Every finding on record at Lakefront Nursing & Rehab CTR

Based on observation, interview, and record review, the facility failed to ensure the outside dumpster's lid was closed in an effort to prevent pest migration. This failure has the potential to affect all 90 residents at the facility. Findings include: The 04/28/2025 the facility resident census was 90. On 04/28/2025 at 10:01am, during the outside dumpster observation with V8 (Dietary Manager) and V10 (Aramark Regional Director of Operations). The outside dumpster has 3 lids. An unbroken box kept one of the dumpster's lids open. V8 stated the dumpster lid should be closed at all times to keep rodents from getting into the dumpster and to keep them from getting into the facility. V10 stated I will inservice them again to make sure the dumpster lids are kept closed at all times. The (undated) Outside Dumpster Expectations documented, in part The lid(s) on the outside dumpster serve multiple purposes including preventing rainwater from entering, containing trash to prevent littering and contain our daily waste and pest infestations. 1. Keep lid closed.

Based on observation, interview and record review, the facility failed to ensure staff don appropriate Personal Protective Equipment (PPE) while providing care to three residents (R10, R18, R343) in an Enhanced Barrier Precaution (EBP) room on the first floor and failed to decrease risk of cross contamination of linens in the laundry room. These failures have the potential to affect all 31 residents on the first floor and all 90 residents in the facility receiving laundry/linen services. Findings include: On 04/28/25 at 11:52 AM, V5 Certified nursing assistant (CNA) was observed in room transferring R10 without use of gown during care, he (V5) stated he did not use a gown on R10 because a gown was not required for transferring R10 into the wheelchair. When V5 was asked why he didn't use a gown when putting R10 into the wheelchair, he (V5) stated he did not change R10, and that he just transferred R10 into the wheelchair, so he (V5) did not need to use a gown. V5 stated he was educated by the Director of Nursing about reading the EBP sign on the door and about wearing gown and gloves during care to residents. On 04/28/25 at 11:56 AM, V6 (CNA) was observed in room transferring R10 without use of gown during care, she (V6) stated she did not use a gown on R10 because a gown was not required for transferring a patient into the chair. V6 stated she was educated about Enhanced Barrier Precautions (EBP) and when to use personal protective equipment (PPE). V6 stated she did see the EBP sign on the door but did not need to use a gown this time during the transfer because she (V6) was only helping to get R10 out of bed. On 4/28/25 at 12:12 PM V5 was observed in room with R18, he (V5) repositioned R18 from a lying position in bed to a sitting position at the side of her (R18's) bed. V5 did not have or use appropriate personal protective equipment in room with enhanced barrier precautions. On 04/29/25 at 11:07 AM, V22 (Physical Therapist) was observed in the room providing therapy care to R343, she (V22) was observed with gloves on and no gown while providing therapy to R343. V22's uniform and arms were observed touching against the bed while she (V22) was providing therapy to R343 in the bed. V22 did not have on any PPE and stated she (V22) could be wearing a gown, but she was done providing therapy to R343 and getting ready to leave the room. V22 stated to be honest there are signs on most doors, and she (V22) has become desensitized to wearing the gowns. When asked the purpose of wearing the gown V22 stated the gown should be used for protection for herself and residents that I am providing care too. On 04/29/25 at 11:58 AM, V24 (Laundry Aide) was observed in laundry room moving a yellow dirty bin past a grey clean linen cart that had linen in the cart. The yellow bin was in front of the dryer while the clean grey clothes cart was in a bin right next to it. V24 stated she is aware to place clean clothes bin in the clean linen room out of the way before she (V24) brings the dirty clothes bin in laundry room to decrease risk of cross over contamination but today has been so busy and she (V24) was rushing and forgot. R10's Face sheet dated April 30, 2025, documents that R10 was admitted to facility on January 29,2024 with diagnosis including osteoarthritis, protein calorie malnutrition, bipolar, hypertension, chronic obstructive pulmonary disease, psychosis, major depressive disorder. R10's MDS (Minimum Data Set) dated March 26,2025, shows R10 has a BIMS (Brief Interview for Mental Status) score of 8 which means R10 has moderate cognitive impairment. Section GG (Functional Abilities) shows that R10 has a score of 1 which means that R10 is dependent for all transfers and requires staff to provide all effort to complete the task for transfers. R10's care plan dated April 2,2024, shows R10 is on Enhanced Barrier Precautions related to gastrostomy tube (G-tube) feeding. Task/Interventions: [staff to ensure gown and gloves are used during high contact resident care activities like transferring resident into chair, feeding tube, changing briefs]. R10's care plan dated February 21,2023 shows that R10 utilizes a H** lift (Mechanical lift) for transfers. Task/Interventions: [staff to transfer resident with two staff assistance]. R10's physician order review report dated March 12,2025, shows R10 has an Enteral Feed of Jevity1.5, 1 carton 237 milliliters (ml) bolus feeding to be given to patient 3 times per day. R18's Face sheet dated April 30, 2025, documents that R18 was admitted to facility on March 5, 2024, with diagnosis of Dysphagia, moderate protein calorie malnutrition, hypertension, seizures, atrial fibrillation. R18's MDS dated [DATE], shows R18 has a BIMS score of 8 which means R18 has moderate cognitive impairment. Section GG (Functional Abilities) shows that R18 has a score of 1 which means that R18 is dependent for transfers and repositioning in bed and requires staff to provide all effort to complete the task. R18's care plan dated February 8,2025, shows R18 has self-care deficit of impaired bed mobility. Task/Intervention: [staff to assist resident to move and reposition in bed from lying position]. R18's care plan dated December 13,2024, shows Enhanced barrier precautions related to G-tube feeding. Task/Interventions: [staff to ensure gown and gloves are used during high contact resident care activities like transferring resident into chair, feeding tube, changing briefs]. R18's physician order review report dated July 18,2024, shows R18 has an Enteral Feed of Jevity1.5 with rate of (60 ml /hour) or until a total volume of 1200 ml infused. Diet order dated March 15,2025, shows R18 has a diet of Regular consistency with thin liquids. R343's Face sheet dated April 30, 2025, documents that R 343 was admitted to facility on April 17,2025, with diagnosis of Hypertension and weakness. R343's MDS dated [DATE], shows R343 has a BIMS score of 15 which means R343 is cognitively intact. Section GG (Functional Abilities) shows that R343 has a score of 1 which means that R43 is dependent for transfers and repositioning in bed and requires staff to provide all effort to complete the task. R343's care plan dated April 18,2025, shows R343 has self-care deficit of impaired bed mobility. Task/Intervention: [staff to assist resident to move and reposition in bed from lying position]. R343's care plan dated April 19,2025, shows Enhanced barrier precautions related to catheter and wound. Task/Interventions: [staff to ensure gown and gloves are used during high contact resident care activities like transferring resident into chair, urinary catheter, dressing, changing linens, providing care]. R343's physician order review report dated April 18,2024, shows R343 has an order for an indwelling catheter. Wound care order dated 4/22/25 shows that R343 has a wound on her right great toe and right medial ankle. On 04/29/25 at 11:18 AM, V25 (CNA supervisor) stated that the Director of Nursing educates the staff about EBP and the use of PPE. She (V25) stated staff is educated to wear PPE in EBP rooms to protect themselves and the residents that they are providing care too, and that the therapy/restorative department has also been educated on EBP and PPE use. V25 stated you are supposed to wear a gown when transferring a patient into the wheelchair who is on EBP. On 04/29/25 at 12:00 PM, V23 (Laundry Manager) stated that dirty clothes bin and clean clothes bin are not supposed to come into contact and laundry staff is aware not to bring dirty clothes bin in laundry if clean clothes are in the path because this could cause cross contamination. On 4/29/25 at 1:38 PM, V3 Director of Nursing (DON) stated she expects all staff to read the Enhanced barrier precautions (EBP) sign outside of the resident's door and follow instructions of EBP while providing care to residents. This includes transferring a patient from bed to wheelchair that is on EBP. She (V3) stated that she provides education too all nursing staff and department directors about EBP and what to wear and give them examples and staff are required to sign the education in-service form. V3 stated she does not in-service therapy department staff because the directors of each department are expected to take the education that she (V3) provides to them and educate their own departments, the therapy director has been educated about EBP. V3 stated the risk of not following EBP and wearing appropriate PPE could result in staff contaminating themselves or other residents. On 4/29/25 at 1:45PM, V3 provided a list titled Residents on Enhanced barrier precautions dated 4/29/25. The residents (R10, R18, R343) where listed on the document as having EBP. V3 also provided an in-service sheet for EBP staff training dated 3/7/25 and (V5 & V6) both signed the in-service form regarding education for EBP. On 04/30/25 at 10:36 AM, V28 (Therapy Director) stated he (V28) has been educated on EBP by the DON. V28 stated he reminds all therapy staff via email and or phone calls when they will be coming into the facility to provide care to residents to wear PPE and adhere to EBP. I expect my staff to wear PPE in rooms that have EBP signs on the door. Facility policy titled, Linen Handling by Laundry Staff, revision date 8/16/24, documents, It is the policy of this facility to wash linens and clothes to produce hygienically clean laundry. Procedures:1). All laundry staff will be trained upon hire how to handle regular soiled linens and isolation linens and clothing properly, to avoid cross contamination. Facility policy titled, Infection Prevention and Control revision date 11/21/24, documents, Policy statement: The facility has established a policy to identify, record, investigate, control, test and prevent infections in the facility. Procedures: 1). Enhanced Barrier Precautions is an infection control intervention designed to reduce transmission of Multiple drug resistant organisms (MDRO's). The goal is to prevent transmission of MDRO' to others. The facility should use a risk-based approach to determine the type of precaution if any are warranted, 2). Involves the use of gloves and gowns during high contact resident care activities for residents infected or colonized with MDRO's as well as residents with indwelling medical devices. Facility Enhanced Barrier Precautions sign documents in part Providers and staff must: wear gloves and gown for the following high-contact resident care activities: not limited to these care areas with residents transferring, dressing, providing hygiene, feeding tube, urinary catheter, changing linens. Facility's Job description titled, Physical therapist, dated 12/1/2019, documents in part, Assure that established infection control and prevention practices and standard precautions are maintained at all times. Facility's Job description titled, Certified Nursing Assistant, dated 5/20/2022, documents in part, Assure that established infection control and prevention practices and standard precautions are always maintained, 2) attends to individual needs of all guests regarding transferring, incontinent care, range of motion. Facility's Job description titled, Laundry Aide dated 12/1/2019, Summary: Laundry workers main function is to wash, dry, fold and mend clothing while following infection control and safety procedures. Essential functions: 2). sort soiled laundry in accordance with established infection control procedures, 3). assure that established infection control and prevention practices and standard precautions are always maintained.

Based on interviews and record reviews, the facility failed to ensure that the code status for one resident (R73) was added to his medical chart. This failure has the potential to affect 90 residents that reside in the facility. Findings include: R73 is [AGE] year old with diagnosis including but not limited to: Chronic Myeloid Leukemia, acute thyroiditis, essential hypertension and type 2 diabetes mellitus. On 4/28/2025 at 11:32 PM during investigation, V17 (LPN/ Licensed Practical Nurse) said that she was not sure what R73's code status was because it was not listed in his (R73's) chart and was not documented on the unit. On 4/28/2025 at 1:30 PM, R73's medical chart was noted with no code status listed. On 4/30/2025 at 12:32 PM, V26 (Regional Director of Clinical Services) said, Upon admission, we ensure that there is a code status. Ethically, a person that wishes to be a DNR (Do not resuscitate) should not be resuscitated. If there is no code status posted in the chart, we automatically default to full code and attempt to resuscitate the resident. The family is notified. On 4/30/2025 at 1:20 PM, V3 (DON/ Director of Nursing) said that all residents should have a code status ordered and entered into their chart so that the nurse is aware of the resident's and family's wishes. V3 also said that a code status is a personal choice and right of the resident and family. R73's Admission Record printed 4/29/2025 documents an admitted [DATE] and excludes a code status or advance directive. R73's Physician Order Sheet dated 4/29/2025 documented all active orders as of 4/29/2025; R73's Physician Order Sheet excludes a code status or advanced directive order. Facility Census dated 4/28/2025 documents 90 active residents in the facility. Facility Policy titled Physician Orders and dated 8/16/2024 documents, physician orders must be documented in the Physician Order Sheet section of the patient's clinical records. Facility policy titled Advance Directive and dated 3/21/2025 documents, an advanced directive form shall be completed with resident and/or legal representative to verify treatment options as well as code status; appropriate information will be added to Physician Order Sheet. Facility policy titled In- house DNR Procedure and dated 7/24/2024 documents, It is the facility's policy to ensure that residents who re DNR (Do Not Resuscitate) receive no resuscitation when found without vital signs.

Based on interviews and record reviews, the facility failed to obtain consent for the use of a psychotropic medication according to their policy for one (R1) of four residents, reviewed for unnecessary psychotropic medication regiment in the sample of 60 residents. Findings include: Face Sheet Documents R1 was transferred from acute care hospital to the facility on [DATE] with the following diagnosis but not limited to Psychosis, Cannabis Abuse with Psychotic Disorder Generalized Anxiety Disorder, Mood Affective Disorder, Major Depressive Disorder. Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 15 which indicates intact cognitive function. Care Plan Report, initiated on 10/6/2020, showed in part that R1demonstrates verbal behavioral distress that is related to mental illness. Problems could manifest by racial ethnic, religious, gender slurs and yelling of certain words in the hallway. Clinical Physician Orders, started date 10/19/2020, showed active orders for Depakote 250mg tablet twice a day and Depakote Delayed Release 500mg tablet, two tablets twice a day. On 4/29/2025 the facility presented consent for Depakote 500mg with 1000mg in parenthesis underneath with frequency BID signed by R1 on 9/28/2017. On 4/30/2025 at 10:11 AM, V1(Administrator), stated that the Psychotropic medication's consent forms should be a teamwork effort and collecting, updating, and maintaining are the responsibilities of all the nurses in the facility. The forms should be obtained and filled out upon admission by the admitting nurse or any other nurse available to help the staff. This includes the Director of Nursing (DON), the assistant of DON, restorative nurse, or a Medical records Nurse. V1 additionally stated that the forms should be updated for all current residents whenever there was a change in regiment. On 4/30/2025 at 10:32AM, V3 (Director of Nursing (DON) stated, that Psychotropic medications consents are filled out and reconciled by all nurses upon admission from other facilities. V3 additionally stated that, when there is increase or decrease in dose or any other changes to medication, a new consent should be filled out and the facility should discard the old consent. V3 stated that R1 should have new consent signed with the dosage changed since the only consent is from 2017. The Facility's policy on Psychotropic Medications Adopted on 5/30/2016 and revised on 2/3/2025 lists under Procedure 2. Obtain consent for each psychotropic medications from the resident or the person responsible for the resident. Obtain consent every time the dose is increased or decreased.

Based on interviews and record review, the facility failed to ensure that one resident (R73's) wound treatment orders were entered per Physicians order. This failure has affected one of four residents reviewed for nursing care. Findings include: R73 is [AGE] year old with diagnosis including but not limited to: Acute osteomyelitis, Chronic Myeloid Leukemia, essential hypertension and type 2 diabetes mellitus. R73 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 4/28/2025 at 12:15 PM, R73 stated that his wound care treatment, which was ordered by his doctor, had not been started at the facility yet. R73 said that his new wound treatments were ordered last month after his last Doctor's visit and that his wound should be healing faster so that he can discharge home. On 4/30/2025 at 12:32 PM, V26 (Regional Director of Clinical Services) said that it is sometimes assumed that if the residents don't give paperwork to the nurse, that there is no change in treatment. V26 said that it is expected that a nurse communicates any changes in orders given from doctor's appointment. On 4/30/2025 at 12:35 PM, V1 (Administrator) said that he expects his staff to reach out and follow-up with the doctor's office after an appointment. On 4/30/2025 at 1:20 PM, V3 (DON/ Director of Nursing) said that all resident's orders should always be entered into the residents' medical records to prevent delay in treatment. R73's Wound Evaluation dated 3/15/2025 documents, partial thickness surgical wound on right great toe; cleanse with normal saline, pat dry and apply betadine to the base of the wound and cover with rolled gauze. Facility email dated 3/28/2025 documents, please send orders for R73 to nursing facility; diagnosis of diabetes Mellitus (DM) and post-op wound hallux; order for packing gauze daily (qd) and dressing change with betadine. R73's Physician Order Sheet dated 4/29/2025 excludes orders for packing gauze and dressing change with betadine. Facility Policy titled Physician Orders and dated 8/16/2024 documents, physician orders must be documented in the Physician Order Sheet section of the patient's clinical records; physician orders will be carried out at a reasonable time. Facility Policy titled skin care regimen and treatment and dated 3/24/2025 documents, it is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdowns.

Based on observations, interviews, and record reviews, the facility failed to follow prescribed therapeutic diet order and failed to provide supplements for 2 of 4 residents reviewed for nutritional supplements. These failures affected two residents (R1, R38,) of four residents reviewed in the final sample of 60 residents. Findings Include: Face Sheet Documents R1 was admitted to the facility on [DATE] with the following diagnosis but not limited to Psychosis, Cannabis Abuse with Psychotic Disorder Generalized Anxiety Disorder, Mood Affective Disorder, Major Depressive Disorder, Personal history of COVID 19, Gastro-Esophageal Reflux Disease without Esophagitis, Vitamin D Deficiency, Hyperlipidemia, Constipation, Atherosclerotic Heart Disease, Hypertension. Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 15 which indicates intact cognitive function. On 4/29/2025 at 09:25 AM, V7 (Registered Nurse), stated that the facility was out of supplements and that they will substitute with another brand supplement which residents do not like. On 4/29/2025 at 11:57 AM, R1 stated that the food is not good and not enough and got upset when talking about food. On 4/29/2025 at 12:46 PM, R1's food tray was a standard portion size tray, consisted of two half links of sausages and potatoes with a small piece of cake and empty cup for coffee. R1's food tray ticket listed items as follows: hotdogs, potatoes, cake, Peanut Butter and Jelly Sandwich. The food tray did not have a peanut butter and jelly sandwich on it as listed per ticket. On 4/29/2025 At 12:48 PM, V10, (Regional Director of Operation), stated that R1's Peanut Butter sandwich should be on the tray. V10 and V17 (Licensed Practical Nurse), both stated that R1's diet order is general diet with thin consistency liquids with double entree. On 4/30/2025 at 10:29 AM, V3 (Director of Nursing, DON), stated that R1's diet order is general diet with a double entree. V3 stated that the expectation for specialized diets is communicated to the kitchen by sending the pink sheet that describes the special instructions, such as double entree for meals and PBJ sandwich with meals. Once pink sheet is received, kitchen will then update the meal ticket and follow the instructions during meal service. V3 additionally stated, that residents could lose weight if not receiving the correct diet and nutritional supplements as ordered by the physician. On 4/30/2025 at 10:55 AM, V9 (Registered Dietician), stated that there was a miscommunication about R1's diet and V9 was not aware of R1 not receiving double portion food trays. V9 stated that R1 should have been receiving double entrees, but R1 told her that facility has not been providing double entrees. On 4/30/2025 at 11:30 AM V8 (Dietary Manager), stated, that there was no pink sheet given to the kitchen for R1's meals instructions about double entrees. V8 also stated that the electronic document system and the Meal tracker system that facility uses, did not transfer data and therefore V8 did not see the order for double entrees for R1. V8 additionally stated, that V8 did not check the diet order in the electronic records for R1. V8 indicated that there should be a pink sheet for the resident with special instructions and that V8 should check the electronic records for diet orders. V8 additionally stated that the past employed dietitian would email V8 diet orders for residents, but V8 never received an email update or a change in diet order for R1. Care Plan Report, initiated on 12/5/2023 showed in part interventions including but not limited to dietary health supplement as ordered, offer between meal snacks and meal substitutions, provide/serve the resident's nutritional diet as ordered. Order Summary Report, Active Diet order started date 9/8/2017, showed General diet Regular texture, Thin liquids consistency, Double Entree portions at mealtimes; Two Peanut Butter and Jelly Sandwiches (PBJs) twice a day (BID) at lunch and Bedtime (HS) snack. Order Summary Report, Active Supplements order started date 12/12/2024, showed House Supplement one time a day ensure daily or Medpass 120ml . 45644 R38's admission diagnoses include but not limited to adult failure to thrive, depression, chronic obstructive pulmonary disease, hypertension, pacemaker, and hypokalemia. R38's (4/18/25) Brief Interview of Mental Status (BIMS) score is 13. R38 is cognitively intact. On 4/28/25 at 11:25 am, R38 stated, I do not get my ensure and have not gotten it but three times this month. Surveyor asked about the ensure on the bedside table. R38 stated, This bottle makes number 3. I am supposed to get it 2 times a day and I need it because I don't always have an appetite. I do not want to lose weight. I am already small. On 4/29/25 at 11:54 am, V8 Dietary Manager stated. In March there was a shortage of ensure but not recently. Staff was giving ensure to residents who was not supposed to be getting it. After the floors get their ensure and run out, they have to get the ensure from the administrator. The administrator keeps ensure in his office. The residents on the weight program get the ensure on their trays. It is not fair for the residents who are supposed to get the ensure not to get it. The ensure is to help sustain weight. On 4/30/25 at 10:25 am, V1 Administrator stated, There is no shortage of ensure in the facility. The goal is to give it to the correct resident. I keep it in the office and pass it out to residents. The ensure is to make sure the resident maintains their weight or gains weight if desirable. If the staff do not have it, they should call me so I can get it. I am not aware of R38 not getting her ensure. It can put her (R38) at risk for not maintaining her weight. R38 should get it based on her orders. On 4/30/25 at 12:02 pm, V3 DON (Director of Nursing) stated that the expectation for supplements in the facility is to give it as ordered. If the ensure is not available, then the staff should call the administrator. If they (residents) do not get it for a couple of days, it can have a little effect on them if it is given for weight loss. I am not aware of R38 not getting her ensure. Surveyor showed V3 R38's MAR for April regarding the ensure and asked what do UV mean that is documented on the MAR? V3 stated, It means Unavailable, she did not get it. On 4/30/25 at 1:33 pm, V9 Dietitian stated that residents who gets ensure, or a supplement get it because they need more calories. Supplements are ideal for failure to thrive residents. It helps to prevent weight loss and maintain muscle. I was not aware of R38 not getting her supplement. R38's active orders as of 4/29/25 documents in part, house supplement two times a day Ensure or med pass 120 ml (prefers Ensure Plus when available). R38's April MAR (Med Administration Record) documents in part, House Supplement two times a day Ensure or Medpass 120 ml (milliliter)prefers ensure when available. House supplement documented unavailable on 4/2/25, (5 pm), 4/3/25 (5 pm), 4/5/25 (9 am and 5 pm), 4/6/25 (5 pm), 4/12/25 (5 pm), 4/13/25 (5 pm), 4/19/25 (5 pm), 4/20/25 (5 pm), 4/25/25 (5 pm), and 4/27/25 (5 pm). R38's care plan documents in part, Focus: R38 is at risk for alteration in nutritional status related to PMH (Primary Medical History) .Adult failure to thrive .Interventions: Provide general, regular, thin liquid diet. House supplement BID (twice daily). Focus: R38 often refuses to eat/resist feedings . Facility's job description titled Director of Dietary Services dated 12/1/2019, documents in part, Essential Functions: 4. Works closely with facility dietitian to ensure meals meet the nutritional needs of the guest. 5. Ensures supplies are appropriated and places orders when necessary.

Based on observation, interview and record review the facility failed to label and date opened multi-dose insulin Kwik pens for 2 residents (R34, R82), failed to date an eye drop for 1 resident (R57) and failed to discard an expired house stock. These failures affected three residents (R43, R57 and R82) and has the potential to affect all residents receiving medications from the second-floor medication cart. Findings include: On [DATE] at 11:09am surveyor observed R34's Kwik Pen with an open date of [DATE]. On [DATE] at 11:10am V11 (Registered Nurse) stated R34's blood sugar runs low, and it should have been discarded already because it's passed the 28-day expiration date. On [DATE] at 11:12am surveyor observed R82's Kwik pen with no date on the insulin pen or plastic bag that held the insulin pen. On [DATE] at 11:20am surveyor observed R57's eyedrops with no open date on it. On [DATE] at 11:21am surveyor observed a bottle of Folic Acid 400mcg, containing pills, with an expiration date of ,d+[DATE]. On [DATE] at 11:22am V11 stated insulin and eye drops should be labeled with open dates so that the nurse can figure out the discard date and the house stock should be discarded by manufacturers expiration date so I will discard it and order a new one. On [DATE] at 12:13pm V3 (Director of Nursing) stated house stock medications should be discarded if they are expired, based on the manufacturer's deadline, and all insulin pens and eyedrops should be dated when opened. V3 stated the purpose of the dating insulin and eye drops is to determine when it expires. Medication Storage, Labeling, and Disposal policy with a revised date of [DATE] documents, in part, house stocks designed for multiple administration will be labeled with the name of the medication, the strength, instruction, and expiration. The information from the manufacturer is enough to meet this requirement. And the medication automatically expires based on the manufacture's guideline. Medication Pass policy with a revised date of [DATE] documents, in part, all medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening and Insulin vials are to be discarded within 28 days after opening.

Based on observation, interview, and record review, the facility failed to ensure equipment used to puree food items was air dried prior to use in an effort to prevent food contamination. This failure has the potential to affect 2 (R21 and R59) residents on puree diet in the total sample of 60 residents. Findings include: On 04/29/2025 at 11:24am, V29 (Dietary Aide) stated we have 2 residents (R21 and R59) on puree diet. On 04/29/2025 at 10:54am, V10 (Aramark Regional Director of Operations) stated we use Quats (Quaternary Ammonium compound) solution on the 'Sanitize' sink of our 3-sink compartment. On 04/30/2025 at 10:35am, during the pureeing of food item observation of V27 (Cook) for 2 residents (R21 and R59). V27 immersed the pitcher blender into the 'wash', 'rinse', and 'Sanitize' sinks of the 3-sink compartment and poured, into the pitcher blender, rice pilaf without air dying the pitcher blender. At this time, V10 (Aramark Regional Director of Operations) was requested to join this surveyor in observing V27. V8 (Dietary Manager) also joined in observing V27. After completing the task of pureeing the rice pilaf, V27 immersed the pitcher blender into the 'wash', 'rinse', and 'Sanitize' sinks of the 3-sink compartment and poured the California blend vegetables into the pitcher blender without air drying the pitcher blender. On 04/30/2025 at 10:39am, V10 stated she (V27) did not let the pitcher blender to dry. She should have dried the pitcher blender. My expectation is for the staff to clean and sanitize the pitcher blender and air dry the pitcher blender prior to pureeing each menu item. The rice pilaf is one menu item, and the California blend vegetable is one menu item. On 04/30/2025 at 10:45am, V8 stated I cannot believe she (V27) did not let the pitcher blender dry prior to pureeing the California blend veggies. My expectation is to air dry the pitcher blender prior to use to prevent food contamination. To prevent the water particles from the sink to go into the food. On 04/30/2025 at 12:22pm, V26 (Regional Director of Clinical Services) stated we only have 2 residents on puree diet. V26 handed R21 and R59's order listing reports and additional records. R21's (Active Order as of: 04/30/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) gastro esophageal reflux disease and chronic obstructive pulmonary disease. Dietary: Regular diet puree texture. Start date: 03/25/2025. R21's (04/10/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R21's mental status as cognitively intact. R59's (Active Order as of: 04/30/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) gastro esophageal reflux disease and dysphagia. Dietary: Regular diet puree texture. Start Date: 11/06/2024. R59's (02/12/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R59's mental status as moderately impaired. The (04/30/2025) In-service sign in sheet documented, in part In-service topic: Puree-contamination Process. 1. Breakdown machine with removing blade, bowl and top. 2. Clean and sanitize each machine item blade, bowl and top. 3. Air dry before using. Once complete, proceed to use to puree food item. Repeat with each menu option. The (undated) Puree Process documented, in part Break down blender with removing blade, bowl, and Top. Clean and sanitize thoroughly Blade, Bowl and top. Allow each to air dry completely before use. Once Air dried Blender is ready for next food product use. Will need to repeat process for each menu item.

Based on observations, interview, and record review the facility failed to provide at least 80 square feet per resident in 6 multiple occupancy resident bedrooms. This affected 17 (R1, R2, R5, R15, R20, R22, R33, R34, R35, R47, R50, R55, R62, R72, R77, R81, R82) residents. Findings include: On 4/28/2025 at 9:45 AM, during the entrance conference with V1 (Administrator), V1 stated that several rooms did not meet the square footage requirements per residents. V1 said that although the facility does not have the required room sizes, the facility follows the guidelines of the State Operations Manual. On 5/1/2025 at 3:30 PM, V2 (Assistant Administrator) said that in addition to rooms 108, 208 and 308, more rooms shall be added to the facility room waiver (107, 207, and 307). V2 said that no construction had been done to rooms 107, 108, 207, 208, 307 or 308, and that all six rooms had three residents in them. On 5/1/2025 at 3:30 PM, V2 said that she did not have the documented square footage of the rooms, but that the measurements of the rooms are the same as previously documented (226 square feet per room; 75.3 square feet per resident). The facility census dated 4/28/2025 documents, 48 rooms in the facility; rooms 107, 108, 207, 208, 307 and 308 are three-resident rooms.

Based on interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R2) of seven residents reviewed for abuse. This failure resulted in R2 and R3 having a physical altercation, resulting in R2 bleeding from a scrape R2 sustained above the right eyebrow. Findings include: Facility's Investigation Report (dated 09/06/2024) notes: On 09/01/2024, at approximately 12:30 PM, R2 and R3 got into a verbal disagreement that resulted in a scuffle. Security immediately intervened and successfully separated both parties. An in-depth investigation was conducted which included staff and resident interviews. R3 was offered a beverage from a staff member. R3 declined which is when R2 chimed in strongly insisting that he accept the beverage. As both residents continued to disagree on the situation they became increasingly agitated with the situation to the point where R2 began to walk into R3's personal space. That is when R3 put out his arms to establish a personal space boundary. When this action took place, he made contact with R2. The assistant administrator interviewed both residents and both of them admitted that things got out of hand, and they did not mean for the situation to escalate. They both were able to identify other methods of handling the situation and agreed to utilize them if they are in a similar situation in the future. Abuse and Neglect Policy (date revised 07/12/2024) notes in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment. Resident Rights Policy (undated) notes in part: You must not be abused by anyone-physically, verbally, mentally, financially or sexually. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Generalized anxiety disorder, insomnia, unspecified, type 2 diabetes mellitus with ketoacidosis without coma, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, unspecified, hypothyroidism, unspecified, other chronic pain. Minimum Date Set (MDS) section C (dated Sep.30, 2024) documents that R2 has a BIMS score of 15, indicating that R2's cognition is intact. Care plan (dated 10/02/2024) documents that R2 is at risk for falls due to decrease functional mobility and poor safety awareness. R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease, with heart failure, generalized anxiety disorder, paranoid schizophrenia, major depressive disorder, schizoaffective disorder, bipolar type, hyperlipidemia, unspecified, heart failure, unspecified. Minimum Date Set (MDS) section C ([DATE]) documents that R3 has a BIMS score of 15, indicating that R3's cognition is intact. Care plan (dated 10/8/2024) documents that R3 uses psychotropic medication and at risk for possible drug reactions dizziness, headache, drowsiness, sedation, hypotension, tremors, poor coordination, impaired balance, constipation, insomnia, tardive dyskinesia and dry mouth. Care plan (dated 11/12/2024) documents that R3 demonstrates behavioral distress, being challenged by mental illness, ineffective coping mechanisms, physically aggressive behavior when agitated. On 11/12/2024, at 11:36 AM, surveyor interviewed R3 regarding the physical altercation that occurred between R2 and R3 on 09/01/2024. The interview took place in R3's room on the 3rd floor. R3 stated, My family is from Virginia, and I have family in North Carolina. I believe in Jehovah, and I follow his laws. The sister (R2) from the second floor was coming on to me and I had to turn it down in the name of Jehovah. R2 said to me that she wanted to make passionate love to me all night long. There was no argument that took place with R2. R2 thought I was born in [NAME], and this is a crazy world. There was no argument, I'm from Virginia and [NAME]. I read several different Bibles and many of them are not true. Jehovah's name was taken out of the Bible. R2 found out that she was my family, and she was still hitting on me. Making love to R2 would be considered incest and I rejected her in the name of Jehovah because R2 is my immediate family. R2 was disappointed but I said no. There was no physical argument or verbal argument that took place between R2 and I that I remember. On 11/12/2024, at 11:54 AM, surveyor interviewed R2 regarding the physical altercation that occurred between R2 and R3 on the date of 09/01/2024. The interview took place in R2's room on the 2nd floor. R2 stated, The incident happened in the hallway. I finished by meal. I went to the hallway to put my tray on the cart and after that I was going to go to my boyfriend's room. R3 was residing on the 2nd floor at the time. While I was in the hallway, R3 was talking to me. At that time, the housekeeper offered R3 a soda pop, and he refused it. R3 started talking to me and the housekeeper in a crazy way. R3 pushed me and my head hit the doorway and I fell . After that, R3 kept hitting me and he beat my a**, while the staff kept watching. R3 was beating me and one of the certified nursing assistants came and separated us. I was bleeding; my face was leaking bad. The security guy from downstairs also came and separated us too. As long as R3 is not on the same floor as me, I feel safe here. I'm a woman and I didn't put my hands on him and R3 kept beating me. They separated us and they sent me to the hospital to get checked out and they also sent R3 to the hospital. On 11/12/2024, at 2:01 PM, V8 (Psychiatric Rehabilitation Services Coordinator) stated, I was not there the day that the incident between R2 and R3 took place. I know that there was an altercation between the two of them and that R3 was evaluated for his behavior. When R3 returned from the hospital, we made sure that R3 is placed on a different floor away from R2. R3 is not historically an aggressive resident. R3 is not a good historian. R3 is very tangential and has a flight of ideas and he goes all over the place. R3's baseline is pretty delusional. R3's standard frame of mind is that he has delusions on everyday basis. R3 is not known to be aggressive, he is mostly in his own world. R3 likes to keep to himself. R2 is friendly and non-aggressive towards anyone. R3 has never had any issues with fighting with anyone since she has been to the facility. On 11/12/2024, at 2:25 PM, V1 (Administrator) stated, I am the Abuse Prevention Coordinator. The residents have the right to be free from abuse, comfortable and feeling like they are at home. The incident between R2 and R3 was a quick encounter that started as a verbal disagreement that turned physical. I believe that the altercation stared as a verbal argument over a pop that was being offered to R3. R3 was also a newer resident to the facility at the time of the altercation. I believe a staff member offered R3 a soda pop. I believe it was a housekeeper who might have offered R3 a pop. That's when R2 interfered with R3 and said to R3 that he should take the pop. From that point, per the investigation, R2 and R3 got into a disagreement over the soda pop. R2 approached R3 and kept getting closer to R3's face. R2 was the aggressor not R3. At that point when R2 got closer to R3's personal space, that's when it turned into a scuffle. The way it was explained to me is that R3 put his arm out to push R2 away from R3, to defend himself and to move R2 away from his personal space. That's when R2 fell . Staff called a code gray right away when R2 fell to the ground. The housekeeper saw the whole incident. The 2 residents were immediately separated. R3 walked away and went into his room. R2 kept trying to go after R3. R2 was more of the aggressor and R2 kept trying to look for assistive devices to hit R3 with. R3 was placed on a 1 to 1 supervision. R2 was also placed on 1 to 1 supervision because she was the aggressor and not R3. R3 is not a resident who bothers other residents. R3 is calm and keeps to himself. R2 was placed on staff supervision because she would not stop going after R3. R2 was so agitated that R2 would not stop going after R3, and R2 had to be sent out. R2 was on the floor because she fell . R2 had to be sent out to get medically checked out and because R2 was aggressive. She needed a psychiatric evaluation. When I investigated this incident, I did not substantiate the incident because it was a behavior. The incident was sparked by R2 and led to R3 also having behaviors. Both residents were separated and kept safe and R3 was moved to a different floor. On 11/13/2024, at 10:26 AM, V11 (Registered Nurse) stated, I am familiar with the incident that took place on 09/01/2024, between R2 and R3. I was working on the 1st floor that day, and the incident took place on the 2nd floor. They called a code gray (fight between residents), and I went to the 2nd floor to respond to the code. When I got to the second floor, I saw that the CNAs (Certified Nursing Assistants) escort R2 back to her room. I did not get a chance to assess the situation because there was a nurse present on the floor and the residents were already separated and I went back downstairs. On 11/13/2024, at 11:37 AM, V12 (Assistant Administrator) stated, On 09/01/2024, I received the initial report that an incident took place between R2 and R3. I proceeded to investigate and ask questions of what took place. I asked the security guard what happened, and I got his statement. I also got the statement from the CNAs and the nurses that were there. From getting the statement, what basically happened is that R3 was offered a soda pop on the second floor. R3 refused the soda pop and that's when R2 put in her two sense and just started telling R3 to just take the pop. As R2 chimed in and started telling R3 to take the pop, R2 was walking towards R3, and that's when R3 put out his hand to protect himself, to establish his personal boundary or his personal space, and that's when the contact happened between R2 and R3. As R3 put out his hand to protect his personal space from R2, I do not recall anybody telling me that R2 fell . R2 did not tell me that she fell when R3 put out his hand to establish his personal space. Staff separated the 2 residents to prevent any further escalation and both residents were placed on 1 to 1 monitoring. The physicians were called and notified, and orders were given to send both residents to the hospital for evaluations. R3 was admitted to the hospital and R2 returned to the facility with no new orders. At the time of the initial report, it was believed that R3 was the aggressor, but in reality, after the investigation was done it was actually R2 who instigated the incident. R2 said to me that R2 should not have put her two cents in when R3 refused the soda. R2 was very remorseful about butting into other people's business. Nobody was the aggressor, because it was not abuse, it was just an incident that unfortunately escalated more than it should have. There was no maliciousness and no intent for abuse. R2 admitted that R3 was putting up his hands to establish his boundary. R2 admitted that when R2 talks to others, she has a tendency to walk towards that person, and R3 misunderstood that that's why he put his hand up as a boundary. On 11/13/2024, at 12:15 PM, V13 (Certified Nursing Assistant) stated, What happened is that day I worked the 7:00 AM to 3:00 PM shift. I was sitting at the nursing station trying to do my documentation on the computer and I heard the noise. I did not know what the noise was. I got up from the chair and I went to the hallway, and I saw both residents, R2 and R3, fighting each other physically. I ran to them and I immediate separated both the residents. I moved R3 to his room and I closed the door so that he is away from R2. R2 was in the hallway. I saw R2 hitting R3 and R3 was hitting R2. They were both physically fighting each other. It looked like R3 had the upper hand above R2 during the fight. I did not see R2 on the floor. I saw R2 lose balance and I saw R2 struggling because R3 had the upper hand during the fight. The code was called, but the residents were separated by me before anyone else arrived. When I saw the residents fighting each other, I moved R3 away from R2. I did not see R2 on the floor, but I saw R2 get hit and I saw R2 hitting R3 as well. I separated the 2 residents immediately and made sure that they are both safe and R3 was in his room with the door closed while the code was called. R2's Progress Notes (dated 09/01/2024) documents, Resident back From ER after evaluation done and found stable condition. Follow up with primary DR. within 3 days. R2's Progress Notes (dated 09/01/2024) documents, Resident on 1-1 ongoing observation. R2's emergency room Record (dated 09/01/2024) documents in part, Patient states she resides in a nursing home, today she reports she was involved in a physical altercation. Patient reports she obtained trauma to the head and chest. States she has pain in the back of her neck, in the chest where she states she was hit and her face. Physical Exam- Head: normocephalic, scrape over right eyebrow. R3's Progress Notes (dated 09/02/2024) documents, Resident is admitted at community hospital for aggressive behavior as per nurse on duty. Called emergency guardian at 6:40 AM with no answer and message cannot be left. The answering machine stated to call back during regular hours.

Based on observation, interview and record review, the facility failed to follow the plan of care to provide mechanically altered diet and nutritional supplements as ordered by physician for 1 (R1) of 4 residents reviewed for improper nursing care. The findings include: R1's admission record documented admitted on 1/28/2021 with diagnoses not limited to Dysphagia, Chronic obstructive pulmonary disease, Gastro-esophageal reflux disease, Essential (primary) hypertension, Hyperlipidemia, Vitamin d deficiency, Atherosclerotic heart disease of native coronary artery, Anxiety disorder, Cocaine abuse, Alcohol abuse, Schizophrenia, Adult failure to thrive. On 10/1/24 at 12:12pm Observed R1 resting on bed, head of bed elevated, appears comfortable, alert and verbally responsive. Lunch tray was served with ham sandwich, potato salad, juice, cookie. R1's meal ticket showed Mechanical Altered/Ground, whole milk, Frozen nutritional treat. Ham/meat was not ground. Whole milk and frozen nutritional treat were not available on the tray. R1 was assisted by V4 (Certified Nursing Assistant) at mealtime. R1 ate 100% of the food. Whole milk and frozen nutritional treat were not provided to R1. On 10/1/24 at 12:41pm V14 (Dietary Manager) stated he has been working in the facility for 6 months. V14 stated his responsibilities include ensuring residents are getting the right diet and correct portion of food, and making sure dietary staff follow the meal ticket. Every resident has meal ticket. R1's meal ticket reviewed with V14 and said R1 is getting regular mechanical ground. He said meat should be ground. He said R1 has a swallowing problem, easy to swallow if grounded. R1 could possibly choke if it is not grounded. Everything on the ticket should be on the meal tray. He said today for lunch, kitchen is serving cold cut sandwiches due to oven replacement. He said notification were sent to the units and residents were made aware. V14 stated at lunch time, R1 received ham sandwich and the ham should have been ground. He said if not ground it could be a choking hazard. R1's meal ticket reflected Whole milk and dietary aide should provide whole milk on the meal tray from the kitchen. Whole milk helps with weight maintenance. He said R1 should have nutritional frozen/ice cream twice a day (lunch and dinner) and should be included in the meal tray. Nutritional frozen treat has high calorie and that helps with weight gain or maintenance. On 10/1/24 at 1:17pm V15 (Registered Dietician) stated she has been working in the facility for almost 3 weeks. She said R1 was evaluated on 9/27/24 upon readmission. R1 needed 1:1 assistance at mealtime. R1 had been eating 100% since readmission. R1's diet is mechanical soft. All meat should be ground- soft bread should be okay. If R1 was served with ham sandwich, the meat should be ground. She said the potential risk if not ground could have a problem chewing and possibly choking. For safety meat should be ground. She said R1 is underweight, and recommendations included 1:1 feed assistance, appetite stimulant, oral nutrition supplement: Frozen nutritional should be included in the lunch tray lunch and dinner. She said frozen nutritional treat, is dense and has high calorie, has a lot of nutrition with a few bites. Helps with weight gain, easy way to get nutrition if appetite is poor. If nutritional treat is not provided or given could potentially not gain weight as it helps with weight gain which is desirable for R1. She said whole milk, provides extra calorie. May help with weight gain. If nutritional supplement is not provided prohibiting from gaining weight. On 10/3/24 At 1:34pm V2 (Director of Nursing) said has been working in the facility for [AGE] years. She said if the diet order is mechanical soft, the meat should be ground to prevent possible choking. She said nutritional treat/supplements should be given to resident as ordered or per dietician's recommendation to help with weight gain. R1's physician order sheet (POS) dated 10/1/24 documented in part: Diet - mechanical soft texture, thin liquids consistency. R1's MDS (Minimum Data Set) dated 8/27/2024 showed cognition is moderately impaired. She needed substantial/maximal assistance with eating. R1's Dietary evaluation/nutritional assessment dated [DATE] documented in part: Regular diet, mechanical soft texture, thin liquids. Supplements: Frozen Nutritional Treat BID (twice a day). Weight: 102lbs on 9/11/24. Height: 67. BMI (Body Mass Index): 16.0 (underweight). R1's Care plan dated 4/6/21 and 6/5/24 documented in part: Despite R1's BMI being underweight for her age, she is at risk for weight fluctuations due to variable PO (oral) intake at mealtimes and increased energy expenditure due to constant involuntary movements. Provide dietary supplements as ordered: Frozen Nutritional Treat BID (twice a day). Provide/serve R1 nutritional diet as ordered: Mechanical Soft, thin liquids. Facility's policy on therapeutic diets (Undated) documented in part: Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. Facility's nutritional assessment and care policy dated 10/1/23 documented in part: To ensure all residents have individualized care plans reflecting their needs and preferences for care. To provide guidance for caregivers to ensure residents maintain an appropriate level of nutritional care. Facility's Nutritional assessment and clinical guidelines dated 8/5/19 documented in part: The nutritional assessment will comprise the following elements but not limited to: therapeutic diet, dietary supplements. Individualized care plans are developed to identify nutrition problems / strengths, goals, and approaches.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure refrigerated food items were dated with a use by date, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) monitor chemical sanitizer concentrations of dish machine for dishware to be properly sanitized, f.) label and date dry storage items stored in bins, g.) clean ice machine and monitor for working order. These failures have the potential to affect all 94 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:15 AM, during initial kitchen tour V9 (Culinary Service Manger) stated refrigerated items should be labeled with a delivery date, the date the item was opened and the use by date. V9 stated the use by date varies depending on what the food item is. V9 stated the kitchen follows the guidelines titled Expiration Dates posted outside the walk-in cooler V9 stated each kitchen employee is responsible for doing their own labeling and dating after using a product. On [DATE] at 9:25 AM, observed the following items in the walk-in cooler: 1.) Opened 1 gallon container Barbeque Sauce dated with delivery date [DATE] and opened date [DATE]. No use by date was documented on the product. V9 stated the Barbeque Sauce should be labeled with a use by date so the staff knows when to discard the product. V9 stated this is important so the product is not used beyond the discard date to cut down on food borne illness. V9 stated upon opening, this product is good for 30 days so the use by date of this product should have been written on the label as [DATE]. 2.) Opened 1 gallon container Sweet Pickle Relish dated with delivery date [DATE] and opened date [DATE]. No use by date was documented on product. V9 stated once the product was opened should have been labeled with a use by date per policy. 3.) Half case of fresh lemons packed on [DATE] and delivered [DATE] per packing stickers on the side of the box. No use by date was documented on the product. Observed most of lemons to be very soft and discolored in light brown and pale gray areas. V9 observed the fresh lemons and stated these should have been thrown out because they are rotten and have gone bad. 4.) Two cases of (Name brand shakes) labeled with delivery date [DATE]. V9 stated this product arrives frozen and is stored in the freezer until it is removed and put into the walk-in cooler so it can be defrosted for use. V9 stated the product is served to the residents after it has been defrosted. V9 stated he remembers seeing the cases taken out of the freezer and put into the walk-in cooler to be defroster when V9 first started working at the facility which was toward the end of February 2024. V9 was not sure how long the items could be kept in the refrigerator after they had been defrosted. On [DATE] at 9:42 AM, observed the floor in the walk-in cooler underneath the metal shelving along the perimeter and behind the cases of food to be dirty with layers of grime and food wrappers. V9 observed the area and stated that area has been neglected, the staff are only cleaning in the middle of the cooler, and that they do not pull anything out to get behind the metal racks to clean the area properly. V9 stated the staff should pull everything away from the walls of the cooler to clean the hard-to-reach areas. On [DATE] at 9:45 AM, observed black material around the exhaust fan in the walk-in cooler, and gray fuzzy material stuck on the ceiling of the walk-in cooler near the exhaust fan extending toward the door. V9 observed the material and stated, they look like dust bunnies. V9 stated that is a physical contaminant because the dust can fall on the open boxes with raw vegetables them. On [DATE] at 9:51 AM, observed two staff members working in the dish room area cleaning dishes. V9 stated the test trips should read 100 parts per million (ppm) which is dark purple color based on the test strip indicator on the side of the bottle. Surveyor asked V10 (Dietary Aide) to run a test strip through the dish machine. Observed V10 send multiple test strips through the dish machine and test the water directly in the side drain. V10 stated V10 has checked the test strips ,d+[DATE]x and none of them are reading anything. V10 showed surveyor the test strip which was wet but still white. It had not changed any color. V9 stated if there is no change in color then that means there is no sanitizing solution in the system and the items are not getting cleaned properly. V9 stated sanitizing solution is needed to disinfect and sanitize the dishes to keep the germs out. V9 stated the dishes are not fully cleaned until they are sanitized. On [DATE] at 10:07 AM, observed in the dry storage room white sugar in a bin in a closed bag not labeled or dated and white rice in a bin not labeled or dated. V9 stated both items should have been labeled and dated when they were filled up. On [DATE] at 10:15AM, observed in cook area where spices were stored the following: 1.) Opened 1 quart bottle of lemon juice dated with an opened date [DATE]. On the bottle manufacturer instructions document refrigerate after opening for best results. V9 stated this lemon juice should be stored in the refrigerator based on the manufacturer guidelines. 2.) Opened 1 gallon container of hot sauce labeled with delivery date [DATE] and opened date [DATE]. V9 stated once opened the hot sauce is good for 6 months. V9 stated the hot sauce is over the 6-month period and should not be used and will be thrown out. 3.) Opened 2-quart bottle of low sodium soy sauce dated with a delivery date [DATE] and opened date [DATE]. On the bottle manufacturer instructions document refrigerate after opening. V9 stated the kitchen follows manufacturer guidelines so this item should have been refrigerated after opening. V9 stated by not storing the lemon juice and low sodium soy sauce in the refrigerator per the manufacturers guidelines those items could grow bacteria which could be harmful to residents if they were to consume them. On [DATE] at 10:23 AM, observed ice machine dripping water from the outside front corner onto the tiled floor. Also observed a white drainage pipe extending from behind the ice machine actively draining large amounts of water (constant stream) into a floor drain near the front corner of the ice machine. The titled area around the front corner of ice machine was observed to have large amounts of wet black material imbedded into the grout and the tile was covered in a white, grayish material. Also, observed a lot of condensation around the lid of the ice machine, and some standing water on the inside lid of the ice machine. Surveyor asked V9 why there was so much running water from the white drainage pipe and V9 stated the drainage pipe was draining water from the ice machine and that the ice machine should not be draining water like that. Surveyor asked how often the ice machine is cleaned and V9 stated we don't clean it; an outside company comes to the facility to do the cleaning. V9 stated the last time the outside company was here to clean the ice machine was [DATE]. V9 stated the wet black material around the tiles looks like mold. On [DATE] at 8:21 AM, observed (Brand name shakes) carton. Printed on the side of the carton by the manufacturer documented Thaw under refrigeration (40 degrees or below). Shake well before using. Open top, then pour and serve. After thawing keep refrigerated. Use within 14 days after thawing. On [DATE], V9 provided list of diet orders for all residents in the facility printed [DATE] at 11:05 AM. V9 stated everyone receives a tray from the kitchen and none of the residents receive nothing by mouth (NPO). Facility provided kitchen policy titled; Food Receiving and Storage undated which documents in part, culinary services will maintain clean food storage areas at all times, dry foods that are stored in bins will be labeled and dated (use by date), and all goods stored in the refrigerator will be covered, labeled and dated (use by date). Facility provided kitchen document titled, Expiration Dates undated which documents in part foods that expire 60 days after opening: BBQ Sauce. Facility provided document titled TCS (Temperature Control for Safety) Foods & 7-Day Labeling dated 2024 documents in part follow the 7-day rule, trust your senses, if the food looks, seems or smells bad before then, throw it out. Facility provided policy titled Cleaning Guidelines Ice Machine undated which documents steps for cleaning. Facility provide policy titled Dishwashing Machine Use undated which documents in part dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine ,d+[DATE] ppm and a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine. Facility provided product description of Sysco Imperial Shakes which documents in part thaw under refrigeration and refrigerate for up to 14 days. Facility provided document titled SAFE Food Handling Standards and Procedures undated which documents in part, the purpose is to establish consistent standards and procedures when serving and delivering food this is important because harmful bacteria can be introduced into food causing foodborne illness. Based on observations, interviews, and record reviews, the facility failed to a.) ensure refrigerated food items were dated with a use by date, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) monitor chemical sanitizer concentrations of dish machine for dishware to be properly sanitized, f.) label and date dry storage items stored in bins, g.) clean ice machine and monitor for working order. These failures have the potential to affect all 94 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:15 AM, during initial kitchen tour V9 (Culinary Service Manger) stated refrigerated items should be labeled with a delivery date, the date the item was opened and the use by date. V9 stated the use by date varies depending on what the food item is. V9 stated the kitchen follows the guidelines titled Expiration Dates posted outside the walk-in cooler V9 stated each kitchen employee is responsible for doing their own labeling and dating after using a product. On [DATE] at 9:25 AM, observed the following items in the walk-in cooler: 1.) Opened 1 gallon container Barbeque Sauce dated with delivery date [DATE] and opened date [DATE]. No use by date was documented on the product. V9 stated the Barbeque Sauce should be labeled with a use by date so the staff knows when to discard the product. V9 stated this is important so the product is not used beyond the discard date to cut down on food borne illness. V9 stated upon opening, this product is good for 30 days so the use by date of this product should have been written on the label as [DATE]. 2.) Opened 1 gallon container Sweet Pickle Relish dated with delivery date [DATE] and opened date [DATE]. No use by date was documented on product. V9 stated once the product was opened should have been labeled with a use by date per policy. 3.) Half case of fresh lemons packed on [DATE] and delivered [DATE] per packing stickers on the side of the box. No use by date was documented on the product. Observed most of lemons to be very soft and discolored in light brown and pale gray areas. V9 observed the fresh lemons and stated these should have been thrown out because they are rotten and have gone bad. 4.) Two cases of (Name brand shakes) labeled with delivery date [DATE]. V9 stated this product arrives frozen and is stored in the freezer until it is removed and put into the walk-in cooler so it can be defrosted for use. V9 stated the product is served to the residents after it has been defrosted. V9 stated he remembers seeing the cases taken out of the freezer and put into the walk-in cooler to be defroster when V9 first started working at the facility which was toward the end of February 2024. V9 was not sure how long the items could be kept in the refrigerator after they had been defrosted. On [DATE] at 9:42 AM, observed the floor in the walk-in cooler underneath the metal shelving along the perimeter and behind the cases of food to be dirty with layers of grime and food wrappers. V9 observed the area and stated that area has been neglected, the staff are only cleaning in the middle of the cooler, and that they do not pull anything out to get behind the metal racks to clean the area properly. V9 stated the staff should pull everything away from the walls of the cooler to clean the hard-to-reach areas. On [DATE] at 9:45 AM, observed black material around the exhaust fan in the walk-in cooler, and gray fuzzy material stuck on the ceiling of the walk-in cooler near the exhaust fan extending toward the door. V9 observed the material and stated, they look like dust bunnies. V9 stated that is a physical contaminant because the dust can fall on the open boxes with raw vegetables them. On [DATE] at 9:51 AM, observed two staff members working in the dish room area cleaning dishes. V9 stated the test trips should read 100 parts per million (ppm) which is dark purple color based on the test strip indicator on the side of the bottle. Surveyor asked V10 (Dietary Aide) to run a test strip through the dish machine. Observed V10 send multiple test strips through the dish machine and test the water directly in the side drain. V10 stated V10 has checked the test strips ,d+[DATE]x and none of them are reading anything. V10 showed surveyor the test strip which was wet but still white. It had not changed any color. V9 stated if there is no change in color then that means there is no sanitizing solution in the system and the items are not getting cleaned properly. V9 stated sanitizing solution is needed to disinfect and sanitize the dishes to keep the germs out. V9 stated the dishes are not fully cleaned until they are sanitized. On [DATE] at 10:07 AM, observed in the dry storage room white sugar in a bin in a closed bag not labeled or dated and white rice in a bin not labeled or dated. V9 stated both items should have been labeled and dated when they were filled up. On [DATE] at 10:15AM, observed in cook area where spices were stored the following: 1.) Opened 1 quart bottle of lemon juice dated with an opened date [DATE]. On the bottle manufacturer instructions document refrigerate after opening for best results. V9 stated this lemon juice should be stored in the refrigerator based on the manufacturer guidelines. 2.) Opened 1 gallon container of hot sauce labeled with delivery date [DATE] and opened date [DATE]. V9 stated once opened the hot sauce is good for 6 months. V9 stated the hot sauce is over the 6-month period and should not be used and will be thrown out. 3.) Opened 2-quart bottle of low sodium soy sauce dated with a delivery date [DATE] and opened date [DATE]. On the bottle manufacturer instructions document refrigerate after opening. V9 stated the kitchen follows manufacturer guidelines so this item should have been refrigerated after opening. V9 stated by not storing the lemon juice and low sodium soy sauce in the refrigerator per the manufacturers guidelines those items could grow bacteria which could be harmful to residents if they were to consume them. On [DATE] at 10:23 AM, observed ice machine dripping water from the outside front corner onto the tiled floor. Also observed a white drainage pipe extending from behind the ice machine actively draining large amounts of water (constant stream) into a floor drain near the front corner of the ice machine. The titled area around the front corner of ice machine was observed to have large amounts of wet black material imbedded into the grout and the tile was covered in a white, grayish material. Also, observed a lot of condensation around the lid of the ice machine, and some standing water on the inside lid of the ice machine. Surveyor asked V9 why there was so much running water from the white drainage pipe and V9 stated the drainage pipe was draining water from the ice machine and that the ice machine should not be draining water like that. Surveyor asked how often the ice machine is cleaned and V9 stated we don't clean it; an outside company comes to the facility to do the cleaning. V9 stated the last time the outside company was here to clean the ice machine was [DATE]. V9 stated the wet black material around the tiles looks like mold. On [DATE] at 8:21 AM, observed (Brand name shakes) carton. Printed on the side of the carton by the manufacturer documented Thaw under refrigeration (40 degrees or below). Shake well before using. Open top, then pour and serve. After thawing keep refrigerated. Use within 14 days after thawing. On [DATE], V9 provided list of diet orders for all residents in the facility printed [DATE] at 11:05 AM. V9 stated everyone receives a tray from the kitchen and none of the residents receive nothing by mouth (NPO). Facility provided kitchen policy titled; Food Receiving and Storage undated which documents in part, culinary services will maintain clean food storage areas at all times, dry foods that are stored in bins will be labeled and dated (use by date), and all goods stored in the refrigerator will be covered, labeled and dated (use by date). Facility provided kitchen document titled, Expiration Dates undated which documents in part foods that expire 60 days after opening: BBQ Sauce. Facility provided document titled TCS (Temperature Control for Safety) Foods & 7-Day Labeling dated 2024 documents in part follow the 7-day rule, trust your senses, if the food looks, seems or smells bad before then, throw it out. Facility provided policy titled Cleaning Guidelines Ice Machine undated which documents steps for cleaning. Facility provide policy titled Dishwashing Machine Use undated which documents in part dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine ,d+[DATE] ppm and a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine. Facility provided product description of (Brand name shakes) which documents in part thaw under refrigeration and refrigerate for up to 14 days. Facility provided document titled SAFE Food Handling Standards and Procedures undated which documents in part, the purpose is to establish consistent standards and procedures when serving and delivering food this is important because harmful bacteria can be introduced into food causing foodborne illness.

Based on observation, interview and record review, the facility failed to prepare and serve mechanical soft food at the appropriate texture. This failure affected 8 (R8, R12, R16, R36, R42, R44, R58, R62) of 12 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 19 residents. Findings Include: On 04/03/24 at 11:45 AM, during tray line observations observed V10 (Dietary Aide) calling out for a mechanical soft/ground diet order. Observed V23 (Cook) give V26 (Cook) slices of pork loin. V26 brought the slices of pork loin to a cutting board near the stove and began to chop the pork using a knife. V26 stated I'm helping to cut this food up for the mechanical soft diets. Observed the final chopped pork product to have no uniformity in size with larger and smaller pieces mixed together and the overall consistency appeared very dry. V26 placed the chopped pork into a container and gave it to V23. On 04/03/24 at 11: 50 AM, observed V23 portion chopped pork onto a plate for a resident's meal ticket which read mechanical soft/ground. No gravy or sauce was served with the chopped pork. On 04/03/24 at 11:55 AM, V23 stated there is no difference between the mechanical soft/ground diets and the mechanical soft/chopped diet. V23 stated for both the ground and chopped diet consistencies the cooks manually chop the meat using a knife and do not put meat through a commercial food processor unless the meat is very tough. On 04/03/24 at 12:05 PM, V9 (Culinary Service Manager) stated the mechanical soft/ground should be prepared using the commercial food processor not chopped with a knife by hand. V9 stated this is because the chopped consistency is not the same as the mechanical soft/ground. V9 stated the chopped consistency has bigger pieces than the mechanical soft and if residents on a mechanical soft/ground diet are given a chopped consistency it could be a choking hazard. On 04/03/24 at 12:14 PM, V25 (Contracted Regional Director of Operations) stated, they should not be serving the same consistency to both mechanical soft/ground and chopped. V25 stated chopped is bite sized pieces and mechanical soft/ground should be run through the commercial food processor to break down the food. On 04/04/24 at 11:34 AM, during phone interview V27 (Speech Language Pathologist) stated residents may need to be on an altered diet consistency if they do not have any teeth, or refuse to wear dentures, or if they have dysphagia which is a swallowing disorder. V27 stated residents with dysphagia are at Increased risk for aspiration which is when food/liquid goes into a resident's trachea or airway instead of going down their esophagus. V27 stated the kitchen should be following the specific diet order. V27 stated meat tends to be dry and therefore V27 recommends that the meat be served with a gravy because having an extra sauce or gravy softens the meat further to ensure safety and to make it easier to chew. 1.) R8's diagnoses includes but not limited to Dysphagia, Chronic Obstructive Pulmonary Disease. R8's Physician Orders ordered 06/22/22 documents in part, diet order is mechanical soft texture. R8's nutrition care plan documents in part, R8 has the following risk factors that place resident at risk for alteration in nutritional status: dysphagia, mechanically altered diet. R8's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 2.) R12's diagnoses includes but not limited to Dysphagia, Oropharyngeal Phase, Cerebral Infarction, Dysphagia Following Other Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease. R12's Physician Orders ordered 10/29/21 documents in part, diet order is mechanical soft texture, honey thick liquids consistency. R12's nutrition care plan documents in part, R12 has the potential for alteration in nutritional status related to dysphagia, history of G-tube feedings, cerebral infarction, COPD, mechanically altered diet and need for thickened liquids. R12's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground, honey liquids and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 3.) R16's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease. R16's Physician Orders ordered 12/21/23 documents in part, diet order is mechanical soft texture. R16's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 4.) R36's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease. R36's Physician Orders ordered 07/14/23 documents in part, diet order is mechanical soft texture. R36's nutrition care plan documents in part, R36 has the potential for alteration in nutritional status related to COPD, mechanically altered diet. R36's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 5.) R42's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease. R42's Physician Orders ordered 06/30/21 documents in part, diet order is mechanical soft texture. R42's nutrition care plan documents in part, R42 has the potential for alteration in nutritional status related to COPD, mechanically altered diet. R42's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 6.) R44's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease, Bell's Palsy. R44's Physician Orders ordered 01/11/23 documents in part, diet order is mechanical soft texture. R44's nutrition care plan documents in part, R44 is at risk for alteration in nutritional status related to mechanically altered diet order. R44's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 7.) R58's diagnoses includes but not limited to Dysphagia, Chronic Obstructive Pulmonary Disease. R58's Physician Orders ordered 04/02/20 documents in part, diet order is mechanical soft texture. R58's nutrition care plan documents in part, R58's nutritional status is compromised due to need for mechanically altered diet order. R58 is edentulous and is without dentures. R58's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 8.) R62's diagnoses includes but not limited to Dysphagia, Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive. R62's Physician Orders ordered 02/03/21 documents in part, diet order is mechanical soft texture. R62's nutrition care plan documents in part, R58's nutritional status is compromised due mechanically altered diet, dysphagia, need for 1:1 feeding assistance, history of unintentional weight loss, adult failure to thrive diagnosis. R62's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. Facility's policy titled, Consistency Modified Diets undated documents in part, mechanical soft consists of ground meats, and lists allowed protein foods as ground eggs, meats, poultry, pork, seafood, meat analogues, legumes, nuts, and seeds served with sauce or gravy, and not allowed protein foods as tough or dry meat products that cannot be served as a moist and cohesive product. Kitchen recipe titled Pork Roast documents in part for ground to grind to appropriate consistency. If needed, add gravy or broth to moisten meat. Kitchen spreadsheet titled Southern SS Diet Guide Sheet for Wednesday (Day 25) lunch mechanical altered/ground pork roast loin garlic herb.

Based on observation, interview, and record review the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day and failed to serve a substantial or nourishing snack at bedtime to residents who are not provided with an individualized evening snack. This deficient food service practice has the potential to affect 64 residents in a total sample size of 94 residents receiving an oral diet from the facilities kitchen. Findings include: On 04/02/24 after initial kitchen tour and tray line observation, V9 (Culinary Service Manager) provided mealtime schedule which documents range of mealtimes between 4:45 PM-5:05 PM for dinner and 7:15-7:35 AM for breakfast and that the nursing units are scheduled to be delivered in the same order for every meal (1st floor, then 2nd floor, and finally 3rd floor). The mealtime schedule documents in part, the 1st floor receives dinner at 4:45 PM and breakfast at 7:15 AM, the 2nd floor receives dinner at 4:55 PM and breakfast at 7:25 AM, the 3rd floor receives dinner at 5:05 PM and breakfast at 7:35 AM. On 04/03/24 at 3:40 PM, V9 stated the delivery mealtimes were changed and are now being used as of 04/02/24 because V25 (Contracted Dietary Regional Director of Operations) said the kitchen needed more time to get the meals out. V9 provided copy of updated meal schedule which documents range of mealtimes between 4:15 PM - 5:15 PM for dinner and 7:15 AM - 8:05 AM for breakfast and that the nursing units are scheduled to be delivered in the same order for every meal (1st floor, then 2nd, and finally 3rd floor). The revised mealtime schedule documents in part, the 1st floor receives dinner between 4:10-4:15 PM and breakfast between 7:15 - 7:25 AM, the 2nd floor receives dinner between 4:20 - 4:45 PM and breakfast between 7:30 -7:45 AM, the 3rd floor receives dinner between 4:50-5:15 PM and breakfast between 7:50-8:05 AM. On 04/02/24 at 10:30 AM, V9 stated not all residents receive an evening snack. V9 pointed to a list posted which listed residents' names by unit and specific food items to be prepared for them. V9 stated the residents on that list receive individual labeled evening snacks after the dinner meal because they are specifically ordered by the resident's doctor or the dietitian. V14 stated that if a resident does not have a specific order for an evening snack. On 04/03/24 at 3:43 PM, observed evening snacks for 04/03/24 prepared for 1st/2nd/3rd floor located in kitchen's walk-in cooler. Each tray contained individually labeled snacks for some residents. Surveyor did not observe any additional snack items on the trays and per observation there was not enough snacks on the trays for all the residents on the floor. On 04/03/24 at 4:18 PM, V9 stated V25 wants the kitchen to start giving snacks out so everyone can get an evening snack so for the past three weeks the kitchen has been sending up cookies when in stock along with the individually labeled snacks. V9 stated prior to this the kitchen was only sending snacks to the residents who were on the list to receive individually labeled snacks. V9 stated because of this change V9 has started to order packaged cookies but said, we don't have any in stock right now. On 04/03/24 at 4:40 PM, observed dinner meal trays in hallway by the elevator. On 04/04/24 at 8:08 AM, observed breakfast meal trays in the hallway by the elevator. V23 (Cook) stated these trays were being delivered to the 2nd floor. On 04/03/24 at 3:48 PM, V28 (Registered Nurse) stated snacks delivered to the 3rd floor after dinner are individually labeled with the resident's name and not all the residents get an individually labeled snacks. V28 stated the kitchen sometimes sends up cookies and juice for the other residents who do not receive individually labeled snacks. V28 stated for some of the resident's the cookies are not enough and those resident's ask us for more food because they complain about still being hungry. V28 stated V28 tells them to talk to the dietitian so they can get something more substantial than cookies for snack. On 04/03/24 at 3:54 PM, viewed the 3rd floor pantry with V28. V28 stated no extra food is stored in the pantry and the kitchen does not stock the pantry with any items for the residents. V28 stated the refrigerator is used only for staff food. V28 stated if a resident complains of hunger in the evening the only thing V28 can give them is a cookie if there are any still left over or available. On 04/03/24 at 3:58 PM, V30 (Registered Nurse) stated V30 was a Certified Nursing Assistant for [AGE] years and has been a RN for the past seven years. V30 stated V30 works on the 2nd floor usually on the (11-7) shift but that every Wednesday V30 does a double shift working from (3-11) and (11-7) shift. V30 stated dinner arrives by 5:00 PM and breakfast is served between 8:00-8:15 AM. V30 stated V30 knows the time breakfast is served because it arrives as V30 is leaving the unit which is around 8:00 AM. On 04/03/24 at 4:02 PM, V31 (Certified Nursing Assistant) stated V31 has been working at the facility for three years and that V31 works the 3-11 shift on the 2nd floor. V31 stated dinner is served by 5:00 PM and snacks arrive after dinner. V31 stated some of the resident's receive individually labeled snacks. V31 stated if a resident does not have an evening snack but wants a snack, the residents can ask the nurse to put in a request for one. V31 stated once the kitchen closes at 7:00 PM we cannot do anything about it and the resident just needs to wait. V31 stated no extra food is served on the unit or in the pantry unit. On 04/03/24 at 4:08 PM, V32 (Registered Nurse) stated the evening snacks arrive on the 1st floor unit between 6:00-6:30 PM. V32 stated some of the residents receive individually labeled snacks. V32 stated for the residents who do not receive an individually labeled snack the kitchen will send up one cookie and some juice. V32 stated if the resident is still hungry after eating the one cookie V32 cannot do anything about it. V32 stated the kitchen closes at 7:00 PM and the kitchen does not stock the unit pantry with any food. V32 stated the residents would like to receive something more substantial for the evening snack like sandwiches instead of only one cookie. V32 stated some of the residents can buy snacks from the vending machines downstairs but that is only if those residents have their own money. On 04/03/24 at 12:32 PM, V14 (Registered Dietitian) stated if there is more than a 14-hour difference supper and breakfast everyone should have access to a snack. V14 stated this is done for nourishment purposes because it is a long period to go without nourishment so that is why they need to have a snack in place. On 04/04/23, surveyor asked V9 for Food Committee Meeting Minutes for the past 12 months and V9 stated V9 could only find minutes from 12/13/23. Surveyor reviewed Resident Council Food Committee Meeting Minutes dated 12/13/23 and there was no mention of resident request or approval for mealtimes to be extend beyond 14 hours lapse time between dinner and breakfast meal. Kitchen facility policy titled, Bedtime (HS) Snacks dated 07/27/23, documents in part: 1.) The facility will provide the residents bedtime snacks in accordance with the federal regulations, 2.) The facility must offer snacks at bedtime daily. 3.) There must be no more than 14 hours between a substantial evening meal and breakfast the following day. 4.) However, if a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day. 49486 On 4/3/24 at 10:15 AM, during the Resident Council Meeting interview, one of the concerns brought up by the group was the lack of evening snacks provided on a consistent basis and the evening snacks not being substantial enough. On 4/3/24 at 10:37 AM, R47 stated R47 gets hungry at bedtime because no evening snack is provided. On 4/3/24 at 10:42 AM, R73 stated the facility offers one cookie and a cup of juice sometimes, but not every day. R73 stated just one cookie is not enough for R73. On 4/3/24 at 12:15 PM, V9 (Culinary Service Manager) stated we do not provide bedtime snacks for every resident. V9 stated we provide bedtime snacks to a few residents on the Snacks list. On 4/4/24 at 9:40 AM, R60 stated R60 eats dinner around 4:30 PM and that is too early for R60. On 4/4/24 at 10:05 AM, R52 stated R52 does not receive an evening snack every day. R52 stated sometimes the staff offers R52 something, but other times they do not give R52 anything for an evening snack. R52 stated R52 would like to get an evening snack every night. On 4/2/24, surveyor reviewed Resident Council Meeting Minutes dated between 04/2023 to 03/2024 provided by the facility and there was no mention of resident request or approval for mealtimes to be extend beyond 14 hours lapse time between dinner and breakfast meal.

Based on observation, interview, and record review the facility failed to determine self-administration of medication was appropriate for 1 (R22) out of 12 residents reviewed for medication administration but allowed the resident to self-administer topical medication. Findings include: On 04/02/24 at 11:54 AM, V7 (Registered Nurse/RN) was observed during medication administration. (Brand name for pain relief cream) was ordered to be applied to R22's right knee. V7 accessed (Brand name for pain relief cream), put the cream in a medicine cup, handed the medicine cup to R22, exited the room, and documented the medication administration in the resident's electronic health record. V7 did not assess the right knee, apply the cream, or observe R22 applying the cream. On 04/03/24 at 09:50 AM, interviewed V7 (RN) who stated that R22 self-applies (Brand name for pain relief cream). V7 stated that R22 is alert and able to put it on himself. V7 stated that it is a stock drug and not a controlled substance. When V7 was asked if an order is needed for R22 to self-administer medication, V7 stated Normally, we are supposed to get an order for the resident to self-administer medicine. V7 and surveyor reviewed the medical record. V7 stated that R22 did not have an order to self-administer prescribed cream or medications. On 04/04/24 09:51 AM during interview, V2 (Director of Nursing) stated that for topical medication administration, the nurse is expected to complete hand hygiene, check the order, prepare the medication, put the cream in a medicine cup so that the nurse does not bring the tube into a resident's room, assess the area where the topical medication is to be applied, and then apply the medicine to the affected area as ordered. V2 stated that if the resident has an order for self-administration, the nurse makes sure that the resident applies the cream as ordered. V2 further stated that the nurse does not sign off on the medication in the electronic health record until the nurse sees the topical cream applied. On 4/4/2024 at 11 AM, R22's electronic health record (EHR) was reviewed. No physician order for medication self-administration was found and no Medication Self-Administration Evaluation Form was found. On 4/4/2024 at 11:30 AM, request was made to V4 (Assistant Administrator) for documentation of medication self-administration assessment for R22. No documentation was provided. On 4/5/2024 at 7 AM, R22's medication orders were again reviewed and now included a discontinuation of Diclofenac Sodium Gel and (Brand name anorectal cream) and the initiation of an order to may self-administer for both medications on 4/4/2024. The order for self-administration of (Brand name anorectal cream) was obtained 4/4/2024 at 11:57 AM. The order for self-administration of Dicofenac Sodium Gel was obtained on 4/4/2024 at 12:01 PM. Review of Medication Pass policy adopted January 5, 2016 and revised July 28, 2023 states in part It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Review of Self-Administration of Medication policy adopted December 3, 2015 and revised July 28. 2023 states: Policy Statement: A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-medicate. Procedure 1. The IDT will assign a staff to evaluate resident's ability to safely administer medication. A self-administration evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching.

Based on observation, interview and record review, the facility failed to develop a timely person-centered care plan until after a resident experienced a forty-five-pound weight loss in less than 3 months from the date of admission. This failure affected 1 (R20) out of 4 residents who were reviewed for nutrition in the final sample of 19 residents. Findings include: During interview with R20 on 04/02/24 at 10:48 AM, R20 stated that the food is good. On 4/3/2024 at 12:36 PM, R20 stated that R20 knows that R20 has lost weight. R20 stated that R20 is happy with the weight loss but wants to gain some of the weight back. During review of record, on 4/3/2024 at 10 AM, R20 was admitted on [DATE]. R20's Minimum Data Set (MDS) dated [DATE] showed it was completed on 2/1/24. R20's weights were documented as: 1/18/2024 - 280 pounds, 2/7/2024 - 274 pounds, 3/9/2024 - 235 pounds. Dietary assessment dated [DATE] was reviewed on 4/3/2024 at 11 AM. The summary stated that the goal for R20 was weight maintenance or gradual weight loss. Dietary Care Plan was not initiated and entered by V14 (Registered Dietician) until 3/30/2024. It was reviewed on 4/3/2024 at 2 PM and stated that R20 has a nutritional problem related to overweight. R20 triggered for significant weight loss at one month which was unintentional and likely related to R20's eating habits being better than when he was living out in the community. The goal was for R20 to maintain body weight within ideal body weight range through the next review date. Interventions included encouraging R20 to follow health eating behaviors, preparing, and serving the prescribed diet as ordered, and weight to be obtained as ordered by physician. During interview with V17 (Care Plan Coordinator) on 4/3/2024 3:00 PM, V17 stated that for new admissions, a care plan is completed within 72 hours. At a minimum, the care plan should include Nursing, Social Services, Restorative, Dietary and Skin. V17 stated that the care plan is updated quarterly, annually and if there is a significant change in condition. V17 described a significant change in condition as a decline in resident function, weight change, decline in eating, or fall. If there is a significant change in condition, the care plan should be updated with interventions. V17 stated, If today we observe something, we must add to the care plan interventions. During interview with V2 (Director of Nursing) on 04/04/24 9:31 AM, V2 stated that at a minimum, the admission care plan should include Nursing, Social Services, Dietary, Restorative and Skin. V2 stated that if there is a significant change in a resident's condition, it should be care planned. Significant change in condition would include weight change, eating problems or ADLs. If there was a significant change in condition, the issue would be raised by the Nurse, Physical Therapy or Social Services. V2 stated, We also meet every morning to discuss care plans. V2 reviewed the care plan for R20. V2 confirmed that R20 had no care plan or dietary assessment from 1/19/2024 until 3/30/2024. When asked if a 45-pound weight loss in less than 3 months would raise concern as a significant change in condition, V2 stated yes. V2 stated that they changed dieticians. V14 (Registered Dietician) started 2 weeks ago. V2 stated, The previous dietician should have caught that. V2 stated that the facility has one person doing the weights so they should raise a concern about weight change and give that information directly to the Dietician. The policy titled Care Plan adopted November 28, 2023 and revised July 27, 2023 states in part Policy Statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Procedures 4. After the comprehensive assessment (state/federal/-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days.

Based on interview and record review, the facility failed to ensure that smoking assessment/evaluation were completed on a quarterly basis. This failure could potentially affect 3 (R16, R78 and R85) of 5 residents reviewed for smoking in a total sample of 19. The findings include: 1.) R16's health record documented admitted on 12/15/23 with diagnoses not limited to schizoaffective disorder bipolar type, Chronic obstructive pulmonary disease, Essential (primary) hypertension, other hyperlipidemia, other seizures, other specified anemias, Gastro-esophageal reflux disease without esophagitis, Human Immunodeficiency Virus (HIV) disease. On 4/2/24 at 10:48am observed R16 alert and oriented x 3, verbally responsive. Stated he is a smoker. MDS dated [DATE] showed R16's cognition was intact. Care plan dated 2/6/2024 documented in part: R16 is a smoker and expresses the desire to smoke at this facility. Assess the resident for smoking safety according to facility policy [assessment/evaluation]. R16's Smoking assessment dated [DATE] documented in part: Resident is considered a safe smoker and may use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. 2.) R78's health record documented admitted on 5/12/22 with diagnoses not limited to Unspecified fracture of upper end of right tibia, Opioid dependence, Unspecified osteoarthritis, Atherosclerotic heart disease of native coronary artery without angina pectoris, Diabetes mellitus, Major depressive disorder, Migraine, Gastro-esophageal reflux disease without esophagitis, Hyperlipidemia, Essential (primary) hypertension, Chronic obstructive pulmonary disease, Vitamin d deficiency, Pure hyperglyceridemia, History of falling, Insomnia, Bipolar disorder, Generalized anxiety disorder, Tobacco use, Bipolar disorder, Alcohol dependence with intoxication, Nondisplaced fracture of right tibial tuberosity. On 4/2/24 at 10:51am observed R78 sitting on the side of the bed, alert, and oriented x 3, verbally responsive. Stated she is a smoker and showed her cigarette inside her bag to the surveyor. MDS dated [DATE] showed R78's cognition was intact. R78's Smoking Program Evaluation dated 7/27/23 documented in part: Resident is considered a safe smoker and may use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. Care plan dated 2/6/2024 documented in part: R78 is a smoker and expresses the desire to smoke at this facility. On 4/2/24 at 2:25pm V8 (Social Service Director) said Smoking assessments are done upon admission, quarterly, and as needed. She stated the purpose of completing the smoking assessment is to evaluate the resident to make sure the resident is a safe smoker. On 4/4/24 at 11:21 am reviewed R16's electronic health record (EHR) with V8 and stated 2 recent smoking assessment were done on 12/16/23 and 4/2/24. She said 2 recent R78's smoking assessment were done on 7/27/23 and 4/2/24. Facility's smoking policy dated 7/28/23 documented in part: -It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner. 46342 3.) On 04/02/24 at 11:40 AM, R85 stated, I smoke and have my cigarettes and lighter right here. R85 reached into a black plastic bag at bedside and took out a pack of cigarettes and a lighter. R85 was initially admitted to the facility on [DATE]. R85's diagnosis included but not limited to Tobacco Use, Psychoactive Substance Abuse, Atherosclerotic Heart Disease, Insomnia, Chronic Pain, Major Depressive Disorder, Iron Deficiency Anemia, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypothyroidism, Personal History of Pulmonary Embolism. R85's MDS (Minimum Data Set) dated 02/23/24 indicates intact cognition with BIMS (Brief Interview for Mental Status) 15/15. R85's initial Smoking Program Evaluation in R85's electronic health record (EHR) completed 11/17/23 documents in part resident agrees to follow smoking rules, is considered a safe smoker and may use/access smoking materials consistent with facility policy, staff is not required to remain in attendance while resident is smoking, and resident is a safe and independent smoker. On 04/04/24 at 8:28 AM, V8 (Social Service Director) reviewed R85's electronic health record (EHR) with surveyor. V8 stated R85 has a Smoking Program Evaluation completed 11/17/23 when R85 was first admitted to the facility. V8 stated R85 should have had another Smoking Program Evaluation completed in February 2024 when quarterly MDS was done. V8 stated a quarterly smoking assessment was not done and it should have been completed because they are supposed to be completed on a quarterly basis.

Based on observations, interviews, and record reviews, the facility failed to follow the dietary recommendations for residents who have weight loss for 3 (R45, R58, R66) out of 4 residents reviewed for nutrition in the final sample of 19 residents. Findings Include: 1.) On 4/02/24 at 12:22 PM, R45 was eating lunch in R45's room. R45's lunch tray consisted of one serving of noodles, one serving of fish, one serving of spinach, apple crisp, coffee, and juice. R45's meal ticket dated 4/2/24 does not indicate double portions. On 4/03/24 at 12:32 PM, R45 was eating lunch in R45's room and R45's lunch tray consisted of one piece of pork roast, one dinner roll, one scoop of mashed potato, juice, coffee, one serving of broccoli florets, and pudding. R45's meal ticket dated 4/3/24 does not indicate double portions. R45's progress notes dated 1/11/2024 at 11:28 PM documented by V15 (Former Registered Dietitian) reads in part: Diet order: CCHO (Consistent Carbohydrate Diet), regular, thin liquids. No known food allergies. Salad added to L/D (Lunch/Dinner). Weight: 128 lbs. (pounds) 1/8/24; BMI 17.9 - -7.2%, -10lb weight loss in 1 month compared to 12/5/23 weight of 138lbs. (R45) with a good appetite, adequate oral intakes 75-100% intakes. No chewing or swallowing difficulty. Food preferences up to date. (R45) at nutritional risk due to dementia diagnosis, HIV; will monitor need for CCHO diet, most recent HgA1C is WNL (within normal limits), good control. Will order 2 boiled eggs to breakfast, will order double protein portions for L/D. Goal for wt. (weight) stability, gradual wt. gain ideal, labs WNL. Recommended to continue with nutrition plan of care, no significant changes since last assessment. R45's weight shows: 3/9/2024 132.0 Lbs., 2/16/2024 134.0 Lbs., and 1/12/2024 136.0 Lbs. R45's physician orders do not show any order for double portion as recommended by V15. 2.) On 4/03/24 at 12:27 PM, R58 was eating lunch in R58's room. R58's lunch tray consisted of one serving of ground pork, one serving of broccoli florets, one serving of mashed potato, one serving of pudding, juice, and coffee. R58's meal ticket dated 4/3/24 does not indicate double portions. R58's progress notes dated 12/5/2023 at 11:26 PM documented by V15 reads in part: Diet: General, Mechanical Soft, Thin Liquids; PO intake 75-100%, Weight 12/5/23 126.0lbs, significant loss of 10.6%, -15lbs compared to 10/26/23 weight of 141.0lbs, -10.6%, -15lbs compared to 6/9/23 weight of 141.0lbs. BMI 20.3-underweight for advanced age. R58 significant loss is undesirable as BMI considered underweight. Since appetite and PO intake is intact, will order double entree portions to help prevent further weight loss, promote weight gain. Will also order house supplement BID. Weight maintenance or gain desired. R58's progress notes dated 3/14/24 at 11:22 AM documented by V15 shows R58 should be receiving double entree portions. R58's weights show: 10/26/23 141 pounds, 12/5/23 125.4 pounds, 1/12/24 125 pounds, 2/16/24 125 pounds, and 3/9/24 128 pounds. R58's physician orders do not show any order for double portion as recommended by V15. On 4/3/24 at 11:34 AM, V14 (Registered Dietitian) stated that it is important to follow the dietary recommendations for the residents especially with weight loss to prevent malnutrition. V14 stated that double portions are recommended for R45 and R58 to provide extra calories to prevent further weight loss. V14 stated that it is the responsibility of the Dietitian to communicate dietary recommendations to the staff and to enter order in the residents' electronic charting. V14 stated that R45 and R58 should have orders for double portions as recommended by V15. V14 stated that Dietary recommendations should be reflected in the residents' meal tickets. 45110 3.) R66 clinical record indicates in part, R66 was admitted on [DATE] with the medical diagnosis of hemiplegia affecting left side, heart disease, osteoarthritis, schizoaffective disorder bipolar type, anxiety, recurrent depressive disorders, essential hypertension, cerebral infarction, chronic obstructive pulmonary disease, prediabetes, and dizziness. Minimum Data Set Brief Interview Mental Status scored (11) indicates R66 is cognitively intact. R66's care plan documented in part: 1/24/24- R66 has actual decline in ability to feed self, and needs staff to set up tray, and monitor. Provide assistance to R66 to scoop food onto spoon with each bite of food. 12/2/22- R66 will be free of significant weight changes of greater than 5%. 12/2/22- Prepare R66's diet as ordered: Regular diet, thin liquids with double portions at mealtimes. R66 weights: lbs. (Pounds) 4/2/24-147lbs., 3/9/24-160.0 lbs., 2/16/24-162.0lbs., 1/12/24- 163.0 lbs., 12/5/23-158.5lbs., 11/10/23-163.0lbs., and 10/26/23-171.0lbs. R66 progress notes in part: 11/15/2023 16:35-Nutrition (Former Dietary) Note Text: Weight Assessment R66, 66 y/o male. PMHx (past medical history) swelling, bipolar disorder, paranoid personality disorder, HTN (hypertension), dysphagia. AOx3. Diet order: general, regular, thins. PO (oral) intake mostly 75-100%. Weight: 163lbs; BMI 24.8-WNL; significant weight loss -11.4%, 21.0lbs compared to 5/5/2023 weight of 184lbs. R66 reports a good appetite, recent oral intakes 75-100%. Since appetite and intake are intact, will order double entree portions at all meals. Goal is for weight stability, adequate oral intakes. V14 (Registered Dietician/RD)] Progress Note: 4/3/2024 10:15 Nutrition (Dietary). Note Text: Significant weight loss review. RD received notification from Restorative Director about R66's weight loss. Current weight record for 4/2/24 is 147# (pounds). Weight over 1, 3, and 6 months are as follows: 1 month - 3/9/24 - 160(8.1%), 3 months - 1/12/24 - 163(9.8%), and 6 months - 10/26/23 - 171(14.0%). Significant weight loss at 1, 3, and 6 months, which is planned and likely related to R66 purposely trying to lose weight as he reports my doctor told me. Writer followed up with CNAs (Certified Nursing Assistants), in which CNAs also confirmed that resident has been cutting back on his intake purposely to adhere to his doctor's orders. MD will be notified of R66's significant weight loss. Weight fluctuations may also occur due to fluid shifts and diuretic use. BMI: 22.3 - underweight; desirable BMI for age >65: 23-29.9 kg/m2. Diet: Regular, thin liquids. Per staff, resident is observed to have fair PO intake at mealtimes. No edema noted. Skin remains intact. Meds: lisinopril, furosemide, atorvastatin calcium, docusate sodium, lactulose, carvedilol, famotidine, polyethylene glycol powder, melatonin. Continue double entree portions at all meals to promote weight maintenance. On 04/2/24 at 11:47 AM, observed R66 eating lunch alone without staff assistance or encouragement. On R66's plate was one strip piece of [NAME] lemon pepper fish, 4 ounces of buttered chopped spinach, 4ounces of buttered egg noodles, one dinner roll, half cup of apple crisp, eight ounce of whole milk, six ounces of red sugar free punch. R66 ate 2 bites of fish and one fork full of his spinach. R66 stated, I don't really have an appetite. I try to eat as much as I can and my clothes are getting big on me, I wonder how much I weigh. I have not been weighed in a few months. Most of the time the food is too salty and greasy, I have not tried or wanted to lose weight, I just don't like how the food is made and I am not hungry. On 4/2/24 at 12:10 PM, Surveyor accompanied V12 (CNA) and R66 in his wheelchair down to the ground level therapy gym to be weighed. V13 (Restorative Aide) turned on the wheelchair scale and zero out the scale. V13 then pushed R66 while sitting in wheelchair without any leg rest, onto the scale and secured the wheelchair. Surveyor, V12 and V13 witnessed the total of the wheelchair and R66 was 189.0 pounds. V12 and V13 took R66 back to his bed and brought the empty wheelchair to the therapy gym. Surveyor and V13 witnessed the empty wheelchair weighed 42.0 pounds. V13 stated, R66 weight is 147.0 pounds. I assist with monthly weights. I am not sure how R66 lost 13 pounds in one month, on 3/9/24 R66 weighed 160.0 pounds. On 4/3/24 at 12:05 PM, V14 stated, I only been working for this facility for two weeks. I have been a registered dietician for five years. Today was my first day working with R66. He said to me that he was purposely trying to lose weight. I spoke to several certified nurse assistants confirmed that R66 has been cutting back on his intake purposely to adhere to his doctor's orders. A weight loss trend for significant weight loss is 5% or more in one month, 7.5% in three months, or 10% or more in six months. R66 weighed 160 pounds on 3/9/24 and on 4/2/24 he weighed 142pounds. R66's clinical record showed, 1 month - 3/9/24 - 160(8.1%), 3 months - 1/12/24 - 163(9.8%), and 6 months - 10/26/23 - 171(14.0%). Significant weight loss was noted at 1, 3, and 6 months. If a resident weight is trending down, I would recommend supplements, sandwich, snacks, or double portions to increase calories. I can enter the recommendation in the facility physician order system as a pending order. The floor nurse would call and give my recommendations to the physician for approval, once the physician approves my recommendation, then the nurse would confirm the recommendation that will become a standing order. Once approved, then I would email the dietary manager my recommendations. My recommendations should be followed out and printed on the resident's diet slip for the next meal. If the physician denied my recommendation, there would be a progress note to reflect the physician's decision. After reviewing the former dietitian assessment notes, double portions were recommended on 11/15/23, I placed in the order for double portions today. R66 was eating well according to his meal intake documentation 76-100% of his meals. If the facility followed the recommendation of double portions dated 11/15/23, it could have potentially slowed down or prevented R66's weight loss, but there is other illness that can also cause weight loss. Surveyor gave V14 R66's physician orders, dietary slip, March 2024, and April 2023 meal intake documentation to review. V14 stated, I do not see any physician order that document for R66 to eat less or to lose weight. I do not see any physician order or diet order that has double portions for R66. Looking at R66 dietary slip dated 4/2/24 and labeled Tuesday Lunch does not reflect R66 to receive double portions. R66's meal intakes from March to present, the majority document that R66 ate 76 to 100% of his meals. After I reviewed R66's progress notes, he did not have any illness documented that would account for a thirteen-pound weight loss in one month. I am not sure where the weight loss in the last thirty days came from. On 4/4/24 at 11:26 AM, V2 (Director of Nursing) stated, A few years ago the facility gave the dieticians access to our system to place in their own recommendations. The floor nurse will open the resident's chart and see there is an order pending, the nurse confirms order with physician then on the computer and the recommendation becomes an order. The nurse then completes a dietary slip and take the order to the kitchen manager. If a recommendation for double portions was placed in the system and given to the kitchen for R66, it could have potentially prevented or slowed down his weight loss. Policy documents in part: Nutritional Assessment (No Date) -The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Weights dated 7/28/23. -The significant weight changes will be assessed and addressed by the interdisciplinary team which includes but not limited to the dietician, physician, and nurses.

Based on observation, interview, and record review, the facility failed to properly discard multi dose insulin vial after 28 days of opening for 1 (R32) resident and properly date opened multi-dose nasal spray for 1 (R83) resident. The facility also failed to properly discard 2 expired house stock multi dose insulin pens from 2 of 3 medication carts and medication storage room inspected for medication storage and labeling. The findings include: 1.) R32's health record documented admitted on [DATE] with diagnoses not limited to Type 2 diabetes mellitus. Atherosclerotic heart disease of native coronary artery, Anxiety disorder, Heart failure, Primary generalized (osteo)arthritis, schizoaffective disorder bipolar type, Major depressive disorder, Hyperlipidemia, Gastro-esophageal reflux disease without esophagitis, Chronic obstructive pulmonary disease, Other psychoactive substance use substance-induced persisting dementia, Essential (primary) hypertension, Nondependent opioid abuse, Alcohol dependence. R32's Physician Order Sheet (POS) with order not limited to Admelog solution 100unit/ml inject as per sliding scale: If ,d+[DATE]=0 u; ,d+[DATE]=1u; ,d+[DATE]=2u; ,d+[DATE]=3u; ,d+[DATE]=4u; ,d+[DATE]=5u. Call MD if BS <60 or >400, subcutaneously with meals. 2.) R83's health record documented admitted on [DATE] with diagnoses not limited to Other asthma, Major depressive disorder, Encounter for screening for other viral diseases, Insomnia, Neuralgia and neuritis, Atherosclerotic heart disease of native coronary artery, Anxiety disorder, Chronic obstructive pulmonary disease with (acute) exacerbation, Gastro-esophageal reflux disease without esophagitis, Polyosteoarthritis, Essential (primary) hypertension, Opioid dependence, Mixed hyperlipidemia. R83's POS with order not limited to Fluticasone Propionate nasal suspension 50mcg/act 2 spray in each nostril one time a day. On [DATE] at 11:15am 1st floor medication cart inspected with V6 (Registered Nurse/RN) and observed R32's Admelog insulin vial date opened [DATE] (expiration date [DATE]) was found inside the medication cart. Pharmacy label indicated: Once opened, refrigerated, or not discard after 28 days. V6 stated insulin should be discarded after 28 days of opening. Observed clear plastic box inside the refrigerator with 4 insulin pens and found 2 expired Glargine insulin pens with manufacturer expiration date on ,d+[DATE]. V6 said 2 Glargine insulin pens expiration date was ,d+[DATE], these should be discarded. On [DATE] at 12:05pm 2nd floor medication cart inspected with V7 (RN) and found R83's Fluticasone 50mcg/act nasal spray opened with no date labelled. V7 stated medication should be dated once opened to know when it was opened and when to discard the medication. On [DATE] at 11:08am V2 (Director of Nursing) said medications should be dated once opened. She said dating/labeling opened medication is important to know when it was opened and when to discard the medication. V2 said nasal spray medication should be dated once opened. She said expired medication/insulin should be discarded as it could potentially put resident at risk or could be hazardous if expired medication was given to resident. Facility's medication storage, labeling and disposal policy dated [DATE] documented in part: -It is the facility's policy to comply with federal regulations in storage, labelling and disposal of medications.

Based on observations, interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 6 out of 48 rooms in the facility. Findings Include: On 4/2/24 at 9:25 AM, during the entrance conference with V1 (Administrator), V1 stated that the facility has multiple residents' rooms that are less than the required square footage per resident and that requires a variance. At 11:57 AM, V3 (Maintenance Director) stated that there are 6 residents' rooms in the facility that have waivers, and they are rooms 107, 108, 207, 208, 307, and 308. V3 stated that all 6 rooms have almost the same measurements. At 11:58 AM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:01 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:03 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:05 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:07 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:09 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. On 4/4/24 at 11:10 AM, V1 stated that the requirement is 80 square footage per resident in a multi bed resident's room. V1 stated that there are currently 6 residents' rooms that do not meet the requirement and that there are 3 beds in each of those rooms. V1 state that the facility has not made any changes in the size of the rooms since the last annual re-certification survey. The 4/2/24 facility daily roster documented that there are 48 rooms in the facility and rooms 107, 108, 207, 208, and 308 are 3-resident rooms. The (undated) room [ROOM NUMBER], 108, 207, 208, 307, and 308 floor plans documented the room floor areas ranges from 205 square feet to 223 square feet. These indicate that each resident is provided 68.3 square feet to 74.3 square feet size space in the room. The (8/3/22) Facility waiver Request Per F912, 42 CFR 483.90 (e) (1) (ii) Survey Type: Annual Certification Survey Date: 7/12/22 documents in part, This is a request for a variation/waiver of the requirement for F912, 42 CFR 483.00 (e)(1)(ii), the requirement that the bedrooms measure at least 80 square feet per resident in multiple resident bedrooms. The variation/waiver is requested for rooms numbered 108, 208 and 308 at [facility].

Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for one (R4) out of three residents reviewed for abuse. This incident resulted in one (R4) resident feeling emotionally and psychologically traumatized. Findings include: R4 is a [AGE] year-old female with a BIMS (Brief Interview for Mental Status) score (4/20/2023) of 15, which means R4's cognition is intact. Per Face sheet, R4 has diagnosis of major depression. R4's abuse care plan documents: History of sexual abuse. On 09/19/2023 at 11:32 AM, R4 was inside her room, alert and able to express her thoughts very well. R4 stated a male resident who she has never seen before, touched her arm and shoulder, tried to wake her up and solicited unilateral aggressive sexual contact. R4 stated that she screamed upon realizing the situation that is transpiring. R4 stated that she screamed for help and then V6 (Registered Nurse) came right away. R4 stated that she was traumatized with the incident and unable to sleep because she had past sexual abuse experience. R4 stated that she was afraid that the unidentified male person would come back into her room. On 09/19/2023 at 11:08 AM V3 (Registered Nurse) stated that he is familiar with R2. V3 stated that when R2 was admitted to the facility on [DATE], on (floor different than R4). V3 stated that R2 is a wanderer. V3 stated that on 08/08/2023 R2 went into R4's room (R4's room is located on a different floor than R2) and made aggressive sexual inappropriate comments to R4. V3 stated that he went into R2's room and saw V6 (Registered Nurse) telling R2 that he cannot make inappropriate comments like that, and it was wrong. V3 stated that he talked to R4. V3 stated that R4 told V3 that she was shocked because R2 touched her arm and neck. V3 stated that R4 told him that she was scared and worried and concerned. R4 told V3 that R2 made inappropriate comments. V3 stated that R4 told him that R2 was trying to wake her up. On 09/19/2023 at 02:01 PM, V6 (Registered Nurse) stated that he was working the 3:00 PM to 11:00 PM shift on (R4's floor) on 08/08/2023. V6 stated that R4 is a resident residing (stated floor location). V6 stated that he did not notice R2 going into R4's room. V6 stated that R4 told him saying, somebody, who she did not recognize, came in her room, and made an inappropriate/sexual proposal. She said no and he left. V6 stated that he went into R2's room and talked to R2. V6 asked R2 if he went into R4's room. R2 stated he did and was looking for R4 to have sex with her. V6 stated that he called R2 outside his room and R4 identified the resident. V6 stated that R2 admitted that he made inappropriate sexual comments to R4. R4 stated that she was anxious. V6 stated, R4 told him, I hope he doesn't come down to my floor and into my room again. V6 assured her that R2 won't come down. R4's progress note by V6 on 08/08/2023 at 07:40 PM documents: Around 7:40pm, resident reported that a male resident came into her room and made an inappropriate verbal proposal to her; she refused. According to Face sheet, R2 is a [AGE] year-old male. R1 has medical diagnosis of schizoaffective disorder, homicidal ideation, and bipolar disorder. On 09/20/2023 at 09:47 AM, V4 (Clinical Manager) stated that at admission we have 72-hour constant observation and monitoring by the interdisciplinary team including social worker, CNA and nurses also watches him. It's our practice to constantly monitor them because we need to understand their behavior. On 09/20/2023 at 10:37 AM, V5 (Social Services Director) stated the resident must be watched for 72 hours by the social worker. We do not have any behavior interventions in place for R2 to monitor and watch him from going into another resident's room. On 09/20/2023 at 2:13 PM, V9 (Nurse Practitioner) stated that schizoaffective is derived of two words. Schizo- meaning prominent psychotic symptoms such as hallucinations, delusions, auditory symptoms, disorganized speech. Affective which means mood such depression, anxiety, and mania. Homicidal Ideation means that there is an intent to harm others. Thought to harm others or specific plan. For example, I want to hurt the nurse with the knife. Intentional motivation to harm others. Schizoaffective disorder can make you sexual aggressive. It's not always but usually. V9 stated, you can google this information. It is the same. Progress Note by V4 (Clinical Manager) for R2 documents in part: R2 presents as danger to self & others and requires immediate hospitalization due to sexually inappropriate behavior. Resident solicited sexual behavior (to) other resident and touched another resident's arm and neck. Resident is irrational, unpredictable, acting on impulsiveness, and likely to engage in harmful behavior due to impaired judgment, and mental health decompensation. V9 was notified with new order noted and carried out. Resident on monitoring. Progress Note by V3 (Registered Nurse) for R2 on 08/08/2023 documents: R2 had an incident where he said inappropriate comments to another resident on (location of R4's floor). Administrator made aware. Resident is being monitored on (R2's floor location) and has been instructed to avoid this resident and (R4's floor location). (R4's) Floor Nurse made aware. Resident is on continuous monitoring. R2's baseline care plan does not have behavior interventions related to R2's mental illness diagnosis. Per census, R2 was admitted on the XXX floor and incident happened on the YYYY floor in R4's room. Per incident report, the incident happened inside R4's room located on the YYYY floor. Facility's Abuse Report Final documents in part: R4 did report difficulty sleeping for two nights after the incident. Facility's Abuse Policy (07/14/2023) documents in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse is the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes to intent harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Even if there is capacity to give consent, consent obtained to intimidation, coercion, or fear is considered sexual abuse.

Based on observation, interview, and record review the facility failed to provide a working wound vacuum and failed to assess one resident's (R85) wound. These failures affected one resident (R85) causing (R85's) wound to have a foul odor, purulent greenish drainage and (R85) feeling embarrassed due to the odor that permeated (R85's) room. Findings include: R85's Face sheet documents R85 has a diagnosis that include but not limited to acute hematogenous osteomyelitis left ankle and foot, unspecified abnormalities of gait and mobility, other lack of coordination, peripheral vascular disease, idiopathic aseptic necrosis of the femur, complete traumatic amputation at level between knee and ankle unspecified lower leg sequela and acquired absence of unspecified foot. R85's Brief Interview for Mental Status (BIMS) dated 03/20/23 documents that R85 has a BIMS score of 15 which indicates that R85 is cognitively intact. On 05/08/23 at 10:49 am, Surveyor observed R85's room door closed. Upon opening R85's room door, surveyor observed R85 in bed asleep and R85's room with a foul odor. Surveyor unable to interview R85 due to R85 asleep. On 05/08/23 at 3:00 pm, V2 (Director of Nursing/DON) stated, V2 was the facility's wound care nurse. Surveyor requested to see R85's wound. V2 stated, that R85's wound is changed on Monday's Wednesday's and Friday's and was already changed and will not be changed again until Wednesday May 10, 2023. On 05/09/23 at 11:40 am, Surveyor and V2 observed R85 sitting in a wheelchair in R85's room with a wound vacuum device in place on R85's amputated left leg area between R85's knee and ankle area and a foul odor in R85's room. R85 stated, Now that my machine (referring to R85's wound vacuum device) is back working, what is the smell and this green drainage in this container (referring to the wound vacuum device canister)? Surveyor and V2 observed R85's wound vacuum canister with moderate amount of foul odorous green drainage. V2 replied to R85, That is the drainage. When V2 was asked regarding the odor in R85's room V2 stated that the foul odor in R85's room was from R85's drainage from R85's wound (referring to R85's wound to left leg area between R85's knee and ankle area). V2 also stated, R85's wound vacuum device was not working for a few days and that R85 was giving a new wound device on May 9, 2023. On 05/09/23 at 11:45 am, R85 stated that on May 5, 2023, R85 informed the nurse (unknown nurse) that R85's wound vacuum device was not working. R85 stated, the broken wound device stayed in place to R85's wound and R85 did not receive a working wound vacuum device until 05/09/23. R85 stated, On 05/07/23 is when I noticed my room developed a foul smell from my wound that made me feel embarrassed. R85 stated, I told V20 yesterday about the smell and V20 did not do anything. I don't want people to think that I smell. My wound vacuum cord was broken, and I only needed a new cord and they (referring to the nurses) waited until Monday to order a whole new machine. On 05/09/23 at 11:47 am, Surveyor and V20 (Licensed Practical Nurse/LPN) observed a foul odor in R85's room. When V20 was asked regarding R85's foul room odor R85 stated, It (referring to R85's foul room odor) is better today. Yesterday it (referring to R85's foul room odor) was bad because R85's wound vacuum was not working. When V20 was asked regarding R85's wound vacuum not working. V20 stated, V20 was aware that R85's wound device stopped working on May 6, 2023, and that V20 informed V2 (DON) on May 8, 2023. V20 explained, R85's wound only gets changed on Monday, Wednesday, Fridays and that R85's wound vacuum device was replaced on Monday May 8, 2023, and that R85 received a new wound vacuum dressing then. V20 was asked regarding the facility's policy for a wound vacuum device if it is not working. V20 stated, We (referring to staff) have to tell the DON. On 05/10/23 at 9:30 am, Surveyor requested to see R85's wound and V2 stated that R85 was not in the building and that R85 was sent to the wound clinic for R85's wound to R85's left leg area between R85's knee and ankle area to be assessed. V2 also stated that V21 (Nurse Practitioner/NP) saw R85 on 05/09/23 and ordered for R85 to go to the wound clinic. On 05/10/23 at 12:43 pm, Surveyor requested R85's wound assessments for the past four weeks from V2 (DON). V2 stated, I (V2) do not have it. I usually do it (referring to R85's weekly wound assessment) every week but I (V2) did not do it. R85's last assessment I (V2) completed in the system was April 5, 2023. On 05/10/23 at 1:45 pm, V21 (Nurse Practitioner) stated, R85 is an alert and oriented resident and that V21 last saw R85 on May 09, 2023. V21 explained, R85 has a vascular wound to her lower left extremity with a wound vacuum device in place that is changed on Monday's, Wednesdays, and Fridays by the facilities nurses as well as R85 also goes to wound clinic (unsure of how often). V21 stated, on May 09, 2023, V21 assessed R85's wound with a foul odor and green drainage in R85's canister. V21 stated, R85's wound should be assessed every time R85's wound vacuum dressing is changed on Monday's, Wednesday's, and Friday's. V21 also explained, If R85's wound vacuum is left in place and goes without being changed or unassessed there is a possibility of sepsis and infection occurring to R85's wound. Surveyor asked V21 if R85's wound vacuum device is not working, what should happen to R85's wound. V21 stated, R85's wound vacuum device should be removed immediately, and a wet-to-dry dressing should be applied to avoid infection from occurring to R85's wound. V21 was asked signs of infection. V21 stated, Foul odor and green drainage are signs of an infection. V21 stated, On May 9, 2023, staff informed V21 that R85's wound vacuum stop working on May 05, 2023, and that R85's wound vacuum was not replaced until May 09, 2023. V21 stated, V21 ordered for R85 to go to the wound clinic on May 10, 2023 and a culture of R85's wound to be collected at R85's wound clinic. On May 10, 2023, at 2:15 pm, V2 (DON) stated that if a residents wound vacuum device is not draining the drainage properly from the wound, then the wound will deteriorate and show signs of infection. V2 stated, Signs of infection include green drainage and foul odor. V2 stated, The purpose of the wound vacuum is to drain the wound drainage, prevent signs of infection and help with wound healing. V2 also stated, If a wound vacuum is left in place and not working for several days the wound can deteriorate and have and odor and show signs and symptoms of infection. V2 explained, the floor nurses are in charge of changing R85's wound vacuum dressing and that V2 was told on May 8, 2023, that R85's wound vacuum device was not working since May 05, 2023. V2 stated on May 08, 2023, V2 called the Durable Medical Equipment (DME) supplier right away to get R85 another wound vacuum device. V2 also explained, R85 was given a working wound vacuum device on May 09, 2023, that was delivered by the wound DME supplier. V2 was asked regarding assessment of R85's wound. V2 stated, R85's wound is expected to be assessed at least weekly and should be assessed every time R85's wound vacuum is removed three times a week. V2 explained, if a wound goes more than a week without being assessed the wound can deteriorate and can have signs of infection. V2 also stated that if a wound vacuum device is not working properly, the wound vacuum device should be reported to V2 immediately, the wound should have a dry dressing placed until the equipment is replaced and the equipment should be replaced as soon as possible. V2 stated, This did not happen with R85. I am not sure why I was not immediately informed. R85's POS (Physician Order Sheet) dated 03/29/23 documents, in part: Change wound vac (vacuum) dressing every 3 days and PRN (as needed) monitor wound weekly every day shift every Monday, Wednesday, Friday related to complete traumatic amputation at level between knee and ankle unspecified lower leg sequela. R85's progress note dated 05/09/23 authored by V2 (DON) documents, in part: R85 noted with mild odor and mild greenish drainage in wound vac . R85 offered to go to the hospital for further evaluation of wound . drainage in vac tubing pale brown in color. R85's care plan dated 03/28/2023 documents, in part: Focus: R85 has venous/stasis ulcer related to PVD (Peripheral Vascular Disease). Goal: R85 will have no signs/symptoms of infection through next review dated. Interventions: Monitor/document/report to MD (Medical Doctor) as needed for signs/symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from wound, excess pain, fever. R85's care plan dated 03/28/23 documents, in part: Interventions: Change dressing using the topical and dressing materials ordered at the prescribed frequency . Frequently reassess the integrity of the dressing. Reinforce dressing as needed. Monitor for changes in amount, type, odor and frequency of drainage and need for reinforcement. R85's Wound Assessment Details Report dated 04/05/23 and authored by V2 (DON) documents R85's last wound assessment prior to 05/10/23. The facility's policy dated 07/28/22 and titled Skin Care Treatment Regimen documents, in part: Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Procedure: . 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician.

Based on observation, interview, and record review the facility failed to assess and rate pain for one resident (R73) that was experiencing a tooth ache and failed to administer pain medication as ordered. This failure resulted in R73 experiencing severe pain with facial grimacing and pain with eating. Findings Include: R73's admission record includes but not limited to diagnoses of schizoaffective disorder, atherosclerotic heart disease, chronic obstructive pulmonary disease, encephalopathy, hypertension, anxiety, and paranoid schizophrenia. R73's (2/21/23) Brief Interview of Mental Status documents a score of 15. (Cognitively intact). On 5/8/23 at 10:55 am surveyor observed R73 lying in bed with the covers pulled over R73's head. R73 pull the covers from over her head and surveyor observed R73 with facial grimacing when talking. R73 stated, My tooth hurts. I told the nurse, but they haven't given me anything. The doctor said he was going to order me some oral gel, but I haven't gotten it yet. My pain is an 8 on a pain scale of 1 to 10. I can hardly eat. I have to switch the food from side to side in my mouth when I'm eating because of the pain. On 5/8/23 at 11:05 am surveyor informed V9 (Registered Nurse/RN) that R73 stated she has tooth pain. V9 stated, I will go and see R73 and call the doctor. On 5/9/23 at 10:20 am surveyor observed R73 in room lying in bed. R73 stated, I still have tooth pain and still haven't gotten anything for my pain. R73 stated, The pain is a 4 on a pain scale of 1 to 10. The surveyor asked R73 if V9 (RN) gave her something for the tooth pain yesterday (5/8/23). R73 stated, No, I didn't get anything. On 5/9/23 at 10:25 am surveyor asked V9 if V9 administered R73 any pain medication for R73's toothache on 5/8/2023 when surveyor informed V9 that R73 was in pain. V9 stated, I did not go into R73's room. I did not give R73 anything for pain or call the doctor yesterday (5/8/23) because I was busy. Surveyor asked V9 if residents are assessed for pain. V9 stated, No I do not ask if the residents are in pain. I only ask if I know someone has chronic pain then, I will ask if they are in pain today. V9 stated, I will call the doctor. R73's (4/25/23) active orders, documents in part, oral relief give 1 application by mouth every 24 hours as needed for tooth pain. On 5/10/23 at 1:40 pm V21 (Nurse Practitioner) stated, R73 said she had tooth pain and needed something for the pain. V21 stated, Oral gel was order for the tooth pain. V21 stated, Nurses are expected to carry out orders and I wasn't aware that R73 did not receive the ordered medication. On 5/10/23 at 2:15 pm V2 (Director of Nursing) stated, pain assessment is done as soon as the resident complain of pain and is documented on the MAR (Medication Administration Record) or progress notes. Nurses are expected to carry out physician orders and manage resident's pain. Surveyor asked if a resident reports pain to nurse, what is the expectation of the nurse? V2 stated, The nurse should go and immediately assess the resident for pain, ask the pain scale and give the appropriate pain relief medication. V2 stated, It is not acceptable for a nurse to not assess a resident for pain and say they are too busy. On 5/10/23 at 2:30 pm, surveyor and V9 (RN) checked the medication cart for R73's oral relief medication ordered on 4/25/23. Medication was not observed on second floor medication cart by surveyor and V9. V9 stated, I will reorder and call the pharmacy. R73's MAR (Medication Administration Record) documents, in part, Oral Relief for dry mouth, Mouth/Throat Gel (Artificial Saliva) Give 1 application by mouth every 24 hours as needed for tooth pain-Start Date- 4/25/2023. Review of MAR shows no documentation R73 received ordered medication from 4/25 to 5/10/23. R73's MAR documents in part, Acetaminophen Tablet 650 mg give 1 tablet by mouth every 4 hours as needed for General Discomfort. Review of MAR shows no documentation R73 received ordered medication from 4/25 to 5/10/23. R73's electronic records shows no pain assessment documentation noted on pain assessment flow sheet, MAR, or progress notes from 4/25/23 to 5/10/23. R73's last pain assessment was documented on 11/16/22. R73's care plan dated 2/21/23 documents in part, at risk for acute and chronic pain. Interventions: observe for non-verbal signs of pain, provide analgesic as ordered, utilize non-pharmacological intervention. Facility Registered Nurse Job Description (5/5/2015) documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guest ER serve, the Registered Nurse (RN) plays a critical role in providing superior customer service and nursing care to all Guests and guest. The RN provides supervision of staff and will safeguard the health, safety, and welfare of all Guest/guest under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 7. Place pharmacy orders, for and administer all newly prescribed medications and document. Facility Pain Policy (7/28/22), documents, in part, Policy Statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. For pain complaints and for situations/ incidents that might result to pain (Example: fall incident, altercation, cuts, bruises, wound care, etc.), the nursing staff may document it in any part of the resident's medical record that includes Nurses Notes, Incident Report, and Medication Administration Record.

Based upon observation, interview and record review the facility failed to ensure that one of six residents (R2) in the sample remains free from abuse/neglect, failed to implement the abuse/neglect policy, and failed to ensure that professional boundaries between staff and residents are not crossed. On 5/10/21, R2 eloped from the facility (approximately 15 hours) with V3 (LPN/Licensed Practical Nurse) while off-duty (unbeknownst to staff). R2 refused to return to the facility therefore was carried by his arms and legs while suspended in the air from [NAME] Street back to the facility (approximately 100 yards) by V1 (Administrator/Abuse Coordinator), V7 (Security Guard), and V14 (CNA/Certified Nursing Assistant). On 5/17/21 at 1:31pm, R2 affirmed he sustained injuries (5/10/21) to his arms, legs and left shoulder. R2's (5/14/21) hospital records state he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. These failures have the potential to affect 90 residents. These failures resulted in an IJ (Immediate Jeopardy). Findings include: The (8/5/20) abuse and neglect policy & procedure includes but not limited to; have procedures to establish a written policy on how to assist staff in identifying abuse. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrators Designee. All allegations will be investigated by the Administrator or Designee immediately. Attending physician will be notified. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed. Protect residents from physical and psychosocial harm during the investigation. If the alleged perpetrator is an employee, the employee will be immediately suspended from working pending the result of the investigation. All allegations of abuse will be reported to IDPH (Illinois Department of Public Health) immediately not exceeding 2 hours after the initial allegation is received. The 5/12/21 census includes 90 residents. On 5/11/21, IDPH (Illinois Department of Public Health) received the following allegations: V3 (Licensed Practical Nurse) has a weird relationship with R2. He's only allowed to eat and socialize if V3 is present or tells R2 to do so. On 5/10/21, V3 took R2 out of the facility at approximately 3am (without authorization) and the facility was unaware that R2 was missing (until dayshift). V3 remains employed by the facility and has access to R2. R2's (5/10/21) progress notes were reviewed, nothing was documented. R2's (4/30/21) cognitive assessment affirms his daily decision making is moderately impaired. On 5/12/21 at 9:50am, surveyor inquired if V3 (LPN) recently left the facility (around 3am) with R2 V1 (Administrator) stated He took him for a walk two days ago (5/10/21) in the neighborhood. He was out for a few hours and they came back. Surveyor inquired if R2 has an outside pass V1 responded No, he went with staff. Surveyor inquired what hours V3 works V1 stated 3-11 pm. Surveyor inquired why V3 was at the facility around 3am if his shift ended at 11pm (4 hours prior) V1 replied He was here finishing up. (R2) is non-compliant but he's compliant with (V3), he has this type of relationship with this resident. [V3's timecard report affirms he clocked out at 11:29pm on 5/9/21 and was off-duty 5/10/21]. On 5/12/21 at 11:34am, R2 refused to communicate with surveyor. Surveyor inquired if R2 is able to talk R3 (Roommate) replied He barely can talk but he won't talk to you that's why (V3) help him out cause he don't associate with no one else. On 5/12/21 at 11:44am, V3 (LPN) was observed in the facility while off-duty [V3's 5/12/21 timecard report affirms he clocked in at 3:00pm]. V3 advised he bought lunch for R2 and stated I'm gonna give him food right now, I do it every day. Surveyor inquired if he left the facility with R2 on 5/10/21, V3 stated After I done my shift, I was helping with his dressing on my off time and we were praying. He asked me if he could go out for a smoke at like 2am (in the smoking area). He then asked me if he could just go around the block, I was thinking why not. Surveyor inquired when R2 returned to the facility V3 replied It was probably in the afternoon. Surveyor inquired if staff were made aware that R2 had left the building around 2am (as stated) V3 responded I told (V16/Registered Nurse) when he called me at 7 in the morning (approximately 5 hours later). Surveyor inquired if an elopement was called (5/10/21) V3 responded Yeah, they called a code yellow. Surveyor inquired why V3 would take R2 out of the facility while off-duty (overnight) V3 stated It's out of the ordinary but I'm trying to make him happy. On 5/12/21 at 12:20pm, surveyor inquired what code yellow means V1 stated Its elopement. Surveyor advised that staff and resident interviews affirm that on 5/10/21, R2 left the facility (unbeknownst to staff) with V3 (while off-duty) and a code yellow was called. R2's safety was at risk, he was outside (overnight) with an unauthorized individual unsupervised. [V3's timecard report affirms he continued to work after aforementioned conversation on 5/12/21, 5/13/21, and 5/14/21]. On 5/13/21 at 12:00pm, surveyor inquired about R2's cognitive status V12 (State Guardian) stated He's confused that's why he has the guardianship in place. Surveyor inquired if permission was given for R2 to leave the facility on or about (5/10/21) V12 responded No. On 5/13/21 at 12:47pm, V9 (Licensed Practical Nurse) affirmed he was assigned to R2 on 5/9/21 (11p-7am). V9 stated When I came in (R2) was with (V3) going in his room and coming out, he usually does that. I recall that about 2am, he was in the building but after that the door is not always open. I did not check on him until the morning around 6:30. Surveyor inquired if V9 was made aware that R2 was leaving the facility with V3 V9 replied No, he didn't tell me that. I would expect them to tell me if a resident is leaving. Surveyor inquired about V3's relationship with R2 V9 stated I noticed that he stays after his shift and this seems like giving him extra attention. I would just say that he takes more time with him, there's extra attention than most. I don't know if there's any kind of relationship other than that, he seems so committed to him, but I don't know why. Maybe sympathy, frankly I don't know. But if you would say that it's a different relationship, I would say that. The (08/18) NCSBN (National Council of State Boards of Nursing) Guide to Professional Boundaries includes Red Flag Behaviors: Nurses who display one or more of the following behaviors should examine their patient relationships for possible boundary crossings or violations. Signs of inappropriate behavior can be subtle at first but, but early warning signs that should raise a red flag can include: believing that you are the only one who truly understands or can help the patient, spending more time than is necessary with a particular patient, showing favoritism, meeting a patient in settings besides those used to provide direct patient care or when you are not at work. Considering reasonable person concept, professional boundaries between V3 and R2 were crossed. V3 buys R2's food (daily), visits him (during hours of sleep), and removed him from the facility (without authorization). R2 not associating with others and non-compliant but he's compliant with (V3) also raises a red flag given R2's cognitive status is moderately impaired. V1 presented an (undated) typewritten statement on 5/12/21, which includes but not limited to: on 5/10 at 7am, it was brought to my attention that (R2) was out overnight with (V3). At approximately 3pm, I met (R2) at the bus stop with 2 other staff and we were able to redirect (R2) back to (Facility). However, on 5/13/21 at approximately 2:46pm, the (5/10/21) video surveillance was reviewed. V3 was observed exiting the facility with R2 (via wheelchair) at 1:02am. At 4:28pm (approximately 15 hours later) V1, V7, and V14 were observed carrying R2 by his arms (near his wrists) and legs (near his ankles) while suspended in the air as his head and neck were unsupported. On 5/13/21 at 3:04pm, surveyor advised V15 (Regional Director of Operations) that after viewing the (5/10/21) video surveillance the manner in which R2 was handled by V1, V7, and V14 was abusive. V15 affirmed that an investigation would be conducted, and the staff involved would be suspended (pending an investigation). [V1 and V7 were observed working in the facility (5/13/21) prior to viewing the video]. R2's (5/10/21) preliminary incident investigation report (re: abuse) was received by IDPH (Illinois Department of Public Health) on 5/13/21 (3 days after the incident occurred). On 5/17/21 at 10:33am, V15 affirmed the following: V1 is the abuse coordinator, and V1, V3, V7, & V14 remain employed by the facility. V15 presented V1's (undated) statement which affirms on 5/10 at approximately 4:30pm: following many hours of (R2) refusing to return to (Facility) with (V3), (V1) and 2 other employees met them at the bench on [NAME] Street. After lifting (R2) up to put in the wheelchair he was unable to be placed safely back in. Given that (R2) was already being suspended in the air, they proceeded to carry him back to the building. [Approximately 100 yards]. On 5/17/21 at 1:31pm, surveyor inquired if R2 was injured while out of the facility (5/10/21) R2 nodded his head yes then pointed to his arms, legs and left shoulder indicating where he was injured. R2's medical records affirm he was not assessed by a Physician until 5/14/21 (4 days after the incident). R2's (5/14/21) hospital records state when patient asked why he has come to the ED (Emergency Department) he put his fists up indicating that there was a fight. Patient seems unable to articulate using words, using motions to indicate he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. The IJ occurred on 5/10/21 at 1:02am when V3 took R2 out of the facility (unauthorized), and at 4:28pm when they returned. The IJ was identified on 5/13/21 at approximately 2:46pm while reviewing (5/10/21) video surveillance which affirms V3 took R2 out of the facility (via wheelchair) and the manner in which R2 was handled by V1, V7, and V14 (upon return) was abusive. He was carried by his arms (near his wrists) and legs (near his ankles) while suspended in the air as his head and neck were unsupported. On 5/25/21 at 2:16pm, V15 (Regional Director of Operations), V19 (Director of Nursing) and V20 (Regional Nurse Consultant) were notified of the F600 IJ. The surveyor confirmed through record review and interview that the facility took the following actions to remove the F600 Immediate Jeopardy: 1. On 5/13/21, R2's Primary Care Physician was notified of the 5/10/21 incident and he was sent to the Hospital for evaluation. 2. On 5/13/21, R2's (5/10/21) abuse investigation was initiated. V1, V7, and V14 were suspended pending investigation. IDPH was notified on 5/13/21. 3. On 5/13/21, V7 and V14 received counseling, re-education and training on Abuse. 4. On 5/14/21, V3 was provided 1:1 in-service regarding boundaries. 5. As of 5/16/21, all staff were in-serviced on the Abuse Policy. 6. On 5/19/21, V1 (responsible for enforcing policies & procedures) was terminated. 7. On 5/21/21, V7 and V14 received CPI (Crises Prevention Intervention) training. CPI training for all staff is ongoing. 8. On 5/24/21, an additional abuse investigation was initiated due to surveyor concerns that V3 was not inclusive in the report received 5/13/21 (as warranted). V3 was suspended pending investigation. IDPH was notified on 5/24/21. 9. On 5/27/21, audits were initiated to ensure allegations of abuse are documented in the clinical record, appropriate authorities are notified, and investigations are conducted immediately. 10. As of 6/1/21, all staff were in-serviced regarding professional boundaries and employee conduct. 11. V3's employee report affirms on 6/2/21 he was terminated (effective 5/24/21). 12. On 6/3/21, the Police were notified of R2's (5/10/21) incident and a report was documented. Based upon record review and interviews conducted 6/7/21 the facility completed all measures on the abatement plan including in-servicing all staff on the Abuse Policy, notifying IDPH/Police, and terminating staff in authority positions. Therefore, the abatement plan could be approved on 6/7/21. The IJ was removed on 6/3/21.

Based upon observation, interview and record review the facility failed to conduct bed checks (every 2 hours), failed to provide supervision to one of six residents (R2) in the sample, and failed to implement the elopement policy. On 5/10/21 at 1:02am, R2 exited the facility with V3 (LPN/Licensed Practical Nurse) while off-duty (unbeknownst to staff), a code yellow was called at approximately 7am (6 hours later). R2 did not return to the facility until 4:28pm (approximately 15 hours after leaving the facility). On 5/17/21 at 1:31pm, R2 affirmed he sustained injuries (5/10/21) to his arms, legs and left shoulder. R2's (5/14/21) hospital records state he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. These failures have the potential to affect 90 residents. These failures resulted in an IJ (Immediate Jeopardy). Findings include: The (8/5/20) elopement policy states it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. Should a resident walk away from the facility and not be located by staff, the following procedure shall be initiated immediately. Notify the Administrator immediately. Call a code yellow, by highest level of supervisor on grounds. Contact the resident's family or responsible party and attending physician. If resident is not located staff are to initiate teams to search the exterior radius of 1 mile from the facility. If resident is not located after the above search efforts and no more than 2 hours have elapsed since the resident was last observed on the grounds, the Administrator and/or Director of Nursing will notify the police department with the resident's physical description and request their assistance in extending the search. As per statutory requirements, the Administrator and/or Director of Nursing will notify the appropriate state agencies of the incident. Complete a head to toe assessment to ensure no injuries and/or signs of distress (physical, mental, psychosocial) occurred during the elopement. Evaluate the need for hospital transfer as needed in accordance to physician's order. Document in the nursing progress note the status of the resident on return. Including assessment, evaluation and follow-up actions related to the resident's elopement. The (5/12/21) census includes 90 residents. On 5/11/21, IDPH (Illinois Department of Public Health) received the following allegations; on 5/10/21, V3 (LPN) took R2 out of the facility at approximately 3am (without authorization) and the facility was unaware that R2 was missing (until dayshift). V3 remains employed by the facility and has access to R2. R2's (5/10/21) progress notes were reviewed, nothing was documented. R2's (4/30/21) cognitive assessment affirms his daily decision making is moderately impaired. On 5/12/21 at 9:50am, surveyor inquired if V3 (LPN) recently left the facility (around 3am) with R2 V1 (Administrator) stated He took him for a walk two days ago (5/10/21) in the neighborhood. He was out for a few hours and they came back. Surveyor inquired where they went V1 replied He took him to the beach, bought him something to eat, that kind of thing. Surveyor inquired if R2 has an outside pass V1 responded No, he went with staff. Surveyor inquired what hours V3 works V1 stated 3-11 pm. Surveyor inquired why V3 was at the facility around 3am if his shift ended at 11pm (4 hours prior) V1 replied He was here finishing up. [V3's time card report affirms he clocked out at 11:29pm on 5/9/21 and was off-duty on 5/10/21]. On 5/12/21 at 11:34am, surveyor inquired about R2's (5/10/21) elopement R3 (Roommate) stated I don't know what time he left, it was about 7am when I woke up and he had left already. He came back that evening about 3:30 or 4:00. On 5/12/21 at 11:42am, surveyor inquired if R2 eloped from the facility (5/10/21) R4 stated They had a code yellow. On 5/12/21 at 11:44am, surveyor inquired if V3 (LPN) left the facility with R2 on 5/10/21, V3 stated After I done my shift, I was helping with his dressing on my off time and we were praying. He asked me if he could go out for a smoke at like 2am (in the smoking area). He then asked me if he could just go around the block, I was thinking why not. Surveyor inquired where he took R2 V3 responded I go around by the facility around, around, and around. I said it's time to go, he didn't want to come back. Surveyor inquired if he took R2 anywhere else V3 stated By the lake (Lake Michigan). Surveyor inquired when R2 returned to the facility V3 replied It was probably in the afternoon. Surveyor inquired if staff were made aware that R2 had left the building around 2am (as stated) V3 responded I told (V16/Registered Nurse) when he called me at 7 in the morning (approximately 5 hours later). Surveyor inquired if an elopement was called on 5/10/21 V3 responded Yeah, they called a code yellow. On 5/12/21 at 11:51am, surveyor inquired about R2's (5/10/21) elopement V6 (Wound Nurse) stated When I was working that day, he was not here (around 7am) so I asked for the Nurse and they said that (V3) took him outside. I made the administrator aware. I also made a statement. Surveyor inquired if there's a sign out sheet for residents leaving the building V6 responded We have a sign out sheet, it's with security. The (5/10/21) resident sign out sheets were requested, however 5/9/21 and (undated) resident sign out sheets were received. R2's name was not inclusive. On 5/12/21 at 12:20pm, surveyor inquired what code yellow means V1 stated Its elopement. Surveyor inquired if a code yellow was called (5/10/21) when R2 was reported missing V1 responded I don't know about a code yellow being called. Surveyor inquired if the police were notified (5/10/21) when R2 was reported missing V1 responded There was nothing to call. He did not elope; he was with staff. Surveyor advised that staff and resident interviews affirm that on 5/10/21, R2 left the facility (unbeknownst to staff) with V3 (while off-duty) and a code yellow was called. R2's safety was at risk, he was outside (overnight) with an unauthorized individual unsupervised. [V3's timecard report affirms he continued to work after aforementioned conversation on 5/12/21, 5/13/21, and 5/14/21]. V1 presented an (undated) typewritten statement on 5/12/21, which includes but not limited to on 5/10 at 7am, it was brought to my attention that (R2) was out overnight with (V3) in the immediate vicinity of (Facility). He stated he is trying to return to the facility however R2 did not return until 4:28pm (approximately 9 hours later). [V3 was not authorized to take R2 out of the facility and the police were not notified]. On 5/13/21 at 9:18am, surveyor inquired if staff are allowed to take residents out of the facility V7 (Security Guard) responded They are only allowed to take them out to the front. On 5/13/21 at 9:53am, surveyor inquired about the elopement policy V2 (Assistant Administrator) stated Code yellow is called when a resident that does not have independent pass privileges leaves the building. They notify the Administrator or me. Surveyor inquired if the police and/or responsible parties are also notified V2 responded It's uh internal. We will do a missing person if the resident is not found after a certain time. Surveyor inquired what timeframe elapses before residents are considered missing, V2 replied It's not a specific time [The elopement policy includes a timeframe]. Surveyor inquired about R2's (5/10/21) elopement V2 stated I got a phone call at 7 in the morning. They told me that he was not in the building, I informed the administrator (V1). Surveyor inquired if V12 (State Guardian) was notified on 5/10/21 of R2's elopement V2 responded I could find out for you. Surveyor inquired if the Police were notified of R2's (5/10/21) elopement V2 replied I do not know. Surveyor inquired if an investigation was conducted after R2's (5/10/21) elopement V2 stated For that you would have to talk to the administrator, he was handling it. Surveyor inquired if staff are allowed to take residents out of the facility when off the clock V2 stated Staff is allowed to take residents out if you're here working, after hours it's unusual. Surveyor inquired if its safe outside (in [NAME] Park/Chicago) at night V2 responded It depends on where you're at and knowing your surroundings. On 5/13/21 at 11:24am, surveyor inquired about R2's (5/10/21) elopement V18 (Restorative Aide) stated The code yellow was called. We searched the floors to see if the resident was in the building and then went outside. I called (V2) and told her that me and my co-worker (V17/Restorative Aide) was gonna go outside and look, it was close to 7:00am. I seen the area and couldn't find him. On 5/13/21 at 11:41am, surveyor inquired about the elopement policy V1 stated The basic steps are head counts, search the perimeter of the facility, regroup and go from there. Sometimes the police are called. Surveyor inquired if the Physician, V12 (State Guardian) or the Police were notified of R2's (5/10/21) elopement V1 stated No, there was no elopement. Surveyor inquired if the facility obtained V12's permission to take R2 out of the building V1 responded I don't think so. On 5/13/21 at 12:00pm, surveyor inquired about R2's cognitive status V12 stated He's confused that's why he has the guardianship in place. Surveyor inquired if V12 gave permission for R2 to leave the facility on or about (5/10/21) V12 responded No. On 5/13/21 at 12:47pm, V9 (Licensed Practical Nurse) affirmed he was assigned to R2 on 5/9/21 (11p-7am). V9 stated When I came in (R2) was with (V3) going in his room and coming out, he usually does that. About 2am, I saw him dressing up (R2) but his bag was still in his room so I believed he didn't leave. But in the morning, I went to his room, and didn't see (R2). So, I looked though the (2nd floor) room by room. When I didn't find him, I contacted the supervisor (V16/Registered Nurse) he called security to activate code yellow. Surveyor inquired when R2 was last observed V9 responded I recall that about 2am, he was in the building but after that the door is not always open. I did not check on him until the morning around 6:30. Surveyor inquired if V9 was made aware that R2 was leaving the facility with V3 V9 replied No, he didn't tell me that. I would expect them to tell me if a resident is leaving. Surveyor inquired if its safe outside (in [NAME] Park/Chicago) at night V9 stated No, I wouldn't recommend that. I wouldn't allow them to leave the facility in the first place at that time for a lot of reasons including safety. On 5/17/21 at 10:33am, V15 (Regional Director of Operations) affirmed V3 remains employed by the facility. On 5/17/21 at 1:08pm, surveyor inquired about R2's (5/10/21) elopement V17 (Restorative Aide) stated I was coming in to start my shift around 6:45am. When I came inside, they were about to call the code yellow. They asked if I saw him outside when I was coming in, but I did not. We (V17 & V18) went outside to look for him around the block, and by the Lake (Lake Michigan) but couldn't find him [Therefore they were not in the immediate vicinity of the facility]. On 5/17/21 at 1:31pm, surveyor inquired if R2 was injured while out of the facility on 5/10/21 R2 nodded his head yes then pointed to his arms, legs and left shoulder indicating where he was injured. R2's medical records affirm he was not assessed by a Physician until 5/14/21 (4 days after the incident). R2's (5/14/21) hospital records state when asked why he has come to the ED (Emergency Department) he put his fists up indicating that there was a fight. Patient seems unable to articulate using words, using motions to indicate he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. On 5/17/21 at 2:55pm, V15 stated There is no policy for bed checks. They just go by the standard of care which is every 2 hours. An IJ occurred on 5/10/21 when R2 left the facility (unauthorized) from 1:02am-4:28pm (per video surveillance), the facility failed to conduct bed checks (every 2 hours) therefore a code yellow (elopement) was not called until approximately 7am. The IJ was identified on 5/12/21 at 12:20pm, when V1 stated R2 did not elope, he was with staff however a code yellow was in fact called (5/10/21) when staff were unable to find R2, V3 was (off-duty) when he took R2 out of the facility (unbeknownst to staff), and V12 (State Guardian) did give permission for R2 to leave the facility. The facility failed to ensure R2's safety as he was out of the facility (unauthorized) in [NAME] Park (located in Chicago) overnight. According to the FBI's Uniform Crime Reports, which was analyzed by Area Vibes (an independent neighborhood ratings site), [NAME] Park's overall crime rate is 22% higher than the national average, and residents have a 1 in 30 chance of being a victim of property, violent or other crimes. On 5/13/21 at 11:41am, V1 remained adamant There was no elopement regarding R2 on 5/10/21. On 5/25/21 at 2:21pm, V15 (Regional Director of Operations), V19 (Director of Nursing) and V20 (Regional Nurse Consultant) were notified of the F689 IJ. On 5/27/21, IDPH (Illinois Department of Public Health) was notified of R2's (5/10/21) elopement (17 days after the incident occurred). The surveyor confirmed through record review and interview that the facility took the following actions to remove the F689 Immediate Jeopardy: 1. On 5/13/21, R2's Primary Care Physician was notified of the 5/10/21 incident and he was sent to the Hospital for evaluation. 2. On 5/14/21, V3 was provided 1:1 in-service regarding taking resident off facility premises and professional boundaries. 3. On 5/19/21, V1 (responsible for enforcing policies & procedures) was terminated. 4. On 5/25/21, random audits were initiated to ensure bed checks (every 2 hours) are completed. 5. As of 5/26/21, all Nurses and CNA's (Certified Nursing Assistants) were in-serviced regarding bed checks every 2 hours. All staff were in-serviced on the elopement policy. A (revised) elopement policy in-service (re: identifying, understanding, and addressing unusual occurrences) for all staff was completed 6/1/21. 6. On 5/27/21 IDPH was notified of R2's (5/10/21) elopement. 7. V3's employee report affirms on 6/2/21 he was terminated (effective 5/24/21). 8. On 6/3/21, the Police were notified of R2's (5/10/21) incident and a report was documented. Based upon record review and interviews conducted 6/7/21 the facility completed all measures on the abatement plan including in-servicing all staff on the Revised Elopement Policy, notifying IDPH/Police, and terminating V1/V3. Therefore, the abatement plan could be approved on 6/7/21. The IJ was removed on 6/3/21.

Based upon observation, interview and record review the facility failed to ensure that one of six residents (R2) reviewed for elopement were assessed for assault, psychosocial well-being and/or injury upon immediate return to the facility, failed to document (R2's) status upon return, and failed to provide the hospital accurate information when (R2) was transferred to the ER (emergency room ) for evaluation. On 5/17/21 at 1:31pm, R2 affirmed he sustained injuries (5/10/21) to his arms, legs and left shoulder. R2's (5/14/21) hospital records state he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. Findings include: The (5/10/21) facility video surveillance affirms V3 (Licensed Practical Nurse) took R2 out of the facility at 1:02am and returned at 4:48pm (approximately 15 hours later) however he was unauthorized to do so. Upon return to the facility the manner in which R2 was handled by V1 (Administrator), V7 (Security Guard), and V14 (Certified Nursing Assistant) was abusive, he was carried by his arms (near his wrists) and legs (near his ankles) while suspended in the air as his head and neck were unsupported. R2's (5/10/21) nursing progress notes were reviewed, nothing was documented. On 5/13/21 at 12:00pm, surveyor inquired if V12 (State Guardian) gave permission for R2 to leave the facility on or about (5/10/21) V12 responded No. On 5/17/21 at 1:08pm, surveyor inquired about R2's (5/10/21) elopement V17 (Restorative Aide) stated They asked if I saw him outside when I was coming in but I did not. We (V17 & V18/Restorative Aide) went outside to look for him around the block and by the Lake (Lake Michigan) but couldn't find him [Therefore he was not within the immediate vicinity of the facility]. R2's (5/13/21) progress notes state; head to toe assessment completed 3:47pm (approximately 1 hour after surveyor reviewed the 5/10/21 video surveillance) however V3 (staff involved in aforementioned incident) documented the assessment. Resident sent out to hospital for possible physical abuse during transfer. NOD (Nurse on Duty) called ER. [V3 was the NOD]. R2's (5/14/21) hospital records affirm he was evaluated by a Physician (4 days after the incident) and the facility provided the hospital limited (inaccurate) information regarding R2's reason for transfer as evidenced by (5/14/21) hospital records which state discussed patient with his nursing facility and the reasoning for why he was sent in. They stated, to make sure there is nothing wrong with him. They report that the patient was taken on a social outing today (He eloped from the facility - 4 days prior) and express concern that someone hurt him. They do not know why it is thought that the patient was hurt (He was suspended in the air by his arms and legs while carried with his head/neck unsupported) or possibly assaulted (He was out of the facility with an unauthorized individual unsupervised) and cannot provide any further background history. When patient asked why he has come to the ED (Emergency Department) he put his fists up indicating that there was a fight. Patient seems unable to articulate using words, using motions to indicate he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. On 5/17/21 at 1:31pm, surveyor inquired if R2 was injured while out of the facility (5/10/21) R2 nodded his head yes then pointed to his arms, legs and left shoulder indicating where he was injured. On 5/24/21 at approximately 11:14am, surveyor inquired if it was appropriate for V3 to conduct a head to toe assessment on R2 if he was the (unauthorized) individual who left the facility with him (5/10/21) and also present when R2 was carried back to the facility V19 (Director of Nursing) stated (V3's name) should not be doing the head to toe assessment due to the fact that he is the one who was with him. Surveyor inquired if it was appropriate that V3 gave report to the hospital considering the 5/10/21 circumstances V19 responded You're saying if he's a perpetrator? I don't think he should be the one. It should be another nurse to do that if he's the perpetrator. The (8/5/20) elopement policy states; complete a head to toe assessment to ensure no injuries and/or signs of distress (physical, mental, psychosocial) occurred during the elopement. Evaluate the need for hospital transfer as needed in accordance to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Including assessment, evaluation and follow-up actions related to the resident's elopement. The (8/5/20) abuse and neglect policy & procedure includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed.