Every finding on record at Terraces at the Clare

Based on interview and record review, the facility failed to ensure one resident (R1), in a sample of three residents reviewed for restraints was free of physical restraint unless medically necessary. R1 was physically restrained with a gait belt wrapped around R1 and a shower chair. This past noncompliance occurred from 6/30/26 to 7/3/26. Prior to the survey date of 8/9/25, the facility had taken the following action to correct the noncompliance: During weekly Resident at Risk meetings, the interdisciplinary Team reviewed the clinical record of residents with are unable to maintain upright posture while seated. Newly admitted residents or residents with a change in condition and who are unable maintain upright posture while seated will be reviewed by the Interdisciplinary Team during the daily clinical meeting to make sure they have any necessary specialty equipment. Per collaboration between the therapy department and nursing department, this includes all residents with diagnoses of hemiplegia, hemiparesis, Parkinson's Disease, spinal cord injury, cerebral palsy and multiple sclerosis. The interdisciplinary team reviewed the facility's Abuse Prevention Policy and Restraint-Free Environment Policy, and to ensure that current behavior interventions are effective and non-effective new interventions were developed to be in compliance with CMS regulations and clinical standards. An Ad Hoc Quality Assurance & Performance Improvement (QAPI) meeting was conducted on 07/01/2026, and this Plan of Correction was developed and implemented. Monthly review of completed audit results and trends will be completed by the Director of Nursing or Designee and reported to the facility's QAPI Committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. Audits will: Include three random residents selected with inability to maintain upright posture (diagnoses of hemiplegia, hemiparesis, Parkinson's Disease, spinal cord injury, cerebral palsy and multiple sclerosis) These audits will be conducted four times a week for four weeks, then weekly for six months, then monthly for five months. These audits will occur at random times of day, including weekends The Medical Director was notified by the Administrator on 07/01/2026. On 06/30/2026-07/03/2026, the Director of Nursing and Designee and completed interviews with all interview able residents with the above diagnoses. All residents interviewed and assessed showed no ill effects and reported feeling safe. The husband identified utilizing deficient practice was educated on 06/30/2026. Caregiver has not returned since the haircut and Husband stated that the caregiver only came for the haircut and will not be returning to The [NAME]. Residents who were not interviewable had skin and pain evaluations completed by the nursing team. No additional residents were identified as having been restrained or affected by similar practices. Administrator is taking responsibility for implementing and communicating interventions and ensuring they are being followed. Findings include:R1's face sheet documents R1 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Cognitive social or emotional deficit following other cerebrovascular disease, Muscle weakness (Generalized) and Other Lack of Coordination.R1's MDS (Minimum Data Set of 7.16.2026) documents Section C Cognitive Skills for Daily Decision Making as severely impaired. Section GG Functional Abilities documents R1 has upper and lower extremities impairment on one side.Facility incident report documents, in part: Nurse on Duty reported to Administrator at approximately 12:50 pm on 06/30/2026 that she had entered (R1's) room as Resident's private caregiver was finishing cutting Resident's hair and was removing a gait belt that had been wrapped around Resident and the shower chair. Nurse reports that she told the private caregiver and husband that the belt could not be used that way.Nurse indicated the belt was not tight and was positioned loosely over Resident's diaphragm. Nurse said Resident could not get up from the chair on her own with or without the belt. The two CNAs on duty were interviewed - one did not observe the belt and the other CNA noted it as it was being removed.Husband stated, On the day in question, my caregiver was simply giving my wife a haircut in her room. Because my wife has significant left-sided weakness following her ischemic stroke, she naturally leans to the left while seated. To help her remain upright and safe during the haircut, a belt was placed around both my wife and the chair solely to provide temporary support and prevent her from falling. There was no intent to restrain her movement, but rather to protect her safety while providing personal grooming. Administrator made Resident's husband aware of alternatives, including a specialty shower chair and use of the salon.8.8.2026 at 2:20 PM via telephone, V5 (CNA/Certified Nursing Assistant) said, on the day of the incident, V13 (R1's Husband) said they (V13 and V14 R1's Caregiver) were going to give R1 a haircut and shower. Later, I saw the call light on. I went into R1's room. R1 was in her wheelchair. All I saw was hair all over the floor. There was a shower chair with a small back in the corner of R1's room. I didn't know they (V13 and V14) got her out of bed and placed her on that shower chair. I would never have allowed them to put her on that chair, she needs support. I transferred R1 to the shower chair in the spa. I told V14 to pull the cord when she was done showering R1 and I would transfer R1 back to her wheelchair. I transferred her from the shower chair into her wheelchair. We dried R1 and got her dressed.8.8.2026 at 2:34 PM via telephone, V7 (CNA/Certified Nursing Assistant) said, I walked into R1's room because the call light was on. R1 was sitting in a shower chair. V13 and V14 were in the process of removing a gait belt from around R1's waist and chair. The gait belt should not have been around her waist. It's a form of abuse, it's a restraint.8.8.2026 at 2:48 PM via telephone, V6 (RN/Registered Nurse) said, I went to visit R1. I noticed that R1 was sitting on a shower chair. I noticed that they (V13 and V14) had a gait belt around her, kind of like above her belly button and below her diaphragm. It wasn't tight, it was loose, it was around her and the chair. It made me feel uncomfortable. We don't do that here; the gait belt was a restraint. 8.9.2026 at 12:1 PM, V2 (DON/Director of Nursing) said, the nurse walked into R1's room and noticed R1 was sitting in a chair with a gait belt loosely to positioned around R1. It was positioned around R1'ss wait and chair to prevent R1 from falling sideways. R1 does have poor trunk control. V13 never asked the staff for assistance. From what I know they (V13 and V14) were giving R1 a haircut. The nurse intervened; the gait belt was removed.Restraints/Isolation policy (reviewed/revised 6.17.2026) documents, in part: Policy: It is the policy of (Facility) to provide a restraint-free facility and an environment free of fear of isolation in compliance with the Code of Federal Regulations Title 42, Section 483.13 (a). (Resident Rights). Purpose: To ensure a home-like environment for the residents without fear of the use of physical or chemical restraints or the fear of retaliation.

Based on interview and record review, it was determined that the facility failed to ensure residents were free of physical restraints. Specifically, the facility failed to ensure one (R1) of three residents reviewed for restraints was free of physical restraints unless medically necessary in the sample of three. R1 was physically restrained with a blanket across the chest that was then tied to the frame of R1's bed.Findings include: Facility's final incident report of 5.24.2026, documents, in part: At approximately 5:45 am on 5.19.2026, a first shift CNA observed that the top left corner of the resident's blanket had been tied to the bed frame near the bed enabler closet to the hallway. The CNA informed the nurse. At approximately 6:15 pm, on 5.19.2026, the third shift CNA returned the DON's calls and texts and spoke with both the DON and Administrator. The CNA stated that she had secured the resident's blanket to the bed in an effort to prevent the resident from getting up independently and potentially falling. The third shift CNA acknowledged prior education and training on abuse prevention, including understanding that the use of physical restraints is considered abuse. The CNA also reported that she informed the nurse on duty of her actions.Based on the known facts, the following conclusions have been made about the original allegation: (V4-Former CNA-Certified Nursing Assistant) admitted that she deliberately tried to physically restrain the resident. The CNA is no longer an employee. (V5-LPN Licensed Practical Nurse) denied knowledge of the event and was assessed as credible.R1's medical record (Face Sheet) documents R1 is a [AGE] year-old female with diagnoses including, but not limited to: Unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified diastolic (congestive) heart failure; paroxysmal atrial fibrillation; essential (primary) hypertension; hypothyroidism, unspecified; Meniere's disease, unspecified ear; major depressive disorder, recurrent, severe with psychotic symptoms; and anxiety disorder, unspecified. R1's MDS (Minimum Data Set-4.6.2026) documents a BIMS (Brief Interview for Mental Status) score of 10 indicating R1 is moderately cognitively impaired. R1's medical record (Care Plans, Assessments, Physicians Order Sheet) does not document an assessment, physician's order or care plan for a restraint.5.31.2026 at 9:30 AM, R1 said was unable to tell the surveyor what happened. 5.30.2026 at 1:03 PM, V1 (Administrator) said, V4 said she told V5 that she tied the blanket to R1's bed; V5 denied the allegation. We don't think he was aware of the situation. The blanket was tied to R1's bed frame, the enabler was closed. It wasn't visible until V6 (CNA-Certified Nursing Assistant) came into R1's room that morning to get R1 up.5.30.2026 at 2:19 PM via telephone, V6 (CNA) said, um, actually I was coming on (to work) at 6:00 AM. I worked my way down to R1's room. She's the first resident I get up. When I went to remove her cover, it was stuck. The blanket was tied on the bed frame that mattress sits on. It was tied on the side that she normally gets out of the bed. So, I was trying to untie it, but it was tied so tight I couldn't get it untied. I went to get the nurse. V5 (LPN) came into the room and was able to untie it. It seemed a little tough for him to remove. I really don't know where the other end was or if it was tied. I couldn't move the blanket. You don't do that to nobody, that's not acceptable. That's like trying to tie a dog down. I didn't like that, that's why I reported it. I think it's abuse. That's a restraint, were not supposed to restrain residents.5.30.2026 at 3:08 PM via telephone, V5 (LPN Licensed Practical Nurse) said, I was informed at the beginning of shift by V4 (Former CNA Certified Nursing Assistant) that R1 was a little restless. I told her that's her baseline and sometimes she goes restless, we just need to make sure she's safe by ensuring the bed is in low position, do rounds every one to two hours and make sure resident is on her bed. R1 is at high risk for falls. Usually, I do rounds prior to going on break and I usually do rounds around 3:00 AM, I normally go on break anywhere from 12:30 AM -1:00 AM. Then after that I think I do rounds at 4:30 AM, that would be my last set. In the morning, um one of the CNAs (V6) notified me, she asked me to untie the knot. I went to R1's room. I thought at first it (blanket) was stuck. I proceeded to untie it, it was simple over and under knot, I'm not sure what you call it, tied to the top right corner of the bed frame. I can't say for sure if it was tied to the other side, I can't say that I checked the other side. The blanket was tied to the bed at the level of R1's chest, it covered R1's chest. It (blanket) should not be tied to the bed because that would restrict her movement. We don't do restraints, anything that is tied on the bed is a restraint, anything that impedes her movement from doing what she wants is a restraint. The CNA could have let me know so that I could spend more time with the resident, that's the only way we make sure she stays safe.5.30. 2026 at 3:57, V2 (DON-Director of Nursing) said, I got a call from V6 (CNA) while I was on my way in to work (incoming call at 7:18 am per cell phone call log). V6 said she needed to speak with me but preferred not to speak with me on the phone. We agreed to meet/speak on the 16th floor. At approximately 8:45 AM, I spoke with V6. She said when she came in for her shift, a blanket was tied to one side of R1's bed, she couldn't get it untied. I immediately let V1 know. When I spoke with V4, she said she tied one side of the blanket to the bed, the other side she tucked in to prevent R1 from falling. I immediately told her, You can't do that, it's a restraint. V4 should have notified the nurse that V4 was having trouble redirecting the resident. V5 could have notified the On Call Supervisor to talk about other possible interventions if the behavior continued.Numerous attempts were made to contact V4 via phone and text (5.30.2026 at 2:34 PM,5.31.2026 at 10:18 AM, 5.31.2026 at 10:19 AM. V4 did not respond to surveyor's calls/text.V5's Employee Behavioral Change Notice (5.23.2026) documents, in part: Behavioral Change Subject: Final Warning. Reason For Discipline: Safety, Work Performance, Policy Violation. V5 was involved in a review related to an abuse investigation on 5.19.26. It was identified that a CNA engaged in an inappropriate care practice (tying a blanket to one side of the bed) and the nurse (V5) was unaware of the action. Contributing factors included low visibility (dark room) and lack of direct supervision at the time of care. This reinforces the nurse's responsibility for supervision and accountability of CNA care delivery.Expectation (proof of awareness of expectations): It is the policy of (facility) to ensure all residents are free from abuse. A key responsibility of leadership and licensed staff is to provide consistent supervision and oversight of resident care to ensure safe, compliant practices are followed at all times.Moving forward, it is expected that you will:-Maintain active supervision and oversight of CNAs during resident care-Remain visibly engaged and aware of care being provided on the floor-Ensure resident care activities are performed safely, appropriately, and in accordance with policy-Intervene immediately when unsafe, noncompliant, or inappropriate practices are observed-Promptly report concerns, incidents, or policy violations to leadership-Promote a culture of accountability, resident safety, and professional supervision through consistent monitoring and leadership presenceStaffIllinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (undated) documents, in part: Your rights to safety: You have a right to be free from physical or chemical restraints.Facility's Abuse Prevention Policy (Reviewed December 22, 2025) documents, in part: The (Facility) affirms the right of its residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This Community therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for preventing foodborne illnesses to ensure foods in the walk-in coolers were properly labeled and dated when they were opened and prepared and discarded on the best by date. The facility also failed to ensure kitchen staff was wearing facial hair/beard restraint while in the kitchen and failed to ensure potentially hazardous refrigerated foods were stored at the appropriate temperatures. These failures have the potential to affect 47 residents in the facility who are receiving oral diet. Findings Include: On [DATE] at 10:47 AM, during the initial tour in the kitchen (17th floor) with V26 (Chef), surveyor observed the main walk-in cooler external thermometer read 49 degrees Fahrenheit (F) and inside thermometer read 47 degrees F. V26 stated a contracted worker will be coming in to fix the cooler because the thermometers are faulty. Inside the main walk-in cooler was found a container of slices of liver with no label. V26 stated it will be served that day. Inside the second walk-in cooler, a container of opened cow milk ricotta with best by date of [DATE] written on the label. On [DATE] at 11:27 AM, V3 (Director of Dining) stated that perishable foods that were prepared and stored inside the coolers need to be used or discarded within three days. Everything that is open and cannot be identified needs to be dated and labeled. The label should include the date when it was opened or prepared and last day of consumption is the day it needs to be discarded or use by. V3 stated that the main reason for this is that spoiled foods can get people sick and could cause harm or illness to the residents. V3 further stated that expired foods need to be discarded on the best by or used by date. On [DATE] at 11:56 AM, surveyor entered the kitchen and observed V12 (Chef) with facial hair (beard) and was not wearing a beard restraint. As soon as V12 saw this surveyor, V12 immediately applied the beard restraint. V12 stated he is the cook for the day. On [DATE] at approximately 11:58 AM, the external thermometer of the main walk-in cooler in the kitchen was observed and read 59 degrees F and the inside thermometer read 59 degrees F. Inside this cooler was a food cart with trays of berry cups, yogurt cups, peeled hard boiled eggs in individual plastic cups, and granola cups with no label of when they were prepared and no use by date. V12 stated they prepared them this morning and will be served to the residents for breakfast tomorrow. V12 stated kitchen staff does not usually label the prepared foods for breakfast. Surveyor also found a container of prepared cream cheese salmon inside a reach in refrigerator with no label when it was prepared or use by. V12 stated it was used this morning and meant to be thrown out. On [DATE] at 12:11 PM, V3 stated that anyone entering the kitchen needs to always wear beard net and hairnet if they have hair and/or a beard. V3 stated that the hair could fall in the food and could potentially cause food borne illness. V3 also stated that there is a work order and a contracted worker scheduled to start on [DATE] to fix the main walk-in cooler because the temperatures are not going down. V3 provided copies of the work order. On [DATE] at 10:22 AM, surveyor observed in the kitchen, the main walk-in cooler's external thermometer read 53 degrees Fahrenheit (F) and inside thermometer read 56 degrees F. While surveyor was looking for a kitchen staff to get food temperatures stored inside the main walk-in cooler, V27 (Dietary Aide) was observed by the dishwashing machine inside the kitchen and noted with facial hair without wearing a hair restraint. On [DATE] at approximately 10:25 AM, surveyor and V12 entered the main walk-in cooler. V12 stated the salad dressings were placed inside last night. Surveyor asked V12 to check the following food items stored in the main walk-in cooler: ranch dressing poured in a container read 56.9 degrees F, balsamic dressing poured in a container read 56.3 degrees F, and a large container of cooked pasta read 56.8 degrees F with the label that showed it was prepared on [DATE] and used by [DATE]. V12 stated that the pasta will be served to the residents for lunch tomorrow. On [DATE] at 10:50 AM, V10 (Registered Dietician) stated that the walk-in coolers must have the right temperatures for food and safety issues to prevent food borne illnesses. V10 stated temperatures should be below 40 degrees F and perishable food items such as protein, dairy, and fish temperatures should be below danger zone (below 40 degrees F). V10 stated that perishable food should not be left in the danger zone for more than 4 hours. On [DATE] at approximately 11:00 AM, V3 entered the main walk-in cooler and asked his kitchen staff to discard all perishable foods and stated all perishable items will be stored inside the second walk-in cooler while the main cooler is getting fixed today and tomorrow. On [DATE] at approximately 2:00 PM, an outside appliance and mechanical service technician worked on the 17th floor walk-in main cooler to stabilize the temperatures. Temperatures read 44 degrees F and trending down. Outside contractor will return on [DATE] until [DATE] to complete the work on the walk-in main cooler. The facility's temperatures logs revealed walk-in main cooler's temperatures as follows: - [DATE] - 41 degrees F (external thermometer)/ 42F (internal thermometer) - [DATE] - 42F/44F - [DATE] - 45F/44F - [DATE] - 46F/45F - [DATE] - 46F/47F - [DATE] - 48F/48F - [DATE] - 52F/54F - [DATE] - 55F/53F - [DATE] - 56F/55F The facility's [DATE] residents' roster documents 48 residents in the facility with 1 resident who is NPO (Nothing By Mouth). The facility's Preventing foodborne illness/dating and labeling policy dated [DATE] documents in part: It is the policy of [facility name] to protect residents from foodborne illnesses by ensuring food is consumed within a safe timeframe. Label and date food items that require storage and refrigeration. Label and date prepared food. Prepared food must be labeled with the date the food was prepared, and the use by date. The use by date should bot exceed 3 days from the preparation date. The facility's Grooming policy dated 2018 documents in part: It is the policy of [facility name] to prevent hair or other foreign objects from contaminating food and food-contact surfaces. The facility's Preventing Foodborne Illness - Temperature Danger Zone dated 2019 documents in part: It is the policy of [facility name] that food will be stored at a proper temperature, to prevent the risk of foodborne illness. The Danger Zone is the temperature between 41 degrees F and 135 degrees F. In this temperature range, most pathogens multiply rapidly. Cold foods need to be held at or below 41 degrees F. If perishable food (both hot or cold) is left in the Danger Zone for more than 2 hours, must be discarded.

Based on observations, interviews, and record reviews, the facility failed to assess, ientify, and involve the local public health department to determine if their water management plan was adequate to prevent the growth of Legionella or other opportunistic waterborne pathogens. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 5/1/25 at 10:30 AM, V8 (Director of Plant Operations) stated that the expansion tank does not have enough air pressure and this could possibly cause growth of Legionella, and that the company will be coming next week Friday 5/9/25 to fix the tank, and the mixing valve will be fixed next week Monday or Tuesday 5/5/25 or 5/6/25. On 5/1/25 at 11:50 AM, V14 (Assistant Director of Nursing/Infection Preventionist) stated that when she became aware of the first legionella results, she notified the physician, family members, and staff to monitor the residents for respiratory symptoms. V14 was not sure of the date. She stated she did not report this to the local health authority because there was no case of a resident with Legionella in the facility. V14 stated that residents could potentially get sick after constant exposure to Legionella since 2024. On 5/1/25 at 12:20 PM, V2 (Director of Nursing) stated that she is aware of the rooms that were identified positive with Legionella, the staff monitor all the residents for respiratory symptoms per the facility protocol but V2 was unable to provide any documentation to show that any risk assessment were done until when the surveyor requested for a list. V2 stated that having residents constantly exposed to water with Legionella could expose the resident to contracting respiratory or gastrointestinal disease. On 5/1/25 at 2:44 PM, V1 (Administrator) stated that the outside water management company recommended water flushing in the facility and did not recommend further action. V1 stated the facility follows any recommendations that the outside water management company provides to the facility. There was no testing in January and February of 2024 because the facility switched the testing company in January 2024. V1 stated the previous company stopped coming because of the long distant to get to the facility. V1 stated that she did not report the positive findings to local health authority because no resident tested positive with Legionella Disease. The water in the building was first tested positive for Legionella in 2023. V1 stated that filters were provided for the identified five rooms and the residents are not drinking from the sink. The residents are using the water for mouth wash, and for shower but there is no documentation to show that bottled water was provided for the residents. On 05/01/2025 at 3:03PM V21 (Certified Nursing Assistant/CNA) stated residents receive their drinking water from the faucet located inside of the 12th floor dining room from the designated faucet. V21 states there are two faucets located inside of the dining room, one is for handwashing and the other is for resident's drinking water. Surveyor observes a water cooler dispenser filled with water and ice located in the hall next to the dining room. V21 states this water cooler is filled periodically throughout the day by the dietary staff for residents to drink. V21 states water used to fill the water cooler is also obtained from the designated faucet located in the dining room. On 05/01/2025 at 3:07PM V22 (Licensed Practical Nurse/LPN) stated residents receive their drinking water from the faucet located inside of the 11th floor dining room from the designated faucet. V22 stated when she is performing her medication administration pass, she obtains resident's drinking water from the 11th floor dining room. V22 states there is also a water cooler located by the dining room that is filled with water from the dining room faucet. Surveyor observes a water cooler dispenser filled with water and ice located in the hall next to the 11th floor dining room. On 05/01/2025 at 3:11PM, surveyor located on the 10th floor inside the medication storage room with V23 (Registered Nurse/RN). Surveyor observed a water cooler dispenser filled with water and ice located in the hall next to the 10th floor dining room. V23 states when he is performing his medication administration pass, he obtains resident's drinking water from the faucet located inside of the 10th floor medication storage room. V23 points to the only faucet inside of the medication room and states that's the one he uses to fill a water pitcher for the residents. V23 states there is also a water cooler located by the dining room that is filled with water for residents to drink. V23 states he believes the dietary staff fills this water cooler from the faucet located inside of the 10th floor dining room. On 5/2/25 at 11:37 AM, attempted to conduct a phone interview with V29 (Medical Director) but no response. At 2:02 she stated that she has been serving the facility for fifteen years, she was informed of positive Legionella test results since 2023 by V1, and V29 does not think the results are harmful even though she is not an expert in water management, but she relies on the water management team. She also stated that the facility is running/flushing the water in the affected rooms and checking the water temperature regularly as recommended, and there are some residents at the facility that are at risk for contracting Legionella' disease. Legionella is a naturally occurring bacterium commonly found in man-made water systems. It can enter through natural water sources like lakes and streams. It thrives in warm, stagnant areas of water systems, multiplying between 68 F and 122 F (20 C and 50 C). The CDC considers a high level of Legionella to be 1 CFU/mL or higher, as this may indicate conditions that could support bacterial growth. However, address extensive colonization to reduce risk, especially in areas that treat or house high-risk populations (such as hospitals or nursing homes) (Water quality frequently asked questions (GSA). The facility Infection Control Policies and Practices dated 2/17/25. The facility Surveillance for Infections dated 2/25/25. Facility untitled and undated document list of residents who are at high risk for Legionella' disease. The facility policy titled: Legionella dated 5/16/24 documents read in part; Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Water Management Environmental Culture Test-Legionella positive result dated 10/9/24 documents in part: L. anisa (Blue-white Legionella sp.) Water Management Environmental Culture Test-Legionella positive result dated 4/02/25 documents in part: L. anisa (Blue-white Legionella sp.) R28 = 0.5 CFU/ML (Colony-Forming Units Per Milliliter), and R204 = 2.0 CFU/ML Water Management Environmental Culture Test-Legionella positive result dated 4/25/25 documents in part: L. anisa (Blue-white Legionella sp.) R22 = 10.0 CFU/ML (Colony-Forming Units Per Milliliter), R30=3.5 CFU/ML, and R209 = 30 CFU/ML

Based on observations, interviews, and record reviews, the facility failed to conduct a thorough risk assessment to identify why opportunistic waterborne Legionella could grow and spread in the facility water. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 4/30/25 at 10:39 AM, V8 (Director of Plant Operations) stated that he has been in this facility for almost two years and the facility checks for legionella quarterly. The testing was done on 3/26/25 and 4/18/25 with positive result in five rooms. He also stated that the facility performs daily flushing twice a day on the affected rooms, obtains water temperature log in one room weekly on each floor, and provided water filters for the sink. At 2:35 PM V8 stated that the facility has been positive with Legionella since February 2023 before he joined the facility. V8 said the facility has been cleaning the mixing valve, but he has no documentation. On 5/1/25 at 10:30 AM, V8 stated he tested on ly three rooms in April instead of five rooms as recommended by the consultant. The facility contacted a plumbing company on 4/29/25 .The plumber came on 4/29/25 for onsite visit with recommendation to clean the units, replace the pressure tank, raise the temperature in the tank and rebuild mixing valve. Surveyor asked what took the facility long to check the pressure tank. V8 stated that he is following the water management plan. The surveyor and V8 went to the storage tank room on the Fifty-third floor where the hot water storage tank read 150-degree Fahrenheit (F) and the mixing valve read 134-degree Fahrenheit. V8 also stated that the expansion tank has not had enough air pressure and this could possibly cause growth of Legionella. The company will be coming next week Friday 5/9/25 to fix the tank, and the mixing valve will be fixed next week Monday or Tuesday 5/5/25 or 5/6/25. Hot water temperature of the identified five rooms with filter are as follows: At 11:16 AM, R209 = 109.2F At 11:18 AM, R30 = 103.6F (V8 stated this is low, there is a problem with the mixing valve, this could be a potential for Legionella). At 11:23 AM, R28 = 124.7F At 11:25 AM, R22 = 112.1F At 11:31 AM, R204 = 119.8F On 4/30/25 at 3:06 PM, V1 (Administrator) stated that the facility water has been positive with Legionella since 2023, but in October 2024 some rooms came negative through flushing as recommended by water management company. She stated that the consultant, and the physician did not say anything about the levels or if the levels are harmful. No resident has been tested positive for legionella. The nurses monitor residents for symptoms. V1 was not sure if it was documented and not sure why only three rooms were retested on [DATE] out of the five rooms that were positive on 4/2/25 with significant increase in legionella level. V1 stated she believes the facility should be following the recommendation to resample positive locations. On 5/1/25 at 2:44 PM, V1 (Administrator) stated that the outside water management company recommended water flushing in the facility and did not recommend further action. V1 stated the facility follows any recommendations that the outside water management company provides to the facility. There was no testing in January and February of 2024 because the facility switched the testing company in January 2024. V1 stated the previous company stopped coming because of the long distant to get to the facility. V1 stated that she did not report the positive findings to local health authority because no resident tested positive with Legionella Disease. The water in the building was first tested positive for Legionella in 2023. V1 stated that filters were provided for the identified five rooms and the residents are not drinking from the sink. The residents are using the water for mouth wash, and for shower but there is no documentation to show that bottled water was provided for the residents. On 5/2/25 at 2:50 PM, V28(Water Hygeine Specialist) stated that he has been working on the facility water management for twelve months, and the results as at 4/25/25 were low level positivity per Center for Disease Control (CDC). V28 said that the goal is to eradicate the positive Legionella results through non-invasive and invasive interventions, but now the facility has called a plumber to inspect the mechanical room on the fifty-third floor. Surveyor asked why were they doing the invasive intervention after two years?V28 stated, I do not have an answer to that. The facility did not have documentation of meeting regularly to discuss the results, perform risk assessment to identify why Legionella continue to grow and spread in the facility water, and no documentation that residents' family were notified. Legionella is a naturally occurring bacterium commonly found in man-made water systems. It can enter through natural water sources like lakes and streams. It thrives in warm, stagnant areas of water systems, multiplying between 68 F and 122 F (20 C and 50 C). The CDC considers a high level of Legionella to be 1 CFU/mL or higher, as this may indicate conditions that could support bacterial growth. However, address extensive colonization to reduce risk, especially in areas that treat or house high-risk populations (such as hospitals or nursing homes) (Water quality frequently asked questions | GSA) Facility Water Management Plan dated 3/20/25. Facility Assessment Tool dated 7/24/24. Facility Flushing Log for Positives Location from 4/2/24 to 5/2/25. Facility Water Temperature Log for The Mixing Valves Locations from 4/1/24 to 4/28/25. The facility policy titled: Legionella dated 5/16/24 documents read in part; Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Water Management Environmental Culture Test-Legionella positive result dated from 2/2023 to 12/2023 documents in part: Legionella species (not pneumophila). Water Management Environmental Culture Test-Legionella positive result dated 10/9/24 documents in part: L. anisa (Blue-white Legionella sp.) Water Management Environmental Culture Test-Legionella positive result dated 4/02/25 documents in part: L. anisa (Blue-white Legionella sp.) R28 = 0.5 CFU/ML (Colony-Forming Units Per Milliliter), and R204 = 2.0 CFU/ML Water Management Environmental Culture Test-Legionella positive result dated 4/25/25 documents in part: L. anisa (Blue-white Legionella sp.) R22 = 10.0 CFU/ML (Colony-Forming Units Per Milliliter), R30=3.5 CFU/ML, and R209 = 30 CFU/ML

Based on observation, interview, and record review, the facility failed to closely monitor a resident receiving continuous oxygen and failed to follow physician's order to ensure a resident was receiving the correct oxygen flow rate for one (R31) out of two residents reviewed for oxygen use in the final sample of 12. Findings Include: On 4/29/25 at 12:03 PM, R31 was sitting on her wheelchair alert and able to verbalize needs. R31 was observed using oxygen (O2) via nasal cannula (NC) and her oxygen concentrator flow rate was set to 2 liters per minute (LPM). R31's oxygen concentrator was located behind her wheelchair and not within R31's reach. R31 stated that somebody comes in in the morning and checks her oxygen. R31 stated she does not know how to change her oxygen setting. R31 stated, I don't even know why I'm on it. The other nurse told me I needed it. Some nurses tell me I don't need it. R31 stated she never touches the dial on the oxygen concentrator because the nurses do it for her and that she can't reach it. On 4/29/25 at 12:09 PM, V9 (Registered Nurse) was asked to verify R31's oxygen order in the electronic health record and the reason why R31 is on oxygen. V9 stated R31 has an order for continuous O2 via NC at 1LPM for acute hypoxia. V9 stated the nurses should monitor the residents' oxygen. On 4/29/25 at 12:12 PM, surveyor and V9 entered R31's room. V9 confirmed the oxygen flow rate was set to 2LPM. V9 changed it to 1LPM. On 4/30/25 at 2:14 PM, V2 (Director of Nursing) stated the oxygen flow rate is followed based on the doctor's order. V2 stated R31 has no order to titrate her oxygen. V2 stated R31 should be on oxygen at 1 LPM via nasal canula. On 4/30/25 at 4:13 PM, surveyor received an email from V2 that reads in part: As mentioned earlier, I conducted my rounds with [R31] and confirmed that she was on 1L/min at that time. I just checked in with her [R31] directly, she shared that she had increased the oxygen flow herself because she was feeling short of breath. When I asked why she [R31] hadn't notified staff, she [R31] explained that the sensation passed and she had planned to return the setting down on her own. I reminded her [R31] of the importance of informing the nursing staff so appropriate support can be provided. She [R31] acknowledged this and assured me she won't make adjustments independently in the future. MD [Medical Doctor] notified, care plan revised and updated. On 5/1/25 at 9:52 AM, V20 (MDS Manager) stated R31's usual performance in locomotion in wheelchair is dependent, meaning she's not able to help at all, and someone needs to push her in the wheelchair. R31's usual performance with transfer from bed to chair is maximal assist meaning somebody needs to help her and R31 can't do it by herself. V20 stated R31's usual performance for personal hygiene is moderate assist meaning she needs assistance and can't do it by herself. V20 stated R31's cognition status is cognitively intact. V20 stated it is not safe for R31 to be reaching her oxygen concentrator and changing the setting herself. V20 stated R31 needs the staff's assistance. R31's clinical records revealed an admitted [DATE] with included diagnoses but not limited to pneumonitis, congestive heart failure, and acute pulmonary edema. R31's Minimum Data Set, dated dated dated [DATE] shows R31 is cognitively intact with BIMS (Brief Interview for Mental Status) of 14, and is dependent on staff's assistance for all activities of daily living. R31's order summary report printed on 4/29/25 reads in part: Continuous O2 1 liter via nasal cannula due to acute hypoxia (ordered 3/28/25). The facility's Oxygen Administration policy dated 2001 documents in part: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing).

Based on observation, interview and record review, the facility failed to maintain accurate record of usage and accountability for 1 resident (R35) who receives controlled substances from 1 of 2 inspected medication carts. Findings Include: On 4/29/25 at 12:29 PM, a narcotic reconciliation count conducted with V2 (Director of Nursing/DON) for the tenth floor's medication cart. Observed R35's Diazepam 2 milligrams (mg) medication administration blister pack had 39 half tablets in the card. The count on R35's CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM documents 60 half tablets were received on 1/30/25 last entry date showed 4/29/25 at 2:30 AM with 40 tablets remaining. V2 stated the count was incorrect. On 4/30/25 at 2:14 PM, V2 (DON) stated that V9 (Registered Nurse) administered one dose of the Diazepam to R35. V2 stated when administered, the nurse will have to sign off that it was given on the controlled substance accountability form. V2 stated all controlled substances should be accounted for. V2 stated two nurses counting the narcotics at the beginning and end of shift. The nurses have to count if the number of the medications are correct in the bingo card and on the count sheets. V2 stated if the count is wrong the nurses will have to notify V2. R35's clinical records show an admitted [DATE] with included diagnoses but not limited to anxiety disorder. R35's order summary report printed on 4/29/25 revealed an order for Diazepam oral tablet 1 mg by mouth four times a day for anxiety (ordered 4/21/25). The facility's Pharmacy Policy: Controlled Substances dated 4/13/25 documents in part: It is the policy of [facility] to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observation, interviews and records review the facility failed to complete a thorough investigation of the alleged injuries of unknown source to rule out physical abuse. This failure affected 1 (R1) out of 3 residents reviewed for abuse. Findings include: R1 subject of the incident is [AGE] years old currently a resident of facility. R1 was initially admitted on [DATE] with medical diagnosis that includes severe dementia, atherosclerotic heart disease of native coronary artery. R1's BIMS (Brief Interview of Mental Status) score is 1 out of 15, indicating R1's cognition is severely impaired. On 03/12/2025 at 11:17 AM, R1 was seen sitting inside her room. R1 was alert, unable to respond to questions within topic. R1 responded to all questions by saying okay. V3 (Registered Nurse) went inside R1's room to assess both arms and hands of R1. R1's left wrist and right hand noted to have small bruises and left eye that shows bruising and redness. V3 stated that bruising and redness on R1's left eye was there for a long time. At 11:41 AM, V4 (Certified Nursing Assistant) stated that R1 used to have bruises on her arms but now they are healed. V4 was not able to say how R1 got the bruise. On 03/12/2025 at 01:05 PM, V6 (Registered Nurse) stated that during endorsement with night nurse and morning CNA. She (V6) was informed about the bruising of R1's bilateral arms which she describes as discoloration. V6 stated that the night nurse already identified the bruising but did not say anything. V6 stated that it was the first time she saw R1's bruising and did not know how R1 got bruises. V6 stated that she was the staff that informed V2 (Director of Nursing). Request to V1 (Administrator) for the full investigation details of incident. V1 stated that V2 (Director of Nursing) did the investigation, and since V2 is not in facility, staff are making contact to V2 to produce full documentation of investigation. V1 suggested that V2 will email documents related to the investigation late when V2 arrives in the facility. V1 was made aware that investigation for injuries of unknown source needs to be readily accessible and is important since this investigation needs to rule out abuse. V1 stated that she will contact V2 and procure the investigation. After a while, V1 came with written statements from the following staff: - V4 (Certified Nursing Assistant) documentation on Certified Nursing Assistant Post Accident Report witness statement that reads: I went into the room this morning to give AM care and notice patient arms and reported it to the nurse. - V8 (Certified Nursing Assistant) documented: I worked with R1 on Monday February 3, 2025. I didn't notice any bruising. I worked with her from 6:00 AM to 2:00 PM. - V9 (Certified Nursing Assistant) documented: I was assigned to work 12th floor on 02/04/2025 but was not assigned to work with room where R1 resides. I am unsure at anything that may have occurred with this resident as I did not personally work with her. V1 was asked where the written statements of V6 (Registered Nurse) the nurse who reported to V2 (Director of Nursing) about the bruises of R1. V1 stated that she will ask V2 because she did the investigation. V1 was asked why there was nothing that mention about location of incident? V1 did not answer. V1 was asked is there are any written statements on facility staff that regularly took care of R1 during the time bruises where seen? V1 did not answer. V7 (Assistant Director of Nursing) submitted incident audit report that shows all documentation of V2 (Director of Nursing) was still in progress with date includes 02/07/2025 and 02/09/2025.V7 identified V6 (Registered Nurse) as the nurse that notified V2. V6's name also appears in progress dated 02/04/2025 but no actual notes were seen under V6's name. V7 was asked on the notes of V6 since she does not have any documentation at all. V7 stated she will inform V2 about my question. On 03/12/2025 at 01:39 PM, V7 came back with V2 on speaker phone. V7 stated that V2 needs to speak to writer because per V2 the notes under her name were done by V6 the nurse who informed V2. V2 stated that since V6 was new, she (V2) logged in and made V6 put her notes under her name. V2 said, V6 did the notes, I was at her side. V2 was asked if all written statement received by writer are complete. V2 stated that all written statements were provided. To ensure that V2 understood the question. Names of V4 (CNA), V8 (CNA) and V9 (CNA) were stated for confirmation. V2 confirmed that V4, V8, and V9 are only staff that have written statement. V2 stated that V4 was assigned to R1, V8 was there but not assigned to R1. And V9 was not present on that day (02/04/2025). V2 was asked why prior shift nurse's statement was not included and who informed V6 about the bruising of R1. V2 replied that she has written statement of the night nurse (V10 / Registered Nurse) in her office. Reminded V2 that she stated a while ago that she only had written statements for V4, V8 and V9. V2 replied that she has a written statement from the night nurse in her office. V2 was made aware that written statements are part of abuse investigation, and it must be readily available or accessible when asked. V2 replied I know it is part of the investigation and should be gathered together. V2 was also informed that by letting V6 put her notes under her (V2) name makes documentation inaccurate. Because although the notes were done by V6 it shows her (V2)'s name. V2 replied, To me it is accurate. I signed into the computer because she (V6) is new, and she (V6) made the documentation under my name. V2 was asked why she did not let V6 sign in with her name? V2 did not replied. V2 was informed that document shows her name, although by her statement that it was done by V6, and it makes documentation confusing which facility staff did the writing. V2 replied, I will own the notes. It is my notes. It is my notes not V6. V2 was asked if these are her notes where is V6 notes? V2 replied, I will own that note. On 03/12/2025 at 01:55 PM, V1 stated that as the administrator she is also the abuse coordinator. V1 stated that it was V2 (Director of Nursing) who did the investigation. And she (V1) reviewed the investigation of R1 that was done by V2. V1 stated that the correct procedure is to interview all staff or let them provide their statement. Their account of the events should be in the incident report. V1 stated that she is struggling to answer because she wants to know if V10 (Registered Nurse) night nurse reported to V6 the bruises of R1. V1 stated that all the staff involved, and in the surrounding time-period should be interviewed since R1 cannot verbalized. V1 said, I do not want to make excuses, I do believe V2 tried to interview all staff that can provide information. But I understand, I think I need to train other staff on the proper investigation of abuse. V1 stated that she should have reviewed all investigations pertaining to the incident, that they (facility staff) were unprepared and stated We will do training to ensure investigation is properly done. Per facility skin assessment of R1 dated 02/04/2025, R1 sustained multiple bruises on both upper extremities. Facility Final Report of R1's incident dated 02/04/2025 documents the following: Staff denies witnessing any incident during care but did mention that resident gets very stiff and resistant during transfer which might cause R1 to accidentally bump her arms on to something. Conclusion of report reads: After thorough interview of residents and staff, abuse was ruled out. R1's bruise might happen due to the combination of resident being on Plavix and the possibility of resident accidentally hitting her arm on something. On final investigation report it documents that staff did mention that resident gets very stiff and resistant during transfer which might cause R1 to accidentally bump her arms on to something. There was no documentation to support who the staff that mention stated above included in the investigation. No time, date and location of R1 seen to be stiff and resistant to care during transfer. Who were the staff that transfer R1. Who were the staff or employees that provided regular care to R1. None of these are included in the investigation. Incident Audit Report documents that V2 (Director of Nursing), V1 (Administrator) and V6 (Registered Nurse) created documentation. And the only documentation that can be seen is V2's notes dated 02/07/2025 and 02/09/2025 that reads: V2 was made aware about R1's bruises on both upper extremities. R1 unable to verbalize what happened. R1 denies pain, and vital signs results. And to whom notification was provided. Incident Audit Report was not accessible to writer via electronic health records access. It was provided when writer requested full investigation. Review of R1's notes from 02/03/2025 to 02/10/2025 does not provide any information related to incident of R1's bruising that was identified on 02/04/2025. V2 clinical notes created on 02/07/2025 marked as late entry done three (3) days after the incident that occurred on 02/04/2025. Full documentation does not provide any information as to bruising of R1's upper extremities, does not mention any bruising of R1, or any investigation done to rule out abuse. It documents that R1 is rarely or never understood, R1's pain level, and day-to-day activities. The investigation has no documentation of V10 (Registered Nurse) night nurse informing V6 (Registered Nurse), morning nurse about R1's bruises. On 03/13/2025, V2 submitted resident written statements via email that was dated 03/04/2025 month after identification of R1's bruises. Abuse policy dated 08/27/2024 reads: Internal investigation for resident with injury of unknown source the person gathering facts will document the injury, the location and time it was observed, any treatment given and notification of proper parties. Investigation Procedure, the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed. Final investigation, the investigator will report the conclusion of the investigation in writing to the administrator of designee within five days of the reported incident. The final investigation report shall contain the following: - The original allegation (note day, time, location, circumstance surrounding the occurrence and any noted injuries). - Facts determined during the process of the investigation, review of medical record and interview of witnesses. - Conclusion of the investigation based on facts.

Based on review of records and interviews the facility failed to maintain accurate and readily available resident records related to abuse investigation. This failure affected one resident (R1) out of 3 residents reviewed. Findings include: R1 subject of the incident is [AGE] years old currently a resident of facility. R1 was initially admitted on [DATE] with medical diagnosis that includes severe dementia, atherosclerotic heart disease of native coronary artery. R1 cognition is severely impaired with BIMS (Brief Interview of Mental Status) of 1. R1 was investigated by the facility related to bruises resident sustained that was identified on 02/04/2025. On 03/12/2025 at 11:17 AM, R1 was seen sitting inside her room. R1 was alert, unable to respond to questions within topic. Facility Final Report of R1's incident dated 02/04/2025 documents the following: Staff denies witnessing any incident during care but did mention that resident gets very stiff and resistant during transfer which might cause R1 to accidentally bump her arms on to something. Conclusion of report reads: After thorough interview of residents and staff, abuse was ruled out. R1's bruise might happen due to the combination of resident being on Plavix and the possibility of resident accidentally hitting her arm on something. Request to V1 (Administrator) for the full investigation details of incident. V1 stated that V2 (Director of Nursing) did the investigation. And since V2 is not in facility staff are making contact to V2 to produce full documentation of investigation. V1 suggested that V2 will email documents related to the investigation late after when V2 arrives in the facility. V1 was made aware that investigation for injuries of unknown source needs to be readily accessible and important since this investigation needs to rule out abuse. V1 stated that she will contact V2 and procure the investigation. After a while, V1 came with written statements from the following staff: - V4 (Certified Nursing Assistant) documentation on Certified Nursing Assistant Post Accident Report witness statement that reads: I went into the room this morning to give AM care and notice patient arms and reported it to the nurse. - V8 (Certified Nursing Assistant) documented: I worked with R1 on Monday February 3, 2025. I didn't notice any bruising. I worked with her from 6:00 AM to 2:00 PM. - V9 (Certified Nursing Assistant) documented: I was assigned to work 12th floor on 02/04/2025 but was not assigned to work with room where R1 resides. I am unsure at anything that may have occurred with this resident as I did not personally work with her. V1 was asked where the written statements of V6 (Registered Nurse) the nurse who reported to V2 (Director of Nursing) about the bruises of R1. V1 stated that she will ask V2 because she did the investigation. V1 was asked why there was nothing that mention about location of incident? V1 did not answer. V1 was asked is there any written statements on facility staff that regularly took care of R1 during the time bruises where seen? V1 did not answer. V7 (Assistant Director of Nursing) submitted incident audit report that shows all documentation of V2 (Director of Nursing) was still in progress with date includes 02/07/2025 and 02/09/2025.V7 identified V6 (Registered Nurse) as the nurse that notified V2. V6's name also appears in progress dated 02/04/2025 but no actual notes were seen under V6's name. V7 was asked on the notes of V6 since she does not have any documentation at all. V7 stated she will inform V2 about my question. On 03/12/2025 at 01:39 PM, V7 came back with V2 on speaker phone. V7 stated that V2 needs to speak to writer because per V2 the notes under her name were done by V6 the nurse who informed V2. V2 stated that since V6 was new, she (V2) logged in and made V6 put her notes under her name. V2 said, V6 did the notes, I was on her side. V2 was asked if all written statement received by writer are complete. V2 stated that all written statements were provided. To ensure that V2 understood the question. Names of V4 (Certified Nursing Assistant), V8 (Certified Nursing Assistant) and V9 (Certified Nursing Assistant) were stated for confirmation. V2 confirmed that V4, V8, and V9 are only staff that have written statement. V2 stated that V4 was assigned to R1, V8 was there but not assigned to R1. And V9 was not present on that day (02/04/2025). V2 was informed why prior shift nurse's statement was not included. And who informed V6 about the bruising of R1. V2 replied that she has written statement of the night nurse (V10 / Registered Nurse) in her office. Reminded V2 that she stated a while ago that she only had written statements for V4, V8 and V9. V2 replied that she has a written of the night nurse in her office. V2 was made aware that written statements are part of abuse investigation. And it must be readily available or accessible when asked. V2 replied I know it is part of the investigation. And should be gathered together. V2 was also informed that by letting V6 put her notes under her (V2) name makes documentation inaccurate, because, although the notes were done by V6, it shows her (V2) name. V2 replied, To me it is accurate. I signed into the computer because she (V6) is new, and she (V6) made the documentation under my name. V2 was asked why she did not let V6 signed in with her name? V2 did not replied. V2 was informed that document shows her name, although by her statement that was done by V6, and that makes documentation confusing which staff did the writing. V2 replied, I will own the notes. It is my notes. It is my notes not V6. V2 was asked if these is her notes where is V6 notes? V2 replied, I will own that note. On 03/12/2025 at 01:55 PM, V1 stated that as the administrator she is also the abuse coordinator. V1 stated that it was V2 director of nursing who did the investigation and that she (V1) reviewed the investigation of R1 that was done by V2. V1 said, All the staff involved, and the in surrounding time-period should be interviewed since R1 cannot verbalized. I do not recognize that we have a complete documentation with all these documentations. V1 stated that staff should document their notes under their name. V1 stated that all documentation that was done in the investigation should be in the same folder. Incident Audit Report documents that V2 (Director of Nursing), V1 (Administrator) and V6 (Registered Nurse) created documentation. And the only documentation that can be seen is V2's notes dated 02/07/2025 and 02/09/2025 that reads: V2 was made aware about R1's bruises on both upper extremities. R1 unable to verbalize what happened. R1 denies pain, and vital signs results. And to whom notification was provided. Incident Audit Report was not accessible to writer via electronic health records access. It was provided when writer requested full investigation. Review of R1's notes from 02/03/2025 to 02/10/2025 does not provide any information related to incident of R1's bruising that was identified on 02/04/2025. V2 clinical notes created on 02/07/2025 marked as late entry done three (3) days after the incident that occurred on 02/04/2025. Full documentation does not provide any information as to bruising of R1's upper extremities. Does not mention any bruising of R1. Or any investigation done to rule out abuse. It documents that R1 is rarely or never understood, R1's pain level, and day-to-day activities. On 03/12/2025 at 01:05 PM, V6 (Registered Nurse) stated that during endorsement night nurse and morning CNA informed her about the bruising of R1 bilateral arms which she describes as discoloration. V6 stated that the night nurse already identified the bruising but did not say anything. V6 stated that it was the first time she saw R1's bruising. And did not know how R1 got bruises. V6 stated that she was the staff that informed V2 (Director of Nursing). R1's notes do not document that V6 and V10 wrote any notes related to R1's bruising. On 03/13/2025, V2 submitted written statements of residents via email that was dated 03/04/2025 month after identification of R1's bruises.

Based on observations, interviews, and record review, the facility failed to ensure staff signed the Narcotic Shift Count Log Sheet at the beginning of the shift and at the end of the shift and failed to ensure staff did not sign the Narcotic Shift Count Log Sheet before the end of the shift. These failures affected 5 residents (R7, R29, R30, R50 and R51) reviewed for controlled medications in the total sample of 34 residents. Findings include: On 04/08/2024 at 11:02am during the medication cart observation with V3 (Licensed Practice Nurse) of the 10th floor medication cart, the 10th floor 04/2024 Narcotic Shift Count Log Sheet noted with missing signatures on shift 7A (am) - 7P (pm) columns 'ON' and 'OFF' on DATE: 3. This was pointed out to V3 (Licensed Practice Nurse). V3 stated whoever came in on 04/03/2024 did not sign the narc (narcotic) sheet. We (staff) are supposed to sign after the count. This surveyor requested V3 to provide a copy of the 10th floor 04/2024 Narcotic Shift Count Log Sheet. On 04/08/2024 at 11:04am, V3 provided this surveyor a copy of the 10th floor 04/2024 Narcotic Shift Count Log Sheet. On 04/08/2024 at 11: 06am, V3 and this surveyor completed reconciliation and physical count of controlled medications of R7, R29, and R51. On 04/08/2024 at 12:24pm during the medication cart observation with V6 (Licensed Practice Nurse -Agency) of the 11th floor medication cart, the (04/2024) 11th floor Narcotic shift Count Log Sheet has missing signatures on shift 7a(m) - 7p(m) columns 'On' and 'OFF' on date: 6. This was pointed out to V6. V6 stated it means whoever worked in the morning shift did not sign it. This surveyor requested V6 to provide a copy of the (04/2024) 11th floor Narcotic shift Count Log Sheet. On 04/08/2024 at 12:26pm, V6 provided this surveyor a copy of the (04/2024) 11th floor Narcotic shift Count Log Sheet. On 04/08/2024 at 12:30pm, V6 and this surveyor completed reconciliation and physical count of controlled medications of R30 and R50. On 04/09/2024 at 11:22am, V2 (Director of Nursing) stated the expectation is to sign right after they counted the controlled medications. The purpose of signing right after they counted is to acknowledge the count is okay. R7's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) pain in limb and aftercare traumatic fx (fracture) hip. Medication(s) Hydrocodone 5mg-acetaminophen 325mg. Order date: 1/11/2023. R29's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) pain, unspecified and pain in left hip. Medication(s) Oxycodone 15mg. Order date: 3/11/2024. R30's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) fracture of left femur and encounter for orthopedic aftercare. Medication(s) Dilaudid oral solution 4m/ml (0.25ml). Order date: 1/16/2024. Lorazepam 2mg/ml (0.25ml). Order Date: 2/20/2024. R50's (04/2024) Physician Order sheet documented, in part Diagnoses: (include but not limited to) encounter for other orthopedic aftercare and polyneuropathy. Medication(s) pregabalin 75mg capsule. Order Date: 3/21/2024. Oxycodone 5mg (2.5mg) Order Date: 3/21/2024. R51's (04/2024) Medications documented, in part Location: 1009 (10th floor room [ROOM NUMBER]). Diagnoses: (include but not limited to) wedge compression fracture of first lumbar vertebra and subsequent encounter for fracture with routine healing. Order. Oxycodone 5mg tablet (0.5) tablet oral. Order Date: 4/3/2024. Discontinued: 04/05/2024. On 04/11/2024 at 2:45pm, in reference to discontinued controlled medication, V2 stated the nurse will remove the medication in the narcotic box and try to ask another nurse to come so they can destroy the medication together. But we (facility) need to do this if both nurses have the time to do it. Resident's safety is first. Further review of the (04/2024) 11th floor Narcotic shift Count Log Sheet also noted a signature on shift 7a(m) - 7p(m) column 'OFF' on date: 8. Of note, this document was received prior to the end of the shift of V6. The (04/11/2024) email correspondence with V1 (Administrator) and V2 (Director of Nursing) documented, in part When do you expect your staff to sign the Narcotic shift count log sheet? Once the count is right. Are staff expected to pre sign? e.g. before the end of the shift? and why? No(,) they are not expected to pre sign before the end of the shift. The off going nurse is signing to say I am leaving the count right and the upcoming nurse is signing to say I received the count right. The (04/08/2024) Staff In-Service/Education sign-In Log documented, in part Given by: V2 (Director of Nursing). Narcotics must be counted and signed at the beginning and end of shift. The (1/26/2024) Licensed Practical Nurse Position Description documented, in part Responsible for the independent supervision of the delivery of care to a group of residents on a nursing unit. Assesses residents(') needs, develops individual care plans, administers nursing care, evaluates nursing care and supervises RCAs /CNAs and other personnel in the delivery of nursing care. Essential Job Duties: 7. Demonstrates knowledge of policies governing medication administration and documentation. The (1/26/2024) Registered Nurse Position Description documented, in part The Registered Nurse provides direct nursing care to the residents and supervises and coordinates the activities performed by the CNAs to ensure a high degree of quality care is maintained. Is responsible for admission, transfers, and discharges of residents. Administers medication and treatments and maintains proper charting for the unit in all accordance with federal, state, and local standards and regulations and department policies and procedures. Essential Job Duties. 4. Ensures facility nursing policies and procedures are consistently and properly followed. The (Reviewed/Revised Date: 07/13/2023) Pharmacy Policy: Controlled Substances documented, in part POLICY: It is the policy of the 'Facility' to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. PURPOSE: the purpose of these guidelines is to ensure the controlled substances are accessed, stored(,) and handled by authorized personnel. PROCEDURE: 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must count together and report any discrepancies to the Director of Nursing Services.

Based on interview and record review, the facility failed ensure treatment orders were in place for a resident with chronic wounds; failed to provide necessary care and services to promote wound healing; failed to ensure assessments are accurate; and failed to inform doctor of significant change within 24 hours per policy. These failures apply to 1 of 4 residents (R2) reviewed for wound management. Findings include: R2 is an [AGE] year old female, admitted to the facility on [DATE] with the following diagnoses: Bilateral Wound Debridement with Biopsy (8/12/23), Chronic Venous Hypertension (Idiopathic) with ulcer and inflammation of bilateral extremity, Cellulitis of right lower limb, Cellulitis of left lower limb, Peripheral Vascular Disease, Cerebrovascular Disease, Idiopathic Chronic Gout, Chronic Kidney Disease stage 3B, Hypoparathyroidism, Vitamin D Deficiency, Weakness, Muscle weakness, Anemia in Chronic Kidney Disease, Bell's Palsy, Localized edema, Obesity, Gastro-esophageal Reflux Disease without Esophagitis, Dry Eye Syndrome of bilateral lacrimal glands and Personal History of Malignant Neoplasm of Breast. R2 was admitted to the facility on [DATE] after undergoing Wound debridement of left and right lower extremities and placement of Unna Boots with order to keep the Unna Boots on until R2 is seen by the Vascular Surgeon on next appointment. An Unna Boot is a special gauze (usually 4 inches wide and 10 yards long) bandage, which can be used for the treatment of venous stasis ulcers and other venous insufficiencies of the leg. The gauze is impregnated with a thick, creamy mixture of zinc oxide and calamine to promote healing. It may also contain acacia, glycerin, [NAME] oil and white petrolatum. (Source: https://en.wikipedia.org/wiki/Unna%27s_boot) Review of R2's medical records affirm the following: R2 was admitted on [DATE] with Unna Boots. Facility was monitoring R2's wound dressing twice daily for any soiling. R2's wounds were assessed by the wound care nurse on 8/27/2023 with Unna Boots in place, clean and intact. R2 went to appointment on 8/29/2023 where R2's Unna Boots were removed; however, facility did not receive new treatment orders for R2's Bilateral lower extremities wound. New Treatment orders were received on 9/1/2023 as follows: Left Leg- cleanse with NSS (Normal Saline Solution), part (sic) dry apply Xeroform to site, cover with ABD (abdominal) pad, kerlix every other day and PRN (as needed). Right Leg- cleanse with NSS (Normal Saline Solution), part (sic) dry apply Xeroform to site, cover with ABD (abdominal) pad, kerlix every other day and PRN (as needed). R2's left leg wounds were assessed on 9/1/23 and 9/8/2023 by the wound care nurse. Progress Notes dated 9/7/2023 7:35 AM documents: Noted increased drainage to both lower legs. Wounds don't appear healing (sic). Wound Care Nurse notified today morning to check on wounds' status. There was no documentation in R2's electronic record that the doctor was informed of significant change observed in R2's wound. Per interview, V5, R2's Primary doctor was not informed until 9/8/23 via email by V3, Wound Care Nurse, which is not part of the resident's medical records. R2 was sent to the hospital on 9/8/2023 at 5:15 PM as ordered by Primary Doctor and was admitted with diagnosis Cellulitis of lower extremities which was more than 24 hours the significant change was observed. On 10/13/2023 at 11:41 AM, V3, Wound Care Nurse/Nursing Supervisor stated, When R2 was admitted R2 had bilateral Unna Boots on. The Unna Boots were removed on a doctor's appointment, I believe on the August 29th, 2023, I assessed her and she had pretty large venous stasis ulcers on both legs. R2 didn't come back with a discharge summary with her, so the nurse called the surgeon and the surgeon faxed over the discharge summary the same day on the 29th of August, however, it was not the correct one, it was from a previous appointment. When R2 came back from the appointment, R2 had Xeroform applied to her bilateral wounds and then I saw her again on Sept. 1st. When asked what dressings were being applied to R2's wounds on 8/30/23 and 8/31/23, V3 stated, If I remember it correctly, R2 was getting Xeroform because that is what she came back with. If dressing changes were done on 8/30/23 and 8/31/2023, it would be documented on the nurses' notes. V3 stated she didn't see any nurses' notes documenting that bilateral wound dressings of R2 were changed on 8/30/23 and 8/31/2023. V3 stated, If dressings are not changed, the wound could have an adverse effect, it could get worse, it could lose the ground that you gained. I saw R2's wounds on 9/1/23 after the Unna Boots were removed, and there were no signs/symptoms of infection, there were no odors. I measured them, the tissue was pink, she had a moderate to large amount of drainage because of how big the wounds are. R2's wounds are chronic, she has been admitted to our facility at least three times, so it's very chronic for her. But this is the first time I have seen her on Unna Boots. She's always had the pain which didn't seen greater than normal, no additional swelling, they weren't hot. On 9/7/2023, we had a care plan meeting with the R2's granddaughter and she asked me about R2's wounds and I reported to her about what I saw on 9/1/23. On 9/8/23, V6, the nurse assigned to R2 told me that the wounds had an odor, so I went and took R2's dressings off. I noticed an odor as well. I measured them and they were a little bit bigger than measurement from 9/1/23. Surveyor showed V3, her wound assessment on 9/8/23 which documents no odor. V4 stated, The wound assessment for the left leg is also wrong, the wound zone should be Anterior 26, referring to the left leg and not Posterior 29 which is referring to the back of R2 and not left leg of R2. That's an error. V3 stated, There were no treatment orders for the left and right leg vascular wounds for 8/30/23 and 8/31/23 and I did not see any documentation on the progress notes that the dressings were changed on 8/30/23 and 8/31/2023. I do wound care dressing changes on Fridays when I do my Weekly wound assessments, the rest of the days it is the floor nurses are responsible for changing the dressing for all wounds. On 10/13/2023 at 2:34 PM, V3, Wound Care Nurse/Nursing Supervisor stated, Since I couldn't get a hold of the surgeon, I received the treatment orders from V5, R2's Primary Doctor on 9/1/2023. From 8/29/2023 until 9/1/23, we didn't have any treatment orders for R2 until I got a hold of V5 on 9/1/23. That is not the protocol, the nurse should have called V5 on 8/29/23 and informed her that the surgeon was not calling back for orders. I didn't know that R2 came back without any treatment orders. I was only informed on 9/1/23, and that's when I called V5 to secure treatment orders. On 10/13/2023 at 12:35 PM, V2, Director of Nursing/DON, stated Based from the information I gathered, R2 did not come back with any paper work from her appointment on 8/29/23. When the nurse called the doctor's office to follow up on the treatment orders, the doctor's clinic sent the Progress Notes from a previous appointment on 7/11/23 and not the one from 8/29/23. If dressings were applied and changed on 8/30/23 and 8/31/23, there should be documentation on the Treatment Administration Record/TAR or Progress Notes. Having a foul odor in wounds is considered a significant change in condition. If dressing changes are not done, it could lead to wound worsening. My expectation is that nurses should call the doctor if there are any significant changes. If the surgeon did not respond, the primary doctor should be called and if the primary doctor did not respond, the nurse should call the Medical Director. On 10/13/2023 at 2:20 PM, V5, R2's Primary Doctor, stated, I remember R2 well, she stayed there multiple times under my care. R2 was admitted on [DATE], when she came the order was the Unna Boot was not changed until she was seen by the vascular clinic on 8/29/23. Then on 8/29, R2 went to see the doctor. They usually tell me if there's new orders or not. She comes back and I am going to assume that nothing really changed because no one contacted me for a change. I saw her on 9/4, her legs were wrapped and there were no odors in the room, she was smiling. I got an email on 9/8 stating that the wound care doctor was going to see R2 on 9/8, the wound care nurse said, the wound is larger, and that they are putting calcium alginate. It didn't mention that there was fold odor. Now I'm thinking there must be a lot of drainage. So, I went to the electronic health record myself and I saw that the nurse on 9/7 documented on the nurses' notes, it mentions there's foul odor. So, I called facility on 9/8 spoke with V6, Registered Nurse and I told V6 that I'm concerned and I told him to send the R2 to the hospital right away. R2's blood sugars were running low so I told him to send her immediately because I was concerned about sepsis. The wound care nurse states she made multiple calls to the surgeon but nobody called her back. We have taken good care of R2 every time she is here at this facility. I understand your concern about the 2 days were there were no orders for treatment, I don't know what happened on those 2 days. I know that she had multiple debridement done when she was sent to the hospital, received antibiotics and that she was discharged back home. Hospital records were requested and was not received upon conclusion of the investigation. Facility Wound Management Policy with effective date of 2/8/2018 documents in part: PURPOSE: Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. PROCEDURE: III.B.6. Orders are verified and obtained as needed. Facility Wound Significant Change Policy with effective date of 7/31/2012 documents in part: POLICY: It is the policy of The Terraces at The [NAME] to notify the resident, his or her Attending Physician, and legal representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). PROCEDURE: 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to include and implement approaches from the elopement risk assessments into the care plan enabling one confused resident to exit the facility and into the community. This failure affected one resident (R1) of 3 residents reviewed for elopement in the sample of 3 residents. The findings include: R1 is a confused, [AGE] year old male who was admitted to the facility on [DATE] for short term rehabilitation services following a stroke per the face sheet and nurses' notes. R1's admission minimum data set (MDS) dated [DATE] documents R1 to have a brief interview mental score of 11, is non-ambulatory, uses a wheel-chair, and requires extensive assist with his activities of daily living. R1's social service note 10/24/22 and nurses' note 10/31/22 document R1 is oriented to self, place and situation. R1's elopement risk assessments dated 10/24/22 and 10/30/22 document R1 to be high risk for elopement. R1's elopement on 10/24/22 was due to R1 leaving the 10th floor and going to the 16th floor where staff found him and took him back to the 10th floor. The elopement risk assessments document the approaches to be use an elopement device, initiate a care plan and place current photo in the elopement binder held at the front desk. During the facility's investigation, it was determined that R1's wander guard bracelet was not always triggering the wander guard alarm. It was 10/30/22 at 2:39 PM when R1 was noticed missing from his floor. V4's (security guard) statement documents that a fell ow security guard reviewed video tape as other staff searched the facility and the surrounding outside areas. R1 was seen exiting the lobby with a female via video. The female was identified as a family member of another resident who was visiting. As the search continued, R1 was found at his residence in the community at 3:30 PM in good condition and returned to the facility at 3:48 PM. The elopement binder failed to have a photo of R1 in the binder and the front desk staff failed to recognize R1 as an elopement risk when staff saw R1 leaving the facility. On 11/16/22 at 10:15 AM, V1 (administrator) stated there was an issue found with the wander guard system and no current photo of R1 in the elopement binder. V1 stated R1 lives a few blocks from the nursing facility and had left facility to go home. V1 stated that R1's wife informed staff that R1 used to walk 3 to 6 miles per day in the community and is very familiar with the surrounding community. V1 stated that R1's wander guard had failed to work on 10/24/22 when R1 was able to leave his floor and go to another floor. R1's wander guard bracelet was replaced. On 10/30/22, the same issue occurred with the wander guard bracelet. V1 stated R1 would wear his bracelet around his ankle. The outside technician informed V1 that the strength was increased in order to ensure the alarm will still trigger if worn on the ankle. V1 stated a technician came out to check the wander guard system and replaced a part. V1 stated the only way a person can leave a floor is to have a FOB that triggers the elevators to open. R1's care plan addresses R1's risk of elopement and documents all ancillary staff being aware of residents identified risk for elopement. The care plan lacks to document a current photo of resident at risk for elopement to be placed in the elopement binder. R1 was discharged home to his wife from the facility on 11/12/22 per the MDS, nurses notes and social service note. On 11/17/22 at 11:55 AM, V11 (MDS/Care Plan Coordinator Manager) did not to have an answer why the approach of placing a current photo of residents at risk for elopement was not included in the care plan. V11 stated going forward will ensure the care plans have the approach of placing a photo into the elopement binder included in the care plan. The facility's policy labeled CARE PLAN - COMPREHENSIVE documents: POLICY: It is the policy of Terraces at the [NAME] to develop an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. PURPOSE: Terraces at the [NAME] Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. PROCEDURE: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions. 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. Interdisciplinary processes require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. The facility's policy labeled Elopement documents state, the purpose of this policy is to ensure the safety and security of all residents while in the health center. The approaches include notifying all staff of residents with potential elopement risk and maintain current photo on file for all residents identified as potential elopement risk.

Based on observation, interview and record review, the facility staff failed to perform hand hygiene prior to entering an isolation room and failed to ensure that staff don appropriate Personal Protective Equipment (PPE) (N-95 mask) prior to entering an isolation room for one resident (R4) in the sample of 11 residents to prevent the spread of infectious microorganisms including COVID-19. Findings include: R4's Brief Interview for Mental Status (BIMS) from Assessment Reference Data (ARD) dated 05/03/22 documents R4 with a score of 14 which indicates that R4 is cognitively intact. R4's face sheet documents that R4 has the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/22 at 1:12 pm, Surveyor observed R4's room with a contact precaution isolation sign on the door that documented, in part: Contact Precautions everyone must clean their hands, including before entering and leaving the room and a droplet isolation sign on the door that documented, in part: Droplet Precautions everyone must clean their hands, including before entering and leaving the room. On 06/16/22 at 1:21 pm, Surveyor observed V6 (Certified Nursing Assistant, CNA) sitting at the 11th floor nursing station near R4 ' s room and then walking to R4's isolation room wearing a surgical mask and a face shield. Surveyor then observed V6 don gloves and a gown prior to entering R4's isolation room that displayed a contact precaution isolation sign on the door that documented, in part: Contact Precautions everyone must clean their hands, including before entering and leaving the room and a droplet isolation sign on the door that documented, in part: Droplet Precautions everyone must clean their hands, including before entering and leaving the room. Surveyor did not observe V6 wearing a N95 mask or perform hand hygiene prior to donning gloves and entering R4's COVID-19 contact/droplet isolation room. On 06/16/22 at 1:25 pm, Surveyor interviewed V6 (CNA) regarding entering R4's COVID-19 isolation room without performing hand hygiene and wearing a N-95 mask. V6 stated, I don't know if I should wear an N-95 mask. When V6 was asked regarding performing hand hygiene prior to entering R4's COVID-19 isolation room V6 stated, I guess I forgot to wash my hands. On 06/21/22 at 11:47 am, V2 (Assistant Director of Nursing, ADON, Infection Preventionist) was interviewed regarding droplet and contact precautions for COVID-19 residents and stated, For residents who are on isolation for COVID-19 precautions we do contact and droplet isolation. Staff who go inside a COVID-19 isolation room should wear gloves, gown, face shield and N95 mask. V2 explained that staff receive a N95 mask that is stored outside the room in the isolation bins and that N95 mask can also be located in the clean utility room on the units. When surveyor asked V2 regarding hand hygiene prior to entering a contact and droplet isolation room for COVID-19, V2 stated, Hand hygiene should be performed before and after staff enters the isolation room and prior to staff putting on any isolation Personal Protective Equipment (PPE). V2 stated that on 06/16/22, R4's was on contact and droplet isolation for testing positive for COVID-19 on 06/10/22. R4's Physicians Order Sheet (POS) with orders dated 06/13/22 documents, in part: Droplet/contact precautions due to COVID-19. Facility's document dated May 16 through June 16, 2022 and titled Resident reported suspected or positive cases of COVID-19 list R4 positive with COVID-19 on 06/10/22. Facility's document dated 05/24/22 and titled COVID-19 Testing Plan and Response Strategy documents, in part: Purpose: To promote infection control and decrease risk of spread of COVID-19 . 2) In the COVID rooms: N-95 mask to be worn . PPE Quantities: Each staff member entering a COVID positive room to be provided with a gown, their fitted N-95 mask, a face shield and gloves.

Based on interview and record review the facility failed to ensure ordered medications were verified, transcribed to the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: R1 was admitted to the facility on [DATE] from a Skilled Nursing Facility and discharged from the facility on 03/31/22. R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. Review of Hospital Discharge Summary date printed 03/19/22 used by V21 (Registered Nurse) to verify medication orders document in part admitted [DATE] and discharge date [DATE]. Review of After visit summary dated 03/19/22 document in part [MEDICATION(S)] 20 mg (Milligrams) daily for 3 days then, 0.5 tablet Daily for 30 days and [MEDICATION(S)] 50 mg every 6 hours as needed for up to 10 days. Stop taking [MEDICATION(S)] 1.5 mg/0.5 ml (Milliliter). Review of March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Care Plan document in part Medication Management: Confirm all orders with physician. On 05/17/22 at 08:27 AM V22 (R1 Family Member) stated R1 was not receiving the [MEDICATION(S)] and was supposed to be weaned off it. On 05/17/22 at 02:02 PM V11 (Social Worker) stated there were concerns related to R1 medications and I relayed the concerns to the nursing team (Director of Nursing, Assistant Director of Nursing). The concerns were brought up in the care plan conference. On 05/17/22 at 02:47 PM V14 (Transitions Manager) stated V22 (R1 Family Member) was concerned about the medication R1 was not getting. I went to the chart and medication list. The nurse was going over it and the [MEDICATION(S)] was not on it. The nurse used the hospital and Skilled Nursing Facility records because they were sent together. V21 (Registered Nurse) looked at the hospital discharge instead of the Skilled Nursing Facility discharge form. I let supervisory staff know about the medication error. The supervisory staff took over from there. The nurse is responsible for transcribing the medication correctly. On 05/17/22 at 04:36 PM V2 (Director of Nursing/Restorative Nurse) stated my expectation is that the nurse review the MAR (Medication Administration Record) sent from the hospital, call the physician to verify the orders and enter the medications in a timely manner into the MAR. There were two discharged summaries sent from the Skilled Nursing Facility and a hospital discharge package for R1. The Skilled Nursing Facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . V21 (Registered Nurse) was counseled for medication transcription, verifying medication from the skilled unit and clarify with the physician. V22 went off the more recent discharge summary and was not aware there are skilled nursing units in the hospital. It is a learning opportunity for the nurse. This is considered as a medication error. The potential of the effect of the medication error, depend on the kind of medication. I do not know what repercussions can be caused by missing [MEDICATION(S)]. On 05/17/22 at 05:03 PM V21 (Registered Nurse) per telephone interview stated R1 received all medications as ordered per V15 (Primary Physician). I was the admitting nurse and verified the medication orders with V15. R1 came to the facility from a skilled nursing facility, and I used the most current discharge summary to verify the orders. I heard through V15 that R1 had been on [MEDICATION(S)]. I was never aware that R1 was on [MEDICATION(S)]. If it was on the Discharge summary, I did not see it and that would be a medication error. The Director of Nursing went over the medication list and I received an in-service on medication verification and transcribing orders. On 05/17/22 at 05:08 PM V15 (Primary Physician) per telephone interview stated I cannot verify who I am talking to. I am not R1 primary doctor, and they should take that off R1 face sheet. I may have seen R1 or twice because R1 was a rehab patient. Any doctor on call could verify orders. Policy: Titled Medication - Administration revised 10/01/21 document in part; It is the policy that all medications will be administered only as prescribed. Purpose: To administer medication, within the state guidelines, in a safe manner.

Based on observation, interview and record review the facility failed follow sanitary guidelines while checking food temperatures and failed to ensure proper hand hygiene was performed during meal preparation and service. The facility also failed to ensure utensils were washed, sanitized and air dried. This deficient practice has the potential to affect 43 out of 43 residents receiving food served from the facility kitchen. Finding Include: On 11/10/20 at 11:34 AM V11 (Server) removed thermometer from sheath and checked the temperature of the Tortilla soup on the eleventh floor steam table reading 176 degrees. V11 wiped off thermometer probe with a paper napkin then checked the temperature of the Macaroni and Cheese reading 78 degrees. V11 wiped off thermometer probe with a paper napkin then checked the temperature of the Green beans and Tomatoes reading 180 degrees. V11 wiped off the thermometer probe with a paper napkin then checked the temperature of the Chicken Cordon Bleu with Mornay Sauce reading 78.6 degrees. V11 wiped of the thermometer probe with a paper napkin then checked the temperature of the Sweet and Sour Meatballs reading 60.9 degrees. On 11/10/20 at 11:40 AM V11 (Server) stated I just grab a towel and wipe off the thermometer. On 11/10/20 at 11:42 AM V11 (Server) was observed touching her mask and glasses with her right gloved hand, touched the sink water faucet, rinsed the knife that was used to cut the Chicken with water, wiped off the knife with a paper napkin and cut the Fresh Strawberry Shortcake in half touching the pastry with her gloved hands. V11 entered the refrigerator with her gloved hands and removed a can of whip cream using the same gloves touched the pastry before and after applying the whip cream and strawberries. On 11/10/20 at 11:56 AM V11 (Server) removed and changed gloves no hand hygiene performed to make a grilled cheese sandwich, touched the sink faucet with her right gloved hand retrieved a spatula from the drawer, turned on the sink faucet with her right gloved hand then touched her face mask and glasses. V11 removed 2 slices of bread from the bag with her right gloved hand, placed the cheese between the bread then placed the bread in a skillet moving the bread around in the skillet with her right gloved hand. On 11/10/20 at 12:02 PM V11 (Server) turned on the sink faucet with her right gloved hand to rinse off the knife. On 11/10/20 at 12:03 PM V11 (Server) turned on sink faucet with her left gloved hand to get ice water then cut the Strawberry Shortcake in half with the knife using her gloved hands. On 11/10/20 at 12:08 PM V11 (Server) turned on the sink faucet with her left gloved hand, rinsed off the knife, dried it with a paper napkin, cut the Strawberry Shortcake in half, applied whip cream and strawberries then picked up the pastry roll with her gloved hands. On 11/10/20 at 12:14 PM V11 (Server) turned on the sink faucet with her left gloved hand. On 11/10/20 at 12:15 PM V11 (Server) removed and changed gloves with no hand hygiene. On 11/10/20 at 12:16 PM V11 (Server) touched the sink faucet with right gloved hand. On 11/10/20 at 12:19 PM V11 (Server) touched the sink faucet then touched and cut the Strawberry Shortcake with her gloved hands, and retrieved another can of whip cream from the refrigerator. On 11/10/20 at 12:21 PM V11 (Server) touched and cut the Strawberry Shortcake with her gloved hands then applied whip cream and strawberries. V11 was observed touching her face mask and glasses. On 11/10/20 at 12:22 PM V11 (Server) touched and cut the Strawberry Shortcake with her gloved hands then applied whip cream and strawberries. On 11/10/20 at 12:26 PM V11 (Server) stated when I checked the food temperature I used the napkin to wipe the food off of the temperature probe. I am supposed to wash my hands between changing gloves. On 11/12/20 at 11:59 AM V12 (Director of Dining Service) stated the thermometer should be sanitized after each use with sanitizing wipes or a clean cloth with sanitizer. It is not acceptable to wipe off the thermometer with a paper napkin. There is a risk of cross contamination if the thermometer is not sanitized. Gloves should be changed in between each task and hands should be washed in between uses. The knife should have been washed with soapy water, rinsed, sanitized and air dried. Different utensils are used for different procedures. There is a dish washer in the kitchenette on each floor. Gloves and utensils used for multiple task can cause cross contamination. If the staff member touch their glasses or mask they are to take off the gloves, wash their hands and put on a different pair of gloves. In services are given to staff about personal hygiene and cross contamination. Sanitizing wipes are usually on the floor but unfortunately there were none on the floor. On 11/12/20 at 03:28 PM V13 (Chef) changed gloves when preparing the Egg Noodles without performing hand hygiene. On 11/12/20 at 03:31 PM V13 (Chef) pulled the cell phone out of his pocket with his left gloved hand then changed gloves without performing hand hygiene. On 11/12/20 at 03:37 PM V13 (Chef) pushed Normandy Blend vegetables from the rim of the pan into the pan with his gloved hands. On 11/12/20 at 04:12 PM V13 (Chef) stated I change gloves when I feel the need from one task to the other. I usually wash my hands as well but I may forget. I'm only human. Policy: Titled Personal Protective Equipment Using Gloves revised July 12, 2018 5. Wash hands after removing gloves. (Note: Gloves does not replace hand washing) Removing Gloves 6. Wash hands Titled Handwashing/Hand Hygiene revised March 1, 2020 It is the policy to consider handwashing/hand hygiene as the primary means to prevent the spread of infection. To ensure that all personnel shall follow the hand washing/hand hygiene procedure to help prevent the spread of infection to other personnel, residents and visitors. 3. The use of gloves does not replace hand washing/hand hygiene. Titled Preventing Foodborne Illness - Food Handling dated 02/01/2018 Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; c. Contaminated equipment 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing food borne illness 9. All food service equipment and utensils will be sanitized according to current guidelines. Titled Preventing Contamination from Equipment, Utensils and Linens dated 01/01/18 It is the policy of the community to prevent cross contamination or transfer of harmful bacteria from food contact with equipment and utensils Food shall only contact surface of: Equipment and utensils that are cleaned with soapy water and are sanitized. Equipment and utensils shall be cleaned: At any time during the operation when contamination may have occurred. Titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated January 2018 It is the policy of the community to ensure appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands: During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task. Gloves are considered single use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. Titled Use of Probe Thermometers dated January 2018 It is the policy of the community to ensure the safety of prepared food by using a probe thermometer to check internal temperatures. Probe thermometers must be cleaned and sanitized before use. Probe thermometers must be cleaned and sanitized between each use. Use alcohol swabs or a sanitizing solution after each use. Sanitizing the probe thermometer will help you avoid cross-contamination. Sample size obtained from the facility census from the 672 form.

Based on observation, interview and record review the facility failed to serve foods at safe holding temperatures to prevent the possibility of food borne illnesses. This deficient practice has the potential to affect 13 out of 15 residents receiving food served from the eleventh floor kitchenette. Findings Include: On 11/10/20 at 11:34 AM V11 (Server) removed thermometer from sheath and checked the temperature of the Tortilla soup on the eleventh floor steam table reading 176 degrees. V11 wiped off thermometer probe with a paper napkin then checked the temperature of the Macaroni and Cheese reading 78 degrees. V11 wiped off thermometer probe with a paper napkin then checked the temperature of the Green beans and Tomatoes reading 180 degrees. V11 wiped off the thermometer probe with a paper napkin then checked the temperature of the Chicken Cordon Bleu with Mornay Sauce reading 78.6 degrees. V11 wiped of the thermometer probe with a paper napkin then checked the temperature of the Sweet and Sour Meatballs reading 60.9 degrees. V11 failed to check the temperature of the puree food that was served. On 11/10/20 at 11:40 AM V11 (Server) stated I bring the food from the kitchen on a cart. On 11/10/20 at 12:26 PM V11 (Server) V11 was unable to tell what the food temperature readings were supposed to be. On 11/12/20 at 11:59 AM V12 (Director of Dining Service) stated the soup should be at least 145 degrees. The meatballs and chicken is supposed to be serve hot at 165 degrees. If the food temperature is not correct it could have created harmful bacteria. The food need to be brought back to the right temperature by reheating. Record review of HACCP (Hazard Analysis and Critical Control Point) Temperature Monitoring Sheet document temperature upon placement into steam tables: Lunch dated 11/10/20 document Tortilla soup 176 degrees, Meatballs 60.9 degrees, Mac cheese 78.0 degrees and chicken 78.6 degrees. Temperatures at end of Service: Tortilla soup 55.5 degrees, Meatballs 62.1 degrees, Mac cheese 78.6 degrees and chicken 79.1 degrees. Record review of document titled Temperature Logs Food Temperature Logs: Hot food no lower than 135 degrees (Corrective Action) - reheat up to 140 degrees. Policy: Titled Preventing Foodborne Illness - Food Handling dated 02/01/2018 Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 1. This facility recognizes that the critical factors implicated in foodborne illness are: b. Inadequate cooking and improper holding temperatures; 6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy Pathogenic microorganisms. Titled Food Temperature dated January 2018 It is the policy of the community to ensure the proper serving temperature of food through the use of a temperature monitoring system. 1. Safe temperatures are: a. Hot food 140 degrees Fahrenheit or above 2. Food shall be brought back to proper temperature before being served. Sample size was obtained from the eleventh floor resident census.

Based on observations, interviews and record reviews, the facility failed to follow their policy on transmission-based precautions when entering a contact isolation room for 1 (R136) of 6 residents reviewed for transmission-based precautions. Findings include: On 11/10/20 at 10:03 AM, V4 (Housekeeping) entered R136's room wearing a mask, face shield and gloves. R136's door has Droplet Precautions and Contact Precautions signage. Contact Precautions signage reads PROVIDERS AND STAFF MUST ALSO: . Put on gown before room entry . At 10:05 AM, V4 left the room to place a vacuum in hallway. V4 re-entered R136's room without a gown. Observed V4 mopping R136's entry way and bathroom without a gown. At 10:24 AM, V5 (Certified Nursing Assistant) stated R136 is on Droplet and Contact Precautions. V5 stated staff need to wear face shield, mask, gown and gloves when entering R136's room. At 11:51 AM, V6 (Nurse) stated R136 is on 14 day isolation for COVID monitoring because R136 is a recent admission. V6 stated all staff including housekeeping staff should wear a mask, face shield, gloves and gown when entering R136's room. On 11/12/2020 at 11:35 AM V3 (Assistant Director of Nursing/Infection Preventionist) stated new admissions and readmissions are placed on 14 days COVID precautions under contact and droplet isolations. V3 stated for contact and droplet precautions all staff including housekeeping are to wear face shield, gown, gloves and N95 mask. At 12:29 PM, record review of R136's physician order [REDACTED]. R136's care plan reads a problem of Covid 19 Precautions. Interventions include to Follow facility protocol for COVID-19 screening/precautions. Facility policy titled Isolation - Categories of Transmission-Based Precautions last reviewed January 2012 under section 'Contact Precautions' reads: 5. Gown a. Wear a disposable gown upon entering the Contact Precautions room or cubicle.

Based on interview and record review, the facility failed to provide documentation regarding resident bed hold notification during hospital transfers, for three of three residents R25, R42 and R47, in the total sample of 12 reviewed for transfers. Findings include: On 3/3/19 at 4:25 PM nursing progress note, Clinical Notes documents in part, R42 noted coughing more than usual. Doctor notified and to send resident to local hospital. R42 admitted to hospital. On 3/8/19 at 12:55 PM Nursing Note- Admission Note documents in part, Resident (R42) arrived at facility admitted post [MEDICAL CONDITION] and recurrent pleural effusion. There was no documentation within the medical record that R42 or the representative, was provided with notification related to the bed hold policy. On 4/3/19 at 11:37 AM, V1 (Administrator) presented documentation of a Bed Hold Policy dated on 4/3/19. On review of the clinical record, R25 was hosptalized on [DATE] and 2/14/19. The clinical record did not include documentation that the resident or representative was provided with written notification related to the facility's bed hold policy. On review of R25's progress notes dated 1/19/19 to 1/21/19 and 2/13/19 to 2/15/19, there was no documentation that facility staff discussed with the resident and/or representative, the facility's bed hold policy prior to the resident's transfer to the hospital. During an interview on 4/2/19 at 2:59 PM V6 (Admissions Representative) stated, everyone gets the bed hold policy upon admission. V6 was not able to provide written documentation that R25 was provided with notification of the Bed Hold policy for hospital transfers on 1/20/19 or 2/14/19. On review of the clinical record, facility staff documented R47 was transferred to the hospital on [DATE]. There was no documentation in the clinical record that the resident or representative, was provided with written notification of the facility's bed hold policy. On 4/2/19 at 3:21 PM, interviewed V2 (Director of Nursing). V2 stated, We document the patient's status, whatever the emergency is, the vital signs and notify the family, the doctor and the receiving facility. Once they are admitted , we call the facility back and ask what the admitting [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to label food when opened and failed to discard food by the use by date. This has the potential to affect 45 residents who received food from the kitchen. Findings include: [DATE] 09:50 AM Kitchen tour findings with V6, Director of Dining Services (DDS): Artificial eggs in dairy fridge opened carton. No date opened labeled on carton. Olive jar on dry pantry shelf use by [DATE]. Green split lentils on shelf in dry pantry bin labeled [DATE] opened and expired [DATE] Bag of white rice use by ,[DATE] in bag sealed with wire twist on pantry shelf. Pastry flour dated [DATE] use by [DATE] in dry pantry in labeled bin V6 (DDS) said V7 (Dishwasher) is in charge of rotating and removing expired stock. V6 said his record shows V7 was in serviced on rotating and removing stock in (MONTH) (YEAR). [DATE] 10:00AM V7, (dishwasher) interview in pantry hall, said he discards food by expiration date. [DATE] 12:34PM V5 (Dietary Server) on 10th floor said the following bread is used to serve the residents on 10th floor: Wheat bread in bag label reads: opened ,[DATE] use by ,[DATE] Raisin Bread in bag label reads: opened ,[DATE] use by ,[DATE] [DATE] 01:56PM per V6 (DDS) open foods in floor refrigerators should be used or disposed of in 5 days. Facility Policy reads: Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on observation, interview, and record review the facility failed to follow their policy for the control and safe storage of medications for residents who can self administer medications for 1 of 12 (R26) residents reviewed for self medication. Findings include: 6/12/18 12:50PM Resident # 26 has a bottle of [MEDICATION NAME] 100,000 unit/gram topical powder on night stand in room. Powder bottle is approximately 3.5-4 inches in height, round, and white. R#26 told surveyor the staff applies that powder and looked over to nightstand where [MEDICATION NAME] powder is. R26 said she is not able to self apply the powder due to weakness to her right arm 6/14/18 10:20AM Interview with V4, Certified Nursing Assistant, (CNA) on 10th floor hallway: V4 said a powder that the nurse keeps in the med cart is applied to R26 after her bed bath daily. V4 said the nurses always keep the powder. Records for R26 do not indicate R26 is capable to self administer medications. R26 [DIAGNOSES REDACTED]. R26's care plan does not include self administration of medication. R26 does not have an order to keep [MEDICATION NAME] powder at bedside or self administer. Facility policy reads: If the interdisciplinary team assessment determines the resident can safely self administer prescribed medications, Nursing will complete the self administration of medication assessment on facility electronic medication monitoring system .The Physician must write an order for [REDACTED].