**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure behaviors were care planned, monitored and evaluated for 1 of 2 residents reviewed. (Resident A)During an observation on 9/15/25 at 10:09 AM the following was observed:Resident A was resting on his bed with the head of the bed elevated. The colostomy bag on the resident's left side of the abdomen was bent at an angel more than 90 degrees and ballooning to the shape of the colostomy bag.In an interview, on 9/15/25 at 10:10 AM, Resident A indicated his colostomy bag had opened unexpectedly in the past. He indicated staff only emptied the bag every couple of days and only when he would tell the staff it needed emptied. He indicated he would take care of the bag himself and hand the bag to the nurses. Resident A indicated caring for the colostomy made him anxious. A record review for Resident A began on 9/15/25 at 11:10 AM. Diagnoses included depression, attention-deficit hyperactivity disorder (ADHD), and hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side.A review of Resident A's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated that the resident needed extensive assistance to use the toilet and was diagnosed with hemiplegia or hemiparesis (the inability to use one side of the body). A review of Resident A's current care plan, dated 8/11/25, titled Colostomy Status Post Bowel Surgery indicated the resident preformed their own colostomy care. Interventions included to change the colostomy bag after each bowel episode or when full, educate Resident A on proper care of the ostomy and how to change the bag, Education Resident A when to alert the nurse to change the bag. A review of Resident A's current care plan, dated 8/11/25, titled Colostomy Phalange indicated Resident A would unseal his colostomy at various times throughout the day. Interventions included a reminder to resident A, not unseal the colostomy (phalange) daily. Observe if resident had unsealed the colostomy, assist the resident with the colostomy seal as needed.A review of Resident A's current care plan, dated 8/11/25, titled depression indicated Resident A had depression after getting a colostomy. Interventions included administration of medications as ordered, psychiatry consultation, and observation of signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, negative statements, repetitive anxious or health-related complaints, or tearfulness. There was no intervention related to Resident A's colostomy. A review of Resident A's current care plan, dated 8/11/25, titled Psychosocial well-being related to anxiety, depression, inability to meet role expectations, lack of acceptance to current condition, recent social isolation. One goal indicated the resident would identify coping mechanisms including keep busy, work with hands, and feeling useful. Interventions included allowing time for the resident to answer questions and verbalize feelings, perceptions, and fears, assist/encourage/support the resident to set realistic goals to promote emotional and physical safety. Initiate referrals as needed or increase social relationships. Observe for and document resident's feelings relative to isolation, unhappiness, anger, and loss. Provide opportunities for the resident and family to participate in care, assist, encourage, and support about identified problems that cannot be controlled. There were no interventions related Resident A's colostomy behaviors. A review of Resident A's current care plan, dated 8/11/25, failed to address Resident A's ADHD diagnosis and behaviors. There were no care plans to address Resident A's colostomy behaviors.A review of physician orders, dated 3/10/25 at 18:00, indicated colostomy care was to be completed by staff every shift and emptied as needed.A review of the Task Administration Record for August 2025 indicated the colostomy bag was emptied as needed on 8/3/25 at 11:05 PM. Routine colostomy care was documented as completed.A review of the Task Administration Record for September 2025 indicated routine colostomy care was not documented as completed on 9/2/25 during day shift.A review of the Bowel Elimination Task dated 9/2/25 to 9/15/25 indicated stool output was recorded only one time on 9/4/25 and 9/12/25.A review of psychiatry progress notes, dated 9/11/25, indicated the physician was not aware of Resident A's most recent depression scale score of 20, indicating severe depression, completed on 8/21/25. There was no mention in the notes of Resident A taking off his colostomy bag, or taking off the bag and flange. A review of progress notes from 8/19/25 to 8/25/25 indicated staff had not notified the physician of the depression scale score result of severe depression. There were no notes related to Resident A taking off his colostomy bag, with or without the flange intact and no notes to indicate Resident A had been educated regarding colostomy care or addressing colostomy behavior. A review of progress notes from 8/19/25 to 8/25/25 indicated staff had not documented when the resident was reminded not to unseal the colostomy (phalange) daily.In an interview, on 9/15/25 at 1:12 PM, LPN 2 indicated colostomy care included cleaning the skin around the colostomy area and emptying the bag of air and or stool. She indicated Resident A would spontaneously take the colostomy bag off including the flange and not tell the staff. In an interview, on 9/15/25 at 1:27 PM, the Assistant Director of Nursing indicated Resident A had taken the colostomy off in the past. The resident wanted to be independent at times and had a plan to move to assisted living. Resident A had the ability to empty the colostomy independently, but Resident A had not been consistent in completing his own care. Resident A had been offered support groups but the resident had refused.In an interview, on 9/15/25 at 1:57 PM, the Administrator indicated Resident A had unsealed his colostomy emptying stool on the floor around the front door of the facility.In an observation, on 9/15/25 at 1:58 PM, the front entrance of the facility was cleaned and rinsed of a large amount of stool. In an interview, on 9/15/25 at 3:33 PM, RN 2 indicated Resident A had not changed or burped their colostomy bag recently. Resident A had needed the colostomy bag emptied 2 or 3 times during most shifts. Regular education had been provided to Resident A about telling staff when the colostomy bag was full. Emptied colostomy tasks should have been documented on the TAR or in the Elimination Task flowsheet. Resident A would would carry the full bag detached from the flange to the nurse's station. In an interview, on 9/15/25 at 4:40 PM, the Social Services Director indicated Resident A had turned the call light on for staff and had been mentally and physically capable of leaving the facility. All facility physicians (providers) had access to all forms and assessments completed by staff. The providers talked with the Social Services Director weekly. On 7/2/25 the physician was notified of Resident A had been drinking alcohol and drove the wheelchair recklessly on 7/1/25, as reported by staff who witnessed the event. The SSD did not indicate the providers had been made aware of Resident A's behavior with his colostomy bag. The policy regarding behavior identification and tracking was requested. There was no further information or policies presented by time of exit. This citation is related to intakes 2614478 and 2567160. 3.1-43(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were provided proper notice prior to an involuntary transfer or discharge for 1 of 4 residents reviewed for hospitalizations (Resident 49). Finding includes: A record review was completed for Resident 49 on 5/1/2025 at 11:32 A.M. Diagnoses included, but were not limited to: anxiety and depression. An admission Minimum Data Set (MDS) assessment, dated 3/13/2025, indicated Resident 49's cognition was mildly impaired and the resident was a current tobacco user. A review of Resident 49's census indicated she was discharged from the facility on 3/3/2025 and re-admitted to the facility on [DATE]. A Discharge assessment, dated 3/3/2025 indicated the resident was being discharged to (a local hotel name). A Physician's Order, dated 3/3/25 indicated to discharge the resident home with medications and discharge instructions. A review of a Nursing Progress note, dated 3/3/2025 at 11:25 A.M., indicated Resident 49 was informed due to her being a danger to others by smoking in the facility. The note indicated she was being immediately discharged . The resident was discharged to the (local hotel name). The note also indicated the facility had paid for the resident to stay at (local hotel name) for three nights. A Nursing Progress note, dated 3/3/2025 at 11:47 A.M. indicated Resident 49 had been notified of her pending discharge and was to be transported out of the facility on 3/3/2025 at 1:30 P.M. Resident 49's record lacked documentation that she received a 30 days notice prior to her involuntary discharge. A Nursing Progress note, dated 3/6/2025 at 4:49 P.M. indicated the Social Services Director went to (local hotel name) to make contact with Resident 49. SSD was informed the resident had not been compliant with the hotel's smoking policy and was being kicked out. The note indicated Resident 49 was returning to the facility for a short term stay due to being removed from the hotel. A Nursing Progress note, dated 3/6/2025 at 5:39 P.M. indicated Resident 49 was re-admitted to the facility. During an interview, on 5/5/2025 at 1:16 P.M., the Quality Assurance Administrator (QAA) indicated Resident 49 had been given 30 days notice. However, a subsequent interview with the QAA, on 5/5/2025 at 3:05 P.M. indicated she was unable to find documentation that Resident 49 had been given 30 days notice of an involunary discharge. On 5/2/2025 at 9:25 A.M., the QAA provided a policy titled, Transfer or Discharge Notices, no date and indicated it was the policy currently being used by the facility. The policy indicated, 1. Except as specified below, the resident and his or her representative are provided with a written notice of an impending transfer or discharge at least 30 days prior to the transfer or discharge

Based on observation, interview and record review, the facility failed to provide showers for 1 of 7 residents reviewed for ADL (Activities of Daily Living) care. (Resident 1) Finding includes: During an observation, on 4/30/2025 at 9:07 A.M., Resident 1 was noted to have a large amount of facial hair on her chin and her fingernails had a brown substance underneath them The record for Resident 1 was reviewed on 5/01/2025 at 1:25 P.M. Diagnosed included, but were not limited to quadriplegia, epilepsy, blindness, arthritis and non-Alzheimer's dementia. A Quarterly MDS (Minimum Data Set) assessment, dated 4/22/2025, indicated the resident had severe cognitive impairment and required extensive assist of 2 staff for bed mobility transfers, toilet use and showering. A current Care Plan, initiated on 12/7/2021, indicated Resident 1 required assistance with ADL's due to her cognitive deficits, arthritis, blindness, and quadriplegia. Interventions included, but were not limited to: I prefer to complete bathing with staff assist and prefer my showers Monday and Thursday evening. Resident 1's shower schedule indicated she was to receive showers on Mondays and Thursdays on the day shift. The shower documentation, dated March 2025, indicated the resident had received a shower on the following dates: 3/18, 3/21 and 3/28, and bed baths on 3/11, 3/14, 3/18, 3/21 and 3/25/2025. The shower documentation, dated April 2025, indicated the resident had received a shower on 4/21, and bed baths on 4/7 and 4/17/2025. There was no documentation to indicate Resident 1 had received showers on 4/3, 4/10, 4/14, 4/21, 4/24 or 4/28/2025. There was no documentation of any shower refusals in the Nursing Progress Notes from March 1st to April 30th for Resident 1. During an interview, on 5/5/2025 at 3:27 P.M., the Director of Nursing indicated she could not provide any further shower documentation for Resident 1. On 5/5/2025 at 3:15 P.M., the Quality Assurance Administrator provided the policy titled, Activities of Daily Living (ADL) Supporting, dated April 2025, and indicated the policy was the one currently used by the facility. The policy indicated . Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . 5. Appropriate care and services are provided for residents who are unable to carry out ADL's independently, with consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) 3.1-38(b)(2)

Based on record review and interview, the facility failed to notify the physician of abnormal blood sugars for 1 of 1 resident reviewed for insulin usage. (Resident 3) Finding includes: During an interview, on 4/29/2025 at 11:25 A.M., Resident 3 indicated she had recently had an abnormally high blood sugar reading of over 300 mg/dL (milligram per deciliter). A record review was completed for Resident 3 on 5/1/2025 at 9:47 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, diabetes with polyneuropathy and acute kidney failure. A Quarterly Minimum Data Set (MDS) assessment, dated 12/23/2024, indicated Resident 3 was cognitively intact and received insulin injections. A current Care Plan, initiated on 4/9/2021 and revised on 10/6/2024, indicated Resident 3 had diabetes mellitus with a goal of Resident 3 would not exhibit signs of hypo/hyperglycemia. Interventions included, but were not limited to: administer medications as ordered by the physician and blood sugar monitoring as ordered by the physician. A Physician's Order, dated 11/13/2024, indicated Resident 3 was to receive Lantus insulin solution inject 10 units subcutaneously daily at bedtime. A Physician's Order, dated 12/21/2024, indicated Resident 3 was to have blood sugar monitoring at bedtime and to notify the physician for a blood sugar reading below 70 mg/dL or above 400 mg/dL. Blood sugar readings, outside the physician ordered parameters, were documented as follows: -12/25/2024 at 9:57 A.M. 60 mg/dL -12/30/2024 at 9:45 A.M. 59 mg/dL There was no documentation the physician had been notified of the blood sugar readings below 70 mg/dL. During an interview, on 5/2/2025 at 9:15 A.M., LPN 8 indicated Resident 3 must have requested a blood sugar level to have been obtained. She indicated the physician should have been notified of the blood sugars below 70 mg/dL. During an interview, on 5/5/2025 at 11:15 A.M., the Assistant Director of Nursing indicated residents have written orders for when the physician should be notified for abnormal blood sugar readings. He indicated that a blood sugar of 59 mg/dL or 60 mg/dL should have had physician notification documented. A policy was provided, on 5/5/2025 at 2:46 P.M., by the Quality Assurance Administrator. The policy titled, Acute Condition Changes, indicated, .Assessment and Recognition .8. The nursing staff will contact the physician based on the urgency of the situation .9. The attending physician will respond in a timely manner to notification of problems or changes in condition and status .Monitoring and Follow-Up .1. The staff will monitor and document the resident's/patient's progress and responses to treatment, and the physician will adjust treatment accordingly 3.1-37(a)

Based on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manor for 2 of 3 residents reviewed for respiratory care. (Resident 1 & 50) Findings include: 1. During an observation, on 4/30/2025 at 9:11 A.M., Resident 1's oxygen concentrator humidification bottle was dated 4/2/2025 and was not hooked up to the concentrator. The oxygen storage bag was dated 4/28/2025 and the nasal cannula tubing was not dated. The record for Resident 1 was reviewed on 5/1/2025 at 1:25 P.M. Diagnoses included, but were not limited to quadriplegia, blindness, arthritis, and non-Alzheimer's dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 4/22/2025, indicated the resident had severe cognitive impairment and required the use of oxygen. Resident 1's current physician orders included: - Oxygen at 2 Liters per minute per Nasal Cannula on continuous to keep oxygen saturation above 90%. - Change the oxygen tubing, and humidification bottle; clean oxygen filter, and inspect easy foam wraps (replace if soiled or missing), on the night shift every Sunday. The oxygen tubing to be changed and dated weekly on night shift and as needed. A current Care Plan, initiated on 7/29/2022, indicated the resident had altered respiratory status: Difficulty breathing related to morbidly obese and SOB (shortness of breath) while flat. The residnet was at risk for alterations in oxygen levels and sometimes removed the oxygen tubing and had to be reminded to leave it in place. During an observation, on 5/1/2025 at 1:29 P.M., Resident 1's oxygen concentrator humidification bottle was still dated 4/2/2025 and was not hooked up to the concentrator. The oxygen nasal cannula tubing was still not dated. During an observation, on 5/1/2025 at 2:30 P.M., Resident 1's oxygen tubing was not hooked up to the humidification bottle, still dated 4/2/2025 and the oxygen tubing was still not dated. During an observation, on 5/2/2025 at 9:55 A.M., with LPN 2, Resident 1's oxygen tubing was not dated, the date on the humidification water bottle was 4/2/2025 and not attached to the concentrator to provide humidified oxygen. During an interview, on 5/2/2025 at 9:56 A.M., LPN 2 indicated the oxygen tubing should have been dated, the humidification water bottle should have been changed, dated, and should have been placed on the concentrator to provide humidified air. 2. During an observation on 4/29/2025 at 9:36 A.M., Resident 50 was observed to have a portable oxygen tank, an oxygen concentrator, a nebulizer machine and a BiPap (bilevel positive airway pressure) machine on the bedside table. The portable oxygen tank was sitting on the floor with the undated nasal cannula on the floor, the oxygen concentrator was at the bedside with an undated nasal cannula tube lying in the upper drawer of the bedside table. The visibly soiled nebulizer mask was lying in the upper drawer of the bedside table and the BiPap mask was lying upright against the wall. There were no respiratory bags for storage of the nasal cannulas or masks noted in the room. During an observation, on 4/29/2025 at 1:54 P.M., the portable oxygen tank with the nasal cannula was observed on the floor, the oxygen concentrator and nasal cannula was observed draped over the top drawer of the bedside table, the visibly soiled nebulizer mask was observed lying in the top drawer of the bedside table and the BiPap mask was observed on the bedside table against the wall. During an observation, on 4/30/2025 at 9:34 A.M. and 5/1/2025 at 1:28 P.M., the portable oxygen tank was observed sitting on the floor. The nasal cannula tubing connected to the portable oxygen tank was also lying on the floor. The oxygen tubing connected to the oxygen concentrator was observed lying in the upper drawer of the bedside table. During an observation, on 5/5/2025 at 9:10 A.M., the nebulizer mask was observed lying in the top drawer of bedside table and the oxygen concentrator nasal cannula tubing was observed draped around the bedside table drawer's hardware. A record review for Resident 50 was completed on 5/1/2025 at 9:13 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), chronic bronchitis and anxiety. An Annual Minimum Data Set (MDS) assessment, dated 3/19/2025, indicated Resident 30 was cognitively intact and received oxygen therapy. Physician Orders included the following orders on 3/10/2025: -Ipratropium-Albuterol Solution 0.5-2.5 milligrams per 3 milliliters one vial inhalation via nebulizer every 6 hours as needed shortness of breath and wheezing related to COPD. -BiPap with two liters of oxygen bled in when napping during the day and sleeping at night related to acute respiratory failure with hypoxia and COPD. -Change oxygen tubing every night shift on Wednesday. -Oxygen at two liters per nasal cannula continuously to maintain oxygen saturations above 90 percent related to acute respiratory failure with hypoxia and COPD. A current Care Plan, initiated 9/1/2023 and revised on 12/19/2024, indicated Resident 30 had an altered respiratory status with difficulty breathing related to bronchitis, COPD and asthma. Interventions included, but were not limited to: -Administer medication/puffers as ordered. -BiPap as ordered. -Nebulizer treatments as directed. -Oxygen as ordered. During an interview, on 5/5/2025 at 11:37 A.M., Qualified Medication Assistant (QMA) 9 indicated respiratory equipment (masks, nasal cannulas) should be stored on a clean surface and stored in a respiratory bag when the equipment was not in use A policy was provided, on 5/5/2025 at 2:46 P.M., by the Quality Assurance Administrator. The policy titled, Respiratory Therapy-Prevention of Infection, indicated, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Infection Control Considerations Related to Oxygen Administration .8. Keep the oxygen cannulae and tubing used PRN [as needed} in a plastic bag when not in use .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in a plastic bag, marked with date and resident's name, between uses 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to attempt a gradual dose reduction of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 20) Finding includes: During an observation, on 4/30/2025 at 9:34 A.M., 5/1/2025 at 2:46 P.M. and 5/5/2025 at 10:24 A.M., Resident 20 was observed seated in the doorway of his room looking into the hallway A record review for Resident 20 was completed on 5/1/2025 at 10:40 A.M. Diagnoses included, but were not limited to: post-traumatic stress disorder (PTSD), major depressive disorder, alcohol dependence with alcohol-induced dementia and other sexual disfunction. A Quarterly Minimum Data Set (MDS) assessment, dated 4/14/2025, indicated Resident 20 had moderate cognitive impairment and received an antipsychotic and antidepressant medications. A current Care Plan, initiated on 1/25/2024 and revised on 10/6/2024, indicated Resident 20 was at risk for yelling and cursing at staff due to a history of these behaviors and dementia. Interventions included, but were not limited to: -Administer medications as needed. -Offer resident snacks and drinks especially Pepsi, chips, and cookies. -Resident to be seen by in-house psych services. -Staff will monitor the resident's behaviors A current Care Plan, initiated on 10/21/2021 and revised on 10/6/2024, indicated Resident 20 had a history of sexually inappropriate comments and exposing himself to staff. Interventions included, but were not limited to: -Continue in-house psychological services. -Educate resident. -Offer resident snacks particularly Pepsi, pretzels, chips, and cookies. -Redirect resident by changing topic to golf, sports, current events, and food. -Redirect resident by encouraging him to participate in his favorite activities including cross word puzzles, bird watching, and watching television especially westerns and action movies. -The interdisciplinary team to review behavior management program quarterly and as needed. A previous Physician's Order, dated 4/19/2024-7/26/2024, indicated an order for Resident 20 to receive risperidone one milligram three times daily for major depressive disorder. A Physician's Order, dated 7/27/2024-2/24/2025, indicated risperidone 0.5 milligrams three times daily for major depressive disorder. A previous Physician's Order, dated 2/24/2025-3/10/2025, indicated an order for Resident 20 to receive risperidone 0.5 milligrams three times daily for alcohol induced-persisting dementia. A current Physician's Order, dated 3/10/2025, indicated Resident 20 was to receive risperidone 0.5 milligrams three times daily for alcohol induced-persisting dementia. A review of Resident 20's behaviors indicated the following behaviors were documented from December 2024 through May 5, 2025: -January 7, 2025 sexual behaviors six times with redirection and changed environment interventions. No other behaviors had been documented during this time period. A Behavioral Health Encounter Note, dated 1/17/2025 at 12:00 A.M., indicated staff were to have montiored for any clinically significant changes in mood or behaviors. A Behavioral Health Encounter Note, dated 1/27/2025 at 12:00 A.M., indicated staff had observed minimal negative behaviors affecting care or safety. Resident 20 had recently changed rooms due to friction with his previous roommate. Resident 20 showed subdued, constricted affect, slowed processing speed and was cooperative. A Behavioral Health Encounter Note, dated 1/30/2025 at 12:00 A.M., indicated Resident 20 was discussed in the behavior/gradual dose reduction meeting with the facility's interdisciplinary team. Staff had reported that Resident 20 had been making inappropriate sexual comments toward staff and had a recent improvement regarding exhibited behaviors since being moved from the locked memory care unit. The note indicated a clinical contraindication would be noted due to ongoing concerns and condition the resident's condition was not well controlled or stable. A Behavioral Health Encounter Note, dated 2/24/2025 at 12:00 A.M., indicated Resident 20 was subdued to somnolent, difficult to rouse and minimally cooperative. Resident 20 showed no signs of agitation or distress. Staff reported Resident 20 continued to be stable overall and had been able to be managed with his current regimen and interventions. Behavioral services were to continue with another provider. A Behavioral Health Encounter Note, dated 2/27/2025 at 12:00 A.M., indicated Resident 20 was discussed in the behavior/gradual dose reduction meeting with the facility's interdisciplinary team. The note indicated there were no pharmacy recommendations to review on this date. Resident 20 was continued on risperidone 0.5 milligrams three times a day with the last gradual dose reduction attempted, on 7/25/2024. An Initial Psychiatry Consult Note, on 3/12/2025 at 11:59 P.M., indicated Resident 20's mood was reported as okay during the visit. The note indicated there would not be any changes to the current medication regimen. Resident 20 would continue to be monitored for mood and adjustment to treatment will be made as necessary. A Pharmacy Recommendation, dated 3/31/2025, indicated a dose reduction for Resident 20's psychotropic medications was due. A reply was handwritten on the bottom of hte recommendation form which indicated no changes at this time. There was no indications as to why a gradual dose reduction was not being attempted. A Behavioral Health Encounter Note, dated 4/15/2025 at 11:59 P.M., indicated Resident 20 reported satisfaction with his current life situation. The note indicated Resident 20 was to be monitored for mood issues and adjustments to the treatment was to be made if necessary. There was no specific contraindication documented regarding the reason for not attempting to reduce the resident's antipsychotic medication. During an interview, on 5/5/2025 at 2:04 P.M., the Social Service Assistant indicated every three months, a gradual dose reduction of psychotropic medications was to be attempted. She indicated the psychiatrist had not wanted to reduce Resident 20's medications since his symptoms were stable. She indicated she did not know if Resident 20 was on the lowest amount of the risperidone to achieve the same symptom control. There was no further documentation provided regarding a reason or contraindication for not attempting to reduce the resident's antipsychotic medication. A policy was provided, on 5/5/2025 at 2:46 P.M., by the Quality Assurance Administrator. The policy titled, Antipsychotic Medication Use, indicated, .1. Residents will only receive antipsychotic medication when necessary to treat specific conditions for which they are indicated and effective. Continues [sic Continued] use of the medication will be reviewed at least quarterly. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks .5. The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications .13. Residents receiving antipsychotic medications will be reviewed at least quarterly by the Interdisciplinary team. Gradual dose reductions [GDR} will occur as required, unless clinically contraindicated. A GDR will be attempted within the 1st year of admittance to the facility [or initiation of the antipsychotic] in 2 separate quarters with at least 1 month in between attempts. [NAME] the 1st year, A GDR will be attempted annually unless clinically contraindicated 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure medication storage areas were clean and free from loose medications and failed to ensure medications were labeled and dated when opened, during medication storage review in 2 of 2 medication carts reviewed. (medication cart 1 on 100/200 hall and Memory Care 400 medication cart). Findings include: 1. During a medication storage observation, on 5/2/2025 at 10:30 A.M., on the medication cart 1 with LPN 2 the following was observed: - An unopened tube of glucose for a discharged resident. - An opened and undated bottle of Milk of Magnesia. - An opened bottle of ant-acid tablets with no resident label on the container. - Fourteen loose pills in the medication cart. - An opened package of Albuterol inhalation vials with no resident identifier. The over flow medication cart had an unopened box of Omeprazole tablets with no resident identifiers on the box. During an interview, on 5/5/2025 at 10:48 A.M., LPN 2 indicated the medications should have been labeled and dated when opened, and there should be labels on the medication bottles. LPN 2 indicated there should have not been loose pills in the medication cart. 2. During a medication storage observation, on 5/5/2025 at 11:02 A.M., on the Memory Care Unit with LPN 7, the following was observed: - Four loose pills in the 2nd and 3rd drawers. During an interview, on 5/5/2025 at 11:10 A.M., LPN 7 indicated the loose pills should have not be in the cart. On 5/5/2025 at 1:58 P.M., the Quality Assurance Adminiww3ws22qstrator provided the policy titled, Medication Labeling and Storage, undated, and indicated the policy was the one currently used by the facility. The policy indicated . Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Medication Labeling 1. Labeling of medications and biological's dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items 3.1-25(j) 3.1-25(r)

Based on observation, interview and record review, the facility failed to ensure a resident's call light was answered timely and care was provided to maintain her dignity for 1 of 4 residents who were reviewed for dignity. (Resident H) Finding includes: A record review was completed on 2/27/2025 at 10:40 A.M. for Resident H. Diagnoses included but were not limited to cerebral palsy, chronic obstructive pyelonephritis and morbid severe obesity. A Quarterly Minimum Data Set (MDS) assessment, dated 1/14/2025, indicated Resident H's cognitively intact, required substantial/maximal assistance for bed mobility and toileting, was dependent for transfers with a mechanical lift, and was always incontinent of her bowel and bladder. A current Care Plan, revised on 7/12/2019, indicated Resident H had an activity of daily living (ADL) self performance deficit and required extensive assistance of two staff members for personal hygiene, bed mobility and transfers. A grievance document, filed on 1/29/2024 by Resident H indicated she had filed a grievance due to having to wait an extended period of time before receiving care. The form indicated it had been confirmed that the resident had to wait 4 hours to be changed and had called the nurses station on her cell phone repeatedly attempting to get help. The Corrective action documented on the form indicated more staff had been hired and staff had been re- educated. Review of a second grievance document, filed by Resident H on 2/19/2025, indicated she had filed a grievance due to not receiving care within 20 minutes of being told by the nurse that Resident H needed assistance. The investigation on the grievance indicated the concern was not verified. During an interview on 2/27/2025 at 11:43 A.M., Resident H recalled the event that had occurred on 2/19/2025 at about 1:00 A.M. She did not have her call light in reach and so she had called the facility on her cell phone to ask someone to retrieve her call light and to inform staff she had had a bowel movement and needed care. The resident indicated she called at least one more time requesting help but no one came until around 3:00 A.M., two hours later, to provide care. She indicated her bottom was sore and irritated after she had laid in bowel movement and cream was applied to her bottom. The resident indicated she felt embarrassed and gross to have to lay in that mess for that long. She indicated bowel movement was all over her legs and her bed sheet. She indicated she had filed a grievance with the social worker later that same day but had not received any resolution or response regarding the grievance. The resident indicated she has had to remember to make sure she has her call light in reach after care as staff often forgot to ensure it was within her reach. Resident H indicated there had been many times she had waited longer than 30 minutes for help. Resident H indicated on 2/27/2025 she had turned on her call light at 10:25 A.M. was told the aides were busy and would be in soon. She turned it on again at 10:55 A.M., and the nurse came in and told her the aides were still with another resident. The resident indicated she waited more than 45 minutes before she received assistance to get out of bed. During an interview on 2/28/2025 at 7:31 A.M., the Director of Quality Assurance indicated according to the grievance filed by the resident on 1/29/2025, it was confirmed that Resident H had waited 4 hours for care. The Director of Quality Assurance indicated the facility was short staffed that day but since then the facility had hired more CNAs. During an interview on 2/28/2025 at 8:42 A.M., LPN 6 indicated she was the charge nurse on 2/19/2025 when Resident H had called into the facility asking for her call light. The LPN indicated she gave the resident her call light. About 15 minutes later, the resident called on the phone again to inform the LPN she had had a very large bowel movement and would need a complete bed change. The LPN informed the CNAs but she could not be sure how long the resident waited as she was too busy with her own tasks to provide care to Resident H or ensure the aides provided care to Resident H in a timely fashion. On 2/28/2025 at 9:05 A.M. a current policy titled, Activities of Daily Living (ADLs), Supporting dated March 2018, was provided by the Director of Quality Assurance. The policy indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate assistance with: a. hygiene This citation relates to complaint IN00453989. 3.1-3(a)(t)

Based on observation, interview and record review, the facility staff failed to follow infection control procedures for a resident on Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for infection control. (Resident M) Finding includes: During an observation on 2/28/2025 at 5:20 A.M., CNA 7 and QMA 8 provided peri-care for Resident M, who had an indwelling urinary catheter. Both the CNA and the QMA entered the room and donned gloves but did not don gowns. There was a sign on the wall next to the door in the hallway for Resident M's room that indicated the resident was on Enhanced Barrier Precautions. During an interview on 2/28/2025 at 5:22 A.M., QMA 8 indicated staff never wore gowns for Resident M and she did not know the resident was on EBP even though he had a urinary catheter and a sign was present in the hall. CNA 7 also indicated, at the same time, she did not know the resident was on EBP isolation. A record review was completed on 2/28/2025 at 5:54 A.M. for Resident M. Diagnoses included, but were not limited to, hemiparesis and hemiplegia to right side, hydronephrosis with ureteral stricture, chronic obstructive uropathy and vascular dementia. An Annual Minimum Data Set (MDS) assessment, dated 2/5/2025, indicated Resident M's cognition was severely impaired, he was dependent for toileting, had an indwelling urinary catheter and needed substantial/maximal assist with bed mobility. Physician Orders included, but were not limited to: -12/3/2024 Enhanced Barrier Precautions - gown and gloves must be worn for the following care: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care or any skin opening requiring a dressing. A current Care Plan, initiated on 7/10/2024, indicated the resident was on EBP for an indwelling urinary catheter and staff should wear gown and gloves for personal hygiene, changing briefs or providing care for a urinary catheter. During an interview on 2/28/2025 at 6:05 A.M., the Director of Quality Assurance indicated staff should have known the resident was on EBP and should have been wearing gowns. On 2/28/2025 at 7:00 A.M., the Director of Quality Assurance provided evidence CNA 7 had received education on EBP on 2/11/2025 and QMA 8 had attended an inservice that included education on EBP on 12/19/2024. On 2/28/2025 at 9:05 A.M., a current policy titled, Enhanced Barrier Precautions, and dated August 2022, was provided by the Director of Quality Assurance. The policy indicated, .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply 3.1-18(a)(2)

Based on record review and interview, the facility failed to ensure pertinent transfer and resident clinical information was completed for neccessary hospital transfers for 1 of 4 residents reviewed for hospitalization. (Resident B) Finding includes: A record review for Resident B was completed on 11/08/2024 at 2:32 P.M. Diagnosis included but were not limited to Cerebral Palsy, hydronephrosis, urogenital implants, and obstructive and reflux uropathy. A Nursing Progress Note, dated 6/19/24 at 11:45 A.M., indicated Resident B had returned from the hospital. There was no documentation a physician's order was obtained prior to Resident B's transfer to the hospital. In addition, there was no documentation a transfer/discharge form or bed hold policy was provided to the resident and/or their representative for this transfer. A Nursing Progress Note, dated 8/16/2024 at 12:00 A.M., indicated Resident B was transferred to a local hospital for back and abdominal pain. The chart lacked a physician's order to send Resident B to the hospital and there was no documentation that a transfer/discharge form or bed hold policy was provided by the facility to the resident and/or their representative for this transfer. A Nursing Progress Note, dated 11/4/2024 at 09:59 A.M., indicated resident B was on a LOA (Leave of Absence) for surgery. The chart lacked documentation to show a transfer/discharge form and bed hold policy was provided by the facility to the resident and/or their representative for this transfer. During an interview, on 11/13/2024 at 09:31 A.M., LPN 20 indicated they have a checklist of all the things they were to do when they sent someone to the hospital, including but not limited to: sending the transfer/discharge form, a bed hold, and documenting the transfer in a nursing progress note. LPN 20 indicated they do not write a physician's order to send someone to the hospital. During an interview, on 11/13/2024 at 10:00 A.M., LPN 19 indicated the nurses had a checklist of things to do for a transfer that two nurses were supposed to sign once completed. This checklist included the following: transfer/discharge form, bed hold policy, and documenting a nursing progress note. LPN 19 indicated the Nurse's Note should include clinical information, physician notification and a physician's order to send the resident to the hospital had been obtained. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not provide any further transfer/discharge forms for Resident B. 3.1-12(a)(6)(A)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to develop a comprehensive person-centered care plan for activities (Resident 54) and medication use (Resident 64) for 2 of 27 residents reviewed for care plans (Resident E) . Findings include: 1. During an observation, on 11/8/2024 at 9:45 A.M., Resident 54 was not observed in the morning reading activity. During an observation, on 11/8/2024, at 2:20 P.M., Resident 54 was observed walking in the activity room of the Dementia Unit and was non-responsive to questions from facility staff. Resident 54 was resistant to sit in the activity room despite staff encouragement and walked out of activity room. During an observation, on 11/12/2024, at 10:21 A.M., Resident 54 walked by the nursing station but was able to be re-directed to sit in a chair located in front of the nursing station intermittently. The record review for Resident 54 was completed on 11/12/2024 at 11:19 A.M. Diagnosis included, but were not limited to: Alzheimer's disease, dementia, anxiety, depression, unsteadiness on feet, hallucinations and hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 10/1/2024, indicated the resident had short and long-term memory issues. The MDS indicated Resident 54 had no indicators of hallucinations or delusions but had had physical behaviors towards others and other behavioral symptoms not directed towards others. Resident 54 required supervision with eating, footwear and upper body dressing, partial assistance with oral hygiene, lower body dressing, personal hygiene and showering/bathing and required substantial assistance with toileting. The MDS indicated the resident received hospice services. A Significant Change MDS, dated [DATE], indicated Resident 54 was non-responsive and gave no responses to activity preference questions. The record lacked a person-centered care plan for Resident 54's activity preferences. During an interview, on 11/14/2024, at 9:10 A.M., the Activities Director (AD) indicated the activity care plans were completed by the AD upon admission and quarterly. The AD indicated all the residents should have an activity care plan. During an interview, on 11/14/2024, at 9:12 A.M., the Social Services Director (SSD) indicated the initial care plans were completed by the admitting resident's nurse but otherwise most care plans sections were updated and created by the Minimum Data Set (MDS) nurse. 2. A record review for Resident E was completed on 11/12/2024 at 10:59 A.M. Diagnoses included, but were not limited to: encephalopathy, diabetes, anxiety, and depression. An admission Minimum Data Set (MDS) assessment, dated 9/20/2024, indicated the resident received antipsychotic and antidepressant medications. Current Physician's Orders included: Risperdal (antipsychotic medication) 2 mg (milligram) give 2 mg by mouth two times a day. Sertraline (antidepressant medication) 50 mg give 1 tablet by mouth one time a day related to depression. There were no care plans for Residenty E regarding the use of the antipsychotic and antidepressant medications. During an interview, on 11/13/2024 at 9:43 A.M., the Social Service Director indicated the resident should have care plans for the use of the antipsychotic and antidepressant medications. On 11/14/2024 at 9:10 A.M., the Corporate Assurance Administrator provided the policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of 9/2022, and indicated the policy was the one currently used by the facility. The policy indicated . 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .8. The comprehensive, person-centered care plan will . c. Describes services that would otherwise be provided for the above . h. Incorporate identified problem areas; i. Incorporate risk factors associated with identified problems . m. Identify the professional services that are responsible for each element of care 3.1-35(a)

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided with activities designed to meet their interest and their physical, mental, and psychosocial well-being for 1 of 4 residents reviewed for activities (Resident 54). Finding includes: During an observation, on 11/8/2024 at 9:45 A.M., Resident 54 was not observed in the morning reading activity. During an observation, on 11/8/2024, at 2:20 P.M., Resident 54 was observed walking in the activity room of the Dementia Unit and was non-responsive to questions from facility staff. Resident 54 was resistant to sit down in the activity room despite staff encouragement and walked out of activity room. During an observation, on 11/12/2024, at 10:21 A.M., Resident 54 walked by the nursing station but was able to be re-directed to sit down intermittently. The record review for Resident 54 was completed on 11/12/2024 at 11:19 A.M. Diagnosis included, but were not limited to: Alzheimer's disease, dementia, anxiety, depression, unsteadiness on feet, hallucinations and hypertension. A Quarterly Minimum Data Set (MDS)assessment , dated 10/1/2024, indicated the resident had short and long-term memory issues, had no indicators of hallucinations or delusions but had had physical behaviors towards others and other behavioral symptoms not directed towards others. The resident also required supervision with eating, footwear and upper body dressing, partial assistance with oral hygiene, lower body dressing, personal hygiene and showering/bathing and substantial assistance with toileting. A Significant Change MDS, dated [DATE], indicated Resident 54 was non-responsive and gave no responses to activity preference questions. There was no care plan to address Resident 54's activity preferences and needs. In addition, there was no documentation Resident 54 had attended any group or individual activities from October 30 through November 9. During an interview, on 11/14/2024, at 9:38 A.M., the AD indicated all activity attendance and participation by each resident was documented in the electronic medical record (EMR). During an interview, on 11/14/2024, at 10:55 A.M., CNA 7 indicated unit activities were scheduled from early morning through early evening when the activity assistant went home. She indicated staff tried to get all residents to attend activities, if the residents were willing. On 11/14/2024 at 1:35 P.M., the DON provided a policy titled, Activity Evaluation, dated May 2013 and indicated the policy was the one currently used by the facility. The policyt indicated .allow the resident to participate in activities of his/her choice and interest . There was no policy to indicate an comprehensive activity assessment of each resident's past and current activity interests and an individualized care plan for activities were completed in regards to providing an individualized activity program. 3.1-33(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure physician orders for extra fluids were discontinued timely. This deficient practice resulted in the resident developing bilateral lower extremity edema requiring the use of diuretic medication. (Resident M) Finding includes: A record review for Resident M was completed on 11/12/24 at 11:23 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, congestive heart failure and vascular dementia. An Annual Minimum Data Set (MDS) assessment, dated 9/11/2024, indicated Resident M had a severe cognitive deficit and received insulin and diuretic medication. Current Physician's Orders, dated 7/19/2024, indicated to encourage Resident M to consume an additional 240 milliliters of fluids every shift for 72 hours. The Medication Administration Record (MAR), from 7/19/2024 through October 2024, indicated Resident M continued to receive 240 milliliters of additional fluids three times a day. A Physician's Progress Note, dated 7/16/2024 at 1:53 P.M., indicated Resident M did not have edema. A Physician's Progress Note, dated 7/19/2024 at 11:28 A.M., indicated to encourage an additional 240 milliliters of fluids every shift for 72 hours. A Physician's Progress Note, dated 7/30/2024 at 4:38 P.M., indicated Resident M was complaining of occasional shortness of breath with moderate activity, random BNP (B-Type Natriuretic Peptide, measures the level of BNP protein in the blood to diagnoses heat failure, range for a person over [AGE] years of age should be less than 450pg/mL) laboratory blood test was performed on 7/20/2024 with a result of 3,134 pg/mL (picogram per milliliter) and Resident M was not on any diuretic. Resident M's assessment indicated he had one plus edema to bilateral lower extremities. The Physician indicated to start Lasix (diuretic) daily for 7 days, to repeat laboratory tests on 8/8/2024 and monitor Resident M's weight. A Physician's Progress Note, dated 8/13/2024 at 2:24 P.M., indicated BNP was 1,481pg/mL. The physician indicated to continue the Lasix treatment, to repeat laboratory tests on 8/28/2024 and monitor Resident M's weight. A Physician's Progress Note, dated 8/21/2024 at 8:42 P.M., indicated Resident M had a chest x-ray on 8/16/2024 that indicated mild congestive heart failure or volume overload. The Physician indicated to administer an additional dose of Lasix 20 milligrams and to start Lasix 20 milligrams daily. Heart Failure (May 15, 2024) was retrieved on 11/14/2024 from the Centers of Disease Control (CDC) website. The guidance for heart failure treatment indicated, but was not limited to, to drink less liquids During an interview, on 11/14/2024 at 9:45 A.M., the Director of Nursing indicated Resident M should not have been receiving additional fluids due to congestive heart failure, and this may have contributed to his need for diuretic therapy. A current policy was provided by the Quality Assurance Administrator, on 11/14/2024 at 1:54 P.M. The policy, titled, Heart Failure-Clinical Protocol, indicated, .The physician will help identify or clarify causes of congestive heart failure .Treatment/Management 4. The physician will prescribe treatments for residents with heart failure that are consistent with relevant guidelines and protocols; for example, those of the American Heart Association 3.1-25(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident with impaired vision received the appropriate follow-up care for 1 of 1 residents reviewed for communication (Resident 35). Finding includes: A record review for Resident 35 was completed on 11/12/2024 at 3:21 P.M. Resident was admitted on [DATE]. Diagnoses included but were not limited to: multiple sclerosis, depression, chronic obstructive pulmonary disease, dementia, anxiety, abnormal weight loss, mood disorder, muscle weakness and hypertension. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 35 had moderate cognitive impairment, had impaired vision and required corrective lens. A Physician's order, dated 11/21/2022, indicated the resident could be seen by an optometrist as needed. Resident 35's current Care Plan, reviewed on 9/12/2024, indicated the resident had impaired visual function. Interventions included but were not limited to: the resident will wear his glasses and adjust the tone of voice when communicating with the resident. During an interview, on 11/13/2024 at 11:19 A.M., the Social Services Director (SSD) indicated the optometry service was last at the facility on 9/7/2024 but Resident 35 was not seen at that time. The SSD indicated that she could not locate any notes indicating resident has seen optometry since their admission to the facility. The SSD spoke with facility scheduler on the phone and the SSD indicated the scheduler did not have any notes of the resident being seen outside of the facility by optometry. The SSD indicated the facility should make sure residents with glasses were seen by optometry every other year due to Medicare regulations. During an interview, on 11/14/2024 at 10:00 A.M., the SSD indicated she still had not determined when Resident 35 was last seen by an eye doctor. On 11/14/2024 at 11:55 A.M., the Regional Quality Assurance Administrator provided a policy titled, Sensory Impairments - Clinical Protocol, dated March 2018 and indicated the policy was the one currently used by the facility. The policy indicated, .physician will identify and order appropriate consultations to help manage .sensory impairments . 3.1-39(a)(b)

3. A record review for Resident M was completed on 11/12/24 at 11:23 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, congestive heart failure and vascular dementia. An Annual Minimum Data Set (MDS) assessment, dated 9/11/2024, indicated Resident M had a severe cognitive deficit received insulin and diuretic medications. Current Physician's Orders, included, but were not limited to: - Jardiance 10 milligrams in the morning initiated on 4/2/2022 The Medication Administration Record, dated November 2024, indicated Resident M missed doses of Jardiance 10 milligrams on 11/1/2024, 11/5/2024, 11/9/2024, 11/10/2024, and 11/12/2024. During an interview, on 11/14/2024 at 9:45 A.M., the Director of Nursing indicated if a medication was unavailable, the nursing staff should have contacted the pharmacy and then the physician to determine if alternate orders were necessary. On 11/14/2024 at 9:10 A.M., the Quality Assurance Administrator provided the policy titled, Emergency Pharmacy Service and Emergency Kits, dated 5/20/2020, and indicated the policy was the one currently used by the facility. The policy indicated .Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved medication supply or by a special order from the pharmacy. An emergency supply of medications, including emergency drugs, antibiotics, controlled substances . If the medication is not available, call/faxes the pharmacy, using the pharmacy or appropriate after-hours emergency number(s) if necessary.5. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box or from the pharmacy A current policy was provided by the Quality Assurance Administrator, on 11/14/2024 at 1:54 P.M. The policy titled, Adverse Consequences and Medication Errors, indicated 5. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professional[s] providing services. 6. Examples of medication errors include: a. Omission-a drug is ordered but not administered .c. Wrong dose 3.1-48(a)(1) 3.1-48(c)(2) 3.1-25(a) Based on record review, interview and observation, the facility failed to ensure physician ordered medications were available for 3 of 24 residents whose medications were reviewed. (Residents E, L and M) Findings include: 1. A record review for Resident E was completed on 11/12/2024 at 10:59 A.M. Diagnoses included, but were not limited to: encephalopathy, diabetes, anxiety, and depression. Resident E's current Physician Order's included the following: Atorvastatin Calcium 20 mg (milligram) give 1 tablet at bedtime for high cholesterol. Esomeprazole Magnesium 20 mg give 2 tablets before breakfast (to decrease stomach acids). Ezetimibe 10 mg give 1 tablet one time a day (lower cholesterol). Metformin 500 mg 2 tablets two times a day (anti diabetic). Risperdal (antipsychotic) 2 mg give 1 tablet two times a day for psychosis. Sitagliptin 100 mg (anti-diabetic) 1 tablet every day for diabetes. Veozah 45 mg every day (to reduce moderate to severe vasomotor symptoms due to menopause). The September Medication Administration Record (MAR) indicated Resident E had not received the following medications on these dates: Atorvastatin 20 mg on 9/14, 9/15 and 9/16/2024. Esomeprazole 40 mg on 9/16, 9/18, 9/19, and 9/28/2024. Ezetimibe 10 mg on 9/15, and 9/16/2024. Sitagliptin 100 mg on 9/16, 9/24, 9/26, 9/27, 9/29, and 9/30/2024. Veozah 45 mg on 9/15, 9/16, 9/17, 9/19, 9/21, 9/22, 9/24, 9/25, 9/27, 9/29 and 9/30/2024. Metformin 1000 mg on 9/15 and 9/16/2024. Risperdal 4 mg on 9/16, 9/24, 9/27, 9/29 and 9/30/2024. Resident E's October MAR indicated she had not received the following medications on these dates: Ezetimibe 10 mg on 10/19, 10/20, 10/22, and 10/23/2024. Sitagliptin 100 mg on 10/1 through 10/6, 10/8 through 10/15, 10/17, 10/19, 10/20, 10/22, 10/23, 10/25, and 10/28 through 10/31/2024. Veozah 45 mg on 10/1 through 10/6, 10/8 through 10/23, and 10/25, and 10/28 through 10/31/2024. The November Medication Administration Record (MAR) indicated Resident E had not received the following medications on these dates: Sitagliptin 100 mg on 11/1 through 11/3, 11/5 through 11/8, 11/11, and 11/2024. Metformin 1000 mg on 11/2/2024. Veozah 45 mg on 11/1 through 11/3, 11/5 through 11/8, and 11/11 through 11/13/2024. The clinical record lacked documentation to indicate the reasons why the medications were not administered. During an interview, on 11/14/2024 at 10:40 A.M., the Director of Nursing indicated the nurse should have called the pharmacy, then looked to see if the medications were in-house, looked in the EDK (emergency drug kit) and called the provider for an alternate medication order and the physician should be called after 3 days if the medication was not administered. 2. During an interview, on 11/7/2024 at 1:54 P.M., Resident L indicated she had not received her pain medication for a month. A record review for Resident L was completed on 11/12/2024 at 3:22 P.M. Diagnoses included, but were not limited to kidney failure, diabetes, osteoarthritis, anxiety, and diabetic polyneuropathy. Current Physician Orders included Lidoderm Patch 5% (Lidocaine) pain reliever apply to bilateral hip/thighs in the morning for chronic pain and remove Lidocaine patches from bilateral hips and bilateral thighs at bedtime every night. The October Medication Administration Record (MAR), indicated the Lidoderm pain patch was not applied on the following dates: 10/6, 10/10, 10/11 and 10/18/204. The October MAR indicated the Lidoderm pain patch was not removed on the following dates: 10/11, 10/18 through 11/24, 11/27, 11/29 and 11/30/2024. The November MAR indicated the Lidoderm pain patch was not applied on the following dates: 11/5, 11/6, and 11/8 through 11/12/2024. The November MAR indicated the Lidoderm pain patch was not removed on the following dates: 11/6, and 11/11 through 11/13/2024 A Medication Administration Note, dated 9/14/2024 at 8:07 P.M. indicated no patch was available to remove. A Medication Administration Note, dated 10/6/2024 at 10:18 A.M., indicated the Lidoderm patch was not available. A Medication Administration Note, dated 10/10/2024 at 9:59 A.M., indicated the Lidoderm patch was on order from the pharmacy. A Medication Administration Note, dated 10/112024 at 10:56 A.M., indicated the Lidoderm patch was on order from the pharmacy. A Medication Administration Note, dated 10/11/2024 at 7:28 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/18/2024 at 8:30 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/19/2024 at 10:46 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/20/2024 at 10:38 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/21/2024 at 10:38 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/22/2024 at 10:38 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/23/2024 at 9:57 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/24/2024 at 9:51 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/25/2024 at 9:54 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/26/2024 at 9:17 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/27/2024 at 9:33 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/29/2024 at 9:43 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 10/30/2024 at 9:37 P.M., indicated the Lidoderm patch was not available for removal. A Medication Administration Note, dated 11/5/2024 at 9:53 A.M., indicated the Lidoderm patch was on order from the pharmacy. A Medication Administration Note, dated 11/6/2024 at 7:48 A.M., indicated the Lidoderm patch was on order from the pharmacy. A Medication Administration Note, dated 11/8/2024 at 9:49 A.M., indicated the Lidoderm patch was on order from the pharmacy. A Medication Administration Note, dated 11/9/2024 at 11:33 A.M., indicated the Lidoderm patch was unavailable. A Medication Administration Note, dated 11/11/2024 at 9:03 A.M., indicated the Lidoderm patch was on order from the pharmacy. A Medication Administration Note, dated 11/12/2024 at 7:40 A.M., indicated the Lidoderm patch was on order from the pharmacy. During an interview, on 11/13/2024 at 2:17 P.M., LPN 20 indicated if the medication was not in the cart, he would let the unit manager know. He would then look in the EDK, and if it was not available in the EDK, he would order the medication unless it was already ordered. If it was ordered, it would show on the MAR. During an interview, on 11/14/2024 at 10:40 A.M., the Director of Nursing indicated the nurse should have called the pharmacy, looked see if the medication was in-house, looked in the EDK (emergency drug kit) and called the provider for an alternative medication order. The DON indicated the physician should be notified after 3 days if the medication was not administered. During a medication storage observation on 11/13/2024 at 11:10 A.M., on the 100 hall with QMA 18 there were no Lidocaine pain patches in the medication cart for Resident L. During an interview, on 11/13/2024 at 11:22 A.M., QMA 18 indicated if the medication was not in the medication cart, she would look in the EDK, and if the medication was not in the EDK, she would reorder it and put a note in the chart indicating: reordered awaiting arrival from pharmacy.

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed related to glove use and handwashing during perineal and catheter care for 1 of 2 residents observed for catheter care. (Resident 50) Finding includes: During an observation, on 11/14/2024 at 11:02 A.M., Certified Nursing Assistant (CNA) 23 was observed to provide incontinence/catheter care to Resident 50. She used a washcloth and cleaned the urinary catheter and tubing. CNA 25, with the assistance of LPN 19, then turned the resident over to his right side. CNA 23 cleansed the smear of feces from her buttocks and LPN 19 applied a barrier cream to his buttocks. Without changing her gloves, or washing her hands, CNA 23 obtained a clean bed pad and clean brief and placed them under the resident and pulled the resident's shirt down in back. The resident was then rolled over and his brief was fastened in the front. CNA 23 moved Resident 50's arms and pillows, then repositioned the resident up in bed. She placed a clean sheet over the resident, and lastley CNA 23 put all the dirty linens in a bag and then removed her contaminated gloves. During an interview, on 11/14/2024 at 11:15 A.M., CNA 23 indicated she should have changed her gloves and washed her hands. On 11/14/2024 at 12:56 P.M., the Quality Assurance Administrator provided the policy titled, Perineal Care, with a revision date of 2/2018, and indicated the policy was the one currently used by the facility. The policy indicated .m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly . 10. Remove gloves and discard into designated container. 11. Wash and dry your hand thoroughly 3.1-18(a)

Based on record review and interview, the facility failed to provide a resident with a pneumococcal vaccination timely for 1 of 5 residents reviewed for vaccinations. (Resident 11) Finding includes: Resident 11's record review was completed on 11/12/2024 at 11:01 A.M. Diagnoses included but were not limited to: multiple sclerosis, anxiety disorder, cerebral infarction, bipolar disorder, hemiplegia and hemiparesis of left side and cerebral aneurysm. Resident 11 had received the Prevnar 13 (pneumococcal vaccine) on 3/15/2023. A document titled, Influenza/pneumococcal/Covid Vaccine/Booster Immunization Consent or Refusal indicated the resident wanted to be given the pneumococcal vaccine(s). Resident 11 signed the document on 10/30/2023. A document titled, Influenza/pneumococcal/Covid Vaccine/Booster Immunization Consent or Refusal indicated the resident wanted to be given the pneumococcal vaccine(s). Resident 11's Power of Attorney/Guardian gave verbal consent for the pneumococcal vaccine on 10/24/2024. During an interview on 11/13/2024 at 10:20 A.M., the Clinical Nurse (CN) indicated the facility followed the recommendations of the Centers for Disease Control and Prevention (CDC) for pneumococcal vaccinations. The CN indicated based on the CDC recommendations, Resident 11 should receive a pneumococcal vaccine at least one year after she had received the Prevnar 13 vaccine. On 11/12/2024 at 2:14 P.M., the Director of Nursing (DON) provided a policy dated, 7/22/2022, and titled, Infection Control. The DON indicated it was the policy currently used by the facility. The policy indicated, .K. Influenza and pneumococcal immunizations . 2. Pneumococcal disease . Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized 3.1-13(a)

Based on record review and interview, the facility failed to provide consented vaccinations for 1 of 4 residents reviewed for immunizations. (Resident 101) Finding includes: A record review for Resident 101 was completed on 12/26/2024 at 10:27 A.M. Diagnoses included, but were not limited to: acute kidney failure, congestive heart failure and bradycardia. A Quarterly Minimum Data Set (MDS) assessment, dated 12/12/2024, indicated Resident 101 had moderate cognitive impairment. The assessment indicated Resident 101's COVID-19 vaccinations were not up to date. admission documents, dated 11/14/2024, indicated consent was given for the COVID-19 booster. Documentation could not be located in the electronic medical record of the vaccination having been administered. A policy for the COVID-19 vaccination was requested on 12/27/2024 at 3:23 P.M. Policies were not provided by the facility. During an interview, on 12/27/2024 at 4:00 P.M., the Director of Nursing (DON) indicated residents or resident representatives that gave consent for vaccinations should have the vaccine ordered immediately and should have received the vaccination upon arrival from the pharmacy. The DON indicated he was unsure why Resident 101 had not receive the consented vaccination.

Based on record review and interview, the facility failed to notify the physician timely of changes for blood glucose readings outside of the ordered parameters for 2 of 3 residents reviewed for insulin usage (Resident 30 & M), for 1 of 2 residents reviewed for death (Resident H) and for 1 of 3 residents reviewed for accidents (Resident 12). Findings include: 1. A record review for Resident 30 was completed on 11/12/2024 at 9:33 A.M. Diagnosis included, but were not limited to Diabetes Type 2, Hepatitis B, depression, anxiety, and dementia. Resident 30's Physician Orders included, but were not limited to: Humalog (a rapid acting) insulin- inject subcutaneous before meals per sliding scale of blood sugar results- if 250 to 500 give 6 units and if over 400 call the MD. Use Freestyle meter for blood sugar levels and call the MD if the result is less than 60 or over 400. Lantus (long acting) insulin pen - inject 20 units subcutaneously two times a day. A current Care Plan, dated 12/3/2024 and revised 5/16/2024, indicated Resident 30 had a diagnosis of Type 2 diabetes with interventions including but not limited to administer my medications as ordered by physician and blood sugar checks as ordered by physician. The Medication Administration Record (MAR) dated October 2024 indicated Resident 30's blood glucose reading's on the following dates were: -10/07/2024 at 11:30 A.M. as 530 -10/07/2024 at 11:30 A.M. as 500 The MAR dated October 2024, lacked the documentation to show Resident 30 had received insulin on the following dates/times: 11:30 A.M. on 10/9/24, and 5:30 P.M. on 10/1, 10/6, 10/18, and 10/28/2024 The MAR dated November 2024 indicated Resident 30 blood glucose reading on 11/12/2024 at 8:00 P.M. was 450. The MAR dated October 2024, lacks the documentation to show Resident 30 had received insulin in the following dates/times: 11:30 A.M. on 11/1, 11/3, 11/4, and 11/10/2024 and at 5:30 P.M. on 11/1, 11/4, and 11/5/2024. During an interview, on 11/13/24 at 12:21 P.M., LPN 19 indicated when residents had a blood glucose out of range, they would notify the physician and make a progress note. If additional units were ordered they would put it in the note, but he would not write it as an order. The chart lacked documentation to show the physician was notified of the blood glucose readings over 400 and no documentation to show physician notification of missed insulin doses.2. A record review for Resident 12 was completed, on 11/12/2024 at 9:20 A.M. Diagnoses included, but were not limited to: hemiplegia affecting right dominant side, aphasia, contracture of right elbow, wrist and hand, dementia, right foot drop and polyneuropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 10/17/2024, indicated Resident 12 was cognitively intact. She had impairment to the upper and lower extremity on one side and required set up or clean up assistance for dining services. A Nursing Progress Note, dated 9/19/2024 at 4:08 P.M., indicated the nurse entered Resident 12's room after a shower was completed where the certified nursing assistant (CNA) observed burns on both of Resident 12's inner thighs. Resident 12 indicated to the nurse that she had wheeled herself in her wheelchair to the nurse's station to get a cup of coffee and the CNA may have filled the cup too full. When Resident 12 placed the cup between her thighs to hold it while self-propelling her wheelchair, the coffee spilled from the opening at the top of the cup and burned her. Resident 12 indicated she did not tell anyone about the burn. A Nursing Progress Note, dated 9/19/2024 at 6:56 P.M., indicated Resident 12 had bilateral redness on both inner upper thighs with no blistering. Resident 12 indicated that the 1st degree burns happened over 48-hours ago and reported symptoms of itching and burning without pain. A Nursing Progress Note, dated 9/20/2024 at 8:06 A.M., indicated Resident 12's left thigh burn had a small scab in the center of the burn from Resident 12 itching the area and her brief rubbing the area. The redness of the bilateral upper thighs continued with the left side being about a fist size and the right side being the size of a quarter. A Nursing Progress Note, dated 9/20/2024 at 11:27 A.M., indicated measurements of the burns were obtained. The left thigh burn measured 3 centimeters by 5 centimeters with a scabbed center of 2 centimeters by 0.25 centimeters. The right thigh burn measured 2 centimeters by 3 centimeters. Resident 12 denied any discomfort. A Nurse Practitioner Note, dated 9/20/2024 at 11:30 A.M., indicated the Nurse Practitioner was notified of the burns to the bilateral, medial upper thighs. The Nurse Practitioner provided orders including, but not limited to: to gently wash the areas with cool water, pat dry, apply Silvadene cream twice daily and leave open to air for seven days. During an interview, on 11/14/2024 at 9:16 A.M., the Director of Nursing (DON) indicated the physician and/or nurse practitioner should be notified immediately for any change of condition. The DON indicated he assessed the burns and contacted the nurse practitioner when he was informed on 9/19/2024 of the burns, but did not feel it was an emergency. He indicated there was no documentation in the medical record that this assessment or nurse practitioner contact had occurred timely. During an interview, on 11/07/2024 at 10:07 A.M., Resident 12 indicated she had fallen and was pointing to her right arm. During an observation on 11/13/2024 at 9:37 A.M., Resident 12 was observed with a sling to her right arm. A Nursing Progress Note, dated 11/5/2024 at 3:38 P.M., indicated Resident 12 was observed to have gotten her wheelchair stuck and it started to tip. Resident 12 had her right side wedged between the over the bed table and bed with her weight against her. Resident 12's immobility to the right side, caused her not to be able to free herself and because she struggled to free herself caused the wheelchair to tip and Resident 12 shifted out of the wheelchair. Resident 12 knocked over several personal items and a cup of coffee as she struggled to free herself. Resident 12 indicated she was not in pain, except for the usual pain in her right leg. Resident 12's right leg was observed to have bright red marks from being wedged. Resident 12 indicated she was fine and was more embarrassed than anything. A Nursing Progress Note, dated 11/8/2024 at 2:23 P.M., indicated Resident 12 was complaining of right arm pain. The nurse practitioner was notified, and an order was obtained for a stat (immediately) x-ray. A Nursing Progress Note, dated 11/8/2024 at 7:20 P.M., indicated the x-ray company was in the building to obtain the ordered images. A General Nurse Practitioner Note, dated 11/10/2024 at 8:39 P.M., indicated she had been informed by the DON of Resident 12's x-ray results obtained on 11/8/2024. The x-ray of the right humerus indicated an acute nondisplaced fracture of the proximal humeral metaphysis/nonsurgical humeral neck and severe diffuse osteopenia. A referral to orthopedics was provided. A General Nurse Practitioner Note, dated 11/10/2024 at 8:54 P.M., indicated she had received a call from the facility nurse reporting the results of the x-ray from 11/8/2024. A Nursing Progress Note, dated 11/11/2024 at 8:33 A.M., indicated Resident 12 was informed of the abnormal x-ray results. During an interview, on 11/14/2024 at 9:16 A.M., the Director of Nursing (DON) indicated the physician and/or nurse practitioner should have been notified immediately for any change of condition. 3. A record review for Resident H was completed on 11/12/2024 at 3:09 P.M. Diagnoses included, but were not limited to: hepatic encephalopathy, alcohol cirrhosis with ascites and severe sepsis with septic shock. An admission Minimum Data Set (MDS) assessment, dated 10/2/2024, indicated Resident H was cognitively intact. A Nursing Progress Note, dated 10/26/2024 at 3:58 P.M., indicated Resident H was observed sitting on the floor next to the bed with a bowel movement on the floor. A Nursing Progress Note, dated 10/26/2024 at 7:15 P.M., indicated Resident H was found sitting on the floor with his head resting on the bed. Resident H was confused and unsure of his location. Resident H had an oxygen saturation of 64 percent on room air, a blood pressure of 81/40 mmHg (millimeters of mercury), a pulse of 100 beats per minute, and a respiration rate of 24 breaths per minute. The temperature was not able to be obtained. A Nursing Progress Note, dated 10/26/2024 at 7:30 P.M., indicated Resident H's oxygen saturation was 77 percent on three liters of oxygen per minute via nasal cannula. A Nursing Progress Note, dated 10/26/2024 at 8:00 P.M., indicated Resident H had an oxygen saturation of 92 percent on three liters of oxygen per minute via nasal cannula, a blood pressure of 97/52 mmHg, a pulse rate of 62 beats per minute, and a respiration rate of 24 breaths per minute. A respiratory treatment was completed keeping the mouthpiece close to the mouth, but Resident H would move the mouthpiece away from his mouth. A Nursing Progress Note, dated 10/26/2024 at 8:30 P.M., indicated Resident H had vital signs of the following: oxygen saturation of 95 percent on three liters of oxygen per minute via nasal cannula, a blood pressure of 100/62 mmHg, a pulse of 66 beats per minute, and a respiration rate of 24 breaths per minute. A Nursing Progress Note, dated 10/26/2024 at 9:00 P.M., indicated Resident H continued resting in bed with no problems noted or voiced. A Nursing Progress Note, dated 10/26/2024 at 9:30P.M., indicated Resident H had a temperature of 100.2 F (Fahrenheit) and oxygen saturations of 63 percent on three liters of oxygen per minute via nasal cannula. The oxygen was increased to four liters per minute and his oxygen saturations increased to 70 percent. Resident H was restless, continued not to be able to know his location with the confusion continuing. A Nursing Progress Note, dated 10/26/2024 at 9:44 P.M., indicated Resident H's oxygen saturation was 77 percent on four liters of oxygen per minute via nasal cannula. The oxygen was increased to five liters per minute. A Nursing Progress Note, dated 10/26/2024 at 9:47 P.M., indicated Resident H had an oxygen saturation of 75 percent on five liters of oxygen per minute via nasal cannula and his breath sounds had wheezing anteriorly and posteriorly. A Nursing Progress Note, dated 10/26/2024 at 9:51 P.M., indicated the nurse practitioner was called. During an interview, on 11/14/2024 at 9:55 A.M., the Director of Nursing indicated the nurse practitioner should have been contacted sooner for the change of condition. 4. A record review for Resident M was completed on 11/12/24 at 11:23 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 and vascular dementia. An Annual Minimum Data Set (MDS) assessment, dated 9/11/2024, indicated Resident M had a severe cognitive deficit and received insulin. A Physician's Order, dated 1/26/2024, indicated glargine solution 100 units per milliliter, inject 18 units subcutaneously at bedtime and notify the physician/nurse practitioner of a blood sugar greater than 500 mg/dL (milligram per deciliter) or less than 60 mg/dL. A Physician's Order, dated 9/30/2024, indicated to obtain a blood sugar daily to notify the medical provider for a blood sugar greater than 400 mg/dL or less than 70 mg/dL. The following blood sugars were documented in the medical record: -11/8/2024 5:24 P.M. 490.0 mg/dL -11/6/2024 8:13 P.M. 452.0 mg/dL -11/2/2024 7:52 P.M. 591.0 mg/dL -10/30/2024 7:46 P.M. 467.0 mg/dL -10/24/2024 10:19 P.M. 435.0 mg/dL -10/20/2024 9:10 P.M. 500.0 mg/dL -10/20/2024 8:11 P.M. 500.0 mg/dL -10/17/2024 4:44 P.M. 438.0 mg/dL -10/16/2024 7:18 P.M. 478.0 mg/dL -10/16/2024 5:14 P.M. 457.0 mg/dL -10/15/2024 8:41 P.M. 430.0 mg/dL -10/14/2024 8:39 P.M. 432.0 mg/dL -10/13/2024 8:10 P.M. 495.0 mg/dL -10/13/2024 4:38 P.M. 442.0 mg/dL -10/12/2024 11:41 A.M. 448.0 mg/dL -10/11/2024 11:32 A.M. 419.0 mg/dL -10/10/2024 9:23 P.M. 404.0 mg/dL -10/10/2024 5:09 P.M. 466.0 mg/dL -10/9/2024 4:40 P.M. 401.0 mg/dL -10/7/2024 12:13 462.0 mg/dL -10/3/2024 22:58 403.0 mg/dL -10/3/2024 19:40 403.0 mg/dL The medical record did not have documentation of the physician and/or nurse practitioner being notified of the blood sugars out of the ordered range. During an interview, on 11/14/2024 at 9:45 A.M., the Director of Nursing indicated notification of out-of-range blood sugars would be individualized to the resident to when notification of the physician/nurse practitioner would occur. He indicated if parameters were not provided, the general notification parameters were to notify the physician/nurse practitioner when a blood sugar was below 70 mg/dL and above 401 mg/dL. The Director of Nursing indicated the staff should be notifying the physician/nurse practitioner when the blood sugars were outside of the ordered range. A current policy was provided on 11/14/2024 at 10:30 A.M., by the Quality Assurance Administrator. The policy, titled, Acute Condition Changes-Clinical Protocol, indicated, .Assessment and Recognition 8. The nursing staff will contact the physician on urgency of the situation. For emergencies, they will call or page the physician and request a prompt response [within approximately one-half hour or less] This citation relates to complaint IN00446004. 3.1-5(a)(1) 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure a transfer/discharge form was provided for 4 of 4 residents reviewed for hospitalization. (Residents B, 52, 55, 69) Findings include: 1. A record review for Resident B was completed on 11/08/2024 at 2:32 P.M. Diagnosis included but were not limited to cerebral palsy, hydronephrosis, urogenital implants, and obstructive and reflux uropathy. A Nursing Progress Note, dated 6/19/24 at 11:45 A.M., indicated Resident B had returned from the hospital. The chart lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident's representative for this transfer. In addition, the Ombudsman was not notified of the resident's transfer. A Nursing Progress note, dated 8/16/2024 at 12:00 A.M., indicated that Resident B was transferred to a local hospital for back and abdominal pain. The chart lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident's representative for this transfer. In addition, the Ombudsman was not notified of the resident's transfer. A Nursing Progress Note, dated 11/4/2024 at 09:59 A.M., indicated resident B was out for a LOA (Leave of Absence) for surgery. The chart lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident's representative for this transfer. In addition, the Ombudsman was not notified of the resident's transfer. During an interview, on 11/13/2024 at 09:31 A.M., LPN 20 indicated they have a checklist of all the things they are to do when they send someone to the hospital, including but not limited to: sending the transfer/discharge form and documenting a nursing note. During an interview, on 11/13/2024 at 10:00 A.M., LPN 19 indicated the nurses have a checklist of things to do for a transfer that two nurses were supposed to sign once completed, this included but was not limited to: sending the transfer/discharge form and documenting a nursing note. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further Transfer/discharge forms in the building for Resident B. During an interview, on 11/14/2024 at 1:10 P.M. with the Social Worker, regarding documentation provided for Ombudsman notification of resident transfers for the months of June and August 2024, she indicated Resident B was not on the list provided to the Ombudsman. 2. A record review for Resident 52 was completed on 11/12/2024 at 1:56 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), pneumonia and acute respiratory failure. A Quarterly Minimum Data Set (MDS) assessment, dated 9/17/2024, indicated Resident 52 was cognitively intact. A Nursing Progress Note, on 5/27/2024 at 4:05 A.M., indicated at 2:45 A.M. Resident 52 requested her lung sounds to be evaluated. Resident 52's lung sounds had scattered wheezing posteriorly and expiratory wheezing anteriorly. Resident 52 refused a nebulizer treatment or an as needed inhalation medication. Resident 52 indicated she felt she had bronchitis and needed an antibiotic. Staff offered for hospice to be called for further instruction. Resident 52 decided to call the Emergency Medical Services for transfer. A Nursing Progress Note, on 7/25/2024 at 8:10 P.M., indicated Resident 52 called emergency services and was transfered to the hospital. The nurse notified hospice services of Resident 52's transfer to the hospital. A Nursing Progress Note, on 9/26/2024 at 11:01 A.M., indicated Resident 52 requested to be sent to the hospital. The medical record lacked any of Resident 52's transfer forms from the facility. During an interview, on 11/13/2024 at 10:29 A.M., the Quality Assurance Administrator produced a stack of un-scanned medical records to review for transfer and discharge forms. After the stack was reviewed, the Quality Assurance Administrator indicated she did not think they had any of the transfer and/or discharge forms. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further transfer and discharge forms after looking for the forms the prior day. She indicated Resident 52 should have had a transfer and discharge form completed. 3. A record review for Resident 55 was completed on 11/12/2024 at 10:18 A.M. Diagnoses included, but were not limited to: congestive heart failure and pneumonia. A Nursing Progress Note, on 8/17/2024 at 7:12 A.M., indicated Resident 55 was sitting on the edge of the bed with shortness of breath, diminished lung sounds, a blood pressure of 175/119 mmHg (millimeters of mercury) and a pulse of 133 beats per minute. There was no documentation that Resident 55 was transferred to the hospital. However, a Nursing Progress Note, on 8/20/2024 at 2:40 A.M., indicated Resident 55 was readmitted to the facility after a brief hospital stay for heart failure, shortness of breath and elevated troponin. The medical record lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident's representative. During an interview, on 11/13/2024 at 10:29 A.M., the Quality Assurance Administrator produced a stack of un-scanned medical records to review for transfer and discharge forms. After the stack was reviewed, the Quality Assurance Administrator indicated she did not think they had the transfer and discharge forms for Resident 55. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further transfer and discharge forms after looking for the forms the prior day. She indicated Resident 55 should have had a transfer and discharge form completed. 4. A record review for Resident 69 was completed on 11/12/2024 3:55 P.M. Diagnoses included, but were not limited to: chronic pancreatitis, atrial fibrillation and acute cholecystitis. A Nursing Progress Note, on 9/16/2024 at 6:05 P.M., indicated Resident 69 was observed to be drowsy and disoriented. Resident 69's blood pressure was 86/54 mmHg, pulse was 130 beats per minute, oxygen saturation was 88 percent and respirations were 18 breaths per minute. Resident 69 was transferred to the hospital via an ambulance. A Nursisng Progress Note, dated 9/16/2024 at 8:57 P.M., indicated Resident 69 returned to the facility. A Nursing Progress Note, on 9/21/2024 at 11:41 A.M., indicated the nurse was notified of Resident 69's skin coloring was not within normal limits. Resident 69 was pale; her demeanor was abnormal, and her oxygen saturations were 82 percent on room air. The nurse practitioner was notified and Resident 69 decided to be transferred to the hospital. A Nursing Progress Note, on 9/24/2024 at 8:22 A.M., indicated Resident 69 would not be returning to the facility. The medical record lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident representative. During an interview, on 11/13/2024 at 10:29 A.M., the Quality Assurance Administrator produced a stack of un-scanned medical records to review for transfer and discharge forms. After the stack was reviewed, the Quality Assurance Administrator indicated she did not think they had the transfer and discharge forms for Resident 69. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further transfer and discharge forms after looking for the forms the prior day. She indicated Resident 69 should have had a transfer and discharge form completed. A current policy was provided by the Quality Assurance Administrator, on 11/14/2024 at 1:54 P.M. The policy, titled, Transfer or Discharge, Facility-Initiated, indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer or Discharge [Emergent of Therapeutic Leave] 3. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: c. An immediate transfer or discharge is required by the resident's urgent medical needs 3.1-12(a)(6)(i)

4. A record review for Resident B was completed on 11/08/2024 at 2:32 P.M. Diagnosis included but were not limited to cerebral palsy, hydronephrosis, urogenital implants, and obstructive and reflux uropathy. A Nursing Progress Note, dated 6/19/24 at 11:45 A.M., indicated Resident B had returned from the hospital. The chart lacked documentation a bed hold was provided by the facility to the resident and/or resident representative for this transfer. A Nursing Progress Note, dated 8/16/2024 at 12:00 A.M., indicated that Resident B was transferred to a local hospital for back and abdominal pain. The chart lacked documentation a bed hold was provided by the facility to the resident and/or resident representative for this transfer. A Nursing Progress Note, dated 11/4/2024 at 09:59 A.M., indicated resident B was out for a LOA (Leave of Absence) for surgery. The chart lacked documentation a bed hold was provided by the facility to the resident and/or resident representative for this transfer. During an interview, on 11/13/2024 at 09:31 A.M., LPN 20 indicated they have a checklist of all the things they are to do when they send someone to the hospital, including but not limited to: sending the bed hold and documenting a nursing note. During an interview, on 11/13/2024 at 10:00 A.M., LPN 19 indicated the nurses have a checklist of things to do for a transfer that two nurses were supposed to sign once completed, this included but was not limited to the bed hold and making a nursing progress note. During an interview on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not provide any further bed hold forms for Residnet B. A policy was provided by the Quality Assurance Administrator, on 11/14/24 at 1:54 P.M. The policy titled, Bed-Hold Policy, indicated, .Before transferring a resident to a hospital, or allowing a Resident to go on therapeutic leave of absence, the Resident, family member, or Resident Representative will be notified in writing of this Resident Bed-Hold Policy 3.1-12(a)(26) Based on record reviews and interview, the facility failed to provide a bed hold form for 4 of 4 residents reviewed for hospitalizations. (Resident 52, 55, 69 & B) Findings include: 1. A record review for Resident 52 was completed on 11/12/2024 at 1:56 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), pneumonia and acute respiratory failure. A Quarterly Minimum Data Set (MDS) assessment, dated 9/17/2024, indicated Resident 52 was cognitively intact. A Nursing Progress Note, on 5/27/2024 at 4:05 A.M., indicated at 2:45 A.M. Resident 52 requested her lung sounds to be evaluated. Resident 52's lung sounds had scattered wheezing posteriorly and expiratory wheezing anteriorly. Resident 52 refused a nebulizer treatment or an as needed inhalation medication. Resident 52 indicated she felt she had bronchitis and needed an antibiotic and was offered for hospice to be called for further instruction. Resident 52 decided to emergency services for transfer and the nurse gathered Resident 52's transfer paperwork. A Nursing Progress Note, on 7/25/2024 at 8:10 P.M., indicated Resident 52 passed the nursing station in her wheelchair, went to her room with several other residents and called emergency services for transportation to the hospital. The nurse completed an assessment and notified hospice services of Resident 52's transfer from the facility. A Nursing Progress Note, on 9/26/2024 at 11:01 A.M., indicated Resident 52 requested to be sent to the hospital for not taking her medications or nourishment for four days. Resident 52 signed the revocation of hospice care. The chart lacked documentation a bed hold policy was provided by the facility. During an interview, on 11/13/2024 at 10:29 A.M., the Quality Assurance Administrator produced a stack of un-scanned medical records to review for bed hold forms. After the stack was reviewed, the Quality Assurance Administrator indicated she did not think the facility had the bed hold forms. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further forms after looking for bed hold the forms the prior day. She indicated Resident 52 should have had a bed form completed. 2. A record review for Resident 55 was completed on 11/12/2024 at 10:18 A.M. Diagnoses included, but were not limited to: congestive heart failure and pneumonia. An Annual Minimum Data Set (MDS) assessment, dated 8/28/2024, indicated Resident 55 was cognitively intact. A Nursing Progress Note, on 8/17/2024 at 7:12 A.M., indicated Resident 55 was sitting on the edge of the bed with shortness of breath, diminished lung sounds, a blood pressure of 175/119 mmHg (millimeters of mercury) and a pulse of 133 beats per minute. A Nursing Progress Note, on 8/20/2024 at 2:40 A.M., indicated Resident 55 was readmitted to the facility after a brief hospital stay for heart failure, shortness of breath and elevated troponin. The chart lacked documentation a bed hold policy was provided by the facility. During an interview, on 11/13/2024 at 10:29 A.M., the Quality Assurance Administrator produced a stack of un-scanned medical records to review for bed hold forms. After the stack was reviewed, the Quality Assurance Administrator indicated she did not think the facility had the bed hold forms. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further bed hold forms after looking for the forms the prior day. She indicated Resident 55 should have had a bed hold form completed. 3. A record review for Resident 69 was completed on 11/12/2024 3:55 P.M. Diagnoses included, but were not limited to: chronic pancreatitis, atrial fibrillation and acute cholecystitis. An admission Minimum Data Set (MDS) assessment, dated 9/9/2024, indicated Resident 69 was cognitively intact. A Nursing Progress Note, on 9/16/2024 at 6:05 P.M., indicated Resident 69 was observed to be drowsy and disoriented. Resident 69's blood pressure was 86/54 mmHg, pulse was 130 beats per minute, oxygen saturation was 88 percent and respirations were 18 breaths per minute. Resident 69 was transferred to the hospital via an ambulance. A Nursing Progress Note, on 9/21/2024 at 11:41 A.M., indicated the nurse was notified of Resident 69's skin coloring was not within normal limits. Resident 69 was pale; her demeanor was abnormal, and her oxygen saturations were 82 percent on room air. The nurse practitioner was notified and Resident 69 decided to be transferred to the hospital. A Nursing Progress Note, on 9/24/2024 at 8:22 A.M., indicated Resident 69 would not be returning to the facility. The chart lacked documentation a bed hold policy was provided by the facility. During an interview, on 11/13/2024 at 10:29 A.M., the Quality Assurance Administrator produced a stack of un-scanned medical records to review for bed hold forms. After the stack was reviewed, the Quality Assurance Administrator indicated she did not think the facility had the bed hold forms. During an interview, on 11/14/2024 at 8:55 A.M., the Quality Assurance Administrator indicated she could not find any further bed hold forms after looking for the forms the prior day. She indicated Resident 69 should have had a bed hold form completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the environment was free from potential hazards for 1 of 4 halls. In addition, the facility failed to ensure interventions were in place to prevent burns for 1 of 3 residents reviewed for accidents. (Resident 12) Findings include: 1. During an observation of room [ROOM NUMBER] on 11/14/2024 at 10:00 A.M., Resident R's bed was pushed against the packaged terminal air conditioner (PTAC) (ductless, self-contained air conditioning unit for heating and cooling small areas). The top and front of the PTAC was warped and melted. The PTAC unit was plugged in but was turned off. Resident R was not in his room. An interview with Resident S, Resident R's roommate, was completed on 11/14/2024 at 10:02 A.M. Resident S indicated the PTAC melted at least five months prior. He indicated his roommate's comforter had been in front of the PTAC unit and due to excessive heat, melted the PTAC unit. He indicated the current Maintenance Director (MD) had checked the unit after it melted and was not able to say if the unit would be replaced. Resident S indicated the melted PTAC was still being used to heat the room when it was cold outside. During an interview on 11/14/2024 at 11:28 A.M., Resident R indicated his comforter was in front of the PTAC and caused the top and front of the PTAC to melt about five months prior. He indicated the MD had inspected the PTAC and told him it would be replaced, but the PTAC was not replaced. Resident R indicated staff had never offered to move his bed away from the PTAC and the melted PTAC was still being used to heat the room. During an interview on 11/14/2024 at 1:07 P.M., CNA 21 indicated she was unable to remember how long ago the PTAC unit had melted, but it was more than one month. She indicated the maintenance department was aware and was supposed to take care of it. During an interview on 11/14/2024 at 1:09 P.M., the Unit Manger (UM) indicated she had reported the melted PTAC unit to maintenance over a week ago and was told maintenance already knew about it. During an interview on 11/14/2024 at 1:20 P.M., Housekeeper 23 indicated the PTAC unit had been melted for weeks, if not months, but she had not reported it to anyone because Residents R and S had told her the maintenance department was already taking care of it. During an interview on 10/14/2024 at 10:30 A.M., the Executive Director (ED) indicated the facility was unaware of the melted PTAC and the MD had been in the room two days prior and the PTAC was not melted at that time. During an interview on 11/14/2024 at 1:30 P.M., the MD indicated he was not aware the PTAC unit was melted and he had been in the room two days prior, changing remote batteries, and would have noticed a melted PTAC unit. The MD indicated the facility used TELS (a web-based platform designed for managing building operations, including maintenance, asset management, and life safety compliance, specifically tailored for senior living communities) to submit and prioritize work orders. However, the MD was unable to provide a list from the facility's TELS system regarding work orders that had been submitted or a list of work orders he was currently working on in the facility. 2. A record review for Resident 12 was completed, on 11/12/2024 at 9:20 A.M. Diagnoses included, but were not limited to: hemiplegia affecting right dominant side, aphasia, contracture of right elbow, wrist and hand, dementia and polyneuropathy. An Annual MDS assessment, compelted on 9/10/2024 and a Quarterly Minimum Data Set (MDS) assessment, completed on 10/17/2024, indicated Resident 12 was cognitively intact, had impairment to the upper and lower extremity on one side and required set up or clean up assistance for dining services. A Nursing Progress Note, dated 9/19/2024 at 4:08 P.M., indicated the nurse entered Resident 12's room after a shower was completed where the certified nursing assistant (CNA) observed burns on both of Resident 12's inner thighs. Resident 12 indicated to the nurse she had wheeled herself in her wheelchair to the nurse's station to get a cup of coffee and the CNA may have filled the cup too full. When Resident 12 placed the cup between her thighs to hold while self-propelling her wheelchair, the coffee spilled from the opening at the top and she had burned herself. Resident 12 indicated she did not tell anyone about the burn. A Hot Liquid Safety Evaluation, dated 9/20/2024, indicated Resident 12 had altered muscle strength of her arms, hands and fingers with altered range of motion or contracture of the joints to the hand and fingers and had a history of spills. The evaluation recommended providing Resident 12 with a cup with a lid or other adaptive equipment and staff assistance. There was no Hot Liquid Safety Evaluation completed for Resident 12 prior to 9/20/2024. The Administrator reported to the Indiana Department of Health, on 9/20/2024 at 11:44 A.M., of Resident 12's burn. On 9/27/2024, the Administrator indicated in a follow-up statement, Resident seen by the wound doctor with treatment in place .resident referred to therapy for recommendations. Hot liquids to be served in a cup with a lid and a cup holder is being purchased A Care Plan, dated 9/26/2024, indicated Resident 12 was at risk for spilling hot liquids and foods related to muscle weakness and deficits due to effects from a previous stroke. The Care Plan goals included, Resident 12 will not have any hot food or liquids transported by herself and will not suffer any burns from food or liquids. Interventions included, but were not limited to: Resident 12 will allow staff to transport her hot food and liquids for her and utilize cups/mugs with handles and lids for all liquids. There was no care plan regarding hot liquid needs/safety for Resident 12 prior to 9/26/2024. During an observation, on 11/13/2024 at 9:37 A.M., Resident 12 was observed in her bed. She had 2 unhandled tumbler cups with lids with unknown substances. Resident 12 indicated she drinks hot liquids without a lid. During an interview, on 11/13/24 at 9:18 A.M., the Director of Rehabilitation indicated Resident 12 had not been recently evaluated for therapy services During an interview, on 11/14/2024 at 9:08 A.M., Dietary Aide 27 indicated special equipment for cup ware would be listed on the meal ticket. The meal ticket was observed, and Dietary Aide 27 indicated Resident 12's hot liquids would be served in a regular cup. Dietary Aide 27 was unaware of the care plan intervention to serve Resident 12's hot liquids in a cup/mug with a handle and lid. During an interview, on 11/14/2024 at 9:16 A.M., the Director of Nursing (DON) indicated the admission nursing assessment specifically asks about cognitive abilities and functional limb abilities to determine risk for burns. On 11/14/2024 at 11:00 A.M., the ED provided an undated document titled, Physical Plant Standards and indicated the facility did not have a policy related to providing a safe environment, but used that document. The document indicated, .The facility shall have adequate plumbing, heating, and ventilating systems as governed by applicable rules of the fire prevention and building safety commission . Each facility shall have an adequate air conditioning system, as governed by applicable rules of the fire prevention and building safety commission On 11/14/2024 at 1:05 P.M., the Quality Assurance Administrator provided a policy titled, First Aid Treatment. The policy indicated, .Residents and employees who experience minor injuries shall be treated at the facility. IF the injuries cannot be treated with basic Red Cross first aid intervention, the emergency medical system [EMS] will be activated 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to adequately label an over the counter medication stored in a medication cart for 1 of 1 medication cart reviewed (400 Unit). The facility also failed to monitor and maintain proper temperatures of a refrigerator where medications were stored for 1 of 1 medication refrigerators reviewed (Nurses Station 1). Findings include: 1. During an observation of the medication cart on the 400 Unit on 11/8/2024 at 11:45 A.M., an opened bottle of Tylenol and an open bottle of melatonin did not have any resident identifying information on the bottles. During an interview on 11/08/2024 at 11:48 A.M., LPN 24 indicated she was not able to identify whose Tylenol and melatonin were observed. She indicated over the counter medications should be labeled with the resident's name and room number. During an interview on 11/8/2024 at 11:51 A.M., the Director of Nursing (DON) indicated all medications should be labeled with the resident's name, prescriber name and dosage information. 2. During an observation of the nursing station 1 medication refrigerator on 11/12/2024 at 9:30 A.M. with LPN 20, the medication refrigerator thermometer indicated the temperature was 32 degrees Fahrenheit (F). The refrigerator had the following medications stored: -A locked Emergency Drug Kit with 1 vial of Humalog (insulin), 1 vial Humulin N (insulin), 1 vial of Humulin R (insulin), 1 vial of Humulin 70/30 (insulin), 1 vial of Novolog (insulin), 1 vial of lorazepam 20 milligrams (mg) (antianxiety), 1 vial of lorazepam 2 mg, 1 vial of Lantus (insulin), 1 vial of Leviemir (insulin), 1 promethazine (relieve or prevent some types of allergy or allergic reactions) 25 mg suppositories. -3 boxes of Tubersol (aid in the diagnosis of tuberculosis) -4 boxes of Aplisol (aid in the diagnosis of tuberculosis) -3 Lantus Solostar (insulin) pens for Resident 30 -4 Gargine (insulin) pens for Resident 26 The temperature log hanging on the front of the Medication Refrigerator had out of range temperatures logged for the following dates: -11/1/2024 33 degrees F -11/2/2024 33 degrees F -11/3/2024 30 degrees F -11/4/2024 30 degrees F -11/5/2024 33 degrees F -11/6/2024 33 degrees F -11/7/2024 33 degrees F -11/8/2024 33 degrees F -11/9/2024 33 degrees F -11/10/2024 32 degrees F -11/11/2024 33 degrees F -11/12/2024 33 degrees F During an interview on 11/12/2024 at 9:33 A.M., LPN 20 indicated the nurses were responsible for checking and recording the medication refrigerator's temperatures. He indicated the temperature of refrigerator was 32 F and believed it was an appropriate temperature. After looking at the acceptable temperature parameters printed on the temperature log, LPN 20 indicated the refrigerator temperature was out of range and he would notify maintenance. On 11/12/2024 at 10:00 A.M., the Executive Director (ED) provided an undated policy titled, Medication Storage in the Facility, and identified it as the policy currently used by the facility. The policy indicated, . K. Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label On 11/12/2024 at 2:14 P.M., the DON provided a policy dated, 4/2007, and titled, Labeling of Medication Containers and identified it as the policy currently used by the facility. The policy indicated, . 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; . d. The name, strength, and quantity of the drug; . i. Directions for use 3.1-25 (j) 3.1-25 (m)

Based on observation, record review and interview, the facility failed to ensure 1 of 2 unit pantries was maintained in a sanitary manner. This had the potential to affect 18 of 18 residents on the 400 unit. Finding includes: An observation of the 400 unit pantry was completed with the Dietary Director (DD) and the Executive Director on 11/13/2024 at 9:13 A.M. The following was observed: - A microwave with dried food splatter on the inside. - A wet white blanket with black and brown stains on the bottom of the cabinet underneath the sink. During an interview on 11/13/2024 at 9:15 A.M., the DD indicated the microwave was dirty and needed to be cleaned. She indicated the blanket was used to catch the dripping water from the leaking plumbing, but was not able to recall the last time the blanket had been changed. The ED indicated the blanket should not be used to absorb the leaking water and she had already notified maintenance about the leaking sink prior to the survey starting. A policy for maintaining the pantry and any cleaning checklists related to the pantry were requested but not provided prior to the survey exit. On 11/13/2024 at 9:16 A.M., the ED indicated the facility did not have a policy for maintaining the pantries, but used an undated document titled, Physical Plant Standards. The three page Physical Plant Standards document did not include information pertaining to the sanitation or upkeep of equipment in pantries or the kitchen. This citation relates to complaint IN00442666. 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a sanitary environment related to urine odors, dirty ceilings and walls and unpainted spackle in resident's rooms and related to gouges and unpainted spackle on the 400 unit hall walls. Findings include: 1. During an observation on 11/8/2024 at 11:06 A.M., a strong smell of urine was detected in room [ROOM NUMBER]. During an Environmental tour with the Maintenance Director (MD), Executive Director (ED) and the Director of Housekeeping (DH) on 11/14/2024 at 9:05 A.M., a strong smell of urine was detected in room [ROOM NUMBER]. During an interview on 11/14/2024 at 9:07 A.M., the DH indicated room [ROOM NUMBER] smelled of urine due to a urine soaked mattress. The DH indicated the resident brought his own mattress on admission and it was not cleanable. The DH indicated there had been conversations with the resident about replacing the mattress, but the resident refused. The DH indicated she did not have any documentation to indicate the resident had been offered a new mattress. On 11/14/2024 at 10:45 A.M., the DH provided cleaning checklists that did not include cleaning resident's mattresses. On 11/14/2024 at 1:00 P.M., the DH provided an undated document indicating the resident wanted to keep his mattress and refused the opportunity to receive a new mattress. The DH indicated the resident had signed the document on 11/14/2024. 2. During an observation of room [ROOM NUMBER] on 11/07/2024 at 2:06 P.M., there were gouges along the wall next to the bed by the door, unpainted spackle on the wall by the ceiling with room decor hanging from the unpainted spackle, and a dark spot on the ceiling near the window. During an Environmental tour with the Maintenance Director (MD), Executive Director (ED) and the Director of Housekeeping (DH) on 11/14/2024 at 9:08 A.M., the following was observed in room [ROOM NUMBER]: gouges along the wall next to the bed by the door, unpainted spackle on the wall by the ceiling with room decor hanging from the unpainted spackle, and a dark spot on the ceiling near the window. During an interview with the MD and DH on 11/14/2024 at 9:10 A.M., the MD indicated he was not aware of the gouges in the wall along the bed. He indicated he had spackled the wall a week prior and had not painted it yet. The MD indicated the ceiling did not leak and it was dirt on the ceiling. The DH indicated it was dirt on the ceiling and it was housekeeping's responsibility to clean the ceiling and Housekeeping should have been dusting from ceiling to floor daily. On 11/14/2024 at 10:45 A.M., the DH provided cleaning checklists. The cleaning check lists did not include dusting the ceiling or walls. 3. During an observation of room [ROOM NUMBER] on 11/07/2024 at 11:04 A.M., there were two holes in the wall next to bed by the door. During an Environmental tour with the Maintenance Director (MD), Executive Director (ED) and the Director of Housekeeping (DH) on 11/14/2024 at 9:12 A.M., room [ROOM NUMBER] had two holes in the wall above the bed closest to the door. During an interview on 11/14/2024 at 9:13 A.M., the MD indicated he was not aware of the holes in the wall in room [ROOM NUMBER]. During an interview on 11/14/2024 at 9:14 A.M., Resident J indicated he admitted to the facility six months prior and the holes had been in the wall since his admission. 4. During an Environmental tour with the Maintenance Director (MD), Executive Director (ED) and the Director of Housekeeping (DH) on 11/14/2024 at 9:16 A.M., the 400 Hall had four large areas along the hallway wall that had been spackled but had not been painted. During an interview on 11/14/2024 at 9:22 A.M., the MD indicated that his assistant had spackled the wall one week prior. The MD indicated the facility used TELS (a web-based platform designed for managing building operations, including maintenance, asset management, and life safety compliance, specifically tailored for senior living communities) to submit work orders for building repairs. He indicated staff submitted work orders and he prioritized work orders based on safety concerns. The MD indicated he completed a daily walk through of the facility's halls and common areas to identify any possible maintenance concerns. He indicated he visited several rooms a day and was in every room at least every two weeks to identify possible maintenance concerns. During an interview on 11/14/2024 at 9:30 A.M., the ED indicated the facility did not have a policy for maintaining the building and environment, but used the document titled, Physical Plant Standards. During an interview on 11/14/2024 at 1:30 P.M., the MD indicated he was not able to provide a list of tasks that had been submitted through TELS or a list of the current tasks he was working on in the facility. On 11/14/2024 at 11:00 A.M., the ED provided an undated document titled, Physical Plant Standards and indicated the facility did not have a policy related to maintaining the facility's environment, but used that document. The document indicated, .(2) Provide each resident with the following items upon request at the time of admission: (A) A bed: . (ii) with a clean and comfortable mattress This citation relates to complaint IN00442666. 3.1-19 (f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective Pest Control Program related to an infestation of fruit flies. This had the potential to affect 68 of the 68 residents who reside in the facility. Finding includes: During an observation of room [ROOM NUMBER] on 11/7/2024 at 2:06 P.M., fruit flies were seen in the resident's room. During an observation of room [ROOM NUMBER] on 11/8/2024 at 11:06 A.M., fruit flies were seen in the resident's room. During an observation of room [ROOM NUMBER] on 11/8/2024 at 11:11 A.M., fruit flies were seen in the resident's room. During the Resident Council Meeting on 11/08/24 at 1:17 P.M., 5 out of 8 residents indicated fruit flies had been a problem for three months or longer. During a record review of the Pest Control binder on 11/8/2024 at 2:00 P.M., no documentation was located to indicate the facility had received any Pest Control visits/treatments related to fruit flies in the last three months. On 11/14/2024 at 8:45 A.M., the ED provided an invoice from a Pest Control company dated, 11/13/2024. The invoice indicated the 100 Hall was inspected for fruit flies. Fruit flies were located in room [ROOM NUMBER], 111, 112, 114, 118, 120 and in a clean utility room behind Nurse's Station 1. The invoice did not include treatment to any other halls besides the 100 Hall. During an Environmental tour with the Maintenance Director (MD), Executive Director (ED) and the Director of Housekeeping (DH) on 11/14/2024 at 9:05 A.M., fruit flies were observed in the following rooms: -402 -406 -110 -112 -229 During an interview on 11/14/2024 at 9:22 A.M., the MD indicated the facility was receiving regular treatments for fruit flies but did not have any invoices to show a Pest Control company had treated the facility other than the invoice on 11/13/2024. During an interview on 11/14/2024 at 9:30 A.M., the ED indicated the facility used a Pest Control company to treat for fruit flies. The ED indicated the facility was having difficulties with the Pest Control company providing invoices after treatments and provided the phone number of the Pest Control company the facility was using. A copy of the Pest Control Policy was requested and the ED indicated she believed she had already submitted the Pest Control Policy but would double check. A policy was not received before the exit of the survey. During an interview on 11/14/2024 at 9:50 A.M., a representative from the Pest Control company indicated any invoices from the last six months would be emailed to the facility immediately. No invoices were received before the exit of the survey. On 11/14/2024 at 1:05 P.M., the ED provided three documents and identified the documents as invoices for Pest Control services. The documents were dated 9/24, 11/12 and 11/14/2024 and did not list a Pest Control company or what services were received. This citation relates to complaint IN00442889. 3.1-19 (f)(4)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents who required dialysis, received assessment/monitoring for complications prior to and/or after their dialysis treatments, according to the facility policy and the resident's plan of care. (Resident D) Finding includes: On 9/4/24 at 11:04 A.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to; End Stage Renal Disease requiring dialysis and diabetic A Care Plan, undated, indicated the resident required hemodialysis, at the Dialysis Center, on Tuesdays, Thursdays and Saturdays related to renal failure. The interventions included, but were not limited to: leave for dialysis at 8:00 A.M., first shift to obtain a weight, vitals signs and record in dialysis binder, upon return obtain post weight and vital signs, resident to take dialysis binder to dialysis center, monitor labs, monitor for peripheral edema, monitor/document any sign/symptoms of infection to access site (fistula). Review of the August Medication Administration Record (MAR and the August Treatment Administration Record (TAR) did not have documentation indicating the fistula was being observed and/or assessed for complications. The Dialysis Communication Forms, located in the dialysis binder, starting on Thursday 8/22/24 and continuing on 8/24/24, 8/27/24, 8/29/24 and 8/31/24 had pre-dialysis vital signs documented, but no post dialysis assessment had been completed by the facility nurse and documented. There was a place for the dialysis center to provide communication to the facility and was the dialysis center had completed the section on 8/27/24, 8/29/24 and 9/3/24. During an observation/interview, on 9/4/24 at 1:30 P.M., Resident D was observed in the hallway, sitting in a wheelchair with a visitor. The resident indicated she was being transferred to the dialysis center on her dialysis days and had not missed receiving her dialysis treatments. She indicated staff really did not ever look at her fistula-access site when she returned from dialysis treatments. During an interview, on 9/6/24 at 11:35 A.M., the Director of Nursing (DON) indicated the facility failed to ensure a post dialysis assessment was completed by the facility nurse once the resident returned from her dialysis treatments. He indicated the facility nurses should have been assessing the fistula every shift and especially after a treatment to ensure no post bleeding from access site (fistula) occurred. On 9/4/24 at 12:04 P.M., the DON provided a policy titled, Dialysis Care Guidelines, dated 9/9/14, and indicated the policy was the one currently used by the facility. The policy indicated .Residents ordered dialysis therapy will be monitored and documentation will be maintained in the medical record. All residents receiving dialysis will be assessed before and after dialysis treatment and for compliance with their individualized plan of care. All residents receiving dialysis treatment will have their access site assessed every shift .2. For Peripheral access, AV [Arteriovenous] Graft or AV [Arteriovenous] Fistula: Check bruit and thrill .4. All access sites are to be assessed for signs of infection This citation relates to Complaint IN00442414. 3.1-37(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 received adequate supervision and the facility's elopement policy was followed for a resident with a traumatic brain injury with cognitive deficits, who was transferred off facility property, to a physician's office appointment, (Resident B) Finding includes: During an interview on 6/13/24 at 12:45 P.M., a Van Driver indicated he transported Resident B to an office building located next to an acute care hospital in a nearby city on 6/5/24 for a 10:00 AM appointment. During the ride the resident was quiet until he reached the (neighboring city name) and began to talk and point out familiar places and indicated this was his old stomping grounds. The van driver parked in front of the building and assisted the resident into the building to the specific physician's office and checked him in with Receptionist 1. The van driver told the receptionist he would be back, he had to park the van. When the van driver returned to the physician's office waiting room, the resident was already being seen in the doctor office. The van driver indicated he never went into the exam rooms with the residents due to privacy. The van driver indicated he waited in the lobby,of the suite area, for over an hour for the resident to reappear from the exam room. Finally, he asked Receptionist i2 f the resident was close to being done with his exam. Receptionist 2 indicated the resident had left through another door about an hour ago. The van driver asked [NAME] way he had gone and asked them to call security. The physician's office contacted security and they assisted the van driver to search for the resident. Resident B was not located, the office security looked at their cameras and was able to determine how Resident B had exited the building. The van driver then called the facility to report what had happened and the police were contacted. The van driver indicated it was his first time he had taken Resident B anywhere and he had never met him prior to the transport. On 6/13/24 at 2:13 P.M., a review of the clinical record for Resident B was conducted. Resident B was admitted to the facility on [DATE]. Diagnoses included, but were not limited to: cocaine dependence-remission, stimulant dependence, cannabis dependence, history of pedestrian/collision traffic accident with traumatic subdural hemorrhage. The resident's profile information on admission indicated the resident had no legal Power of Attorney (POA),was his own responsible party and had one emergency contact, a sister. A Social Service Note, dated 3/1/24 at 12:17 P.M., indicated the resident was admitted to the facility after being struck by a vehicle, with an admitting diagnosis of traumatic subdural hemorrhage. Resident B had a cocaine and nicotine dependence and severe cognitive deficits. He required cueing and reminders for daily care. The resident had previously been homeless and was to remain in the facility, for long term placement. A Care Plan, dated 3/1/24, indicated the resident had an alteration in neurological status related to a traumatic brain injury. The interventions included, but were not limited to: cueing and reorientation as needed. An Elopement/Wander Risk Evaluation, dated 3/12/24, indicated the resident was forgetful, had no history of wandering and was a low risk for elopement. A Nursing Progress Note, dated 6/5/24 at 12:30 P.M., indicated the facility had been notified of the resident exiting a physician's office out of the view of the van driver. The note indicated the van driver had alerted the hospital's security and the office building was searched. Resident B was unable to be located. Facility staff were dispatched to assist the van driver with the search for Resident B. A Nursing Progress Noted, dated 6/5/24 at 1:27 P.M., indicated the department was local police department was called and an officer met with the interim Director of Nursing (DON) at the doctor's office. The officer was made aware Resident B was unable to be located. The Police officer spoke with the hospital's security and viewed the cameras to see where the resident had gone. The officer indicated he would talk to his superior to see if they could file a missing person report. At 2:55 P.M., the hospital security officer stated Resident B was seen on the office camera leaving the office at approximately 10:55 A.M. Staff from the facility searched the surrounding areas, including places where the resident had frequented before his admission. Local Emergency Rooms and police stations were contacted and advised of the situation. As of 6/5/2024 at 1:27 P.M., when the note was documented, the resident had not been located. A Nursing Progress Note dated 6/6/24 10:31 P.M., indicated staff had searched the surrounding areas from 9:30 A.M. to 1:30 P.M. Staff resumed their search later in the evening. due to a staff member had reported seeing Resident B in a nearby city in the afternoon. Resident B was not located. The local police department was provided with resident information and the resident's sister was updated. A Nursing Progress Note, dated 6/7/24 at 5:41 P.M., indicated staff had resumed their search throughout the day in the surrounding areas. There were no sightings of Resident B. The resident's sister and the police were updated. A Nursing Progress Note, dated 6/8/24 at 3:15 P.M., indicated the police had called the facility indicating the resident had been found and the sister was aware. An Indiana Department of Health (IDOH) Incident Report dated 6/5/24 at 02:21 P.M. indicated .Resident transported to ortho appt [appointment] per facility bus driver. The driver is familiar with the facility as he had transported other residents to this location. Driver escorted resident into the building and checked in at the office reception desk, telling the staff he was going to move the facility bus to a parking area. After bus moved, driver immediately returned to the waiting area. Resident was in the exam room being seen. After a period of approximately an hour, driver approached the desk to inquire about the resident, speaking to a different receptionist as the original one was not available. Receptionist stated the resident had already left. The driver had been in the waiting area the entire time after moving the bus. Resident had not exited from the usual door driver picks residents up at, but exited in his wheelchair from a different door that was not visible from where the driver was seated. Driver requested for receptionist to contact security. Driver searched all floors of medical facility, but unable to locate resident. Driver notified facility that resident was unable to be located. The police (case number INC-2-24-000640) were notified. They observed resident on the camera footage leaving the facility. Family and physician notified. Information received from resident sister regarding places resident frequented as he had previously lived in this area. Facility staff members sent to area to assist with search for resident on date of occurrence and again this date. Resident currently unable to be located A Nursing Progress Note, dated 6/11/24 at 2:06 P.M., indicated a Wanderguard (a device to track residents within set borders) had been placed on the resident's right ankle. An Elopement Assessment, completed on 6/13/24, indicated the resident was at moderate risk for an elopement. A Care Plan, initiated on 6/13/24, indicated the resident had exhibited behaviors, such as leaving the facility without notice and talking about living in the woods. The interventions included: Wanderguard placement to remind resident not to leave building alone and IDT (Interdisciplinary Team) to review behavior management program quarterly and as needed. During an observation on 6/13/24 at 3:50 P.M., the resident was locatedout in the courtyard by himself. He was alert to self and place but not oriented to the month or to the name of the current president, but said it really did not matter to him. During an interview with Resident B, on 6/13/2024 at 3:50 P.M., he indicated he had left the doctor's office because he was done and decided to check out some familiar places and friends in the area. He stayed with his friends and ate with them one day, but traveled to a nearby city by walking behind his wheelchair or propelling himself while sitting in it. Resident B indicated he wanted to check on some things. He had lived in the woods nearby and wanted to see if his things were still there. Resident B stayed in his former shelter and ate the canned goods he had stored there. He had built the shelter out of tarps and had lived there several months before he was hit by a truck in a parking lot. Resident B indicated he just wanted to be free and live by himself in his home in the woods. The police had stopped him 3 times, after he left the physician's office and asked where he belonged and if he needed anything. He told them he did not need anything. At one point, the police told him the facility was looking for him, Resident B told them he did not live there anymore. He wanted to live in his shelter, try to get a job and get his food card pin number and just be free. Resdient B indicated the facility had been nice to him and helped him recuperate from the accident, but he just really wanted to go back to his shelter. He was upset his sister had told the facility where to look for him. Resident B willingly came back with a lady who worked at the facility. Resident B stated again he just wanted to be free to live back in his home-made shelter. On 6/14/24 at 10:10 A.M., the Director of Nursing (DON) provided the address of the physician's office and the address where she had picked Resident B up at, which indicated the resident had traveled 4.5 miles. She indicated the police would not issue a Missing Person alert. She also indicated there was no documentation, after the resident was returned to the facility from his elopement, that the resident was supervised and checked on at least every 15-30 minutes to ensure of his whereabouts. On 6/13/24 at 3:05 P.M., the Administrator provide a policy titled, Elopement, dated June 2023 and indicated the policy was one currently used by the facility. The policy indicated .It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing residents and to be proactive in preventing resident elopement .Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff .Any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care This citation relates to Complaint IN00436526. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure staff spoke to residents respectfully for 1 of 20 residents reviewed for resident rights, and failed to ensure personal dignity was provided 1 of 2 residents reviewed for Foley (urinary) catheter use. (Residents 5 & 33) Findings include: 1. During an interview, on 5/14/2024 at 10:04 A.M., Resident 5 indicated that when ordering coffee, a dietary worker yelled at her about telling the surveyors the food was cold. On 5/14/2024 at 12:23 P.M., Resident 5 indicated that she had not informed the staff of this incident, and agreed to allow the surveyor to inform the administrator, and at 12:27 P.M. the administrator was informed of Resident 5's allegation. On 5/14/2024 at 1:50 P.M., the Director of Nursing (DON) and the Administrator indicated that they reported the allegation to the Indiana Department of Health. A record review of Resident 5 was completed on 5/15/2024 at 2:21 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, and bipolar disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 4/18/2024, indicated Resident 5 was cognitively intact. A Nurses Note, dated 5/14/2024 at 12:30 P.M., indicated Resident 5 alleged to a state surveyor that dietary assistant was not kind to her by throwing her under the bus for speaking to the surveyors about the food. Resident 5 felt this invaded her privacy. The physician and the police were notified. This incident was reported to the Indiana Department of Health by the Administrator on 5/14/2024 at 12:30 P.M. The report indicated the dietary assistant was taken off the schedule pending an investigation, and the staff member denied the allegation. A Nurse's Note, dated 5/14/2024 at 3:53 P.M., indicated the police came to the facility, and no report was filed. A handwritten statement from [NAME] 12 indicated, .As I'm making everyone their drikes [sic] Resident 5 says oh the coffee is hot today and I reply [Resident 5] I don't know why that is a surprise the coffee is always hot it comes out of a machine we don't make it so I don't know why she got cold coffee yesterday and she kept say [sic] well it was cold yesterday and I told her we made it the same way we made it today. So she wanted to keep going so as I was walking away to finish passing drinks I did say well I don't know Resident 5 I'm not going to win with you During an interview on 5/17/2024 at 1:55 P.M., the Administrator indicated that the dietary staff should have approached her with any concern, and she didn't feel the dietary staff member spoke to Resident 5 in a degrading tone. A current policy was provided by the Director of Nursing on 5/17/2024 at 2:43 P.M. The policy titled, Resident Rights, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: b. be treated with respect kindness, and dignity 2. During observations of Resident 33 on 5/13/2024 at 7:43 A.M. and 8:48 A.M., a Foley catheter bag could be seen with urine in the bag from the hallway hanging on the frame of the bed. A record review was completed on 5/15/2024 at 10:29 A.M. Diagnoses included, but were not limited to: obstructive and reflux uropathy, hydronephrosis, BPH, and hemiplegia affecting dominant side. A Significant Change Minimum Data Set (MDS) assessment, dated 2/20/2024, indicated Resident 33 had an indwelling urinary catheter. A Physician's Order, dated 2/21/2024, indicated Resident 33 to receive catheter care every shift. A Care Plan, dated 2/16/2023, indicated Resident 33 had an indwelling catheter related to obstructive uropathy and hydronephrosis. An intervention was to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During an interview on 5/17/2024 at 8:08 A.M., the Director of Nursing (DON) indicated a catheter should be covered with a dignity bag. A current policy was provided by the Director of Nursing on 5/17/2024 at 8:00 A.M. The policy titled, Catheter Care, Urinary, did not address the use of a dignity bag over the Foley catheter drainage bag. 3.1-3(a)(2)(D) 3.1-3(t)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop person centered care plans for behaviors for 2 of 22 residents whose care plans were reviewed. ( Residents 63 & 64) Findings include: 1. A record review was completed on 5/15/2924 at 1:48 P.M. for Resident 63. Diagnoses included but were not limited to Vascular dementia, falls, hypertension, and insomnia. An admission MDS (Minimum Data Set) assessment, dated 4/24/2024, indicated the resident had no behaviors during the assessment period and required supervision for eating needs, and substantial to maximum assist for bathing and transfer needs. The resident had a fall prior to admission and fell after admission and received antipsychotic and antidepressant medications. Resident 63's current medications included: Trazodone 150 mg (milligram) (antidepressant) give 1.5 tablet by mouth at bedtime for sleep. Mirtazapine 7.5 mg (antidepressant) give 0.5 tablet by mouth at bedtime for insomnia. Olanzapine Oral Disintegrating (an antipsychotic) 5 mg give 1 tablet by mouth three times a day for psychosis. A Discharge summary, dated [DATE], indicated the resident was discharged from the facility and admitted to a psychiatric hospital due to increased behaviors and confusion. The psychiatric hospital's discharge recommendations were for ongoing psychiatric follow up with close monitoring of psychiatric medications. A current Care Plan, dated 5/1/2024, indicated the resident was on antipsychotic medications related to behavior management. Interventions included, but were not limited to; .Administer medications as ordered. Observe/document for side effects and effectiveness per facility policy. Consult with pharmacy. MD to consider dosage reduction when clinically appropriate. Observe the resident every shift for effectiveness of medications. Refer to psych as indicated. The resident will be followed by a behavior management program There was no person centered care plan to address the resident's exhibited behaviors. During an interview, on 5/17/2024 at 10:24 A.M., Social Service staff indicated she was unaware of Resident 63's behaviors. She said if there were behaviors, they should be documented in the progress notes. She indicated the care plan was not person centered. 2. A record review was completed on 5/16/2024 at 9:12 A.M. for Resident 64. Diagnoses included but were not limited to dementia, psychotic disorder, anxiety, and post traumatic stress disorder. Resident 64's current Physician Orders included: Quetiapine (antipsychotic) 150 mg every day for psychotic disorder. A Behavior Note, dated 4/25/2024 at 10:50 A.M., indicated the resident was standing at the doorway to unit 4 and blocking the door yelling, PAIN MED over and over. The nurse asked the resident to back up from door, and the resident backed up but continued yelling pain med. The nurse explained she was there to hook up his intravenous medication and would find out what medication she could give him. The resident told the nurse to get the h--- out of here A Nurses' Note, dated 4/26/2024, indicated: the following: alert with confusion. Excessive call light use, gets agitated and loud if not answered immediately. Stated he is speaking with staff in morning to leave. A Social Service Note, dated 4/29/2024 at 2:28 P.M., indicated: [Name of Resident] admitted for short term rehab to home- currently living in a hotel and states he likes it very well and wants to return there. [Name of Resident] has diagnoses of depression, PTSD (Post Traumatic Stress Disorder), and unspecified dementia. Currently taking Quetiapine and Duloxetine. A current Care Plan, dated 4/29/2024, indicated the resident had a diagnosis of depression and exhibited behaviors such as tearfulness and verbal expression of sadness. The interventions included, but were not limited to; Offer a calm and quiet space for the resident to have some alone time. Offer to go outside and get fresh air. Offer to turn on Southern Rock music. The record lacked a person centered Care Plan for the use of the Antipsychotic medications and for the yelling behavior. During an interview on 5/17/2024 at 10:24 A.M., Social Service staff indicated the Care Plan was not person centered. On 5/17/2024 at 1:55 P.M., the Director of Nursing provided the policy titled, Care Plan, Comprehensive Person-Centered, dated 9/2022, and indicated the policy was the one currently used by the facility. The policy indicated: .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developes and implements a comprehensive person-centered care plan for each resident. 2. The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment. 7. The care planning process will: .b. Include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences 8 .h. Incorporate identified problem areas; i. Incorporate risk factors associated with identified problems .10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint f an interdisciplinary process 3.1-35(a)

Based on interview and record review, the facility failed to provide care plan meeting for 1 of 4 residents reviewed for care planning. (Resident 32) Finding includes: During an interview, on 5/14/2024 at 9:28 A.M., Resident 32 indicated he did not have routine care plan meetings. A record review of Resident 32 was completed on 5/15/2024 at 12:05 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, obesity, and gastroesophageal reflux disorder (GERD). A Care Plan Note, dated 3/2/2023, indicated a care plan meeting had occurred A Care Plan Note, dated 1/4/2024, indicated a care plan meeting had occurred. A Multidisciplinary Care Conference Note, dated February 2024, indicated a care plan meeting had occurred. During an interview, on 5/17/2024 at 9:12 A.M., the Social Service Director indicated care conferences were normally held quarterly, and Resident 32 should have had care conferences held quarterly between March 2023 and January 2024. A current policy was provided by the Director of Nursing (DON) on 5/17/2024 at 2:43 P.M. The policy titled, Care Planning Policy & Procedure, indicated, .7. Each resident's care plan shall be reviewed at least quarterly and will include the Resident's strengths and weaknesses and incorporate personal and cultural preferences in developing care plans 3.1-35(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an interview on 5/13/2024 at 7:35 A.M., Resident 32 indicated he had not received his showers timely. He indicated he had been waiting a week and this happened frequently. A record review was completed on 5/15/2024 at 12:05 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 and obesity. A Quarterly Minimum Data Set (MDS) assessment, dated 2/7/2024, indicated Resident 32 required partial/moderate staff assistance for bathing. A 30-day review of the documented showers in the electronic health record for Resident 32 indicated his shower days were on Tuesday and Friday in the evening, and he received showers on 4/18/2024 at 10:54 P.M., 4/21/2024 at 2:42 A.M., 5/3/2024 at 4:53 A.M. and 11:37 P.M. and 5/16/2024 at 12:24 A.M. A Care Plan, dated 3/15/2021, indicated Resident 32 required assistance with his activities of daily living due to pain and arthritis in his left hip. Review of shower sheets for the month of May 2024, provided by the Director of Nursing (DON) on 5/17/2024 at 10:58 A.M., indicated Resident 32 had only one shower sheet dated 5/17/2024. The DON indicated this was all the completed shower sheets for Resident 32 available for the month of May. During an interview on 5/17/2024 at 11:20 A.M., CNA 17 indicated Resident 32 was scheduled to receive his showers on Tuesdays and Fridays according to the shower book. During an interview on 5/17/2024 at 1:44 P.M., the DON indicated she could not find any further shower sheets for Resident 32. Resident 32 should have received showers per the schedule of at least showers per week and if the resident refused a shower, the nurse needed to be notified, and the refusal should be documented in the medical record. A current policy was provided by the Director of Nursing on 5/17/2024 at 2:43 P.M. The policy titled, Shower/Bathing Policy, indicated, .If the resident refuses a shower, a bed bath will be offered and provided as per the residents' preference 3.1-38(b)(2) Based on observation, interview and record review, the facility failed to provide showers at least twice weekly for 3 of 5 residents reviewed for ADL's (activities of daily living). (Residents 20, 65 and 32) Findings include: 1. During an interview on 5/14/2024 at 9:02 A.M., Resident 20 indicated she had not had any showers since admission. Resident 20 was admitted on [DATE]. A record review was completed on 5/15/2024 at 9:04 A.M.for Resident 20. Diagnoses included, but were not limited to depression, anxiety, hypertension, hemiplegia, seizures, and diabetes. An admission MDS (Minimum Data Set) assessment, dated 5/6/2024, indicated the resident had impairment to her ROM(range of motion) on one side to both upper and lower extremities. She required substantial to maximum assist for toileting, and used a mechanical lift for transfers. A current Care Plan, dated 5/8/2024, indicated the resident had an ADL (activities of daily living) Self Care Performance Deficit related to a history of CVA (cerebral vascular accident), recent hospital stay for pneumonia and UTI (urinary tract infection). An intervention included: BATHING: The resident is totally dependent on staff to provide a bath/Shower weekly and as necessary. The shower schedule indicated Resident 20 was to receive showers on Wednesday and Saturday evenings. The shower documentation for Resident 20, dated May 2024, indicated the resident received a bed bath on Wednesday 5/1/2024. There was no documented shower on Saturday 5/4, 5/8, and 5/11/2024 During an interview on 5/17/2024 at 3:26 P.M., the Director of Nursing indicated the resident should have had more showers. 2. During a observation on 5/14/2024 at 9:41 A.M., Resident 65 was observed with whiskers to his face. During an observation on 5/15/2024 at 9:24 A.M., Resident 65 was observed with white facial whiskers 1/4 inch in length and his hair looked greasy. A record review was completed on 5/15/2024 at 9:26 A.M. for Resident 65. Diagnoses included, but were not limited to acute kidney failure, dementia, Type 2 diabetes mellitus, and retention of urine. An admission MDS (Minimum Data Set) assessment, dated 5/1/2024, indicated the resident exhibited no behavioral symptoms, required bathing and dressing lower body assistance and required maximum assistance with showering. A current Care Plan, dated 4/28/2024, indicated Resident 65 required assist with ADL's due to: dementia, musculoskeletal impairment, limited mobility, and a weakened state. Interventions included, but were not limited to: the resident preferred to complete bathing with extensive assist as needed . The shower schedule for Resident 65 indicated he was to receive showers on Wednesday and Saturday evenings. The shower documentation for Resident 65, dated April and May 2024, indicated the resident received a shower on 4/26, and a bed bath on 4/28/24 and 5/8/2024. There were no documented showers for 5/1, 5/4, and 5/11/2024. During an interview, on 5/17/2024 at 3:27 P.M., the Director of Nursing indicated the resident should have had more showers.

Based on observation, record review and interview, the facility failed to provide the appropriate care and services to prevent urinary tract infections related to a urinary catheter drainage bag on the floor for 1 of 3 residents reviewed for catheters. (Residents 65) Finding include: During an observation, on 5/15/2024 9:00 A.M., Resident 65 was in his wheelchair with his urinary catheter drainage bag dragging on the floor. During an observation, on 5/15/2024 at 10:52 A.M., Resident 65 was observed wandering in his wheelchair with the urinary catheter drainage bag dragging on the floor. During an observation, on 5/15/2024 at 11:25 A.M., a staff member was observed pushing Resident 65 to the dining room with the urinary catheter drainage bag dragging the floor. During an observation, on 5/15/2024 at 2:17 P.M., Resident 65 was wandering in his wheelchair with the urinary catheter drainage bag dragging on the floor. During an interview, on 5/16/2024 at 3:28 PM QMA 15 indicated the drainage bag should not be in the floor. During an observation, on 5/16/2024 at 3:30 P.M., Resident 65 was lying in bed with the urinary drainage bag laying directly on the floor. During an interview, on 5/16/2024 at 3:28 P.M., QMA 15 indicated the drainage bag should not be in the floor. During an observation, on 5/17/2024 at 11:35 A.M., Resident 65 was sitting in his wheel chair in the dining room with the urinary drainage bag next to him in the wheel chair, above the level of his bladder During an interview, on 5/17/2024 at 11:40 A.M., QMA 14 indicated the drainage bag should not be in the wheelchair A record review was completed on 5/15/2024 at 9:26 A.M. for Resident 65. Diagnoses included, but were not limited to urinary tract infection, acute kidney failure, dementia, diabetes mellitus, and retention of urine. An admission MDS (Minimum Data Set) assessment, dated 5/1/2024, indicated the resident required maximum assistance with bathing, toileting, and showering and received Macrodantin (antibiotic) 50 mg (milligrams) 1 capsule two times a day for urinary tract infection. A current Care Plan, dated 4/28/2024, indicated the resident currently has a urinary catheter #16 Foley with 10 cc balloon due to: Urinary Retention. Interventions included, but were not limited to: .Catheter Assessment quarterly and as needed to assess the need for continued use of the catheter. Change my catheter bag as ordered. Keep the catheter system as closed as much as possible. Notify my MD of any signs of infection. Offer me fluids frequently. Provide catheter care as per facility policy. Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine) . On 5/17/2024 at 8:00 A.M., the Director of Nursing provided the policy titled, Catheter Care, Urinary, dated 2014, and indicated the policy is the one currently used by the facility. The policy indicated: . The purpose of this procedure is to prevent catheter- associated urinary tract infections . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . b. Be sure the catheter tubing and drainage bag are kept off the floor 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to assess the use of a side rail before maintaining the bedrail in the upright position for 1 of 5 Residents (Resident 42) reviewed for accidents. Finding Includes: During an interview, on 05/13/2024 at 11:50 A.M., Resident 42 indicated he had a fall and he was supposed to use this to get up. (The resident then pointed to his siderail on the right side of the bed) A record review was completed on 5/16/24 at 11:36 A.M., Diagnoses included, but were not limited to: heart failure, rhabdomyolysis, hypoxemia, fall on same level, difficulty in walking, muscle weakness, vascular dementia, bradycardia, hypertension, anemia, bells palsy, dyspnea and insomnia. A Quarterly MDS (Minimum Data Set) assessment, dated 4/17/2024 indicated Resident 42 had moderate cognitive cognition, utilized wheelchair for ambulation and was at risk for falls. A Nursing Progress Note, dated 3/2/2024 at 4:42 A.M., indicated Resident 42 was found sitting on floor beside his bed. Resident indicated he had slid off of his bed and denies any injury. Resident was assessed and assisted, no injury noted. DON, NP and family were notified. Facility to start neuro sheet. A Care Plan, with a revision date of 12/1/2023, indicated Resident 42 was at risk for falls related to Cognitive impairment, balance deficits, alcohol withdrawal, Bell's palsy, obesity and neuropathy. A Fall Risk Evaluation was completed on 3/2/2024 and indicated Resident 42's balance was not normal and he required assistive devices. An Interdisciplinary Team (IDT) Note, dated 3/2/2024, indicated a siderail was to be applied to Resident 42's bed, as an intervention to assist with positioning. During an interview, on 05/16/2024 at 01:48 P.M., the Director of Nursing indicated there was no side rail assessment completed prior to adding the intervention and one should have been completed. A policy was provided on 5/16/2024 at 2:22 P.M., by the Director of Nursing. The policy, titled, Use of Bed Rails indicated, .3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using bed rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility, b. ability to change positions, transfer to and from bed or chair, and to stand and toilet, c. potential risks with the use of bed rails, and d. that the bed's dimensions are appropriate for the residents size and weight 3.1-45 (1)(2)

Based on observation and interview, the facility failed to post the daily nursing staffing at the beginning of the shift. Finding includes: During an observation, on 5/13/2024 at 7:34 A.M., the nursing staff posting was dated 5/11/2024. During an interview, on 5/17/2024 at 8:26 A.M., the Director of Nursing (DON) indicated night shift completes the nursing staff posting for the next day. The third shift should have posted the nursing staffing by midnight. A policy was provided by the DON on 5/17/2024 at 3:43 P.M. The policy titled, Posting Direct Care Daily Staffing Numbers, indicated, .Our facility will post, on a daily basis for each shift the number of nursing personnel responsible for residents

Based on observation, record review and interview, the facility failed to ensure narcotics were counted and documented every shift for 1 of 2 narcotic count log books reviewed. (Skilled Hall) Finding includes: A medication storage observation of the Skilled Hall medication cart was completed, on 5/16/2024 at 6:47 A.M., with LPN 4. The the narcotic log book there were 30 missing signatures from 4/16/2024 thru 5/15/2024. During an interview, on 5/16/2024 at 6:53 A.M., LPN 4 indicated the narcotic log sheets should be signed every shift. On 5/16/2024 at 10:35 A.M., the Director of Nursing provided the policy titled, Controlled Substance,undated, and indicated the policy was the one currently used by the facility. The policy indicated .9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and thru nurse going off duty must make the count together 3.1-25(3)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, served and delivered in a sanitary manner in 1 of 1 kitchens. This had the potential to affect 67 of 67 residents who consumed food from the kitchen. Findings include: During an observation of the kitchen on 5/13/2024 at 7:42 A.M., with [NAME] 16, the following was observed: the freezer had a bag of waffles, a bag of pancakes, 2 pizzas, a bag of broccoli, a bag of hamburger patties, 4 bags of cereal and a bag of chicken strips that were all undated and opened. the prep counter had crumbs and a grease like substance on top the storage bins were dirty with dried crumbs stuck to the lid the delivery cart had dried food particles and crumbs covering the top the dishwasher was dirty on the top and covered with crumbs the cooler had an undated bowl of fruit and salad. During an interview, on 5/13/2024 at 8:07 A.M., [NAME] 16 indicated the items should have been dated and /or thrown out if expired and the counters, storage bins, delivery cart and dishwasher should have been cleaned 2. During a continuous observation, on 5/13/2024 from 8 :16 A.M. to 8:24 A.M., six observations were made of LPN 5 placing her thumb on the food surface of dinner plates and touching the rim of cups with her fingers while serving food to residents. During an observation, on 5/13/2024 at 9:12 A.M., QMA 9 was observed carrying a meal tray without a cover in hall. During an interview, on 5/13/2024 at 9:15 A.M., QMA 9 indicated the plate should have been covered. During an interview, on 5/13/2024 at 2:17 P.M., the Dietary Manager indicated the staff should not have their fingers beyond the rim of the plate or cup during meal service and all meals should be delivered covered. All items in storage and in the coolers should be dated with arrival date and discard date and discarded when expired. On 5/15/2024 at 1:30 P.M., the Dietary Manager provided the policy titled, Labeling and Dating, dated 5/2018 and indicated this is the current policy being used. The policy indicated .Label with the date item is placed in storage and the date of discard . On 5/16/2024 at 12:09 P.M., the Dietary Manager provided the policy titled, Employee Sanitary Practices, dated 7/23 and indicated this is the current policy being used. The policy indicated .Clean equipment and work units after use. All small equipment, counters, delivery carts are to be cleaned after each use. Storage bins and dishwasher are to be cleaned daily On 5/16/2024 at 12:11 P.M., a policy was requested related to correctly delivering meals during dining and one was not provided. This relates to Complaint IN00434221 and Complaint IN00434242 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program related to gnats in residents rooms and in common areas in the facility in 1 of 4 units observed for environment. (200 Hall). Finding includes: On 5/16/2024, from 1:48 P.M. through 2:36 P.M., an environmental tour was conducted with the Administrator and the Maintenance Director. The following observations contained the following concerns: - room [ROOM NUMBER] the bathroom had 3 gnats. During an interview with Resident 32, on 5/16/2024 at 1:33 P.M., he indicated he has had concerns about gnats being in his room and had complained to staff about them. A pest control invoice was received on 5/17/2024, and indicated the last pest management was on 4/17/2024, and was due next on 5/17/2024, then scheduled monthly. On 5/16/24 at 2:45 P.M., the Director of Housekeeping indicated there was no policy regarding environmental cleaning. On 5/16/24 at 2:57 P.M., the Housekeeping Supervisor provided an untitled form which indicated the following tasks a housekeeper should be providing to each resident's room, 7 days a week: -Empty all trash, cans, cups and wrappers from room and bathroom. -Clean mirror, sink, counter, toilet, toilet risers and rails. -Wipe down all flat surfaces (dresser, window sill, side tables and night stand. -Sweep and mop-under the bed, room and bathroom. This Federal deficiency relates to Complaints IN00434242 and IN00434221. 3.1-19(f)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party of a transfer to the emergency room for 1 of 3 residents reviewed for transfer and discharge. (Resident D) Findings include: On 12/18/23 at 10:18 A.M., the clinical record for Resident D was reviewed. Resident D was admitted to the facility on [DATE] with the most recent readmission date of 3/16/23. The resident's diagnoses included, but were not limited to, a history of stroke, gastrostomy (tube in the stomach for feeding), hemiplegia (partial paralysis), hemiparesis (partial weakness), aphasia (loss of ability to speak), and intracranial abscess (infected area in the brain). The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/23, indicated Resident D rarely or never understood others and rarely or never made himself understood. Resident D had severe cognitive impairment, was not ambulatory, was dependent on others for all activities of daily living, and required a feeding tube for all nutrition. Progress Notes, dated 11/26/23 at 3:16 P.M., indicated, .[resident's nurse] was summoned to pts [patient's] room on assessment [resident's nurse] observed that the pts g tube was dislodged also note a small amount of bleeding and facial grimaces indicating some discomforts. [Resident's Nurse] was able to replace site .could also hear audible gurgling and wheezing. Lung assessment indicated some distress [patient's nurse] notified MD [medical doctor] and was given order to transfer out to [local hospital] .phoned [local ambulance] and pt was prepped for transfer . An in-service training, dated from 11/27/23 to 12/01/23 and titled, Transfers/Change of Condition/Notification, indicated nursing staff signed the training form specifying, When there is a change of condition with a resident, nurses are to call MD, DON [Director of Nursing], and Family, Nurses MUST include in their note that they have call MD and Family and DON. Nurses are to call family if the resident is sent out to ER and note it in the nurses note . During an interview on 12/20/23 at 10:45 A.M., LPN 2 indicated Resident D's sister called the facility and informed her the resident's responsible party notified her that the resident had been taken to the Emergency Room. LPN 2 indicated she explained why the resident was transferred to the ER at that time. LPN 2 indicated she had not notified Resident D's responsible party at the time the resident was transferred to the ER, and that nursing staff were responsible to notify the responsible party of transfers. During an interview with Resident D's responsible party on 12/20/23 at 1:00 P.M., she indicated she received a call from the ER on [DATE] around 5:30 P.M., notifying her the Resident was in the ER. The facility never notified her of the transfer nor a decline in the resident's condition. A policy titled, Acute Condition Changes-Clinical Protocol, dated 3/18 was provided by the Administrator on 12/20/23 at 12:20 P.M., and indicated, . A policy titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, was provided as current by the Administrator on 12/20/23 at 12:20 P.M. The policy indicated, .For an emergency transfer or discharge to a hospital or other acute care institution .When a resident is transferred or discharged from the facility, the following information is documented in the medical record .That an appropriated notice was provided to the .legal representative . This citation relates to Complaint IN00422875. 3.1-5(a)(2)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the correct clinical information was provided to a receiving hospital that was necessary to meet a resident's needs and ongoing care, for 1 of 3 residents reviewed for transfer and discharge, (Resident D). Finding includes: On 12/18/23 at 10:18 A.M., the clinical record for Resident D was reviewed. Resident D was admitted to the facility on [DATE] with the most recent readmission date of 3/16/23. The resident's diagnoses included, but were not limited to, a history of stroke, gastrostomy (tube in the stomach for feeding), hemiplegia (partial paralysis), hemiparesis (partial weakness), aphasia (loss of ability to speak), and intracranial abscess (infected area in the brain). The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/23, indicated Resident D rarely or never understood others and rarely or never made himself understood. Resident D had severe cognitive impairment, was not ambulatory, was dependent on others for all activities of daily living, and required a feeding tube for all nutrition. Resident D's current Out of Hospital Do Not Resuscitate Declaration and Order (DNR), was dated 3/16/23. Resident D's current Physician's Orders included, DNR, nothing by mouth diet, and tube feeding for nutrition. Progress Notes, dated 11/26/23 at 3:16 P.M., indicated, .[resident's nurse] was summoned to pts [patient's] room on assessment [resident's nurse] observed that the pts g tube was dislodged also note a small amount of bleeding and facial grimaces indicating some discomforts. [Resident's Nurse] was able to replace site .could also hear audible gurgling and wheezing. Lung assessment indicated some distress [patient's nurse] notified MD [medical doctor] and was given order to transfer out to [local hospital] .phoned [local ambulance] and pt was prepped for transfer . The Transfer/Discharge Report, dated 11/26/23, Prehospital Care Report Summary, dated 11/26/23, Clinical Resident Profile, dated 11/26/23, and Order Summary Report, dated 11/26/23, which were sent by the facility with the resident to the local ER, were provided by the local hospital's Medical Records Department on 12/19/23 at 9:30 A.M. The Transfer/Discharge Report indicated a different resident's (Resident F's), information was sent with Resident D to the ER, which included Resident F's name, date of birth , and medication list. The Transfer/Discharge Report indicated Resident F had a Full Code status, and that Resident F was diabetic. The Prehospital Care Report Summary, which was the summary of the service provided by the ambulance that transported Resident D to the ER, indicated Resident D's birthrate, social security number, and physical assessment, but Resident F's diagnoses. The report summary also included another Transfer/Discharge Report with all of Resident D's correct information. The Clinical Resident Profile was Resident D's current clinical information. The Order Summary Report was Resident D's current Physician's Order Summary. During an interview on 12/18/23 at 11:00 A.M., the Executive Director indicated that on 11/26/23, Resident D developed respiratory difficulty and was sent to a local ER for care. The facility had 2 residents with the same first and last names (Residents D & F) and some of Resident F's information was incorrectly sent the the ER along with some of Resident D's information. During an interview on 12/203 at 10:45 A.M., LPN 2 indicated when she attempted to printed out Resident D's clinical paperwork to be transferred to the ER with the resident via the local Emergency Medical Technicians (EMT), the papers did not print out, so she attempted to print the information again. The second time she printed the information, it did print at the printer, but she believed she may have mistakenly printed Resident F's information first, and on the second attempt, she printed off Resident D's information, and both sets of information printed and Resident F's information was mistakenly sent to the local ER along with Resident D's information. A policy titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, was provided by the Administrator on 12/20/23 at 12:20 P.M. as current. The policy indicated, .For an emergency transfer or discharge to a hospital or other acute care institution .Prepare for medical record transfer .the following information is communicated to the receiving facility .Resident representative information, Advance directive information .All special instructions or precautions for ongoing care .diagnoses .medications .resident's discharge summary . This citation relates to Complaint IN00422875. 3.1-12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the misappropriation of narcotics for 3 of 4 residents reviewed who were being administered narcotics. (Resident G, Resident F and Resident K) Findings includes: During an interview, on 8/3/23 at 1:58 P.M., LPN 4 indicated approximately 2 weeks ago Resident G had a missing Controlled Drug Record and the resident had approximately 10-12 tables left on the drug card. LPN 4 implied LPN 3 had wasted them and there were no other witnesses. LPN 4 indicated Resident F had requested a pain pill from her on July 16th and she explained to him it was to early to have a dose, since he had one a 6:00 A.M. The resident indicated to her he had never received a pain pill at 6:00 A.M. on the morning of July 16th. 1. On 8/4/223 at 10:15 A.M., a review of the clinical record for Resident G was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: unspecified pain and dementia with anxiety. The Physician Orders indicated the resident was to be administered Hydrocodone-Acetaminophen 5/325 milligrams (mg). Order stated to give 1 tablet, by mouth, every 4 hours as needed for pain. The start date was 6/14/23 with a stop date of 6/29/23, then updated on 6/29/23 to continue order until 7/13/23. The current order, started on 7/17/23, indicated to administer Hydrocodone/Acetaminophen 5/325 mg tablet, by mouth, four times a day. The June 2023 Medication Administration Record (MAR) indicated the resident was being administered, as needed, the Hydrocodone/Acetaminophen 5/325 mg. tablet on the following dates and times: - 6/17 at 7:15 A.M. and 2:00 P.M. - 6/18 at 7:36 A.M. and 2:00 P.M. - 6/21 at 6:57 A.M., 12:22 P.M. and 8:02 P.M. - 6/22 at 8:30 A.M. - 6/23 at 7:05 P.M. - 6/24 at 6:05 A.M. - 6/25 at 12:03 A.M. and 8:24 P.M. - 6/26 at 2:20 A.M., 6:45 P.M., 12:00 P.M. and 7:50 P.M. - 6/27 at 8:00 A.M., 12:30 P.M., 4:15 P.M. and 10:00 P.M. - 6/28 at 4:40 P.M. and 11:28 P.M. - 6/29 at 8:00 P.M. - 6/30/23 at 9:?? (form cut off minutes) This equaled 24 tablets administered. The July 2023 MAR indicated the resident was administered, as needed, a Hydrocodone/Acetaminophen 5/325 mg. tablet on the following dates and times: - 7/1 at 8:46 AM and 8:04 P.M. - 7/2 at 6:22 A.M. This equaled 3 tablets administered. A Controlled Drug Records (CDR) form for June and July of 2023, were provided by the Director of Nursing. The CDR indicated LPN 6 signed for the receipt of 28 tablets of Hydrocodone/Acetaminophen 5/325 mg from the pharmacy, on 6/14/23. Documentation of those 28 tablets, being removed for administration, started on 6/17/23, with first dose removed on 6/17/23, by LPN 3 and last dose removed on 7/2/23 by LPN 6. This CDR form indicated 28 tablets were removed for administration, however the CDR indicated LPN 6 had removed a tablet for administration on 6/30 at 2:00 AM but did not document as administered, to the resident, on the MAR. The July 2023 MAR indicated the resident was administered, as needed, Hydrocodone/Acetaminophen 5/325 mg tablet on the following dates and times: - 7/4 at 7:06 P.M. - 7/5 at 12:58 A.M., 9:30 A.M. and 3:59 P.M. - 7/6 at 2:54 A.M. and 8:00 P.M. - 7/7 at 12:58 A.M. - 7/8 at 12:23 P.M. and 9:58 P.M. - 7/9 at 7:03 A.M. - 7/10 at 1:07 P.M. and 8:25 P.M. - 7/11 at 2:11 A.M. and 7:30 P.M. - 7/12 at 2:58 A.M. and 7:22 P.M. - 7/13 at 1:39 P.M. The order indicated a stop date of 7/13/23. This equaled 17 tablets administered. There was no CDR form indicating the removal of the Hydrocodone/Acetaminophen 5/325 mg from 7/4/23 through 7/13/23. During an interview, on 8/4/23 at 2:10 P.M., the Director of Nursing (DON) indicated she had provided all the CDRs for June and July. She indicated a new Controlled Drug Record would have been started and would have had the signature, of the receiving nurse and the number of tablets received. The DON did not know the amount of of tablets the facility received due to the next CDR form, starting on 7/4/23, was missing. The DON indicated LPN 3 had destroyed all the remaining medications, on the dispensing card and had another nurse witness the destruction. The DON indicated the CDR was placed in the medical records box/folder by LPN 3, and was never found. A typed Investigation, dated 7/16-7/21/23, indicated on 6/16/23 a narcotic record (CDR) was missing for Resident G. An interview was conducted with LPN 3. LPN 3 indicated she .disposed of the medication with a witness as the medication was completed per the EMR [electronic medication record] . she was the only nurse in the building and had a CAN (sic) [Certified Nurse Aide] witness this The investigation indicated LPN 4 was concerned LPN 3 took the medication and did not destroy them, however LPN 4 indicated she had seen the form in LPN 3's hands and observed her to walking to the front office and then left the building The DON came to the building to check the medical records box and the CDR was not in the box. The DON and the Administrator searched everywhere but could not locate the form. During an interview, on 8/7/23 at 12:08 P.M., LPN 3 indicated she had destroyed Resident G's Norco (Hydrocodone/Acetaminophen) with CNA 7. LPN 3 indicated she was going to administer, Resident G, a dose of the Norco, but realized the order had been discontinued. So to ensure she nor anyone else made an error, she had CNA 7 witness the count of the remaining pills, approximately 10 tablets, with her. She then crushed them, put them in water and disposed of them, down the drain, in the shower room. She was aware she should not of had the CNA 7 sign the count for the destruction of those medications, she thinks she might have been the only nurse on the unit and/or the facility. She indicated she had taken the destruction form (CDR) to the front office and placed in the Medical Records box as she was leaving the facility. 2. On 8/4/223 at 2:00 P.M., a review of the clinical record for Resident F was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: left tibia fracture, non-displace fracture of the of clavicle, multiple fractures of the ribs, motorcycle driver injuries, alcohol abuse and stimulant abuse. A Care Plan, dated 6/11/23, indicated the resident had pain related to fractures and surgical wounds. The interventions included, but were not limited to: administer analgesic (pain reliever) as ordered and monitor/record/report to nurse complaints of pain or requests for pain medication. The Physician Orders, dated 6/7/23, indicated Oxycodone/Acetaminophen 7.5/325 mg. Give 1 tablet by mouth every 12 hours as needed for pain. A Controlled Drug Record (CDR), dated 6/27/23, indicated the LPN 6 had received 30 tablets of Ocycodone/Acetaminophen 7.5/325 mg from the pharmacy The MAR from 6/27/23-6/30/23, indicated the resident was administered Ocycodone/Acetaminophen 7.5/325 mg. tablet on the following dates and times: - 6/27 at 4:10 A.M., 10:30 A.M. and 4:18 P.M. - 6/28 at 1:30 A.M. and 3:32 P.M. - 6/29 at 12:57 A.M., 9:08 A.M. 4:22 P.M. and 11:55 P.M. - 6/30 at 7:?? (minutes cut of form) and 3:?? (minutes were cut off form) This equaled 11 tablets administered. The CDR indicated an Ocycodone/Acetaminophen 7.5/325 mg. tablet had been removed from the narcotic container/card on the following dates and times: - 6/27 at 4:10 A.M., 10:30 A.M. and 2 tablets at 4:30 P.M. (dosing order was for 1 tablet, 2 removed by LPN 3) - 6/28 at 1:30 A.M., 9:00 A.M. and 3:30 P.M. (the 9:00 A.M.,administration was not document on the MAR by QMA 8) - 6/29 at 1:00 AM, 9:00 A.M., 4:30 P.M. and 11:53 P.M. - 6/30 at 7:05 A.M. and 3 :10 P.M. Surveyor did not receive the CDR for previous days in June. This equaled 13 tablets were removed for administration. The MAR from 7/1/23 - 7/19/23, indicated the resident was administered Ocycodone/Acetaminophen 7.5/315 mg. tablet on the following dates and times: - 7/1 at 2:31 A.M., 8:30 A.M. and 2:30 P.M. - 7/2 at 7:32 A.M. and 8:38 P.M. - 7/3 at 4:07 A.M., 1:31 P.M. and 8:49 P.M. - 7/4 at 12:06 P.M. and 6:20 P.M. - 7/5 at 12:24 A.M., 8:01 A.M., 3:41 P.M. and 11:05 P.M. - 7/6 at 8:12 A.M., 3:00 P.M. and 10:00 P.M. - 7/7 at 15:27 P.M. - 7/8 at 12:50 P.M., 9:04 A.M., 3:45 P.M. and 10:14 P.M. - 7/9 at 8:17 P.M. and 4:39 P.M. - 7/10 at 12:28 A.M., 8:40 A.M., 4:15 P.M. and 11:30 P.M. - 7/11 at 8:14 A.M., and 4:20 P.M. - 7/12 at 1:08 P.M., 8:43 A.M., 4:10 P.M. and 10:42 P.M. - 7/13 at 8:32 A.M. and 4:00 P.M. - 7/14 at 11:15 P.M. - 7/15 at 7:50 P.M. and 9:00 P.M. - 7/16 at 3:02 A.M., 12:00 P.M. and 6:25 P.M. - 7/17 at 12:11 A.M. and 9:19 A.M. - 7/18 at 8:25 A.M. and 3:18 P.M. - 7/19 no doses documented as administered. This equaled 46 tablets recorded as administered. The CDRs indicated an Ocycodone/Acetaminophen 7.5/325 mg. tablet had been removed from the narcotic container/card on the following dates and times: - 7/1 at 2:30 A.M., 8:30 A.M., and 2:30 P.M. with one dose sent with resident, at 6:30 P.M.,he was attending a wedding. - 7/2 at 8:00 A.M., 2:00 P.M. and 8:38 P.M. (2 tabs removed at 2:00 P.M.-1 dropped and destroyed by LPN 3 & LPN 4 and 1 tab not recorded as administered by LPN 3) - 7/3 at 4:00 A.M., 1:30 P.M. and 8:50 P.M. - 7/4 at 4:30 A.M., 12:06 P.M. and 6:20 P.M. (4:30 A.M. tablet was not documented, as administered, on the MAR, by QMA 9) - 7/5 at 12:20 A.M., 8:00 A.M. and 4:00 P.M. - 7/6 through 7/14 CDR was not received from the DON - 7/15 at 9:00 P.M. - 7/16 at 3:00 AM, 6:00 A.M., 12:00 P.M., 6:25 P.M. (6:00 A.M. administration was administered 3 hours to early, by LPN 3) - 7/17 at 12:00 A.M., 9:00 A.M. and 3:00 P.M. ( 3:00 P.M. tablet was not documented, as administered, on the MAR, by LPN 10) - 7/18 at 8:20 A.M., 3:20 P.M. and 10:45 P.M. ( 10:45 P.M. tablet was not documented, as administered, on the MAR, by LPN 11) - 7/19 at 7:30 A.M. and 2:30 P.M. (Both tablets were not documented, as administered, on MAR, by LPN 12) This equaled 30 tablets recorded as removed. The final CDR indicated 16 tablets were sent home with the resident. A typed Investigation, dated 7/16-7/21/23, indicated on 7/16/23 Resident F could not recall if he received the medication or not. On 7/17/23, LPN 3 was interviewed as part of the investigation and she indicated she had administered medications at the resident's request. The investigation results indicated results of the investigation the facility was unable to prove any misconduct. LPN 3 was provided one on one education, given a final notice and going forward will have another nurse or QMA sign out all narcotics administered. During an interview, on 8/7/23 at 12:08 P.M., LPN 3 indicated she had done a medication error with Resident F because he came and asked for a pain pill around 6:00 A.M., however it was to early to give him another one. LPN 3 thought about it and stated the man had several fractures and was in pain so gave it to him early. On 8/9/23 at 11:18 A.M., the DON indicated there was no medication error form or documentation regarding the medication error for Resident F, performed by LPN 3. 3. On 8/7/23 at 11:50 A.M., a review of the clinical record for Resident K was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: fusion of spine-lumbar region with neurogenic claudication and vertebrogenic low back pain. A Care Plan, dated 7/15/23, indicated the resident had acute and chronic pain. The interventions included, but were not limited to: administer analgesic (pain reliever) as ordered, monitor/record/report to nurse complaints of pain or requests for pain medication and evaluate the effectiveness of pain interventions. A Physician's Order, dated 7/15/23, indicated the resident had an order for Oxycotin 10 mg. extended release(ER),by mouth, every 12 hours for pain. And another order, dated 7/15/23, for Oxycodone 5 mg every 4 hours as needed for pain. Progress Note, dated 7/15/23 at 9:35 P.M., indicated Oxycodone 5 mg was administered to the resident for pain. Resident rated pain a 6 out of 10 on the 1-10 pain scale. Another Progress Note, dated 7/15/23 at 10:51 P.M., indicated the administration of the pain medication was effective as the resident rated his pain a 2 on the pain scale. An Emergency Drug Kit (EDK) Replacement Form, dated 7/15/23, indicated 1 dose of Oxycodone 5 mg was removed, on 7/15/23 at 10:00 P.M., for Resident K. The 2 nurses who signed the removal was LPN 3 and QMA 13. The MAR from 7/15/23 - 7/31/23, indicated the resident was administered Oxycotin 10 mg. tablet on the following dates and times: - 7/15, LPN 3 documents, on the MAR, the Oxycotin 10 mg was not available at 8:00 P.M. - 7/16 at 8:00 P.M. - 7/17 at 8:00 A.M. and 8:00 P.M. - 7/18 at 8:00 A.M. and 8:00 P.M. - 7/19 at 8:00 A.M. and 8:00 P.M. - 7/20 at 8:00 A.M. and 8:00 P.M. - 7/21 at 8:00 A.M. and 8:00 P.M. - 7/22 at 8:00 A.M. and 8:00 P.M. - 7/23 at 8:00 A.M. and 8:00 P.M. - 7/24 LPN 4 and LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 A.M. & 8:00 P.M. - 7/25 at 8:00 A.M., LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. - 7/26 at 8:00 A.M., LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. - 7/27 at 8:00 A.M., LPN 11 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. - 7/28 at 8:00 P.M., LPN 14, documents, on the MAR, the Oxycotin was not available, at 8:00 A.M. - 7/29, LPN 4 & LPN 15, documents, on the MAR, the Oxycotin was not available, at 8:00 A.M. & 8:00 P.M. - 7/30 at 8:00 A.M., LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. This equaled 20 tablets recorded as administered, to the resident. A CDR, dated 7/15/23, signed by QMA 13, indicated the facility had received 12 tablets of the Oxycotin. The CDR indicated an Ocycotin 10 mg. extended release tablet had been removed from the narcotic container/card on the following dates and times: - 7/15 at 10:00 P.M. (not documented on the MAR as administered by LPN 3) - 7/16 at 8:50 A.M. and 8:00 P.M. - 7/17 at 8:00 P.M. - 7/18 at 8:00 A.M. and 8:00 P.M. - 7/19 at 8:00 A.M. and 8:00 P.M. - 7/20 at 8:30 A.M. and 9:00 P.M. - 7/21 at 8:00 A.M. and 9:00 P.M. This equaled 12 tablets recorded as removed. Surveyor did not receive the next CDR as the next one received started in August. A CDR, dated 7/15/23, signed by QMA 13, indicated the facility had received 10 tablets of the Oxycodone 5 mg. Another CDR, undated and unsigned, indicated the facility received 30 more tablets of the Oxycodone 5 mg. The CDR, indicated an Oxycodone 5mg tablet had been removed from the narcotic container/card on the following dates and times. (Some nurses started using 1 or 2 of the Oxycodone to replace the Oxycontin 10 mg extended release. Oxycodone and Oxycotin would be the same except for the extended release feature for the 10 mg dose) - 7/15 at 9:30 P.M. and was documented on MAR, as administered by LPN 3. (She had removed a dose at 8:00 P.M. from the EDK also) - 7/16 at 2:30 A.M. and 4:15 P.M. - 7/17 at 9:00 A.M. and 3:00 P.M. removed by LPN 10 and documented on MAR as administering 1 Oxycotin at 8:00 A.M. - 7/17 at 7:15 P.M - 7/18 at 8:09 A.M., removed by RN 16 and document on MAR as administering 1 Oxycotin at 8:00 A.M. - 7/20 at 3:50 P.M. - 7/22 at 9:10 P.M. - 7/23 at 8:00 A.M. and 8:00 P.M. - 7/24 at 7:30 P.M. and 8:00 P.M. - 7/25 at 8:00 A.M., and 3:00 P.M., LPN removed Oxycodone 5 mg at each time, documents on MAR as administering 1 dose of Oxycotin 10 mg as administered at 8:00 A.M. - 7/26 at 8:00 A.M., LPN 18 removed 1 Oxycodone 5 mg, documents on MAR as administering 1 Oxycotin 10 mg - 7/26 at 19:26 P.M. - 7/27 at 8:00 A.M., LPN 14 removed 1 Oxycodone 5 mg, documents on MAR as administering 1 Oxycotin 10 mg - 7/28 at 8:30 P.M. - 7/30 at 8:00 A.M., LPN 10 removed 1 Oxycodone 5 mg, documents on MAR as administering 1 Oxycotin 10 mg - 7/30 at 8:00 A.M. LPN 10 removed 1 Oxycodone 5 mg, docments on MAR as administering 1 Oxycotin 10 mg - 7/31 at 7:00 P.M. During an interview, on 8/4/23 at 2:10 P.M., the DON indicated Oxycodone 5 mg had been removed from the EDK for Resident K and it's removal should be documented in the Progress Notes. During an interview, on 8/7/23 at 12:08 P.M., LPN 3 indicated there was a medication error incident with Resident K was, she had taken an Oxycodone 5 mg tablet out of the EDK for him and then his medication came from the pharmacy and she also gave him the Oxycotin 10 mg. During an interview, on 8/8/23 at 11: 05 A.M., the DON indicated facility was having difficulty getting he Oxycotin 10 mg ER from pharmacy and staff were using the 5 mg-giving 2 at a time. She indicated they may have documented the dosage in the Progress Notes. All Progress Notes reviewed from 7/15-7/31/23 had no documentation indicating a nurse had administered 2 tablets of the Oxycodone 5 mg. instead of the Oxycotin 10 mg. ER. There was documentation indicating the medication wasn't being received from the pharmacy. An Event recorded by the Administrator, dated 6/9/23, indicated the DON and ADON (Assistant Director of Nursing) were conducting a narcotic audit due to heresay regarding narcotics were missing. The Event indicated staff were educated on the counting of narcotics, the significance of making sure the count is correct and to ensure if signed out on narcotic form (CDR) it is also signed, as administered, on the MAR. A typed form, undated, indicated, .when pulling a narcotic from the EDK you must have another nurse present and BOTH nurses must sign. Or a nurse and QMA [Qualified Medication Assistant] With this undated form was an In-Service Attendance form, dated 6/7/23, 6/8/23, 6/9/23 and 6/10/23. The form indicated the following staff had attended the in-service: LPN 3, LPN 6, QMA 8, QMA 9, LPN 11, LPN 12, QMA 13, LPN 14 and LPN 15. A Corrective Action Form, dated 7/21/23, indicated LPN 3 was suspended, on 7/21/22, for discrepancy in narcotic audits while issue was being investigated and given a final warning. On 8/3/23 at 2:19 P.M., the DON provided a policy titled, Abuse Policy, dated 11/28/16 with a revision on 9/22, and indicated the policy was the one currently used by the facility. The policy indicated .Misappropriation of resident property: is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or without the resident consent On 8/8/23 at 12:33 P.M., the Administrator provided a policy titled, Controlled Medications, dated 5/21/18 with a review on 6/23/23 and indicated the policy was the one currently used by the facility. The policy indicated 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication record (MAR): a. Date and time of administration B. Amount administered ac. Signature of the administering the dose, completed after the medication is actually administered This Federal tag relates to complaints IN00408204 and IN00414158. 3.1-28(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and/or maintain a system that accounted for, periodically reconciled and ensured the disposition of all controlled drugs, related to incomplete and inaccurate documentation of narcotic medications for 3 of 4 residents reviewed who were administered narcotic medications. (Resident G, Resident F and Resident K) Findings include: 1. On 8/4/223 at 10:15 A.M., a review of the clinical record for Resident G was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: unspecified pain and dementia with anxiety. The Physician Orders indicated the resident was to be administered Hydrocodone-Acetaminophen 5/325 milligrams (mg). Order stated to give 1 tablet, by mouth, every 4 hours as needed for pain. The start date was 6/14/23 with a stop date of 6/29/23, then updated on 6/29/23 to continue order until 7/13/23. The July 2023 MAR indicated the resident was administered, as needed, Hydrocodone/Acetaminophen 5/325 mg tablet on the following dates and times: - 7/4 at 7:06 P.M. - 7/5 at 12:58 A.M., 9:30 A.M. and 3:59 P.M. - 7/6 at 2:54 A.M. and 8:00 P.M. - 7/7 at 12:58 A.M. - 7/8 at 12:23 P.M. and 9:58 P.M. - 7/9 at 7:03 A.M. - 7/10 at 1:07 P.M. and 8:25 P.M. - 7/11 at 2:11 A.M. and 7:30 P.M. - 7/12 at 2:58 A.M. and 7:22 P.M. - 7/13 at 1:39 P.M. The order indicated a stop date of 7/13/23 This equaled 17 tablets administered. There was no CDR form indicating the removal of the Hydrocodone/Acetaminophen 5/325 mg from 7/4/23 through 7/13/23. During an interview, on 8/4/23 at 2:10 P.M., the Director of Nursing (DON) indicated she had provided all the CDRs for June and July. She indicated a new Controlled Drug Record would have been started and would have had the signature, of the receiving nurse and the number of tablets received. The DON did not know the amount of of tablets the facility received due to the next CDR form, starting on 7/4/23, was missing. The DON indicated LPN 3 had destroyed all the remaining medications, on the dispensing card and had another nurse witness the destruction. DON indicated the CDR was placed in the medical records box/folder by LPN 3, and was never found. A typed Investigation, dated 7/16-7/21/23, indicated on 6/16/23 a narcotic record (CDR) was missing for Resident G. An interview was conducted with LPN 3. LPN 3 indicated she .disposed of the medication with a witness as the medication was completed per the EMR [electronic medication record] . she was the only nurse in the building and had a CAN (sic) [Certified Nurse Aide] witness this The investigation indicated LPN 4 was concerned LPN 3 took the medication and did not destroy them, however LPN 4 indicated she had seen the form in LPN 3's hands and observed her to walking to the front office and then left the building. The DON came to the building to check the medical records box and the CDR was not in the box. The DON and the Administrator searched everywhere but could not locate the form. During an interview, on 8/7/23 at 12:08 P.M., LPN 3 indicated she had destroyed Resident G's Norco (Hydrocodone/Acetaminophen) with CNA 7. LPN 3 indicated she was going to give Resident G a dose of the Norco, but realized the order had been discontinued. So to ensure she nor anyone else made an error, she had CNA 7 witness the count of the remaining pills, approximately 10 tablets, with her. She then crushed them, put them in water and disposed of them, down the drain, in the shower room. She was aware she should not of had the CNA 7 sign the count for the destruction of those medications, she thinks she might have been the only nurse on the unit and/or the facility. She indicated she had taken the destruction form (CDR) to the front office and placed in the Medical Records box as she was leaving the facility. During an interview, on 8/7/23 at 3:24 P.M., the DON indicated their policy was to use a drug buster (deactivates/breaks down pharmaceuticals into a chemically inactive form), which was located in the medication room on unit 1. 2. On 8/4/223 at 2:00 P.M., a review of the clinical record for Resident F was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: left tibia fracture, non-displace fracture of the of clavicle, multiple fractures of the ribs, motorcycle driver injuries, alcohol abuse and stimulant abuse. The Physician Orders, dated 6/7/23, indicated Oxycodone/Acetaminophen 7.5/325 mg. Give 1 tablet by mouth every 12 hours as needed for pain. The July MAR indicated the resident was administrated Oxycodone/Acetaminophen on 7/16 at 3:02 A.M., 12:00 P.M. and 6:25 P.M. The CDR indicated LPN 3 had removed a dose of the Oxycodone/Acetaminophen, on 7/16/23 at 3:00 A.M. and at 6:00 A.M. During an interview, on 8/7/23 at 12:08 P.M., LPN 3 indicated she had done a medication error with Resident F because he came and asked for a pain pill around 6:00 A.M., however it was to early to give him another one. LPN 3 thought about it and stated the man had several fractures and was in pain so gave it to him early. On 8/9/23 at 11:18 A.M., the DON indicated there was no medication error form or documentation regarding the medication error for Resident F, performed by LPN 3. 3. On 8/7/23 at 11:50 A.M., a review of the clinical record for Resident K was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: fusion of spine-lumbar region with neurogenic claudication and vertebrogenic low back pain. A Physician's Order, dated 7/15/23, indicated the resident had an order for Oxycotin 10 mg. extended release(ER),by mouth, every 12 hours for pain. And another order, dated 7/15/23, for Oxycodone 5 mg every 4 hours as needed for pain. The MAR from 7/15/23 - 7/31/23, indicated the resident was administered Oxycotin 10 mg. tablet on the following dates and times: - 7/15, LPN 3 documents, on the MAR, the Oxycotin 10 mg was not available at 8:00 P.M. - 7/16 at 8:00 P.M. - 7/17 at 8:00 A.M. and 8:00 P.M. - 7/18 at 8:00 A.M. and 8:00 P.M. - 7/19 at 8:00 A.M. and 8:00 P.M. - 7/20 at 8:00 A.M. and 8:00 P.M. - 7/21 at 8:00 A.M. and 8:00 P.M. - 7/22 at 8:00 A.M. and 8:00 P.M. - 7/23 at 8:00 A.M. and 8:00 P.M. - 7/24 LPN 4 and LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 A.M. & 8:00 P.M. - 7/25 at 8:00 A.M., LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. - 7/26 at 8:00 A.M., LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. - 7/27 at 8:00 A.M., LPN 11 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. - 7/28 at 8:00 P.M., LPN 14, documents, on the MAR, the Oxycotin was not available, at 8:00 A.M. - 7/29, LPN 4 & LPN 15, documents, on the MAR, the Oxycotin was not available, at 8:00 A.M. & 8:00 P.M. - 7/30 at 8:00 A.M., LPN 6 documents, on the MAR, the Oxycotin was not available, at 8:00 P.M. This equaled 20 tablets recorded as administered, to the resident. A CDR, dated 7/15/23, signed by QMA 13, indicated the facility had received 12 tablets of the Oxycotin. The CDR indicated an Ocycotin 10 mg. extended release tablet had been removed from the narcotic container/card on the following dates and times: - 7/15 at 10:00 P.M. (not documented on the MAR as administered by LPN 3) - 7/16 at 8:50 A.M. and 8:00 P.M. - 7/17 at 8:00 P.M. - 7/18 at 8:00 A.M. and 8:00 P.M. - 7/19 at 8:00 A.M. and 8:00 P.M. - 7/20 at 8:30 A.M. and 9:00 P.M. - 7/21 at 8:00 A.M. and 9:00 P.M. This equaled 12 tablets recorded as removed. Did not receive the next CDR as the next one received started in August. A CDR, dated 7/15/23, signed by QMA 13, indicated the facility had received 10 tablets of the Oxycodone 5 mg. Another CDR, undated and unsigned, indicated the facility received 30 more tablets of the Oxycodone 5 mg. The CDR, indicated an Oxycodone 5mg tablet had been removed from the narcotic container/card on the following dates and times. (Some nurses started using 1 or 2 of the Oxycodone to replace the Oxycontin 10 mg extended release. Oxycodone and Oxycotin would be the same except for the extended release feature for the 10 mg dose) - 7/15 at 9:30 P.M. and was documented on MAR, as administered by LPN 3. (She had removed a dose at 8:00 P.M. from the EDK also) - 7/16 at 2:30 A.M. and 4:15 P.M. - 7/17 at 9:00 A.M. and 3:00 P.M. removed by LPN 10 and documented on MAR as administering 1 Oxycotin at 8:00 A.M. - 7/17 at 7:15 P.M - 7/18 at 8:09 A.M., removed by RN 16 and document on MAR as administering 1 Oxycotin at 8:00 A.M. - 7/20 at 3:50 P.M. - 7/22 at 9:10 P.M. - 7/23 at 8:00 A.M. and 8:00 P.M. - 7/24 at 7:30 P.M. and 8:00 P.M. - 7/25 at 8:00 A.M., and 3:00 P.M., LPN removed Oxycodone 5 mg at each time, documents on MAR as administering 1 dose of Oxycotin 10 mg as administered at 8:00 A.M. - 7/26 at 8:00 A.M., LPN 18 removed 1 Oxycodone 5 mg, documents on MAR as administering 1 Oxycotin 10 mg - 7/26 at 19:26 P.M. - 7/27 at 8:00 A.M., LPN 14 removed 1 Oxycodone 5 mg, documents on MAR as administering 1 Oxycotin 10 mg - 7/28 at 8:30 P.M. - 7/30 at 8:00 A.M., LPN 10 removed 1 Oxycodone 5 mg, documents on MAR as administering 1 Oxycotin 10 mg - 7/30 at 8:00 A.M. LPN 10 removed 1 Oxycodone 5 mg, docments on MAR as administering 1 Oxycotin 10 mg - 7/31 at 7:00 P.M. During an interview, on 8/4/23 at 2:10 P,.M. the DON indicated Oxycodone 5 mg had been removed from the EDK for Resident K and it's removal would be documented in the Progress Notes. During an interview, on 8/7/23 at 12:08 P.M., LPN 3 indicated the medication error incident with Resident K was, she had taken an Oxycodone 5 mg tablet out of the EDK for him and then his medication came from the pharmacy and she also gave him the Oxycotin 10 mg. During an interview, on 8/8/23 at 11: 05 A.M., the DON indicated facility was having difficulty getting he Oxycotin 10 mg ER from pharmacy and staff were using the 5 mg-giving 2 at a time. She indicated they may have documented the dosage in the Progress Notes. All Progress Notes reviewed from 7/15-7/31/23 and there was no documentation indicating a nurse had administered 2 tablets of the Oxycodone 5 mg. instead of the Oxycotin 10 mg. ER. On 8/8/23 at 9:21 A.M., the Administer provided a policy titled, Discarding and Destroying Medications, dated October 2014, and indicated the policy was the one currently used by the facility. The policy indicated .Medications will be disposed of in accordance with federal state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances On 8/8/23 at 10:05 A.M., the Administrator provided a policy titled, Controlled Medication Destruction, dated 5/21/18 and reviewed on 6/23/23, and indicated the policy was the one currently used by the facility. The policy indicated .1. The director of nursing and the consultant pharmacist are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. 2. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record [Controlled Drug Record] on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason On 8/8/23 at 10:05 A.M., the Administrator provided a policy titled, Medication Administration General Guidelines, dated 5/21/18 and reviewed on 6/23/23 and indicated the policy was the one currently used by the facility. The policy indicated .d Follow the six rights of medication administration i. Right medication ii. Right dose iii. Right patient iv. Right route v. Right time vi. Right documentation 3.1-25(b)(3) 3.1-25(b)(9) 3.1-25(e)(2)(3) 3.1-25(o) 3.1-25(s)(1)(2)(3)(4)(5)(6)(7)(8)

Based on record review and interview the facility failed to provide appropriate timely skin treatment for a resident with a stage 2 pressure ulcer development for 1 of 1 resident reviewed for skin condition. (Resident B) Finding includes: A clinical record review of Resident B was completed on 3/16/2023 at 9:35 A.M. Diagnoses included, but were not limited to: dementia, convulsions, congestive heart failure, chronic obstructive pulmonary disease (COPD), and depression. An admission Minimum Data Set (MDS) Assessment, dated 8/31/2022, indicated Resident B had moderate cognitive impairment. He required limited assistance with one staff member for bed mobility and toileting. He was occasionally incontinent of bladder and frequently incontinent of bowel. Resident B had moisture associated skin damage with application of a nonsurgical dressing and application of ointment and/or medication. The preventative measures in place included a pressure reducing device for the bed. An admission Nursing Evaluation, dated 8/26/2022, indicated the resident had a sacrum pressure ulcer, stage 2. The assessment indicated the area was newly dressed with a Mepilex border (a dressing to absorb and retain exudate), and an assessment would be completed on the next shift. A Weekly Skin Review, on 8/28/2022, indicated mild excoriation to the gluteal cleft and peri-area. On 9/4/2022, a Weekly Skin Assessment indicated no new area of concern noted or reported. Resident B continues with excoriation to bottom. On 9/11/2022 and 9/18/2022, a Weekly Skin Assessment indicated the residents redness of pre-existing origin. A Braden Scale for Predicating Pressure Score Risk was completed on 9/29/2022. The score indicated; Resident B was at risk for pressure ulcer development. The Weekly Skin Review indicated redness, but had not indicated a location. A Nurse's Note, on 9/30/22 at 11:49 P.M., indicated an open area was found to the left and right buttocks. A new order was obtained for Duoderm (a dressing used for stage 2-4 pressure ulcers) to the left and right buttock to be changed every 72 hours. On 10/2/2022 at 2:03 A.M., a Skilled Nursing Note indicated, .New open area to Lt buttocks observed and the start of an open area on the Rt buttocks. Duoderm in place A Skin and Wound Note on 10/3/2022 at 12:15 P.M., indicated, .This writer assessed area to coccyx, area is MASD, 5.5 cm x 2.0 cm x 0.1 cm New order was received for Triad Paste received for the midline at the top of the buttocks, and to discontinue the Duoderm. A Wound Evaluation Flow Sheet was initiated on 10/3/2022. The assessment indicated moisture associated skin damage to the top midline buttocks and sacrum. The area measured 5.5 cm (centimeters) by 2 cm by 0.2 cm. The current preventative interventions included a pressure redistribution mattress and a wheelchair cushion. On 10/3/2022 at 12:32 P.M., a Skin and Wound Note addendum was placed that revised the area assessed to the sacrum. An outside clinical assessment group evaluated Resident B on 10/3/2023. The assessment indicated, . [Resident's name] was seen today for wound follow-up. He has a midline pressure sore to his sacrum that he is currently being treated per wound doctor. Today, treatment was changed. We will do DC [discontinue] and Triad paste twice daily and as needed was started. He declined assessment of area at this time, reported comfortable in chair . MASD: Continue with Triad paste twice daily and as needed; continue with treatment plan per facility Dr. [doctor] And notify of any needs/concerns A Care Plan was initiated on 10/3/2022, indicated Resident B had the potential or actual impairment to skin integrity related to moisture associated skin damage. The goals included to encourage good nutrition and hydration, monitor skin injury, report abnormalities, and to treat as ordered. During an interview on 3/20/2023 at 1:46 P.M., the Director of Nursing (DON) indicated Resident B was not followed by wound care. While on the phone with Assistant Director of Nursing, the DON indicated, .We need to mitigate the pressure [ulcer] versus excoriation The [NAME] indicated Resident B did not have any orders for the excoriation or MASD unless the staff had used house barrier cream. There was no documentation that house barrier cream was in use. On 3/20/23 at 3:50 P.M., the Administrator provided the policy titled, Skin and Wound Management System. The policy indicated, .It is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or skin integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes .An assessment of skin integrity is to be performed on each resident upon admission to the center by completing: a. a head-to-toe physical assessment of skin condition, and b. A risk evaluation for predicting pressure will be used to determine risk status, such as the Braden Scale .4. Preventative interventions will be implemented for residents identified at risk as appropriate .5. Residents with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. Wound location, characteristics and a physician's order for treatment are documented in the medical record. Wound status will be evaluated and documented in [electronic medical record name] on the Wound Evaluation Flow Sheet form This Federal tag relates to Complaint IN00394202. 3.1-40(a)(2)

Based on record review an interview, the facility failed to identify a Residents risk for falls for 1 of 4 residents reviewed for falls. (Resident F) Findings include: A record review for Resident F was completed on 3/17/2023 at 1:40 P.M. Diagnoses included, but were not limited to: hemiparesis and hemiplegia following a cerebral infarction (stroke) affect the right dominant side, diabetes mellitus type 2, and cognitive communication deficit. An admission Nursing Evaluation on 2/10/2023, was not completed to determine fall risk. An admission MDS (Minimum Data Set) Assessment, dated 2/10/2023, indicated Resident F had moderate cognitive impairment. He required extensive assistance with two or more staff members for transfer, bed mobility, and toileting. He had a Foley catheter and was always continent of bowel. Resident F had a fall in the previous month. A late entry Nursing Note, on 2/11/2023 at 9:30 A.M., indicated Resident F attempted to transfer self to the bathroom and fell. No injuries were noted at the time, and Resident F denied pain or discomfort. On 2/12/2023 at 7:32 P.M., a Nurse's Note indicated that Resident F denied pain or discomfort in the morning. Family approached the nurse and stated Resident F had complained of pain to the right chest when taking a deep breath. Light bruising was observed measuring 4 cm (centimeters) by 2 cm at the site Resident F complained of pain. A new order was obtained for a 2-view chest x-ray. On 2/12/2023 at 8:33 P.M., a Nurse's Note indicated the nurse received a call from the Power of Attorney (POA). The POA indicated Resident F had discomfort with breathing and soreness to the chest and flank. The POA requested Resident F be sent to the Emergency Department for evaluation. A Care Plan for falls was initiated on 2/12/2023. An Emergency Department History and Physical on 2/13/2023 at 12:25 A.M., indicated, .Patient reports that he has been mostly wheelchair-bound at the nursing facility, while attempting to transfer from wheelchair to bed he fell and landed on his right side. He reports that this happened a couple of days ago. On Saturday patient was again attempting to transfer from the wheelchair to the bed and fell landing on his right side. He did [sic] initially have pain but did not want to be seen at the hospital as he thought the pain would resolve on its own, however the pain in his right side of his chest continued. He describes the pain as sharp and stabbing 8 out of 10 in severity at worst. He has significant pain with deep breath or cough .Patient will be admitted for further evaluation and treatment of right-sided rib fracture, pulmonary toilet, and pain control .Assessment and Plan: Rib fractures. CT of the chest fields nondisplaced right lateral ninth rib fracture and minimally displaced right posterior lateral 10th rib fracture On 2/13/2023 at 12:00 P.M., a Nurse's Note indicated Resident had been admitted to the hospital for rib fractures. During an interview on 3/20/2023 at 1:31 P.M., the Director of Nursing (DON) indicated nursing evaluations, including fall risk, should be completed upon admission. On 3/20/2023 at 3:50 P.M., the Administrator provided a policy titled, Falls Management System. The policy indicated, .It is the policy of this center to provide each resident with appropriate evaluation and intervention to prevent falls and to minimize complications of a fall occurs. Additionally, all resident falls in this center are analyzed and trended through the Performance Review process to maintain a safe environment .a. At the time of admission, each resident is evaluated to determine his/her risk for sustaining a fall This Federal tag relates to Complaint IN00394560. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe, clean and comfortable environment was maintained, related to a low temperature in a shower room, clogged sink, stains and gouged areas on walls, dirty floors, missing call light covers, a broken electrical box, chipped paint, metal, missing floor tiles, faucets that continuously run, leaking toilets, broken ceiling tiles and black/rust colored substances around the bases of toilets in 3 of 4 units observed and 2 of 3 shower rooms. (100, 300 & 400 halls) Findings include: During an environmental observation, on 3/21/2023 at 12:09 P.M. to 12:53 P.M., with two (2) Administrators, and the Maintenance director, the the following was observed: 1. On 3/21/2023 at 12:16 P.M., on the 300 hall: the shower room temperature was 70.6 degrees, the sink was filled with a tan colored water and was not draining. The Maintenance Director indicated it should be 71 degrees and the sink will be fixed today. The resident bathroom in the shower room had a orangish stain along the back wall behind the toilet and beside the sink. room [ROOM NUMBER] had an electrical outlet behind the bathroom door that did not have a cover and there were 2 dirty heater knobs/cover on the window seal with the window cracked along the left side. In room [ROOM NUMBER] the faucet would not stop running, and the closet doors were broken and not hung up. 2. On the 400 hall (locked unit) the following was observed: In room [ROOM NUMBER] an electrical outlet next to a residents bed had a broken cover, the closet doors would not close due to numerous clothing items. There were 3 dirty glass vases on the floor in the bathroom. A ceiling tile in the hallway by room [ROOM NUMBER] was stained, there was an odor of urine, missing floor tiles and the faucet was running. room [ROOM NUMBER] had a dirty substance around the toilet base. room [ROOM NUMBER] the baseboard was coming off under the sink and the room smelled musty. 3. On the 100 hall the following issues were observed: A light cover by the nurses station was missing. Light cover by room [ROOM NUMBER] broken. The shower room had a dirty floor. room [ROOM NUMBER] had a towel wrapped around the base of the toilet that was stained yellow along with the floor. room [ROOM NUMBER] had large scrapes on the wall by bed 2 with no call light cover outside the room. rooms [ROOM NUMBER] did not have call light covers outside the rooms. During an interview, on 3/21/2023 at 1:03 P.M., the Administrator indicated all the items should have been fixed with preventative maintenance. On 3/21/2023 at 1:02 P.M., the Administrator provided the policy titled, Maintenance Administration, dated 3/2015. The policy indicated . 4. Maintains documentation of functionality/compliance for: d. Call Bells . j. Heating/cooling systems .16. Makes rounds daily On 3/21/2023 at 1:25 P.M., the Director of Nursing provided the policy titled,Housekeeping Administration, dated 3/2015. The policy indicated .3. Assuring the clean and sanitary condition of the facility to provide a safe and hygienic environment for residents and staff . 1. Conducts rounds daily for identification of areas of improvement . 5. Proactive awareness of admissions, room changes and discharges for terminal cleaning process to be completed.8 Implements a procedure for housekeeping emergencies when housekeeping in not available. 9. Provides individualized services where practical to meet the needs of the residents This Federal tag relates to Complaints IN00388683, IN00394202, IN00394334 and IN00404072. 3.1-19(f)