Every finding on record at Saline Care Nursing & Rehab

Based on observation, interview and record review the facility failed to provide similar nutritive value food alternatives at meals. This has the potential to affect all 100 residents residing in the facility. The Findings Include:On 5/26/26 at 12:00 PM, the lunch meal observed in the steam table included pork loin, greens, corn bread and rice. There were no alternate meal selections available on the steam table for residents. V4 (Cook) confirmed this at this time those were the only hot food options available for residents at that meal. On 5/26/26 at 12:30 PM, V4 (Cook) stated that the only substitutes they offer residents are leftovers from the previous meal if there is any left, a grilled cheese, peanut butter and jelly or bologna sandwich. V4 went on to state that if they have to make the grilled cheese, bologna sandwich or peanut butter and jelly sandwich those residents will have to wait until the serving is complete. During the resident council meeting on 5/26/26 at 1:30PM, R73, R70, R69 who are all alert and oriented stated they do not find out what is being served at the meals until it is delivered to them. R69 and R73 went on to state that it never matches what is on the meal ticket served with the meal either. On 5/27/27 at 12:45 PM, R69 stated that they never serve what is on the ticket, and she isn't sure if that is because they are serving the wrong foods or handing out the wrong ticket. R69 stated she would like to know ahead of time what is planned for the meal and then she could order something else. R69 stated that she keeps ramen noodles in her room in case there is nothing else offered as an alternate so she at least has that to eat. R69 stated that is what she did for dinner on 5/25/26. R69 went on to state that the meatballs served today are so hard there is no way she could even bite into them. On 5/27/26 at 12:10 PM, the lunch meal was observed in the steam table included spaghetti and meatballs, mixed vegetables, and sliced bread was observed on the steam table with no other hot alternate foods available to serve. V4 confirmed at this time there were no other alternate food options available to serve off the steam table. On 5/27/26 from 12:30 PM-1:00 PM while observing the lunch meal service R18, R69, R75, R94 and R97 all stated that the meatballs were too hard to eat but they were not aware of another alternative food options so they would just eat around the meatballs. R94 picked up the meatball during this time and let it hit the plate and stated, it is like a hockey puck, would you eat this? R18 and R75 both alert to person and place stated that the vegetables were so overcooked that you could not even tell that the white mush was once a piece of cauliflower. At this time the vegetables did appear to be overcooked. The blend of carrots, broccoli and cauliflower which were all losing their integrity and turning into a soft pile with no texture. On 5/27/26 at 12:50 PM, R97 was observed pushing her meatballs around and stating that she does not have good teeth and she barely could get a piece of that meatball bit off it was so hard. The mealtime observation for food acceptance and food replacement policy dated 2020 documents that the residents will be observed during mealtimes to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy .5. Staff members observing melas in the dining room will offer appropriate meal and beverage substitutions for a noted poor intake of a food item or an expressed concern about taste, temperature or quality of the meal served 10. The dining services manager is responsible for following up with individual residents that are observed to have decreased appetite/intake, someone who refuses food replacement or a resident that has expressed concern about the dining services. The Long-Term Care Facility Application for Medicare and Medicaid dated 5/26/26, documents 100 residents reside in the facility.

Based on observation, interview and record review the facility failed to follow the pre-planned meals based on the Diet Spreadsheet. This failure has the potential to affect all 100 residents residing in the facility. The Findings Include: On 5/26/26 at 11:30 AM, V4 (Cook) stated that they do not have marshmallows for the ambrosia salad for dessert for lunch today and do not have the sauteed squash due to the evening shift does not ever follow the menu. V4 stated this causes issues due to the cook preparing what he wants rather than what is scheduled and uses up the food items scheduled for lunch meals. V4 went on to state that if the evening cook doesn't like what is scheduled, he just makes what he wants based on what he sees available in the freezer and refrigerator, not what is based off the planned menu. On 5/26/26 the planned lunch meal per the Diet Spreadsheet had brown sugar pork loin, lemon wedge, garlic parslied rice, sauteed summer squash, cornbread and ambrosia. The meal served did not have a lemon wedge and frozen greens were used in place of the squash and oranges and pineapple were served in place of the ambrosia. On 5/27/26 the planned lunch menu per the Diet Spreadsheet had spaghetti & meatballs, Italian blend vegetables, breadstick and fruited gelatin with whipped topping scheduled. On 5/27/27 at 8:15 AM, V1 (Administrator) was seen coming into the facility with frozen vegetables and boxes of gelatin. On 5/27/27 at 11:45 AM, V4 stated that they did not have the Jello made and firmed up to get it served for lunch, so they were switching the lunch and dinner dessert item and having the California Blend Vegetables in place of the Italian vegetables. V4 confirmed at this time that they had to go to the grocery store this morning when she realized that she did not have the vegetables or the gelatin to make the planned lunch meal per the spreadsheet. V4 went on to state that bread slices were served in place of the breadstick due to not having them available to prepare. On 5/27/26 at 12:45 PM, R69 who was alert to person, place and time, stated that they never serve what is on the ticket, and she isn't sure if that is because they are serving the wrong foods or handing out the wrong meal ticket. R69 stated she would like to know ahead of time what is planned for the meal and then she could order something else if she doesn't like it. R69 stated that she keeps ramen noodles in her room in case there is nothing else offered as an alternate, so she at least has that to eat. R69 stated that is what she did for dinner on 5/25/26. On 5/27/26 during the lunch meal service from 12:15 PM-12:45 PM, R18, R97 and R75 who are all alert to person, place and time stated that they never get served what their meal ticket states. R18, R97 and R75 stated that they don't know why they get a tray card when it has different food listed than what they get and they are never notified of what the planned meal is for any of the meals. The Long-Term Care Facility Application for Medicare and Medicaid dated 5/26/26, documents that 100 residents are residing in the facility.

Based on observation, interview, and record review the facility failed to obtain a physician order and consent for a physical restraint and assessed adaptive equipment to ensure safety and freedom for normal movement for 4 (R1, R2, R3, & R63) 4 residents reviewed for physical restraints in a sample of 70. Findings included: 1. R63's admission Record documented an admission date to the facility of 1/25/2016 with diagnoses including unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified severity, with other behavioral disturbance, bipolar disorder, muscle weakness, chronic fatigue, and cerebral infarction, unspecified. R63's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 02, which indicates severe cognitive impairment. Section P- Restraints and Alarms does not document R63 has any restraints. R63's Physicians Order Summary dated 5/2/26 documents and order for a self releasing belt when up in wheelchair for proper wheelchair positioning and safety. Order date 9/11/24. R63's Care Plan had a focus area of R63 at risk for falls with an intervention listed of a self-release seat belt for proper positioning when up in wheelchair and as an additional safety measure. R63's Assistive Device, Restraint Evaluation, Consent dated 1/15/2025 documented R63 was being evaluated for a self-release belt. Section G. Assessment Summary/Determination documents: Resident has poor trunk control and often leans forward when up in wheelchair and leads to resident sliding out of her wheelchair. Resident can self propel in her wheelchair. Upon discussion with IDT (Interdisciplinary Team) and V20 (Physician) it was felt the best intervention for resident would be the self-releasing belt to assist with proper wheelchair positioning. Under section I. Signatures, it was documented that V13 (Family) gave verbal consent on 1/15/2025. This form does not document what staff member was given verbal consent by V10, but is signed by V19 (Registered Nurse). R63's Assistive Device, Restraint Evaluation, Consent dated 5/27/2026 documented R63 was being evaluated or a seat belt. Section G. Assessment Summary/Determination documents: Resident has poor trunk control and often leans forward when up in wheelchair and leads to resident sliding out of her wheelchair. Resident can self propel in her wheelchair. Upon discussion with IDT and V20 it was felt the best intervention for resident would be the self-releasing belt to assist with proper wheelchair positioning. Under section I. Signatures, it was documented that V13 (Family) gave verbal consent on 5/27/2026. This form documents V10 obtained the verbal consent form V13. On 05/27/2026 at 11:47 AM, R63 was observed sitting in her wheelchair with her seat belt on at the dining table. On 05/27/2026 at 12:40 PM, V10 (Quality Assurance/Licensed Practical Nurse/LPN) stated typically V9 (Remote Minimum Data Set/MDS Coordinator) will complete the physical restraint assessment at the same time she completes the quarterly assessments and should be located under assessments. On 05/28/2026 at 9:21 AM, V17 (LPN) stated R63 does have a seat belt she uses while in her wheelchair. V17 stated, the facility does assess R63's seat belt per policy. On 05/28/2026 at 9:52 AM, V7 (Director of Nursing/DON) stated seat belt assessments are completed annually and at initial placement. V7 stated, according to the facility policy if the last annual assessment for the seat belt had been on 1/15/2025 then the annual assessment would have been completed 1/15/2026. On 05/28/2026 11:25 AM, R63 was observed sitting in her wheelchair with her seat belt on at the dining room table. Observed V8 (LPN) asking R63 to remove her seat belt on command, R63 was unsuccessful on multiple attempts of asking. On 05/28/2026 at 11:33 AM, V13 (Family) stated she had not been contacted on 5/27/2026 or 5/28/26 to give verbal consent for R63's seat belt. V13 stated, she had not been contacted prior to that date regarding the seat belt. V13 stated, she found out about the seat belt when she came to visit over this past Mother's Day weekend. V13 stated, the staff told her that they have the seat belt in place because of falls. V13 stated, she is over R63's medical care and should be contacted on her care. On 05/28/2026 11:42 AM, R63 was observed sitting at the dining table with her seat belt on. R63 appeared tired and when asked by staff to remove her seat belt, she declined and stated to this surveyor that she has a temper and its showing. This surveyor asked R63 if she could unbuckle her seatbelt and R63 stated, she just put it back in. R63 did attempt more than 3 times to unbuckle the seatbelt, unsuccessfully. On 05/28/2026 at 11:46 AM, V10 stated she completed R63's annual restraint evaluation on 5/27/2026. V10 stated, she spoke with V13 (Family) by phone around 6:30 PM on 5/27/2026. On 05/28/2026 at 12:16 PM, V10 stated she received verbal consent for R63's seat belt from V13 (Family) about 10 minutes ago on 5/28/2026. V10 stated R63 does not have any paperwork on file for a power of attorney but per R63's request the facility is to notify her of care. V10 stated she is not aware how R63's is able to make her medical decisions with a BIMS of 2. On 05/29/2026 at 8:33 AM, V7 (Director of Nursing/DON) stated R63 does not have a power of attorney listed and makes her own decisions for care. V7 stated R63 should be the person giving consent for a seat belt and not V13 (Family). V2 stated, when V10 completed the physical restraint assessment on 5/27/2026 it should have been completed face to face with the resident and consent given by R63. 2. R1's admission Record documented R1 was admitted to the facility on [DATE]. The diagnoses listed include chronic obstructive pulmonary disease, pneumonia, dementia, depression, essential hypertension and unspecified psychosis. R1'S Minimum Data Set (MDS) with assessment reference date as 04/10/2026 documents a BIMS (Brief Interview for Mental Status) of 06, indicating R1 is severely cognitively impaired. Section P- Restraints and Alarms does not document R1 has any restraints. R1's Care Plan documented a focus area of risk for falls. Interventions listed are alarming SRSB (Self releasing seat belt). No date was listed. R1's Physicians Order Summary dated 05/29/2026 does not document an order for a self-releasing seat belt. R1's Restraint assessment dated [DATE] documented type of restraint as seat belt. Under section 5. IDT Recommendations b. physician order, including medical diagnosis for use, obtained? Answered 3. N/A On 05/27/2026 at 12:08 P.M. R1 was observed in the dining room in his wheelchair with a seatbelt on. On 05/28/2026 at 12:10 P.M. R1 was observed in the dining room in his wheelchair with a seatbelt on. On 05/29/2026 at 9:40 A.M. R1 was observed in the dining room in his wheelchair with a seatbelt on. 3. R2's admission Record documents an admission date to the facility of 03/14/2023. The diagnoses listed include unspecified psychosis, type 2 diabetes mellitus, essential hypertension, disorientation unspecified, altered mental status, and depression. R2's Minimum Data Set with assessment reference date as 03/13/2026 documents R2 has a BIMS (Brief Interview for Mental Status) of 03 indicating R2 is severely cognitively impaired. Section P- Restraints and Alarms does not document R2 has any restraints. R2's Physicians Order Summary dated 05/28/2026 documented ensure seatbelt is functioning properly every shift with an order date of 03/26/2026. R2's care plan did not have a focus area or an intervention related to the seatbelt. There were no restraint assessments found in R2's record. There were no restraint consents found in R2's record. On 05/26/2026 at 9:59 AM R2 was observed to be in a low bed. R2's wheelchair was observed to be sitting next to his nightstand and had an alarm and a seatbelt attached. On 05/27/2028 at 12:05 P.M. R2 was observed in the dining room, sitting in his wheelchair. The wheelchair had a seatbelt attached to it. On 05/28/2026 at 9:23 A.M. R2 was observed to be in bed. Wheelchair was observed in room next to nightstand. The wheelchair had an alarm and a seatbelt attached to it. On 05/28/2026 at 9:25 A.M. V5 (Certified Nurse Assistant/CNA) stated R2 uses a seatbelt when he is in the wheelchair. V5 stated R2 stands up and could fall and the seatbelt keeps him safe. On 05/28/2026 at 9:27 A.M. V6 (CNA) stated R2 has a seatbelt to the wheelchair that he uses when he is in the wheelchair. V6 stated that he would get hurt if he stood up without help. On 05/28/2026 at 12:04 P.M. V8 (LPN) stated the seatbelt for R2 was removed yesterday (05/27/2026) per the direction of the management team. V8 stated it was supposed to be removed and V11 (Maintenance) removed it. On 05/28/2026 at 12:06 P.M. R2 was observed sitting in the dining room with no seatbelt in his wheelchair. On 05/28/2026 at 12:08 P.M. V11 (Maintenance) stated he was asked to take the seat belt off R2's chair by V10 (Licensed Practical Nurse). On 05/28/2026 at 12:20 P.M. V10 stated R2's seat belt was discontinued last night because R2 no longer needed it. V10 stated staff told her that R2 was taking off the seat belt. V10 stated R2 now has an alarm instead of a seatbelt. V10 stated on 05/27/2026 between the time of 12:30 P.M. and 1:30 P.M. she was in the dining room and saw that R2 had a seatbelt. V10 stated that is when she determined he no longer needed the seat belt. V10 stated she asked V11 to remove the seatbelt sometime on 05/27/2026. V10 stated it is her understanding that the seatbelt was removed. On 05/28/2026 at 2:20 P.M. V2 (Administrator) was asked if there were orders, consents and assessments for the restraints, V2 stated if it is not in the information that he handed me, then they do not have what I am asking for. 4. R3's admission Record documents an admission date of 11/15/2022 and includes diagnosis of Anxiety Disorder, Unspecified Dementia, Moderate Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Unspecified Psychosis Not Due To A Substance or Known Physiological Condition, Essential Hypertension, and Malignant Neoplasm of Unspecified Site of Unspecified Female Breast. R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 which suggest severe cognition impairment. MDS dated [DATE] Section P- Restraints and Alarms does not document R3 has any restraints. Section GG -Functional Abilities, R3 requires Substantial/maximal assistance with lying on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub transfer. R3's Physician's Order Summary dated 5/28/26 documents R3 has a self-release seat belt when up in wheelchair. Start date 5/23/25. R3's Care Plan documents R3 is at risk for falls. Interventions for falls includes but not limited to: assist with transfers and ambulation, bed in lowest position when occupied, call light within reach, observe for unsafe actions and intervene, seat belt applied to wheelchair and wheelchair for locomotion. No dates given when interventions were implemented. On 5/27/2026 at 12:20PM, R3 was noted to be in the dining room in wheelchair with seat belt noted. R3 was asked about her seatbelt and if she could remove it and she looked down and grabbed it and after a while she pulled on seatbelt and released the seat belt. R3's Restraint assessment dated [DATE] documents type of restraint is seatbelt. Under Medical Symptoms Necessitating Restraint marked as : Unsafe mobility, postural instability and agitated behavior. Under IDT (Interdisciplinary Team) documents continue with current restraint. Restraint consent signed by resident/responsible party is marked Not Applicable and has consent been signed within the last year marked not applicable. R3's Assistive Device / Restraint Evaluation/Consent dated 5/27/2026 at 1:39PM documents under Physical and Mental Consideration: device being evaluated is seat belt, 1. mental status marked able to follow directions easily. 2. sitting balance is poor upper trunk control, standing balance is poor upper trunk control, and ambulation is unsteady on feet and loses balance. Section G Assessment Summery/ Determination documents 1. Device to be used is self-releasing seat belt. 1.a. This device is a/an: enabler (assistive device that allows the resident to maintain function and independence and does not limit movement or access to one's body.) 1.b. Reason for use of restraint- describe behavior prompting use a. Unsteady gait, Agitated/aggressive behavior, frequent falls, sliding out of wheelchair and attempts to self-transfer and is unable to safely transfer. 2. Reason for use of enabler: Balance. Date verbal consent received was documented as 5/23/2025 at 11:00AM. Authored by V10 (LPN). R3's Assistive Device / Restraint Evaluation/Consent dated 5/27/2026 and R3's Restraint assessment dated [DATE] documents type of restraint is seatbelt. Both assessments document one of the reasons for the seatbelt including Agitated /Aggressive Behavior. On 5/27/2026 1:50PM, V1 (Administrator) was presented with R3's restraint assessments, one was dated 5/23/2025 and the second one was dated 5/27/2026. V1 was asked if there were any more Restraint Assessments completed between 5/23/2025 through 5/27/2026. V1 stated no and we completed the one today because of the ARD (Assessment Reference Date) date for R3. R3's Behavior Tracking reports from December 2025 to May 2026 were reviewed and documented R3 was being tracked for :Resident becomes combative with staff. Interventions include: 1. Listen to resident in a nonjudgmental way/attempt to calm resident. 2. Attempt return conversation to reality-based/redirect with activity or snack. 3. Step back and return later, if possible. Each month reviewed has less than 50% completion. On 5/27/2026 at 2:00PM, V1 Administrator came to conference room and asked to review R3's Restraint Assessments she had previously presented and stated she believed the one done today was incorrect. V1 also brought in a progress note dated 5/23/2025 that documented R3's son was aware of placement of seat belt. V1 was asked for signed consent for Seat Belt and V1 stated they did not have a signed consent but R3's son was aware. V1 stated the Restraint Assessments are only done annually and that is their policy. On 5/27/2026 at 2:20PM, V10 was asked if she revised the assessment she had completed on 5/27/2026 and V10 stated no she did not revise, and didn't know why it says that. V10 stated she will have to complete a new one on the correct form. V10 was asked if she knew how often the assessments for restraints are done and V10 stated, I believe they are supposed to be done quarterly but I have to check. On 5/28/2026 at 10:42AM, R3 was observed sitting in her wheelchair in her room. Noted seatbelt in place. R3 was asked several times in the presence of V3 (Social Service Director) to release her seat belt and R3 was unable to follow commands and release seat belt. R3 would answer her name but was unable to answer questions appropriately and again was unable to follow commands.

Based on interview and record review the facility failed to ensure a resident with a mental illness was referred to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination of need for any specialized services for 1 (R99) of 7 residents reviewed for PASARR requirements in the sample of 70.The findings Include:R99's admission Record documented an admission date to the facility of 11/21/2025. Diagnoses listed include unspecified psychosis, dementia, and altered mental status.R99's 11/10/2025 Notice of PASARR Level I Screen Outcome documented no level II required and no serious mental illness. Rationale: The level 1 screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted.On 05/28/2026 at 10:22 A.M. V9 (Corporate Minimum Data Set Nurse) stated the person who completed the admission MDS (Minimum Data Set) for R99 coded section I wrong. V9 stated that the next person who completed the next MDS captured the psychosis diagnosis. V9 stated the psychosis diagnosis should have been listed on the initial PASARR screen conducted on 11/10/25. V9 stated once the facility received all the information regarding the resident, saw the diagnosis, they should have called the screening service and asked for a new screen to be completed. V9 stated she will modify the admission MDS diagnosis to include the psychosis and reach out to have another screen completed. Facility policy titled Resident Assessment - Coordination with PASRR Program documents: 1. All individuals with a mental disorder or intellectual disability who apply for admission to the facility will be screened in accordance with the State's Medicaid rules for screening.

Based on interview and record review the facility failed to ensure a resident was free from unnecessary psychotropic medications for 1 of 5 residents (R99) reviewed for medications in a sample of 70. The Findings Include: R99's admission record documents an admission date of 11/21/25 and includes the following diagnosis: altered mental status, unspecified dementia/unspecified severity with anxiety, unspecified dementia with severe psychotic disturbance, unspecified psychosis not due to a substance or known physiological condition. R99's Physician's order summary report dated 5/29/26 documents orders including: ziprasidone 20 mg (milligrams) two times a day for dementia. Start date 1/21/26. Depakote 125 mg 1 tablet three times a day for dementia, Depakote 25o mg tablet three times a day for dementia. Started 1/21/26. Lorazepam 0.5 mg a day at bedtime for unspecified dementia with psychotic disturbance. Start date 4/15/26.A consultant pharmacist's medication regimen review dated 3/5/26 requested a supporting diagnosis is needed due to the resident currently receiving Ziprasidone 20mg that requires a diagnosis of one of the following: bipolar 1 disorder acute treatment of manic episodes, bipolar 1 acute treatment of depressive episodes, bipolar 1 disorder maintenance therapy, or schizophrenia. Under the 'The Physicians Response dementia with psychosis is typed in. A consulting pharmacy progress note dated 3/4/26 documents: that a monthly pharmacy consult was completed for R99 monthly medication regimen review. After a thorough review, a supporting diagnosis was requested on Ziprasidone per CMS guidelines. On 5/29/26 at 11:45 AM, V7 (Director of Nursing) stated that she could not locate any behavior tracking for R99 regarding behaviors related to the psychotropic medications ordered for dementia and psychotic disorders. V7 confirmed at this time that there was not a supporting diagnosis for Ziprasidone as requested by the pharmacy recommendation.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 2 of 4 residents (R10 and R30), reviewed for MDS accuracy, in a sample of 70. Findings Included:1. R10's admission Record documented an admission date to the facility on 7/16/2020 with diagnoses including major depressive disorder, recurrent, unspecified, anxiety disorder, schizophrenia, unspecified and other specified depressive episodes. R10's Annual Minimum Data Set (MDS) dated [DATE] documented under A1500: Preadmission Screening and Resident Review (PASRR): is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? No. Documented under Psychiatric/Mood Disorder, R10 has anxiety disorder, depression disorder, and schizophrenia. R10's Care Plan documented focus areas of R10 uses psychotropic, antianxiety and antidepressant medications and R10 has depression 3 times a week with diagnoses of schizophrenia, major depressive disorder, unspecified dementia with behavioral disturbances and anxiety with a goal to reduce signs and symptoms of distress, symptoms of depression, anxiety or sad mood to 1 time a week. R10's PASRR level II screening dated 9/5/2025 documented under outcome Level II- Approved with no special services. 2. R30's admission Record documented an admission date to the facility on 1/4/2023 with diagnoses including paranoid schizophrenia, depression, unspecified, and insomnia, unspecified. R30's Annual Minimum Data Set (MDS) dated [DATE] documented under A1500: Preadmission Screening and Resident Review (PASRR): is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? No. Documented under Section I0020B. Primary Medical Condition with Paranoid Schizophrenia. R30's Care Plan documented a focus area of R30 has delusions 7 times a week with diagnoses paranoid depression, depression medication, aripiprazole, and trazadone with a goal for R30 will have fewer episodes of delusions. R30's PASRR level II screening dated 4/4/2024 documented under outcome Level II- approved with no special services. On 05/27/2026 at 12:15 PM, V12 (Infection Preventionist/IP) stated the facility does not have an MDS coordinator in house. V12 stated, V9 (Remote MDS) completes all MDS assessments. On 05/27/2026 at 12:31 PM, V7 (Director of Nursing/DON) stated, the facility does not have a MDS coordinator in the building. V7 stated, V9 completes all MDS assessments. On 05/27/2026 at 2:20 PM, V9 (Remote MDS) stated, she does help complete all MDS assessments. V9 stated, she does review the PASRR assessment in the system to determine if a resident is approved at the level II evaluation prior to completing the MDS section on an annual assessment. On 05/27/2026 at 2:38 PM, V9 stated R30 would not be documented as a level II on his screening. V9 stated, it does not mean that he may not qualify for specifics services. V9 stated, she looks at more documentation to see if there is qualification for a level II approval, that will include other documentation like supplemental security income (SSI), hospitalizations, resident history, etc. The facility's Resident Assessment-Coordination with PASRR Program (dated 1/2023) documented under Policy Explanation and Compliance Guidelines:.3. Recommendations, such as specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.

Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R1, R22, R24, and R36) reviewed for room size in a sample of 70. The Findings Include: On 5/29/26 at 9:44 AM, V18 (Owner) stated that Side 2 of the facility has a room size waiver assessment. V1 stated these rooms are Medicaid certified for two residents. V1 stated rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, 244-248 are all waivered rooms and don't meet the proper room size. On 5/29/26 at 1:06 PM, V13 (Maintenance Director) stated R1's room was less than 80 square feet per resident, which is less than the requirement. V13 used the measuring tape to measure the length and width of R1's room and stated, 12.5 by 12 feet, indicating that the room was 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. At that time R1 was in their room and stated that they have no issues with the room size. The room contained two beds and two nightstands. On 5/29/27 at 1:15 PM, V13 stated that R22's room was less than 80 sq ft per resident, which is less than the requirement. V13 measured the room and it measured the same size of 12.5 by 12 feet for a total of 150 sq ft. or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. The room contained two beds and two nightstands. R22 was not present in the room while it was measured.On 5/29/27 at 1:25PM, V13 stated that R24's room was less than 80 sq ft per resident, which is less than the requirement. V13 measured the room and it measured the same size of 12.5 by 12 feet for a total of 150 sq ft or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. The room contained two beds and two nightstands. R24 was not present in the room while it was measured.On 5/29/27 at 1:30 PM, V13 stated that R36's room was less than 80 sq ft per resident, which is less than the requirement. V13 measured the room and it measured the same size of 12.5 by 12 feet for a total of 150 sq ft. or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. The room contained two beds and two nightstands. R36 was present in the room while it was measured and stated that they had no issue with the room size.An undated facility room roster provided by V1(Administrator) on 05/26/26, documented R1, R22, R24, and R36 reside in the waivered rooms measured by V13.Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms.

Based on interview and record review, the facility failed to prevent resident to resident physical abuse for 2 of 4 residents (R1, R3) reviewed for abuse in the sample of 4. The past non-compliance occurred between 03/31/25 and 04/07/25. Findings include: 1. R1's admission Record dated 04/17/25 documents an admission date of 05/04/24 with diagnoses including traumatic subdural hemorrhage, bipolar disorder, anxiety disorder, heart failure, unspecified osteoarthritis, and chronic kidney disease. R1's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 12 which indicates R1 has moderately impaired cognition. Section GG documents R1 is independent with most ADL (Activities of Daily Living) functions. R1's Care Plan documents a focus area of Peer pushed resident to the ground before staff could intervene with a date initiated of 03/31/25. Interventions for this focus area include: 1. N.O (new order) received for new pain medication, 2. Peer was removed from the area. Resident was assessed for injuries by charge nurse. 3. Per facility protocol MD (Medical Doctor) and Administrator updated r/t (related to) incident. N.O. received for (Local Mobile X-ray) Xray. 4. Resident was sent to (Local Hospital) for evaluation r/t complaints of pain. Negative findings with x-rays of lumber spine and hips. 5. Staff to attempt to limit contact between the two residents. Social Service or designee to follow up with resident to ensure that he feels safe in his home. R2's admission Record dated 04/17/25 documents an admission date of 02/23/21 with diagnoses including: Major Depressive Disorder, anxiety disorder, insomnia, Paranoid schizophrenia, and unspecified psychosis. R2's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R2 is cognitively intact. Section GG documents Supervision and set-up help with ADL functions. R2's Care Plan documents a focus area of (R2) pushed peer before staff could intervene r/t reside got in his face. Date initiated 03/31/25. Interventions for this focus area include: 1. 1:1 completed with resident (BIMS score 15) related to inappropriateness of actions and the need to get to charge nurse or CNA (Certified Nurse Assistant) to discuss issues he is having with peer, to leave the area and talk with staff. 2. MD and Administrator notified of incident. Social Service spoke with resident. 3. MD updated related to event and medication change ordered fluid restriction added. 4. Staff immediately separated the 2 residents. R1's Progress Notes dated 03/31/25 at 7:14AM by V8 (Assistant Director of Nursing/ADON) documents in part (R1) in dining room by serve out station. Heard a thump from a cup hitting the ground. Then heard residents yelling back and forth. Staff Attempted to intervene. Before this writer could make it to the residents, (R1) was in the motion of falling backwards. (R1) fell backward and landed on buttocks. Peer immediately removed from dining room. (R1) assessed with complaint of hip pain. No contact with head. R2's Progress Note dated 03/31/25 at 7:13AM by V4 (Licensed Practical Nurse/LPN) documents This writer was passing medications when I heard some commotion behind me. (R2) slammed his cup down on the table and it flew on the floor, and he started yelling. Other resident (R1) started yelling back at resident. Staff tried to intervene between both residents. (R2) pushed (R1) down on the ground. (R1) fell on back. (R2) was removed from the dining room until further notice. This writer contact (Psychiatric NP) and Informed (R2's Primary Physician) of resident to resident. A Report titled Illinois Department of Public Health Initial Report dated 04/05/25 at 7:00AM documents: Date of Incident 03/31/25. Time of Incident 7:00AM. Resident Name: (R1) and (R2). Final report: (R2) a 67 y/o (year old) male with a diagnosis of Paranoid schizophrenia within the dining room when he had a verbal issue with a peer. (R1) a 75 y/o male with a diagnosis of bipolar disorder. (R2) then made contact with (R1) and (R1) stepped back and lost his balance. Both residents were assessed by nursing. (R2) is alert to self with a BIMS of 15 and is ambulatory without devices. (R2) is on a 1800cc (cubic centimeters) fluid restriction. (R2) was in the dining room and was holding a coffee cup when he threw the cup onto the floor. (R2) was upset that he could not have multiple cups of coffee due to his fluid restriction. (R2) was very delusional and making statements about the coffee and who owns the coffee and informed administrator later that (R1) told him that he owned the coffee, and he could not have any of his coffee. (R1) is alert to self and has a BIMS score of 12 and is ambulatory. (R2) thought that (R1) said that he could not have any coffee. (R2) then became more delusional and made contact with (R1) resulting in him stepping backwards and losing his balance. (R1) fell onto his back. Residents were separated and both were assessed. (R1) complained of pain in his hip and was sent for x-rays and were negative. The (Psychiatric Nurse Practitioner) was notified of the incident and reviewed both residents' medications. (R2) has been very delusional, and a medication increase has been initiated. The administrator spoke with (R2) and he stated that he was upset that peer stated that he owns the coffee and that he could not have any. Explained to resident that he is on fluid restriction and that he had all the coffee that was allowed on the restriction and that he needed to follow the physician orders and informed him that the peer does not own the coffee. Social Service will meet with (R1) 3 times a week for 2 weeks. (R2) had the medication changed and will be monitored for 14 days. Social Service will meet with (R2) 3 times a week for 2 weeks both charts and behavior tracking have been reviewed. On 04/16/25 at 10:25AM, R1 stated that he did have an altercation with R2 on 03/31/25. R1 stated that R2 was in the dining room yelling and hitting his coffee cup on the counter and then threw the coffee cup. R1 said he told R2 to stop hitting his cup and throwing it. R1 said that R2 then turned around and shoved him and he fell on his buttocks and back. R1 said after he fell, he was having some pain, and the nursing staff did send him over to the local hospital to be checked out and they didn't find any breaks or fractures. On 04/16/25 at 12:21PM, R2 stated that he remembers the day that him and R1 got into an altercation on 03/31/25. R2 said that he was wanting another cup of coffee, and he was trying to get staff to give him another cup. R2 said staff was telling him that he couldn't have another cup right that second. R2 said that he got mad and threw his coffee cup and then R1 got in his face and told him he didn't need to be doing all that. R2 said that R1 was a bigger guy, and he didn't want him in his face, so he pushed R1 back and R1 fell. R2 said that he knows that he should not have pushed R1. R2 said that he was mad about not getting his coffee and when R1 got in his face and was much bigger than him he wanted R1 out of his face and just tried to get him away from him not make him fall. On 04/16/25 at 12:23PM, V4 (Licensed Practical Nurse/LPN) stated she was working on 03/31/25 when R1 and R2 had an altercation. V4 said R2 was in the dining room and had already had a cup of coffee and he is on a fluid restriction. V4 said that R2 was hitting his cup on the table and threw his cup and then R1 got up and walked over to R2 and told R2 he didn't need to be hitting his cup and throwing things. V4 said that R1 was close to R2's face and R2 kept telling R1 to get out of his face. V4 said that R1 went to step back and fell. V4 said that she didn't see R2 push R1. V4 said that R2 had been having increased delusions for the past couple of days and seemed more agitated. V4 said that after the altercation she did contact the psychiatric Nurse Practitioner and she gave a new order to increase R2's medication related to the increased delusions. 2. R3's admission Record dated 04/17/25, documents an admission date of 11/12/21 with diagnoses including: Alzheimer's, major depressive disorder, other schizophrenia, generalized anxiety, and pica in adults. R3's MDS dated [DATE] documents in Section C under staff assessment for mental status short term memory problems and long-term memory problems. Section GG documents walking as supervision. R3's Care Plan documents a focus area in part of (R3) will wonder the halls, she will pace from one side of the unit to another with a date initiated of 10/27/24. Documented interventions include: 1. Attempt bringing resident to a high visibility area. 2. Redirect resident when wandering into other residents' rooms. 3. (R3) wanders on the unit sometimes will have accident with her bowels while she is wandering. She does not like to wear a brief she will take it off. R4's admission Record dated 04/17/25 documents an admission date of 11/27/20 with diagnoses including: schizoaffective disorder, vascular dementia, anxiety, and obstructive and reflux uropathy. R4's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R4 is cognitively intact. Section GG documents Supervision with most ADL functions. R4's Care Plan documents a focus area of (R4) has delusions 5X's a week Dx (diagnosis) : schizoaffective disorder, generalized anxiety disorder with a date initiated of 11/20/24. Documented interventions include: 1. (R4) has delusions 5x's a week attempt to turn conversations to reality based. 2. Offer snacks or drink 3. Offer resident to sit outside weather permitting. Another focus area of (R4) is/has potential to be verbally aggressive date initiated of 05/22/24. Documented interventions include: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness 2. Analyze of key times, places, circumstances, trigger, and what de-escalates behavior and document. 3. Assess and anticipate resident needs, food thirst, toileting needs, comfort level, body positioning, pain, etc. A Report titled Illinois Department of Public Health Initial Report dated 04/13/25 at 8:00PM documents date of incident 04/07/25 and time 10:00AM. Residents Name R3 and R4. Final report: On 04/07/25 at 10:00AM staff witnessed (R4) 71 y/o male with a diagnosis of schizoaffective disorder and vascular dementia, make unwanted contact with (R3) 71 y/o female with a diagnosis of Alzheimer's, while in the hallway. Residents were immediately separated and assessed for injuries. No injuries were noted to either resident. (R4) is up and ambulatory on the unit. (R4) is alert with a BIMS of 15. (R4) was coming out of the bathroom when he saw a peer, (R3) walking down his hall. Per staff (R4) then makes contact with (R3's) chest area after he came out of the bathroom. Staff immediately separated the residents. (R4) denied that anything happened, but then stated he would not do that again. (R3) is up ambulatory throughout the unit. (R3) is alert to name and a BIMS is unable to be completed. (R3) went down a hall that she normally does not ambulate down when a peer, (R4) came out of the bathroom and made contact with (R3's) chest area. Staff intervened and assisted (R3) from the area. (R3) was assessed by the nurse with no injuries noted. The physician was notified, and a urinalysis was ordered as (R4) was making some delusional statements. The urinalysis was positive, and the physician has ordered medication. An appointment is scheduled for 04/22/25 for an appointment with urologist. Social Service meet with (R4) 3 times a week for 2 weeks. (R4's) chart and behavior charting have been reviewed. (R3) had no injuries. (R3's) chart and behavior charting have been reviewed. Social service to meet with (R3) 3 times a week for 2 weeks. (R3) is on 15-minute checks. R3's Progress Note dated 04/07/25 at 11:07AM by V6 documents in part Housekeeper came to nurse to inform resident had been hit in the chest by peer. Housekeeper stated, 'Peer came out of the bathroom and went up to (R3) and hit her in the chest' housekeeper immediately separated them. On 04/16/25 at 12:35PM, R4 stated he does remember the altercation between him and R3 on 04/07/25. R4 stated that R3 kept coming down his hallway which is an all-males hallway. R4 said that he told R3 that she needed to go back to her hallway. R4 said that he went to the bathroom and when he came out of the bathroom that R3 was right there. R4 said that he pushed R3 in the chest to get her to go back to her hallway. R4 said that he did not hit R3 in the chest, but that he did push her. R4 said that he would never hurt anyone on purpose. R4 said that he did have an infection in his urine which was probably making him not act like himself that day. On 04/17/25 at 1:15PM, V13 (Housekeeper) stated that R4 got to the bathroom to brush his teeth and when he came out of the bathroom R3 was coming down the hall. V13 said that R4 was telling R3 that it wasn't her hall that that she needed to go back to her hallway. V13 said that R4 then pushed R3 in the chest area and told her that she needed to go back to her hallway. V13 said that she couldn't tell how hard R4 pushed R3 in the chest. V13 said that R4 was just trying to get R3 back to her hallway. On 04/17/25 at 2:00PM V1 (Administrator/ADM) stated that after R1, R2, R3, and R4's altercations that they have social service meet with those residents 3 times a week for 2 weeks. V1 said they did medication reviews on R1, R2, R3, and R4. R2's medication was increase related to his delusions per the Psychiatrist Nurse Practitioner. V1 said that R3 was placed on 15 Minute checks to monitor her. R1 and R2 no longer sit at the same table and are not allowed on the same hallway. V1 said that R4 was checked for a urinary infection, and he was positive for a urinary tract infection and R4 is currently being treated with antibiotics and has an appointment to see a urologist on 04/22/25. V1 said that R1 and R2 are not allowed to smoke at the same time. V1 said that the facility has taken every step to try to prevent any further altercations between these residents and all residents. V1 said that they try doing increased activities to help keep residents busy. V1 said that on 03/31/25 they had an IDT (Interdisciplinary Team)/QA (Quality Assurance) Meeting to discuss the altercation between R1 and R2. V1 said they also had an IDT/QA meeting on 04/07/25 to discuss R3 and R4's altercation. The facility policy titled Abuse Prevention dated 08/16/2019 documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. Social service to meet with R1, R2, R3, and R4 3 times a week for 2 weeks. 2. R1 and R2's medications were reviewed on 03/31/25 and R2 received a medication increase on Divalproex sodium which is used to treat his paranoid schizophrenia. 3. R1 and R2 have been moved to different tables in the dining room and on halls since 03/31/25. 4. R1 and R2 have different smoke times initiated on 03/31/25 5. R3 was placed on 15-minute checks on 04/07/25. 6. R4 was checked for urinary tract infection on 04/07/25. 7. The facility had an IDT/QA meeting on 03/31/25 to discuss the altercation between R1 and R2. In attendance was V1 (Administrator), V10 (Assistant Administrator), V2 (Director of Nursing/DON), V8 (Assistant Director of Nursing/ADON), V11 (Infection Preventionist/IP), V3 (Social Service/SSD), and V12 (SSD). Notes document in part The psychiatric NP (Nurse Practitioner) was notified of the incident and reviewed residents' medications. R2 is on a fluid restriction and becomes very upset when he cannot have extra drinks. R3 has been very delusional, and a medication increase has been indicated and will be monitored for 14 days. A root cause R2 upset over fluid restriction and not being able to have more coffee and becomes more delusional when he thought R1 stated that he owned the coffee and could not have any. R2 reminded that he needs to follow physician orders for his fluid restriction. 8. The facility had an IDT/QA meeting on 04/07/25 to discuss that altercation between R3 and R4. In attendance was V1, V10, V2, V8, V11, V3, and V12. Notes documents in part R3 had no injuries. R3's chart and behavior charting were reviewed. Social service will meet with her 3 times a weekly for 2 weeks. R3 is on 15-minute checks. Cause is R3 was walking on a different hallway and R4 was having increased delusions related to UTI (Urinary Tract Infection). R4's physician was notified, and a urinalysis was ordered as R4 was making some delusional statements. The urinalysis was positive, and the physician has ordered medication. An appointment is scheduled for R4 on 04/22/25 for an appointment for urologist. Social service will meet with R4 3 times a week for 2 weeks. R4's chart and behavior charting have been reviewed. Root cause is R4 has increased delusions r/t UTI.

Based on observation, interview, and record review the facility failed to provide fingernail care for one (R81) of one resident reviewed for hygiene in the sample of 41. Findings include: R81's Admission Record documents an initial admitted [DATE]. R81's Admission Record documents diagnosis in part Type 2 Diabetes, Other Lack of Coordination, Cognitive Communication Deficit, and Psychomotor Deficit. R81's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status of 07 which indicates severe cognitive impairment. Section GG of that same MDS documents resident is substantial/maximal assistance for personal hygiene which includes in part washing and drying of hands. R81's Care Plan documents R81 has an activities of daily living self-care performance deficit with an initiation date of 05/22/2024. On 03/31/2025 at 12:57 PM, V3 (Family Member) was observed cleaning under R81's fingernails. R81's nails had a large amount of black substance under her nails that had a strong odor. V3 stated he had been asking for 2 weeks for someone to clean under R81's nails and they have not been cleaned. On 04/03/2025 at 12:27 PM, V3 stated he couldn't recall who he talked to about R81 needing her nails cleaned but did recall asking nursing staff several times. On 04/2/2025 at 09:06 AM, V4 (Certified Nursing Assistant/CNA) stated they clean nails when they give residents showers and V4 stated residents get showers 2 times a week. V4 stated she would have cleaned under R81's nails when she showered her last, which V4 stated she thinks it was a week or more ago. On 04/02/2025 at 09:08 AM, V5 (CNA) stated R81 does not usually clean herself well, so she does require assistance. V5 stated she cleans nails when she showers residents, but she has not showered R81 in over a week. On 04/02/2025 at 09:10 AM, V6 (CNA) stated R81 can do some personal hygiene by herself but does need assistance to finish. V6 stated she doesn't remember when she provided nail care for R81 but stated it was sometime previous week. On 04/02/2025 at 09:19 PM, V7 (CNA) stated R81 will ask to do some personal hygiene but does still require assistance. V7 states activities take care of nail cleaning and trimming but if dirty nails are observed they should be cleaned during showering. On 04/02/25 at 12:50 PM, V8 (Activities Aide) stated they do nails on Wednesdays and Fridays of every week. They remove polish and polish nail. V8 stated they clean nails once or twice a month by soaking them. On 04/02/25 at 12:50 PM, V2 (Director of Nursing) stated they do not have a specific day or time they clean nails or a set schedule. V2 stated they try to do it on days they are well staffed. V2 stated she will tell staff at the beginning of the day to do nail care on residents during that day. V2 stated nails should also be checked during showering. V2 stated if a family member tells a staff member that a residents fingernails need to be cleaned then that staff member should either clean the nails or ask someone else to do it. On 04/02/25 at 12:23 PM, V1 (Administrator) stated residents get showers twice a week. R81's Shower sheets documents R81 received showers on 03/17/2025, 03/20/2025, 03/21/2025, and 03/28/2025. These sheets did contain any information related to R81's fingernails. A policy titled Fingernails/Toenails, Care of dated February 2018 documents The purposes of this procedure are to clean the nail bed, to keep nails trimmer and to prevent infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident . General Guidelines: 1. Nail care includes regular cleaning and regular trimming .

Based on observation, interview, and record review the facility failed to identify, assess, and treat wounds for 1 of 5 (R92) residents reviewed for wounds in the sample of 41. Findings Include: R92's Admission Record with a print date of 4/3/25 documents R92 was admitted to the facility on [DATE] with diagnoses that include cellulitis, sepsis, hypertension, hypotension, chronic obstructive pulmonary disease, cirrhosis of liver, and urinary retention. R92's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating R92 is cognitively intact. This same MDS documents R92 requires substantial/maximal assistance of staff for bed mobility and has pressure ulcers, deep tissue injuries, and skin tears. R92's current Care Plan documents a Focus area of At risk for alteration in skin integrity. Date Initiated: 10/25/24. This same Focus area documents the following interventions all initiated on 10/24/24, Educate resident and family on skin conditions and prevention of skin breakdown .Float heels while in bed Incontinence care. Apply barrier cream Monitor labs that can affect skin .Notify dietary as needed Observe for signs and symptoms of skin breakdown/infection Pressure reducing cushion to wheelchair Pressure relieving mattress .Provide supplements as ordered Skin assessment on admission and weekly .Treatment orders: see POS (physician order sheet) and skin and wound tab . On 4/3/25 at 11:06 AM, V11 (Registered Nurse/RN) was observed administering treatments with V16 (Regional Nurse), V18 (Certified Nursing Assistant/CNA), and V17 (Wound Specialist). R92 had multiple open areas on the sacrum that were identified as pressure ulcers with previous treatment orders in place. The areas were cleaned and treated as ordered by the physician using current standards of practice. After R92's sacrum was assessed and treated this surveyor asked V11 (RN) and V18 (CNA) if that was the only open areas/wounds R92 had and they responded, Yes. As they were repositioning R92, this surveyor noted active bleeding in R92's groin and asked V11 and V18 about it. V17 (Wound Specialist) identified the area as a skin tear and gave orders for treatment of the area. V11 (RN) administered the treatment as ordered per current standards of practice. During treatment of the skin tear, this surveyor noted a separate area just below R92's buttock that was open. This surveyor brought this area to the attention of V11 (RN) who got V17 (Wound Specialist) who had left the room after giving orders for the skin tear. V17 (Wound Specialist) assessed the area below R92's buttocks and gave orders for a treatment. V11 (RN) treated the area per current standards of practice. After the area was treated this surveyor asked to see R92's feet and heels. V18 (CNA) removed R92's socks and this surveyor noted an open area that was covered with eschar and the surrounding tissue was red on the outer aspect of R92's right ankle. There was a dressing covering the inner aspect of R92's right ankle. Again, V11 (RN) got V18 (Wound Specialist) who had left R92's room. V17 (Wound Specialist) removed the dressing to the inner aspect of R92's ankle, assessed both areas, gave orders for the areas and again left the room. V11 (RN) hand sanitized, donned gloves, cleaned the area on the inner aspect of R92's ankle, without changing gloves or hand sanitizing, V11 then cleaned the wound on the outer aspect of R92's ankle. V11 doffed his gloves and hand sanitized and treated the inner aspect and outer aspect, again without changing his gloves or hand sanitizing between the two areas. This surveyor then asked to do a skin check on R92's upper body. After removing R92's shirt a skin tear was noted to R92's right elbow. There was no treatment in place on this area. Again V11 (RN) got V17 (Wound Specialist) who had left the room, V17 assessed the area on R92's right elbow and gave treatment orders. R92's Skin and Wound Evaluation dated 3/26/25 documents a deep tissue injury on R92's sacrum acquired in house. This same assessment does not document any of the other areas noted during the observation. R92's Wound Specialist Note dated 3/27/25 documents R92 had an unstageable deep tissue injury to his sacrum and a skin tear to his left hand. The other areas noted during the observation were not documented on this assessment. R92's Order Summary Report dated 4/3/25 documents a physician order to clean left inner ankle with wound cleaner, pat dry, and apply hydrocolloid every three days and as needed with a start date of 4/3/25 and an order to clean wound on the sacrum, pat dry, apply hydrocolloid dressing every three days and as needed. There are no orders documented on the Order Summary Report for the other wounds noted during the observation. R92's Progress Notes document on 4/2/25, New order obtained-left inner ankle- cleanse with wound cleaner. Pat dry. Apply hydrocolloid. Change every 3 days and PRN (as needed) . There is no assessment and/or measurement of this area documented in R92's medical record. R92's Skin Observations: Comprehensive CNA Shower Review dated 4/2/25 documents one open area on R92's left foot and documents under Charge Nurse Assessment: MD (Physician) aware-see wound Dr (doctor) tomorrow- tx (treatment) in place. R92's Physician Telephone Orders dated 4/2/25 documents an order to see wound dr (doctor) for left foot wounds duoderm every three days. R92's report titled Other dated 4/2/25 documents under Nursing Description, Resident has a new open area to right inner ankle. Area assessed and noted granulation tissue with no drainage or odor noted. Notified (name of primary physician) and he gave new orders to cleanse with wound cleaner. Pat dry-Apply Hydrocolloid. Change every 3 days and PRN (as needed) and wound doctor to see and fully assess in the morning on 4/3/25. R92's Wound Specialist Progress note dated 4/3/25 documents the following wounds, 1. Stage 2 pressure wound to sacrum that measures 6.5 x 8.9 x 0.2 cm (centimeter), 2. skin tear left dorsal hand that measures 0.5 x 0.9 x 0.2 cm, 3. skin tear of right groin that measures 3.5 x 2.4 x 0.2 cm, 4. unstageable deep tissue injury right lateral ankle that measure 1.1 x 0.9 x not measureable cm greater than one day in duration, 5. non pressure wound of right upper medial foot that measures 1.5 x 2.1 x 0.2 cm greater than one day in duration, and 6. skin tear wound of right forearm that measures 2.0 x 2.0 x 0.2 cm greater than one day in duration. On 04/03/25 at 2:24 PM, V2 (Director of Nurses) stated she would expect newly identified wounds to be measured, assessed, and an incident report to be filed out. V2 stated she would expect nursing staff to change their gloves and hand sanitize after cleaning and/or treating a wound and before cleaning/treating another wound. The wound policy provided to this surveyor titled, Prevention of Pressure Ulcers/Injuries dated July 2017 documents, .Any areas identified while performing or assisting with personal care or ADL's (Activities of Daily Living) charge nurse will be notified f. Nursing will do a complete review of the area and notify the physician for further orders/treatments/assessments. g. Assessments of new wounds will be completed within 24 hours and/or according to physician orders

Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R1, R13, R56, and R97) reviewed for room size in a sample of 41. Findings include: On 4/1/25 at 10:30 AM, V1 (Administrator) stated that Side 2 of the facility has a room size waiver assessment. V1 stated these rooms are Medicare/Medicaid certified for two residents. V1 stated rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, 244-248 are all waivered rooms and don't meet the proper room size. On 4/3/25 at 1:56 PM, V13 (Maintenance Director) stated R13 and R56's room was less than 80 square feet per resident, which is less than the requirement. V13 used the measuring tape to measure the length and width of R13 and R56's room and stated, 12.5 by 12 feet, indicating that the rooms were 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. A that time R13 and R56 were both in their room. The smaller sized room contained two beds and two nightstands. On 4/3/25 at 1:56 PM, R13 and R56 who were both alert to person, place and time stated they are ok with their room size and do not have problems with it. On 4/3/25 at 2:04 PM, V13 stated R97 and R1's room was less than 80 square feet per resident, which is less than the requirement. V13 used the measuring tape to measure the length and width of R97 and R1's room and stated, 12.5 by 12 feet, indicating that the rooms were 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. R97 and R1 were both in their room. The smaller sized room contained two beds and two nightstands. On 04/03/25 at 2:04 PM, R97 and R1 who were both alert to person, place and time stated they are fine with their room. An undated facility room roster provided by V1 on 03/31/25, documents R13, R56, R97, and R1 reside in the rooms observed and measured by V13. Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms.

Based on observation, interview and record review, the facility failed to keep resident care areas clean and in a good state of repair for 5 (R3, R4, R6, R8 - R20) of 16 residents reviewed for homelike environment in a sample of 20. Findings Include: On 09/24/2024 at 9:54 A.M. an observation in the 100-hall shower room revealed the following: shower stall had a black / orange substance around the caulking strip area between the wall and the floor. The black substance was observed as being around both side walls and the back wall of the shower stall. The vinyl liner for the shower curtain was observed as having black speckles on the bottom 12 inches. The vinyl liner also had an orange / brown substance on the bottom 6 inches of it. The legs of the shower chair had a orangish / black substance above the wheels. On 09/24/2024 at 11:32 A.M. V4 (Family member) stated the facilities shower rooms are gross and are filled with mold. V4 stated she expressed her concern in the last care plan meeting she had with the facility on 08/29/2024. V4 stated she showed V2 (Director of Nursing) and V12 (Social Service) pictures of the shower room and the shower room curtain liner. V4 stated she was told that it wasn't mold and there had been nothing done about the shower curtain liner. On 09/24/2024 at 12:03 P.M. V5 (Housekeeping Supervisor) was observed cleaning the shower stall on the 300-hall shower room. V5 stated she is not sure what the black / orange substance is that is on the stripping of the shower stall where the wall and floor meet. V5 stated the facility has tried removing it with different cleaning products including bleach. V5 stated that she has been unsuccessful as she thinks it is the glue coming through. V5 stated the shower rooms are cleaned at least daily and more often if needed. V5 stated that the facility is in the process of preparing to remodel all three shower rooms. On 09/24/2024 at 12:31 P.M. V1 (Administrator) stated she does not think the discoloration in the shower rooms is mold. V1 stated they have sprayed it with bleach, and it does not change the color or make it where it will come off. V1 stated she feels that is the glue from the tiles and stripping causing the black appearance. V1 stated it is very sticky and won't come off. On 09/24/2024 at 2:50 P.M. V1 and V9 (Regional Nurse) were shown the shower curtain liner on 100 halls. V1 stated that she was unaware that there was soap scum build up on the back of the shower curtain liner. V1 stated they will immediately take them down. V1 stated the buildup on the shower chair legs was not mold it was soap scum. V1 stated that she has no complaints from residents or families about the condition of the shower rooms. On 09/25/2024 at 8:56 A.M. the 100-hall shower room was observed to have a new vinyl liner with the shower curtain. On 09/25/2024 at 08:30 A.M. V1 stated that all of the shower chairs are being taken outside and being power washed. V1 stated that this occurs twice a month for each side. V1 stated that the facility is getting ready to start a remodel on three of the shower rooms. V1 stated they are waiting for all the materials to be delivered so the project can get started. On 09/25/2024 at 9:01 A.M. V2 (Director of Nursing) stated she was in the care plan with V4. V2 stated she remembers V4 telling them about the shower room but does not remember V4 stating issues with the shower curtain or liner. V2 stated after the care plan meeting, she looked at the shower and does not believe it is mold. V2 stated she believes it is glue coming through. V2 stated the facility is getting ready to start a remodel on all three shower rooms. On 09/25/2024 at 9:35 A.M. V1 stated that all housekeeping staff have been instructed to monitor the liners in the shower room and to change them as needed. Facility Census sheet printed 9/24/24 documented R3, R4, R6, R8 - R20 live on the 100 hall.

Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for 1 (R56) of 2 residents reviewed for advanced directives in the sample of 43. The Findings Include: R56's Facesheet with a print date of [DATE] documents R56 was admitted to the facility on [DATE] with diagnoses that include schizophrenia, anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, hypothyroidism, benign prostatic hyperplasia, anemia, gastroesophageal reflux disease, and influenza. R56's POLST form dated [DATE] documents under Orders for Patient in Cardiac Arrest, a check mark next to, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation . On [DATE] at 9:19 AM, a review of R56's electronic health record documents a physician order that indicates R56's POLST states as Full Code. On [DATE] at 12:07 PM, V1 (Administrator) stated R56's Power of Attorney changed R56's status from full code to DNR (do not resuscitate) on [DATE]. V1 stated they changed it everywhere in the electronic health records but they didn't put the new POLST status in R56's physician's orders. R56's undated Physician Orders List with active orders only provided to this surveyor by V1 (Administrator) does not document a physician order related to advance directives. The untitled and undated physician order provided to this surveyor by the facility documents a physician order of Full Code with a start date of [DATE], a discontinue date of [DATE], and a last modified date of [DATE]. On [DATE] at 1:15 PM, V1 stated she discontinued the order after the discrepancy was brought to her attention by this surveyor. The facility Advance Directives Policy dated ,d+[DATE] documents, Advance directives will be respected in accordance with state law and facility policy 19. The Director of Nursing Services or designee will notify the attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has ad ethical or conscientious objection.

Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 5 of 5 residents (R3, R23, R46, R64, R72) reviewed for room size in a sample of 43. Findings include: An observation on 4/3/24 at approximately 3:14 pm, revealed R23 is in his room alone currently but will have his roommate back after his therapy is completed. It was a smaller sized bedroom with two beds and 2 night stands and had a limited area to move around inside the room. An observation on 4/3/24 at approximately 3:18 pm, revealed R46 was in his room alone with no roommate at this time. It was a smaller sized bedroom with two beds and 1 night stand and a recliner. The room had limited area to move around inside. An observation on 4/3/24 at approximately 3:20 pm, revealed that R64 was in the bedroom alone. It was a smaller sized bedroom with one bed, one recliner and 1 night stand. The room had limited area to move around inside. An observation on 4/3/24 at approximately 3:25 pm, revealed that R72 and R3 were in a room together. It was smaller sized bedroom with 2 beds and 2 night stands. This room had limited area to move around inside. During a tour with the V2 (Maintenance Director) on 4/3/24 at 3:14pm, V2 was asked to measure R3, R23, R46, R64 and R72's bedroom sizes. V2 used the measuring tape to measure the length and width of R3, R23, R46, R64 and R72's room and stated, 12.5 by 12 feet, indicating that the rooms were 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. During an interview on 4/3/24 at approximately 3:30pm, when asked about the size for two-resident bedrooms, V2 stated that he is unsure of the required square feet for resident rooms and has never measured the rooms before. On 4/2/24 at 2:30pm, V1 (Administrator) stated that Side 2 of the facility (where R3, R23, R46, R64 and R72 reside) has a room size waiver assessment. V1 stated that most of these residents do not have roommates but are still certified for two residents. V1 stated rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, 244-248 are all waivered rooms and don't meet the proper room size. A facility room roster provided by the facility on 4/2/24 and dated 4/1/24, documents that R3, R23, R46, R64 and R72 reside in the rooms observed and measured by V2. Inquiries regarding the size of these rooms during the survey from 04/02/24 to 04/05/24, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. During interview, on 04/03/24, R3, R23, R46, R64 and R72 all voiced no concerns with the size of their rooms during interviews. Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms.

Based on interview and record review the facility failed to accurately report Registered Nurse (RN) hours to the payroll-based journal. This has the potential to affect all 104 residents residing in the facility. Findings Include: Review of Staffing Data Submission Payroll Based Journal (PBJ) found at, https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission and last modified 9/23/23 stated, .CMS (Centers for Medicare & Medicaid Services) has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. Review of the facility's PBJ report for Fiscal Year Quarter 1 2024 (October 1 - December 31), documented No RN hours on the following dates: 10/07/23, 10/08/23, 10/22/23, and 12/28/23. Nursing schedules reviewed for RN coverage on 10/7/23, 10/8/23, 10/22/23, and 12/28/23 documented coverage was provided by V1 (Administrator), who was a contracted Registered Nurse at the facility during that time. On 04/05/24 at 10:54 AM, V1 confirmed that she did work the days in question as the Registered Nurse at the facility, although the origination of discrepancy in the PBJ hours reported cannot be determined at this time. The Long Term Care Facility application for Medicare and Medicaid dated 4/2/24, documented 104 residents reside in the facility.

Based on interview and record review, the facility failed to maintain acceptable nutritional and hydration parameters for a non-verbal resident with a diagnosis of dysphagia for 1 of 3 residents (R1) reviewed for nutrition and hydration in a sample of 12. This failure resulted in R1 experiencing a significant weight loss of 5% in 1 week due to not receiving nutrition for 16 days, with subsequent hospitalization for malnutrition, critically low potassium levels, dehydration, and electrolyte imbalance. A reasonable person not being provided any form of nutrition for 16 days would react with feelings of emotional/psychological distress, weakness, anxiousness, as well as discomfort or cramping related to hunger pangs. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 5/20/23, when the facility failed to provide nutrition and adequate hydration to R1 for 16 days leading to R1's significant weight loss of 5% in 1 week, and subsequent hospitalization for malnutrition, critically low potassium levels, dehydration, and electrolyte imbalance. V1(Administrator in training) and V22 (Director of Operations) were notified of the Immediate Jeopardy on 6/22/23 at 11:12am. This surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 6/23/23 at 8:00am, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Face Sheet in the medical record documents that R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified affecting unspecified side, dysphagia (oropharyngeal phase) following other cerebrovascular disease, aphasia, and Gastro-esophageal Reflux Disease. R1's June 2023 Physician's Order Sheet (POS) documents an order dated 1/20/23 for a pureed diet with NTL (nectar thickened liquids) and assist with meals as needed. R1's MDS assessment dated [DATE] in Section B, Hearing, Speech & Vision documents R1's speech clarity as No speech - absence of spoken words. Subsequent MDS assessments dated 4/14/23 and 5/30/23 document R1's speech clarity as Unclear Speech - slurred or mumbled words. R1's MDS (Minimum Data Set) dated 5/30/23 documents in Section C, Cognitive Patterns, that R1 has a BIMS (Brief Interview of Mental Status) of 99, indicating R1 was unable to complete the interview. The same MDS assessment documents in Section G, Functional Status, documents that the self-performance and support provided under the section Eating as Activity did not occur-activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7 day period. A Nurse's Note in R1's medical record authored by V30 (Licensed Practical Nurse) dated 5/20/23 at 1:54 PM documents in part Resident (R1) started coughing during breakfast and lunch today that caused her to expel her food up both meals and for the past couple days she needed to be suctioned following 2 meals which she was and tolerated well. I called primary care today and talked to the Dr (doctor) on call which is (V35- Nurse Practitioner) she said to send to the emergency room . Ambulance called and was transported to (local hospital #1). R1's ED (Emergency Department) Discharge Instructions dated 5/21/23, authored by V24 (emergency room Physician) documents a final diagnosis of dysphagia, concern for aspiration. Discharge Instructions document that R1 is on 125 cc (cubic centimeters) of D5 (Dextrose 5%) 1/2 NS (Normal Saline) 20 KCl (Potassium Chloride), needs swallow evaluation, please contact the facility physician to order swallow evaluation, this needs to be done tomorrow morning, keep the patient NPO (nothing by mouth) until the swallow eval is done, check blood sugar, fingerstick, every 6 hours, and follow up with PCP (Primary Care Physician) in 24 hours. A Miscellaneous Nursing Note from the hospital records dated 5/21/23 documents spoke with (name of facility). Nurse reports that they have the capability to do swallow evals in their facility Monday through Friday. (Name of facility) also, has the capability to give IV fluids. I spoke with provider and he is willing to send (R1) back to (name of facility) as long as they are comfortable with the IV fluids and NPO status. Attempting to return call to (name of the facility). The Nursing Note further documents pt (patient) to be discharged back to the facility. Report called to (V18- Licensed Practical Nurse). A Nurse's Note dated 5/21/23 at 11:52 AM documents in part that (R1) returned from (local hospital #1) at 2050. New orders for IV fluids. A Nurse's Note dated 5/22/23 at 2:00 AM documents in part Resting in bed at this time. HOB (head of bed) elevated 30 degrees. #20 gauge IV patent in left hand. No redness or swelling noted, flushes without difficulty. N.O. (new order) from (local Hospital #1) to start D5 1/2 NS 20KCl at 125 mL (milliliters) per hr (hour) until morning. IV fluids running per orders. Keep NPO until swallow eval ordered and done. R1's June 2023 POS documents orders dated 5/22/23 for a swallow eval next available Dx (diagnosis): dysphagia, keep NPO until swallow eval is done, and check blood glucose Q (every) 6 hours and an order dated 5/23/23 for Dextrose 5%- 0.45%NaCl (Sodium Chloride) IV (Intravenous) solution at 125mL/ hour. On 6/21/23 at 8:30 AM, V18 (Licensed Practical Nurse) said that she admitted R1 back to the facility after the 5/21/23 trip to the emergency room . V18 said she was specifically told a swallow exam by the hospital. V18 said that she told them that they could do a bedside swallow test but could not do a barium swallow or a video test. V18 said that she put R1 on the doctors list for rounds. V18 said that R1 was ordered to be NPO at that time. V18 said the doctor does rounds on Wednesdays and Fridays and sometimes the weekend and they usually clip the hospital orders on the list and put them in a folder labeled MD (Medical Doctor) rounds. V18 said that R1 came back on IV fluids and the hospital sent a bag of fluids with her. V18 said the fluids were D5 1/2 NS. V18 said that when she hears swallow evaluation to her that means to have a speech therapy evaluation not video or barium swallow test. V18 said when she received report from the hospital, a video or barium swallow test was never mentioned. V18 said the folder for physician rounds, that included R1's hospital records, was left at the nurse's station. V18 said that on 5/18/23 she had to suction R1. V18 said that there was no food in what she suctioned. V18 said it was clear frothy phlegm. Nurse's Notes dated 5/21/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23 and 5/27/23 all document that R1 continues to be NPO until the swallow evaluation is completed. A Nurse's Note dated 5/30/23 at 9:26 AM, documents that R1 has left the facility to have a swallow eval done. A hospital Fluoroscopy Esophagram Report (from local hospital #2) documents the reason for the exam as dysphagia with an order dated 5/22/23 by V21 (Physician). The Fluoroscopy Esophagram results dated 5/30/23 at 9:48 AM, documents under findings that the patient was unable to swallow barium. There is a history of aspiration. This is a non-diagnostic exam. Is suggested that the patient be scheduled for a video swallow with speech pathologist to evaluate which consistencies the patient can tolerate without aspiration. On 6/14/23 at 7:00am, V3 (DON/Director of Nurses) said that they tried to get a barium swallow done for R1 but the 2 local hospitals could not do it. V3 said they did get an appointment for 5/30 but that R1 would not swallow the barium so it could not be completed. V3 said that V21 saw R1 at the facility on 5/31/23 in the morning and was unsure what the family's choice would be- hospice or feeding tube and then the family made the decision to get a feeding tube that same afternoon. V3 said they were following physician orders by keeping R1 NPO since that is what he ordered. A Nurse's Note by V3 dated 5/31/23 at 12:56 AM documents (R1) remains NPO. She was unable to complete swallow eval today. (V21) is aware of study failure. Awaiting further orders. IV site to left upper arm patent and clear without evidence of infiltration. D5 0.45%NS infusing at 125mL per hour. Glucose readings wnl (within normal limits). Oral care provided. A facility Progress Note dated 5/31/23 by V21 (Physician) documents under plan that Orders reviewed and signed and continue current regimen. Patient (R1) has been in and out of the hospital emergency room several times over the last couple weeks. (R1) was diagnosed with progressively worsening dysphagia to the point that she is been kept NPO due to constant aspiration. We would attempt esophagram and she was unable to do due to dysphagia. Staff has been in contact with (V36 Power of Attorney-POA/ Family). (V36) is contemplating hospice versus PEG (percutaneous endoscopic gastrostomy) tube feeding. Patient has been on IV fluids. Patient is non-verbal but does not show any signs of discomfort or pain. As soon as the family decides we will proceed with orders. A Nurse's Note dated 5/31/23 at 11:43 AM documents TC (telephone call) to (V36) in regards to being placed on hospice service or have a feeding tube placed. (V36) said she wants a feeding tube placed and doesn't want her on hospice care. A Wound/ Weight Meeting Note authored by V32 (Licensed Practical Nurse) dated 6/1/23 at 10:34 AM documents in part Current weight 113.6 lbs (pounds) which is 6.2 lbs loss since being placed on NPO status with IV D5 1/2NS continuous at 125 mL/hr, pending swallow study, which she failed. Call placed to (V36) regarding options of feeding tube placement or hospice care. (V36) has opted for feeding tube. MD notified and PEG tube placement is pending . A Nurse's Note dated 6/1/23 at 2:06 PM documents June 8th at 2 PM (local hospital #3) for G (gastrostomy) tube placement. On 6/25/23 at 9:00am, V3 (DON) said that they were able to get another appointment at another local hospital for G tube placement on 6/8/23. V3 said that V21 was able to find a surgeon to place the feeding tube and sent R1 to the hospital on 6/6/23. R1's Admission History and Physical (from local hospital #3) dated 6/6/23 under the section HPI (history of present illness)/ Subjective documents in part that R1 presents with traumatic brain injury, aphasia, dysphagia, spastic right hemiparesis was brought into ER (emergency room ) today from the nursing home for possible PEG tube placement .(V36) stated that (R1) has been without food for 2 weeks since an episode of aspiration. She has been awaiting evaluation by speech therapist .Routine labs obtained today show severe hypokalemia 1.8. UA (urinalysis) is pending. Chest X-rays unremarkable for cardiopulmonary pathology. Under the section Plan it documents traumatic brain injury with spastic right hemiparesis, aphasia, dysphagia on puree with inconsistent swallow and history of aspiration with poor oral intake, anorexia and dehydration with severe electrolyte derangement, hypokalemia, monitor on telemetry, check magnesium as well and replete all electrolytes, Speech and Swallow eval, NPO, D5NS with KCL (potassium) at 100 mL/hr. General surgery consulted for a PEG tube placement. A document titled ST (Speech Therapy) Bedside Swallow Evaluation from the hospital records dated 6/7/23 by V14 (Hospital Speech Therapist at local hospital #3) document an impression of moderate oral dysphagia and pharyngeal dysphagia suspected. A pureed diet with nectar thickened liquids was recommended and a goal of R1 participating in dysphagia treatment in order to further determine safest and least restrictive diet level. An inpatient speech therapy note by V14 dated 6/12/23 documents that R1 swallowed nectar thickened liquids and pureed consistencies with no overt signs and symptoms of aspiration and speech therapy was not needed at this time due to R1's goals were met and a recommendation was made for discharge to a skilled nursing facility. A Nutritional Assessment in the hospital records dated 6/9/23 document that R1 meets ASPEN (American Society for Parental and Enteral Nutrition) criteria for severe protein calorie malnutrition related to inability to consume adequate nutrition as evidenced by patient with aspiration two weeks ago and reportedly uncooperative with previous SLP (Speech and Language Pathologist) evaluation who has been without food for two weeks and presents with critical hypokalemia 1.8 and critical hypophosphatemia 0.7 as well as (by mouth) intake 0% of estimated needs for 2 weeks, significant fat wasting noted per NFPE (Nutrition Focused Physical Exam): moderate orbital pad, significant muscle wasting per NFPE: moderate clavicular, moderate dorsal hand/interosseous. Under the section Evaluation it documents that R1 is tolerating diet order of pureed diet and nectar thickened liquids as recommended by SLP (Speech-Language Pathologist) based on bedside evaluation, ate 75% of lunch and dinner yesterday (6/8/23), and ate 100% of breakfast this morning (6/9/23). On 6/15/23 at 10:46 AM, V14 (Hospital Speech Therapist at local hospital #3) said that speech therapy makes the recommendation for a resident to be NPO (nothing by mouth). V14 said you cannot leave someone without eating for that long. V14 said she did a bedside swallow evaluation on R1 when she was admitted to the hospital and that R1 was safe for PO (by mouth) intake and could have eaten if R1 was seen by speech therapy. V14 said she is not sure why R1 was not seen at the facility. V14 said they were going to put a feeding tube in a lady that did not need it. V14 said that R1 is still in the hospital and is on a full pureed diet and is doing great and has had no feeding tube. On 6/15/23 at 10:30 AM, V12 (Contracted Speech Therapist for facility) said that she could have done a bedside swallow evaluation on R1 if it was ordered by the Physician but that she never received any order or information for R1. On 6/15/23 at 10:35 AM, V13 (Director of Rehabilitation/COTA/Certified Occupational Therapist) said a bedside swallow evaluation could have been done but was not ordered by the physician. On 6/20/23 at 11:35am, V3 said that the Dietician saw R1 at the facility on 5/19/23. V3 said that the dietician was not here while R1 was NPO, therefore did not see R1. V3 also said that R1 received her medications crushed in applesauce and did not receive any of them while she was NPO. V3 said that V21 was aware. A facility document labeled Vital Signs Grid documents that R1 weighed 119.8 on 5/24/23 and 113.6 on 5/29/23, a weight loss 6.2 pounds (5.2%), in 5 days. There were no interventions or dietary notes documented in R1's medical record to address this weight loss. On 6/20/23 at 2:06 PM, V23 (RD/Registered Dietician) said she was not aware of R1's weight loss during that time. V23 said unfortunately she was not made aware that R1 was NPO for 16 days. V23 said she saw R1 on 5/19/23 and she was eating. V23 said she would have expected to have been notified that R1 was going that long without eating since R1 needed a liquid nutrition rather than just IV fluids for hydration. On 6/20/23 at 8:25am, V21 (Physician) said that R1 had had 2-3 episodes of aspiration. V21 said he sent R1 to a local hospital emergency room and doesn't understand if they were unable to do any kind of swallow testing, then why did they not send her to a facility where it could be done. V21 said he tried and tried to find someone to place a feeding tube with no success and finally found one and that is why they sent R1 out on 6/6/23. V21 said he did not realize that R1 went 16 days without eating and said he is not surprised about the weight loss. V21 said he doesn't know what else he could have done. V21 said that as soon as V36 made the choice of putting in the feeding tube, they called all over southern Illinois trying to get someone to put the tube in. V21 said no one from the facility asked about a bedside swallow eval to be done at the facility. V21 said he was aware the facility had Speech Therapy but did not know what their hours were. A letter dated 6/19/23 provided by V22 (Director of Operations) from V21's office and signed by V21, documents In my medical opinion, the risk of aspiration posed by conducting a bedside swallowing evaluation was greater than the risk of remaining NPO pending the swallowing study that was originally ordered. R1 was monitored while NPO for dehydration and glucose readings remained within parameters. Given her history of aspiration with resultant pneumonia maintaining her NPO status and IV therapy pending definitive evaluation and treatment of her dysphagia was deemed the safest course of action. On 6/15/23 at 9:00 AM, V22 said that they did what the physician ordered. V22 said the physician (V21) ordered R1 to be NPO. V22 said they scheduled R1 for a barium swallow on 5/30/23 but R1 did not swallow the barium. V22 said they then had an appointment for 6/8/23 and that is the soonest they could get an appointment then sent R1 out on 6/6/23. V22 said he does not know what else they could have done. R1's Care Plan documents a Care Plan Description of Nutritional Risk difficulty swallowing with a Goal of Maintain or improve weight and health status with a start date of 5/22/23. Documented interventions include: diet as ordered (start date 5/22/23), provide adaptive equipment as needed (start date of 5/22/23), weight as ordered (start date of 5/22/23), swallow eval as ordered by physician (start date of 5/22/23), NPO until swallow eval completed (start date 5/22/23), IV fluids per orders (start date of 5/23/23), transfer to (local hospital) for PEG tube placement (start date 6/6/23), and fortified pudding per orders once clearance after swallow study (start date 5/24/23). There were no orders, interventions, nor documentation in R1's medical record for a referral to the dietician, speech therapy, or orders for blood work to monitor R1's electrolytes during the 16 days that R1 was on NPO status. There is no documentation in R1's medical record that R1 received any nutrition, orally or parentally, from 5/20/23 until R1's hospitalization on [DATE]. The surveyor confirmed through interview and record review that the Immediate Jeopardy that began on 5/22/23 was removed on 6/23/23 when the facility took the following actions to remove the immediacy: *All licensed staff and department heads have been educated to ensure if there are reports of change in swallowing or decrease in nutrition for any resident, they are to ensure that the proper referral gets sent to the corresponding interdisciplinary team member. Education was provided by V22 and V3. *Completed on 6/20/2023 and morning of 6/21/2023, all licensed staff and department heads have been educated on receiving the information needed for the immediate care of the resident's needs. All orders, for initial admission, change of condition, or readmission, are to be clarified with residents' Attending Physician, and documented to ensure all orders are transcribed accurately and implemented. Education was provided by V22 and V3. *Electronic medical records have been reviewed to identify residents that may be affected by the same deficient practice and have a diagnosis of dysphasia and aspiration. Care plans have been reviewed to ensure the interventions put into place are appropriate and effective. This was completed by the V22. Completed at 12:13p 6/22/23. *On 6/22/23 at 1:32 PM, the QA (Quality Assurance) team was notified of the Immediate Jeopardy and the abatement plan that has been put into place. The QA team will review the results of the daily audits once per week for 2 weeks, then monthly for two months to ensure plan of correction is effective.

Based on interview and record review, the facility failed to: a) protect a resident from neglect when they failed to maintain acceptable nutritional and hydration parameters for a non-verbal resident with a diagnosis of dysphagia for 1 (R1) of 3 residents reviewed for abuse and neglect in a sample of 12. This failure resulted in R1 experiencing a significant weight loss of 5% in 1 week due to not receiving nutrition for 16 days, with subsequent hospitalization for malnutrition, critically low potassium levels, dehydration, and electrolyte imbalance; and b) failed to ensure a resident was free from abuse for 1 (R2) of 3 residents reviewed for abuse and neglect in a sample of 9. The findings include: a.) R1's Face Sheet in the medical record documents that R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified affecting unspecified side, dysphagia (oropharyngeal phase) following other cerebrovascular disease, aphasia, and Gastro-esophageal Reflux Disease. R1's June 2023 Physician's Order Sheet (POS) documents an order dated 1/20/23 for a pureed diet with NTL (nectar thickened liquids) and assist with meals as needed. R1's MDS assessment dated [DATE] in Section B, Hearing, Speech & Vision documents R1's speech clarity as No speech - absence of spoken words. Subsequent MDS assessments dated 4/14/23 and 5/30/23 document R1's speech clarity as Unclear Speech - slurred or mumbled words. R1's MDS (Minimum Data Set) dated 5/30/23 documents in Section C, Cognitive Patterns, that R1 has a BIMS (Brief Interview of Mental Status) of 99, indicating R1 was unable to complete the interview. The same MDS assessment documents in Section G, Functional Status, documents that the self-performance and support provided under the section Eating as Activity did not occur-activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7 day period. A Nurse's Note in R1's medical record authored by V30 (Licensed Practical Nurse) dated 5/20/23 at 1:54 PM documents in part Resident (R1) started coughing during breakfast and lunch today that caused her to expel her food up both meals and for the past couple days she needed to be suctioned following 2 meals which she was and tolerated well. I called primary care today and talked to the Dr (doctor) on call which is (V35- Nurse Practitioner) she said to send to the emergency room . Ambulance called and was transported to (local hospital #1). R1's ED (Emergency Department) Discharge Instructions dated 5/21/23, authored by V24 (emergency room Physician) documents a final diagnosis of dysphagia, concern for aspiration. Discharge Instructions document that R1 is on 125 cc (cubic centimeters) of D5 (Dextrose 5%) 1/2 NS (Normal Saline) 20 KCl (Potassium Chloride), needs swallow evaluation, please contact the facility physician to order swallow evaluation, this needs to be done tomorrow morning, keep the patient NPO (nothing by mouth) until the swallow eval is done, check blood sugar, fingerstick, every 6 hours, and follow up with PCP (Primary Care Physician) in 24 hours. A Miscellaneous Nursing Note from the hospital records dated 5/21/23 documents spoke with (name of facility). Nurse reports that they have the capability to do swallow evals in their facility Monday through Friday. (Name of facility) also, has the capability to give IV fluids. I spoke with provider and he is willing to send (R1) back to (name of facility) as long as they are comfortable with the IV fluids and NPO status. Attempting to return call to (name of the facility). The Nursing Note further documents pt (patient) to be discharged back to the facility. Report called to (V18- Licensed Practical Nurse). A Nurse's Note dated 5/21/23 at 11:52 AM documents in part that (R1) returned from (local hospital #1) at 2050. New orders for IV fluids. A Nurse's Note dated 5/22/23 at 2:00 AM documents in part Resting in bed at this time. HOB (head of bed) elevated 30 degrees. #20 gauge IV patent in left hand. No redness or swelling noted, flushes without difficulty. N.O. (new order) from (local Hospital #1) to start D5 1/2 NS 20KCl at 125 mL (milliliters) per hr (hour) until morning. IV fluids running per orders. Keep NPO until swallow eval ordered and done. R1's June 2023 POS documents orders dated 5/22/23 for a swallow eval next available Dx (diagnosis): dysphagia, keep NPO until swallow eval is done, and check blood glucose Q (every) 6 hours and an order dated 5/23/23 for Dextrose 5%- 0.45%NaCl (Sodium Chloride) IV (Intravenous) solution at 125mL/ hour. On 6/21/23 at 8:30 AM, V18 (Licensed Practical Nurse) said that she admitted R1 back to the facility after the 5/21/23 trip to the emergency room . V18 said she was specifically told a swallow exam by the hospital. V18 said that she told them that they could do a bedside swallow test but could not do a barium swallow or a video test. V18 said that she put R1 on the doctors list for rounds. V18 said that R1 was ordered to be NPO at that time. V18 said the doctor does rounds on Wednesdays and Fridays and sometimes the weekend and they usually clip the hospital orders on the list and put them in a folder labeled MD (Medical Doctor) rounds. V18 said that R1 came back on IV fluids and the hospital sent a bag of fluids with her. V18 said the fluids were D5 1/2 NS. V18 said that when she hears swallow evaluation to her that means to have a speech therapy evaluation not video or barium swallow test. V18 said when she received report from the hospital, a video or barium swallow test was never mentioned. V18 said the folder for physician rounds, that included R1's hospital records, was left at the nurse's station. V18 said that on 5/18/23 she had to suction R1. V18 said that there was no food in what she suctioned. V18 said it was clear frothy phlegm. Nurse's Notes dated 5/21/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23 and 5/27/23 all document that R1 continues to be NPO until the swallow evaluation is completed. A Nurse's Note dated 5/30/23 at 9:26 AM, documents that R1 has left the facility to have a swallow eval done. A hospital Fluoroscopy Esophagram Report (from local hospital #2) documents the reason for the exam as dysphagia with an order dated 5/22/23 by V21 (Physician). The Fluoroscopy Esophagram results dated 5/30/23 at 9:48 AM, documents under findings that the patient was unable to swallow barium. There is a history of aspiration. This is a non-diagnostic exam. Is suggested that the patient be scheduled for a video swallow with speech pathologist to evaluate which consistencies the patient can tolerate without aspiration. On 6/14/23 at 7:00am, V3 (DON/Director of Nurses) said that they tried to get a barium swallow done for R1 but the 2 local hospitals could not do it. V3 said they did get an appointment for 5/30 but that R1 would not swallow the barium so it could not be completed. V3 said that V21 saw R1 at the facility on 5/31/23 in the morning and was unsure what the family's choice would be- hospice or feeding tube and then the family made the decision to get a feeding tube that same afternoon. V3 said they were following physician orders by keeping R1 NPO since that is what he ordered. A Nurse's Note by V3 dated 5/31/23 at 12:56 AM documents (R1) remains NPO. She was unable to complete swallow eval today. (V21) is aware of study failure. Awaiting further orders. IV site to left upper arm patent and clear without evidence of infiltration. D5 0.45%NS infusing at 125mL per hour. Glucose readings wnl (within normal limits). Oral care provided. A facility Progress Note dated 5/31/23 by V21 (Physician) documents under plan that Orders reviewed and signed and continue current regimen. Patient (R1) has been in and out of the hospital emergency room several times over the last couple weeks. (R1) was diagnosed with progressively worsening dysphagia to the point that she is been kept NPO due to constant aspiration. We would attempt esophagram and she was unable to do due to dysphagia. Staff has been in contact with (V36 Power of Attorney-POA/ Family). (V36) is contemplating hospice versus PEG (percutaneous endoscopic gastrostomy) tube feeding. Patient has been on IV fluids. Patient is non-verbal but does not show any signs of discomfort or pain. As soon as the family decides we will proceed with orders. A Nurse's Note dated 5/31/23 at 11:43 AM documents TC (telephone call) to (V36) in regards to being placed on hospice service or have a feeding tube placed. (V36) said she wants a feeding tube placed and doesn't want her on hospice care. A Wound/ Weight Meeting Note authored by V32 (Licensed Practical Nurse) dated 6/1/23 at 10:34 AM documents in part Current weight 113.6 lbs (pounds) which is 6.2 lbs loss since being placed on NPO status with IV D5 1/2NS continuous at 125 mL/hr, pending swallow study, which she failed. Call placed to (V36) regarding options of feeding tube placement or hospice care. (V36) has opted for feeding tube. MD notified and PEG tube placement is pending . A Nurse's Note dated 6/1/23 at 2:06 PM documents June 8th at 2 PM (local hospital #3) for G (gastrostomy) tube placement. On 6/25/23 at 9:00am, V3 (DON) said that they were able to get another appointment at another local hospital for G tube placement on 6/8/23. V3 said that V21 was able to find a surgeon to place the feeding tube and sent R1 to the hospital on 6/6/23. R1's Admission History and Physical (from local hospital #3) dated 6/6/23 under the section HPI (history of present illness)/ Subjective documents in part that R1 presents with traumatic brain injury, aphasia, dysphagia, spastic right hemiparesis was brought into ER (emergency room ) today from the nursing home for possible PEG tube placement .(V36) stated that (R1) has been without food for 2 weeks since an episode of aspiration. She has been awaiting evaluation by speech therapist .Routine labs obtained today show severe hypokalemia 1.8. UA (urinalysis) is pending. Chest X-rays unremarkable for cardiopulmonary pathology. Under the section Plan it documents traumatic brain injury with spastic right hemiparesis, aphasia, dysphagia on puree with inconsistent swallow and history of aspiration with poor oral intake, anorexia and dehydration with severe electrolyte derangement, hypokalemia, monitor on telemetry, check magnesium as well and replete all electrolytes, Speech and Swallow eval, NPO, D5NS with KCL (potassium) at 100 mL/hr. General surgery consulted for a PEG tube placement. A document titled ST (Speech Therapy) Bedside Swallow Evaluation from the hospital records dated 6/7/23 by V14 (Hospital Speech Therapist at local hospital #3) document an impression of moderate oral dysphagia and pharyngeal dysphagia suspected. A pureed diet with nectar thickened liquids was recommended and a goal of R1 participating in dysphagia treatment in order to further determine safest and least restrictive diet level. An inpatient speech therapy note by V14 dated 6/12/23 documents that R1 swallowed nectar thickened liquids and pureed consistencies with no overt signs and symptoms of aspiration and speech therapy was not needed at this time due to R1's goals were met and a recommendation was made for discharge to a skilled nursing facility. A Nutritional Assessment in the hospital records dated 6/9/23 document that R1 meets ASPEN (American Society for Parental and Enteral Nutrition) criteria for severe protein calorie malnutrition related to inability to consume adequate nutrition as evidenced by patient with aspiration two weeks ago and reportedly uncooperative with previous SLP (Speech and Language Pathologist) evaluation who has been without food for two weeks and presents with critical hypokalemia 1.8 and critical hypophosphatemia 0.7 as well as (by mouth) intake 0% of estimated needs for 2 weeks, significant fat wasting noted per NFPE (Nutrition Focused Physical Exam): moderate orbital pad, significant muscle wasting per NFPE: moderate clavicular, moderate dorsal hand/interosseous. Under the section Evaluation it documents that R1 is tolerating diet order of pureed diet and nectar thickened liquids as recommended by SLP (Speech-Language Pathologist) based on bedside evaluation, ate 75% of lunch and dinner yesterday (6/8/23), and ate 100% of breakfast this morning (6/9/23). On 6/15/23 at 10:46 AM, V14 (Hospital Speech Therapist at local hospital #3) said that speech therapy makes the recommendation for a resident to be NPO (nothing by mouth). V14 said you cannot leave someone without eating for that long. V14 said she did a bedside swallow evaluation on R1 when she was admitted to the hospital and that R1 was safe for PO (by mouth) intake and could have eaten if R1 was seen by speech therapy. V14 said she is not sure why R1 was not seen at the facility. V14 said they were going to put a feeding tube in a lady that did not need it. V14 said that R1 is still in the hospital and is on a full pureed diet and is doing great and has had no feeding tube. On 6/15/23 at 10:30 AM, V12 (Contracted Speech Therapist for facility) said that she could have done a bedside swallow evaluation on R1 if it was ordered by the Physician but that she never received any order or information for R1. On 6/15/23 at 10:35 AM, V13 (Director of Rehabilitation/COTA/Certified Occupational Therapist) said a bedside swallow evaluation could have been done but was not ordered by the physician. On 6/20/23 at 11:35am, V3 said that the Dietician saw R1 at the facility on 5/19/23. V3 said that the dietician was not here while R1 was NPO, therefore did not see R1. V3 also said that R1 received her medications crushed in applesauce and did not receive any of them while she was NPO. V3 said that V21 was aware. A facility document labeled Vital Signs Grid documents that R1 weighed 119.8 on 5/24/23 and 113.6 on 5/29/23, a weight loss 6.2 pounds (5.2%), in 5 days. There were no interventions or dietary notes documented in R1's medical record to address this weight loss. On 6/20/23 at 2:06 PM, V23 (RD/Registered Dietician) said she was not aware of R1's weight loss during that time. V23 said unfortunately she was not made aware that R1 was NPO for 16 days. V23 said she saw R1 on 5/19/23 and she was eating. V23 said she would have expected to have been notified that R1 was going that long without eating since R1 needed a liquid nutrition rather than just IV fluids for hydration. On 6/20/23 at 8:25am, V21 (Physician) said that R1 had had 2-3 episodes of aspiration. V21 said he sent R1 to a local hospital emergency room and doesn't understand if they were unable to do any kind of swallow testing, then why did they not send her to a facility where it could be done? V21 said he tried and tried to find someone to place a feeding tube with no success and finally found one and that is why they sent R1 out on 6/6/23. V21 said he did not realize that R1 went 16 days without eating and said he is not surprised about the weight loss. V21 said he doesn't know what else he could have done. V21 said that as soon as V36 made the choice of putting in the feeding tube, they called all over southern Illinois trying to get someone to put the tube in. V21 said no one from the facility asked about a bedside swallow eval to be done at the facility. V21 said he was aware the facility had Speech Therapy but did not know what their hours were. A letter dated 6/19/23 provided by V22 (Director of Operations) from V21's office and signed by V21, documents In my medical opinion, the risk of aspiration posed by conducting a bedside swallowing evaluation was greater than the risk of remaining NPO pending the swallowing study that was originally ordered. R1 was monitored while NPO for dehydration and glucose readings remained within parameters. Given her history of aspiration with resultant pneumonia maintaining her NPO status and IV therapy pending definitive evaluation and treatment of her dysphagia was deemed the safest course of action. On 6/15/23 at 9:00 AM, V22 said that they did what the physician ordered. V22 said the physician (V21) ordered R1 to be NPO. V22 said they scheduled R1 for a barium swallow on 5/30/23 but R1 did not swallow the barium. V22 said they then had an appointment for 6/8/23 and that is the soonest they could get an appointment then sent R1 out on 6/6/23. V22 said he does not know what else they could have done. R1's Care Plan documents a Care Plan Description of Nutritional Risk difficulty swallowing with a Goal of Maintain or improve weight and health status with a start date of 5/22/23. Documented interventions include: diet as ordered (start date 5/22/23), provide adaptive equipment as needed (start date of 5/22/23), weight as ordered (start date of 5/22/23), swallow eval as ordered by physician (start date of 5/22/23), NPO until swallow eval completed (start date 5/22/23), IV fluids per orders (start date of 5/23/23), transfer to (local hospital) for PEG tube placement (start date 6/6/23), and fortified pudding per orders once clearance after swallow study (start date 5/24/23). There were no orders, interventions, nor documentation in R1's medical record for a referral to the dietician, speech therapy, or orders for blood work to monitor R1's electrolytes during the 16 days that R1 was on NPO status. There is no documentation in R1's medical record that R1 received any nutrition, orally or parentally, from 5/20/23 until R1's hospitalization on [DATE]. The facility policy titled Abuse Prevention Policy and Procedures (dated 8/16/19) documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Under the section titled Definitions, neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. b). R2's face sheet documents R2 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, hallucinations, unspecified, Essential (primary) hypertension, bilateral transient visual loss, bradycardia, unspecified. R2's MDS (Minimum Data Set) assessment dated [DATE] documents in section C, Cognitive Patterns, a (Brief Interview for Mental Status) score of 99, indicating that an interview could not be conducted due to resident is rarely/never understood. The IDPH (Illinois Department of Public Health) Incident report labeled Final report dated 5/31/23 documents that on 5/26/23 at 11pm, V2 (Administrator) received a call from a CNA (Certified Nurse Assistant) reporting an allegation of abuse that took place between the nurse in charge and R2. V19 (LPN/Licensed Practical Nurse) was removed from the floor by V2 and asked to write a statement. Immediate assessment of residents was given by V3 (DON/Director of Nurses) with no injuries noted. Police were called and two officers arrived and interviewed V19, then viewed video footage along with the owner (V1) and interviewed R2. The nurse (V19) was suspended pending outcome of investigation. Physician, POA (Power of Attorney), Ombudsman, and police were notified. Head to toe assessment completed on R2 with no injuries noted. R2 did not recall anything happening tonight. V19 was interviewed by V1 (Owner) Administrator and police. V19 stated she was trying to keep R2 from getting all the snacks. V19 said she was following training that she had been given at a psychiatric hospital. It was explained to V19 that we do not put our arms around residents and escort them down hallways. V19 was suspended pending the investigation. The investigation determined R2 was seeking snacks from the snack cart and V19 told her to stop because she was taking all the snacks. V19 moved R2 away from the snack cart and then started to argue with R2. V19 then escorted R2 to a chair, had her sit down. R2 then attempted to obtain snacks from the nurse's cart. V19 then took R2 by the arms with her (V19) around her and led her (R2) to hallway leading to resident's room. Resident interviews were conducted with no resident reporting knowledge of incident or that they witnessed incident. Staff interviews indicate witnessing V19 arguing and escorting R2 to her hallway leading to R2's room with her arms around her. Based on employee statements, V19 interacted with R2 in an inappropriate manner, along with a direct violation of training provided to her as an employee, and facility protocols. Due to the outcome of this investigation, her (V19) employment will be terminated. On 6/14/23 at 5:45 AM, V1 (Owner) said that V19 (LPN) was holding R2 from behind with her arms around her. V1 said that V19 took R2 away from the area the snacks were in and then shoved R2 on her shoulders and walked away. V1 said that they have video footage of the incident, but cannot go back that far to view it now. V1 said that V19 was immediately fired. On 6/14/23 at 5:50 AM, V26 (CNA) said she witnessed V19 put arms around R2 and push her up the hall and was yelling at her. V26 said another staff had reported it to the Administrator. On 6/14/23 at 6:05 AM, V27 (CNA) said she was there for the incident between V19 and R2. V27 said she saw V19 put her arms around R2 and take her up the hall and was yelling at her. V27 said she felt this was wrong and she called the Administrator and reported it. The facility policy titled Abuse Prevention Policy and Procedures (dated 8/16/19) documents under the section titled Definitions, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on observation, interview, and record review the facility failed to consistently and accurately weigh residents and ensure residents with a history of weight loss received ordered supplements with meals for 4 of 13 residents (R70, R90, R94, and R96) reviewed for nutrition status in a sample of 49. This failure resulted in R70 who had a history of severe weight loss continuing to have an 10 % (significant weight loss) in the past six months. Findings include: 1. R70's face sheet documented an admitted [DATE] and diagnoses including: Alzheimer's disease, schizophrenia, generalized anxiety disorder. R70's 12/9/22 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment. R70's Physician Orders documented: 8/23/22 order for whole milk at all meals, 8/23/22 order for add 2 [NAME] to hot vegetables at lunch and supper, 12/31/22 order for give ice cream or sherbet at lunch and supper. R70's nutritional risk care plan start date 11/12/21 documented interventions: 8/23/22 whole milk served at all meals, 6/1/22 give ice cream or sherbet at lunch and supper, 8/23/22 add [NAME] to hot vegetables at lunch and supper. R70's unnamed weight log printed 1/31/23 documented weights as: 2/21/22 165.0 pounds, 3/9/22 165.4 pounds, 4/10/22 154.4 pounds, 5/9/22 154.2 pounds, 6/10/22 149.8 pounds, 7/7/22 151.2 pounds, 8/15/22 148.7 pounds, 8/29/22 149.2 pounds, 9/5/22 150.6 pounds, 10/3/22 146.5 pounds, 10/10/22 144.4 pounds, 10/17/22 143.9 pounds, 10/25/22 144.9 pounds, 10/31/22 142.6 pounds, 12/10/22 140 pounds, 1/11/23 139.4 pounds, 1/29/23 136 pounds. This represents an approximate 8.54% (Significant weight loss) in the previous six months. R70's 6/29/22 progress note made by V4 Registered Dietitian (RD) documented in part .RD Wt (Weight) Note: Wt: 6/10 149.8# . resident is showing a wt loss of 9.4% in 3 months (3/9 165.4#), loss of 13.7% in 6 months (121/5 sic. (12/5) 173.6#) . remains on regular diet with ice cream/ sherbet at lunch and supper . suggest to change milk served to whole and add 2 [NAME] to hot vegetables at lunch and supper for added calories . R70's 8/21/22 progress note made by V4 (RD) documented in part .RD Wt Note: . WT: 8/15 148.7# . resident showing loss of 10% in 6 months (2/21 165#) . remains on diet plan of regular with ice cream or sherbet at lunch and supper . at this time will suggest to please add weekly wts to monitor weight fluctuations and change milk served to whole and add 2 [NAME] to hot vegetables at lunch and supper for added calories R70's 1/26/23 progress note made by V5 (RD) documented in part . RD Weight Review . WT- 139.4# . Resident is showing a gradual weight loss over the past 6 months (148.7# on 8/15/) . (R70) does have pertinent dx (diagnosis) of Alzheimer's and Schizophrenia, on Clonazepam and Risperidone which can affect intakes and weights . She is confused at all times, often wandering all around facility which can also contribute to weight decline (increase energy expenditure) .supplements/ supplemental foods in place to add extra calories. Current order: whole milk at all meals, 2 [NAME] to hot vegetables at lunch and supper . ice cream or sherbet at lunch and supper . On 1/24/23 at 1:07 PM, R70 was sitting in the dining room and was served a noon time meal tray with chicken, rice, broccoli and cheese, tea, coffee, and pureed fruit. No butter or ice cream was served to R70. R70's ice cream was observed to be in a bag at the serving station with R70's name on it. On 1/26/23 at 1:16 PM, R70 was sitting in the dining room and was served the noon time meal consisting of Meat loaf, hashbrowns, green beans, dinner roll, apple sauce, lemonade, tea, ice cream, and one pat of butter open by her plate but not used. No milk was served to R70 and no butter was put on her hot vegetables. R70's 1/26/23 meal ticket documented in part ice cream or sherbet; 2 pats butter to hot vegetables . whole milk . On 1/26/23 10:58 AM, V5 (RD) said if R70 did not receive the two pats of butter to hot vegetables, ice cream, and whole milk R70 would not have received approximately 300 calories. V5 said if staff are not serving all the ordered items to residents it could contribute to weight loss. V5 said R70 has had a gradual weight loss over a period of several months. V5 said she expected all staff to follow the resident's diet orders. 2. R94's face sheet documented an admitted [DATE] and diagnoses including: memory deficit following unspecify cerebrovascular disease, secondary hypertension, hyperlipidemia muscle weakness, vitamin B12 deficiency anemia. R94's 10/28/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. R94's Physician Orders documented a 1/25/23 order for 2 pats of butter to vegetables at noon and supper meals. R94's Nutritional Risk care plan with a start date of 7/27/22 documented interventions: 7/27/22 diet as ordered. R94's unnamed weight log printed 1/31/23 documented: 7/27/22 185 pounds, 8/1/22 188.4 pounds, 9/5/22 191.2 pounds, 10/10/22 184.1 pounds, 11/7/22 184.9 pounds, 12/10/22 182 pounds, 1/12/23 165.8 pounds, 1/25/23 164 pounds. R94's 1/26/23 meal ticket documented in part . 1ea (each)/ 1 tsp (teaspoon) - Dinner Roll/ Margarine . 2 pats of butter on hot vegetable . On 1/26/23 at 1:23 PM, R94's noon time meal of meat loaf, hash browns, green beans, a dinner roll, and applesauce was delivered to his room with only one pat of butter on his tray. On 1/26/23 at 1:53 PM, V7 Certified Nurse's Assistant (CNA) reviewed R94's 1/26/23 noon meal ticket with the surveyor and said R94 should have received two [NAME] on his noon time meal tray. On 1/26/23 at 3:40 PM, V5 (RD) said on the 1/26/23 noon time meal R94 should have received three pats of butter (1 for the dinner roll and 2 on the hot vegetables.) On 1/27/23 at 2:12 PM, V4 (RD) said the intervention of adding 2 pats of butter is ensured by watching meal service. V4 said the staff member delivering the resident's tray is responsible for ensuring residents with an order for 2 pats of butter on hot vegetables has the butter delivered. On 1/31/23 at 12:06 PM, V5 (RD) was asked why there was no RD review note when R94 had a 7.1 pound weight loss (3.7%) from 9/5/22 at 191.2 pounds to 10/10/22 at 184.1 pounds V5 responded she did not know why there was no RD review. V5 said the RD will run a weight report to review all monthly and weekly weights in the facility and any changes will be captured in that report. V5 said she was not familiar with R94 and if weight fluctuations were normal and if a 3.7% loss in a month would require a RD review. R94's 1/25/23 progress note from V5 (RD) documented in part .RD Weight & Quarterly Review . Wt (weight) 165.8# (pounds) (1/12) . Resident is showing significant weight loss of 10.4% x 6 months (185# on 7/27) and 9.9% x3 months (184.1# on 10/10). Staff shared with RD an updated wt from today (1/25)- 159.6# which represents some further weight loss . Due to weight loss, would recommend starting . adding 2 pats of butter to hot vegetable sides at lunch and supper for extra calories. Monitor weights and intakes: Refer to RD as needed. R94's Progress noted dated 1/26/23 at 7:02 AM documented in part .RD reviewed weights for (R94) and suggested added 2 pats of butter to hot vegetables and health shake at Breakfast. Dr. (Doctor) notified and approved new orders. Tray card and snack list has been updated . The facility's October 2017 Therapeutic Diet policy documented in part . 2. A therapeutic diet must be prescribed by the resident's attending physician (or non- physician provider). The attending physician may delegate this task to a registered or licensed dietitian . 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet . 3. R76's face sheet documents a date of admission to the facility on [DATE]. This same face sheet documents R76 has diagnoses including vascular dementia with behavioral disturbance, other schizophrenia, and anxiety disorder. R76's MDS (Minimum Data Set) dated 1/13/23 documents a BIMS (Brief Interview of Mental Status) score of 99, indicating R76 has severe cognitive impairment. Section G of the same MDS notes that R76's self-performance for eating is extensive assistance and support given is one- person physical assist. The same MDS notes that for transfers, walk in room, walk in corridor, locomotion on and off unit, R76's support provided is extensive assistance and one-person physical assist. R76's MDS also notes that she uses a wheelchair as a mobility device and her balance during transitions and walking is not steady, only able to stabilize with staff assistance. On 1/31/23, V1 (Administrator) said that R76 uses a wheelchair and requires staff assistance but R76 is also impulsive and will get up without asking for assistance. V1 said that R76 has an unsteady gait. R76's care plan with a start date of 5/5/21 documents a focus area of Nutritional Risk, with history of refusing some meals, diabetic, low Vitamin D. The goal listed on the same care plan is to maintain or improve weight and health status. Some of the interventions listed on R76's care plan include diet as ordered, encourage oral intake, provide non-distracting eating environment as needed, weights as ordered. R76's Physician Orders List documents an order dated 5/6/21 for LCS (low concentrated sweets), NAS (No added salt), mechanical soft diet. This document also notes an order dated 6/19/21 for weekly weights. On 1/32/23 at 9:35am, V1 said that the 6/19/21 order for weekly weights should have been discontinued and the original order should have said weekly weights times 4, then monthly, and then only back to weekly when the RD (Registered Dietician) recommends them. V1 said this is how they do all admissions. The same physician order list documents an order on 12/16/22 for whole milk with meals, add ice cream to supper and on 1/26/23 to add 2 pats of butter with hot vegetables, health shakes BID (twice daily) between meals. R76's Vital Sign Grid documents that on 1/29/22, R76 weighed 129.6 pounds (lbs) and approximately one year later on 1/25/23, R76 weighed 118 lbs. R76 was sometimes being weighed weekly and sometimes monthly during this time frame. R76's vital sign grid documents the following additional weights: 01/08/22: 129.2 lbs 01/11/22: 140.2 lbs 01/15/22: 126.4 lbs 01/29/22: 129.6 lbs 05/09/22: 131 lbs 06/10/22: 119 lbs 06/23/22: 138 lbs 07/07/22: 134.8 lbs 08/15/22: 149.1 lbs 10/29/22: 147.8 lbs 11/07/22: 123.8 lbs 11/19/22: 126.9 lbs 12/10/22: 128.3 lbs 12/26/22: 120.1 lbs 12/31/22: 116.8 lbs 01/11/23: 116 lbs 01/25/23: 118 lbs 01/29/23: 127 lbs R76's progress note written by V4 (Registered Dietician/RD) documents on 10/29/22, RD Quarterly Nutritional Review: HT (height) 63, WT (weight) 10/10 147.8#, BMI (Body mass index) 26.3 noted that HTN (hypertension), anxiety disorder, T2DM (type 2 diabetes mellitus) schizophrenia, h/o (history of) UTI (urinary tract infection) noted with medication of: Aricept, HCTZ (hydrochlorothiazide), quetiapine, ativan, levothyroxine, escitalopram, melatonin, pravastatin, metformin and others, is tolerating a diet plan of NAS (no added salt), LCS (low concentrated sweets) mechanical soft with intakes reported around 50-100%. Resident is reported to eat in the main dining area and feeds herself. Wts (weights) are showing gradual increase in the last 6 months and currently stabilizing round 147-149#, Present wt range is within desirable per BMI . at this time diet plan remains appropriate and no changes requested. Refer to RD as needed. R76's Vital Sign Grid documents the next weights after the 10/29/22 RD Quarterly Nutritional Review were on 11/7/22 (123.8 lbs) and 11/19/22 (126.9 lbs). This shows a 24 pound weight loss in 9 days, from 147.8 lbs on 10/29/22 to 123.8 lbs on 11/07/22. R76's progress note documents on 11/25/22 RD wound/wt Review: HT: 63, WT/CBW (weight/current body weight): 126.9#, BMI: 22.5 resident is reviewed related to showing significant wt loss 14.1% in last month (10/10 147.8#) and loss of 14.9% in the last 3 months (8/15 149.1), .noted wts had been fluctuating 130-150# range and at this time noted in upper 120# area diet plan remains on LCS, NAS, mechanical soft and intakes are reported around 100% of meals and fluids around 480ml (milliliters) at this time will request to please recheck wt and place resident on weekly weights. No change in diet plan at this time with intakes noted .monitor weekly wts and refer to RD as needed. There is no evidence to show that R76's weight was rechecked at this time. R76's weight grid documents that the next weight after the 11/25/22 recommendation to re-weigh her was 126.2 lbs on 11/30/22. There are no weights documented again until 12/10/22. R76's progress note by V4 dated 12/15/22 titled RD WT note documents HT: 63, WT: 12/10 128.32#, BMI: 22.8 noted that resident is showing wt loss in the last 3 months of 13.9% (8/15 149.1#) .noted diet plan of mechanical soft LCS, NAS and intakes are around 100% of meals .at this time will request to please add to weekly wts to monitor and please change milk served to whole and add ice cream to supper for added calories, continue to monitor intakes and wts and refer to RD as needed. R76's weight grid documents the next weights are as follows: 12/26/22 - 120.1 lbs, 12/31/22 - 116.8 lbs, 1/11/23 - 116 lbs and on 1/25/23 - 118 lbs. R76's progress note by V4 documents on 1/25/23 RD weight/Wound & Quarterly Review: HT: 63, Wt: 116.0#, BMI: 20.55 Resident showing significant weight loss of 13.9% x(times) 6 months (134.8# on 7/7) and 21.5% x3 months (147.8# on 1010/22) .resident remains on LCS, Mech soft diet with thin liquids. She feeds herself with meal intakes averaging 75-100% per record. For extra calories, resident receives whole milk at meals and ice cream at supper. Per discussion with staff, resident is very active. Self propels in wheelchair all around facility. Amount of activity is likely contributing to weight decline and increasing R76's needs .would recommend adding extra 2 pats butter to hot vegetable sides at lunch and supper and start health shake as snack between meals at 10am & 2pm. Continue rest of nutrition plan monitoring weights and intakes. RD will follow routinely but please consult as needed. R76's diet card dated 1/26/23 documents LCS (low concentrated sweets), dental soft (mechanical soft), thin liquids. The same diet card also notes milk - 4 fluid ounces (oz), #8 dip - Ground Meatloaf w/ (with) gravy. #8 dip/2oz gvy (gravy) - Mashed potatoes and gravy, 4oz spdl (spoodle) - soft country cooked country chpd (chopped) Green Beans - No bacon, 1 ea (each)/1 tsp (teaspoon) - Dinner Roll/margarine, 4oz spdl - cinnamon peaches, 1 cup diet beverage. Additional notes on R76's diet card list to add ice cream, 2 pats butter to hot vegetable, whole milk. On 1/26/23 at 12:15pm, R76 was noted to propel herself to the dining table and remained at the table until her meal was served at 12:30pm. At 12:30pm, R76's meal tray was noted to have cut up meatloaf with no gravy, mashed potatoes with no gravy, green beans without 2 pats of butter, and no dinner roll with margarine. R76 was observed at this time to consume 100% of her meal. On 1/26/23 at 12:30pm, when questioned about R76's diet card, V7 (CNA/Certified Nurse Assistant) stated that they were out of gravy and then went to get 2 pats of butter and put this on R76's vegetables. No dinner roll with margarine was ever brought back to R76. On 1/26/23 at 12:35pm, V6 (CNA) said they frequently do not go by the menu. She stated if they are out of something, they substitute it. V6 also said that R76 almost always consumes 100% of her meals and they document her intakes with every meal. On 1/26/23 at 11:17am, V1 (Administrator) stated that the process for weighing residents is that the weekly weights have to be done by Sunday. V1 said that the weights are then sent to the nursing director, and they are reviewed. V1 said if there are any weights that are really off, they have staff go re-weigh them. V1 said the problem with the weights being off is that V4 (Registered Dietician) thought she would be helpful and enter them without sending them to the nursing director, and that lead to missing weight loss and residents not getting re-weighed. On 1/27/23 at 2:12pm, V4 said she can't explain (R76's) 24-pound weight loss in 1 week. V4 said if there is a weight really off, she would ask for them (residents) to be re-weighed. V4 said she would not know if weekly weights were not being done usually until the next month when she comes back. V4 said in her notes she says refer to RD if needed and therefore would expect the facility to let her know of the weight. V4 said there are a lot of variances with being weighed .type of scale, location, whether they have had a bowel movement, the time of day. V4 said she looks at a trend with weights and if she notices a weight off, she would ask for a re-weigh and if not she would make a recommendation. On 1/31/23 at 8:35am, V1 stated that R76 is eating all the time and gets a lot of snacks. V1 said there is no way R76 lost that much weight in a week (in reference to the 24- pound loss from 10/29/22 to 11/7/22) and should have been re-weighed. V1 stated that they use a wheelchair scale on side 2. It can also be used as a standing scale. V1 said she believes the problem with (R76's) big weight loss in 1 week is due to staff not subtracting the wheelchair when they weigh residents. 40666 4. R96's facility Face Sheet with a print date of 1/27/23 documents R96 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, anxiety disorder, and nutritional deficiency. R96's MDS (Minimum Data Set) dated 8/19/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R96 is cognitively intact. R96's current Care Plan dated 8/19/22 documents a focus area of At risk for fluid imbalance/weight loss. This same care plan includes the following interventions, weights as ordered (8/19/22), two [NAME] to hot vegetables at lunch and supper (8/23/22), whole milk with meals (11/9/22), house shakes with ice cream at 10am, 2pm, and 6pm (11/9/22), add ice cream to lunch and supper (11/9/22), double portions at meals (11/9/22), Boost drink (11/9/22), mirtazapine as ordered for appetite (1/4/23). R96's progress notes documents on 11/26/22, RD (Registered Dietitian) QUARTERLY REVIEW: HT (height): 68, WT (weight)/CBW (calculated body weight): 121.5# (pounds), BMI (Body Mass Index): 18.5 noted resident for quarterly nutritional review and at this time with dx (diagnosis) of pancreatic cancer w/ s/p (with status post) wipple procedure, COPD (chronic obstructive pulmonary disease), anxiety disorder, depression, HTN (hypertension). medications include: selenium, venlafaxine, bupropion, and others. currently on po (oral) diet plan of regular with thin liquids, whole milk at meals, ice cream at lunch and supper, 2 pats butter to hot vegetables at lunch and supper, double portions at meals along with house shakes with ice cream at 10a/2p/8p. intakes of meals currently 50-75% with fluids around 480 ml (milliliter). noted as of 11/9 tube for feeding was removed. resident wt is to be monitored weekly. at this time wts are showing progressive gain since removal of tube from 116.2# on 11/9 to present wt of 121.5#. no skin or lab concerns reported. also informed that daughter provides resident boost shakes and other snacks for her to keep in her room . at this time no change in diet plan. continue with weekly wts and refer to RD as needed. R96's Progress Notes dated 12/08/22 documents, Wound and weight meeting held today. Current weight is 120.9 which is a 1 lb gain from last weight. Current diet is regular with whole milk at meals, ice cream with lunch and supper and health shakes at snack time three times daily. She eats meals in her room independently. Family has provided snacks to keep in her room. She has recently started PT (Physical Therapy) and is more physically active. She will remain on weekly weight monitoring at this time. (Name of physician and family member) are aware of current weight, diet, and treatment plan. R96's progress notes document on 1/25/23 RD WEIGHT REVIEW: Ht (height)-68, Wt (weight)-112.0#, BMI- 17.03. Resident is showing significant weight loss of 7.9% x3 months (121.6# on 10/10) and 7.4% x1 month (120.9# on 12/5). Resident's PMH (past medical history) includes pancreatic cancer s/p wipple procedure, COPD, anxiety disorder, depression, HTN. Hx (history) of J-tube for supplemental tube feedings- removed 11/9 due to consistent tolerance of PO (oral) diet . No wounds/skin issues. (R96) continues on regular diet as tolerated with thin liquids. She (R96) feeds herself, typically eats in her room and meal intakes vary with average 25-75%- best at supper. She (R96) has reported a poor appetite. She is receiving a variety of supplements and supplemental foods to support her weight. Current orders: whole milk at meals, ice cream at lunch and supper, 2 pats butter to hot vegetables at lunch and supper, double portions at meals, and house shakes with ice cream at 10a/2p/8p. In addition, her daughter brings in snacks and Boost shakes for resident to keep in her room. Due to resident's weight loss and report of poor appetite, she was started on Mirtazapine on 1/4. She feels it is starting to help her feel more hungry and her intakes are showing some improvement. Feel that current nutrition plan is appropriate to support resident's weight, especially with initiation of appetite stimulant. Continue to monitor weights and intakes; RD will follow routinely but please consult as needed. R96's untitled weight report printed 1/27/23 includes the following weights, 8/21/22- 119.4 lbs. (pounds), 9/5/22- 118.0 lbs., 10/04/22 - 120.6 lbs., 11/07/22- 120.2 lbs., 12/27/22 - 113.2 lbs., 1/11/23 - 112.0 lbs., and 1/25/23 - 114.0 lbs. R96's Vital Signs Grid with a print date of 1/31/23 include the following weights, 11/14/22 - 118.9 lbs., 11/26/22 - 121.5 lbs., 11/28/22- 119.9 lbs., 12/05/22 - 120.9 lbs., 12/10/22 - 120.8 lbs., 12/17/22 - 115.3 lbs., 1/2/23 - 112 lbs., 1/11/23 - 112 lbs., 1/29/23 117 lbs. This indicates R96 had a weight loss of 7 pounds (5.8%) from 11/07/22 to 12/27/22 and weight gain of 5 pounds (4.09%) from 1/11/23 to 1/29/23. On 01/24/23 at 9:30 AM, R96 was observed sitting on the side of her bed with a meal tray on her bedside table. R96's tray had partially eaten scrambled eggs and a whole piece of sausage. R96's meal tray also had a bowl of mostly eaten dry cereal. There was a small cup of thick milk shake type drink on R96's tray. There were no other glasses located on R96's meal tray or bedside table. R96 stated she had weight loss, but they had started her on an appetite stimulant. When asked if she preferred to eat her cereal dry without milk, R96 stated she doesn't always get served milk and sometimes she has to ask for it. R96 stated if she asks for it the staff will say they will get it and then never come back. R96 stated she was not served any liquids with this meal other than the shake type drink. On 01/24/23 at 12:59 PM, R96 was served chicken, rice, broccoli with cheese, oranges, and tea. There was no milk on R96's tray. R96 asked for milk and unknown staff returned with a glass of milk. There was no ice cream observed on R96's meal tray. On 01/27/23 at 08:30 AM, R96 was observed sitting on the edge of her bed with a partially eaten breakfast tray in front of her. R96 was eating dry cereal with no milk. There was an empty glass observed on R96's meal tray that appeared to have had milk in it. When asked if she was served milk R96 stated she was but she had drunk it, since she was thirsty. R96 stated they had forgotten to bring her milk at supper on 1/26/23. When asked if she would like milk for her cereal R96 stated she would. This surveyor reported to the nursing staff passing meal trays R96 would like some milk for her cereal. R96's undated meal ticket documents R96 is to be served a regular diet with 2 pats butter to vegetable (lunch and supper), double portions to meals. Under Notes the same meal ticket documents, Send ice cream with empty glass, whole milk, 2 pats of butter on hot vegetables, double portions, whole milk all meals. R96's Physician Orders dated 01/2023 includes the following dietary orders, 8/20/22- regular diet as tolerated, 8/23/22- whole milk with meals, 11/09/22- add ice cream to lunch and supper, and mirtazapine 15 milligrams once daily. On 01/26/23 at 3:42 PM, when asked why R96 was not served milk and/or ice cream, V1 (Administrator) stated, I don't know. I didn't serve her meals. When asked if she would expect R96 to be served ice cream and milk as recommended by the dietitian V1 stated, It should have been served. On 01/26/23 at 3:08 PM, V4 (Dietitian) stated R96 is to have whole milk served at all meals. V4 stated R96 is to have ice cream served at lunch and supper and then a health shake with ice cream at 10 AM, 2:00 PM, and 6:00 PM. This surveyor reviewed with V4 observations of breakfast on 1/24/23 with no milk served to R96 and lunch on 1/24/23 when R96 had to ask for milk and was not served ice cream. When asked if not getting her supplements as recommended would have an impact on R96's weight, V4 stated the supplements would provide extra calories but it could be a combination of factors causing the weight loss. V4 stated they would have to investigate further to determine if that was causing the weight loss. On this same date at this same time, V5 (Dietitian) stated she was aware of R96's weight loss and that an appetite stimulant had been started. V5 stated R96's weights were trending up since starting the stimulant. 01/31/23 at 9:28 AM, V1 (Administrator) stated when she spoke with R96 in December 2022, related to her weight loss, R96 reported she didn't have an appetite. V1 stated they contacted R96's physician and he gave them an order for an appetite stimulant that wasn't covered by R96's insurance. V1 stated then they contacted the physician a second time for a different appetite stimulant. V1 stated that is when mirtazapine was ordered. On 1/26/23 at 12:40pm, V6 (CNA) said that when they weigh a resident, they use the wheelchair scale. If a resident is able to walk they stand on it, if not they push the resident in the wheelchair on the scale. V6 said they have to subtract the weight of the wheelchair after weighing a resident in a wheelchair. 32765

Based on observation, interview, and record review the facility failed to follow dietary menu portion sizes for 13 of 13 residents (R4, R10, R19, R27, R48, R52, R55, R57, R63, R71, R73, R76, and R311) reviewed for nutrition out in a sample of 49. Findings Include: On 1/26/23 at 12:32 PM the noon time meal service was started with meat loaf, hash browns, green beans, a dinner roll, and applesauce being served. Residents with puree or mechanical soft diets were served mashed potatoes for substitution for the hash browns. The scoop of mashed potatoes being served appeared to be a very small amount, approximately the scoop size of a golf ball. On 1/26/23 at 1:23 PM, V12 (Dietary Aide) said all the residents who had a pureed or mechanical soft diet were served mashed potatoes. V12 said she was unsure what size scoop was being used to portion out the mashed potatoes. V12 was not able to find the scoop size on the portion scoop. On 1/26/23 at 1:28 PM, V11 (Dietary Manager) identified the scoop used for the mashed potatoes as a #20 scoop. V11 said the #20 scoop measured out 1.7 ounces. V11 said the recipe documented a #8 scoop was supposed to be used. V11 said a #8 scoop measured out 2 ounces. On 1/26/23 at 3:40 PM, V5 Registered Dietitian (RD) said she expected facility staff to follow recipes with correct portion scoops. V5 said a #8 scoop measured out half a cup. The facility's Diet Spreadsheet for 1/26/23 documented a #8 scoop was supposed to be used for the mashed potatoes. On 1/26/23 a list was requested from the facility of all residents who were currently being served a mechanical soft or puree diet for lunch that day. Face sheets and Physician's order sheets were provided for R4, R10, R19, R27, R48, R52, R55, R57, R63, R71, R73, R76, and R311's After a review of the current Physician's Order for January 2023 for R4, R10, R19, R27, R48, R52, R55, R57, R63, R71, R73, R76, and R311's the diet breakdowns were as follows: R10, R48, R52, R55, R57, R63, R71, R73, R76, and R311's were ordered a mechanical soft diet; R4, R19, and R27 were ordered a puree diet. On 1/31/23 at 10:34 AM, V13 (Chief Executive Officer) said the facility was unable to produce a portion scoop size grid because there was not one accessible to staff and there was not one in the facility. According to https://foodbuyingguide.fns.usda.gov/Content/TablesFBG/Table13_FBG.pdf , Table 13: Sizes and Capacities of Scoops documented a #8 scoop as half a cup and a #20 scoop as three and one third tablespoons.

Based on observation, interview, and record review the facility failed to allow a resident to make choices pertaining to their diet needs by providing requested food items for 1 out of 13 (R42) residents reviewed for nutrition in a sample of 49. Findings include: R42's facility Face Sheet with a print date of 1/26/23 documents R42 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, hypertension, diabetes, heart disease, major depressive disorder, and generalized anxiety disorder. R42's MDS (Minimum Data Set) dated 7/11/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R42 is cognitively intact. R42's Care Plan under At Risk for Complications From Diabetes : Baseline CP (Care Plan) Nutrition with a start date of 7/12/22 documents interventions as: Current diet: See POS (Physician Order Sheet), Monitor blood sugar and monitor for signs and symptoms of hyper/hypoglycemia, Monitor meal percentage intake, and offer bedtime snack. R42's Physician Order List documented a 7/12/22 diet order for regular consistency/ consistent carb diabetic diet with snacks at 10 AM, 2 PM, and 10 PM. R42's Departments Notes dated 1/2/23 at 6:42 PM by V15 Licensed Practical Nurse (LPN) documents, Resident (R42) walked up to where they were serving out food with his plate. One on one with (R42) he could not go up where they were serving. (R42) told this writer to shut up. (R42) sit down (sic). Asked (R42's) nurse if he could have extras. She said his (R42's) blood sugars had been running high at night. They had potatoes and yams (sic). Tried educating (R42) on his diet and DM (diabetes mellitus). (R42) said he didn't care about his sugar. Told him that we did. (R42) asked this writer what my name was. I told him. (R42) said I'm going to tell my daughter. This writer called and updated Admin (administrator) (V1). R42's Departmental Notes dated 1/13/23 at 2:53 PM by V16 Licensed Practical Nurse (LPN) documents, At lunch I observed this resident (R42) tell male peer sitting at this table that if he didn't want his food, he (R42) will take it. Other resident eats slow and stopped eating and handed his nearly full plate to (R42) who scraped off food into his plate. (V16 (LPN)) .went to tell them both that cannot do that, and this resident (R42) started screaming. Screaming and cursing us (sic). I have talked to both residents before about this, but they continue to do the same. On 1/27/23 at 9:07 AM, R42 stated if you ask for more food after the meal rarely do you get anything else. Most of the time they just ignore me. I'm hungry often. I don't know why they can't give me more, they have it right there (meaning the steam table serving area in the dining room). On 1/26/23 at 12:15 PM, V15 (LPN) said on 1/2/23 serving staff came to ask her if R42 could have extra food after R42 had finished his meal tray. V15 said all that was left on the steam table was mashed potatoes and yams. V15 said R42's blood sugar had been running in the 300s and would have to get extra insulin coverage. V15 said she told R42 he could not have any second helping and R42 became angry and started cursing at V15. V15 said if a diabetic resident asks for more food after finishing their meal it would depend on what their blood sugar was if they would be allowed more. On 1/26/23 at 12:06 PM, V16 (LPN) said if a resident was to ask for second helping after they have eaten their meal facility staff should come ask the nurse if the resident may have more food. V16 stated if they wanted an extra piece of cake and their blood sugar was running high I would say no. I would educate them to substitute a protein. V16 said R42 was alert and oriented, sometimes forgetful, and not delusional. On 1/26/23 at 3:40 PM, V4 Registered Dietitian (RD) said if a resident eats all of their meal and tells staff they are still hungry she expected staff to give them an extra portion as long as it was included on the resident's diet plan. V4 said if the resident is diabetic, carbohydrate intake should be monitored. V4 said a resident should be educated on dietary restrictions, but have the right to choose if they want something. V4 said she did not expect any staff to tell a resident asking for more to eat no may not have something. On 1/27/23 at 2:50 PM this surveyor reviewed with V14 (Physician), R42's request for extra food and high carbohydrate food items that was denied by the facility since R42 was diabetic. V14 stated they could adjust the medications to accommodate R42 eating extra food and/or eating food high in carbohydrates. V14 stated R42's last hemoglobin A1C was 9.4 which is not fabulous but if R42 is hungry they should allow him to eat. V14 stated if they need to adjust the medications they can. The facility's December 2016 Resident Rights policy documented in part . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's rights to: . e. self-determination . bb. Be informed of safety or clinical restrictions or limitations related to care and diets; inform the resident of the best course for their care, ie refusal of treatments, medications, not following diets, etc .

Based on interview, observation and record review, the facility failed to ensure residents were free from abuse for 1 of 3 (R1) residents reviewed for abuse in the sample of 43. This failure resulted in R1 being slapped in the face and having a blanket pushed into R1's mouth by V4. This resulted in swelling, bruising and a small laceration of R1's upper lip. Findings Include: 1. R1's facility record Face Sheet documents R1 as being [AGE] years of age with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly resident assessment dated [DATE], Section C, Cognitive Assessment documents R1 with a BIMS (Brief Interview for Mental Status) score of 12 out of 15 indicating moderate cognitive impairment. According to V10's written statement dated 6-30-2021, on the morning of 6-29-2021, V10 and V12, both CNA's, went into R1's room around lunch and noted swelling to R1's upper lip. On 7-9-2021 at 12:50 PM, V10 stated this was immediately reported to V9, (Licensed Practical Nurse.) V9's undated written statement documents V9 assessed R1 and noted R1's top lip looked swollen and with further assessment, V9 observed a small v shaped cut on the inside of her R1's top lip. V9 further documented in her statement that at this time, R1 told V9, with V10 and V12 present, that the lady with the big hips had done it the day before. On 7-13-2021 at 11:20 AM, V9 stated that R1's story kept changing on when it had happened and what exactly had happened and she assumed R1 had bit her lip and did not report it as an allegation of abuse. According to V7's (RN) 6-29-2021 written statement, At 9:00 PM on 6-29-2021, V7 was assessing R1 after being told by staff that R1 had a swollen lip and noted R1's upper lip as large and puffy with some dried blood noted on both upper and lower lips. V7 further documented that R1 told her I know you may not believe this but the girl with the wide hips, that was wearing a red and black vest smacked me in the mouth and told me to shut up. She then stuffed a piece of clothing or maybe a blanket into my mouth. V7 documented R1 told V7 that it had happened when she was being put back to bed after a meal. On 7-9-2021 at 9:55 AM, V7 verified that the statement she had written and signed was accurate. V7 further stated she had immediately notified V6, the on call Registered Nurse, of the abuse allegation. On 7-9-2021 at 8:40 AM, V1, Facility Owner/Licensed Nursing Home Administrator stated he became aware of an allegation of abuse made by R1, when he received a call on the evening of 6-29-2021 from V6 RN ADON, telling him that V7 had contacted V6 and reported that R1 had made an allegation of abuse by staff to V7. V6 then contacted V8, Director of Nursing and V1 and reported the allegation. V1 stated police were notified immediately and an investigation was immediately initiated. V1 further stated that thru the investigation, it was determined that V4 CNA was who R1 was alleging had slapped her then shoved something in her mouth. V1 stated V4 was not present in the building at the time he became aware of the alleged abuse but was scheduled for work the following morning. V1 stated, V4 was not allowed on the floor the following morning 6-30-2021 and the investigation continued with V4 being brought in for a statement. V1 stated V4 told him that on 6-29-2021, after breakfast V4, had gone in to put R1 to bed and R1 had accused her of hitting her but denied any interaction with R1. V1 stated V4 was asked if anyone else was present and V4 stated that V5, CNA was in the room at the time R1 had accused her of slapping her. V1 stated police were called to the facility after V4's statement was obtained and a statement was also obtained from V5. V1 stated that V5 admitted , with the police present, she had witnessed V4 slap R1 and roll a blanket up and put it in R1's mouth. V1 stated V4 was arrested at this time and removed from the building by police. On 7-9-2021 at 1:00 PM, V5 stated that V4 had gone into R1's room sometime right after breakfast on 6-29-2021 because R1 was yelling loudly, and V5 had followed V4 into R1's room. V5 said V4 was talking to R1 at which time she observed V5 slap R1 in the face and put a blanket in R1's mouth. V5 admitted she did not report the abuse at that time. On 7-9-2021 at 1:55 PM, R1 was observed in her room in her bed. R1 was asked about an incident in which she had reported that someone who worked here had hit her and put something in her mouth. R1 sighed and looked away and stated that she really did not want to discuss it, that she wanted it to all just wash away. She then stated she is in jail now and she does not work here anymore. I asked her if she felt safe here and if she felt the staff here were trying to keep her safe and she replied yes. I asked if she could tell me if anyone else was in the room when this event had occurred and she stated honey, I don't know, I just want to forget it. I observed a small area of fading bruising above her upper lip at this time. When asked about the bruising, R1 stated it had happened when the woman had shoved something in her mouth. V13 Medical Doctor examined R1 at the facility on 6-30-2021 and documented in a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No bleeding [CONDITION(S)] at this time but areas of abrasion noted on mucosal surfaces of lips. No other bruising, skin [CONDITION(S)] noted on patient's body. Denies pain anywhere but around lips. Because the witnessed abuse of R1 and R1's allegation of abuse was not reported immediately to the Administrator, V4 remained in the building and on duty providing resident care for the remainder of V4's shift which allowed for the potential for contact with all 43 residents of Side 2 of the facility. This was verified by V8. A 6-29-2021 'Punch Summary Report' verified V4 clocked in at 5:47 AM and clocked out at 2:01 PM on 6-29-2021. On 7-9-2021 at 8:40 AM, V1, Owner and Licensed Nursing Home Administrator, verified that the allegation of staff to resident abuse of R1 was not reported to the State Survey Agency until later, on the evening of 6-29-2021, after he was made aware of the allegation. The facility Abuse Prevention Policy and Procedures dated 8-16-2019 documents, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Employees are required to report any incident, allegation or suspicion of crime or potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator .Supervisors shall immediately inform the administrator or in the absence of the administrator, the person in charge of the facility, of all reports of incidents, allegations or suspicions of potential abuse, neglect or misappropriation of property. Under Section V. Protection of Residents, the facility Abuse Prevention Policy and Procedures documents Employees of the facility who have been accused of abuse, neglect or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible abuse . shall not complete the shift and will be suspended pending the outcome of the investigation.

A. Based on observation, interview and record review, the facility failed to ensure hot water temperatures are maintained at safe levels in areas accessible to cognitively impaired, mobile residents. This has the potential to affect 22 residents (R5, R6, R8, R9, R13, R14, R17, R18, R20, R22, R27, R30, R33, R49, R51, R53, R55, R58, R97, R98, R101, and R108) who utilize the facility's Side 2 west hall shower rooms and 7 additional cognitively impaired, mobile residents (R90, R64, R29, R71, R21, R106, and R111) who have access to this same shower room. This failure resulted in an Immediate Jeopardy which was identified to have begun on 02/05/19 when the facility failed to identify hot water temperatures in order to protect residents from potential injury from the hot water. While the Immediate Jeopardy was removed on 02/06/19, the facility remains at Severity Level 2 as the facility continued to update policies, repair tempering valves, and in-service staff as needed. Findings include: On 02/05/19 at 11:58 AM, R101 stated the shower water goes hot and then cold which makes her not want to take a shower because the water temperatures are inconsistent. R101's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 14, indicating R101 is cognitively intact. R101's MDS section G documents R101 requires supervision/oversight for mobility and showering. On 02/05/19 at 1:45 PM, R22 stated the water temperature was either ice cold or scalding hot. R22 stated she had been burnt before while in the shower. R22 stated it was maybe last week and the water in the shower had turned hot. R22 clarified that there was no blistering or sores from the hot water, but that her leg had turned red for a little while. R22's MDS dated [DATE] documents a BIMS score of 12, indicating R22 has a moderate cognitive impairment. R22's MDS section G documents R22 requires supervision/oversight for mobility and showering. On 02/06/19 at 08:56 AM R97 stated when she is in the shower and someone else uses the water her shower water gets cold and then when the water is turned off elsewhere her shower water eventually gets hot again and it's bad. R97's MDS dated [DATE] documents a BIMS score of 10 which indicates a moderate cognitive impairment. R97's MDS section G documents R97 requires supervision/oversight for mobility and showers. On 2/6/19 at 12:15 PM R53 stated when she took a shower she would adjust the temperature and then while she was in the shower the temperature would change and go hot or cold. R53's MDS dated [DATE] documents a BIMS score of 13, which indicates R53 is cognitively intact. R53's MDS section G documents R53 requires supervision/oversight for mobility and showering. On 2/5/19, water temperatures were taken throughout the facility using a calibrated digital metal stemmed thermometer. Calibration was completed utilizing an ice-point method. On 2/5/19 at 2:30 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer on Side 1 at the hand sink in the unlocked shower room (not numbered) on the North Hall was 122 °F. On 2/5/19 at 2:33 PM, the hot water temperature taken with calibrated digital metal stemmed thermometer on Side 2 at the hand sink in the unlocked shower room labeled B33 on the west hall was 133.9 degrees Fahrenheit (°F). On 2/5/19 at 2:39 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer on Side 2 at the hand sink in the unlocked shower room labeled B32 on the west hall was 132.2 °F. On 2/5/19 at 2:45 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer on Side 1 at the hand sink in the unlocked shower room (not numbered) on the South Hall was 126 °F. On 2/5/19 at 2:53 PM, the temperature in the shower stall of B33 was 139.0 °F using the surveyor's calibrated digital thermometer and 142.2 °F with V6's (Maintenance) thermometer. During this same time period, R101 came to the doorway of shower room B33 and stated this is it, this is the room the water is messed up in. On 2/5/19 at 4:09 PM, V7 (Certified Nursing Assistant/CNA) stated she typically worked on west hall and assists residents on that hall with showers. When asked if she had any complaints or concerns related to the water temperature, V7 called the water temperatures on west hall [MEDICAL CONDITION] because the water temperatures were so inconsistent. V7 stated the temperatures had been inconsistent for approximately a month and she had filled out a maintenance form about a month ago. V7 stated when a resident is in the shower and the temperature changes (from hot to cold, and cold to hot), V7 moves the water spray from the resident and readjusts it until the water temperature is appropriate for bathing. V7 stated R97 and R53 on the west hall had complained about the water temperatures. When asked if there were any residents that would not be able to communicate to the staff if the water temperature was too hot or too cold V7, CNA stated (Name of R20), but he is always screaming. When asked if R20 yelled out while in the shower, V7 stated if the water temperature is adjusted he yells out and then he calms down. V7 then stated some other residents who would be unable to communicate if the water temperature changed would be R58, R14 and R13. On 2/05/19 at 2:39 PM, V6 (Maintenance) stated he keeps the facility temperatures under 110 degrees Fahrenheit. V6 stated the facility's hot water heater for the Side 2 west hall had been replaced a couple of weeks ago and he had not checked the temperatures since the water heater had been replaced. On 2/5/19 at 4:16 PM, V9 (CNA) was asked if she has ever had any issues with water temperature during showers. V9 stated yes, it gets too hot and then gets too cold as recently as yesterday. V9 said she gets it regulated before she puts residents in the shower, but it takes a long time, and then she has to adjust it sometimes while residents are in the shower, especially the shower in B33. V9 stated she didn't tell anyone, she just kept working with it. On 2/05/19 at 4:20 PM, V6 stated he adjusted the hot water heater on Side 2 (which serves shower rooms labeled B32 and B33), to 120 degrees (as low as it will go) and will recheck the temperature in the morning. V6 added that he just checked the temperatures last month (1/30/19 per the temperature logs). On 2/6/19 at 8:45 AM, V1 (Administrator) stated the hot water problem is due to a mixing valve, and the facility is calling a plumber. V1 added the facility couldn't get the water below 114 last night, so they shut the shower rooms down until it can be corrected. On 2/7/19 at 10:59 AM, V7 (CNA) again stated I filled out the maintenance form about 3 weeks ago and added that she put it on the nurse's desk or in the black letter holder on their desk. V7 said they (administration) told me this morning I should tape it to the QA (Quality Assurance) nurses desk. On 2/7/19 at 9:10 AM, V10 (Plumber) stated they have ordered the part for the mixing valve. The facility has two hot water heaters, and the mixing valve that is out serves Side 2 of the facility. When asked if a tempering valve can cause issues that would cause the water to get hotter or colder, V10 replied yes. V10 stated he got a call on 2/6/19 that the facility had a problem with the unit (hot water heater). V10 stated he put a new hot water heater in the facility a month or so ago. V10 stated the tempering valve evidently failed, and that being mechanical, has the potential to fail 365 days per year. V10 stated one thing he suggested for the facility is a high temperature alarm. V10 said it's not mandated by anyone or anything, but it would have alerted the facility immediately of high temperatures. On 2/6/19 at 3:00 PM, V4 (Owner) stated they had been checking water temperatures monthly until today, and added that the facility will start taking temperatures daily. On 2/6/19 at 3:15 PM, V4 (Owner) verified the mixing valves that control the amount of hot and cold water being distributed into the facility, have to be replaced frequently at the facility due to the town having hard water, which causes the mixing valves to build up calcification. V4 stated he has had to replace several of those valves in this facility. On 2/7/19 at 1:50 PM, V4 verified the facility does not currently have a hot water monitoring policy; the facility had just been taking temperatures once a month, but are creating a new policy to monitor water temperatures daily. On 2/7/19 at 4:15 PM, V4 (Owner) stated they have been through all the maintenance work orders over the last several months and are not able to locate a work order related to water temperatures during the past month. The facility's water temperature logs were reviewed for Side 1 and Side 2 from (MONTH) (YEAR) to (MONTH) 2019. The logs indicated that maintenance checked the water temperatures of multiple residents' bathrooms and shared shower rooms once per month on the following dates: 9/28/18, 10/18/18, 11/27/18, 12/4/18, and 1/30/19. All recorded water temperatures were noted to be within safe temperature ranges. No further temperatures were recorded after 1/30/19. Katcher, [MI]K. (1981). [MEDICAL CONDITION] Hot Tap Water. Journal of Am Med Assoc., 246 (11), 1219-1222), documents Many residents in long-term care facilities have conditions that may put them at increased risk [MEDICAL CONDITION] by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, [MEDICAL CONDITION], decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns, written by Moritz and A.R. Henriques F.C. Jr., dated 1947, documents the damage to skin causing a 3rd degree burn in relation to the temperature of the water and the length of time of exposure as follows: 155 degrees F for 1 second (sec) ; 148 degrees F for 2 sec; 140 degrees F for 5 sec; 133 degrees for 15 sec; 127 degrees for 1 minute (min); 124 degrees for 3 minutes; and 120 degrees F for 5 minutes. On 2/6/19, the facility provided a list of residents who were cognitively impaired and mobile. The following residents were on this list: R21, R29, R64, R71, R90, R106, and R111. R21's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 99, indicating R21 was unable to complete the interview. R21 is assessed as requiring supervision with Activities of Daily living and mobility. R29's MDS dated [DATE] documents a BIMS score of 06, which indicates R29 has a severe cognitive impairment R29's MDS section G documents R29 requires one person physical assist for mobility and physical help with transfer only to shower. R64's MDS dated [DATE] documents a BIMS score of 13, which indicates R64 is cognitively intact. R64's MDS section G documents R64 requires supervision for mobility and physical help limited to transfer only for showers. R71's MDS dated [DATE] documents a BIMS score of 11, which indicates R71 is moderately cognitively impaired. R71's MDS section G documents R71 requires limited assistance with mobility and physical help limited to transfer only for showering. R90's MDS dated [DATE] documents a BIMS score of 12, indicating R90 is moderately cognitively impaired. R90's MDS section G documents R90 requires limited assistance with mobility and physical help in part of bathing. R106's MDS dated [DATE] documents a BIMS score of 10, which indicates R106 has a moderate cognitive impairment. R106's MDS section G documents R106 requires supervision with mobility and showering. R111's MDS dated [DATE] documents a BIMS score of 09, which indicates R111 is a moderately cognitively impaired. R111's MDS section G documents R111 requires supervision for mobility and showering. In addition, the facility provided a list of all residents that utilize the Side 2 west hall shower rooms. The following residents were included on the list: R5, R6, R8, R9, R13, R14, R17, R18, R20, R22, R27, R30, R33, R49, R51, R53, R55, R58, R97, R98, R101, and R108. The Immediate Jeopardy began on 2/05/19, when it was discovered that the facility staff failed to identify hot water temperatures. On 2/5/19 at 2:33 PM, (V6) was made aware that the water was too hot in the Side 2 west hall shower rooms labeled B32 and B33. On 02/06/19, surveyors determined through observation, interview and record review, the facility took the following actions to remove the Immediacy: 1. On 2/5/19 at approximately 3:00 PM, the Side 2 west hall shower rooms labeled B32 and B33 were immediately shut down by Administrator (V1), and the Maintenance Supervisor (V6) began adjusting the temperature on hot water heater and the mixing valve. Residents and staff were notified verbally the Side 2 west hall shower rooms were closed for repairs. Signs were placed at both affected rooms and the doors were closed. The water was shut off to Side 2 west hall. All residents were monitored closely and directed or assisted to the alternate bathrooms. 2. On 2/5/19 at 3:00 PM, V1 (Administrator) began in-servicing on-duty staff on State Regulation for water temperatures 100?-110?, and if they identify issues with the water temperatures, they should notify Administrator immediately. The hot water heater supplying the west hall shower rooms was completely emptied by V6. 3. On 2/5/19 at 3:30 PM, temperatures were taken in all areas available to residents including common baths on North, West, and South halls on Side 1 and Side 2. All were within the temperature range of 100°-110°, except for Side 2 west hall bath labeled B32 and B33 which was still out of range and was closed pending repairs. 4. On 2/6/19 at 8:00 AM, V10 (Plumber) was called and a new mixing valve was ordered. The facility was advised by V10 to remove the mixing valve for Side 2 west hall and clean. 5. On 2/6/19 at 9:00 AM, the bathrooms on the facility west hall were shut down to adjust/clean the mixing valve. This was completed by V28 (Regional Maintenance Director) and V3 (Director of Operations). 6. On 2/6/19 at 11:00 AM, V3 (Director of Operations) continued in-servicing all on-duty staff on hot water temperatures, as well as the newly implemented Safe Bathing and Showering Policy. All in-coming staff were in-serviced at shift change. V3 also verified with V6, that he was competent on State Requirements of water temperatures 100?-110?, and V6 was educated on the new Safe Bathing & Showering policy being implemented by the facility. 7. On 2/7/19 at 2:30 PM, completed in-service for employees who were not working on 2/5/19 and 2/6/19. Water is being checked three times per day and will continue to be checked three times daily by V6. Weekend managers will complete water temperature checks during the weekend. New water temperature policy in place to require temperatures to be checked daily at various locations throughout the building. All temperatures to be logged and checked by V1 (Administrator) daily for 30 days. If temperatures are in compliance after 30 days, V1 will audit temperatures weekly. B. Based on observation, interview, and record review the facility failed to address clothing issues as a risk for falls and to assess balance as potential cause for falls for 1 of 6 residents (R55) reviewed for falls in the sample of 83. Findings include: On 2/06/19 at 9:25 AM, on 2/7/2019 at 2 PM, on 2/8/2019 at 2 PM and at various times throughout each day of the survey, R55 was consistently seen walking through the Side 2 dining room hallway with unsteady, shuffling, and sometimes lurching gait. During those times R55's shoe laces were dragging the floor, tongues of both shoes were hanging out beyond toes of shoes. R55 was wearing pants that were too long and were dragging the floor and were rumpled up around shoes. On 2/15/2019, at 9:20 AM, R55 was walking down the hallway near her room, tongues of shoes were hanging out and no laces were in her shoes. R55 stated, They are out of shoe laces. An entry on R55's current Care Plan documents Problem Onset 12/23/2017- Resident states she slipped and fell to floor. Resident had on her shoes and floor was dry. Pants were noted to be too long. Possible pant legs got under her shoes causing her to slip. Pants will be hemmed during activities. There were no injuries. Goal: No further falls. Achieved 2/23/2018. R55's current Care plan documents, Problem Onset 7/5/18- Res coming into facility from patio fell backwards and hit head on rug no injuries noted. The Approach added to this care plan in relation to this fall was Resident instructed to walk slower and view surroundings. A Resident Incident Report for R55 states that on 8/15/2018 at 4:00 PM, R55 stood up out of dining room chair, lost her balance, and fell backward resulting in a knot on the back of the head with no bleeding. Under Additional Follow-ups, on this same form is the statement,: Resident was being combative at the time of the fall. R55's Intervention Log includes an entry for this fall which states Behavior Tracking put in place for being combative toward staff and peers. Monitored daily. On 9/17/2018 at 8:05 PM, a Resident Incident Report states that R55 approached staff to make a request, turned around, stumbled, lost her balance and fell back against door facing to North hall ,then fell on her left side. No apparent injuries. This same document includes: under Additional Follow-ups, Resident reminded to turn around slowly, and states addressed in Care plan. There is an intervention noted for this fall on R55's Intervention Log which states; Falls Focus exercise group will be encouraged, i.e. movement with reaching. Resident Incident Report for R55 for 11/11/2018 at 11:41 states that R55 fell as a result of catching the toe of her shoe on a chair. Resident reminded not to shuffle her feet and be aware of surroundings and that Resident was noted to be wearing shoes that did not belong to her and were too big. Care Plan was updated on 11/12/2018. Approaches added include: Medication review related to recent medication reduction; Resident will wear her own shoes at all times; Ensure resident has and wears properly fitting shoes non-skid shoes for ambulation. Assess resident's balance, vitals signs B/P (blood pressure) lying down and standing at least every (this is blank). Document results and report abnormalities to physician. Target date is 2/12/2019. A Resident Incident Report for 11/30/2018 at 12:54 PM states that R55 caught toe of shoe in chair and lost her balance, and lowered herself to the floor. A Post Incident Actions report for R55 dated 11/30/2019 states: Resident states she was getting up from the dining room table caught toe of shoe on the chair lost her balance lowered herself to the floor. Immediate Post- Incident Action: Reminded resident to be mindful of environment and maybe not be in a rush. Immediate Actions Taken : Head to toe assessment assisted from sit to stand denies hitting her head. A Resident Incident Follow Up For R55 regarding this same incident includes in part the following : Addressed in Care Plan 12 /3/2018 and Additional Follow-ups 12/3/2018 will have pharmacy and MD do med review. A document titled Saline Care Center Intervention Log for R55 includes an entry for 11/30/2019 regarding above -mentioned incident and states Med (medication review by MD (medical doctor) and pharmacy. A document titled Departmental Note with entry dated 12/3/2019 at 4:45 PM states, Pharmacy sent DRR (Drug Regimen Review) and received back with no rec. (recommendation) sent to (R55's MD )at the this time for his review awaiting response. R55's Current Plan does not include a problem onset or an approach with this date. On 2/7/2018 V17 (Certified Occupational Therapist) states that there are no referrals for a Physical Therapy evaluation or therapy services received for R55 that she is aware of. On 2/14/2019 at 10 AM, V13 (Director of Clinical of Operations) stated that all residents receive a quarterly Therapy Screening, and that should have been completed for R55, and presented copies of screenings dated 9/2018 (no day documented) and 2/5/2018. On 2/15/2019 at 9:20 AM, V16 (Speech and Language Therapist) reviewed a Multidisciplinary Screening Form for R55 completed by V16. V16 stated these are screenings, I get my information for this screening from the nurse, face to face, I don't see the resident for a screening, that would be an evaluation. This form includes the question, More than one fall in the last 90 days? This is checked no. On the Multidisciplinary Screening Form for R55 completed in 9/18, the question regarding falls in the past 90 days is not answered, and no recommendations for referrals to Physical Therapy are made.

Based on observation, interview and record review the facility failed to protect residents from avoidable accidents resulting in injuries for 2 residents (R7, R24) reviewed for falls/injuries in the sample of 27. These failures resulted in R7 being taken to the local emergency room and received 12 sutures to her right hand on 12-09-11 as a result of a fall. Also R24 was taken to the local emergency room and was treated for [REDACTED].. Findings include: 1. R7 is a [AGE] year old woman residing in the facility since 5/27/2011 according to facility admission records of that date. The Physician order [REDACTED]. A review of R7's record on 2/5/2012 notes documentation on the facility's Occurrence Reports of 19 falls occurring from 6/5/2011 thru 12/22/2011. A review on 2/5/2012 of nurses notes for 6/5/2011 thru 1/25/2012 identifies notations of 21 incidents/accidents including; 6/5/2011 found in floor in bathroom, sent to local hospital emergency room for x-ray and complaint of knee pain and hitting head on floor, 6/9/2011 noted lying on left side on bedroom floor, stated she hit her head on the floor, 6/13/2011 found in bathroom on the floor, 6/13/2011 noted lying on floor on stomach, (wheelchair alarm applied, placed at nurses station), 6/15/2011 noted in floor on left side (moved to a room to be closer to nurses station), 6/17/2011 found on floor in front of recliner, 6/27/2011 found on floor in dining room beside the table, 7/4/2011 found lying on floor on left side(laceration to back of head), 8/7/2011 found sitting on buttock in middle of the room 8/22/2011 found sitting on floor , 9/17/2011 fell standing from table (laceration to head, sent to local hospital emergency room for treatment), 10/1/2011 found on floor between wheelchair and recliner, 10/11/2011 found on floor leaning on recliner chair, 10/13/2011 found lying on floor on right side 10/30/2011 found sitting on floor at end of bed, 12/8/2011 found on bottom in room, 12/9/2011 found lying on floor on stomach in front of bathroom door (sent to local hospital emergency room 12 sutures to right hand), 12/15/2011 found lying on floor face down, 12/22/2011 found lying on bathroom floor on left side, 1/21/2012 found on floor. The Fall Risk Assessment of 11/20/11 with a score of 17 indicates R7 is high risk for falls. The Functional Status on the Minimum Data Set/MDS of 11/20/2011 notes R7 is extensive physical assistance of one person for transfers, limited assist of one person using a wheelchair for travel about the facility, has unsteady balance during transition and walking, and is occasionally incontinent of urine. The Care Plan updated 11/23/2011 has a goal for R7 to avoid future falls, 5 falls occurred since this care plan was last revised. Interventions identified on the care plan of 11/23/2011 list having R7 rise slowly from sitting to standing or lying to upright position, assess environment to prevent recurrent falls, perform assessments and evaluation of R7 post fall, observe for 48-72 hours after falls, refer to physical therapy for evaluation, and remind R7 to ask for assistance. Also added to the care plan are notations on 6/9/2011 to add personal alarm, 6/13/2011 1 hour checks, 6/15/2011 moved to room 104 (closer to nurses station), 8/7/2011 remind to ask staff for help, 8/22/2011 reeducate R7 on standing and transferring without assistance. The Care Plan fails to monitor effectiveness of the interventions and modify the interventions accordingly. The Quarterly Functional Assessment Transfer/Bed Mobility notes R7 is alert, confused, cooperative, uncooperative, and follows cues, and requires moderate-maximal assist of 2 with transfers. During an interview on 2/8/2012 at 10:30 am with E1 (Executive Director) and E2 (Administrator) about plans to prevent falls/injuries to R7, E1 stated "we have tried everything and we don't know what else to do, she has a right to fall and I spoke with her this morning and asked her if she knew she would probably fall if she kept getting out of the chair without asking for help and she replied "I know but I am going to keep getting up." E1 continued talking and asked "what do you want me to do tie her down in the chair I won't do that." E2 stated "we have tried everything I know without restraining her, I don't know what else to do." E2 added she has spoken with R7's family and they were not able to offer any suggestions on how to prevent R7 from falling. Both E1 and E2 stated the family does not want her restrained. On 2/09/2012 at 9:45 am R7 was observed sitting slumped down in a wheelchair in the dining room waiting for activities to begin. R7 was not wearing a self releasing belt or personal body alarm and no alarm was noted attached to the wheelchair. At this time R7 was interviewed about falls, injuries, and about asking for assistance from staff when needed. R7 was noted to be pleasant and confused and was not able to explain risks and benefits of consenting to fall, or her right to do so. R7 denied falling, or getting out of the chair without asking for help. R7 denies falling and being injured. When asked about using the call light to alert staff she needs help R7 stated "that's what they say that is for but I don't know about that". R7 was able to state her birthday is next month , and on the 15 th, she was unable to tell her correct age, she first stated she was 90, then said 95. R7 is actually [AGE] years old. When R7 was asked about her knees/legs hurting she denied pain, when asked about the injury to her hand, R1 picked at a old scab and denied an injury. 2. R 24 is a [AGE] year old woman residing in the facility since 7/29/1986 according to facility admission records of that date. The Physician order [REDACTED]. A review of R24's record on 2/5/2012 notes documentation on the facility's Occurrence Reports of 10 falls occurring from 8/11/2011 thru 1/23/2012. A review on 2/5/2012 of nurses notes for this period identified occurrences/accidents including; 10/21/2011 found sitting on floor in room, 11/4/2011 found sitting on floor, 11/12/2011 found on the floor,(complaining of left hip pain), 12/8/2011 found lying on floor on left side (complaining of face hurting), 1/10/2012 observed sitting on floor in room, 1/23/2012 (sent to local hospital emergency room treated for [REDACTED]. The Fall Risk assessment dated [DATE] notes a score of 21 indicating high risk for falls. The Functional Status on the Minimum Data Set/MDS of 12/11/2011 notes R24 is limited physical assistance of one person for transfers, limited assist of one person using a wheelchair for travel about the facility, has impairment of the upper extremity, and is occasionally incontinent of urine. The Care Plan updated 12/15/2011 has an identified problem with falls, at risk due to [DIAGNOSES REDACTED]. The goal for this problem is falls will be avoided and safety will be maintained. R24 has sustained 2 additional falls since the care plan was updated. Interventions for the fall problem include check to ensure the mobility/transfer device works properly, check environment for risk factors, encourage wearing rubber sole and non skid slippers, ensure clothing does not cause tripping, ensure lighting is adequate, put to bed when sleeping in wheelchair, remind to use call light, assist when incontinent. The Quarterly Functional Assessment for Transfer/Bed Mobility of 12/26/2011 identified R24 to be alert, cooperative, uncooperative and severely hard of hearing. On 2/9/2012 at 11:00 am an interview with R24 was attempted. The interview noted R24 to be extremely hard of hearing and speech was difficult to impossible to understand. R24 was asked if she had been falling and R24 nodded yes. When asked if she had fallen out of bed R24 nodded yes. When asked if she could tell why she was falling or if she asked staff for help R24 did not respond. It is unclear and difficult to determine which questions R24 heard or understood and how accurate or appropriate her answers are.