Based on observation, interview, and record review, the facility failed to ensure medications were stored safely or under proper temperature controls for 2 of 15 residents sampled for medications on the floor, and 2 of 2 medication storage rooms. (Resident D, Resident M, 100 Hall Medication Storage Room, 300/400 Hall Medication Storage Room) Findings include: 1. On 10/15/24 at 9:19 A.M., the 100 Hall Medication Storage Room medication refrigerator log was observed to be missing temperatures. The 100 Hall medication refrigerator log lacked a temperature on days from 10/1/24 through 10/15/24. The 100 Hall medication refrigerator log was missing a temperature for night shift on 10/1/24, 10/2/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/9/24, 10/10/24, 10/12/24, 10/13/24, and 10/14/24. At that time, QMA (Qualified Medication Aide) 11 indicated that temperatures were taken twice a day and logged for medication refrigerators. The 300-400 Hall medication refrigerator log was observed to be missing temperatures for day shift from 10/2/24 through 10/15/24. The log was observed to be missing a temperature for night shift on 10/10/24. A note on the temperature log indicated Medications must be kept 36-46 degrees F [Fahrenheit] in Refrigerator. The temperatures on night shift were recorded as the following: 10/1/24 30 10/2/24 32 10/3/24 28 10/4/24 20 10/5/24 30 10/6/24 33 10/7/24 32 10/8/24 32 10/9/24 30 10/11/24 32 10/12/24 34 10/13/24 34 During an interview on 10/17/24 at 2:35 P.M., the Administrator indicated the temperature in medication refrigerator should be in the range that was in the policy. Policy for Medication Storage indicated temperature range should be 36-46 degrees Fahrenheit. The Administrator indicated he would ask maintenance if there had been any work orders for the refrigerator. During an interview on 10/17/24 at 3:14 P.M., the Administrator indicated maintenance had not worked on the refrigerator, but he checked the temperatures and it was working correctly. 2. On 10/21/24 at 8:56 A.M., an oval peach colored pill was observed lying on the floor next to bottom of bed of Resident M. At that time LPN 15 indicated the pill was Namenda 5 mg which Resident M took twice a day. She verified the identity of the pill with the pill card in the medication cart. LPN 15 indicated she didn't know why the pill was on the floor or how long it had been there. She indicated she stayed with resident while he took his medication. On 10/21/24 at 10:06 A.M., Resident M's clinical records were reviewed. Diagnosis included, but was not limited to dysphagia, oropharyngeal phase, and dementia, unspecified severity. The most recent Significant Change in Condition MDS (Minimum Data Set) assessment, dated 10/3/24, indicated Resident M had moderate cognitive impairment and required extensive assistance of two for bed mobility, transfers and toilet use and supervision with set up for eating. Physician orders included, but was not limited to the following: memantine tablet (Namenda) (medication used to treat dementia) 5 mg; oral Twice A Day 07:00 AM - 11:00 AM, 07:00 PM - 11:00 PM, dated 9/20/2024. Review of the MAR (Medication Administration Report) for 10/20/24 and 10/21/24 indicated memantine had been given on 10/20/24 at 7:00 P.M. - 11:00 P.M. and on 10/21/24 from 7:00 A.M. - 11:00 A.M. Care Plan: Resident frequently spits his medication, pockets his medications in his mouth and spit his food out, Interdisciplinary Team (IDT) discussed crushing medications and resident declined Start date: 9/25/24 Approach Start Date: 9/25/24 Staff to encourage resident not to spit food/medications out or hold food in mouth. On 10/21/24 at 9:46 A.M., the Director of Nursing (DON) indicated Resident M would pocket medications and food sometimes, and an action plan had been started to make sure all residents were taking their medications when administered. At that time, she indicated no other residents had that concern. She indicated she had met with all staff administering medications on all shifts individually to go over the action plan. 3. On 10/21/24 at 9:11 A.M., Resident D's room was observed. A small pink round pill was observed on the floor under the bedside table with marking 1 on one side, and 30 on the other. At that time, Licensed Practical Nurse (LPN) 17 indicated it was a 10mg (milligram) rosuvastatin, which Resident D took once a day at around 4:00 P.M. On 10/21/24 at 10:02 A.M., Resident D's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus, anxiety, and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 8/18/24, indicated no cognitive impairment. Resident D required setup assistance with eating, and substantial to maximum assistance with showering, toileting, and transfers. Current physician orders included, but were not limited to: Crestor (rosuvastatin) 10mg once a day, at 5:00 P.M., dated 10/17/23. Resident D's Medication Administration Record (MAR) for October 2024 indicated the last time rosuvastatin was administered was at 5:00 P.M. the previous evening, 10/20/24. On 10/21/24 at 9:23 A.M., LPN 15 indicated when passing medications, staff should stay with the resident to make sure the pills were taken, and if one dropped, it should be put into the drug buster and a new pill administered. On 10/21/24 at 10:14 A.M., an action plan for medications on the floor was provided that was initiated 10/15/24. Actions to be taken from staff included, but were not limited to, asking resident to open mouth after taking medications to make sure they were swallowed, staff to offer additional water when taking medications to ensure they were swallowed, and guiding the resident's hand to mouth when taking medications. On 10/21/24 at 10:27 A.M., the DON provided a current General Dose Preparation and Medication Administration policy, dated 4/30/24, that indicated If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy . Observe the resident's consumption of the medication(s) On 10/17/24 at 1:30 P.M., a Medication Storage policy, dated August, 2022 was provided by the Administrator which indicated Temperature is maintained between 36-46 degrees Fahrenheit. Daily temperature logs must be maintained and visible. This citation relates to Complaint IN00445700. 3.1-25(m)

Based on interview, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 1 of 2 kitchen observations. Foods were not labeled correctly, food was stored uncovered, and the facility failed to dispose of outdated food. Findings include: On 10/15/24 at 9:13 A.M., the following was observed in the kitchen: Freezer in the kitchen: -- 5 undated, uncovered, and unlabeled bowls of pink ice cream -- 5 covered bowls undated and unlabeled. Refrigerator in the kitchen: -- clear container with cheese that had a label printed on 10/2/24 with a discard date of 10/8/24 -- applesauce with an opened date of 10/8/24 and a discard date of 10/14/24 -- clear container of lettuce undated and unlabeled -- 3 trays of fruit with several bowls uncovered on all 3 trays -- silver container with hotdogs and hamburgers undated and unlabeled -- silver container with an unknown substance that was undated and unlabeled Walk in freezer -- apple roasted pork prepared on 9/29/24 with a discard date of 10/1/24 During an interview on 10/17/24 at 11:30 A.M., the Dietary Manager indicated if there are multiple items of the same food, staff only placed a label on one time. All items should be covered and all staff is required to dispose of expired items, and she does a morning walk through to discard of expired items. On 10/17/24 at 1:34 P.M., the Administrator provided a current Food Storage policy, reviewed 5/24, that indicated, .Leftover prepared foods .are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded .Frozen Foods .should be covered or wrapped tightly, labeled, and dated with the date the item is being placed in the freezer . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure resident safety during transportation for 1 of 3 residents reviewed for accidents. A resident was improperly loaded onto a transportation vehicle lift causing the resident to fall backwards from a wheelchair onto the lift platform. (Activity Assistant 3, Resident B) Finding includes: During a review of facility reported incidents on 6/19/24 at 10:35 A.M., an incident that occurred on 6/3/24 at 2:45 P.M., indicated that Resident B was being transferred out of the facility transportation van and fell off the lift. Resident B was sent to the emergency room and received eight sutures to the right shin. During an observation and interview on 6/19/24 at 11:00 A.M., Resident B was sitting in her wheelchair in the dining room. Resident B indicated that she had fallen off of the facility transportation vehicle when the vehicle lift was not out properly. Resident B indicated she needed 8 stitches to her right leg and thinks she landed on a metal part of the lift which cut her leg. Resident B indicated the driver of the transportation vehicle had assisted her with the lift before and had always been able to do it by herself, calling the incident a freak accident. During record review on 6/19/24 at 11:15 A.M., Resident B's diagnoses included, but were not limited to, morbid obesity, muscle weakness, and unsteadiness on feet. Resident B's most recent annual MDS (Minimum Data Set) assessment, dated 5/23/24, indicated that the resident had no cognitive impairment, used a wheelchair for mobilization, and required partial to moderate assistance in the wheelchair. Resident B's nurse's progress notes included, but were not limited to the following: - On 6/3/24 at 7:20 P.M., Resident B returned to the facility post fall while at appointment. Resident was sent to emergency room from appointment due to the fall. Resident complained of pain to right lower extremity which was noted to have a laceration. Eight sutures were applied to the laceration. - On 6/4/24 at 5:02 P.M., IDT (Inter-disciplinary team) review, Resident B was on the facility bus being transferred onto the lift to be taken off the bus. Resident had fallen off the lift and sustained a laceration to the right lower extremity. Interventions put into place to address the root cause of fall included; ensure resident is secure on lift and ensure resident wheelchair brakes are locked and staff education on use of lift and securement of items. Bus was inspected with no mechanical issues found. During a review of the facility's investigation into the incident on 6/19/24 at 11:30 A.M., a signed written statement by Activity Assistant 3, dated 6/5/24, included, on 6/3/24, Activity Assistant 3 and Resident B arrived at at appointment at 2:10 P.M. on facility bus. Activity Assistant 3 parked bus, engaged, emergency break, proceeded to the back door, and lowered the mechanical lift. Activity Assistant 3 rode the lift up and unbuckled Resident B and took the restraints off, then moved from the back of the bus to the front of the bus from inside the bus, removed the restraints and started backing resident out of bus onto the lift. Activity Assistant 3 noticed the mechanical lift was no longer all the way up. Activity Assistant 3 tried to pull Resident B back inside the bus but was not strong enough to pull her back in or hold her in place. Resident B, while in wheelchair, went off backwards. Activity Assistant 3 got off the bus and spoke to Resident B who was alert and oriented, then ran inside for help. Nurses came out and assessed Resident B and Emergency Medical Services were called. Resident B was loaded into ambulance and taken to hospital for evaluation. On 6/19/24 at 11:35 A.M., the DON (Director of Nursing) supplied a facility policy titled, Transportation, and dated 11/2015. The policy included, .Requirements for resident transportation: 1. The driver must complete and document pre-trip inspections of the bus/van prior to resident transport . During an interview and observation on 6/19/24 at 1:40 P.M., Activity Assistant 3 indicated that they completed a pre-trip inspection but did not document the inspection and do not use a check off sheet or inspection form to complete. Activity Assistant 3 then demonstrated what had happened on 6/3/24 while attempting to unload Resident B from the facility van/bus. Activity Assistant 3 indicated the lift was raised to allow her to get up in the back of the bus, however, when Resident B was being pushed backward onto the lift the lift had lowered due to an unknown reason to approximately six inches above the ground. This caused the metal plate that spanned the gap between the back of the van to the lift to rotate vertically, leaving a gap between the plate and the van. Activity Assistant 3 indicated Resident B's wheelchair went back into the gap and then flipped backwards allowing Resident B to fall an additional one foot onto the metal lift platform where she received a laceration to her right shin. Activity Assistant 3 indicated not knowing how the lift lowered after she had rode the lift up to the back of the van and indicated that the control may have been inadvertently pressed while getting around Resident B to detach the safety straps. During an interview on 6/19/24 at 1:55 P.M., the Maintenance Director indicated that the van and lift were inspected following the incident on 6/3/24 and that no mechanical issues were found and indicated that Resident B's fall was due to Resident B being improperly loaded onto the lift. On 6/20/24 at 11:21 A.M., Regional Nurse 5 supplied a facility policy titled Fall Management Policy, dated 3/2024. The policy included, It is the policy of [Facility] to ensure residents residing within the community have adequate assistance to prevent injury related falls. This citation relates to Complaints IN00436159 and IN00436199. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for ADL (activities of daily living) care provided. A resident was not assisted by two staff members during a transfer during incontinence care per the resident's plan of care. (Resident D, Resident C) Finding includes: During an interview on 2/6/24 at 10:35 A.M., Resident D indicated that they had reported CNA 9 for punching her in the stomach while providing care. Resident D indicated that CNA 9 transferred her from her wheelchair to her bed using a Hoyer mechanical lift prior to providing incontinence care. Resident D indicated that CNA 9 slipped and accidentally hit her stomach while providing care. During record review on 2/6/24 at 11:30 A.M., Resident D's diagnoses included, but were not limited to unspecified multiple injuries, person injured in unspecified motor vehicle accident, chronic pain, displaced commuted fracture of right patella, fracture of sternum, fracture of unspecified forearm, and fracture of right lower leg. Resident D's most recent admission MDS (Minimum Data Set) dated 12/23/23, indicated the resident's cognition was moderately impaired, had upper extremity impairments to both sides, had lower extremity impairments to 1 side, required substantial to maximum assistance to roll left and right, and was dependent with form bed to chair. Resident D's physician orders included, but were not limited to; activity level: up as needed with two person assist (started 12/17/23). Resident D's care plan included, but was not limited to; Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: impaired mobility, recent motor vehicle accident, with multiple fractures, pain. An intervention included, two assist with transfers (started 12/18/23). During a review of facility reported incidents on 2/6/24 at 11:00 A.M., a facility reported incident dated 1/30/24 included that Resident D told Resident C that CNA 9 hit her in the stomach. During a review of the facility's investigation into the allegation involving an incident between Resident D and CNA 9, a typed statement signed by Resident C and dated 1/30/24, included, [CNA 9] was observed by [Resident C] using the Hoyer on room mate [Resident D] alone . A written interview between the facility administrator and DON (director of Nursing) and CNA 9, signed and dated 1/30/24, included, .[CNA 9] stated he used the Hoyer to transfer [Resident D] form (wheelchair) to bed. He stated she was wet (and) he changed her in bed During an interview on 2/6/24 at 1:45 P.M. LPN 8 indicated she was Resident D's nurse the date of 1/30/24 when an allegation of abuse was made against CNA 9. LPN 8 indicated she was unaware of any other staff members being in Resident D's room while CNA 9 provided care and was accused of hitting Resident D. During an interview on 2/6/24 at 1:50 P.M., CNA 3 indicated that if a resident is care planned for assistance of 2, staff should find a second staff member to assist during care. CNA 3 indicated that there should always be 2 staff members present when transferring a resident with a Hoyer mechanical lift. On 2/6/24 at 2:25 P.M., the DON supplied a skills validation sheet titled, Mechanical Lift, dated 3/2012. The validation sheet included, Two (2) staff is required at all times when using a mechanical lift. This citation relates to complaint IN00427390. 3.1-35(g)(2)

Based on observation and interview, the facility failed to ensure the resident's right of dignity was promoted and protected for 2 of 3 residents reviewed for dignity. A visibly soiled resident was not stopped by staff on his way to the dining room and a resident receiving incontinence care was told the staff was going to change his diaper. (Resident 35, Resident 40) Findings include: 1. On 8/7/23 at 3:09 P.M., Resident 35 was laying in bed with a urinary catheter hanging on the right side of his bed. On 8/9/23 at 1:30 P.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, prostate cancer, stroke, and hemiplegia on left side. The most recent admission MDS (Minimum Data Set) Assessment, dated 7/7/23, indicated the resident was moderately cognitively impaired, an extensive assist of 2 staff for bed mobility and toileting, and had a urinary catheter but was incontinent of bowel movements. On 8/10/23 at 2:55 P.M., incontinence care given by CNA (Certified Nurse Aide) 14 and CNA 28 was observed on Resident 35. During that care, CNA 14 unfastened both sides of the incontinence pad and told the resident We are going to change your diaper. During an interview on 8/14/23 at 11:12 A.M., CNA 3 indicated they are not supposed to use the word diaper to describe a resident's incontinence pad. When she is going to provide incontinence care, she will introduce herself, ask the resident if it is ok to change them, and will call the incontinence pad a brief if she needs to. At that time, she indicated it was not right to say change your diaper to an adult. 2. On 8/10/23 at 11:55 A.M., LPN (Licensed Practical Nurse) 10 was observed performing a glucose check for Resident 40. LPN 10 left the door open while performing the check, and the resident was in full view of the roommate on the other side of the room. At that time, Resident 40 was observed with a darkened wet spot in his groin area, the inside of his thighs, and the bottom of his shirt. When completed, LPN 10 indicated to Resident 40 he could go on down the hall to the dining room for lunch. Resident 40 left the room at the end of the hall and propelled himself down the length of the hall and into the dining room passing six staff members, before RN (Registered Nurse) 6 indicated to the resident she needed to escort him back to his room to get cleaned up. On 8/11/23 at 2:32 P.M., Resident 40's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus. The most recent annual MDS Assessment, dated 6/26/23, indicated no cognitive impairment. Resident 40 required extensive assistance of two staff with toileting, extensive assistance of one staff with dressing, and was frequently incontinent of urine. On 8/11/23 at 2:35 P.M., RN 6 indicated Resident 40 would not have been able to tell staff that he was wet, and all staff would be expected to assist a resident to clean up if a wet spot was observed on them. On 8/14/23 at 1:00 P.M., a current Resident Rights policy, dated 7/2023, indicated 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 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure residents that were self-administering medications were assessed for capability to self administer medications for 1 of 2 residents reviewed for accidents and 1 of 5 residents reviewed for medication administration. Resident clinical records lacked a self administration of medication assessment. (Resident 6, Resident 65) Findings include: 1. On 8/11/23 at 8:29 A.M., Resident 6 was observed sitting in his room in his wheelchair. At that time, there was a medicine cup sitting on his bedside table with 1 white, circular pill in it. On 8/10/23 at 9:03 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and diabetes mellitus type II. The most current significant change MDS (Minimum Data Set) Assessment, dated 7/17/23, indicated resident was severely cognitively impaired and was an extensive assist of 2 staff members for bed mobility, transferring, and toileting. Resident 6's clinical record lacked a physician's order for self administering medication. Resident 6's clinical record lacked a self administration of medications care plan. Resident 6's clinical record lacked a self administration of medication assessment. During an interview on 8/11/23 at 8:35 A.M., RN (Registered Nurse) 6 indicated the medication should not be left with the resident to take on his own. At that time, she indicated the resident did not self administer medication. She looked at the resident's medications in the medication cart and spoke with the QMA (Qualified Medication Aide) 33 that passed the pills to the resident that morning and they agreed it was the resident's metformin. 2. On 8/10/23 at 7:11 A.M., QMA 9 was observed to take Resident 65 a medication cup with her morning medications. QMA 9 entered the room, greeted the resident, then sat the medication cup on the bedside table in front of the resident. QMA 9 left the room without observing the resident take the medications. On 8/11/23 at 1:51 P.M., Resident 65's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus and anxiety. The most recent admission MDS Assessment, dated 7/26/23, indicated Resident 65 was cognitively intact and required extensive assistance of two staff with bed mobility, transfers, and toileting, supervision of one staff with eating, and was totally dependent of two staff with bathing. Resident 65's clinical record lacked a self administration of medications order. Resident 65's clinical record lacked a self administration of medications care plan. Resident 65's clinical record lacked a self administration of medications assessment. On 8/11/23 at 1:45 P.M., LPN 10 indicated Resident 65 did not have a self administration of medications assessment, and staff was supposed to wait for all residents to take their medications prior to leaving their room. On 8/14/23 at 1:00 P.M., a current Self Administration of Medications policy, dated 1/2015, was provided and indicated If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation . A physician order will be obtained specifying the resident's ability to self-administer medications . The resident's care plan will be updated to include self administration 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure assessments were conducted and completed following an emergency room visit where all insulin medications were discontinued for a diabetic resident for 1 of 3 residents reviewed for change of condition. (Resident 31) Findings include: On 8/7/23 at 2:25 P.M., Resident 31 was observed sitting in a wheelchair in the dining room. At that time, he was observed sweating, with a yellow substance in the outer corner of the left eye, and a built up white substance on his teeth at the gum line. On 8/9/23 at 9:57 A.M., Resident 31's clinical record was reviewed. Diagnosis included, but were not limited to, heart failure and diabetes. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/23, indicated no cognitive impairment, no behaviors, required extensive assistance of two staff with bed mobility and toileting, supervision of one staff with eating, and was totally dependent of two staff with transferring and bathing. Resident 31 did not receive insulin in the 7-day look back period. Physician Orders included, but were not limited to: Diet: Regular Special Instructions: cups with handles. Double protein with all meals per resident request, from 6/10/21 through 6/21/23. Diet: Regular Special Instructions: cups with handles with meals & Double protein with all meals per resident request, ordered 6/21/23 through current. Accu check as needed for signs and symptoms of hypo/hyperglycemia, dated 2/9/23 through current. Physician Orders prior to admission to a hospitalization on 2/7/23 included, but were not limited to: insulin lispro solution; 100 unit/mL (milliliter); 30 units; subcutaneous, give with meals three times a day, ordered 12/29/22 through 2/8/23. Levemir U-100 Insulin (insulin detemir u-100) solution; 100 unit/mL; 94 units; subcutaneous, twice a day, ordered 12/29/23 through 2/8/23. BMP; CBC w/diff; on the 11th of March and September, ordered 12/29/22. HgbA1c; on the 11th of March and September, ordered 12/29/23. A current diabetes care plan, dated 12/12/19, indicated observe resident for symptoms of hyperglycemia and hypoglycemia, monitor blood sugars as ordered, labs as ordered, and diet as ordered. A current refusal of medications and insulin care plan, dated 1/7/21, indicated to provide resident and representative with education regarding risk/benefits, review choice and options with attending physician, and revisit options as needed. Progress Notes included, but were not limited to, the following: 2/07/2023 at 12:24 P.M. Family thinks resident is over medicated and would like a med review completed and concerned about him not eating or drinking much. Explained to family that NP [Nurse Practitioner] would be in to see him today . 2/7/23 at 12:28 P.M. NP here to see resident. Coordinated with [psych services] and several medications D/C [discontinued] with labs ordered for tomorrow . Resident 31's insulin was not discontinued at that time. 2/7/23 at 2:50 P.M. EMS [Emergency Medical Services] called and report called to ER [Emergency Room] . Resident alert, but O2 sats [oxygen saturation] 86-88% 2/9/23 at 2:00 P.M. indicated Resident 31 returned from the hospital and an admission assessment was completed. admission assessment requested and not provided. 2/10/23 at 12:22 A.M. indicated Nurse helped res. to reposition in bed, and res. wanted to be re-adjusted more. Nurse stated she had to get another staff member to help. Nurse left to do a tx [treatment] in another room, and ten minutes later res. was screaming help me. Staff entered room and res. was having a panic attack. Res. kept trying to swing legs over side of bed. Res. stated he was having a panic attack because they took him off all his medication . At that time, a blood sugar was not checked. 2/11/23 at 1:41 P.M. indicated resident was sitting in a wheelchair by the nurses station rocking back and forth with heavy breathing noted. Resident indicated he as having a panic attack. An as needed anti-anxiety medication was administered. At that time, a blood sugar was not checked. 2/13/23 at 11:56 A.M. indicated Called and spoke with sister regarding med changes. She expressed her concerns with over medicating resident. Explained to her that meds had been d/c and that the hospital had started them back up. Informed her that [NP] was calling in today to review meds and that we would let her know the changes Hospital progress notes included, but were not limited to, the following: 2/8/23 . Suspect AKI [acute kidney injury] secondary to post renal obstruction from urinary retention given patient's polypharmacy [use of multiple medications]. Urine output is adequate. Renal [kidney] function is improving. All medications have been held . Blood sugars reasonable on carb [carbohydrate] controlled diet without any supplemental insulin at this time. Patient on very high levels of insulin as an outpatient. Suspect this is secondary to his diet 2/9/23 . Nearly all the patient's medications were held during this hospitalization and was [sic] AKI resolved with which [sic] evacuation of his bladder and IV [intravenous] fluid . Patient is a diabetic with a recent A1c [blood test to measure average blood sugar levels over the past 3 months] of 7.7% [normal: below 5.7%]. While on a carb consistent diet at the hospital his blood sugars were never elevated greater than 185 [normal: between 70 and 100]. Home regimen of insulin was significant with 94 units of Levemir and 30 units of Humalog at meals. Discussed with patient that he does not need large amounts of insulin if he is able to control his diet. Would recommend dietary modification and initiation of metformin [an anti-diabetic medication] with goal to titrate up and start either SGOT 2 inhibitor [a class of anti-diabetic medication] or GLP agonist [a class of anti-diabetic medication] if able in the future. Additionally his blood sugars are better controlled and does not require significant dosages of insulin is highly likely that his blood pressure will improve. It was reasonably controlled without any medications during this [2 day] hospitalization . Patient was held on a consistent carb diet and did not require any insulin . Patient strongly encouraged to continue with constant carb diet. Metformin will also be added and his insulin will be stopped. The note indicated an adult diet consistent carbs was effective 2/7/23. 2/10/23 at 9:51 P.M. Patient was brought by ambulance from the nursing home for evaluation of back pain and left leg pain. Patient has had longstanding issues with radiculopathy. He was recently taken off/reduced on his medications for treatment of the radiculopathy. He was felt to be overmedicated. Patient has been having increasing pain since. The nursing home states he could control his pain and sent him here [sic]. He complains of pain radiating down the anterior aspect of his left leg. He has had several back surgeries. There has been no recent history of injury falls or trauma . The patient was recently hospitalized here and discharged back to nursing home yesterday. The hospitalist service had discontinued multiple medications as the patient was felt to be overmedicated . A nutrition review note, dated 2/20/23, written by the registered dietician, indicated .Resident remains at nutrition risk r/t . COPD, diabetes, heart failure, heart disease, major depressive disorder, vitamin D deficiency, vitamin B12 deficiency anemia, dysphagia and muscle weakness. On metformin for blood glucose management (potential for weight change), and receives supplemental vitamin D3 . Resident continues on a regular diet with double protein with meals per resident request. Currently with fair-good oral intakes, 41% breakfast, 71% lunch and 100% dinner. He is able to self-feed with set up assistance, utilizes adaptive equipment of cup with handles to promote independence as well . Resident 31's clinical record lacked information related to the CCHO ordered from the hospital being added when the resident returned from the hospital, or refusal from the resident at that time. An evaluation, dated 2/16/23 at 6:19 P.M., indicated resident was refusing meds related to not being able to swallow pills, and continued to be upset with staff with behaviors. Multiple medications discontinued as per most recent ER orders and family request. Insulins were discontinued as per ER orders, accuchecks three times a day and trends reviewed, will continue to monitor for hyper/hypoglycemic episodes, and CCHO diet recommended. Most recent HgbA1c (hemoglobin A1c) was 8.30% on 9/13/22 with a routine HgbA1c ordered. Resident 31's labs for the last 12 months indicated, but were not limited to, the following abnormal values: 9/13/22 HgbA1c 8.30% (reference range: 4.00 - 6.00 %) 9/13/22 blood glucose 152 (reference range: 74 - 106) 2/7/23 blood glucose 177 (reference range: 74 - 106) 2/9/23 HgbA1c 7.70% (reference range: 4.00 - 6.00 %) 2/10/23 Urine ketones trace (reference range: negative) 2/10/23 blood glucose 163 (reference range: 74 - 106) 3/11/23 blood glucose 177 (reference range: 74 - 106) 5/9/23 blood glucose 224 (reference range: 74 - 106) 6/20/23 urine glucose >=1000 (reference range: negative) A Progress Note dated 6/20/23 at 9:06 A.M. indicated (Doctor) here and reviewed urine results, normal, no new orders. No reference was made related to urine glucose >=1000. Resident 31's Medication Administration Record (MAR) for January 2023 indicated Resident 31 had an order for an accu check four times a day from 12/29/22 through 2/8/23. Resident 31's blood sugars ranged from 94 to 388, with an average of 173.7. One accu check was missed. Resident 31's MAR for February 2023 (until discontinued on 2/8/23) indicated blood sugars ranged from 106 to 208, with an average of 136.6. One accu check was missed. Resident 31's MAR for February 2023 through August 2023 indicated an accu check was not done until requested on 8/9/23, which was 497 at 1:49 P.M. Follow up accu checks were as follows: 8/9/23 5:05 P.M. 378 8/9/23 7:19 P.M. 394 8/10/23 4:21 A.M. 380 A copy of the MAR that included insulin administration from January 2023 through August 2023 was requested and not provided. Resident 31's clinical record lacked an Interdisciplinary Team (IDT) meeting note upon return from the hospital on 2/9/23 or on 2/10/23 related to the abrupt discontinuance of insulin. The clinical record lacked an assessment or review of medications upon returning from the hospital on 2/9/23 or 2/10/23. Resident 31's clinical record lacked an assessment related to the result or potential outcome of the abrupt discontinuance of insulin from the hospitalization on 2/7/23 through current. On 8/9/23 at 1:35 P.M., Resident 31 indicated he was unaware of signs and symptoms to watch out for with a high blood sugar (hyperglycemia). He indicated staff had not educated him on what to watch out for or to tell staff if he were to experience them. He indicated at that time he was not feeling well, but could not explain why. Only that he had not felt normal for several weeks. On 8/9/23 at 1:42 P.M., a blood sugar was requested for Resident 31. Licensed Practical Nurse (LPN) 10 completed the test and Resident 31's blood sugar was 497. At that time, LPN 10 indicated some things to watch out for with hyperglycemia might include fatigue or confusion. At that time, LPN 10 reported the blood sugar reading to LPN 7, who was Resident 31's nurse. On 8/9/23 at 2:22 P.M., LPN 10 indicated she notified the doctor of Resident 31's blood sugar reading, and that he was coming in the following day to probably order labs. On 8/9/23 at 2:06 P.M., LPN 10 and LPN 6 indicated on 2/7/23, Resident 31 went to the ER for low O2 sats. He had been refusing medications and meals for a few days prior to the ER visit. Resident 31's power of attorney (POA) had been notified about his condition and indicated they though he was being overmedicated and wanted his medications reviewed. The facility coordinated with the NP and psych services and sent him out. He came back on 2/9/23. On 2/10/23, Resident 31 was having behaviors, so was sent to the ER again to rule out a medical condition related to complaints of pain. At that time, LPN 10 indicated Resident 31's diet never changes and that he was on a regular diet with double protein per resident request that would only change if he came back from the hospital with a new diet order. LPN 10 indicated the Medical Director took over for the facility in May, 2023 and would need to come in to review Resident 31's recent labs to determine if new labs needed to be done related to his diabetes. She indicated prior to the hospitalization on 2/7/23, Resident 31's blood sugars were up and down. She also indicated Resident 31's insulin use had not been assessed since his hospitalization on 2/7/23 because the doctor at the hospital discontinued the insulin, and staff at the facility did not question the doctor's orders. She indicated when a doctor gives an order, staff should follow that order. At that time, RN 6 indicated at times, such as when Resident 31 ordered food from outside, staff may want to check his blood sugars, but because of his refusals in the past, that was not being done. On 8/9/23, the following order was made for Resident 31: metformin 500mg once a day (same order was already in place from 2/9/23). On 8/10/23, the following orders were placed for Resident 31: HgbA1c; PSA; Other Test: (EP2) on the 2nd Tuesday of April. CBC w/diff; Chem 20; HgbA1c; on the 4th Tuesday of October. CBC w/diff; Chem 14; HgbA1c; on the 4th Tuesday of January and July. FreeStyle Libre 14 Day Sensor (flash glucose sensor), once a day on Friday, every 2 weeks, to start 8/14/23. On 8/14/23 at 11:12 A.M., Certified Nurse Aide (CNA) 3 indicated symptoms that needed to be reported to the nurse related to hypoglycemia included paleness. At that time, she was not sure of any symptoms related to hyperglycemia. Notes related to education given to Resident 31 related to his diet, or information related to importance of insulin when needed were requested and not provided. On 8/14/23 at 1:00 P.M., a current Nursing Admission/Return admission Policy, dated 6/2023, was provided and indicated It is the policy of [company name] to provide baseline and accurate documentation of the mental and physical condition of each resident admitted or readmitted to the facility . admission Medication Regimen Review completed upon admission or as close to admission as possible per policy . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medications were administered free of error for 1 of 5 residents reviewed for medication administration. A resident was administered the wrong dose of (2) medications, resulting in an error rate of 8%. (Resident 65) Findings include: On 8/10/23 at 7:11 A.M., Qualified Nurse Aide (QMA) 9 was observed to administer medications to Resident 65 that included, but were not limited to, the following: Auryxia (an iron supplement medication) 210mg (milligram) tablet (one tablet) hydralazine (a blood pressure medication) 100mg tablet (one tablet) Breakfast was not provided at the time of the medication administration. On 8/11/23 at 1:51 P.M., Resident 65's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes and anxiety. The most recent admission MDS (minimal data set) Assessment, dated 7/26/23, indicated no cognitive impairment. Resident 65 required extensive assistance of two staff with bed mobility, transfers, and toileting. Current physician orders included, but were not limited to, the following: Auryxia (ferric citrate) 210mg tablet, give 420mg with meals three times a day, dated 7/27/23. hydralazine 50mg tablet, give 50mg three times a day, dated 7/28/23. On 8/11/23 at 1:43 P.M., the medication cart that held Resident 65's medications was observed with QMA 33. At that time, a discontinued medication card for hydralazine 100mg was turned around backward in the back of the cart, with a discontinued date of 7/28/23. A current medication card for hydralazine 50mg was observed with Resident 65's other medication cards, facing the front of the cart. At that time, QMA 33 indicated Resident 65's Auryxia was supplied in 210mg tablets, and staff was supposed to administer two tablets for a total of 420mg. On 8/14/23 at 1:00 P.M., a current Medication Pass Procedure, reviewed 6/2016, was provided, and indicated Medications checked 3 times to verify order with label . 3.1-48(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop resident specific care plans and implement interventions for 4 of 4 residents reviewed for care plans. A resident's care plan indicated to encourage fluids when the resident was NPO (nothing by mouth). Two residents had orders that did not match care plans for dental services. A resident with falls did not have interventions in place. (Resident 6, Resident 49, Resident 51, Resident 62) Findings include: 1. On 8/8/23 at 10:05 A.M., Resident 62 was observed lying in bed with the head of her bed elevated 30 degrees, on her right side,eyes closed, moving her right arm around. Her tube feeding was infusing at 45 ml/hr (milliters/hour) per pump. An oxygen mask, dated 8/8/23, was over the tracheostomy. High flow humidified oxygen was on at 6 L/min (Liters per minute). Foley catheter was hanging on the right side of the bed covered with a bag and draining yellow urine with sediment. Suction machine was sitting on the bedside cabinet. Call light was within reach. On 8/11/23 at 8:51 A.M., Resident 62 was observed lying in bed with eyes closed. The head of the bed was elevated 30 degrees. The resident was coughing. Tube feeding was infusing at 45 ml/hr per pump. The humidified, high flow O2 (oxygen) was on at 6 L/min per tracheostomy mask. Foley catheter was hanging on the right side of the bed, draining yellow urine, and covered with a bag. On 8/9/23 at 1:19 P.M., Resident 62's clinical records were reviewed. She was admitted on [DATE]. Her diagnosis included, but were not limited to, generalized epilepsy and epileptic syndromes, intractable, with status epilepticus, pneumonitis due to inhalation of food and vomit, urinary tract infection, acute and chronic respiratory failure with hypoxia, persistent vegetative state, and cognitive communication deficit. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 7/26/23, indicated Resident 62 had severe cognitive impairment and was totally dependent on 2 assistants for bed mobility, transfers, toilet use and bathing and 1 assistant for eating. She required O2, tracheostomy, suctioning, catheter, and tube feeding. The Physician's Orders included, but were not limited to, the following: NPO, dated 5/19/23 Enteral feeding: Continuous feeding formula Jevity 1.5 at 45 ml/hr, dated 8/7/23 Trach (tracheostomy) orders: Routine trach care including oral care. Per standard of practice with sterile water and normal saline, dated 8/7/23 Cath (catheter) care: Foley catheter care, catheter securement device in place, nurse to record output every shift, dated 8/4/23 A care plan for Impaired Respiratory Function: Pneumonia, dated 8/7/23, included interventions to encourage fluids and food intake and encourage activity as tolerated, dated 8/7/23. A care plan for Urinary Tract Infection (UTI), dated 8/4/23 included an intervention to encourage fluids, dated 8/4/23. A care plan for an indwelling urinary catheter related to chronic vegetative state, dated 5/23/23 included an intervention to encourage fluids, dated 5/23/23. A care plan for skin breakdown due to: impaired mobility, epilepsy, morbid obesity, chronic respiratory failure with hypoxia, asthma, rectal abscess, sensory perception is very limited, skin is constantly moist, bedfast, mobility is completely immobile, probably inadequate nutrition, problem with friction and shear, dated 5/19/23, included an intervention to encourage resident to eat at least 75 % of meals, dated, 5/19/23. A care plan of Resident is NPO d/t (due to) continuous G-tube feedings, dated 5/19/23, included an intervention to assist resident with oral care, dated 5/19/23. During an interview on 8/14/23 at 12:17 P.M., the MDS Coordinator indicated care plans were resident specific. If a resident was NPO, the care plan should not list encourage fluids as an intervention. She indicated she picked general care plans and didn't remove encourage fluids from the interventions listed. 2. On 8/7/23 at 12:04 P.M., Resident 6 was observed sitting in his room in his wheelchair. A fall mat was laying on the side of his bed. On 8/7/23 at 12:16 P.M., Resident 6 was observed in the main dining room sitting in his wheelchair wearing regular socks on both feet. On 8/7/23 2:21 P.M., Resident 6 was observed sitting by the nurses station in the common area in his wheelchair, watching TV, and wearing regular socks on both feet. On 8/10/23 at 1:25 P.M., Resident 6 was observed sitting in his room in his wheelchair and his urinal was hanging on the trash can. On 8/11/23 at 8:29 A.M., Resident 6 was sitting in his room in his wheelchair and his urinal was not within sight. On 8/10/23 at 9:03 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and diabetes mellitus type II. The most current significant change MDS Assessment, dated 7/17/23, indicated resident was severely cognitively impaired and was an extensive assist of 2 staff members for bed mobility, transferring, and toileting. Current Physician's Orders included, but were not limited to, the following: Up ad lib (at pleasure) in WC (wheelchair) with anti rollback with assist of 2 for transfers, dated 5/4/23 and discontinued 8/8/23 Up ad lib in WC with anti rollback with assist of 2 with hoyer lift for transfers, dated 8/8/23 Mat on floor to open side of bed, dated 7/20/23 and discontinued 8/9/23 A current falls care plan, dated 8/30/22, included, but was not limited to, the following interventions: Keep urinal at bedside at eye level, initiated 2/6/23 Keep pathways free of clutter, initiated 8/30/22 Non-skid footwear, dated 8/30/22 On 8/14/23 at 12:30 P.M., a current CNA (Certified Nurse Aide) assignment sheet was provided by the MDS Coordinator and included, but was not limited to, the following interventions: Keep pathways free of clutter Keep urinal at bedside at eye level Non-skid footwear During an interview on 8/11/23 at 8:35 A.M., RN (Registered Nurse) 6 observed the resident's urinal was not in sight at that time. After searching the room and questioning the resident, she indicated they would get him another one. During an interview on 8/11/23 at 2:04 P.M., LPN (Licensed Practical Nurse) 10 indicated staff dressed Resident 6 and he should wear non-skid socks and to her knowledge there was not a reason he shouldn't wear them. His urinal should be kept at eye level, usually on bedside table not the trash can. Staff could have put it on the trash can, but he could use it and move it too. At that time, she indicated care plan interventions should be followed. During an interview on 8/14/23 at 12:17 P.M., the MDS Coordinator indicated new interventions should be added to the care plan right away and if they were CNA task related, they would add them to their CNA sheets. Staff were expected to follow interventions for each resident. 3. On 8/9/23 at 9:28 A.M., Resident 49's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus and anxiety. The most recent Significant Change MDS Assessment, dated 7/5/23, indicated Resident 49 had a mild cognitive impairment, had refused care 1-3 days of the previous 7-day assessment period, and had no change in behavior from the previous assessment. Current Physician Orders included, but were not limited to: May be seen by Podiatrist, Dentist, Optometrist, and Audiologist, dated 6/29/23. Discontinued Physician Orders included, but were not limited to: May be seen by Podiatrist, Dentist, Optometrist, Audiologist from 4/15/22 through 5/10/23. May be seen by Podiatrist, Dentist, Optometrist, Audiologist, from 5/16/23 through 6/27/23. A current care plan, dated 4/27/22 and last revised 7/17/23, indicated Resident has declined ancillary services including dental, audiology, podiatry, and optometry. Potential for declines in condition related to lack of dental, audiology, optometry and podiatry care A social services note, dated 2/16/22, indicated . Declined ancillary during stay. States he has an Audiology appt 2/16/22. Res cancelled [sic] appt today and rescheduled for 2/18/22 . admission paperwork, dated 4/15/22, indicated Resident 49 requested to be seen for audiology, eye care, and podiatry. Nothing was documented related to dentistry. 4. On 8/8/23 at 10:09 A.M., Resident 51 was observed lying in bed. She had missing and broken teeth. At that time, Resident 51 was confused, and not interviewable. On 8/9/23 at 10:04 A.M., Resident 51's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and depression. The most recent Quarterly MDS Assessment, dated 6/20/23, indicated no cognitive impairment, and no dental concerns. Current physician orders included, but were not limited to: May be seen by Podiatrist, Dentist, Optometrist, Audiologist, dated 7/1/22. A current care plan, dated 8/29/21 and last revised 7/3/23, indicated Resident has declined ancillary services including dental. Potential for declines in condition related to lack of dental care A progress note, dated 10/7/22 at 9:29 A.M., indicated Resident 51 was seen by dental on 10/4/22. A progress note, dated 6/28/23 at 9:18 A.M. indicated Resident 51 was seen by the facility's dentist. An annual assessment/Social Service progress note, dated 3/28/23, indicated . Ancillary support services in place: Psychiatric, Dental . On 8/10/23 at 1:34 P.M., the Social Services Director (SSD) indicated Resident 51 was admitted with a note that dental services were declined. In 10/2021, a consent was signed for all ancillary services except dental. She indicated nothing could be found about a dentist who was a different provider, and she had seen the care plan where dental had been declined. She indicated that care plan was not correct and should have been updated. On 8/11/23 at 2:19 P.M., LPN 10 and RN 6 indicated upon admission every resident was assessed to implement resident-centered care plan, and revisions were completed as needed. If an intervention no longer applied, that intervention would have been removed or revised. LPN 10 indicated care plans were pre-populated within the computer system, but should always be revised to be resident-centered. At that time, LPN 10 indicated there was not a specific policy related resident-centered care plans. On 8/14/23 at 1:00 P.M., a current Comprehensive Care Plan Policy, revised 10/2019, indicated It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial needs .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition . 3.1-35(a) 3.1-35(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment in 3 of 4 resident restrooms on 2 of 3 halls and 1 of 1 shower rooms checked for water temperatures. Resident restrooms and the shower room water temperature reached 126 degrees Fahrenheit (F) . (Resident 23, Resident 35, Resident 48, Resident 7, Resident 5, Resident 3, Room and the 300/400 Shower room) Findings include: 1. During an interview on 8/24/21 at 11:15 A.M. Resident 23 indicated they use the restroom connected to their room, as did Resident 7 in the conjoining room. During an observation on 8/24/21 at 11:20 A.M., Resident 23 and Resident 7's restroom sink water temperature was at 126 degrees F. During an observation on 8/24/21 at 1:50 P.M., the Maintenance Supervisor recorded at water temperature of Resident 23 and Resident 7's restroom sink at 126 degrees F. During record review on 8/30/21 at 10:45 A.M., Resident 23's most recent quarterly MDS (Minimum Data Set) dated 7/25/21, indicated the resident was cognitively intact and required extensive assistance for transfers and toilet use. 2. During record review on 8/24/21 at 2:00 P.M., Resident 48's most recent admission MDS, dated [DATE], indicated the resident was cognitively intact and required extensive assistance with toileting. During an observation, Resident 48's restroom sink water temperature was at 126 degrees F. 3. During an observation on 8/24/21 at 1:25 P.M., Resident 35's restroom sink water temperature was at 126 degrees F. During record review 8/26/21 at 10:10 A.M., Resident 35's most recent significant change MDS, dated [DATE], indicated the resident had severe cognitive impairment and required extensive assistance with transfers and toileting. 4. During an observation on 8/24/21 at 1:35 P.M., the 300/400 Hall Shower Room shower temperature read 122 degrees F. The 300/400 Hall Shower Room sink water temperature read 126 degrees F. During an interview on 8/24/21 at 1:30 P.M., LPN 4 indicated the 300/400 Hall Shower Room was used for resident showers. During an interview on 8/24/21 at 2:30 P.M. the Maintenance Supervisor indicated that the water temperatures are checked routinely but that a mixing valve had recently been replaced and that the water temperature had not been adjusted afterwards. The Maintenance supervisor indicated the water temperature in resident area were supposed to be kept between 105 and 115 degrees F. On 8/25/21 at 9:00 A.M., the DON (Director of Nursing) supplied a Logbook Documentation form, dated 8/24/21. The form included, Ensure patient room water temperatures are between 105 (degrees) and 115 (degrees) Fahrenheit . 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 properly prevent and/or contain COVID-19 and to ensure infection control practices were followed during resident treatments for residents who used C-PAP or Bi-PAP machines during sleep were placed in transmission based precautions during use of the equipment and up to one hour after the use of their equipment. (Resident 32, Resident 27, Resident 5, Resident 42, Resident 45, Resident 28) Findings include: 1. During an interview on 8/25/21 at 10:05 A.M., Resident 32 indicated they used a Bi-Pap machine (a machine that helps push air into the lungs) at night and during naps through out the day. Resident 32 indicated they had not been placed on transmission based precautions during the use of the Bi-Pap and for one hour after they had used the Bi-Pap machine. During an observation on 8/25/21 at 10:25 A.M., no signage was positioned on the door identifying Resident 32 was placed on transmission based precautions during the use of the equipment and up until one hour after the end of the use of the Bi-Pap machine (aerosol generating equipment) at night or during his naps. No PPE (personal protection equipment) station was located outside his door. The clinical record of Resident 32 was reviewed on 8/27/21 at 10:50 A.M. The record indicated the diagnoses for Resident 32 included, but were not limited to, chronic obstructive pulmonary disease (COPD). The most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/4/21, indicated Resident 32 was cognitively intact and had shortness of breath and trouble breathing when lying flat. The Physician's order, dated 12/12/1, read as follows: .Resident to wear BiPAP at hours of sleep . 2. During an observation on 8/25/21 at 9:35 A.M., no signage was positioned on the door identifying Resident 27 was placed on transmission based precautions during the use of the equipment and up until one hour after the end of the use of a Bi-Pap machine. No PPE station was located outside the door. The clinical recorded of Resident 27 was reviewed on 8/26/21 at 12:30 P.M. The record indicated the diagnoses for Resident 27 included, but was not limited to, COPD, heart disease, anxiety, and morbid obesity. The most recent Quarterly MDS, dated [DATE], indicated Resident 27 was cognitively intact and had shortness of breath and trouble breathing when lying flat. Physician's orders for Resident 27 included, but were not limited to, Resident to wear BiPAP during hours of sleep and napping (ordered 1/18/21). 3. During an observation on 8/25/21 at 10:25 A.M., no signage was positioned on the door identifying Resident 5 was placed on transmission based precautions during the use of the equipment and up until one hour after the end of the use of her C-PAP machine (aerosol generating equipment) at night. No PPE station was located outside her door. The clinical record of Resident 5 was reviewed on 8/30/21 at 9:50 A.M. The record indicated the diagnoses for Resident 5 included, but were not limited to, sleep apnea and dyspnea. The most recent Annual MDS assessment, dated 6/17/21, indicated Resident 5 was cognitively intact and used a BiPAP/CPAP machine. The Physician's order, dated 10/10/19, read as follows: .C-PAP 12-15 worn during hours of sleep . 4. During an observation on 8/25/21 at 10:28 A.M., no signage was positioned on the door identifying Resident 42 was placed on transmission based precautions during the use of the equipment and up until one hour after the end of the use of her C-PAP machine (aerosol generating equipment) at night. No PPE (personal protection equipment) station was located outside her door. The clinical record of Resident 42 was reviewed on 8/30/21 at 9:52 A.M. The record indicated the diagnoses for Resident 42 included, but were not limited to, obstructive sleep apnea. The most recent Quarterly MDS assessment, dated 8/13/21 , indicated Resident 42 was cognitively intact. The Physician's order, dated 3/9/21, read as follows: .Auto C-PAP .At Bedtime . 5. During an observation on 8/25/21 at 10:29 A.M., no signage was positioned on the door identifying Resident 45 was placed on transmission based precautions during the use of the equipment and up until one hour after the end of the use of his C-PAP machine (aerosol generating equipment) at night. No PPE station was located outside the resident's door. The clinical record of Resident 45 was reviewed on 8/30/21 at 9:55 A.M. The record indicated the diagnoses for Resident 45 included, but were not limited to, obstructive sleep apnea. *The most recent Significant Change MDS assessment, dated 8/1/21, indicated Resident 45 was cognitively intact and used a BiPAP/CPAP machine. The Physician's order, dated 6/8/19, read as follows: .Resident to use Auto C-PAP during hours of sleep . 6. During an observation on 8/25/21 at 10:31 A.M., no signage was positioned on the door identifying Resident 28 was placed on transmission based precautions during the use of the equipment and up until one hour after the end of the use of his C-PAP machine (aerosol generating equipment) at night. No PPE (personal protection equipment) station was located outside her door. The clinical record of Resident 28 was reviewed on 8/30/21 at 10:00: A.M. The record indicated the diagnoses for Resident 28 included, but were not limited to, obstructive sleep apnea. *The most recent Quarterly MDS assessment, dated 8/3/2, indicated Resident 28 was cognitively intact and had shortness of breath and difficulty breathing when lying flat. The Physician's order, dated 6/14/21, read as follows: .C-PAP .to be worn at HS [bedtime] and periods of sleep . On 8/25/21 at 2:40 P.M., the DON (Director of Nursing) supplied a facility policy titled, Aerosol Generating Procedure Guidance, dated 3/22/21. The policy included, .Green Zones: Resident is placed on transmission-based precautions: Droplet Plus precautions for the duration of the procedure and 1 hour post procedure. This included N-95 mask, eye protection, gown and gloves and keeping the door closed throughout the procedure and one hour after, and disinfecting all surfaces following the procedure. 3.1-18(b)(2)