Every finding on record at Warren Barr Lincoln Park

Based on observation, interview, and record review, the facility failed to supervise a resident with a history of falls. This failure affected one resident (R2)out of 3 residents reviewed for accidents and supervision in the facility. As a result, R2 fell and sustained a laceration of the head requiring sutures.Findings Include:On 11/29/25 at 8:24 pm, an initial Facility Reported Incident was submitted to Illinois Department of Public health (IDPH) that documented, Around 11:25 am, a resident (R2) was observed lying on his back on the floor in the bathroom of his room. (R2's) fall was unwitnessed and resulted in (R2) having a laceration to the right forehead, that required (R2) to get two sutures. (R2) can stand and ambulate with a walker, cues, and standby assist. Resident primarily uses a wheelchair for mobility. The final report was submitted to IDPH on 12/5/25 at 3:50 pm. R2's diagnoses include but are not limited to syncope, collapse, falling, transient cerebral ischemic attack, hypertension, abnormal gait and mobility, chronic fatigue, and Alzheimer's Disease.R2's Minimum Data Set (MDS), dated [DATE], documents, Section C. Brief Interview for Mental Status (BIMS) score is a 5. R2 has severe cognitive impairment. Section GG. Self-Care: C. toileting hygiene is coded with a 4 which indicates supervision or touching assistance. (Helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently). Mobility: I. Walk 10 feet is coded with a 4 which indicates supervision or touching assistance. Mobility devices: B. Walker.R2's Physician Order Set (POS) active orders as of 3/13/26 documents, May use bed and chair alarm.R2's (4/26/25) care plan documents, (R2) at high risk for falls related to dementia, behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Cognitive deficit such as poor awareness, decrease comprehension impulsive memory deficit. Interventions: Remind me to ask for assistance. Reorientate me on how to use the call light if necessary. Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. (4/26/25) R2 requires assistance with Activity of Daily Livings (bed mobility, transfers, dressing, walking, personal hygiene, eating, and toileting). (6/27/25) (R2) demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming. Interventions: (R2) to be frequently monitored. (9/30/25) Focus: (R2) uses chair/bed alarm related to potential fall.R2's (11/29/25) hospital record documents, Chief complaint syncope, Patient reports walked to bathroom used the bathroom, got up and walked a few steps and then only remembered waking up on floor. Laceration to forehead s/p (status/post) repair with sutures. Computerized Tomography (CT) of head shows small right superficial frontal scape hematoma.R2's (11/29/25) fall risk assessment documents, D. Cognition: 1. Does the resident display a memory problem, YES. F. Mobility: 2. The resident gait would be described as 1. UNSTEADY. G2. History: Did the resident just have a fall? YES. R2's fall risk score is 13 which indicates R2 is high risk for falls. R2's (12/1/25) fall risk evaluation documents, 1. Is this assessment an annual significant change in status and /or quarterly? NO. R2's score is 0, which indicates low risk for falls. R2's (1/5/26) fall risk evaluation documents in part, 1. Is this assessment an annual significant change in status and /or quarterly? NO. R2's score is 0, which indicates low risk for falls.R2's progress notes, dated 11/29/25 at 11:25 am, documents, Writer (V11, License Practical Nurse/LPN) was notified by (R4) that (R2) was on the floor in the shared bathroom. Upon assessment, resident was observed laying on his back in the bathroom. When asked what happened, the resident stated, 'I don't recall, it all happened so fast.' An open area with blood and swelling was noted to the resident's forehead. Area was cleaned with normal saline and applied pressure until bleeding subsided. The resident is alert and verbally responsive. 911 was called, writer and Certified Nursing Assistant (CNA) on duty remained with the resident until the arrival of the (city) Fire Dept paramedics.On 3/13/26 at 11:00 am, R2 was in R2's room lying in bed. R2 stated he did not recall falling in the facility. R2 sat up on the side of the bed and the bed alarm sounded. V4, License Practical Nurse (LPN), was already in the room. R2's call light was observed at the head of R2's bed on the floor. V4 stated the call light should not be on the floor and should be in R2's reach in case R2 needed something. On 3/13/26 at 11:50 am, V2, Director of Nursing (DON), stated, We did have only one nurse with three CNAs on the second floor for 38 residents. I would consider that to be a staffing problem. One nurse cannot give quality care to that many residents and it can put the residents at risk. DON was asked is it safe to have one nurse taking care of 38 residents? V2 DON stated, In my opinion, No. On 3/13/26 at 1:48 pm, V7, Nurse Practitioner, stated, (R2) lived alone and kept falling at home, and that is why he was admitted to the facility. (R2) has a history of being impulsive and should have been on fall precautions. He was moved close to the nurse's station; his call light should be in reach whether he uses it or not. I am not sure if the bed alarm was in place at the time of (R2's) fall. If (R2) had assistance with toileting, it would have prevented him from falling. He does need supervision and constant safety reminders. Supervision should be in place to prevent falls.On 3/13/26 at 2:25 pm, V11, License Practical Nurse (LPN), stated, (R2) was in the bathroom, and a resident was passing by and saw (R2) on the floor. I responded immediately and at that time (R2) was alert and responsive. (V12, Certified Nursing Assistant/CNA) came into the room and helped. We encourage him to use the call light, but he always gets up by himself. He does require frequent monitoring. He should have been supervised going to the bathroom or when ambulating. He is at high risk for falls because he does have a history of falls. He was on fall precautions at that time. He had a bed alarm, but I did not hear the bed alarms. I had the whole floor and was at the other end of the hallway. At that time, I was the only nurse working the entire floor. There were 3 CNAs also working on the floor. It could have been a safer environment if there was more than one nurse working on the floor.On 3/13/26 at 2:45 pm, V12, CNA, stated, I was assigned to (R2) the day of the fall. I heard one of the roommates say, 'That boy done fell' (sic). I went into the bathroom in the room and (R2) was laying on his back, there was blood coming out of the front of his head. I called the nurse to come into the room. He did not have his walker with him at that time. When he has the urge to go to the bathroom, he will just go. He did have the bed alarm at that time. The alarm was very faint like the battery needed to be changed. The alarm could not be heard in the hallway. If it had not been for the roommate, we would not have known he had fallen. I had already rounded that room I was a few rooms over. We make rounds every 2 hours. His call light should be in place if the residents need anything, they can get help instead of the other resident saying, 'That boy needs help.'On 3/13/26 at 3:00 pm, V2, Director of Nursing/DON stated only residents who are at high risk for falls have bed alarms. If a fall occurred, they should be considered as high risk for falls. Surveyor inquired about R2's December 2025 and January 2026 fall risk evaluation that R2 was categorized as low risk for falls with a score of 0. V2 stated, That assessment is not accurate; he should be high risk for falls. Bed alarms batteries are changed by the restorative aides and CNAs. Call lights should always be in reach whether they are used or not. Staff should be rounding on residents every two hours and PRN (As Needed). Facility's job description titled, LPN Floor Nurse, dated 12/1/19, documents, Summary/ Objective: In keeping with our organization's goal of improving the lives of the guest we serve, the LPN plays a critical role in providing superior customer service and nursing care to all guests. The LPN provides supervision of staff and will safeguard the health, safety and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures.Facility's job description titled Certified Nursing Assistant, dated 5/20/22, documents, Summary/ Objective: In keeping with our organization's goal of improving the lives of the guest we serve, the CNA plays a critical role in providing superior customer service and nursing care to all guests. The CNA safeguards the health, safety and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential function: 11. Follow established safety precautions when performing tasks and using equipment and supplies. 13. Report all hazardous conditions, damaged equipment, accidents/incidents and supply issues to the supervisor.Facility's policy titled, Fall Occurrence, dated 6/30/25, documents, Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure: 1. A fall risk assessment form will be completed by the nurse or the falls coordinator upon admission, readmission, quarterly, significant change, and annually. 2. Those identified as high risk for falls will be provided fall interventions. 3. If a resident had fallen the resident is automatically considered as high risk for falls.

Based on observation, interview, and record review, the facility failed to display [NAME] information in a public and accessible location, informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition.These failures have the potential to affect all 85 residents in the facility. Findings include: On 11/18/2025 at 2:36 PM, V5 (Social Service Director) stated V30 ([NAME] agent) is the agent that works for [NAME] program. V5 submitted a list of six (6) residents with two (2) residents crossed out. V5 stated the 2 residents that were crossed out were already discharged , not through [NAME] program. V5 was asked if residents included on the list were being coordinated to V30 ([NAME] Agent). V5 stated she communicates with V30 including email communication. V5 was requested to submit email correspondence related to [NAME] Program and other document to support coordination between facility and V30. V5 was then requested to go to the location where [NAME] information is posted informing residents with [NAME] program. V5 went to the 2nd floor in front of elevator where a bulletin board with glass sliding was located. V5 checked each poster and stated there is no [NAME] Program posted. V5 said, I can see it is not there; somebody may have taken it out. V5 was asked if there are other places to check for the [NAME] information. V5 replied there are no other places information being posted except this bulletin board. On 11/19/2025 at 12:00 PM, a follow up was done to V5 on the request of documents related to [NAME] program. V5 replied she will follow up on the request. V5 was asked specific question related to participation of facility related to [NAME] program. V5 replied, I need to follow up with that, to most of the questions. When asked about providing educational materials or information on [NAME] program to residents, V5 stated she was not aware on providing educational information to residents regarding [NAME] program. On 11/20/2025 at 10:37 AM, V1 (Administrator) stated the [NAME] program for resident is to be able to get housing and be notified of their ability to get housing through the program. V1 stated the [NAME] agent can access (Online System); the facility does not need to provide information to [NAME] agent. V1 was asked if all the information in (online system) including educational material, discharge paperwork is accessible via (online system). V1 stated, I will get back on that, I don't know yet. V1 was made aware the facility does not have [NAME] information posted for resident referral. V1 stated, I get that you are asking for proof or evidence that facility is coordinating with the [NAME] agent. Facility's [NAME] policy and procedure was also requested from V1. All requests to V5 and V1 related to [NAME] program were not provided.

Based on observation, interview, and record review, the facility failed to properly label and store food. These deficient practices have the potential to affect all 85 residents receiving food prepared in the facility kitchen. Findings include: On 11/18/2025 at 10:03AM, a tour of the kitchen was conducted with V20 (Food Service Manager). V20 and surveyor observed in the walk in-cooler, the following food items: - *1 open box of multiple heads of romaine lettuce that is wet and discolored a dark black color, with a receive date of 11/17/25.- * 1 open box of multiple heads of cabbage with discolored black spots on different areas of the cabbage leaves, with a receive date of 11/10/25.- * Multiple packages of ground beef meat inside a gray bin with a receive date of 11/17/2025, no use by date or expiration date labeled on the bin. V20 was observed removing the box of romaine lettuce from the cooler and stated the lettuce looks bad and believe it's molded already. V20 stated she has to discard the box of lettuce.V20 was observed removing the outer layers of the cabbage leaves, which contained the discolored black spots, from multiple heads of cabbage. V20 was observed discarding the cabbage leaves. On 11/18/2025 at 10:24AM, surveyor observed inside the dry food storage room with V20. Surveyor observed two white deep freezers located inside. V20 stated one freezer is the vegetable storage freezer, and the other freezer is the meat storage freezer. Surveyor observed the following inside the vegetable storage freezer: - *1 open bag of carrots, no receive date, and no use by date or expiration date labeled on the bag of carrots.- *1 open bag of cauliflower, no receive date, and no use by date or expiration date labeled on the bag of cauliflower. Surveyor observed the following inside the meat storage freezer: - *1 open box of sausage, no use by date or expiration date labeled on the box of sausage. V20 stated all food items stored in the coolers and freezers should have an open date and expiration date written on the packaging. V20 stated all food items without an expiration date or use by date should be discarded and not stored in the cooler or freezer for resident use. V20 stated there is no way to determine how long a food item has been stored if it is not labeled with a date. If residents are served expired food items in the facility, then there is a potential for residents to contract a food borne illness. Facility document, dated 11/19/2025, titled Order Listing Report documents there are no residents who are NPO/nothing by mouth in the facility. Facility document, dated 11/18/2025, titled Client List Report documents a total of 85 residents receive food prepared in the facility's kitchen. Facility policy dated 06/30/2025 titled, Kitchen documents, Food should be free of slime and mold. Refrigerated food should be covered, dated, labeled, and shelved to allow air circulation. Open containers or potentially hazardous food or left over should be dated and used within 3-5 days in the refrigerator.

Based on observation, interview, and record review, the facility failed to ensure discontinued medications are not administered and properly destroyed for 1 (R72) out of 5 residents reviewed for medication administration in a sample of 18. Findings Include:On 11/19/2025 at 10:34 AM during the medication pass, V24 (Registered Nurse, RN) opened the medication cart on the third floor, unlocked the narcotic medication bin, and dispensed a Tramadol 50 mg tablet. V24 was asked, What do the physician orders indicate as far as the medication dose, route and frequency? V24 logged in to the electronic medical record (EMR) and stated, I do not see an active order for (R72) to receive a Tramadol 50 mg tablet.On 11/19/2025 at 10:39 AM, V24 was asked what is the process for medication administration and what is the nurse required to do after narcotic medication has been discontinued per physician orders. V24 stated, I must complete a pain assessment, check the MAR (Medication Administration Record). I will call the Director of Nursing, and we will have to dispense this medication together. V24 stated she did not know the medication was no longer active. She stated she dispensed the medication without verifying the orders in the EMR because she remembered R72 had some Tramadol in the narcotic bin inside the medication cart.On 11/19/2025 at 10:49 AM, V2 (Director of Nursing, DON) verified R72 did not have an active physician order for Tramadol 50 mg tablet. V2 stated, There is no active order for this medication, we will have to discard it, and I will remove it from the medication cart.On 11/19/2025 at 1:30 PM, V2 stated, The nurse should first complete a pain assessment using a pain scale of 0-10, verify the EMR and confirm that the resident has an active order for a pain medication, and lastly verify the right patient, the right medication, right dose, right route, and the right time. (R72) does not have an active order for a Tramadol 50 mg tablet. The medication was originally prescribed on October 13, 2025. The order was for Tramadol 50 mg tablet; Take 1 tablet by mouth every 6 hours as needed for moderate to severe pain times 14 days. Tramadol 50 mg tablet was discontinued on October 21st, 2025. The nurses on several shifts administered the medication on 10/23/25, 10/26/2025, 10/28/2025, 11/7/2025, 11/10/2025, 11/12/2025, 11/15/2025, 11/16/2025, and 11/18/2025. V2 was asked what can potentially happen if a narcotic medication is given to resident for long term use. V2 stated, It can cause an adverse effect, abuse of narcotics, and dependence.Policy titled Controlled Substances, with review date of 09/2018, documents, Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with states and federal laws and regulations. Accurate inventory of all controlled medications is always maintained. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): Date and time of administration, amount administered, remaining quantity, signature of nursing personnel administering the dose, initial of the nurse administering the dose.

Based on interview and review of records, the facility failed to document offering vaccination to 1 out of 5 residents (R87) reviewed for vaccination Findings include: R87's immunization record does not document the resident received or was offered Covid 19 vaccination. On 11/19/2025 at 10:34 AM, V6 (Infection Preventionist / Registered Nurse) statedshe just started as an Infection Preventionist. V6 stated she still needs to address vaccination of some residents. Currently, residents that do not have documentation as to their immunizations were not offered vaccination yet. V6 stated vaccination is a priority, the importance of vaccination is to protect them (residents) and protect people around residents from infection. Covid 19 Vaccination Policy, dated 07/16/2024:The facility will comply with the applicable CMS, CDC, and/or IDPH guidance on Covid 19 vaccination. The facility will offer Covid 19 vaccination to residents and document administration in the resident's record.

Based on record review and interview, the facility failed to offer vaccination to 3 out of 5 residents (R7, R86, R87) reviewed for vaccination related to infection prevention. Findings include: R7's immunization history documents the last time resident received influenza vaccination was on 11/13/2022. Pneumococcal vaccine was not administered, due to refusal, since 07/21/2023. No documentation was available for each vaccine that was offered for the current year 2025. R86's immunization record documents the last time resident received influenza vaccination was on 01/04/2025. Pneumococcal vaccination (PCV13) received on 01/22/2020. Clinical Management / Infection Prevention, dated 03/04/2025, reads: Adult 50 years and older recommends PCV15, PCV20 or PCV21 pneumococcal vaccination. R87's immunization record does not document the resident received pneumococcal vaccination. On 11/19/2025 at 10:34 AM, V6 (Infection Preventionist / Registered Nurse) stated she just started as an Infection Preventionist. V6 stated she still needs to address vaccination of some residents. Currently, residents that do not have documentation as to their immunizations were not offered vaccination yet. V6 stated vaccination is a priority, the importance of vaccination is to protect them (residents) and protect people around residents from infection. Pneumococcal Vaccination Policy dated 07/15/2025:It is the policy of the facility to offer and administer pneumococcal vaccinations to each resident. Pneumococcal vaccination will be offered upon admission. Influenza Vaccination dated 07/15/2025:It is the policy of the facility to annually offer and administer vaccination against influenza to each resident.

Based on observation, interview, and record review, the facility failed to ensure discontinued narcotics are removed and disposed of from the medication cart for one resident (R72) out of a sample of 3 resident's reviewed for medication storage and labeling on a total sample of 18 residents.Findings include:On 11/20/2025 at 10:32 AM, during medication pass, V24 (Registered Nurse/ RN) wasleaving medication cart on the third floor unlocked and unattended.On 11/20/2025 at 10:34 AM, V24 opened the medication cart on the third floor, unlocked the narcotic medication bin, and dispensed a Tramadol 50 mg tablet before checking to see if the medication was still active on the medication administration record (MAR). V24 was asked to verify the medication order. V24 logged in to the electronic medical record (EMR) and stated, The Tramadol 50 mg tablet is no longer an active order. V24 was asked what can potentially happen if a medication that has been discontinued remains in the medication cart. V24 stated, The nurse can administer the medication to the resident.On 11/20/2025 at 10:49 AM, V2 (Director of Nursing, DON) logged in the EMR to verify if R72 had an active physician order for Tramadol 50 mg tablet. V2 stated, There is no active order for this medication, we will have to discard it, and I will remove it from the medication cart.On 11/19/2025 at 1:30 PM, V2 stated, Once the order is discontinued the nurse will give it to me along with the sheet, we do the medication reconciliation together, and then I will remove it from the medication cart.Policy titled Controlled Substance Disposal, with review date of 09/2018, documents, Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. All controlled substances remaining in the facility after a resident has been discharged or an order discontinued are disposed of: In the facility by the Director of nursing and consultant pharmacist (or other licensed personnel as permitted by states regulations), or by returning to the Drug Enforcement Administration (DEA), or by retaining for destruction by an agent of the DEA, or by sending to the appropriate state agency, as directed by states laws and regulations, and by the DEA.

Based on observation, interview, and record review, facility to ensure resident was receiving nutrition via G-tube according to physician orders for 1 (R8) out of three residents reviewed for tube feeds in a sample of 18.Findings include:R8's face sheet documents R8 is a [AGE] year-old male with a medical diagnosis of gastrostomy malfunction. R8's physician order sheet documents: In the evening Enteral feeding- G-Tube type: Osmolite 1.5 Rate:70ml/hour, start at 5pm and infuse until 1540 ml total volume is reached per day. Turn off during Activity of daily living care and as needed and every shift. On 11/18/2025 at 11:35 PM, R8 had a G-tube that was not connected to tube feeding and not running. On 11/18/2025 at 2:00 PM, V29 (Agency Licensed Practical Nurse/:PN) stated she is R8's nurse for today. V29 was asked, If (R8) has an order for G-tube feeding, what time do you start the feeding? V29 replied the evening nurse starts the feeding at 5:00 PM, and when it is empty by morning, she (V29) takes it down and the next feeding will be hung by the evening nurse again. V29 stated one osmolyte bottle is 1200mL. V29 was asked, If (R8's) order states that he should get 1540mL total, how long should the feeding run for at a rate of 70mL? V29 replied, For 22 hours. If (R8's) feeding starts at 5:00 PM, it should run till 3:00 PM. V29 stated R8 is not getting his full nutritional amount. V8 stated this has the potential to lead to weight loss.On 11/20/2025 at 11:15 AM, V2 (Director of Nursing) stated R8's feeding starts at 5:00 PM and should go till 3:00 PM, based on the rate and total amount that needs to be delivered. V2 stated this has the potential to lead to poor nutritional intake and weight loss if R8 does not receive his required tube feeding amount. Facility's enteral tube feeding care policy (6/30/2025) documents: The procedure is for the nurse to check the physician order sheet or medication administration record, for the order for enteral feeding interventions such as: feeding formula, type (bolus/continuous), rate, and duration.

Based on interview and record review, the facility failed to refer one resident with a known mental illness for a new level I Pre-admission Screening and Resident Review (PASRR) screening. This failure affects one (R64) out of eight residents reviewed in a total sample of eighteen. Findings Include:According to the admission Record, R64 is [AGE] years old, admitted to the facility on [DATE] with diagnosis of bipolar disorder with psychotic features, and major depression. On 11/20/25 at 10:55 AM, V28 (Admissions Director) stated R64's PASRR level I should be done prior to admission into the facility on 4/23/24 to determine if the nursing facility is able to meet R64's needs. V28 also stated R64's PASRR level I was incorrectly done in 2024 by the hospital, but the facility did not follow up until 11/18/25. The facility policy for PASARR Screening, dated 7/16/25, documents: The Medicaid-certified nursing facility will ensure that level I of the Pre-admission Screening and Resident Review (PASRR) is completed either by transferring hospital/facility, upon admission, or as soon as practicable thereafter, by the facility for all residents, regardless of payor, to determine if they have a Mental Disorder or Intellectual Disability.

Based on interview and record review, the facility failed to develop a comprehensive and individualized care plan for a Stage IV pressure for one (R3) of four residents reviewed for improper nursing care. The findings include: R3's face sheet's showed admit date on 4/18/25, with diagnoses not limited to Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, Pressure ulcer of sacral region stage 4, Type 2 diabetes mellitus, Essential (primary) hypertension, Disorder of prostate, Unspecified dementia. R3's health record showed discharge date on 8/1/25. MDS (Minimum Data Set), dated 7/7/2025, showed R3's cognition was intact. He needed Substantial / maximal assistance with eating, oral and personal hygiene; Dependent with toileting hygiene, shower / bathe self, upper and lower body dressing, chair / bed transfer. R3 was always Incontinent of bowel and bladder. MDS showed 1 Stage IV pressure ulcer that was present upon admission / entry.On 9/26/25 at 10:01 AM, V7 (Wound Care Coordinator, LPN / Licensed Practical Nurse) stated she has been working in the facility for almost a year. V7 stated R3 had no skin breakdown upon initial admission. V7 said R3 went to the hospital several times and came back to the facility with Stage IV pressure ulcer on sacral area. SR3 was followed up by wound Nurse Practitioner/NP. V7 said skin breakdown / pressure ulcer should be care planned. The care plan is a document that needs to be known for the resident so staff would be able to know how to care for the resident. V7 said care plan will show what needs to be done or it is the plan of the care of the resident that would include goals and interventions. She said she is responsible in doing the care plan for skin impairment.Survey resumed on 11/14/25 due to Federal Government Shutdown that began on 10/1/25.On 11/14/25 At 12:41pm, V2 (DON / Director of Nursing) stated care plan should be person centered and individualized. It includes problem / concerns, goals, and interventions. V2 said plan of care would direct staff on how to care for the resident. Surveyor reviewed R3's care plan with V2; no care plan found for R3's stage IV pressure on Sacrum. She said there should be a care plan for Stage IV pressure ulcer done by wound care nurse. On 11/14/25 At 12:51pm, V7 (Wound Care Coordinator) stated Care plan should be done for residents with skin impairment including pressure ulcer. She said care plan should be individualized and includes concern/ comorbidities, type of wound and stage of pressure ulcer, goals and interventions. V7 said care plan is the plan of care of the resident that would direct staff what to do. Surveyor reviewed R3's care plan with V7, no care plan found for R3's stage IV pressure ulcer to sacrum.V26 (Wound Nurse Practitioner / NP) notes, dated 7/28/25, showed: R3 with Stage 4 pressure ulcer on sacral. Wound size: 8cm x 12.5cm x 1.3cm. Wound base: 60% granulation, 40% slough. Exposed tissues: Subcutaneous, muscle / fascia, tendon/ligament, Bone. Exudate: Heavy amount of serous. R3's skin / wound evaluation, dated 7/5/25, showed: Community acquired Stage IV pressure ulcer to sacrum. Measurement: 10.5 x 6.5 x 1.6cm. R3's POS (Physician Order Sheet), order date 7/29/25, showed: Clean sacrum with normal saline pat dry apply Betadine-soaked gauze cover with dry dressing secure with a border dressing daily and PRNR3's hospital records, dated 8/1/25, showed: R3 presented on 8/1/25 with sacral ulcer. During this admission, ID (Infectious Doctor) and general surgery were consulted for stage IV sacral wound infection. R3 underwent sacral bone debridement with bone biopsy on 8/6/25 and the bone biopsy culture grew polymicrobial. His AMS (Altered Mental Status) has been improved, which is likely secondary to UTI (Urinary Tract Infection) and sacral wound infection given significant improvement after starting antibiotic and surgery.R3's TAR (Treatment Administration Record) for the month of July reviewed with no concern.R3's care plan reviewed on 9/24/25, 9/26/25, 9/30/35, and 11/14/25; no care plan found for Stage IV pressure ulcer to sacrum. On 11/17/25, facility provided R3's care plan that showed care plan for skin impairment with information and documentation that was not present on the previous care plan records provided to and reviewed by surveyor with V2 and V7. Facility's care plan policy, dated 6/30/25, showed: It is the facility of the facility to ensure that all care plan are in conjunction with the federal regulations. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7days.

Based on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are accurately documented for eight (R8, R16, R26, R33, R53, R61, R127, R277) out of eight residents reviewed for resident records. Findings include: On 10/29/2024 at 11:30 AM, V14 (Certified Nursing Assistant/CNA) stated, I believe there are 10 residents I am responsible for. Surveyor questioned V14 what room numbers she was responsible for. V14 voiced the room numbers she was assigned to. V14 stated she works from 7:00 AM until 3:00 PM. Surveyor questioned V14 on what her next duties/tasks she was going to carry out. V14 stated, I was waiting on the other lady to come in, so she can chart under my name, lunch is about to come, she doesn't have a log in. V14 reported she is just helping the lady out with the charting. Surveyor questioned V14 for the name of the person that doesn't have log in. V14 stated the other CNA is V15 (CNA). V14 stated, If the resident received care and it is documented, that is what matters. On 10/29/2024 at 1:07 PM, V15 stated she works through an agency, and she works for the facility once in a blue moon. V15 stated she is documenting resident's care provided under another CNAs account. V15 stated she has not been able to log in the account she was given. On 10/29/2024 at 1:09 PM, V3 (Assistant Director of Nursing) stated all agency staff are provided with an individual electronic login access to document their work. On 10/30/24 at 3:48 PM, V32 (Certified Nursing Assistant) stated =she has worked for the facility for about 7 months. V32 stated she has her own individualized login to POC (Plan of Care) access. V32 stated POC is where the CNAs document what care they provided. V32 stated staff are not allowed to share login information. V32 stated, If I can't remember my password, I will request new one. It is private information. HIPAA (Health Insurance Portability and Accountability Act) law. Employees cannot share that information. It doesn't matter if I was assigned CNA yesterday. The facility's floor assignment, dated 10/29/2024, documents the assignments assigned to V14 and V15. V15 is assigned to R8, R16, R33, R52, R61, R127, and R277. R8's bowel task, dated 10/29/2024 at 11:24 AM, documents R8 had a bowel movement, and it was documented by V14 (CNA). R8's urinary/bladder task, dated 10/29/2024 at 11:24 AM, documents R8 is continent, and it was documented by V14. R16's urinary/bladder, dated 10/29/2024 at 1:21 PM, documents R16 is continent, and it was documented by V14. R16's bowel task, dated 10/29/2024 at 1:21 PM, documents none and it was documented by V14. R26's bowel task, dated 10/29/2024 at 11:48 AM, documents none and it was documented by V14. R26's bladder task, dated 10/29/2024 at 11:48 AM, documents continent and it was documented by V14. R33's bowel task, dated 10/29/2024 at 1:24 PM, documents none and documented by V14. R33's bladder task, dated 10/29/2024 at 1:24 PM, documents incontinent and it was documented by V14. R52's urinary/bladder task, dated 10/29/2024 at 11:37 AM, documents incontinent and it was documented by V14. R52's behavior monitoring, and intervention task, dated 10/29/2024 at 11:28 AM, documents no behaviors observed, and it was documented by V14. R52's bowel task, dated 10/29/2024 at 11:37 AM, documents none and it was documented by V14. R61's urinary/bladder task, dated 10/29/2024 at 11:40 AM, documents incontinent and it was documented by V14. R127's urinary/bladder task, dated 10/29/2024 at 1:35 PM, documents incontinent and it was documented by V14. R127's behavior monitoring and intervention task, dated 10/29/2024 at 1:35 PM, documents no behaviors observed and documented by V14. R277's urinary/bladder, dated 10/29/2024 at 11:44 AM, documents continent and it was documented by V14. R277's bowel task, dated 10/29/24 at 11:44 AM, documents none and it was documented by V14. Facility document, dated 05/20/2022, titled Certified Nursing Assistant documents, in keeping with our organization's goal of improving the lives of the guests we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Completes medical records documenting care provided and other information in accordance with nursing policies while maintaining strict confidentiality.

Based on observation, interview, and record review, the facility failed to date and label insulins and eye drops per policy; failed to maintain medication carts free from insulin that were expired; failed to store controlled substances inside a double locked storage; and failed to maintain medication storage area free from controlled substance that was discontinued. These failures affect 6 residents (R19, R30, R2, R1, R53, and R3) reviewed for drug storage. Findings include: On [DATE] at 10:25 AM, with V10 (Registered Nurse / Agency), the following insulins were found: R19's Insulins Lispro had no date and Fiasp insulin had written as follows: date opened [DATE], and date expired was [DATE]. V10 stated it should not be in the medication cart because it was already expired. R30's insulins Lispro and Fiasp both had no date written. V10 stated, All of insulins are being used because it is inside the medication cart. It should have been dated when opened and the expiration date is 28 days after opening. R2's Lorazepam Injection Solution 2 MG per ML was not in the medication cart. V10 stated, It is in the refrigerator at the nurse station. All floors of the facility with residents does not have medication room. They have a cabinet with small refrigerator where medications are stored. At the nurse station, there is a cabinet that has a small refrigerator inside. The cabinet door has a lock and the refrigerator has a padlock.Both of them were not in a locked position. It could be opened without using a key. V10 opened the cabinet and padlock. Both of them were already opened and not locked. V10 was asked why both cabinet door and padlock was left unlock when there is narcotic inside the refrigerator. V10 stated it supposed to be locked, but he forgot. Inside the refrigerator, V2's Lorazepam vial was found. V10 stated, It needs to be locked because there is narcotic inside the refrigerator. Without locking either the cabinet door or the refrigerator anyone can access the narcotic medicine. Review of R2's Lorazepam order by the physician reads this medication was discontinued on [DATE], but ir still inside the refrigerator, with other medication was for general usage. On [DATE], at 10:53 AM, with V11 (Licensed Practical Nurse), the following insulins were found: R1's Novolog insulin vial has written as follows: date opened [DATE], and date expired [DATE]. R53's Humulin ,d+[DATE] insulins has written as follows: date opened [DATE], and date expired [DATE]. And Lantus insulin has no date. R3's insulins Lantus and Humulin ,d+[DATE] insulin has no date written. On [DATE], at 11:15 AM, R65's Latanoprost eye drop, inside the medication cart, has no date. On [DATE], at 10:43 AM, with V2 (Director of Nursing) stated, Insulin needs to have an open date and expiration date when first opened. When narcotic medication is discontinued, normally nursing staff brings it and be destroyed per Pharmacy guidelines.All narcotics should be stored in double lock storage. 10 CC's of water per pill. Medication Pass policy dated [DATE], reads: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Under medication labeling, all opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening and Xalatan eye drops which can be discarded 6 weeks after opening. Follow pharmacy recommendation as to when the medication should be discarded after opening. Insulin vials are to be discarded within 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening. Under controlled substances, all scheduled 2 controlled substances will be stored properly and double locked.

Based on observation, interview, and record review, the facility failed to ensure narcotic medication or controlled substance were accounted correctly as to recording compared to the actual medication per policy; failed to separate each medication during gastronomy tube administration; and failed to ensure insulin is available per physician order to avoid delay of administration. These failures affect 6 residents (R23, R2, R53, R127, R69, and R11) reviewed for medication administration. These failures affect 6 residents (R2, R11 R23, R53, R69, R127) in receiving proper pharmaceutical services. On [DATE], at 10:25 AM, V10 (Registered Nurse / Agency) gave a folder that includes narcotic record documents. A document titled Shift Change Accountability Record for Controlled Substances, dated [DATE], was not signed/initialed. V10 stated, I forgot to sign that narcotic medications were counted as correct. The nurse that will be leaving and the nurse that is incoming (V10) during change of shift need to count all narcotics to make sure that the count is correct. V10 was asked if the counting was done. V10 did not answer. All narcotic medications inside the cart were counted with V10. After counting, R23's Pregabalin 75 MG was seen with discrepancy. Controlled Drug Administration Record documents from the pharmacy reads there is one (1) capsule left. The card for the same narcotic was seen without any medicine left. V10 said he forgot to sign, took out his pen and was about to sign the document. When V10 gave both copies after request, both documents were filled up to correct discrepancies. V10 stated when he went to the nurse station, he signed the documents. On [DATE] at 10:53 AM, with V11 (Licensed Practical Nurse) inside the medication carts two resident's narcotic medications did not tally to the records, and the actual count of medicines were: R53 Oxycodone 10 MG record has 4, actual count of tablets has 3. R127 Morphine Sulfate 15 MG record has 18, actual count of tablets has 17. V11 stated she was supposed to sign when giving narcotic medications, but forgot. On [DATE], at 9:34 AM, V12 (Licensed Practical Nurse) was preparing medications to administer via gastronomy tube to R69. The following medications in tablets form were prepared: - Senna Plus 8XXX,d+[DATE] MG 2 tablets - Amlodipine 10 MG 1 tablet - Carvedilol 25 MG 1 tablet - Modafinil 200 MG 1 tablet - Vitamin C 250 MG 2 tablets V12 popped each tablet out, putting it inside the medication cups. Each cup was stacked on top of each another. All four cups were exposed to high touch areas and made contact with the medicine. Not all medications were placed in individual medication cups. Amlodipine and Carvedilol medications were placed in a single cup. After V12 washed her hands and put on her gloves, V12 touched the bed surroundings, including the rails and bed remote control to elevate the head of the bed. V12 then administered each cup touching the enteral/gastronomy tube with one hand and the other hand inserting the syringe to the tube to administer the medication. V12 uses the same gloves that touched unclean surrounds/environment. V12 stated she placed two different medications in a single cup because they are both blood pressure medicines. V12 stated she should have separated those two medications since they need to be flushed independently with 10 ML of water in between. V12 stated she should refrain from touching high touched areas to maintain cleanliness including contacting the tubing, but she forgot. On [DATE] at 12:28 PM, V13 (Restorative Director / Licensed Practical Nurse) took the blood sugar of R11; the result was 243. After getting the result of blood sugar, V13 used an alcohol pad to apply to the open skin of R11's finger. V13 then put a tissue on the bed which was open and was sticking out of the box. V13 then wiped the blood off R11's finger. V13 returned to her medication cart and took the insulin out for R11, that read Humalog insulin. V13 was asked, Is this the insulin that you will give to (R11)? V13 stated, Yes. V13 was then asked, For how long does this insulin expire? V13 stated, 28 days. The insulin had a written open date of [DATE] and expiration date of [DATE]. The number 30 was written on top of the original number. V13 was asked if the calculation of 28 days after [DATE] is correct? V12 (Licensed Practical Nurse), sitting at the nurse station near V13, stated after checking her phone's calendar, It expired on [DATE]. It was corrected by V13 to [DATE] after rechecking. V13 then checked her medication cart and could not find R11's insulin that was not expired. V13 was not able to give R11's insulin until 2:20 PM. Per V13, she needed to call the physician to get a one-time dose, because the only available insulin is a pen, and not a vial. On [DATE] at 10:43 AM, V2 (Director of Nursing) stated, Insulin needs to have an open date and expiration date when first opened. Nurses who gave narcotic medication should sign on the eMAR (electronic Medication Administration Record) and pharmacy document in the narcotic book. When giving medication via G Tube (stomach tube), each medication needs to in separate cups to identify each medication in case the resident vomited when administering. It also needs to be flushed with 10 CC's of water per pill. Medication Pass policy dated [DATE], reads: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Under medication labeling, all opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening and Xalatan eye drops which can be discarded 6 weeks after opening. Follow pharmacy recommendation as to when the medication should be discarded after opening. Insulin vials are to be discarded within 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening. Under controlled substances, all scheduled 2 controlled substances will be stored properly and double locked. Under procedure related to G - Tube medications, separate each medication in medication cup and flush in between each medicine with at least 5 ML of water. Can use the water to rinse the medication cup as flushing in between medicine. Under controlled substances, all scheduled 2 controlled substances will be stored properly and double locked. Controlled Medications Count policy dated [DATE], reads: It is the policy of the facility to maintain accurate count of Scheduled 2 controlled medications. Under procedure, after removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken.

45000 Based on observation, interview, and record review, the facility failed to ensure appropriate use of personal protective equipment (PPE) worn by staff caring for a resident with a known infectious disease (R50), and failed to ensure staff maintains clean technique/infection control practice while performing a bed bath (R3) for one resident. These failures affect 2 residents (R3 and R50) reviewed for infection prevention and control in a total sample of 21 residents reviewed. Findings include: 1. R50's physician order sheet/POS, dated 10/21/2024, documents R50 is on contact isolation precautions for shingles. On 10/29/2024, at 11:41 AM, V5 (Registered Nurse/RN) stated R50 is on contact isolation in the facility due to R50 being diagnosed with shingles. On 10/29/2024, at 11:48 PM, surveyor observed a sign posted on R50's door that reads, Contact Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. On 10/29/2024 at 12:39 PM, V6 (Certified Nursing Assistant/CNA Supervisor) entered R50's room with a meal tray, without donning any personal protective equipment/PPE. V6 observed moving items on R50's bedside table and placing the meal tray on R50's bedside table. V6 then observed exiting R50's room. V6 stated she was aware R50 has shingles. V6 stated she is aware staff only need to wear PPE inside of R50's room whenever staff are providing direct patient care. After reading the sign on the door, V6 stated she should have worn a gown and gloves prior to entering R50's room. V6 stated she did not really read the sign posted on R50's door. V6 stated she could potentially cross contaminate and spread R50's infectious disease to another resident if the appropriate PPE is not worn while inside of R50's room. On 10/29/2024 at 1:16 PM, V7 (Certified Nursing Assistant/CNA) was observed entering R50's room without donning any personal protective equipment/PPE. V7 was observed grabbing R50's meal tray located on R50's bedside table. V7 then exited R50's room and placed the meal tray onto a meal cart located outside of R50's room. V7 stated she is aware R50 has shingles. V7 stated she was made aware by management, the nursing department, and the infection preventionist that staff does not have to wear PPE inside of R50's room if staff are only passing meal trays. V7 stated she was made aware she only needs to wear PPE inside of R50's room if she has contact with R50. After reading the sign, V7 stated she should have worn a gown and gloves prior to entering R50's room. V7 stated she is not the only staff member who enters R50's room without wearing PPE. V7 stated she could potentially spread R50's infectious disease to another resident if the appropriate PPE is not worn while inside of R50's room. On 10/30/2024 at 2:28 PM, V4 (Infection Preventionist/RN) stated he expects staff to perform hand hygiene prior to entering a resident's room who is on contact isolation. V4 stated staff should also wear a gown and gloves prior to entering a contact isolation room regardless of what services are being provided, including passing meal trays. V4 stated if the appropriate PPE is not worn while inside of a contact isolation room, there is potential for transmission of the infection by the staff members. Facility policy, dated 07/31/2024, titled Infection Prevention and Control documents in part, 2. Contact Precaution- Intended to prevent transmission of infectious agents spread by direct or indirect contact with a patient or the environment. b. Use of gown and gloves is necessary prior to room entry. 49666 2. R3's Face sheet documents R3 is a [AGE] year-old female admitted to the facility on [DATE], who has diagnoses not limited to: morbid (severe) obesity due to excess calories, chronic diastolic (congestive) heart failure, hemiplegia and hemiparesis following cerebral infarction, neuromuscular dysfunction of bladder. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R3 is cognitively intact. R3's Minimum Data Set (MDS), section GG dated 08/23/2024, documents in part R3 requires Substantial/maximal assistance for shower/bathe self. On 10/29/2024 at 11:09 AM, R3 was lying on her bed, alert and responsive, and in no apparent distress. R3 stated there are certain CNAs (certified nursing assistants) that don't give her adequate bed baths, and R3 stated they just dab and don't clean her perineal area well. R3 stated staff don't clean certain areas on the body, and they need to clean between the buttocks. R3 stated the CNAs tell her that they are told they can't go that far, and they won't clean between her buttocks, by her rectum. R3 stated she last had a bed bath on Friday and is due for today. R3 stated she has had times where her skin is irritated and feels itchy under her breasts. R3 stated she once thought she had a bowel movement and when the CNA checked her, R3 didn't have a bowel movement, but the smell was coming from R3's right under arm. On 10/29/2024 at 11:30 AM V14 (Certified Nursing Assistant/CNA) stated that she has one resident's bed bath to complete. V14 stated that R3's bed bath is scheduled today. V14 stated she just started working on October 15, 2024. V14 stated that she has been a CNA for a long time. On 10/29/2024at 1:39 PM, V14 gathered supplies for R3's bed bath. V14 was approached by V29 (CNA/Wound Tech) to ask V14 if she needed her assistance. V14 agreed for V29 to assist her. CDC (Centers for Disease Control and Prevention) enhanced barrier precaution sign outside of R3's bedroom door. Both V14 and V29 applied disposable gowns, gloves, and entered R3's room. V14 grabbed R3's basin, filled it with R3's body wash and water. V14 handed R3 a wet washcloth and R3 washed her face and then arms. V14 was standing watching television. V29 was standing too. V14 proceeded to remove soiled linen and applied new gloves. R3 stated, Can you get under my breast, it's really itchy. V14 lifted R3's breast and cleaned under it. V14 washed both of R3's under arms, rinsed the same washcloth with the same water. V14 proceeded to dry R3's under breast and under arms and threw the drying towel on the floor. V29 covered R3's breast for privacy. Surveyor observed bin with unclean water/murky appearance water. V14 questioned R3 if she would like for her to change the water, and R3 responded no. V14 did not verbalize any words to R3, and V14 then proceeded to use the same washcloth and clean R3's perineal area. V14 cleaned area around urinal catheter. R3 requested for V14 to clean her perineal area again. V14 cleaned area and proceeded to assist R3 to turn to her right side. V29 standing next to R3's right side for support. V14 cleansed R3's upper, mid, and lower back with the same washcloth that V14 cleaned R3's perineal area. V14 proceeded to wash R3's buttocks and rectal area. R3 noted with light brown stool between R3's buttocks. V14 used a clean new dry towel to dry R3's back. V14 looked at surveyor and stated, Just so you know this is not how I give bed baths. V14 continued to use the large dry towel to wipe R3's stool and V14 wiped all R3's stool. V29 applied body lotion onto R3's back. V14 changed her gloves and proceeded to apply new flat linen sheet, new yellow disposable brief, and assisted R3 to turn and lay on her back. R3 turned to her left side with assistance. R3's linen and brief were straightened out under her. R3 turned and laid on her back. V14 applied a clean hospital gown onto R3. R3's call light placed within reach. R3 placed in a comfortable position. V14 stated that he has completed the bed bath for R3. On 10/30/2024 at 10:36 AM, V4 (Infection Preventionist/Registered Nurse) stated, If they want to clean the perineal area, they should have one washcloth, and then they must change the gloves and the washcloth to prevent infection. The best practice is start from head to toes and clean from the cleanest area of the body to the dirtiest area the body. V4 stated once the nurse aid finishes washing the perineal area with the washcloth, they should grab a new washcloth to clean another part of the area. On 10/30/2024 at 2:12 PM, V30 (Regional Nurse Consultant) stated there is no bed bath procedure policy. V30 stated, The facility hosts skills fair; you have staff go over skills that were trained to reiterate on how to do the procedure, we do have those. Facility documen,t dated 08/19/24, titled Shower and Hygiene documents in part, it is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. Maintain clean techniques and isolation precautions as indicated. Facility document, dated 7/31/24, titled Infection Prevention and Control documents in part, the facility has established a policy to identify, record, investigate, control, test, and prevent infections in the facility. Staff will be educated about current infection control practices and procedures at least annually.

Based on observation, interview, and record review, the facility failed to follow their policy on resident food preferences for one (R70) resident in a total sample of 21 residents reviewed. Findings include: R70's Nutrition Progress Note, dated 10/20/2024, documents in part, Review of diet tolerance, PO (by mouth) intakes, appetite changes, weights, labs, medications, skin conditions. Recommend: Continue current diet, provide food preferences, provide foods from alternative menu, provide assistance with meals as needed, closely monitor diet tolerance, PO intakes, labs, and weights. Continue Pro Stat three times daily to maintain skin integrity. Will continue to monitor and make changes as necessary. Facility menu documents eggs were served in the facility for breakfast on 10/27/24, and 10/28/24. On 10/29/2024, at 11:50 AM, R70 stated the facility staff continues to serve her eggs on her meal trays for breakfast although she has informed the facility that she does not like eggs to eat. R70 states she has informed the Dietary Manager (identified as V8) of her dislike for eggs, and the facility still serves them to her on her meal tray. On 10/30/2024, at 9:55 AM, R70 states the facility served her eggs again today for breakfast, so she refused her breakfast meal tray. On 10/30/2024 at 10:06 AM, V8 stated she is aware R70 does not like eggs as a food preference. V8 stated she completes a food preference interview form with all the residents who are admitted to the facility. V8 stated she usually tries to complete the form within 2 days of the resident being admitted to the facility. V8 stated she completed a food preference interview form for R70, but is unable to locate the form in her files in her file cabinet. V8 then observed looking inside of a dark colored tote bag sitting in a chair next to V8. V8 took out a storage clipboard from the bag. V8 opened the storage clipboard and located R70's food preference interview form. R70's food preference interview form documented no eggs written in ink on the form. V8 observed deploying R70's facility dietary meal ticket on the computer. V8 stated R70's no egg preference was not documented on R70's facility dietary meal ticket. V8 stated R70's no egg preference should be documented on R70's facility dietary meal ticket. On 10/31/2024 at 1:36 PM, V8 stated eggs were served for breakfast in the facility yesterday on 10/30/2024, but did not print on the facility's menu. Facility policy, dated 07/26/2024, titled Food Preference Policy documents, Purpose: The facility will provide food that accommodates allergies and preferences. Policy: 1) The facility will identify resident's allergies, intolerances, and preferences based on medical record and interviews.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer preventative measures were accurately applied for two residents (R4 and R62) in a sample of 18 residents reviewed for pressure ulcer. Findings include: 1. R4's POS (Physician Order Summary) has active order, Patient to be on low air loss mattress at all times daily, afterrnoon, and every shift for pressure reduction, order date 8/27/24. On 10/29/24 at 12:40 PM, R62 was lying in bed on a low air loss. A fitted sheet was on the mattress, and a flat sheet folded two times was between R62 and the mattress. On 10/29/24 at 12:45 PM, V2 verified there was a fitted sheet, a flat sheet folded two times, and R62 was wearing a brief. 2. R62's POS has active order, Patient on LAL (Low Air Loss) mattress at all times every shift for pressure reduction. Order date 9/23/24. On 10/29/24 at 1:00 PM, R4 was lying in bed on a low air loss mattress. A fitted sheet was on the mattress. On 10/29/24 at 1:05 PM, V22 verified there was a fitted sheet, a flat sheet folded two times used as a draw sheet, and R4 was wearing a brief. V22 stated, Wound care said a fitted sheet and a draw sheet can be used on the low air loss mattress. On 10/31/24 at 2:00 PM, V28 (Wound Care Manager) stated, I started here May 21, 2024. According to company protocol, the air loss mattress should have a flat or fitted sheet, not both. They (staff) cannot use a draw sheet. They cannot use the flat sheet folded twice. That is four layers. They can use a blue pad or a chuck in place of the draw sheet, and the resident can have a brief on. There can be nothing more, no more layers. (R4) and (R62) are on a low air loss mattress by weight. (R4) needs the mattress for preventative measures. (R62) needs the mattress because (R62) has active wounds. There should be only three layers between the mattress and the resident, a sheet, blue pad, and a diaper. It was not correct to have the flat sheet folded two times. Proactive Medical Products Operation Manual reads in part: Installation Instructions Step 2, you may place a thin cotton sheet over the quilted mattress to cover. Operating Instructions Step 5, Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. Med-Aire 8 Alternating Pressure Mattress Replacement System With Low Air Loss User Manual, obtained from https://www.unitedmedsupply.com/drive-14027-drv14027 reads in part: Recommended Linen: Drive DeVilbiss Healthcare bed support surfaces are designed to be used with appropriate linens. Deep pocketed fitted or flat sheets are recommended. Multiple layering of linens or underpads beneath the patient should be avoided, when possible, for the prevention and treatment of pressure injuries.

Based on interview and record review, the facility failed to address a high blood sugar result for 1 out of 3 residents (R75) reviewed for blood sugar testing. Findings include: R75 was [AGE] years old, initially admitted on [DATE], in the facility with medical diagnosis that includes diabetes mellitus. V25 (Registered Nurse) progress notes, dated [DATE], reads R75 expired in the facility pronounced expired by EMS (Emergency Medical Service) at 3:15 PM. Also on the same progress notes, at 2:31 PM, R75's blood sugar was obtained, with 397 result. Per physician order, R75 was receiving Paxlovid medication for Covid-19 from [DATE] to [DATE]. There was an order to check R75's blood sugar before meals and at bedtime, and to call the MD (Medical Doctor) if blood sugar result is below 60 or above 300. R75's MAR (Medication Administration Record), dated [DATE], R75's blood sugar result was scheduled at 11:00 AM. R75's result was 33,3 which was above 300 that per physician order to call physician. Review of all documentation in R75's resident record does not reflect any documentation that any physician or nurse practitioner was informed of R75 blood sugar result. On [DATE] at 10:35 AM, V2 (Director of Nursing) stated during the time that R75 expired, she was not in the facility. V2 stated, I am not sure if the doctor was notified when blood sugar was 333. But I don't see any documentation that the doctor was aware. My expectation with my nurses is that they should follow doctor's order. A result of 333 was high blood sugar and the order was to notify the physician. Therefore, there should have been proper notification. V2 stated V25 is not employed by the facility anymore. On [DATE] at 11:13 AM, V13 (Restorative Director / Licensed Practical Nurse) stated she worked as nurse manager that day. V25 did not inform her R75's blood sugar was elevated. On [DATE], at 2:10 PM, V27 (Nurse Practitioner) stated R75's high blood sugar may be due to Covid-19, and may be due to non-complianace with diet. The first blood sugar result was more than 300. He was informed, but he did not get the next result until after 2:00 PM. V27 stated he instructed V25 to monitor R75. V27 stated he did not know R75's blood sugar further increased to 397 after 2:00 PM. V27 stated he should have been informed also about the other result which is 397. V27 stated normally he would order Hgb (Hemoglobin) A1C in this situation to address the problem, but did not. V27 stated he just ordered V25 to monitor R75. V27 stated he did some notes he saw R75 that day in the morning. V27 stated he did not document V25 informing him of R75's elevated blood sugar because the notes were done in the morning before he was informed by V25. Upon further review of V27's progress notes, it documents the progress notes were created on [DATE], contrary to R27's statement that he made his notes prior to R75's elevated blood sugar result. V27 was asked why he failed to document R75's blood sugar was elevated, and what has he done to address the problem? V27 stated he was referring to his early encounter; that is why he did not include R75's elevated blood sugar result. V27 was asked if he was informed by V25 that R75 had an elevated blood sugar result of 333. Was it important enough to include what care that was provided in his progress notes? V27 responded he did not document regarding R75 elevated blood sugar. He understands there was no documentation to support his statement he was informed of R75's elevated blood sugar, or that he addressed R75's elevated blood sugar. V27 said, Well you cannot prove that I was informed by (V25). I understand that if it was not documented, then it was not done. Management of Diabetes in Long Term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, dated 2016, reads: Glucose meter readings .250 mg/dL two or more times within 24-h period accompanied by a new or change in medical or functional status: - Call practitioner, - Increase frequency of glucose monitoring Glucose meter readings. Glucose meter readings .300 mg/dL during all or part of 2 consecutive days: - Confirm high glucose value by laboratory test, - Evaluate nutritional intake Any glucose reading too high to measure by glucose meter, - Adjust diabetes regimen as needed c If glucose levels are persistently high after changes to the diabetes regimen, consider medical evaluation for other causes.

Based on interview and record review, the facility failed to initiate a new Level I screen for one (R70) resident reviewed for Pre-Admission Screening and Record Review (PASARR) in a total sample of 21. Findings include: R70's Facesheet documents R70 was admitted to the facility on [DATE]. R70's Level I PASARR outcome documents R70 has an exempted hospital discharge, with a 30-day length of stay that expired on [DATE]. On [DATE], at 2:19 PM, V1 (Administrator) states the facility checks to see if a resident has a PASARR screening upon admission. V1 states the PASARR indicates the determination of needs/DON score for the individual resident. V1 states based on the DON score, it is determined if a resident is appropriate for the nursing home setting or not. V1 states she is unaware of the DON score ranges or what the different DON score ranges are indicative of. V1 states a PASARR Level II is needed for a resident if it is determined that the resident has an SMI/severe mental illness. V1 states the determination for a Level II PASARR screening is based off of the results of the Level I PASARR screening. V1 states R70 has been admitted to the facility for longer than 30 days, therefore, R70's exemption status has expired. V1 states R70's PASSAR screening expired on [DATE]. V1 states once a resident's PASARR screening expires, a new Level I PASARR screening has to be submitted to the designated screening agency. V1 states the purpose of the PASARR screening is to determine if a resident have any significant mental illnesses and to ensure that the facility is an appropriate setting for the residents. Facility policy, dated [DATE], titled PASSAR Screening of Residents with Mental Disorder of Intellectual Disability documents, Policy: It is the facility's policy to ensure that resident's with Mental Disorder and those with Intellectual Disorder will receive PASSAR Screening within the timeframe allowed.

Based on interview and record review, the facility failed to accurately complete one residents (R29) comprehensive annual assessment. Findings include: On 10/30/24 at 3:58 PM, V24 (Regional Director of Clinical Data Quality and Performance Audits) stated, Someone is covering MDS (Minimum Data Set) from another facility. On 10/30/24 at 4:25 PM, V1 (Administrator) stated, We do not have a current MDS Coordinator. On 10/31/24 at 9:10 AM, V19 (MDS Consultant) stated, (R29's) Census, 5/18/2024, is an error. (R29) went to the hospital and was admitted and returned with qualifying nights at the hospital. (R29) came back to the facility as dual (Medicaid and Medicare payor). MDS is scheduled in sequence. The census line has an error. The submitted MDS on 10/17/24, was a quarterly assessment, modified to be inactivated. MDS annual created it to be finalized on 10/31/24, with the same ARD (Assessment Reference Date) of the submitted MDS (10/17/24). Census drives the MDS. Assessments are in sequence. A quarterly was sent. The type of assessment was an error. We inactivated the quarterly and made an annual. Today (10/31/2024) is the last day to complete the annual. Entry and admission assessment and comprehensive are done yearly. Quarterly is every 92 days. A quarterly does not suffice as an annual, it is not comprehensive. We submitted the quarterly in place of annual in error. According to document provided by facility on 10/31/24, R29's next full ARD is 10/23/2024; next quarterly ARD is 1/17/2025. A quarterly assessment was submitted 10/17/2024 and inactivated. Annual and inactivation of quarterly are in progress.

Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by staff. This failure affected one resident (R1) who was handled roughly and was hit on the arm and the back by a facility CNA (Certified Nursing Assistant) as she attempted to redirect R1. This was identified as an Immediate Jeopardy which began on 06/30/24 when V20, Certified Nursing Assistant, physically abused R1. The immediacy was removed on 07/22/24. On 07/17/24, V1 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 07/17/24 at 2:41pm. The facility provided an acceptable removal plan on 07/22/34 at 5:34pm. On 07/23/24, through onsite observation, interviews, and record reviews, the surveyor confirmed the implementation of facility's removal plan. Although the immediacy was removed and the removal plan accepted, the deficiency remains at the second level of harm until the facility can determine the effectiveness of the implementation of removal. Findings include: R1's medical record documented R1 was admitted [DATE], with diagnoses that includes but not limited to Dementia in other diseases classified elsewhere mild with agitation, insomnia due to medical condition, essential hypertension, and chronic obstructive pulmonary disease. R1's plan of care for potential to demonstrate verbally and physically aggressive behaviors related to dementia, with initial date 08/11/2022, listed interventions including but not limited to when R1 becomes agitated, staff should walk calmly away, and approach later. R1's plan of care for presence of abuse and neglect factors, initiated 05/18/2024, has goals that include R1 will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect). On 07/10/24 at 10:34am, R1 was noted in the dining area, which is also used for activity with peers. R1 does not speak English, but is able to understand greetings in English language. At 12:25pm, V14 (Activity Director) stated R1 speaks Chinese; R1 was unable to recollect or speak of any abuse incident. On 7/10/24 at 12:26pm, V4 (Registered Nurse) and V5 (Registered Nurse) assessed R1's body, which showed bruising to the right antecubital area, which V4 attributed to R1's visitation to ER (emergency room ) on 07/08/24. V4 stated the bruising might be from possible IV insertion site at the hospital ER (emergency room ). On 07/10/24 at 3:00pm, V20, CNA (Certified Nursing Assistant), stated, I (V20) will tell you the truth. It happened about two weeks ago, and the whole thing was in the hallway where the video camera can pick it up (see it). Another staff, (V21, CNA) was also present when the incident occurred. V20 checked the calendar for the day she worked, and stated the incident happened on 06/30/24. V20 stated, (R1) was trying to sit on the floor. (R1) usually does this, and I was trying to grab (R1) quickly to get (R1) seated in the chair to avoid sitting on the floor. (R1) hit me with the elbow on the same spot I have being having pain. To be honest with you, I hit (R1) on the right hand. V20 was asked whether hitting a resident is a form of abuse, and whether V20 reported it to V1 (Administrator). V20 stated, Yes it is a form of abuse, but I never saw it as an abuse. When V20 was asked about the facility abuse policy and prevention of abuse and what V20 will do if she witnesses a resident being abused by staff, peers, or family member, V20 stated, I will report it immediately within 2 hours. On 07/10/24 3:13pm, V1, Administrator, stated the camera is reviewed daily and only 7 days of recording is stored. The only video camera recording history was from 07/01/24 to 07/10/24. V1 stated, The history from 06/30/24 has been wiped off. V1 was asked about the facility policy, and whether it is appropriate for staff to hit any of the residents. V1 stated, Abuse is a willful act that causes harm. V1 was asked under what situation/condition it is appropriate for your staff to hit a resident? V1 stated, Under no condition. V1 was asked whether hitting is a form of abuse, and V1 stated, Yes. On 07/11/24 at 4:05pm, V21 (CNA), whom V20 stated was present and witnessed the incident at the time of alleged abuse, stated, (R1) has dementia and can be combative at times, but that does not mean that the staff should abuse him ). I was in the dining area, and I saw (V20) hitting (R1) multiple times on the back, hands, and grabbing (R1) roughly on the arm. I told (V20) not to hit (R1), and (V20) said that (R1) hit her first, and 'I am not going to let (R1) hit me.' I told (V20) that she should have handled it in a better way that does not involve hitting (R1), which will not be abusive. No staff should hit any of the residents or handle them roughly, even with their bad behavior. V21 stated R1 has dementia and does not speak English. V21 stated, (R1) was crying and shouting, and that was why I looked in their direction. I reported it to the nurse (on duty) (V10), and nothing was done until you (referring to the surveyor) came here (facility). V21 was asked when would you report any alleged abuse. V21 stated, Immediately as soon as you see it. I reported it to the nurse on duty (V10) and they did nothing. She did it in front of the camera, it's not like she was hiding it. Even when I told her that it is not right, (V20) was confrontational about it. (V20) retaliated by hitting (R1) and that is wrong. On 07/11/24 at 4:30pm, V2, Director of Nursing (DON), stated, It is not appropriate for any of the staff to hit or handle any of the resident roughly. It should be reported when that happens. According to facility investigation, the facility concluded the allegation of abuse cannot be substantiated. On 07/23/24 at 2:09pm, V27 (Facility Medical Director) was asked whether hitting a resident is a form of abuse in V27's professional opinion. V27 stated, In this case, we (facility) think it is a form of self-defense. Residents should not be touched (physically abused). We protect them at all costs. They (staff) have the right to defend themselves. V27 stated the staff should defend themselves without aggressively attacking the resident and de-escalate the situation. V27 was asked whether staff should be correcting residents' aggressive behavior by hitting or slapping a resident. V27 stated, Of course not, no one should hit anyone. De-escalate. Protect your face, move away, and ask for help. On 7/23/24 at 2:26pm, V28 (Social Services Director) stated, (R1) has dementia and that was why (R1) was discharged to a memory care unit at a long-term care yesterday (07/22/24). (R1) has wandering behavior. Cognitively is severely impaired. Some behavior problems with history of verbal and physical aggression. V28 was asked whether V28 was informed of R1 being physically hit by staff. V28 stated, Yes, by (V1) when (V1) was informed (07/10/24). V28 stated staff hitting a resident is a form of physical abuse. V28 stated, It is never appropriate to hit a resident. Staff should de-escalate a resident's aggressive behavior, separate, get help, and make sure the resident is safe. V28 stated the Abuse Coordinator (V1), the Administrator, must be informed of any alleged abuse incident. On 7/23/24 at 3:09pm, V1 (Administrator) was asked whether it is appropriate for staff to hit a resident to de-escalate aggressive behavior. V1 stated, No, it is not appropriate. At no time is it appropriate for staff to hit a resident. V1 was asked how about in self-defense. V1 stated, It is not appropriate to hit a resident. It is a form of abuse. The facility policy titled Abuse and Neglect, with revised date of 06/06/24, documented it is the policy of the facility to provide professional care and services in an environment that is free from abuse, corporal punishment, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Abuse is defined as willful infliction mistreatment that includes punishment. The policy documented examples of physical abuse that includes but not limited to hitting, slapping, grabbing, and roughly handing. Potential aggressors listed include but not limited to facility staff. The policy listed 7 steps in abuse prevention including reporting/response. Listed procedure includes all allegations and/or suspicion of abuse must be reported to the administrator immediately. The facility Behavior Monitoring of Residents presented, with revised date of 06/06/24, documented policy statement it is the facility's policy to ensure that the residents with aggressive behavior are monitored. Listed procedure includes but not limited to if the resident's aggressive behavior is monitored anytime. On 07/23/24, the surveyor through observations, interviews, and record review, confirmed the following removal plan by the facility: 1. V20 suspended 07/10/14. 2. R1 is no longer residing at the facility. R1 has been discharged to another Long-Term Care on 07/11/24 3. R1 full skin assessment conducted 07/10/24. 4. R1 seen by psychotherapist on 07/10/24. 5. R1 evaluated by Physiatrist. 6. R1 screened for abuse/neglect 07/10/24. 7. V21 was suspended on 07/11/24 for not reporting to V1, pending investigation. 8. Staff are being educated on Abuse, initiated 07/10/24, with quiz to monitor effectiveness. 9. Abuse in-service completed 07/16/24. 10. Abuse in-service on Handling Aggressive Behaviors with quiz for 5 staff members three times per week for 12 weeks on-going. 11. Social Work outside consultation group initiated monthly in-service on de-escalation techniques and handling aggressive residents, initiated 07/19/24. 12. Staff training on facility code gray for aggressive behavior/violence, initiated and completed 07/22/24. 13. QA (Quality Assurance) audit on 3 times weekly times 12 weeks to ensure direct staff care staff (Nurses and CNA's), initiated 07/15/24. 14. Thirteen residents R1, R7, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22, were reviewed for abuse and aggressive behaviors. List of residents with behaviors provided and posted at the nurse's station inside a closed cupboard. 15. V27 (Medical Director) interviewed and was aware of the removal plan with V27's approval. 16. Staff interviewed: V4, V33, V40, RN (Registered Nurse), V14 (Activity Director), V29, V38 (Activity Aides), V22, HR (Human Resources), V28, SSD (Social Services Director), V31 (restorative aide), V37 (Certified Nurse's Aide Supervisor), V30, V32, V36 CNAs (Certified Nurse's Aides), V24, V26, V34 and V39 LPNs (Licensed Practical Nurses) were interviewed. No concerns identified.

Based on interview and record review, the facility failed to monitor R2, a cognitively impaired resident who was a known wanderer with an electronic monitoring safety device on R2's right wrist and left ankle; failed to respond to a stairwell door alarm; failed to identify R2, who was assessed at risk for elopement, on the facility's elopement risk list; failed to check the placement of R2's electronic monitoring safety device every shift per facility policy; and failed to weekly test the functioning of R2's electronic monitoring safety device per facility policy. These failures affected R2 who eloped from the facility on 6/4/23, was in an apartment 4 miles away and was returned to the facility over 15 hours later by the local police department which placed R2 at a potential risk for harm when reviewed for improper nursing care in the sample of six elopement risk residents (R2, R5, R6, R7, R8, R9). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 6/4/23 at 11:08 am when facility video footage showed R2 walking out the back door of the facility by R2's self into the parking lot then into the street. On 6/12/23 at 12:57 pm, V1 (Administrator) and V2 (Director of Nursing, DON) were notified of the Immediate Jeopardy. The survey team confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/21/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Admission Record documents, in part, that R2's diagnoses include traumatic subdural hemorrhage, cognition communication deficit, restlessness and agitation, lack of coordination, unsteadiness on feet, abnormalities of gait and mobility and repeated falls. R2's admitted to the facility was documented as 5/13/23. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 2 which indicates that R2 has severe cognitive impairment. R2's Functional Status indicates that for R2's ADL (Activities of Daily Living) task like walking in room, walking in corridor and locomotion on unit, R2 is coded for a staff support of supervision - oversight, encouragement or cueing. On 6/6/23 at 11:38 am, R2 was asked about leaving the facility (eloping) on 6/4/23. R2 stated, R2 doesn't go outside. R2, asked again about walking out of the facility on 6/4/23. R2 stated, R2 doesn't remember. On 6/6/23 at 1:19 pm, V1 (Administrator) viewed the facility's video footage from separate video camera views as follows: 3rd floor video camera: 6/4/23 11:05 am: R2 observed walking in the hallway near the nurse's station wearing a hoodie jacket, shirt, pants, and shoes. R2 turns out of the view of video camera back towards R2's room. 6/4/23 11:06 am: V4 (Agency Registered Nurse, RN) and V5 (Agency Certified Nursing Assistant, CNA) observed at the 3rd floor nurse's station. V4 is standing outside of the nurse's station with the medication cart up against the nurse's station wall. V5 is sitting in a chair at nurse's station. R2 enters the video camera view and walks behind V4 (who's back was to R2) and walks down the 3rd floor hallway. R2 was wearing a hoodie jacket (color appears gray or pale brown), shirt, pants, and shoes. 6/4/23 11:06:50 am: R2 observed pushing the 3rd floor west stairwell door open and exiting through the door. V4 observed with V4's head down looking at the medication cart. V5 observed sitting in the nurse's station in a chair with V5's head down looking at V5's cellular phone. Neither V4 or V5 turn their heads towards the west stairwell alarm or make any attempt to respond to the alarm. 6/4/23 11:08 am: V15 (Housekeeper) observed in view next to V4 still standing at the 3rd floor nurse's station medication cart. V15 observed conversing with V4 at the medication cart. 6/4/23 11:09 am: V5 observed walking down the 3rd floor hallway. V3 (CNA) observed walking out of the bathroom directly next to the nurse's station. After observing the 3rd floor video footage (from 6/4/23), V1 showed the video footage in a split screen with the 1ST floor back door, 3RD floor, and 2ND floor cameras at the same time. 1st floor video camera: 6/4/23 11:07:46: R2 observed walking out of the west stairwell into1st floor hallway. 6/4/23 11:07:56: R2 observed walking out of the first back door of the facility. V18 (Dietary Aide) observed walking in the 1st floor hallway towards the back door direction. Blue laundry bins observed in the 1st floor hallway. 2nd floor video camera: 6/4/23 11:07 am: 2nd floor nurse's station observed with several staff members sitting in chairs at the nurse's station. V1 stated, the electronic monitoring safety device alarm wasn't going off on the second floor. Parking lot camera: 6/4/23 11:08:12 am: R2 observed walking from the second back door of the facility into the parking lot. R2 walked through the small parking lot to the adjoining street (alley-like). R2 walked south (turning left) and then turned and walked north in the street. 6/4/23 11:08:53 am: R2 last observed on the facility video footage. On 6/6/23 at 11:17 am, V3 (CNA) stated, V3 was working on 6/4/23 on the 7:00 am to 3:00 pm shift on the 3rd floor and was R2's assigned CNA. V3 stated, (R2) speaks Spanish and a little English. (R2) likes to walk around all on the floor. (R2) goes into other resident's rooms. When (R2) does, I (V3) do redirection. When asked if R2 responds to the redirection, V3 stated, Sometimes redirection don't work. V3 stated, the 3rd floor is not a locked floor, and staff have a code for the stairwell doors when they exit via the stairwell doors. When asked to see the code keypad for the stairwell door, V3 walked to the west stairwell door. V3 then demonstrated, that the stairwell door will open by pushing the bar on the door, but then the alarm goes off, and staff must put in the code on the keypad, which V3 performed, to stop the alarm. When asked about R2's elopement from the facility on 6/4/23, V3 stated, It was around 11:00 am. When asked V3 about seeing R2 prior to 11:00 am on 6/4/23, V3 stated, V3 saw R2 in R2's bed at 7:00 am when V3 started the shift. V3 stated, (R2) ate (R2's) breakfast. (R2) was already dressed. Wandering, which is constant for (R2). I (V3) would redirect (R2). (R2) was going into other resident's rooms. They (other residents) were frightened. They (other residents) would put on the call light, and they would say, 'There's a (person) in my room.' I (V3) know who they (other residents) were talking about. Then I (V3) would see (R2) and redirect (R2) out of their (other persons') room. When asked about R2's cognitive status on 6/4/23, V3 stated (R2) was up and alert that morning. (R2) was roaming in other rooms. I (V3) was redirecting (R2), but I (V3) have to clean other patients and am doing my rounds. When asked the last time that V3 saw R2 on 6/4/23, V3 stated, It was in the hallway, but I (V3) don't know the exact time. When (R2) went missing, I (V3) was in the washroom. I (V3) heard the alarm going off when I (V3) came out of the bathroom walking down the hallway. (V4, Agency RN) or CNA (V5) heard it. They (V4, V5) were saying, 'Where did (R2) go?' I (V3) hear the alarm going off, possibly (R2) could have closed it (the west stairwell door). I (V3) then went down the stairs (west stairwell) and didn't see (R2). I (V3) asked (V21, Receptionist), and (V21) didn't see (R2). I (V3) thought that maybe (R2's) still here, so I went out the back door to the parking lot. I (V3) didn't see (R2). I (V3) came back to the floor, and we (staff) searched all the rooms and in empty room, room [ROOM NUMBER]. When asked how is V3 ensuring that a resident who wanders, like R2, is safely supervised, V3 stated, For me (V3) personally, I know (R2) likes to walk. I (V3) let (R2) walk. (R2) doesn't like being in (R2's) room. I (V3) let (R2) walk sometimes and give (R2) a cookie if (R2) goes into someone's room. I (V3) have rounds to do. I (V3) have other patients to care for. V3 stated, Sometimes (R2's) confused and V3 gives R2 verbal cues if R2 needs it. R2's Progress Notes, on 6/4/23 at 2:48 pm, V4 (Agency RN) documents, in part, 11:05 am: (R2) walked up to (V4) to get (R2's) scheduled medication. 11:10 am: It was reported that (R2) was no longer in (R2's) room. Room search was done on the facility and a code was called. (R2) was still not found. (V1) was called and the security camera reviewed that (R2) left through the back door. On 6/7/23 at 4:00 pm, V4 (Agency RN) stated, V4 works frequently at the facility as an agency nurse, and V4 stated, on 6/4/23, V4 worked the 7:00 am to 3:00 pm shift on R2's floor (3rd floor). When asked about R2 on 6/4/23 at beginning of V4's shift, V4 stated, I (V4) saw (R2) standing by (R2) room. (R2) stood there. I (V4) said, 'Hi, I am your nurse. I am going to be giving you your meds.' (R2) said (R2) wanted to go pee in the staff bathroom. I (V4) told (R2) there is a bathroom in (R2's) room; pointing to (R2's) room. V4 stated, the staff bathroom is not open for R2 to use. V4 stated, I (V4) told the CNAs (V4 and V5, Agency CNA) to pay attention to (R2). V4 stated, (R2) looked confused. V4 stated, Sometimes, I (V4) did not understand (R2). (R2) would go to elevator. (R2) always asking for (R2's) insurance money. (R2) needs (R2's) money. (R2) needs to go get it. At the moment, I (V4) didn't understand. I (V4) then put 2 and 2 together. V4 stated, R2 was making these statement about getting R2's money on 6/4/23 prior to eloping from the facility. When asked if R2 had spoken about getting R2's money prior to 6/4/23, V4 stated, On other occasions, (R2) had talked about getting money from somewhere. When asked if R2 would give specifics about where R2 was wanting to go to get R2's money, V4 stated, No location. (R2) would point to elevator to go down. V4 stated, V4 never see him get in the elevator, but R2 would stand next (to the) elevator and did not get in the elevator because (R2) didn't recognize that there was a button. V4 stated, (R2) has (an) alarm. (R2) never seen that (R2) activated an (electronic monitoring safety device) alarm. V4 stated, (R2) always had on (electronic monitoring safety device). Surveyor asked V4 if V4 observed R2's electronic monitoring safety device prior to 6/4/23. V4 stated, Yes, before June 4th, (R2) had on (electronic monitoring safety device). Asked what R2 continued to do throughout the morning on 6/4/23. V4 stated, The next time I (V4) see (R2). I (V4) push my (medication) cart down the hall. I (V4) saw (R2). (R2) says, 'Where's my room?' (R2) came again into another resident's room. I (V4) redirected (R2) to (R2's) room. I (V4) talked to the CNAs (V3, V5) and told them to watch (R2), and it's not appropriate for (R2) to go into another resident's room. When asked which room did R2 go into, V4 stated that it was the room opposite, the room right across the stair door at the (west) end. V4 stated, R2 took one medication from V4. V4 stated, I (V4) told (R2) (about the medication). (R2) refused. So, I (V4) pushed back and at 11:00 am, (R2) said, (R2) wants (R2's) meds. V4 stated, on 6/4/23 at 11:00 am, V4 stated, I (V4) asked (R2) why (R2) was wearing a sweater. (R2) said, 'It was cold.' Then in a 5-to-7-minute time (frame), it was 'Where was (R2) '?' V4 stated, (R2) was not in (R2's) room. Oh, okay. I (V4) felt like (R2) was confused. I (V4) told CNAs (V3, V5) to focus on (R2) all the time. 'You need to pay attention.' Redirect as much as possible. (R2) listens. It's a different story if (R2) doesn't listen. No pacing. (R2) was just walking. When asked where was V4 at 11:07 am on 6/4/23, V4 stated, Then I (V4) was at nurse's station at the med cart. I (V4) had to do (blood sugar checks) and had the paper and was checking from the (medication) cart; from the people (residents) and marking through the names. I (V4) checked my list. Then (R2) walked behind me. V4 stated, 5 minutes later. I (V4) turned to (V15, Housekeeper) 'Where's (R2)?' (V15) said, 'Where is (R2)?' I (V4) said let's check the bathroom. Nobody. We opened all the bathrooms. V4 stated, First thing, (R2) was walking close to the stairs. Maybe (R2) went through. That was by the original bathroom (R2) was trying to get into. V4 stated, We checked all resident rooms. When asked did V4 hear any alarms on 6/4/23 at 11:07 am, I (V4) was focusing on it (blood sugar checks). There was like a bed alarm. When a resident moves (with a bed alarm) and it (stairwell alarm) was the same thing. I (V4) look at all the residents. My thinking, it was the alarm. I (V4) was thinking it (stairwell alarm) was a bed alarm. When asked where other staff (V3, V5) were at when V4 heard the alarm, V4 stated, People were looking, moving around, and came back to my station. (V15) was there in front of (R2's) room. CNA (V3) was in the (staff) bathroom. My mind was that (R2) was in the bathroom. V4 stated, V3 (CNA) then went to the 2nd floor. V4 stated, V4 called the 4th floor staff and R2 was not on the 4th floor. V4 stated, I (V4) called down to reception (V21) for a code (yellow). V4 stated, I (V4) did hear (the stairwell) alarm. It wasn't loud, so you can know that someone can pass through. It was like a bed alarm. I (V4) am not familiar with stairs alarm. People don't use the stairs. 'Where is this alarm coming from?' V4 stated, CNA (V5) was running with me (V4). We have resident bathroom down there. We were looking. I (V4) called him then, called a code (yellow). (V21, Receptionist) said, 'I didn't see (R2) down there.' I (V4) said, 'Be on the lookout. (R2) didn't go on elevator.' V4 stated, I (V4) hear it, (stairwell) alarm, but it's like a bed alarm. You use a code to stop it (stairwell alarm). V4 stated, (V3, CNA) was down the stairs then. I guess we (V3, V4) met at reception. We can't find (R2). On 6/6/23 at 2:15 pm, V5 (Agency CNA) stated, on 6/4/23 from 7:00 am to 3:00 pm, V5 worked on R2's floor (3rd floor). V5 stated, on 6/4/23 prior to R2's elopement, I (V5) see (R2). Both in (R2's) room and hallway. At the beginning, (R2) was in other resident rooms. I (V5) was assisting (R2) back to (R2's) room. I would redirect (R2) saying, 'Hey, let's go back to your room. You are in someone else's room.' (R2) didn't speak much English. (R2) speaking back in Spanish. I (V5) escorted (R2) in (R2's) room for a while then (R2) came back out. I (V5) was at nurse's station. (V4) asked me (V5) by the stairs (about R2's location). I (V5) didn't see (R2) walk out it (stairwell door). When asked where was V5 on 6/4/23 at 11:07 am, I (V5) was at nurse's station. (V3) was in the bathroom. (V4) was at the med cart who saw (R2) walking towards (the west stairwell) door. I (V5) didn't hear the stair alarm. Surveyor asked if R2 had an electronic monitoring safety device on. V5 stated, Yes. On (R2's) wrist and ankle. Normally, the alarm will go off. That's what the CNA (V3) told me. I (V5) didn't hear it. That's why I (V5) didn't see (R2) leave. On 6/8/23 at 11:17 am, V15 (Housekeeper) stated, V15 worked on the 3rd floor on 6/4/23 from 7:00 am to 3:00 pm. When asked if V15 was familiar with R2, V15 stated, I (V15) could say something specific about (R2). (R2) was walking whenever (R2) wanted and sometimes coming from other people rooms. So, CNAs and nurse keep eye on (R2) all the time. Sometimes (R2) would go back to (R2's) room. (R2) was nervous about it. (R2) would do whatever (R2) wanted to do. It was Sunday (6/4/23). That morning, (R2) was the same. Nothing different in (R2's) behavior. I (V15) said, 'How are you?' V15 stated, (R2) was talking to (V4, Agency RN). (R2) going back and forth to (V4) and (R2's) room. When asked on 6/4/23 at 11:07 am, where was V15 on the 3rd floor, and V15 stated, When I (V15) came to clean (R2's) room. (R2) was there, standing in the door. (R2) going back and forth to (V4) and talking about something. (R2) coming back and forth. I (V15) cleaned (R2's) room and mopped the floor. I (V15) was at the door and (R2) was there just a couple of minutes ago and I (V15) didn't see (R2). I (V15) told (V4) that I didn't see (R2). Then (V4) and CNA went to look (for R2). They checked other rooms, bathrooms and shower room on the floor and didn't find (R2). When asked the description of what (R2) was wearing, V15 stated, Jacket with zipper in front. Put zipper on. (V4) turned. (V4) asked (R2) 'Why (R2's) wearing jacket? It's hot here.' R2 said, '(R2's) cold.' That's when (R2) was coming out of (R2's) room to the nurse's station. (V4) was standing by nurses' station at (medication) cart. In front of cart. One CNA (V5). I (V15) don't remember where other CNA (V3) came from. When asked if V15 heard any alarms, V15 stated, No, I (V15) didn't hear any alarm from the stairs. On 6/12/23 at 11:00 am, V21 (Receptionist) stated, V21 worked from 8:30 am to 9:00 pm on 6/4/23 at the receptionist station at the desk in the front lobby of the facility. V21 stated, as part of V21's responsibilities, the video footage images are monitored by us (receptionists) of each screening area in the facility including the back door on the 1st floor. When asked about the 1st floor back door alarm, V21 stated, We are also monitoring. They (visitors) must ring doorbell. Back door visitors must be buzzed in 24 (hours)/7 (days a week). Workers or employees will use code for entry. Visitors must be buzzed in. When asked if V21 is sitting at the receptionist desk in the front lobby, can V21 visually see the back door, and V21 stated, Sitting there physically. I (V21) can see normally down the hallway. I (V21) can see that door. When asked would V21 be able to see someone leaving the facility via the back door, V21 stated, It depends. I (V21) can see. I (V21) can't make there person out. I could make out body stance. There are 3 racks with towels. When those (racks) are there, they are blocking. (They're) not all the way blocking the (back) door. It's iffy, I (V21) can't see. I (V21) can't make them (person exiting back door) out. When asked if the blue laundry bins (racks) are in the 1st floor hallway on the wall, can V21 physically see a person exiting at the back door without the video camera screen, and V21 stated, No, not really. When asked how would V21 be able to see the person leaving out the back door then, V21 stated, Camera. V21 stated, it's not a clear picture of individuals with seeing the back of their head since the video camera is positioned from the hallway view outward. When asked if there is an alarm system on facility 1st floor doors, V21 stated, Yes. They (front and back doors) both do. V21 stated, the 1st floor front and back doors are equipped with an electronic monitoring safety device alarm, and when a resident with an electronic monitoring safety device gets near the front and back doors, the alarm would be activated. V21 stated, I (V21) would hear 'beep and beep' as I am sitting there at desk. V21 stated, when the 1st floor back door alarm is triggered, V21 would hear the alarm noise at the back door location. When asked if V21 can hear the 1st floor back door electronic monitoring safety device alarm, V21 stated, I (V21) would have to be listening. If they (the resident with an electronic monitoring safety device) got out. I (V21) would hear beep, beep. I (V21) would see on the camera and see if there is an individual. A resident or something that would have caused the issue. I (V21) physically go down (to the back door) and disarm the alarm. When asked how the alarm is disarmed, V21 stated, V21 puts in a number code, and it (alarm) will fade out and go away. V21 stated, It will continue to beep until you disarm it. When asked if V21 knew R2 prior to R2's elopement on 6/4/23, V21 stated, Yes that it was when R2 was first admitted to the facility (R2's admitted is 5/13/23). When asked if V21 would be able to visually recognize R2 in physical appearance, V21 stated, Yes. V21 stated, On 6/4/23, it was a typical morning. Around 11:00 am something. I (V21) can't recall exact time. I (V21) got a call from (V4), asking if I knew where abouts of R2. I (V21) told (V4) that I (V21) haven't seen (R2). I (V21) asked 'What happened?' (V4) said, (V4) don't see (R2) in (R2's) room. I (V21) told (V4) that I (V21) never saw (R2) come down the front or side elevators. I (V21) am thinking if (R2) came down the stairs, I (V21) could see the back of (R2). But how did (R2) get downstairs? I (V21) told (V4) if you are not seeing (R2), I (V21) will call code yellow. After (V4) confirmed, I (V21) got on overhead page. When asked where was V21 at 11:08 am on 6/4/23, V21 stated, I (V21) was at the receptionist desk, speaking to (R13) in a wheelchair. When asked where was R13 positioned when V21 was conversing with R13, V21 stated, R13 was kitty corner (diagonal) on my right side, and I (V21) am facing the middle elevator. V21 stated, from the back area (on 1st floor), R2 did not come towards the receptionist desk, Not at all. V21 stated, never heard anything. Nothing alarmed that someone got out there (back door). When asked if the back stairwell (west stairwell) is locked on the first floor, V21 stated, No. Residents can take a stairwell down. When asked if V21 heard an electronic monitoring safety device alarm from the 1st floor back door on 6/4/23 at 11:08 am, V21 stated, No. Nope. When asked if there were blue laundry bins (racks) in the 1st floor hallway on 6/4/23, V21 stated, Yes. When asked if V21 saw R2 on the 1st floor back door video camera view on 6/4/23 at 11:08 am, V21 stated, No. If there was an image, I (V21) wouldn't have known it was (R2). (R2) would have had an (electronic monitoring safety device) on. We have regular employees who walk back there. I (V21) would not be able to make (R2) out. On 6/14/23 at 2:01 pm, V21 (Receptionist) stated, the elopement risk list (residents who are assessed as an elopement risk) is posted at the receptionist's desk in a red binder. V21 stated, V21 checked the elopement risk list on 6/4/23. V21 was asked on 6/4/23, was R2 on the elopement risk. V21 stated, No, I (V21) don't think so. On 6/8/23 at 1:42 pm, V18 (Dietary Aide) stated, V18 works in the kitchen and works on the weekends. V18 stated, on 6/4/23, V18 worked from 6:00 am to 2:00 pm. When asked on 6/4/23 at 11:08 am, did V18 see R2 eloping from back door on the 1st floor, and V18 stated, No, I (V18) don't recall. V18 stated, V18 had met R2 prior to 6/4/23 and V18 would see R2 in R2's bed each time V18 would be picking up meal trays. V18 stated, I (V18) know (R2's) general appearance. I (V18) would recognize (R2) if I saw (R2). This surveyor informed V18 that this surveyor and V1 viewed the facility video footage from 6/4/23 when R2 eloped out the 1st floor back door. When asked where V18 was going when V18 was walking down the 1st floor hallway towards the back door direction on 6/4/23 (as observed on the video), V18 stated, Around that time, I (V18) turned to the laundry or lady's locker room. When asked on 6/4/23 at 11:08 am, did V18 hear alarms at the back door, V18 stated, No, I (V18) didn't hear anything. On 6/8/23 at 11:30 am, V16 (Clinical Care Coordinator) stated, V16 was the manager on duty or MOD on 6/4/23 and arrived around 9:10 am. V16 stated, one of V16's responsibilities as the MOD is to use the remote for the electronic monitoring safety device alarm systems for the 1st floor front and back doors in the facility. V16 stated, V16 checked the doors on 6/4/23 around 10:00 am after V16 did V16's rounds and the remote showed Good when the door is working. V16 stated, So, I was in my office, around 11:00 am. (V21, Receptionist) said (V4, Agency RN) was saying that they can't find (R2). I (V16) asked (V4) when (V4) saw (V4) last, and (V4) said, 'Recently. I (V4) just gave (R2) (R2's) medications.' I (V16) said, 'Did you see (R2) in what direction?' (V4) could not identify which door and maybe (R2) left in back door because (V21) didn't see (R2). When asked as the MOD, does V16 review the elopement risk list? V16 stated, It's at the front desk at receptionist (desk). Yes, I (V16) check on it. When asked on 6/4/23, did V16 check the elopement risk list, and V16 stated, I (V16) check the list, but we were already searching (for R2). I (V16) check on the pictures. We are looking for (R2). When asked was R2 on the elopement risk list on 6/4/23, V16 stated, I (V16) don't think so. V16 verified with this surveyor that it was the elopement risk list, updated on 6/2/23, that V16 saw on 6/4/23. V16 stated, (R2) was not on this (elopement risk) list at this time. When asked did V16 have knowledge that R2 was at risk for elopement (prior to 6/4/23), V16 stated, No, not really. On 6/7/23 at 12:53 pm, V13 (Social Worker) stated, I (V13) report to (V11, Social Services Director, SSD) and was assigned to the 3rd floor and half of the 2nd floor. V13 stated, When (R2) was first admitted , (R2) was confused and wandering a little bit. Since (R2) was Spanish speaking, we had a couple staff members who speak Spanish. A CNA who speaks Spanish translated for (the social services) intake. (R2) had wandering tendencies. Nursing was asking if we could put an (electronic monitoring safety device) on (R2). I (V13) put it (electronic monitoring safety device) on (R2) on 5/16/23. I (V13) placed it on (R2's) right wrist. I (V13) checked it (electronic monitoring safety device) prior to putting it on (R2). We had the old one (from the previous electronic monitoring safety device alarm system). And then I (V13) grabbed a new one. And I (V13) checked it prior. I (V13) used a remote to check it. We can get the remote. It's (remote for electronic monitoring safety device checks) in (V12's, Maintenance Director) office. V13 stated, I (V13) did see (R2) walking and pacing the hallway. When asked who the nurse was who asked for the electronic monitoring safety device to be placed on R2, V13 stated, It was the nurse on the floor, the restorative nurse (V14). When asked if V13 ever tested R2's electronic monitoring safety device after applying it on R2 on 5/16/23, V13 stated, I (V13) had tested it on another day because I (V13) tested it prior (to putting it on R2). When asked when this date was, V13 stated, It was on a really busy for (V11, SSD). (V11) does the updates on Fridays. I (V13) did it that next Friday (5/19/23). It (R2's electronic monitoring safety device) was functioning at that time. V13 was asked to demonstrate the testing method of a resident's electronic monitoring safety device with the remote (present in the conference room on the table), You turn it on. And the message says good. I (V13) tested it that way with (R2). V13 stated, V13 performed the elopement risk assessment for R2 on 5/16/23 as part of R2's social services admission assessments and V13 did (R2's) care plan. When asked about the score of R2's elopement risk assessment, V13 said, Score, right down here, would be (R2's) score. At risk. V13 stated, V13 fills out all the elopement risk evaluation questions, and the questions that are marked with yes totals for the final score. V13 stated, any score above a 4 is a high risk on the elopement risk evaluation. V13 stated for at risk for elopement residents does include behaviors that would be concerning, like wandering tendency. V13 stated, (R2) was at risk for elopement. Wandering tendency. Keep eye on (R2). Eye on (R2) and a personal safety alarm device. When asked what the personal safety alarm device (electronic monitoring safety device) is, V13 stated, It sounds an alarm that someone has gotten in the elevator or gone out one of the doors. Bracelets made to one of those 4 exits. Doors on the main floor and elevators, there's an alarm. V13 stated, (R2) is oriented to self. Oriented to person and not to situation or what was going on. When asked about testing R2's wander guard other than when V13 stated on 5/16/23 and on 5/19/23, V13 stated, I (V13) don't recall testing (R2) another time. When asked if V13 informed V11 (SSD) when V13 placed R2's electronic monitoring safety device on R2 on 5/16/23, V11 stated, I (V13) did not that day. It's one of those things that slipped through the crack. When asked V13 in reference to the elopement risk list, can V13 update the elopement risk list, and V13 stated, That's (V11, SSD.) I (V13) have not updated it. V13 stated, For the elopement risk list, they (residents) all have (electronic monitoring safety devices) on them attached. V13 stated, residents who are at risk for elopement are making statements, consecutively needing to go to the store, saying 'I need to pay my bills.' They have more of an idea or plan. Obsessive thinking with poor cognition. They have it in their mind that 'I have to do it.' V13 stated, (R2) was pacing, walking into rooms. Now (R2) has 1:1 sitter. V13 stated with R2's electronic monitoring safety device, (R2's) on the list now. That's how staff are able to know who an elopement risk is. V13 stated, on 5/16/23 when V13 applied R2's electronic monitoring safety device, I (V13) did not document the device number or mode. I (V13) was unaware that we needed to document it. On 6/8/23 at 3:39 pm, V13 (Social Worker) asked if she checked the functioning of the electronic monitoring safety device on 5/16/23 after placing it on R2. V13 stated, Since I (V13) checked it right before, I didn't check after putting on (R2). V13 asked if V13 completed electronic monitoring safety device inventory log. V13 stated, (V11) does the (electronic monitoring safety device) log. Not me. So, no. R2's Elopement Risk Evaluation, dated 5/16/23, documents, in part, 8 questions to be completed for the risk score total. V13 performed and documented R2's 5/16/23 Elopement Risk Evaluation and answered Yes to the following 3 questions: The resident has the physical ability to leave the facility, The resident has a firm desire/intent to leave the facility, and The resident has attempted or has an actual elopement in the last year. Question #8 (The resident is confused to time and place and has the physical ability to leave the building?) was not answered Yes or No by V13 (left blank). V13 documented that all interventions that apply to R2 is Personal Safety Alarm Device. On 6/20/23 at 1:58 pm, reviewed the 5/16/23 elopement risk evaluation V13 performed for R2, V13 stated, the answers to the questions determine the risk score. V13 stated, That's why (R2) had score of 3 because (R2) had 3 yeses. V13 stated, with question #5 The resident has attempted or has an actual elopement in the last year, V13 documented yes because of R2's wandering. V13 stated, R2 was at 'low risk' with a score of 3. This surveyor then pointed out to V13 that V13 did not answer question #8 The resident is confused to time and place and has the physical ability to leave the building? When asked why did V13 not answer question #8, V13 stated, It was a mistake. When asked if not answering question #8 on the elopement risk evaluation would change R2's risk score if it's answered, V13 stated, Yes, it would change (R2's) score. It would have changed (R2's) score to a '4' and put (R2) in the high-risk (elopement risk) category. V13 stated, V13 had alarms that was in place with R2 being at risk for elopement. On 6/8/23 at 11:00 am, V14 (Restorative Nurse) stated, I (V14) am the only one (restorative nurse) in the facility. V14 confirmed, V14 performed the restorative assessment for R2 on 5/16/23. When asked if V14 requested from V13 to have an electronic monitoring safety device to be placed on R2, V14 stated, I (V14) cannot remember. V14 stated, If they (residents) need an (electronic monitoring safety device), we coordinate with social services. V14 stated, (R2) walks around hallways. Due to (R2's) cognitive impairment, (R2) needs to be redirected from time to time. V14 stated, when staff place an electronic monitoring safety device on a resident, social services staff will put the resident on the elopement risk list. V14 stated, the elopement risk list is then placed at the receptionist's desk and the

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview, and record review, the facility failed to ensure staff followed appropriate standard and transmission based infection control practices to prevent the spread of COVID-19. This failure had the high likelihood to affect the six residents (R5, R6, R7, R8, R9 and R10) who were primarily under the care of one Nursing Assistant (NA1). R7, R8, R9 and R10 were PUIs (Persons under Investigation) and did not have definitive [DIAGNOSES REDACTED]. The IJ began on 5/5/20 at approximately 11:40am, when NA1 entered the room shared by R1, R2, R3, and R4, all diagnosed with [REDACTED]. NA1 did not remove her universal gown and did not don an isolation gown before she entered the isolation room. After approximately 15 minutes, NA1 exited the room without removing the universal gown and proceeded to where the dietary cart was located at the end of the hall. The surveyor informed the Director of Nursing (DON) about the observation, who immediately told NA1 to remove her universal gown which was considered contaminated. The facility had 10 residents positive for COVID-19 that were currently residing in the facility and nine PUIs at the time of this survey. The facility was located in a county with sustained community transmission, with many active COVID-19 cases and deaths. Findings include: According to the Centers for Disease Control and Prevention (CDC), Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from severe infections, hospitalization s, and death .Dedicate Space in the Facility to Monitor and Care for Residents with COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility .Resident with new-onset suspected or confirmed COVID-19. Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible .Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes- responding.html. During an entrance interview on 5/5/20 at 11:10am, with the Administrator and the Director of Nursing, when asked whether the facility had positive cases of COVID-19, the Administrator stated, Yes, we have some residents on the second floor. The DON added, I think we have eight COVID-19 positives and some PUIs. The DON further stated, Our second floor is our COVID-19 floor. When asked for their personal protective equipment (PPE) inventory. The DON responded, We have a lot. We recently received supplies from our corporate office. The DON further stated that the facility also received PPE from the Chicago Public Health Department. On 5/5/20 at approximately 11:40am, NA1 entered the room shared by R1, R2, R3 and R4 all diagnosed with [REDACTED]. NA1 immediately closed the door after she entered the room. A few minutes later LPN1 (with complete PPE) was observed to enter the same room to administer R3's medication. At approximately 11:55am, NA1 exited the room without removing the universal gown. NA1 proceeded to walk towards the end of the hallway where the dietary cart was located and was about to deliver the lunch trays. The surveyor informed the DON (who was also on the floor) about the observation; the DON then told NA1 to remove her universal gown since she had worn it into a room with positive COVID-19 residents. On 5/5/20 at approximately 12:10pm, LPN1 was asked about the observation. LPN1 stated, When I saw (name of NA1) inside the room without the proper PPE, I immediately told her to go out of the room and change into an isolation gown. LPN1 continued, But she did not listen to me. When asked whether staff had to reuse gowns, masks, and or googles. LPN1 stated that they did not and stated that the facility had enough PPEs. On 5/5/20 at approximately 12:20pm, the DON stated, They have been in-serviced on proper donning and doffing of PPE including when to use the isolation gown. The DON confirmed, NA1 should have changed into an isolation gown before she entered the isolation room, we have the sign and the set up outside the room. The DON added, It's not like we do not have available PPE's, we have enough. The DON was asked whether all the residents on the unit were COVID-19 positive or PUIs. The DON explained that one resident was on contact isolation due to ESBL (Extended Spectrum Beta Lactamase) infection of the urine and the remaining residents were not on any kind of isolation and not considered PUIs. When asked what her thoughts were knowing that not all residents had the same infectious disease. The DON stated, I know, I totally understand the risk (of transmission), especially with COVID. Below were the record reviews of the four residents diagnosed with [REDACTED].>1. Review of R1's electronic health record (EHR) under Progress Notes revealed, R1 was readmitted to the facility on [DATE] at 4:30pm from an acute care hospital with admitting [DIAGNOSES REDACTED]. 2. Review of R2's EHR under Progress Notes revealed, R2 was readmitted to the facility on [DATE] at 5:30pm from an acute care hospital with admitting [DIAGNOSES REDACTED]. 3. Review of R3's EHR under Progress Notes revealed, R3 was readmitted to the facility on [DATE] at 9:30pm from an acute care hospital with admitting [DIAGNOSES REDACTED]. 4. Review of R4's EHR under Progress Notes revealed, R4 was readmitted to the facility on [DATE] from an acute care hospital with admitting [DIAGNOSES REDACTED]. On 5/5/20 at approximately 1:35pm, NA1 was asked about the observation. NA1 stated, I am so sorry, I know I was wrong. NA1 further stated, I should have changed to a new gown before entering the room. NA1 explained that she was only talking to NA2 about a misunderstanding with another staff member. NA1 claimed she was nowhere near the residents. When asked what the process was before entering the room of a COVID-19 positive resident. NA1 described, Before we go up (to the units), we are given this blue (universal) gown, mask and other PPE. The universal gown is the one we use anywhere in the facility. NA1 continued that staff would remove the universal gown, hang it up on the hook outside the room, change into an isolation gown, enter the room, do the cares and discard the isolation gown and gloves before exiting the contact/droplet isolation room. NA1 was further queried whether there was a time when staff had to reuse PPE. NA1 stated, No, I do not think so. Review of NA1's room assignment indicated NA1 was assigned to rooms 210-215 on 5/5/20. When asked how many residents were under her care. NA1 verbalized that she had six residents namely R5, R6, R7, R8, R9 and R10. NA1 stated that although she was primarily assigned to the aforementioned residents she would still help other residents as needed. NA1 explained that staff were expected to help all residents whether they were assigned to them or not. On 5/5/20 at approximately 2:15pm when asked about the observation, NA2 (who was already in the room before NA1 entered) explained, I was busy with R2 when NA1 came inside the room. I know it was wrong for (name of NA1) to enter without changing into an isolation gown. When asked whether staff had reused gowns and other PPEs before, NA1 responded, No, we have not. We always have masks, gowns. Review of the facility's Resident Census List dated 5/5/20 for the second floor revealed the list were divided into four groups. There were ten residents with positives affixed next to their names, one resident on contact isolation due to ESBL, nine residents had PUI affixed next to their names and the remaining nine residents had blank next to their names. On 5/11/20 at 3:55pm, the DON confirmed that the last nine residents were not PUIs, not COVID positives nor did they have a different type of infection. The DON explained, They are no longer on the second floor, we moved some of them in another unit unless their results came back positive after we tested all the residents. Below were the record reviews of the six residents under NA1's care: 1. Record review of R5's EHR under Progress Notes revealed R5 had [DIAGNOSES REDACTED]. Further review of the entire EHR revealed R5 was not a PUI and did not have a definitive [DIAGNOSES REDACTED]. 2. Record review of R6's EHR under Progress Notes revealed R6 had [DIAGNOSES REDACTED]. Further review of the entire EHR revealed R6 was not a PUI and did not have a definitive [DIAGNOSES REDACTED]. 3. Record review of R7's EHR on 5/5/20 under [DIAGNOSES REDACTED]. 4. Record review of R8's EHR on 5/5/20 under [DIAGNOSES REDACTED]. 5. Record review of R9's EHR on 5/5/20 under Progress Notes revealed R9 had [DIAGNOSES REDACTED]. Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings revised on 4/13/20 under 2. Adhere to Standard and Transmission-Based Precautions revealed, .HCP (see Section 5 for measures for non-HCP visitors) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Review of the CDC's guidelines titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 dated 3/30/20 revealed, How to Put On (Don) PPE Gear. More than one donning method may be acceptable. Training and practice using your healthcare facility's procedure is critical .2.Perform hand hygiene using hand sanitizer. 3. Put on isolation gown. Tie all of the ties on the gown .Further review of the same document revealed, Doffing (taking off the gear) .2. Remove gown. Untie all ties .Reach up to the shoulders and carefully roll the gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. 3. HCP (Healthcare Personnel) may now exit the room . Based on the facility's COVID-19 Guidelines and Emergency Preparedness revised on 4/30/20 under C. Isolation revealed, Suspect PUIs. Patients should be asked to wear a surgical mask .Airborne infection isolation room (AIIR) or formerly negative pressure room. In LTC setting, the AIIR is not applicable but the patient should be isolated in a room if the respiratory illness is undiagnosed and placed on Standard, Contact, and Droplet Precaution. Healthcare personnel entering the room should use Standard, Contact, Droplet Precautions, and use eye protection . The Administrator and the DON were notified that the immediacy was removed on 5/11/20 at 4:27pm after the surveyor verified (through observation and interview) implementation of an acceptable removal plan that included the following: 1. Formally in-serviced NA1 on proper donning and doffing of PPE especially the importance of removing PPE prior to leaving the room followed by hand hygiene. 2. In serviced all staff on all shifts regarding infection control protocol including donning and doffing of PPE when leaving the isolation room. 3. The DON provided a list of residents on isolation for positive COVID 19 and a list of PUIs with undiagnosed respiratory illness to ensure that if staff were in the isolation room of a COVID positive resident, they remove their PPEs before exiting the room and before caring for other residents, including the PUIs with undiagnosed respiratory illness. After removal of the Immediacy, the non-compliance remained at the level of no actual harm with the potential for more than minimal harm that is no Immediate Jeopardy until sustained compliance is verified.