Based on interview and record review, the facility failed to ensure a resident's code status preference was documented accurately in the clinical record for 1 of 16 residents reviewed for advanced directives (code status). (Resident 18) Finding includes: On 7/19/23 at 1:51 p.m., the clinical record for Resident 18 was reviewed. The diagnoses included, but were not limited to, dementia, acquired absence of left leg above the knee, and adult failure to thrive. Resident 18's face sheet indicated the resident was a full code (meaning a desire for all life sustaining measures to be implemented) and had an Emergency Contact person responsible for making health care decisions on behalf of the resident. The Quarterly MDS (Minimum Data Set) assessment, dated 6/20/23, indicated Resident 18 was severely cognitively impaired. Resident 18's care plan, initiated on 7/25/19 and current through 9/29/23, indicated Resident/legal representative prefers a full code status .code status will be honored .review advanced directives [code status] with resident/legal representative during care conferences and as needed . Physician Orders, dated 5/4/22, indicated Resident 18 was a full code, effective 5/4/22, with no end date noted. On 7/21/23 at 8:15 a.m., the Director of Nursing Services (DNS) provided a copy of Resident 18's State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, dated 6/5/20. A review of the document indicated Resident 18's code status was Do not attempt resuscitation [DNR]. Resident 18's Emergency Contact person provided verbal consent via phone on 6/5/20. The document was signed by two witnesses and the physician on 6/5/20. No other advanced directive code status documents were provided. On 7/24/23 at 10:40 a.m., the DNS provided copies of the following progress notes and corresponding care plan meeting results as it related to Resident 18's code status: - Progress notes, dated 9/14/20 at 5:00 p.m., indicated .[Resident] continues with full code status . - Progress notes, dated 9/16/20 at 11:10 a.m., indicated .Resident .moderate cognitively impaired .[Emergency Contact] remains the same .wishes to remain a full code . - Progress notes, dated 1/11/22 at 12:20 p.m., indicated .Resident is full code status and prefers to remain so at this time .[Resident is] moderate cognitively impaired .resident and family invited to care plan [meeting]. The Care Plan Summary, dated 1/20/22, indicated neither the resident or Emergency Contact person attended the meeting. - Progress notes, dated 5/11/22 at 12:21 p.m., indicated .resident on this day able to participate in MDS assessment .[moderately cognitively impaired] .resident is a full code status . The clinical record lacked a response from the Emergency Contact person regarding the planned care plan meeting. - Progress notes, dated 11/14/22 at 1:53 p.m., indicated .attempted to contact [Emergency Contact] to schedule quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 4/3/23 at 2:30 p.m., indicated .attempted to contact [Emergency Contact] to invite to quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 7/13/23 at 10:44 a.m., indicated .attempted to call [Emergency Contact] to set quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 7/20/23 at 9:58 a.m., indicated .attempted to contact [Emergency Contact] to schedule quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 7/24/23 at 9:58 a.m., indicated .attempted to call [Emergency Contact] to discuss resident's code status. No reply or answer . The clinical record lacked a response from the Emergency Contact person. On 7/24/23 at 10:40 a.m., the DNS provided copies of the following Observation - Care Plan Summaries related to Resident 18's code status. A review of the documents indicated: - Summary dated: 6/25/20 at 9:57 a.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 12/15/20 at 12:15 p.m., indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 2/3/21 at 12:54 p.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 7/27/21 at 11:28 a.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 10/28/21 at 2:38 p.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 6/30/23 at 2:41 p.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. During an interview on 7/20/23 at 11:00 a.m., the DNS indicated Resident 18's code status was considered a full code. During an interview on 7/20/23 at 2:38 p.m., Resident 18's Emergency Contact person indicated, the Out of Hospital DNR document was completed on 6/5/20. The document indicated Resident 18 was a DNR and that decision had not changed. During an interview on 7/24/23 at 11:29 a.m., the DNS indicated the only advanced directive document for Resident 18 was the 6/5/20 Out of Hospital DNR document. On 7/21/23 at 8:15 a.m., the DNS provided a copy of Resident Rights policy, dated November 2016, and indicated it was the current policy in use by the facility. A review of the policy indicated, .this document informs each resident/responsible party of his/her rights and responsibilities regarding medical care while a resident at the facility .all staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care . On 7/21/23 at 8:15 a.m., the DNS provided a copy of Advanced Directives policy, dated February 2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .the facility's care will reflect the resident's wishes as expressed in the Directive . 3.1-4(f)(4)(A)(ii)

Based on observation, interview, and record review, the facility failed to prevent accident and hazards for 2 of 2 residents reviewed for accidents. A thin liquid treatment was left at a resident's bedside. (Resident 12, Resident 39) Finding includes: During an observation on 7/20/23 at 10:30 a.m., Licensed Practical Nurse (LPN) 4 was observed at the treatment cart, located next to the nurse's station. LPN 4 retrieved Resident 12's physician's prescribed betadine solution from the treatment cart. LPN 4 poured the betadine solution into a small medication (med) cup and then carried the un-covered med cup to Resident 12's room, located at the far end of the hall. The following was observed on 7/20/23 from 10:32 a.m. to 10:40 a.m.: - Resident 12 was resting on his bed in the supine position upon entry into the room. Resident 12 was then observed to independently reposition self into a sitting position on the side of the bed. Resident 12's bed and chair were observed to be within 8 inches from each other and were approximately 8 feet from the small table where the betadine med cup was placed. - Resident 12's roommate, Resident 39, was observed sitting in his chair, next to his bed. Resident 39 was approximately 10 feet from the small table where the betadine med cup was placed. - LPN 4 placed the betadine med cup on the small table next to the restroom door. - LPN 4 entered the adjoining restroom for approximately 10 seconds before exiting. - LPN 4 exited Resident 12's room, entered a resident's room across the hall, and then was observed walking down the hall toward the nurse's station. During that time, the med cup containing the betadine was observed on the small table. - LPN 4 returned to Resident 12's room. LPN 4 moved the betadine med cup from the small table and placed it on Resident 12's chair, located next to the bed on where Resident 12 was sitting. LPN 4 spilled a small amount of the betadine solution onto the chair. At that time, LPN 4 indicated she needed to get something to clean up the spill. The betadine med cup was left on the chair and LPN exited the room. - LPN 4 returned to Resident 12's room, cleaned up the spill, and then applied the remaining betadine to Resident 12's scabbed areas on the left hand. No facility staff were observed in the resident's room or in the immediate area during the time periods that LPN 4 had left the betadine med cup unattended in the resident occupied room. 1. On 7/19/23 at 1:48 p.m., the clinical record for Resident 12 was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and dementia. Physician orders, included, but were not limited to, .apply betadine [a thin liquefied antiseptic non-sterile topical solution that works on a broad range of germs and used on minor wounds] to scabbed skin tears on left hand each shift .start date 7/19/23 with no end date noted . The Annual Minimum Data Set (MDS) assessment, dated 5/10/23, indicated Resident 12 was severely cognitively impaired and required set up assistance with ambulation. 2. On 7/21/23 at 9:57 a.m., the clinical record for Resident 39 was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and dysphagia (difficulty swallowing foods or liquids). Physician orders included, but were not limited to, regular diet with nectar thick/mildly thick liquids .start date 3/28/23 with no end date noted . The Significant Change Minimum Data Set (MDS) assessment, dated 6/9/23, indicated Resident 39 was severely cognitively impaired and required set up assistance with ambulation. On 7/21/23 at 11:00 a.m., a review of a betadine solution label indicated .keep out of reach . During an interview on 7/20/23 at 3:08 p.m., the Director of Nursing Services (DNS) indicated the betadine solution medication should not have been left unattended in the resident's room. The DNS indicated Resident 12 and Resident 39 were severely cognitively impaired and were able to ambulate independently. During an interview on 7/21/23 at 2:23 p.m., the Infection Preventionist (IP) indicated she was near the nurse's station on 7/20/23 around 10:35 a.m. LPN 4 was in the hall at that time and had requested the IP staff member to monitor Resident 12's hall to ensure no residents entered Resident 12's room. The IP staff member indicated she remained at the nurse's station area during that time and indicated LPN 4 should not have left the betadine solution unattended in Resident 12's room. During an interview on 7/24/23 at 9:25 a.m., LPN 4 indicated medications were not to be left unattended in a resident's room. On 7/21/23 at 9:10 a.m., the DNS provided a copy of the Medication Pass Procedure Section: Skills Validation policy, dated December 2016, and indicated it was the current policy in use by the facility. A review of the policy indicated, .7. Medications-not left at bedside . 3.1-45(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure paper towels were available for facility staff and residents for 11 of 24 rooms observed. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 7/20/23 at 10:35 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 2. On 7/20/23 at 10:36 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 3. On 7/20/23 at 10:37 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 4. On 7/20/23 at 10:38 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 5. On 7/20/23 at 10:39 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 6. On 7/20/23 at 10:45 a.m., room [ROOM NUMBER]'s bathroom was observed. The paper towel dispenser was not able to dispense paper towels. During an interview on 7/20/23 at 10:30 a.m., Licensed Practical Nurse (LPN) 1, indicated the paper towel dispenser in room [ROOM NUMBER] was out of paper towels. During an interview on 7/20/23 at 10:45 a.m., Housekeeper 3 indicated the available paper towels were too small for the automatic paper towel dispenser, and indicated most of the paper towel holders in the facility did not work. They have not worked for awhile, and indicated she reported the issue to her supervisor. During an interview on 7/20/23 at 11:00 a.m., Certified Nursing Assistant (CNA) 2 indicated the only working paper towel dispenser was located behind the nursing station. During an interview on 7/20/23 at 10:35 a.m., the Director of Nursing indicated all the resident bathrooms should have paper towels available for proper hand hygiene. During an interview on 7/20/23 at 12:55 p.m., the Administrator was unaware the paper towel dispensers were not dispensing paper towels properly. The batteries were dead in some of the dispensers, but the dispensers all had paper towels in them. During an interview on 7/21/23 at 9:00 a.m., Regional Corporate Support Director indicated the facility should always have paper towels available in all the residents rooms. On 7/20/23 at 12:55 p.m., the Administrator provided a policy titled Hand Hygiene, dated February, 2010, and indicated it was the current policy being used by the facility. A review of the policy indicated, 1. check that sink areas are supplied with soap and paper towels.8. Use clean paper towel; dry hands and wrists.10. Use paper towel to turn off faucet. 3.1-19(f)(5)