Every finding on record at Manderley Health Care Center

Based on record review, interview, and observation, the facility failed to prevent an accident during a transfer for 1 of 3 residents reviewed for accident hazards. (Resident B) Findings include: The clinical record for Resident B was reviewed on 08/27/2026 at 11:00 A.M. An Annual Minimum Data Set (MDS) assessment, dated 06/10/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, morbidly obese (excessive amount of body fat), and depression (mood disorder that causes a persistent feeling of sadness) . The resident was dependent (required a mechanical device to move) with transfers. A Progress Note, dated 08/07/2026 at 10:22 P.M., indicated Resident B was transferred to the local hospital after a mechanical lift flipped over landing on top of the resident. During an interview, on 08/27/2026 at 9:28 A.M., Resident B indicated he was dropped while being transferred from his wheelchair to his bed a few weeks ago. He was lifted out of his wheelchair and while the two staff members positioned him over his bed the mechanical lift flipped over landing him on the floor next to his bed. He was unsure what the lift was caught on that caused the tip, but the two staff members were talking and laughing with each other while operating the lift. During an interview, on 08/27/2026 at 3:05 P.M., Certified Nursing Assistant (CNA) 2 indicated she assisted Resident B to bed when he fell while in the mechanical lift. While CNA 2 was pushing the mechanical lift towards the resident's bed she met resistance with the wheels. She switched places with the second CNA to attempt to push past the resistance and when they attempted to force the lift forward, a second time, the mechanical lift tipped over dropping Resident B. During an interview and observation, on 08/27/2026 at 2:48 P.M., the Maintenance Supervisor demonstrated with the mechanical lift involved from the fall incident that when the mechanical lift was pulled backwards sometimes the feet of the lift close slowly. If the leg of the lift was bumped on anything the feet would close. There was no locking mechanism on the lift to lock the feet in the widespread position. If the feet of the lift closed, the lift would lose its balance/strength to prevent from tipping over. The lift was taken out of service after the incident and the facility had all new mechanical lift devices at that time. A current undated facility policy titled, Lifting Machine - using a Mechanical, was provided by the Administrator on 08/27/2026 at 4:27 P.M. The policy indicated, .principles of safe lifting using a mechanical lift device .clear an unobstructed path for the lift machine . This deficiency was corrected on 08/13/2026, after the facility provided education to all staff related to operating the mechanical lift and began ongoing monitoring audits to watch staff complete mechanical lift transfers. This citation relates to Intake 3153693. 410 IAC (Indiana Administrative Code) 3.1-45(a)(1)410 IAC (Indiana Administrative Code) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure all mechanical, electrical, equipment was maintained in safe operating condition related to the heat source in a resident's room for 1 of 3 residents reviewed for environment. (Resident D) Findings include:During an interview and observation, on 08/03/2026 at 9:14, Resident D indicated his ceiling caved in on him over a month ago. They moved him to a new room while repairs were being made to the ceiling, but he had been back in his room for about a month now. The ceiling was observed over Resident D's bed with approximately an 8 foot by 8-foot section of drywall with new white plaster covering it blending it in with aged cream-colored plaster along the privacy curtain and extending all the way to above the residents exterior window and wall above his headboard. During an interview, on 08/04/2026 at 9:14 A.M., the Maintenance Director indicated that when he entered Resident D's room after the incident there was a 4-foot by 4-foot piece of drywall detached from the ceiling and a 4-foot by 4-foot section dangling down held on by wires from the ceiling. The building had electrical heating that was wired through the ceiling. The entire building had drywall on the ceiling and then electrical wiring attached to the drywall covered up by plaster. The wiring was connected to the thermostats in the resident's room and that's what heats the residents room. Each room had its own breaker for that system, so he cut the breaker out for Resident D's room as soon as he arrived at the facility the morning, he was told the ceiling fell. The room currently had no heat available in it, and he was unsure what the facility was going to do to fix it before winter, but the room would need a new heat source. The drywall was repaired without repairing the electric heat. During an interview, on 08/04/2026 at 11:10 A.M., the Administrator was unaware that Resident D's repaired room had no heat capability now and had no current plan as to how they would administer heat in the resident's room when it was cold. Review of the clinical record for Resident D on 08/04/2026 at 10:40 A.M., indicated the resident's diagnoses included, but were not limited to anxiety (feelings of fear, dread, and uneasiness) and depression (mood disorder characterized by persistent sadness). A Progress Note, dated 06/11/2026 at 9:04 A.M., indicated Resident D was moved to a new room while the original room was under construction. A Progress Note, dated 07/10/2026 at 10:31 A.M., indicated Resident D was moved back into his original room. An Invoice, dated 08/03/2026, indicated the facility paid for drywall ceiling repair in a resident's room. The current undated facility policy titled, Resident Rights, was provided by the Administrator on 08/04/2026 at 2:31 P.M. The policy indicated, .Federal and state laws guarantee basic rights to all residents of this facility. These rights include the residents right to: A. a dignified existence .kk. equal access to quality of care . The current facility policy, dated 03/2015, titled, Maintenance Administration, was provided by the Administrator on 08/04/2026 at 1:17 P.M. The policy indicated, . Communicates with the administrator and nursing department to ensure that residents are relocated if their environment cannot be maintained in a safe and comfortable level. This citation relates to Intakes 3096676 and 3096762.

Based on record review, and interview, the facility failed to follow physician's orders related to cardiac medication hold parameters, obtaining vital signs and weights, and notifying the physician of weight changes for 3 of 17 residents reviewed for Quality of Care. (Residents 3, 40 and 14)Findings include: 1.Resident 3's clinical record was reviewed on 01/21/2026 at 2:34 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, dementia (decline in mental abilities), anxiety, depression, bipolar disorder (a chronic mental illness characterized by extreme mood swings), and orthostatic hypotension(sustained increase in blood pressure after standing). A Pharmacy Consultant Note To Attending Physician/Prescriber, dated 07/02/2025, indicated the resident had an order for Midodrine 2.5 milligrams (mg) three times a day. The resident's blood pressures were being recorded twice a day, and some Systolic Blood Pressures (SBP) (top number) were measuring 130 or higher. Please consider adding a hold parameter to this medication, so BP (Blood Pressure) must be assessed, recorded, and evaluated for medication administration. A Physician's order, with a start date of 07/03/2025 and end date of 07/17/2025, indicated the resident was to receive Midodrine 2.5 mg after each meal related to hypotension. The medication was to be held if the resident's SBP was greater than 115 or the DBP (bottom number) was greater than 65. The July 2025 Electronic Medication Administration Record (EMAR), indicated the resident had received the medication when their systolic blood pressure was greater than 115, or the diastolic blood pressure was greater than 65, or when the blood pressure was not obtained, on the following dates and times: - 07/08/2025 at 6:00 P.M., when the blood pressure was 124/69, - 07/10/2025 at 1:00 P.M., when the blood pressure was 142/87 and at 6:00 P.M., when the blood pressure was 144/78,- 07/11/2025 at 9:00 A.M., when the blood pressure was 114/66 and at 1:00 P.M., when the blood pressure was not obtained, - 07/12/2025 at 9:00 A.M., when the blood pressure was 113/69 and at 1:00 P.M., when the blood pressure was not obtained, - 07/14/2025 at 6:00 P.M., when the blood pressure was 129/80, - 07/15/2025 at 9:00 A.M., when the blood pressure was 114/80, at 1:00 P.M., when the blood pressure was 100/72, and at 6:00 P.M., when the blood pressure was 108/72, - 07/16/2025 at 9:00 A.M., when the blood pressure was 90/72, and at 1:00 P.M., when the blood pressure was 101/72, and - 07/17/2025 at 1:00 P.M., when the blood pressure was 107/68. During an interview, on 01/23/2026 at 10:40 A.M., RN 2 indicated the physician's orders should be followed regarding medication parameters. If there are blood pressure parameters, then the blood pressure should be obtained prior to each medication administration. 2. The clinical record for Resident 40 was reviewed on 01/21/2026 at 2:42 P.M. A Quarterly MDS assessment, dated 11/18/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, renal insufficiency, coronary artery disease, and seizure disorder. The resident's current physician's order included, but were not limited to, an open-ended physician's order, with a start date of 10/29/2025, that indicated staff were to obtain the resident's vital signs (blood pressure, heart rate, temperature, and respiratory rate) once a week in the evenings on Wednesdays. The resident's record lacked documentation of the resident's vital signs since the order was put in place on 10/29/2025. During an interview, on 01/23/2026 at 2:08 P.M., the Director of Nursing (DON) indicated the order was put in the computer on 10/29/2025, but no weekly vital sign assessments were documented. 3.The clinical record for Resident 14 was reviewed on 01/21/2026 at 2:14 P.M. A Quarterly MDS assessment, dated 10/20/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, anemia, congestive heart failure, lower extremity edema, and dementia. The resident's EMAR indicated the resident had a physician's order to be weighed daily on day shift. Staff were to notify the MD if the resident had a weight gain of greater than three pounds in one day, or five pounds in one week. The order had a start date of 09/05/2025, and a discontinued date of 01/14/2026. The physician's phone number was listed on the order. The staff failed to notify the physician or obtain the resident's weight on the following days: -09/07/2025, the resident weighed 119.5 pounds,-09/08/2025, the resident weighed 125.6 pounds, a gain of 6.1 pounds,-09/12/2025, no weight was obtained,-09/18/2025, no weight was obtained,-10/20/2026, no weight was obtained,-10/26/2025, no weight was obtained,-10/27/2025, no weight was obtained,-11/04/2025, no weight was obtained,-11/06/2025, no weight was obtained,-12/07/2025, the resident weighed 117.5 pounds-12/08/2025, the resident weighed 120.8 pounds, a gain of 3.3 pounds,-01/01/2026, the resident weighed 121.4 pounds,-01/02/2026, the resident weighed 124.8 pounds, a gain of 3.4 pounds. The Progress Notes, dated from September 2025 to January 2026, lacked documentation the physician was notified of the resident's weight gains or why the resident's weights were not obtained. During an interview, on 01/28/2026 at 10:31 A.M., RN 2 indicated the resident had a fall at home and had surgery for a hip fracture. She had some swelling in her lower legs. Weights were documented on the computer. Normally, they would document in a progress note when the physician was notified. For residents on daily weights, if there was an increase, staff should notify the physician. The resident's weights would be documented either in the Vitals section of the resident's record or on the EMAR. During an interview, on 01/28/2026 at12:52 P.M., the DON indicated the facility did not have a policy that stated nurses were to follow physician's orders, it was just standard nursing practice. The current Change in a Resident's Condition or Status policy, with a revised date of February 2021, was provided by the DON on 01/28/2026 at 12:51 P.M. The policy indicated.Our facility promptly notifies .attending physician .of changes in the resident's medical .condition .when there has been .specific instruction to notify the physician of changes in the resident's condition . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner for 2 of 3 kitchen observations and unmarked random food containers in the resident snack refrigerator for 1 of 1 resident snack refrigerators observed. Findings include: During the initial kitchen tour with the Dietary Manager (DM), on 01/20/2026 at 10:33 A.M., the following was observed: -a large, enclosed meal tray cart had a tray on top with a toaster sitting on the tray. The tray was heavily littered with breadcrumbs. An unlabeled respiratory medication inhaler was sitting on top of the cart within an inch of a bottle of seasoning spices, -The walk-in freezer had two frozen bottles of water, one was a green two-liter bottle, one was a clear old juice bottle, both were stained brown. The DM indicated they regularly used the bottles to cool down the pitchers of prepared iced tea, -An open rack of dishes consisting of small bowls and plates was littered with crumbs, the DM indicated they were clean dishes, -One large trash can that sat at the end of a food prep table had no lid and was over half full of garbage. The DM indicated they were getting ready to take it out. The lid was trapped between the can and the food prep table. The lid had a six-to-eight-inch hole in the center with pieces of food stuck on the lid surrounding the hole. No staff were actively using the trash can or in the process of taking it out, -In the dry storage room,-One large blue tub with a lid, labeled Flour Filled 10/4/24, with a small amount of flour and a scoop inside the tub, and-An eight-inch hole in the floor covered with a towel that the DM indicated was a drain. There were two pipes with open ends that extended over the hole, The DM indicated the inhaler was the cook's and she had asthma. During an interview, on 01/28/2026 at 10:03 A.M., Dietary Aide (DA) 5, indicated the sugar bin had a place to put the scoop, she did not leave the scoop in the bin with the sugar. She generally just managed the dish washing. During a tour of the kitchen, on 01/28/2026 at 11:02 A.M., the following was observed: -A clear, brown-stained bottle of frozen water was in the walk-in freezer, and-One large blue tub with a lid, labeled Flour Filled 10/4/24, with a small amount of flour and a scoop inside the tub. During an interview, while still in the kitchen, scoops should not be left in the flour bin. They put the frozen bottle of water in the tea because over the summer the tea had become sour tasting. They had commercial frozen stick cylinders they put in the pitchers of white and chocolate milk when they were serving in the dining room. They ran the cylinders through the dishwasher. The bottle of water got washed every night and refilled, it was just stained from the tea. The residents' snack refrigerator was observed on 01/28/2026 at 12:22 P.M., with RN 2 and contained the following: -A Styrofoam meal container, dated 01/20/2026, in a plastic grocery bag, the RN indicated was for a resident who was admitted from another facility over the weekend, and -A small, sealed snack tray with no resident name, room number, or date. During an interview, on 01/28/2026 at 12:55 P.M., the Administrator indicated they did not have a policy related to staff personal items in the kitchen food prep area. The INDIANA DEPARTMENT OF HEALTH Retail Food Establishment Sanitation Requirements for 2025 indicated, .Sec. 118. (a) Single-use articles means utensils and bulk food containers designed and constructed to be used once and discarded.The term includes items, such as.jars.plastic tubs or buckets.bottles. The current Food from Outside Sources policy, with a revised date of 07/2023, was provided following the Entrance Conference. The policy indicated, .Visitors/family members will label food and beverages with the resident's name, room number, and date.Perishable foods with a use by date which is 3 days from the date that it was brought into the facility. 3.1-(i)(3)

Based on interview and record review, the facility failed to obtain a resident's ordered blood tests for 1 of 5 residents reviewed for laboratory services. (Resident 9)Findings include:Resident 9's clinical record was reviewed on 01/21/2026 at 2:49 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/06/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, anemia (deficiency of health red blood cells), hypertension (high blood pressure), hypothyroidism (under active thyroid), and seizure disorder (neurological condition characterized by recurrent unprovoked seizures). The resident's current medication orders included, but were not limited to, the following:- An open-ended physician's order, with a start date of 07/10/2025, for Synthroid, 25 Micrograms daily for hypothyroidism.- An open-ended physician's order, with a start date of 07/10/2025, for Depakote Sprinkles capsules, 500 milligrams twice a day for a seizure disorder.The resident's current physician's orders included an open-ended order, with a start date of 10/15/2024, to obtain the following blood tests every six months, in September and March:- Depakote level, - Complete Metabolic Panel (CMP),- Complete Blood Count (CBC), - Thyroid Stimulating Hormone (TSH),- Free Thyroxine level (T4), and - Hemoglobin A1C (a test that measured the average blood sugar levels over the past three months).The resident's record lacked blood test results for Depakote levels, TSH, T4, and A1C levels that should have been obtained in March 2025 and September 2025.During an interview, on 01/28/2026 at12:52 P.M., the DON indicated the resident's Depakote, TSH, T4, and A1C blood tests were not obtained in March 2025 and September 2025. The blood tests were missed and should have been completed. The current Lab and Diagnostic Test Results - Clinical Protocol with a revision date of November 2018, was provided by the DON on 01/28/2026 at 12:44 P.M. The policy indicated, .The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests .3.1-49(a)

Based on observation and interview, the facility failed to follow appropriate food handling guidelines related to food storage, open dating, and protecting food and drinks from gnats. This deficient practice had the potential to affect 47 of 48 residents receiving food and drink items from the kitchen. Findings include: 1.a. During an observation, on 07/21/25 at 8:07 A.M., of the facilities kitchen refrigerators, freezers, and dry food storage the following was observed: - a raw premade frozen hamburger patty was lying on the floor of the freezer in the back left corner of the kitchens walk in freezer, - Two popsicles were lying on the floor under the shelves in the walk-in freezer, - An undated, half full, opened half gallon of nectar thick orange juice was in the refrigerator, - An undated, three fourths full, opened half gallon of nectar thick cranberry juice was in the refrigerator, and - Three unopened salt packets, lying on the floor, in the center walkway of the floor into the dry food storage area. During an interview and observation, on 07/21/25 at 8:25 A.M., Kitchen Staff 2 indicated that all foods and drinks should be dated; and if something was undated and opened it needed to be disposed of. Kitchen Staff 2 then disposed of the undated items. During an interview, on 07/21/25 at 9:37 A.M., the Dietary Manager indicated that there should never be food on the floor in the walk-in freezer. 1.b. During an observation and interview, on 07/21/25 at 8:07 A.M., in the kitchen multiple gnats were observed flying in the air near the dry food storage area. Upon entering the dry storage room, the number of gnats increased. Five gnats landed on an unopened bag of cereal on a shelf at eye level. Three gnats landed on an unopened can of cheese approximately four feet off the ground on a metal shelf. 2. During an observation, on 07/21/25 at 11:22 A.M., while in the kitchen three gnats were visualized on the outside plastic of a hotdog bun package partially used and resealed. Multiple other gnats were flying in the air around the kitchen area. The hotdog bun package was sitting at the end of the food preparation table behind the steam tables used for serving residents. Approximately more than 50 gnats were surrounding a commercial sized coffee machine actively brewing a pot of coffee on the left side of the kitchen's refrigerator. Approximately 15 gnats landed on the buttons of the coffee machine directly above the pot being brewed. Multiple gnats were flying around the trash can at the end of the food prep table with seven gnats visualized on the trash can lid close to the open hole on the can. Staff were observed picking up the pieces of raw chicken and placing them in milk and egg mixture then breading them with corn flakes for the residents' noon meal. During this process multiple gnats were visualized flying around the staff and the chicken pieces, as they were preparing. During an observation, on 07/21/25 at 4:32 P.M., in the kitchen there was a pan with precooked sliced meat. The pan was sitting on the left of the stove and the meat was stacked around one foot tall. The pan was uncovered and multiple gnats were visualized flying around the uncovered meat. During an interview, on 07/21/25 at 4:35 P.M., the Dietary Manager indicated the uncovered meat should have been covered and the Dietary Manager proceeded to cover the meat. A current facility policy titled Care of Storage Room, was provided by the Administrator on 7/21/25 at 2:39 P.M., with a revision date of 11/2024 , stated .The floors, walls, shelves, and equipment in the storeroom are clean. A current facility policy titled Storage Areas, was provided by the Administrator on 7/21/25 at 2:39 P.M., with a revision date of 07/2023 , stated .Food items will be stored on shelves.all containers must be legible and accurately labeled and dated. This citation relates to Complaint 1814346. 3.1-21(i)(1)3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the facility was free of gnats. This deficient practice had the potential to affect 47 of 48 residents residing in the facility. Findings include:During an observation and interview, on 07/21/25 at 8:07 A.M., in the kitchen there were multiple gnats observed flying in the air near the dry food storage area. Upon entering the dry storage room, the number of gnats increased. Five gnats landed on an unopened bag of cereal on a shelf at eye level. Three gnats landed on an unopened can of cheese approximately four feet off the ground on a metal shelf. A blue light was in the dry food storage area, plugged into the wall inside the doorway. The device was approximately two inches wide by five inches long. It had a plastic cover housing the blue light and a tacky substance strip on the inside covered in an abundance of dead gnats. Kitchen Staff 3 indicated the gnats had been an ongoing problem for months within the kitchen. A company came in to clean the drains and spray three days prior, and the number of gnats currently was mild compared to what it was. During an interview, on 07/21/25 at 9:37 A.M., the Dietary Manager indicated the gnat problem wasn't as bad when he started in February but had increased since the weather had warmed up. There was an issue with the drain in the kitchen clogging up from food. A plumber came in and cleaned it out approximately two months ago. Approximately one and a half weeks ago a chemical supplier came in and hooked up a line to keep chemicals in the drain constantly to prevent food from clogging it. It had been an ongoing problem in the kitchen. During an observation, on 07/21/25 at 11:22 A.M., while in the kitchen three gnats were visualized on the outside plastic of a hotdog bun package partially used and resealed. Multiple other gnats were observed flying in the air. The hotdog bun package was sitting at the end of the food preparation table behind the steam tables used for serving residents. Approximately more than 50 gnats were surrounding a commercial sized coffee machine actively brewing a pot of coffee on the left side of the kitchen's refrigerator. Approximately 15 gnats landed on the buttons of the coffee machine directly above the pot being brewed. Multiple gnats were flying around the trash can at the end of the food prep table with seven gnats visualized on the trash can lid by the opening in the lid. Staff were preparing breaded chicken approximately 3 feet away from trash can. During an interview, on 07/21/25 at 3:33 P.M., the Administrator indicated that the gnats had been a problem since June 24, 2025. When the gnats were discovered they deep cleaned the kitchen, and had a pest control company come in monthly to spray. The Pest Control Visit Records for the last three months were provided by the Administrator on 07/21/25 at 10:55 A.M.A Summary of Service Note, dated 05/16/2025, indicated the pest control targeted pests were ants and spiders. The pest Summary indicated the kitchen drain under the ice machine needed scraped clean and hot spot treatments have helped some but not removed the entire buildup. Large trash cans only emptied a few times a day and that might have allowed additional pest concerns and feeding. A Summary of Service Note, dated 06/21/25, indicated the pest control targeted pests were flies and gnats. The pest Summary indicated 5 to 10 gnats were found in the kitchen.A Summary of Service Note, dates 0718/25, indicated the pest control targeted pests were skink bug, boxelder bug, spider, ants, and multicolored lady beetles. The pest Summary indicated the cafeteria area of the kitchen only and lacked any indication of the kitchen area specific. The current facility policy titled, Pest Control, with a revision date of 7-23 and was provided by the Administrator on 07/21/25 at 11:53 A.M. The policy indicated, .If pests are seen in the kitchen.Appropriate action will be taken to eliminate any reported pest situation in the department. This citation relates to Complaint 1814346. 3.1-19(f)(4)

Based on observation, record review, and interview, the facility failed to treat a resident in a dignified manner during a meal service for 1 of 2 dining observations. (Resident 15) Findings include: Meal service was observed in the Main Dining Room on 01/27/25 at 12:01 P.M. At 12:10 P.M., Certified Nurse Aide (CNA) 6 stood upright next to Resident 15's wheelchair, to the resident's left side, with the resident's head at chest height to the CNA. The CNA was saying the resident's name over and over again, to get her attention, as she spooned food into the resident's mouth. Several empty chairs were observed in the dining room. Another staff member was sitting down in a chair, at the same table, assisting another resident with their meal. CNA 6 continued to stand over Resident 15 while she assisted the resident with her meal until 12:36 P.M. The clinical record for Resident 15 was reviewed on 01/28/25 at 1:29 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/15/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, dementia, anxiety, depression, and psychotic disorder. The resident was dependent on staff for assistance with eating. During an interview on 01/30/25 at 10:05 A.M., CNA 4 indicated when assisting a resident with their meal, they would apply a clothing protector to the resident, pull up a chair, sit down next to the resident, and assist them with eating their meal. The current Resident Rights policy, with a revised date of June 2023, was provided by the Director of Nursing (DON) on 01/30/25 at 10:25 A.M. The policy indicated, .Employees shall treat all residents with kindness, respect, and dignity . 3.1-3(a)

Based on observation, record review, and interview, the facility failed to maintain resident records in a private manner related to information visible on a computer screen and on top of a medication cart for 2 of 6 random observations. (100 and 300 Hall Medication Carts) Findings include: 1. During a continuous observation on 01/27/25 from 2:17 P.M. to 2:39 P.M., the 100 Hall Medication Cart was left unattended. Resident 249's information was visible on the screen, - On 01/27/25 at 2:17 P.M., two Certified Nurse Aides (CNA) walked by the medication cart. - On 01/27/25 at 2:23 P.M., The computer screen on the medication cart remained unattended. - On 01/27/25 at 2:25 P.M., two CNAs walked by the medication cart. - On 01/27/25 at 2:28 P.M., a CNA walked by the medication cart. - On 01/27/25 at 2:31 P.M., RN 3 walked to the medication cart, made some notes on a piece of paper, and walked back to the nurse's station without closing the computer screen. - On 01/27/25 at 2:33 P.M., a Laundry Aide walked by the medication cart. - On 01/27/25 at 2:38 P.M., two CNAs and a Laundry Aide walked by the medication cart. During an observation and interview on 01/27/25 at 2:39 P.M., RN (3) approached the medication cart and indicated the Qualified Medication Aide was passing medications that shift. The computer screen should have been locked when left unattended. During the observation there were mobile residents in the general area three to five feet of the medication cart. 34232 2. During a continuous observation on 01/29/25 from 10:37 A.M. to 10:45 A.M., the medication cart for the 300 Hall was left unattended. A CNA Report Sheet was laying on the top of the cart and had several resident names listed with resident care information next to each name. A stack of empty medication cards were on top of the cart with one for Resident 27 lying on the top of the stack. No staff were standing in the immediate area of the cart. Several staff members and an independently mobile resident using a walker walked next to the cart during the observation time period. - On 01/29/25 at 10:39 A.M., two staff members walked past the medication cart, - On 01/29/25 at 10:39 A.M., a staff member walked past the medication cart carrying clean linens, - On 01/29/25 at 10:40 A.M., a staff member walked past the medication cart, - On 01/29/25 at 10:40 A.M., a QMA walked past the medication cart, - On 01/29/25 at 10:41 A.M., a staff member walked past the medication cart, - On 01/29/25 at 10:41 A.M., another staff member walked past the medication cart, - On 01/29/25 at 10:42 A.M., Resident 9, who was independently mobile with their walker, walked past the medication cart, and - On 01/29/25 at 10:45 A.M., a QMA walked up to the cart and began tearing off the portion of the medication cards containing the residents' names. During an interview on 01/29/25 at 11:18 A.M., QMA 8 indicated nothing should be left on top of the medication carts with resident names visible. The current Confidentiality of Information and Personal Privacy policy, with a revised date of 10/2017, was provided by the Director of Nursing (DON) on 01/30/25 at 10:25 A.M. The policy indicated, .Our facility will protect and safeguard resident confidentiality and personal privacy .of all resident personal and medical records .The facility will strive to protect the resident's privacy regarding his or her .medical treatment .personal care .Access to resident personal and medical records will be limited to authorized staff and business associates . 3.1-3(o)

Based on record review and interview, the facility failed to follow the physician's orders related to hold parameters for medications for 2 of 15 residents reviewed for Quality of Care. (Residents 15 and 24) Findings include: 1. The clinical record for Resident 15 was reviewed on 01/28/25 at 1:29 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/15/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, coronary artery disease, diabetes, and hypertension. A current open-ended physician's order, with a start date of 09/05/24, indicated the resident was to take Coreg (a cardiac medication) 25 milligrams (mg), two times a day related to hypertensive heart disease. The medication was to be held (not given) for a Heart Rate (HR) of less than or equal to 60 beats per minute and/or a blood pressure less than or equal to 110/50. The current October 2024, December 2024, and January 2025, Electronic Medication Administration Record (EMAR) for the resident's Coreg was provided by the Director of Nursing (DON) on 01/30/25 at 1:29 PM., and indicated the resident had received the Coreg medication when the resident's HR was less than or equal to 60 for the following dates and times: - 10/02/24 at bedtime the HR was 57, - 10/03/24 at 7:00 A.M. the HR was 60, - 10/04/24 at bedtime the HR was 60, - 10/06/24 at 7:00 A.M., the HR was 60, - 10/07/24 at 7:00 A.M., the HR was 60, - 10/09/24 at 7:00 A.M., the HR was 60, - 10/09/24 at bedtime the HR was 60, - 10/11/24 at bedtime the HR was 60, - 10/12/24 at bedtime the HR was 56, - 10/13/24 at 7:00 A.M., the HR was 60, - 10/13/24 at bedtime the HR was 54, - 10/15/24 at 7:00 A.M., the HR was 60, - 10/15/24 at bedtime the HR was 59, - 10/16/24 at 7:00 A.M., the HR was 60, - 10/21/24 at 7:00 A.M., the HR was 60, - 10/24/24 at 7:00 A.M., the HR was 60, - 10/24/24 at bedtime the HR was 59, - 10/25/24 at 7:00 A.M., the HR was 55, - 10/29/24 at bedtime the HR was 47, - 10/30/24 at 7:00 A.M., the HR was 60, - 12/04/24 at bedtime the HR was 59, - 12/05/24 at bedtime the HR was 59, - 12/06/24 at 7:00 A.M. the HR was 60, - 12/06/24 at bedtime the HR was 60, - 12/10/24 at 7:00 A.M., the HR was 60, - 12/11/24 at 7:00 A.M., the HR was 60, - 12/13/24 at 7:00 A.M., the HR was 60, - 12/14/24 at 7:00 A.M., the HR was 60, - 12/14/24 at bedtime the HR was 58, - 12/16/24 at bedtime the HR was 58, - 12/17/24 at bedtime the HR was 56, - 12/20/24 at bedtime the HR was 60, - 12/21/24 at bedtime the HR was 60, - 12/22/24 at 7:00 A.M., the HR was 60, - 12/24/24 at bedtime the HR was 60, - 12/25/24 at 7:00 A.M., the HR was 60, - 12/26/24 at 7:00 A.M., the HR was 60, - 12/27/24 at bedtime the HR was 60, - 12/28/24 at 7:00 A.M., the HR was 60, - 12/31/24 at 7:00 A.M., the HR was 60, - 01/01/25 at 7:00 A.M., the HR was 60, - 01/04/25 at 7:00 A.M., the HR was 60, - 01/06/25 at bedtime the HR was 60, - 01/07/25 at 7:00 A.M., the HR was 60, - 01/08/25 at 7:00 A.M., the HR was 60, - 01/14/25 at 7:00 A.M., the HR was 60, - 01/14/25 at bedtime the HR was 60, - 01/15/25 at 7:00 A.M., the HR was 60, - 01/15/25 at bedtime the HR was 60, - 01/17/25 at 7:00 A.M., the HR was 60, - 01/19/25 at bedtime the HR was 60, - 01/21/25 at 7:00 A.M., the HR was 60, - 01/23/25 at 7:00 A.M., the HR was 60, - 01/25/25 at bedtime the HR was 60, and - 01/27/25 at 7:00 A.M., the HR was 60. The Consultant Pharmacist's Medication Regime Review records for October and December 2024, were provided by the DON on 01/30/25 at 1:45 P.M., and indicated the following: - On 10/16/24, the pharmacist indicated there were times when the Coreg medication should have been held due to the resident's HR. This was not documented as such on the Medication Administration Record (MAR). Please educate the staff, and - On 12/18/24, the pharmacist indicated there were times when the Coreg medication should have been held due to the resident's HR. This was not documented as such and to please educate the staff. During an interview on 01/30/25 at 10:40 AM., the DON indicated she received the pharmacy recommendations when they came in. Once they came in, she would give the Nurse Practitioner (NP) the recommendations designated for the NP/MD. For the ones designated for nursing, she would address them. Pharmacy recommendations usually came in around the middle of the month. She tried to have them addressed within 30 days. The Care Plan for the resident being at risk for a cardiac event related to hypertension and coronary artery disease was provided by the DON on 01/30/25 at 1:45 P.M. The interventions included, but were not limited to, monitor vital signs as ordered. 38769 2. The clinical record for Resident 24 was reviewed on 01/28/25 at 10:05 A.M. A Quarterly MDS assessment, dated 12/10/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hip and knee replacement, hypertension, anxiety, depression, and chronic pain syndrome. A physician's order, dated 09/06/24 through 01/23/25, indicated the resident was to take Midodrine 10 mg, three times a day for low blood pressure. The staff were to hold the medication when the resident's systolic blood pressure (top) number was greater than 110 or the diastolic blood pressure (bottom number) was greater than 70. A current open-ended physician's order, with a start date of 01/23/25, indicated the resident was to take Midodrine 10 mg, with meals for low blood pressure. The staff were to hold the medication when the resident's systolic blood pressure number was greater than 110 or the diastolic blood pressure was greater than 70. The current November and December 2024 and January 2025 EMAR indicated the resident had received the Midodrine when the resident's systolic blood pressure was greater than 110 or the diastolic was greater than 70 for the following dates and times: - 11/04/24 at bedtime when the blood pressure was 114/67, - 11/09/24 at bedtime when the blood pressure was 120/61, - 11/14/24 in the morning when the blood pressure was 112/64, - 11/15/24 at midday when the blood pressure was 112/65, - 11/18/24 in the morning when the blood pressure was 112/60, - 11/26/24 in the morning when the blood pressure was 114/70, - 11/27/24 in the morning when the blood pressure was 114/60, - 12/16/24 in the morning when the blood pressure was 114/68, - 12/20/24 at bedtime when the blood pressure was 115/80, - 12/25/24 at midday when the blood pressure was 115/78 and at bedtime when the blood pressure was 110/82, - 01/01/25 at bedtime when the blood pressure was 127/88, - 01/04/25 in the morning when the blood pressure was 112/75, - 01/05/25 at bedtime when the blood pressure was 116/75, - 01/08/25 in the morning when the blood pressure was 102/72, - 01/10/25 at bedtime when the blood pressure was 123/79, - 01/13/25 in the morning when the blood pressure was 110/72 and at bedtime when the blood pressure was 115/67, - 01/15/25 at bedtime when the blood pressure was 115/69, - 01/17/25 at bedtime when the blood pressure was 111/74, and - 01/22/25 at bedtime when the blood pressure was 119/80. During an interview on 1/30/25 at 10:12 A.M., RN 2 indicated if a medication had hold parameters, then she would obtain the resident's vital signs and if the vitals were within the acceptable parameters, then she would give the medication. If the vitals were not within the parameters, she would not administer the medications and document why the medication was not administered. The current facility policy titled, Administrating Medications, with a revised date of December 2012, was provided by the DON on 01/30/25 at 1:29 P.M. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The following information must be checked/verified for each resident prior to administering medications: .Vital signs, if necessary . 3.1-37(a)

Based on record review and interview, the facility failed to treat a Urinary Tract Infection (UTI) in a timely manner for 1 of 2 residents reviewed for UTIs. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 01/28/25 at 2:10 P.M. An Admission Minimum Data Set assessment, dated 11/07/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, dementia, aortic valve disorder, urinary retention, and hypertension. A Nursing Note, dated 11/02/24 (Saturday) at 11:51 P.M., indicated new physician's orders were received to obtain a Urinalysis and Culture and Sensitivity (UA/CS). A Nursing Note, dated 11/03/24 (Sunday) at 8:38 A.M., indicated the resident denied pain or discomfort but experienced frequent incontinent episodes and frequent feelings of needing to void. The resident's urine had a strong odor. The laboratory (lab) report for the urinalysis indicated the resident's urine was collected on 11/06/24 (Wednesday) and the results were reported on 11/08/24 (Friday). The report indicated the following bacteria were detected in the sample: - Klebsiella pneumoniae, with an estimated high microbial load, - Citrobacter freundii/braak/koseri, with an estimated moderate microbial load, - Proteus mirabilis, with an estimated moderate microbial load, - Pseudomonas aeruginosa, with an estimated moderate microbial load, - Actinobaculum schaalii, with an estimated low microbial load, - Enterobacteriaceae, with an estimated low microbial load, and - Enterococcus faecalis, with an estimated low microbial load. The report recommended potential antibiotics to treat the bacteria. A Nursing Note, dated 11/11/24 (Monday) at 3:31 P.M., indicated a new physician's order was received to administer Fosfomycin (an antibiotic), 3 milligrams every 72 hours for three doses. A Nursing Note, dated 11/11/24 at 4:10 P.M., indicated the facility requested the pharmacy to STAT (immediate) send the Fosfomycin packet. A Shift Level Administration Note, dated 11/11/24 at 7:04 P.M., indicated the resident received first dose of the antibiotic to treat her UTI. During an interview on 01/31/25 at 11:12 A.M., the Director of Nursing (DON) indicated If UA/CS results were available on a Friday, the facility could contact the physician and the pharmacy and get an antibiotic started on the weekend. The current Physician Orders policy, with a revised date of 03/17/22, was provided by the DON on 01/30/25 at 10:25 A.M. The policy indicated, .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines . 3.1-41(a)(2) 3.1-49(a)

Based on observation and interview, the facility failed to store medications appropriately for 1 of 2 medication carts reviewed. (100-Hall Medication Cart) Findings include: During a continuous observation on 01/27/25 from 2:17 P.M. to 2:39 P.M., the 100-Hall Medication Cart was unlocked and left unattended, - On 01/27/25 at 2:17 P.M., two Certified Nurse Aides (CNA) walked by the medication cart, - On 01/27/25 at 2:23 P.M., The medication cart remained unlocked and unattended, - On 01/27/25 at 2:25 P.M., two CNAs walked by the medication cart, - On 01/27/25 at 2:28 P.M., a CNA walked by the medication cart, - On 01/27/25 at 2:31 P.M., RN 3 walked to the medication cart, made some notes on a piece of paper, and walked back to the nurse's station without locking the medication cart, - On 01/27/25 at 2:33 P.M., a Laundry Aide walked by the medication cart, and - On 01/27/25 at 2:38 P.M., two CNAs and a Laundry Aide walked by the medication cart. During an observation and interview on 01/27/25 at 2:39 P.M., RN 3 approached the medication cart and indicated the Qualified Medication Aide (QMA) had been passing medications this shift. The medication cart should be locked when left unattended. During the observation there were mobile residents in the general area three to five feet of the medication cart. The current facility policy, titled Storage of Medications, with a revision date of April 2007, was provided by the Director of Nursing (DON) on 01/30/25 at 10:25 A.M. The policy indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 3.1-25(o)

Based on interview and record review, the facility failed to obtain a blood test and a urinalysis for 1 of 5 residents reviewed for laboratory services. (Resident 1) Findings include: 1a. The clinical record for Resident 1 was reviewed on [DATE] at 2:10 P.M. An Admission Minimum Data Set assessment, dated [DATE], indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, dementia, and aortic valve disorder. The resident's [DATE] physician's orders included, but were not limited to, the following: - An order, with a start date of [DATE], to administer warfarin (an anticoagulant) medication. The resident was to receive 3.5 milligrams (mg), every Monday, Wednesday, Thursday, Saturday, and Sunday and 4 mg every Tuesday and Friday, and - An order, with a start date of [DATE], to obtain a weekly PT/INR (a blood test that measured how long it took for a blood sample to clot). A Nursing Note, dated [DATE] at 4:51P.M., indicated the laboratory (lab) technician had an expired sample collection tube and would have to obtain the blood sample on [DATE]. A Nursing Note, dated [DATE] at 2:56 P.M., indicated the lab was unable to collect the PT/INR sample on [DATE], [DATE], or [DATE]. The facility spoke with the lab, and they were going to come and collect a STAT (immediate) PT/INR. The lab report for the PT/INR blood test indicated the sample was collected on [DATE] and resulted on [DATE]. The results were within the recommended therapeutic range for the resident. A Nursing Note, dated [DATE] at 11:22 A.M., indicated the Nurse Practitioner was updated on the PT/INR results. The resident was to continue the current dose of warfarin. During an interview on [DATE] at 11:12 A.M., the Director of Nursing (DON) indicated the lab said they couldn't obtain a sample from the resident so there was an order for a STAT PT/INR on [DATE]. The sample was collected by the lab on [DATE] and resulted on [DATE]. She would have liked to have had the lab drawn before [DATE]. 1b. A Nursing Note, dated [DATE] (Saturday) at 11:51 P.M., indicated new physician's orders were received to obtain a Urinalysis and Culture and Sensitivity (UA/CS) for Resident 1. A Nursing Note, dated [DATE] (Sunday) at 8:38 A.M., indicated the resident denied pain or discomfort but experienced frequent incontinent episodes and frequent feelings of needing to void. The resident's urine had a strong odor. A Shift Level Administration Note, dated [DATE] (Monday) at 1:08 A.M., indicated the resident's urine sample was obtained and placed in the refrigerator. The laboratory (lab) report for the urinalysis indicated the resident's urine was collected on [DATE] (Wednesday) and the results were reported on [DATE] (Friday). The report indicated the following bacteria were detected in the sample: - Klebsiella pneumoniae, with an estimated high microbial load, - Citrobacter freundii/braak/koseri, with an estimated moderate microbial load, - Proteus mirabilis, with an estimated moderate microbial load, - Pseudomonas aeruginosa, with an estimated moderate microbial load, - Actinobaculum schaalii, with an estimated low microbial load, - Enterobacteriaceae, with an estimated low microbial load, and - Enterococcus faecalis, with an estimated low microbial load. The report recommended potential antibiotics to treat the bacteria. A Nursing Note, dated [DATE] (Monday) at 3:31 P.M., indicated a new physician's order was received to administer Fosfomycin (an antibiotic), 3 milligrams every 72 hours for three doses. During an interview on [DATE] at 9:25 A.M., RN 2 indicated the lab would pick up specimens on Thursdays, Fridays, and Saturdays. If the facility had a urine specimen that needed to be sent out at any other time the facility would have to ship it. During an interview on [DATE] at 11:12 A.M., the DON indicated nursing staff were to collect the urine sample and contact the lab to pick up the sample. If the sample was collected on a day the lab didn't come to the facility, they would have to ship the sample out. She was unsure where the lab company was located. The current Lab and Diagnostic Test Results - Clinical Protocol with a revision date of [DATE], was provided by the DON on [DATE] at 2:54 P.M. The policy indicated, .The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . 3XXX,d+[DATE](a)

Based on observation and interview, the facility failed to store foods in a sanitary manner related to unlabeled and outdated foods for 1 of 3 kitchen observations. This deficient practice had the potential to affect 45 of 47 resident that receive food from the kitchen. Findings include: During the initial tour of the facility kitchen on [DATE] at 10:35 A.M., the following items were observed: - A ,d+[DATE] full half gallon of lactose free 2% milk that expired on [DATE], - An unopened half gallon of lactose free 2% milk that expired on [DATE], and - A metal pan ,d+[DATE] full of brown gravy. The pan was covered with plastic wrap and dated [DATE]. During an interview on [DATE] at 10:40 A.M., [NAME] 5 indicated the milk and brown gravy were expired and should have been thrown out. The current facility policy, titled Policy: Storage Areas, dated ,d+[DATE], was provided by the Director of Nursing on [DATE] at 10:25 A.M. The policy indicated, .Leftover food is used within 3 days or discarded .All foods should be covered, labeled, and dated . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheter care for 1 of 2 residents reviewed for infection control. (Resident 19) Findings include: 1a. During an observation on 01/27/25 at 1:50 P.M., Resident 19 was lying in bed. His entire urinary catheter bag was lying on the floor. The urine in the tubing appeared to be cloudy. During an observation 01/30/25 at 10:17 A.M., half of the resident's urinary catheter bag was lying on the floor. During an interview and observation on 01/30/25 at 10:18 A.M., Qualified Medication Aide (QMA) 7 indicated the resident's urinary catheter bags should be below bladder level and should not touch the floor. She went to Resident 19's room, donned gloves and removed the urinary catheter bag off the floor and secured it to the side of the bed. The clinical record for the resident was reviewed on 01/29/25 at 10:15 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, neurogenic bladder and obstructive uropathy. The resident had a urinary catheter and was dependent on staff for all care. The clinical record indicated the resident was on enhanced barrier precautions due to having a urinary catheter. The current facility policy titled Catheter Care, Urinary, with a revised date of September 2014, was provided by the Director of Nursing (DON) on 01/30/25 at 11:12 A.M. The policy indicated, .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . 1b. During an observation on 01/31/25 at 1:01 P.M., Certified Nurse Aide (CNA) 9 entered Resident 19's room and donned a gown and gloves. She was performing urinary catheter care on the resident when CNA 10 walked into the room and donned gloves. CNA 10 went to the right side of the resident's bed, held the dirty washcloths for CNA 9 and placed them in a bag. After the urinary catheter care was completed CNA 10 rolled the resident to his left side to check his backside and laid him on his back. She retrieved a pillow and as she was getting ready to place it behind the resident, the pillow touched her clothing. As the care was completed CNA 9 indicated she was aware that CNA 10 did not don a gown when she entered the room to help care for the resident. During an interview on 01/31/25 at 1:07 P.M., CNA 9 indicated when CNA 10 entered the room to help with urinary catheter care she should have donned a gown. The current facility policy titled, Enhanced Barrier Precautions updated April 2024 was provided by the Administrator on 01/31/25 at 1:23 P.M. The policy indicated, .Enhanced barrier precautions [EBPs] are utilized to prevent the spread of multi-drug resistant organisms [MDROs] to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activities .Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include .providing hygiene .changing briefs or assisting with toileting .device care or use .urinary catheter .EBPs are indicated [when contact precautions for not otherwise apply] for residents with wounds and/or indwelling medical devices regardless of MDRO colonization . 3.1-18(b) 3.1-41(a)(2)

Based on observation and interview, the facility failed to prepare and serve food in a safe and sanitary manner for 2 of 3 dining observations. (Main Dining Room and 300 Hall Room Trays) Findings include: 1.a. During and observation and interview in the Main Dining Room on 03/04/24 at 12:13 P.M., Resident 4 indicated his meatloaf was not done and was pink in the middle. His meatloaf had a quarter size pink spot in the middle. He had asked for a grilled cheese sandwich, which he was eating at that time. Resident 19 was sitting at a different table with her head slumped down, asleep. Her meal tray was sitting in front of her, and her meatloaf was cut into pieces. There was a quarter size spot in the meatloaf that was pink. The Dietary Manager indicated the meat had been frozen and appear raw, but it was not. She would get any resident something else to eat if they wanted it. During an interview on 03/04/24 at 12:22 P.M., RN 8 indicated she had served resident's their meals and assisted with cutting up the meatloaf. She didn't see any concerns with the meat. If she had, she would have alerted the kitchen staff. During an interview on 03/04/24 at 12:23 P.M., CNA (Certified Nurse Aide) 9 indicated she had not seen any resident's meat that was not cooked. If she had seen undercooked meat, she would have taken the food, thrown it away, let the kitchen staff know, and gotten the resident new food. During an interview on 03/04/24 at 12:25 P.M., the Dietary Manager indicated the meatloaf was cooked in a big pan and cut into four sections. They had obtained temperatures in two of the four sections. During an interview on 03/04/24 at 12:27 P.M., Cook 2 indicated Resident 4 had shown him his meatloaf, it had looked a little raw. He told him not to eat it and had informed the other kitchen staff. He got the resident a grilled cheese sandwich. It didn't look like much of the meat was raw. He didn't see any other resident's meatloaf that looked raw. During an interview on 03/04/24 at 12:35 P.M., the DON (Director of Nursing) indicated there had not been any residents sick from a food borne illness in the building. The current facility policy titled, GENERAL FOOD PREPARATION AND HANDLING, with a revision date of 7/2023, and provided by the DON on 03/07/24 at 3:03 P.M. The policy indicated, .All meats are to be cooked or heated to a safe minimum internal temperature . 1.b. During an observation in the Main Dining Room on 03/04/24 at 11:47 A.M., CNA 9 had rubbed her nose with her left hand, opened a cabinet door by the sink using her left hand, retrieved a cup from inside the opened kitchen door, and used her left hand to get sugar packets from the drink station. She held the cup in her left hand and filled it with ice from the ice chest and served it to Resident 42. CNA 9 took a menu to Resident 19 and asked her what she wanted for lunch. She took the menu back to the kitchen. She scratched her chin with her left hand then asked Resident 7 what he would like to drink. She went to the ice chest and opened it with her left hand, retrieved a cup, held it in her left hand, placed ice and the resident's drink choice in the cup and served it to the resident. CNA 9 then got Resident 4 two glasses of tea, scratched her face with her right hand, took dirty cups to the dirty dish side of the kitchen door, and then sanitized her hands. During an interview on 03/08/24 at 1:14 P.M., CNA 10 indicated when serving resident trays she would wash her hands, give residents' drinks, and sanitize between every couple of residents. Staff shouldn't touch any part of their selves and if they did, they should wash their hands. 34232 1.c. On 03/04/24 at 11:43 A.M., in the Main Dining Room, the following was observed: Cook 2 served a meal plate to Resident 15 and opened their ice cream cup, served a meal plate to Resident 9 and opened their ice cream cup, served a meal plate to Resident 30, removed rolled silver ware and a clothing protector from a cabinet, opened Resident 30's ice cream cup, then washed his hands with soap and water, turning on the water with his bare hands. He shut the water off with his bare hands then dried his hands on paper towels. He served a plate to Resident 9's family member, grabbed rolled silverware out of a drawer, put the silverware back in the drawer, passed a stack of black napkins from a staff member through the kitchen door to a kitchen staff member, served a meal plate to Resident 19 and opened their ice cream cup, dropped the lid on the floor, picked it up, threw it away, then washed his hands with soap and water, shutting the water off with paper towels. 2. On 03/04/24 at 12:46 P.M., meal trays were being passed to rooms on the 300 Hall by DA (Dietary Aide) 6 and the following was observed: DA 6 served Resident 6 their meal, touched and moved their over the bed table, went into another room, served Resident 10 their meal, touched their over the bed table, opened their ice cream, went into another room, served Resident 27 their meal, touched items on their over the bed table, opened a straw for them, then used hand sanitizer. During an interview on 03/08/24 at 1:11 PM., the DM (Dietary Manager) indicated when staff took meals to residents' rooms, they should sanitize their hands after delivering each tray served. When serving in the dining room, staff should sanitize their hands after serving each meal as well. Staff should not touch their person before serving a meal. If they did, they should wash their hands before serving another tray. When washing their hands, staff should turn the water on, get some soap, wash their hands, rinse their hands, dry their hands with paper towels, then shut the water off with the paper towel. The current Hand Washing policy, with a revised date of 07/2023, was provided by the DM on 03/08/24 at 1:34 P.M. The policy indicated, .When to Wash Hands .After touching bare human body parts other than clean hands .How to Wash Hands .Turn on the faucet using a paper towel to avoid contaminating the faucet .Wet hands and forearms with warm water .apply .soap .Scrub .Rinse .Dry hands with paper towel. Turn the faucet off with the towel . The current Assisting the Resident with In-Room Meals policy, with a revised date of December 2013, was provided by the DM on 03/08/24 at 1:34 P.M. The policy indicated, .Employees must wash their hands before serving food to residents .if there is contact with .the resident's personal effects, the employee must wash his/her hands before serving food to the next resident . 3.1-21(i)(3)

Based on observation and interview, the facility failed to maintain resident records in a private manner related to records left unattended on the nurse's station counter and a computer screen left open with visible resident information for 3 of 45 residents who resided in the facility. (Residents 27, 14, and 20) Findings include: 1a. During an observation 03/05/24 at 3:27 P.M., the paperwork for Resident 27 was left laying on the upper counter of the nurse's station with a visible doctor's written order. 1b. A report for Resident 14 was visible on top of a stack of several papers. These were the only two visible resident names. Independently mobile residents were walking by the nurse's station. No staff members were sitting at the nurses station near the papers. The current Confidentiality of Information and Personal Privacy policy with a revised date of October 2017, was provided by the DON on 03/08/24 at 3:23 P.M. The policy indicated, .The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .Access to resident personal and medical records will be limited to authorized staff and business associates . 38239 2. The computer screen on the med (medication) cart for the 200 hall was observed on 03/04/24 at 11:52 A.M. Resident 20's information was visible on the screen and the med cart was unattended. - On 03/04/24 at 11:53 A.M. a staff member walked by the med cart. - On 03/04/24 at 11:55 A.M., a resident walked by the med cart. - On 03/04/24 at 11:57 A.M., two CNAs (Certified Nurse Aides) and a housekeeping staff member walked by the med cart. - On 03/04/24 at 12:01 P.M., a CNA walked by the med cart. - On 03/04/24 at 12:02 P.M., a laboratory services technician walked by the med cart. - On 03/04/24 at 12:07 P.M., a visitor pushing a resident in a wheelchair walked by the med cart. - On 03/04/24 at 12:11 P.M., a visitor walked back by the med cart. - On 03/04/24 at 12:12 P.M., a message on the computer screen indicated it would log out of the system in one minute. - On 03/04/24 at 12:13 P.M., the computer logged out of the system due to inactivity. During an interview on 03/08/24 at 1:32 P.M., CNA 3 indicated computer screens should be locked and papers should be turned over to prevent resident's information being seen by others. The current facility policy, titled Electronic Medical Records, with a revision date of March 2014, was provided by the Administrator on 03/08/24 at 1:19 P.M. The policy indicated, .Only authorized persons .will be permitted access to the electronic medical records system .the facility will make reasonable efforts to limit the use or disclosure of protected health information . 3.1-3(o)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a blood pressure medication for 1 of 15 residents reviewed for quality of care. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 03/07/24 at 2:02 P.M. A Quarterly (Minimum Data Set) assessment, dated 01/23/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, cirrhosis of the liver, hypertension, heart failure, anxiety, and depression. A current physician's order, with a start date of 01/03/24, indicated the resident was to get Midodrine 10 mg (milligrams), before meals, for hypertensive heart disease with heart failure. The staff were to hold the medication if the resident's systolic (top number) blood pressure was greater than 110. The January, February, and March 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received the medication when the systolic blood pressure was greater than 110 or when the blood pressure was not obtained on the following dates and times: - 01/05/24 at 7:00 A.M., the blood pressure was 124/68, - 01/08/24, at 4:00 P.M., the blood pressure was not documented, - 01/10/24 at 7:00 A.M., the blood pressure was 118/60, - 01/10/24 at 11:00 A.M., the blood pressure was not obtained, - 01/10/24 at 4:00 P.M., the blood pressure was not obtained, - 01/11/24 at 7:00 A.M., the blood pressure was 130/68, - 01/11/24 at 11:00 A.M., the blood pressure was not obtained, - 01/11/24 at 4:00 P.M., the blood pressure was not obtained, - 01/12/24 at 7:00 A.M., the blood pressure was 118/68, - 01/12/24 at 11:00 A.M., the blood pressure was not obtained, - 01/12/24 at 4:00 P.M., the blood pressure was not obtained, - 01/16/24 at 7:00 A.M., the blood pressure was 120/68, - 01/16/24 at 11:00 A.M., the blood pressure was not obtained, - 01/16/24 at 4:00 P.M., the blood pressure was not obtained, - 01/17/24 at 7:00 A.M., the blood pressure was 140/68, - 01/17/24 at 11:00 A.M., the blood pressure was not obtained, - 01/17/24 at 4:00 P.M., the blood pressure was not obtained, - 01/18/24 at 7:00 A.M., the blood pressure was 130/74, - 01/18/24 at 11:00 A.M., the blood pressure was not obtained, - 01/18/24 at 4:00 P.M., the blood pressure was not obtained, - 01/19/24 at 11:00 A.M., the blood pressure was 120/64, - 01/19/24 at 4:00 P.M., the blood pressure was 118/64, - 01/20/24 at 7:00 A.M., the blood pressure was 146/80, - 01/22/24 at 7:00 A.M., the blood pressure was 120/66, - 01/22/24 at 4:00 P.M., the blood pressure was 116/68, - 01/26/24 at 11:00 A.M., the blood pressure was 112/70, - 01/26/24 at 4:00 P.M., the blood pressure was 112/74, - 01/30/24 at 4:00 P.M., the blood pressure was 112/62, - 02/01/24 at 4:00 P.M., the blood pressure was 114/62, - 02/02/24 at 4:00 P.M., the blood pressure was 116/60, - 02/08/24 at 7:00 A.M., the blood pressure was 112/68, - 02/09/24 at 11:00 A.M., the blood pressure was 118/68, - 02/15/24 at 4:00 P.M., the blood pressure was 114/68, - 02/20/24 at 7:00 A.M., the blood pressure was 126/68, - 02/20/24 at 11:00 A.M., the blood pressure was 126/68, - 02/22/24 at 7:00 A.M., the blood pressure was 112/66, - 02/28/24 at 4:00 P.M., the blood pressure was 112/70, and - 03/03/24 at 7:00 A.M., the blood pressure was 112/74. During an interview on 03/07/24 at 1:51 P.M., RN 5 indicated the blood pressure should be taken prior to the medication administration and if there were hold parameters, they should be followed. The current facility policy titled, Administering Medications, with a revised date of December 2012, was provided by the Director of Nursing on 03/08/24 at 8:53 A.M. The policy indicated, .2. Medications must be administered in accordance with the orders . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to address and monitor weight loss concerns in a timely manner (Residents 41 and 35) and monitor fluid intake (Resident 4) for 3 of 5 residents reviewed for nutrition and hydration. Findings include: 1. Resident 41's clinical record was reviewed on 03/07/24 at 11:15 A.M. An Admission MDS (Minimum Data Set) assessment, dated 10/30/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension and diabetes. The resident was 6' 3'' and weighed 226 Lbs. (pounds). The resident had no swallowing issues and did not receive a therapeutic or mechanically altered diet. Weight loss or weight gain was unknown. The following weights were documented in the resident's EHR (Electronic Health Record): - On 10/23/23 the resident weighed 226.2 Lbs., - On 11/03/23 the resident weighed 227.6 Lbs., - On 11/13/23 the resident weighed 225.2 Lbs., - On 11/14/23 the resident weighed 202.6 Lbs., and - On 11/20/23 the resident weighed 202.6 Lbs. The EHR lacked any indication the resident's weight loss was acknowledged or addressed. A Dietary Note, dated 12/12/23 at 12:51 P.M., indicated the resident was recently in the hospital. There was a possible weight variance due to the resident's current weight being below his usual weight range. Recommendations included, but were not limited to, obtaining a current weight, and weighing the resident weekly for monitoring related to the weight variance. The RD (Registered Dietician) added a reduced concentrated sweets diet, related to the resident's diagnosis of diabetes. - On 12/12/23 at 12:33 P.M., the resident weighed 196.6 Lbs. The resident's EHR lacked documentation the resident's weight was obtained again in the month of December 2023. The RD Recommendations Worksheet, dated 12/29/23, indicated several residents in the facility were reviewed. The worksheet lacked any indication the RD reviewed Resident 41. - On 01/02/24 the resident weighed 180.2 Lbs. - On 01/06/24 the resident weighed 181.4 Lbs. An NP (Nurse Practitioner) Progress Note, dated 01/10/24, indicated a new order for the resident to receive Remeron (as an appetite stimulant) 7.5 mg (milligrams) daily. During an interview on 03/08/24 at 9:52 A.M., the DON (Director of Nursing) indicated they recently hired a new RD. They started giving the resident health shakes last month in addition to the appetite stimulant prescribed in January. 34232 2. On 03/05/24 at 12:14 P.M., Resident 35 was observed in the main dining room with her meal in front of her on a regular plate. The resident's eyes were closed, and her head was bowed. She had no staff members assisting her with her meal. The resident had a plate of smoked sausage, sauerkraut, and apple sauce, a full cup of ice water, and a full cup of chocolate milk. At 12:18 P.M., the resident was covering her mouth with her clothing protector in a huddled position. On 03/06/24 at 11:06 A.M., the resident was observed in her wheelchair in the main dining room covered with a blanket. Her eyes were closed and she sat in a huddled position. At 11:42 A.M., the resident was served three drinks. Two cups of chocolate milk with lids and straws, and one cup of ice water. The staff did not tell the resident she had drinks or where they were located, they just sat them down on the table and left. At 11:57 A.M., a staff member served the resident her meal and directed her hand to the spoon in her bowl of chili. The resident fed herself one bite then stopped, appearing to dose off. At 12:23 P.M., the resident took her hand off her spoon and covered her mouth with her hand and her clothing protector. No staff offered her assistance or cueing for her meal until 12:25 P.M., 28 minutes after her meal was served, when CNA 3 told her where her food was located based on a clock. The resident refused his help and gave herself one more bite of chili then went back to her huddled position. The clinical record was reviewed on 03/06/24 at 12:09 P.M. An Annual MDS/State Optional assessment, dated 03/01/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, legal blindness, arthritis, dementia, anxiety, depression, and psychotic disorder. The resident needed extensive assistance of one staff member for eating. A Quarterly/State Optional MDS assessment dated [DATE], indicated the resident needed supervision with one person's physical assistance for eating. On 08/01/2023, the resident weighed 142.8 lbs. On 02/01/2024, the resident weighed 122.6 pounds which was a - (negative) 14.15 % Loss in 180 days. On 12/07/2023, the resident weighed 134.2 lbs. On 01/01/2024, the resident weighed 124.4 pounds which was a -7.30 % Loss in 30 days. The resident's weight loss was not mentioned or addressed in the RECOMMENDATIONS WORKSHEET - REGISTERED DIETICIAN records for January 23, 2024, or February 6, or 20, 2024. The February 2024 records indicated the RD was in the building on 02/06/24 and 02/20/24. The resident's weight loss was not addressed until 03/06/24, when Mirtazapine 7.5 mg (milligrams) was ordered for an appetite stimulant. The current [NAME] CNA Report Sheet was provided by CNA 3 on 03/06/24 at 9:40 A.M. The record indicated Resident 35 needed extensive assistance of one to two staff members, was blind, incontinent, on a regular diet with thin liquids, had their own teeth, and was to have finger foods. During an interview on 03/07/24 at 10:36 A.M., the DON indicated the RD was in every two weeks and usually had recommendations each time she was in the building. All residents were weighed monthly. She reviewed the weights, and the RD did as well. If a resident's weight changed by three to five pounds or more in a month, she would obtain a reweigh. Then, once she had the weights in, she would look at them to see who was triggering for a 5% or 10% weight loss or gain over the last 30 or 180 days. When she identified those individuals, she looked to see if it was a desired weight loss, if it was edema (swelling), or if a resident was trying to lose weight. She also communicated that to the NP (Nurse Practitioner) and the RD. The RD reviewed the residents' weights when she was in the building and the DON would alert her to any significant weight changes for the residents. If it was not a desired weight loss and the DON felt a resident needed a supplement, she would talk to the NP to ensure the residents got an order for what they needed. When a resident had significant weight loss, the staff should address the concerns right away. The NP was in every week and the staff communicated significant weight changes to her. The staff could get an order though Telehealth 24 hours a day, seven days a week. The DON had the NP's phone number and could contact her directly. The Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol policy, was provided by the DON on 03/06/24 at 11:11 A.M. The policy indicated, .The staff .will .identify individuals with .weight loss or gain, and significant risk for impaired nutrition .The staff will report to the physician significant weight gains or losses .The physician will limit prescribing of appetite stimulants to situations in which underlying causes cannot be identified or treated, other pertinent interventions have not worked or are not feasible, these medications have a valid indication, and improving appetite and weight is consistent with the individual's condition, prognosis, and wishes .A pertinent assessment and meaningful review of possible medical and non-medical causes of altered nutritional status should precede the use of such medications . The current Serving of Food policy, with a revised date of 07/2023, was provided by the DM on 03/08/24 at 1:51 P.M. The policy indicated, .Food shall be prepared and served in a manner that meets the individual needs of each resident .The Culinary and Nutritional Services team member will work in conjunction with the Nursing team member to ensure the correct food items are provided to the resident to meet meal preferences and diet restrictions . Residents who require assistance with eating will be provided with self-help devices or provided staff assistance as needed . 38769 3. The clinical record for Resident 4 was reviewed on 03/05/24 at 2:17 P.M. A Quarterly MDS assessment, dated 02/28/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, hypertension, diabetes, and depression. A Medical Diagnosis list included, but was not limited to, hypertensive heart and chronic kidney disease without heart failure, with Stage 1 through Stage 4 chronic kidney disease, or unspecified chronic kidney disease. An open-ended physician's order, with a start date of 01/18/24, indicated the resident was on a fluid restriction: 1500 ml (milliliters) total per 24 hours. The Dietary department total was 1080 ml to be served with meals: (breakfast 360 ml, lunch 360 ml, and dinner 360 ml). The Nursing department total was 420 ml: (days 180 ml, afternoons 150 ml, and evenings 90 ml). The clinical record lacked any documented fluid intake amounts. During an interview on 03/05/24 at 2:39 P.M., RN 4 indicated the resident was on a fluid restriction. They would keep track of the resident's fluid intakes. His mother brought in sodas for him. The facility would educate the resident on the importance of the fluid restriction. The resident's order for a fluid restriction was written as an FYI (For your Information) with nowhere to document how much the resident had consumed. During an interview on 03/05/24 at 2:48 P.M., the DON (Director of Nursing) indicated if a resident was on a fluid restriction and had and order for it then the resident's fluids would be monitored. The staff would monitor how much the resident was given throughout the day. The order indicated how much the resident was allotted from dietary and nursing. Outside of the amount the resident could drink, there was no documentation of how much they consumed. There was no place to document if the resident had more than the recommended amount. The current facility policy titled, Encouraging and Restricting Fluids with a revision date of 1/2019 and provided by the DON on 03/06/24 at 8:45 A.M. The policy indicated, .The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids .Record fluid intake on the intake side of the intake and output record as per md [MD] order . 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to follow a physician's order related to medication reduction for 1 of 5 residents reviewed for pharmacy services. (Resident 25) Findings include: During an observation on 03/07/24 at 9:00 A.M., Resident 25 was lying in bed, awake and eating breakfast. His call light was in reach, and he had no concerns. The clinical record was reviewed on 03/06/24 at 9:43 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/06/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, respiratory failure, anemia, hypertension, renal insufficiency, diabetes, anxiety, and depression. The resident had received an antidepressant during the review period. A Care Plan for taking an antidepressant, with a start date of 11/24/23, included an intervention, but was not limited to, .Give antidepressant medications ordered by the physician ., with a start date of 11/24/23. A Psychiatry Progress Note, dated 02/26/24, indicated the resident was to continue Zoloft (sertraline), 50 mg (milligrams), daily and will decrease next visit. A Physician's Order, dated 02/26/24, indicated to discontinue sertraline 100 mg every day and start sertraline 50 mg every day. A Progress Note, dated 02/26/24 at 1:57 P.M., indicated there was a new order to lower the resident's Zoloft from 100 mg daily to 50 mg daily per the Psychiatry Nurse Practitioner (NP). The family was made aware. The February and March 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked documentation that the resident started sertraline 50 mg after the sertraline 100 mg was discontinued on 02/26/24. During an interview on 03/07/24 at 1:13 P.M., the DON (Director of Nursing) indicated the resident was seen by psychiatry services. When the Psychiatry NP came to the facility she would visit with the residents and would write her orders on paper and give them to the nurse. The nurse would then transcribe the orders into the resident record. The NP would then send her notes from the visit, and they would be uploaded into the clinical record. No one reviewed the notes once they were faxed to the facility. The resident's order should have been started for 50 mg and was missed. The current facility policy titled, Physician Orders, with a revision date of 1/2018, was provided by the DON on 03/07/24 at 3:03 P.M. The policy indicated, .All physician/practitioner orders, including verbal/telephone orders, are recorded on the Physician's Order form for each resident and must be signed and dated within 14 days by the ordering physician, physician assistant or nurse practitioner unless state regulations mandate sooner .The receiving nurse or therapist immediately records telephone or verbal orders and documents their name, title, and the date . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide supervision of a resident ambulating without her walker which resulted in a head injury. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/23/17 at 10:00 AM. The Care Plan for falls indicated the resident was at risk for falls related to the need for extensive assistance with ambulation, transfers, and bed mobility. The resident had multiple documented falls, the two most recent dated 4/26/17 & 5/2/17. Interventions for this care area included assist of one staff to ambulate in room, corridor, and on/off unit with her walker; all staff were to monitor the resident using the walker while walking as resident was unsteady; and intervene as needed,. The Minimum Data Set (MDS) Quarterly Review assessment, dated 3/21/17, indicated Resident B had a Brief Interview of Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitively impaired. The [DIAGNOSES REDACTED]. The resident required extensive, one person assistance for bed mobility, transfers, walking in the room and corridor. The resident was not steady on her feet, was only able to stabilize with human assistance for moving from seated to standing position, and walked with assistive device. The Incident/Accident Investigation Report dated 5/2/17 for Resident B was provided by the Assistant Director of Nursing (ADON) on 5/23/2017 at 11:10 AM and reviewed at that time. The report indicated the resident was leaving the dining area without her walker or staff present and fell hitting her head on the floor. Her head bounced off the floor causing a hematoma and skin tear and her level of consciousness was comatose (unresponsive). The resident was sent to the emergency room for evaluation. A physician's orders [REDACTED]. During an observation of the video of Resident B taped on 5/2/17 at 12:00 PM, it showed the resident exited the dining area without a walker or the assistance of any staff. The resident staggered, zigzagged down the hall, and tripped on her own feet resulting in a fall sustaining a head injury. During an anonymous interview during the survey dates of May 23 & 24, 2017, a staff member indicated they thought the fall could have been avoided if there had been more staff in the dining area to monitor the residents. Resident B had been more agitated that day. Resident 6 had attempted to try to get Resident B to sit down, wait for help, and get the staff's attention to assist her with ambulation. They indicated Resident B had walked between tables and at one point lifted the walker to ambulate between wheelchairs at the tables. The resident then set the walker aside near the piano and exited the dining area. During an interview on 5/23/17 at 2:32 PM, CNA 5 indicated if a resident was a high risk for falls, then they would needed to be monitored and have staff walk with them. During an interview on 5/23/17 at 2:43 PM, CNA 6 indicated if a resident was a high fall risk then they would needed to be monitored. During staff assisted ambulation with a walker the resident would need to have a gait belt. During an interview on 5/24/17 at 9:47 AM, with Physical Therapy (PT) 8, she indicated Resident B was an extensive assistance with 80-100% of the time needing to be cued to use the walker. Staff had to be there the whole time of ambulation. The facility had tried to get Resident B to use the wheelchair, but she would not sit still and would try to get up causing a safety concern. The resident did not comprehend the safety issue. During an interview on 5/24/17 at 1:00 PM with CNA 10, she indicated she had noticed Resident B trying to get up from a dining room chair near the window which was not her usual spot. She offered to help Resident B get up from the chair and gave her the walker. She offered to assist Resident B to the hall, but Resident B was insistent she could do it herself so she pointed to the door of the dining area. She turned her back to Resident B to serve another resident their meal and didn't notice Resident B setting the walker aside and exiting the dining area. During an interview on 5/24/17 at 1:20 PM with Resident 6, she indicated Resident B had walked around in the dining area with her walker, set it aside, and exited the dining area. During an interview on 5/24/17 at 1:35 PM with CNA 11, she indicated Resident B sometimes walked with staff and sometimes didn't. Resident B's feet would sometimes get tangled up, but once she got started walking she would do ok. A Physical Therapy Plan of Care Report for Resident B, dated 10/11/16, was provided by the Physical Therapist on 5/24/17 at 10:02 AM and reviewed at that time. The Plan indicated Resident B was referred due to several incidents of falls and unsteady gait putting the resident at risk for injury. Resident B's current level was the need for stand by assistance close enough to reach the resident if assistance was needed as the resident required contact due to unsteadiness to ambulate. A Physical Therapy Progress & Discharge Summary, dated 11/08/16, for Resident B was provided by the Physical Therapist on 5/24/17 at 10:02 AM and reviewed at that time. The Summary indicated Resident B's dementia was affecting her ability to follow instructions for safe mobility, needed direction most of the time, and for staff to assist Resident with gait if needed. A Falls and Fall Risk Policy was provided by the ADON (Assistant Director of Nursing) on 5/24/17 at 11:10 AM and reviewed at that time. The policy indicated .staff would identify interventions related to the resident's specific risk and causes to try to prevent the resident fro falling .staff will monitor .to reduce falling . A CNA assignment sheet was provided by the ADON on 5/24/17 at 1:50 PM and reviewed at that time. The CNA sheet indicated Resident B was a 1 person assist with ADL's (Activities of Daily Living). This Federal Tag relates to Complaint IN 943. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the sling of a Hoyer lift was properly attached during a transfer resulting in a resident falling and sustaining a fractured hip. This affected 1 of 4 residents reviewed for accidents in a sample of 4. ( Residents # Z) Findings included: During the initial tour with RN/# 1 on 7/8/2012 at 10:18 P.M., she indicated Resident # Z was taken to the hospital last week after a fall from a Hoyer lift during a transfer by two C.N.A.'s On 7/10/2012 at 4:00 P.M., review of clinical record of Resident # Z indicated the resident was admitted with, but not limited to [DIAGNOSES REDACTED]. Review of a patient transfer form, dated 6/28/12, indicated the resident was transferred to local hospital, "fell out of full body lift during transfer, c/o (complained of) pain to R (right) arm & bilat (bilateral) legs, R hip." A nurse's note, dated 6/28/12 at 2200 (10:00 P.M.) stated, "C.N.A.'s called nurses to Res (resident) RM (room)- found Res lying on her stomach @ foot of room mates bed." "C.N.A.'s report was transferring Res from w/c (wheelchair) to bed using hoyer and R strap supporting R leg came loose causing Res to fall to floor on her knees." "Res c/o R arm, R hip, and bilat knee pain." "T(temperature) 97.3, P(pulse) 88, R(respirations) 20, B/P(blood pressure) 140/68, Admin(Administrator) & DON called at this time to update, MD updated-911 enroute, Res to remain in position until EMT arrival." On "6/28/12 at 2230 (10:30 P.M.) 911 here Res enroute to local hospital ER." On "6/28/12 at 2235 (10:35 P.M.)- Report called to local hospital ER." A nurse's note, dated 6/29/12 - 0100 (1:00 A.M.) "Rec'd (received) call from (nurse's name), local hospital ER nurse c (with) update on res, res has R hip Fx (fracture) and is being transferred to (Hospital's name) for surgery, R/T (related to) 0 (no) orthopedic surgeons at local hospital this weekend, res sister-in-law (name) notified, Dr.(name) aware." "A nurse's note, dated 6/29/12 at 0110 (1:10 A.M.) - Administrator notified." During an interview with the Director of Nursing on 7/9/2012 at 4:15 P.M., she indicated that both C.N.A.s involved received a first warning notice for failing to properly attach the sling to the Hoyer lift and inservices have been completed for nursing department staff on full body and sit to stand lifts. This Federal tag relates to Complaint IN 329. 3.1-45(a)(2)