**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation for 2 of 3 residents reviewed pharmaceutical services. Resident's narcotic medications went missing after being delivered from the pharmacy which caused residents to miss physician ordered routine medications. (Resident D, Resident G) Findings include: 1. During record review on 5/29/25 at 10:30 A.M., Resident D's diagnoses included, but were not limited to; osteoarthritis, chronic kidney disease, and diabetes. Resident D's most recent annual Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment, had occasional pain rated two (2) on a scale of zero (0) - ten (10) (zero being no pain and ten being the most pain), and received opiod medication. Resident D's physician orders included, but were not limited to; oxycodone hydrochloride (HCL) 5 milligrams (mg), one tablet by mouth twice a day for pain (started 10/9/23), and Tylenol 325 mg, two tablets by mouth every six hours as needed (PRN) for pain. Resident D's Medication Administration Record (MAR) included: 4/7/25 at 10:22 A.M. - PRN medication given - Tylenol 325 mg - 2 tablets given (due to) out of oxycodone until new script obtained. for pain. 4/8/25 at 2:17 P.M. - PRN medication given - Tylenol 325 mg - 2 tablets for pain 4/9/25 at 7:38 A.M. - PRN medication given - Tylenol 325 mg - 2 tablets for pain 4/9/25 at 3:56 P.M. - PRN medication given - Tylenol 325 mg - 2 tablets for pain 4/10/25 at 7:00 A.M. - PRN medication given - Tylenol 325 mg - 2 tablets for pain Resident D's Controlled Drug Record for medication oxycodone hydrochloride (HCL) 5 milligrams (mg), one tablet by mouth twice a day, was dated as received from the pharmacy on 3/20/25 with a total of 28 doses received. The last dose was signed out on 4/5/25 at 4:00 P.M. A pharmacy delivery sheet, dated 3/20/25, indicated Resident D received a total of 58 doses of the medication oxycodone hydrochloride (HCL) 5 milligrams (mg), one tablet by mouth twice a day (one 28 dose sheet, and one 30 dose sheet). The delivery sheet was signed by facility staff as received at 10:30 P.M. on 3/20/25. 2. During record review on 5/29/25 at 11:30 A.M., Resident G's diagnoses included, but were not limited to; malignant neoplasm of left breast, diabetes, left sided hemiplegia, and cirrhosis of liver. Resident G's most recent quarterly Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident had severe cognitive impairment, had frequent pain rated at a five (5) on a scale zero (0) - ten (10), and received an opiod medication. Resident G's physician orders included, but were not limited to; Norco (hydrocodone-acetaminophen 5 mg - 325 mg 1 tablet by mouth three times a day for pain (ordered 3/25/25), and Tylenol Extra Strength 500 mg 2 tablets by mouth twice a day as needed (PRN) for pain (ordered 6/18/22). Resident G's Medication Administration Record (MAR) included: 4/3/25 at 12:45 P.M. - PRN medication given: Tylenol Extra Strength 500 mg 2 tablets due to Norco no available at this time. Resident G's Controlled Drug Record for medication Norco (hydrocodone-acetaminophen 5 mg - 325 mg 1 tablet by mouth three times a day was dated as received from the pharmacy on 3/25/25 with a total of 12 doses received. The last dose given was signed out on 4/1/25 at 7:00 A.M. Two more doses were available and not signed out on the count sheet. A pharmacy delivery sheet, dated 3/25/25, indicated Resident G received a total of 42 doses of the medication Norco (hydrocodone-acetaminophen 5 mg - 325 mg 1 tablet by mouth three times a day (one 12 dose sheet, and one 30 dose sheet). The delivery sheet was signed by facility staff as received at 10:20 P.M. on 3/25/25. During an interview on 5/29/25 at 12:15 P.M., RN 2 indicated that full sheets of narcotic medications had recently went missing from the medication cart. RN 2 indicated nursing staff should count all narcotic medications, fill out the narcotic count sheet, and sign the narcotic count sheet at each shift change. On 5/29/25 at 12:30 P.M. an Indiana Department of Health (IDOH) Facility Reportable Incident (FRI) form, dated 4/1/25 at 10:30 A.M., indicated (added 5/9/25) the Facility Administrator was notified of a potential concern with medications missing on 4/1/25 and 4/9/25 realized as nursing staff was attempting to refill medications from the pharmacy. The facility investigation into missing medications included an unsigned, typed note that indicated on 4/1/25 at 10:30 A.M., RN 4 reported to the Director of Nursing (DON) that 30 Norco medications for Resident G were missing. After an unsuccessful search for the medications, pharmacy was contacted to ensure delivery of the medications. RN 7 had received the medication from the pharmacy on 3/25/25. RN 7 left the medications for LPN 9 to secure in the locked medication cart. LPN 9 documented that 2 cards of 42 medications of Resident G's Norco medication was added to the medication cart. All controlled medication cards were counted in the cart on the morning of 3/26/25 for a total of 34 medication cards. The medications cards were counted again that afternoon at 2:00 P.M. for a total of 34. No night shift medication card count was completed on the night of 3/26/25. The medications card sheets were not counted again on 3/27/25 morning shift at 6:00 A.M., or the afternoon shift at 2:00 P.M When the medications cards were counted again on the night of 3/27/25, 32 cards were counted. When RN 4 attempted to reorder Resident G's Norco medication on 3/29/25, the pharmacy responded that the medications were delivered on 3/25/25. The facility investigation also included that Resident G had missed routine doses of narcotic medications on the night of 4/2/25 and the morning of 4/3/25. Resident D had missed routine doses of narcotic medications on the mornings and nights of 4/7/25, 4/8/25, 4/9/25, and 4/10/25. During an interview on 5/29/25 at 1:55 P.M., the Facility Administrator and DON indicated Resident D and Resident G were each missing a sheet of narcotic medications along with the controlled substance count sheet that correlated with the medications cards. Due to nursing staff not completing counts every shift and due to count sheets missing, an exact total of missing medications was unable to be determined. Resident D and Resident G received PRN pain medication while the facility obtained new orders and waited on the pharmacy to refill the lost medications. On 5/29/25 at 2:55 P.M., the Facility Administrator supplied a facility policy titled, Controlled Substance Policy, dated 07/2024. The policy included, Purpose: To ensure appropriate and consistent procedures for safeguarding controlled substances are followed from delivery through the actual administration and/or destruction of the medications . 2. Controlled Substances Count a. All controlled substances will be counted by 2 nurses at each shift change . This citation relates to complaint IN00459224. 3.1-28(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/6/25 at 1:08 P.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, osteomyelitis, end stage renal disease, diabetes mellitus type II, and peripheral vascular disease. On 1/9/25 at 1:40 P.M., all completed transfer and discharge notices from January 2024 to present were requested. During an interview on 1/9/25 at 4:40 P.M., the Clinical and Quality Consultant indicated Resident 13 was transferred and hospitalized on the following dates: 1/17/24, returned 1/20/24 6/7/24, returned 6/9/24 6/17/24, returned 6/19/24 9/23/24, returned 9/25/24 10/18/24, returned 12/3/24 1/2/25, returned 1/6/25 The clinical record lacked documentation of the resident and representative receiving a notice of transfer or discharge at the time of the hospitalizations. During an interview on 1/13/25 at 2:05 P.M., the Clinical and Quality Consultant indicated she could not provide completed transfer and discharge notices for the following dates: 6/7/24 6/17/24 9/23/24 10/18/24 1/2/25 During an interview on 1/13/25 at 2:05 P.M., the Clinical and Quality Consultant indicated when the resident was transferred, the transfer and discharge notices should have been completed, copied, sent with the resident, and the copy should have been placed in the resident's clinical record. On 1/14/25 at 9:00 A.M., a current Transfer and Discharge Policy, revised October 2022, was provided by the Clinical and Quality Consultant and indicated Purpose: The facility will comply with regulations regarding initiating a transfer or discharge of a resident and the accompanying documentation that must be included in the medical record . the facility will notify the resident and the resident's representative of the transfer and reasons for the move in writing and in a language the resident understands . the facility will document in the medical record, before or as close as possible to the actual time of transfer or discharge . 3.1-12(a) Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 3 of 3 residents reviewed for hospitalizations. The transfer discharge form was not completed. (Resident 27, Resident 37, Resident 13) Findings include: 1. On 1/6/25 at 11:20 A.M., Resident 27's clinical records were reviewed. Diagnoses included, but were not limited to anemia, dementia, neurogenic bladder, and chronic kidney disease, stage 4. The most current Quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, indicated Resident 27 had moderate cognitive impairment, required set up or clean up for eating, bed mobility, toilet use and transfer, and had a suprapubic catheter. On 1/6/25 at 11:47 A.M., Resident 27's clinical records indicated he was hospitalized from [DATE] to 12/5/24. Clinical records lacked transfer/discharge paperwork. During an interview on 1/9/25 at 1:35 P.M., Licensed Practical Nurse (LPN) 9 indicated she was unable to find the last hospitalization information or discharge paperwork. She indicated when a resident was transferred the paperwork was given to Director of Nursing (DON ) and she would ask the Assistant Director of Nursing (ADON) where the paperwork was located. During an interview on 1/13/25 at 2:00 P.M., the Clinical and Quality Consultant indicated the nurse who transferred Resident 27 to the hospital did not keep a copy of the transfer/discharge paperwork. 2. On 1/6/25 at 1:02 P.M., Resident 37's clinical records were reviewed. Diagnoses included, but were not limited to atrial fibrillation, heart failure, dementia, depression, and psychotic disorder. The most current Annual MDS assessment, dated 9/6/24, indicated Resident 37 had severe cognitive impairment, required set up or clean up for eating, bed mobility, toilet use and transfer. Clinical records indicated Resident 37 was hospitalized on [DATE] to 2/29/24, 11/1/24 to 11/12/24, and 11/16/24 to 11/30/24. Clinical records lacked transfer/discharge paperwork. During an interview on 1/9/24 at 4:43 P.M., the Clinical and Quality Consultant indicated they were still looking for the transfer/discharge paperwork.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/6/25 at 1:08 P.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, osteomyelitis, end stage renal disease, diabetes mellitus type II, and peripheral vascular disease. On 1/9/25 at 1:40 P.M., all completed bed hold notices from January 2024 to present were requested. During an interview on 1/9/25 at 4:40 P.M., the Clinical and Quality Consultant indicated Resident 13 was transferred and hospitalized on the following dates: 1/17/24, returned 1/20/24 6/7/24, returned 6/9/24 6/17/24, returned 6/19/24 9/23/24, returned 9/25/24 10/18/24, returned 12/3/24 1/2/25, returned 1/6/25 The clinical record lacked documentation of the resident and representative receiving a bed hold notice and policy at the time of the hospitalizations. During an interview on 1/13/25 at 2:05 P.M., the Clinical and Quality Consultant indicated she could not provide completed bed hold notices for the following dates: 1/17/24 6/7/24 6/17/24 9/23/24 10/18/24 1/2/25 During an interview on 1/13/25 at 2:05 P.M., the Clinical and Quality Consultant indicated when the resident was transferred, the bed hold notice should have been completed, copied, sent with the resident, and the copy should have been placed in the resident's clinical record. On 1/14/25 at 9:00 A.M., a current Bed Hold Policy, revised October 2017, was provided by the Clinical and Quality Consultant and indicated Purpose: To provide notice in writing before transfer or a resident to a hospital . at the time of transfer for a resident for hospitalization or therapeutic leave, the facility will provide to the resident and the resident representative written notice . 3.1-12(a)25 3.1-12(a)26 Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 3 of 3 residents reviewed for hospitalizations. The bed hold form was not completed. (Resident 27, Resident 37, Resident 13) Findings include: 1. On 1/6/25 at 11:20 A.M., Resident 27's clinical records were reviewed. Diagnoses included, but were not limited to anemia, dementia, neurogenic bladder, and chronic kidney disease, stage 4. The most current Quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, indicated Resident 27 had moderate cognitive impairment, required set up or clean up for eating, bed mobility, toilet use and transfer, and had a suprapubic catheter. On 1/6/25 at 11:47 A.M., Resident 27's clinical records indicated he was hospitalized from [DATE] to 12/5/24 for sepsis and weakness with a one week history of nausea, vomiting, diarrhea and abdominal pain. Clinical records lacked bed hold paperwork. During an interview on 1/9/25 at 1:35 P.M., Licensed Practical Nurse (LPN) 9 indicated she was unable to find the last hospitalization information or bed hold paperwork. She indicated when a resident was transferred the paperwork was given to Director of Nursing (DON) and she would ask the Assistant Director of Nursing (ADON) where the paperwork was located. During an interview on 1/13/25 at 2:00 P.M., the Clinical and Quality Consultant indicated the nurse who transferred Resident 27 to the hospital did not keep a copy of the bed hold paperwork. 2. On 1/6/25 at 1:02 P.M., Resident 37's clinical records were reviewed. Diagnoses included, but were not limited to atrial fibrillation, heart failure, dementia, depression, and psychotic disorder. The most current Annual MDS assessment, dated 9/6/24, indicated Resident 37 had severe cognitive impairment, required set up or clean up for eating, bed mobility, toilet use and transfer. Clinical records indicated Resident 37 was hospitalized on [DATE] to 2/29/24 for sepsis, chronic atrial fibrillation, cellulitus of right lower extremity, Streptococcal bacteremia and chronic right heart failure,11/1/24 to 11/12/24 for major neurocognitive disorder with behaviors, and 11/16/24 to 11/30/24 for cellulitus of the right leg, cellulitus of right little finger, sepsis secondary to cellulitus, fall, delirium and mood disorder with behavior disturbances. Clinical records lacked bed hold paperwork. During an interview on 1/9/24 at 4:43 P.M., the Clinical and Quality Consultant indicated they were still looking for the bed hold paperwork.

Based on interview, and record review, the facility failed to provide adequate supervision and prevent falls for 2 of 6 residents reviewed for accidents. Fall assessments and care plans were not updated in a timely manner and family was not notified a fall. (Resident 44, Resident 33) Findings include: 1. On 1/6/25 at 1:23 P.M., Resident 44's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus, hypertension, and dementia. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 11/5/24, indicated Resident 44 had a severe cognitive impairment, and he required substantial or maximal assistance on toileting and transferring. The MDS indicated Resident 44 had 2 or more falls since the last MDS assessment. Resident 44's care plans included, but were not limited to, a potential for falls, dated 11/8/24. Resident 44's fall history included, but was not limited to the following: Fall 1--1/12/24 Resident 44's clinical record lacked a care plan update and indicated the fall assessment for the 1/12/24 fall was completed on 2/5/24. Fall 2-- 2/15/24 Resident 44's clinical record lacked a care plan update and a fall assessment. Fall 3-- 11/5/24 Resident 44's clinical record indicated the fall assessment was completed on 11/14/24. Fall 4-- 11/18/24 Resident 44's clinical record indicated the fall assessment was not completed until 11/25/24, and Resident 44's family was not notified of the fall. Fall 5-- 11/29/24 Resident 44's clinical record lacked a care plan update. Fall 6-- 12/2/24 Resident 44's clinical record indicated the fall assessment was not completed until 1/9/25. Fall 7-- 1/2/25 Resident 44's clinical record indicated the fall assessment was not completed until 1/9/25. 2. On 1/6/25 at 1:50 P.M., Resident 33's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 10/10/24 indicated Resident 33 had a severe cognitive impairment and, and she required substantial or maximal assistance on toileting and transferring. Resident 33's care plans included, but were not limited to, a potential for falls, dated 11/8/24. Resident 44's fall history included, but was not limited to the following: Fall 1-- 11/5/24 Resident 33's clinical record lacked a fall assessment and notification to the family of the fall. During an interview on 1/14/25 at 10:31 A.M., the Clinical and Quality Consultant indicated family should be notified on same shift as the fall, the care plan should be updated immediately with every fall, and fall assessments should be completed within 4 hours of the fall. On 1/13/25 at 11:05 A.M., the Clinical and Quality Consultant provided a Fall Assessment and Prevention Protocol, revised 5/2024, that indicated, .A new fall assessment will also be completed after each fall .Notify the POA (power of attorney) or other legal representative .Complete a new fall assessment .and discuss the new intervention that was immediately implemented .Update the resident care plan .with appropriate intervention(s) to keep resident safe . 3.1-45(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice for 3 of 3 residents reviewed for respiratory care. Oxygen tubing was not changed, portable oxygen tanks were not checked, and oxygen concentrator machine filters were not cleaned. (Resident C, Resident B, Resident D) Findings include: 1. On 1/2/25 at 1:57 P.M., Resident C was observed laying in bed wearing oxygen per nasal cannula at 2 liters per minute (LPM). The tubing was dated 12/8/24. The oxygen concentrator machine filter was soiled with dust and hair. On 1/8/25 at 9:57 A.M., Resident C was observed laying in bed wearing oxygen per nasal cannula at 2 LPM. The oxygen concentrator machine filter was soiled with dust and hair. During an observation of room [ROOM NUMBER] on 1/13/25 11:40 A.M., the Maintenance Supervisor came into the room, observed the oxygen concentrator machine filter was soiled with dust and hair, indicated it needed to be cleaned, and took it to the Housekeeping Supervisor to have her clean it. On 1/6/25 at 12:20 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). The most recent Quarterly Minimum Data Set (MDS) assessment, dated 10/27/24, indicated Resident C's cognition was moderately impaired and was receiving oxygen therapy. Current Physician's Orders included, but were not limited to, the following: Change oxygen tubing one time per week on Sunday nights, ordered 5/19/24 Clean oxygen concentrator and filters (to be done by housekeeping and maintenance) one time per week on Monday mornings, ordered 5/19/24 A current COPD Care Plan, dated 7/7/24, included, but was not limited to the following intervention: Change oxygen tubing and clean concentrator weekly, initiated 7/7/24 During an interview on 1/13/25 at 9:43 A.M., Licensed Practical Nurse (LPN) 9 indicated the night nurse is responsible for changing the oxygen tubing weekly on Sunday nights. When the tubing was changed, it should be documented in the TAR and the tubing should have that date on it. 2. On 1/2/25 at 1:30 P.M., Resident D was observed lying in bed with head of the bed (hob) elevated wearing oxygen (O2) at 5 liters per minute (lpm) per nasal cannula. The filter on the back of the concentrator was dusty. On 1/8/25 at 9:44 A.M., Resident D was observed lying in bed with hob elevated with O2 on at 5 lpm per nasal cannula, television on, call light in reach, oxygen tubing was dated 1/5/25 and filter on the back of the oxygen concentrator was dusty. On 1/6/25 at 9:07 A.M., Resident D's clinical records were reviewed. Diagnoses included, but were not limited to Chronic Obstructive Pulmonary Disease (COPD), hypertension, and anxiety disorder. The most current Quarterly Minimum Data Set (MDS) assessment, dated 11/30/24, indicated Resident D had moderate cognitive impairment, required partial/moderate assistance with toilet use and bed mobility, set up or clean up assistance for eating, transfer was not attempted, on hospice and uses oxygen. Physician orders included, but were not limited to the following: RESPIRATORY TREATMENT: Administer oxygen 2.0 liter/min - 5 (per nasal cannula) continuous, dated 4/8/2024 RESPIRATORY TREATMENT: Clean O2 concentrator and filters to be done by housekeeping and maintenance 1 x wk, Monday A.M. , dated 05/19/2024 RESPIRATORY TREATMENT: Change oxygen tubing 1 x wk. Sunday night, dated 05/19/2024 During an interview on 1/9/25 at 10:28 A.M., Registered Nurse (RN) 3 indicated oxygen tubing was dated and changed weekly on Sunday, and the maintenance man cleaned oxygen concentrator filters on Monday. 3. On 1/9/25 at 10:25 A.M., Resident B was sitting in wheelchair at resident council meeting, O2 on per nasal cannula with portable tank, arrow on tank just above red. On 1/9/25 at 11:12 A.M. RN 3 went to activity room and indicated the portable oxygen tank was set at 4 lpm (liters per minute). The arrow on the portable tank was in the red area, and RN 3 indicated the tank was empty. RN 3 wheeled Resident B out of the activity room to replace portable O2 tank. On 1/9/25 at 11:14 A.M., RN 3 was observed checking Resident B's O2 saturation level. Oxygen saturation level was 92-97. At that time, Certified Nurse Aide (CNA) 37 replaced the portable O2 tank with a new one and attached the nasal cannula. On 1/13/25 at 2:53 P.M., Resident B was observed sitting in wheelchair in activity room with O2 on at 4 lpm (liters per minute) per nasal cannula using the oxygen concentrator instead of a portable tank. On 1/9/25 at 3:20 P.M., Resident B's clinical records were reviewed. Diagnoses included, but were not limited to advanced dementia, atrial fibrillation, coronary artery disease, heart failure, chronic kidney disease, stage 3, and pneumonia. The admission MDS assessment had not been completed. Resident B was admitted on [DATE]. Physician orders included, but were not limited to the following: RESPIRATORY TREATMENT: Change oxygen tubing 1 x week. Sunday night, dated 1/3/2025 RESPIRATORY TREATMENT: Administer oxygen 4.0 liter/min (minute) (per nasal cannula) continuous, dated 1/3/2025 During an interview on 1/13/25 at 11:30 A.M., RN 3 indicated the portable O2 tanks were checked about 2 hours after they were changed since they only lasted about 2 hours. On 1/14/25 at 11:20 A.M., the Clinical and Quality Consultant provided an Oxygen-Appropriate Use, Management, and Storage policy, revised 9/2021, which indicated Purpose was to follow current standards of practice with regard to oxygen supply changes, infection control practices, and safe storage .2. Oxygen Management: a .The skill of applying a nasal cannula or oxygen mask (not adjusting oxygen flow rate) can be delegated to Certified Nurse Aides (C.N.A.s)[sic]. The nurse is responsible for assessing the resident's respiratory system, response to oxygen therapy and setup of the oxygen therapy and liter flow, including the adjustment of oxygen flow rate .e. For oxygen supply changes, please ensure that in addition to the provider order for a 7-day (weekly) supply change, that you also document the weekly supply change in the Electronic Treatment Administration Record (eTAR) and date/initial the supply change on the product when put into use . This citation relates to Complaint IN00450791. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure competent nurse staffing necessary to provide services to meet resident rights and well-being for 1 of 3 residents reviewed for respiratory care and 1 random observation. A resident's order for an expectorant was not administered, a wound dressing was initiated without an order or notification to the physician, and a bandage was left on a resident for six days. (Resident 43, Resident 46) Findings include: 1. On 1/6/25 at 10:42 A.M., Resident 43's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and allergic rhinitis. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/24, indicated cognition status could not be assessed, and resident required substantial to maximal assistance with bed mobility and transfers, and was dependent on staff for toileting and bathing. Physician orders included, but were not limited to: guaifenesin ER (extended release) (an expectorant) 600 mg (milligrams) twice a day through 1/4/25, ordered 12/28/24. Medication was discontinued 1/2/25. Resident 43's Medication Administration Record (MAR) for December 2024 through January 2025 indicated guaifenesin had not been administered. Progress notes included, but were not limited to, the following: 12/28/24 at 1:37 P.M. Resident was lethargic, sinus congestion and cough. New order was placed for (guaifenesin). 12/29/24 at 7:04 P.M. guaifenesin held - medication unavailable. 12/30/24 at 6:44 A.M. guaifenesin held - medication unavailable. 12/30/24 at 7:26 P.M. guaifenesin held - medication unavailable. 12/31/24 at 6:53 A.M. guaifenesin held - medication unavailable. 12/31/24 at 6:58 P.M. guaifenesin held - medication unavailable. 1/1/25 at 11:25 A.M. guaifenesin held - medication unavailable. 1/1/25 at 8:24 P.M. guaifenesin held - medication unavailable. On 1/8/25 at 9:33 A.M., Resident 43 was observed sitting in a recliner in the activity room coughing several times. On 1/9/25 at 10:16 A.M., Resident 43 was observed sitting in a recliner in the activity room coughing. On 1/9/25 at 8:50 A.M., the Clinical and Quality Consultant indicated when an over the counter medication was ordered, the nurse would let the Director of Nursing (DON) know. The DON would then order the medication through (pharmacy name). She indicated the medication was not ordered for Resident 43, and because the resident was not having symptoms that warranted the medication anymore, it was discontinued before it was given. On 1/14/25 at 9:30 A.M., the Regional Director indicated the nurse was supposed to check and see if there was a facility stock of the medication Resident 43 had been ordered, and then notify the DON if the facility did not have it. The nurse failed to notify the DON so it was not ordered. 2. On 1/8/25 at 9:41 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and depression. The most recent Annual Minimum Data Set (MDS) Assessment, dated 12/6/24, indicated a severe cognitive impairment and no behaviors. Resident 46 required substantial to maximal assistance with toileting, partial to moderate assistance with bed mobility and transfers, and was dependent on staff with bathing. Resident 46 had no skin conditions. Resident 46's clinical record lacked an order for skin treatments. A potential for tissue integrity impairment care plan, dated 9/3/24, indicated to assess skin status and keep the physician informed. Skin assessments included the following from September 2024 through January 2025: 9/30/24 pale and dry with no skin problems or lesions. 11/11/24 warm and dry. 12/13/24 pale, warm, and dry with no skin problems or lesions. On 1/8/25 at 1:32 P.M., Resident 46 was observed in her room sitting in a wheelchair. The resident's family member was observed sitting in front of her. At that time, a bandage was observed on the resident's left wrist/forearm and was dated 1/4/24. A dark area was observed seeping through the middle of the bandage. The family member indicated he had noticed the bandage when he got there, and had asked two staff members (did not remember who), and the staff members were unaware of why she had the bandage. On 1/9/25 at 10:01 A.M., Resident 46 was observed with Certified Nurse Aide (CNA) 45 and CNA 15 in her bathroom getting dressed. At that time, a bandage was observed on the resident's left wrist/forearm dated 1/8/25. A bandage was also observed in the crease of the left arm above the forearm (gauze type material with tape holding it on). CNA 45 and CNA 15 were unaware why the resident had the bandage on her wrist/forearm, and CNA 45 attempted to remove the tape from the inside of the elbow. The tape was stuck on the skin and the CNA was unable to remove it. She indicated at that time that she would notify the nurse to remove. On 1/9/25 at 10:51 A.M., Resident 46 was observed sitting in a wheelchair at the nurses station. Licensed Practical Nurse (LPN) 9 indicated Resident 46 had a skin tear on the left wrist, and she had changed the dressing the day before because she noticed the would was seeping through the dressing that was on. She indicated at that time she was unaware how or when the skin tear occurred, and there was not a physician's order for the dressing. She indicated she was unaware of the tape on the resident's arm, and was from a blood draw that was done on 1/3/25 (6 days prior). At that time, she rolled the resident's left sleeve up and removed the tape which was stuck tightly to the resident's skin. On 1/9/25 at 2:10 P.M., Registered Nurse (RN) 3 indicated all dressings required a physician's order to change. If there was no order, the nurse should call the physician to get the order. She further indicated bandages left from a blood draw should be removed by the nurse within 24 hours. On 1/9/25 at 2:50 P.M., the Clinical and Quality Consultant indicated when a resident experienced a skin tear, it was facility protocol to cover the area and notify the physician. If not that day, then by the next business day. She indicated Resident 46 did not have an order for the treatment given to her left arm. On 1/13/25 at 10:14 A.M., RN 3 indicated not all residents received a skin assessment weekly. Only if they have a treatment they would have an order for a weekly skin assessment. On 1/13/25 at 2:12 P.M. the Clinical and Quality Consultant indicated skin assessments should be performed on every residents weekly. She further indicated nurses should obtain a treatment order after doing any first aid for residents. On 1/9/25 at 2:00 P.M., the Clinical and Quality Consultant provided a current Physician Order Summary policy, dated 6/2022, that indicated It is the policy of this facility to ensure medication and treatment accuracy by a review of each resident's monthly Physician Order Summary (POS), Medication Administration Records (MAR), and Treatment Administration Records (TAR) by a licensed nurse On 1/9/25 at 2:00 P.M., the Clinical and Quality Consultant provided a current House Supplied (Floor Stock) Medications policy, dated 5/21/18, that indicated The facility maintains a supply of commonly used over-the-counter medications considered as floor stock or house medications as permitted by state regulation On 1/14/25 at 9:00 A.M., the Clinical and Quality Consultant provided a current Skin Care Management policy, dated 9/2024, that indicated Skin integrity will be monitored at least weekly on the resident's bath day for all residents that are identified at risk . Initial wound documentation will be entered into the Pressure-Injury Assessment folder (for any pressure-injuries) or Non-Pressure Wounds folder (for all other wound types) . The treatment protocol will be initiated using the Skin Treatment Management Protocol and the attending physician orders . The nurse will notify the resident's responsible party of any skin integrity issues and/or changes in treatment and document this in the nursing progress notes On 1/14/25 at 9:00 A.M., the Regional Director provided a current Notification of Director of Nursing policy, dated 11/2023, that indicated It is the policy of this facility to ensure timely notification by the charge nurse to the Director of Nursing or designee, regardless of time of day, of emergency situations . Any situation of ordered but unavailable supplies, medications or equipment 3.1-14(a)(1) 3.1-25(l)

Based on observation, interview, and record review, the facility failed to ensure person-centered dementia treatment and services were provided for 2 of 4 residents reviewed for dementia care. (Resident 46, Resident 47) Findings include: 1. On 1/2/25 at 11:14 A.M., Resident 46 was observed sitting in a wheelchair in front of the nurses station with her head drooped down and eyes closed. Staff were observed walking by the resident without engaging. On 1/8/25 at 9:12 A.M., Resident 46 was observed sitting in a wheelchair by the nurses station with her eyes closed. Staff were observed walking by the resident without engaging. On 1/8/25 at 9:34 A.M., Resident 46 was assisted to the activities room and transferred from a wheelchair to a recliner facing a television. On 1/8/25 at 1:32 P.M., Resident 46 was observed sitting in her room in a wheelchair with a family member. The family member indicated when he got to the facility that day, Resident 46 was sitting at the nurses station weeping. On 1/9/25 at 10:51 A.M., Resident 46 was observed sitting in a wheelchair at the nurses station. Staff were observed walking by the resident without engaging. On 1/9/25 at 2:03 P.M., Resident 46 was observed sitting in a recliner in the activity room facing a television. Her left sock and shoe were both off and the resident was grimacing while moving around in the recliner, leaving forward and pulling knees up. During a continuous observation on 1/13/25 from 10:03 A.M. until 11:00 A.M., Resident 46 was observed sitting in a recliner in the activity room facing a television with an activity going on behind her. At 10:49 A.M., the resident was brought to the nurses station in a wheelchair. Nothing was given to the resident for stimulation, and the resident was observed fidgeting. Staff was not engaging with the resident. On 1/8/25 at 9:41 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and depression. The most recent Annual Minimum Data Set (MDS) assessment, dated 12/6/24, indicated a severe cognitive impairment and no behaviors. Resident 46 required substantial to maximal assistance with toileting, partial to moderate assistance with bed mobility and transfers, and was dependent on staff with bathing. A dementia care plan, dated 9/4/24, indicated nurses should engage in conversation and encourage participation. Nurse's aides should encourage attendance and participation in scheduled activities, and offer conversation, snacks and other interventions as needed. Resident 46 experienced 5 falls from 2/2024 through 12/2024, all unwitnessed and resident was found on the floor. On 1/9/25 at 2:20 P.M., Registered Nurse (RN) 3 indicated Resident 46 enjoyed taking walks, liked candy, and getting her nails and hair done. She indicated at that time that dementia care consisted of an individualized plan of care for each resident. 2. On 1/2/25 at 11:12 A.M., Resident 47 was observed sitting in a wheelchair at the nurses station. The resident was talking nonsensical to herself and Licensed Practical Nurse (LPN) 9. The resident was observed to attempt to get up out of the wheelchair several times and LPN 9 attempted to redirect. LPN 9 was observed indicating to the resident what are you doing?, huh?, stay right there, stay right there, and you can't get up, you have to sit down and get ready for lunch. After each interaction with the resident, LPN 9 turned to work on the computer, and Resident 47 continued to fidget and move around. On 1/2/25 at 1:11 P.M., Resident 47 was observed sitting in a wheelchair at the nurses station with no supervision. The kitchen manager came by the nurses station, as well as the Clinical and Quality Consultant, and staff did not engage with the resident. The resident was observed with nothing in her lap or hands. On 1/8/25 at 9:18 A.M., Resident 47 was observed sitting in a wheelchair in the activity room closing her eyes off and on. At that time, there was music being played from the television. On 1/8/25 at 1:28 P.M., Resident 47 was observed sitting in a wheelchair by the nurses station with nothing in her hands or lap. She was not talking with one hand on her forehead. Staff was not engaging with the resident. On 1/9/25 at 9:12 A.M., Resident 47 was observed sitting in a recliner in the activity room facing a television. On 1/9/25 at 11:01 A.M., Resident 47 was observed still sitting in the recliner in the activity room facing a television. At that time there was a blanket over her and she was holding the blanket. On 1/9/25 at 2:21 P.M., Resident 47 was observed sitting in a wheelchair at the nurses station. At that time, Licensed Practical Nurse (RN) 3 indicated staff sat the resident at the nurses station because she likes to get up. She indicated Resident 47 was not easily directed and could get feisty. Talking to her would worked sometimes. She indicated the activity room had activity boards for the residents to use to keep busy, but there were none at the nurses station. During a continuous observation on 1/13/25 from 10:03 A.M. until 10:53 A.M., Resident 47 was observed sitting in a wheelchair at the nurses station with nothing to do, fidgeting with the wheelchair, seat, handles, her pants, socks, hands, hair, and arms. Staff walking by and at the nurses station did not acknowledge the resident or attempt to engage with her. At 10:28 A.M., the Assistant Director of Nursing (ADON) sat at the nurses station and asked the resident how she was, then turned away from the resident. At 10:53 A.M., Certified Nurse Aide (CNA) 45 pushed the resident away from the nurses station and down the hall. On 1/6/25 at 10:29 A.M., Resident 47's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and depression. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/29/24, indicated a severe cognitive impairment and no behaviors. Resident 47 required partial to moderate assistance with bed mobility and transfers, and was dependent on staff for toileting and bathing. An alteration in thought processes related to dementia care plan, dated 11/6/24, indicated to ask the resident to play ball toss/balloon toss, sing-along activity, and include resident in reminiscing activities. On 1/13/25 at 2:12 P.M., the Clinical and Quality Consultant indicated dementia care consisted of individualized plans for each resident. On 1/14/25 at 9:00 A.M., the Clinical and Quality Consultant provided a current Dementia Management policy, dated 9/2022, that indicated To ensure that facility staff members understand the needs of residents who display or are diagnosed with dementia and provide appropriate treatment and services to meet the highest practicable physical, mental, and psychosocial well-being of these individuals . Encouraging meaningful resident-centered physical activity . Providing meaningful stimulation (to avoid boredom) . Ensuring an adequate number and type of activities on all shifts 3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure proper storage of medications in 2 of 3 medication carts. Narcotic boxes were not double locked in the medication carts. (200 Hall medication cart, 400 Hall medication cart) Findings include: 1. On 1/2/25 at 9:58 A.M., the narcotic box was observed unlocked in the 200 Hall medication cart. On 1/9/25 at 11:23 A.M., the narcotic box was observed unlocked in the 200 Hall medication cart. 2. On 1/2/25 at 10:00 A.M., the narcotic box was observed unlocked in the 400 Hall medication cart. During an interview on 1/2/25 at 10:03 A.M., Registered Nurse (RN) 21 indicated the narcotic boxes in the medication carts should be locked when not in use. On 1/14/25 at 11:20 A.M., a current Controlled Substances Policy, revised April 2021, was provided by the Clinical and Quality Consultant and indicated Purpose: To ensure appropriate and consistent procedures for safeguarding controlled substances are followed from deliver through the actual administration and/or destruction of the medications . all schedule 2 [two] controlled substances must be stored in double locked areas . 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 7 of 16 observations of medication administration. Gloves were not changed and hand hygiene was not performed between dirty and clean tasks during peri care, hand hygiene was not performed prior to administering medications, and staff performed a 2 second hand lather. (Resident B, Resident F, Resident 37, Resident 12, Resident 14, Resident 39, Resident 46, Resident 2, Resident 41). Findings include: 1. On 1/13/25 at 11:04 A.M., Resident B transferred from the wheelchair to the toilet by Certified Nurse Aide (CNA) 37 and CNA 41. CNA 37 used both gloved hands to remove the foot pedals on Resident B's wheelchair. CNA 37 failed to change gloves and perform hand hygiene before she removed Resident B's incontinence pad. CNA 37 removed the soiled brief and failed to change gloves or perform hand hygiene before she put the clean incontinence pad on Resident B. CNA 37 then wrapped toilet paper around her gloved hands and gave the toilet paper to CNA 41. CNA 41 wiped the resident, removed her gloves, and failed to perform hand hygiene prior to putting the gait belt on Resident B. 2. During an observation on 1/9/25 at 11:23 A.M., Registered Nurse (RN) 3 passed medications to Resident 37. After the medications were given, RN 3 performed an 8 second hand lather. 3. During an observation on 1/9/25 at 11:34 A.M., RN 3 passed medications to Resident 13. After the medications were given, RN 3 performed a 2 second hand lather. 4. During a medication pass on 1/9/25 at 11:10 A.M., staff was observed not washing hands or using antibacterial hand rub (ABHR) before or after administering medications to the following residents: Resident 14 Resident 39 Resident 46 Resident 2 Resident 41 5. On 1/9/25 at 3:55 P.M., incontinence care performed on Resident F by Certified Nurse Aides (CNA)45 and CNA 41 was observed. Both CNAs put gloves on, attached hoyer straps, CNA 45 operated the mechanical lift controls while CNA 41 moved the vacated wheelchair out of the way. Once Resident F was laid in her bed, both CNAs unhooked the lift pad from the lift. CNA 45 performed perineal care while CNA 41 held the resident on her left side. CNA 45 removed Resident F's pants and CNA 41 unfastened the soiled incontinence pad. CNA 45 took off the soiled incontinence pad and discarded it in the trash can. CNA 45 grabbed a wipe and wiped the resident's backside from front to back, folded the wipe, and wiped again from front to back. CNA 45 removed her gloves and put a new pair of gloves on without sanitizing her hands. Resident 41 was rolled onto her back and CNA 45 grabbed a new wipe, wiped the resident's vaginal area, from top to bottom, folded the wipe, and wiped again. CNA 45 and CNA 41 assisted the resident back to her left side, placed a clean incontinence pad under Resident F, rolled her back onto her back, fastened the new incontinence pad, and put resident F's pants back on. Both CNAs removed their gloves. After transferring the resident with the mechanical lift back into the wheelchair, CNA 45 removed the mechanical lift from the room and wiped the lift down with a disinfectant wipe. CNA 41 pushed Resident F up the hallway to the nurse's station. Neither CNAs were observed sanitizing their hands after leaving Resident F's room. During an interview on 1/14/25 at 10:56 A.M., the Assistant Director of Nursing (ADON) indicated prior to providing incontinence care, staff should remove gloves and perform hand hygiene after touching random items, she would expect staff to perform hand hygiene and change gloves between dirty to clean tasks, and perform hand hygiene prior to and after providing care and medication passes. When washing hands, staff should lather with soap 45-60 seconds. When performing perineal or incontinence care, staff should clean the front side and then the back side. On 1/14/25 at 11:20 A.M., a current Medication Administration General Guidelines Policy, reviewed 5/21/18, was provided by the Clinical and Quality Consultant and indicated . hand hygiene is completed before and after every medication preparation or administration . On 1/14/25 at 1:40 P.M., a current Hand Hygiene handout used as the policy, revised August 2009, was provided by the Clinical and Quality Consultant and indicated . Duration of the entire procedure for hand washing (if hands are visibly soiled): 40-60 seconds . Duration of the entire procedure for using hand rub: 20-30 seconds . [should be performed] before touching a patient . before clean/aseptic procedure . after body fluid exposure risk . after touching a patient . after touching patient surroundings . the use of gloves does not replace the need for cleaning your hands . On 1/14/25 at 1:40 P.M., a current non dated Perineal Care handout used as the policy, was provided by the Clinical and Quality Consultant and indicated . wash and dry patient's upper thighs. washed labia majora, retract labia from thigh with nondominant hand, use dominant hand to wash skinfolds, wiped front to back, repeated on opposite side with separate section of wash cloth, rinse and dry area thoroughly. Separate labia wash urethral meatus and vaginal orifice front to back use separate section of cloth for each stroke, rinse and dry area thoroughly . 3.1-18(l)

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist (IP) worked at least part-time at that facility, and the interim IP lacked an infection control certification. Finding includes: During an interview on 1/13/25 at 1:47 P.M., the Clinical and Quality Consultant indicated the Director of Nursing (DON) is the IP, but she was currently out on leave, and the interim IP was the Assistant Director of Nursing (ADON) . At that time, she indicated the ADON lacked a certification related to infection control. During an interview on 1/14/25 at 9:24 A.M., the Clinical and Quality Consultant indicated the facility lacked documentation on how many hours were dedicated to IP. At that time, she indicated the DON had a weekly schedule that she followed. During an interview on 1/14/25 at 10:56 A.M., the ADON indicated the DON was the IP. At that time, she further indicated that she was the interim IP when the DON was not in the building, but she was not certified. On 1/14/25 at 1:40 P.M., the Director of Nursing weekly routine provided by the Clinical and Quality Consultant was provided. The DON weekly routine had Thursday's dedicated to infection control, and lacked any other infection control days for the rest of the week. On 1/13/25 at 2:00 P.M., the Administrator provided an Infection prevention and Control Officer job description, revised 1/2017, that indicated, At least a part time clinical who is responsible for supporting the facilities systems for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents and others in the facility .will have specialized training and education in infection prevention and control beyond their initial professional degree .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14. On 1/2/25 at 10:31 A.M., the bathroom in room [ROOM NUMBER] was observed with the rings at both ends of the grab bar above the toilet paper roll not attached. The pull cord chain was rusted, the edge of the floor in front of the tub was brown, the sink faucet was loose and moving around, and the vent over the sink was caked with dust. On 1/14/25 at 11:11 A.M., the same was observed. 15. On 1/2/25 at 10:54 A.M., the bathroom in room [ROOM NUMBER] was observed with an area on the back of the shower wall with a brown substance that was halfway sticking to the shower and hanging off on the other end. The vent over the sink was caked with dust, and rust was observed on the call light chain. On 1/14/25 at 11:10 A.M., the same was observed. During on interview on 1/13/25 at 2:29 P.M., the Regional Director indicated there was no policy on checking the residents' fridges. It would be their policy to check the the temperatures daily on resident fridges. During an interview on 1/14/25 at 11:25 A.M., the Clinical and Quality Consultant indicated they did not have an environment policy, but providing a homelike environment would be their policy. On 1/14/25 at 9:00 A.M., a current Food from Outside Sources For Resident Consumption policy, dated 2/2021, was provided and indicated Nursing staff will monitor resident's room and facility refrigeration units for food and beverage disposal . All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to state and federal standards . The Refrigerator Temperature Log will be utilized for logging this information On 1/14/25 at 11:20 A.M., a current Housekeeping policy, dated 9/2020, was provided and indicated To maintain rooms in a clean and sanitary manner . Routine room dusting, vacuuming and wipe down of touch surfaces should occur daily . Report any defective equipment or repairs needed to your supervisor . Check walls and doors. Wipe clean of dirt and spots and clean walls . On 1/14/25 at 1:40 P.M., a current Infection Prevention and Control Program Policy, revised February 2024, was provided by the Clinical and Quality Consultant and indicated Purpose: To establish and maintain facility guidelines for the effective prevention . Facility staff will handle, store, process and transport all linens in a manner to prevent the spread of infection . Routine (occupied) and terminal (discharge) room cleaning policies will be followed to ensure appropriate cleaning and disinfection of resident rooms . 3.1-19(f) 3.1-19(f)(5) 3.1-19(g)(2) 8. On 1/2/25 at 10:40 A.M., Resident 44's room was observed with debris scattered throughout the room and spiderwebs on the ceiling in the bathroom. On 1/13/25 at 11:18 A.M., the same was observed in Resident 44's room and bathroom. 9. On 1/2/25 at 10:43 A.M., Resident 32's door to enter the room had a loose circular piece behind the doorknob. On 1/13/25 at 11:21 A.M., Resident 32's piece behind the doorknob was still loose. During an observation on 1/2/25 at 1:22 P.M., Resident 32's refrigerator in his room had a refrigerator log on it that lacked a refrigerator temperature from December 15, 2024 through December 31, 2024. At that time, Resident 32 indicated he used the refrigerator. During an observation on 1/13/25 at 12:02 P.M., Resident 32's refrigerator had a January temperature log that lacked a recorded temperature on the following dates: 1/1, 1/4, 1/5, 1/6, 1/7, 1/9/, 1/10, 1/11, 1/12. 10. During an observation on 1/2/25 at 1:53 P.M., Resident 26's refrigerator in her room had a refrigerator log on it that lacked a refrigerator temperature from December 15, 2024 through December 31, 2024. At that time, Resident 26 indicated she used the refrigerator. Based on observation and interview, the facility failed to ensure a sanitary and home-like environment for 3 of 3 halls, 1 of 1 shower rooms reviewed for environment, and 19 of 19 resident personal refrigerator temperature logs reviewed. Personal items and linens were not labeled and uncovered, vent fans were caked with dust, toilets were soiled, paint was missing, baseboards were falling off or missing, and a toilet seat riser was uncovered on the floor under the sink in the shower rooms. (200 Hall, 300 Hall, 400 Hall, Shower Room, room [ROOM NUMBER], room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, room [ROOM NUMBER]-1, room [ROOM NUMBER]-2, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-2) Findings include: 1. On 1/2/25 at 10:49 A.M., the following was observed in the shower room: blinds were dusty and broken, towels and wash cloths were stored uncovered on top of a storage bin, a pair of blue checked socks were laying on the floor, two pairs of pants and shirts were laying on a cabinet uncovered, an unlabeled comb and brush were laying on cabinet, missing tiles along baseboard of shower, paint chipping off wall corners, piece of baseboard tile laying in the very back corner, cobweb hanging from the ceiling in shower, bugs in light covers by shower, unlabeled bottle of shampoo/conditioner combo, exfoliating scrub, two bottles of body wash on handrails in shower not labeled, a dent in the wall by cabinet in toilet area, a pair of pants and a shirt were hanging uncovered on the handrail by the toilet, a brown substance on back of the toilet seat and side of lid closest to the sink, yellow water in the toilet, caulk around toilet soiled with brown substance and coming off, toilet seat riser behind trash can on the floor under sink uncovered, unlabeled hair brush laying on top of sharps container, fan inside door is coming down from ceiling, cobweb hanging from ceiling behind the door, sink water temperature was 56.6 degrees Fahrenheit On 1/13/25 at 11:16 A.M., the following was observed in the shower room: blinds were dusty and broken, towels and wash cloths were stored uncovered on top of a storage bin, a drawer of storage bin open and full of miscellaneous large bottles lotions, body washes, and shampoos, bottles of bathing soaps on handrails in shower unlabeled, cobweb hanging from the ceiling in the shower, bugs in the light covers by the shower, a dent in the wall by cabinet in toilet area, two pairs of pants and a shirt were hanging uncovered on the handrail by the toilet, toilet seat riser on floor uncovered under sink, cobweb hanging from the ceiling behind the door. At that time, Certified Nurse Aide (CNA) 15 indicated staff put the resident's clothing in the shower room to change some of the residents and she was not sure how long they had been in there. She also indicated staff use the bottles of bathing soaps in shower on multiple residents if they don't have their own. 2. During an observation of room [ROOM NUMBER] (shared by two residents) on 1/2/25 at 2:02 P.M., the following was observed: vent on wall over bed has blackened on the cover and on the ceiling near it, the portable fan in the room was caked with dust, paint missing and scrapes by both beds, individual refrigerator temperature in room [ROOM NUMBER]-2 was observed to be 44 degrees Fahrenheit, log sheet on the front of the refrigerator was dated for December 2024 and the last temperature completed for it was 12/20/24 During an observation of room [ROOM NUMBER] (shared by two residents) on 1/13/25 at 11:38 A.M., the same was observed. The individual refrigerator temperature in room [ROOM NUMBER]-2 was observed to be 44 degrees Fahrenheit, log sheet on the front of the refrigerator was dated for January 2025 and the last temperature completed for it was 1/8/25. During an observation of room [ROOM NUMBER] on 1/13/25 11:40 A.M., the Maintenance Supervisor came into the room, observed the same refrigerator (409-2), filled in the 8th, 9th, and 13th of January 2025 with a temperature of 40 degrees Fahrenheit. At that time, he indicated the Housekeeping Supervisor usually took temperatures once a day but she was out this weekend so it wasn't done. 3. During an observation of room [ROOM NUMBER] (shared by two residents) on 1/2/25 at 1:28 P.M., the following was observed: baseboard coming off by bathroom door, uncovered incontinence pad on back of the toilet, vent on wall above bed was blackened, coming away from the ceiling, and the ceiling and wall near the vent was blackened, 3 toothbrushes uncovered and unlabeled by sink in bathroom During an observation of room [ROOM NUMBER] (shared by two residents) on 1/8/25 at 10:12 A.M., the same was observed except an uncovered incontinence pad was laying on the shower chair in the bathtub and not on the back of the toilet. 4. During an observation of room [ROOM NUMBER] (only one resident) on 1/2/25 at 1:22 P.M., the following was observed: brown substance was on the wall close to the television near the bedside commode, towels laying in the bathtub uncovered, cobwebs in corner of bathroom hanging from ceiling, red substance splattered on and in sink, baseboard missing by entrance to bathroom door During an observation of room [ROOM NUMBER] (only one resident) on 1/8/25 at 9:55 A.M., the baseboard was still missing by entrance to bathroom door. 5. On 1/2/25 at 1:16 P.M., the entire 400 Hall was observed with a strong bowel movement odor. On 1/8/24 at 9:55 A.M., the same was observed. 6. On 1/2/25 at 10:35 A.M., the 400 Hall carpet in the hallway was observed with debris and the baseboard was falling off the wall by the kitchen door. On 1/13/25 at 11:26 A.M., the baseboard was still falling off the wall by the kitchen door in the 400 Hall. 7. On 1/13/25 at 12:00 P.M., copies of the resident refrigerator temperature logs for December 2024 were requested for Rooms 208, room [ROOM NUMBER]-2. On 1/13/25 at 12:11 P.M., the following mirror image copies of 19 resident refrigerator temperatures were provided by the Maintenance Supervisor and indicated each refrigerator temperature was 40 degrees Fahrenheit every day of December 2024 and initialed by the Housekeeping Supervisor: room [ROOM NUMBER], room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, room [ROOM NUMBER]-1, room [ROOM NUMBER]-2, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-2. During an interview on 1/8/25 at 9:59 A.M., Housekeeper 31 indicated housekeeping should clean around the bed, floors, and vents above bed when resident's were not in the room, usually at lunch. She indicated she did not clean resident's fan in room [ROOM NUMBER]-2 and was not sure who should clean fans. She indicated there really was no checklist to follow when she was cleaning, but when she worked, she started cleaning in the activity room, emptied trash, and swept and mopped floors. Then she did the same thing in the break room, clean utility, and went down the halls to clean the rooms and indicated the cleaning should be done daily. There were usually two housekeepers and one cleaned the 400 and 200 Halls and the other does 100 and 300 Halls but sometimes only one housekeeper which made it hard to get to everything completed. She indicated the 400 Hall was the worst with odors usually because a lot of the residents on that hall have accidents (incontinence). Sometimes resident incontinence pads sit in the trash and housekeepers just find soiled toilets instead of notifying housekeeping that something needs cleaned. She indicated the Housekeeping Supervisor checked the temperatures of the resident's refrigerators. During an interview on 1/13/25 at 11:40 A.M., the Maintenance Supervisor indicated when staff noticed things of concern, they were supposed to fill out a work order in the work order book behind the nurse's station for non urgent things and he checked it every morning. If it was an urgent concern, staff should call him day or night. He indicated there was a shortage of housekeeping and maintenance staff so they were trying to catch up. He indicated the blackened vents of 400 Hall rooms were dirty and he did have a calendar for deep cleaning rooms and those should be part of that cleaning, but staff do not document anywhere that it was done. Resident rooms, bathrooms, hallways, and shower rooms should be cleaned daily. The Housekeeping Supervisor was mostly responsible for taking the resident refrigerator temperatures daily and should write it on the log on the front of the refrigerator. The portable fans should be cleaned by staff when dust appeared otherwise it just got blown all over. He indicated there were checklists filled out after each cleaning daily and filed in the maintenance office. During an interview on 1/13/25 at 1:56 P.M., the Housekeeping Supervisor indicated she was responsible for taking the temperatures of the resident refrigerators daily and filling out the resident refrigerator logs. When she was off work, she told the housekeeping staff to check the temperatures for her, write the temperatures down, and she would put them on the log when she returned to work. All the temperatures and initials match exactly because she was the one who filled them out. At that time, she indicated the refrigerator temperatures usually hang around 40 degrees Fahrenheit. During an interview on 1/14/25 at 10:56 A.M., the Assistant Director of Nursing (ADON) indicated clothing should be stored in resident's closets and brought into the shower room in a bag when they shower and should go in the soiled linens if they were brought in and not used and linens such as wash cloths and towels should be covered. Personal items should be labeled and covered. 11. During an interview on 1/2/25 at 02:11 P.M., a family member of one of the residents in room [ROOM NUMBER] indicated he didn't feel like the place was clean, and the room spelled like urine during his last visit. On 1/13/25 at 10:13 A.M., room [ROOM NUMBER] was observed to have multiple brown spots on floor next to bed A and in front of the bedside cabinet. There was no smell of urine in the room. On 1/14/25 at 11:22 A.M., room [ROOM NUMBER] was observed to have multiple brown spots on floor next to bed A and in front of bedside cabinet. 12. On 1/3/25 at 1:33 P.M., in room [ROOM NUMBER]'s bathroom, a bar of soap was observed on the sink, white with brown edges and the call light chain was wrapped around the grab bar two times and was rusty. On 1/13/25 at 10:06 A.M., in room [ROOM NUMBER]'s bathroom, a small bar of white soap with brown edges was observed laying on a wire shelf, call light chain was wrapped around the grab bar twice and rusty, and trash can was overflowing with paper towels laying on the floor. 13. On 1/3/25 at 1:37 P.M., in room [ROOM NUMBER]'s bathroom, the toilet paper holder (bar/tube that holds the toilet paper) was observed to be missing, toilet paper was sitting on the grab bar above the holder, call light chain was too long, resting on the floor behind and underneath the trash can and chain was dark and rusty. On 1/13/25 at 10:25 A.M., in room [ROOM NUMBER]'s bathroom, toilet paper holder was observed to be missing, toilet paper was sitting on the grab bar above the holder, call light chain was still hanging down to floor and rusty, and there was brown water in toilet. During an interview on 1/13/25 at 2:01 P.M., the housekeeping supervisor indicated rooms were cleaned daily, the floors were cleaned, the bathrooms were cleaned, and the trash emptied.

Based on observation, interview and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen. A resident's oxygen was not given as ordered and the oxygen concentrator and filter were not cleaned. (Resident 12) Findings include: On 12/6/23 at 2:09 P.M., Resident 12 was observed laying in bed watching TV with oxygen on per nasal cannula at 3 LPM (liters per minute). The oxygen tubing was not dated and the oxygen concentrator machine and filter were dusty. On 12/13/23 at 11:08 A.M., Resident 12 was observed laying in bed with the oxygen concentrator set at 3 LPM oxygen per nasal cannula. The oxygen concentrator machine and filter were dusty. On 12/11/23 at 12:49 P.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to Chronic Obstructive Pulmonary Disease (COPD). The most recent MDS (Minimum Data Set) Assessment, dated 9/15/23, indicated Resident 12's cognition was moderately impaired and he required supervision with setup of 1 staff for bed mobility, transfer, and eating. Current Physician's Orders included, but were not limited to, the following: administer oxygen at 2 LPM per nasal cannula for COPD, continuous, dated 5/9/22 A current Respiratory Distress Care Plan, dated 12/6/23, included, but was not limited to the following intervention: administer oxygen at 2 LPM per nasal cannula, continuous, 12/6/23 On 12/12/23 at 1:58 P.M., current CNA (Certified Nurse Aide) assignment forms were provided by RN (Registered Nurse) 16 and indicated Resident 12 was on 2 LPM of oxygen. During an interview on 12/12/23 at 10:30 A.M., Hospice RN indicated that the communication was effective between hospice and staff. She indicated Resident 12's oxygen was set at 2 LPM and was verified with order when they visit the resident at least a couple times a week. On 12/13/23 at 11:35 A.M., Corporate Consultant 1 observed Resident 12's oxygen concentrator was set at 3 LPM and dusty. At that time, she indicated the physician's order needed to be clarified with the ordering physician and also should check with hospice to see if it was changed by them and just not updated in the resident's chart. During an interview on 12/13/23 at 11:33 A.M., Corporate Consultant 1 indicated Resident 12's current oxygen order was 2 LPM, she's not sure how often staff should check the LPM and the concentrator filter and machine should be cleaned by staff, but she wasn't sure how often. During an interview on 12/13/23 at 1:56 P.M., Corporate Consultant 1 indicated Resident 12's oxygen order was clarified and changed to 3 LPM and the filter and concentrator were cleaned. A current Oxygen Management policy, dated September 2021, was provided by Corporate Consultant 1 and indicated . a. Treat oxygen as a medication. As with any drug, continuously monitor the dosage or concentration of oxygen and routinely check the provider's orders to verify that the patient is receiving the prescribed oxygen concentration . 3.1-47(a)(6)

Based on observation and interview the facility failed to provide hot food for 1 of 1 lunch trays sampled on 1 of 2 halls. Food that was supposed to be served hot was served cold. (300 hall and 400 hall) Finding includes: During an interview on 12/12/23 at 10:08 A.M., two anonymous residents indicated the food that should be hot was served cold. During an observation on 12/13/23 at 11:15 A.M., the 300 hall and 400 hall trays were being distributed on an open cart. The individual trays were covered with an insulated dome without the use of a base. At 11:22 A.M., a hall tray was sampled. The Bar-B-Que Chicken temperature was 102.6 degrees Fahrenheit, felt cold, and tasted cold. During an interview on 12/14/23 at 9:43 A.M., the Dietary Manager indicated she would expect the chicken to be 160 degrees Fahrenheit when the residents received a tray. On 12/13/23 at 2:45 P.M., Corporate Consultant 1 provided a current Food Temperatures policy, reviewed 4/21, that indicated, .typical serving temperature standards: Solids (meats/vegetables): 160 degrees Fahrenheit . 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a Baseline Care Plan was implemented to provide person centered care for 1 of 1 residents reviewed for pressure ulcers. (Resident 23) Finding includes: On 9/28/21 at 10:43 A.M., CNA 3 and QMA 4 were observed to turn and reposition Resident 23. Resident 23 was observed to be lying on his right side. CNA 3 and QMA 4, provided incontinence care for Resident 23. At that time, a small dressing was observed on Resident 23's coccyx. CNA 3 and QMA 4 repositioned Resident 23 to his left side. On 9/22/21 at 12:58 P.M., Resident 23's wife indicated Resident 23 had a pressure ulcer on his bottom. Resident 23's family member indicated it was almost healed and she was unsure if Resident 23 was admitted with the pressure ulcer. On 9/23/21 at 2:07 P.M., Resident 23's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 7/29/21, indicated that Resident 23 was rarely or never understood, had a diagnosis of diabetes mellitus, was dependent on two persons for bed mobility, transfers, toilet use, and personal hygiene, and had a Stage 4 pressure ulcer not present upon admission. The admission MDS (Minimum Data Set) assessment, dated 2/10/21, indicated Resident 23 had two Stage 1 pressure ulcers. The Progress Notes, included, but were not limited to: 9/2/21 at 11:35 P.M., Pressure Ulcer: Yes, started on 1/12/21 per wound clinic documentation. The Base Care Plan Summary, dated 2/4/21, included, but was not limited to: Skin: At risk/Potential for, turn and reposition, admitted with purple are to left heel, treatment skin prep and EZ boots. On 9/28/21 at 10:15 A.M., the DON indicated that the facility believes Resident 23 was admitted with the area to the coccyx. The DON indicated that the facility did not assess the area upon admission. On 9/28/21 at 1:20 P.M., the DON provided the current Skin Management policy, revised 8/2021. The policy included, but was not limited to: Within 4 hours of admission a complete body check is completed by the nurse. If any issues are found on this comprehensive body check, a Skin Care Flow Sheet will be completed. At that time, the DON indicated the facility did not have a policy for implementation of Baseline Care Plans. 3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 3 of 7 residents observed for medication administration, 3 of 27 opportunities observed were administered incorrectly. This resulted in an error rate of 12%. (Resident 204, Resident 16, Resident 13) Findings include: 1. On 9/24/21 at 10:08 A.M., RN 2 was observed to prepare medications for Resident 204. RN 2 obtained an insulin aspart pen, opened the cap, placed the needle on the pen, and dialed the insulin pen to 30 units. RN 2 entered Resident 204's room and administered the insulin. RN 2 was not observed to prime the insulin pen with two units to ensure the correct dosage was administered. On 9/28/21 at 11:23 A.M., Resident 204's Physician's Orders were reviewed. Resident 204's Physician's Orders included, but were not limited to: Novolog, Insulin Aspart, 100 units/mL (milliliters), subcutaneous, 30 units, three times a day. On 9/28/21 at 12:55 P.M., RN 2 indicated she did not prime the insulin pen prior to administration of Resident 204's insulin injection. 2. On 9/24/21 at 10:54 A.M., LPN 1 was observed to prepare insulin for Resident 16. LPN 1 obtained a bottle of Humalog insulin for the medication cart and set it on top of the medication cart to obtain additional supplies. The identification of the wrong resident was brought to the nurse's attention, the Humalog insulin bottle was observed to have Resident 47's name on it. At that time, LPN 1 indicated she knew Resident 16 had a bottle of Humalog insulin in the medication cart because she had administered the morning dose of insulin on that day. LPN 1 was unable to locate Resident 16's bottle of Humalog insulin in the medication cart and had to obtain a new bottle from the medication room. On 9/28/21 at 11:27 A.M., Resident 16's Physician's Orders were reviewed. Resident 16's Physician's Orders included, but were not limited to: Humalog, Insulin Lispro 100 unit/mL, subcutaneous, 3 units, three times a day. 3. On 9/24/21 at 11:03 A.M., LPN 1 was observed to prepare insulin for Resident 13. LPN 1 obtained a bottle of Novolog insulin, cleaned the top of the bottle, donned gloves, opened the syringe, and drew up 3 units of insulin into the syringe. LPN 1 locked the medication cart and entered Resident 13's room. LPN 1 administered the insulin to Resident 13. On 9/28/21 at 11:29 A.M., Resident 13's Physician's Orders were reviewed. Resident 13's Physician's Orders included, but were not limited to: Novolog, Insulin Aspart, 100 unit/mL subcutaneous, 6 units, twice a day, upon rising and midday. On 9/28/21 at 1:20 P.M., the DON indicated the facility did not have a policy for insulin pen use or the 5 rights of Medication Administration. The DON further indicated that insulin pens should be primed prior to administration and facility staff should ensure that the correct resident receives their medication at the correct dose. 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure infection control mitigation measures were implemented to prevent the spread of COVID-19 for 1 of 1 residents observed with an aerosol generating procedure and 1 of 7 residents observed for medication administration. Personal Protective Equipment was not worn and gloves were not changed. (Resident 204, Resident 16, Secure Unit- 300 hall, 400 hall) Findings include: 1. On 9/21/21 at 1:50 P.M., Resident 204 was observed lying in bed with a CPAP machine on and in use. At that time, there were no signs posted on the door, or PPE placed in the hall by the door. There was no indication that the resident had an aerosol generating procedure. The door was closed. During an interview on 9/21/21 at 2:38 P.M., LPN 1 indicated Resident 204 wore the CPAP at night and while sleeping during the day, and was independent with using it. She indicated staff may enter the room at any time, whether the CPAP was in use or not, wearing a surgical mask and eye protection only. During an interview on 9/21/21 at 2:43 P.M., the DON (Director of Nursing) indicated residents using a CPAP should have their door shut during and 1 hour after use, and there should be a sign on the door indicating the CPAP was in use with what PPE (personal protective equipment) should be worn. She indicated there was a sign on Resident 204's door, and was unsure what happened to it. She further indicated staff had been inserviced to wear N95 masks, eye protection, and gowns to enter the room during CPAP use, and 1 hour after use. On 9/28/21 at 1:20 P.M., a current Coronavirus (COVID-19) - Aerosol Generating Procedures policy, dated 9/8/20, was provided and indicated Precautions When Performing Aerosol Generating Procedures (AGPs) . Staff in the room should wear an N95 or higher-level respirator, eye protection, gloves and a gown 2. The following employees were observed in resident care areas wearing unapproved eye protection, which did not completely ensure the employees eyes were protected from splashes or sprays, with gaps in the forehead area: On 9/23/21 at 9:57 A.M., CNA 3 was observed to be wearing unapproved eye protection on the 400 hall. On 9/23/21 at 9:58 A.M., CNA 5 was observed to be wearing unapproved eye protection on the 400 hall. On 9/23/21 at 10:11 A.M., LPN 1 was observed to be wearing unapproved eye protection on the Secure Unit (300 hall) On 9/24/21 at 11:03 A.M., CNA 5 was observed to be wearing unapproved eye protection on the Secure unit. 3. On 9/24/21 at 10:54 A.M., LPN 1 was observed to prepare medications for Resident 16. LPN 1 readjusted her mask and eye protection., opened the medication cart, donned gloves, wiped her brow with her left gloved hand, prepared an insulin injection, assisted Resident 16 to the utility room, and administered the insulin injection. No hand hygiene was observed. LPN 1 removed her gloves, washed her hands for 12 seconds, and placed her eye protection back on her face. On 9/28/21 at 1:00 P.M., the DON indicated eye protection should be flush against the forehead. 3.1-18(b)(1) 3.1-18(l)