Based on interview and record review, the facility failed to adequately address resident grievances regarding call light wait times for 18 of 18 residents reviewed for call-light wait times, (Residents B, C, D, E, F, G, H, K, L, M, N, P, Q, R, S, T, and U).Findings include:During an interview, on 9/17/25 at 9:10 A.M., the Director of Nursing indicated the facility call light system was in working order and had not been out of working order at any time that she was aware of. The Director of Nursing indicated that each resident had a staff member, called a Guardian Angel, who checked on their assigned residents addressing concerns including concerns regarding call ight wait times. The Director of Nursing indicated when residents had concerns, the Guardian Angel was to address the concern and/or file a grievance or complete a Call Light Response Survey form. The Director of Nursing provided a call light audit form that had been created following the previous annual survey on 4/28/25, and indicated call light wait time audits were ongoing but there was no audit documentation completed after 6/30/25. The Director of Nursing indicated there was no further documentation of call light monitoring after 6/30/25. There was no explanation as to why the auditing had been discontinued after 6/30/25.On 9/17/25 at 9:58 A.M., during a telephone interview with Resident B's family member, she indicated Resident B's call light often went unanswered, or staff turned the light off and did not return.During an interview, on 9/17/25 at 10:20 A.M., the Assistant Director of Nursing (ADON) indicated when residents initiated the call button from their rooms, the call went to a beeper system, first to the Aide on the floor, then if not answered in a certain amount of time, the floor nurse was alerted via the beeper system. The ADON indicated there were no lights outside resident doors and no lights at the nurse's station to visualize when call-lights had been activated by the residents. The ADON indicated that the aides and nurses were responsible for checking the beepers frequently. The ADON indicated that the facility no longer utilized their call light monitoring system because the facility felt the call light times were accurate due to nursing staff not consistently turning the call light off when resident's needs had been met. The Assistant Director of Nursing indicated the call light system was in place at the most recent Annual Survey on 4/28/25 when the facility had been cited for excessive call light wait times. The Assistant Director of Nursing could not say when the call light monitoring system had been discontinued. The Assistant Director of Nursing indicated the facility did not have a specific policy regarding the answering of call lights nor was there an expectation of a reasonable period of time when a call light should be answered. She indicated the facility followed Nursing Standards of Practice, but was unable to indicate what the Nursing Standard of Practice was for a reasonable period of time a resident should have to wait for their call light to be answered. The ADON indicated an Education/In-service had been completed on 8/5/25 in response to a grievance that had been filed on 7/25/25 regarding a resident who had waited two hours to have her call light answered. The Assistant Director on Nursing indicated the Education/In-Service record, dated 8/5/25, indicated the education included when to provide Activities of Daily Living (ADLs) care and honoring resident's preferences. The Assistant Director of Nursing indicated the Education/In-service Record had not specifically listed an education and instructions regarding answering call lights in a timely manner.On 9/17/25 from 12:00 P.M. to 1:08 P.M., during a facility tour, resident interviews were conducted throughout the facility. The interviews indicated the following:On the [NAME] Unit, Resident C indicated she had to wait over 30 minutes to get help after she had pressed her call light. She indicated it often took longer than 30 minutes and it had frustrated her because she had not wanted to wet herself but has had no choice. She indicated staff had not asked her if she had concerns about anything, because she would have told them she has concerns about the call lights not being answered timely.Resident D indicated staff were terrible about answering call lights. She indicated she had waited over an hour for someone to answer the light and then staff sometimes turned the light off and had not helped her to the bathroom. She indicated this had been an ongoing problem and she had filed a grievance.On the St. Paul's Unit, Resident E, indicated there was a serious concern with her call light not being answered in a timely manner. Resident E indicated she normally waited 1 1/2 hours to 2 hours for help. The resident indicated that she ended up wetting herself and she had become very uncomfortable and indicated she felt embarrassed. The resident indicated that it was just not right to make a person wait so long for help. Resident E indicated she had filed grievances for having to wait so long for help, but no one had addressed the concern with her.On the St. Joseph's Unit, Resident F indicated she waited over an hour for help.Resident G indicated she had filed grievances about the long wait for her call light to be answered, but nothing had improved and no one had talked to her about her grievances. The resident indicated her wait times were at least 30 minutes during the day and at least 2 hours at night. Resident G indicated she got very uncomfortable and dreaded the nighttime because she would not get help when call light was used. Resident G indicated she felt like crying due to the call light response issue.Resident H indicated she was very upset about the long call light wait times. She indicated she had to wait over an hour for her needs to be met and many times the call light was not answered at all. Resident H indicated she has had to wet herself and that made her feel angry and humiliated.On the St John's Unit, Resident K indicated her call light was normally answered within 30 minutes (after she had activated it) and that was fine because she knew the staff were busy and she had not wanted to complain.On the St. Mark's Unit, Resident L, indicated she has had to lay in her own urine for hours at a time waiting for staff to answer the call light. She indicated she did not feel human sometimes because of the lack of care related to toileting. Resident L indicated staff came into her room and turned off the call light and left without helping her, many times. The resident indicated the staff had told her they would be back but they never came back. The resident indicated it did no good to complain about it because it did not make a difference and if she complained, it would probably get worse for her.Resident M, indicated she has had to lay in her own feces for 2 hours. She indicated she laid and cried and cried because she was so humiliated. Resident M indicated the night shift was the worst, but no shifts answered her light in a timely manner.An interview with Resident M's family member indicated when they pressed the call light button for help, it took a very long time to get answered and then staff came in the room and turned the call-light of saying they would return, but they did not return.Resident N, indicated he always has to wait at least 15 minutes for anyone to answer his call light and it was usually longer. He indicated he used a bed pan for BMs and it got very uncomfortable to have to wait for help to get him off the bed pan and he felt frustrated.The following resident records were reviewed on 9/17/225 at 4:30 P.M.:Resident B had diagnoses that included, but were not limited to, syncope and collapse, history of falling, orthostatic hypotension, difficulty in walking. Resident B had moderate cognitive impairment and required substantial to maximal assistance for toileting hygiene and was always incontinent of bowel and bladder. The resident's Care Plan included a plan for Activities of Daily Living (ADLs), dated 6/18/25, which indicated the resident required assistance with activities of daily living.Resident C had diagnoses that included, but were not limited to atrial fibrillation, congestive heart failure, stoke, cognitive communication deficit, urine retention. Resident C cognitive ability had not been assessed, but the resident was able to answer questions during the interview process. The Care Plans included but were not limited to Self-Care Deficit associated with need for assistance with ADLs including transfers, and monitoring of incontinence of bowel and bladder and to provide incontinence care as needed, dated 1/23/25.Resident D had diagnoses that included, but were not limited to, difficulty in walking, muscle weakness, depression, anxiety, and unsteadiness on feet. Resident D was cognitively intact, required substantial to maximal assistance for toileting and most ADLs and was frequently incontinent of bladder and occasionally incontinent of bowel. Resident D's Care Plans included but were not limited to Self-Care Deficit dated 8/30/19 to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident E had diagnoses that included, but were not limited to, hip displacement, stroke, anxiety, history of falling, need for assistance with personal care. Resident E was cognitively intact, required substantial to maximal assistance for toileting and most ADLs and was occasionally incontinent of bladder and frequently incontinent of bowel. Resident E's Care Plans included but were not limited to Self-Care Deficit dated 8/31/23 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident F had diagnoses that included but were not limited to, chronic kidney disease, muscle weakness, lack of coordination, difficulty in walking, and anxiety. Resident F had severe cognitive impairment. The residents' ADLs had not been assessed during the current assessment period. Resident F's undated Care Plans included but were not limited to Self-Care Deficit with goals to be neat, clean, without odor with assistance as needed. Incontinence for bowel and bladder, to check for incontinence; change if wet or soiled.Resident G had diagnoses that included but were not limited to, Parkinson's Disease, lack of coordination, difficulty in walking, and anxiety. Resident G was cognitively intact. Resident G's Care Plans included but were not limited to Self-Care Deficit dated 3/22/25 with goals to be neat, clean, without odor with assistance as needed.Resident H had diagnoses that included but were not limited to, hemiplegia following a stroke. Resident H's cognition was not assessed. The resident required assistance for toileting and was frequently incontinent of bladder and always incontinent of bowel. Resident H's Care Plans included but were not limited to Self-Care Deficit dated 5/24/18 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident K had diagnoses that included but were not limited to, epilepsy, chronic respiratory failure, neuropathy, and difficulty in walking. Resident Ks cognition was not assessed. The resident was dependent on others for toileting and personal care and was always incontinent of bladder and bowel and utilized a catheter. Resident K's Care Plans included but were not limited to Self-Care Deficit dated 8/9/25 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident L had diagnoses that included but were not limited to respiratory failure, congestive heart disease, lack of coordination, and difficulty in walking. Resident L was cognitively intact. Resident L's Care Plans included but were not limited to Self-Care Deficit dated 5/24/18 with goals to be neat, clean, without odor with assistance as needed. Resident M had diagnoses that included but were not limited to, Pyogenic arthritis, difficulty in walking, lack of coordination, heart failure, renal impairment, chronic kidney disease, and corneal degeneration. Resident M's cognition was not assessed. Resident M's Care Plans included but were not limited to Self-Care Deficit dated 9/8/25 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident N had diagnoses that included but were not limited to, congestive heart failure, atrial fibrillation, muscle wasting, and abnormal gait. Resident N was cognitively intact. Care Plans included but were not limited to Self-Care Deficit dated 9/11/25 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Review of facility Grievances from 7/1/25 to 9/15/21 included but were not limited to the following:On 7/1/25, Resident Q indicated to his Guardian Angel that he recently had had to wait 30 to 60 minutes for assistance during the night. Actions taken indicated the facility was monitoring call lights to improve the call light times. The Grievance form did not indicate that the concern had been resolved.On 7/10/25, Resident D indicated she felt it took staff an hour to answer the call light sometimes. Action taken indicated, call light report. The Grievance form did not indicate that the concern had been resolved.On 7/25/25, Resident E indicated her call light had not gotten answered for over 2 hours on the night of 7/24/25. The Action taken indicated that the Certified Nursing Assistance (CNA) and Nursing staff had been educated and in-serviced on call light response times. The Resolution indicated the resident was satisfied with the resolution at that time.On 7/30/25, Therapy indicated Resident T's call light was on upon the therapist's arrival. The patient had been very upset and stated her call light had been on for hours throughout the morning. The resident's CNA was observed in the cubicle on a phone call before and after the therapy session. The Action taken indicated that staff had spoken with the resident and reassured the resident that they would be watching the response times and had discussed the concern with the CNA. On 8/5/25, Resident R reported to the therapy department that she had not had help during the night so she had called the cops because her call light was not working and she needed help. Actions taken indicated staff had not been aware of the long call-light issue and they had discussed the importance of having their pagers with them and checking the screen often.On 8/8/25, Resident S' family member reported to the Chaplin that they had waited 45 minutes for the call light to be answered and the resident had been waiting for a long time to go to the bathroom. They indicated that the CNA had came into the room and turned off the light without completing the tasks. Action taken indicated the facility had apologized for the delay in answering the call light and had spoken with the CNA and nurse. They had checked both the pager and batteries and had assured resident and family they were addressing the concern.On 8/12/25, Resident U indicated it took 25 to 30 minutes to get help. Action taken indicated there had been no action taken regarding the long call-light wait.On 8/12/25, Resident P indicated she had turned on the call-light and it was not answered for 1 hour and 5 minutes. Action taken indicated the CNA who had not answered the light had been terminated.On 8/13/25 Resident R reported to therapy staff that she had called 911 during the night because the call light had not worked. Action Taken indicated the call light was checked and it was functioning properly. Guest did report she is becoming delirious from sleep deprivations. Her complaint is more about sleep and wanting Ambien ordered. The Resolution indicated the resident was not satisfied with the outcome.On 8/18/25, Resident R contacted the front desk and had informed them she had been waiting an hour to get cleaned up. The receptionist indicated she looked at the nurse's pager and had not seen the resident's light on, and the CNA indicated she told Resident R that she would be back to clean her up when she had finished with another resident. The receptionist indicated she observed many occasions when Resident R would use the call light as staff left her room. The receptionist indicated staff had spoken to Resident R asking her to request all needs in one trip. The Resolution indicated Resident R was not satisfied with the resolution and planned to call 911 if response times were greater than 15 minutes. The form did not indicate why the nurse's pager had not been carried by the nurse and was left at the desk for the receptionist to view.On 8/29/25, Resident G's family member had indicated she and the resident were concerned about the call light response times and that the resident sometimes had to wait for over 1 hour for help. The family member indicated she had come to visit and the Resident was soaked with urine and urine was dripping off of the resident's chair. Action taken indicated staff working during that period had been given corrective actions.Review of an Education/In-service Record, dated 8/5/25 related to Resident E's concerns on a 7/25/25 Grievance, indicated the in-service topic were ADL care for residents. It had not specifically indicated education related to answering resident call-lights had been provided.On 9/15/25 at 3:30 P.M., the Assistant Director of Nursing provided an undated policy titled, FEDERAL RESIDENT RIGHTS & FACILITY RESPONSIBILITIES, and indicated that it was the current facility policy regarding resident rights. The policy indicated, .The resident has a right to a dignified existence, self-determination.Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in and environment that promotes maintenance or enhancement of his or her quality of life.Resolution of Grievances. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.This citation relates to Complaint 1232367.3.1-3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively act and resolve Resident Council's concerns related to long call light response times. This failure affected 2 of 7 residents attending the Resident/Surveyor group meeting. Findings Include: During a Resident/surveyor meeting on 4/22/25 at 12:59 P.M., seven of seven residents indicated the Resident Council had complained about long wait times for their call lights to be answered. Two of seven residents reported they were experiencing continued delays, and Resident B stated he had waited as long as an hour within the past couple of weeks. A review of Resident Council meeting minutes revealed repeated concerns over the past year about delayed call light responses on the following months: - 1/27/2025 - 10/16/2024 - 7/8/2024 During an interview on 4/24/2025 at 10:00 A.M., the Executive Director (ED) acknowledged he had been made aware of the Resident Council concerns regarding long call light response times. He indicated he had identified two potential causes for the issue related to long call light response times: the call light system required a 2-3 second hold to properly reset and some staff ignored call light alarms assuming they had already been answered and care had been provided. The ED indicated the call light concerns and system had been addressed in the facility's QAPI (Quality Assurance and Performance Improvement) meetings and a Performance Improvement Project (PIP) had been implemented for both October 2024 and January 2025. However, the long call light response/wait times had persisted. The ED indicated call light response times had been added to QAPI as a PIP in October 2024 and the plan had been closed out after two months because he was not receiving complaints from residents anymore. The ED indicated the staff had been educated on the call light system and the need to hold the reset buttons on the call lights but he was unable to provide the documentation of the education prior to the exit of the survey. In January 2025, call lights were again added to QAPI as a Performance Improvement Plan (PIP) after several complaints. One intervention was the facility had implemented was running daily reports for call light times and discussing the reports at the morning meetings. Another intervention was to have an Administrator hold a call light pager while they were in the building and the on-call manager held the call light pager while in the building on the weekends. The ED indicated after the Administrators left for the day, there was no one to monitor the call lights during the evening and night shifts. In addition, the ED indicated staff had not followed up with the residents that had experienced long call light wait times based on the call light response reports. He indicated the maintenance department was aware of the problem and had worked on the system several times. Although the facility had implemented PIP plans, the ED indicated he had based the call light wait times on resident feedback, but again indicated no one had followed up with the residents who had experienced long call light wait/response times from the call light report A review of the call light report was completed on 4/24/2025 at 11:00 A.M. The following dates and times had a call light response time of 30 minutes or longer. When asked what the facility considered a reasonable maximum call light wait/response time, the ED indicated he was not able to give a timeframe regarding when the call light should have been answered because the answer would have been different based on what the staff were working on at the time the call light went alarmed. -4/10/2025 at 12:12 A.M. call light from room [ROOM NUMBER] took 45 minutes to be turned off. -4/10/2025 at 12:23 A.M. call light from room [ROOM NUMBER] took 1 hour 15 minutes to be turned off. -4/10/2025 at 12:46 A.M. call light from room [ROOM NUMBER] took 51 minutes to be turned off. -4/10/2025 at 2:08 A.M. call light from room [ROOM NUMBER] took 59 minutes to be turned off. -4/10/2025 at 4:05 A.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 5:07 A.M. call light from room [ROOM NUMBER] took 34 minutes to be turned off. -4/10/2025 at 8:19 A.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 8:37 A.M. call light from room [ROOM NUMBER] took 1 hour and 36 minutes to be turned off. -4/10/2025 at 8:41 A.M. call light from room [ROOM NUMBER] took 1 hour and 45 minutes to be turned off. -4/10/2025 at 12:23 A.M. call light from room [ROOM NUMBER] took 59 minutes to be turned off. -4/10/2025 at 9:48 A.M. call light from room [ROOM NUMBER] took 35 minutes to be turned off. -4/10/2025 at 10:45 A.M. call light from room [ROOM NUMBER] took 56 minutes to be turned off. -4/10/2025 at 10:57 A.M. call light from room [ROOM NUMBER] took 1 hour and 37 minutes to be turned off. -4/10/2025 at 11:07 A.M. call light from room [ROOM NUMBER] took 34 minutes to be turned off. -4/10/2025 at 1:52 P.M. call light from room [ROOM NUMBER] took 37 minutes to be turned off. -4/10/2025 at 1:59 P.M. call light from room [ROOM NUMBER] took 34 minutes to be turned off. -4/10/2025 at 2:10 P.M. call light from room [ROOM NUMBER] took 1 hour and 33 minutes to be turned off. -4/10/2025 at 2:28 P.M. call light from room [ROOM NUMBER] took 53 minutes to be turned off. -4/10/2025 at 2:53 P.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 3:14 P.M. call light from room [ROOM NUMBER] took 1 hour and 46 minutes to be turned off. -4/10/2025 at 4:30 P.M. call light from room [ROOM NUMBER] took 32 minutes to be turned off. -4/10/2025 at 5:28 P.M. call light from room [ROOM NUMBER] took 41 minutes to be turned off. -4/10/2025 at 6:05 P.M. call light from room [ROOM NUMBER] took 30 minutes to be turned off. -4/10/2025 at 6:44 P.M. call light from room [ROOM NUMBER] took 1 hour and 57 minutes to be turned off. -4/10/2025 at 7:10 P.M. call light from room [ROOM NUMBER] took 40 minutes to be turned off. -4/10/2025 at 7:58 P.M. call light from room [ROOM NUMBER] took 60 minutes to be turned off. -4/10/2025 at 8:42 P.M. call light from room [ROOM NUMBER] took 38 minutes to be turned off. -4/10/2025 at 9:58 P.M. call light from room [ROOM NUMBER] took 45 minutes to be turned off. -4/10/2025 at 10:01 P.M. call light from room took 2 hours and 26 minutes to be turned off. -4/10/2025 at 10:03 P.M. call light from room [ROOM NUMBER] took 51 minutes to be turned off. -4/10/2025 at 10:13 P.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 10:15 P.M. call light from room [ROOM NUMBER] Bed A took 30 minutes to be turned off. -4/10/2025 at 10:43 P.M. call light from room [ROOM NUMBER] Bed B took 2 hours and 1 minute to be turned off. -4/10/2025 at 11:35 P.M. call light from room [ROOM NUMBER] Bed A took 32 minutes to be turned off. -4/11/2025 at 1:08 A.M. call light from room [ROOM NUMBER] Bed B took 1 hour and 40 minutes to be turned off. -4/11/2025 at 1:27 A.M. call light from room [ROOM NUMBER] took 36 minutes to be turned off. -4/11/2025 at 1:29 A.M. call light from room [ROOM NUMBER] took 1 hour and 44 minutes to be turned off. -4/11/2025 at 4:15 A.M. call light from room [ROOM NUMBER] took 1 hour and 9 minutes to be turned off. -4/11/2025 at 5:07 A.M. call light from room [ROOM NUMBER] took 2 hours and 45 minutes to be turned off. -4/11/2025 at 5:20 A.M. call light from room [ROOM NUMBER] took 1 hour and 5 minutes to be turned off. -4/11/2025 at 6:35 A.M. call light from room [ROOM NUMBER] took 2 hours and 7 minutes to be turned off. -4/11/2025 at 8:59 A.M. call light from room [ROOM NUMBER] took 1 hour and 2 minutes to be turned off. -4/11/2025 at 10:20 A.M. call light from room [ROOM NUMBER] took 38 minutes to be turned off. -4/11/2025 at 10:35 A.M. call light from room [ROOM NUMBER] took 1 hour and 40 minutes to be turned off. -4/11/2025 at 11:57 A.M. call light from room [ROOM NUMBER] took 53 minutes to be turned off. -4/11/2025 at 12:15 P.M. call light from room [ROOM NUMBER] took 2 hours to be turned off. -4/11/2025 at 1:10 P.M. call light from room [ROOM NUMBER] took 1 hour and 8 minutes to be turned off. -4/11/2025 at 1:39 P.M. call light from room [ROOM NUMBER] took 2 hours and 48 minutes to be turned off. -4/11/2025 at 3:01 P.M. call light from room [ROOM NUMBER] took 1 hour and 28 minutes to be turned off. -4/11/2025 at 3:20 P.M. call light from room [ROOM NUMBER] took 1 hour and 10 minutes to be turned off. -4/11/2025 at 3:36 P.M. call light from room [ROOM NUMBER] took 1 hour to be turned off. -4/11/2025 at 4:30 P.M. call light from room [ROOM NUMBER] took 30 minutes to be turned off. -4/11/2025 at 6:41 P.M. call light from room [ROOM NUMBER] took 59 minutes to be turned off. -4/11/2025 at 6:46 P.M. call light from room [ROOM NUMBER] Bed A took 43 minutes to be turned off. -4/11/2025 at 8:08 P.M. call light from room [ROOM NUMBER] Bed B took 54 minutes to be turned off. -4/11/2025 at 8:21 P.M. call light from room [ROOM NUMBER] took 48 minutes to be turned off. -4/11/2025 at 8:38 P.M. call light from room [ROOM NUMBER] took 40 minutes to be turned off. -4/11/2025 at 9:15 P.M. call light from room [ROOM NUMBER] took 41 minutes to be turned off. -4/11/2025 at 9:44 P.M. call light from room [ROOM NUMBER] took 35 minutes to be turned off. -4/11/2025 at 10:39 P.M. call light from room [ROOM NUMBER] took 1 hour and 29 minutes to be turned off. -4/11/2025 at 11:14 P.M. call light from room [ROOM NUMBER] took 40 minutes to be turned off. This citation relates to Complaint IN00454362. 3.1-19(u)

Based on record review and interview, the facility failed to ensure the Discharge Minimum Data Set (MDS) assessment was completed and submitted in a timely manner for 1 of 4 residents who were reviewed for discharge assessments. (Resident 29) Findings include: Resident 29's record review was completed on 04/23/2025 at 10:47 AM. Diagnoses included, but were not limited to: hypertension, atrial fibrillation, and arthritis. Resident 29 was discharged on 12/22/2024. Resident 29's Discharge MDS assessment was completed and submitted on 4/23/2025, 122 days after discharge. During an interview on 04/28/25 at 11:15 AM, the Director of Nursing (DON) indicated the MDS assessment had not been completed or submitted timely. The DON also indicated the facility did not have a policy related to MDS assessment completion and followed the Resident Assessment Instrument (RAI) manual as their guidance. According to the RAI User's Manual, Chapter 2, Page 2-17, a Discharge assessment must be completed (i.e., signed and dated as complete) within 14 days after the resident had been discharged from the facility, and submitted within 14 days of completion.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 2 of 17 residents reviewed for care planning ( Resident 22-bowel issues) and (Resident 27-skin issues). Findings include: 1. A record review was completed on 4/23/2025 at 9:01 A.M. for Resident 22. Diagnoses included, but were not limited to, Parkinson's disease and chronic kidney disease. A Significant Change Minimum Data Set (MDS) assessment, dated 1/29/2025, indicated Resident 22's cognition was moderately impaired and he was occasionally incontinent of bowels. Physician Orders included, but were not limited to: -3/20/2025 Linzess 145 micrograms (mcg) by mouth daily for constipation. -3/13/2025 polyethylene glycol 17 grams by mouth daily mixed with 4-8 ounces of water for constipation. -12/10/2024 docusate sodium 100 milligrams (mg) by mouth twice a day for constipation. The record lacked a care plan that addressed bowel issues, including constipation, and the use of bowel medications. During an interview on 4/25/2025 at 1:40 P.M., the ADON confirmed although Resident 22 received three different medications for his bowels, there was no care plan addressing the bowel issues or medication use. 2. During an observation of a medication administration on 04/23/2025 at 8:51 A.M., Resident 27 had a dime-sized blister located directly below the G-tube site on his abdomen. LPN 4 indicated the blister was new and attributed it to friction caused by the G-tube tubing being too long. LPN 4 pointed to a band-aid located toward the center of Resident 27's abdomen and indicated the resident had developed a similar blister several days earlier due to friction from the tubing rubbing on the resident's skin. LPN 4 indicated the resident did not have an order for the treatment of the second blister and she did not know if the facility had created a Care Plan to address further blister formation from the G-tube. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but were not limited to: cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. An admission Minimum Data Set (MDS) assessment, dated 1/28/2025, indicated the had a G-tube. There was no care plan for Resident 27 to address the skin issues caused by his gastostomy tube. A Nurse's Progress Note, dated 04/21/2025, indicated, Blister noted to belly near G-Tube holder, red, unopened, possibly due to friction and rubbing of G-tube and clamp. Repositioned tubing, secured with paper tape and blister covered with band aid for protection. Clinical Care Coordinator (CCC) was aware. During an interview with the Director of Nursing (DON) on 4/25/2025 at 10:59 A.M., the DON indicated Resident 27 should have had a G-tube care plan created after admission. On 4/25/2025 at 1:18 P.M., the Director of Nursing (DON) indicated the facility did not have a policy related to creating care plans and the facility used the Nursing Standards of Practice for creating care plans. American Nurses Association (ANA), Nursing: Scope and Standards of Practice, 4th Edition, 2021, included, The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes. The plan reflects current evidence, is derived from the assessment, and is modified as needed in response to the patient's condition or situation 3.1-35 (d)

Based on observation, interview and record review, the facility failed to ensure the skin of a resident with a Gastronomy tube (G-tube) did not develop blisters caused by the friction from the G-tube for of 1 of 6 residents who were reviewed for skin problems. (Resident 27) Finding includes: During an observation of a medication administration on 04/23/2025 at 8:51 A.M., Resident 27 had a dime-sized blister directly located below the G-tube site on his abdomen. LPN 4 indicated the blister was new and attributed it to friction caused by the G-tube tubing being too long. LPN 4 pointed to a band-aid located toward the center of Resident 27's abdomen and indicated the resident had developed a similar blister several days earlier due to friction from the tubing rubbing on the resident's skin. LPN 4 indicated the resident did not have an order for the treatment of the second blister and she did not know if the facility had created a Care Plan to address further blister formation from the G-tube. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but were not limited to: cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. A Nurse's Progress Note, dated 04/21/2025, indicated, Blister noted to belly near G-Tube holder, red, unopen, possibly due to friction and rubbing of G-tube and clamp. Repositioned tubing, secured with paper tape and blister covered with band aid for protection. Clinical Care Coordinator (CCC) was aware. Resident 27's record lacked the documentation that the provider had been notified of the new blister, orders for treatment of the new blister had been obtained, or a Care Plan had been created after either blister developed. During an interview with the CCC and the Director of Nursing (DON) on 4/25/2025 at 10:59 A.M., the CCC indicated she had been notified verbally about the blister but because the notification was verbal, she had forgotten to follow up. The CCC indicated the provider and family had not been notified but should have been and the resident's plan of care should have been updated. The CCC indicated, in addition, physician orders should have been obtained regarding treatment of the blister and preventative treatments for the G-tube site. The DON indicated Resident 27 should have had a care plan created for a G-tube after the first blister had formed On 4/25/2025 at 1:18 P.M., the Director of Nursing (DON) indicated the facility did not have a policy for contacting the provider for a change in the resident's condition or a policy related to creating care plans. The DON indicated the facility used the Nursing Standards of Practice for contacting the provider and creating a care plan. American Nurses Association (ANA), Nursing: Scope and Standards of Practice, 4th Edition, 2021, included, The registered nurse communicates effectively in all areas of practice. This includes timely and appropriate communication with healthcare providers regarding changes in patient condition The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes. The plan reflects current evidence, is derived from the assessment, and is modified as needed in response to the patient's condition or situation. 3.1-37 (a)

Based on record review and interviews, the facility failed to ensure there was adequate monitoring of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 25) Findings include: A record review for Resident 25 was completed on 4/23/2025 at 4:01 P.M. The resident's diagnoses included, but were no limited to: hypertension, diabetes mellitus, anxiety, depression, bipolar disorder and hereditary and idiopathic neuropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 4/15/2025, indicated Resident 25 was cognitively intact. The MDS assessment indicated the resident had no potential indicators of psychosis, no behavioral symptoms, had not demonstrated any rejection of care and had no wandering behaviors. In addition, the MDS assessment indicated the resident was receiving an antipsychotic, an antidepressant, an anticoagulant and a diuretic medication. A Physician Order, dated 2/20/2025, indicated the resident was to receive Aripiprazole (anti-psychotic) 2 mg (milligrams) tablet oral six times weekly for bipolar disorder. A Pharmacy Consultation Report, dated 8/8/2024, recommended an AIMS (Abnormal Involuntary Movement Scale) or similar assessment be completed for Resident 25, as one had not been completed in the previous 6 months. A Pharmacy Consultation Report, dated 9/17/2024, indicated a second request for an AIMS assessment, or similar assessment, be completed for Resident 25. The recommendation was signed by the medical provider. However, an AIMS assessment was not completed for Resident 25 until 1/19/2025. A current Care Plan, revised 1/19/2025, indicated Resident 25 had a diagnosis of bipolar disorder and was treated with an antipsychotic medication. Interventions included, but were not limited to: perform an AIMS test quarterly and as needed. During an interview, on 4/24/2025 at 3:22 P.M., the Assistant Director of Nursing (ADON) indicated Resident 25 has been on an antipsychotic and had an AIMS assessment completed in January and April of 2025. The ADON indicated the facility's policy was for nursing to complete AIMS assessments for residents taking antipsychotic medications every quarter or with any new dosage changes. During an interview, on 4/25/2025 at 10:02 A.M., the Social Services Worker (SSW) indicated she created the care plans for the residents in conjunction with the Unit Manager. SSW indicated the interventions in the care plan were monitored for completion by herself and the Unit Manager or other nursing management. SSW indicated she was unsure how the completion of AIMS assessments were being monitored. During an interview, on 4/25/2025 at 2:52 P.M., the ADON indicated there was no written facility policy regarding AIMS but that the facility standard was to perform an AIMS assessment every 6 months on any resident taking an antipsychotic. 3.1-25(i)

Based on observation and interview, the facility failed to ensure the kitchen equipment was in working order for 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 66 of 66 residents who received meals from the kitchen. Finding includes: On 4/21/2025 at 9:26 A.M., an observation included the northernmost sink of the cooking area of the kitchen. This sink was leaking underneath into the drainage area from the drain pipe in addition to the faucet slowly running and unable to be turned off. During an interview, on 4/21/2025 at 10:15 A.M., the Dietary Manager indicated Maintenance was aware of the broken sink and she indicated maintenance was waiting for a part to fix the sink. During an interview, on 4/24/2025 at 1:44 P.M., the Maintenance Director indicated he had never received a work order for the kitchen sink and was unaware of any broken sink in the kitchen. During an interview, on 4/24/2025 at 1:51 P.M., Registered Dietician 1 indicated she was unaware of any leaking sink in the kitchen and stated, I usually just go through there and haven't noticed anything. On 4/24/2025 at 3:15 P.M., the Director of Nursing (DON) provided a policy titled, Director of Dining Services, undated and indicated the policy was the one currently used by the facility. The policy indicated, .the Director of Dining Services .directs and conducts safety, sanitation, and maintenance programs . On 4/24/2025 at 3:15 P.M., the DON provided a policy titled, Registered Dietitian, undated and indicated the policy was the one currently used by the facility. The policy indicated, .The Registered Dietitian .set and communicate objectives, communicate, and reinforce high standard in all areas, monitor performance and addresses issues . 3.1-19(bb)

2. During an observation of a medication administration on 04/23/2025 at 8:51 AM, LPN 4 administered a 200 milliliter (mL) water flush to Resident 27 Gastrostomy tube while only wearing gloves. LPN 4 was not wearing a gown when she administered the flush. An Enhanced Barrier Precautions (EBP) sign was hanging on Resident 27's to room door. During an interview on 04/23/2025 at 8:58 AM, LPN 4 indicated Resident 27 was in EBP and she should have worn a gown while administering the flush. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but were not limited to: cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. A current Physician's order, dated 02/04/2025, indicated Resident 27 was on EBP. A current Care Plan, initiated on 01/28/2025, indicated Resident 27 was on EBP related to a Gastrostomy Tube (G-tube). On 04/23/2025, the Assistant Director of Nursing (ADON) provided a policy, dated 11/12/2024, and titled Infection Prevention. The ADON indicated it was the policy currently used by the facility. The policy indicated: .2. Enhanced Barrier Precautions .The use of gown and gloves for high-contact resident care activities may be indicated, when Contact Precautions do not otherwise apply, for nursing home residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization 3.1-18(a) Based on observation, record review and interview, the facility failed to ensure enhanced barrier precautions were followed for 2 of 5 residents reviewed for isolation needs. (Resident 27 and 35) Findings include: 1. The clinical record of Resident 35 was reviewed on 4/24/2025 at 10:26 A.M. The resident's diagnoses included, but were no limited to: diabetes mellitus, septicemia, obstructive uropathy, hypertension, anxiety and depression. An Annual Minimum Data Set (MDS) assessment, dated 2/24/2025, indicated Resident 35 was moderately cognitively impaired, was taking an antibiotic and had an indwelling catheter. A Physician Order, dated 10/19/2024, indicated Resident 35 was to be in enhanced barrier precautions; with instructions noted to maintain enhanced barrier precautions during high-contact resident care activities. A current Care Plan, created 5/31/2024, indicated Resident 35 required enhanced barrier precaution isolation. During an observation and interview on 4/24/2025 at 11:08 A.M., CNA 3 entered Resident 35's room without any PPE (personal protective equipment or gear worn to minimize exposure to workplace hazards that could cause serious injuries or illnesses, such as chemical, radiological, physical, electrical, or mechanical hazards) in place. The PPE cart was located outside of the resident's room door. CNA 3 then performed hand hygiene with hand sanitizer and donned clean gloves once inside Resident 35's room but she did not don a gown or a mask. CNA 3 then transferred Resident 35 from her bed to her wheelchair. CNA 3 exited Resident 35's room after removing her gloves and performed hand hygiene. CNA 3 indicated she was unaware the resident was on contact precautions as CNA 3 indicated the nurse had not instructed her regarding the need for enhanced barrier precautions. CNA indicated if the resident was on enhanced barrier precautions, she should have been following the policy and worn a gown and mask.

Based on observation and interview the facility failed to ensure water faucets were functional in 4 of 30 rooms in the long term care unit. (Rooms W7, W12, W15 and W24) Findings include: 1. During an observation on 4/25/2025 at 2:00 P.M., the faucet in Room W7 was running and could not be turned off. During an interview on 4/25/2025 at 2:00 P.M., Resident 57 indicated it had been running for quite awhile but did not know how long. She had reported it to the facility but it had not been fixed yet. She indicated she turned her television volume up louder so she forgot about it and was able to sleep. 2. During an observation of Room W24 on 4/22/2025 at 11:12 A.M., the faucet was missing and water was continuously dripping down the back of the sink. 3. During an observation of W15 on 4/22/2025 at 9:44 A.M., the faucet was dripping continuously. 4. During an observation of Room W12 on 4/22/2025 at 9:45 A.M., the faucet was dripping continuously. During a tour and an interview on 4/25/2025 at 2:35 P.M., the Maintenance Director indicated he had tried to fix the faucets but they needed to be replaced and he was not sure how many leaking sinks the facility had but admitted there were several. He indicated he had ordered new parts several months ago, and the parts had come in, but he was now waiting on a new tool that he had ordered. When asked when the tool was ordered he returned with the tool indicating it had just been delivered, and he would begin fixing the leaking faucets. On 4/25/2025 at 2:35 P.M. dates of work orders for leaking faucets and invoices, or purchase orders for parts and tools were requested, but none were provided prior to the exit of the survey. During an interview on 4/28/2025 at 11:00 A.M., the ED. indicated the facility did not have a policy for maintenance of the building. 3.1-19(f)

Based on record review and interviews the facility failed to ensure a resident received the required transfer assistance for 1 of 2 residents reviewed for accident hazards. (Resident E) Finding includes: The record for Resident E was reviewed on 6/24/24 at 1:41 P.M. Resident E's diagnoses, included but were not limited to: cerebrovascular accident and osteoporosis. The admission Minimum Data Set (MDS) assessment, dated 5/29/24, indicated Resident E's cognition was moderately impaired and she was dependent on staff to complete all activities of daily living (ADLs) including transfers. A care plan for Resident E, dated 5/23/24, indicated the resident had a self care deficit related to right side hemiparesis and staff were to transfer the resident with the extensive assistance of 2 staff members. During an interview on 6/24/24 at 1:53 P.M., Resident E's family member indicated during her visit on 6/6/24, the resident told her she had fallen and her leg was injured. During an interview on 6/24/24 at 1:42 P.M., the DON indicated during the investigation of the incident regarding a potential fall for Resident E and leg injury, all staff who had cared for Resident E on 6/6/2024 were interviewed and no one was aware and/or had witnessed any falls for Resident E. However, a CNA reported she had transferred the resident without any assistance from another staff person. An x-ray was completed on 6/8/24 for Resident E and indicated the resident had a non-displaced fracture of the right tibia and fibula. The Nursing Progress notes, dated 6/8/24, indicated the resident's family member was notified of the fracture, the resident was sent to the emergency room for an evaluation and was later admitted to the hospital. During an interview on 6/25/24 at 11:54 A.M., CNA 3 indicated when she received her assignments for her shift she checked the computer for any care information for her residents. There was a Resident Care Summary posted on the inside of the resident's closet doors. If a resident required a 2 person transfer, she would ask a co-worker for help. If another CNA was not available she would ask the nurse or a staff member from a nearby unit for help. CNA 3, when asked directly why she had transferred Resident E by herself previously, gave no reason for the incorrect transfer. CNA 3 kept repeated the above information regarding where she obtained resident information regarding the care needs of her assigned residents. During an interview on 6/25/24 at 11:32 A.M., the DON indicated the facility did not have a policy regarding following resident's plan of care. She initiated there had not been any other issues or resident injuries reported regarding CNA 3 not following the plans of care. This citation relates to complaint IN00436381. 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide the resident or representative, a notice of transfer/discharge or a copy of the bed hold policy for 1 of 1 resident reviewed for hospitalizations. (Resident 65) Finding includes: During an interview, on 5/14/24 at 10:29 A.M., Resident 65 indicated he was hospitalized a couple of weeks ago but could not recall why. A record review for Resident 65 was conducted on 5/16/24 at 9:31 A.M. Diagnoses included, but were no limited to, partial amputation of right foot and diabetes mellitus. A Five Day Minimum Data Set assessment, dated 4/19/24, indicated Resident 65 had an intact cognition Nursing Progress Notes, dated 5/1/24, indicated Resident 65 was sent to the emergency room for a change in condition and was admitted to the acute care center with a diagnosis of pneumonia. The record lacked documentation a notice of transfer/discharge or a bed hold policy was given to the resident when he was sent to the emergency room. During an interview, on 5/17/24 at 2:23 P.M., the DON indicated she was unable to find tdocumentation Resident 65 was provided a notice of transfer/discharge or a copy of the bed hold policy for the 5/1/24 admission to the hospital. On 5/20/24 at 3:24 P.M., the DON provided a checklist form for transfers and indicated there was not a policy that addresses documents that should be sent when a resident goes to the hospital but she did provide a checklist. 3.1-12(a)(25)(26)

Based on record review and interview, the facility failed to develop a person-centered care plan addressing depression for 1 of 21 residents whose care plans were reviewed. (Resident 53) Finding includes: A record review was completed on 5/15/2024 at 12:22 P.M. for Resident 53. Diagnoses included, but were not limited to major depressive disorder, chronic obstructive pulmonary disease, and heart failure. A Care Plan, dated 4/29/2024, indicated Resident 53 had mood and behavior concerns related to depression. Interventions included: administer medications as ordered; provide a calm and quiet environment; monitor for triggers of mood changes and provide appropriate interventions as needed. There were no specific interventions to address what specific triggers the resident exhibited or what appropropriate interventions were planned for Resident 53. During an interview, on 5/20/2024 at 10:08 A.M., the Assistant Director of Nursing indicated Resident 53 did not have person-centered interventions for her Care Plan. A policy for developing person-center care plans was requested from the Director of Nursing, on 5/20/2025 at 10:30 A.M. During an interview on 5/20/2024 at 1:22 P.M., the Director of Nursing indicated the facility did not have a policy for person-centered care plans. 3.1-35(a)

Based on record review, and interview, the facility failed to ensure care plans were revised and care conferences were held quarterly for 2 of 3 residents reviewed for care planning. (Resident 37 & 58) Finding include: During an observation, on 5/14/2024 at 3:18 P.M., Resident 37's right hand was contracted and there was no splint on the resident's right hand. During an observation, on 5/15/2024 at 9:16 A.M., Resident 37 was wearing a soft splint to her right hand. During an observation, on 5/17/2024 at 9:11 A.M., Resident 37 was not wearing a soft splint to her right hand. A Physicians Order, dated 8/31/2019, indicated to apply a soft resting hand splint to the right hand daily, place on prior to bed and take off upon rising. A Care Plan, dated 5/22/2020, indicated the following: -I have right side hemiparesis related to cardiovascular accident. Interventions included: I wear a soft splint to my right hand, on in AM, off HS (hour of sleep). -I have self care deficits associated with need for assistance with activities of daily living (ADL's). Interventions included: right soft resting hand splint to right hand daily ON PB (prior to bed). - I am at risk for skin breakdown. Interventions included: right soft resting hand splint to right hand daily, on prior to bed, off at hour of sleep. During an interview, on 5/17/24 at 1:26 P.M., LPN 14 indicated Resident 37's soft right hand splint got put on in the evening prior to bed time and removed upon waking. She indicated the care plan needed to be revised. On 5/20/24, at 3:31 P.M., a policy for revising care plans was requested and one was not provided prior to the survey exit. During an interview, on 5/15/24 at 9:18 A.M., Resident 37's family indicated it had been more than a year since they had been invited to a care conference. A record review was completed on 5/16/24 at 9:56 A.M., for Resident 37. Diagnosis included, but were not limited to: Type 2 diabetes, aphasia, major depressive disorder, and dementia. There was no documentation in the record to indicate Resident 37 had a care conference conducted since 3/30/2023. During an interview, on 5/20/24 at 3:25 P.M., the DON indicated Resident 37 had not had a care conference in the last year and should have. 2. A record review was completed, on 5/16/24 at 3:12 P.M., for Resident 58. Diagnoses included, but were not limited to scoliosis, hypertensive heart disease, adjustment disorder with anxiety and depressed mood, and insomnia. During an interview, on 5/14/24 at 10:03 A.M., Resident 58's family indicated it had been 6-9 months since they were invited to a care conference. There was no documentation int he record to indicate Resident 58 had a care conference conducted between 6/27/23 and 3/21/24. During an interview, on 5/20/24 at 3:25 P.M., the DON indicated Resident 37 and Resident 58 did not have a care conference every quarter and should have had one scheduled. On 5/20/24, at 3:28 P.M., a policy for care conferences was requested and one was not provided prior to the survey exit. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to bed baths, shaving, and turning and positioning per standards of care for 2 of 3 residents reviewed for ADL care. (Resident 37 & 46) Finding includes: 1. During an observation, on 5/14/24 at 3:18 P.M., Resident 37's fingernails were long and dirty. During an observation, on 5/15/2024 at 9:16 A.M., Resident 37's fingernails remained long and dirty. During an observation, on 5/16/2024 at 10:19 A.M., Resident 37's fingernails remained long and dirty. A record review was completed on 5/16/2024 at 9:56 A.M. for Resident 37. Diagnoses included, but were not limited to hemiplegia and hemiparesis, type 2 diabetes, major depressive disorder, dementia, and aphasia. A Quarterly Minimum Data Set (MDS) assessment, dated 3/6/2024, indicated that Resident 37 had severely impaired cognition and was dependent on staff with bed mobility, transfers, dressing, toileting, hygiene and bathing, and required a mechanical lift (hoyer) with two staff for transfers. A current Care Plan, dated 8/8/2019, was provided and indicated Resident 37 required staff assistance with deficits of activities of daily living (ADLs) with a current intervention of Assist with personal hygiene. On 5/20/2024 at 10:30 A.M., Resident 37's shower record from 3/8/2024 to 5/16/2024 was provided by the Administrator. Resident 37 received one bed bath between 4/16/2024 and 4/30/2024, and one bed bath between 5/3/2024 and 5/13/2024, with no refusals of care documented for that time period. During an interview, on 5/16/24 at 11:01 A.M., CNA 13 indicated during a sponge bath warm water and soap were used and staff washed the resident's entire body. Nail care was included in sponge baths and whenever staff observed the resident needed it. During an interview, on 5/21/24 at 09:11 A.M., the DON indicated the resident should have had additional bed bath during the timeframe where there were large gaps between dates. 2. During an interview on 5/15/2024 at 9:25 A.M., Resident 46 indicated that he never gets shaved unless CNA 12 worked, she was the only one who shaved him. When he lived at home, he shaved every day, and he preferred to be shaved daily. He was observed to be unshaven at the time of the interview During an observation on 5/15/2024 at 2:56 P.M., he was remained unshaved. During an observation and interview on 5/16/2024 at 10:44 A.M., Resident 46 indicated he had not been washed up yet or shaved today and his call light was on to be changed. During an observation and interview on 5/16/2024 at 3:05 P.M., Resident 46 indicated he was not shaved today, facial hair was present. During an observation on 5/17/2024 at 9:15 A.M., Resident 46 was unshaven. During an observation on 5/17/2024 at 2:08 P.M., Resident 46 was unshaven. During an observation and interview on 5/20/2024 at 9:24 A.M. Resident 46 indicated he had not been shaved all weekend, he had an increased growth of whiskers. During an observation on 5/21/2024 at 9:35 A.M., Resident 46 was unshaven. A record review was completed on 5/17/2024 at 9:05 A.M. for Resident 46. Diagnoses included, but were not limited to cardiovascular accident, hemiplegia, hemiparesis, peripheral vascular disease and depression. A Quarterly Minimum Data Set Assessment, dated 4/24/2024, indicated Resident 46 was dependent for oral hygiene, personal hygiene, shower/bath, upper and lower body dressing, toileting, transfers and bed mobility. He had limited range of motion on one side to the upper and lower body extremity. A Care Plan, dated 2/12/2019, for self care deficit associated with need for assistance with ADL's related to history of cerebrovascular accident resulting in left sided weakness, included a goal the for the resident to be neat, clean and well-groomed. A Resident Summary on activities of daily living care/bathing, dated 1/3/2022, indicated Resident 46 was extensive assist of 2 with a hoyer lift for transfers and bed mobility, supervision with eating, assist with oral care twice daily, expressed a shower preference of twice a week and had full dentures. On 5/17/2024 at 11:30 A.M., the DON indicated resident preferences could be found on the resident's summary. During an interview on 5/16/2024 at 1:42 P.M., CNA 5 indicated when she completed morning care, she washed the resident's underarms and peri-area, brushed the resident's teeth, applies lotion, combed the resident's hair and made the bed. During an interview on 5/16/2024 at 2:01 P.M., CNA 6 indicated that when she completed morning care, she provided a bed bath, applied lotion, assisted with dressing, brushed the resident's teeth, combed the resident's hair and offered a shave. During an interview on 5/17/2024 at 9:18 A.M., CNA 7 indicated that when she completed morning care, she washed the resident's upper body, then peri-area, put on a brief, assisted with dressing, and brushed the resident's teeth. During an interview on 5/20/2024 at 11:13 A. M., the Director of Nursing indicated she did not have a policy on activities of daily living or shaving. During an interview on 5/15/2024 at 9:25 A.M., Resident 46 indicated that the staff did not turn him every two hours. He indicated he would like to get the pressure off his buttock, he became sore at times and rarely got out of bed. During an observation and interview on 5/16/2024 at 10:44 A.M., Resident 46 indicated he had not been washed up yet or shaved today and his light was on to be changed. Resident 46 was lying in a supine position in bed. During an observation on 5/16/2024 at 3:05 P.M., Resident 46 was on his back in bed. During an observation on 5/17/2024 at the following times: 9:15 A.M., 10:28 A.M., 11:48 A.M., 1:18 P.M., 2:08 P.M., resident was in bed positioned on his back. During an interview on 5/17/2024 at 11:48 A.M., Resident 46 indicated no one has turned and repositioned him today. During an observation on 5/20/2024 at the following times: 9:24 A.M., 11:50 A.M. and 2:37 P.M. the resident was lying on his back in bed. During an observation on 5/21/2024 at 9:35 A.M., the resident was lying on his back in bed. The CNA documentation on turn and reposition for Resident 46 in the electronic medical record indicated the following:: 5/14/2024 1:51 P.M. 5/14/2024 9:13 P.M. 5/15/2024 3:20 A.M. 5/15/2024 11:29 A.M. 5/15/2024 2:25 P.M. 5/16/2024 12:10 A.M. 5/16/2024 2:08 P.M. 5/16/2024 3:46 P.M. 5/16/2024 11:52 P.M. 5/17/2024 10:35 A.M. 5/17/2024 9:49 P.M. 5/18/2024 12:43 A.M. 5/18/2024 12:59 P.M. 5/18/2024 7:13 P.M. 5/19/2024 5:40 A.M. 5/19/2024 9:23 P.M. 5/20/2024 3:59 A.M. 5/20/2024 10:50 A.M. 5/20/2024 9:25 P.M. 5/21/2024 12:14 A.M. A Care Plan, dated 2/12/2019, for risk for skin breakdown related to left side hemiparesis, weakness, and history of cerebrovascular accident, with an intervention to assist with turning and repositioning as directed on resident summary. A Resident Summary for Resident 46, , on mobility/specialized devices dated 9/16/2021, indicated to ensure resident is lying in the middle of the bed, and position the legs and feet to prevent pressure injuries. Skin care dated 9/16/2021 indicated care of the supra pubic catheter to prevent skin breakdown. During an interview on 5/17/2024 at 11:40 A.M., CNA 7 indicated when she took care of a dependent resident, she would turn and reposition them every two hours, and do range of motion, provided a drink of water, if nothing by mouth (NPO) she would provide oral care every time she changed them. During an interview on 5/17/2024 at 11:43 A.M., CNA 8 indicated when she took care of a dependent resident, she checked and changed them every two hours and assisted with meals if needed. During an interview on 5/21/2024 at 9:11 A.M., the DON indicated the resident summary did not mention turning and repositioning the resident, she would expect her staff to do rounds every couple of hours to keep residents clean and repositioned. The staff were not charting in the kiosk like she would prefer regarding turning and repositioning of residents. She indicated there needed to be more information be added to the resident summary. On 5/20/2024 at 11:13 A.M., the DON indicated they did not have a policy regarding turning and repositioning or completing the resident summary. 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to ensure a resident with a limited range of motion received appropriate treatments and services to prevent further decrease in range of motion for 1 of 3 residents for range of motion. (Resident 46) Finding includes: During an interview and observation on 5/15/2024 at 9:35 A.M., Resident 46 indicated RN 4 is was the only nurse that put his left hand splint on him. There was no splint observed on the resident's left hand. During an observation and interview on 5/16/2024 at 10:42 A.M., the resident was awake and indicated he had not seen his nurse today. The resident did not have a splint on his left hand. During an observation on 5/17/2024 at 10:59 A.M. at 10:59 A.M., 1:18 A.M., and 2:09 P.M. Resident 46 did not have a left hand splint on. The splint was noted on the nightstand. During observations on 5/20/2024 at 9:25 A.M., 11:49 A.M., and 2:37 P.M., Resident 46's left hand splint was not on the resident's hand. The splint was observed on the top of his nightstand. During an observation on 5/21/2024 at 9:35 A.M., Resident 46 was awake and his hand splint was not on the left hand. A record review was completed on 5/17/2024 at 9:05 A.M., for Resident 46. Diagnoses included, but were not limited to cardiovascular accident, hemiplegia, hemiparesis, peripheral vascular disease and depression. A Physician Order, dated 11/3/2022, indicated : orthosis/splint two times a day, apply to the left hand resting splint, on upon risking and off prior to bed. A Care Plan for self- care deficit, dated 2/12/2019, included an intervention to apply left hand resting splint upon rising and may remove prior to bed and for hygiene and skin inspection. The May 2024 TAR (Treatment Administration Record), indicated that the splint was applied on the following dates: 5/15/2024, 5/16/2024. 5/17/2024 and 5/20/2024. During an interview on 5/20/2024 at 3:30 P.M., the DON indicated the day nurse was finishing her end of shift report and had not completed her scheduled day shift treatments. During an interview on 5/21/2024 at 9:26 A.M., the DON indicated she would expect her staff to follow the physician's orders for splints/braces. During an interview on 5/21/2024 at 9:31 A.M., LPN 9 indicated that Resident 46 wore a left hand splint and she sometimes put it on him after noon, even though the order was upon rising. She completed her treatment last because the med pass was so heavy and sometimes she did not finish until 5:00 P.M. During an interview on 5/21/2024 at 9:26 A.M., the DON indicated there had no policy for splint or braces 2.1-42(a)(2)

Based on observation and interview, the facility failed to ensure medications stored in the med cart were labeled according to accepted professional standards for 1 of 3 medication carts observed. (St. John's Way medication cart) Finding includes: During an observation of the medication cart on St. John's Way, on 5/20/24 at 10:16 A.M., with LPN 11, a half full bottle of milk of magnesia was found without a pharmacy label or any information to identify the resident to whom it belonged. During an interview, on 5/20/24 at 10:16 A.M., LPN 11 indicated she did not know to whom the milk of magnesia belonged. She did not know why it was there and it should not be kept in the cart. Resident medications were kept in their room in a locked cabinet. On 5/20/24 at 2:07 P.M., the Executive Director provided a policy titled, Storage and Expiration Dating of Medications, Biological's, dated 8/7/23, and indicated the policy was the one currently used by the facility. The policy included, but was not limited to, .Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels 3.1-25(j)

Based on observation, interview, and record review, the facility failed to follow standards of practice for infection control to help prevent the development and transmission of communicable diseased and infections for 1 of 3 residents who received pressure ulcer care requiring enhanced barrier precautions (EBP) and 1 of 4 residents observed during medication administration. (Residents 181 and 16) Findings include: 1. During an observation, on 5/17/24 at 11:41 A.M., RN 10 was documenting on the computer immediately before donning gloves to perform a blood glucose check for Resident 181. He did not wash his hands prior to donning the gloves. He cleansed the resident's finger with an alcohol swab and fanned the area with his gloved hand. During an interview, on 5/17/24 at 11:45 A.M., RN 10 indicated he should have washed his hands before applying the gloves and did not know fanning the swabbed area was an infection control issue. 2. During an observation of wound dressing change for Resident 16 on 5/17/2024 at 1:53 P.M., LPN 9 applied alcohol based hand rub (ABHR), donned gloves and soaped up washcloths, placed them on a towel on the bed, removed the resident's ace wrap and the soiled dressing from his heel. Next, she picked up the washcloths, cleaned the wound, then applied the treatment, kerlix and ace wrap. She then gathered the trash, removed her gloves and washed her hands. Prior to the dressing change the nurse did not don a gown. There was no isolation signage on the door and no isolation supplies noted in the room or just outside the room in the hallway. A record review was completed on 5/16/2024 at 1:53 P.M., for Resident 16. Diagnoses included, but were not limited to type 2 diabetes, peripheral vascular disease and chronic kidney disease. A Physician Order, dated 5/15/2024, indicated wound care for a stage 3 pressure ulcer: cleanse the right heel with soap and water, pat dry, apply collagen to wound base, cover with ABD and wrap with rolled gauze. The dressing was to be changed daily and as needed. A Physician Order, dated 5/1/2024, indicated Enhanced Barrier Precautions (EBP), maintain EBP during high contact resident care activities. An undated active Care Plan indicated: EBP due to the wound on the heel. An undated active Care Plan for at risk of complications related to right heel stage 3 included an intervention for staff to perform treatment as ordered. During an interview on 5/17/2024 at 2:00 P.M., LPN 9 indicated after she removed a soiled dressing, she should continue to follow the orders. ecause she had a wound, she did not put on the required personal protective equipment (PPE) because it was not available in the resident's room. She indicated she would have put it on if it had been in the room During an interview on 5/17/2024 at 2:37 P.M., the Director of Nursing indicated when a dressing change was done, she would expect the staff member to gather supplies, wash their hands, remove the soiled dressings, then remove their gloves and wash their hands and put clean gloves on, then cleanse the wound per treatment order, secure, pick-up trash, remove gloves and wash their hands. When completing a treatment in an EBP room, a gown and gloves should be worn during a wound dressing change. On 5/20/2024 at 9:13 A.M., the DON indicated they do not have a policy on dressing changes, but they followed the standard of practice, physician orders and handwashing. On 5/20/2024 at 11:29 A.M., the DON provided a policy titled, Hand Hygiene, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Hand hygiene occurs before and after direct resident contact. Hand hygiene occurs after contact with blood, body fluids, secretions, excretions, and equipment, or contaminated articles . On 5/21/2024 at 8:37 A.M., the DON provided a policy titled, Enhanced Barrier Precautions, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Gloves and Hand Hygiene - Wear gloves during the course of providing high contact resident care. - Avoid contaminating other surfaces with gloved hand, - Remove gloves before leaving the resident's room and immediately wash hands with an antimicrobial agent or use waterless hand sanitizer. Gown- Wear gown during high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. - Remove gown before leaving the room and immediately perform hand hygiene . 3.1-18(l)

Based on interview, observation and record review, the facility failed to maintain appropriate food temperatures of the meal trays on St. Paul's Unit. This had the potential to affect the 21 Residents who eat on St. Paul's Unit. Finding includes: During an interview, on 4/15/2024 at 11:15 A.M., Resident 117 indicated he ate his meals in the dinning area on the unit and most of his meals were cold. Resident 117 was able to request to have his meals heated to a warmer temperature, but stopped asking because every meal was cold. An observation of food temperatures for the meal trays on St. Paul's Unit was completed, on 5/20/2024 at 12:13 P.M. The Dietary Project Manager pulled the first tray off the food cart and used her thermometer to take the temperature of the food. The cabbage had a temperature of 135 degrees Fahrenheit and the pot roast had a temperature of 141 degrees Fahrenheit. The Dietary Project Manger requested a dietary aide begin microwave each plate. There were 21 trays on the food cart. During an interview, on 5/20/2024 at 12:15 P.M., the Dietary Project Manager indicated the cabbage and pot roast were not at the correct temperature to serve and all the meals trays on St. Paul's Unit would have to be heated in the microwave until the food was 145 degrees Fahrenheit. On 5/20/2024 at 2:13 P.M., the Administrator provided a current policy, dated 1/2024, and titled, Meal Quality and Temperature. The policy indicated, .Food and drinks are palatable, attractive and served at a safe and appetizing temperature to ensure resident satisfaction and to meet nutrition and hydration needs 3.1-21(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner in 1 of 1 kitchens observed. The facility also failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety and used for food and beverages only for 4 of 4 panty rooms observed. This deficient practice had the potential to affect 76 of 77 residents who resided in the facility and consumed from from the kitchen or pantries Findings include: 1. Upon entering the kitchen on 5/14/2024 at 9:05 A.M., on top of the ice machine was 2 scoops lying uncovered, and the storage container was open but empty. During an interview on 5/14/2024 at 9:06 A.M., the Dietary Supervisor indicated that the scoop storage container was broken, and they had just been laying the scoops on top of the machine, another container had been ordered. On 5/15/2024 at 3:33 P.M., the Administrator provided a policy titled, Sanitation and Infection Prevention/Control, dated 1/24 and indicated the policy was the one currently used by the facility. The policy indicated .Use a scoop to remove ice from the storage bin into the receptacle used for service. Store the scoop in a self-draining container, in an area protected from contamination. The scoop cannot be stored in the ice bin, unless the container for the scoop is placed in a way that does not allow the ice scoop handle to come in contact with the ice . 2. On 5/14/2024 at 9:07 A.M. to 9:44 A.M., an initial tour of the kitchen was completed with the Dietary Supervisor and the following was observed: a. Dry storage there was a bag of stuffing with an open date of 4/7/2024 with a best used by date of 4/10/2024, a bag of wheat pasta opened 12/12/2023 with best used by date of 5/9/2024, a bag of ziti noodles opened 3/23/2023 with best used by date of 3/21/2024, a box of Orzo opened 4/20/2024 with best used by date of 4/23/2024 and a container of coriander spice expired 2/27/2024. b. In the freezer the following items were opened, unsealed and undated: a box of cooked sausage crumble, chicken Kiev portions, pate scones, cookies and green beans. There was also an opened unsealed bag of carrots open dated 5/11/2024 and [NAME] fish dated 5/11/2024. During an interview on 5/14/2024 at 9:17 A.M., the Dietary Supervisor indicated the food should be dated when open and sealed. On 3/15/2024 at 3:24 P.M., the Administrator provided a policy titled, PRODUCTION, PURCHASING, STORAGE, FOOD AND SUPPLY STORAGE, dated 1/24, and indicated the policy was the one currently used by the facility. The policy indicated, .Most but not all products contain an expiration date. The words sell-by, best-by, enjoy by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the used-by, sell-by, best-by, or enjoy-by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label. 3. During a follow up observation in the kitchen, on 5/16/2024 at 11:10 A.M.,the Sous Chef 2 was pureeing zucchini and pasta. The Sous Chef had a mustache and a goatee, approximately 1/4 inch long, neatly trimmed, without a hair restraint. During an interview on 5/16/2024 at 11:26 A.M., the Sous Chef indicated he did not have to wear a hair restraint because he kept it short. The State allowed it. The Project Manager handed him a hair restraint. On 5/16/2024 at 12:10 P.M., the Project Manager provided a policy titled, Safety and Sanitation, Hair Restraints/Beard Guards, revised 2/2018, and indicated the policy was the one currently used by the facility. The policy indicated .Beards* are not recommended for any team member who handles food however if a team member had a beard/Facial Hair 1/4' growth or more than a beard guard must be worn at all times while in the kitchen and/or handing food. *Please refer to the local state requirements . 4. During a dining room observation on 5/14/2024 at 12:05 P.M., Resident 4 was given his tray with the food covered. At 12:15 P.M., the resident's food was uncovered and CNA 3 sat down to assist the resident with his meal of sandwich and chips. CNA 3 was observed feeding the resident his sandwich and potato chips with her bare hands. During an interview on 5/14/2024 at 12:24 P.M., CNA 3 indicated she should be wearing gloves when assisting with finger-foods, however, the DON had informed her they were not to wear gloves outside the resident's rooms. CNA 3 indicated she was confused regarding when she should be wearing gloves. On 5/15/2024 at 3:29 P.M., the DON indicated they did not have a policy on assisting with meal service with dependent residents or the passing of trays. 5. During an observation on 5/20/2024 at 10:07 A.M., St. John's nourishment refrigerator contained a covered dinner plate with a note stating SAVE containing a chef's salad, a store bag with 4 containers of Okio brand yogurt without a label or date. 6. During an observation on 5/20/2024 at 10:08 A.M., the St. Mark's refrigerator/freezer contained three resident's treatment ice packs in the freezer with ice cream cups. The Project Manager did not know why the treatment ice packs were in the freezer with food items. 7. During an observation on 5/20/2024 at 10:11 A.M., the St. Luke's unit freezer contained had 4 resident's treatment ice packs, along with an unlabeled frozen dinner and ice cream cups. 8. During an observation on 5/20/2024 at 10:18 A.M., the St. [NAME] Way refrigerator contained a cardboard pizza box, dated 5/18/2024 and labeled [first name]. The Project Manager indicated it was a staff member's pizza. 9. During an observation on 5/20/2024 at 10:21 A.M., the St. Paul's refrigerator contained take out containers from the store of chicken [NAME] and 2 salads with Resident 16's name on it, all undated. During an interview on 5/20/2024 at 10:23 A.M., the Project Manager indicated food brought in by the residents needed to be labeled with their name and the date. Employee foods should not have been in the resident refrigerator and residents' treatment ice packs caused cross contamination. On 5/20/2024 at 11:28 A.M., the Project Manager provided a policy titled, Use and STORAGE OF FOOD BROUGHT TO RESIDENTS FROM THE OUTSIDE. revised 1/24, and indicated the policy was the one currently used by the facility. The policy indicated .The outside food must be stored in a container with a tight-fitting lid, clearly labeled with the residents name and room number, the date the food was brought to the resident, and the use-by date . On 5/20/2024 at 12:55 P.M., the Project Manger provided a policy titled, Cleaning of Refrigerators, revised 11/1/2019, and indicated the policy was the one currently used by the facility. The policy indicated .3. Food for colleagues shall not be stored in the resident refrigerator . 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to assess and monitor a wound for 1 of 1 residents reviewed for skin conditions. (Resident 45) Finding includes: The record for Resident 45, reviewed on 5/22/2023 at 1:54 P.M., indicated the resident's diagnosis included, but were not limited to: hypertensive heart disorder, scoliosis, constipation, pain, hearing loss, cerospinal (sic) shunt, history of falling, unspecified severe protein, adjustment disorder and insomnia. The most recent MDS assessment, completed as a quarterly review on 4/13/2023, indicated the resident was moderately cognitively impaired and required extensive assistance of one person for dressing and personal hygiene needs. During an observation of Resident 46, on 5/18/2023 at 11:36 A.M., a moist, dark pink/red colored centered, pencil eraser sized open sore was observed on the right side of her face. The resident indicated the sore was taking a long time to heal and she tried not to pick at it. The resident was observed on 5/19/2023 to have an open, moist, pencil eraser sized wound on the right side of her face. The resident was observed on 5/20/2023 to have an open, moist, pencil eraser sized wound on the right side of her face. During an observation, on 5/22/23 at 9:00 A.M., the open area on Resident 46's face was observed to be dry and covered with a dark reddish/pink scab. There was no documentation in the nursing progress notes or recent skin assessments regarding the wound on Resident 46's face. During an interview with the Director of Nursing, on 5/22/23 at 4:00 P.M., he indicated the resident had a spot on her face that she picked at so it was open at times and then closed at times. He indicated the resident had a treatment for dermatitis. The resident's daughter had reported the open area on her face, over the past weekend and nursing staff were going to document on the area and notify the physician today. Review of the current physician's orders, indicated a treatment, initiated on 11/23/2022 for Triamcinolone acetonide .1% cream to be applied two times a week to Resident 46's face after washing her face with soap and water. The current care plan for risk for skin, indicated the nurse was to be notified of any impaired or red areas for further assessment and the physician was to be notified of impaired skin integrity issues and orders obtained as needed. During an interview with the ADON, on 5/23/23 at 4:11 P.M., she indicated there was no policy regarding skin assessments, just to follow the physician's orders to complete the assessment for every resident twice a week. 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the physician's order was followed regarding pressure ulcer treatment for 1 of 3 residents reviewed for pressure ulcer care. (Resident 42) Finding includes: 1. Resident 42 was admitted to the facility on [DATE] with diagnoses included, but not limited to: unspecified dementia, status post fracture of the left femur, anemia, diabetes and severe protein calorie malnutrition. A care plan, created on 3/3/2023, for Resident 42 indicated she was at risk for skin breakdown. The goal was to reduce her risks and keep her free from skin breakdown. The interventions included monitoring the skin, using lotions as needed and notifying the MD of any impairments. A change in condition nursing progress note, dated 3/8/2023 at 3:58 P.M., indicated a 3cm (centimeter) by 2.4 cm SDTI (superficial deep tissue injury) area purple and blanchable in color to the left heel. The resident complained of pain. The note indicated skin prep was ordered and protective boots applied. On 3/8/2023 a care plan was created for the SDTI of the left inner heel. Interventions included nutritional vitamins and supplements as ordered, treatment as ordered and assessment of area and pain level. On 3/8/2023 a care plan was created for the Stage 2 pressure ulcer to the left buttock. Interventions included nutritional vitamins and supplements as ordered, treatment as ordered and assessment of area and pain level. The current physician's orders related to the treatment of Resident 42's pressure ulcers were as follows: Skin prep to left inner heel, reordered 5/18/2023, Skin prep to right ankle - discontinued on 4/28/2023 and cleanse with normal saline, apply skin prep to dark area of wound and Purocal (collagen dressing) to open area of wound, cover with mepilex daily for a stage 2 pressure ulcer to the coccyx. During an observation with LPN 12, of the dressing change for Resident 42, on 5/22/23 at 11:39 A.M., the old dressing, removed from the resident's buttocks wound, was dated 5/19/2023. A superficial open wound, in the shape of a very small crescent shaped slit was observed just left of the gluteal fold on the lower coccyx. At this time, LPN 12 confirmed the date on the dressing, which she had removed, was 5/19/2023. During an interview with LPN 12, on 5/22/23 at 1:50 P.M., she verified the treatment orders for Resident 42's coccyx wound as a daily dressing change. Review of the facility policy and procoedure, titled, Pressure injury management, long-term care provided by the Administrator on 5/22/23 at 2:00 P.M., included instructions on basic wound care and skin assessment recommendations but did not specifically address following the physician's orders to ensure treatments were completed timely. 3.1-40

Based on observation, record review and interview, the facility failed to ensure narcotics were stored appropriately and failed to ensure liquid medications were dated when opened for 1 of 1 narcotic storage areas and 1 of 12 residents whose medications were observed. (Rehab Narcotic Drawer and Resident 202) Findings include: 1. During a random observation, on 5/22/2023 at 3:14 P.M., the narcotic storage cart was observed to be unlocked. During an interview, on 5/22/2023 at 3:20 P.M., LPN 2 indicated the cart should have been locked. 2. During a medication storage observation, on 5/22/2023 at 3:28 P.M., in Resident 202's medication storage area the following was noted: -An opened and undated bottle of Latanoprost eye drops. -An opened and undated bottle of Dorzolamide 2% eye drops. -An opened and undated bottle of Debrox Ear drops. During an interview, on 5/22/2023 at 3:30 P.M., LPN 2 indicated the opened bottles should have been dated. On 5/23/2023 at 11:46 P.M., the Director of Nursing provided the policy titled,Storage and Expiration Dating of Medications and Biological's, with a revision date of 7/21/2022, and indicated the policy was the one currently used by the facility. The policy indicated .3.1 Facility should store Schedule II -V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device . 5. Facility staff should record the date opened on the pharmacy medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened . 5.4 When an ophthalmic solution or suspension has a manufacture's shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container 3.1-25(n)