Every finding on record at Majestic Care of Terre Haute

Based on observation, interview, and record review, the facility failed to assess, prevent, and treat skin conditions for 1of 7 residents reviewed for daily care needs (Resident L). Findings include:On 2/4/26 at 2:40 p.m., observed Resident L sitting in the activity lounge participating in Bingo. The residents hair was uncombed and very disheveled. Her clothing was stained with food. A splint brace was on the right wrist and the resident indicated it was not hurting her. She moved her left arm and wrist freely and indicated she was not having pain in the wrist or arm. She was alert and answered questions appropriately. When asked if she had received a shower today she indicated she had received a shower the previous evening. On 2/4/26 at 10:30 a.m., the medical record of Resident L was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but was not limited to psychotic disorder (a serious mental illness that causes a person to lose touch with reality, making it hard for them to distinguish what is real from what is imagined), delusions (a strong, fixed, false belief that persists even when presented with clear evidence it's untrue), bipolar disorder (a chronic mental health condition characterized by severe, alternating mood swings between extreme emotional highs and lows), and hallucinations (seeing, hearing, smelling, tasting, or feeling something-that seems real but isn't actually present). A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had cognitive limitations, and no behaviors of rejecting care had occurred. The MDS indicated the resident required assistance with ADL care needs. A care plan, dated 12/1/24, indicated the resident exhibits behavior symptoms of delusional thinking. Intervention included if resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure, re-approach as needed. A care plan, dated 10/21/25, indicated the resident required assistance with activities of daily living. Interventions included but were not limited to Assist with ADL (activities of Daily Living) as needed bathing/showering nail care on bath day and as necessary. Report any changes to the nurse. Requires assistance from staff with dressing, requires assistance from staff with personal hygiene. The medical record lacked documentation of a specific care plan and interventions to address refusal of care. A quarterly MDS, dated [DATE], indicated no behaviors of rejecting care had occurred, and the resident required assistance for ADL care needs. A quarterly MDS, dated [DATE], indicated the resident had cognitive limitations. The MDS indicated no behaviors of rejecting care had occurred and the resident required assistance with ADL care needs. A change of condition MDS, dated [DATE], indicated the resident had cognitive limitations. The MDS indicated no behaviors of rejecting care had occurred and the resident required assistance with ADL care needs. A discharge MDS, dated [DATE], indicated the resident had cognitive limitations. The MDS indicated the resident required assistance from staff for ADL care needs and had exhibited rejection of care 1 to 3 times during the assessment period. The medical record indicated a skin assessment was completed for Resident L on the following dates: 1/1/26, 1/3/26, 1/17/26, 1/22/26, 1/24/26. Skin assessment indicated no skin issues. A skin assessment, dated 1/9/26, indicated skin issue to right wrist. A skin assessment, dated 2/4/26, indicated redness under breasts. A nursing admission assessment, dated 2/4/26, indicated physical assist with bathing and redness under breasts. On 2/4/26, the Director of Nursing (DON) provided a copy of Resident L's shower sheets. An internal document used to record shower administration and identification of skin issues. The records indicated the resident received a shower on 1/16/26. The shower records did not include shower sheets for any other days other than when the resident refused a shower on 1/20/26 and again on 1/23/26. Review of the electronic medical record (POC) point of care, which was the documentation of bathing indicated, the resident was not provided a bath from 1/17/26 through 1/27/26. Documentation included refusal of care on 1/20/26 and 1/23/26. The resident was at a Behavior Center from the evening of 1/27/26 to 2/3/26. She returned to the facility on 2/3/26 A physician order, dated 2/4/26, indicated to administer Fluconazole 200 milligram (mg) tablet 1 tablet by mouth once daily for yeast under breasts. A physician order, dated 2/4/26, indicated to administer one doxycycline hyclate (antibiotic) 100 mg capsule by mouth once daily for urinary tract infection prophylaxis. A physician order, dated 2/4/26, indicated to administer antifungal powder to bilateral breasts every shift and as needed. The medical record lacked documentation in the nurses progress notes or the social services notes of resident refusing showers or bathing care. In addition, the medical record lacked documentation of notification being provided to the resident's family regarding refusal of care. On 2/4/26 at 12:00 p.m., during an interview Certified Nurse Aide (CNA) 2 indicated, the facility records showers on the facility shower sheets and in POC. If the resident refused a shower or bath she would approach later and try again. She indicated Resident L did not refuse showers as long as it was administered before dark. The CNA indicated if a resident had skin issues she would report it to the nurse and record it on the shower sheets. On 2/4/26 at 2:35 p.m., during an interview Certified Nurse Aide (CNA) 5 indicated the last shower Resident L received was on 1/16/26. She did not recall any skin issues on the resident's body. She indicated the resident often would not allow the staff to change her and she would only allow one person to assist her at times. She indicated if a resident had a wound or skin issue she would write it on the shower sheet and report it to the nurse. On 2/5/26 at 9:50 a.m., during a phone interview, the resident's POA indicated that the behavioral facility the resident was sent to notified her they had to cut her bra off because it was so tight it was cutting into her skin and they could not remove it. She indicated the resident had a rash in the past under her breasts and had a rash now. She indicated she was not aware of any issues with the resident not receiving a shower at the facility or refusing to take a shower. She indicated the facility often called her about the hallucinations, and the facility wanted to send her to the behavioral hospital for frequent psychiatric evaluations, but she had never been notified of refusal to shower or refusing a bath. The POA believed the hallucinations were due to the Parkinson's disease and she saw a neurologist for treatment. She indicated this was not new and she has had hallucinations for years. She indicated when she was at the facility visiting the resident on 2/4/26 as she was checking the resident's skin the nurse came in and informed her the other facility had not administered a shower to the resident while she was there. On 2/5/26 at 11:00 a.m., during an interview with The Director of Therapeutic Services at the Behavior Center, she indicated Resident L was admitted to their facility on 1/27/26. At the time of the admission the resident's skin was assessed. At the time of the assessment the resident was wearing a lace bralette. She indicated the nurse cut off the garment because it was too tight to remove. Once removed the resident was noted to have green and yellow pus under both breasts. The area was cleaned and a dry bandage was applied. She indicated the resident's heels were purple and reddened noted to have stage 1 (discoloration and non-broken skin) deep tissue injury (a serious form of pressure injury where soft tissue is damaged underneath intact skin, often appearing as a deep, non-blanchable purple or maroon bruised area). She indicated the behavioral center did not contact [NAME] Care of Terre Haute regarding their concerns, but they did contact the resident's daughter who was her POA. She indicated upon admission, the physician ordered the following medications to treat the areas under the breasts. Fluconazole 200 mg daily for yeast infection. Nystatin topical powder under the breast daily, and Bactroban topical ointment under the breasts twice daily for bacterial skin infection. Review of the medical records with the Behavioral Center's Facility Director indicated the resident arrived at the facility on 1/27/26 at 4:45 p.m. the Pt [Patient] was brought on the unit in WC (wheelchair) with personal belongings.Gown and non-skid socks placed on pt. Pt arrived wearing a white lace bralette. Bralette was cut off of patient due to garment being tight against the skin, appearing to cut into the underneath breast region. Bralette was saturated with green and yellow pus and had a foul odor.boggy left heel with discoloration. BIL (bilateral) under breast area excoriated and seeping yellow green pus.Under breast area was cleaned with wound cleanse, dried with non-woven gauze, ABD (abdominal pad) pads placed under both breasts to contain drainage. MD made aware. The skin assessment included wound diagram and wound measurements. Skin tear 1 cm [centimeter] x [by] 1 cm to right third toe. Stage 1 non-blanchable deep tissue injury 3 cm x 3 cm purple discolored stage 1 pressure injury, non-blanchable, boggy. Excoriated areas. The Director verified the records were completed by a Registered Nurse (RN). Review of the facility daily care record indicated the resident was administered a bath on 1/28/26, 1/29/26, and administered a shower on 1/30/26. On 2/5/26 at 1:00 p.m., during an interview Licensed Practical Nurse (LPN) 7 indicated, when she sent a resident to the hospital she would do a skin assessment prior to the resident leaving the facility. She indicated she was not aware of skin issues other than bruising to the right arm of Resident L. She indicated the resident had a little redness under her breasts. She indicated they were now applying Nystatin powder under breasts for redness. On 2/5/26 at 1:08 p.m., during an interview CNA 6 indicated Resident L required assistance to put on and take off her bra, upper and lower body clothing. She indicated she was not aware of any skin issues. On 2/5/26 at 1:10 p.m., during an interview the DON indicated she did not think it was a policy to do a skin assessment prior to discharge. She indicated she would not normally do a skin assessment prior to discharge. She indicated the facility does weekly skin checks and monthly skin sweeps. The DON indicated the resident did not have any skin issues at this time. On 2/5/26 at 1:20 p.m., during an interview the Administrator indicated the CNA who provided care for the resident on 1/27/26 provided bathing assistance to Resident L. The administrator indicated if a resident refused to be administered a shower the facility would contact the family and ask them to talk with the resident. In addition, they would attempt several times to administer a shower or bath to the resident. On 2/5/26 at 1:35 p.m., during an interview CNA 8 indicated on 1/27/26 she took care of Resident L. She indicated she did not administer a shower, but she administered a partial bath. She had some redness under the breast. She indicated the resident had a white bra and a [NAME] orange bra which is tight, but she could not remember which one she had on that day. She indicated she assisted the resident to wash under her breasts, her back and under arms. She indicated she removed the resident's bra while assisting with bath. In addition, she provided care to her an hour prior to discharge and helped her dress. She indicated there was nothing unusual about her skin at that time. Resident L's medical record lacked documentation of this partial bath on 1/27/26. On 2/5/26 at 1:38 p.m., the Administrator provided a document, titled, Activities of Daily Living, dated 12/12/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. On 2/5/26 at 1:38 p.m., the Administrator provided a document, titled, Wound Management Policy, dated 5/10/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Promotion of treatment and healing of skin integrity impairment.It is the policy of this facility that those residents with impaired skin integrity are recognized by our care team, treated timely, and healing interventions are exhausted until the skin is healed. This citation relates to Intake 2731569. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure expired foods were disposed of and failed to ensure food was labeled properly in the walk-in refrigerator for 1 of 2 kitchen observations, and failed to ensure facial hair was covered with hair restraints during 1 of 2 kitchen observations. This deficient practice had the potential to affect 68 out of 69 residents who consumed food out of the kitchen. Findings include:1. During the initial tour of the kitchen, on 9/7/25 at 9:48 a.m., [NAME] 6 identified the dry storage area. The following items were noted on the top shelf of the bread rack:a. A moldy unopened package of hamburger buns. b. An entire loaf of French bread that contained mold. c. A package of sliced raisin bread with a use by date of 8/29/25.d. A 1/2 package of sliced raisin bread with a use by date of 8/29/25.e. Two unopened loaves of sliced raisin bread with a use by date of 8/29/25.During an interview, on 9/7/25 at 10:00 a.m. [NAME] 6 indicated the bread should have been discarded because it was past the use by date and was moldy. In the walk-in refrigerator the following items were observed:a. A plastic container that was full of cooked spiral pasta, the container did not contain a label with a prepared date or use by date. b. A metal container of leftover mashed potatoes, the container did not contain a label with a prepared date or use by date. c. A metal container of leftover chicken noodle soup, the container did not contain a label with a prepared date or use by date. d. A sheet pan full of leftover garlic bread, there was no label with a prepared date or use by date. During an interview, on 9/7/25 at 10:05 a.m. [NAME] 6 indicated leftover food was good for 3 days and then should be discarded. She indicated all food should be labeled with a prepared date and a use by date. 2. During a second kitchen observation on 9/9/25 at 11:02 a.m., [NAME] 9 entered the kitchen and obtained a loaf of bread, block of cheese, and ham slices. The cook washed his hands at the sink and then went to a table in the food prep area and began to make ham and cheese sandwiches for 4 residents. The cook had a full beard and mustache; the beard restraint was not worn properly; the sides of his beard were uncovered along with his mustache. The back of the cook's head was also uncovered; his hair net did not cover the entire back side of his head.During an interview, on 9/9/25 at 11:12 a.m., the Dietary Manager indicated all facial hair should be covered with beard restraints. On 9/7/25 at 11:45 a.m., the Administrator provided a document with a date of 1/2/24, titled, Labeling & Dating Guideline, and indicated it was the current policy being used by the facility. The policy indicated, .All opened and leftover items will be labeled with the date of opening/date stored and a discard/use by date. Storage time frames are as follows: 3 days (72 hours) .Label with the date of storage and the date of discard.When in doubt, throw it out.On 9/9/25 at 11:42 a.m., the Administrator provided a document with a revised date of 2/5/25, titled, Safe Food Handling, and indicated it was the current policy being used by the facility. The policy indicated, .c. shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.b. Leftover foods will be protected, labeled and dated with the date of original preparation and date of discard.3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure fingernail care (Residents 4, 5, and 10) and shaving (Resident 52) was provided to residents who required assistance with activities of daily living (ADL) care for 4 of 24 residents reviewed for ADLs. Findings include:1. On 9/7/25 at 11:13 a.m., Resident 4 was observed with long, jagged fingernails on both hands. The resident's fingernails had chipped nail polish and dark debris underneath them. On 9/8/25 at 11:48 a.m., Resident 4 was observed with long, jagged fingernails on both hands. The resident's fingernails had chipped nail polish and dark debris underneath them. Resident 4's record was reviewed on 9/8/25 at 3:16 p.m. Diagnoses on the resident's profile included, but were not limited to, dementia a general term for a group of conditions that cause a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving) and type two diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). A significant change Minimum Data Set (MDS) assessment, dated 8/5/25, indicated the resident had a severe cognitive impairment and required substantial assistance from the staff for personal hygiene. The assessment lacked documentation the resident refused care. A care plan, initiated on 8/23/23, indicated the resident required assistance with ADLs. Interventions included, but were not limited to, nail care on bath days and as needed and report any changes to the nurse. Progress notes, dated August and September 2025, lacked documentation the resident was offered, refused, or provided fingernail care. The electronic point of care (POC) bathing documentation for the last 30 days indicated the resident was scheduled for a shower on Mondays and Thursdays. Shower sheets, dated August and September 2025, indicated the resident received a shower on 8/4/25, 8/7/25, 8/11/25, 8/14/25, 8/18/25, 8/21/25, 8/25/25, 8/28/25, 9/4/25, and 9/8/25. The shower sheets lacked documentation the resident was offered, provided, or refused fingernail care. During an interview, on 9/10/25 at 10:50 a.m., the Director of Nursing (DON) indicated Resident 4 sometimes refused ADL care, but she was not sure if refusals were documented or care planned. During an interview, on 9/10/25 at 11:42 a.m., the Social Services Director (SSD) indicated she was unable to find documentation Resident 4 refused fingernail care. 2. During an interview, on 9/8/25 at 11:03 a.m., Resident 5's family member indicated when they visited the resident they often found the resident's fingernails not clean. On 9/8/25 at 11:47 a.m., Resident 5 was observed up in the dining room for lunch. The resident's fingernails on both hands had dark debris underneath them. On 9/9/25 at 1:23 p.m., Resident 5 was observed with dark debris underneath her fingernails and chipped nail polish. Resident 5's record was reviewed on 9/9/25 at 2:24 p.m. Diagnoses on the resident's profile included, but were not limited to, cerebral infarction (blood flow to brain interrupted causing brain damage), hemiplegia and hemiparesis (neurological conditions that affect one side of the body) following cerebral infarction, and type two diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). A quarterly Minimum Data Set (MDS) assessment, dated 6/12/25, indicated the resident had a severe cognitive impairment and was dependent on staff assistance for personal hygiene. The assessment lacked documentation the resident refused care. A care plan, initiated on 12/23/23, indicated the resident required assistance with ADLs. Interventions included, but were not limited to, nail care on bath days and as needed and report any changes to the nurse. Progress notes, dated August and September 2025, lacked documentation the resident was offered, provided, or refused fingernail care. The electronic point of care (POC) bathing documentation for the last 30 days indicated the resident was scheduled for a shower on Tuesdays and Fridays. Shower sheets indicated the resident received a shower on 8/1/25, 8/5/25, 8/8/25, 8/12/25, 8/15/25, 8/19/25, 8/22/25, 8/26/25, 8/29/25, 9/2/25, 9/5/25, and 9/9/25. The shower sheets lacked documentation the resident was offered, provided, or refused fingernail care. During an interview, on 9/10/25 at 10:42 a.m., the Director of Nursing (DON) indicated fingernail care should have been provided with showers. If the resident refused fingernail care it probably should have been documented on the shower sheets, but they may just notify the nurse or manager. Nurses provided fingernail care to diabetic residents. During an interview, on 9/10/25 at 10:50 a.m., the DON indicated Resident 5 sometimes refused ADL care, but she was not sure if it was documented or care planned. During an interview, on 9/10/25 at 11:42 a.m., the Social Services Director (SSD) indicated Resident 5 sometimes became physically aggressive with care but was unable to provide documentation the resident refused fingernail care. The SSD indicated care refusal was not normally care planned. 3. On 9/8/25 at 9:51 a.m., during initial observation, observed Resident 10 noted to have long fingernails with debris under nails and heavy beard growth. On 9/10/25 9:53 a.m., observed Resident 10 in wheelchair noted to have heavy beard growth. The resident indicated he is supposed to be shaved during showers, but the staff had not shaved him for a long time. The resident indicated he would like to be shaved. He indicated he had trimmed his nails, but they needed to be trimmed again. Nails were long with debris under the nails. On 9/10/25 at 9:00 a.m., reviewed the medical record of Resident 10. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but was not limited to type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). A quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident had limited cognition and required assistance of one to provide activities of daily care needs. Review of the Certified Nurse aide (CNA) documentation indicated the resident was administered a shower by the staff at least twice weekly. 4. On 9/8/25 at 10:00 a.m., during initial observation and interview, Resident 52 was noted to have heavy bead growth. The resident indicated he would like to be shaved but the staff had not provided any assistance to shave him. On 9/10/25 at 11:00 a.m. during random observation, Resident 52 had not been shaved. Review of the medical record indicated the resident was admitted to the facility on [DATE]. admission diagnosis included but not limited to congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A quarterly MDS, dated [DATE], indicated the resident had a mild cognition deficient and required assistance with daily care needs including grooming and dressing. Review of the CNA documentation the record indicated the resident was administered a shower by the staff at least twice weekly. On 9/10/25 at 10:00 a.m., during interview, Licensed Practical Nurse (LPN) 5 indicated the staff shaved residents and trimmed nails on shower days and as needed. She indicated the nurses trimmed nails of diabetic residents. On 9/10/25 at 10:05 a.m., during interview, CNA 11 indicated she shaved the residents on shower days and trimmed their nails if needed. On 9/10/25 at 10:45 a.m., during interview, the Director of Nursing (DON) indicated the residents should be shaved and nail care done on shower days and as needed. On 9/10/25 at 11:49 a.m., the Administrator provided a document, titled, Activities of Daily Living (ADLs), dated 12/12/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Care and Services will be provided for the following activities of daily living.1. Bathing, dressing, grooming and oral care. On 9/10/25 at 10:48 a.m., the DON provided a document, titled, Nail Care, dated 12/12/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.3. Routine cleaning and inspection will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing will be provided on a regular schedule.6. b. Only licensed nurse shall trim or file fingernails of residents with diabetes. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer (a localized area of tissue damage that develops when prolonged pressure is applied to the skin, usually over a bony prominence) dressing changes were performed with appropriate hand hygiene (Residents 4 and 43), pressure ulcers were staged accurately, and treatments were adjusted when a wound changed (Resident 4) for 2 of 4 residents reviewed for pressure ulcers. Findings include:1. On 9/9/25 at 10:03 a.m., the Wound Nurse was observed completing Resident 4's pressure ulcer dressing change, assisted by Certified Nurse Aides (CNAs) 11 and 13. The Wound Nurse put on a gown and gloves prior to entering Resident 4's room and was not observed to have washed her hands. The Wound Nurse knocked on the resident's door, opened the door, and carried the dressing supplies into the room with her gloved hands. The Wound Nurse placed the supplies directly on the resident's bedside table, with no barrier between the supplies and the table. The Wound Nurse was not observed to clean the resident's bedside table prior to placing the dressing supplies on it. While CNAs 11 and 13 were assisting the resident to stand, the Wound Nurse touched the privacy curtain and the resident's wheelchair with her gloved hands. The Wound Nurse cleansed the wound on the resident's coccyx; while wearing the same gloves she had entered the room with. The Wound Nurse removed the gloves and donned new gloves but did not perform hand hygiene with the glove change. The Wound Nurse applied cream to the wound bed and placed the dressing on the wound. The Wound Nurse removed her gloves, did not perform hand hygiene, and opened the resident's door to retrieve more supplies for the resident's care. Resident 4's record was reviewed on 9/8/25 at 3:16 p.m. Diagnoses on the resident's profile included, but were not limited to, dementia a general term for a group of conditions that cause a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving) and type two diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). A significant change Minimum Data Set (MDS) assessment, dated 8/5/25, indicated the resident had a severe cognitive impairment, required substantial assistance from the staff for activities of daily living (ADLs), and had one stage 3 (full thickness tissue loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed, and slough may be present but does not obscure the depth of tissue loss) pressure ulcer that was not present upon admission. A skin evaluation, dated 5/30/25, indicated the resident had a new area of skin impairment on the coccyx (tailbone). The wound was a stage 2 (partial thickness skin loss with a red pink wound bed, without slough) pressure ulcer and measured 1.3 centimeters (cm) in height, 0.7 cm in width, and 0.1 cm in depth. The evaluation indicated a treatment was applied to the area. A physician's order, dated 5/31/25 and discontinued on 7/1/25, indicated cleanse coccyx with wound cleanser, pat dry, apply collagen (promotes healing and new cell growth) to wound bed, and cover with a bordered gauze daily and as needed if soiled or dislodged. A skin condition evaluation, dated 6/10/25, indicated the resident's coccyx wound remained a stage 2 pressure ulcer and measured 1.5 cm in height, 0.8 cm in width, and 0.2 cm in depth. The wound bed was 100 percent granulation tissue (new pink or red tissue). A skin condition evaluation, dated 6/17/25, indicated the resident's coccyx wound remained a stage 2 pressure ulcer and measured 1.3 cm in height, 0.5 cm in width, and 0.2 cm in depth. The wound bed was 100 percent granulation tissue. A skin condition evaluation, dated 6/24/25, indicated the resident's coccyx wound remained a stage 2 pressure ulcer and measured 1.3 cm in height, 0.4 cm in width, and 0.2 cm in depth. The wound bed was 100 percent granulation tissue. A skin condition evaluation, dated 7/1/25, indicated the resident's coccyx wound remained a stage 2 pressure ulcer and measured 1.5 cm in height, 1 cm in width, and 0.5 cm in depth. The wound bed was 80 percent granulation tissue and 20 percent slough (dead, non-viable tissue only present in stage 3 or greater pressure ulcers). The evaluation lacked documentation the pressure ulcer's stage was upgraded to a stage 3 upon the discovery of slough in the wound bed. A physician's order, dated 7/2/25 and discontinued on 7/22/25, indicated cleanse wound on coccyx with wound cleanser, pat dry, apply hydrogel (treatment to maintain a warm, moist wound bed), and cover with bordered gauze daily and as needed if soiled or dislodged. A skin condition evaluation, dated 7/8/25 indicated the resident's coccyx wound remained a stage 2 pressure ulcer and measured 1.4 cm in height, 0.4 cm in width, and 0.4 cm in depth. The wound bed was 100 percent granulation tissue. A skin condition evaluation, dated 7/15/25, indicated the resident's coccyx wound deteriorated to a stage 3 and measured 2.3 cm in height, 1.4 cm in width, and 0.6 cm in depth. The wound bed was 30 percent granulation tissue and 70 percent slough. The evaluation lacked documentation the physician was notified of the deterioration in the pressure ulcer. Progress notes, dated 7/15/25 to 7/23/25, lacked documentation the physician was notified the resident's pressure ulcer deteriorated. A care plan, last revised on 7/16/25, indicated the resident had a stage three pressure ulcer to the coccyx. Interventions included, but were not limited to, document abnormal findings and notify the physician and notify the physician of worsening or unrelieved symptoms. A skin condition evaluation, dated 7/22/25, indicated the resident's coccyx wound remained a stage 3 and measured 2.1 cm in height, 1.4 cm in width, and 0.5 cm in depth. The wound bed was 100 percent slough. A physician's order, dated 7/23/25, indicated cleanse coccyx with normal saline, apply Santyl (helps remove non-viable tissue) to wound bed, apply calcium alginate (manages wound drainage), and cover with bordered gauze daily and as needed if soiled or dislodged. A skin condition evaluation, dated 9/2/25, indicated the resident's coccyx wound remained a stage 3 and measured 1.9 cm in height, 0.4 cm in width, and 0.4 cm in depth. The wound bed was 50 percent granulation tissue and 50 percent slough. During an interview on 9/10/25 at 1:16 p.m., the Wound Nurse indicated she thought she may have forgotten to bring her hand sanitizer into Resident 4's room for the dressing change so she had not used it when she changed her gloves. She put gloves on before she entered the resident's room so she had to touch her door to open it and enter the room. She was not sure if the wound should have been upgraded to a stage 3 pressure ulcer when slough was noted in the wound bed. The Wound Nurse indicated she thought she had two weeks to notify the physician of changes in the wound, but when asked if there was a change in the wound's condition would the physician be notified right away she indicated, Well, yeah. During an interview, on 9/10/25 at 1:40 p.m., the Director of Nursing (DON) indicated they were not required to put a barrier down between dressing change supplies and the bedside table if they cleaned the bedside table first. The DON indicated the Wound Nurse told her she cleaned the bedside table, but the DON was not sure. During an interview, on 9/10/25 at 1:50 p.m., the DON indicated if there was slough in the wound bed then it was not a stage two and should have been upgraded to a stage three. If there was a change or deterioration in the wound, such as an increase in the size or stage, the physician should have been notified the same day. During an interview, on 9/10/25 at 1:53 p.m., the Wound Nurse indicated she was unable to provide further documentation the physician was notified when the wound deteriorated on 7/15/25, prior to 7/23/25, when the treatment was changed. On 9/10/25 at 11:44 a.m., the Administrator provided a document titled, Wound Management, dated 1/2/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Procedure.5. Treatment decisions will be based on.b. Characteristics of the wound: i. Pressure injury stage.ii. Size.vi. Condition of the tissue in the wound bed.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing, b. Changes in the characteristics of the wound (see above). On 9/10/25 at 11:44 a.m., the Administrator provided a document titled, Wound Management Policy, dated 5/30/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.It is also the policy of this facility that those residents with impaired skin integrity are recognized by our care team, treated timely, and interventions to heal are not exhausted until the skin is healed.Promotion of treatment and healing of skin integrity impairment: It is the policy of this facility that those residents with impaired skin integrity are recognized by our care team, treated timely, and healing interventions are exhausted until the skin healed.The treatment plan will be professionally interconnected with RCT [Resident Care Team] members to optimize a healing solution. 2. Resident 43's wound dressing change was observed on 9/9/25 at 10:43 a.m. The procedure was performed by the facility wound nurse and assisted by Certified Nursing Assistant (CNA) 11. Prior to entering the resident's room, the wound nurse gathered all supplies from the wound treatment cart. At the same time, she indicated she had already washed her hands prior to gathering the supplies. She was observed with gloves already on her hands. After entering the resident room the wound nurse placed all the supplies for the procedure directly onto the resident's mattress without a barrier. She removed the old dressing from the resident's hip and discarded the dressing into the trash bag which was sitting on the floor next to the bed. She removed her gloves, sanitized her hands with hand sanitizer, donned new gloves and completed procedure. She removed her gloves and threw the gloves into the trash bag next to the bed. The nurse then sanitized her hands with hand sanitizer, left the room, returned to the treatment cart and gathered supplies to perform a treatment to a surgical wound on the resident. She returned to the room, placed the treatment supplies directly onto the resident's bedside table without a barrier. She then donned new gloves and proceeded to begin the treatment. The nurse was not observed to wash her hands between the treatment procedures. Resident 43's record was reviewed on 9/9/25 at 11:23 a.m. The profile indicated the resident's diagnoses included, but were not limited to, syringomyelia (the development of a fluid-filled cyst [a syrinx] within the spinal cord that can compress and damage the cord, causing symptoms like pain, muscle weakness, numbness, and balance issues), syringobulbia (a related condition where this cyst extends into the brainstem, leading to more severe symptoms such as breathing difficulties and swallowing problems), and hemiparesis and hemiplegia following a cerebral infarction (hemiparesis is weakness on one side of the body, while hemiplegia is complete paralysis of one side of the body caused by a stroke). A quarterly Minimum Data Set (MDS) assessment, dated 6/2/25, indicated the resident had severe cognitive deficit, was substantial/maximal to totally dependent with all ADLs (activities of daily living-basic self-care tasks that individuals perform on a regular basis to maintain their daily life) and had a stage 4 pressure wound (a deep, open sore where the damage extends through all skin layers and into the underlying muscle, tendon, cartilage, or bone, often causing extensive tissue destruction). A care plan, dated 8/18/25, indicated the resident had a stage 4 pressure wound to his right hip. Interventions included, but were not limited to, keep the area clean and provide treatment as ordered. A physician's order, dated 9/1/25, indicated to cleanse wound to right hip with wound cleanser, pat dry, apply collagen and calcium alginate, then cover with a bordered dressing daily and as needed for soilage or dislodgement. During an interview, on 9/10/25 at 1:45 p.m., the Director of Nursing (DON) indicated that a barrier should have been used under the wound treatment supplies to keep the supplies clean and handwashing should have been completed between treatments of different wounds. On 9/10/25 at 1:45 p.m., the DON provided an undated document, titled, Validation Checklist Wound Care, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To determine if the individual performing wound care is doing so in accordance with facility policy.Procedure Observed.4. Cleaned bedside table as needed.8. Maintained supplies as sterile/clean as indicated, avoiding contamination.13. Performed hand hygiene. 3.1-40(a)(2)

Based on observation and interview, the facility failed to ensure medications were stored and medications were dated when opened for 2 of 2 observations. Findings include:On 9/7/25 at 9:50 a.m., observed unattended medications on the counter at the nurses' station. The prescription label indicated the medications were for Resident 47. The resident was discharged from the facility 9/7/25.On 9/7/25 at 9:55 a.m., during interview Licensed Practical Nurse (LPN) 5 indicated the medications should not be left unattended at the nurses' station. She indicated the resident had just passed away and the medications were removed and left there. She indicated they should have been in the pharmacy.On 9/7/25 at 2:19 p.m., during interview RN 8 the medication cart and computer screen must be locked when she was not at the medication cart.On 9/9/25 at 1:18 p.m., observed 200 hall pharmacy medication room with LPN 5. Observed an opened and undated vial of Aplisol Tuberculin testing solution in the refrigerator. The LPN indicated the vial should have been dated when opened.On 9/7/25 at 11:45 a.m., the Administrator provided a document, titled, Medication Storage, dated 12/12/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.1. General Guidelines.a. All drugs and biologicals will be stored in locked compartments.On 9/9/25 at 2:10 p.m., the Director of Nursing provided a document, titled, Medication Administration, dated 1/27/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.3. Multi-dose medication vials/devices a. should be labeled with date opened/accessed.3.1-25(j)

Based on record review and interview, the facility failed to ensure that medications were documented as administered, for 1 of 5 residents reviewed for unnecessary medications (Resident 1). Findings include:Resident 1's record was reviewed on 9/8/25 at 2:39 p.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin) and hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). An admission Minimum Data Set (MDS) assessment, dated 6/11/25, indicated the resident had no cognitive deficit and had no documented behavior of refusals of care. A review of the resident's care plan lacked documentation of the resident refusal of medications, treatments, or care. A physician's order, dated 6/4/25, indicated to administer 8 units of Insulin Glargine medication to treat diabetes 100 units per milliliter (ml) at bedtime for diabetes. The July 2025 Medication Administration Record (MAR) lacked documentation of the 6:00 p.m., dose of the medication being administered on 7/22/25. The record lacked documentation of a resident refusal or unavailability. A physician's order, dated 6/4/25, indicated to administer one 300 milligram (mg) capsule of Gabapentin (medication used to treat seizures and nerve pain) by mouth three times daily for pain. The August 2025 MAR lacked documentation of the morning dose of the medication being administered on 8/15/25. The record lacked documentation of a resident refusal or unavailability. A physician's order, dated 6/5/25, indicated to administer insulin Aspart (medication to treat diabetes mellitus) 100 unit per ml via sliding scale (where the dose of insulin is adjusted based on a person's current blood sugar level) with meals for diabetes. The July 2025 MAR lacked documentation of the 5:00 p.m., dose of the medication being administered on 7/22/25. The record lacked documentation of a resident refusal or unavailability. A physician's order, dated 6/27/25, indicated to administer 50 mcg (micrograms) of levothyroxine sodium (medication to treat hypothyroidism), by mouth two times a day for hypothyroidism. The August 2025 MAR lacked documentation of the morning dose of the medication being administered on 8/15/25. The record lacked documentation of a resident refusal or unavailability. During an interview, on 9/9/25 at 10:00 a.m., the Director of Nursing (DON) indicated medications should be administered at the time they were scheduled. The administration should be documented on the MAR or if not administered a reason why should have been documented. On 9/9/25 at 10:50 a.m., the DON provided a document, dated 1/2/24, titled, Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.14. Administer medications as ordered.17. Sign MAR after administered. 3.1-50(a)(1)

Based on observation, record review, and interview, the facility failed to ensure respiratory equipment was cleaned and stored appropriately after use for 1 of 1 resident reviewed for respiratory care (Resident 27). Findings include:On 9/07/2025 11:34 a.m., during an initial observation, observed Resident 27 lying in bed. Observed undated nebulizer equipment (a main nebulization unit, a reservoir for holding the liquid for nebulization, and a mouthpiece through which drug aerosol is inhaled), unbagged next to the bedside table. Observed an oxygen storage bag on the bedside table dated 8/25/25.On 9/08/2025 at 10:00 a.m., observed undated nebulizer equipment unbagged on the bedside table of Resident 27.On 9/09/2025 at 9:00 a.m., observed nebulizer mask and tubing unbagged lying in Resident 27 bed. On 9/9/25 at 9:30 a.m., reviewed the medical record of Resident 27. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, 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) and COPD (chronic obstructive pulmonary disease, a group of diseases that cause airflow blockage and breathing-related problems).An admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had limited cognition and required assistance from the staff for daily care needs. A physician order, dated 7/15/25, indicated to administer albuterol sulfate 2.5 mg (milligrams)/3 ml (milliliter) 0.083% nebulization solution inhale 1 vial by mouth every 6 hours as needed for shortness of breath /wheezing.A physician order, dated 9/6/25, indicated to administer ipratropium-albuterol 0.5-2.5 (3) mg/3 ml solution. Inhale 1 vial by mouth via nebulizer every 4 hours for shortness of breath for 7 days.A care plan, dated 7/18/25, indicated the resident was at risk for respiratory distress related to COPD.A care plan, dated 7/14/25, indicated the resident needed assistance with activities of daily living.Review of the Medication Administration Record (MAR) indicated the resident was assessed by the nurse after nebulizer treatment.On 9/9/25 at 10:55 a.m., during interview Licensed Practical Nurse LPN (10) indicated once a resident had completed a nebulizer treatment she would assess the resident and obtain vital signs she would then clean the nebulizer equipment with bleach wipe and leave it to dry for three minutes.On 9/9/25 at 2:00 p.m., the Director of Nursing (DON) provided a document, titled, Oxygen Administration, dated 7/2/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.E.5. Keep delivery devices covered in plastic bag when not in use.3.1-47(a)(4)3.1-47(a)(5)3.1-47(a)(6)

Based on observation record review and interview, the facility failed to ensure timely documentation and reporting regarding change of resident condition for 1 of 1 resident reviewed for catheter (a thin, flexible catheter used especially to drain urine from the bladder). (Resident 65) Findings include:On 9/07/25 at 12:05 p.m., during interview and observation, Resident 65 had a suprapubic catheter (SPC, a tube that drains urine from the bladder by inserting it through a small incision in the lower abdomen and into the bladder). Resident 65 indicated he did not know why he had a catheter, it was not draining now, and it was leaking. No urine was observed in the tubing or the drainage bag (a collection bag used to drain and store urine).On 9/7/25 at 1:00 p.m., the medical record of Resident 65 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), urinary retention (inability to empty the bladder after urinating), and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks).A physician order, dated 1/4/24, indicated supra pubic tube catheter to bedside drainage urinary retention with neurogenic bladder (a condition where the bladder muscles and nerves do not function properly, leading to difficulty or inability to control urination).A physician order, dated 8/28/25, indicated change supra pubic catheter every 4 weeks routinely.A physician order, dated 3/20/24, indicated to provide super pubic catheter care every shift.On 9/8/25 at 1:30 p.m., observed Resident 65 lying in bed. Observed the catheter bag empty of urine and no urine in the drain tube. The resident indicated he had just been changed and was very wet.On 9/8/25 at 1:35 p.m., during interview Registered Nurse RN (8) indicated she was not aware the catheter had not been draining since 9/7/25 and no one had informed her. During review of the medical record with the Unit Manager she indicated the last entry of output was at 5:43 a.m., on 9/8/25 the record indicated urinary output recorded as 450 cc. (cubic centimeters, a unit of measure)On 9/8/25 at 2:00 p.m., during interview the Director of Nursing (DON) indicated the resident had a long standing issue with the catheter and continued to urinate normally. She indicated the nurse had called the physician after being notified of the lack of urine and the catheter was not working. She acknowledged the Certified Nurse Aide (CNA) documentation should only document actual output from catheter.On 9/9/25 at 11:00 a.m., during interview Certified Nurse Aide CNA (7) indicated if a resident had a foley catheter and it was leaking or not draining urine she would report the issue immediately to the nurse as a change in condition.On 9/9/25 at 2:00 p.m., the DON provided a document, titled, Documentation in the medical record, dated 12/12/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.3. Principles of documentation include, but are not limited to.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and /or responses to care.3.1-41(a)(1)

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect, when the facility failed to ensure a resident was provided adequate monitoring and care for 8 hours for 1 of 3 residents reviewed for neglect (Resident B). Findings include: During a confidential interview, on [DATE] at 6:33 p.m., the interviewee indicated Resident B was not provided monitoring or care from 7:14 p.m. the night of [DATE] until 4:06 a.m. the morning of [DATE]. Resident B was found deceased in her bed in her room by staff at 4:06 a.m. on [DATE]. The family was notified of the death at 4:12 a.m. The family arrived at the facility 21 minutes after they received the call, and Resident B was cold and hard to the touch. The family had installed motion sensor video cameras in the room that verified staff had not checked on the resident for 8 hours. The video was only activated on [DATE] at 7:13 p.m. and then again at [DATE] at 4:06 a.m. Those were the only 2 times staff were noted to be in the resident's room. Review of motion censor camera footage time stamped on [DATE] at 7:13 p.m. indicated staff was in Resident B's room providing care. Resident was resting in bed. Review of motion censor camera footage time stamped on [DATE] at 4:06 a.m. indicated RN 6 entered Resident B's room and found her deceased . On [DATE] at 7:47 p.m., Resident B's record was reviewed, her diagnoses included, but were not limited to, fracture of head and neck of right femur (a break in the bone near the hip joint), acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate blood, resulting in low blood oxygen levels), chronic diastolic (congestive) heart failure (a condition where the heart's left ventricle doesn't relax and fill properly during diastole [the filling phase], despite having normal ejection fraction [the amount of blood pumped out with each beat]), and chronic kidney disease stage 3 (moderate kidney damage, where the kidneys are not filtering waste and excess fluid as efficiently as they should). Facility census information indicated Resident B was admitted to the facility on [DATE]. A 5-day Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B had severe cognitive impairment and was frequently incontinent of urine. A care plan, dated [DATE], indicated the resident needed assistance with activities of daily living due to fracture of the right hip, congestive heart failure, and chronic kidney disease. Interventions included, but were not limited to, assisting with incontinent care, requiring assistance from staff with bed mobility, requiring assistance from staff with personal hygiene, requiring assistance from staff with transfers, and require assistance from staff for toilet use. The record lacked documentation of any nurse's progress notes from 7:14 p.m. on [DATE] till 4:06 a.m., on [DATE]. During an interview, on [DATE] at 7:31 p.m., Certified Nurse's Aide (CNA) 2 indicated that she mostly worked evening shift at the facility and would sometimes work over into night shift as well. She completed bed checks every 2 to 3 hours during her shift. During an interview, on [DATE] at 7:40 p.m., CNA 3 indicated that she mostly worked the evening shift at the facility and would sometimes work over into the night shift as well. She completed 3 bed checks during her 8-hour shift. She indicated most of the staff that she worked with were in the residents' rooms at least every 3 hours. During an interview, on [DATE] at 8:15 p.m., CNA 4 indicated she had gotten to the facility at 8 p.m. on [DATE] and worked through the night shift until morning of [DATE]. CNA 4 indicated she was in Resident B's room at around 9 to 9:30 p.m. on [DATE] and her eyes were closed, but she was breathing (shallow). CNA 4 completed bed checks every 2 hours. CNA 4 was back in Resident B's room around 1:00 a.m. and she wasn't wet (incontinent) and was breathing. The next time she was in the resident's room would have been after 4:00 a.m. and the resident was deceased , and she was cold to touch. During a phone interview, on [DATE] at 8:20 p.m., Registered Nurse (RN) 6 indicated she had obtained Resident B's vitals at the beginning of her shift on [DATE] and entered them into the computer later in the shift on [DATE]. She indicated she no longer waited to enter vitals in the computer anymore and documented them right after they were obtained. RN 6 found Resident B deceased on [DATE] at 4:06 a.m., she indicated the resident was cold to the touch at that time. RN 6 was not made aware of a change in condition for Resident B by any staff members throughout the shift. Review of a staff statement, on [DATE] at 5:50 p.m., indicated CNA 4 was in Resident B's room at 2:00 a.m. on [DATE] and she was still breathing but it was shallow. She advised the nurse at that time of the resident's breathing. Review of a staff statement, on [DATE] with no time stamp, indicated CNA 7 had arrived at the facility at 2:00 a.m. on [DATE] for her shift and she saw CNA 4 leaving Resident B's room at that time. Review of an undated staff statement, indicated RN 6 had arrived to the facility at 6:00 p.m. the night of [DATE] and obtained vital signs from the residents. She was in Resident B's room at 10:00 p.m. with CNA 4 and they were changing her. The next time she was in the resident's room was 4:00 a.m. on [DATE] and she was found deceased and cold to the touch. RN 6 had assumed that CNA 4 had checked on Resident B during the night. Review of an undated staff statement, indicated CNA 8 had worked at the facility from 6-10 p.m. on [DATE]. He was at the doorway for Resident B when he gave report to CNA 4 before he left for the night. During an interview, on [DATE] at 9:58 a.m., the Administrator indicated they had a facility video surveillance that was reviewed by her, and she was unable to verify that staff members were in Resident B's room during the times they had stated in their statements. The Administrator had started an investigation due to the facility becoming aware that the family had a camera in the room and indicated that Resident B was not attended to throughout the night. The facility was unable to verify anyone had entered the room for 8 hours. The family was aware that Resident B was not in good health but had concerns about the care that was not received. CNA 4 was no longer working at the facility as of the evening of [DATE]. During an interview, on [DATE] at 10:04 a.m., the Director of Nursing (DON) indicated it was not okay that staff had not been in Resident B's room for 8 hours. She indicated it was upsetting that staff had lied to them on their statements about how often they were in the resident's room. During an interview, on [DATE] at 10:59 a.m., the DON indicated CNA 8 and RN 6 were currently suspended and not on the schedule pending their investigation. On [DATE] at 10:47 a.m., the Administrator provided a document, dated [DATE], titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .The resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility.c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. On [DATE] at 10:47 a.m., the Administrator provided a document with a revised date of [DATE], titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, and indicated it was the policy currently being used by the facility. The policy indicated, .Neglect is the failure of the facility, it's Care Team Members or facility service providers to provide goods and services to a resident/patient necessary to avoid physical harm, pain, mental anguish, or emotional distress. This citation relates to Complaint 2571065. 3.1-27(a)3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 1 of 2 kitchen observations. This had the potential to affect 35-38 residents who ate meals from the kitchen. Finding includes: During a continuous kitchen observation of the puree (a smooth, crushed, or blended food that has the consistency of a creamy paste or liquid) food preparation, on 8/27/24 at 10:31 a.m. to 10:50 a.m., [NAME] 11 washed her hands at the sink for less than 20 seconds and began to scoop vegetables into a plastic container to puree them. She proceeded to scoop chicken broth into the container as well. [NAME] 11 turned on the puree blender and then went over to the steam table to scoop roasted potatoes and chicken broth into another plastic container to puree that was drying on the counter, she grabbed a paper towel to dry it further. She turned on the potatoes and then went back to the vegetables to see if they were completed. The cook had to add thickener to the vegetables because they were too runny. She went back to the potatoes and emptied them into a pan and took the plastic container they were pureed in and began to clean it at the three-compartment sink (manual procedure for cleaning and sanitizing dishes in commercial settings) along with a spatula. She went back to the other counter to check on the vegetables. She grabbed the spatula that was still wet from where she had washed it and used it to place the vegetables in another container and place in oven. [NAME] 11 took the container that she pureed the vegetables and washed in the 3-compartment sink, she then grabbed a paper towel and dried the container with the paper towel. The cook went back to the steam table and obtained 4 slices of ham and 4 slices of bread with a glove on one hand. The cook finished the ham and placed it into another container and placed in oven. During this entire observation the cook washed her hands at the start of the puree process and no other hand hygiene was observed. During a kitchen observation, on 8/27/24 at 10:55 a.m., Dietary Aide 10 was preparing lemonade into a [NAME] pitcher by using lemonade powder and water. The dietary aid placed his ungloved finger on the inside of the pitcher rim to remove a small particle and in doing so he touched the inside of the pitcher along with the lemonade as it began to splash out. He then placed a lid on the pitcher along with a sticker that contained a date of when it was prepared. The lemonade was being prepared for the lunch meal service. During an interview, on 8/27/24 at 11:00 a.m., the Dietary Manager indicated staff should not touch the inside of a drink pitcher with ungloved hands and she would be throwing out the lemonade that was contaminated this morning. The Dietary Manager indicated staff should be performing hand hygiene during the puree process when they go from a dirty to clean environment. [NAME] 11 would have cross contaminated the food going from the clean utensils to dirty utensils to clean again. She further indicated the utensils should be left to air dry and not used if still wet to puree with. On 8/27/24 at 12:28 p.m., the Dietary Manager provided a document, dated 12/12/23, titled, Dietary Personnel, and indicated it was the policy currently being used by the facility. The policy indicated, .The dietary department will employ sufficient and qualified staff to prepare and serve meals and maintain a sanitary environment On 8/27/24 at 12:28 p.m., the Dietary Manager provided a document, dated 12/12/23, titled, Food Production, and indicated it was the policy currently being used by the facility. The policy indicated, .4. Bare hands should never touch raw or ready to eat food directly .Gloves will be worn for single task preparation then removed and hand hygiene performed On 8/27/24 at 1:55 p.m., the Administrator provided a document, dated 12/23/23, titled, Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .c. rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed, addressed, and dated in a timely manner and failed to ensure documented rationale of pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident 45). Finding includes: Resident 45's record was reviewed on 8/16/24 at 2:16 p.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems), chronic diastolic congestive heart failure (occurs when left ventricle of the heart becomes still and can't relax properly. This prevents the heart from filling with enough blood between beats, resulting in several symptoms), and end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). An annual Minimum Data Set (MDS) assessment, dated 6/17/24, indicated the resident received medications which included, but were not limited to, insulin injections (medication use to lower blood sugar), anti-depressants (used to treat depressive symptoms), anti-coagulants (used to prevent or reduce blood clots from forming in the bloodstream), diuretics (increase the amount of urine produced in the kidneys) and opioid (prescription pain relief medication). a. A pharmacy recommendation, dated 8/6/23, recommended to reduce midodrine (a medication used to treat low blood pressure that causes severe dizziness or fainting) dose to 2.5 milligrams (mg) three times a day or discontinue if possible. The pharmacy recommendation was not signed, dated, or addressed by the physician. The resident's record lacked documentation of the pharmacy recommendation being accepted or denied and the rationale for the decision. A current physician order, dated 4/5/24, indicated to administer midodrine 5 mg, give one tablet by mouth three times a day. b. A pharmacy recommendation, dated 8/6/23, recommended to discontinue the medication Hiprex (used to treat bladder and kidney infections) because the medication was contraindicated with any degree of renal impairment. The pharmacy recommendation was not signed, dated, or addressed by the physician. The resident's record lacked documentation of the pharmacy recommendation being accepted or denied and the rationale for the decision. A current physician order, with an original start date of 2/7/23, indicated to administer Hiprex 1 gram, give one tablet twice a day. c. A pharmacy recommendation, dated 8/6/23, recommended to obtain lab work for the following drugs: atorvastatin (used to treat high cholesterol and triglyceride levels) obtain lipid profile (lab test that measures level of cholesterol and other fats in your blood) every 6 months, insulin obtain Hgb (hemoglobin) a1c (lab test that measures a person's blood sugar level over the past two to three months) every 3 months, furosemide (diuretic medication) obtain BMP (basic metabolic panel [a blood sample test that measures eight different substances in your blood]) every 6 months, cholecalciferol (vitamin D) obtain vitamin D every 6 months, cyanocobalamin (vitamin b12) obtain vitamin b[AGE] yearly, and a CBC (complete blood count [medical test that measures the number and types of cells in your blood]) The pharmacy recommendation was not signed, dated, or addressed by the physician. Review of a physician progress note, dated 8/21/23, indicated to continue medication as prescribed. The record lacked documentation of which medications the doctor reviewed to continue or a rationale behind continuing the medications. d. A pharmacy recommendation, dated 11/5/23, recommended to reduce the dose or attempt to hold the dose for 2 weeks and if no gastrointestinal symptoms occur, discontinue the medication. The resident was currently on Protonix (used to treat acid reflux and a damaged esophagus) 40 mg twice a day. The physician signed and dated the recommendation on 12/20/23 to reduce the medication to 40 mg daily. A current physician order, dated 12/23/23, indicated to administer Protonix 40 mg, give one tablet by mouth daily. e. A pharmacy recommendation, dated 6/6/24, recommended to attempt a dose reduction of Cymbalta (antidepressant medication). The physician signed and dated the recommendation on 8/9/24 to discontinue the Cymbalta. A social service note, dated 6/11/24 at 9:02 a.m., indicated a behavior meeting was conducted due to gradual dose reduction was due on Resident 45's Cymbalta. Social Service Director (SSD) indicated the facility would request the medication to be discontinued. A physician order, with a discontinued date of 8/13/24, indicated to administer Cymbalta 30 mg, give one capsule by mouth daily. f. A second request pharmacy recommendation, dated 6/7/24, recommended labs to be obtained. These were the same labs as advised above. The physician signed and dated the recommendation on 8/9/24. He agreed with recommendation. During an interview, on 8/26/24 at 2:49 p.m., the Director of Nursing (DON) indicated she was not aware of how long it took for some physicians to respond to pharmacy recommendations but should be timely. During an interview, on 8/26/24 at 2:52 p.m., the SSD indicated they had one physician that did not respond to pharmacy recommendations in a timely manner. During an interview, on 8/26/24 at 3:15 p.m., the DON indicated she understood the pharmacy recommendations were not addressed timely, and they may had to involve the Medical Director when physicians were not addressing them in a timely manner. On 8/27/24 at 9:48 a.m., the Administrator provided a document, with a revised date of 2/8/19, titled, Pharmacy Products and Services, and indicated it was the policy currently being used by the facility. The policy indicated, .iii) .For those issues that require provider intervention, the provider must identify whether they accept or reject part or the whole of the recommendation and must document rationale of why they recommendation is rejected in the resident's medical record .iv) The responsible provider will respond to the identified irregularities/recommendations within the time frame listed in the facility's policy or at most 30 days 3.1-48(a)(5)

Based on observation, interview, and record review, the facility failed to ensure multi-dose bottle of eye drops and multi-dose vial of tuberculin solution were dated when opened for 1 of 2 medication carts, and 1 of 1 medication rooms observed for medication storage (Resident 126). Findings include: 1. On 8/27/24 at 10:00 a.m., the 200-hall medication cart contained a multi-dose bottle of Latanoprost (treats high pressure in the eye, also known as glaucoma) eye drops for Resident 126. The bottle was opened and not dated. During an interview on 8/27/24 at 10:01 a.m., Licensed Practical Nurse (LPN) 5 indicated that the bottle and the container both should be dated when opened in case they get separated. On 8/29/24 at 9:02 a.m., a record review for Resident 126 was completed. Her diagnoses included, but were not limited to, glaucoma (a chronic eye disease that can cause vision loss and blindness by damaging the optic nerve). A physician's order, dated 8/21/24, indicated to administer Latanoprost solution 0.005%, one drop in both eyes at bedtime for glaucoma. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:53 a.m., she indicated that the Latanoprost eye drops were only good for 6 weeks after opening. 2. On 8/27/24 at 10:06 a.m., the 200-hall medication storage room refrigerator contained a multi-dose vial of Tuberculin Aplisol solution (injectable medication used to test for tuberculosis) that was opened and not dated. On 8/27/24 at 10:07 a.m., LPN 5 indicated that normally the box was dated when opened and the vials had recently been delivered. The package indicated that medication was ordered on 6/5/24, the lot number was 77298. She did not know when the vial could have been opened. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:53 a.m., she indicated that the Tuberculin solution was only good for 30 days after opening. On 8/27/24 at 10:46 a.m., the Executive Director (ED) provided and identified a document as current facility policy, titled, Medication Administration, dated 5/20/2022. The policy indicated, .To ensure that the facility, in coordination with the licensed pharmacist, provide for accurate labeling to facilitate safe administration of medications and consideration of precautions in accordance with the currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable .1. Medication labeling must be typed or printed and clearly indicate .3. Multi-dose medication vials/devices .a. should be labeled with date opened/accessed .ii. Once opened/accessed the vial/device should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for vial/device after opened/accessed On 8/29/24 at 1:54 p.m., the DON provided and identified a document as current facility policy, titled, Drug Expiration Dating, dated 2/22/2022. The policy indicated, .**ALL medication(s) with shortened expiration dates after opening must be marked with the date opened** .Aplisol/Tubersol .Expiration date * .28 days from date opened** On 8/29/24 at 2:12 p.m., the DON provided and identified a document as the manufacturing package insert from Pfizer for Resident 126's Latanoprost eye drop solution with a revised date of August 2011. The package insert indicated, .Package insert for the 2.5 mL fill - package of 1 bottle: Xalatan, latanoprost ophthalmic solution 0.005% .Storage .Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees C (77 degrees F) for 6 weeks 3.1-25(j) 3.1-25(k)

Based on observation, interview, and record review, the facility failed to follow physician orders for 1 of 4 residents observed for medication administration (Resident 126). Findings include: During an observation of medication pass, on 8/27/24 at 9:48 a.m., observed Licensed Practical Nurse (LPN 5) confirm Resident 126's order and prepared a Lidocaine patch (patch wore on the skin for pain relief) by initialing and dating it. When the LPN went to apply the new patch, she had to remove an undated Lidocaine skin patch that was located on the resident's back, then she applied the new one. During an interview on 8/27/24 at 9:50 a.m., LPN 5 indicated that the patch she removed from the resident's back before placing the new one was not labeled, did not have a date on it, and should have been removed last night. The patch was only to be left on for 12 hours at a time then left off for 12 hours. She reviewed the medication administration record and determined that the last patch was documented as being applied on 8/26/24 at 8:54 a.m. There was not a place in the MAR to document that patches were removed. On 8/29/24 at 9:02 a.m., a record review for Resident 126 was completed. Her diagnoses included, but were not limited to, osteoporosis (a disease that causes bones to become fragile and more likely to break), and pain. A physician's order, dated 8/22/24, indicated to apply Lidocaine 5% patch, 1 patch to low back daily, every morning for pain. On for 12 hours then off for 12 hours. A Medicare 5-day Minimum Data Set (MDS) assessment, dated 6/8/24, indicated the resident had a brief interview for mental status (BIMS) score of 12, indicating she had moderate cognitive impairment. On 8/27/24 at 10:46 a.m., the Executive Director (ED) provided and identified a document as current facility policy titled, Medication Administration, dated 1/2/24. The policy indicated, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, frequency, rout, and time .14. Administer medication as ordered 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment, and the facility failed to ensure a physician order was obtained for nebulizer treatments for 2 of 4 residents reviewed for respiratory care (Residents 22 and 4). Findings include: 1. On 8/23/24 at 3:03 p.m., Resident 22's unbagged nebulizer mouthpiece and tubing were observed on the resident's side table, there was a clear liquid in the medication chamber (small plastic bowl where medication is placed). The nebulizer machine was observed on the resident's bed. Resident 22's record was reviewed on 8/26/24 at 11:00 a.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems) and acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [inadequate supply of oxygen] with or without hypercapnia [too much carbon dioxide in your blood]). An admission Minimum Data Set (MDS) assessment, dated 6/19/24, indicated the resident was cognitively intact and was not on oxygen therapy at the time. A care plan, dated 6/13/24, indicated the resident was at risk for respiratory distress related to chronic respiratory failure. Interventions included but were not limited to, administer medication as ordered and oxygen as ordered. A physician order, dated 8/16/24 with a discontinue date of 8/21/24, indicated ipratropium-albuterol inhalation solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier); 0.5-2.5mg (milligrams) 3 ml (milliliters). Order was to administer 1 vial inhale orally four times a day for pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) for 5 days. The record lacked a physician order for a nebulizer treatment beyond 8/21/24. During an interview, on 8/27/24 at 9:38 a.m., Resident 22 indicated she was getting breathing treatments for a few days due to her having pneumonia. She was also using oxygen at night per nasal cannula (a device that delivers extra oxygen through a tube and into your nose). During an interview, on 8/28/24 at 9:15 a.m., Qualified Medication Aide (QMA) 8 indicated she had given Resident 22 a nebulizer treatment on the morning of 8/28/24. During an interview, on 8/28/24 at 9:20 a.m., Resident 22 indicated she had received a breathing treatment this morning. During an interview, on 8/28/24 at 9:36 a.m., the Director of Nursing (DON) indicated Resident 22 did not have an order currently for routine or as needed breathing treatments and staff should not administer a medication without a physician order. During an interview, on 8/28/24 at 9:57 a.m., Licensed Practical Nurse (LPN) 4 indicated nebulizer equipment should be placed in a dated bag for storage while not in use. 34525 2. On 8/23/24 at 9:05 a.m., a nebulizer unit (a machine that turns liquid medicine into a mist that can be inhaled through a mouthpiece or mask) was observed sitting on Resident 4's bed side table. At the same time, the resident indicated she had as needed (PRN) breathing treatments. The nebulizer mouthpiece and tubing were unbagged. During a random observation, on 8/26/24 at 12:02 p.m., the resident's nebulizer remained on the bed side table. The nebulizer mouthpiece and tubing were unbagged. During a random observation, on 8/27/24 at 9:12 a.m., the resident's nebulizer remained on the bed side table. The nebulizer mouthpiece and tubing were unbagged. Resident 4's record was reviewed on 8/27/24 at 8:56 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems). A quarterly Minimum Data Set (MDS) assessment, dated 7/17/24, indicated the resident had no cognitive deficit, had shortness of breath or trouble breathing when lying flat, and was not on oxygen therapy at the time. A care plan, dated 6/23/23, indicated the resident was at risk for respiratory distress related to COPD and was unable to lie flat due to it causing shortness of breath. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 6/22/23, indicated to administer 2 puffs of albuterol sulfate (a medication that treats and prevents breathing problems caused by lung diseases like asthma and COPD) HFA inhalation aerosol solution (a type of propellant spray) 108 (90 base) micrograms (mcg), every 4 hours as needed for shortness of breath or oxygen saturation (the amount of oxygen circulating in the blood) less than 95%. A historical review of the physician orders lacked documentation of an order for nebulizer treatments. A review of the resident's progress notes from January 2024 through August 2024 lacked documentation that any nebulizer treatments had been administered or that the resident had any order for nebulizer treatments. During an interview, on 8/27/24 at 9:00 a.m., Licensed Practical Nurse (LPN) 3 indicated she had never given the resident a nebulizer treatment because she did not believe the resident had an order for a nebulizer. She did have a PRN inhaler ordered, but she rarely requested it. During an interview, on 8/27/24 at 9:18 a.m., Resident 4 indicated she had an inhaler that she would usually use. There had been a day, a couple months ago, that she had a very difficult time breathing and the nurse brought in the nebulizer and gave her a breathing treatment. She was unable to remember what nurse had administered the nebulizer treatment for her. During an interview, on 8/27/24 at 10:17 a.m., the Director of Nursing (DON) indicated she was not aware that the resident had a nebulizer treatment ordered. The nebulizer should not be at the bedside if the resident did not have an order for it and the resident should never be given a nebulizer treatment if there was no order for it. The proper storage of a nebulizer was to ensure the mouthpiece and tubing were stored in a plastic bag when not in use. On 8/27/24 at 10:46 a.m., the Executive Director (ED) provided a document, dated 12/12/23, titled. Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Medications are administered .as ordered by the physician .Procedure: .10. Review MAR to identify medication to be administered. 11. Compare medication source .with MAR to verify resident name, medication .14. Administer medications as ordered .,17. Sign MAR after administration On 8/27/24 at 10:55 a.m., the ED provided a document, dated 12/12/23, titled, Oxygen Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .5 .e. Keep delivery devices covered in plastic bag when not in use 3.1-47(a)(6)

Based on observations, interviews, and record review, the facility failed to accurately document medication administration for 1 of 1 resident reviewed for peritoneal dialysis (Resident 43). Findings include: On 8/23/24 at 3:03 p.m., observed a peritoneal dialysis (PD) machine (a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body), on Resident 43's bedside table. On 8/27/24 at 11:41 a.m., a record review was completed for Resident 43. His diagnoses included, but were not limited to, chronic kidney disease stage 5 (end stage kidney failure), and dependence on renal dialysis (treatment that helps people whose kidneys are no longer able to filter blood properly). A current physician's order, updated 4/25/24, indicated to follow PD orders through the dialysis center. The physician orders were ongoing and could change daily based on clinical assessments reported to the provider. A physician's order, dated 8/16/24, indicated to administer PD treatment: 1.5 (yellow) x 2 (6 Liter) bags (dialysis solutions) via cycler (PD machine) at bedtime. A quarterly Minimum Data Set (MDS) assessment, dated 8/17/24, indicated the resident had a primary medical condition, chronic kidney disease, stage 4, severe. Had an additional diagnosis of dependence on renal (kidney) dialysis, and received dialysis while a resident. On 8/27/24 at 12:16 p.m., a review of the June 2024 Medication Administration Record (MAR) indicated that on 6/9/24, QMA 17 documented that the PD had been administered. On 6/21/24, QMA 18 documented that the PD had been administered. On 8/27/24 2:44 p.m., a review of the July 2024 MAR indicated that on 7/16/24, QMA 16 documented that the PD dialysis had been administered. On 7/18/24, QMA 18 documented that the PD had been administered. On 7/19/24 QMA 16 documented that the PD had been administered. On 7/20/24, QMA 15 documented that the PD had been administered. During an interview on 8/27/24 at 3:11 p.m., QMA 12 indicated that as a QMA he was not trained to administer PD, so the nurse came and set it up for him at night. He was not allowed to get certified. The nurse must call the dialysis center every day to give them an assessment report and receive new orders based on outflow and recorded vitals. Only someone who was certified was allowed to hook up and administer the PD. During an interview on 8/27/24 at 3:20 p.m., Licensed Practical Nurse (LPN) 5 indicated that the dialysis company came to train nursing staff on every new resident who received PD, the training included parameters they wanted them to follow. It was mandatory training to be able to give PD to that patient. During an interview on 8/29/24 at 9:32 p.m., QMA 15 indicated that Resident 43 received PD every day. To her knowledge, QMA's were not allowed to be trained to do it. When the nurse came to set up the PD, it was the nurse's responsibility to chart that it was completed. When asked about the MAR dated 7/20/24 where she had charted the PD as being completed, she confirmed that they were her initials documented that day. She was not sure if she just accidently clicked the button. Then indicated she thought that it was possible that she did not sign out of the computer on the medication cart that they parked outside of the resident's room they were working in. She indicated that it was possible that the nurse did not realize that it was logged in under someone else's credentials before going in to sign off that the PD was completed. It had happened before with insulin, and they had to go back and strike it out in an addendum. During an interview on 8/29/24 at 9:46 a.m., when asked about the dates the PD was documented by a QMA, the Director of Nursing (DON) indicated that it was likely that the computer was still logged in under the QMAs when the nurse came and hooked up the PD. QMA 17 and QMA 18 no longer work at the facility. During an interview on 8/29/24 at 11:34 a.m., the Unit Manager indicated that staff should not leave themselves logged into the computers and unlocked to leave it up to possible give access to information or for someone to potentially get in and document something that you did not do. Staff should never document something that they did not do. Staff should not document under someone else's login, it was their credentials, they should not give anyone their login or password information. Everyone had their own access information. If something like that did happen, they should let someone know as soon as they realize it happened so they could amend it. She was not sure what happened on the days that the QMAs signed off on the PD but they know their scope and what they should and should not sign off on. A QMA cannot do assessments of bruit and thrill, cannot do before and after treatment assessments, and only nurses were trained to administer PD. On 8/27/24 at 10:46 a.m., the Executive Director (ED) provided and identified a document as current facility policy, titled, Medication Administration, dated 5/20/2022. The policy indicated, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection 3.1-50(a)

Based on observation, interview, and record review, the facility failed to provide sufficient dietary support personnel in the kitchen for 72 of 73 residents who received food from the kitchen for 1 of 1 week of the survey. Findings include: During an observation of lunch service in the main dining room, on 6/26/23 at 11:30 a.m., the residents received their lunch meals on paper plates. On 6/26/23 at 11:44 a.m., the Dietary Manager (DM) indicated they were using paper plates for the residents' lunches because there was only two dietary staff for the kitchen. On 6/28/23 at 2:31 p.m., the Registered Dietician Consultant (RD) indicated the facility had challenges for staffing in the kitchen. There used to be three to four dietary staff for each shift, not two staff for a shift, which made it hard for the staff to complete all the kitchen duties. The paper plates were used in the dining room because the facility did not have enough dietary staff to wash the dishes. On 6/28/23 at 3:23 p.m., the RD provided and identified a document as a current facility policy titled, Dietary Services-Staffing, dated February 2023. The policy indicated, .Policy: The facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services .6. The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the Food and Nutrition Services 3.1-20(h) 3.1-35(c)(2)(C)

Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment and failed to obtain and follow physician orders for 2 of 2 residents reviewed for respiratory care (Residents 25 and 10). Findings include: 1. On 6/26/23 at 10:28 a.m., Resident 25's unbagged nebulizer mouthpiece and tubing were observed on the resident's nightstand table next to the nebulizer machine. The resident was resting in her recliner. On 6/28/23 at 9:10 a.m., Resident 25 was observed to be sitting in her recliner talking with her spouse. An unbagged nebulizer mouthpiece and tubing were observed on the resident's nightstand table next to the nebulizer machine. On 6/29/23 at 9:40 a.m., Resident 25 was observed to be resting in her recliner. An unbagged nebulizer mouthpiece and tubing were observed on the resident's nightstand table next to the nebulizer machine. Resident 25's record was reviewed on 6/27/23 at 3:08 p.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems) and chronic and acute respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [inadequate supply of oxygen] with or without hypercapnia [too much carbon dioxide in your blood]). A significant change in status Minimum Data Set (MDS) assessment, dated 6/4/23, indicated the resident was cognitively intact and received oxygen therapy. A care plan, dated 6/16/23, indicated the resident was at risk of respiratory distress related to chronic respiratory failure and COPD. Interventions included but were not limited to, administer medications as ordered and oxygen as ordered. A physician's order, dated 6/1/23, indicated albuterol sulfate nebulization solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier); 2.5 milligrams (mg)/3 milliliters (ml) 0.83%. 1 vial orally via nebulizer 4 times a day. During an interview, on 6/29/23 at 2:25 p.m., Licensed Practical Nurse (LPN) 12 indicated after the resident had completed their nebulizer treatment, the nurse was to rinse out the nebulizer equipment and then place in a plastic bag for storage while not in use. During an interview, on 6/30/23 at 8:23 a.m., the Regional Nurse Consultant indicated nebulizer tubing and mouthpiece should be placed in a bag after use. On 6/30/23 at 9:32 a.m., the Regional Nurse Consultant provided an undated document, titled, Oxygen Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .e. Keep delivery devices covered in plastic bag when not in use 2. On 6/27/23 at 10:06 a.m., Resident 10 was observed to be resting in bed, the resident was receiving oxygen through a nasal cannula at 3.5 liters (L). No date was noted to be on the oxygen tubing. On 6/28/23 at 10:14 a.m., Resident 10 was observed to be resting in bed, the resident was receiving oxygen through a nasal cannula at 3.5L. No date was noted to be on the oxygen tubing. On 6/29/23 at 12:11 p.m., Resident 10 was observed to be resting in bed, the resident was receiving oxygen through a nasal cannula at 3.5L. No date was noted to be on the oxygen tubing. On 6/29/23 at 2:40 p.m., Resident 10 was observed to be resting in bed, the resident was receiving oxygen through a nasal cannula at 3.5L. No date was noted to be on the oxygen tubing. On 6/30/23 at 08:23 a.m., Resident 10 was not noted to be in her room. The Oxygen concentrator in her room was on and the oxygen level was set at 3.5L. Resident 10's record was reviewed on 6/28/23 at 11:23 a.m. The profile indicated the resident diagnoses included, but were not limited to, COPD and chronic and acute respiratory failure with or without hypercapnia. An admission Minimum Data Set (MDS) assessment, dated 4/28/23, indicated the resident was cognitively intact and received oxygen therapy. A care plan, dated 5/1/23, indicated the resident was at risk for respiratory distress related to chronic respiratory failure and COPD. Interventions included but were not limited to, administer medications as ordered and oxygen as ordered. A physician's order, dated 5/1/23, indicated Oxygen at 5L per nasal cannula at all times due to COPD. The record lacked a physician order for tubing to be dated and changed out weekly. During an interview, on 6/27/23 at 10:06 a.m., Resident 10 indicated she had an order for 5L of oxygen to be administered per nasal cannula. During an interview, on 6/29/23 at 2:20 p.m., LPN 14 indicated oxygen tubing was changed and dated weekly unless soiled and needed to be changed out before then. LPN 14 indicated resident 10 had an order for 5L of oxygen per nasal cannula. During an interview, on 6/30/23 at 8:23 a.m., the Regional Nurse Consultant indicated Resident 10's oxygen concentrator did show a level of 3.5L of oxygen, she was unsure why the resident was not being administered the 5L as ordered by the physician. On 6/30/23 at 9:32 a.m., the Regional Nurse Consultant provided an undated document, titled, Oxygen Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Oxygen is administered under orders of a physician .b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated 3.1-47(a)(6)

Based on record review and interview, the facility failed to accurately report weekend staffing hours in the PBJ (payroll-based journal) reporting during the second quarter of 2023 for 1 of 2 quarters of staffing reviewed. Finding includes: During review of CASPER (Community Assessment for Public Health Emergency Response) report on 6/26/23 at 07:00 a.m., the CASPER report indicated the facility had reported low weekend staffing and a 1-star staffing rate for the second quarter of 2023. During an interview, on 6/30/23 at 10:48 a.m., the Administrator indicated the facility triggered low weekend staffing on the PBJ report due to the facility not reporting salaried staff employees' hours when they worked and performed direct patient care. She indicated the Social Service Director was also a certified nurse's aide and a qualified medication aide, her hours were not reported accurately when she worked in the direct patient care area. The administrator also indicated they had hired weekend staff to help facilitate the low weekend staffing issue. The facility also moved a licensed nursing staff member to work weekends to help with coverage. During an interview, on 6/30/23 at 2:00 p.m., the Administrator indicated the facility did not have a policy regarding the PBJ reporting and the facility follows the state regulation regarding this. The deficient practice was corrected by 5/15/23 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included hiring more licensed and unlicensed staff for the weekends, moving staff to work the weekends, and accurately reporting staffing hours. 3.1-17(a)

Based on record review and interview, the facility failed to ensure the complete investigation of a resident-to-resident abuse allegation for 2 of 2 residents reviewed for abuse allegations (Residents 20 and 18). Findings include: On 6/28/23 at 2:04 p.m., a document titled, Indiana Department of Health (IDOH) Survey Report System, dated 6/18/23 at 9:35 a.m., was provided by the Executive Director (ED). The document indicated Resident 20 had reported to a nurse that Resident 18 had touched her inappropriately. No physical injury had been noted. The immediate action taken was to place Resident 18 on one on one (1:1) observation while out of bed and every 15-minute checks while in bed. The ED, Director of Nursing (DON), family, and physician had all been made aware. On 6/19/23, Resident 18 was sent out to a behavioral health facility. The document lacked any further follow-up information. 1. Resident 20's record was reviewed on 6/28/23 at 1:33 p.m. The profile indicated the resident's diagnoses included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 5/23/23, indicated the resident had moderate cognitive deficit. A progress note, dated 6/18/23 at 10:20 a.m., indicated the resident had come to the nurse's station in her wheelchair and was crying. The nurse took the resident to her room where she told the nurse the Resident 18 had pulled up her shirt and touched her breast, then pulled on her pants out and stuck his hand down the front of her pants. The resident demonstrated how the incident had happened. The nurse provided reassurance and notified the ED and DON. 2. Resident 18's closed record was reviewed on 6/28/23 at 2:06 p.m. The profile indicated the resident's diagnoses included, but were not limited to, cellulitis of left lower limb (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) and alcohol dependence uncomplicated (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking). A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 5/21/23, indicated the resident had severe cognitive deficit and had no documented behaviors. A Social Services Director (SSD) progress note, dated 6/19/23 at 9:49 a.m., indicated the resident had presented with sexually inappropriate behavior towards another resident. He was immediately placed on one on one. Family and doctor notified. Patient being admitted to behavioral health for evaluation and treatment. During an interview, on 6/29/23 at 8:34 a.m., Certified Nurse Aide (CNA) 5 indicated she had just heard about the incident from Resident 20. No one had ever interviewed her about the incident. During an interview, on 6/29/23 at 8:38 am, Licensed Practical Nurse (LPN) 7 indicated she only heard about the incident from other staff. No one had ever interviewed her about the incident. During an interview, on 6/29/23 at 8:39 am, CNA 8 indicated she had been at the nurse's station when the resident reported it to the nurse. No one had ever interviewed her about the incident. During an interview, on 6/29/23 at 9:00 a.m., the SSD indicated she and the ED made the decision to send the resident out. The physician had no questions or concerns and gave the order to send the resident to the behavioral health facility. There had been no other behaviors with the resident towards other residents reported. There had been a report of an inappropriate request for sexual favors from a female staff on 2/10/23, when he had attempted to reach up a staff's shirt and requested the staff perform oral sex on him. The resident had a care plan addressing this behavior. She further indicated she had not been a part of the investigation process. During a telephone interview, on 6/29/23 at 9:32 a.m., LPN 11 indicated she was working the unit where the incident happened but did not witness the incident. She was a new nurse at the facility, and the resident went to another nurse to report it. She may have been on a break or at lunch when it happened. She was told about it from the other nurse who the resident reported it to. The other nurse had already contacted the ED and DON. No one had ever interviewed her about what she knew about the incident prior to this call today. During a telephone interview, on 6/29/23 at 9:40 a.m., CNA 10 indicated she was walking down the hall and Resident 20 told her what had happened. She immediately reported it to her nurse on the unit and to another nurse who had been a nurse at the facility longer than the nurse on her hall. The male resident was immediately placed on 1:1 and he was in constant sight of the staff the entire shift. As far as she was aware of, the male resident had never done anything like that to another resident in the facility before. She had been told he had made suggestive comments to other staff during his shower times but had not done so to her personally. No one had ever interviewed her regarding the incident. During an interview, on 6/29/23 at 10:14 a.m., the Business Office Manager (BOM) indicated she had come into the facility, on the date of the incident, because she lived close to the facility, and interviewed all female residents in the facility. At the same time, she provided a document with names of the residents on it. The document had handwritten notes next to the female names on the document. The document was not presented as part of the investigation packet by the ED on 6/28/23 at 2:04 p.m., when the investigation report information had been initially presented. During an interview, on 6/28/23 at 11:10 a.m., the ED indicated the male resident had not ever acted out towards any of the other residents before this incident. The incident happened in a common area of the facility. No one witnessed the incident. The female resident approached staff and was upset and told them what had happened. They immediately placed the male resident on 1:1. A full skin assessment was completed on the female resident, with no findings, and support was provided for her. After contacting the physician, the physician gave the order for a psych evaluation on the resident. The resident was placed in a behavioral health facility for evaluation and treatment. On 6/28/23 at 2:04 p.m., the ED provided a document, with a revision date of March 2021, titled, Abuse Prevention Program, and indicated it was the policy currently being used by the facility. The policy indicated, .Protection of the Resident .Should an incident or suspected incident of resident abuse .be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The individual conducting the investigation will, at a minimum .Interview the person(s) reporting the incident; Interview witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A completed copy of the incident report and written statements .must be provided .The Administrator will provide a written report of the results of all abuse investigations 3.1-28(a) 3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure a resident was provided a comfortable and sanitary environment for 1 of 24 residents reviewed for a home-like environment (Resident 6). Finding includes: On 6/26/23 at 8:05 a.m., Resident 6 was observed lying in bed with the bed against the wall. The wall was marked and scratched up significantly with a large area of the white drywall showing on the wall. On 6/27/23 at 10:18 a.m., Resident 6 was observed lying in bed with the bed against the wall. The wall was marked and scratched up significantly with a large area of the white drywall showing on the wall. On 6/29/23 at 9:25 a.m., Resident 6 was observed lying in bed with the bed against the wall. The wall was marked and scratched up significantly with a large area of the white drywall showing on the wall. On 6/29/23 at 12:29 p.m., the Maintenance Supervisor indicated the staff got the bed too close to the wall and the bed should be pulled out away from the wall. The wall needed to be repaired and painted. Staff should have sent him a work order to have the wall repaired, but he had not received a work order about the wall being marked up. On 6/29/23 at 2:30 p.m., the Maintenance Supervisor provided and identified an undated document as a current facility policy titled, Resident Environmental Quality. The policy indicated, .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .12. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue 3.1-9(a) 3.1-19(f)

Based on observation, interview and record review, the facility failed to ensure services were provided to prevent pressure areas for 1 of 3 residents reviewed with either a history of, or current, pressure ulcers in a sample of 17, in that a resident identified with pressure ulcers lacked pressure reducing devices. This deficient practice resulted in Resident #26 developing multiple stage 2 pressure ulcers. Findings include: During initial tour on 7/11/11 which began at 9:50 a.m. with LPN #2, LPN #2 indicated Resident #26 was dependant on staff for all needs and had a stage II area to the right heel. On 7/11/11, during the initial tour which began at 9:50 a.m., with LPN #2, an alternating pressure mattress was noted on Resident #26's bed frame. The pump attached to the mattress indicated the mattress and pump was a "Static CVC low Air loss and Alternating pressure mattress." The pump was observed to be set at 350 on firm. During interview of LPN #2 on 7/11/11, during the initial tour which began at 9:50 a.m., LPN #2 indicated she was responsible for keeping track of any skin problems of the residents. The LPN indicated the unit nurses were responsible for performing treatments to open areas and she, LPN #2, measures the areas one time a week. The LPN indicated each resident receives a shower or full bath at least two times a week, and the CNA providing the care is responsible for filling out a shower sheet and identifying any skin issues the resident may have. LPN #2 indicated the completed shower sheets are given to the unit nurse who is working on the day the resident receives his/her shower and/or bath. The shower sheet is then given to the DON (Director of Nursing) and then to her (LPN #2). On 7/12/11 at 10:30 a.m., LPN #4 and CNA #3 provided care to Resident #26. The resident was observed in bed on her back and the staff repositioned the resident on her right side. An open area was noted on the resident's left buttocks. LPN #2 entered the room and observed the area on the left buttocks. The resident was then repositioned to her left side and a large red area was noted on the resident's right hip with a dark purple area in the center. LPN #2 indicated to CNA #3 to place a cushion in the resident's wheelchair, prior to getting the resident up. During interview of LPN #2 on 7/11/11 at 11 a.m., the LPN verified she was unaware of these areas. The LPN indicated she had checked the shower sheets from the day before concerning Resident #26, and the shower sheets did not indicate any skin issues other than the left heel. On 7/12/11 at 1:40 p.m. Resident #26 was observed sitting in a wheelchair. The resident was sitting on the sling type seat of the wheelchair. A cushion was lacking. At 3 p.m., and 4 p.m., the resident was observed to be in the wheelchair without a cushion. At 4 p.m., the resident was observed to be leaning toward the right with right hip resting against the metal side piece of the wheelchair. On 7/13/11 at 9:55 a.m., and 11:35 a.m., Resident #26 was observed in a wheelchair, with a sling seat, without a pressure relieving cushion. At 12:30 p.m. the resident was observed to be propelled, while in the wheelchair, from the lounge to the dining area. During interview of CNA #3 at 11:45 a.m., the CNA indicated the resident did not have a cushion in her wheelchair. On 7/13/11 at 1:10 p.m., LPN #2 and CNA #3 transferred Resident #26 from a wheelchair to the bed. The sling seat of the wheelchair was observed not to have a cushion. The alternating mattress was observed to be deflated. The on-off switch on the pump was observed to be in the off position. The staff left the room without attempting to inflate the mattress. At 2:30 p.m., LPN #18 performed a treatment on Resident #26's heel. During the treatment, the mattress was noted to be deflated. The LPN left the room without attempting to turn the mattress on. The on-off switch on the pump was observed to be in the off position. At 3:35 p.m., LPN #2 was summoned to Resident #26's room. LPN #2 indicated the resident's alternating mattress was deflated and was turned off. The LPN switched the mattress to an on position and the mattress began inflating. During interview of LPN #2 on 7/14/11 at 4:15 p.m., the LPN indicated she had found a new pressure area on 7/14/11 on the resident's right buttock. Resident #26's clinical record was reviewed on 7/12/11 at 11:20 a.m. An admitted was noted of 6/8/11. A nursing assessment indicated the resident was admitted with an unstageable pressure area on the left heel. An initial RAI (resident assessment instrument) was noted, dated 6/17/11. The assessment indicated the resident was at risk for further pressure ulcers due to impaired mobility and documented that pressure reducing devices were to be utilized on the resident's bed and chair. The following wound/skin healing records were provided on 7/14/11 at 4:15 p.m. from LPN #2; Wound sheet indicating an onset date of 7/12/11, of an unstageable purple pressure area on the resident's right hip measuring .4 X .5 cm. Wound sheet indicating an onset date of 7/12/11, of a stage II pressure ulcer on the resident's left buttock measuring 1.5 X .8 cm with less than .1 cm in depth Wound sheet indicating an onset date of 7/14/11 of a stage II pressure ulcer on the resident's right buttock measuring .2 X .2 cm. A facility policy titled "SKIN CARE MANAGEMENT" received on 7/15/11 from LPN #2, indicated "Preventative measures will be established and implemented for all residents assessed as moderate to high risk for pressure sore development (using the Braden Scale) including but not limited to a. Pressure-reducing mattress/overlay b. Pressure reducing cushion in chair...." 3.1-40(a)(2)