Based on interview and record review, the facility failed to ensure a resident's representative was notified of an assessed significant weight loss for 1 of 3 residents reviewed for notification of change. (Resident B) Findings include: On 3/6/25 at 11:25 a.m., Resident B's clinical record was reviewed. The diagnosis included, but was not limited to, dementia with behavior disturbance. A review of Resident B's weights indicated the following: - On 1/2/25, the resident weighed 156.8 pounds. - On 1/17/25, the resident weighed 157.1 pounds. - On 1/23/25, the resident weighed 144.2 pounds. - On 1/30/25, the resident weighed 146.2 pounds. - On 2/11/25, the resident weighed 137.4 pounds. - On 2/19/25, the resident weighed 127.9 pounds. There was an assessed significant weight loss of 18.59% from 1/17/25 to 2/19/25. The resident's progress notes indicated the following: - A Nutrition/Dietary note from 2/17/25 at 12:30 p.m., indicated Resident B had a significant change of 19.4 pounds and 12.4% weight loss over 30 days. The clinical record for Resident B lacked documentation of the resident's representative having been notified of the assessed significant weight loss. During an interview on 3/6/25 at 12:00 p.m., the Minimum Data Set Coordinator (MDS) indicated the resident had lost weight and the resident's representative should have been notified but was not. On 3/6/25 at 1:15 p.m., the Administrator provided the facility policy, Family Notification of Changes to a Resident's Plan of Care, dated 7/2009, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy: It is the policy of this facility to immediately inform the resident . notify the resident's legal representative . when there are changes to the resident's care . This citation relates to Complaint IN00454567. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a fall was documented for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 3/6/25 at 11:25 a.m., Resident B's clinical record was reviewed. The diagnosis included, but was not limited to, dementia with behavior disturbance. The resident's nursing progress notes indicated the following: - On 2/8/25 at 1:47 p.m., new orders for X-ray of right ribs, right femur, right hip, total views of all X-rays. - On 2/8/25 at 2:45 p.m., follow-up day 2 of 3 awaiting X-rays of right ribs, right femur and right hip due to complaints of pain with movement. - On 2/9/25 at 7:20 a.m., nurse was notified by CNA's that resident was unable to straighten right leg, while assessing resident it was noted pain and discomfort while attempting to change and reposition resident. He was noted to have a recent fall on 2/6/25 and orders were obtained 2/8/25 for X-rays. - On 2/9/25 at 8:05 a.m., hospital ambulance arrived to transport resident to emergency room for evaluation and treatment. - On 2/9/25 at 11:15 a.m., resident returned to facility via ambulance stretcher. The resident was treated for a right hip contusion. The clinical record for Resident B lacked documentation of the resident having had a fall on 2/6/25. During an interview on 3/6/25 at 12:00 p.m., the Minimum Data Set Coordinator (MDS) indicated Resident B's last fall was on 2/2/25, and was unaware of the resident having had a fall on 2/6/25. During an interview on 3/6/25 at 12:23 p.m., RN 1 indicated Resident B had a fall during the night shift on 2/6/25. She worked the next day and was the nurse who ordered the X-rays due to the resident's pain in the right leg. On 3/6/25 at 1:22 p.m., the Administrator provided the facility policy, Procedure for Falls, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure for Falls 6. Chart incident in nurses notes . This citation relates to Complaint IN00454567. 3.1-50(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's choice of code status was documented accurately for 1 of 3 residents reviewed for advanced directives. (Resident 12) Finding includes: On [DATE] at 2:37 p.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and a history of transient ischemic attack (temporary blockage of blood flow to the brain, causing stroke like symptoms). The Advanced Directives, a choice of treatment document, dated [DATE], was signed by the Resident's POA (power of attorney), and indicated the resident was to be comfort measures only (No CPR to be performed). The Physician's Orders, dated [DATE], indicated resident had a current order for CPR (cardiopulmonary resuscitation). A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR (do not resuscitate). A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR. A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR. No additional documentation was in the clinical record to reflect the change in advanced directive. During an interview with the Administrator on [DATE] at 11:05 a.m., she indicated she was unsure why the advanced directive was changed. The Administrator indicated there was no documentation noted in the record indicating a request from the POA to change resident's advanced directive from DNR to CPR. During an interview with the DON on [DATE] at 11:00 a.m., she indicated that according to resident's medical record and current order, the code status was CPR. She indicated that staff would initiate CPR, if needed (contradictory to the resident's advanced directive). On [DATE] at 12:00 p.m., the Administrator provided the choice of treatment policy. The policy was undated, the administrator indicated this was a current policy for the facility. The policy indicated . each resident is afforded the privilege of death with dignity if he/she so desires. In the event the resident is unable to make this determination and the family desires a NO CODE this wish shall be carried out . 3.1-4(f)(5)

Based on record review and interview, the facility failed to ensure an accurate assessment for 1 of 1 residents reviewed for resident assessment. (Resident 234) Finding includes: On 2/18/25 at 2:04 p.m., Resident 234's clinical record was reviewed. The diagnoses included, but not limited to, schizoaffective disorder (condition that combines symptoms of schizophrenia and a mood disorder) and dementia. Notice of PASARR (Preadmission Screening and Resident Review) Level II Outcome, dated 2/15/23, indicated, Final Determination By: Determination Date: 2/15/23, Level II Outcome: Long Term Approval without Specialized Services. A Significant Change MDS (Minimum Data Set) assessment, dated 9/24/24, did not indicate the resident was a PASARR level II. During an interview with the MDS coordinator on 2/20/25 at 10:10 a.m., she indicated section A1500 on MDS assessment, dated 9/24/24, was marked no in error and indicated it should have been marked yes for PASARR Level II. She indicated they did not have a MDS assessment coding policy, they followed the Resident Assessment Instrument (RAI) manual for coding the MDS assessment. On 2/20/25 at 11:30 a.m., a review of the RAI,Version 3.0 User's Manual, 10/2023, for section A1500 of MDS, Code 1, yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID [Intellectual disability]/DD [Developmental disability] or related condition . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was labeled with the date for 1 of 3 residents reviewed for respiratory care. (Resident 1) Findings include: On 2/18/25 at 2:40 p.m., Resident 1 was observed sitting in his wheelchair outside his room with oxygen being administered via nasal cannula (N/C) at 4L (liters). There was no date observed on the N/C tubing. On 2/19/25 at 9:55 a.m., Resident 1 was observed sitting in his wheelchair in the dining room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/19/25 at 11:43 a.m., Resident 1 was observed sitting in his wheelchair in the dining room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/20/25 at 2:44 p.m., Resident 1 was observed sitting in his wheelchair inside his room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/20/25 at 10:42 a.m., Resident 1 was observed laying asleep in bed with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. Resident 1's clinical record was reviewed on 2/18/25 at 3:09 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis) and traumatic brain injury. Current physician orders, dated 2/20/25, indicated, . O2 [oxygen] per nasal cannula at 4 lpm [liters per minute] every shift for low O2 sats [saturations] . During an interview on 2/20/25 at 10:20 a.m., the MDS (Minimum Data Set) Coordinator indicated the tubing was changed every Sunday, however, Resident 1 wanted a longer tubing so hospice brought it and must not have marked it with the date. During an interview on 2/20/25 at 10:39 a.m., the MDS Coordinator indicated Resident 1 did not have an order to change the oxygen tubing every Sunday. On 2/20/25 at 12:00 p.m., the Administrator provided the facility policy, Oxygen Concentrator, undated, and indicated it was a policy currently being used. A review of the policy did not indicated putting a date on the oxygen tubing. 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]). Findings include: Review of the facility's Rooms Size Certification, received from the Administrator on 2/17/25 at 12:50 p.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], were observed on 2/19/25 at 2:00 p.m The rooms were observed to have the following number of beds two beds in each room. During an interview on 2/19/25 at 2:10 p.m., the facility Administrator indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had the room variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 3.1-19(l)(2)(A)

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 kitchen observations. Findings include: During an initial kitchen tour on 2/17/25 at 10:45 a.m., a large container containing opened bags of rice was observed without a lid in the dry storage area. During a follow-up visit on 2/20/25 at 12:01 p.m., the same rice container was observed uncovered in the dry storage area. During an interview at that time, the Dietary Manager indicated the container should have a lid since there were opened bags of rice in it. On 2/20/25 at 12:40 p.m., the Administrator provided a copy of the facility policy, Storage of Dry Food and Supplies, undated, and indicated it was the policy currently being used. A review of the policy indicated, . Use seamless or plastic containers with tight-fitting covers to store products . On 2/21/25 at 10:45 a.m., the Indiana State Department of Health, RETAIL FOOD ESTABLISHMENT SANITATION REQUIREMENTS. TITLE 410 IAC 7-24, dated 11/13/04, was reviewed. A review of the rule indicated, . food shall be protected from contamination by storing the food as follows: . (2) Where it is not exposed to splash, dust, or other contamination . (5) In packages, covered containers, or wrappings 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure accurate reconciliation and disposition of controlled substances for 1 of 3 residents reviewed for medication reconciliation. (Resident B) Findings include: During an interview on 1/17/25 at 9:45 a.m., the Administrator (ADM) indicated she was notified regarding missing pills for Resident B. The ADM's investigation singled out two nurses, the Director of Nursing (DON) and LPN 1, during the time the pills went missing. The facility never found the missing pills. On 1/17/24 at 9:50 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, malignant neoplasm of the breast, history of malignant neoplasm of the brain, and low back pain. An 11/7/24 physician's order indicated the resident was ordered oxycodone (a controlled substance medication used to treat moderate to severe pain) 7.5-325 milligrams every 6 hours, as needed for pain. A review of the drug disposal form did not indicate the resident's oxycodone was disposed. A review of the controlled substance inventory count sheet indicated one card was removed from the A cart, on 12/4/24 for Resident B. The form did not contain the signatures of two licensed nurses for verification. During an interview on 1/17/25 at 10:41 a.m., the DON indicated she conducted an audit and discovered there was a discrepancy between the pill count and inventory sheet. Someone had signed off they had removed a card, but there was no initial so she did not know who pulled the medication. She asked LPN 1 if she removed the medication and LPN 1 informed the DON they had destroyed the pills on 12/4/24. She indicated two nurses should sign off on the drug disposal sheet when the drug was destroyed. The DON indicated she did not destroy Resident B's medication, rather it was different resident's medication. On 1/17/25 at 1:30 p.m., the ADM provided the facility policy, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, dated 3/12/12, and indicated it was the policy currently being used. A review of the policy indicated, . B. When a dose of a controlled medication is removed from the container for administration . it is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose . This citation relates to Complaint IN00448728 3.1-25(e)(2) 3.1-25(e)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were observed on 4/23/24 at 11:00 a.m. The rooms were observed to have the following number of beds: room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds A review of the facility's Rooms Size Certification, received from the Administrator on 4/26/24 at 11:00 a.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER] - 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER] - 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER] - 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. During an interview on 4/26/24 at 11:15 a.m., the Administrator indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had the room variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 3.1-19(l)(2)(A)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 of 1 residents reviewed for a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). (Resident 6) Findings include: On 3/17/23 at 11:00 a.m., Resident 6 was observed to have a colostomy bag attached to his side. During an interview on 3/17/23 at 11:02 a.m., the resident indicated he usually changed the colostomy bag when needed. Nursing staff assisted him when he needed assistance. During an interview on 3/17/23 at 11:20 a.m., LPN 1 indicated the resident frequently changed his colostomy bag, and sometimes required nursing staff assistance with this task. During an interview on 3/17/23 at 11:54 a.m., the DON indicated there was no care plan in place in reference to the resident's colostomy care. On 3/17/23 at 12:10 p.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, paraplegia and diabetes. The Quarterly Minimum Data Set (MDS) assessment, dated 2/23/23, indicated the resident had an ostomy (an ostomy is surgery to create an opening from an area inside the body to the outside). A physician's order, dated 6/7/22 through 3/31/23 indicated, colostomy change as needed. The Resident Care Plan Conference document, dated 3/2/23, indicated the resident had an ostomy. The resident's clinical record lacked a care plan regarding the care of the resident's colostomy. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to provide services to maintain the residents highest practicable quality of care for 1 of 1 residents reviewed for positioning. A resident was not provided positioning assistance. (Resident 8) Finding includes: On 3/16/23 at 11:15 a.m., Resident 8 was observed self-propelling down the hallway in a wheelchair. She was observed slouching down and to the right side in her wheelchair without any positioning aides. On 3/17/23 at 10:00 a.m., Resident 8 was observed self-propelling down the hallway in a wheelchair. She was observed slouching to the right side in her wheelchair without any positioning aides. On 3/17/23 at 12:31 p.m., Resident 8 was eating lunch in the main dining room. She was observed slouching to the right side in her wheelchair without any positioning aides. During an interview, at that time, the resident indicated she would like a pillow on her right side to help with positioning. During an interview on 3/17/23 at 1:00 p.m., CNA 4 indicated she tried to put a pillow under the resident's affected (right) arm to help with positioning and prevent her from getting any scratches on her elbow. On 3/17/23 at 1:07 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, stroke and hemiplegia (paralysis) and hemiparesis (weakness). A Quarterly Minimum Data Set (MDS) assessment, dated 2/9/23, indicated the resident had moderately impaired cognition and had one-sided impairment in her upper and lower extremities. A review of the resident's care plans indicated no care plans were implemented to address the resident's positioning. A review of the resident's record indicated no occupational therapy notes. A review of the March, 2023, physician's orders indicated there were no orders which addressed the resident's positioning. During an interview on 3/17/23 at 2:51 p.m. the MDS Coordinator indicated she did not have any clinical documentation related to the staff addressing the resident's positioning. She further indicated the facility did not have a policy in regard to positioning. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide services for a pressure ulcer for 1 of 2 residents reviewed. A wound care referral was not completed and the weekly wound assessments were not completed. (Resident 4) Findings include: During an interview on 3/14/23 at 2:51 p.m., Resident 4 indicated he had a black-colored pressure ulcer on the bottom on his left foot for the last 3-4 months. He has not had any wound care from anyone outside of the facility. He had his right foot amputated and did not want to have the same thing happen to his left foot. At that time, during an observation, Resident 4 was observed to be wearing a pressure relieving device to his left foot and had a below the knee amputation of his right foot. During an observation on 3/16/23 at 10:23 a.m., Resident 4 was observed to be sitting in his wheelchair participating in therapy with his pressure relieving device on his left foot. During an observation on 3/17/23 at 12:54 p.m., Resident 4 was observed to be sitting in his wheelchair his pressure relieving device on his left foot. On 3/16/23 at 10:45 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, below the knee amputation, diabetes mellitus, osteomyelitis (infection of the bone), and arteriosclerosis (hardening of the walls of the arteries). The care plan, dated 1/2/23 and current through 4/2/23, indicated Resident 4 had a pressure area to his left heel. His interventions were to measure the area weekly, document the measurements and the appearance of the wound; the wound team to assess the area weekly; change treatment per wound team and physician recommendations; and a pressure relieving device to the left foot. The Nurse's Notes indicated the following: - On 1/14/23 at 2:00 p.m., Resident 4's left heel had a moderate amount of pink drainage. The area of deep tissue injury became open during his shower. - On 1/24/23 at 11:00 a.m., Resident 4 received an order for referral of wound care. The Physician's Progress notes, dated 1/24/23, indicated Resident 4 had a heel wound. Resident 4 indicated he had a painful heel ulcer and was interested in starting with wound care. The physician ordered wound care for further evaluation and management. The March 2023 Physician's Order indicated the following: - Cleanse left heel with normal saline; pat dry; paint with iodine; cover with dressing and secure with tape daily (start date 1/14/23). - Referral of wound care (start date 1/24/23). - Pressure relieving device to left foot (start date 2/7/23) The Weekly Wound Assessment and Summary indicated the following: - On 1/3/23, Resident 4's left heel unstageable pressure injury measurements were 4.5 centimeter (cm) length and 6.5 cm width. - On 1/12/23, Resident 4's left heel unstageable pressure injury measurements were 4.0 cm length and 7.0 cm width. - On 1/19/23, Resident 4's left heel unstageable pressure injury measurements were 4.0 cm length and 7.0 cm width. - On 1/26/23, Resident 4's left heel unstageable pressure injury measurements were 4.2 cm length and 7.0 cm width. - On 2/2/23, Resident 4's left heel unstageable pressure injury measurements were 4.4 cm length and 7.0 cm width. - On 2/9/23, Resident 4's left heel unstageable pressure injury measurements were 4.5 cm length and 6.8 cm width. - On 2/16/23, Resident 4's left heel unstageable pressure injury measurements were 4.7 cm length and 6.7 cm width. - On 2/23/23, the weekly wound assessment and summary lacked documentation of wound measurements or assessment. - On 3/2/23, the weekly wound assessment and summary lacked documentation of wound measurements or assessment. - On 3/9/23, Resident 4's left heel unstageable pressure injury measurements were 4.0 cm length and 2.5 cm width. The clinical record lacked documentation of Resident 4 refusing a wound care referral or wound care assessment. The targeted behaviors symptoms lacked documentation of refusal of care. During an interview on 3/16/23 at 11:34 a.m., the Director of Nursing (DON) indicated Resident 4 refused to have referral for wound care. She indicated the clinical record lacked documentation of Resident 4 refusing wound referral. During an interview on 3/17/23 at 11:07 a.m., the DON indicated pressure ulcers are measured and assessed weekly and documented on the Weekly Wound Assessment and Summary. If the resident refused to have pressure ulcer assessed or measured, the nurse would document the refusal on wound summary or nurses notes. During an interview on 3/17/23 at 11:25 a.m., the DON indicated Resident 4's Weekly Wound Assessment and Summary lacked documentation on 2/23/23 and 3/2/23. On 3/17/23 at 2:20 p.m., the MDS nurse provided the facility policy, Pressure Injury Prevention, dated 11/1/22 and indicated this was the policy currently being used by the facility. A review of the policy indicated .8. Each resident who has a skin issue that has been identified (pressure or non-pressure) will be kept in the wound book and measure weekly . 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: Review of the facility's Rooms Size Certification, received from the Administrator on 3/17/23 at 12:50 a.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], 6, and 8, rooms with the variances, were observed on 3/15/23. The rooms were observed to have the following number of beds: room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds During an interview on 3/17/23 at 12:50 p.m., the facility Administrator indicated rooms [ROOM NUMBER] had the room variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 3.1-19(l)(2)(A)

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of infections for 34 of 34 residents residing in the building. A water management program was not implemented to prevent water borne pathogens and gloves were not worn while obtaining a blood glucose level. (Resident 4, RN 1) Findings include: 1. On 3/17/23 at 12:00 p.m., the Administrator (ADM) presented the Water Management Binder. The binder contained the Water Borne Pathogen Prevention Policy which indicated the facility would implement a water management program which follows a preventative guide. The binder lacked documentation of monthly, semi-annually, and annually preventative maintenance. On 3/17/23 at 12:36 p.m., the ADM indicated the Water Management binder lacked documentation of any completed preventative maintenance. On 3/17/23 at 12:50 p.m., the ADM provided the facility policy, Water Borne Pathogen Prevention Policy, dated 11/2017 and indicated this was the policy currently being used by the facility. A review of the policy indicated .1. The facility will conduct risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system 2. The facility will implement a water management program which follow the preventative maintenance guide .: MONTHLY: CENTRAL BATHING SEMI-ANNUALLY: RESIDENT ROOMS .ANNUALLY: DOMESTIC WATER SYSTEMS .2. On 3/16/23 at 11:05 a.m., Registered Nurse (RN) 1 was observed to obtain a blood glucose level for Resident 4 by pricking the finger with a lancet (small, sharp needle) and obtaining a small amount of blood. No gloves were observed to be worn during the procedure. During an interview on 3/16/23 at 11:20 a.m., RN 1 indicated she should have worn gloves during the blood glucose check for Resident 4. On 3/17/23 at 12:47 p.m., the Minimum Data Set (MDS) Coordinator provided the policy, Blood Glucose Meters Cleaning and Disinfecting, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure: 1. Gloves should be worn for all blood glucose monitoring checks and hands washed after removal of gloves . 3.1-18(b)(1)