Based on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication was not ordered beyond 14 days or the attending physician documented their rationale in the resident's medical record to indicate the duration for the PRN order for 1 of 5 residents reviewed for unnecessary medications. (Residents 62) Finding includes: The clinical record for Resident 62 was reviewed on 8/9/24 at 1:44 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, dependence on a ventilator (machine to move air in and out of your lungs), tracheostomy, seizure, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. A physician's order, dated 2/14/24, indicated to give one (1) lorazepam (an anxiety medication) 1 milligram (mg) tablet by gastrostomy tube (a tube inserted through the abdomen directly to the stomach). The facility may administer up to 2 tablets in 24 hours as needed (PRN). A care plan, dated 4/2/24, indicated the resident required the use of an anxiety medication. The interventions included, but were not limited to, administer medication as ordered and observe for changes in mood or behavior. During an interview, on 8/9/24 at 9:14 a.m., the Administrator indicated if the resident had an order for PRN lorazepam the medication would need to have a stop date after 14 days. A current policy, titled PRN Medications, dated as revised 9/2017 and received by the Clinical Support Nurse on 8/9/24 at 2:17 p.m., indicated .Residents shall not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs shall be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. 3.1-48(a)(2) 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to keep medications within eyesight or stored in a location not accessible to residents or unauthorized personnel for 3 of 3 residents' medications randomly observed for medication storage. (Residents 70, 33 and 74) Finding includes: During an observation, on 8/8/24 at 3:46 p.m., the following medications were found on top of the medication cart: a. One plastic container which contained Erythromycin Benzoyl ointment (used for acne) for Resident 70. b. A bottle of Lansoprazole (a medication used to treat stomach acid) and a bottle of Topiramate (an anticonvulsant medication) for Resident 33. c. A bottle of Cefpodoxime (an antibiotic medication) for Resident 74. There were no staff observed in the hallway. Resident 22 was observed on multiple occasions wandering the halls. During an interview, on 8/8/24 at 3:46 p.m., QMA 3 indicated the medications were from the refrigerator and she should have put them back. A current policy, titled Storing Drugs, received from the Clinical Support Nurse on 8/9/24 2:20p.m., indicated .drug and biologicals will be stored in a safe, secure and orderly manner at appropriate temperatures and accessible only to licensed nursing and pharmacy personnel or staff members lawfully authorized to administer medications 3.1-25(m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff covered their clothing with personal protective equipment while providing catheter care for 1 of 1 resident observed for catheter care and Enhanced Barrier Precautions. (Resident K) Finding includes: During an observation, on 8/9/24 at 10:29 a.m., LPN 2 donned a disposable yellow gown and did not tie the gown at the neck or the waist. The gown fell to LPN 2's elbows as she was leaning over the bed to provide catheter care, and her shirt was not covered by the gown. LPN 2 then indicated the gown was bothering her and she removed the gown and put on a new disposable yellow gown. She did not tie the second gown at the neck or the waist. She continued to provide catheter care, and the gown fell off her shoulders and down to her elbows. Her shirt was not covered by the gown and the gown was laying on the resident's bed instead of covering the shirt of LPN 2. During an interview, on 8/9/24 at 10:36 a.m., LPN 2 indicated she should have tied the gown. The clinical record for Resident K was reviewed on 8/9/24 at 10:40 a.m. The diagnoses included, but were not limited to, cerebral palsy, tracheostomy status, gastrostomy status, adult failure to thrive, and cystostomy (surgical opening in the bladder) with a suprapubic catheter. During an interview, on 8/9/24 at 10:54 a.m., the Regional Director indicated the staff should tie the disposable gowns. A current policy, titled Enhanced Barrier Precautions, dated 10/2019 and received from the Administrator at entrance, indicated .Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. These precautions entail the use of gown and gloves during 'high contact' resident care activities that provide opportunities for transfer of MDROs [multi drug resistant organisms] to staff hands and clothing to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs. A current Center for Disease Control (CDC) procedure, not dated and provided by the Clinical Support Nurse on 8/9/24 at 2:17 p.m., indicated .Sequent for putting on personal protective equipment .GOWN .Fully cover torso from neck to knees, arms to end of wrists, and [NAME] around the back .Fasten in back of neck and waist This citation relates to Complaint IN00440500. 3.1-18(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft) per resident in 1 of 33 resident rooms reviewed. (Rooms 16) Finding includes: During the initial facility observation, on 8/5/24 at 11:45 a.m., room [ROOM NUMBER] was found to have three beds. room [ROOM NUMBER] had 3 beds and was 237.9 square feet. This was 79.3 square feet for each resident. During the entrance conference, the Regional Director provided a copy of the Indiana Department of Health recommendation, dated 7/13/23, to approve the room size waiver for room [ROOM NUMBER]. 3.1-19(l)(2)(A)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide at least 80 square feet (sq. ft) per resident for 1 of 33 resident rooms in the facility. (Rooms 16) Finding includes: During the initial facility observation, on 5/3/23 at 11:45 a.m., room [ROOM NUMBER] was found to have three beds. Facility documentation of room size certification, requested on 5/3/23, and provided by the Administrator on 5/5/23 upon entrance, indicated the following: 1. room [ROOM NUMBER], 3 beds/NF 237.9 Sq.ft./79.3 sq.ft. for each resident. During an interview, on 5/5/23 at 10:30 a.m., the Administrator indicated a room size waiver had been requested in the past and was granted. 3.1-19(l)(2)(A)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide at least 80 square feet (sq. ft) per resident in 1 of 33 resident rooms in the facility. (room [ROOM NUMBER]). Finding includes: During the initial facility observation, on 6/9/22 at 11:30 a.m., room [ROOM NUMBER] was found to have three beds. Measurement of room [ROOM NUMBER] indicated the following: room [ROOM NUMBER] had 3 beds/237.3 square feet/79.1 square feet per resident. During an interview, on 6/9/22 at 12:30 p.m., the Administrator indicated a room size waiver had been requested in March of 2020 and was granted. 3.1-19(l)(2)(A)