Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents who were in EBP and failed to ensure a staff member (CNA 2) completed hand hygiene after the removal of soiled gloves for 2 of 3 residents reviewed for infection control. (Residents F and D)Findings include:1. During an observation on 9/16/25 at 9:24 a.m., CNA 1 entered Resident F's room and assisted the resident into the bathroom. There was a sign on the door of the room that indicated EBP was required. CNA 1 had gloves on and no gown. The Director of Nursing (DON) entered and exited the bathroom and observed CNA 1 providing care without the use of a protective gown. She indicated a protective gown should have been worn. CNA 1 exited the bathroom with a soiled brief in a clear garbage bag for disposal.During an observation on 9/17/25 at 8:23 a.m., Resident F was lying in bed. There was a mid-line IV catheter inserted and dressed on the upper left arm and a urinary catheter was present.Resident F's record was reviewed on 9/16/25 at 3:39 p.m. The diagnoses included, but were not limited to urinary tract infection and endocarditis. The Profile Guide Care Plan, dated 9/16/25, indicated EBP was required for high contact care due to the presence of an intravenous catheter line (IV) and a urinary catheter. 2. During an observation on 9/16/25 at 9:37 a.m., there was a sign on Resident D's room door that indicated EBP was required. Resident D shared the room with another resident. Resident D was sitting on the toilet and CNA 2 was assisting the resident. CNA 2 wore gloves and a mask. A protective gown was not used. The resident remained on the toilet and the CNA exited the room and indicated the urinary catheter leg bag had been leaking and a new bag was needed. She was unsure which resident in the room required EBP. CNA 2 returned to the room, applied gloves, and changed the urinary drainage leg bag. A protective gown was not used. She then exited the bathroom and the resident remained on the toilet. She exited the room with the gloves still worn, removed the gloves in the hallway and placed them in the Medication Cart Trash Bin, walked to the Nurses' Desk and began writing a note to the Nurse. When asked about hand hygiene CNA 2 indicated she had not completed the care on the resident and was going back to continue care. Resident D's record was reviewed on 9/16/25 at 3:09 p.m. The diagnoses included, but were not limited to, urinary tract infection and urinary retention.A Quarterly Minimum Data Set assessment, dated 8/2/25, indicated an intact cognitive status, required set up assistance for toileting, and an indwelling urinary catheter was present.A Care Plan, dated 6/12/25, indicated EBP was required during high-contact care related to the indwelling urinary catheter. The interventions included a gown and gloves would be utilized per the EBP policy and hand hygiene would be completed before and after care.A facility EBP policy, dated 4/2024, indicated EBP would be implemented during high-contact care activities for resident with, but not limited to, catheters and central lines. PPE was to be worn even if blood and body fluid exposure is not anticipated. High-contact care activities included, but were not limited to, morning activities of daily living care and toileting.A facility hand hygiene policy, dated 3/2027, indicated hand hygiene was to be completed before and after having direct physical contact with residents and after removal of gloves.This citation relates to Intake 2612583.3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: On 2/27/25 at 10:06 a.m., Resident C was observed in bed asleep. The resident's bed was against the wall, he had bed rails, and there was a trapeze bar above the bed. The room was clean and clutter free and the call light was within reach. There were no bolsters observed on the resident's bed. On 2/27/25 at 10:25 a.m., and 1:10 p.m., the resident was observed sitting on the side of the bed. There were no bolsters on the bed. Record review for Resident C was completed on 2/27/25 at 10:36 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), stroke, chronic obstructive pulmonary disease (COPD), depression, and diabetes. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident was cognitively impaired. The resident required substantial/maximum assistance with shower/bathing, toileting, lower body dressing, and putting on footwear. The resident was on hospice services. The resident had impairment on one side of upper and lower extremities, used a wheelchair, and required hospice services. A Care Plan, last reviewed on 1/9/25, indicated the resident was at risk for falls related to weakness and impaired physical functioning. Approaches were to provide a trapeze to assist resident with positioning, place bed against the wall, have hospice review medications, and have hospice provide bolsters to the resident's bed. The last two months were reviewed and the resident had four falls on the following dates: 1/6/25 2/9/25 2/11/25 2/26/25 A Nurses's Progress Note, dated 2/26/25 at 9:04 p.m., indicated the writer entered the room to respond to the call light, the resident was lying on the floor. The resident claimed he was trying to reposition himself in bed using the trapeze bar when he slipped and fell out of bed. A Nurses's Progress Note, dated 2/11/25 at 11:18 a.m., indicated the resident was found kneeling on the floor next to his bed. The resident claimed he was attempting to sit up in bed and began to slide out. A Nurses's Progress Note, dated 2/09/25 at 7:00 a.m., indicated the resident was found kneeling next to his bed. The resident was assessed with no signs and symptoms noted. A Nurses's Progress Note, dated 1/06/25 at 7:01 a.m., indicated the resident had turned on the call light and upon entering the room, the resident was observed sitting on the floor with his back against the bed. The resident indicated he was lying there and was not reaching for anything. The resident was assisted back to bed via Hoyer (mechanical) lift. During an interview on 2/27/25 at 1:18 p.m., RN 1 indicated the resident does not have bolsters on his bed or in his room. She could not recall the resident ever having bolsters on his bed. During an interview on 2/27/25 at 1:44 p.m., the Director of Nursing (DON) acknowledged the care plan had bolsters as an approach and she would go observe the resident. During an interview on 2/27/25 at 2:36 p.m., the DON indicated the resident did not have bolsters on his bed and she had no additional information to provide. This citation relates to Complaint IN00449145. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident had Physician's Order to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 38) Finding includes: During random observations on 11/21/24 at 10:20 a.m. and 2:04 p.m., and on 11/22/24 at 8:30 a.m., 10:21 a.m., and 1:24 p.m., Resident 38 was observed in bed. At those times, there was a bottle of nasal saline spray on her overbed table. On 11/22/24 at 2:45 p.m., LPN 1 was observed in the resident's room. At that time, she was made aware of the nasal saline spray on the overbed table. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had an unplanned significant weight loss and received a therapeutic diet. The resident received oxygen therapy while at the facility. There was no Care Plan to self-administer medications. Physician's Orders, dated, 8/26/24, indicated Saline Nasal Spray 0.65%, 1 spray to each nare for dryness twice a day as needed. There was no order for the resident to self-administer the nasal spray. During an interview on 11/22/24 at 2:46 p.m., LPN 1 indicated the resident did not have any orders to leave the nasal spray in her room or to self-administer the nasal spray. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing had no additional information to provide. 3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a physician was notified of abnormal vital signs for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Finding includes: The record for Resident 5 was reviewed on 11/22/24 at 2:17 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, hypertensive heart disease and diabetes mellitus. The admission MDS assessment, dated 10/11/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfers. A Physician's Order, dated 10/8/24, indicated to give carvedilol (medication used to treat hypertension) 25 milligrams (mg) twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The October 2024 Medication Administration Record (MAR) indicated the medication had been given twice daily from 10/8/24 through 10/15/24. The resident was sent to the hospital on [DATE], and returned on 10/24/24. The October and November 2024 MAR indicated he received the medication twice daily from 10/24/24 through 11/11/24. It was not given once on the evening of 11/4/24, the MAR note indicated he was unavailable. A Progress Note, dated 11/12/24, indicated the Physician had assessed the resident and there was a new order to decrease the carvedilol to 12.5 mg twice daily due to low heart rate. A Physician's Order, dated 11/12/24, indicated to give carvedilol, 12.5 mg, twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The November 2024 MAR indicated the resident received the new dose of carvedilol once on 11/12/24. He was again sent to the hospital on [DATE] and returned on 11/16/24. The resident received the medication twice daily from 11/17/24 through 11/24/24. It was not given once in the evening of 11/21/24, the MAR note indicated the medication was unavailable. During October and November 2024, the resident's heart rate was documented below 55 beats per minute (bpm) on the following dates: 10/11- 50 bpm 10/12- 52 bpm 10/27- 53 bpm 10/31- 53 bpm 11/1- 49 bpm 11/2- 48 bpm 11/3- 52 bpm 11/5- 53 bpm 11/10- 50 bpm 11/11- 46 bpm 11/12- 40 bpm 11/13- 49 bpm There were no additional vital signs for review on the November MAR after 11/17/24. There was no documentation the physician had been notified of the heart rates below 55 beats per minute. During an interview on 11/25/24 at 11:30 a.m., the Director of Nursing was made aware of the the lack of Physician notification of the abnormal heart rates. No additional information was provided. The guidelines for carvedilol were retrieved from the [NAME] Drug Guide website at www.drugguide.com/ddo/view/[NAME]-Drug Guide/51134/all/carvedilol on 11/25/24, and indicated, .Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position. If heart rate decreases below 55 bpm, decrease dose . Implementation-PO [by mouth] Take apical pulse before administering. If < [less than] 50 bpm or if arrhythmia occurs, withhold medication and notify health care professional The policy, Physician-Provider Notification Guidelines, dated 12/17/23, indicated, .Purpose to ensure the resident's physician or practitioner (may include NP, PA or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care 3.1-5(a)(2)

Based on observation and interview, the facility failed to ensure a resident's privacy was maintained related to the electronic medication record (EMR) left open and unlocked in the hallway during medication pass for 1 of 8 residents observed during medication pass. (Resident 363) Finding includes: On 11/21/24 at 12:21 p.m., RN 1 was observed disconnecting an intravenous medication for Resident 363. She had the electronic medication record open on the computer as she gathered her supplies from the 300 Hall cart and then walked towards the resident's room to disconnect the medication and flush the line. The computer screen was left open and on, leaving the residents medications and personal information available to view. At 12:28 p.m., RN 1 was observed returning to the 300 Unit Nurses' Station where she sat down. The 300 Hall cart computer was still open and could be viewed in the hallway. During an interview on 11/21/24 at 12:28 p.m., RN 1 indicated she did not realize she had left the screen open, but the screen should always be locked when not in use. She proceeded to close the computer so that the record could no longer be seen in the hallway. During an interview on 11/25/24 at 2:57 p.m., the Director of Nursing indicated the computer screen should have been locked when the nurse walked away from the computer. 3.1-3(p)(2)

Based on record review and interview, the facility failed to ensure residents were involved in decisions about their care related to new medications and ensuring a resident attended and participated in care planning conferences for 2 of 2 residents reviewed for participation in care planning. (Residents 38 and 49) Findings include: 1. During an interview on 11/21/24 at 10:18 a.m., Resident 38 indicated she was not always informed of new medications, laboratory tests or treatments. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 11/14/24, indicated Remeron (an antidepressant medication) 15 milligrams (mg), give 1/2 tablet at bedtime. A Nurse's Note, dated 8/26/24 at 10:09 a.m., indicated the resident's daughter was made aware of the new order for Remeron. Physician's Orders, dated 10/1/24, indicated Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) and Magnesium levels to be drawn. A Nurse's Note, dated 10/1/24 at 2:36 p.m., indicated the resident's daughter was notified of the new orders for the labs of CBC, CMP and Magnesium levels to be drawn. There was no documentation the resident was made aware of the new medications and lab draws. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the resident should have been notified of the change in medication and of the labs to be drawn. 2. During an interview on 11/21/24 at 2:27 p.m., Resident 49 indicated he had not attended or been invited to a care plan conference and was not always kept informed of medication changes. The record for Resident 49 was reviewed on 11/22/24 at 10:54 a.m. Diagnoses included, but were not limited to, right knee replacement, acute kidney failure, hypertensive chronic kidney disease, type 2 diabetes, heart disease, falls, bradycardia, and anemia. The 9/29/24 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The Scheduled 5 day MDS assessment, dated 10/29/24, indicated the resident was moderately impaired for daily decision making. The 9/30/24 Care Plan, indicated the resident demonstrated moderate cognitive impairment which was anticipated to progress due to the intrinsic nature of the disease process. The approaches were to encourage the resident to participate in familiar activities and daily tasks. A Physician's Order, dated 11/1/24, indicated Protonix 40 milligrams (mg) give 1 tablet two times a day. A Nurse's Note, dated 11/1/24 at 5:31 p.m., indicated the resident's wife was made aware of the new order for Protonix and draw the resident's blood on Monday. A Physician's Order, dated 11/20/24, indicated Doxycycline 100 mg twice a day. A Nurse's Note, dated 11/20/24 at 3:09 p.m., indicated the resident's wife was notified of the new order for the antibiotic of Doxycycline. Care Plan conference documentation, dated 11/11/24 at 1:00 p.m., indicated the resident's spouse and daughter were in attendance and plans were discussed regarding discharge. There was no documentation the resident was notified of the new medications or the lab draws. There was also no documentation if the resident was invited or attended the care conference. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing had no additional information to provide. During an interview on 11/26/24 at 8:55 a.m., the Administrator indicated the resident was invited to the care plan conference, however, the family did not want the resident there. They did not hold a separate conference with only the resident. 3.1-35(d)(2)(B)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The record for Resident 5 was reviewed on 11/22/24 at 2:17 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, hypertensive heart disease and diabetes mellitus. The admission MDS assessment, dated 10/11/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfers. A Physician's Order, dated 10/8/24, indicated to give carvedilol (medication used to treat hypertension) 25 milligrams (mg) twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The October 2024 Medication Administration Record (MAR) indicated the medication had been given twice daily from 10/8/24 through 10/15/24. The resident was sent to the hospital on [DATE], and returned on 10/24/24. The October and November 2024 MAR indicated he received the medication twice daily from 10/24/24 through 11/11/24. It was not given once on the evening of 11/4/24, the MAR note indicated he was unavailable. A Progress Note, dated 11/12/24, indicated the Physician had assessed the resident and there was a new order to decrease the carvedilol to 12.5 mg twice daily due to low heart rate. A Physician's Order, dated 11/12/24, indicated to give carvedilol, 12.5 mg, twice daily for hypertension. There were no blood pressure or heart rate parameters in place when to hold the medication. The November 2024 MAR indicated the resident received the new dose of carvedilol once on 11/12/24. He was again sent to the hospital on [DATE] and returned on 11/16/24. He received the medication twice daily from 11/17/24 through 11/24/24. It was not given once in the evening of 11/21/24, the MAR note indicated the medication was unavailable. During October and November 2024, the resident's heart rate was documented below 55 beats per minute (bpm) on the following dates: 10/11- 50 bpm 10/12- 52 bpm 10/27- 53 bpm 10/31- 53 bpm 11/1- 49 bpm 11/2- 48 bpm 11/3- 52 bpm 11/5- 53 bpm 11/10- 50 bpm 11/11- 46 bpm 11/12- 40 bpm 11/13- 49 bpm There were no additional vital signs for review in the November MAR after 11/17/24. During an interview on 11/25/24 at 11:10 a.m., the Director of Nursing indicated holding the medications would depend on the patient, if a heart rate was in the 40's it should probably be held. A policy was requested but not provided. The guidelines for carvedilol was was retrieved from the [NAME] Drug Guide website at www.drugguide.com/ddo/view/[NAME]-Drug Guide/51134/all/carvedilol, on 11/25/24, indicated, .Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position. If heart rate decreases below 55 beats/min, decrease dose . Implementation-PO Take apical pulse before administering. If < [less than] 50 bpm or if arrhythmia occurs, withhold medication and notify health care professional 3.1-37(a) Based on observation, record review, and interview, the facility failed to ensure blood pressure medication was administered as ordered according to parameters for 1 of 1 resident reviewed for blood pressure parameters and for 1 of 5 residents reviewed for unnecessary medications. (Residents 38 and 5) Findings include: 1. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident received oxygen therapy while at the facility. Physician's Orders, dated 12/22/22, indicated Hydralazine (a medication used to lower the blood pressure) 25 milligrams (mg) twice a day and to hold if systolic blood pressure was less than 110 and the heart rate was less than 60. Metoprolol succinate (a medication used to lower the blood pressure and heart rate) extended release 25 mg once a day and hold if systolic blood pressure was less than 110 and/or the heart rate was less than 60. The 9/2024 Medication Administration Record (MAR) indicated the Hydralazine was administered on following dates: 11:00 a.m.-1:30 p.m.: - 9/12/24 and the blood pressure was 108/61. - 9/20/24 and the blood pressure was 109/69. - 9/25/24 and the blood pressure was 109/64. 6:30 p.m.-10:30 p.m. - 9/1/24 and the blood pressure was 99/59. - 9/5/24 and the blood pressure was 89/44. - 9/7/24 and the blood pressure was 99/54. - 9/10/24 and the blood pressure was 98/58. - 9/18/24 and the blood pressure was 102/70. The 9/2024 MAR indicated the Metoprolol was administered on following dates at 11:00 a.m.-1:30 p.m.: - 9/2/24 and the heart rate was 57. - 9/8/24 and the heart rate was 59. - 9/12/24 and the blood pressure was 108/61. - 9/15/24 and the blood pressure was 102/68. - 9/20/24 and the blood pressure was 106/69. - 9/24/24 and the blood pressure was 97/57 and the heart rate was 59. - 9/25/24 and the blood pressure was 109/64. The 10/2024 MAR indicated the Hydralazine was administered on the following dates: 11:00 a.m.-1:30 p.m. - 10/10/24 and the blood pressure was 100/54. - 10/30/24 and the blood pressure was 107/61. 6:30 p.m.-10:30 p.m. -10/8/24 and the blood pressure was 106/65. The 10/2024 MAR indicated the Metoprolol was administered on the following dates at 11:00 a.m.-1:30 p.m. -10/10/24 and the blood pressure was 100/54. -10/30/24 and the blood pressure was 107/61. The 11/2024 MAR indicated the Hydralazine was administered on the following dates at 11:00 a.m.-1:30 p.m.: - 11/6/24 and the blood pressure was 84/56. - 11/14/24 and the blood pressure was 97/51. - 11/16/24 and the blood pressure was 104/63. - 11/19/24 and the blood pressure was 104/62. - 11/22/24 and the blood pressure was 106/62. The 11/2024 MAR indicated the Metoprolol was administered on the following dates at 11:00 a.m.-1:30 p.m.: - 11/6/24 and the blood pressure was 84/56. - 11/14/24 and the blood pressure was 97/51. - 11/16/24 and the blood pressure was 104/63. - 11/19/24 and the blood pressure was 104/62. - 11/20/24 and the blood pressure was 95/64. - 11/22/24 and the blood pressure was 106/62. During an interview on 11/22/24 at 2:46 p.m., LPN 1 indicated a QMA had passed the medications on her unit. She was told by the QMA that she held the Metoprolol for the resident and did not administer it. She indicated the medication was to be administered according to the parameters. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the medication should have been administered as ordered by the Physician.

3. The record for Resident 13 was reviewed on 11/22/24 at 1:42 p.m. Diagnoses included, but were not limited to, sepsis, urinary tract infection, pneumonia, hemiplegia (paralysis on one side of the body) due to a stroke, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 11/1/24, indicated the resident was cognitively intact and had an indwelling urinary catheter. A Care Plan, updated 6/27/23, indicated the resident had an indwelling urinary catheter. An intervention indicated to monitor and document urinary output. A Physician's Order, dated 1/30/24, indicated the urinary output was to be monitored every shift, three times per day, at the following times: 7:00 a.m. - 2:00 p.m., 3:00 p.m. - 10:00 p.m., 11:00 p.m. - 7:00 a.m. The resident's record indicated urinary outputs were measured once per day on 11/14/24, 11/18/24, 11/19/24, 11/21/24, 11/22/24, 11/23/24, and 11/24/24. Urinary output was documented twice per day on 11/15/24, 11/16/24, and 11/17/24. During an interview on 11/25/24 at 10:28 a.m., CNA 1 indicated she emptied the urine bag three times per shift and documented the amount in the resident's record. During an interview on 11/25/24 at 11:13 a.m., the DON indicated the CNAs should be documenting a urine output every shift and offered no further information. 3.1-41(a)(2) 2. On 11/21/24 at 10:39 a.m., Resident 216 was observed seated in her wheelchair in the lounge area near the 100 Hall Nurse's Station. The urinary catheter bag was hanging from the bottom of her wheelchair and resting on the floor. On 11/21/24 at 2:34 p.m., Resident 216 was observed seated in her wheelchair in her room. The urinary catheter bag was hanging from the bottom of her wheelchair and resting on the floor. On 11/22/24 at 11:02 a.m., Resident 216 was seated in her wheelchair in her room. No urinary catheter bag was visible. Resident 216 pulled up her pant leg and a urinary catheter leg bag was observed. Resident 216's record was reviewed on 11/22/24 at 10:38 a.m. Diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes mellitus, and dementia. The admission Minimum Data Set assessment, dated 11/12/24, indicated the resident was cognitively impaired and had an indwelling urinary catheter. The Physician's Order Summary, dated 11/2024, indicated to monitor urine output every shift. There were no orders related to the use of a urinary catheter leg bag. A care plan, updated 11/20/24, indicated the resident required a urinary catheter for neurogenic bladder. The interventions included, record urinary output. There were no interventions related to the use of a urinary catheter leg bag. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 11/2024, indicated the urinary output had been signed off as monitored every shift (12 hour shifts) but no amounts had been recorded. The resident had received cefdinir (an antibiotic) 300 mg (milligrams) every 12 hours from 11/8/24 through 11/11/24 for acute cystitis (inflammation of the bladder) with hematuria (blood in the urine). The vital signs urine output documentation, dated 11/8/24 through 11/22/24, indicated the urine output had only been recorded once a day on the following dates: 11/10/24 at 1:16 p.m. 11/13/24 at 1:45 p.m. 11/16/24 at 12:38 p.m. 11/17/24 at 10:56 a.m. 11/18/24 at 12:12 p.m. During an interview on 11/22/24 at 2:26 p.m., the Director of Nursing was made aware of the resident's urinary catheter bag resting on the floor. She indicated the urinary output should have been documented on each shift and there were two shifts per day. There was no specific policy related to urine output documentation, or the type of urinary catheter bag used. A policy was requested related to urinary catheter bag placement. No further information was provided. Based on observation, record review, and interview, the facility failed to ensure urinary output was documented as ordered and an indwelling Foley (urinary) catheter collection bag was off of the floor for a resident with a history of infection for 3 of 3 residents reviewed for urinary catheters. (Residents 6, 216, and 13) Findings include: 1. Record review for Resident 6 was completed on 11/25/24 at 9:57 a.m. Diagnoses included, but were not limited to, neurogenic bladder, end stage renal disease, Alzheimer's, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/22/24, indicated the resident was cognitively impaired. The resident required maximum assistance for toileting. The resident had an indwelling urinary catheter. A Care Plan, dated 10/10/22 and revised 11/11/24, indicated the resident used a Foley catheter. The resident was at risk for complications, including a urinary tract infection. An intervention included to record the resident's urinary output. The November 2024 Physician's Order Summary (POS) indicated an order to monitor urinary output every shift. The November 2024 Medication Administration Record (MAR) had the urinary output signed off as completed each shift, but lacked the amount of output. The Urinary output section of the Vital Signs had urine output documented only on day shifts for the past 30 days on the following dates: -10/26, 10/27, 10/28, 10/29, 11/2, 11/3, 11/4, 11/5, 11/8, 11/9, 11/10, 11/12, 11/14, 11/16, 11/21, 11/22, 11/23, 11/24, and 11/25/24. There was a lack of documentation to indicate the urinary output was documented on any other shift other than the day shift. During an interview on 11/26/24 at 9:26 a.m., the Director of Nursing (DON) indicated the nurses worked 12 hour shifts. There should be documentation of the urine output every shift.

Based on record review and interview, the facility failed to monitor weekly weights and nutritional intake for meals and supplements as ordered for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition. (Resident 38) Finding includes: The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and weighed 78 pounds. The resident had an unplanned significant weight loss and received a therapeutic diet. The revised Care Plan, dated 11/12/24, indicated the resident was malnourished/ at risk for malnutrition related to inadequate nutrient/ energy intakes, and/or metabolic demands. The approaches were to provide diet, supplements, medications, and adaptive equipment as ordered. A Physician's Order, dated 3/3/23 and on the current Physician Order Statement dated 11/2024, indicated point of care tasks: check breakfast, lunch and dinner. A Physician's Order, dated 5/14/24, indicated regular fortified foods with meals. A Physician's Order, dated 8/16/24, indicated med pass (nutritional supplement) 90 milliliters (ml) daily. The resident's weight was 77 pounds on 7/11/24 and on 8/2/24 she weighed 70 pounds. The resident's current weight on 11/14/24 was 78 pounds. A Registered Dietitian (RD) Note, dated 8/15/24 at 11:46 a.m., indicated the resident had a significant weight loss of 8.2% in the last 30 days. The RD suggested adding med pass supplement of 90 ml daily and obtaining weekly weights times four weeks. There was no documentation the weekly weights were completed for 4 weeks. The consumption of the of the med pass supplement was not documented as being administered on 10/6, 10/7, 10/10, 10/11, 10/15, 10/17, 11/9, 11/14, 11/15, and 11/21/24. The meal consumption log indicated there was no documentation for the breakfast meal on 9/2, 10/11, 11/1, 11/3, 11/5, 11/7, 11/12, and 11/19/24 The meal consumptions indicated there was no documentation for the lunch meal on 9/2, 10/11, 11/1, 11/3, 11/5, 11/19, and 11/21/24. The meal consumptions indicated there was no documentation for dinner meal on 9/2, 9/5, 9/9, 9/14, 9/18, 9/22, 10/1, 10/5, 10/9, 10/11, 10/14, 10/18, 10/21, 10/23, 10/26, 11/1, 11/5, 11/8, 11/10, 11/14, 11/17, 11/18, and 11/19/24. During an interview on 11/25/24 at 2:20 p.m., the Director of Nursing indicated the meal and supplement consumptions were incomplete. During an interview on 11/26/24 at 9:10 a.m., the Director of Nursing indicated the weekly weights were not completed. 3.1-46(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a peripherally inserted central catheter (PICC) line was maintained related to bandage changes for 1 of 1 resident reviewed for infections. (Resident 363) Finding includes: During an interview on 11/21/24 at 11:15 a.m., Resident 363 indicated he had received intravenous (IV) antibiotics for a wound infection in his foot. The PICC line bandage had not been changed since he had been at the facility and one of the ports did not work. The white split gauze sponge under the clear tegaderm was observed with brown dried blood. There was no date on the bandage of the PICC line. On 11/21/24 at 3:20 p.m., the resident was sitting up in his wheelchair inside his room. The PICC line bandage remained the same as above. During an interview on 11/22/24 at 8:25 a.m., the resident indicated the nurse had changed his PICC line bandage that morning. The record for Resident 363 was reviewed on 11/22/24 at 10:27 a.m. Diagnoses included, but were not limited to, absence of the right foot, osteomyelitis, abscess of the right foot, type 2 diabetes, arteriosclerosis, peripheral vascular disease, heart disease, heart failure, depression, and anxiety. The resident was admitted to the facility on [DATE]. The 11/13/24 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making, received an antibiotic, and had an IV. The Care Plan, dated 11/8/24, indicated the resident required IV medication. The approaches were IV site care as ordered. Physician's Orders, dated 11/7/24, indicated change PICC dressing every 5 days and measure external catheter length. The Treatment Administration Record (TAR) for the month of 11/2024, indicated the PICC line dressing change was not signed out as being completed on 11/12 and 11/17/24. The first time it was signed out as being completed was on 11/22/24. There was no documentation on 11/12 or 11/17/24 the PICC line bandage was changed. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing had no additional information to provide. The current and revised 12/2015 Catheter Insertion and Care policy, provided by the Assisted Living Director as current on 11/25/24 at 3:15 p.m., indicated the midline catheter dressing was to be changed at specified intervals or when needed to prevent catheter-related infections. The midline catheter was to be changed every five to seven days, or if it was wet, dirty, not intact, or compromised in any way. 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrators were set at the correct flow rate for 1 of 2 residents reviewed for oxygen therapy. (Resident 38) Finding includes: During random observations on 11/21/24 at 10:20 a.m. and 2:04 p.m., and on 11/22/24 at 8:30 a.m., 10:21 a.m., and 1:24 p.m., Resident 38 was observed in bed. At those times, she was wearing oxygen via nasal cannula and the oxygen concentrator was set at 2.5 liters per minute. On 11/22/24 at 2:45 p.m., LPN 1 was observed in the resident's room. At that time, she was made of the oxygen setting and immediately changed the rate to 3 liters. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident received oxygen therapy while at the facility. The Care Plan, revised on 11/11/24, indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory disease. The approach was to provide oxygen. Physician's Orders, dated 9/15/24, indicated set oxygen at 3 liters nasal cannula continuously During an interview on 11/22/24 at 2:46 p.m., LPN 1 indicated the oxygen should be on as ordered by the physician. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing was informed of the oxygen and had no additional information to provide. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 2 residents reviewed for pain. (Resident 157) Finding includes: On 11/21/24 at 3:18 p.m., Resident 157 was observed sitting in his wheelchair in his room. He was grimacing, shifting in his chair, and complaining of back pain rated 7 out of 10 for severity. The resident indicated his back pain was not well controlled and he felt like he needed new or changed pain medications. On 11/25/24 at 9:26 a.m., the resident was observed fidgeting and attempting to reposition himself in bed. He indicated he was having back pain and the Fentanyl (an opioid pain medication) patch and Norco (an opioid pain pill) he had received were not controlling his pain. The resident's record was reviewed on 11/25/24 at 10:32 a.m. Medical diagnoses included, but were not limited to, cellulitis of the legs, heart failure, chronic kidney disease, atrial fibrillation, depression, spinal stenosis, and opioid use. The admission Observation and Data Collection, dated 11/17/24, indicated the resident had moderate cognitive impairment, and was able to make needs known. The current Pain Care Plan indicated a goal that the resident's pain would be at a tolerable level with interventions. Interventions included, but were not limited to, observe for and record verbal and non-verbal signs of pain, administer medications as ordered, and attempt non-pharmacological interventions. The November 2024 Medication Administration Record (MAR) indicated the resident could receive diclofenac gel (a topical anti-inflammatory) as needed for pain, but he had not received it. There was no indication any non-pharmacological interventions had been attempted to manage the resident's pain. During an interview on 11/25/24 at 2:00 p.m., RN 2 indicated the non-pharmacological interventions for pain were rest and repositioning, and the resident did that himself. The resident was never given the diclofenac gel because he did not ask for it, but she did not know if he knew he could have it. QMA 1 then got the diclofenac gel from the medication cart, and went into the resident's room. On 11/25/24 at 2:15 p.m., the resident indicated he was glad the QMA applied the diclofenac to his back as he had not tried it before, and did not know it was available to him. During an interview on 11/26/24 at 10:35 a.m., the Director of Nursing was informed of the pain concerns and no further information was received. A facility policy, titled, Guidelines for Pain Observation and Management, received from the Administrator as current, indicated, . Procedures . 5. Educate the resident / family / caregivers on the pain management interventions . 6. Implement the care plan approaches to assist with pain management. 7. Evaluate the effectiveness of pain management interventions and modify as indicated. 3.1-37(a)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to the correct medication administration route for 1 of 1 resident reviewed for tube feeding. (Resident 41) Finding includes: During an interview on 11/21/24 2:15 p.m., Resident 41's daughter indicated the resident received her medications sometimes through the tube and sometimes she got them by mouth. The record for Resident 41 was reviewed on 11/25/24 at 9:05 a.m. Diagnoses included, but were not limited to, colitis, dehydration, congestive heart failure, dementia, Alzheimer's disease, heart disease, Parkinson's disease, dysphagia (difficulty swallowing), peg tube (a tube inserted directly into the stomach for nutrition) The 10/21/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a peg tube through which she received 25% or less of nutrition. Physician's Orders, listed on the current Physician Order Summary dated 11/2024, indicated the medications of Carbidopa-Levodopa 25-250 milligrams (mg) give 1 tablet orally four times a day, and Pepcid 20 mg, give 1 tablet orally at night time. There was no order to administer the medications through the peg tube. During an interview on 11/25/24 at 11:23 a.m., RN 3 indicated she had administered the resident's medications through the peg tube, however, there was no physician's order to administer the medications through the peg tube. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the resident had received her medications orally and not through the peg tube, but since her decline, she received the medications through the peg tube. 3.1-50(a)(2)

2. During a medication pass observation on 11/21/24 at 11:31 a.m., RN 1 was observed checking Resident 363's blood sugar and administering ampicillin (antibiotic medication) via a peripheral intravenous central catheter (PICC). Upon entering the resident's room, a sign on the door indicated the resident was in Enhanced Barrier Precautions (EBP), which required staff to wear a gown and gloves while performing any high contact care with the resident. RN 1 entered the room and donned clean gloves. She did not wash her hands prior to putting on the gloves. She checked the resident's blood sugar, removed her gloves, and then donned a new pair of gloves without performing hand hygiene between glove use. She had mixed a 3 gram ampicillin vial with a 50 cc bag of 0.9% normal saline solution and then primed intravenous (IV) tubing with the medication. She placed a cap over the end of the IV tubing once it was primed. While attaching the IV tubing to the PICC line, the IV tubing was observed touching the floor. She continued to administer the medication, then removed her gloves and performed hand hygiene. During an interview on 11/21/24 at 12:14 p.m., RN 1 indicated she should have washed her hands in between glove changes each time. She was unaware the tubing had touched the floor, but she had tried to keep it off of the floor while moving the tubing around. The resident was in Enhanced Barrier Precautions (EBP), but it was only required while caring for his wound or catheter. A gown was not required for the PICC line medication administration, but it would not have hurt to have it on during care. During an interview on 11/25/24 at 2:57 p.m., the Director of Nursing indicated she had no further information to provide. A policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, noted as current, indicated .1. Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include: i. All residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. All Residents with indwelling medical devices 1. Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes .2. Personal protective equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities .3. High-contact care activities include but are not limited to: morning and evening ADL care, toileting, and showers.: A policy titled, Guideline for Handwashing/Hand Hygiene, noted as current, indicated .1. All health care workers (HCW) shall utilize hand hygiene frequently and appropriately .3. HCW shall use hand hygiene at times such as: .c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc . 3.1-18(b) Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to enhanced barrier precautions (EBP) not in use for a resident with pressure ulcers during a wound treatment and for a resident with a peripherally inserted central catheter (PICC) line during medication pass. The facility also failed to change gloves in between pressure ulcer treatments and perform hand hygiene after glove removal during medication pass for 1 of 2 residents observed during a pressure ulcer treatment and for 1 of 8 residents observed during medication administration. (Residents 41 and 363) (Hospice CNA 1, Hospice RN 1, and RN 1) Findings include: 1. During an observation on 11/25/24 at 10:33 a.m., Hospice CNA 1 and Hospice RN 1 were observed in Resident's 41 room. At that time, Hospice CNA 1 indicated she was going to give the resident a complete bed bath and Hospice RN 1 was going to change the resident's bandages for her pressure ulcers. The CNA and RN both had performed hand hygiene and donned a pair of clean gloves to both hands and proceeded to give the resident a bed bath. Neither one of them donned a gown to provide care and give the bath. They turned the resident over on her right side and there were 5 foam bandages on the residents back side. The hospice nurse removed her gloves and washed her hands with soap and water. She donned a clean pair of gloves to both hands and removed the bandage to the sacrum. The pressure ulcer on sacrum had thick black necrotic tissue and a large amount of drainage. The RN cleaned the wound with normal saline wearing the same pair of gloves to both hands, and patted it dry. With the same gloves, she squeezed a moderate amount of Cal Zinc cream on her gloved hands and proceeded to spread the cream around the wound. She then placed a clean foam bandage over the wound. During an interview at that time, Hospice RN 1 indicated the pressure sore was much worse and she thought it was now a Kennedy ulcer (a dark, irregularly shaped sore that develops rapidly in the final stages of life) and the focus would be to prevent further breakdown, as the ulcer would need debridement. Using the same pair of gloves, she removed the bandage on the left ischium and cleaned the wound with normal saline. She patted the wound dry and squeezed a small amount of the Cal Zinc cream into the same pair of gloves and proceeded to spread the cream over the pressure ulcer on the ischium. She then placed a foam bandage over the wound. After she had finished completing the treatments, she removed her gloves and washed her hands with soap and water. At that time, there was a sign on the outside of the resident's door that indicated the resident was in EBP and a gown and gloves were needed if coming in contact with the resident. During an interview at that time, Hospice CNA 1 and Hospice RN 1 both indicated they were not aware the resident was in EBP. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the resident was in EBP and a gown was required while providing wound treatments, bathing, and turning and repositioning the resident. The current 12/31/23 Dressing Changes policy, provided by the Director of Nursing on 11/26/24 at 10:40 a.m., indicated the pressure ulcer procedure was to wash hands with soap and water and put on the first pair of gloves. Remove the soiled dressing, discard in a plastic bag or trash can and dispose of the gloves. Wash hands with soap and water and put on a second pair of disposable gloves. Follow the doctor's recommendations for treatments, apply a dressing and secure with tape. After completing the treatment, remove the gloves, discard, and wash hands with soap and water.

Based on record review and interview, the facility failed to follow up on a notification of a change of condition with a resident's physician, for 1 of 4 residents reviewed for physician notification. (Resident F) Finding includes: Resident F's record was reviewed on 6/12/24 at 10:36 a.m. The diagnoses included, but were not limited to, stroke and cellulitis. A Nurse's Progress Note, dated 5/8/24 (Wednesday) at 3:57 p.m., indicated 2+ left lower leg edema and 1+ right lower leg edema. The resident had gained 2.5 pounds in two days. The resident stated he usually took an extra dose of Lasix (diuretic) when edema was present. The physician was faxed the assessment information and the resident and family were notified and would be updated when the physician responded to the notification. There was no documentation that indicated the physician had responded to the fax sent to him on 5/8/24 at 3:57 p.m. and there was no follow up phone call with the condition changes. A Nurse's Progress Note, dated 5/9/24 at 5:51 a.m., indicated the resident complained of wheezing. Wheezing was heard in the posterior bilateral lobes of the lung. He denied a cough, shortness of breath, or chest pain. There were no signs and symptoms of respiratory distress. His oxygen saturation was 97%. A fax was sent to the physician. A Skilled Charting Progress Note, dated 5/9/24 at 9 p.m., indicated the resident had 4+ left lower leg edema and 3+ right lower leg edema. His breath sounds were clear. There had been no documentation which indicated the physician had responded to the faxes sent to him on 5/8/24 and 5/9/24 and there was no follow up phone call with the condition changes. A Nurse's Progress Note, dated 5/10/24 at 3:07 a.m., indicated there was no wheezing in the lungs and the edema of the right and left lower legs continued. The facility was still waiting on a response from the fax to the physician. A Physician's Progress Note, dated 5/10/24 at 8:54 p.m., indicated the Physician assessed the resident due to the edema that was secondary to congestive heart failure and was associated with the weeping of fluid from the legs. There was no acute distress and the lungs were clear. There was at least 3+ edema of the bilateral lower legs. The Lasix was increased to 80 mg (milligrams) daily for three days and potassium 40 milliequivalents daily was ordered for three days. The physician indicated the other medications the resident was possibly contributing to the edema. During an interview on 6/12/24 at 3:37 p.m., the Director of Nursing indicated she was unable to find further information of when or if the physician responded to the faxed condition change notifications. A provider notification policy, dated 9/12/17 and received as current from the RN Corporate Nurse, indicated during non-office hour times, the nurse was to notify the provider by phone if physician intervention was needed. The provider was to be notified by phone if there was an immediate need. If the provider was paged, a call back was expected to be within 15 minutes to one hour depending on the severity of the concern. If the facility was unable to reach the primary provider, the Medical Director was to be notified. If there had been no response to a fax by the provider within 12 hours, the nurse on duty was to call the physician. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to care for peripherally inserted central catheter (PICC line - long catheter inserted through a peripheral vein for intravenous treatments) in accordance with professional standards of practice, related to lack of measurement of the catheter length and arm circumference above the site, dressing changes to the sites, assessments of the site, and flushes of the catheters, for 3 of 3 residents with PICC lines. (Residents E, F, and C) Findings include: 1. During an observation on 6/12/24 at 10:55 a.m., LPN 1 prepared and administered Resident E's antibiotic of piperacillan tazobactam 3.3555mg in 50 cc's (cubic centimeters) of 0.9% normal saline (NS). LPN 1 indicated she would use a 0.9% NS flush for the right upper arm PICC line lumen prior to the administration of the antibiotic. LPN 1 cleaned the PICC line's needleless connector with an alcohol prep pad, unclamped the PICC line lumen, and flushed the lumen with 10 cc's of 0.9% NS. She indicated she used 10 cc's of the NS for the flush. The IV (intravenous) antibiotic medication was then administered per the Physician's Orders. During an observation on 6/12/24 at 11:37 a.m., LPN 1 indicated the IV antibiotic had been infused and she would be flushing the PICC line lumen with 5 cc's of heparin (blood thinner) and another 10 cc's of 0.9% NS. She then removed the IV tubing from the PICC line lumen and covered the end of the tubing with a cap. She then wiped the PICC line's needleless connector with an alcohol prep pad and administered the 5 cc's of heparin and then 10 cc's of 0.9% NS. Resident E's record was reviewed on 6/13/24 at 10:39 a.m. The diagnoses included, but were not limited to, Right leg cellulitis. A Nursing admission Assessment Observation form, dated 6/6/24 at 6:17 p.m., indicated the resident had an intact cognitive status and there was no IV/central line present. A Nurse's Progress Note, dated 6/6/24 at 6:29 p.m., indicated the resident arrived at the facility from the hospital with right leg cellulitis and had physician's orders for two IV antibiotics. The Nursing admission Assessment Observation and admission Nurse's Progress Note, both dated 6/6/24, had not documentation the resident had a PICC line and there was no assessment of the PICC line insertion site, measurement of the PICC line catheter, and the right arm circumference. A Nurse's Progress Note, dated 6/7/24 at 5:48 a.m., indicated the there was a double lumen PICC line present and both ports had been flushed with blood returned. There was no assessment of the PICC line insertion site, measurement of the PICC Line Catheter, and the right arm circumference. The Nurse's Progress Note had not indicated where the double lumen PICC line was located. The admission Physician's Orders, dated 6/6/24, indicated the PICC line site was to be monitored for signs and symptoms of infiltration every shift, and the PICC lumens were to be flushed with 5 cc's of normal saline before and after the antibiotic administration. Physician's Orders, dated 6/12/24, indicated the PICC Line dressing change was to be completed every five days and the external catheter length was to be measured and documented. The right arm circumference was to be measured with the PICC line dressing change. A Care Plan, dated 6/10/24 and revised on 6/12/24, indicated a right upper extremity IV was present for antibiotic therapy. The interventions indicated, complications from the IV would be assessed - infection, dislodgement, infiltration, phlebitis, fluid overload, dehydration, air embolus, electrolyte imbalance, IV insertion site care would be completed as ordered, the PICC site would be observed for swelling, redness, tenderness, and warmth, and the medication/flushes would be administered as ordered. The Medication Administration Record, dated 6/2024, indicated the first measurement of the PICC line length and right arm circumference was completed on 6/12/24 on the day shift. During an interview on 6/12/24 at 11 a.m., LPN 1 indicated she had flushed the PICC lumen with 10 cc's of NS and the ordered was for 5 cc's of NS. During an interview on 6/13/24 at 11:22 a.m., the Director of Nursing (DON) indicated she was unable to locate an assessment of the PICC line insertion, dressing, catheter length, and arm circumference upon admission into the facility. 2. During an observation on 6/13/24 at 8:37 a.m., LPN 2 entered Resident F's room to provide care to the PICC line, located in the resident's right upper arm, after the administration of the IV antibiotic. She flushed the PICC line lumen with 5 cc's of 0.9% NS then 5 cc's of heparin, followed with 5 cc's of NS. Resident F's record was reviewed on 6/12/24 at 10:36 a.m. The diagnoses included, but were not limited to, stroke and cellulitis. An admission MDS (Minimum Data Set) assessment, dated 5/2/24, indicated a moderately impaired cognitive status, no antibiotics, and no IV's or IV medication. A Nurse's Progress Note, dated 5/28/24 at 4:33 p.m., indicated the resident had returned from a hospital leave of absence and had a PICC line in the right upper arm. He was diagnosed with cellulitis and was to receive vancomycin through the PICC line every 18 hours for four weeks. A Care Plan, dated 5/29/24, indicated a PICC line was present. The interventions included, the Physician would be notified an any complication, complications from the IV would be assessed every shift and as needed for infection, electrolyte imbalance, air embolus, dislodgement, infiltration, phlebitis, fluid overload, and dehydration, PICC line site care would be completed as ordered, the PICC site would be assessed for swelling, redness, tenderness, and warmth, and the medication/flushes would be administered as ordered by the Physician. There was no documented assessment of the PICC site, length of the catheter, and arm circumference upon admission. The Physician's Orders, dated 5/29/24, included the PICC dressing change was to be completed every five days and the external catheter length was to be measured with the dressing change. The Medication Administration Record, dated 6/2024, indicated the PICC dressing had been changed on 6/2/24. There was no measurement of the catheter length. The dressing change and measurement of the catheter length on 6/7/24 had not been completed and was documented as not administered/not previously done for the reason the change had not occurred. There were no measurements of the right arm circumference in the Nurses' Progress Notes and the Medication Administration Record from 5/29/24 through 6/12/24. During an interview on 6/12/24 at 12:15 p.m., the DON was made aware of the concerns of the dressing changes not completed, assessments of the PICC catheter length and arm circumference not not assessed. During an interview on 6/12/24 at 3:37 p.m., the DON indicated she was unable to find further information in regard to the concerns. 3. Resident C's closed record was reviewed on 6/12/24 at 1:42 p.m. The diagnoses included, but were not limited to, infection to a surgical site. An admission Observation and Assessment, dated 4/11/24 at 4 p.m., indicated a PICC line was present and the dressing was dry and intact. A Nurse's Progress Note, dated 4/11/24 at 7:13 p.m., indicated the resident arrived at the facility by ambulance, was oriented to the room, call light, medications, and meal times. There was no location of the PICC line, assessment of the site, measurement of the external catheter, or measurement of the arm circumference documented on the assessment or in the admission Progress Notes. A Physician's Order, dated 4/11/24, indicated the PICC line dressing change was to be completed every five days and as needed. A Care Plan, dated 4/12/24, indicated IV medication was required. The interventions indicated the physician would be notified if there were complications, assessments every shift and as needed would be completed for complications of infection, electrolyte imbalance, air embolus, dislodgement, infiltration, phlebitis, fluid overload, and dehydration. The IV site care would be completed as ordered by the physician, the IV site would be assessed for swelling, redness, tenderness, and warmth, and the the medications and flushes would be administered as ordered. An admission MDS assessment, dated 4/14/24, indicated an intact cognitive status, received and antibiotic, had IV medications and an IV access. The MAR, dated 4/2024, indicated the PICC dressing change was scheduled on 4/12/24, 4/17/24, 4/22/24, and 4/27/24. The MAR indicated the dressing was changed on on 4/12/24, 4/17/24, and 4/27/24. The length of the catheter was not measured on 4/17/24 and 4/27/24. The arm circumference was not measured on 4/12/24, 4/17/24, and 4/27/24. The MAR indicated the dressing had not been completed on 4/22/24 because it had been completed on 4/21/24. There was no documentation that indicated the dressing change had been completed or the external catheter and arm circumference was measured on 4/21/24 on the MAR dated 4/2024 and in the Nurses' Progress Notes, dated 4/21//24. The MAR, dated 4/2024, indicated the PICC line site had not been assessed for swelling, redness, tenderness, and warmth from 4/11/14 through 4/27/24. During an interview on 6/12/24 at 3:33 p.m., the DON indicated she was unable to locate any further information on the PICC line care and dressing change. During the Exit Conference on 6/13/24 at 4:14 p.m., the DON indicated she was unable to find any further information on the PICC line care for Residents E, F, and C. The facility policy for infusion therapy, dated 12/2015 and received as current from the Employee Experience Manager, indicated the upper arm circumference should be measured on admission and monitored for swelling possibly caused by infiltration. The external catheter length should be monitored on admission and with each dressing change for outward migration of the catheter. This citation relates to Complaint IN00434520. 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff were aware of which residents were in Enhanced Barrier Precautions (EBP), failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 3 and LPN 2) when providing care to a resident who was in EBP, and failed to ensure staff removed soiled gloves and washed hands after touching contaminated surfaces, for 1 of 3 residents observed for infection control and EBP (Resident F) This had the potential to affect 2 residents with PICC lines (peripherally inserted central catheter - long catheter inserted through a peripheral vein for intravenous treatments). (Residents E and F). Findings include: 1. During the initial tour of Hall 100 on 6/12/24 at 8:49 a.m., LPN 1 indicated Residents E and F had PICC lines in place. There were no signs on the entry doors to Resident E and F's rooms that indicated the residents were on EBP. There was no cart outside the rooms that indicated the resident's were on EBP. During an interview on 6/12/24 at 9 a.m., Resident Care Associate 4 indicated she was not a CNA and could only make beds, pass ice waters, and other non-resident care duties. She stated she was trained by a CNA to wear gloves when changing the beds and only use gowns if the resident was in isolation. She was unsure about EBP precautions. During an interview on 6/12/24 at 9:05 a.m., CNA 5, indicated if a resident was on EBP, there would be a sign on the door and an isolation cart outside the door. The sign on the door would tell staff to contact the nurse before entering. During an interview and observation on 6/12/24 at 9:09 a.m., CNA 3 indicated if a resident was on EBP they would have a sign on their door. The staff were to don a gown and gloves for residents with IV's, catheters, and wounds. She indicated she had received education on EBP. CNA 3 then answered the Resident F's call light. Resident F was in the bathroom sitting on the toilet. CNA 3 donned gloves and stood next to the toilet to assist the resident. CNA 3 was stopped and asked about EBP and she indicated the resident had a PICC. She removed the gloves and went to the closet for a gown and indicated no one had restocked the gowns. She then left the room and brought a packet of gowns to the room and placed in the closet, donned the gown and gloves and assisted the resident with the care. During an interview on 6/12/24 at 9:15 a.m., the LPN Infection Control Nurse indicated there were suppose to be signs on the resident's doors that indicated they were in EBP. The gowns, gloves, and masks were to be kept in the closet of each resident. She indicated there were no signs on Resident E and F's doors. During an interview 6/12/24 at 9:45 a.m., the LPN Infection Control Nurse indicated she had not had an all staff education on EBP. She had completed education during, staff huddles (hallway meetings). She had not had staff sign their names to indicate the education had been completed. a) During an observation on 6/12/24 at 11:37 a.m., Resident E was observed with a PICC line inserted into the right upper arm. Resident E's record was reviewed on 6/13/24 at 10:39 a.m. The diagnoses included, but were not limited to, Right leg cellulitis. A Nurse's Progress Note, dated 6/6/24 at 6:29 p.m., indicated the resident arrived at the facility from the hospital with right leg cellulitis and had physician's orders for two IV antibiotics. A Care Plan, dated 6/10/24, indicated EBP was required related to a PICC line being present. The interventions included, hand hygiene would be performed before and after care. A gown and gloves were to be used during indwelling device care (PICC) and all high contact care. b) During an observation on 6/12/24 at 10:33 a.m., Resident F was observed with a PICC line inserted in his right upper arm. Resident F's record was reviewed on 6/12/24 at 10:36 a.m. The diagnoses included, but were not limited to, stroke and cellulitis. A Nurses Progress Note, dated 5/28/24 at 4:33 p.m., indicated the resident had returned from a hospital leave of absence and had a PICC line in the right upper arm. He was diagnosed with cellulitis and was to receive vancomycin (antibiotic) through the PICC line every 18 hours for four weeks. A Care Plan, dated 5/29/24, indicated EBP was required related to a PICC line was present. The interventions included, hand hygiene would be performed before and after care. A gown and gloves were to be used during indwelling device care (PICC) and all high contact care. 2. During an observation on 6/13/24 at 8:37 a.m., LPN 2 entered Resident's F's room to tend to the PICC line. The antibiotic administered through the PICC line had been completed, needed to be unhooked, and the PICC line flushed. There was a sign on the entry door that indicated the resident was on EBP. LPN 2 washed her hands and donned gloves, prepared the normal saline and heparin flushes and started to initiate care and was stopped and she was asked about EBP. She indicated the resident was on EBP and stopped the PICC line care. She removed her gloves, washed her hands, donned a gown, mask, and new gloves. Prior to initiating the flushes, she picked up the trash can in the room, and pushed a gown that had been thrown away down into the the trash can, and moved the trash can next to her. She then started to pick up the normal saline flush syringe and was stopped prior to initiating the care. She acknowledged she should have changed gloves and washed her hands. LPN proceeded to remove gloves, washed her hands, and donned new gloves prior to the PICC care being initiated. An enhanced barrier precautions policy, dated 4/1/24, and received from the LPN Infection Control Nurse as current, indicated PPE was to be used even if blood and body fluid exposure was not anticipated. Staff were to wear gloves and gowns during high-contact care activities. EBP was to be used for residents with central lines and any indwelling medical device. A facility handwashing policy, dated 2/9/17, and received as current from the Corporate RN, indicated all health care workers were to utilize hand hygiene frequently and appropriately and were to complete hand hygiene after removing gloves and after resident equipment was touched. This citation relates to Complaint IN00434520. 3.1-18(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were given as ordered to prevent significant medication errors for 1 of 3 residents reviewed for medication errors. (Resident B) The deficient practice was corrected by [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the medication error. The facility's plan of action included staff education related to counseling and education on medication administration and dosage calculations. Medication administration competencies were completed for nurses and QMAs. Audits began for as needed (PRN) injectable medications. Finding includes: Resident B's record was reviewed on [DATE] at 9:35 a.m. Diagnoses included, but were not limited to, encephalopathy, diabetes mellitus, and congestive heart failure. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was moderately cognitively impaired for daily decision making. A Progress Note, dated [DATE] at 6:09 a.m., indicated the resident was awake yelling for help. The resident was demonstrating confusion and was re-oriented. A Progress Note, dated [DATE] at 12:45 a.m., indicated the resident was yelling for help and was found on her knees with her upper half of body still in bed. A neurological assessment was completed and she was at her baseline with continued confusion. Redirection was provided at this time and appropriate parties were notified. A Progress Note, dated [DATE] at 1:00 a.m., indicated a new order for molnupiravir (an antiviral medication) 800 mg twice daily for five days for COVID-19. A Progress Note, dated [DATE] at 4:48 a.m., indicated the resident was screaming out help, help. Redirection was provided, but was ineffective. Staff sitting with resident in her room was also not effective. A Progress Note, dated [DATE] at 5:05 a.m., indicated the resident continued to scream out, yelling eve with staff inn the room. The Physician was called and new orders were given for Haldol (an antipsychotic medication) 1 milligram (mg) intramuscular (IM) injection one time now. A Progress Note, dated [DATE] at 6:16 a.m., indicated 1 mg Haldol was ordered by the Physician, 5 mg of IM Haldol was administered. There were no adverse reactions noted. The Physician was notified and no new orders were given. The family was updated. The resident's vital signs were stable, she continued to rest in bed talking to herself. Her neurological assessment remained at baseline. A Progress Note, dated [DATE] at 11:57 a.m., indicated the Physician was in the facility and was informed of the resident's status change, prior testing, and family requests for more testing. A Progress Note, dated [DATE] at 4:42 p.m., indicated during the last neurological check, the resident was noted to remain lethargic and unresponsive to touch or speech. Her vital signs remained stable, slight twitches to hands and arms, and her fingers were purple and cold to the touch. The family requested the resident be sent to the emergency department for evaluation. 911 arrived and transported the resident to the hospital. During a phone interview on [DATE] at 11:28 a.m., the Physician indicated the resident was out of control with her behaviors on the morning of [DATE], so he gave the order for Haldol due to the resident becoming combative and physically aggressive with the staff, for her safety and the safety of the staff. The nurse administered the incorrect dose of the medication. The resident went to the hospital later that afternoon due to lethargy. Haldol has a very short half-life. Someone who is taking Haldol as a scheduled medication or for recurring behaviors would have to take it anywhere from two to three times a day. He had never seen Haldol affect anyone to that degree in his practice and it would be unlikely that it would cause death two days later due to the half-life of the medication. During a phone interview on [DATE] at 12:09 p.m., the Consultant Pharmacist indicated the half-life of the medication is around 20 hours. Side effects of the amount given would be increased sedation and possible hypotension, but that was rare. It would not have had any affect on her blood sugar besides the sedation causing poor intake. A good portion of the medication would have been out of her system from time of administration until [DATE] when she passed. During an interview on [DATE] at 9:59 a.m., the Director of Nursing (DON) indicated RN 1 received an order for one time dose of Haldol 1 mg IM on [DATE] around 5:30 a.m. RN 1 mistakenly gave 1 milliliter, which was equivalent to 5 milligrams of Haldol. RN 1 called the doctor immediately after she realized the error and the doctor did not give any new orders. The resident had just had a fall recently, was still in isolation due to having COVID-19, and was having new behaviors. RN 1 had an aide sit in the room with the resident because she was so anxious and restless. She was becoming combative with the staff. After RN 1 administered the medication, the resident slept a lot. The resident's family became concerned and requested that she go to the hospital. The resident was admitted at the hospital and the next day ([DATE]) the resident was arousable, sitting up, and eating. On [DATE], she coded in the hospital and died. After the incident occurred, the DON provided education to all of the nurses on medication pass procedures and error prevention, dosage calculations, performed medication pass observations, blood sugar monitoring, and injectable medication audits were started weekly. This citation relates to Complaint IN00425412. 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 1 residents reviewed for hospitalization. (Resident 45) The closed record for Resident 45 was reviewed on 11/30/23 at 10:40 a.m. Diagnoses included, but were not limited to, chronic kidney disease and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, indicated the resident was cognitively intact. A Progress Note, dated 10/10/23, indicated the resident was lethargic, her heart rate was 44, and her oxygen saturation was 60%. The resident's blood pressure was not able to be assessed. The resident was put on a rebreather mask. The Nurse Practitioner checked on the resident. The family and Physician were notified and the resident was sent to the hospital. There was a lack of documentation any hospital transfer form had been completed or the State transfer form had been provided in writing to the resident or her responsible party. Interview with the Director of Nursing (DON) on 12/04/23 at 1:33 p.m., indicated there was no transfer/discharge paperwork in the system. She was unable to provide any further documentation. 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a baseline care plan was developed and implemented that included an assistive device within 48 hours of admission for 1 of 19 residents reviewed for care plans. (Resident 97) Finding includes: On 11/27/23 at 11:37 a.m. and 11/28/23 at 1:00 p.m., Resident 97 was observed wearing a back brace. Record review for Resident 97 was completed on 11/28/23 at 1:03 p.m. The resident was admitted to the facility on [DATE]. An admission Observation Form, dated 11/20/23, included the resident's Baseline Care Plans. The Assistive Device section indicated the resident did not have a brace or a splint. There was not a baseline care plan put into place related to the resident's back brace. Interview with LPN 1 on 11/28/23 at 1:16 p.m., indicated the resident was admitted to the facility with the back brace. She could not find any documentation to indicate a baseline care plan for the back brace was put into place. 3.1-30(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of Physician's Orders in place for a wound treatment for 1 of 2 residents reviewed for non-pressure skin conditions and for a back brace for 1 of 3 residents reviewed for positioning and limited range of motion. (Residents 102 and 97) Findings include: 1. On 11/27/23 at 11:41 a.m., Resident 102 was observed sitting in a wheelchair in the dining room. The resident had a bandage to his right elbow. There was writing on the bandage that was not legible. On 11/28/23 at 11:02 a.m., Resident 102 was observed sitting in a wheelchair in his room. The resident had a bandage to his right elbow that was dated 11/27/23. He indicated he had fallen a while ago and had been wearing a bandage to his elbow since then. The nurses changed the bandage once in a while. Record review for Resident 102 was completed on 11/28/23 at 11:03 a.m. An admission Observation Form, dated 11/17/23, indicated the resident had no skin issues noted to the right elbow. There was a lack of documentation to indicate what the skin condition was or what caused it. There was not a Physician's Order in place for a treatment to the right elbow that included how often the bandage was to be changed. Interview with LPN 1 on 11/28/23 at 11:08 a.m., indicated the resident had a scabbed area to his elbow from a previous fall. She had changed the resident's bandage yesterday. The bandage had been on there for multiple days prior to changing it. There was not a current Physician's Order for a treatment to the area to his elbow. 2. On 11/27/23 at 11:37 a.m., Resident 97 was observed sitting in a wheelchair in the Therapy Department. The resident had a back brace in place. On 11/28/23 at 1:00 p.m., Resident 97 was observed sitting in a wheelchair in her room. The resident was wearing a back brace. The back brace was wrapped around her waist and had straps that came over her shoulders. The straps over her shoulders were not buckled to the waist. The resident indicated she had fallen and fractured her back and now had to wear the back brace all the time. She indicated she needed help putting it on and taking it off. Sometimes the staff would help her put it on and take it off. Record review for Resident 97 was completed on 11/28/23 at 1:03 p.m. The resident was admitted to the facility on [DATE]. A Physician Note, dated 11/24/23 at 7:43 a.m., indicated the resident was admitted to the facility for rehab after a T6 compression fracture. The resident had a TLSO (Thoracic-Lumbar-Sacral-Orthosis)brace. An Occupational Therapy Note, dated 11/24/23, indicated the resident was to have the TLSO brace on when out of bed. There was a lack of documentation to indicate a Physician's Order was in place for the back brace, that included when the resident was supposed to wear it and that she needed assistance to apply it and take it off. Interview with LPN 1 on 11/28/23 at 1:16 p.m., indicated the resident was admitted to the facility with the back brace. The resident was supposed to wear the brace any time she was out of bed. The resident needed assistance putting it on and taking it off. She was unaware there was not a Physician's Order in place for the back brace and there should have been one. 3.1-37(a)

Based on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 11/30/23 at 9:06 a.m. Diagnoses included, but were not limited to, congestive heart failure and atrial fibrillation. The admission Minimum Data Set (MDS) assessment, dated 9/23/23, indicated the resident was cognitively impaired and required supervision with eating. The resident weighed 200 pounds on 10/26/23 and 183 pounds on 11/26/23. A Registered Dietician Note, dated 11/21/23, indicated the resident had a significant weight loss of 10.9% weight loss in 30 days. The Meal Consumption Log for November 2023 lacked documentation of the following meals: - Breakfast on 11/2/23, 11/9/23, 11/11/23, and 11/20/23. - Lunch on 11/2/23, 11/9/23, 11/11/23, 11/20/23, and 11/24/23. - Dinner on 11/2/23, 11/5/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/12/23, 11/18/23, 11/21/23, 11/24/23, 11/25/23, 11/26/23, and 11/27/23. Interview with the Evening Supervisor on 12/1/23 at 10:09 a.m., indicated the food consumption logs were incomplete. There had been some trouble with their electronic charting program recording documentation at times. She was unable to provide any further documentation. 3.1-46(a)(1) 3.1-46(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident was assessed for self-medication administration prior to leaving medications at the bedside for 1 of 1 random observations of medications left at bedside. (Resident 7) Finding includes: On 12/13/22 at 12:52 p.m., Resident 7 was observed lying in bed. There was a plastic medicine cup on her bedside table with a blue pill in it. The resident indicated she did not know what it was. The resident's record was reviewed on 12/13/22 at 1:27 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's dementia. The current Social Aspects Care Plan indicated the resident had moderate cognitive impairment which was anticipated to progress due to the nature of the disease process. There was no self-medication assessment. Interview with RN 1 on 12/13/22 at 1:03 p.m., indicated the resident was not assessed for self-medication administration. The RN went to the resident's room, and indicated the medication was no longer there, the resident had taken it. 3.1-11(a)

Based on interview, observation, and record review, the facility failed to honor a resident's food preferences for wanting his diet upgraded for 1 of 1 residents reviewed for choices. (Resident 44) Finding includes: On 12/12/22 at 10:18 a.m., Resident 44 was observed sitting up in bed watching television. He indicated he was on a mechanical diet and not sure why. He did not like his food ground up and had asked multiple times for someone to explain to him why he had to have his food prepared this way. He further indicated he had speech therapy a while ago and had never had a problem chewing or swallowing his food his whole life. He indicated he asked for a hamburger every day and they would tell him he could only have one ground up. The only other food he could choose from that he liked was a toasted peanut butter sandwich. On 12/13/22 at 1:15 p.m., Resident 44 was observed sitting up in bed. The resident could be heard from the hallway telling a CNA that he wanted a hamburger for lunch. CNA 2 told the resident he could have a hamburger if it was ground up. He then asked for a salad and the CNA told him he could not have that either. He told the CNA he had never had a problem eating food his whole life and wanted to speak to someone about getting the food he wanted. CNA 2 asked the resident if he wanted his toasted peanut butter sandwich and he said, I guess if that's the only thing I can have. The CNA left the room. On 12/14/22 at 12:00 p.m., Resident 44 was observed sitting in a wheelchair in the Main Dining Room waiting to be served for lunch. The resident asked a staff member for a hamburger. The staff member told him he could only have a hamburger if it was cut up due to his diet. The resident told the staff member he did not want the hamburger cut up. The staff member asked him if he would like a toasted peanut butter sandwich. The resident once again said, I guess if that's the only thing I can have. He once again told a staff member he wanted to talk to someone about his diet. Record review for Resident 44 was completed on 12/14/22 at 2:26 p.m. Diagnoses included, but were not limited to, stroke, dementia, malnutrition, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 9/16/22, indicated the resident was moderately cognitively impaired. The resident required supervision of 1 person for eating. The resident had no swallowing disorder and was on a mechanically altered diet. A Care Plan for Nutrition, dated 6/22/22 and revised 12/13/22, indicated the resident had impaired swallowing requiring a mechanically altered diet. An intervention included to obtain consults as needed in example from dietary and Speech Therapy. A Speech Therapy Discharge Note, dated 7/19/22, indicated the resident had reached maximum potential with skilled services. The resident received mechanical soft/chopped textures for oral intake and thin liquids. Interview with CNA 2 on 12/13/22 at 1:17 p.m., indicated the resident couldn't have a salad because he was old and could not chew and swallow it right. The Dietician wanted him on mechanical soft foods. She further indicated he complained daily about not wanting the food he was served so he usually ate a toasted peanut butter sandwich. Interview with the Evening Supervisor on 12/13/22 at 1:18 p.m., indicated the resident was on mechanical soft due to swallowing issues. She was unsure the last time he had a swallow study completed or which the last time he was evaluated by Speech Therapy. She indicated he complained a lot about not wanting to have his food ground up. They would tell him daily it was because therapy wanted him to have a mechanical diet. Interview with Speech Therapist on 12/15/22 at 10:31 a.m., indicated the last time she saw the resident in therapy she believed was in June 2022. When the resident ended therapy, she recommended he was on a mechanical altered diet due to chewing and swallowing issues. Nursing would have to come and tell therapy if the resident wanted to be re-evaluated again for a diet upgrade. Since then she had not received any orders from nursing that the resident had wanted his diet upgraded. Interview with the Director of Nursing (DON) on 12/15/22 at 10:55 a.m., indicated she was unaware the resident was wanting his diet upgraded and that nursing should have let therapy know if he had been complaining about wanting other types of foods. Therapy would then have to do an evaluation to see if the resident's diet could be upgraded. 3.1-3(u)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident 28 was completed on 12/16/22 at 10:02 a.m. Diagnoses included, but were not limited to, sepsis and COVID-19. The admission MDS assessment, dated 11/15/22, indicated the resident was moderately cognitively impaired. The resident was discharged to the hospital on [DATE] due to sepsis. The resident returned to the facility on [DATE]. A Hospital Progress Note, dated 11/27/22, indicated the resident had severe sepsis and the etiology was not clear. The hospital could not rule out pneumonia vs UTI (urinary tract infection) vs mild sacral cellulitis. A blood culture indicated E. coli (bacteria). The resident was to stay on meropenem (antibiotic) for 10 more days and have a follow up blood culture done in 2 weeks. The December 2022 Physician's Order Summary indicated orders for culture blood test (times 2) sets on 11/28/22, 11/29/22, and 12/13/22. The resident received meropenem 1 gram IV for UTI sepsis every 12 hours on 11/28/22 and discontinued on 12/8/22. A Progress Note, dated 12/13/2022 at 6:23 p.m., indicated a medical clinic was called to request a blood culture. The medical clinic claimed they were unable to do blood cultures. The Director of Nursing (DON) was notified. The record lacked any documentation the blood cultures had been completed as ordered or that the Physician was notified the blood cultures were not completed. Interview with the DON on 12/16/22 at 12:59 p.m. indicated they had been having problems getting the supplies needed to draw the blood cultures. She would have to look into whether or not the doctor was notified the blood cultures had not been completed since the resident returned from the hospital. Follow up interview with the DON on 12/19/22 at 11:50 a.m., indicated the supplies for the blood culture arrived to the facility that day. She could not provide any further documentation the Physician had been notified that the blood cultures had not been completed as ordered. 3.1-37(a) Based on observation, record review, and interview, the facility failed to ensure Physician orders for labs were completed or completed in a timely manner and a skin discoloration was identified and monitored for 1 of 5 residents reviewed for respiratory care (Resident 56), 1 of 2 residents reviewed for non-pressure skin conditions (Resident 7) and 1 of 5 residents reviewed for unnecessary medications. (Resident 28) Findings include: 1. Resident 56's record was reviewed on 12/13/22 at 9:27 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, acute and chronic respiratory failure and congestive heart failure. The admission Minimum Data Set assessment, dated 9/24/22, indicated the resident had severe cognitive impairment. A Physician's Note, dated 12/7/22, indicated to have a BMP (basic metabolic panel), CBC (complete blood count), and Magnesium labs drawn. There were no results for the above labs. There was no indication the labs had been ordered or completed. The Director of Nursing indicated she would look into it. Interview with RN 3 on 12/14/22 at 1:25 p.m., indicated nurses did their own lab draws and they were picked up on midnight shift by pharmacy. Interview with the Director of Nursing on 12/14/22 at 9:18 a.m., indicated the Physician would put his orders in his notes. The orders had not been entered or completed until 12/13/22. 2. On 12/13/22 at 12:52 p.m., Resident 7 was observed in bed. She had a dark brown/ blackish discoloration approximately eight centimeters round on her right forearm. The resident indicated she did not know what it was or what had happened. The resident's record was reviewed on 12/13/22 at 1:27 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's dementia. There was no documentation regarding the discoloration in the Progress Notes. Interview with RN 1 on 12/13/22 at 1:03 p.m., indicated she was not aware the resident had a skin discoloration. Interview with the Director of Nursing (DON) on 12/13/22 at 1:55 p.m., indicated there were no skin events recorded for the resident. The current policy, Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, was received from the DON on 12/13/22, indicated, .May complete Bruise Event in EHR (electronic health record) by an RN/LPN if the bruise warrants documentation due to the extent and or location

Based on observation, record review, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed for residents with significant weight loss for 2 of 3 residents reviewed for nutrition. (Residents 53 and 49) Findings include: 1. On 12/13/22 at 12:58 p.m., Resident 53 was observed lying in bed with her eyes open. She had a plate of spaghetti on the bedside table in front of her. The silverware was still wrapped in a napkin and no drinks were observed on the table. At 1:25 p.m., Occupational Therapist (OT) 1 was observed assisting the resident up in bed to eat. At 1:29 p.m., OT 1 was observed bringing the resident a Styrofoam cup of liquid to her room. Interview with OT 1 at the time indicated she assisted the resident up in bed to eat. She indicated the resident told her she did not know her food was in the room. The resident had refused to get up in the wheelchair to eat. She was unsure why the resident did not have any drinks on her tray, so she went and got her a cup of milk. On 12/14/22 at 12:01 p.m., Resident 53 was observed sitting in the Main Dining Room eating lunch. At 12:20 p.m., the Employee Engagement Specialist (EES) was observed asking the resident if she was done with her lunch. The resident indicated yes and the EES removed and discard the resident's lunch plate. Interview with the EES at the time of the observation indicated she was unaware how much food the resident had consumed. She was also unaware the resident's meal intakes were supposed to documented. Record review for Resident 53 was completed on 12/13/22 at 1:04 p.m. Diagnoses included, but were not limited to, fracture of left ileum, dementia, and malnutrition. The admission Minimum Data Set (MDS) assessment, dated 11/7/22, indicated the resident was cognitively impaired. The resident's assistance level needed for eating was not marked. On 11/7/2022, the resident weighed 124 lbs. On 12/8/2022, the resident weighed 98 pounds which was a 20.97% loss. A Registered Dietician Note, dated 12/12/22 at 2:58 p.m., indicated due to the resident's underweight status, weight loss was not desirable. The resident received a regular diet with meal intakes variable, though mostly 26-50%. Marinol was ordered and may aid in increased appetite, Ensure supplement was ordered three times a day with good acceptance. She suggested to do weekly weights for 4 weeks for further weight monitoring. Staff may offer ice cream with lunch and dinner for added calories and protein. The December 2022 Physician's Order Summary (POS) indicated orders for the following: - Marinol (appetite stimulant) 2.5 mg (milligrams) prior to breakfast and lunch everyday - Intake and Output Care Assist Order to check breakfast, lunch, and dinner daily - Ensure supplement 237 ml (milliliters) three times a day The meal consumption log for November 2022 had 34 out of 81 meals with no value documented. The December 2022 log had 16 out of 39 meals with no value documented. Interview with the Director of Nursing on 12/14/22 at 12:29 p.m., indicated the staff should be documenting how much food the resident was eating at each meal. 2. On 12/13/22 at 1:00 p.m., Resident 49 was observed sitting in a wheelchair in her room eating lunch. The resident refused room entry and indicated her food was fine. Record review for Resident 49 was completed on 12/14/22 at 1:30 p.m., Diagnoses included, but were not limited to, hypertension, dementia, depression, and anxiety. The Quarterly MDS assessment, dated 10/28/22, indicated the resident was cognitively impaired. The resident required supervision setup assistance for eating. The resident was on a mechanical diet and had weight loss which was not documented as physician prescribed. On 6/3/2022, the resident weighed 200 lbs. On 12/09/2022, the resident weighed 154 pounds which was a 23.00% loss. A Registered Dietician (RD) Note, dated 11/17/22 at 3:40 p.m., indicated the resident had weight loss. The resident was overweight and weight loss was not detrimental. The resident had an ordered diet of mechanical soft with fortified foods. Remeron (antidepressant) was ordered and ice cream was offered at lunch and dinner for additional calories. The resident did not like or want nutritional supplements. She had previously stated that she was happy with her weight loss. The RD suggested to continue present nutrition management. The December 2022 POS indicated orders for the following: - mirtazapine (antidepressant) 7.5 mg (milligrams) at bedtime for appetite stimulant - Diet: Regular, Mechanical Soft solids, thin liquids, fortified foods with meals (no shakes), ice cream with lunch and dinner - Intake and Output Care Assist Order to check breakfast, lunch, and dinner daily The meal consumption log for December 2022 had 18 out of 39 meals with no value documented. Interview with the DON on 12/14/22 at 2:48 p.m., indicated the weight loss was desired weight loss to the resident. Staff should be marking the resident's meal intakes. 3.1-46(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/12/22 at 10:54 a.m., Resident 27 was observed with no oxygen in place. There was no oxygen concentrator or equipment set up in her room. On 12/13/22 at 1:21 p.m., Resident 27 was observed lying in bed in her room with no oxygen in place. There was no oxygen concentrator or equipment set up in her room. Record review for Resident 27 was completed on 12/14/22 at 11:07 a.m. Diagnoses included, but were not limited to, anxiety disorder, Alzheimer's disease, and dyspnea. The Quarterly Minimum Data Set (MDS) assessment, dated 10/25/22, indicated the resident was cognitively impaired, received oxygen therapy and hospice care. The Physician's Order Summary, dated 12/2022, indicated an order for oxygen 2 liters continuously per nasal cannula. The Medication Administration Record (MAR), dated 12/2022, indicated the resident had received the oxygen as ordered. Interview with the DON on 12/13/22 at 1:57 p.m., indicated she would check the resident's oxygen orders. A facility policy, titled, Administration of Oxygen, received from the Director of Nursing as current, indicated .1. Verify Physician's order for the procedure .17. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 3.1-47(a)(6) 2. On 12/12/22 at 12:58 p.m., Resident 36 was observed lying in bed. The resident had oxygen in use via a nasal cannula and set at a flow rate of 3.5 liters. The resident indicated she was unsure how much oxygen she was supposed to be using. On 12/13/22 at 11:43 a.m., Resident 36 was observed lying in bed. The resident had oxygen in use via a nasal cannula and set at a flow rate of 3.5 liters. Record review for Resident 36 was completed on 12/13/22 at 11:40 a.m. Diagnoses included, but were not limited to, heart failure and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 9/11/22, indicated the resident was cognitively intact. The resident required an extensive 2+ person assist with bed mobility. No oxygen therapy was marked. A Care Plan, dated 2/6/2020 and revised 12/13/22, indicated the resident had potential for cardiovascular distress related to a diagnosis of hypertension. An intervention included to administer oxygen per order. The record lacked any documentation for a Physician's Order for oxygen for the resident. Interview with RN 1 on 12/13/22 at 1:33 p.m., indicated she was unsure how much oxygen the resident was supposed to be using, but believed it to be 2 liters. She then looked into the resident's Physician's Orders and was unable to find an order for oxygen. She further indicated there should have been a Physician's Order for the oxygen. Based on observation, record review, and interview, the facility failed to ensure Physician's orders were in place for residents receiving oxygen, and oxygen was in place as ordered for 3 of 5 residents reviewed for respiratory care. (Residents 43, 36 and 27) Findings include: 1. On 12/12/22 at 1:49 p.m. and 12/13/22 at 3:04 p.m., Resident 43 was observed in her bed. She had a nasal cannula in place and oxygen was flowing at 2 liters per minute (lpm). The resident's record was reviewed on 12/13/22 at 2:58 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, emphysema. The admission Minimum Data Set assessment, dated 11/17/22, indicated the resident had moderate cognitive impairment. There was no Physician's order for oxygen. A Respiratory Care Plan indicated the resident had the potential for complications related to emphysema and to use oxygen as ordered. Interview with the Nurse Consultant on 12/14/22 at 11:48 a.m., indicated there had been no order in place for the resident's oxygen.

Based on record review and interview, the facility failed to ensure each resident ' s medication regimen was managed and monitored to promote or maintain the resident ' s highest practicable mental, physical, and psychosocial well-being related to a blood pressure medication not administered as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 47) Finding includes: Record review for Resident 47 was completed on 12/13/22 at 11:42 a.m. Diagnoses included, but were not limited to, hypertension, atrial fibrillation, hyperlipidemia, and stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 11/28/22, indicated the resident was cognitively impaired. A Care Plan, dated 2/24/22 and revised on 12/13/22, indicated the resident had a potential for cardiovascular distress related to diagnosis of atrial fibrillation, hypertension, and hyperlipidemia. An intervention included to give medications as ordered. The December 2022 Physician's Order Summary indicated an order for clonidine (blood pressure medication) patch 0.1 mg (milligrams) weekly. Special instructions included to remove old patch prior to placing new one every Friday. The November and December 2022 Medication Administration Records indicated the resident had not received the clonidine patch as ordered on the following days: - 11/18/22: not administered/refused - 11/25/22: not administered; drug item unavailable - 12/2/22: not administered; drug item unavailable - 12/9/22; not administered; drug item unavailable. There was no documentation to indicate the facility was monitoring the resident's blood pressure since he had not received his blood pressure patch since November. There was no documentation to indicate the Physician or pharmacy was notified that the facility did not have the resident's patches. Interview with the Director of Nursing on 12/16/22 at 9:48 a.m., indicated she had spoken with the doctor and told him about the resident not receiving the clonidine patch. The doctor indicated to hold the patch x 2 weeks and check the blood pressure twice a day. She further indicated they had just checked the residents blood pressure and it was within normal limits. The facility should have notified the doctor and pharmacy if the resident had not received his patch and the nurses should have been monitoring his blood pressure. 3.1-48(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to not wearing personal protective equipment (PPE) correctly when entering a transmission based precaution (TBP) isolation room, not completing hand hygiene prior to donning PPE, not removing PPE correctly after exiting a TBP isolation room, and not completing hand hygiene after doffing PPE for random observations of infection control. (Rooms 114, 113, 115, and 110) Findings include: 1. During a random observation on 12/13/22 at 9:41 a.m., RN 2 was observed preparing to pass medications to the resident in room [ROOM NUMBER]. There were signs on the door that indicated the resident was in droplet/contact isolation. RN 2 was observed to be wearing an N95 mask and a face shield. She stopped outside the room door and removed her face shield. She donned a gown and put a surgical mask over her N95 mask. She then put her face shield back on, donned gloves, and entered the room. She had not performed hand hygiene prior to donning the PPE. At 9:43 a.m., RN 2 was observed exiting the room. She doffed the gown, gloves, surgical mask, and face shield. She kept the same N95 mask on. She used hand sanitizer and obtained a new face shield. The resident was in isolation due to being COVID-19 positive. 2. During a random observation on 12/13/22 at 9:49 a.m., CNA 1 was observed delivering breakfast to the resident in room [ROOM NUMBER]. There were signs on the door that indicated the resident was in droplet/contact isolation. CNA 1 was observed to be wearing an N95 mask and face shield. She stopped outside the room door and donned a gown and gloves, then entered the room. She had not performed hand hygiene prior to donning the PPE. At 9:51 a.m., CNA 1 was observed exiting the room. She doffed the gown and gloves. She kept the same N95 mask and face shield on. She had not performed hand hygiene after doffing the PPE or cleaned her face shield. The resident was on isolation for COVID-19 symptoms and C. Diff (clostridium difficile, a bacterial infection). 3. During a random observation on 12/13/22 at 9:53 a.m., RN 2 was observed delivering breakfast to the resident in room [ROOM NUMBER]. There were signs on the door that indicated the resident was in droplet/contact isolation. RN 2 was observed to be wearing an N95 mask and a face shield. She stopped outside the room door and removed her face shield. She donned a gown and gloves and put a surgical mask over her N95 mask. She then put her face shield back on and entered the room. She had not performed hand hygiene prior to donning the PPE. As RN 2 exited the room, she doffed the gown, gloves, surgical mask, and face shield. She kept the same N95 mask on. She used hand sanitizer and obtained a new face shield. The resident was in isolation due to being COVID-19 positive. 4. During a random observation on 12/13/22 at 10:04 a.m., CNA 1 was observed delivering breakfast to the resident in room [ROOM NUMBER]. There were signs on the door that indicated the resident was in droplet/contact isolation. CNA 1 was observed to be wearing and N95 mask and face shield. She stopped outside the room door and donned a gown and gloves, then entered the room. She had not performed hand hygiene prior to donning the PPE. At 10:08 a.m., CNA 1 was observed exiting the room. She doffed the gown and gloves. She kept the same N95 mask and face shield on. She had not performed hand hygiene after doffing the PPE or cleaned her face shield. The resident was in isolation due to being COVID-19 positive. CNA 1 then went to answer the call light for room [ROOM NUMBER]. Interview with the Director of Nursing (DON) on 12/13/22 at 1:57 p.m., indicated she would provide the current facility policies related to transmission-based precautions and hand hygiene. A facility policy, titled, COVID-19 Guidelines for PPE, received from the Director of Nursing as current, indicated . Facemasks for Health Care Providers .When used for care of a resident in isolation, facemasks should be removed and discarded after the resident care encounter and a new one should be donned . A facility policy, titled, Guideline for Handwashing/Hand Hygiene received from the Director of Nursing as current, indicated .3. Health Care Workers shall use hand hygiene at times such as .d. After removing gloves . 3.1-18(b)