Momence Meadows Nursing & Rehab

Based on interview and record review, the facility failed to report allegations of staff to resident abuse and an allegation of resident-to-resident abuse to the Illinois Department of Public Health within the required timeframes. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse reporting.The findings include:1.On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 had a knife and held it to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that 12/7/25 she worked the night of 12/7/25 and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2 DON (Director of Nursing) instructed her to search R1's room after it was reported that R1 had threatened R5. On 12/24/25 at 11:10am, V3 said while searching R1's room, she found a taser and a pocketknife under R1's bed. On 12/17/25 at 9:30 am, a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters were present in the medication room. At 3:16 pm V2 DON (Director of Nursing) removed the items and brought them to V1's (Administrator) office. The knife in V1's desk was metal and was like a folding boxcutter or utility knife. Unfolded, it was about 6 inches long, with the top half holding an angled blade.On 1/2/26 at 5:50 pm, V1 Administrator verified the objects found belonged to R1. V1 stated they were confiscated the night R1 went to the hospital and other potentially dangerous items were found and taken the next day. V1 said that she did not report R5's allegation of 12/7/25 to the Illinois Department of Public Health.2. On 12/19/25 at 2:32 pm, R9, who was alert and oriented, said that on 12/14/25 staff ripped his shirt and had their knee on his neck during a verbal altercation between himself and the staff. R9 said that he told the CNA (Certified Nurse's Assistant) that night that they ripped his shirt, and he told the nurse that the CNAs had their knees on his neck. On 12/14/25 at 11:10 am, V5 CNA verified that R9 did tell her and show her that his shirt was ripped during the altercation. V5 said that R9 was sent to the hospital that night for his behaviors and she reported the allegation to the Administrator and the DON. On 1/2/26 at 5:50 pm, V1 said that R9 did report that the staff ripped his shirt and staff was being physically aggressive to him. V1 said that the incident happened on 12/14/25. The facility Initial Report dated 12/23/24 at 8:10 pm (nine days after the incident) to the Illinois Department of Public Health showed that on 12/14/25, at 1:30 PM, R9 alleged that staff engaged in physical contact with him. The incident report did not include the alleged report of staff ripping R9's shirt. 3. On 12/23/25 at 1:59 pm, R5, who was alert and oriented, said that once she was choking and a CNA helped her, but V17 CNA told her that he would have let her choke. R5 said that she reported it to V1 (Administrator). On 12/24/25 at 3pm, V1 said that R5 did report the incident to her but R5 said that it happened right before V1 had started at the facility, so she did not report it to IDPH. The facility's Abuse Prevention Program policy (revised 01/2019) showed that the staff are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of residence property, mistreatment or a crime against a resident they observe, her about, or suspect to the Administrator.Complete an incident report immediately. Fax report to IDPH (Illinois Department of Public Health) immediately. The Administrator or the absence of the administrator the DON is then responsible for forwarding a final written report of the results of the investigation and any corrective actions taken to the Department of Public health within 5 working days of the reported incident.

Based on observation, interview, and record review, the facility failed to ensure significant medications were administered as ordered.This applies to 6 residents (R10, R12, R18, R19, R20, R28) reviewed for medications.The findings include:1.On December 31, 2025, at 11:00 AM, R19 was still in bed and was restless. R19 asked for his medications and stated he did not get his morning medications. R19 stated he goes a lot of nights without getting his 9:00 PM medications until around midnight, adding he also goes a lot of days without getting his morning meds until around 11 or 12:00 PM, too. R19 stated I need them- I am very sick and me not getting my medications on time is making me sicker. R19's October 10, 2025, MDS (Minimum Data Set) showed R19 is cognitively intact.R19's Face Sheet showed he his diagnoses include malignant lung neoplasm, absence of his right and left legs above the knee, and hydradentis suppurativa (a chronic and painful skin condition that causes recurrent abscess-like lumps). R19's December 31, 2025, Order Summary Report showed Physician Orders for baclofen three times daily for muscle spasms and gabapentin three times daily for muscle spasms. R19's December 2025 MAR (Medication Administration Record) showed the two medications were scheduled to be administered daily at 9:00 AM, 5:00 PM, and 9:00 PM. The Medication Administration Audit Report for December 31, 2025, showed he received his first doses of both medications at 11:24 AM, his 5:00 PM doses at 4:35 PM (five hours later), and his 9:00 PM doses at 8:10 PM (under four hours after that). On December 31, 2025, at 11:05 AM, V20 LPN (Licensed Practical Nurse) was at his medication cart, passing medications using the facility's EMR (Electronic Medical Record). The computer screen showed the eMAR (electronic Medication Administration Record) in pink for residents whose medications had not been passed. V20 verified that the pink color for the residents showing meant that there were overdue medications and that there were 14 total residents on the hall who had overdue medications, including R19, R28, R10, R20, and R18.2. On December 31, 2025, at 11:05 AM, R28's MAR was pink. R28's Face Sheet showed his diagnoses include diabetes with hyperglycemia. R28's December 31, 2025, Order Summary Report showed Physician Orders for 6 units of short-acting insulin injected three times daily for diabetes, and 25 units of long-acting insulin injected once daily. R28's December 2025 MAR showed his short-acting insulin was scheduled for administration before meals at 7:00 AM, 11:00 AM, and 4:00 PM. The same MAR showed his daily dose of long-acting insulin was scheduled for administration at 8:00 PM. The MAR showed the 7:00 AM and 11:00 AM doses of R28's short-acting insulin were administered on December 31, 2025, and the MAR showed both doses were signed off at 11:35 AM, as does R28's Medication Administration Audit Report for December 31, 2025. R28's MAR showed his once daily long-acting insulin scheduled for 8:00 PM was signed off as administered on 12/25, 12/26, 12/27, refused on 12/28, and signed off again on 12/29. R28's December 2025 Medication Administration Audit Report showed the 8:00 PM dose on 12/25 was administered at 6:21 AM on 12/26, his 8:00 PM dose on 12/26 was administered at 5:57 AM on 12/27, his 12/27 8:00 dose was administered 12/28 at 7:08 AM, his 12/28 refused dose at 8:00 PM was administered 12/29 at 6:48 AM. The Audit Report showed his actual 12/29 8:00 PM dose was administered 14 hours later at 8:34 PM.3. On December 31, 2025, at 11:05 AM, R10's MAR was pink. R10's Face Sheet showed her diagnoses include the bi-polar type of schizoaffective disorder, and recurrent major depressive disorder. R10's December 31, 2025, Order Summary Report showed Physician Orders for benztropine mesylate two times daily for Parkinson's, and clozapine every twelve hours and lithium carbonate three times daily, both related to bipolar-type schizoaffective disorder. R10's MAR showed the benztropine and clozapine were both scheduled for administration at 9:00 AM and 9:00 PM, and lithium was scheduled for 9:00 AM, 1:00 PM, and 9:00 PM. The Medication Administration Audit Report for December 31, 2025, showed all three 9:00 AM scheduled doses were signed off as administered at 12:58 PM, with the second 1:00 PM scheduled dose of lithium signed off as administered at 12:59 PM. The same Audit Report showed on 12/30/25, R10's 9:00 AM doses of clozapine, lithium, and benztropine were signed off as administered at 2:58 PM, and her 1:00 PM scheduled dose of lithium signed off as administered at 2:20 PM. 4. On December 31, 2025, at 11:05 AM, R20's MAR was pink. R20's Face Sheet showed his diagnoses include diabetes with hyperglycemia and foot ulcer, combined heart failure, and hypertension. R20's December 31, 2025, Order Summary Report showed Physician Orders for amlodipine and lisinopril daily for hypertension with parameters to hold the medications for a systolic blood pressure value under 110, orders for 45 units of long-acting insulin injected at bedtime, and orders for short-acting insulin injected three times daily with a sliding scale.R20's MAR showed to administer the amlodipine and lisinopril at 9:00 AM. On December 31, 2025, at 12:00 PM, V26 RN (Registered Nurse) prepared R20's medications. V26 stated she just began passing medications around 11:00 AM because she had been working on the other side. V26 stated she was about to take R20's blood pressure and it was last taken the day before at 3:03 PM. The Medication Administration Audit Report for December 31, 2025, showed R20's hypertension medications were administered on December 31, 2025, at 12:09 and 12:11 PM. The Medication Administration Audit Report showed for the previous day on December 30, 2025, that R20's 9:00 AM scheduled hypertension medications were administered at 3:00 PM.R20's MAR showed to check his blood glucose and inject short-acting insulin as needed per sliding scale before meals at 6:00 AM, 11:00 AM, and 4:00 PM. R20's MAR showed the 11:00 AM insulin dose on 12/28 was administered at 6:20 PM and the 11:00 AM dose on 12/30 was administered at 2:23 PM. R20's Medication Administration Audit Report for his bedtime dose of long-acting insulin (scheduled for 9:00 PM) showed his 12/26 dose was administered at 6:05 AM on 12/27, his 12/27 dose was administered on 12/28 at 7:11 AM, his 12/28 dose was administered on 12/29 at 6:43 AM, and his 12/29 dose was administered at 8:47 PM, approximately 14 hours later.5. On December 31, 2025, at 11:05 AM, R18's MAR was pink. R18's Face Sheet showed her diagnoses include malignant neoplasm of brain and epileptic seizures. R18's December 31, 2025, Order Summary Report showed Physician Orders for levetiracetam and lacosamide twice daily for seizures. R18's MAR showed both seizure medications were to be administered twelve hours apart at 9:00 AM and 9:00 PM. R18's December Medication Administration Audit Report showed the two 9:00 AM seizure medications were administered on 12/26 at 10:41 and 10:44 AM and the 9:00 PM dose was administered on the next day on 12/27 at 6:03 and 6:04 AM; her 12/27 9:00 AM doses were administered seven hours later at 1:06 PM and her 12/27 9:00 PM doses were administered on 12/28 at 6:52 AM; her 12/28 9:00 AM doses were administered at 6:24 PM and her 9:00 PM doses were administered on 12/29 at 6:30 AM; her 12/29 9:00 AM doses were administered just over seven hours later at 1:45 PM, her 12/29 9:00 PM seizure medications were administered at 8:52 PM, just over seven hours after that, making that a third dose within 15 hours. The Audit Report showed her 12/30 9:00 AM doses were administered at 2:58 PM, with the 12/30 9:00 PM doses not being signed off as administered at all. The same Audit Report showed the 12/31 9:00 AM doses were administered at 1:00 PM, 22 hours later.6. R12's Face Sheet showed his diagnoses include functional quadriplegia, dysphagia, and history of acute respiratory failure and pneumonia. R12's December 24, 2025, hospital Discharge Summary showed Weaned off oxygen successfully. [Intravenous] Zosyn (antibiotic) transitioned to [oral] antibiotic. R12's Transition of care section showed 1. Medication changes: start levofloxacin (antibiotic) 750 mg (milligrams) daily for five days.R12's Order Summary Report had the order transcribed to give levofloxacin 750 mg two times a day via his gastrostomy tube every five days. R12's MAR showed 9:00 AM and 5:00 PM doses were signed off as administered on 12/25 and 12/30, instead of once daily for five straight days. Further, R12's Medication Administration Audit Report showed his 9:00 AM dose on 12/30 was administered at 5:19 PM, and his 5:00 PM dose was administered at 7:13 PM, less than two hours later. R12's Advanced Practice Nurse progress note late entry from date of service of 12/29 also showed [History of Present Illness]: .started on a five-day course of levofloxacin 750 mg one tab via [gastrostomy tube] two times a day for infection prophylaxis following [Emergency Department] visit.started 12/25 with no end date.R12's December 25, 2025, pharmacy Physician's Order Note from 7:38 AM showed This order is outside the recommended dose or frequency. levofloxacin Oral Tablet 750 MG (Levofloxacin) Give 1 tablet via G-tube two times a day every 5 days for prophylaxis- The frequency of 2 times per 5 days is below the usual frequency of every 2 days to daily.The facility's undated Policy and Procedure- Medication Administration Errors showed Procedure: A medication error is any preventable event that may cause or lead to inappropriate medication use. Such events may be related to professional practice. administration. The Medication Administration Error Policy listed Medication not administered within the allowed time frame which is greater than one hour from its scheduled administration time or exceeds the time in relation to meals, and missed medication as administration-based errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have enough licensed nursing staff to pass medications in a timely manner and to consistently provide a resident's gastrostomy tube feeding as ordered.This applies to 15 residents (R1, R10, R12, R18-R29) reviewed for licensed nurse staffing. The findings include:On December 31, 2025, at 11:00 AM, R19 was still in bed and was restless. R19 asked for his medications and stated he did not get his morning medications. R19 stated he goes a lot of nights without getting his 9:00 PM medications until around midnight, adding he also goes a lot of days without getting his morning meds until around 11 or 12:00 PM, too. R19 stated I need them- I am very sick and me not getting my medications on time is making me sicker. R19's October 10, 2025, MDS (Minimum Data Set) showed R19 is cognitively intact.On December 31, 2025, at 11:05 AM, V20 LPN (Licensed Practical Nurse) was at his medication cart, passing medications using the facility's EMR (Electronic Medical Record). The computer screen showed the eMAR (electronic Medication Administration Record) in pink for residents whose medications had not been passed. V20 verified that the pink color for the residents showing meant that there were overdue medications and that there were 14 total residents on the hall who had overdue medications, including R1, R10, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, and R29. V20 stated there was only one nurse down here on this side and there are supposed to be two. V20 stated he did not know if someone had called off or why there was only one nurse. V20 stated nurses work 12-hour shifts and he had worked the overnight shift as well. On December 31, 2025, at 12:00 PM, V26 RN (Registered Nurse) prepared R20's late 9:00 AM medications. V26 stated she just started passing medications around 11:00 AM because she had been working on the other side with another nurse because she's new. V26 stated she had been at the facility since the previous evening at 11:00 PM. V26 stated she was about to take R20's blood pressure. The Medication Administration Audit Report for December 31, 2025, showed R20's two 9:00 AM hypertension medications with blood pressure parameters for dosing were administered late on December 31, 2025, at 12:09 and 12:11 PM. R12's Face Sheet showed he was admitted to the facility on [DATE]th, 2022, with diagnoses including functional quadriplegia, dysphagia, and gastrostomy status for tube feeding. R12's December Physician Orders show he takes no food orally and receives nutrition from a gastrostomy tube feeding only. R12's electronic health records showed his weight was 114.2 pounds on 11/19/25. On 12/26/25 at 12:35 PM, R12 was weighed at the facility again and his weight was 98.8 pounds. On 12/30/25 at 10:29 AM, V7 (R12's Primary Care Physician) stated that he had just examined R12 and there was nothing wrong with R12 medically that would cause him to lose weight. V7 said that if R12 is losing weight, it would only be from him not being fed.On 1/2/25 at 3:51pm, V9 ADON (Assistant Director of Nursing) said that the facility's minimum for nurses is 3 on day shift and 2 on night shift. The shifts are twelve-hour shifts scheduled from 7am to 7pm, and 7pm to 7am. V9 was reviewed the facility's November 2025 and December 2025 daily floor assignment sheets, the daily staffing sheets, and the staff time sheets. V9 confirmed the following information to be true:On Nov. 17th, 2025, there was only 1 nurse on from 7pm to 7am.On 11/22/25 there was 1 nurse on from 7pm - 7am. On 11/29/25 there were 2 nurses 2 on from 7am - 7pm. On 12/3/25 there was 1 nurse from 9pm - 7am. On 12/13/25 there were 2 nurses from 7am - 7pm and only 1 nurse from 12am to 7am. On 2/14/25 there was 1 nurse from 7am - 4:30pm, and only 2 nurses from 4:30pm to 7pm.On 12/17/25 there were 2 nurses from 7am - 815am.On 12/18/25 there were 2 nurses from 2pm until 7pm, and only 1 nurse from 11pm - 7am. On 12/19/25 there were 2 nurses from 7am - 1045 am and only 1 nurse from 8:45 pm to 7am. On 12/22/25 there were 2 nurses from 7am - 845 am. On 12/23/25 there was 1 nurse from 7am - 745 am.On 12/25/25 there were 2 nurses from 7am - 730am, and only 1 nurse from 830pm - 7am. On 12/30/25 there were only 2 nurses from 7am - 7 pm.On 12/31/25 there were 2 nurses from 7am - 7pm, and only 1 nurse from 10pm to 7am. V9 (ADON) continued and said that her expectations for staffing are for the facility to meet the minimum requirements. V9 said, if not, it affects the care that should be provided, such as passing medications and tube feedings given on time.On 12/31/2025 at 2:55 PM, V20 (LPN) stated he thought the facility was short on nurses.On 12/26/25 at 2:34 pm, R3, who was alert and oriented, said there is not enough staff at the facility. R3 said that some nights there is no nurse on duty, and he does not get his medications. R3 said that he has had to yell for his medications and threaten to call 911. R3 said that sometimes he is unable to sleep because he hasn't gotten his pain medications that night. On 12/26/25 at 2:48 pm, R15, who was alert and oriented said that some nights there are no nurses on the floor, and she does not get her pain medications. R15 said that she has threatened to call the state about it. On 12/26/25 at 2:45 pm, R16 who was alert and oriented, said that sometimes he is unable to sleep at night because he has not gotten his medications to help him sleep. On 12/26/25 at 2:55pm, R17, who was alert and oriented, said that he does not get his medications at night, including his medications to help him sleep. On 1/2/26 at 5:50 pm, V1 (Administrator) said that her expectations are that the minimum number of staff work to provide care. V1 said that it is not acceptable to have just one nurse on the floor. V1 acknowledged that it is not safe for only one nurse to have the whole facility, and it happens. On 12/23/25 at 4:13 pm, V2 DON (Director of Nursing) said that the minimum of nurses on at night shift is 2. V2 said that on 12/14/25 at 1:17 am, she was aware that there was only 1 nurse working in the facility. On 12/24/25 at 11:10 am V3 CNA (Certified Nurses Assistant) said that there are not enough nurses. V3 said that some residents don't get their medications and their G-tube feedings, and some residents must wait to get their medications. On 12/27/25 at 2:30 pm, V4 CNA said that there are times that there is only 1 nurse working on the floor and she has made V2 aware of it. V4 said that she has seen residents begging for their medications and threatening to call 911 to get their medications. On 12/26/25 at 10:20 am, V15 CNA said that on 12/14/25 at 9:18 am, V15 sent a text to V1 and V2 telling them that there was only 1 nurse on the floor and there were residents waiting on medications. V15 said the text also informed V1 and V2 that there were resident behaviors happening. V15 said that neither V1 nor V2 replied to her text. The facility's Strategies to Mitigate Staffing Shortages policy dated 5/1/2020 showed that Maintaining staffing is essential to provide a safe work environment for healthcare professionals and safe patient care.The facility Assessment Tool dated 11/17/2025 showed the Staffing Plan with the total number of licensed nurses providing direct care needs to be 3 on days and 2 on nights. The Staffing Plan also showed that the facility had zero for average number of residents for the category, behavioral symptoms and cognitive performance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube feeding received care and services to maintain his weight. This failure resulted in a resident experiencing significant weight loss of 13.49% in less than 39 days. This applies to 1 of 2 residents (R12) reviewed for gastrostomy tube use.The findings include:R12 is a [AGE] year-old male admitted to the facility on [DATE]th, 2022, with diagnoses including brain damage from a lightning strike, functional quadriplegia, dysphagia, cognitive communication deficit, and gastrostomy status for tube feeding. R12's December Physician Orders show he takes no food orally and receives nutrition from a gastrostomy tube feeding only. On 12/26/25 at 12:17 PM, R12 was in a wheelchair in his room. R12 appeared very thin and frail. R12 was alert and oriented and communicated using a communication board. R12 communicated that he frequently does not get fed and frequently does not get his medications. R12 communicated that when he does get fed, it is often late. R12 communicated that he is always depressed because of the care he is receiving at the facility. On 12/24/25 at 11:10 AM, V3 CNA (Certified Nurse's Assistant) said that R12 has told her that he is hungry. V3 said that she tells R12's nurse and they will tell her that they will get to it or that it is next on their list. V3 said that R12 has lost a lot of weight. V3 said that the nurses tell R12's family that R12 was fed when he has not been fed. V3 said that she works 6:00 AM to 2:00 PM and she had never seen R12 get a 6:00 AM feeding until the family started complaining about it. On 12/26/25 at 10:20 AM, V15 (CNA) said that R12 has told her that he was hungry. V15 said He has lost tons of weight and looks like a skeleton. He cannot get out of bed and relies on staff to feed him. He should not look like a skeleton.On 12/24/25 at 11:10 AM, V5 (CNA/Restorative Aide) also said that R12 has communicated to her that he is hungry, and she has let the nurse know. On 12/27/25 at 2:30 PM, V4 (CNA) said that she works the 10:00 PM to 6:00 AM shift. V4 said that she noticed R12 has been losing weight and she has never seen him be fed on the night shift. V4 said that sometimes on the night shift the residents don't get fed or don't get their medications because there is only one nurse in the facility. R12's electronic health records showed his weight was 114.2 pounds on 11/19/25. On 12/26/25 at 12:35 PM, R12 was weighed at the facility again and his weight was 98.8 pounds, a 13.49% weight loss in 38 days. R12's December 24, 2025, hospital Discharge Summary listed a diagnosis of severe protein calorie malnutrition, and comments under the physical exam described his appearance as cachectic (extremely thin and frail due to severe unintentional weight loss, primarily from muscle and fat). R12's Summary further showed Weight: 30% weight loss in less than one year. Muscle mass severe loss to clavicular and temporalis muscle areas. Malnutrition: severe.R12's December 2025 Medication Administration Record (MAR) showed R12's order as Enteral Feed Order every 6 hours for Diet- Jevity 1.2, 300 [milliliters] every 6 hours. R12's MAR had the feedings scheduled four times daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Up to December 20, 2025, R12's December 2025 MAR had every box checked as though the tube feeding was administered as scheduled except four times, which are 12/1 at 6:00 AM and 6:00 PM, on 12/16 at 6:00 AM, and 12/19 at 6:00 PM, and those were left blank. On 12/23/25 at 4:13 PM, V2 (Director of Nursing) said that if there is nothing documented in the EMAR, the medications or feedings were not given.R12's December 2025 Medication Administration Audit Report showed the times when the remaining entries were actually signed off as administered:On 12/2/2025, R12's 12:00 AM and 6:00 AM feedings were both signed off as given at 6:55 AM.On 12/5/2025, R12's 12:00 AM and 6:00 AM feedings were both signed off by V2 (Director of Nursing), two days later, on 12/8/2025 at 2:26 PM.On 12/6/2025, R12's 12:00 AM and 6:00 AM feedings were both signed off at 7:16 AM.On 12/8/2025, R12's 6:00 AM feeding was signed off by V2 at 8:52 PM.On 12/14/2025, R12's 12:00 AM feeding was signed off at 5:27 AM, and his 6:00 AM feeding was signed off at 5:19 PM. R12's 12:00 PM and 6:00 PM feedings were both signed off as given at 6:04 PM. On 12/15/2025, R12's 12:00 AM feeding was signed off at 8:44 AM, his 6:00 AM was signed off at 8:45 AM, and his 12:00 PM was signed off at 5:28 PM.On 12/17/2025, R12's 12:00 AM feeding was somehow signed off at 12:30 AM the day before, and his 12/17 6:00 AM was also signed off the day before at 5:56 AM. R12's 6:00 PM feeding was signed off at 10:49 PM.On 12/18/2025, R12's 12:00 AM feeding was signed off at 4:54 AM, his 6:00 AM was signed at 6:04 AM, and his 6:00 PM was signed at 8:54 PM.On 12/19.2025, R12's 12:00 AM and 6:00 AM were both signed off as administered at 6:16 AM, and his 12:00 PM was signed off as administered at 4:51 PM.In addition to what is already outlined, R12's Audit Report for 12/1-12/20 also showed ten times where his feeding administration times were signed off as administered more than three hours later than scheduled: on 12/1 for the 12:00 AM feeding, 12/6 for the 12:00 PM, 12/7 for the 12:00 AM, 12/9 for the 12:00 AM and the 12:00 PM, 12/10 for the 12:00 AM, 6:00 AM, and 12:00 PM, and 12/13 for the 12:00 AM and 6:00 AM feedings. Additionally, there are three times where R12's scheduled feedings were signed off more than four hours past their scheduled administration times: on 12/4 for the 12:00 AM feeding, on 12/8 for the 12:00 PM feeding, and 12/12 for the 12:00 AM feeding.On 12/30/25 at 10:29 AM, V7 (R12's Primary Care Physician) said that he was not made aware of R12's weight loss or that he was not getting his feedings as ordered. V7 said that he was also unaware of R12 asking for food. V7 said that he had just examined R12 and there was nothing wrong with R12 medically that would cause him to lose weight. V7 said that if R12 is losing weight, it would only be from him not being fed. On 12/30/25 at 11:09 AM, V16 (R12's Registered Dietician) said that if R12 was getting his feedings as ordered, he would not have lost any weight because his feedings were exceeding his needs. V16 said the only reason for R12's weight loss is that he is not getting enough feedings. On 1/2/26 at 5:50 PM, V1 (Administrator) said that it is her expectation that the residents get their tube feeding as ordered. V1 said that she does not expect R12 to be losing weight because he is to be feed as ordered. V1 said that she is aware of R12 not being fed and that he is malnourished, and it is not acceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe resident environment after a resident was able to obtain objects that could be used to threaten others. This applies to 2 residents (R1, R5) reviewed for safe environment. The findings include:On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 had a knife and held it to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that 12/7/25 she worked the night of 12/7/25 and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. V4 said R1 also threatened to burn down the facility before she was discharged to the hospital that night. V4 said that the facility was trying to send her to jail, but she went to the hospital instead. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2 DON (Director of Nursing) instructed her to search R1's room after it was reported that R1 had threatened R5. On 12/24/25 at 11:10am, V3 said while searching R1's room, she found a taser and a pocketknife under R1's bed. V3 said that she was instructed by V2 to put the items in the medication room. V3 said the night before after R1 was sent to the hospital, a hammer and drill were also found in R1's room. V3 said that the reason R1 was sent to the hospital on [DATE] was because R1 threatened R5, and after the police arrived, R1 threatened to burn down the facility. On 12/24/25 at 4:51 pm, R1, who was alert and oriented, said that she had kept a hammer, a drill and a pocketknife in her room for her protection.On 12/17/25 at 9:30 am, a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters were present in the medication room. At 3:16 pm V2 DON (Director of Nursing) removed the items and brought them to V1's (Administrator) office. The knife in V1's desk was metal and was like a folding boxcutter or utility knife. Unfolded, it was about 6 inches long, with the top half holding an angled blade.On 1/2/26 at 5:50 pm, V1 Administrator verified the objects found belonged to R1. V1 stated they were confiscated the night R1 went to the hospital and other potentially dangerous items were found and taken the next day. V1 said when residents have these types of items in the facility it makes the facility unsafe. R1's 12/7/25 11:55 pm nurses note showed that R1 threatened to burn the facility down and was transferred to the local community hospital for evaluation. R1's 11/13/25 care plan showed that R1 displays maladaptive behaviors that may detrimentally affect others. R1's care plan did not show a focus on any aggressive behaviors or previous possession of objects that could be used as weapons. R5's electronic health records showed on 10/8/25 that her cognition is intact and her 7/31/2025 care plan shows a risk for alteration in mood and psychosocial well-being, with an intervention to provide a calm and positive environment. The facility's 6/20/2023 Guidelines for Homelike Environment policy showed that the facility will ensure that the environment is safe. The policy showed that the furnishings should be safe, clean, and comfortable .

Based on interview and record review, the facility failed to investigate reported allegations of resident abuse, and subsequently failed to ensure residents were protected while the reported allegations were investigated. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse. The findings include:1. On 12/19/25 at 2:32 pm, R9, who was alert and oriented, said that on 12/14/25, staff ripped his shirt and had their knee on his neck during a verbal altercation between R9 and the staff. R9 said that he told the CNA (Certified Nurse's Assistant) that night that they ripped his shirt, and he told the nurse that the CNAs had their knees on his neck. On 12/14/25 at 11:10 am, V5 CNA verified that R9 did tell her and show her that his shirt was ripped during the altercation. V5 said that R9 was sent to the hospital that night for his behaviors and she reported the incident to the Administrator and the DON. On 1/2/26 at 5:50 pm, V1 (Administrator) said that R9 did report that the staff ripped his shirt and the staff was being physically aggressive to him. V1 said that the incident happened on 12/14/25 and she investigated it on 12/23/25. V1 said that she did not investigate the allegation until after R9 reported it to IDPH (Illinois Department of Public Health). The facility Initial Report dated 12/23/24 at 8:10 pm to the Illinois Department of Public Health showed that on 12/14/25, at 1:30 PM, R9 alleged that staff engaged in physical contact with R9. The facility reported the incident 9 days after the incident. The incident report did not include the alleged report of staff ripping R9's shirt. 2. On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 held a knife to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that on 12/7/25 she worked that night, and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2 DON (Director of Nursing) instructed her to search R1's room after it was reported that R1 had threatened R5. On 12/24/25 at 11:10am, V3 said while searching R1's room, she found a taser and a pocketknife under R1's bed. On 1/2/25 at 10:48 am, V5 CNA said that on 12/8/25 the following day, R5 reported to her that R1 had a knife in her room and held it to her neck and she was scared. V5 said that the facility found the knife, a hammer and drill. On 1/2/26 at 5:50 pm, V1 Administrator verified the objects found belonged to R1. V1 stated they were confiscated the night R1 went to the hospital and other potentially dangerous items were found and taken the next day. V1 said that she did not investigate R5's abuse allegation of 12/7/25 or report it to the Illinois Department of Public Health (IDPH).3. On 12/23/25 at 1:59 pm, R5, who was alert and oriented, said that once she was choking and a CNA helped her, but V17 CNA told her that he would have let her choke. R5 said that she reported it to V1. On 12/24/25 at 3pm, V1 Administrator said that R5 did report the incident to her but R5 said that it happened right before V1 had started at the facility, so she did not investigate the incident, nor did she report the incident to the Illinois Department of Public Health. The facility's Abuse Prevention Program policy (revised 01/2019) showed .After notification of alleged abuse.the Administrator.shall immediately commence an investigation of the incident reported.If you suspect abuse- separate the alleged perpetrator and assure all residents safety.complete an Incident Report immediately. Under Investigation, the policy showed any incident or allegation involving abuse. against a resident will result in an abuse investigation.

Based on observation, interview, and record review, the facility failed to ensure a resident remained free from abuse. The facility also failed to keep a resident free from physical abuse, resulting in one resident striking another in the head with his cane and that resident requiring sutures.This applies to 1 out of 6 residents (R29) reviewed for neglect and abuse.The findings include: On 12/31/25 at 12:26 pm, R29 was observed with a bruise to his upper right cheek below the eye, and three sutures on the right eye lid. R29's 12/26/25 6:45 am progress notes showed that R29 was observed with bleeding from below his right eye. The progress note showed that it was reported that another resident hit R29. R29's 12/26/25 hospital report showed that R29 sustained a head injury and a laceration requiring three sutures. The facility's 12/26/25 incident report to Illinois Department of Public Health showed that on 12/26/25, R2 and R29 engaged in inappropriate physical contact. On 1/2/26 at 5:50 pm, V1 Administrator said that it was reported to her that R2 hit R29 in the head with his cane. V1 said that R29 was sent to the hospital and received sutures. R29's 12/24/25 care plan shows a focus for a history of suspected abuse with interventions including assure R29 is in a safe environment.R2's 10/16/25 care plan showed a focus on inappropriate sexual behavior, but did not identify an assessment for the potential for physical abuse against others.The facility's Abuse Prevention Program policy (revised 01/2019) defined physical abuse as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. The Policy also showed It is the policy of this facility to prohibit and prevent resident abuse, neglect against a resident in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide care to a resident dependent on staff for ADL (activities of daily living). This applies to 1 of 3 (R5) residents reviewed for ADL care.The findings include:According to the Electronic Medical Record (EMR), R5 was admitted to the facility on [DATE], with multiple diagnoses including acquired absence of left leg above knee, cellulitis of groin, hidradenitis suppurativa, and pressure ulcer of sacral region, stage 3. R5's MDS (Minimum Data Set) dated June 5, 2025, showed R5 had mild cognitive impairment and required maximum assist with toileting hygiene, shower, and bathing. R5's Care Plan dated April 13, 2025, showed R5 has an ADL (Activity of Daily Living) self-care deficit and required staff assistance and showed that R5 is incontinent of bladder and bowel. Interventions include the CNA (Certified Nurse Aide) should check and change R5 every 2 hours and as needed.On August 25, 2025, at 12:40 PM, R5 was in bed with an empty urinal on his bedside dresser table. R5 stated that he uses the urinals and was incontinent of bowel. R5 also stated that he calls the CNA (Certified Nursing Assistant) when he needs to be cleaned up after a bowel movement and has had to wait up to 30 minutes sometimes. R5 also added that he has had chronic ulcers for about 20 years and developed a sore on his buttock at the facility about 3 months ago.On August 26, 2025, R5 was awake in bed with his urinal almost about half full of urine. R5's room was noted with a strong urine odor, and the bed linens and padding were stained and heavily soiled with urine. On August 26, 2025, at 9:33 AM V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they are scheduled from 6 AM to 2 :00 PM and are both assigned to R5's room. V6 and V7 stated they were working in other rooms and giving bed baths. V6 and V7 stated they were getting ready to check in on R5. When V6 and V7 attempted to provide care to R5, a large area of R5's beddings, disposable pad and blanket were soiled with urine. On August 26, 2025, at 9:49 AM, V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they typically complete their morning rounds during their shift around 10:30 AM. On August 26/2025 at 12:09 PM, V2 (Director of Nursing / DON) stated that CNAs (Certified Nursing Assistant) work from 6:00 AM to 2:00 PM and should complete their morning rounds which includes, checking on their residents, attending to their needs, and checking with the nurses to determine any specific needs for the resident such as an appointment or anything else. V2 also stated that the CNAs should prioritize attending to the residents who needs incontinence care right away unless another resident was experiencing an emergency. V2 added that CNAs are expected to complete incontinence care for all residents within the first 2 hours of their shift.R5's nurse practitioner progress note created by V4 dated August 22, 2025 documents R5 has a sacral wound, and a history of (IAD) incontinence associated dermatitis. On August 25, 2025, at 3:52 PM, V4 (Nurse Practitioner) stated she determined R5's skin irritation to be incontinence associated because R5 wears incontinence briefs, and it gets really moist from his incontinence episodes and also has leakage from having HS.The facility's Guidelines for A.M. Care policy dated March 21, 2023, stated, Policy: It is the policy of the facility to see that residents receive A.M. care in preparation for the activities of the day.The facility's Guidelines for Incontinence Care dated September 21, 2025, stated, Policy: It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with daily care. Frequency depends on bladder diary results and/or routine minimal q [every] 2 hour checks as well as care planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to prevent resident to resident abuse.
This applies to 2 of 5 residents (R2 and R3) reviewed for abuse in the sample of 10.
The findings include:
1. FRI (Facility Reported Incident) report documents an incident of April 14, 2025, alleging that R1 made inappropriate contact with R2. The report indicates that immediate action taken: Residents were immediately separated. Body and pain assessments completed on R1 and R2. Police was notified. R1 was placed on 1:1 monitoring until sent out to the hospital for further evaluation. After interviewing staff and residents, it was discovered that R1 and R2 were waiting in the hallway to go out for smoke break but staff did not witness the incident.
R2's EMR included diagnoses of End Stage Renal Disease; Chronic Obstructive Pulmonary Disease; Major Depressive Disorder, Recurrent; Unspecified Bipolar Disorder, Schizoaffective Disorder unspecified
R2's admission MDS dated [DATE], showed that R2 was cognitively intact.
R1's EMR (electronic medical records) included diagnoses of other Lack of Coordination; Hypothyroidism, Unspecified; Dementia In Other Diseases Classified Elsewhere, Moderate, With Other Behavioral Disturbance; Weakness; Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris.
R1's quarterly MDS (minimum data set) dated April 14, 2025 showed that R1 was moderately impaired cognition.
On May 1, 2025 at 10:20 AM, R2 stated that she doesn't remember the date or time of the incident. R2 continued We were lining up for smoke break. He (R1) came out of his room and came by me and said Hi and I said Hi. I have always said Hi (previously). This time he decided to touch me on my breast. He was just rubbing across. Then he decided that he was going to move his hand down below on my vagina through my clothes and I smacked is hand and said 'No.' He didn't stop. That was the end of it as they (staff) were to open the door, and he stopped as he didn't want to get caught. I went to V7 (Activity Aide), who opened the door and came to hand out the cigarettes. But she didn't see it. She told somebody who was over her about it and I guess they send him to the hospital for a while .
On May 1, 2025 at 10:39 AM, V4 CNA (Certified Nursing Assistant) was seen seated outside R1's door and stated that R1 is on 1:1 monitoring since he got back from the hospital on April 19, 2025. V4 continued He has had two or three incidents of inappropriate touching of other residents. It was R5 and another resident who is no longer here. That resident did not report it until she was getting to leave at the door. I don't know if those incidents happened. He (R1) has been on 1:1 monitoring after each incident
On May 1, 2025 at 11:36 AM, V1 stated that during investigation, R2 stated that while she was in line to go for cigarette break, R1 touched her breasts and tried to touch her vagina area and that she pushed his hand away. V1 stated that there were no more witnesses of the incident so it was not substantiated. V1 continued that R1 had had another allegation against him on November 15, 2024 alleging that he was touching another resident on the breasts which was witnessed by a Dietary staff. V1 added that this was investigated by IDPH and cited for the same. V1 stated that as a precautionary measure, R1 is placed on 1:1 monitoring until facility finds an alternate placement for him.
2. FRI (Facility Reported Incident) report included that R4 made physical contact with R3 on April 24, 2025.
The facility concluded afrer interviewing staff and residents, that R3 wandered into R4's room and tried to remove some items from his table and R4 tried to stop her. The staff came into the room and removed R3 from the room. R3 and R4 were assessed and noted without pain or serious injury. R3 was noted to have a small skin alteration to her left eyebrow.
R3's EMR included diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Generalized Anxiety Disorder. R3's quarterly MDS, dated [DATE], showed that R3 was severely impaired in cognition.
R4's EMR included diagnoses of Hypothyroidism, Unspecified; essential (Primary) Hypertension; hyperlipidemia, Unspecified; weakness; dementia in Other Diseases Classified Elsewhere, Mild, With Mood Disturbance; and Anxiety Disorder, Unspecified. R4's quarterly MDS, dated [DATE], showed that R4 was severely impaired in cognition.
On May 1, 2025 at 10:20 AM and 10:56 AM, R3 was seen wandering from hallway to hallway. R3 was also
seen walking about during activities eating pudding from a disposable container and going from table trying to feed it to other residents or touching them and those residents appeared annoyed. V7 and V8 (both activity aides) stated that R3 is a wanderer. V7 and stated that R3 just walks around and tries to touch people. V8 stated that R3 touches people and some residents say, get away.'
On May 1, 2015, at 11:04 AM, R4 was resting in bed and when asked, stated that no residents bothered him. V10 (LPN-Nurse) who was in the vicinity, stated that R4 is confused and not aware of any incidents with other residents.
On May 1, 2025 at 12:45 PM, R10 stated that R4 is his roommate. [R4] and the other person [R3] who was a female were fighting. I was sleeping and woke up and he was hitting her. They were both down on the floor and were wrestling. He said that she took something of his, and he was trying to get it back. He hit her right by the eye. I went to get V4 (CNA) who was standing by the front desk as I did not want to get involved and everything.
On May 1, 2025 at 11:46 AM, V1 stated that R3 had wandered into R4's room and was trying to get something from his over the bed table and he was trying to stop her from getting into his stuff. V1 stated that R4's roommate R10 woke up and ran to get help. V1 continued V4 (CNA) came in there and called for more help and another V5 (CNA) came and got V6 (Licensed Practical Nurse) for more help. V6 took R3 out of the room and assessed her. V4 did not take her out of the room earlier as she was on the floor and she did not want to move her. V6 did a head to toe assessment and R3 had a small scratch over her left eyebrow. R3 has severe Dementia and wanders a lot and means no harm and tends to tap people as she is walking
On May 5, 2025, at 3:35 PM, V6 confirmed the above and stated that when she entered the room, R3 was sitting on the floor and R4 was on his bed. V6 stated that when she assessed R3 and observed a scratch on her eyebrow that was bleeding a little bit
Facility provided other reportable's for R3 which showed R3's history of wandering and altercations.
November 25, 2024: R3 wandered into the dining room and tried to touch things on R9's table and R10 tried to push her away.
November 5, 2024 : R3 wandered into R8's room and touched her.
September 30, 2024: R3 wandered in the hallway and touched R7.
September 24, 2024: R3 wandered into R6's room and touched her.
Facility policy and procedure titled Abuse Prevention Program (last revised January 1, 2019) included as follows:
Policy: It is the policy of this facility to prohibit and prevent resident abuse.
Abuse prevention program:
As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches regularly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident was free from abuse for one of three residents (R3) reviewed for abuse in a sample of 3. This failure resulted in R3 being physically slapped by a staff member which caused R3 to experience emotional distress and led to R3 displaying increased agitation, aggression, and combative behavior.
Findings include:
R3's face sheet indicated that resident admitted to the facility on [DATE] and has a past medical history not limited to: cerebral infarction due to thrombosis, metabolic encephalopathy, bipolar disorder, personal history of physical injury and trauma, and tension-type headaches.
R3's screening assessment for indicators of aggressive and/or harmful behavior dated 09/16/2024 revealed that R3 is at minimal risk for aggression with dementia, related interventions of re-orientation, re-assurance, emphasis on safety/security, and severe mental illness interventions of stress management/relief and harm reduction.
Review of R3's active physician's orders summary on 01/21/2025 showed the following: divalproex sodium delayed release 125 milligram (mg), give 2 capsules by mouth three times a day for manic depression with start date of 10/11/2024; topiramate 50 mg tablet, give 1 tablet by mouth two times a day for bipolar disorder with start date of 10/24/2024; trazodone hcl 50 mg, give 1 tablet by mouth at bedtime for depression, insomnia.
The facility's final report with incident date of 10/22/2025 indicated that the facility had conducted an investigation of physical contact made to R3 by staff member V3 (Certified Nursing Assistant). The facility substantiated the alleged act based on witness reports that revealed V3 (CNA) was observed striking R3 on the hand when R3 attempted to grab at V3's laptop. R3 responded by hitting V3 (CNA).
Review of R3's Minimum Data Set (MDS) Section C - Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) score of 08/15 dated 12/11/2024 that indicated moderate cognitive impairment.
On 01/21/2025 at 10:30 AM, R3 was observed in his wheelchair across from the 200 unit nurse's station. R3 appeared to be in a calm and pleasant mood and did not recall the physical abuse incident.
On 01/21/2025 at 10:35 AM, V4 (Certified Nursing Assistant) said R3 can get agitated at times due to loudness or if someone bumps into him for example. V4 added that she has never seen R3 be aggressive with staff because his arms can be stiff, almost contracted at times.
On 01/21/2025 at 12:06 PM, V1 (Administrator) said on the date of incident, V3was assigned to R3 for 1:1 monitoring and was told to take R3 into the dining room. While in the dining room, R3 was attempting to reach for V3's personal laptop that she should not have had with her at work. V3 was observed by staff members V5 (Restorative Nurse) and V7 (Activity Aide) slap R3's hand away then R3 punched V3 in the face. V1 (Administrator) then said that V3 was immediately removed from the dining room and suspended pending the outcome of her investigation. V1 added that she always tells staff they cannot hit a resident under any circumstances and that V3 should have called for assistance, attempted to redirect R3, and/or should have removed her laptop from R3's immediate area. V1 (Administrator) then said that V3 was terminated because the abuse allegation was substantiated. V1 added that R3 was not sent out to be evaluated.
On 01/21/2025 during interview from 12: 28 PM to 12:40 PM, V5 said she was standing in the doorway of the main dining room and facing inside the room where she observed R3 sitting in the dining room at a table seated next to V3. V5 then said that she saw R3 was grabbing at V3's laptop then V3 had pushed R3's hand away, but R3 kept grabbing for the laptop. V5 then saw V3 slap R3's left hand with her right hand, and R3 immediately punched V3 in the face. V5 approached the table and informed V3 that V10 (Registered Nurse) would stay with R3. V5 then said that she escorted V3 to V2's (Director of Nursing) office and informed V2 of the incident. V5 added that R3 has a known behavior to get nervous and react when people don't explain things to him, approach him with a loud tone, or if they rush R3 to do tasks. V5 then said that V3's behavior was not appropriate because staff should not use physical methods to redirect a resident. V5 added that V3's slap triggered R3's aggression towards her.
On 01/21/2025 at 12: 44 PM, V6 (Assistant Director of Nursing) said around 02:30 PM on day of incident, she was standing in the doorway of the dining room but was facing towards the hallway. V5was standing next to her facing inside the dining room when she heard a slap sound. V6 added that V5 then turned to her (V6) and said, did you see that, she just slapped him on the hand like he was a kindergartener. V6 then said after she heard the slap sound, she turned around and saw R3 hit V3 in the face. V6 approached V3 and told her to go to her office, then briefly assessed R3 for any apparent injuries before reporting the incident to V1 (Administrator). V6 added that if staff interact with R3 in an aggressive manner, he will become aggressive. Staff must talk to him in calm manner, then said R3's voice became louder after V3 slapped him. V6 also said that staff who are familiar with R3 are knowledgeable of this calm approach, and that V3 normally worked with him and knew about his temperament.
On 01/21/2025 during interview from 1:01PM to 01:10 PM, V10 (Registered Nurse) said V3 was in the dining room with R3 on day of incident and he was R3's nurse. V10 said as he approached the dining room to relieve V3 for a meeting, he saw V5 and V6 standing in the doorway and heard V5 saying that V3 had hit R3. V10 then said he observed R3 beginning to calm down as V3 was being removed from the dining room. V10 added that R3 is much calmer now and has had no further issues since the incident.
On 01/21/2025 at 01:25 PM, V3 said she was assigned to R3 for 1:1 monitoring. V3 said she took him into the dining room, put him up to a table, and had put the wheel locks on to the wheelchair, V3 then sat down next to him, but he kept trying to unlock the wheelchair and slapped at her hand when she tried to cover the wheelchair lock with her own hand. V3 then said R3 started digging his nails into her wrist, forearm, and right hand and then began digging harder so she slapped her own forearm to get R3 to understand that he was hurting her. V3 said R3 then punched her in the face with a closed fist. V3 added that R3 can have aggressive behaviors but she did not call out for assistance and knows that hitting residents isn't allowed. V3 then indicated that V13 and V7 were both present in the dining room and had both observed the incident then indicated that V13 no longer is employed at the facility. V3 then said she was told by V6 that there was an allegation of abuse by V3 towards R3, so she was walked out of the facility and then terminated on 10/29/2024 because the abuse allegation was substantiated.
Review of V3's employee disciplinary action form dated 10/29/2024 revealed that V3 was terminated due to an allegation of physical abuse of physical abuse towards a resident was substantiated.
Review of V13's (Certified Nursing Assistant) signed confidential witness statement dated 10/28/2024 revealed that V13 did not personally observe the incident between R3 and V3 (CNA).
On 01/21/2025 at 2:09 PM, V7 said at about 03:00 PM on day of the incident, V3 was in the dining room with R3 and that he (V7) was nearby them and could see that V3 was trying to prevent R3 from standing up from his wheelchair. V7 then said after a few minutes, R3 was getting agitated, and it looked like he was scratching at V3's (CNA) arm when he then saw V3 slap R3's hand then R3 punched V3 in the face immediately afterwards. V7 added that after V3 was removed from the area, R3 then began to calm down.
Review of undated employee roster on 01/21/2025 showed that V3 and V13 are not currently employed at the facility.
Review of Abuse Prevention Program policy on 01/21/2025 that was last revised 01/2019 reads in part:
It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party.
Protection of Residents: the facility will take steps to prevent mistreatment while the investigation is underway. Residents and visitors are protected from any retaliation or possible harm. Staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and suspended from duty, pending the outcome of the investigation, prosecution or disciplinary action against the employee.
Prevention: The facility desires to prevent abuse, neglect, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach.
Abuse and Crime Reporting: this facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: hitting slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.
After notification of alleged abuse, neglect or a suspected crime against a resident, the administrator or DON in the administrator's absence shall immediately commence an investigation of the incident reported. The findings of such investigation will be provided to the administrator within 5 working days of the occurrence of such incidents. The administrator shall either rule-out or substantiate the allegation of abuse. The administrator or DON shall review the findings of the investigation and determine if further training or other corrective action is needed to prevent future occurrences.

Based on observation, interview and record review the facility failed to keep a resident free from sexual abuse. This applies to 1 of 6 residents (R1) reviewed for abuse.
The findings include:
On December 3, 2024 at 11:15 AM, V10 (Cook) stated she had been coming out of the hallway bathroom on 11/15/2024, when she witnessed R2 patting R1 above her right breast on the outside of her clothing. V10 stated R2 then slipped his hand down the neckline of and underneath R1's shirt to her left breast. V10 stated she knew R2 could feel her presence because he stopped and left. V10 stated at first she thought R2 was just checking on her, then she saw him slip his hand down her shirt. V10 stated R1 is nonverbal and blind and regardless of if she reacted or not, R1 cannot defend herself.
V10's written statement from the facility's 11/15/2024 investigation showed she .saw [R2] sitting in the hallway near the small dining room. I saw [R2] touch [R1] by her right side of her chest. I saw him put his hand under her shirt close to her left breast. Then when [R2] saw me he hurried up and moved his hand and moved out of the hallway .
R1's Face Sheet showed her diagnoses include profound intellectual disabilities, aphasia, cerebral infarction, congenital malformations of lower limbs, and unspecified sequelae of nontraumatic intracerebral hemorrhage. R1's 11/26/2024 MDS (Minimum Data Set) showed staff determined her cognition was severely impaired.
On 11/29/2024 at 1:20 PM, R1 was in her wheelchair in the hallway, sitting cross-legged. R1 continuously shook her head back and forth rhythmically from side to side. On 11/29/2025 at 1:25 PM, V5 LPN (Licensed Practical Nurse) stated R1 is vision-impaired and believes R1 has some vision, but only peripherally.
On 12/5/2024, V9 (Nurse Practitioner) stated any groping that is not consensual would elicit a negative reaction. V9 stated if it were you or I, we would be upset, but humiliation would not come into play.
R1's Abuse care plan (revised 4/18/2023) showed her comprehensive assessment reveals a possible [history] of suspected abuse, neglect, exploitation, possible past trauma and/or other factors that may increase my susceptibility to abuse/neglect (weakness, intellectual disability). [R1] demonstrates: Hearing/Vision Loss, Impaired Cognition/Communication, Difficulty in adjustment & generalized mood distress. Given her poor and compromised health status, cognitive issues, physical assistance needs and need for 24-hour care, the [Inter-Disciplinary Team] recognizes that [R1] is considered a vulnerable adult.
R2's Face Sheet showed diagnoses of unspecified alcohol abuse with intoxication, moderate dementia with other behavioral disturbance, anxiety, and tobacco use.
R2's Boundaries care plan (revised 10/08/2024) showed R2 demonstrates behavior symptoms concerning inappropriate personal boundaries due to: Cognitive impairment secondary to Alzheimer's disease or a related dementia. These symptoms are manifested by: Making sexually explicit and/or insensitive remarks to another person.
R2's written interview (written by staff) from the facility's 11/15/2024 investigation showed Nothing happened. I did not touch anyone inappropriately. I was not near her.
The 11/15/2024 Police Field Report for the abuse incident showed the interview with V10 (Cook) which included .[V10] saw [R2] rubbing [R1's] chest and it appeared as if he was checking on her when she then noticed his hand was inside of her shirt and he was fondling her breast. [V10] further related she believes [R2] heard her and he stopped .
The facility's Final investigation reported to the Illinois Department of Public Health showed Facility is unable to substantiate the allegation of abuse.
The facility's Abuse Prevention Program-Abuse and Crime Reporting policy (revised 01/2019) showed For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain .Abuse: the willful infliction .means the individual must have acted deliberately . Sexual Abuse: Including, but not limited to, sexual harassment, sexual coercion, or sexual assault .

Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness.This applies to 74 residents in the facility receiving dietary services.
Findings include:
On 11/14/24 4:36 PM, V2 DON (Director of Nursing) stated 74 residents were served from dietary services on 11/12/24.
On 11/12/24 at 10:45 AM, the dry storage contained:
A large bin of breadcrumbs with use by date of 7/28/24.
A large bin of oatmeal with use by date of 11/9/24.
A large bin of rice with use by date of 10/30/24.
A large bin of flour with use by date of 9/18/24.
A large bin of thickener with use by date of 7/9/24.
A clear plastic bag with dry penne pasta open to air.
Two clear plastic bags containing dry fettuccini pasta open to air.
Dented cans in rotation for use:
Diced beats 6lb (pounds) 8 oz (ounces).
Diced carrots 6lb 9 oz.
Three cans of diced potatoes 6lb 6oz.
Two cans of chunk tuna 4.16lb.
The facility policy Storge of Dry Foods / Supplies dated 9/18/23 states dry goods will be handled and stored to maintain the integrity of the packaging until the item is ready to use. Dented cans will be stored separately with a dented cans sign and marked for return or disposal.
On 11/12/24 at 10:58 AM, the milk cooler had a sour/spoiled odor.
The facility policy Storage of Refrigerated / Frozen foods dated 4/26/2024 states refrigeration units are routinely cleaned and free from garbage and other waste.
On 11/12/24 at 11:00 AM, the walk-in cooler contained:
Corn in a clear plastic bag open to air.
Pancakes in a clear plastic bag open to air.
Breakfast sausage patties in a clear plastic bag open to air.
On 11/12/24 at 11:03 AM, the walk-in cooler contained:
Yellow cheese slices partially wrapped in plastic with the exposed cheese hardened and open to air.
Bologna open to air without an open on or use by date.
A large bag of shredded yellow cheese open to air and falling out of the bag.
Large unsliced turkey meat wrapped in plastic stored above diced potatoes.
Plastic storage container of peeled boiled eggs with use by date of 11/9/24.
A 10lb box of hot dogs open to air dated 11/6/24.
Six bags of raw liquid eggs in a plastic container with use by date of 11/9/24.
The facility policy Receiving and Handling dated 4/2017 states All foods are wrapped in moisture proof wrapping or placed in suitable containers to prevent freezer burn. Items are labeled and dated. Meats, fish, and poultry will be stored on lower shelves below, fruits, vegetables or other ready to eat food to prevent contamination. Food items will be arranged so that older items will be used first. Expiration dates will be monitored.
On 11/12/24 at 11:14 AM, an oscillating fan located in the dish area was covered with dust and grease.
On 11/12/24 at 11:20 AM, the kitchen contained:
A storage bin containing flakes of corn cereal with a use by date of 9/25/24.
A storage bin containing crisped rice cereal with a use by date of 9/25/24.
A storage bin containing frosted flakes of corn cereal with a use by date of 9/25/24.
On 11/13/24 at 03:59 PM, V5 Dietary Manager stated we do not have a separate log for documenting the sanitizer concentration for the red sanitizing buckets. V5 stated dented cans can spoil or become contaminated and should be sent back to the distributor. V5 stated it's important to have the correct date of when the food came in, when it was opened and use by, so we aren't serving outdated or spoiled food items, and the food items should be properly wrapped / stored to prevent contamination and to make sure the food quality remains fresh. V5 stated the turkey should not have been stored over the potatoes, you don't want juice from the turkey getting in the potatoes and contaminating them.
V5 stated the cereal wouldn't spoil it would just be stale. I don't have a reference for how long dry goods are good for. It should have been dated with the original expiration from the packaging or the delivery date. The pasta should be labeled dated and sealed.
The policy Sanitizing Buckets dated 9/22/23 states sanitizer concentration will be checked using a test kit. Concentration will be documented on the sanitizer solution log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to change PICC (Peripherally Inserted Central Catheter) dressings.This applies to 1 of 7 residents (R75) reviewed for infection control in a sample of 18.
Findings include:
R75's face sheet showed R75 admitted to the facility on [DATE] with diagnoses that includes cellulitis of the right lower limb, diabetes mellitus, and cutaneous abscess of the foot. R75's MDS (Minimum Data Set) dated 10/29/24 shows she is cognitively intact.
On 11/12/24 at 1:01 PM, R75 showed the surveyor the single lumen PICC line in her right upper arm. The PICC had a border gauze dressing in place that had drainage in the center of it. R75 stated the dressing had been in place 4 to 5 days and she had changed it herself. R75 stated the staff did not do the dressing changes on her PICC line.
On 11/14/24 at 1:20 PM, R75 stated the dressing on her PICC line had not been changed. R75 showed the surveyor her PICC line had the same stained border gauze dressing, with more soiling and rolled on the sides, exposing the PICC insertion site.
On 11/14/24 at 1:41 PM, V3 ADON (Assistant Director of Nursing) stated PICC line dressings are changed every seven days and as needed when a transparent dressing is in place. V3 was unsure the frequency of PICC line dressing changes if a border gauze was in place.
On 11/14/24 at 1:51 PM, V2 DON (Director of Nursing) PICC lines and Central line dressings are done every seven days and as needed if a transparent dressing is in place. A gauze type dressing should be changed daily. The gauze has an increased risk of infection.
On 11/14/24 at 5:51 PM, V3 ADON stated there was no documentation for R75's PICC dressing changes in her electronic medical record.
R75's physician orders document change transparent dressing on admission, then weekly and as needed thereafter. Monitor site every shift for signs / symptoms of infection and or infiltration. R75's current care plan for the PICC line includes monitoring for signs and symptoms of infection.
The facility policy Dressing Change, Midline Catheter dated April 2011 states gauze dressings are changed: 24 hours post insertion or upon admission, every 48 hours or if the integrity of the dressing has been compromised (wet loose or soiled). Assessment of venous access site is performed: during dressing changes and at least once every shift when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide in writing to residents and their families/POA (Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 4 of 4 residents (R7, R26, R38, R74)) reviewed for discharge in a sample of 18.
The findings include:
1. On 11/13/24 at 2:27 PM, V2 (DON-Director of Nursing) stated, We hold the bed for 10 days. That's guaranteed to the patient. We don't typically keep a copy of the bed hold notice.
R74's face sheet shows an admission date of 9/9/24 to the facility.
R74's progress notes document the following:
On 9/19/24 at 10:30 AM, (R74) observed on floor positioned on buttock with against door in bedroom. No injuries no skin alterations. Resident noted being verbally aggressive towards staff. MD (Medical Doctor) notified. Received order to transfer to (Hospital) for CT (Computerized Tomography) scan and psych evaluation. Order carried out. DON (Director of Nursing) and family POA made aware.
On 9/20/24 at 9:54 AM, (R74) admitted to hospital with a diagnosis of aggressive behavior.
Review of R74's electronic medical record shows nothing was uploaded regarding the bed hold provided to the resident/POA.
The facility was unable to show proof the bed-hold policy was provided to R74.
2. R7's face sheet showed R7 was admitted to the facility on [DATE]. R7 had multiple diagnoses which included acute respiratory failure with hypoxia, weakness, atrial fibrillation, diabetes, dementia, muscle wasting, and anxiety disorder. R7's MDS (Minimum Data Set) dated 09/20/24 showed R7 had moderate cognitive impairment.
R7's progress notes showed the following:
On 08/27/24 at 8:06 PM while doing rounds, (R7) observed lying on floor in front of his toilet. Skin alteration to rt eye. Ice placed on rt eye. Tylenol given for pain. Resident transferred into bed. First aid rendered. BP 74/62, O2 79%, resp 20, pulse, 90 BS 134. MD notified with new orders to send to (Hospital), DON notified. Family attempted to be reached x3. Unable to leave message. Will continue to try to reach family. On 08/28/24 at 6:31 AM called into (Hospital) for update. (R7) being admitted d/t low hemoglobin.
On 09/24/24 at 11:00 AM writer observed (R7) face to be drooping to left side, puffy face, swelling to right hand/arm. Vitals 143/68, 97.6, 92, 18, 81% r/a, applied O2 n/c @ 2L, SPO2 now at 99%. MD notified received order to transfer out to hospital, order carried out. 911 called to transport (R7) to hospital. Family, DON and ADON made aware. On 09/24/24 at 11:25 AM Paramedics have arrived to transport (R7) to (Hospital) via stretcher. On 09/25/24 (R7) admitted to (Hospital). Admitting dx DVT to rt arm.
On 09/29/24 at 8:30 AM While doing rounds (R7) observed with SOB, low O2, and diaphoretic. Vitals taken. Increased O2. MD notified. Per MD ok to send to (Hospital) for eval and treat. On 09/29/24 at 3:24 PM Called ER for update. (R7) being admitted for SOB and hypoxia.
R7's electronic medical record showed no uploaded information regarding provision of a bed hold policy for each discharge to the hospital. The facility was unable to provide information regarding the bed hold policy given R7 or his POA.
3. R26's face sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which included multiple fractures of ribs, muscle wasting and atrophy, schizoaffective disorder, major depressive disorder, epilepsy, post-traumatic stress disorder, and suicidal ideations. R26's MDS dated [DATE] showed R26 was cognitively intact.
R26's progress notes showed the following:
On 05/08/24 at 9:00 PM 911 arrived to the facility stating that R26 had just placed a call to the suicide hotline. Prior to R26 placing a call she was observed resting in her bed. When R26 was asked by the writer and the police officers what was wrong, R26 stated that she was depressed and did not want to talk about it. Ambulance arrived to facility and transported to (Hospital). MD made aware. On 05/09/24 at 3:11 AM Writer placed a call to the hospital for an update on R26 status. R26 got admitted to (Hospital). Dx depression.
On 07/22/24 at 6:15 PM R26 expressing suicidal ideations d/t not wanting to be at the facility anymore. R26 stated she wants to die and that she has a plan. She stated she could take a lot of pills to die. Contacted NP and orders are to send out to be further evaluated. R26 placed on 1:1 until ambulance arrived. R26 is her own responsible party. On 07/22/24 at 7:11 PM ambulance arrived to transport R26 to (Hospital) x 3 EMT via stretcher. R26 is her own responsible party. Report from off going nurse states all parties were informed. On 07/23/24 at 5:12 AM Call placed to (Hospital) to get update on R26. Shift change is taking place. Advised to call back. Will endorse to oncoming nurse.
R26's electronic medical record showed no uploaded information regarding provision of a bed hold policy for each discharge to the hospital. The facility was unable to provide information regarding the bed hold policy given R26 or her POA.
4. R38's face sheet showed R38 was admitted to the facility on [DATE]. R38 had multiple diagnoses which included cerebral infarction due to embolism of right cerebellar artery, metabolic encephalopathy, asthma, acute respiratory failure with hypoxia, malignant neoplasm of the colon, need for assistance with personal care, and cocaine abuse. R38's MDS dated [DATE] showed R38 was cognitively intact.
R38's progress notes showed the following:
On 08/24/24 at 6:35 PM Altered mental status noted during rounding. V/S 98/64, 86, 16, 99.9, 83% on room air (O2 applied), blood glucose 257, not responding to painful stimuli. MD was notified and said to send R38 to the ER. 911 called and arrived shortly. R38's emergency contacts were called. Both of their phone numbers were disconnected. Bed hold policy in placement. The DON was contacted. On 08/24/24 at 10:54 PM per (Nurse) from (Hospital) R38 was admitted for Pneumonia, Hypoxia, UTI, and Acute Kidney Injury.
On 09/16/24 at 6:28 PM R38 observed in bed not easily aroused. Sternum rub applied no response. Vitals taken B/P 119/69, P 89, T98, R16, O2 90% room air. Blood sugar 161. Elevated head of bed applied 3L O2 NC O2 stats increased to 95%. Attempted to arouse, unable. Placed call to 911. MD, ADON notified. Attempt to reach family no answer. On 09/16/24 at 6:35 PM EMT arrived to facility. Transferred resident onto gurney. Exiting building to (Hospital) ER. Report called in to charge nurse. MD/DON aware. On 09/17/24 at 6:48 AM Called (Hospital) to get report. Shift change happening. (Hospital) will call back later. On 09/19/24 at 12:14 AM Spoke with RN at (Hospital). R38 admitted to IMCU with a dx of Acute Renal Failure. R38 is expected to be discharged back to the facility within the next 48 hours.
On 09/25/24 at 12:15 PM R38 noted with change in condition. R38 unable to arouse. Checked vitals, B/P 83/53, P 74, R16, T97.9, O2 90% room air. Call placed to MD orders to send out to (Hospital) for further evaluation and treatment. Call placed to 911 for transport. POA notified. On 09/25/24 at 12:28 PM EMT arrived to facility, transferred onto gurney by EMT. Exiting the building. On 09/26/24 at 6:58 AM (Hospital) called. R38 admitted for observation with dx of generalized weakness & altered mental status. Med list faxed.
R38's electronic medical record showed no uploaded information regarding provision of a bed hold policy for each discharge to the hospital. The facility was unable to provide information regarding the bed hold policy given R38 or his POA.
On 11/14/24 at 3:22 PM, V1 (Administrator) stated residents and or family representatives should receive a bed hold policy each time a resident is discharged from the facility or admitted to the hospital. The residents did not receive a bed hold policy for the admissions to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a resident and/or his family/POA (Power of Attorney) the reason of transfer to the hospital in writing. The facility also failed to notify the ombudsman of the transfer.This applies to 4 of 4 residents (R7, R26, R38, R74) reviewed for discharge in a sample of 18.
The findings include:
1. On 11/13/24 at 2:27 PM, V2 (DON-Director of Nursing) stated, We don't notify the ombudsman about the transfer to the hospital. We don't get the ombudsman involved in the discharge or transfer of a resident. We only notify the ombudsman if the resident is non-compliant with something, or we can't reach an agreement with the resident. We didn't give a written notice to (R74) and his POA at the time of discharge to the hospital or afterwards. We notified the POA by phone. If we can't reach the POA, then social services emails or gives them a written notice. There's nothing uploaded in the resident's chart regarding the written notice of discharge to the hospital or notification that the ombudsman was notified.
R74's face sheet shows an admission date of 9/9/24 to the facility.
R74's progress notes document the following:
On 9/19/24 at 10:30 AM, (R74) observed on floor positioned on buttock with against door in bedroom. No injuries, no skin alterations. Resident noted being verbally aggressive towards staff. MD (Medical Doctor) notified. Received order to transfer to (Hospital) for CT (Computerized Tomography) scan and psych evaluation. Order carried out. DON (Director of Nursing) and family POA made aware.
On 9/19/24 at 10:45 AM, Paramedics have arrived to transport resident to (Hospital) ER (Emergency Room) via stretcher. Bed hold policy in place.
On 9/20/24 at 9:54 AM, (R74) admitted to hospital with a diagnosis of aggressive behavior.
On 10/11/24 at 12:10 PM, (R74) readmitted to facility A+O x 1-2 with confusion in stable condition. All safety precautions in place. MD made aware of all orders verified.
Review of R74's electronic medical record shows nothing was uploaded regarding the discharge notice to the resident/POA.
Facility's policy titled Discharge/Transfer of the Resident (1/1/2020) shows: Transfer: 3. Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or persons (s) responsible for care. Note: If emergency transfer, Transfer or Discharge Notice form may be completed later, but as soon as possible.
2. R7's face sheet showed R7 was admitted to the facility on [DATE]. R7 had multiple diagnoses which included acute respiratory failure with hypoxia, weakness, atrial fibrillation, diabetes, dementia, muscle wasting, and anxiety disorder. R7's MDS (MDS/Minimum Data Set) dated 09/20/24 showed R7 had moderate cognitive impairment.
R7's progress notes showed the following:
On 08/27/24 at 8:06 PM while doing rounds, (R7) observed lying on floor in front of his toilet. Skin alteration to rt eye. Ice placed on rt eye. Tylenol given for pain. Resident transferred into bed. First aid rendered. BP 74/62, O2 79%, resp 20, pulse, 90 BS 134. MD notified with new orders to send to (Hospital), DON notified. Family attempted to be reached x3. Unable to leave message. Will continue to try to reach family. On 08/28/24 at 6:31 AM called into (Hospital) for update. (R7) being admitted d/t low hemoglobin.
On 09/24/24 at 11:00 AM writer observed (R7) face to be drooping to left side, puffy face, swelling to right hand/arm. Vitals 143/68, 97.6, 92, 18, 81% r/a, applied O2 n/c @ 2L, SPO2 now at 99%. MD notified received order to transfer out to hospital, order carried out. 911 called to transport (R7) to hospital. Family, DON and ADON made aware. On 09/24/24 at 11:25 AM Paramedics have arrived to transport (R7) to (Hospital) via stretcher. On 09/25/24 (R7) admitted to (Hospital). Admitting dx DVT to rt arm.
On 09/29/24 at 8:30 AM While doing rounds (R7) observed with SOB, low O2, and diaphoretic. Vitals taken. Increased O2. MD notified. Per MD ok to send to (Hospital) for eval and treat. On 09/29/24 at 3:24 PM Called ER for update. (R7) being admitted for SOB and hypoxia.
R7's electronic medical record showed no uploaded information regarding the discharge letter to R7 or R7's representative. The facility was unable to provide information regarding the discharge or notification of the ombudsman of the discharge.
3. R26's face sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which included multiple fractures of ribs, muscle wasting and atrophy, schizoaffective disorder, major depressive disorder, epilepsy, post-traumatic stress disorder, and suicidal ideations. R26's MDS dated [DATE] showed R26 was cognitively intact.
R26's progress notes showed the following:
On 05/08/24 at 9:00 PM 911 arrived to the facility stating that R26 had just placed a call to the suicide hotline. Prior to R26 placing a call she was observed resting in her bed. When R26 was asked by the writer and the police officers what was wrong, R26 stated that she was depressed and did not want to talk about it. Ambulance arrived to facility and transported to (Hospital). MD made aware. On 05/09/24 at 3:11 AM Writer placed a call to the hospital for an update on R26 status. R26 got admitted to (Hospital). Dx depression.
On 07/22/24 at 6:15 PM R26 expressing suicidal ideations d/t not wanting to be at the facility anymore. R26 stated she wants to die and that she has a plan. She stated she could take a lot of pills to die. Contacted NP and orders are to send out to be further evaluated. R26 placed on 1:1 until ambulance arrived. R26 is her own responsible party. On 07/22/24 at 7:11 PM ambulance arrived to transport R26 to (Hospital) x 3 EMT via stretcher. R26 is her own responsible party. Report from off going nurse states all parties were informed. On 07/23/24 at 5:12 AM Call placed to (Hospital) to get update on R26. Shift change is taking place. Advised to call back. Will endorse to oncoming nurse.
R26's electronic medical record showed no uploaded information regarding the discharge letter to R26 or R26's representative. The facility was unable to provide information regarding the discharge or notification of the ombudsman of the discharge.
4. R38's face sheet showed R38 was admitted to the facility on [DATE]. R38 had multiple diagnoses which included cerebral infarction due to embolism of right cerebellar artery, metabolic encephalopathy, asthma, acute respiratory failure with hypoxia, malignant neoplasm of the colon, need for assistance with personal care, and cocaine abuse. R38's MDS dated [DATE] showed R38 was cognitively intact.
R38's progress notes showed the following:
On 08/24/24 at 6:35 PM Altered mental status noted during rounding. V/S 98/64, 86, 16, 99.9, 83% on room air (O2 applied), blood glucose 257, not responding to painful stimuli. MD was notified and said to send R38 to the ER. 911 called and arrived shortly. R38's emergency contacts were called. Both of their phone numbers were disconnected. The DON was contacted. On 08/24/24 at 10:54 PM per (Nurse) from (Hospital) R38 was admitted for Pneumonia, Hypoxia, UTI, and Acute Kidney Injury.
On 09/16/24 at 6:28 PM R38 observed in bed not easily aroused. Sternum rub applied no response. Vitals taken B/P 119/69, P 89, T98, R16, O2 90% room air. Blood sugar 161. Elevated head of bed applied 3L O2 NC O2 stats increased to 95%. Attempted to arouse, unable. Placed call to 911. MD, ADON notified. Attempt to reach family no answer. On 09/16/24 at 6:35 PM EMT arrived to facility. Transferred resident onto gurney. Exiting building to (Hospital) ER. Report called in to charge nurse. MD/DON aware. On 09/17/24 at 6:48 AM Called (Hospital) to get report. Shift change happening. (Hospital) will call back later. On 09/19/24 at 12:14 AM Spoke with RN at (Hospital). R38 admitted to IMCU with a dx of Acute Renal Failure. R38 is expected to be discharged back to the facility within the next 48 hours.
On 09/25/24 at 12:15 PM R38 noted with change in condition. R38 unable to arouse. Checked vitals, B/P 83/53, P 74, R16, T97.9, O2 90% room air. Call placed to MD orders to send out to (Hospital) for further evaluation and treatment. Call placed to 911 for transport. POA notified. On 09/25/24 at 12:28 PM EMT arrived to facility, transferred onto gurney by EMT. Exiting the building. On 09/26/24 at 6:58 AM (Hospital) called. R38 admitted for observation with dx of generalized weakness & altered mental status. Med list faxed.
R38's electronic medical record showed no uploaded information regarding the discharge letter to R38 or R38's representative. The facility was unable to provide information regarding the discharge or notification of the ombudsman of the discharge.
On 11/14/24 at 3:22 PM, V1 (Administrator) stated the ombudsman should be notified each time a resident is admitted to the hospital. I was not aware that we were supposed to send a written copy as to why a discharge or transfer to the hospital was occurring to the residents/representative. The residents did not receive written documentation notifying of the reason why they were transferring to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain physician orders for residents to have medications at the bedside and failed to complete self-administration of medication assessments. This applies to 3 of 3 residents (R18, R38, R58) reviewed for medications in a sample of 18.
The findings include:
1. On 11/13/24 at 11:34 AM, R58 was observed sleeping in her bed. Her Fluticasone Propionate nasal spray 50 MG (Milligrams) was inside a box labeled with her name on the dresser that belonged to her roommate (R18) behind her curtain. Surveyor asked (R18) if it was hers and if she ever used it. R18 just stared at Surveyor and smiled. V6 (RN-Registered Nurse/Wound Nurse) who was in the room stated that R18 was nonverbal.
On 11/13/24 at 2:18 PM, V2 (DON-Director of Nursing) said, I currently don't have any residents that can self-administer any medications. Any meds (medications) at the bedside need an order from the doctor. The nurse also must do a self-administration of medication assessment. It's important because we need the resident to be competent and that they understand the dosage.
On 11/14/24 at 10:42 AM, R58's Fluticasone Propionate nasal spray was still on top of R18's (roommate) dresser. Surveyor asked R58 if this was hers. She said, Yes and I've been looking for it. She said it's always kept in her room. R58 said, No one taught me how to use it. I know how to do it. I use it at bedtime. R58 then put the box of Fluticasone Propionate in her basin which was on her bedside table.
R58's face sheet shows diagnoses of need for assistance with personal care and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
R58's MDS (Minimum Data Set) dated 10/18/24 shows she is cognitively intact. R58's POS (Physician Order Sheet) shows an order for Fluticasone Propionate Nasal Suspension 50 MCG (Micrograms)/ACT-1 spray in both nostrils two times a day for antihistamine. There was no order for the nasal spray to be at the bed side upon review of her POS. There was no self-administration of medication assessment uploaded into her electronic medical record. There was no care plan stating she can self-administer.
R18's face sheet shows diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder recurrent, severe with psychotic symptoms, bipolar disorder, and anxiety disorder. Review of her POS shows no order for Fluticasone Propionate nasal spray. R18's MDS dated [DATE] shows a blank score for her mental status. R18's care plans do not state she can self-administer any medications.
Facility's policy titled Self-Administration of Medications by Residents (Undated) shows: 2. If the resident desires to self-administer medications, an assessment is conducted by an interdisciplinary team. This assessment includes the resident's cognitive, physical, and visual ability to carry out this responsibility. 3. An interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment as follows: b. The resident is instructed in the use of the package, purpose of the medication, reading of the label, scheduling of medication doses and side effects. D. The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms, e.g. inhaler, to verbalize the steps above involved in administration. e. If bedside storage is to be used, the resident is asked to complete a bedside record indicating the administration of the medication. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. A. The storage does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. B. The storage method prevents access by other residents. 6. Once the order has been obtained, the procedure is explained to the resident.
2. On 11/12/24 at 11:59 AM, R38 was not in his room. R38 had two white pills on the bedside table next to a medication cup. On 11/12/24 at 12:14 PM V2 (Director of Nursing) went to R38's room with the surveyor. The two white pills remained on the bedside table.
R38's face sheet showed multiple diagnoses which included cerebral infarction, metabolic encephalopathy, malignant neoplasm of the colon, need for assistance with personal care, cocaine abuse, weakness. R38's MDS dated [DATE] showed R38 was cognitively intact. R38 had no self-administration of medication assessment in the electronic medical record. R38's POS for November 2024 showed no orders for medications to be left at the bedside. R38 did not have a care plan for self-administering medications.

Based on interview and record review, the facility failed to refund resident funds after residents discharged from the facility. This applies to 3 of 3 residents (R1-R3) reviewed for resident funds.
The findings include:
The facility's Admission/Discharge To/From Report shows that R1 was discharged on 2/13/24, R2 was discharged on 2/26/24, and R3 was discharged on 1/29/24 (all over three months earlier). R1's Resident Fund Statement from 12/30/23-3/29/24 shows a balance of $2,097.70 in her account. R2's Resident Fund Statement from 12/30/23-3/29/24 shows a balance of $120.08 in her account. R3's Resident Fund Statement from 12/30/23-3/29/24 shows a balance of $30.09 in his account.
On 5/31/24 at 10:41 AM, V3 (BOM/Business Office Manager) said when R1 was discharged from the facility she went to the hospital and then from the hospital he believes that she was sent to another facility, but that facility never contacted V3 to transfer R1's funds over. V3 said he will try to find out where R1-R3 are currently residing and get their funds sent over. At 1:09 PM, V3 said he found out where R1 and R2 were transferred to and contacted those facility's BOMs and let them know that R1 and R2 have trust fund money that he will be forwarding over. V3 said he told the other facility's BOMs that the checks will be in the mail on Monday or Tuesday next week. V3 said he was unable to get ahold of R3, he will keep trying and if unsuccessful, he will send his check to social security. At 2:03 PM, V3 said he usually tries to get the resident funds sent over to the resident's new residence as soon as possible and this was an oversight. V3 said he knew that R1 went to the hospital and didn't return to the facility and it was like out of sight, out of mind.
On 5/31/24 at 3:02 PM, V4 (Corporate BOM) said the facility has 30 days to return resident funds to them after discharge.
The facility's policy titled, Resident Trust Fund Policy dated February 2020 states, Policy: Resident funds are maintained in accordance with the State guidelines. The management of the funds of the residents is the responsibility of the Administrator and the Business Office Manager .It is mandatory that a reconciliation between the resident trust fund and the bank statement be completed monthly .Procedure: .8 When a resident is discharged , provide a report to the resident/responsible party, and refund the personal funds to the proper person .

Based on observation, interview and record review, the facility failed to follow the menu plan and serve residents with alternatives for food items refused. This applies to 11 of 11 (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R14) residents reviwed for meal service.
The findings include:
The facility's lunch meal for 5/15/24 listed Cuban style pork chop, red beans and rice, chocolate mousse, corn bread, margarine, and beverage. Their menu for lunch, or the substitute menu was not posted for the residents on the notice board in the hallway. After checking the temperature V4 (Cook) began to plate the food for the residents. During Lunch instead of chocolate mousse they served Banana Cream Pie. Corn bread was not available during lunch. By the end of serving R4 and R15 did not get, red beans and rice, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R14 did not receive Banana Cream Pie instead they were given [NAME] Crackers for dessert.
On 5/21/24 dietary staff did not post the breakfast or lunch menu until 10:00AM and the menu in the kitchen and the menu posted in the hallway for the residents were not the same. Residents were noted to get glazed ham, broccoli, herb stuffing, dinner roll with margarine and pears with whipped topping.
R1 was interviewed on 5/21/24 and stated that the menu served on 5/21/24 for lunch was not the planned menu and so R1 requested a vegetable salad in place. According to R1, dietary staff refused to provide the salad since she did not order it the previous day. R1 added that most days the menu is not posted for residents.
R2 and R4 were also interviewed and stated that the menu is not posted and that food service often changes the menu and so residents cannot order the substitute the day before. Both residents claimed that the facility runs out of food items and they just, give us what they have.
V3 (Dietary Manager) was interviewed on 5/15/24 at 12:20PM and stated that the food order is not always correct. V3 added that there was a mix up with the new system.
V1 (Administrator) confirmed on 5/21/24 at 10:09AM that the facility should not run out of food.
Facility 's grievances and concern forms were reviewed from February until May of 2024 and the resident council minutes were also reviewed. On 4/5/24 the Resident council minutes indicated that the kitchen keeps running out of hot dog and hamburger buns and alternative selections continue to not be followed. The residents also complained that food portions have gotten smaller. On 4/24/24 Resident council Meeting minutes indicated Kitchen keeps running out of hot dog buns and hamburger buns.
Facility provided undated unsigned policy and procedure for meal service; it indicated under Procedure 2. In part . Each resident will be served a diet that is appropriate for the physical cognitive and the psychosocial need of the resident.
The menu Filing and substitution policy indicated under guideline, all menus served shall be kept on file for 30 days. All menus for the current week shall be clearly posted and dated to adequately document foods that have been served, and guides staff in proper meal service.
3. The menu for the current week is posted somewhere accessible to residents and families. 4. change made for any menu follow the substitution procedure see menu substitution guideline.

Based on observation, interview and record review, the facility failed to provide alternate food to meet residents need. This applies to 3 of 3 residents (R1, R6, and R15) reviewed for alternate food and nutritional adequacy in the sample of 15.
R1's MDS (minimum data set) dated April 25, 2024, indicated R1 has a BIMS (brief interview of mental status) score of 15 and she is cognitively intact. On 5/21/24 at 9:30 AM, R1 stated during interviews that she is not getting the food alternatives because she did not order the item the previous day. R1 stated that during the lunch meal she did not get the item that was listed on the planned menu and she requested a vegetable salad. According to R1, the dietary staff refused to give R1 the vegetable salad that she wanted since the menu as planned was not served. R1 added that staff refused to give her the salad since she did not order the salad the previous day. R1 continued and stated that residents do not get a breakfast menu but whatever the kitchen wants to serve.
On 5/21/2024, R6 stated during interview that dietary staff refused to give R6 the peanut butter and jelly sandwich as a substitute. R6 is documented as being cognitively intact per the latest MDS assessment. R4 was also not given a peanut butter and jelly sandwich as requested during the meal.
R15 is also assessed to be cognitively intact and interview per the MDS assessment of 4/25/24. R15 stated during interview of 5/21/24 at 9:47AM that the kitchen did not serve the lactose free milk to R15. According to V3 (Dietary Manager) the facility cannot obtain this item.
V3 (Dietary Manager) was interviewed on 5/16/24 at 12:20PM and stated that meal substitutes need to be ordered the day before.
V1 (Facility Administrator) stated during interview of 5/21/24 that substitutes do not need to be ordered the previous day.
The resident grievances and concerns document complaints of the kitchen running out of food items such as hotdog and hamburger buns and the kitchen not serving the alternative food items.
Facility's policy stated substitution was reviewed and under Guideline: 2. Indicted his substitution will be selected from the same food group as the item being replaced. his salad consisting of mostly fruit shall be replaced with a fruit whereas a salad consisting of cottage cheese and fruit is considered a protein item and will need to be substituted accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's POA (Power of Attorney) of the resident's change in condition. This applies to 1 of 3 residents (R1) reviewed for notification of changes.
The findings include:
R1's 12/04/23 progress notes from 3:14 PM showed R1 was difficult to arouse, had not eaten breakfast or lunch, had increased fatigue, and his pulse was elevated (116). The note showed R1's physician was notified and new orders were given for metoprolol tartrate and lab work. No documentation of POA being notified of change in condition.
On 12/27/23 at 10:39 AM, V3 (LPN/Licensed Practical Nurse) said on 12/4/23 from 6:30 AM until 7:00 PM, she was the nurse for R1 for part of the shift. V3 said R1 was in his room with breakfast tray. V3 said R1 was not eating his breakfast. V3 said she spoke with R1 and R1 said he was not hungry. V3 said she offered R1 an alternative meal, but he refused. V3 said R1 seemed tired like he wanted to sleep in. V3 said at lunch time she noticed R1 was more fatigued, and more difficult to wake up. V3 said she checked R1's vitals and R1's pulse was elevated. V3 said she called R1's doctor and gave an update on R1's condition. V3 said new orders were received for a blood pressure medication and labs. V3 said she did not notify R1's daughter or POA of change in condition. V3 said when residents have a change in condition, it is the nurse's responsibility to do an assessment, report the findings to the provider, follow doctor's orders and document. If residents have a POA, the POA is notified of new medications and change of condition.
On 12/27/23 at 1:36 PM, V9 (Director of Nursing) said that on 12/4/23, she was informed by the floor nurse that R1 was having a change of condition. V9 said she assessed R1. V9 said R1's blood pressure was normal, but R1's heart rate was elevated. V9 said she endorsed to the floor nurse to notify the doctor to see if orders could be obtained for an elevated pulse. V9 said R1's daughter (POA) was not notified of the change of condition. V9 said when residents have a change in condition, the family and physician are notified. V9 said if resident's situation is emergent, 911 will be called.
R1's Face Sheet showed R1 was admitted on [DATE] with diagnoses of cerebral infarction, unspecified dementia, fall, Covid 19, weakness, and moderate protein calorie malnutrition. R1's MDS (MDS/Minimum Data Set) dated 12/06/23 showed R1 had moderate cognitive impairment. The facility's Change in Resident's Condition or Status Policy showed 2. Unless otherwise instructed by the resident (if resident is alert and oriented and their own representative) the nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental or psychosocial status.

Based on observation, interview and record review, the facility failed to ensure anti-contracture devices were applied as ordered. This applies to 1 resident (R72) reviewed for anti-contracture devices in a sample of 31.
The findings include:
On 12/19/23 at 10:18 AM, R72 was in bed. R72's left hand was closed and in a fist position. R72 was not wearing a hand splint. R72 said she wears a splint to her left hand when the staff applies it.
On 12/20/23 at 08:53 AM, V14 (CNA/Certified Nursing Assistant/Restorative) said she did not apply left hand splint to R72 yesterday because she was busy doing weights. V14 said the floor CNAs can apply splints as well, but they did not apply it yesterday. V14 said R72 should have the splint applied every day due to the left-hand contracture.
On 12/21/23 at 09:45 AM, V15 (Restorative LPN/Licensed Practical Nurse) said R72's PROM (Passive Range of Motion) and splint application is scheduled every day during morning care, between 6:30 AM -7:30 AM, prior to breakfast. V15 said R72's splint is removed before lunch, at 12 PM. V15 said she did not know why R72 did not have the splint on. V15 said it is expected that restorative aides or unit CNAs perform PROM and apply splints 6-7 days per week.
R72's face sheet showed R72 had the following diagnoses- hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, weakness, and contracture of left-hand muscle. R72's MDS (MDS/Minimum Data Set) dated 12/11/23 showed that R72's cognition was moderately impaired. R72's POS (POS/Physician Order Sheet) showed R72 had an order to wear left (grip wrist/hand splint) daily, on before breakfast and off before lunch, for left hand/wrist contracture. R72's splint/brace care plan dated 5/17/23 showed to apply left hand splint per splint schedule to help maintain and or improve the current status and prevent any further deterioration.
The facility's policy dated 09/01/11, 02/20/15 showed 6. Splints will be applied according to the facility splint schedule and will be designated for application on an AM or PM shift schedule .

Based on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications and obtain physician orders for residents' medication to be at the bedside. This applies to 2 residents (R31 & R68) reviewed for bedside medication in a sample of 31.
Findings include:
1. On 12/19/23 at 10:20 AM, a cup containing 2 pills, 1 white and round, and 1 white and oval was observed on R31's bedside table next to a cup of water. R31 was in her bed asleep. At 11:39 AM the medications were observed gone and R31 said she thought she had taken the medications herself.
On 12/21/23 at 9:21 AM, V2 DON (Director of Nursing) said that medication should not be left at the resident bedside and that no residents in the facility can administer medications by themselves. V2 said that residents should be assessed to see if they are competent before administering medication to themselves. V2 said that if medications are left at the bedside someone else can take the medications.
R31's electronic record did not show an order for self-administration of medication and did not show an assessment of self-administration of medication. The facility's 5.3 Self-Administration of Medications by Residents policy showed that an assessment needs to be made to determine if the resident can self-administer medications. A physician order is obtained to self-administer medication if the assessment has been approved for the resident to self-administer medications.
2. On 12/19/23 at 11:43 AM, a medication cup labeled with R68's room and bed number was on his nightstand. The medication cup had one white pill and one tan colored pill.
On 12/19/23 at 12:22 PM, V19 LPN (Licensed Practical Nurse) stated the last time she gave pills to R68 was 12/18/23 before he went out on pass.
On 12/20/23 at 12:05 PM, R68 stated he took the pills on his nightstand when he returned to the facility. R68 stated the pills were his seizure medications. R68 stated sometimes the nurses write his name on the medication cup and leave it for him because they are passing medications to other residents.
On 12/21/23 at 3:50 PM, V2 DON (Director of Nursing) stated R68 was not assessed to self-administer medications. Nursing staff should not leave medications at resident's bedside because they need to monitor and make sure the medications were taken.
R68's medical record show he has diagnoses of Epilepsy, Bipolar disorder, schizoaffective disorder, and noncompliance with medical treatment. R68's MDS (Minimum Data Set) dated 11/14/23 shows he is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/19/23 at 11:02 AM, R36 was observed with bilateral hand contraction with a splint with his right hand (more severe). R36 was observed with a call light push button attached to linen under his left elbow. Upon the surveyor's request to use the call light, R36 attempted to put the call light and stated, I can't use it. R36 is a [AGE] year-old male admitted on [DATE] having moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE].
On 12/19/23/ at 11:10 AM, V7 (Licensed Practical Nurse / LPN) stated, I will call maintenance to change his push button call light to a press button, which will be easier for him to use with his left hand. On 12/20/23 at 10:45 AM, V2 (Director of Nursing) stated, R36 should have been given that press call light before for his easier use.
Based on observation, interview, and record review, the facility failed to have the call lights accessible to dependent residents. This applies to 2 of 2 residents (R9 and R36) reviewed for accommodation of needs in a sample of 31.
The findings include:
1. On 12/19/23 at 10:41 AM, R9 was in bed asleep. R9 did not have a call light cord attached to the wall. R9 did not have any other methods of notifying staff of needing assistance. On 12/20/23 at 09:08 AM, R9 was in bed sleeping. R9 again did not have a call light cord attached to the wall, or any other methods of notifying staff of needing assistance. On 12/20/23 at 2:20 PM, R9 was in bed sleeping. R9 still did not have a call light cord or any other methods of notifying staff.
R9's face sheet showed her dianoses include dementia, blindness, diabetes, weakness, congestive heart failure, hypertension, gait and mobility abnormalities, mixed conductive and sensorineural hearing loss. R9's MDS (MDS/Minimum Data Set) dated 12/05/23 showed R9 required partial/moderate assistance for bed mobility, transferring, and ambulation. R9's communication care plan revised 03/07/23 showed interventions to ensure/provide a safe environment, and to have the call light in reach. R9's risk for falls care plan initiated 02/08/23 showed a working and reachable call light as an intervention.
On 12/20/23 at 2:20 PM, V3 (Maintenance Director) said R9 does not have a call light in her room because she is blind and deaf and pulls the call cord out of the wall. V3 said that R9 should have some form of communication in the room to notify staff that she needs assistance. V3 said he does not know when was the last time R9 had a call light in the room. V3 said all residents should have some form of communication in their rooms.
On 12/21/23 at 11:21 AM, V2 (Director of Nursing) stated she did not know why R9 did not have a call light. V2 said staff checks on R9 throughout the day. V2 said there was no documentation to show that staff checks on R9 throughout the day. V2 said if R9 needed staff for an emergent situation, there is nothing in place right now that would allow R9 to alert staff.
The facility's Call Lights policy stated it is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance and to ensure that the call system is in proper working order. Procedure 9 from the policy stated always be sure that the resident has a functioning call light that is the easiest type for them to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a home-like environment for residents. This applies to one resident (R56) reviewed for homelike environment in a sample of 31.
The findings include:
On 12/19/23 at 10:53 AM, during the initial tour rounds, R56's floor was dirty, had food, candy on the floor by the bedside and the trash can was overflowing with garbage in the trash can and on the floor, there were several empty bottles of water. On 12/20/23 at 10:17 AM, R56's floor was still dirty with food and candy, and the trash can was still overflowing with garbage. R56 said she told housekeeping staff yesterday that her floors were dirty and that the trash can needed to be emptied, but the housekeeping staff did not show up yesterday nor this morning. R56 said that housekeeping staff does not come to their rooms everyday to clean or sweep the floors, and she does not have access to a broom so she can sweep. R56 said it does not feel like home to her and does not like it that there is garbage on the floor in her room. R56's Minimum Data Set (MDS) dated [DATE], shows that R56's cognition was intact.
On 12/21/23 at 12:23 PM, V2 (DON/Director of Nursing) said that housekeeping staff are to clean the residents' rooms and bathrooms daily.
On 12/21/23 at 12:34 PM, V11 (Housekeeping Manager) said that resident's rooms and bathrooms are cleaned every day, and they remove garbage from resident's rooms daily and more frequently if needed.
The facility's Environment of Care Manual- General Cleaning Policies and Procedures Resident Room Clean (undated) states to provide a clean, attractive, and safe environment for residents, visitors and staff, pick up loose trash, and remove general waste from the resident's room.

Based on observation, interview, and record review, the facility failed to prevent a resident-to-resident assault.
This applies to two residents (R32 and R49) reviewed for abuse in a sample of 31.
The findings include:
On 12/19/23 at 2:06 PM, a scab was observed under R49's left eye near the bridge of his nose. R49 stated his previous roommate had punched him in the face.
On 12/21/23 at 3:50 PM, V2 DON (Director of Nursing) stated R32 hit R49 in the face and the two residents were separated. R32 was moved to another room. R32 MDS (Minimum Data Set) dated 12/19/23 documents R32 has physical and verbal behavioral symptoms of aggression directed towards others. R32's behavior occurs one to three days per week. Nursing progress note for R49 dated 12/18/23 at 4:49 AM documents R49 being hit by R32.
On 12/21/23 at 4:01 PM, V1 stated R32 and R49 were immediately separated and R32 was sent to the hospital for evaluation after the altercation. V1 stated the final report of resident-to-resident abuse will be completed on 12/22/23. The facility's initial report and submission of the incident documents R49 being hit by R32.
The facility's Abuse Prevention policy revised date 01/2019 states, it is the policy of the facility to prohibit and prevent resident abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 12/19/23 at 11:02 AM, R36 was observed with bilateral hand contractions and wore a splint on his right hand. R36 had dirty, long nails with a blackish substance under nails on both hands. R36 is a [AGE] year-old male admitted on [DATE] having moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. MDS also indicates that R36 is dependent on personal hygiene.
On 12/19/23 at 10:45 AM, V2 (Director of Nursing) stated, Our certified nursing assistants (CNAs) are supposed to provide nail care.
The facility presented an undated policy on Activities of Daily Living (ADL) document: Assist the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, and appropriate skin care (as indicated and as per the care plan).
Based on observation, interview, and record review, the facility failed to ensure residents who require ADL (Activities of Daily Living) assistance received grooming cares. This applies to 5 residents (R31, R33, R61, R36 & R230) reviewed for ADLs in the sample of 31.
1. On 12/19/23 at 1:57 PM, R61 was observed in the hallway in her wheelchair with the hair on the back of her head matted.
R61's electronic health records showed that she is an [AGE] year old female with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, age-related osteoporosis, Alzheimer's disease, non-suicidal self-harm, and major depressive disorder. R61's care plan 1/9/23 showed, Self-Care Deficit with impaired Dressing and Grooming abilities . keeping nails short with no more than Extensive Assist time 1 Staff 6-7 days weekly . Special Note for ADL Care: may have fluctuations in . normal day to day ADL Assistance and Staff Support Needs due to . Chronic Disease Process and/or any Acute exacerbations. The Restorative Aides and/or Certified Nursing Assistant will provide Dressing and Grooming assistance 6-7 days weekly. On 12/21/23 a review of R61's progress note did not show resident refused to have hair brushed. The facility was unable to provide a behavior sheet or any documentation showing R61 refused to have her hair combed.
2. On 12/19/23 at 10:13 AM, R33 was observed with oily hair. R33 said that she would like to take a shower and she has been waiting for the staff to tell her she could take one. R33 said the last time she took a shower was last week. R33 said, Look at my hair, it is depressing, very depressing.
R33 is a [AGE] year old female with diagnoses including major depressive disorder reoccurrence severe without psychotic features, suicidal ideations, anxiety, difficulty walking and weakness. R33's 8/24/22 care plan showed a Self-Care Deficit with impaired Dressing and Grooming abilities as evidence by risk factors and potential contributing Diagnosis: Diabetes Mellitus, General Weakness and/or fatigue. ADL Care: may have fluctuations in normal day to day ADL Assistance and Staff Support Needs due to Chronic Disease Process and/or any Acute exacerbations. On 12/21/23 a review of R33's progress notes from 12/11/23 through 12/21/23 did not show R33 refusing of any ADL care.
3. On 12/19/23 at 12:23 PM, R230 was observed with nails long, curling, and with brown substances under nails. R230's electronic health record showed that he is a [AGE] year old male with diagnoses including acute chronic systolic heart failure, diabetes mellitus, weakness, blindness in right and left eye, and generalized anxiety disorder. R230's 12/13/23 MDS (Minimum Data Set) showed that his mental status is severely impaired. R230's 12/10/23 care plan showed; Self-Care Deficit with impaired Dressing and Grooming abilities and . would benefit from participation in a Dressing/Grooming Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: Diabetes Mellitus, General Weakness and/or fatigue. Special Note for ADL Care: may have fluctuations day to day ADL Assistance and Staff Support Needs due to my Chronic Disease Process and/or any Acute exacerbations. The Restorative Aides and/or Certified Nursing Assistant will provide Dressing and Grooming assistance 6-7 days weekly. On 12/21/23 a review of R230's progress notes from 12/5/23 - 12/21/23 at 4:44 pm did not show any refusing ADL care.
On 12/21/23 at 9:21 AM, V2 DON said ADLs should be provided daily and as needed, for personal hygiene and nails should be clean and cut.
4. On 12/19/23 at 10:20 AM, R31 was observed with long jagged nails with brown substances under the nails. V31 said she could not recall the last time they were cut.
R31's 10/2/23 care plan Self-Care Deficits showed R31 is impaired with Grooming abilities as evidenced by the following risk factors and diagnoses: Psychosis, Osteoarthritis, and Impaired cognition. The Restorative Aides and/or Certified Nursing Assistant will provide her established Dressing and Grooming assistance. On 12/21/23 a record review of R31's of progress notes from 12/21/23 through 11/16/23, did not show R31 refusing ADL care. A review of R31's 12/4/23 - 12/18/23 shower sheet did not show any documentation of fingernail grooming. R31's behavior tracking sheets for 12/1/23 - 12/31/23 did not show any behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure medications were completely flushed through a gastrostomy tube, and failed to ensure alcohol was dry before obtaining a blood glucose value. This applies to 2 residents (R3, R72) reviewed for quality of care in a sample of 31.
Findings include:
1. On 12/20/23 at 10:51 AM, V12 (Nurse) was observed preparing R3's medications for administration via R3's gastric tube (G-tube). V12 crushed up 6 medications and put them in individual cups: 81mg Aspirin, 10mg Lisinopril, 1mg Benztropine, 600mg Guaifenesin , 5000 IU Vitamin D 125mg, 20mg Baclofen
V12 checked for placement in R3's G-tube and then began administering his medications. V12 was observed placing the crushed medications in the syringe, in its powdered form, then would add 20 to 25cc of water in the syringe. V12 did not dilute the medications with water prior to placing them in the syringe. V12 did this with all 6 of the medications. After V12 gave the last crushed medication, V12 removed the syringe. Residual medication remained in the bottom of the syringe. Then V12 took the syringe to the bathroom and rinsed the remainder of the medications down the drain.
On 12/20/23 at 11:40 AM, V12 said she saw that there was medication left in the syringe, but she didn't think she should give it to R3. V12 said R3 had already been given his allotted amount of water for his 200cc flush.
On 12/21/23, V2 DON (Director of Nursing) said that G-tube medications should be mixed with water before putting them in the syringe, all the medication including any residual should be given before the next medication given, and a 30cc flush of water should be given after each medication. V2 said this should be done to keep the free flowing of liquids in the G-tube. V2 said that if there was medication left in the syringe and then washed/rinsed away, the resident did not get all his medications.
The Facility's Enteral Tube Medication Administration policy and procedure dated 11/1/11 showed when preparing the medications the medication is to be crushed and diluted with 10-30cc of water and keep medications separate. Instill medications in syringe and flush with 5cc-10cc of water and ensure that all medications have been administered and there is no residual left. Then the nurse is to flush again with 30cc of water after the last medication is given.
2. On 12/20/23 at 11:52 AM, V7 (Nurse) obtainied a blood glucose sample for R72. R72 is a [AGE] year old female with diagnoses including type one diabetes, insulin dependent. V7 wiped R7's left 1st finger with an alcohol wipe and then collected a drop of blood. V7 did not wait for the alcohol on R72's finger to dry before collecting the sample of blood. R72's blood glucose was 315. V7 has an order dated 8/3/23 Novolin R insulin for sliding scale. The order showed R72 was to receive 8 units. V7 then gave R72 8units of Novolin R.
On 12/21/23 at 9:21 AM, V2 DON said that the nurse should let the alcohol dry before collecting a blood sample. V2 said if not, it can give a false reading and if the resident is on a sliding scale, the wrong amount of insulin can be given.
The facility was unable to provide a requested policy or procedure on how to obtain a blood sample for a blood sugar level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/19/23 at 11:05 AM, R36 was observed with long, curly, and dirty toenails on both feet.
R36 is a [AGE] year-old male admitted on [DATE] having moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. MDS also indicates that R36 is dependent on personal hygiene.
On 12/19/23 at 2:50 PM, V2 (Director of Nursing) stated, R36 is not seen by a podiatrist yet.
Based on observation, interviews, and record review, the facility failed to ensure residents' toenails were cut, and failed to protect the feet of a resident with circulatory problems. This applies to 2 of 10 residents (R36, R49) reviewed for foot care in a sample of 31.
The Findings include:
1. On 12/19/23 at 9:40 AM, R49 was observed ambulating with a walker and wearing non-skid socks. R49 was being escorted outside by V4 PTA (Physical Therapy Assistant)
On 12/19/23 at 2:06 PM, R49 stated because of the bandages on his feet, his shoes did not fit. R49 stated the staff offered him double-socks to wear. R49 stated he was never offered any other footwear to accommodate his bandages.
On 12/20/23 at 11:07 AM, V5 (Wound Nurse) stated R49 did not have any special equipment for his feet. At 11:36 AM, long and overgrown toenails and crusty white substance were noted on R49's feet and legs.
On 12/20/23 at 11:45 AM, V6 (Wound Physician) stated he had not been informed that R49 was unable to wear his shoes with the dressings in place. V6 stated R49 should have shoes on while walking outside to protect his feet from injury.
On 12/21/23 at 9:54 AM, V4 stated she was aware R49 did not have shoes on when she took him outside. V4 stated R49 did not have shoes that fit with his dressings in place. V4 stated she did not inform the nurse that R49 did not have shoes to wear.
Review of the MDS (Minimum Data Set) dated 9/20/2023 shows R49 is cognitively intact. R49 did not have any physician order for special footwear. R49's medical record shows a history of peripheral vascular disease and chronic peripheral venous insufficiency. Review of Weather.com local temperature on 12/19/23 high was 32 degrees.
The facility was unable to provide a requested policy regarding resident foot care.

Based on observation, interview, and record review, the facility failed to ensure a resident's room was free of trip hazards. This aplies to 1 of 31 residents (R69) reviewed for environmental risk in a sample of 31.
The findings include:
On 12/19/23 at 11:28 AM, surveyor tripped on broken floor tile in R69's room. The broken tile located in the pathway between R69's bed and bathroom door. R69 was observed standing from his wheelchair and unsteadily walking into the bathroom. R69's medical record shows he diagnoses of dementia, seizures, and weakness. R69's MDS (Minimum Data Set) dated 9/18/23 shows he has moderate cognitive impairment. R69 requires staff supervision / touch assistance with walking and transfers.
On 12/20/23 at 1:51 PM, V3 Maintenance Director stated he was not aware of the broken tile. V3 stated he and V12 (Psychiatric Services Director / Social Services) are assigned to do guardian angel rounds on that unit. V3 stated he did not do his assigned rounding on the unit. V3 stated nursing staff are able to submit repair request through the computerized system or the work order book. V3 stated the broken tile poses a fall hazard.
On 12/21/23 at 3:50 PM, V2 stated R69 was unsteady and should not be walking unassisted, but sometimes does.

2. On 12/19/23 at 10:53 AM, R56's CPAP machine was on the bedside table, and the tubing and mask were in the drawer, not contained. R56's CPAP machine was dusty, and the mask was dirty with a dry, whitish substance on it. On 12/20/23 at 10:17 AM, R56's CPAP machine was still noted on the bedside table, the mask and the tubing were in the drawer, still not contained. R56 said she uses the CPAP machine every night and staff does not clean it, but she changes the tubing and mask once a month. On 12/21/23 at 9:52 AM, R56's CPAP machine was still noted on her bedside table, with the mask and tubing in the drawer, not contained.
R56's EMR (Electronic Medical Record) shows a diagnosis of mild intermittent asthma. R56's POS (Physician Order Sheet) shows an order of Auto CPAP at bedtime for obstructive sleep apnea, wear at all times when sleeping/napping. R56's care plan (initiated 10/12/23) shows that R56 presents with altered sleeping and breathing secondary to CPAP, related to obstructive sleep apnea.
On 12/21/23 at 9:34 AM, V10 (ADON/Assistant Director of Nursing) said respiratory equipment should be stored in clear plastic bags when not in use to prevent growth of microorganisms on the machine.
On 12/21/23 at 12:22 PM, V2 (DON/Director of Nursing) said the facility does not have a policy that addresses how to store or contain respiratory equipment when not in use. V2 said that it should be contained when not in use.
Based on observation, interview, and record review, the facility failed to ensure sanitary storage/containment of respiratory equipment when not in use, and failed to ensure that a resident could use their BiPAP (Bilevel Positive Airway Pressure) as ordered by the physician. This applies to 2 of 2 residents (R42 and R56) reviewed for use of respiratory equipment in a sample of 31.
The findings include:
1. On 12/19/23 at 10:45 AM, R42's BiPAP (Bilevel Positive Airway Pressure) machine was on the nightstand. The BiPAP mask was on top of the machine and not contained. On 12/20/23 at 09:09 AM R42's BiPAP mask was still on top of the BiPAP machine and not contained. R42 stated she is supposed to use the BiPAP machine every night but is currently not using it because the mask does not fit. R42 said she informed the nurses that the mask does not fit. On 12/21/23 at 01:15 PM R42's BiPAP mask continued to be on top of the machine and not contained.
On 12/21/23 at 11:21 AM, V2 (DON) said all BiPAP masks while not in use should be in a plastic bag or some covering to prevent contamination. V2 said she was unaware of R42's BiPAP mask not fitting her face. V2 said it is expected that staff nurses report and have the medical supply company come out a do a fitting for a new mask. V2 said doctors' orders for BiPAP should be followed. The resident could go into respiratory distress of severe sleep apnea from not wearing her BiPAP.
R42's face sheet showed diagnoses of chronic obstructive pulmonary disease, acute respiratory failure with hypercapnia, acute on chronic congestive heart failure, and obstructive sleep apnea. R42's physician order sheet showed R42 had orders to wear BiPAP everyday during naps and every night for obstructive sleep apnea. R42's care plan dated 09/12/22 showed R42 to wear BiPAP during sleep including naps. The care plan's interventions showed to monitor for BiPAP usage and mask positioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to maintain temperature logs, label food items, and discard outdated food items. This applies to 2 residents (R10 & R6) reviewed for personal food storage in a sample of 31 residents.
The findings include:
1. On 12/19/23 at 10:53 AM, R60 did not have a thermometer, or a temperature log for the personal refrigerator in the room. R60's refrigerator contained a pack of lunch meat that was opened and did not have a date on it. On 12/21/23 at 12:58 PM, R60's refrigerator still did not have a thermometer or a temperature log. The opened lunch meat continued to be not dated.
R60's face sheet showed R60 was admitted to the facility on [DATE].
2. On 12/19/23 at 12:15 PM, R10 did not have a thermometer, or temperature log for the personal refrigerator in the room. On 12/20/23 at 11:55 PM, R10's refrigerator still did not have a thermometer or a temperature log.
R10's face sheet showed R10 was admitted to the facility on [DATE].
The facility's Refrigerator policy (Facility/Resident Rooms) page 14 stated ensure a working thermometer is present inside the unit.

Based on observation, interview, and record review, the facility failed to post isolation signs for Personal Protective Equipment (PPE), and failed to follow infection control guidelines for pericare, hand hygiene, and wound care. This applies to 5 residents (R3, R7, R31, R59, R230) reviewed for infection control practices in a sample of 31.
The findings include:
1. On 12/19/23 at 1:32 PM, R3 was observed in his room with a personal protective equipment (PPE) box at the door side and no isolation posting/signage or stop sign at the door side to indicate the type of isolation and the PPEs visitors should wear to enter the room. R3's 11/21/23 Minimum Data Set showed he has severely impaired cognition.
On 12/20/23 at 10:51 AM, there were still no signs showing staff and visitor to put on proper PPE (personal protective equipment) before entering the room. At 11:22 V8 (R3's sister-in-law) was observed going into R3's room without any PPE. At 11:50 AM, V8 stated, I visit R3 every day, and I took him to Bingo last Thursday, and nobody ever mentioned to me to wear a gown. I was told R3 had Escherichia coli (E. coli) infection, and it was cleared, and that's why I wasn't wearing any gown. Nobody told me R3 had a history of Carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pneumoniae carbapenemase (KPC) with sputum requiring me to wear a gown. V10 (Assistant Director of Nursing/Infection Preventionist) then told V8 that R3 has been on contact isolation for the last 2 months. V8 then put on PPE after she had already been in R3's room. The garbage can by R3's door for containment and disposal of the PPE was observed without a lid.
On 12/20/23 at 11am, V10 said that R3's room should have a sign on the door for contact isolation and the garbage can for the disposed PPE should have a lid on it to prevent the spread of organisms. On 12/21/23 at 9:21 AM, V2 DON (Director of Nursing) said that lids should be on cans for PPE in isolation rooms to reduce the risk of cross contaminations.
On 12/20/23 at 1:15 PM, V3 stated, V8 thought that as R3 was cleared with E-Coli, she doesn't need to wear a gown. There should be a stop sign posted on the door or isolation signage posted at the door to indicate the type of isolation to determine the PPEs that need to be worn prior to entering the room.
The facility presented infection control /isolation guidelines revised on February 2023 document under the Initiation of Isolation Precaution (Page 5) documents: F. The nurse who is the admitting nurse for the resident will place appropriate signage (CDC) on the door (Indication not to enter without checking at the nurse's station for instruction/education.)
The policy is also documented under the Visitors subtitle (Page 6/6) A. The clinical personnel (Licensed Nurses) on the unit are responsible for assuring that visitors are properly educated as to what their actions/requirements need to be before, during, and after a visit to any residents in isolation precautions.
2/3. On 12/19/23 at 11:40 am, V17 and V18 CNAs (Certified Nurses' Assistants) were observe providing incontinence care for R7. V17 was observed with gloved hands wiping stool from R7's perineal area, using a disposable wipe, wiping areas two and three times without folding the wipe or disposing of the wipe. After providing incontinence care, V17 then put a new brief on R7, and pulled up her pants, but never removed her gloves and cleaned her hands. V17 then removed her gloves, did not clean her hands and assisted R7 out of the room. V17 put on new gloves and began providing incontinence care for R31. V18 was also providing incontinence care for R31. V18 was observed wiping stool from R31's perineal area with disposable wipes wiping 2 and 3 times with the same wipe without folding the wipe or disposing the wipe between each wipe. After done with incontinence care V18 attached R31's new brief and adjusted her linen and bed with dirty gloved hands. V17 then removed her gloves, did not clean her hands, put on new gloves and removes the garbage from the room.
On 12/19/23 at 12:10 PM, V17 said that she did not think she had to clean her hands if she was still working on the same resident while providing care. On 12/19/23 at 12:15 PM V18 said she did not wash her hands after and before gloving because she did not have any hand sanitizer, but she knew she was supposed to do it. V18 said she was aware that she wiped the resident two and three times with the same wipe without folding it. V18 said she did it because she could not see where she was wiping. V18 said she knows doing this can cause cross contamination and infections. V18 said that she does not recall receiving any hand hygiene in-services or training.
On 12/12/23 at 9:21 AM, V2 DON (Director of Nursing) said that staff should only wipe once with a disposable wipe while performing incontinent care especially if the resident has had a bowel movement. V2 said that staff cannot fold the wipe and use it again. V2 said that whenever a staff is going from a dirty area to a clean area while performing incontinent care, they should clean their hands before putting on new gloves, this should be done because of cross contamination.
4. On 12/21/23 at 12:15 pm, V5 was observed providing wound care for R59. R59 is on contact precautions for MRSA (Methicillin Resistant Staphylococcus Aures) infection. V5 provided wound care to R59's left great toe, 5th toe and plantar, she removed some supplies, removed gloves and then put on new gloves without cleaning her hands. Then V5 cleaned R59's wounds to his groin area then she applied betadine to the wounds and then applied a dressing to the groin area. V5 did not clean her hands and apply clean gloves after cleaning the wound and before applying the betadine. V5 then continued to R50's buttocks where she cleaned the wounds on his buttocks, applied the betadine and a dressing to the wounds with the same dirty gloved hands she cleaned the wounds in the groin area. V5 Then with her dirty gloved hands removed the soiled brief attached the new brief pulled up R59's pants then she removed her gloves. V5 then collected and disposed of her supplies in the garbage. V5 then removed her gown and put it in the garbage can next to the door. The garbage can was without a lid and it was the can used for disposing of PPE.
On 12/21/23 at 12:28 pm, V5 said that she should have cleaned her hands before and after cleaning the wounds, and before going to a new wound site. V5 said she should have cleaned her hands before putting on new gloves after removing dirty gloves. V5 said she should do this for the prevention of cross contamination and the spread of bacteria and infections.
The facility did not provide a wound care policy.
5. On 12/19/23 at 12:23 PM R230 was observed in his room asleep and a urinal with 300 cc of a yellow liquid was observed on his over the bed table. At 12:34 pm, V17 CNA was observed going into R230's room with his lunch tray, picking up the urinal stilled filled with 300cc of yellow liquids in one hand and placing his lunch tray down on his over the bed table right where the urinal was. Then V17 removed the urinal cleaned her hands and prepared R230's lunch but did not clean his table at any time.
On 12/19/23 at 12:43 PM, V17 said the R230's over the bed table probably needed some cleaning because it was unsanitary and could cause cross contamination.
On 12/20/23 at 9:21am, V2 DON said that residents' urinal should be stored in the bathrooms, and staff should have cleaned the over the bed table before putting the lunch tray down for infection control and prevention of cross contamination of bacteria.
The facility's bedpan and urinal policy date 12/21/23 shows that urinal should be away from any clean area such as overbed tables.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's Cosentyx was available for administration. This failure resulted in a resident experiencing a psoriasis flare-up. This applies to 1 of 4 residents (R1) reviewed for medications in a sample of 7.
The findings include:
R1's Face Sheet showed his diagnoses include psoriatic arthritis mutilans, generalized pustular psoriasis, and other psoriasis.
On December 14, 2023 at 11:50 AM, R1 stated he had psoriasis and starting having skin issues when he was around [AGE] years old. R1 said he has been waiting on the pharmacy to receive his Cosentyx injections, stating he has not gotten it. R1 stated it works great when he received the starter doses. R1 stated if he does not get it, he turns out like I am now .with scales, itchy, and painful. R1 rated his pain at a 7 and stated he takes oxycodone for his pain. R1 denied he had any open skin areas and again described his skin as scaly, itchy, and painful. The skin on R1's face and hands was clear. R1's September 28, 2023 Minimum Data Set showed he is cognitively intact.
On December 14, 2023 at 1:45 PM, V8 LPN (Licensed Practical Nurse- Wound Nurse) went with Surveyors to R1's room to visualize the skin on more areas of R1's body. R1 was in bed lying on his left side and he was under the covers. R1 wore a long-sleeved shirt and sweat pants. R1 lifted up his right sleeve, and the skin to R1's forearm was dry, thicker, cracked, scaly, and dusty white and it was dotted with tiny scabs. While still on his left side, R1 raised up his shirt; the skin on his back, sides, abdomen, and chest were 100% covered with either scaly skin, scabs, cracked skin, or superficial/raw open areas. The largest of the open areas was to R1's mid-back, which appeared to be approximately five inches long and around an inch wide. Two other open areas were present on his ride side, one approximately two inches long and the other around three inches long. R1 rolled over in the bed and an open area around three inches long was noted on his left side.
R1's Active Physician Orders as of June 1, 2023 showed a Cosentyx loading dose order of 300 mg (milligrams) to be injected subcutaneously every Tuesday until June 13, 2023, and then a monthly dose of 300 mg injected monthly on the 13th every month thereafter.
R1's Medication Administration Records (MAR) from June, July, August, September, October, November and December of 2023 showed to inject 300mg of Cosentyx on the 13th of each month. Instead of a check mark on the 13th for all seven months (indicating the medication was administered), 9 was written. The legend for Chart Codes on the MAR showed 9 means Other/See Nurse Notes. Nursing notes from June 13, 2023 showed a note written by V13 (LPN) at 5:51 PM given this AM [first name] LPN; from July 13, V12 RN (Registered Nurse) wrote medication on order; from August 13, V11 (LPN) wrote N/A, reordered. Notes were not present in R1's medical record regarding the lack of R1's Cosentyx administration for September 13 or October 13, 2023. For November 13, V10 (RN) wrote Med not available. Needs prior [authorization]. The December 13, 2023 nursing note regarding R1's Cosentyx medication on that day showed not available.
On December 14, 2023 at 3:15 PM, V2 (Director of Nursing) stated R1's Primary Care Physician was not who prescribed R1's Cosentyx and it has to come from a specialty pharmacy. V2 stated it is R1's Dermatologist that prescribed Cosentyx and there needs to be a verification in place so R1's insurance would cover the medication so the specialty pharmacy will send it.
On December 19, 2023 at 10:00 AM, V2 stated when she called the specialty pharmacy on December 18, 2023 (during the survey), she was told the pharmacy had been emailing with R1's Mother, so she called her. V2 stated she was hoping the facility could take over handling the Cosentyx verifications, and added if there was no break in medication administration, another verification would not be needed for a year.
On December 14, 2023 at V16 (Pharmacy Technician at specialty pharmacy that dispenses Cosentyx) stated their records showed that four of the five weekly loading doses of R1's Cosentyx were dispensed on March 22, 2023. V16 stated their system can tell that additional Cosentyx doses were not ordered from anywhere else.
R1's MDS history showed he was out of the facility two different times when his monthly April and May doses were due.
On December 14, 2023 at 3:05 PM, V17 (Pharmacist at specialty pharmacy) stated generally it is best that a patient is adherent [to the dosing schedule] so there is no relapse. V17 added she could not say how soon symptoms would return if a dose was missed, and usually the prescribing physician will assess for the medication efficacy at three months.
On December 19, 2023 at 12:20 PM, V20 (Assistant Director of Nursing) stated if a medication is not available, pharmacy and the physician should be notified. V20 stated nurses can find out of there is an alternative medication if a medication is not available. V20 stated if there is an issue with insurance, call the pharmacy and call the insurance and see what needs to be sent over. V20 stated this process should happen immediately and a progress note should be made.
On December 19, 2023 at 10:25 AM, V9 (R1's Primary Physician) stated psoriasis must be controlled with medication, otherwise, it will flare up. V9 stated he has no control over insurance, but he expects the facility to follow up and try to get the medication.
R1's psoriasis exacerbation care plan (revised 8/25/22) showed R1 has lesions to his entire body related to psoriasis exacerbation with a goal for psoriasis lesions to be healed by review date (target date of) 12/27/23. Interventions include Administer medication as ordered
The facility's undated 5.2 Medication Administration policy showed Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The facility's undated 2.6 Ordering Medications policy showed Policy: Medications and related products are ordered from (pharmacy name) on a timely basis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect when a resident did not receive his psoriasis medication to prevent a psoriasis flare-up, and when the resident did not have weekly skin assessments to monitor his flare-up. These failures resulted in R1 experiencing a psoriasis flare-up, and then subsequently his skin lesions were not monitored. This applies to 1 of 7 residents reviewed for neglect in the the sample of 7.
The findings include:
1. R1's Face Sheet showed his diagnoses include generalized pustular psoriasis, psoriatic arthritis mutilans, and unspecified psoriasis.
On December 14, 2023 at 11:50 AM, R1 stated he had psoriasis and starting having skin issues when he was around [AGE] years old. R1 said he has been waiting on the pharmacy to receive his Cosentyx injections, stating he has not gotten it. R1 stated it works great. R1 stated if he does not get it, he turns out like I am now .with scales, itchy, and painful. R1 rated his pain at a 7 and stated he takes oxycodone for his pain. R1 denied he had any open skin areas and described his skin as scaly, itchy, and painful. The skin on R1's face and hands was clear. R1's September 28, 2023 Minimum Data Set showed he is cognitively intact.
On December 14, 2023 at 1:45 PM, V8 LPN (Licensed Practical Nurse- Wound Nurse) went with Surveyors to R1's room to visualize the skin on more areas of R1's body. R1 was in bed lying on his left side and he was under the covers. R1 wore a long-sleeved shirt and sweatpants. R1 pulled up his right sleeve, and the skin to R1's forearm was dry, thicker, cracked, scaly, and dusty white, and it was dotted with tiny scabs. While still on his left side, R1 raised up his shirt; the skin on his back, sides, abdomen, and chest were 100% covered with either scaly skin, scabs, cracked skin, or superficial/raw open areas. The largest of the open areas was to R1's mid-back, which appeared to be approximately five inches long and around an inch wide. Two other open areas were present on his ride side, one approximately two inches long and the other around three inches long. R1 rolled over in the bed and an open area around three inches long was noted on his left side.
R1's Active Physician Orders as of June 1, 2023 showed a Cosentyx injection was to be administered on the 13th of every month after the starter doses. R1's Medication Administration Records for June through December 2023 show that no Cosentyx was administered because it was not available.
On December 19, 2023 at 10:25 AM, V9 (R1's Primary Physician) stated psoriasis must be controlled with medication, otherwise, it will flare up. V9 stated he has no control over insurance, but he expects the facility to follow up and try to get the medication.
The facility's undated 5.2 Medication Administration policy showed Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The facility's undated 2.6 Ordering Medications policy showed Policy: Medications and related products are ordered from (pharmacy name) on a timely basis .
2. On December 14, 2023 at 1:05 PM, the last weekly skin check noted in R1's Electronic Medical Record (EMR) was dated and signed September 14, 2023, which showed R1 had loss of skin integrity that was not new. Under Ulcers, Wounds, and Skin Problems on R1's September 28, 2023 Minimum Data Set (two weeks later), it showed None of the above were present.
R1's November 2, 2023 Physician Progress Note showed R1 had a rash under his Review of Systems and Physical Exam. The Assessment area in the Note showed extensive psoriasis improving psoriatic erythroderma . The same language was used in R1's December 7, 2023 Physician Progress note.
R1's October 19, 2023 Weekly Wound Evaluation showed R1 has chronic psoriasis, and showed an unhealed wound was identified on August 22, 2022. Regarding the peri-wound, the Evaluation showed wound margins are defined, the surrounding tissue texture is dry and scaly, with dry, cracked, and fissured skin. The October 19, 2023 note was signed on December 15, 2023 (during the survey).
On December 19, 2023 at 2:15 PM, V2 DON (Director of Nursing) stated floor nurses or the wound nurse complete the skin assessments. V2 stated the assessment pops in the computer for the nurse to complete and then they can fill the form.
On December 14, 2023 at 12:50 PM, V8 LPN (Licensed Practical Nurse- Wound Nurse) stated she only treats actual wounds and the floor nurses are supposed to do the ointments and powders. At 1:55 PM, V8 LPN stated she has not done any skin assessments and does wounds. V8 was asked for a copy of R1's last skin assessment, which was completed on September 14, 2023.
On December 19, 2023 at 10:30 AM, R1's EMR was reviewed again for assessments. Weekly Skin Assessments were present for September 21st and 28th, 2023; October 5th, 12th, 19th, and 26th, 2023; November 9th, 16th, 23rd, 30th, 2023; and December 7th, and 14th, 2023. All said R1 did not have a loss of skin integrity-including the one dated as completed on December 14, 2023- and all assessments were signed between 1:50 PM and 2:20 PM on December 15, 2023.
The Purpose of the facility's undated Skin Integrity Guideline showed To provide a comprehensive approach for monitoring skin conditions, and To promote healing of wounds of any etiology . Objectives include Provide a guideline for optimal care to promote healing to patients/residents with all identified alterations in skin integrity (i.e. surgical incisions, skin tears, bruising, etc.) . The General Guidelines section showed .develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings .Wound status is monitored on a weekly basis . Under Documentation and Care Interventions for Skin Integrity it showed Patients/Residents will be observed by CNA daily for reddened/open areas .Changes will be reported to the licensed nurse and documented . The Documentation of Weekly Skin Evaluation/Observations section showed Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review ., and Licensed nurse to document weekly on identified wounds using the 'Wound Evaluation Flow Sheet' .
The facility's Abuse Prevention Program (revised 01/2019) showed Policy- It is the policy of this facility to prohibit and prevent resident neglect . The Program continued to show definitions, as 8. Neglect/Mistreatment: means the failure to provide .adequate medical care .that is necessary to avoid physical harm, mental anguish .

Based on observation, interview and record review the facility failed to provide daily feeding tube site care. This applies to 2 of 3 residents (R2, R4) reviewed for feeding tubes in a sample of 17.
Findings include:
On 11/7/2023 at 12:10 PM, V2 (Director of Nursing) confirmed care and cleansing of the feeding tube site is completed daily and documented on the Treatment Administration Record (TAR). V2 stated if the care is not documented and signed off as completed on the TAR it is considered not done.
1. On 10/30/2023 at 1:30 PM, V5 (Nurse), provided R2's bolus feeding. R2's feeding tube did not have a dressing present and the skin surrounding the the feeding tube had moderate amount of dried drainage present.
R2's Physician Order Summary Report dated 11/8/2023 documents R2 with an order dated 11/26/2022 to cleanse the feeding tube site and cover with a dressing every day.
R2's September and October Treatment Administration Record does not document R2's feeding tube site care being provided every day as ordered.
2. On 10/30/2023 at 11:50 AM, R4's continuous tube feeding was infusing into her feeding tube site which was covered with a dressing.
R4's Physician Order Summary Report dated 11/8/2023 documents R4 with an order dated 4/12/2023 to cleanse the feeding tube site and cover with a dressing every day as needed.
R2's September and October Treatment Administration Record does not document R2's feeding tube site care being provided every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent employee to resident mental abuse. This applies to 1 of 16 residents (R1) reviewed for abuse in a sample of 16.
The findings include:
R1's admission Record dated 11/3/2023 documents R1 was admitted on [DATE] with diagnoses to include major depression, cocaine dependence, opioid dependence, suicide attempt, self harm sharp glass, restless, agitation, violent behavior and anxiety.
An Initial facility Incident Report, dated 10/26/2023, documents on 10/25/2023 V5 (Nurse) used inappropriate language in the presence of R1.
On 11/1/2023 at 11:28 AM V2 (Director of Nursing/DON) stated, R1 had alleged she was raped early morning 10/25/2023, was transported to hospital, and returned a few hours later. After she returned, R1 was hallucinating and packing her bags saying she was leaving. Orders were received from a nurse practitioner for R1 to be directly admitted for a psychiatric evaluation.
On 10/26/23 at 1:15 PM, R1 sat on her bed in her room. When asked about her hospital trips on 10/25/23, R1 stated, They said I was stealing. I was not. They would not give me my medication. I have one pill that makes me feel better and an antibiotic. I did not feel safe while they were taking care of me. I just don't know if I feel safe though, they just started hollering at me. R1 said that the staff that cared for her the previous night just started hollering at her and saying things that weren't true.
On 11/2/2023 at 10:29 AM, V4 CNA (Certified Nursing Assistant) stated she worked 6 AM to 10 PM on 10/25/2023 and around 2 PM, V4 was asked to help calm down R1, who was ordered to be sent back to the hospital for a psychiatric evaluation; R1 was packing up her things saying she wanted to leave. V4 stated she spoke with R1 who believed she was being sent out for again because she lied. V4 was able to calm her and R1 was placed 1:1 until the ambulance arrived for transport to the hospital. V4 saw the ambulance arrive, and R1 who was calm, along with V4 and V6 (CNAs) stopped at the nurses station to ask if there were any papers required for R1's transfer. With V5, V7 and V15 (all Nurses) present at the nurses station, V7 said, You came from (prior facility)? and R1 responded, Yes, are you trying to get rid of me? V4 stated V7 then came from behind the nurses station and said, Yeah, you are making all these accusations so you do not want to be here. R1 responded with Accusations, is that what you call them? and R1 then started making racial slurs, using inappropriate language directed towards V7, and she moved closer to V7. V4 stated she stepped between R1 and V7 and brought R1 to the main entrance. V4 stated V7 did not cuss or yell, but his body language and tone set R1 off. V4 explained every time anyone said anything to R1 about accusations on that day it was upsetting her because she thought they were saying she was lying. V4 stated she called V2 (Director of Nursing) and was outside the main entrance doors when V6 CNA (Certifed Nursing Assistant) texted her to return into the building because V5 was yelling. V4 stated, when she returned, V5 was saying in the presence of R1, She needs to get her f****** s*** and get out- she does not need to come back.
On 11/1/2023 at 11:45 AM V6 (CNA) stated on 10/25/2023 when this incident occurred, she was sitting 1:1 with R1 until R1 was picked up for psychiatric evaluation. V6 stated she saw the ambulance arrive, and R1, V4 and V6 walked to the nurses station. V6 stated the the nurses present (V5, V7 and V15) were notified the ambulance arrived, and V4 and V6 asked if there was any paperwork R1 would need for the transfer. V7 stated to R1 What facility were you at? and R1 answered V7's question. V7 then asked, Do you want to go back? Because of the accusations you made, you cannot come back here. R1 then got upset and started getting closer to V7 and became verbally aggressive towards V7. V6 stated V4 stepped between them and R1 was taken to the front entrance arriving at the time the Emergency Medical Technicians (EMTs) were arriving. V6 stated one EMT stayed in the hall by the main entrance door and the other went to the nurses station. V4 left to call V2 (Director of Nursing) and shortly after V4 left, V5 came to the front entrance and yelled at V6, instructing her to Go pack up her stuff, then V5 said s***, R1 is not coming back. V6 texted V4 asking her to return to the main entrance as this was occurring. V6 stated V7 kept a calm voice and did not cuss during his interactions with R1. V6 stated V5 was yelling to the EMT, cussing, and talking over R1 as R1 was yelling at V5.
On 11/3/2023 at 10:02 AM V27 (Nurse Practitioner) confirmed R1 has a history of psychiatric illness. V27 stated she expects residents to be free from abuse, for staff behavior to be appropriate, and staff to correctly handle resident behaviors. V27 stated inappropriate and abusive staff-to-resident interactions can cause the resident to become emotionally distraught, agitated and aggressive. V27 denied any residents reporting any other abuse or inappropriate staff behavior, further stating, And they tell me everything.
On 11/1/2023 at 2:20 PM, a video clip from 10/25/2023 from between 9:18-9:31 PM was viewed in the presence of V1 (Administrator) and V2. At 9:18 PM, V7 and V5 (Nurses), and V4 and V6 (Nursing Assistants) can be seen with R1 at the nursing station: R1 is barely visible and appears as a shadow while present at the nurses station. V7 is then seen pointing a finger and talking to V4 with body language indicating V7 as upset. V4 then steps between R1 and V7, leaving the immediate area with R1. V4, V6 and R1 are then next seen at the front entrance. At 9:22 PM, V12 and V13 (Emergency Medical Technicians/EMT's) enter the facility and are seen talking to R1, V4 and V6 who are still at the front entrance. V12 then goes to the nurses station and is seen interacting with V5. At 9:24 PM, V5 leaves the nursing station and walks toward the main entrance and is next seen talking to V4, V6 and R1, with body language consisting of waving his arms and pointing his finger and it appears V5 is yelling (no audio). At 9:26 PM, V6 is seen leaving this area with V5 and V4 is on the phone remaining at the front entrance. V5 is next observed back at the nurses station and his body language continues to appear as if he is upset. At 9:29, V12 returns to the front entrance and V12 and V13 leave with R1 at 9:30 PM. A resident, R11, was seen intermittently in this video, wandering in the hallways and in the vicinity of both the nurses station and main entrance.
A 10/25/2023 Progress Note documents R11 as alert and oriented. On 11/1/2023 at 2:50 PM, R11 stated he did observe portions of the incident that occurred on 10/25/2023. R11 stated he heard one of the male nurses tell R1 she can't come back a couple times and R1 responded with you can't make that decision. R11 also stated he heard one of the male nurses tell one of the female nursing assistants to go get R1's stuff and the other nursing assistant say he can't do that.
The ambulance Patient Care Report dated 10/25/23 showed that at 9:42 PM, the ambulance attendants V12 and V13 encountered two CNAs with R1 and noted that R1 was calm. The reports showed V12 went to get report from staff at the nurses station and that a nurse was yelling at V12 and stormed off towards the front hall. This report documents this nurse came to the location where R1 was with V13 and stated the nurse yelled at R1 and V13 and said they need to get her stuff because she is not returning. The nurse accused R1 of stealing things and R1 denied this. During transport, R1 stated she admitted to cutting three weeks prior to current complaint and she has a history of substance abuse, suicide attempts, anxiety, and major depressive disorder. R1 was noted to speak in organized sentences and organized thoughts. R1 reported to during transport of the RN Yelling at me to crew. It is documented R1 remained talkative, calm and cooperative during transfer.
The facility Abuse Prevention Program policy dated 1/2019 documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This policy documents employees are required to immediately report any incident, allegation or suspicion of potential abuse or mistreatment they observe, hear about, or suspect to the Administrator. In the absence of the Administrator, reporting can be made to the DON.
The facility Abuse Prevention Program: Abuse and Crime Reporting dated 1/2019 documents mental abuse as humiliation, harassment, threats of punishment, or withholding of treatment or services.

Based on interview and record review, the facility failed to immediately report an allegation of abuse to the Administrator or designee. This applies to 1 of 16 residents (R1) reviewed for abuse reporting in a sample of 16.
Findings include:
The facility Abuse Prevention Program policy dated 1/2019 documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This policy documents employees are required to immediately report any incident, allegation or suspicion of potential abuse or mistreatment they observe, hear about, or suspect to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing).
An Initial facility Incident Report, dated 10/26/2023, documents on 10/25/2023 V5 (Nurse) used inappropriate language in the presence of R1.
On 10/26/23 at 1:15 R1 stated, .I just don't know if I feel safe though, they just started hollering at me. R1 said that the staff that cared for her the previous night just started hollering at her and saying things that weren't true.
On 11/2/2023 at 10:29 AM, V4 (Nursing Assistant) stated the evening of 10/25/2023, while conversing with nurses regarding R1's pending transfer to the hospital for a psychiatric evaluation, V7 (Nurse) said to R1, You came from (prior facility)? and R1 responded, Yes, are you trying to get rid of me? V4 stated V7 then came from behind the nurses station and said, Yeah, you are making all these accusations so you do not want to be here. R1 responded with Accusations, is that what you call them? and then R1 started making racial slurs and using inappropriate language directed towards V7 as she moved close to V7. V4 stated she stepped between R1 and V7 and removed R1 from the area. V4 stated she left the area leaving R1 at the main entrance with V6 (Nursing Assistant) and when she returned, V5 was saying, She needs to get her f****** s*** and get out, she does not need to come back.
On 11/3/2023 at 1:35 PM V2 (Director of Nursing) stated, the allegation and incident of 10/25/2023 was not reported as abuse to herself or V1 (Administrator) until approximately 6 AM on 10/26/2023. V2 confirmed staff are to immediately report all incidents of suspected abuse.

Based on observation, interview, and record review, the facility failed to employ sufficient staff to carry out the functions of food service. This has the potential to affect all the residents who eat by mouth from the facility.
The findings include:
On 9/20/23 Facility data sheet indicated facility has 79 residents. Two of their residents are NPO (Nothing By Mouth) and do not consume food from the kitchen.
On 9/20/23 surveyor entered the facility Kitchen at 10:56 AM. V5 (Cook), and V6 (Dietary Aide) were the only staff members working in the kitchen. The kitchen floor was not clean and a box of buttermilk biscuits was sitting directly on the floor. The freezer floor was noted with a box of scrambled egg mix sitting directly on the freezer floor. On top of the scrambled eggs, eleven boxes of food items were found stacked on top of each other. One box of ready-to-serve fresh-cut produce, fresh shelled eggs, another box of broccoli cuts were also sitting directly on the freezer floor. Three boxes of opened and unlabeled items were also directly on the floor. On 9/20/23 at 10:56 AM, V6 stated someone had gone home at 10:00 AM [V3] (Dietary Manager) hasn't been here for awhile. At 11:10 AM, V5 added we don't have a lot of help, which is slowing me down.
On 9/20/23 at 11:20 AM V5 said, He (Food Truck Driver) just dropped it and I'm trying to cook. I don't have enough staff to put away the items. On 9/21/23 at 9:05 AM, V5 stated V3 (Dietary Manager) has been off for two months.
Facility's Kitchen Schedule dated September 17th- September 30, 2023, was reviewed and it reflected they have only one [NAME] (V5) from 5:30 AM-2:00 PM and have no Manager. No one was listed as working the [NAME] position (C2) for 12:00 PM-7:30 PM.

Based on observation, interview, and record review the facility failed to ensure food on the menu was served as posted. This has the potential to affect all the residents who consume food from the facility kitchen.
The findings include:
The 9/20/23 Facility Data Sheet showed the facility census was 79 residents. Two residents are on NPO (Nothing by Mouth) status.
On 9/20/23 surveyor entered the Facility Kitchen at 10:56 AM. On 9/20/23 at 10:56 AM, V5 (Cook) stated V11 (Kitchen Manager) is the supervisor he hasn't been here for a while.
The facility's lunch menu for 9/20/23 showed Meatballs with Tomato Sauce, Spaghetti Noodles, Italian Blend Vegetables, Garlic Texas Toast, with Strawberry Blondies for dessert. Instead on 9/20/23 during lunch, the Kitchen served mashed potatoes, turkey stew, a bun, and apple sauce. On 9/20/23 at 11:00 AM, V5 (Cook) stated I don't have Meatballs and I don't have Strawberry Blondies .I have substituted turkey stew with mashed potatoes and applesauce. At 11:15 AM, V5 stated the food that is needed is not being ordered. V5 stated there was a food delivery today and it did not bring enough food.
On 9/21/23 the lunch menu showed BBQ Meat loaf, Scalloped Potatoes, [NAME] Peas, Bread, and Sugar Cookies for dessert. For lunch served on 9/21/23, there was only one box of Sugar Cookies, which was not enough for all their residents. No green peas were available, so mixed vegetables were substituted also. On 9/21/23 at 9:05 AM, V5 (Cook) stated, food that is needed has not been being ordered. V5 stated there were not enough Sugar Cookies and the only thing he would have would be graham crackers. V5 stated this is every day.
The facility's 2017 Menu Planning policy showed 11. Substitutes are made only when necessary in a disaster situation, due to a supply problem, observed quality problem, and/or a special event 12. Copies of menus will be clearly posted and visible to staff and residents . The facility's 2017 Menu Substitutions policy showed Guideline: Menu substitutions shall be made only for reasons of food shortage or delivery problems, equipment malfunction, or disaster

Based on interview and record review, the facility failed to follow a physician's medication order. This applies to 1 of 3 residents (R1) reviewed for medication administration.
The findings include:
R1's Face Sheet showed his diagnoses included anxiety disorder and violent behavior. R1's June 21, 2023 MDS (Minimum Data Set) showed R1 was moderately cognitively impaired.
On August 11, 2023 at 9:38 AM, R1 stated that recently an agency nurse (V5) prepared some medication in a syringe and gave it to R1 under R1's tongue. R1 stated the resident in the same room with him (R2) received morphine for his pain. R1 stated the nurses had never given him any medication under his tongue before, so R1 asked the nurse what the name of the medication was. R1 stated the nurse told him it was morphine. R1 stated the morphine made him throw up twice and his bed was wet from the vomit. R1 stated he also felt some constipation for three or four days. R1 stated V5 does not work at the facility every day and he does not know her name.
On 8/11/23 at 2:19 PM, V3 (Registered Nurse/Infection Preventionist) verified that V5 (Agency Nurse) gave R1 an incorrect medication at 6:27 AM and shortly after that, R1 had a small emesis. V3 stated the medication was given to R1 in a syringe under the tongue.
R1's Physician's order dated 06/15/23 showed R1 takes scheduled valproic acid solution 250mg (milligrams)/5ml (milliliter) and to give 5 ml (250mg) via jejunostomy tube (feeding tube) two times a day for behaviors. On 8/11/23 at 3:00 PM, R1's bottle of R1's valproic acid solution reflected the same order.
The facility's Medication Discrepancy Report dated 8/2/23 indicated alleged wrong medication and medication administered and consumer not harmed. The Report described the incident as the assigned nurse reported that patient was given his liquid valproic acid medication in a syringe under his tongue and the resident had a small emesis episode about 20 minutes after administration of the medication. The Report also showed Describe Increased Monitoring if Applicable: Monitoring conducted for the possibility of increased lethargy and monitoring for decreased respirations and adverse effects.
R2's Physician's Orders showed an order for morphine (20mg/ml), 0.25ml (5mg) to be administered three times daily sublingually (under the tongue).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document when a resident's narcotic pain medication was administered. This applies to 1 of 2 residents (R9) reviewed for pain medication administration in a sample of 25.
Findings include:
R9 is a [AGE] year-old male with intact cognition per Minimum Data Set (MDS) dated [DATE].
Record review on the narcotics log sheet indicates that 23 doses of Norco 10/325 milligrams were pulled from R9's locked narcotics box from 3/9/23 to 3/15/23.
R9's March 2023 Medication Administration Record (MAR) showed that only three doses were documented as administered.
On 3/16/23 at 11:20 AM, V2 (Director of Nursing - DON) stated controlled medications, including Norco, should be documented on the Narcotics log when they pull that medication from the Narcotics box, and then must be documented on the eMAR after administering it.
The facility provided policy and procedure on Controlled Substance (undated) documents: Records shall be maintained by authorized nursing personnel of all schedule II drugs administered.

Based on observation, interview, and record review, the facility failed to obtain orders for providing PICC (Peripherally Inserted Central Catheter) line care, and failed to change a PICC line dressing. This applies to 1 of 1 residents (R66) reviewed for intravenous access care in a sample of 25.
Findings include:
On March 14, 2023, at 11:00 am, R66's left upper arm PICC line was dressed in gauze and clear transparent dressing. The dressing was dated 3/1/23 (13 days earlier). R66 stated his PICC line dressing should have been changed. R66's March 2023 Physician Orders showed a March 1, 2023 order for a PICC line insertion. On March 14, 2023, at 5:53 pm, Physician Orders were entered for PICC line dressing change to left upper extremity every day shift Tuesday and as needed (13 days after R66's PICC line was placed).
On March 16, 2023, at 9:23 am, V2 DON (Director of Nursing) stated the RNs (Registered Nurse) do the central line dressing changes. V2 stated central line dressings should be changed every seven days and as needed, and stated R66's PICC line dressing should have been changed on March 8, 2023.
On March 14, 2023, at 8:50 pm, a physician order was entered to flush line with 5 to 10 milliliters saline before and after use and as needed every shift. On March 14, 2023, at 8:51 pm, a physician order was entered to measure the arm circumference daily and as needed one time a day. On March 14, 2023, at 8:53 pm a physician order was entered to measure the PICC line catheter length every day and as needed one time a day.
Review of Nursing documentation lists the PICC line dressing was first changed on March 14, 2023, at 12 pm. The PICC line catheter length and arm circumference measurements were first documented on March 15, 2023, at 9 am, 14 days after placement.
The facility's undated PICC line dressing policy states PICC line catheter insertion site is a potential entry for bacteria that could produce catheter related infection . Initial PICC dressings are changed 24 hours after placement of the line Transparent dressings are changed every 7 days and sooner if the integrity of the dressing is compromised Dressings with gauze shall be changed every 48 hours Assessment of the catheter site should be performed during dressing change, before and after administration of intermittent intravenous medications, at least every 24 hours when maintained for access only and every 2 hours during continuous therapy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow Physician Orders for a pressure ulcer treatment and failed to follow clean technique during pressure ulcer dressing changes.
This applies to 1 of 2 residents (R9) reviewed for pressure ulcers in a sample of 25.
Findings include:
1. R9 is a [AGE] year-old male with intact cognition as per Minimum Data Set (MDS) dated [DATE]. R9's March 15 2023 Order Summary Report showed his diagnoses included pressure-induced deep tissue damage of his left and right heels and showed to perform treatments to both wounds daily. On 3/14/23 at 1:40 PM, during wound care, R9 stated, The facility is not following the physician's order to change my left leg dressing daily. I am not getting a wound dressing change every day. I refused wound dressing change only one day, and that was because of the way the wound care nurse was interacting (rude) with me. R9's February and March Treatment Administration Record (TAR) showed R9's wound dressing changes were not signed off as completed on 2/01, 2/02, 2/04, 2/05, 2/06, 2/07, 2/10, 2/11, 2/16, 2/24, 2/26, 3/8, 3/9, and 3/11.
03/16/23 11:20 AM, V2 (Director of Nursing - DON) stated, The staff should follow the dressing change order in changing wound dressing. If the resident refuses a dressing change, it should be documented in the TAR. They should also follow the clean technique to provide wound care.
2. On 3/14/23 at 1:23 PM, V3 (Wound Care Nurse) and V4 (Certified Nursing Assistant - CNA) perfomed R9's left heel wound dressing change. V4 lifted R9's left leg and held it six inches above the mattress. V3 removed R9's drainage-soiled dressing and placed it underneath R9's left heel. V3 cleansed the wound with wet gauze and piled the used gauze underneath R9's left heel. At 1:30 PM, V4 still held R9's leg and allowed R9's left heel to drift onto the dirty wet gauze and old dressing with drainage. The surveyor notified V3, and V3 continued to apply ointment and calcium alginate without cleaning the wound again, then covered it with a bordered foam dressing and wrapped it.
On 3/14/23 at 2:03 PM, V3 (Wound Care Nurse) and V4 (Certified Nursing Assistant - CNA) performed R9's right heel wound dressing change. V4 lifted R9's right leg and held it six inches above the mattress. V3 removed R9's old dressing and cleansed the wound with wet gauze.
On 3/14/23 at 2:08 PM, V3 put ointment on a tongue blade, opened calcium alginate, and requested V4 to place R9's right leg on the clean blue pad underneath the right heel. V3 then handed the ointment and opened calcium alginate to V4 (right hand) to get bordered foam from the treatment cart. At 2:10 PM, V4 picked up multiple pieces of garbage (from left heel/leg dressing change) from the floor using his left hand and switching the opened calcium alginate from right hand to left hand, contaminating the calcium alginate. At 2:15 PM, V3 stated, V4 is not a nurse, and he was not aware of cross-contamination.
On 3/16/23 at 12:20 PM, V5 (Wound Care Physician) stated, The facility should follow my wound dressing change order. If the wound comes in contact with a dirty dressing after cleansing it, they should cleanse it again before applying a new dressing.
The facility's 2006 Clean Dressing Change policy showed Procedure: 1. Place a plastic bag near the foot of the bed to receive a soiled dressing 7. Remove the soiled dressing and discard it in a plastic bag .

Based on observation, interview, and record review, the facility failed to provide a warm and clean environment.
This applies to 8 residents (R241, R53, R46, R21, R240, R51, R32, and R66) reviewed for homelike environment in a sample of 25.
The findings include:
1. On 3/14/23 at 11:37 AM, R241 was observed in her room wearing a t-shirt, sweater, winter coat and winter hat. R241 said she was cold and there is no heat in here. R241 had winter gloves laying on her bed and said she wears those when she gets really cold. On 3/14/23 at 3:00 PM, R241 was observed in the hallway wearing winter coat, hat, and gloves and said she was colder now than she was earlier. On 3/15/23 at 9:43 AM, R241 was observed in her room wearing a winter hat, gloves and a fleece coat.
2. On 3/14/23 at 11:07 AM, R53 was observed in her room wearing two nightgowns and said she was cold and that facility staff told her they were going to caulk around her window two weeks ago, but had not done that yet. On 3/15/23 at 9:36 AM, R53 was lying in bed with two nightgowns on and four blankets on top of her. R53 said facility staff told her to keep the door open to help some of the heat from the hallway come into the room.
3. On 3/14/23 at 11:02 AM, R46 was in wheelchair with thick fleece blanket pulled up over her shoulders and said she was cold. On 3/15/23 at 9:31 AM, R46 said she was just as cold as the day before.
4. On 3/14/23 at 11:16 AM, R21 was asleep in bed wearing a hooded sweatshirt with the hood pulled up, and a fleece blanket pulled up over her shoulders. On 3/15/23 at 9:37 AM, R21 was in her room wearing sweatshirt and jacket, fleece pants, and fuzzy slippers. R21 said she was cold.
5. On 3/14/23 at 10:33 AM, R240 said he was cold, it gets really cold at night, and there is a draft coming off his window.
On 3/15/23 at 4:10 PM, R53, R46, R21, and R240 were asked what they thought were comfortable room temperatures. R53 and R21 both said 72 degrees Fahrenheit (F). R46 said 70 degrees F. R240 said he is comfortable at 68 degrees F, but his room gets much colder than 68 degrees here at night.
On 3/15/23 at 12:10 PM, ambient room temperatures were checked with V6 (Maintenance Director). All bedroom doors were open during room temperature checks and temperatures taken in degrees F. R46's room was 68 degrees, and R53, R21, and R240's room temperatures were 69 degrees. On 3/16/23 at 9:30 AM, ambient room temperatures were again checked with V6. R241's room was 68 degrees, R46's room and R240's rooms were 69 degrees, and R53 and R21's room was 70 degrees. On 3/16/23 V6 said he thought the temperature in the building should be between 70-75 degrees.
On 3/15/23 at 11:02 AM, V8 LPN (Licensed Practical Nurse) said residents have complained to her about being cold and she has seen residents wearing multiple layers. V8 said some resident rooms in the building have thermostats and other rooms are controlled by the thermostats in the hallway. On 3/15/23 at 12:10 PM, V6 (Maintenance Director) said the heat for R241, R53, R46, R21, and R240's rooms is controlled by the thermostat in their hallway, so if they have their doors closed, the heat will not circulate into their rooms and the thermostat will only adjust the temperature in the hallway. V6 said the windows were caulked outside in the Fall of 2022 and he was not aware of R53's recent request to caulk inside around her window.
On 3/15/23 at 10:30 AM, V2 DON (Director of Nursing) said R240 complained of being cold, and she was not aware of any other residents wearing multiple layers or complaining of being cold. On 3/15/23 at 12:14 PM, V1 (Administrator) said he was not aware residents were cold or wearing multiple layers to stay warm.
The facility's Grievance Log showed two concerns filed in November 2022 regarding cold temperatures in the building in November of 2022, both of which having been signed off as resolved by V1. The January 2023 Resident Council Meeting minutes listed a concern for resident rooms not being warm enough.
The facilitys' Heating and/or Cooling policy showed 4. If temperatures are not maintained between 71-81 degrees F, Maintenance Director will obtain alternate source of heating or cooling until repairs are complete .
6. On March 14, 2023, at 10:45 am, R51's room had dirt and trash on the floor. In R51's bathroom, dried feces were on the toilet bowl and chipped and peeling paint was on the walls.
On March 15, 2023, at 11:13 am, R51's bed was soaked with urine and smeared with feces. At 11:28 am V10 Registered Nurse (RN) stated the CNA's are responsible for cleaning the residents and changing the bed sheets. CNAs should be rounding every two hours. If there is a resident that needs to be cleaned or sheets need to be changed the CNA should do it at that time.
On March 16, 2023, at 9:43 am, R51 had the same soiled sheets in place from the previous day.
7. On March 14, 2023, at 10:45 am, stains and crusty debris were present on R32's bed sheet and pillowcases.
R32 stated the CNA (Certified Nursing Assistants) were supposed to change his linen today for his shower day, but they did not.
On March 15, 2023, at 11:13 am, R32 had the same stained sheet and pillowcase with crusty debris from the previous day. R32 stated he's had the same dirty sheets on his bed for over a week. R32 stated he requested staff to change his sheets the previous day, but they did not change them.
On March 16, 2023, at 9:43 am, R32 was noted to have the same dirty sheets and pillowcases on his bed from March 14, 2023.
8. On March 14, 2023, at 11:00 am, R66's room floor was dirty and had debris scattered. [NAME] stains and crusty debris were present on R66's bed sheets and pillowcases. Two days later on March 16, 2023 at 9:45 am, the stains and debris remained on R66's bed linen.
On March 16, 2023, at 9:23 am V2 DON (Director of Nursing) stated CNAs are responsible for changing the resident's sheets and linen changes are not documented. Guardian Angel rounds are done, and concerns brought up in the morning meeting are addressed that morning. (On March 16, 2023, at 11:57 am, V6 Maintenance Supervisor stated he did not conduct his assigned Guardian angel rounds for the last two days.)
On March 16, 2023, at 9:47 am, V12 CNA stated she was assigned to R51, R32, and R66 for that day and the previous day. V12 stated she did not change the sheets because she did not have clean linen available. V12 stated she requested clean linen from the laundry staff both days.
On March 16, 2023, at 9:53 am, V13 Housekeeping Aid in Laundry stated no one asked her for any extra linen and she did not have any clean linen ready for use.
The facility's undated Activities of Daily Living (ADL) policy showed residents are given routine daily care by the CNA or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care of the resident includes but is not limited to assisting in maintenance of belongings and immediate environment of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure privacy for residents by leaving residents' urinary catheter drainage bags in view of passersby. This applies to 2 of 2 residents (R13 and R23) reviewed for catheter care in a sample of 25.
Findings include:
1. R13 is a [AGE] year-old female with mild cognitive impairment as per Minimum Data Set (MDS) dated [DATE].
On 3/15/23 at 2:07 PM, R13 was observed in her bed sitting at the bedside with an indwelling catheter drainage bag which was visible to roommates and visitors.
2. R23 is a [AGE] year-old male with moderate cognitive impairment as per MDS dated [DATE].
On 3/15/23 at 11:42 AM, R23 was observed in his bed with a urinary catheter drainage bag visible to his roommate and visitors.
On 3/15/23 at 10:16 PM, V2 (Director of Nursing - DON) stated, We don't have any specific policy on privacy bag with urinary catheter bag. A privacy bag should be around the urinary catheter bag, especially with roommates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to manage a resident's pain for a wound dressing change. This applies to 1 of 2 residents (R9) reviewed for pain management in a sample of 25.
Findings include:
R9 is a [AGE] year-old male with intact cognition as per Minimum Data Set (MDS) dated [DATE]. R9's March 15 2023 Order Summary Report showed his diagnoses included pressure-induced deep tissue damage of his left and right heels and showed to perform treatments to both wounds daily.
On 3/14/23 at 1:23 PM, V3 (Wound Care Nurse) and V4 CNA (Certified Nursing Assistant) provided a left heel wound dressing change. R9 was not assessed for pain. V4 raised R9's left leg up and held it six inches above the mattress. V3 then removed the old dressing with drainage and cleansed the wound with wet gauze. R9 vocalized, it hurts .it hurts. V3 continued with the dressing change and did not ask R9 about his pain.
On 3/14/23 at 2:15 PM, V3 stated, I didn't assess R9 for pain because I know he was given pain medication. R9's March 2023 Physician Order Sheet (POS) documents that R9 can have Norco 10/325 mg every four hours as needed. On 3/14/23 at 2:16 PM, R9 was asked by the Surveyor if his wound care was painful. R9 replied it was really painful . my pain was 6/10. At 2:20 PM, V14 (R9's Nurse) stated, R9 was given Norco 10/325 milligram (mg) at 9:00 AM. He could have got another dose at 1:00 PM before wound care.
Record review on the facility-provided pain management policy (undated) document: This policy aims to accomplish that mission through an effective pain management program .through using pain medications judiciously to balance the residents' desired level of pain relief
On 3/15/23 at 10:16 AM, V2 (Director of Nursing) stated that the wound care nurse (V3) should have assessed resident (R9) for pain before she started with wound care.

Based on observation, interview, and record review, the facility failed to check for safe food temperatures and failed to provide palatable foods. This applies to 83 residents who receive meals from the kitchen. Three residents do not eat food from the kitchen due to receiving nutrition via a gastrostomy tube.
Findings include:
1. On March 14, 2023, the food temperatures for lunch were not checked.
On March 15, 2023, at 10:47 AM, the food temperature log was reviewed. During review, several dates were not filled out for breakfast and lunch, including February 27, 2023, February 28, 2023, March 1, 2023, March 2, 2023, March 4, 2023, March 5, 2023, March 7, 2023, March 8, 2023, March 9, 2023, and March 10, 2023.
On March 15, 2023, at 10:55 AM, V7 (Cook) said he did not put the temperatures in the log and forgot to do it. On March 17, 2023, at 1:16 PM, V17 (Cook/Dietary Aide) said the cook was supposed to fill out the log and temperatures should be done because there is a risk for residents to get a foodborne illness.
On March 17, 2023, at 9:27 AM, V16 (Dietician) said the food temperatures should be taken for each item when they are placed onto the steam table. V16 said if the food is not at adequate temperatures, it is not safe to serve to the residents as it could cause foodborne illnesses. V16 said the temperatures should also be checked every 20 to 30 minutes during meal service to ensure they are holding at the appropriate temperatures. V16 said the staff working in the serving area should be checking the food temperatures.
On March 17, 2023, at 9:40 AM, V15 (Former Dietary Manager and current Activity Director) said the food temperatures should be checked three times during the meal prepping and serving process. V15 said the temperature that needed to be logged in the book was for when the food was on the steam table, right before meal service began. V15 said the final check should be done after the meal service to ensure the food temperatures stayed within the range of acceptable temperatures and to ensure there were no issues with the steam table. V15 said if the food did not remain in the acceptable temperature ranges, it could cause bacteria to multiply. V15 said the [NAME] should be checking and recording the temperatures in the log.
The facility's 2017 Serving Food and Beverages policy shows The [NAME] shall take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Food temperatures shall be recorded.
2. The facility's F/W Menu 22/23 Week at a glance for General Week 2 for Thursday March 16, 2023 shows lunch: Beef Stroganoff, mashed potatoes, broccoli and cauliflower, and pear crisp with topping. A lunch test tray received at 12:43 PM, and it consisted of ground beef in a thin brown gravy, spooned over mashed potatoes, mushy broccoli and cauliflower, and diced peaches on the side. There was no pear crisp.
On 3/15/23 at 10:45 AM, R12 said the food is not cooked all the way, the vegetables are watery, and she can't eat the food. On 3/16/23 at 12:56 PM after lunch was finished, R12 said it was supposed to be beef stroganoff for lunch, but it was mashed potatoes with hamburger on top and that is not beef stroganoff. R12 said the broccoli was mushy and she asked for something else and they gave her a hot dog instead.
On 3/14/23 at 11:37 AM, R241 said the food is terrible and most of the time she eats bologna sandwiches because she doesn't like the food they give her. R241 said sometimes she will order take-out chicken and the CNA (Certified Nurse Assistant) will go pick it up for her on break. On 3/15/23 at 9:29 AM, V8 LPN (Licensed Practical Nurse) said R241's insulin was held this morning because she only ate half of her oatmeal. On 3/15/23 at 9:43 AM, R241 said she only ate half her oatmeal for breakfast because it was too watery.
On 3/14/23 at 10:33 AM, R240 said he cannot eat the food at the facility because it gave him diarrhea. On 3/16/23 at 10:27 AM R240 said the food is not any better. R240 said he only ate half a ham sandwich for dinner the day prior because he needs to watch his salt intake due to his cardiac history. R240 said he was still hungry. On 3/16/23 at 12:56 after lunch, R240 was asked if he ate the beef stroganoff and he said, I tried, but it was too greasy.
On 3/15/23 at 11:02 AM, V8 (LPN) said residents have complained to her about the food. On 3/16/23 at 9:49 AM, V9 (LPN) said, Nobody likes the food here. The residents say there is no taste or flavor and that there are not enough choices.
On 3/16/23 at 9:14 AM, V2 (Director of Nursing) said she had heard nitpicky complaints about the food, but nothing more than being fussy over food like a toddler.
The facility's The Dining Experience policy showed Guideline: Residents will have an exceptional dining experience that provides attention to each resident's individual plan of care and dining wishes . Procedure: .6. Meals will be nourishing, attractive, palatable, .