2. The clinical record for Resident 2 was reviewed on 11/26/24 at 10:12 a.m. The diagnoses included, but were not limited to, congestive heart failure, pleural effusions, and acute and chronic respiratory failure with hypoxia. A physician's order, dated 8/2/24, indicated Resident 2 received catheter care every shift and an order, dated 8/5/24, indicated Resident 2 was to have the hospice provider complete pleural drain care two times per week. An observation conducted, on 11/22/24 at 11:10 a.m., indicated no enhanced barrier precaution signage was in Resident 2's room or any personal protective equipment (PPE) was located in or near the resident's room. Based on observation, interview, and record review, the facility failed to ensure the use of enhanced barrier precautions (EBP) for 3 of 3 residents reviewed for EBP (Resident 3, Resident 11, and Resident 2), and failed to ensure a feeding tube piston syringe was dated for 1 of 1 resident reviewed for enteral feeding management (Resident 11). 1. The clinical record for Resident 3 was reviewed on 11/25/2024 at 11:30 a.m. The medical diagnoses included chronic kidney disease. A Quarterly Minimum Data Set Assessment, dated 11/13/2024, indicated Resident 3 had an indwelling urinary catheter. A physician order, dated 5/16/2024, indicated Resident 3 utilized an indwelling urinary catheter. A urinary care plan, last revised 11/15/2024, indicated Resident 3 utilized an indwelling urinary catheter. The care plan did not indicate the use of EBP. During an interview on 11/22/2024 at 12:29 p.m., Certified Nursing Assistant (CNA) 2 indicated she did not know what EBP was. When she provided care to residents with indwelling medical devices, such as catheters and feeding tubes, she only utilized gloves, but not a gown or other personal protective equipment. During an interview on 11/22/2024 at 12:45 p.m., the Director of Nursing (DON) indicated the facility did not have anyone on EBP and they did not utilize it currently. 3. During an observation on 11/22/24 at 11:56 a.m., Resident 11 was sitting in her recliner. The resident had a bottle of formula for a gastrostomy tube (feeding tube) hanging on a pole with a piston (syringe for administering formula, medication, and water into the gastrostomy tube and checking placement of the gastrostomy tube) hanging next to the formula bottle in a bag with no date. Observation of the resident's room and bathroom indicated there was no PPE visible. During an interview on 11/22/24 at 12:55 p.m., the DON verified the piston syringe was not dated. The DON indicated the nurse was responsible to date the piston syringe when it was opened. The DON verified there was no PPE located in Resident 11's room. The clinical record for Resident 11 was reviewed on 11/25/24 at 11:10 a.m. The diagnoses included, but were not limited to, dementia, gastrostomy status, congestive heart failure, hypertension, anxiety and diabetes. The physician recapitulation for Resident 11, dated November 2024, indicated the resident was to have the peg-tube (artificial nutrition through a tube into the stomach) flushed with 60 milliliters (ml) of water, check tube placement and residual prior to administration of formula or flushing of the feeding tube. During an interview on 11/25/24 at 11:40 a.m., Registered Nurse (RN) 1 indicated the facility does not have a policy for enhanced barrier precautions (EBP). The enteral nutrition policy was provided by RN 1 on 11/25/24 at 1:30 p.m. The policy indicated the staff caring for residents with feeding tubes would be trained on potential adverse effects of tube feeding, such as feeding-tube complications. 3.1-18(b)(1) 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to maintain the stove hood in a cleanly manner. This had the potential to affect 12 of 12 residents in the facility. Findings include: A tour of the kitchen was conducted with the Dietary Manager (DM) on 11/22/24 at 12:00 p.m. During the tour, an observation of the stove hood was made. There were several intricate looking cobwebs strung between the gaps in the vent covers on the left side of the hood. The cobwebs were brown in color. There was fuzzy debris built up on the right side of the hood. These areas were directly above the stove. An interview was conducted with Dietary Aide 5 during observation of the stove hood. She indicated a separate company was responsible for cleaning the stove hood, and it had been a couple of months since they came. On 11/22/24 at 12:56 p.m., an interview was conducted with the DM, who provided the, 3/4/24, service report from the company who cleaned the facility's stove hood. The service report indicated the exhaust hood was cleaned on 3/4/24. The DM indicated the Maintenance Director provided her with the, 3/4/24, service report as verification of the last time the stove hood was cleaned. She was unsure how often it was supposed to be cleaned, but the stove hood was pretty bad during the tour. On 11/22/24 at 12:45 p.m., the DM provided verification of a, 10/1/24, semi-annual kitchen hood suppression inspection and the, 10/23/24, wet and dry fire sprinkler system inspection reports. None of them referenced cleaning of the stove hood. An interview was conducted with the DM on 11/22/24 at 1:17 p.m. She indicated there was no facility policy on cleaning the stove hood, but they were due for a cleaning this month. 3.1-21(i)(3)

2. The clinical record for Resident 4 was reviewed on 9/19/2023 at 11:10 a.m. The medical diagnoses included diabetes and kidney disease. A Quarterly Minimum Data Set Assessment, dated for 6/8/2023, indicated that Resident 4 was cognitively intact and at risk for developing pressure ulcers. An observation on 9/19/2023 at 10:12 a.m. indicated that Resident 4 had on pressure relieving boots and had a foam dressing to his left gluteal. An interview with LPN 3 at this time indicated that Resident 4 had two open areas to his left gluteal that were in the stages of healing, and they were utilizing a foam dressing to treat. A physician order, dated for 9/4/2023, indicated to change the foam dressing to Resident 4's dressing as a treatment for .open areas on left gluteal. Review of the care plans indicated Resident 4 was at risk for developing skin impairments but did not encapsulate the open areas to his left gluteal. An interview with the Director of Nursing on 9/21/2023 at 1:45 p.m. indicated the facility did not have a care plan to address the current open areas to Resident 4's left gluteal. 3. The clinical record for Resident 9 was reviewed on 9/20/2023 at 1:41 p.m. The medical diagnoses included diabetes and anxiety disorder. A Quarterly Minimum Data Set Assessment, dated for 8/2/2023, indicated that Resident 9 was cognitively impaired, had one fall during the review period, and utilized antianxiety medications. An observations on 9/19/2023 at 1:45 p.m. indicated Resident 9 was sleeping in her recliner and had bolsters to her mattress. An observations on 9/20/2023 at 10:45 a.m. indicated Resident 9 was sitting in her recliner and had bolsters to her mattress. A physician order, dated for 9/8/2023, indicated Resident 9 utilized Zoloft (an antidepressant) for anxiety. Review of the care plans for Resident 9 did not indicate the use of a bolster mattress. A care plan, dated for 6/29/2023, indicated that Resident 9 utilized antianxiety medications (Buspar) but did not encapsulate the use of Zoloft. An interview with the Director of Nursing on 9/21/2023 at 1:50 p.m. indicated that the facility did not have a care plan to utilize a bolster mattress for Resident 9 nor have a care plan for her use of Zoloft. A policy entitled, Care Planning-Interdisciplinary Team, was provided by the Director of Nursing on 9/22/2023 at 10:45 a.m. The policy indicated, .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of individualized comprehensive care plan for each resident . 3.1-35(a) 3.1-35(b)(1) Based on interview, and record review, the facility failed to develop or update care plans for the use of Prolia, new skin impairments, a bolster mattress and antidepressant for Resident 9. This affected 3 of 11 residents reviewed for care plan development. (Residents 2, 4, and 9) Findings include: 1. Resident 2's record was reviewed on 9/21/23 at 11:33 a.m. The record indicated Resident 2 had diagnoses that included, but were not limited to, osteoporosis (weakened bones). Current physician's orders included, but were not limited to, Prolia, 60 milligrams, given under the skin one time a day, every 180 days for osteoporosis, with a start date of 6/23/2023. No care plan could be found for the medication nor the diagnosis. On 9/22/23 at 11:28 a.m., the Director of Nurses indicated they do not have a care plan for the use of Prolia to treat osteoporosis.

Based on interview and record review, the facility failed to report required nursing staffing data to the payroll based journal (PBJ) for April 1-June 30, 2023, for 1 of 1 Quarter reviewed on Certification and Survey Provider Enhanced Reporting (CASPER). Findings include: A PBJ Staffing Data Report, dated 9/12/2023, indicated it encapsulated data from April 1-June 30, 2023, and was triggered for failure to submit data for the quarter. A Staff Activity Report, dated for 9/18/2023, indicated that no staffing hours were reported between April 1-June 30, 2023. An interview with the Business Office Manager on 9/18/2023 at 1:30 p.m., indicated that she reported the PBJ information quarterly by manually entering the data into the system. An interview with the Business Office Manager on 9/18/2023 at 2:30 p.m., indicated that did not have validation report and confirmed that no hours had been reported for April 1-June 2023 per the Staff Activity Report for that timeframe. A policy entitled, Staffing, was provided by the Business Office Manager on 9/19/2023 at 2:22 p.m. The policy indicated, .Our facility furnished information from payroll records setting forth the hours worked by nursing personnel on each day for each quarter and reported to the appropriate state agency .

Based on interview and observation, the facility failed to provide visitation between the hours of 6 p.m. and 9 a.m. for 1 of 1 resident reviewed for visitation. (Resident 12) Findings include: An interview with family member of Resident 12 indicated that in the middle of July 2022, she attempted to visit Resident 12 at 5:55 p.m. A staff member answered the door and told her visiting hours were over and she could not visit. A Center Medicare and Medicaid Services Memorandum, revised on 3/10/2022, with a Reference of QSO-20-39-NH indicated, .Visitation is allowed for all residents at all times . And interview with the Administrator on 8/5/2022 at 10:11 a.m. indicated that visitation is from 9 a.m. to 6 p.m. If a visitor comes before 5:55 p.m., they are welcome to stay longer, but they do not have the staffing to screen at the door after 6 p.m. A policy entitled, Visitation, was provided by the Administrator on 8/4/2022 at 2:15 p.m. The policy indicated, .Visiting hours are 9a - 6 p due to Covid-19 restrictions . 3.1-8(b)(7)

Based on observation, interview, and record review, the facility failed to keep Resident 7's urinary catheter bag free from the floor for 1 of 1 residents reviewed for indwelling urinary catheters. Findings include: The medical record for Resident 7 was reviewed on 8/3/2022 at 11:09 a.m. The medical diagnoses included, but were not limited to, urinary retention, urinary tract infection, and chronic kidney disease. A Quarterly Minimum Data Set Assessment, dated 6/15/2022, indicated that Resident 7 was cognitively intact, needed assistance with hygiene activities of daily living, and utilized and indwelling urinary catheter. An observation on 8/2/2022 at 1:12 p.m., indicated Resident 7 was lying in bed with his urinary catheter bag off the left side of his bed. The bottom of the bag was in contact with the floor. An observation on 8/2/2022 at 1:50 p.m., indicated Resident 7 was lying in bed with his urinary catheter bag off the left side of his bed. The bottom of the bag was in contact with the floor. An observation on 8/3/2022 at 2:52 p.m., indicated Resident 7 was lying in the bed with his urinary catheter bag off the right side of the bed. The bottom of the bag was laying on the bottom bar of the bedside table. An interview with LPN 2 on 8/3/2022 at 2:53 p.m., indicated the urinary catheter bag should not be making contact with the bottom of the bedside table and she would change the catheter bag. A urinary tract infection care plan, dated 1/8/2020, indicated to provide catheter care every shift and check the tubing every shift for Resident 7. A policy entitled, Catheter Care, was provided by the Administrator on 8/4/2022 at 2:12 p.m. The policy indicated, .Keep drainage bag of [sic, off] floor at all times . 3.1-41(a)(2)

Based on interview and record review, the facility failed to provide 8 hours of consecutive registered nurse (RN) coverage for 2 of the last 30 days reviewed. Findings include: Nursing schedules for 7/10/2022 though 8/6/2022 were reviewed on 8/3/2022 at 10:55 a.m. The scheduled indicated that on 7/16/2022 and 7/30/2022, Licensed Practical Nurses (LPNs) were scheduled from midnight until 11 p.m. then RN 6 was scheduled from 11 p.m. Saturday until 7 a.m. on Sunday. An interview with Administrator on 8/4/2022 at 1:51 p.m. indicated that he had overlooked those dates but would get it fixed going forward. An interview with Administrator on 8/5/2022 at 12:54 p.m. indicated they did not have a specific policy for RN coverage but would follow the Center for Medicare and Medicaid regulation. 3.1-17(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to assure a staff member that was not up-to-date on their covid-19 vaccination tested at least weekly for 1 of 5 staff reviewed for infection control. (Staff 4) Findings include: The Staff Vaccination Matrix was provided by the Business Office Manager on 8/3/2022 at 11:05 a.m. This form indicated Staff 4 was not up-to-date on their vaccination. Testing logs for Staff 4 indicated that between 7/1/2022 and 7/30/2022 had tested for Covid-19 on: 7/11/2022 7/29/2022 7/30/2022 A time sheet for Staff 4 indicated from 7/1/2022 to 7/30/2022 they had worked on: 7/2/2022 7/4/2022 7/7/2022 7/8/2022 7/9/2022 7/10/2022 7/11/2022 7/14/2022 7/16/2022 7/17/2022 7/21/2022 7/22/2022 7/23/2022 7/24/2022 7/28/2022 7/29/2022 7/30/2022 And interview with the Administrator on 8/4/2022 at 2:20 p.m., indicated he had not been tracking the county level, but that staff were to be testing every day before their shift since 6/26/2022. Center for Disease Control and Prevention Covid-19 Community Level logged the historical values for [NAME] County, Indiana as: 6/23/2022 - Medium (Yellow) 6/30/2022 - High (Red) 7/7/2022 - Medium (Yellow) 7/14/2022 - Medium (Yellow) 7/21/2022 - High (Red) 7/28/2-2022 - Medium (Yellow) An interview with the Business Office Manager on 8/5/2022 at 11:01 a.m. indicated that Staff 4 had missed testing in July 2022. A Center Medicare and Medicaid Services Memorandum, revised on 3/10/2022, with a Reference of QSO-20-38-NH indicated that for a level of yellow to test once a week and red to test twice a week. The memorandum indicated that facilities should monitor their level of community transmissibility at least every other week. A policy entitled, Employee Infection, Vaccination Status and Covid-19 staff vaccination requirements, was provided by the Administrator on 8/4/2022 at 2:15 p.m. The policy had not been updated to reflect guidance for staff that were not up-to-date. An interview with the Administrator on 8/4/2022 at 2:20 p.m. indicated that the policy provided was the most up to date.

Based on interview and observation, the facility failed to adhere to their mitigation strategy by having unvaccinated staff members wear a face shield or eye protection during resident care for 1 of 5 staff members effecting 3 residents reviewed for infection control. (Resident 3, 5, and 7) Findings include: The Staff Vaccination Matrix was provided by the Business Office Manager on 8/3/2022 at 11:05 a.m. This form indicated Staff 2 was unvaccinated. On 8/3/2022 at 2:20 p.m. Staff 2 was observed going into and out of residents' rooms on the green zone (zone utilized for residents that do not have Covid-19 and have not been identified as being a risk for exposure for Covid-19) with just an N-95 face mask on. (Resident 5 and Resident 7) On 8/3/2022 at 2:55 p.m. Staff 2 was observed going into and out of residents' rooms on the green zone. She then donned personal protection equipment to go onto the red zone (area where residents with active Covid-19 were residing). (Resident 5 and Resident 3) An interview with Staff 2 on 8/3/2022 at 2:55 p.m. indicated they did not need to wear eye protection on the green zone, only in red or yellow rooms. An interview with the Administrator on 8/4/2022 at 2:20 p.m. indicated that the policy provided was the most up to date and that unvaccinated staff should be wearing approved eye protection or glasses. A policy entitled, Employee Infection, Vaccination Status and Covid-19 staff vaccination requirements, was provided by the Administrator on 8/4/2022 at 2:15 p.m. The policy indicated, .Any employee (direct hire or contracted) that is unvaccinated and has been granted an exemptions .must comply with the following: .Wear an N-95 mask with an approved face-shield or glasses . 3.1-18(a)