**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor a resident's preference regarding meal service for 1 of 3 records reviewed for quality of care (Resident C). Findings include: During a wound care observation on 5/14/25 at 1:59 p.m., accompanied by LPN 5 and the Assistant Director of Nursing (ADON), the resident indicated he had lunch in the dining room, but he would rather eat in his room. The staff made him go to the dining room for all meals. The ADON indicated to the resident that he knew why they liked him to go to the dining room and smiled at him. He indicated to the ADON that he could eat on his own without problems. The clinical record for Resident C was reviewed on 5/14/25 at 9:49 a.m. Diagnoses included hypertensive heart disease without heart failure, dysphagia, anxiety disorder, major depressive disorder, diabetes mellitus type II, and obesity. A significant change Minimum Data Set (MDS) assessment, dated 4/21/25, indicated the resident had was cognitively intact, required partial moderate assistance with eating, and was receiving hospice care. He had no impairment of range of motion of his upper extremities and was dependant on staff for transfers. He felt down, depressed and hopeless daily and found little pleasure or interest in doing things. He had no delusions, hallucinations or rejection of care. A current health care plan, dated 4/4/23, indicated the resident had a diagnosis of malnutrition and muscle wasting. Interventions included to assist the resident with setting up his tray at meals as needed. A current health care plan, dated 4/22/19, indicated the resident was at risk for increased anxiousness related to his diagnoses of anxiety. Interventions included to offer him choices. A speech therapy Discharge summary, dated [DATE], indicated to facilitate safety and efficiency, it was recommended the resident use general swallow techniques/precautions, alternation of liquid and solids, and rate modification. The resident should sit upright during meals and upright posture for greater than 30 minutes after meals. The resident should have close supervision during meals. A physician's order, dated 3/27/25, indicated the resident's diet texture as pureed and nectar thick liquids. The order was discontinued on 4/14/25. A current physician's order, dated 4/14/25, indicated the resident's diet texture as regular and thin liquids. A Client Coordination Note Report, dated 4/14/25, from the hospice provider included that the resident indicated he could feed himself, but sometimes he had a hard time getting hand to mouth during meals. The nurse educated the resident regarding the risk of aspiration (inhaling food particles and liquids into the lungs) with a regular textured diet and thin liquids. The resident verbalized his understanding and awareness, but requested a regular textured diet and thin liquids. During a telephone interview on 5/15/25 at 1:08 p.m., the hospice nurse case manager indicated she had educated the resident regarding his risk for choking and he made it clear that he wanted to eat in his room. He had indicated he had not gone to breakfast because he had not wanted to go to the dining room. She had spoken to the staff regarding his comment that he had not been eating breakfast because he does not want to go to the dining room. The staff indicated it was the policy that he would have to go to the dining room during meals due to him being a choking risk. A review of Resident C's meal intake record indicated the resident had refused breakfast 17 times, lunch 3 times, and dinner 5 times, over a 28 day period. During an interview on 5/14/25 at 3:10 p.m., the DON indicated all residents who were assisted to eat were required to eat in the dining room for meals. During an interview on 5/15/25 at 10:53 a.m., Resident C indicated it was embarrassing for him to eat in the dining room because he can be a messy eater. It was also embarrassing having staff helping him to eat his meals. His preference has always been to eat in his room. He was aware of his risk for aspiration, but would really prefer to eat in his room and it had upset him being made to go to the dining room for all his meals. During an interview on 5/15/25 at 10:59 a.m., Resident C's spouse indicated she felt her husband should be able to eat in his room despite the risk of him choking. He had always eaten in his room since he admitted to the facility and that was what he wants to do now. During an interview on 5/15/25 at 12:16 p.m., the DON indicated it was safer for Resident C to go to the dining room for meals, and he had been pushed and encouraged to go to the dining room. Behaviorally, Resident C did what he wanted or did not do what he did not want to do. He was struggling with acceptance of needing more staff help. During an interview on 5/15/25 at 12:25 p.m., the Administrator indicated the other residents who require assistance to eat want to go to the dining room. This had been a non-issue. Resident C had not wanted a pureed texture diet and as his health had declined, he had become more behavioral. He struggled to accept his need for increased staff assistance. He had been accepting of going to the dining room for meals unless his family was present, then he would put on a better show and became more argumentative. When he had an audience, he became less agreeable to going to the dining room for meals. A current facility policy, dated 7/12/13, titled, Guidelines for Observing and Implementing - Resident Rights, provided by the Administrator on 5/15/25 at 2:49 p.m., indicated the following: .Procedure: .7) It is important that staff be aware of the Resident Rights to include, but not limited to: .Self-determination - residents should control their own lives - as much as is possible with consideration of any physical, mental, emotional, social or cognitive deficits .Residents must have the ability to exercise their Resident Rights as a citizen of the United States This Federal tag relates to Complaint IN00458584. 3.1-3(a)(1)

Based on record review and interview, the facility failed to ensure a reweight was completed for a resident with a significant weight change for 1 of 3 residents reviewed for nutrition (Resident 47). Findings include: Resident 47's record was reviewed on 9/26/24 at 10:48 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), chronic pain syndrome (symptoms beyond pain alone, like depression and anxiety, which interfere with one's daily life), and need for assistance with personal care. A physician's order, dated 1/27/22 indicated to provide the resident a general diet, regular texture, and thin liquids. A quarterly Minimum Data Set (MDS) assessment, dated 8/21/24, indicated the resident had severe cognitive deficit, was on a therapeutic diet, and had both a 5% or more in 1 month or 10% or more in 6 months weight loss and weight gain documented. A care plan, dated 7/8/22, indicated the resident was at increased nutritional risk secondary to diagnoses of dementia and mild depression. Interventions included, but were not limited to, weigh the resident monthly and as needed. Review of the resident's 6-month weight history indicated the resident weighed 122.5 pounds (lbs) on 6/2/24 and had decreased to 111.5 lbs on 7/1/24. The resident's weight loss was 11 lbs or 8.98 percent (%). The weight history lacked documentation that the resident had been reweighed after the significant decrease in her weight was noted. A nutrition at risk (NAR) progress note, dated 7/4/24, indicated the resident was being monitored due to a significant weight loss. The resident had triggered for significant weight loss of 9.00% in the past 30 days. An order to receive house shakes (drinks which were fortified with essential vitamins, minerals, protein, and fiber to help support overall health and well-being) three times daily (TID) and add weekly weights to ensure weight stabilization. The note lacked documentation of any reweight of the resident being completed. A NAR progress note, dated 7/11/24, indicated a Registered Dietician (RD) follow-up for significant weight loss of 9.4% in 30 days, 7.9% in 90 days and 12.3% in 180 days. A 0.5% weight loss was noted since last review on 7/4/24 and was considered fairly stable. Recommended to continue with house shakes and weekly weights. The note lacked documentation of any reweight of the resident being completed. A NAR progress note, dated 7/17/24, indicated an RD follow-up for significant weight loss. The resident had triggered for an 8.1 % weight gain since recent weight loss. Possible weight inaccuracy related to wheelchair weighing would be confirmed through weekly weights. Recommended to continue with house shakes and weekly weights. The note lacked documentation of any reweight of the resident being completed. During an interview, on 9/26/24 at 3:45 p.m., Registered Nurse (RN) 7 indicated it was her understanding if a resident had a significant weight discrepancy from one weigh to another, the staff would reweigh the resident as soon as the discrepancy was discovered. The nurse would also assess the resident for any edema or anything else that may have caused the weight fluctuation. During an interview, on 9/26/24 at 3:48 p.m., RN 8 indicated the staff should reweigh any resident immediately if there was a significant discrepancy in a weight from one weight to another. On 9/26/24 at 3:20 p.m., the Director of Nursing (DON) provided a document, dated 4/2017, titled, Weights, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .Nursing will notify the dietician or designee of any significant weight changes .A reweight will be obtained and recorded for all significant weight changes 3.1-46(l)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a pharmacy recommendation had been addressed in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 35). Findings include: Resident 35's record was reviewed on 9/26/24 at 9:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease late onset (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks that occurs after [AGE] years of age). A quarterly Minimum Data Set (MDS) assessment, dated 5/1/24, indicated the resident had severe cognitive deficit and received no scheduled or as needed (PRN) pain medication. A quarterly Minimum Data Set (MDS) assessment, dated 8/5/24, indicated the resident's cognitive status was unable to be assessed and she received no scheduled or PRN medication. A care plan, dated 12/2/23, indicated the resident had the potential for pain. Interventions included, but were not limited to medications as ordered. A pharmacy recommendation, dated 2/12/24, indicated the resident had two PRN orders for acetaminophen (medication used to relieve pain and/or fever). The orders indicated to administer two 500 milligrams (mg) tablets of acetaminophen every 6 hours PRN and a second order to administer two 325 mg tablets of acetaminophen every 4 hours PRN. The recommendation was to discontinue one of the orders to prevent possible overdose. The form lacked documentation that the physician had addressed the recommendation and lacked a signature and date of when the physician had reviewed the recommendation. A pharmacy recommendation, dated 6/9/24, indicated a second notice that the resident's two PRN for the acetaminophen were still in the resident's physician orders. The physician documented that he agreed with the recommendation and had ordered the discontinuation of the administration of the two 500 mg tablets of acetaminophen every 6 hours PRN. The physician signed and dated the form on 6/18/24. A historical review of the resident's physician's orders indicated the medication had been discontinued on 6/18/24. During an interview, on 9/26/24 at 1:17 p.m., the Administrator (ADM) indicated the pharmacy recommendation, dated 2/12/24, had not been addressed by the Director of Nursing (DON) or the physician. The Pharmacist had written the recommendation again on 6/9/24. This recommendation was addressed as required. She was not aware why the initial recommendation had not been addressed. Pharmacy recommendations were to be addressed as soon as they were received. On 9/26/24 at 2:50 p.m., the ADM provided an undated document titled, Distribution of Medication Regimen Review Report, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: .Each recommendation must be acted upon. Procedure: .3. The report will be directed to the Director of Nursing. 4. The attending physician and/or Medical Director will document their review and response to the recommendation .directly on the medication regimen review form 3.1-48(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate sanitation of drinking glasses, pitcher, and kitchen equipment for 2 of 2 kitchen observations, and failed to ensure snacks were served in a sanitary manner for 1 of 1 random snack distribution observation. Finding includes: 1a. On 9/24/24 at 9:53 a.m., during initial kitchen tour, a thick white cloudy substance was observed on the inside surface of a 2-gallon pitcher. The pitcher was used to make lemonade, juice, and or tea for the residents. A thick cloudy substance was observed on a sink in the kitchen. The white substance was noted on the faucet base and went down into the inside of the sink. During an interview, on 9/25/24 at 10:41 a.m., Resident 21 indicated the plastic glasses that come from the kitchen were filthy and he did not like to drink out of them. During an interview, on 9/26/24 at 11:54 a.m., the Dietary Manager indicated she was aware of the facility having an issue with lime deposits on the plastic glasses and the 3-compartment sink. They had checked the salt levels to make sure it was at the appropriate level. They had tried running bleach through the dishwasher and used a de-[NAME] solution which had worked. The only way she had been able to remove the lime on the drinking cups was to have staff scrub each individual cup by hand and she did not have the staff to be able to do that. During an interview, on 9/27/24 at 8:53 a.m., Registered Nurse (RN) 7 indicated they have had issues in the past with lime deposits on the drinking glasses on the closed unit, but they had purchased new ones, and she hadn't noticed an issue lately. During an interview, on 9/27/24 at 9:00 a.m., Resident 6 indicated she had noticed a white cloudy substance on the drinking glasses, and it had been an issue for a while. During an interview, on 9/27/24 at 9:01 a.m., Resident 37 indicated she had noticed a white cloudy substance on the inside of the drinking glasses ever since she had been there. She indicated she had been at the facility for a few weeks. During an interview, on 9/27/24 at 9:04 a.m., Resident 32 indicated she had noticed a white cloudy substance on the inside of the drinking glasses for as long as she could remember, and she thought it was because of the hard water. She indicated at home she would use vinegar water to treat it. 1b. On 9/27/24 at 10:50 a.m., during a second kitchen observation, a thick white cloudy substance was observed on the inside of several plastic drinking cups stored on 3 pallets full of drinking cups. The Dietary Manager held up two of the plastic drinking cups and both contained a thick white cloudy substance. During an interview, on 9/27/24 at 10:55 a.m., the Dietary Manager, indicated they tried to run a de-[NAME] solution through the dishwasher once a week. She had considered purchasing glass cups if the lime did not come off the plastic cups. During an interview, on 9/27/24 at 10:56 a.m., [NAME] 13 indicated they needed to run the de-[NAME] solution through the dishwasher again because the glasses were getting bad. He indicated the de-[NAME] was ran through about once or twice a month. During an interview, on 9/27/24 at 11:38 a.m., the Administrator indicated she had hard water at home, and she believed that was why they had issues with lime at the facility. During an interview, on 9/27/24 at 2:18 p.m., the Administrator indicated the kitchen had a schedule for the de-liming to be done twice a week. She indicated the cleaning list was check marked as if it had been completed. During an interview, on 9/30/24 at 1:30 p.m., the Administrator indicated they had a service man come to the facility over the weekend to look at the dishwasher and he did not identify a concern with the equipment, but he did take a plastic glass from the facility to run some tests on it. She indicated she had not received a lab report yet from the company. On 9/27/24 at 12:00 p.m., the Administrator provided an undated document, titled, Sanitizing Equipment and Food Contact Surfaces, and indicated it was the policy currently being used by the facility. The policy indicated, .Employees shall sanitize equipment and food contact surfaces utilizing proper sanitizing solution .3. Sanitizing solutions are changed in accordance with manufacturer instructions or when the become visibly soiled. In general, each should prepare fresh solutions 2. During a random snack distribution observation, on 9/26/24 at 9:39 a.m., Activity Aide 14 was on the closed unit and was removing an oatmeal cream pie from its plastic packaging and removing the snack with her bare hands and handed one to a female resident. Activity Aide 14 proceeded to hand two other residents an oatmeal cream pies in the same manner as the first one. The activity aide was not observed using gloves or hand sanitizer during the observation. During an interview, on 9/27/24 at 9:35 a.m., Certified Nurse's Assistant (CNA) 15 indicated she would place on a pair of gloves when serving a resident a food item or use the plastic cover to hand the resident the item. The CNA indicated staff should not touch food with their bare hands. On 9/27/24 at 11:31 a.m., the Administrator provided a documented with a date of 4/2017, titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility will practice safe food handling and avoid cross contamination through proper use of gloves .The Food and Nutrition Department Manager or designee will ensure that employees practice proper use of gloves .Single-use gloves should be used, and bare-hand contact must be avoided when handling ready to eat food 3.1-21(i)(3)

3. On 8/07/23 at 11:56 a.m., observed Licensed Practical Nurse (LPN) 4, assisted Resident 52 in his wheelchair, from the main dining room, and wheeled him into the main hallway in front of the reception desk. LPN 4 donned gloves and cleaned a glucometer machine (an instrument for measuring the concentration of glucose in the blood) with disinfectant wipes. The nurse picked up the glucometer, a testing strip, and stuck the resident's finger with a lancet, obtained a blood sample and completed the glucometer reading. She cleansed the finger of the resident with an alcohol prep pad (a two-layer pad which contain 70% isopropyl alcohol. Prep Pads help clean the skin and can be used on cuts, scrapes, and abrasions prior to bandaging), and assisted the resident back to the dining room. On 8/14/23 at 11:43 a.m., record review resident had diagnoses of but not limited to, type 2 diabetes mellitus (DM), (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) dated 4/7/2022. Type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes) dated 7/26/2023. Physician orders, dated 8/1/23, NovoLOG FlexPen, (insulin medication) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 100 - 120 = 0; 121 - 160 = 2; 161 - 200 = 4; 201 - 240 = 6; 241 - 280 = 8; 281 - 320 = 10; 321 - 360 = 12; 361 - 400 = 15 contact MD (medical doctor), subcutaneously before meals for DM subcutaneously At breakfast and Lunch for DM breakfast and lunch only. Do not give at qhs (at bedtime). A care plan, dated 10/12/22, indicated, the resident had a diagnosis of diabetes with risk for Hypo/or Hyperglycemia. Nursing intervention, dated 10/12/22, check blood sugars per order. A Medicare 5-day Minimum Data Set Assessment (MDS), a standardized assessment tool that measures health status in nursing home residents, dated 7/28/23, indicated the resident was on insulin and had a diagnosis of type 2 diabetes mellitus. On 8/7/23 at 3:29 p.m., the Administrator provided an undated document titled, Policy and Procedure Cleaning/Disinfecting/Maintaining Glucose Meters and indicated this was the current policy of the facility. The policy indicated .Procedure cleaning and disinfecting .4. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 5. Dispose of the towelette. 6. Obtain a second towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood borne pathogens. The meter must be maintained wet for 2 minutes with the Super Sani cloth wipe. When utilizing any other type of sanitizing (bleach) wipe, the meter must be maintained wet paper towelette manufacturer's recommendation. A 1/10 bleach solution requires a 10-minute contact time .When glucometers are being discontinued from isolation, the glucometer is to be discarded in biohazard .10. Dispose of the used towelette. 11. Remove gloves. 12. Wash hands (may use ABHR [alcohol based hand rub]) 3.1-3(a) 3.1-3(b)(1) 3.1-3(b)(1)(2) Based on observation, interview, and record review, the facility failed to ensure residents' rights to privacy and dignity were maintained for 3 of 3 residents when completing blood glucose testing (Residents 27, 41, and 52). Findings include: 1. On 8/7/23 at 11:28 a.m., Resident 27 was observed propelling herself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 27 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 27's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/14/23 at 12:27 p.m., Resident 27's record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/19/23, indicated the resident was cognitively intact and required supervision-oversight, encouragement, or cueing of one person for locomotion on and off the unit. A care plan, dated 7/9/21, indicated, the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. A physician's order, dated initiated 7/9/21, indicated, blood glucose monitoring before meals and HS (bedtime) for the diagnosis of DM. 2. On 8/7/23 at 11:32 a.m., Resident 41 was observed propelling himself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 41 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 41's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/7/23 at 11:37 a.m., LPN 4 indicated, per the facility policy, staff were allowed to perform blood glucose testing on residents in the hallway. All residents have their own glucose meters. She had forgotten to wash her hands and should have washed or sanitize her hands between residents. Resident 41's record was reviewed, on 8/9/23 at 3:37 p.m. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident had a moderate cognitive impairment and required extensive assistance of one person for locomotion on the unit and limited assistance of one person for locomotion off the unit. A physician's order, dated 1/16/23, indicated blood glucose monitoring four times a day for the diagnosis of DM. A care plan, dated 1/17/23, indicated, the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. On 8/8/23 at 8:28 a.m., the Administrator (ADM) indicated, staff were to complete accuchecks/blood glucose testing on residents in a private area for dignity. Staff should wash hands, when visibly soiled and before and after direct contact with residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide comfortable water temperatures of more than 105 degrees Fahrenheit (F) and less than 115 degrees F in 8 of the 9 shared resident bathrooms on the secured memory care area observed for unsafe water temperatures. Findings include, During the initial tour, on 8/7/23 at 11:15 a.m., Resident 40 was observed standing at the sink in his shared bathroom. Steam was observed rising from the water, the resident indicated the water was too hot to touch. Water temperature was 129.6 Fahrenheit (F). Temperature with the Maintenance Director on 8/7/23 at 12:25 p.m. was 122.9 F. On 8/07/23 11:19 a.m., water temperature in the bathroom sink on the 100 hall was 129.0 F. A visitor observed steam rising from the water and the thermometer temperature and indicated it was too hot for Resident 63. On 8/07/23 at 11:36 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 130.6 F. Temperature with the Maintenance Director on 8/8/23 at 9:48 a.m. was 100.3 F. On 8/07/23 at 11:53 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 129.0 F. Temperature with the Maintenance Director on 8/08/23 at 9:49 a.m. was 103.4 F. On 8/07/23 at 11:57 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 118.2 F. Temperature with the Maintenance Director on 8/08/23 at 9:54 a.m. was 101.2 F. On 8/07/23 at 12:06 p.m., water temperature in the bathroom sink shared between rooms 108 and the dining room was 124.5 F. Temperature with the Maintenance Director on 8/08/23 at 9:51 a.m. was 103.4 F. On 8/09/23 at 9:33 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 104.4 F. On 8/09/23 at 9:31 a.m., Housekeeper 27 was observed cleaning a shared bathroom between rooms [ROOM NUMBERS]. She had not noticed the water temperature in the resident's bathrooms either being too hot or too cold, she used a special cleaner and did not usually turn on resident water in the sinks. During an interview on 8/08/23 at 9:57 a.m., the Maintenance Director indicated, he thought resident bathroom sink water temperatures were supposed to be between 110-120 F. He was not sure but would ask. He indicated he thought the fluctuations were due to residents getting showers and the holding tank. He had adjusted the water value the day before, but the difference in temperatures from hot to cooler could also have been from routine water use on the unit once residents got up in the morning and water being used during showers. During an interview on 8/08/23 at 10:24 a.m., Registered Nurse (RN) 11 indicated, she had never noticed the resident's bathroom water being too hot or tepid, she did not wash her hands in their bathrooms or assist them to wash their hands in their bathrooms. A Domestic Hot Water Temperature Log, Daily Check, dated July 2023, indicated 18 of 44 temperatures documented as being in resident rooms were between 115.1 - 127.1. There were no documented temperatures for weekend dates, or in the afternoon hours on Monday 7/17/23 and Tuesday 7/18/23. Form instructions indicated initial to right of row. There were no initials documented. During an interview with the Maintenance Director and Administrator (ADM) on 8/9/23 at 10:15 a.m., the Maintenance Director indicated he did not check water temperatures and record with a visitor on 8/7/23, then restated he had checked temperatures and observed some resident bathroom temperatures out of range but had not recorded them as he had already recorded temperatures in the morning on his log. The ADM indicated the water temperatures were supposed to run between 100 F - 120 F. On 8/9/23 at 11:57 a.m., the ADM provided Physical Plants--Daily Inspections instructions, undated, and indicated the instructions for Domestic Water Temperatures were currently to be followed by the Maintenance Director. The instructions indicated, Take water temperature readings daily [once during morning rounds and once in the afternoon during the high usage times] from 1 area of each hot water system and document in the Domestic Water Temperature log to be kept on file. On 8/9/23 at 11:57 a.m., the ADM provided a blank Maintenance Supervisor Orientation Checklist, updated 3/26/21, and indicated the water temperatures section was the one currently to be followed by the Maintenance Director. The Specific Responsibilities and Duties indicated, Water Temperatures 1. Check daily to maintain between 105 - 115 degrees. 2. Anything above 115 must be reported to Administrator and [NAME] President of Property Management immediately On 8/9/23 at 11:57 a.m., the ADM provided a copied paper, undated, and indicated it was a copy of the current state regulation regarding water temperatures. The regulation indicated, Hot water temperatures for all bathing and hand washing facilities shall be controlled by an automatic control valve. Water temperature at point of use must be maintained between one hundred [100] degrees Fahrenheit and one hundred twenty [120] degrees Fahrenheit. 3.1-19(r)(1) 3.1-19(r)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plans were revised for concerns and interventions for 3 of 19 residents' care plans reviewed (Residents 14, 41 and 32). Findings include: 1. On 8/08/23 at 10:15 a.m., during initial observation Resident 14, did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/09/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed on the left side of her upper left arm. The resident's left hand was contracted, palm pillow was not applied to the left hand. Fingernails of both hands were long and jagged. On 8/11/23 at 11:00 a.m., observed the resident sitting in a wheelchair. Palm pillow soft hand pillow device was applied to the contracted left hand. Fingernails on the right and left hands were cut to a level which prevented them from pushing into the palm of the hands. On 8/10/23 at 11:40 a.m., medical record review. Diagnoses included but were not limited to vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) left side, contracture of the left wrist, and contracture of the left hand. A Physician's order, dated 6/29/22, indicated an order for, patient to wear Palm Pillow hand splint on the left hand at all times during day except for meals, hygiene care and ROM (range of motion) to prevent skin integrity issues and to help prevent further contractures. Instructions indicated to dry the resident's hand before applying splint each time and to monitor for any signs and symptoms of redness or swelling. On 8/10/23 at 10:04 a.m., Certified Nurse Aide (CNA) 10 indicated she had not seen a brace or splint on the residents left hand and it was not indicated on her assignment record. On 8/10/23 at 10:06 a.m., Registered Nurse (RN) 9 indicated she was a PRN (as needed) staff member, and she did not know if the resident was to have a palm pillow applied to her contracted left hand. On 8/10/23 at 10:09 a.m., the Director of Nursing (DON) indicated she did not know if the resident had an order for a palm pillow to be applied in her contracted left hand. A care plan, dated 6/9/2016, titled contracted left hand indicated the resident had a contracture of the left hand and arm, secondary to decrease mobility and history of CVA (cerebral vascular accident, stroke). Goal was for the resident to have no further contractures and the contracture to not worsen. Interventions included inform MD (medical doctor) of any changes to contracture, restorative care as needed, and therapy as needed. The care plan lacked documentation indicating an intervention of palm pillow or splint to the left hand. A quarterly Minimum Data Set (MDS) assessment a standardized assessment tool that measures health status in nursing home residents, dated 5/29/23, lacked documentation of palm pillow or anticontracture splint to contracted left hand. An annual MDS, dated [DATE], lacked documentation of palm pillow to contracted left hand. On 8/10/23 at 3:08 p.m., the MDS nurse indicated section O of the MDS, restorative services would identify a brace or splint that were being used for the resident. She indicated she was not aware the resident had an order for a palm pillow and had not identified it on the MDS. 2. On 8/8/23 at 11:44 a.m., Resident 41's CPAP mask was observed unbagged on the resident's bed. Resident 41 indicated, he used the CPAP machine with the mask every night to help him breath while sleeping. On 8/11/23 at 10:59 a.m., Resident 41's CPAP mask was observed unbagged on the nightstand. On 8/11/23 at 11:28 a.m., the Director of Nursing (DON) indicated, Resident 41 wore the CPAP throughout the day, when he was napping and took it off and put it on by himself. The facility needed to educate staff and the resident to bag the CPAP mask when not in use. Resident 41's record was reviewed, on 8/9/23 at 3:37 p.m. The profile indicated the resident had been admitted to the facility, on 1/16/23, for diagnoses included, but were not limited to, dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), sleep apnea (sleep disorder in which breathing repeatedly stops and starts) and chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident had a moderate cognitive impairment, was an extensive assistance of one person for bed mobility, limited assistance of one person for transfers, and an extensive assistance of one person for personal hygiene. A physician's order, dated 1/16/23, indicated CPAP at bedtime for the diagnosis of sleep apnea. A sleep apnea care plan, initiated on 1/27/23 and revised on 3/30/23, with interventions included, but not limited to, keep head of bed raised as tolerated and oxygen per physician's order and a goal of the resident would be free of respiratory distress, lacked documentation or interventions for the CPAP usage. On 8/14/23 at 11:10 a.m., the DON indicated, the resident should have CPAP interventions for the sleep apnea care plan. The CPAP should be bagged and stored per the facility policy. On 8/14/23 at 11:53 a.m., the DON provided and identified an undated document as a current facility policy, titled, Continuous Positive Airway Pressure (CPAP). The policy indicated, .Purpose: To improve ventilation on patients with obstructive sleep apnea (OSA), airway obstruction and upper airway resistance .15. When the CPAP machine is not in use the face mask is stored in a plastic bag at the bedside 3. Resident 32's record was reviewed, on 8/10/23 at 2:25 p.m. The profile indicated the resident had been admitted to the facility, on 9/26/22, with diagnoses included, but not limited to, quadriplegia (paralysis that affects all a person's limbs and body from the neck down), multiple sclerosis (progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and had an unstageable pressure ulcer (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar [dead tissue that has fallen off (sheds) from healthy skin]) to the right gluteal fold/perineum (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks and the tiny patch of sensitive skin between the genitals and anus) and was on hospice (end of life) services. A quarterly Minimum Data Set (MDS) assessment, dated 6/16/23, indicated the resident had a moderate cognitive impairment, was an extensive assistance of two persons for bed mobility, toilet use, dressing, and personal hygiene, was total dependence of two persons for transfers and bathing, was on hospice services, and had a pressure ulcer. A physician's order, dated 8/2/23, indicated to apply Triad Hydrophilic wound paste topically to the pressure ulcer and cover with a bandage in the evening for wound care. A skin and wound progress note, by the wound nurse practitioner, dated 7/11/23 at 9:47 a.m., indicated the resident had a pressure ulcer to the perineal/buttocks that had separated into 2 areas as the wound was healing with epithelial tissue (new skin tissue) separating the wound beds and was classified as a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A pressure ulcer to the perineum care plan, initiated on 9/28/22 and revised on 11/28//22, with a goal of wound will not show signs/symptoms of infection and will improve with next review had interventions included, but not limited to, complete wound treatment per physician's order and resident to be followed by the wound nurse practitioner. The care plan lacked documentation of interventions for the wound separation into 2 areas of the wound. On 8/14/23 at 10:53 a.m., the MDS Corporate Consultant indicated, since Resident 32 was admitted with the stage 4 pressure ulcer, even though it split it would still be listed as 1 pressure ulcer. There should be a more specific care plan for the pressure ulcers. The Director of Nursing (DON), on 8/14/23 at 12:20 p.m., provided and identified a document as a current facility policy, titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated 11/25/17. The policy indicated, .Policy .The Comprehensive Care Plan will further expand on the resident's risks, goals, and interventions using the 'Person-Centered' Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs .The facility Interdisciplinary team in conjunction with the resident, resident's family, surrogate or representative as appropriate along with a 'hands on' caregiver, such as a Certified Nursing Assistant will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident .9. The Comprehensive Care plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues 3.1-35(a) 3.1-35(c)(1)

Based on observation, record review, and interview, the facility failed to trim the fingernails of a resident's contracted hand to prevent the nails from pressing into the palm of the hand for 1 of 24 residents reviewed for activities of daily living (Resident 14). Finding includes: On 8/08/23 at 10:15 a.m., during initial observation Resident 14, did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/09/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed on the left side of her upper left arm. The resident's left hand was contracted, and palm pillow was not applied to the left hand. Fingernails of both hands were long and jagged. On 8/11/23 at 11:00 a.m., observed the resident sitting in a wheelchair. Palm pillow soft hand pillow device was applied to the contracted left hand. Fingernails on the right and left hands were cut to a level which prevented them from pushing into the palm of the hands. On 8/10/23 at 11:40 a.m., Resident 14's medical record was reviewed. Diagnosis included but were not limited to vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) left side, contracture of left wrist, and contracture of left hand. On 8/08/23 at 10:32 a.m., Certified Nurse Aide (CNA) 7 indicated showers were given one to two times per week. The shower schedule information was provided on the pocket worksheet of the CNA. The CNA indicated Resident 14's nails were trimmed on shower days and the CNA's were only allowed to trim the fingernails. If the resident was a diabetic the nurse would cut their nails. On 8/09/23 at 11:43 a.m., CNA 13 indicated showers were given two days a week depending on the resident's schedule. The information was provided on the CNA assignment sheet and the fingernails would be trimmed on the resident's shower day. Diabetic resident's fingernails were cut by the nurse. The podiatrist would cut the toenails of the diabetic residents. On 8/15/23 at 10:15 a.m., the facility Administrator provided an undated document titled Nail Care, and indicated, this is the current policy of the facility. The policy indicated. Policy .This includes clean, smooth nails at a well-groomed safe length acceptable to the resident .NOTE: ONLY A LICENSED NURSE CAN TRIM THE NAILS OF A DIABETIC RESIDENT .Procedure .9. Trim nails and file for smoothness as needed .14. Document on ADL worksheets or PCC 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure medication was labeled properly for 2 of 2 medication carts and 1 of 2 medication storage rooms reviewed for medication storage (Resident 8 and 24), and the facility failed to ensure expired medications were disposed of for 1 of 2 medication storage rooms reviewed. Findings include: 1a. On 8/10/23 at 9:31 a.m., the closed unit medication cart contained 2 undated and opened insulin (medication used to lower blood sugar) pens. The insulin pens contained labels that indicated they were ordered for Resident 24. During an interview, on 8/10/23 at 9:32 a.m., Registered Nurse (RN) 11 indicated insulin pens were supposed to have an open date on them and were good for 28 days once they were opened. She was not aware of the date Resident 24's insulin pens were opened. She would dispose of the pens in the medication cart and get new ones from the medication storage refrigerator. Resident 24's record was reviewed on 8/10/23 at 10:03 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A physician order, dated 7/4/23, indicated Levemir (insulin medication) 100 unit/ml (milliliter), by subcutaneous (under the skin) injection. Inject 10 units at bedtime. A physician order, dated 7/7/23, indicated Novolog (insulin medication) 100 unit/ml, by subcutaneous injection per sliding scale two times a day. 1b. On 8/11/23 at 9:30 a.m., the medication cart on the east wing of skilled unit contained an undated and unopened insulin pen. The insulin pen contained a label that indicated it was ordered for Resident 8. During an interview, on 8/11/23 at 9:32 a.m., Assistant Director of Nursing (ADON) indicated the insulin pen should remain in the refrigerator until opened and once opened should be labeled with the date. She indicated insulin was good for 28 days once opened. She was unaware of how long Resident 8's insulin pen had been in the cart, but it was delivered to the facility from the pharmacy on 8/4/23. Resident 8's record was reviewed on 8/11/23 at 11:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus. A physician order, dated 5/24/23, indicated Semglee (insulin medication) 100 unit/ml by subcutaneous injection. Inject 54 units subcutaneously at bedtime. 2. On 8/10/23 at 9:35 a.m., the closed unit medication storage room contained an opened and undated multi use vial of Aplisol (a sterile aqueous solution of a purified protein fraction for intradermal administration as an aid in the diagnosis of tuberculosis) solution. During an interview, on 8/10/23 at 9:35 a.m., RN 11 indicated the Aplisol vial should be dated when it was opened. She was unaware of how long the solution was good for once it was opened. She indicated the solution was used by the facility for new admissions. During an interview, on 8/10/23 at 1:30 p.m., Director of Nursing (DON) indicated the Apilsol vial should be dated by staff when it was opened. She was not aware of how long the solution was good for once it was opened. During an interview, on 8/10/23 at 3:04 p.m., Administrator (ADM) indicated the Aplisol solution was good for 30 days from the open date. The facility follows manufacturer guidelines for medication use, labeling, and storage. 3. On 8/10/23 at 9:35 a.m., the closed unit medication storage refrigerator contained 6 prefilled syringes of flu vaccine. The vaccines had an expiration date of 6/30/23. During an interview, on 8/10/23 at 9:35 a.m., RN 11 indicated she was unaware there were flu vaccines in the refrigerator, and they should have been disposed of due to it being past the expiration date. On 8/10/23 at 1:20 p.m., the ADM provided and identified an undated document as a current facility policy, titled, Guidelines for Insulin Pens. The policy indicated, .Procedure: 3. Upon opening for the first time, the insulin pen will have a date sticker applied .The date will reflect the date the seal was broken for use .6 .Insulin pens will be considered expired after 28 days On 8/10/23 at 1:20 p.m., the ADM provided and identified a document as a current facility policy, titled, 3.1: Medication Storage in the Facility, dated March 2023. The policy indicated, .14. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility 3.1-25(j) 3.1-25(o)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the licensed occupational therapist had the knowledge, competencies to enter a completed physicians order into the medical record of 1 of 24 residents reviewed (Resident 14). Finding Includes: On 8/8/23 at 10:15 a.m., during initial observation Resident 14 did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/9/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed on the left side of her upper left arm. The resident's left hand was contracted, palm pillow was not applied to the left hand. Fingernails of both hands were long and jagged. On 8/11/23 at 11:00 a.m., observed the resident sitting in a wheelchair. Palm pillow soft hand pillow device was applied to the contracted left hand. Fingernails on the right and left hands were cut to a level which prevented them from pushing into the palm of the hands. On 8/10/23 at 11:40 a.m., medical record review. Diagnoses included but were not limited to vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) left side. Contracture of left wrist, contracture of left hand. A Physician's order dated 6/29/22 indicated, an order for, patient to wear Palm Pillow hand splint on the left hand at all times during day except for meals, hygiene care and ROM (range of motion) to prevent skin integrity issues and to help prevent further contractures. Instructions indicated to dry the patient's hand before applying splint each time. Please monitor for any signs and symptoms of redness or swelling. On 8/10/23 at 10:04 a.m., Certified Nurse Aide (CNA) 10 indicated she had not seen a brace or splint on the residents left hand and it was not indicated on her assignment record. On 8/10/23 at 10:06 a.m., Registered Nurse (RN) 9 indicated she was a PRN (as needed) staff member, and she did not know if the resident was to have a palm pillow applied to her contracted left hand. On 8/10/23 at 10:09 a.m., the Director of Nursing (DON) indicated she did not know if the resident had an order for a palm pillow to be applied in her contracted left hand. On 8/11/23 at 9:55 a.m., the Occupational Therapist (OT) indicated, she entered a physician's order for Resident 14 for something that was for both anticontracture and to prevent the nails from digging into resident's palm. She indicated she was not sure what she had originally ordered and would look at her original notes. The OT reviewed the care notes and the physician's order and acknowledged she entered a physician's order for a palm pillow splint and had not been instructed on how to enter an order into Point Click Care, which enabled the staff to document the order as completed in the medical record. She indicated she would enter a physician's order into the medical record and would print a copy of the physician's order for the physician to sign and would notify the nurse of the new physician's order. On 8/11/23 at 12:28 p.m., the OT provided a copy of the progress notes for Resident 14, dated 6/25/22 and 6/27/23, and indicated the resident was to have a palm pillow to prevent hands from becoming irritated from fingers and nails. She indicated she was focusing on the contracture of the arm and not so much on the hand. The OT indicated she was a Licensed Occupational Therapist and was authorized to enter telephone and verbal physician orders into the resident's medical record. She indicated she had an approval relationship with the physician, and she could enter orders without first notifying the physician and he would sign the order when he came into the facility. A care plan, dated 6/9/2016, titled contracted left hand indicated the resident had a contracture of left hand and arm secondary to decrease mobility and history of CVA (cerebral vascular accident, stroke). The care plan lacked documentation indicating an intervention of palm pillow or splint to the left hand. A Quarterly Minimum Data Set (MDS) assessment a standardized assessment tool that measures health status in nursing home residents dated 5/29/23, lacked documentation of palm pillow or anticontracture splint to contracted left hand. The annual MDS dated [DATE], lacked documentation of palm pillow to contracted left hand. On 8/10/23 at 3:08 p.m., the MDS nurse indicated section O of the MDS, restorative services would identify any brace or splints being used for the resident. She indicated she was not aware the resident had an order for a palm pillow and had not identified it on the MDS. On 8/11/23 at 1:40 p.m., the facility Administrator provided a document titled PHYSICIAN ORDERS - (FOLLOWING PHYSICIAN ORDERS) dated, July 2017 and indicated it was the current policy of the facility.Policy It is the policy of the facility to follow the orders of the physician .Procedure .2. As assessments are completed, orders will be received from the physician to address significant findings of the assessments .4. All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility 3.1-23(b)

Based on record review and interview, the facility failed to accurately report weekend staffing hours in the PBJ (payroll-based journal) reporting system for the 1 of 3 staffing quarters in 2023. Findings include: During review of the CASPER (Community Assessment for Public Health Emergency Response) report, on 8/11/23 at 9:00 a.m., the CASPER report indicated the facility had reported low weekend staffing and a 1-star staffing rate for the second quarter of 2023. During an interview, on 8/14/23 at 2:44 p.m., the Administrator (ADM) indicated she assisted in staff scheduling and the facility staffing was scheduled in-line with the PPD (Per Patient Day). She was not sure how the PBJ triggered low weekend staff and 1-star staffing. The PBJ information was inputted by the facility's corporate office. During an interview, on 8/15/23, the Administrator (ADM) indicated the facility did not have a policy regarding the PBJ reporting and the facility followed the state regulation regarding this. The deficient practice was corrected by 4/1/23, prior to the start of the survey and was therefore Past Noncompliance. The facility had implemented a systemic plan that included hiring more licensed and unlicensed staff for the weekends, moving staff to work the weekends, and accurately reporting staffing hours. Current staffing was reviewed during the survey without concerns. 3.1-17(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B1. On 8/7/23 at 12:00 p.m., during the noon meal service observed Certified Nurse Aide (CNA) 3 feeding Resident 34 while feeding a second resident at the same time. The CNA failed to disinfect her hands between residents. The admission date of resident 34 was on 9/20/22. A quarterly Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 7/3/23, indicated the resident required extensive assistance of one person to eat. On 8/7/23 at 12:00 p.m., during the noon meal service observed CNA 3 feeding Resident 36 while feeding a second resident at the same time. The CNA failed to disinfect her hands between residents. The admission date of resident 36 was on 3/12/21. A quarterly MDS, dated [DATE], indicated the resident required extensive assistance of one person to eat. A. Based on observation, interview, and record review, the facility failed to ensure proper handwashing in the kitchen, and sanitary practices while pureeing foods and measuring the temperature of food to be served from the kitchen, during 4 of 4 kitchen observations. This deficient practice had the potential to effect 11 of 11 residents who received pureed food, and 63 of 63 residents who received food from the kitchen. B. Based on observations, interview, and record review, the facility failed to use proper hand hygiene when 3 certified nursing aides (CNA's) were observed assisting 6 residents to eat during 1 of 2 dining room observations (Residents 34, 36, 14, 30, 9, and 37). Findings include: A1. During a random continuous observation of the kitchen, on 8/7/23 from 10:07 a.m. to 10:31 a.m., Dietary Aide 5 was observed taking a soiled drinking pitcher from the dining room window and without wearing gloves, removed the soiled straw by the mouthpiece and tossed it in an open garbage container positioned partially under a stainless steel drain board (area for scraping or rinsing food into garbage containers or disposer). Dietary Aide 5 loaded a plastic rack with soiled dishes and ran it through the dishmachine (warewashing machine). She then went to the refrigerator and removed a drink pitcher and poured an unidentified pink liquid into multiple clean plastic glasses being prepared for the next meal. Dietary Aide 5 went back to the dishwashing area and scrubbed out a soiled pan. She then set up drinks and prepared trays with cereal, napkins, and silverware on lunch meal trays. Dietary Aide 5 was not observed to be wearing gloves or to wash her hands during the observation as she moved back and forth between the dirty dishmachine area and clean food preparation areas where she assisted the day cook by touching items on the counters and in the refrigerator, clean glasses, trays, and silverware. On 8/7/23 at 10:10 a.m., Dietary Aide 5 indicated as there were just 2 staff members in the kitchen at this time, she was responsible for washing dishes and helping with whatever was needed in the kitchen. On 8/7/23 at 10:10 a.m., a garbage container in the kitchen was positioned partially under a stainless steel drain board in the dirty dishmachine area, the lid was on the ground under the drain board against the wall. Subsequent observations of the kitchen on 8/10, and 8/14 indicated the garbage container with soiled paper products and food, was never observed to be covered with a lid. On 8/10/23 at 11:01 a.m., Dietary Aide 18 was observed to be making peanut butter and grape jelly sandwiches. She then removed her gloves, threw the gloves and other items into an open garbage container, then moved the garbage container underneath the drain board with her bare hands. Dietary 18 then returned to the workstation, poured leftover jelly into a pan, covered the pan with plastic wrap, and placed the pan in the refrigerator. She was not observed to wash her hands after removing her gloves, touching the garbage container, and then pouring the jelly into a pan and placing it in the refrigerator. On 8/10/23 at 11:03 a.m., [NAME] 19 was observed to enter the kitchen, walk through the food preparation area, entered the dietary office, and back to the food preparation area where she obtained and donned a hair net from a cabinet containing spices. [NAME] 19 was observed to wash her hands, she turned the faucets on and off with her bare hands. Observation of the dietary staff washing their hands, indicated, a. On 8/10/23 at 1:47 p.m., Dietary Aide 19 was observed to wash her hands, she turned the faucets on and off with her bare hands. Subsequent observations of hand washing on this date at 1:53 p.m., 1:58 p.m., and 2:02 p.m., she was observed to turn the faucets on and off with her bare hands. b. On 8/10/23 at 2:08 p.m., Dietary Aide 5 was observed to wash her hand for less than 5 seconds, she turned the faucets on and off with her bare hands. c. On 8/10/23 at 2:08 p.m., Dietary Aide 20 was observed to wash his hands, he turned the faucets on and off with his bare hands. A second observation of the dietary staff washing their hands, indicated, a. On 8/14/23 at 10:23 a.m., Dietary Aide 5 was observed to wash her hands, she turned the faucets on and off with her bare hands. b. On 8/14/23 at 10:24 a.m., [NAME] 19 was observed to wash her hands, she used a towel to dry her hands, used the same wet paper towel to turn off the faucets. She was not wearing a hair net. c. On 8/14/23 at 10:32 a.m., [NAME] 19 was observed to wash her hands, she used a towel to dry her hands, used the same wet paper towel to turn off the faucets. She was observed to then don a hair net. d. On 8/14/23 at 10:37 a.m., [NAME] 19 was observed to wash her hands, she used a towel to dry her hands, used the same wet paper towel to turn off the faucets. e. On 8/14/23 at 10:40 a.m., Dietary Aide 20 was observed to wash his hands, he used a paper towel to dry his hands, used the same wet towel to turn off the faucets. A handwashing poster taped above the kitchen handwashing sink indicated, wash your hands with soap and water for at least 20 seconds, there were no further instructions. During an interview on 8/14/23 at 10:43 a.m., the Dietary Manager (DM) indicated staff were required to have hair nets on before entering the kitchen that was why hair nets were stored outside the kitchen for easy access. Proper hand washing procedure included turn on the water with a dry paper towel, let the water flow a few seconds to clear the water and bring it up to temp, wash hands for 20 - 30 seconds, leave water running while using a paper towel to dry hands, then turn off faucets with a new dry paper towel. Staff were to make sure hands were dry before donning gloves, and hands were to be washed every time gloves were changed. The dishwasher was to wash their hands between washing dishes and helping in the rest of the kitchen, as they were going from dirty to clean areas. The garbage containers were supposed to always have a lid on when not in use. A2. On 8/14/23 at 10:20 a.m., [NAME] 19 was observed mixing food in a large metal bowl, indicated she was making spaghetti sauce for dinner. The cook was not wearing a hair net. On 8/10/23 at 2:10 p.m., [NAME] 19 was observed to check the temperature of and puree beef stroganoff for dinner. She was observed to remove a food thermometer from a basket that contained items to include thermometers, pens, and scissors. [NAME] 19 was not observed to clean the thermometer before putting it into the beef stroganoff and temping the food at 164 degrees Fahrenheit (F), she indicated it should be 165 F. Food temperatures were not observed to be logged. On 8/14/23 at 10:30 a.m., [NAME] 21 was observed checking the temperature of meat in the oven. She was observed to clean a thermometer by rubbing an alcohol prep up and down the thermometer probe, then laid the thermometer on a food tray on the island among other cooking utensils without replacing the thermometer probe cover. Cook 21 demonstrated the technique for cleaning a food thermometer and checking the temperature of meat. Indicated, remove thermometer cover, and clean the probe with an alcohol prep. Place the probe into the center of product, wait until the digital numbers stop moving, then clean probe ready for next temp. Demonstrated cleaning thermometer probe by running alcohol prep up and down the probe multiple times. On 8/14/23 at 10:39 a.m., [NAME] 21 was observed checking the temperature of a tray of meat, she did not clean the thermometer after having been laid without the probe cover on a tray among other cooking utensils. She was observed to remove a second tray of meat from the oven, put the meat into a metal pan and placed it on the steam table, she was not observed to check the temperature of the 2nd tray of meat. The food temperatures were not observed to be logged. On 8/14/23 at 11:03 a.m., review of food temperature logs with the DM, dated 8/7/23 - 8/14/23. The food temperature logs lacked documentation of temperatures observed for lunch food on 8/14/23 that had been observed being placed on the steam table. The DM indicated, cooks were only documenting final temperatures before food was served, they did not document holding temperatures. DM indicated she had been instructed by a regional supervisor, only final temperatures needed logged, they were not required to log holding temps. Acknowledged, by using this process, cooks would have no way of knowing if food dropped below acceptable holding temperatures, or if the food would need to be re-heated or re-cooked. Food temperature logs, dated 8/7 - 8/14, indicated the column titled final internal preparation temperatures were filled out with food temperatures. The 2 columns titled meal service holding temps were blank on all forms. The forms also lacked re-temping documentation, time food temperatures were checked, or initials of person temping the food as instructed on the form. During an interview on 8/14/23 at 10:43 a.m., the DM indicated, when the cook was checking the temperatures of food, the thermometer was calibrated every day to reset by putting the thermometer into cold and hot water. The food thermometer was cleaned before and after temping food with alcohol wipes or with sanitizer. The entire thermometer was to be cleaned from the top (handheld area) to tip of the probe, then cleaned with a 2nd wipe from probe to tip. The cleaning prep was not to be rubbed up and down, potentially re-contaminating the probe. Let the thermometer dry before use. Probe was inserted into the thickest part of the food, wait for the digital temperature to stop, and record the temperature on the food log. If food was not hot enough, the food was to be reheated and re-temped before being placed on the steam table or being served. The thermometer was to be stored in the thermometer sleeve between uses, it was not appropriate to lay the thermometer down without the cover on the counters or among other kitchen items where it could get exposed to contaminants. The cook was supposed to check the temperature of food when placing it on the steam table, every 30 minutes while holding, and again before serving. Food on the steam table was not supposed to be held for more than 2 hours or if the food dropped below 135 F. Food temperatures were supposed to be logged every time taken. If food temperatures dropped below 135 F on the steam table, the food must be tossed and recooked. On 8/14/23 at 3:15 p.m., the Regional Director of Operations indicated, to his knowledge the dietary staff did not calibrate the food thermometer before using to temp food, they just turned it on and used. There was no policy, procedure, or staff training documentation on calibrating or cleaning of the food thermometers. A3. Dining room mealtimes were posted at dining room entrance, indicated breakfast at 6:45 a.m., lunch at 11:45 a.m., and dinner at 4:45 p.m. On 8/10/23 at 11:15 a.m. [NAME] 19 indicated she tried to have all food pureed for the evening meal by 2:00 p.m. On 8/10/23 at 2:10 p.m., [NAME] 19 was observed to scoop beef stroganoff into a metal container to puree and put the remaining pan of stroganoff onto the steam table. [NAME] 19 scooped the stroganoff into a blender using a rubber spatula, turned on the blender, checked the consistency of the stroganoff, then retrieved 2% milk from the refrigerator at the prompting of the Administrator (ADM) and added it to the puree mixture. [NAME] 19 then used the rubber spatula to scrape the stroganoff from the blender into a pan, used her finger to remove the stroganoff from the spatula into the pan, and removed food that was on the rim of the pan with her finger and put it into the pan. [NAME] 19 was observed to wear the same gloves from the time she took the stroganoff from the oven, through the pureeing process, while retrieving milk from the refrigerator, and while scooping food with her fingers into the serving pan. She was not observed to replace her gloves or wash her hands during the observation. On 8/14/23 at 1:46 p.m., ADM provided copy of pureed list of residents, indicated on this date there were 11 residents receiving pureed diets. There were no residents receiving nutrition via tube feeding, and 52 residents were receiving regular diets. During an interview on 8/14/23 at 10:43 a.m., the DM indicated when the cook pureed vegetables, she was required to first assure the internal temperature of the food. Food was then taken and put into the food processor, food was pulsed to texture, she was to follow the recipe for what was used to thin food as needed, re-temp the food after adding liquid, and if food was too thin add bread. The food was scooped out of the food processor into a metal pan and placed on the steam table. Staff were not allowed to use their hands to scoop food off the spatula or outside of pan to put excess food into the pan that was to be served to residents. On 8/11/23 at 2:30 p.m., the ADM provided a Monitoring Food Temperatures for Meal Service policy, dated 2017, and indicated the policy was the one currently being used by the facility. The policy indicated, Food temperatures will be monitored daily to prevent food borne illness and to ensure foods are served at palatable temperatures .2. The temperature for each food item shall be recorded on the Food Temperature Log. Foods that require a corrective action, like reheating; will have the new temperature recorded on the log .3. Proper procedures are used to ensure measured temperatures are accurate and contamination is avoided. a. A properly functioning, calibrated thermometer is used when taking temperatures .b. Thermometers are clean, rinsed, and sanitized before and after each meal use. An alcohol swab may be used to sanitize between uses during the same meal. c. When taking temperatures, the thermometer is inserted in the thickest part of the food .4. If hot food is not 135 F or higher when checked, they will be reheated to at least 165 F for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within 2 hours . Indiana State Department of Health, Food Protection Program (October 29, 2022), also retrieved 8/16/23 at United States Dietary Association (USDA.gov), indicated instructions for thermometer calibration by using the ice point method when placing thermometer into a container of ice water at 32 F, or boiling point method when putting thermometer into water that reaches a complete rolling boil at 212 F. Either method should permit calibration to within 1.0 F. Remember: sanitize thermometers before use and in between uses, and calibrate thermometers frequently. Retail Food Establishment Sanitation Requirements, effective November 13, 2004, hand cleaning and drying procedure indicated clean hand and exposed portions of arms with a cleaning compound at a handwashing sink that is equipped as specified, by vigorously rubbing together the surfaces of their lathered hands and arms for at least 20 seconds. Hands should be washed after handling soiled surfaces, equipment, and utensils. During food preparation, as often as possible to remove soil and contamination and to prevent cross-contamination when changing tasks, when touching food and food-contact surfaces, before placing gloves on hands, and after engaging in other activities that contaminate the hands. B2. During an observation of lunch dining service in the main dining room, on 8/7/23 at 12:06 p.m., Certified Nursing Assistant (CNA) 24, assisted Residents 14 and 30 with eating their food, without hand sanitation and after touching the residents' clothing, the residents' wheelchairs, and wiping her hands on her pants, after giving bites of food to the residents. B 3. During an observation of lunch dining service in the main dining room, on 8/7/23 at 12:09 p.m., Certified Nursing Assistant (CNA) 16, assisted Residents 9 and 37 with eating their food, without hand sanitation and after touching the residents' clothing, the residents' wheelchairs, and wiping her hands on her pants and touching her face, after giving bites of food to the residents. On 8/8/23 at 8:35 a.m., the Administrator (ADM) indicated staff should sanitize their hands with alcohol-based hand gel between assisting each resident with their meal. At that time, the ADM provided and identified an undated document as a current facility policy, titled, Dignity. The policy indicated, .As an extension of appropriate interactions between staff and residents, the following will be practices of the facility .Dining .10.) When feeding resident(s), only 2 resident can be fed at once. Hand hygiene must take place if staff touch one of these residents; prior to going back to assisting the other of the two residents 3.1-21(a)(2) 3.1-21(i)(1) 3.1-21(i)(3)

B1. On 8/07/23 at 11:56 a.m., observed Licensed Practical Nurse (LPN) 4, assisted Resident 52 in his wheelchair, from the main dining room, and wheeled him into the main hallway in front of the reception desk. The LPN donned (for to (put) on) gloves and cleaned a glucometer machine (an instrument for measuring the concentration of glucose in the blood) with disinfectant wipes. The nurse picked up the glucometer, a testing strip, and a lancet and stuck the resident's finger with a lancet, obtained a blood sample and completed the glucometer reading. She cleaned the finger of the resident with an alcohol prep pad (a two-layer pad which contain 70% isopropyl alcohol. Prep Pads help clean the skin and can be used on cuts, scrapes, and abrasions prior to bandaging), and assisted the resident back to the dining room. The nurse failed to remove soiled gloves, sanitize hands and donned clean gloves prior to completing the blood glucose test. On 8/14/23 at 11:43 a.m., record review resident had diagnosis's of but not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) dated 4/7/2022. Type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes) dated, 7/26/2023. A care plan dated 10/12/22, indicated, the resident had a diagnosis of diabetes with risk for Hypo/or Hyperglycemia. Nursing intervention dated, 10/12/22 check blood sugars per order.A. Based on observation, interview, and record review, the facility failed to ensure proper handling of oral and eye drop medication for 2 of 2 residents observed during the medication administration observation (Residents 63 and 42). B. Based on observation, interview, and record review, the facility failed to ensure hand sanitization was performed in between glucometer blood testing for 3 of 3 residents observed during medication administration (Residents 52, 27, and 41). Findings include: A1. During a medication administration observation, on 8/10/23 at 9:14 a.m., RN 11 was administering eye drops to Resident 63. The RN administered the eye drops to the resident with her bare hands. The resident received a drop in each eye and the nurse touched underneath each eye with her bare finger. During an interview, on 8/10/23 at 11:40 a.m., Director of Nursing (DON) indicated she would need to pull the policy on rather staff were to wear gloves during eye drop administration. Resident 63's record was reviewed on 8/10/23 at 3:30 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified glaucoma (a group of eye conditions that can cause blindness). A physician order, dated 6/20/23, indicated Alphagan P Ophthalmic Solution 0.1% (eye drop medication for glaucoma), instill 1 drop in both eyes two times a day. A2. During a medication administration observation, on 8/10/23 at 9:25 a.m., RN 11 was preparing oral medications for Resident 42. The RN placed a potassium pill into a cup and she touched the pill with her bare hands to break it in half. She placed water into the cup with the pill to help dissolve the pill. RN 11 indicated it helped the resident to swallow the pill if it was not whole. During an interview on 8/10/23 at 11:40 a.m., DON indicated staff was not to touch oral medication with their bare hands. Resident 42's record was reviewed on 8/10/23 at 2:57 p.m. The profile indicated the resident's diagnosis included, but were not limited to, hypokalemia (a blood level that is below normal in potassium, an important body chemical). A physician order, dated 4/12/23, indicated Potassium Chloride extended release 20 milliequivalent (meq), give 1 tablet by mouth two times a day. On 8/10/23 at 1:20 p.m., the Administrator (ADM) provided an undated document, titled, Eye Medications, Administration of, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure:1. Put on gloves On 8/10/23 at 4:15 p.m., the ADM provided a document, dated March 2023, titled, 5.1: Drug Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .a. A tablet splitter is used to avoid contact with the tablets B2. On 8/7/23 at 11:28 a.m., Resident 27 was observed propelling herself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 27 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 27's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/14/23 at 12:27 p.m., Resident 27's record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/19/23, indicated the resident was cognitively intact and required supervision-oversight, encouragement, or cueing of one person for locomotion on and off the unit. A care plan, dated 7/9/21, indicated the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. A physician's order, dated initiated 7/9/21, indicated blood glucose monitoring before meals and HS (bedtime) for the diagnosis of DM. B3. On 8/7/23 at 11:32 a.m., Resident 41 was observed propelling himself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 41 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 41's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/7/23 at 11:37 a.m., LPN 4 indicated, per the facility policy, staff were allowed to perform blood glucose testing on residents in the hallway. All residents have their own glucose meters. She had forgotten to wash her hands and should have washed or sanitize her hands between residents. Resident 41's record was reviewed, on 8/9/23 at 3:37 p.m. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident had a moderate cognitive impairment and required extensive assistance of one person for locomotion on the unit and limited assistance of one person for locomotion off the unit. A physician's order, dated 1/16/23, indicated blood glucose monitoring four times a day for the diagnosis of DM. A care plan, dated 1/17/23, indicated, the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. On 8/7/23 at 3:29 p.m., the ADM provided and identified an undated document as a current facility policy, titled, Policy and Procedure Cleaning/Disinfecting/Maintaining Glucose Meters. The policy indicated, .The Glucose meters will be disinfected between each resident use to prevent the spread of microorganisms including blood borne pathogens .If a resident has their own meter, it still must be cleaned after each use .Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and the second wipe for disinfecting .Note: Always create a dry 'barrier' between the meter and any surface on which it is placed during actual use or cleaning .Procedure: .Cleaning and Disinfecting .1. [NAME] nonsterile gloves .2. Inspect for blood/debris/dust/lint anywhere on the meter .3. Open the towelette container or package and remove one towelette .4. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids .5. Dispose of the towelette .6. Obtain a second towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood borne pathogens. The meter must be maintained wet for 2 minutes with the Super Sani cloth wipe .7. Once the exterior of the glucose meter has remained wet for the appropriate contact time, the meter may be wiped dry with a dry cloth .10. Dispose of the used towelette .11. Remove gloves .12. Wash hands (may use ABHR [alcohol-based hand rub] On 8/8/23 at 8:28 a.m., the Administrator (ADM) indicated, staff were to complete accuchecks/blood glucose testing on residents in a private area for dignity. Staff should wash hands, when visibly soiled and before and after direct contact with residents. The ADM, on 8/7/23 at 3:29 p.m., provided and identified a document as a current facility policy, titled, Handwashing/Hand Hygiene, dated 2001. The policy indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: .a. When hands are visibly soiled .c. Before and after coming on duty .7. Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .a. Before and after direct contact with residents .b. Before preparing or handling medications .c. Before performing any non-surgical invasive procedures .e. Before donning sterile gloves .h. After contact with a resident's intact skin .i. After contact with blood or bodily fluids .k. After contact with objects (e.g., medical equipment) in the immediate vicinity .l. After removing gloves .The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .10. Single-use disposable gloves should be used: .When anticipating contact with blood or body fluids 3.1-18(a) 3.1-18(b) 3.1-18(b)(1)

Based on record review and interview, the facility failed to ensure a skin assessment and post fall assessment were completed for 1 of 3 residents reviewed for accidents (Resident C). Findings include: Resident C's record was reviewed on 3/14/2023 at 1:57 p.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin), hyperlipidemia ( known as high cholesterol, when there are too many lipids (fats) in the blood), depression (a mental health disorder with persistently depressed mood or loss of interest in activities, causing impairment in daily life), chronic pancreatitis (a condition where the pancreas (a small organ located behind the stomach) becomes permanently damaged from inflammation). A quarterly Minimum Data Set (MDS) assessment, dated 11/22/2022, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was cognitively intact. The resident was continent of bladder and occasionally incontinent of bowel. The resident required extensive assist of 2 persons with bed mobility and one-person physical assist with toilet use, dressing, and personal hygiene. A care plan, dated 11/18/2022, and revised on 12/21/2022, indicated the resident was a risk for falls due to decline in mobility, shortness of breath and malnutrition. Interventions included, but were not limited to, attempt to keep areas free of clutter, initiate floor bed to decrease risk of injury, keep call light in reach, and offer to assist resident to walk with staff as resident requests, pending the ability to do so safely. A care plan, dated 11/18/2022, indicated the resident was a risk for skin breakdown due to diagnosis of COPD, chronic pancreatitis, EtOH (alcohol), and meth (methamphetamine is a synthetic stimulant that is addictive and can cause considerable health adversities) abuse. Interventions included, but were not limited to, skin assessment per facility policy and keep clean and dry. The care plan lacked documentation of any skin injuries. Review of fall risk review, dated 12/16/2022 at 6:27 a.m., indicated resident was a high risk for falls with a score of 17. Review of nursing progress note, dated 12/16/2022 at 8:19 a.m., indicated resident had a fall. The doctor and son were notified. Review of daily skilled nursing note, dated 12/17/2022 at 1:42 a.m., indicated the resident had a fall. The doctor was notified and gave an order for a one time dose of Xanax (medication used to treat anxiety) 0.5 milligrams (mg). Review of IDT (interdisciplinary team) note, dated 12/17/2022, indicated resident was found on the floor in her room, resident indicated she was attempting to try to go to the bathroom. No injuries noted at this time. Review of nursing progress noted, dated 12/20/2022 at 7:47 a.m., indicated resident was found on the floor in her room. No injuries were noted. Hospice and family were notified. The record lacked documentation of a post fall assessment. Review of IDT note, dated 12/21/2022, indicated resident was found in the seated position on her floor mat, she was in between her bed and wheelchair. Resident noted to have a small skin tear on her left arm. The skin tear was closed with steri-strips. The record lacked documentation of a progress note of the fall, post fall assessment, and skin assessment. Review of December 2022 TAR (treatment administration record) indicated the record lacked documentation of treatment for the resident's skin tear on her left forearm. During an interview, on 3/15/2023 at 2:00 p.m., the Director of Nursing (DON) indicated a skin assessment should be completed weekly and after an event. Any new skin areas should be documented on the skin assessment. During an interview, on 3/15/2023 at 2:45 p.m., the Administrator (ADM) indicated they were not able to provide documentation of a post fall assessment for the falls that occurred on 12/20/2022 and 12/21/2022. She further indicated there were no skin assessments related to the skin tear. On 03/14/2023 at 11:25 a.m., the ADM provided an undated document, titled, Incidents/Accidents/Falls, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: . 2. In the case of a fall, the resident will have a head to toe assessment .7 a progress note within the resident's medical record is to be included This Federal tag relates to Complaint IN00399519. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the ombudsman was notified of a resident's discharge to the hospital for 1 of 5 residents reviewed for discharge (Resident 27). Findings include: Resident 27's record was reviewed on 5/23/22 at 9:43 a.m. A significant change Minimum Data Set (MDS) assessment, dated 3/16/22, indicated the resident had a moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE], and was hospitalized from [DATE] to 1/28/22. A progress note, dated 1/26/22, indicated the resident was admitted to the hospital with a diagnosis of renal (kidney) failure. A notice of transfer or discharge, dated 1/26/22, was provided to the resident's representative, but lacked documentation a copy was provided to the ombudsman. A progress note, dated 1/28/22, indicated the resident returned to the facility. Progress notes, dated 1/28/22 to 5/23/22, lacked documentation the ombudsman was notified of the resident's discharge to the hospital. During an interview, on 5/23/22 at 2:08 p.m., the Administrator indicated they should have notified the ombudsman monthly of all hospitalizations and discharges. The previous Social Services Director (SSD) was responsible for the notifications, so she would have to check to see if she could find her e-mails. During an interview, on 5/23/22 at 2:50 p.m., Ombudsman 13 indicated he reviewed his e-mail communications, and he had not received any recent communication from the facility regarding discharges and hospital transfers. During an interview, on 5/24/22 at 9:22 a.m., the Administrator indicated she was unable to find documentation the ombudsman was notified of the resident's hospital stay. The ombudsman should have been notified in February. During an interview on 5/24/22 at 10:18 a.m., the Administrator indicated there was no written facility policy for the ombudsman notification, but they followed the regulation. They should have notified the ombudsman of the hospital transfer the following month. 3.1-12(a)(6)(A)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 2 of 4 residents reviewed for care plan meetings (Residents 13 and 9). Findings include: 1. During an interview, on 5/17/22 at 1:41 p.m., Resident 13 indicated she did not remember being invited to or attending a care plan meeting. It had been about two years since she had a care plan meeting. Resident 13's record was reviewed on 5/19/22 at 9:43 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/6/22, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A care plan note, dated 10/14/21, indicated a care plan invitation was mailed to the resident's family. The note lacked documentation the resident was invited to the care plan meeting. The record lacked documentation of the resident's family member's response to the invitation, and any further care plan invitations or meetings. During an interview, on 5/20/22 at 8:58 a.m., the Administrator indicated she was unable to find any documentation a care plan meeting was conducted since 2019. The resident representative was invited to a care plan in October 2021, but there was no further documentation of the representative's response or the resident being invited. 2. During an interview, on 5/17/22 at 2:24 p.m., Resident 9 indicated he did not remember being invited to or attending a care plan meeting. Resident 9's record was reviewed on 5/23/22 at 11:16 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/28/22, indicated the resident had a moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. Resident 9's record lacked documentation a quarterly care plan meeting was completed in 2022. During an interview, on 5/19/22 at 12:07 p.m., the Administrator (ADM) indicated Resident 9 had a care plan meeting on 10/26/21. The resident should have had care plan meetings quarterly every three months. On 5/20/22 at 8:45 a.m., the Administrator provided and identified a document as a current facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans, dated 3/23/21. The policy indicated, .Procedure: .5. The facility Social Service Director or designee will notify the resident's responsible party either by letter or a phone call to inform them of the scheduled Care Plan Conference to include the date and time. This notification will continue for subsequent Care Plan Conferences. These notifications will be documented for reference .6. The facility Social Service Director or designee will notify the resident of their scheduled Care Plan Conference and will invite and encourage the resident to attend. This notification will continue for any subsequent Care Plan Conferences. These notifications will be documented for reference .9. The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues 3.1-35(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure treatments were initiated for pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and pressure ulcers were staged (an assessment of how deep a pressure ulcer is) appropriately for 1 of 2 residents reviewed for pressure ulcers (Resident 29). Findings include: Resident 29's record was reviewed on 5/23/22 at 11:27 a.m. A five day Minimum Data Set (MDS) assessment, dated 3/28/22, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE], and was hospitalized from [DATE] to 2/11/22 and from 3/9/22 to 3/21/22. An admission assessment, dated 1/28/22, indicated the resident had a stage one (superficial reddening of the skin that does not turn white when pressed) area to the coccyx (the base of the spine), measured 0.5 centimeters (cm) in length, 0.3 cm in width, and less than 0.5 cm in depth. The assessment lacked documentation of a treatment initiated for the area. A Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated January 2022, lacked documentation any treatment was ordered for the residents coccyx. Weekly wound evaluations, dated January 2022, lacked documentation the resident had an open area to the coccyx or sacrum. A re-admission assessment, dated 2/11/22, lacked documentation the resident had any skin impairment to the sacrum (the bottom of the spine, directly above the coccyx) or coccyx. A MAR and TAR, dated February 2022, lacked documentation any treatment was ordered for the resident's coccyx or sacrum. Weekly wound evaluations, dated February 2022, lacked documentation the resident had an open area to the coccyx or sacrum. A re-admission assessment, dated 3/21/22, lacked documentation the resident had any skin impairment to the sacrum or coccyx. A contracted wound services note, dated 3/30/22, indicated the resident had a suspected deep tissue injury (a localized area of discolored intact skin) to the sacrum. The wound was originally noted on 3/21/22. The requested treatment was a hydrocolloid (a breathable dressing that adheres to the skin) dressing weekly and as needed. A weekly wound evaluation, dated 3/31/22, indicated the resident had a stage four (a deep wound that reaches muscles, ligaments, or bones) pressure ulcer to the sacrum, present prior to the resident's admission, originally identified on 3/23/22. The wound measured 3.99 cm in length, 1.81 cm in width, and 0.01 cm in depth. A MAR and TAR, dated March 2022, lacked documentation any treatment was ordered for the resident's coccyx or sacrum. A contracted wound services note, dated 4/6/22, indicated the resident had a suspected deep tissue injury (a localized area of discolored intact skin) to the sacrum. The wound was originally noted on 3/21/22. The requested treatment was a hydrocolloid dressing weekly and as needed. A weekly wound evaluation, dated 4/7/22, indicated the resident had a stage four pressure ulcer to the sacrum, present prior to the resident's admission, originally identified on 3/23/22. The wound measured 3.1 cm in length, 4.37 cm in width, and 0 cm in depth. A weekly wound evaluation, dated 4/13/22, indicated the resident had a stage four pressure ulcer to the sacrum, present prior to the resident's admission, originally identified on 3/23/22. The wound measured 4 cm in length, 4.5 cm in width, and 0.1 cm in depth. A physician's order, dated 4/14/22 and discontinued on 4/19/22, indicated cleanse area on coccyx with wound cleanser, pat surrounding area dry, apply Medihoney (a gel used to treat wounds and burns) to wound base, cover with a four by four Allevyn (foam) dressing daily and as needed for wound care. A physician's order, dated 4/20/22 and discontinued on 4/21/22, indicated cleanse area on coccyx with wound cleanser, pat surrounding area dry, apply Santyl (a medication to remove dead tissue from wounds) to wound base, cover with a four by four Allevyn dressing daily and as needed for wound care. A wound center note, dated 4/21/22, indicated the resident had a stage two (partial thickness skin loss) pressure ulcer to the mid-line coccyx, acquired 3/11/22, measured 2.2 cm in length, 2.8 cm in width, and 0.1 cm in depth. The requested treatment was cleanse are with normal saline, apply Medihoney gel to the wound, cover with a four by four foam dressing once daily. A weekly wound evaluation, dated 4/22/22, indicated the resident had a stage two pressure ulcer to the sacrum, present upon admission, originally identified on 3/23/22. The wound measured 2.2 cm in length, 2.8 cm in width, and 0.1 cm in depth. The evaluation lacked documentation of why the area changed from a stage four to a stage two pressure ulcer. A physician's order, dated 4/22/22 and discontinued 5/12/22, indicated cleanse coccyx with normal saline, apply Medihoney, and cover with a four by four Allevyn dressing every day shift for wound. A weekly wound evaluation, dated 4/29/22, indicated the resident had a stage two pressure ulcer to the sacrum, present upon admission, originally identified on 3/23/22. The wound measured 3 cm in length, 3.3 cm in width, and 0.1 cm in depth. A weekly wound evaluation, dated 5/6/22, indicated the resident had a stage two pressure ulcer to the sacrum, present upon admission, originally identified on 3/23/22. The wound measured 1.2 cm in length, 1.1 cm in width, and 0.2 cm in depth. A weekly wound evaluation, dated 5/12/22, indicated the resident had a stage two pressure ulcer to the sacrum, present upon admission, originally identified on 3/23/22. The wound measured 3 cm in length, 3.3 cm in width, and 0.1 cm in depth. A physician's order, dated 5/13/22, indicated cleanse coccyx with normal saline and betadine (an antiseptic), apply Medihoney, and cover with a four by four Allevyn dressing every day shift for wound. A weekly wound evaluation, dated 5/21/22, indicated the resident had a stage two pressure ulcer to the sacrum, present upon admission, originally identified on 3/23/22. The wound measured 2.2 cm in length, 1.2 cm in width, and 0.2 cm in depth. During an interview, on 5/24/22 at 10:23 a.m., Registered Nurse (RN) 6 indicated the wound nurse had not documented correctly when it was indicated the coccyx wound was a stage four. The original admission assessment, dated 1/28/22, indicated the resident had a stage one area to the coccyx. The contracted wound service assessed all residents admitted with skin impairment, and should have resolved any areas noted on the admission assessment which were no longer present when they completed their assessment. She thought the stage one area had already healed when the contracted wound service assessed the resident, but there was no documentation of this. There was no treatment order for the coccyx at the time of admission. The wound nurse put the treatment order in the system wrong in April 2022, and that is what caused the treatment to not show up on the MAR and TAR until 4/22/22. She thought the treatment was completed, but was unable to find any documentation. The resident re-admitted to the facility from his last hospital stay on 3/21/22. During the assessment completed at the time of that admission, the wound nurse considered the area on the resident's coccyx to be diaper dermatitis, and it was not assessed as a pressure ulcer or noted. The wound was acquired in the hospital, according to the wound center dates, but it was not documented on the re-admission assessment, and there was no treatment ordered at the time of admission. On 5/24/22 at 1:31 p.m., the Director of Nursing (DON) provided a document titled, S.W.A.T. Skin Weight Assessment Team-Guidelines Pressure Ulcers, and indicated it was the policy currently being utilized by the facility. The policy indicated, .Definition: A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure combined with shear. A number of contributing or confounding factors are also associated with pressure ulcers; both intrinsic and extrinsic. Policy: It is the policy of the facility to ensure .that a resident who enters the facility with pressure ulcers receives the necessary care and services to promote healing, prevent infection and prevent new sores from developing. Procedure: RISK ASSESSMENT: .NOTE: If upon assessment an actual pressure ulcer is found-immediate steps will be taken .to further see that a treatment and any needed interventions are obtained .Procedure: PRESSURE ULCER ASSESSMENT: 1) Pressure Ulcer Assessments will be performed on all pressure ulcers at least weekly. At this time, a trained clinician in staging will assess the wound and record the dimensions to include length, width, and depth .2) It is important to remember that pressure ulcers cannot be reverse graded. A Stage 4 pressure ulcer cannot heal to become a Stage 2 pressure ulcer. It would be considered a healed Stage 4 pressure ulcer .Pressure Ulcer Management: TREATMENT OF PRESSURE ULCERS-NPUAP POINTS-RECOMMENDATIONS: Once a pressure ulcer is established, the following must be investigated, established, documented and addressed to resolution: .Ensure all assessments are timely and accurate. Ensure that staging is done by a trained clinician and is documented .Monitor treatments for efficacy 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the development of person-centered (care focused on knowing the unique person through respectful close relationships that foster normalcy, choice, purpose, belonging, security and strengths) dementia plan for care and services for 1 of 2 residents reviewed for dementia care (Resident 157). Findings include: Resident 157's record was reviewed on 5/18/22 at 1:30 p.m. The profile indicated the resident had been admitted to the facility on [DATE], with diagnoses which included, but were not limited to, unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). The admission Minimum Data Set (MDS) assessment, dated 5/13/22, and documented as still in progress, indicated the resident had severe cognitive deficit. A care plan, dated 5/10/22, indicated the resident had a diagnosis of dementia with short-term and long-term (damage to the brain caused by dementia which can affect areas of the brain involved in creating and retrieving memories) memory problems. Interventions included, but were not limited to reminisce with resident when able. The documentation lacked specific person-centered interventions for the resident. During an interview, on 5/18/22 at 2:22 p.m., Certified Nurse Assistant (CNA) 7 indicated she learned personal information about the Resident 157 by speaking with the resident and his family. On the facility's memory care units the activity department staff would gather personal information on the residents at admission. Each memory care resident had a information sheet in their room with personal things they enjoyed talking about, but there were nothing like that for the residents outside of the memory care units. During an interview, on 5/18/22 at 2:38 p.m., the Activity Director (AD) indicated a document titled, About Me, was developed for all of the residents of the memory care unit,. The document was designed so that staff would know the topics of interest to discuss with the resident of units. Nothing like that was developed for the resident's with dementia outside of those units. On 5/19/22 at 2:46 p.m., the Administrator (ADM) provided an undated document, titled, Resident Preferences, and indicated it was the policy currently being used by the facility. The policy, indicated, Policy: It is the policy of the facility to ensure that as part of a person centered approach to care, the resident receives care as their preference and choice .Procedure: 1. Upon admission as part of the admission process, the resident will be interviewed as to their individual preferences .This will be done by a staff member, usually the Activity Director or Social Services Director. It will be well documented on a specific form to state and track their choices 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications (Resident 21). Finding includes: On 5/19/22 at 11:34 a.m., Resident 21's record was reviewed. Resident 21 was admitted to the facility on [DATE] with a diagnosis included, but was not limited to, hypothyroidism [(underactive thyroid) a condition in which the thyroid gland does not produce enough of certain crucial hormones]. A current May 2022 physician's orders indicated Resident 21 received 25 micrograms (mcg) of levothyroxine sodium at bedtime for the diagnosis of hypothyroidism. A care plan, initiated on 3/12/21, indicated the resident had a diagnosis of hypothyroidism with interventions included, but not limited to, medications as ordered, labs as ordered, and observe Resident 21 for adverse effects of alopecia (hair loss), excessive weight gain, ataxia (impaired balance or coordination), bradycardia (slow heart rate) with a goal of Resident 21 will exhibit no signs or symptoms of hypothyroidism thru next review. A pharmacy consultation report, dated 5/17/21, recommended Resident 21 to have blood lab work of a TSH (thyroid stimulating hormone) related to the medication, levothyroxine, to be completed every six months. The physician agreed to the recommendation, undated. A pharmacy consultation report, dated 9/15/21, recommended Resident 21 to have blood lab work of a TSH (thyroid stimulating hormone) related to the medication, levothyroxine, to be completed every six months. The physician agreed to the recommendation on 9/28/22. Resident 21's record revealed the resident had other blood lab work completed on 8/10/21, but lacked documentation a TSH blood lab work had been completed until 10/5/21. On 5/19/22 at 3:28 p.m., the Administrator indicated the pharmacy consultation report recommendations should be addressed within 7 days of the receipt of the recommendation. At that time, the Administrator provided and identified an undated document as a current facility policy titled, Policy and Procedure - Pharmacy Recommendations, which indicated, .Policy: It is the policy of the facility to monitor medication by pharmacy regimen reviews conducted monthly or more often if indicated. The objective being to ensure that the residents are receiving medications that are effective and safe .A response as to the action to be taken regarding the Pharmacy Consultant's recommendation will be documented within 7 days of the receipt of the recommendation 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent based on medication errors observed during 2 of 30 opportunities for errors during random medication administration observations resulting in a medication error rate of 6.7 percent (Residents 27 and 13). Findings include: 1. During a random medication administration observation, on 5/20/22 at 9:18 a.m., Licensed Practical Nurse (LPN) 16 administered Advair (a medication used to treat chronic lung problems) 100-50 micrograms (mcg), one puff by mouth to Resident 27. The resident completed the inhalation independently. LPN 16 offered Resident 27 a drink, but he declined. LPN 16 did not instruct Resident 27 to rinse and spit after the Advair administration. Resident 27's record was reviewed on 5/20/22 at 2:14 p.m. A significant change Minimum Data Set (MDS) assessment, dated 3/16/22, indicated the resident had a moderate cognitive impairment. Diagnoses on the resident's profile included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of lung disease that block air flow and make it difficult to breathe). A physician's order, dated 2/4/22, indicated Advair diskus aerosol powder, 100-50 mcg dose, one inhalation orally two times a day for COPD. The order lacked documentation the resident should rinse and spit after using the inhaler. On 5/20/22 at 1:36 p.m., the Administrator provided a document titled, PATIENT INFORMATION ADVAIR DISKUS ., and indicated it was the policy currently being used by the facility. The policy indicated, .How should I use ADVAIR DISKUS? .Rinse your mouth with water without swallowing after each dose of ADVAIR DISKUS. This will help lessen the chance of getting a yeast infection (thrush) in your mouth and throat 2. During a random medication administration observation, on 5/20/22 at 11:30 a.m., Licensed Practical Nurse (LPN) 16 administered Humalog (a rapid acting insulin) 11 units (u) subcutaneously (SQ) (the fatty layer beneath the skin) to Resident 13 related to a blood sugar of 134. On 5/20/22 at 11:50 a.m., Resident 13's lunch was served and she began eating. Resident 13 was not offered any food prior to lunch being served. Resident 13's record was reviewed on 5/19/22 at 9:43 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/6/22, indicated the resident was cognitively intact. Diagnoses on the resident's profile included, but were not limited to, type two diabetes mellitus (an impairment in the way the body regulates and uses sugar) without complications. A physician's order, dated 5/18/22, indicated insulin lispro (Humalog) six u SQ with meals for type two diabetes mellitus. A physician's order, dated 5/18/22, indicated insulin lispro, inject per sliding scale, for blood sugar 130-150 inject 5 u SQ with meals for type two diabetes mellitus. During an interview, on 5/20/22 at 2:07 p.m., Registered Nurse (RN) 6 indicated the staff should have followed the physician's order for the timing of insulin administration. The resident should have rinsed his mouth after using Advair. On 5/20/22 at 1:36 p.m., the Administrator provided a document titled, Package leaflet: Information for the user. Humalog 100 units/ml KwikPen solution for injection in a pre-filled pen insulin lispro ., and indicated it was the policy currently being used by the facility. The policy indicated, .It works very quickly and lasts a shorter time than soluble insulin .You should normally use Humalog within 15 minutes of a meal 3.1-48(c)(1)

Based on interview and record review, the facility failed to address grievances in a manner which could be tracked for 3 of 3 months reviewed for grievance resolutions of the Resident Council. This potentially affected all the residents who resided in the facility (53 Residents). Findings include: Resident Council minutes were provided by the Activity Director (AD) on 5/19/22 at 9:07 a.m. The minutes indicated the following concerns by the Resident Council: 1. Call lights taking too long to be answered by staff 2. Vital being taken on night shift 3. Overhead lights turned on during bed checks 4. Beds not being made During an interview with the Activities Director (AD), on 5/19/22 at 9:07 a.m., indicated that she took minutes for the Resident Council meetings and then spoke to the Administrator (ADM), the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and sometimes she talked to staff about the Resident Council's concerns. There was not a written follow up for the Resident Council's concerns. The ADON did an audit on call lights and the staff had been in-serviced on the concerns at times. During an interview, on 05/19/22 at 10:04 a.m., the Administrator indicated the Resident Council meeting concerns should have been written onto a grievance form called, I have a question, and those written concerns should be addressed by the proper department and the Administrator. The residents' concerns are also discussed in staff morning meetings. At the Resident Council meetings, the Activities Director should have been addressing the old business residents' concerns with the written resolutions for the concerns. Administrator indicated she had done in-services with the staff, but to her knowledge, the Resident Council's concerns had not been followed up in writing by the facility to the Resident Council. On 5/19/22 at 9:54 a.m., the AD provided and identified a document as a current facility titled, Resident Council Policy, dated 3/1/16. The policy indicated, .The Resident Council is an independent, organized group of residents who meet on a regular basis to create change, address quality and dignity of care provided in the facility, plan activities and discuss other matters brought before the council. The role of the Resident Council is to improve the quality of life of the residents who reside in the facility and to take part in actions to maintain a positive living environment .The Resident Council offers an avenue by which residents can have an active role in influencing decisions which will affect them. Participation and involvement in the Resident Council gives the resident a sense of being in control which results in a positive impact on their physical and mental health. Some objectives of the council are as follows: .A. Improves communication between staff and residents .C. Helps to identify quality of life issues .D. Assists individual residents to speak and be heard in a collective voice to affect change .E. Identify issues early when they may be easier to correct; before becoming larger scale .I. Encourages a person centered philosophy of care through recommendations .J. Communicate information from center staff on issues that may affect residents .5. The facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings .6. When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility 3.1-18(a)