Every finding on record at Hutsonwood at Brazil

Based on observation, interview, and record review, the facility failed to follow infection control measures when handling clothing and waste for prevention of transmission of multidrug-resistant organisms (MDRO) for 4 of 4 residents reviewed for infection control. (Residents B, C, D, and E). This deficient practice had the potential to affect 75 of the 75 residents residing in the facility.Findings include:During a random observation on 5/11/26 at 11:05 a.m., Receptionist 1 was observed walking out of Resident C and Resident D's room, wearing gloves and holding a pile of clothing in her hands. The clothing was not in a bag and would brush the front of her shirt as she walked. During the observation, Receptionist 1 indicated the clothing was some dirty clothes she was taking to the soiled utility. She indicated she could not find a bag to place them in, so she just donned gloves and was carrying them.1. During an interview on 5/11/26 at 11:50 a.m., Resident C indicated he had not observed staff putting on a gown when they entered his room to care for him. The staff do perform catheter care and bowel incontinent care with gloves on, but he had not observed them putting on a gown. When the staff collect his dirty clothing and linens, they carried it out using a clear plastic bag. He had not seen red bags being used.A record review for Resident C was completed on 5/11/26 at 1:30 p.m. Diagnoses included end stage renal disease, dependence on renal dialysis and benign prostatic hyperplasia.A change of condition Minimum Data Set (MDS) assessment, dated 2/19/26, indicated Resident C was cognitively intact and used a walker and/or wheelchair for mobility. He required substantial to maximum assistance of staff for bathing, dressing, transfers, and toileting. The resident was occasionally incontinent of bowel.A current health care plan with a start date 1/6/26, included Resident C required Enhanced Barrier Precautions (EBP) isolation related to colonized targeted MDRO and indwelling devices. Interventions included staff to wear gown and gloves, depending on bodily fluid exposure.A current health care plan with a start date of 1/28/25, indicated Resident C was at risk for complications related to renal failure and receiving dialysis. Interventions included to assess his shunt for bruit and thrill and to ensure shunt site dressing was clean, dry and intact.A current health care plan with a start date of 1/27/25, included activities of daily living functional status. Interventions included one staff member assistance for dressing/grooming, bathing, and transfer. The resident required the assistance of two staff members for bed mobility.A current health care plan with a start date of 2/4/25, indicated Resident C had altered bowel functioning as evidenced by frequent incontinence of bowel. Interventions included to assist with toileting transfer and hygiene as needed.2. A record review for Resident D was completed on 5/11/26 at 12:06 p.m. Diagnoses included obstructive and reflux uropathy and urinary retention.A quarterly MDS assessment, dated 4/10/26, indicated Resident D was cognitively intact and used a wheelchair or cane for mobility. He required staff supervision for showering and had an indwelling urinary catheter.A current health care plan with a start date of 1/6/26, indicated Resident D required EBP isolation related to colonized targeted MDRO and an indwelling device. Interventions included gown and gloves, depending on bodily fluid exposure.A current health care plan with a start date of 12/12/25, indicated Resident D was at risk of complications related to an indwelling catheter. Interventions included empty catheter bag every shift and as needed and measure and record output amount.A current health care plan with a start date of 12/17/25, indicated Resident D had impaired abilities to perform independent ADLs with bed mobility, transfers, and toileting. Interventions included to encourage resident and provide assistance as needed for bed mobility, toileting, and transfers.3. During an interview on 5/11/26 at 2:45 p.m., Resident B indicated staff members sometimes wore gloves when caring for her, but only a very few have put on a gown. The resident's spouse indicated he visits her everyday and had not observed staff putting on a gown. She had a needle in her left upper arm that she had received antibiotics for some infection in her urine.A record review for Resident B was completed on 5/11/26 at 11:33 a.m. Diagnoses included urinary tract infection and ESBL.A quarterly MDS assessment, dated 3/5/26, indicated Resident B had moderate cognitive impairment and used a wheelchair or walker for mobility. She required assistance from staff for toileting, transferring, showering, and dressing. She was frequently incontinent of bowel and bladder.A current health care plan with a start date of 9/26/25, indicated isolation related to infectious disease, Extended Spectrum Beta Lactamase (ESBL) resistance in urine. Interventions included following agency, state and federal guidelines for infectious disease, use protective equipment (mask, gown, gloves, goggles) as indicated, linen and trash barrels in room, and patient specific equipment in room (stethoscope, blood pressure cuff, thermometer.)A current health care plan with a start date of 7/15/25, indicated Resident B had impaired ability to perform independent Activities of Daily Living (ADLs) due to weakness and debility. Resident required extensive assistance from staff for bed mobility, transfers, eating, and toileting. Interventions included assist as needed for proper grooming, oral hygiene, nail care and toileting. Resident B required assistance from 1-2 staff to complete ADLs.4. During an interview on 5/11/26 at 3:04 p.m., Resident E indicated he had two bags on his abdomen that collect his urine and his stool. He indicated staff rarely, if ever, put a gown on to care for his ostomies. They do wear gloves. He indicated his dirty clothing was collected in a clear plastic bag. The bag and hamper were observed in the room with a clear plastic bag lining the hamper. He had not seen any red bags being used to collect his clothing or trash.A record review for Resident E was completed on 5/11/26 at 3:10 p.m. Diagnoses included end stage renal disease and dependence on renal dialysis.A quarterly MDS assessment, dated 3/5/26, indicated Resident E was cognitively intact and uses a walker or wheelchair for mobility. He required assistance of staff for bathing and dressing and had a urostomy and colostomy.A current physician's order, dated 1/6/26, indicated Enhanced Barrier Precautions Isolation. This order was not included in the resident's health care plan record.A current health care plan with a start date of 2/2/24, indicated Resident E was at risk for complications related to renal failure and receiving dialysis. Interventions included assessing shunt for bruit and thrill and to ensure shunt site dressing was clean, dry and intact.A current health care plan with a start date of 2/8/24, indicated Resident E required staff assistance for ADLs. Interventions included one staff assistance required for dressing and grooming, bathing, bed mobility and emptying his ostomies daily as needed. He requested the assistance of two staff for transfers.5. During an observation of the laundry rooms on 5/11/26 at 4:25 p.m., Laundry Aide 6 was observed folding blankets and towels. He was using his chest and abdomen to rest the blanket and towels on to fold them. During the observation, Laundry Aide 6 indicated he wore gloves when he sorted the dirty clothing for wash. The laundry did receive red bags of clothing and linens to wash separately from the clean bagged clothing and linens. He was trained to wear gloves when processing the red bags. He was not instructed to wear a gown or any type of barrier. He was not aware that some of the EBP resident laundry arrived in clear plastic bags. He had just started with the facility, and he had just finished orientation.During an interview on 5/11/26 at 4:46 p.m., the Housekeeping Supervisor indicated isolation linens should be placed in a red bag. The laundry staff were to gown and glove when handling this clothing and linens. Gloves should be worn during the sorting of all dirty laundry, not just the red bagged laundry. During an interview on 5/11/26 at 3:33 p.m., CNA 4 indicated she would don a gown and gloves prior to entering an EBP room to perform care that required close contact with a resident. She had placed dirty linens from these rooms in a red bag. She rarely had seen staff enter an EBP room requiring close contact care but had seen this happen.During an interview on 5/11/26 at 3:24 p.m., the Infection Preventionist (IP) indicated in any kind of isolation rooms, the resident's dirty clothing and linens should be placed in a red bag, and trash in a separate red bag. The DON indicated the clothing and linens received by laundry in red bags were washed separately from other residents clothing and linens.A current facility policy, revised 5/4/26, titled, Infection Prevention and Control Program, provided by the IP on 5/11/26 at 3:45 p.m., included the following: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines:.4. Standard Precautions:.c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.12. Linens: a. Laundry and direct care staff shall handle, store, process and transport linens to prevent spread of infection. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is completed the bag shall be closed securely and placed in the soiled utility room.A current facility policy, dated 1/15/26, titled, Enhanced Barrier Precautions, provided by the Administrator on 5/11/26 at 11:49 a.m., included the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions:.b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i.indwelling medical devices (e.g., central lines, urinary catheters.hemodialysis catheters, PICC lines.ii. Infection or colonization with DCD-targeted MDRO when Contact Precautions do not otherwise apply.4. High-Contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care of use: central lines, urinary catheters.hemodialysis catheters, PICC lines.8. Additional epidemiologically important MDROs may include, but are not limited to:.b. ESBL-producing Enterobacterales. Guidelines for Environmental Infection Control in Health-Care Facilities (2003) was retrieved on 5/13/26 at 12:10 p.m. from the Centers of Disease Control (DCD website. The guidance included the following: .3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics.Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely.This citation relates to Intake 3002456.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, interview, and record review, the facility failed to provide range of motion or appropriate interventions for 2 of 2 residents reviewed for range of motion (Residents 69 and 12) resulting in actual harm when a cognitively impaired dependent resident developed contractures of the left hand and arm (Resident 69). Findings include:1. On 1/5/26 at 10:00 a.m., during initial observation, Resident 69 was sitting in a high back wheelchair in the lounge area. Observed the left arm bent upwards at the elbow and the left hand contracted. Nails were pressed into the palm of her hand. No anticontracture devices observed on hand or arm. On 1/6/26 at 10:29 a.m., resident observed sitting in wheelchair in lounge area and noted to have contracture of the left hand and lower left arm. No anticontracture device observed in place. On 1/6/26 at 9:34 a.m., during an interview Licensed Practical Nurse (LPN) (10) indicated Resident 69 walked with therapy for a time but acted like she was afraid and they discontinued therapy. She indicated physical therapy did not continue providing services for long. She indicated the facility did not provide any type of restorative program in the memory care unit. On 1/12/26 at 10:00 a.m., during follow-up observation noted Resident 69, sitting in a high backed wheelchair. She was slumping very low in the chair with both legs extended over the foot petals. The resident was leaning over the left side of the chair with the left arm hanging over with no support under the arm and shoulder to aide in positioning. A loosely rolled washcloth was loose in the residents left hand. Nails on the left hand were long and jagged. On 1/9/26 at 11:45 a.m., during an interview, the Physical Therapy Director indicated they did not have a restorative aide. On 1/9/26 at 1:27 p.m., during an interview, Licensed Practical Nurse (LPN) 16 indicated the Certified Nurse Aides (CNA) provided range of motion (ROM) with the residents as needed. She indicated they did not have any orders for ROM for Resident 69 and acknowledged she had noticed the resident's hand was very contracted and nails were pressing into her palm. She did not know when the contracture had started. She indicated they should be using some type of anticontracture device in her hand. On 1/9/26 at 1:39 p.m., during an interview, Certified Nurse Aide 15 indicated she did range of motion when moving and dressing the residents only. She indicated she did not do active (moving a body part using the individuals own muscles) or passive (when someone else or a machine moves the limbs and joints of the body) ROM. On 1/9/26 at 2:52 p.m., the medical record of Resident 69 was reviewed. The record indicated the resident was admitted to the facility on [DATE]. Admitting diagnosis included but were not limited to neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by abnormal protein clumps or Lewy bodies damaging brain cells, leading to thinking problems (similar to Alzheimer's, plus slowed movement, rigidity, tremor), type 2 diabetes mellitus with diabetic neuropathy (a disease that occurs when your blood glucose, also called blood sugar, is too high, neuropathy is nerve damage caused by high blood sugar from diabetes). The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/30/25, indicated the resident was cognitively impaired and was dependent upon the staff for mobility and positioning. The MDS lacked documentation of contractures. Review of the resident's care plans lacked documentation of contractures and preventive measures. The record lacked documentation of preventive measures or interventions including treatments and ROM to joints prior to survey. The resident's record lacked documentation of orders for range of motion or interventions to prevent or treat contractures. On 1/12/26 at 10:05 a.m., during an interview, Licensed Practical Nurse LPN 11 indicated Resident 69 would not sit up in chair and would not allow the staff to reposition her. She indicated when the staff repositioned the resident she moved back into the low position. She indicated the resident would not allow the staff to move the fingers of the left hand or arm but would allow the staff to trim her fingernails. She indicated the resident was not receiving a specific range of motion (ROM) program to prevent contractures. She acknowledged the medical record lacked documentation of exercises to the hands, fingers or arm and acknowledged the medical record lacked documentation of contracture of the left arm and hand. On 1/12/26 at 10:15 a.m., during an interview, Certified Nurse Aide 9 indicated they attempted to provide ROM for Resident 69, but it was difficult. She indicated they had placed hand rolls in her left hand, but she removed them. The CNA was not sure when the contracture started. On 1/12/26 at 1:40 p.m., during an interview, the therapy manager indicated she had not been informed the resident had developed a contracture of the left arm and hand till 1/9/26. She indicated she was in the memory care unit daily where the resident resides, and staff would usually inform her of any changes in residents conditions including changes in ROM and contractures. She did not know when the contracture started. She indicated when she was informed of a change, therapy would assess the resident for therapy services. The therapy manager indicated they used anticontracture devices to help prevent contractures and to prevent increased contractures in residents limbs and hands. 2. On 1/5/26 at 2:15 p.m., during a phone interview, the Power of Attorney for Resident 12 indicated the resident was walking and had received physical therapy while at the hospital. She indicated when the resident returned to the facility, she did not receive much therapy and had declined rapidly since returning. She indicated the resident was no longer walking though she was ambulatory prior to falls. She indicated she was concerned about her general decline and concerned she was not receiving preventive care. On 1/5/26 at 2:00 p.m., during an initial observation, Resident12 was observed sleeping in bed. The resident was lying on her back with her head hyperextended. The bed was in the low position. A padded mat was on the floor next to the left side of the bed. The call light was lying on the foot of the bed. On 1/9/26 at 10:00 a.m., the medical record of Resident 12 was reviewed. The most recent admission to the facility was on 9/25/25. admission diagnosis included, but was not limited to, fracture of right femur (bone fracture of the right hip), pain in right hip, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A significant change Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident was cognitively impaired and was dependent upon staff for all daily care needs including transferring and ambulation. A care plan, dated 10/8/25, indicated, ADLs Functional Rehabilitation Potential Intervention included, but was not limited to, approaches of independent transfer with start date of 4/25/23 and independent bed mobility with start date of 4/25/23. The care plan lacked documentation of updated specific interventions to prevent decline in ADL. On 1/6/26 at 9:34 a.m., during an interview, Licensed Practical Nurse (LPN) 10 indicated Resident 12 walked with therapy for a time but acted like she was afraid and they discontinued therapy. She indicated the facility did not provide any type of restorative program in the memory care unit where Resident 12 resided. On 1/9/26 at 11:45 a.m., during an interview the Physical Therapy Director indicated Resident 12 could ambulate 200 to 250 feet in the hall, but she had come to the place when she resisted the therapy staff and refused. She indicated the resident was discharged because it was causing her more distress, but the resident was able to ambulate after she had fractured her hip in a fall. She indicated no one had looked at the hyperextension of the resident's neck and the staff were educated on exercises to bring her chin forward and range of motion (ROM) exercises. She indicated therapy would be picking her back up again next week. She did not have specific documentation reflecting staff education regarding ROM and decline in mobility. On 1/9/26 at 1:27 p.m., during an interview, Licensed Practical Nurse (LPN) 16 indicated the Certified Nurse Aide (CNA) provided range of motion (ROM) (how far and in what direction a joint can move, from bending to stretching representing the joint's flexibility and movement potential without pain) for the residents as needed. She indicated they did not have any orders for ROM for Resident 12. She indicated Physical Therapy (PT) advised them to walk Resident 12, but she did not recall any instruction from therapy regarding range of motion (ROM). She indicated the staff walked Resident 12 to the bathroom at times but due to rigidity she was not able to walk as much. On 1/9/26 at 1:39 p.m., during an interview, Certified Nurse Aide 15 indicated she did range of motion when moving and dressing the residents. She indicated she remembered therapy providing education regarding ROM. She indicated Resident 12 did not want to walk, and prior to falls Resident 12 was very ambulatory. On 1/9/26 at 2:05 p.m., during an interview, the Director of Nursing (DON) acknowledged the staff should follow therapy with ROM as needed to keep the residents mobile. She acknowledged the staff had not been providing ROM as recommended by physical therapy. On 1/9/26 at 2:33 p.m., the DON provided a document, titled, prevention of decline in Range of Motion, dated 1/1/25, and indicated it was the policy currently being used by the facility. The policy indicated, .3. b. The facility will provide treatment and care in accordance with professional standards of practice. c. Care plan interventions will be developed and delivered through the facilities restorative program.4. Preventive care a. Staff will be educated on the risk factors for decline in range of motion. These include but are not limited to: 1. Limbs or digits immobilized because of injury or surgical procedures. 3.1-38(a)(1) 3.1-42(a)(1)

Based on observation, record review, and interview, the facility failed to ensure the dietary staff were trained and competent in infection control measures to prevent food borne illness during 4 observations of the dietary department. The deficient practice had the potential to affect 77 of 77 residents who received food and/or drinks from the kitchen. Findings include: On 1/5/26 at 10:45 a.m., during a kitchen observation with the Dietary Manager, the dishwasher temperature was not within the recommended range for sanitation. Review of the temperature logs indicated the logs were incorrect. The Dietary Manager confirmed the documentation had been recorded inaccurately by the employee. On 1/5/26 at 11:00 a.m., observed the Dietary Manager wash her hands and dried hands on rolled damp paper towels that were on top of the counter in the food prep area. She indicated the dispenser batteries were low, and the paper towel dispenser was not working. The Dietary Manager acknowledged the paper towels were not sanitary. On 1/5/26 at 12:38 p.m., during a follow up in the dietary department observed the Dietary Manager wash her hands and dried her hands on the roll of damp paper towels that were placed on a counter in the food perp area. She indicated the paper towel dispenser was still not working. On 1/7/26 at 11:05 a.m., during an interview the Dietary Manager asked if she should use disposable plates due to the dishwasher temperature not reaching recommended levels to sanitize dishes. She then indicated she would use disposable utensils and plates for meal service. She did not know if the service provider had been to the facility to repair the dishwasher. On 1/7/26 at 11:10 a.m. during an interview the Assistant Dietary Manager indicated she did not know what the risks were if food was served on dishes that had not been sanitized. She indicated if the dishwasher was not working at the required temperature she would notify the Administrator. On 1/7/26 at 11:15 a.m., during an interview the Dietary [NAME] indicated if dishes were not sanitized it could cause illness to the residents including stomach issues. On 1/7/25 at 10:48 a.m., observed the Dietary Manager and Dietary Aide 7, wash their hands in the designated handwashing sink in the kitchen both employees dried their hands on damp rolled paper towel that had been placed on a counter in the food prep area. The Dietary Manager indicated it was their handwashing sink and indicated the paper towel dispenser was not working. Cross reference F812 On 1/7/26 at 11:21 a.m., the Director of Nursing provided a document, titled, Hand Hygiene, dated, 1/1/25 and indicated it was the policy currently being used by the facility. The policy indicated, .5. Hand hygiene technique when using soap and water.e. Dry thoroughly with a single use paper towel. f. Use clean towel to turn off the faucet. On 1/7/26 at 11:21 a.m., the Director of Nursing provided a document, titled, Dishwasher Temperature, dated 1/1/25, and indicated it was the policy currently being used by the facility. The policy indicated, .1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items.3. A The wash temperature shall be 150 - 165 degrees Fahrenheit.b. The final rinse temperature shall be 180 degrees Fahrenheit or above but not to exceed 194 degrees Fahrenheit. 3.1-20(h)3.1-35(c)(2)(C)

A. Based on observations, record review, and interview, the facility failed to ensure frozen foods were dated prior to use and failed to ensure dishwasher was sanitizing dishes and utensils at the recommended temperatures for sanitation during 6 dietary observations. This deficient practice had the potential to affect 77 of 77 residents who receive food and drinks from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure ice was distributed in a safe and sanitary manner during 1 of 1 lunch meal service observations. This deficient practice had the potential to affect all residents that were being served in the main dining room on 1/5/26. Findings include: A. On 1/5/26 at 10:45 a.m., during a kitchen observation with the Dietary Manager the following was noted. The wash temperature of the dishwasher reached 140 degrees. The rinse temperature reached 162 degrees. The Dietary manager indicated the dishwasher was not at the appropriate temperature. Review of the temperature logs for breakfast on 1/5/26 indicated the temperature had been recorded as 150 degrees for the wash cycle and 190 degrees for the rinse cycle. The dietary manager confirmed this was inaccurate documentation. Review of the temperature logs from 1/1/26 to 1/7/26 indicated temperatures were recorded as wash 150 degrees and rinse 190 degrees for breakfast, lunch and dinner every day. The record from 12/1/25 to 12/31/25 indicated the same readings for all three meals. During an observation of the freezer the following frozen foods were not dated. Frozen eggs, frozen chicken, and frozen angel food cakes. On 1/5/26 at 11:00 a.m., observed the Dietary Manager washing her hands. She dried her hands with damp rolled paper towels that had been placed on top of a counter in the food prep area. She indicated the paper towel dispenser was not working because the dispenser batteries were low. On 1/5/26 at 12:38 p.m., during a follow up visit, the Dietary Manager washed her hands and dried her hands from damp rolled paper towels that had been placed on a counter in the food prep area. She indicated the paper towel dispenser was still not working. On 1/7/26 at 10:48 a.m., observed the Dietary Manager and Dietary Aide wash their hands in the designated handwashing sink in the kitchen. The paper towel dispenser was not working, and both employees dried their hands on rolled damp paper towel sitting on a counter in the food prep area. The Dietary Manager indicated this was their handwashing sink. On 1/7/26 at 11:00 a.m., observed the dishwasher temperature readings were at 140 degrees for the wash and 160 degrees for the rinse. During interview the Dietary Manager indicated she would use disposable utensils and plates for meal service. She indicated she had called the service provider on 1/5/26 and requested service for the dishwasher she did not know if they had been to the facility to repair it. On 1/7/26 at 11:10 a.m. during an interview the Assistant Dietary Manager indicated she did not know what risks were if food was served on dishes that had not been sanitized. She indicated if the dishwasher was not working at the required temperature, she would notify the administrator. On 1/7/26 at 11:30 a.m., during an interview the Dietary Manager indicated she talked to the maintenance person, and he indicated he had spoken to the dishwasher service provider, and they were to send someone out to the facility first thing Tuesday 1/6/26. She indicated she was busy on one of the units on Tuesday and forgot about the dishwasher needing service. She indicated she did not realize they had not come in until 1/7/26. She indicated the staff had not cleaned the dishes in the three way sink and had continued to use the dishwasher. She indicated she had not reported the issue with the dishwasher to the Administrator. On 1/7/26 at 11:45 a.m., during an interview the Administrator indicated he had not been informed on 1/5/26 of the issues with the dishwasher temperature. On 1/7/26 at 12:00 p.m., during an interview with the Dietary Manager she indicated she had found out the service provider had come into the building on 1/6/26 and indicated he told someone it was an issue with the circuit board and they only had to flip the switch and the dishwasher would work. She was not sure what time the service provider came into the facility. She indicated the dishwasher was at the correct temperature for the remaining meals on 1/6/26. She acknowledged she could not confirm this and was going by the temperature log record. A Dietary Aide indicated she thought the service provider came in around 10:30 a.m., time of arrival and departure could not be confirmed. The Dietary Manager acknowledged the dishwasher was not indicating the correct temperatures on the morning on 1/7/26 up to 12:00 p.m. She acknowledged the documentation on the temperature log was incorrect. On 1/9/26 at 11:38 a.m., the Director of Nursing provided a document titled, Date Marking for Food Safety, dated 1/1/25, and indicated it was the policy currently being used by the facility. The policy indicated, .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. On 1/7/26 at 11:21 a.m., the Director of Nursing provided a document, titled, Dishwasher Temperature, dated 1/1/25, and indicated it was the policy currently being used by the facility. The policy indicated, .1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items.3. A The wash temperature shall be 150 – 165 degrees Fahrenheit.b. The final rinse temperature shall be 180 degrees Fahrenheit or above but not to exceed 194 degrees Fahrenheit. Cross reference F802. B. During lunchtime meal service in the main dining room on 1/5/26 at 11:47 a.m., the following was observed: Certified Nurses Aide (CNA) 3 was preparing a drink for a female resident. She obtained ice and placed it in a cup with an ice scoop; she placed the ice scoop back into the clear plastic container that contained the ice. The scoop and handle were in contact with the ice. She proceeded to serve the drink to the resident. At 11:49 a.m. CNA 3 took the ice scoop out of the ice container and placed ice in a cup for another female resident. The CNA placed the ice scoop back into the plastic container of ice and the scoop and handle was in contact with the ice. She served the cup of ice water to the resident. At 11:52 a.m. Qualified Medication Aide (QMA) 4 walked by the drink cart and noted the ice scoop was in the ice container she picked it up and placed it in an empty plastic container that was allocated for the scoop. The QMA did not sanitize the ice scoop before placing it back into the empty container. During an interview, on 1/12/26 at 9:46 a.m., the Activity Director indicated that she would help with meal service and passing trays to the residents in the main dining room at times. She indicated the ice scoop should not be placed in the container with the ice and it had its own container it should be placed in when not in use. On 1/12/26 at 10:06 a.m., the Administrator provided a document with a revised date of 1/23/25, titled, Ice Machines and Portable Ice Carts, and indicated it was the current policy being used by the facility. The policy indicated .6. Ice scoops should be cleaned every 24 hours and placed in a clean container outside of the bin or the cart after every use. Do not store the ice scoop in the ice bin/cart. 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to assess a resident for pain and administered narcotic medication without documentation of pain symptoms for 1 of 5 residents reviewed for unnecessary medications (Resident 13). Findings include:On 1/5/26 at 11:00 a.m., observed Resident 13 sleeping in bed. He was not restless and was sleeping soundly. No outward signs of pain observed. On 1/5/26 at 12:30 p.m., observed resident sitting in a high back wheelchair during the noon meal service. Resident was relaxed and no visual indicators of pain noted. The resident was relaxed and looked comfortable On 1/7/26 at 10:40 a.m., the medical record of Resident 13 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included, but was not limited to, hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), and pain. An annual Minimum Data Set (MDS) assessment, dated 9/17/25, indicated the resident was cognitively impaired, required maximum assistance for daily care needs, and received opioid medications during the assessment period. A care plan, dated 12/19/24, indicated pain. Interventions included, but were not limited to, medications as ordered and observe routinely for effectiveness and notify physician of unmanaged pain, numeric scale to evaluate pain and treatment effectiveness and use interventions before pain becomes severe. A physician order, dated 9/4/23, indicated to administer acetaminophen tablet 500 mg (milligram) 1 tablet by mouth every 6 hours as needed for pain. A Physician order, dated 9/10/25, indicated to administer hydrocodone-acetaminophen -Schedule II (narcotic) tablet 5-325 mg amt: 1 tablet by mouth four times a day for pain. A physician order, dated 8/15/22, indicated to evaluate resident's pain level using either a verbal rating, FACES scale, or PAIN scale. Record pain rating and/or if resident says yes or no to pain. Special Instructions: use medication note for pre pain score, post pain score, and non-pharm interventions every shift. A pharmacy review and recommendation, dated 8/9/25, indicated the resident had been receiving Norco 5/325 mg every 6 hours routinely since 10/20/24 and no symptoms of pain were noted on the most recent assessment. A recommendation was presented to change Norco to three times per day (TID). The attending physician agreed to the recommendation. The facility did not change the administration of the medication to TID as recommended. On 1/8/26 at 10:10 a.m., the review of the vital signs record and Medication Administration Records for Resident 13, from 8/1/25 to 1/5/26, lacked documentation of pain assessment. On 1/8/26 at 10:20 a.m., during an interview, Licensed Practical Nurse (LPN) 16 indicated the resident complained of pain occasionally. She indicated she would assess residents for pain at least every shift. She indicated some orders had pain scale in the order and some did not. She indicated if a resident was not complaining of pain and they were provided hospice services she would let hospice manage the pain medication. If the resident was not on hospice she would notify the physician. She indicated the pain scale can also be entered into the residents vital signs record. On 1/8/26 at 10:30 a.m., during an interview the Director of Nurses indicated the nurse should enter a pain level into the medical record of each resident at least every shift. She acknowledged the medical record of Resident 13 lacked documentation of level of pain. She acknowledged if a resident was on a pain medication and was not experiencing pain the nurse should notify the physician and request reduction or discontinuance of routine pain medication. On 1/7/26 at 11:21 a.m., the DON provided a document with a date of 1/1/25, titled, Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Written communications from the pharmacist shall become a permanent part of the resident's medical record.f. All pharmacy recommendations requiring a physician's action will be brought to the attention of the appropriate physician in a timely manner (within 7 business days). 3.1-48(a)(1)3.1-48(a)(2)3.1-48(a)(3)3.1-48(a)(4)3.1-48(a)(5)3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to ensure multi-use vials of medication had open dates documented, for 1 of 3 medication carts reviewed. Findings include: On 1/9/26 at 10:46 a.m., an observation of medication cart 1 of the back hall indicated the following a. An open bottle of nasal spray for Resident 71 lacked documentation of an open date. Resident 71's record was reviewed on 1/9/26 at 11:15 a.m. The profile indicated the residents' diagnoses included, but were not limited to, nasal congestion (when the tissues lining the nasal passages are swollen and inflamed, making it hard to breathe through the nose, often accompanied by runny nose). A physician's order, dated 1/6/26, indicated to administer 2 sprays of Vicks [NAME] 12-hour non-aerosol nasal spray (a nasal decongestant that shrinks swollen blood vessels in your nose), 2 sprays in each nostril, two times a day. b. An open bottle of fluticasone propionate nasal spray (a type of medication used to treat and prevent inflammation in the nose caused by allergies or other conditions) for Resident 19 lacked documentation of an open date. Resident 19's record was reviewed on 1/9/26 at 11:19 a.m. The profile indicated the residents' diagnoses included, but were not limited to, nasal congestion (when the tissues lining the nasal passages are swollen and inflamed, making it hard to breathe through the nose, often accompanied by runny nose). A physician's order, dated,10/29/25, indicated to administer fluticasone propionate spray 50 micrograms (mcg) per actuation (spray), 1 spray in both nostrils, two times a day. During an interview, on 1/9/26 at 10:46 a.m., the Unit Manager indicated the medications would be dated when the bottles were opened. The bottles would be opened when the seal was broken. On 1/12/26 at 11:21 a.m., the Director of Nursing (DON) provided a document, dated 1/1/25, titled, Labeling of Medication and Biologicals, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: .8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed. 3.1-25(j)

Based on record review and interview, the facility failed to ensure documented physician rationale for a declination of a pharmacy recommendation and failed to ensure a pharmacy recommendation was addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications (Residents 11 and 13). Findings include:1. Resident 11 record was reviewed on 1/6/26 at 3:46 p.m. The profile indicated the resident's diagnoses included, but were not limited to, diabetes mellitus (a group of metabolic diseases marked by consistently high blood sugar (glucose) due to the body's inability to produce or properly use insulin), overactive bladder (a common condition marked by a sudden, uncontrollable urge to urinate, often leading to frequent bathroom trips, and chronic kidney disease stage 3 (your kidneys have moderate damage, filtering blood less effectively, leading to waste buildup and potential complications like high blood pressure, anemia (low iron), and fatigue). Facility census information indicated Resident 11 was admitted to the facility on [DATE]. A significant change in status Minimum Data Set (MDS) assessment, dated 10/21/25, indicated the resident was cognitively intact. Review of pharmacy recommendation, dated 11/5/25, indicated Resident 11 received the urinary anesthetic medication phenazopyridine (relieves symptoms caused by irritation of the urinary tract, such as pain, burning, and passing frequent small amounts of urine) 100mg (milligrams) daily since return from the hospital on 10/15. Could this be discontinued? The recommendation was marked disagree by physician and was signed and dated by physician on 11/19/25. The recommendation lacked a rationale as to why the physician disagreed with the recommendation. The electronic health record lacked documentation of a physician rationale for a declination of the pharmacy recommendation. During an interview, on 1/7/26 at 11:01 a.m., the Director of Nursing (DON) indicated she was unsure if they had any documentation as to why the physician declined the pharmacy recommendation. She was new to the role of DON and was still learning all the regulations for pharmacy recommendations. During an interview, on 1/7/26 at 11:12 a.m., the DON indicated she was unable to find documentation of any rationale from the physician as to why he disagreed with the recommendation. During an interview, on 1/7/26 at 11:33 a.m., the DON indicated she was unable to find a specific policy related to pharmacy recommendations, but the facility should follow state and federal guidelines regarding pharmacy recommendations. On 1/7/26 at 11:21 a.m., the DON provided a document with a date of 1/1/25, titled, Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Written communications from the pharmacist shall become a permanent part of the resident's medical record.f. All pharmacy recommendations requiring a physician's action will be brought to the attention of the appropriate physician in a timely manner (within 7 business days). 2. On 1/7/26 at 10:40 a.m., the medical record of Resident 13 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but was not limited to hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), and pain. A physician order, dated 8/15/22, indicated to evaluate resident's pain level using either a verbal rating, FACES scale, or PAIN scale. Record pain rating and/or if resident says Yes or no to pain. Special Instructions: use medication note for pre pain score, post pain score, and non-pharm interventions every shift. A care plan, dated 12/19/24, indicated pain. Interventions included, but were not limited to, medications as ordered and observe routinely for effectiveness and notify physician of unmanaged pain, numeric scale to evaluate pain and treatment effectiveness and use interventions before pain becomes severe. A pharmacy review and recommendation, dated 8/9/25, indicated the resident had been receiving Norco 5/325 mg every 6 hours routinely since 10/20/24 and no symptoms of pain were noted on the most recent assessment. A recommendation was presented to change Norco to three times per day (TID). The attending physician agreed to the recommendation. The facility did not change the administration of the medication to TID as recommended. A Physician order, dated 9/10/25, indicated to administer hydrocodone-acetaminophen -Schedule II (narcotic) tablet 5-325 mg amt: 1 tablet by mouth four times a day for pain. An annual Minimum Data Set (MDS) assessment, dated 9/17/25, indicated the resident was cognitively impaired, required maximum assistance for daily care needs, and received opioid medications during the assessment period. On 1/8/26 at 10:10 a.m., the review of the vital signs record and Medication Administration Records for Resident 13, from 8/1/25 to 1/5/26, lacked documentation of pain assessment. On 1/8/26 at 10:30 a.m., during an interview the Director of Nurses indicated the nurse should enter a pain level into the medical record of each resident at least every shift. She acknowledged the medical record of Resident 13 lacked documentation of level of pain. She acknowledged if a resident was on a pain medication and was not experiencing pain the nurse should notify the physician and request reduction or discontinuance of routine pain medication. On 1/7/26 at 11:21 a.m., the DON provided a document with a date of 1/1/25, titled, Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Written communications from the pharmacist shall become a permanent part of the resident's medical record.f. All pharmacy recommendations requiring a physician's action will be brought to the attention of the appropriate physician in a timely manner (within 7 business days). 3.1-25(h)

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 3 of 7 residents observed during the medication pass. There were 26 opportunities for errors observed with 3 medication errors, resulting in a medication error rate of 11.54 percent (Residents 34, 78, and 8). Findings include:1a. On 1/8/26 at 8:28 a.m., Licensed Practical Nurse (LPN) 8 administered medications to Resident 34. The medications included, but were not limited to, fluticasone propionate (Flonase) 50 micrograms (mcg) nasal spray (a corticosteroid medication used to relieve allergy symptoms) 1 spray to each nostril two times daily. The LPN shook the nasal spray container and placed the tip into the resident's left nostril and sprayed. She then placed the tip of the nasal spray into the resident's right nostril and sprayed it. The LPN failed to instruct the resident to pinch off his opposite nostril as she administered the nasal spray. An active physician's order, reconciled on 1/9/26 at 1:57 p.m., indicated to administer 1 spray of 50 mcg fluticasone propionate nasal spray to bilateral (both sides) nostrils, two times daily. On 1/9/26 at 2:48 p.m., Registered Pharmacist 20 indicated the manufacturer's guidelines for administering fluticasone propionate nasal spray, was to close the opposite nostril as the medication was administered. b. On 1/8/26 at 8:41 a.m., Licensed Practical Nurse (LPN) 8 administered medications to Resident 78. The medications included, but were not limited to, fluticasone propionate (Flonase) 50 micrograms (mcg) nasal spray (a corticosteroid medication used to relieve allergy symptoms) 2 sprays to each nostril two times daily. The LPN shook the nasal spray container and placed the tip into the resident's left nostril and sprayed. She then placed the tip of the nasal spray into the resident's right nostril and sprayed it 2 times. The LPN failed to instruct the resident to pinch off his opposite nostril as she administered the nasal spray. An active physician's order, reconciled on 1/9/26 at 2:06 p.m., indicated to administer 2 sprays of 50 mcg fluticasone propionate nasal spray to bilateral (both sides) nostrils, two times daily. During a telephone interview, on 1/9/26 at 2:48 p.m., Registered Pharmacist 20 indicated the manufacturer's guidelines for administering fluticasone propionate nasal spray, was to close the opposite nostril as the medication was administered. During an interview, on 1/9/26 at 8:47 a.m. the Director of Nursing (DON) indicated the expectation was that nasal sprays should be administered as per physician's order, facility policy, and acceptable standards of practice.On 1/9/26 at 10:46 a.m., the DON provided a document, dated 2024, titled, Nasal Spray Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Nasal spray medications are administered.in accordance with professional standards of practice. 2. On 1/8/26 at 8:59 a.m., Licensed Practical Nurse (LPN) 8 administered medications to Resident 8. The medications included, but were not limited to, tiotropium 0.018 milligram (mg) inhalation powder (Spiriva) (a prescription maintenance medication used once daily to manage chronic obstructive pulmonary disease [COPD-a progressive lung disease that blocks airflow, making it hard to breathe, caused by permanent damage to the airways and lung tissues] in adults), inhale 1 puff daily. Rinse mouth and spit after each administration. The LPN prepared the inhaler and handed it to the resident. The resident inhaled 1 puff and handed the inhaler back to LPN 8. The LPN left the resident's room and failed to have the resident rinse and spit after the inhaler was administered. An active physician's order, reconciled on 1/9/26 at 2:17 p.m., indicated to administer 1 puff of tiotropium 0.018 mg inhalation powder (Spiriva) daily. Rinse mouth and spit after administration. During an interview, on 1/9/26 at 8:47 a.m. the Director of Nursing (DON) indicated the expectation was that inhalers should be administered as per physician's order, facility policy, and acceptable standards of practice.On 1/9/26 at 10:46 a.m., the DON provided a document, dated 2024, titled, Administration of Metered Dose Inhaler, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines.16.allow the resident to rinse and gargle with water.to remove medication from mouth and back of throat.3.1-4(c)(1)

Based on observation, interview, and record review, the facility failed to ensure that resident personal information was protected from exposure, during 1 of 2 medication administration observations (Residents 34, 78, and 8). Findings include:During observation of medication administration with Licensed Practical Nurse (LPN) 8, on 1/8/26, the following was observed: a. On 1/8/26 at 8:28 a.m., LPN 8 set up the medications to administer to Resident 34. She was observed to use the desk computer to rectify the medications. At the same time, she indicated she was using the desk computer at the nurse's station because the laptop on the medication cart would not stay charged. She left the nurse's station to administer the medications and left the resident's personal information exposed on the computer screen without closing or covering the screen. b. On 1/8/26 at 8:41 a.m., LPN 8 set up the medications to administer to Resident 78. She was observed to use the desk computer to rectify the medications. She left the nurse's station to administer the medications and left the resident's personal information exposed on the computer screen without closing or covering the screen. c. On 1/8/26 at 8:59 a.m., LPN 8 set up the medications to administer to Resident 8. She was observed to use the desk computer to rectify the medications. She left the nurse's station to administer the medications and left the resident's personal information exposed on the computer screen without closing or covering the screen. During an interview, on 1/9/26 at 8:47 a.m. the Director of Nursing (DON) indicated the expectation was that the resident's personal information be covered when the nurse was away from the cart or desk. The nurse should have been using the computer on the cart if possible. On 1/9/26 at 10:46 a.m., the DON provided a document, dated 1/1/25, titled, Confidentiality of Personal and Medical Records, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: .8. Paper notes and/or electronic medical records or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons. 3.1-3(o)

Based on observation, record review, and interview, the facility failed to initiate or revise interventions to prevent falls for 1 of 1 residents reviewed for accidents (Resident 12). Findings include:On 1/5/26 at 2:00 p.m., during an initial observation, Resident 12 was observed sleeping in bed. The resident was lying on her back with her head hyperextended. The bed was in the low position. A padded mat was on the floor next to the left side of the bed. The call light was lying on the foot of the bed. On 1/9/26 at 10:00 a.m., the medical record of Resident 12 was reviewed. The most recent admission to the facility was on 9/25/25. admission diagnosis included, but was not limited to, fracture of right femur (bone fracture of the right hip), pain in right hip and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A significant change Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident was cognitively impaired and was dependent upon staff for all daily care needs including transferring and ambulation. A care plan, dated 9/2/22 with the most recent edited date of 11/23/25, indicated the resident was at risk for falls related to weakness, gait and balance deficits, use of medications which may cause dizziness, and change in normal routine and environment. Care plan interventions included assist to transfer, footwear to prevent slipping, call light within reach, room well lit, pathways free of clutter, personal items and used items within reach, observe for medication side effects, prompt toileting assistance, therapy screen, obtain labs, medication review, redirect to dining room for meals, comfortable seating, and touch pad call light. Review of events in the medical record indicated on 2/1/25 at 7:30 p.m., the resident fell in her room. The record indicated the bed was in a low position and the resident was sitting on the floor next to the bed. The record lacked documentation if the resident had nonskid socks or shoes on at the time of the fall. The root cause indicated the resident had been ambulating. Interventions included nonskid footwear. The documentation lacked evidence of new interventions to prevent falls. On 2/14/25 at 8:20 a.m., the resident fell in the dining room area. The resident was found lying on the floor on her right side. The root cause indicated the resident had been ambulating. The record lacked documentation of resident wearing nonskid shoes. Interventions included monitor vital signs and medication review. The record lacked documentation of vital signs at the time of the fall, no new interventions were implemented to prevent falls, and the record lacked documentation of medication review results. On 9/22/25 at 5:00 p.m., the resident was found lying on the floor in the doorway of her room. Documentation indicated the resident was wearing nonskid shoes. Root cause indicated the resident had been ambulating. The resident was complaining of pain of the right hip. She was placed on one-to-one supervision and sent to the hospital for evaluation. The resident was admitted to the hospital with diagnosis of fracture of the right hip. On 9/25/25 the resident returned to the facility from hospital stay. The medical record lacked documentation of new interventions to prevent falls. On 10/9/25 at 5:30 p.m., the resident was in the main dining room area. She attempted to stand from the wheelchair and fell backwards onto the floor. The record indicated the resident had nonskid shoes on her feet. Interventions were monitoring vital signs and report to physician or nurse practitioner, wheelchair, activities and offer comfortable seating. The record lacked evidence of vital signs at the time of the fall and lacked evidence of new interventions specific to prevent falls. On 11/12/25 at 3:49 p.m., the resident stood from her bed and fell on the floor. The fall was witnessed by an employee. Documentation indicated the vital signs at the time of the fall were temperature 97.6, pulse 81, respirations 18, blood pressure 140/79. The resident sustained a skin tear to her hand and a 2 centimeter (cm) by 1cm laceration to the right side of her forehead. Intervention was to add touch pad call light. The record lacked documentation of new interventions to prevent falls. On 1/6/26 at 9:34 a.m., during an interview, Licensed Practical Nurse (LPN) (10) indicated Resident 12 walked with therapy for a time but acted like she was afraid and they discontinued therapy. She indicated physical therapy did not continue providing services for long and the therapist would notify the physician to determine if the resident needed to continue with therapy. She indicated the facility did not provide any type of restorative program in the memory care unit where Resident 12 resided. She indicated preventive fall measures were to keep the resident in her wheelchair at the nurse's station to observe and to prevent falls. On 1/9/26 at 11:45 a.m., during an interview the Physical Therapy Director indicated therapy was a minimum of five days a week per discipline. Therapy may be provided on weekends as well. She indicated Resident (12) could ambulate 200 to 250 feet in the hall, but she had come to the place she resisted the therapy staff and refused. She indicated the resident was discharged because it was causing her more distress, but the resident was able to ambulate after she had fractured her hip in a fall. She indicated they did not have a restorative aide, but the staff was educated regarding walking the resident and they were instructed if she stood, they must try to walk her. She indicated no one had reviewed the hyperextension of the resident's neck, but the staff were educated on exercises to bring her chin forward including range of motion (ROM) exercises. She indicated therapy would be providing services again next week. On 1/9/26 at 1:25 p.m., during an interview the MDS nurse indicated she would update the care plan within 14 days if there was a significant change in the resident's condition. She indicated if a resident fell she would update the care plan the next day. She indicated she does not delete interventions because she may want to use them again. She did not enter care plans for therapy; they would enter their own. On 1/9/26 at 1:27 p.m., during an interview Licensed Practical Nurse (LPN) 16, indicated the Certified Nurse Aide (CNA) provides range of motion (ROM) (how far and in what direction a joint can move, from bending (flexion) to stretching (extension), representing the joint's flexibility and movement potential without pain) for the residents as needed. She indicated they did not have any orders for ROM for Resident 12. She indicated Physical Therapy (PT) advised them to walk Resident 12, but she did not recall any instruction from therapy regarding ROM. She indicated the staff walked Resident 12 to the bathroom at times but due to rigidity she could not walk as much. She indicated if a resident had a fall the interventions would be determined by the individual resident. She indicated Resident 12 no longer tried to get up on her own and she had a mat on the floor due to risk of falling out of bed. On 1/9/26 at 1:39 p.m., during an interview, Certified Nurse Aide 15 indicated she did passive (PROM) (when someone or something else (like a therapist or machine) moves a joint through its full range of movement, without the person using their own muscles), when moving and dressing the residents. She indicated she did not provide PROM to the residents, but she remembered therapy providing education regarding ROM. She indicated Resident 12 did not want to walk, and prior to her falls Resident 12 was very ambulatory. She indicated the resident liked her room quiet, so they kept her lights turned off when she was in the room. On 1/9/26 at 1:45 p.m., observed resident lying in bed in her room. The room was dark, the bed was in a low position, a padded mat was on floor on the left side of the bed, and the soft touch call light was lying on the foot of the bed. The medical record lacked documentation or interventions of low bed or mat to the floor. On 1/9/26 at 2:05 p.m., during an interview the Director of Nursing (DON) indicated if a resident fell, they would look at why the resident fell and enter specific interventions. The DON acknowledged the staff should follow therapy services with range of motion (ROM) as needed to keep the resident's mobile. On 1/12/26 at 1:22 p.m., the DON provided a document, titled, Fall prevention program, dated 1/1/25, and indicated it was the policy currently being used by the facility. The policy indicated, .3. The baseline care plan will include the identification of the fall risk score and interventions. 4.a. Interventions will be monitored for effectiveness.e. Review the resident's care plan and update as indicated.h. Fall events will be reviewed by the IDT to establish root cause and update interventions/treatment plans as needed in the resident's electronic health record. 3.1-45(a)

Based on observation, record review and interview, the facility failed to ensure a resident had physician's order and a care plan for an indwelling urinary catheter (a thin, flexible tube left inside the bladder, typically through the urethra, to continuously drain urine into an external collection bag), failed to ensure the catheter's external urine collection bag (catheter bag) and tubing were prevented from contact with the floor, and failed to ensure the catheter bag was maintained in a dignified manner, for 1 of 1 resident observed for urinary catheter (Resident 21). Findings include: During an initial observation of Resident 21, on 1/6/26 at 9:14 a.m., the resident's catheter bag was observed in contact with the floor. The resident was sitting in her wheelchair next to her bed. During a random observation, on 1/7/26 at 9:04 a.m., the resident was observed in her room in her wheelchair. The resident's catheter tubing was in contact with the floor. During a random observation, on 1/7/26 at 1:06 p.m., the resident was sitting in her wheelchair in her room. The resident's catheter bag was facing the door to the hallway. The dignity bag (a covering that is placed over the urinary drainage bag to prevent the exposure of urine in the bag and provide dignity to the resident) was observed in a position as to leave the catheter bag with urine exposed. Resident 2's record was reviewed on 1/8/26 at 1:25 p.m. The profile indicated the resident had been admitted on [DATE], for diagnoses which included, but were not limited to, urinary tract infection (UTI-a common bacterial infection in any part of your urinary system) and overactive bladder (a sudden, strong, uncontrollable urge to urinate, even when the bladder isn't full). Review of the events indicated the resident had been admitted with a UTI on 11/17/25 and had other UTIs documented on 12/11/25 and 12/26/25. A quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, indicated that the resident had no cognitive deficit, was dependent with toileting, was always incontinent of bladder, and lacked documentation of the resident having an indwelling urinary catheter. The record lacked documentation of a catheter care plan. A historical review of the resident's physician's orders lacked documentation of orders for a indwelling urinary catheter upon admission. A skilled nurse assessment, dated 11/18/25, indicated the resident had a UTI, but lacked documentation of any indwelling urinary catheter. A skilled nurse assessment, dated 12/2/25, lacked documentation of any indwelling urinary catheter. The census indicated that the resident had been hospitalized from [DATE] to 12/11/25, for change on mental status. The hospital history and physical report, dated 12/2/25, indicated the resident had a urinary tract infection. A post hospital Clinical Admission/re-admission document, dated 12/11/25 at 1:51 p.m., lacked documentation that the resident had an indwelling urinary catheter when returning from the hospital. A physician's order, dated 12/14/25, indicated to remove the catheter and start a voiding trial (a medical test to determine if a patient can urinate (void) normally and empty their bladder adequately after a urinary catheter has been removed) one time. A physician's order, dated 12/16/25, indicated to anchor a Foley (indwelling urinary catheter) if retaining urine over 200 milliliters (ml) and no voiding within 6 hours. The record lacked documentation of results of a voiding trail to justify the placement of a indwelling urinary catheter. Review of the resident's progress notes, dated 11/17/25 through 1/9/26, lacked documentation of an indwelling urinary catheter. On 1/12/26 at 9:42 a.m., the resident was observed in her room sitting in her wheelchair. At the same time the resident indicated that her indwelling urinary catheter had been removed 2 days prior.On 1/12/26 at 9:48 a.m., review of the resident's progress notes and physician's orders lacked documentation of any orders to remove the resident's indwelling urinary catheter or nurse's notes documenting the removal.During an interview, on 1/12/26 at 9:53 a.m., the Director of Nursing (DON) indicated she was not aware that there were no orders for the resident's catheter. She believed she came with a catheter on her original admission date. It was removed on 12/14/25, per MD order for a voiding trial. The voiding trial was successful. She was not sure when or why the resident had another catheter placed. She was unable to find any documentation or orders for the new catheter or about the catheter being removed. The expectation was that a physician's order should have been in place in the resident's record any time there was an indwelling urinary catheter in place and before it was removed. The nurse should document the catheter in the progress notes to ensure it was being observed as expected. During an interview, on 1/7/26 at 3:26 p.m., the DON indicated there was not a policy specifically related to the catheter bag and/or tubing on the floor, but the facility would follow standards of nursing practice. The expectation was that catheter bags and/or tubing should never come in contact with the floor as it was an infection control risk. On 1/7/26 at 3:26 p.m., the DON provided a document, dated 2024, titled, Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation: .2. Privacy bags will be available and catheter drainage bags will be covered at all times, while in use.On 1/12/26 at 11:00 a.m., the DON provided a document, dated 2024, titled, Consulting Physician/Practitioner Orders, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines.2. For consulting physician/practitioner orders.the nurse in a timely manner will: a. Call the attending physician to verify the order. B. Follow facility procedures for.orders including: noting the order, submitting to pharmacy, and transcribing to.record.3.1-41(a)(1)

Based on record review and interview, the facility failed to obtain a resident's medications in a timely manner after their admission to the facility for 1 of 6 residents reviewed for pharmaceutical services (Resident B). Findings include:Resident B's record was reviewed on 1/9/26 at 10:14 a.m. Census information indicated the resident was admitted to the facility on [DATE]. A Medication Administration Record (MAR), dated December 2025, included the following information. -A physician's order, dated 12/19/25, indicated administer ascorbic acid (supplement) 250 milligrams (mg) by mouth daily for muscle wasting. The medication was not administered, on 12/19/25, related to pharmacy delivery tonight. The medication was not administered, on 12/27/25, 12/28/25, and 12/31/25, related to awaiting from pharmacy. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administrations. -A physician's order, dated 12/19/25, administer enoxaparin (blood thinner) 30 mg/0.3 milliliters (ml) subcutaneously (SQ) once daily for sick sinus syndrome (group of heart rhythm disorders). The medication was not administered, on 12/19/25, related to pharmacy delivery tonight. The first administration of the medication was on 12/20/25. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administration. -A physician's order, dated 12/19/25, indicated administer metoprolol succinate (blood pressure medication) extended release (ER) 50 mg by mouth daily for essential primary hypertension (high blood pressure). The medication was not administered, on 12/19/25, related to pharmacy delivery tonight. The first administration of the medication was on 12/20/25. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administration. -A physician's order, dated 12/19/25, indicated administer metronidazole (antimicrobial medication) 500 mg by mouth twice daily. The medication was not administered on the morning of 12/19/25, related to pharmacy delivery tonight. The first administration of the medication was in the evening of 12/19/25. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administration. -A physician's order, dated 12/19/25, indicated administer sodium bicarbonate (antacid) 650 mg by mouth twice daily for functional dyspepsia. The medication was not administered on the morning of 12/19/25, related to pharmacy delivery tonight. The first administration of the medication was in the evening of 12/19/25. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administration. -A physician's order, dated 12/19/25, indicated administer venlafaxine (antidepressant) 75 mg by mouth daily for depression. The medication was not administered, on 12/19/25, related to pharmacy delivery tonight. The first administration of the medication was on 12/20/25. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administration. A progress note, dated 12/18/25, indicated the resident was admitted to the facility at 10:00 p.m. The progress note lacked documentation the pharmacy was notified of the resident's admission or her medications were ordered from a back-up pharmacy. Progress notes, dated 12/19/25, lacked documentation the physician or the pharmacy were contacted regarding the resident's missed medication administrations. During an interview, on 1/9/26 at 1:42 p.m., the Assistant Director of Nursing (ADON) indicated when a resident was admitted to the facility orders were put in the electronic medical record, and a medication list should have been faxed to the pharmacy. The pharmacy should have filled the resident's medications based on this information. If a resident was admitted at 10:00 p.m., the nurse should have pulled available medications out of the emergency drug kit (EDK) and called the pharmacy to have the other medications sent from a back-up pharmacy on a stat (immediate) delivery. Medication orders had to be received by the pharmacy by 5:00 p.m., in order for the medications to be sent on the regularly scheduled pharmacy delivery. If medications were unavailable for administration the physician should have been notified. On 1/9/26 at 1:26 p.m., the Director of Nursing (DON) provided an untitled document, last revised on 3/8/22, and indicated it was the list of medications currently available in the facility's EDK. The list indicated metoprolol succinate and metronidazole were available in the EDK. The DON did not provide documentation either of the available medications were pulled from the EDK for the resident. On 1/9/26 at 2:24 p.m., the ADON provided a document titled, Medication Ordering and Receiving From Pharmacy, last revised in November 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Emergency Pharmacy Services and Emergency Kits. Policy: Emergency pharmacy services are available on 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from [Pharmacy Name].II. To access medication from the emergency medication supply, secondary to a new order or when medication for which there is a current prescription is not readily available, the appropriate facility personnel should not take a medication from the e-box [EDK].without checking allergies on the medical record and possible drug-drug interactions. 1. The appropriate facility personnel confers with the prescriber to determine whether the order is a true emergency, i.e., order cannot be delayed until the scheduled pharmacy delivery. The appropriate facility personnel may alert the physician to the listing of medications that are readily available in the emergency supply.2. Only after verifying that the above communication has occurred, the pharmacy has received a complete prescription, and medication allergies, interactions, and other contraindications have been checked, the appropriate facility personnel may remove the required medication from the emergency medication supply. If the medication is not available in the emergency medication supply, the appropriate facility personnel contacts the pharmacy, using the after0hours emergency number(s) if necessary.5. Use of the emergency medication is noted on the resident's medication administration record. This citation relates to intake 2705536. 3.1-25(a)

A. Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a thin, flexible tube left inside the bladder, typically through the urethra, to continuously drain urine into an external collection bag), external urine collection bag (catheter bag) and tubing were prevented from contact with the floor, for 1 of 1 resident observed for urinary catheter (Resident 21). B. Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during medication administration for 1 of 2 medication administration observations. Findings include:A. During an initial observation of Resident 21, on 1/6/26 at 9:14 a.m., the resident's catheter bag was observed in contact with the floor. The resident was sitting in her wheelchair next to her bed. During a random observation, on 1/7/26 at 9:04 a.m., the resident was observed in her room in her wheelchair. The resident's catheter tubing was in contact with the floor. Resident 2's record was reviewed on 1/8/26 at 1:25 p.m. The profile indicated the resident had been admitted on [DATE], for diagnoses which included, but were not limited to, urinary tract infection (UTI-a common bacterial infection in any part of your urinary system) and overactive bladder (a sudden, strong, uncontrollable urge to urinate, even when the bladder isn't full). Review of the events indicated the resident had been admitted with a UTI on 11/17/25 and had other UTIs documented on 12/11/25 and 12/26/25. During an interview, on 1/7/26 at 3:26 p.m., the DON indicated there was not a policy specifically related to the catheter bag and/or tubing on the floor, but the facility would follow standards of nursing practice. The expectation was that catheter bags and/or tubing should never come in contact with the floor as it was an infection control risk. B. During the medication administration observation, on 1/8/26 at 8:15 a.m., Licensed Practical Nurse (LPN) 8 was observed to wash her hands prior to setting up her first administration. She performed the handwashing procedure appropriately. A visitor approached the LPN and requested a cup of ice. The LPN obtained the ice for the visitor, touching the outside of the ice bucket, the ice scoop, and the netting surrounding the ice cart, and then proceeded to set up and perform the initial medication pass without sanitizing her hands.During an interview, on 1/9/26 at 8:47 a.m. the Director of Nursing (DON) indicated hand washing and sanitation should always be completed prior to and after each medication pass for the residents. If the nurse touched anything prior to administration, she should have washed her hands again prior to starting the administration. On 1/12/26 at 12:06 p.m., the DON provided a document, dated 1/1/25, titled, Hand Hygiene Table, and indicated it was the policy currently being used by the facility. The policy indicated, .After handing contaminated objects.Before preparing or handling medications. 3.1-18(k)(1)

Based on interview and record review, the facility failed to transport a resident to a scheduled surgical procedure for 1 of 3 resident reviewed for quality of care. (Resident B)Findings include:A clinical record review for Resident B was completed on 8/14/25 at 10:00 a.m. Diagnoses included urinary tract infection, Parkinson's disease, obstructive and reflux uropathy, and dementia. A physician's order, dated 8/10/25, indicated resident was to have nothing by mouth after midnight due to a scheduled surgery on the morning of 8/11/25. Administer morning medications with a small sip of water. The order had a discontinued date of 8/3/25 due to resident being out of the facility at an acute care hospital.A nursing progress note, dated 8/3/25, unknown time, indicated resident B reported not feeling well. She was short of breath and warm to touch. Her heart rate was elevated at 113 beats per minute. The physician was notified and the resident was transferred via ambulance to an acute care hospital.A nursing progress note, dated 8/4/25 at 4:56 a.m., indicated Resident B was admitted to the acute care hospital with kidney stones and hypokalemia (low blood potassium), possibly leading to septicemia (an infection in the blood). A nursing progress note, dated 8/8/25 at 11:48 p.m., indicated Resident B had returned from the acute care hospital. discharge instructions, dated [DATE], provided by the Director of Nursing (DON) on 8/14/25 at 11:26 a.m., included the resident had a scheduled follow-up appointment for surgery on 8/11/25 at 9:15 a.m.A Final Report from the acute care hospital, dated 8/8/25, provided by the DON on 8/14/25 at 11:26 a.m., included the following: .Discharge Disposition follow-up with Uro [Urology] as scheduled Plan .Will plan to follow up with [urologist name] on 8/11/25 for URS/LL {Ureteroscopy and Laser Lithotripsy (surgical procedure to examine the upper urinary system and to remove kidney stones) A progress note, dated 8/11/25 at 10:29 a.m., included, the urologist office had been contacted regarding rescheduling the resident's surgery. During a telephone interview on 8/14/25 at 11:29 a.m., Resident B's spouse indicated he had called the morning of the surgery, 8/11/25 between 7:00 and 7:30 a.m., RN 2 indicated the resident was leaving the facility at 7:45 a.m. He went to the hospital at 8:00 a.m., and the hospital staff indicated his wife had been a no-show for her procedure. The hospital staff suggested he call the facility. He called the facility and was told no one was available. He drove from the hospital to the facility and talked with RN 2 who indicated the DON had arrived at the facility that morning and indicated Resident B had had her surgical procedure during her hospital stay and would not need to go that morning. He became very upset. He asked to speak to the DON who just kept blaming everyone else for the resident missing her surgery. During an interview on 8/14/25 at 11:51 a.m., the DON indicated Resident B returned from her hospital stay on Friday evening, 8/8/25, and her surgery was scheduled for Monday morning on 8/11/25. Transporter 2 had asked if she returned on Friday, if she would be going to surgery on Monday. The DON had told Transporter 2 she would have to look at the discharge paperwork to confirm the surgery because Resident B had a procedure while she was in the hospital. The DON indicated the resident had not returned by the time she left to go home. She had told Transporter 2 to assume Resident B was having her surgery on Monday, 8/11/25. When the DON arrived to the facility on Monday at around 8:30 a.m., she did not realize Transporter 2 had not taken the resident to the hospital. The surgery department had called RN 3 and indicated the resident had not shown up for her procedure. Transporter 2 had not shown up to take her to her appointment. During an interview on 8/14/25 at 1:18 p.m., Transporter 2 indicated on Friday afternoons, he reviewed the following weeks schedule and had noticed Resident B was in the hospital. He asked Unit Manager (UM) 4 and the DON if Resident B returned to the facility, would she be going to have the surgery on Monday morning, 8/11/25. He had been told by UM 4 that Resident B had already had her procedure when she was in the hospital. The DON indicated she would confirm things and would contact him if the surgery was a go or no-go. He did not hear back from the DON or any staff at the facility. He arrived on Monday, 8/11/25, at his usual time, 8:00 a.m., and believed the surgery had already been completed while the resident was in the hospital. The staff informed him that Resident B had missed her surgery.During an interview on 8/14/25 at 1:37 p.m., UM 4 indicated she had already gone home by the time Resident B returned from the hospital on Friday, 8/8/25. Transporter 2 had come into the DON's office Friday afternoon, 8/8/25, and reviewed transports for Monday, 8/11/25. The DON had told Transporter 2 they would not know for sure about Resident B's surgery until she returned with her discharge paperwork. UM 4 indicated the hospital had not contacted the facility for report prior to transfer back to the facility by the time she left the facility for the weekend. During a telephone interview on 8/14/25 at 2:01 p.m., RN 3 indicated she looked where they kept the appointment paperwork for the day and saw Resident B was scheduled for surgery that morning. The Surgery Center had called that morning, and she asked if she should hold her morning medications. The Surgery Center staff indicated she could take her morning medications, but to hold her morning insulin injection. RN 3 got the resident ready and she was up in her wheelchair, and ready to go when Transporter 2 arrived approximately 7:45 a.m. She noticed at 7:55 a.m., he had not left the facility for transport yet. Transporter 2 indicated he had spoken to the DON and the surgery for that morning had been cancelled. RN 3 returned the resident to her bed and administered her insulin dose. The resident's spouse arrived a little bit later and asked why she had not arrived for her surgery. He was very upset because the procedure was not cancelled. She interrupted the staff's morning meeting to let the Administrator and DON know the resident's husband was there to talk with them regarding his wife being a no-show for her surgery. She felt when Transporter 2 had told her the surgery was cancelled, she should have called the DON at that time to confirm. She felt bad about not confirming, but he had seemed so sure of the cancellation. She had not had access to the discharge paperwork from the resident's hospital stay, as they had been given to the DON or UM 4 to be reviewed and entered into the electronic health record after the weekend. She had explained to Transporter 2 that she had been contacted by the Surgery Center and the surgery was confirmed. A current facility policy, dated 1/1/25, titled, Transporting a Resident (Facility Van), provided by the DON on 8/14/25 at 3:33 p.m., included the following: Policy: It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary.A current facility policy, dated 1/1/25, titled, Consulting Physician/Practitioner Orders, provided by the DON on 8/14/25 at 3:33 p.m., included the following: Policy Explanation and Compliance Guidelines: .2 For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: .b. Document the verification order by entering the order into the EMRThis citation relates to Intake 2586289.3.1-37(b)

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 9 residents' MDS assessments reviewed (Resident E). Findings include: During an observation on 2/10/25 at 2:00 p.m., Resident E was sitting up in her wheelchair with a tray table attached to the right side of her wheelchair. Her right arm was resting on the table. Resident E's record was reviewed on 2/12/25 at 9:42 a.m. An admission MDS assessment, dated 12/9/24, indicated the resident had severe cognitive impairment and no functional limitation in range of motion (ROM) to the upper or lower extremities. Diagnoses on the resident's profile included, but were not limited to, hemiplegia (paralysis or weakness on one side of the body) unspecified affecting right dominant side. An admission observation, dated 12/3/24, indicated the resident had impairment on one side of the upper extremities. A Physician's Progress Note, dated 12/4/24, indicated the resident's assessment showed right sided hemiparesis (weakness or paralysis on one side of the body). A care plan, initiated on 12/4/24, indicated the resident was at risk for self-care deficit related to right sided hemiplegia. During an interview, on 2/12/25 at 10:44 a.m., Certified Nurse Aide (CNA) 4 indicated Resident E was not able to use her right arm or hand at all. Resident E used her left hand and arm to put on a shirt and perform other activities. The resident used the tray table to rest her arm on when she was in the wheelchair. During an interview, on 2/12/25 at 10:51 a.m., the MDS Coordinator indicated she was not sure if the resident's hemiplegia should have been coded as an impairment in ROM because the resident was able to walk. She indicated she would check if the impairment to the resident's upper extremity should have been coded. During an interview, on 2/12/25 at 12:02 p.m., the DON indicated Resident E's limitation in ROM should have been coded on the MDS assessment but, it had been missed. On 2/12/25 at 12:14 p.m., the DON provided the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual version 3.0, Section GG, dated October 2024, and indicated it was the policy currently being used by the facility. The RAI Manual indicated, .GG0115: Functional Limitation in Range of Motion. Code for limitation that interfered with daily functions or placed resident at risk for injury in the last 7 days. Coding: 1. No impairment. 1. Impairment on one side. 2. Impairment on both sides .Upper extremity (shoulder, elbow, wrist, hand) .Steps for Assessment: 1. Review the medical record for references to functional range-of-motion limitation during the 7-day observation period. 2. Talk with staff members who work with the resident as well as family/significant others about impairment in functional ROM. 3. Coding for functional ROM limitations is a three-step process: Test the resident's upper and lower extremity ROM .If the resident is noted to have any limitation of upper .ROM, review GG0130 and GG0170 and/or directly observe the resident to determine whether the limitation interferes with function or places the resident at risk for injury. Code GG0115A and GG0115B as appropriate based on the above assessment This citation relates to complaint IN00451478.

Based on interview, observation, and record review, the facility failed to ensure limitations in range of motion were assessed, treated, and required interventions communicated to staff effectively for 3 of 3 residents reviewed for limitations in range of motion (Residents B, E, and F). Findings include: 1. During an interview, on 2/10/25 at 12:00 p.m., Resident B's family member indicated the resident had splints for her hands that she needed to prevent contractures (permanent or prolonged shortening of muscles, tendons, ligaments, or skin that restricts range of motion and can lead to deformities). The splints arrived to the facility with the resident at admission and were kept beside. The splints were not used until 12/14/24. The family member indicated they asked staff about using the splints, but the staff were not aware of them. On 12/13/24, therapy put the splints on the resident and indicated if there was no redness or soreness they would be used at night. On 12/14/24, a regimen for the hand splints was finally established. Resident B's record was reviewed on 2/10/25 at 2:18 p.m. An admission Minimum Data Set (MDS) assessment, dated 12/9/24, indicated the resident had severe cognitive impairment and no functional limitation in range of motion (ROM) to the upper extremities. Census information indicated the resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 12/9/24, indicated the resident had severe cognitive impairment and no functional limitation in range of motion (ROM) to the upper extremities. A nursing admission assessment, dated 12/3/24, indicated the resident had weakness and a functional limitation in ROM on both sides of the upper extremities. Other equipment the resident brought included hand braces. A Physician's Order, dated 12/5/24, indicated skilled Occupational Therapy (OT) services five times a week for four weeks to address basic activities of daily living (ADLs), wheelchair positioning, patient safety, patient education, following directions, therapy exercises and activities, and upper body strengthening. A care plan, dated 12/11/24, indicated the resident was at risk for impaired mobility related to osteoporosis (weak and brittle bones) an osteoarthritis (chronic joint disease). The care plan lacked documentation of the resident's functional limitation in ROM and the resident's hand splints. An OT Treatment Encounter Note, dated 12/13/24, indicated, .stretching to bilateral [both] hands prior to application of splints. Hand splints worn for 3 hours without sign of increased skin irritation The note lacked documentation the need for hand splints was communicated to the nursing staff. A Treatment Administration Record (TAR), dated December 2024, included two Physician's Orders, dated 12/19/24. The orders indicated hand splints on during the night and off during the day. The TAR lacked documentation the hand splints were ordered prior to 12/19/24. An OT Discharge Summary, dated 12/26/24, included a short term goal of increased ROM and strength in the resident's left upper extremity. Goal notes, dated 12/18/24 and 12/24/24, indicated the resident's left hand continued to struggle with grasp and release due to contractures. During an interview, on 2/11/25 at 11:30 a.m., Certified Occupational Therapy Assistant (COTA) 6 indicated he was familiar with Resident B, and both of her hands were basically contracted. During therapy, he massaged and stretched her hands. The resident was able to wear the hand splints in therapy for three hours without redness, and eventually wore them at night. The residents hands were contracted when she was admitted to the facility. He thought the family brought the splints in after she was admitted , but he was not told about them for a couple of days. He was not aware the splints came with the resident upon admission. Once he became aware of the splints, he began to work with the resident to wear them. During an interview, on 2/11/25 at 12:12 p.m., the Director of Nursing (DON) indicated Resident B's hands had impaired mobility, but she was not sure if they were contracted. She did not think the hand splints arrived to the facility until later, after admission. Upon review of the admission assessment, she indicated the hand splints were noted on the resident's admission. If a resident was admitted to the facility with hand splints the staff should have notified the therapy department so therapy could work with the resident on how and when the splints should have been applied. During an interview, on 2/11/25 at 2:06 p.m., the MDS Coordinator indicated a care plan should have been initiated, on 12/19/24, when the hand splints were ordered. If the hand splints arrived with the resident on admission, then the physician should have been consulted at admission to determine the orders for the hand splints. Had the hand splints been ordered at admission, they would have been added to the resident's care plan then. 2. During an observation on 2/10/25 at 2:00 p.m., Resident E was observed sitting up in her wheelchair with a tray table attached to the right side of the chair. The resident's right arm was resting on the tray table. Resident E's record was reviewed on 2/12/25 at 9:42 a.m. An admission Minimum Data Set (MDS) assessment, dated 12/9/24, indicated the resident had a severe cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, hemiplegia (paralysis or weakness on one side of the body) unspecified, affecting the right dominant side. An admission observation, dated 12/3/24, indicated the resident had impairment on one side of the upper extremities. A Physician's Progress Note, dated 12/4/24, indicated the resident's assessment showed right sided hemiparesis (weakness or paralysis on one side of the body). A care plan, initiated on 12/4/24, indicated the resident was at risk for self-care deficit related to right sided hemiplegia. The care plan lacked documentation of the the right-sided tray table. Current Physician's Orders lacked documentation of an order for the right-sided tray table. An Occupational Therapy (OT) Discharge Summary, dated 1/30/25, lacked documentation the resident was assessed or treated by OT for the use of the right-sided tray table. During an interview, on 2/12/25 at 10:44 a.m., Certified Nurse Aide (CNA) 4 indicated the resident was not able to use her right arm or hand. The resident used her left arm to assist with putting on clothing and performing activities of daily living (ADLs) The right-sided tray table was able to be removed from the wheelchair but was supposed to be on the wheelchair when the resident was up. The resident used the table to rest her arm. CNA 4 was not aware how interventions and care requirements were communicated to the staff. Usually, the other staff told her things during their report between shifts or she could ask the nurse. During an interview, on 2/12/25 at 10:51 a.m., the Director of Nursing (DON) indicated she was not aware the resident had a tray table for her wheelchair. She did not know when it was placed on the wheelchair. During an interview, on 2/12/25 at 11:05 a.m., the DON indicated therapy put the right-sided tray table on the resident's wheelchair as a comfort measure when she was admitted to the facility. The resident was able to communicate with the staff regarding if she wanted the tray table on or not. Normally, the tray-table would have been added to the resident's profile, but she was unable to find documentation of this for Resident E. She was not sure if there should have been a Physician's Order. The therapy department told her they communicated the tray table intervention to the CNA on duty, but she was not sure if it was communicated to the rest of the nursing staff. During an interview, on 2/12/25 at 11:41 a.m., Registered Nurse (RN) 7 indicated Resident E used the right-sided tray table all the time. Resident E was able to remove the tray table from the wheelchair but needed assistance to put it back on. There was not an assignment sheet which included interventions such as tray tables, and the information was passed along through verbal report. During an interview, on 2/12/25 at 11:48 a.m., the DON indicated she was unable to find communication between therapy and nursing regarding the resident's right-sided tray table. There were no therapy notes pertaining to the tray table. The tray table should have been evaluated by therapy, and communicated through a communication form from therapy to nursing. Then a Physician's Order should have been obtained and the intervention added to the care plan. 3. During an observation, on 2/10/25 at 1:55 p.m., Resident F was observed up in her wheelchair with a half tray table attached to the left side of her wheelchair. The resident's left hand was contracted (permanent or prolonged shortening of muscles, tendons, ligaments, or skin that restricts range of motion and can lead to deformities). During an observation, on 2/12/25 at 11:34 a.m., Resident F was observed up in her wheelchair with the left-sided tray table in place. Resident F's record was reviewed on 2/12/25 at 11:22 a.m. An annual Minimum Data Set (MDS) assessment, dated 11/17/24, indicated the resident had moderate cognitive impairment and functional limitation in range of motion (ROM) on one side of the upper and lower extremities. Diagnoses on the resident's profile included, but were not limited to, hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. The resident's Physician's Orders lacked documentation of an order for the left-sided tray table. A care plan, last revised 12/12/24, indicated cerebrovascular (blood vessels in brain) with left hemiplegia, dysphagia (difficulty swallowing, and aphasia (language disorder affecting the ability to communicate) and was at risk for cerebrovascular complications related to cerebrovascular accident (CVA) (stroke). The care plan lacked documentation of the left-sided tray table. During an interview, on 2/12/25 at 11:37 a.m., Certified Nurse Aide (CNA) 4 indicated Resident F was able to remove the tray table from her wheelchair but needed assistance to put it back on. CNA 4 was not sure when the tray table was placed on the resident's wheelchair, but the resident had it in place since she started working at the facility. She was not sure how the nursing staff would have communicated the resident's needs to her if it was a resident she was not familiar with. The interventions, such as tray tables, were usually just communicated during a verbal report. During an interview, on 2/12/25 at 11:41 a.m., Registered Nurse (RN) 7 indicated Resident F had the left-sided tray table in place for a long time, but she was not sure exactly how long. Resident F was able to remove the tray table from the wheelchair but needed assistance to put it back on. There was not an assignment sheet which included interventions such as tray tables, and the information was passed along through verbal report. During an interview, on 2/12/25 at 12:02 p.m., the Director of Nursing (DON) indicated she was unable to find supporting documentation for Resident F's tray table, such as therapy notes, a Physician's order, or care plan. On 2/11/25 at 2:00 p.m., the DON provided a document titled, Use of Assistive Devices, dated 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: 1. Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities. They may help the individual move around, see, communicate, eat, or get dressed. Assistive devices include .e. Mobility aids .f. Orthotic or prosthetic equipment .2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care .5. Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device. 6. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed This citation relates to complaint IN00451478. 3.1-42(a)(2)

Based on record reviews and interviews, the facility failed to ensure a pharmacy recommendation was addressed for 1 of 5 residents reviewed for unnecessary medications (Resident 32). Findings include: On 10/21/24 at 9:27 a.m., pharmacy recommendations were reviewed for Resident 32. A recommendation, printed 10/23/23, indicated that the resident was receiving Zoloft (medication used to treat depression, anxiety, and other disorders) 50 milligrams (mg) daily, and asked the physician to determine if a gradual dose reduction may be attempted. The physician signed and dated the form on 10/25/23 indicating to decrease the Zoloft to 25 mg daily. A recommendation, printed 12/17/23, notified the physician to investigate the recommendation made on 10/23/23 for the gradual dose reduction because their record indicated that the Zoloft would be decreased to 25 mg, however a dose reduction had not been ordered. A record review was conducted on 10/21/24 at 10:12 a.m. Resident 32's diagnoses included, but were not limited to, major depressive disorder (depressed mood or loss of interest in activities for a prolonged period), and dementia with behavioral disturbance (a group of neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life). A nursing progress note entered by the Director of Nursing (DON), recorded as a late entry on 10/26/24 at 8:51 a.m., for 10/25/23, indicated there was a pharmacy recommendation to decrease Zoloft to 25 mg daily. The physician and psychologist agreed. Resident 32 was notified, and they would continue to monitor. A physician's order, dated 4/19/23, indicated to administer Zoloft 50 mg, one tab by mouth daily. The record lacked documentation of the order being changed until 12/20/24. During an interview on 10/21/24 at 11:40 a.m., the Assistant Director of Nursing (ADON) indicated that she was not sure if the pharmacy recommendation in question had been worked on the day that they had split them up because there were so many. The DON had to leave and take oxygen to another facility that day, and it may have gotten missed in the mix of things. During an interview on 10/21/24 at 3:07 p.m., the DON indicated that after the behavior meeting related to the pharmacy recommendation, she left everything on her desk and left to deliver oxygen to another facility. On her way she was in a car accident and did not return for 6 months. While she was gone, the current ADON and corporate nursing support were responsible for resuming unfinished work. During an interview on 10/21/24 at 3:07 p.m., the ADON indicated that when she picked up the stack of pharmacy recommendations off the DON's desk after the accident, she did not know where she had left off. She went on to the next recommendation without realizing it had not been completed, and did not notice it was not done until the next meeting in December. Everything she thought was done she moved it to the side. She indicated she thought it was done, but did not verify it had been completed in the resident's electronic medical record. On 10/22/24 at 11:23 a.m., the Administrator (ADM) provided an undated document, titled, Medication Orders, and indicated it was the policy currently being used by the facility. The policy indicated, .Documentation of Medication orders. a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR) .g. when a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date, or discontinue the order as per the electronic software instructions and retype the new order .h. Enter the new order on the MAR or ensure the new order is in the electronic MAR .i. notify resident's sponsor/family of new medication order .5. a. Handwritten order signed by the physician - The charge nurse on duty at the time the order is received should note the order and enter it on the physician's order sheet or electronic order format, if not written by the physician. If necessary, the order should be clarified before the physician leaves the nursing station 3.1-48(a)

Based on observation, record review, and interview, the facility failed to ensure proper handling of oral medications during the medication administration pass and failed to ensure medication was administered according to manufacture guidelines resulting in a medication error rate of greater than 5 percent for 2 of 4 residents reviewed for medication administration (Residents 10 and 217). Findings Include: On 10/22/24 at 7:10 a.m., during routine medication administration observation, Registered Nurse 18 placed medications for Resident 10 into her bare hand then placed the medications in a medication cup, and then administered medications to the resdient. The RN prepared Novolog insulin with an insulin pen (a pre-filled pen device filled with insulin. Doses are provided in one-unit increments for insulin medicines) The nurse failed to first prime the pen according to manufacture guidelines prior to administration of the insulin to Resident 10. Observed the nurse administer Arnuity Ellipta 200 mcg (micrograms) 1 inhalation, (an inhaled corticosteroid (ICS) medicine. ICS medicines help prevent symptoms of asthma by reducing airway inflammation) to Resident 10. The nurse failed to instruct the resident to swish and spit with water after administration of the medication as instructed on the medication prescription label directions. On 10/22/24 at 7:47 a.m., during medication administration, Registered Nurse 18 placed medications for Resident 217 into her bare hand then placed the medications in a medication cup, and administered medication to the resident. The RN prepared Levemir insulin and Fiasp insulin with an insulin pen to be administered to Resident 217. The nurse failed to first prime the pen according to manufacture guidelines prior to administration of insulin to the resident. On 10/22/24 at 7:50 a.m., during an interview, RN 18 indicated the medications should be placed into the medication cup and not into her bare hands. She acknowledged the insulin pens should be primed prior to preparing insulin for administration. Manufacture guidelines to prime the Fiasp insulin pen prior to administration include. Turn the dose selector to select 2 units hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top press and hold in the dose button until the dose counter shows 0. Check to make sure the dose selector is set at 0. Turn the dose selector to select the number of units you need to inject. Manufacture guidelines to prime the Levemir insulin pen prior to administration include. Before each injection, prime your pen by performing an air shot. Turn the dose selector to select 2 units. Press and hold the green push button. Make sure a drop of insulin appears at the needle tip turn the dose selector to the number of units you need to inject. On 10/21/2024 at 11:00 a.m., the Director of Nursing (DON) provided a document titled, Medication Administration, dated 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .14. Remove medication from source, taking care not to touch medication with bare hand On 10/21/2024 at 11:00 a.m., the Director of Nursing (DON) provided a document titled, Insulin Pen, dated 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .11. Procedure .g. Attach pen needle .i. Remove the pen cap from the insulin pen .iii. Screw the pen needle onto the insulin pen. h. Prime the insulin pen. i. dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger and watch to see that at least one drop appears On 10/22/2024 at 10:00 a.m., the Director of Nursing (DON) provided a document titled, Inhaler Administration, dated 8/14/2019, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .11. These are general instructions, so be certain to follow specific directions that accompany the inhaler 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure contracted staff completed a resident assessment and vital signs in privacy for 1 of 1 resident reviewed for privacy (Resident 26). Findings include: During the meal service on the memory care unit, on 10/16/24 at 12:04 p.m., Resident 26 was sitting in her Broda chair (a wheelchair or seating device designed to provide comfort and support for long-term patients) at a table waiting for lunch to be served. A contracted hospice nurse entered the dining area where Resident 26 was sitting. Hospice Nurse 23 obtained vital signs on Resident 26. The nurse obtained a temporal (forehead) temperature, blood pressure (using a wrist cuff), pulse oximeter reading, heart rate, and a circumference of her right arm (using a tape measure). The hospice nurse leaned in next to the resident's ear to ask her some questions about how she was feeling. There were several residents sitting at the table during this time along with the licensed practical nurse and certified nurses' aide. During an interview, on 10/16/24 at 12:09 p.m., Licensed Practical Nurse (LPN) 7 indicated the hospice nurse should not be completing an assessment or vital signs on a resident during meal service. Resident 26's record was reviewed on 10/17/24 at 2:53 p.m. The profile indicated the resident diagnoses included, but were not limited to, unspecified dementia (a person's mild cognitive impairment has yest to be diagnosed as a specific type of dementia) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A quarterly Minimum Data Set (MDS) assessment, dated 9/29/24, indicated the resident was severely impaired cognitively and was on hospice services. During an interview, on 10/17/24 at 8:37 a.m., the Director of Nursing (DON) indicated the hospice nurse should not have completed an assessment or vital signs during meal service on a resident. During an interview, on 10/18/24 at 8:55 a.m., the Administrator indicated that he had spoken with the hospice nurse and she was aware that she should not have completed an assessment and vital signs on the resident during meal service. She was in a hurry and wasn't thinking. On 10/17/24 at 8:51 a.m., the DON provided an undated document titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .V .The resident has the right to personal privacy and confidentiality .A. Personal privacy includes accommodations, medical treatment .I Dignity: A facility must care for its residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition in his or her individuality . 3.1-3(t)

Based on observations, interviews, and record review, the facility failed to ensure a call light device was within reach for 1 of 16 residents observed for call lights (Resident 7). Findings include: On 10/17/24 at 10:08 a.m., observed Resident 7 in his room, sitting in a Broda chair (a wheelchair or seating device designed to provide comfort and support for long-term patients) facing the window. He was leaning to the right side of the chair, the left side of his face was directly in the sunlight, the room temperature was hot, and his cheeks were reddened. Two button-press call lights were observed to be on the beds, not within reach of the resident. On 10/17/24 at 10:13 a.m., requested assistance from Certified Nursing Assistant (CNA) 5, upon entering Resident 7's room, she indicated the room was hot and that it looked like the resident was leaning to get out of the sunlight. She indicated the resident did not have his call light, but he did not use it. Before leaving the room, she provided him with a button-press call light. On 10/21/24 at 1:34 p.m., observed Resident 7 resting in bed with eyes closed. Two button-press call lights were observed to be in a recliner at the foot of the bed, not within reach of the resident. During an interview on 10/21/24 at 1:57 p.m., the Director of Nursing (DON) indicated that if a resident had mobility problems, moved around a lot in bed, or could not remember to use a button-press call light, they could have soft touch call devices (sensitive to touch). She indicated that everyone was to have a call device. On 10/22/24 at 10:53 a.m., Resident 7's record was reviewed. His diagnoses included, but were not limited to, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out everyday tasks), cognitive communication deficit (range of difficulties that can affect a person's ability to think, communicate, and function in social situations), and dementia (neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life). A quarterly Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident 7's cognitive skills for daily decision making was moderately impaired. A care plan, edited 10/22/24, with a problem start date of 11/12/18, indicated Resident 7 was at risk for falls related to poor safety awareness, required assistance with activities of daily living, was incontinent of bowel and bladder, had a diagnosis of Alzheimer's disease, and had a history of falls. On 10/22/24 at 11:43 a.m., observed a hospice nurse in Resident 7's room, two soft touch call devices had been installed. During an interview on 10/22/24 at 12:03 p.m., the Administrator (ADM) indicated that he installed the soft touch call device and was not aware that Resident 7 did not have one before yesterday, but if a resident was not able to use a button-press call device, they should have a soft touch. If they are not able to press it or remember to press it, when they move it would activate the call light system. On 10/22/24 at 2:39 p.m., the DON provided an undated document, titled, Call Lights: Accessibility and Timely Response, and indicated it was the policy currently being used by the facility. The policy indicated, .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system, including cognitive and physical ability to use the call light. Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.). Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .The call system should be accessible to a resident lying on the floor .Process for responding to call lights .If assistance is needed with a procedure, summon help by using the call light 3.1-3(v)(1)

Based on record review, observation, and interview, the facility failed to follow CDC guidance during a pandemic and ensure infection control practices for COVID-19 were implemented to prevent the potential for spread of [MEDICAL CONDITION] after 6 dementia care unit employees tested positive for COVID-19 and residents began exhibiting symptoms of COVID-19, for 13 of 13 residents who resided on the dementia care unit. Contact droplet precautions were not implemented for 3 of 4 residents reviewed for infection control who had symptoms of COVID-19. Resident E on dementia care unit and Residents B and C who resided on a green unit (a unit that houses residents with low risk of infection/who have not been exposed) with 25 other residents. Four additional residents began to exhibit symptoms of COVID-19 on [DATE] (Residents H, J, K, and L). The Immediate Jeopardy began on [DATE], when Resident E had an elevated temperature and was not placed in isolation (special precautions to prevent the spread of germs). Resident E resided on the memory care unit, where there were six confirmed positive staff, with 12 residents. Residents B and C were observed residing on a green unit with no isolation precautions and symptoms of COVID-19. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 6:05 p.m., on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of a Long Term Care Respiratory Surveillance Line List, provided by the Director of Nursing (DON) on [DATE], and a document with employees' positive result dates and days last worked, provided by the Executive Director (ED) on [DATE], indicated there were six staff members who worked on the memory care unit who tested positive for COVID-19: a. Employee 8 had Covid-19 symptoms on [DATE], was tested on an unknown date with positive results on [DATE]; and worked on [DATE], [DATE], and [DATE]. b. Employee 9 had Covid-19 symptoms on [DATE], was tested on [DATE] with positive results on [DATE]; and worked on [DATE], [DATE], and [DATE]. c. Employee 10 had Covid-19 symptoms on [DATE], was tested on [DATE] with positive results on [DATE]; and worked on [DATE], [DATE], and [DATE]. d. Employee 11 had Covid-19 symptoms on [DATE], was tested on [DATE], with positive results on [DATE]; and worked on [DATE], [DATE], and [DATE]. e. Employee 12 had Covid-19 symptoms on [DATE], was tested on [DATE] with positive results on [DATE]; and worked on [DATE], [DATE], and [DATE]. f. Employee 13 had Covid-19 symptoms on [DATE], was tested on [DATE] with positive results on [DATE]; and worked on [DATE], [DATE], and [DATE]. The CDC guidance, updated [DATE], - Responding to Coronavirus (COVID-19) in Nursing Homes, Responding to COVID-19: Considerations for the Public Health Response to COVID-19 in Nursing Homes indicated, .HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset .Prioritize these HCP for [DIAGNOSES REDACTED]-CoV-2 testing. Exclude HCP with COVID-19 from work until they have met all return to work criteria. Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset .Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED].Exposed HCP should be assessed for risk and need for work exclusion .If testing is available, asymptomatic residents and HCP who were exposed to HCP with COVID-19 should be considered for testing (see information on testing below). If testing identifies infections among additional HCP, further evaluation for infections among residents and HCP exposed to those individuals should be performed as described above. During an interview on [DATE] at 2:35 p.m. the DON indicated there were currently 12 residents on the dementia care unit. 1. Resident E's record was reviewed on [DATE] at 12:15 p.m. [DIAGNOSES REDACTED]. A vital signs record, dated [DATE], indicated the resident's temperature was 99.0 degrees Fahrenheit (F). A vital sign record, dated [DATE], indicated the resident's temperature was 99.5 degrees F. A nurse's note, dated [DATE], indicated Resident E had been in bed and was lethargic. The resident's oxygen saturation (level of oxygen in the blood) was 92 percent and his temperature was 99.8 degrees F. The resident was put on oxygen at two liters (L) to improve the saturation. A nurse's note, dated [DATE], indicated the resident was on continuous oxygen at four liters related to a physician's orders [REDACTED]. Standard universal precautions were in place. A vital signs record, dated [DATE], indicated the resident's temperature was 98.9 degrees F. A physician's orders [REDACTED]. The physician's orders [REDACTED]. A nurse's note, dated [DATE], indicated the resident's oxygen saturation was in the 70 and 80 percentile range. Respirations were labored. A vital signs record, dated [DATE], indicated the resident's temperature was 99.0 degrees F. A nurse's note, dated [DATE] at 11:48 a.m., indicated the resident was not responsive, received oxygen at four liters through a Venturi mask (a mask to deliver oxygen), and the oxygen saturation was 80 percent. The physician and power of attorney (POA) were notified, and Hospice (specialized care for terminal patients) was consulted. A nurse's note, dated [DATE] at 11:20 p.m., indicated the resident's vital signs ceased. A Treatment Administration Record (TAR), dated [DATE], indicated the resident may have a COVID-19 test every three to seven days. The record indicated the resident was tested on [DATE]. Census information indicated the resident resided on the memory care unit and expired on [DATE]. A Bed Board, dated [DATE], indicated the resident had a roommate, Resident H. Nurse's notes, dated [DATE] to [DATE], lacked documentation the resident was placed in droplet isolation precautions related to symptoms of COVID-19. During an interview, on [DATE] at 9:43 a.m., the Administrator indicated the entire memory care unit was considered a red (a unit where all residents are infected with COVID-19 and require droplet isolation precautions) unit. During an interview, on [DATE] at 12:04 p.m., the Assistant Director of Nursing (ADON) indicated she was the Infection Preventionist (IP) for the facility. When the staff entered the room of any resident positive for COVID-19 they were required to wear personal protective equipment (PPE) including goggles, gowns, N95 masks, gloves, and shoe covers. Staff only used this PPE for the one positive resident on the memory care unit. For all other residents on the memory care unit, staff should have worn an N95 mask and gloves, but not a gown, goggles, or shoe covers. During an interview, on [DATE] at 2:50 p.m., the Director of Nursing (DON) indicated she thought the resident's symptoms and death were related to his heart condition. After review of the resident's symptoms and their facility policy for when to isolate, the resident should have been placed in droplet isolation precautions. The resident had not been isolated and had a roommate. During an interview, on [DATE] at 3:37 p.m., the DON indicated there were six employees of the facility who tested positive for COVID-19. All of them worked on the memory care unit. When the staff became positive for COVID-19 they changed their staff screening tool to include a symptom of loss of sense of taste or smell, made the memory care unit have its own entrance and exit, and initiated the use of N95 masks (a particulate filtering respirator) on the memory care unit. They had not changed anything regarding how the residents were screened or cared for with the new onset of staff positive cases. On [DATE], the facility tested all residents for COVID-19, but they had not received test results yet. On [DATE] at 2 p.m. the DON provided the updated LTC Respiratory Surveillance Line List and indicated Resident H, Resident E's roommate, was symptomatic with a cough as of [DATE]. During an interview, on [DATE], the Administrator indicated Resident E's test results were negative for COVID-19, but Resident H's test results were positive for COVID-19. 2. Resident B's record was reviewed on [DATE] at 10:54 a.m. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had a severe cognitive impairment, wandering (moving throughout the facility without purpose) occurred four to six days of the look back period, and required extensive staff assistance with bed mobility, transfers, dressing, and personal hygiene. A nurse's note, dated [DATE], indicated the resident was wandering that morning. A nurse's note, dated [DATE], indicated the resident was wandering that morning. An infection event, dated [DATE], indicated the physician ordered [MEDICATION NAME] (an antibiotic) for five days for a respiratory infection. Symptoms included runny nose or sneezing and stuffy nose or congestion. The event lacked documentation the resident was placed on droplet isolation precautions. A physician's orders [REDACTED]. physician's orders [REDACTED]. A nurse's note, dated [DATE], indicated the resident had green nasal drainage, cough, and diminished lung sounds. The physician was notified and ordered [MEDICATION NAME] for five days. The nurse's note lacked documentation the resident was placed in droplet isolation precautions. A care plan, initiated [DATE], indicated the resident received an antibiotic for URI. The care plan lacked documentation the resident required droplet isolation precautions. A Bed Board, dated [DATE], indicated the resident resided on a green unit, and had a roommate, Resident F. A Treatment Administration Record (TAR), dated [DATE], indicated the resident may have a COVID-19 test every three to seven days. The record indicated the resident was tested on [DATE]. A Physician's progress note, dated [DATE], indicated the resident had decreased lung sounds in the base of the lungs. The note lacked documentation the resident required droplet isolation precautions. A care plan, goal target dated [DATE], indicated the resident was at risk for COVID-19 exposure. Interventions included, but were not limited to, resident refused to wear a mask related to anxiety and would be encouraged to wear a mask, and observe for signs and symptoms of COVID-19 including fever, coughing, sneezing, sore throat, and respiratory issues. A care plan, goal target dated [DATE], indicated the resident wandered up and down hallway, and into other residents' rooms. During an interview, on [DATE] at 10:16 a.m., Registered Nurse (RN) 6 indicated Resident B had a runny nose, but was not considered suspicious for COVID-19. If a resident exhibited symptoms of COVID-19, they should have been placed in droplet isolation precautions. On [DATE] at 10:35 a.m., Resident B's room was observed with no isolation precautions in place. The resident had a roommate. On [DATE] at 11:32 a.m., Resident B was observed outside of his room on the green unit, with his mask pulled down underneath his nose. Qualified Medication Aide (QMA) 7 adjusted the residents mask, bare handed, then wiped her hand on her pants. During an interview, on [DATE] at 12:04 p.m., the Assistant Director of Nursing (ADON) indicated she was not aware Resident B had respiratory symptoms. The resident was not isolated because he had not had a fever. The resident wandered and was non-compliant with wearing a mask. During an interview, on [DATE], at 12:29 p.m., the Administrator indicated if a resident had a new onset of URI, they should have been placed in droplet isolation precautions. However, she thought if a resident did not have a fever, it was fine for them to be out of their room. During an interview, on [DATE] at 2:50 p.m., the Director of Nursing (DON) indicated she reviewed Resident B's chart and the policy for isolation, and he should have been isolated. The physician had diagnosed a URI, however, according to the facility policy, he should have been placed in droplet isolation precautions. The resident had a roommate. 3. Resident C's record was reviewed on [DATE] at 11:50 a.m. [DIAGNOSES REDACTED]. A five day admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact and required extensive assistance from staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A Treatment Administration Record (TAR), dated [DATE], indicated the resident may have a COVID-19 test every three to seven days. The record indicated the resident was tested on [DATE]. A Bed Board, dated [DATE], indicated the resident resided on a green unit, and had a roommate, Resident G. A Physician's progress note, dated [DATE], indicated the staff reported the resident was congested. The physical exam indicated the resident's chest and lungs were tight (diminished air flow) with fine crackles (fine, short, high-pitched crackling sounds can be caused from air passing through fluid, pus, or mucus) in the left lung fields. The assessment indicated the resident had a cough. The physician's plan included, but was not limited to, chest x-ray and COVID-19 testing this week, to be done for all residents. The note lacked documentation the resident required droplet isolation precautions. A physician's orders [REDACTED]. physician's orders [REDACTED]. A care plan, goal target dated, [DATE], indicated the resident was at risk for COVID-19 infection related to pandemic. Interventions included, but were not limited to, initiate isolation precautions immediately for presumptive symptoms. During an interview, on [DATE] at 10:16 a.m., Registered Nurse (RN) 6 indicated Resident C had new onset chest congestion, but was not suspicious for COVID-19. If a resident exhibited symptoms of COVID-19, they should have been placed in droplet isolation precautions. On [DATE] at 10:35 a.m., Resident C's room was observed with no isolation precautions in place. The resident had a roommate, Resident G. During an interview, on [DATE] at 12:04 p.m., the Assistant Director of Nursing (ADON) indicated she was the Infection Preventionist (IP). She was not aware Resident C had respiratory symptoms. She was not sure why the resident did not require droplet isolation precautions. She had not reviewed the resident's charting to determine if the resident required isolation. During an interview, on [DATE] at 12:29 p.m., the Director of Nursing (DON) indicated she thought residents with low oxygen saturation (level of oxygen in the blood), fever above 100.4 degrees Fahrenheit (F), or shortness of breath should have been placed in droplet isolation precautions. During an interview, on [DATE] at 1:02 p.m., the DON indicated they would follow CDC guidelines for what residents required droplet isolation precautions. After review of Resident C's charting and the facility policy, Resident C should have been placed in droplet isolation precautions. She was not notified the resident had symptoms of COVID-19. Symptoms should have been reported by facility staff to the DON and physician immediately. During an interview, on [DATE] at 1:10 p.m., RN 6 indicated she noticed Resident C had new onset chest congestion that morning when her shift started at 6:00 a.m., and she notified the physician between 6:30 a.m. and 6:45 a.m. The physician examined the resident later when he came into the facility. She had not notified the DON. On [DATE] at 2:00 p.m., the DON provided the updated LTC Respiratory Surveillance Line List. The list indicated 6 residents were identified as symptomatic during the audit on [DATE] (Residents B, C, J, K on 200 hall and Residents H and L on dementia care unit). Resident H, roommate to Resident E, was symptomatic with a cough as of [DATE]. During an interview, on [DATE], the Administrator indicated Resident C's test results were positive for COVID-19. 4. On [DATE] at 1:30 p.m., in the Yellow zone droplet isolation area, the doors to the rooms of Resident J, Resident K and Resident B were observed open with the residents in the rooms. On [DATE] at 5:50 p.m., in the Yellow zone droplet isolation area, the doors to the rooms of Resident J, Resident C, Resident K, and Resident B were observed open with the residents in the rooms. On [DATE] at 10:45 a.m., in the Yellow zone droplet isolation area, the doors to the rooms of Resident J, Resident M, Resident C, and Resident B were observed open with residents in the rooms. The DON indicated, she was not aware the isolation room doors should be closed to the isolation rooms. On [DATE] at 11:15 a.m., the Administrator indicated, they had updated the facility's policy to include that droplet isolation room doors were to remain closed at all times. On [DATE] at 1:02 p.m., the DON provided a document titled, Active Screening of Residents, and indicated it was the policy currently being used by the facility. The policy was attached to an email, dated [DATE], and lacked documentation it was updated since that date. The screening tool indicated, Evaluate residents for the following every 12 hours: Common Signs and Symptoms: Fever greater than or equal to 99.0 degrees F, Cough, Shortness of breath-increased oxygen requirements or increased frequency of nebulizer treatments may be surrogate symptoms of shortness of breath. Less common Signs and Symptoms: Confusion or change in mental status and if noted, check pulse oximetry to determine if increased oxygen requirements, Muscle aches, headache, Sore throat, runny nose, Chest pain, Diarrhea, nausea, vomiting. Probable case: any two of the common signs/symptoms-Initiate contact and droplet precautions. Check a room air pulse-oximetry. Increase frequency of vital signs, including pulse oximetry to every 8 hours. Screen for influenza. If negative, screen for COVID-19 (in areas of community outbreak may consider concomitant testing based on clinicians assessment). Possible case: any one of the common signs/symptoms and greater than or equal to 1 of the less common signs/symptoms-Initiated contact and droplet precautions. Check a room air pulse-oximetry. The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, indicated, Evaluate and Manage Residents with Symptoms of COVID-19 .Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 .Actively monitor all residents upon admission and at least daily for fever (T 100.0oF) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below .Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0oF might also be a sign of fever in this population . Identification of these symptoms should prompt isolation and further evaluation for COVID-19 During staff interviews on [DATE], Employee 7, Employee 16, and Employee 17 indicated they had received in-services on isolation precautions, and to watch for signs or symptoms of COVID including abnormal temperatures of more than 100.3 degrees Fahrenheit. The ISDH Guidance for out-of-hospital facilities, dated [DATE], indicated, The following is guidance for out of hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles: 1. Placement of patient /resident in contact-droplet precautions with proper PPE, including gown, glove, mask with face shield or eye protection. 2. Proper donning and doffing of personal protection equipment when in contact with COVID-19 residents Reduce the movement of staff between patients with and without COVID-19 precautions with proper PPE- gown, glove, mask with face shield or eye protection .Patients/residents with known or suspected COVID-19 should be cared for in a single-person (private) room with the door closed .Patients/residents with known or suspected COVID-19 should not share bathrooms with other patients/residents . Patients with close contact with a confirmed COVID-19 patient (e.g., roommate or infected staff without wearing PPE) should be isolated and follow 14 day self-monitoring guidelines. If they develop symptoms, and are confirmed or suspected to have COVID-19, they should remain isolation until at least 7 days after symptom onset and 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms (e.g., cough), whichever is longer The CDC guidance, updated [DATE], - Responding to Coronavirus (COVID-19) in Nursing Homes, Responding to COVID-19: Considerations for the Public Health Response to COVID-19 in Nursing Homes, indicated, .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections .Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms .Counsel all residents to restrict themselves to their room to the extent possible .HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents .If testing is available, asymptomatic residents and HCP who were exposed to the resident with COVID-19 (e.g., on the same unit) should be considered for testing The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, indicated, If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario. Public health authorities can assist with decisions about resident placement .If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected [DIAGNOSES REDACTED].g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident During a telephone interview, on [DATE], the Administrator indicated the results of the resident testing had come back and an additional 5 residents had positive results for COVID-19, four residents resided on the dementia unit and one resident was on the yellow isolation unit after being identified as symptomatic during the survey. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility reviewed all residents and residents with symptoms/known exposure were tested and placed in isolation with appropriate door signage and orders for isolation. Staff were reeducated on the isolation policies and procedures, and a plan was created to monitor for isolation procedures for residents with symptoms/pending tests or known exposures. The noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. 3XXX,[DATE](a)

Based on record review and interview, the facility failed to ensure fortified food interventions were implemented as recommended for a resident who experienced severe weight loss of 18 % within a 6 month period for 1 of 1 resident reviewed for nutrition (Resident 39). Findings include: Resident 39's record was reviewed on 11/1/19 at 9:40 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 9/30/19, indicated the resident had severe cognitive impairment, required extensive assistance of one person for eating, and had a significant weight loss, but was not on a physician prescribed weight loss regimen. A nutritional status care plan, initiated on 6/18/18 and last revised on 10/25/19, indicated the resident was at risk for potential alteration of nutrition and/or weight status with significant weight loss. Interventions included, but were not limited to, provide diet as ordered, assist resident as needed for eating/drinking, provide supplements and medications as ordered, honor preferences and offer alternate items if consumption was poor, obtain and evaluate weights as ordered/per policy, and notify physician, dietitian, and family of any significant changes. A review of the resident's electronic medical record for weights and body mass index (BMI) indicated: 4/16/19: weight was 127.2 pounds (lbs.) and BMI was 22.53 (normal). 7/22/19: weight was 118.4 lbs., BMI was 20.97 (normal), and had 6.92% weight loss 9/1/19: weight was 107.2 lbs., BMI was 18.99 (normal), and had a 15.72% weight loss 9/25/19: weight was 108 lbs., BMI was 19.09 (normal) 10/1/19: weight was 106.2 lbs., BMI was 18.81 (normal) 10/8/19: weight was 107.6 lbs., BMI was 19.06 (normal) 10/15/19: weight was 104.2 lbs., BMI was 18.46 (underweight) 10/25/19: weight was 104.2 lbs., BMI was 18.46 (underweight), and had a 18.08% weight loss A Dietary Manager's (DM) progress note, dated 7/25/19 at 10:35 a.m., indicated the DM had returned a phone call and left a voice mail message to Resident 39's family. Reason for call was returning family's call regarding concerns of increased weight loss with the resident. Dietician and writer discussed the next step would be to add fortified milk, fortified cereal, and fortified mashed potatoes to resident's meal plan. The writer was to follow up with family to ensure they were made aware of dietary changes to assist with resident's weight loss. A DM's progress note, dated 7/26/19 at 12:42 p.m., indicated the DM had spoken with family, and informed them of the dietician and writer's decision to start resident on fortified foods to address weight loss. Family was pleased with this decision. Writer to check in with family in a couple weeks to report progress with intakes and weight of resident. A Registered Dietitian (RD) progress note, dated 10/17/19, indicated mighty shake had been added to meal times, but resident continued with inconsistent intake of food on puree diet. Weight continued to be monitored weekly. No additional recommendations at this time. A RD nutrition observation note, dated 10/25/19 at 12:55 p.m., indicated the resident had experienced significant weight loss in 90 days and 180 days, with a BMI of 18.46%, the underweight range A RD progress note, dated 11/1/19, indicated the resident was receiving a puree diet with a divided plate, fortified milk, magic cup, and mighty shake at all meals. [MEDICATION NAME] (appetite stimulant) 15 milligrams (mg) was added by the physician on (MONTH) 30. The DM to follow up with resident's family regarding clarification of current interventions. An October, 2019 physician order [REDACTED]. The record lacked documentation any additional nutritional supplements or fortified foods were ordered for the resident. During an interview, on 11/1/19 at 10:57 a.m., the RD indicated the resident's weight had been stable since (MONTH) 1, 2019. In June, the resident was evaluated by therapy and placed on a puree diet and given magic cups ice cream with meals. The resident had the weight loss due to poor intake and dementia. For the most recent weight loss, mighty shakes with meals was included. The doctor added the medication, [MEDICATION NAME], an appetite stimulant, on 10/30/19. The resident received fortified milk with each meal, but the resident did not receive any additional fortified foods. The fortified foods order should have been documented and ordered, on 7/26/19, when the DM had talked to the family. The fortified foods order just got missed. The RD indicated, she was unsure of the facility's policy and procedure for significant weight loss, since she was a contracted employee. The Director of Nursing (DON) should have a facility policy and procedure for weight loss. During a telephone interview, on 11/1/19 at 1:56 p.m., Resident 39's family indicated they had not spoken to staff at the facility about Resident 39's weight loss, since the care plan meeting on 10/21/19. The family was concerned about her weight loss and the pureed diet. She was wasting away. At the care plan meeting, the family had requested Resident 39 be reevaluated by therapy to be put back on her finger foods diet. On 11/1/19 at 2:30 p.m., the DON provided and identified as a current facility policy and procedure, dated 1/15/12, titled, Interventions For Unintended Weight Loss, which indicated, .The facility has a weight tracking program to identify any individuals with unintended weight loss to assess problems and appropriately intervene On 11/4/19 at 3:34 p.m., the DON provided a facility document, titled Performance Improvement Plan, dated 9/24/19, which indicated .Identified Issue(s): Weights obtained timely and follow-up completed with weight change .Resident who had a triggered for a significant weight change had an Event completed with the Physician and Responsible notification completed. Each of the identified residents were reviewed by the Registered Dietician for appropriate interventions. Care plans were reviewed and updated as appropriate .The Registered Dietician will review residents with significant weight changes. The Registered Dietician will complete the Observation in the Medical Record and make recommendation as appropriate and will provide the Director of Nursing a list of said recommendations 3.1-46(a)(1)