Based on observation, interview, and record review, the facility failed to maintain infection control practices to help mitigate the spread of COVID-19. Staff failed to complete proper hand hygiene, touched resident furnishings without performing hand hygiene, and placed a dirty glove on top of a medication cart during 2 of 3 observations of care. (Resident C, Resident D) Findings include: 1. During an observation on 10/29/24 at 10:49 A.M., CNA 7 was providing urostomy care and incontinence care for Resident C. CNA 7 indicated Resident C required Enhanced Barrier Precautions due to the urostomy. Following urostomy care, CNA 7 removed Resident C's soiled brief and provided peri-care. CNA 7 then removed both gloves and completed a 10 second handwashing. CNA 7 then applied new gloves and placed a new brief on the resident. CNA 7 indicated they had forgotten to apply a pad around the urostomy insertion site. CNA 7 removed gloves and completed a 12 second handwashing. CNA 7 applied new gloves and placed a pad around the ostomy insertion site. CNA 7 then removed and disposed of gloves, pulled the trash bag from the bin next to the resident's bed, grabbed the resident's privacy curtain with bare hands and pulled the curtain to the side, then entered the resident's bathroom to complete hand hygiene. 2. During an observation on 10/29/24 at 11:05 A.M., RN 4 completed glucose monitoring for Resident D. RN 4 completed hand hygiene, donned gloves, pricked Resident D's finger with a lancet drawing a drop of blood from the finger, then checked the resident's blood sugar level with a glucometer. RN 4 instructed Resident D to grab a tissue for her finger, then RN 4 removed one glove as she exited the resident's room, carrying the glucometer in the other hand. RN 4 then placed one used glove on a medication cart in the hall, placed the glucometer on the medication cart, removed the other glove, and then threw both gloves in the trash on the medication cart. RN 4 then completed hand hygiene. RN 4 proceeded to ask a resident across the hall if they would like a pain medication. During an interview on 10/29/24 at 12:30 P.M., CNA 7 indicated that staff should wash hands with a scrub time of 20 seconds. CNA 7 indicated she was counting during hand hygiene and counted between 15-20 seconds during all handwashing, then stated she may have been counting fast. On 10/29/24 at 11:20 A.M., the Director of Nursing (DON) supplied a facility policy titled, Guideline for Handwashing/ Hand Hygiene, dated 2/9/17. The policy indicated, .3. Health Care Workers (HCW) shall use hand hygiene at times such as: .c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc . Procedures 1. Hand Washing a) Turn on water . b) wet hands with running water. Apply liquid soap and work into lather. c) Wash well for at least 20 seconds . This citation relates to complaint IN00441635. 3.1-18(b) 3.1-18(l)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed for incontinence care. Gloves were not changed and hands were not sanitized between dirty and clean tasks. A resident's incontinence pad was laid on the bathroom floor before it was placed on the resident. (Resident 39, Resident 7) Findings include: 1. On 7/25/24 at 10:40 A.M., CNA (Certified Nurse Aide) 48 and CNA 56 were observed providing incontinence care on Resident 39. CNA 48 put on shoes on the resident, transferred resident from her bed to her wheelchair, and pushed Resident 39 into the bathroom. She washed her hands with a 5 second lather and put gloves on. CNA 56 washed her hands with a 10 second lather and put on gloves. CNA 48 then went out of the bathroom and back into the bathroom using a gloved hand to open the door and close it. CNA 48 and CNA 56 assisted the resident to stand from the wheelchair and transfer to the toilet. While resident was sitting, CNA 48 laid the clean incontinence pad on the bathroom floor, took off the residents pants and dirty incontinence pad, picked up the incontinence pad from the bathroom floor, put it and her pants back on. She assisted resident to stand and grabbed a wipe. She wiped the resident from front to back, folded the wipe, and wiped the resident from front to back again. After discarding the wipe, she pulled up the incontinence pad and pants, pulled her shirt down, pushed the wheelchair to the sink for the resident to wash her hands. She pushed for the soap to dispense, and grabbed paper towels for the resident to wipe her hands with. CNA 48 pushed the resident out of the bathroom into the hallway. CNA 56 washed her hands with a 4 second lather and exited the room. As CNA 48 was walking away, CNA 48 was questioned her about about performing hand hygiene. At that time, she indicated she did not perform hand hygiene and proceeded to enter Resident 39's bathroom and washed her hands with a 6 second lather. 2. On 7/25/24 at 10:32 A.M., Certified Nurse Aide (CNA) 23 and CNA in training 21 provided incontinence care on Resident 7. CNA 23 used her gloved hands to move the bedside table, grabbed a trash bag from the trash can, opened the trash bag and placed it on the bed. Next, CNA 23 used the same gloved hands to raise Resident 7's head of the bed with the remote, moved an oxygen tank, removed the blankets, and removed 2 pillows that were under the resident. CNA in training 21 wiped Resident 7 while CNA 23 used the same gloved hands to hold Resident 7's [NAME] (excess skin and fat that hangs down from the abdomen). At that time, CNA 23 rolled Resident 7 by touching her leg and arm with her gloved hands and CNA in training 21 used 5 wipes to clean Resident 7's bottom. CNA in training 21 failed to change gloves and perform hand hygiene before she placed the clean brief under the resident. CNA in training 21 used both gloved hands to assist Resident 7 to roll. CNA 23 and CNA in training 21 both fastened the clean brief and pulled down Resident 7's gown. At that time, CNA 23 and CNA in training 21 removed gloves, and CNA 23 failed to perform hand hygiene before she pulled up Resident 7's blankets. CNA 23 donned a new pair of gloves and placed a pillow under the resident's feet, handed Resident 7 her phone, and then lowered the head of the bed with the remote. CNA 23 removed gloves, but failed to perform hand hygiene and placed the bedside table next to resident 7 and then opened the door to leave the room. During an interview on 7/25/24 at 1:41 P.M., the DON (Director of Nursing) indicated staff should lather their hands with soap for 20-30 seconds during hand hygiene. She would expect staff to wash hands, put gloves on, and perform incontinence care without touching other items. If they would touch other items such as doorknobs, bed controller, or bedside table, she would expect gloves to be changed and hand hygiene performed between. At that time, the DON indicated staff should not lay the incontinence pad on the bathroom floor. On 7/25/24 at 1:00 P.M., Regional Support 2 provided a current Guideline for Handwashing/Hand Hygiene policy, reviewed 12/31/23 that indicated, Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of antiseptic hand rub .1. All health care workers shall utilize hand hygiene frequently and appropriately .After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen,etc . 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure care plan conferences were completed. Quarterly care plan conferences were not completed for 4 of 5 residents reviewed for unnecessary medications. (Resident 28, Resident 8, Resident 19, Resident 29) Findings include: 1. On 7/23/24 at 1:59 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and hypertension. Resident 28's clinical record lacked a care conference between 1/2/24 and 6/3/24. 2. On 7/23/24 at 8:12 A.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder and depression. Resident 8's clinical record lacked a care conference between 12/12/23 and 5/8/24. 3. On 7/24/24 at 9:21 A.M., Resident 19's clinical record was reviewed. Diagnoses included, but was not limited to, hypertension and anxiety disorder. Resident 19 lacked a care conference between 8/27/23 and 1/3/24 and 5/30/24. 4. On 7/23/24 at 10:39 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, fibromyalgia and depression. Resident 29 lacked a care conference between 8/27/23 and 12/12/23 and 6/11/24. During an interview on 7/24/24 at 9:23 A.M., the Social Service Director (SSD) indicated Resident 28, Resident 8, Resident 19, and Resident 29 should have had a care plan conference every 3 months. On 7/25/23 at 1:03 P.M., Regional Support 2 provided a current Resident's First Meeting Guidelines policy, reviewed 12/31/23 that indicated, .communication and participation regarding the resident's plan of care, medical condition and care needs between the resident, family, resident and care givers .2. Subsequent meeting for .residents should be conducted at a minimum of quarterly . 3.1-35(d)(2)(B)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a sanitary and homelike environment was provided for 3 of 3 resident halls observed and 1 of 1 shower room. Resident toilets were visibly soiled, fracture pans and urine hats were uncovered and placed between the handrail and wall, vitals machine and lift equipment were visibly soiled. The carpet was stained on the 200 Hall. The shower room grout was soiled, tiles were chipped, and there was a broken tile by the bathroom wall. (100 Hall, 200 Hall, 300 Hall, Shower Room) Findings Include: 1. On 7/22/24 at 11:02 A.M., the bathroom of room [ROOM NUMBER] was observed. There was a brown substance on the back of the toilet and an uncovered fractured (flattened) bedpan on the handrail. There were black scuffs on the walls. On 7/26/24 8:21 A.M., the same was observed. 2. On 7/22/24 at 9:14 A.M., the bathroom of room [ROOM NUMBER] was shared by 2 residents and was observed to have an uncovered fractured bedpan on the handrail. On 7/26/24 at 8:22 A.M., the same was observed. 3. On 7/21/24 at 8:56 A.M., a sit to stand lift was observed in room [ROOM NUMBER] with food and other debris on the area where the residents place their feet. On 7/26/24 at 8:47 A.M., the same was observed. 4. On 7/22/24 at 10:08 A.M., room [ROOM NUMBER] was observed. In the bathroom, the vent fan and handrail behind the toilet were dusty. In room [ROOM NUMBER], there was a package of open wipes on the bedside table, the bar under the bottom of the bed closest to the door was dusty, the walls under the clock and facing the bathroom door were plastered without paint, a brown substance was on the door frame and wall, and black scuff marks were along the walls by the bathroom door. There was a wheelchair sitting next to the bed closest to the window with flaking leather on both armrests. On 7/26/24 at 9:12 A.M., the same was observed except for the open wipes on the bedside table. 5. On 7/22/24 at 10:18 A.M., room [ROOM NUMBER] was observed. In the bathroom, there was an uncovered gray fractured bedpan on the handrail and the vent fan was dusty. In room [ROOM NUMBER], there was large sized area of the wall to the left of the head of bed where the wallpaper had been taken off and not covered, a fan by the bedside in use that was dusty, and linens for the bed stored on a stand by the air conditioner unit. Out in the hallway, there was a black smear and scuffs that went down the hall from the entrance door of room [ROOM NUMBER] to the exit doors at the back of the hall. On 7/26/24 at 9:25 A.M., the same was observed except there were no linens stored in the room. 6. On 7/22/24 at 10:24 A.M., room [ROOM NUMBER] was observed. In the bathroom, there was paint rubbed away by the handrail, the call light cord was brown, there was a black substance smeared in front of the toilet, the inside of the toilet bowl was soiled, a used glove behind the trash can on the floor, brown smears on the wall behind the trash can, a package of open wipes on the back of the toilet, an uncovered urine hat on the handrail, and above the cabinet there was peeling paint and plaster hanging from the ceiling. In room [ROOM NUMBER], there was an uncovered cracker and pieces of chips on a paper towel on the cabinet by the closet, the closet door was propped open, and food debris was scattered on the floor around the recliner. On 7/26/24 at 9:08 A.M., the same was observed in the bathroom except for the used glove behind the trash can. The food in the room was now in bags on the cabinet by the closet and there was less food debris on the floor. 7. On 7/22/24 at 10:32 A.M., room [ROOM NUMBER] was observed. In the bathroom, there were 2 uncovered pink dish pans and 1 gray uncovered bed pan laying under the sink on the floor, the floor was sticky and the bathroom had a strong urine smell. On 7/26/24 at 9:06 A.M., the same was observed except the gray bed pan was covered. 8. On 7/22/24 10:48 A.M., the Shower Room was observed. There was an upholstered chair with stains on the seat, a brown substance and dust were behind the door in the corner, the door frame had a brown substance on it, the grout in the tiles throughout the room were soiled, there was a broken tile by the bathroom door, and tiles throughout the floor were chipped. There was a black substance smeared throughout the shower room on the floor. The cloth covering where the towels are kept had 3 brown smudges on the top, the inside of the toilet bowl was soiled and there was a blackish brown substance on the toilet seat, used paper towels were on the floor, and a spider web was in the corner behind toilet. The toilet paper holder was missing on one side, the vent fan was dusty, and the sink facet had brown along the caulking. Over by the spa, there was hair, dust, food debris, and trash scattered on the floor. The carpet outside the shower room was blackened. Wallpaper just past the Shower Room door was peeling off. On 7/26/24 at 8:48 A.M., the same was observed. 9. On 7/22/24 at 10:37 A.M., the following was observed in the 200 Hall. The vitals machine by room [ROOM NUMBER] was dusty, there was black smears and brown spots. On 7/26/24 at 8:47 A.M., the same was observed. 10. The ABHR (Anti Bacterial Hand Rub) dispensers by Rooms 210, 207, 206, 204, and 203 were dusty on top and had black dust on the bottom catch plate. On 7/26/24 at 8:47 A.M., the same was observed. 11. A sit to stand lift in the hall by room [ROOM NUMBER] was rusty, dusty, and had food and other debris on the foot plate and black scuffs on the legs. On 7/26/24 at 8:47 A.M., the same was observed. 12. The carpet in the 200 hall had blackish/brown spots by the medication cart and black and brown marks in hall between room [ROOM NUMBER] and 206. There was random food and trash debris throughout. On 7/26/24 at 8:47 A.M., the same was observed. 13. On 7/22/24 at 2:18 P.M., where the 300 Hall starts, there was a piece of the wood floor missing and the carpet was observed coming loose. On 7/26/24 at 9:21 A.M., the same was observed. On 7/26/24 at 10:00 A.M., the resident grievances for the past 6 months were reviewed and indicated the following: 3/6/24 Dirty carpet - carpet in TV room has had spots of food on it for a while 4/30/24 Recliner and carpet needs cleaned 5/5/24 TV room dusty - Son stated TV room was dusty and did not want grandchildren in room with the dust. Got washrag from staff and dusted room himself 6/25/24 Room had a odor of urine - resident had a complaint of room smelling like urine . 7/14/24 smell in room (urine) - asking to change to a different room d/t [due to] urine smell in current room, stated has smelled like this since arrival On 7/26/24 at 10:15 A.M., a Daily Cleaning Schedule was provided by the Environmental Services Director and she indicated the the following should be done in each room daily, staff should sign and date that it was completed, and list any comments about the room: Restroom: clean toilet and toilet bottom clean sink and sink pipes mirrors/lights/vents check toilet paper/soap/towels clean handrail shower if needed sweep and mop Resident Room: wash mattress dust all furniture dust flat surfaces dust overbed light clean bedside table and bottom check bed for dust clean window vacuum room During an interview on 7/26/24 at 10:51 A.M., the Environmental Service Director indicated the housekeeping staff have a schedule for deep cleans performed monthly but they should do the daily cleaning list on every room every day. She indicated the carpets were cleaned monthly with the big machines and done weekly with a smaller one usually on Wednesdays. They are not in charge of cleaning the resident equipment such as the vitals machines or sit to stand lifts. The shower room should be cleaned daily in the afternoon and the last housekeeper here and evening shift laundry should do it before they leave, but there wasn't a checklist for that. She would expect them to dust, sweep, mop, and sanitize. The grout has not been cleaned in awhile but they do clean it. She was unsure if the upholstered chair in the shower room was kept in there or how they clean or sanitize it. She indicated the hand sanitizer dispensers on the walls should be cleaned daily and the fractured bed pans and urine hats should be stored in plastic bags in the resident nightstands. During an interview on 7/26/24 at 11:01 A.M., the Maintenance Director indicated staff should notify him via TELS (electronic maintenance software) program that he has on his phone and computer and he addresses things from there. Staff was aware of what to look for and should notify him of rooms needing attention. During an interview on 7/26/24 at 11:10 A.M., the Administrator indicated CNAs (Certified Nurse Aides) were in charge of cleaning the resident equipment. During an interview on 7/26/24 at 11:11 A.M., CNA 23 indicated she was not sure who was supposed to clean the resident equipment. She did know she was to notify nurse/housekeeping/maintenance if there was a concern in a room, but she was not shown how to enter a work order into the system so she tells them verbally. At that time, she indicated linens, clean or dirty, were not to be kept in resident rooms. During an interview on 7/26/24 at 11:30 A.M., Regional Support 2 indicated there was not a policy for the cleanliness of equipment but it should be done when found soiled or dirty and anyone could do it. It is not said in the policy, but the urine hats were to be single use so those hats should not be stored and the fractured bedpans/dishpans should be covered. During an interview on 7/26/24 at 11:46 A.M., Regional Support 4 indicated there was not a policy for environment but it would be their policy to strive to provide a homelike environment. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure storage of food in a safe and sanitary manner and failed to follow proper sanitation for 2 of 2 kitchen observations. Food items were observed unlabeled and open to air. The dishwasher did not reach the proper rinse temperature. Temperature logs were not completed correctly. (Kitchen) Findings include: 1. On 7/21/24 at 9:10 A.M., a box of beef patties and a box of chicken breasts were observed open to air and not labeled in the walk in freezer. On 7/22/24 at 9:34 A.M., a box of beef patties was observed open to air and unlabeled in the walk in freezer. 2. On 7/21/24 at 9:45 A.M., the high temperature dish washer was observed to reach a temperature of 168 degrees during the rinse cycle. On 7/21/24 at 9:56 A.M., Daily Data Sheets were provided for 7/14/24 through 7/20/24 which lacked documentation of food temperatures, dish machine temperatures, refrigerator and freezer temperatures and manual ware washing concentration for the evening shift on 7/14/24, 7/15/24, and 7/20/24. One sheet lacked a date, evening meal temperatures, dish machine temperatures for all meals, A.M. and P.M. refrigerator and freezer temperatures, and manual ware washing concentration for all meals. The dishwasher rinse temperature on 7/20/24 was logged as 170 for breakfast and 172 for noon meal. During an interview on 7/21/24 at 9:53 A.M., [NAME] 17 indicated if the dishwasher rinse cycle did not reach 180 degrees, he would notify the Dietary Manager or if he saw the maintenance man he would tell him. Neither one was here yesterday when he recorded the rinse temperature at 170 degrees at breakfast and 172 degrees at lunch so he didn't notify anyone. He had not notified anyone that morning about the rinse temperature being below 180. He indicated he didn't know when the company had been there last for maintenance. The Dietary Manager or Maintenance Director would call the company to work on the dishwasher. During an interview on 7/21/24 at 11:25 A.M., the Administrator indicated that she had just been notified that the dishwasher had not been reaching 180 degrees rinse temperature, and the facility was going to start using a three compartment sink to wash all dishes. During an interview on 7/21/24 at 11:37 A.M., the Administrator indicated all dishes washed this morning will be rewashed in three compartment sink and plastic would be used for lunch if the dishes couldn't be rewashed in time. Since there have been inconsistencies in the rinse temperatures, a service man has been called to service the dishwasher. During an interview on 7/21/24 at 11:42 A.M., the Administrator indicated the kitchen staff was going to run the dishes back through the dishwasher since it was back up to 180 degrees. The staff felt they have time to rewash them before lunch. During an interview on 7/21/24 at 12:03 P.M., two cognitively intact random residents indicated there have been no Styrofoam dishes used for meals recently. On 7/22/24 at 9:34 A.M. The rinse cycle temperature was observed to be 174 degrees on the dish washer. Dishes were used to serve meals from 7/21/24 through 7/26/24. No disposable dishes were used. During an interview on 7/24/24 at 10:02 A.M., the Dietary Manager indicated all temperatures should be logged 3 (three) times a day with each meal for the kitchen. During an interview on 7/24/24 at 11:32 A.M., the Dietary Manager indicated food in freezers should be in plastic containers with lids with the food left in plastic bags with labels or kept in plastic bags rolled down with box closed and labeled. On 7/21/24 at 11:25 A.M., the Administrator provided a Dish Machine Standard Operating Policy, dated 5/31/2016, which indicated .Check that temperatures are appropriate: High Temp- .Rinse temp (temperature) should be 180-185 degrees F (Fahrenheit) . On 7/21/24 at 11:25 A.M., the Administrator provided a Dishmachine Temp (Temperature)/Sanitizer Policy, dated 5/31/2016, which indicated .2. Dishmachine temperatures and sanitizer concentration will be recorded at each meal .3. If the wash or rinse cycle temperatures or sanitizer concentration do not meet the minimum requirements, the Dining Services manager will be notified . On 7/22/24 at 9:49 A.M., the Administrator provided a Hot and Cold Temperature Holding Guideline Policy, dated 5/31/2016, which indicated The temperatures of all foods on the serving line will be measured prior to resident service and recorded at every meal . On 7/22/24 at 2:55 P.M., the Administrator provided a Storage Procedures Policy, dated 5/31/2016, which indicated .3. All food in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place to prevent a resident with a history of exit-seeking behavior from exiting the facility for 1 of 3 residents reviewed for elopement. A resident unknowingly exited the facility and was found in the facility's parking lot approximately 45 minutes later. (Resident C) Finding includes: During a review of facility reported incidents on 3/18/24 at 10:15 A.M., an incident dated 3/13/24 at 7:07 P.M. included that a staff member noted resident C to be sitting in his wheelchair near the heath center sign located outside the health center entrance. During record review on 3/18/24 at 10:45 A.M., Resident C's diagnoses included, but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, dysphagia, aphasia, depression, unsteadiness on feet, lack of coordination, and history of falling. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/12/24, included that the resident's cognition was severely impaired, used a manual wheelchair for locomotion, and could wheel himself 50 feet with partial/moderate assistance. Resident C's physician orders included but were not limited to check function of wandering alert bracelet/device daily (started 8/28/23). Resident C's care plan included, but was not limited to Resident exhibits exit-seeking behaviors. A target goal included, resident will not elope from the facility (started 8/28/23). Resident C's nurse's notes included the following: 8/27/23 6:16 P.M. - Resident has been wandering today. He was sitting by front door but not trying to exit. Another resident's family exited out the door to sit on entrance. Resident C followed them out there. Staff went looking for him and found him sitting outside with other resident's family. Staff asked the family if they were going to leave, to come find staff so staff could assist Resident C back inside. Family came back in the building and left Resident C outside alone. Resident was found laying in the parking lot. When the other resident's family was leaving the facility they found Resident C near their car laying on the ground. 03/13/2024 at 8:00 P.M. - Resident was found outside by a staff member leaving for the day. Noted resident was outside the front entrance and was brought back in. Resident had wander guard on his wheelchair, but the alarm system was not functioning. Resident was brought to a secure location to monitor his safety and well being. 15 minute checks started on this resident. During an observation on 3/18/24 at 2:40 P.M., Resident C was laying in bed with his wheelchair next to the bed. A wander guard bracelet was around the resident's wheelchair. During an interview on 3/20/24 at 9:00 A.M., LPN 4 indicated that Resident C can transfer himself to his wheelchair and can wheel himself around the facility. LPN 4 indicated the resident often wanders and likes to look out the facility doors. LPN 4 indicated the main entrance door was not functioning properly when Resident C was able to exit on 3/13/24. Staff check the residents' wander guard bracelet to ensure proper functioning daily and chart in the record. Maintenance checks the doors Monday - Friday and assigned staff check the doors on the weekends. During an interview on 3/18/24 at 1:22 P.M., Activities 6 indicated that she saw Resident C sitting outside in the parking lot just past the health center sign on 3/13/24. Activities 6 indicated that she was leaving the facility for the day when she saw Resident C and that he was happy to be outside and found it funny that he was able to get out. During an interview on 3/18/24 at 12:52 P.M., Maintenance 8 indicated that the device he uses to check the doors indicates that door is functioning properly but the alert system did not detect the resident's wander guard bracelet and the door did not lock as it should have. During an interview on 3/18/24 at 1:15 P.M., LPN 10 indicated that the doors should automatically lock and signal an alarm when a resident with a wander guard is in close proximity to an exit. During an interview on 3/18/24 at 10:45 A.M., the facility administrator indicated that Resident C was observed on camera exiting the health center main exit door at 7:07 P.M. on 3/13/24 and was brought back inside at 7:53 P.M. The facility administrator indicated that the wandering alert system had been checked on the doors and that the main health center door is currently not being used. A new wander alert system had been ordered and would be installed as soon as possible. On 3/18/24 at 2:15 P.M., the facility administrator supplied a facility policy titled, Elopement Risk Assessment and Prevention, dated 12/31/23. The policy included, .These policies assist to define the mechanisms and procedures for monitoring and managing residents at risk for elopement, help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision . Procedure . 8. A check will be completed of alarmed doors and individual resident alarms to ensure proper functioning . The deficient practice was corrected on 3/14/24 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI on 3/14/24 an action plan included inservice review of policy for elopement with all staff, wander guard sensor and testing, elopement risk assessments of all residents, and the on going monitoring of the residents for elopement risk, staff training with elopement drills, and the monitoring of the wander guard system. This tag relates to complaint IN00430645. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide assistance with bathing for 4 of 5 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (bathing) according to the plan of care and bathing schedule. (Resident B, Resident C, Resident D, Resident F) Findings include: 1. During a review of facility grievances on 1/25/24 at 10:15 A.M., Resident B's family member had submitted a grievance, dated 12/27/23, that included, it had been two weeks since resident had a shower . During record review on 1/25/24 at 12:30 P.M., Resident B's diagnoses included, but were not limited to hemiplegia and hemiparesis following cerebral infarction, heart disease, dementia, weakness, and depression. Resident B's most recent admission MDS (Minimum Data Set) assessment, dated 12/4/23, included that the resident was cognitively intact, had upper and lower one-side extremity impairments, and was dependent for bathing activities. Resident B's care plan included but was not limited to; resident requires staff assistance to complete ADL tasks completely and safely with a goal of; Resident will have functional needs met safely by staff, and an approach including provide facial shaving and nail care on shower days (initiated 11/2/23). Resident B's scheduled shower days were Tuesdays and Fridays during day shift. During review of Resident B's documented bathing from 12/1/23 thru 1/25/23, the following showers/complete bed baths were provided: 12/5/23 - Shower 12/8/23 - Complete Bed Bath 12/12/23 - Shower (Resident missed two consecutive bathing days on 12/15/23 and 12/19/23.) 12/22/23 - Shower (Resident missed three consecutive bathing days on 12/26/23, 12/29/23, and 1/2/24.) 1/5/24 - Complete Bed Bath 1/6/23 - Shower 1/9/24 - Shower 1/12/24 - Shower (Resident missed two consecutive bathing days on 1/16/24 and 1/19/24.) 1/23/23 - Shower During an observation and interview on 1/26/24 at 10:45 A.M., Resident B was sitting up in her wheelchair, in her room, dressed, and groomed. Resident B indicated she received assistance with bathing about once a week. 2. During record review on 1/25/24 at 1:10 P.M., Resident C's diagnoses included, but were not limited to Alzheimer's disease, dementia, type 2 diabetes, and muscle weakness Resident C's most recent significant change MDS (Minimum Data Set) assessment, dated 10/3/23, included that the resident was unable to complete a cognitive function assessment, had a one-sided lower extremity impairment, and was dependent for bathing activities. Resident C's care plan included but was not limited to; resident requires staff assistance to complete ADL tasks completely and safely with a goal of; Resident will have functional needs met safely by staff, and an approach including provide facial shaving and nail care on shower days (initiated 6/2/23). A progress note, dated 7/3/23, included Resident C's family member was visiting and requested that Resident C's nails be trimmed, and expressed, displeasure of resident care. During review of Resident C's documented bathing from 7/1/23 thru 9/20/23, the following showers/complete bed baths were provided: (7 days without documented offered bathing) 7/8/23 - Complete Bed Bath (13 days without documented offered bathing) 7/22/23 - Resident Refused (13 days without documented offered bathing) 8/5/23 - Resident Refused (12 days without documented offered bathing) 8/18/23 - Complete Bed Bath (10 days without documented offered bathing) 8/29/23 - Shower (No documented complete bed baths or showers in September, 2023.) 3. During record review on 1/26/24 at 9:15 A.M., Resident D's diagnoses included, but were not limited to type 2 diabetes, visual loss, dizziness and giddiness, and muscle weakness. Resident D's most recent annual MDS (Minimum Data Set) assessment, dated 12/20/23, included that the resident was cognitively intact, had upper and lower one-side extremity impairments, and required substantial to maximum assistance for bathing activities. Resident D's care plan included but was not limited to; resident requires staff assistance with ADL's (initiated 3/29/23). Resident D's scheduled shower days were Tuesdays and Fridays during day shift. During review of Resident D's documented bathing from 12/1/23 thru 1/25/24, the following showers/complete bed baths were provided: (Resident missed two consecutive shower days on 12/1/23 and 12/5/23.) 12/8/23 - Shower 12/12/23 - Shower (Resident missed two consecutive shower days on 12/15/23 and 12/19/23.) 12/22/23 - Complete Bed Bath (Resident missed three consecutive shower days on 12/26/23, 12/29/23, and 1/2/24.) 1/6/24 - Shower 1/9/24 - Shower 1/12/24 - Shower (Resident missed two consecutive shower days on 1/16/24 and 1/19/24.) 1/23/24 - Shower 4. During record review on 1/26/24 at 10:00 A.M., Resident F's diagnoses included, but were not limited to. Resident F's most recent quarterly MDS (Minimum Data Set) assessment, dated 11/22/23, included that the resident was cognitively intact and required partial to moderate assistance with bathing activities. Resident F's care plan included but was not limited to; resident requires staff assistance with ADL's (initiated 7/11/17). Resident F's scheduled shower days were Wednesdays and Saturdays during evening shift. During review of Resident F's documented bathing from 12/20/23 thru 1/25/24, the following showers/complete bed baths were provided: 12/20/23 - Shower (Resident missed a shower day on 12/23/23.) 12/27/23 - Resident refused (Resident missed eight consecutive shower days on 12/30/23, 1/3/24, 1/6/24, 1/10/24, 1/13/24, 1/17/24, 1/20/24, and 1/24/24.) During an interview on 1/26/24 at 10:15 A.M., CNA 4 indicated all residents should receive a complete bed bath or a shower, per their preference, at least twice weekly. Staff should offer bathing on the residents' scheduled shower days and document in the residents' record the type of bathing that occurred. Should the resident refuse their bathing, staff should document the refusal. On 1/26/24 at 1:00 P.M., the Facility Administrator supplied a facility policy titled, Nursing ADL Documentation Guidelines, dated 12/31/23. The policy included, .2. ADL services will be conducted and documented by the CNA each shift at the 'point of care' or as reasonably possible after care . This citation is related to complaints IN00418698 and IN00424901. 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and prevent falls for 1 of 3 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls. Current physician orders differed from the care plan in place. (Resident B) Finding includes: On 8/15/23 at 1:09 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety disorder, and a history of falling. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/17/23, indicated Resident B was severely cognitively impaired. The MDS indicated Resident B required an extensive assist of 1 staff member for bed mobility, transfers, and toileting. The MDS indicated Resident B had 2 or more falls since admission/ reentry. Resident B's care plan included, but was not limited to, Resident is at risk for falling R/T [related to]: requires assistance with ADL's [activities of daily living], has balance issues, on antidepressant, hx [history] of falls and has diagnoses of dementia, anxiety, HTN [hypertension], hypothyroidism, and diabetes, revised 5/31/23. Interventions included, but were not limited to, non skid strips in front of the toilet, dated 6/28/23. Resident has impairment in functional status in regards to bed mobility, transfers, toileting, and eating R/T: requires assistance with ADL's, has balance issues . dated 4/12/23. Interventions included, but were not limited to, Resident requires .1-2 assist with transfers, 1-2 assist with bed mobility, and 1-2 assist with toileting . Resident B's current Physician Orders included, but were not limited to, Activity: up ad lib, dated 3/30/23 and Non skid strips to floor in front of toilet; check placement q [every] shift 06:00 PM - 06:00 AM, 06:00 AM - 06:00 PM, dated 6/28/23. On 8/15/23 at 2:30 P.M., LPN (Licensed Practical Nurse) 7 provided a CNA (Certified Nurse Aide) Assignment Form for that day that indicated that Resident B was I for transfers and the sheet indicated .encourage activities, she likes to clean. Toilet frequently in a.m., night light in room, enco [sic] non skid strips by toilet . Resident B's fall history included the following for the last 90 days: Fall 1: On 6/7/23 at 11:45 P.M., Resident B tripped over shoes when going to the bathroom. The new intervention at that time was, Keep resident's shoes on table in eyesight at night. Fall 2: On 6/8/23 at 8:38 A.M., Resident B was found on the floor between the bathroom and bedroom. The new intervention at that time was, Non skid strips by doorway of bathroom. Fall 3: On 6/27/23 at 6:05 A.M., a CNA (Certified Nurse Aide) heard a loud noise followed by the bathroom call light being activated and found Resident B on her left side in front of the toilet. The new intervention at that time was, Non skid strips in front of toilet. Fall 4: On 7/9/23 at 9:45 A.M., Resident B was found on the bathroom floor with regular socks on. The new intervention at that time was, Encourage resident to wear non skid socks to bed. Fall 5: On 7/23/23 at 6:39 P.M., Resident B was behind the nurses station and bent over to throw something in the trashcan and when she stood up, she grabbed onto a rolling chair that rolled away which caused the resident to fall. The new intervention at that time was, Encourage purposeful activity after meals. Fall 6: On 7/28/23 at 6:35 A.M., Resident B fell when ambulating. The new intervention at that time was, Encourage resident to wear hipsters. During an observation on 8/16/23 at 8:01 A.M., Resident B's bathroom lacked non-skid strips in front of the toilet. During an observation on 8/16/23 at 8:28 A.M., Resident B had on shoes and pushed her walker down the hallway and entered her room with QMA (Qualified Medication Aide) 3. Resident B did not have a gait belt on. When QMA 3 prepared Resident B's bed, Resident B walked over to the other side of the room by the window and failed to take her walker. QMA 3 failed to take Resident B her walker and assist her back to bed. During an interview on 8/16/23 at 8:06 A.M., CNA 9 indicated Resident B was an assist of 1 staff member for transfers. During an interview on 8/16/23 at 8:11 A.M., QMA 5 indicated she was unsure if Resident B was up independently or if she was a standby assist. She indicated that some interventions put in place to keep Resident B from falling included non skid socks, non skid strips in the bathroom entrance, and non skid strips should be in front of the toilet, but they were pulled off the floor by another resident. At that time, she indicated Resident B had so many falls due to being impulsive. During an interview on 8/16/23 at 8:25 A.M., CNA 11 indicated Resident B was an assist of 1 staff member for transfers and she should have non skid strips in front of the toilet. CNA 11 indicated the I on the CNA Assignment Form is to alert staff that Resident B can stand up by herself, was a standby assist, and a gait belt should be utilized. During an interview on 8/16/23 at 10:37 A.M., LPN 7 indicated Resident B had a Physician's Order to be up ad lib therefore, the resident was able to transfer without assistance. On 8/16/23 at 10:15 A.M., the Administrator provided the Falls Management Program Guidelines policy, reviewed, 3/16/22. The policy indicated [name of company] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .The resident care plan should be updated to reflect any new or change in interventions . This Federal tag relates to Complaint IN00411865. 3.1-45(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident experienced a dignified existence for 1 of 3 residents reviewed for respect and dignity. (Resident 199) Findings include: On 6/4/23 at 8:45 A.M., Resident 199 was observed asleep in bed, uncovered, wearing only a brief, with the door to the room wide open. There were no staff in the room. Several staff were in the hallway outside the resident's room across from his door and no one closed his door or covered him. The resident was in a private room. On 6/5/23 at 7:00 A.M. Resident 199 was observed asleep in bed, uncovered, wearing only a brief, with the door to the room wide open. There were no staff in room. Several staff were passing by the room in the hallway and no one closed his door or covered him. During an interview on 6/5/23 at 8:39 AM with LPN 25, she indicated resident was going home on Tuesday with Specialty Home Health. On 6/5/23 at 12:17 P.M. the resident's clinical records were reviewed. The admission Minimum Data Set (MD'S) Assessment, dated 3/16/23, indicated the resident had severe cognitive impairment and required extensive assistance of 2 or more for bed mobility and transfers, setup and assistance of 1 for eating, and physical assistance with part of bathing. Diagnoses included, but were not limited to, traumatic subdural hemorrhage with loss of consciousness, multiple fractures of ribs, right side, orthostatic hypotension. Current physician orders included, but were not limited to, therapy evaluation and treatment by physical therapy (PT); occupational therapy (OT), and speech therapy (ST); Activity - sit to stand lift; [NAME]-Stedy with 2 assist for all transfers. Care plan dated 4/14/23 indicated the resident likes to sleep late and resident's preferences would be honored. The facility resident rights policy, revised on 12/31/22, and received from the administrator on 6/9/23 at 11:00 A.M., indicated that residents have a right to be treated with dignity and respect. 3.1-3(a)

Based on interview and record review, the facility failed to ensure compliance with the requirements for advance directives. An advanced directive order and DNR (Do Not Resuscitate) form was not signed by the physician for 1 of 2 reviewed for advanced directives. (Resident 24) Finding includes: On 6/5/23 at 1:59 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II and non-pressure chronic ulcer of other part of left foot. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 4/12/23, indicated Resident 24 was an extensive assist of 2 staff for transferring and supervision of 2 staff for bed mobility and toileting. The resident was cognitively intact. Current physician's orders included, but were not limited to, the following: Code Status: DNR, dated 4/11/23 The DNR order lacked a physician or nurse practitioner's signature. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form, dated 4/7/23, lacked a physician or nurse practitioner's signature. Interview on 6/07/23 at 9:45 A.M., LPN (Licensed Practical Nurse) 23 indicated they would look in (name of electronic health record) for code status, but administration keeps a paper copy of advanced directives up front. At that time they indicated if the order was not signed in (name of electronic health record) then they would go to administration to get the paper copy of the DNR. They further indicated if the resident did not have an advanced directive, the facility protocol was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive) status. Interview on 6/7/23 at 9:56 A.M., the Administrator indicated upon admission, the admitting nurse would verbally ask if the resident had an advanced directive. If it was a DNR, she would choose that and a DNR indicator would appear in the top left corner of the resident's clinical record as a reference for the staff to look at. They did not keep paper copies of the signed advanced directives. Once signed, they were scanned into (name of electronic health record). At that time, the Administrator was not sure if an order and/or DNR form that was not signed by the physician or nurse practitioner would be valid to use as a code status or if the resident would default to the facility protocol of full code status. Interview on 6/7/23 at 10:04 A.M., the Regional Consultant indicated the physician would indicate DNR status, an order would be put into (name of electronic health record), and the DNR form would be signed by the resident and witnesses. At that time, it would be scanned into the chart. The paper copy of the signed DNR would be given or sent to the physician to sign. Once signed, it would be scanned into (name of electronic health record) again. The order would be put into (name of electronic health record) and should go into an electronic list of orders to be signed by the physician. Until the DNR form was signed by the resident, the facility protocol was full code status. At that time, the Regional Consultant and Administrator observed the unsigned DNR order and DNR form in (name of electronic health record). Both indicated that the physician should sign orders/DNR form within 30 days or sooner. Interview on 6/8/23 at 3:05 P.M., QMA (Qualified Medication Aide) 15 indicated if there was a DNR order that was not signed by the physician, they would use the protocol and treat the resident as a full code status. At that time, LPN 23 indicated if the DNR order was not signed by the physician then the order was not valid and they would be treated as a full code status. A current Guidelines for Orders policy, dated May 2016, was provided by the Administrator on 6/8/23 at 11:12 A.M., and indicated . physician orders/progress notes must be signed and dated in accordance with state regulations . Telephone or verbal orders shall be countersigned by the physician as designated by state regulation . A current Guidelines for Advanced Directives policy, dated 11/28/16, was provided by the Administrator on 6/7/23 at 12:00 P.M., and indicated . The 'DNR' form will be completed documenting these desires and scanned into the medical record . 3.1-4(f)(7)

Based on observation, interview, and record review, the facility failed to ensure an intervention was implemented for 1 of 5 residents reviewed for accidents. Resident's bathroom did not have non skid strips placed in front of the toilet. (Resident 24) Finding includes: During an interview on 6/4/23 at 9:28 A.M., Resident 24 indicated she was able to transfer herself without help of staff. On 6/5/23 at 1:59 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, history of falls, unsteadiness on feet, abnormalities of gait and mobility, and non-pressure chronic ulcer of other part of left foot. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 4/12/23, indicated Resident 24 was an extensive assist of 2 staff for transferring and supervision of 2 staff for bed mobility and toileting. The resident was cognitively intact. Current physician's orders included, but were not limited to, the following: Non skid strips in front of toilet, dated 5/25/23 A current falls care plan, dated 2/21/22, included but was not limited to, the following interventions: Educated resident to call for assistance and grip strips placed in from (sic) of toilet, dated 5/25/23 The TAR (Treatment Administration Record) for 5/25/23-5/31/23 was reviewed and indicated non skid strips were observed in front of the toilet twice daily from 6:00 A.M.-6:00 P.M. and 6:00 P.M.-6:00 A.M. The TAR (Treatment Administration Record) for 6/1/23-6/7/23 was reviewed and indicated non skid strips were observed in front of the toilet twice daily from 6:00 A.M.-6:00 P.M. and 6:00 P.M.-6:00 A.M. Interview on 6/8/23 at 3:05 A.M., QMA (Qualified Medication Aide) 15 observed non skid strips were not placed on the floor in front of the toilet. At that time, they indicated if there is an order for them, they should be placed. Interview on 6/9/23 10:10 A.M., the Administrator indicated the facility used an electronic system for maintenance work orders and everyone had access to put in things that needed to be done. When a nurse puts an order into the resident's chart, they should have also put it into the maintenance system so he was aware it needed to be done. He should prioritize those tasks but she would expect it to be done in a timely manner. Interview on 6/9/23 at 2:09 P.M., the Administrator indicated the maintenance man was not aware non skid strips needed to be placed in Resident 24's bathroom. At that time, she also indicated there was not a policy on following orders, but it would be the facility policy to carry out any orders given. 3.1-35(a) 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided care according to the physician orders and maintenance of the respiratory equipment for 1 of 1 residents reviewed for respiratory care. (Resident 8) Findings included: On 6/5/23 at 10:34 A.M., Resident 8 was observed out of bed, dressed, and sitting in wheelchair. A Continuous Positive Air Pressure (CPAP) machine was on her night stand. During an interview, the resident indicated she only uses CPAP when sleeping. Upon inspection, the gross particle filter on the CPAP machine was observed to be covered with white lint-like substance. There was no oxygen concentrator in the room and the resident indicated she was not using oxygen at that time. On 6/6/23 at 11:47 AM the resident's clinical records were reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus with unspecified complications, obstructive sleep apnea (adult), shortness of breath, and acute respiratory failure. The annual Minimum Data Set (MDS) Assessment, dated 2/15/23, indicated the resident was cognitively intact, and required extensive assistance of 1 for bed mobility, transfers, and toileting, setup and supervision for eating, and physical help with part of bathing. Physician orders included, but were not limited to: Oxygen 1 to 4 liters per minute (LPM) as needed to keep oxygen saturation levels above 90% (dated 9/21/22); place CPAP on at bedtime, remove upon rising. This order must be followed and checked on during bed checks (dated 11/19/22). Care Plan: Resident has potential for complications, functional and cognitive status decline related to respiratory disease R/T: COPD, and OSA (start date 3/3/22). Interventions included: 1. Respiratory therapy per orders. 2. Monitor oxygen saturation via pulse oximetry as ordered. 3. Administer oxygen per orders. (3/3/22) 4. Resident requires elevation of head of bed due to shortness of breath while lying flat as needed. 5. Monitor lung sounds per orders or as needed. 6. Observe and report signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds). 7. Assess for change in level of consciousness, coherency. Report changes. The care plan lacked an intervention for the CPAP machine. On 6/7/23 at 10:27 A.M. the resident's clinical records were reviewed and indicated oxygen saturations from 5/7/23 to 6/7/23 ranged from 93% to 100% on room air. On 6/6/23 at 1:30 PM the tubing on resident's CPAP machine was observed. There was no date or time noted on tubing or machine. During an interview on 6/6/23 at 9:16 A.M. with the resident, she indicated she did not sleep well last night because her CPAP machine was beeping. The large particle filter was observed to still be covered with white lint-like substance. During an interview on 6/6/23 at 11:34 A.M. with representative of respiratory care company, the representative indicated he did not know if the CPAP machine had any filters. When asked to check, he saw the gross particle filter. He removed it and showed the clean side. When asked to show the other side, he turned it over and saw it was dirty. He then washed it out. The representative said he does not usually do that. He indicated he did not know if the CPAP had a fine particle filter. He indicated the respiratory therapists (RT's) are the only ones who can do anything with the machines. When asked how often the RT's make rounds to the facilities, he indicated he did not know. The reason for his visit was to put new tubing on resident's CPAP machine, he indicated it was on the truck and he was going to go get it and replace the tubing. Interview with the Administrator on 6/6/23 at 11:41 A.M., a copy of the agreement with respiratory care company was requested and not received. Interview with the Administrator on 6/6/23 at 11:57 A.M., the administrator provided a copy of the bill from respiratory company, which indicated the respiratory therapist had visited the facility on 3/20/23. She indicated they have oxygen concentrators on site if they are needed. Interview with the administrator on 6/9/23 at 2:00 P.M., the administrator indicated the RT's had been to the facility in April and May to service machines. The facility's policy on respiratory care was requested but not received. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure behavioral health services were provided to maintain resident's highest practicable well-being. A Resident that required behavioral health monitoring was not evaluated for these services and not monitored for behaviors for 1 of 3 residents reviewed for dignity. (Resident G) Findings include: During an observation on 6/4/23 at 12:42 P.M., Resident G indicated that she needed to use the restroom. At that time, CNA (certified nurse aide) 3 was passing drinks to other residents as Resident G continued to say she needed to go to the restroom. CNA 3 indicated in a harsh tone you can't go right now, you can only go pee every 2 hours. On 6/6/23 at 9:34 P.M., Resident G's clinical record was reviewed. Diagnosis included, but were not limited to, heart failure, hypertension, and overactive bladder. The most recent annual MDS (minimum data set) Assessment, dated 5/12/23, indicated Resident G's cognitive status was severely impaired, and Resident G was occasionally incontinent. During an observation on 6/07/23 at 10:09 A.M., a white dry erase board was observed sitting in Resident G's room that indicated bathroom again at 12:30 am. Resident G's clinical record lacked any orders related to her repeated requests to go to the bathroom. Documentation related to behavior monitoring was requested and not received. Resident G's clinical record lacked any care plans related to her repeated requests. During an interview on 6/9/23 at 8:35 A.M., the DON (director of nursing) indicated that Resident G had a behavior of repeatedly asking to use the restroom, and it should be monitored and care planned. A dry erase board was in her room and indicated when the resident was able to use the restroom. It was used as a reminder when Resident G asked 5 minutes after going to the restroom. On 6/9/23 at 9:17 A.M., the administrator provided a Guideline for Mental Health Wellness Program policy, dated 12/31/22. The policy indicated .3. If behavior concerns are identified a baseline Behavior Plan of Care shall be developed and initiated. a. The plan of care shall address the identified root cause of the behaviors. 4. Behavior interventions shall be communicated to the interdisciplinary team for implementation .10. The Mental Health Wellness/ Behavior Management Program shall consist of: a. A care plan initiated or updated with realistic, effective interventions which complements the resident's cognitive status, and incorporates their total care. b. Communication to Social Service Director and Physician alerting them to new, exacerbated behaviors, current status, intervention of effectiveness .11. Interdisciplinary team findings shall be contained in the clinical record . This Federal tag relates to Complaint IN00404924. 3.1-37(a) 3.1-43(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for antibiotic use. A resident received 9 doses of an antibiotic that were double the ordered dose and a resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 9, Resident 13) Findings include: 1. On 6/8/23 at 9:54 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, non-Hodgkin lymphoma, hypo-osmolality, and hyponatremia. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 3/14/23, indicated that the resident was moderately cognitively impaired and an extensive assist of 2 staff for bed mobility and toileting. The current physician's orders included, but was not limited to, the following: Bactrim 400-80 mg (milligram) tablet orally once a day on Tuesday, Thursday, and Saturday for UTI (urinary tract infection) prevention A current ADL (Activities of Daily Living) care plan, dated 3/21/23, included, but was not limited to the following intervention: Medications per MD (Medical Doctor) order, dated 3/21/23 Progress notes included, but were not limited to, the following: 4/14/23 12:51 P.M. QMA noted wrong dose of Bactrim 4/13/2023 was given double strength (sic) on Tuesday, Thursday, and Saturday. Nine pills were punched out. Daughter and nurse practitioner were notified. No ill effects from double strength. Pharmacy was called and informed wrong dose was sent to our building. The March 2023 MAR (Medication Administer Record) was reviewed from 3/16/23-3/31/23 and indicated 1 dose of Bactrim 400-80 mg was given on the following dates: 3/16/23 3/18/23 3/21/23 3/23/23 3/25/23 3/28/23 3/30/23 The April 2023 MAR was reviewed from 4/1/23-4/13/23 and indicated 1 dose of Bactrim 400-80 mg was given on the following dates: 4/1/23 4/4/23 4/6/23 4/8/23 4/11/23 4/13/23 During an interview on 6/8/23 at 1:40 P.M., LPN (Licensed Practical Nurse) 23 indicated when a medication was delivered from the pharmacy, staff should check the order and check the card to make sure they match before putting it into the cart. At that time, they indicated while the medication was administered, one should check the order in the electronic record and make sure it matched the label on the medication card from the cart three times before the patient received the medication. During an interview on 6/8/23 at 2:45 P.M., (pharmacy name)'s Executive Director/pharmacist indicated they received an order for single dose Bactrim 400-80 mg from the facility; however, when it was dispensed on 3/14/23, it was mistakenly dispensed as Bactrim 800-160 mg. He indicated there were 9 doses given until the error was discovered on 4/14/23 by facility. correct dose was dispensed on 4/14/23 so the facility should have received it 4/15/23. During an interview on 6/8/23 at 4:09 P.M., the Regional Consultant indicated Resident 9 received 9 incorrect doses of Bactrim. 2. On 6/8/23 at 8:03 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and anxiety disorder. The most recent quarterly MDS Assessment, dated 5/19/23, indicated that the resident was cognitively intact and needed an extensive assist of 2 staff for bed mobility and transfers. Current physician's orders included, but were not limited to, the following: lorazepam 0.5 mg administer 0.25 mg orally once daily PRN for anxiety, dated 4/18/23-6/6/23 Resident 13's clinical record lacked documentation that a physician or nurse practitioner reviewed the PRN lorazepam order every 14 days. During an interview on 6/8/23 at 10:40 A.M., the Administrator indicated there was no documentation of the PRN lorazepam being reviewed every 14 days. During an interview on 6/8/23 at 10:46 A.M., the Regional Consultant indicated a review should have been done by the physician or nurse practitioner for the PRN lorazepam order to continue. During an interview on 6/8/23 at 4:09 P.M., the Regional Consultant indicated there was not a policy for staff to follow to put medication cards delivered from the pharmacy into the medication cart, but she would expect staff to match the manifest (delivery list) to the cards delivered and the staff that administered the medication would verify dosage before administering to residents. She indicated there was no policy for following doctor orders, but it was standard nursing practice to follow physician's orders. A current medication administration policy, dated November 2018, was provided by Regional Staff and indicated . 4. Five Rights--Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away . a. Check #1: Select the Medication-- label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose-- the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights when putting the medication away . A current psychotropic medication policy, dated October 2017, was provided by the Administrator on 6/8/23 at 11:12 A.M., and indicated . PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication 3.1-48(a)(6)

2. On 6/9/23 at 8:45 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, Osteoarthritis, urinary incontinence, and pain. The most recent MDS Assessment, dated 5/19/23, indicated Resident 15 was cognitively intact and an extensive assist of 2 staff for bed mobility and toileting and totally dependent on 2 staff for transfers. On 6/8/23 at 1:44 P.M., Resident 15 was observed for incontinence care. CNA (Certified Nurse Aide) 3 and CNA 6 put on gloves upon entering the room. CNA 3 browsed the resident's closet touching the clothes. Wearing the same gloves, CNA 6 left the room to get the sit to stand lift and brought it back into the room, moved the resident's bedside table, pulled the privacy curtain, went back out of room to get the resident's wheelchair, moved the sit to stand lift, pulled privacy curtain, moved the wheelchair, grabbed clothes from CNA 3, moved bedside table that was blocking Resident 15's roommate's walker that she needed to use to go to the restroom, moved the roommate's walker to her, opened and closed the restroom door. Then CNA 3 and CNA 6 pulled Resident 15's blankets down, grabbed the bed pad and lifted it to move the resident up in bed. CNA 6 lowered the bed, put on Resident 15's pants, put shoes on and touched shoe bottoms, grabbed sit to stand lift, put lift pad on Resident 15, adjusted the lift, pulled on privacy curtain, went back into the restroom to get wipes while CNA 3 held the resident up in a sitting position from the back. CNA 6 lifted the resident to the standing position with the lift while she held wipes in her left hand, undid the incontinence brief, preformed incontinence care in the front then in back, removed soiled brief and held brief in left hand while snapping the new incontinence brief on and pulling up pants with right hand. CNA 6 went to the restroom to dispose of soiled brief, changed gloves without sanitizing or washing hands, lowered resident into wheelchair, unhooked straps of lift pad, removed pad from behind resident, took off the resident's shirt, put on new shirt, removed gloves, and washed her hands. CNA 3 removed gloves and washed her hands. On 6/9/23 at 8:45 A.M., the administrator provided a current Guideline for Handwashing/ Hand Hygiene policy, revised 2/9/17. The policy indicated .3. Health Care Workers (HCW) shall use hand hygiene at times such as: .d. After removing gloves . During an interview on 6/9/23 at 10:40 A.M., the DON (Director of Nursing) indicated hand hygiene should be done before and after going into and out of room. She indicated if staff went out of room with gloves on, and come back into the room to do incontinence care, she would expect staff to take off those gloves, sanitize hands, and put on new gloves. At this time, the Regional Consultant indicated there was not a policy to specifically change gloves after touching multiple surfaces before doing incontinence care on a resident. 3.1-18(l) 3.1-18(b) Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 observations of resident care. Handwashing was not completed between dirty to clean tasks. Gloves were not changed between dirty and clean tasks. (Resident G, Resident 15) Findings include: 1. During an observation on 6/8/23 at 8:23 A.M., CNA (certified nurse aide) 6 toileted Resident G in the restroom. CNA 6 donned gloves, used the remote to raise the recliner, opened the door, removed gloves, donned a new pair of gloves and wiped the resident after she used the restroom. CNA 6 failed to sanitize or wash hands between changing gloves. During an interview on 6/9/23 at 8:37 A.M., the IP (infection preventionist) indicated between dirty to clean tasks that hands should be washed for 20 seconds or hand sanitizer should be used.

Based on interview and record review, the facility failed to provide required notices to residents who were being discharged from Medicare services for 1 of 3 residents reviewed. The SNF-ABN form (Skilled Nursing Facility-Advanced Beneficiary Notification) was not provided to a resident. (Resident 11) Finding includes: On 10/27/21 at 1:40 A.M., Resident 11's discharge from Medicare services was reviewed. Resident 11 was discharged from Medicare services on 9/2/21 and remained in the facility. The SNF Beneficiary Protection Notification indicated an SNF-ABN form was not provided to the resident. During an interview on 10/8/19 at 10:36 A.M., the Business Office manager indicated that an SNF- ABN letter should have been provided to the resident. A dated 6/22/21 and titled, NOMNC Completion ., was provided by the Administrator on 6/29/21 at 11:50 A.M. and read as follows: .For residents receiving therapy under Medicare part A social services will issue a NOMNC prior to therapy discharge. If the resident has Medicare days remaining and is staying at the campus after therapy discharge social services will issue the SNF-ABN form in addition to the NOMNC. 3.1-4(f)(2)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled with an open date, resident's physician's name, dosage, prescription number, and pharmacy information for 2 of 4 medication carts and 1 of 1 medication storage rooms reviewed. (Resident 26, Resident 33) Findings include: On 10/29/21 at 10:20 A.M., the 2 medication carts on the 100 Hall and 1 medication storage room were reviewed 1. During an observation on 10/29/21 at 10 55 A.M., three bottles of Z Stack 60 (containing 60 tablets in each bottle) were observed on medication cart 2 on 100 Hall. The resident's last name was hand written on a piece of beige tape which was attached to the lid of the Z stack 60 bottle. No other information identifying the physician's or prescriber's name, the dosage, the prescription number, or the pharmacy was documented on the bottles. 2. During an observation on 10/29/21 at 10 55 A.M., one bottle of B-12 vitamins and one bottle of D-3 vitamins were observed on medication cart 1 on 100 Hall. No other information identifying the resident, the physician's or prescriber's name, the dosage, the prescription number, or the pharmacy was documented on the vitamin bottles. During an interview on 10/29/21 at 11:00 A.M., LPN 66 indicated all medications stored in the medication carts were supposed to have the prescribing information and the resident's names on the bottles. 3. During an observation of the medication room located behind the nurses station 10/29/21 at 11:20 A.M., two bottles of wine (one bottle of which was opened) were observed stored in the medication storage refrigerator. The ADON indicated he was unsure whether wine could be stored with the medications. During an interview on 10/29/21 at 11:30 A.M., the Regional Consultant indicated the policy for the facility was that bottles of wine which belonged to a resident was supposed to be labeled with information that included the residents name, room number, dosage, time to be administered, and the physician's name. A policy dated 5/31/21 and titled, Alcoholic Beverages, which was provided by the Regional Consultant and reviewed on 10/29/21 at 11:45 A.M., read as follows: .7. The nurse receiving the alcoholic beverage shall label the bottle with the following information: a. The resident's name and room number. b. The exact dosage to be administered. c. The times(s) each dose is administered. d. The name of the physician. 8. Alcoholic beverages will be treated as medication and stored in the medication room . A policy dated 1/17 and titled, Medication Ordering and Receiving From Pharmacy, which was provided by the Regional Consultant and reviewed on 10/29/21 at 11:45 A.M., read as follows: .A. Labels are errantly affixed to the outside of the prescription container .B. Each prescription medication label includes .Resident's name .Specific directions for use .Medication name .Strength of medication .Prescriber's name .Date Dispensed .Quaintly of medication .Beyond use date . 3.1-25(l)(1) 3.1-25(l)(2)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety in 2 of 2 observations of the kitchen and main dining room. Items were observed in the refrigerator not dated and others past the use by date, debris was built up inside the juice and coffee machines in the dining room, the dry storage room had dented cans, and staff failed to wash hands according to recommended technique and duration. (Kitchen, Dining Room) Findings include: 1. On 10/25/21 at 9:20 A.M., the following was observed in the kitchen and main dining room: In the dry storage room, two 106 ounce spaghetti cans were observed on the can rack, both containing a large dent. A bag of Swiss cheese was in the refrigerator with a use by date of 10/24/21. A bag of cucumbers was in the refrigerator with a use by date of 10/23/21. A bowl of strawberries was in the refrigerator without a label, non-dated. A bowl of red jello was in the refrigerator without a label, non-dated. The inside of the juice machine in the main dining room had a build up brown ring of debris around the spouts, and debris was located underneath the boxes of juice. The inside of the coffee machine in the main dining room had a white substance on the back wall. 2. On 10/28/21 at 11:00 A.M., the following was observed in the kitchen and main dining room during lunch preparation: In the dry storage room, two 106 ounce spaghetti cans were observed on the can rack, both with a large dent. Cook 15 was observed to obtain soap, then rub hands together under running water. Cook 5 was observed to wash hands twice. The first time lathered for 4 seconds, then rinsed. The second time lathered for 5 seconds, then rinsed. After washing hands, [NAME] 5 touched their mask to remove it and placed it back, without washing hands after. Cook 7 was observed to wash hands with a 4 second lather, then rinse. Cook 21 was observed to wash hands twice. The first time lathered for 7 seconds, then rinsed. The second time lathered for 4 seconds, then rinsed. The Kitchen Manager indicated at that time that staff should not have placed the dented cans of spaghetti on the rack, and removed them. She also indicated the fridge was supposed to be assessed daily and anything past the use by date disposed of. On 10/29/21 at 9:00 A.M., a Refrigerated Storage policy, dated 5/31/16, was provided and indicated Prepared perishables . stored in a refrigerator and covered, labeled, and dated until used. The policy also indicated not to use any can that was dented. On 10/29/21 at 9:00 A.M., a Handwashing/Hand Hygiene policy, dated 3/12/20, was provided. The Regional Consultant indicated the same policy was used facility wide, including in the kitchen. The policy indicated hands should be lathered with soap for 20 seconds before rinsing. A policy on disposal of items by use by date was requested, and not provided. 3.1-21(i)(2) 3.1-21(i)(3)