Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 3 of 3 residents reviewed for complete and accurate documentation. (Resident B, Resident C, Resident D) Findings include: 1. The clinical record for Resident B was reviewed on 1/23/25 at 8:20 a.m. The diagnoses included, but were not limited to, osteomyelitis of vertebrae, peripheral vascular disease, neurogenic bladder, and diabetes. An Annual Minimum Data Set (MDS) assessment, dated 10/17/24, indicated Resident B was cognitively intact. The physician's order included, but were not limited to: - Cleanse coccyx (tailbone) wound with wound cleanser, apply wound vac (wound dressing that uses suction to remove drainage and encourage new tissue growth) to coccyx at 125 mmHg (millimeters of Mercury) on day shift every Monday, Wednesday, and Friday. Initiated on 12/16/24 and discontinued on 1/8/25. - Cleanse coccyx wound with wound cleanser, apply calcium alginate, apply kerlex, cover with absorbent dressing on day shift. Initiated on 1/9/25 and discontinued on 1/15/25. - Cleanse left hip wound with wound cleanser, apply medical grade honey, cover with bordered gauze on day shift, every day. Initiated on 1/9/25 and discontinued on 1/15/25. - Cleanse right scapula/flank wound with wound cleanser, apply calcium alginate to wound bed, cover with absorbent dressing on day shift, very day. Initiated on 1/9/25 and discontinued on 1/15/25. The December 2024 TAR (Treatment Administration Record) lacked documentation that the coccyx wound vac treatment was completed, on 12/18/24 and 12/27/24. The January 2025 TAR lacked documentation as follows: - lacked documentation that the coccyx wound vac treatment was completed on 1/3/25, 1/6/25, and 1/8/25. - lacked documentation that the coccyx calcium alginate treatment was completed on 1/10/25, 1/12/25, and 1/15/25. - lacked documentation that the left hip medical grade honey treatment was completed on 1/10/25, 1/12/25, and 1/15/25. - lacked documentation that the right scapula/flank calcium alginate treatment was completed on 1/10/25, 1/11/25, 1/12/25, and 1/15/25. During an interview on 1/23/25 at 10:20 a.m., the Director of Nursing (DON) indicated the documentation for Resident B's treatments should have been completed. 2. During an interview on 1/23/25 at 10:04 a.m., Resident C's indicated the nurses completed her wound dressing changes as the doctor had ordered. At that time, observed a dressing on Resident C's right heel. The dressing was clean, dry, and intact. The right heel dressing was initialed and dated 1/22/25. The clinical record for Resident C was reviewed on 1/23/25 at 10:30 a.m. The diagnoses included, but were not limited to, diabetes, dementia, and cancer. An admission MDS assessment, dated 12/19/24, indicated Resident C was cognitively intact. The physician's orders included, but were not limited to: - Apply triad hydrophilic wound paste to sacrum every shift, initiated on 12/16/24. - Cleanse right heel with wound cleanser, apply hydrogel to wound and cover with bordered gauze, every shift. Initiated on 1/9/25 and discontinued on 1/13/25. - Cleanse right heel wound with wound cleanser, apply collagen to new tissue, cover entire wound with silver alginate, cover with bandage and secure with gauze on day shift every day, initiated on 1/14/25. The January 2025 TAR lacked documentation as follows: - lacked documentation that the sacrum hydrophilic wound paste treatment was completed on 1/17/25. - lacked documentation that the right heel hydrogel dressing was completed on day shift on 1/9/25 and 1/13/25. - lacked documentation that the right heel collagen dressing was completed on 1/14/25, 1/17/25, and 1/19/25. During an interview on 1/23/25 at 10:20 a.m., the Director of Nursing (DON) indicated the documentation for Resident C's treatments should have been completed. 3. The clinical record for Resident D was reviewed on 1/23/25 at 10:45 a.m. The diagnoses included, but were not limited to, necrotizing fasciitis, diabetes, venous insufficiency. An admission MDS assessment, dated 12/12/24, indicated Resident D was cognitively intact. The physician's orders included, but were not limited to: - Cleanse sacral/buttocks surgical wound with normal saline, pat dry with gauze, apply moistened hydrofera blue to wound bed, cover with bordered gauze every shift, initiated on 12/16/24. - Swab left great toe and left third toe venous ulcers with betadine and leave open to air on day shift every day. Initiated on 1/9/25 and discontinued on 1/13/25. - Cleanse left lateral plantar foot venous ulcer with wound cleanser, apply medical grade honey, cover with bordered gauze on day shift every day. Initiated on 1/9/25 and discontinued on 1/13/25. - Swab right lateral foot with betadine and leave open to air on day shift every day, initiated on 1/9/25. The January 2025 TAR lacked documentation as follows: - lacked documentation that the sacral/buttock hydrofera blue treatment was completed on day shift on 1/17/25. - lacked documentation that the left great toe and left third toe betadine treatment was completed on 1/10/25 and 1/13/25. - lacked documentation that the left lateral plantar foot honey treatment was completed on 1/10/25. - lacked documentation that the right lateral plantar foot betadine treatment was completed on 1/10/25 and 1/17/25. During an interview on 1/23/25 at 10:20 a.m., the Director of Nursing (DON) indicated the documentation for Resident C's treatments should have been completed. During an interview on 1/23/25 at 9:59 a.m., LPN 1 indicated documentation for wound care should have been completed in the medical record. On 1/23/25 at 12:00 p.m., the Administrator provided a copy of a facility policy, titled Documentation in the Medical Record, dated 1/2/24, and indicated this was the current policy used by the facility. A review of the policy indicated each resident's medical record shall contain complete, accurate, and timely documentation. This citation relates to Complaint IN00451705. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for 1 of 2 residents reviewed for respiratory care. (Resident 213) Finding includes: On 10/30/24 at 9:56 a.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L (liters) per minute and the N/C (nasal cannula) sitting on her face and not in the nostrils. On 10/30/24 at 2:49 p.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C sitting on her face and not in the nostrils. On 11/1/24 at 9:38 a.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C in her nostrils. On 11/1/24 at 2:33 p.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C sitting on her face and not in the nostrils. On 11/4/24 at 11:06 a.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C in her nostrils. Resident 213's clinical record was reviewed on 11/1/24 at 10:00 a.m. The diagnoses included, but were not limited to, anemia, supraventricular tachycardia, and hypertension. Physician orders for Resident 213 indicated, . Oxygen at 2 L per minute via nasal cannula every shift . The start date was 10/11/24. During an interview on 11/4/24 at 11:50 a.m., LPN 1 indicated Resident 213's oxygen order was for 3 L per N/C and confirmed the oxygen concentrator was set at 3 L per N/C. On 11/4/24 at 4:07 p.m., the Administrator provided the facility's policy, Medication Administration, dated 5/20/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure: 1. Preparation/Administration d. Follow the six rights of medication administration . ii. right dose . 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 ensure a medication cart on the 300 unit was locked for 1 of 8 medication carts observed. (300 Unit Medication Cart) Findings include: On 10/30/24 from 10:18 a.m. until 10:38 a.m., the medication cart outside of room [ROOM NUMBER] was observed to be unlocked and unattended by staff. The medication cart contained medications for residents on the 300 unit. During an interview on 10/30/24 at 10:39 a.m., RN 1 indicated she had been at the other end of the hallway providing care to residents from another medication cart, and the medication cart was to be locked if it was unattended by staff. On 11/4/24 at 4:00 p.m., the Director of Nursing provided the Facility Drug Product Storage Requirements, revised 2/22/22, and indicated this was the policy currently used by the facility. A review of the policy indicated, .all drug storage areas shall be kept secure from unauthorized entry and shall be limited to authorized personnel . 3.1-25(m)

Based on observation, interview, and record review, the facility failed to provide repositioning in order to prevent moisture acquired skin damage for 1 of 6 residents reviewed for pressure sores. (Resident 72) Findings include: On 1/26/23, from 2:07 p.m. until 4:30 p.m., Resident 72 was observed in his bed lying on his back. He was not repositioned during this time. On 1/27/23, from 9:30 a.m. until 12:40 p.m., Resident 72 was observed in his bed lying on his back. He was not repositioned during this time. On 1/27/23 at 3:00 p.m., Resident 72's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, dementia, and hemiplegia (paralysis of one side of the body). The Significant Change MDS (Minimum Data Set) assessment, dated 10/31/22, indicated the resident was not cognitively intact, always incontinent of urine and bowel, not on a toileting program, required extensive physical assistance of two people to turn or reposition in bed, and was free of moisture acquired skin damage. The Braden Skin Evaluation (an assessment used to determine a person's risk for developing pressure sores), dated 1/18/23, indicated the resident was at high risk for pressure sores and skin friction and shearing due to being very moist, having very limited mobility, and being chairfast. The Skin Only Evaluation, dated, 11/6/22 indicated the resident had moisture acquired skin damage (MASD) to the coccyx. The Skin Only Evaluation, dated 11/9/22 indicated the resident had a fluid filled blister on the left buttock. The Skin Only Evaluation, dated 11/16/22 indicated the resident had a fluid filled blister on the left buttock. The Skin Only Evaluation, dated 12/12/22 indicated the resident had MASD to the right buttock. The Skin Only Evaluation, dated 12/27/22 indicated the resident had excoriation (a wearing off of the skin) of the left buttock. The Skin Only Evaluation, dated 1/10/23 indicated the resident had excoriation of the left buttock. The Skin Only Evaluation, 1/25/23 indicated the resident had MASD to the right and left buttock. A care plan with a start date of 7/20/22 and revision date of 1/26/23 indicated the resident was at risk for impaired skin integrity due to incontinence and a need for assistance with toileting and bed mobility. During an interview on 1/30/23 at 10:05 a.m., Licensed Practical Nurse 1 indicated the resident was occasionally resistant to care and repositioning, but was to be repositioned at least every 2 hours to prevent skin damage. During an interview on 1/30/23 at 2:06 p.m., the Director of Nursing indicated the resident had moisture acquired skin damage to his buttocks. He was to be regularly repositioned and was frequently resistant to hands on care. During an interview on 1/31/23 at 9:45 a.m., Certified Nurse Aide 1 indicated the resident was to be repositioned every 2 hours if possible, however, on extremely busy shifts the resident may have gone without repositioning every 2 hours. On 1/31/23 at 9:30 a.m., the Director of Nursing provided the Repositioning policy with a revised date of May 2013, and indicated this was the policy used by the facility. A review of the policy indicated, .residents who are in bed should be on at least an every 2 hour repositioning schedule .if ineffective, the turning and repositioning frequency will be increased .record in the resident's medical record the position in which the resident was placed .the name and title of the individual who gave the care .if the resident refused the care .the signature and title of the person recording the data . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to apply a hand splint on a resident with an assessed limited range of motion (amount of movement around a specific joint) for 1 of 5 residents review for mobility. (Resident 24) Findings include: During an interview on 1/24/23 at 11:09 a.m., Resident 24 indicated he had a stroke and had impaired mobility of his left hand and left leg. He was unsure if he was receiving nursing services for the impaired mobility of his left arm and leg. During an observation on 1/26/23 at 10:26 a.m., Resident 24 was observed to be actively participating in activities. He was observed to have his left hand resting on his left leg with no splint on his left hand. During an observation on 1/30/23 at 3:07 p.m., Resident 24 was observed to be propelling himself in his wheelchair. He was observed not to have on a splint on his left hand. During an observation on 1/31/23 at 11:12 a.m., Resident 24 was observed to be sitting in his wheelchair with no hand splint on his left hand. On 1/27/23 at 2:32 p.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), left side hemiplegia (weakness on entire side the body), and left hand contracture (permanent shortening of a muscle or joint). The Quarterly Minimum Data Set (MDS) assessment, dated 11/2/22, indicated Resident 24 was cognitively intact, had limited range of motion (amount of movement around a specific joint) of upper and lower extremity on one side; had no days of active or passive range of motion restorative program; and had no days of splint or brace assistance. A care plan, dated 10/18/21 and current through target date 2/27/23, indicated Resident 24 had left side hemiplegia due to cerebral infarction and had a contracture to left hand. The care plan lacked interventions of left hand splint or any range of motion to left arm or left leg. A care plan, dated 10/18/21 and current through target date 2/27/23, indicated Resident 24 had the potential for impaired skin integrity related to left side hemiplegia. The intervention was to apply left hand splint in the morning and remove at bedtime. The care plan lacked any intervention of any range of motion to left arm or left leg. The Therapy Communication to Nursing for Functional Program Maintenance dated 12/23/21, indicated Resident 24 to wear a hand splint when up in wheelchair. Resident 24's Order Summary Report dated 1/30/23, indicated apply the left hand splint on in the morning and off at bedtime with a start date of 10/25/21. The care plan lacked documentation of Resident 24 refusing to wear his left hand splint. The progress notes dated, 1/4/23 through 1/30/23, lacked documentation of Resident 24 refusing to wear his left hand splint. The Medication and Treatment Administration Record dated, 1/1/23 through 1/31/23, lacked documentation of Resident 24 refusing to wear his left hand splint. During an interview on 1/30/23 at 10:53 a.m., Qualified Medication Aide (QMA) 1 indicated Resident 24 wore a splint to his left hand. If he wanted to remove the splint, she would inform her nurse so the nurse could document this in his nurses notes. During an interview on 1/31/23 at 10:23 a.m., the Director of Nursing (DON) indicated they do not have a nursing restorative program. During an interview on 1/31/23 at 11:29 a.m., the Licensed Practical Nurse (LPN) 2 indicated Resident 24 wore a splint to his left hand. If he refused to wear the splint, they would document the refusal in the nurses notes. During an interview on 1/31/23 at 11:53 a.m., the DON indicated Resident 24 was one of the few residents who wore their splints. On 1/31/23 at 12:25 p.m., the Administrator provided the facility policy, Nurse Aide Qualifications and Training Requirements, revised date of 8/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .j. basic restorative services .(6) care and use of prosthetic and orthotic devices . 3.1-42(a)(2)