents there are currently 34 residents residing at the facility.

Based on interview and record review, the facility failed to provide timely pain management including assessment and treatment in accordance with facility policy for 1 (R2) of 3 residents reviewed for pain management in the sample of 9. This failure resulted in R2 experiencing unrelieived pain after orthopedic surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: R2's face sheet documented an admitted [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's face sheet also documented a fracture around internal prosthetic Right knee joint, fracture of upper and lower end of the right fibula, and displaced fracture of the 5th metatarsal joint. R2's 10/15/22 progress note documented arrival to the facility at 18:48 (6:48 PM). R2's Discharge Plan Instructions and Recap of Stay documents a discharge date of [DATE]. R2's 10/19/22 Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated R2 was cognitively intact. Section G of the same MDS noted that R2 was an extensive assist with personal hygiene, toilet use, dressing, transfer and bed mobility. On 11/2/22 at 2:58pm, R2 said that she was in terrible pain when she arrived to the facility (on 10/15/22). R2 stated she had just rode in a box car [van] and was bouncing all over the place. R2 said when she was discharged from the out of state hospital, they did not give her anything for pain prior to her leaving. R2 said she did ask for pain medication after she arrived to the facility, and also through the night into the next day. R2 said she finally got pain medicine the next evening. On 11/2/22 at 1:40pm, V2 (Director of Nursing/DON) said she admitted R2 to the facility. V2 said she helped R2 get off the cart when she arrived. V2 said that R2 did not have any pain. When V2 was asked if she did an assessment on R2, she replied no and that she just kind of looked at her and had her squeeze her hands. V2 said she did not chart any assessment. V2 said she also did not fax any orders to the pharmacy and that V14 (Licensed Practical Nurse/LPN) was to fax the orders. V2 said that a pain assessment should be done when admitting a resident and expects it should be done within 20 minutes of admission to the facility and it is not acceptable for an assessment to be done at 9am the next day. V2 said R2's medication should have been delivered the evening of 10/15/22. V2 said there is no cut off time to send new orders to pharmacy to receive the same night. V2 said that it is unacceptable R2's medications were not delivered to the facility the night of 10/15/22 and that someone should have been on the phone long before that. V2 was asked about medications in their emergency kit. V2 said that their cube x (emergency kit) was exhausted since that was their 4th admission of the weekend. V2 said she is not aware of any staff notifying pharmacy that the cube x was exhausted. When asked about R2's pain medications, V2 acknowledged that R2 went over 24 hours without any pain medication. V2 said that V10 (MDS Coordinator/LPN) does not work on the weekends and was not present on 10/15/22 when R2 was admitted . V2 said V10 completed the initial pain assessment. On 11/2/22 at 2:00pm, V3 (Regional Clinical Director) said that the cube x was not exhausted and there was plenty of [MEDICATION(S)] to be given if needed. On 11/2/22 at 2:49pm, V14 (LPN) said she worked on 10/15/22 6am to 6pm and believes it was her that faxed R2's medication orders to the pharmacy on the evening of 10/15/22 when R2 was admitted . V14 said that she also worked 10/16/22 6am to 6pm. V14 said that R2 was lethargic and tired. V14 said R2 told her she was exhausted from the long ride to get to the facility on [DATE]. V14 said that R2 never complained of out right pain on her shift on 10/16/22. V14 said that R2 slept most of the day except when her family was here. On 11/2/22 at 3:20pm, V4 (Registered Nurse/RN) said that she came on her shift on 10/16/22 at 6pm. V4 said when she went to assess R2, since she was a new resident, she asked her about pain. V4 said R2 stated she was miserable and has been here a day and could not even get a f***ing Tylenol. V4 said R2 did take [MEDICATION(S)] but she said they make her loopy and she would rather take Tylenol. V4 said she passed this on in report. On 11/3/22 at 10:06am, V16 (Certified Nurse's Assistant/CNA/CNA Supervisor) said she was present when R2 arrived at the facility on 10/15/22. V16 said that R2 did complain of pain from the ride to V16 and the nurse gave R2 some Tylenol. R2's Pain Questionnaire noted a Reason for Screen was assessment at admission. This document was dated 10/18/22 at 11:08am and signed by V10 (MDS Coordinator/LPN). Section B noted R2 was alert, had pain daily, intensity of pain was moderate, other observations of pain such as facial expressions, guarding, moaning, restlessness, rubbing area. The same document notes a score 5 or greater indicates comprehensive assessment was needed. The document also noted R2 had a pain score of 7 at that time. R2's Comprehensive pain assessment for admission was signed on 10/18/22 at 11:25am noted the location of pain as right ankle (inner) and right lower leg (rear) and the most recent pain level was 5 on 10/18/22 at 0808 (8:08 am), pain is relieved by medication, throbbing and discomfort as pain characteristics, receives as prn (as needed) medications and medication is effective. The conclusion noted pain management intervention is necessary, refer to resident plan of care. R2's Care Plan Meeting noted the type as 48 hour/initial dated 10/20/22. Document labeled Baseline Care Plan noted that R2 had presence of pain. Pain location noted is Right lower leg (rear) and right ankle (outer). Most recent pain level and date was left blank. R2's progress note dated 10/16/22 written by V14 (LPN) documented in part .this nurse has spoke with pharmacy twice this shift regarding resident's medications. Pharmacy has assured me that meds will be in this evening including pain medications. Will continue to monitor . R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain Management with an order date of 10/15/22, but no start date listed. Monitor and document pain level every shift for pain management with an order date of 10/15/22 and a start date of 10/17/22. Acetaminophen Tablet 325mg (milligrams) Give 2 tablets by mouth every 4 hours as needed for prophylaxis with an order date of 10/16/22 and a start date of 10/16/22. [MEDICATION(S)] HCI tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for pain with an order date of 10/16/22 and a start date of 10/16/22. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The section for Monitor and document pain level every shift for pain management notes a start date of 10/17/22 and discharge date of [DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry in this section of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The night shift pain level was documented as 4. These entries continued as required after 10/17/22 through R2's date of discharge on 10/26/22. The section for Acetaminophen Tablet 325mg Give 2 tablet by mouth every 4 hours as needed (PRN) for prophylaxis notes a start date of 10/16/22 and discharge date of [DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The dates of 10/16/22 and 10/17/22 are blank for both pain level rating and PRN given. The dates of 10/18/22 and 10/19/22 document pain levels of 5 and 7, respectively, with the medication being administered and marked as E for effective. The dates of 10/20/22 and 10/24/22 are also blank. The dates of 10/21-10/23/22 and 10/25-10/26 all documented pain ratings with the medication being administered and marked as E for effective. The section for [MEDICATION(S)] HCI tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for pain notes a start date of 10/16/22 and discharge date of [DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A pain rating of 9 is documented on 10/16/22 at 2011 (8:11pm), with a checkmark to indicate the medication was administered with an E marked for effective. This was the first documentation of pain medicine being administered to R2 and was over 24 hours after her admission. The are 3 other entries for the rest of that day left blank. On 10/17/22, the following pain ratings were documented: 7 at 0336 (3:36am); 8 at 0744 (7:44am); 8 at 1204 (12:04pm), 9 at 1606 (4:06pm), all with a checkmarks to indicate the medication was administered, and an E marked for effective. There is no documentation to show [MEDICATION(S)] was given from 10/18/22 thru discharge on 10/26/22, as those entries are all blank. The facility Pain Management policy documents in part, the purpose is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The facility will achieve these goals through: Promptly and accurately assessing and managing pain to the greatest extent possible. The same document notes under Pain Management Procedure, that pain will be assessed and managed in a timely fashion especially if it is of recent onset. Under Nursing Commitment to Pain Management documents, a Pain Questionnaire is to be completed with input from the resident upon admission, readmission, quarterly, upon a change in condition or when new pain is suspected. If the resident scores a 5 or above on the pain questionnaire, a Comprehensive Pain Assessment will be completed.

Based on observations, interview, and record review, the facility failed to implement safety measures for 3 of 3 (R1, R2, and R11) residents reviewed for accidents in the sample 11. This failure resulted in R2 ingesting a whole napkin, being transferred to the local hospital for symptoms of aspiration, a full paper towel being removed from his airway, and intubation being required. Findings Include: 1. R2's facility admission record dated 11/06/2020 documents R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set) dated 10/08/2020 documents R2 has a BIMS (Brief Interview for Mental Status) score of 01, which indicates R2 has a severe cognitive deficit. R2's current care plan (not dated) documents an undated focus area of self-care deficit in feeding r/t (related to) impaired sight and impaired cognition with interventions that include; provide verbal cues and use hand over hand if needed. R2's nurses notes dated 10/23/2020 at 6:45 PM document res (resident-R2) was sitting upright in w/c (wheelchair) at table in dining room feeding self r/t (related to) evening meal. This nurse observed large amt (amount) of thick yellow sputum noted in mouth. Res alert resp (respirations) uneven et (and) labored O2 sat 81% .unable to cough or clear airway .O2 applied at 15 L (liters) .transferred res from w/c to bed . (name of local ambulance service) notified for transfer to ER The local ambulance service patient care report dated 10/23/2020 documents Primary survey showed pt (patient) had no life-threatening injuries or symptoms Staff advised he may have aspirated on his dinner tonight and he's a little combative, and we heard stridor with his breathing so we put him on 15 LPM (liters per minute) .Pt was transported to (name of local hospital), where care was transferred without incident . R2's local hospital record dated 10/23/2020 documents under ED (Emergency Department) provider notes, The patient is a [AGE] year old nursing home patient who is at baseline nonverbal and requires help for all activities of daily living who presents to the emergency department with increased work of breathing according to the nursing home. He was apparently being fed when he started to have difficulty breathing. Nursing home noted stridor. He was given supplemental oxygen but did not improve with saturation in the high 80's. Additionally, the (sic) stated to EMS (Emergency Service Personnel) that they suspected aspiration although no obvious vomiting. Upon arrival the patient was noted to be hypoxic a 70 (oxygen saturation) on non-rebreather the and (sic) and was in respiratory distress .Upon arrival the patient is in acute [MEDICAL CONDITION] with [MEDICAL CONDITION] and at risk of respiratory arrest. Pneumothorax was ruled out with a chest x-ray .Decision to intubate patient.Testing in (sic) sedated with retrieval of a full-size paper towel within the airway going down into the chords. Under history and physical R2's active hospital problems and plan includes acute [MEDICAL CONDITION] secondary to aspiration of foreign body. On 11/04/2020 at 5:04 PM, V3 (Registered Nurse) stated she was at the facility on 10/23/2020 when R2 was transferred to the local emergency room for possible aspiration. V3 stated she was in the dining room and observed R2 having trouble breathing and not communicating normally. V3 confirmed the progress note she wrote documented R2 was eating independently at the time of the occurrence. Reviewed the care plan that documents verbal cues with hand over hand assistance during meals and V3 stated she had not observed R2 to require hand over hand assist during meals. On 11/10/2020 at 10:32 AM, V19 (Dietary Manager) stated she had worked at the facility for approximately [AGE] years. V19 stated R2 was not eating in his room so he was to have his meals served in the dining room. When asked what supervision R2 should have received during meals, V19 stated, They should have been watching him eat. V19 stated the new employees didn't know R2 wasn't supposed to receive a napkin with his meal and she has a note up on the wall now for that reason. When asked how long R2 had not been receiving napkins with his meals, V19 stated she thought it was care planned. When asked if R2 had attempted to ingest napkins before, V19 stated Once in a while. He can't see what he is eating. V19 stated this is maybe the third time R2 has attempted to eat a napkin. On 11/10/2020 at 2:28 PM, V19 stated there was probably no documentation related to previous incidents of R2 attempting to ingest a napkin because staff always intervened in time to stop him. V19 stated staff would take the paper napkin off R2's tray when they delivered it and R2 would use a cloth (bib like) napkin. When asked if that was a decision V19 made independently stated, No, it was a team decision but not the team I have now. It was before them. On 11/10/2020 at 2:44 PM, V16 (Activities Director) stated she did not remember R2 attempting to ingest napkins prior to the incident on 10/23/2020, but she remembered R2 attempting to ingest a magazine during an activity. V16 stated she took the magazine away and began to monitor R2 closely during activities. V16 stated it occurred a while back and she can't remember if she told anyone else about it. V16 states she thinks she remembers hearing R2 was not to have napkins. On 11/11/2020 at 10:45 PM, V18 (Certified Nursing Assistant) stated she had never witnessed R2 attempt to ingest napkins (non-food items) but stated she remembers someone (unknown) saying R2 had a history of [REDACTED]. On 11/05/2020 at 8:37 PM, V9 (Certified Nursing Assistant) stated she had never witnessed R2 attempting to ingest non-food items, but she thinks R2 may have in the past. On 11/10/2020 at 12:32 PM, V20 (Family Member) stated she had been notified by the local hospital that R2 was admitted to the hospital and had ingested a whole napkin. V20 stated she had not been told R2 had a history of [REDACTED]. V20 stated she had been to visit R2 prior to Covid and did not remember him receiving a napkin with his meal but did remember him having a bib. On 11/10/2020 at 1:28 PM, V2 (Director of Nurses) stated she was not aware R2 had attempted to ingest napkins in the past. V2 stated she believed R2 had finished his evening meal and was drinking coffee at the time of the incident. V2 stated R2 would eat independently and usually consumed 100% of his meals and then liked to drink a couple of cups of coffee. V2 stated the dining room was being monitored by staff and she believes the registered nurse (V3) was monitoring the dining room at the time of the incident. On 11/12/2020 at 2:10 PM, V23 (Physician) stated he is not aware of R2 attempting to ingest non-food items in the past, but R2 is confused and very sick. V23 stated R2 ingesting a full size paper towel should not have happened while someone was supervising him and R2 was intubated because of the acute aspiration of the paper towel which resulted in [MEDICAL CONDITION]. 2. R11's admission record documents R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11's MDS (Minimum Data Set) dated 10/01/2020 has a BIMS (Brief Interview for Mental Status) score of 00, which indicates he has a severe cognitive deficit. On 11/05/2020 at 12:01 PM, R11 was observed in the dining room. R11 was served his plate by staff. R11 had a surgical mask on his face covering his nose and mouth. R11 took a bite of food and attempted to put it in his mouth through the mask. R11 then took a second bite of his food and attempted again to put it in his mouth through the mask. R11 began attempting to chew the food and the mask appeared to be partially in R11's mouth as he chewed. Staff continued to serve trays to residents and did not observe R11 attempting to eat through his mask. This surveyor told V24 (Regional Clinical Director) who immediately removed R11's face mask. On 11/10/2020 at 10:32 AM, V19 (Dietary Manager) stated R11 was served his meals in the dining room because he wasn't eating well in his room. V19 stated he just needs prompting to eat. On 11/10/2020 at 1:28 PM, V2 (Director of Nurses) stated R11 feeds himself and wasn't eating well in his room so he was moved to the dining room. V2 stated R11 requires cueing to eat. V2 stated she wasn't aware of R11 attempting to eat his meal through his mask on 11/05/2020 and would implement interventions. 3. R1's admission record dated 11/06/2020 documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated 10/01/2020 documents R1 has a severe cognitive impairment. Under section G R1's MDS documents, R1 requires two person physical assist to toilet. R1's fall risk assessment dated [DATE] documents a score of 12, which indicates R1 is at high risk for falls. R1's current care plan (not dated) documents a focus area of ADL (Activities of Daily Living) self-care deficit related to dementia and impaired balance. The interventions listed include; R1 requires total staff participation to use toilet and transfer and to encourage R1 to use the bell to call for assistance. On 11/04/2020 at 9:01 AM, R1 was observed sitting in a wheelchair in her room with her head laying flat down on a pillow on her bedside table. V4 (Certified Nursing Assistant/CNA) stated R1 was ok and he was getting ready to take her to the bathroom. At 9:31 AM, R1 was in the bathroom with V4 when V6 (Licensed Practical Nurse) asked V4 to assist her. V4 left the bathroom and left R1 unattended on the commode. Continuous observation was done and V4 returned to the bathroom at 9:57 AM (26 minutes) to assist R1 off the commode. No other staff were observed entering or exiting the bathroom. There was no call bell or light observed in the bathroom. On 11/05/2020 at 11:55 AM, V4 (CNA) confirmed there were no call lights/bells in any of the bathrooms and that he left R1 on the commode. V4 stated, She wouldn't use the call light anyway. On 11/10/2020 at 1:28 PM, V2 (Director of Nurses) confirmed there were no working call lights/bells in the bathrooms on 11/04/2020. V2 stated it was not typical for staff to leave R1 on the commode unattended. When asked what she would expect staff to do V2 stated, I would expect the staff member to stay with the resident or stand right outside the door. I was there that day. They could have come and gotten me.