Every finding on record at Majestic Care of Bloomington

Based on observation, interview, and record review, the facility failed to ensure food was labeled with an open date for 1 of 2 kitchen observations. This had the potential to affect 99 out of 99 residents.Findings include:During an initial kitchen tour with the Dietary Manager (DM) on 9/2/25 at 10:05 a.m., an opened container of ranch dressing, an open container of salsa, an opened container of mustard, and an opened container of vanilla icing were observed without an opened date. The DM was observed to remove the items from the refrigerator, toss them, and he indicated the foods needed to have an open date. On 9/18/25 at 12:15 p.m., the Administrator provided the facility policy, LABELING & DATING GUIDELINES, revised on 12/12/23, and indicated it was the policy currently being used. A review of the policy indicated, All opened and leftover items will be labeled with the date of opening/date stored and discard/use-by date .3.1-21(i)(2)3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide restorative nursing (nursing care designed to maintain functional ability of residents) of passive range of motion for 4 of 4 residents review for mobility. (Resident 3, Resident 25, Resident 70, and Resident 71) Findings include: 1.During an interview on 9/3/25 at 11:20 a.m., Resident 3 indicated she had a stroke and had limited range of motion (decreased ability to move a joint) of her left arm and hand. She did not get exercises anymore. At that time. Resident 3 was observed to have limited range of motion of her left arm and hand.On 9/8/25 at 10:20 a.m., CNA 1 was observed to provide morning care to Resident 3. At that time, no passive range of motion was provided. On 9/8/25 at 10:55 a.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side) and dementia.The annual Minimum Data Set (MDS) assessment, dated 6/16/25, indicated Resident 3 was cognitively intact, had limited range of motion on one side of the upper and lower extremities, and had no days of passive range of motion.A care plan, initiated on 8/27/25, indicated Resident 3 would benefit from passive range of motion due to hemiplegia. The intervention was to provide 10 repetitions of passive range to left hand daily.The Restorative Nursing flow sheet indicated the following:-On 8/29/25 at 6:56 p.m., Resident 3 did not receive any minutes or repetitions.-On 8/30/25 at 2:03 p.m., Resident 3 did not receive any minutes or repetitions.-On 8/31/25 at 10:29 a.m., Resident 3 did not receive any minutes or repetitions.-On 9/1/25., Resident 3 did not receive any minutes or repetitions. -On 9/2/25., Resident 3 did not receive any minutes or repetitions.-On 9/3/25 at 1:12 p.m., Resident 3 did not receive any minutes or repetitions.-On 9/4/25 at 1:49 p.m., Resident 3 received 11 minutes and 8 repetitions of passive range of motion.-On 9/5/25, Resident 3 did not receive any minutes or repetitions.-On 9/6/25, Resident 3 did not receive any minutes or repetitions.-On 9/7/25, Resident 3 did not receive any minutes or repetitions.During an interview on 9/8/25 at 10:35 a.m., CNA 1 indicated she was unsure if Resident 3 received passive range of motion. If she did, the restorative aid would provide Resident 3's passive range of motion. She was unsure who would provide the passive range of motion if the restorative aid was not working.2. On 9/3/25 at 11:13 a.m., Resident 25 indicated she had hemiplegia and was unsure if she received any exercises for it. On 9/8/25 at 9:53 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia and stroke.The annual MDS assessment, dated 7/13/25, indicated Resident 25 had moderate cognitive impairment, had limited range of motion on both sides of lower extremities, and had no days of passive range of motion.A care plan, initiated on 8/27/25, indicated Resident 25 would benefit from passive range of motion due to hemiplegia. The intervention was to provide 10 repetitions of passive range to left upper and lower extremities daily.The Restorative Nursing flow sheet indicated the following:-On 8/29/25 at 6:55 p.m., Resident 25 did not receive any minutes or repetitions.-On 8/30/25 at 2:02 p.m., Resident 25 did not receive any minutes or repetitions.-On 8/31/25 at 10:28 a.m., Resident 25 did not receive any minutes or repetitions.-On 9/1/25., Resident 25 did not receive any minutes or repetitions. -On 9/2/25., Resident 25 did not receive any minutes or repetitions.-On 9/3/25 at 1:11 p.m., Resident 25 did not receive any minutes or repetitions.-On 9/5/25, Resident 25 did not receive any minutes or repetitions.-On 9/6/25, Resident 25 did not receive any minutes or repetitions.-On 9/7/25, Resident 25 did not receive any minutes or repetitions.3. On 9/3/25 at 10:00 a.m., Resident 70 was observed to have right-sided hemiplegia. On 9/8/25 at 11:30 a.m., Resident 70 was observed to be sitting in her wheelchair, and her right hand was contracted. On 9/8/25 at 9:30 a.m., Resident 70's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia on right side and dementia.The quarterly MDS assessment, dated 6/13/25, indicated Resident 70 had severe cognitive impairment, had limited range of motion on both sides of lower extremities and had limitation on one side of the upper extremity, and had no days of passive range of motion.A care plan, initiated on 7/1/25, indicated Resident 70 would benefit from passive range of motion to right hand to prevent contracture due to hemiplegia. The intervention was to provide 10 repetitions of passive range to right hand daily.The Restorative Nursing flow sheet indicated the following:-On 8/29/25 at 6:53 p.m., Resident 70 did not receive any minutes or repetitions.-On 8/30/25 at 1:56 p.m., Resident 70 did not receive any minutes or repetitions.-On 8/31/25 at 10:24 a.m., Resident 70 did not receive any minutes or repetitions.-On 9/2/25 at 1:44 p.m., Resident 70 received 8 minutes and 4 repetitions of passive range of motion.-On 9/3/25 at 1:01 p.m., Resident 70 did not receive any minutes or repetitions.-On 9/4/25 at 1:48 p.m., Resident 70 received 11 minutes and 5 repetitions of passive range of motion.-On 9/5/25, Resident 70 did not receive any minutes or repetitions.-On 9/6/25, Resident 70 did not receive any minutes or repetitions.-On 9/7/25, Resident 70 did not receive any minutes or repetitions.4. On 9/2/25 at 2:11 p.m., Resident 71 was observed to be resting in bed. She was observed to have a right-hand contracture. On 9/5/25 at 9:22 a.m., Resident 71 was observed to be resting in bed. She was observed to have a right-hand contracture.On 9/8/25 at 9:20 a.m., Resident 71's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia on right side and dementia.The quarterly MDS assessment, dated 8/13/25, indicated Resident 71 had severe cognitive impairment, had limited range of motion on both sides of lower extremities and had limitation on one side of the upper extremity, and had no days of passive range of motion.A care plan, initiated on 8/26/25, indicated Resident 71 would benefit from passive range of motion due to hemiplegia. The intervention was to provide 10 repetitions of passive range to bilateral upper and lower extremities daily.The Restorative Nursing flow sheet indicated the following:-On 8/29/25 at 1:55 p.m., Resident 71 did not receive any minutes or repetitions.-On 8/30/25, Resident 71 did not receive any minutes or repetitions.-On 8/31/25, Resident 71 did not receive any minutes or repetitions.-On 9/2/25, Resident 71 did not receive any minutes or repetitions.-On 9/4/25, Resident 71 did not receive any minutes or repetitions.-On 9/5/25 at 3:53 p.m., Resident 71 did not receive any minutes or repetitions.-On 9/6/25, Resident 71 did not receive any minutes or repetitions.-On 9/7/25, Resident 71 did not receive any minutes or repetitions.During an interview on 9/8/25 at 11:07 a.m., CNA 2 indicated she did restorative nursing Monday through Friday. CNA 3 did restorative nursing Wednesday through Sunday. She was the only restorative aide Mondays and Tuesdays. If they have one restorative aide, they did not have the time to get every resident restorative program completed.During an interview on 9/8/25 at 11:57 a.m., the MDS nurse indicated they had 2 restorative aides. On the days they had one restorative aide, it was hard to get all the passive range of motion restorative nursing done.During an interview on 9/8/25 at 1:40 p.m., the MDS nurse indicated if the date lacked documentation, the passive range of motion was not completed.On 9/8/25 at 2:23 p.m., the Administrator provided the facility policy, Restorative Nursing Program, dated 1/2/24, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .6. Residents.will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include: a. Passive or active range of motion.3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 residents reviewed for behavior and mood. (Resident 35)Finding includes:On 9/4/25 at 9:49 a.m., Resident 35's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder and major depressive disorder.A physicians order, dated 3/10/25, indicated Buspirone HCl Tablet (a medication used to treat anxiety disorder) 5 milligrams three times daily. The order was discontinued on 8/21/25.A physicians order, dated 3/11/25, indicated Escitalopram Oxalate Tablet (a medication used to treat depression and anxiety disorder) 20 milligrams daily.The Quarterly MDS assessment, dated 7/15/25, did not indicate the resident was on antidepressant or antianxiety medications.During an interview with the MDS Coordinator on 9/8/25 at 1:45 p.m., she indicated the resident was taking antianxiety and antidepressant medications during the ARD (Assessment Reference Date) window of the Quarterly MDS assessment, dated 7/15/25. The MDS Coordinator indicated the assessment should have been marked yes for antidepressant and antianxiety medications. The MDS coordinator indicated they used the RAI (Resident Assessment Instrument) manual to code the MDS assessments.A review of the RAI, Version 3.0 User's Manual, on 9/8/25 at 1:53 p.m., indicated .Item N0415, High-Risk Drug Classes: Use .N0415B1. Antianxiety: Check if an anxiolytic (an antianxiety or antidepressant medication) medication was taken by the resident at any time during the 7-day look-back period .N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period . 3.1-31(d)

Based on record review and interview, the facility failed to ensure a resident who was administered psychotropic medications was monitored for adverse side effects for 1 of 5 residents reviewed for unnecessary medications. (Resident 61)Finding includes: On 9/4/25 at 11:10 a.m., Resident 61's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's Disease, major depression, and bipolar disorder. The Physician's orders included, but were not limited to:- Ability (antipsychotic medication), 10 mg (milligrams) daily, initiated 1/23/25.- Buproprion (antidepressant medication) 100 mg, twice daily, initiated 8/30/25.- Trazadone (antidepressant medication) 0.5 mg, daily, initiated 5/15/25.- Citalopram (antidepressant medication) 40 mg, twice daily, initiated 8/13/25. The clinical record lacked documentation of the monitoring of adverse side effects for an antipsychotic medication and antidepressant medications. During an interview on 9/8/25 at 2:10 p.m., the Director of Nursing indicated monitoring of adverse side effects were to be documented in the electronic Medication Administration Record, and there was a lack of documentation of the monitoring of adverse side effects for antipsychotic medication and antidepressant medications. 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 3 of 3 residents reviewed for complete and accurate documentation. (Resident B, Resident C, Resident D) Findings include: 1. The clinical record for Resident B was reviewed on 1/23/25 at 8:20 a.m. The diagnoses included, but were not limited to, osteomyelitis of vertebrae, peripheral vascular disease, neurogenic bladder, and diabetes. An Annual Minimum Data Set (MDS) assessment, dated 10/17/24, indicated Resident B was cognitively intact. The physician's order included, but were not limited to: - Cleanse coccyx (tailbone) wound with wound cleanser, apply wound vac (wound dressing that uses suction to remove drainage and encourage new tissue growth) to coccyx at 125 mmHg (millimeters of Mercury) on day shift every Monday, Wednesday, and Friday. Initiated on 12/16/24 and discontinued on 1/8/25. - Cleanse coccyx wound with wound cleanser, apply calcium alginate, apply kerlex, cover with absorbent dressing on day shift. Initiated on 1/9/25 and discontinued on 1/15/25. - Cleanse left hip wound with wound cleanser, apply medical grade honey, cover with bordered gauze on day shift, every day. Initiated on 1/9/25 and discontinued on 1/15/25. - Cleanse right scapula/flank wound with wound cleanser, apply calcium alginate to wound bed, cover with absorbent dressing on day shift, very day. Initiated on 1/9/25 and discontinued on 1/15/25. The December 2024 TAR (Treatment Administration Record) lacked documentation that the coccyx wound vac treatment was completed, on 12/18/24 and 12/27/24. The January 2025 TAR lacked documentation as follows: - lacked documentation that the coccyx wound vac treatment was completed on 1/3/25, 1/6/25, and 1/8/25. - lacked documentation that the coccyx calcium alginate treatment was completed on 1/10/25, 1/12/25, and 1/15/25. - lacked documentation that the left hip medical grade honey treatment was completed on 1/10/25, 1/12/25, and 1/15/25. - lacked documentation that the right scapula/flank calcium alginate treatment was completed on 1/10/25, 1/11/25, 1/12/25, and 1/15/25. During an interview on 1/23/25 at 10:20 a.m., the Director of Nursing (DON) indicated the documentation for Resident B's treatments should have been completed. 2. During an interview on 1/23/25 at 10:04 a.m., Resident C's indicated the nurses completed her wound dressing changes as the doctor had ordered. At that time, observed a dressing on Resident C's right heel. The dressing was clean, dry, and intact. The right heel dressing was initialed and dated 1/22/25. The clinical record for Resident C was reviewed on 1/23/25 at 10:30 a.m. The diagnoses included, but were not limited to, diabetes, dementia, and cancer. An Admission MDS assessment, dated 12/19/24, indicated Resident C was cognitively intact. The physician's orders included, but were not limited to: - Apply triad hydrophilic wound paste to sacrum every shift, initiated on 12/16/24. - Cleanse right heel with wound cleanser, apply hydrogel to wound and cover with bordered gauze, every shift. Initiated on 1/9/25 and discontinued on 1/13/25. - Cleanse right heel wound with wound cleanser, apply collagen to new tissue, cover entire wound with silver alginate, cover with bandage and secure with gauze on day shift every day, initiated on 1/14/25. The January 2025 TAR lacked documentation as follows: - lacked documentation that the sacrum hydrophilic wound paste treatment was completed on 1/17/25. - lacked documentation that the right heel hydrogel dressing was completed on day shift on 1/9/25 and 1/13/25. - lacked documentation that the right heel collagen dressing was completed on 1/14/25, 1/17/25, and 1/19/25. During an interview on 1/23/25 at 10:20 a.m., the Director of Nursing (DON) indicated the documentation for Resident C's treatments should have been completed. 3. The clinical record for Resident D was reviewed on 1/23/25 at 10:45 a.m. The diagnoses included, but were not limited to, necrotizing fasciitis, diabetes, venous insufficiency. An Admission MDS assessment, dated 12/12/24, indicated Resident D was cognitively intact. The physician's orders included, but were not limited to: - Cleanse sacral/buttocks surgical wound with normal saline, pat dry with gauze, apply moistened hydrofera blue to wound bed, cover with bordered gauze every shift, initiated on 12/16/24. - Swab left great toe and left third toe venous ulcers with betadine and leave open to air on day shift every day. Initiated on 1/9/25 and discontinued on 1/13/25. - Cleanse left lateral plantar foot venous ulcer with wound cleanser, apply medical grade honey, cover with bordered gauze on day shift every day. Initiated on 1/9/25 and discontinued on 1/13/25. - Swab right lateral foot with betadine and leave open to air on day shift every day, initiated on 1/9/25. The January 2025 TAR lacked documentation as follows: - lacked documentation that the sacral/buttock hydrofera blue treatment was completed on day shift on 1/17/25. - lacked documentation that the left great toe and left third toe betadine treatment was completed on 1/10/25 and 1/13/25. - lacked documentation that the left lateral plantar foot honey treatment was completed on 1/10/25. - lacked documentation that the right lateral plantar foot betadine treatment was completed on 1/10/25 and 1/17/25. During an interview on 1/23/25 at 10:20 a.m., the Director of Nursing (DON) indicated the documentation for Resident C's treatments should have been completed. During an interview on 1/23/25 at 9:59 a.m., LPN 1 indicated documentation for wound care should have been completed in the medical record. On 1/23/25 at 12:00 p.m., the Administrator provided a copy of a facility policy, titled Documentation in the Medical Record, dated 1/2/24, and indicated this was the current policy used by the facility. A review of the policy indicated each resident's medical record shall contain complete, accurate, and timely documentation. This citation relates to Complaint IN00451705. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for 1 of 2 residents reviewed for respiratory care. (Resident 213) Finding includes: On 10/30/24 at 9:56 a.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L (liters) per minute and the N/C (nasal cannula) sitting on her face and not in the nostrils. On 10/30/24 at 2:49 p.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C sitting on her face and not in the nostrils. On 11/1/24 at 9:38 a.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C in her nostrils. On 11/1/24 at 2:33 p.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C sitting on her face and not in the nostrils. On 11/4/24 at 11:06 a.m., Resident 213 was observed to be lying asleep in bed with the oxygen concentrator level set at 3 L per minute and the N/C in her nostrils. Resident 213's clinical record was reviewed on 11/1/24 at 10:00 a.m. The diagnoses included, but were not limited to, anemia, supraventricular tachycardia, and hypertension. Physician orders for Resident 213 indicated, . Oxygen at 2 L per minute via nasal cannula every shift . The start date was 10/11/24. During an interview on 11/4/24 at 11:50 a.m., LPN 1 indicated Resident 213's oxygen order was for 3 L per N/C and confirmed the oxygen concentrator was set at 3 L per N/C. On 11/4/24 at 4:07 p.m., the Administrator provided the facility's policy, Medication Administration, dated 5/20/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure: 1. Preparation/Administration d. Follow the six rights of medication administration . ii. right dose . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a medication cart on the 300 unit was locked for 1 of 8 medication carts observed. (300 Unit Medication Cart) Findings include: On 10/30/24 from 10:18 a.m. until 10:38 a.m., the medication cart outside of room [ROOM NUMBER] was observed to be unlocked and unattended by staff. The medication cart contained medications for residents on the 300 unit. During an interview on 10/30/24 at 10:39 a.m., RN 1 indicated she had been at the other end of the hallway providing care to residents from another medication cart, and the medication cart was to be locked if it was unattended by staff. On 11/4/24 at 4:00 p.m., the Director of Nursing provided the Facility Drug Product Storage Requirements, revised 2/22/22, and indicated this was the policy currently used by the facility. A review of the policy indicated, .all drug storage areas shall be kept secure from unauthorized entry and shall be limited to authorized personnel . 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure the posted daily staffing information sheet included the facility name for 5 of 5 daily staffing sheets reviewed. Findings include: On 10/29/24 at 2:30 p.m., the daily nurse staffing information sheet was observed posted near the front entrance door. The staffing information sheet lacked documentation of the facility name. During a review of the posted staffing sheets, dated 10/29/24, 10/30/24, 10/31/24, 11/1/24, and 11/4/24 indicated the staffing information sheets lacked documentation of the facility name. During an interview on 11/4/24 at 3:40 p.m., the Administrator indicated the staffing sheet was printed daily through a new company program. He indicated he was not aware the facility name should be on the report. During a interview on 11/4/24 at 3:58 p.m., the Administrator indicated the facility did not have a policy regarding posted daily staffing information.

Based on observation, interview, and record review, the facility failed to provide repositioning in order to prevent moisture acquired skin damage for 1 of 6 residents reviewed for pressure sores. (Resident 72) Findings include: On 1/26/23, from 2:07 p.m. until 4:30 p.m., Resident 72 was observed in his bed lying on his back. He was not repositioned during this time. On 1/27/23, from 9:30 a.m. until 12:40 p.m., Resident 72 was observed in his bed lying on his back. He was not repositioned during this time. On 1/27/23 at 3:00 p.m., Resident 72's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, dementia, and hemiplegia (paralysis of one side of the body). The Significant Change MDS (Minimum Data Set) assessment, dated 10/31/22, indicated the resident was not cognitively intact, always incontinent of urine and bowel, not on a toileting program, required extensive physical assistance of two people to turn or reposition in bed, and was free of moisture acquired skin damage. The Braden Skin Evaluation (an assessment used to determine a person's risk for developing pressure sores), dated 1/18/23, indicated the resident was at high risk for pressure sores and skin friction and shearing due to being very moist, having very limited mobility, and being chairfast. The Skin Only Evaluation, dated, 11/6/22 indicated the resident had moisture acquired skin damage (MASD) to the coccyx. The Skin Only Evaluation, dated 11/9/22 indicated the resident had a fluid filled blister on the left buttock. The Skin Only Evaluation, dated 11/16/22 indicated the resident had a fluid filled blister on the left buttock. The Skin Only Evaluation, dated 12/12/22 indicated the resident had MASD to the right buttock. The Skin Only Evaluation, dated 12/27/22 indicated the resident had excoriation (a wearing off of the skin) of the left buttock. The Skin Only Evaluation, dated 1/10/23 indicated the resident had excoriation of the left buttock. The Skin Only Evaluation, 1/25/23 indicated the resident had MASD to the right and left buttock. A care plan with a start date of 7/20/22 and revision date of 1/26/23 indicated the resident was at risk for impaired skin integrity due to incontinence and a need for assistance with toileting and bed mobility. During an interview on 1/30/23 at 10:05 a.m., Licensed Practical Nurse 1 indicated the resident was occasionally resistant to care and repositioning, but was to be repositioned at least every 2 hours to prevent skin damage. During an interview on 1/30/23 at 2:06 p.m., the Director of Nursing indicated the resident had moisture acquired skin damage to his buttocks. He was to be regularly repositioned and was frequently resistant to hands on care. During an interview on 1/31/23 at 9:45 a.m., Certified Nurse Aide 1 indicated the resident was to be repositioned every 2 hours if possible, however, on extremely busy shifts the resident may have gone without repositioning every 2 hours. On 1/31/23 at 9:30 a.m., the Director of Nursing provided the Repositioning policy with a revised date of May 2013, and indicated this was the policy used by the facility. A review of the policy indicated, .residents who are in bed should be on at least an every 2 hour repositioning schedule .if ineffective, the turning and repositioning frequency will be increased .record in the resident's medical record the position in which the resident was placed .the name and title of the individual who gave the care .if the resident refused the care .the signature and title of the person recording the data . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to apply a hand splint on a resident with an assessed limited range of motion (amount of movement around a specific joint) for 1 of 5 residents review for mobility. (Resident 24) Findings include: During an interview on 1/24/23 at 11:09 a.m., Resident 24 indicated he had a stroke and had impaired mobility of his left hand and left leg. He was unsure if he was receiving nursing services for the impaired mobility of his left arm and leg. During an observation on 1/26/23 at 10:26 a.m., Resident 24 was observed to be actively participating in activities. He was observed to have his left hand resting on his left leg with no splint on his left hand. During an observation on 1/30/23 at 3:07 p.m., Resident 24 was observed to be propelling himself in his wheelchair. He was observed not to have on a splint on his left hand. During an observation on 1/31/23 at 11:12 a.m., Resident 24 was observed to be sitting in his wheelchair with no hand splint on his left hand. On 1/27/23 at 2:32 p.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), left side hemiplegia (weakness on entire side the body), and left hand contracture (permanent shortening of a muscle or joint). The Quarterly Minimum Data Set (MDS) assessment, dated 11/2/22, indicated Resident 24 was cognitively intact, had limited range of motion (amount of movement around a specific joint) of upper and lower extremity on one side; had no days of active or passive range of motion restorative program; and had no days of splint or brace assistance. A care plan, dated 10/18/21 and current through target date 2/27/23, indicated Resident 24 had left side hemiplegia due to cerebral infarction and had a contracture to left hand. The care plan lacked interventions of left hand splint or any range of motion to left arm or left leg. A care plan, dated 10/18/21 and current through target date 2/27/23, indicated Resident 24 had the potential for impaired skin integrity related to left side hemiplegia. The intervention was to apply left hand splint in the morning and remove at bedtime. The care plan lacked any intervention of any range of motion to left arm or left leg. The Therapy Communication to Nursing for Functional Program Maintenance dated 12/23/21, indicated Resident 24 to wear a hand splint when up in wheelchair. Resident 24's Order Summary Report dated 1/30/23, indicated apply the left hand splint on in the morning and off at bedtime with a start date of 10/25/21. The care plan lacked documentation of Resident 24 refusing to wear his left hand splint. The progress notes dated, 1/4/23 through 1/30/23, lacked documentation of Resident 24 refusing to wear his left hand splint. The Medication and Treatment Administration Record dated, 1/1/23 through 1/31/23, lacked documentation of Resident 24 refusing to wear his left hand splint. During an interview on 1/30/23 at 10:53 a.m., Qualified Medication Aide (QMA) 1 indicated Resident 24 wore a splint to his left hand. If he wanted to remove the splint, she would inform her nurse so the nurse could document this in his nurses notes. During an interview on 1/31/23 at 10:23 a.m., the Director of Nursing (DON) indicated they do not have a nursing restorative program. During an interview on 1/31/23 at 11:29 a.m., the Licensed Practical Nurse (LPN) 2 indicated Resident 24 wore a splint to his left hand. If he refused to wear the splint, they would document the refusal in the nurses notes. During an interview on 1/31/23 at 11:53 a.m., the DON indicated Resident 24 was one of the few residents who wore their splints. On 1/31/23 at 12:25 p.m., the Administrator provided the facility policy, Nurse Aide Qualifications and Training Requirements, revised date of 8/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .j. basic restorative services .(6) care and use of prosthetic and orthotic devices . 3.1-42(a)(2)

Based on interview, observation, and record review, the facility failed to ensure that a resident received adequate supervision to prevent a resident to resident altercation for 2 of 2 residents reviewed for accidents (Resident 17 and Resident 4), the failed to ensure hot water temperatures remained at a safe and comfortable level, below 120 degrees Fahrenheit for 7 of 33 residents whose rooms were assessed for safe water temperature (Residents 12, 13, 14, 17, 33, 44, and 58), and the facility failed to ensure a safe environment after janitor's closet was found to be unlocked and unattended with hazardous materials for 1 of 1 janitor's closet observed during a random observation. Findings include: 1. Resident 17's clinical record was reviewed on 10/25/21 at 2:25 p.m. Diagnoses included, but were not limited to: Alzheimer's disease with late onset and unspecified dementia without behavioral disturbance. The Admission Minimum Data Set assessment, completed on 10/14/2021, indicated Resident 17 was interviewable and cognitively intact. During an observation, on 10/21/21 at 9:43 a.m., Resident 17's room was observed with a Velcro white band across door at about chest height with a large red stop sign in the middle. During an observation, on 10/22/21 at 11:37 a.m., Resident 4 was observed to be walking in the hallway near the 500 hallway nursing station. Resident was attempting to go into an occupied room adjacent to dining room area. During an interview, on 10/21/21 at 11:47 a.m., Licensed Practical Nurse (LPN) 1 indicated the Velcro stop sign band was in place to help prevent other residents from wandering into Resident 17's room. Some residents do wander and are watched to prevent wandering into other residents' rooms. LPN 1 was not aware of any resident having wandered into Resident 17's room since the band had been put into use. During an interview, on 10/22/21 at 10:20 a.m., Resident 17 was observed with a scabbed laceration on her left forearm, the size of a dime, close to where she wears her wristwatch. Resident 17 indicated the laceration came from another female resident (Resident 4) who came into her room, held her arms, and scratched her. The laceration might have happened when she was trying to get out of the other resident's grip and said staff came in to help her. That same resident had entered her room at times. This causes her some anxiety, but she did not wish to move rooms or move hallways. A review of Resident 17's progress notes indicated the following: -Nursing note, 10/6/21 at 4:17 a.m., Res [resident] heard calling out. Staff entered room to see res attempting to move away from [Resident 4's medical record number] who was holding both wrists. Residents separated by staff. When asked what happened res stated 'She just walks in like she owns the place. I told her to get out when she grabbed me and wouldn't let go.' 1 cm x 1.2 cm skin tear noted to left wrist, blood noted on wristwatch. -Social services note, 10/6/21 at 7:53 p.m., SSD [Social Service Director] met with resident to follow up on any distress due to altercation with another resident. Resident reported the other female resident had entered resident's room and grabbed resident's wrist. Resident reported she then called for staff. Resident said the other resident was 'bossy.' Resident denied any fear, anger or tearfulness due to altercation. Resident was appreciative of the follow up. Staff reported no changes in resident's daily routine. -Nursing note, 10/22/21 at 11:39 a.m., While providing medications this AM, resident spoke of scratches on left arm from an incident that occurred 'shortly after we came home.' Resident was referring to the move from Garden Villa [NAME] to Garden Villa Bloomington on the 5th of October. Scratches continue to heal well, no s/s of infection observed. Resident denies pain/discomfort and exhibits no distress. When asked if the stop sign banner across her door is helpful, resident states 'I'll reserve judgement for the future.' Res clarified that she's glad to have it up to 'hopefully discourage [Resident 13] and others.' Resident rests quietly in her room with call light in reach. Resident 4's clinical record was reviewed on 10/25/21 at 2:51 p.m. Diagnoses included, but were not limited to: Alcohol dependence with alcohol-induced persisting dementia, other recurrent depressive disorders, [CONDITION(S)] with delusions due to known physiological condition, and major depressive disorder recurrent mild. Clinical record indicated that Resident 4 had known history of intrusive wandering. Resident 4 resided in the secure unit of the facility. The Admission Minimum Data Set assessment, completed on 10/6/2021, indicated Resident 4 was non-interviewable and severely cognitively impaired. This same assessment further indicated that Resident 4 had delusions (misconceptions or beliefs that are firmly held, contrary to reality), behavioral symptoms including verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others), wandering behaviors, and that she was coded at a 1 (requires supervision, oversight, encouragement, or cueing) for her functional status for walking in room, walking in corridor, and locomotion on unit. A review of Resident 4's care plans indicated the following: -A care plan, initiated on 12/3/2018 and current through 1/3/2022, for Resident 4 indicated, Resident has episodes of intrusively wandering and socially inappropriate behavior of rummaging through others belongings and climbing into bed with others r/t dx [diagnosis] of dementia and anxiety. -A care plan, initiated on 2/25/2019 and current through 1/3/2022, for Resident 4 indicated, Resident has episodes of physical aggression towards others and staff during care activities. Resident can become easily annoyed, slap others, slap staff, grabbing others and threw a cup of liquid on staff. Resident goal is will have no further episodes of verbal aggression or physical aggression toward others through next review. Interventions indicated, but were not limited to, 15 minutes checks as needed . observe for increased signs or symptoms of confusion, agitation, and any signal leading to verbal aggression A review of Resident 4's progress notes indicated the following: -Nurses note, on 10/6/21 at 4:28 a.m., Staff heard yelling from [Resident 17's room]. Res seen holding [Resident 17] by both wrists. Residents separated. 15 min checks initiated x 3 days (for three days). POA (Power of Attorney) and NP (Nurse Practitioner) notified. When asked what happened res stated 'I don't know what she's yelling about'. -Social services note, on 10/6/21 at 8:46 p.m., .care plans for delusions, exit seeking, physical aggression towards others and staff during care, irritability, intrusive wandering/rummaging, code status, long term placement, affectionate behavior towards others, impaired cognition and psychosocial well-being . will be developed. -Nurses note, on 10/9/21 at 2:34 a.m., resident intrusively wandering into other resident's rooms which in turn upset that resident. -Nurses note, on 10/11/21 at 2:46 a.m., Intrusive wandering noted. Staff able to redirect. -Social services note, on 10/11/21 at 4:53 p.m., .Be aware at times that [Resident 4] can have aggressive behaviors with other residents. -Nurses note, on 10/11/21 at 6:37 p.m., Resident intrusive but easily directed. -Nurses note, on 10/12/21 at 6:25 p.m., .Awake all afternoon and intrusive mostly after supper meal. Redirects easily this shift . -Nurses note, on 10/13/21 at 11:14 p.m., .Intrusive wandering noted . -Nurses note, on 10/14/21 at 5:54 a.m., .has been wandering around the unit, attempting to go in other resident's rooms. -Nurses note, on 10/17/21 at 6:30 p.m., Resident took another residents flowers that was brought in today and throwed [sic] the jar and the flowers on the floor and glass went every where . -Nurses note, on 10/18/21 at 11:35 p.m., Intrusive wandering noted. Able to redirect. Res seen by staff pulling decorations and name plate off walls. -Nurses note, on 10/19/21 at 6:31 a.m., Res found laying in bed with another resident. Staff able to get res to her own bed. -Nurses note, on 10/23/21 at 10:38 p.m., Intrusive wandering noted. Argumentative at times with redirection. -Nurses note, on 10/24/21 at 11:38 p.m., Intrusive wandering noted. Able to redirect. -Nurses note, on 10/25/21 at 6:36 p.m., Resident intrusive into rooms but easily re-directed . On 10/27/21 at 2:45 p.m., the Assistant Director of Nursing provided the facility policy, Resident Rights, with a revised date of December 2016, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: . c. be free from abuse . 2. During an observation, on 10/22/21 at 10:35 a.m., of resident rooms the following was observed: -Room 516's hot water was observed to be hot to the touch, unable to keep hand under for more than a few seconds. -Room 517's hot water was observed to be hot to the touch, unable to keep hand under for more than a few seconds. During an observation, on 10/22/21 at 11:23 a.m., the following hot water temperatures were observed: -Room 515 had a hot water temperature of 123.6 degrees Fahrenheit. -Room 516 had a hot water temperature of 121.6 degrees Fahrenheit. -Room 517 had a hot water temperature of 124.3 degrees Fahrenheit. -Room 518 had a hot water temperature of 120.4 degrees Fahrenheit. During an observation, on 10/22/21 at 12:24 p.m., with the Director of Environmental Services present, the following was observed: -Room 516 had a hot water temperature of 126.0 degrees Fahrenheit. -Room 517 had a hot water temperature of 125.4 degrees Fahrenheit. During an interview, on 10/22/21 at 12:35 p.m., the Director of Environmental Services indicated the water temperatures were too hot. During an interview, on 10/22/21 at 12:37 p.m., the Director of Environmental Services indicated he had turned the main water heater down and it was observed to read at 117 degrees Fahrenheit. The following residents resided in the identified rooms: Resident 33's clinical record was reviewed on 10/27/21 at 2:05 p.m. Diagnoses included, but were not limited to: Unspecified dementia, depression, and unspecified [CONDITION(S)]. The Admission Minimum Data Set assessment, completed on 10/16/21, indicated Resident 33 was non-interviewable and severely cognitively impaired. Resident was coded as not independently ambulatory and required extensive assistance with ambulation, mobility, and personal hygiene. Resident 58's clinical record was reviewed on 10/27/21 at 2:15 p.m. Diagnoses included, but were not limited to: Unspecified dementia and anxiety disorder. The Admission Minimum Data Set assessment, completed on 10/12/21, indicated Resident 58 was non-interviewable and severely cognitively impaired. Resident was coded as not independently ambulatory and required extensive assistance with ambulation, mobility, and personal hygiene. Resident 12's clinical record was reviewed on 10/27/21 at 2:30 p.m. Diagnoses included, but were not limited to: [CONDITION(S)] (loss of ability to understand or express speech), unspecified dementia, depression, and unspecified [CONDITION(S)]. The Admission Minimum Data Set assessment, completed on 10/14/21, indicated Resident 12 was non-interviewable and severely cognitively impaired. Resident was coded as not independently ambulatory and required extensive assistance with ambulation, mobility, and personal hygiene. Resident 44's clinical record was reviewed on 10/27/21 at 2:40 p.m. Diagnoses included, but were not limited to: Unspecified dementia and depression. The Admission Minimum Data Set assessment, completed on 10/8/21, indicated Resident 44 was non-interviewable and severely cognitively impaired. Resident was coded as independently ambulatory with supervision (oversight, encouragement, or cueing) for walking in room and in corridor and required extensive assistance with personal hygiene. Resident 13's clinical record was reviewed on 10/27/21 at 2:50 p.m. Diagnoses included, but were not limited to: Alzheimer's disease, [CONDITION(S)], unspecified dementia, anxiety disorder, depression, and unspecified [CONDITION(S)]. The Admission Minimum Data Set assessment, completed on 10/14/21, indicated Resident 13 was non-interviewable and severely cognitively impaired. Resident was coded as independently ambulatory for walking in room and in corridor and required extensive assistance with personal hygiene. Resident 14's clinical record was reviewed on 10/27/21 at 3:00 p.m. Diagnoses included, but were not limited to: unspecified dementia, anxiety disorder, and depression. The Admission Minimum Data Set assessment, completed on 10/14/21, indicated Resident 14 was non-interviewable and assessment could not be completed. Resident was coded as not independently ambulatory and required extensive assistance with ambulation, mobility, and personal hygiene. Resident 17's clinical record was reviewed on 10/25/21 at 2:25 p.m. Diagnoses included, but were not limited to: Alzheimer's disease with late onset and unspecified dementia without behavioral disturbance. The Admission Minimum Data Set assessment, completed on 10/14/21, indicated Resident 17 was interviewable and cognitively intact. Resident was coded as not independently ambulatory and required extensive assistance with ambulation, mobility, and personal hygiene. During an observation, on 10/22/21 at 11:33 a.m., Resident 17 was observed to sit on side of her bed, put on her shoes, and ambulate independently to the restroom in her room with the use of a rolling walker. During an observation, on 10/26/21 at 11:55 a.m., Resident 17 was observed exiting her room. Resident ducked under the Velcro stop sign band across her door and ambulated out into the main dining room independently with the use of a rolling walker. During an observation, on 10/27/21 at 10:50 a.m., Resident 17 was observed out at activities in the dining room and ambulated independently back to her room with the use of a rolling walker. On 10/27/21 at 2:33 p.m., the Assistant Director of Nursing provided the facility policy, Safety of Water Temperatures, with a revised date of December 2009, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit, or the maximum allowable temperature per state regulation . 3. On 10/21/21 at 10:10 to 10:15 a.m., during entrance tour of the facility, the janitor's closet at the end of the hallway, where residents resided, was found to be unlocked and unattended. Inside the janitor's closet were bleach, urinal/drain treatment, and disinfectant which indicated not to drink. During an interview, on 10/21/21 at 10:15 a.m., Housekeeper 1 indicated the door should be locked. On 10/28/21 at 3:59 p.m., the Assistant Director of Nursing (ADON) provided the facility policy titled, Safety and Supervision of Residents, revision date July, 2017, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide . priorities . 3.1-45 (a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was administered oxygen as indicated by the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 29) Findings include: On 10/21/2021 from 12:15 p.m. through 12:26 p.m., Resident 29 was observed to be sitting in the dining room in a Broda chair with oxygen nasal cannula (N/C) tube positioned in her nose. The oxygen tank dial was observed to be set at 0. During an interview, on 10/21/2021 at 12:26 p.m., Unit Manager (UM) 1 indicated the oxygen should be set at 2 liters (L) The UM was observed to turn the dial on the oxygen tank to 2 L. During an interview, on 10/21/2021 at 12:29 p.m., UM 1 indicated the MD (Medical Doctor) order was for oxygen 2.5 L at all times. She was observed to turn the oxygen dial to 2.5 L. On 10/28/2021 at 10:30 a.m., Resident 29's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated October, 2021, indicated, . O2 [oxygen] at 2.5 L per N/C every shift . A care plan, initiated on 2/8/2021, and current through target date 1/14/2022, for Resident 29 indicated, . Focus: acute and chronic respiratory failure with [CONDITION(S)], oxygen dependent . Goal: symptoms of shortness of breath daily . Interventions: oxygen as ordered by MD or as a nursing measure . On 10/28/2021 at 2:34 p.m., the Administered provided the facility's policy, Oxygen Administration with a revised date of 10/2020, and indicated this was the policy currently being used by the facility. A review of the policy did not indicated following MD orders when administering oxygen . 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 3 of 24 residents reviewed for accuracy of assessments (Resident 20, 41, and 47). Findings include: 1.) On 10/25/21 at 11:35 a.m., Resident 20's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 20's admission MDS assessment, dated 10/7/21, indicated the resident was administered an antipsychotic medication 7 times during the assessment period. A review of Resident 20's October, 2021, MAR (Medication Administration Record) indicated the resident did not have an antipsychotic medication ordered nor administered. During an interview, on 10/28/21 at 2:58 p.m., the Assistant Director of Nursing indicated she did not see an antipsychotic medication administered to Resident 20 on their October, 2021, MAR and their admission MDS assessment was not accurate. 2.) On 10/25/21 at 11:40 a.m., Resident 41's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 41's admission MDS assessment, dated 10/7/21, indicated the resident was administered an anticoagulant medication 7 times during the assessment period. A review of Resident 41's October, 2021, MAR (Medication Administration Record) indicated the resident did not have an anticoagulation medication ordered, nor administered. During an interview, on 10/28/21 at 2:58 p.m., the Assistant Director of Nursing indicated she did not see an anticoagulant medication administered to Resident 41 on their October, 2021, MAR and their admission MDS assessment was not accurate. 3.) On 10/21/21 at 3:00 p.m., Resident 42 was observed to be edentulous (no natural teeth) and without dentures. On 10/25/21 at 11:45 a.m., Resident 42's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 42's admission MDS assessment, dated 10/7/21, indicated the resident was not edentulous. During an interview, on 10/28/21 at 10:31 a.m., LPN 2 indicated Resident 42 is completely edentulous. A review of Resident 42's Inventory of Person Effects, dated 10/5/21, indicated, . Dentures [NO] . Husband states does not wear dentures . During an interview, on 10/28/21 at 2:58 p.m., the Assistant Director of Nursing indicated Resident 42 was edentulous and the admission MDS assessment was incorrect. 3.1-31(d)

Based on interview and record review, the facility failed to ensure staff accurately documented in the clinical record a pressure ulcer skin assessment for a resident with an identified pressure ulcer for 1 of 4 resident reviewed for pressure ulcer/injury. (Resident 9) Findings include: On 10/25/21 at 12:29 p.m., Resident 9's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9's admission evaluation, dated 10/5/21, indicated the resident was admitted with a stage 3 (full thickness skin loss) pressure ulcer to their right heel. Resident 9's skin assessment, dated 10/13/21, indicated the resident had a stage 3 pressure ulcer to their right heel. Resident 9's skin assessment, dated 10/21/21, indicated the resident had a stage 3 pressure ulcer to their right heel. Resident 9's skin assessment, dated 10/28/21, indicated the resident had a stage 3 pressure ulcer to their right heel. An undated care plan for Resident 9 indicated, Pressure ulcer to right heel. DTI [Deep Tissue Injury]. A review of progress notes indicated the resident the resident had a DTI wound to the right heel upon admission. Resident 9's Progress notes indicated the following: -On 10/5/21, .Skin issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: rt [right] heel . -On 10/13/21, .Skin issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: right medial heel pressure ulcer . -On 10/21/21, .Skin issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: right medial heel . -On 10/27/21, .Skin issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: right medial heel . Resident 9's admission MDS (Minimum Data Set) assessment, dated 10/6/21, indicated the resident was admitted with a stage 3 pressure ulcer. During an interview, on 10/28/21 at 12:58 p.m., the Assistant Director of Nursing indicated the resident did not have a deep tissue injury, and documentation which indicated the stage 3 pressure ulcer was a DTI was inaccurate. 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure yellow zone (COVID-19 status unknown, being monitored due to potential exposure) staff discarded isolation gowns after resident care prior to leaving the residents' room and the facility failed to ensure washable isolation gowns were stored in a manner such that they remain clean until use for 1 of 2 yellow zones reviewed for infection control. This deficiency had the potential to affect 8 residents who resided in a yellow zone unit of 78 residents who resided in the nursing facility. Findings include: 1.) During an interview, on 1/5/21 at 9:45 a.m., the Infection Preventionist (IP) Nurse indicated the facility had an increase of 8 COVID-19 residents in the last week. The facility had 16 residents on the red zone (COVID-19 Positive). The facility was a yellow zone or a red zone. During an observation, on 1/5/21 at 1:45 p.m., CNA 2 and CNA 3 were observed to remove their washable gown inside a resident's room. CNA 2 and CNA 3 then exited the resident's room holding their washable gown, walked across the hall to the room marked Resident Bath, entered the bath and discarded the washable gown in a soiled linen barrel. During an observation, on 1/5/21 at 1:55 p.m., CNA 2 and CNA 3 were observed to remove their washable gown on the yellow zone hallway. After CNA 2 and CNA 3 removed their washable gown, they walked across the hall to the room marked Resident Bath, entered the bath and discarded their washable gown in the soiled linen barrel. During an interview, on 1/5/21 at 2:00 p.m., CNA 2 indicated the residents' rooms on the yellow zone did not have soiled linen barrels to discard the washable isolation gowns, after resident care, and prior to leaving the resident room. If she performed resident care down at the end of the yellow zone, she would take the soiled linen barrel with her to discard the washable isolation gowns after resident care. During an interview, on 1/5/21 at 10:06 a.m., CNA 1 indicated she had worked the yellow zone and was to wear full Personal Protective Equipment (PPE). She utilized the washable isolation gowns during resident care on the yellow zone. After the resident care, she would discard the washable isolation gown into a soiled linen barrel on the hallway. During an interview, on 1/5/21 at 11:45 a.m., the IP nurse indicated the facility utilized washable gowns on the yellow zone. When the CNA would finish care with a resident, the CNA would remove the washable gown, and discard the washable gown in a soiled linen barrel on the hallway. The COVID-19 LTC (Long Term Care) Facility Infection Control Guidance Standard Operating Procedure, updated 11/22/20, indicated, .b. Trash cans should be near the door or exit of the zone for doffing. An isolation cart and trash can may exist in the hallway in the contained COVID zone, otherwise trash cans should be used inside each individual resident room that is in TBP (transmission based precautions) . On 1/5/21 at 3:49 p.m., the Director of Nursing (DON) provided the facility's policy, Personal Protective Equipment-Contingency and Crisis Use of Isolation Gowns (COVID-19 Outbreak), dated April 2020, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .e. Fold or roll into a bundle and discard in a waste container . The facility lacked instructions for the placement of the waste container. 2.) During an interview, on 1/5/21 at 9:45 a.m., the IP (Infection Preventionist) Nurse indicated the facility had an increase of 8 COVID-19 residents in the last week. The facility had 16 residents on red zone (COVID-19 positive). The facility was a yellow zone or a red zone. During an observation, on 1/5/21 at 11:45 a.m., three residents' room doors were closed on the yellow zone. On each of the 3 residents' doors were two washable isolation gowns, which hung from a white hook outside (hallway side) of the resident's room. During an observation, on 1/5/21 at 1:55 p.m., one resident's door was closed on the yellow zone. On the resident door were two washable isolation gowns, which hung from a white hook outside (hallway side) of the resident's room. During an interview, on 1/5/21 at 10:06 a.m., CNA 1 indicated she had worked the yellow zone and was to wear full PPE. She utilized the washable isolation gowns during resident care on the yellow zone. After the resident care, she would discard the washable isolation gown into a soiled linen barrel on the hallway; get a clean washable isolation gown out of a clean linen barrel; and place the clean washable isolation gown on the white hook on the resident's door. During an interview, on 1/5/21 at 11:45 a.m., the IP Nurse indicated the facility utilized washable gowns on the yellow zone. When the CNA would finish care with a resident, the staff would discard the washable isolation gown into a soiled linen barrel on the hallway; get a clean washable isolation gown out of a clean linen barrel; and place the clean washable isolation gown on the white hook on the resident's door. The washable isolation gowns which hung from a white hook on the closed resident's doors outside of the resident's room were clean. On 1/5/21 at 3:49 p.m., the Director of Nursing (DON) provided the facility's policy, Personal Protective Equipment-Contingency and Crisis Use of Isolation Gowns (COVID-19 Outbreak), dated April 2020, and indicated it was the policy currently being used by the facility. A review of the policy lacked instructions for the placement of clean washable gowns for resident care. 3.1-18(b)

Based on observation, interview, and record review, the facility failed failed to ensure separation of red and yellow isolation zones and that each residents' door had isolation signage posted which indicated what type of isolation precautions to implement and what staffed needed to wear to enter into the rooms for 3 residents who resided in a red zone and for 19 residents who resided in a yellow isolation zone of 136 residents who reside in the Nursing Facility. Findings include: On 11/19/20 at 10:00 a.m., during a facility tour, the 400 hall was observed to have a sign posted which indicated the entire 400 hall was a red zone (COVID-19 confirmed positive residents). There were 3 COVID-19 positive residents who resided on the same 400 hall with 19 COVID-19 negative residents. During an interview, on 11/19/20 at 12:00 p.m., the Director of Nursing indicated the entire 400 hall was determined to be a red zone since the residents on the hall had exposure to a COVID-19 positive staff member and 3 COVID-19 positive residents. At that time, the Executive Director indicated the 19 residents on the 400 hall had tested negative, but were likely all exposed to COVID-19 and will test positive. On 11/19/20 at 12:30 p.m., the red zone stop sign was observed to be removed and a yellow zone (unknown COVID-19 status) sign was posted. At that time, no sign was observed posted on the residents' doors indicating what type of personal protective equipment (PPE) were necessary to enter into the residents' room nor what type of isolation the residents were placed. During an interview, on 11/19/20 at 1:00 p.m., CNA (certified nursing assistant) 1 indicated the facility did not have signs posted on the doors which indicated what type of PPE was required to enter nor what type of isolation the residents were placed. She knew what to wear based on what was in the supply caddy outside of the resident room. On 11/23/20 at 3:30 p.m., a review of the Indiana COVID-19 Toolkit, Infection Control Steps when you have a . Resident Test Positive for COVID-19, updated 11/22/20 , indicated, .b. Place a sign on the door indicating Droplet- Contact Precautions Signs are posted immediately outside of resident rooms indicating appropriate precautions and required personal protective equipment (PPE) . The COVID-19 Toolkit further indicated, Additional Instructions for Other (Non-Long Term Care) Provider Types: Education and Signage . Where the patient/resident is sleeping at the health care facility, signage on the patient ' s room is important to ensuring that all staff are aware of the necessary infection control steps. https://www.cdc.gov/infectioncontrol/pdf/droplet-precautions-sign-P.pdf . A review of COVID-19 Toolkit, GENERAL COVID-19 INFECTION CONTROL FOR LONG-TERM CARE FACILITIES, updated 11/22/20 indicated, . COVID-19 Positive (Red) - These are residents who are confirmed COVID-19 positive and . still warrant transmission based precautions. Unknown COVID-19 status (Yellow): All residents in this category warrant transmission based precautions (droplet and contact.) . On 11/23/20 at 2:50 p.m., a review of the CDC (Centers for Disease Control) website, Responding to Coronavirus (COVID-19) in Nursing Homes, updated on 4/30/20, indicated, .Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 . the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19 . On 11/23/20 at 12:04 p.m., the Executive Director provided the facility's policy, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised on April, 2020, indicated, .17. Signage on the used of specific PPE (for staff) is posted in appropriate locations in the facility (e.g. outside of resident's room, wing, or facility-wide). During an interview, on 11/29/20 at 1:10 p.m., the Director of Nursing indicated there should be signs posted on each resident door. 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure staff implemented fall interventions for 2 of 6 residents reviewed for accidents (Resident 33 and Resident 84) and failed to ensure the environment was free from sharp edged screws protruding from the walls on the 400 unit hallway for eight residents who were independently ambulatory with no assistive devices and 9 residents who were independently ambulatory with assistive devices of 22 residents on the 400 unit. Findings include: A 1. On 2/20/20 at 03:09 p.m., Resident 84 was observed to be resting in her bed with no Call don't fall sign in her room. On 2/21/20 at 10:03 a.m., Resident 84 was observed to be resting in her bed with no Call don't fall sign in her room. On 2/21/20 at 2:20 p.m., Resident 84 was observed to be resting in her bed with no Call don't fall sign in her room. On 2/24/20 at 10:44 a.m., Resident 84 was observed to be resting in her bed with no Call don't fall sign in her room. On 02/21/20 02:54 p.m., Resident 84's clinical record was reviewed. The [DIAGNOSES REDACTED]. A care plan, initiated on 7/11/19 and current through 12/4/19, for Resident 84 indicated: Focus: .(Resident name) is at risk for falls d/t (due to) left radial fx (fracture), hx (history) of falls, [MEDICAL CONDITIONS](hypertension) with antihypertensive (medication for hypertension) use, [MEDICAL CONDITION] with shortness of breath, low back pain, anxiety with antianxiety medication, depression with antidepressant use, diuretic use, narcotic use, incontinence, need for assist with bed mobility, transfers and toileting GOAL: (Resident name) will not experience major injury from falls .INTERVENTIONS .place call don't fall sign in (Resident name) room . The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 84 was cognitively intact and required staff's supervision with transfers in and out of bed and between surfaces. Interview, on 2/24/20 at 10:17 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident 84 had a history of [REDACTED]. Interview, on 2/24/20 at 1:02 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident 84 had a history of [REDACTED]. Interview, on 2/24/20 at 2:25 p.m., the Unit Manager (UM) indicated Resident 84 was a risk for falls. Resident 84 did not have a call don't fall sign in her room. The sign should have been laminated with the words call don't fall and would have been placed on the wall on Resident 84's left side so she could see the reminder to ask for help with transfers. Interview, on 2/24/20 at 3:35 p.m., the Director of Nursing (DON) indicated Resident 84 had changed rooms on 8/10/19 and the call don't fall sign was not moved to Resident 84's new room. On 2/24/20 at 3:41 p.m., the DON provided the facility policy, Falls-Clinical Protocol, revision date March 2018, and indicated it was the policy currently being used by the facility. A review of the policy indicated, 3. If interventions have been successful in fall prevention, the staff will continue with current approaches . A2.) On 2/18/20, from 11:50 A.M. to 12:20 P.M., Resident 33 was observed walking, unassisted, in the 400 unit hallway and dining area. The resident was wearing socks, which did not have a non-skid substance on the sock bottoms. On 2/19/20, from 10:40 A.M. to 11:10 A.M., Resident 33 was observed walking, unassisted, in the 400 unit hallway and dining area. The resident was wearing, socks which did not have a non-skid substance on the sock bottoms. On 2/19/20 at 11:20 A.M., Resident 33 was observed sitting in a chair in her room. She was wearing socks, which did not have a non-skid substance on the sock bottoms. During an interview, on 2/19/20 at 11:22 A.M., Restorative Aide, Dixie, indicated the resident was not wearing non-skid socks she was supposed to be wearing for fall prevention. On 2/19/20 at 3:00 P.M., Resident 33's clinical record was reviewed. [DIAGNOSES REDACTED]. The fall risk evaluation, dated 1/1/20, indicated the resident was at risk of falls due to confusion, incontinence, balance problems, decreased muscular coordination. The resident had 3 or more falls in the past 3 months. The quarterly Minimum Data Set assessment, dated 12/2/19, indicated the resident was unable to complete the Brief Mental Status assessment to ascertain mental cognition. The resident's care plan, initiated date of 11/5/17 and current through 2/20, indicated, .Focus .risk for falls related to dementia, [MEDICAL CONDITIONS] .Interventions .wear proper and non slip footwear/socks . B.) During the initial tour, on 2/18/20 at 10:30 A.M., a total of 13 phillips head screws with sharp edges were observed to be protruding approximately 1/4 of an inch from the walls at torso level outside rooms 402, 406, 410, 412, 414, 415, 417, and 418. Three residents were observed to independently ambulate past the screws, utilizing the handrail directly beneath the protruding screws. During an interview, on 2/19/20 at 11:30 A.M., the facility Administrator indicated the screws were used to hold up picture boxes outside resident rooms and could pose a possible safety concern, should a resident rub against them while walking near or against the wall. On 2/24/20 at 10:00 A.M., the Admissions Director provided the Resident Rights, effective date of 7/13/17, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .the resident has the right to .a safe, clean, comfortable, and homelike environment . 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident received oxygen (O2) as indicated on the physician's orders for 1 of 1 resident reviewed for respiratory care (Resident 143). Findings include: On 2/24/20 at 9:37 a.m., Resident 143's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Review of Resident 143's Vitals Summary indicated the following: -On 1/24/20 at 5:55 p.m., the resident's O2 saturation was 90% with O2 via nasal cannula (a tube which delivers O2 through the nostrils). -On 1/24/20 at 9:47 a.m., the resident's O2 saturation was 93% with O2 via nasal cannula. -On 1/23/20 at 12:09 p.m., the resident's O2 saturation was 93% with O2 via nasal cannula. -On 1/23/20 at 11:26 a.m., the resident's O2 saturation was 93% with O2 via nasal cannula. -On 1/19/20 at 11:01 a.m., the resident's O2 saturation was 96% with O2 via nasal cannula. -On 1/13/20 at 7:55 a.m., the resident's O2 saturation was 93% with O2 via nasal cannula. Review of Resident 143's, 11/1/19 through 2/29/20, Physician's Orders lacked documentation for oxygen therapy. Interview, on 2/24/20 at 2:20 p.m., LPN 3 indicated Resident 143 was on continuous oxygen therapy, via nasal cannula, which flowed at 3 liters per minute. Interview on, 2/24/20 at 3:28 p.m., the Director of Nursing (DON) indicated she did not see an order for [REDACTED].>On 2/24/20 at 3:13 p.m., the DON provided the facility policy, Oxygen Administration, revised October, 2010, and indicated it was the policy currently being used. Review of the policy indicated, . 1. Verify that there is a physician's order for this procedure . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to update a resident's care plan to reflect to current plan of care for 1 of 26 residents reviewed for revision of a care plan (Resident 36). Findings include: Interview, on 2/20/20 at 10:00 a.m., Resident 36 indicated she has not had a Foley catheter (a flexible tube inserted into the urethra to drain urine from the bladder) for a couple of weeks. No Foley catheter was observed anchored to the resident at that time. On 2/24/20 at 9:50 a.m., Resident 36's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 36's admission Minimum Data Set (MDS) assessment, dated 12/6/19, indicated the resident was cognitively intact and had a stage 3 pressure ulcer. Resident 36's current, February, 2020, physician's orders [REDACTED]. The order was discontinued, on 2/12/20. A care plan initiated on 11/29/19, with no target date, for Resident 36 indicated, Pressure Ulcer to coccyx . Interventions . Foley catheter for wound healing. Date Initiated: 1/17/20 . The care plan lacked documentation to discontinue the Foley catheter care. Interview, on 2/24/20 at 10:01 a.m., LPN 2 indicated Resident 36 did not have a Foley catheter because they will only allow a resident to have a Foley catheter for two weeks for wound healing. Interview, on 2/24/20 at 3:29 p.m., the MDS coordinator indicated staff looks over new orders every day and will update the residents' care plans within 2-3 days. Interview, on 2/24/20 at 3:45 p.m., the MDS coordinator indicated she removed the Foley catheter intervention on Resident 36's UTI care plan, but did not update the resident's pressure ulcer care plan to reflect the catheter discontinuation. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure residents were informed of the state and local advocacy organization and contact information for filing grievances and complaints for 11 of 11 residents who were present at the resident council meeting (Resident 2, 16, 24, 44, 58, 60, 68, 69, 71, 113, 132). Findings include: During an initial facility tour, on 1/15/19 at 10:30 a.m., a small sign with the ombudsman and state advocacy information was observed to be posted in the entry lobby, which was not observed to be frequented by residents. No signs were posted directing visitors or residents as to where this information was located. During a resident council interview, on 1/18/19 at 1:46 p.m., the following was indicated: -Resident 2 did not know where the ombudsman and state advocacy information was located. -Resident 16 did not know where the ombudsman and state advocacy information was located. -Resident 24 did not know where the ombudsman and state advocacy information was located. -Resident 44 did not know where the ombudsman and state advocacy information was located. -Resident 58 did not know where the ombudsman and state advocacy information was located. -Resident 60 did not know where the ombudsman and state advocacy information was located. -Resident 68 did not know where the ombudsman and state advocacy information was located. -Resident 69 did not know where the ombudsman and state advocacy information was located. -Resident 71 did not know where the ombudsman and state advocacy information was located. -Resident 113 did not know where the ombudsman and state advocacy information was located. -Resident 132 did not know where the ombudsman and state advocacy information was located. A review of the monthly Resident Council Meeting Minutes, dated 1/29/18 through 12/26/18, indicated the ombudsman and state advocacy information was not discussed during the monthly Resident Council meetings. During an interview, on 1/23/19 at 3:08 p.m., the Activities Director indicated she does not go over how to formally complain to the State Department of Health. On 1/23/19 at 3:0 p.m., the Executive Director provided the facility policy, Resident Rights, revised December, (YEAR), and indicated it was the policy currently being used. A review of the policy indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . u. voice grievances to . other agency that hears grievances . x. communicate with outside agencies (e.g, local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter . 3.1-4(j)(3)(A) 3.1-4(j)(3)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident who was admitted with pressure did not develop pressure and when pressure developed the facility failed to ensure the resident was repositioned in a manner that off loaded pressure to the coccyx for 1 of 14 sampled residents reviewed for pressure ulcers, in a facility sample of 30 in that, the resident was admitted with a stage I, pressure area-red coccyx, which worsened to a stage IV wound to the coccyx. Resident #57. Findings include: The clinical record of Resident #57 was reviewed on 04/17/12 at 2:15 P.M. The record indicated the [DIAGNOSES REDACTED]. The record further indicated, Resident #57 had been admitted on [DATE]. During the initial tour on 04/11/12 at 9:30 A.M., the Unit Manager #2 identified Resident #57 as having an unstageable wound on the coccyx. Resident #57 was observed on 04/16/12 at 10:50 A.M. lying in bed with his shoulders tilted to the left and his buttocks on the bed. The wife and daughter of Resident #57 were observed at the bedside at that time. During an interview with the spouse of Resident #57, at that time, she stated, "They don't always turn him every two hours." The spouse further indicated she had been at the resident's bedside for about 20 minutes. Resident #57 was observed on 04/16/12 at 11:50 A.M. lying in bed with his shoulders tilted to the left and his buttocks on the bed. The wife and daughter of Resident #57 were observed at the bedside at that time. During an interview at that time, both indicated his position had not been changed since their arrival. Resident #57 was observed on 04/16/12 at 1:45 P.M. lying in bed with his shoulders tilted to the right and his buttocks on the bed. Resident #57 was observed on 04/16/12 at 2:55 P.M. lying in bed with his shoulders tilted to the right and his buttocks on the bed. Resident #57 was observed on 04/17/12 at 9:06 A.M. lying in bed on his back. Resident #57 was observed on 04/17/12 at 10:10 A.M. lying in bed on his back. During an observation of care on 04/17/12 at 11:10 A.M. CNA #5 and CNA #6 were observed to reposition Resident #57 to his right side. CNA #5 was observed the prop the resident's upper body with pillows, allowing the buttocks to remain in contact with the bed. In an interview with CNA #5, at that time, she indicated Resident #57 was to be turned and repositioned every hour. Resident #57 was observed on 04/17/12 at 12:15 P.M. to be lying in bed with his shoulders tilted to the right and his buttocks on the bed. At that time, the spouse and daughter were observed to be at the resident's bedside. Both indicated, at that time, the resident's position had not been changed. Resident #57 was observed on 04/17/12 at 2:00 P.M. to be lying in bed with his shoulders tilted to the right side and his buttocks on the bed. During an interview, at that time, the spouse of Resident #57 indicated the physician had just left and the resident had been repositioned back to his right side when the physician was finished. During an observation of care on 04/18/12 at 9:05 A.M. Resident #57 was observed to be lying in bed. During an interview at that time, CNA #3 and CNA #4 indicated they were repositioning the resident to his left side. CNA #3 then indicated the procedure was complete. At that time, Resident 357 was observed to be lying in bed with his shoulders tilted to the left and his buttocks on the bed. In an interview with LPN #2 on 04/17/12 at 2:40 P.M. she identified herself as the nurse who completed the admission skin assessment. She indicated she observed the area on the coccyx upon admission and stated, "it was very dark red, but not open." She further stated, "just looked like a lot of pressure". The Initial Wound Visit/Re-evaluation dated 04/10/12 indicated the resident experienced an" o/a (open area) coccyx/buttocks...aggravated by pressure..." The Wound Progress Note/Reassessment dated [DATE] indicated the coccyx wound was a Stage IV pressure wound which measured 6.0 X 5.0 X 2.0 with a wound bed of 70% [MEDICATION NAME]/slough and 30% necrotic tissue that was deteriorating and required debridement. The Medication Administration Report from (name of hospital) dated 03/22/12 to 03/23/12 indicated the resident was being treated at the hospital with [MEDICATION NAME] (a topical skin(protectant) for a reddened coccyx. A hospital document dated 03/21/12 was provided by the Unit Manager, #2 on 04/17/12 at 2:30 P.M. indicated Resident #57 had a Stage 1 area on his coccyx and "area is pink but it blances (sic). Xenederm(sic) to be ordered, and PUP (Pressure Ulcer Prevention) plan of care." The Admission Nursing assessment dated [DATE] at 12:30 P.M. lacked any documentation of skin condition. The assessment included a sketch of a body with a handwritten note over the area of the coccyx that indicated, "dark red". A Nursing Note dated 03/24/12 at 12:30 P.M. indicated, "...Skin assessment completed (sic). Noted bil (bilateral) inner buttocks red..." A Nursing Note dated 03/31/12 at 9:15 A.M. indicated, "Previously noted dark red area gluteal crease/butt is now dark purple with 4 separate open areas. All 4 (four) are clean, beefy red wound beds with mod (moderate) amt (amount) bl (bloody) drainage, surrounding tissue is deep purple...staff informed to turn et (and) reposition q 1 (every one hour) while in bed..." A Wound Report indicated a DTD (Deep Tissue Damage) on the gluteal crease related to pressure measured 5.0 X 5.0 X 0.0 and began on 03/31/12. The report further indicated on 04/09/12 the wound deteriorated to a Stage IV (four) and measured 6.0 X 6.0 X not measurable with 100% black eschar present. The Wound Risk assessment dated [DATE] Section 2 question 10 lacked any documentation the resident had a history of [REDACTED]. The assessment indicated the resident was a high risk for pressure The most recent Wound Risk assessment dated [DATE] indicated the resident was a "very high risk" for pressure. The Wound Protocol...Protocols Initiated based on Wound Risk assessment dated [DATE] included, but was not limited to, "...turn and reposition every 1 (one) hour..." A plan of care dated 03/31/12 for "pressure ulcer...gluteal crease" included, but was not limited to, an intervention of "T & R (turn and reposition) q 1 hour while in bed..." The most recent MDS (Minimum Data Set Assessment) dated 03/31/12 indicated Resident #57 was severely cognitively impaired, required extensive assist of two staff for bed mobility, had 5 unhealed areas of unstageable pressure ulcers with suspected deep tissue injury in evolution that were not present on admission. The policy and procedure for Prevention of Pressure Ulcers provided by the HFA (Health Facility Administrator on 04/18/12 at 10:30 A.M. indicated, "General Information Relative to Pressure Ulcers: Pressure ulcers are usually formed when a resident remains in thee same position for an extended period of time causing increased pressure or a decrease of circulation(blood flow) that area, which destroys the tissues... Pressure ulcers are often made worse by continual pressure.." 3.1-40(a)(1) 3.1-40(a)(2)