Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Floors and equipment were soiled. (Kitchen) On 3/4/25 at 9:30 a.m., the kitchen was observed to have the following: 1. The burners on the stove had grease and food build up. 2. Debris was observed on the floor under the two and three compartment sinks, under the racks that held the pots and pans, under stainless steel prep tables, in the dishwasher area, around the hot water heater, under the stove and steam table. 3. The hot water heater had dirt/dust on the top of heater and on the pipes. 4. Five food carts had debris on the surfaces. 5. The side of the steamer unit had debris. The same was observed on 3/5/25 at 11:05 a.m. On 3/5/25 at 11:07 a.m. Dietary Aide 2 indicated night staff are supposed to sweep and mop the floors, including under equipment, all staff have a schedule for what is supposed to be cleaned. On 3/5/25 at 12:01 p.m., the Dietary Manager provided the current policy food safety requirements with a revision date of February 2023. The policy included, but was not limited to: It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety . On 3/5/25 at 11:59 a.m., the Dietary Manger provided the current kitchen cleaning schedules. The schedule included, but was not limited to: .clean the 2 & 3 compartment sink areas .clean stove top area .clean both cooks tables including tops & underneath Clean all regular 3 tier carts . This citation relates to Complaint IN00453432. 3.1-21(i)(3) 3.1-21(i)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications at bedside (Resident 49, Resident 23) Finding include: 1. On 7/21/24 at 10:16 A.M., Desitin was observed be to be on Resident 49's bedside table with Resident's name and physician noted on the label. On 7/21/24 11:10 A.M., Resident 49's clinical record reviewed. Diagnosis included, but not limited to, Alzheimer's disease with late onset. The MDS (Minimum Data Set) assessment dated [DATE] indicated that Resident 49 is severely cognitively impaired, required substantial/maximal assistance with toileting, substantial or maximal assistance with bathing, and substantial or maximal assistance with bed mobility. The clinical record lacked any self-administration of medication assessment or care plans. Physician orders included but were not limited to Desitin External Paste 40 % Zinc Oxide Topical, as needed, dated 6/28/24. QMA 8 indicated during interview on 7/25/24 at 11:20 A.M., that if medication was found at bedside it would be put away immediately and the nurse would have been notified. Also that Desitin in not a medication allowed to be kept at bedside. 2. On 7/24/24 at 12:02 P.M., a medicine cup with one pill in it was observed sitting on Resident 23's bedside table. On 7/25/24 at 10:57 A.M., Resident 23's clinical record was reviewed. Diagnosis included, but was not limited to, cerebral infarction with some residual weakness on the right side. The most current Annual Minimum Data Set (MDS) Assessment, dated 7/9/24, indicated Resident 23 was cognitively intact and required setup assistance for eating. The clinical record lacked an order, care plans, and assessment for self administration of medications. On 7/25/24 at 1:53 P.M., the Administrative Support indicated medications were not to be left at beside. On 7/26/24 at 8:00 A.M., the Administrative Support indicated Resident 23 did not have a self administration of medication assessment. On 7/26/24 at 8:00 A.M., the Administrative Support provided a Resident Self-Administration of Medication policy, undated, that indicated The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure resident privacy for 2 of 2 random observations. Resident information was left visible on a computer screen during medication administration. (Resident 13, Resident 16) Finding includes: 1. On 7/24/24 at 10:00 A.M., Licensed Practical Nurse (LPN) 5 was observed gathering medications at a medication cart. When LPN 5 walked away from the medication cart and down the hall, the computer screen was left up with Resident 13's information visible (picture, name, date of birth , and medication list). LPN 5 came back to the cart at 10:04 A.M., and promptly left the cart again to enter a resident's room. At 10:06 A.M., Resident 3 was observed walking by the medication cart. LPN 5 returned to the cart at 10:06 A.M. 2. On 7/24/24 at 11:17 A.M., the medication cart was observed sitting between the nurses station and elevator with the computer screen open and Resident 16's information visible. LPN 5 was observed at that time in the Dining Room with a resident. At 11:19 A.M., Certified Nurse Aide (CNA) 3 was observed pushing a resident past the medication cart on the way to the Dining Room, then LPN 5 was observed to come back to the medication cart. On 7/24/24 at 3:04 P.M., LPN 7 indicated when leaving the medication cart, staff should hide and/or lock the computer screen to ensure resident privacy. On 7/26/24 at 8:00 A.M., a current non-dated Confidentiality of Personal and Medical Records policy was provided that indicated This facility honors the resident's right to secure and confidential personal and medical records 3.1-3(o)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to protect the resident's rights to be free from physical abuse for 1 of 1 residents reviewed. Resident 36 was hit by CNA(Certified Nurse Aide) while receiving care resulting in laceration above the left eye. (Resident 36) Findings include: On 7/22/24 at 10:28 A.M., Resident 36 was observed in a chair smiling. On 7/22/24 at 1:21 P.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, ALZHEIMER'S DISEASE and Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. The current Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 36 was severely cognitively impaired. The resident was dependent on transfer, toileting, and dressing. Current physician orders included, but were not limited to: Lexapro Tablet 10 MG (Milligrams) (Escitalopram Oxalate)(Antidepressant medication). Give 1 tablet by mouth one time a day for depression/anxiety related to adjustment disorder with mixed anxiety and depressed mood dated 9/9/22. Seroquel oral tablet 50 MG (Quetiapine Fumarate)(Antipsychotic medication) Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE and Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance dated 8/8/23. The current care plan indicated the resident may exhibit verbal/physical behaviors with care r/t (Related to) the inability to comprehend the need for care r/t cognitive status. Interventions included, but were not related to: Allow resident time to respond to directions or requests d/t (due to) dementia more time is required to absorb instructions. Be cognizant of invading resident's personal space. Approach the resident slowly and from the front. Be sure to have the resident's attention before speaking or touching. Those interventions were dated 7/11/22. A nursing progress note dated 7/5/24 at 9:30 P.M., indicated QMA (Qualified Medicine Aide) 4 working unit heard resident yelling from hallway. Upon entering room QMA 4 observed a resident with a skin tear above left eyebrow. QMA 4 assisted resident to safe position. CNA (Certified Nurse Aid) 6 reported to QMA 4 on unit resident was being combative, hitting and scratching him. CNA 6 also reported he was defending himself when the resident obtained a skin tear 3 cm x 0.5 cm above left eyebrow. QMA called on call management. Head to toe assessment completed. Cleaned left eye with normal saline and applied steri strips. Resident denies pain. No change in ROM. No change in LOC. Neurological assessments x 72 hours initiated. Administrator notified, DON, POA (Power of Attorney) , PCP (Primary Care Physician) . The progress note was recorded by an RN in the facility at the time. A Social Service Progress note done on 7/8/24 at 9:20 A.M., indicated there was a Psychosocial Assessment completed and the resident was not having s/s (signs or symptoms) of sadness, anxiety, or fear. The resident voiced no concerns, and none noted in body language or overall mood. A Psychiatric Nurse Practitioner dated 7/8/24 at 12:22 P.M., indicated there was a new order to discontinue Melatonin (sleep aid) and to notify Nurse Practitioner of issues with insomnia. On 7/10/24 at 4:45 P.M., the Social Service Progress Note indicated there was another Psychosocial Assessment completed and the resident was not exhibiting s/s of sadness, fear, or anxiety. The resident was up doing normal routine and was not voicing concerns or observed via body language On 7/11/24 at 12:28 P.M., the Social Service Progress Note indicated there was another Psychosocial Assessment completed and the resident was not exhibiting s/s of sadness, fear, or anxiety. The resident was up doing normal routine and was not voicing concerns or observed via body language. Reviewed at the time of the medical record review, an Indiana Department of Health Form was dated 7/5/24 at 1:33 P.M. The form indicated on 7/5/24, the resident was involved in an altercation with CNA (Certified Nurse Aide) 6 while receiving care. QMA ( Qualified Medicine Aide) 4 heard the resident yelling and being combative with CNA 6. CNA 6 indicated in the report the resident was combative and scratching CNA 6. The on-call nurse manager, DON (Director of Nursing), Administrator, physician, and family made aware. Follow up dated 7/8/24 indicated the scratch was 0.3 cm (Centimeters) x (By)) 0.5 cm was cleaned with saline and stertripes. Resident Assessment completed there was no loss of consciousness or range of motion. A Psychological Assessment was completed with no s/s of fear, anxiety, or sadness. The nurse practitioner saw the resident on 7/8/24 and was to continue present orders, clean wound, keep dry and clean and monitor for signs and symptoms of infection, were to continue present orders and monitor for behaviors. CNA 6 indicated in a written statement dated 7/5/24 he is changing urine-soaked socks. The resident was kicking in response to the care and protesting not wanting clothes changed. CNA 6 calmly spoke with the resident, but resident got more aggressive and tried to scratch CNA 6 while turning and fastening the brief. CNA 6, again, tried to calmly talk to the resident while the resident was physically assaulting him and yelling. CNA 6 indicated he has had post-traumatic stress from childhood abuse of a parent and allowed his anger to take over. During an interview on 7/22/24 at 3:05 P.M., the wife indicated that she was told the resident was hit by CNA that was apparently witnessed. During an interview on 7/23/24 at 2:31 P.M., the Human Resources Director indicated she was told that CNA 6 reacted to the situation with the resident that swung at him. There were no complaints against the CNA and was popular with staff and residents liked him. She indicated there were no indications that CNA 6 was angry. During an interview on 7/23/24 at 7:10 PM., QMA 4 indicated she did not really witness the incident but was in the hallway outside the resident's door. QMA 4 heard the resident say, don't hit me. QMA 4 then went into the room and CNA 6 was trying to tell QMA 4 what happened, and the resident was saying you're lying. QMA 4 also noted CNA 6 was trying to clean the gash above the resident's left eye not knowing how big it was. QMA 4 indicated CNA 6 had asked if QMA 4 was going to report this and she said she had to because she was not going to lose her license. She stated CNA 6 was angry with himself about the situation and was apologizing to her and the resident. She immediately came to the nurse on call and (Director of Nursing) who came to assess the resident. They in turn called the family, who did not come to the facility. During an interview on 7/24/2 at 8:41 A.M., the Nurse Manager on Call indicated QMA 4 had called her and indicated there was an incident with Resident 36 and CNA 6. CNA 6 was doing care and QMA 4 had walked into the room and the resident had blood above his left eyebrow. QMA 4 indicated she had asked what had happened and CNA 6 had admitted that he had struck the resident 1 time, but the resident had been resistive to care with the resident had been scratching and hitting him. There was a skin tear. QMA 4 had CNA 6 leave the room and she immediately called her. She called the Administrator and the DON, she then called said that they had made a 3-way call with QMA 4 where she indicated that the resident had been scratching CNA 6 chest and reaching for face while the resident was also trying to hit CNA 6. They then spoke with CNA 6, and he was crying about the incident . CNA 6 was remorseful. He never indicated anything about PTSD (Post Traumatic Stress Disorder) or having flash back. The conversation was only a few minutes. The nurse on call indicated the resident and CNA 6 had never had a problem. The DON said that the wife and family actually preferred CNA 6 to take care of the resident. They feel that this incident was an isolated incident and he had never had a problem like this before. On 7/26/24 at 8:00 A.M., the Administrator Support Person provided a current policy Abuse, Neglect, and Exploitation Policy dated 3/31/23. The policy indicated .it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing written policies and procedures that prohibit abuse .the facility will have written procedures to assist staff in identifying the different types of abuse mental/verbal abuse, sexual abuse, physical abuse .This include staff to resident abuse and certain resident to resident altercations . Possible indicators of abuse include, but are not limited to: resident, staff, or family report of abuse and physical marks .on a resident's body . 3.1-27(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services upon admission for 1 of 3 residents reviewed for skin impairment. A resident who was admitted with skin impairment did not have treatment orders put in place upon admission. (Resident 101) Finding includes: On 9/4/24 at 11:09 A.M., Resident 101's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 4, (severe), type 2 diabetes mellitus without complications. An admission MDS (Minimum Data Set) Assessment, dated 9/3/24, was still in progress and indicated Resident 101's cognition was moderately impaired. Care plans included, but were not limited to: Resident has actual impairment to skin integrity AEB (as evidenced by) diabetic ulcer to left 2nd toe and diabetic ulcer to left heel, and shearing to sacrum r/t (related to) diabetes mellitus, and impaired mobility, date initiated 8/27/24, revision 9/4/24. Interventions included but were not limited to: Alert MD (medical doctor) if wound worsens or does not show any improvement within a 14 day period. Treatments per order. Weekly skin assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessments, pain/discomfort at site, date initiated 8/27/24 Resident has actual skin impairment to skin integrity AEB skin tear to back of right hand w/sutures, skin tear to right and left forearm, blister to 3rd toe r/t previous fall, dog bite, and impaired mobility, date initiated 8/27/24. Interventions included but were not limited to: Alert MD if wound worsens or does not show improvement within a 14 day period. Treatments per order. Weekly skin assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessments, pain/discomfort at site, date initiated 8/27/24 Resident is at risk for infection r/t open lesion 2/2 to MASD (Moisture Associated Skin Damage) and right hip fracture secondary to in house MDRO (multi-drug resistant organisms) AEB surgical incision to right hip and other skin issues, date initiated 8/28/24, revision 9/4/24. Interventions included but were not limited to: Treatments as per MD order, evaluate surgical incision for signs/symptoms of infection weekly with skin assessment and as needed, date initiated 8/28/24. Resident has a potential for further impaired skin integrity r/t generalized weakness, impaired mobility, DMII (diabetes mellitus type 2), s/p (status post) right femur fracture, date initiated 8/27/24. Interventions included but were not limited to: Treatments per order. Weekly skin assessment by licensed nurse, notify physician of any new areas of concern, date initiated 8/27/24. Resident has actual impairment to skin AEB open lesion to gluteal cleft 2/2 to MASD r/t impaired mobility, incontinence, right femur fracture, date initiated 9/4/24 Interventions included but were not limited to: Alert MD if wound worsens or does not show any improvement within a 14 day period. Treatments as ordered. date initiated 8/27/24. Weekly skin assessments of site to include full measurements, drainage, odor, wound bed assessments, surrounding tissue assessment, pain/discomfort at site, date initiated 9/4/24. A nursing admission skin assessment dated [DATE] indicated the following skin impairments: Right trochanter (hip) surgical incision, incision covered with Aquacell (sic) - c, d, i Right hand (back) skin tear with sutures 4.3 cm (centimeters) x 1.2 cm Left heel diabetic ulcer 3 cm x 3 cm left toe(s) 2nd toe diabetic ulcer 2.6 cm x 1.2 cm Left toe(s) 3rd toe blister 1 cm x 1 cm Sacrum shearing 1.5 cm x 1 cm Other (specify) left forearm skin tear 3.7 x 2 cm Other (specify) right forearm skin tear 0.2 cm x 0.2 cm Other (specify) scattered bruising to bilateral arms and multiple locations unable to measure August 2024 orders were reviewed and included, but were not limited to: Leave Aquacel dressing on right hip surgical incision until follow up appointment on 8/30/24. May shower, call [name] with any questions every shift for right hip surgical incision until 8/30/24, order date 8/27/24. Weekly VS (vital signs), nursing summary, and skin assessment per schedule- document VS in wt/vitals tab in resident chart, order date 8/27/24. No skin treatment orders were in place on the August 2024 physician orders. A daily skilled nurses note dated 8/29/24 indicated skin conditions - surgical wound. A daily skilled nurses note dated 9/2/24 indicated skin conditions- skin intact/no skin issues. A skin and wound evaluation, effective date 9/4/242 at 12:07 P.M., included, but was not limited to: Type: Moisture Associated Skin Damage (MASD) In-house acquired New Wound measurements: Area- 7.3 cm2 (centimeters squared) Length- 3.9 cm Width - 3.2 cm Practitioner notified Progress notes were reviewed and included, but were not limited to: 9/3/24 at 7:33 P.M., indicated, res (resident) c/o (complains of) soreness to her bottom, upon assessment noted 3cmx1cm open area to inner buttocks. wound bed bright pink, no drainage, perimeter wound edges intact, normal. 9/4/24 at 10:43 A.M., indicated, [name] office called at this time new orders for calmoseptine to inner buttock q (every) shift till healed. 9/4/24 at 12:19 P.M., Skin assessment completed areas are as follows right trochanter incision with 16 staples intact measuring 8.5 cm right back of hand skin tear with sutures 4.3 cm x 1.2 cm left heel diabetic ulcer 3cm x 3cm resident has stated has had for years left 2nd toe diabetic ulcer 2.6cm x 1.2 cm resident stated has had for years sacrum MASD 3cm x 1cm left forearm skin tear 0.2cm x 0.2 cm scattered bruising to bilateral arms. 9/4/24 at 1:21 P.M., Call placed to [name] office for clarification orders to when to remove sutures to top of right hand. Will address with MD and return call with further orders. 9/4/24 at 1:46 P.M., Staples removed from right hip. No redness or s/s (signs and symptoms) of infection noted. Edges well approximated. Resident tolerated procedure well. 9/4/24 at 2:07 P.M., New order from [name] ok to remove sutures to top of right hand today and apply steri strips after removing. Resident aware of new order. TAR (Treatment Administration Record) updated. A summary of Resident 101's physician's visit dated 9/2/24 was reviewed and included, but was not limited to: Skin: Inspection and palpation: no rash or jaundice and good skin turgor; abrasions on forearms from scratching. Nails: abnormal (clubbing). On 9/5/24 at 9:45 A.M., Resident 101 indicated she did not remember if treatments were done to her skin areas before she came to the facility at the hospital or before she went to the hospital. She was unsure what areas she had. She indicated she had dry skin. On 9/4/24 at 1:50 P.M., the Administrator provided a typed piece of paper indicating it was an explanation of why treatment orders were not put in place upon Resident 101's admission. The paper indicated: The resident was admitted to our facility with longstanding skin impairments, which she reports had been present for several years. Prior to admission resident reported, both her physician and the hospital had assessed these impairments and did not initiate any treatment. At the time of admission, no active treatment orders were prescribed for these conditions, as they were not being actively treated at the hospital or prior to hospitalization. Upon admission, we thoroughly assessed and measured the skin impairments and immediately included them in the care plans on 8/27/24. One of our key interventions was to monitor the conditions closely and notify the physician if they worsened or did not show improvement. Since admission, the resident has been evaluated by both her nurse practitioner and physician, and no new treatment orders or recommendations were made. Follow-up assessment and measurements are being performed today as we do them every week and are due to be done this week. When we observed changes in the sacral shearing, we acted in accordance with our care plan by notifying the MD. On 9/5/24 at 9:55 A.M., LPN (Licensed Practical Nurse) 14 was observed to do the treatment to Resident 101's inner buttocks. LPN 14 removed Resident 101's socks and indicated there were no skin areas to the right foot. The left heel appeared to be dry. The second toe on the left foot appeared it may have betadine on it. She was unaware of any treatments except to the coccyx area. On 9/5/24 at 11:30 A.M., the Administrator indicated he was not sure why the skin and wound assessment dated [DATE] indicated the MASD area was documented as new and in-house acquired. It was not new and was present on admission. The nurse may have charted it that way because it increased in size. On 9/5/24 at 11:21 A.M., the Administrator provided the current wound management policy with a reference date of 2019. The policy included but was not limited to: .Policy explanation and compliance guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type, of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . 3.1-30(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/21/24 at 11:10 A.M., Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease with late onset. The MDS (Minimum Data Set) assessment dated [DATE] indicated resident was not cognitively intact, required use of wheelchair, required partial/moderate assistance with eating, substantial/maximal assistance with toileting, substantial or maximal assistance with bathing, and substantial or maximal assistance with bed mobility. Care plan initiated on 6/28/24 had the following interventions: get resident's attention before beginning to speak to resident, provide reassurance and patience when communicating with resident. Care plan initiated on 7/8/24 included the following: allow resident time to respond to directions or requests (due to dementia more time is required to absorb instructions), approach the resident slowly and from the front, be cognizant of not invading resident's personal space, be sure you have the residents attention before speaking or touching, if strategies are not working, leave resident and reapproach at later time and/or different staff. On 7/21/24 at 12:46 P.M. CNA 84 performed incontinence care on Resident 49. Care plan was not implemented at that time. Resident 49 resisted this care, cried out for CNA to stop and attempted to push CNA 84 away repeatedly. CNA continued providing incontinence care. Resident 49 told CNA 84 she did not want to get out of bed. After CNA 84 performed incontinence care, transferred Resident to wheelchair while resident continued to yell out and push CNA away. On 7/25/24 at 1:02 P.M. QMA 8 indicated that if Resident 49 exhibited behaviors/resisted care, staff would have stopped what they were doing to prioritize safety. Staff would have been expected to give resident space, time, and reapproach at another time. QMA 8 indicated there would have been 2 staff members caring for Resident 49. One staff member to have kept Resident calm while the other performed care. During an interview on 7/25/24 at 1:51 P.M. the DON (Director of Nursing) indicated care plans should be updated any time there are new orders or new issues with the resident. On 7/26/24 at 8:00 A.M. Administrative Support provided a undated policy titled Comprehensive Care Plans that indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.1-35(a) Based on record review and interview, the facility failed to ensure person-centered care plans were developed and implemented for 2 of 5 residents reviewed for unnecessary medications and behaviors. (Resident 37, Resident 49) Finding includes: 1. On 7/23/24 at 1:59 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated Resident 37 was severely cognitively impaired, required substantial assistance from staff for toileting and bathing, and was receiving antianxiety, antidepressant, diuretic, antiplatelet, and hypoglycemic medications. Current physician orders included, but were not limited to: Lexapro (antidepressant medication) 10 mg (milligram) Give 1 tablet by mouth at bedtime, start date 12/8/23. Ativan (antianxiety medication) 0.5 mg (Lorazepam) Give 1 tablet by mouth one time a day, start date 4/12/24. Lasix (diuretic medication) 20 mg Give 1 tablet by mouth one time a day, start date 1/27/23. Aspirin (antiplatelet medication) 81 mg Give by mouth one time a day, start date 2/9/22. Metformin (hypoglycemic medication) 1000 mg Give by mouth two times a day, start date 2/24/23. Invokana (hypoglycemic medication) 100 mg Give 1 tablet by mouth one time a day, start date 1/24/24. Januvia (hypoglycemic medication) 100 mg Give by mouth one time a day, start date 1/24/24. Current care plans included, but were not limited to: Resident is at risk for altered blood sugars and resulting physical complications related to diabetes, Observe for hypo-/hyperglycemic reactions. Date Initiated: 4/26/21. The clinical record lacked care plans related to monitoring of antianxiety, antidepressant, diuretic, and antiplatelet medications.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents reviewed for unnecessary medications. A resident was given the wrong medication resulting in rebound congestion when the medication was discontinued. (Resident 56) Finding includes: On 7/23/24 at 9:23 A.M., Resident 56's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, depression, and psychotic disorder. The most recent admission MDS (Minimum Data Set) Assessment, dated 5/6/24, indicated no cognitive impairment and no behaviors. Resident 56 required supervision with bed mobility, eating, transfers, and toileting. Physician orders included, but were not limited to: Nasal spray nasal solution 0.05% (Oxymetazoline HCl) 2 sprays in both nostrils two times a day for allergies, dated 6/3/24 through 7/1/24. (medication if used more than 3 days may cause rebound congestion) Saline nasal solution 0.65% (Saline) 2 sprays in both nostrils four times a day for nasal congestion for 5 days, dated 7/3/24. A Nurse Practitioner (NP) visit note, dated 6/3/24, indicated the resident complained of nasal congestion. The NP sent an order through triage to begin nasal saline 2 sprays in each nostril at bedtime for nasal congestion. Nursing progress notes included, but were not limited to, the following: 7/1/24 at 5:56 A.M. Triage called to discontinue the nasal spray (Oxymetazoline HCl) and to report if the resident had any rebound nasal congestion in the following 3-5 days. 7/3/24 at 2:26 A.M. The resident was very upset the nasal spray had been discontinued due to a lot of rebound symptoms. 7/3/24 at 4:28 P.M. A new order for saline nasal spray 2 sprays each nostril four times a day for 5 days was received from the NP. On 7/24/24 at 9:37 A.M., the DON indicated when the NP was in the facility, she would put any new orders through triage to be entered into the resident's record. She indicated she could not remember the conversation, but would look in the communication history to see what was communicated about the resident taking the Oxymetazoline HCl nasal spray for over 3 days. At that time, a triage communication form was reviewed for Resident 56 from 6/3/24 that indicated the NP ordered nasal saline two sprays each nostril at bedtime for nasal congestion. On 7/24/24 at 10:30 A.M., the NP indicated she did not order the Oxymetazoline HCl nasal spray for Resident 56 and instead wanted the resident to have nasal saline spray. She indicated she was unaware how the order was put in for Oxymetazoline HCl, but when it was noticed, it was discontinued. On 7/26/24 at 8:00 A.M., a current non-dated Medication Orders policy was provided that indicated When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered 3.1-48(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/25/24 at 2:17 P.M., Resident 55's clinical record was reviewed. Diagnoses included but were not limited to, Type 2 diabetes mellitus with diabetic neuropathy, unspecified and peripheral vascular disease, unspecified, and pressure ulcer of left heel, unstageable The current Quarterly MDS (Minimum Data Set) assessment dated 7/16 indicated the resident was cognitively intact. The resident needed substantial help toileting and transferring. During the 7 day look back period the resident had an unstageable pressure ulcer. Current physician orders included, but were not limited to: Heel lift boots on when in bed every shift for pressure relief to pressure ulcer of left heel, unstageable dated 1/9/24. Betadine swab to the left heel every shift for wound care related to pressure ulcer of left heel unstageable dated 1/22/24. Weekly vital signs, nursing summary, and skin assessment per schedule dated 3/22/24. Current care plan indicated the resident has an actual impairment to skin integrity related to as evidenced by deep tissue injury to left medial heel related to type 2 diabetes and peripheral vascular disease area turned to unstageable 3/8/24. Interventions included but were not to: Weekly assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessment, pain/discomfort at site dated 1/23/2024. The record lacked weekly regular skin and wound assessments. During an interview on 7/25/24 at 10:09 A.M., the Administrative Support Person indicated there should be weekly skin assessments done and the wound person had not been doing them. On 7/25/24 at 8:00 A.M., the Administrative Support Person provided a current, nondated policy Pressure Injury Prevention and Management The policy indicated .the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing or existing pressure injuries .licensed nurses will conduct, .weekly skin assessment .findings will be documented in the medical records . On 7/26/24 at 8:00 A.M., a current non-dated Pressure Injury Surveillance policy was provided and indicated A system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsened pressure injuries in the facility On 7/26/24 at 8:00 A.M., a current non-dated Wound Dressing policy was provided and indicated to change dressings as directed by the physician or wound nurse. 3.1-40(a) 3.1-40(a)(2) Based on observation, interview, and record review, the facility failed to ensure prevention of pressure ulcers for 2 of 3 residents reviewed for pressure injury. Interventions were not followed, and wound assessments were not completed as ordered. (Resident 54, Resident 55) Findings include: 1. On 7/21/24 at 12:42 P.M., Resident 54 was observed lying in bed on her back. When the resident was rolled to the left side, there was no dressing observed covering the pressure area on her sacrum. At that time, the area was observed slightly open in the middle revealing subcutaneous tissue, and the area surrounding the pressure injury was observed a dark pink color indicative of a deeper wound under the skin. No drainage was observed. Granulation tissue (healing connective tissue in the wound bed) was observed in the middle of the wound. At that time, Licensed Practical Nurse (LPN) 21 did not indicate anything about a missing dressing. On 7/22/24 at 1:24 P.M., Resident 54 was observed lying on her back with the head of the bed raised and knees elevated. On 7/2/24 at 8:14 A.M., Resident 54 was observed lying on her back with the head of the bed raised. On 7/22/24 at 1:00 P.M., Resident 54's clinical record was reviewed. Resident 54 was admitted [DATE]. Diagnosis included, but were not limited to, Alzheimer's disease, anxiety, and Stage 3 pressure ulcer. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 5/5/24, indicated total dependence for bed mobility and toileting, and one Stage 3 pressure ulcer. Cognition level could not be assessed. Current physician orders included, but were not limited to: Cleanse pressure injury to sacrum with normal saline, apply Medihoney to wound bed, and cover with bordered foam dressing every night shift for wound care, dated 7/17/24. A current care care plan for impaired skin integrity indicated as of 4/5/24, the area on the sacrum was a Stage 3. Interventions included, but were not limited to: treatments per order, dated 3/11/24 and weekly assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessment, and pain/discomfort at site, dated 3/11/24. A current potential for further impaired skin integrity, dated 10/4/23, included but was not limited to, an intervention for weekly skin assessments by a licensed nurse, also dated 10/4/23. Progress notes included, but were not limited to: 3/4/24 at 9:43 P.M. Weekly assessment revealed an abrasion to coccyx measuring 1 cm (centimeter) x 0.1 cm with barrier cream applied. A fax was sent to the doctor regarding treatment for the area. 3/11/24 at 6:12 P.M., a Physician's Order note indicated to cleanse pressure injury to sacrum with normal saline, apply Hydrogel to wound bed and cover with bordered foam dressing. The order was received from triage. 4/8/24 at 2:54 P.M., a Dietary note from the Registered Dietician (RD) indicated they were notified of the resident having a Stage 3 pressure injury to the sacrum. 4/9/24 at 10:44 A.M., an MDS Quarterly Assessment Note indicated resident had a Stage 3 pressure injury to the medial sacrum related to impaired mobility and incontinence, and treatment to the area was completed daily per licensed nursing staff. 4/9/24 at 1:31 P.M. a Social Services note indicated resident was severely impaired with decision making and that resident would be at risk for skin breakdown and poor nutrition without staff intervention as the resident would not request routine care and did not make decisions related to care needs. A Braden Scale for predicting pressure sore risk was completed on the following dates: 10/4/23 1/5/24 4/5/24 4/30/24 All assessments indicated a high risk for pressure. Weekly skin assessments prior to the development on the sacrum were completed with the exception of the following dates: No assessment between 11/7/23 and 11/21/23 No assessment between 12/12/23 and 12/26/23 A skin assessment on 3/4/24 indicated the coccyx had an abrasion measuring 1 cm x 0.1 cm. A skin assessment on 3/11/24 indicated a pressure area was present to the sacrum. Wound assessments were started on 3/11/24, and included the following information: 3/11/24 unstageable pressure to sacrum, measuring 1.4 cm x 0.8 cm. 3/19/24 unstageable pressure to sacrum, measuring 1.2 cm x 0.6 cm. (completed 8 days after the previous assessment) 3/28/24 Stage 3 pressure to sacrum, measuring 1.0 cm x 0.5 cm. (completed 9 days after the previous assessment) 4/5/24 Stage 3 pressure to sacrum, measuring 0.9 cm x 0.5 cm. (completed 8 days after the previous assessment) 4/16/24 Stage 3 pressure to sacrum, measuring 0.8 cm x 0.3 cm. (completed 11 days after the previous assessment) 4/30/24 Stage 3 pressure to sacrum, measuring 0.6 cm x 0.2 cm. (resident was in the hospital from [DATE] through 4/30/24) 5/10/24 Stage 2 pressure to sacrum, measuring 0.6 cm x 0.3 cm. (completed 10 days after the previous assessment) 5/17/24 Unstageable pressure to sacrum, measuring 3.2 cm x 1.3 cm. 5/23/24 Unstageable pressure to sacrum, measuring 3.2 cm x 1.1 cm. 5/31/24 Unstageable pressure to sacrum, measuring 2.3 cm x 0.8 cm. (completed 8 days after the previous assessment) 6/7/24 Unstageable pressure to sacrum, measuring 1.6 cm x 0.8 cm. 6/11/24 Unstageable pressure to sacrum, measuring 1.4 cm x 0.7 cm. 6/20/24 Unstageable pressure to sacrum, measuring 1.7 cm x 0.8 cm. (completed 9 days after the previous assessment) 6/28/24 Stage 3 pressure to sacrum, measuring 2.9 cm x 0.6 cm. (completed 8 days after the previous assessment) 7/9/24 Stage 3 pressure to sacrum, measuring 1.7 cm x 1.0 cm. (completed 11 days after the previous assessment) 7/17/24 Stage 3 pressure to sacrum, measuring 3.7 cm x 0.4 cm. (completed 8 days after the previous assessment) On 7/23/24 at 10:45 A.M., LPN 5 indicated wound assessments were completed weekly, but had not been completed when she was on vacation from 6/28/24 through 7/6/24. She indicated she followed the National Pressure Ulcer Advisory Panel for staging pressure ulcers and that Resident 54's sacral pressure was a Stage 3 that began with yellow and slough granulation. She indicated once a pressure was staged a 3, it was always a 3, and could not be labeled anything lower. She indicated Resident 54's pressure had gotten worse at the hospital, but was currently getting better. She indicated the area should be kept covered at all times, and if staff needed assistance with the dressing, they could ask her for help. (The National Pressure Ulcer Advisory Panel indicates that full thickness loss of skin, in which adipose tissue is visible in the ulcer, meets the definition of a Stage 3 pressure injury. Granulation tissue and epibole (rolled wound edges] are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this becomes an Unstageable Pressure Injury) On 7/23/24 at 1:32 P.M., LPN 5 was observed to change Resident 54's sacral dressing. The old dressing was removed, and the wound was observed with two open areas. No drainage was observed, and the surrounding area was a dark pink. LPN 5 indicated areas were measuring 0.4 cm x 0.3 cm each. LPN 5 emptied a vial of normal saline onto gauze, then indicated she was unsure if the order was for normal saline or wound cleanser, then sprayed wound cleanser on a gauze and used that to wipe the area. Medihoney was applied to a bordered dressing, and placed on the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. Current physician orders included, but were not limited to: Fall reduction measures: Non-skid strips to side of bed, personal night light, raised toilet seat. 4/17/23. Sensor alarm to wheelchair; check placement, function every shift for decreased safety awareness 12/13/22 Care plans included, but were not limited to: Resident is at high risk for falls characterized by history of falls, impaired vision, dementia, osteoarthritis, other abnormalities of gait and mobility, and medication usage. Resident frequently forgets or refuses to use call light or ask for staff assistance. Date Initiated: 03/26/2018. Substantial/maximal assist, [NAME] transfer aide for all transfers, Date initiated 3/29/18. Resident to wear non-skid shoes or gripper socks at all times, Date initiated: 11/20/18. Raised toilet seat, Date initiated 4/17/23. Visual aid call before you fall placed on bathroom door and wall in resident's room, Date initiated 12/7/23. Anti-rollbacks to wheelchair, Date initiated 1/3/24. Staff education on fall prevention, Date initiated 2/19/24. Non-skid strips to floor in front of toilet, Date initiated: 4/9/24. The clinical record indicated Resident 28 had 10 falls in the past 12 months. The following indicates the time each fall occurred, how it occurred, and the intervention put in place by the IDT (interdisciplinary team) according to the Fall Event Notes provided by the DON (Director of Nursing) on 7/26/24 at 8:00 A.M. Fall #1 9/7/23 at 1:35 P.M.; A CNA (Certified Nurse Aide) was assisting Resident 28 to the bathroom when Resident 28 began to fall, the CNA lowered resident 28 to the floor. The intervention put in place was for Two (2) staff members to assist with transfers from wheelchair to commode and transfers to bed. Fall #2 10/20/23 at 9:49 P.M.; Staff was transferring Resident 28 to bed when Resident was assisted to floor. The intervention put in place was for staff to use [NAME] transfer aid (device to assist with pivot transfers) and two (2) staff during transfers. Fall #3 11/14/23 at 11:45 A.M.; A CNA was transferring Resident 28 from the right side of the bed to the shower chair when the bed began to roll and Resident was lowered to the floor. The intervention put in place was for maintenance to fix the locks on the bed. Fall #4 12/6/23 at 3:58 P.M.; Resident 28 was attempting to toilet herself after activity and fell in the bathroom. The intervention put in place was a 'Call Don't Fall' sign placed in the Residents room. Fall #5 12/29/23 at 2:55 P.M.; Resident 28 was found by staff in bathroom floor. The intervention put in place was staff education on checking Resident's wheelchair alarm while up in chair. Fall #6 2/14/24 at 4:15 P.M.; Resident 28 was brought back to room by staff and instructed to reposition self in wheelchair, resulting in sliding out of wheelchair. Intervention put in place was staff education to prevent falls. Fall #7 2/21/24 at 12:41 P.M.; Resident 28 was in activities when she slid out of her wheelchair. Intervention put in place was educate staff on proper positioning in wheelchair. Fall #8 3/10/24 at 7:04 P.M.; Resident 28 Resident was found sitting in floor of bathroom. Intervention put in place was educate staff regarding toileting resident after meals. Fall #9 4/8/24 at 2:00 P.M.; Staff found Resident 28 sitting in bathroom floor. Intervention put in place was non-skid strips in front of toilet in bathroom. Fall #10 4/29/24 at 1:50 P.M.; A CNA attempted to transfer Resident 28 from the toilet to the wheelchair, resulting in Resident to slide into floor. Intervention put in place was for Resident to see physical therapy three (3) times a week for eight (8) weeks and occupational therapy three (3) times as week for four (4) weeks. During an interview on 7/25/24 at 9:24 A.M., the DON (Director of Nursing) indicated Resident 28 should be transferred with assistance from two staff members. During an interview on 7/26/24 at 10:58 A.M., the DON indicated she was unable to provide the staff education as fall interventions on 12/29/23, 2/14/24, 2/21/24, 3/10/24 because the education did not exist. 3. On 7/23/24 at 11:35 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness, generalized and idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, bilateral secondary osteoarthritis of knee. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The resident is mildly cognitively impaired and needs limited assist of 1 for transfer, toileting, and bed mobility. MDS indicated the resident had a history of falls within the last 3 months. Current physician orders included, but were not limited to: Activity level: up in wheelchair with assist from staff; turn transfer with 2 assist to be used for all transfers dated 7/2/24. Resident should not wear gripper socks with shoes. Nurses/ QMA (Qualified Medicine Aide) to check every shift for pressure relief dated 1/23/24. The current care plan indicated Resident is at risk for falls r/t (related to) seizure disorder, abnormality of gait,mild cognitive impairment, and potential to become easily frustrated and/or overstimulated and may set herself on the floor as a result. Resident has reported falls that have not been witnessed or have been questionable if they were behavioral in nature r/t anxiety and attention seeking. Interventions included, but were not limited to, resident is often resistive to any intervention or offer of extra help and Transfers: [NAME] transfer aide with 2 assists for all transfers. Progress notes included but were not limited to: On 7/24/24 8:55 P.M., a Nurse's note indicated a CNA was assisting Resident 11 from commode back to the wheelchair and reported resident fell forward on to knees bumping head on floor. The wheel chair was located outside of the bathroom near the sink. The fall occurred in front of the wheelchair. When asked what happened, the resident indicated my legs gave out. Resident was assisted up from floor to bed and was reminded to call for assistance from the staff. On 7/24/2024 at 9:11 P.M., at post fall evaluation indicated that the fall was witnessed and occurred when a CNA (Certified Nurse Aide) was assisting resident from the bathroom to the w/c (Wheelchair)The resident did not require a visit to the ER (Emergency Room) or hospitalization. A contributing factor was noted to be loss of balance and weakness. On 7/24/24 at 7/24/2024 at 9:07 P.M., the Fall Rise Evaluation indicated: the resident had a history of falls in the past 3 months, there was no loss of consciousness. The resident had 1-2 predisposing factors. Fall Risk Score: 13.0 On 6/27/24 at 8:00 P.M., Resident 11's roommate reported that resident had fallen from her recliner. The resident was found sitting on her left hip leaning against recliner with wet clothing due to incontinence episode. Neurochecks began and were within normal limits. MD, family, and DON made aware. Intervention added was to have the resident transfer with 2 assists. On 7/26/24 at 8:00 A.M., a current non-dated Fall Prevention Program policy was provided and indicated Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care [and] the plan of care will be revised as needed . When any resident experiences a fall, the facility will . Review the resident's care plan and update as indicated 3.1-45(a) 3.1-45(a)(2) Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for falls. Interventions were not updated following falls. (Resident 52, Resident 28, Resident 11 Findings include: 1. On 7/21/24 at 9:43 A.M., Resident 52 indicated she had fallen about a month ago when she lost her footing. At that time, Resident 52 was sitting in a recliner with her walker in front of her. On 7/23/24 at 11:42 A.M., Resident 52's clinical record was reviewed. Diagnosis included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/18/24, indicated no cognitive impairment, and no behaviors. Resident 52 required supervision assistance of one staff with transfers. Current physician orders included, but were not limited to: Up with walker and staff assist and non skid shoes, dated 1/4/24. A current risk for falls care plan, dated 6/13/23, indicated the following interventions: 1/4 side rails in bed for mobility enablers, dated 6/13/23. Call light within reach, dated 6/13/23. Ensure environment is free of clutter, dated 6/13/23. Have commonly used articles within easy reach, dated 6/13/23. Non skid footwear at all times, dated 3/20/24. Non skid strips in front of the toilet, dated 12/29/23. Reminder sign to call for assistance in room, dated 7/15/24. Shoes with backs when ambulating, dated 8/24/23. Roho cushion with Dycem underneath in resident's recliner, dated 8/18/23. Independent with transfers, initiated 6/13/23 and revised 12/20/23. Resident 52 experienced the following falls since 12/18/23: Fall 1 12/18/23 at 12:05 A.M. Fall was not witnessed. Resident was found lying on the floor on her back, with a walker near her feet. A hematoma measuring 5cm (centimeters) x5cm was observed on the back of her head. An ice pack was applied to the hematoma, and neuro checks were initiated. The resident indicated she was trying to pull back the curtain and lost her balance. The immediate intervention put into place was for the resident to call for assistance. A post fall evaluation, dated 12/20/23, indicated the resident was attempting to self toilet at the time of the fall. An Interdisciplinary Team (IDT) note, dated 12/28/23, indicated Resident 52 was diagnosed with RSV (Respiratory Syncytial Virus) and pneumonia at the time of the fall, and physical therapy was to evaluate for weakness related to the diagnosis. The falls care plan intervention for mobility was updated 12/20/23 to indicate independent with transfers. Fall 2 12/29/23 at 3:44 A.M. Fall was unwitnessed. Resident was found on the bathroom floor sitting upright with feet extended out and back facing the toilet. The resident indicated she had just used the bathroom, and when she went to grab her walker it slid causing her to lose her balance. The falls care plan was updated the same day to include non skid strips in front of the toilet. Fall 3 3/19/24 at 5:10 A.M. Fall was unwitnessed. Resident was attempting to self toilet, resulting in a fall and skin tear to the right forearm. A post fall evaluation, dated 3/19/24 at 2:54 P.M., indicated the resident was wearing non-skid shoes/socks at the time of the fall. The falls care plan was updated 3/20/24 to include non skid footwear at all times. Fall 4 5/21/24 at 6:45 P.M. Fall was unwitnessed. Resident fell in her room sneaking water. Resident was at the sink attempting to get extra water at mealtime. The falls care plan was not updated with a new intervention following fall. Fall 5 6/27/24 at 8:00 A.M. Fall was unwitnessed. Resident was found sitting on the floor to the right of the commode attempting to self toilet. The resident indicated she slid herself down to the floor. The falls care plan was not updated with a new intervention following fall. Fall 6 7/14/24 at 7:00 P.M. Fall was unwitnessed. Resident was attempting to self toilet when her legs got weak. The falls care plan was not updated with a new intervention following fall. On 7/24/24 at 9:52 A.M. the Director of Nursing (DON) indicated therapy had deemed Resident 52 not safe to be up independently and the resident and family were aware, but the resident continued to get up without asking for assistance. The DON indicated Resident 52's falls were from her wanting to be independent. She further indicated all falls were discussed the following morning during a meeting, and new interventions were added to the care plan. On 7/24/24 at 2:55 P.M., Certified Nurse Aide (CNA) 32 indicated Resident 52 should be assisted by staff to get up and with transfers by one staff. She indicated the resident required moderate assistance and supervision with mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order for 1 of 1 reviewed for respiratory care. (Resident 24) Findings include: On 7/21/21 9:14 A.M., Resident 24 was observed sitting in recliner with nasal cannula in nostrils. The tubing was connected to an oxygen concentrator with a date of 6/30/24 written on the side of the tubing. There was also no oxygen warning sign on the outside of the door. On 7/22/24 at 9:40 A.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease) and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The current Annual MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was mildly cognitively impaired. The resident needed partial assistance with toileting and dressing and was wearing O2 (Oxygen). Current physician orders included but were not limited to: Change oxygen tubing and supplies weekly every night shift every Sunday dated 12/3/23. The current care plan indicated the resident has a potential for an altered respiratory status related to COPD. Interventions included but were not limited to providing oxygen as ordered and changing O2 tubing, water, and clean filter weekly. During an interview on 7/23/24 at 3:41 P.M., LPN (Licensed Practical Nurse) 5 indicated the O2 tubing should be changed weekly and should be dated with tape label or written on the side. On 7/26/24 at 8:00 A.M., the Administrative Support Person provided a current nondated policy Oxygen Concentrator. The policy indicated . staff is responsible for the use of oxygen .is administered under the orders of the attending physician .to place an oxygen warning sign on the resident's door .change oxygen tubing and mask/cannula weekly and as needed. 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/23/24 at 1:59 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated Resident 37 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. Current physician orders included, but were not limited to: Ativan (antiaxiety medication) oral tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth one time a day, start date 4/12/24. Lexapro (antianxiety/antidepressant medication) oral tablet 10 mg (Escitalopram Oxalate) Give 1 tablet by mouth at bedtime for change in mood, Start date 11/29/23. A progress note, dated 3/30/24 at 12:22 A.M., indicated (Resident) is up with his walker pacing up and down the hallways and in lobby. He states he is waiting for his wife to pick him up. He has had various belongings wrapped in a shirt carrying them with him. He took all of his HS (hour of sleep bedtime)medications and is pleasant with staff just insistent that he is leaving. Sitting in the front lobby at present. A progress note, dated 6/21/24 at 6:11 A.M., indicated At the beginning of this shift Resident was agitated and exit seeking yelled at staff asking, who put me here Resident is very hard of hearing and staff was trying to communicate with him by speaking loudly and slowly however he did not understand that this was his home and his family was not able to take care of him. He was incontinent of urine and bowel which may have been increasing his agitation. He was assisted back to his room and staff helped him get a dry adult brief on and clothes changed, given a snack and diet coke, communication was written out for him that he was spending the night. He huffed at staff. He had no further exit seeking however he was awake all night packing his things up on his bed as if he was getting ready to leave. A progress note, dated 7/11/24 at 1:11 A.M., indicated (Resident) had a witnessed fall at 0015 (12:15 A.M.). (Resident) was exit seeking and became angry thrashing his walker around and yelling when he lost his balance and landed on his right side. This occurred while (resident) was trying to get in the dining room. (Resident) was able to stand backup with assist of 1 staff member. VS were obtained. Head to toe assessment performed. Res obtained an abrasion to his left knee and a small ST and bruise to left elbow. MD notified. Care ongoing. An elopement evaluation, dated 6/3/24, indicated Resident 37 had not expressed the desire to go home, packed belongings to go home or stayed near an exit door, and did not wander. The clinical record lacked care plans relating to anxiety or exit seeking behaviors. On 7/25/24 at 3:31 P.M., Administrative Support provided a policy titled Elopements and Wandering Residents Policy, dated 4/10/23, that indicated The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 3.1-37(a) Based on record review and interview, the facility failed to ensure proper interventions were in place for monitoring symptom, side effects, and behaviors of medications for 2 of 2 residents reviewed for dementia. (Resident 46, Resident 37) Findings include: 1. On 7/23/24 at 4:09 P.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to unspecified dementia, unspecified severity, mood disturbance and anxiety disorder. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 46 was significantly cognitively impaired. Resident 46 was dependent for bathing, dressing, and toileting. MDS indicated the resident has a diagnosis of No Alzheimer dementia. Current physician orders included but were not limited to: Seroquel Oral Tablet 25 MG (Milligrams) (Quetiapine Fumarate).Give 1 tablet by mouth at bedtime for dementia with mood disturbance related to unspecified dementia, unspecified severity, with mood disturbance dated 4/15/24. Xanax Oral Tablet 0.25 MG (Alprazolam) Give 0.25 mg by mouth three times a day for anxiety/restlessness related to anxiety disorder dated 1/3/24. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsules by mouth two times a day for mood disorder related to unspecified dementia, unspecified severity, with mood disturbance, depression unspecified, unspecified mood [affective] disorder. Open capsule and sprinkle in food vehicle of choice dated 7/5/24. There is no current care plan designated for dementia care. During an interview on 7/24/24 at 10:41 A.M., the Licensed Social Worker indicated that she places a care plan related to dementia for residents. On 7/26/24 at 8:00 A.M., the Administrative Support Person provided a current, nondated policy Dementia Care. The policy indicated .it is the policy of the facility to provide the appropriate treatment and services with residents diagnosed with dementia .the facile will assess, develop, and implement care plans through and interdisciplinary team . the care plan goals will be achievable .interventions will be related to each resident's individual symptomology and rate of dementia progression .

Based on interview and record review, the facility failed to ensure routine medications were available and dispensed according to physician's orders for 1 of 6 residents reviewed for medication administration. (Resident 28) Finding includes: On 7/23/24 at 10:08 A.M., Resident 28's clinical record was reviewed. Diagnosis included, but was not limited to, hyperlipidemia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 5/8/24, indicated Resident 28 had severe cognitive impairment and required setup assistance of staff for eating. Current physician orders included, but was not limited to: Pravachol (a medication to treat high cholesterol) Tablet 80 MG (milligrams) - Give 1 tablet by mouth one time a day for hyperlipidemia, dated 7/17/22. The July 2024 MAR (Medication Administration Record) indicated resident did not receive the medication on 7/18, 7/19, and 7/22 because it was on order. The MAR indicated the resident received the medication on 7/20 and 7/21. On 7/23/24 at 10:18 A.M., the pharmacy indicated Resident 28's Pravachol was reordered early the morning of 7/23/24 and had not been dispensed yet. The medication had last been dispensed from the pharmacy on 6/13/24. On 7/23/24 at 1:27 P.M., the Director of Nursing (DON) provided a list of medications available in the facility's Emergency Drug Kit (EDK). Pravachol was not available in the EDK. On 7/25/24 at 9:54 A.M., the DON indicated she was not sure how Resident 28 could have received Pravachol on 7/20 and 7/21 and it may have been marked in error. On 7/25/24 at 12:12 P.M., Licensed Practical Nurse (LPN) 36 indicated medication should be reordered 7 days before the medication runs out. On 7/26/24 at 9:03 A.M., the Administrative Support provided a Charting and Documentation policy, revised July 2017, that indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. On 7/26/24 at 9:13 A.M., the Administrative Support provided an Order and Receiving Medications policy, dated 1/17/15, that indicated Reorder medication when a four day supply remains, in advance of need, to assure an adequate supply is on hand. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Medication and Treatment Orders policy, revised July 2016, that indicated drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. 3.1-25(a)

Based on record review and interview the facility failed to ensure a resident was free from unnecessary medications for 1 of 1 residents reviewed for hospice. A resident's as needed anti-anxiety medication was ordered for more than 14 days. (Resident 49) Finding includes: On 7/21/24 at 11:10 A.M., Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease with late onset and Anxiety Disorder . The MDS (Minimum Data Set) dated 7/6/24 indicated that Resident 49's cognition was severely impaired and was currently receiving hospice services. Current physician orders included but were not limited to lorazepam oral tablet 0.5 MG, 1 tablet by mouth every 4 hours as needed for anxiety and agitation related to Anxiety Disorder. The order was dated 6/28/24 with no end date. On 07/25/24 at 10:53 A.M. the DON (Director of Nursing) indicated that PRN antianxiety medications should have been evaluated every 14 days, also that it would have been expected for the end date to be 14 days when order was put in. A Use of Psychotropic Medication Policy was provided by administration on 7/25/24 at 2:00 P.M. The policy stated PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). 3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and professional standards for 2 of 26 opportunities, resulting in a medication administration error rate of 7.69%. (Resident 53 and Resident 23) Findings include: 1. On 7/23/24 at 11:35 A.M., Licensed Practical Nurse (LPN) 46 was observed preparing a Humalog Kwikpen for insulin administration for Resident 53. An AccuCheck (blood glucose test) indicated the resident had a blood sugar of 313. LPN 46 indicated the resident received sliding scale insulin and was to receive 3 units of insulin Lispro (a fast acting insulin) for a blood glucose reading of 313. LPN 46 set the insulin pen to 3 units. She cleaned the tip of the pen, attached the needle, and administered 3 units of insulin to Resident 53 in her lower left abdomen. LPN 46 did not prime the insulin pen before administration of the medication. 2. On 7/24/24 at 12:02 P.M., Licensed Practical Nurse (LPN) 7 was observed preparing a Humalog Kwikpen (Lispro Insulin) for insulin administration for Resident 23. LPN 7 indicated the resident received scheduled insulin and was to receive 5 units of insulin lispro (a fast acting insulin) with her lunch meal. LPN 7 set the insulin pen to 5 units. She cleaned the tip of the pen, attached the needle, and administered 5 units of insulin to Resident 23 in her right arm. LPN 7 did not prime the insulin pen before administration of the medication. On 7/25/24 at 9:54 A.M., the Director of Nursing (DON) indicated insulin pens needed to be primed before insulin was administered to the resident but was unsure how many units with which to prime the pen. On 7/25/24 at 9:45 A.M., the Humalog Kwikpen user manual was reviewed. It indicated Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 8 times. If you still do not see insulin, change the needle and repeat priming steps 6 to 8. On 7/25/24 at 10:35 A.M., the DON provided an Insulin Pen policy, undated, that indicated Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle point up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. 3.1-48(c)(1)

Based on interview and record review, the facility failed to obtain consent before administering influenza vaccines for 2 of 5 residents reviewed for immunizations. (Resident 37 and Resident 36) Findings include: 1. On 7/22/24 at 2:00 P.M., Resident 37's clinical record was reviewed. Resident 37 received the influenza vaccine on 10/20/23. The clinical record lacked a signed consent for the influenza vaccination received on 10/20/23. On 7/23/24 at 1:27 P.M., the Director of Nursing (DON) provided the most current influenza vaccination consent form signed by Resident 37 dated 4/26/21. 2. On 7/22/24 at 1:45 P.M., Resident 36's clinical record was reviewed. Resident 36 received the influenza vaccine on 10/11/23. The clinical record lacked a signed consent for the influenza vaccination received on 10/11/23. On 7/23/24 at 10:43 A.M., Licensed Practical Nurse (LPN) 5 indicated that it took too long to call every family for influenza vaccination consent every year so if they accepted it once, she did not call them again. At that time, she indicated the floor nurse gave the influenza vaccine to Resident 36 without a signed consent as all vaccines were declined by the resident's wife when the resident was admitted to the facility. On 7/26/24 at 9:13 A.M., the Administrative Support provided an Infection Prevention and Control Program, revised 1/23/2023, that indicated Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. Residents will have the opportunity to refuse the immunizations. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations. 3.1-13(a)

Based on interview and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with showering/bathing for 4 of 4 residents reviewed for dependent ADL care. (Resident 28, Resident 37, Resident 57, Resident 6) Findings include: On 7/23/24 at 3:10 P.M., multiple Resident's attending the Resident Council meeting voiced concern of not receiving routine showers and/or complete bed baths as scheduled. 1. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. A self-care deficit care plan, dated 3/26/18, indicated Resident 28 had need for assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Tuesdays and Fridays. A record review from 5/1/24 through 7/26/24 indicated Resident 28 had only received 3 of 25 scheduled showers, with no documented refusals. 2. On 7/23/24 at 1:59 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated Resident 37 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. A self-care deficit care plan, dated 4/26/21, indicated Resident 37 had need for assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Mondays and Thursdays. A record review from 5/1/24 through 7/26/24 indicated Resident 37 had only received 8 of 25 scheduled showers, with one documented refusal on 5/2/24. 3. On 7/24/24 at 8:53 A.M. Resident 57's clinical record was reviewed. Diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent admission MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident 57 was moderately cognitively and was completely dependent on staff for toileting and showers. A self-care deficit care plan, dated 6/11/24, indicated Resident 57 required assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers twice a week starting 6/10/24. A record review from 6/10/24 through 7/26/24 indicated Resident 57 had only received 3 showers in the past 7 weeks, with no documented refusals. 4. On 7/25/24 at 11:18 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes and chronic kidney disease. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/23/24, indicated Resident 6 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. A self-care deficit care plan, dated 1/16/24, indicated Resident 6 required assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident should receive showers twice a week. A record review from 5/1/24 through 7/26/24 indicated the Resident 6 had only received twice weekly showers for 5 weeks during the 12 week period. During an interview on 7/25/24 at 1:51 P.M., the DON (Director of Nursing) indicated Resident's should receive at least two (2) showers each week, or a complete bed bath only if it is their personal preference, and should receive a partial bed bath each day, and staff should document showers given or refused in the POC tasks each day. On 7/25/24 at 1:30 P.M., a shower policy was request but was not provided. 3.1-38(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with limited range of motion or mobility received services to maintain or improve mobility for 4 of 4 residents reviewed for restorative therapy. (Resident 6, Resident 28, Resident 52, Resident 55) Findings include: 1. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. Current care plans included, but were not limited to: Resident requires RNP (Restorative Nursing Program) of ROM (Range of Motion), Date initiated 11/2/22. Resident to perform BLE (bilateral lower extremities) exercises throughout all planes x 20 reps or on cubii pedaler on Level 1 for 15 minutes 3-4x/week, Date initiated: 11/9/23. Resident to perform BUE (bilateral upper extremities) strengthening exercises at 1-2 sets of 15 reps utilized light resistance thera-band (red) 3-4x/week, Date initiated: 11/9/23. Resident will perform BUE (bilateral upper extremities) strengthening exercises on arm bike x6-8 min with rest breaks as needed (2 sets) 3-4x/week, Date initiated 7/21/23. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for restorative nursing therapy was reviewed from 5/1/24 through 7/26/24 and indicated Resident 28 had only received 5 days of restorative nursing therapy during the 12 week period. 2. On 7/25/24 at 11:18 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes and chronic kidney disease. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/23/24, indicated Resident 6 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. Current care plans included, but were not limited to: Resident requires RNP (Restorative Nursing Program) of ROM (Range of Motion) due to diabetes insipidus, impaired mobility, and to help resident remain at his highest level of physical functioning, Date initiated: 3/13/24. Resident will perform BUE strengthening exercises x 10 reps; BLE exercises x 10 reps (2 sets) seated 3-4x/week x 90 days. Resident will walk > (greater/more than) 200ft 3-4x/week Date initiated, 3/13/24. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for restorative nursing therapy was reviewed from 5/1/24 through 7/26/24 and indicated Resident 6 had only received 5 days of restorative nursing therapy during the 12 week period.4. On 7/22/24 at 12:22 P.M., Resident 55 was observed sitting in wheelchair in dining room with wife. On 7/23/24 at 9:00 A.M., Resident 55 was observed sitting in wheelchair in room watching television. On 7/25/24 at 10:20 A.M., Resident 55 was observed sitting in wheelchair in room after morning care. On 7/25/24 at 2:17 P.M., Resident 55's clinical record was reviewed. Diagnoses included but were not limited to, Type 2 diabetes mellitus with diabetic neuropathy, unspecified and peripheral vascular disease, unspecified. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact. The resident needed substantial help toileting and transferring. MDS indicated there was a restorative program. During the 7 days look back period 0 minutes were recorded daily for restorative care. The medical record lacked current physician orders for restorative care. The current care plan indicated the resident requires RNP (Restorative Nursing Program) related to impaired mobility due to diabetic neuropathy. Interventions included but were not limited to: Resident will perform active ROM (Range of motion) to BUE( Bilateral Upper Extremities) for strengthening seated or supine x(Times) 15 minutes 3-4x /week x 90 days and resident will walk 50-100 feet with FWW(Full Weight Bearing) and GB(Gait Belt), Min A-CGA (Minimum Activity -Comprehensive Geriatric Assessment 3-4x/week dated 4/15/24. On 7/25/24 at 1:55 P.M., LPN (Licensed Practical Nurse) 2 provided the CNA(Certified Nurse Aide) Tasks for Nursing Rehabilitation that was for Active ROM BUE for strengthening seated or supine x15 minutes 3-4x/week the only days from 6/26/240-7/22/24 that included Nursing Rehabilitation times were as follows: 6/30/24 at 2:40 P.M. for 15 minutes 7/1/24 at 9:29 P.M. for 5 minutes 7/8/23 at 6:29 P.M. for 15 minutes 7/9/24 at 3:15 P.M. for 15 minutes 7/21/24 at 6:29 P.M. for 4 Minutes 7/22/24 at 6:29 P.M. for 3 minutes During an interview on 7/25/24 at 1:50 P.M., LPN 2 indicated there was no restorative aide for the facility. On 7/26/24 at 8 A.M., Administrative Support provided an undated policy titled Restorative Nursing Program that indicated It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. On 7/24/24 at 10:45 A.M., the DON provided a current Restorative Nursing Services policy, revised 7/2017, that indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence At that time, the Administrative Support indicated restorative nursing had not been done. On 7/26/24 at 8 A.M., Administrative Support provided an undated policy titled Restorative Nursing Program that indicated It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. On 7/24/24 at 10:45 A.M., the DON provided a current Restorative Nursing Services policy, revised 7/2017, that indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence At that time, the Administrative Support indicated restorative nursing had not been done. 3.1-42(a)(1) 3.1-42(a)(2) 3. On 7/23/24 at 11:42 A.M., Resident 52's clinical record was reviewed. Diagnosis included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/18/24, indicated no cognitive impairment, no behaviors, and no days of restorative. Resident 52 required supervision assistance of one staff with transfers. A current restorative nursing program care plan, dated 7/6/23, indicated an intervention but was not limited to, resident to walk up to 150-200 feet with staff 3-4 times per week, dated 5/17/24. In the last 30 days, Resident 52 had received restorative nursing that entailed resident walking up to 150-200 feet with staff on 7/21/24 for 10 minutes. On 6/27/24, Resident 52 refused. All other dates were not completed. On 7/24/24 at 9:50 A.M., the Director of Nursing (DON) indicated they had been trying to get a dedicated Certified Nurse Aide (CNA) for restorative nursing, but currently did not have one. She indicated whatever CNA was working was responsible for doing restorative nursing tasks with the residents. On 7/24/24 at 9:59 A.M., CNA 3 indicated restorative nursing range of motion exercises were performed with Resident 52 in the room with transfers. She indicated there was nothing in particular that needed to be done with the resident as far as which extremities and whatever was done was supposed to be documented in the clinical record.

Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures and chemicals were within range and logs were completed for 1 of 2 kitchens observed. (Cottage kitchen) Findings include: 1. On 7/21/24 at 10:14 A.M. during an initial kitchen tour of the Cottage, Dietary Aide 40 indicated the dishwasher was a high temperature dishwasher, but she was unsure what the temperature was supposed to be when the machine was running. She indicated there was water on the floor when she came in that morning so she was not certain if the machine was functioning properly and would call maintenance to look at it. At that time, Dietary Aide 40 provided the dishwasher temperature logs for June and July. Sixty-Four of 90 opportunities for wash and rinse temperature testing were not filled out in June. Fifty-one of 61 opportunities for wash and rinse temperature testing were not filled out in July. Dietary Aide 40 indicated she was supposed to fill out the temperature logs at the end of her shift. On 7/22/24 at 9:45 A.M., Dietary Aide [NAME] 10 indicated the dishwash temperature should get to 120 degrees Fahrenheit (F). She indicated that sometimes she had to run the cycle several times to get the temperature up to where it needed to be. At that time, she ran a dishwasher cycle. The dishwasher thermometer read 113 F. She ran the cycle again and the thermometer read 115 F. She ran the cycle five more times with the thermometer reading 116 F each time. At that time, she indicated she wasn't sure why it wasn't reaching 120 F and would let maintenance know. On 7/22/24 at 12:45 P.M., the Administrative Support provided the instruction manual for the Dishwasher, undated, that indicated Recommended temp 140 degrees F . required minimum temp 120 degrees F . follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottle of the glasses. Concentration should be 50 p.p.m. (parts per million) minimum to 100 p.p.m. maximum. If concentration is incorrect contact your chemical supplier . low heat during operation likely cause low incoming water temperature (below 140 degrees F). On 7/22/24 at 2:20 P.M., [NAME] 10 indicated there were chemicals hooked up to the dishwasher. The chemicals were dated 6/14. She indicated she tested the dishwasher chemicals with a test strip once a day if she remembered, but did not log the results anywhere. At that time, a dishwasher cycle was observed. [NAME] 10 used a test strip to test for p.p.m. of hypochlorite. The test strip read 0 p.p.m. On 7/23/24 at 7:42 A.M., a sign on the cottage dishwasher indicated Out of Order! Use 3 compartment sinks to wash and sanitize dishes! Thank you!. On 7/23/24 at 11:05 A.M., the Dietary Manager indicated that the Cottage dishwasher was a low temperature dishwasher. Staff should be recording the wash temperature and the sanitizing solution readings twice a day. She indicated the dishwasher log used in the Cottage was not the right form. She further indicated the dishwasher worked on and off and had told staff multiple times that if the wash temperature was not at or over 120 F or the chemicals were not reading to not use the dishwasher, but staff wouldn't listen. 2. On 7/21/24 at 10:14 A.M., Dietary Aide 40 provided the Cottage Equipment Temperature logs for June and July. The temperature logs indicated the following: The pantry refrigerator, pantry freezer, pantry freezer, kitchen refrigerator, and kitchen freezer temperatures were missing 13 times during the morning shift and 29 times during the evening shift in June, and 16 times during the morning shift and 20 times during the evening shift in July. At that time, Dietary Aide 40 indicated she was supposed to fill out the temperature logs at the end of her shift. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Dishwasher Temperature policy, undated, that indicated For low temperature dishwashers (chemical sanitization): the wash temperature shall be 120 degrees F. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse . Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Monitoring of Cooler/Freezer Temperature policy, undated, that indicated Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. Temperatures will be checked and logged at least twice per day by designated personnel. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 3 of 3 residents reviewed for transmission based precautions, and failed to position fans to prevent cross contamination in the laundry processing area for 1 of 2 random observations of the laundry room. (Resident 57, Resident 60, Resident 17, and Laundry Room) Findings include: 1. On 7/23/24 at 7:57 A.M., a PPE (personal protective equipment) cart was observed outside of Resident 57's room. There was no sign observed indicating instructions for specific use of the PPE or to see the nurse before entering the room. On 7/23/24 at 8:00 A.M., Resident 57's clinical record was reviewed. The clinical record lacked orders, care plans, and progress notes related to transmission based precautions. On 7/23/24 at 8:15 A.M., Licensed Practical Nurse (LPN) 23 indicated that Resident 57 was on EBP because he had a feeding tube. 2. On 7/23/24 at 8:15 A.M., LPN 23 indicated Resident 60 was on EBP because he had an indwelling urinary catheter. At that time, she indicated they do not hang signs to indicate instructions for PPE use, but there is usually a flyer hanging in the nurse's station. She could not locate the flyer in the nurse's station. On 7/23/24 at 8:23 P.M., no PPE cart or sign was observed outside of Resident 60's room indicating transmission based precaution requirements. At that time, LPN 23 indicated Resident 60 had just gotten the catheter and the PPE cart hadn't been put out yet. On 7/23/24 at 8:34 A.M., Resident 60's clinical record was reviewed. Current physician orders included, but was not limited to: Foley Catheter for retention, dated 7/20/2024. The clinical record lacked orders, care plans, and progress notes related to transmission based precautions. 3. On 7/23/24 at 9:30 A.M., a PPE cart was observed outside of Resident 17's room. There was no sign observed indicating instructions for specific use of the PPE or to see the nurse before entering the room. LPN 25 indicated that residents who were on transmission based precautions had a bumblebee sticker on their nameplate. Staff got the indication for precautions and instructions for PPE use during report or had to look through the physician orders. On 7/23/24 at 9:36 A.M., Resident 17's clinical record was reviewed. Physician orders included, but was not limited to: Observe Enhanced Barrier Precautions - every shift for indwelling Foley catheter, dated 4/23/24 On 7/24/24 at 2:36 P.M., the Infection Preventionist indicated that residents who were on EBP had a bumblebee sticker on their nameplate which would signify to anyone who went into the room that they needed some form of PPE. She indicated either she or the admitting nurse was responsible for placing the signage and PPE carts outside of the room upon order. On 7/25/24 at 10:15 A.M., the Administrative Support indicated any resident who required EBP should have a physician's order and a care plan for it. 4. On 7/21/24 at 12:47 P.M., a fan was observed sitting on top of the small washing machine blowing from side of room where soiled linen was stored to the side of the room where clean linen was stored. On 7/25/24 at 11:32 A.M., the Environmental Services Manager indicated that laundry staff had a fan in the laundry processing area, but the fan was supposed to stay on the clean side of the room and not blow from dirty to clean. On 7/26/24 at 9:13 A.M., the Administrative Support provided an Enhanced Barrier Precautions Policy that indicated Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube .) . Make gowns and gloves available immediately outside of the resident's room. On 7/26/24 at 9:13 A.M., the Administrative Support provided an Infection Prevention and Control Program, revised 1/24/2024, that indicated Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Laundry policy, undated, that indicated Soiled laundry shall be kept separate from clean laundry at all times. 3.1-18(b)(1) 3.1-18(b)(2)

2. On 4/19/23 at 9:18 A.M., Resident 5's bed was observed in the middle of the room with only the head of the bed against a wall. On 4/20/23 at 10:58 A.M., CNA 25 indicated that Resident 5 had dementia and would get out of bed and walk to the bathroom or in the halls; however, ever since his fall the staff kept an eye on him, and he didn't try to get up anymore. On 4/21/23 at 10:38 A.M., Resident 5's bed was observed in the middle of the room with only the head of the bed against a wall. At that time, LPN 15 indicated that the bed had been against the wall, but it was difficult to care for Resident 5 with the bed in that position because they needed two people to get him up out of bed. On 4/21/23 at 9:06 A.M., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, fracture of neck of left femur and dementia. The most recent Significant Change MDS assessment, dated 2/28/23, indicated Resident 5 required extensive assistance of 2 or more staff with bed mobility and transfers, required total assistance of 1 staff with toileting and bathing, and had a mild cognitive impairment. A current falls care plan, initiated 5/27/22, indicated Resident 5 was at risk for falls. Interventions included, but were not limited to, quarter side rails in bed for mobility enablers (dated 5/27/22), bed placed against wall (dated 12/28/22), call light within reach (dated 5/27/22), environment free of clutter (dated 5/27/22), commonly used articles within easy reach (dated 5/27/22), resident to wear non-skid footwear (dated 5/31/22), and hoyer lift used for transfers (dated 4/6/23). A current care plan, initiated 5/27/22, indicated Resident 5 had a self-care deficit. Interventions included, but were not limited to, assistance to complete all personal hygiene tasks including bathing, oral care, and dressing (dated 5/27/22). The Quarterly Fall Risk Assessment, dated 9/1/22, indicated Resident 5 was a high risk for falls. Resident 5's falls included: Fall 1: On 12/23/22 at 5:15 A.M., Resident 5 sustained an unwitnessed fall in his bedroom while reaching for his electric razor. The immediate intervention implemented was to place the resident's bed against the wall to allow the resident to be up in a safe position when reaching for personal belongings on his dresser. Fall 2: On 2/15/23 at 5:00 A.M., Resident 5 sustained an unwitnessed fall in his bedroom. Resident 5 indicated he was walking to the bathroom when he started leaning to his left side. He then grabbed onto the bedside table to steady himself; however, the bedside table rolled away from him causing him to fall. At that time, Resident 5 had 3 small round bruises to the bony prominence's of his left elbow. Resident complained of left hip pain upon standing and ambulating, and an order was given for an x-ray. The immediate intervention implemented was to check, change, or assist resident to the toilet as able every 3 hours throughout the night. On 2/16/23 at 1:10 A.M., a follow up fall note indicated the x-ray showed No acute osseous (bone) abnormality. On 2/17/23 at 11:15 A.M., Resident 5 was sent to the ER (emergency room) due to a decline in condition. On 2/17/23 at 4:20 P.M., a follow up fall note indicated that the hospital confirmed Resident 5 had a hip fracture. An orthopedic procedure was performed to repair the fracture. Fall 3: On 2/25/23 at 5:25 P.M., Resident 5 sustained a witnessed fall in the hallway. The resident was ambulating unassisted. The resident complained of increased pain and was sent to the ER. The resident returned to the facility at 11:45 P.M. the same day with no new injuries noted. The falls care plan was not updated at that time with a new intervention. On 4/21/23 at 11:01 A.M., LPN 32 indicated that having Resident 5's bed against the wall should have been discontinued because it would be hard to care for the resident with the bed in that position since Resident 5 was a larger person that required total assistance after the fracture. On 4/21/23 at 11:23 A.M., the DON indicated that the care plan should have been updated to reflect the need for total care when Resident 5 returned to the facility on 2/21/23, but the care plan was not updated. A current Fall Prevention Program Policy was provided on 4/17/23 at 9:27 A.M. The policy indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definition a fall is an event in which an individual unintentionally comes to rest on the ground The event may be witnessed, reported, or presumed when a resident is found on the floor, . can occur anywhere . Policy explanation and compliance guidelines .7 a . interventions will be monitored for effectiveness. b the plan of care will be revised as needed 8. when any resident experiences a fall the facility will: a. assess the resident .e review the resident's care plan and actions with updates . 3.1-45(a)(1) Based on interviews, and record review, the facility failed to ensure residents environment remained free from accident hazards for 2 of 4 residents reviewed for falls. New interventions were not implemented following falls. (Resident H, Resident 5) Findings include: 1. On 4/19/23 at 11:40 A.M., Resident H was observed wondering the unit in a wheel chair. On 4/18/23 at 2:41 P.M., Resident H's clinical record was reviewed. The diagnoses included, but were not limited to, unspecified dementia and displaced midcervical fracture of left femur. The Quarterly MDS (Minimum Data Set) assessment, dated 3/23/23, indicated Resident H had severe cognitive impairment and required extensive assistance for transferring and dressing. Resident H was a high risk for falls. Resident H's physician orders included, but were not limited to, alarming floor mat, check placement, and functioning every shift, antirollback to wheelchair two times a day for fall reduction measure, and place resident's bed against the wall per family request. Resident H's care plan dated 6/22/22 included, but not limited to: Resident is at high risk for falls per fall risk assessment. The interventions included, but were not limited to, touch pad call light within reach at all time and transfer with extensive assist of 1 to 2. Fall events from 2/6/23 to 4/16/23 Fall 1 - Post Fall Evaluation On 2/6/23 at 3:15 A.M., the resident had an unwitnessed fall that occurred in the resident's room. The CNA went into to the resident's room, heard the floor mat alarm sounding, and found resident sitting on the alarming mat. The resident was noted to also be incontinent. No new interventions were implemented. Fall 2 - Post Fall Evaluation On 3/6/23 at 4:14 A.M., The nurse heard resident floor alarm sounding. As nurse got to residents room, resident was noted standing and fell to floor on buttocks, hitting head on side of bed rail. Light was off. Resident was noted to be incontinent. Resident had no footwear on. Full head to toe skin assessment completed. Resident does have small bump on top of scalp, slight toward right. No neurochecks were documented at this time. Fall 3 - Post Fall Evaluation On 4/16/23 at 5:30 P.M., resident had a witnessed fall in the dining room while trying to transfer from a chair back into wheelchair. She sustained bruising to the left eye brow. The wheel chair was unlocked at the time of the fall. No new interventions were implemented. On 4/20/23 at 1:00 P.M., the DON provided the alarm frequency monitoring for the week for 3/10/23 to 3/17/23. The monitoring was to see if the resident was attempting to self transfer and set off alarms during days and night. - On 3/11/23 day shift was not documented. - On 3/12/23 day shift was not documented. - On 3/13/23 day shift was not documented. - On 3/14/23 night shift was not documented. - On 3/15/23 night shift was not documented. - On 3/16/23 day shift was not documented. During an interview on 4/20/23 at 1:17 P.M., CNA 9 indicated she did not know the fall interventions for the residents off the top of her head off but could look at her IPAD for the care plan information.

Based on observation, interview, and record review, the facility failed to ensure services of a RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 2 of 7 days reviewed for nurse staffing. Findings include: On 4/19/23 at 10:30 A.M., the daily nursing assignment sheets were provided for the week of 4/3/23 through 4/10/23 and reviewed. The sheets indicated there was no RN coverage for Saturday, 4/8/23 and Sunday, 4/9/23. During an interview on 4/21/23 at 4:45 P.M., the Administrator indicated there was not RN coverage for those dates and there should have been 8 hours of consecutive RN coverage every day. On 4/21/23 at 4:45 P.M., a current undated Nursing Services and Sufficient Staff policy, was provided by the Administrator and indicated . the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 3.1-17(b)(3)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 1 residents reviewed for hospice. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 46) Finding includes: On 4/18/23 at 12:51 P.M., Resident 46's clinical record was reviewed. The diagnosis included, but was not limited to, anxiety. The Significant Change MDS (Minimum Data Set) Assessment, dated 3/21/23, indicated Resident 46's cognition was severely impaired and was currently on hospice. Current physician orders included, but were not limited to: Lorazepam Intensol Oral Concentrate (anti-anxiety medication) 2 MG (milligram)/ML (milliliter). Give 0.25 ml by mouth every 6 hours as needed for anxiety; restlessness related to anxiety disorder, dated 3/13/23. Resident 46's clinical record lacked any physician reassessment for lorazepam after the initial 14 days after it was ordered. The clinical record lacked a care plan addressing the anti-anxiety medication. During an interview on 4/20/23 at 1:23 P.M., the DON indicated Resident 46 did have an order for as needed lorazepam since 3/13/23, that did not have a stop date or an assessment from a physician after 14 days. The DON further indicated that PRN psychotropic medications should have a stop date if continued longer than 14 days. On 4/20/23 at 1:50 P.M., a current Antipsychotic Medication Use policy, revised December 2016, was provided and indicated The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. 3.1-48(a)(2)

Based on observation, interview, and record review the facility failed to ensure deteriorated medications carts were disposed of for 2 of 4 medication carts. Loose pills were found in the bottom of the medication cart drawers. (North Hall, South Hall) Findings include: 1. On 4/19/23 at 7:58 A.M., the medication cart on the North Hall was observed to have the following medications laying loose in the bottom of 2 drawers: 1 large white pill #12 1 small round pill with R # 25 1 small round blue pill with no writing 1 small round pill with # 1484 1 oblong peach pill with # 722 1 small round peach pill with PH # 034 1 small round white pill with #10 1/2 yellow pill could not read number 1 large round white pill with PH #020 1 small round white pill with no writing 1 white capsule with SG #179 1 peach round small pill with #OH 034 1 scored small white pill with # AC 152 1/2 small white pill with #49 1 small round clear orange 1 small oblong white pill with no number 1 large oblong pill with K #46 1 large round white pill with no number 1 small red round pill with PH # 32 1 small round red pill no number 1 crushed white capsule no number 1 reddish brown oblong pill with #12 21 1 large white pill round with TCL # 340 1 small round pill with #210 1 red oblong pill with #796 1 small round white pill with #3040 1/2 white oblong pill no number 1 small multi brown colored pill with # 0140 2. On 4/19/23 at 8:40 A.M., the medication cart in the South hall was observed with the following medications in the bottom of 1 drawer: 1 small white oblong pill with # 6948 1 large oblong yellow pill with #18 1 small red pill with LS # 203 2 large oblong white pills with C#484 1 small round white pill with MP #668 During an interview on 4/19/23 at 8:07 A.M., LPN 42 indicated loose medication found in a drawer should be removed and disposed of into a a bottle of liquid drug disposal. During an interview 4/19/23 at 8:30 A.M., the DON, indicated when there were loose medications found in the medication cart drawers, the nurse/QMA (Qualified Medication Aide) immediately placed the pills into the drug buster and notified the DON and Administrator. During an interview on 4/19/23 at 8:45 A.M., LPN 21 indicated many of the pills pop out because the cards are stuffed tightly into the drawers. LPN 21 indicated when she found loose medication in a drawer the pills are placed in the bio hazard sharps container. A current Storage of Medications and Biological's policy, reviewed 5/12/21, was provided by DON on 4/19/21 at 12:30 P.M. The policy indicated In accordance with State and Federal laws ., the facility must store all medications and biologicals in locked compartments or storage rooms .Procedure . 21. Disposal of medication(s) should be completed for medication(s) that are without secure, outdated, contaminated or deteriorated. a. Disposal needs to be timely .c. Disposal of medication(s) per medication disposal procedure . 3.1-25(o)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. On 4/19/23 at 10:09 A.M., Resident F was observed sitting in her wheelchair in the lobby area of the unit. On 4/19/23 at 8:18 A.M., Resident F's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's dementia, muscle weakness, and difficulty in walking. The Quarterly MDS assessment, dated 3/14/23, indicated Resident F's required extensive assistance from staff for eating, bed mobility, and transfers. The Care Plans included but were not limited to: Resident requires RNP of ROM, dated 5/20/22. The interventions included, but were not limited to, document participation in program daily, monitor progress, resident will perform AROM/AAROM to BUE/BLE seated or lying down for 15 repetitions 6-7 times per week. A Nursing Rehab documentation report from 4/1/23 through 4/19/23 indicated Resident F did not receive RNP with AROM on the following dates: 4/1/23 through 4/3/23 4/5/23 through 4/8/23 4/10/23 through 4/13/23 4/15/23 through 4/19/23 During an interview on 4/19/23 at 11:49 A.M., CNA 7 indicated she thought there was a restorative aide that comes once a week or maybe it was therapy she did not know the answers. During an interview on 4/20/23 at 2:03 P.M., LPN 21 indicated there was not a restorative aide and she was not sure who was in charge of doing restorative services, probably CNA's. During an interview on 4/20/23 at 2:09 P.M., the MDS Coordinator indicated they had not had a restorative aide for at least 6-8 months. The CNA's should have known who the residents were that needed restorative services from the updated list. She indicated the services should be documented in tasks if completed or if the resident refused. During an interview on 4/21/23 at 8:24 A.M., RN 3 indicated that it was the responsibility of the CNA assigned to the unit to perform restorative therapy care for residents on the restorative care list, and that the schedule used by the CNA, to know who is on the care list, was updated immediately after a new order was placed for restorative care. On 4/21/23 at 3:05 P.M., a current Restorative Nursing Services policy, revised July 2017, was provided by the Administrator and indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence This Federal tag relates to Complaints IN00404282, IN00404286, and IN00401379. 3.1-42(a)(2) 6. On 4/19/23 at 9:20 A.M., Resident G was observed sitting in her wheelchair in her room eating breakfast. On 4/18/23 at 1:43 P.M., Resident G's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure, osteoporosis, and chronic pain. The most recent Quarterly MDS assessment, dated 3/7/23, indicated Resident G was cognitively intact. Resident G required supervision of one with bed mobility, transfers, and toilet use. Resident G required set up help only with eating and bathing. A Care Plan, dated 6/2/22, indicated Resident G requires RNP (Restorative Nursing Program) of ROM (range of motion). The interventions, dated 6/2/22, included, but were not limited to, document participation in program daily, monitor progress, resident will perform AAROM/AROM to BUE seated for 15 repetitions 6-7 times per week. A Care Plan, dated 6/2/22, indicated Resident G requires RNP of walking. The interventions, dated 6/2/22, included, but were not limited to, document participation in program daily, monitor progress, resident will walk 150-200 feet with front-wheeled walker, gait belt, and stand by assist/contact guard assist to eat in dining room or participate in activities 6-7 times per week. Physical therapy evaluation and plan of treatment, dated 9/15/22, indicated will discharge with RNP and resident may be up ad lib [as desired] in her room. Nursing Progress Notes included the following information: On 3/7/23 at 8:17 P.M., Resident is in RNP for AAROM/AROM BUE/BLE seated for 15 repetitions 6-7 times a week. Resident has not participated in task in look back period. Resident is also in RNP for walk 150-200 feet four wheeled walker, gait belt, and stand by assist/contact guard assist to eat in dining room or participate in activities 6-7 times a week. Resident has not participated in task in look back period. Quarterly evaluation of RNP completed on this date. Resident has not participated in either RNP task in 7 day look back period. Will continue RNP and tasks/goals involved and will reevaluate at next assessment period or sooner if need arises. On 4/19/23 at 1:20 P.M., the DON (Director of Nursing) provided a nursing rehab task documentation for March and April, 2023 which indicated Resident G received AAROM/AROM on 3/21/23 and 3/27/23. Resident G did not walk 150-200 feet in March or April. 5. On 4/17/23 at 10:00 A.M., Resident E was observed dressed and sitting up in a wheelchair. On 4/21/23 at at 9:47 A.M., Resident E's clinical records were reviewed. The diagnoses included, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, muscle weakness, and difficulty in walking, The Quarterly MDS assessment, dated 4/18/23, indicated the resident was cognitively intact and required extensive assistance of one for bed mobility, extensive assist of two for transfers, supervision of one assist for eating, and was totally dependent for toileting and bathing. Current physician orders included, but were not limited to: - AAROM to left upper extremity/active range of motion to right upper extremity for 15 repetitions 6-7 times per week, ordered on 3/21/23. - Transfers from bed to wheelchair (stand pivot transfer) with device 2-3 repetitions 6-7 times per week, ordered on 3/21/23. A Nursing Rehab task documentation from 3/22/23 to 4/18/23 indicated the resident did not receive restorative nursing services for active assisted range of motion to left upper extremity/active range of motion to right upper extremity for 15 repetitions 6-7 times per week on: 3/23/34 through 4/4/23 4/6/23 4/7/23 4/9/23 through 4/18/23 A Nursing Rehab task documentation from 3/22/23 to 4/18/23 indicated the resident did not receive restorative nursing services for transfers from bed to wheelchair (stand pivot transfer) with device 2-3 repetitions 6-7 times per week on: 3/23/23 through 4/4/23 4/6/23 4/7/23 4/9/23 through 4/18/23 3. On 4/17/23 at 10:02 A.M., Resident H was observed in wheel chair. On 4/19/23 at 11:40 A.M., Resident H was observed in a wheel chair sitting in the hall way with fellow residents. On 4/18/23 at 2:41 P.M., Resident H's clinical record was reviewed. The diagnosis included, but was not limited to, unspecified dementia. The most recent Quarterly MDS assessment, dated 3/23/23, indicated Resident H's cognition was severely impaired. Resident H required extensive assist for transfer and dressing. The Care Plans included, but were not limited to: Resident requires RNP for ROM, revised 11/2/22. The interventions included, but were not limited to, AAROM (Active Assisted Range of Motion) to BUE seated for 15 repetitions 6-7 times per week. A Nursing Rehab task from 4/1/23 through 4/16/23 indicated Resident H did not receive the restorative nursing services with AAROM to BUE on the following dates: 4/1/23 through 4/3/23 4/5/23 through 4/8/23 4/10/23 through 4/16/23 4. On 4/17/23 at 10:05 A.M., Resident J was lying in bed with the head of bed slightly elevated with her left leg on the pillow. On 4/18/23 at 12:57 P.M., Resident J's clinical record was reviewed. The diagnosis included, but was not limited to, unspecified dementia. The most recently Quarterly MDS assessment, dated 1/23/23, indicated that Resident J was severely cognitively impaired. Resident J needed extensive assistance of 1 with transfers. The Care Plans included, but were not limited to: Resident requires RNP of ROM, revised 3/24/23. The interventions included, but were not limited to, resident will perform AAROM/AROM to BUE/BLE being mindful of posterior hip precautions for 15 repetitions 6 to 7 times per week. A Nursing Rehab task from 4/1/23 through 4/18/23 indicated Resident J did not receive the restorative nursing services with AAROM/AROM to BUE/BLE on the following dates: 4/1/23 through 4/3/23 4/5/23 through 4/8/23 4/10/23 through 4/18/23Based on observation, interview, and record review, the facility failed to ensure residents who required restorative nursing services received services for 7 of 8 residents reviewed. (Resident B, Resident C, Resident E, Resident F, Resident G, Resident H, Resident J) Findings include: 1. On 4/18/23 at 8:21 A.M., Resident B was observed sitting in a chair, rocking with her eyes closed, and the TV turned on. On 4/18/23 at 12:44 P.M., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, age-related osteoporosis and congenital (present form birth) blindness. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 1/17/23, indicated Resident B was moderately cognitively impaired and that AROM (active range of motion) restorative therapy was provided 4 of 7 days and walking restorative therapy was provided 2 of 7 days within the seven day look back period. Resident B required extensive assist of 1 staff for bed mobility, transfers, and toileting. Care plans included, but were not limited to: Resident requires RNP (Restorative Nursing Program) for ROM (Range of Motion), revised 3/8/22. The interventions included, but were not limited to, document participation in program daily, monitor progress, resident will perform active range of motion to bilateral lower extremities and ankles seated for 15 repetitions 6 to 7 times per week. Resident requires RNP for walking, revised 3/8/22. The interventions included, but were not limited to, document participation in program daily, monitor progress, and resident will walk with four wheeled walker, gait belt, and contact guard assist 150 feet in the hallway 6 to 7 times per week. A Physical Therapy Discharge summary, dated [DATE], indicated the resident required RNP to maintain the current level of function. A Nursing Rehab task from 3/1/23 to 4/19/23 indicated that Resident B did not receive restorative nursing services with AROM on the following dates: 3/2/23 3/3/23 3/6/23 3/8/23 3/10/23 through 3/26/23 3/29/23 through 3/31/23 4/3/23 4/6/23 4/8/23 through 4/14/23 4/16/23 through 4/19/23 A Nursing Rehab task from 3/1/23 to 4/19/23 indicated that Resident B did not receive restorative nursing services with walking on the following dates: 3/2/23 3/3/23 3/6/23 3/8/23 3/10/23 through 3/26/23 3/29/23 through 3/31/23 4/3/23 4/6/23 4/8/23 through 4/14/23 4/16/23 through 4/19/23 2. On 4/18/23 at 10:14 A.M., Resident C indicated she should be getting restorative services, and the staff did their best, but they were short staffed. On 4/19/23 at 2:08 P.M., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, right knee unilateral primary osteoarthritis, and left knee unilateral primary osteoarthritis. The most recent Annual MDS assessment, dated 2/21/23, indicated Resident C was cognitively intact and required the supervision of 1 staff for bed mobility, transfers, and toileting. It also indicated that AROM (active range of motion) restorative therapy was provided 0 of 7 days and walking restorative therapy was provided 0 of 7 days within the seven day look back period. Care plans included, but were not limited to: Resident requires RNP of ROM, revised 3/30/21. The interventions included, but were not limited to, resident will perform AROM (Active Range of Motion) to BLE (bilateral lower extremities) seated or lying down for 10 repetitions and BUE (bilateral upper extremities) strengthen tasks with 1-3 pound weights for 10 repetitions 6-7 times per week, dated 12/27/22. Resident requires RNP for walking, revised 3/30/21. The interventions included, but were not limited to, resident will walk 20-40 feet with four wheeled walker, gait belt, and stand by assistance or contact guard assistance with wheelchair following behind 6-7 times per week. A Nursing Rehab task from 3/1/23 to 4/19/23 indicated that Resident B did not receive restorative nursing services with AROM on the following dates: 3/3/23 3/6/23 3/8/23 through 3/17/23 3/20/23 through 3/23/23 3/25/23 3/27/23 3/29/23 through 3/31/23 4/1/23 4/3/23 4/4/23 4/6/23 through 4/9/23 4/13/23 4/14/23 4/16/23 4/17/23 4/19/23 A Nursing Rehab task from 3/1/23 to 4/19/23 indicated that Resident B did not receive restorative nursing services with walking on the following dates: 3/1/23 through 3/6/23 3/8/23 through 3/25/23 3/27/23 through 3/31/23 4/1/23 through 4/10/23 4/12/23 through 4/19/23 During an interview on 4/21/23 at 9:00 A.M., Resident C indicated that she felt weaker when she transferred from the bed to her wheelchair and when transferring to go to the bathroom. During an interview on 4/21/23 at 11:25 A.M., CNA 60 indicated after the last restorative aide left, the CNAs were supposed to do restorative care with the residents on their list. At that time, she indicated that they try to do some restorative services during care if they can. She further indicated recently she was going to walk Resident B but then got pulled somewhere else and never got back to do it.

Based on observation, record review, interview, the facility failed to ensure infection control practices were implemented for 2 of 8 observations of residents receiving personal care. Hand hygiene was not completed after completing incontinence care, with glove removal, and when touching soiled items. (Resident 26, Resident 42, Resident 57) Findings include: 1. On 4/3/19 at 3:20 p.m., CNA 2 was observed to provide incontinence care for Resident 26. CNA 2 did not change gloves and perform hand hygiene, and assisted Resident 26 to put on pants and shoes prior to transferring to her wheelchair per Hoyer lift with assist of CNA 3. CNA 2 was observed to take the bagged soiled linen to the soiled area and open the lid with his bare hand, drop the bag inside, and failed to perform hand hygiene prior to crossing the hall and entering Resident 42's room to assist with care. 2. On 4/3/19 at 3:45 p.m., CNA 1 was observed to sanitize the shower chair and remove her gloves with no hand hygiene, obtain towels from the closet, and place a bag in the trash can. CNA 1 then went to Resident 57's room and assisted her to ambulate to the shower room. CNA 1 was observed to assist Resident 57 take a shower, with Resident 57 performing self care upper body and peri area. CNA assisted Resident 57 to dry herself off and dress. CNA removed her gloved, with no hand hygiene observed, and ambulated Resident 57 to her room. CNA 1 returned to the shower room, applied gloves, and sanitized the shower chair. CNA 1 was observed to utilize the towels used during the shower to wipe up water on the floor, place the used towels and washcloths in a plastic bag, placed in a soiled barrel, and washed her hands. On 4/8/19 at 10:35 a.m., CNA 5 indicated she was to do hand hygiene before she started providing care, when giving care to a private, dirty spot, and when she came in contact with soiled linens. She was never to lay linens on the floor, and always place them in a plastic bag. On 4/8/19 at 10:38 a.m., CNA 6 indicated she was to do hand hygiene before care, when touching residents and linens, and wash her hands after placing soiled linens in the dirty linen barrel. On 4/8/19 at 8:30 a.m., the Administrator provided the current facility policy, Hand Hygiene Policy, undated. The Policy indicated, but was not limited to, hand hygiene will be done before and after direct resident care, after removal of gloves and on completion of each job/task. Hand hygiene means cleaning your hands either handwashing with soap and water or using an alcohol-based antiseptic hand rub. On 4/8/19 at 8:30 a.m., the Administrator provided the current facility policy, Glove Policy, dated 3/5/15. The Policy indicated, but was not limited to, gloves are to be changed during a procedure on one resident after completing peri care and before adjusting clothing. 3.1-18(l) 3.1-18(b)

Based on record review and interview, the facility failed to ensure an individual working as a certified nursing assistant had a State certification within 4 months of employment for 1 of 1 reviewed with an out of state certification. A CNA with an out of state certification had not obtained a certification within 120 days of employment through the State Department of Health. (CNA 4) Findings include: During review of the CNA certifications on 4/8/19 at 9:20 a.m., CNA 4 was observed to have began employment at the facility on 6/11/18. CNA 4 had a CNA certification from another state. The certification indicated the CNA was active in that state. Review of the CNA schedule for March 1, 2019 through April 8, 2019, indicated the CNA 4 had worked as followed: 3/1/19: 6:16 a.m. - 10:19 a.m. 3/5/19: 6:22 a.m. - 10:21 a.m. 3/6/19: 6:22 a.m. - 1:27 p.m. 3/8/19: 6:24 a.m. - 10:30 a.m. 3/8/19: 10:54 a.m. - 2:31 p.m. 3/12/19: 6:25 a.m. - 10:26 a.m. 3/13/19: 6:18 a.m. -10:22 a.m. 3/14/19: 6:16 a.m. - 10:21 a.m. 3/15/19: 6:15 a.m. - 10:30 a.m. 3/15/19: 10:57 a.m. - 2:31 p.m. 3/18/19: 6:26 a.m. - 10:23 a.m. 3/19/19: 6:22 a.m. - 10:39 a.m. 3/20/19: 6:23 a.m. - 10:31 a.m. 3/21/19: 6:18 a.m. - 10:26 a.m. 3/22/19: 6: 22 a.m. - 10:31 a.m. 3/22/19: 10:59 a.m. - 2:30 p.m. 3/25/19: 6:25 a.m. - 12:26 p.m. 3/27/19: 6:26 a.m. - 10:32 a.m. 3/27/19: 11:02 a.m. - 2:23 p.m. 3/28/19: 6:22 a.m. - 11:21 a.m. 3/29/19: 6:25 a.m. - 11:21 a.m. 4/1/19: 6:25 a.m. - 10:24 a.m. 4/2/19: 6:22 a.m. - 10:25 a.m. 4/3/19: 6:07 a.m. - 10:33 a.m. 4/8/19: 6:17 a.m. - 8:22 a.m. The facility lacked documentation of CNA 4's certification from the Indiana State Department of Health. On 4/8/19 at 9:25 a.m., RN 1 indicated the facility had not been able to locate the CNA's certification from the present state. RN 1 indicated the CNA had been sent home for the day. On 4/8/19 at 10:05 a.m., the Administrator indicated the facility did not have a policy for the hiring and use of the CNA's but followed the regulation for obtaining the certification of 120 days. 3.1-14(b)