Every finding on record at Miller's Merry Manor

Based on record review and interview, the facility failed to ensure each residents' dignity and rights were maintained related to not responding to complaints of excessive television volume in a timely manner for 3 of 4 resident council members and one random resident that resided on the 100 unit. (Residents 6, 30, 41 and 45)Finding includes:The resident council interview was completed on 3/4/26 at 2:00 p.m. with four council members present. Residents 6, 30 and 41 indicated that Resident 25 on the 100 unit continually kept his television excessively loud and refused to close his door. The residents indicated they had complained to staff about the loud volume several times, but nothing had changed. Resident 6 indicated her room was next to his and the television would keep her up at night. Resident 41 indicated he had been Resident 25's previous roommate but had requested a different room due to the loud television. Resident 30 indicated they had been told by staff that the resident had the right to listen to his television at the volume he preferred, but she felt their rights were being infringed upon. There were no grievances related to the loud television volume in the past six months. Resident 25's record was reviewed on 3/5/26. A General Note, dated 12/3/25, indicated the resident had his TV on very loud and was educated by the nurse that it was disturbing the other residents. The resident turned his TV off. A General Note, dated 12/9/25, indicated the resident had his TV turned up to 100. He was redirected to turn it down several times but would turn the volume back up when the nurse left the room. A General Noted, dated 12/11/25, indicated the Social Service Director 1 (SSD 1) discussed moving the resident's bed to the back of the room and installing the TV to the side of the wall closer to him. He rejected the idea and did not see a problem with the volume. A General Note, dated 12/11/25, indicated the SSD had discussed the TV volume concerns with the resident's family member. They discussed checking into child control locks to limit the volume. Also discussed were the headphones they had provided but the resident refused to use. The family member wanted to get his hearing tested, but the resident had refused to go out to appointments. They discussed having the physician check his ears for wax buildup and having an audiology visit inhouse. A Psychological Evaluation, dated 12/16/25, indicated, .Staff report patient is very hard of hearing and has a tendency to turn his television up so high that it disrupts the unit and bothers other residents. Despite multiple conversations, patient's behavior has not changed The use of headphones was discussed, but the patient was not interested. The patient seemed legitimately unable to hear the TV at lower volumes. The summary indicated the resident would likely not benefit from psychotherapy due to hearing and cognitive impairments. An inhouse Audiology visit was completed on 12/18/25. The resident was found to have a moderate to profound hearing loss but did not want anything to do with hearing aids at that time. Headphones were discussed and he did not want those either. A General Note, dated 1/8/26, indicated Social Services had attempted to call the Ombudsman to discuss the concerns with the TV volume and disturbing other residents. A voicemail was left and the Ombudsman was e-mailed regarding the situation. Behavior monitoring was initiated on 1/29/26 and documented in the Treatment Administration Record. Interventions included to remind the resident that the volume should be turned down to about 50, offer headphones, and turn the TV off if the resident was sleeping. During an interview on 3/4/26 at 2:40 p.m., SSD 2 indicated he was aware of the concerns with Resident 25's TV volume. They had provided him with headphones, but he would not use them, and he didn't like to keep the door closed. He was aware roommates had moved out due to the television volume. He had not completed an official grievance form but had been documenting interventions attempted in the resident's record. During an interview on 3/4/26 at 3:42 p.m., the Regional [NAME] President (RVP) indicated she was aware of the situation and had been involved with trying to resolve it. They had tried to contact the Ombudsman for assistance but had not heard back. They provided headphones, offered to move the TV closer but the resident declined all interventions. During an interview on 3/5/26 at 10:40 a.m., Resident 45, who resided on the 100 unit, indicated she heard the resident's TV all the time as it was very loud and irritating. She indicated she had complained to staff about it, but nothing had changed. During a follow-up interview on 3/5/26 at 9:15 a.m., the RVP indicated she had spoken to the resident's family member, and they were going to bring in a television with parental controls this weekend and were cooperative in trying to resolve this issue. She had also made a written agreement with the resident not to exceed a volume of 54 in the meantime as a reminder. She indicated staff didn't want to shut the resident's door against his wishes because they were fearful of infringing on his rights. The document, Social Services Policy and Procedure, was provided by SSD 2 on 3/4/26 and indicated, Miller's Merry Manor strives to address all resident concerns and complaints immediately to the satisfaction of the resident and/or family . and, I. Follow up with the involved party will be completed until the concern is resolved to the satisfaction of the resident and/or party and documented 410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on record review and interview, the facility failed to invite and hold care planning conferences for residents and/or their family members for 2 of 16 residents whose care plans were reviewed. (Residents 34 and 6)Findings include:1. During an interview on 3/3/26 at 3:22 p.m., Resident 34 indicated she had not been invited to or attended a care plan meeting. The record for Resident 34 was reviewed on 3/4/26 at 9:45 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, chronic kidney disease, major depressive disorder, dysphagia (difficulty swallowing), epilepsy, and stroke. The resident was admitted to the facility on [DATE]. The 1/22/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. A Facility Pre-Discharge Planning Assessment, dated 10/6/25, indicated the resident had her first care planning conference with the facility. There was no documentation the resident had a care plan conference after 10/6/25.During an interview on 3/5/26 at 10:15 a.m., the Social Service Director (SSD) indicated the first care plan meeting with the resident and her family was completed at the time of admission and documentation could be found in the pre-discharge planning assessment. During an interview on 3/5/26 at 1:15 p.m., the SSD indicated the resident had only had one initial care plan meeting when she was first admitted . She had notified the family about the next care conference but had not heard back from them. She was aware she could have held the meeting with just the resident. 2. During an interview on 3/2/26 at 2:04 p.m., Resident 6 indicated she was not aware of being invited to or attending a care plan meeting.The record for Resident 6 was reviewed on 3/4/26 at 9:21 a.m. Diagnoses included, but were not limited to, stroke, heart disease, osteoarthritis, and morbid obesity. The 12/11/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The Long Term Resident Care Plan Meeting Template indicated the resident had care planning conferences held on 1/7/25, 3/25/25, and on 10/3/25. The resident had attended all three meetings. There were no care plan meetings held between 3/25/25 and 10/3/25. There were also no care plan meetings held after 10/3/25. During an interview on 3/5/26 at 1:15 p.m., the Social Service Director indicated there were no other care planning conferences completed for the resident. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure bruises were assessed and monitored for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 34)Finding includes: During a random observation on 3/2/26 at 11:10 a.m., Resident 34 was observed with a reddish purple discoloration to the right forearm. The resident was not wearing geri sleeves (protective skin coverings for fragile skin) or long sleeves to either arm. During an interview on 3/4/26 at 11:50 a.m., the resident indicated staff did not always put her geri sleeves on her arms. During an observation on 3/5/26 at 9:31 a.m., CNA 2 was providing morning care for the resident. At that time, he removed both geri sleeves from her arms. There was a red and purple discoloration to the right forearm. The record for Resident 34 was reviewed on 3/4/26 at 9:45 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, chronic kidney disease, and stroke. The resident was admitted to the facility on [DATE]. The 1/22/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The Care Plan, dated 10/3/25, indicated the resident was on anticoagulant therapy for deep vein thrombosis (blood clot) prevention. The approaches were to monitor for signs and symptoms of bleeding such as bruising. A Physician's Order, dated 10/4/25, indicated Apixaban (an anticoagulant medication) 2.5 milligrams (mg), give one tablet by mouth two times a day. A Physician's Order, dated 12/22/25, indicated geri sleeves were to be on at all times except for bathing and hygiene. Skin checks were to be completed every shift. A Care Plan, dated 2/18/26, indicated the resident was at risk for developing bruises and skin tears. The approach was to apply geri sleeves. There was no documentation in the nursing notes regarding the bruise to the right forearm. The Nursing Weekly Assessments, dated 2/12, 2/19, and 2/25/26, indicated there was no documentation of any new bruising to the resident's arm. During an interview on 3/5/26 at 2:30 p.m., the Director of Nursing (DON) indicated there was a bruise on the resident's right forearm. There was no prior assessment of the bruise before 3/5/26. The current 4/23/24 Wound Assessment policy, provided by the DON on 3/5/26 at 2:30 p.m., indicated all non wound skin altercations would be completed on the nursing-new skin alteration assessment. The non wound area would be placed on the treatment administration record with instructions to monitor at least daily until healed. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 2 residents reviewed for accidents. (Resident 2)Finding includes:During a random observation on 3/3/26 at 11:35 a.m., Resident 2 was observed seated in her wheelchair in the doorway of her bathroom. The resident was wearing a pair of white tube socks. She was not wearing any shoes or non-skid socks. During an interview at that time, the resident indicated that she needed to go to the bathroom and that she was able to transfer herself. On 3/3/26 at 2:04 p.m., the resident was seated in her wheelchair in her room. Her feet were resting on the foot pedals of the wheelchair. The resident was wearing white socks and no shoes or non-skid socks. On 3/4/26 at 10:30 a.m., the resident was seated in her wheelchair. Her feet were resting on the foot pedals and she was propelling herself down the hall. The resident had a pair of tan fuzzy socks on over her white socks. The tan socks did not have a non-skid surface. At 11:30 a.m. and 1:45 p.m., the resident continued to have the tan socks on over her white socks. On 3/5/26 at 8:52 a.m., the resident was seated in her wheelchair in her room. The resident was wearing tan socks over her white socks. During an interview at that time, the resident indicated the tan socks she was wearing were her own and they did not have a non-skid surface. On 3/6/26 at 8:08 a.m., the resident was seated in her wheelchair in the dining room eating breakfast. The resident had on green fuzzy socks over her white socks. The green socks did not have a non-skid surface. The record for Resident 2 was reviewed on 3/4/26 at 11:08 a.m. Diagnoses included, but were not limited to, aftercare following joint replacement surgery, left artificial hip joint, and difficulty walking. The Significant Change Minimum Data Set (MDS) assessment, dated 1/29/26, indicated the resident was cognitively intact. The resident required partial to moderate assistance with sit to stand transfers and toilet transfers. A Care Plan, dated 12/26/25, indicated the resident was at risk for falls due to a recent left hip replacement and generalized weakness. Interventions included, but were not limited to, encourage and assist with wearing non-skid footwear. During an interview on 3/6/26 at 10:55 a.m., the Director of Nursing indicated the resident should have been wearing either shoes or non-skid socks when up during the day. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure proper medication storage related to eye drops not labeled with directions for use and the physician's name, insulin pens used past their expiration date, and Tuberculin multi-use vials not labeled when opened, for 1 of 8 residents observed during medication administration, 2 of 2 medication carts, and 1 of 1 medication room observed. (Resident 39, the ICF and Rosewood medication carts, and the main medication room)Findings include: 1. During the medication administration observation on 3/3/26 at 10:21 a.m., RN 1 was preparing medications for Resident 39. She indicated she would be administering two eye drops to the resident, however, they would be 10 minutes apart. She removed the first eye drop of Brimonidine ophthalmic 0.1%. The bottle had a small label on it with the resident's name. There were no directions for use or the physician's name on the bottle. There was no original bag with a pharmacy-prepared label for the eye drops. During an interview on 3/3/26 at 11:03 a.m., RN 1 indicated the pharmacy labeled package for the eye drops was not available and could have been discarded. During an interview on 3/5/26 at 1:20 p.m., the Director of Nursing (DON) had no additional information regarding the labeling of the eye drops. The current 4/24/19 Medication Labels policy, provided by the DON on 3/5/26 2:30 p.m., indicated each prescription medication label included directions for use. 2. During an observation on 3/3/26 at 10:02 a.m., of the ICF medication cart, there was a Lantus insulin kwik pen with an open date of 1/26/26. The sticker on the pen indicated to discard after 28 days. During an interview at that time, LPN 2 indicated the pen should have been discarded. 3. During an observation on 3/5/26 at 10:07 a.m., of the Rosewood medication cart, there was a Lantus insulin kwik pen with an open date of 2/3/25. The sticker on the pen indicated to discard after 28 days. During an interview at that time, RN 1 indicated the pen should have been discarded. During an interview on 3/5/26 at 1:20 p.m., the Director of Nursing (DON) indicated the insulin pens were to be discarded after 28 days. 4. During an observation on 3/5/26 at 2:00 p.m., the medication room was observed. There was one opened multi-use vial of Tuberculin (TB testing solution) with no date as to when it was opened. During an interview at that time, the Director of Nursing indicated the tuberculin vial should have been dated after opening. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(k)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-25(k)(5)410 IAC (Indiana Administrative Code) 16.2-3.1-25(k)(6)

Based on observation and interview, the facility failed to ensure infection control practices were in place and implemented related to not wearing personal protective equipment (PPE) in enhanced barrier precaution rooms, and failing to disinfect multi-use equipment during random infection control observations. (Residents 57 and 39) Findings include:1. During an intravenous (IV) antibiotic medication administration observation for Resident 57 on 3/3/26 at 12:55 p.m., LPN 1 was observed with the IV antibiotic ball of Cefepime 2 grams. The LPN entered the resident's room and performed hand hygiene with soap and water. She donned clean gloves to both hands and raised the resident's shirt sleeve to gain access to the single lumen PICC (peripherally inserted central catheter) line. She flushed the single lumen with saline and connected the antibiotic. At that time, she helped the resident reposition herself in bed by placing pillows under her leg. The LPN removed her gloves and washed her hands with soap and water. She did not don an isolation gown prior to the administration of the IV antibiotic. At 2:38 p.m., LPN 1 entered the resident's room to disconnect the IV antibiotic. She performed hand hygiene and donned a clean pair of gloves to both hands. She removed the IV tubing, flushed the port with saline followed by Heparin (an anticoagulant), removed her gloves and performed hand hygiene. She did not don an isolation gown prior to disconnecting the IV antibiotic from the PICC line. During an interview on 3/3/26 at 2:45 p.m., LPN 1 indicated she was aware the resident was in enhanced barrier precautions and she was supposed to wear an isolation gown while administering and removing the IV antibiotic. During an interview on 3/5/26 at 1:20 p.m., the Director of Nursing indicated nursing staff were required to wear PPE when administrating the IV antibiotic. 2. During the medication administration observation on 3/3/26 at 10:21 a.m., RN 1 was preparing medications for Resident 39. She entered the resident's room with the multi-functional blood pressure machine. She wrapped the cuff around the resident's arm and placed the pulse oximeter on her finger. After she checked the resident's vital signs she administered the resident's medications. She left the room and returned the blood pressure machine to the space by the wall and plugged it in. She did not wipe down the blood pressure machine or sanitize it after she had used it. She performed hand hygiene, signed the medications out on the computer, and proceeded onto the next resident.During an interview on 3/3/26 at 11:03 a.m., RN 1 indicated she did not clean the multi-function blood pressure machine after use. During an interview on 3/5/26 at 1:20 p.m., the Director of Nursing (DON) indicated the blood pressure machine was to be wiped down and sanitized after each use. There was no facility policy for cleaning the multi-function blood pressure machine. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on record review and interview, the facility failed to ensure CNAs had a current and valid certificate to work in the facility for 1 of 15 CNA records reviewed. (CNA 1)Finding includes:The employee files were reviewed on [DATE] at 3:00 p.m. The certification for CNA 1 expired on [DATE].The staff schedule indicated CNA 1 worked on the following days since her certification expired: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].During an interview on [DATE] at 3:14 p.m., the Human Resources Director indicated CNA 1's certification expired, and she was going to help her fix it.During an interview on [DATE] at 10:22 a.m., the Corporate Administrator indicated there was a system in place to check certifications monthly, but CNA 1 was missed. 410 IAC (Indiana Administrative Code) 16.2-3.1-14(f)

Based on observation, record review, and interview, the facility failed to ensure a resident received proper assistance to prevent accidents, related to a CNA (CNA 1) transferring a dependent resident from a chair to the bed without following the plan of care, causing an injury to the left lower leg, which required an emergency room (ER) visit and 19 sutures to the injury, for 1 of 3 residents reviewed for mechanical lift usage. (Resident E)Finding includes: During an observation on 10/14/25 at 10:53 a.m., CNA 2 and CNA 3 used a mechanical lift and transferred Resident E from the bed to a chair. There was a light pink area observed on the resident's left lower calf area. CNA 2 indicated the resident had been previously transferred from a chair to the bed without the use of the mechanical lift and an injury occurred to the left lower leg.Resident E's record was reviewed on 10/14/25 at 3:22 p.m. The diagnosis included, but were not limited to, rheumatoid arthritis and osteoporosis.A Care Plan, dated 12/17/24, indicated the resident was dependent on staff for activities of daily living (ADL's). The interventions indicated the staff were to refer to the Nurse Aide Assignment sheet (Pocket Guide) for details on transfer assistance. An intervention added on 4/4/25 indicated a mechanical lift was to be used for transfers.A Physician's Order, dated 4/3/25, indicated a mechanical lift for transfers could be utilized.A Nurse Aide Pocket Guide, dated 7/18/25, indicated the resident was to be transferred with a mechanical lift.A Nursing-Occurrence Assessment, dated 7/30/25 at 6:45 p.m., indicated the resident was in her room. A skin tear to the left lower leg occurred after the resident had been transferred from the wheelchair to the bed. The resident was lying on her back, leaning to the left side. Her legs were extended out of the bed. A staff member was applying pressure to the left lower leg area and there was a pool of blood on the floor. There was a 14 centimeter (cm) by 5.5 cm skin tear on the left lower leg with continuous bleeding. The Physician was notified and an order was received for the resident to be transferred to the ER (emergency room) if the bleeding continued. The resident had been transferred to the hospital ER.A Post Occurrence IDT (Interdisciplinary Team) and Fall Risk Assessment, dated 7/30/25 at 6:45 p.m., indicated the CNA had transferred the resident from the wheelchair to the bed. There was a partial flap loss skin tear to the left lower leg that measured 14 cm by 5.5 cm. The leg had been bumped on the wheelchair during the transfer. The staff member was educated due to the improper transfer technique. A sheepskin was applied to the wheelchair for protection. The resident was to be transferred with the mechanical lift.The ER documentation, dated 7/30/25 at 9:29 p.m., indicated the sutures were to be removed in eight to ten days.There was no documentation that indicated what time the resident returned to the facility or an assessment of the injury of the left lower extremity.A Concern/Grievance, dated 7/31/25 at 8:45 a.m., indicated a skin tear was obtained from an improper transfer technique. The injury required an ER visit and sutures. The investigation indicated CNA 2 stated she always used a mechanical lift when the resident needed to be transferred. The lift had been used when the resident was transferred from the bed to the chair and the pad for the mechanical lift had been removed from under the resident at her request. CNA 2 had reported to CNA 1 at the change of shift that the pad would have to be placed back under the resident when she was transferred from the chair to the bed. CNA 1 had indicated she was aware the resident required a mechanical lift to be used when transferred. The pad had not been underneath the resident, so she had transferred the resident by herself into the bed.A Wound-Non-Pressure Wound Assessment (the first assessment documented upon return from ER), dated 8/5/25 at 11:13 a.m., indicated the left lower extremity wound was 13.5 cm length by 8.5 cm width with a depth of 0.1 cm. The injury was irregular shaped and open with unattached and irregular wound edges. The area had redness, was moist, and the peeled skin had 19 sutures. There was moderate sanguineous drainage from the area and the resident indicated it hurt a little bit.A Quarterly Minimum Data Set assessment, dated 9/10/25, indicated a severely impaired cognitive status, no behaviors, and was dependent on staff for all transfers.During an interview on 10/14/25 at 1:22 p.m., CNA 1 indicated she was under the impression the resident could be transferred without the mechanical lift on 7/30/25. The resident was sitting in the chair and had wanted to go to bed. She had transferred her to the bed and then saw the blood and called for help. She indicated there was not a mechanical lift pad underneath the resident and she was unsure how to put the pad underneath her while she was in the chair. The resident's skin was snagged by a piece on the wheelchair. The facility has pocket guides the CNA's carry that informed them of what type of care the residents required. That night, there were none available and she had been told they were updating them. She had taken care of the resident prior and had not known she required a mechanical lift for transfers. She had been told by other staff she could lift the resident into the chair or bed.During an interview on 10/14/25 at 4:08 p.m., LPN 1 indicated the Pocket Guides for the CNA's were always available.During an interview on 10/14/25 at 4:25 p.m., the Unit Manager indicated the mechanical lift was and had been listed on the Pocket Guide for all transfers for Resident E. The guides are updated with all changes in care and they were always available for the staff.This citation relates to Intake 2634993.3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received the necessary care and services related to an antibiotic medication not administered as ordered by the Physician for 1 of 3 residents reviewed for urinary tract infections. (Resident E) Finding includes: The record for Resident E was reviewed on 7/2/25 at 1:39 p.m. Diagnoses included, but were not limited to, hypertension, type 2 diabetes mellitus, and atrial fibrillation. The resident was admitted to the facility on [DATE]. A Physician's Order, dated 6/26/25, indicated to give Levaquin 500 mg (milligrams) by mouth every 24 hours for 3 days for a urinary tract infection. A Nurse Practitioner Note, dated 6/27/25 at 2:23 p.m., indicated the resident was admitted to the facility on [DATE] on Levaquin (levofloxacin, an antibiotic) after being treated in the hospital for a urinary tract infection. She was to complete the course of antibiotics. The Medication Administration Record (MAR), dated 6/2025, indicated the antibiotic medication had been given on 6/26/25 and 6/27/25. On 6/28/25 at 8:05 p.m., a 3 was documented which indicated to hold/see progress notes. There were no other documented administrations of the medication. A Medication Administration Note, dated 6/28/25 at 8:05 p.m., indicated the Levaquin was unavailable, there was none in the Pyxis (a machine that dispenses medications), and it was ordered from pharmacy. During an interview with the Director of Nursing (DON) on 7/1/25 at 3:27 p.m., she indicated the antibiotic had not been given as ordered. She had checked the Pyxis, and the Levaquin was available. She was not sure why the nurse had not given the antibiotic. This citation relates to Complaints IN00457883. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to food not labeled and dated for 1 of 1 kitchen. (The Main Kitchen) This had the potential to affect all residents receiving food from the kitchen. Findings include: During the Initial Kitchen Sanitation Tour on 1/6/25 at 8:57 a.m., with the Assistant Kitchen Manager, the following was observed: a. There was a tray of individual cups of pickles and mayonnaise in the refrigerator which were not labeled. b. There was an undated, opened bag of sweet corn nuggets in the freezer. c. There was an undated, unlabeled, opened bag of white powder in a cabinet in the food preparation area. During an interview on 1/6/25 at 8:58 a.m., the Assistant Kitchen Manager indicated all items should be labeled with the date they were received, the date they were opened, and contents if removed from their original container. She threw away the cups of pickles and mayonnaise and indicated the bag of white powder was food thickener that had been taken from a larger container in the storage room. During an interview on 1/8/25 at 9:13 a.m., the Kitchen Manager indicated all food items should be labeled when received and when opened, and that she already started re-educating staff. A policy titled, Food Protection and Storage, received as current on 1/10/25, indicated, . The Dietary Manager will check the food storage area for: . open boxes, containers of food should are securely enclosed, labeled, and dated . food not in original containers are clearly labeled for contents, dated, and stored in food rated containers with tight fitting lids . 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to perform hand hygiene after glove removal and prior to donning personal protective equipment (PPE) for 1 of 8 residents observed during medication administration, enhanced barrier precautions (EBP) not followed, and glove use in the hallway during random infection control observations. (Residents 1, 51, and 13) Findings include: 1. On 1/9/25 at 8:45 a.m., LPN 1 was observed preparing medications for Resident 1. The LPN donned a pair of gloves to place medications into a medication cup. After placing the medications in four separate cups, he removed his gloves. He did not sanitize his hands after removing his gloves. The LPN proceeded to enter the resident's room. The resident's medications were going to be given by the way of a gastrostomy tube (a tube inserted through the abdominal wall into the stomach). The LPN donned a gown, gloves, mask, and a face shield. The LPN did not sanitize his hands prior to donning the personal protective equipment (PPE). During an interview on 1/9/25 at 1:35 p.m., the Director of Nursing (DON) indicated the LPN should have sanitized his hands after removing his gloves and prior to donning the PPE. 10770 2. During a random observation on 1/8/25 at 10:56 a.m., CNA 2 was observed walking out of a resident's room wearing gloves to both hands and carrying uncontained soiled linens in her arms. There was another resident yelling help me over and over again, so the CNA walked over to her room, still carrying the uncontained linen and told the resident I have to get rid of these soiled linens he had a huge bm (bowel movement). She then walked into the soiled utility room with the dirty linens. During an interview on 1/8/25 at 11:00 a.m. CNA 2 indicated she knew better and was not supposed to walk out of the room with the uncontained soiled linens but heard a resident calling for help and just left that other resident's room carrying all of the linen. During an interview on 1/9/25 at 2:15 p.m., the Director of Nursing (DON) indicated the CNA should not have walked out of the resident's room with uncontained soiled linens. The current 11/10/16 Linen Handling policy, provided by the DON on 1/9/25 at 2:34 p.m., indicated linens and laundry were handled or transported in a manner to prevent the spread of infection. 3. During a wound treatment observation on 1/8/25 at 2:00 p.m., the Assistant Director of Nursing (ADON) and RN 1 were observed preparing to do the bandage change for Resident 51. At that time, they both performed hand hygiene and donned clean gloves to both hands. Neither one of them donned an isolation gown prior to the treatment change. The wound was cleaned and a new bandage was placed over the open area. After the treatment was completed they both doffed their gloves and performed hand hygiene. During an interview at that time, the ADON indicated she would only don a gown if the resident had draining wounds. The record for Resident 51 was reviewed on 1/7/25 at 1:35 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation, high blood pressure, history of falling and high cholesterol. The 12/18/24 Admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had one venous ulcer. A Physician's Order, dated 12/20/24, indicated enhanced barrier precautions (EBP) During an interview on 1/9/25 at 1:10 p.m., the Director of Nursing indicated the resident was on EBP and staff were to don gloves and a gown prior to having any contact with the resident. 4. During an observation on 1/7/25 at 2:44 p.m., Agency CNA 1 entered Resident 13's room and was going to assist her to bed. At that time, the CNA performed hand hygiene and donned a pair of clean gloves to both hands. She assisted the resident into bed by placing her arms around her waist and holding onto her pants. The CNA then removed the resident's pants and provided incontinence care. At that time, there was a bandage on the resident's coccyx area with a date of 1/6/25. The CNA did not donn an isolation gown prior to making contact with the resident. During an interview on 1/7/25 at 2:54 p.m., Agency CNA 1 indicated she was not aware the resident had a pressure ulcer and was informed by the nurse if there was an EBP sign on the door she was supposed to go into the oxygen room and get a gown. During an observation on 1/8/24 at 2:20 p.m., CNA 1 answered the resident's call light, and the resident wanted to go to bed. The CNA performed hand hygiene and donned clean gloves to both hands. She then asked the resident how she transferred to bed and the resident motioned by lifting up her arms as to go around the CNA's neck. The CNA told the resident she would go and get help to get her into bed. RN 1 and CNA 1 both came back to the room and performed hand hygiene and donned clean gloves to both hands. Neither one of them donned an isolation gown. The resident was transferred to bed by both staff members and RN 1 left the room after the transfer. CNA 1 proceeded to provide incontinence care to the resident. Again there was a bandage on the resident's coccyx area that was almost falling off. The CNA cleaned the resident without wearing an isolation gown. The record for Resident 13 was reviewed on 1/8/25 at 10:00 a.m. Diagnoses included, but were not limited to, fracture left lower leg, adult failure to thrive, anemia, type 2 diabetes, osteoarthritis, and peripheral vascular disease. The 12/6/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making. The resident needed substantial to max assistance for the ability to come to a standing position from sitting in a chair to the side of the bed and had 1 stage 3 pressure ulcer that was not present on admission. A Care Plan, dated 9/9/24, indicated the resident required enhanced barrier precautions during high contact care due to a wound. A Physician's Order, dated 9/9/24, indicated Enhanced Barrier Precautions during high contact resident care every shift for a wound. During an interview on 1/8/25 at 3:10 p.m., the Infection Control Nurse indicated the resident was in EBP and there was a sign on her door before, however, the sign was removed. A gown and gloves should have been worn to perform incontinence care and the transfer. During an interview on 1/9/25 at 1:10 p.m., the Director of Nursing indicated the resident was in EBP and staff were to wear a gown and gloves when providing incontinence care. The current 4/6/23 Enhanced Precautions for novel and targeted MDRO's policy, provided by the Infection Preventionist on 1/10/25 at 10:25 a.m., indicated enhanced precautions were used to prevent the spread of MDRO's (multi drug resistant organisms) from one resident to another via health care workers' hands and clothing and to protect vulnerable residents. EBP was targeted use of gown and gloves during high contact resident care activities for residents with wounds, feeding tubes, indwelling catheters, and central lines. Examples of high contact resident care include but were not limited to, dressing, bathing, transferring, changing briefs, and performing wound care. 3.1-18(b)

Based on observation and interview, the facility failed to provide a sanitary, comfortable environment for staff, residents, and the public related to the strong odor of urine on 1 of 3 halls. (The 100 hall/ICF) This had the potential to affect all residents residing on the ICF wing. Finding includes: During multiple random observations throughout the day on 1/6/25 and 1/7/25, a pungent odor of urine was present upon entering and throughout the ICF hall. During an interview on 1/6/25 at 2:20 p.m., a resident's family member indicated the whole wing (ICF) constantly smelled of urine. During an interview on 1/8/25 at 11:02 a.m., LPN 1 indicated the smell may be coming from garbage in the dirty utility room. He took bags of garbage out of the room and sprayed air freshener around the unit. On 1/9/25 at 9:33 a.m., the urine odor was less, but still present. During an interview on 1/9/25 at 2:35 p.m., the Maintenance Director indicated he definitely noticed the odor over the last few weeks, but thought it was from a resident, and he didn't know anything about them. During an interview on 1/9/25 at 2:40 p.m., the Administrator was informed of the findings and indicated she would look into finding the source of the odor and get the carpets cleaned. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure the resident's responsible party was promptly notified after the development of a venous stasis foot ulcer (a wound caused by abnormal or damaged veins) for 1 of 1 resident reviewed for notification of change. (Resident 51) Finding includes: During a wound treatment observation on 1/8/25 at 2:00 p.m., Resident 51 was observed lying in bed. At that time, the Assistant Director of Nursing (ADON) and RN 1 were in the room to complete the treatment for a venous ulcer on her foot. The open area on the left great toe was pink and red in color. A new area was identified on the bottom of her foot at that time, which was non-blanchable (an area of redness that does not fade when pressure was applied) and red with no drainage. The record for Resident 51 was reviewed on 1/7/25 at 1:35 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation, high blood pressure, and high cholesterol. The 12/18/24 Admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had one venous ulcer. A Nursing-Assess Skilled Assessment, dated 12/15/24, indicated the resident had developed an open area to the left inner great toe that measured 0.8 centimeters (cm) by 0.5 cm. A Physician's Order, dated 12/15/24, indicated to monitor the open area to the left great toe daily until resolved and monitor for signs and symptoms of infection, increased pain, or unusual changes and report to physician. Cleanse the open area to the left great toe with wound cleanser, pat dry and put skin prep around the area and cover with a foam adhesive bandage every 3 days. There was no documentation the resident's family was notified on 12/15/24 of the development of the ulcer on the left great toe. During an interview on 1/9/25 at 4:00 p.m., the Director of Nursing (DON) indicated the staff nurse assessed the resident's open area on 12/15/24 and there was no documentation the resident's family was notified. The DON indicated the ADON, who was the Wound Nurse, notified the resident's family on 12/19/24 when she first assessed the wound and new orders were obtained. The 5/14/24 and current Physician and Family Notification of Condition Changes policy, provided by the DON on 1/10/25 at 11:08 a.m., indicated notify the resident and responsible party of any change in condition that may or may not warrant a change in treatment plan, including critical lab values, abnormal radiology, or diagnostic testing results. 3.1-5(a)(2)

Based on record review and interview, the facility failed to file a grievance form for multiple complaints regarding pain, care, dignity, and room location that were reported by the resident to the Administrator for 1 of 1 resident reviewed for grievances. (Resident 32) Finding includes: During an interview on 1/7/25 at 9:48 a.m., Resident 32 indicated he had multiple complaints when he first arrived at the facility regarding pain medication, his bed, and how a nurse said to him you ugly. The resident indicated he reported all of his concerns to the Administrator, but did not know if an official grievance had been written up for him. The record for Resident 32 was reviewed on 1/8/25 at 11:25 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, fracture of the right tibia, end stage renal disease, dependence on renal dialysis, heart failure, high blood pressure, type 2 diabetes, diabetic neuropathy, major depressive disorder, and anxiety. The 12/13/24 Admission Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. During an interview on 1/9/25 at 10:10 a.m., the Administrator indicated the resident had some concerns and she wrote them down on yellow ledger paper. He had concerns about his pain medication and not being able to have it, a nurse calling him ugly, wanting his door closed and wanting to move to the other bed in his room. The Administrator indicated she investigated all his concerns, however, failed to document them on a grievance form. There was also no follow up documentation regarding a resolution with the resident. The current 11/17/16 Grievance Procedure policy provided by the Administrator on 1/9/25 at 1:00 p.m., indicated residents were encouraged to speak to any staff member whenever their expectations of care and service were not met so immediate action could be taken. The facility would investigate, act upon, and resolve to the best of their ability the resident or family concern. 3.1-7(a)(2)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to not providing showers twice a week for 3 of 4 residents reviewed for ADLs (Residents 24, 40, and 8), and not providing oral care for 2 of 2 residents with a feeding tube reviewed for ADLs. (Residents 24 and 40) Findings include: 1. During an interview on 1/6/25 at 11:24 a.m., Resident 24 indicated she was supposed to be getting showers twice a week, but was not. She had a feeding tube (a tube inserted through the abdominal wall into the stomach) and no one had brushed her teeth (dentures) or helped her clean her mouth since she was admitted to the facility on [DATE]. During an interview on 1/7/25 at 1:30 p.m., the resident indicated not getting a shower had been an ongoing problem. She wanted to shower and brush her teeth. At that time, she appeared disheveled, wearing the same clothing as observed on 1/6/25. On 1/8/25 at 11:04 a.m., the resident was observed resting in bed. Her hair appeared greasy and uncombed, and she was wearing the same clothing as on 1/6/25 and 1/7/25. The record for Resident 24 was reviewed on 1/7/25 at 3:08 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, cancer of the stomach, and chemotherapy. The 12/15/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, required supervision/touching assistance with oral hygiene, maximal assistance with shower/bathing, and moderate assistance with transferring. A Care Plan, dated 12/8/24, indicated the resident required moderate to maximum assistance with ADLs due to hospitalization for nausea, pancreatic mass, and weakness. The Care Plan indicated the resident had a feeding tube and full dentures. The approaches included encouraging oral care twice a day and assisting as needed. The facility's shower schedule indicated the resident was to receive showers on Tuesday and Friday. The Task List indicated the resident did not receive or refuse a bath or shower on 12/24/24, 12/31/24, and 1/7/25. A Physician's Order, dated 12/8/24, indicated the nurse was to provide mouth care every shift. During an interview on 1/9/25 at 11:25 a.m., LPN 1 indicated he documented on the treatment record that he provided mouth care which meant he looked in the resident's mouth for broken or missing teeth, and would offer oral swabs if needed, but the resident hadn't needed anything. He indicated the CNAs should brush the residents' teeth. During an interview on 1/9/25 at 1:50 p.m., the Director of Nursing (DON) indicated the resident should have received a shower every Tuesday and Friday, but she did not. Mouth care should include cleaning or swabbing the mouth and/or brushing the teeth, and the CNAs and nurses should have completed or assisted the resident with this task. 2. During an interview on 1/6/25 at 2:08 p.m., Resident 40 indicated she was not getting bathed twice a week. She had a feeding tube (a tube inserted through the abdominal wall into the stomach) and the staff had not been cleaning her mouth. On 1/7/25 at 2:22 p.m., the resident was observed resting in bed. Her hair was uncombed, and she was wearing the same clothing as on 1/6/25. On 1/8/25 at 1:55 p.m., the resident was observed resting in bed, appeared disheveled with crumbs on her shirt, uncombed hair, and was wearing the same clothing as on 1/6/25 and 1/7/25. At that time, she indicated she wanted a bath and still had not been offered assistance with mouth care. During an interview on 1/10/25 at 10:20 a.m., the resident indicated the staff finally cleaned her up on 1/9 and helped her clean her mouth for the first time, and it felt good. The record for Resident 40 was reviewed on 1/8/25 at 2:29 p.m. Diagnoses included, but were not limited to, hemiplegia (weakness on one side of the body) following a stroke, dysphagia (difficulty swallowing), feeding tube, rheumatoid arthritis, and gout. The 11/30/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, required moderate assistance with oral hygiene, dependent/total assistance with showering/bathing, and maximal assistance with transferring. A Care Plan, dated 11/30/24, indicated the resident required maximum/total assistance with ADLs due to a stroke resulting in left-sided weakness. The Care Plan indicated the resident had a feeding tube. The approaches included encouraging oral care twice a day and assisting as needed. The facility's shower schedule indicated the resident was to receive showers on Tuesday and Friday. The Task List indicated the resident did not receive or refuse a bath or shower on 12/17/24, 12/24/24, and 1/7/25. The record lacked documentation of mouth care. During an interview on 1/9/25 at 1:50 p.m., the Director of Nursing (DON) indicated the resident should have received a shower every Tuesday and Friday, but she did not. The CNAs and nurses should have completed or assisted the resident with mouth care, but she was not sure where or if the CNAs documented mouth care. No further information was received. 3. During an interview on 1/6/25 at 11:10 a.m., Resident 8 indicated she was not getting showers as frequently as she should. During an interview on 1/9/25 at 8:40 a.m., the resident indicated she was supposed to get a shower the previous day, but they did not have enough staff. The record for Resident 8 was reviewed on 1/9/25 at 10:46 a.m. Diagnoses included, but were not limited to, heart failure, type 2 diabetes, dementia, and depression. The 11/11/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, required moderate assistance with showering/bathing, and moderate assistance with transferring. A Care Plan, dated 11/22/24, indicated the resident required moderate assistance with ADLs due to heart failure, aortic stenosis, and anemia. A Nurse's Note, dated 11/22/24, indicated the resident was not on the shower schedule, and stated she had not had a shower. The facility's shower schedule indicated the resident was to receive showers on Wednesday and Saturday. The Task List indicated the resident did not receive or refuse a bath or shower on 12/11/24, 12/14/24, 12/18/24, 12/21/24, and 1/8/25. During an interview on 1/9/25 at 1:50 p.m., the DON indicated the resident should have been getting showers twice a week, and she was not informed the resident told a nurse she was not getting them. 3.1-38(a)(3) 3.1-38(a)(3)(C)

Based on observation, record review, and interview, the facility failed to ensure signs and symptoms of constipation were addressed for 1 of 1 resident reviewed for constipation, residents were transported and arrived to physician visits on time and heels were floated for non-pressure ulcers for 2 of 6 residents reviewed for non-pressure skin conditions, and insulin was administered as ordered for 1 of 5 residents reviewed for unnecessary medications. (Residents 7, 32, and 51) Findings include: 1. During an interview on 1/6/25 at 2:10 p.m., Resident 7 indicated she had issues with constipation. The record for Resident 7 was reviewed on 1/8/25 at 10:30 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, chronic kidney disease, Alzheimer's disease, high blood pressure, anxiety, and constipation. The 11/29/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and was always incontinent of bowel, but not on a bowel program. A Care Plan, dated 5/24/24, indicated the resident had the potential for constipation. The interventions were to administer laxatives and/or stool softeners as ordered and monitor for signs and symptoms of constipation. A Physician's Order, dated 6/19/24, indicated Polyethylene Glycol 3350 Powder (a laxative), give 17 grams by mouth every 24 hours as needed for constipation. The resident's bowel movement flow sheet indicated the resident had no documented bowel movements on 10/26-10/29/24, 11/28-12/1/24, 12/29/24-1/1/25, and 1/3-1/5/25. A Nursing Note, dated 10/29/24 at 1:30 p.m., indicated the Polyethylene Glycol powder was administered to the resident for complaints of constipation. A Nursing Note, dated 10/30/24 at 1:36 a.m., indicated the resident's results for the complaints of constipation were unknown. A Nursing Note, dated 11/28/24 at 10:15 p.m., indicated the Polyethylene Glycol Powder was administered for complaints of constipation. A Nursing Note, dated 11/29/24 at 6:57 a.m., indicated the resident's results for the complaints of constipation were unknown. A Nursing Note, dated 12/5/24 at 11:27 a.m., indicated the Polyethylene Glycol Powder was administered for complaints of constipation. A Nursing Note, dated 12/5/24 at 10:24 p.m., indicated the resident's results for the complaints of constipation were ineffective. A Nursing Note, dated 1/1/25 at 9:46 a.m., indicated the Polyethylene Glycol Powder was administered for complaints of constipation. A Nursing Note, dated 1/2/25 at 9:39 a.m., indicated the resident's results for the complaints of constipation were ineffective. During an interview on 1/9/25 at 3:00 p.m., the Director of Nursing had no additional information to provide. The current 1/3/2001 Bowel Elimination policy, provided as current by the DON on 1/9/25 at 2:34 p.m., indicated if a resident complained of constipation or at least on the third day with no bowel movement, an ordered bowel aide or stool softener would be administered. If within eight hours of administering the bowel aide or softener, the resident has not had a bowel movement, another bowel aide would be administered. If within another 8 hours the resident has not had a bowel movement, the nurse will do an abdominal assessment, and notify the physician. 2. During an interview on 1/7/25 at 10:02 a.m., Resident 32 indicated he had arrived at his orthopedic surgeon's appointment late so he was unable to see him as the doctor had left for surgery. The record for Resident 32 was reviewed on 1/8/25 at 11:25 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, fracture of the right tibia, type 2 diabetes, and diabetic neuropathy. The 12/13/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Nursing Transfer to Appointment Form, dated 12/19/24 at 2:10 p.m., indicated the resident left per facility van to (physician name) orthopedic appointment. A Nursing Note, dated 12/19/24 at 3:35 p.m., indicated the resident had returned from the scheduled appointment per the facility van. During an interview on 1/9/25 at 10:20 a.m., a maintenance associate indicated he was hired to drive the residents to appointments part time and also to work in maintenance the rest of his time. On 12/19/24, he had to take another resident to an appointment around the same time as Resident 32 needed to be at an appointment. His plan was to take the other resident a little bit earlier and then be back in enough time to get Resident 32. The resident's appointment was at 2:10 p.m., they arrived at 2:30 p.m. (20 minutes late) and the physician had already left the office for surgery, so he missed the appointment. He indicated there was no back up plan and he did not call his supervisor to let him know he was not going to make it back in time to get Resident 32 to the appointment on time. During an interview on 1/9/25 at 1:10 p.m., the Director of Nursing (DON) indicated she was aware the resident missed his appointment for the orthopedic surgeon on 12/19/24. The facility van was used to transport the residents to their appointments. A Physician's Order, dated 12/7/24, indicated Insulin Lispro Injection, inject 10 units subcutaneously (delivers medication into the fatty tissue beneath the skin) three times a day for diabetes. The 12/2024 and 1/2025 Medication Administration Records, indicated the Lispro Insulin administration times were 7:30 a.m., 11:30 a.m., and 4:30 p.m. On the resident's dialysis days of Monday, Wednesday, and Friday a 2 was coded (LOA without meds) for the 11:30 a.m. administration. During an interview on 1/9/25 at 4:00 p.m., the DON indicated the Lispro insulin times should not have conflicted on dialysis days. The current 11/2/16 Van Transportation Program policy, provided by the Administrator as current on 1/9/25 at 11:00 a.m., indicated the facility would offer transportation services for residents of the facility to include, but not limited to, physician appointments. The facility would work with local transportation companies for back up transportation services. 3. During random observations on 1/7/25 at 1:31 p.m. and on 1/8/25 at 9:45 a.m. and 10:27 a.m., Resident 51 was observed in bed. At those times, both of her heels were laying flat on the bed and not floated. On 1/8/25 at 2:00 p.m., the resident was in bed and her heels were not floated. The Assistant Director of Nursing and RN 1 performed the wound treatment to her left great toe. The open area on the left great toe was pink and red in color. A new area was identified on the bottom of her foot at that time, which was non blanchable (an area of redness that does not fade when pressure was applied) and red with no drainage. After the completion of the treatment, they covered the resident with the bed linens and left the room. Both of her heels were observed flat on the bed and not floated. At 3:30 p.m., the resident was observed in bed and both heels remained flat on the bed. The record for Resident 51 was reviewed on 1/7/25 at 1:35 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation, high blood pressure, and high cholesterol. The 12/18/24 Admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had one venous ulcer. A Care Plan, dated 12/17/24, indicated the resident developed an arterial wound to the left great toe. The approaches were to float heels off of the bed. A wound measurement, dated 12/30/24, indicated the left great toe venous ulcer measured 0.5 centimeters (cm) by 0.5 cm. and was stable. A Nursing Note, dated 1/8/25 at 2:38 p.m., indicated the physician was notified of a non-blanching red area with some maceration (skin softening) that measured 1.4 cm in length by 2.2 cm in width over the bunion area. The new area was not present on the last assessment. During an interview on 1/9/25 at 1:10 p.m., the Director of Nursing had no additional information to provide. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to assist a resident with eating, monitor nutritional intake for meals, obtain readmission and post dialysis weights, and provide breakfast before dialysis for residents with a history of significant weight loss for 2 of 2 residents reviewed for nutrition. (Residents 19 and 32) Findings include: 1. During a random observation on 1/6/25 at 1:52 p.m., Resident 19 was observed in bed. Her lunch tray was in front of her and untouched. There was a spoon in her pudding and nothing else had been touched on the tray. There was no staff in the area assisting the resident. On 1/9/25 at 8:29 a.m., the resident was observed in bed and her breakfast tray was delivered to her and placed on the over bed table. The resident's eyes were closed, and CNA did not attempt to wake her up or assist her to eat. She just left the meal on the tray table and left the room. The resident was served cold cereal, one serving of scrambled eggs, one piece of raisin toast, and apple juice. At 8:39 a.m., the Admission Coordinator entered the room and closed the door. Upon leaving the room, the resident was awake and was observed holding a spoon in her hand. At 9:00 a.m., the resident had not eaten any of her breakfast meal. The resident indicated she was hungry, however, there was no staff in the area to help her eat. On 1/9/25 at 1:04 p.m., the resident was observed in bed with her eyes closed and her lunch tray in front of her on the over bed table. No staff were observed in or around the room to assist the resident to eat. No food had been eaten as it was untouched. The record for Resident 19 was reviewed on 1/7/25 at 2:10 p.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, stroke, hemiplegia, aphasia, dysphagia (difficulty swallowing), and peg tube (a tube inserted directly into the stomach for nutrition). The resident was admitted to the hospital on 12/23/24 and returned to the facility on [DATE]. She was sent out to the hospital on 1/2/25 and returned on 1/3/25. A new Significant Change Minimum Data Set (MDS) assessment was currently in progress. The 11/14/24 Significant Change MDS assessment indicated the resident was not cognitively intact for daily decision making and weighed 316 pounds, with no significant weight loss. The resident had a peg tube and only needed set up or clean up assistance for eating. A Care Plan, dated 8/27/24, indicated the resident was at nutritional risk related to tube feeding, recent hospitalization and weight fluctuations. The approaches were to serve double protein at breakfast and monitor weights and intakes. A Physician's Order, dated 9/19/24, indicated the resident was to receive a mechanical soft carb controlled diet. The weight record indicated the following weights: - 11/5/24 the resident weighed 317 pounds - 12/8/24 the resident weighed 280 pounds - 12/16/24 the resident weighed 272 pounds. There were no other weights documented for the rest of 12/2024 and on 1/3/25. A Registered Dietitian (RD) Narrative Note, dated 12/11/24, indicated the resident had a significant weight loss in the last 30 days. The note recommend resuming the enteral feeding and running it through the night. A Physician's Order, dated 12/13/24, indicated Glucerna 1.583 milliliters (ml) times 12 hours, on at 6:00 p.m. and off at 6:00 a.m. Flush the peg tube with 120 ml of water three times a day. There were no other RD notes available for review. The meal consumption log indicated there was no documentation on 1/6/25 for dinner, 1/7/25 and 1/8/25 for breakfast and lunch. Hospital discharge notes, dated 12/31/24, indicated the resident weighed 314 pounds before leaving the hospital. A weight obtained on 1/7/25 indicated the resident weighed 302 pounds. During an interview on 1/9/25 at 1:04 p.m., CNA 3 indicated the resident was able to feed herself. The CNA was questioned about that statement, as the resident had been observed not eating or able to feed herself. The CNA indicated again she was able to feed herself. During an interview on 1/9/25 at 3:00 p.m., the Director of Nursing (DON) indicated there were no readmission weights documented after the resident returned from the hospital. There had been no assessments by the RD since the hospital returns and 12/11/24 was the most recent. The resident was in need of assistance during meals. The 3/2/16 Enteral/Parental Nutrition policy provided by the DON on 1/9/25 at 2:34 p.m., indicated for existing enteral nutrition orders, the Dietary Manager (DM) would review the weight at least monthly and notify the consultant dietitian of concerns. The DM would report any other pertinent concerns to the dietitian. The dietician would review and evaluate all residents receiving enteral nutrition for adequacy. 2. During an interview on 1/7/25 at 9:57 a.m., Resident 32 indicated he only sometimes received breakfast prior to dialysis on Monday, Wednesday, and Friday. He did not take a lunch and was not given a snack before he left. His chair time was at 9:00 a.m. He usually left the facility around 8:30 a.m. and arrived back to the facility between 2:30 p.m. and 3:00 p.m. He indicated he was very hungry when he returned to the facility. The record for Resident 32 was reviewed on 1/8/25 at 11:25 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, and type 2 diabetes. The 12/13/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident received dialysis while at the facility and weighed 208 pounds with no significant weight loss. A Care Plan, dated 12/7/24, indicated the resident was at nutritional risk related to hemodialysis. The approaches were to serve double protein at breakfast and monitor weights and intakes. The resident's current weight as of 12/28/24 was 209 pounds. A Physician's Order, dated 12/6/24, indicated to serve a 3 to 4 gram sodium carb controlled diet with no orange juice, bananas, tomatoes, and potatoes. A Registered Dietitian (RD) Assessment, dated 12/10/24, indicated the resident's weight was stable but she suggested weekly weights, same day, post dialysis. There were no other RD notes available for review. There were no post dialysis weights available for review on 12/20/24, 12/30/34 and 1/8/25. The meal consumption log indicated there was no total food consumption for breakfast and lunch on 1/5/25, 1/7/25, and 1/8/25. There was no dinner food consumption documented on 12/22/24, 12/28/24, 12/31/24, and 1/6/25. During an interview on 1/9/25 at 10:20 a.m., a maintenance associate indicated he was hired to drive the residents to appointments part time and also to work in maintenance the rest of his time. He transported the resident to dialysis every Monday, Wednesday and Friday. He usually went down to the resident's room by 8:15 a.m. to make sure the resident was up because he wanted to leave at 8:30 a.m. to make sure he got there on time. The majority of the time, he had not eaten breakfast and did not get breakfast before they left. During an interview on 1/9/25 on 10:43 a.m., the Dietary Food Manager indicated she had a board in the kitchen and his name was on it for early breakfast. His breakfast was prepared every Monday, Wednesday and Friday, but the CNA did not come and pick it up. She has told nursing that a CNA had to come and pick up the tray to serve it to him. During an interview on 1/9/25 at 1:10 p.m., the Director of Nursing (DON) indicated she was not aware the resident was not receiving his breakfast tray. Food consumption totals were to be completed after every meal and post dialysis weights were not documented on post dialysis sheets from the dialysis center. 3.1-46(a)

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 36) Finding includes: On 1/7/25 at 9:46 a.m. and 1:19 p.m., Resident 36 was observed in his room in bed with oxygen by the way of a nasal cannula in use. The oxygen concentrator was set at 3 liters. On 1/8/25 at 8:17 a.m., 11:35 a.m., and 2:04 p.m., the resident was again observed in his room in bed. His oxygen was in use and the oxygen concentrator was set at 3 liters. On 1/9/25 at 8:28 a.m., the resident was in his room eating breakfast. His oxygen was in use and the oxygen concentrator was set at 3 liters. At 8:37 a.m., the Nurse Case Manager confirmed the oxygen concentrator was set at 3 liters. The record for Resident 36 was reviewed on 1/8/25 at 11:29 a.m. Diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The Quarterly Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the resident was cognitively intact for daily decision making and he received oxygen therapy. A Care Plan, dated 10/19/24, indicated the resident had intermittent congestion. Interventions included, but were not limited to, administer oxygen as ordered. A Physician's Order, dated 4/16/24 and listed as current on the January 2025 Physician's Order Summary (POS), indicated the resident was to receive oxygen at 2 liters per minute per nasal cannula continuously for chronic respiratory failure. During an interview on 1/9/25 at 1:35 p.m., the Director of Nursing indicated the resident's oxygen concentrator was set at the incorrect flow rate. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 1 resident reviewed for pain. (Resident 32) Finding includes: During an interview on 1/7/25 at 9:44 a.m., Resident 32 indicated he went four days without pain medications when he first was admitted to the facility. The record for Resident 32 was reviewed on 1/8/25 at 11:25 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, fracture of the right tibia, high blood pressure, diabetic neuropathy, and anxiety. The 12/13/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident received an opioid medication in the last 7 days. He received PRN (as needed) pain medication and had pain almost constantly in the last 5 days that had frequently affected his sleep, interfered with therapy, and day to day activities. The resident rated his pain a 10 out of 10. A Care Plan, dated 12/11/24, indicated the resident was at risk for complications related to healing from right tibia fracture. The approaches were to monitor for pain and give pain medications as ordered. A Care Plan, dated 12/7/24, indicated the resident had the potential for pain and discomfort related to right tibia fracture. The goal was for the resident's pain to be controlled at an acceptable level. The approaches were to notify the physician as needed, administer pain medications as ordered, acknowledge the presence of pain and discomfort, and listen to the resident's concerns. A hospital note, dated 11/25/24, indicated the patient was brought in by his sons for a change in mental status. The patient had gone to an urgent care the previous day and was found to have a tibia/fibula (lower leg bones) fracture, placed in a splint, and was sent home with Norco (a narcotic pain medication). The family did not know how much he took or how he fractured his foot. The resident was given Narcan (temporarily reverse the effects of an opioid medicine) while in the emergency room , as a blood test indicated he had opiates in his system. On 12/3/24, the resident had surgery for an open reduction internal fixation of the right distal tibia and distal fibula fractures with repair of the medial collateral ligament (ligament in the knee that connects the thigh bone to the shin bone). During his hospital stay he received Dilaudid (a narcotic used for severe pain) intravenously (IV) and also received Norco 7.5-325 milligrams (mg) 1 or 2 tablets every 4 hours. A Physician's Order, dated 12/6/24, indicated Acetaminophen Tablet 325 mg, give two tablets by mouth every 4 hours as needed for mild pain. The resident's pain levels (on a scale from 1-10 with 10 being the highest) were as follows: - 12/7/24 at 11:16 p.m. an 8 - 12/8/24 at 3:30 a.m., a 6 - 12/8/24 at 9:46 a.m., and 12:53 p.m. an 8 - 12/9/24 at 8:21 a.m., 3:41 p.m., and 11:45 p.m., a 7 - 12/10/24 at 10:04 a.m., an 8 A Nursing Note, dated 12/8/24 at 8:38 a.m., indicated Acetaminophen Tablet 325 mg, 2 tablets was administered to the resident for complaints of pain. A follow up assessment at 9:46 a.m., indicated the pain medication was ineffective as his pain level was an 8. There was no communication with the physician in regards to the resident's complaints of severe pain with levels between 6-8 from 12/7-12/10/24. A Nursing Note, dated 12/10/24 at 2:29 p.m., indicated the physician was finally notified of the resident's pain level and Norco 5-325 mg every 6 hours PRN for pain was ordered for the resident. During an interview on 1/9/25 at 1:10 p.m., the Director of Nursing (DON) indicated the resident, as well as his sons, came to her and spoke about his pain medication on 12/10/24. She notified the physician (Medical Director) and asked him for the Norco, however, the physician was hesitant because of the condition he was brought into the ER and having to have Narcan. She was not made aware the resident was having a lot of pain prior to 12/10/24 and the nursing staff should have notified the physician over the weekend or before 12/10/24. The current 4/10/24 Pain Management Program policy, provided by the DON on 1/9/25 at 2:34 p.m., indicated it was the goal of the facility to assist residents in achieving their optimal level of comfort by providing an effective pain management program. Assess pain by using the following scale, mild pain 1-3, mild moderate pain 3-5, moderate severe 5-7, severe to unbearable 7-9, and worst pain ever a 10. 3.1-37(a)

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored related to not monitoring the resident's blood pressure for medications with blood pressure parameters for 2 of 5 residents reviewed for unnecessary medications. (Residents 21 and 29) Findings include: 1. The record for Resident 21 was reviewed on 1/9/25 at 2:07 p.m. Diagnoses included, but were not limited to, dementia and hypertension. The Medicare 5 day Minimum Data Set (MDS) assessment, dated 12/8/24, indicated the resident had severe cognitive impairment. A Physician's Order, dated 12/1/24, indicated to give Midodrine (a medication that treats low blood pressure) 2.5 milligrams (mg) two times a day, hold for blood pressure greater than 120/80. The record lacked any documentation of blood pressure monitoring for 12/4/24, 12/5/24, 12/6/24, 12/10/24, 12/14/24, 12/16/24, 12/24/24, 12/25/24, 1/3/25, 1/6/25, and 1/7/25. Blood pressures were only documented once per day on 12/1/24, 12/7/24, 12/9/24, 12/11/24, 12/12/24, 12/13/24, 12/15/24, 12/17/24, 12/18/24, 12/19/24, 12/20/24, 12/21/24, 12/22/24, 12/23/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/4/25, 1/5/25, and 1/8/25. During an interview on 1/10/25 at 10:30 a.m., LPN 1 indicated the resident's blood pressure should be checked before each dose of a medication with a parameter, but he did not always document the blood pressure unless he was holding the medication because the unit was so heavy. 2. The record for Resident 29 was reviewed on 1/8/25 at 11:25 a.m. Diagnoses included, but were not limited to, dementia, heart attack, and atrial fibrillation (irregular heart rhythm). The Significant Change Minimum Data Set (MDS) assessment, dated 11/7/24, indicated the resident had moderate cognitive impairment. A Physician's Order, dated 7/24/24, indicated to give Metoprolol Tartrate (a blood pressure medication) twice a day, hold if the blood pressure was below 100/60. The record lacked any documentation of blood pressure monitoring for 12/1/24, 12/2/24, 12/3/24, 12/4/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24, 12/11/24, 12/13/24, 12/14/24, 12/15/24, 12/16/24, 12/17/24, 12/18/24, 12/20/24, 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/3/25, 1/4/25, 1/5/25, and 1/6/25. Blood pressures were only documented once per day on 12/5/24, 12/9/24, 12/12/24, 12/19/24,12/26/24, 1/2/25, and 1/7/25 During an interview on 1/10/25 at 10:42 a.m., the Director of Nursing indicated vitals should be taken and documented with each scheduled dose of a medication with parameters. 3.1-48(a)(3)