Based on observation, interview, and record review, the facility failed to ensure a physician's ordered skin tear treatment was followed for 1 of 3 residents reviewed for skin integrity. Wound dressings were not dated and initialed and the dressing change was continued beyond the physician's orders.(Resident 6) Findings include: During an observation on 12/10/24 at 10:45 a.m., Resident 6 was observed sitting in her wheelchair in the hall near her room. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, Resident 6 indicated she was unsure when or why the dressing had been applied to her leg. On 12/12/24 at 1:15 p.m., Resident 6 was observed in her room and was sitting in her recliner with both legs elevated. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, Resident 6 indicated she was unsure when the staff had applied the dressing to her leg. During an observation with RN 3 on 12/12/24 at 1:35 p.m., Resident 6 was observed sitting in her recliner with both legs elevated. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, RN 3 indicated the dressing should have indicated the date and who had applied the dressing to Resident 6's mid-shin area. RN 3 indicated the shin skin tear was considered healed several weeks ago and since that time, the dressings were still being applied to Resident 6's mid-shin area as a preventative measure as per Resident 6's family request. On 12/12/24 at 12:15 p.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, anemia, generalized weakness, dementia, restless leg syndrome, tremors, and a potential for impaired skin integrity. The Quarterly Minimum Data Set (MDS) assessment, dated 11/17/24, indicated Resident 6 was severely cognitively impaired and indicated Resident 6 had a skin tear. Resident 6's care plan, revised on 1/12/23, indicated the resident had potential for impaired skin integrity. The care plan was reviewed and considered current through 2/16/25. The care plan indicated Resident 6's skin would be kept clean and intact. Physician orders included, but were not limited to, monitor skin tear to lower left leg daily and change bordered foam dressing daily and as needed until healed .start date: 10/7/24 . Resident 6's Skin Assessments included, but were not limited to, the following: - Skin assessment, dated 10/5/24, indicated Resident 6 had a new left lower leg skin tear, approximately five centimeters in length, physician was notified, treatment order was in place, and staff were to monitor the area. - Skin assessment, dated 11/23/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 11/27/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 11/30/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 12/7/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 12/11/24, indicated Resident 6 had no impairments with skin integrity. A review of the November 2024 Treatment Administration Record (TAR) record indicated that staff had monitored the left shin skin tear and had applied a new dressing to the left shin area on a daily basis from 11/1/24 through 11/30/24. A review of the December 2024 TAR record indicated that staff had monitored the left shin skin tear and had applied a new dressing to the left shin area on a daily basis from 12/1/24 through 12/12/24. The clinical record lacked documentation that indicated a physician's prescribed treatment order to discontinue the daily dressing changes for a healed skin tear was followed. The physician was not notified and a new treatment order received prior to the continued dressing treatments having been applied to a healed skin tear from 11/24/24 through 12/12/24. During an interview on 12/12/24 at 3:40 p.m., the Director of Nursing Services (DNS) indicated Resident 6's left mid-shin skin tear was identified on 10/5/24 and the physician prescribed dressing changes were applied. When the skin tear was considered healed on 11/23/24, staff should have contacted the physician to obtain a revised treatment plan. All treatment dressings were to include the date and who had applied the dressings. On 12/12/24 at 2:15 p.m., the DNS provided a copy of the Envive Healthcare Policies and Procedures Manual: Subject-Skin Tears policy, dated August 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .apply the ordered dressing and secure .label with date and initials to top of dressing . On 12/16/24 at 9:05 a.m., the DNS provided a copy of the Envive Healthcare Policies and Procedures Manual: Change in Resident's Condition or Status policy, dated August 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Our facility promptly notifies the resident, his or her attending physician .of changes in the resident's medical/mental condition and/or status .nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 3.1-37(a)

Based on interview and record review, the facility failed to document the drug dispositions for 1 of 2 residents reviewed for closed records. (Resident 47) Finding includes: On 12/13/24 at 12:36 p.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hypertension, cerebral infarction (stroke), and hyperlipidemia (high cholesterol). A physician's order summary report of medications, dated for active orders as of 9/17/24, included but were not limited to: - hydralazine HCL 25 milligrams (mg) for hypertension (high blood pressure) - atorvastatin calcium 80 mg for lowering cholesterol - carvedilol 3.125 mg for hypertension - hydrochlorothiazide 12.5 mg for hypertension The Envive Discharge Summary document, was initiated on 9/16/24 in anticipation for Resident 47's planned discharge. A review of the document indicated Resident 47's current medications were to be sent home with the resident on her scheduled discharge date of 9/17/24. The record included Resident 47's current medications; however, it lacked the actual number of pills per medication that were to be provided to the resident upon her discharge. The clinical record lacked a completed drug disposition record for Resident 47 upon her discharge from the facility. During an interview on 12/13/24 at 1:15 p.m., RN 3 indicated Resident 47 was discharged home on 9/17/24 and the facility lacked a drug disposition record for Resident 47 medications. During an interview on 12/16/24 at 11:46 a.m., the Director of Nursing Services (DNS) indicated Resident 47's current medications were sent home with the resident. The DNS indicated she was unsure of the number of pills for each specific medication that were sent home with the resident or how many were returned to the pharmacy. The DNS indicated the facility lacked a drug disposition record for Resident 47's medications. On 12/16/24 at 9:05 p.m., the DNS provided an undated copy of the Discharge Medications policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .discharge medications are counted or the volume of liquid estimated and the following information is entered on the discharge medication documentation form .date .name and strength of each medication .quantity or amount .facility will adhere to the rules and regulations of their specific State Health Department . 3.1-25(s)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a soiled utility room lock was repaired for 1 of 1 soiled utility rooms observed. Findings included: On 12/10/24 at 10:00 a.m., observed the door to the Soiled Utility Room between room [ROOM NUMBER] and room [ROOM NUMBER] to be unlocked. An observation of the lock to the door was missing numerical key pads and the door latch was taped to prevent the door from locking when the door closed. In the unlocked room, a barrel labeled trash, three barrels labeled soiled linen, and two barrels containing items in biohazard bags were observed. The door to the Soiled Utility Room had a sign which read, Restricted Area, Authorized Personnel Only. During an interview on 12/10/14 at 10:05 a.m., Qualified Medication Aide (QMA) 2 indicated the door should have been locked, but the lock was broken and there should have been a work order for it. During an interview on 12/10/24 at 10:22 a.m., the Director of Nursing (DON) indicated the door should have been locked. On 12/10/24 at 2:03 p.m., the DON provided, a copy of CDC Infection Control, Regulated Medical Waste, dated 1/8/24, and indicated it was the current policy in use by the facility. A review of the document indicated, .Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure foods were maintained and served in a sanitary and safe manner for 4 of 4 observations. Staff hair was not covered while in the kitchen food preparation and serving area. (Dietary Manager) Findings include: 1. The initial kitchen tour was conducted with the Dietary Manager (DM) on 12/10/24 from 9:00 a.m. to 9:20 a.m. The DM was observed walking through out the kitchen area and near the food preparation table where the noon meal was being prepared. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 2. During a follow up kitchen observation on 12/10/24 from 11:25 a.m. to 11:45 a.m., the DM was observed at and near the steam table where the noon meal foods were being held. The DM was observed taking and recording the noon meal food temperatures. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 3. Prior to the noon meal service on 12/10/24 from 12:15 p.m. to 12:45 p.m., the DM was observed at and near the steam table that was located in the main dining room area. The DM was taking and recording the starting food temperatures for the foods being held at the steam table. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 4. During a follow up observation on 12/10/24 from 12:50 p.m. to 12:55 p.m., the DM was observed in the main dining room area where the steam table was located. The steam table held the noon meal foods. The DM was observed taking the ending food temperatures. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. During an interview on 12/10/24 at 1:00 p.m., the DM indicated staff hair was to be kept covered while in the kitchen and when working with resident foods. On 12/11/24 at 10:45 a.m., the Director of Nursing Services provided a copy of the Envive Healthcare Policies and Procedures Manual: Preventing Foodbourne Illness-Employee Hygiene and Sanitary Practices policy, dated August 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Hair Nets .beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens . On 12/10/24 at 3:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to .effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Resident's Advanced Directive (code status) preference was implemented and recorded accurately in the clinical record for 1 of 16 residents reviewed for Advanced Directives. (Resident 46) Finding includes: On [DATE] at 2:45 p.m., Resident 46's clinical record was reviewed. Resident 46 was admitted to the facility on [DATE]. The new admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident 46 was severely cognitively impaired. Resident 46's baseline care plan indicated .Focus: [NAME] Care Guide, date initiated: [DATE] and current through [DATE] .Goal: The resident's care will be provided .Interventions: Code status/advanced directive [decision regarding health care intervention]: Full code [meaning a desire for all life sustaining measures were to be implemented] . Resident 46 had an appointed Health Care Power of Attorney (a legal document that grants a trusted person the authority to make healthcare decisions on your behalf). On [DATE] at 9:30 a.m., the Administrator provided a copy of Resident 46's Indiana Physician Orders for Scope of Treatment (POST) form. During an interview at that time, the Administrator indicated on [DATE] that the facility's admission Director had assisted Resident 46's Healthcare Power of Attorney in the completion of the POST form on behalf of Resident 46. A review of the document indicated the Resident's code status preference was Do Not Attempt Resuscitation/DNR. Resident 46's Healthcare Power of Attorney signed the document on [DATE]. The POST form lacked the physician's signature to indicate to the best of my knowledge that these orders are consistent with the patient's current medical condition and preference . Therefore, the DNR code status was unable to be executed due to the missing physician's signature. On [DATE] at 2:20 p.m., the Director of Nursing Services provided an updated version of Resident 46's POST form. A review of this POST form indicated Resident 46's Healthcare Power of Attorney had chosen the DNR (Do Not Attempt Resuscitation) code status as indicated by his signature on [DATE]. This document was also signed by the physician on [DATE] which indicated to the best of my knowledge that these orders are consistent with the patient's current medical condition and preference Resident 46's Healthcare Power of Attorney's preferred DNR code status was then able to be executed on [DATE]. During an interview on [DATE] at 3:55 p.m., the Corporate Nurse Consultant indicated that Resident 46's code status preference was DNR. The POST form was initiated on [DATE] as indicated by the Health Care Power of Attorney's signature. The facility had misfiled the POST form and so the required physician's signature on the document was not obtained until [DATE]. Therefore, Resident 46's preferred code status was not honored until the POST form was completed and executed on [DATE]. On [DATE] at 2:26 p.m., the Corporate Nurse Consultant provided a copy of the Comprehensive Care Plan Guideline policy, dated [DATE], and indicated it was the current policy in use by the facility. A review of the document indicated, .to ensure appropriateness of services and communication that will meet the resident's needs .care plans need to remain accurate and current . On [DATE] at 9:13 a.m., the Corporate Nurse Consultant provided a copy of the Advanced Directives policy, dated [DATE], and indicated it was the current policy in use by the facility. A review of the document indicated, .if the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .the Attending Physician will provide information to the resident and legal representative regarding the Resident's health status, treatment options, and expected outcomes during the development of the initial comprehensive assessment and care plan .plan of care for each resident will be consistent with his or her documented treatment preference and/or advanced directive .the resident has the right to refuse treatment .a resident will not be treated against his or her own wishes .do not resuscitate-indicates that, in case of respiratory or cardiac failure, the resident .legal representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used .will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record . 3.1-4(f)(4)(A)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to initiate a baseline care plan for a newly admitted resident for 1 of 2 residents reviewed for baseline careplans. (Resident 27) Finding includes: On 12/12/23 at 1:38 p.m. the clinical record for Resident 27 was reviewed. The diagnoses included, but were not limited to, Diabetes Mellitus and fractured left patella. Resident 27 was admitted on [DATE]. The clinical record lacked a personalized baseline careplan. During an interview 12/14/23 at 2:12 p.m., RN 2 indicated Resident 27 should have had a baseline careplan initiated within 48 hours of admission. On 12/14/23 at 2:30 p.m., the Director of Nursing provided a policy titled Nursing Admission/Return Admission, dated August of 2022, and indicated it was the current policy being used by the facility. A review of the policy indicated .6. After completion of the admission nursing assessment a Baseline care plan will be initiated for all new admissions . 3.1-30(a)